Uterine cervix

Protocol applies to all carcinomas of the cervix.

Procedures

• Cytology

• Incisional Biopsy

• Excisional Biopsy

• Hysterectomy

• Pelvic Exenteration

 

This protocol is intended to assist pathologists in providing clinically useful and relevant information as a result of the examination of surgical specimens. Use of this protocol is intended to be entirely voluntary. If equally valid protocols or similar documents are applicable, the pathologist is, of course, free to follow those authorities. Indeed, the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual circumstances presented by a specific patient or specimen.

 

It should be understood that adherence to this protocol will not guarantee a successful result. Nevertheless, pathologists are urged to familiarize themselves with the document. Where a physician chooses to deviate from the protocol based on the circumstances of a particular patient or specimen, the physician is advised to make a contemporaneous written notation of the reason for the procedure followed.

 

The College recognizes that this document may be used by hospitals, attorneys, managed care organizations, insurance carriers, and other payers. However, the document was developed solely as a tool to assist pathologists in the diagnostic process by providing information that reflects the state of relevant medical knowledge at the time the protocol was first published. It was not developed for credentialing, litigation, or reimbursement purposes. The College cautions that any uses of the protocol for these purposes involve considerations that are beyond the scope of this document.

 

I. Cytologic material               back     Top     Main Page

      A.  Clinical information

            1.   Patient identification

                  a.   Name

                  b.   Identification number

                  c.   Age (birth date)

            2.   Responsible physician(s)

            3.   Date of procedure

            4.   Other clinical information

                  a.   Relevant history

                        (1)  previous cytologic and histologic diagnoses

                        (2)  hormones

                        (3)  pregnant/not pregnant

                        (4)  use of IUD

                        (5)  in utero DES exposure

                        (6)  previous treatment  (radiation therapy, chemotherapy, etc.)

                  b.   Relevant findings (e.g. pelvic examination, colposcopy)

                  c.   Procedure (e.g. vaginal pool aspiration, endocervical aspiration, fine needle aspiration)

                  d.   Type(s) or site(s) of specimen(s)

 

      B.   Macroscopic examination

            1.   Specimen

                  a.   Unfixed/fixed (specify fixative)

                  b.   Number of slides received (if appropriate)

                  c.   Other (e.g. cytologic preparation  from tissue)

                  d.   Results of intraprocedural consultation

            2.   Material submitted for microscopic evaluation (e.g. smear, touch preparation)

            3.   Special studies (specify)  (e.g. immunocytochemistry)

     

      C.  Microscopic evaluation (Note A)

            1.   Adequacy of specimen for evaluation
                  (if unsatisfactory, specify reason)

            2.   Tumor, if present

                  a.   Histologic type (if possible)

                  b.   Other features

            3.   Additional cytologic findings, if present

            4.   Results/status of special studies (specify)  (Note B)

            5.   Comments

                  a.   Correlation with intraprocedural consultation, as appropriate

                  b.   Correlation with other specimens, as appropriate

                  c.   Correlation with clinical information, as appropriate

II. Incisional or Excisional Biopsy                             back     Top     Main Page

 

      A.  Clinical information

            1.   Patient identification

                  a.   Name

                  b.   Identification number

                  c.   Age (birth date)

            2.   Responsible physician(s)

            3.   Date of procedure

            4.   Other clinical information

                  a.   Relevant history

                        (1)  previous cytologic and histologic diagnoses

                        (2)  hormones

                        (3)  pregnant/not pregnant

                        (4)  use of IUD

                        (5)  in utero DES exposure

                        (6)  previous treatment (radiation therapy, chemotherapy, etc.)

                  b.   Procedure (e.g. LEEP conization, cervical biopsy, endocervical curettage)

                  c.   Operative findings

                  d.   Documentation of orientation of specimen by surgeon, if appropriate (Note C)

                  e.   Type(s) or site(s) of specimen(s)

 

      B.   Macroscopic examination

            1.   Specimen (Note C)

                  a.   Unfixed/fixed (specify fixative)

                  b.   Number of pieces, size or size range

                  c.   Descriptive features

                  d.   Orientation (if designated by surgeon)

                  e.   Results of intraoperative consultation

            2.   Tumor

                  a.   Dimensions, if appropriate

                  b.   Descriptive features

                  c.   Additional pathologic findings, if present

                  d.   Tissue submitted for microscopic evaluation (Note D)

e.       Frozen section tissue fragment(s) (unless saved for special studies)                                            

f.        Special studies (specify) (Note B)

 

C.  Microsopic evaluation

            1.   Tumor

                  a.   Histologic type (Note E)

                  b.   Histologic grade (Note F)

                  c.   Extent of tumor (Note G)

                        (1)  Noninvasive (intraepithelial)

                              i.    Degree of severity (Note E)

                        (2)  Invasive (depth of invasion) (Note G)

                              i.    endocervical

                              ii.    ectocervical

                              iii.   deep

                  d.   Blood/lymphatic vessel invasion (Note H)

            2.   Resection margins (Note I)

            3.   Additional pathologic findings, if present (Note J)

            4.   Results/status of special studies (specify) (Note B)

            5.   Comments

                  a.   Correlations with intraoperative consultation, as appropriate

                  b.   Correlation with other specimens, as appropriate

                  c.   Correlation with clinical information, as appropriate

III. Hysterectomy               back     Top     Main Page

      A.  Clinical Information

            1.   Patient identification

                  a.   Name

                  b.   Identification number

                  c.   Age (birth date)

            2.   Responsible physician(s)

            3.   Date of procedure

            4.   Other clinical information

                  a.   Relevant history

                        (1)  previous cytologic and histologic diagnoses

                        (2)  hormones

                        (3)  pregnant/not pregnant

                        (4)  use of IUD

                        (5)  in utero DES exposure

                        (6) previous treatment (radiation therapy, chemotherapy, etc.)

                  b.   Relevant findings (e.g. on pelvic examination, on colposcopy)

                  c.   Clinical diagnosis

                  d.   Procedure (e.g. hysterectomy, radical hysterectomy with left salpingo-oophorectomy and bilateral lymphadenectomy)

                  e.   Operative findings

                  f.    Documentation of orientation of specimen by surgeon if appropriate (Note C)

                  g.   Type(s) or site(s) of specimen(s)

 

      B.   Macroscopic Examination

            1.   Specimen

                  a.   Organ(s)/tissue(s) included

                  b.   Unfixed/fixed (specify fixative)

                  c.   Number of pieces

                  d.   Dimensions

                  e.   Orientation (if designated by surgeon)

                  f.    Results of intraoperative consultation

            2.   Cervix

                  a.   Tumor, if present

                        (1)  location (e.g. left, endocervix and ectocervix)

                        (2)  dimensions

                        (3)  extent (to other tissues and organs)

                        (4)  distance from all pertinent margins

                        (5)  descriptive features

                  b.   Additional pathologic findings, if present

                  3.   Vagina

                        a.   Dimensions including length of vaginal cuff

                        b.   Descriptive features

                        c.   Tumor, if present

                              (1)  dimensions

                              (2)  descriptive features

                              (3)  relation to cervical tumor

                        d.   Additional pathologic findings, if present

                  4.   Uterine corpus

                        a.   Dimensions

                        b.   Descriptive features of endometrium, myometrium and serosa

                        c.   Tumor, if present

                              (1)  dimensions

                              (2)  descriptive features

                              (3)  relation to cervical tumor

                        d.   Additional pathologic findings, if present

                  5.   Parametria

                        a.   Amount (Note K)

                        b.   Tumor, if present

                              (1)  dimensions

                              (2)  descriptive features

                              (3)  relation to cervical tumor

                        c.   Additional pathologic findings, if present

                  6.   Regional lymph nodes

                        a.   Number at each location as specified by surgeon

                        b.   Number involved by tumor

                        c.   Dimensions of involved nodes

                        d.   Descriptive features

                  7.   Additional organs and tissues

                        a.   Tumor, if present

                              (1)  dimensions

                              (2)  descriptive features

                              (3)  relation to cervical tumor

                        b.   Additional pathologic findings, if present

                  8.   Tissue submitted for microscopic evaluation

                        a.   No macroscopic tumor, process cervix as a cone biopsy (Note D)

                        b.   Tumor

                              (1)  one section per centimeter of greatest tumor dimension

                              (2)  point of deepest invasion (full thickness through cervical wall if possible)

                              (3)  interface with adjacent cervix

                        c.   Grossly uninvolved cervix

                        d.   Margins of resection

                        e.   Vagina

                        f.    Anterior cervix (bladder reflection)

                        g.   Posterior cervix/vagina (rectovaginal septum)

                        h.   Uterine corpus

                        i.    Parametria (right and left) (Note K)

                        j.    Area(s) of special interest marked by surgeon

                        k.   Lymph nodes (at least one section from each hemisected node)

                        l.    Ovaries and fallopian tubes

                        m.  Other organs and tissues

                        n.   Frozen section tissue fragment(s) (unless saved for special studies)

                        o.   Special studies (specify) (Note B)

     

C.  Microscopic evaluation

            1.   Tumor

                  a.   Histologic type (Note E)

                  b.   Histologic grade (optional if squamous) (Note F)

                  c.   Extent of invasion (Note G)

                        (1)  depth and width of invasion in cervix

                        (2)  extension to vagina (specify extent and depth of invasion)

                        (3)  extension to corpus uteri (specify extent and depth of invasion)

                  d.   Blood/lymphatic vessel invasion (Note H)

                  e.   Status of resection margins(Note I)

                        (1)  vaginal

                        (2)  anterior and posterior cervical

                        (3)  parametrial

                  f.    Additional pathologic findings, if present

                  g.   Results/status of special studies (specify) (Note B)

            2.   Comments

                  a.   Correlation with intraoperative consultation, as appropriate

                  b.   Correlation with other specimens, as appropriate

                  c.   Correlation with clinical information, as appropriate

 

IV. Pelvic exenteration          back     Top     Main Page

      A.  Clinical Information

            1.   Patient identification

                  a.   Name

                  b.   Identification number

                  c.   Age (birth date)

            2.   Responsible physician(s)

            3.   Date of procedure

            4.   Other clinical information

                  a.   Relevant history

                        (1)  previous cytologic and histologic diagnoses

                        (2)  hormones

                        (3)  pregnant/not pregnant

                        (4)  use of IUD

                        (5)  in utero DES exposure

                        (6)  previous treatment (radiation therapy, chemotherapy, etc.)

                  b.   Relevant findings (e.g. on pelvic examination, on colposcopy)

                  c.   Clinical diagnosis

                  d.   Procedure (e.g. anterior pelvic exenteration, total pelvic exenteration)

                  e.   Operative findings

                  f.    Documentation of orientation of specimen by surgeon if appropriate (Note C)

                  g.   Type(s) or site(s) of specimen(s)

 

      B.   Macroscopic Examination

            1.   Specimen

                  a.   Organ(s)/tissue(s) included

                  b.   Unfixed/fixed (specify fixative)

                  c.   Number of pieces

                  d.   Dimensions

                  e.   Orientation (if designated by surgeon)

                  f.  Results of intraoperarive consultation

            2.   Cervix

                  a.   Tumor, if present

                        (1)  location (e.g. left, endocervix/ectocervix)

                        (2)  dimensions

                        (3)  extent (to other tissues and organs)

                        (4)  distance from all pertinent margins

                        (5)  descriptive features

                  b.   Additional pathologic findings, if present

            3.   Vagina

                  a.   Dimensions, including length of vaginal cuff

                  b.   Descriptive features

                  c.   Tumor, if present

                        (1)  dimensions

                        (2)  descriptive features

                        (3)  relation to primary tumor

                  d.   Additional pathologic findings, if present

            4.   Uterine corpus

                  a.   Dimensions

                  b.   Descriptive features of endometrium, myometrium and serosa

                  c.   Tumor, if present

                        (1)  dimensions

                        (2)  descriptive features

                        (3)  relation to cervical tumor

                  d.   Additional pathologic findings, if present

            5.   Parametria

                  a.   Amount  (Note K)

                  b.   Tumor, if present

                        (1)  dimensions

                        (2)  descriptive features

                        (3)  relation to cervical tumor

                  c.   Additional pathologic findings, if present

            6.   Ovaries

                  a.   Dimensions

                  b.   Descriptive features

                  c.   Tumor, if present

                        (1)  dimensions

                        (2)  descriptive features

                        (3)  relation to cervical tumor

                  d.   Additional pathologic findings, if present

            7.   Fallopian tubes

                  a.   Dimensions

                  b.   Descriptive features

                  c.   Tumor, if present

                        (1)  dimensions

                        (2)  descriptive features

                        (3)  relation to cervical tumor

                  d.   Additional pathologic findings, if present

            8.   Bladder (Note L)

                  a.   Dimensions

                  b.   Descriptive features

                  c.   Tumor, if present

                        (1)  dimensions

                        (2)  descriptive features

                        (3)  relation to cervical tumor

                  d.   Additional pathologic findings, if present

            9.   Ureter

                  a.   Dimensions

                  b.   Descriptive features

                  c.   Tumor, if present

                        (1)  dimensions

                        (2)  descriptive features

                        (3)  relation to cervical tumor

                  d.   Additional pathologic findings, if present

            10. Rectum (Note L)

                  a.   Dimensions

                  b.   Descriptive features

                  c.   Tumor, if present

                        (1)  dimensions

                        (2)  descriptive features

                        (3)  depth of invasion into rectal wall

                        (4)  relation to cervical tumor

                  d.   Additional pathologic findings, if present

            11. Additional organs and tissues, specify

                  a.   Dimensions

                  b.   Descriptive features

                  c.   Tumor, if present

                        (1)  dimensions

                        (2)  depth of invasion into rectal wall

                        (3)  relation to cervical tumor

                  d.   Additional pathologic findings, if present

            12. Regional lymph nodes

                  a.   Number at each location as specified by surgeon

                  b.   Number involved by tumor

                        (1)  dimensions of involved nodes

                        (2)  descriptive features

            13. Tissue submitted for microscopic  evaluation

                  a.   No macroscopic tumor, process cervix as a cone biopsy (Note D)

                  b.   Tumor

                        (1)  one section per centimeter of greatest tumor dimension

                        (2)  at point of deepest invasion (full thickness through cervical wall if possible)

                        (3)  at interface with adjacent cervix

                  c.   Grossly uninvolved cervix

                  d.   Margins of resection

                  e.   Vagina

                  f.    Anterior cervix (bladder reflection)

                  g.   Posterior cervix/vagina (rectovaginal septum)

                  h.   Parametria (right and left) (Note K)

                  i.    Urinary bladder at site(s) of possible invasion

                  j.    Rectum at site(s) of possible invasion

                  k.   Other tissues at site(s) of possible invasion

                  l.    Area(s) of special interest marked by surgeon

                  m.  Lymph nodes (at least one section from each hemisected node)

                  n.   Ovaries and fallopian tubes

                  o.   Other organs and tissues

                  p.   Frozen section tissue fragment(s) (unless saved for special studies)                                

      14. Special studies (specify) (Note B)

 

      C.  Microscopic evaluation (Note E)

            1.   Tumor

                  a.   Histologic type (Note E)

                  b.   Histologic grade (optional if squamous) (Note F)

                  c.   Extent of invasion  (Note G)

                        (1)  into the vagina (specify extent and depth of invasion)

                        (2)  into the corpus uteri (specify extent and depth of invasion)

                        (3)  into parametria

                        (4)  into the bladder (specify extent and depth of invasion)

                        (5)  into rectum (specify extent and depth of invasion)

                        (6)  other (ovaries, fallopian tubes, ureter(s), etc.)

            2.   Blood/lymphatic vessel invasion (Note H)

            3.   Status of resection margins (Note I)

                  a.   Vaginal

                  b.   Anterior and posterior cervical

                  c.   Parametrial

            4.   Regional lymph nodes

                  a.   Number at each site

                  b.   Number involved by tumor at each site

            5.   Additional pathologic findings, if present

                  a.   Intraepithelial

                  b.   Therapy-related

                  c.   Other

            6.   Distance metastasis (specify site(s))

            7.   Results/status of special studies (specify)

            8.   Comments

                  a.   Correlation with intraoperative consultation, as appropriate

                  b.   Correlation with other specimens, as appropriate

                  c.   Correlation with clinical information, as appropriate

 

Explanatory Notes

 

A.  Cytology Diagnosis         back     Top     Main Page 

The Bethesda System of cytologic classification(1) is recommended for consistency in reporting and is shown below.  Although other classification systems may be used, the Papanicalaou class designation system is not recommended. The Bethesda System has been adopted by several cytology and pathology organizations for the classification of cytologic specimens from the female genital tract. According to this system the terms “low-grade squamous intraepithelial lesion” and “high-grade squamous intraepithelial lesion” are used to encompass the spectrum of intraepithelial lesions otherwise classified as dysplasia-carcinoma in situ (CIN). Cellular changes characteristic of HPV, mild dysplasia, and a combination of both are classified as low- grade squamous intraepithelial lesions, and moderate (CIN 2) and severe dysplasia-carcinoma in situ (CIN 3) are classified as high-grade squamous intraepithelial lesions.

 

Cervical / Vaginal Cytologic Classification

(The Bethesda System)

SPECIMEN ADEQUACY

·         Satisfactory for evaluation (describe presence or absence of endocervical/transformation zone component and any other quality indicators, e.g., partially obscuring blood, inflammation, etc.)

·         Unsatisfactory for evaluation ... (specify reason)

·         Specimen rejected/not processed (specify reason)

·         Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of (specify reason)

GENERAL CATEGORIZATION (optional)

·         Negative for Intraepithelial Lesion or Malignancy

·         Epithelial Cell Abnormality: See Interpretation/Result (specify ‘squamous’ or ‘glandular’ as appropriate)

·         Other: See Interpretation/Result (e.g. endometrial cells in a woman ³ 40 years of age)

AUTOMATED REVIEW

If case examined by automated device, specify device and result.

ANCILLARY TESTING

Provide a brief description of the test methods and report the result so that it is easily understood by the clinician.

DESCRIPTIVE INTERPRETATIONS/DIAGNOSES

NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY (when there is no cellular evidence of neoplasia, state this in the General Categorization above and/or in the Interpretation/Result section of the report, whether or not there are organisms or other non-neoplastic findings)

ORGANISMS:

·         Trichomonas vaginalis

·         Fungal organisms morphologically consistent with Candida spp

·         Shift in flora suggestive of bacterial vaginosis

·         Bacteria morphologically consistent with Actinomyces spp.

·         Cellular changes consistent with Herpes simplex virus

OTHER NON NEOPLASTIC FINDINGS (Optional to report; list not inclusive):

·         Reactive cellular changes associated with

·         inflammation (includes typical repair)

·         radiation

·         intrauterine contraceptive device (IUD)

·         Glandular cells status post hysterectomy

·         Atrophy

OTHER

·         Endometrial cells (in a woman ³ 40 years of age)
(Specify if ‘negative for squamous intraepithelial lesion’)

EPITHELIAL CELL ABNORMALITIES

SQUAMOUS CELL

·