Document Bundle - Stanzbiopsie Mamma - Breast Cancer Specification v0.1.0

Breast Cancer Specification - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Bundle: Document Bundle - Stanzbiopsie Mamma

Document Details

Document Subject

Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)

Document Content

Pathologiebefundbericht

Klinische Angaben

Herdbefund/Architekturstörung linke Brust, BI-RADS 4b. US-gestützte Stanzbiopsie.

Material

HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille

Makroskopie

Stanzzylinder	2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke
Paraffinblöcke	1

Mikroskopie

In beiden vollständig gebetteten, mit jeweils vier Schnittstufen aufgearbeiteten Punktionszylindern lipomatös und fibrolipomatös transformiertes Brustdrüsengewebe, das zu großen Teilen eingenommen wird von Tumorstrukturen eines mittelgroßzelligen, vordergründig trabekulär, solid und dissolut einzelzellig wachsenden invasiven Mammakarzinoms mit mäßiger Zell- und Kernpolymorphie sowie ganz vereinzelt nachweisbaren Mitosen (weniger als 5/10 HPF). Im Tumorzentrum unterschiedlich ausgeprägte Stromasklerose und herdförmige -elastose. An der Tumorperipherie schüttere bis mitteldichte rundzellig entzündliche Stromareaktion.

Diagnostische Schlussfolgerung

Diagnose: Invasives Mammakarzinom NST (ICD-O 8500/3)

ICD-O-3 Morphologie	M8500/3
Nottingham-Grad	Grad 2 (Score 6: Tubuli 3, Pleomorphie 2, Mitosen 1)
ER	Positiv (85% positive Tumorzellkerne)
PR	Positiv (50% positive Tumorzellkerne)
HER2	Negativ (nicht amplifiziert)
Ki-67	10%
B-Klassifikation	B5b (NHSBSP)
Relevante Mikroverkalkungen	Nein
Präparateradiogramm	Gesehen
Korrelation Mikroverkalkung	Vorliegende Verkalkung radiologisch nicht relevant (kleiner 100 Mikrometer)

Additional Resources Included in Document

Entry 2 - fullUrl = http://breastcancerspec.org/Patient/Patient4

Resource Patient:

Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)

Entry 3 - fullUrl = http://breastcancerspec.org/Organization/PathologyLabOrganization

Resource Organization:

identifier: http://example.hospital.de/organization-ids/ORG-PATH-001
name: Institut für Pathologie

Entry 4 - fullUrl = http://breastcancerspec.org/Practitioner/PathologistPractitioner

Resource Practitioner:

identifier: http://example.hospital.de/practitioner-ids/PATH-001
name: Elisabeth Hoffmann
Qualifications
- Code
* Pathology

Entry 5 - fullUrl = http://breastcancerspec.org/Practitioner/BreastSurgeonPractitioner

Resource Practitioner:

identifier: http://example.hospital.de/practitioner-ids/GYN-001
name: Thomas Richter
Qualifications
- Code
* Gynecology

Entry 6 - fullUrl = http://breastcancerspec.org/Encounter/CoreNeedleBiopsyEncounter

Resource Encounter:

identifier: http://example.hospital.de/encounters/E_25_105
status: completed
class: AMB
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)

Entry 7 - fullUrl = http://breastcancerspec.org/Condition/CoreNeedleBiopsyDiagnosisPreOp

Resource Condition:

Profile: MII PR Diagnose Condition version: 2026.0.0
clinicalStatus: Active
verificationStatus: Provisional
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_105; status = finished; class = AMB (AMB)
onset: 2025-01-10
recordedDate: 2025-01-10
note:
Herdbefund/Architekturstörung linke Brust, BI-RADS 4b. Indikation zur US-gestützten Stanzbiopsie.

Entry 8 - fullUrl = http://breastcancerspec.org/ServiceRequest/CoreNeedleBiopsyReportRequest

Resource ServiceRequest:

Profile: MII PR Patho Service Request version: 2026.0.0
identifier: Placer Identifier/PATH-RPT-2025-105
status: Completed
intent: Order
category: Pathology consultation, comprehensive, records and specimen with report (procedure)
code: No display for ServiceRequest.code (concept: Breast Pathology biopsy 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_105; status = finished; class = AMB (AMB)
requester: Practitioner Thomas Richter
performer: Practitioner Elisabeth Hoffmann
supportingInfo: No display for ServiceRequest.supportingInfo (reference: ->Diagnostic Report for 'MG Breast Screening' for '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Specimen from breast obtained by core needle biopsy (specimen); note = HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.

Entry 9 - fullUrl = http://breastcancerspec.org/DiagnosticReport/CoreNeedleBiopsyImagingReport

Resource DiagnosticReport:

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/Architekturstörung linke Brust, 5 Uhr, 5 cm von Mamille. Indikation zur histologischen Abklärung mittels Stanzbiopsie.

Entry 10 - fullUrl = http://breastcancerspec.org/DiagnosticReport/CoreNeedleBiopsyReport

Resource DiagnosticReport:

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 2025-01-17 15:00:00+0100
Reported 2025-01-17 17:00:00+0100
Performer Practitioner Elisabeth Hoffmann
Identifier Accession ID/E_25_105
Report Details
Code Value Flags When For
Pathology report gross observation Narrative (Structure of lower outer quadrant of left breast (body structure)) Final 2025-01-16 08:30:00+0100
Pathology report final diagnosis Narrative Final 2025-01-17
Invasives Mammakarzinom NST (ICD-O 8500/3), Nottingham Grad 2 (Score 6: Tubuli 3, Kernpleomorphie 2, Mitosen 1). ER+ (85%), PR+ (50%), HER2- (nicht amplifiziert), Ki-67 10%. B-Klassifikation B5b.

Entry 11 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenPart

Resource Specimen:

Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0
identifier: Placer Identifier/BX25_105_A, Filler Identifier/E_25_105_A
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
status: Available
type: Specimen from breast obtained by core needle biopsy (specimen)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
request: ServiceRequest Breast Pathology biopsy report
Collections
- Collector Collected[x] Method BodySite
* Practitioner Thomas Richter 2025-01-15 09:30:00+0100 Core needle biopsy (procedure) No display for Specimen.collection.bodySite (concept: Structure of lower outer quadrant of breast (body structure))
container
note:
HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.

Entry 12 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenBlock01

Resource Specimen:

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_105_A_1
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105; status = available; type = Specimen from breast obtained by core needle biopsy (specimen); note = HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.
Collections
- Collected[x] Method
* 2025-01-16 08:00:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung 2025-01-16 08:00:00+0100
container

Entry 13 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideHE01

Resource Specimen:

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_105_A_1_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 1)
time: 2025-01-16 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-01-16 09:15:00+0100
container

Entry 14 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideHE02

Resource Specimen:

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_105_A_1_1_HE_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 2)
time: 2025-01-16 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-01-16 09:15:00+0100
container

Entry 15 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideHE03

Resource Specimen:

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_105_A_1_1_HE_03
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 3)
time: 2025-01-16 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-01-16 09:15:00+0100
container

Entry 16 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideHE04

Resource Specimen:

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_105_A_1_1_HE_04
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 4)
time: 2025-01-16 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-01-16 09:15:00+0100
container

Entry 17 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideER01

Resource Specimen:

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_105_A_1_1_ER_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-01-16 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: ER-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-01-16 10:00:00+0100
container

Entry 18 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideER02

Resource Specimen:

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_105_A_1_1_ER_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-01-16 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: ER-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-01-16 10:00:00+0100
container

Entry 19 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlidePR01

Resource Specimen:

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_105_A_1_1_PR_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:35:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-01-16 09:35:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: PR-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-01-16 10:05:00+0100
container

Entry 20 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlidePR02

Resource Specimen:

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_105_A_1_1_PR_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:35:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-01-16 09:35:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: PR-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-01-16 10:05:00+0100
container

Entry 21 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideHER2-01

Resource Specimen:

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_105_A_1_1_HER2_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:40:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-01-16 09:40:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HER2 Bright-field Dual In-Situ Hybridization (B-DISH)
additive: Substance Tissue stain (substance)
time: 2025-01-16 10:30:00+0100
container

Entry 22 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideHER2-02

Resource Specimen:

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_105_A_1_1_HER2_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:40:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-01-16 09:40:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HER2 Bright-field Dual In-Situ Hybridization (B-DISH)
additive: Substance Tissue stain (substance)
time: 2025-01-16 10:30:00+0100
container

Entry 23 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideKi67-01

Resource Specimen:

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_105_A_1_1_Ki67_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:45:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-01-16 09:45:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Ki-67 Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-01-16 10:10:00+0100
container

Entry 24 - fullUrl = http://breastcancerspec.org/Specimen/CoreNeedleBiopsySpecimenSlideKi67-02

Resource Specimen:

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_105_A_1_1_Ki67_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_105
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_105_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-01-16 09:45:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-01-16 09:45:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Ki-67 Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-01-16 10:10:00+0100
container

Entry 25 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyMacroscopicGrouper

Resource Observation:

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: 2025-01-16 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
bodySite: Structure of lower outer quadrant of left breast (body structure)
hasMember:
Observation Size.maximum dimension in Tumor
Observation Quantity (attribute)
Observation Quantity (attribute)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 26 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyMacroscopicTotalLength

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: Gesamtlänge der Stanzzylinder
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-16 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 22 mm (Details: UCUM codemm = 'mm')
bodySite: Structure of lower outer quadrant of left breast (body structure)
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Specimen from breast obtained by core needle biopsy (specimen); note = HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 27 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyMacroscopicCylinderCount

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: Anzahl Stanzzylinder
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-16 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 2 count (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Specimen from breast obtained by core needle biopsy (specimen); note = HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 28 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyMacroscopicBlockCount

Resource Observation:

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: 2025-01-16 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 1 count (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Specimen from breast obtained by core needle biopsy (specimen); note = HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 29 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyDiagnosticConclusionGrouper

Resource Observation:

Profile: MII PR Patho Diagnostic Conclusion Grouper version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy 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: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
hasMember:
Observation Histology and Behavior ICD-O-3 Cancer
Observation Histology type in Cancer specimen Narrative
Observation Histologic grade [Score] in Breast cancer specimen by Nottingham
Observation Nottingham total score of primary malignant neoplasm of breast (observable entity)
Observation Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain
Observation Cells.estrogen receptor/cells in Breast cancer specimen by Immune stain
Observation Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain
Observation Cells.progesterone receptor/cells in Breast cancer specimen by Immune stain
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
Observation HER2 [Interpretation] in Tissue
Observation Cells.Ki-67 nuclear Ag/cells in Breast cancer specimen by Immune stain
Observation Screening interpretation (observable entity)
Observation Presence of microcalcification in excised breast specimen (observable entity)
Observation Specimen mammography (procedure)
Observation Microcalcification, calcified structure (morphologic abnormality)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 30 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyHistologicalTypeICDO3

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Histology and Behavior ICD-O-3 Cancer
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: Invasives duktales Karzinom (NST)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 31 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyMorphologyFreeText

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Histology type in Cancer specimen Narrative
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: Invasives Karzinom, NST
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 32 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyNottinghamGrade

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Histologischer Tumorgrad (Elston-Ellis-Grad)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: Nottingham Grad 2 (Score 6)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom:
Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' 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)

Entry 33 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyNottinghamSummaryScore

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy 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: 2025-01-17
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_105_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' 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}')

Entry 34 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyERStatus

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: ER positiv
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_ER_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' 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

Entry 35 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyERPercentage

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Cells.estrogen receptor/cells in Breast cancer specimen by Immune stain
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: 85 % (Details: UCUM code% = '%')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_ER_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' 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

Entry 36 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyPRStatus

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: PR positiv
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_PR_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' 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

Entry 37 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyPRPercentage

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Cells.progesterone receptor/cells in Breast cancer specimen by Immune stain
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: 50 % (Details: UCUM code% = '%')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_PR_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' 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

Entry 38 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyHER2ISH

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Presence of receptor tyrosine-protein kinase erbB-2 in primary malignant neoplasm of breast by in situ hybridization
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: HER2 negativ (nicht amplifiziert)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_HER2_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' 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

Entry 39 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyKi67

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Cells.Ki-67 nuclear Ag/cells in Breast cancer specimen by Immune stain
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: 10 % (Details: UCUM code% = '%')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_Ki67_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' 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

Entry 40 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyInterpretation

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: B-Klassifikation
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: B5b
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 41 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyMicrocalcification

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy 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: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: Keine relevanten Mikroverkalkungen
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 42 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsySpecimenRadiography

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Präparateradiogramm
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: Präparateradiogramm gesehen
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Specimen from breast obtained by core needle biopsy (specimen); note = HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 43 - fullUrl = http://breastcancerspec.org/Observation/CoreNeedleBiopsyMicrocalcificationCorrelation

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Breast Pathology biopsy report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Korrelation Mikroverkalkung
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-01-17
performer: Practitioner Elisabeth Hoffmann
value: Vorliegende Verkalkung radiologisch nicht relevant (kleiner als 100 Mikrometer)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_105; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 44 - fullUrl = http://breastcancerspec.org/QuestionnaireResponse/QuestionnaireResponseCoreNeedleBiopsy

Resource QuestionnaireResponse:

LinkID Text Definition Answer
QuestionnaireResponseCoreNeedleBiopsy Questionnaire:http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy

cnb.root Stanzbiopsie Mamma

cnb.patient Patientendaten

cnb.patient.name Familienname Becker

cnb.patient.given Vorname Sabine

cnb.patient.dob Geburtsdatum 1971-03-15

cnb.patient.id Patienten-Identifikator PAT-2025-105

cnb.clinical Klinische Angaben

cnb.clinical.indication Untersuchungsanlass Herdbefund/Architekturstörung linke Brust

cnb.clinical.birads BI-RADS 4b

cnb.clinical.imaging Bildgebungsmodalität Ultraschall

cnb.specimen Untersuchungsmaterial

cnb.specimen.type Materialart HG-Stanzen/Mamma

cnb.specimen.side Seitenlokalisation SNOMED CT: 7771000 (Left (qualifier value))

cnb.specimen.clock Uhrzeigerlokalisation 5 Uhr

cnb.specimen.distance Abstand von Mamille 5 cm (Details: UCUM codecm = 'cm')

cnb.specimen.length Gesamtlänge der Stanzzylinder 22 mm (Details: UCUM codemm = 'mm')

cnb.specimen.cylinders Anzahl Stanzzylinder 2

cnb.specimen.blocks Anzahl Blöcke 1

cnb.histology Histologischer Tumortyp

cnb.histology.icdo3 Histologischer Typ ICD-O-3 unknown: 8500/3 (Invasives duktales Karzinom (NST))

cnb.grading Nottingham-Grading

cnb.grading.grade Nottingham-Grad G2

cnb.grading.score Elston-Ellis Summenscore 6

cnb.grading.tubules Tubulusbildung 3

cnb.grading.pleomorphism Kernpleomorphie 2

cnb.grading.mitoses Mitoserate 1

cnb.biomarkers Biomarker

cnb.biomarkers.er Östrogenrezeptor SNOMED CT: 52101004 (Present (qualifier value))

cnb.biomarkers.er.pct ER Prozent 85

cnb.biomarkers.pr Progesteronrezeptor SNOMED CT: 52101004 (Present (qualifier value))

cnb.biomarkers.pr.pct PR Prozent 50

cnb.biomarkers.her2 HER2 Amplifikation Negativ (nicht amplifiziert)

cnb.biomarkers.ki67 Ki-67 10

cnb.bclassification B-Klassifikation

cnb.bclassification.value B-Klassifikation (NHSBSP) B5b

cnb.microcalcification Mikroverkalkungen

cnb.microcalcification.relevant Relevante Mikroverkalkungen SNOMED CT: 2667000 (Absent (qualifier value))

cnb.microcalcification.radiography Präparateradiogramm Gesehen

cnb.microcalcification.correlation Korrelation Mikroverkalkung Vorliegende Verkalkung radiologisch nicht relevant (kleiner als 100 Mikrometer)

Documentation for this format

LinkID	Text	Answer
QuestionnaireResponseCoreNeedleBiopsy		Questionnaire:http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy
cnb.root	Stanzbiopsie Mamma
cnb.patient	Patientendaten
cnb.patient.name	Familienname	Becker
cnb.patient.given	Vorname	Sabine
cnb.patient.dob	Geburtsdatum	1971-03-15
cnb.patient.id	Patienten-Identifikator	PAT-2025-105
cnb.clinical	Klinische Angaben
cnb.clinical.indication	Untersuchungsanlass	Herdbefund/Architekturstörung linke Brust
cnb.clinical.birads	BI-RADS	4b
cnb.clinical.imaging	Bildgebungsmodalität	Ultraschall
cnb.specimen	Untersuchungsmaterial
cnb.specimen.type	Materialart	HG-Stanzen/Mamma
cnb.specimen.side	Seitenlokalisation	SNOMED CT: 7771000 (Left (qualifier value))
cnb.specimen.clock	Uhrzeigerlokalisation	5 Uhr
cnb.specimen.distance	Abstand von Mamille	5 cm (Details: UCUM codecm = 'cm')
cnb.specimen.length	Gesamtlänge der Stanzzylinder	22 mm (Details: UCUM codemm = 'mm')
cnb.specimen.cylinders	Anzahl Stanzzylinder	2
cnb.specimen.blocks	Anzahl Blöcke	1
cnb.histology	Histologischer Tumortyp
cnb.histology.icdo3	Histologischer Typ ICD-O-3	unknown: 8500/3 (Invasives duktales Karzinom (NST))
cnb.grading	Nottingham-Grading
cnb.grading.grade	Nottingham-Grad	G2
cnb.grading.score	Elston-Ellis Summenscore	6
cnb.grading.tubules	Tubulusbildung	3
cnb.grading.pleomorphism	Kernpleomorphie	2
cnb.grading.mitoses	Mitoserate	1
cnb.biomarkers	Biomarker
cnb.biomarkers.er	Östrogenrezeptor	SNOMED CT: 52101004 (Present (qualifier value))
cnb.biomarkers.er.pct	ER Prozent	85
cnb.biomarkers.pr	Progesteronrezeptor	SNOMED CT: 52101004 (Present (qualifier value))
cnb.biomarkers.pr.pct	PR Prozent	50
cnb.biomarkers.her2	HER2 Amplifikation	Negativ (nicht amplifiziert)
cnb.biomarkers.ki67	Ki-67	10
cnb.bclassification	B-Klassifikation
cnb.bclassification.value	B-Klassifikation (NHSBSP)	B5b
cnb.microcalcification	Mikroverkalkungen
cnb.microcalcification.relevant	Relevante Mikroverkalkungen	SNOMED CT: 2667000 (Absent (qualifier value))
cnb.microcalcification.radiography	Präparateradiogramm	Gesehen
cnb.microcalcification.correlation	Korrelation Mikroverkalkung	Vorliegende Verkalkung radiologisch nicht relevant (kleiner als 100 Mikrometer)
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