Reporting Data Item

Business Justification

Definition

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

Permissible Values

7. PATHOLOGY

7.0

Date specimen taken

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

The date on which the specimen was extracted.

7.1

ENCDv4.5b (8.10)

Histological diagnosis

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

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

NHS Wales Data Dictionary

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

*Permissible values will be dependent upon the output specifications.

7.2 ENCDv4.5b (8.11)

Grade of differentiation

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

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

Permissible values are agreed by the clinical steering groups and conform to the requirements of the reporting output specifications. Currently there is no explicit requirement to map to terminologies or classifications. This will be kept under review Grade of differentiation is not appropriate or cannot be assessed

•    Grade of differentiation is not appropriate or cannot be assessed

•    Well differentiated

•    Moderately differentiated

•    Poorly differentiated

•    Undifferentiated/anaplastic

7.3

ENCDv4.5b (8.16)

T (Tumour) category (pathological)

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

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

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

7.4

ENCDv4.5b (8.17)

N (Node) category (pathological)

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

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

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

7.5

ENCDv4.5b (8.18)

M (Metastasis) category (pathological)

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

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

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