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Pathology
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 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 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 a 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 a 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 a 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 in 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 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 a tumor is present in the abdomen in the absence of ascites.