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-5">
  <subject>
    <reference value="Patient/8003608333354363"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <clinicalInformation value="Anterior resection"/>
    <typeOfOperation>
      <code value="4558008"/>
    </typeOfOperation>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="55"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="32713005"/>
    <maxTumourDiameter>
      <value value="52"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="45"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distanceNearerProxOrDistal>
    <tumourPerforation value="2667000"/>
    <otherMacroComments
                        value="A segment of large bowel 175mm in length with an internal diameter of up to 52mm. The bowel has been opened prior to receipt. The peritoneal reflection has not been included in the specimen. Arising at 45mm from the presumed distal margin, a raised ulcerated firm tan tumour is present measuring 55x32mm. On slicing the tumour measures up to 10mm in thickness and infiltrates into the mesocolic fat. On the antimesenteric border, the tumour abuts the serosal surface. Tumour perforation is not seen. No other lesions are identified within the mucosa elsewhere. Blocks 1, 2 - reps of tumour with mesocolic fat. Blocks 3,4,5 - tumour with peritoneal surface. Block 6 - distal resection margin. Block 7 - apical lymph node. Block 8 - one lymph node. Block 9 - four lymph nodes. Block 10 - five lymph nodes. PP. (TW.LD)"/>
    <natureAndSiteOfBlocks
                           value="Blocks 1,2 - reps of tumour with mesocolic fat.  Blocks 3, 4, 5 - tumour with peritoneal surface.  Block 6 - distal resection margin.  Block 7 - apical lymph node.  Block 8 - one lymph node.  Block 9 - four lymph nodes.  Block 10 - five lymph nodes. PP (TW. LD)"/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399611001"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance value="&gt;10mm"/>
    <lymphNodeInvolvement value="52101004"/>
    <lymphNodesDetails>
      <site value="Left"/>
      <numPos value="2"/>
      <numExamined value="11"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="2667000"/>
    <apicalNodeInvolvement value="2667000"/>
    <intramuralVeinInvasion value="not_identified"/>
    <extramuralVeinInvasion value="not_identified"/>
    <smallVesselInvasion value="not_identified"/>
    <perineuralInvasion value="369731000"/>
    <histoConfDistMetastases value="2667000"/>
    <relCoexistPathabnorm>
      <code value="260386005"/>
    </relCoexistPathabnorm>
    <microResidualTumourStatus value="Complete"/>
    <neoadjuvantTherapy value="no_prior_treatment"/>
  </micro>
  <ancillaryTests>
    <comments
              value="Immunohostochemical stains for microsatellite instability will be performed and a supplementary report issued."/>
  </ancillaryTests>
  <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>