Surgery Maturity Level: 0 Draft

Diagnosis reference in case the treatment was done for baseline

EpisodeEvent element containing the data regarding the patient's cancer, in case the treatment was done for an episode event (progression, recurrence...)

Primary surgery/re-excision (check with unplanned or excisional biopsy)

Check

"Surgery (with date) is a procedure occurrence, which is referred to in the EPISODE_EVENT table. Provider of the procedure can be defined based on the hospital.

If type of surgery is not specified use SURGICAL PROCEDURE."

CHILDREN

Surgical procedure - 4301351 Local excision - 4315400 Amputation - 4217482 Limb operation - 4181193

Whether or not a surgical procedure was performed and whether it was performed at the registering hospital or another hospital. Diagnostic procedures (biopsy) are not included.

Date of the surgery for primary tumor with or without neck surgery Is there a new excision surgery to treat the cancer by removing the tumor ? Yes : New event Is the tumor that is going to be removed metastatic ? Yes: Add True for Surgery on M, with the same date than the surgery date Is the tumor on the Neck ? Yes: add true for Neck Surgery, with the same date than the surgery date Is the neck surgery accompanied by a dissection ? Yes : fill the type of dissection

Palliative: surgery performed with the intent of improving quality of life or relieving symptoms caused by advanced disease. Curative: surgery performed with the intend of oncologic cure, regardless of its result (R0 / R1/R2)

Palliative - 4179711 Curative procedure intent - 4162591

Describes the approach to tumor resection whether it includes skin incision (extenal or open ), or it 's aproached through a natural orifice (Transnasal/transorbital/transoral) or if the approach combines two or more of the previous ones Maybe should be a flag

External/Open - 4236080 Transnasal - 4050374 Transorbital - 4044897 Transoral - 4038679 Craniofacial - 4333339 Combined surgical approach - 2000100027

The R0 (“no residual rumor”) category applies only to cases in which residual tumor cannot be detected by conventional diagnostic methods. A more exact definition would read “no detectable residual tumor.”This category corresponds to surgical resection for cure. The R1 category is reserved exclusively for cases in which residual tumor is found by histologic examination. This category may apply to biopsy sampling of the regional tissue at the site of resection or of a distant site at the time of surgery. It also applies to microscopic examination of the resection margins of the surgical resection specimen by the pathologist. R2 applies to cases with macroscopically visible residual tumor that is detected either clinically or pathologically.

R0: No residual tumor - 1634643 R1: Microscopic residual tumor - 1633801 R2: Macroscopic residual tumor - 1634484

Tumor rupture Yes/No Cancer modifiers (associated with diagnosis)

For Absence use value_as_concept_id = ABSENT

Tumor Rupture - 36768904

Describes the presence or absence of radiological signs of extracapsular extension by histopathologic examination or not, as defined in the AJCC 8th Ed. It's also present in the Clinical/Pathological stages for baseline diagnosis. check CODEs

ENE- - 36769946 ENE+ - 36770618

Surgical specimen Mitotic count

Number of mitoses per 10 high power fields - 4227243

Provides the grading for surgical specimen only for untreated tumours

Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085

Local flap / regional pedicled flap / free flap

Yes - 4188539 No - 4188540

Describes whether a surgical procedure to treat and address the neck was performed or not.

Yes - 4188539 No - 4188540

Date of the surgery on the neck

Describes laterality of the neck surgical procedure: Ipsilateral when only the neck ipsilateral to the tumor has been treated Contralateral when only the neck contralateral to the tumor has been treated Bilateral: when both sides of the neck have been treated

Ipsilateral - 4112106 Bilateral Sampling - 4117496 Controlateral - 4112107

Describes whether surgery is performed to treat the Metastasis

Yes - 4188539 No - 4188540

Date of the surgery on the metastasis

Describes if site of surgery on metastasis

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Describes if site of surgery on metastasis is soft tissue

Metastasis to soft tissues - 35225724

Describes if site of surgery on metastasis is dystan lymph node

Distant spread to lymph node - 36769243

Describes if site of surgery on metastasis is lung

Metastasis to lung - 36770283

Describes if site of surgery on metastasis is bone

Metastasis to bone - 36769301

Describes if site of surgery on metastasis is liver

Metastasis to liver - 36770544

Describes if site of surgery on metastasis is pleura

Metastasis to pleura - 35226258

Describes if site of surgery on metastasis is peritoneum

Metastasis to peritoneum - 35226253

Describes if site of surgery on metastasis is brain

Metastasis to brain - 36768862

Describes if site of surgery on metastasis is other viscera Use the generic metastasis code or a metastasis subsumed in it, 36769180

Metastasis - 36769180

Describes if site of surgery on metastasis is unknown

Unknown - 4129922

Describes presence and grade of complications after a surgical procedure,

Absent - 4132135 Clavien-Dindo complication scale: Grade I - 715974 Clavien-Dindo complication scale: Grade II - 715975 Clavien-Dindo complication scale: Grade III - 715976 Clavien-Dindo complication scale: Grade IIIA - 715977 Clavien-Dindo complication scale: Grade IIIB - 715978 Clavien-Dindo complication scale: Grade IV - 715979 Clavien-Dindo complication scale: Grade IVA - 715980 Clavien-Dindo complication scale: Grade IVB - 715981 Clavien-Dindo complication scale: Grade V - 715982

Surgery Maturity Level: 0 Draft

Diagnosis reference in case the treatment was done for baseline

EpisodeEvent element containing the data regarding the patient's cancer, in case the treatment was done for an episode event (progression, recurrence...)

Primary surgery/re-excision (check with unplanned or excisional biopsy)

Check

"Surgery (with date) is a procedure occurrence, which is referred to in the EPISODE_EVENT table. Provider of the procedure can be defined based on the hospital.

If type of surgery is not specified use SURGICAL PROCEDURE."

CHILDREN

Surgical procedure - 4301351 Local excision - 4315400 Amputation - 4217482 Limb operation - 4181193

Whether or not a surgical procedure was performed and whether it was performed at the registering hospital or another hospital. Diagnostic procedures (biopsy) are not included.

Date of the surgery for primary tumor with or without neck surgery Is there a new excision surgery to treat the cancer by removing the tumor ? Yes : New event Is the tumor that is going to be removed metastatic ? Yes: Add True for Surgery on M, with the same date than the surgery date Is the tumor on the Neck ? Yes: add true for Neck Surgery, with the same date than the surgery date Is the neck surgery accompanied by a dissection ? Yes : fill the type of dissection

Palliative: surgery performed with the intent of improving quality of life or relieving symptoms caused by advanced disease. Curative: surgery performed with the intend of oncologic cure, regardless of its result (R0 / R1/R2)

Palliative - 4179711 Curative procedure intent - 4162591

Describes the approach to tumor resection whether it includes skin incision (extenal or open ), or it 's aproached through a natural orifice (Transnasal/transorbital/transoral) or if the approach combines two or more of the previous ones Maybe should be a flag

External/Open - 4236080 Transnasal - 4050374 Transorbital - 4044897 Transoral - 4038679 Craniofacial - 4333339 Combined surgical approach - 2000100027

The R0 (“no residual rumor”) category applies only to cases in which residual tumor cannot be detected by conventional diagnostic methods. A more exact definition would read “no detectable residual tumor.”This category corresponds to surgical resection for cure. The R1 category is reserved exclusively for cases in which residual tumor is found by histologic examination. This category may apply to biopsy sampling of the regional tissue at the site of resection or of a distant site at the time of surgery. It also applies to microscopic examination of the resection margins of the surgical resection specimen by the pathologist. R2 applies to cases with macroscopically visible residual tumor that is detected either clinically or pathologically.

R0: No residual tumor - 1634643 R1: Microscopic residual tumor - 1633801 R2: Macroscopic residual tumor - 1634484

Tumor rupture Yes/No Cancer modifiers (associated with diagnosis)

For Absence use value_as_concept_id = ABSENT

Tumor Rupture - 36768904

Describes the presence or absence of radiological signs of extracapsular extension by histopathologic examination or not, as defined in the AJCC 8th Ed. It's also present in the Clinical/Pathological stages for baseline diagnosis. check CODEs

ENE- - 36769946 ENE+ - 36770618

Surgical specimen Mitotic count

Number of mitoses per 10 high power fields - 4227243

Provides the grading for surgical specimen only for untreated tumours

Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085

Local flap / regional pedicled flap / free flap

Yes - 4188539 No - 4188540

Describes whether a surgical procedure to treat and address the neck was performed or not.

Yes - 4188539 No - 4188540

Date of the surgery on the neck

Describes laterality of the neck surgical procedure: Ipsilateral when only the neck ipsilateral to the tumor has been treated Contralateral when only the neck contralateral to the tumor has been treated Bilateral: when both sides of the neck have been treated

Ipsilateral - 4112106 Bilateral Sampling - 4117496 Controlateral - 4112107

Describes whether surgery is performed to treat the Metastasis

Yes - 4188539 No - 4188540

Date of the surgery on the metastasis

Describes if site of surgery on metastasis

Describes if site of surgery on metastasis is soft tissue

Metastasis to soft tissues - 35225724

Describes if site of surgery on metastasis is dystan lymph node

Distant spread to lymph node - 36769243

Describes if site of surgery on metastasis is lung

Metastasis to lung - 36770283

Describes if site of surgery on metastasis is bone

Metastasis to bone - 36769301

Describes if site of surgery on metastasis is liver

Metastasis to liver - 36770544

Describes if site of surgery on metastasis is pleura

Metastasis to pleura - 35226258

Describes if site of surgery on metastasis is peritoneum

Metastasis to peritoneum - 35226253

Describes if site of surgery on metastasis is brain

Metastasis to brain - 36768862

Describes if site of surgery on metastasis is other viscera Use the generic metastasis code or a metastasis subsumed in it, 36769180

Metastasis - 36769180

Describes if site of surgery on metastasis is unknown

Unknown - 4129922

Describes presence and grade of complications after a surgical procedure,

Absent - 4132135 Clavien-Dindo complication scale: Grade I - 715974 Clavien-Dindo complication scale: Grade II - 715975 Clavien-Dindo complication scale: Grade III - 715976 Clavien-Dindo complication scale: Grade IIIA - 715977 Clavien-Dindo complication scale: Grade IIIB - 715978 Clavien-Dindo complication scale: Grade IV - 715979 Clavien-Dindo complication scale: Grade IVA - 715980 Clavien-Dindo complication scale: Grade IVB - 715981 Clavien-Dindo complication scale: Grade V - 715982

Surgery Maturity Level: 0 Draft

Diagnosis reference in case the treatment was done for baseline

EpisodeEvent element containing the data regarding the patient's cancer, in case the treatment was done for an episode event (progression, recurrence...)

Primary surgery/re-excision (check with unplanned or excisional biopsy)

Check

"Surgery (with date) is a procedure occurrence, which is referred to in the EPISODE_EVENT table. Provider of the procedure can be defined based on the hospital.

If type of surgery is not specified use SURGICAL PROCEDURE."

CHILDREN

Surgical procedure - 4301351 Local excision - 4315400 Amputation - 4217482 Limb operation - 4181193

Whether or not a surgical procedure was performed and whether it was performed at the registering hospital or another hospital. Diagnostic procedures (biopsy) are not included.

Date of the surgery for primary tumor with or without neck surgery Is there a new excision surgery to treat the cancer by removing the tumor ? Yes : New event Is the tumor that is going to be removed metastatic ? Yes: Add True for Surgery on M, with the same date than the surgery date Is the tumor on the Neck ? Yes: add true for Neck Surgery, with the same date than the surgery date Is the neck surgery accompanied by a dissection ? Yes : fill the type of dissection

Palliative: surgery performed with the intent of improving quality of life or relieving symptoms caused by advanced disease. Curative: surgery performed with the intend of oncologic cure, regardless of its result (R0 / R1/R2)

Palliative - 4179711 Curative procedure intent - 4162591

Describes the approach to tumor resection whether it includes skin incision (extenal or open ), or it 's aproached through a natural orifice (Transnasal/transorbital/transoral) or if the approach combines two or more of the previous ones Maybe should be a flag

External/Open - 4236080 Transnasal - 4050374 Transorbital - 4044897 Transoral - 4038679 Craniofacial - 4333339 Combined surgical approach - 2000100027

The R0 (“no residual rumor”) category applies only to cases in which residual tumor cannot be detected by conventional diagnostic methods. A more exact definition would read “no detectable residual tumor.”This category corresponds to surgical resection for cure. The R1 category is reserved exclusively for cases in which residual tumor is found by histologic examination. This category may apply to biopsy sampling of the regional tissue at the site of resection or of a distant site at the time of surgery. It also applies to microscopic examination of the resection margins of the surgical resection specimen by the pathologist. R2 applies to cases with macroscopically visible residual tumor that is detected either clinically or pathologically.

R0: No residual tumor - 1634643 R1: Microscopic residual tumor - 1633801 R2: Macroscopic residual tumor - 1634484

Tumor rupture Yes/No Cancer modifiers (associated with diagnosis)

For Absence use value_as_concept_id = ABSENT

Tumor Rupture - 36768904

Describes the presence or absence of radiological signs of extracapsular extension by histopathologic examination or not, as defined in the AJCC 8th Ed. It's also present in the Clinical/Pathological stages for baseline diagnosis. check CODEs

ENE- - 36769946 ENE+ - 36770618

Surgical specimen Mitotic count

Number of mitoses per 10 high power fields - 4227243

Provides the grading for surgical specimen only for untreated tumours

Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085

Local flap / regional pedicled flap / free flap

Yes - 4188539 No - 4188540

Describes whether a surgical procedure to treat and address the neck was performed or not.

Yes - 4188539 No - 4188540

Date of the surgery on the neck

Describes laterality of the neck surgical procedure: Ipsilateral when only the neck ipsilateral to the tumor has been treated Contralateral when only the neck contralateral to the tumor has been treated Bilateral: when both sides of the neck have been treated

Ipsilateral - 4112106 Bilateral Sampling - 4117496 Controlateral - 4112107

Describes whether surgery is performed to treat the Metastasis

Yes - 4188539 No - 4188540

Date of the surgery on the metastasis

Describes if site of surgery on metastasis

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Describes if site of surgery on metastasis is soft tissue

Metastasis to soft tissues - 35225724

Describes if site of surgery on metastasis is dystan lymph node

Distant spread to lymph node - 36769243

Describes if site of surgery on metastasis is lung

Metastasis to lung - 36770283

Describes if site of surgery on metastasis is bone

Metastasis to bone - 36769301

Describes if site of surgery on metastasis is liver

Metastasis to liver - 36770544

Describes if site of surgery on metastasis is pleura

Metastasis to pleura - 35226258

Describes if site of surgery on metastasis is peritoneum

Metastasis to peritoneum - 35226253

Describes if site of surgery on metastasis is brain

Metastasis to brain - 36768862

Describes if site of surgery on metastasis is other viscera Use the generic metastasis code or a metastasis subsumed in it, 36769180

Metastasis - 36769180

Describes if site of surgery on metastasis is unknown

Unknown - 4129922

Describes presence and grade of complications after a surgical procedure,

Absent - 4132135 Clavien-Dindo complication scale: Grade I - 715974 Clavien-Dindo complication scale: Grade II - 715975 Clavien-Dindo complication scale: Grade III - 715976 Clavien-Dindo complication scale: Grade IIIA - 715977 Clavien-Dindo complication scale: Grade IIIB - 715978 Clavien-Dindo complication scale: Grade IV - 715979 Clavien-Dindo complication scale: Grade IVA - 715980 Clavien-Dindo complication scale: Grade IVB - 715981 Clavien-Dindo complication scale: Grade V - 715982