Breast Discharge

NAME OF PROCEDURE

Breast Discharge

TEST CODE

NGYN

CPT CODE

88104 – Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation.

APPLIES TO

Breast Discharge, Breast Secretion Breast Smear, Nipple Discharge, Nipple Secretion, Nipple Smear

SPECIAL INSTRUCTIONS

Information regarding the site, admitting diagnosis, and pertinent clinical data (i.e. age, clinical impressions, past diagnosis, radiographic findings) is essential to interpretation and should be noted on the requisition.

SPECIMEN

Smear(s) from expressed breast discharge (spray-fixed smears or smears in fixative).

CONTAINER

Glass slides, slide container with 95% alcohol, and/or cardboard slide holders and spray fixative.  Please label any containers with a minimum of two patient identifiers.

COLLECTION TECHNIQUE

  1. Pre-label slides with the patient’s name and initial
  2. Pre-label alcohol fixative container with the patient’s name, initial and hospital number
  3. Express discharge from nipple
  4. Place discharge on pre-labeled glass slide
  5. Placed slide in fixative container
  6. Complete requisition form with information
    1. EG:
      1. Bloody/clear from right/left nipple
      2. Indicate test required: Cytology
  7. Submit to the laboratory for evaluation
  8. Alternate method if no alcohol fixative container is available: Follow steps 1-4 above.
  9. Immediately spray slide(s) with cytology spray fixative, holding container 6-12 inches from slide. Lightly mist entire slide with fixative.
  10. Place slide(s) in cardboard slide holder and allow to dry completely before closing and securing.
  11. Complete requisition form with information
    1. EG:
      1. Bloody/clear from right/left nipple
      2. Indicate test required: Cytology
  12. Submit to the laboratory for evaluation.

REQUEST FORM

Complete a Anatomical Pathology Requisition as indicated in the Test Ordering section of this manual. The patient information section as well as the Non-Gyn Cytology portion of the form should be completed.

CAUSES FOR REJECTION

Specimen container or slides not properly labeled.

Slide(s) irreparably broken.

LIMITATIONS

Allowing smears to dry before they are fixed will render them unsatisfactory for cytologic evaluation.

METHODOLOGY

Preparations are examined cytologically using the Pap stain method.

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