V Nongynecological Cytology Reporting

Nongynecological Cytology Practice Guidlines

prepared by the American Society of Cytopathology, Cytopathology Practice Committee.

Adopted by the ASC Executive Board, March 2, 2004

 

V Nongynecological Cytology Reporting

The nongynecological cytology report must include the patient’s name and/or unique identifier, patient’s age and/or date of birth, the name of the ordering physician (where appropriate) and the laboratory’s accession number. If the collection date is provided, it should be noted on the report. Information regarding the date and time of receipt of the sample and release of the report must be readily accessible if it is not printed on the report itself.56 The final report must include useful data that are legible and accurate, and must be released only to persons authorized by law to receive and use the information.57

The nongynecological cytology report should include the type of specimen and quantity submitted, as well as a gross description of the specimen received (fixed or air-dried for smears, color and turbidity for fluids). The source/site and method of collection should be noted as well as the preparation method (automated liquid-based, cytocentrifugation, membrane filtration, or cell block.)

V.A. Reporting Specimen Adequacy and Cytological Findings

The laboratory must indicate on the patient report any information regarding the condition of a sample if it fails to meet the criteria for acceptance,58 such as inappropriate specimen submitted for the test requested, inadequate patient identification, lack of proper fixation, etc.

It is important to consider the adequacy of each sample and to note in the report if a specimen is suboptimal. “Insufficient for diagnosis”, “Non-diagnostic specimen”, or “Unsatisfactory”, are comments that can mean less than adequate samples. Commenting on the material that is submitted and its limitations is important to assist the clinician in patient follow-up. Factors limiting the interpretation of the specimen, such as degeneration or obscuring elements should be noted.

If the sample is diagnostic, the report should be as specific as possible using histopathological terms. If a specific interpretation cannot be rendered then the report should include a differential diagnosis as appropriate.

Laboratories must decide if any nongynecological cytology results qualify as critical values (i.e. immediate impact on patient care) for their respective institutions.59 If a laboratory has established critical values for nongynecological cytology then procedures must be in place for notification of the clinician who submitted the cytology specimen and this notification should be documented in a laboratory record. Any other results that are communicated to the clinician should also be documented.6

Incorporating into the report any patient history and clinical information provided on the requisition may aid the clinician in correlating cytological with clinical findings.60 The laboratory should attempt to correlate cytological findings with histological material, if available.

V.B. Storage and Retrieval of Laboratory Records

See Section X.

V.C. Referral Laboratories

The laboratory director is responsible for selecting referral laboratories. All referral laboratories must be CLIA ’88 certified for high complexity testing. It is the responsibility of the laboratory director to monitor the quality of testing received from all referral laboratories. The name and address of the laboratory performing the test must be available to the requestor if it does not appear on the report. The referring laboratory must report all test results from the referral lab without alterations that could affect clinical interpretation. The referring laboratory must retain a record of all reports from testing performed by a referral lab.61

V.D. Variability of Practice

Nongynecological cytology cases may be screened by a cytotechnologist prior to examination by a pathologist or cases may be sent directly to a pathologist after processing. Cell blocks can be prepared for processing in the cytology or histology departments, while the cytology staff usually prepares cytology slides. If two separate reports are issued on a case for cytological slides and a cell block, respectively, then the same pathologist should interpret the two samples or the reports at least should reference each other. Any diagnostic discrepancies between the two specimen preparation methods should be explained.

The descriptive nomenclature used to report nongynecological cytology results varies. Laboratories can assign categorical terminology for use within an individual laboratory. Information regarding the adequacy of the sample should be conveyed to the clinician in the report. Some laboratories call clinicians with the results of all malignant cases; however, this is not required. In some laboratories, certain diagnoses require an additional pathologist review prior to releasing the report. Laboratories may document this additional review in the report or keep internal documentation only. For multiple reviews and consultations, refer to Section VI.

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Bibliography/References

6     College of American Pathologists. Commission on Laboratory Accreditation Inspection Checklist 2002 edition, Northfield, Illinois.

56     Clinical Laboratory Improvement Amendments of 1988; Final Rule.  Federal Register.  Jan. 24, 2003; Vol. 68: 493.1291(c).

57     Clinical Laboratory Improvement Amendments of 1988; Final Rule.  Federal Register.  Jan. 24, 2003; Vol. 68: 493.1291(f).

58     Clinical Laboratory Improvement Amendments of 1988; Final Rule.  Federal Register.  Jan. 24, 2003; Vol. 68: 493.1283(a)(3).

59     Clinical Laboratory Improvement Amendments of 1988; Final Rule.  Federal Register.  Jan. 24, 2003; Vol. 68: 493.1291(g).

60     DeMay RM: The Art & Science of Cytopathology. Volume 2, Aspiration Cytology.  Chapter 21: Lung.  ASCP Press, Chicago, 1996.

61     Clinical Laboratory Improvement Amendments of 1988; Final Rule. Federal Register. Jan. 24, 2003; Vol. 68: 493.1291(i)(1)(2)(3)