LifeBridge Health - Department of Pathology Anatomic Pathology

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CYTOPATHOLOGY:GENERAL

Cytopathology service at for LifeBridge Health is provided at a consolidated core laboratory located at Sinai Hospital od Baltimore.

Request Forms: All specimens must be accompanied by a properly prepared and completed Cytopathology Consultation Request Form.

Inpatient: Patient information label, specimen source, clinical information, physician name and signature and date of procedure.

Outpatient/Outside Patient: Patient information must include name, address, date of birth, social security number, physician name and signature, specimen source, pertinent clinical information and insurance/billing information.

Specimen Fixative Bottles: Bottles containing 50% alcohol solution available 24 hours a day in cabinet above the under counter sink in Cytology specimen processing area.

Specimens Requiring Special Handling:Fine Needle Aspirations (FNA) - call x25104 to schedule (Monday - Friday 0730 to 1630.)

Cytology Rejection Policy: Specimens with the any of the following problems will not be processed unless the problem can be resolved.

1. Slide/specimen without accompanying requisition form
2. Slide/container/requisition form lacking appropriate patient identifiers
3. Slide/container/requisition with discrepant information
4. Slide broken beyond repair
5. Fresh specimens deemed too old for reliable results or non-refrigerated
6. Specimens received in PreservCyt Solution with expired expiration date.
7. No signature of requesting physician

Transportation: Specimen delivery is provided daily by hospital personnel and courier

Results: Final reports are accessible by Cerner Powerchart. Copies of final reports are distributed to all listed physicians and specimen location. NOTE: Gynecologic specimens (i.e. cervical, endocervical, vaginal) are reported using descriptive terminology that employs the Modified Bethesda System for gynecologic samples.

CYTOPATHOLOGY: GYNECOLOGIC SPECIMENS

Patient Preparation: Certain factors (e.g. menstruation, creams, lubricants, douches) can affect the quality and accuracy of the Pap smear. A woman can improve the quality of her smear if she is instructed to:

1. Avoid douches, vaginal medications or vaginal contraceptives for 24 hours before the examination.
2. Avoid sexual intercourse for 24 hours before the examination.
3. Visit her gynecologist 1-2 weeks after the end of menses.
4. Record the date of her last menstrual period.
5. Inform the gynecologist about any prior abnormal Pap smears, surgery, treatment for vaginal infections, current medications, symptoms, etc.

Cytology Requisition: Complete records are important to ensure accurate data from previous testing and enable the laboratory to obtain prior Pap smears and histologic slides for comparison of an abnormality. In order to comply with the Department of Health and Human Services (DHHS) regulations (CLIA '88) published on February 28, 1992, laboratories require the following patient information.

1. Patient name, sex, age, date of birth, complete financial numbers if applicable.
2. Site sampled (combined vaginal pool, endocervix, ectocervix, vaginal wall, vulvar)
3. Referring physician name and signature
4. Date of collection
5. Last menstrual period (LMP)
6. Pertinent clinical information: previous abnormal report, method of birth control, hormonal therapy, gynecologic surgery, radiation exposure, risk factors for developing cancer etc.

Gynecologic Slide Preparation: Write the patient's name in pencil on the frosted end of each slide and on the specimen container. A one-slide smear as described below is preferred. If more than one slide is prepared, each slide must be identified as to source and area sampled.

CYTOPATHOLOGY GYNECOLOGICAL SAMPLING AND COLLECTION

THINPREP™  PAP TEST SPECIMEN COLLECTION:

Purpose:  The ThinPrep™ 2000 System is intended as a replacement for the conventional method of Pap smear preparation for use in screening for the presence of atypical cells, cervical cancer, or it's precursor lesions (LGSIL, HGSIL) as well as other cytologic categories as defined by the Bethesda System for Reporting Cervical Cytology.

Specimens: Vaginal, cervical and endocervical sampling.

Supplies:  This test requires ThinPrep™ Pap test supplies, Cytopathology requisition and a permanent marker.

Collection Procedure: 

Verify PreservCyt vial expiration date and label vial with app patient identifiers, specimen source and date of collection. Obtain specimen prior to bimanual examination. Use an unlubricated speculum (saline or warm water may be used). After visualization of the cervix is accomplished, collect the sample.  Obtain an adequate sampling from the cervix using a broom-type (e.g. Wallach) collection device or endocervical brush/plastic spatula combination (following NCCLS guidelines GP-15A).

BROOM Collection: Insert the central bristles of the broom into the endocervical canal deep enough to allow the shorter bristles to fully contact the ectocervix. Push gently, and rotate the broom in a clockwise direction five times.  Rinse the broom-type collection device into the PreservCyt™ Solution vial by pushing it into the bottom of the vial 10 times, forcing the bristles apart.  As a final step, swirl the collection device vigorously to further release material.  Discard the collection device.

BRUSH/SPATULA Collection: Obtain an adequate sampling from the ectocervix using a plastic spatula.  Rinse the spatula into the PreservCyt™ Solution vial by swirling the spatula vigorously in the vial 10 times. Discard the spatula. Insert the brush into the cervix until only the bottom most fibers are exposed.  Slowly rotate or turn one-half turn in one direction.  DO NOT OVER-ROTATE.  Rinse the brush in the PreservCyt™ Solution by rotating the devise in the solution while pushing against the vial wall. Swirl. Tighten the cap so that the torque line on the cap passes the torque line on the vial.  Complete the Cytopathology Requisition including the Physicians signature (required by Maryland State Law).

Place the vial in the inner pouch of a double biohazard bag and place the Cytopathology requisition in the outer pouch to avoid possible contamination of the paper work.

Conventional Gynecologic Sampling and Collection:

1. Transformation Zone: The transformation zone MUST be sampled. The transformation zone is the area of the squamocolumnar junction of the cervix and is the primary sampling target. This zone is the site where the majority of epithelial abnormalities arise. Variations exist in the location of the transformation zone. In young women, this area is easily sampled. As a cervix matures, this zone may move further up the endocervical canal making sampling more difficult. Using a combined technique (spatula and cervical brush) should result in satisfactory specimens. Cervical brushes should be used with caution in pregnant patients.
2. Smear Uniformity: Uniform smears are required for accurate evaluation and will:

• A.  Ensure even and uniform fixation
• B.  Assist in uniform staining in the laboratory
• C.  Make the screening process easier and less tiring for the cytotechnologist as cells are not hidden in the thick areas of the smear
• D.  Render more of the sample available for assessment

Specimen Fixation: When using the spray fixative, immediate application is ESSENTIAL.

1. Write the patient's name on the frosted end of the slide with pencil before beginning. After the slide is wet, the pencil will not write as easily.
2. Hold the slide with the thumb over the frosted end of the slide.
3. Hold the spray container at 6- 1 0 inches from the slide to avoid blasting the material on the slide.
4. Begin the spray at the thumb end in the event that the first gush of spray from the container is air.
5. Cover the specimen completely with fixative. The slide must be glistening wet.
6. Allow 10 minutes drying time before placing the slide in the folder for transport to the laboratory. This is especially important if a barcode label is to be applied to the folder. A wet folder will render the barcode unreadable.
7. Check to ensure that the name on the slide, slide container and requisition form match.

Sampling Technique, Women of Child Bearing Age:

1. With a spatula (finger end) obtain endocervical/ectocervical material.
2. Place the material on the slide near the label end. DO NOT SMEAR.
3. With a cervical brush, obtain a sample from the endocervical canal by rotating the brush a full turn (360 degrees).
4. Combine the spatula and brush material and smear uniformly by rolling the brush across the slide.
5. Fix immediately: Immediate fixation is essential for proper and accurate microscopic evaluation. See Specimen Fixation described above for correct technique.

Sampling Technique, Post Menopausal Women: In addition to routine cervical sampling, a vaginal pool sample has advantages for menopausal women. The vaginal pool may contain cells shed from an endometrial carcinoma (more prevalent in older women) and may also reveal an abnormal hormonal status.

1. With a spatula (round end) obtain vaginal pool material.
2. Place the material on the slide near the label. DO NOT SMEAR.
3. With a cervical brush, obtain a sample from the endocervical canal by rotating the brush a full turn (360 degree).
4. Combine the material from the spatula and brush and smear uniformly by rolling the brush across the slide.
5. Fix immediately: Immediate fixation is essential for proper and accurate microscopic evaluation. See Specimen Fixation described above for correct technique.

CYTOPATHOLOGY: NON-GYNECOLOGIC SPECIMENS

General Instructions:

1. Non-gynecologic specimens are not to be sent to the lab using the pneumatic tube system. These specimens must be manually delivered to the lab.
2. Specimens must be placed in double pouch biohazard bag being careful to separate the Cytopathology requisition from the patient sample.
3. Cytopathology will make every attempt to process specimens. However, if delays in delivery have occurred which may render the specimen unreliable, it will be discarded and/or a disclaimer as to its validity will be made in the final cytology report.
4. The submitting physician will be notified of unsatisfactory specimens and a repeat specimen will be requested.
5. During hours when the laboratory is closed, questions concerning specimen processing may be addressed by contacting the on call Pathologist through the page operator of the hospital.

Urinary: Patients should be well hydrated before collecting urine. Any instrumentation must be noted on the requisition form. Delay in delivery to the laboratory should be avoided. If necessary, refrigerate the specimen until the time of transportation to the laboratory. Collect the urine with equal volumes of cytology fixative containing 50% ethyl alcohol. For routine urine collection, emphasize the need for a clean catch specimen. Random mid-day collection is preferred. Discard first morning specimen.

Sputum: Sputum must be deeply coughed from the lungs. Avoid oral contamination and saliva. The best collection time is early in the morning upon rising. The specimen should be received in the laboratory as soon after collection as possible. Refrigerate the specimen until the time of transport. Deep cough specimens are the most reliable sputum sample.

Body Cavity and Joint Fluids: In general, these specimens are submitted fresh to the laboratory. If clotting presents a problem, fluids and effusions may be collected in a bottle containing 3 units of Heparin/ml of anticipated fluid. Refrigerate all specimens until the time of transportation. Otherwise, collect the fluid with an equal volume of 50% ethyl alcohol cytology fixative.

Cerebrospinal Fluid (CSF): Place the fluid in a clean vial. Prompt delivery (preferably within 30 minutes) to the laboratory is essential since CSF cells deteriorate rapidly. Refrigerate until time of transportation.

Gastric, Esophageal, Duodenal, Colonic Brushes: After collecting the specimen, swish the brush in 50% ethyl alcohol cytology fixative. Leave the brush in the solution for transportation to the Cytology laboratory.

Submission of-Prepared Slides: Specimen examples include: oral, nipple discharges, imprints, scrapings

1. Write the patient's name on the frosted end of the slide with pencil before beginning. After the slide is wet, the pencil will not write as easily.
2. Hold the slide with the thumb over the frosted end of the slide.
3. Hold the spray container at 6- 1 0 inches from the slide to avoid blasting the material on the slide.
4. Begin the spray at the thumb end in the event that the first gush of spray from the container is air.
5. Cover the specimen completely with fixative. The slide must be glistening wet.
6. Allow 10 minutes drying time before placing the slide in the folder for transport to the laboratory. This is especially important if a barcode label is to be applied to the folder. A wet folder will render the barcode unreadable.
7. Check to ensure that the name on the slide, slide holder and requisition form match.

WARNING: Any air drying will result in poor cytologic detail and potentially cause unsatisfactory results.

Fine Needle Aspirations (FNA): Cytotechnologists are available on during normal hours of operation to assess the adequacy of the FNA sample. It is desirable to schedule these procedures in advance with Cytology to insure the availability of the technologist. Contact the Cytology Laboratory at 601-5104 (SHB) or 521-5910 for scheduling and to obtain immediate assistance.

Unassisted Fine Needle Aspirations (FNA): If the fine needle aspiration (FNA) is performed without the assistance of the cytotechnologist, please note the following procedure:

1. Write the patient's name on each slide (4-6 as needed) using a lead pencil.
2. Have a container of CytoLyt™ Fixative open and ready.
3. Place a drop of the material at 1/8 inch below the frosted end of the slide.
4. Hold a hemacytometer coverglass or second slide between the thumb and forefinger.
5. Place the coverglass at the bottom of the drop allowing the drop to flow to the edges.
6. Using a quick motion, push the coverglass toward the frosted end and then toward the opposite end of the slide.
7. If the drop is adequate, the smear will be thin and should reach the end of the slide.
8. If the drop is too large, the hemacytometer coverglass should not be used. Use the two slide pulled together technique.
9. Make two slides from each pass

   One slide: air-dried and placed in a plastic slide holder.

   One slide spray-fixed or placed immediately in 95% alcohol solution.

10. Rinse the needle and syringe with 50% ethyl alcohol cytology fixative and submit with the prepared slides to Cytology.
11. Submit to the Cytopathology Department.

Respiratory Tract Specimens:

1. Bronchial brushings: After collecting the specimen with the brush, swish the brush in 50% ethyl
2. Alcohol cytology fixative. Leave the brush in the solution for transportation to the Cytology laboratory.
3. Bronchial washings: Collect the bronchial washings into jars containing 50% ethyl alcohol cytology fixative for transportation to the Cytology laboratory.
4. Transbronchial needle aspiration (TBNA): Collect the aspirated material and express into Cytolyt™ Solution for transportation to Cytology.
5. Bronchoalveolar lavage (BAL): After collecting the specimen, express the material into jars containing 50% ethyl alcohol cytology fixative for transportation to the Cytology laboratory.
6. Post-bronchoscopy sputum: See Sputum description above.