GUIDELINES FOR NON-GYN CYTOLOGY

PRINCIPLE

Examination of cellular material harvested from body fluids is one tool used for early detection of cancer and other pathologic conditions. Because of the difficulty and expense incurred in obtaining these specimens, it is imperative that they are handled with care to preserve cellular detail. The fixative of choice at WPM Pathology Laboratory is CytoRich Red, a polyethylene glycol solution with an autolytic agent, which protects the cells during air drying. (CytoRich Red must not be used for urine.) If unprotected during air drying on the microscope slide, cells will undergo shrinkage beyond that which occurs in alcohol. The shrinkage is caused by the collapse of submicroscopic spaces, in the protoplasm, that are vacated by the evaporating alcohol. CytoRich Red, when used as a fixative, occupies these spaces and prevents their collapse. CytoRich Red is used with all non-gyn cytology specimens except urine, for which Carbowax is required.

SPECIMEN TYPES

Ascitic Fluid
Breast Aspirates
Bronchial Washings and Brushings
Cerebrospinal Fluids
Gastric Washings and Fluids
Other Assorted Aspirates and Fluids Pleural Fluids
Sputum
Urine

SPECIMEN ACCEPTABILITY

In order to maintain specimen integrity and accuracy of reporting, acceptable specimens must meet the following criteria:

A properly and completely filled out WPM test request form must accompany the specimen (see page 13).
The information on the specimen container must match the information on the test request form.
The attending physician must be identified.
The specimen site must be properly designated.
The specimen must be fixed properly.

WPM staff will make every possible effort to obtain necessary information and remediate specimen acceptability issues via telephone. However, to avoid delays it is advised that all clinic/hospital staff involved in the collection and handling of specimens be thoroughly knowledgeable of these policies.

MATERIALS

WPM provides 30 ml vials, which are pre-filled with 10 ml of CytoRich Red fixative. These blue top vials may be used for all non-gyn cytology specimens except urine (see specific instructions for urine). WPM also provides regular carbowax for use with urine specimens. Test request forms and biohazard bags are provided, as well.

STORAGE

Cytology specimens must be fixed immediately after collection. Once properly fixed, specimens will keep for several days and do not require refrigeration.

LABELING OF SPECIMEN CONTAINERS

Specimen containers must be labeled with the following information:

Patient name
Date of specimen collection
Site of collection and type of specimen

SUBMISSION

See pages 44 - 48 for specific specimen instructions.

TURN AROUND TIME

In most cases non-gyn cytology reports will be issued within one to two working days of specimen receipt.

NON-GYN CYTOLOGY RECOMMENDED TECHNIQUE FOR SPECIMEN COLLECTION AND PREPARATION

GENERAL

WPM Pathology Laboratory utilizes SurePath thin-layer instrumentation and methodology to prepare all non-gyn cytology slides. Utilizing a centrifuge and sedimentation process, SurePath produces a single layer of cells, creating a superior slide preparation. The result is an unobscured view of cellular structures, previously unobtainable through standard slide preparation. WPM requests that all non-gyn cytology specimens (except urine, which is fixed in Carbowax) be fixed, in provided blue top containers, with equal amounts of CytoRich Red fixative, and shipped to WPM Pathology Laboratory in this form. Slide preparation will be done by WPM Pathology Laboratory.

All fluid specimens collected for cytologic examination must be fixed immediately after collection in an equal volume of fixative. WPM Pathology Laboratory provides specific containers (Blue capped 30 ml containers with 10 ml CytoRich Red already included) for this purpose*. A 50/50 mix of body fluid and fixative is optimal, but most mixtures are acceptable as long as the volume of fixative is equal to or greater than the volume of body fluid. Care should be taken to not contaminate the outside of the primary container when adding body fluid. Properly fixed specimens do not need refrigeration.

*NOTE: Urine specimens should NOT be fixed in the blue top containers due to the autolytic agent in the CytoRich Red fixative. Urine specimens should be fixed, in a clean, sealable container, with regular Carbowax.

Specimen container must be properly labeled with patient name, collection date, and type/location of specimen. Care must be taken to insure that the container is securely capped. Container should be placed inside of a secondary container which will contain the specimen should the primary container leak or break in transit to the laboratory. WPM Pathology Laboratory provides biohazard bags for use as a secondary container.

WPM Pathology Laboratory Cytotechnologists and Pathologists are available by telephone during normal working hours for assistance.

ASCITIC FLUID

The fixed specimen should be tightly capped, properly labeled, and placed in a biohazard bag. Transport to WPM along with a properly filled out WPM "SURGICAL PATHOLOGY AND NON-GYN CYTOLOGY" request form requesting: “NON Gyn Cytolog”y, and “Othe”r.

BREAST ASPIRATES

See page 48, "Fine Needle Aspiration"

BRONCHIAL WASHINGS AND BRUSHINGS

The fixed specimen should be tightly capped, properly labeled, and placed in a biohazard bag. Transport to WPM Pathology Laboratory along with a properly filled out WPM SURGICAL PATHOLOGY AND NON-GYN CYTOLOGY request form requesting: “NON Gyn Cytology”, and “Lung Washings”.

CEREBROSPINAL FLUIDS

GASTRIC WASHINGS AND FLUIDS

To insure optimum recovery of the cytologic material, the patient must be properly prepared. The stomach must be free of contamination of food and barium.

Gastric specimens require special treatment to prevent enzymatic destruction of cells. Before intubating the patient, collection bottles should be filled with Carbowax fixative and placed in cracked ice, where they remain throughout the collection procedure.

If acid studies are performed, they should be done first, with the cytologic material being collected afterward. The first aspiration of gastric material is poor for cellular studies. This initial sample often contains mucus, respiratory elements and cells of long standing which have lost their cellular integrity.

After the initial aspiration, the patient is vigorously lavaged. Washings, brushings, and biopsies are then completed.

The fixed specimen should be tightly capped, properly labeled, and placed in a biohazard bag. Transport to WPM Pathology Laboratory, along with a properly filled out WPM SURGICAL PATHOLOGY AND NON-GYN CYTOLOGY request form requesting: “NON Gyn Cytology”, and “Other”.

PLEURAL FLUIDS

SPUTUM

Sputum specimens should be collected in a clean container. A sputum cup works best for this purpose because of the wide mouth (a urine cup will also work). Specimen should be immediately transferred to the blue top cytology container provided by WPM. Sputa are easier to obtain in the morning, immediately after the patient has risen. Sputum should not be collected after eating. It is advisable to have the patient rinse mouth , before providing specimen, to avoid food contamination.

NOTE: Handle all sputa as if they are capable of transmitting an infectious disease (i.e. tuberculosis).

URINE

Urine specimens submitted for cytologic study may be collected any time of day after the first morning void. An aliquot of reasonable size is requested from large volume specimens. See page 47 "Specimen Volumes".

Specimen should be placed in a clean, sealable, container, fixed with an equal, or greater, amount of Carbowax fixative.

NOTE: Urine specimens should not be placed in the blue top cytology containers provided by WPM Pathology Laboratory, as the fixative in these containers includes an autolytic agent.

OTHER ASSORTED ASPIRATES AND FLUIDS

Specimen should be tightly capped, properly labeled, and placed in a biohazard bag. Transport to WPM Pathology Laboratory along with a properly filled out WPM SURGICAL PATHOLOGY AND NON-GYN CYTOLOGY request form requesting: “NON Gyn Cytology”, and “Other”.

RECOMMENDED SPECIMEN VOLUMES

Specimen aliquots of reasonable volume are requested. Available specimen volume is dependent upon many variables, but the following guidelines are suggested as target volumes.

Ascitic Fluid:	10 ml, well mixed (50 ml maximum)
Breast Aspirates:	whatever is available
Bronchial Washings and Brushings:	10 ml, or whatever is available
Cerebrospinal Fluids:	1 ml, or whatever is available
Gastric Washings and Fluids:	up to 3 - 5 ml
Pleural Fluids:	10 ml, well mixed (50 ml maximum)
Sputum:	whatever is available
Urine:	60 ml (150 ml maximum)

NOTE: Please submit all clotted material, as well.

FINE NEEDLE ASPIRATION

Fine needle aspiration (FNA) is essentially a type of needle biopsy to sample material from palpable lumps, nodules or tumors using a thin needle (outside diameter 0.6 to 0.9 mm) with negative pressure supplied by an attached syringe. This type of biopsy obtains cellular material for cytologic examination, rather than a segment of tissue. The FNA technique is very different from a cutting needle (14 gauge) biopsy, which obtains a core of tissue for histologic examination.

Because a fine needle can be moved in a back-and-forth motion and in different directions, different parts of the lesion may be sampled. This greatly increases the chances of obtaining cellular material that accurately represents the lesion's pathology.

The effectiveness of FNA is well documented in medical literature. In order to maximize the effectiveness of this technique, a close working relationship between the pathologist and the clinician is essential. Communication as to the patient's clinical history and physical findings contributes greatly to the accurate interpretation of the cellular features in the FNA preparations.

PROCEDURE

Label container. (WPM Pathology Laboratory blue top container is preferred. However, if unavailable, a sterile container containing Carbowax may be used.)
As soon as atmospheric pressure is established in syringe, remove needle.
Express the withdrawn fluid from the syringe directly into the labeled container with equal or greater amount of fixative. (Fluid cytology containers supplied by WPM Pathology Laboratory contain 15 ml Cytorich Red fixative.) The syringe may be "washed out" by aspirating and expressing the fluid/fixative solution several times.

Specimen should be tightly capped, properly labeled, and placed in a biohazard bag. Transport to WPM Pathology Laboratory along with a WPM SURGICAL PATHOLOGY AND NON-GYN CYTOLOGY request form requesting: “NON Gyn Cytology”, and “Breast” or “Other”, depending upon specimen site. PLEASE DO NOT SEND NEEDLES TO WPM PATHOLOGY LABORATORY.

NOTE: If blood appears in the syringe, stop the procedure and choose a new aspiration site. Use a new syringe and needle for the new site. Send both samples, in separate containers, to WPM Pathology Laboratory.

GYN-CYTOLOGY REQUISITION FORM

Pap smears must be submitted with this form. All specimens must be properly identified.

Label slide
- Use pencil only
- Write patient name on bottom 2/3 of frosted end of slide
- Last name, first initial
Requisition form must be properly and fully filled out:
- Patient name (last, first, middle initial)
  - If last name has recently changed, please include former name
- Patient social security number
- Physician name
- Patient date of birth (month, date, year)
- Clinic/hospital patient ID number (optional)
- Patient insurance information (not necessary if billed to clinic/hospital)
- Diagnosis (IDC-9 codes are requested)
- Test requested (606 is regular pap, and 610 is pap with Maturity Index)
- Specimen collection date
- Source of specimen
- Patient history (will print out on results report)
  - LMP and hx. of abnormal pap, tx., and surgery are required by CLIA
Medicare patients
- If clinic/hospital does not have accurate three year history of patient, and is unsure of whether patient has had pap smear in last three years, patient should sign waiver, which is located in middle section of requisition form.
Clinic/hospital keeps yellow (back) copy of requisition form, and sends white (top) copy, in biohazard bag with pap pak, to lab. More than one specimen may be placed in a biohazard bag, by folding and wrapping the requisition form around the pap pak and securing it with a rubber band or paper clip.

NOTE: CLIA regulations dictate that the following information must be recorded on the test request form:

Patient name
Patient date of birth
Patient last menstrual period (LMP)
Patient history of abnormal pap, tx., and surgery