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

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A cytology report recorded as suspicious is not considered as diagnostic of cancer. Unless supported by a positive biopsy (as reported on a pathology report) or by a clinical impression of cancer, these cases should not be abstracted. The Papanicolaou 1 classification of cells for the detection the past is as follows: of malignancy ("Pap_ smear) used in Class Interpretation I II III IV V No evidence of a malignant neoplasm, no atypical cells Atypical cells present but no evidence of malignant neoplasm Cells present causing suspicion of malignant neoplasm Fairly conclusive evidence of malignant neoplasm Conclusive evidence of malignant neoplasm Some medical records will contain more than one cytology report. If there are multiple reports on the same type and source of specimen, record the findings on the first positive report. If they are based on different types and sources of specimens, summarize all pertinent findings. According to the National Cancer Institute Workshop on Terminology for Cervical and Vaginal Cytology, December 12-13, 1988, "While the Papanicolaou Classes have a significant historical association with the early development of cytology, it can no longer be relied upon to communicate clinically relevant information. In particular, the Papanicolaou Classes do not reflect current understanding of cervical neoplasia, do not provide for the diagnosis of non-cancerous entities, and, as a result of numerous idiosyncratic modifications over the years, no longer reflect uniform diagnostic interpretations. Accordingly, it is our conclusion that the Papanicolaou Class System is not acceptable in the practice of diagnostic cytology." Their organization of the new terminology and classifications is as follows: (a) a STATEMENT ON ADEQUACY OF THE SPECIMEN, (b) a GENERAL CATEGORIZATION of the diagnosis (within normal limits or other), and (c) the DESCRIPTIVE DIAGNOSIS For Squamous Cell the following terminology is used: III.A.1 Atypical squamous cells of undetermined significance (specify recommended follow-up and/or further investigative procedures) III.A.2 Squamous intraepithelial lesions (Comment on presence or absence of cellular changes consistent with Human papillomavirus (HPV) infection) III.A.2a Low grade squamnus intraepithelial lesion encompassing: Cellular changes consistent with HPV infection Mild dysplasia / CIN 1 1George Nicolas Papanicolaou was a Greek physician, anatomist, and cytologist in the United States. 243
lII.A.2b III.A.3 High grade squamousintraepitheliallesions encompassin&: Moderatedysplasia / CIN 2 Severe dysplasia / CIN 3 Carcinomain situ / CIN 3 Squamouscarcinoma At first you may find it somewhat disconcertingto discover that more than one type of form may be used to report similar findings. However, as you study Examples G12-GI5, you will find that they contain similar information. Example G12 contains check lists for recording most of the types of information. For example: The source of the specimen is recordedby checking one of the blocks on the left of the report. This reportis of special interestto the new cancerregistrarbecauseit lists the majorsources of materialused as specimens for a cytologic examination. At the top left of the report, the clinical diagnosis may be summarized. This need not be recorded on the abstract. In many cases the laboratorystudy was orderedon the basis of a previouslysuspicious Pap smear. The findings of the examination will be recorded by checking one of the blocks listed in the section describingthe tissue statuson the lower right. 244
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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: 3/11/91. Expl. Lap.: L
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PRACTICAL EXERCISE The following pa
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These operative reports can be abst
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EXAMPLE F18A OPERATIVE REPORT Name
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EXAMPLE F18B OPERATIVE REPORT Name
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Example F18 can be abstracted as fo
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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 246 and 247: CYTOLOGIC EXAMINATION The study of
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
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