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)

GCI

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

GCI

FIGO (International Federation of Gynaecology & Obstetrics) pathological stage

To allow for site specific FIGO (International Federation of Gynaecology & Obstetrics) classifications to be taken into account in the analysis of treatment and outcome. Required for the reporting of the gynaecological clinical indicators.

The FIGO (International Federation of Gynaecology & Obstetrics) stage maps directly to TNM (Tumour Node and Metastasis) classification, with the exception of cervical and vaginal carcinoma where only the T and M categories map directly to FIGO.

The histological evidence of the extent of the primary tumour and the presence or absence of metastasis.

Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours (mapped to FIGO (International Federation of Gynaecology & Obstetrics)), with the exception of cervical and vaginal carcinoma where only the T and M categories map directly to FIGO.

7.7

GCI

Nodes examined number

(for cervix and vulva only)

Prognostic value to the assessment of node negative / positive patients. Required for the reporting of the gynaecological clinical indicators.

The number of local/regional nodes examined. 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.

7.8

GCI

Nodes positive number

(for cervix and vulva only)

Prognostic value to the assessment of node negative / positive patients. Required for the reporting of the gynaecological clinical indicators.

The number of local/regional 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.

7.9

GCI

Excision margin(s) status

To allow the excision margins to be taken into account in the analysis of treatment and outcome. Required for the reporting of the gynaecological clinical indicators.

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.

•     Margin involved

•     <1mm clear

•     1-5mm clear

•     >5mm clear

•     Uncertain

7.10

GCI

Residual disease

(for ovary only)

Prognostic indicator. Required for the reporting of the gynaecological clinical indicators.

The absence or size of residual tumour after treatment. The measurement of residual disease demonstrates the effects of therapy, influences further therapeutic procedures and is a strong predictor of prognosis.

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.

•     0cm

•     ≤2cm

•     >2cm