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-9">
  <subject>
    <reference value="Patient/8003608333353852"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <clinicalInformation
                         value="Rectosigmoid adeno ca.; high anterior resection."/>
    <perforation value="not-stated"/>
    <clinicalObstruction value="not-stated"/>
    <tumourLocation value="49832006"/>
    <typeOfOperation>
      <code value="4558008"/>
    </typeOfOperation>
    <anteriorResectionType value="75540009"/>
    <preoperativeRadiotherapy value="not-stated"/>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="175"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="34402009"/>
    <maxTumourDiameter>
      <value value="40"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="40"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="25"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <natureAndSiteOfBlocks
                           value="A - proximal resection margin
B - distal resection margin
C - proximal edge of tumour
D and E - closest serosal surface and attached epiploic appendicies
F - tumour + fat
G - distal edge of tumour + radial margin
H- Q - lymph nodes from peritoneal fat
H - apical lymph node
I - next most apical lymph node bisected
J - apical fat
K - next most apical node bisected
L - three nodes
M to O - each contain one node bisected
P - four nodes
R - lymph node furtherest away from bowel wall
S - five possible nodes
T - one node
U and V - sigmoid mesentery."/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399611001"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <marginsMicroClearance value="21mm"/>
    <nonperitonealisedCircumMargin value="not_involved"/>
    <microClearanceRectum>
      <value value="21"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </microClearanceRectum>
    <lymphNodeInvolvement value="2667000"/>
    <lymphNodesDetails>
      <site value="pN0"/>
      <numPos value="0"/>
      <numExamined value="13"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="2667000"/>
    <apicalNodeInvolvement value="2667000"/>
    <intramuralVeinInvasion value="not_identified"/>
    <extramuralVeinInvasion value="not_identified"/>
    <smallVesselInvasion value="not_identified"/>
    <perineuralInvasion value="385001000"/>
    <histoConfDistMetastases value="not-stated"/>
    <relCoexistPathabnorm>
      <code value="260386005"/>
    </relCoexistPathabnorm>
    <microResidualTumourStatus
                               value="R0, complete resection, margins histologically negative, no residual tumour left after resection (primary tumour, regional nodes)."/>
  </micro>
  <ancillaryTests>
    <mlh1 value="normal_staining"/>
    <pms2 value="normal_staining"/>
    <msh2 value="normal_staining"/>
    <msh6 value="normal_staining"/>
    <comments
              value="Preserved nuclear staining for mismatch repair proteins MLH1, PMS2, MSH2 and MSH6 indicates a low likelihood of microsatellite instability phenotype."/>
    <braf>
      <code value="373121007"/>
    </braf>
    <kras>
      <code value="373121007"/>
    </kras>
  </ancillaryTests>
  <synthesisOverview>
    <tumourStageT value="395707006"/>
    <tumourStageN value="n0"/>
    <tumourStageM value="mx"/>
    <tumourStageGrouping value="261614003"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
    <diagnosticSummary
                       value="Diagnostic Summary:
Specimen type:High anterior resection
Tumour site: Rectum-sigmoid colon
Tumour type: Adenocarcinoma
Tumour stage: pT3. n0, Mx, R0
Completeness of excision: Completely excised

Diagnosis:
1. Anterior resection:
- Moderately differentiated adenocarcinoma, recto-sigmoid, completely excised.
- Focus suspicious for lymphovascular invasion
- no evidence of malignancy in thirteen lymph nodes (0/13)
- pT3, n0, MX, R0, stage IIA (Dukes stage B)
2. Distal donut - No evidence of malignancy
3. Proximal donut - No evidence of malignancy"/>
  </synthesisOverview>
</Colorectal>