A cytology report recorded as suspicious is not considered as diagnostic of cancer and unless supported by a positive biopsy (as reported on a pathology report) or by a clinical impression of cancer, these cases should not be abstracted.
The Papanicolaou classification of cells for the detection of malignancy ("Pap" smear) used in the past is as follows:
- No evidence of a malignant neoplasm, no atypical cells
- Atypical cells present but no evidence of malignant neoplasm
- Cells present causing suspicion of malignant neoplasm
- Fairly conclusive evidence of malignant neoplasm
- Conclusive evidence of malignant neoplasm
Some medical records will contain more than one cytology report. If there are multiple reports on the same type and source of specimen, record the findings on the first positive report. If they are based on different types and sources of specimens, summarize all pertinent findings.
According to the National Cancer Institute Workshop on Terminology for Cervical and Vaginal Cytology, December 12-13, 1988, "While the Papanicolaou Classes have a significant historical association with the early development of cytology, it can no longer be relied upon to communicate clinically relevant information. In particular, the Papanicolaou Classes do not reflect current understanding of cervical neoplasia, do not provide for the diagnosis of non-cancerous entities, and as a result of numerous idiosyncratic modifications over the years, no longer reflect uniform diagnostic interpretations. Accordingly, it is our conclusion that the Papanicolaou Class System is not acceptable in the practice of diagnostic cytology". Their organization of the new terminology and classifications is a follows:
- a STATEMENT ON ADEQUACY OF THE SPECIMEN,
- a GENERAL CATEGORIZATION of the diagnosis (within normal limits or other), and
- the DESCRIPTIVE DIAGNOSIS
For Squamous Cell the following terminology is used:
III.A.1 Atypical squamous cells of undetermined significance (specify recommended follow-up and /or further investigative procedures)
III.A.2 Squamous intraepithelial lesions (Comment on presence or absence of cellular changes consistent with Human papillomavirus (HPV) infection
III.A.2a Low grade squamous intraepithelial lesion encompassing: Cellular changes consistent with HPV infection Mild dysplasia/CIN 1
III.A.2b High grade squamous intraepithelial lesion encompassing:
Moderate dysplasia/CIN 2
Severe dysplasia/CIN 3
Carcinoma in situ/CIN 3
III.A.3 Squamous carcinoma
At first you may find it somewhat disconcerting to discover that more than one type of form may be used to report similar findings. However, as you study Examples G12-G15, you will find that they contain similar information. For example:
The source of the specimen is recorded by checking one of the blocks on the left of the report. This report is of special interest to the new tumor registrar because it lists the major sources of material used as specimens for a cytologic examination.
At the top left of the report, the clinical diagnosis may be summarized. This need not be recorded on the abstract. In many cases the laboratory study was ordered on the basis of a previously suspicious Pap smear.
The findings of the examination will be recorded by checking one of the blocks listed in the section describing the tissue status on the lower right.