Pathology

 

Reporting Data Item

Business Justification

Definition

Note: Where ‘NHS Wales Data Dictionary’ the definition is as per the Data Dictionary.

Permissible Values

7. PATHOLOGY

7.0

Date specimen taken

Details the date the pathological specimen was taken to enable cross-referencing with the surgical procedures performed.

The date on which the specimen was extracted.

 

7.1

ENCDv4.5b (8.10)

 

NOGCA

Histological diagnosis

 

 

To determine the incidence of tumours of different histology and behaviour for epidemiological purposes.

A morphology code providing increased specificity for neoplasm recorded under diagnosis.

Refer to morphology code as in the extract of the International Classifications of Diseases for Oncology on "Morphology of Neoplasms" in ICD10.

 

*Permissible grouped values and labels will be dependent upon the output specifications.

7.2 ENCDv4.5b (8.11)

 

GOCI

 

Grade of differentiation

Prognostic factor. This field records the histopathological grade of the tumour as found in the specimen presented for examination. In tumours containing several areas of different grade, the grade of the predominant component should be recorded. For the majority of tumours (squamous carcinomas, adenosquamous carcinomas, adenocarcinomas and transitional cell carcinomas) the UICC (International Union Against Cancer) differentiation grading system should be used. Also enables survival analysis i.e. survival by grade.

Qualitative assessment of the differentiation of the tumour expressed as the extent to which a tumour resembles the normal tissue at that site.

 

Permissible values are agreed by the clinical steering groups and conform to the requirements of the reporting output specifications. Currently there is no explicit requirement to map to terminologies or classifications. This will be kept under review.

      Grade of differentiation is not appropriate or cannot be assessed

      Well differentiated

      Moderately differentiated

      Poorly differentiated

      Undifferentiated/anaplastic

7.3

ENCDv4.5b (8.16)

 

NOGCA

 

GOCI

T (Tumour) category (pathological)

 

 

To allow for the pathological T (Tumour) stage to be taken into account in the analysis of treatment and outcome.

Post surgical staging: the extent of the primary tumour after excision of the primary cancer. This is derived from Local Invasion - Tumour Extent and Structure (s) Invaded data items on the Pathology dataset.

Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours

7.4 ENCDv4.5b (8.17)

 

NOGCA

 

GOCI

N (Node) category (pathological)

 

 

To allow for the pathological N (Node) stage to be taken into account in the analysis of treatment and outcome.

The histological evidence of the absence or presence and extent of regional lymph node metastases. This is derived from Local/Regional nodes positive, Other Nodes positive and Marker lymph node 1 positive data items on the Pathology dataset.

Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours

7.5

ENCDv4.5b (8.18)

 

NOGCA

 

GOCI

M (Metastasis) category (pathological)

 

To allow for the pathological M (Metastasis) stage to be taken into account in the analysis of treatment and outcome.

The histological evidence of the absence or presence of distant metastases. This is derived from the Distant Metastases data item on the Pathology dataset.

Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours

7.6

NOGCA

Proximal margin involved

To determine the adequacy of the excision. Required for submission to the national oesophago-gastric cancer audit.

The minimum distance from the proximal specimen margin to tumour is measured from histological slides. If this is less than or equal to 1 mm the margin is by definition involved.

      Yes

      No

7.7

NOGCA

Distal margin involved

To determine the adequacy of the excision. Required for submission to the national oesophago-gastric cancer audit.

The minimum distance from the distal specimen margin to tumour is measured from histological slides. If this is less than or equal to 1 mm the margin is by definition involved.

      Yes

      No

 

7.8

NOGCA

Circumferential margin involved

To determine the adequacy of the excision. Required for submission to the national oesophago-gastric cancer audit.

The minimum distance from the circumferential specimen margin to tumour is measured from histological slides. If this is less than or equal to 1 mm the margin is by definition involved.

      Yes

      No

7.9

NOGCA

 

GOCI

Nodes examined number

To determine the number of lymph nodes examined in resected specimens. Required for submission to the national oesophago-gastric cancer audit.

The number of local/regional lymph nodes examined and reported. Local/regional nodes are defined by the UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Atlas and vary with the primary cancer site

 

7.10

NOGCA

Nodes positive number

To determine the number of positive lymph nodes in resected specimens. Required for submission to the national oesophago-gastric cancer audit.

The number of local/regional lymph nodes reported as being positive for the presence of tumour metastases. Local/regional nodes are defined by the UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Atlas and vary with the primary cancer site.