HL7 Australia Implementation Guide: home
Logical Model Mappings FHIR Resources HL7 V2.4 Messaging

Colorectal Report

This implementation guide is developed from the Royal College of Pathologists of Australasia's (RCPA) "Colorectal Cancer - Structured Reporting Protocol" (2nd edition 2012). The colorectal cancer protocol is not intended to apply to tumours of the appendix, small bowel and anus. Local excisions of colorectal carcinomas will be dealt with in a subsequent protocol. Synchronous primary tumours should have separate protocols recorded for each tumour.

This is the Colorectal Logical Model. For context, see the explanation of how this guide works.

Colorectal Report

NameFlagsCard.TypeDescription & Constraintsdoco
.. Colorectal
... subject Σ1..1Reference(Australian Patient (Human))
... requester Σ0..1Reference(Practitioner)
... performer Σ0..1Reference(Practitioner), Reference(Organization)
... preAnalytic I0..101: If there is a perforation, the perforation type must be indicated.
.... clinicalInformation 0..1string
.... operatingSurgeonDetails Σ0..1Reference(Practitioner)
.... perforation I0..1codeBinding: PresentAbsentNotstated (required)
.... natureOfPerforation 0..*codeBinding: PerforationType (required)
.... clinicalObstruction 0..1codeBinding: PresentAbsentNotstated (required)
.... tumourLocation I0..*codeBinding: ColorectalCancerTumourLocation (required)
02: If the tumour location is rectum, then the distance from the anal verge must be recorded.
.... synchronousTumours 0..1string
.... distanceAnalVerge 0..1Quantity
.... typeOfOperation 0..1
..... code I0..1codeBinding: ColorectalCancerOperationType (required)
03: If other procedure(s) is selected, then record the type of procedure.
04: If anterior resection is selected, record anterior resection type.
..... other 0..1string
.... anteriorResectionType 0..1codeBinding: HiLowUltralow (required)
.... preoperativeRadiotherapy I0..1codeBinding: YesNoNotStated (required)
05: If pre-operative radiotherapy is done, then the type of course is to be recorded.
.... typeOfCourse 0..1codeBinding: TypeOfCourse (required)
.... surgeonsOpinion 0..1string
.... adjacentOrgans 0..1string
.... newPrimaryOrRecurrence I0..1codeBinding: CancerPrimaryOrRecurrence (required)
06: If regional (local) recurrence or distant metastasis describe.
.... RecurrenceDescription 0..1string
.... pathologyAccessionNumber 0..1string
.... otherRelevantDetails 0..1string
... macro I0..109: If lymph nodes are received, record the number of nodes
15: If lymph nodes have been received the tumour inolvement in the lymph nodes is to be recorded.
.... specimenLength 1..1Quantity
.... tumourSite I1..1codeBinding: ColorectalCancerTumourLocation (required)
07: If tumour site is rectum, the relationship to anterior peritoneal reflection is to be recorded.
08: If tumour site is rectum, the intactness of mesorectum is to be recorded.
13: If the tumour is a rectal tumour the status of the nonperitonealised circumferential margin (rectal tumours) is to be recorded.
.... maxTumourDiameter 1..1Quantity
.... distanceNearerProxOrDistal 1..*Quantity
.... distNonperitonCircumMargin 0..1Quantity
.... tumourPerforation 1..1codeBinding: PresentAbsent (required)
.... relToAntPeritonealReflection 0..1codeBinding: CrcRelAnteriorPeritonealReflection (required)
.... intactnessOfMesorectum 0..1codeBinding: MesorectumIntactness (required)
.... peritoneum 0..1stringBinding: CrcPeritoneumInvasion (required)
.... lymphNodes I0..1codeBinding: ReceivedNotreceived (required)
.... noLymphNodesPerCassette 0..*string
.... polyps I0..1codeBinding: PresentAbsentNa (required)
10: If polyps are present, provide a polyp summary.
.... polypSummary 0..1string
.... otherMacroComments 0..1string
.... natureAndSiteOfBlocks 1..*string
... micro 0..1
.... tumourType 1..1codeBinding: ColorectalCancerTumourType (required)
.... histologicalGrade 1..1codeBinding: HistologicalGrade (required)
.... maxDegreeLocalInvasion 1..1codeBinding: DegreeInvasionBowelWall (required)
.... proximalOrDistalResectionMargins I1..1codeBinding: InvolvedNotinvolved (required)
11: If the tumour is involved in the proximal or distal resection (‘cut-end’) margins, then record invovled margin(s).
12: If the tumour is not involved in the proximal or distal resection (‘cut-end’) margins, then record the microscopic clearance.
.... involvedMargins 0..*codeBinding: DistalProximal (required)
.... marginsMicroClearance 0..1string
.... nonperitonealisedCircumMargin I0..1codeBinding: InvolvedNotinvolved (required)
14: If the tumour is a rectal tumour and the status of the nonperitonealised circumferential margin (rectal tumours) is not involved, then the clearance is to be recorded.
.... microClearanceRectum 0..1Quantity
.... lymphNodeInvolvement I0..1codeBinding: PresentAbsentNa (required)
16: If tumour positive lymph nodes are present then record the site(s) and numbers of lymph nodes.
.... lymphNodesDetails 0..*
..... site 0..1string
..... numPos 0..1string
..... numExamined 0..1string
.... extramuralTumourDeposits 0..1codeBinding: PresentAbsentNa (required)
.... apicalNodeInvolvement 0..1codeBinding: PresentAbsentNa (required)
.... venousSmallVesselInvasion 0..1string
.... intramuralVeinInvasion 1..1codeBinding: IntramuralVeinInvasion (required)
.... extramuralVeinInvasion 1..1codeBinding: ExtramuralVeinInvasion (required)
.... smallVesselInvasion 1..1codeBinding: SmallVesselInvasion (required)
.... perineuralInvasion 1..1codeBinding: PerineuralInvasion (required)
.... histoConfDistMetastases I1..1codeBinding: PresentAbsentNotstated (required)
17: If histologically confirmed distant metastases are present then the sites are to be recorded.
.... histoConfDistMetastasesSite 0..1string
.... relCoexistPathabnorm 0..*
..... code I0..1codeBinding: CoexistentPathologicalAbnormalities (required)
18: If polyps are present as relevant coexistent pathological abnormalities, then polyp details are to be recorded.
19: If Ulcerative colitis is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded.
20: If Crohn's disease is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded.
21: If other abnormalities is selected as relevant coexistent pathological abnormality, then other abnormaily details are to be recorded.
..... other 0..1string
.... polypDetails 0..1string
.... dysplasia 0..1codeBinding: Dysplasia (required)
.... otherAbnormality 0..1string
.... microResidualTumourStatus 0..1string
.... neoadjuvantTherapy 0..1codeBinding: ResponseToNeoadjuvantTherapy (required)
.... microComments 0..1string
... ancillaryTests 0..1string
.... mlh1 0..1codeBinding: StainType (required)
.... pms2 0..1codeBinding: StainType (required)
.... msh2 0..1codeBinding: StainType (required)
.... msh6 0..1codeBinding: StainType (required)
.... comments 0..1string
.... msi I0..1
..... code I0..1codeBinding: MsiOptions (required)
22: If MSI unstable, record laboratory performing test and report number
23: If MSI stable, record laboratory performing test and report number
..... comments 0..1string
..... labDetails 0..1string
.... braf I0..1
..... code I0..1codeBinding: MutatedWildtype (required)
24: If BRAF mutated, record laboratory performing test and report number
25: If BRAF wild type, record laboratory performing test and report number
..... comments 0..1string
..... labDetails 0..1string
.... kras I0..1
..... code I0..1codeBinding: MutatedWildtype (required)
26: If KRAS mutated, record laboratory performing test and report number
27: If KRAS wild type, record laboratory performing test and report number
..... comments 0..1string
..... labDetails 0..1string
... synthesisOverview 0..1
.... tumourStageT 0..1codeBinding: CrcTumourStageT (required)
.... tumourStageN 0..1codeBinding: CrcTumourStageN (required)
.... tumourStageM 0..1codeBinding: CrcTumourStageM (required)
.... tumourStageGrouping 1..1codeBinding: CrcTumourStageGrouping (required)
.... tumourStagingSystem 1..1string
.... residualTumourStatus 1..1codeBinding: ResidualTumourStatus (required)
.... diagnosticSummary Σ0..1string
.... newPrimaryOrRecurrence 0..1codeBinding: NewCancerOrRecurrence (required)
.... newDescription 0..1string
.... overarchingComment 0..1string

doco Documentation for this format

Data Element Definitions

Colorectal
Definition

Colorectal cancer This protocol contains standards and guidelines for the preparation of structured reports for colorectal cancer. It is not intended to apply to tumours of the appendix, small bowel and anus. Local excisions of colorectal carcinomas will be dealt with in a subsequent protocol. Synchronous primary tumours should have separate protocols recorded for each tumour.

Control0..?
LOINC Code67189-1
Colorectal.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Colorectal.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Colorectal.subject
Definition

The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources.

Control1..1
TypeReference(Australian Patient (Human))
Alternate NamesPatient
Colorectal.requester
Definition

The practitioner that holds legal responsibility for ordering the investigation.

Control0..1
TypeReference(Practitioner)
LOINC Code22027-7
Colorectal.performer
Definition

The diagnostic service that is responsible for issuing the report.

Control0..1
TypeChoice of: Reference(Practitioner), Reference(Organization)
Requirements

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Alternate NamesLaboratory, Service, Practitioner, Department, Company
Comments

This is not necessarily the source of the atomic data items - it is the entity that takes responsibility for the clinical report.

Colorectal.preAnalytic
Definition

Pre Analytic component - information collection prior to specimen receipt at laboratory.

Control0..1
Comments

This is just a group/section header and is not a result field.

InvariantsDefined on this element
01: If there is a perforation, the perforation type must be indicated. (: perforation = 'present' implies natureOfPerforation.exists())
LOINC Code70949-3
Colorectal.preAnalytic.clinicalInformation
Definition

All clinical information as documented on the request form must be recorded verbatim.

Control0..1
Typestring
LOINC Code55752-0
Colorectal.preAnalytic.operatingSurgeonDetails
Definition

The operating surgeon name and contact details.

Control0..1
TypeReference(Practitioner)
LOINC Code22027-7
Colorectal.preAnalytic.perforation
Definition

Presence or absence of a perforation.

Control0..1 This element is affected by the following invariants: null
BindingA code that indicates whether perforation is present
The codes SHALL be taken from PresentAbsentNotstated
Typecode
Requirements

If present, record the nature of perforation.

LOINC CodeLN-RCPA-00059
Colorectal.preAnalytic.natureOfPerforation
Definition

The type of perforation.

Control0..*
BindingA code that indicates the type of perforation
The codes SHALL be taken from PerforationType
Typecode
LOINC CodeLN-RCPA-00060
Colorectal.preAnalytic.clinicalObstruction
Definition

Whether a clinical obstruction is present or absent.

Control0..1
BindingA code that indicates whether a clinical obstruction is present
The codes SHALL be taken from PresentAbsentNotstated
Typecode
LOINC CodeLN-RCPA-00061
Colorectal.preAnalytic.tumourLocation
Definition

Anatomical location of the tumour from a given list.

Control0..* This element is affected by the following invariants: null
BindingA code that indicates the antomical location of the tumour from a given list
The codes SHALL be taken from ColorectalCancerTumourLocation
Typecode
InvariantsDefined on this element
02: If the tumour location is rectum, then the distance from the anal verge must be recorded. (: $this = 'Rectum' implies distanceAnalVergen.exists())
LOINC Code33725-3
Colorectal.preAnalytic.synchronousTumours
Definition

For synchronous tumours indicate each other site.

Control0..1
Typestring
Requirements

Conditional on rectum being selected. Measured in cm for RCPA requirements.

Comments

Note : Synchronous tumours should be reported separately – this serves only to identify the presence of other synchronous tumours for which separate reports will be submitted.

LOINC CodeLN-RCPA-00062
Colorectal.preAnalytic.distanceAnalVerge
Definition

Quantitative measurement of distance from anal verge.

Control0..1
TypeQuantity
Requirements

Conditional on rectum being selected. Measured in cm for RCPA requirements.

Comments

Conditional on rectum being selected Note : Measured in cm by longstanding surgical convention.

LOINC Code33748-5
Colorectal.preAnalytic.typeOfOperation
Definition

The type of operation selected from a list.

Control0..1
Requirements

Type of operation.

LOINC Code29306-8
Colorectal.preAnalytic.typeOfOperation.code
Definition

A code for the type of operation selected from a list.

Control0..1 This element is affected by the following invariants: null, null
BindingA code that indicates the type of operation
The codes SHALL be taken from ColorectalCancerOperationType
Typecode
Requirements

Single selection value list. If other procedure(s) is selected, record type of procedure. If anterior resection is selected, record anterior resection type.

InvariantsDefined on this element
03: If other procedure(s) is selected, then record the type of procedure. (: $this ='Other procedure(s.exists()' implies typeOfProcedure.exists())
04: If anterior resection is selected, record anterior resection type. (: $this = 'Anterior resection' implies anteriorResectionType.exists())
LOINC Code29306-8
Colorectal.preAnalytic.typeOfOperation.other
Definition

Type of procedure - other.

Control0..1
Typestring
Colorectal.preAnalytic.anteriorResectionType
Definition

The type of anterior resection.

Control0..1
BindingA code that idicates the type of anterior resection
The codes SHALL be taken from HiLowUltralow
Typecode
Requirements

Single selection value list.

Colorectal.preAnalytic.preoperativeRadiotherapy
Definition

An indication of pre-operative radiotherapy.

Control0..1 This element is affected by the following invariants: null
BindingA code that indicates whether pre-operative radiotherapy was used
The codes SHALL be taken from YesNoNotStated
Typecode
Requirements

Single selection value list. If yes, record type of course.

InvariantsDefined on this element
05: If pre-operative radiotherapy is done, then the type of course is to be recorded. (: $this = 'Yes' implies typeOfCourse.exists())
LOINC CodeLN-RCPA-00063
Colorectal.preAnalytic.typeOfCourse
Definition

The type of course of pre-operative radiotherapy.

Control0..1
BindingA code that indicates the type of course of pre-operative radiotherapy
The codes SHALL be taken from TypeOfCourse
Typecode
Colorectal.preAnalytic.surgeonsOpinion
Definition

Surgeons opinion on the existence of local residual cancer postsurgery.

Control0..1
Typestring
LOINC Code81169-5
Colorectal.preAnalytic.adjacentOrgans
Definition

Involvement of adjacent organs.

Control0..1
Typestring
LOINC CodeLN-RCPA-00064
Colorectal.preAnalytic.newPrimaryOrRecurrence
Definition

An indication of whether a new primary cancer or a recurrence.

Control0..1 This element is affected by the following invariants: null
BindingA code that indicates whether a new primary cancer or an recurrence
The codes SHALL be taken from CancerPrimaryOrRecurrence
Typecode
Requirements

Single selection value list. If regional (local) recurrence or distant metastasis describe.

Comments

? If need to make an invariant due to the conditional statement.

InvariantsDefined on this element
06: If regional (local) recurrence or distant metastasis describe. (: ($this = 'Regional (local) recurrence' or $this = 'Distant metastases') implies describe.exists())
LOINC Code21983-2
Colorectal.preAnalytic.RecurrenceDescription
Definition

Description of regional (local) recurrence or distant metastases.

Control0..1
Typestring
LOINC CodeLN-RCPA-00065
Colorectal.preAnalytic.pathologyAccessionNumber
Definition

The pathology accession number of the specimen must be recorded.

Control0..1
Typestring
LOINC Code57723-9
Colorectal.preAnalytic.otherRelevantDetails
Definition

Other relevant details Any clinical information received in other communications from the requestor or other clinician should be recorded together with the source of that information.

Control0..1
Typestring
LOINC Code55752-0
Colorectal.macro
Definition

Macroscopic findings.

Control0..1
Comments

This is just a group/section header and is not a result field.

InvariantsDefined on this element
09: If lymph nodes are received, record the number of nodes (: lymphNodes = 'Received'implies noLymphNodesPerCassette.exists())
15: If lymph nodes have been received the tumour inolvement in the lymph nodes is to be recorded. (: lymphNodes = 'Received' implies lymphNodeInvolvement.exists())
LOINC Code70949-3
Colorectal.macro.specimenLength
Definition

The specimen length must be recorded. This and all other measurements in this protocol should be made in millimetres unless otherwise stated.

Control1..1
TypeQuantity
Requirements

measurement in mm.

Comments

Query if measurements are in mm is international ie USA and query if this comment needs to be refined to AUS? Ditto for subsequent metric measurements. ***Meagan Judge response: USA may be in cm's for colorecatal, but internationally the measurement is in mm. Ditto - internationally all other measurements are in mm, unless otherwise stated.

LOINC CodeLN-RCPA-00066
Colorectal.macro.tumourSite
Definition

The site of the tumour must be recorded. The determination of the site is based on the assessment by the pathologist and the information provided by the surgeon on the request form. The anatomical site of the tumour is relevant for the following reasons: - It provides correlation with previous investigations. - It indicates whether a non-peritonealised (circumferential) margin is likely to be present. - The natural history and treatment of rectal cancer differs significantly from colonic cancer. - It defines the presence of regional lymph nodes versus non-regional lymph nodes. Strictly the rectum is that part of the large bowel distal to the sigmoid colon and its upper limit is indicated by the end of the sigmoid mesocolon. Standard anatomical texts put this at the level of the 3rd sacral vertebra but it is generally agreed by surgeons that the rectum starts at the sacral promontory. It was agreed by an international expert advisory committee that any tumour whose distal margin is seen at 15 cm or less from the anal verge using a rigid sigmoidoscope should be classified as rectal. The pathologist can identify the upper end of the rectum as the point where the colonic taeniae coli merge to form a single external muscle layer.

Control1..1 This element is affected by the following invariants: null, null, null
BindingA code that indicates the site of the tumour
The codes SHALL be taken from ColorectalCancerTumourLocation
Typecode
InvariantsDefined on this element
07: If tumour site is rectum, the relationship to anterior peritoneal reflection is to be recorded. (: $this = 'Rectum' implies relToAntPeritonealReflection.exists())
08: If tumour site is rectum, the intactness of mesorectum is to be recorded. (: $this = 'Rectum' implies intactnessOfMesorectum.exists())
13: If the tumour is a rectal tumour the status of the nonperitonealised circumferential margin (rectal tumours) is to be recorded. (: Colorectal.preAnalytic.tumourLocation != 'Rectum' implies Colorectal.micro.nonperitonealisedCircumMargin.exists())
LOINC Code33725-3
Colorectal.macro.maxTumourDiameter
Definition

The maximum tumour diameter must be recorded. - The prognostic significance of maximum tumour size is not established. - Tumour size must be recorded for correlation with subsequent microscopic examination and to allow correlation with imaging undertaken prior to surgery. - If possible, distinguish carcinoma from inflammatory changes, as the latter may account for a considerable volume of tumour in some cases.

Control1..1
TypeQuantity
Requirements

measurement in mm.

LOINC Code21889-1
Colorectal.macro.distanceNearerProxOrDistal
Definition

The distance of the tumour to the nearer proximal or distal "cut end" margin must be recorded. - This is the measurement from the nearer cut end of the specimen and not the non-peritonealised (circumferential, radial) margin. - Tumour at a longitudinal margin has always been considered a poor prognostic feature but it occurs very rarely. The necessity of sampling this margin has therefore been questioned. It is essential to sample this margin and examine it histologically if the tumour is close to the margin (within 30 mm), or if the tumour is found by histology to have an exceptionally infiltrative growth pattern, to show extensive blood vascular or lymphatic permeation, or to be a signet ring, small cell or undifferentiated carcinoma. - If included, doughnuts must be embedded for histological examination. - The difficulty presented by staples is recognised. In this situation, it is important for blocks taken immediately adjacent to the line of staples along the plane of the staple line to be examined.

Control1..*
TypeQuantity
Requirements

measurement in mm.

LOINC Code81175-2
Colorectal.macro.distNonperitonCircumMargin
Definition

The distance of the tumour to the circumferential margin must be recorded. - This is the measurement to the nonperitonealised (ie the circumferential or radial) margin. - This measurement is useful for comparison with and validation of the microscopic measurement. - It is not only the continuous spread of the primary tumour that is important for this measurement, but also discontinuous spread in the form of lymph node metastases, extramural deposits, and tumour in vessels and lymphatics. Even if the main tumour appears ‘well clear’ of this margin, it is important to block the tissue between the nearest tumour edge and the nonperitonealised resection margin to ensure picking up any discontinuous areas of spread. It may be that the tissue has to be embedded in two or more sequential blocks but this margin must be well sampled. - This combined with the clinical and microscopic findings is used to define the R code status (see Chapter 5).

Control0..1
TypeQuantity
Requirements

measurement in mm.

LOINC CodeLN-RCPA-00067
Colorectal.macro.tumourPerforation
Definition

The presence or absence of tumour perforation must be recorded. - Perforation through the tumour into the peritoneal cavity is a well established adverse prognostic factor in colonic22 and rectal cancer.23 It is suggested that a block be taken from the area of perforation for histological confirmation. If perforation is present, then this is regarded as pT4 in the TNM staging system, regardless of other factors. - Perforation of the proximal bowel as a result of a distal obstructing tumour must not be recorded as tumour perforation, but should be noted. - It is important to distinguish, where possible, between perforation occurring at the time of surgery and perforation before surgery.

Control1..1
BindingA code that indicates the presence or absence of a tumour perforation
The codes SHALL be taken from PresentAbsent
Typecode
Requirements

Single selection value list.

LOINC CodeLN-RCPA-00068
Colorectal.macro.relToAntPeritonealReflection
Definition

For rectal tumours the relationship of the tumour to the anterior peritoneal reflection must be recorded. - The anterior aspect of the rectum is covered by peritoneum down to the peritoneal reflection. On the posterior aspect the nonperitonealised margin extends upwards as a triangular shaped bare area containing the rectal arteries, which then continues up to the start of the sigmoid mesocolon. - The nonperitonealised margin is also known as the radial or circumferential resection margin. It consists of a ‘bare’ area of connective tissue at the surgical plane of excision that is not covered by serosa. Low rectal tumours will be completely surrounded by a non-peritonealised margin (the circumferential margin), while upper rectal tumours have a non-peritonealised margin posterolaterally and a peritonealised (serosal) surface anteriorly. Tumours below the peritoneal reflection have the highest rates of local recurrence.

Control0..1
BindingA code that indicates the site of tumour in relation to the anterior level of the peritoneal reflection
The codes SHALL be taken from CrcRelAnteriorPeritonealReflection
Typecode
Requirements

Single selection value list. Conditional on rectum being selected in Tumour Site.

LOINC CodeLN-RCPA-00069
Colorectal.macro.intactnessOfMesorectum
Definition

For rectal resections the intactness of the mesorectum must be recorded. - The prognosis of rectal carcinoma has significantly improved with the use of total mesorectal excision (TME). Gross pathological assessment of the intactness of the mesorectum has been shown to correlate with patient outcome. The intactness of the specimen is recorded as one of the following: - Incomplete: little bulk to the rectum, defects in the mesorectum down to the muscularis propria, after transverse sectioning the circumferential margin appears very irregular. - Nearly complete: moderate bulk to the mesorectum, irregularity of the mesorectal surface with defects greater than 5 mm but none extending to the muscularis propria, no areas of visibility of the muscularis propria except at the insertion site of the levator ani muscles. - Complete: Intact bulky mesorectum with a smooth surface, only minor irregularities of the mesorectal surface, no surface defects greater than 5 mm in depth, no coning towards the distal margin of the specimen, after circumferential sectioning the circumferential margin appears smooth.

Control0..1
BindingA code that indicates the intactness of the mesorectum
The codes SHALL be taken from MesorectumIntactness
Typecode
Requirements

Single selection value list. Conditional on rectum being selected in Tumour Site.

LOINC Code33730-3
Colorectal.macro.peritoneum
Definition

Any involvement of the peritoneum should be recorded. This should be recorded as one of the following : - Tumour invades to the peritoneal surface - Tumour has formed nodule(s) discrete from the tumour mass along the serosal surface Tumour involvement of the serosa discontinuous from the site of the main tumour is to be recorded as a metastasis.

Control0..1
BindingA code that indicates the tumour invovlement in the peritoneum
The codes SHALL be taken from CrcPeritoneumInvasion
Typestring
Requirements

Single selection value list.

LOINC Code66111-6
Colorectal.macro.lymphNodes
Definition

If lymph nodes are received, then they should be recorded.

Control0..1 This element is affected by the following invariants: null, null
BindingA code that indicates if lymph nodes were received
The codes SHALL be taken from ReceivedNotreceived
Typecode
Requirements

Conditional: If received, record the number of nodes.

LOINC Code66112-4
Colorectal.macro.noLymphNodesPerCassette
Definition

The number of lymph nodes placed in each cassette should be recorded.

Control0..*
Typestring
Comments

The RCPA require the following be recorded: "Numeric: in cassette: " Query how to record this?

LOINC Code44621-1
Colorectal.macro.polyps
Definition

The number, diameter and gross configuration of polyps should be summarised. The pathologist should be cognisant of the presence of polyposis syndromes. These include: - Familial Adenomatous Polyposis (FAP) - Serrated - MutYH - Juvenile - Peutz–Jeghers At the present time the criteria for hyperplastic (serrated) polyposis syndrome: 1. At least five histologically confirmed hyperplastic (serrated) polyps proximal to the sigmoid colon, of which two are greater than 1 cm in diameter 2. Any number of hyperplastic (serrated) polyps proximal to the sigmoid colon in a subject with a first-degree relative with hyperplastic polyposis 3. More than 20 hyperplastic (serrated) polyps of any size distributed evenly throughout the colon.

Control0..1 This element is affected by the following invariants: null
BindingA code that indicates the presence or absence of polyp(s)
The codes SHALL be taken from PresentAbsentNa
Typecode
Requirements

Conditional: If present, provide a polyp summary.

InvariantsDefined on this element
10: If polyps are present, provide a polyp summary. (: $this = 'Present' implies polypSummary.exists())
LOINC CodeLN-RCPA-00070
Colorectal.macro.polypSummary
Definition

The polyp summary should include the numbers, diameter range and gross appearance.

Control0..1
Typestring
LOINC Code33745-1
Colorectal.macro.otherMacroComments
Definition

A descriptive or narrative field should be provided to record any macroscopic information that is not recorded in the above standards and guidelines, and that would normally form part of the macroscopic description.

Control0..1
Typestring
LOINC Code22634-0
Colorectal.macro.natureAndSiteOfBlocks
Definition

The nature and sites of all blocks must be recorded.

Control1..*
Typestring
LOINC Code81178-6
Colorectal.micro
Definition

Microscopy of the sample.

Control0..1
Comments

This is just a group/section header and is not a result field.

LOINC Code70949-3
Colorectal.micro.tumourType
Definition

The tumour type must be recorded. A single selection value list from WHO Classification of Tumours. The description must be based on the WHO Histological Classification of Tumours of the Colon and Rectum (refer to Appendix 4).8 This publication, as well as a current version of the American Joint Commission on Cancer (AJCC) Cancer Staging Manual9 should be readily accessible to the reporting pathologist.

Control1..1
BindingA code from the WHO Calssification that indicates the tumour type
The codes SHALL be taken from ColorectalCancerTumourType
Typecode
Requirements

Single selection value list from WHO Classification of Tumours. Pathology and Genetics of Tumours of the Digestive System (2010).

Comments

How to represent this result group which has heading and components cf the bindings file is a flat file??

LOINC CodeLN-RCPA-00071
Colorectal.micro.histologicalGrade
Definition

The histological grading of the tumour must be recorded.

Control1..1
BindingA code that indicates the histological grade of the tumour
The codes SHALL be taken from HistologicalGrade
Typecode
Requirements

Single selection value list.

LOINC Code33732-9
Colorectal.micro.maxDegreeLocalInvasion
Definition

The maximum degree of local invasion into or through the bowel wall must be recorded. This is based on the T component of the TNM staging system, as outlined in the AJCC Cancer Staging Manual.

Control1..1
BindingA code that indicates the maximum degree of local invasion into or through the bowel wall
The codes SHALL be taken from DegreeInvasionBowelWall
Typecode
Requirements

Single selection value list.

LOINC CodeLN-RCPA-00072
Colorectal.micro.proximalOrDistalResectionMargins
Definition

Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recorded.

Control1..1 This element is affected by the following invariants: null, null
BindingA code that indicates involvement of the proximal or distal resection (cut-end) margins
The codes SHALL be taken from InvolvedNotinvolved
Typecode
Requirements

Single selection value list. If involved is selected, record involved margin(s) If not involved is selected, record microscopic clearance.

InvariantsDefined on this element
11: If the tumour is involved in the proximal or distal resection (‘cut-end’) margins, then record invovled margin(s). (: $this = 'Involved' implies involvedMargins.exists())
12: If the tumour is not involved in the proximal or distal resection (‘cut-end’) margins, then record the microscopic clearance. (: $this = 'Not involved' implies microClearance.exists())
LOINC CodeLN-RCPA-00073
Colorectal.micro.involvedMargins
Definition

Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recorded.

Control0..*
BindingA code that indicates the involvement at the margins
The codes SHALL be taken from DistalProximal
Typecode
Requirements

Multi select value list (select all that apply). This is a conditional field.

LOINC Code44699-7
Colorectal.micro.marginsMicroClearance
Definition

If the margin is less than 10 mm, the clearance must be recorded.

Control0..1
Typestring
Requirements

Numeric: ___mm (if the margin is less than 10 mm) OR Clearance is ≥10mm.

Comments

Query how to achieve this??

LOINC CodeLN-RCPA-00074
Colorectal.micro.nonperitonealisedCircumMargin
Definition

The status of the nonperitonealised circumferential margin in rectal tumours must be recorded. - In rectal tumours, the minimum distance in millimetres between the tumour and the nonperitonealised (circumferential, radial) margin must be recorded from the histological slides. - Rectal tumours frequently (5–36%) involve the nonperitonealised surgical circumferential resection margin (CRM) and this is associated with significantly higher rates of local recurrence and cancer-related death.

Control0..1 This element is affected by the following invariants: null
BindingA code that indicates the status of the nonperitonealised circumferential margin in rectal tumours
The codes SHALL be taken from InvolvedNotinvolved
Typecode
Requirements

Single selection value list. Conditional on rectum being selected in S2.02 If not involved is selected, record microscopic clearance.

InvariantsDefined on this element
14: If the tumour is a rectal tumour and the status of the nonperitonealised circumferential margin (rectal tumours) is not involved, then the clearance is to be recorded. (: $this ='Not involved' implies microClearanceRectum.exists())
LOINC CodeLN-RCPA-00075
Colorectal.micro.microClearanceRectum
Definition

In rectal tumours, the minimum distance in millimetres between the tumour and the nonperitonealised (circumferential, radial) margin must be recorded from the histological slides.

Control0..1
TypeQuantity
Requirements

Is conditional.

LOINC CodeLN-RCPA-00076
Colorectal.micro.lymphNodeInvolvement
Definition

Results of lymph node histopathology must be recorded. - The finding of positive lymph nodes is a major determinant of whether the patient receives adjuvant therapy. The probability of finding a positive node increases with the number of nodes found. Although this probability curve flattens out after finding 12–15 nodes, all identified lymph nodes must be microscopically examined. In general, a minimum of 10-12 lymph nodes should be identified and examined.

Control0..1 This element is affected by the following invariants: null
BindingA code that indicates lymph node involvement
The codes SHALL be taken from PresentAbsentNa
Typecode
Requirements

Single selection value list. Conditional on nodes being received in G2.02. If G2.02 has been recorded as “not received” this standard is not required. If present, record site(s) and number of lymph nodes.

InvariantsDefined on this element
16: If tumour positive lymph nodes are present then record the site(s) and numbers of lymph nodes. (: $this ='Present' implies lymphNodesDetails.exists())
LOINC Code21892-5
Colorectal.micro.lymphNodesDetails
Definition

If lymph node(s) received then the site(s) and numbers of lymph nodes must be recorded.

Control0..*
Colorectal.micro.lymphNodesDetails.site
Definition

The site(s) of the lymph nodes must be recorded.

Control0..1
Typestring
LOINC Code39111-0
Colorectal.micro.lymphNodesDetails.numPos
Definition

Number of positive nodes from this site.

Control0..1
Typestring
LOINC Code21893-3
Colorectal.micro.lymphNodesDetails.numExamined
Definition

Total number of nodes from this site.

Control0..1
Typestring
LOINC Code21894-1
Colorectal.micro.extramuralTumourDeposits
Definition

The presence or absence of isolated extra-mural tumour deposits is to be recorded.

Control0..1
BindingA code that indicates the presence or absence of isolated extra-mural tumour deposits.
The codes SHALL be taken from PresentAbsentNa
Typecode
Requirements

Single selection value list.

LOINC CodeLN-RCPA-00077
Colorectal.micro.apicalNodeInvolvement
Definition

Involvement of the apical lymph node should be recorded, if required where staging systems additional to TNM staging are in use. Both the Australian Clinicopathological Staging System and the Dukes staging system are in use in some institutions in Australasia. These require the status of the apical lymph node to be recorded.

Control0..1
BindingA code that indicates apical node involvement
The codes SHALL be taken from PresentAbsentNa
Typecode
Requirements

Single selection value list.

LOINC CodeLN-RCPA-00078
Colorectal.micro.venousSmallVesselInvasion
Definition

For all tumours, venous and small vessel invasion must be reported and its anatomic location specified as intramural or extramural. - Venous invasion by tumour has been repeatedly shown by multivariate and univariate analyses to be a stage independent adverse prognostic factor. However some studies identifying venous invasion as an adverse factor on univariate analysis have failed to confirm its independent impact on prognosis on multivariate breakdown. Similar disparate results have also been reported for lymphatic invasion. In other reports, vascular invasion as a general feature was prognostically significant, but no distinction between lymphatic and venous vessels was made. In a few studies the location as well as the type of the involved vessels (eg extramural veins) were both considered strong determinants of prognostic impact. Data from the many studies are difficult to amalgamate but nevertheless, the importance of venous and small vessel (lymphovascular) invasion by tumour is generally accepted, and it is considered that venous and small vessel invasion must be sought and separately recorded.

Control0..1
Typestring
Comments

This is just a header and is not a data field ?? How to be entered in the resource.

LOINC Code33761-8
Colorectal.micro.intramuralVeinInvasion
Definition

Intramural invasion must be reported on.

Control1..1
BindingA code that indicates intramural vein invasion
The codes SHALL be taken from IntramuralVeinInvasion
Typecode
Requirements

Single selection value list.

LOINC CodeLN-RCPA-00079
Colorectal.micro.extramuralVeinInvasion
Definition

Extramural invasion must be reported on.

Control1..1
BindingA code that indicates extramural vein invasion
The codes SHALL be taken from ExtramuralVeinInvasion
Typecode
Requirements

Single selection value list.

LOINC CodeLN-RCPA-00080
Colorectal.micro.smallVesselInvasion
Definition

Small vessel invasion must be reported on.

Control1..1
BindingA code that indicates small vessel invasion
The codes SHALL be taken from SmallVesselInvasion
Typecode
Requirements

Single selection value list.

LOINC Code33739-4
Colorectal.micro.perineuralInvasion
Definition

Perineural invasion should be assessed using routine histology and reported. - There is some evidence that perineural infiltration by tumour is an important indicator of spread, particularly in rectal tumours where it may involve the sacral plexus and this may be an indication for radiotherapy.

Control1..1
BindingA code that indicates perineural invasion
The codes SHALL be taken from PerineuralInvasion
Typecode
Requirements

Single selection value list.

LOINC Code33741-0
Colorectal.micro.histoConfDistMetastases
Definition

The presence or absence of histologically confirmed distant metastases must be recorded. - Disease classifiable as distant metastasis may sometimes be present within the primary tumour resection specimen (eg a serosal or mesenteric or greater omental deposit that is distant from the primary tumour mass). - Metastatic deposits in lymph nodes distant from those surrounding the main tumour or its main artery in the specimen will usually be submitted separately by the surgeon. Metastatic deposits in lymph nodes distant from the tumour or its main artery (ie nonregional nodes) may be seen in extended colectomy specimens and are regarded as distant metastases (pM1).

Control1..1 This element is affected by the following invariants: null
BindingA code that indicates the presence or absence of histologically confirmed distant metastases
The codes SHALL be taken from PresentAbsentNotstated
Typecode
Requirements

Single selection value list. If present, record sites.

InvariantsDefined on this element
17: If histologically confirmed distant metastases are present then the sites are to be recorded. (: $this ='Present' implies site.exists())
LOINC CodeLN-RCPA-00081
Colorectal.micro.histoConfDistMetastasesSite
Definition

The site of histologically confirmed distant metastases must be recorded.

Control0..1
Typestring
Requirements

Is conditional.

LOINC Code21920-4
Colorectal.micro.relCoexistPathabnorm
Definition

The relevant coexistent pathological abnormalities must be recorded.

Control0..*
Requirements

Multi select value list (select all that apply). ?? How is this indicated?? If Polyps is selected provide details If Ulcerative colitis or Crohn’s disease is selected record dysplasia If other is selected, provide details in “other abnormality”.

LOINC Code81317-0
Colorectal.micro.relCoexistPathabnorm.code
Definition

The presence of any relevant coexistent pathological abnormalities in the bowel must be recorded. - The presence of polyps (type, number, and whether having the criteria of a polyposis syndrome), presence and type of chronic inflammatory bowel disease, with or without dysplasia, and any other clinically relevant pathology is important information that needs to be recorded.

Control0..1 This element is affected by the following invariants: null, null, null, null
BindingA code that indicates the relevant coexistent pathological abnormalities
The codes SHALL be taken from CoexistentPathologicalAbnormalities
Typecode
Requirements

Multi select value list (select all that apply). ?? How is this indicated?? If Polyps is selected provide details If Ulcerative colitis or Crohn’s disease is selected record dysplasia If other is selected, provide details in “other abnormality”.

InvariantsDefined on this element
18: If polyps are present as relevant coexistent pathological abnormalities, then polyp details are to be recorded. (: $this ='Polyps' implies polypDetails.exists())
19: If Ulcerative colitis is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded. (: $this ='Ulcerative colitis' implies dysplasia.exists())
20: If Crohn's disease is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded. (: $this ='Crohns disease' implies dysplasia.exists())
21: If other abnormalities is selected as relevant coexistent pathological abnormality, then other abnormaily details are to be recorded. (: $this ='Other' implies otherAbnormality.exists())
LOINC Code81317-0
Colorectal.micro.relCoexistPathabnorm.other
Definition

The relevant coexistent pathological abnormalities (other abnormalities) must be recorded.

Control0..1
Typestring
LOINC Code8251-1
Colorectal.micro.polypDetails
Definition

The polyp details (type, number, polyposis syndrome criteria met etc) is to be recorded.

Control0..1
Typestring
Requirements

Is conditional.

LOINC Code33745-1
Colorectal.micro.dysplasia
Definition

If Ulcerative colitis or Crohns disease is selected for relevant coexistent pathological abnormalities record dysplasia.

Control0..1
BindingA code that indicates dysplasia if Ulcerative colitis or Crohn's disease is selected for relevant coexistent pathological abnormalities
The codes SHALL be taken from Dysplasia
Typecode
Requirements

Single selection value list. Is conditional.

Comments

Cannot have an apostrophe in a spreadsheet eg Crohn apostrophe s.

Colorectal.micro.otherAbnormality
Definition

Record any other abnormality.

Control0..1
Typestring
LOINC Code44624-5
Colorectal.micro.microResidualTumourStatus
Definition

The microscopic residual tumour status (completeness of resection) is to be recorded.

Control0..1
Typestring
LOINC CodeLN-RCPA-00082
Colorectal.micro.neoadjuvantTherapy
Definition

The response to neoadjuvant therapy should be recorded.

Control0..1
BindingA code that indicates the response to neoadjuvant therapy
The codes SHALL be taken from ResponseToNeoadjuvantTherapy
Typecode
LOINC CodeLN-RCPA-00083
Colorectal.micro.microComments
Definition

Other Microscopic comments should be recorded.

Control0..1
Typestring
LOINC Code22635-7
Colorectal.ancillaryTests
Definition

Ancillary test findings are to be recorded.

Control0..1
Typestring
Requirements

Immunohistochemical stains for microsatellite instability will be performed and a supplementary report issued.

Comments

This is just a group/section header and is not a result field, but some example reports this field was used as a comment field.

LOINC Code70949-3
Colorectal.ancillaryTests.mlh1
Definition

MLH-1 testing.

Control0..1
BindingA code that indicates MLH-1 testing
The codes SHALL be taken from StainType
Typecode
Requirements

Single selection value list.

LOINC Code50322-7
Colorectal.ancillaryTests.pms2
Definition

PMS-2 testing.

Control0..1
BindingA code that indicates PMS-2 testing
The codes SHALL be taken from StainType
Typecode
Requirements

Single selection value list.

LOINC Code50328-4
Colorectal.ancillaryTests.msh2
Definition

MSH-2 testing.

Control0..1
BindingA code that indicates MSH-2 testing
The codes SHALL be taken from StainType
Typecode
Requirements

Single selection value list.

LOINC Code50323-5
Colorectal.ancillaryTests.msh6
Definition

MSH-6 testing.

Control0..1
BindingA code that indicates MSH-6 testing
The codes SHALL be taken from StainType
Typecode
Requirements

Single selection value list.

LOINC Code50324-3
Colorectal.ancillaryTests.comments
Definition

Mismatch repair enzyme comments can be recorded.

Control0..1
Typestring
LOINC Code8262-8
Colorectal.ancillaryTests.msi
Definition

Microsatellite instability (MSI) to be recorded.

Control0..1 This element is affected by the following invariants: null, null
Requirements

Single selection value list. If unstable or stable, record laboratory performing test and report number.

Comments

This is just a group/section header and is not a result field.

Colorectal.ancillaryTests.msi.code
Definition

Microsatellite instability (MSI) to be recorded.

Control0..1
BindingA code that indicates Microsatellite instability (MSI)
The codes SHALL be taken from MsiOptions
Typecode
InvariantsDefined on this element
22: If MSI unstable, record laboratory performing test and report number (: $this ='Unstable' implies LabDetails.exists())
23: If MSI stable, record laboratory performing test and report number (: $this ='Stable' implies LabDetails.exists())
LOINC Code43368-0
Colorectal.ancillaryTests.msi.comments
Definition

Microsatellite instability (MSI) comments can be recorded.

Control0..1
Typestring
Requirements

Conditional.

LOINC Code8265-1
Colorectal.ancillaryTests.msi.labDetails
Definition

Microsatellite instability (MSI) laboratory performing test and report number can be recorded.

Control0..1
Typestring
Requirements

Conditional.

LOINC Code30954-2
Colorectal.ancillaryTests.braf
Definition

BRAF (V600E mutation) testing.

Control0..1 This element is affected by the following invariants: null, null
Requirements

Single selection value list. If mutated or wild type, record laboratory performing test and report number.

Comments

This is just a group/section header and is not a result field.

Colorectal.ancillaryTests.braf.code
Definition

BRAF (V600E mutation) testing.

Control0..1
BindingA code that indicates the BRAF (V600E mutation)
The codes SHALL be taken from MutatedWildtype
Typecode
InvariantsDefined on this element
24: If BRAF mutated, record laboratory performing test and report number (: $this ='Mutated' implies LabDetails.exists())
25: If BRAF wild type, record laboratory performing test and report number (: $this ='Wild type' implies LabDetails.exists())
LOINC Code58483-9
Colorectal.ancillaryTests.braf.comments
Definition

BRAF (V600E mutation) comments can be recorded.

Control0..1
Typestring
LOINC Code8264-4
Colorectal.ancillaryTests.braf.labDetails
Definition

BRAF (V600E mutation) laboratory performing test and report number can be recorded.

Control0..1
Typestring
LOINC Code30954-2
Colorectal.ancillaryTests.kras
Definition

KRAS gene mutation (codons 12 and 13) testing should be recorded. - Testing for the presence of mutations in the KRAS gene is typically requested by the clinician when metastatic disease is present. Therefore, such testing will most often be performed after the colorectal resection. In this situation, the result should be appended to the initial pathology report.

Control0..1 This element is affected by the following invariants: null, null
Comments

This is just a group/section header and is not a result field.

Colorectal.ancillaryTests.kras.code
Definition

KRAS gene mutation (codons 12 and 13) testing.

Control0..1
BindingA code that indicates the KRAS gene mutation (codons 12 and 13)
The codes SHALL be taken from MutatedWildtype
Typecode
InvariantsDefined on this element
26: If KRAS mutated, record laboratory performing test and report number (: $this ='Mutated' implies LabDetails.exists())
27: If KRAS wild type, record laboratory performing test and report number (: $this ='Wild type' implies LabDetails.exists())
LOINC Code21703-4
Colorectal.ancillaryTests.kras.comments
Definition

KRAS gene mutation (codons 12 and 13) comments can be recorded.

Control0..1
Typestring
LOINC Code8266-9
Colorectal.ancillaryTests.kras.labDetails
Definition

KRAS gene mutation (codons 12 and 13) laboratory performing test and report number can be recorded.

Control0..1
Typestring
LOINC Code30954-2
Colorectal.synthesisOverview
Definition

Synthesis and Overview are to be recorded.

Control0..1
Comments

This is just a group/section header and is not a result field.

LOINC Code70949-3
Colorectal.synthesisOverview.tumourStageT
Definition

Tumour stage T is to be recorded.

Control0..1
BindingA code that records tumour stage T
The codes SHALL be taken from CrcTumourStageT
Typecode
Requirements

Single selection value list.

LOINC Code21899-0
Colorectal.synthesisOverview.tumourStageN
Definition

Tumour stage N is to be recorded.

Control0..1
BindingA code that records tumour stage N
The codes SHALL be taken from CrcTumourStageN
Typecode
Requirements

Single selection value list.

LOINC Code21900-6
Colorectal.synthesisOverview.tumourStageM
Definition

Tumour stage M is to be recorded.

Control0..1
BindingA code that records tumour stage M
The codes SHALL be taken from CrcTumourStageM
Typecode
Requirements

Single selection value list.

LOINC Code67211-3
Colorectal.synthesisOverview.tumourStageGrouping
Definition

Tumour stage grouping is to be recorded.

Control1..1
BindingA code that records tumour stage grouping
The codes SHALL be taken from CrcTumourStageGrouping
Typecode
Requirements

Single selection value list.

Comments

Check the formatting of the result group.

LOINC Code21902-2
Colorectal.synthesisOverview.tumourStagingSystem
Definition

Year and/or edition of staging system is to be recorded.

Control1..1
Typestring
Requirements

Numeric: year AND/OR Text: Edition eg 1st, 2nd etc.

LOINC Code67203-0
Colorectal.synthesisOverview.residualTumourStatus
Definition

The residual tumour status must be recorded according to the AJCC Cancer Staging Manual (7th Edition).

Control1..1
BindingAn R code that records the residual tumour status
The codes SHALL be taken from ResidualTumourStatus
Typecode
LOINC CodeLN-RCPA-00084
Colorectal.synthesisOverview.diagnosticSummary
Definition

The ‘Diagnostic summary’ section of the final formatted report should include: a. specimen type (S1.02) b. tumour site (S2.02) c. tumour type (S3.01) d. tumour stage (S5.01) e. completeness of excision (S5.03).

Control0..1
Typestring
Requirements

Include: a. specimen type b. tumour site c. tumour type d. tumour stage e. completeness of excision.

LOINC Code22637-3
Colorectal.synthesisOverview.newPrimaryOrRecurrence
Definition

Record if this is a new primary cancer or a recurrence of a previous cancer, if known.

Control0..1
BindingA code that records whether a new primary cancer or a recurrence
The codes SHALL be taken from NewCancerOrRecurrence
Typecode
Requirements

Single selection value list. If regional (local) recurrence or distant metastasis describe.

LOINC Code21983-2
Colorectal.synthesisOverview.newDescription
Definition

Description of regional (local) recurrence or distant metastases.

Control0..1
Typestring
Requirements

Conditional.

LOINC CodeLN-RCPA-00065
Colorectal.synthesisOverview.overarchingComment
Definition

Synthesis and overview overarching comment This field may be used, for example, to: - list any relevant ancillary tests - document any noteworthy adverse gross and/or histological features - express any diagnostic subtlety or nuance that is beyond synoptic capture - document further consultation or results still pending. Use of this field is at the discretion of the reporting pathologist.

Control0..1
Typestring
Requirements

Conditional.

LOINC Code22638-1