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.

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

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

7.2 ENCDv4.5b (8.11)

Grade of differentiation

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

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

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

•    Grade of differentiation is not appropriate or cannot be assessed

•    Well differentiated

•    Moderately differentiated

•    Poorly differentiated

•    Undifferentiated/anaplastic

7.3

ENCDv4.5b (8.16)

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

7.6

WBCCA

DCIS (Ductal Carcinoma In Situ) grade

Prognostic factor. Required for submission to the Welsh Breast Cancer Clinical Audit. Also enables survival analysis i.e. survival by grade.

Qualitative assessment of the grade of DCIS (Ductal Carcinoma In Situ).

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.

•    High

•    Intermediate

•    Low

•    Not assessable

7.7

WBCCA

Invasive lesion size

To allow for the invasive lesion size to be taken into account in the analysis of treatment and outcome. Required for submission to the Welsh Breast Cancer Clinical Audit.

This field records the maximum diameter of the invasive lesion in millimetres. The value recorded should be the most accurate measurement that can be obtained from either macroscopic or microscopic measurements.

Millimetres

7.8

WBCCA

Whole size of tumour including DCIS (Ductal Carcinoma In-Situ)

To allow for the whole size of the tumour to be taken into account in the analysis of treatment and outcome. Required for submission to the Welsh Breast Cancer Clinical Audit.

This field records the whole size of the invasive tumours diameter including ductal carcinoma in-situ in millimetres. The value recorded should be the most accurate measurement that can be obtained from either macroscopic or microscopic measurements.

Millimetres

7.9

WBCCA

Multifocal indicator

To allow for the multifocal indicator to be taken into account in the analysis of treatment and outcome. Required for submission to the Welsh Breast Cancer Clinical Audit.

An indicator for multifocal lesions.

•    Yes

•    No

7.10

WBCCA

Cancer vascular or lymphatic invasion

To allow for the extent of vascular or lymphatic invasion to be taken into account in the analysis of treatment and outcome. Required for submission to the Welsh Breast Cancer Clinical Audit.

To report the presence of unequivocal tumour in vascular spaces.

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.

•    No, vascular/lymphatic invasion not present

•    Yes, vascular/lymphatic invasion present

•    Uncertain whether vascular invasion is present or not

7.11

WBCCA

Excision margin(s) status

To allow for the excision margins to be taken into account in the analysis of treatment and outcome. Required for submission to the Welsh Breast Cancer Clinical Audit.

Whether all the excision margins were clear of tumour. The reporting data item ‘excision margins’ relates to multiple margins which may have been assessed therefore the permissible reporting item will relate to all margins e.g. Excision margins clear will only be reported if all margins assessed are clear.

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.

•    Excision margins clear

•    Excision margin involved

•    Uncertain

7.13

WBCCA

BCI

Local / regional nodes examined

Required for the submission to the Welsh Breast Cancer Clinical Audit and the information requirements of the breast cancer clinical indicators (To determine histologically node negative patients having 1-7 nodes examined).

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

7.14

WBCCA

BCI

Local / regional nodes positive

Required for the submission to the Welsh Breast Cancer Clinical Audit and the information requirements of the breast cancer clinical indicators To determine histologically node negative patients having 1-7 nodes positive).

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

7.15

WBCCA

BCI

ER (Oestrogen Receptor) status

Required for the submission to the Welsh Breast Cancer Clinical Audit to assess the level of testing is appropriate in addition to the information requirements of the breast cancer clinical indicators (To determine the % of ER (Oestrogen Receptor) positive women).

To indicate whether the pathologist identified that the lesion was oestrogen receptor positive.

Measure of oestrogen receptor expression.

Refer to the Allred Score Classification

•    Positive

•    Strongly positive

•    Moderately positive

•    Weakly positive

•    Negative

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

7.16

WBCCA

PgR (Progesterone Receptor) status

Required for submission to the Welsh Breast Cancer Clinical Audit, to assess the level of testing is appropriate in addition to determining the PgR status of breast cancer patients.

To indicate whether the pathologist identified that the lesion was progesterone receptor positive.

Measure of progesterone receptor expression.

Refer to the Allred Score Classification

•    Positive

•    Strongly positive

•    Moderately positive

•    Weakly positive

•    Negative

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

7.17

WBCCA

HER-2 (Human Epidermal growth factor Receptor 2) status

To determine the HER-2 (Human Epidermal growth factor Receptor 2) status of breast cancer patients. Required for submission to the Welsh Breast Cancer Clinical Audit.

Measure of Human Epidermal growth receptors HER-2 (also referred to as ErbB-2) expression.

Refer to the Allred Score Classification

•    Positive

•    Strongly positive

•    Moderately positive

•    Weakly positive

•    Negative

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