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-8">
  <subject>
    <reference value="Patient/8003608833354889"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <clinicalInformation value="No mets. Equivocal lymph nodes on imaging."/>
    <perforation value="not-stated"/>
    <clinicalObstruction value="not-stated"/>
    <tumourLocation value="34402009"/>
    <typeOfOperation>
      <other value="Laparoscopic ultralow anterior resection"/>
    </typeOfOperation>
    <preoperativeRadiotherapy value="not-stated"/>
    <RecurrenceDescription value="Presence of distant metastasis:  Absent."/>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="260"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="34402009"/>
    <maxTumourDiameter>
      <value value="30"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="12"/>
      <unit value="mm (distal)"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm (distal)"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="3"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <relToAntPeritonealReflection value="entirely_below"/>
    <intactnessOfMesorectum value="408659008"/>
    <otherMacroComments
                        value="Pedunculated polyp 8mm, situated 55mm proximal to tumour."/>
    <natureAndSiteOfBlocks
                           value="A - proximal margin; B - distal margin
C/D - paired transverse slice of tumour (radial margin in C)
E/F - paired transverse slice of tumour (E - radial margin)
G -  transverse slice of tumour with radial margin
H - tumour with adjacent mucosa
I - pedunculated polyp 55mm proximal to tumour
J - apical lymph node
K to N - peritumoural/distal lymph nodes (up to 6 lymph nodes per cassette)
O to S - lymph nodes proximal to tumour (O to R - 6 lymph nodes per cassette, S - 4 lymph node4s per cassette)
T to Z - fat with possible lymph nodes."/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399415002"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance value="5mm (anterior)"/>
    <nonperitonealisedCircumMargin value="not_involved"/>
    <microClearanceRectum>
      <value value="5"/>
      <unit value="mm (anterior)"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm (anterior)"/>
    </microClearanceRectum>
    <lymphNodeInvolvement value="2667000"/>
    <lymphNodesDetails>
      <site value="pN0"/>
      <numPos value="0"/>
      <numExamined value="36"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="2667000"/>
    <apicalNodeInvolvement value="2667000"/>
    <intramuralVeinInvasion value="not_identified"/>
    <extramuralVeinInvasion value="369734008"/>
    <smallVesselInvasion value="not_identified"/>
    <perineuralInvasion value="385001000"/>
    <histoConfDistMetastases value="2667000"/>
    <relCoexistPathabnorm>
      <code value="254588001"/>
    </relCoexistPathabnorm>
    <microResidualTumourStatus value="R0"/>
    <neoadjuvantTherapy value="not_applicable"/>
  </micro>
  <ancillaryTests>
    <mlh1 value="373121007"/>
    <pms2 value="normal_staining"/>
    <msh2 value="373121007"/>
    <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="395707006"/>
    <tumourStageN value="n0"/>
    <tumourStageM value="m0"/>
    <tumourStageGrouping value="261614003"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
    <diagnosticSummary
                       value="Diagnostic Summary:
Specimen type: Ultra-low anterior resection
Tumour site: Rectum
Tumour type: Adenocarcinoma, poorly differentiated tumour budding
Tumour stage: pT3N0 cM, stage IIA
Completeness of excision: Complete

Diagnosis:
1. Rectum and Sigmoid, ultrlow anterior resection:
- Adenocarcinoma NOS, 30x28x15mm, poorly differentiated tumour budding, focal extramural venous invasion.
- radial clearance 5mm, distal clearance 12mm.
Lymph nodes: 0/36; thirty-six benign lymph nodes.
TNM class, AJCC stage (7th): pT3N0 cM0, stage IIA, R0
Polyp, upper rectum: Tubulovillous adenoma, 8mm.
2. Distal donut: No evidence of malignancy"/>
  </synthesisOverview>
</Colorectal>