Cytopathology GYN Reference Guide

WELCOME

This pocket reference is intended as a guide for practice by health care

providers who are responsible for conducting the screening examination
and appropriate follow-up activities. The recommendations herein are
not intended to be a substitute for sound professional judgement by
providers in individual cases, nor are they intended to replace or alter the
fundamental responsibilities inherent in the provider-patient relationship.

Guangzhou Hongqi Optical Instrument Technology Co., Ltd.

Marketing Department
ph +86-20-32214380 fax +86-20-32203590
 CONTENTS

Pap test Collection ______________________________________________ 1

Endocervical Brush/Spatula Protocol _______________________________ 1
Broom-Like Device Protocol ____________________________________ 2
When to Repeat Paps ____________________________________________ 3

Collection Tips ________________________________________________ 3

The Bethesda System ____________________________________________ 4

Quick Diagnostic Guide __________________________________________ 6

Unsatisfactory Pap Tests _________________________________________ 1 0

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PAP TEST COLLECTION

Hongqi LBC Pap Test Quick Reference Guide -

%NDOCERVICAL "RUSH3PATULA 0ROTOCOL
OBTAIN an adequate sampling from the ectocervix using
a plastic spatula.

RINSE the spatula as quickly as possible into the Cell

Preservation Solution vial by swirling the spatula vigorously
in the vial 10 times. Discard the spatula.

OBTAIN an adequate sampling from the endocervix using

an endocervical brush device. Insert the brush into the
cervix until only the bottommost fibers are exposed. Slowly
rotate 1/4 or 1/2 turn in one direction.
DO NOT OVER-ROTATE.

RINSE the brush as quickly as possible in the Cell

Preservation Solution by rotating the device in the solution
10 times while pushing against the Cell Preservation Solution
vial wall. Swirl the brush vigorously to further release material.
Discard the brush.
TIGHTEN the cap so that the torque line on the cap
passes the torque line on the vial.

RECORD the patient’s name and ID number on the vial

....the patient information and medical history on the
cytology requisition form

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PAP TEST COLLECTION

Hongqi LBC Pap Test Quick Reference Guide -

"ROOM ,IKE $EVICE 0ROTOCOL
OBTAIN an adequate sampling from the cervix using a
broom-like device. Insert the central bristles of the broom
into the endocervical canal deep enough to allow the
shorter bristles to fully contact the ectocervix. Push gently,
and rotate the broom in a CLOCKWISE direction five times.
RINSE the broom as quickly as possible into the Cell
Preservation Solution vial by pushing the broom into the
bottom of the vial 10 times, forcing the bristles apart. As
a final step, swirl the broom vigorously to further release
material. Discard the collection device.

TIGHTEN the cap so that the torque line on the cap

passes the torque line on the vial.

RECORD the patient’s name and ID number on the vial.

RECORD the patient information and medical history on
the cytology requisition form

SPECIAL COLLECTION SITUATIONS

0OST (YSTERECTOMy - It is important to note if the patient has had a

supracervical hysterectomy. A cervical stump can be sampled in the same
manner as an intact cervix. A woman without a cervical stump should have
the Pap Test taken from the upper third of the vaginal vault.
!TROPHIC 6AGINITIS It is important to visualize the cervix. If the cervix
cannot be visualized or the Pap test is resulted as “unsatisfactory”
treatment with an estrogen cream may be needed.
0REGNANCY AND 0OST 0ARTUM If a cervical brush is used, care must
be taken to insert the brush only to the depth necessary. Gentle rotation
should be used to obtain the sample. Post-Partum Paps should not be
taken prior to six weeks post-partum due to increased false positive
results, likely due to reparative changes in the cervix

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 WHEN TO REPEAT PAPS 3

4O 2EPEAT OR .OT TO 2EPEAT

4HAT IS THE QUESTION

$O REPEAT
$O .OT REPEAT

s For an ASCUS Pap s 7HEN TAKING A BIOPSY n only an ECC
in 6-12 months brush should be done if necessary
s If unsatisfactory s )N LESS THAN  MONTHS n compromises
Pap Test result cytology, cervix needs time to
regenerate
s &OR ENDOMETRIAL CELLS n needs clinical
exam and possible endometrial biopsy
s &OR MISSING ENDOCERVICAL COMPONENT
– before 6 months

COLLECTION TIPS

3UBOPTIMAL TIMES FOR 0AP 4EST #OLLECTION

s $URING MENSES AND INFECTION increased chance for unsatisfactory
specimens.
s Within 48 hours of douching or use of vaginal medication, and vaginal
contraceptives.

(ONGQI ,"# 0AP 4EST #OLLECTION 4IPS

s Always wipe away mucus from cervix before cell collection for a Hongqi LBC Pap
Test (however for a conventional smear do not wipe mucus away from cervix).
s Collect Pap specimen BEFORE the application of acetic acid or
iodine solution.
s Do not use lubricant – doing so limits the amount of cellular material
s Identify the transformation zone, if visible and direct sampling efforts to
encompass this area.

s 4IGHTEN LIDS of Cell Preservation Solution vials before transport.

s !LWAYS NOTE THE PRESENCE OF AN )5$ which can simulate abnormal
cellular changes, on the Pap Test requisition.

s Refrain from collecting Pap Tests UNTIL AFTER SIX WEEKS POST PARTUM due
to increased false positive results from reparative changes in the cervix.

s Lack of an endocervical component does NOT affect the adequacy of the

specimen. Post-menopausal women may have no identifiable endocervical
component, especially when there is marked epithelial atrophy.

GUANGZHOU HONGQI
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THE BETHESDA SYSTEM

The Bethesda System (TBS) was the result of a workshop sponsored by

the National Cancer Institute (NCI) in 1988 (with revision in 1991) to
standardize terminology and reporting of cervical cytology. It has been
widely adopted both in the United States and internationally.
In 2001, the NCI sponsored a third workshop-Bethesda 2001- to evaluate
changes in the practice of cytopathology since TBS 1991, including
methods, introduction of ancillary techniques/testing, and automation.
The final recommendations of the group modify the existing Bethesda
System-most notably as it deals with specimen adequacy and general
categorization. Those revisions are summarized in the tables that follow.

TBS GENERAL CATEGORIZATION

TBS 1991 TBS 2001 CHANGE

Within Normal Limits (WNL) Negative for Intraepithelial WNL is now named .EGATIVE
Lesions or Malignancy FOR )NTRAEPITHELIAL
s /RGANISMS ,ESIONS OR -ALIGNANCY
and includes the previous
s /THER NON NEOPLASTIC
findings category of BCC as a
descriptor only.

Benign Cellular Changes BCC was eliminated as a

(BCC) diagnostic category (see
s )NFECTION above).
s 2EPAIR

Other Endometrial cells in This category is new.

a woman > 40 years old
(specify if negative
for SIL)

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TBS GENERAL CATEGORIZATION

TBS 1991 TBS 2001 CHANGE

3ATISFACTORY 3ATISFACTORY FOR %VALUATION For liquid-based cytology, an adequate
(Describe presence or absence of sample would have a minimum of
endocervical transformation zone 5,000 epithelial cells to be satisfac-
component and any other quality tory. The presence of an epithelial cell
indicators, e.g., partially obscur- abnormality automatically makes a
ing blood, inflammation, etc) specimen satisfactory-regardless of the
number of epithelial cells.

3ATISFACTORY but limited by (SBLB) The category SBLB has been elimi-
s ,ACK OF ENDOCERVICAL CELLS nated. The descriptors are to be used
s /BSCURING BLOOD in a comment section, but not to
s /BSCURING INmAMMATION determine adequacy.
s !IR DRYING ARTIFACT

5NSATISFACTORY 5NSATISFACTORY FOR EVALU The reason to refer to a specimen

s /BSCURING BLOOD ATION Specimen rejected/ as unsatisfactory have been re-
s /BSCURING INmAMMATION not processed Specimen duced to the reasons noted (left).
s !IR DRYING ARTIFACT processed and examined, but
unsatisfactory –too few cells,
poor preservation, totally
obscured by blood

TBS 1991 TBS 2001 CHANGE

%PITHELIAL #ELL !BNORMALITY EPITHELIAL #ELL !BNORMALITY The multiple subcategories
3QUAMOUS #ELLS 3QUAMOUS #ELLS of ASCUS have been reduced
s !3#53 ATYPICAL SQUAMOUS s !TYPICAL SQUAMOUS CELLS OF to the two noted (ASC-
cells of undetermined undetermined significance US, ASC-H) with no other
significance) -favor reactive, (ASC-US) -cannot excluded modifying statements.
favor dysplasia HSIL (ASC-H)
s ,3), s ,3),
s (3), s (3),
s 3QUAMOUS CELL CARCINOMA s 3QUAMOUS CELL CARCINOMA
%PITHELIAL CELL !BNORMALITY %PITHELIAL #ELL !BNORMALITY The subcategories of AGUS
'LANDULAR #ELLS 'LANDULAR #ELLS have been expanded to
s !'53 ATYPICAL GLANDULAR ª Atypical (NOS) -Endocervi- allow for a more descriptive
cells of undetermined cal cells, endometrial cells, diagnosis of glandular
significance) -favor reactive, glandular cells abnormalities.
favor neoplasia s !TYPICAL FAVOR NEOPLASTIC AIS is now a distinct entity.
s !DENOCARCINOMA endocervical cells, glandular
cells
s %NDOCERVICAL ADENOCARCI-
noma in situ (AIS)

GUANGZHOU HONGQI
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QUICK DIAGNOSTIC GUIDE

!3#53
.AME Atypical Squamous Cells of Undetermined Significance
(OW SHOULD IT BE TRIAGED Repeat Pap test in 6-12 months,
reflex HPV testing

4HE DIFFERENT MORPHOLOGIC LOOKS OF !3#53x

Nucleus of intermediate cell is 2-3 times normal, atypical parakeratosis, in
addition to other unexplained atypias, smooth nuclear outlines

!3# (
.AME Atypical Squamous Cells cannot rule out a High-grade neoplasm
(OW SHOULD IT BE TRIAGED Colposcopy, biopsy and ECC Pap Test or
traditional ECC, NOT HPV reflex testing

4HE DIFFERENT MORPHOLOGIC LOOKS OF !3# (x

Nuclear to cytoplasmic ratio is increasing, nuclear hyperchromasia,

GUANGZHOU HONGQI 4/08

 7
QUICK DIAGNOSTIC GUIDE

,3),
.AME Low grade squamous intraepithelial lesion
7HAT BIOPSY DIAGNOSIS CORRELATES CIN I
(OW SHOULD IT BE TRIAGED Colposcopy, biopsy, traditional ECC or ECC
Pap Test. Patients b 20 years of age should have repeat cytology only.

4HE DIFFERENT MORPHOLOGIC LOOKS OF ,3),x

Enlarged, hyperchromatic nucleus, presence of koilocytes, binucleation,
moderate variation in nuclear size and shape

(3),
.AME High-Grade Squamous Intraepithelial Lesion
7HAT BIOPSY CORRELATES CIN II, CIN III
(OW SHOULD IT BE TRIAGED Colposcopy, biopsy, traditional ECC or ECC
Pap Test

4HE DIFFERENT MORPHOLOGIC LOOKS OF (3),x

Small cells with hyperchromatic nuclei, increased nuclear to cytoplasmic
ratio, immature cytoplasm, chromatin finely to coarsely granular, nucleoli
are absent, irregular nuclear outlines

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QUICK DIAGNOSTIC GUIDE

!'#
.AME Atypical Glandular Cells (endocervical, endometrial)
#LINICAL 3IGNIlCANCE Possible glandular lesion that needs to be further
investigated
(OW SHOULD IT BE TRIAGED Colposcopy, biopsy, ECC or ECC Pap Test,
Endometrial sampling

4HE DIFFERENT MORPHOLOGIC LOOKS OF !TYPICAL GLANDULAR CELLSx

Cell borders are ill-defined, nuclear atypia that exceeds obvious reactive or
reparative changes
But lack unequivocal features of invasive adenocarcinoma.

!)3
.AME Adenocarcinoma In-Situ
#LINICAL 3IGNIlCANCE A glandular lesion that needs to be further
investigated
(OW SHOULD IT BE TRIAGED Colposcopy, ECC, biopsy

4HE DIFFERENT MORPHOLOGIC LOOKS OF !)3x

Abnormal cells occur in sheets, strips, and rosettes with nuclear crowding
and overlap, ill-defined cell borders, variation in nuclear size and shape,
mitotic figures may be seen.

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QUICK DIAGNOSTIC GUIDE

31#!
.AME Squamous Cell Carcinoma
(OW SHOULD IT BE TRIAGED Biopsy

4HE DIFFERENT MORPHOLOGIC LOOKS OF 31#!x

Cells with increased ratios, irregular nuclear outlines, associated tumor
diathesis consisting of necrotic debris and old blood are often present,
cells occur singly, less commonly in aggregates, coarse chromatin, marked
variation in cellular size and shape (caudate and spindle cells)

HISTORY

)MPORTANT (ISTORY TO PROVIDEx

IUD Pregnancy

GUANGZHOU HONGQI 4/08

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UNSATISFACTORY PAP TESTS

Unsatisfactory Pap Tests are frustrating not only to the laboratory and
clinic but also for the patient. Some things to keep in mind regarding
Unsatisfactory Results
s Unsatisfactory Pap tests incorrectly designated as negative infer the
absence of disease (SIL or malignancy) and may not prompt adequate
follow-up
s Reporting numerically challenged Pap tests as “satisfactory” may have
potential negative legal implications
s Unsatisfactory Pap tests are most often from high-risk patients,
containing significantly more SIL/neoplasia on follow-up
s It is dangerous to label a specimen less than 5,000 cells satisfactory,
since optimal detection rates of HSIL and LSIL are achieved when sample
cellularity is greater than 20,000 cells

FREQUESNTLY ASKED QUESTIONS

&REQUENTLY ASKED QUESTIONS

 3HOULD LUBRICANTS BE USED DURING 0AP TESTING
NCCLS Guidelines recommend that no lubricant be used during Pap testing. ACOG
recommends that care be taken not to contaminate the specimen with lubricant
because this may lead to an unsatisfactory result. Please refer to NCCLS Document:
Papanicolaou Technique; Approved Guideline and ACOG Practice Bulletin, no. 45,
August 2003. For physicians using plastic specula, or in instances where a lubricant
must be used, take care not to contaminate the cervix or collection devices with
lubricant. A tiny amount of lubricant may be used, just enough to sparingly coat the
speculum with a gloved finger, avoiding the tip of the speculum.
 3HOULD PATIENTS POST HYSTERECTOMY FOR BENIGN DISEASE PATIENTS CONTINUE TO
HAVE 0AP4ESTS
Although there is some controversy of Pap Tests in post-hysterectomy patients for
benign disease our laboratory recommends the continuation of annual Pap testing.
 7HAT AGE SHOULD PATIENTS BEGIN 0AP 4EST SCREENING
Three years after the onset of sexual activity but no later than 21 years of age according
to the America Cancer Society Guidelines.

GUANGZHOU HONGQI