Generated Narrative: Composition CoreNeedleBiopsyComposition identifier: Accession ID/PATH-COMP-2025-105 status: Final type: Tissue pathology biopsy report (record artifact) encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_105; status = finished; class = AMB (AMB) date: 2025-01-17 17:00:00+0100 author: Institut für Pathologie title: Histopathologischer Befundbericht - Stanzbiopsie Mamma links Attesters - Mode Party * Legal Organization Institut für Pathologie custodian: Organization Institut für Pathologie Events - Code Detail * pathology report entry task ServiceRequest Breast Pathology biopsy report
Tissue pathology biopsy report (record artifact)
Histopathologischer Befundbericht - Stanzbiopsie Mamma links
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)
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 CoreNeedleBiopsyEncounter identifier: http://example.hospital.de/encounters/E_25_105 status: Finished class: [not stated]: AMB (AMB) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
Generated Narrative: Condition CoreNeedleBiopsyDiagnosisPreOp 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.
Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse
Herdbefund/Architekturstörung linke Brust, BI-RADS 4b. Indikation zur US-gestützten Stanzbiopsie.
Generated Narrative: ServiceRequest CoreNeedleBiopsyReportRequest 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: 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 reasonCode: Mammographic architectural distortion of breast (finding) supportingInfo: 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.
Pathology consultation, comprehensive, records and specimen with report (procedure)
Mammographic architectural distortion of breast (finding)
Generated Narrative: DiagnosticReport CoreNeedleBiopsyImagingReport 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.
BI-RADS 4b: Herdbefund/Architekturstörung linke Brust, 5 Uhr, 5 cm von Mamille. Indikation zur histologischen Abklärung mittels Stanzbiopsie.
Generated Narrative: DiagnosticReport CoreNeedleBiopsyReport 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.
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.
Generated Narrative: Specimen CoreNeedleBiopsySpecimenPart 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) Structure of lower outer quadrant of breast (body structure) Containers - Type Additive[x] * Specimen vial (physical object) Neutral buffered formalin (substance) note: HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.
Specimen from breast obtained by core needle biopsy (specimen)
Structure of lower outer quadrant of breast (body structure)
HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille, US-gestützte Stanzbiopsie. 2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke.
Generated Narrative: Specimen CoreNeedleBiopsySpecimenBlock01 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-01-16 08:00:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Gross examination and sampling of tissue specimen (procedure)
Preparation of formalin fixed paraffin embedded tissue specimen (procedure)
General specimen container (physical object)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideHE01 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) procedure: Sectioning of tissue block (procedure) time: 2025-01-16 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-01-16 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 CoreNeedleBiopsySpecimenSlideHE02 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) procedure: Sectioning of tissue block (procedure) time: 2025-01-16 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-01-16 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideHE03 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) procedure: Sectioning of tissue block (procedure) time: 2025-01-16 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-01-16 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideHE04 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) procedure: Sectioning of tissue block (procedure) time: 2025-01-16 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-01-16 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideER01 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 procedure: Sectioning of tissue block (procedure) time: 2025-01-16 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: 2025-01-16 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Immunohistochemistry procedure (procedure)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideER02 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 procedure: Sectioning of tissue block (procedure) time: 2025-01-16 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: 2025-01-16 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlidePR01 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 procedure: Sectioning of tissue block (procedure) time: 2025-01-16 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: 2025-01-16 10:05:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlidePR02 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 procedure: Sectioning of tissue block (procedure) time: 2025-01-16 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: 2025-01-16 10:05:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideHER2-01 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_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 procedure: Sectioning of tissue block (procedure) 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) procedure: Nucleic acid hybridization procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-01-16 10:30:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
HER2 Bright-field Dual In-Situ Hybridization (B-DISH)
Nucleic acid hybridization procedure (procedure)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideHER2-02 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 procedure: Sectioning of tissue block (procedure) 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) procedure: Nucleic acid hybridization procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-01-16 10:30:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideKi67-01 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_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 procedure: Sectioning of tissue block (procedure) time: 2025-01-16 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: 2025-01-16 10:10:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen CoreNeedleBiopsySpecimenSlideKi67-02 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 procedure: Sectioning of tissue block (procedure) time: 2025-01-16 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: 2025-01-16 10:10:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Observation CoreNeedleBiopsyMacroscopicGrouper 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)'
Structure of lower outer quadrant of left breast (body structure)
Generated Narrative: Observation CoreNeedleBiopsyMacroscopicTotalLength 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)'
Generated Narrative: Observation CoreNeedleBiopsyMacroscopicCylinderCount 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)'
Generated Narrative: Observation CoreNeedleBiopsyMacroscopicBlockCount 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)'
Generated Narrative: Observation CoreNeedleBiopsyDiagnosticConclusionGrouper 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)'
Generated Narrative: Observation CoreNeedleBiopsyHistologicalTypeICDO3 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)'
Infiltrating duct carcinoma (morphologic abnormality)
Generated Narrative: Observation CoreNeedleBiopsyMorphologyFreeText 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)'
Histology type in Cancer specimen Narrative
Generated Narrative: Observation CoreNeedleBiopsyNottinghamGrade 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)
Histologic grade [Score] in Breast cancer specimen by Nottingham
Histologischer Tumorgrad (Elston-Ellis-Grad)
G2: Moderately differentiated histologic grade (qualifier value)
Generated Narrative: Observation CoreNeedleBiopsyNottinghamSummaryScore 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}')
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 CoreNeedleBiopsyERStatus 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
Estrogen receptor Ag [Presence] in Breast cancer specimen by Immune stain
Observation using immunohistochemistry (observable entity)
Generated Narrative: Observation CoreNeedleBiopsyERPercentage 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
Cells.estrogen receptor/cells in Breast cancer specimen by Immune stain
Generated Narrative: Observation CoreNeedleBiopsyPRStatus 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
Progesterone receptor Ag [Presence] in Breast cancer specimen by Immune stain
Generated Narrative: Observation CoreNeedleBiopsyPRPercentage 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
Cells.progesterone receptor/cells in Breast cancer specimen by Immune stain
Generated Narrative: Observation CoreNeedleBiopsyHER2ISH 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
Presence of receptor tyrosine-protein kinase erbB-2 in primary malignant neoplasm of breast by in situ hybridization
Generated Narrative: Observation CoreNeedleBiopsyKi67 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
Cells.Ki-67 nuclear Ag/cells in Breast cancer specimen by Immune stain
Generated Narrative: Observation CoreNeedleBiopsyInterpretation 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)'
Screening interpretation (observable entity)
Generated Narrative: Observation CoreNeedleBiopsyMicrocalcification 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)'
Presence of microcalcification in excised breast specimen (observable entity)
Generated Narrative: Observation CoreNeedleBiopsySpecimenRadiography 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)'
Generated Narrative: Observation CoreNeedleBiopsyMicrocalcificationCorrelation 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)'
Microcalcification, calcified structure (morphologic abnormality)
Vorliegende Verkalkung radiologisch nicht relevant (kleiner als 100 Mikrometer)
Generated Narrative: QuestionnaireResponse QuestionnaireResponseCoreNeedleBiopsy LinkID Text Definition Answer QuestionnaireResponseCoreNeedleBiopsy Questionnaire:http://breastcancerspec.org/Questionnaire/Core-Needle-Biopsy #xD; cnb.root Stanzbiopsie Mamma #xD; cnb.patient Patientendaten #xD; cnb.patient.name Familienname Becker #xD; cnb.patient.given Vorname Sabine #xD; cnb.patient.dob Geburtsdatum 1971-03-15 #xD; cnb.patient.id Patienten-Identifikator PAT-2025-105 #xD; cnb.clinical Klinische Angaben #xD; cnb.clinical.indication Untersuchungsanlass Herdbefund/Architekturstörung linke Brust #xD; cnb.clinical.birads BI-RADS 4b #xD; cnb.clinical.imaging Bildgebungsmodalität Ultraschall #xD; cnb.specimen Untersuchungsmaterial #xD; cnb.specimen.type Materialart HG-Stanzen/Mamma #xD; cnb.specimen.side Seitenlokalisation SNOMED CT: 7771000 (Left (qualifier value)) #xD; cnb.specimen.clock Uhrzeigerlokalisation 5 Uhr #xD; cnb.specimen.distance Abstand von Mamille 5 cm (Details: UCUM codecm = 'cm') #xD; cnb.specimen.length Gesamtlänge der Stanzzylinder 22 mm (Details: UCUM codemm = 'mm') #xD; cnb.specimen.cylinders Anzahl Stanzzylinder 2 #xD; cnb.specimen.blocks Anzahl Blöcke 1 #xD; cnb.histology Histologischer Tumortyp #xD; cnb.histology.icdo3 Histologischer Typ ICD-O-3 unknown: 8500/3 (Invasives duktales Karzinom (NST)) #xD; cnb.grading Nottingham-Grading #xD; cnb.grading.grade Nottingham-Grad G2 #xD; cnb.grading.score Elston-Ellis Summenscore 6 #xD; cnb.grading.tubules Tubulusbildung 3 #xD; cnb.grading.pleomorphism Kernpleomorphie 2 #xD; cnb.grading.mitoses Mitoserate 1 #xD; cnb.biomarkers Biomarker #xD; cnb.biomarkers.er Östrogenrezeptor SNOMED CT: 52101004 (Present (qualifier value)) #xD; cnb.biomarkers.er.pct ER Prozent 85 #xD; cnb.biomarkers.pr Progesteronrezeptor SNOMED CT: 52101004 (Present (qualifier value)) #xD; cnb.biomarkers.pr.pct PR Prozent 50 #xD; cnb.biomarkers.her2 HER2 Amplifikation Negativ (nicht amplifiziert) #xD; cnb.biomarkers.ki67 Ki-67 10 #xD; cnb.bclassification B-Klassifikation #xD; cnb.bclassification.value B-Klassifikation (NHSBSP) B5b #xD; cnb.microcalcification Mikroverkalkungen #xD; cnb.microcalcification.relevant Relevante Mikroverkalkungen SNOMED CT: 2667000 (Absent (qualifier value)) #xD; cnb.microcalcification.radiography Präparateradiogramm Gesehen #xD; cnb.microcalcification.correlation Korrelation Mikroverkalkung Vorliegende Verkalkung radiologisch nicht relevant (kleiner als 100 Mikrometer) #xD; Documentation for this format
Herdbefund/Architekturstörung linke Brust