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

More documents

Recommendations

Info

CYTOLOGIC EXAMINATION The study of cells, their origin, structure, function, and pathology is called cytology. Cells are continually shed (exfoliated) from tissues that line the cavities and hollow organs of the body. These exfoliated cells may float in the fluid and mucous material which bathes or passes through these cavities. These cells can be examined microscopically to determine their tissue of origin and whether or not they are malignant. The term exfoliative cytology refers to "microscopic examination of cells contained within body fluids." The three body cavities, the pleura (enclosing the lungs), the peritoneum (enclosing the intestinal tract), and the pericardium (enclosing the heart), may be checked for fluid. The normal fluids within the body cavities are limited to an insignificant lubricating layer that cannot be aspirated. Therefore, fluid in any body cavity which can be aspirated indicates a pathological process, commonly malignant and metastatic. It is believed that the formation of aseites (fluid in the abdominal cavity), for example, is brought about by colonies of cancer cells which damage the capillaries and lymphatics resulting in leakage of cancer ceils and plasma directly into the abdominal cavity. The table below lists the sources of some of the specimens that are examined histologically and some that are examined cytologically. As a further guide, histology is the study of tissues, while cytology is the study of cells. Histolo_ic Examination Cytologic Examinations Biopsy material Sputum Bronchial washing Frozen section Breast Secretion Prostate secretion Bone marrow biopsy/aspiration (tissue) Gastric fluid Spinal fluid Operative specimen Peritoneal fluid Urinary sediment Autopsy specimen Pleural fluid Cervical & vaginal smears Bone man'ow aspiration (cells) Tracheal washing Bronchial brushing 241
CYTOLOGY AND ITS PROCEDURES Cytology is the study of the structure and function of cells; the examination of cells under a microscope as used in the diagnosis of cancer. There are a variety of procedures employed to obtain material for cytologic examination from fine needle aspiration of superficial or internal lesions to exfoliated cells obtained by aspiration, washing, brushing, smears, or scraping of vaginal secretions, sputum, urine, abdominal fluid, prostate secretions, etc. The more common techniques include: Brushings--the procedure of brushing the lining of an organ for the purpose of obtaining cells Punctures--Inserting a hollow needle into a cavity or organ for the purpose of removal of some portion of the contents (fluid, bone marrow, tissue) Paracentesis--Surgical puncture of a cavity for aspiration of fluid, such as the abdominal cavity Thoracentesis--Surgical puncture for aspiration of fluid from the chest Scrapings--the procedure of scraping the lining of a structure with an instrument for the purpose of obtaining cells Swabs--Using a swab or similar device to obtain fluid and secretions which then can be used to make a smear Washings--the removal of fluid from a hollow organ or structure for the purpose of collecting any cells in the fluid which may have exfoliated 242
Page 2 and 3:
SEER Program Self InstructionalManu
Page 4 and 5:
TABLE OF CONTENTS BOOK 5: ABSTRACTI
Page 6:
SECTION A OBJECTIVES AND CONTENT OF
Page 10:
SECTION B THE COMPOSITION AND ORGAN
Page 13 and 14:
Physical Examination General (gener
Page 15 and 16:
FORMS USED TO RECORD INFORMATION IN
Page 18:
SECTION C ABSTRACTING A MEDICAL REC
Page 21 and 22:
WHEN TO ABSTRACT CASES While it may
Page 23 and 24:
Local Registry Number A patient's r
Page 25 and 26:
Marital Status Select appropriate a
Page 27 and 28:
Abstracting Diagnostic Procedures S
Page 30 and 31:
SECTION D DIAGNOSTIC PROCEDURES: GE
Page 32:
SECTION E CLINICAL EXAMINATIONS: PH
Page 36:
EXAMPLE E1 Name: Sarah O. Luckless
Page 40:
EXAMPLE E2 Name: Hector Breathless
Page 44 and 45:
BODY SECTION RADIOGRAPHY. Body sect
Page 46:
E. Lower GI Series or Barium Enema:
Page 50:
Example E3 can be abstracted as fol
Page 54:
Page 58:
Page 62:
Example E6 might be abstracted as f
Page 66:
Page 70:
EXAMPLE E9 Name: Hardy Smooker Hosp
Page 74:
Examples E8-E10 can be abstracted a
Page 78:
EXAMPLE Ell Name: Emma Bronchilli H
Page 81 and 82:
DIAGNOSTIC NUCLEAR MEDICINE EXAMINA
Page 84:
EXAMPLE El2 THE DIVISION OF NUCLEAR
Page 88:
EXAMPLE E14 Record No.: 000014 Name
Page 92:
MAGNETIC RESONANCE IMAGING: Magneti
Page 96:
EXAMPLEE16 MRI CONSULTATIONREPORT N
Page 100 and 101:
HEMATOLOGIC EXAMINATION A hematolog
Page 102 and 103:
Granulocytes or granular leukocytes
Page 104 and 105:
Certain types of disease associated
Page 106 and 107:
EXAMPLE E17 HEMATOLOGY LABORATORY N
Page 108 and 109:
EXAMPLEE18 HEMATOLOGY LABORATORY Na
Page 110 and 111:
EXAMPLE E19 HEMATOLOGY LABORATORY R
Page 112 and 113:
PRACTICAL EXERCISE ANSWERS Example
Page 114 and 115:
Bone Marrow Studies. Examination of
Page 116 and 117:
EXAMPLE E20 Name: Bo Comeaway Hospi
Page 118 and 119:
Example E20 can be abstracted as fo
Page 120 and 121:
Blood Serum Studies Automation and
Page 122 and 123:
Other Laboratory Studies Marrow Aci
Page 124 and 125:
Totalprotein. This test measures th
Page 126 and 127:
SECTION F MANIPULATIVE AND OPERATIV
Page 128 and 129:
SECTION F MANIPULATIVE AND OPERATIV
Page 130 and 131:
EXAMPLE FI Rec. No. 000019 Name Iv_
Page 132 and 133:
The manner in which the findings in
Page 134 and 135:
EXAMPLE F2 LARYNGOSCOPY REPORT Hosp
Page 136 and 137:
The illustrated report can be abstr
Page 138 and 139:
I EXAMPLE F3 REPORT OF CYSTOSCOPY N
Page 140 and 141:
Example F3 is abstracted as follows
Page 142 and 143:
EXAMPLE F4 GASTROINTESTINAL DIAGNOS
Page 144 and 145:
The information described in Exampl
Page 146 and 147:
EXAMPLE F5 SIGMOIDOSCOPY REPORT Rec
Page 148 and 149:
EXAMPLE F6 PROCTOSCOPY REPORT Rec.
Page 150 and 151:
EXAMPLE F7 GASTROSCOPIC REPORT Hosp
Page 152 and 153:
EXAMPLE F8 GASTROSCOPIC REPORT Hosp
Page 154 and 155:
EXAMPLE F9 BRONCHOSCOPY REPORT Hosp
Page 156 and 157:
EXAMPLE FIO BRONCHOSCOPY REPORT Hos
Page 158 and 159:
EXAMPLE Fll BRONCHOSCOPY REPORT Hos
Page 160 and 161:
EXAMPLE F12 BRONCHOSCOPY REPORT Hos
Page 162 and 163:
PRACTICAL EXERCISE ANSWERS These en
Page 164 and 165:
Example F10: 5/5/91. Bronchoscopy:
Page 166 and 167:
In all of the "oscopies" described
Page 168 and 169:
EXAMPLE F13 OPERATIVE REPORT Name:
Page 170 and 171:
This operative report may be abstra
Page 172 and 173:
OPERATIVE PROCEDURES Exploratory_Su
Page 174 and 175:
EXAMPLE F14 OPERATIVE REPORT Servic
Page 176 and 177:
The operative record used as an ill
Page 178 and 179:
Page 180 and 181:
Example F15: 3/11/91. Expl. Lap.: L
Page 182 and 183:
PRACTICAL EXERCISE The following pa
Page 184 and 185:
Page 186 and 187:
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 230 and 231: PRACTICAL EXERCISE ANSWERS Example
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 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
Page 280 and 281: SELECTED BIBLIOGRAPHY Cancer Regist
Page 282 and 283: INDEX Abstract, 3, 9, 11, 15-17, 21
Page 284 and 285: Cerebral angiogram, 40 Chemistry (S
Page 286 and 287: Endoscopic examination (Cont'd) Exa
Page 288 and 289: Laryngogram, 65, 69 Example E9, 65,
Page 290 and 291: Papanicolaou classification, 243 Pa
Page 292 and 293: Special examinations, 8 SPECT, 71 S
Page 294 and 295: Index of Examples E_mmple E1 29, 31
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?