Download The Cytologic Sample Papanicolaou (PAP Test)

Anatomic Pathology and Cytology
The Cytologic Sample
Cytologic Studies: Papanicolaou smear (Pap test, GYN cytology), fluid cytology, fine needle biopsy. Cytologic
samples are cellular suspensions, which are spread, smeared or centrifuged on to glass microscope slides. These are
immediately fixed with 95 % ethanol or air-dried and subsequently stained for morphologic evaluation. The optimal sample
is a preparation consisting of a monolayer of viable cells with immediate (rapid) fixation. Specimens, which are routinely
processed for cytology include: cervical and vaginal scrapes of the gynecologic tract (Pap smears); fine needle biopsies of
all body sites; cerebrospinal fluids; pleural effusions; peritoneal effusions; peritoneal washes; urines; and scrapings or
brushing from either skin, respiratory or gastrointestinal sites.
Papanicolaou (PAP Test)
Purpose
The purpose of obtaining a Pap test (a scraping of cells from the uterine cervix) is to detect cervical cancer and its
precursors. Inflammation, reparative changes and other abnormalities of the reproductive tract may also be detected during
the examination of the specimen.
Patient Preparation
Obtaining the specimen for Pap smear is usually done during routine or diagnostic pelvic examinations. Obtaining Pap tests
during menstruation is not recommended. Vaginal medications, douches, or vaginal contraceptives are discouraged for 48 hours
prior to the appointment.
Completing the Cytology Order
Electronic ordering or a cytology requisitions when electronic ordering is not available must be completed to comply with all
government regulations.
1. Patient Name (Last, First, Middle initial, if available)
2. Medical Record Number
3. Patient location
4. Social Security Number (other identifier for outpatients)
5. Patient Date of Birth
6. Ordering Physician Name
7. Any additional physicians to who report should be sent
8. Advanced Beneficiary Notice (must be signed and submitted in certain cases for Medicare – see Section Two on
Compliance and use of the ABN for complete instructions)
9. Date and Time of Collection
10. Clinical information
a. The date the specimen is obtained.
b. Specimen source (either cervical or vaginal)
c. The last menstrual period MUST be included.
d. The patient history items should be addressed.
i. Prenatal.
ii. Postpartum.
iii. Postmenopausal.
iv. Previous biopsy specimen.
v. Previous abnormal cytology.
vi. Presence of abnormal bleeding.
vii. Presence of radiation therapy.
viii. IUD use.
Obtaining the Specimen
All materials used to obtain the Papanicolaou test should be ready prior to the collection of the sample. The Pap Test should
be collected before an HPV specimen.
Rev 12/7/2016
Anatomic Pathology and Cytology
HPV Testing and Collection
The primary cause of cervical cancer is infection with a high-risk virus called the human papillomavirus (HPV). High-risk
HPV infection is very common. In fact, an estimated 8 out of 10 women get HPV at some point in their lives. HPV
usually goes away on its own before causing any symptoms or problems. Most women don’t know they have the virus.
Only an HPV infection with a high-risk type of HPV that doesn’t go away can cause cell changes leading to cervical
cancer.
Collecting an HPV Specimen.
Insert Cervical Sampler brush 1-1.5 centimeters into the cervical os until the largest outer bristles of the brush
touch the ectocervix. Rotate three (3) full turns in a counterclockwise direction. Do not insert brush completely into
cervical canal. Remove brush from the canal. Avoid touching the bristles to the outside of the tube or to any other object.
Insert brush to bottom of transport tube. Then, snap off sampler shaft at score line, leaving brush-end inside tube. Re-cap
tube securely by snapping it in place.
IUHPL has simplified the ordering process for clinicians. HPV testing is now automatically ordered by the lab based on
ACOG guidelines.
Patients in the 21-29 year old age group will automatically have HPV testing ordered as a reflex to an ASC-US diagnosis.
Patients in the 30-65 year old age group will have HPV co-testing with the SurePath Pap test.
Patients in the 30-65 year old age group who test Negative with cytology Pap test and Positive HR HPV will automatically
reflex to High Risk HPV Genotyping. This follows ACOG Guidelines for preventive care and is the only circumstance in
which auto-reflex will be performed. The Genotype will detail HPV type 16, HPV type 18 and 12 other High Risk HPV
Genotypes into a pooled result.
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Anatomic Pathology and Cytology
Non-Gynecologic Cytology
Non-gynecologic cytology is the morphologic evaluation of fine needle biopsies, body cavity fluids, washings, scrapings,
brushings, and urine specimens. The primary goal of non-gynecologic cytology examination is to detect malignancy. The
non-gynecologic order should be completed electronically with all required fields addressed. Absence of information will
limit the ability of the cytologist to fully evaluate the specimen.
Respiratory tracts brushing and washings
These specimens are usually acquired via fiber optic bronchoscopy. The brush must be removed through the scope with
retraction into the protective sheath. The brush should be submitted in a cytology fixative, leaving at least one inch of cable
above the brush. Brushing specimens should be obtained prior to cutting (forceps) biopsies and followed by saline wash.
These should be submitted fresh to the laboratory as soon as possible.
Effusions
These specimens are the result of fluid accumulation in the potential spaces of the pleura, peritoneum, or pericardium.
Immediately deliver the specimen to the Cytology lab to avoid degeneration. If this is not possible, an effusion specimen
may be safely refrigerated. Ensure that an electronic order is placed including pertinent patient history. Cytology testing
that is added onto a specimen already in the lab should be called to client services for assistance. 317-491-6000.
Peritoneal washings
These samples are usually used for staging of abdominal neoplastic disease, especially of gynecologic origin. After washing
with a balanced salt solution or saline, the specimen should be submitted to the laboratory in Shandon’s fixative. A
specimen submitted without fixative yields poor cytology.
Brushing and Washing Specimens
These specimens are obtained by washing cells from surfaces or abrading surfaces with small brushes. Classically, this
involves the gastrointestinal and respiratory tracts and peritoneal cavity. In general, washings are generally attained after
brushing. All samples should be transported rapidly to the laboratory. Brushes should be immediately submerged in
cytology fixative provided. The brush should be agitated briskly in the fluid and clipped off into the container. (Please
leave two inches of cable in the brush.) All specimens must be labeled as to the specific site, especially if several areas are
sampled.
Urine
The patient should be well hydrated prior to the collection of the specimen, if possible. Patient ambulation is favorable for
increasing the natural exfoliation of cells into the urine. Once 20 to 50 milliliters of urine is collected, it must be placed on
ice and brought to the laboratory as soon as possible. First morning urines are NOT suitable for cytologic diagnosis. If
catheterization is unavoidable, it must be clearly noted on the requisition. Urinalysis and microbiological evaluation of the
urine are not performed in cytology and a separate specimen should be sent to chemistry or microbiology for these studies.
Sputum Cytology
Early morning deep cough specimens are the most cellular and most representative of the respiratory regions. The oral
cavity should be rinsed thoroughly prior to collection of the specimen. A preservative agent should be added immediately, if
a fresh specimen cannot be sent in. An adequate sputum evaluation for cancer consists of three consecutive early morning
samples.
Breast Secretions
Nipple discharge or breast secretions can be obtained to evaluate the presence or absence of malignant diseases of the
breast. Patient preparation: The nipple should be cleansed with an alcohol sponge. The breast should be stripped and the
initial breast secretions discarded. [Lactiferous sinuses (near the nipple)] often hold secretions for a long period of time and
contain degenerated cells. Initial expressions from the nipple should always be discarded prior to making smears.] After the
initial secretions are discarded, allow a drop to accumulate. Support the areola and nipple with one hand, and with the other
hand place a slide upon the nipple, pause to allow material to spread laterally, and then draw the slide quickly across the
nipple. Immediately fix the slide using spray fixative. If no fixative is available, the specimen may be sent to the lab after it
is allow to air-dry, in an appropriate slide container.
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Anatomic Pathology and Cytology
Surface Scraping Cytology (Skin or Mucosal Scrapings)
Cytologic samples of these slides are taken to rule out the possibility of malignancy or infection when biopsy of the area is
not desirable.
Preparations: Glass slides with frosted ends, labeled with the patient’s name and date of birth. Other supplies include: 95
% ethanol fixative in a Coplin jar, wooden spatula, or endocervical brush, and glove with gauze.
Sampling: A moistened gauze square of single thickness over gloved finger or endocervical brush or a moistened wooden
spatula should be used for sampling. (Moistening the spatula is essential to avoid air-drying.) Endocervical brushes may be
most useful for mucosal lesions. Keratotic lesions should be abraded to remove much of the surface keratin. Stop abrading
if small bleeding points appear. Using fresh gauze, brush or spatula to sample, smear the specimen on the slide or send in a
vial of cytology preservative or formalin.
Minor Body Cavity Fluids
The minor body cavity fluids include cerebrospinal fluids, eye chamber fluids, joint-space fluids, peritoneal cul-de-sac
fluids and cyst fluids. These fluids are usually less cellular and of smaller volumes and rarely present a problem with
clotting. Because of their low cellularity and relative difficulty in repeat sampling, proper specimen handling is essential.
These specimens should all be collected using sterile technique.
Fine Needle Biopsy (FNA)
The fine needle aspiration biopsy is a rapid, inexpensive, simple cytologic technique that can be done on an outpatient
basis. Both palpable subcutaneous masses and deep-seated lesions of the head, chest or abdomen can be sampled
radiologically. Most FNA require the assistance of radiology. A pathologist is available to perform FNA of palpable
masses. Please call 317-491-6000 to schedule an appointment.
The technique employs the following equipment:
1. several 10 ml disposable plastic syringes,
2. 4 - 6 23 or 25 gauge needles
3. alcohol swabs
4. 8 - 12 clean glass microscope slides.
5. Local anesthesia (1 % solution of Xylocaine, Lidocaine or other anesthesia) is used for skin infiltration.
Physiologic saline solutions or a small vial of fixative may be used for needle rinses.
Obtaining a palpable fine needle aspirate:
1. A time out and verification of site to be biopsied is completed by performing personnel.
2. The skin is cleansed using an alcohol swab.
3. A small amount of local anesthetic is infiltrated into the skin and subcutaneous tissue.
There are two accepted methods for obtaining fine needle cytologic specimens: the “aspirate” technique and the “noaspirate” technique.
To perform an aspiration
1. 25-gauge needle attached to a syringe, is inserted into a lesion.
2. Negative pressure is applied and the needle moved back and forth within the lesion, with a slight redirection of
the needle during each motion.
3. Needle pressure is released prior to removing the needle from the skin.
4. The needle is withdrawn.
5. The syringe and needle are handed to the cytotechnologist who expresses the cells and smears them between two
slides
6. A single slide is air-dried and the other is immediately spray fixed.
7. Needles may be rinsed in a cytology fixative for cell block preparation
8. This is repeated four to six times until the lesion is well-sampled.
Rev 12/7/2016