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-4">
  <subject>
    <reference value="Patient/8003608333354355"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <clinicalInformation
                         value="Pre-operative radiotherapy: Unknown
Presence of any distant metastases: Unknown
Other: Nil"/>
    <typeOfOperation>
      <code value="4558008"/>
    </typeOfOperation>
    <preoperativeRadiotherapy value="not-stated"/>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="185"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="49832006"/>
    <maxTumourDiameter>
      <value value="60"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="28"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="3.5"/>
      <unit value="mm (10mm above the anterior peritoneal reflection)"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm (10mm above the anterior peritoneal reflection)"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <relToAntPeritonealReflection value="astride"/>
    <intactnessOfMesorectum value="408657005"/>
    <polyps value="52101004"/>
    <polypSummary value="2 polyps"/>
    <otherMacroComments
                        value="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
                           value="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."/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399415002"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance value="20 mm (longitudinal and circumferential)"/>
    <nonperitonealisedCircumMargin value="not_involved"/>
    <microClearanceRectum>
      <value value="20"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </microClearanceRectum>
    <lymphNodeInvolvement value="2667000"/>
    <lymphNodesDetails>
      <numPos value="0"/>
      <numExamined value="30"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="2667000"/>
    <apicalNodeInvolvement value="2667000"/>
    <intramuralVeinInvasion value="not_identified"/>
    <extramuralVeinInvasion value="not_identified"/>
    <smallVesselInvasion value="not_identified"/>
    <perineuralInvasion value="385001000"/>
    <histoConfDistMetastases value="2667000"/>
    <relCoexistPathabnorm>
      <code value="254588001"/>
    </relCoexistPathabnorm>
    <polypDetails
                  value="Benign hyperplastic polyp and tubular adenoma with low grade dysplasia"/>
    <neoadjuvantTherapy value="uncertain"/>
  </micro>
  <ancillaryTests>
    <braf>
      <code value="373121007"/>
    </braf>
    <kras>
      <code value="373121007"/>
    </kras>
  </ancillaryTests>
  <synthesisOverview>
    <tumourStageT value="395707006"/>
    <tumourStageN value="n1b"/>
    <tumourStageM value="m0"/>
    <tumourStageGrouping value="261614003"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
  </synthesisOverview>
</Colorectal>