Data Set APSR 2.0 - Concept Tumor formula (TNM)

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Name	ID[‑]	Datatype[‑]	Property[‑]	Example[‑]	Codes[‑]	Description[‑]	Source[‑]	Rationale[‑]	Status[‑]	Terminology[‑]	Value Set[‑]	Type[‑]	Parent concept[‑]
Tumor formula (TNM)	psr-dataelement-3					Tumor formula including T-, M- and N-values as well as further details (staging) and grading, well known as TNM classification, hosted by UICC	Sobin LH, Gospodarowicz MK, Wittekind Ch: TNM classification of malignant tumors.7th ed. 2010, 4th corrected postprint, Wiley&Sons		draft	Pathologic TNM stage grouping (observable entity) (SNOMED Clinical Terms: 399588009) Clinical TNM stage grouping (observable entity) (SNOMED Clinical Terms: 399537006)		Group
Stage	psr-dataelement-74	Code		IVB	Value Set: UICC Stage (7ed) (2015-06-23T16:43:02) stage X stage 0 stage 0a stage 0is stage I stage IA1 stage IA2 stage IB stage IB1 stage IB2 stage IC stage IS stage II stage IIA stage IIA1 stage IIA2 stage IIB stage IIC stage III stage IIIA stage IIIB stage IIIC stage IV stage IVA stage IVB stage IVC	Stage system (hosted by UICC) of a tumor disease, compiling the elements of TNM classification			draft	Stage group.pathology Cancer (Logical Observation Identifier Names and Codes: 21902-2)	UICC Stage (7ed) 2015-06-23T16:43:02 (dynamic)	Item	Tumor formula (TNM)
Posttherapeutic	psr-dataelement-29	Code	Fixed value: y			Symbol for TNM: Is this Observation performed after a multimodal therapy?			draft	y - During therapy/following treatment (tumor staging) (SNOMED Clinical Terms: 277649004)		Item	Tumor formula (TNM)
Autopsy	psr-dataelement-28	Code	Fixed value: a			Symbol for TNM: Has this tumor formula been derived first at autopsy?			draft	a - At autopsy (tumor staging) (SNOMED Clinical Terms: 277646006)		Item	Tumor formula (TNM)
Postoperative	psr-dataelement-59	Boolean	Fixed value: p			Qualifier (prefix) for T, N, and M category: Is this Observation performed after operative therapy, i.e. information comes from the pathologist			draft	p-pathological (1.2.276.0.76.3.1.131.1.5.1: tnmCp)		Item	Tumor formula (TNM)
Clinical	psr-dataelement-60	Code	Fixed value: c		Value Set: TNM_Praefix_CP_UICC (2015-11-04T15:52:34) p c Asked but unknown	Qualifier (prefix) for T, N, and M category: Is this Observation performed by clinical methods?			draft	c-clinical (1.2.276.0.76.3.1.131.1.5.1: tnmCp)	TNM_Praefix_CP_UICC 2015-11-04T15:52:34 (dynamic)	Item	Tumor formula (TNM)
Multiplicity	psr-dataelement-61	Code		pT2(m); pT2(3)	Value Set: UICC Multiplicity (2015-11-06T10:44:54) (m) (2) (3) (4) (5) (6) (7) (8) (9) (10) Asked but unknown	Qualifier for pT category: Are there multiple tumors in the specimen removed or how many multiple tumors are in the specimen?			draft	m-multiple tumors (1.2.276.0.76.3.1.131.1.5.1: tnmMultiplicity)	UICC Multiplicity 2015-11-06T10:44:54 (dynamic)	Item	Tumor formula (TNM)
Recurrence	psr-dataelement-26	Code	Fixed value: r			Symbol for TNM: Is this tumor recurring from a previous disease..			draft	r - Tumor recurrence (tumor staging) (SNOMED Clinical Terms: 277647002) r (TNM Edition7 UICC: r) r (TNM Edition6 UICC: r) r (TNM Edition5 UICC: r)		Item	Tumor formula (TNM)
Observation Timestamp	psr-dataelement-13	Date/time	Timestamp precision: at least day (DD), month (MM) and year (YYYY)			point in time when this observation was made			draft			Item	Tumor formula (TNM)
Nodes Affected	psr-dataelement-12	Quantity				How many nodes are affected by tumor?			draft			Item	Tumor formula (TNM)
Nodes Examined	psr-dataelement-11	Quantity				number of nodes examined			draft			Item	Tumor formula (TNM)
Sentinel Lymph Nodes	psr-dataelement-102	Code				Regional lymph nodes according the sentinel concept: first draining lymph node for a tumor site			draft	Specimen from sentinel lymph node (specimen) (SNOMED Clinical Terms: 441709004)		Item	Tumor formula (TNM)
Isolated tumor cells (ITC)	psr-dataelement-103	Code			Value Set: UICC Isolated Tumor Cells (2017-03-13T09:48:35) (i+) (i-) (mol+) (mol-) Asked but unknown	Single tumor cells or small cluster of tumor cells, not larger than 0.2 mm in diameter, usually detected by immunohistochemistry or molecular pathology. No typical characteristics of metastases (stromal reaction, proliferation). If such ITC are detected in lymph nodes, those are classified as pN0(i+) or pN0(mol+) (regional) or as pM0(i+) or pM0(mol+) (non-regional). For negativity of immunohistochemical or molecular pathologic findings in lymph nodes the same rules are applied (i- or mol-)			draft		UICC Isolated Tumor Cells 2017-03-13T09:48:35 (dynamic)	Item	Tumor formula (TNM)
Micrometasis	psr-dataelement-106	Code			mi ((mi))	Micrometasis (equal or less than 0.2 mm in largest diameter) in regional or extra-regional lymph nodes (pN1 or pM1). Used as suffix for N- and M-category in TNM			draft			Item	Tumor formula (TNM)
N-category	psr-dataelement-8	Code			Value Set: UICC N category (2017-07-21T10:00:53) N0 N1 N1mi N1a N1b N1c N2 N2a N2b N2c N3 N3a N3b N3c Nx N0 N1 N1mi N1a N1b N1c N2 N2mi N2a N2b N2c N3 N3mi N3a N3b N3c Nx Asked but unknown	N-category (regional lymph nodes) of the TNM classification			draft	Regional lymph nodes.pathology [Class] Cancer (Logical Observation Identifier Names and Codes: 21900-6)	UICC N category 2017-07-21T10:00:53 (dynamic)	Item	Tumor formula (TNM)
M-category	psr-dataelement-7	Code		M0, i.e. no distant metastases	Value Set: UICC M category (2017-07-21T10:31:38) M0 M1 M1(mi) M1a M1b M1c M1d M1e M1(cy) MX M0 M1 M1a M1b M1c M1d M1(cy) MX Asked but unknown	M-category (distant metastases) of the TNM classification			draft	Distant metastases.pathology [Class] Cancer (Logical Observation Identifier Names and Codes: 21901-4)	UICC M category 2017-07-21T10:31:38 (dynamic)	Item	Tumor formula (TNM)
T-category	psr-dataelement-6	Code			Value Set: UICC T category (2017-07-07T15:06:39) Ta Tis Tis(DCIS) Tis(LCIS) Tis(Paget) Tis(pu) Tis(pd) T0 T1 T1mi T1a T1a1 T1a2 T1b T1b1 T1b2 T1c T1d T2 T2a T2a1 T2a2 T2b T2c T2d T3 T3a T3b T3c T3d T4 T4a T4b T4c T4d T4e TX Ta Tis Tis(LAMN) Tis(DCIS) Tis(LCIS) Tis(Paget) Tis(pu) Tis(pd) T0 T1 T1mi T1a T1a1 T1a2 T1b T1b1 T1b2 T1c T1c1 T1c2 T1c3 T1d T2 T2a T2a1 T2a2 T2b T2c T2d T3 T3a T3b T3c T3d T3e T4 T4a T4b T4c T4d T4e TX Asked, but unknown	T-category of the TNM classification			draft	Primary tumor.pathology Cancer (Logical Observation Identifier Names and Codes: 21899-0)	UICC T category 2017-07-07T15:06:39 (dynamic)	Item	Tumor formula (TNM)
Residual tumor status	psr-dataelement-46	Code			Value Set: UICC Residual tumor (R) classification (2015-06-25T11:23:51) Residual tumor stage R0 (finding) Surgical circumferential margin is closest uninvolved margin to malignant neoplasm (finding) Residual tumor stage R1 (finding) Surgical circumferential margin involved by malignant neoplasm (tumor present 0-1 mm from circumferential resection margin) (finding) Residual tumor stage R2 (finding) Residual tumor stage RX (finding) RX R0 > 1mm R0 < 1mm R1 R1-dir R1(is) R1(cy) R2 R2a R2b R2c CRM positive CRM negative Asked but unknown	Status of residual tumor after any therapy			draft	Status of residual neoplasm (observable entity) (SNOMED Clinical Terms: 445200009)	UICC Residual tumor (R) classification 2015-06-25T11:23:51 (dynamic)	Item	Tumor formula (TNM)
Grading	psr-dataelement-53	Code			Value Set: UICC Grade 4 tiered (2015-11-13T19:46:53) G1 G2 G3 G4 GX 0 X lG mG hG B U T Asked but unknown	Method of histopathology to describe semiquantitatively resp. to classify the grade of differentiation / grade of malignancy of a malignant tumor. It results in four-tiered, three-tiered or two-tiered tumor grades. There is a tendency to reduce all systems to a two-tiered grading of low and high grade.		Large deviations from normal histoarchitecture, high pleomorphism of cells, and high proliferative activity correspond with a highly malignant behaviour. Low structural abnormalities, low pleomorphism and a low proliferative activity correspond with a rather good prognosis. This holds true for the vast majority of malignant tumors.	draft	Histological grade finding (finding) (SNOMED Clinical Terms: 373372005)	UICC Grade 4 tiered 2015-11-13T19:46:53 (dynamic)	Item	Tumor formula (TNM)