DB35T 1985-2021 原發(fā)性肝癌臨床數(shù)據(jù)集　

35DB35/T1985—2021原發(fā)性肝癌臨床數(shù)據(jù)集Primarylivercancerclinicaldataset2021-06-21發(fā)布2021-09-21實施福建省市場監(jiān)督管理局發(fā)布I 本文件按照GB/T1.1—2020《標(biāo)準(zhǔn)化工作導(dǎo)則第1部分：標(biāo)準(zhǔn)化文件的結(jié)構(gòu)和起草李海濤、閭海榮、郭武華、陳麗紅、王海瀛、廖祥文、郭鵬飛、陳振偉、劉紅枝、黃起楨、林孔英、陳傳椿、陳森。1GB/T2261.1—2003個人基本信息分類與代碼第GB/T2261.2—2003個人基本信息分類與代碼第GB/T3304—1991中國各民族名稱的WS363.1—2011衛(wèi)生信息WS364.3衛(wèi)生信息數(shù)據(jù)元值域代碼WS364.10衛(wèi)生信息數(shù)據(jù)元值域代碼第10部分WS364.12衛(wèi)生信息數(shù)據(jù)元值域代碼第12部分WS/T370—2012衛(wèi)生信息基本數(shù)WS445.5電子病歷基本數(shù)據(jù)集AJCC：美國癌癥聯(lián)合委員會（AmericanJointCoDSA：數(shù)字減影血管造影（DigitalSubtrHBV-DNA：乙型肝炎病毒脫氧核糖核酸（HepatitisBVirusDHCV-RNA：丙型肝炎病毒核糖核酸（HepatitisCVirusRi2MRI：核磁共振成像（MagneticMVI：微血管侵犯（MicrovasculaRECIST：實體瘤療效評價標(biāo)準(zhǔn)（ResponseEvaluationCriTACE：經(jīng)導(dǎo)管動脈化療栓塞術(shù)（TranscatheterArterial34—D——————— 5—— ————N————6型-標(biāo)識患者是否為吸煙者，吸煙者指每天至少吸1支，連續(xù)或累計吸煙6個月及以上者L—N—N—N—L—N—N—L—7NN4..5,1—NN3..5,2—2.中等N—N N—N—N—————L—L—————L —L—L —L—8—L—L—L—L —L—L——L——N—腫瘤國際疾病分類中解剖部位的編碼，包括ICD-10和ICD L —L—L—9— L L —式—N—N—N—N—N —N——N—N——N—NN..3,1—單位容積血清中膽固醇酯與游離膽固醇的總含量，計NN..5,2—NN..5,2 NN..5,2—酶N N—N——N———— NN..5,1——N—NN..5,1——NN..5,1——NN..5,1—型———————————碼————碼—志L—小超聲、CT、MRI檢查中腫瘤直徑的測量值NN..2,1 —位—量超聲、CT、MRI檢查中肝臟內(nèi)腫瘤的數(shù)N——L——L— L L—L——L—L— L L—型碼碼——N—名——名 N—碼表N———型—N—NN..2,1————L— L 位————離NN..2,1————級—NN..10,2——積N——N——NN..2,2— N — 療 —N ———療——— NN..2,1 L 病理確診原發(fā)性肝癌所在腫瘤國際疾病分類中解剖NN..2,1——N—— — 變 — L 期 —L——L———型—DSA檢查患者肝臟腫瘤所在國際疾病分類中解剖部位的 NN..2,1——況—型——L——L— —————數(shù)），N——型 ———），N——型—————L——對患者實施介入治療后進(jìn)行療效評價的時間間N——————型—— ——N——— ——L——L——N—— ——型———— ——度N——量N——量N—小NN..2,1— 位型—L——N——————型———— —放射治療95%PTV體積所接受的最低吸收劑N——N—————————L——對患者實施放射治療后進(jìn)行療效評價的時間間N——型—————L— —————L——————L——— L ——————L— —L———————L— ————L——— L —對患者實施系統(tǒng)治療后進(jìn)行療效評價的時間間N— L—— ———L———L— ———L———L————L———D——L——L—L————D———N—NN..2,1———L ——型—D— 腫瘤國際疾病分類中解剖部位的編碼，包括ICD-10和IC—N—NN..2,1 —— L —L——L——L——L— L —L——L——L——L——L— L —L——L——L——L—值011級能自由走動及從事輕體力活動，包括一22級能自由走動及生活自理，但已喪失工作能力，日間不少345值12349值A(chǔ)BC值12349值1234值1234值12M1（低危組）：≤5個MVI，且發(fā)生于近癌旁肝組織區(qū)域(≤1cm）3M2（高危組5個MVI，或MVI發(fā)生于遠(yuǎn)癌旁肝組織區(qū)域14值1234569值12PR：目標(biāo)病灶（動脈期增強顯影）的直徑總和34PD：目標(biāo)病灶（動脈期增強顯影）的直徑總和增加≥20%值12349值1234癌胚抗原.............................................................................表6靶區(qū)定義............................................................................表14白蛋白...............................................................................白細(xì)胞計數(shù).........................................................................伴隨癥狀.............................................................................表3標(biāo)準(zhǔn)化肝臟體積.......................................................................表9丙氨酸氨基轉(zhuǎn)移酶.....................................................................表6丙肝抗體.............................................................................表6病案號...............................................................................表2病理診斷淋巴結(jié)轉(zhuǎn)移標(biāo)志..............................................................表10病理診斷切除轉(zhuǎn)移/侵犯病灶...........................................................表10病理診斷肉眼癌栓標(biāo)志................................................................表10病理診斷原發(fā)性肝癌AJCC分期..........................................................表10病理診斷原發(fā)性肝癌MVI分級...........................................................表10病理診斷原發(fā)性肝癌癌前病變..........................................................表10病理診斷原發(fā)性肝癌標(biāo)志..............................................................表10病理診斷原發(fā)性肝癌部位..............................................................表10病理診斷原發(fā)性肝癌大小..............................................................表10病理診斷原發(fā)性肝癌數(shù)量..............................................................表10病理診斷原發(fā)性肝癌衛(wèi)星結(jié)節(jié)標(biāo)志......................................................表10Child-Pugh分級.......................................................................表9CT檢查結(jié)論...........................................................................表7CT檢查所見...........................................................................表7CT掃描方式代碼.......................................................................表7超聲造影檢查結(jié)論.....................................................................表7超聲造影檢查所見.....................................................................表7出生日期.............................................................................表2出院日期.............................................................................表2處方劑量............................................................................表14穿刺粒子置入途徑....................................................................表13膽管癌栓標(biāo)志.........................................................................表5低密度脂蛋白.........................................................................表6碘125放射性粒子活度.................................................................表13碘125放射性粒子數(shù)量.................................................................表13碘125放射性粒子植入麻醉方式.........................................................表13碘125放射性粒子植入手術(shù)日期.........................................................表13碘125放射性粒子植入術(shù)中所見腫瘤部位.................................................表13碘125放射性粒子植入術(shù)中所見腫瘤大小.................................................表13碘125放射性粒子植入術(shù)中所見腫瘤數(shù)量.................................................表13碘125放射性粒子植入影像引導(dǎo)方式.....................................................表13碘125放射性粒子植入治療名稱.........................................................表13碘125放射治療療效評價標(biāo)志...........................................................表13碘125放射治療療效評價標(biāo)準(zhǔn)...........................................................表13碘125放射治療療效評價次數(shù)...........................................................表13碘125放射治療療效評價間隔時間.......................................................表13碘125放射治療療效評價檢查類型.......................................................表13碘125放射治療療效評價結(jié)果...........................................................表13碘油沉積............................................................................表11放療中聯(lián)合治療......................................................................表14放射治療方式........................................................................表14放射治療療效評價標(biāo)志................................................................表14放射治療療效評價標(biāo)準(zhǔn)................................................................表14放射治療療效評價次數(shù)................................................................表14放射治療療效評價間隔時間............................................................表14放射治療療效評價檢查類型............................................................表14放射治療療效評價結(jié)果................................................................表14放射治療目的........................................................................表14放射治療診斷........................................................................表14分割次數(shù)............................................................................表14分子靶向治療標(biāo)志....................................................................表15分子靶向治療不良反應(yīng)................................................................表15分子靶向治療不良反應(yīng)標(biāo)志............................................................表15分子靶向治療劑量調(diào)整標(biāo)志............................................................表15分子靶向治療劑量調(diào)整方案............................................................表15分子靶向治療劑量調(diào)整日期............................................................表15分子靶向治療起始日期................................................................表15分子靶向治療藥物名稱................................................................表15分子靶向治療藥物用量................................................................表15分子靶向治療終止日期................................................................表15復(fù)發(fā)標(biāo)志.............................................................................表5復(fù)發(fā)次數(shù).............................................................................表5腹壁皮下靜脈曲張標(biāo)志.................................................................表4腹部疤痕.............................................................................表4腹部超聲檢查結(jié)論.....................................................................表7腹部超聲檢查所見.....................................................................表7腹部反跳痛標(biāo)志.......................................................................表4腹部外形.............................................................................表4腹部壓痛標(biāo)志.........................................................................表4腹部移動性濁音標(biāo)志...................................................................表4腹肌緊張度...........................................................................表4甘油三酯.............................................................................表6肝病面容標(biāo)志.........................................................................表4肝大標(biāo)志.............................................................................表4肝動脈灌注化療次數(shù)..................................................................表11肝動脈灌注化療類型..................................................................表11肝動脈灌注化療藥物名稱..............................................................表11肝動脈灌注化療藥物用量..............................................................表11肝頸靜脈回流征標(biāo)志...................................................................表4肝內(nèi)膽管癌的分化程度................................................................表10肝內(nèi)膽管癌的組織學(xué)類型..............................................................表10肝區(qū)叩擊痛標(biāo)志.......................................................................表4肝細(xì)胞癌的分化程度..................................................................表10肝細(xì)胞癌的細(xì)胞學(xué)類型................................................................表10肝細(xì)胞癌的組織學(xué)類型................................................................表10肝血流阻斷...........................................................................表8肝掌標(biāo)志.............................................................................表4高密度脂蛋白.........................................................................表6功能性標(biāo)準(zhǔn)化肝體積比.................................................................表9鞏膜黃染標(biāo)志.........................................................................表4姑息治療............................................................................表16姑息治療方案........................................................................表16HBV-DNA定量..........................................................................表6HCV-RNA定量..........................................................................表6合并癥...............................................................................表5呼吸頻率.............................................................................表4患者電話號碼.........................................................................表2患者姓名.............................................................................表2婚姻狀況代碼.........................................................................表2急性放射損傷........................................................................表14籍貫-?。ㄗ灾螀^(qū)、直轄市、特別行政區(qū)）................................................表2籍貫-市（縣、盟、州）................................................................表2既往史...............................................................................表3甲胎蛋白.............................................................................表6甲胎蛋白異質(zhì)體比率................................................................間接膽紅素...........................................................................表6結(jié)節(jié)狀腫瘤染色部位..................................................................表11結(jié)節(jié)狀腫瘤染色大小..................................................................表11結(jié)節(jié)狀腫瘤染色數(shù)量..................................................................表11結(jié)節(jié)狀腫瘤染色血供情況..............................................................表11介入治療化療標(biāo)識....................................................................表11介入治療療效評價標(biāo)志................................................................表11介入治療療效評價標(biāo)準(zhǔn)................................................................表11介入治療療效評價次數(shù)................................................................表11介入治療療效評價間隔時間............................................................表11介入治療療效評價檢查類型............................................................表11介入治療療效評價結(jié)果................................................................表11介入治療手術(shù)日期....................................................................表11介入治療栓塞標(biāo)識....................................................................表11就診科室名稱.........................................................................表2局部消融次數(shù)........................................................................表12局部消融方式........................................................................表12局部消融療效評價標(biāo)志................................................................表12局部消融療效評價標(biāo)準(zhǔn)................................................................表12局部消融療效評價次數(shù)................................................................表12局部消融療效評價間隔時間............................................................表12局部消融療效評價檢查類型............................................................表12局部消融療效評價結(jié)果................................................................表12局部消融麻醉方式....................................................................表12局部消融手術(shù)日期....................................................................表12局部消融影像引導(dǎo)方式................................................................表12局部消融治療名稱....................................................................表12開始吸煙年齡.........................................................................表3開始飲酒年齡.........................................................................表3抗病毒治療標(biāo)志......................................................................表16抗病毒治療起始日期..................................................................表16抗病毒治療藥物名稱..................................................................表16抗病毒治療藥物用量..................................................................表16抗病毒治療中斷標(biāo)志..................................................................表16抗病毒治療中斷日期..................................................................表16空腹血糖值...........................................................................表6淋巴結(jié)清掃...........................................................................表8淋巴結(jié)腫大...........................................................................表8MRI檢查結(jié)論..........................................................................表7MRI檢查所見..........................................................................表7MRI掃描方式代碼......................................................................表7麻醉方法.............................................................................表8麻醉醫(yī)師姓名.........................................................................表8脈率.................................................................................表4門診號.........................................................................免疫治療標(biāo)志........................................................................表15免疫治療不良反應(yīng)....................................................................表15免疫治療不良反應(yīng)標(biāo)志................................................................表15免疫治療劑量調(diào)整標(biāo)志................................................................表15免疫治療劑量調(diào)整方案................................................................表15免疫治療劑量調(diào)整日期................................................................表15免疫治療起始日期....................................................................表15免疫治療藥物名稱....................................................................表15免疫治療藥物用量....................................................................表15免疫治療終止日期....................................................................表15民族.................................................................................表2凝血酶原國際標(biāo)準(zhǔn)化比值...............................................................表6凝血時間.............................................................................表6PS評分...............................................................................表4皮膚黃染標(biāo)志.........................................................................表4破裂出血標(biāo)志.........................................................................表5切緣受累標(biāo)志........................................................................表10日吸煙量......................................................................入院日期.............................................................................表2射線類型............................................................................表14身份證件號碼.........................................................................表2身份證件類別代碼.....................................................................表2身高.................................................................................表4剩余肝臟體積.........................................................................表9收縮壓...............................................................................表4手術(shù)后非藥物治療.....................................................................表9手術(shù)后藥物治療.......................................................................表9手術(shù)名稱.............................................................................表8手術(shù)前非藥物治療.....................................................................表9手術(shù)前藥物治療.......................................................................表9手術(shù)切緣距離.........................................................................表8手術(shù)日期.............................................................................表8手術(shù)時程.............................................................................表8手術(shù)醫(yī)師姓名.........................................................................表8舒張壓...............................................................................表4術(shù)后并發(fā)癥...........................................................................表9術(shù)后輸血類型.........................................................................表9術(shù)后輸血量...........................................................................表9術(shù)后輸血量計量單位...................................................................表9術(shù)后營養(yǎng)支持.........................................................................表9術(shù)前輸血類型.........................................................................表9術(shù)前輸血量...........................................................................表9術(shù)前輸血量計量單位...................................................................表9術(shù)前營養(yǎng)支持.........................................................................表9術(shù)前診斷編碼.........................................................................表8術(shù)中并發(fā)癥...........................................................................表8術(shù)中膽管癌栓標(biāo)志.....................................................................表8術(shù)中失血量...........................................................................表8術(shù)中輸血類型代碼.....................................................................表8術(shù)中輸血量...........................................................................表8術(shù)中輸血量計量單位...................................................................表8術(shù)中所見腫瘤大小.....................................................................表8術(shù)中所見腫瘤數(shù)量.....................................................................表8術(shù)中所見腫瘤位置.....................................................................表8術(shù)中血管癌栓標(biāo)志.....................................................................表8術(shù)中診斷編碼.........................................................................表8栓塞劑..............................................................................表11栓塞效果............................................................................表11隨訪方式............................................................................表17隨訪復(fù)發(fā)標(biāo)志........................................................................表17隨訪復(fù)發(fā)部位........................................................................表17隨訪復(fù)發(fā)次數(shù)........................................................................表17隨訪復(fù)發(fā)大小........................................................................表17隨訪復(fù)發(fā)后治療方式.................................................................隨訪復(fù)發(fā)確診依據(jù)....................................................................隨訪復(fù)發(fā)日期........................................................................表17隨訪復(fù)發(fā)數(shù)量........................................................................表17隨訪生存標(biāo)志........................................................................表17隨訪失訪標(biāo)志........................................................................表17隨訪時間............................................................................表17隨訪腫瘤轉(zhuǎn)移部位....................................................................隨訪腫瘤轉(zhuǎn)移大小....................................................................隨訪腫瘤轉(zhuǎn)移后治療方式.............................................................隨訪腫瘤轉(zhuǎn)移確診依據(jù)..............................................................隨訪腫瘤轉(zhuǎn)移日期....................................................................隨訪腫瘤轉(zhuǎn)移數(shù)量....................................................................隨訪轉(zhuǎn)移標(biāo)志........................................................................表17TACE治療次數(shù)........................................................................表11TACE治療類型........................................................................表11TACE治療藥物名稱....................................................................表11TACE治療藥物用量....................................................................表11糖鏈抗原199..........................................................................表6體溫.................................................................................表4體重.................................................................................表4天門冬氨酸氨基轉(zhuǎn)移酶.................................................................表6完全消融標(biāo)志........................................................................表12晚期放射損傷........................................................................表14危及器官限量........................................................................表14吸煙標(biāo)志.............................................................................表3吸煙時長.............................................................................表3系統(tǒng)化學(xué)治療標(biāo)志....................................................................表15系統(tǒng)化學(xué)治療不良反應(yīng)................................................................表15系統(tǒng)化學(xué)治療不良反應(yīng)標(biāo)志............................................................系統(tǒng)化學(xué)治療起始日期................................................................表15系統(tǒng)化學(xué)治療藥物名稱................................................................表15系統(tǒng)化學(xué)治療藥物用量................................................................表15系統(tǒng)治療療效評價標(biāo)志................................................................表15系統(tǒng)治療療效評價標(biāo)準(zhǔn)................................................................表15系統(tǒng)治療療效評價次數(shù)................................................................表15系統(tǒng)治療療效評價間隔時間............................................................系統(tǒng)治療療效評價檢查類型............................................................系統(tǒng)治療療效評價結(jié)果................................................................表15現(xiàn)病史...............................................................................表3現(xiàn)居住地-省（自治區(qū)、直轄市、特別行政區(qū)）............................................表2現(xiàn)居住地-市(縣、盟、州)..............................................................表2消融途徑............................................................................表12性別.................................................................................表2血管癌栓標(biāo)志.........................................................................表5血紅蛋白.............................................................................表6血小板計數(shù)...........................................................................表6陽性癥狀持續(xù)天數(shù).....................................................................表3乙肝e抗體............................................................................表6乙肝e抗原............................................................................表6乙肝表面抗體.........................................................................表6乙肝表面抗原.........................................................................表6乙肝核心IgM抗體......................................................................表6乙肝核心抗體.........................................................................表6異常凝血酶原.........................................................................表6吲哚氰氯15分鐘滯留率.................................................................表9飲酒標(biāo)志.............................................................................表3飲酒時長.............................................................................表3營養(yǎng)狀態(tài).............................................................................表4影像檢查膽管癌栓標(biāo)志.................................................................表7影像檢查復(fù)發(fā)標(biāo)志.....................................................................表7影像檢查腹水標(biāo)志.....................................................................表7影像檢查肝硬化標(biāo)志.........