Lung Cancer Pathology Data Standards

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1 For reference only Do Not Use For more information contact: Lung Cancer Pathology Data Standards June 2008 National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 74A Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: to: Website: Lung Cancer Pathology Data Standards

2 Section 1 - Overview & Background... 1 Overview... 1 Lung Cancer Pathology Data Standards... 2 Background to NCDDP... 2 Generic Data Items... 3 Clinical Terminology... 3 Date Recording... 3 Published Data Standards... 6 Generic and Previously Consulted Section 2. - Lung Cancer Pathology Data Standards Distance from Bronchial or Medial Excision Margin (Lung Cancer) Extent of Atelectasis (Lung Cancer) Extent of Local Invasion (Lung Cancer) Submission of Lymph Nodes Lymph Nodes Group (Lung Cancer) Involvement (Cancer) Resection Margins (Lung Cancer) Emphysema Present Degree of Emphysema Diffuse Parenchymal Lung Disease Present Diffuse Parenchymal Lung Disease: Pattern of Disease Present Aetiology of Diffuse Parenchymal Lung Disease TNM Tumour Classification (Pathological) (Non-small Cell Carcinoma of Lung) TNM Nodal Classification (Pathological) (Non-small Cell Carcinoma of Lung) TNM Metastases Classification (Pathological) (Non-small Cell Carcinoma of Lung) Grade of Differentiation (Lung Cancer) Pre-Invasive Lung Lesions (Lung Cancer)...19 Lung Cancer Pathology Data Standards

3 Section 3. - Pleural Mesothelioma Pathology Data Standards TNM Tumour Classification (Pathological) (Pleural Mesothelioma) TNM Nodal Classification (Pathological) (Pleural Mesothelioma) TNM Metastases Classification (Pathological) (Pleural Mesothelioma) Histological Diagnosis (Pleural Mesothelioma)...22 Appendix 1 - Working Group Membership Appendix 2 Consultation Distribution List Lung Cancer Pathology Data Standards

4 Section 1 - Overview & Background Overview The Scottish Cancer Group supports the development of Lung Cancer Pathology Data Standards for NHS Scotland in order to ensure a national approach to the collection of pathological data items relating to cancer. The aim is to ensure intercompatibility of national clinical information systems, and support the implementation of an electronic integrated health record. Cancer already has a range of individual national data sets for audit, screening and registration and these standards build on these systems. National data standards will support data sharing and allow secondary use of data for these purposes. A multi-disciplinary Clinical Working Group, established in August 2006 and supported by the National Clinical Dataset Development Programme (NCDDP) Support Team in Information Services Division (ISD), carried out the development of these cancer data standards. The Lung Cancer Pathology Data Standards will: Define common data items recommended for collection in a wide variety of clinical settings Support the exchange of patient information between healthcare providers Support the consistent recording of patient information throughout NHS Scotland It is important to emphasise that these are data standards rather than a dataset. This means that the individual data items included in this document are not required to be recorded together in a single clinical information system. However where it is considered appropriate to record a particular data item as part of the record of care, the information should be recorded in accordance with the nationally agreed standard. Some background information on the NCDDP and Lung Cancer Pathology Data Standard development can be found below. If you have any further queries, please go to our website or contact Lung Cancer Pathology Data Standards 1

5 1. Lung Cancer Pathology Data Standards The membership of the Cancer Pathology Data Standards Clinical Working Group is shown in appendix 1. This group agreed the inclusion of individual data items using the following criteria: 1. Is the data item one that would reasonably be expected to be collected for all lung cancer pathology? 2. Is the data item necessary for the healthcare of cancer patients? 3. Is the data item one that is likely to be shared among health care professionals? Once consultation is complete the Lung Cancer Pathology Data Standards will be submitted to the NCDDP Programme Board for formal approval as a national standard, and then passed to the ehealth National Clinical Information Steering Group and the NHS Scotland Information Standards Group for endorsement. Once approved the Lung Cancer Pathology Data Standards will be freely and widely available through publication in the Health and Social Care Data Dictionary (www.datadictionary.scot.nhs.uk). As far as possible they are UK compatible. It is expected that the Lung Cancer Pathology Data Standards will be implemented within existing and emerging national clinical information systems and commercially procured national products, as well as being available to commercial developers to ensure the ability of their systems to support national information requirements. Background to NCDDP The National Clinical Dataset Development Programme (NCDDP) supports clinicians to develop sets of interoperable national datasets to facilitate the implementation of the integrated care records across NHS Scotland. These standards will: Support direct patient care, by reflecting current best practice guidance Facilitate effective communication between health care professionals Improve data quality and support secondary data requirements where possible including data to support clinical governance Be freely and widely available through publication in the web based Health & Social Care Data Dictionary Incorporate agreed national clinical definitions and implement national terminology Be UK compatible where possible The programme was established by the Chief Medical Officer in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-health Strategy. More information can be found on our website. Lung Cancer Pathology Data Standards 2

6 Generic Data Items Data standards which are relevant to all patients and are used across specialties, disciplines and settings have already been developed by wider Generic Data Standards clinical working groups and approved as national data standards for NHS Scotland. The Cancer Pathology Core Data Standards working group selected several generic data items for inclusion in their standards. These data items names and definitions are listed in this document for information. The detail of these existing standards are available on the web based Health and Social Care Data Dictionary. Clinical Terminology The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that clinical information systems will record clinical data using this international standard. It is intended that the NCDDP Support Team will develop recommended SNOMED CT specifications as part of the data standards and datasets it supports. Date Recording It is good record-keeping practice always to identify the date of recording of any clinical information. It is expected that all clinical information systems should include date stamping as standard functionality, therefore the Lung Cancer Pathology Data Standards do not deal with this issue. In many clinical situations, the date of an event, investigation, etc. is required for clinical purposes and should be visible to the health care professional. This date may not be the same as the date on which the data are entered onto the system. In these instances the system must allow the health care professional to enter whichever date is appropriate. These issues must be addressed during system specification and development. The Cancer Generic Data Standards do not include standards for recording dates, though the date format for storage and management within a system should conform to the Government Data Standards Catalogue format: CCYY-MM-DD. However, this does not preclude entry or display of data on the user interface using the traditional DD-MM-CCYY format. Lung Cancer Pathology Data Standards 3

7 Lung Cancer Pathology Data Standards The membership of the Cancer Pathology Data Standards Clinical Working Group is shown in appendix 1. This group agreed the inclusion of individual data items using the following criteria: 4. Is the data item one that would reasonably be expected to be collected for all lung cancer pathology? 5. Is the data item necessary for the healthcare of cancer patients? 6. Is the data item one that is likely to be shared among health care professionals? Once consultation is complete the Lung Cancer Pathology Data Standards will be submitted to the NCDDP Programme Board for formal approval as a national standard, and then passed to the ehealth National Clinical Information Steering Group and the NHS Scotland Information Standards Group for endorsement. Once approved the Lung Cancer Pathology Data Standards will be freely and widely available through publication in the Health and Social Care Data Dictionary (www.datadictionary.scot.nhs.uk). As far as possible they are UK compatible. It is expected that the Lung Cancer Pathology Data Standards will be implemented within existing and emerging national clinical information systems and commercially procured national products, as well as being available to commercial developers to ensure the ability of their systems to support national information requirements. Background to NCDDP The National Clinical Dataset Development Programme (NCDDP) supports clinicians to develop sets of interoperable national datasets to facilitate the implementation of the integrated care records across NHS Scotland. These standards will: Support direct patient care, by reflecting current best practice guidance Facilitate effective communication between health care professionals Improve data quality and support secondary data requirements where possible including data to support clinical governance Be freely and widely available through publication in the web based Health & Social Care Data Dictionary Incorporate agreed national clinical definitions and implement national terminology Be UK compatible where possible The programme was established by the Chief Medical Officer in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-health Strategy. More information can be found on our website. Lung Cancer Pathology Data Standards 4

8 Generic Data Items Data standards which are relevant to all patients and are used across specialties, disciplines and settings have already been developed by wider Generic Data Standards clinical working groups and approved as national data standards for NHS Scotland. The Cancer Pathology Core Data Standards working group selected several generic data items for inclusion in their standards. These data items names and definitions are listed in this document for information. The detail of these existing standards are available on the web based Health and Social Care Data Dictionary. Clinical Terminology The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that clinical information systems will record clinical data using this international standard. It is intended that the NCDDP Support Team will develop recommended SNOMED CT specifications as part of the data standards and datasets it supports. Date Recording It is good record-keeping practice always to identify the date of recording of any clinical information. It is expected that all clinical information systems should include date stamping as standard functionality, therefore the Lung Cancer Pathology Data Standards do not deal with this issue. In many clinical situations, the date of an event, investigation, etc. is required for clinical purposes and should be visible to the health care professional. This date may not be the same as the date on which the data are entered onto the system. In these instances the system must allow the health care professional to enter whichever date is appropriate. These issues must be addressed during system specification and development. The Cancer Generic Data Standards do not include standards for recording dates, though the date format for storage and management within a system should conform to the Government Data Standards Catalogue format: CCYY-MM-DD. However, this does not preclude entry or display of data on the user interface using the traditional DD-MM-CCYY format. Lung Cancer Pathology Data Standards 5

9 Published Data Standards Generic and Previously Consulted 1 Generic Data Items Person Family Name Person Given Name Person Birth Date Person Sex at Birth Location Code Health Record Identifier CHI Number Associated Professional - Identifier - Group - Role Cancer Generic Data Items Date Histo/Cytopathological specimen taken Histo/Cytopathology report number Histo/Cytopathology investigation report date Site of Origin of Primary tumour Tumour Type (Morphology of Tumour) (Cancer) Most Valid Basis of Diagnosis Previously Treated for Cancer Cancer Pathology Generic Data Items Maximum Macroscopic Tumour Diameter (Cancer) Maximum Microscopic Tumour Diameter (Cancer) Distance to Nearest Margin (Cancer) Definition That part of a person s name which is used to describe family, clan, tribal group or marital association. The forename or given name of a person. The date of which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate. This is a factual statement, as far as is known, about the phenotypic (biological) sex of the person at birth. 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 patients/clients home. A patient Health Record Identifier is a code (set of characters) used to uniquely identify a patient within a health register or a health records system e.g. PAS. 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. Associated Professionals are those individuals who are involved with the client/ patient in a professional capacity e.g. consultant, social worker, occupational therapist etc. Definition This is the date the histo/ cytopathological specimen was taken. The reference number of the histo/cytopathology specimen. The date that the result of the specimen was reported by the pathology laboratory. The anatomical site of origin of the primary tumour according to the International Classification of Diseases for Oncology (ICD-O(3)). The morphology of the tumour according to the International Classification of Diseases for Oncology (ICD-O(3)). The best evidence in support of the diagnosis of cancer. A record of whether or not the patient has had treatment for the management of a previous cancer. Definition The macroscopic size of the tumour as measured in millimetres (mm). The microscopic size of the tumour as measured in millimetres (mm). An indicator of whether all the excision margins were clear of tumour i.e. that there was complete resection of the tumour at all margins. Distance to Deep Margin Synchronous Tumour Indicator (Cancer) This denotes the distance of the tumour from the deep margin in millimetres (mm). A record of the presence of multiple tumours at the same time. 1 All data items in the table above are existing nationally approved data standards, which can be found in the Health and Social care Data Dictionary. Lung Cancer Pathology Data Standards 6

10 Section 2. - Lung Cancer Pathology Data Standards 2.1 Distance from Bronchial or Medial Excision Margin (Lung Cancer) Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: The distance in millimetres of the invasive carcinoma from the bronchial or medial resection margin. Format: Numeric Field length: 3 Sub-data items: Status Code Value 96 Not applicable 2.2 Extent of Atelectasis (Lung Cancer) Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: The presence and extent of atelectasis /obstructive pneumonitis. Code Value Explanatory Notes 00 No significant atelectasis None or less than 2 categories below 01 Involving Hilar Region but not Whole Lung T2 02 Involving Whole Lung T3 03 Not assessable Further information: Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles), or by very shallow breathing. Lung Cancer Pathology Data Standards 7

11 2.3 Extent of Local Invasion (Lung Cancer) Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: A record of the extent of local invasion. Field length: 3 Codes Value Subcode Sub-value 00 None 01 Visceral Pleura Breach of superficial elastic layer of pleura. 02 Parietal Pleura / Chest Wall 03 Mediastinal Pleura 04 Pericardium 05 Diaphragm 06 Great Vessel 07 Atrium, Heart 08 Malignant Pleural Effusion 09 Separate Tumour Nodules in Same Lobe 96 Not applicable 98 Other (specify) A B C D E Aorta Central Pulmonary Artery Central Pulmonary Vein Superior Vena Cava Inferior Vena Cava Recording guidance: IT systems should allow for multiple recording of this item. Explanatory Notes Users may wish to augment code 98 Other specify with a free text field for recording this item. Lung Cancer Pathology Data Standards 8

12 2.4 Submission of Lymph Nodes Main source of standard: The Royal College of Pathologists, Standards and Datasets for Reporting Cancers. Definition: A record of whether or not lymph nodes were submitted for pathological examination. Code Value 00 Not Submitted 01 Submitted 96 Not applicable Recording guidance: IT systems should allow for multiple recording of this item. Lung Cancer Pathology Data Standards 9

13 2.5 Lymph Nodes Group (Lung Cancer) Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: The anatomical groups of lymph nodes. Code Description Explanatory notes 01 Intrapulmonary Lymph Nodes Node stations Ipsilateral Hilar Lymph Nodes Node station Ipsilateral Mediastinal Lymph Nodes Node stations Contralateral Mediastinal, Hilar Lymph Nodes 05 Ipsilateral or Contralateral Scalene or Supraclavicular Lymph Nodes 96 Not applicable e.g No nodes sampled. Attributes: Laterality: Right, Left, Bilateral, Midline Related data items: Submission of Lymph Nodes Involvement (Cancer) Recording guidance: Each type of lymph node selected from the list should also have the laterality, the submission of lymph nodes and involvement recorded. IT systems should allow for multiple recording of this item. Lung Cancer Pathology Data Standards 10

14 2.6 Involvement (Cancer) Main source of standard: The Royal College of Pathologists, Standards and Datasets for Reporting Cancers. Definition: The involvement of an organ or tissue with cancer. Code Value 00 Not Involved 01 Involved 02 Not assessable 96 Not applicable Recording guidance: IT systems should allow for multiple recording of this item. Lung Cancer Pathology Data Standards 11

15 2.7 Resection Margins (Lung Cancer) Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: The resection margins in patients with lung cancer. Code Value 01 Bronchial Margin 02 Mediastinal Margin 03 Vascular Margin 04 Chest Wall Margin 05 Diaphragmatic margin 96 Not applicable Attributes: Laterality: Right, Left, Bilateral, Midline Related data item: Involvement (Cancer) Recording guidance: Each type of margin recorded should also have the laterality and involvement recorded. IT systems should allow for multiple recording of this item. 2.8 Emphysema Present Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: An indication of the presence of emphysema. Code Value Explanatory Notes 00 Not present 01 Present 96 Not applicable e.g Not sampled. Lung Cancer Pathology Data Standards 12

16 2.9 Degree of Emphysema Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: A record of the degree of emphysema. Code Value Explanatory Notes 01 Mild 02 Moderate 03 Severe 96 Not applicable e.g Not sampled Diffuse Parenchymal Lung Disease Present Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: An indication of the presence of diffuse lung disease (other than emphysema). Code Value Explanatory Notes 00 Not present 01 Present 96 Not applicable e.g Not sampled. Lung Cancer Pathology Data Standards 13

17 2.11 Diffuse Parenchymal Lung Disease: Pattern of Disease Present Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: A record of the pattern of disease present. Code Value Explanatory Notes 01 Non-specific Interstitial Pneumonia 02 Usual Interstitial Pneumonia 03 Respiratory Bronchiolitis 04 Granulomatous Disease 96 Not applicable 98 Other (specify) Related data item: Diffuse Lung Disease Recording guidance: This item may occur more than once throughout a patient s record. Users may wish to augment code 98 Other specify with a free text field for recording this item. Lung Cancer Pathology Data Standards 14

18 2.12 Aetiology of Diffuse Parenchymal Lung Disease Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September 2007 and American Lung Association, Definition: A record of the cause of diffuse lung disease. Field length: 3 Code Value Subcode 01 Occupational/Environ mental exposure Sub-value Explanatory Notes Workers such as miners exposed to asbestos or metal dusts that can damage the lungs, especially the small airways and air sacs, and cause scarring (fibrosis). Agricultural workers also can be affected by some organic substances, such as mouldy hay, and other fumes found on farms. A Hypersensitivity Pneumonitis e.g. Farmer s lung B Asbestosis C Silicosis D E Coal Worker s Pneumoconiosis Effects of tobacco smoke (other than emphysema) Z Other (specify) 02 Sarcoidosis 03 Chemo/Radiotherapy e.g. treatment for breast cancer 04 Features suggestive of underlying connective tissue disease 98 Other (specify) 96 Not applicable e.g. Not sampled. Related data item: Diffuse Lung Disease Diffuse Lung Disease: Pattern of Disease Present Further information: Sub values are not applicable for pathological use. Recording guidance: Users may wish to augment code 98 Other specify with a free text field for recording this item. e.g. Respiratory bronchiolitis-associated interstitial lung disease (RBILD), Desquamative interstitial lung disease (DIP). Lung Cancer Pathology Data Standards 15

19 2.13 TNM Tumour Classification (Pathological) (Non-small Cell Carcinoma of Lung) Common name: Pathological TNM Tumour stage (Lung Cancer) Main source of standard: TNM Classification (TNM Classification of Malignant Tumours, Sixth Edition, UICC, 2002). Definition: A record of the size and extent of the tumour of the lung following resection of the primary cancer. Code Value Explanatory Notes 00 TNM Classification pt0 No evidence of primary tumour 01 TNM Classification ptis Carcinoma in situ (CIS) 02 TNM Classification pt1 Tumour up to 3cm, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e. not the main bronchus). 03 TNM Classification pt2 Tumour with any of the of the following: Tumour >3 cm Involves main bronchus, 2cm or more distal to the carina Invades visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung. 04 TNM Classification pt3 Tumour of any size that directly invades any of the following: chest wall (including superior sulcus tumours), diaphragm, mediastinal pleura, parietal pericardium; or tumour in the main bronchus < 2cm distal to the carina, (The uncommon superficial spreading tumour of any size with its invasive component limited to the bronchial wall, which may extend proximal to the main bronchus, is also classified as T1) but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung. 05 TNM Classification pt4 Tumour of any size that invades any of the following: Mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina; separate tumour nodule(s) in the same lobe; tumour with malignant pleural effusion. Most pleural effusions with lung cancer are due to tumour. In a few patients, however, multiple cytopathological examinations of pleural fluid are negative for tumour, and the fluid is non-bloody and is not an exudate. Where these elements and clinical judgement dictate that the effusion is not related to the tumour, the effusion should be excluded as a staging element and the patient should be classified as T1, T2 or T3. 06 TNM Classification ptx Primary tumour cannot be assessed Lung Cancer Pathology Data Standards 16

20 Related data items: TNM Nodal Classification (Pathological) (Lung Cancer) TNM Metastases Classification (Pathological) (Lung Cancer) 2.14 TNM Nodal Classification (Pathological) (Non-small Cell Carcinoma of Lung) Common name: Pathological TNM Nodal stage (Lung Cancer) Main source of standard: TNM Classification (TNM Classification of Malignant Tumours, Sixth Edition, UICC, 2002) Definition: A record of the extent of regional lymph node metastases. Code Value Explanatory Notes 00 TNM Classification pn0 No regional lymph nodes metastasis. 01 TNM Classification pn1 Metastases in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension. (Node stations 10-14). 02 TNM Classification pn2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s). (Node stations 1-9). 03 TNM Classification pn3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s). 04 TNM Classification pnx Regional lymph nodes cannot be assessed (e.g. previously removed). Related Data items: TNM Tumour Classification (Pathological) (Lung Cancer) TNM Metastases Classification (Pathological) (Lung Cancer) Lymph Nodes Type Submitted (Lung Cancer) Lymph Nodes Type Involved (Lung Cancer) Lung Cancer Pathology Data Standards 17

21 2.15 TNM Metastases Classification (Pathological) (Non-small Cell Carcinoma of Lung) Common name: Pathological TNM Metastases Classification (Lung Cancer) Main source of standard: TNM Classification (TNM Classification of Malignant Tumours, Sixth Edition, UICC, 2002) Definition: A record of the extent of metastatic spread of the tumour as detected by microscopy. Code Value Explanatory Notes 00 TNM Classification pm0 No distant metastases. 01 TNM Classification pm1 Distant metastases present, includes separate tumour nodule(s) in a different lobe (ipsilateral or contralateral). 02 TNM Classification pmx Presence of distant metastases cannot be assessed. Related data items: TNM Nodal Classification (Pathological) (Lung Cancer) TNM Tumour Classification (Pathological) (Lung Cancer) 2.16 Grade of Differentiation (Lung Cancer) Main source of standard: TNM Classification (TNM Classification of Malignant Tumours, Sixth Edition, UICC, 2002) Definition: A description of how closely the tumour resembles normal morphology. Code Value Explanatory Notes 01 Grade I Well Differentiated, (Differentiated NOS) 02 Grade II Moderately Differentiated, (Intermediate Differentiation), (Moderately Well Differentiated). 03 Grade III Poorly Differentiated 04 Grade IV Undifferentiated, (Anaplastic) 05 Not assessable 96 Not applicable Attributes: Classification: Lung Cancer Pathology Data Standards 18

22 UICC Recording guidance: If the description of the tumour overlaps categories e.g. poor to moderate, record the worst mentioned grade i.e. poorly differentiated. In specimens with a tumour comprising both invasive and non-invasive components record the grade for the invasive part Pre-Invasive Lung Lesions (Lung Cancer) Main source of standard: The Royal College of Pathologists, Dataset for Lung Cancer Histopathology Reports (2 nd edition), September Definition: An indication of the type of pre-invasive lesions present. Field length: 3 Code Value Subcode 00 None 01 Squamous Metaplasia 02 Squamous Dysplasia 03 Squamous carcinoma in-situ 04 Hyperplasia A 05 Not assessable 96 Not applicable Attributes: Severity Mild Moderate Severe B Sub-value Atypical Adenomatous Neuroendocrine Cell Explanatory Notes Recording guidance: IT systems should allow for multiple recording of this item. Lung Cancer Pathology Data Standards 19

23 Section 3. - Pleural Mesothelioma Pathology Data Standards 3.1 TNM Tumour Classification (Pathological) (Pleural Mesothelioma) Common name: Pathological TNM Tumour stage (Pleural Mesothelioma) Main source of standard: TNM Classification (TNM Classification of Malignant Tumours, Sixth Edition, UICC, 2002). Definition: A record of the size and extent of the tumour of the lung following resection of the primary cancer. Field length: 3 Code Value Subcodvalue Sub- Explanatory Notes 00 TNM Classification pt0 No evidence of primary tumour 01 TNM Classification pt1 Tumour involves parietal pleura, with or without focal involvement of visceral pleura. 02 TNM Classification pt2 03 TNM Classification pt3* A pt1a Tumour involves ipsilateral parietal (mediastinal, diaphragmatic) pleura. No involvement of visceral pleura. B pt1b Tumour involves ipsilateral parietal (mediastinal, diaphragmatic) pleura, with focal involvement of the visceral pleura. Tumour involves any ipsilateral pleural surfaces, with at least one of the following: Confluent visceral pleural tumour (including the fissure) Invasion of diaphragmatic muscle Invasion of lung parenchyma. Tumour involves any ipsilateral pleural surfaces, with at least one of the following: Invasion of endothoracic fascia Invasion into mediastinal fat Solitary focus of tumour invading soft tissues of the chest wall Non-transmural involvement of the pericardium. Lung Cancer Pathology Data Standards 20

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