Cytology 3 Report

CYTOLOGY (III)
LABORATORY REPORT OF
&
NAME
MOGANAMBIKAI A/P RAGAVAN
SEMESTER
5 / 6 YEAR 3
INTAKE
APRIL 2013
CONTENT
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CONTENT
GENERAL WORKFLOW
CYTOLOGY DEPARTMENT WORKFLOW
SPECIMEN COLLECTION
SPECIMEN REJECTION CRITERIA
SAMPLE STORAGE IN CYTOLOGY
INTRODUCTION TO CYTOPATHOLOGY
QUALITY CONTROL PROGRAM IN CYTOLOGY
LABORATORY INFORMATION SYSTEM
AUTOMATED ANALYZERS
A. CYTYC THINPREP 2000 SYSTEM
B. TISSUE-TEK DRS 2000 AUTOMATIC SLIDE STAINER
C. THIN PREP IMAGING SYSTEM
D. CYTOSPOIN 3
FLOWCHART OF SPECIMEN PROCESSING
FIXATION METHOD
PROCESSING OF GYNAECOLOGY SPECIMEN
THIN PREP PAP TEST
CONVENTIONAL PA SMEAR
PROCESSING OF NON-GYNAECOLOGY SPECIMEN
FINE NEEDLE ASPIRATION CYTOLOGY (FNAC)
CELL BLOCK
CYTOLOGY STAINING
A. PAPANICALOAU (PAP) STAIN
B. MAY-GRUNWALD GIEMSA (MGG) STAIN
C. DIFF QUICK STAIN
D. ZIEHL NELLSEN STAIN
DESTAINING OF STAINED SMEAR
MOUNTING
NORMAL CELLS OF CERVICAL SMEAR
A. SUPERFICIAL CELL
B. INTERMEDIATE CELL
C. REPAIR CELL
D. BASAL AND PARABASAL CELL
E. ENDOMETRIUM CELL
F. ENDOCERVICAL CELL
BETHESDA SYSTEM
WORKPLACE SAFETY AND SAFETY MEASURES
PERSONAL PROTECTIVE EQUIPMENT (PPE)
HAZARD SYMBOLS
CONCLUSION
GENERAL WORKFLOW
At CSR department specimen and request form
received from Operation Theatre (OT) or wards.
Check the request form and specimen label.
Request form and specimen

Request form and
form not tally. The request
specimen form tally. The
form isnt complete.
request form is complete.
Reject the specimen and

Place the specimen together
inform the nurse or doctor in
with the request form into
charge.
appropriate container.
The correct action is taken.

Dispatch the specimen to Submit the right sample and
appropriate department. completed request form at CSR
department.
There are 7 departments:

1.
2.
3.
4.
5.
6.
Haematology
Blood Bank
Clinical Chemistry
Microbiology
Cytology
Histopathology
7. Parasitology
CYTOLOGY DEPARTMENT WORKFLOW

2. REGISTRATION
1. SPECIMENS RECEPTION
Check patients name tally

with the specimen written.
3. SPECIMEN
Check clinical finding
and PROCESSING
clinical history or either one
must be there.
MRNs must be there.
Date and time is important.
Doctor signature is important.
Non-Gynae
Gynae
1.
2.
1. Urine
Thin prep (in container) 2. CSF
Smear when is done, you will
3. get
OR any fluids
How to treat is in 3
a monolayer
Reduce obstructing elements. ways:
Routine way
(red blood cells, mucous, white
blood cells)
Cyto spin way
FNAC
**if it came in big container, it
Conventional smear
should reach and process as
Contains a lot of layers/ more
soon as possible to prevent the
layer
autolysis. If you cant, please
Increase of obstructing elements.
keep in the fridge to slow down
the autolysis process taken
place.
Stain the slides with:

1. Pap stain.
2. May-Grunwald stain.
3. Diff-Quick stain.
10. LABEL THE SLIDE THEN PASS TO PATHOLOGIST

4
SPECIMEN COLLECTION
All cytology specimens received by the laboratory must be accompanied by a

completed cytology requisition that includes the following information:
Patients full and legal name

Patients Medical Record Number (MRN)
Patients National Registration Identity Card (NRIC) number
Patients date of birth
Physician(s) name
Signature of the physician(s) requesting the test
Date of specimen collection
Test(s) requested must be clearly indicated
Source of specimen (anatomic site)
Brief clinical history (CLIA requirement)
Specimen Container:
Patient's
Patients
Patients
Patients
Full Name
National Registration Identity Card (NRIC) number
Medical Record Number (MRN) number
Date of Birth
Slides for Cytopathology:
Patient's Full Name

Patients National Registration Identity Card (NRIC) number
Types of sample
Containers
Liquid Based Pap Smear Samples
Conventional Pap Smear Samples
Non-Gynaecology Samples (with cytolyt

solution)
SPECIMEN REJECTION CRITERIA

5
All specimens must be properly labelled to ensure patient safety and prevent errors
in diagnosis and treatment.
1. Inappropriate sample type (e.g. surgical pathology sample sent to
diagnostic cytology laboratory).
2. Sample improperly preserved.
3. Sample too old for analysis (e.g. for unfixed samples delayed in transit).
4. Sample transport issues (e.g. Leaking sample, improper adherence to
packing).
5. Requirements including specific temperature ranges, delays in transport and
delivery.
6. Broken sample containers or slides.
7. Improperly labelled sample or incomplete requisition form (e.g. missing
mandatory identifiers listed above). (E.g; label on the lid, not the side of
the container).
8. Unlabelled sample containers and/or slides.
9. Mismatched information between sample/container label and requisition
10.
form.
Sample and requisition form identifiers match but belong to the wrong
patient (this may only be discovered after a test has been run, with unusual
or unexpected results questioned by sending physician).

11.
Without test requested physician(s) signature.
12.
Specimen arriving without a requisition form.
13.
Receiving requisition form without sample.
SAMPLE STORAGE IN CYTOLOGY
Sample storage in cytology is mostly in form of stained slide, paraffin cell

block and PreservCyt fixed samples.
Slide
Cell Block :
All cell block will be a non-gynae sample.
So it will be labelled as N.
Cell blocks will be stored in form of paraffin blocks in boxes
accordingly by following the lab accession number.
The blocks will be kept in storage for several years according to SOP.
Thin
:
Slide can be classified as Gynae and Non-gynae.
For gynae type slide, a label will be given with a code labelled C.
For Non-gynae samples, the slides will be labelled with a code N.
This coding help is storage of slides in cytology.
All the screened slides will be later filed in a box accordingly with the
lab accession number.
All the slides will be stored for several years according to the standard
operative procedure (SOP).
Prep sample :
All Thin Prep samples are gynae sample.
The samples will be stored once the sample is processed into slides.
All this samples will be arranged accordingly by following the lab
accession number and will be sealed with its holder.
Sealed holder will be labelled with processed date and month and
stored.
All this sample will be discarded after the storage duration fixed in the
SOP.
INTRODUCTION TO CYTOPATHOLOGY
Cytopathology is a branch of pathology that studies and diagnoses diseases on
the cellular level. The discipline was founded by George Nicolas Papanicolaou in
1928. A common application of cytopathology is the Pap smear, used as
a screening tool, to detect precancerous cervical lesions and prevent cervical
cancer. Cytopathology is also commonly used to investigate thyroid lesions,
diseases involving sterile body cavities (peritoneal, pleural, and cerebrospinal), and
a wide range of other body sites. It is usually used to aid in the diagnosis of cancer,
but also helps in the diagnosis of certain infectious diseases and other inflammatory
conditions. Cytopathology is generally used on samples of free cells or tissue
fragments, in contrast to histopathology, which studies whole tissues.
Cytopathologic tests are sometimes called smear tests because the samples may
be smeared across a glass microscope slide for subsequent staining and
microscopic examination. However, cytology samples may be prepared in other
ways, including cytocentrifugation. Different types of smear tests may also be used
for cancer diagnosis. In this sense, it is termed a cytologic smear.
Cytopathology is frequently, less precisely, called cytology, which means "the study
of cells.
QUALITY CONTROL PROGRAM IN CYTOLOGY.
PURPOSE:
Test performed in the laboratory are subjected to quality control following
procedures constitute what is called internal quality control and external quality
control.
The Internal QC Program (QCP) is used for daily or when required. The External
Quality Control Program (EQCP) is used as a tool to compare the performance of
the laboratories locally or internationally.
A. INTERNAL QC PROGRAM:
1. Pap Staining
2. May Grunwald Giemsa Staining
3. Diff Quick Staining (DQ)
4. Ziehl Neelsen (ZN)
B. EXTERNAL QC PROGRAM:
1. Slides supplied by the organizer.
PREPARATION OF QUALITY CONTROL SMEAR:
Specimen from relevant cases is chosen, labelled and make smear.
Type of staining specimen:
May Grunwald Giemsa- body fluids

PAP-Sputum/ Urine
Diff Quick-body fluids
STORAGE OF CONTROL SMEARS:

Control smear slides are kept appropriately in the Control smear slide box.
Staining of control smear:
Internal Quality Control Program

a. Perform control staining according to the schedule as tabulated.
External Quality Control Program
b. Perform external control (where revert) as schedule as tabulated.
Stain control smear.
Dispatch slide to senior Cytotechnologist/Medical Officer /Pathologist to
review.
Record in the Internal Quality Control for Papanicoloau Stain, May- Grunwald
Giemsa stain and Diff Quick stain
ACTION PLAIN FOR OUTLIER:
If stained control slides are not acceptable, perform troubleshooting thus

corrective action using the procedures below as a guidelines:
a) Check Specimen control.
1. Ensure that the control smears used to correct.
2. Ensure that control smear slides do not contain artifacts, bubbles,
and floaters.
3. Prepare control slides for a week
b) Check reagent.
1. Expiry date and content of reagent and pH. of reagent used.
2. Refer to test insert and work instruction
3. Reagents are changed according to schedule
4. It staining of control slides are still unacceptable, inform vendor to
perform further troubleshooting to corrective the problem.
INSTRUMENT:
i.
ii.
iii.
iv.
Setting
Cleanliness
Reaction temperature
Maintenance
10
LAB INFORMATION SYSTEM

INTRODUCTION:
In cytology of SJMC, it uses TD-Synergy LIS. It provides a very good

managing system for every lab managing operations.
It is able to run on Window XP, Vista, Window 7 and window 8.
FEATURES OF TD-SYNERGY:
From testing, specimen tracking, result delivery, and quality control, it can
be managed by this LIS.
All the lab staffs able to manage different disciplines which is located at
different section with only one TD-synergy LIS.
It serves very easy system configuration
It is internally connected to Hospital information system (HIS). This feature
reduces the chances of error in data entry.
It serves very fast and easier software upgrades.
Instrument interfaces and result acquisition
Interfaces with numerous different analyser types
Sophisticated user-rights management
Test request creation, specimen collection and identification, sample and
request dispatching.
Sample storage, routing and tracking and review of results.
Consolidation and distribution of results.
Quality control
Billing and statistic management
OPERATING DISCIPLINES:
Clinical Chemistry
Haematology
Medical Microbiology
Immunology
Serology
Virology
Histopathology
Blood banking
CYTOLOGY
Molecular Biology
Genetics
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AUTOMATED
ANALYZERS
12
CYTYC THINPREP 2000 SYSTEM
INTRODUCTION:
This system is used as a replacement for conventional method of Pap smear
preparation for use in screening for the presence of abnormal cells.
PRINCIPLE:
ThinPrep 2000 uses mechanical, pneumatic, and fluidic principle involving:
A. Dispersion: The TransCyt Filter rotates within the sample vial, creating
currents in the fluid that separates debris and disperse mucus with no effect
on cell appearance.
B. Cell collection: A gentle vacuum, which is created within the filter, collects
cells on the exterior surface of the membrane.
C. Cell transfer: It involves the transfer of cells to the slide. The filter gently
inverts and presses against the ThinPrep Microscope slide.
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MATERIALS PROVIDED:
A. ThinPrep Processor Instrument
B. PreservCyt solution vial: methanol-based buffered solution to preserve cells
during transportation and slide preparation.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Gyn ThinPrep Pap Test Filter

Program memory card
Waste bottle- with bottle, bottle cap, tubing set, fittings, and waste filter.
Filter caps
Spare filter seal O-rings
Power cord
ThinPrep microscope slides
Fixative vials.
Cervical collection device
MATERIALS NEEDED BUT NOT PROVIDED:

a. 20ml PreservCyt solution vial
b. Coverslip and mounting media
c. Staining reagents
PROCEDURES:
1. Label a ThinPrep microscope slides with the lab number, followed by patients
name and the MRN.
2. Open the door of the ThinPrep 2000 by sliding it to the right. Make sure the
fixative vial (contains 95% alcohol) is placed on its position.
3. Insert the slide onto the clamps of the instrument.
4. Take a ThinPrep Pap Test Filter and insert it into the filter cap properly. Insert
the filter assembly into the analyzer.
5. Mix well and remove the cap of the PreservCyt sample vial. Place the vial into
the sample holder properly.
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6. Close the door and press number 4 for gynaecologic sample. The test will
run.
7. After the test has completed, the control panel will read as completed.
8. Open the door and remove the fixative vial and place the slide into staining
rack that is in a staining dish containing 95% alcohol. Return back the vial
into its holder.
9. Remove the sample vial and recap it firmly. Keep the vial aside.
10. Remove the filter assembly using a tissue. Discard the filter and wipe clean
the filter cap.
QUALITY CONTROL (QC):
QC is performed every day. Following are the procedures of running QC:
Take small amount of DOW CORNING high vacuum grease and grease the
filter cap.
Insert a ThinPrep Pap Test Filter into the filter cap and put into the analyzer.
Insert a ThinPrep microscope slides onto the clamps of the analyzer.
Fill an empty ThinPrep Pap Test Filter with distilled water until the marked
line. Place the vial into the sample holder.
Replace the fixative vial by discarding the alcohol and adding in new alcohol.
Place the vial into its position.
Close the door and press number 4.
MAINTENANCE:
1. Daily:
Clean the filter cap
Cap seal cleaning
2. Weekly: Cap seal O-ring lubrication
3. Monthly: General cleaning
4. 6 months: Waste tubing replacement
5. As needed:
Emptying waste bottle: Empty the bottle before the fluid level reaches the
MAX marking on the bottle.
Filter seal O-ring lubrication and replacement
Cleaning door
Replace waste filter
COMMENTS AND NOTES:
ThinPrep Pap Test Filter must be used only once and cannot be reused.
The PreservCyt vial contains 20ml of PreservCyt solution.
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TISSUE-TEK DRS 2000 AUTOMATIC SLIDE

STAINER.
INTRODUCTION:
It is an automated random-access stainer that carries out multiple staining
protocols simultaneously. Its process includes staining of tissue sections
mounted on glass slides, frozen specimens, and cellular specimens (either nongynaecological or gynaecological).
PRINCIPLE:
A microprocessor controls the movement of the robotic arm. It carries the slide
baskets to the appropriate stations. The staining procedures can be performed
in two ways:
1. Batch mode.
2. Continuous mode: The ability to program one of the three options (exact,
delta, and infinite) at each stations for optimum accuracy. Two types of
staining can be performed, which is PAP stain and nuclear stain.
MATERIALS:
1. Reagent reservoirs and lid.
2. Wash reservoirs
3. Basket adapter, basket hood and slide basket.
REAGENT RESERVOIRS AND LID.

MATERIALS NEEDED BUT NOT PROVIDED:
SLIDE BASKET.
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a.
b.
c.
d.
Staining solutions for PAP stain and Haematoxylin & Eosin stain.
Distilled water.
Changes of alcohol (100%, 95%, 70%, 50%)
Xylene.
PROCEDURES:
A. Loading slide rack:
1. Open the lower door.
2. Place the slide rack into the empty holder in the staining machine.
Close the door.
3. Press START on the control panel. If the staining protocol are not
correct, press METHOD key and choose the correct protocol using the
UP or DOWN arrow keys. Press SELECT and START again.
B. Unloading slide rack:
1.
2.
3.
4.
Press
Open
Press
Open
REMOVE key on the control panel.

the lower door and close it back,
CONFIRM key.
the lower door and remove the slide rack. Mount the slides.
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I.
II.
PAP CONVENTIONAL/ NON-GYNAE

STATION
SOLUTION
TIME
START STATION
DISTILLED WATER
20 SEC
11
DISTILLLED WATER
20 SEC
NUCLEAR STAIN (HARRIS

HAEAMTOXYLIN)
7 MIN
13
DISTILLED WATER
30 SEC
23
DISTILLED WATER
30 SEC
10
RINSE SOLUTION
5 SEC
DISTILLED WATER
30 SEC
12
BLUING SOLUTION
30 SEC
10
11
DISTILLED WATER
20 SEC
11
E-ALC 95%
1 MIN
12
ORANGE G SOLUTION
5 MIN
13
E-ALC 95%
33 SEC
14
EA 50
5 MIN
15
E-ALC 95%
1 MIN
16
19
E-ALC 100 %
1 MIN
17
18
E-ALC 100%
1 MIN
18
16
XYLENE
30 SEC
19
15
XYLENE
30 SEC
20
END STATION
NUCLEAR STAINING FOR IMAGER

STATION
SOLUTION
18
START STATION
25
E-ALC 70%
24
E-ALC 50%
23
DISTILLED WATER
NUCLEAR STAIN (HARRIS

HAEAMTOXYLIN)
DISTILLED WATER
10
RINSE SOLUTION
11
DISTILLED WATER
12
BLUING SOLUTION
10
13
DISTILLLED WATER
11
E-ALC 50%
12
E-ALC 95%
13
ORANGE G SOLUTION
14
E-ALC 95%
15
E-ALC 95%
16
EA-50
17
E-ALC 95%
18
20
E-ALC 95%
19
19
E-ALC 100%
20
18
E-ALC 100%
21
17
E-ALC 100%
22
16
XYLENE
23
MAINTENANCE:
END STATION
a. Daily:
Wipe clean any spills in the interior or exterior part
Check for any water leaks
b. Weekly:
Dust the exterior with soft-dampened cloth
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c. Monthly:
Clean paraffin residue in the drying station
Replace the activated carbon filter
COMMENTS AND NOTES:
Always filter the staining reagents and distilled water every day before
starting staining.
Make sure that all lids are removed from reservoirs before loading slides for
staining.
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THINPREP IMAGING SYSTEM
INTRODUCTION:
An automated imaging and review system for use with ThinPrep Pap test. This
system combines imaging technology to identify microscopic fields of diagnostic
interest with automated stage movement of a microscope in order to locate
these fields. In routine use, this system selects 22 fields of view. It allows
physical marking of locations of interest for cytopathologist to review.
PRINCIPLE:
This system consists of image processor and one or more review scopes. The
alphanumeric slide accession identifier is recorded and the x and y coordinates
of 22 fields of interest are stored in the computer database during the slide
imaging. Communication of information between the image processor and
review scopes are also coordinated by the computer. The review scope is a
microscope with an automated stage that assists in the locating the 22 fields
containing cells of interest.
PROCEDURE:
a. ThinPrep slide is loaded into a slide cassette and slotted into the image
processing station.
b. The system scans the alphanumeric slide accession and scans the entire cell
spot. It identifies objects of interest on the slide.
c. 22 fields of interest with the highest integrated optical density will be selected
and stored in the computer database.
d. Remove the cassette and place a slide on the microscope stage.
e. The microscope scans the slide and shows the 22 fields of interest.
f. Use the Auto Locate Function in which suspected cells are marked and view
the fields of interest.
g. Record the results.
COMMENTS AND NOTES:
a. Carefully load and unload the glass slides on the image processing station to
prevent slide breakage or injury.
b. Make sure the slides are carefully orientated in the cassette
21
CYTOSPIN 3
INTRODUCTION:
It is a versatile and reliable cytocentrifuge that is used to separate and deposit a
thin layer of cells on slides while maintaining the cellular integrity. It is usually used
for urine and CSF specimens.
PRINCIPLE:
This cytocentrifuge use low-speed centrifugal force to separate and deposit
monolayer of cells on slides. The Cytospin deposits cells onto a clearly-defined area
of a glass slide and allows for the absorption of the residual fluid into the sample
chambers filter card. The instruments spinning action tilts the Cytofunnels upright
and centrifuges cells onto the deposition area of the slide, giving all cell types equal
opportunity for presentation.
MATERIALS:
a. Centrifuge tube
b. Parafilm
c. Cytofunnel
d.
e.
f.
g.
Microscope slide
Micropipette
95% alcohol
PAP stain
22
PROCEDURES:
1. Specimen is registered in the lab system.
2. Label a centrifuge tube with patients name, medical registration number
(MRN) and date.
3. Pour the fluid into the tube. If the fluid is a lot then use plenty of tubes.
4. Seal the tube with parafilm and centrifuge at 1500 rpm for 5 minutes.
5. Discard 80% of the supernatant and mix the pellet.
6. Label a microscope slide and place it on the holder.
7. Pipette 50l of the pellet into the cytofunnel and place it into the cytospin.
8. Spin the cytofunnel at 1000rpm for 5 minutes.
9. Remove the cytofunnel and fix the slide in 95% alcohol.
10. Perform PAP stain.
COMMENTS AND NOTES:
A. Make sure the supernatant is discarded into appropriate waste container.
B. Always make sure the patients detail in the requisition form and on the vial
are the same.
23
FLOW CHART OF SPECIMEN PROCESSING

INTRODUCTION:
This procedure are used by all MLTs and Assistant Health Attendants in the
cytology Lab, wards, clinics and district hospitals that sending the specimens to
other Cytology Lab and Hospital Tuanku Jaafar Seremban. A guideline for MLTs
and Assistant Health Attendants for receiving specimen and available forms that is
used in Cytology Laboratory.
Assistant Health Attendant
Receiving specimens with completed

form.
INCOMPLETE
COMPLETE & TALLY
Inform the MLTs in charge

Stamp time and date on
for cytology department.
both request forms and
Despatch book.
Written the received specimen

Reject the specimen.
details and place signature on
despatch book.
Chop the traceable stamp on the request form and process the
samples according to standard operation procedure (SOP).
24
FIXATION METHODS
INTRODUCTION:
Immediate fixation of cytology specimens is critical to the preservation of the
cellular components. It is important that no air-drying occurs prior to
fixation. If a smear is already air-dried it should not be put in alcohol
fixative. Please note on the requisition if the slide(s) being submitted are
fixed or air-dried. Formalin fixation is not appropriate for cytology specimens.
Specimens should not be exposed to formalin or formalin fumes. This alters
the cells and interferes with the staining reactions. There are several fixation
techniques available, depending on the type and volume of the specimen.
These are the specimen collection techniques and fixation procedures for
specific details.
PROCEDURE:
1. Spray Fixative suitable for specimens that are submitted on a slide(s). This
would include specimens such as Pap smears, FNA specimens, and
endoscopic brushing specimens.
2. 95% alcohol (usually used within a Coplin jar) - suitable for specimens that
are submitted on a slide(s). This would include specimens such as Pap
smears, FNA specimens, and endoscopic brushing specimens. The slides
should be immersed in the alcohol for a minimum of 15 minutes.
3. Saccomanno Collection Fluid a green coloured fixative for the collection of

sputum.
25
4. CytoLytSolution - a clear fixative for the collection of fluid specimens. A

50/50 ratio of specimen to fixative is appropriate (if this unavailable use 50%
alcohol).
26
PROCESSING OF
GYNAECOLOGY
SPECIMEN
27
PROCESSING OF GYNAECOLOGY SPECIMEN

INTRODUCTION:
The gynaecological specimens collected from Female Genital Tract (FGT) include
cervical smear, vaginal smear, aspiration from posterior fornix of vagina (vaginal
pool smear) and endometrial smear.
PRINCIPLE:
Cervical smear: Cancer of the uterine cervix is the commonest cancer in the Female
Genital Tract (FGT). Almost all invasive cancers of the cervix are preceded by a
phase of pre-invasive disease, which demonstrates microscopically a continuing
spectrum of events progressing from cervical intraepithelial neoplasia (CIN) grade I
to III including carcinoma in-situ before progressing to squamous cell carcinoma.
This progressive course takes about 10 to 20 years. Early detection even at the
pre-invasive stage is possible by doing cervical smear (Pap Smear Test). This can
identify patients who are likely to develop cancer and appropriate interventions
may be carried out.
PROCEDURE:
1. Receive properly labelled slide and completely filled legible request forms at
Cytology Specimen Counter.
2. Check label and slide against request forms and requester dispatch book.
3. If acceptable, log-in each specimen. Proceed with step (5)
4. If unacceptable, reject the request.
Refer to Criteria Rejection of Specimen.
5. Wear Protective Personal Equipment (PPE).
6. Log-in slide in the Cerner-Pathnet Application: Maintain Case to generate
the prefix number (GY-).
External case: check clients status in the online system, if new client,
register in the online system as E.g. (A1), if already registered, add
encounter and continue as (A1).
7. Label slide and request form with the generated prefix number (GY-).
In-house case: Write clients name and prefix number at the frosted
end of the slide. If it is a labelled slide, remove the label and repeat
the above. If the slide is non-frosted, use xylene-resistant pen or
diamond pen.
External case: Write cytology number at the frosted end.
8. Place the labelled slide into a slide rack.
9. Proceed with Papanicoloau staining.
10. Mount the slide using mounting media.
11.
Generate printed label in the Cerner-Pathnet Application, Worklist and
label.
12. Write the name of patient onto the printed label and label slide correctly.
13. Record in cytology dispatch book.
14. Despatch slide and request form to cytoscreener/MO for examination.
28
THIN PREP PAP-TEST

INTRODUCTION:
It is a liquid-based cytology that is introduced as a new method over the
conventional Pap smear.
PRINCIPAL:
The specimen is taken from the cervix at the transition zone (also known as
squamous-columnar junction) for the detection of abnormal cells. The ThinPrep
Pap test sample is preserved in PreservCyt solution before being sent to the
laboratory.
MATERIALS:
A. PreservCyt solution vial
B. Broom-like collection device
C. Speculum
D. ThinPrep microscope slide
29
E. Cytyc ThinPrep 2000 system
F. Tissue-Tek DRS 2000 Automatic

Slide Stainer
G. ThinPrep Imaging system
PROCEDURES: (COLLECTING SPECIMEN)

a. Sample collection is performed by a doctor using a broom-like collection
device.
b. After the sample is taken, the broom is rinsed well in the PreserCyt solution
vial.
c. The vial is sent to the laboratory.
d. Once the vial has been registered in the laboratory system, sample
processing is performed using Cytyc ThinPrep 2000 system.
e. The slides are then stained using PAP stain in the Tissue-Tek DRS 2000
Automatic Slide Stainer.
f. After that, mount the slides and screened by cytopathologist using ThinPrep
Imaging system.
30
1.
2.
3.
A speculum was inserted to

expose the cervix
Vaginal Discharge was cleaned

before collecting sample
The sample was obtained with

a brush or spatula
The sample obtained from

4.
cervix with the brush is rinsed

in the PreservCyt (A special
fixative of ThinPrep)
Patients name, ID and

5.
collection date or time should

be recorded on the sample for
recordings.
PROCEDURE: (PROCESSING SPECIMEN IN THINPREP 2000 ANALYSER)

31
1. Loading the fixative

bath.
2. Loading the ThinPrep

Microscopic slide.
3. Loading the sample

into the processor
after uncapped the
container.
4. Attaching the filter

and cap with aspirator.
5. Closing the window of

processor
32
6. Press 4 to run
Gynae sample.
7. Cells are transferring

onto the slide.
8. Smear is fixed in
alcohol to be
proceeded with
staining.
COMMENTS AND NOTES:

1) Make sure that the sample is preserved in the PreservCyt solution.
2) Always make sure the patients detail in the requisition form and on the vial
are the same.
3) The benefits of this method are:
4) Make
All of the samples is collected

Even distribution of cells
Minimize obscuring elements such as mucus and blood.
sure perform Quality Control of ThinPrep 2000 analyser before
performing patient specimen.

5) Fixative bath should be changed every day to avoid cross contamination.
6) Do not reuse the filter.
CONVENTIONAL PAP SMEAR

33
INTRODUCTION:
It is a traditional smear method in which collected samples are smeared directly
onto slide.
PRINCIPLE:
The collection of sample is the same as in the ThinPrep test for the detecting or
abnormal cells. The sample that is taken should have minimal artifacts and
obscuring elements.
MATERIALS:
1. Speculum
2. Spatula
3. Microscope slide
4. Slide holder
5. Cytology fixative spray or 95% alcohol
34
6. Tissue-Tek DRS 2000 Automatic Slide Stainer
PROCEDURE:
1. Sample collection is the same as in ThinPrep Pap test but using a spatula.
2. The spatula is smeared on the slide and immersed in 95% alcohol or sprayed
with fixative spray.
3. Specimen is sent to the cytology department in which the registration is

performed.
4. Slide is removed from the holder and labelled appropriately.
5. The slide is then stained using PAP stain in the Tissue-Tek DRS 2000 Automatic
Slide Stainer and then mounted.
6. Cytopathologist will screen the slide and report if any abnormal finding is
observed.
COMMENTS AND NOTES:
a. Always make sure the patients detail in the requisition form and on the vial
are the same.
b. The disadvantages of this method are:

Majority of the cells are not captured
Clumping and overlapping cells
Presence of obscuring elements.
35
PROCESSING OF
NONGYNAECOLOGY
SPECIMEN
36
PROCESSING OF NON-GYNAECOLOGY SPECIMEN

INTRODUCTION:
This guideline is used in Cytology section, Anatomic Pathology department, Hospital
Selayang. The scope outlines processing of sputum, effusion (pleural, peritoneal,
pericardial fluid and synovial fluid), urine, cerebrospinal fluid (CSF), Bronchial
Alveolar Lavage (BAL), bronchial, peritoneal and gastric washing, Tzanck, nipple,
imprint and nasopharynx smear. Provides a guideline for handling of non-gynae
specimens. Techniques for preparation of non-gynaecological samples to acquire
optimal and representative cytologic smears for assessment.
PRINCIPLE:
The technique applied will depend on type of cytologic sample received. The
accumulation of excess fluids in the body cavities is capital significance. The mere
presence of fluid in any of the body cavities indicates a pathologic process. A
variety of technique has been develop to deal with characteristic of the fluids with
low cellularity such as universal centrifuge, cytocentrifuge, membrane filters and
direct smear from the sediments yield adequate preparation.
PROCEDURE:
1. Receive properly labeled specimen and completely filled legible request forms
at Cytology Counter.
2. Check label and specimen against request forms and requester dispatch
book.
3. Wear Protective Personal Equipment (PPE).
4. Log-in specimen in the Cerner-Pathnet Application: Maintain Case to
generate the prefix number (NY-).
External case: check clients status in the online system, if already
registered, add encounter and continue as (d), if new client register in the
online system and continue as step above.
5. Process each specimen according to the type and all processing must be
done in Biosafety Cabinet Class II.
COMMENT AND NOTES:
1. Handling of rejected specimen:
Please proceed with specimen processing and staining while waiting for
clarification, except for slides that needed clarification whether it is air-dried or
alcohol-fixed smear
37
PREPARATION OF SAMPLES BY DIRECT SMEAR:

SPUTUM:
1.
2.
3.
4.
5.
6.
7.
Label two slides with patients name and cytology number (NY-).
Examine sputum and choose suspicious area, e.g blood-stained areas.
By using applicator stick, transfer chosen area on to both glass slide.
Use one glass slide as spreader and make even smears on both slides.
Immediately fix both slides in 95% ethyl alcohol for at least 30minutes.
Stain with Papanicolaou staining.
Perform Ziehl-Nelson Staining for acid fast bacilli for cases clinically
suspected of Tuberculosis.
8. Mount the slides using mount media.
9. Update in the Cerner-Pathnet Application:
Maintain case: Result Prompt- transcribes clinical information from online
system or request form, into Cytology Result Entry (Clinical information
column).
Processing Task Order Entry- to add the number of slide prepared.
10.
Generate printed label in the Cerner-Pathnet Application: Worklist and
Label.
11.
Write the name of patient onto the printed label and label slide
12.
13.
correctly.
Record in cytology dispatch book.
Despatch slide and request form to cytoscreener/MO/Pathological for
examination.
38
PREPARATION OF SAMPLES BY CENTRIFUGATION:

EFFUSION (PLEURAL, PERITONEAL, PERICARDIAL, SYNOVIAL FLUID):
Universal Centrifugation:
1. Examine specimen and document the macroscopic findings (volume, colour,
texture). Mix well.
2. Label centrifuge tubes with patients name and cytology number (NY-).
3. Specimen is processed according to volume :
I.
II.
III.
Less than 10ml

10ml 40ml
More than 40ml
Pour all the specimens in one tube.

Divide into two tubes.
Stand the specimen for one hour and pipette
sediment. Transfer at least for 4 centrifuge tubes.
4. Discard supernatant using Pasteur pipette and leave about 1 ml of precipitate in
the test tube. Mix well.
5. Check for cellularity:
A. Place a small drop of the precipitate onto glass slide and make smear.
B. Stain with Diff Quick.
C. If cellularity is satisfactory, proceed with the following step.
D. If low cellularity, proceed with cytospin step.
6. Prepare labelled slides according to volume and cellularity of specimen (not
more than 4 slides).
7. Pipette out about 0.5ml of precipitate and drop precipitate onto the labelled
slides.
8. Make smears, fix two slides in 95% ethyl alcohol for 30minutes and the other
two smears for air drying.
9. Call block will be prepared upon request by pathologist.
10.
Perform PAP staining for wet-fixed smears and MGG staining for air dried
smears.
11.
Mount slides with mounting medium.
12.
Update in the Cerner-Pathnet Application:
Maintain Case: Result Prompt- transcribe clinical information from online
system or request form, into Cytology Result Entry (Clinical Information).
Processing Task Order Entry to add the number of slide prepared.
13.
Generate printed label in the Cerner-Pathnet Application: Worklist and label.
14.
Write the name of patient onto the printed label and label slide correctly.
15.
16.
Despatch slide and request form to cytoscreener/MO/Pathologist for
examination.
Cytospin Centrifugation:
1.
2.
3.
4.
Prepare 2 labelled slides.

Clip slides to slide clips together with filter card and cytofunnel.
Put 2 to 4 drops of precipitate from the universal centrifugation into cytofunnel.
Place into cytospin centrifuge.
39
5. Centrifuge at 1200rpm for 4 minutes.

6. Immediately fix one slide in 95% ethyl alcohol for 30 minutes and the other
slide for air drying.
7. Perform PAP staining for wet-fixed smear and MGG staining for air-dried smear.
8. Mount slides using mounting medium.
Maintain Case: Result Prompt-transcribe clinical information from online
system or request form, into Cytology Result Entry (Clinical Information
10.
11.
12.
13.
column).
examination.
40
URINE:
1. Examine specimen and document the macroscopic findings (volume, colour,
2.
3.
4.
5.
6.
texture).
Mix well.
Pour a maximum of 10ml of specimen into centrifuge tube.
Centrifuge at 2500rpm for 5 minutes.
Discard supernatant by using pipette.
Proceed with cytospin procedure.
1.
2.
3.
4.
5.
6.
7.
8.
Prepare two labelled slides.

Place into cytospin centrifugation.
Centrifuge at 600 rpm for 4 minutes.
Immediately fix both slides in 95% ethyl alcohol for 30 minutes.
Perform PAP staining for wet fixed smear.
Mount with mounting media.
column).
9. Generate printed label in the Cerner-Pathnet Application :Worklist and label
10.
11.
12.
correctly
Record in cytology dispatch book
examination
41
CEREBROSPINAL FLUID (CSF):

1.
2.
3.
4.
5.
6.
7.
Immediate process once received.

Place 2 to 4 drops of specimen in cytofunnel.
Centrifuge at 600 rpm for 4 minutes.
Immediately fix one slide in 95% ethyl alcohol for 30 minutes and another
one for air drying.

8. Perform PAP staining for alcohol fixed smear and MGG for air dried smear.
9. Mount with mounting media.
10.
column).
11.
Generate printed label in the Cerner-Pathnet Application :Worklist and
label
12.
13.
14.
correctly
examination
42
BRONCHIAL ALVEOLAR LAVAGE (BAL):

1. Examine specimen and document macroscopic findings (volume, texture, and
colour). Mix well.
2. Label centrifuge tubes with patients number and cytology number (NY-).
3. Specimen is process according to their volume:
I.
II.
III.
Less than 10ml

10ml 40ml
More than 40ml

4. Centrifuge at 2500 rpm for 5 minutes.
5. Discard the supernatant using pasture pipette and leave about 1ml of
sediment in test tube and mix well.
6. Check the cellularity:
A. Place a drop of precipitate on to glass slide and make a smear.
B. Stain with Diff-Quick stain.
C. If cellularity is satisfactory, proceed with following steps.
D. If low cellularity, proceed with cytospin steps.
7. Prepared labelled slides according to the volumes and cellularity (not more
than 4 slides).
8. Pipette out 0.5ml of precipitate and drop precipitate onto labelled slides.
9. Make smears, fix two slides in 95% ethyl alcohol and the other two smears
for air drying.
10.
Cell block will prepare upon request of pathology.
11.
Perform PAP stain for alcohol fixed smears and MGG for air dried
smears.
12.
Perform Ziehl- Neelsen stain for tuberculosis suspected.
13.
14.
column).
15.
label.
16.
correctly.
17.
18.
examination.
1. Prepare two labelled slides.
43
2.
3.
4.
5.
Clip slides to slide clips together with filter card and cytofunnel,
Put 2 to 4 drops of precipitate from universal centrifugation into cytofunnel.
Immediately fix one slide in 95% ethyl alcohol and the other slide for air
6.
7.
8.
9.
drying.
Perform PAP stain for alcohol fixed smear and MGG for air dried smear.
Perform Ziehl-Neelsen staining for acid fast bacilli for suspected tuberculosis.
column).
10.
label
11.
correctly
12.
13.
examination
44
BRONCHIAL, PERITONEAL AND GASTRIC WASHING:

colour)
2. Mix well.
3. Label centrifuge tubes with patients number and cytology number (NY-)
I.
II.
III.
Less than 10ml

10ml 40ml
More than 40ml

than 4 slides)
10.
Make smears, fix two slides in 95% ethyl alcohol and the other two
11.
12.
smears for air drying.

smears.
13.
14.
column)
Processing Task Order Entry- to add the number of slide prepared
15.
label
16.
17.
18.
correctly
examination
1. Prepare two labelled slides.
45
2.
3.
4.
5.
6.
7.
8.
9.
drying.
Perform Ziehl-Neelsen staining for acid fast bacilli for suspected tuberculosis.
system or request form, into Cytology Result Entry(Clinical Information
column)
10.
label
11.
correctly
12.
13.
examination
46
BRONCHIAL BRUSHING, TZANCK, NIPPLE, IMPRINT AND NASOPHARYNX

SMEAR:
1. Label slides with patients name and cytology number (NY-).
2. Stain the slides depending on type of slide preparation either alcohol fixed
and air dried.
3. Perform PAP staining for alcohol fixed smear and MGG staining for air dried
smear.
4. Mount the slides with mounting media.
6.
7.
8.
9.
column).
examination.
Pre-treatment for heavily blood stained specimen:

1.
2.
3.
4.
5.
6.
7.
8.
Pour the sample into test tube (approximately 10ml).

Centrifuge at 2500rpm at 5 minutes.
Pour off the supernatant into specimen container.
Disperse the cells button and add 10ml of cytolyt solution.
Mix well and let it sit for 30 minutes.
Pour off the supernatant.
Dispense the cell button and prepare smear.
COMMENTS AND NOTES:
Make sure the supernatant is discarded into appropriate waste container.
Perform the procedure inside a fume hood.
Perform cell block technique if the requisition form has stated.
47
FINE NEEDLE
ASPIRATION
CYTOLOGY
48
FINE NEEDLE ASPIRATION CYTOLOGY (FNAC)

INTRODUCTION:
FNAC is a diagnostic procedure used to investigate superficial (just under the skin)
lumps or masses. In this technique, a thin, hollow needle is inserted into the mass
for sampling of cells that, after being stained, will be examined under a microscope.
PRINCIPLE:
Fine needle aspiration (FNA) is a percutaneous (through the skin) procedure that
uses a fine gauge needle (21 or 23 gauge).It is a procedure for diagnostic sampling
of cells with the aid of a needle and is particularly useful in organs which are
unsuitable for exfoliate cytology, e.g breast, thyroid, salivary glands and lymph
nodes. It is an office procedure, well accepted by the patient and does not require
an anaesthetic.
MATERIALS:
A.
Equipment/materials must be available in FNA cart:

Syringe holder for all transcutaneous FNAs
Microscopic glass slides with frosted ends
Coplin jars of 95% alcohol for immediate fixation of smears
Slide racks for placing the air-dried smears
Pencil and permanent marker pen for slide labelling
Specimen container with formalin solution
Microscope
Diff Quick Stain
Hair dryer
Cell wash solution in test tubes
Glove
Face mask/N95
Slide tray
Plaster
B.
Equipment /materials must be available in the procedure room/ward:

20ml disposable plastic syringe
Disposable needles of the various sizes: 21 or 23 gauge
Alcohol swabs
Sterile gauze pads
PROCEDURE:
49
Specimen Collection:
1. Ensure that written consent is available and endorsed by the attending
medical officer/Pathologist.
2. Aspiration is performed by the attending medical officer/Pathologist.
3. Scientific Officer/Medical laboratory technologist assists in the preparation of
the smears.
Aspiration Technique:
A. Aspiration with syringe
1. Swab skin with alcohol swabs.
2. Immobilize lesion with one hand, in a favourable position.
3. Insert the needle into the mass.
4. Apply suction by retracting the plunger and maintain the suction
throughout the sampling.
5. Equalize the pressure of the syringe by releasing the plunger before
the needle is withdrawn from the lesion.
6. Proceed with preparation of smears.
B. Aspiration without syringe (for highly vascularised lesion e.g
thyroid)
1. Swab skin with alcohol swabs
2. Immobilize lesion with one hand, in a favourable position
3. Insert the needle into the mass
4. Move the needle back and forth in the mass several times
5. Remove the needle from the mass and attach air filled syringe to the
needles
6. Proceed with preparation of smears
Aspiration biopsy of cystic lesion:
If the lesion is cystic, the above procedure is used, but the fluid can be
drawn off into the syringe and collected in a sterile container and will be
processed as a fluids. If the cyst does not completely collapse.
Preparation of smears:
1. Label slide with patients name and MRN before the aspiration is performed.
2. When the aspiration has been completed and after the needle has been
withdrawn, the syringe is disconnected from the needle, filled with air and
reconnected.
3. Expel the material in the needle onto the labelled glass slide.
4. Smear the material along the slide with the spreader.
5. Prepare smears according to amount of material aspirated but must consists
of at least one smear for each Diff Quick, PAP and MGG stains.
6. Immediately fix the smears in the 95% alcohol for pap stain.
7. For MGG stain, place slides on the slide rack for air drying.
8. Rinse the remaining material in the syringe with call wash solution.
9. Cell block is prepared as requested by Pathologist.
50
Rapid staining using Diff Quick Stain:

1.
2.
3.
4.
5.
6.
7.
8.
9.
Dry slide using hair dryer

Fix smear in solution 1 (fixing) for 12 seconds
Stain in Solution 2 for 12 seconds
Wash in water
Stain in DQ Solution 3 for 10 seconds
Wash in water
Put smear in buffer solution pH. 7.2 for 12 seconds
Remove excess water
Examine under the microscope
PREPARATION OF SAMPLES BY CENTRIFUGATION:

colour)
2. Mix well.
3. Label centrifuge tubes with patients number and cytology number (NY-)
I.
II.
III.
Less than 10ml

10ml 40ml
More than 40ml


than 4 slides)
10.
Make smears, fix two slides in 95% ethyl alcohol and the other two
11.
12.
smears for air drying.

smears.
13.
14.
column)
51

15.
label
16.
17.
18.
correctly
Cytospin centrifugation (less than 1ml / low cellularity)
1.
2.
3.
4.
5.

6.
7.
8.
9.
drying.
10.
11.
column)
label
12.
13.
14.
correctly
examination
Pre-treatment for Heavily Blood Stained Specimen:

1.
2.
3.
4.
5.
6.
7.
8.
Pour the sample into test tube (approximately 10ml).

Centrifuge at 2500rpm at 5 minutes.
Pour off the supernatant into specimen container.
Disperse the cells button and add 10ml of cytolyt solution.
Mix well and let it sit for 30 minutes.
Pour off the supernatant.
Dispense the cell button and prepare smear.
COMMENT AND NOTES:

A. Before perform each procedure the patient details are inspected and checked
by make sure it is tally with the request form to avoid sample miss label and
52
other unwanted accidents.

B. The puncture site must be cleansed with sterile swabs to sterilize the area.
C. Do not make up to 2 punctures as a practice of patient care.
D. PPE must be used at all the time to protect our self against pathogenic
specimens.
E. The slide must be quickly stained to make a rapid diagnosis or for second
puncture if needed.
53
CELL BLOCK
54
CELL BLOCKING
INTRODUCTION:
This technique is performed from residual tissue fluids and fine-needle aspirations
for a definitive Cytopathologic diagnosis
PRINCIPLE:
Cell block prepared from residual body fluids and fine-needle aspirations can be
useful adjuncts to smears for establishing a more definitive Cytopathologic
diagnosis. The cell block technique employs the retrieval of small tissue fragments
from a cytology specimen which are processed to form a paraffin block. It is widely
accepted that cell block technique increases the cellular yield and improves
diagnostic accuracy. The ability to obtain numerous tissue sections allows for
multiple immunostains and other studies to be performed akin to paraffin sections
produced in histopathology.
MATERIALS:
Apparatus
/Items:
Test tube
Pipette
Universal centrifuge
Reagents:
Thrombin reagent
Plasma
Cell wash solution
10% neutral buffered formalin
55
PROCEDURE:
1. Centrifuge the
sample/ FNA +
2ml cytospin
solution
2. Then, remove
the
supernatant of
the sample.
3. Drop 3- 4
plasma and
thrombin in
equal (1:1)
into the test
tube.
4. Mix carefully
and leave it to
clot.
5. After that, put

it in the freeze
paper.
6. Put in the tissue cassette and dip into 10% formal saline.
7. Continue process as other cytological specimens.
8.
56
CYTOLOGY
STAINING
57
STAINING OF CYTOLOGY SPECIMEN.
INTRODUCTION:
Numerous staining techniques are available today for routine and ancillary stain for
cytology. For routine diagnostic cytology, the Papanicolaou stain is recommended.
The use of Papanicolaou stain results in well stained nuclear chromatin, differential
cytoplasmic counterstaining and cytoplasmic transparency. Many modifications
have been developed by others. The intensity of nuclear stain and the depth and
colour of cytoplasmic staining are largely matter of personal preference. Staining
times may be adjusted to produce optimal results. Other staining that applied in
cytology such as Modified May-Grunwald-Giemsa is for air dried cytologic
preparation, Diff Quick Stain is for rapid stain and processed using one half the
timing of Pap stain. The ancillary stain such as Ziehl-Nielsen and other
immunocytochemistry stains is depend on the case and upon request of the
pathologist.
TYPES OF CYTOLOGY STAINING:

1.
2.
3.
4.
PAPANICOLOAU STAIN (PAP)

MODIFIED MAY-GRUNWALD GIEMSA (MGG)
DIFF-QUIK STAIN (DQ)
ZIEHL-NEELSEN STAINING (ZN)
58
PAPANICOLOAU STAIN (PAP)

PRINCIPLE:
The use of Papanicolaou stain results in well stained nuclear chromatin, differential
cytoplasmic counterstaining and cytoplasmic transparency.
SPECIMEN
Alcohol-fixed smears
EQUIPMENT /TOOLS USED:
Automated Slide Stainer with cover slipping Leica
Automated Slide Stainer Leica STS010 XL 197600
Slide racks
Funnel
Filter paper
Cover slips
PREPARATION OF SOLUTION:
a. Commercially prepared :
Haematoxylin 2
EA-50
OG-6
Bluing reagent
Absolute Alcohol
95% Alcohol
Xylene
METHOD:
Procedure
Slides introduced to 70%
Timing
1 min
alcohol
Slides introduced to 50%
1 min
alcohol
Slides were brought into
1 min
Purpose of doing
To completely hydrate the
section from alcohol for
better staining.
To completely hydrate the
distilled water
smear as preparation for next
Smear was stained with
7 min
staining procedure.
To stain the nucleus and its
Nuclear Stain
10 sec
particles.
To remove excess stain in the
1 min
slides.
To differentiate the Nuclear
distilled water
Smears were rinsed with
rinsing solution
stain by removing excess and

unbound stains from the
smear.
59
30 sec
To remove excess rinsing
distilled water
solution and stop the
differentiation process.
It is a bluing step to enhance
30 sec
bluing reagent
the blue pigment from the
30 sec
Nuclear stain stained particle.

To rinse away bluing reagent.
distilled water
Slides were placed in 50%
30 sec
Slides were gradually
alcohol
30 sec
dehydrated to alcohol for
alcohol
prior preparing for next

staining step it is alcohol
2 min
based stain.
Is a counterstain which stains
solution
Slides were rinsed in 95%
30 sec
the Keratinized cell and RBC.

Slides are rinsed to remove
Alcohol
Slides were rinsed in 95%
30 sec
Alcohol
Smear stained in EA-50
4 min
Smear stained in Orange G
excess stain from the slide by
solution
two alcohol sets

This is a counterstain which
stains the Cytoplasm of
1 min
Alcohol
1 min
Alcohol
Slides left in Absolute
30 sec
epithelial cells.
To remove excess EA-50
solution and prolong the
Alcohol
30 sec
Alcohol
30 sec
Alcohol
Slides were rinsed in Xylene
1 min
dehydration
For complete dehydration
To clear all the alcohol as a

complete dehydration
Mounting
process.
-
STAINING RESULT:
Cytoplasm Cyanophilic (basophilic)
blue-green
60
Cytoplasm eosinophilic (acidophilic)

Cytoplasm keratinized
Erythrocytes
Nuclei
Microorganisms
Trichomonads
pink
pink-orange
red
blue, black, dark violet
grey-blue
grey-green
INTERPRETATION OF RESULTS:
ThinPrep Slide showing

squamous cells
After Stain ThinPrep Smear
COMMENTS AND NOTES:
1. Make sure all the staining reagents are filtered before using in a day to avoid
scum formation.
2. Full PPE is recommended to wear to avoid any chemical exposure.
3. Before staining patient samples, it is recommended to run a quality control
sample to monitor staining quality of each day.
MAY-GRUNWALD GIEMSA STAINING (MGG)

PRINCIPLE:
It is a neutral dye, which consist of a combination of basic thiazine dye (methylene
blue and Azura B) and acid stain that is eosin. This stain is best to exhibit
cytoplasmic differentiation. It combines two stains: May- Grunwald Stain and
Giemsa Stain. These are neutral mixtures very distinct properties. They are not
active in an alcoholic medium and only act selectively when released in a buffered
aqueous solution. This releasing induces the precipitation of neutral stain.
61
SPECIMEN:
Air-dried smears
EQUIPMENT USED:
Conical flask
Coplin jars
Disposable Pasteur pipette
Staining rack
Giemsa Stain
Filter Giemsa stain using filter paper.
Combine 10ml of stock Giemsa stain with 90ml of phosphate buffer (pH.
May
6.8).
Mix well and allow standing for at least 10minutes.
Prepare fresh each batch of slide
Grunwald Stain
Filter May-Grunwald stain using filter paper
Combine 10ml of stock May-Grunwald stain with 10ml of phosphate buffer
(pH. 6.8)
Mix well and allow to stand at least 10minutes
Prepare fresh each batch of slide
Phosphate Buffer (Available commercially, or in tablet form)
Dissolve 1 tablet of buffer in 1 litter of deionized water or distilled water.
METHOD:
The staining procedures are as follows with steps in succession:
1. Run QC slide and ensure that the QC is passed
2. Fixed air-dried smears in methanol for 30 minutes. Ensuring each coplin jar
is only for one patient
3. Flood smear with May-Grunwald stain for 10 minutes
4. Rinse in phosphate-buffer (ph6.8)
5. Flood smear with Giemsa stain for 10 minutes
6. Rinse in distilled water
7. Flood smear in phosphate buffer (pH. 6.8) in 2 minutes
8. Drain until dry
9. Mount and label slides
RESULT:
Nuclei: Purple
Cytoplasm: Pink or blue
Red cells and eosinophils: Pink or red
62
63
DIFF-QUIK STAIN (DQ)

PRINCIPLE:
Diff-Quick is rapid staining kit that reduces the classical staining method to 2
minutes staining time. The staining with Diff-Quick results in predominantly
magenta stained nuclei. This is based on the molecular interaction of the
Eosin Y dye and complex of Azura B with DNA. Both dyes assemble to an
Eosin Y-Azura B-DNA complex and the intensity of the resulting stain
depends on the content of Azura B and the ratio of Azura B: Eosin Y.
SPECIMEN:
Air-dried smears
EQUIPMENT/TOOLS USED:
Coplin jar
Slide rack
Hair dryer
Microscope
The reagents are commercially prepared:
Solution 1(fixation)
Solution 2(colour reagent red)
Solution 2(colour reagent blue)
Buffer solution pH. 7.2
METHOD:
Run QC slide and ensure that the QC is passed

Fix smear with Solution 1 (fixation) for 12 dips
Stain smear with Solution 2 (colour reagent red) for 12 dips
Rinse in distilled water
Stain smear with Solution 2(colour reagent blue)for 10 dips
Rinse in distilled water
Put smear in buffer solution ph7.2 for 12 dips
Drain until dry
RESULTS:
RBC: pink or yellowish red

Platelets: violets or purple granules
Neutrophils: blue nucleus and pink cytoplasm
Eosinophils: blue nucleus and cytoplasm
Basophils: purple or dark blue nucleus
Monocyte: violet nucleus and light blue cytoplasm

64
Platelets - violet to purple

Helicobacter - dark blue
Background - light blue
Monocytes
Nucleus (lobulated) - violet
Cytoplasm - sky blue
Neutrophils
Nucleus - dark blue
Cytoplasm - pale pink
Eosinophils
Nucleus blue
Cytoplasm blue
Granules - red to red/orange
Basophils
Nucleus - purple or dark blue
Granules - dark purple/black
COMMENTS AND NOTES:

1) Do not wash the slide under fast running tap water.
2) Always cover the staining jar if not using.
65
ZIEHL-NEELSEN STAINING (ZN)

PRINCIPLE
This is the traditional Ziehl-Neelsen method for the demonstration of Acid/Alcohol
fast bacilli (Tubercle) at room temperature; it involves the heating of the Carbol
Fuchsine most to boiling point, which causes phenol fumes to be released.
Tubercular bacilli have a lipid-rich cell wall, which is capable of taking up strong
phenol-dye solution in such a way that they retain the dye upon subsequent
differentiation in acid or alcohol because they are acid and alcohol fast. Most other
organisms lose the dye and take up the counterstain.
SPECIMEN:
Air-dried smears
EQUIPMENT/TOOLS USED:
Disposable Pasteur pipette
Staining rack
Burner
Distilled water
The reagent is commercially prepared:
Carbol Fuchsine
3% Acid alcohol
Methylene Blue 0.5%
METHOD:
1) Flood case and control smears with Ziehl-Neelsens Carbol Fuchsine and heat
2-3 times until steam rises (do not allow stain to boil or to dry on the slide)
2) Let stand for 1 minute
3) Wash with water
4) Apply several changes of acid alcohol until no more colour seems to come
from the preparation
5) Rinse with water and counter stain with Methylene Blue for 1 minute
6) Rinse with water, drain until dry
7) Mount and label slides
RESULTS:
66
Acid Fast Bacilli: Red

Background: Pale Blue
67
DESTAINING OF STAINED SMEARS

PURPOSE:
For restraining of faded stained smears

To use the stained smear for other staining procedure.
SPECIMEN:
All stained smears
PRINCIPLE:
Destaining and restaining smears can be performed on most samples but will
produce optimal results only when the original cell samples was properly fixed
(especially Pap smears).
There are several methods of removing the coverslip. Once this is achieved the
next step is removal of mounting medium, which may take several hours
immersion in xylene. The older the slide, more time is needed. Time will also
depend on the amount and type of mounting medium used.
The next step is removal of the nuclear dye. It is necessary to place the slide in a
diluted hydrochloric acid, either an aqueous or alcohol-based solution. The removal
of haematoxylin may take from 5 to 20 minutes or longer depending on the
thickness of cell sample. The slide is then rinsed gently in running tap water for 10
to 15 minutes.
PROCEDURE:
Removing Coverslip:
Place slide in xylene until coverslip falls away from slide. Do not apply
pressure to remove coverslip. (This step may take hours or even days
depending on the age of slide and mounting medium used)
Place slide in clean xylene solution until mounting medium is removed.
Proceed to Destaining procedures
Destaining Procedures:
Rinse in Xylene (3 times)- 10 dips each

Rinse in absolute alcohol ethanol (3 times)- 10 dips each
Rinse in 95% ethanol (2 times)- 10 dips each
Rinse in tap water
Soak in acid alcohol solution for 3 to 5 minutes or until smear appear
colourless
Run under water for 5 to 10 minutes to remove all traces of acid
Restain with required staining method
68
MOUNTING
INTRODUCTION / PURPOSE:
It is a media used in cytopathology laboratory in SDMCSJ to cover the specimen on
the slide with coverslip. It is also to improve the image quality. DPX Mounting
medium is colourless and synthetic resin is a rapid mounting medium for
microscopy. Minimizing drying time is critical to successful slide presentation. A fast
drying mounting medium prevents moisture from developing under the cover glass
and the consequent clouding of the specimen.
PROCEDURE:
1. After the staining procedure taken place, the slide was dipped into Xylene
2. Then a coverslip was added with 1 drop of DPX mounting medium
3. Then the slide which consist of DPX mounting medium was covered with
coverslip
4. Then the slide is finalized and submitted to the pathologist for reporting.
Example of DPX mounting medium

ADVANTAGES OF DPX MOUNTING MEDIUM:
1. Excess mounting medium may be stripped from slides very easily once the
medium has dried.
2. Long lasting for a slide.
3. Stick easily with Histolene during mounting.
69
NORMAL CELLS OF
CERVICAL SMEAR
70
SUPERFICIAL CELLS
Cytology Appearance: -
Superficial cells are polygonal.

Transparent, eosinophilic, and flat/thin.
Nucleus is pyknotic, round/oval; are like intermediate cells, but with pyknotic
and smaller nuclei.
Example: Superficial Cells
INTERMEDIATE CELL
Cytology Appearances:
- Cytoplasm is polygonal,
transparent, basophilic, and flat/thin
- Nucleus is about the size of a red
blood cell, is vesicular, round/oval;
nuclear
texture and size is reference for dysplasia
- May see cytolysis / dirty background, Lactobacilli
71
Example: Intermediate Cell
72
REPAIR CELLS
Cytology Appearances: -
Cohesive monolayers of cells with well-defined or indistinct borders,

abundant cytoplasm (usually blue but no organgophilia/keratinization),
uniform enlarged nuclei, finely granular and evenly distributed chromatin;
nuclei may be hypo- to hyperchromatic, but almost all have prominent round
nucleoli and normal N/C ratio
Cells still keep their order and do not overlap, although they may fold on
themselves
Almost all cases have a chronic inflammatory infiltrate
Normal mitotic figures may be seen
Single cells are rare
In liquid based cytology, repair groups are more rounded because of
preparation
Example: Repair Cell
BASAL CELL AND PARABASAL CELL

73
-
Single round/oval cells or aggregates with indistinct cell borders (syncytia)

Cytoplasm is dense, basophilic or grey
Nucleus is round to oval with evenly distributed chromatin and inconspicuous
nucleoli
Nuclear size is slightly larger than a red blood cell
Higher N/C ratio and smaller size than intermediate cells
Example of basal and parabasal cell
ENDOMETRIUM CELL
74
-
Exfoliated endometrial cells often present as small cells arranged in balls

with scant cytoplasm, dark nuclei and nuclear moulding and fragmentation
Abraded endometrial cells may present as large and small tissue fragments
with glands and stromal cells
Resemble histiocytes
Easier to identify if in clusters
Example: Endometrium Cell
ENDOCERVICAL CELL
75
Cytology Appearance:
-
-Slightly cylindrical appearance

-occurs in groups and strips of three or more cells
-cytoplasm: deeply basophilic the that of the parabasal cell
Example: Endocervical Cell
METAPLASIA CELL
76
Cytology Appearance:
-
Bridge and tails

Nucleus enlarged
Vesicular
Example: Metaplastic Cell
77
BETHESDA SYSTEM
78
THE BETHESDA SYSTEM

INTRODUCTION:
This is a system introduced to report abnormal gynaecological diagnostic finding by
using Pap smear screening report such as:
ASCUS (Atypical Squamous Cell Undermined Significance)

ASC-H (Atypical Squamous Cell-Cannot Exclude HSIL)
LSIL (Low Grade Squamous Intraepithelial Lesion)
HSIL (High Grade Squamous Intraepithelial Lesion)
SCC (Squamous Cell Carcinoma)
AIS (Adenocarcinoma in situ)
AGC (Atypical Glandular Cell)
SPECIMEN USED TO REPORT:

1. Liquid Based Smear.
2. Conventional Smear
3. Other Smear
SPECIMEN ADEQUACY:
1. Satisfactory for evaluation:The presence or absence of endocervical/transformation zone component
and any other quality indicators, e.g., partially obscuring blood, inflammation
must be described)
2. Unsatisfactory for evaluation:The specific reason must be stated.
3. Specimen rejected/not processed:The specific reason must be stated.
4. Specimen processed and examined, but unsatisfactory for evaluation of
epithelial abnormality:The specific reason must be stated.
INTERPRETATION OF RESULTS / METHOD OF REPORTING:

When there is no cellular evidence of neoplasia, Negative for intraepithelial
lesion or malignancy (NILM) is stated in the General Categorization above
79
and/or in the result section of the report, whether or not there are organisms or
other non-neoplastic findings).
Microorganism:
1. Trichomonas vaginalis
2. Fungal organisms morphologically consistent with Candida species.
3. Shift in flora suggestive of bacterial vaginosis.
4. Bacteria morphologically consistent with Actinomyces species.
5. Cellular changes consistent with Herpes Simplex Virus.
Other Non-Neoplastic Findings (Optional):
1. Reactive cellular changes associated with
- Inflammation (includes typical repair)
- Radiation
- Intrauterine contraceptive device (IUCD)
2. Glandular cells status post hysterectomy.
3. Atrophy.
ACTINOMYCES
Gram positive non-acid fast
branching filamentous
bacteria.
Aggregates of pseudo
filamentous material, often
with acute angle branching.
May have wool appearance.
80
CANDIDA ALBICANS
(HYPHAE AND SPORE)
Candida Albicans: pseudo
hyphae and yeasts- reactive
squamous epithelial cells in the
form of shish kebab.
Mild hyperkeratosis,
inflammation and minimal
nuclear changes (atypical).
Candida hyphae is identified

with branching out root like
appearance and candida spore
can be identified by looking at
the yeast budding
HUMAN PAPILLOMA VIRUS

(HPV)
Koilocyte are superficial or
intermediate squamous cells
with large and irregular, well
defined perinuclear halos with
a cookie cutter border and
cytoplasmic thickening.
Nuclei are enlarged (two to
three times normal size) with
undulating (raisin-like) nuclear
membrane and rope-like
chromatin.
81
Often bi- or multinucleated

with variation in nuclear size.
HERPES SIMPLEX VIRUS (HSV)

Early changes can include
mononucleated cells.
Multinucleated cells with
dense, intranuclear Cowdrytype viral Inclusions.
Nuclei have ground glass
appearance due to
accumulation of viral Particles,
which causes peripheral
margination of chromatin.
Some cases have nuclei
moulding.
82
CYTOMEGALOVIRUS (CMV)
Involvement of glandular and
squamous cells
Cellular enlargement, nuclear
enlargement and large nuclear
Inclusion surrounded by a halo
owls eye.
Occasionally smaller nuclear or
cytoplasmic inclusions
Multinucleated with no nuclear
moulding
83
Epithelial Cell Abnormalities:

SQUAMOUS CELL:
I. Atypical Squamous Cells:
Of undetermined significance (ASC-US).
Cannot exclude HSIL (ASC-H).
Ii. Low Grade Squamous Intraepithelial Lesion (LSIL):
(Encompassing: HPV/mild dysplasia/CIN 1).
Iii. High Grade Squamous Intraepithelial Lesion (HSIL):
(Encompassing: moderate and severe dysplasia, CIS, CIN 2 and CIN 3).
With features suspicious for invasion (if invasion is suspected).
Iv. Squamous Cell Carcinoma.
GLANDULAR CELL:
1) Atypical:
- Endocervical cells (The comment must be specifically mentioned).
- Endometrial cells (The comment must be specifically mentioned).
- Glandular cells (The comment must be specifically mentioned).
2) Endocervical Adenocarcinoma In Situ.
3) Adenocarcinoma:
- Endocervical
- Endometrial
- Extrauterine
Other Malignant Neoplasm: The comment must be specifically mentioned.
Low Squamous Intraepithelial

Lesion (LSIL)
Koilocyte may be seen
Bi-nucleation
Enlarged and mild hyperchromasia
Irregular nuclear membrane
84
High Squamous Intraepithelial

Lesion (HSIL)
Hyperchromatic
Enlarged nucleus
Keratinization can be seen
Atypical Squamous Cell

Undermined Significance (ASCUS)
Mild nuclear enlargement and
irregularity
Moderate hyperchromasia
Minimal nuclear Atypia
Atypical Squamous Cell-Cannot

Exclude HSIL (ASC-H)
Have some features of HSIL
Metaplastic like cells
Shows mild nuclear irregularity
Squamous Cell Carcinoma (SCC)

Tumour diathesis
Presence of Tadpole cells
Enlarged and irregular nuclei
Prominent nucleolus
85
Adenocarcinoma in situ (AIS)

Formation of rosettes
Feathering cytoplasm
Course granulation in nucleus
Atypical Glandular Cell (AGC)

Enlarged nuclei
Mild nuclear irregularity
Adenocarcinoma Endocervical
Crowded cell
Hyperchromatic nucleus
Presence of tumour diathesis
Adenocarcinoma Endometrial
Large and vacuolated cells
Associated with neutrophils
Enlarged nucleus
Prominent nucleoli
WORKPLACE SAFETY AND SAFETY MEASURES

86
INTRODUCTION:
Safety in every lab is composes details about type of hazards, ways to prevent
hazardous accident, prevention on chemical exposure and includes general
laboratory rules.
1) GENERAL RULES OF A LABORATORY:
Drinking and eating is strictly prohibited in laboratory.
Lab coat should be worn at all time for each practical session.
Long hair should be tied back neatly and away from shoulder.
Covered shoes (Toe covered and enclosed footwear) must be worn at all
time while the practice is carrying on.
Do not eat or put items from laboratory in mouth for example chemicals,
pencils, fen and also finger).
Cover or bandage any exposed area or cuts on the skin on hand or wear a
powder less glove.
Do not keep or carry personal belongings or items such as pen, pencil, paper
and books while handling samples such as body fluids.
Latex glove or Nitrite glove should be worn at all the time while handling
samples and carrying out any tests in the lab.
Once the test is completed using biological samples, make sure the bench
and table top is disinfected with alcohol wipes.
Do not keep or take any biohazard out of the lab without the permission of
the Lab safety officer.
2) BIOHAZARDS:
Biohazards are also known as biological hazards or biological sample such as
Blood sample, Body fluid, urine samples, tissues or biopsies which could
carry infectious materials.
Potentially it brings harm and danger through exposure.
All the biohazards are disposed into a Biohazard bin which is in yellow colour.
For biohazards which are sharp, it must be disposed in a sharp hazard bin.
Biohazard Bin
Sharp Biohazard Bin
87
3) SAFETY FEATURES OF A LAB:

For a medical laboratory certain equipment must prepared by the lab
management as a safety measures which protects the working staff such
as :
I.
Fire Extinguisher
For fire accident of electronics, the lab must have carbon dioxide
based extinguisher as it wont make further damage to the electronics.
While a lab should also have a powder based fire extinguisher for
general fire accidents.
In-charge should monitor the functionality and expiry date of the
extinguisher.
Lab management must make sure all lab staff is thought how to use
the fire extinguisher in a proper manner.
II.
Emergency Eye Wash And Shower
This equipment gives an immediate decontamination of hazardous
exposure.
Because certain exposure can cause severe injury if treatment in
delayed.
Emergency shower also effective to extinguish clothing fire.
Every lab or section must equipped with emergency shower with an
easy access.
As a safety measures, in-charge should check the water pressure and
water supply to the emergency shower and eyewash station.
Make sure the access is not blocked.
III.
Fire Exit
Every lab must have fire exits.
In case of major fire accidents, fire exits are life saver to escape from
the accident.
Fire exits in every lab must be labelled as it is for easy identification.
Access to the fire exit must be free while walking and not blocked with
and objects cause difficulties in opening or reaching them.
IV.
First Aid Box
It is also important to have first aid box in every laboratory.
First aid box can be used to do first aid for an injured staff in lab
without waiting for certain procedures.
The first aid box must be equipped with dressing kit (Iodine, cotton
swab, cotton ball, bandage, adhesive bandage, and antiseptic cream),
plastic tweezers, gloves and pain killer or paracetamol.
This equipment will be very use full to reduce the severity of injury.
88
PERSONAL PROTECTIVE EQUIPMENT (PPE)
Type of PPE
Gloves
Goggles
Covered Shoe
Lab Coat
Apron
Cryo-Glove
Details
Must use during routine parasite lab processes such
as slide making and other work which involves the
biohazards.
When the hand has cuts or wound, it is
recommended to use glove to cover the wound.
Useful during procedure involves production of steam
and heat.
Also avoid serious injury when explosion occurred.
Extra precaution while handling corrosive materials.
Toe covered shoe.
Avoid serious injury when there is chemical accident
or spilling.
White colour long sleeve coat.
Protects body and cloth when there is invisible
spilling of sample and chemicals.
Reduce chances of exposure to infectious material
which could spread through lab equipment.
It is available in plastic and fabric material.
Very useful while performing routine parasitology
processes.
Besides that it also can be used when handling with
hot materials and dealing with procedures where
involved dealing with heat.
Made with very good quality fabrics.
Used to handle specimen under negative
temperature to avoid serious injury.
Hand wash techniques

Hand wash is a technique practiced in healthcare industries to protect oneself
and surrounded persons by control the chances of infections through direct
skin contact.
Usually we tend to miss certain parts of hand while doing hand wash with
own techniques.
So a standard method is invented so all the parts of hand is completely
washed.
While performing the hand wash, assume that the surrounding such as sink
and tab are contaminated, so avoid touching them.
Before begin the hand wash, make sure accessories such as watch and rings
are removed from hand.
This hand wash technique consist of 8 steps as follows:
89
Rinse or wet the hand under running

tab water and apply the soap onto the
palm.
Then, rub the palm for 5 minutes to

clean the palm and spread the soap.
Later, rub right palm over the back of

left hand up to wrist level 5 times.
Same step repeated for the other
hand
With right hand over back of left hand,

rub finger 5 times. Do the same for
the other hand
90
wash thumbs of each hand separately

using rotating movement
Rub the tips if fingers against the

opposite palm using circular motion.
Ensure all nail beds are washed
Rinse the hand through under running tab

water to remove all traces of soaps
Dry the hand completely with disposable

paper towel
Discard the paper towel in waster bin using

foot pedal only to avoid contamination
91
HAZARD SYSMBOL
92
CONCLUSION
93

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CYTOLOGY (III)

MOGANAMBIKAI A/P RAGAVAN

Check the request form and specimen label.

Request form and specimen

Reject the specimen and

The correct action is taken.

There are 7 departments:

CYTOLOGY DEPARTMENT WORKFLOW

Check patients name tally

Stain the slides with:

10. LABEL THE SLIDE THEN PASS TO PATHOLOGIST

All cytology specimens received by the laboratory must be accompanied by a

Patients full and legal name

Slides for Cytopathology:

Patient's Full Name

Liquid Based Pap Smear Samples

Conventional Pap Smear Samples

Non-Gynaecology Samples (with cytolyt

SPECIMEN REJECTION CRITERIA

or unexpected results questioned by sending physician).

SAMPLE STORAGE IN CYTOLOGY

Sample storage in cytology is mostly in form of stained slide, paraffin cell

QUALITY CONTROL PROGRAM IN CYTOLOGY.

May Grunwald Giemsa- body fluids

STORAGE OF CONTROL SMEARS:

Internal Quality Control Program

ACTION PLAIN FOR OUTLIER:

If stained control slides are not acceptable, perform troubleshooting thus

LAB INFORMATION SYSTEM

In cytology of SJMC, it uses TD-Synergy LIS. It provides a very good

CYTYC THINPREP 2000 SYSTEM

Gyn ThinPrep Pap Test Filter

MATERIALS NEEDED BUT NOT PROVIDED:

TISSUE-TEK DRS 2000 AUTOMATIC SLIDE

REAGENT RESERVOIRS AND LID.

REMOVE key on the control panel.

PAP CONVENTIONAL/ NON-GYNAE

NUCLEAR STAIN (HARRIS

NUCLEAR STAINING FOR IMAGER

NUCLEAR STAIN (HARRIS

THINPREP IMAGING SYSTEM

FLOW CHART OF SPECIMEN PROCESSING

Assistant Health Attendant

Receiving specimens with completed

Inform the MLTs in charge

Written the received specimen

3. Saccomanno Collection Fluid a green coloured fixative for the collection of

4. CytoLytSolution - a clear fixative for the collection of fluid specimens. A

PROCESSING OF GYNAECOLOGY SPECIMEN

THIN PREP PAP-TEST

B. Broom-like collection device

D. ThinPrep microscope slide

E. Cytyc ThinPrep 2000 system

F. Tissue-Tek DRS 2000 Automatic

G. ThinPrep Imaging system

PROCEDURES: (COLLECTING SPECIMEN)

A speculum was inserted to

Vaginal Discharge was cleaned

The sample was obtained with

The sample obtained from

cervix with the brush is rinsed

Patients name, ID and

collection date or time should

PROCEDURE: (PROCESSING SPECIMEN IN THINPREP 2000 ANALYSER)