| 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 | ||||