IV.1.7 Pathology

In the pathology text area, enter the source of the specimen(s), size of the largest tumor, and other details needed per the following list:

• Describe the location of the primary site or sub-site and laterality of the primary tumor. See Section V.1 and Section V.2.
• Record the histologic diagnosis and identify the appropriate ICD-O-3 code. See Section V.3.2 and Section V.3.3.
• Describe multiple tumors and multiple sites of origin.
• Document the extent of disease and stage at diagnosis.  See Section V.4.1 and  Section V.4.2.
• Describe the number of lymph nodes examined and the number positive for cancer.
• Determine the method of diagnosis or confirmation.
• Identify all specimens examined microscopically.

Record all tumor related gross (non-microscopic) and microscopic cytologic and histologic finding whether positive or negative, and include differentiation. If additional space is needed, continue the pathology text in the Staging Text field.

For details about microscopic diagnoses, see Section IV.2.

For grade and differentiation, see Section V.3.5.

If there is a pathology report, all the Path Report  fields must be completed.  If the medical record only includes "hearsay" information or the physician only refers to a report finding, but there is no report in the medical record, do not complete the Path Report fields, but include the information in the text field.

Enter the facility ID number, dates, report types, and pathology numbers.   See Path Report Facility (1-5) Section IV.4.1, Path Report Numbers (1-5) Section IV.4.2, Path Date Specimen Collected (1-5) Section IV.4.3, and Path Report Type (1-5) Section IV.4.4.  

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