Narcotext

 

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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).

http://bethesda2001.cancer.gov/terminology.html