7.0

DAHNO

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)

DAHNO

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)

DAHNO

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)

DAHNO

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)

DAHNO

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

DAHNO

Date of pathology report

Required for submission to the national clinical head & neck cancer audit.

The date of the pathology report.

7.7

DAHNO

Pathology specimen type

To record the type of specimen reported for analysis. Required for submission to the national clinical head & neck cancer audit.

The type of specimen reported. Permissible values opposite are as specified by the Royal College of Pathologists.

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.

•     Cytology sample

•     Biopsy sample

•     Excision sample

•     Uncertain / other

7.8

DAHNO

Specimen nature

To record the nature of the specimen reported for analysis. Required for submission to the national clinical head & neck cancer audit.

The nature of the specimen reported.

Where have these values come from? Are these specified by DAHNO?

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.

•     Primary tumour

•     Re-excision of primary tumour

•     Recurrence

•     Nodes

•     Metastatic site other than nodes

7.9

DAHNO

Excision margin(s) status

To allow the excision margins to be taken into account in the analysis of treatment and outcome. Required for submission to the national clinical head & neck cancer 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.

•     Margin involved

•     <1mm clear

•     1-5mm clear

•     >5mm clear

•     Uncertain