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Thy.doc

  1. 1. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Appendix for Thyroid Cancer Table of contents Cancer Care Spell..................................................................................................................................... Thyroid Cancer Specific Codes............................................................................................................... Additional data items for Thyroid Cancer............................................................................................... Version 0.5 Page 1 of 24 Issue Date: 20.01.04
  2. 2. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Cancer Care Spell In Thyroid cancer, a cancer care spell describes a single lesion of one histological type (same first three digits of the morphology code) even if the lesion crosses site boundaries. Multifocal cancers (i.e. discrete tumours apparently not in continuity with other primary cancers but originating in the same tissue or ICD site at the three alphanumeric level) would result in one Cancer Care Spell (unless they have different histology and/or different laterality). Simultaneous bilateral tumours with the same histology would result in two Cancer Care Spells, one for the right and one for the left body site. Recurrence at the same site is considered to be part of the same care spell but would be the subject of a new care plan for its management. All incidental thyroid cancers found at pathological examination should be included. Version 0.5 Page 2 of 24 Issue Date: 20.01.04
  3. 3. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Thyroid Cancer Specific Codes 3.3 CANCER IMAGING MODALITY [Imaging modality] Standard radiography 1 Chest X-ray 1A Sinus X-rays 1B Mastoid views 1C Orthopantomogram (OPG) 1D Skull base views 1E CT Scan with contrast 2A CT scan without contrast 2B MRI scan with contrast 3A MRI scan without contrast 3B PET scan 4 Ultrasound 5 Nuclear Medicine imaging 6 Bone scan 6A Other isotope scan 6B Barium 8 Barium swallow 8B Lymphoscintigraphy 9 Other 99 3.4 ANATOMICAL EXAMINATION SITE [Anatomical site examined] OPCS-4 Code OPCS-4 description Brain Z01.9 Tissue of brain nec Skull base Z63.8 Specified bone of cranium nec Head Z92.1 Head nec Parotid gland Z26.1 Parotid gland Submandibular gland Z26.2 Submandibular gland Neck Z92.3 Neck nec Larynx Z24.2 Larynx Thyroid gland Z13.1 Thyroid gland Thorax Z52.8 Specified chest wall nec Chest Z92.4 Chest nec Upper abdomen Z92.6 Abdomen nec Liver Z30.1 Liver Bone Z87.1 Bone nec 4.2 PRIMARY DIAGNOSIS (ICD) [Primary site] ICD-10 Codes for Primary Site (Diagnosis) C73.X Thyroid gland C75.0 Parathyroid gland C80.X Unknown primary Version 0.5 Page 3 of 24 Issue Date: 20.01.04
  4. 4. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix 4.5 HISTOLOGY [Histology] SNOMed Codes for Histology (Pathology) (SNOMed III (1993)/ICD-O-2 (1990) unless stated) The order shown is a clustering by pathological type, followed by an alphabetical list, and supplemented by some SNOMed only codes. The details in brackets identify that the codes only apply to the sites shown. See also data item T.36 – Thyroid histology Thyroid M8330/3 Follicular adenocarcinoma, NOS (C73) M8331/3 Follicular adenocarcinoma, well differentiated (C73) M8332/3 Follicular adenocarcinoma, trabecular (C73) M8340/3 Papillary carcinoma, follicular variant (C73) M8510/3 Medullary carcinoma NOS M8511/3 Medullary carcinoma with amyloid stroma (C73) SNOMed only codes – these relate to items not found in ICD-0-2 M9990/3 No microscopic confirmation, clinically malignant tumour M9990/6 No microscopic confirmation, clinically metastatic tumour 4.6 GRADE OF DIFFERENTIATION (AT DIAGNOSIS) [Grade of differentiation] Most pathologists do not grade thyroid cancer, so this data item is not required. Version 0.5 Page 4 of 24 Issue Date: 20.01.04
  5. 5. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix 7.10 PRIMARY PROCEDURE (OPCS) [Main surgical procedure] 7.11 PROCEDURE (OPCS) [Sub-procedure(s)] OPCS/Read Codes for Surgical Procedures (5 byte Version 2 Read Codes) 1. NECK DISSECTIONS (USING WATKINSON OPCS CODE EXTENSIONS) NECK DISSECTION RADICAL T85.1 7H600 NECK DISSECTION MODIFIED T85.1A modified Type I accessory preserved T85.1AI modified Type II accessory +IJV kept T85.1AII modified Type III sternomastoid,IJV + T85.1AIII accessory kept SELECTIVE NECK DISSECTION (SND) T85.1B 7H610 SND Level 1 (suprahyoid) T85.1BI 7H606 SND Level 1-3 (supra-omohyoid) T85.1BII SND Level 1-4 (anterolateral) T85.1BIII SND Level 2-4 (lateral) T85.1BIV SND Level 5 (posterior) T85.1BV SND Level 2-5 (posterolateral) T85.1BVI SND Level 6 (central compartment) T85.1BVII SND Level 7 (superior mediastinum) T85.1BVIII Excision or biopsy of cervical lymph node T87.2 7H621 2. THYROID Lobectomy + subtotal/near total lobectomy B08.8 Partial thyroidectomy NEC B08.6 71105 Version 0.5 Page 5 of 24 Issue Date: 20.01.04
  6. 6. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Lobectomy of thyroid NEC B08.4 71103 Isthmusectomy B08.5 71104 Hemithyroidectomy B08.3 71102 Thyroidectomy, subtotal B08.2 71101 Bilateral subtotal lobectomy B08.2 + Z94.1 Total thyroidectomy B08.1 71100 Biopsy/excision nodule B12.2 If the thyroid remnant after excision is <1ml in volume, then it can be called a "near-total lobectomy" (thyroidectomy if surgery is bilateral.) If the remnant is >1ml, then it should be called a sub-total thyroidectomy. Note: the following is a list of OPCS-4 procedures containing ‘thyroid’. B08.1 Total thyroidectomy B08.2 Subtotal thyroidectomy B08.3 Hemithyroidectomy B08.4 Lobectomy of thyroid gland nec B08.5 Isthmectomy of thyroid gland B08.6 Partial thyroidectomy nec B08.8 Excision of thyroid gland OS B08.9 Excision of thyroid gland unspecified B09.1 Excision of substernal thyroid tissue B09.2 Excision of sublingual thyroid tissue B09.8 Operations on aberrant thyroid tissue OS B09.9 Operations on aberrant thyroid tissue unspecified B12.1 Excision of lesion of thyroid gland B12.2 Biopsy of lesion of thyroid gland B12.3 Incision of lesion of thyroid gland B12.4 Exploration of thyroid gland B12.8 Other operations on thyroid gland OS B12.9 Other operations on thyroid gland unspecified B14.1 Global parathyroidectomy & transposition parathyroid tissue B14.2 Global parathyroidectomy nec B14.3 Partial parathyroidectomy & transposition parathyroid tissu Version 0.5 Page 6 of 24 Issue Date: 20.01.04
  7. 7. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix B14.4 Partial parathyroidectomy nec B14.5 Excision of lesion of parathyroid gland B14.8 Excision of parathyroid gland OS B14.9 Excision of parathyroid gland unspecified B16.1 Modification of transposed parathyroid gland B16.2 Biopsy of lesion of parathyroid gland B16.3 Exploration of parathyroid gland B16.8 Other operations on parathyroid gland OS B16.9 Other operations on parathyroid gland unspecified 8.11 GRADE OF DIFFERENTIATION [Grade of differentiation] Most pathologists do not grade thyroid cancer, so this data item is not required. 9.9 DRUG REGIMEN ACRONYM (CANCER) [Regimen acronym] Doxorubicin single agent Doxorubicin combinations Other 14.8 MORBIDITY CODE (CANCER SURGERY)[Treatment Related Morbidity] Coding for post-operative complications (ICD-10) Major complications Leak T85.6 Abscess T81.4 Bleed T81.0 Version 0.5 Page 7 of 24 Issue Date: 20.01.04
  8. 8. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Other complications Wound infection: Without prosthesis graft T81.4 With prosthesis T85.7 Lower chest infection J22(X) Upper chest infection J06.9 Urinary infection N39.0 Post-operative +Y83.2 Excision of an organ +Y83.3 Thromboembolic T81.7 MRSA Cardiac I97.8 Abscess T81.4 Aspiration Bacteraemia T81.4 Septicaemia T81.4 Chyle leak T85.5 Cerebrovascular accident T81.7 Eating/swallowing difficulty R13 + Y83.- Fistula K12.2 + T81.8 Pharyngocutaneous J39.2 + Y83.- Tracheo-oesophageal J85.0 or J95.0 following tracheo. Haematoma T81.0 T85.8 Nerve damage/division G97.8 re-admission Pulmonary embolus T81.7 Deep vein thrombosis T85.8 Myocardial infarction I21.9 + Y83.- Version 0.5 Page 8 of 24 Issue Date: 20.01.04
  9. 9. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Wound dehiscence T81.3 Keloid L91.0 Hypocalcaemia (if lasting for more than a year) Voice change (if lasting for more than year) Version 0.5 Page 9 of 24 Issue Date: 20.01.04
  10. 10. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Additional data items for Thyroid Cancer Recording details about imaging – thyroid cancer specific items Data Item Repeating? Source of definition T.20 Imaging type No NCDS T.20 Imaging type 131I 01 123I 02 99mTc-MIBI 03 18F-FDG (PET) 04 201Tl; 05 99mTc-DMSA(V) 06 111In-octreotide 07 123I-MIBG 08 131I –MIBG 09 99mTc 10 Recording details about the management plan – thyroid cancer specific items The following data items should be collected for thyroid cancer, at the time that the first management plan is drawn up. Data Item Repeating? Source of definition T.1 History of thyroid disease Yes NCDS T.2 Previous irradiation Yes NCDS T.3 Previous treatment for thyroid related Yes NCDS disease T.4 Family history of thyroid disease Yes NCDS T.5 Family history of other non-thyroid Yes NCDS cancers Version 0.5 Page 10 of 24 Issue Date: 20.01.04
  11. 11. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix T.5a RELATIONSHIP TO PERSON [Family Yes NCDS history – relationship] T.5b PRIMARY DIAGNOSIS OF RELATION Yes NCDS (ICD) [Site of relation’s cancer] T.6 Medullary carcinoma No NCDS T.7 Genetic screening No NCDS T.7a Results of genetic screening No NCDS T.1 History of thyroid disease Record any thyroid disease in past medical history, obtained directly from information given by the patient or from documented medical history. Multiple responses are permitted. Under active thyroid 1 Over active thyroid 2 Lump, within or related to the thyroid 3 Other 4 None 5 T.2 Previous irradiation Record whether the patient has received previous irradiation, unrelated to thyroid cancer management Yes, therapeutic 1 Yes, environmental 2 No 3 T.3 Previous treatment for thyroid related disease This should be obtained directly from information given by the patient or from documented medical history. Multiple responses are permitted. Surgery (previous operative procedure to the thyroid) 1 Radioiodine (administration of 131Iodine) 2 Version 0.5 Page 11 of 24 Issue Date: 20.01.04
  12. 12. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Drug treatment for thyrotoxicosis (carbimazole, methimazole, 3 propylthiouracil) Thyroid hormone therapy T4 and T3 4 None 5 T.4 Family history of thyroid disease Record information about first- and second-degree blood relatives only. Multiple responses are permitted. FH of under-active thyroid 1 FH of over-active thyroid 2 FH of other thyroid disease 3 FH of non-medullary thyroid cancer 4 FH of thyroid surgery for other reason 5 FH details unknown 6 T.5 FAMILY HISTORY OF CANCER T.5a RELATIONSHIP TO PERSON [Family history – relationship] If the patient has a relation who has, or has had cancer, record the relationship to the patient. Note that this applies only to close, blood relatives (except for ‘husband’ and ‘wife’). Aunt A Brother B Child unspecified C Daughter D Father F Grandparent G Husband H Cousin K Version 0.5 Page 12 of 24 Issue Date: 20.01.04
  13. 13. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Mother M Nephew/niece N Parent unspecified P Sister S Uncle U Wife W Grandchild unspecified X Son Z T.5b PRIMARY DIAGNOSIS OF RELATION (ICD) [Site of relation’s cancer] If the patient has a close family relative who has, or has had cancer, record the site of any cancer. Record as ICD-10 codes. T.6 Medullary carcinoma Familial basis for some medullary carcinomas Yes Y No N Unknown 9 T.7 Genetic screening Mutation known to be present for MEN 1 Mutation not identified for MEN 2 Other 3 Genetic screening not carried out 4 T.7a Results of genetic screening MENIIa 1 Version 0.5 Page 13 of 24 Issue Date: 20.01.04
  14. 14. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix MENIIb 2 FMTC 3 Other 9 T.8 Method of presentation Replaces presenting symptoms. To include all incidental thyroid cancers found at pathological examination. Thyroid mass 01 Incidental via imaging 02 Incidental pathological –at thyroid surgery 03 Incidental pathological –at other surgery 04 Neck node metastasis 05 Distant metastasis 06 Genetic screening 07 Other 08 T.9 Result of THY for cytology Based on RCPath, best practice document and RCP guidelines. Thy1- non-diagnostic (inadequate or where technical artefact precludes 1 interpretation. Smears must contain six or more groups of greater than 10 thyroid follicular cells to be considered adequate.) Thy2- non-neoplastic (features consistent with a nodular goitre or 2 thyroiditis) Thy3- all follicular lesions and other aspirates in which neoplasia cannot 3 be fully excluded. Thy4- abnormal, suspicious of malignancy (suspicious, but not 4 diagnostic, of papillary, medullary or anaplastic carcinoma or of lymphoma) Version 0.5 Page 14 of 24 Issue Date: 20.01.04
  15. 15. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Thy5- diagnostic of malignancy (unequivocal features of papillary, 5 medullary or anaplastic carcinoma, or of lymphoma or metastatic tumour) Not done 9 Version 0.5 Page 15 of 24 Issue Date: 20.01.04
  16. 16. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Recording details about surgery and other procedures – thyroid cancer specific items The following additional data items should be collected for thyroid cancer. Data Item Repeating? Source of definition T.10a Operative findings No NCDS T.12 Thyroid hormone commencement date No NCDS T.10a Operative findings 1 Macroscopic local extension beyond thyroid capsule 2 Suspected lymph node metastases 3 Recurrent laryngeal nerve involvement T.12 Thyroid hormone commencement date Collect this, in date format. Version 0.5 Page 16 of 24 Issue Date: 20.01.04
  17. 17. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Recording details about pathology – thyroid cancer specific items The following pathology data items should be collected for thyroid cancer. Data Item Repeating? Source of definition T.36 Thyroid histology No NCDS T.14 Pathological features 1 No NCDS T.15 Pathological features 2 No NCDS T.16 Pathological features No NCDS T.17 Undifferentiated component No NCDS T.18 Pathological features of adjacent gland. Yes NCDS T.19 Parathyroid gland(s) identified No NCDS T.36 Thyroid histology The histology of the tumour is recorded in the generic dataset (data items 4.5 and 8.10) using ICD-O-2 coding. The additional level of data required below is not represented by ICD-O-2 with unique codes, so this additional data item is required. Papillary carcinoma 01 Follicular carcinoma 02 Oncocytic follicular (Hurthle cell) carcinoma 03 Medullary carcinoma 04 Poorly differentiated carcinoma 05 Insular carcinoma 06 Undifferentiated/anaplastic carcinoma 07 Mixed/combination tumour 08 Lymphoma 09 Other tumours 10 No residual tumour 11 T.14 Pathological features 1 Record for papillary carcinoma. Version 0.5 Page 17 of 24 Issue Date: 20.01.04
  18. 18. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Classical 01 Follicular 02 Encapsulated 03 Cystic 04 Tall cell 05 Columnar cell 06 Trabecular 07 Oncocytic 08 Diffuse sclerosing 09 Cribriform 10 Solid 11 Incidental microcarcinoma 12 Other 99 T.15 Pathological features 2 Record for any type of thyroid tumour Single lesion 1 Multiple intrathyroidal foci 2 Not recorded 9 T.16 Pathological features Record for follicular carcinoma Minimally invasive 1 Widely invasive 2 T.17 Undifferentiated component The presence of undifferentiated or poorly differentiated component in a differentiated tumour Version 0.5 Page 18 of 24 Issue Date: 20.01.04
  19. 19. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Yes Y No N T.18 Pathological features of adjacent gland. Multiple responses are permitted. Thyroiditis 1 Nodular goitre 2 Other 3 Not recorded 9 T.19 Parathyroid gland(s) identified Record the actual number within the pathological specimen. Version 0.5 Page 19 of 24 Issue Date: 20.01.04
  20. 20. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Recording details about radio-iodine ablation and therapy – thyroid cancer specific items The following data items should be collected for thyroid cancer. Note: multiple occurrences of this section are permitted, as radio-iodine therapy may be repeated on several occasions. This section may occur many times Data Item Repeating? Source of definition T.24 Administered activity No NCDS T.22 Date No NCDS T.21 Result Yes NCDS T.25 Thyroglobulin level No NCDS T.26 TSH level No NCDS T.27 Thyroid hormone status Yes NCDS T.24 Administered activity Amount of iodine administered in Giga Bequerels T.22 Date Record the date of the report. T.21 Result Neck and whole body scan report (Multiple responses are permitted) Only physiological uptake 1 Thyroid bed 2 Neck nodes 3 Distant – lung 4 Distant – bone 5 Distant – other 6 Version 0.5 Page 20 of 24 Issue Date: 20.01.04
  21. 21. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix T.25 Thyroglobulin level Actual value in micrograms/litre T.26 TSH level Actual value, mU/litre T.27 Thyroid hormone status On thyroid hormone therapy 1 Off thyroid hormone therapy 2 rhTSH 3 Version 0.5 Page 21 of 24 Issue Date: 20.01.04
  22. 22. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix Recording details about follow-up – thyroid cancer specific items The following data items should be collected for thyroid cancer. Data Item Repeating? Source of definition T.29 Marker response No NCDS T.30 Marker level No NCDS T.35 Assay method No NCDS T.30a Follow-up imaging result No NCDS T.31 Subsequent salivary complications Yes NCDS (Note: in addition to Cancer Dataset generic data item 14.8) Subsequent non-thyroid malignancy No NCDS Cord mobility No NCDS T.29 Marker response This should be collected in addition to marker response defined in generic dataset (14.5) TSH 1 Thyroglobulin RIA 2 Thyroglobulin IMA 3 Thyroglobulin antibody 4 Calcitonin RIA 5 Calcitonin IMA 6 CEA 7 T.30 Marker level Actual value in nanograms/litre T.35 Assay method Record the method used in measuring thyroglobulin or calcitonin. The coding system used is from UK NEQAS. BY3 BYK Liaison/Nichols Version 0.5 Page 22 of 24 Issue Date: 20.01.04
  23. 23. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix CI2 CIS ELSA DC11 DPC Immulite 2000 DC7 DPC Immulite GD1 Genesis Diagnostics HE1 Brahms DYNOtest IN2 DiaSorin IRMA IT1 Immunotech IRMA MP1 Medipan SELco NI1 Nichols Allegro NI2 Nichols Institute [C] NI4 Nichols Advantage OO10 In-house [IMA] OO61 In-house Salford IRMA OOO In-house [RIA] PH2 Wallac Delfia [Perkin Elmer] SA1 Bangui Biotech ELSA SF3 Sanofi Pasteur UUU undefined/vague T30a Follow-up imaging result Negative/normal 1 Positive/abnormal – loco regional 2 Positive/abnormal – distant 3 T.31 Subsequent salivary complications Salivary gland problems 1 Other 2 T.32 Subsequent non-thyroid malignancy Haematological malignancy/myelodysplasia solid tumours –bladder,colon breast,other Version 0.5 Page 23 of 24 Issue Date: 20.01.04
  24. 24. Cancer Dataset Cancer Data Manual – Thyroid Cancer Appendix To be collected using ICD-10 coding. T.34 Cord mobility Only performed if voice change detected. Normal 1 Abnormal 2 Version 0.5 Page 24 of 24 Issue Date: 20.01.04

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