SPECIMEN ADEQUACY

Satisfactory for evaluation (describe presence or absence of endocervical/transformation zone component and any other quality limiting factors)

Unsatisfactory for evaluation ... (specify reason)

Specimen rejected (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/diagnosis (specify 'squamous' or 'glandular' as appropriate)

Other: See interpretation/diagnosis (e.g. endometrial cells in a woman > 40 years of age)

AUTOMATED REVIEW

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

DESCRIPTIVE INTERPRETATIONS/DIAGNOSES

NON-NEOPLASTIC

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/Diagnosis section of the report, whether or not there are non-neoplastic findings)

ORGANISMS:

Trichomonas vaginalis

Fungal organisms morphologically consistent with Candida spp

Shift in vaginal flora suggestive of bacterial vaginosis

Bacteria morphologically consistent with Actinomyces spp.

Cellular changes associated with Herpes simplex virus

NON-NEOPLASTIC FINDINGS:

Reactive cellular changes associated with

inflammation (includes typical repair)

radiation

intrauterine contraceptive device (IUD)

OTHER NON-NEOPLASTIC FINDINGS: (optional [e.g. atrophy, inflammation, benign-appearing glandular cells status-post hysterectomy ]) )

OTHER

Endometrial cells (in a woman > 40 years of age)

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

- endometrial cells

- glandular cells

Atypical glandular/endocervical cells, favor neoplastic

Endocervical adenocarcinoma in situ

Adenocarcinoma

- endocervical

- endometrial

- extrauterine

- not otherwise specified (NOS)

OTHER MALIGNANT NEOPLASMS: (specify)

EDUCATIONAL NOTES AND RECOMMENDATIONS (optional)

Recommendations should be concise, phrased in the form of a suggestion, and consistent with clinical follow-up guidelines published by professional organizations (references to relevant publications may be included).

Référence :
Solomon D, Davey D, Kurman R, et al.The 2001 Bethesda System : terminology for reporting results of cervical cytology. JAMA. 2002 ; 287 : 2114 – 2119.