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

Overview of Value Sets

Value Sets	OID	Short Term	German	English
Tumors	1.2.276.0.76.11.1	uicctumor	ValueSet für Tumore in der Tumordokumentation	ValueSet for tumors in the cancer documentation
Nodes	1.2.276.0.76.11.2	uiccodes	ValueSet für Knoten in der Tumordokumentation	ValueSet for nodes in the cancer documentation
Metastases	1.2.276.0.76.11.3	uiccmetastasen	ValueSet für Metastasen in der Tumordokumentation	ValueSet for metastases in the cancer documentation
ResidualTumor	1.2.276.0.76.11.4	uiccresidualtumor	ValueSet für Residualtumor in der Tumordokumentation	ValueSet for residual tumor in the cancer documentation
Stage Classification	1.2.276.0.76.11.5	uiccstages	ValueSet für die Stadiengruppier ung in der Tumordokumentation	ValueSet for stages in the cancer documentation
Venous Invasion	1.2.276.0.76.11.6	uiccveneninvasion	ValueSet für die Veneninvasion in der Tumordokumentation	ValueSet for venous invasion in the cancer documentation
Lymphatic Invasion	1.2.276.0.76.11.7	uicclymphsysteminvasion	ValueSet für die Lymphsysteminvasion in der Tumordokumentation	ValueSet for the lymphatic system invasion in the cancer documentation
Perineural Invasion	1.2.276.0.76.11.8	uiccneuralscheideninvasion	ValueSet für die Neuralscheideninvasion in der Tumordokumentation	ValueSet for the perineural invasion in the cancer documentation
TNM Qualifier	1.2.276.0.76.11.9	uicctnmqualifier	ValueSet für die TNM-Qualifier in der Tumordokumentation	ValueSet for tnm qualifier in the cancer documentation
TNM Localisation for Tumor Documentation	1.2.276.0.76.11.10	uicclocalisation	ValueSet für die TNM-Seitenlokalisation in der Tumordokumentation	ValueSet for tnm localisation in the cancer documentation

Overview of Coding Schemata

Vocabulary Domain/Coding System	OID	Short Term
ICD10GM
ICD­10 GM Version 2012	1.2.276.0.76.5.409	icd10gm2012
ICD­10 GM Version 2011	1.2.276.0.76.5.388	icd10gm2011
ICD­10 GM Version 2010	1.2.276.0.76.5.384	icd10gm2010
ICD­10 GM Version 2009	1.2.276.0.76.5.356	icd10gm2009
ICD­10 GM Version 2008	1.2.276.0.76.5.330	icd10gm2008
ICD­10 GM Version 2007	1.2.276.0.76.5.318	icd10gm2007
ICD­10 GM Version 2006	1.2.276.0.76.5.311	icd10gm2006
ICD­O
ICD­O­3	2.16.840.1.113883.6.43.1	icd­o­3
ICD­O­DA­1978	n.a.
ICD­O­DA­2002	n.a.
TNM
C­Faktor	1.2.276.0.76.5.341	c­faktor­tumor
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	dignitaet­tumor
Cell­ Type	1.2.276.0.76.5.413
Validity R­Classification	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
Gleason­Score
Gleason­Score: Loss of Differentiation	1.2.276.0.76.5.402
Gleason­Score: Growth Pattern	1.2.276.0.76.5.403
Gleason­Score: Grading	1.2.276.0.76.5.404
Ann­Arbor	1.2.276.0.76.5.405
Papanikolaou: Grading	1.2.276.0.76.5.406
Alpha­ID
Alpha­ID 2012	1.2.276.0.76.5.408	alphaid2012
Alpha­ID 2011	1.2.276.0.76.5.387	alphaid2011
Alpha­ID 2010	1.2.276.0.76.5.383	alphaid2010
Alpha­ID 2009	1.2.276.0.76.5.355	alphaid2009
Alpha­ID 2008	1.2.276.0.76.5.329	alphaid2008
Alpha­ID 2007	1.2.276.0.76.5.316	alphaid2007
Alpha­ID 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

Diagnosis Types In Germany

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

ICD-O Codes

Dignity

Meaning	Code
0	benign
1	Neoplasm 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

Grade of Differentiation/Grading

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 2­4)		Prostata
	Malignant melanoma arising from a naevus		Malignant Melanoma of Conjunctiva
2	moderately differentiated	Mäßig differenziert	all 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
3­4	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 (G1­G2)	Niedriggradig maligne (G1­G2)
M	intermediate malignity (G2­G3)	Mittelgradig maligne (G2­G3)
H	high malignity (G3­G4)	Hochgradig maligne (G3G4)
B	Borderline	Grenzfall
X	grade of differentiation cannot be assessed	Differenzierungs­grad nicht be­stimmbar

Cell Type

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

Validity of R Classification

Code	Meaning	Explanation
L	locoregionary tumor	nearby tumor(s)
M	distant metastasis	distant secondary tumors
G	overall phenomenon

Existence of Residual Tumor

Code	Meaning	Explanation
L	locoregionary tumor	nearby tumor(s)
F	distant metastasis	distant secondary tumors
B	both
U	unknown	nullFlavor=UNK

Codes for TNM-Classification

Tumors

Code	Description	Explanation	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

Nodes

				UICC	UICC	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

Metastasis

Code	Description	German	Entity	5.	6.	7.
				UICC	UICC	UICC
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

Residual Tumor

Code	Description	German
R0	No residual tumour	kein Residualtumor
R1	Microscopic residual tumour	nur mikroskopisch Residualtumor nachweisbar
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

Stage grading as of UICC

Code	Description	Meaning	5.	6.	7.
			UICC
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
IIIA		T2, N2, M0
IIIA		T3, N1,2, M0
IIIB		T4, each N, M0	X	X	X
IIIB		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

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

Lymphatic System Invasion

Code	Description	German
L0	no lymphatic invasion	keine Lymphsysteminvasion
L1	lymphatic invasion	Lymphsysteminvasion
LX	lmphatic invasion cannot be assessed	Lymphsysteminvasion nicht fest­stellbar

Perineural Invasion

Code	Description	German
Pn0	no perineural invasion	keine perineurale Invasion
Pn1	Perineural invasion	perineurale Invasion
PnX	unknown	Unbekannt

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	TNM­Befund für Rezidivtumor
y	Classification of initial multimodal therapy	Klassifikation nach initialer multi­modaler Therapie

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, Magnet­Resonanz­Tomographie
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

Localisation of Distant Tumours / Metastases

Code	Description	German	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

Codes for 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 gang­like 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 carcinoma­like)	(komedo­karzinomähnlich)
	b) Irregularly shaped formations of an undifferentiated carcinoma, which only just discernible glandular formation or is identified vacuoles (signet ring­like) than adenocarcinoma	Unregelmäßig begrenzte Formationen eines undifferenzierten Karzinoms, das nur durch gerade noch erkennbare Drüsenbildung oder Vakuolen (siegelringähnlich) als Adenokarzinom zu identifizieren ist