Self Instructional Manual for Cancer Registrars - SEER - National ...

Example F3 is abstracted as follows:
Example F3: 1/14/91. Cystoscopy: Localized sessile lesion in (R) superior lateral
portion of bladder. No other overt lesions.
Multiple Bx's taken. Dx: Carcinoma of bladder.
Comments:
I'yelogram: Prob. cyst in upper pole of (R) kidney. (L) collecting system normal. No
ureteral defects.
TURB done.
Bimanual examination: No evidence of induration within bladder wall or other pelvic
abnormality.
a. Three examinations are described in this report (eystoscopy, retrograde pyelogram, and
bimanual examination) as well as surgical treatment (TURB).
b. Some reports will indicate the presence or absence of cancer as a "diagnosis." Other reports
will contain a statement of the "impression." Do not attempt to distinguish between the two.
Simply use whatever term appears on the report.
The general procedures for abstracting a cystoscopy report are as follows:
1. Record date and type of procedure.
2. Record pertinent findings.
3. Record statement of diagnosis, if given.
4. Record that Bx's and TURB were done, locate pathology reports, and record the pertinent
findings.
Gastroscopy. The gastroscopy is the visual examination of the interior of the stomach. This report
may also contain examination findings as the scope is passed through the esophagus as in Example
F4. Abstract what you think is pertinent in this example and compare with the suggested abstraction
on page 139.
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