Home --> Diagnosis Wording --> Unterine Cervix (To activate copy function, allow Adobe Flash to run)
Cervix and Endocervix: Click sections headings below (in blue) to expand or collapse the content
Diagnostic Headings (i.e. specimen & procedure)
|
Diagnostic |
Headings |
|
|
|
|
Uterine cervix, biopsy: |
Uterine cervix, LEEP: |
|
|
|
Uterine cervix, at ___ O'clock, biopsy: |
Uterine cervix, conization: |
|
|
|
Endocervix, curettage: |
Specimen designated as "___", biopsy: |
|
|
|
Endocervix, biopsy: |
Uterus, total hystorectomy: |
|
Dx. Menu -- Wording of Common Abnormalities
|
This subsection lists key diagnostic line for the most common diseases in this organ / system. Copy the relevant line(s) by clicking on the button and paste to your report to construct your own report. |
Normal and Inflammatory:
-- No diagnostic abnormality.
-- Small fragments of endocervical mucosa with mild inflammation.
-- Diffuse prominent acute and chronic cervicitis.
-- Ectocervical mucosa with cervicitis and focal squamous atypia, favor reactive.
-- No cervical transformation zone or squamous component is present in this biopsy.
Polyps and Metaplasia:
-- Prominent microglandular hyperplasia with acute and chronic inflammation and immature squamous metaplasia.
-- Benign endocervical polyp.
Neoplastic:
-- Cervical transformation zone with focal low-grade squamous intraepithelial lesion (CIN-1).
-- Focal high-grade squamous intraepithelial lesion (HSIL) (moderate dysplasia / CIN-2).
-- Invasive squamous cell carcinoma arising in severe squamous dysplasia (see Tumor Synopsis).
=============
Clinical scenario: .
Uterine cervix, at 9:00, biopsy:
-- No diagnostic abnormality.
Slides examined: H&E x 3
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
=============
Clinical scenario: .
Endocervix, curettage:
-- Small fragments of endocervical mucosa with mild inflammation.
-- No dysplasia or significant atypia.
-- No squamous component is present.
Note: 02958203.
Slides examined: H&E x 1
CPT code: 88305 x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
=============
Clinical scenario: .
Uterine cervix, at 3 o'clock, biopsy:
-- Diffuse prominent acute and chronic cervicitis.
-- Focal squamous atypia, favor reactive.
-- No definite squamous dysplasia (see note)
Note: In the presence of acute and chronic inflammation, it is difficult to accurately assess the nature of the metaplastic squamous atypia. Although reactive atypia is favored, mild squamous dysplasia cannot entirely excluded. In any case, there is no high grade squamous intraepithelial lesion (CIN-2 or -3) is identified.
Slides examined: H&E x 3
CPT code: 88305 x 1
=============
Clinical scenario: .
Uterine cervix, 6 o'clock, biopsy:
-- Prominent chronic endocervicitis.
-- No glandular dysplasia or carcinoma.
-- No cervical transformation zone or squamous component is present in this biopsy.
Slides examined: H&E x 3
CPT code: 88305 x 1
=============
Clinical scenario: .
Uterine cervix, at 6:00, biopsy:
-- Ectocervical mucosa with cervicitis and focal squamous atypia, favor reactive
-- No viral cytopathic change or squamous dysplasia.
-- No cervical transformation zone is present in this biopsy
Note: The patient’s recent cervical Thin PAP material (Cyto-11-01024, dated 10/24/2015) is also reviewed concurrently. The abnormality observed in the cytology material are not present in the current biopsy material. Thus, the histological changes in the currently biopsy material cannot explain the abnormal findings on the Pap smear.
Slides examined: H&E x 3
CPT code: 88305 x 1
=============
Clinical scenario: .
Uterine cervix, __ O'clock, biopsy:
-- Mild chronic cervicitis.
-- No viral cytopathic change or dysplasia (see Note).
Note: The patient's recent cervical cytology material (CyT-___, dated ___) is also reviewed concurrently. Abnormality in the cytology material is confirmed but do not seem to be correlated with or explained by this endocervical curettage specimen in very small/minute volume.
Slides examined: H&E x 3
CPT code: 88305 x 1
Editor's comment:
Correlation with findings on PAP is usually indicated for "ASCUS cannot rule out HSIL".
=============
Clinical scenario: .
Uterine cervix, at 12 o'clock, biopsy:
-- Focal acute and chronic cervicitis with reactive squamous atypia.
-- No viral cytopathic change or squamous dysplasia.
Slides examined: H&E x 3
CPT code: 88305 x 1
Microglandular Hyperplasia & Benign Polyps
=============
Clinical scenario: .
Uterine cervix, at 9:00, biopsy:
-- Prominent microglandular hyperplasia with acute and chronic inflammation and immature squamous metaplasia.
-- No viral cytopathic change or squamous dysplasia.
Slides examined: H&E x 3
CPT code: 88305 x 1
Editor's comment:
A diagnostic pitfall in cytology is the immature metaplastic squamous cells masquerading as HSIL. Documenting the finding of microglandular hyperplasia with immature squamous dysplasia can help cytological interpretation / correlation of subsequent PAP.
Endocervix: Normal, Inflammation and Neoplasm
=============
Clinical scenario: .
Endocervix curettage:
-- No diagnostic abnormalities in endocervical glandular epithelium.
-- No squamous component is present in this biopsy.
Slides examined: H&E x 3
CPT code: 88305 x 1
=============
Clinical scenario: .
Endocervix, polypectomy:
-- Benign endocervical polyp with focal mucosal erosion and acute and chronic inflammation.
-- No dysplasia or malignancy.
Slides examined: H&E x 3
CPT code: 88305 x 1
=============
Clinical scenario: .
Endocervix curettage:
-- Benign endocervical mucosa with chronic and acute inflammation.
-- Metaplastic squamous epithelium with acute inflammation.
-- No viral cytopathic change, dysplasia or carcinoma.
=============
Clinical scenario: .
Endocervix curettage:
-- Benign endocervical mucosa with mild chronic inflammation.
-- No viral cytopathic change or dysplasia.
-- No squamous component is present.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
=============
Clinical scenario: .
Endocervix curettage:
-- Benign endocervical polyp with microglandular hyperplasia and extensive immature squamous metaplasia.
-- No viral cytopathic change, dysplasia or carcinoma.
Slides examined: H&E x 3
CPT code: 88305 x 1
=============
Clinical scenario: .
Endocervix curettage:
-- Fragments of squamous epithelium with human papillomavirus (HPV) effect.
OR
-- Detached squamous epithelium with viral cytopathic changes suggestive of human papillomavirus (HPV) effect.
-- No abnormality in scant fragments of ectocervical glands.
-- No dysplasia or carcinoma.
Slides examined: H&E x 3
CPT code: 88305 x 1
=============
Clinical scenario: .
Endocervix curettage:
-- Moderate to severe squamous dysplasia (CIN 2-3), two small detached fragments.
=============
Clinical scenario: .
Endocervix curettage:
-- Detached fragment of squamous epithelium with at least moderate squamous dysplasia (CIN-2).
Slides examined: H&E x 3
CPT code: 88305 x 1
=============
Clinical scenario: .
Uterine cervix, ___ o'clock, biopsy:
-- Focal cytopathic changes consistent with HPV effect.
-- No squamous dysplasia.
-- No cervical transformation zone is present in this biopsy.
Slides examined: H&E x 2
CPT code: 88305 x 1
=============
Clinical scenario: .
Endocervix, curettage:
-- At least low-grade squamous intraepithelial lesion (mild CIN 1/mild squamous dysplasia)
-- Moderate chronic and focally acute endocervicitis.
-- No glandular dysplasia or carcinoma.
Note: Assessment is limited by fragmentation of the specimen and coexistence of reactive atypia. Although low-grade squamous intraepithelial lesion (CIN-1) is strongly favored, a higher grade of squamous dysplasia cannot be entirely excluded.
Slides examined: H&E x 3
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
=============
Clinical scenario: .
Uterine cervix, __ O'clock, biopsy:
-- Diffuse low grade squamous intraepithelial lesion (CIN-1/mild squamous dysplasia and human papillomavirus effect)
-- No high grade dysplasia or carcinoma.
-- Moderate chronic cervicitis.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
Squamous Intraepithelial Lesion (Squamous Dysplasia / CIN), Biopsy
=============
Clinical scenario: .
Uterine cervix, 12 o'clock, biopsy:
-- Focal high-grade squamous intraepithelial lesion (HSIL) (moderate dysplasia / CIN-2), 1.5 mm horizontal span, with superficial glandular involvement.
-- Extensive human papillomavirus (HPV) cytopathic changes.
-- Focal acute inflammation.
Slides examined: H&E x X
CPT code: 8830X x X
=============
Clinical scenario: 32-year old woman with abnormal PAP -- ASCUS cannot exclude HSIL..
Uterine cervix, 3:00, biopsy:
-- Cervical transformation zone with focal low-grade squamous intraepithelial lesion (CIN-1).
-- Extensive human papillomavirus (HPV) cytopathic changes
-- Focal acute inflammation.
Editor's comment:
Unless high grade squamous intraepithelial lesion (i.e., CIN-2 or CIN-3) or invasive carcinoma is identified in the specimen, it's recommended to indicate whether cervical transformational zone is present in the specimen.
=============
Clinical scenario: 54-year old woman.
Uterine cervix, 5 o'clock, biopsy:
-- Low-grade squamous intraepithelial lesion (CIN-1) arising in atrophic metaplastic squamous epithelium (see Note).
-- Prominent acute and chronic endocervicitis
-- No carcinoma or definite high grade squamous intraepithelial lesion.
Note: It is often very difficult to assess the degree of squamous dysplasia accurately in the background of metaplasia and atrophy, as in this case. Although CIN-1 is unequivocally idendified, higher grade of dysplasia cannot be entirely excluded.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
The presence or absence of transformation zone does not have to be specified but instead indicated by reporting associated changes such as "endocervicitis".
Squamous Dysplasia, LEEP or Hysterectomy
=============
Clinical scenario: .
Uterine cervix, loop electrosurgical excision procedure (LEEP):
-- High grade squamous intraepithelial lesion (CIN 2-3), present in 6 to 9, and 9 to 12 quadrants, 6 mm in single greatest horizontal span, focally involving superficial endocervical glands.
-- No stromal invasion is identified.
-- Previous biopsy site changes.
-- The ectocervical, endocervical and deep resection margins are free of high grade squamous intraepithelial lesion.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
It is highly desired to include the following data elements in report squamous dysplasia in LEEP specimen: degree, location and extent of dysplasia, whether glandular involvement and stromal invasion are present, and status of margins of excision.
=============
Clinical scenario: .
Uterine cervix, loop electrosurgical excision procedure (LEEP):
-- Focal low-grade squamous intraepithelial lesion (mild squamous dysplasia / CIN-1).
-- Focal microglandular hyperplasia with immature squamous metaplasia.
-- No (previous) biopsy site changes.
-- No high-grade squamous intraepithelial lesion or carcinoma (see Note).
Note: The patient's prior cervical biopsy with high-grade dysplasia (SP-12-99999) is reviewed concurrently. Current LEEP specimen includes the cervical transformational zone circumferentially. The specimen is entirely submitted for histological examination. Multiple additional levels of all blocks are examined. No residual high-grade squamous dysplasia is identified.
Reportedly, as high as 24% LEEPs in women with high grade squamous intraepithelial lesion (HSIL) in index biopsy yield negative findings or only low grade squamous intraepithelial lesion (see reference). Approximately 10% of patients with positive HSIL biopsy results but negative LEEP findings for LSIL show HSIL on follow-up biopsy or excision.
Reference:
B. L. Witt et al: Negative Loop Electrosurgical Cone Biopsy Findings Following a Biopsy Diagnosis of High Grade Squamous Intraepithelial Lesion: Frequency and Clinical Significance. Archives of Pathology & Lab Medicine. 136(10): 1259-1261, 2012.
Editor's comment:
In the cited study, the incidence also includes low-grade SIL, as this example.
=============
Clinical scenario: 35-yo woman; hx/o CIN-3 on prior biopsy.
Uterine cervix, loop electrosurgical excision procedure (LEEP):
-- Focal mild acute and chronic endocervicitis and a small nabothian cyst.
-- Focal microglandular hyperplasia with immature squamous metaplasia.
-- Previous biopsy site changes.
-- No viral cytopathic change or dysplasia identified (see note).
Note: The patient's prior cervical biopsy with high-grade dysplasia (SP-12-99999) is reviewed concurrently. Current cone excision includes the squamocolumnar junction circumferentially. The specimen is entirely submitted for histological examination. Multiple additional levels of all blocks are examined. Selected sections are also reviewed by a second pathologist. However, no viral cytopathic change or squamous dysplasia is identified.
Absence of dysplasia in a cervical cone resection specimen is not an uncommon finding in patients with biopsy proven dysplasia. About 14% LEEP specimens from patients with HSIL on prior biopsy are completely negative. A negative LEEP is not a reassuring finding and was associated with a recurrence rate similar to those of a positive LEEP. Both negative and positive populations should be carefully followed.
Reference:
C. A. Livasy et al: The Clinical Significance of a Negative Loop Electrosurgical Cone Biopsy for High-Grade Dysplasia. Obstetrics & Gynecology. 104(2):250-254, 2004.
Editor's comment:
In the cited study, the LEEP specimens are entirely negative for dysplasia as this example. See also the reference for the last example.
Invasive Squamous Cell Carcinoma
=============
Clinical scenario: .
Uterine cervix, loop electrosurgical excision procedure (LEEP):
-- Invasive squamous cell carcinoma arising in severe squamous dysplasia (see Tumor Synopsis).
Tumor Synopsis (for LEEP Specimen
Specimen Type: Uterine cervix
Surgical Procedure: LEEP resection
Tumor histological type: Squamous cell carcinoma
Tumor grade: Well to moderately differentiated
Tumor horizontal span: Approximately 12 mm
Vertical (depth) of invasion: Greater than 7 mm measured on slide
Tumor site: 12-3 o’clock quadrant
Ectocervical margin: Positive (for invasive component)
Endocervical margin: Positive for both in situ and invasive component
Deep margin: Negative for invasive component
Carcinoma in situ (HGSIL): Present and extensive 9-12-3 quadrants
Angiolymphatic invasion: Present
Pathology Stage: pT1NxMx
Slides examined: H&E x 22
CPT code: 88307 x X1
Editor's comment:
To prepare "Synoptic Report" with an on-line tool, go to Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.
Cervical Glandular Dysplasia and Adenocarcinoma
=============
Clinical scenario: .
Uterine cervix, conization:
-- Cervical adenocarcinoma in situ (AIS), 6 mm in horizontal span, in 9 to 12 o'clock quadrant.
-- Severe squamous dysplasia (CIN-3/squamous cell carcinoma in situ), 3 mm in greatest horizontal span, 9 to 12 o'clock quadrant
-- Previous biopsy site changes
-- No severe dysplasia or in situ carcinoma is present at the ectocervical, endocervical and deep resection margins.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.