BETHESDA SYSTEM 2001-TBS
SPECIMEN TYPE检验方法:
Indicate conventional smear(Pap smear)vs.1iquid based vs other
应指出:1.传统抹片(巴氏涂片);2.液基细胞学;3.其他
SPECIMEN ADEQUACY标本质量:
a)Satisfactory for evaluation(describe presence or absence of endocervical/
transformation zone component and any other quality indicators,e.g.,partially
obscuring blood,inflammation,etc.)
标本评估满意(描述宫颈内膜有或缺如),可判读。同时列出影响标本品质之各种因素,如:子宫颈内膜细胞及过渡区细胞之存在与否,以及其它可能干扰视野之因素,如:血或炎细胞等等。判断标准遵照TBS1
b)Unsatisfactory for evaluation...(specify reason)标本评估不满意,无法判读--注明原因,如:
·Specimen rejected/not processed(specify reason)标本不能接受/没处理--注明原因(如玻璃片破碎,或抹片和申请单的名字、号码不符等)
·Specimen processed and examined,but unsatisfactory for evaluation O{epithelial abnormality because of(specify reason)标本处理和检验,但标本评估不满意--注明原因――标准和TBS1类似,但小幅度修改。
GENERAL CATEGORIZATION(optional)概括性的诊断或结论。这部分可有可无,由医师自行决定:
a)Negative for Intraepithelial Lesion Or Malignancy(上皮内病变或恶性改变阴性)
b)Epithelial Cell Abnormality: See Interpretation/Result
(specify ’squamous’or’glandular’as appropriate)上皮细胞不正常,请看解释或结果.如有必要可在此注明鳞状或腺上皮细胞
C)Other:See Interpretation/Result(e.g.endometrial cells in a woman=/>40 years of age)其他:请看最后结果--例如在40岁或40岁以上妇女发现子宫内膜细胞等.
AUTOMATED REVIEW自动阅片.
If case examined by automated device, specify device and result 如果标本经自动仪器检测,请注明使用的仪器名称和结果
ANCILLARY TESTNG补助性检验:
Provide a brief(1escriptiuoil of the test methods and report the result so that it is easily understood by the clinician请简要说明方法和结果,让临床医师能了解其意义。
INTERPRETATlON/RESULT判读/结果
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 nonneoplastic findings)正常,无上皮内病变或恶性肿瘤:
●ORGANISMS微生物:
a) Trichomonas vaginalis **滴虫
b)Fungal organisms morphologically consistent with candida spp类似Candida(白色念珠菌属)的霉菌
c)Shift in flora suggestive of bacterial vaginosis细菌生态变化,可能患有细菌性**病症
d)Bacteria morphologically consistent With Actinomyces spp.类似Actinomyces(放线菌属)的细菌
e)Cellular changes consistent with Herpes simplex virus;类似疱疹病毒所致的细胞病变
●OTHER NON-NEOPLASTIC FINDINGS(Optional to report; list not inclusive)其他非肿瘤性的状况,叙述与否,由医师自行决定:
a)Reactive cellular changes associated with反应性细胞变化,可能和下列状况有关:
·Inflammation includes typical repair发炎包括典型修复
·Radiation放射治疗
·Intrauterine contraceptive device(1UD)子宫内避孕器
b)Glandular cells status post hysterectomy子宫切除后,发现腺细胞
c)Atrophy**萎缩
●OTHER其他
Endometrial cells(in a woman =/>40 years of age),specify if’Negative for squamous intraepithelial lesion’在40岁或40岁以上妇女发现子宫内膜细胞,并无上皮内病变
EPITHELIAL CELL ABNORMALITIES上皮细胞异常
●SQUAMOUS CELL鳞状细胞
a)Atypical squamous cells 不典型鳞状细胞
·Of undetermined significance(ASC-US)意义不明的不典型鳞状细胞
·Cannot exclude HSIL(ASC-H)不能排除高度上皮内病变的不典型鳞状细胞
b)Low grade squamous intraepithelial lesion (LSIL),encompassing:HPV/mild dysplasia/CIN l 低度上皮内病变—LSIL,包括HPV的细胞变化、轻度异型增生和CIN 1
c)High grade squamous intraepithelial lesion(HSIL),encompassing:moderate and severe
dysplasia,CIS/CIN 2 and CIN 3高度上皮内病变-HSIL,涵盖中及高度异型增生、原位癌、CIN 2和CIN 3
·With features suspicious for invasion(if invasion is suspected)疑侵袭癌的高度鳞状上皮内病变
d)Squamous cell carcinoma鳞状细胞癌
●GLANDUIAR CELL.腺细胞
a)Atypical不典型腺细胞
·Endocervical cells(NOS Or specify in comments)不典型子宫颈内膜细胞,未明示NOS
·Endometrial cells(NOS Or specify in comments)不典型子宫内膜细胞,未明示NOS
·Glandular cells(NOS Or specify in comments)不典型腺细胞,未明示NOS
b)Atypical疑肿瘤的不典型腺细胞
·Endocervical cells,favor neoplastic疑肿瘤的不典型子宫颈内膜细胞
·Glandular cells,favor neoplastic疑肿瘤的不典型腺细胞
C)Endocervical adenocarcinoma in situ子宫颈内膜原位腺癌
d)Adenocarcinoma腺癌
·Endocervical子宫颈内膜腺癌
·Endometrial子宫内膜腺癌
·Extrauterine子宫外腺癌,亦即由外部直接侵袭或转移的腺癌
·Not otherwise specified未明示的腺癌
OTHER MALIGNANT NEOPLASMS(Specify)其他恶性肿瘤
EDUCATIONAL NOTES AND SUGGESTIONS(Optional)解释和建议
Suggestions should be concise and consistent with clinical follow-up guidelines published by professional organizations(reference to relevant publications may be included)建议必须简要,且附和最新临床医学会刊登的追踪方法和原则