This page is part of the RCPA Cancer Protocols IG (v0.1.0: Release 1 Draft) based on FHIR R3. . For a full list of available versions, see the Directory of published versions

Generated Example

<Colorectal xmlns="http://hl7.org/fhir" id="Colorectal-genexample-10">
  <subject>
    <reference value="Patient/8003608166687558"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <clinicalInformation
                         value="Ca rectum - was quite large. Post long course radio Tx.  Pre radio Tx staging T3N1M0"/>
    <tumourLocation value="34402009"/>
    <typeOfOperation>
      <code value="4558008"/>
    </typeOfOperation>
    <preoperativeRadiotherapy value="373066001"/>
    <typeOfCourse value="260384008"/>
    <RecurrenceDescription value="Presence of distant metastasis:  Absent."/>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="270"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="34402009"/>
    <maxTumourDiameter>
      <value value="15"/>
      <unit value="x10mm (ulcer)"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="x10mm (ulcer)"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="75"/>
      <unit value="mm (distal)"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm (distal)"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="15"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <relToAntPeritonealReflection value="entirely_below"/>
    <intactnessOfMesorectum value="408657005"/>
    <otherMacroComments value="Entire ulcer/tumour bed embedded"/>
    <natureAndSiteOfBlocks
                           value="A - proximal margin
B - distal margin
C to I - ulcer
J - apical node bisected
K - periapical node
L to O - four lymph nodes in each, above anterior peritoneal reflection
P to U - lymph nodes below anterior peritoneal reflection
P - four lymph nodes
Q - three lymph nodes
R - one bisected lymph node
S - two lymph nodes with posterior margin
T - three lymph nodes
U - two lymph nodes"/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399415002"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance value="15mm"/>
    <nonperitonealisedCircumMargin value="not_involved"/>
    <microClearanceRectum>
      <value value="15"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </microClearanceRectum>
    <lymphNodeInvolvement value="52101004"/>
    <lymphNodesDetails>
      <site value="pN 1b"/>
      <numPos
              value="2 (with fibrosis regarded as treatment effect in additional 3 nodes)"/>
      <numExamined value="23"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="2667000"/>
    <apicalNodeInvolvement value="2667000"/>
    <intramuralVeinInvasion value="not_identified"/>
    <extramuralVeinInvasion value="369734008"/>
    <smallVesselInvasion value="not_identified"/>
    <perineuralInvasion value="385001000"/>
    <histoConfDistMetastases value="not-stated"/>
    <relCoexistPathabnorm>
      <code value="260386005"/>
    </relCoexistPathabnorm>
    <microResidualTumourStatus value="R0"/>
    <neoadjuvantTherapy value="grade_2"/>
  </micro>
  <ancillaryTests>
    <pms2 value="normal_staining"/>
    <msh2 value="loss_of_staining"/>
    <msh6 value="loss_of_staining"/>
    <comments
              value="There is strong nuclear staining (normal pattern) ini only a minor component of the residual tumour (block 1C) and attenuated (MSH2) or loss (MSH6) to staining in the rest.  Whilst this abnormal staining pattern is likely to be secondary to the neoadjuvant therapy, thurther investigation to exclude germline mutation in MSH2 and MSH6 should be considered."/>
    <msi>
      <code value="373121007"/>
    </msi>
    <braf>
      <code value="373121007"/>
    </braf>
    <kras>
      <code value="373121007"/>
    </kras>
  </ancillaryTests>
  <synthesisOverview>
    <tumourStageT value="395707006"/>
    <tumourStageN value="n1b"/>
    <tumourStageM value="m0"/>
    <tumourStageGrouping value="261639007"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
    <diagnosticSummary
                       value="Diagnostic Summary:
Specimen type:Anterior resection
Tumour site: Upper rectum 300mm above level of anterior peritoneal reflection
Tumour type: Adenocarcinoma NOS Low grade (post therapy) microsatellite stable
Tumour stage: ypT3 N1b cMx cM0; stage IIIB
Completeness of excision: R0

Diagnosis:
1. Upper rectum:
Upper rectum
- Redidual adenocarcinoma NOS, minimal response to therapy (TRG 2)
- Extramural venous invasion
Lymph nodes
- +2/23; metastatic carcinoma in two of twenty-three nodes, treatment related changes in additional three nodes, apical node clear.
TNM class AJCC Stage (7th) 
- ypT3N1b cM0; stage IIIB; R0
MMR IHC
- Pending, supplementary report to follow
2. Distal rectal donut - No evidence of malignancy"/>
  </synthesisOverview>
</Colorectal>