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

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PRACTICAL EXERCISE ANSWERS Example G6: 3/17/91. Path. Rpt. $91-1017: Right axillary node dgr,ection. Metastatic malignant melanoma in 3/18 nodes, one node in each level Dr,: metas, malignant melanoma Example GT: 3/3/91. Path. Rpt. $91-8955: Bx's arytenoids, (R) and (L) pyriform sinus, erieoid, posterior wall of R hypopharynx, pyriform sinus polyp. Arytenoids neg; all other spee. epid. carcinoma. Dx: Epidermoid careinoma--hypopharynx, (R) and (L) pyriform sinuses and polyp on (R) erieoid (main tumor) Comment: Should negative findings be reported? We recommend that you report pertinent negative findings as well as positive findings to provide a complete picture of the extent of the disease. Example G8: 8/9/91. Path. Rpt. $91-7896: Bone marrow biopsy:. 90% abnormal cells; in leukemic phase. Malignant lymphoma Example G9: 1/15/91. Path. Rpt. $91-0300: Antrum of stomach--9 cm lesion. Dx: Poorly differentiated adenocarcinoma infiltrating through muscular wall and involving serosa. Surgical margins free of tumor. 5/9 mesenteric lymph nodes contain metastatic carcinoma; tumor nodules involving fat. Comments: a. Be sure you coordinate the numbered descriptions with the specimen named above. b. The operative report for histopathologic Example G9 may be found in Example F17. 225
C. The Autopsy (Necropsy; Postmortem) Report The most important portion of the autopsy report as far as the abstractor is concerned is the section entitled "Final Diagnosis." It usually will describe the primary site, histologic type, and extension and metastases of the tumor based on a histopathologic examination of the tissues obtained after death. All of the major organs are examined unless, as sometimes happens, the autopsy is restricted to certain organs. All pertinent findings should be recorded. Autopsy findings confirm the diagnosis of cancer made prior to death, if still present, and may determine the primary site of a tumor which may have been incorrectly diagnosed or unknown prior to death. The histologic findings described in the autopsy report relative to the primary site and cell type usually take precedence over those reported in prior pathology reports. On occasion, the presence of cancer will be an incidental discovery at the time of autopsy. When this occurs, the patient's history and physical examination findings should be reviewed to rule out a clinical diagnosis of cancer prior to death. In instances where the diagnosis of cancer was first made at autopsy, the cases are abstracted and identified as "diagnosed at autopsy." In such cases the date of diagnosis is the date of death. The autopsy report for patients who died in your hospital should be included in the medical record. The autopsy protocols for those who died after discharge may be available from other hospitals or coroners' offices. Your Committee on Cancer should decide whether or not you will attempt to obtain autopsy reports (and Death Certificates) for those patients who died elsewhere. If the autopsy report is based on gross observation alone (no microscopic exam) this should be noted. However, as a part of most autopsies, a histologic examination of tissue removed from the body will be performed routinely. Example G10 is a typical autopsy report. with the suggested abstraction on page 231. Abstract what you think is pertinent and then compare 226
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SEER Program Self InstructionalManu
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TABLE OF CONTENTS BOOK 5: ABSTRACTI
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SECTION A OBJECTIVES AND CONTENT OF
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SECTION B THE COMPOSITION AND ORGAN
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Physical Examination General (gener
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FORMS USED TO RECORD INFORMATION IN
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SECTION C ABSTRACTING A MEDICAL REC
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WHEN TO ABSTRACT CASES While it may
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Local Registry Number A patient's r
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Marital Status Select appropriate a
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Abstracting Diagnostic Procedures S
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SECTION D DIAGNOSTIC PROCEDURES: GE
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SECTION E CLINICAL EXAMINATIONS: PH
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EXAMPLE E1 Name: Sarah O. Luckless
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EXAMPLE E2 Name: Hector Breathless
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BODY SECTION RADIOGRAPHY. Body sect
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E. Lower GI Series or Barium Enema:
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Example E3 can be abstracted as fol
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Example E6 might be abstracted as f
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EXAMPLE E9 Name: Hardy Smooker Hosp
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Examples E8-E10 can be abstracted a
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EXAMPLE Ell Name: Emma Bronchilli H
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DIAGNOSTIC NUCLEAR MEDICINE EXAMINA
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EXAMPLE El2 THE DIVISION OF NUCLEAR
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EXAMPLE E14 Record No.: 000014 Name
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MAGNETIC RESONANCE IMAGING: Magneti
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EXAMPLEE16 MRI CONSULTATIONREPORT N
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HEMATOLOGIC EXAMINATION A hematolog
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Granulocytes or granular leukocytes
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Certain types of disease associated
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EXAMPLE E17 HEMATOLOGY LABORATORY N
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EXAMPLEE18 HEMATOLOGY LABORATORY Na
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EXAMPLE E19 HEMATOLOGY LABORATORY R
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PRACTICAL EXERCISE ANSWERS Example
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Bone Marrow Studies. Examination of
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EXAMPLE E20 Name: Bo Comeaway Hospi
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Example E20 can be abstracted as fo
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Blood Serum Studies Automation and
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Other Laboratory Studies Marrow Aci
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Totalprotein. This test measures th
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SECTION F MANIPULATIVE AND OPERATIV
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SECTION F MANIPULATIVE AND OPERATIV
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EXAMPLE FI Rec. No. 000019 Name Iv_
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The manner in which the findings in
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EXAMPLE F2 LARYNGOSCOPY REPORT Hosp
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The illustrated report can be abstr
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I EXAMPLE F3 REPORT OF CYSTOSCOPY N
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Example F3 is abstracted as follows
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EXAMPLE F4 GASTROINTESTINAL DIAGNOS
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The information described in Exampl
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EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec
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EXAMPLE F6 PROCTOSCOPY REPORT Rec.
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EXAMPLE F7 GASTROSCOPIC REPORT Hosp
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EXAMPLE F8 GASTROSCOPIC REPORT Hosp
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EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
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EXAMPLE FIO BRONCHOSCOPY REPORT Hos
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EXAMPLE Fll BRONCHOSCOPY REPORT Hos
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EXAMPLE F12 BRONCHOSCOPY REPORT Hos
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PRACTICAL EXERCISE ANSWERS These en
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Example F10: 5/5/91. Bronchoscopy:
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In all of the "oscopies" described
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EXAMPLE F13 OPERATIVE REPORT Name:
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This operative report may be abstra
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OPERATIVE PROCEDURES Exploratory_Su
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EXAMPLE F14 OPERATIVE REPORT Servic
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The operative record used as an ill
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EXAMPLE F15 OPERATIVE REPORT Servic
Page 180 and 181: Example F15: 3/11/91. Expl. Lap.: L
Page 182 and 183: PRACTICAL EXERCISE The following pa
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Page 186 and 187: EXAMPLE F17 OPERATIVE REPORT Servic
Page 188 and 189: These operative reports can be abst
Page 190 and 191: EXAMPLE F18A OPERATIVE REPORT Name
Page 192 and 193: EXAMPLE F18B OPERATIVE REPORT Name
Page 194 and 195: Example F18 can be abstracted as fo
Page 196 and 197: SECTION G PATHOLOGICAL EXAMINATIONS
Page 198 and 199: SECTION G PATHOLOGICAL EXAMINATIONS
Page 200 and 201: A. The BiopsyReport The termbiopsy(
Page 202 and 203: EXAMPLE G1 DEPARTMENT OF PATHOLOGY
Page 204 and 205: Example G1 can be abstracted as fol
Page 206 and 207: Abstracting the Pathology Report Le
Page 208 and 209: EXAMPLE G2 PATHOLOGY REPORT Path. N
Page 210 and 211: EXAMPLE G3 PATHOLOGICAL SPECIMEN RE
Page 214 and 215: EXAMPLE (34 (continued) DIAGNOSIS:
Page 218 and 219: The information which should be abs
Page 220 and 221: PRACTICAL EXERCISE In the following
Page 222 and 223: EXAMPLE G6 PATHOLOGY REPORT Name Be
Page 232 and 233: EXAMPLE G10 AUTOPSY REPORT IDENTIFI
Page 234 and 235: EXAMPLE G10 (continued) CLINICOPATH
Page 236 and 237: Example G10 can be abstracted as fo
Page 238 and 239: EXAMPLE Gll DEPARTMENT OF PATHOLOGY
Page 240 and 241: EXAMPLE G11 (Continued) DEPARTMENT
Page 242 and 243: EXAMPLE Gll (Continued) DEPARTMENT
Page 244 and 245: Example G11 can be abstracted as fo
Page 246 and 247: CYTOLOGIC EXAMINATION The study of
Page 248 and 249: A cytology report recorded as suspi
Page 250 and 251: PRACTICAL EXERCISE Summarize the fi
Page 252 and 253: EXAMPLE G13 i ! PATIENT NO. DATE 10
Page 254 and 255: EXAMPLE G14 Patient No. 000050 DATE
Page 256 and 257: EXAMPLE GI_ CLINICAL RECORD - TISSU
Page 258 and 259: Examples G12-15 may be abstracted a
Page 260 and 261: COMMON ABBREVIATIONS Abbreviation T
Page 262 and 263: HEENT Head, _ eara, ame & throat LE
Page 264 and 265: SARC Sarcoma UMB Navel (umbilicus)
Page 266 and 267: COMMON ABBREVIATIONS Definition Ind
Page 268 and 269: Impression IMP Lumbar spine L-SPINE
Page 270 and 271: Staphylococcus STAPH Within normal
Page 272 and 273: COMMON SYMBOLS Symbol Index Symbol
Page 274 and 275: ACRONYMS FOR ORGANIZATIONS CONCERNE
Page 276 and 277: WORLDWIDE ORGANIZATIONS IACR Intern
Page 278 and 279: ACRONYMS FOR STUDY GROUPS The follo
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SELECTED BIBLIOGRAPHY Cancer Regist
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INDEX Abstract, 3, 9, 11, 15-17, 21
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Cerebral angiogram, 40 Chemistry (S
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Endoscopic examination (Cont'd) Exa
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Laryngogram, 65, 69 Example E9, 65,
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Papanicolaou classification, 243 Pa
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Special examinations, 8 SPECT, 71 S
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Index of Examples E_mmple E1 29, 31
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