IG:HL7 diagnosis

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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

Terminology

Introduction

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

Ann Arbor Codes

Papanicolaou Coding

Appendix A: Other

Appendix B: Indices

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