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SPECIMEN TYPE: Indicate conventional smear (Pap smear) vs. liquid based vs. other

SPECIMEN ADEQUACY

• Satisfactory for evaluation (describe presence or absence of endocervical/transformation zone component and any other quality indicators, e.g., partially obscuring blood, inflammation, etc.)

• Unsatisfactory for evaluation ... (specify reason)

  • Specimen rejected/not processed (specify reason)

  • Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of (specify reason)

GENERAL CATEGORIZATION (optional)

• Negative for Intraepithelial Lesion or Malignancy

• Epithelial Cell Abnormality: See Interpretation/Result (specify ‘squamous’ or ‘glandular’ as appropriate)

• Other: See Interpretation/Result (e.g. endometrial cells in a woman ³ 40 years of age)

AUTOMATED REVIEW

If case examined by automated device, specify device and result.

ANCILLARY TESTING

Provide a brief description of the test methods and report the result so that it is easily understood by the clinician.

INTERPRETATION/RESULT

NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY (when there is no cellular evidence of neoplasia, state this in the General Categorization above and/or in the Interpretation/Result section of the report, whether or not there are organisms or other non-neoplastic findings)

ORGANISMS:

• Trichomonas vaginalis

• Fungal organisms morphologically consistent with Candida spp

• Shift in flora suggestive of bacterial vaginosis

• Bacteria morphologically consistent with Actinomyces spp.

• Cellular changes consistent with Herpes simplex virus

OTHER NON NEOPLASTIC FINDINGS (Optional to report; list not inclusive):

• Reactive cellular changes associated with

  • inflammation (includes typical repair)

  • radiation

  • intrauterine contraceptive device (IUD)

• Glandular cells status post hysterectomy

• Atrophy

OTHER

• Endometrial cells (in a woman ³ 40 years of age)
  (Specify if ‘negative for squamous intraepithelial lesion’)

EPITHELIAL CELL ABNORMALITIES

SQUAMOUS CELL

• Atypical squamous cells

  • of undetermined significance (ASC-US)

  • cannot exclude HSIL (ASC-H)

• Low grade squamous intraepithelial lesion (LSIL)
            encompassing: HPV/mild dysplasia/CIN 1

• High grade squamous intraepithelial lesion (HSIL)
            encompassing: moderate and severe dysplasia, CIS/CIN 2 and CIN 3

  • with features suspicious for invasion (if invasion is suspected)

• Squamous cell carcinoma

GLANDULAR CELL

• Atypical

  • endocervical cells (NOS or specify in comments)

  • endometrial cells (NOS or specify in comments)

  • glandular cells (NOS or specify in comments)

• Atypical

  • endocervical cells, favor neoplastic

  • glandular cells, favor neoplastic

• Endocervical adenocarcinoma in situ

• Adenocarcinoma

  • endocervical

  • endometrial

  • extrauterine

  • not otherwise specified (NOS)

OTHER MALIGNANT NEOPLASMS: (specify)

EDUCATIONAL NOTES AND SUGGESTIONS (optional)

Suggestions should be concise and consistent with clinical follow-up guidelines published by professional organizations (references to relevant publications may be included).