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-2">
  <subject>
    <reference value="Patient/8003608166687152"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <tumourLocation value="34402009"/>
    <typeOfOperation>
      <code value="4558008"/>
    </typeOfOperation>
    <anteriorResectionType value="260362008"/>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="240"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="34402009"/>
    <maxTumourDiameter>
      <value value="45"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="6"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="10"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <relToAntPeritonealReflection value="astride"/>
    <intactnessOfMesorectum value="408657005"/>
    <peritoneum value="tumour_invades_to_peritoneal_surface"/>
    <lymphNodes value="440622005"/>
    <noLymphNodesPerCassette
                             value="1 in cassette 1
4 in cassette 2
3 in cassette 3"/>
    <polyps value="2667000"/>
    <otherMacroComments
                        value="Tumour appears plaquelike, remaining mucosa appears normal."/>
    <natureAndSiteOfBlocks
                           value="Blocks 1: shaved vascular margin, 2 to 4: tumour with greatest depth of invasion, radial inked red, distal inked blue. 5 – tumour with adjacent mucosa. 6-9 lymph nodes"/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399415002"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance
                           value="&gt;10mm (Proximal);
9 mm (Distal);
13mm (Circumferential)"/>
    <nonperitonealisedCircumMargin value="248448006"/>
    <microClearanceRectum>
      <value value="1"/>
      <comparator value="&lt;"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </microClearanceRectum>
    <lymphNodeInvolvement value="2667000"/>
    <lymphNodesDetails>
      <numPos value="0"/>
      <numExamined value="8"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="52101004"/>
    <apicalNodeInvolvement value="2667000"/>
    <intramuralVeinInvasion value="not_identified"/>
    <extramuralVeinInvasion value="not_identified"/>
    <smallVesselInvasion value="not_identified"/>
    <perineuralInvasion value="385001000"/>
    <histoConfDistMetastases value="2667000"/>
    <relCoexistPathabnorm>
      <code value="260386005"/>
    </relCoexistPathabnorm>
    <microResidualTumourStatus value="Complete"/>
    <neoadjuvantTherapy value="no_prior_treatment"/>
    <microComments
                   value="The submucosal nodule 20mm from the distal margin is a well differentiated carcinoid tumour, completely excised."/>
  </micro>
  <ancillaryTests>
    <mlh1 value="normal_staining"/>
    <pms2 value="normal_staining"/>
    <msh2 value="normal_staining"/>
    <msh6 value="normal_staining"/>
    <comments
              value="Positive &gt;10% strong to moderate staining of nucleus.
Normal positive expression of DNA mismatch repair proteins in adenocarcinoma."/>
  </ancillaryTests>
  <synthesisOverview>
    <tumourStageT value="395707006"/>
    <tumourStageN value="n0"/>
    <tumourStageM value="m0"/>
    <tumourStageGrouping value="261614003"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
    <diagnosticSummary
                       value="Low rectal tumour, ultralow anterior resection with proximal and distal donuts:
- Moderately differentiated adenocarcinoma, invading into perirectal fat.
- Less than 1mm from circumferential radial margin.
- Proximal and distal margins free of tumour.
- 8 lymph nodes, all benign.
- No MSI loss detected by immunohistochemistry."/>
    <newPrimaryOrRecurrence value="new-primary"/>
    <overarchingComment value="Mismatch repair gene deficiency identified."/>
  </synthesisOverview>
</Colorectal>