HL7 Australia Implementation Guide:

RCPA Cancer Protocols IG (v0.1.0: Release 1 Draft). This is the current published version based on FHIR R3. See the Directory of published versions

Generated Example


<Colorectal xmlns="http://hl7.org/fhir" id="Colorectal-genexample-1">
  <subject>
    <reference value="Patient/8003608333428779"/>
  </subject>
  <requester>
    <reference value="Practitioner/8003616566682137"/>
  </requester>
  <performer>
    <reference value="Organization/8003623233350148"/>
  </performer>
  <preAnalytic>
    <perforation value="2667000"/>
    <clinicalObstruction value="2667000"/>
    <tumourLocation value="34402009"/>
    <distanceAnalVerge>
      <value value="6"/>
      <unit value="cm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="cm"/>
    </distanceAnalVerge>
    <preoperativeRadiotherapy value="373066001"/>
    <typeOfCourse value="260402009"/>
    <surgeonsOpinion value="None noted"/>
    <newPrimaryOrRecurrence value="new_primary"/>
    <RecurrenceDescription value="No metastatic lesions"/>
    <otherRelevantDetails value="Tissue banking:   No
Specimen images:   Yes"/>
  </preAnalytic>
  <macro>
    <specimenLength>
      <value value="130"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </specimenLength>
    <tumourSite value="34402009"/>
    <maxTumourDiameter>
      <value value="50"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </maxTumourDiameter>
    <distanceNearerProxOrDistal>
      <value value="20"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distanceNearerProxOrDistal>
    <distNonperitonCircumMargin>
      <value value="15"/>
      <unit value="mm"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm"/>
    </distNonperitonCircumMargin>
    <tumourPerforation value="2667000"/>
    <relToAntPeritonealReflection value="astride"/>
    <intactnessOfMesorectum value="408657005"/>
    <peritoneum
                value="tumour_formed_nodule(s)_discrete_from_tumour_mass_along_the_serosal_surface"/>
    <lymphNodes value="440622005"/>
    <noLymphNodesPerCassette
                             value="3 in cassette 1 
4 in cassette 2
7 in cassette 3"/>
    <polyps value="52101004"/>
    <polypSummary value="Two 5mm polyps are noted."/>
    <otherMacroComments
                        value="Tumour appears ulcerated and scarred. Overlying serosa appears normal. Extramuscular spread to 15mm"/>
    <natureAndSiteOfBlocks
                           value="Blocks 1 to 6: tumour. Block 7: distal margin. Blocks 8 &amp; 9 : circumferential margin. Blocks 10 to 16: 14 lymph nodes (2 in each block)."/>
  </macro>
  <micro>
    <tumourType value="35917007"/>
    <histologicalGrade value="399415002"/>
    <maxDegreeLocalInvasion value="395707006"/>
    <proximalOrDistalResectionMargins value="not_involved"/>
    <lymphNodeInvolvement value="52101004"/>
    <lymphNodesDetails>
      <site value="Perirectal LN basin"/>
      <numPos value="2"/>
      <numExamined value="14"/>
    </lymphNodesDetails>
    <extramuralTumourDeposits value="2667000"/>
    <apicalNodeInvolvement value="2667000"/>
    <intramuralVeinInvasion value="present"/>
    <extramuralVeinInvasion value="not_identified"/>
    <smallVesselInvasion value="not_identified"/>
    <perineuralInvasion value="385001000"/>
    <histoConfDistMetastases value="2667000"/>
    <relCoexistPathabnorm>
      <code value="254588001"/>
    </relCoexistPathabnorm>
    <polypDetails value="Two tubular adenomata confirmed."/>
    <microResidualTumourStatus value="Complete resection"/>
    <neoadjuvantTherapy value="grade_2"/>
    <microComments
                   value="The submucosal nodule 20mm from the distal margin is a well differentiated carcinoid tumour, completely excised."/>
  </micro>
  <ancillaryTests>
    <mlh1 value="normal_staining"/>
    <pms2 value="normal_staining"/>
    <msh2 value="normal_staining"/>
    <msh6 value="normal_staining"/>
    <comments
              value="Immunohistochemistry for mismatch repair gene products:  staining of carcinoma cells for MLH-1, PMS-2, MSH-2 and MSH-6 is present."/>
  </ancillaryTests>
  <synthesisOverview>
    <tumourStageT value="395707006"/>
    <tumourStageN value="n1b"/>
    <tumourStageM value="m0"/>
    <tumourStageGrouping value="261639007"/>
    <tumourStagingSystem value="AJCC 2010, 7th edition"/>
    <residualTumourStatus value="r0"/>
    <diagnosticSummary
                       value="Low anterior resection:
Rectal adenocarcinoma, excision complete, ypT3, pN1b, cM0, Stage IIIB.
Comment:
Two small tubular adenomas and a well differentiated carcinoid tumour are also present.  
Mismatch repair gene deficiency not identified."/>
    <newPrimaryOrRecurrence value="new-primary"/>
    <overarchingComment
                        value="Mismatch repair gene deficiency is not identified."/>
  </synthesisOverview>
</Colorectal>