SNOMED CT codes for gynaecological neoplasms Authors: Brian Rous1 and Naveena Singh2 1Cambridge University Hospitals NHS Trust and 2Barts Health NHS Trusts Background (summarised from NHS Digital): • SNOMED CT is a structured clinical vocabulary for use in an electronic health record. It forms an integral part of the electronic care record, and serves to represent care information in a clear, consistent, and comprehensive manner. • The move to a single terminology, SNOMED CT, for the direct management of care of an individual, across all care settings in England, is recommended by the National Information Board (NIB), in “Personalised Health and Care 2020: A Framework for Action”. • SNOMED CT is owned, managed and licensed by SNOMED International. NHS Digital is the UK Member's National Release Centre for the creation of, and delegated authority to licence the SNOMED CT Edition and derivatives. • The benefits of using SNOMED CT in electronic care records are that it: • enables sharing of vital information consistently within and across health and care settings • allows comprehensive coverage and greater depth of details and content for all clinical specialities and professionals • includes diagnosis and procedures, symptoms, family history, allergies, assessment tools, observations, devices • supports clinical decision making • facilitates analysis to support clinical audit and research • reduces risk of misinterpretations of the record in different care settings • Implementation plans for England: • SNOMED CT must be implemented across primary care and deployed to GP practices in a phased approach from April 2018. • Secondary care, acute care, mental health, community systems, dentistry and other systems used in direct patient care must use SNOMED CT as the clinical terminology, before 1 April 2020. This includes pathological disease coding. • The list below provides topography and morphology codes for Tumours of the Female Genital Tract as listed in the WHO blue book (2014). • The purpose of this list is to promote the use of uniform codes within our specialty and avoid duplication of work in searching for these via NHS Digital or TRUD (Technology Reference data Update Distribution), as the system is complex and several codes may be applicable for the same Guidance document: List of SNOMED CT codes for gynaecological neoplasms, 1 version 1.0, dated January 2019 neoplasm. These may be incorporated within pathology laboratory informations systems/reports at local and individual discretion. 1. Topography codes: Female genital tract (Table 1) Table 1. Topography codes for tumours of the female genital tract Topography codes Anatomical SNOMED 2/3 SNOMED CT term SNOMED CT site code Ovary T-87000/T- Entire ovary (body 181464007 87000 structure) Fallopian T-86000/ T- Entire fallopian tube 181463001 tube 88000 (body structure) OvaryT- and86920 Fallopian tube and ovary 110642008 Fallopian (combined site) (body tube structure) Peritoneum T-Y4400/ T- Peritoneum (serous 15425007 D4400 membrane) structure (body structure) Broad T-86300/ T- Entire broad ligament 362723009 ligament D6500 (body structure) Round T-86700/ T- Entire round ligment of 245495009 ligament D6507 uterus (body structure) Uterine T-82600/ T- Entire uterine ligament 272668006 ligament D6400 (body structure) Ovarian T-87430/ Entire ovarian ligament 279916003 ligament T_D6501 (body structure) Uterus T-82000 / T- Uterine structure (body 35039007 83000 structure) Uterine T-83000 / T- Cervix uteri structure 71252005 cervix 83200 (body structure) Myometrium T-85000 / T- Myometrial structure 27232003 83600 (body structure) Endometrium T-84000 / T- Endometrial structure 2739003 83400 (body structure) Vulva T-80000/T- Entire vulva (body 265796001 81000 structure) Clitoris T-80400/ T- Entire clitoris (body 181442003 81400 structure) Vagina T-81000/ T- Entire vagina (body 181441005 82000 structure) Placenta T-88000/ T- Entire placenta (body 181455002 F1100 structure) Product of No specific Entire product of 280706002 conception code (use T- conception (body Guidance document: List of SNOMED CT codes for gynaecological neoplasms, 2 version 1.0, dated January 2019 88000)/ T- structure) F0000 2. Morphology Codes: Tumours of the Ovary (Table 2) Table 2: Morphology codes for tumours of the ovary Morphology codes: Ovary WHO 2014 ICD-O SNOMED CT Term SNOMED CT code Category code Epithelial Tumours: Serous Benign serous M-84410 Serous cystadenoma 51608009 cystadenoma Benign serous M-90140 Serous adenofibroma 2026006 adenofibroma Serous surface M-84610 Serous surface 67073007 papilloma papilloma Serous borderline M-84421 Serous cystadenoma, 128849004 tumour borderline malignancy Serous adenofibroma 128885004 of borderline malignancy Serous borderline M-84602 Serous borderline 703559005 tumour - tumor, micropapillary micropapillary variant High-grade serous M-84613 High grade serous 703563003 carcinoma carcinoma Low-grade serous M-84603 Low grade serous 703561001 carcinoma carcinoma Benign mucinous M-84700 Mucinous 67182003 cystadenoma cystadenoma Epithelial Tumours: Mucinous Mucinous M-90150 Mucinous 10705005 adenofibroma adenofibroma Mucinous M-84721 Mucinous cystic tumor 128852007 borderline tumour of borderline malignancy Mucinous 128887007 adenofibroma of borderline malignancy Mucinous M-84803 Mucinous 2495009 carcinoma adenocarcinoma Epithelial Tumours: Endometrioid Benign M-83800 Endometrioid 71106006 Guidance document: List of SNOMED CT codes for gynaecological neoplasms, 3 version 1.0, dated January 2019 endometrioid adenoma cystadenoma Benign M-83810 Endometrioid 20829008 endometrioid adenofibroma adenofibroma Endometrioid M-83801 Endometrioid 75987005 borderline tumour adenoma, borderline malignancy Endometrioid 25874003 adenofibroma, borderline malignancy Endometrioid M-83803 Endometrioid 30289006 carcinoma carcinoma Epithelial Tumours: Clear Cell Clear cell M-84430 Clear cell cystadenoma 128687009 cystadenoma Clear cell M-83130 Clear cell 58161009 adenofibroma adenofibroma Clear cell M-83131 Clear cell cystic tumor 128688004 borderline tumour of borderline malignancy Clear cell 128890001 adenofibroma of borderline malignancy Clear cell M-83103 Clear cell 30546008 carcinoma adenocarcinoma Epithelial Tumours: Brenner Benign Brenner M- Benign Brenner tumor 253051001 tumour 90000 Borderline M-90001 Brenner tumor, 89996007 Brenner tumour borderline malignancy Malignant Brenner M-90003 Brenner tumor, 42194009 tumour malignant Epithelial Tumours: Seromucinous Benign M-84740 Seromucinous 703564009 seromucinous cystadenoma cystadenoma Benign M-90140 Seromucinous 703652007 seromucinous adenofibroma adenofibroma Seromucinous M-84741 Seromucinous 703565005 borderline tumour borderline tumor Seromucinous M-84743 Seromucinous 703568007 carcinoma carcinoma Epithelial Tumours: Undifferentiated Undifferentiated M-80203 Undifferentiated 38549000 Guidance document: List of SNOMED CT codes for gynaecological neoplasms, 4 version 1.0, dated January 2019 carcinoma carcinoma Mesenchymal tumours Low-grade M-89313 Endometrial stromal 128726006 endometrioid sarcoma, low grade stromal sarcoma (morphologic abnormality) High-grade M-89303 Endometrial stromal 70555003 endometrioid sarcoma, high grade stromal sarcoma (morphologic abnormality) Mixed Epithelial and Mesenchymal Tumours Adenosarcoma M-89333 Adenosarcoma 31470003 Carcinosarcoma M-89803 Carcinosarcoma 623264007 Sex cord-stromal tumours Pure stromal tumours Fibroma M-88100 Fibroma, no 112682009 International Classification of Diseases for Oncology subtype (morphologic abnormality) Cellular fibroma M-88101 Cellular fibroma 128882001 (morphologic abnormality) Thecoma M-86000 Thecoma, no 52490000 International Classification of Diseases for Oncology subtype (morphologic abnormality) Luteinized Thecoma, luteinized thecoma M-86010 (morphologic 54482004 associated abnormality) with sclerosing peritonitis Fibrosarcoma M-88103 Fibrosarcoma 53654007 (morphologic abnormality) Sclerosing stromal M-86020 Sclerosing stromal 64512009 tumour tumor (morphologic abnormality) Signetring stromal M-85900 Signet-ring stromal 703598000 tumour tumor (morphologic abnormality) Microcystic M-85900 Microcystic stromal 703599008 stromal tumour tumor (morphologic abnormality) Guidance document: List of SNOMED CT codes for gynaecological neoplasms, 5 version 1.0, dated January 2019 Leydig cell tumour M-86500 Leydig cell tumor, 5014008 benign (morphologic abnormality) Steroid cell M-87600 Compound nevus 49409001 tumour (morphologic abnormality) Steroid cell M-87603 Steroid cell tumor, 128907008 tumour, malignant malignant, (morphologic abnormality) Pure sex cord tumours Adult granulosa M-86203 Granulosa cell tumor, 18861007 cell tumour malignant (morphologic abnormality) Juvenile granulosa M-86221 Juvenile granulosa cell 77029009 cell tumour tumor (morphologic abnormality) Sertoli cell tumour M-86401 Sertoli cell tumor, no 128857001 International Classification of Diseases for Oncology subtype (morphologic abnormality) Sex cord tumour M-86231 Sex cord tumor with 72457004 with annular annular tubules tubules (morphologic abnormality) Mixed sex cord-stromal tumours Sertoli-Leydig cell tumours Well differentiated M-86310 Sertoli-Leydig cell 34110004 tumor, well differentiated (morphologic abnormality) Moderately M-86311 Sertoli-Leydig cell 128905000 differentiated tumor of intermediate differentiation (morphologic abnormality) With heterologous M-86341 Sertoli-Leydig cell 128725005 elements tumor, intermediate differentiation, with heterologous elements (morphologic abnormality)