Gyenocologic Pap Test Collection Procedure

PROCEDURES FOR GYNECOLOGIC PAP TEST

COLLECTION AND SUBMISSION TO THE CYTOLOGY LABORATORY

University of Virginia Health System

Department of Medical Laboratories

Division of Cytopathology

  Revised October 2010

Revised September 2012

PROCEDURES FOR GYNECOLOGIC PAP TEST COLLECTION

 AND SUBMISSION TO THE CYTOLOGY LABORATORY

A Pap test is a screening test that can also be a diagnostic test. Its primary purpose is to identify patients who have cellular changes that place them at risk for the development of cervical cancer. The Pap test is a highly complex laboratory test requiring careful patient preparation, skill in clinical collection, highly skilled and controlled laboratory processing, and professional interpretation.  Like all laboratory tests, the Pap test is not perfect. A Pap test is best viewed as a moderately sensitive, highly specific test with an established false negative rate of no less that 5%.

In cases of routine screening for cervical cancer and its precursors, cellular material can be obtained from the uterine cervix using a variety of sampling devices. Most clinics at the University of Virginia Health Sciences Center use the spatula and/or an endocervical brush. The cervix and the area adjacent to the cervix (fornices) must be fully visible.  The ecto- and endocervix should be sampled separately. The material obtained can be rinsed into liquid medium (ThinPrep Pap test), our preferred method, or, only exceptionally, spread on one or two glass slide slides (conventional Pap smear).

ThinPrep Pap test supplies are available from the Hospital Storeroom: Item ID 92189 tray of 25 Thinprep Pap test vials and Item ID 92190 bag of 25 collector sets (spatulas and brushes). Cervex broom collectors and conventional Pap test supplies are available through Laboratory Customer Service at 924-LABS. Carefully read the manufacturer's instructions for proper applications and all contraindications prior to using the cytobrush.

PATIENT PREPARATION/INSTRUCTIONS 

1. The patient should NOT make an appointment for her Pap test during her menstrual period. The preferred time for the examination is two weeks after the first day of her last menstrual period.

2. The patient should be instructed NOT to use vaginal medications, vaginal contraceptives, lubricants, or douches for 48 hours before her appointment. Intercourse is not recommended the night before the examination.

TECHNICAL SUGGESTIONS FOR PHYSICIANS 

1. The physician should not use any lubricant during his examination prior to collecting the cell sample.

2. Every effort is made to identify and sample the squamo-columnar junction and/or transformation zone since the majority of squamous lesions arise within this area.

3. Excess blood, mucus, or inflammatory exudate may be gently blotted away with a gauze pad. Do not scrape or wash this material away since such actions may adversely affect the subsequent cellular sample.

4. The Pap test should always be taken prior to other testing (e.g. cultures, tissue sampling, application of acetic acid, etc.)

The ThinPrep Pap test requires unique specimen collectors and a special collection fluid. Some physician training in proper collection techniques is also needed. To arrange training, contact Laboratory Customer Service at 924-LABS. In addition, an instructional video on ThinPrep Pap test collection is available from the Cytology Laboratory (924-2770) and on-line from Hologic Corporation (see #9 below).

THINPREP PAP TEST PROCUREMENT

1.  Assemble collection devices and ThinPrep Pap test vial.

2.  Obtain an adequate sampling of the ectocervix using a plastic spatula. (A wooden spatula is not suitable as the cellular material is more difficult to rinse into the collection fluid.)

3.  Rinse the spatula into the solution vial by swirling the spatula vigorously in the vial 10 times. Discard the spatula.

4.  Obtain an adequate sampling from the endocervix using an endocervical brush device. Insert the brush into the endocervical canal until only the bottom-most fibers are exposed. Slowly rotate ¼ or ½ turn in one direction. DO NOT OVER ROTATE.

5.   Rinse the brush in the solution vial by rotating the device in the solution 10 times while pushing against the vial wall. Swirl the brush vigorously to further release material. Discard the brush.

6.   Tighten the cap so that the torque line on the cap passes the torque line on the vial.

7.   Record the patient’s name and history number on the vial or attach a printed patient identification label. Complete a cytopathology test request form (in preprinted paper form or test order printed from Epic).

8.   Send labeled specimen vial and completed request form to the laboratory for processing. No refrigeration of the specimen is necessary.

9.   On-line video available: www.thinprep.com/hcp/specimen_collection/view_video.html

SMEAR PREPARATION FOR THE CONVENTIONAL PAP TEST

NOTE: Currently 99.9% of Pap tests are ThinPrep, which is the expected sample type.

1. Using a lead pencil, write the patient's name and/or medical record number on the frosted end of each glass slide to be used. Use a diamond point pencil to label plain glass slides. All slides submitted to the laboratory must be clearly labeled with the patient identification information at the time of specimen collection. Paper labels affixed to the slides are NOT an acceptable means of slide identification. Federal regulations require that unlabeled slides must be returned to the sender for identification and correction. Laboratory personnel cannot correct this error.

2. Have spray fixative nearby to allow for immediate fixation of the prepared slides. Review and follow the manufacturer's instructions for correct application. 

3. Under direct vision, sample the ectocervix and endocervix separately using the appropriate sampling device. Prepare one combined slide or two separate slides.

a.        To prepare a single combined smear, sample the endocervix first using the endocervical brush.  Insert the brush into the external os and gently rotate the device using ¼ or ½ turn to obtain the cell sample (over rotation may cause bleeding).  Do not smear, but allow the material to remain on the brush.  Scrape the ectocervix with the spatula and spread the material rapidly onto the upper end of the slide.  Quickly roll the endocervical brush through the ectocervical material to the end of the slide.  Perform this technique as rapidly as possible to prevent drying artifacts.  Immediately spray fix by thoroughly soaking the cellular sample while holding the spray fixative container about 6-8 inches from the slide. Allow spray fixative to evaporate.

b.         To prepare separate slides, rotate the spatula with pressure over the entire ectocervix. Spread the cellular material evenly and rapidly across the glass slide being careful to avoid the labeled area. Immediately spray fix by thoroughly soaking the cellular sample while holding the spray fixative container about 6-8 inches from the slide. Allow spray fixative to evaporate.

 For the second slide, insert the endocervical brush into the external os and obtain the cell sample as previously described.  Remove the brush and roll it across the slide to remove the cellular material. Rubbing or scraping the brush across the slide creates artifacts that may hamper evaluation. Immediately spray fix by thoroughly soaking the cellular sample while holding the spray fixative container about 6-8 inches from the slide. Allow spray fixative to evaporate.

4. Place fixed slides in an appropriate container designed to prevent breakage for transport to the laboratory. Complete a cytopathology test request form (in preprinted paper form or test order printed from Epic).

5.  Deliver specimen slides and request form to the laboratory at the convenience of the submitting physician or department.

IN PATIENTS AT RISK FOR ENDOMETRIAL DISEASE, CERVICAL SAMPLES ARE USUALLY INADEQUATE TO SENSITIVELY DETECT ENDOMETRIAL LESIONS. Aspiration of material from the vaginal pool may provide some information; however, more direct sampling is preferred. There are several procedures for obtaining endometrial material, all of which require specialized skills and equipment. Consultation with clinicians in the Department of Obstetrics and Gynecology who are familiar with such procedures is recommended prior to specimen collection.

THE CYTOPATHOLOGY TEST REQUEST

A cytopathology test request form (in preprinted paper form or test order printed from Epic) containing the following required information must accompany each specimen:

1. Patient name, patient history number (medical record number), and date of birth (age is not sufficient as a means of patient identification).
2. Name of the ATTENDING physician or authorized nurse practitioner requesting the test. A resident may be listed only if accompanied by the name of a staff physician.
3. Clinic, floor, or service generating the specimen.
4. Date of specimen collection.
5. ICD-9 code indicating the medical necessity for the test. The code should be included in the space/field provided. Medicare regulations for ICD-9 coding are written on the back of the multipart preprinted test request form.
6. Type or source of specimen (check box on form or use drop down box in Epic).
7. Test order: check the appropriate box on the paper form or use the on-line dropdown list in Epic to order Pap test screening alone or Pap test with HPV testing. Explanations for HPV test ordering) are on the back of the top copy of the paper request form.
8. All pertinent clinical history/findings or other data relating to the requested evaluation.

For preprinted versions of the Cytopathology Request form, computer generated registration labels are the preferred method for providing patient identification information (i.e. name, history number, date of birth) for outpatients.

Clinical history or findings include the information listed below. This information is important for accurate interpretation of smears and should correlate with the assigned ICD-9 code provided on the request form.

1. All previous disease processes (e.g. dysplasia, cancer, etc.) and/or therapy (e.g. radiotherapy, cryo/laser therapy, estrogen replacement therapy, etc.) that could influence the cytologic interpretation of the Pap test. Case numbers from previous cytology or surgical specimens are helpful, but should NOT replace written descriptions of previous findings.

The 2001 Bethesda Conference provided a review of the application of TBS over the previous 10 years. After much discussion, significant revision of reporting terminology was made. The most significant change was the combination of the “within normal limits” category and the “benign cellular changes” category under the heading of “Negative for Intraepithelial Lesion or Malignancy.” Infectious organisms are reported directly with the “Negative” interpretation. Benign findings are considered optional and are reported as additional findings under the “Negative” heading. The revised version was published as a reporting system for cervical cytology.

The UVA Cytology Laboratory uses a slightly modified version of TBS for reporting cervical interpretations. The modifications are generally in specific wording and in the inclusion of additional descriptive diagnosis in order to facilitate patient management by clinicians at our institution.  The intent, content, and scope of TBS remain intact.

THE STATEMENT OF ADEQUACY

Satisfactory for Interpretation:

Satisfactory gynecologic specimens are defined as specimens having sufficient numbers of well-preserved, well-stained, unobscured epithelial cells such that a cytologic interpretation can be rendered.  No conditions exist (e.g. excessive inflammation or blood, poor preservation, etc.) that prevent the cytologic interpretation. 

Relevant clinical information and/or history are considered necessary for accurate evaluation of Pap smears.  These data may clarify otherwise uncertain cytologic findings.  Therefore, the provision of pertinent patient information that may influence the interpretation of the smears is necessary for a "satisfactory" specimen.

Some specimens may have conditions that hamper but do NOT prevent a reasonable cytologic interpretation. The cellular material remains sufficient to render an interpretation although that interpretation may be somewhat limited in scope or specificity. Reasons for the limitations are stated in the report under the heading “Statement of Adequacy.”

Unsatisfactory specimens are defined as specimens in which conditions exist (e.g. too few epithelial cells, excessive inflammation or blood, poor preservation, etc.) that prevent a reasonable cytologic interpretation.  Rendering a cytologic interpretation on the specimens would not meet basic standards of care. In this category the statement of adequacy or lack thereof, becomes the descriptive interpretation.  All identifiable limiting factors for the unsatisfactory results are stated in the report.  No cytologic interpretation is given.

If abnormal cells are detected, regardless of other factors, the specimen is NEVER categorized as unsatisfactory.

The laboratory has procedures in place to avoid reporting unsatisfactory results whenever possible. Prior to recording a specimen as unsatisfactory, the residual material in the specimen vial is evaluated for physical findings that may indicate that additional processing could potentially improve sample adequacy. If merited, additional slides are made. In addition, all specimens in which basic criteria for adequacy are not met are sent for a second cytotechnologist review and sign out. If the two cytotechnologists agree, the unsatisfactory results are reported. If the two reviewers do not agree, the case is referred to the pathologist for final interpretation.

DESCRIPTIVE INTERPRETATION/RESULTS;

The interpretation element of the report is largely self-explanatory.  The descriptive terminology used in our laboratory is listed on pages 8-10.  TBS limits the term "atypical cells" to those cases in which the cytologic findings are of undetermined significance.  Whenever possible, the use of the term should be further clarified when a high-grade lesion cannot be excluded. The old numerical Papanicolaou classification system is not considered acceptable in the modern practice of diagnostic cytopathology.

SUGGESTIONS FOR FOLLOW-UP

Suggestions for follow-up are optional.  When included in the report, they should be concise and consistent with clinical follow-up guidelines published by professional organizations (e.g., ASCCP). TBS does not contain guidelines for patient management.

ANCILLARY TESTING:

The results of any ancillary testing performed on the specimen will be given either in the final report or as an addendum to that report. The results will provide a brief description of the test method and the test outcome so that clinicians can easily understand them. Refer to the section on HPV testing pages 10-11.

DESCRIPTIVE TERMINOLOGY FOR REPORTING CYTOLOGIC INTERPRETATIONS 

I.          Statement of adequacy

Satisfactory for interpretation – limiting factors listed as needed

Unsatisfactory specimen - requires explanation, give all limiting factors

Limiting factors for satisfactory specimens:

Scant numbers of epithelial cells

Endocervical/transformation zone component absent/scant

Poor fixation or preservation

Partially obscuring inflammatory exudate

Partially obscuring blood

Partially obscuring bacterial overgrowth

Mechanical distortion

Cellular degeneration

Pertinent clinical information that may affect cytologic interpretation was not provided.

Explanations for unsatisfactory specimens:

Insufficient numbers of epithelial cells for adequate cytologic interpretation

Completely obscuring inflammatory exudate

Completely obscuring blood

Completely obscuring bacterial overgrowth

Poor fixation or preservation of the epithelial cells prevents adequate cytologic evaluation

Mechanical distortion of the epithelial cells prevents adequate cytologic evaluation

Cellular degeneration prevents adequate evaluation of the epithelial cells

II.        Descriptive interpretation/results categories

Negative for Intraepithelial Lesion or Malignancy

Infections (reported with the Negative interpretation):

Fungal organisms consistent with Candida species

Bacteria morphologically consistent with Actinomyces species

Trichomonas vaginalis infection

Cellular changes indicative of cytomegalovirus

Cellular changes indicative of Herpes simplex virus

Additional cytologic findings (reporting optional):

Benign cellular changes associated with an inflammatory process

Atrophic cervicitis/vaginitis

Benign cellular changes associated with a reactive/reparative process

Benign cellular changes associated with atrophy

Benign cellular changes, associated cause not identified

Benign cellular changes associated with presence of intrauterine contraceptive device

Tubal metaplasia present

Effects of nonsteroidal estrogen exposure

Parakeratosis (reported only when present in quantity)

NOTE:  This entity may occur alone in response to various stimuli, or may be                             associated with squamous neoplasia.

Anucleated squamous cells present (reported only when present in quantity)

NOTE:  This entity may occur alone in response to various stimuli, or may be                             associated with squamous neoplasia.

Endometrial material present in postmenopausal woman

Endometrial material present, recommend clinical correlation

NOTE:  This is reported in women 40 years or older when not accounted for by patient history.

Pregnancy elements present

Endocervical-type cells present in vaginal smear

Epithelial cells abnormalities:

Atypical squamous cells present

Atypical squamous cells, cannot exclude a high-grade intraepithelial lesion

Low-grade squamous intraepithelial lesion (mild dysplasia)

High-grade squamous intraepithelial lesion (moderate dysplasia)

High-grade squamous intraepithelial lesion (severe dysplasia)

Squamous cell carcinoma (statement of grade and type may be made)

Atypical endocervical cells present

Atypical endometrial cells present

Atypical glandular cells present

Atypical endocervical cells present, favor neoplastic

Atypical glandular cells present, favor neoplastic

Endocervical adenocarcinoma-in-situ

Suspicious for malignancy

Squamous cell carcinoma

Adenocarcinoma (if possible site of origin suggested)

Adenosquamous carcinoma

Small cell undifferentiated or neuroendocrine carcinoma

Malignant mixed mullerian tumor     

Sarcoma

Metastatic carcinoma

Other malignancies (identify type if possible)

Other diagnoses (free text)

Comments for interpretations:

Paucity of atypical cells prevents definitive diagnosis

Predominance of cocci/bacilli consistent with shift in vaginal flora

III.       Suggestions for follow-up