GYNECOLOGICAL CYTOLOGY REPORTING
The 2001 Bethesda System (TBS) is the cytology reporting system used by WPM Pathology Laboratory to report results of gynecological cytology. The following definitions for each category are used:
SPECIMEN ADEQUACY
- “SATISFACTORY FOR EVALUATION” indicates that the specimen has all of the following:
- Appropriate labeling and identifying information.
- Relevant clinical information.
- Adequate number of well-preserved and well-visualized squamous epithelial cells. Minimal requirements for the conventional smear are an estimated 8,000-12,000 well-visualized squamous epithelial cells and 5,000 squamous cells for liquid-based preparations.
- At least ten well-preserved endocervical or squamous metaplastic cells are present. A notation is made under Specimen Adequacy regarding the absence of the endocervical component if no endocervical or metaplastic cells are identified.
- Other quality indicators where a notation may be made in the report include the presence of inflammation, blood or foreign material that may be partially obscuring 50-75% of the sample area.
- “UNSATISFACTORY” indicates that the specimen has one of the following:
- Scant squamous epithelial component (well- preserved and well-visualized cells covering less than 10% of the slide surface.)
- Obscuring blood, inflammation, thick areas, poor fixation, air-drying artifact, contaminant, etc… that precludes interpretation of approximately 75% or more of the epithelial cells.
INTERPRETATION
- NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY indicates no squamous or glandular epithelial abnormality is identified.
- “REACTIVE AND OR REPARATIVE CELLULAR CHANGES NOTED” will appear as an additional comment under this interpretation in the section titled “ADDITIONAL FINDINGS.” Reactive changes that are benign in nature, associated with inflammation (includes typical repair), atrophy with inflammation (“atrophic vaginitis”), radiation, an IUD, and other nonspecific causes. This designation includes reparative changes or “typical repair”, which may involve squamous epithelium, squamous metaplasia or columnar epithelium.
- ATYPICAL SQUAMOUS CELLS- UNDETERMINED SIGNIFICANCE ASC-US is defined as cytologic changes suggestive of a LSIL (Low Grade Squamous Intraepithelial Lesion) that are quantitatively or qualitatively insufficient for a definitive diagnosis.
- ATYPICAL SQUAMOUS CELLS- CANNOT EXCLUDE HIGH GRADE INTRAEPITHELIAL LESION ASC-H is defined as cytologic changes suggestive of HSIL that are quantitatively or qualitatively insufficient for a definitive diagnosis.
- ATYPICAL GLANDUALR CELLS OF ENDOCERVICAL ORIGIN
- ATYPCIAL GLANDUALR CELLS OF ENDOMETRIAL ORIGIN
- ATYPICAL ENDOCERVICAL CELLS, FAVOR NEOPLASTIC
Defined as suggestive, but not diagnostic of Adenocarcinoma in situ. - ATYPICAL ENDOMETRIAL CELLS, FAVOR NEOPLASTIC
Defined as suggestive, but not diagnostic of Adenocarcinoma in situ. - SQUAMOUS INTRAEPITHELIAL LESION
- Low grade
- High grade
- SQUAMOUS CELL CARCINOMA
- ADENOCARCINOMA
A malignant tumor of glandular cells. - MALIGNANT NEOPLASMS, NOS
Malignant cells of uncertain histogenesis.
ADDITONAL FINDINGS
- “REACTIVE AND OR REPARATIVE CELLULAR CHANGES NOTED” Reactive changes that are benign in nature, associated with inflammation (includes typical repair), atrophy with inflammation (“atrophic vaginitis”), radiation, an IUD, and other nonspecific causes. This designation includes reparative changes or “typical repair”, which may involve squamous epithelium, squamous metaplasia or columnar epithelium.
- GARDNERELLA PRESENT
- ACTINOMYCES PRESENT
- TRICHOMONAS PRESENT
- CELLULAR CHANGES COMPATIBLE WITH HERPES
- NON-DODERLEIN BACTERIA PRESENT
- CANDIDA ORGANISIMS PRESENT
- OUT OF PHASE ENDOMETRIAL CELLS, PREMENOPAUSAL
- ENDOMETRIAL CELLS, NO MENSTRUAL HISTORY
- ENDOMETRIAL CELLS PRESENT
- BENIGN APPEARING GLANDULAR CELLS, POST HYSTERCTOMY
ANCILLARY TESTING
All ancillary testing comments and results will be reported here.