Cytopathology

Medical Director: Nicole Massoll, M.D.
Laboratory Supervisor: Leslie Cloar, CT (ASCP)

The Cytology Laboratory is located on the fifth floor of the Cancer Institute, room CI-5108. The laboratory is open for receiving specimens Monday through Friday between the hours of 8:00 a.m. and 4:30 p.m. (with the exception of legal state holidays). A cytopathologist is on call for STAT cases after hours and on weekends, and can be reached by contacting the Pathology resident on call 501-688-2009.

All specimens brought to the Cytology Laboratory should be accompanied by a Cytopathology Request form which has been properly completed. Cytology requisition forms are available on the UAMS Intranet site #2382 or #622. Current Federal Regulations (CLIA ’88) mandate the information required on each request form to include:

• Patient’s name
• Unit (history) number
• Birthdate
• Collection date
• Physician’s name
• Source of specimen
• Pertinent clinical history
• Location of the patient
• Specifically for Pap smears include:
  • Last menstrual period
  • Previous abnormal report
  • Previous treatment or biopsy

Every effort should be made to submit specimens during laboratory hours. In the event that this is not possible, then specimens should be placed in the specimen refrigerator located next to the Histology Laboratory on the ground floor of the hospital, Room B.007. Please contact the Cytology Laboratory, at 501-686-6540 for instructions on fixation of specimens submitted after hours.

Do Not Take The Specimen To The Clinical Laboratory In The Hospital.

Cell Collection and Display Modalities

The goal of all methods for the collection and display of cells is to display the cells under the optimum conditions for microscopic examination and to utilize as much of the collection area as possible to display a representative sample of the original specimen. Pap smears and non-gynecological smears prepared by the clinician should be collected on 3 x 1, plain glass slides, frosted at one end. The glass should appear colorless, transparent, and be free of pits, nicks, bubbles, scratches and cloudiness when viewed in front of a dark surface. The material should be distributed evenly over as much of the surface of the slide as possible, leaving the frosted end of the slide free for numbering. Slides should be labeled with patient identifiers at the time of collection, using a #2 pencil on the frosted end of the slide. Immediate fixation of the specimen in 95% ETOH or with a spray fixative is essential in order to prevent air-drying.

Vaginal and Cervical Cytology (PAP SMEAR)

1. The patient should not have douched or applied medication vaginally 24 hours before the examination.
2. Have in immediate proximity:
   1. A Thin Prep pap smear collection vial (PreservCyt solution)
   2. A plastic broom-like collection device or a plastic spatula and Cytobrush. Wooden spatulas and/or cotton-tipped applicators are not to be used for liquid-based pap smear collection. Note: This is the preferred collection method. More than 95% of pap smears performed here at UAMS are liquid-based, mono-layer preparations. Supplies are available in the Cytology laboratory.
3. Place the patient in the lithotomy position.
4. Insert the speculum without lubricants (just warm tap water). To use the plastic broom, the long central bristles are inserted into the os until the lateral bristles bend against the ectocervix and are rotated 3-5 times in clockwise and counter-clockwise directions.
5. After specimen collection, rotate the broom-like device or spatula and Cytobrush several times in the collection vial to remove the specimen, firmly cap the vial, and discard the collection devices. Affix a patient identification label to the vial.
6. Package the sealed vial in a plastic specimen bag, along with a properly filled-out cytology requisition form, and send or deliver it to C1-5108.
7. If liquid-based Pap smear supplies are not on hand, and a conventional pap smear is to be done, prepare a clean glass slide marked with the patient’s name. and assemble an Ayre spatula, a cervical brush or “broom,” and a non-aerosol (pump) spray fixative.
8. If performing a conventional pap, insert the spatula into the cervix, rotate it 360 degrees to perform a scraping, and make a smear lengthwise along one side of a glass slide labeled previously with the patient’s name.
9. Insert the cervical brush into the os with gentle pressure and rotate only 90 to 180 degrees to minimize bleeding. Quickly make an adjacent, lengthwise smear on the same slide. Immediately fix the smears by spraying with fixative, held 10-12 inches away from the slide.

Note: Any air-drying will hinder the cytologic interpretation.

Send to the lab (CI-5108) or tube to station #511 in a cardboard or plastic slide holder along with a properly filled-out cytology requisition form.

(“Broom”: Another collection instrument for Pap Smears is a plastic “broom-like brush which simultaneously samples the endocervix and ectocervix. To use the broom, the long central bristles are inserted into the os until the lateral bristles bend against the ectocervix and are rotated 3-5 times in clockwise and counter-clockwise directions.)

Collection and Fixation of Non-Gyn (extra-vaginal) Specimens

Smears

Send to lab in cardboard or plastic slide carriers, or in tightly sealed tubes of 95% ETOH. Attach completed Cytopathology Requisition Form with pertinent clinical history. Evenly smear specimen on clean glass slides labeled with patient’s name and record number.

Fix Any Prepared Smear Immediately In 95% Etoh Or Spray Fixative.

• Gyn (Pap Smears) Brushings (Bronchial, Gastric, Esophageal, Ureteral, etc.)
• Breast discharges

Body Fluids and Washings

Send to lab in an appropriately labeled and well-constructed container with a secure lid to prevent leakage during transport. If necessary, place container in plastic bag and attach requisition to outside of bag. Do not send collection needle. Submit complete Cytopathology Requisition Form with pertinent clinical history.

Do Not Take Specimens To The Clinical Laboratory.

• Body Fluids and Washings: Specimens should be submitted fresh, preferably during working hours. If obtained after hours, place in specimen refrigerator located in the Histology Laboratory on the ground floor of the hospital, Room B.007
• Urine: Bring immediately to lab. Requisition should indicate whether specimen is a catheterized or voided collection
• Sputum: Three separate, early morning fresh specimens obtained on three consecutive days, sent immediately to lab
• Bronchoalveolar Lavage (BAL): Bring the specimen directly to the Cytopathology Laboratory after completing the procedure. It will be processed and evaluated on a STAT basis only during regular laboratory hours
• CSF: ONLY on weekends, holidays, and in emergency cases, take CSF specimens to the Clinical Lab, marked “Attention Hematology.” They will prepare slides for Cytology.

Preparation of Cerebrospinal Fluid for Cytology

Weekends And After Hours Only

1. Specimen should be submitted fresh to the lab as soon as possible. Record amount and appearance on requisition. Centrifuge the entire available specimen in a 50 ml conical, capped tube for 10 minutes at 2200 rpm. Pour off supernatant down to approx. .5 ml. Add four drops of albumin to concentrated specimen and mix. Assemble four cytospin funnels in cytocentrifuge. Divide specimen/albumin mixture in the four funnels and cytospin for two minutes at 800 rpms. Quickly disassemble the slides and allow two slides to air-dry and spray-fix the other two.
2. Notify the Cytology Lab to pick up the prepared slides.

Procedure for Fine Needle Aspirations

The cytology service offers fine needle aspiration of palpable masses. A cytopathologist will see the patient, perform the aspiration, and provide a rapid interpretation of the findings. Any need for additional studies, or delay in the final diagnosis will be discussed when the rapid interpretation is provided.

If aspirated material is needed for special investigations (flow cytometry, cytogenetics, etc.), this should be ordered at time of the initial request.

All fixatives, as well as provisions for special stains or embedding techniques will be provided by the attending cytopathologist.

Fine needle aspirations can be scheduled by calling the cytology laboratory at Ext. 501-686-6540, or the FNA clinic (for ambulatory patients) at 501-686-8064.

Aspiration of deep masses requiring radiographic guidance should be scheduled with the radiology department. A cytopathologist attends these procedures.

The following considerations apply to clinicians wishing to perform their own aspirations:

• Laboratory personnel can provide teaching in the basic methods of specimen preparation.
• The type of material most appropriate for evaluating a given clinical problem varies with the nature of the lesion, and the preferences of the cytopathologist on service at the time. Among others, the options include air-dried smears, fixed smears, needle-rinse material, and embedded samples fixed in alcohol, glutaraldehyde or formalin. Discussing the case with a cytopathologist prior to the procedure will optimize your preparation and the diagnostic results.
• Observations made at the time of the procedure should be noted on the request form. For example, one often sees abundant colloid when smears from a benign thyroid mass are prepared, but this diagnostically critical material frequently “washes away” when the slide is stained.

Submitting Suspected or Known Infectious Diseases

When a specimen is taken from a patient with suspected or known infectious disease, the specimen must be submitted properly bagged and labeled with a Blood and Body Fluids Precautions sticker. For specimens not submitted as outlined, the physician will be contacted to do so and an incident report will be filed.

All cases are reported utilizing a combination of message codes and free text as necessary. The report stored in each patient’s lab computer record includes the following:

• Name and other demographics
• Cytology number
• Type of specimen
• No. of slides made
• Clinical information as provided
• Cytotechnologist
• Diagnosis
• Comment
• Attending pathologist
• Reviewing pathologist
• Ordering physician
• Date specimen obtained
• Date specimen reported

The categories in bold type are reported to the patient’s medical chart as the Cytotechnology Report. The original is retained in the Cytology Laboratory files.

Unacceptable Specimen Criteria

Unlabeled specimens cannot be accepted. The submitting physician or nursing station will be notified and will be expected to submit a fresh, correctly labeled specimen; if not possible, the submitting physician or nursing station may personally identify and label the existing specimen and sign a witnessed voucher.

Mislabeled or misidentified (patient specimen and Cytology Accession Form have different names) specimens cannot be accepted. The submitting physician or nursing station will be notified and asked to submit a fresh correctly labeled specimen; if not possible, the submitting physician or nursing station personnel may identify and re-label the existing specimen and sign a witnessed requisition.

Unidentified specimens (cases in which the specimen is labeled with the patient’s name, but contains no identification of specimen type or source). These specimens cannot be accepted until the physician or nursing station is notified. The specimen will then be documented as received unidentified.

Specimens submitted in the improper container cannot be accepted. The submitting physician or nursing station will be notified and will be expected to retrieve the specimen and submit it correctly.

Specimens not accompanied by a Cytology Accession Form as appropriate cannot be accepted.

Incorrect Accession Form (tissue specimens received with an accession form from another patient service, e.g. Microbiology) cannot be accepted.

Soiled Accession Forms (soiled or wet with fixative, blood or any other fluid) are not accepted. The physician or nursing station will be notified, requested to prepare a clean Accession Form and sign an Incident Form.

Other conditions for non-acceptance include:

• insufficient quantity of specimen,
• containers received “empty,”
• improper storage and no clinical history

These specimens will not be accepted until the submitting physicians or nursing station is notified.