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-11">
  <subject>
    <reference value="Patient/8003608833364953"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <clinicalInformation
                         value="Ca restum; family history CRC; low anterior resection, proximal and distal donuts.
The histopathology report on previous rectal biopsy, xxxx-xxxx from 24/9/2015, is noted."/>
    <perforation value="not-stated"/>
    <clinicalObstruction value="not-stated"/>
    <tumourLocation value="34402009"/>
    <typeOfOperation>
      <code value="4558008"/>
    </typeOfOperation>
    <anteriorResectionType value="62482003"/>
    <preoperativeRadiotherapy value="not-stated"/>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="165"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="34402009"/>
    <maxTumourDiameter>
      <value value="30"/>
      <unit value="x25mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="x25mm"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="30"/>
      <unit value="mm (distal)"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm (distal)"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="5"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <relToAntPeritonealReflection value="entirely_above"/>
    <intactnessOfMesorectum value="408657005"/>
    <natureAndSiteOfBlocks
                           value="A and B - shave of the distal resection margin
C and D - shave of the proximal resection margin
E - surgical high tie of mesentery with one apical lymph node
F and G - one full face section of the tumour showing deepest invasion and closest circumferential margin
H and I - second full face section of the tumour showing deepest invasion and slosest circumferential margin
J - one full face section of tumour with ?invovled lymph node 
K -  four lymph nodes
L - four lymph nodes
M - three lymph nodes
N and O - lymph nodes taken from mesentery distal to tumour:
N - three lymph nodes
O -  three lymph nodes"/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399611001"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance value="5mm"/>
    <microClearanceRectum>
      <value value="5"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </microClearanceRectum>
    <lymphNodeInvolvement value="52101004"/>
    <lymphNodesDetails>
      <site value="pN2a"/>
      <numPos value="4"/>
      <numExamined value="16"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="52101004"/>
    <apicalNodeInvolvement value="52101004"/>
    <intramuralVeinInvasion value="369733002"/>
    <extramuralVeinInvasion value="369734008"/>
    <smallVesselInvasion value="present_and_extensive"/>
    <perineuralInvasion value="369731000"/>
    <histoConfDistMetastases value="not-stated"/>
    <relCoexistPathabnorm>
      <code value="260386005"/>
    </relCoexistPathabnorm>
    <microResidualTumourStatus value="R0"/>
    <neoadjuvantTherapy value="not_applicable"/>
  </micro>
  <ancillaryTests>
    <mlh1 value="normal_staining"/>
    <pms2 value="normal_staining"/>
    <msh2 value="normal_staining"/>
    <msh6 value="normal_staining"/>
    <comments
              value="High-level microsatellite instability (MSI-H) is very unlikely."/>
    <msi>
      <code value="373121007"/>
    </msi>
    <braf>
      <code value="373121007"/>
    </braf>
    <kras>
      <code value="373121007"/>
    </kras>
  </ancillaryTests>
  <synthesisOverview>
    <tumourStageT value="395707006"/>
    <tumourStageN value="n2a"/>
    <tumourStageM value="mx"/>
    <tumourStageGrouping value="261639007"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
    <diagnosticSummary
                       value="Diagnostic Summary:
Specimen type:Low anterior resection
Tumour site: Rectum
Tumour type: Adenocarcinoma NOS, microsatellite stable, variable differentiation including poorly differentiated areas
Tumour stage: pT3cN2aMx; stage IIIB
Completeness of excision: R0

Diagnosis:
1. Low anterior resection rectum:
- High grade adenocarcinoma NOS, 30x25mm, microsatellite stable
- Venous invasion, lymphatic permeation and perineural invasion present
Lymph nodes
- +4/16; metastatic carcinoma in four of sixteen nodes
- Apical node involved
- extranural satellite deposits x2.
TNM class AJCC Stage (7th) 
- pT3cN2aMX; stage IIIB; R0
2. Proximal donut - Benign colonic tissue
3. Distal  donut - Benign rectal tissue"/>
  </synthesisOverview>
</Colorectal>