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

Abstracting the Pathology Report
Let us now examine the following pathology reports (G2-GS). A number of important
features of these reports are given below:
a. The date of the report. This date should coincide with the date of the corresponding
operative report, not the date the slides were read nor the date of dictation.
b. A short clinical history of the patient. This information describes the reasons why the
tissue was removed.
c. In the space labeled "pre-operative diagnosis" or _elinical diagnosis" will be a brief
description of the diagnosis as based on the physical examination and/or on a
statement provided by a referring physician.
d. The "gross description" of the report will contain a description of the material
received for examination and will include the source of the specimen. The size of
tissue fragments taken at biopsy and how they are received and the size of the
surgical specimen are not important to the abstraetor and should not be reported, but
if the tumor size is given it should be recorded.
e. The "microscopic description" of the report contains the pathologist's description of
the specimen(s) examined. Of special significance is the total size of the tumor, and
where it has extended or metastasized. Size will usually be reported in centimeters
(cm), and often the length, breadth, and thickness of the tumor will be given. The
abstractor need only report the largest dimension of the tumor. If there is a
discrepancy between the microscopic and gross description of the excised tumor, the
microscopic takes precedence.
f. The "diagnosis" section will summarize the microscopic findings for each specimen
examined. The diagnosis confirms or denies gross findings of malignancy, giving the
histologic type of the cancer and, in some instances, giving the grade of the cancer
(the degree to which the malignant cells have lost their normal configuration).
g. Complete excision of the tumor may also be confirmed or denied by describing
whether or not surgical margins are clear of tumor. This most often appears in the
microscopic, but may be found in the final diagnosis.
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