IG:HL7 diagnosis

Representation of Diagnosis based on the Clinical Document Architecture Rel.2 for Healthcare in Germany

Version 1.1

Representation of Cancer Diagnosis

Introduction

In this chapter, diagnostic aspects in documentation of tumor diseases will be discribed. Different aspects of diagnostical discriptions of tumor diseases are discribed by ICD-O (Oncology) and by further classifications to constitute the determination of expansion respectivly of the diseases stage.

Last one is mostly classified by the TNM-System.

Especially for hemato oncological diseases (Leukemias and Lymphomas), other systems (e.g. Ann-Arbor-Classification) are used. TNM-System discribes:

• Expansion of primary tumor (extent repectivly spread in distant organs)
• Affection of lymph nodes in lymph flow area
• Exisistence of distant metastasis.

For not by TNM – System classifiable diseases or in addition to TNM-System there are a number of further classification systems:

• Ann Arbor
• Rai
• Binet
• CML-Phasen
• FAB
• Durie and Salmon
• Gleason-Score

Discriptions can be found here: http://www.med.uni-giessen.de/akkk/gtds/grafisch/doku/bd5f.htm http://www.tumorzentren.de/tl_files/dokumente/adt_basis.pdf

This list probably will be always incomplete because of the medical progress.

ICD-O

Third Edition of ICD-O [DIMDI, WHO] is the topical one. ICD-O consists of two axes, Topography- and Morphology-Axis. In ICD-O, tumor can be classified by

• Site
• Tissue Structure (Histology)
• Biological behaviour (Dignity)
• Tissue grading (mostly in two or four stages)

In this case, tissue structure and tissue grading is redundant. Precisely: The first four digits of morphology-code describe tissue-type. The fifth one describes biological behaviour (dignity-code):

• /0 = benign
• /1 = neoplasm with uncertain or unknown behaviour
• /2 = Cancer in situ
• /3 = malignant, primary tumor
• /6 = malignant, metastasis (not used in tumor documentation)
• /9 = malignant, uncertain wether primary tumor or a metastatic

The sixth digit describes grading, differentiation or phenotype (Histology/Pathology):

• 1 = Grade I, well differentiated (Low grade)
• 2 = Grade II, moderately differentiated (Intermediate grade)
• 3 = Grade III, poorly differentiated (High grade)
• 4 = Grade IV, undifferentiated (High grade)
• 9 = Grade IX, grade cannot be assessed

For Leukemias and Lymphomas, the sixth digit signifies the immunophenotype

• 5 = T-Cell
• 6 = B-Cell, Pre-B-Cell, B-Ancestor-Cell
• 7 = Null-Cell, Not-T-Cell-Not-B-Cell
• 8 = NK-Cell, Natural Killer Cell
• 9 = Determination of Cell Type was not accomplished, not specified or not applicable

TNM System describes

• Expansion of primary tumor (extent repectivly spread in distant organs)
• Affection of lymph nodes in lymph flow area
• Exisistence of distant metastasis

For the topography axis, there exists an (hierarchical) enlargement, the ‘localisation key’ (Wagner, G. (HRSG.): Tumorlokalisationsschlüssel, 5. Auflage, Springer Verlag, Berlin, Heidelberg, New York, Tokyo 1993), which can supply at some positions clinical relevant differentiation. The morphology axis is composed of a four-digit code for tissue basic structure, a characteristic number for dignity and an additional grading item. The key itself does not contain all possible combinations of histology and dignity, but points out those ones, for whome exist special discriptions. Vice versa not all combinations of basic structure and dignity are possible (so there is no ‘benign leukemia’). Not either there is a grading system available for all kinds of tumor. For some ones, additional information (for Example ‘Cell-line’) is used at the corresponding position.

Tumor Localization

For Tumor-Coding first of all, the site is important. It will be classified by the Topography -Axis of ICD-O. Topographical -Codes of ICD-10 are based on chapter II (Neoplasm –C 00 – C 97) of ICD-10. However, some of the topographical Codes of ICD-10 (Codes) are not used, because their content is discribed by histology- and digit-Codes of ICD-O. (e.g. Differentiation in situ/ infiltrated, melanoma vs. scin cancer).

Tumor Histology and Dignity

Furthermore, in ICD-O, tumor morphology i.e. tissue structure (histology) and biological behavior (dignity) is discribed by special Codes. Tumor histology is coded by a four-digit number, which is assumed of the morphology-axis of Standardized Nomenclature of Patholoy (SNOP). Dignity-Code is attendant on morphology-Code, seperated by /. Examples:

• 8060/0 squamous epithelium - papillomatose
• 8070/2 squamous epithelium – cancer in situ undifferentiated
• 8070/3 squamous epithelium – cancer undifferentiated
• 8070/6 squamous epithelium – cancer metastasis undifferentiated

Tumor Grading

Grading is derived from the comparison of primary tissue with the neoplasm of this tissue. There are five grading-degrees (s.o.) and further three degrees for Malignant Lymphoma. Registration of tumor grading is also provided in TNM.

Qualifier of Tumor Formular

ICD-O –Codes can be specified by the following qualifier:

Here ICD-O provides additionally the following codes for Lymphoma, which specify the Cell line: B-Cell, T-Cell, Null-Cell Lymphoma. ICD-O uses the Codes 1 – 9. A detailled System is discribed in Chapter 9 under 9.5.2 and 9.53.

Example

GRAPHIC IS MISSING

DisplayName is only available in correlation to qualifiers. According to ICD-O-3 formation rule there are much more discriptions possible as ICD-Catalog proposes.

Terminology

Introduction

9. Terminology 9.1. Introduction This chapter separates codes in use from normative specifications, in order to allow updates to such codes without having to rewrite the normative part. Therefore this chapter is just informative. Current codes have to be requested.

Due to pending third-party copy rights regarding some of the the following tables, the textual descriptions may not be given here such that the respective fields remain empty.

9.2. Overview of Value Sets Value Sets OID Short Term

Tumor Diagnoses German English Tumors 1.2.276.0.76.11.1 uicc¬tumor ValueSet für Tumore in der Tumordokumen¬ ValueSet for tumors in the cancer docume¬ tation ntation Nodes 1.2.276.0.76.11.2 uicc¬nodes ValueSet für ValueSet for Knoten in der nodes in the Tumordokumen¬ cancer docume¬ tation ntation Metastases 1.2.276.0.76.11.3 uicc¬ ValueSet für ValueSet for metastasen Metastasen in der Tumor¬dokumentation metastases in the cancer documentation Residual¬ 1.2.276.0.76.11.4 uicc¬ ValueSet für ValueSet for Tumor residualtumor Residualtumor in residual tumor in der Tumor¬ the cancer dokumentation documentation State Classi¬fication 1.2.276.0.76.11.5 uicc¬stages ValueSet für die Stadiengruppier ung in der Tumordokumen¬ tation ValueSet for stages in the cancer documen¬tation

Venous Invasion 1.2.276.0.76.11.6 uicc¬ veneninvasion ValueSet für die Veneninvasion in der Tumor¬dokumentation ValueSet for venous invasion in the cancer documentation Lymphatic Invasion 1.2.276.0.76.11.7 uicc¬lymph¬system¬invasion ValueSet für die Lymphsystem¬invasion in der Tumordokumen¬tation ValueSet for the lymphatic system invasion in the cancer documen¬tation Perineural Invasion 1.2.276.0.76.11.8 uicc¬neural¬scheiden¬invasion ValueSet für die Neuralscheiden¬invasion in der Tumordokumen¬tation ValueSet for the perineural invasion in the cancer documen¬tation TNM¬ Qualifier 1.2.276.0.76.11.9 uicc¬tnm¬qualifier ValueSet für die TNM¬Qualifier in der Tumor¬dokumentation ValueSet for tnm qualifier in the cancer documen¬tation TNM Localisation for Tumor Documen¬tation 1.2.276.0.76.11.10 uicc¬localisation ValueSet für die TNM¬ Seiten¬lokalisation in der Tumor¬dokumentation ValueSet for tnm localisation in the cancer documen¬tation Table 12: Value Sets

9.3. Overview of Coding Schemata Vocabulary Domain/Coding System OID Short Term ICD10GM ICD¬10 GM Version 2012 1.2.276.0.76.5.409 icd10gm2012 ICD¬10 GM Version 2011 1.2.276.0.76.5.388 icd10gm2011 ICD¬10 GM Version 2010 1.2.276.0.76.5.384 icd10gm2010 ICD¬10 GM Version 2009 1.2.276.0.76.5.356 icd10gm2009 ICD¬10 GM Version 2008 1.2.276.0.76.5.330 icd10gm2008 ICD¬10 GM Version 2007 1.2.276.0.76.5.318 icd10gm2007 ICD¬10 GM Version 2006 1.2.276.0.76.5.311 icd10gm2006 ICD¬O ICD¬O¬3 2.16.840.1.113883.6.43.1 icd¬o¬3 ICD¬O¬DA¬1978 n.a. ICD¬O¬DA¬2002 n.a. TNM C¬Faktor 1.2.276.0.76.5.341 c¬faktor¬tumor TNM 5. Edition 2.16.840.1.113883.15.8 tnm5 TNM 6. Edition 2.16.840.1.113883.15.7 tnm6 TNM 7. Edition 2.16.840.1.113883.15.6 tnm7 Dignity 1.2.276.0.76.5.335 dignitaet¬tumor Cell¬ Type 1.2.276.0.76.5.413 Validity R¬Classification 1.2.276.0.76.5.414 Existence of Residual Tumor 1.2.276.0.76.5.415 Tumor Diagnoses 1.2.276.0.76.5.334 tumordiagnosen Grading 1.2.276.0.76.5.336 grading_tumor ¬Localisation of Metastases 1.2.276.0.76.5.401 Scores Gleason¬Score Gleason¬Score: Loss of Differentiation 1.2.276.0.76.5.402 Gleason¬Score: Growth Pattern 1.2.276.0.76.5.403 Gleason¬Score: Grading 1.2.276.0.76.5.404 Ann¬Arbor 1.2.276.0.76.5.405 Papanikolaou: Grading 1.2.276.0.76.5.406 Alpha¬ID Alpha¬ID 2012 1.2.276.0.76.5.408 alphaid2012 Alpha¬ID 2011 1.2.276.0.76.5.387 alphaid2011 Alpha¬ID 2010 1.2.276.0.76.5.383 alphaid2010 Alpha¬ID 2009 1.2.276.0.76.5.355 alphaid2009 Alpha¬ID 2008 1.2.276.0.76.5.329 alphaid2008 Alpha¬ID 2007 1.2.276.0.76.5.316 alphaid2007 Alpha¬ID 2006 1.2.276.0.76.5.309 alphaid2006 MeSH MeSH 2.16.840.1.113883.6.177.5 MSHGER Snomed CT SNOMED CT 2.16.840.1.113883.6.96 SNOMED CT ID Macs ID Macs 1.2.276.0.76.5.305 id_macs

Typing Diagnosis 1.2.276.0.76.5.342 Table 13: Coding Schemata 9.4. Diagnosis Types in Germany The following codes are being used for typing of diagnoses. This table is a pragmatic collection of the current state-of-the-art in german systems. An international classification is not available at this time. Code Meaning DX Diagnosis, not specified any further

 RFFDX 	Referral Diagnosis
 ENTDX 	Entry Diagnosis
 TRFDX 	Transfer Diagnosis
 ADMDX 	Admittance Diagnosis
 CDDX 	Clinical Department’s Diagnosis
   CDXDX 	Clinical Department’s extra Diagnosis
   CDTDX 	Clinical Department’s Treatment Diagnosis
   CDDISDX 	Clinical Department’s Discharge Diagnosis
   CDADMDX 	Clinical Department’s Admittance Diagnosis
 SUCCDX 	Successive Diagnosis (with continuing sick leave) 
 DISDX 	Discharge Diagnosis 
 TDX 	Transfer Diagnosis 
 PERMDX 	Permanent Diagnosis
   APERMDX 	Anamnestic Permanent Diagnosis
   BPERMDX 	Treatment-related Permanent Diagnosis 
   EMERDX 	Emergency-related Diagnosis
 REIMDX 	Reimbursement Diagnosis 
 POSTOPDX 	Post-operative Diagnosis
 PREOPDX 	Pre-operative Diagnosis 
 ADR 	UAW ¬Observed Unwanted Side Effects 
 ADRPD 	UAW Main Disease 
 ADRCCD 	UAW Side Disease 

 IFSGDX 	If–G ¬Diagnoses 
 IFSGSUSPDX 	If–G ¬Suspicious Diagnoses
 IFSGDD 	If–G ¬Differential Diagnoses
 COD 	Cause of Death (fatal disease) 
 CCCOND 	Accompanying Diseases 
 EXTCS 	External Cause 
 NEO 	Neoblasts 
 UAE 	Unwanted Medication Event 
   UAW 	Unwanted Medication Effect12 
 CAREDX 	Care Diagnosis
 SYMDX 	Symptom 
 OTHDX 	Miscellaneous Diagnosis 

Table 14: Diagnosis Types (OID 1.2.276.0.76.5.342) 9.5. ICD¬O¬Codes 9.5.1. Dignity Dignity refers to a tumor property related to their biological behavior in the body. 13

Code Meaning 0 benign 1 Neoplast with uncertain or unknown behaviour 2 Carcinoma in situ 3 malign, Primary Tumor 6 malign, Metastasis 9 malign, not differentiated between Primary Tumor or Metastasis Table 15: Dignity ¬Codes (OID 1.2.276.0.76.5.335)

12 In this case, a cause has to be documented along with the diagnosis – but that is not covered in this implementation guide. It also has to be clarified whether such diagnosis is equal to “suspicious for”. 13 DIMDI www.dimdi.de ICD¬10¬GM, ICD¬O¬3

9.5.2. Grade of Differentiation/Grading The following table lists possible gradings. The entity column lists to what tumor entities these grades apply.14 Code Description German Entity 0 Primary acquired melanosis Malignant Melanoma of Conjunctiva 1 well differentiated Gut differenziert all but Prostata, Malignant Melanoma of Conjunctiva Well differentiated (slight anaplasia) (Gleason 2¬4) Prostata Malignant melanoma arising from a naevus Malignant Melanoma of Conjunctiva 2 moderately differentiated Mäßig differenziert alle but Prostata, Malignant Melanoma of Conjunctiva Moderately differentiated (moderate anaplasia) (Gleason 5–6) Prostata Malignant melanoma arising from primary acquired melanosis Malignant Melanoma of Conjunctiva 3 poorly differentiated Schlecht differenziert all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva Malignant melanoma arising de novo Malignant Melanoma of Conjunctiva 3¬4 Poorly differentiated/ undifferentiated (marked anaplasia) (Gleason 7– 10) Prostata Poorly differentiated/ undifferentiated Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra 4 undifferentiated Undifferenziert all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva 9 Grading not performed, not given or not applicable L low malignity (G1¬G2) Niedriggradig maligne (G1¬G2) M intermediate malignity (G2¬G3) Mittelgradig maligne (G2¬G3) H high malignity (G3¬G4) Hochgradig maligne (G3G4) B Borderline Grenzfall X grade of differentiation cannot be assessed Differenzierungs¬grad nicht be¬stimmbar Table 16:Grade of Differentiation/Gradings (OID 1.2.276.0.76.5.336) 14 DIMDI www.dimdi.de ICD¬O¬3

This Grading may either be a qualifier in a containing ICDO or be documented as a component in a stand-alone code.

9.5.3. Cell Type This qualifier identifies the immune phenotype related to a lymphoma. Code Meaning Explanation

T T¬ cell type affects T ¬lymphocytes B B¬ cell type affects B lymphocytes N Null cell type NHL Th0, null cell type lymphoma (and T-cell)

K Natural¬ Killer cell type affects NK¬ cells: rare lymphoma, mostly in nose or of nasal type X not determineable (undifferentiated lymphoma) 9 affected cell type determination not performed, not specified or not applicable U unknown, nullFlavor=UNK Table 17: Lymphoma-Affected Cell Type (OID 1.2.276.0.76.5.413) 9.5.4. Validity of R¬Classification This qualifier documents the focus of the Residual¬ Classification15. Code Meaning Explanation L locoregionary tumor nearby tumor(s) M distant metastasis distant secondary tumors G overall phenomenon

Table 18: Validity of R¬Classifikation (OID 1.2.276.0.76.5.414) 

15 Altmann based on TNM V7, Giessen, 2010

9.5.5. Existence of Residual Tumor This qualifier indicates, where a Residual Tumor16 exists. Code Meaning Explanation L locoregionary tumor nearby tumor(s) F distant metastasis distant secondary tumors B both U unknown nullFlavor=UNK

9.6. Codes for TNM-Classification

The TNM¬ classification according to UICC is being a codesystem as a whole. Therefore all tables share the same OID for documentation purposes. An easy way to handle this is the definition of value sets, each with the respective permitted values. Each code may only be used in some documentation if the respective UICC edition is checkmarked in our table– which states that the respective code is a part of that edition .

16 Dudeck J. Basisdokumentation für Tumorerkrankte. Giessen. 1999.

9.6.1. Tumors This section lists known T¬-Categories17 (without representing possible extensions). Descriptions vary with the related entity. Codes shall be used along with tumor diagnosis, as one code may have different meanings. (e.g. T1 may refer to 2¬3 cm or 2¬4 cm). Code Description Meaning 5. 6. 7. Ta X X X Tis Carcinoma in situ non invasive X X X T0 No evidence of primary tumour X X T1 X X X T1mic micro invasion X X X T1a X X X T1a1 X X X T1a2 X X X T1b X X X T1b1 X X X T1b2 X X X T1c X X X T1d X T2 X X X T2a X X X T2a1 X T2a2 X T2b X X X T2c X X X T2d X T3 X X X T3a X X X T3b X X X T3c X X X T3d X X T4 X X X T4a X X X T4b X X X T4c X X X T4d X X X T4e X TX Primary tumor cannot be assessed Stage of primary tumor cannot be determined Table 20: (T) Tumor¬Codes Value Set (OID 1.2.276.0.76.11.1) UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition (OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6) 17 TNM 5.,6.,7. Edition

9.6.2. Nodes Any code for involvement of lymph nodes shall only be used together with tumor diagnosis. UICC Code Description Meaning Entity 5. 6. 7. N0 No regional lymph node metastasis no lymph node affected all X X X N1 X X X N1mi Bilateral regional lymph node metastasis vulva X X N1a all X X X N1b X X X N1b1 X N1b2 X N1b3 X N1b4 X N1c X X N2 X X X Table 21: (N) Lymph Node ¬Codes Value Set (OID 1.2.276.0.76.11.2) UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6) 9.6.3. Metastasis Code describing distant metastases shall only be used together with tumor diagnosis. UICC Code Description German Entity 5. 6. 7. M0 No distant metastasis Fernmetastasen nicht vorhanden all X X X M1 Distant metastasis Fernmetastasen vorhanden all X X X M1a only oesophagus / prostate X X X M1b only oesophagus / prostate X X X M1c X X X M1d X M1e X MX Distant metastasis cannot be assessed all X X X Table 22: (M) Metastasis ¬Code Value Set (OID 1.2.276.0.76.11.3) UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition (OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6) 9.6.4. Residual Tumor Code Description German R0 No residual tumour kein Residualtumor R1 Microscopic residual tumour nur mikroskopisch Residualtumor nachweisbarer R2 Macroscopic residual tumour and makroskopischer Residualtumor und R2a microscopically not confimed ¬mikroskopisch nicht bestätigt R2b microscopically confimed ¬mikroskopisch bestätigt RX Presence of residual tumour cannot be assessed Unbekannt Table 23: Residualtumor¬Codes Value Set (OID 1.2.276.0.76.11.4) UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition (OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6)

9.6.5. Stage grading as of UICC UICC Code Description Meaning 5. 6. 7. okk TX, N0, M0 X X X 0 Carcinoma in situ Tis, N0, M0 X X X 0a X X X 0is X X X I X X IA T1, N0, M0 X X X IA1 X X X IA2 X X X IB T2, N0, M0 X X X IB1 X X X IB2 X X X IC X X X II X X X IIA T1, N1, M0 X X X IIA1 X IIA2 X IIB T2, N1, M0 X X X IIC T3, N0, M0 X X X III X X X IIIA T1, N2, M0 X X X T2, N2, M0 T3, N1,2, M0 IIIB T4, each N, M0 X X X each T, N3, M0 IIIC X X X IS X X X IV each T, each N, M1 X X X IVA X X X IVB X X X IVC X X X not defined X X X not recommended X X Table 24: Stage Classification18 Value Set (OID 1.2.276.0.76.11.5) UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition (OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6)

9.6.6. Venous Invasion Code Description German V0 no venous invasion keine Veneninvasion V1 microscopic venous invasion mikroskopische Veneninvasion V2 macroscopic venous invasion makroskopische Veneninvasion VX venous invasion cannot be assessed Veneninvasion nicht feststellbar Table 25: Venous Invasion ¬Code Value Set (OID 1.2.276.0.76.11.6) UICC 5. Auflage (OID 2.16.840.1.113883.15.8) UICC 6. Auflage (OID 2.16.840.1.113883.15.7) UICC 7. Auflage (OID 2.16.840.1.113883.15.6)

9.6.7. Lymphatic System Invasion Code Description German L0 no lymphatic invasion keine Lymphsysteminvasion L1 lymphatic invasion Lymphsysteminvasion LX lmphatic invasion cannot be assessed Lymphsysteminvasion nicht fest¬stellbar Table 26: Lymphatic Invasion ¬Codes Value Set (OID 1.2.276.0.76.11.7) UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition (OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6)

9.6.8. Perineural Invasion Code Description German Pn0 no perineural invasion keine perineurale Invasion Pn1 Perineural invasion perineurale Invasion PnX unknown Unbekannt Table 27: Perineural Invasion Code Value Set (OID 1.2.276.0.76.11.8) UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition (OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6) 18 In: Schmoll HJ, Höffken K, Possinger K eds. Kompendium Internistische Onkologie. „Collection of Internistic Oncology “. Springer. 4. Edition; 2006 9.6.9. Qualifier Code Description German c Assessment according to clinical criteria Beurteilung nach klinischen Kriterien p according to the pathological results nach dem pathologischen Befund r TNM result of recurrent tumor TNM¬Befund für Rezidivtumor y Classification of initial multimodal therapy Klassifikation nach initialer multi¬modaler Therapie Table 28: TNM¬Qualifier Value Set (OID 1.2.276.0.76.11.9) UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition (OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6) 9.6.10. Certainty Code Description of Evidence german C1 Evidence from standard diagnostic means (e.g., inspection, palpation, and standard radiography, intraluminal endoscopy for tumours of certain organs) Nachweis durch diagnostische Standardmethoden (Inspektion, Palpation, einfache Röntgenaufnahmen) C2 Evidence obtained by special diagnostic means (e.g., radiographic imaging in special projections, tomography, computerized tomography [CT], ultrasonography, lymphography, angiography; scintigraphy; magnetic resonance imaging [MRI]; endoscopy, biopsy, and cytology) Nachweis durch spezielle klinische diagnostische Methoden einschließlich Computertomogramm, Magnet¬Resonanz¬Tomographie C3 Evidence from surgical exploration, including biopsy and cytology Nachweis durch Operation, einschließlich Biopsie und Zytologie C4 Evidence of the extent of disease following definitive surgery and pathological examination of the resected specimen Nachweis durch operative Behandlung mit pathologischer Untersuchung der entnommenen Gewebeteile C5 Evidence from autopsy Nachweis durch Autopsie

Table 29: Certainty Factor ¬Codes (OID 1.2.276.0.76.5.341) 9.6.11. Localisation of Distant Tumours / Metastases Code Description German and Explanation PUL Pulmonary Pulmonal Lungenmetastase OSS Osseous Ossär Knochenmetastase HEP Hepatic Hepatisch Lebermetastase BRA Brain Cerebral Hirnmetastase LYM Lymph Nodes Lymphonodulär Lymphknotenmetastase OTH Others Andere Andere Metastase MAR Bone Marrow Medullär Knochenmarkmetastase PLE Pleura Pleural RippenfellMetastase ADR Adrenals Adrenal Nebennierenmetastase SKI Skin dermal Hautmetastase Table 30: Metastases ¬Localisation ¬Codes (OID 1.2.276.0.76.5.401)

9.7. Codes für Gleason¬Score Code Description German 1 Round to oval equal individual glands, lying close to each other, sharply demarcated from the surrounding area Runde bis ovale gleich große Einzeldrüsen, dicht nebeneinander liegend, scharf gegen die Umgebung abgegrenzt 2 Slightly less uniform single glands, separated by small amounts of stroma, less sharply defined tumor margin Etwas weniger uniforme Einzeldrüsen, getrennt durch geringe Mengen von Stroma, weniger scharf begrenzter Tumorrand 3 a) Irregularly large and irregularly shaped glands, usually with abundant stroma, sometimes also stored tightly irregular and indistinct tumor border Unregelmäßig große und unregelmäßig gestaltete Drüsen mit gewöhnlich reichlicherem Stroma, gelegentlich auch dicht gelagert, unregelmäßige und unscharfe Tumorgrenze b) Papillary or cribriform structures, sometimes in large gang¬like formations Papilläre oder kribriforme Strukturen, z.T. in großen gangähnlichen Bildungen 4 a) Large irregular Epithelformationen by glandular fusion ("fused glands") and branched glands with irregular infiltration into the surrounding area Große unregelmäßige Epithelformationen durch Drüsenverschmelzung („fused glands“) sowie verzweigte Drüsen mit unregelmäßiger Infiltration in die Umgebung b) Adenocarcinoma with prominent clear cytoplasm similar to clear cell adenocarcinomas of the kidney Adenokarzinom mit ausgeprägt klarem Zytoplasma ähnlich hellzelligen Adenokarzinomen der Niere 5 a) Circumscribed round epithelial clusters with mostly solid and cribriform construction, usually with central necrosis Scharf begrenzte runde Epithelhaufen mit meist solidem und kribriformem Bau, gewöhnlich mit zentraler Nekrose (comedo carcinoma¬like) (komedo¬karzinomähnlich) b) Irregularly shaped formations of an undifferentiated carcinoma, which only just discernible glandular formation or is identified vacuoles (signet ring¬like) than adenocarcinoma Unregelmäßig begrenzte Formationen eines undifferenzierten Karzinoms, das nur durch gerade noch erkennbare Drüsenbildung oder Vakuolen (siegelringähnlich) als Adenokarzinom zu identifizieren ist

Table 31: Loss of Differentiation according to Gleason¬Score19 (OID 1.2.276.0.76.5.402) Documentation by the GleasonSum (Gleason¬Score) as the sum of the two most dominating findings: Uniformly structured tumors: two times the points of above table. Non-uniformly structured tumors: points for the dominating share of findings (so-called primary grading) + points for second-largest share (secondary grading), if punch biopsy show more than two grades, the second component will be based on the most adverse component found.

19: Dt. Gesellschaft f. Urologie e.V.

9.8. Ann ¬Arbor ¬Codes Principal Stages Code Description I cancer is located in a single region, usually one lymph node and the surrounding area II cancer is located in two separate regions, an affected lymph node or organ and a second affected area, and that both affected areas are confined to one side of the diaphragm III cancer has spread to both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen IV diffuse or disseminated involvement of one or more extralymphatic organs Table 33: Ann Arbor (OID 1.2.276.0.76.5.405)

Modifiers Code Description A absence of constitutional symptoms is denoted by adding an "A" B presence of constitutional (B-type) symptoms is denoted by adding a "B" Table 34: Ann¬ Arbor constitutional symptoms (OID 1.2.276.0.76.5.416)

Code Description E disease is "extranodal" (not in the lymph nodes) or has spread from lymph nodes to adjacent tissue. S the disease has spread to the spleen.

X the largest deposit is >10 cm large ("bulky disease"), or the mediastinum is wider than 1/3 of the chest on a chest X-ray.

Table 35: Ann Arbor Modifiers for Spreading (OID 1.2.276.0.76.5.417)

9.9. Papanicolaou Coding Results of the so-called Pap Test Code Meaning Pap0 non representative sample PapI normal cell findings PapII atypical, benign disorder, infection, metaplasia, atrrophy, bacteria, viruses, PapIIw insufficient samples PapIII cell proliferation and atypic cells PapIIID dysplastic , mostly with HPV infection PapIIIG moderate/severe dyskaryosis and/or dysplasia PapIV biopsy sample and histological clarification required PapIVa carcinoma in situ PapIVb single certain tumour cells, carcinoma very certain PapV many certain tumour cells, carcinoma certain, cellular changes suggestive of invasive squamous carcinoma, and cellular changes indicative of adenocarcinoma of the uterine cervix and other invasive cancer.

Table 36: Grading according to Papanicolaou (OID 1.2.276.0.76.5.406)