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

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
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