College of American Pathologists
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  Guidelines for reporting nongyn cytology specimens


CAP Today




January 2010
PAP/NGC Programs Review

Rosemary Tambouret, MD

In the November 2009 issue of the Archives of Pathology & Laboratory Medicine is a comprehensive article from the CAP Cytopathology Committee, approved by the CAP Council on Scientific Affairs, that details guidelines for the standardized reporting of nongynecologic cytology specimens (Crothers BA, et al. 2009;133:1743–1756). The guidelines comply with established regulations and standards of CLIA ’88, JCAHO, and the CAP Laboratory Accreditation Program for reporting of pathology specimens. The guidelines are meant to promote safety and to improve communication between pathologists and clinicians, in a fashion similar to the Bethesda system for reporting cervical cytology and to surgical pathology templates for the reporting of tumors. Some of the required elements of the report include the header, demographic data, specimen type, collection method, specimen preparation, and immediate evaluation results. Procedural guidance, stains used, and documentation of time-out are among the optional elements. Two options for reporting the interpretation are offered. The first includes a general category (negative/benign, atypical/suspicious, positive for malignancy) followed by a descriptive diagnosis. The second option consists of a concise diagnosis using WHO or SNOMED terminology. The article provides clear illustrations of the guidelines in the form of tables with the corresponding referenced Laboratory Accreditation Program checklist questions that apply to each component. An in-depth discussion of the guidelines enhances understanding and provides insights into the issues, subtleties, and nuances of each section. Illustrations of well-constructed reports using the guidelines are provided, along with examples of incomplete reports. The article does not promote rigid adherence to one format; rather, it presents a model that laboratories should find useful in implementing standardized reporting in their own settings.

Dr. Tambouret, American Society of Cytopathology liaison to the CAP Cytopathology Committee, is assistant pathologist and director of the cytopathology fellowship program, Massachusetts General Hospital, Boston.