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| Zeile 131: |
Zeile 131: |
| | | | |
| | ==Representation for specific Use Cases== | | ==Representation for specific Use Cases== |
| − |
| |
| − | ==Terminology==
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| − | ===Introduction===
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| − | 9. Terminology
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| − | 9.1. Introduction
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| − | 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.
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| − |
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| − |
| |
| − | 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.
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| − |
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| − |
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| − | 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¬
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| − | tation ntation
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| − | Nodes 1.2.276.0.76.11.2 uicc¬nodes ValueSet für ValueSet for
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| − | Knoten in der nodes in the
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| − | Tumordokumen¬ cancer docume¬
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| − | tation ntation
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| − | Metastases 1.2.276.0.76.11.3 uicc¬ ValueSet für ValueSet for
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| − | metastasen Metastasen in der Tumor¬dokumentation metastases in the cancer documentation
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| − | Residual¬ 1.2.276.0.76.11.4 uicc¬ ValueSet für ValueSet for
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| − | Tumor residualtumor Residualtumor in residual tumor in
| |
| − | der Tumor¬ the cancer
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| − | dokumentation documentation
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| − | State Classi¬fication 1.2.276.0.76.11.5 uicc¬stages ValueSet für die Stadiengruppier ung in der Tumordokumen¬
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| − | tation ValueSet for stages in the cancer documen¬tation
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| − |
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| − | Venous
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| − | Invasion 1.2.276.0.76.11.6 uicc¬
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| − | veneninvasion ValueSet für die
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| − | Veneninvasion
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| − | in der Tumor¬dokumentation ValueSet for
| |
| − | venous invasion in the cancer documentation
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| − | Lymphatic
| |
| − | Invasion
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| − | 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
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| − | Perineural
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| − | Invasion
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| − | 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
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| − | 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
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| − | 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
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| − | Table 12: Value Sets
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| − |
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| − | 9.3. Overview of Coding Schemata
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| − | Vocabulary Domain/Coding System OID Short Term
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| − | ICD10GM
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| − | ICD¬10 GM Version 2012 1.2.276.0.76.5.409 icd10gm2012
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| − | ICD¬10 GM Version 2011 1.2.276.0.76.5.388 icd10gm2011
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| − | ICD¬10 GM Version 2010 1.2.276.0.76.5.384 icd10gm2010
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| − | ICD¬10 GM Version 2009 1.2.276.0.76.5.356 icd10gm2009
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| − | ICD¬10 GM Version 2008 1.2.276.0.76.5.330 icd10gm2008
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| − | ICD¬10 GM Version 2007 1.2.276.0.76.5.318 icd10gm2007
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| − | ICD¬10 GM Version 2006 1.2.276.0.76.5.311 icd10gm2006
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| − | ICD¬O
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| − | ICD¬O¬3 2.16.840.1.113883.6.43.1 icd¬o¬3
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| − | ICD¬O¬DA¬1978 n.a.
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| − | ICD¬O¬DA¬2002 n.a.
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| − | TNM
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| − | C¬Faktor 1.2.276.0.76.5.341 c¬faktor¬tumor
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| − | TNM 5. Edition 2.16.840.1.113883.15.8 tnm5
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| − | TNM 6. Edition 2.16.840.1.113883.15.7 tnm6
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| − | TNM 7. Edition 2.16.840.1.113883.15.6 tnm7
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| − | Dignity 1.2.276.0.76.5.335 dignitaet¬tumor
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| − | Cell¬ Type 1.2.276.0.76.5.413
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| − | Validity R¬Classification 1.2.276.0.76.5.414
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| − | Existence of Residual Tumor 1.2.276.0.76.5.415
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| − | Tumor Diagnoses 1.2.276.0.76.5.334 tumordiagnosen
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| − | Grading 1.2.276.0.76.5.336 grading_tumor
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| − | ¬Localisation of Metastases 1.2.276.0.76.5.401
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| − | Scores
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| − | Gleason¬Score
| |
| − | Gleason¬Score: Loss of Differentiation 1.2.276.0.76.5.402
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| − | Gleason¬Score: Growth Pattern 1.2.276.0.76.5.403
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| − | Gleason¬Score: Grading 1.2.276.0.76.5.404
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| − | Ann¬Arbor 1.2.276.0.76.5.405
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| − | Papanikolaou: Grading 1.2.276.0.76.5.406
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| − | Alpha¬ID
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| − | Alpha¬ID 2012 1.2.276.0.76.5.408 alphaid2012
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| − | Alpha¬ID 2011 1.2.276.0.76.5.387 alphaid2011
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| − | Alpha¬ID 2010 1.2.276.0.76.5.383 alphaid2010
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| − | Alpha¬ID 2009 1.2.276.0.76.5.355 alphaid2009
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| − | Alpha¬ID 2008 1.2.276.0.76.5.329 alphaid2008
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| − | Alpha¬ID 2007 1.2.276.0.76.5.316 alphaid2007
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| − | Alpha¬ID 2006 1.2.276.0.76.5.309 alphaid2006
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| − | MeSH
| |
| − | MeSH 2.16.840.1.113883.6.177.5 MSHGER
| |
| − | Snomed CT
| |
| − | SNOMED CT 2.16.840.1.113883.6.96 SNOMED CT
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| − | ID Macs
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| − | ID Macs 1.2.276.0.76.5.305 id_macs
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| − |
| |
| − | 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.
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| − | Code Meaning
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| − | DX Diagnosis, not specified any further
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| − | RFFDX Referral Diagnosis
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| − | ENTDX Entry Diagnosis
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| − | TRFDX Transfer Diagnosis
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| − | ADMDX Admittance Diagnosis
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| − | CDDX Clinical Department’s Diagnosis
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| − | CDXDX Clinical Department’s extra Diagnosis
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| − | CDTDX Clinical Department’s Treatment Diagnosis
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| − | CDDISDX Clinical Department’s Discharge Diagnosis
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| − | CDADMDX Clinical Department’s Admittance Diagnosis
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| − | SUCCDX Successive Diagnosis (with continuing sick leave)
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| − | DISDX Discharge Diagnosis
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| − | TDX Transfer Diagnosis
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| − | PERMDX Permanent Diagnosis
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| − | APERMDX Anamnestic Permanent Diagnosis
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| − | BPERMDX Treatment-related Permanent Diagnosis
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| − | EMERDX Emergency-related Diagnosis
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| − | REIMDX Reimbursement Diagnosis
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| − | POSTOPDX Post-operative Diagnosis
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| − | PREOPDX Pre-operative Diagnosis
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| − | ADR UAW ¬Observed Unwanted Side Effects
| |
| − | ADRPD UAW Main Disease
| |
| − | ADRCCD UAW Side Disease
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| − |
| |
| − | IFSGDX If–G ¬Diagnoses
| |
| − | IFSGSUSPDX If–G ¬Suspicious Diagnoses
| |
| − | IFSGDD If–G ¬Differential Diagnoses
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| − | COD Cause of Death (fatal disease)
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| − | CCCOND Accompanying Diseases
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| − | EXTCS External Cause
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| − | NEO Neoblasts
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| − | UAE Unwanted Medication Event
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| − | UAW Unwanted Medication Effect12
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| − | CAREDX Care Diagnosis
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| − | SYMDX Symptom
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| − | OTHDX Miscellaneous Diagnosis
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| − | 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
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| − |
| |
| − | Code Meaning
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| − | 0 benign
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| − | 1 Neoplast with uncertain or unknown behaviour
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| − | 2 Carcinoma in situ
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| − | 3 malign, Primary Tumor
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| − | 6 malign, Metastasis
| |
| − | 9 malign, not differentiated between Primary Tumor or Metastasis
| |
| − | Table 15: Dignity ¬Codes (OID 1.2.276.0.76.5.335)
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| − |
| |
| − | 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”.
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| − | 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
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| − | Well differentiated (slight anaplasia) (Gleason 2¬4) Prostata
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| − | Malignant melanoma arising from a naevus Malignant Melanoma of Conjunctiva
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| − | 2 moderately differentiated Mäßig differenziert alle but Prostata, Malignant Melanoma of Conjunctiva
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| − | Moderately differentiated (moderate anaplasia) (Gleason 5–6) Prostata
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| − | Malignant melanoma arising from primary acquired melanosis Malignant Melanoma of Conjunctiva
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| − | 3 poorly differentiated Schlecht differenziert all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva
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| − | Malignant melanoma arising de novo Malignant Melanoma of Conjunctiva
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| − | 3¬4 Poorly differentiated/ undifferentiated (marked anaplasia) (Gleason 7– 10) Prostata
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| − | Poorly differentiated/ undifferentiated Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra
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| − | 4 undifferentiated Undifferenziert all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva
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| − | 9 Grading not performed, not given or not applicable
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| − | L low malignity (G1¬G2) Niedriggradig maligne (G1¬G2)
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| − | M intermediate malignity (G2¬G3) Mittelgradig maligne (G2¬G3)
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| − | H high malignity (G3¬G4) Hochgradig maligne (G3G4)
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| − | B Borderline Grenzfall
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| − | X grade of differentiation cannot be assessed Differenzierungs¬grad nicht be¬stimmbar
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| − | Table 16:Grade of Differentiation/Gradings (OID 1.2.276.0.76.5.336)
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| − | 14 DIMDI www.dimdi.de ICD¬O¬3
| |
| − |
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| − |
| |
| − | This Grading may either be a qualifier in a containing ICDO or be documented as a component in a stand-alone code.
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| − |
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| − |
| |
| − | 9.5.3. Cell Type
| |
| − | This qualifier identifies the immune phenotype related to a lymphoma.
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| − | Code Meaning Explanation
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| − |
| |
| − | T T¬ cell type affects T ¬lymphocytes
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| − | B B¬ cell type affects B lymphocytes
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| − | N
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| − | Null cell type [[NHL]] Th0, null cell type lymphoma (and T-cell)
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| − |
| |
| − | K Natural¬ Killer cell type
| |
| − | affects NK¬ cells: rare lymphoma, mostly in nose or of nasal type
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| − | X not determineable (undifferentiated lymphoma)
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| − | 9 affected cell type determination not performed, not specified or not applicable
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| − | U unknown, nullFlavor=UNK
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| − | 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.
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| − | Code Meaning Explanation
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| − | L locoregionary tumor nearby tumor(s)
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| − | M distant metastasis distant secondary tumors
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| − | G overall phenomenon
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| − | Table 18: Validity of R¬Classifikation (OID 1.2.276.0.76.5.414)
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| − | 15 Altmann based on TNM V7, Giessen, 2010
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| − |
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| − |
| |
| − |
| |
| − | 9.5.5. Existence of Residual Tumor
| |
| − | This qualifier indicates, where a Residual Tumor16 exists.
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| − | Code Meaning Explanation
| |
| − | L locoregionary tumor nearby tumor(s)
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| − | F distant metastasis distant secondary tumors
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| − | B both
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| − | U unknown nullFlavor=UNK
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| − |
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| − | 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 .
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| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − |
| |
| − | 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
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| − | T1a1 X X X
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| − | T1a2 X X X
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| − | T1b X X X
| |
| − | T1b1 X X X
| |
| − | T1b2 X X X
| |
| − | T1c X X X
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| − | 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
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| − | T4d X X X
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| − | 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)
| |
| | | | |
| | ==Appendix A: Other== | | ==Appendix A: Other== |
| | | | |
| | ==Appendix B: Indices== | | ==Appendix B: Indices== |
Representation of Diagnosis based on the Clinical Document Architecture Rel.2 for Healthcare in Germany
Version 1.1
Introduction
Introduction
Scope
Diagnosis Types
Common Diagnosis Descriptions
Diagnosis Model in HL7 V3
Representation of Diagnosis in specific Codesystems
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.
TNM Classification
Ann Arbor Classification
FIGO Stages
Gleason Score
Papanikolaou
WHO Grading
Conclusion
Cancer Diagnosis in HL7 V3
Representation for specific Use Cases
Appendix A: Other
Appendix B: Indices
