Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Referral - Oesophago-gastric (OG). To carry referral details for OG  (One occurrence of this group)

Source of Referral for Out-patients (CWT) *

The source of referral classification used to identify the source of referral of each episode or referral

Note: The adjacent codes are not present in Core but have been added here as a site specific requirement. Whilst the Core data item has additional codes, only the adjacent codes are applicable to the Upper GI - Oesophago-gastric site-specific standard.

Code List

20

Open Access Endoscopy

R

Source of Referral for Out-patients (CWT) (CR1600)

21

From Barrett's Surveillance

99

Not Known

Diagnosis - Oesophago-gastric (OG). To carry diagnosis details for OG  (One occurrence of this group)

Pre-Treatment Tumour Site

Specify the characteristics of the OG cancer at diagnosis 

Note: Where possible this should be derived from Core data item Primary Diagnosis (ICD) or Primary Diagnosis (SNOMED)

Code List

01

Oesophagus upper third

D

N/A

02

Oesophagus middle third

03

Oesophagus lower third

04

Siewert 1

05

Siewert 2

06

Siewert 3

07

Fundus

08

Body of stomach

09

Antrum

10

Pylorus

Staging Procedures

Record the investigations performed to establish the stage of disease

Code List

00

None

R

N/A

01

CT Scan

02

PET/PET-CT

03

Endoscopic US/EUS

04

Staging laparoscopy

05

EUS Fine needle aspiration

97

Other

Comorbidity

Specify what other long term conditions the patient has at diagnosis.    To detail the nature of any pre-existing conditions/co-morbidity which may have an effect on subsequent treatment.

Note: Multiples can be selected, however the code None cannot be used with any other code

Code List

00

None

R

N/A

01

COPD/Asthma

02

Chronic Renal Impairment

03

Liver Failure or Cirrhosis

04

Diabetes

05

Mental Illness

06

Barrett’s Oesophagus

97

Significant Other

07

Ischemic Heart Disease

08

Cerebrovascular Disease

09

Peripheral Vascular Disease

Dietetic Involvement Before Treatment

Specify what type of dietetic involvement (or planned involvement) the patient will receive between diagnosis and treatment.

Code List

1

Assessment and advice from a general dietitian

R

N/A

2

Assessment and advice from a specialist OG dietitian

3

Assessment and advice from a dietitian not known if general or specialist

4

No contact with a dietitian as no dietitian available

5

No contact with a dietitian as assessed as not required

6

No contact with a dietitian

Investigations - Oesophago-gastric (OG). To carry staging investigations details for OG (One occurrence of this group)

Staging Procedures

Indicate the staging investigations performed in order to establish the cancer stage

Note: Multiples can be selected, however the code None cannot be used with any other code

Code List

00

None

R

N/A

01

CT Scan

02

PET/PET-CT

03

Endoscopic US/EUS

04

Staging laparoscopy

05

EUS Fine needle aspiration

97

Other

Cancer Care Plan - Oesophago-gastric (OG). To carry details of the cancer care plan for OG  (One occurrence of this group)

Planned Cancer Treatment
Type *

This is the clinically proposed treatment,
usually agreed at a Multidisciplinary Team Meeting, and may not be the same as the
treatment which is subsequently agreed with the patient.
More than one planned treatment type may be recorded, and these may either be
alternative or sequential treatments.

Note: The codes Endoscopic Mucosal Resection, Palliative surgery, Palliative oncology: Unspecified and Endoscopic palliative therapy: Unspecified are not present in Core but have been added here as a site specific requirement. Whilst the Core data item has additional codes, only the adjacent codes are applicable to the Upper GI - Oesophago-gastric site-specific standard.

Code List

01

Surgery

R

Cancer Treatment Modality CR2040

02

Teletherapy

03

Chemotherapy

15

Endoscopic Mucosal Resection

14

Radiotherapy - Other

16

Palliative surgery

17

Palliative oncology: Unspecified

18

Endoscopic palliative therapy: Unspecified

07

Biological Therapy

Surgery - General - Oesophago-gastric (OG). To carry surgery details for OG (One occurrence per Core Surgery and Other Procedure group)

Palliative Treatment Reason
(Upper GI)

Rationale for palliative treatment

Code List

1

Extensive intrahepatic disease

M

Palliative Treatment Reason
(Upper GI) (UG13810)

2

Widespread disease

3

Both extensive intrahepatic and widespread disease

4

Biliary obstruction

5

Gastric outlet obstruction

6

Pain

Surgical Admission Date

The date of admission for the hospital stay during which the main surgical procedure took place

ccyymmdd

N/A

N/A

R

N/A

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: only for completion if 1 or 2 is chosen as value in Surgical Pathway Type

Code List

1

Yes

R

N/A

2

No, but partial completion

3

No, non-completion

9

Unknown/Not documented

Post Operative Tumour Site (Upper GI)

The main cancer site for which the patient is receiving care, as established in the resected specimen.  

Note: Cardia should no longer be used to describe adenocarcinoma located at the gastro-oesophageal junction - instead these tumours should be described by the appropriate Siewert type

Code List

01

Oesophagus upper third

R

Post Operative Tumour Site (Upper GI) (UG14230)

02

Oesophagus middle third

03

Oesophagus lower third

04

Siewert 1

05

Siewert 2

06

Siewert 3

07

Fundus

08

Body of stomach

09

Antrum

10

Pylorus

Main Procedure

The main surgical procedure carried out

Note: Where possible this should be derived from Core data item Primary Procedure (OPCS) or Primary Procedure (SNOMED)

Code List

01

Left Thoraco-abdominal Oesophagectomy

D

N/A

02

2-Phase (Ivor-Lewis) Oesophagectomy

03

3-Phase (McKeown) Oesophagectomy

04

Transhiatal Oesophagectomy

05

Thoracotomy (Open & Shut)

06

Total Gastrectomy

07

Extended Total Gastrectomy

08

Proximal Gastrectomy

09

Distal Gastrectomy

10

Completion Gastrectomy

11

Merendino Gastrectomy

12

Wedge/localised gastric resection

13

Bypass procedure/Jejunostomy only

14

Laparotomy (Open and Shut)

Surgical Access Thoracic *

Record the approach used to perform the thoracic part of the main procedure

Note: Of the adjacent codes, only Open Surgery and Not applicable are present in Core. The remaining codes have been added here to provide greater granularity. Whilst the Core data item has additional codes, only the adjacent codes are applicable to the Upper GI - Oesophago-gastric site-specific standard.

Code List

01

Open Surgery

R

Surgical Access Type (CR6310)

2a

Thoracoscopic with planned conversion to open surgery

2b

Thoracoscopic with unplanned conversion to open surgery

04

Thoracoscopic completed

5a

Robotic converted to open

5b

Robotic completed

Z

Not applicable 

Surgical Access Abdominal *

Record the approach used to perform the abdominal part of the main procedure

Note: Of the adjacent codes, only Open Surgery is present in Core. The remaining codes have been added here to provide greater granularity. Whilst the Core data item has additional codes, only the adjacent codes are applicable to the Upper GI - Oesophago-gastric site-specific standard.

Code List

01

Open surgery

R

Surgical Access Type (CR6310)

03

Laparoscopic with unplanned conversion to open surgery

04

Laparoscopic completed

5a

Robotic converted to open

5b

Robotic completed

Nodal Dissection

Record the extent of the lymphadenectomy performed

Code List

0

None

R

N/A

1

1-field

2

2-field

3

3-field

4

DO (peri-gut resection)

5

D1

6

D2

7

D3

Discharge Date

The date the patient was discharged or died in hospital

ccyymmdd

N/A

N/A

R

N/A

Death in Hospital

Indicates whether the patient died in hospital following surgical treatment. To monitor the proportion of deaths for surgically treated patients.  

Code List

Y

Yes

R

N/A

N

No

Post Operative Nutritional Support During Admission

Record the type of nutritional support/intervention the patient receives during their admission for surgery

Code List

1

Nasojejunal tube

R

N/A

2

Jejunostomy

3

Oral Nutrition

4

Parenteral Nutrition

7

Other

9

No Management

Dietetic Involvement After Surgery

Record the type of dietetic involvement that the patient received after surgery

Code List

1

Assessment and advice from a general dietitian

R

N/A

2

Assessment and advice from a specialist OG dietitian

3

Assessment and advice from a dietitian not known if general or specialist

4

No contact with a dietitian as no dietitial available

5

No contact with a dietitian as assessed as not required

6

No contact with a dietitian

Post Operative Nutritional Support on Discharge

Record the type of ongoing nutritional support that the patient receives after surgery

Code List

1

Nasojejunal tube

R

N/A

2

Jejunostomy

3

Oral Nutrition

4

Parenteral Nutrition

7

Other

9

No Management

No of Surgeons Involved in Original Operation

Record the number of surgeons involved in the original surgery.  

Note: Surgeons involved in follow up surgery for complications should not be included here

max n1
Range 1 - 4

N/A

N/A

R

N/A

Consultant Code of Surgeon Responsible for Original Operation

Record the Consultant Code of the surgeon responsible for the original operation

Note: Refer to NHS Wales Data Dictionary definition for Consultant Code for further information on the code's format

an8

N/A

N/A

R

N/A

Consultant Code of any Additional Surgeons involved

Record the Consultant Codes of any additional surgeons that were involved in the original operation

Note: 
i. This is a repeating data item. Up to 3 additional surgeons may be included
ii. Refer to NHS Wales Data Dictionary definition for Consultant Code for further information on the code's format

an8

N/A

N/A

R

N/A

Surgery - Upper Gastrointestinal (GI). To carry additional surgery details for Upper GI - Esophageal Database (ESODATA) (One occurrence per Core surgery group)

Surgical Complications - International
Esophageal Database (ESODATA)

The types of complications as defined in the International Esophageal Database (ESODATA).

This list has been compiled by the Esophageal Complications Consensus Group (ECCG)

Note:
1. The code Haemorrhage is not present in COSD but has been added here as a site specific requirement.
ii. This is a repeating data item and multiple codes can be recorded

Code List

0100

Gastrointestinal

R

Surgical Complications - International
Esophageal Database (ESODATA) (UG15010)

0101

No post-operative complications

0102

Oesophagoentric leak from anastomosis, staple line, or localised conduit necrosis

0103

Conduit necrosis/failure requiring surgery

0104

Ileus defined as small bowel dysfunction preventing or delaying enteral feeding

0105

Small bowel obstruction

0106

Feeding J-tube complication

0107

Pyloromyotomy/Pyloroplasty complication

0108

Clostridium Difficile infection

0109

GI bleeding requiring intervention or transfusion

0110

Pancreatitis

0111

Liver dysfunction

0112

Delayed conduit emptying requiring intervention or delaying discharge or requiring maintenance of ng drainage >7 days post op

0113

Bowel ischaemia

0199

None

0200

Pulmonary

0201

Pneumonia

0202

Pleural effusion requiring additional drainage procedure

0203

Pneumothorax requiring intervention

0204

Atelectasis mucous plugging requiring bronchoscopy

0205

Respiratory failure requiring intubation

0206

Acute respiratory distress syndrome

0207

Acute aspiration

0208

Tracheobronchial injury

0209

Chest drain requirement for air leak for >10 days post op

0299

None

0300

Cardiac

0301

Cardiac arrest requiring CPR

0302

Myocardial infarction

0303

Dysrhythmia atrial requiring intervention

0304

Dysrhythmia ventricular requiring intervention

0305

Congestive heart failure requiring intervention

0306

Pericarditis requiring intervention

0399

None

0400

Thromboembolic

0401

DVT (Deep Vein Thrombosis)

0402

PE (Pulmonary Embolus)

0403

Stroke (CVA)

0404

Peripheral thrombophlebitis

0499

None

0500

Urologic

0501

Acute renal insufficiency (defined as: doubling of baseline creatinine)

0502

Acute renal failure requiring dialysis

0503

Urinary tract infection

0504

Urinary retention requiring reinsertion of urinary catheter, delaying discharge, or discharge with urinary catheter

0599

None

0600

Infection

0601

Wound infection requiring opening wound or antibiotics

0602

Central iv line infection requiring removal or antibiotics

0603

Intrathoracic/Intra-abdominal abscess

0604

Generalised sepsis

0605

Other infections requiring antibiotics

0699

None

0700

Neurologic/Psychiatric

0701

Recurrent nerve injury

0702

Other neurologic injury

0703

Acute delirium

0704

Delirium tremens

0799

None

0800

Wound/Diaphragm

0801

Thoracic wound dehiscence

0802

Acute abdominal wall dehiscence/hernia

0803

Acute diaphragmatic hernia

0899

None

0900

Other

0901

Chyle leak

0902

Chyle leak severity/type

0903

Reoperation for thoracic bleeding

0904

Reoperation for abdominal bleeding

0905

Reoperation for reasons other than bleeding, anastomotic leak or conduit necrosis

0906

Multiple organ dysfunction syndrome

0950

Haemorrhage

0999

None

1000

Additional comments

1001

The patient had other complications that is not in the ECCG recommended complications list above

Leak Severity Type

Record the severity of the leak.

Note: Only required if code Oesophagoentric leak from anastomosis, staple line, or localised conduit necrosis is recorded for data item  Surgical Complications - International
Esophageal Database (ESODATA)

Code List

1

Type I

R

Leak Severity Type (UG15020)

2

Type II

3

Type III

9

Not known (not recorded)

Conduit Necrosis/Failure Type

Record the conduit necrosis/failure type

Note: Only required if code Conduit necrosis/failure requiring surgery is recorded for data item Surgical Complications - International Esophageal Database (ESODATA)

Code List

1

Type I

R

Conduit Necrosis/Failure Type (UG15030)

2

Type II

3

Type III

9

Not known (not recorded)

Recurrent Laryngeal Nerve Injury Involvement Type

Record any recurrent laryngeal nerve injury involvement type

Note: Only required if code Recurrent nerve injury is recorded for data item Surgical Complications - International Esophageal Database (ESODATA)

Code List

1

Type Ia

R

Recurrent Laryngeal Nerve Injury Involvement Type (UG15040)

2

Type Ib

3

Type IIa

4

Type IIb

5

Type IIIa

6

Type IIIb

9

Not known (not recorded)

Chyle Leak Severity Type

Record any Chyle leak severity type

Note: Only required if code Chyle lead severity/type is recorded for data item Surgical Complications - International Esophageal Database (ESODATA)

Code List

1

Type Ia

R

Chyle Leak Severity Type (UG15050)

2

Type Ib

3

Type IIa

4

Type IIb

5

Type IIIa

6

Type IIIb

9

Not known (not recorded)

Clavien-Dindo Classification of Surgical Classifications

Record the overall grade as per the Clavien-Dindo Classification of Surgical Classifications

Code List

1

Grade I

R

Clavien-Dindo Classification of Surgical Classifications (UG15060)

2

Grade II

3

Grade IIIa

4

Grade IIIb

5

Grade IVa

6

Grade IVb

7

Grade V

9

Not known (not recorded)

Additional Complications

Did the patient have any complications that is not in the ECCG recommended complication list above?   

Note:
i. Only required if code the patient had other complications that is not in the ECCG recommended complications list above is recorded for data item Surgical Complications - International Esophageal Database (ESODATA)
ii. This is a repeating data item and multiple codes can be recorded

max an150

N/A

N/A

R

Additional Complications (UG15070)

Surgery - Upper Gastrointestinal (GI) - Outcome Measures. To carry additional surgery details for Upper GI - Eosophageal Database (ESODATA) (May be up to one occurrence per Core surgery group)

Change in Level of Care

Record if there was any change in the level of care required for the patient?

Code List

1

No escalation in level of care required

R

Change in Level of Care (UG15110)

2

Required escalation in level of care (ICU, ITU/HDU)

9

Not Known (Not recorded)

Blood Product Utilisation

Record if there were any blood products required?

Code List

1

Intra-operative transfusions

R

Blood Product Utilisation (UG15120)

2

Post-operative transfusions

3

Intra and post op transfusions

8

Not Applicable (None - no transfusions)

9

Not known (not recorded)

Number of Units Transfused

Record the number of units of blood transfused

Code List

1

1-2 Units

R

Number of Units Transfused (UG15130)

2

3-4 Units

3

5 or more Units

9

Not Known (Not recorded)

Upper Gastrointestinal (GI) - Surgery - Oesophagectomy. To carry additional surgery details for - Oesophagectomy (One occurrence per Core surgery group)

Surgical Approach Type

Record the type of surgical approach used during the Oesophagectomy

Code List

1

Open Oesophagectomy

R

Surgical Approach Type  (UG15200)

2

Minimally Invasive Oesophagectomy

9

Not Known (Not recorded)

Open Approach Type

Record the type of open surgical approach used during the Oesophagectomy

Code List

1

Trans Thoracic Oesophagectomy

R

Open Approach Type (UG15210)

2

Trans Hiatal Oesophagectomy

Minimally Invasive Approach Type

Record the type of minimally invasive approach used during the Oesophagectomy

Code List

1

Total Minimally Invasive

R

Minimally Invasive Approach Type (UG15220)

2

Abdominal part minimally invasive

3

Chest part minimally invasive

Anastomosis Type

Record the type of anastomosis used during the Oesophagectomy

Code List

1

Neck anastomosis

R

Anastomosis Type (UG15230)

2

Chest anastomosis

3

None

8

Other

9

Not known (not recorded)

Oesophageal Conduit Type

Record the type of oesophageal conduit used during the Oesophagectomy

Code List

1

Stomach

R

Oesophageal Conduit Type (UG15240)

2

Small bowel 

3

Colon

4

None

5

Other

9

Not known (not recorded)

Neck Dissection

Record if there was any neck dissection during the Oesophagectomy

Code List

Y

Neck dissection

R

Neck Dissection (UG15250)

N

No neck dissection

9

Not known (not recorded)

Surgery - Oesophago-gastric (OG) - Endocsopic or Radiological Procedures (One occurrence per Core Surgery )

Planned Course of Multiple Treatments

Record if the first procedure is part of a planned course of multiple endoscopic treatments

Code List

Y

Yes

R

N/A

N

No

9

Not Known

Endoscopic Procedure Type

The main endoscopic procedures carried out. 

Note:
1. The codes ESD - Endoscopic Submucosal Dissection and EMR - Endoscopic Mucosal Resection are  not present in COSD but have been added here as a site specific requirement.
ii. This is a repeating data item and multiple codes can be recorded

 

Code List

1

Stent insertion

M

Endoscopic Procedure Type (UG14290)

2

Laser therapy

3

Argon plasma coagulation

4

Photodynamic therapy

5

Gastrostomy

6

Brachytherapy

7

Dilation

8

Other

9

ESD - Endoscopic Submucosal Dissection

10

EMR - Endoscopic Mucosal Resection

Stent Placement

Record the method used to place the stent

Note: Only required if Stent insertion is recorded for data item Endoscopic Procedure Type

Code List

1

Fluroscopic control

M

N/A

2

Endoscopic control

3

Fluroscopic and Endoscopic control

9

Not known

Anaesthesia Used

Record the type of anaesthetic used during the procedure

Code List

1

Sedation

M

N/A

2

Local anaesthetic spray

3

General anaesthetic

4

Sedation and local anaesthetic spray combined

9

Not Known

Endoscopic or Radiological Complication Type

The types of complications that the patient experiences during the admission for the endoscopic procedure. 

Note: This is a repeating data item and multiple codes can be recorded

Code List

00

No complications

M

Endoscopic or Radiological Complication Type (UG13090)

02

Perforation

03

Haemorrhage

09

Pancreatitis

10

Cholangitis

88

Other

Pathology - For Oesophago-gastric (OG) (in addition to core pathology) (One Occurrence per Path Report)

Pathology Investigation Type *

The type of pathology investigation procedure carried out

Note:
1. The codes Fresh - Upper GI and Formulin Fixed - Upper GI are not present in Core but have been added here as a site specific requirement.

Code List

CY

Cytology

R

Pathology Investigation Type (pCR0760)

BU

Biopsy

EX

Excision

PE

Partial Excision

RE

Radical Excision

FE

Further Excision

CU

Curettage

SB

Shave Biopsy

PB

Punch Biopsy

IB

Incisional Biopsy

99

Uncertain/Other

FR

Fresh - Upper GI

FF

Formulin Fixed - Upper GI

Excision Margin (Proximal)

Identify whether the proximal margin is involved.

Note:
i.  Both proximal and distal are recorded in one data item in COSD, but these have been added as separate data items here as a site specific requirement
ii. Involved = 1mm or less, Not involved = >than 1 mm

Code List

0

Margin not involved

R

Excision Margin (Proximal, Distal) (pUG14480)

1

Margin involved

9

Not Known

Excision Margin (Distal)

Identify whether the distal margin is involved. 

Note:
i.  Both distal and proximal are recorded in one data item in COSD, but these have been added as separate data items here as a site specific requirement
ii. Involved = 1mm or less, Not involved = >than 1 mm

Code List

0

Margin not involved

R

Excision Margin (Proximal, Distal) (pUG14480)

1

Margin involved

9

Not Known

Excision Margin (Circumferential)

Identify whether circumferential margin is involved.

Note: Involved = 1mm or less, Not involved = >than 1 mm

Code List

0

Margin not involved

R

Excision Margin (Circumferential) (pUG14490)

1

Margin involved

9

Not Known

Biomarkers - Oesophago-gastric (OG)

HER2 Status
(at diagnosis)

To record the HER2 Status for the patient, at diagnosis

Note: All patients having palliative chemotherapy with diagnosis of OG should have a known HER2 Status

Code List

1

Positive

R

N/A

2

Negative

3

Not done

9

Not known

Dihydropyrimidine Dehydrogenase (DPD) Status

To record the DPD Status for the patient, if performed
 

Code List

1

DPYP variant homozygous

R

N/A

2

DPYP variant heterozygous

3

No variant detected

9

Not known (Not Performed)

Oncology - Radiotherapy Details - Oesophago-gastric (OG)

Start Date of Radiotherapy

The date that the first cycle of radiotherapy was started

ccyymmdd

N/A

N/A

R

N/A

Outcome of Radiotherapy

Specify if the patient completed their treatment as prescribed

Code List

1

Treatment Completed as Prescribed

R

N/A

2

Treatment Not completed

9

Not known (outcome)

Reason for Incomplete Radiotherapy

Specify the reason if Radiotherapy was not completed

Code List

1

Patient died

R

N/A

2

Progressive disease during radiotherapy

3

Toxicity

4

Patient choice (stopped or interrupted treatment)

7

Other

9

Not known (reason)

Oncology  - Chemotherapy Details - Oesophago-gastric (OG)

Chemotherapy Start Date

The date that the first cycle of chemotherapy was started

ccyymmdd

N/A

N/A

R

N/A

Outcome of Chemotherapy

Specify if the patient completed their treatment as prescribed

Code List

1

Treatment Completed as Prescribed

R

N/A

2

Treatment Not completed

9

Not known (outcome)

Reason for Incomplete Chemotherapy

Specify the reason if Chemotherapy was not completed

Code List

1

Patient died

R

N/A

2

Progressive disease during radiotherapy

3

Toxicity

4

Patient choice (stopped or interrupted treatment)

7

Other

9

Not known (reason)

Proceeded to Planned Curative Surgery

Record if the patient proceeded to curative surgery after neoadjuvant chemotherapy

Note: Yes, would be derived where SACT adjunctive therapy = neoadjuvant. No and Not applicable should be recorded manually

Code List

Y

Yes

D

N/A

N

No

8

Not applicable

Oncology  - Immunotherapy - Oesophago-gastric (OG)

Start Date of Immunotherapy

The date that the first cycle of immunotherapy was started

ccyymmdd

N/A

N/A

R

N/A

Outcome of Immunotherapy

Specify if the patient completed their treatment as prescribed

Code List

1

Treatment Completed as Prescribed

R

N/A

2

Treatment Not completed

9

Not known (outcome)

Reason for Incomplete Immunotherapy

Specify the reason if Immunotherapy was not completed

Code List

1

Patient died

R

N/A

2

Progressive disease during radiotherapy

3

Toxicity

4

Patient choice (stopped or interrupted treatment)

7

Other

9

Not known (reason)

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Diagnosis - Liver - Core. To record diagnostic details for Liver Hepatocellular Carcinoma (HCC) & Cholangiocarcinoma (CC) (One Occurrence per core diagnosis group)

Liver Surveillance Scans

Record if the patient was receiving liver cancer surveillance scans?

Code List

Y

Yes

R

Liver Surveillance Scans (LV16000)

N

No

9

Not Known

Liver Cirrhosis Type

Record the type of liver cirrhosis

Code List

1

Compensated

R

Liver Cirrhosis Type (LV16010)

2

Decompensated

8

Patient does not have cirrhosis of the liver

9

Not Known

Cause of Liver Cirrhosis

Is the patient's liver cirrhosis caused by known risk factors for liver disease?

Note: This is a repeating data item and multiple codes can be recorded

Code List

01

Alcohol excess

R

Cause of Liver Cirrhosis (LV16020)

02

Hepatitis B virus infection

03

Hepatitis C virus infection

04

Non-alcohol related fatty liver disease

05

Hereditary haemochromatosis

06

Autoimmune hepatitis

07

Primary sclerosing cholangitis

10

Primary biliary cholangitis

98

Other

99

Not Known

Transplantation - Liver (for all types HCC, CC, Mets). To record liver transplantation details for the patient

Liver Transplantation

Was the patient listed for transplantation?

Code List

Y

Yes

R

Liver Transplantation  (LV16200)

N

No

9

Not known

Surgery - Liver (for all types HCC, CC, Mets) To record surgery details for Liver (One occurrence per core surgery)

Surgery Type

What type of liver surgery was performed?

Code List

1

Liver Resection

R

Surgery Type (LV16210)

2

Liver Transplantation

Surgery - Liver - Core. To record further surgical details for all Liver (HCC,CC,Liver Mets) (One occurrence per Core  group)

Clavien-Dindo Classification of Surgical Classifications

Record the overall grade as per the Clavien-Dindo Classification of Surgical Classifications

Code List

1

Grade I

R

Clavien-Dindo Classification of Surgical Classifications (UG15060)

2

Grade II

3

Grade IIIa

4

Grade IIIb

5

Grade IVa

6

Grade IVb

7

Grade V

9

Not known (not recorded)

Treatment & Prognostic Indicators - Liver - Core. To record further staging details for Liver HCC & CC (One occurrence per Core Treatment group)

Portal Invasion

Record whether there is tumour present in the main portal vein, or if there is tumour present in a branch of the portal vein or if there is no tumour present in the portal vein.

Code List

1

Branch

R

Portal Invasion (LV16120)

2

Main

3

Not Present

9

Not known

Liver - Hepatocellular Carcinoma (HCC). Record additional data items for all HCC Malignancies

Staging Details -  Liver - HCC

Number of Liver Lesions Seen

Total number of liver lesions seen on imaging

max n2

N/A

N/A

M

N/A

Size of Largest Liver Lesion

Record the size of the largest liver lesion seen on imaging

max n2

N/A

N/A

M

N/A

Vascular Invasion

Record if vascular invasion is present or absent

Code List

Y

Present

M

N/A

N

Not present

9

Not Known

Chronic Liver Disease

Record if chronic liver disease is present or absent

Code List

Y

Present

M

N/A

N

Not present

9

Not Known

Cause of Chronic Liver Disease

Is the patient's cause of chronic liver disease  caused by known risk factors?

Note: This is a repeating data item and multiple codes can be recorded

Code List

01

Alcohol excess

M

N/A

02

Hepatitis B virus infection

03

Hepatitis C virus infection

04

Non-alcohol related fatty liver disease

05

Hereditary haemochromatosis

06

Autoimmune hepatitis

07

Primary sclerosing cholangitis

10

Primary biliary cholangitis

98

Other

99

Not Known

Child-Pugh Score

Record the overall Child-Pugh score.  This is the level of disease of the liver.

Code List

A

Child-Pugh A

M

Child-Pugh Score (LV16140)

B

Child-Pugh B

C

Child-Pugh C

Alpha Fetoprotein (Serum)

Maximum Serum level of alpha feto protein at diagnosis.  AFP units recorded in kU/l  
(values > 100,000 are recorded)
 

max n6
Range 0-999999

N/A

N/A

M

Alpha Fetoprotein (Serum) (CR8920)

CT or MRI - full information recorded

Specify if patient's CT or MRI report contains the specified full information required to enable the correct management decisions to be made at the MDT

Note: This is derived data item. The derived code will be based on whether all the data items in the Staging Details -  Liver - HCC section have been recorded

Code List

Y

Yes

D

N/A

N

No

9

No CT or MRI done

Site Specific Staging  - Liver - HCC. To record site specific staging details (One occurrence per Core Staging group)

Barcelona Clinic Liver Cancer (BCLC) Stage

The Barcelona Clinic Liver Cancer (BCLC) stage, includes both anatomic and non-anatomic factors and is widely used within the UK to predict prognosis and determine treatment.

Code List

0

Very early

M

Barcelona Clinic Liver Cancer (BCLC) Stage (LV16100)

A

Early

B

Intermediate

C

Advanced

D

Terminal

Pathology - Liver. To record additional pathology details for Liver, HCC (One occurrence per pathology)

Number of Tumours Present

Specify the number of tumours present

max n2

N/A

N/A

R

N/A

Bile Duct Invasion

An indication of whether bile duct invasion was present or absent 

Code List

Y

Yes - Present

R

N/A

N

No - Not Present

Type of Fibrosis/Cirrhosis in background liver

Specify the type of fibrosis  Fibrosis/Cirrhosis in Background Liver

Code List

1

Not Bridging

R

N/A

2

Bridging

3

Bridging with nodules

4

Complete Cirrhosis

0

None present

Treatment - Liver. To record other procedure details  Liver - HCC (One occurrence per Core Treatment group)

Ablative Therapy Type

Describe type of ablative (ie locally destructive treatment) therapy used if any.

Code List

R

Radiofrequency ablation

R

Ablative Therapy Type (LV16300)

M

Microwave ablation

8

Other ablative treatment

9

Not Known

Embolisation Modality

What modality of the Liver Trans Arterial Embolisation was used?
This refers to the type of material injected into the hepatic artery.

Code List

1

TAE/BLAND

R

Embolisation Modality (LV16320)

2

C-TACE

3

DEB-TACE

4

RO DEB-TACE

5

SIRT

9

Not known

Treatment & Prognostic Indicators - Liver - HCC (One occurrence per Core Treatment group)

Child-Pugh Score

Record the overall Child-Pugh score.  This is the level of disease of the liver.

Code List

A

Child-Pugh A

R

Child-Pugh Score (LV16140)

B

Child-Pugh B

C

Child-Pugh C

UKELD Score

Record the UKELD score. The UKELD score is calculated using bilirubin, INR, creatine and sodium. It predicts the risk of mortality due to liver cirrhosis and is used to assess need for liver transplantation.

Note: The UKELD calculator is available at:  https://www.basl.org.uk/index.cfm/content/page/cid/34

max n2
Range 0-99

N/A

N/A

R

UKELD Score (LV16130)

Liver - Cholangiocarcinoma (CC). Record for all Cholangiocarcinoma (CC) Malignancies

Diagnosis - Cholangiocarcinoma. To record diagnostic details for Cholangiocarcinoma (One occurrence per core diagnosis group)

Cholangiocarcinoma Category

State where the Cholangiocarcinoma is present, using the designated categories.  Any cholangiocarcinoma which involves the anatomical hilum of the liver must be classified as perihilar

Note: 1. The code Distal is not present in COSD but has been added here as a site specific requirement.

Code List

1

Intrahepatic

M

Cholangiocarcinoma Category (LV16400)

2

Perihilar

3

Extrahepatic

4

Distal

Preoperative Drainage Type

Specify the pre-operative drainage type

Note: Only required where Perihilar is recorded for data item Cholangiocarcinoma Category

Code List

1

PTC (Percutaneous Transhepatic Cholangiogram)

R

N/A

2

ERCP (Endoscopic Retrograde Cholangiopancreatography)

3

No drainage required

Treatment - Liver - CC  (One occurrence per Core Treatment group)

Date of Referral for Palliative Chemotherapy

Specify the date the referral was made for palliative chemotherapy

ccyymmdd

N/A

N/A

R

N/A

Liver - Liver Metastases. To be recorded for all types of Pathways - Primary progression/Non Primary  Pathway - Progression & Recurrence.
Ensure that all core items (Mets at diagnosis) and other treatment pathways flag liver Mets data collection if 03 liver Mets is chosen. To be Recorded for all Liver Mets regardless of Primary Site. Attach liver Mets data to the Original Primary Tumour Site (ICD10)

Treatment - Liver Metastases. To record other procedure details  Liver Mets (One occurrence per Core Treatment group)

Ablative Therapy Type

Describe type of ablative (ie locally destructive treatment) therapy used if any.

Code List

R

Radiofrequency ablation

R

Ablative Therapy Type (LV16300)

M

Microwave ablation

8

Other ablative treatment

9

Not Known

Embolisation Modality

What modality of the Liver Trans Arterial Embolisation was used?
This refers to the type of material injected into the hepatic artery.

Code List

1

TAE/BLAND

R

Embolisation Modality (LV16320)

2

C-TACE

3

DEB-TACE

4

RO DEB-TACE

5

SIRT

9

Not known

Pathology - Liver Metastases. To record additional pathology details for Liver Mets (One occurrence per core surgery)

Total Number of Colorectal Metastases in Liver Code

Record the total number of colorectal metastases identified in the resected liver

max n2

N/A

N/A

R

Total Number of Colorectal Metastases in Liver Code (pUG14500)

Number of Tumours Present

Specify the number of tumours present

max n2

N/A

N/A

R

N/A

Bile Duct Invasion

An indication of whether bile duct invasion was present or absent 

Code List

Y

Yes - Present

R

N/A

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Surgery - GIST. To record additional surgery details for GIST tumours (One occurrence per surgery)

Tumour Rupture

Record if the tumour ruptured at the time of surgery

Code List

Y

Yes

R

N/A

N

No

Pathology - GIST. To record additional pathology details for GIST tumours (One occurrence per pathology)

Mitotic Count

Record the mitotic count per 5mm²

max n2
Range 0-50

R

N/A

Tumour Rupture (Pathology)

Record if the tumour ruptured at the time of surgery as seen within sample

Code List

Y

Yes

R

N/A

N

No

Molecular & Biomarkers - GIST. To record additional Molecular & Biomarker details for GIST tumours

Date Referred for Mutational Analysis

Record the date the patient was referred for mutational analysis

ccyymmdd

N/A

N/A

R

N/A

Wild Type

Specify if the marker tested resulted in a mutation

Code List

1

Mutation detected

R

N/A

2

No mutation detected

3

No Mutational Analysis Performed

Prognostic Index - GIST. To record Prognostic details for GIST tumours

Risk Recurrence Score

Record the associated risk recurrence score

Code List

0

No Risk

R

N/A

1

Very Low Risk

2

Low Risk

3

Moderate Risk

4

High Risk

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Diagnosis

NET Primary Site Code
(SNOMED)

The NET primary site SNOMED code as defined by the Specialist

Whilst Core has data items for Primary Diagnosis Site Code, this has been added here as a site specific requirement to give greater granularity

min n6 max n18

N/A

N/A

M

N/A

NET Primary Site Code Description (SNOMED)

The NET primary site SNOMED description of code as defined by the Specialist

Note: This is derived data item and is the description associated with NET Primary Site Code (SNOMED)

max an100

N/A

N/A

D

N/A

Key  Investigations

Functioning Status (Syndrome)

A record of the functioning status for the patient (at diagnosis)

Code List

Y

Yes - Patient has 'carcinoid syndrome'/patient has a functioning tumour

R

N/A

N

No - Patient has a non-functioning tumour

8

Not applicable

9

Not recorded

Gut Hormone Profile

The result of gut hormone profile blood test
(at diagnosis)

Code List

1

Abnormal

R

N/A

2

Normal

3

Not done

4

Patient refused

8

Not applicable

9

Not recorded

Gut Hormone Profile Type

Specify the type found within the gut hormone profile (at diagnosis)

Note:
i. If Functioning Status (Syndrome) is recorded as Yes or Gut Hormone Profile is recorded as Abnormal the Gut Hormone Profile Type should be specified
ii. If Functioning Status (Syndrome) is recorded as No or Gut Hormone Profile is recorded as Normal, the Gut Hormone Profile Type should be recorded as Not applicable

Code List

1

Insulin

R

N/A

2

Gastrin

3

Glucagon

4

VIP (Vasoactive Intestinal Peptide)

5

Somatostatin 

8

Not applicable

9

Not recorded

5-HIAA Test

The result of 24 hour 5 hydoxyindole acetic acid (5-HIAA) urine test

Note: Only required for small bowel tumours

Code List

1

Abnormal (High)

R

N/A

2

Normal

3

Not done

4

Patient refused

8

Not Applicable

9

Not recorded

Chromogranin (CgA) Value

Specify the absolute value of the Chromogranin test (at diagnosis).

Integer n3
pmol units per litre

N/A

N/A

M

N/A

Chromogranin A (CgA) Test Result

The result of the Chromogranin A blood test
(at diagnosis)

Note: This is a derived data item. Abnormal (High) would be derived where the Chromogranin (CgA) Value is 61 and above and Normal would be derived where the Chromogranin (CgA) Value is 0-60. All other codes should be recorded manually.

Code List

1

Abnormal (High)

D

N/A

2

Normal

3

Not done

4

Patient refused

8

Not Applicable

9

Not recorded

Serotonin Test

The result of the Serotonin blood test
(at diagnosis)

Code List

1

Abnormal (High)

R

N/A

2

Normal

3

Not done

4

Patient refused

8

Not Applicable

9

Not recorded

Key Imaging

Date of Somatostatin Receptor Imaging (Octreoscan)

The date somatostatin receptor imaging (octreotide scan/octreoscan) was completed as part of NETs diagnostic work-up

Note: This is a derived data item from Core data items Imaging Code (NICIP) or Imaging Code (SNOMED CT) PLUS Procedure Date (Cancer Imaging)

ccyymmdd

N/A

N/A

D

N/A

Date of MRI

The date MRI imaging was completed as part of NETs diagnostic work-up

Note: This is a derived data item from Core data items Imaging Code (NICIP) or Imaging Code (SNOMED CT) PLUS Procedure Date (Cancer Imaging)

ccyymmdd

N/A

N/A

D

N/A

Date of CT

The date CT Imaging was completed as part of NETs diagnostic work-up

Note: This is a derived data item from Core data items Imaging Code (NICIP) or Imaging Code (SNOMED CT) PLUS Procedure Date (Cancer Imaging)

ccyymmdd

N/A

N/A

D

N/A

Date of FDG PET CT

The date FDG PET CT imaging was completed as apart of NETs diagnostic work-up

Note: This is a derived data item from Core data items Imaging Code (NICIP) or Imaging Code (SNOMED CT) PLUS Procedure Date (Cancer Imaging)

ccyymmdd

N/A

N/A

D

N/A

Date of Gallium 68 PET

The date Gallium68 PET Imaging was completed as part of NETs diagnostic work up

Note: This is a derived data item from Core data items Imaging Code (NICIP) or Imaging Code (SNOMED CT) PLUS Procedure Date (Cancer Imaging)

ccyymmdd

N/A

N/A

D

N/A

Surgery

Clavien-Dindo Classification of Surgical Classifications

Record the overall grade as per the Clavien-Dindo Classification of Surgical Classifications

Code List

1

Grade I

R

Clavien-Dindo Classification of Surgical Classifications (UG15060)

2

Grade II

3

Grade IIIa

4

Grade IIIb

5

Grade IVa

6

Grade IVb

7

Grade V

9

Not known (not recorded)

Pathology

Histological Type and Grade

Specify the histological type and grade of the NET resection

Code List

01

Well-differentiated, NET G1 (M8240/3)

R

N/A

02

Well-differentiated, NET G2

03

Well-differentiated, NET G3

04

Well-differentiated, grade cannot be assessed

05

Poorly differentiated NEC G3, small cell

06

Poorly differentiated NEC G3, large cell

07

Poorly differentiated NEC, NOS

08

Mixed NE-non NE carcinoma/MiNEN
(for gastric/colorectal/duodenal/ampullary/proximal jejunal/lower jujunal/ileal NET resections)

09

Gangliocytic paraganglioma (for duodenal/ampullary/proximal jejunal/pancreatic NET resections)

97

Other

Proliferation Index with Ki-67

Record the Proliferation Index with Ki-67

Code List

1

Low (<6%)

R

N/A

2

Intermediate (6-10%)

3

High (>10%)

Mitotic Count

Record the Mitotic count

Integer
max n4/2 mm²

N/A

N/A

R

N/A

Presence of Necrosis

Record whether there is presence of necrosis

Code List

1

Present

R

N/A

2

Not Identified

Perineural Invasion

A record to determine whether there was perineural invasion noted after pathological reporting of tumour sample.

Code List

Y

Yes (Perineural invasion present)

R

N/A

N

No (Perineural invasion not present)

8

Not applicable (Not sampled)

9

Not recorded (not recorded in pathology report)

Immunohistochemistry - Chromogranin

A record to determine whether chromogranin immunohistochemistry (IHC) stain was carried out on tumour sample

Code List

1

Positive

R

N/A

2

Negative

3

Equivocal

4

Insufficient material

5

Not done (No surgery/biopsy)

9

Not recorded (not recorded in pathology report)

Immunohistochemistry - Synaptophysin

A record to determine whether synaptophysin Immunohistochemistry (IHC) stain was carried out on tumour sample

Code List

1

Positive

R

N/A

2

Negative

3

Equivocal

4

Insufficient material

5

Not done (No surgery/biopsy)

9

Not recorded (not recorded in pathology report)

Immunohistochemistry - CD56

A record to determine whether CD56 immunohistochemistry (IHC) stain was carried out on tumour sample

Code List

1

Positive

R

N/A

2

Negative

3

Equivocal

4

Insufficient material

5

Not done (No surgery/biopsy)

9

Not recorded (not recorded in pathology report)

Pathology - For Gastric NETs

Gastric NET Type

Specify the type of Gastric NET

Code List

1

Type I

R

N/A

2

Type II

3

Type III

9

Cannot Be Assessed

MDT Details

MDT Decision *

This denotes the decision the MDT took on the management of the patients care

Note:
i. Of the adjacent codes, only Surgery, Chemotherapy, Biological Therapy and Not Recorded/Not Known are present in Core. The remaining codes have been added here to provide greater granularity. Whilst the Core data item has additional codes, only the adjacent codes are applicable to the Upper GI - NET site-specific standard.
ii. This is a repeating data item. Up to 3 decisions may be included

Code List

01

Surgery

R

Planned Cancer Treatment Type (CR0470)

03

Chemotherapy 

07

Biological Therapy

19

Transartierial (Chemo)-embolisation (TACE)

20

Radiofrequency Ablation (RFA)

21

Radionuclide Treatment

22

Further Imaging/ Diagnostic Tests

23

Somatostatin Analogues (SSAs)

24

No further treatment/follow up required

25

Follow up only

26

Supportive Care Only

98

Not applicable

99

Not Recorded/Not Known

Treatments

Type of First Cancer
Treatment *

This denotes the first specific treatment modality administered to a patient

Note: Of the adjacent codes, Transartierial (Chemo)-embolisation (TACE), Radionuclide Treatment, Somatostatin analogues (SSA), Supportive Care Only, Patient died before treatment and Not recorded 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 Upper GI - NET site-specific standard.

Code List

01

Surgery

R

Planned Cancer Treatment Type (CR0470)

05

Teletherapy (Beam Radiation excluding Proton Therapy)

08

Active Monitoring

02

Anti-Cancer Drug Regimen (Cytotoxic Chemotherapy)

21

Biological Therapies (excluding Immunotherapy)

15

Anti-Cancer Drug Regimen (Immunotherapy)

10

Radiofrequency ablation (RFA)

12

Cryotherapy

24

Transartierial (Chemo)-embolisation (TACE)

25

Radionuclide Treatment

26

Somatostatin analogues (SSA)

27

Supportive Care Only

97

Other Therapy/Other Treatment

96

Patient died before treatment

98

Patient refused all therapies/All treatment declined

99

Not Recorded

Date of First Cancer Treatment

This denotes the date the Type of First Cancer Treatment was given to the patient

Note: This is a derived data item from Core Treatment Start Date (Cancer) where Cancer Treatment Event Type is recorded as First Definitive Treatment for a New Primary Cancer

ccyymmdd

N/A

N/A

D

N/A

Liver Ablative Therapy

A record of whether liver ablative therapy was performed

Code List

1

Microwave ablation

R

N/A

2

Radiofrequency ablation (RFA)

3

Patient died before treatment

4

Patient refused treatment

8

Not applicable

9

Not recorded

Liver Ablative Therapy Date

This denotes the date on which liver ablative therapy was performed

Note: If liver ablative therapy is not carried out, record as 10101010 (inapplicable)

ccyymmdd

N/A

N/A

R

N/A

Embolisation Therapy

This denotes if the patient had transarterial chemoembolisation (TACE), transarterial embolisation (TAE) or selective internal radiation therapy (SIRT) treatment

Code List

1

TACE (Transarterial chemoembolisation)

R

N/A

2

TAE (Transarterial embolisation)

3

SIRT (Selective internal radiation therapy)

4

Patient died before embolisation therapy

5

Patient refused embolisation therapy

8

Not Applicable (no embolisation therapy given)

9

Not Recorded

Embolisation Therapy Date (TACE/TAE/SIRT) 

This denotes the date on which chemoemolisation (TACE), TAE or SIRT was performed

Note: If TACE is not carried out, record as 10101010 (inapplicable)

ccyymmdd

N/A

N/A

R

N/A

Peptide Receptor Nuclide Therapy (PRRT) Type

This denotes the type of peptide receptor nuclide therapy (PRRT)

Code List

01

MIBG (Metaiodobenzylguanidine)

R

N/A

02

Lutetium 177 (LU 177/Lutathera)

03

Yttrium 90 (YU 90)

04

Patient died before PRRT

05

Patient refused PRRT

98

Not applicable (no PRRT given)

97

Other 

99

Not recorded

Peptide Receptor Nuclide Therapy (PRRT) Type - Other

Where Peptide Receptor Nuclide Therapy (PRRT) Type is recorded as Other, please specify the type

max an50

N/A

N/A

R

N/A

Peptide Receptor Nuclide Therapy (PRRT) - Start Date

This denotes the date on which peptide receptor nuclide therapy (PRRT) was commenced

Note: If PRRT is not carried out, record as 10101010 (inapplicable)

ccyymmdd

N/A

N/A

R

N/A

Peptide Receptor Nuclide Therapy (PRRT) - End Date

This denotes the date on which peptide receptor nuclide therapy (PRRT) was completed

Note: If PRRT is not carried out, record as 10101010 (inapplicable)

ccyymmdd

N/A

N/A

R

N/A

Bassi Classification

Morbidity and mortality after pancreatic surgery as recorded using the Bassi Classification.

Code List

01

A - Any definition from the normal po-operative course without pharmacologic treatment or surgical, endoscopic and radiological interventions. Allowed therapeutic regimens are drugs such as antiemetics, antipyretics, analgesics, diuretics, electrolytes and physiotherapy. This grade also includes wound infections opened at the bed side

R

N/A

02

B - Requiring pharmacologic treatment with drugs other than ones allowed for grade A complications. Blood transfusion and total parental nutrition are also included C-Ca-Cb

03

C - Requiring surgical, endoscopic or radiology intervention

04

C(a) - Intervention not under general anaesthesia

05

C(b) - Intervention under general anaesthesia

06

D - Life threatening complication requiring intermediate care/intensive care unit management

07

D(a) - Single organ dysfunction

08

D(b) - Multi organ dysfunction

09

E - Death of a patient

10

Suffix ‘d’- If the patient suffers from complication at the time of discharge, the suffix 'd' (for disability) is added to the respective grade of complication

98

Not applicable

99

Not recorded

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD

Surgery  -  Pancreatic  (One occurrence per Core Surgery)

Clavien-Dindo Classification of Surgical Classifications

Record the overall grade as per the Clavien-Dindo Classification of Surgical Classifications

Code List

1

Grade I

R

Clavien-Dindo Classification of Surgical Classifications (UG15060)

2

Grade II

3

Grade IIIa

4

Grade IIIb

5

Grade IVa

6

Grade IVb

7

Grade V

9

Not known (not recorded)

Vascular Resection

Were vessels resected to ensure tumour margins negative?

Note: This is a repeating data item and multiple codes may be recorded 

Code List

0

No vascular resection

R

N/A

1

Partial portal vein/SMV resection (cuff)

2

Circumferential portal vein/SMV resection

3

Arterial resection

4

IVC resection

Splenic Resection

Was the spleen removed during the Procedure?

Code List

0

No Splenectomy

R

N/A

1

Planned Splenectomy

2

Unplanned Splenectomy for Oncological Reasons

3

Unplanned Splenectomy for Non-Oncological Reasons

Surgical Palliation Type

Type of surgical palliation performed if any e.g., Hepaticojejunostomy

Code List

0

None

R

Surgical Palliation Type (UG13240)

1

Gastric bypass

2

Biliary bypass

3

Gastric/biliary bypass

4

Celiac plexus block

9

Not Known

Pre-Operative Stenting

Did the patient have a biliary stent placed prior to surgery?

Code List

0

None

R

N/A

1

Plastic

2

Metal covered

3

Metal uncovered

Surgery - Pancreas - Endocsopic or Radiological Procedures (One occurrence per Core Surgery)

Endoscopic Procedure Type

The main endoscopic procedures carried out.

Note:
i. Whilst the COSD data item has additional codes, only the adjacent codes are applicable to the Upper GI - Pancreas site-specific standard.
ii. This is a repeating data item and multiple codes may be recorded   
 

Code List

1

Stent insertion

R

Endoscopic Procedure Type (UG14290)

4

Photodynamic therapy

8

Other

Endoscopic or Radiological Complication Type

The types of complications that the patient experiences during the admission for the endoscopic procedure.

Note: This is a repeating data item and multiple codes may be recorded 

Code List

00

No complications

R

Endoscopic or Radiological Complication Type (UG13090)

02

Perforation

03

Haemorrhage

09

Pancreatitis

10

Cholangitis

88

Other

Cancer Care Plan - Pancreas. To carry details of the cancer care plan for Pancreas  (One occurrence of this group)

Resectability Based on Radiology

Record the MDT opinion of tumour resectability

Code List

1

Resectable

R

N/A

2

Borderline

3

Locally Advanced

4

Unresectable due to Metastatic Disease

Tumour Markers

CA19-9 and Chromogranins A + B
(for pNET only)

Code List

1

Ca 19-9 Value

R

N/A

2

Chromogranin A Value

3

Chromogranin B Value

Pathology - Pancreas. To record additional pathology details for Pancreas tumours (One occurrence per pathology)

Neurovascular Invasion

Is there evidence of neurovascular invasion in the resected specimen

Code List

1

Present

R

N/A

2

Not Present

Resection Margin Status

Is there evidence of margin involvement?

Code List

1

Tumour >1mm from resection margins

R

N/A

2

Tumour <1mm from resection margin

3

Tumour present at resection margin

4

Margins grossly involved

Margins Involved

Specify which margins are involved?

Note: This is a repeating data item and multiple codes may be recorded

Code List

01

Anterior pancreatic surface

R

N/A

02

SMA dissection margin

03

SMV dissection margin

04

Proximal enteric transection margin

05

Distal duodenal transection margin

06

Pancreatic transection margin

07

Bile duct transection margin

08

Posterior dissection margin

Reporting Data Item

Definition

Format

Code List (Code)

Code List (Text)

Status

COSD