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National Cancer Data Base - Data Dictionary PUF 2015

CANCER IDENTIFICATION

Regional Lymph Nodes Positive

DD_category: 
PUF Data Item Name: 
REGIONAL_NODES_POSITIVE
NAACCR Item #: 
820
length: 
2
Allowable values: 
00 - 99
text: 
Right Justified, Zero-filled
Description: 
Records the exact number of regional lymph nodes examined by the pathologist and found to contain metastases.
Registry Coding Instructions: 
  • Only record information about regional lymph nodes in this item.
  • This item is based on pathology information only. If no lymph nodes were removed for examination, or if a lymph node drainage area was removed, but no lymph nodes were found, code 98.
  • Record the total number of regional lymph nodes removed and found to be positive by pathologic examination.
  • The number of regional lymph nodes positive is cumulative from all procedures that removed lymph nodes through the completion of surgeries in the first course of treatment.
  • This item is to be recorded regardless of whether the patient received preoperative treatment.
  • Any combination of positive aspirated, biopsied, sampled or dissected lymph nodes is coded 97 if the number of involved nodes cannot be determined on the basis of cytology or histology.

Code 99 for the following sites and histologies:

  • Brain and Cerebral Meninges (C70.0, C71.0-C71.9)
  • Other Parts of Central Nervous System (C70.1, C70.9, C72.0-C72.5, C72.8-C72.9)
  • Hodgkin and non-Hodgkin Lymphoma (M-959-972 EXCEPT 9700/3 and 9701/3)
  • Hematopoietic, Reticuloendothelial, Immunoproliferative and Myeloproliferative Neoplasms (M-9731-9734, 9740-9742, 9750-9758, 9760-9762, 9764-9769, 9800-9801, 9805, 9820, 9823, 9826-9827, 9831-9837, 9840, 9860-9861, 9863, 9866-9867, 9870-9876, 9891, 9895-9897, 9910, 9920, 9930-9931, 9940, 9945-9946, 9948, 9950, 9960-9964, 9970, 9975, 9980, 9982-9987, 9989)
  • Unknown and Ill-Defined Primary Sites (C42.0-C42.4, C76.0-C76.5, C76.7-C76.8, C77.0-C77.5, C77.8-C77.9, C80.9; Note: For C42.x and C77.x other than hematopoietic, reticuloendothelial, immunoproliferative and myeloproliferative neoplasms as listed above, Hodgkin and non-Hodgkin Lymphomas as listed above, and Kaposi sarcoma 9140/3)
Analytic Note: 

This item became part of the Collaborative Stage Data Collection System when CS was implemented in 2004. The PUF item reflects data submitted at any time, regardless of the applicable manual.

Regional Lymph Nodes Examined

DD_category: 
PUF Data Item Name: 
REGIONAL_NODES_EXAMINED
NAACCR Item #: 
830
length: 
2
Allowable values: 
00 - 90, 95 - 99
text: 
Right Justified, Zero-filled
Description: 
Records the total number of regional lymph nodes that were removed and examined by the pathologist.
Registry Coding Instructions: 
  • Only record information about regional lymph nodes in this data item.
  • This data item is based on pathology information only. If no lymph nodes were removed for examination, or if a lymph node drainage area was removed, but no lymph nodes were found, code 00.
  • Record the total number of regional lymph nodes removed and examined by the pathologist.
  • The number of regional lymph nodes examined is cumulative from all procedures that removed lymph nodes through the completion of surgeries during the first course of treatment.
  • Code 98 if lymph nodes are aspirated and other lymph nodes are removed.
  • This data item is to be recorded regardless of whether the patient received preoperative treatment.
  • If a lymph node biopsy was performed, code the number of nodes removed, if known. If the number of nodes removed by biopsy is not known, code 96.

Code 99 for the following primary sites and histologies:

  • Placenta (C58.9)
  • Brain and Cerebral Meninges (C70.0, C71.0-C71.9)
  • Other Parts of Central Nervous System (C70.1, C70.9, C72.0-C72.5, C72.8-C72.9)
  • Hodgkin and non-Hodgkin Lymphoma (M-959-972) EXCEPT 9700/3 and 9701/3)
  • Hematopoietic, Reticuloendothelial, Immunoproliferative and Myeloproliferative Neoplasms (M-9731-9734, 9740-9742, 9750-9758, 9760-9762, 9764-9769, 9800-9801, 9805, 9820, 9823, 9826-827, 9831-9837, 9840, 9860-9861, 9863, 9866-9867, 9870-9876, 9891, 9895-9897, 9910, 9920, 9930-9931, 9940, 9945-9946, 9948, 9950, 9960-9964, 9970, 9975, 9980, 9982-9987, 9989)
  • Unknown and Ill-Defined Primary Sites (C42.0-C42.4, C76.0-C76.5, C76.7-C76.8, C77.0-C77.5, C77.8-C77.9, C80.9); Note: For C42.x and C77.x, other than hematopoietic, reticuloendothelial, immunoproliferative and myeloproliferative neoplasms as listed above, Hodgkin and non-Hodgkin Lymphomas as listed above, and Kaposi sarcoma 9140/3)
Analytic Note: 

This item became part of the Collaborative Stage Data Collection System when CS was implemented in 2004. The PUF item reflects data submitted at any time, regardless of the applicable manual.

Diagnostic Confirmation

DD_category: 
PUF Data Item Name: 
DIAGNOSTIC_CONFIRMATION
NAACCR Item #: 
490
length: 
1
Allowable values: 
1, 2, 4 - 9
Description: 
Records the most definitive method of diagnostic confirmation of the cancer being reported at any time in the patient's history.
Registry Coding Instructions: 

For solid tumors only (histologies other than 9590-9992), this is a hierarchical schema to identify how the malignancy was determined - from histologic confirmation (1) being most precise to unknown (9) being the least. Lower numbered codes take precedence over higher numbered codes. The code must be changed to a lower code if a more definitive method confirms the diagnosis at any time during the course of the disease. Code 3 in the table below does NOT apply to solid tumors.

Separate rules were established for non-solid tumors (histology codes 9590-9992) in 2010. Prior to that, registrars were instructed to use Code 1 for positive hematologic findings and bone marrow specimens for leukemia, including peripheral blood smears and aspiration biopsies. Otherwise, to use Code 2 for positive brushings, washings, cell aspiration, and hematologic findings (except for leukemia).

For non-solid tumors (histology codes 9590-9992) beginning in 2010, the table below is NOT hierachical, and the rules for assignment are specific to non-solid tumors.

Coding Instructions for All Tumors

  • Assign Code 1 when the microscopic diagnosis is based on tissue specimens from biopsy, frozen section, surgery, autopsy, D&C or from aspiration or biopsy of bone marrow specimens.
  • Assign Code 2 when the microscopic diagnosis is based on cytologic examination of cells such as sputum smears, bronchial brushings, bronchial washings, prostatic secretions, breast secretions, gastric fluid, spinal fluid, pleural fluid, urinary sediment, cervical or vaginal smears, or from paraffin block speciments from concentrated spinal, pleural or peritoneal fluid. These methods are rarely used for hematopoietic or lymphoid tumors.
  • Assign Code 5 when the diagnosis of cancer is based on laboratory tests or marker studies which are clinically diagnostic for that cancer.
  • Assign Code 6 when the diagnosis is based only on the surgeon's operative report or from a surgical exploration or endoscopy or from gross autopsy findings in the absence of tissue or cytologic findings.

Additional Coding Instructions for Hematopoietic or Lymphoid Tumors (Histologies 9590-9992)

  • There is no priority hierachy for coding Diagnostic Confirmation for hematopoietic and lymphoid tumors. Most commonly, the specific histologic type is diagnosed by immunophenotypoing or genetic testing. See the Hematopoietic Database (DB) for information on the definitive diagnostic confirmation for specific tumors.
  • For leukemia only, assign Code 1 when the diagnosis is based only on the complete blood count (CBC), white blood count (WBC) or peripheral blood smear. Do not use Code 1 if the diagnosis was based on immunophenotyping or genetic testing using tissue, bone marrow, or blood.
  • Assign Code 3 when there is a histologic positive for cancer AND positive immuniphenotyping and/or postiive genetic testing results. Do not use Code 3 for neoplasms diagnosed prior to January 1, 2010.
  • Assign Code 8 when the case was diagnosed by any clinical method that can not be coded as 6 or 7. A number of hematopoietic and lymphoid neoplasms are dignosed by tests of exclusion where the tests for the disease are equivocal and the physician makes a clinical diagnosis based on the information from the equivocal tests and the patient's clinical presentation.
  • Assign Code 6 when the diagnosis is based only on the surgeon's operative report from a surgical exploration or endocscopy or from gross autopsy findings in the absence of tissue or cytologic findings.
  • Assign Code 1 when microscopic diagnosis is based on tissue specimens from biopsy, frozen section, surgery, autopsy or D&C or from aspiration of biopsy bone marrow specimens.
  • Assign Code 2 when microscopic diagnosis is based on cytologic examination of cells such as sputum smears, bronchial brushings, bronchial washings, prostatic secretions, breast secretions, gastric fluid, peritoneal fluid, urinary sediment, or peritoneal fluid. These methods are rarely used for hematopoietic or lymphoid cancers.
  • Assign Code 5 when the diagnosis of cancer is based on laboratory tests or marker studies which are clinically diagnostic for that specific cancer.
Analytic Note: 

In 2010, cancer registries in North America adopted new rules for coding hematopoietic and lymphoid tumors.  At that time, this item was modified for cases diagnosed in 2010 or later to better reflect the ways these tumors are diagnosed.  Code 3 was defined and implemented at that time, and the rules for coding were refined.  The instructions and table presented here represent a combination of the new instructions and the older instructions that still apply to solid tumors.

Grade

DD_category: 
PUF Data Item Name: 
GRADE
NAACCR Item #: 
440
length: 
1
Allowable values: 
1-9
Description: 
Describes the tumor's resemblance to normal tissue. Well differentiated (Grade I) is the most like normal tissue, and undifferentiated (Grade IV) is the least like normal tissue.
Registry Coding Instructions: 
  • Code grade according to ICD-O-3 (pp. 30-31 and 67).
  • Code the grade or differentiation as stated in the final pathologic diagnosis. If the differentiation is not stated in the final pathologic diagnosis, use the information from the microscopic description or comments.
  • When the pathology report(s) lists more than one grade of tumor, code to the highest grade, even if the highest grade is only a focus (Rule G, ICD-O-3, p. 21).
  • Code the grade or differentiation from the pathologic examination of the primary tumor, not from metastatic sites.
  • When there is no tissue diagnosis, it may be possible to establish grade through magnetic resonance imaging (MRI) or positron emission tomography (PET). When available, code grade based on the recorded findings from these imaging reports.
  • If the primary site is unknown, code the grade/differentiation as 9 (Unknown).
  • Code the grade for in situ lesions if the information is available. If the lesion is both invasive and in situ, code only the invasive portion. If the invasive component grade is unknown, then code 9.
  • Do not use "high grade", "low grade", or "intermediate grade" descriptions for lymphomas as a basis for differentiation. These terms are categories in the Working Formulation of Lymphoma Diagnoses and do not relate to grade/differentiation.
  • Codes 5-8 define T-cell or B-cell origin for leukemias and lymphomas. T-cell, B-cell, or null cell classifications have precedence over grading or differentiation.
  • Do not use the WHO grade to code this data item.
  • If no grade is given for astrocytomas, then code 9 (Unknown).
  • If no grade is given for glioblastoma multiforme, then code 9 (Unknown).
Analytic Note: 

Although ICD-O-2 and ICD-O-3 Grade/Differentiation are collected as separate items, the only difference between the two editions is that code 8 (NK cells) was added after ICD-O-2 was initially published. They are combined in the PUF, as an output to the ICD-O-2 to ICD-O-3 conversion used for histology and behavior.

Behavior

DD_category: 
PUF Data Item Name: 
BEHAVIOR
length: 
1
Allowable values: 
0 - 3
Description: 
Records the behavior of all cases reported to the NCDB. The fifth digit of the morphology code is the behavior code.
Analytic Note: 

This item is the product of the application of the conversion rules expressed in ICDO2-3_SEER.xls (http://seer.cancer.gov/tools/conversion/index.html) for cases diagnosed prior to 2001, which were originally coded according to ICD-O-2, and ICD-O-3 codes reported by facilities for cases diagnosed in 2001 or later.

Note: the xls file was modified from that available from the SEER web site – behavior code 1 associated with juvenile astrocytomas (9421) has been changed to 3 by agreement among North American registry standard setters, making it consistent with ICD-O-2.

Benign tumors or tumors of uncertain behavior (behavior codes 0, 1) are not reported to the NCDB except for the following sites: meninges (C70._), brain (C71._), spinal cord, cranial nerves, and other parts of central nervous system (C72._), pituitary gland (C75.1), craniopharyngeal duct (C75.2) and pineal gland (C75.3). These were not required to be reported until 2004.

Histology

DD_category: 
PUF Data Item Name: 
HISTOLOGY
length: 
4
Allowable values: 
See ICD-O-3 and the Hematopoeitic and Lymphoid Manual
Description: 
Records the tumor histology of all cases reported to the NCDB in International Classification of Disease for Oncology, Third Edition (ICD-O-3) terms.
Analytic Note: 

This item is the product of the application of the conversion rules expressed in ICDO2-3_SEER.xls (http://seer.cancer.gov/tools/conversion/index.html) for cases diagnosed prior to 2001, which were originally coded according to ICD-O-2, and the ICD-O-3 codes reported by registries for cases diagnosed in 2001 and subsequently. In addition, beginning with 2010 diagnoses, malignant hematopoietic and lymphoid histology codes not yet printed in the ICD-O-3 were added. For a list of the added codes, consult http://seer.cancer.gov/tools/heme/; the codes are in Appendix D of the Hematopoietic and Lymphoid Manual which can be accessed from the online or downloadable database files on that site. Hematopoietic and lymphatic cancers diagnosed prior to 2010 retain the earlier ICD-O-3 values.

A list of histologies and labels may be found on the online ICD-O-3 site: (http://codes.iarc.fr/home).

Laterality

DD_category: 
PUF Data Item Name: 
LATERALITY
NAACCR Item #: 
410
length: 
1
Allowable values: 
0 - 5, 9
Description: 
Identifies the side of a paired organ or the side of the body on which the reportable tumor originated. This applies to the primary site only.
Registry Coding Instructions: 
  • Code laterality for all paired sites (see Analytic Note).
  • Code all nonpaired sites 0 (see Analytic Note).
  • Record laterality for unknown primary site (C80.9) as 0 (not a paired site).
  • Do not code metastatic sites as bilateral involvement.
  • Code midline lesions 5 (see Analytic Note).
Analytic Note: 

Beginning with cases diagnosed in 2010, the code 5 is used for midline of paired sites. This code is applicable for very few sites, because it requires that the two lateral portions be contiguous (laterality of the skin of most parts of the body has a midline; laterality of the breast does not). For cases diagnosed prior to 2010, the midline was coded 9. Those cases are rare, but will be coded 9 in pre-2010 PUF cases.

The following are paired sites:

Parotid gland
Submandibular gland
Sublingual gland
Tonsillar fossa
Tonsillar pillar
Overlapping lesion of tonsil
Tonsil, NOS
Nasal cavity (excluding nasal cartilage and nasal septum)
Middle ear
Maxillary sinus
Frontal sinus
Main bronchus (excluding carina)
Lung
Pleura
Long bones of upper limb and scapula
Short bones of upper limb
Long bones of lower limb
Short bones of lower limb
Rib and clavicle (excluding sterum)
Pelvic bones (excluding sacrum, coccyx, and symphysis pubis)
Skin of eyelid
Skin of external ear
Skin of other and unspecified parts of face
Skin of trunk
Skin of upper limb and shoulder
Skin of lower limb and hip
Peripheral nerves and autonomic nervous system of upper limb and shoulder
Peripheral nerves and autonomic nervous system of lower limb and hip
Connective, cutaneous and other soft tissue of upper limb and shoulder
Connective, cutaneous and other soft tissue of lower limb and hip
Breast
Ovary
Fallopian tube
Testis
Epididymis
Spermatic cord
Kidney, NOS
Renal pelvis
Ureter
Eye and lacrimal gland
Cerebral meninges, NOS (beginning with 2004 diagnoses)
Cerebrum (beginning with 2004 diagnoses)
Frontal lobe (beginning with 2004 diagnoses)
Temporal lobe (beginning with 2004 diagnoses)
Parietal lobe (beginning with 2004 diagnoses)
Occipital lobe (beginning with 2004 diagnoses)
Olfactory lobe (beginning with 2004 diagnoses)
Optic lobe (beginning with 2004 diagnoses)
Acoustic lobe (beginning with 2004 diagnoses)
Cranial nerve, NOS (beginning with 2004 diagnoses)
Adrenal gland
Carotid body

Primary Site

DD_category: 
PUF Data Item Name: 
PRIMARY_SITE
NAACCR Item #: 
400
length: 
4
Description: 
Identifies the primary site, that is, the anatomic site of origin for the cancer.
Registry Coding Instructions: 
  • Record the ICD-O-3 (International Classification of Diseases for Oncology, Third Edition) topography code for the site of origin.
  • Consult the physician advisor to identify the primary site or the most definitive site code if the medical record does not contain that information.
  • Primary site codes may be found in the ICD-O-3 Topography, Numerical List section (ICD-O-3, p. 43) and in the Alphabetic Index (ICD-O-3, p. 105).
  • Topography codes are indicated by a "C" preceding the three-digit code number (do not record the decimal point).
  • Follow the coding rules outlined in ICD-O-3, pp. 20-40.
  • Use subcategory 8 for single tumors that overlap the boundaries of two or more sub-sites and the point of origin is not known.
  • Use subcategory 9 for multiple tumors that originate in one organ.
  • Code adenocarcinoma in multiple polyps as a single primary even if they involve more than one segment of the colon.
  • Code leukemias to bone marrow (C42.1).

Exception: Code myeloid sarcoma to the site of origin (see ICD-O-3 for coding rules).

Analytic Note: 

The ICD-O-3 is not publicly available for electronic download, but the manual can be borrowed from hospital registrars. The codes are similar to ICD-10, but not identical; they may be found in an appendix of some ICD-10 publications (not to be confused with the ICD-10-CM).

Year of Diagnosis

DD_category: 
PUF Data Item Name: 
YEAR_OF_DIAGNOSIS
NAACCR Item #: 
390
length: 
4
format: 
CCYY
Description: 
Records the year of initial diagnosis by a physician for the tumor being reported.
Registry Coding Instructions: 

Use the first date of diagnosis whether clinically or histologically confirmed. If the physician states that in retrospect the patient had cancer at an earlier date, then use the earlier date as the date of diagnosis.

Use the date therapy was started as the date of diagnosis if the patient receives a first course of treatment before a definitive diagnosis.

Refer to the list of "Ambiguous Terms" in Section One of Facility Oncology Registry Data Standards (FORDS) for language that represents a diagnosis of cancer.

Analytic Note: 

Cancer registries record the full date of initial diagnosis, only the year portion of the reported date is provided in the PUF.

Cases with unknown year of diagnosis are not submitted to NCDB.

Code Label
CCYY Four digit year
9999 Year of diagnosis unknown (excluded from the PUF)


Class of Case

DD_category: 
PUF Data Item Name: 
CLASS_OF_CASE
NAACCR Item #: 
610
length: 
2
Allowable values: 
00, 10-14, 20-22, 30-38, 40-43, 49, 99
Description: 
Classifies cases recorded in the database.
Registry Coding Instructions: 

Class of Case has 24 categories. Analytic cases are coded 00-22. Nonanalytic cases are coded 30-99.

Abstracting for analytic cases is to be completed within six months of the date of first contact.

Analytic Note: 

The CoC Accreditation Program does not require hospitals to abstract nonanalytic cases (30-99). Nonanalytic cases are not in the PUF data set, and are not included in the code definitions that follow.

The CoC Accreditation Program does not require Class of Case 00 cases diagnosed in 2006 or later to be staged or followed. They are included in the PUF, but PUF users may want to omit them from some forms of analysis.

Codes for Class of Case were expanded in 2010. For cases diagnosed prior to 2010, conversion of analytic cases was generally to Class of Case 00, 10 and 20; the other codes will not be well populated for earlier cases.

Only analytic Class of Case codes are included in the table below.

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