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

Example F15: 3/11/91. Expl. Lap.: Large, fixezl mass on posterior wall of fundus of stomach
invading the spleen. Numerous nodes along lesser
curvature of stomach. Some tumor studdings in left lobe
of liver. Node was Bx'ed. Post-op dx: Carcinoma of the
stomach.
Comments:
The following points should be noted with respect to the operative record used in
this illustration.
a. A clinical history is presented. Sometimes this is not present. When it is, it can be very
useful. For example, this clinical history indicates that the patient was admitted with
symptoms possibly related to cancer--60 lb. weight loss in 8 months.
b. The clinical history indicates that one or more reports of a GI series should be present in
the medical record. They should report a lesion in the fundus of the stomach.
c. Other diagnostic reports mentioned in the clinical history include chest films and liver scan
which did not indicate metastatic spread.
d. The location of the primary site on the posterior wall of the fundus of the stomach is
described.
e. According to the surgeon, the mass was invading the spleen and was metastatic to the liver.
It appeared to involve nodes along the lesser curvature of the stomach. This indicates that
the mass had extended beyond its primary site.
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