The most accurate methods for diagnosing cancer are: 1) the microscopic examination of tissues removed from the site of a suspected cancer and 2) the microscopic examination of cells contained in fluid which bathes a suspected site. The purpose of the microscopic examination includes determination of characteristics of the tissues and cells indicative of a malignancy. Histologic examination (study of tissue) will be discussed beginning on page 194. The histologic information is found on the Pathology Report, sometimes called the Histopathology Report. Cytologic examination (study of cells) will be discussed in the Cytologic Examination learning section. The cytologic information is usually found on a Cytology Report, sometimes called a Cytopathology Report, but it may be submitted on a Pathology Report.
Both the operative reports and the pathologic reports should be reviewed by the tumor registry abstractor. The operative report may contain information regarding the size, location and extent of disease. It may also contain information on spread of disease to tissues which were not excised. For example, liver metastasis may be observed by the surgeon at the time of abdominal surgery, and a biopsy may not be taken. The surgeon may also describe the size of the tumor as well as apparent metastases to lymph nodes and other organs. It is important that this information be abstracted for a complete and accurate description of the extent of the disease. If there is a discrepancy between the operative report and the pathology report with respect to involvement of excised tissues, the pathology report takes precedence over the operative report.
The following are two topics included in this learning section.