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-7">
  <subject>
    <reference value="Patient/8003608500020565"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <clinicalInformation value="Rectum/anus, Rectal Ca"/>
    <perforation value="not-stated"/>
    <clinicalObstruction value="not-stated"/>
    <tumourLocation value="34402009"/>
    <typeOfOperation>
      <code value="265414003"/>
    </typeOfOperation>
    <preoperativeRadiotherapy value="not-stated"/>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="280"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="34402009"/>
    <maxTumourDiameter>
      <value value="30"/>
      <unit value="x 25mm, occupies 25% circumference"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="x 25mm, occupies 25% circumference"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="40"/>
      <unit value="mm (distal)"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm (distal)"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="35"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <relToAntPeritonealReflection value="entirely_below"/>
    <intactnessOfMesorectum value="408657005"/>
    <otherMacroComments
                        value="Additional small polyps, 1-4mm in diameter, 4 within the c=vicinity of the tumour, 6 proximal to the tumour."/>
    <natureAndSiteOfBlocks
                           value="A - proximal resection margin, B/C - distal resection margin
D to H - tumour
D/E - T/S, deepest invasion, nearest radial margin in E (inked blue)
F - t/s, G - l/s proximal tumour edge, radial margin inked in blue; 
H - l/s distal tumour edge, with dentate line
I - scarred area all embedded
J, K - polyps proximal to level of anterior peritoneal reflection, three polyps in each block
L- polyps surrounding the tumour
M - diverticula
N - apical node
O - four nodes from mesentery
P to AA - mesocolic and mesorectal nodes proximal to tumour:
P, Q - six nodes in each block; R to U - one node in each block;
V - six nodes; W, X - one node in each block; Y - six nodes; Z -  one node; AA - four nodes
AB, AC - peritumoral, mesorectal and distal nodes
AB - one node, AC - four nodes. LZ6"/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399415002"/>
    <maxDegreeLocalInvasion value="395706002"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance value="35mm"/>
    <microClearanceRectum>
      <value value="35"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </microClearanceRectum>
    <lymphNodeInvolvement value="52101004"/>
    <lymphNodesDetails>
      <site value="pN1a"/>
      <numPos value="1  (4mm deposit in peritumoral / distal node)"/>
      <numExamined value="41"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="2667000"/>
    <intramuralVeinInvasion value="not_identified"/>
    <extramuralVeinInvasion value="not_identified"/>
    <smallVesselInvasion value="not_identified"/>
    <perineuralInvasion value="385001000"/>
    <histoConfDistMetastases value="not-stated"/>
    <relCoexistPathabnorm>
      <code value="254588001"/>
    </relCoexistPathabnorm>
    <microResidualTumourStatus value="R0"/>
    <neoadjuvantTherapy value="not_applicable"/>
  </micro>
  <ancillaryTests>
    <pms2 value="normal_staining"/>
    <msh6 value="normal_staining"/>
    <comments
              value="High-level microsatellite instability (MSI-H) is very unlikely."/>
    <msi>
      <code value="373121007"/>
    </msi>
    <braf>
      <code value="373121007"/>
    </braf>
    <kras>
      <code value="373121007"/>
    </kras>
  </ancillaryTests>
  <synthesisOverview>
    <tumourStageT value="395706002"/>
    <tumourStageN value="n1a"/>
    <tumourStageM value="mx"/>
    <tumourStageGrouping value="261638004"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
    <diagnosticSummary
                       value="Diagnostic Summary:
Specimen type: Abdominoperineal resection
Tumour site: Distal rectum, 35mm below anterior peritoneal reflection, 12 mm above dentate line.
Tumour type: Low grade adenocarcinoma NOS, microsatellite stable (IHC)
Tumour stage: pT2N1aMX, stage IIIA
Completeness of excision: R0

Diagnosis:
Abdominoperineal resection, distal rectum
- low grade adenocarcinoma NOS, 30mm, microsatellite stable (IHC)

Lymph nodes 
-  +1/41, metastatic carcinoma in one of forty-one nodes, apical node clear

TNM class AJCC stage (7th)
- pT2N1aMX, stage IIIA, R0

Polyps 
- Hyperplastic polyps x9 (&lt;5mm)"/>
  </synthesisOverview>
</Colorectal>