• Number of lymph nodes removed (if not documented in pathology text field) • Size of tumor removed (if not documented in pathology text field) • Documentation of residual tumor • Evidence of invasion of surrounding areas (if not documented in pathology text field) • If surgery planned but not performed; reason primary site surgery could not be completed Path Text Requirements: Date(s) of procedure(s) and type of tissue specimen(s) • Tumor type and grade (include all modifying adjectives, such as predominantly, with features of, • with foci of) Tumor size and extent of tumor spread • Involvement of resection margins • Number of lymph nodes involved and examined • Positive and negative findings. Record positive test results first. • Path Text Recommendations: Note if pathology report is a slide review or a second opinion from an outside source (AFIP, Mayo, etc.). • Record any additional comments from the pathologist, including differential diagnoses considered, • ruled out or favored. Primary Site Text Requirements: Location of the primary site of the tumor, including subsite. • Tumor laterality • Histology Text Requirements: Histologic type (adenocarcinoma, sarcoma, CLL, squamous cell, etc.) and behavior (benign, in situ, • malignant) Grade, differentiation from scoring systems such as Grade, etc. • Gleason’s Score, Bloom-Richardson Staging Text Requirements: Tumor Size (if not documented in pathology text field) • Date(s) of biopsy and/or other procedure(s) (including clinical) that provided information for • assigning stage (if not documented in pathology text field) Extent of tumor (depth of spread in primary and other organs involved by direct extension) (if not • documented in pathology text field) Status of margins (if not documented in pathology text field) • Number and sites of positive lymph nodes (and condition of nodes if applicable matted vs. • – moveable) (if not documented in pathology text field) Site(s) of distant metastasis (if not documented in pathology text field) • Notation of TNM and summary stage schema specifics •
• Number of lymph nodes removed (if not documented in pathology text field) • Size of tumor removed (if not documented in pathology text field) • Documentation of residual tumor • Evidence of invasion of surrounding areas (if not documented in pathology text field) • If surgery planned but not performed; reason primary site surgery could not be completed Path Text Requirements: • Date(s) of procedure(s) and type of tissue specimen(s) • Tumor type and grade (include all modifying adjectives, such as predominantly, with features of, with foci of) • Tumor size and extent of tumor spread • Involvement of resection margins • Number of lymph nodes involved and examined • Positive and negative findings. Record positive test results first. Path Text Recommendations: • Note if pathology report is a slide review or a second opinion from an outside source (AFIP, Mayo, etc.). • Record any additional comments from the pathologist, including differential diagnoses considered, ruled out or favored. Primary Site Text Requirements: • Location of the primary site of the tumor, including subsite. • Tumor laterality Histology Text Requirements: • Histologic type (adenocarcinoma, sarcoma, CLL, squamous cell, etc.) and behavior (benign, in situ, malignant) • Grade, differentiation from scoring systems such as Gleason’s Score, Bloom-Richardson Grade, etc. Staging Text Requirements: • Tumor Size (if not documented in pathology text field) • Date(s) of biopsy and/or other procedure(s) (including clinical) that provided information for assigning stage (if not documented in pathology text field) • Extent of tumor (depth of spread in primary and other organs involved by direct extension) (if not documented in pathology text field) • Status of margins (if not documented in pathology text field) • Number and sites of positive lymph nodes (and condition of nodes if applicable – matted vs. moveable) (if not documented in pathology text field) • Site(s) of distant metastasis (if not documented in pathology text field) • Notation of TNM and summary stage schema specifics
abstract-plus-training-manual-v35.docx