Information Specification

The data items required for National Cancer Data Standards for Wales – Site Specific – Gynaecology 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 – Gynaecology

 

Data Item

Definition

Format

Code List
(Code)

Code List (Text)

Status

COSD

Surgery. (One occurrence per Core Surgery)

Early onset (< 30 days post surgery) complications

The complication(s) which arise less than or equal to 30 days post surgery.

Multiple responses are possible.

Code List

1

Blood loss => 1000 ml

R

N/A

2

Wound infection

3

Superficial wound breakdown

4

Wound dehiscence (full thickness)

5

Anastomotic leak

6

Paralytic ileus

7

Vault Haematoma

8

Pelvic abscess

9

Bladder injury

10

Ureteric injury

11

Bowel injury

12

Deep vein thrombosis/pulmonary embolism

13

Myocardial infarct

14

Other: infection requiring treatment

15

Other: resulting in return to theatre

16

Other: resulting in an unscheduled stay on intensive care unit/HDU

97

Other: specify

Other Early onset (< 30 days post surgery) complications

If Other: Specify is recorded for Early onset (< 30 days post surgery) complications, specify the complications that arose

(Free Text field)

max an60

N/A

N/A

N/A

N/A

Grade of early onset (< 30 days post surgery) complication(s)

The worse case grade of each complication which arises less than or equal to 30 days post surgery - Refer to the Clavien Dindo classification of surgical complications

Code List

1

Grade I

R

N/A

2

Grade II

3

Grade IIIa

4

Grade IIIb

5

Grade IVa

6

Grade IVb

7

Grade V

9

Not Known/Not Recorded

Surgeon Grade

Grade of senior surgeon present at operation

Note: 'Colposcopist NOS' - Where the procedure is a colposcopy this may be a qualified colposcopist who is not a surgeon

Code List

S

Subspecialist Gynaecological Oncologist

R

Surgeon Grade

C

Consultant Gynaecologist (not subspecialist)

N

Non training sub consultant grade

T

Trainee including subspecialty fellow and ST Trainee

G

General Surgeon/other surgical specialty

Z

Colposcopist NOS

Residual Disease

The estimated maximal tumour diameter of residual disease (tumour) left after the surgery, as documented by the surgeon at the completion of the procedure, and would be captured by/at the MDT. 

Note: This data item would apply to ovarian, fallopian tube and peritoneal cancers managed surgically

Code List

1

0 cm

R

Residual Disease

2

>0 and <1 cm

3

>= 1 cm

Pathology. To carry pathology details for Gynae. (One occurrence per Path Report)

Fallopian Tube Involvement

For endometrial and epithelial/ovarian cancers, is there microscopic involvement of fallopian tubes

Code List

1

Not involved

R

Fallopian Tube Involvement

2

Right involved

3

Left involved

4

Both involved

X

Not assessable

Ovarian Involvement

For endometrial and fallopian cancers, is there microscopic involvement of ovaries

Code List

1

Not involved

R

Ovarian Involvement

2

Right involved

3

Left involved

4

Both involved

X

Not assessable

Serosal Involvement

For endometrial, epithelial/ovarian and fallopian cancers, is there microscopic involvement of uterine serosa

Code List

I

Invasive carcinoma

R

Serosal Involvement

B

Borderline changes (non-invasive implants)

N

Not Involved

X

Not assessable

Omental Involvement

For endometrium, ovary, fallopian tube and primary peritoneal cancers, is there involvement of the omentum

Code List

1

Involved - deposit size not specified

R

Omental Involvement

2

Involved - deposit(s) 20 mm or less

3

Involved - deposit(s) greater than 20 mm

4

Not Involved

X

Not assessable/Not sent

Pathology - For Fallopian Tube, Ovarian Epithelial & Primary Peritoneal. (One occurrence per Path Report)

Capsule Status

Capsule status of ovaries (record the most severe)

Code List

1

Intact

R

Capsule Status

2

Disrupted

3

Involved

X

Not assessable

Ovarian Surface Involvement

Is there involvement of the surface of either ovary

Code List

Y

Yes

R

Ovarian Surface Involvement

N

No

X

Not assessable

Peritoneal Cytology

Result of peritoneal cytology

Code List

1

Involved

R

Peritoneal Cytology

2

Not involved

3

Equivocal

X

Not sent

Peritoneal Involvement

Is there peritoneal involvement

Code List

I

Invasive carcinoma/invasive implants

R

Peritoneal Involvement

B

Non-invasive borderline implants

N

No (Not involved)

X

Not assessable/Not sent

Grade of Differentiation (Pathological) *

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

 

Note: In Core there is a code of GX (Grade of differentiation is not appropriate or cannot be assessed). That code is not applicable within the Gynaecology site-specific standard.

 

Code List

G1

Well differentiated

R

Grade of Differentiation (Pathological)

G2

Moderately differentiated

G3

Poorly differentiated

G4

Undifferentiated/anaplastic

Pathology - For Endometrial. (One occurrence per Path Report)

Involvement of Cervical Stroma

Is there microscopic involvement of cervical stroma

Code List

Y

Yes (involved)

R

Involvement of Cervical Stroma

N

No (Not involved)

X

Not Assessable

Myometrial Invasion

Is there microscopic evidence of myometrial invasion

Code List

3

Greater than or equal to 50%

R

Myometrial Invasion

4

None or less than 50%

Parametrium Involvement

Is there microscopic involvement of parametrium

Code List

Y

Yes (Involved)

R

Parametrium Involvement

N

No (Not involved)

X

Not assessable

Peritoneal Washings

Were peritoneal washings submitted and if so were malignant cells seen

Code List

P

Positive

R

Peritoneal Washings

N

Negative

X

Not sent/Not assessable

Peritoneal Involvement

Is there peritoneal involvement for endometrial cancer

Code List

Y

Involved

R

Peritoneal Involvement (Endometrial)

N

Not involved

X

Not assessable

Site of Peritoneal Involvement

If there is peritoneal involvement, which site is involved

Code List

P

Pelvic  

R

Site of Peritoneal Involvement

A

Abdominal

X

Not assessable

Pathology - For Cervical. (One occurrence per Path Report)

CGIN Grade

Specify presence and grade of CGIN (cervical glandular intra-epithelial neoplasia)

Code List

1

Low

R

CGIN Grade

2

High

3

Not present

X

Not assessable

CIN Grade

Specify presence and grade of CIN (cervical intra-epithelial neoplasia)

Code List

1

Grade 1

R

CIN Grade

2

Grade 2

3

Grade 3

4

Not present

X

Not assessable

SMILE

Specify presence of SMILE (Stratified Mucin-Producing Intra-epithelial lesion)

Code List

1

Present

R

SMILE

2

Absent

X

Not assessable

Excision Margin (Pre Invasive)

Is there evidence of resection margin involvement by in-situ/pre-invasive disease (CIN/CGIN and SMILE)

Code List

Y

Yes

R

Excision Margin (Pre Invasive)

N

No

X

Not assessable

Paracervical or Parametrial Involvement

Is there evidence of paracervical and/or parametrial involvement

Code List

Y

Yes

R

Paracervical or Parametrial Involvement

N

No

X

Not assessable

Thickness Uninvolved Stroma

Minimum thickness of uninvolved cervical stroma in mm (minimum tumour free rim)

max n2. max n2

N/A

N/A

R

Thickness Uninvolved Stroma

Vaginal Involvement

Is there evidence of microscopic vaginal involvement

Code List

Y

Yes

R

Vaginal Involvement

N

No

X

Not assessable

Invasive Thickness

The thickness or depth of the invasive lesion in mm

max n2.max n2

N/A

N/A

R

Invasive Thickness

Pathology - For Nodes. (One occurrence per Path Report)

Nodes Examined Number (Para-aortic)

The number of para-aortic nodes examined. 

Note: Not applicable for vulval cancers.  Use 0 if nodes not sent

max n2

N/A

N/A

R

Nodes Examined Number (Para-aortic)

Nodes Positive Number (Para-aortic)

The number of para-aortic nodes reported as being positive for the presence of tumour metastases. 

Note: Not applicable for vulval cancers

max n2

N/A

N/A

R

Nodes Positive Number (Para-aortic)

Nodes Examined Number (Pelvic)

The number of pelvic nodes examined

Note: Not applicable for vulval cancers.  Use 0 if nodes not sent

max n2

N/A

N/A

R

Nodes Examined Number (Pelvic)

Nodes Positive Number (Pelvic)

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

Note: Not applicable for vulval cancers

max n2

N/A

N/A

R

Nodes Positive Number (Pelvic)

Nodes Examined Number (Inguino-Femoral)

The number of inguino-femoral nodes examined. 

Note: Only applicable to vulval cancers.  Use 0 if nodes not sent

max n2

N/A

N/A

R

Nodes Examined Number (Inguino-Femoral)

Nodes Positive Number (Inguino-Femoral)

The number of inguino-femoral nodes reported as being positive for the presence of tumour metastases.

Note: Only applicable to vulval cancers

max n2

N/A

N/A

R

Nodes Positive Number (Inguino-Femoral)

Extranodal Spread

Is there evidence of extranodal spread/extension

Code List

Y

Yes

R

Extranodal Spread

N

No 

X

Not assessable

Staging

Final FIGO Stage

The FIGO stage is generally confirmed at pathology review in MDT meetings following surgery for uterine and vulval malignancies and for ovarian malignancies undergoing primary surgery. For ovarian malignancies planned to undergo neo-adjuvant chemotherapy and for cases of cervical cancer (which is staged clinically), the final FIGO stage is determined at the time of review of clinical findings, imaging, cytology, and biopsy histology at the MDT meeting

max an7

N/A

N/A

M

Final FIGO Stage

Patient

Oestrogen Receptor Status

The oestrogen receptor status of the patient at diagnosis (from specimen)

Code List

1

Positive

O

N/A

2

Negative

9

Not Recorded

Progesterone Receptor Status

The progesterone receptor status of the patient at diagnosis (from specimen)

Code List

1

Positive

O

N/A

2

Negative

9

Not Recorded