Information Specification

The data items required for National Cancer Data Standards for Wales – Site Specific – Urology and their equivalent labels in COSD V9.0, where there is an equivalent, are listed below.

 

Where the specification cites NHS Wales Data Dictionary, please refer to the Dictionary for the relevant guidance i.e. definition, format, or code list.

 

For consistency, all dates listed in the Specification are standardised as ccyymmdd.

 

Where D is denoted in Status, this indicates that the information should be derived from another data item. This typically occurs with data items that are simply text representations of their code counterparts. Other Status codes are M (Mandatory), R (Required) – the data item should be recorded where applicable and O (Optional).

 

 

Core data items should be collected for all cancers.  To reduce replication of information, Core data items have not been listed in this site-specific Standard and users should refer to National Cancer Data Standards for Wales 1. National Cancer Data Set - Full list DSCNs.xlsx (live.com) for a list of Core requirements. However, in some cases, the site-specific application of Core data items may differ e.g. a particular tumour site may require additional or fewer codes to those already published in Core, or perhaps have additional business rules as to how the Core data item should be coded. Where this occurs, the Core data item will be replicated in the site-specific Standard with the respective additional site-specific detail. These are flagged in the following table with an * next to the data item name.

 

 

For data items used in the National Cancer Data Standards for Wales that already exist within the NHS Wales Data Dictionary. These data items have been flagged with an † next to the data item name, as whilst this introduces a change to an existing information standard, the immediate use of this mandate will be used as a framework for the development of the CIS, therefore service/data providers should continue with ‘business as usual’ in terms of the data being collected and reported.

 

 

National Cancer Data Standards for Wales – Urology: Prostate

 

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Prostate - Diagnostic Procedures  To carry cancer diagnostic details for Prostate  (One occurrence per core diagnostic procedure group)

Prostate Biopsy Technique

Record the type of prostate biopsy technique performed before treatment.  

Note: Of the adjacent codes, Template Biopsy is not present in COSD. This has been added here to provide greater granularity.

Code List

10

TRUS guided biopsy (standard)

M

Prostate Biopsy Technique (UR15410)

11

TRUS guided biopsy (targeted)

12

TRUS guided biopsy (targeted & standard)

13

Transperineal biopsy (systematic)

14

Transperineal biopsy (targeted)

15

Transperineal biopsy (targeted & systematic)

16

Template Biopsy

99

Not known

Biopsy Anaesthetic

Record the type of anaesthetic used during the biopsy

Code List

1

Local

M

Biopsy Anaesthetic (UR15440)

2

Sedation

3

General

9

Not known

Prostate - Diagnosis  To carry specific diagnosis details for Prostate  (One occurrence per core diagnosis group)

mpMRI Pre-Biopsy

Was a multiparametric mpMRI performed on the patient before the biopsy

Code List

Y

Yes

R

mpMRI Pre-Biopsy (UR15500)

N

No

9

Not Known

MRI/Fusion Biopsy

Was a MRI/Fusion biopsy performed on the patient

Code List

Y

Yes

R

MRI/Fusion Biopsy (UR15510)

N

No

9

Not Known

PSA (Diagnosis)

Prostate Specific Antigen blood level in ng/ml measured at time of diagnosis

maxn5.n1

N/A

N/A

R

PSA (Diagnosis) (UR15070)

Treatment  - Prostate  To carry additional  cancer treatment details for Prostate  (One occurrence per Core Treatment)

Type of First Cancer Treatment*

This denotes the first specific treatment modality administered to a patient  
(Multiple responses possible)

Note: Of the adjacent codes, Watchful Waiting, Radical Prostatectomy, Transurethral Resection of Prostate (TURP), Bilateral Orchidectomy, Focal Therapy (any modality), Low Dose Rate Brachytherapy, High Dose Rate Brachytherapy, Continuous Androgen Deprivation Therapy,
Intermittent Androgen Deprivation Therapy, Neoadjuvant Hormone Therapy, Adjuvant Hormone Therapy and Palliative Radiotherapy are not present in Core. These have been added here to provide greater granularity. Whilst the Core data item has additional codes, only the adjacent codes are applicable to the Urology - Prostate site-specific standard.

Code List

43

Watchful Waiting

R

Cancer Treatment Modality (Registration) (CR2040)

08

Active Monitoring (excluding non-specialist Palliative Care)

32

Radical Prostatectomy

33

Transurethral Resection of Prostate (TURP)

34

Bilateral Orchidectomy

12

Cryotherapy

11

High Intensity Focused Ultrasound (HIFU)

35

Focal Therapy (any modality)

05

Teletherapy (Beam Radiation excluding Proton Therapy)

36

Low Dose Rate Brachytherapy

37

High Dose Rate Brachytherapy

38

Continuous Androgen Deprivation Therapy

39

Intermittent Androgen Deprivation Therapy

40

Neoadjuvant Hormone Therapy

41

Adjuvant Hormone Therapy

02

Anti-cancer Drug Regimen (Cytotoxic Chemotherapy)

42

Palliative Radiotherapy

07

Specialist Palliative Care

97

Other Treatment

Treatment - Surgery - Prostate  To carry additional surgical cancer treatment details for Prostate  (One occurrence per Core Treatment)

Procedure - Nerve Sparing

Extent of surgical nerve sparing.   

Code List

1

Bilateral

R

Procedure - Nerve Sparing (UR15420)

2

Unilateral

3

None

9

Not known

Radical Prostatectomy Margin Status

The surgical margin status following radical prostatectomy

Code List

1

Negative margins

R

Radical Prostatectomy Margin Status (UR15430)

2

Positive margins <3mm in length

3

Positive margins >3mm in length

4

Positive margins, length unknown

9

Not Known

Pathology - Prostate  To carry the cancer pathology details for Prostate  (One occurrence per path report)

Gleason Grade (Primary)

What is the most extensive Gleason grade?

an1

 

Range 2-5 (in categories)

R

Gleason Grade (Primary) (pUR15210)

Gleason Grade (Secondary)

If additional grades are present, what is the highest grade (biopsy) or the second most extensive grade (TURP and radicals).   If no additional grades are present, primary and secondary are the same

an1

 

Range 2-5 (in categories)

R

Gleason Grade (Secondary) (pUR15220)

Gleason Grade (Tertiary)

Is there a different third grade in addition to the primary and secondary grades and what is the value?

Note: The Tertiary Grade is not the added value of the Primary and Secondary Gleason grades

an1

 

Range 3-5 (in categories)

R

Gleason Grade (Tertiary) (pUR15230)

8

Not applicable

Perineural Invasion

Is there perineural invasion (invasion into perineurium of nerve bundles - PNI)

Code List

Y

Yes (Present)

R

Perineural Invasion (pUR15240)

N

No (Not identified)

9

Not Known

TURP Tumour Percentage

For TURP only, what percentage of tumour if clinically unsuspected tumour.  

max n3
Range 0-100

N/A

N/A

R

TURP Tumour Percentage (pUR15270)

Other - Prostate

Low Volume Metastases

Is there low volume metastases present
(Low Volume = 5 or less)

Code List

Y

Yes 

R

N/A

 

 

National Cancer Data Standards for Wales – Urology: Bladder

 

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Imaging - Bladder - Urological To carry the additional imaging details for Bladder cancers

Date of Image Request

The date on which imaging is requested that contributes to pre-treatment staging

Multiples may be added for various imaging modalities.

Note:   This data item is required for CT Urogram/MRI/CT Abdo & Pelvis

ccyymmdd

N/A

N/A

R

N/A

FDG PET-CT Required Due to Indeterminate Findings on CT/MRI

Record if there are indeterminate findings identified on CT or MRI justifying a FDG PET CT. This is required for MIBC and High Risk NMIBC patients prior to radical treatment with indeterminate findings on MRI or CT.

Note:
i. High Risk Non Muscle Invasive Bladder Cancer (HR-NMIBC) = any grade with T1, Grade 3 pTa, CIS
ii. Muscle Invasive Bladder Cancer (MIBC) = T2 and above

Code List

Y

Yes

R

N/A

N

No

9

Not Known

Cancer Care Plan - Bladder - Urological To carry the cancer care plan details for Urological cancers  (One occurrence per Core Cancer Care Plan)

Hydronephrosis

Consequence of reduced outflow of urine from Kidney.  May be present in one or both kidneys

Code List

0

None

R

Hydronephrosis  (UR15010)

L

Left

R

Right

B

Bilateral

8

Not Applicable (No kidneys)

9

Not known

Treatment - Bladder  To carry the cancer treatment details for Bladder   (One occurrence per Core Treatment)

Intravesical Chemotherapy Received Indicator

Only required for patients having chemotherapy. This distinguishes patients having intravesical chemotherapy from those receiving intravenous therapy.

Record Post Op Single Dose if the patient received a single dose of chemotherapy post operatively within 24 hours and/or 6 Week Chemotherapy Course if the patient was treated with a 6 week course of chemotherapy.

Note: Of the adjacent codes Post Op Single Dose and 6 Week Chemotherapy Course are not present in COSD. They have been added here to provide greater granularity.

Code List

P

Post Op Single Dose

M

Intravesical Chemotherapy Received Indicator (UR15100)

S

6 Week Chemotherapy Course

N

No

9

Not Known

Intravesical Chemotherapy - Date Course Completed

Record the date that the intravesical  6 week course of chemotherapy was completed.

Note: Only required for completion if
6 Week Chemotherapy Course is recorded for Data Item Intravesical Chemotherapy Received Indicator

ccyymmdd

N/A

N/A

R

N/A

Intravesical Immunotherapy Received Indicator

Only required for patients having immunotherapy. This distinguishes patients having intravesical immunotherapy from those receiving intravenous therapy.
 
Record Induction Course if the patient is having intravesical immunotherapy as an induction treatment and/or Maintenance Course if the patient is having intravesical immunotherapy as a maintenance course of treatment 

Note: Of the adjacent codes Induction Course and Maintenance Course are not present in COSD. They have been added here to provide greater granularity.

Code List

I

Induction Course

M

Intravesical Immunotherapy Received Indicator (UR15110)

M

Maintenance Course

N

No

9

Not Known

Intravesical Immunotherapy - Maintenance course  completed

Only required for patients having immunotherapy.  

Record Yes for patients who have completed a maintenance course of intravesical immunotherapy for at least 1 year

Code List

Y

Yes

R

N/A

N

No

9

Not Known

Surgery - Bladder  To carry additional surgical details for Bladder Cancer where TURBT is the procedure undertaken

Documentation Recorded Describing Tumour details

Only required for patients having undergone a TURBT procedure.

Indicate if there is a bladder diagram detailing the  tumour location, size, number and appearance at initial resection. If there is not a bladder diagram, detail can be provided using text only.

Code List

 Y

Yes

R

N/A

N

No

Resection Complete at Time of Initial TURBT

For all TURBT procedures, record if the resection was complete at the time of the initial TURBT

Code List

Y

Yes

R

N/A

N

No

9

Not known

Tumour located in bladder diverticulum

Record if the tumour is located in a bladder diverticulum

Code List

Y

Yes

R

N/A

N

No

9

Not known

Surgery - Bladder  To carry additional surgical details for High Risk Non Muscle Invasive Bladder Cancer

Second TURBT or early Cystoscopy (with or without biopsy) performed

Record if a  second resection of TURBT or early cystoscopy (with or without biopsy) was done. For a definition of early cystoscopy refer to QPI guidelines 

Code List

 Y

Yes

R

N/A

N

No

Date second TURBT or Early Cystoscopy was performed

Record the date the second resection of TURBT or early cystoscopy was performed

ccyymmdd

 

 

R

N/A

Was this within 6 weeks (42 days) of the initial resection

Record if the second resection of TURBT or early cystoscopy was done within 6 weeks (42 days) of the initial resection

Code List

Y

Yes

R

N/A

N

No

Surgery - Bladder  To carry additional surgical details for Bladder Cancer

Surgical Pathway Type

Record the type of surgical pathway that the patient followed

Code List

1

A protocol enhanced recovery (ERAS) without daily documentation in medical notes

R

N/A

2

A protocol enhanced recovery (ERAS) with daily documentation in medical notes

3

A standard surgical pathway

9

Not Known

ERAS Pathway Completed

Did the patient complete the ERAS pathway

Note: This data item is only required where Surgical Pathway Type is recorded as A protocol enhanced recovery (ERAS) without daily documentation in medical notes or A protocol enhanced recovery (ERAS) with daily documentation in medical notes

Code List

1

Yes

R

N/A

2

No, but partial completion

3

No, non-completion

9

Unknown/Not documented

Hospital Admission Details - Bladder  To carry hospital admission details for Bladder Cancer

Date of Re-admission to Hospital follow Cystectomy

Only required for patients who have received a cystectomy.

Record the date of re-admission following cystectomy where this was within 90 days following cystectomy.

Any subsequent admission to hospital required within 90 days is assumed related to cystectomy surgery

ccyymmdd

N/A

N/A

R

N/A

 

 

 

 

 

 

 

Pathology - Bladder  To carry the cancer pathology details for Bladder  (One occurrence per path report)

Date of Pathology Report

The date the pathology report was authorised

Required for clinical indicator reporting - To determine the time interval between date sample taken  and pathology being reported 

ccyymmdd

N/A

N/A

R

N/A

Detrusor Muscle Presence Indicator

Presence or absence of detrusor muscle in the specimen

Code List

1

Present (Yes)

R

Detrusor Muscle Presence Indicator (pUR15120)

2

Absent (No)

3

Indeterminate

X

Not applicable

Tumour Grade (Urology)

Specify whether Low, High Grade or PUNLMP  (Papillary Urothelial Neoplasm of Low Malignant Potential)

Code List

L

Low

R

Tumour Grade (Urology) (pUR15290 )

H

High

P

PUNLMP

X

Not applicable

Associated Carcinoma in situ (CIS)

Presence or absence of associated carcinoma in situ in the specimen

Note: only for completion when recorded morphology (Core data item Histological Diagnosis (Morphology) (ICD)) is 8120/3 or 8130/3

Code List

Y

Present (Yes)

R

 N/A

N

Absent (No)

9

Not Known

Necrosis

Presence or absence of necrosis in the specimen

Code List

Y

Present (Yes)

R

 N/A

N

Absent (No)

8

Not Applicable

Lymphovascular Invasion*

An indication of the presence of absence of unequivocal tumour in lymphatic and/or vascular spaces.    
 
Note:
i. Data item not applicable to Haematological diagnoses
ii. Of the adjacent codes Not Applicable is not present in Core. This has been added here to provide greater granularity.

Code List

NU

No, vascular/lymphatic invasion not present

R

Cancer vascular or lymphatic invasion pCR0870

YU

Yes, vascular/lymphatic invasion present

YV

Vascular invasion only present

YL

Lymphatic invasion only present

YB

Both lymphatic and vascular invasion present

UU

Uncertain whether vascular/lymphatic invasion is present or not

XX

Cannot be assessed

99

Not known

98

Not Applicable

Biomarkers  (One occurrence of this group per Core )

PD-L1 Expression

Select the recorded outcome for the PD-L1 

Code List

1

Present (Yes)

R

N/A

2

Absent (No)

5

Indeterminate/Test Failed

9

Not Known

PDL1 % Value

Specify the absolute % value of the PD-L1 expression

an3

N/A

N/A

R

N/A

 

 

National Cancer Data Standards for Wales – Urology: Testicular

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Cancer Care Plan - Urological - Testicular  To carry the cancer care plan details for Urological cancers

S-Category

Based on serum tumour markers AFP, HCG and LDH.  For Testicular Cancer S-Category is an additional prognostic factor

Code List

SX

Tumour marker studies not available or not performed

R

S-Category  (UR15030)

S0

Tumour marker levels within normal limits

S1

LDH <1.5 X Normal and HCG (mIU/ml) <5000 and AFP (ug/ml) < 1000

S2

LDH 1.5-10 X Normal or HCG (mIU/ml) 5000-50,000 or AFP (ug/ml) 1000-10,000

S3

LDH >10 X Normal or HCG (mIU/ml) >50,000 or AFP (ug/ml) >10,000

Laboratory Results - Urological - Testicular  To carry Urological Laboratory result details  (One occurrence per Core - Lab results)

S-Category AFP

AFP (Alpha Feto-Protein) is a serum tumour marker.  
To be collected once at diagnosis by specialist MDT

max n6
Range (0-999999)

N/A

N/A

R

 S-Category AFP  (UR15040)

S-Category HCG

HCG (Human Chorionic Gonadotropin) is a serum tumour marker. 
To be collected once at diagnosis by specialist MDT

max n7
Range (0-9999999)

N/A

N/A

R

S-Category HCG  (UR15050)

S-Category LDH

LDH (Serum Lactate Dehydrogenase) is a serum tumour marker. 
To be collected once at diagnosis by specialist MDT

max n6
Range (0-999999)

N/A

N/A

R

S-Category LDH (UR15060)

Normal LDH
 

This is the upper limit of normal for the LDH (Lactate Dehydrogenase Level) assay which is used to calculate the S Category
To be collected once at diagnosis by specialist MDT

max n6
Range (0-999999)

N/A

N/A

R

Normal LDH (UR15020)

Site Specific Staging - Testicular  To carry staging details for Testicular Cancer  (One occurrence per Core site specific staging group)

Stage Grouping (Testicular)

Nationally agreed anatomical stage groupings as defined by The Royal Marsden Hospital (RMH)

Code List

1

Stage 1 - Confined to testis

R

Stage Grouping (Testicular) (UR15300)

1S

Stage 1S

1M

Stage 1M - Rising post orchidectomy markers only

2A

Stage 2A - Abdominal lymphadenopathy <2cm

2B 

Stage 2B - Abdominal lymphadenopathy 2cm-5cm

2C

Stage 2C - Abdominal lymphadenopathy >5 cm

3A

Stage 3A - Supradiaphragmatic lymphadenopathy with abdominal lymphadenopathy <2cm

3B 

Stage 3B - Supradiaphragmatic lymphadenopathy with abdominal lymphadenopathy 2cm-5cm

3C 

Stage 3C - Supradiaphragmatic lymphadenopathy with abdominal lymphadenopathy >5cm

4A 

Stage 4A - Extralymphatic metastases with abdominal lymphadenopathy <2cm

4B 

Stage 4B - Extralymphatic metastases with abdominal lymphadenopathy 2cm-5cm

4C 

Stage 4C - Extralymphatic metastases with abdominal lymphadenopathy >5cm

Extranodal Metastases 

For Testicular Cancer Stage 4 only. 
Indicate the extent of metastatic spread.  This is a repeating data item.

Code List

H

Liver involvement

R

Extranodal Metastases  (UR15320)

B

Brain involvement

M

Mediastinal involvement

N

Neck nodes

L

Lung involvement

Lung Metastases Sub Stage Grouping

Where lung metastases are identified, specify the RMH grouping.

Code List

L1

Less than or equal to 3 metastases

R

Lung Metastases Sub Stage Grouping  (UR15330)

L2

Greater than 3 metastases

L3

Greater than 3 metastases, one or more greater than or equal to 2 cm diameter

Pathology - Testicular  To carry the cancer pathology details for Testicular  (One occurrence per path report)

Rete Testes Invasion

For Seminoma only
Does the tumour invade the rete testis

Code List

Y

Yes (Present)

M

Rete Testes Invasion (pUR15310)

N

No (Not identified)

X

Not applicable (cannot be assessed)

Size of Tumour

For Seminoma only
Outline the description the size of the tumour

Code List

1

>=4 cm

M

N/A

 

 

 

2

<4 cm

 

 

 

 

National Cancer Data Standards for Wales – Urology: Renal (Kidney)

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Cancer Care Plan - Urological - Renal  To carry the cancer care plan details for Urological cancers

Estimated Glomerular Filtration Rate
 

This is the estimated Glomerular Filtration Rate.  It is a measurement of kidney function in mls/min/1.73m2.   
This is to be collected once at diagnosis.  

max n2

Positive numerical values (categories can be derived from this at a later stage)

Range (0-99)

N/A

N/A

R

Estimated Glomerular Filtration Rate  (UR15000)

Pathology - Renal/Kidney  To carry the cancer pathology details for Kidney  (One occurrence per path report)

Tumour Necrosis Indicator

Is there evidence of coagulative tumour necrosis

Code List

1

Macroscopic (confluent)

R

Tumour Necrosis Indicator (pUR15130)

2

Microscopic (coagulative)

3

Not identified

8

Cannot be assessed (eg, post embolisation)

Perinephric Fat Invasion

Is there evidence of perinephric fat invasion

Code List

Y

Yes (Present)

R

Perinephric Fat Invasion (pUR15140 )

N

No (Not identified)

9

Cannot be assessed/Not applicable

Adrenal Invasion

Is there evidence of direct adrenal invasion

Code List

1

Present, direct extension

R

Adrenal Invasion (pUR15150)

2

Present, metastasis

3

Not identified

8

Cannot be assessed/Not applicable

Renal Vein Tumour

Is there evidence of tumour thrombus in the renal vein

Code List

1

Microscopic involvement only

R

Renal Vein Tumour (pUR15160)

2

Gross involvement confirmed microscopically

3

Not identified

8

Cannot be assessed/Not applicable

Gerota's Fascia Invasion

Is there evidence of invasion into Gerota's fascia

Code List

Y

Yes (Present)

R

Gerota's Fascia Invasion (pUR15170)

N

No (Not identified)

9

Cannot be assessed/Not applicable

Prognostic Score - For Metastatic Renal Cell Carcinoma  To carry prognostic score details for patients who present with metastatic renal cell ca or develop metastatic disease as part of primary/non primary cancer pathway

IMDC/HENG Absolute Value
(International Metastatic RCC Database Consortium) Risk Score (formerly known as Heng score)

Record the absolute value for IMDC/HENG

an1
Range (0-6)

 N/A

 N/A

R

N/A

IMDC/HENG Risk Score
(International Metastatic RCC Database Consortium) Risk Score (formerly known as Heng score)

Record the associated risk factor for the patient.   The prognostic score predicts survival in patients with metastatic renal cell carcinoma treated with systemic therapy

Note: This data item is derived from the absolute value recorded in IMDC/HENG Absolute Value

Code List

0

0 - Favourable Risk

D

N/A

1

1-2 - Intermediate Risk

2

3-6 - Poor Risk

 

 

 

National Cancer Data Standards for Wales – Urology: Penile

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Diagnostic Procedures - Staging - Sentinel Node Details - Penile  To carry specific staging details for Penile  (One occurrence per core diagnosis group)

Nodes Examined Number (Sentinel)
Right Laterality

The number of Sentinel nodes examined
Record 0 if nodes not sent

max n2

N/A

N/A

R

N/A

Nodes Positive Number (Sentinel)
Right Laterality

The number of sentinel nodes reported as being positive for the presence of tumour metastases. 

max n2

N/A

N/A

R

N/A

Extra Capsular Extension (Sentinel)
Right Laterality

Is there evidence of extra capsular spread/extension?

Code List

Y

Yes (Present)

R

N/A

N

No (Not identified)

X

Cannot be assessed

Nodes Examined Number (Sentinel)
Left Laterality

The number of Sentinel nodes examined
Record 0 if nodes not sent

max n2

N/A

N/A

R

N/A

Nodes Positive Number (Sentinel)
Left Laterality

The number of sentinel nodes reported as being positive for the presence of tumour metastases. 

max n2

N/A

N/A

R

N/A

Extra Capsular Extension (Sentinel)
Left Laterality

Is there evidence of extra capsular spread/extension?

Code List

Y

Yes (Present)

R

N/A

N

No (Not identified)

X

Cannot be assessed

Pathology - Penile  To carry the cancer pathology details for Penis  (One occurrence per path report)

Sub-Type of Tumour

Further details to record the sub-type of tumour
(Multiple response can be chosen if tumour is a mixed tumour)

Code List

1

Squamous Carcinoma (usual type)

R

N/A

2

Basaloid Squamous Carcinoma

3

Warty/Condylomatous Carcinoma

4

Verrucous Carcinoma

5

Papillary Squamous Carcinoma

6

Sarcomatoid/Spindle Cell Carcinoma

7

Other

Other - Sub Type of Tumour

If Other is chosen in Sub-type of tumour, specify the other type

an50

N/A

N/A

R

N/A

Grade of Differentiation (Pathological)*

Grade of Differentiation is the definitive grade of the tumour based on the evidence from a pathological examination

Note:
i. In Core there are codes of G4 (Undifferentiated/anaplastic) and GX (Grade of differentiation is not appropriate or cannot be assessed). Those codes are not applicable within the Urology - Penile site-specific standard. 
ii. Of the adjacent codes Sarcomatoid Areas Present is not present in Core. This has been added here to provide greater granularity.

Code List

G1

Well differentiated

R

Grade of Differentiation (Pathological) (pCR0860)

G2

Moderately differentiated

G3

Poorly differentiated

G5

Sarcomatoid Areas Present

Maximum Tumour Width

Record the size in mm of the maximum tumour width
Record 0 if Not Assessable

max n2

N/A

N/A

R

N/A

Depth of Tumour Invasion

Record the depth of invasion of the tumour in mm
Record 0 if Not Assessable

max n2

N/A

N/A

R

N/A

Perineural Invasion

Presence or absence of perineural invasion (PNI) invasion in the specimen

Note: Of the adjacent codes Cannot be Assessed is not present in COSD. This has been added here to provide greater granularity.

Code List

Y

Yes (Present)

R

Perineural Invasion (pUR15240)

N

No (Not identified)

X

Cannot be assessed

Excision Margin*

An indication as to whether the excision margin was clear of the tumour and, if so, by how much. Where the measurement is more than one measurement, record the closest or closest relevant margin.
Where measurements are not taken use 01, 05, 06

Note: Of the adjacent codes, Excision margins are clear (tumour 1mm from the margin), Excision margins are clear (tumour 2mm from margin), Excision margins are clear (tumour 3mm from margin), Excision margins are clear (tumour 4mm from margin) and Excision margins are clear (tumour 5mm from margin) are not present in Core. These have been added here to provide greater granularity. Whilst the Core data item has additional codes, only the adjacent codes are applicable to the Urology - Penile site-specific standard.

Code List

01

Excision margins are clear (distance from margin not stated)

R

Excision Margin (pCR0880)

02

Excision margins are clear (tumour >5 mm from the margin)

05

Tumour reaches excision margin

06

Uncertain

10

Excision margins are clear (tumour 1mm from the margin)

11

Excision margins are clear (tumour 2mm from margin)

12

Excision margins are clear (tumour 3mm from margin)

13

Excision margins are clear (tumour 4mm from margin)

14

Excision margins are clear (tumour 5mm from margin)

98

Not applicable

99

Not Known

Associated PeIN

Presence or absence of PeIN in the specimen

Code List

Y

Yes (Present)

R

N/A

N

No (Not identified)

X

Cannot be assessed

Sub-Type of PeIN

Record the subtype of PeIN

Code List

1

Undifferentiated

R

N/A

2

Differentiated

Corpus Spongiosum Invasion

Is there evidence of invasion into corpus spongiosum

Code List

Y

Yes

R

Corpus Spongiosum Invasion (pUR15180)

N

No

Corpus Cavernosum Invasion

Is there evidence of invasion into corpus cavenosum

Code List

Y

Yes

R

Corpus Cavernosum Invasion (pUR15190)

N

No

Urethra or Prostate Invasion

Is there evidence of invasion into the urethra or prostate

Code List

Y

Yes

R

Urethra or Prostate Invasion (pUR15200)

N

No

p16 Testing Indicator

Indicate the result of p16 Immunohistochemistry
(Applicable for invasive and PeIN)

Note: This is applicable to PeIN and Invasive tumours

Code List

P

Positive

R

p16 Testing Indicator (pHN9500)

N

Negative

X

Not Performed/Not Known

Frozen Section Pathology - Penile  To carry the details of the frozen section pathology for Penile  (One occurrence per path report)

Tumour Present

Is there tumour present in the frozen section specimen

Code List

Y

Yes

R

N/A

N

No

Presence of PeIN

Presence or absence of PeIN in the frozen section specimen

Code List

Y

Yes (Present)

R

N/A

N

No (Not identified)

X

Cannot be assessed

Pathology -  For Nodes  To carry the details of  pathology  for Nodes  (One occurrence per path report)

Nodes Examined Number (Inguinal)
Right Laterality

The number of inguinal nodes examined
Record 0 if nodes not sent

max n2

N/A

N/A

R

N/A

Nodes Positive Number (Inguinal)
Right Laterality

The number of inguinal nodes reported as being positive for the presence of tumour metastases. 

max n2

N/A

N/A

R

N/A

Extracapsular Extension (Inguinal)
Right Laterality

Is there evidence of extra capsular spread/extension?

Code List

Y

Yes (Present)

R

N/A

N

No (Not identified)

X

Cannot be assessed

Nodes Examined Number (Inguinal)
Left Laterality

The number of inguinal nodes examined
Record 0 if nodes not sent

max n2

N/A

N/A

R

N/A

Nodes Positive Number (Inguinal)
Left Laterality

The number of inguinal nodes reported as being positive for the presence of tumour metastases. 

max n2

N/A

N/A

R

N/A

Extracapsular Extension (Inguinal)
Left Laterality

Is there evidence of extra capsular spread/extension?

Code List

Y

Yes (Present)

R

N/A

N

No (Not identified)

X

Cannot be assessed

Nodes Examined Number (Pelvic)
Right Laterality

The number of pelvic nodes examined
Record 0 if nodes not sent

max n2

N/A

N/A

R

N/A

Nodes Positive Number (Pelvic)
Right Laterality

The number of pelvic nodes reported as being positive for the presence of tumour metastases. 

max n2

N/A

N/A

R

N/A

Extracapsular Extension (Pelvic)
Right Laterality

Is there evidence of extra capsular spread/extension?

Code List

Y

Yes (Present)

R

N/A

N

No (Not identified)

X

Cannot be assessed

Nodes Examined Number (Pelvic)
Left Laterality

The number of pelvic nodes examined
Record 0 if nodes not sent

max n2

N/A

N/A

R

N/A

Nodes Positive Number (Pelvic)
Left Laterality

The number of pelvic  nodes reported as being positive for the presence of tumour metastases. 

max n2

N/A

N/A

R

N/A

Extracapsular Extension (Pelvic)
Left Laterality

Is there evidence of extra capsular spread/extension?

Code List

Y

Yes (Present)

R

N/A

 

 

National Cancer Data Standards for Wales – Urology: pTa and Carcinoma in Situ (CIS) Tumours

Carcinoma in situ is an important prognostic indicator. It is essential that that pTa/CIS tumours are recorded in the correct way; this is as follows:

 

Stage pTa/Ta Tumours Graded 1/2/3 – (ICD10 codes D41.* & D09.*)

 

There are TWO different grading systems which are to be used to record information on these tumours:

1. WHO 1973: Non-invasive Papillary urothelial (transitional cell) carcinoma – Grade 1, Grade 2 or Grade 3

2. WHO 2004: Non-invasive Papillary Urothelial Neoplasm of Low Malignant Potential (PUNLMP); Papillary Urothelial carcinoma - Low Grade or High Grade

 

Neoplasm of Uncertain Behaviour of -

Diagnosis: D41* - Neoplasm of Uncertain Behaviour of ………………….

(4th digit: D410 Kidney, D411 Renal Pelvis, D412 Ureter, D413 Urethra, D414 Bladder, D419 Unspecified Urinary organ)

 

Morphology:

M8130/1 – Grade 1 (stage pTa) papillary urothelial (transitional cell) neoplasm of low malignant potential (PUNLMP)

M8130/1 - Grade 1 (pTa) papillary urothelial (transitional cell) neoplasm/carcinoma

M8130/1 - Papillary (stage pTa) urothelial (transitional cell) neoplasm of low malignant potential (PUNLMP)

 

pTa Tumours

Diagnosis: D09* - Carcinoma in-situ of …………………………

(4th digit: D090 Bladder, D091 Other and unspecified urinary sites)

 

Morphology:

M8130/2 – Papillary urothelial (transitional cell) neoplasm/carcinoma NOS

M8130/2 – Grade 1 (stage pTa) papillary low grade urothelial (transitional cell) neoplasm/carcinoma

M8130/2 – Grade 2 (stage pTa) papillary low grade urothelial (transitional cell) neoplasm/carcinoma

M8130/2 – Papillary low grade urothelial (transitional cell) neoplasm/carcinoma NOS (stage pTa)

M8130/2 – Grade 2 (stage pTa) papillary high grade urothelial (transitional cell) neoplasm/carcinoma

M8130/2 - Grade 2 (stage pTa) papillary urothelial (transitional cell) neoplasm/carcinoma

M8130/2 – Papillary high grade urothelial (transitional cell) neoplasm/carcinoma NOS (stage pTa)

M8130/2 – Grade 3 (stage pTa) papillary high grade urothelial (transitional cell) neoplasm/carcinoma

M8130/2 – Papillary high grade urothelial (transitional cell) neoplasm/carcinoma NOS (stage pTa)

 

Carcinoma in-situ of -

Diagnosis: D09* - Carcinoma in-situ of …………………………

(4th digit: D090 Bladder, D091 Other and unspecified urinary sites)

 

Morphology:

M8120/2 - Any TCC/papillary TCC with CIS is coded to 8120/2

M8130/1 or M8130/2 - Any TCC/papillary TCC without CIS is coded to 8130/1 or 8130/2

 

Examples: 

Papillary G1 pTa and CIS would be registered as M8120/2

Papillary G3 pTa and CIS would be registered as M8120/2

 

Malignant Tumours should to be recorded as follows:

Malignant Neoplasm of -

Diagnosis: C67* - Malignant Neoplasm of Urinary Bladder

 

Morphology:

M8120/3 - Transitional cell carcinoma

 

As with all other site specific categories, Core data items should also be collected for Urology: pTa and Carcinoma in Situ (CIS) Tumours and users should refer to National Cancer Data Standards for Wales – Core (DSCN 2019/09)( http://www.nwisinformationstandards.wales.nhs.uk/sitesplus/documents/299/20191210-DSCN%202019%2009-National%20Cancer%20Data%20Standards%20for%20Wales%20-%20Core-v1-0.pdf) for a list of Core requirements. In addition to the Core requirements, Urology: pTa and In Situ Tumours should also record the following information:

 

 

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Tumour Grade (Urology)

Specify whether Low, High Grade or PUNLMP  (Papillary Urothelial Neoplasm of Low Malignant Potential)

Code List

L

Low

R

Tumour Grade (Urology) (pUR15290 )

H

High

P

PUNLMP

X

Not applicable