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Surgical Reports

All surgical procedures should be noted in a written operative report, either as a separate entry or as part of progress report. Pertinent observations from operative procedures should be noted, including the location of the tumor and any direct extension, nodal involvement, or metastatic spread. Information from the operative or procedure report supplements the information noted in the pathology report. The operative report should state whether the procedure is considered curative or palliative. If a pallative procedure is done, any residual tumor remaining may be biopsied.

Non-cancer directed surgeries such a cystotomy, gastrotomy, laparotomy, and thoracotomy may contribute information on involvement of organs, tissues, or lymph nodes that were not resected. Bypass surgery may be performed to create a passage around a tumor, often for palliation of symptoms. Bypass surgeries such as esophagogastrostomy, gastrostomy, and urethrostomy may provide information on the extent of the tumor involvement.

To summarize, cancer-directed surgery reports should describe the removal and size of the tumor. Observations of regional lymph nodes, adjacent structures, and organs should be included. The pathology report will confirm the presence or absence of tumor in resected specimens.