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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 of absence
of tumor in resected specimens.
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