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Data Definitions for the National Minimum Core Dataset for Sarcoma. Developed by ISD Scotland, 2014

Sarcoma

Data Definitions for the National Minimum Core Data Set to support the introduction of Sarcoma Quality Performance Indicators

Definitions developed by ISD Scotland in Collaboration with the Sarcoma Quality Performance Indicator Development Group

Version 3.2: June 2019

To be used in conjunction with: 1. Sarcoma Clinical Quality Performance Indicators (Latest Published Version). 2. Sarcoma QPI Dataset Validations (Latest Published Version). 3. Sarcoma Measurability of Quality Performance Indicators (Latest Published Version).


DOCUMENT CONTROL SHEET Key Information

Title Sarcoma – Data Definitions for Minimum Core Dataset for Quality Performance Indicators (QPIs)

Date Published/Issued June 2019

Date Effective From 1

st April 2018 (TNM 8 changes effective from 1

st

April 2018)

Version/Issue Number V3.2

Document Type Guidance

Document Status Final

Standard Audience NHS staff involved in implementing and recording Sarcoma Quality Performance Indicators.

Cross References Sarcoma Quality Performance Indicators Sarcoma Measurability of Quality Performance Indicators

Author Information Services Division of NHS National Services Scotland

Revision History

Version Date Summary of Changes

Name Changes Marked

V2.0 March 2015 Changes agreed after QA of validation documents and Changes agreed at 9mth Review.

Jane Garrett See page x

V2.1 July 2015 Changes agreed out with review to support

data collection.

Jane Garrett See page xi

V2.2 Nov 2015 Changes agreed out with review to support

data collection.

Jane Garrett See page xi

V2.3 Aug 2016 Changes agreed at Baseline Review

Charlotte Anthony

See page viii

V2.4 Jul 2017 Changes agreed out with review to support

data collection.

Jane Garrett See page viii

V2.5 September 2017

Changes agreed out with review to support

data collection.

Hannah Ebbins

See page vi

V2.6 April 2018 Changes agreed out with review to support data collection

Jane Garrett See page v

V3.0 July 2018 Changes agreed at Formal Review

Jane Garrett See page iv

V3.1 December 2018

Changes agreed out with review to support data collection

Jane Garrett See page iii

V3.2 June 2019 Changes agreed out Jane Garrett See page iii


with review to support data collection


CONTENTS PREFACE ................................................................................................................................ i NOTES FOR IMPLEMENTATION OF CHANGES ................................................................. ii CONVENTIONS ...................................................................................................................... ii REVISIONS TO DATASET .................................................................................................... iii CRITERIA FOR INCLUSION OF PATIENTS IN AUDIT ...................................................... xiv DOWNLOAD FORMAT ......................................................................................................... xv

Section 1: Demographic Items ............................................................................... 1 Person Family Name (at Diagnosis) ...................................................................................... 2 Person Given Name ............................................................................................................... 3 Patient Postcode at Diagnosis ............................................................................................... 4 Date of Birth ........................................................................................................................... 5 Person Sex at Birth ................................................................................................................ 6 CHI Number ........................................................................................................................... 7

Section 2: Pre-treatment Imaging & Staging Investigations ................................ 8 Location of Diagnosis {Cancer}.............................................................................................. 9 Site of Origin of Primary Tumour {Cancer} .......................................................................... 10 Location of Sarcoma ............................................................................................................ 14 Date of Histological Diagnosis {Sarcoma} ........................................................................... 15 TNM Tumour Classification (Clinical) {Sarcoma} ................................................................. 16 TNM Nodal Classification (Clinical) {Sarcoma} .................................................................... 18 TNM Metastases Classification (Clinical) {Sarcoma}........................................................... 19 Date Staging CT Scan Complete ......................................................................................... 20 Date Staging CT Scan Report ............................................................................................. 21 WHO/ ECOG Performance Status ....................................................................................... 22 Date Discussed by Care Team (MDT) ................................................................................. 23 Type of First Cancer Treatment ........................................................................................... 24 Date of First Cancer Treatment ........................................................................................... 25 Date of Definitive Treatment {Sarcoma} .............................................................................. 26

Section 3: Surgery................................................................................................. 27 Location Code {Cancer Surgery} ......................................................................................... 28 Consultant in Charge of Surgery.......................................................................................... 29 Date of Surgery .................................................................................................................... 30 Presentation Type (Surgical) ............................................................................................... 31 Intent of Surgery................................................................................................................... 32 Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} ..................................... 33 Primary Flap Reconstruction ................................................................................................ 45

Section 4: Pathological Details ............................................................................ 46 Morphology of Tumour ......................................................................................................... 47 Surgical Margins .................................................................................................................. 51 TNM Tumour Classification (Pathological) {Sarcoma}......................................................... 52 TNM Nodal Classification (Pathological) {Sarcoma} ............................................................ 54 TNM Metastases Classification (Pathological) {Sarcoma} .................................................. 55 TNM Histopathological Tumour Grade {Soft Tissue Sarcoma} ........................................... 56 Gastrointestinal Stromal Tumour (GIST) Risk Score ........................................................... 57 Mutational Analysis (GIST) .................................................................................................. 58 Date of Mutational Analysis (GIST)...................................................................................... 59

Section 5: Oncology ............................................................................................. 60 Radiotherapy Course Type {Sarcoma} 1-3 .......................................................................... 61 Date Treatment Started (Radiotherapy) {Sarcoma} 1-3 ...................................................... 62 Date Treatment Completed (Radiotherapy) {Sarcoma} 1-3 ................................................ 63 Type of Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3 .......................................... 64 Multi-agent Chemotherapy {Sarcoma} ................................................................................. 65 Biological Therapy Agent {Sarcoma} ................................................................................... 66 Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3 ................ 67 Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3 .......... 68

Section 6: Clinical Trials ....................................................................................... 69 Patient Entered into Clinical Trial ......................................................................................... 70

Section 7: Death Details........................................................................................ 71 Date of Death ....................................................................................................................... 72


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PREFACE

Following the publication of Better Cancer Care: An Action Plan in October 2008, the Scottish Government established the Scottish Cancer Taskforce to oversee its implementation. The NHS Scotland Healthcare Quality Strategy in 2010 expands on this by articulating quality ambitions. A quality measurement framework has been developed setting out measures and targets which will be used to monitor, challenge, manage and report progress. Part of this strategy is the development of quality performance indicators (QPIs) to drive quality improvement in cancer care throughout NHS Scotland. As high quality data are required to enable comparisons over time and between regions, it is important that national data definitions are used to facilitate consistent data collection. National data definitions already in use have been used as much as possible to allow electronic data capture, thereby minimising duplication of data collection. Where national data definitions do not already exist, definitions used in other systems have been incorporated. To ensure that findings are comparable across Scotland, the national dataset and data definitions in conjunction with the final quality performance indicators were agreed through public engagement and are now ready for implementation for patients diagnosed from 1st April 2014.


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NOTES FOR IMPLEMENTATION OF CHANGES The following changes should be implemented for all patients who are diagnosed with Sarcoma on or after 1st April 2018, who are eligible for inclusion in the Sarcoma cancer audit. NB: Dataset applies for data reported within the 2018-2019 reporting cohort with the exception of the following data item which should be applied for patients diagnosed from 1st April 2017: Gastrointestinal Stromal Tumour (GIST) Risk Score Changes to definitions fall into the following categories:

to address problems with ongoing audit and standardise data definitions, where feasible, between different cancer sites

to address problems with existing definitions

to allow Quality Performance Indicators to be measured and reported against

If you have difficulties in using individual definitions within this document please contact General Enquiries on the Collection of the Minimum Core Data Set If you have any comments on the attached data definitions ISD would welcome your feedback. Please contact:

[email protected] CONVENTIONS The layout for each item is standard as shown below where it is applicable: Common Name(s): Main Source of Data Item Standard: Definition: Field Name: Field Type: Field Length: Notes for Users: Codes and Values: Related Data Item(s): In addition the following two conventions have been used in the document:

{curly brackets} - definition relates to one specific named data set

'described elsewhere' - indicates there is a definition for the named item within this document

mailto:[email protected]


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REVISIONS TO DATASET

Revisions to Dataset outwith Review (June 2019) Site of Origin of Primary Tumour {Cancer} – Codes and Values table add C31.0 Maxillary sinus

Date of Histological Diagnosis {Sarcoma} - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’

Date Staging CT Scan Complete - Notes for Users amend ‘10/10/1010’ to

’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’

Date Staging CT Scan Report - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’

and ‘09/09/0909’ to ‘09/09/1900’ Date Discussed by Care Team - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Date of First Cancer Treatment - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Date of Definitive Treatment - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Date of Surgery - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} – Codes and Values table add S05.9 Microscopically controlled excision of lesion of skin - unspecified; V01.8 Plastic repair of cranium - unspecified Date of Mutational Analysis (GIST) - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Date Treatment Started (Radiotherapy) {Sarcoma} - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Date Treatment Completed (Radiotherapy) {Sarcoma} - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Date Treatment Started Systemic Anti-Cancer Therapy (SACT) - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Date of Death - Notes for Users amend ‘10/10/1010’ to ’10/10/1900’ and ‘09/09/0909’ to ‘09/09/1900’ Revisions to Dataset outwith Review (December 2018) Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} – Codes and Values table add - B08.3 Hemithyroidectomy


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Morphology of Tumour – Codes and Values table add Follicular Dendritic Cell Sarcoma is 9758/3 Revisions to Dataset at Formal Review July 2018 Database Specification Measurement of Macroscopic Residual Disease – Remove Data item Systemic Therapy Agent {Sarcoma} – Remove Data Item Date Staging CT Scan Report - Add new Data Item Field Name: CTREPORTDATE, Field Type: Date (DD/MM/CCyy), Field Length: 10 Multi-agent Chemotherapy {Sarcoma} - Add new Item Field Name: MULTAGENT, Field Type: Integer, Field Length: 2 Dataset Site of Origin of Primary Tumour {Cancer} - Required for QPI(s): delete ‘5’, ‘11’ Location of Sarcoma - Required for QPI: Delete ‘8’, add ‘5’ Date of histological Diagnosis {Sarcoma} - Required for QPI(s) change ‘1’ to ‘1-11’; Notes for Users add ‘Required for national survival analysis and national comparative analysis.’ TNM Tumour Classification (Clinical) {Sarcoma} – Notes for Users delete ‘This may be at any MDT meeting up until first treatment however’, add ‘Within the table below the following sites are classified as bone sarcomas: Appendicular skeleton, trunk, skull and facial bones; Spine and Pelvis, The following sites are classified as soft tissue sarcomas: Extremity and superficial trunk; Retroperitoneum; Head & Neck; Thoracic and Abdominal viscera; Codes and Values table reformatted. TNM Nodal Classification (Clinical) {Sarcoma} - Notes for Users delete ‘This may be at any MDT meeting up until first treatment however’. TNM Metastases Classification (Clinical) {Sarcoma} - Notes for Users delete ‘This may be at any MDT meeting up until first treatment however’; add ‘Where the presence of distant metastases has been documented this should be recorded as M1. Where the absence of metastases has been documented this should be recorded as M0.’ Date Staging CT Scan Complete – Delete Required for QPI: 3 Date Staging CT Scan Report – Add new data item Type of First Cancer Treatment - Required for QPI(s) add ‘6, 9’; Codes and Values add code 16 – Hormone therapy’ Date of First Cancer Treatment - Required for QPI(s) delete ‘2, 10’; Notes for users add ‘If hormone therapy is the first treatment, it is not always clearly documented when hormone therapy starts. In the patient discharge or clinic letter the clinician may


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ask the GP to prescribe hormone therapy, in this case, record the date as two days from the day the discharge letter or clinic letter was typed’ Date of Definitive Treatment – Notes for Users add ‘Where this has subsequently been confirmed at MDT, the date of MDT should be recorded’ Date of Surgery - Required for QPI(s): delete ‘3, 9’ add ‘11’ Intent of Surgery - Required for QPI: delete ‘4’ Final Definitive (or Only) surgery Performed (Surgery) {Sarcoma} - Required for QPI(s): delete ‘8, 10’. Codes and Values table add code V14.4 – excision of lesion of mandible Measurement of Macroscopic Residual Disease – Remove data item Surgical Margins - Required for QPI: delete 8 TNM Tumour Classification (Pathological) {Sarcoma} – Notes for Users add ‘Within the table below the following sites are classified as bone sarcomas: Appendicular skeleton, trunk, skull and facial bones; Spine and Pelvis, The following sites are classified as soft tissue sarcomas: Extremity and superficial trunk; Retroperitoneum; Head & Neck; Thoracic and Abdominal viscera; Codes and Values table reformatted. TNM Histopathological Tumour Grade {Soft Tissue Sarcoma} - Required for QPI: delete ‘8’ Gastrointestinal Stromal Tumour (GIST) Risk – Codes and Values table updated Type of Systemic Anti-Cancer Therapy (SACT) {Sarcoma} - Required for QPI: delete ‘9’ Systemic Therapy Agent {Sarcoma} – Remove data item Multi-agent Chemotherapy {Sarcoma} - Add new data item

Revisions to Dataset outwith review (April 2018)

Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} – Codes and Values table add S08.1 “Curettage and cauterisation of lesion of skin of head or neck P05.4 “Excision of lesion of vulva NEC G50.1 Excision of lesion of duodenum G59.1 Excision of lesion of jejunum L79.8 Other specified other operations on vena cava M41.1 Open extirpation of lesion of bladder S17.9 Unspecified distant flap of skin and muscle S27.9 Unspecified other local flap of skin T33.1 Open excision of lesion of peritoneum T37.1 Excision of lesion of mesentery of small intestine T37.8 Other specified operations on mesentery of small intestine T37.9 Unspecified operations on mesentery of small intestine


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V14.1 Hemimandibulectomy V24.8 Other specified decompression operations on thoracic spine V25.4 Primary posterior laminectomy decompression of lumbar spine Y75.1 Laparoscopically assisted approach to abdominal cavity Site of Origin of Primary Tumour {Cancer} – Codes and Values table add codes C44.4 Skin of scalp and neck C44.5 Skin of trunk C17.1 Jejunum C17.2 Ileum C54.1 Endometrium TNM Histopathological Tumour Grade {Soft Tissue Sarcoma} – Codes and Values table amend G2 Low grade should be changed to G2 intermediate grade. Morphology of Tumour – Codes and Values table add 8930/3 Endometrial stromal sarcoma TNM Tumour Classification (Clinical) {Sarcoma} - Standard and Definition changed from Seventh Edition, 2009 to Eighth Edition 2017; Remove codes and values table and insert new codes and values tables; Remove ‘8’ from Required from QPIs TNM Nodal Classification (Clinical) {Sarcoma} - Standard and Definition changed from Seventh Edition, 2009 to Eighth Edition 2017, Add ‘*’ to ‘Regional lymph nodes cannot be assessed’ and add ‘*NX: Regional lymph node involvement is rare for GISTs, so that cases in which the nodal status is not assessed clinically or pathologically could be considered N0 instead of NX.’; Remove ‘8’ from Required from QPIs TNM Metastases Classification (Clinical) {Sarcoma} - Standard and Definition changed from Seventh Edition, 2009 to Eighth Edition 2017; Remove ‘8’ from Required from QPIs TNM Tumour Classification (Pathological) {Sarcoma} - Standard changed from Seventh Edition, 2009 to Eighth Edition 2017; Remove Codes and Values table and insert new Codes and Values tables TNM Nodal Classification (Pathological) {Sarcoma} - Standard changed from Seventh Edition, 2009 to Eighth Edition 2017; Add ‘*’ to ‘Regional lymph nodes cannot be assessed’ and add ‘*pNX: Regional lymph node involvement is rare for GISTs, so that cases in which the nodal status is not assessed clinically or pathologically could be considered pN0 instead of pNX.’

TNM Metastases Classification (Pathological) - Standard changed from Seventh Edition, 2009 to Eighth Edition 2017; delete pM0 - No distant metastasis; add ‘microscopically confirmed’ to pM1 ‘; Add ‘Note – pM0 and pMX are not valid categories’

Revisions to Dataset outwith review (September 2017)


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Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} – Codes and Values table add codes A38.1 – Extirpation of lesion of meninges of cortex of brain Q09.2 – Open myomectomy C01.1 Exenteration of orbit S35.3 Split autograft of skin to head or neck NEC G69.3 Ileectomy and anastomosis of ileum to ileum Y50.2 Laparotomy approach NEC Y75.2 Laparoscopic approach to abdominal cavity NEC T36.1 Omentectomy S24.2 - Local myocutaneous subcutaneous pedicle flap NEC S36.2 Full thickness autograft of skin NEC Person Family Name (at Diagnosis)(PATSNAME) – Link updated Person Given Name (PATFNAME) – Link updated Patient Postcode at Diagnosis {Cancer} – Link updated Date of Birth (DOB) – Link updated Site of Origin of Primary Tumour {Cancer} – Codes and Values table add code C44.3 Skin of other and unspecified parts of face

Revisions to Dataset outwith review (July 2017)

Site of Origin of Primary Tumour {Cancer} – Codes and Values table add codes C00.9 - Malignant neoplasm, lip, unspecified C01.X - Malignant neoplasm of base of tongue C02.9 - Malignant neoplasm, tongue, unspecified C04.9 - Malignant neoplasm, floor of mouth, unspecified C05.9 - Malignant neoplasm, palate, unspecified C06.9 - Malignant neoplasm, mouth, unspecified C07.X - Malignant neoplasm of parotid gland C08.9 - Malignant neoplasm, major salivary gland, unspecified C09.9 - Malignant neoplasm, tonsil, unspecified C10.9 - Malignant neoplasm, oropharynx, unspecified C11.9 - Malignant neoplasm, nasopharynx, unspecified C12.X - Malignant neoplasm of pyriform sinus C13.9 - Malignant neoplasm, hypopharynx, unspecified C19.X - Malignant neoplasm of rectosigmoid junction C20.X - Malignant neoplasm of rectum C22.9 - Malignant neoplasm, liver, unspecified C23.X - Malignant neoplasm of gall bladder C24.9 - Malignant neoplasm, biliary tract, unspecified C25.9 - Malignant neoplasm, pancreas, unspecified C26.9 - Malignant neoplasm, ill-defined sites within the digestive system C31.9 - Malignant neoplasm, accessory sinus, unspecified C33.X - Malignant neoplasm of trachea C37.X - Malignant neoplasm of thymus C39.9 - Malignant neoplasm, ill-defined sites within the respiratory system C40.9 - Malignant neoplasm, bone and articular cartilage of limb, unspecified C41.9 - Malignant neoplasm, bone and articular cartilage, unspecified


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C44.9 - Malignant neoplasm, of skin, unspecified C47.9 - Malignant neoplasm, peripheral nerves and autonomic nervous system, unspecified C50.9 - Malignant neoplasm, breast, unspecified C51.9 - Malignant neoplasm, vulva, unspecified C52.X - Malignant neoplasm of vagina C54.9 - Malignant neoplasm, corpus uteri, unspecified C55.X - Malignant neoplasm of uterus, part unspecified C56.X - Malignant neoplasm of ovary C57.9 - Malignant neoplasm, female genital organ, unspecified C58.X - Malignant neoplasm of placenta C60.9 - Malignant neoplasm, penis, unspecified C62.9 - Malignant neoplasm, testis, unspecified C63.9 - Malignant neoplasm, male genital organ, unspecified C64.X - Malignant neoplasm of kidney, except renal pelvis C65.X - Malignant neoplasm of renal pelvis C66.X - Malignant neoplasm of ureter C67.9 - Malignant neoplasm, bladder, unspecified C68.9 - Malignant neoplasm, urinary organ, unspecified C69.9 - Malignant neoplasm, eye, unspecified C70.9 - Malignant neoplasm, meninges, unspecified C71.9 - Malignant neoplasm, brain, unspecified C72.9 - Malignant neoplasm, central nervous system, unspecified C73.X - Malignant neoplasm of thyroid gland C74.9 - Malignant neoplasm, adrenal gland, unspecified C75.9 - Malignant neoplasm, endocrine gland, unspecified C77.9 - Malignant neoplasm, lymph node, unspecified C80.X - Malignant neoplasm of unspecified site C96.9 - Malignant neoplasm of lymphoid, haematopoietic/related tissue, unspecified Morphology of Tumour – Codes and Values table add 8811/1 Cellular Fibroma

Revisions to Dataset following Baseline Review (August 2016)

Location of Diagnosis –Notes for Users add ‘GP surgery codes can be recorded in this field if this is the location the diagnosis was first made.’ Site of Origin of Primary Tumour {Cancer} – Codes and Values table add C17.0 – Duodenum C32.9 - Larynx unspecified C34.9 - Solitary malignant fibrous tumour of the lung C44.0 - Dermatofibrosarcoma C44.6 – Skin of Upper limb, including shoulder C44.7 – Skin of lower limb, including hip C47.1 – Peripheral Nerves of Upper limb, including shoulder C47.2 – Peripheral Nerves of Lower limb including hip C47.5 – Peripheral Nerves of pelvis C50.0 – Phylloides tumour C53.9 – Leiomyosarcoma of the cervix C63.1 – Liposarcoma of the Spermatic cord TNM Tumour Classification (Clinical) {Sarcoma} – Notes for Users add ‘Sarcoma that are diagnosed at surgery with no pre-treatment investigations should be


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recorded as not applicable (96). For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96).’ TNM Tumour Classification (Pathological) {Sarcoma} - Notes for Users add ‘ Sarcoma that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96). For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96).’ TNM Nodal Classification (Clinical) {Sarcoma} – Notes for Users add‘ Sarcoma that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96).For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96).’ TNM Nodal Classification (Pathological) {Sarcoma} – Notes for Users add‘Sarcoma that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96).For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96).’ TNM Metastases Classification (Clinical) {Sarcoma} – Notes for Users add ‘Sarcoma that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96).For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96).’ TNM Metastases Classification (Pathological) {Sarcoma} - Notes for Users add ‘ Sarcoma that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96).For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96).’ Date Staging CT Scan Complete – Notes for Users add ‘The CT carried out closest to the date of diagnosis should be used. If this is not clear or if Date ......’ Date of First Cancer Treatment – Notes for Users add ‘first date the decision was taken not to give the patient treatment as part of their primary therapy’ has been removed and replaced with ‘the date the MDT recommend supportive care as the treatment option.’ Presentation Type (Surgical) – Codes and Values table remove from explanatory notes for code 02 – Emergency ‘ If presentation is classed as ‘urgent’, code as ‘emergency’ only if surgery is performed within 72 hours of admission’ Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} – Codes and Values table add A44.4 – Excision of extradural lesion B25.1 – Excision of lesion of adrenal gland E03.2 – Excision of lesion of septum of nose E29.1 - Total Laryngectomy G49.0 - Excision of duodenum Excludes: Pancreaticoduodenectomy (J56) G49.1 - Gastroduodenectomy G49.2 - Total excision of duodenum G49.3 – Partial excision of duodenum G49.8 - Excision of duodenum Other specified G49.9 - Excision of duodenum Unspecified G51.0- Bypass of duodenum Excludes: Bypass of duodenum by anastomosis of duodenum to colon (G51.4) G51.1 - Bypass of duodenum by anastomosis of stomach to jejunum


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G51.2 - Bypass of duodenum by anastomosis of duodenum to duodenum G51.3 - Bypass of duodenum by anastomosis of duodenum to jejunum G51.8 - Bypass of duodenum Other specified G51.9 - Bypass of duodenum Unspecified G69.9 – Excision of ileum unspecified J56.2 – Pancreaticoduodenectomy and resection of antrum of stomach (Whipple’s resection) L79.7 – Excision of lesion of vena cava M02.5 – Nephrectomy NEC S06.5 – Excision of lesion of skin of head or neck NEC S06.7 – Re-excision of skin margins NEC S06.9 – Other excision of lesion of skin unspecified T39.1 – Excision of lesion of posterior peritoneum V25.1 – Primary extended decompression of lumbar spine and intertransverse fusion of joint of lumbar spine V25.7 – Primary anterior corpectomy of lumbar spine and reconstruction HFQ V67.2 – L2 Hemilaminectomy Includes: Duodenectomy not elsewhere classified Morphology of Tumour – Codes and Values table add 8936/1 - Gastrointestinal stromal tumour, NOS Gastrointestinal Stromal Tumour (GIST) Risk Score – Notes for Users add the following text ‘Risk of Aggressive Behaviour in GISTs (from Fletcher et al 2002, Human Pathology 33(5):459 65. It is frequently referred to either as the NIH risk table or as the Fletcher risk table.’ Replaced with ‘Risk of Progressive Disease (Gastric) (from Miettinen M, Lasota J. Semin Diagn Pathol 2006:23:70-83. This is included in the Royal College of Pathologists Dataset for Gastrointestinal Stromal Tumours (GISTs). If the risk score is not documented, or there are any inconsistencies the score should not be calculated and the relevant pathologist should be contacted for clarification.’ Codes and Values (Fletcher table replaced with Miettinen (below): None / ≤2 cm / ≤5 (in 5mm2) Very low (1.9%) / >2 - ≤5 cm / ≤5 (in 5mm2) Low (3.6%) / >5 - ≤10cm / ≤5 (in 5mm2) Moderate (10%) / >10 cm / ≤5 (in 5mm2) Insufficient data / ≤2 cm / >5 (in 5mm2) Moderate (16%) / >2 - ≤5 cm / >5 (in 5mm2) High (55%) / >5 - ≤10cm / >5 (in 5mm2) High (86%) / >10 cm / >5 (in 5mm2) 96 / Not applicable / Not gastrointestinal stromal tumour 99/ Not Known / Includes not recorded

Radiotherapy Course Type {Sarcoma} 1-3 – Notes for Users add ‘For patients undergoing chemoradiotherapy the radiotherapy element should be recorded as code 06. The Chemotherapy element of this combined treatment should be recorded separately in fields CHEMTYPE1, CHEMTYPE2 or CHEMTYPE3. Codes and Values table add 05 – Radical – It is primary treatment and is given with curative intent. 06 – Chemoradiotherapy – Radical radiotherapy given in combination with chemotherapy, either concurrently or sequentially. Type of Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3 – Notes for Users add ‘For patients undergoing chemoradiotherapy the radiotherapy element should be recorded as code 08 and recorded in Radiotherapy Course Type [RCOURSETYPE1,


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RCOURSETYPE2 and RCOURSETYPE3].’ Codes and Values table add 08 – Chemoradiotherapy – Chemotherapy given in combination with radical radiotherapy either concurrently or sequentially. Systemic Therapy Agent {Sarcoma} 1-3 – Definition removed or biological therapy’

Revisions to Dataset outwith review (November 2015)

Morphology of Tumour – Codes and Values table ICD10 code C61._ added to the morphology list alongside morphology code 8980/3 – Carcinosarcoma NOS; add morphology code 9020/3 – Phyllodes tumour, malignant (C50._)

TNM Tumour Classification (Clinical) {Sarcoma} – Codes and Values table add code 96 ‘Not applicable’ TNM Nodal Classification (Clinical) {Sarcoma} – Codes and Values table add code 96 ‘Not applicable’ TNM Metastases Classification (Clinical) {Sarcoma} – Codes and Values table add code 96 ‘Not applicable’(Query 1033)

Radiotherapy Course Type {Sarcoma}1-3 Notes for Users delete ‘For patients undergoing chemoradiotherapy the radiotherapy element should be recorded as code ‘06’ and recorded also in SACT under code ‘05’’Type of Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3 (CHEMTYPE1) – Notes for Users delete ‘For patients undergoing chemoradiotherapy the chemotherapy element should be recorded as code ‘05’ and recorded also in ‘Radiotherapy Course Type) under code ‘06’’. Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} – Codes and Values table add V05.1 Extirpation of lesion of cranium

Revisions to Dataset outwith review (July 2015) Location of Diagnosis {Cancer} – Codes and Values table remove X1010=Not applicableSite of Origin of Primary Tumour {Cancer} (SITE) – Codes and Values table add site code C61 prostate Morphology of tumour – Codes and Values table add morphology code 8980/3 – Carcinosarcoma NOS

Revisions to Dataset following 9 month review (April 2015)

Database Specification

TNM Metastases Classification (Clinical) {Sarcoma} – Field length amend to 3


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Date Staging CT Scan Complete (Pre-treatment) –Title remove word ‘Pre-treatment’ Date of First Cancer Treatment – Format (DD/MM/CCYY) Date of Definitive Treatment - Format (DD/MM/CCYY) Date of Surgery - Format (DD/MM/CCYY) Surgical Margins – Field type Characters

Dataset Location of Diagnosis – Delete Error! Reference source not found Site of Origin of Primary Tumour {Cancer} – Amend Field Type: Characters, Remove Liver Cell Carcinoma, Codes and Values table Location of sarcoma add Code 96 ‘Not applicable’ – Primary location not known, add Code ‘03’ - GIST TNM Tumour Classification (Clinical) {Sarcoma} – Field Name change to cTSARC, add Bone and GIST TNM TNM Nodal Classification (Clinical) {Sarcoma} – Filed name change to cNSARC TNM Metastases Classification (Clinical) {Sarcoma} – Field Name change cMSARC,and field length 3 add Bone and GIST TNM Date Staging CT Scan Complete (Pre-treatment) – Title remove word ‘Pre-treatment’ Date Discussed by Care Team (MDT) - Notes for Users add ‘This won’t necessarily be a Sarcoma MDT’ Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} - Codes and Values table update list of codes Morphology of tumour - Notes for Users add ‘If unsure check with Pathologist’, add an explanatory note to code 8851/3 to say ‘Atypical Lipomatous tumour’ TNM Tumour Classification (Pathological) {Sarcoma} – Field Name change pTSARC, add ‘Not applicable’ and Bone and GIST TNM TNM Nodal Classification (Pathological) {Sarcoma} – Field Name change pNSARC, add ‘Not applicable’ TNM Metastases Classification (Pathological) {Sarcoma} – Field Name change pMSARC, ‘Not applicable’ TNM Histopathological Tumour Grade {Soft Tissue Sarcoma} – Notes for Users add ‘Should be documented and if not check with pathologist, add not assessable code ‘93’ .Mutational Analysis (GIST) add 'mutational analysis is not routinely performed for low risk GIST, however if performed this should be recorded'


xiii

Revisions to Dataset outwith review (July 2014) Database Specification Date of Definitive Treatment {Sarcoma} - Add New Data Item: Field Name: DEFTREATDATE, Field Type: Date, Field Length: 10. Date of Histological Diagnosis {Sarcoma} – Field Name amended from HDIAG to DIAGDATE

Dataset Date of Diagnosis {Cancer} – Remove Data Item Location of Sarcoma - Notes for Users addition Date of Histological Diagnosis {Sarcoma} – Filed Name amended Date Staging CT Scan Complete (Pre-treatment) - Notes for Users amended Date Discussed by Care Team - Notes for Users amended Date of Definitive Treatment {Sarcoma} – Add New Data Item Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} – Codes and Values table amendment Primary Flap Reconstruction - Definition amended and amendments made to Notes for users Measurement of Macroscopic residual Disease - Notes for Users amended Surgical Margins - Notes for Users addition TNM Histopathological Tumour grade {Soft Tissue Sarcoma} – Codes and Values table removed Code 04 (High Grade) Mutational Analysis (GIST) - Codes and Values table added Code 04 (insufficient sample) Date of Mutational Analysis (GIST) – Notes for Users addition Radiotherapy Course Type {Sarcoma} – Codes and Values table removed code 02 (Radical) and code 06 (Chemoradiotherapy) Type of Systemic Anti-Cancer Therapy (SACT) {Sarcoma} - Codes and Values table removed 1-3 code 05 (Chemoradiotherapy) Systemic Therapy Agent {Sarcoma} 1-3 - Notes for Users amended


xiv

CRITERIA FOR INCLUSION OF PATIENTS IN AUDIT To facilitate national comparisons the same patients must be audited throughout Scotland. The following eligibility criteria have been documented for this purpose. Include:

All patients with a confirmed new primary invasive sarcoma or gastrointestinal stromal tumour (GIST). This includes all patients who have had previous primary malignancy of any site or concurrent primary malignancy of another site.

Exclude:

Patients where the origin of the primary is uncertain

Patients with tumour types other than sarcoma

Patients with benign tumours or neoplasms of uncertain/borderline behaviour of soft tissue or bone

Patients with metastases originating from another primary site

Patients with recurrent disease (as opposed to a new primary)

Patient where their only record of their cancer is from a death certificate (DCO)

Patients with normal residence outwith Scotland

Patients whose definitive cancer treatment was privately funded or undertaken outwith NHS Scotland

NB:

Only treatments as part of the initial treatment plan should be recorded.


xv

DOWNLOAD FORMAT

To assist with downloading data to ISD for the National Quality Assurance Programme and other agreed activities, all sites should be able export data according to the following specification.

DATABASE SPECIFICATION

Data Item Field Name Field Type Size Page

Section 1: Demographic Items 1

Person Family Name (at Diagnosis) PATSNAME Characters 35 2

Person Given Name PATFNAME Characters 35 3

Patient Postcode at Diagnosis PATPCODE Characters 8 4

Date of Birth DOB Date (DD/MM/CCYY)

10 5

Person Sex at Birth SEX Integer 2 6

CHI Number CHINUM Characters 10 7

Section 2: Pre-treatment Imaging & Staging Investigations 8

Location of Diagnosis {Cancer} HOSP Characters 5 9

Site of Origin of Primary Tumour {Cancer}

SITE Characters 5 10

Location of Sarcoma SITELOCATION Characters 3 14

Date of Histological Diagnosis {Sarcoma}

DIAGDATE Date (DD/MM/CCYY)

10 15

TNM Tumour Classification (Clinical) {Sarcoma}

cTSARC Characters 3 16

TNM Nodal Classification (Clinical) {Sarcoma}

cNSARC Characters 2 18

TNM Metastases Classification (Clinical) {Sarcoma}

cMSARC Characters 3 19

Date Staging CT Scan Complete CTDATE Date (DD/MM/CCYY)

10 20

Date Staging CT Scan Report CTREPORTDATE Date (DD/MM/CCYY)

10 21

WHO/ ECOG Performance Status PSTATUS Integer 1 22

Date Discussed by Care Team (MDT) MDTDATE Date (DD/MM/CCYY)

10 23

Type of First Cancer Treatment FIRSTTREATTYPE Integer 2 24

Date of First Cancer Treatment FIRSTTREATDATE Date (DD/MM/CCYY)

10 25

Date of Definitive Treatment DEFTREATDATE Date (DD/MM/CCYY)

10 26

Section 3: Surgery 27

Location Code {Cancer Surgery} HOSPSURG Characters 5 28

Consultant in Charge of Surgery SURGCON Characters 20 29

Date of Surgery DSURG Date (DD/MM/CCYY)

10 30

Presentation Type (Surgical) SURGPRESENT Integer 2 31

Intent of Surgery OPINTENT Integer 2 32

Final Definitive (or Only) Surgery OPCODE1 Characters 5 33


xvi

Performed (Surgery) {Sarcoma}

Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma}

OPCODE2 Characters 5 33

Primary Flap Reconstruction PRIMFLAP Integer 2 45

Section 4: Pathological Details 46

Morphology of Tumour MORPHOL Characters 6 47

Surgical Margins SURGMARG Characters 4 51

TNM Tumour Classification (Pathological) {Sarcoma}

pTSARC Characters 4 52

TNM Nodal Classification (Pathological) {Sarcoma}

pNSARC Characters 3 54

TNM Metastases Classification (Pathological) {Sarcoma}

pMSARC Characters 3 55

TNM Histopathological Tumour Grade {Soft Tissue Sarcoma}

TUMGRADE Characters 2 56

Gastrointestinal Stromal Tumour (GIST) Risk Score

GISTRISK Integer 2 57

Mutational Analysis (GIST) MUTANALYSIS Integer 2 58

Date of Mutational Analysis (GIST) DMUTANALYSIS Date (DD/MM/CCYY)

10 59

Section 5: Oncology 60

Radiotherapy Course Type {Sarcoma} 1-3

RCOURSETYPE1 Integer 2 61





Date Treatment Started (Radiotherapy) {Sarcoma} 1-3

RSTARTDATE1 Date (DD/MM/CCYY)

10 62



10 62



10 62

Date Treatment Completed (Radiotherapy) {Sarcoma} 1-3

RCOMPDATE1 Date (DD/MM/CCYY)

10 63



10 63



10 63

Type of Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3

CHEMTYPE1 Integer 2 64





Multi-agent Chemotherapy {Sarcoma} MULTAGENT Integer 2 65

Biological Therapy Agent {Sarcoma} BIOAGENT Integer 2 66

Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3

CHEMDATE1 Date (DD/MM/CCYY)

10 67


xvii



10 67



10 67

Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3

CHEMENDATE1 Date (DD/MM/CCYY)

10 68



10 68



10 68

Section 6: Clinical Trials 69

Patient Entered into Clinical Trial TRIAL Integer 2 70

Section 7: Death Details 71

Date of Death DOD Date (DD/MM/CCYY)

10 72


1

Section 1: Demographic Items


2

Person Family Name (at Diagnosis) Common Name(s): Surname, Family name Main Source of Data Item Standard: Government Data Standards Catalogue Definition: That part of a person's name which is used to describe family, clan, tribal group, or

marital association at the time of diagnosis. Field Name: PATSNAME Field Type: Characters Field Length: 35

Notes for Users: Main Source of Standard: Government Data Standards Catalogue The surname of a person represents that part of the name of a person indicating the family group of which the person is part. It should be noted that in Western culture this is normally the latter part of the name of a person. However, this is not necessarily true of all cultures. This will, of course, give rise to some problems in the representation of the name. This is resolved by including the data item Name Element Position in the structured name indicating the order of the name elements. From SMR Definitions and Codes

Notes by Users:

http://webarchive.nationalarchives.gov.uk/20120404204735/http:/umbr4.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards/person_information/person_name/person_family_name.aspx


3

Person Given Name

Common Name(s): Forename, Given Name, Personal Name Main Source of Data Item Standard of Standard: Government Data Standards Catalogue Definition: The forename or given name of a person.

Field Name: PATFNAME Field Type: Characters Field Length: 35 Notes for Users: Main Source of Standard: Government Data Standards Catalogue The first forename of a person represents that part of the name of a person which after the surname is the principal identifier of a person. Where the person's preferred forename is not the first forename, the related data item 'Preferred Forename' should be used to indicate this.

Notes by Users:

http://webarchive.nationalarchives.gov.uk/20120404204736/http:/umbr4.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards/person_information/person_name/person_given_name.aspx


4

Patient Postcode at Diagnosis Main Source of Data Item Standard: Government Data Standards Catalogue Definition: Postcode of patient's usual place of residence on the date of diagnosis Field Name: PATPCODE Field Type: Characters Field Length: Maximum 8

Notes for Users: Postcode is included in BS7666 Address (GDSC) but there is also a separate Post Code standard which will be populated from BS7666 Address Post Code. This item can be derived from the date of diagnosis and patient address at that time Related Data Item(s): Date of Diagnosis Notes by Users:

http://webarchive.nationalarchives.gov.uk/20120404201641/http:/umbr4.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards/address/postcode.aspx


5

Date of Birth Main source of Data Item Standard: Government Data Standards Catalogue Definition: The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate. . Field Name: DOB Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: If the patient's date of birth is recorded differently on different occasions, the most frequently used or latest date should be recorded. The patient's full date of birth inclusive of the century should be recorded. The format should be DD/MM/CCYY e.g. 01/02/2011. Related Data Item(s): CHI Number Notes by Users:

http://webarchive.nationalarchives.gov.uk/20120404201701/http:/umbr4.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards/person_information/person_birth_date.aspx


6

Person Sex at Birth Common Name(s): Sex at Birth Main Source of Data Item Standard of Standard: Derived from the nearest equivalent Government Data Standards Catalogue standard ‘Person Gender at Registration’ Definition: This is a factual statement, as far as is known, about the phenotypic (biological) sex of the person at birth Field Name: SEX Field Type: Integer Field Length: 2 Notes for Users: A person’s sex has clinical implications, both in terms of the individual’s health and the health care provided to them. In the majority of cases, the phenotypic (biological) sex and genotypic sex are the same and the phenotypic sex is usually easily determined. In a small number of cases, accurate determination of genotype may be required Codes and Values: Code Value Explanatory Notes

01 Male

02 Female

09 Not specified/Indeterminate Where it has not been possible to determine if the person is male or female at birth, e.g. intersex / hermaphrodite.

99 Not recorded

Related Data Item(s): CHI Number Notes by Users:


7

CHI Number Main Source of Data Item Standard of Standard: Scottish Executive Health Department. Definition: The Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. Field Name: CHINUM Field Type: Characters Field Length: 10 Notes for Users: The Community Health Index (CHI) is a computer based population index whose main function at present is to support primary care services. CHI contains details of all Scottish residents registered with a General Practitioner and was originally envisaged and implemented as a population-based index to help assess the success of immunisation and screening programmes. It is therefore closely integrated with systems for child health, cervical cytology and breast screening call and recall…It is intended that this number, the Scottish equivalent of the new NHS number in England and Wales, should become the Unique Patient Identifier throughout the NHS in Scotland. From Designed to Care - Scottish Office The CHI number is a unique numeric identifier, allocated to each patient on first registration with the system. The CHI number is a 10-character code consisting of the 6-digit date of birth (DDMMYY), two digits, a 9th digit which is always even for females and odd for males and an arithmetical check digit. (ISD, Information Services, NHS National Services Scotland) The CHI number should always be used to identify a patient. However, Health record identifiers, such as hospital numbers in Patient Administration Systems (PAS), may be used locally, in conjunction with the CHI number or in the absence of the CHI number, to track patients and their records.

Although there may be no number when a patient presents for treatment, there must be an allocation at some point in the episode of care as CHI is mandatory on all clinical communications. Non-Scottish patients and other temporary residents can have a CHI number allocated if required but it is envisaged that future development may allow the identifying number used in other UK countries to be used in Scotland. Related Data Item(s): Date of Birth, Person Sex at Birth. Notes by Users:


8

Section 2: Pre-treatment Imaging & Staging Investigations


9

Location of Diagnosis {Cancer} Main Source of Data Item Standard: The National Audit Cancer Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The patient's hospital of investigation in which the diagnosis of cancer was first made. Field Name: HOSP Field Type: Characters Field Length: 5 Notes for Users: Required for analysis purposes and clarifying responsibility for data collection. Details of location codes for hospitals can be found in the "Definitions and Codes for the NHS in Scotland" manual produced by ISD Scotland. Location codes for hospitals are five character codes maintained by ISD Scotland and the General Register Office (Scotland). The first character denotes the health board, the next three are assigned and the fifth denotes the type of location (H=hospital) e.g. A111H=Crosshouse Hospital G107H=Glasgow Royal Infirmary X9999=Not recorded If a patient was provisionally diagnosed at one hospital but transferred to another for confirmation of the diagnosis only e.g. biopsy, then returns to the original hospital, the first hospital should be recorded as the Location of diagnosis. GP surgery codes can be recorded in this field if this is the location the diagnosis was first made. Codes and Values: Related Data Items:


10

Site of Origin of Primary Tumour {Cancer} Main Source of Data Item Standard: The World Health Organisation (WHO) and the Cancer Registration New Data definitions for Socrates (August 1999 Version 8.0).

Definition: The anatomical site of origin of the primary tumour according to the International Classification of Diseases (ICD-O(3)). Field Name: SITE Field Type: Characters Field length: 5 Notes for Users: Required for QPI(s): 1, 2, 3, 4, 6, 7, 8 For ICD-O(3), tumours should be assigned to the subcategory that includes the point of origin of the tumour. A tumour that overlaps the boundaries of two or more subcategories and whose point of origin cannot be determined should be classified as subcategory ‘C49.8’. It should be noted that this subcategory should only be used where it is impossible to identify the specific site of origin of the tumour. Codes and Values: ICD-10 Code

Value Notes on Inclusion

C00.9 Malignant neoplasm, lip, unspecified

C01.X Malignant neoplasm of base of tongue

C02.9 Malignant neoplasm, tongue, unspecified

C03.9 Gum, unspecified

C04.9 Malignant neoplasm, floor of mouth, unspecified

C04.9

C05.9 Malignant neoplasm, palate, unspecified C05.9

C06.9 Malignant neoplasm, mouth, unspecified C06.9

C07.X Malignant neoplasm of parotid gland C07.X

C08.9 Malignant neoplasm, major salivary gland, unspecified

C08.9

C09.9 Malignant neoplasm, tonsil, unspecified C09.9

C10.9 Malignant neoplasm, oropharynx, unspecified

C10.9

C11.9 Malignant neoplasm, nasopharynx, unspecified

C11.9

C12.X Malignant neoplasm of pyriform sinus

C12.X

C13.9 Malignant neoplasm, hypopharynx, unspecified

C13.9

C15.0 Cervical oesophagus

C15.1 Thoracic oesophagus

C15.2 Abdominal part of oesophagus

C15.3 Upper third of oesophagus Proximal third of oesophagus Up to 20cm from back of teeth

C15.4 Middle third of oesophagus 20-30cm from back of teeth

C15.5 Lower third of oesophagus Distal third of oesophagus 30-40cm from back of teeth

C15.8 Overlapping lesion of oesophagus


11

C15.9 Oesophagus, NOS

C16.0 Cardia, NOS Gastric cardio Cardio-oesophageal junction Oesophagogastric Junction

C16.1 Fundus of stomach Gastric fundus

C16.2 Body of stomach Corpus of stomach Gastric corpus

C16.3 Gastric antrum Antrum of stomach Pyloric antrum

C16.4 Pylorus Prepylorus Pyloric canal

C16.5 Lesser curvature of stomach, unspecified Lesser curvature of stomach, not classifiable to C16.0 –C16.4

C16.6 Greater curvation of stomach, unspecified Greater curvature of stomach, not classifiable to C16.0 –C16.4

C16.8 Overlapping lesion of the stomach

Anterior wall of stomach, NOS Not classifiable to C16.0 to C16.4 Posterior wall of stomach, NOS Not classifiable to C16.0 to c16.4

C16.9 Stomach, unspecified Gastric, NOS

C17.0 Duodenum

C17.1 Jejunum

C17.2 Ileum

C17.9 Small Intestine, unspecified

C18.0 Caecum Ileocaecal valve; Ileocaecal junction

C18.1 Appendix

C18.2 Ascending colon Right colon

C18.4 Transverse colon

C18.5 Splenic flexure

C18.6 Descending colon Left colon

C18.7 Sigmoid colon Sigmoid NOS; Sigmoid flexure of colon; Pelvic colon

C18.8 Overlapping lesion of colon

C18.9 Colon, unspecified Large intestine; Large Bowel MOS

C19.X Malignant neoplasm of rectosigmoid junction

C20.9 Rectum Rectal ampulla

C20.X Malignant neoplasm of rectum C20.X

C22.9 Malignant neoplasm, liver, unspecified C22.9

C23.X Malignant neoplasm of gall bladder C23.X

C24.9 Malignant neoplasm, biliary tract, unspecified

C24.9

C25.9 Malignant neoplasm, pancreas, unspecified

C25.9

C26.9 Malignant neoplasm, ill-defined sites within the digestive system

C26.9

C31.0 Maxillary sinus

C31.9 Malignant neoplasm, accessory sinus, unspecified

C31.9

C32.9 Larynx unspecified

C33.X Malignant neoplasm of trachea

C33.X

C34.9 Solitary malignant fibrous tumour of the


12

lung

C37.X Malignant neoplasm of thymus

C39.9 Malignant neoplasm, ill-defined sites within the respiratory system

C40.0 Scapula and long bones of upper limbs Includes: Glenoid, Humerus, Ulna, Radius

C40.1 Short bones of upper limb Includes: Carpal, Metacarpal, Phalanges

C40.2 Long bones of lower limb Includes: Femur, Tibia, Fibula

C40.3 Short bones of lower limb Includes: Metatarsus, Phalanges, Tarsus

C40.9 Malignant neoplasm, bone and articular cartilage of limb, unspecified

C40.9

C41.0 Bones of skull and face Includes: orbital bones

C41.2 Vertebral column Includes: Cervical, Thoracic, Lumbar spine

C41.3 Rib, sternum and clavicle

C41.4 Pelvic bones, sacrum and coccyx Includes: Ilium, Ischium, Pubis, Acetabulum

C41.9 Malignant neoplasm, bone and articular cartilage, unspecified

C41.9

C44.0 Dermatofibrosarcoma

C44.3 Skin of other and unspecified parts of face

C44.4 Skin of scalp and neck

C44.5 Skin of trunk

C44.6 Skin of Upper limb, including shoulder

C44.7 Skin of Lower limb, including hip

C44.9 Malignant neoplasm, of skin, unspecified C44.9

C47.1 Peripheral Nerves of Upper limb, including shoulder

C47.2 Peripheral Nerves of Lower limb including hip

C47.5 Peripheral Nerves of pelvis

C47.9 Malignant neoplasm, peripheral nerves and autonomic nervous system, unspec

C47.9

C48.0 Retroperitoneal

C48.2 Peritoneum, unspecified Includes: Intraperitoneal

C49.0 Connective and soft tissue of head, face and neck

Includes: Ear, eyelid

C49.1 Connective and soft tissue of upper limb, including shoulder

Includes: Shoulder girdle, upper arm, elbow, forearm, hand / wrist

C49.2 Connective and soft tissue of lower limb, including hip

Includes: Thigh, knee, lower leg, ankle / foot

C49.3 Connective and soft tissue of thorax Includes: Axilla, diaphragm, great vessels, intrathoracic

C49.4 Connective and soft tissue of abdomen Includes: Abdominal wall, hypochondrium

C49.5 Connective and soft tissue of pelvis Includes: Buttock, groin, perineum

C49.6 Connective and soft tissue of trunk, unspecified

Includes: Upper trunk, lower trunk, back NOS

C49.8 Overlapping lesion of connective and soft tissue

C49.9 Connective and soft tissue, unspecified

C50.0 Phylloides tumour

C50.9 Malignant neoplasm, breast, unspecified

C54.1 Endometrium

C51.9 Malignant neoplasm, vulva, unspecified


13

C53.9 Leiomyosarcoma of the cervix

C54.9 Malignant neoplasm, corpus uteri, unspecified

C54.9

C55.9 Uterus, part unspecified

C56.X Malignant neoplasm of ovary C56.X

C57.9 Malignant neoplasm, female genital organ, unspecified

C57.9

C58.X Malignant neoplasm of placenta C58.X

C60.9 Malignant neoplasm, penis, unspecified C60.9

C61.X Prostate

C62.9 Malignant neoplasm, testis, unspecified C62.9

C63.1 Liposarcoma of the spermatic cord

C63.9 Malignant neoplasm, male genital organ, unspecified

C63.9

C64.X Malignant neoplasm of kidney, except renal pelvis

C65.X Malignant neoplasm of renal pelvis

C66.X Malignant neoplasm of ureter

C67.9 Malignant neoplasm, bladder, unspecified

C68.9 Malignant neoplasm, urinary organ, unspecified

C68.9

C69.6 Orbit Includes: Connective tissue of orbit

C69.9 Malignant neoplasm, eye, unspecified

C70.9 Malignant neoplasm, meninges, unspecified

C71.9 Malignant neoplasm, brain, unspecified

C72.9 Malignant neoplasm, central nervous system, unspecified

C73.X Malignant neoplasm of thyroid gland

C74.9 Malignant neoplasm, adrenal gland, unspecified

C75.9 Malignant neoplasm, endocrine gland, unspecified

C77.9 Malignant neoplasm, lymph node, unspecified

C80.X Malignant neoplasm of unspecified site

C96.9 Malignant neoplasm of lymphoid, haematopoietic

C99.X Not recorded

Related Data Items:


14

Location of Sarcoma Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the Scottish Pathology Network supported by Information Services. Definition: This indicates the location of the sarcoma within a given site. Field Name: SITELOCATION Field Type: Characters Field Length: 3 Notes for Users: Required for QPI: 5 If location of Sarcoma is not clear; seek clarification from the relevant Clinician.

Code Value Sub-Value Notes on Inclusion

01A Bone

Intraosseous Located inside of the bone

01B Extraosseous Located outside of the bone

02A

Soft Tissue

Cutaneous

02B Subcutaneous

02C Superficial to Fascia

02D Deep to Fascia

03 GIST

96 Not applicable Primary location known

99 Not recorded

Related Data Items:


15

Date of Histological Diagnosis {Sarcoma} Main Source of Data Item Standard: The National Audit Cancer Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is the date that the histological/cytological microscopic examination of the specimen to determine the presence of malignancy and the classification of the malignant tumour was performed. Field Name: DIAGDATE Format: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for QPI(s): 1 – 11 Required for national survival analysis and national comparative analysis. There may be more than one biopsy/histology report. The first histology report should be recorded as the definitive report if prior to treatment. If no histological diagnosis was made, record as 10/10/1900 (Not applicable) If the exact date is not documented, record as 09/09/1900 (Not recorded). The date recorded is the date the procedure was performed, not the date the report was issued. Related Data Items:


16

TNM Tumour Classification (Clinical) {Sarcoma} Common name: Clinical TNM Tumour Classification Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017). Definition: The size and extent of the tumour as determined by pre-treatment investigations (not pathological), coded according to the official TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, 2017). Field Name: cTSARC Field Type: Characters Field length: 3 Notes for Users: Required for QPI(s): 3, 5 Clinical TNM is derived from all the clinical, radiological and biochemical results prior to treatment. The TNM system is base on the assessment of three components (T tumour, N node and M metastases) and the addition of numbers after the letter components to indicate the extent of the malignant disease. This is a pre/non-operative classification as defined by the Multidisciplinary Team Meeting (MDT) based on best knowledge. There may be emergency cases where it is allocated earlier than the MDT meeting. Sarcomas that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96). For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96). Within the table below the following sites are classified as bone sarcomas: Appendicular skeleton, trunk, skull and facial bones; Spine and Pelvis The following sites are classified as soft tissue sarcomas: Extremity and superficial trunk; Retroperitoneum; Head & Neck; Thoracic and Abdominal viscera. Codes and Values: Code Value

TX Primary tumour cannot be assessed

T0 No evidence of primary tumour

T1 Appendicular skeleton, trunk, skull and facial bones: Tumour 8cm or less Spine: Tumour confined to single vertebral segment or two adjacent vertebral segments Extremity & superficial trunk / Retroperitoneum: Tumour 5cm or less Head & Neck: Tumour 2cm or less Thoracic & abdominal viscera: Tumour confined to a single organ GIST: Tumour 2cm or less

T1a Pelvis: A tumour 8cm or less in size and confined to a single pelvic segment with no extraosseous extension

T1b Pelvis: A tumour greater than 8cm in size and confined to a single pelvic segment with no extraosseous extension


17

T2 Appendicular skeleton, trunk, skull and facial bones: Tumour more than 8cm Spine: Tumour confined to three adjacent vertebral segments Extremity & superficial trunk / Retroperitoneum: Tumour more than 5cm but no more than 10cm in greatest dimension Head & Neck: Tumour more than 2cm but no more than 4cm in greatest dimension GIST: Tumour more than 2cm but not more than 5cm

T2a Pelvis: A tumour 8cm or less in size and confined to a single pelvic segment with extraosseous extension or confined to two adjacent pelvic segments without extraosseous extension Thoracic & abdominal viscera: Tumour invades serosa or visceral peritoneum

T2b Pelvis: A tumour greater than 8cm in size and confined to a single pelvic segment with extraosseous extension or confined to two adjacent pelvic segments without extraosseous extension Thoracic & abdominal viscera: Tumour with microscopic extension beyond the serosa

T3 Appendicular skeleton, trunk, skull and facial bones: Discontinuous tumours in primary bone site Spine: Tumour confined to four adjacent vertebral segments Extremity & superficial trunk / Retroperitoneum: Tumour more than 10cm but no more than 15 cm in greatest dimension Head & Neck: Tumour more than 4cm Thoracic & abdominal viscera: Tumour invades another organ or macroscopic extension beyond the serosa GIST: Tumour more than 5cm but not more than 10cm

T3a Pelvis: A tumour 8cm or less in size and confined to two pelvic segments with extraosseous extension

T3b Pelvis: A tumour greater than 8cm in size and confined to two pelvic segments with extraosseous extension

T4 Extremity & superficial trunk / Retroperitoneum: Tumour more than 15cm GIST: Tumour more than 10cm

T4a Spine: Tumour invades into the spinal canal Pelvis: Tumour involving three adjacent pelvic segments or crossing the sacroiliac joint to the sacral neuroforamen Head & Neck: Tumour invades the orbit, skull base or dura, central compartment viscera, facial skeleton, and or pterygoid muscles Thoracic & abdominal viscera: Multifocal tumour involving no more than two sites in one organ

T4b Spine: Tumour invades the adjacent vessels or tumour thrombosis within the adjacent vessels Pelvis: Tumour encasing the external iliac vessels or gross tumour thrombus in major pelvic vessels Head & Neck: Tumour invades the brain parenchyma, encases the carotid artery, invades prevertebral muscle or involves the central nervous system by perineural spread Thoracic & abdominal viscera: Multifocal tumour involving more than two sites but not more than 5 sites

T4c Thoracic & abdominal viscera: Multifocal tumour involving more than five sites

Related data items: TNM Nodal Classification (Clinical) {Sarcoma} TNM Metastases Classification (Clinical) {Sarcoma}


18

TNM Nodal Classification (Clinical) {Sarcoma} Common name: Clinical TNM Nodal Classification Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017). Definition: The extent of regional lymph node metastases as determined by pre-treatment investigations (not pathological), coded according to the official TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, 2017). Field Name: cNSARC Field Type: Characters Field length: 2 Notes for Users: Required for QPI(s): 3, 5 Clinical TNM is derived from all the clinical, radiological and biochemical results prior to treatment. The TNM system is base on the assessment of three components (T tumour, N node and M metastases) and the addition of numbers after the letter components to indicate the extent of the malignant disease. This is a pre/non-operative classification as defined by the Multidisciplinary Team Meeting (MDT) based on best knowledge. There may be emergency cases where it is allocated earlier than the MDT meeting. Sarcomas that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96). For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96). Codes and Values: Code Value Explanatory Notes

NX Regional lymph nodes cannot be assessed*

N0 No regional lymph node metastasis.

N1 Regional lymph node metastasis

96 Not applicable

99 Not recorded

*NX: Regional lymph node involvement is rare for GISTs, so that cases in which the nodal status is not assessed clinically or pathologically could be considered N0 instead of NX.

Related Data items: TNM Tumour Classification (Clinical) {Sarcoma} TNM Metastases Classification (Clinical) {Sarcoma}


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TNM Metastases Classification (Clinical) {Sarcoma} Common name: Clinical TNM Metastases Classification Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017). Definition: The extent of metastatic spread of the tumour as determined by pre-treatment investigations (not pathological), coded according to the official TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, 2017). Field Name: cMSARC Field Type: Characters Field length: 3 Notes for Users: Required for QPI(s): 3, 5 Clinical TNM is derived from all the clinical, radiological and biochemical results prior to treatment. The TNM system is base on the assessment of three components (T tumour, N node and M metastases) and the addition of numbers after the letter components to indicate the extent of the malignant disease. This is a pre/non-operative classification as defined by the Multidisciplinary Team Meeting (MDT) based on best knowledge. There may be emergency cases where it is allocated earlier than the MDT meeting. Where the presence of distant metastases has been documented this should be recorded as M1. Where the absence of metastases has been documented this should be recorded as M0. Sarcomas that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96). For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96).. Codes and Values: Code Value

Soft Tissue Bone GIST

M0 No distant metastasis

M1 Distant metastasis

M1a n/a Lung n/a

M1b n/a Other distant sites n/a

96 Not applicable

99 Not recorded

Related data items: TNM Tumour Classification (Clinical) {Sarcoma} TNM Nodal Classification (Clinical) {Sarcoma}


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Date Staging CT Scan Complete Definition: The date that staging investigations were completed by imaging. Field Name: CTDATE Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Several investigations may be undertaken to complete TNM clinical staging. As a minimum a CT of the chest with or without a CT of the abdomen should be completed before first treatment commences. These investigations may be done separately and at different times. Record the date that ALL items are complete, e.g. if CT chest and CT abdomen done on separate days then record the final date. The CT carried out closest to the date of diagnosis should be used. If this is not clear or if Date Staging CT Scan Complete is not available seek clarification from relevant Clinician. If CT chest +/- abdomen were not completed, record as not applicable (10/10/1900). If the exact date is not documented, record as not recorded (09/09/1900). Related data item(s): Notes by Users:


21

Date Staging CT Scan Report Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by the Information Services. Definition: The date that staging investigations by CT are reported. Field Name: CTREPORTDATE Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 3 If more than one CT scan is undertaken the date of the report of the final CT scan should be recorded to align with date of investigation. If CT chest +/- abdomen were not completed, record as not applicable (10/10/1900). If the exact date is not documented, record as not recorded (09/09/1900). Related data item(s): Notes by Users:


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WHO/ ECOG Performance Status Main Source of Data Item Standard: WHO (World Health Organisation) and ECOG (Eastern Cooperative Oncology Group) Definition: An overall assessment of the functional/physical performance of the patient. Field Name: PSTATUS Field Type: Integer Field length: 1 Notes for Users: Required for survival analysis The WHO/ECOG performance status is a grade on a five point scale (range 0 to 4) at the time of investigation in which '0' denotes normal activity and '4' a patient who is 100% bedridden. If it is not documented do not deduce from other information and record as 'Not recorded'. This item may occur more than once throughout a patient’s record. This field relates to pre-treatment performance status i.e. at the time of the MDT closest to actual treatment. If the performance status falls between two scores, record the higher value i.e. the worst performance status. Codes and values: Code Value

0 Fully active, able to carry on all pre-disease performance without restriction

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g. light housework, office work

2 Ambulatory and capable of self care but unable to carry out any work activities: up and about more than 50% of waking hours

3 Capable of only limited self care, confined to bed or chair more than 50% of waking hours

4 Completely disabled, cannot carry on any self care, totally confined to bed or chair

9 Not recorded

Related Data Items:


23

Date Discussed by Care Team (MDT) Common name: Date discussed by multidisciplinary team (MDT) {Cancer} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date the care team meeting was held to discuss the management of the patient's care. Field Name: MDTDATE Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 2 May be used for analysis of QPI relating to MDT meetings. A cancer multidisciplinary care team may include surgeons, oncologists, radiologists, pathologists, nurses, speech language therapists, physiotherapists and others relevant to the treatment of a specific cancer. The team meets on a regular basis to discuss optimal patient management. Documentation of the discussion should be included in the case-note or other formal documentation. The first MDT meeting where the patients Sarcoma was discussed date will be recorded, this won’t necessarily be a Sarcoma MDT. If the patient has not been discussed at the MDT record as 10/10/1900 (Not applicable). If the date of the MDT meeting is unknown record as 09/09/1900 (Not recorded)

Related data Item(s):


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Type of First Cancer Treatment Common name: Mode of first treatment

Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the first specific treatment modality administered to a patient. Field Name: FIRSTTREATTYPE Field Type: Integer Field length: 2 Notes for Users: Required for QPI(s): 2, 6, 9 For any particular modality it is the first treatment and not specifically the definitive treatment i.e. this does not include purely diagnostic biopsies such as incisional biopsies, needle biopsies or core biopsies. Record patients as having ‘supportive care only’ if a decision was taken not to give the patient any active treatment as part of their primary therapy. No active treatment includes watchful waiting and supportive care but not palliative chemotherapy and/or radiotherapy. Codes and Values:

Code Description Explanatory notes 01 Surgery

02 Radiotherapy

03 Chemotherapy

05 Endoscopic

07 Supportive care No active treatment 11 Other therapy

12 Watchful waiting No active treatment 13 Biological therapy

15 Chemoradiotherapy

16 Hormone therapy e.g. letrozole

94 Patient died before treatment

95 Patient refused all therapies

99 Not recorded

Related Data Item(s): Date of First Cancer Treatment


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Date of First Cancer Treatment Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date the type of first cancer treatment was given to the patient. Field Name: FIRSTTREATDATE Field Type: Date (DD/MM/CCYY) Field Length: 10

Notes for Users: Required for QPI(s):

This field should be recorded for all patients including those with supportive care only (‘No active treatment’) (see below). If type of first cancer treatment is ‘supportive care only’, the date recorded should be the date the MDT recommends supportive care as the treatment option. The aim of this date is to distinguish between patients who have initially had no treatment but receive some therapy when symptoms develop. If hormone therapy is the first treatment, it is not always clearly documented when hormone therapy starts. In the patient discharge or clinic letter the clinician may ask the GP to prescribe hormone therapy, in this case, record the date as two days from the day the discharge letter or clinic letter was typed. The date recorded should be that of the first type of cancer treatment. If the exact date is not documented, record as 09/09/1900 (Not recorded). If the patient died before treatment or the patient refused treatment, record as 10/10/1900 (Not applicable). Related Data Item(s): Type of First Cancer Treatment


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Date of Definitive Treatment {Sarcoma} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date definitive cancer treatment was given to the patient. Field Name: DEFTREATDATE Field Type: Date (DD/MM/CCYY) Field Length: 10

Notes for Users: Required for QPI: 2

For patients with sarcoma definitive treatment will be either:

Surgery;

Radiotherapy; or

Systemic Anti Cancer Therapy. It is the date of this treatment that should be recorded. If a patient receives more than one of the treatments listed it is the first which should be recorded. For patients undergoing no active treatment (e.g. supportive care only) the date recorded should be the first date the decision was taken not to give the patient treatment as part of their primary therapy. Where this has subsequently been confirmed at MDT, the date of MDT should be recorded. This will therefore be the same date as the First Treatment Date for these patients. If the exact date is not documented, record as 09/09/1900 (Not recorded). If the patient died before treatment or the patient refused treatment, record as 10/10/1900 (Not applicable). Related Data Item(s):


27

Section 3: Surgery


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Location Code {Cancer Surgery} Common Name(s): Location, Location of Contact. Main Source of Data Item Standard: NHS National Reference Files, http://www.natref.scot.nhs.uk/. Definition: This is the reference number of any building or set of buildings where events pertinent to NHS Scotland take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patient/client’s home. Field Name: HOSPSURG Field Type: Characters Field Length: 5 Notes for Users: Required for survival analysis and comparative analysis. This is the hospital of first definitive surgery which removes the primary tumour. This may be a planned excision even if close margins are found and further surgery is required. On occasion, this result will be achieved by excision biopsy. This should be included as site of first definitive surgery. Each location has a location code, which is maintained jointly by ISD and General Register Office (Scotland).http://www.show.scot.nhs.uk/smrfiles/information.html – datafiles. Location must be viewed as an address and not a code. If any new locations arise where NHS healthcare is delivered/administered, please ensure that the Reference Files Team at ISD is informed using form LOC-NEW (which can be downloaded from the website below) so that a new code may be issued as appropriate. http://www.show.scot.nhs.uk/smrfiles Information about location should be electronically stored, managed and transferred using the relevant location code. IT systems should allow the recording and display of locations on the user interface as the relevant location name and associated address, etc. If the location code is not documented, record as X9999. If surgery has not been performed or the patient has refused surgery, record as inapplicable, X1010. Examples of codes are given below:

Code Institution A111H CROSSHOUSE HOSPITAL

C418H ROYAL ALEXANDRA HOSPITAL

F704H VICTORIA HOSPITAL, KIRKCALDY

G107H GLASGOW ROYAL INFIRMARY

G405H SOUTHERN GENERAL HOSPITAL, GLASGOW

Related Data Item(s):

http://www.natref.scot.nhs.uk/

http://www.show.scot.nhs.uk/smrfiles


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Consultant in Charge of Surgery Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is the name of the consultant who is in charge of the final definitive (or only) surgery. Field Name: SURGCON Field Type: Characters Field Length: 20 Notes for Users: Required for survival analysis and comparative analysis The surname and forename of the consultant should be recorded to distinguish between consultants with common surnames. NB: On the database, the consultant’s name will be stored as a GMC number If the clinician’s name is not recorded code as 9999. If no surgery was performed record as not applicable (1010). If the patient is managed by a team rather than with a consultant in overall charge, record as inapplicable, 1010. If the patient is managed by a locum, record only that the clinician is a locum consultant, LOCUM. Related Data Item(s):


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Date of Surgery Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is the date the main (definitive) surgery was performed. Field Name: DSURG Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI(s): 1, 6, 8, 10, 11 This is the date of tumour resection and not the date of any diagnostic surgical procedures. If the exact date of surgery is not known, record as 09/09/1900 (Not recorded). If no surgery was performed, record as 10/10/1900 (Not applicable). All treatments given as part of the initial treatment plan. Related Data Items: Location Code {Cancer Surgery} Measurement of Macroscopic Residual Disease


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Presentation Type (Surgical) Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: How the patient presented for surgery.

Field Name: SURGPRESENT Field Type: Integer Field Length: 2 Notes for Users: Required for QPI(s): 1, 9 Both categories incorporate:

1. Transfer from another consultant and/or significant facility and/or specialty and/or hospital in the same or another trust where the patient was already undergoing hospital care for treatment.

2. A patient presenting for surgery while undergoing hospital care for an unrelated condition (incidental finding).

Codes and Values:

Code Value Explanatory Notes

01 Elective (routine) A patient who presents for surgery as planned.

02 Emergency A patient, who for clinical reasons, presents unplanned for surgery.

96 Not applicable If no operation was performed.

99 Not recorded

Related Data Item(s): Notes by Users:


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Intent of Surgery Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: Final assessment of intent of surgery as defined by the Multidisciplinary Team (MDT).

Field Name: OPINTENT Field Type: Integer Field length: 2 Notes for Users: Required for QPI: 11 This information should be recorded at MDT, clinical letter or within electronic prescribing systems, this should not be deduced. Record the intent established pre-operatively. Codes and Values:

Code Value Explanatory Note

01 Curative

02 Palliative

96 Not applicable

99 Not recorded



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Final Definitive (or Only) Surgery Performed (Surgery) {Sarcoma} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is the main (definitive) or only operation performed for treatment of Sarcoma. Field Name: OPCODE1 OPCODE2 Field Type: Characters Field Length: 5 Notes for Users: Required for QPI(s): 1, 4, 6 Where OPCS codes have been recorded in the patient notes by the surgeon, this code should be used. Where no OPCS code has been recorded, the table below should be used. For queries or issues regarding recording OPCS please contact [email protected].

Operation is coded to the 4-digit code according to the Fourth Revision of the OPCS Classification of Surgical Operations (OPCS4). Coding instructions and a full list of codes are included in the OPCS4 manual. It should be noted that it may be necessary to record two codes in order to fully specify the operation Key = NEC – Not elsewhere classified

Codes and Values

OPCS 4.6 Code

Description

N05.1 Bilateral subcapsular orchidectomy

N05.2 Bilateral orchidectomy NEC

N05.3 Bilateral inguinal orchidectomy

N05.8 Other specified bilateral excision of testes

N05.9 Unspecified bilateral excision of testes

N06.1 Subcapsular orchidectomy NEC

N06.2 Excision of aberrant testis

N06.3 Orchidectomy NEC

N06.4 Excision of testicular appendage

N06.5 Division of cremaster

N06.6 Inguinal orchidectomy NEC

N06.8 Other specified other excision of testis

N06.9 Unspecified other excision of testis

A38.1 Extirpation of lesion of meninges of cortex of brain

A44.4 Excision of extradural lesion

B08.3 Hemithyroidectomy

B25.1 Excision of lesion of adrenal gland

B27.1 Total mastectomy and excision of both pectoral muscles and part of chest wall

B27.2 Total mastectomy and excision of both pectoral muscles NEC

B27.3 Total mastectomy and excision of pectoralis minor muscle

B27.4 Total mastectomy NEC

B27.5 Subcutaneous mastectomy



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B27.6 Skin sparing mastectomy

B27.8 Other specified total excision of breast

B27.9 Unspecified Mastectomy NEC

B28.2 Partial excision of breast NEC Includes: Wedge excision of breast NEC, Wide excision of breast NEC

B28.3 Excision of lesion of breast NEC Includes: Lumpectomy of breast NEC

B28.5 Wire guided partial excision of breast Includes: Wire guided wedge excision of breast Wire guided wide excision of breast

B28.7 Wire guided excision of lesion of breast Includes: Wire guided lumpectomy of breast

C01.1 Exenteration of orbit

G28.1 Partial gastrectomy and anastomosis of stomach to duodenum

G28.2 Partial gastrectomy and anastomosis of stomach to transposed jejunum

G28.3 Partial gastrectomy and anastomosis of stomach to jejunum NEC

G28.4 Sleeve gastrectomy and duodenal switch

G28.5 Sleeve gastrectomy NEC

G28.8 Other specified partial excision of stomach

G28.9 Unspecified partial excision of stomach

G29.2 Open excision of lesion of stomach NEC

G58.4 Partial jejunectomy and anastomosis of jejunum to ileum

G58.5 Partial jejunectomy and anastomosis of duodenum to colon

G58.8 Other specified excision of jejunum

G58.9 Unspecified excision of jejunum

Q22.1 Bilateral Salpingoophorectomy

M41.1 Open extirpation of lesion of bladder

M42.1 Endoscopic resection of lesion of bladder

G28.5 Sleeve gastrectomy NEC

G27.9 Total Gastrectomy

G28.9 Partial Gastrectomy

G01.1 Right 2 phase sub total oesophagectomy

G01.8 L thoraco-abdominal oesophagectomy (oesophago-gastrectomy)

G02.2 McKeown 3 stage sub total oesophagectomy

G03.8 Trans-hiatal oesophagectomy

T30.9 Laparotomy

T03.9 Thoracotomy

G05.4 Bypass procedure/Jejunostomy

E03.2 Excision of lesion of septum of nose

E29.1 Total Laryngectomy

E54.1 Total pneumonectomy Includes: Pneumonectomy NEC

E54.2 Bilobectomy of lung

E54.3 Lobectomy of lung

E54.4 Excision of segment of lung

E54.5 Partial lobectomy of lung NEC

E54.8 Excision of lung, Other specified

E54.9 Excision of lung, Unspecified

E55.1 Open decortication of lesion of lung

E55.2 Open excision of lesion of lung Includes: Excision of lesion of lung NEC, Excision of bulla of lung

E55.3 Open cauterisation of lesion of lung

E55.4 Open destruction of lesion of lung NEC

E55.8 Open extirpation of lesion of lung, Other specified

E55.9 Open extirpation of lesion of lung, Unspecified

E59.1 Needle biopsy of lesion of lung Includes: Needle biopsy of lung

E59.2 Aspiration biopsy of lesion of lung Includes: Aspiration biopsy of lung

E59.3 Biopsy of lesion of lung NEC Includes: Biopsy of lung NEC

H01.2 Emergency excision of abnormal appendix NEC

H02.1 Interval appendicectomy

H02.2 Planned delayed appendicectomy

H02.3 Prophylactic appendicectomy

H02.4 Incidental appendicectomy

H04.1 Panproctocolectomy and Ileostomy

H04.2 Panproctocolectomy and Anastomosis of Ileum to Anus and Creation of Pouch

H04.3 Panproctocolectomy and Anastomosis of Ileum to Anus , NEC

H04.8 Total Excision of Colon and Rectum; Other Specified


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H05.1 Total Colectomy and Anastomosis

H05.2 Total Colectomy and Ileostomy with Creation of Rectal Fistula

H05.3 Total Colectomy and Ileostomy NEC

H05.8 Total Excision of Colon; other specified

H06.1 Ext Right Hemicolectomy and end to end Anastomosis

H06.2 Ext Right Hemicolectomy and Anastomosis of Ileum to Colon

H06.3 Ext Right Hemicolectomy and anastomosis NEC

H06.4 Ext Right Hemicolectomy and Ileostomy HFQ

H06.5 Ext Right Hemicolectomy and end to side anastomosis

H06.8 Extended Excision of Right Hemi colon; other specified

H07.1 Right Hemicolectomy and end to end anastomosis of Ileum to Colon

H07.2 Right Hemicolectomy and side to side anastomosis of Colon to Colon

H07.3 Right Hemicolectomy and anastomosis NEC

H07.4 Hemicolectomy and Ileostomy HFQ

H07.5 Right hemicolectomy and end to side anastomosis

H07.8 Other Excision of Right Hemi colon; other specified

H08.1 Transverse Colectomy and end to end Anastomosis

H08.2 Transverse Colectomy and Anastomosis of Ileum to Colon

H08.3 Transverse Colectomy and Anastomosis NEC

H08.4 Transverse Colectomy and Ileostomy HFQ

H08.5 Transverse Colectomy and Exteriorisation of Bowel NEC

H08.6 Transverse colectomy and end to side anastomosis

H08.8 Excision of Transverse Colon; other specified

H09.1 Left Hemicolectomy and End to End Anastomosis of Colon to Rectum

H09.2 Left Hemicolectomy and End to End Anastomosis of Colon to Colon

H09.3 Left Hemicolectomy and Anastomosis NEC

H09.4 Left Hemicolectomy and Ileostomy HFQ

H09.5 Left Hemicolectomy and Exteriorisation of Bowel NEC

H09.6 Left Hemicolectomy and end to side anastomosis

H09.8 Excision of Left Hemi colon; other specified

H10.1 Sigmoid Colectomy and end to end Anastomosis of Ileum and Rectum

H10.2 Sigmoid Colectomy and Anastomosis of Colon to Rectum

H10.3 Sigmoid Colectomy and Anastomosis NEC

H10.5 Sigmoid Colectomy and Exteriorisation of Bowel NEC

H10.6 Sigmoid colectomy and end to side anastomosis

H10.8 Excision of Sigmoid colon; other specified

H11.1 Colectomy and end to end Anastomosis of Colon to Colon NEC

H11.2 Colectomy and side to side Anastomosis of Ileum to Colon NEC

H11.3 Colectomy and Anastomosis of Ileum NEC

H11.4 Colectomy and Ileostomy NEC

H11.5 Colectomy and Exteriorisation of Bowel NEC

H11.6 Colectomy and end to side anastomosis

H11.8 Other Excision of Colon; other specified

H12.1 Excision of Diverticulum of Colon

H12.2 Excision of Lesion of Colon NEC

H12.3 Destruction of Lesion of Colon NEC

H12.8 Other Excision of Colon; other specified

H13.0 Bypass of Colon

H15.1 Loop Colostomy

H15.2 End Colostomy

H18.1 Open Colonoscopy

H18.8 Open Endoscopic Operations on Colon; other specified

H29.1 Subtotal excision of colon and rectum and creation of colonic pouch and anastomosis of colon to anus

H29.2 Subtotal excision of colon and rectum and creation of colonic pouch NEC

H29.3 Subtotal excision of colon and creation of colonic pouch and anastomosis of colon to rectum

H29.4 Subtotal excision of colon and creation of colonic pouch NEC

H29.8 Other specified subtotal excision of colon

H29.9 Unspecified subtotal excision of colon

H30.1 Radiological Reduction of Intussusception of Colon using Barium Enema

H30.2 Intubation of Colon for Pressure Manometry

H30.3 Passage of Flatus Tube to reduce Volvulus of Sigmoid Colon


36

H30.4 Intubation of Colon NEC

H30.8 Other Operations of Colon; other specified

H21.4 Fibreoptic endoscopic insertion of expanding metal stent into colon.

H24.4 Endoscopic insertion of expanding metal stent into lower bowel using fibreoptic sigmoidoscope

H27.4 Endoscopic insertion of expanding metal stent into sigmoid colon using rigid sigmoidoscope

H31.4 Image guided insertion of colorectal stent

H31.5 Image guided removal of colorectal stent

H33.1 Abdominoperineal Excision of Rectum and End Colostomy

H33.2 Proctectomy and Anastomosis of Colon to Anus

H33.3 Anterior Resection of Rectum-Anastomosis of Colon to Rectum using Staples

H33.4 Anterior Resection of Rectum-Anastomosis NEC

H33.5 Rectosigmoidectomy and Closure of Rectal Stump and Exteriorisation of bowel

H33.6 Anterior Resection of Rectum and Exteriorisation of bowel

H33.8 Excision of Rectum; other specified

H40.1 Transsphincteric Excision of Mucosa of Rectum

H40.2 Transsphincteric Excision of Lesion of Rectum

H40.3 Transsphincteric Destruction of Lesion of Rectum

H40.4 Transsphincteric Anastomosis of Colon to Anus

H40.8 Operations on Rectum through Anal Sphincter; other specified

H34.1 Open Excision of Lesion of Rectum

H34.2 Open Cauterisation of Lesion of Rectum

H34.3 Open Cryotherapy of Lesion of Rectum

H34.4 Open Laser Destruction of Lesion of Rectum

H34.5 Open Destruction of Lesion of Rectum

H34.8 Open Extirpation of Lesion of Rectum; other specified

H41.1 Rectosigmoidectomy and Peranal Anastomosis

H41.2 Peranal Excision of Rectum

H41.3 Peranal Destruction of Lesion of Rectum

H41.4 Peranal Mucosal Proctectomy and Endoanal Anastomosis

H41.8 Other Operations on Rectum through Anus; other specified

H20.1 Fibreoptic Endoscopic Snare Resection of Lesion of Colon

H20.2 Fibreoptic Endoscopic Cauterisation of Lesion of Colon

H20.3 Fibreoptic Endoscopic Laser Destruction of Lesion of Colon

H20.4 Fibreoptic Endoscopic Destruction of Lesion of Colon NEC

H20.8 Endoscopic Extirpation of Lesion of Colon; other specified

H21.1 Fibreoptic Endoscopic Dilation of Colon

H21.2 Fibreoptic Endoscopic Coagulation of Blood Vessel of Colon

H21.8 Other Therapeutic Endoscopic Operations on Colon; other specified

H23.1 Endoscopic Snare Resection of Lesion of Lower Bowel using Fibreoptic Sigmoidoscope

H23.2 Endoscopic Cauterisation of Lesion of Lower Bowel using Fibreoptic Sigmoidoscope

H23.3 Endoscopic Laser Destruction of Lesion of Lower Bowel using Fibreoptic Sigmoidoscope

H23.4 Endoscopic Snare Resection of Lesion of Lower Bowel using Fibreoptic Sigmoidoscope

H23.8 Endoscopic Extirpation of Lesion of Lower Bowel Using Fibreoptic Sigmoidoscope; other specified

H24.1 Endoscopic Dilation of Lower Bowel using Fibreoptic Sigmoidoscope

H24.2 Endoscopic Coagulation of Blood Vessel of Lower Bowel using Fibreoptic Sigmoidoscope

H24.8 Other Endoscopic Operations – Lower Bowel using Fibreoptic Sigmoidoscope; other specified

H26.2 Endoscopic Cauterisation of Lesion of Sigmoid Colon using Rigid Sigmoidoscope

H26.3 Endoscopic Laser Destruction of Lesion of Sigmoid Colon using Rigid Sigmoidoscope

H26.4 Endoscopic Cryotherapy to Lesion of Sigmoid Colon using Rigid Sigmoidoscope NEC

H26.8 Endoscopic Extirpation of Lesion of Sigmoid Colon using Rigid Sigmoidoscope; other specified

H27.1 Endoscopic Dilation of Sigmoid Colon using Rigid Sigmoidoscope

H27.8 Other Endoscopic Operations on Sigmoid Colon using Rigid Sigmoidoscope; other specified

J02.1 Right hemihepatectomy

J02.2 Left hemihepatectomy

J02.3 Resection of segment of liver

J02.4 Wedge excision of liver

J02.6 Extended right hemihepatectomy

J02.7 Extended left hemihepatectomy

J03.2 Destruction of lesion of liver

J03.3 Thermal ablation of single lesion of liver

J03.4 Thermal ablation of multiple lesions of liver


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J03.5 Excision of multiple lesions of liver

J12.4 Percutaneous radiofrequency ablation of lesion of liver

G49.0 Excision of duodenum – Excludes Pancreaticoduodenectomy (J56)

G49.1 Gastroduodenectomy

G49.2 Total excision of duodenum

G49.3 Partial excision of duodenum

G49.8 Excision of duodenum - Other specified

G49.9 Excision of duodenum - Unspecified

G50.1 Excision of lesion of duodenum

G51.0 Bypass of duodenum – Excludes Bypass of duodenum by anastomosis of duodenum to colon (G51.4)

G51.1 Bypass of duodenum by anastomosis of stomach to jejunum

G51.2 Bypass of duodenum by anastomosis of duodenum to duodenum

G51.3 Bypass of duodenum by anastomosis of duodenum to jejunum

G51.8 Bypass of duodenum - Other specified

G51.9 Bypass of duodenum - Unspecified

G59.1 Excision of lesion of jejunum

G69.3 Ileectomy and anastomosis of ileum to ileum

G69.9 Excision of ileum unspecified

J56.2 Pancreaticoduodenectomy and resection of antrum of stomach (Whipple’s resection)

G74.1 Creation of continent ileostomy

G74.2 Creation of temporary ileostomy

G74.3 Creation of defunctioning ileostomy

L79.7 Excision of lesion of vena cava

L79.8 Other specified other operations on vena cava

M02.5 Nephrectomy NEC

Note: Use additional code to identify a VATS procedure (Y74.4)

S05.9 Microscopically controlled excision of lesion of skin - unspecified

S06.5 Excision of lesion of skin of head or neck NEC

S06.7 Re-excision of skin margins NEC

S06.9 Other excision of lesion of skin unspecified

S08.1 Curettage and cauterisation of lesion of skin of head or neck

S17.9 Unspecified distant flap of skin and muscle

S24.2 Local myocutaneous subcutaneous pedicle flap NEC

S27.9 Unspecified other local flap of skin

S35.3 Split autograft of skin to head or neck NEC

S36.2 Full thickness autograft of skin NEC

T01.1 Thoracoplasty

T01.3 Excision of lesion of chest wall

T01.8 Partial excision of chest wall, Other specified

T01 9 Partial excision of chest wall, Unspecified

T31.1 Biopsy of lesion of anterior abdominal wall, Includes: Biopsy of anterior abdominal wall

T31.2 Excision of lesion of anterior abdominal wall and insert of prosthetic material into anterior abdominal wall

T31.3 Excision of lesion of anterior abdominal wall NEC

T33.1 Open excision of lesion of peritoneum

T36.1 Omentectomy

T37.1 Excision of lesion of mesentery of small intestine

T37.8 Other specified operations on mesentery of small intestine

T37.9 Unspecified operations on mesentery of small intestine

T39.1 Excision of lesion of posterior peritoneum

T43.2

Diagnostic endoscopic examination of peritoneum and biopsy of lesion of intraabdominal organ NEC Includes: Diagnostic endoscopic examination of peritoneum and biopsy of intraabdominal organ NEC, Laparoscopic biopsy of lesion of intraabdominal organ NEC, Laparoscopic biopsy of intraabdominal organ NEC

Y74.4 Thoracoscopic video-assisted approach to thoracic cavity

Note: Use subsidiary site code as necessary

T51.1 Excision of fascia of posterior abdominal wall

T51.2 Excision of fascia of pelvis

T53.1 Excision of lesion of fascia

T53.2 Destruction of lesion of fascia

T57.2 Biopsy of lesion of fascia Includes: Biopsy of fascia


38

T77.1 Excision of whole muscle group (compartmentectomy)

T77.2 Wide excision of muscle Includes: Wide excision of lesion of muscle

T77.3 Partial excision of muscle NEC Includes: Excision of lesion of muscle NEC, Excision of Volkmann contracture of forearm

T77.4 Debridement of muscle NEC

T77.8 Excision of muscle, Other specified

T77.9 Excision of muscle, Unspecified

T81.1 Percutaneous biopsy of muscle Includes: Percutaneous biopsy of lesion of muscle

T81.2 Biopsy of neuromuscular junction Includes: Biopsy of muscle for biochemical study, Biopsy of muscle for physiological study

T81.3 Biopsy of lesion of muscle NEC

T81.8 Biopsy of muscle, Other specified

T81.9 Biopsy of muscle, Unspecified

T85.1 Block dissection of cervical lymph nodes

T85.2 Block dissection of axillary lymph nodes

T85.3 Block dissection of mediastinal lymph nodes

T85.4 Block dissection of paraaortic lymph nodes

T85.5 Block dissection of inguinal lymph nodes

T85.8 Block dissection of lymph nodes, Other specified

T85.9 Block dissection of lymph nodes, Unspecified

T87.1 Excision or biopsy of scalene lymph node

T87.2 Excision or biopsy of cervical lymph node NEC

T87.3 Excision or biopsy of axillary lymph node Includes: Excision or biopsy of supraclavicular lymph node

T87.4 Excision or biopsy of mediastinal lymph node

T87.5 Excision or biopsy of paraaortic lymph node

T87.6 Excision or biopsy of porta hepatis lymph node

T87.7 Excision or biopsy of inguinal lymph node

T87.8 Excision or biopsy of lymph node, Other specified

T87.9 Excision or biopsy of lymph node, Unspecified

T91.1 Biopsy of sentinel lymph node

T96.1 Excision of cystic hygroma

T96.2 Excision of lesion of soft tissue NEC

T96.3 Debridement of soft tissue NEC

T96.8 Other operations on soft tissue, Other specified

T96.9 Other operations on soft tissue, Unspecified

T76.1 Microvascular free tissue transfer of flap of muscle

T76.8 Transplantation of muscle, Other specified

T76.9 Transplantation of muscle, Unspecified

L97.3 Isolated limb perfusion

X14.1 Total exenteration of pelvis

X14.2 Anterior exenteration

X14.3 Posterior exenteration of pelvis

X14.8 Other specified clearance of pelvis

X14.9 Unspecified clearance of pelvis

X23.6 Reversal of rotation plasty of ankle for correction of congenital deformity of leg

V01.8 Plastic repair of cranium - unspecified

W05.1 Articulated prosthetic replacement of bone

W05.2 Implantation massive endoprosthetic replacement of bone

W05.3 Implantation endoprosthetic replacement of bone NEC

X07.1 Forequarter amputation

X07.2 Disarticulation of shoulder

X07.3 Amputation of arm above elbow

X07.4 Amputation of arm through elbow

X07.5 Amputation of arm through forearm

X07.8 Amputation of arm, Other specified

X07.9 Amputation of arm, Unspecified

X08.1 Amputation of hand at wrist

X08.2 Amputation of thumb, Excludes: Amputation of duplicate thumb (X21.5)

X08.3 Amputation of phalanx of finger

X08.4 Amputation of finger NEC, Excludes: Amputation of supernumerary finger (X21.6)

X21.5 Amputation of duplicate thumb


39

X21.6 Amputation of supernumerary finger NEC

X08.8 Amputation of hand, Other specified

X08.9 Amputation of hand, Unspecified

X09.1 Hindquarter amputation

X09.2 Disarticulation of hip

X09.3 Amputation of leg above knee

X09.4 Amputation of leg through knee

X09.5 Amputation of leg below knee

X09.8 Amputation of leg, Other specified

X09.9 Amputation of leg, Unspecified

X10.1 Amputation of foot through ankle

X10.2 Disarticulation of tarsal bones

X10.3 Disarticulation of metatarsal bones

X10.4 Amputation through metatarsal bones

X10.8 Amputation of foot, Other specified

X10.9 Amputation of foot, Unspecified

X11.1 Amputation of great toe

X11.2 Amputation of phalanx of toe

X27.3 Amputation of supernumerary toe

X11.8 Amputation of toe, Other specified

X11.9 Amputation of toe, Unspecified Includes: Disarticulation of toe

X12.1 Reamputation at higher level

X12.2 Excision of lesion of amputation stump

X23.6 Reversal of rotation plasty of ankle for correction of congenital deformity of leg

Y50.2 Laparotomy approach NEC

Y75.1 Laparoscopically assisted approach to abdominal cavity

Y75.2 Laparoscopic approach to abdominal cavity NEC

W05.1 Articulated prosthetic replacement of bone

W05.2 Implantation massive endoprosthetic replacement of bone

W05.3 Implantation endoprosthetic replacement of bone NEC

W05.8 Prosthetic replacement of bone, Other specified

W05.9 Prosthetic replacement of bone, Unspecified

W06.1 Total excision of cervical rib

W06.2 Total excision of rib NEC

W06.3 Total excision of patella

W06.4 Total excision of sesamoid bone NEC

W06.5 Total excision of bone of foot NEC

W06.6 Total excision of coccyx

W06.7 Total excision of pelvic bones

W06.8 Total excision of bone, Other specified

W06.9 Total excision of bone, Unspecified Includes: Ostectomy NEC

W07.1 Excision of cross union of bone

W07.2 Excision of periarticular ectopic bone

W07.3 Excision of intramuscular ectopic bone

W07.8 Excision of ectopic bone, Other specified

W07.9 Excision of ectopic bone, Unspecified

W08.1 Excision of natural protuberance of bone Includes: Excision of tuberosity of bone, Excision of tubercle of bone

W08.2 Excision of overgrowth of bone

W08.3 Excision of excrescence of bone

W08.4 Excision of fragment of bone

W08.5 Partial excision of bone NEC

W08.6 Disarticulation for amputation of limb (X07-X11)

W08.7 Excision of accessory ossicle

W08.8 Other excision of bone, Other specified

W08.9 Other excision of bone, Unspecified

W09.1 Excision of lesion of bone

W09.2 Curettage of lesion of bone and graft HFQ

W09.3 Curettage of lesion of bone NEC

W09.4 Destruction of lesion of bone NEC

W09.5 Curettage of tumour of bone and graft HFQ


40

W09.6 Curettage of tumour of bone NEC

W09.7 Excision of tumour of bone NEC

W09.8 Extirpation of lesion of bone, Other specified

W09.9 Extirpation of lesion of bone, Unspecified

W28.1 Application of internal fixation to bone NEC

W28.2 Adjustment to internal fixation of bone NEC

W28.3 Removal of internal fixation from bone NEC

W28.4 Insertion of intramedullary fixation and cementing of bone

W28.8 Other internal fixation of bone, Other specified

W28.9 Other internal fixation of bone, Unspecified

W31.1 Inlay autograft to cortex of bone

W31.2 Onlay autograft to cortex of bone

W31.3 Cancellous strip autograft of bone

W31.4 Cancellous chip autograft of bone

W31.5 Vascularised pedicle autograft of bone

W31.6 Muscle pedicle autograft of bone

W31.7 Bone tendon autograft of bone

W31.8 Other autograft of bone, Other specified

W31.9 Other autograft of bone, Unspecified

W32.1 Prepared graft of bone

W32.2 Allograft of bone NEC Excludes: Allograft of bone marrow NEC (W34.2)

W32.3 Xenograft of bone

W32.4 Synthetic graft of bone

W32.8 Other graft of bone, Other specified

W32.9 Other graft of bone, Unspecified

W33.1 Open biopsy of lesion of bone Includes: Open biopsy of bone

W36.1 Percutaneous needle biopsy of lesion of bone Includes: Percutaneous needle biopsy of bone

W36.2 Needle biopsy of lesion of bone NEC Includes: Needle biopsy of bone NEC, Biopsy of lesion of bone NEC, Biopsy of bone NEC

W36.5 Diagnostic extraction of bone marrow NEC Includes: Aspiration of bone marrow NEC, Biopsy of bone marrow NEC

W37.1 Primary total prosthetic replacement of hip joint using cement

W37 2 2 Conversion to total prosthetic replacement of hip joint using cement

Note: Use subsidiary conversion from code as necessary

W37.3 Revision of total prosthetic replacement of hip joint using cement

W37.4 Revision of one component of total prosthetic replacement of hip joint using cement

W37.8 Total prosthetic replacement of hip joint using cement , Other specified

W37.9 Total prosthetic replacement of hip joint using cement , Unspecified

W37.0 Conversion from previous cemented total prosthetic replacement of hip joint

W38.1 Primary total prosthetic replacement of hip joint not using cement

W38.2 Conversion to total prosthetic replacement of hip joint not using cement


W38.3 Revision of total prosthetic replacement of hip joint not using cement

W38.4 Revision of one component of total prosthetic replacement of hip joint not using cement

W38.8 Total prosthetic replacement of hip joint not using cement, Other specified

W38.9 Total prosthetic replacement of hip joint not using cement, Unspecified

W38.0 Conversion from previous uncemented total prosthetic replacement of hip joint

W39.1 Primary total prosthetic replacement of hip joint NEC

W39.2 Conversion to total prosthetic replacement of hip joint NEC


W39.3 Revision of total prosthetic replacement of hip joint NEC

W39.4 Attention to total prosthetic replacement of hip joint NEC

W39.5 Revision of one component of total prosthetic replacement of hip joint NEC

W39.6 Closed reduction of dislocated total prosthetic replacement of hip joint

W39.8 Other total prosthetic replacement of hip joint, Other specified

W39.9 Other total prosthetic replacement of hip joint, Unspecified

W39.0 Conversion from previous total prosthetic replacement of hip joint NEC

W93.1 Primary hybrid prosthetic replacement of hip joint using cemented acetabular component

W93.2 Conversion to hybrid prosthetic replacement of hip joint using cemented acetabular Component


W93.3 Revision of hybrid prosthetic replacement of hip joint using cemented actebular component


41

W93.8 Hybrid prosthetic replacement of hip joint using cemented acetabular component, Other specified

W93.9 Hybrid prosthetic replacement of hip joint using cemented acetabular component, Unspecified

W93.0 Conversion from previous hybrid prosthetic replacement of hip joint using cemented acetabular component

W94.1 Primary hybrid prosthetic replacement of hip joint using cemented femoral component

W94.2 Conversion to hybrid prosthetic replacement of hip joint using cemented femoral component. Note: Use subsidiary conversion from code as necessary

W94.3 Revision of hybrid prosthetic replacement of hip joint using cemented femoral component

W94.8 Hybrid prosthetic replacement of hip joint using cemented femoral component, Other specified

W94.9 Hybrid prosthetic replacement of hip joint using cemented femoral component, Unspecified

W94.0 Conversion from previous hybrid prosthetic replacement of hip joint using cemented femoral component

W95.1 Primary hybrid prosthetic replacement of hip joint using cement NEC

W95.2 Conversion to hybrid prosthetic replacement of hip joint using cement NEC


W95.3 Revision of hybrid prosthetic replacement of hip joint using cement NEC

W95.4 Attention to hybrid prosthetic replacement of hip joint using cement NEC

W95.8 Hybrid prosthetic replacement of hip joint using cement, Other specified

W95.9 Hybrid prosthetic replacement of hip joint using cement, Unspecified

W95.0 Conversion from previous hybrid prosthetic replacement of hip joint using cement NEC

W40.1 Primary total prosthetic replacement of knee joint using cement

W40.2 Conversion to total prosthetic replacement of knee joint using cement


W40.3 Revision of total prosthetic replacement of knee joint using cement

W40.4 Revision of one component of total prosthetic replacement of knee joint using cement

W40.8 Total prosthetic replacement of knee joint using cement, Other specified

W40.9 Total prosthetic replacement of knee joint using cement, Unspecified

W40.0 Conversion from previous cemented total prosthetic replacement of knee joint

W41.1 Primary total prosthetic replacement of knee joint not using cement

W41.2 Conversion to total prosthetic replacement of knee joint not using cement


W41.3 Revision of total prosthetic replacement of knee joint not using cement

W41.4 Revision of one component of total prosthetic replacement of knee joint not using cement

W41.8 Total prosthetic replacement of knee joint not using cement, Other specified

W41.9 Total prosthetic replacement of knee joint not using cement, Unspecified

W41.0 Conversion from previous uncemented total prosthetic replacement of knee joint

W42.1 Primary total prosthetic replacement of knee joint NEC

W42.2 Conversion to total prosthetic replacement of knee joint NEC


W42.3 Revision of total prosthetic replacement of knee joint NEC

W42.4 Attention to total prosthetic replacement of knee joint NEC

W42.5 Revision of one component of total prosthetic replacement of knee joint NEC

W42.8 Other total prosthetic replacement of knee joint, Other specified

W42.9 Other total prosthetic replacement of knee joint, Unspecified

W42.0 Conversion from previous total prosthetic replacement of knee joint NEC

W43.1 Primary total prosthetic replacement of joint using cement NEC

W43.2 Conversion to total prosthetic replacement of joint using cement NEC


W43.3 Revision of total prosthetic replacement of joint using cement NEC

W43.4 Revision of one component of total prosthetic replacement of joint using cement NEC

W43.8 Total prosthetic replacement of other joint using cement, Other specified

W43.9 Total prosthetic replacement of other joint using cement, Unspecified

W43.0 Conversion from previous cemented total prosthetic replacement of joint NEC

W44.1 Primary total prosthetic replacement of joint not using cement NEC

W44.2 Conversion to total prosthetic replacement of joint not using cement NEC


W44.3 Revision of total prosthetic replacement of joint not using cement NEC

W44.4 Revision of one component of total prosthetic replacement of joint not using cement NEC

W44.8 Total prosthetic replacement of other joint not using cement, Other specified

W44.9 Total prosthetic replacement of other joint not using cement, Unspecified

W44.0 Conversion from previous uncemented total prosthetic replacement of joint NEC

W45.1 Primary total prosthetic replacement of joint NEC


42

W45.2 Conversion to total prosthetic replacement of joint NEC


W45.3 Revision of total prosthetic replacement of joint NEC

W45.4 Attention to total prosthetic replacement of joint NEC

W45.5 Revision of one component of total prosthetic replacement of joint NEC

W45.8 Other total prosthetic replacement of other joint, Other specified

W45.9 Other total prosthetic replacement of other joint, Unspecified

W45.0 Conversion from previous total prosthetic replacement of joint NEC

W46.1 Primary prosthetic replacement of head of femur using cement

W46.2 Conversion to prosthetic replacement of head of femur using cement


W46.3 Revision of prosthetic replacement of head of femur using cement

W46.8 Prosthetic replacement of head of femur using cement, Other specified

W46.9 Prosthetic replacement of head of femur using cement, Unspecified

W46.0 Conversion from previous cemented prosthetic replacement of head of femur

W47.1 Primary prosthetic replacement of head of femur not using cement

W47.2 Conversion to prosthetic replacement of head of femur not using cement


W47.3 Revision of prosthetic replacement of head of femur not using cement

W47.8 Prosthetic replacement of head of femur not using cement, Other specified

W47.9 Prosthetic replacement of head of femur not using cement, Unspecified

W47.0 Conversion from previous uncemented prosthetic replacement of head of femur

W48.1 Primary prosthetic replacement of head of femur NEC

W48.2 Conversion to prosthetic replacement of head of femur NEC


W48.3 Revision of prosthetic replacement of head of femur NEC

W48.4 Attention to prosthetic replacement of head of femur NEC

W48.5 Closed reduction of dislocated prosthetic replacement of head of femur

W48.8 Other prosthetic replacement of head of femur, Other specified

W48.9 Other prosthetic replacement of head of femur, Unspecified

W48.0 Conversion from previous prosthetic replacement of head of femur NEC

W49.1 Primary prosthetic replacement of head of humerus using cement

W49.2 Conversion to prosthetic replacement of head of humerus using cement


W49.3 Revision of prosthetic replacement of head of humerus using cement

W49.4 Resurfacing hemiarthroplasty of head of humerus using cement

W49.8 Prosthetic replacement of head of humerus using cement, Other specified

W49.9 Prosthetic replacement of head of humerus using cement, Unspecified

W49.0 Conversion from previous cemented prosthetic replacement of head of humerus

W50.1 Primary prosthetic replacement of head of humerus not using cement

W50.2 Conversion to prosthetic replacement of head of humerus not using cement


W50.3 Revision of prosthetic replacement of head of humerus not using cement

W50.4 Resurfacing hemiarthroplasty of head of humerus not using cement

W50.8 Prosthetic replacement of head of humerus not using cement, Other specified

W50.9 Prosthetic replacement of head of humerus not using cement, Unspecified

W50.0 Conversion from previous uncemented prosthetic replacement of head of humerus

W51.1 Primary prosthetic replacement of head of humerus NEC

W51.2 Conversion to prosthetic replacement of head of humerus NEC


W51.3 Revision of prosthetic replacement of head of humerus NEC

W51.4 Attention to prosthetic replacement of head of humerus NEC

W51.5 Resurfacing hemiarthroplasty of head of humerus NEC

W51.8 Other prosthetic replacement of head of humerus, Other specified

W51.9 Other prosthetic replacement of head of humerus, Unspecified

W51.0 Conversion from previous prosthetic replacement of head of humerus NEC

W96.1 Primary total prosthetic replacement of shoulder joint using cement

W96.2 Conversion to total prosthetic replacement of shoulder joint using cement


W96.3 Revision of total prosthetic replacement of shoulder joint using cement

W96.4 Revision of one component of total prosthetic replacement of shoulder joint using cement


43

W96.8 Total prosthetic replacement of shoulder joint using cement, Other specified

W96.9 Total prosthetic replacement of shoulder joint using cement, Unspecified

W96.0 Conversion from total prosthetic replacement of shoulder joint using cement

W97.1 Primary total prosthetic replacement of shoulder joint not using cement

W97.2 Conversion to total prosthetic replacement of shoulder joint not using cement


W97.3 Revision of total prosthetic replacement of shoulder joint not using cement

W97.4 Revision of one component of total prosthetic replacement of shoulder joint not using cement

W97.8 Total prosthetic replacement of shoulder joint not using cement, Other specified

W97.9 Total prosthetic replacement of shoulder joint not using cement, Unspecified

W97.0 Conversion from total prosthetic replacement of shoulder joint not using cement

W98.1 Primary total prosthetic replacement of shoulder joint NEC

W98.2 Conversion to total prosthetic replacement of shoulder joint NEC


W98.3 Revision of total prosthetic replacement of shoulder joint NEC

W98.4 Attention to total prosthetic replacement of shoulder joint NEC

W98.5 Revision of one component of total prosthetic replacement of shoulder joint NEC

W98.8 Total prosthetic replacement of shoulder joint, Other specified

W98.9 Total prosthetic replacement of shoulder joint, Unspecified

W98.0 Conversion from total prosthetic replacement of shoulder joint NEC

W52.1 Primary prosthetic replacement of articulation of bone using cement NEC

W52.2 Conversion to prosthetic replacement of articulation of bone using cement NEC


W52.3 Revision of prosthetic replacement of articulation of bone using cement NEC

W52.8 Prosthetic replacement of articulation of other bone using cement, Other specified

W52.9 Prosthetic replacement of articulation of other bone using cement, Unspecified

W52.0 Conversion from previous cemented prosthetic replacement of articulation of bone NEC

W53.1 Primary prosthetic replacement of articulation of bone not using cement NEC

W53.2 Conversion to prosthetic replacement of articulation of bone not using cement NEC


W53.3 Revision of prosthetic replacement of articulation of bone not using cement NEC

W53.8 Prosthetic replacement of articulation of other bone not using cement, Other specified

W53.9 Prosthetic replacement of articulation of other bone not using cement, Unspecified

W53.0 Conversion from previous uncemented prosthetic replacement of articulation of bone NEC

W54.1 Primary prosthetic replacement of articulation of bone NEC

W54.2 Conversion to prosthetic replacement of articulation of bone NEC


W54.3 Revision of prosthetic replacement of articulation of bone NEC

W54.4 Attention to prosthetic replacement of articulation of bone NEC

W54.8 Other prosthetic replacement of articulation of other bone, Other specified

W54.9 Other prosthetic replacement of articulation of other bone, Unspecified

W54.0 Conversion from previous prosthetic replacement of articulation of bone NEC

O06.1 Primary hybrid prosthetic replacement of shoulder joint using cemented humeral component

O06.2 Conversion to hybrid prosthetic replacement of shoulder joint using cemented humeral component


O06.3 Revision of hybrid prosthetic replacement of shoulder joint using cemented humeral component

O06.8 Hybrid prosthetic replacement of shoulder joint using cemented humeral component, Other specified

O06.9 Hybrid prosthetic replacement of shoulder joint using cemented humeral component, Unspecified

O06.0 Conversion from previous hybrid prosthetic replacement of shoulder joint using cemented humeral component

O07.1 Primary hybrid prosthetic replacement of shoulder joint using cemented glenoid component

O07.2 Conversion to hybrid prosthetic replacement of shoulder joint using cemented glenoid component


O07.3 Revision of hybrid prosthetic replacement of shoulder joint using cemented glenoid component

O07.8 Hybrid prosthetic replacement of shoulder joint using cemented glenoid component, Other specified

O07.9 Hybrid prosthetic replacement of shoulder joint using cemented glenoid component, Unspecified

O07.0 Conversion from previous hybrid prosthetic replacement of shoulder joint using cemented glenoid component

O08.1 Primary hybrid prosthetic replacement of shoulder joint using cement NEC

O08.2 Conversion to hybrid prosthetic replacement of shoulder joint using cement NEC



44

O08.3 Revision of hybrid prosthetic replacement of shoulder joint using cement NEC

O08.4 Attention to hybrid prosthetic replacement of shoulder joint using cement NEC

O08.8 Hybrid prosthetic replacement of shoulder joint using cement, Other specified

O08.9 Hybrid prosthetic replacement of shoulder joint using cement, Unspecified

O08.0 Conversion from previous hybrid prosthetic replacement of shoulder joint using cement NEC

O09.1 Implantation of vertical expanding prosthetic titanium rib

O09.8 Placement of bone prosthesis, Other specified

O09.9 Placement of bone prosthesis, Unspecified

O10.1 Extraarticular scapular resection with reconstruction of shoulder, Includes: Tikhoff Linberg reconstruction

O10.8 Complex reconstruction of shoulder, Other specified

O10.9 Complex reconstruction of shoulder, Unspecified

P05.4 Excision of lesion of vulva NEC

V05.1 Extirpation of lesion of cranium

V14.1 Hemimandibulectomy

V14.4 Excision of lesion of mandible

V24.8 Other specified decompression operations on thoracic spine

V25.1 Primary extended decompression of lumbar spine and intertransverse fusion of joint of lumbar spine

V25.4 Primary posterior laminectomy decompression of lumbar spine

V25.7 Primary anterior corpectomy of lumbar spine and reconstruction HFQ

V43.1 Excision of lesion of cervical vertebra

V43.2 Excision of lesion of thoracic vertebra

V43.3 Excision of lesion of lumbar vertebra

V43.8 Extirpation of lesion of spine, Other specified

V43.9 Extirpation of lesion of spine, Unspecified

V47.1 Biopsy of cervical vertebra

V47.2 Biopsy of thoracic vertebra

V47.3 Biopsy of lumbar vertebra

V47.8 Biopsy of spine, Other specified

V47.9 Biopsy of spine, Unspecified

V67.2 L2 Hemilaminectomy – Includes Duodenectomy not elsewhere classified

Q07.1 Abdominal hysterocolpectomy and excision of periuterine tissue

Q07.2 Abdominal hysterectomy and excision of periuterine tissue NEC

Q07.3 Abdominal hysterocolpectomy NEC

Q07.4 Total abdominal hysterectomy NEC. Includes: Hysterectomy NEC

Q07.5 Subtotal abdominal hysterectomy

Q07.6 Excision of accessory uterus

Q07.8 Other specified

Q07.9 Unspecified

Note: Use as a supplementary code when associated with concurrent repair of prolapse of vagina (P23) Use a supplementary code for concurrent excision of ovary and/or fallopian tube (Q22–Q24)

Q08.1 Vaginal hysterocolpectomy and excision of periuterine tissue

Q08.2 Vaginal hysterectomy and excision of periuterine tissue NEC

Q08.3 Vaginal hysterocolpectomy NEC

Q08.8 Other specified

Q08.9 Unspecified. Includes: Vaginal hysterectomy NEC

Q09.2 Open myomectomy


95 Patient refused treatment

96 Not applicable – E.g. Non-surgical patient

99 Not recorded – Evidence in the patient record that surgery was received but details of the type of surgery is not recorded


45

Primary Flap Reconstruction Main Source of Data Item Standard: The National Audit Cancer Datasets developed by the regional Cancer Networks supported by Information Services. Definition: Denotes whether the patient underwent a primary flap reconstruction following surgical resection. Field Name: PRIMFLAP Format: Integer Field length: 2 Notes for Users: Required for QPI: 7 Successful has been defined as patients who do not need to return to theatre for unplanned surgical debridement of a sufficient volume of the flap reconstruction such that secondary reconstruction is required.. Examples of an unsuccessful primary flap reconstruction would include: flap failure, partial flap failure This information should be available from surgical notes a few days after surgery. Processes may need to be established with the relevant Clinician locally to make this information accessible. Codes and Values:

Code Value Explanatory Notes 01 Yes – successful

02 Yes – unsuccessful

03 No E.g. Patient required but did not have for other reasons

95 Patient refused

96 Not applicable E.g. Not required

99 Not recorded

Related Data Items:


46

Section 4: Pathological Details


47

Morphology of Tumour Main Source of Data Item Standard: Pathology and Genetics of Tumours of the Digestive System, WHO Histological Classification of Tumours. Definition: This is the morphology of the tumour according to the International Classification of Diseases for Oncology (ICD-O(3)). Field Name: MORPHOL Field Type: Characters Field Length: 6 Notes for Users: Required for QPI(s): 3, 5, 8, 9 and for sub-analysis and inclusion criteria. Where there is a biopsy and a surgical specimen examined then the surgical specimen should take precedence. However, in non-surgical patients, information from a biopsy can be used. If unsure check with Pathologist. The morphology terms have five-digit code numbers which run from 8000/0 to 9989/1; the first four digits indicate the specific histologic terms and the fifth digit, after the slash, is a behaviour code.

If material supplied cannot be assessed code to ‘not assessable’ (1111/1).

If the pathology report is negative code to 8888/8. Morphology codes are shown below. This list is not exhaustive and if a code is not on the list please contact mailto:[email protected] for advice. Examples of Morphology codes

Code Description Explanatory Notes Soft tissue tumours and sarcomas, NOS; Fibromatous neoplasms; Myxomatous neoplasms; Lipomatous neoplasms; Myomatous neoplasms

8710/3 Glomangiosarcoma; Glomoid Sarcoma Only include if behaviour code is 3

8711/3 Malignant Glomus tumour Only include if behaviour code is 3

8800/3 Sarcoma, NOS; soft tissue sarcoma; soft tissue tumour, malignant; mesenchymal tumour, malignant

8800/9 Sarcomatosis, NOS

8801/3 Spindle cell sarcoma

8802/3 Giant cell sarcoma (except of bone M9250/3); pleomorphic cell sarcoma

8803/3 Small cell sarcoma; round cell sarcoma

8804/3 Epithelioid sarcoma; epithelioid cell sarcoma

8805/3 Undifferentiated sarcoma

8806/3 Desmoplastic round cell tumour

8810/3 Fibrosarcoma, NOS

8811/1 Cellular Fibroma

8811/3 Fibromyxosarcoma

8812/3 Periosteal fibrosarcoma (C40._, C41._); periosteal sarcoma, NOS (C40._, C41._)

8813/3 Fascial fibrosarcoma

8814/3 Infantile fibrosarcoma; congenital fibrosarcoma

8815/3 Solitary fibrous tumour, malignant

8821/3 Malignant Fibromatosis Usually uncertain behaviour so only



48

include if behaviour code is 3.

8822/3 Malignant abdominal fibromatosis Usually uncertain behaviour so only include if behaviour code is 3.

8823/3 Malignant Desmoplastic fibroma Usually benign so only include if behaviour code is 3.

8825/3 Fibromatous sarcoma

8830/3 Fibrous histiocytoma, malignant; fibroxanthoma, malignant

8832/3 Dermatofibrosarcoma, NOS (C44._); dermatofibrosarcoma protuberans, NOS (C44._)

8833/3 Pigmented dermatofibrosarcoma protuberans; Bednar tumour

8840/3 Myxosarcoma

8841/3 Malignant Angiomyxoma Usually uncertain behaviour so only include if behaviour code is 3.

8850/3 Liposarcoma, NOS; fibroliposarcoma

8851/3 Liposarcoma, well differentiated; Liposarcoma, differentiated

Atypical Lipomatous tumour

8852/3 Myxoid Liposarcoma; myxoliposarcoma

8853/3 Round cell liposarcoma

8854/3 Pleomorphic liposarcoma

8855/3 Mixed liposarcoma

8857/3 Fibroblastic Liposarcoma

8858/3 Dedifferentiated liposarcoma

8860/3 Malignant angiomyolipoma Usually benign so only include if behaviour code is 3.

8890/3 Leiomyosarcoma, NOS

8891/3 Epithelioid leiomyosarcoma

8894/3 Angiomyosarcoma

8895/3 Myosarcoma

8896/3 Myxoid leiomyosarcoma

8900/3 Rhabdomyosarcoma, NOS; rhabdosarcoma

8901/3 Pleomorphic rhabdomyosarcoma

8902/3 Mixed type rhabdomyosarcoma; Mixed Embryonal & Alveolar Rhabdomyosarcoma

8910/3 Embryonal rhabdomyosarcoma; sarcoma botryoides; botryoid sarcoma

8912/3 Spindle cell rhabdomyosarcoma

8920/3 Alveolar rhabdomyosarcoma

8921/3 Rhabdomyosarcoma with ganglionic differentiation; Ectomesenchymoma

8930/3 Endometrial stromal sarcoma

Complex Mixed and Stromal Neoplasms

8936/1 Gastrointestinal stromal tumour, NOS

8936/3 Gastrointestinal stromal sarcoma; Gastrointestinal stromal tumour, malignant; GIST malignant.

8963/3 Rhabdoid sarcoma; Malignant rhabdoid tumour; rhabdoid tumour NOS.

Mixed mesenchymal sarcoma; embryonal sarcoma

8982/3 Malignant myoepithelioma

8990/3 Mesenchymoma, malignant; mixed mesenchymal sarcoma

8991/3 Embryonal sarcoma

Synovial-like neoplasms

9040/3 Synovial sarcoma, NOS; synovioma, NOS; synovioma, malignant

9041/3 Synovial sarcoma, spindle cell

9042/3 Synovial sarcoma, epithelioid cell

9043/3 Synovial sarcoma, biphasic

9044/3 Clear cell sarcoma (except of kidney M8964/3); clear cell sarcoma, of tendons and aponeuroses (C49._); melanoma, malignant, of soft parts (C49._)

Blood vessel tumours; lymphatic vessel tumours; osseous and chondromatous neoplasms; giant


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cell tumours; miscellaneous bone tumours; odontogenic tumours

9120/3 Haemangiosarcoma, angiosarcoma

9130/3 Haemangioendothelioma, malignant; Hemangioendothelial sarcoma

9133/3 Epithelioid haemangioendothelioma, malignant

9140/3 Kaposi sarcoma; Multiple haemorrhagic sarcoma

9150/3 Haemangiopericytoma, malignant

9170/3 Lymphangiosarcoma; lymphangioendothelial sarcoma; lymphangioendothelioma, malignant

9180/3 Osteosarcoma, NOS (C40._, C41._); osteogenic sarcoma, NOS (C40._, C41._); osteochondrosarcoma (C40._, C41._); osteoblastic sarcoma (C40._, C41._)

9181/3 Chondroblastic osteosarcoma (C40._, C41._)

9182/3 Fibroblastic osteosarcoma (C40._, C41._); osteofibrosarcoma (C40._, C41._)

9183/3 Telangiectatic osteosarcoma (C40._, C41._)

9184/3 Osteosarcoma in Paget's disease of bone (C40._, C41._)

9185/3 Small cell osteosarcoma (C40._, C41._)

9186/3 Central osteosarcoma (C40._, C41._); Conventional central osteosarcoma (C40._, C41._); Medullary osteosarcoma (C40._, C41._).

9187/3 Intraosseous well differentiated osteosarcoma (C40._, C41._); Intraosseous low grade osteosarcoma (C40._, C41._).

9192/3 Parosteal osteosarcoma (C40._, C41._); Juxtacortical osteosarcoma (C40._, C41._); juxtacortical osteogenic sarcoma (C40._, C41._);

9193/3 Periosteal sarcoma (C40._, C41._)

9194/3 High grade surface osteosarcoma (C40._, C41._)

9195/3 Intracortical osteosarcoma (C40._, C41._)

9220/3 Chondrosarcoma, NOS (C40._, C41._); fibrochondrosarcoma (C40._, C41._)

9221/3 Juxtacortical chondrosarcoma (C40._, C41._)

9230/3 Chondroblastoma, malignant (C40._, C41._)

9231/3 Myxoid chondrosarcoma

9240/3 Mesenchymal chondrosarcoma

9242/3 Clear cell chondrosarcoma, (C40._, C41._)

9243/3 Dedifferentiated chondrosarcoma (C40._, C41._)

9250/3 Giant cell tumour of bone, malignant (C40._, C41._); osteoclastoma, malignant (C40._, C41._); giant cell sarcoma of bone (C40._, C41._)

9251/3 Malignant giant cell tumour of soft parts

9252/3 Malignant tenosynovial giant cell tumour (C49._); giant cell tumour of tendon sheath, malignant (C49._).

9260/3 Ewing's sarcoma, Ewing's tumour

9261/3 Adamantinoma of long bones; tibial adamantinoma (C40.2)

Miscellaneous tumours

9020/3 Phyllodes tumour, malignant (C50._)

9364/3 Peripheral neuroectodermal tumour; neuroectodermal tumour, NOS

9365/3 Askin tumour

9370/3 Chordoma

9371/3 Chondroid chordoma

9372/3 Dedifferentiated chordoma

9473/3 Primitive neuroectodermal tumour

8980/3 Carcinosarcoma NOS (C61._)

Nerve sheath tumours, Granular cell tumours, Alveolar soft part sarcoma

9540/3 Malignant peripheral nerve sheath tumour MPNST, NOS; MPNST with glandular or mesenchymal differentiation; Epithelial MPNST

9560/3 Neurilemmoma, malignant; malignant schwannoma, NOS; neurilemmosarcoma


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9561/3

Malignant peripheral nerve sheath tumour with rhabdomyoblastic differentiation; Triton tumour, malignant; malignant schwannoma with rhabdomyoblastic differentiation

9758/3 Follicular dendritic cell sarcoma

9571/3 Perineurioma, malignant; Perineural MPNST

9580/3 Granular cell tumour, malignant; granular cell myoblastoma, malignant

9581/3 Alveolar soft part sarcoma

1111/1 Not assessable

8888/8 Negative Pathology

9999/9 Not recorded

1010/0 Not applicable

Related Data Items:


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Surgical Margins Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: Surgical margin in a pathology report defines the visible margin or free edge of "normal" tissue. Field Name: SURGMARG Field Type: Characters Field Length: 4 Notes for Users: Required for QPI: 4 This will be confirmed by microscopic examination and the result can be found on the

pathology report relating to the specimen from the final definitive (or only) surgery

performed as described elsewhere.

Where there is no residual disease after neo-adjuvant chemotherapy or radiotherapy, record as ‘8888’ ‘Not Assessable’. This is the final excision margin. If no distance is given or if a second procedure is carried out to achieve clear margins record as code ’R0’ if no residual disease Sometimes a measurement will be given which can be added to original margin of clearance but often it is only stated as “clear” in which case it should be recorded as Code R0. Code R0 confirms the margins are clear and would be compliant with previous QIS standard. If Surgical Margins are not clearly documented seek clarification from relevant Clinician. If the patient is not treated by surgery, code as 96 (inapplicable). Codes and Values: The distance is measured in millimetres. Code Value Explanatory Notes

R0 No residual disease Margins confirmed as clear

R1 Evidence of microscopic residual tumour Margins confirmed as NOT clear

R2 Evidence of macroscopic residual tumour

Margins confirmed as NOT clear

8888 Not assessable

96 Not applicable

99 Not recorded

Related Data Items:


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TNM Tumour Classification (Pathological) {Sarcoma}

Common name: Pathological TNM Tumour Classification (Sarcoma)

Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017).

Definition: A record of the size and extent of the tumour following resection of the primary cancer.

Field Name: pTSARC Field Type: Characters Field length: 4

Notes for Users: Required for national survival analysis and national comparative analysis

If stage is not documented in the pathology report do not deduce from other information and record as ‘not recorded’.

To adhere to the stage grouping in the TNM classification, recording the subdivision codes ‘a’ and ‘b’ in the codes and values table is recommended.

Pathology taken within 6 months of a patient initially refusing further investigation or whose initial treatment is ‘Watch and Wait’ can also be recorded.

Sarcomas that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96).

For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96). Within the table below the following sites are classified as bone sarcomas: Appendicular skeleton, trunk, skull and facial bones; Spine and Pelvis The following sites are classified as soft tissue sarcomas: Extremity and superficial trunk; Retroperitoneum; Head & Neck; Thoracic and Abdominal viscera.

Codes and Values:

Code Value

pTX Primary tumour cannot be assessed

pT0 No evidence of primary tumour

pT1 Appendicular skeleton, trunk, skull and facial bones: Tumour 8cm or less Spine: Tumour confined to single vertebral segment or two adjacent vertebral segments Extremity & superficial trunk / Retroperitoneum: Tumour 5cm or less Head & Neck: Tumour 2cm or less Thoracic & abdominal viscera: Tumour confined to a single organ GIST: Tumour 2cm or less

pT1a Pelvis: A tumour 8cm or less in size and confined to a single pelvic segment with no extraosseous extension

pT1b Pelvis: A tumour greater than 8cm in size and confined to a single pelvic segment with no extraosseous extension

pT2 Appendicular skeleton, trunk, skull and facial bones: Tumour more than 8cm Spine: Tumour confined to three adjacent vertebral segments Extremity & superficial trunk / Retroperitoneum: Tumour more than 5cm but no more


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than 10cm in greatest dimension Head & Neck: Tumour more than 2cm but no more than 4cm in greatest dimension GIST: Tumour more than 2cm but not more than 5cm

pT2a Pelvis: A tumour 8cm or less in size and confined to a single pelvic segment with extraosseous extension or confined to two adjacent pelvic segments without extraosseous extension Thoracic & abdominal viscera: Tumour invades serosa or visceral peritoneum

pT2b Pelvis: A tumour greater than 8cm in size and confined to a single pelvic segment with extraosseous extension or confined to two adjacent pelvic segments without extraosseous extension Thoracic & abdominal viscera: Tumour with microscopic extension beyond the serosa

pT3 Appendicular skeleton, trunk, skull and facial bones: Discontinuous tumours in primary bone site Spine: Tumour confined to four adjacent vertebral segments Extremity & superficial trunk / Retroperitoneum: Tumour more than 10cm but no more than 15 cm in greatest dimension Head & Neck: Tumour more than 4cm Thoracic & abdominal viscera: Tumour invades another organ or macroscopic extension beyond the serosa GIST: Tumour more than 5cm but not more than 10cm

pT3a Pelvis: A tumour 8cm or less in size and confined to two pelvic segments with extraosseous extension

pT3b Pelvis: A tumour greater than 8cm in size and confined to two pelvic segments with extraosseous extension

pT4 Extremity & superficial trunk / Retroperitoneum: Tumour more than 15cm GIST: Tumour more than 10cm

pT4a Spine: Tumour invades into the spinal canal Pelvis: Tumour involving three adjacent pelvic segments or crossing the sacroiliac joint to the sacral neuroforamen Head & Neck: Tumour invades the orbit, skull base or dura, central compartment viscera, facial skeleton, and or pterygoid muscles Thoracic & abdominal viscera: Multifocal tumour involving no more than two sites in one organ

pT4b Spine: Tumour invades the adjacent vessels or tumour thrombosis within the adjacent vessels Pelvis: Tumour encasing the external iliac vessels or gross tumour thrombus in major pelvic vessels Head & Neck: Tumour invades the brain parenchyma, encases the carotid artery, invades prevertebral muscle or involves the central nervous system by perineural spread Thoracic & abdominal viscera: Multifocal tumour involving more than two sites but not more than 5 sites

pT4c Thoracic & abdominal viscera: Multifocal tumour involving more than five sites

Related Data Items: TNM Nodal Classification (Pathological) {Sarcoma} TNM Metastases Classification (Pathological) {Sarcoma}


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TNM Nodal Classification (Pathological) {Sarcoma}

Common name: Pathological TNM Nodal Classification (Sarcoma). Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017). Definition: A record of the extent of metastatic spread of the tumour as detected by microscopy. Field Name: pNSARC Field Type: Characters Field length: 3 Notes for Users: Required for QPI(s): national survival analysis and national comparative analysis If stage is not documented in the pathology report do not deduce from other information and record as ‘not recorded’. Pathology taken within 6 months of a patient initially refusing further investigation or whose initial treatment is ‘Watch and Wait’ can also be recorded. Sarcomas that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96). For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96). Codes and Values:

Code Value Explanatory Notes pNx Regional lymph nodes cannot be assessed*

pN0 No regional lymph node metastasis.

pN1 Regional lymph node metastasis

96 Not applicable

99 Not recorded

*pNX: Regional lymph node involvement is rare for GISTs, so that cases in which the nodal status is not assessed clinically or pathologically could be considered pN0 instead of pNX.

Related Data Items: TNM Tumour Classification (Pathological) {Sarcoma} TNM Metastases Classification (Pathological) {Sarcoma}


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TNM Metastases Classification (Pathological) {Sarcoma} Common name: Pathological TNM Metastases Classification (Sarcoma). Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017).

Definition: The extent of metastatic spread of the tumour as detected by

microscopy.

Field Name: pMSARC Field Type: Characters Field length: 3 Notes for Users: Required for QPI(s): national survival analysis and national comparative analysis In cases where there are multiple tumours, the tumour with the worst TNM stage should be recorded. If stage is not documented in the pathology report do not deduce from other information and record as ‘not recorded’. Pathology taken within 6 months of a patient initially refusing further investigation or whose initial treatment is ‘Watch and Wait’ can also be recorded. Sarcomas that are diagnosed at surgery with no pre-treatment investigations should be recorded as not applicable (96). For gynaecological sarcomas, no TNM is required and should be recorded as not applicable (96).

Codes and Values:


pM1 Distant metastasis microscopically confirmed

96 Not applicable

99 Not recorded e.g. M status not assessed.

Note – pM0 and pMX are not valid categories

Related Data Items: TNM Tumour Classification (Pathological) {Sarcoma} TNM Nodal Classification (Pathological) {Sarcoma}


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TNM Histopathological Tumour Grade {Soft Tissue Sarcoma} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is the tumour grade for soft tissue sarcomas according to the official TNM Classification (TNM Classification of Malignant Tumours, Seventh Edition, UICC, 2009) following resection of the primary tumour Field Name: TUMGRADE Field Type: Characters Field length: 2 Notes for Users: Should be documented, if not check with pathologist Codes and Values:


GX Grade cannot be assessed

G1 Low grade - well differentiated

G2 Intermediate grade – moderately differentiated

G3 High grade – poorly differentiated

93 Not assessable

96 Not applicable No pathological assessment

99 Not recorded



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Gastrointestinal Stromal Tumour (GIST) Risk Score Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: Scheme used for predicting the risk of recurrence or metastasis of a surgically resected primary GIST. Field Name: GISTRISK Field Type: Integer Field length: 2 Notes for Users: Required for QPI(s): 5, 10 Risk of Progressive Disease (Gastric) (from Miettinen M, Lasota J. Semin Diagn Pathol 2006;23:70–83. This is included in the Royal College of Pathologists Dataset for Gastrointestinal Stromal Tumours (GISTs). If the risk score is not documented, or there are any inconsistencies the score should not be calculated and the relevant pathologist should be contacted for clarification. Codes and Values:


15 None

16 Very Low

17 Low

18 Moderate

19 Insufficient Data

20 High

96 Not applicable Not gastrointestinal stromal tumour

99 Not known Includes not recorded



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Mutational Analysis (GIST) Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: Denotes if a patient diagnosed with gastrointestinal stromal tumour has had mutational analysis carried out. Field Name: MUTANALYSIS Field Type: Integer Field length: 2 Notes for Users: Required for QPI: 5 Mutational analysis of confirmed gastrointestinal stromal tumour (GIST) may be needed to confirm an uncertain diagnosis, to choose the appropriate drug dose, to give additional prognostic information, or to predict response to a specific drug.

Mutational analysis is not routinely performed for low risk GIST, however if performed this should be recorded. The date recorded is the date the procedure was performed, not the date the report was issued. Codes and Values:


01 Yes

02 No

04 Insufficient sample

94 Patient died before analysis

96 Not applicable E.g. Not GIST

99 Not recorded

Related Data Item(s): Data of Mutational Analysis (GIST)


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Date of Mutational Analysis (GIST) Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The date on which the patient diagnosed with gastrointestinal stromal tumour has had mutational analysis carried out. Field Name: DMUTANALYSIS Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 5 Mutational analysis of confirmed gastrointestinal stromal tumour (GIST) may be needed to confirm an uncertain diagnosis, to choose the appropriate drug dose, to give additional prognostic information, or to predict response to a specific drug. The date recorded is the date the procedure was performed, not the date the report was issued. If the exact date is not documented, record as 09/09/1900 (Not recorded). If the patient did not have mutational analysis, use the code 10/10/1900 (Not applicable). Mutational Analysis is carried out in Dundee Related Data Item(s): Mutational Analysis (GIST)


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Section 5: Oncology


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Radiotherapy Course Type {Sarcoma} 1-3 Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The type of course of external beam radiotherapy administered for the treatment of the cancer. Field Name: RCOURSETYPE1 RCOURSETYPE2 RCOURSETYPE3 Field Type: Integer Field length: 2 Notes for Users: Required for QPI(s): 8, 11 Combined treatments may be administered concurrently/synchronously e.g. chemotherapy and radiotherapy, intra-operative radiotherapy. For patients undergoing chemoradiotherapy the radiotherapy element should be recorded as code 06. The Chemotherapy element of this combined treatment should be recorded separately in fields CHEMTYPE1, CHEMTYPE2 or CHEMTYPE3 All treatments given as part of the initial treatment plan

Codes and Values: Code Value Explanatory Notes

01 Adjuvant It is given after potentially curative surgery. .

03 Palliative The aim is solely to relieve symptoms.

04 Neo-adjuvant It is given before potentially curative surgery.

05 Radical It is primary treatment and is given with curative intent.

06 Chemoradiotherapy Radical radiotherapy given in combination with chemotherapy, either concurrently or sequentially.

94 Patient died before radiotherapy treatment

95 Patient refused radiotherapy treatment

96 Not applicable e.g. no radiotherapy given.

99 Not recorded

Related Data Items: Date Treatment Started (Radiotherapy) {Sarcoma} 1-3 Date Treatment Completed (Radiotherapy) {Sarcoma} 1-3


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Date Treatment Started (Radiotherapy) {Sarcoma} 1-3 Main Source of Data Item Standard: The National Audit Cancer Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The date cancer treatment course commenced. Field Name: RSTARTDATE1 RSTARTDATE2 RSTARTDATE3 Field Type: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for QPI(s): 3, 8, 9 This is the first fraction of a course of radiotherapy. Up to three courses may be recorded For the purposes of national audit, only radiotherapy given as part of the primary treatment plan should be recorded. Palliative radiotherapy to other (metastatic) sites is only recorded if part of the initial treatment plan. If the date radiotherapy started is unknown, record as 09/09/1900 (Not recorded). If radiotherapy has not been given or the patient has refused radiotherapy, record as 10/10/1900 (not applicable). Related Data Items: Radiotherapy Course Type {Sarcoma}



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Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services Definition: The date cancer treatment course ended. Field Name: RCOMPDATE1 RCOMPDATE2 RCOMPDATE3 Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 11 This is the last fraction of a course of radiotherapy. It should be noted this can be the same day as the day the therapy started. If the date treatment completed is unknown, record as 09/09/1900 (Not recorded). If treatment has not been given, record as 10/10/1900 (not applicable). Related Data Item(s): Date Treatment Started (Radiotherapy) {Sarcoma} 1-3 Radiotherapy Course Type {Sarcoma}


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Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The type of course of cytotoxic or biological drugs administered for the treatment of the cancer. Cytotoxic drugs are drugs which destroy cells. Field Name: CHEMTYPE1 CHEMTYPE2 CHEMTYPE3 Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 11 Patients may have ongoing systemic therapy both before and after surgery. These patients should be recorded under neo-adjuvant Type. Some patients may have separate completion chemotherapy post-operatively. This may be recorded as two courses neo-adjuvant and adjuvant. For patients undergoing chemoradiotherapy the chemotherapy element should be recorded as code 08 and recorded in Radiotherapy Course Type [RCOURSETYPE1, RCOURSETYPE2 and RCOURSETYPE3]. Systemic therapy must be treatment received for initial management and not treatment for recurrence or relapse. Codes and Values:


01 Neoadjuvant Therapy given prior to radiotherapy or first definitive surgery to reduce tumour size.

02 Adjuvant

04 Palliative Systemic therapy given for symptom control without curative intent e.g. for patients with metastatic disease at time of diagnosis.

07 Biological Therapy

08 Chemoradiotherapy Chemotherapy given in combination with radical radiotherapy, either concurrently or sequentially.

94 Patient died before SACT treatment

i.e. Patient who died before receiving planned SACT treatment

95 Patient refused SACT treatment

96 Not applicable e.g. Systemic therapy not given as primary part of therapy.

99 Not recorded

Related Data Items: Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3 Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3


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Multi-agent Chemotherapy {Sarcoma} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: A record of whether the patient received multi-agent chemotherapy used to treat sarcoma. Field Name: MULTAGENT Field Type: Integer Field length: 2 Notes for Users: Required for QPI: 9 Multi-agent chemotherapy is where more two or more systemic therapy agents are administered simultaneously or within a few days. This field should only be used to record multi-agent chemotherapy which is given as first line treatment to patients with sarcoma. Chemotherapy drugs can be given in or outwith the context of a clinical trial. Codes and Values:


01 Yes

02 No

96 Not applicable

99 Not recorded


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Biological Therapy Agent {Sarcoma}

Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services.

Definition: The type of biological agent administered for the treatment of cancer. Field Name: BIOAGENT Field Type: Integer Field length: 2 Notes for Users: Required for QPI(s): 10, 11 Biological therapy must be treatment received for initial management and not treatment for recurrence or relapse. Biological therapy given directly after adjuvant therapy is still regarded as primary treatment. If biological therapy was not given as part of the primary treatment, code as ’96’ Not Applicable. The biological agent can be given in or out-with the context of a clinical trial. Codes and values:


01 Imatinib Glivec

02 Sunitinib Sutent

08 Other


i.e. Patient who died before receiving planned biological treatment

95 Patient refused treatment

96 Not applicable e.g. Biological therapy not given as primary part of therapy.

99 Not recorded

Related data items: Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Sarcoma} 1-3


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Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The date cancer treatment course commenced. Field Name: CHEMDATE1 CHEMDATE2 CHEMDATE3 Field Type: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for QPI(s): 3, 9, 10 This is the first dose of the first cycle of a course of chemotherapy or biological therapy. If the date SACT started is unknown, record as 09/09/1900 (Not recorded). If SACT has not been given or the patient has refused SACT, record as 10/10/1900 (not applicable).


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Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services.

Definition: The date systemic anti-cancer therapy course ended. Field Name: CHEMENDATE1 CHEMENDATE2 CHEMENDATE3 Field Type: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for QPI: 9 This is the first day of the last cycle of a course of chemotherapy. It should be noted this can be the same day as the day the therapy started. If the date treatment started is unknown, record as 09/09/1900 (Not recorded). If SACT has not been given or the patient has refused SACT, record as 10/10/1900 (Not applicable).


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Section 6: Clinical Trials


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Patient Entered into Clinical Trial Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: An indication of whether or not the patient received treatment within the context of a clinical trial.

Field Name: TRIAL Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 10 This relates only to participation in clinical trials which may be national or international multi-centred trials. The majority of non-commercial multi-centred trials available in Scotland are NCRN badged or equivalent. Some academic and university units may have ongoing local trials which should not be included here. These can be recorded on local trials databases. Codes and Values: Code Value

01 Yes

02 No

99 Not recorded

Related Data Items:


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Section 7: Death Details


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Date of Death

Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is the certified date of death as recorded by the General Register Office (Scotland) (GRO(S)). Field Name: DOD Field Type: Date (DD/MM/CCYY). Field Length: 10 Notes for Users: Required for QPI(s): 2, 11 If the exact date is not documented, record as 09/09/1900 (Not recorded). If the patient is alive use the code 10/10/1900 (Not applicable). Related Data Items:

sarcoma - isdscotland.org · type of first cancer treatment - required for qpi(s) add ‘6, 9’;...

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