8.1 Medical Terminology & Standard Abbreviations for Cancer Abstracting
Key Takeaways
Most oncology terms are built from a root plus a prefix or suffix: adeno- (gland) + carcin (epithelial cancer) + -oma (tumor) = adenocarcinoma, a malignant tumor of glandular epithelium.
The suffix -sarcoma marks a malignant tumor of connective tissue (osteo-, chondro-, lipo-, leiomyo-, rhabdomyo-), while -blastoma usually marks an embryonal tumor of immature cells.
Surgical suffixes differ: -ectomy removes, -otomy cuts into, -ostomy creates an opening, and -scopy views with an instrument.
Abbreviations such as "r/o" (rule out) and "c/w" (consistent with) reverse the meaning of a diagnostic statement for reportability, so always expand abbreviations before applying ambiguous-term rules.
Registry text fields should use only standard abbreviations from the registry's approved list, because other readers (central registries, auditors) must interpret the text without the source record.
Why terminology is tested
"Medical terminology and standard abbreviations" is a Domain 3 topic, and it underlies every other data identification skill. A registrar who cannot read "s/p TAH-BSO, peritoneal washings neg, omentum w/ microscopic mets" quickly and correctly cannot stage an ovarian cancer. Terminology questions are usually embedded in case scenarios rather than asked as definitions.
Building terms from parts
Medical terms combine a root (the core meaning), often a prefix (at the start) and a suffix (at the end), with a combining vowel (usually "o") between parts.
Tissue-of-origin roots and prefixes
| Word part | Meaning | Example |
|---|---|---|
| adeno- | gland | adenocarcinoma, adenoma |
| angio-, hemangio- | vessel, blood vessel | angiosarcoma, hemangioma |
| carcin- | cancer of epithelium | carcinoma, carcinogen |
| chondro- | cartilage | chondrosarcoma |
| cyst- | sac, bladder | cystoscopy, cystadenocarcinoma |
| hepato- | liver | hepatocellular carcinoma |
| leiomyo- | smooth muscle | leiomyosarcoma |
| rhabdomyo- | skeletal (striated) muscle | rhabdomyosarcoma |
| lipo- | fat | liposarcoma |
| lympho- | lymph, lymphocyte | lymphoma, lymphadenopathy |
| melano- | black, pigment | melanoma |
| meningio- | meninges | meningioma |
| myelo- | bone marrow (or spinal cord) | myeloma, myelodysplastic |
| neuro- | nerve | neuroblastoma, neuroendocrine |
| osteo- | bone | osteosarcoma |
| squam- | scale-like | squamous cell carcinoma |
Suffixes
| Suffix | Meaning | Example |
|---|---|---|
| -oma | tumor or mass (not always malignant) | lipoma (benign), carcinoma (malignant) |
| -sarcoma | malignant tumor of connective tissue | osteosarcoma |
| -blastoma | tumor of immature (embryonal) cells | nephroblastoma (Wilms), retinoblastoma |
| -plasia | formation or growth | hyperplasia (more cells), dysplasia (disordered growth), metaplasia (one cell type replaced by another), anaplasia (loss of differentiation), neoplasia (new, autonomous growth) |
| -ectomy | surgical removal | mastectomy, lobectomy, colectomy |
| -otomy | cutting into | laparotomy, thoracotomy |
| -ostomy | surgically created opening | colostomy, ileostomy |
| -scopy | visual examination with an instrument | colonoscopy, bronchoscopy |
| -penia | deficiency | neutropenia, pancytopenia |
| -emia | blood condition | leukemia, anemia |
| -megaly | enlargement | splenomegaly, hepatomegaly |
Watch the traps: "-oma" is not always malignant (lipoma, adenoma, meningioma), and "lymphoma" and "melanoma" are malignant even though they end in "-oma."
Directional and descriptive terms
- Anterior/posterior, superior/inferior, medial/lateral, proximal/distal, superficial/deep.
- Ipsilateral means on the same side, contralateral the opposite side, and bilateral both sides. These matter for laterality coding and for deciding whether nodes are regional or distant (for example, contralateral axillary nodes in breast cancer are distant).
- Paired organs have right and left sides. The registry must record Laterality [410]: 0 = not a paired site; 1 = right; 2 = left; 3 = only one side involved, origin not specified; 4 = bilateral involvement, origin unknown, single primary; 5 = paired site, midline tumor; 9 = paired site, laterality unknown.
Pathology vocabulary
| Term | Meaning for the registrar |
|---|---|
| In situ / intraepithelial / noninvasive | Malignant cells that have not crossed the basement membrane (behavior /2) |
| Invasive / infiltrating | Malignant cells that have crossed the basement membrane (behavior /3) |
| Microinvasion | Invasion of 1 mm or less (for example, breast T1mi) |
| Differentiation | How much the tumor resembles normal tissue: well, moderately or poorly differentiated, or undifferentiated |
| LVI | Lymphovascular invasion (tumor in lymphatic or vascular spaces) |
| PNI | Perineural invasion |
| ENE | Extranodal extension (tumor beyond the lymph node capsule) |
| Margin | The cut edge of the specimen; "positive" means tumor at the ink |
| Satellite / tumor deposit | A discontinuous tumor nodule near the primary or in the drainage field |
High-yield abbreviations
| Area | Abbreviations |
|---|---|
| Procedures | FNA (fine-needle aspiration), bx (biopsy), SLNB (sentinel lymph node biopsy), ALND (axillary lymph node dissection), BCS (breast-conserving surgery), MRM (modified radical mastectomy), WLE (wide local excision), TURBT (transurethral resection of bladder tumor), TURP (transurethral resection of prostate), TAH-BSO (total abdominal hysterectomy with bilateral salpingo-oophorectomy), LAR (low anterior resection), APR (abdominoperineal resection), EGD, ERCP, EUS (endoscopic ultrasound), EBUS (endobronchial ultrasound), VATS (video-assisted thoracoscopic surgery) |
| Imaging | CXR, CT, MRI, PET or PET/CT, US (ultrasound), BI-RADS, PI-RADS, LI-RADS |
| Lab and markers | CBC, WBC, CEA, PSA, AFP, beta-hCG, LDH, CA-125, CA 19-9 |
| Pathology and biomarkers | IHC (immunohistochemistry), FISH, NGS, ER/PR/HER2, MSI, MMR, PD-L1, Ki-67 |
| Treatment | XRT or RT (radiation), EBRT, IMRT, SBRT, SRS, HDR/LDR brachytherapy, ADT (androgen deprivation therapy), BCG (intravesical immunotherapy) |
| Clinical shorthand | Dx, Tx, Hx, Sx, s/p (status post), h/o (history of), r/o (rule out), c/w (consistent with), NED (no evidence of disease), AWD (alive with disease), ECOG, KPS (performance status) |
Abbreviations that change reportability
- "R/o carcinoma" means rule out. It is not diagnostic and is not on the reportable ambiguous-terms list.
- "C/w carcinoma" means consistent with. It is a reportable ambiguous term (see Section 9.4).
- "Hx of breast CA" describes a history, not a new diagnosis. Decide whether the disease is active or history only before you assign a Class of Case.
Safe abbreviation practice
- Expand any unfamiliar or ambiguous abbreviation before you code. "PE" can mean physical exam or pulmonary embolism, and "MS" can mean multiple sclerosis or morphine sulfate.
- Use only approved abbreviations in registry text fields. Central registries, auditors and future abstractors must understand the text without the source record.
- Follow the Joint Commission "Do Not Use" principle for clinical orders. In registry text, the same rule means never writing an abbreviation that someone could reasonably misread.
Practice: decode a pathology line
"LUL wedge bx: poorly diff adenoCA, c/w lung primary (TTF-1+, CK7+, CK20−); LVI present; margins neg; 0/3 LN."
- LUL = left upper lobe (C34.1); Laterality = 2 (left).
- "Poorly diff adenoCA" = poorly differentiated adenocarcinoma (8140/3; grade recorded according to the Grade Manual).
- "C/w lung primary" = consistent with a lung primary, supported by the IHC profile (TTF-1 and CK7 positive, CK20 negative).
- LVI present; negative margins; zero of three lymph nodes positive.
A discharge summary states "Lung mass, r/o bronchogenic carcinoma; biopsy pending." No other information is available. How should the registrar treat this statement?
As reportable, because "r/o" is an abbreviation for "reportable oncology"
As reportable, because any mention of carcinoma in a discharge summary is diagnostic
As not diagnostic, because "r/o" means "rule out," which is not an ambiguous term that establishes reportability
As reportable, because "r/o" means "rule of" and indicates a confirmed rule-based diagnosis
A pathology report diagnoses a "rhabdomyosarcoma." Which description is correct?
A benign tumor of smooth muscle
A malignant tumor of skeletal (striated) muscle
A malignant tumor of glandular epithelium
A benign tumor of fat
An operative report states "s/p TAH-BSO." What does this abbreviation describe?
A scheduled total abdominal hysterectomy with bone scan
Suspected pelvic tumor with bilateral salivary obstruction
A subtotal hysterectomy with sparing of the ovaries
A patient who has had a total abdominal hysterectomy with bilateral salpingo-oophorectomy
Sections you finish are checked off in the contents.