CYTOLOGY SECTION

Cytology is the study of cells removed from the body by scraping, aspiration, irrigation or other methods.  After processing and staining, these cells are examined microscopically for cytologic changes associated with malignant or possible pre-malignant conditions.  In addition, numerous other conditions either affect cellular morphology or are otherwise detectable microscopically.  These include such conditions as nutritional inadequacies, some drugs and other therapies, various disease states and infections by viral, bacterial, fungal or parasitic agents.  Please note that if a biopsy specimen is collected and submitted together with a  Pap smear specimen, please submit both on the same requisition. 

REQUESTS FOR PATHOLOGY MATERIAL TO BE SENT TO CONSULTANTS

We receive periodic requests from physicians and patients to have pathology or cytology slides, blocks and reports sent to additional consultants.  Our procedure is to re-cut and process the material, type an enclosure letter and forward by commercial transport the material to the requested consultant.  RML charges a minimum fee for processing these requests and additional charges will be based on a pro-rata basis.  The patient can expect to receive an additional bill from the consultant, especially for second opinion requests from the patient.  Please be aware that these charges are over and above what RML has charged for the initial work.  Some third party payors may not cover these charges.  Should this be the case, the patient is responsible for reimbursing RML for these services.  Please allow ample time to locate material, process the request and forward to consultant.

Please direct your requests to the Pathology office, extension 6979.

TABLE OF CONTENTS

• Body Fluid (Pleural, Peritoneal, Pericardial, Synovial) Specimen Collection
• Breast Secretion Specimen Collection
• Brushing Specimens for Cytology (Bronchial, Gastric, Esophageal, Urinary Bladder, etc.)
• Buccal Smear Specimen Collection
• Cerebrospinal Fluid Specimen Collection
• Fine Needle Aspiration Specimen Collection
• Gastric Washing Specimen Collection
• Pap Smear Specimen Collection
  • Anal Pap Smear
  • AutoCyte Prep Pap Collection
  • Descriptive Diagnoses for Bethesda Reporting System
  • Instructions for Completion of Test Request
  • Results using the Bethesda Reporting System
• Skin Lesion Specimen Collection
• Sputum Specimen Collection
• Urine Specimen Collection
• Washings for Cytology (Bronchial, Esophageal, Bladder, etc.)

Please contact our Cytology Department if you have any questions concerning cytology.

BODY FLUID (PLEURAL, PERITONEAL, PERICARDIAL, SYNOVIAL) SPECIMEN COLLECTION

SPECIMEN REQUIRED:
As much fluid as available to a maximum of 1,000 ml.

The specimen should be collected in a sterile container.  If the fluid appears to contain blood, an anticoagulant should be added.

• Heparin  -  5 to 10 units/ml fluid
• EDTA  -  1 mg/ml fluid
• Sodium Citrate (3.8%)  -  1 ml/10 ml fluid

The specimen should be refrigerated and shipped cool.  If a delay of more than 24 hours is anticipated, mix specimen to suspend cellular elements, remove an aliqot and mix with equal parts of CytoLyt fixative. Please indicate on the Test Request and container that CytoLyt has been added.

Back to Table Of Contents

BREAST SECRETION SPECIMEN COLLECTION

SPECIMEN REQUIRED:
Two to six fixed slides per breast.

The following procedure may be used to collect specimens for cytology from spontaneous or induced breast secretions:

1. Label two clean frosted-end glass slides with the patient's last name.  If both breasts are involved, label four slides, writing "L" (for left) on two and "R" (for right) on the other two.
2. Gently clean any fluid from the nipple(s) with an alcohol-moistened gauze or towelette.
3. Gently strip the subareolar area and nipple using thumb and forefinger.  If secretion occurs, allow a drop about the size of a pea to accumulate on the apex of the nipple (see Figure 1-A).
4. Support the areola and nipple with one hand and with the other hand place a prepared slide on the nipple.  Allow the drop of secretion to spread slightly and then draw the slide rapidly across the nipple.
5. Immediately spray-fix the slide using cytology spray fixative.  Immediate fixation is critical.
6. Repeat Steps 3-5 for the second slide and for the other breast if necessary.
7. If the secretions from the nipple are sufficient, an additional 2-4 slides can be made.

SPECIMEN REQUIRED:
1-4 fixed slides per brush.

NOTE:  All brushing specimens for cytology must be obtained prior to biopsy of the site.

To prepare slides for cytology from a brushing, the following procedure should be followed:

1. Label 2-4 frosted-end glass slides with the patient's last name.
2. Withdraw the brush quickly from the instrument and roll or smear it gently over a small area (approximately dime-sized) of the glass slide.
3. Immediately spray-fix the slide or place it in 95% ethyl (or reagent) alcohol.  Speed is critical as air drying is the most common diagnostic problem with this type of specimen.
4. Quickly prepare 1-3 more slides in the same manner.

BUCCAL SMEAR SPECIMEN COLLECTION

SPECIMEN REQUIRED:
Four fixed slides.

To obtain a satisfactory specimen for Barr body examination, the following procedure should be observed:

1. The patient's mouth should be rinsed and/or the teeth brushed to remove all cellular debris and other foreign material rom the surface of the mucosa.
2. Label four frosted-end glass slides with the patient's last name.
3. Use the edge of a tongue depressor to energetically scrape the inner surface of the cheek along the buccal surface.
4. The material obtained is quickly spread in a thin smear on the prepared slides.
5. Immediately fix the specimen with spray fixative or place in 95% ethyl (or reagent) alcohol.  Immediate fixation is critical.

CEREBROSPINAL FLUID SPECIMEN COLLECTION

SPECIMEN REQUIRED:
A minimum of 1.0 ml spinal fluid in a sterile container.

The patient should be prepared and the spinal tap performed using standard procedures.  If the specimen is very bloody, the first few drops should be discarded or an anticoagulant should be added.  Collect as much fluid as clinical judgement allows.

THE SYRINGE SHOULD NOT BE USED AS A CONTAINER TO SUBMIT THE SPECIMEN.  If other tests are to be performed, submit the cytology specimen in a separate container.

Mix the specimen for cytology with an equal volume of CytoLyt preservative which is available upon request from the RML Purchasing Department.

FINE NEEDLE ASPIRATION SPECIMEN COLLECTION AND SMEAR PREPARATION

SPECIMEN REQUIRED:
Four to eight slides (plus CytoLyt rinse and/or cyst fluid in CytoLyt preservative if necessary. 

Transthoracic and transabdominal aspirations are often complex procedures requiring imaging equipment and occasional surgical intervention.  These aspirations should be performed according to the operating procedures of the facility where the specimen is being collected.

Aspirations of palpable masses, on the other hand, are relatively simple procedures requiring some practice but require little in the way of equipment and time and can be performed in the office or clinic.  The following procedure will generally produce good results:

1. Examine the patient with review of the clinical history.
2. Determine the gross characteristics of the mass to be aspirated including location relative to other structures, estimated depth, consistency and any evidence of pulsation or bruit.
3. Explain the procedure to the patient, including possible complications and obtaining informed consent.
4. Assemble the syringe, needle (22-26 gauge, depending on preference and site) and the syringe pistol (if one is to be used).  Prepare the frosted-end slides with patient's name and if a fixative is to be used, place it where it is easily accessible.
5. Clean the skin over the puncture site with an alcohol skin preparation pad.
6. Lay the needle point on the skin over the puncture site and determine the angle of approach to the mass.
7. Grasp the mass firmly with the free hand and insert the needle with one swift motion (see Figure 2).
8. Determine that the mass has been penetrated either by noting the resistance encountered on puncture or by moving the syringe slightly from side-to-side while feeling that the mass moves beneath the fingers of the palpating hand (see Figure 3-A).
9. Apply full vacuum pressure to the syringe (see Figure 3-B).
10. If the mass is a fluid-filled cyst, evacuate the cyst and place the fluid in a sterile container with CytoLyt preservative.  If there is any residual mass, continue with the aspiration using a new syringe and needle.  THE SYRINGE ITSELF MUST NOT BE USED AS THE SPECIMEN CONTAINER.
11. If blood is aspirated into the syringe, stop the procedure immediately and choose another aspiration site.  Use a new needle and syringe for the repeat aspiration.
12. If pus is encountered, withdraw as much of the material as possible and perform a repeat aspiration in an adjacent area using a new needle and syringe.  The pus may be sent for culture in proper collection tubes as appropriate.
13. For solid masses, move the needle back and forth within the mass at slightly different angles while full vacuum is maintained (see Figure 3-C).
14. Observe the junction of the needle and syringe for the appearance of any sample or continue to make back and forth passes within the mass about a dozen times.
15. Conclude the aspiration at the first appearance of any sample within the syringe or after about a dozen passes by releasing the vacuum pressure in the syringe.
16. Withdraw the needle from the mass and place pressure on the puncture site with a gauze pad.  NO VACUUM PRESSURE SHOULD EVER BE APPLIED TO THE SYRINGE DURING WITHDRAWAL OF THE NEEDLE (see Figure 3-D).

SMEAR PREPARATION:
The following procedure should be used to prepare slides for cytology from fine needle aspirations:

1. After the needle is removed from the mass, detach it from the syringe, fill the syringe with air and
   re-attach the needle.   
2. Place the bevel of the needle against a pre-labeled, frosted-end glass slide with no intervening air space between the slide and needle.  Express a small drop of aspirated material onto the center of the slide.  This needle position helps to prevent splattering and drying artifacts in alcohol-fixed smears.  If too much material is expressed onto the slide, withdraw the syringe plunger slightly and re-aspirate a portion of the material.
3. If the cellular material is semi-solid in nature, place another slide on top of the drop and allow the specimen to spread between the slides (see Figure 4-A).  When the material has spread as much as possible, pull the slides quickly and smoothly apart (see Figure 4-B).
4. Aspirated material diluted by fluid or blood is smeared using the technique used for differential blood smears.  Back the edge of a slide or cover glass into the drop (see Figures 5-A and 5-B).  As the material spreads along the edge, push the slide forward pulling the cellular material away from the fluid or blood (see Figure 5-C).  Be careful not to exert too much pressure when preparing these smears to avoid cell distortion or crush artifact.
5. Immediately wet-fix the smears in 95% ethyl (or reagent) alcohol or spray-fix with cytology fixative.
   
   If a lymph node or thyroid is aspirated, spray-fix or alcohol-fix half of the slides prepared and allow the other half to air dry.  Indicate on the slides which are air dried.
   
6. In cases of scant material (less than two drops), immediately re-aspirate the mass with a new needle and syringe.  If this second attempt also yields scant material, prepare as many slides as possible and then rinse the needles with CytoLyt preservative and submit the rinse along with the slides.  DO NOT SUBMIT THE SYRINGE AND NEEDLE.
7. If any cyst fluid is collected, the fluid should be placed in CytoLyt preservative and forwarded to the laboratory for processing.
8. If no slides are available or the aspirator is uncomfortable making the smear preparation, the entire sample may be placed in CytoLyt preservative by rinsing the needle and syringe and forwarding the sample to the laboratory.
9. The needle and syringe used for aspiration should be disposed of properly and never submitted to the laboratory.

GASTRIC WASHING SPECIMEN COLLECTION

SPECIMEN REQUIRED:
Four fixed slides.

Gastric washings may be collected either during endoscopy or using a lavage tube.  However the specimen is to be collected, the stomach should be cleansed prior to the washing.  Routine stomach contents are useless for cytologic examination.

The washings that are obtained must be processed immediately since a half-hour delay results in total cellular digestion by stomach secretions even with refrigeration and/or alcohol fixation.  Immediately after the specimen is obtained, it should be placed on ice and taken to the laboratory or other preparation area.

Centrifuge the specimen at 600G for ten minutes.  Carefully decant the supernatant.  The sediment remaining should be thinly smeared on four pre-labeled, frosted-end glass slides and spray-fixed immediately or placed in 95% ethyl (or reagent) alcohol.

PAP SMEAR SPECIMEN COLLECTION

CONVENTIONAL PAP SMEAR
SPECIMEN REQUIRED:
One fixed slide.

GENERAL CONSIDERATIONS:
The most important factors in obtaining a good diagnostic Pap smear are:

1. Adequate sampling of the area of interest.
2. Rapid fixation of the collected material.
3. Avoid contamination of the sample with extraneous material.  Steps which should be taken to avoid contamination include
   1. Washing the glove powder from gloves prior to examination.
   2. Using no lubricant other than saline on the speculum.
   3. Removing mucus and other contaminants from the cervix prior to sampling.
   4. In addition, instruct the patient not to
      1. Have sexual intercourse for 24 hours prior to examination.
      2. Douche or use lubricant prior to examination.
      3. Have examination during menses.

The Pap smear specimen should include material from the vaginal wall and/or the vaginal pool.  If they are present, the specimen should also include material from the cervix and endocervical canal.

TECHNIQUE:
Position the patient (usually in the dorsolithotomy position) and insert an appropriately sized bivalve speculum into the vagina so that the cervix can be adequately visualized and sampled (see Figure 6)

The Pap smear should be obtained prior to any digital examination, treatment or biopsy.

Any excessive blood, mucus or other discharges should be removed from the cervix prior to obtaining the specimen.  This can be done by blotting gently with a folded gauze pad held with forceps or with a dry cotton swab.  Do not rub the surface or rinse the cervix with saline.

There are numerous methods available for the collection of Pap smear specimens.  Although some individuals obtain excellent results using only the Ayre type spatula, a recent study involving a large number of sample takers concluded that a smear obtained with an Ayre type spatula and a cytobrush produced the best overall results.  In addition, in another study conducted here at RML, the endocervical Brush produced excellent results in almost all cases.

THE AYRE TYPE SPATULA:
The following procedure is used with the wooden spatula. 

Insertion

1. When the cervices have normal curve or anterior position, press down on the smooth part of the spatula toe during introduction into the endocervical canal (see Figure 7-A).
2. When cervices are in any posterior position, press up on the smooth part of the spatula toe during introduction into the endocervical canal (see Figure 7-B).

ROTATION
Without pressure, quickly rotate the spatula for one complete rotation to scrape the entire circumference of the squamo-columnar junction (regardless of its location) and the ectocervix.  A light scraping technique eliminates the possibility of blood in the specimen (see Figure 7-C).

REMOVAL

1. Press down on the smooth part of the spatula toe during removal from a normal or anterior positioned cervix (see Figure 7-A).
2. Press up on the smooth part of the spatula toe during removal from any posterior positioned cervix (see Figure 7-B).

Use the short toe of the spatula for scraping the vaginal wall and for an enlarged (pregnant) cervix.  Spread the cells on the slide (see "Slide Preparation").

THE CYTOBRUSH IS USED AS FOLLOWS:

1. Gently insert the cytobrush into the endocervix until only the bristles closest to the handle are visible.
2. Slowly rotate 1/2 to one full turn (see Figure 8).
3. Remove the brush and prepare slide (see "Slide Preparation").

THE ENDOCERVICAL BRUSH (CERVICAL CELL SAMPLER) IS USED AS FOLLOWS:

1. Using gently pressure, insert the central, long brushes of the Endocervical Brush into the cervical os until the lateral bristles are bent fully against the ectocervix (see Figure 9-A).
2. Maintain gentle forward pressure on the shaft of the Endocervical Brush and rotate it 3-5 times clockwise only. (see Figure 9-B).
3. Remove the Endocervical Brush and prepare slide (see "Slide Preparation").

SLIDE PREPARATION - SPATULA:
To express endocervical cells on glass slides, hold the spatula head at a 45 degree angle, press the serrated edges of the long toe against the glass slide and move from right to left to remove the attached cells from the serrated edges to the glass slide. Then flatten the spatula to the slide for additional material.  This material is smeared onto the "E" section of the VCE slide (see Figure 10-A).

To express ectocervical cells on glass slides, hold the spatula head at a 45 degree angle, press the serrated edges of the flange part of the spatula onto the glass slide and move from left to right to remove the attached cells from the serrated edge.  Then flatten the spatula onto the slide for additional material.  This material is smeared onto the "C" section of the VCE slide (see Figure 10-B).

If necessary, material from the endocervical and ectocervical region may be combined in the "C" and "E" sections of the VCE slide.

Material obtained from the vaginal wall should be smeared onto the "V" section of the VCE slide.

SLIDE PREPARATION - CYTOBRUSH:
Prepare the slide by rolling and twisting with moderate pressure across the slide to produce a thin, even smear.  The material obtained by the cytobrush is smeared onto the "E" section of the VCE slide.  If there is excessive material or if the section is too small for the specimen, the material may be combined with that in the "C" portion of the slide (see Figure 10-C).  To avoid excessive air drying of the material, it is recommended that the specimens not be smeared until all the samples are collected.  The various samples are then smeared and immediately spray-fixed.

SLIDE PREPARATION - ENDOCERVICAL BRUSH TM:
Transfer the sample from each side of the Endocervical Brush to the "CE" portion of the VCE slide with a single paint stroke action (see Figure 9-C).

Examine the slide after the first stroke.  If the material on the slide appears thick, do not smear the second side of the brush on the slide.

If the second side of the Endocervical Brush is to be smeared, turn the Endocervical Brush over and paint the slide again in exactly the same area.

When the slides are smeared, spray-fix immediately.

FIXATION:
As soon as the specimens are smeared, immediately spray-fix the slide by holding the slide in a horizontal position and with the spray fixative approximately 12 inches from the slide, cover the entire slide with fixative until wet (see Figure 10-D).  Allow the slide to dry completely before placing it in the folder.

OTHER:
In older women, some method of detecting endometrial lesions should be included in the gynecologic examination, such as a posterior vaginal pool specimen, cervical canal aspiration or some other technique.  The short toe of the Ayre type spatula can be used to obtain a specimen from the vaginal pool.  Specimens from the vaginal pool are smeared in the "V" section of the VCE slide.  Cervical canal aspirations are smeared in the "E" section of the VCE slide.

When a hormonal evaluation is desired, the lateral vaginal wall should be scraped with either the short toe of the Ayre type spatula or with a tongue depressor.  The material obtained should be placed in the "V" section of the VCE slide (see Figure 10-E).

SUREPATH PREP PAP COLLECTION:

1. Cervical sample collection.  Insert the Rovers Cervex-Brush into the endocervical canal.  Apply gentle pressure until the bristles form against the cervix.  Maintaining gentle pressure, hold the stem between the thumb and forefinger and rotate the brush five times in a clockwise direction only.
2. Preserve the entire sample.  Placing your thumb against the back of the brush pad, simply disconnect the entire brush from the stem into the CytoLyt preservative vial.
3. Securely Cap and label vial with test requisition numbered label.  Place the cap on the vial and tighten.  Label the vial and lab requisition form with patient's name and/or number, physician name and date.
4. Place the labeled vial and requisition into a specimen bag and send to the laboratory.

NOTE:  For more comprehensive collection instructions, contact the RML Marketing Department for a video presentation.

ANAL PAP SMEAR

SPECIMEN REQUIRED:
Smeared and alcohol-fixed sample on a glass slide.  Smeared,  properly fixed and labeled slide sent in crush-proof container to the laboratory for evaluation.

GENERAL CONSIDERATIONS:
The anal Pap smear is a relatively new application of a well established technique.  The principle involves collection of cells from the transition zone of the anal squamous epithelium to the rectal glandular epithelium and screening the sample for abnormal cells.  The sampling is recommended for patients at high risk for Human Papilloma Virus (HPV) infection and squamous cell carcinoma of the anal canal, particularly HIV-positive homosexual and bisexual men who have an increased risk for anal HPV infection and anal squamous cell carcinoma.  The abnormal cells are reported in a similar fashion as cervical Pap smears.  The categories include negative, atypical squamous cells of undetermined significance (ASCUS), low grade anal squamous intraepithelial lesion (LG ASIL), high grade anal squamous intraepithelial lesion (HG ASIL) and carcinoma.  The technique is a screening technique and if a visible lesion is identified, biopsy is recommended.  The follow-up of patients within the diagnostic categories stated is not well established.  The sensitivity and specificity have not been proven in large clinical trials and will be subject to both false-negative and -positive results.  Please see additional information in the discussion of cervical Pap smears in this portion of the RML Laboratory Manual.

TECHNIQUE:
The sample is obtained by introducing a cotton swab or other similar collection device into the anal canal and sampling the area of the transition zone.  The resulting sample is then smeared onto a glass slide labeled with the patient's name and fixed in alcohol (liquid or spray) immediately after smearing.  The properly labeled slide is transported to the laboratory and screened for abnormal cells.  Routine turnaround time for result is 5-7 days.  Performed by Papanicolau stain of alcohol-fixed smears.

PAP SMEAR RESULTS USING THE BETHESDA REPORTING SYSTEM

The Pap smear result will consist of two sections:

1. Results.
2. Patient information.

1. RESULTS
   The results section of the report (see facsimile on page 14) may consist of up to six parts:  1) General Category, 2) Specimen Adequacy, 3) Descriptive Diagnosis, 4) Comments, 5) Hormonal Evaluation, 6) Recommendations.
   1. General Category - This part of the report is used to sort results and consists of one of the following phrases:
      1. "NONE" - Used if the slide is unsatisfactory for diagnosis.
      2. "WITHIN NORMAL LIMITS" - There is nothing unusual about the slide.
      3. "OTHER" - Indicates physician action required.  See diagnosis.
   2. Specimen Adequacy - This part of the report is an evaluation of the suitability of the slide for diagnosis.  There are three possible responses:
      1. "SATISFACTORY" - Indicates that the slide is suitable for evaluation without qualification.
      2. "UNSATISFACTORY" - Indicates that the slide is not acceptable for evaluation and repeated sampling may be necessary.  Reasons for the classification will be given in the "Comment" section of the report.
      3. "SEE COMMENT" - Indicates that the slide may be evaluated with some difficulty but the quality of the slide is not as good as it might be.  The reason for the difficulty will be given in the "Comment" section.
   3. Descriptive Diagnosis - This part of the report describes any significant findings on the slide.  An outline of those items that may be included in this part of the report is found on the enclosed outline.
   4. Comments - This part of the report consists of comments on the diagnostic statements in Part C and of additional components of the specimen whose presence may affect the diagnosis.
   5. Hormonal Evaluation - This part of the report is included only if requested and is a comparison of the hormonal pattern displayed on the slide and the age and history of the patient.  There are three possible responses:
      1. "HORMONAL PATTERN COMPONENT WITH AGE AND HISTORY GIVEN".
      2. "HORMONAL PATTERN INCOMPATIBLE WITH AGE AND HISTORY GIVEN" — Reasons will be given.
      3. "HORMONAL EVALUATION NOT POSSIBLE" - Reasons will be given.
   6. Recommendations - This part of the report consists of recommendations for follow-up, if any.
2. PATIENT INFORMATION
   The patient information section of the report consists of the patient data provided to the laboratory with the Test Request..

If you have any questions concerning the Bethesda Reporting System for Pap smears, please contact the Cytology Department at RML.

DESCRIPTIVE DIAGNOSES FOR BETHESDA REPORTING SYSTEMINFECTION

1. 1. Fungal
      1. Fungal organisms morphologically consistent with candida species.
      2. Other:  Specify.
   2. Bacterial
      1. Cellular changes suggestive of bacterial vaginosis.
      2. Micro-organisms morphologically consistent with actinomyces species.
      3. Cellular changes suggestive of chlamydia species infection.
      4. Other:  Specify.
   3. Protozoan
      1. Trichomonas.
      2. Other:  Specify.
   4. Viral
      1. Cellular changes associated with cytomegalovirus.
      2. Cellular changes associated with herpes virus simplex.
      3. Other:  Specify.
         
2. REACTIVE AND REPARATIVE CHANGES
   1. Inflammation
      1. Associated cellular changes.
      2. Follicular cervicitis.
   2. Miscellaneous changes (as related to patient history)
      1. Effects of therapy.
      2. Ionizing radiation.
      3. Chemotherapy.
      4. Other: Specify.
         
3. EPITHELIAL CELL ABNORMALITIES
   1. Squamous cell
      1. Atypical squamous cells of undetermined significance.
      2. Squamous intraepithelial lesion (with presence of HPV changes noted if present).
         1. Low grade
            1. Changes associated with human papilloma virus.
            2. Mild dysplasia (CIN I).
         2. High grade
            1. Moderate dysplasia (CIN II).
            2. Severe dysplasia/carcinoma in situ (CIN III).
            3. Squamous cell carcinoma
   2. Glandular cell
      1. Presence of endometrial cells in one of the following circumstances:
         1. Out of phase in a menstruating woman.
         2. In a postmenopausal woman.
         3. No menstrual history available.
      2. Atypical glandular cells of undetermined significance
         1. Endometrial.
         2. Endocervical.
         3. Not otherwise specified.
      3. Adenocarcinoma
         1. Endocervical.
         2. Endometrial.
         3. Not otherwise specified.
   3. Other:  Specify
      
4. NON-EPITHELIAL MALIGNANT NEOPLASM:  SPECIFY
5. OTHER CELLULAR CHANGES OF NOTE

PAP SMEAR - INSTRUCTIONS FOR COMPLETION OF TEST REQUEST

PATIENT INFORMATION FOR PAP SMEARS (MUST ACCOMPANY SMEAR)
CHECK THE APPROPRIATE BOXES AND ENTER INFORMATION AS REQUIRED

ITEMS MUST BE FILLED OUT IN ORDER FOR A PAP SMEAR TO BE PERFORMED.

1. Complete the top portion of the Test Request form, giving full patient name, date collected, date of birth, Social Security number, patient address and complete billing information. 
2. Include patient diagnosis.
3. Check test selection box "
4. Give LMP and check appropriate information boxes.
5. Give any cancer risk factors.

Please include any additional patient history which may be of use in providing a more accurate diagnosis and assisting in the quality assurance program.  If necessary, use the back of the sheet.  (Example:   Previous atypical Pap smears or gynecological biopsies and types of gynecologic surgeries.

SKIN LESION SPECIMEN COLLECTION

SPECIMEN REQUIRED:
One or more fixed slides.

The surface of the skin is physiologically dry; therefore, most superficial lesions should be moistened with a dripping wet compress for 15-20 minutes before scraping.  This not only makes it softer for easier scraping but also removes most of the loose, degenerated cellular debris and serum crust that otherwise would clutter the smear.

After removal of the crust, the small ulceration produced should be energetically scraped with a sharp curette.  With a versicle or bulla, the dome should be removed and the margins of the ulceration scraped.

To sample an oozing lesion, the lesion should be either scraped and smeared on a slide or it may be gently abraded with a cotton swab soaked in albumin which is then smeared onto one or more slides.

However the material is collected, it is spread onto one or more slides and spray-fixed immediately.

SPUTUM SPECIMEN COLLECTION

SPECIMEN REQUIRED:
A minimum of 2 ml of sputum in a screw-top container with an equal volume of CytoLyt preservative.

The ideal sputum specimen consists of a deep early morning cough uncontaminated by food or excessive saliva.  The following steps will help the patient produce a good specimen:

1. Upon awakening, have the patient first brush their teeth, rinse their mouth and gargle.
2. Have the patient inhale as deeply as possible several times and cough vigorously.  A deep cough specimen from the lungs themselves is required.  Saliva is useless for diagnostic purposes.
3. Collect the specimen in a screw-top container containing CytoLyt preservative.  Screw the cap on tightly and shake the container vigorously.  Outpatients do not have CytoLyt preservative containers and should refrigerate specimen at home and deliver to the laboratory ASAP.
4. The specimen(s) and Test Request should then be submitted to RML as soon as possible.  The fixative will keep the specimen preserved satisfactorily for about one week.

If the patient is unable to produce an adequate specimen, 5-10 minutes of inhalation therapy prior to coughing may be helpful.  Sputum specimens collected the day following procedures such as bronchial washing or brushing are often particularly rich in diagnostic cellular material.

It is recommended that for best results, three consecutive morning specimens be collected and submitted daily.

Specimen collection kits are available from the RML Purchasing Department upon request.

URINE SPECIMEN COLLECTION

SPECIMEN REQUIRED:
50-100 ml.

MALE PATIENTS:  Voided urine - collect the last third of the first morning specimen or a catheterized urine specimen may be submitted.

FEMALE PATIENTS:  A catheterized urine specimen is preferred because of the contamination of voided specimens by vaginal secretions.  If a catheterized specimen cannot be obtained, the last third of the first morning voided urine should be submitted.

1. Mix the specimen with an equal volume of CytoLyt preservative.
2. Label the specimen "Urine in CytoLyt".
3. Refrigerate the specimen and ship as soon as possible.

SPECIMEN REQUIRED:
5-100 ml of wash fluid.

The hollow organs of the body and various wound and surgical sites may be rinsed and the washings submitted for cytologic analysis.  The procedure for the collection of cytology specimens is the same for all sites except for gastric washings.

1. Collect the aspirated rinse in a sterile container.
2. If the fluid is bloody, add one of the following
   • Heparin - 5-10 units/ml fluid
   • EDTA - 1 mg/ml fluid
   • Sodium Citrate 3.8% - 1 ml/10 ml fluid
3. Refrigerate the specimen and ship cool as soon as possible.
4. If a delay of more than six hours is anticipated before processing, add an equal volume of CytoLyt preservative.