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

{
  "resourceType" : "Colorectal",
  "id" : "Colorectal-genexample-4",
  "subject" : {
    "reference" : "Patient/8003608333354355"
  },
  "requester" : {
    "reference" : "Practitioner/8003616566682137"
  },
  "performer" : {
    "reference" : "Organization/8003623233350148"
  },
  "preAnalytic" : {
    "clinicalInformation" : "Pre-operative radiotherapy: Unknown
Presence of any distant metastases: Unknown
Other: Nil",
    "typeOfOperation" : {
      "code" : "4558008"
    },
    "preoperativeRadiotherapy" : "not-stated"
  },
  "macro" : {
    "specimenLength" : {
      "value" : 185,
      "unit" : "mm",
      "system" : "http://unitsofmeasure.org",
      "code" : "mm"
    },
    "tumourSite" : "49832006",
    "maxTumourDiameter" : {
      "value" : 60,
      "unit" : "mm",
      "system" : "http://unitsofmeasure.org",
      "code" : "mm"
    },
    "distanceNearerProxOrDistal" : [
      {
        "value" : 28,
        "unit" : "mm",
        "system" : "http://unitsofmeasure.org",
        "code" : "mm"
      }
    ],
    "distNonperitonCircumMargin" : {
      "value" : 3.5,
      "unit" : "mm (10mm above the anterior peritoneal reflection)",
      "system" : "http://unitsofmeasure.org",
      "code" : "mm (10mm above the anterior peritoneal reflection)"
    },
    "tumourPerforation" : "2667000",
    "relToAntPeritonealReflection" : "astride",
    "intactnessOfMesorectum" : "408657005",
    "polyps" : "52101004",
    "polypSummary" : "2 polyps",
    "otherMacroComments" : "Captured image of the specimen: No
1.  The specimen is labelled ‘sigmoid colon and rectum’ and consists of a portion of sigmoid colon and rectum measuring 185mm in length.  Sigmoid mesentery extends to a depth of 75mm.  Resection margins are stapled.  28mm from the distal resection margin, there is an ulcerated lesion with raised everted edges which extends around 90% of the circumference of the bowel.  The tumour measures 60mm in length and extends 15mm distal to the anterior peritoneal reflection and 45mm proximal to this reflection.  Occasional sessile polyps are noted elsewhere along the mucosa.  Sectioning through the tumour shows it to invade into the outer aspect of the muscularis propria to possibly just extend into adjacent pericolic fat.  The tumour extends close to the serosal surface approximately 10mm above the anterior peritoneal reflection.  Multiple lymph nodes are present within the pericolic fat.
2. The specimen is labelled ‘donuts’ and consists of two donuts of bowel tissue, one measuring 18mm in diameter and 6mm in length and the other 20mm in diameter and 15mm in length.",
    "natureAndSiteOfBlocks" : [
      "Specimen 2:
Specimen labelled:  Donuts

1A proximal resection margin; 1B sessile polyps, vascular resection margin and most apical lymph node bisected; 1C distal resection margin with tumour; 1D and 1E representative sections of tumour and possible extension to anterior serosa; 1F possible invasion through muscularis propria into pericolic fat; 1G to 1K sections of all lymph nodes with multiple nodes in each block.  
Representative sections of each donut in 2A and 2B respectively."
    ]
  },
  "micro" : {
    "tumourType" : "35917007",
    "histologicalGrade" : "399415002",
    "maxDegreeLocalInvasion" : "395707006",
    "proximalOrDistalResectionMargins" : "not_involved",
    "marginsMicroClearance" : "20 mm (longitudinal and circumferential)",
    "nonperitonealisedCircumMargin" : "not_involved",
    "microClearanceRectum" : {
      "value" : 20,
      "unit" : "mm",
      "system" : "http://unitsofmeasure.org",
      "code" : "mm"
    },
    "lymphNodeInvolvement" : "2667000",
    "lymphNodesDetails" : [
      {
        "numPos" : "0",
        "numExamined" : "30"
      }
    ],
    "extramuralTumourDeposits" : "2667000",
    "apicalNodeInvolvement" : "2667000",
    "intramuralVeinInvasion" : "not_identified",
    "extramuralVeinInvasion" : "not_identified",
    "smallVesselInvasion" : "not_identified",
    "perineuralInvasion" : "385001000",
    "histoConfDistMetastases" : "2667000",
    "relCoexistPathabnorm" : [
      {
        "code" : "254588001"
      }
    ],
    "polypDetails" : "Benign hyperplastic polyp and tubular adenoma with low grade dysplasia",
    "neoadjuvantTherapy" : "uncertain"
  },
  "_ancillaryTests" : {
    "braf" : {
      "code" : "373121007"
    },
    "kras" : {
      "code" : "373121007"
    }
  },
  "synthesisOverview" : {
    "tumourStageT" : "395707006",
    "tumourStageN" : "n1b",
    "tumourStageM" : "m0",
    "tumourStageGrouping" : "261614003",
    "tumourStagingSystem" : "AJCC 2010, 7th edition",
    "residualTumourStatus" : "r0"
  }
}