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-3">
  <subject>
    <reference value="Patient/8003608166687160"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <clinicalInformation
                         value="A: Specimen labelled : right hemicolectomy
B: Mesentric lymph node"/>
    <typeOfOperation>
      <code value="235326000"/>
    </typeOfOperation>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="85"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="32713005"/>
    <maxTumourDiameter>
      <value value="90"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="70"/>
      <unit value="mm (Proximal)"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm (Proximal)"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="15"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <lymphNodes value="440622005"/>
    <noLymphNodesPerCassette
                             value="21 in total.
A11 – 1 node, serially sliced
 A12 – 1 node, serially sliced
 A13 – 1 node, serially sliced
 A14 – 1 node, serially sliced
 A15 – 1 node, apical node, bisected and entirely submitted.
A16 – 3 nodes
 A17 – 3 nodes
 A18 – 3 nodes
 A19 – 6 nodes, 1 bisected
 B - Mesentric lymph node Bisected and entirely submitted in 1 block"/>
    <polyps value="2667000"/>
    <natureAndSiteOfBlocks
                           value="A1-A2 - Omentum.
A3 - Ileal margin with adjacent noninvolved ileum.
A4 - Appendix with base painted.
A5-A6 - Tumour at ileocaecal junction.
A7-A8 - Representative sections of tumour.
A9 - Tumour with nonperitonealised margin.
A10 - Ascending colon and distal resection margin.
Lymph nodes as above"/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399415002"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance
                           value="&gt;10mm (Proximal);
&gt; 10mm (Distal);
&lt;1mm (Circumferential)"/>
    <lymphNodeInvolvement value="52101004"/>
    <lymphNodesDetails>
      <site value="Left"/>
      <numPos value="2"/>
      <numExamined value="21"/>
    </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"/>
  </micro>
  <synthesisOverview>
    <tumourStageT value="395707006"/>
    <tumourStageN value="395711000"/>
    <tumourStageM value="m0"/>
    <tumourStageGrouping value="261639007"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
    <newPrimaryOrRecurrence value="new-primary"/>
  </synthesisOverview>
</Colorectal>