The Operative Pathology Report
The Operative Pathology Report (Surgical Specimen)
The operative pathology report of the surgical specimen contains a description of the gross and microscopic examination of the surgical specimen. This report is important for you, the tumor registrar, because it may tell you which structures and organs of the body are involved by the tumor. It verifies the primary site of the cancer and describes the extent to which it has spread.
Tumor size will usually be stated in the gross description of the surgical specimen. It is usually specified in centimeters and needs to be converted to millimeters. The tumor size given on the pathology report should always be recorded.
Abstracting the Pathology Report
Let us now examine the following pathology reports (G2-G5). A number of important features of these reports are given below:
- The date of the report. This date should coincide with the date of the corresponding operative report, not the date the slides were read nor the date of dictation.
- A short clinical history of the patient. This information describes the reasons why the tissue was removed.
- In the space labeled "pre-operative diagnosis" or "clinical diagnosis will be a brief description of the diagnosis as based on the physical examination and/or on a statement provided by a referring physician.
- The "gross description" of the report will contain a description of the material received for examination and will include the source of the specimen. The size of the tissue fragments taken at biopsy and how they were received and the size of the surgical specimen are not important to the abstractor and should not be reported, but if the tumor size is given it should be recorded.
- The "microscopic description" of the report contains the pathologist's description of the specimen(s) examined. Of special significance is the total size of the tumor, and where it has extended or metastasized. Size will usually be reported in centimeters (cm), and often the length, breadth, and thickness of the tumor will be given. The abstractor need only report the largest dimension of the tumor. If there is a discrepancy between the microscopic and gross description of the excised tumor, the microscopic takes precedence.
- The "diagnosis" section will summarize the microscopic findings for each specimen examined. The diagnosis confirms or denies gross findings or malignancy, giving the histologic type of the cancer and, in some instances, giving the grade or degree of differentiation (the degree to which the malignant cells resemble the normal tissue they originated from).
- Complete excision of the tumor may also be confirmed or denied by describing whether or not surgical margins are clear of tumor. This most often appears in the microscopic, but may also be found in the final diagnosis.
When summarizing the pathology report, record the following information:
- The date and name of the report
- Slide number
- The source of the specimen
- The primary size
- Tumor size
- The histologic diagnosis, including the grade or degree of differentiation
- The extent of disease within and beyond the primary site
Try abstracting some sample operative reports in Practical Examples.