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

EXAMPLE
GI_
CLINICAL RECORD - TISSUE EXAMINATION
Name: Sid Pathe Hospital No. 000051
Age 56 Sex Male Race White Reg. No. 51 Ward 13East
Specimen submitted by Date obtained
Specimen Bronchial washing (CYTOLOGY)
Brief Clinical History RLL and RML collapse
Pre-operative diagnosis Carcinoma
Operative findings Same
Post-operative
Diagnosis
Signature and Title C. Hall
Name of Laboratory C_/topatholo_ Accession No(s). L-91-34
GROSS DESCRIPTION, HISTOLOGIC EXAMINATION AND DIAGNOSES:
The filter (1 ml. on millipore), cell block sections (3) and smears (3) prepared from the
bronchial washing show leukocytes, histiocytes (many pigmented), erythrocytes, fibrin,
bacteria and proteinaceous material. There are numerous cells present showing radiation
effects. There are other cells which appear viable, with enlarged irregular nuclei, clumped
chromatin, prominent irregular nucleoli and orangeophilic cytoplasm.
INTERPRETATION:
Bronchial washing: consistent with bronchogenic carcinoma.
Date 8/24/91 Maria Bronsky, MD
Pathologist
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