Patient data
COGNOME Surname TEXT [20] Last name of the patient
NOME Forename TEXT [15] First name of the patient
DATANASC Date of birth DATE [10] Date of birth of patient
ANNONASC Year of birth NUMERIC (LONG) [4] Year of birth of patient
COMUNENASC Birth place TEXT [27] Town of birth of patient
PROVNASC District TEXT [2] District of birth of patient
TESSERA ID 1 TEXT [16] Identification number
CF ID 2 TEXT [16] Identification number
INDIRIZZO Address TEXT [27] Home address of patient
COMUNERES Town TEXT [27] Town of residence of patient
PROVRES District TEXT [2] District of residence of patient
TELEFONO Tel. TEXT [12] Telephone number of patient
TELEFONO2 2nd telephone number of patient TEXT [12] 2nd telephone number of patient
STATOORMO Menstrual status CODED [1] Hormonal status 1 = fertile
2 = pregnancy
3 = post-menopause
4 = replacement therapy
9 = unknown
TAGLIA Size CODED [2] Bra size 1 = 32/70
2 = 34/75
3 = 36/80
4 = 38/85
5 = 40/90
6 = 42/95
7 = 44/100
8 = >46/105
9 = unknown
FAMILIARITA Family History CODED [1] Family history (coded) 0 = No
1 = Immediate family member <50y.
2 = Other
9 = Unknown
ALTRAFAM Family history (description) TEXT [25] Family history (description)
PRECCANCRO Prev. breast Ca CODED [1] Previous breast cancer 0 = no
1 = yes
9 = unknown
DATAPC Date DATE [10] Date of diagnosis of previous breast Ca
DIAGNOSI Diagnosis TEXT [15] Diagnosis of previous cancer
PARTTRIAL Trial CODED [1] Entry in clinical trials 0 = No
1 = Yes
9 = Unknown
NOMETRIAL Trial name TEXT [30] Trial name

Person follow-up
O01 Department TEXT [20] Department
O02 Date of first check-up visit DATE [10] Date of first check-up visit
O03 Patient status CODED [1] Patient status 0 = alive NED
1 = alive with stable illness
2 = alive with illness progression
3 = alive (illness status unknown)
4 = died of breast Ca
5 = died of another cause
6 = died of an unknown cause
7 = emigrated (life status unknown)
8 = lost to follow up
9 = unknown
O04 Patient status update DATE [10] Date of latest patient status updated
O05 Distant metastases CODED [1] Localisation of metastases 0 = none
1 = bone
2 = lung
3 = liver
4 = CNS
5 = non-axillary lymph node
6 = multiple
7 = other
8 = metastases, site unknown
9 = unknown
O06 Other site of mts TEXT [22] Other site of metastases
O07 Date of metastasis DATE [10] Date of first diagnosis of metastases
O08 New lesion CODED [1] Diagnosis of a new breast cancer 0 = no
1 = yes
9 = unknown
O09 Date of new lesion DATE [10] Date of diagnosis of the new lesion
O10 Date of examination 2 DATE [10] Date of examination 2
O11 department of examination 2 TEXT [20] department of examination 2
O12 Date of examination 3 DATE [10] Date of examination 3
O13 department of examination 3 TEXT [20] department of examination 3
O14 Date of examination 4 DATE [10] Date of examination 4
O15 department of examination 4 TEXT [20] department of examination 4
O16 Date of examination 5 DATE [10] Date of examination 5
O17 department of examination 5 TEXT [20] department of examination 5
O18 Date of examination 6 DATE [10] Date of examination 6
O19 department of examination 6 TEXT [20] department of examination 6
O20 Date of examination 7 DATE [10] Date of examination 7
O21 department of examination 7 TEXT [20] department of examination 7
O22 Date of examination 8 DATE [10] Date of examination 8
O23 department of examination 8 TEXT [20] department of examination 8
O24 Date of examination 9 DATE [10] Date of examination 9
O25 department of examination 9 TEXT [20] department of examination 9
O26 Date of examination 10 DATE [10] Date of examination 10
O27 department of examination 10 TEXT [20] department of examination 10
O28 Date of mammogram 1 DATE [10] Date of mammogram 1
O29 Date of mammogram 2 DATE [10] Date of mammogram 2
O30 Date of mammogram 3 DATE [10] Date of mammogram 3
O31 Date of mammogram 4 DATE [10] Date of mammogram 4
O32 Date of mammogram 5 DATE [10] Date of mammogram 5
O33 Notes TEXT [35] Notes from the person follow-up section
ID TEXT [9]

Information on lesion
B01 Breast side CODED [1] Side location of the lesion D = right
S = left
N = unknown
B02 Lesion site CODED [2] Predominant area 1 = superior-external
2 = central-external
3 = inferior-external
4 = inferior-central
5 = inferior-internal
6 = central-internal
7 = superior-internal
8 = superior-central
9 = areolar
88 = diffuse
99 = unknown
B03 Other lesions CODED [1] Classification of this lesion with respect to any other lesions recorded in the QT for the same pat. 1 = single or main
2 = double, contralateral
3 = double, ipsilateral
4 = metachronous contralateral
5 = metachronous ipsilateral
9 = unknown
B04 First lesion CODED [1] First lesion 0 = no
1 = yes
2 = first among malignant
9 = unknown
B05 Case for discussion BOOLEAN [1] Case for discussion
B06 DATE [10]
B07 TEXT [15]

Screening
C01 Screening centre TEXT [3] Screening centre code
C02 Categories of cases CODED [1] Classification of lesion in respect to screening status 1 = screen-detected
2 = self-referred woman
3 = interval
4 = not respondent woman
5 = not yet invited woman
6 = not registered or untraced woman
7 = screen-detected (i.m.)
8 = interval (i.m.)
9 = unknown
C03 Interval cases classif. CODED [1] Radiological classification of interval cancer cases 1 = true interval
2 = mammogram occult
3 = minimal signs
4 = false negative
5 = other
8 = unclassifiable
9 = unknown
C04A Date of diagn. mammo DATE [10] Data of the diagnostic mammogram for interval cancer
C04B Dept. TEXT [20] Name of the dept. which diagnostic mammogram was done
C04C Diagnostic mammogram CODED [1] Diagnostic mammogram for int. ca. 0 = not performed
1 = performed
2 = performed, in screening file
9 = unknown
C04D Notification CODED [1] Source of info on the int.ca. 1 = woman returned for symptoms
2 = woman
3 = active research
4 = GP
5 = other physician
6 = routine call
7 = other
9 = unknown
C05 Round number NUMERIC (BYTE) [1] Number (sequential) of invitations to attend screening received
C06 Test number NUMERIC (BYTE) [1] Number (sequential) of screening tests actually taken within the programme
C09 Date DATE [10] Date of screening mammogram
C09B Date of penultimate level 1 test DATE [10] Date of penultimate screening mammogram
C09C Result CODED [1] Result of last screening mammogram 0 = not performed
1 = negative
2 = positive
3 = assessment for symptoms
8 = unsuitable
9 = unknown
C10 Result radiologist 1 CODED [1] First radiologist's report on screening mammogram 0 = I level not performed
1 = negative
2 = positive
3 = symptomatic woman
8 = inadequate
9 = unknown
C10B Radiologist 1 TEXT [20] Radiologist 1
C11 Result radiologist 2 CODED [1] Second radiologist's report on screening mammogram 0 = double reading not performed
1 = negative
2 = positive
3 = symptomatic woman
8 = inadequate
9 = unknown
C11B Radiologist 2 TEXT [20] Radiologist 2
C12 Assessment date DATE [10] Date of further assessment after a positive screening test
C12B dept. level II TEXT [20] Assessment clinic department
C13 Radiologist TEXT [20] Code for radiologist present at the assessment clinic
C14 Surgeon TEXT [20] Surgeon present at the assessment clinic
C15 Notes TEXT [35] Notes

Diagnosis
D01 Source of referral CODED [1] Source of referral 1 = referral from screening programme
2 = other
9 = unknown
D02 Mammogram finding CODED [1] Result of mammogram 0 = not performed
1 = R1-Negative
2 = R2-Benign lesion
3 = R3-Abn. indetermined significance
4 = R4-Suspicious of malignancy
5 = R5-Malignant features
9 = Unknown
D02B CODED [1] 1 = in situ
2 = invasive
9 = unknown
D03 Date DATE [10] Date of mammogram
D04 Mammogram pattern CODED [1] Mammographic pattern 1 = regular opacity
2 = irregular opacity
3 = spiculated opacity
4 = stellate opacity
5 = distortion
6 = asymmetry
7 = other
9 = unknown
D05 Other pattern TEXT [24] Other pattern
D05B Microcalcifications CODED [1] Microcalcifications 0 = absent
1 = mainly punctiform
2 = mainly pleomorphic/granular
3 = mainly linear
8 = unspecified aspect present
9 = unknown
D06 Ultrasound finding CODED [1] Ultrasound scan 0 = Not performed
1 = U1-Negative
2 = U2-Benign lesion
3 = U3-Abn. indetermined significance
4 = U4-Suspicious of malignancy
5 = U5-Malignant features
9 = Unknown
D06B Descriptive res. TEXT [30] Descriptive result of ultrasound scan
D07 Date DATE [10] Date of ultrasound scan
D08 FNA CODED [1] Cytological result (Fine Needle Aspiration) 0 = Not performed
1 = C1-Inadequate
2 = C2-Benign epithelial cells
3 = C3-Atypia probably benign
4 = C4-Suspicious of malignancy
5 = C5-Malignant
9 = Unknown
D08A Date DATE [10] Date of sample
D08B dept. TEXT [20] Cytopathology department
D08C Guide CODED [1] Guide 1 = palpation
2 = ultrasound scan
3 = mammogram
4 = stereotaxy
9 = unknown
D08D No. sampl. NUMERIC (BYTE) [1] No. of samples
D09 Core biopsy CODED [1] Implementation of fine needle aspiration biopsy (Core Biopsy, tru-cut) 0 = Not performed
1 = B1-Unsatisfactory/Normal
2 = B2-Benign
3 = B3-Benign uncertain
4 = B4-Suspicious of malignancy
5 = B5-Malignant
9 = Unknown
D10 CODED [1] 1 = in situ
2 = invasive
9 = unknown
D10A Date DATE [10] Date
D10B Guide CODED [1] Guide 1 = palpation
2 = ultrasound scan
3 = mammogram
4 = stereotaxy
9 = unknown
D10C Specimen x-rays CODED [1] Radiography of biopsy specimen 0 = Not performed
1 = malignant calcifications present
2 = only benign calcifications present
3 = calcifications absent
9 = unknown
D10D No. sampl. NUMERIC (BYTE) [1] No. of samples
D10E Needle gauge CODED [1] Gauge of needle 0 = Core Biopsy, not specified
2 = G 18 or more
3 = G 16-17
4 = G 15
5 = G 14
6 = G 9-13
8 = G 8
7 = Vacuum-assisted not spec.
9 = unknown
D10F dept. TEXT [20] Department
D11 Disease extent CODED [1] Disease extent 0 = localized
1 = multifocal
2 = multicentric
9 = unknown
D12 Palpable lesion CODED [1] Palpable lesion 0 = no
1 = yes
9 = unknown
D13 Other clin.findings TEXT [15] Other clinical findings
D13A Clinical opinion CODED [1] Opinion of surgeon 1 = normal
2 = benign
3 = suspect
9 = unknown
D13B Date of clinical test DATE [10] Date of clinical test
D14 Nipple discharge CODED [1] Nipple discharge 0 = absent
1 = present
9 = unknown
D15 Nipple discharge cytology CODED [1] Nipple discharge cytology finding 0 = not performed
1 = benign not papillary
2 = papillary
3 = doubious
4 = suspicious of malignancy
5 = malignant
8 = unsatisfactory
9 = unknown
D16 Imaging/clinical size NUMERIC (INT) [3] Tumour size by imaging or clinical examination
D17 Size-method CODED [1] Method employed in determining size 1 = ultrasound
2 = mammographic
3 = clinical
9 = unknown
D18 Special T cases CODED [3] Special T cases TX = primary cancer not assessable
T0 = no primary cancer
T4A = extens. to chest wall
T4B = oedema or ulceration or nodules
T4C = both T4a and T4b
T4D = inflammatory ca.
TIS = carcinoma in situ
99 = unknown
D19 T TEXT [2] T by imaging or clinical examination
D20 N CODED [1] Regional nodes affected X = X
0 = 0
1 = 1
2 = 2
3 = 3
4 = 4
D21 M CODED [1] Distant metastases X = X
0 = 0
1 = 1
D23 Date of referral DATE [10] Date of surgical decision to operate or first therapy referral
D24 Recommendations CODED [1] Final recommendations to patient 0 = none
1 = normal controls
2 = follow-up
3 = exeresis
4 = CT neoadjuvant
5 = only RT
6 = only RT+CT
8 = assessment refused
9 = unknown
D24A Test CODED [1] Follow-up test prescribed 1 = only clinical test
2 = mammogram
3 = ultrasound scan
4 = FNA or CB
5 = other
9 = unknown
D24B Months NUMERIC (INT) [2] Months of follow-up
D25 Notes TEXT [35] Notes from diagnostic section

Histopathology
I01 Main diagnosis CODED [1] Final pathology 1 = benign
2 = in situ
3 = microinvasive
4 = invasive
5 = non epithelial
6 = other
9 = unknown
I02 other TEXT [13] Other main diagnosis at final pathology
I03 DCIS component CODED [1] Presence or absence of ductal IS component 0 = absent
1 = present
2 = E.I.C.
9 = unknown
I04 DCIS NUMERIC (INT) [3] Percentage of DCIS
I05 Benign type CODED [2] Histological type of benign lesions 0 = normal tissue
1 = fibroadenoma
2 = cysts
3 = atyp.ductal hyperplasia
4 = atyp.lobular hyperplasia
5 = atyp.apochrine metaplasia
6 = fibrocystic mastopatia
7 = ben.phylloid tumor.
8 = schlerosing adenosis
9 = radial scar
10 = papilloma/papillomatosis
88 = other
99 = unknown
I06 Invasive type CODED [2] Invasive histological type at final pathology 1 = ductal NST
2 = lobular
3 = medullary
4 = mucinous
5 = tubular, cribriform
6 = mixed ductal/lobular
7 = mixed ductal NST + other
8 = mixed tubular/lobular
10 = metastatic
11 = other
88 = not assessable
99 = unknown
I07 other TEXT [20] Other invasive type
I08 Histological grade CODED [1] Grade of invasive cancer 0 = not performed
1 = I
2 = II
3 = III
9 = unknown
I09 Classification CODED [1] Classification used for grade 1 = OMS
2 = Elston-Ellis
3 = other
9 = unknown
I10 Vascular invasion CODED [1] Presence or absence of vascular invasion (blood or lymphatic) 0 = not seen
1 = yes
8 = not evaluated
9 = unknown
I11 In situ type CODED [2] In situ histological type 1 = ductal NST
2 = ductal solid
3 = comedo
4 = papillary
5 = micropapillary
6 = cribriform
7 = clinging
10 = lobular
11 = other
88 = not assessable
99 = unknown
I12 other TEXT [20] Other in situ type
I13 Histological grade CODED [1] Grade of in situ (DCIS) lesions 0 = not performed
1 = low
2 = intermediate
3 = high
9 = unknown
I14 Classification CODED [1] Classification used for DCIS grading 1 = European Group
2 = Holland et al.
3 = Van Nuys
4 = Nottingham
9 = unknown
I15 Paget's disease CODED [1] Presence or absence of Paget's 0 = no
1 = yes
9 = unknown
I16 Disease extent CODED [1] Disease extent 0 = single
1 = multiple
9 = unknown
I17 Weigth of specimen NUMERIC (INT) [3] Fresh or fixed weight of specimen removed (gm)
I18 Marker distance NUMERIC (INT) [3] Distance between marker positioned preoperatively and margin of the lesion
I19 Specimen cut CODED [1] Indicate whether specimen has been opened in theatre 0 = no
1 = yes
9 = unknown
I20 Specimen orientation CODED [1] Specimen orientation 0 = no
1 = yes
9 = unknown
I21 Pathological size (mm) NUMERIC (INT) [3] Pathological size (mm)
I22 Total size (mm) NUMERIC (INT) [3] Total size (invasive + in situ)
I23 Final margins CODED [1] Evaluation of margins at final pathology after last operation 1 = T does not reach margins
2 = ca.in proximity
3 = inv.ca.focally reaches margins
4 = inv.ca.reaches margins
5 = DCIS in proximity
6 = DCIS focally reaches margins
7 = DCIS reaches margins
9 = unknown
I23B Margins after 1st operation CODED [1] Evaluation of margins after first operation (if >1 intervention) 1 = T does not reach margins
2 = ca.in proximity
3 = inv.ca.focally reaches margins
4 = inv.ca.reaches margins
5 = DCIS in proximity
6 = DCIS focally reaches margins
7 = DCIS reaches margins
9 = unknown
I24 min (inv.) NUMERIC (INT) [3] Minimum distance of the tumour from the margins
I24B min (inv.) NUMERIC (INT) [3] Minimum distance of the tumour from the margins
I25 max NUMERIC (INT) [3] Maximum distance of the tumour from the margins
I25A min (CDIS) NUMERIC (INT) [3] Minimum distance of the tumour from the margins
I25B min (CDIS) NUMERIC (INT) [3] Minimum distance of the tumour from the margins
I26 pT CODED [4] pT X
0
IS
1
1A
1B
1C
1mic
2
3
4
4A
4B
4C
4D
99
I27 Lymph nodes CODED [1] Lymph nodes 0 = negative
1 = positive
9 = unknown
I28 pN CODED [3] PN X = X
0 = 0
0LS = 0LS
1 = 1
1A = 1A
1B = 1B
1B1 = 1B1
1B2 = 1B2
1B3 = 1B3
1B4 = 1B4
2 = 2
3 = 3
999 = 999
I29 LN recovered NUMERIC (INT) [2] Number of lymph nodes examined by the pathologist
I30 Positive LN NUMERIC (INT) [2] Number of axillary lymph nodes containing tumour
I32 Histology no./date diagn. rep. TEXT [13] Diagnostic histopathology report number
I33 Date of diagnostic histopathology report DATE [10] Date of diagnostic histopathology report
I34 Date last report DATE [10] Date of histopathology report on last surgery
I35 Date LN report DATE [10] Date of histopathology report on lymph nodes
I36 Path. Dpt. TEXT [20] Pathology department
I37 Patholog. TEXT [20] Pathologist
I38 ER CODED [1] Oestrogen receptor status 0 = not performed
1 = negative
2 = positive
9 = unknown
I38A % pos. cells NUMERIC (INT) [3] Percentage of positive cells
I39 PgR CODED [1] Progesterone receptor status 0 = not performed
1 = negative
2 = positive
9 = unknown
I39A Score CODED [1] Score 0 = 0
1 = 1
2 = 2
3 = 3
4 = 4
5 = 5
6 = 6
7 = 7
8 = 8
9 = unknown
I40 Method CODED [1] Evaluation method adopted for hormonal receptor status 1 = immunohistochemistry
2 = biochemical
3 = immunological
9 = unknown
I41 Other markers CODED [1] Other prognostic markers 0 = no
1 = yes
9 = unknown
I41A TEXT [20]
I42 Date receptor status DATE [10] Date of report on hormonal receptors status
I43 Notes TEXT [35] Notes

Radiotherapy
L01 Radiotherapy (RT) performed CODED [1] Radiotherapy (RT) performed 0 = no
1 = yes
2 = patient refusal
9 = unknown
L02 Radiotherapy dpt. TEXT [20] Radiotherapy department
L03 Date of presentation DATE [10] Date of first RT appointment
L04 Date of first RT DATE [10] Date of first RT fraction
L05 Scheduled date of last RT DATE [10] Scheduled date of last RT fraction
L06 Actual date of last RT DATE [10] Actual date of last RT fraction
L07 Dose per fraction (dGy) NUMERIC (INT) [3] Conventional RT fraction
L08 Reas. for departure TEXT [20] Reason for not using conventional RT fraction
L09 Total dose (dGy) NUMERIC (INT) [3] Total administered dose
L10 Boost dose (dGy) NUMERIC (INT) [3] Boost dose administered
L11 Breast CODED [1] Breast 0 = No
1 = Cobalt60
2 = x-MV
3 = Other
8 = yes, unknown method
9 = Unknown
L12 MV NUMERIC (LONG) [3] MV
L13 Radiotherapy boost CODED [1] Radiotherapy boost 0 = No
1 = Electrons
2 = x-MV
3 = Interstitial brachytherapy
4 = Other
8 = yes, unknown method
9 = Unknown
L14 MeV NUMERIC (LONG) [3] MeV
L15 Chest wall CODED [1] Chest wall 0 = No
1 = Cobalt60
2 = x-MV
3 = X-rays
4 = Electrons
5 = Contact brachytherapy
7 = Other
8 = yes, unknown method
9 = Unknown
L16 MeV NUMERIC (LONG) [3] MeV
L17 Supra/infra clavic.nodes CODED [1] Supra/infra clavicular nodes 0 = No
1 = Cobalt60
2 = x-MV
3 = Other
9 = Unknown
L18 MV NUMERIC (LONG) [3] MV
L19 Internal mamm.nodes CODED [1] Internal mammary nodes 0 = No
1 = Cobalt60
2 = x-MV
3 = Electrons
4 = Other
9 = Unknown
L20 MeV NUMERIC (LONG) [3] MeV
L21 Axilla CODED [1] Axilla 0 = No
1 = apex
2 = in toto
9 = unknown
L22 CODED [1] 1 = Cobalt60
2 = x-MV
3 = Other
9 = Unknown
L23 MV NUMERIC (LONG) [3] MV
L24 Interruption to therapy CODED [1] Interruption to therapy for technical reasons 0 = no
1 = yes
9 = unknown
L25 Notes TEXT [35] Notes

Hormono\chemotherapy
M01 Endocrine therapy performed CODED [1] Endocrine therapy performed 0 = no
1 = yes
2 = patient refusal
9 = unknown
M02 Ovarian ablation CODED [1] Ovarian ablation performed 0 = no
1 = surgery
2 = radiotherapy
3 = GnRH analogs
4 = other
9 = unknown
M03 other types TEXT [20] Other type of ovarian ablation
M04 Hormonotherapy CODED [1] State if hormone therapy has been prescribed 0 = no
1 = yes
9 = unknown
M05 Drug CODED [1] Drug prescribed 1 = tamoxiphen
2 = letrozole
3 = formestan
4 = anastrozole
5 = exemestan
6 = toremiphen
7 = other
9 = unknown
M06 Other type of drug TEXT [20] Other type of drug
M07 Start date DATE [10] Treatment start date
M08 End date DATE [10] Treatment end date
M09 Expected duration (m) NUMERIC (INT) [2] Expected duration of treatment in months
M10 Withdrawal due to toxicity CODED [1] Withdrawal due to toxicity 0 = no
1 = yes
9 = unknown
M11 Chemohormonotherapy CODED [1] Treatment in association with chemotherapy 0 = no
1 = yes
9 = unknown
M12 Type of association CODED [1] Type of association with chemotherapy 1 = synchronous
2 = sequential
9 = unknown
M13 Chemotherapy performed CODED [1] Chemotherapy performed 0 = no
1 = yes
2 = patient refusal
9 = unknown
M14 Start date DATE [10] Date of first cycle
M15 End date DATE [10] Date of last cycle
M15A Scheme CODED [30] Combination of drugs 1 = AC
2 = CMF 1-8
3 = EPI+CMF 1-8
4 = FAC
5 = FEC
6 = EPI 120
7 = CEF 1-8
8 = EC
9 = ADM-TAX
10 = EPI-TAX
11 = AT
12 = other
99 = unknown
M28 Withdrawal due to toxicity CODED [1] Withdrawal due to toxicity 0 = no
1 = yes
9 = unknown
M29 Dept. TEXT [20] Department
M30 Notes TEXT [40] Notes
M31 Breast Ca CODED [1] Breast cancer 0 = not documented
1 = histologically documented
2 = histologically documented (CB)
3 = cytologically documented
4 = clinically certain case
M32 Histological report CODED [1] Histology report is data source 0 = no
1 = yes, consulted
2 = yes, copy in file
9 = unknown
M33 Specimen x-ray in file CODED [1] X-ray of the operating specimen in file 0 = no
1 = yes
9 = unknown

Early complications
M34 Breast CODED [1] Postoperative complications of breast 0 = none
1 = haematoma
2 = necrosis
3 = abscess
4 = dehiscence
5 = other
9 = unknown
M35 Axilla CODED [1] Postoperative complications of axilla 0 = none
1 = lymphorrhoea
2 = lympho-schlerosis
3 = lymphorrhoea and lymphsclerosis.
4 = other
9 = unknown
M36 Post-radiotherapy CODED [1] Post radiotherapy complications 0 = none
1 = serious radiation dermatititis
2 = costal fracture
3 = other
9 = unknown
M37 other type TEXT [20] Other type of complication
M38 Therapy for complications CODED [1] Therapy undertaken for the complications 0 = none
1 = medical
2 = surgical
3 = physiotherapy
4 = other
9 = unknown
M39 other therapy TEXT [20] Other therapy for the complications

Documentation
N00 Operated CODED [1] patient operated on 0 = no
1 = yes
9 = unknown
N00A Reason for no intervention CODED [1] Reason for non-intervention 0 = not yet operated
1 = refusal
2 = inoperable cancer
9 = unknown
N00B Date of updating DATE [10] Date of updating

Recurrence
N01 Recurrence CODED [1] Loco-regional recurrence is present 0 = no
1 = yes
9 = unknown
N01B Diagnosis of first relapse CODED [1] Diagnosis of first relapse 2 = in situ
3 = microinvasive
4 = invasive
6 = other
9 = unknown
N02 Breast CODED [1] Local recurrence in residual breast 0 = no
1 = yes
9 = unknown
N03 Date DATE [10] Date of diagnosis of first breast recurrence
N04 Axilla CODED [1] Regional recurrence in axilla 0 = no
1 = yes
9 = unknown
N05 Date DATE [10] Date of diagnosis of first axillary recurrence
N06 Chest wall CODED [1] Regional recurrence in chest wall 0 = no
1 = yes
9 = unknown
N07 Date DATE [10] Date of diagnosis of chest wall recurrence
N08 Other CODED [1] Other loco-regional recurrence 0 = no
1 = yes
9 = unknown
N09 Other site of recurrence TEXT [30] Other site of recurrence

Late complications
N10 Late complications CODED [1] Late complications 0 = no
1 = yes
8 = not evaluated
9 = unknown
N11 Lymphoedema CODED [1] Lymphoedema 0 = no
1 = yes
9 = unknown
N12 Date of diagnosis DATE [10] Date of diagnosis of lymphoedema
N13 Assessment method CODED [1] Method to assess lymphoedema 1 = arm circunference
2 = other
9 = unknown
N14 other method TEXT [21] Other assessment method
N15 Difference (%) NUMERIC (INT) [3] Difference in arm circumference compared to contralateral arm, in percent
N16 Loco-regional pain CODED [8] Loco-regional pain 0 = no
1 = yes
9 = unknown
N17 Date of diagnosis DATE [10] Date of loco-regional pain diagnosis
N18 Shoulder-joint distress CODED [1] Shoulder-joint distress 0 = no
1 = yes
9 = unknown
N19 Date of diagnosis DATE [10] Date of shoulder-joint distress diagnosis
N20 Other CODED [1] Other complications 0 = no
1 = yes
9 = unknown
N21 Other complications TEXT [20] Other complications
N22 Date of diagnosis DATE [10] Date of diagnosis of other complications
N23 Notes TEXT [35] Notes
N24 Date of visit DATE [10] Date of examination
N25 Reduced overall dimensions CODED [1] Reduced overall dimensions 0 = no
1 = yes
9 = unknown
N26 Percentage reduction in overall dimensions NUMERIC (INT) [3] Percentage reduction in overall dimensions
N27 Changes in substance loss profile CODED [1] Alterations in loss of substance profile 0 = no
1 = yes
9 = unknown
N28 mm. NUMERIC (SINGLE) [5] mm. alterations in loss of substance profile
N29 Jugular-nipple distance (healthy side) NUMERIC (SINGLE) [5] Jugular-nipple distance (healthy side)
N30 Horizontal plane difference NUMERIC (SINGLE) [5] Horizontal plane distance
N31 Vertical plane difference NUMERIC (SINGLE) [5] Vertical plane difference
N32 Non linear scar CODED [1] Non-linear scar 0 = no
1 = yes
9 = unknown
N33 Retracting scar CODED [1] Retracting scar 0 = no
1 = yes
9 = unknown
N34 Keloid scar CODED [1] Keloid scar 0 = no
1 = yes
9 = unknown
N35 Subcutaneous fibrosis CODED [1] Subcutaneous fibrosis 0 = no
1 = yes, palpable
2 = yes, visible and palp.
9 = unknown
N36 Teleangiectasis CODED [1] Teleangectasis 0 = no
1 = yes
9 = unknown
N37 Stain CODED [1] Stain 0 = no
1 = yes
9 = unknown
N38 Keloid scar CODED [1] Keloid scar 0 = no
1 = yes
9 = unknown
N39 Retracting scar CODED [1] Retracting scar 0 = no
1 = yes
9 = unknown
N40 Adherent scar CODED [1] Adherent scar 0 = no
1 = yes
9 = unknown
status NUMERIC (INT) [1]

INTERVENTIONS
E01 Admission date DATE [10] Date of admission for 1st intervention
E02 Discharge date DATE [10] Date of a discharge after 1st intervention
E03 Dept. Code TEXT [6] Hospital dept. code at 1st intervention
E04 Dept. TEXT [20] Other hospital dept. at 1st intervention
E05 Date of interv. DATE [10] Date of 1st breast operation
E06 Surgical team TEXT [20] Name of 1st surgeon for 1st breast operation
E06B Name of 2nd surgeon for 1st breast operation TEXT [20] Name of 2nd surgeon for 1st breast operation
E07 Anaesthes. CODED [1] Type of anaesthesia at 1st breast operation 1 = local
2 = general
9 = unknown
E08 Breast procedure CODED [1] Type of conclusive operation performed during surgical session (1st breast operation) 2 = excisional biopsy/lumpectomy
3 = wide resection
4 = quadrantectomy
5 = subcutaneous mastectomy
6 = mastectomy
7 = skin sparing mastectomy
8 = other
9 = unknown
E08B Periareolar inc. CODED [1] Type of periareolar incision in 1st breast operation 1 = simple
2 = widened
3 = skin on lesion
4 = skin on scar
5 = radial extension
9 = unknown
E09 other TEXT [20] Other type of intervention (1st breast operation)
E10 Initial proc. CODED [1] Breast procedure prior to conclusive operation in the same surgical session 0 = none
1 = biopsy
2 = lumpectomy
3 = wide excision
4 = quadrantectomy
9 = unknown
E11 Marker posit. CODED [1] Positioning of marker wires or other means of localisation of impalpable breast lesions 0 = none
1 = hypodermic or tatoo
2 = hookwire system
3 = carbon deposition
4 = other
9 = unknown
E12 other TEXT [20] Other positioning (1st breast operation)
E13 Specimen X-ray CODED [1] Specimen X-ray (1st breast operation) 0 = no
1 = yes, 1 view
2 = yes, 2 views
3 = yes
9 = unknown
E13B Specimen X-ray result CODED [1] Result of RX specimen (1st breast operation) 0 = No lesion
1 = Lesion present and centred
2 = Lesion present but not centred
9 = unknown
E14 Frozen section - lesion CODED [1] Result of frozen section of the lesion (1st breast operation) 0 = not performed
1 = yes, negative
2 = yes, dubious
3 = yes, positive for CIS
4 = yes, positive for inv. Ca.
5 = yes, result unknown
9 = unknown
E15 Frozen section - margins CODED [1] Result of frozen section of the lesion (specimen margins) (1st breast operation) 0 = not performed
1 = T does not reach margin
2 = CIS in proximity
3 = inv. ca. in proximity
4 = CIS reaches margin
5 = inv. Ca. reaches margin
6 = done, result unknown
9 = unknown
E16 Weight of specimen NUMERIC (INT) [3] Total weight (in grams) of the mammary tissue excised (1st breast operation)
E17 Antibiotic prophylaxis CODED [2] Antibiotic prophylaxis at 1st intervention 0 = no
1 = yes
9 = unknown
E18 Marker drawing CODED [2] Drawing of patient at 1st intervention 0 = not done
1 = with patient supine
2 = with patient sitting
3 = done, unknown pos.
9 = unknown
E19 Length of incision (mm) NUMERIC (SINGLE) [4] Length of incision at 1st intervention
E20 Location of incision CODED [2] Location of incision at 1st intervention 1 = Above the tumour
2 = Away from the tumour
9 = unknown
E21 Skin excision CODED [2] Skin excision at 1st intervention 1 = done
2 = not done
3 = unknown
E22 Scalpel no. CODED [2] Scalpel number at 1st intervention 1 = 10
2 = 10A
3 = 11
4 = 12
5 = 15
6 = 18
7 = 20
8 = 21
9 = 22
10 = 23
11 = 24
12 = 25
99 = unknown
E23 Type of incision CODED [2] Type of incision at 1st intervention 1 = radial
2 = peri-areolar
3 = arcued concentric
4 = under-breast sulcus
5 = other
9 = unknown
E24 Excision of lesion CODED [2] Type of scalpel used for excision at 1st intervention 1 = with scalpel or scissors
2 = with acusector
3 = with ultrasound scalpel
4 = other
9 = unknown
E25 Exc. of sheath of musc. tissue CODED [2] Excision of sheath of muscular tissue at 1st intervention 0 = no
1 = yes
9 = unknown
E26 Tissue mobilis. and remodelling CODED [2] Mobilisation and remodelling of the tissue at 1st intervention 0 = no
1 = yes
9 = unknown
E27 Suture of breast parenchyma CODED [2] Suture of breast parenchyma at 1st intervention 0 = no
1 = yes patient sitting
2 = yes patient supine
3 = yes, unknown position
9 = unknown
E28 Skin suture CODED [2] Cutaneous suture at 1st intervention 1 = detached/stitches
2 = det./silk
3 = det./Steri-strip
4 = det./glue
5 = intradermal stitches
6 = continual/Steri-strip
7 = cont./glue
8 = intradermal continual
9 = cutis stitches
10 = cut.silk
11 = cut.Steri-strip
12 = cut.glue
E29 Drainage CODED [2] Draining at 1st intervention 0 = none
1 = "falling"
2 = capillary
3 = aspiration
9 = unknown
E30 Medication CODED [2] Medication at 1st intervention 0 = no
1 = compressive
2 = remodelling
3 = compr.and remod.
4 = flat
9 = unknown
E31 Duration in hours NUMERIC (INT) [2] Duration in hours of bandaging at 1st intervention
E32 Axilla incision CODED [2] Axilla incision at 1st intervention 1 = separated
2 = in continuity
3 = longitudinal
4 = transversal
5 = transversal curvilinear
9 = unknown
E33 Controlateral remodelling CODED [2] Controlateral remodelling at 1st intervention 0 = no
1 = yes
9 = unknown
F01 Admission date DATE [10] Date of admission for 2nd intervention
F02 Discharge date DATE [10] Date of a discharge after 2nd intervention
F03 Dept. Code TEXT [6] Hospital dept. code at 2nd intervention
F04 Dept. TEXT [20] Other hospital dept. at 2nd intervention
F05 Date of interv. DATE [10] Date of 2nd breast operation
F06 Surgical team TEXT [20] Name of 1st surgeon for 2nd breast operation
F06B Name of 2nd surgeon for 2nd breast operation TEXT [20] Name of 2nd surgeon for 2nd breast operation
F08 Breast procedure CODED [1] Type of conclusive operation performed during surgical session (2nd breast operation) 2 = lumpectomy
3 = wide resection
4 = quadrantectomy
5 = subcutaneous mastectomy
6 = mastectomy
7 = skin sparing mastectomy
8 = other
9 = unknown
F08B Periareolar inc. CODED [1] Type of periareolar incision in 2nd breast operation 1 = simple
2 = widened
3 = skin on lesion
4 = skin on scar
5 = radial extension
9 = unknown
F09 other TEXT [20] Other type of intervention (2nd breast operation)
F17 Antibiotic prohylaxis CODED [2] Antibiotic prophylaxis at 2nd breast operation 0 = no
1 = yes
9 = unknown
F18 Marker drawing CODED [2] Drawing of patient at 2nd breast operation 0 = not done
1 = with patient supine
2 = with patient sitting
3 = done, unknown pos.
9 = unknown
F19 Length of incision (mm) NUMERIC (SINGLE) [4] Length of incision at 2nd breast operation
F20 Location of incision CODED [2] Location of incision at 2nd breast operation 1 = Above the tumour
2 = Away from the tumour
9 = unknown
F21 Skin excision CODED [2] Skin excision at 2nd breast operation 1 = done
2 = not done
3 = unknown
F22 Scalpel no. CODED [2] Scalpel number at 2nd breast operation 1 = 10
2 = 10A
3 = 11
4 = 12
5 = 15
6 = 18
7 = 20
8 = 21
9 = 22
10 = 23
11 = 24
12 = 25
99 = unknown
F23 Type of incision CODED [2] Type of incision at 2nd breast operation 1 = radial
2 = peri-areolar
3 = arcued concentric
4 = under-breast sulcus
5 = other
9 = unknown
F24 Excision of lesion CODED [2] Type of scalpel used for excision at 2nd breast operation 1 = with scalpel or scissors
2 = with acusector
3 = with ultrasound scalpel
4 = other
9 = unknown
F25 Exc. of sheath of musc. tissue CODED [2] Excision of sheath of muscular tissue at 2nd breast operation 0 = no
1 = yes
9 = unknown
F26 Tissue mobilis. and remodelling CODED [2] Mobilisation and remodelling of tissue at 2nd breast operation 0 = no
1 = yes
9 = unknown
F27 Suture of breast parenchyma CODED [2] Suture of breast parenchyma at 2nd breast operation 0 = no
1 = yes radial
2 = yes concentric
3 = yes patient sitting
4 = yes patient supine
9 = unknown
F28 Skin suture CODED [2] Cutaneous suture at 2nd breast operation 1 = detached/stitches
2 = det./silk
3 = det./Steri-strip
4 = det./glue
5 = intradermal stitches
6 = continual/Steri-strip
7 = cont./glue
8 = intradermal continual
9 = cutis stitches
10 = cut.silk
11 = cut.Steri-strip
12 = cut.glue
F29 Drainage CODED [2] Drainage at 2nd breast operation 0 = none
1 = "falling"
2 = capillary
3 = aspiration
9 = unknown
F30 Medication CODED [2] Medication at 2nd breast operation 0 = no
1 = compressive
2 = remodelling
3 = compr. and remod.
4 = flat
9 = unknown
F31 Duration in hours NUMERIC (INT) [2] Duration in hours of bandaging at 2nd breast operation
F32 Incision of axilla CODED [2] Axillary incision at 2nd breast operation 1 = separated
2 = in continuity
3 = longitudinal
4 = transversal
5 = transversal curvilinear
9 = unknown
F33 Controlateral remodelling CODED [2] Controlateral remodelling at 2nd breast operation 0 = no
1 = yes
9 = unknown
F34 Admission date DATE [10] Date of admission for 3rd breast operation
F35 Discharge date DATE [10] Date of discharge after 3rd breast operation
F36 Dept. Code TEXT [6] Hospital dept. code at 3rd breast operation
F37 Dept. TEXT [20] Other dept. at 3rd breast operation
F38 Date of interv. DATE [10] Date of 3rd breast operation
F39 Surgical team TEXT [20] Name of 1st surgeon for 3rd breast operation
F39B Name of 2nd surgeon for 3rd breast operation TEXT [20] Name of 2nd surgeon for 3rd breast operation
F40 Breast procedure CODED [1] Type of conclusive operation performed during 3rd surgical session 3 = wide resection
4 = quadrantectomy
5 = subcutaneous mastectomy
6 = mastectomy
7 = skin sparing mastectomy
8 = other
9 = unknown
F40B Periareolar inc. CODED [1] Type of periareolar incision at 3rd breast operation 1 = simple
2 = widened
3 = skin on lesion
4 = skin on scar
5 = radial extension
9 = unknown
F41 other TEXT [20] Other type of intervention (3rd breast operation)

Axillary dissection
G01 Execution of axillary operation CODED [1] Execution of axillary operation 0 = no
1 = yes
9 = unknown
G02 Timing CODED [1] Time relationship between axillary operation and breast surgery on the same lesion 1 = 1st breast surgery
2 = 2nd breast surgery
3 = 3rd breast surgery
4 = at a separate session
9 = unknown
G03 Admission date DATE [10] Date of admission (axillary operation)
G04 Discharge date DATE [10] Date of discharge (axillary operation)
G05 Dept. Code TEXT [6] Hospital department code
G06 Dept. TEXT [20] Hospital department
G07 Date of interv. DATE [10] Date of intervention (axillary operation)
G08 Surgical team TEXT [20] Name of 1st surgeon for axillary operation
G08B Name of 2nd surgeon for axillary operation TEXT [20] Name of 2nd surgeon for axillary operation
G09 Dissection type CODED [1] Type of axillary operation (level) 1 = level I
2 = levels I+II
3 = levels I+II+III
4 = other
9 = unknown
G10 other TEXT [20] Other LN procedure
G11 Dissection of TD nerve CODED [1] Section of thoracodorsal nerve 0 = no
1 = yes
9 = unknown
G12 Dissection of ICB nerve CODED [1] Section of intercostobrachial nerve 0 = no
1 = yes
9 = unknown
G13 Dissection of LT nerve CODED [1] Section of long thoracic nerve (Bell's nerve) 0 = no
1 = yes
9 = unknown
G14 Pectoral muscles CODED [1] Total or partial excision of pectoral muscles 1 = both intact
2 = minor removed
3 = both removed
9 = unknown
G15 Skin suture CODED [2] Cutaneous suture in the axillary dissection 1 = detached/stitches
2 = det./silk
3 = det./Steri-strip
4 = det./glue
5 = intradermal stitches
6 = continual/Steri-strip
7 = cont./glue
8 = intradermal continual
9 = cutis stitches
10 = cut.silk
11 = cut.Steri-strip
12 = cut.glue

Surgery summary
H01 Number of operations CODED [1] Number of interventions made for the same lesion 1 = one
2 = two
3 = more than two
9 = unknown
H02 Reason for more than one op. CODED [1] Reason for recourse to subsequent interventions 1 = dissection
2 = edges or radicalisation
3 = edges+dissec.
4 = neoad treatment.
5 = other
9 = unknown
H03 other TEXT [20] Other reason for several interventions
H04 Immediate breast reconstr. CODED [1] Immediate reconstruction 0 = no
1 = yes
9 = unknown
H05 Type of reconstruction CODED [1] Type of immediate reconstruction 0 = none
1 = tissue expander
2 = prosthesis
3 = flap
4 = other
9 = unknown
H06 other TEXT [20] Other type of reconstruction
H07 Failed biopsy CODED [1] Failed biopsy 0 = no
1 = yes
9 = unknown
H08 date DATE [10] Date of failed biopsy
H09 Reason CODED [1] Reason for failed biopsy 1 = reperage
2 = radiologist
3 = pathologist
4 = surgeon
5 = other
9 = unknown
H10 other reason TEXT [20] Other reason for failed biopsy
H11 Surgeon TEXT [20] Name of surgeon
H12 Dept. Code TEXT [6] Hospital dept. code
H13 Dept. TEXT [16] Other dept.
H14 Notes TEXT [35] Notes

Sentinel lymph node
P01 Sentinel lymph node procedure CODED [1] Sentinel lymph node procedure 0 = no
1 = yes
9 = unknown
P02 Timing CODED [1] Time relationship between SLN and breast surgery on the same lesion 1 = 1st breast surgery
2 = 2nd breast surgery
3 = 3rd breast surgery
4 = at a separate session
9 = unknown
P03 Admission date DATE [10] Date of admission (sentinel lymph node)
P04 Discharge date DATE [10] Date of discharge (sentinel lymph node)
P05 Dept. Code TEXT [6] Hospital department code
P06 Dept. TEXT [20] Hospital department
P07 Date of interv. DATE [10] Date of intervention on sentinel lymph node
P08 Surgical team TEXT [20] Name of 1st surgeon sentinel lymph node
P09 Name of 2nd surgeon sentinel lymph node TEXT [20] Name of 2nd surgeon sentinel lymph node
P10 Blue dye CODED [1] Blue dye 0 = no
1 = yes
9 = unknown
P11 Minutes prior to intervention NUMERIC (BYTE) [1] Minutes prior to intervention
P12 Number of injections NUMERIC (BYTE) [1] Number of injections
P13 Volume (cc) NUMERIC (LONG) [4] Volume of dye
P14 Intradermal injection CODED [1] Site of intradermal injection of dye 0 = no
1 = site of higher count
2 = subareolar site
3 = subcutaneous site
4 = in cavity
5 = site of previous biopsy
9 = unknown
P15 Intratumoural CODED [1] Intratumoural injection 0 = no
1 = yes
9 = unknown
P16 Peritumoural CODED [1] Peritumoural injection 0 = no
1 = yes
9 = unknown
P17 Lymphatic collectors CODED [1] Lymphatic collectors 0 = no
1 = yes
9 = unknown
P18 Number of nodes CODED [1] Number of lymph nodes 0 = 0
1 = 1
2 = 2
3 = 3
4 = >3
9 = unknown
P19 Isotope CODED [1] Radio guided 0 = no
1 = yes
9 = unknown
P20 Hours of injection prior to intervention NUMERIC (BYTE) [1] Hours prior to intervention
P21 Dose injected (MBq) NUMERIC (LONG) [4] Dose injected (MBq)
P22 Subcutaneous CODED [1] Subcutaneous injection 0 = no
1 = yes
9 = unknown
P23 Peritumoural CODED [1] Peritumoural injection 0 = no
1 = yes
9 = unknown
P24 Intratumoural CODED [1] Intratumoural injection 0 = no
1 = yes
9 = unknown
P25 Site of previous biopsy CODED [1] Site of previous biopsy 0 = no
1 = yes
9 = unknown
P26 Lymphoscintigraphy identification CODED [2] lymphoscintigraphical identification 0 = no
1 = yes
9 = unknown
P27 Identification time NUMERIC (BYTE) [1] Hours for lymphoscintigraphical identification
P28 Minutes for lymphoscintigraphical identification NUMERIC (BYTE) [1] Minutes for lymphoscintigraphical identification
P29 Marker positioning CODED [1] Positioning of marker 0 = no
1 = yes
9 = unknown
P30 Lymphatic collectors CODED [1] Lymphatic collectors 0 = no
1 = yes
9 = unknown
P31 Stations CODED [1] Axillary stations 1 = 1 axillary
2 = 2 axillary
3 = internal breast
4 = 1 int. breast.1 axillary.
5 = intramammary
9 = unknown
P32 Number of lymph nodes CODED [1] Number of lymph nodes 0 = 0
1 = 1
2 = 2
3 = 3
4 = >3
9 = unknown
P33 Pre-operating isotope count CODED [1] Preoperating isotope count 1 = 0-8
2 = 9-30
3 = 31-100
4 = >100
9 = unknown
P34 Intra-operating isotope count CODED [1] Intraoperating isotope count 1 = 0-8
2 = 9-30
3 = 31-100
4 = 101-200
5 = 201-300
6 = 301-400
7 = 401-500
8 = >500
9 = unknown
P35 Residual axilla isotope count CODED [1] Isotope count at residual axilla 1 = <30
2 = >30
9 = unknown
P36 Coinciding LN CODED [1] Coinciding lymph nodes 0 = no
1 = yes
9 = unknown
P37 Time for identification (min) NUMERIC (BYTE) [1] Time for identification (min)
P38 Frozen section CODED [1] Frozen section result 1 = not done
2 = not involved
3 = involved
4 = not found
9 = unknown
P39 Histology CODED [1] Definitive histologic result 2 = not involved
3 = involved
4 = not found
9 = unknown
P40 if involved CODED [1] Descriptive result (if invaded LN) 1 = capsular break
2 = massive
3 = embolic
4 = only immunohystochemical
9 = unknown
P41 Dissection of TD nerve CODED [1] Dorsal thoracic nerve sectioned 0 = no
1 = yes
9 = unknown
P42 Dissection of ICB nerve CODED [1] Intercostobrachial nerve sectioned 0 = no
1 = yes
9 = unknown
P43 Dissection of LT nerve CODED [1] Long thoracic nerve sectioned 0 = no
1 = yes
9 = unknown
P44 Skin suture CODED [1] Cutaneous suture of sentinel lymph node 1 = detached/stitches
2 = det./silk
3 = det./Steri-strip
4 = det./glue
5 = intradermal stitches
6 = continual/Steri-strip
7 = cont./glue
8 = intradermal continual
9 = cutis stitches
10 = cut.silk
11 = cut.Steri-strip
12 = cut.glue