Key information (information to look for and pay attention
to and to document with regard to collecting pertinent information
about the patient's cancer): primary site of neoplasm;
cell type and grade; behavior of tumor (in situ, microinvasive,
cervical intraepithelial neoplasia); Gleason's grade or score
for prostate, Bloom-Richardson score for breast, Fuhrman grade
for kidney; location within organ, exact location within specimen;
presence of multiple tumors in organ; number of microscopic
foci (if tumor is occult); exact size of lesion; invasion
of blood vessels and/or lymphatic channels within specimen;
invasion of capsule; depth of invasion (mucosa, musculature,
supporting
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tissues); involvement of surgical margins
and serosal surface of organ; names of structures and
organs removed; size and number of lymph nodes involved
(ipsilateral or contralateral, including micrometastases);
number and location of uninvolved lymph nodes; results
of biopsies of possible metastatic sites; whether tumor
arose in adenomatous polyp, villous adenoma or tubular
adenoma; distance from tumor to edge of resected specimen;
intraluminal extension (for example, extension along
inner surface to contiguous segments of colon); location
and number of lymph nodes positive and number of nodes
pathologically
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examined; extension to adjacent tissues (peritoneum, serosa,
omentum, mesentery adjacent fat, adjacent organs); depth of
penetration of tumor through organ wall; involvement of other
organs (surface vs parenchymal); biopsy results of any additional
tumor sites noted during operation.
ABDOMINAL WASHINGS
instillation of approximately 200 ml. of saline solution into
the abdomen during laparotomy. After the solution is allowed
to contact surfaces in the abdomen for about five minutes,
it is aspirated and sent for cytologic examination. This procedure
is used to determine whether tumor is present in the abdomen
in the absence of ascites.
BLADDER WASHINGS instillation
of saline solution into the bladder during cystoscopy. After
the solution is allowed to contact surfaces in the area for
about five minutes, it is aspirated and sent for cytologic
examination. This procedure is used to determine whether tumor
is present in the absence of visible tumor.
BONE MARROW BIOPSY
Also called bone marrow aspiration. Aspiration of bone marrow
cells to determine involvement by tumor. This procedure is
optional in low stage lymphoma cases. Bilateral bone marrow
biopsies and aspirations should be done for higher stage and
symptomatic lymphoma cases.
BRONCHIAL WASHINGS
Includes: bronchial washings, bronchial brushings obtained
through a bronchoscope.
BRUSHINGS Also called:
exfoliative cytology. Tumor is obtained by passing a small
brush through an endoscopy tube and scraping cells from the
lesion. This tissue is analyzed cytologically.
CLOSED CHEST NEEDLE BIOPSY
Includes: skinny-needle biopsy of chest, fine needle aspiration
(FNA). This procedure is performed by inserting a long needle
through the surface of the chest to penetrate the lung cavity.
Fluid suitable for cytologic analysis is drawn up into the
needle, which is then withdrawn from the chest. Excludes:
any procedure requiring incision into chest cavity.
CSF STUDIES cytologic
analysis of cerebrospinal fluid for detection of bacteria,
fungi, and malignant cells, as well as protein and glucose
values.
CYTOLOGY aspiration
(fine or skinny needle) of a cyst or tumor, cells or fluid
from a mass or lymph node; also pleural effusion or ascites;
procedures include endoscopic brushings or washings of ulcerated
areas, Pap smears; cytology of vaginal, cervical, endometrial
and/or abdominal fluid.
CYTOLOGY REPORTS: cytologic
examination of urinary sediment for malignant cells; fine
needle aspiration of a cyst or tumor (detects 70% of bladder
cancers); also pleural effusion (thoracentesis) or ascites
(paracentesis).
DILATATION AND CURETTAGE (D
& C) Also called: D and C. Dilation of the cervix and
scraping or aspirating the contents for cytologic examination.
Key words/possible involvement: tumor, lesion, mass,
neoplastic tissue, atypical epithelium, friable tissue.
Other words/no involvement: if there is no reference
to abnormality in the cervix.
ENDOMETRIAL OR PELVIC WASHINGS
instillation of saline solution into a body cavity to evaluate
for occult tumor. After the solution is allowed to contact
surfaces in the area for about five minutes, it is aspirated
and sent for cytologic examination.
FRACTIONAL CURETTAGE separate
scraping of material from the endocervix and walls of uterine
corpus in a set order to determine which site may be the source
of the malignancy. This is the preferred diagnostic procedure
for endometrial cancer.
Key words/possible involvement: tumor, lesion, mass,
chunky material, neoplastic tissue, abnormal tissue, gray,
necrotic, or friable tissue.
Other words/no involvement: if there is no reference
to abnormality in the endometrium or endocervix.
NEEDLE BIOPSY AND ASPIRATION
Includes: skinny-needle biopsy, fine needle aspiration (FNA).
This procedure is performed by inserting a needle through
the surface into the questionable mass. Fluid suitable for
cytologic analysis is drawn up into the needle, which is then
withdrawn from the mass.
OMENTECTOMY surgical
removal of the omentum, the fatty covering in the anterior
abdomen, usually performed in the presence of ovarian cancer.
The omentum can then be examined for nonpalpable metastases.
This may be either a partial (infracolic) or complete omentectomy.
PAP SMEAR aspiration,
scraping or brushing of the cervix for cytologic evaluation.
PAP smear is not a reliable method for ruling out endometrial
cancer when used by itself.
PARACENTESIS removal
of fluid from abdomen for cytologic analysis by inserting
a long-needle syringe into the abdominal cavity.
PELVIC LYMPHADENECTOMY
a procedure during which the lymph nodes of the pelvis are
removed for evaluation. Also called: staging lymphadenectomy,
pelvic lymph node dissection. May also be performed via a
laparoscope.
PERITONEAL/PELVIC WASHINGS
instillation of saline solution into a body cavity to evaluate
for occult tumor. After the solution is allowed to contact
surfaces in the area for about five minutes, it is aspirated
and sent for cytologic examination.
SPLENECTOMY surgical
removal of the spleen. Splenectomy may occur as part of a
full staging laparotomy or occasionally as a separate procedure.
Unsuspected Hodgkin's disease is found in about 25% of splenectomy
specimens.
SPUTUM CYTOLOGY a specimen
of lung secretions obtained by deep cough for cytologic examination.
THORACENTESIS removal
of part of an abnormal collection of fluid from the pleural
cavity for cytologic analysis by inserting a long needle-syringe
instrument into the pleural cavity. Also called: chest tapping,
paracentesis thoracic, paracentesis pulmonis.
TRANSRECTAL/TRANSPERINEAL
NEEDLE BIOPSY Includes: standard needle biopsy, core
biopsy, skinny-needle biopsy, fine needle aspiration (FNA).
Sometimes called a sextant biopsy because needle biopsies
are taken from all regions of the prostate. Excludes: any
procedure requiring incision or transurethral approach. This
procedure is performed by inserting a needle through the perineum
(external) or via the rectum through the rectal wall to penetrate
areas of nodularity or induration of the prostate. Fluid or
tissue suitable for cytologic analysis is drawn up into the
needle, which is withdrawn from the prostate. Multiple random
needle biopsies may be performed to determine if tumor is
multifocal.
URINE CYTOLOGY cytologic
examination of urinary sediment for malignant cells; fine
needle aspiration of a cyst or tumor (detects 70% of bladder
cancers).
WASHINGS instillation
of approximately 200 ml. of saline solution into the abdomen
or pelvis during laparotomy. After the solution is allowed
to contact surfaces in the area for about five minutes, it
is aspirated and sent for cytologic examination. This procedure
is used to determine whether tumor is present in the abdomen
in the absence of ascites.
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