Generated Narrative: Composition BreastResectionComposition identifier: Accession ID/PATH-COMP-2025-210 status: Final type: Pathology report (record artifact) encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_210; status = finished; class = IMP (IMP) date: 2025-02-10 17:00:00+0100 author: Institut für Pathologie title: Pathologisch-Anatomische Begutachtung - Makroskopische Beurteilung (BET) Attesters - Mode Party * Legal Organization Institut für Pathologie custodian: Organization Institut für Pathologie Events - Code Detail * pathology report entry task ServiceRequest Pathology synoptic report
Pathologisch-Anatomische Begutachtung - Makroskopische Beurteilung (BET)
Klinische Angaben Z.n. Stanzbiopsie (E_25_105) mit Nachweis eines invasiven Mammakarzinoms NST, G2. BI-RADS 4b. BET links indiziert. Drahthäkchenmarkierung. Keine neoadjuvante Therapie. Ersterkrankung. Keine bekannte genetische Prädisposition. Präparateradiographie beigelegt. Material BET-Exzisionspräparat Mamma links, mit Haut, Drahthäkchen in situ Makroskopie Größe 42 × 35 × 18 mm Gewicht 10 g Quadrant Unterer äußerer Quadrant Zifferblatt 5 Uhr Abstand Mamille 50 mm Lamellierung 8 Scheiben à 5 mm Schnittfläche Grau-weißlich, derber Herdbefund zentral in Scheibe III–V, ca. 18 mm Paraffinblöcke 7 Mikroskopie Invasives Mammakarzinom des NST (kein spezieller Typ), maximal 18 mm messend. Das Karzinom zeigt ein überwiegend trabekuläres und solides Wachstumsmuster mit mäßiger Kern- und Zellpolymorphie. Mitosen sind vereinzelt nachweisbar (4/10 HPF). In der Tumorperipherie zeigt sich ein begleitendes duktales Carcinoma in situ (DCIS) mit intermediärem Kerngrad und überwiegend kribriformem Wachstumsmuster, maximal 8 mm. Zentrale Komedo-Nekrosen. Assoziierte Mikroverkalkungen im DCIS-Areal. Alle Resektionsränder tumorfrei. Mindestabstand invasiv: 5 mm (posterior), DCIS: 3 mm. Keine Lymphgefäßinvasion. Diagnose Invasives Mammakarzinom NST (ICD-O 8500/3), pT1c ICD-10 C50.5 ICD-O-3 Morphologie M8500/3 Operatives Verfahren BET (brusterhaltende Therapie) Seitenlokalisation Links Fokalität Unifokal Max. Durchmesser invasiv 18 mm Max. Gesamtdurchmesser 22 mm Nottingham-Grad Grad 2 (Score 6: Tubuli 3, Pleomorphie 2, Mitosen 1) Assoziiertes DCIS Vorhanden, ohne extensive intraduktale Komponente (EIC), intermediärer Kerngrad, kribriform, zentrale Komedo-Nekrosen Tumorausdehnung Auf Brustdrüse beschränkt pT-Kategorie pT1c Resektionsränder RR-Status invasiv Nicht befallen (R0) Nächster tumorfreier RR Posterior Mindestabstand invasiv 5 mm RR-Status DCIS Nicht befallen Mindestabstand DCIS 3 mm Biomarker ER Positiv (90%, stark) PR Positiv (60%, mäßig) HER2 (IHC) 1+ HER2 (ISH) Nicht amplifiziert HER2-Gesamtstatus Negativ Ki-67 15% Weitere Befunde Lymphgefäßinvasion Nicht nachgewiesen Mikrokalzifikationen In DCIS assoziiert Kommentar: Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung.
Generated Narrative: Patient Patient4 Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
Generated Narrative: Organization PathologyLabOrganization identifier: http://example.hospital.de/organization-ids/ORG-PATH-001 name: Institut für Pathologie
Generated Narrative: Practitioner PathologistPractitioner identifier: http://example.hospital.de/practitioner-ids/PATH-001 name: Elisabeth Hoffmann Qualifications - Code * Pathology
Generated Narrative: Practitioner BreastSurgeonPractitioner identifier: http://example.hospital.de/practitioner-ids/GYN-001 name: Thomas Richter Qualifications - Code * Gynecology
Generated Narrative: Encounter BreastResectionEncounter identifier: http://example.hospital.de/encounters/E_25_210 status: Finished class: [not stated]: IMP (IMP) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
Generated Narrative: Condition BreastResectionDiagnosisConfirmed Profile: MII PR Diagnose Condition version: 2026.0.0 clinicalStatus: Active verificationStatus: Confirmed category: Encounter Diagnosis code: Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_210; status = finished; class = IMP (IMP) onset: 2025-01-15 recordedDate: 2025-02-05 note: Z.n. Stanzbiopsie (E_25_105) mit Nachweis eines invasiven Mammakarzinoms NST, G2. BI-RADS 4b. BET links indiziert.
Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse
Z.n. Stanzbiopsie (E_25_105) mit Nachweis eines invasiven Mammakarzinoms NST, G2. BI-RADS 4b. BET links indiziert.
Generated Narrative: ServiceRequest BreastResectionReportRequest Profile: MII PR Patho Service Request version: 2026.0.0 identifier: Placer Identifier/PATH-RPT-2025-210 status: Completed intent: Order category: Pathology consultation, comprehensive, records and specimen with report (procedure) code: Pathology synoptic report subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_210; status = finished; class = IMP (IMP) requester: Practitioner Thomas Richter performer: Practitioner Elisabeth Hoffmann reasonCode: Malignant neoplasm of breast (disorder) supportingInfo: Condition Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse Diagnostic Report for 'MG Breast Screening' for '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Observation Personal history of primary malignant neoplasm of breast (situation) Observation Cancer treatment --preoperative Observation Lesion size, largest dimension (observable entity) Observation Insertion of marker into breast using X-ray guidance (procedure) Observation 80865008|Specimen mammography|:363702006|Has focus|=185008008|Medical reports sent| Observation Diathesis, function (observable entity) Observation Quadrant Breast Observation Radial position in breast [Angle] in Breast cancer specimen Observation Distance of primary malignant neoplasm of breast to nipple in excised breast specimen (observable entity) Observation Screening interpretation (observable entity) specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ.
Pathology consultation, comprehensive, records and specimen with report (procedure)
Generated Narrative: DiagnosticReport BreastResectionImagingReport MG Breast Screening (Radiology) Subject Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) When For 2025-01-08 Report Details BI-RADS 4b: Herdbefund linke Brust, unterer äußerer Quadrant, 5 Uhr, 5 cm von Mamille. Radiologische Ausdehnung ca. 15 mm. Mammografie und Ultraschall. Indikation zur BET.
BI-RADS 4b: Herdbefund linke Brust, unterer äußerer Quadrant, 5 Uhr, 5 cm von Mamille. Radiologische Ausdehnung ca. 15 mm. Mammografie und Ultraschall. Indikation zur BET.
Generated Narrative: Observation BreastResectionCancerHistory status: Final code: Brustkrebsvorgeschichte subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Ersterkrankung
Personal history of primary malignant neoplasm of breast (situation)
Generated Narrative: Observation BreastResectionPriorTherapy status: Final code: Vorchirurgische Therapie bei invasivem Karzinom subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Keine neoadjuvante Therapie
Vorchirurgische Therapie bei invasivem Karzinom
Generated Narrative: Observation BreastResectionRadiologicalExtent status: Final code: Radiologische Ausdehnung subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: 15 mm (Details: UCUM codemm = 'mm')
Lesion size, largest dimension (observable entity)
Generated Narrative: Observation BreastResectionSpecimenMarking status: Final code: Befundmarkierung subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Drahthäkchen
Insertion of marker into breast using X-ray guidance (procedure)
Generated Narrative: Observation BreastResectionSpecimenRadiographyClinical status: Final code: Präparateradiographie beigelegt subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Ja, beigelegt
80865008|Specimen mammography|:363702006|Has focus|=185008008|Medical reports sent|
Generated Narrative: Observation BreastResectionGeneticPredisposition status: Final code: Genetische Prädisposition subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Nicht bekannt
Generated Narrative: DiagnosticReport BreastResectionReport Profile: MII PR Patho Report version: 2026.0.0 Pathology Synoptic report (Surgical Pathology) Subject Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) When For 2025-02-10 14:00:00+0100 Reported 2025-02-10 17:00:00+0100 Performer Practitioner Elisabeth Hoffmann Identifier Accession ID/E_25_210 Report Details Code Value Flags When For Pathology report gross observation Narrative (Breast structure (body structure)) Final 2025-02-06 08:30:00+0100 Pathology report final diagnosis Narrative Final 2025-02-10 Invasives Mammakarzinom NST (ICD-O 8500/3), pT1c, Nottingham Grad 2 (Score 6: Tubuli 3, Kernpleomorphie 2, Mitosen 1). Begleitendes DCIS, intermediärer Kerngrad, kribriform, fokale Komedo-Nekrosen. Alle Resektionsränder tumorfrei (invasiv 5 mm, DCIS 3 mm). Keine LVI. ER+ (90%), PR+ (60%), HER2 1+ (nicht amplifiziert), Ki-67 15%.
Invasives Mammakarzinom NST (ICD-O 8500/3), pT1c, Nottingham Grad 2 (Score 6: Tubuli 3, Kernpleomorphie 2, Mitosen 1). Begleitendes DCIS, intermediärer Kerngrad, kribriform, fokale Komedo-Nekrosen. Alle Resektionsränder tumorfrei (invasiv 5 mm, DCIS 3 mm). Keine LVI. ER+ (90%), PR+ (60%), HER2 1+ (nicht amplifiziert), Ki-67 15%.
Generated Narrative: Specimen BreastResectionSpecimenPart Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: Placer Identifier/OP25_210_A, Filler Identifier/E_25_210_A accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Specimen from breast obtained by excision (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) request: ServiceRequest Pathology synoptic report Collections - Collector Collected[x] Method BodySite * Practitioner Thomas Richter 2025-02-05 10:00:00+0100 Wide local excision of breast lesion (procedure) Structure of lower outer quadrant of breast (body structure) Containers - Type Additive[x] * Specimen vial (physical object) Neutral buffered formalin (substance) note: BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ.
Specimen from breast obtained by excision (specimen)
Wide local excision of breast lesion (procedure)
Structure of lower outer quadrant of breast (body structure)
BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ.
Generated Narrative: Specimen BreastResectionSpecimenBlock01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue block specimen (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. Collections - Collected[x] Method * 2025-02-06 08:00:00+0100 Gross examination and sampling of tissue specimen (procedure) Processings - Extension Description Procedure Time[x] * Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe III Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:00:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Gross examination and sampling of tissue specimen (procedure)
Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe III
Preparation of formalin fixed paraffin embedded tissue specimen (procedure)
General specimen container (physical object)
Generated Narrative: Specimen BreastResectionSpecimenBlock02 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_2 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue block specimen (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. Collections - Collected[x] Method * 2025-02-06 08:10:00+0100 Gross examination and sampling of tissue specimen (procedure) Processings - Extension Description Procedure Time[x] * Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe V Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:10:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe V
Generated Narrative: Specimen BreastResectionSpecimenBlock03 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_3 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue block specimen (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. Collections - Collected[x] Method * 2025-02-06 08:20:00+0100 Gross examination and sampling of tissue specimen (procedure) Processings - Extension Description Procedure Time[x] * Zuschnitt und Paraffineinbettung - Resektionsrand superior Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:20:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - Resektionsrand superior
Generated Narrative: Specimen BreastResectionSpecimenBlock04 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_4 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue block specimen (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. Collections - Collected[x] Method * 2025-02-06 08:25:00+0100 Gross examination and sampling of tissue specimen (procedure) Processings - Extension Description Procedure Time[x] * Zuschnitt und Paraffineinbettung - Resektionsrand inferior Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:25:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - Resektionsrand inferior
Generated Narrative: Specimen BreastResectionSpecimenBlock05 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_5 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue block specimen (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. Collections - Collected[x] Method * 2025-02-06 08:30:00+0100 Gross examination and sampling of tissue specimen (procedure) Processings - Extension Description Procedure Time[x] * Zuschnitt und Paraffineinbettung - Resektionsrand medial (Scheibe I) Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:30:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - Resektionsrand medial (Scheibe I)
Generated Narrative: Specimen BreastResectionSpecimenBlock06 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_6 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue block specimen (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. Collections - Collected[x] Method * 2025-02-06 08:35:00+0100 Gross examination and sampling of tissue specimen (procedure) Processings - Extension Description Procedure Time[x] * Zuschnitt und Paraffineinbettung - Resektionsrand lateral (Scheibe VIII) Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:35:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - Resektionsrand lateral (Scheibe VIII)
Generated Narrative: Specimen BreastResectionSpecimenBlock07 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_7 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue block specimen (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. Collections - Collected[x] Method * 2025-02-06 08:40:00+0100 Gross examination and sampling of tissue specimen (procedure) Processings - Extension Description Procedure Time[x] * Zuschnitt und Paraffineinbettung - Resektionsrand posterior Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:40:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - Resektionsrand posterior
Generated Narrative: Specimen BreastResectionSpecimenSlideHE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:00:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 1) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Hematoxylin and eosin stain method (procedure)
Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideHE02 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_HE_02 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:00:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 2) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideER01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_ER_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:30:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: ER-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Immunohistochemistry procedure (procedure)
Generated Narrative: Specimen BreastResectionSpecimenSlidePR01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_PR_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:35:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:35:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: PR-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:05:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideHER2IHC01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_HER2IHC_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:40:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:40:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HER2-Immunhistochemie procedure: Human epidermal growth factor receptor 2 gene detection by immunohistochemistry (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:30:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Human epidermal growth factor receptor 2 gene detection by immunohistochemistry (procedure)
Generated Narrative: Specimen BreastResectionSpecimenSlideKi67-01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_Ki67_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:45:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:45:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Ki-67 Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:10:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideCK18-01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_CK18_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:50:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:50:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: CK18-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:35:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlidep40-01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_p40_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:55:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:55:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: p40-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:40:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideECad-01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_1_1_ECad_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 10:00:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 10:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: E-Cadherin-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:45:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideBlock02-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_2_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:20:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 1) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:20:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:35:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideBlock02-HE02 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_2_1_HE_02 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:20:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 2) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:20:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:35:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideRR-Superior-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_3_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_3; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:25:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:25:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:40:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideRR-Inferior-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_4_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_4; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:28:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:28:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:43:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideRR-Medial-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_5_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_5; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:31:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:31:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:46:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideRR-Lateral-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_6_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_6; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:34:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:34:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:49:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen BreastResectionSpecimenSlideRR-Posterior-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210_A_7_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_210 status: Available type: Tissue section (specimen) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) parent: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_7; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:37:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:37:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:52:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Substance BreastResectionSubstanceER Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: Estrogen Receptor (Dako Omnis)
Generated Narrative: Substance BreastResectionSubstancePR Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: Progesterone Receptor (Dako Omnis)
Generated Narrative: Substance BreastResectionSubstanceHER2IHC Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: VENTANA HER2 (4B5), Roche
Generated Narrative: Substance BreastResectionSubstanceKi67 Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: Ki-67 Antigen (Dako Omnis)
Generated Narrative: Substance BreastResectionSubstanceCK18 Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: Cytokeratin 18 (DC10), Dako Omnis
Generated Narrative: Substance BreastResectionSubstancep40 Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: p40 (BC28), Biocare Medical
Generated Narrative: Substance BreastResectionSubstanceECadherin Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: E-Cadherin (NCH-38), Dako Omnis
Generated Narrative: Observation BreastResectionMacroscopicGrouper Profile: MII PR Patho Macroscopic Grouper version: 2026.0.0 status: Final category: Laboratory code: Pathology report gross observation Narrative subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann bodySite: Breast structure (body structure) hasMember: Observation Specimen size.maximum dimension in Breast tumor Observation Specimen size additional dimension 1 in Breast tumor Observation Specimen size additional dimension 2 in Breast tumor Observation Specimen wt Tiss Qn Observation Quadrant Breast Observation Radial position in breast [Angle] in Breast cancer specimen Observation Distance of primary malignant neoplasm of breast to nipple in excised breast specimen (observable entity) Observation Number of paraffin embedded tissue blocks examined from excised specimen (observable entity) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Generated Narrative: Observation BreastResectionMacroLength Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: ProbeGröße1 subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann value: 42 mm (Details: UCUM codemm = 'mm') bodySite: Breast structure (body structure) specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Specimen size.maximum dimension in Breast tumor
Generated Narrative: Observation BreastResectionMacroWidth Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: ProbeGröße2 subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann value: 35 mm (Details: UCUM codemm = 'mm') bodySite: Breast structure (body structure) specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Specimen size additional dimension 1 in Breast tumor
Generated Narrative: Observation BreastResectionMacroDepth Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: ProbeGröße3 subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann value: 18 mm (Details: UCUM codemm = 'mm') bodySite: Breast structure (body structure) specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Specimen size additional dimension 2 in Breast tumor
Generated Narrative: Observation BreastResectionMacroWeight Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: Gewicht der Probe subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann value: 10 g (Details: UCUM codeg = 'g') bodySite: Breast structure (body structure) specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Generated Narrative: Observation BreastResectionMacroQuadrant Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: Quadrantenlokalisaion subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann value: Unterer äußerer Quadrant specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Generated Narrative: Observation BreastResectionMacroClock Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: Zifferblattlokalisation subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann value: 5 o'clock (Details: UCUM code{clock position} = '{clock position}') specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Radial position in breast [Angle] in Breast cancer specimen
Radial location of primary malignant neoplasm in excised breast specimen (observable entity)
Generated Narrative: Observation BreastResectionMacroDistanceNipple Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: Abstand von der Mamille subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann value: 50 mm (Details: UCUM codemm = 'mm') specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Distance of primary malignant neoplasm of breast to nipple in excised breast specimen (observable entity)
Generated Narrative: Observation BreastResectionMacroBlockCount Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: Anzahl Paraffinblöcke subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann value: 6 Blöcke (Details: UCUM code{blocks} = '{blocks}') specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Number of paraffin embedded tissue blocks examined from excised specimen (observable entity)
Generated Narrative: Observation BreastResectionDiagnosticConclusionGrouper Profile: MII PR Patho Diagnostic Conclusion Grouper version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory code: Pathology report final diagnosis Narrative subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann hasMember: Observation Surgery procedure Observation Specimen type Observation Specimen laterality (observable entity) Observation Body structure included in specimen [Anatomy] in Specimen Observation Qualitative distribution of primary malignant neoplasm of breast in excised breast specimen (observable entity) Observation Inv comp size max dim BT Observation Size.maximum dimension in Tumor Observation Histo type BT Observation Histology type in Cancer specimen Narrative Observation Nottingham combined grade of primary malignant neoplasm of breast (observable entity) Observation Nottingham total score of primary malignant neoplasm of breast (observable entity) Observation Number of mitoses per 10 high power fields (observable entity) Observation DCIS intraduct ext Br ca spec Ql Micro Observation Nuclear grade of ductal carcinoma in situ of breast (observable entity) Observation Growth pattern of DCIS [Type] in Breast cancer specimen by Light microscopy Observation DCIS necrosis [Type] in Breast cancer specimen by Light microscopy Observation Adjacent structure invaded by tumor [Anatomy] in Breast cancer specimen by Light microscopy Observation Margin involved BT Observation IC uninv marg closest BT Observation IC uninv marg dist closest BT Observation Surgical margin DCIS involvement [Presence] in Breast cancer specimen by Light microscopy Observation DCIS.uninv marg dist.closest BT Observation Lymph-vascular invasion Ca spec Observation Presence of microcalcification in excised breast specimen (observable entity) Observation Estrogen receptor [Interpretation] in Tissue Observation Cells.estrogen receptor/cells in Breast cancer specimen by Immune stain Observation Estrogen receptor fluorescence intensity [Type] in Breast cancer specimen by Immune stain Observation Progesterone receptor [Interpretation] in Tissue Observation Cells.progesterone receptor/cells in Breast cancer specimen by Immune stain Observation Intensity of stain of progesterone receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity) Observation HER2 [Presence] in Breast cancer specimen by Immune stain Observation Presence of receptor tyrosine-protein kinase erbB-2 in primary malignant neoplasm of breast by in situ hybridization (observable entity) Observation HER2 [Interpretation] in Tissue Observation Cells.Ki-67 nuclear Ag/cells in Breast cancer specimen by Immune stain Observation pT category (observable entity) Observation Pathology report comments [Interpretation] Narrative derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Generated Narrative: Observation BreastResectionOperativeProcedure Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Operatives Verfahren subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Brusterhaltende Therapie (BET) specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Specimen collection procedure (observable entity)
Generated Narrative: Observation BreastResectionMaterialType Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Materialart subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Exzisionspräparat specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Generated Narrative: Observation BreastResectionLaterality Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Seitenlokalisation der Probe subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Links specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Generated Narrative: Observation BreastResectionAttachedTissue Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Material/anhängendes Gewebe subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Haut specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Body structure included in specimen [Anatomy] in Specimen
Generated Narrative: Observation BreastResectionFocality Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: (Multi)fokalität subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Unifokal specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Qualitative distribution of primary malignant neoplasm of breast in excised breast specimen (observable entity)
Generated Narrative: Observation BreastResectionMaxDiameterInvasive Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Maximaler Durchmesser invasives Karzinom subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 18 mm (Details: UCUM codemm = 'mm') specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Greatest length dimension of excised primary malignant neoplasm (observable entity)
Maximaler Durchmesser invasives Karzinom
Generated Narrative: Observation BreastResectionMaxOverallDiameter Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Maximaler Gesamtdurchmesser der Läsion subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 22 mm (Details: UCUM codemm = 'mm') specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Generated Narrative: Observation BreastResectionHistologicalType Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Histologischer Tumortyp WHO subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Invasives duktales Karzinom (NST) specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Histologic type of primary malignant neoplasm of breast (observable entity)
Infiltrating duct carcinoma (morphologic abnormality)
Generated Narrative: Observation BreastResectionMorphologyFreeText Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Morphologie Freitext subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Invasives Mammakarzinom des NST (kein spezieller Typ), maximal 18 mm messend. Das Karzinom zeigt ein überwiegend trabekuläres und solides Wachstumsmuster mit mäßiger Kern- und Zellpolymorphie. Mitosen sind vereinzelt nachweisbar (4/10 HPF). In der Tumorperipherie zeigt sich ein begleitendes duktales Carcinoma in situ (DCIS) mit intermediärem Kerngrad und überwiegend kribriformem Wachstumsmuster, maximal 8 mm. Fokale Komedo-Nekrosen. Assoziierte Mikroverkalkungen im DCIS-Areal. Alle Resektionsränder tumorfrei. Mindestabstand invasiv: 5 mm (posterior), DCIS: 3 mm. Keine Lymphgefäßinvasion. specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Histology type in Cancer specimen Narrative
Invasives Mammakarzinom des NST (kein spezieller Typ), maximal 18 mm messend. Das Karzinom zeigt ein überwiegend trabekuläres und solides Wachstumsmuster mit mäßiger Kern- und Zellpolymorphie. Mitosen sind vereinzelt nachweisbar (4/10 HPF). In der Tumorperipherie zeigt sich ein begleitendes duktales Carcinoma in situ (DCIS) mit intermediärem Kerngrad und überwiegend kribriformem Wachstumsmuster, maximal 8 mm. Fokale Komedo-Nekrosen. Assoziierte Mikroverkalkungen im DCIS-Areal. Alle Resektionsränder tumorfrei. Mindestabstand invasiv: 5 mm (posterior), DCIS: 3 mm. Keine Lymphgefäßinvasion.
Generated Narrative: Observation BreastResectionNottinghamGrade Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Histologischer Tumorgrad (Nottingham-Grad) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Nottingham Grad 2 specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Observation Nottingham total score of primary malignant neoplasm of breast (observable entity)
Nottingham combined grade of primary malignant neoplasm of breast (observable entity)
Histologischer Tumorgrad (Nottingham-Grad)
G2: Moderately differentiated histologic grade (qualifier value)
Generated Narrative: Observation BreastResectionNottinghamSummaryScore Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Elston-Ellis-Summenscore subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 6 score (Details: UCUM code{score} = '{score}') specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' component code: Glandular differentiation [Score] in Breast cancer specimen by Nottingham value: 3 score (Details: UCUM code{score} = '{score}') component code: Nuclear pleomorphism in Breast tumor by Nottingham value: 2 score (Details: UCUM code{score} = '{score}') component code: Mitotic rate [Score] in Breast cancer specimen by Nottingham value: 1 score (Details: UCUM code{score} = '{score}')
Nottingham total score of primary malignant neoplasm of breast (observable entity)
Glandular differentiation [Score] in Breast cancer specimen by Nottingham
Nuclear pleomorphism in Breast tumor by Nottingham
Mitotic rate [Score] in Breast cancer specimen by Nottingham
Generated Narrative: Observation BreastResectionMitosisCount Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Mitosezahl subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 4 per 10 HPF (Details: UCUM code{HPF} = '{HPF}') specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Number of mitoses per 10 high power fields (observable entity)
Generated Narrative: Observation BreastResectionAssociatedDCIS Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Klassifikation eines assoziiertes DCIS subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: DCIS vorhanden, ohne extensive intraduktale Komponente (EIC) specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
DCIS present without extensive intraductal component (EIC)
DCIS vorhanden, ohne extensive intraduktale Komponente (EIC)
Generated Narrative: Observation BreastResectionDCISGrade Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Kerngrading / WHO-Grading nichtinvasiv subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Intermediär (Grad 2) specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Nuclear grade of ductal carcinoma in situ of breast (observable entity)
Ductal carcinoma in situ nuclear pleomorphism, grade 2: neither nuclear grade 1 nor nuclear grade 3 (finding)
Generated Narrative: Observation BreastResectionDCISArchitecture Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: DCIS Architektur subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: kribriformer Typ specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Growth pattern of DCIS [Type] in Breast cancer specimen by Light microscopy
Architectural pattern of ductal carcinoma in situ in breast (observable entity)
Generated Narrative: Observation BreastResectionDCISNecrosis Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Nekrosen subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Zentral (Komedo-Nekrosen) specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
DCIS necrosis [Type] in Breast cancer specimen by Light microscopy
Present, central (expansive "comedo" necrosis)
Generated Narrative: Observation BreastResectionTumorExtent Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Tumorausdehnung subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Auf Brustdrüse beschränkt specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Adjacent structure invaded by tumor [Anatomy] in Breast cancer specimen by Light microscopy
Status of extension by tumor (observable entity)
Anatomic location directly invaded by primary malignant neoplasm of breast (observable entity)
Generated Narrative: Observation BreastResectionMarginStatusInvasive Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Resektionsrandstatus invasiv subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Nicht befallen (R0) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Presence of neoplasm at excised surgical margin (observable entity)
Surgical margin involved by primary malignant neoplasm of breast in excised breast specimen (observable entity)
Generated Narrative: Observation BreastResectionClosestMargin Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Richtung des nächsten tumorfreien RR subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Posterior specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_7_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Surgical margin closest to malignant neoplasm in excised specimen of breast (observable entity)
Generated Narrative: Observation BreastResectionMinDistanceInvasive Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Mindestabstand des invasiven Tumor zum nächstgelegenen Resektionsrand subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 5 mm (Details: UCUM codemm = 'mm') specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_7_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Distance of invasive carcinoma of breast from closest surgical margin in excised breast specimen (observable entity)
Mindestabstand des invasiven Tumor zum nächstgelegenen Resektionsrand
Generated Narrative: Observation BreastResectionMarginStatusNonInvasive Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Resektionsrandstatus nichtinvasiv subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Nicht befallen derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Surgical margin DCIS involvement [Presence] in Breast cancer specimen by Light microscopy
Presence of ductal carcinoma in situ at surgical margin in excised specimen of breast (observable entity)
Generated Narrative: Observation BreastResectionMinDistanceNonInvasive Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Mindestabstand vom RR zum nichtinvasiven Tumor subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 3 mm (Details: UCUM codemm = 'mm') derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Mindestabstand vom RR zum nichtinvasiven Tumor
Generated Narrative: Observation BreastResectionLVI Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Peritumorale Gefäßinvasion subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Nicht nachgewiesen specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. Mit Haut, Drahthäkchen in situ. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Presence of direct invasion by primary malignant neoplasm to lymphatic vessel and/or small blood vessel (observable entity)
Generated Narrative: Observation BreastResectionMicrocalcification Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Presence of microcalcification in excised breast specimen (observable entity) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Microcalcifications present in DCIS specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Presence of microcalcification in excised breast specimen (observable entity)
Generated Narrative: Observation BreastResectionERStatus Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Hormonrezeptorstatus Östrogen subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Positiv specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_ER_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] ESR1
Estrogen receptor [Interpretation] in Tissue
Observation using immunohistochemistry (observable entity)
Generated Narrative: Observation BreastResectionERPercentage Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: PP ER subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 90 % (Details: UCUM code% = '%') specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_ER_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] ESR1
Cells.estrogen receptor/cells in Breast cancer specimen by Immune stain
Percent of cells with estrogen receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Generated Narrative: Observation BreastResectionERIntensity Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Färbeintensität ER subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Stark specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_ER_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] ESR1
Estrogen receptor fluorescence intensity [Type] in Breast cancer specimen by Immune stain
Intensity of stain of estrogen receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Severe (severity modifier) (qualifier value)
Generated Narrative: Observation BreastResectionPRStatus Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Hormonrezeptorstatus Progesteron subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Positiv specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_PR_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] PGR
Progesterone receptor [Interpretation] in Tissue
Generated Narrative: Observation BreastResectionPRPercentage Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: PP PR subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 60 % (Details: UCUM code% = '%') specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_PR_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] PGR
Cells.progesterone receptor/cells in Breast cancer specimen by Immune stain
Percent of cells with progesterone receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Generated Narrative: Observation BreastResectionPRIntensity Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Färbeintensität PR subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Mäßig specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_PR_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] PGR
Intensity of stain of progesterone receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Moderate (severity modifier) (qualifier value)
Generated Narrative: Observation BreastResectionHER2IHC Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Her2 Score subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 1+ specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HER2IHC_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] ERBB2
HER2 [Presence] in Breast cancer specimen by Immune stain
Presence of receptor tyrosine-protein kinase erbB-2 in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Generated Narrative: Observation BreastResectionHER2ISH Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Her2 Amplifikation subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Nicht amplifiziert specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HER2IHC_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] ERBB2
Presence of receptor tyrosine-protein kinase erbB-2 in primary malignant neoplasm of breast by in situ hybridization (observable entity)
Human epidermal growth factor 2 gene amplification not detected (finding)
Generated Narrative: Observation BreastResectionHER2Overall Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Her2neuStatus subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Negativ specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_HER2IHC_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] ERBB2
Generated Narrative: Observation BreastResectionKi67 Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Ki67-Index subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: 15 % (Details: UCUM code% = '%') specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210_A_1_1_Ki67_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_210; status = available; type = Tissue section (specimen) derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Components - Code Value[x] * Gene studied [ID] MKI67
Cells.Ki-67 nuclear Ag/cells in Breast cancer specimen by Immune stain
Percent of cell nuclei positive for proliferation marker protein Ki-67 in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Generated Narrative: Observation BreastResectionPT Profile: MII PR Onkologie TNM T-Kategorie version: 2026.0.0 status: Final code: pT category (observable entity) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 value: T1 method: 8. Auflage
Generated Narrative: Observation BreastResectionComment Profile: MII PR Patho Finding version: 2026.0.0 basedOn: ServiceRequest Pathology synoptic report status: Final category: Laboratory, Pathology report final diagnosis Narrative code: Kommentar subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 performer: Practitioner Elisabeth Hoffmann value: Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung. derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Pathology report comments [Interpretation] Narrative
Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung.
Generated Narrative: QuestionnaireResponse QuestionnaireResponseBreastResection LinkID Text Definition Answer QuestionnaireResponseBreastResection Questionnaire:http://breastcancerspec.org/Questionnaire/OP-Mamma #xD; bet.root BET Mamma #xD; bet.clinical Klinische Angaben #xD; 11951 Proben limitiert auswertbar SNOMED CT: 373067005 (No (qualifier value)) #xD; 11912 Präsentationsmodus Frisch #xD; 11147 Klinische Befunde / Anlass Z.n. Stanzbiopsie mit Nachweis eines invasiven Mammakarzinoms NST, G2 #xD; 11923 Brustkrebsvorgeschichte Ersterkrankung #xD; 11952 Vorchirurgische Therapie SNOMED CT: 373067005 (No (qualifier value)) #xD; 11918 Bildgebungsmodalität Mammografie, Ultraschall #xD; 11953 Radiologische Ausdehnung 15 mm (Details: UCUM codemm = 'mm') #xD; 10160 Befundmarkierung Drahthäkchen #xD; 10130 Präparateradiographie Ja, beigelegt #xD; 11954 Genetische Prädisposition Nicht bekannt #xD; bet.macro Makroskopie #xD; 10900 Probengröße 1 (Länge) 65 mm (Details: UCUM codemm = 'mm') #xD; 10910 Probengröße 2 (Breite) 45 mm (Details: UCUM codemm = 'mm') #xD; 10920 Probengröße 3 (Tiefe) 30 mm (Details: UCUM codemm = 'mm') #xD; 10890 Gewicht 55 g (Details: UCUM codeg = 'g') #xD; 10030 Quadrant SNOMED CT: 33564002 (Structure of lower outer quadrant of breast (body structure)) #xD; 10040 Zifferblattlokalisation 5 Uhr #xD; 10070 Abstand Mamille 50 mm (Details: UCUM codemm = 'mm') #xD; bet.general Allgemeine Befunde #xD; 11130 Nichtinvasive Läsion SNOMED CT: 52101004 (Present (qualifier value)) #xD; 11270 Invasives Karzinom SNOMED CT: 52101004 (Present (qualifier value)) #xD; 11919 Operatives Verfahren SNOMED CT: 237371007 (Wide local excision of breast lesion (procedure)) #xD; 10140 Materialart Exzisionspräparat #xD; 10800 Seitenlokalisation SNOMED CT: 7771000 (Left (qualifier value)) #xD; 11040 Anhängendes Gewebe Haut #xD; 11440 Fokalität Unifokal #xD; bet.invasive Invasives Karzinom #xD; 11400 Max Durchmesser invasiv 18 mm (Details: UCUM codemm = 'mm') #xD; 11420 Max Gesamtdurchmesser 22 mm (Details: UCUM codemm = 'mm') #xD; 11280 Histologischer Tumortyp unknown: 8500/3 (Invasives duktales Karzinom (NST)) #xD; 11290 Morphologie Freitext Invasives Mammakarzinom des NST, überwiegend trabekuläres und solides Wachstumsmuster #xD; 11330 Nottingham-Grad G2 #xD; 11340 Tubulus-Score 3 #xD; 11350 Kernpleomorphie-Score 2 #xD; 11925 Mitosezahl 4/10 HPF #xD; 11360 Mitoserate-Score 1 #xD; 11390 Elston-Ellis-Summenscore 6 #xD; 11300 Assoziiertes DCIS SNOMED CT: 52101004 (Present (qualifier value)) #xD; 149 DCIS Kerngrading Intermediär (Grad 2) #xD; 150 DCIS Architektur Kribriform #xD; 151 DCIS Nekrosen Fokal (Komedo-Nekrosen) #xD; 11926 Tumorausdehnung Auf Brustdrüse beschränkt #xD; bet.margins Resektionsränder #xD; 11470 RR-Status invasiv SNOMED CT: 2667000 (Absent (qualifier value)) #xD; 11490 Nächster tumorfreier RR Posterior #xD; 11480 Mindestabstand invasiv 5 mm (Details: UCUM codemm = 'mm') #xD; 11968 RR-Status nichtinvasiv SNOMED CT: 2667000 (Absent (qualifier value)) #xD; 11970 Mindestabstand nichtinvasiv 3 mm (Details: UCUM codemm = 'mm') #xD; bet.additional Weitere Befunde #xD; 11430 LVI SNOMED CT: 2667000 (Absent (qualifier value)) #xD; 10880 Mikrokalzifikationen In DCIS assoziiert #xD; bet.biomarkers Biomarker #xD; 11750 ER-Status SNOMED CT: 52101004 (Present (qualifier value)) #xD; 11720 ER Prozent 90 #xD; 11730 ER Färbeintensität Stark #xD; 11790 PR-Status SNOMED CT: 52101004 (Present (qualifier value)) #xD; 11760 PR Prozent 60 #xD; 11770 PR Färbeintensität Mäßig #xD; 11810 HER2-Score (IHC) 1+ #xD; 11820 HER2-Amplifikation (ISH) Nicht amplifiziert #xD; 11830 HER2-Gesamtstatus Negativ #xD; 11840 Ki-67-Index 15 #xD; bet.tnm TNM #xD; 169 pT-Kategorie pT1c #xD; bet.comment Kommentar #xD; 11900 Kommentar Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung. #xD; Documentation for this format
Z.n. Stanzbiopsie mit Nachweis eines invasiven Mammakarzinoms NST, G2
Invasives Mammakarzinom des NST, überwiegend trabekuläres und solides Wachstumsmuster