Document Bundle - Integrierter Bericht (BET + SLN) - 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 - Integrierter Bericht (BET + SLN)

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

Z.n. Stanzbiopsie (E_25_105) mit Nachweis eines invasiven Mammakarzinoms NST, G2. BI-RADS 4b. BET links mit SLN-Biopsie Axilla indiziert. Drahthäkchenmarkierung. Keine neoadjuvante Therapie. Ersterkrankung. Keine bekannte genetische Prädisposition. Präparateradiographie beigelegt. Axilla klinisch unauffällig (cN0).

Material

A) BET-Exzisionspräparat: Mamma links, mit Haut, Drahthäkchen in situ

B) SLN-Exzisat: Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert)

Makroskopie Mamma

Größe	42 × 35 × 18 mm
Gewicht	10 g
Quadrant	Unterer äußerer Quadrant
Zifferblatt	5 Uhr
Abstand Mamille	50 mm
Lamellierung	8 Scheiben à 5 mm
Schnittfläche	Grau-weißlich, derber Herdbefund zentral in Scheibe III–V, ca. 18 mm
Paraffinblöcke	6

Makroskopie Axilla

SLN #1	12 × 8 × 6 mm, Patentblau-markiert, halbiert
SLN #2	10 × 7 × 5 mm, Patentblau-markiert, halbiert
Einbettung	Beide SLN vollständig eingebettet, je 1 Paraffinblock

Schnellschnitt

SLN #1: Tumorfrei im Schnellschnitt. SLN #2: Tumorfrei im Schnellschnitt. → Keine Axilladissektion.

Hinweis: Mikrometastase in SLN #1 erst in den Paraffinschnittstufen nachgewiesen.

Mikroskopie Mamma

Invasives Mammakarzinom des NST (kein spezieller Typ), maximal 18 mm messend. Das Karzinom zeigt ein überwiegend trabekuläres und solides Wachstumsmuster mit mäßiger Kern- und Zellpolymorphie. Mitosen sind vereinzelt nachweisbar (4/10 HPF). In der Tumorperipherie zeigt sich ein begleitendes duktales Carcinoma in situ (DCIS) mit intermediärem Kerngrad und überwiegend kribriformem Wachstumsmuster, maximal 8 mm. Fokale Komedo-Nekrosen. Assoziierte Mikroverkalkungen im DCIS-Areal. Alle Resektionsränder tumorfrei. Mindestabstand invasiv: 5 mm (posterior), DCIS: 3 mm. Keine Lymphgefäßinvasion.

Mikroskopie Axilla

SLN #1: Im Randsinus Nachweis einer Mikrometastase, maximal 1,2 mm messend. Keine Kapseldurchbrechung. SLN #2: In allen Schnittstufen tumorfrei. Kein Anhalt für isolierte Tumorzellen (ITC).

Diagnostische Schlussfolgerung

Diagnose: Invasives Mammakarzinom NST (ICD-O 8500/3), pT1c pN1mi(sn)

ICD-10	C50.5
ICD-O-3 Morphologie	M8500/3
Operatives Verfahren	BET (brusterhaltende Therapie) mit SLN-Biopsie
Seitenlokalisation	Links
Fokalität	Unifokal
Max. Durchmesser invasiv	18 mm
Max. Gesamtdurchmesser	22 mm
Nottingham-Grad	Grad 2 (Score 6: Tubuli 3, Pleomorphie 2, Mitosen 1)
Assoziiertes DCIS	Vorhanden, intermediärer Kerngrad, kribriform, fokale Komedo-Nekrosen
Tumorausdehnung	Auf Brustdrüse beschränkt

Resektionsränder

RR-Status invasiv	Nicht befallen (R0)
Nächster tumorfreier RR	Posterior
Mindestabstand invasiv	5 mm
RR-Status DCIS	Nicht befallen
Mindestabstand DCIS	3 mm

Axilläre Lymphknoten

Prozedur	Sentinel-Lymphknoten-Biopsie
Untersuchte SLN	2
Befallene SLN	1
Untersuchte Non-SLN	0
Befallene Non-SLN	0
Gesamtzahl untersuchter LK	2
Gesamtzahl befallener LK	1
Makrometastasen	0
Mikrometastasen	1
ITC	0
Größte Metastasenausdehnung	1,2 mm
Extranodale Infiltration	Nicht vorhanden

Biomarker

ER	Positiv (90%, stark)
PR	Positiv (60%, mäßig)
HER2 (IHC)	1+
HER2 (ISH)	Nicht amplifiziert
HER2-Gesamtstatus	Negativ
Ki-67	15%

Weitere Befunde

Lymphgefäßinvasion	Nicht nachgewiesen
Mikrokalzifikationen	In DCIS assoziiert

TNM-Staging

pT1c pN1mi(sn)

Kommentar: Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. SLN #1 mit Mikrometastase (1,2 mm), erst in Paraffinschnittstufen nachgewiesen (Schnellschnitt war tumorfrei). Keine extranodale Infiltration. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung.

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/IntegratedEncounter

Resource Encounter:

identifier: http://example.hospital.de/encounters/E_25_300
status: completed
class: IMP
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)

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

Resource Condition:

Profile: MII PR Diagnose Condition version: 2026.0.0
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis
code: Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_300; status = finished; class = IMP (IMP)
onset: 2025-01-15
recordedDate: 2025-02-05
note:
Z.n. Stanzbiopsie (E_25_105) mit Nachweis eines invasiven Mammakarzinoms NST, G2. BI-RADS 4b. BET links mit SLN-Biopsie Axilla indiziert.

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

Resource ServiceRequest:

Profile: MII PR Patho Service Request version: 2026.0.0
identifier: Placer Identifier/PATH-RPT-2025-300
status: Completed
intent: Order
category: Pathology consultation, comprehensive, records and specimen with report (procedure)
code: No display for ServiceRequest.code (concept: Pathology synoptic report)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_300; status = finished; class = IMP (IMP)
requester: Practitioner Thomas Richter
performer: Practitioner Elisabeth Hoffmann
supportingInfo:
No display for ServiceRequest.supportingInfo (reference: ->Condition Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse)
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)')
No display for ServiceRequest.supportingInfo (reference: ->Observation Personal history of primary malignant neoplasm of breast (situation))
No display for ServiceRequest.supportingInfo (reference: ->Observation Cancer treatment --preoperative)
No display for ServiceRequest.supportingInfo (reference: ->Observation Lesion size, largest dimension (observable entity))
No display for ServiceRequest.supportingInfo (reference: ->Observation Insertion of marker into breast using X-ray guidance (procedure))
No display for ServiceRequest.supportingInfo (reference: ->Observation 80865008|Specimen mammography|:363702006|Has focus|=185008008|Medical reports sent|)
No display for ServiceRequest.supportingInfo (reference: ->Observation Diathesis, function (observable entity))
specimen:
Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.

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

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 linke Brust, unterer äußerer Quadrant, 5 Uhr, 5 cm von Mamille. Radiologische Ausdehnung ca. 15 mm. Mammografie und Ultraschall. Klinisch unauffällige Axilla (cN0). Indikation zur BET mit SLN-Biopsie.

Entry 10 - fullUrl = http://breastcancerspec.org/Observation/IntegratedCancerHistory

Resource Observation:

status: Final
code: Brustkrebsvorgeschichte
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
value: Ersterkrankung

Entry 11 - fullUrl = http://breastcancerspec.org/Observation/IntegratedPriorTherapy

Resource Observation:

status: Final
code: Vorchirurgische Therapie bei invasivem Karzinom
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
value: Keine neoadjuvante Therapie

Entry 12 - fullUrl = http://breastcancerspec.org/Observation/IntegratedRadiologicalExtent

Resource Observation:

status: Final
code: Radiologische Ausdehnung
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
value: 15 mm (Details: UCUM codemm = 'mm')

Entry 13 - fullUrl = http://breastcancerspec.org/Observation/IntegratedSpecimenMarking

Resource Observation:

status: Final
code: Befundmarkierung
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
value: Drahthäkchen

Entry 14 - fullUrl = http://breastcancerspec.org/Observation/IntegratedSpecimenRadiographyClinical

Resource Observation:

status: Final
code: Präparateradiographie beigelegt
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
value: Ja, beigelegt

Entry 15 - fullUrl = http://breastcancerspec.org/Observation/IntegratedGeneticPredisposition

Resource Observation:

status: Final
code: Genetische Prädisposition
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
value: Nicht bekannt

Entry 16 - fullUrl = http://breastcancerspec.org/DiagnosticReport/IntegratedReport

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 2025-02-10 14:00:00+0100
Reported 2025-02-10 17:00:00+0100
Performer Practitioner Elisabeth Hoffmann
Identifier Accession ID/E_25_300
Report Details
Code Value Flags When For
Pathology report gross observation Narrative Final 2025-02-06 08:30:00+0100
Pathology report final diagnosis Narrative Final 2025-02-10
Invasives Mammakarzinom NST (ICD-O 8500/3), pT1c pN1mi(sn), Nottingham Grad 2 (Score 6: Tubuli 3, Kernpleomorphie 2, Mitosen 1). Begleitendes DCIS, intermediärer Kerngrad, kribriform, fokale Komedo-Nekrosen. Alle Resektionsränder tumorfrei (invasiv 5 mm, DCIS 3 mm). Keine LVI. ER+ (90%), PR+ (60%), HER2 1+ (nicht amplifiziert), Ki-67 15%. SLN 1/2 befallen (Mikrometastase 1,2 mm in SLN #1), keine extranodale Infiltration.

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

Resource Specimen:

Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0
identifier: Placer Identifier/OP25_300_A, Filler Identifier/E_25_300_A
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
status: Available
type: Specimen from breast obtained by excision (specimen)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
request: ServiceRequest Pathology synoptic report
Collections
- Collector Collected[x] Method BodySite
* Practitioner Thomas Richter 2025-02-05 10:00:00+0100 Wide local excision of breast lesion (procedure) No display for Specimen.collection.bodySite (concept: Structure of lower outer quadrant of breast (body structure))
container
note:
BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.

Entry 18 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSpecimenBlock01

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_300_A_1
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
Collections
- Collected[x] Method
* 2025-02-06 08:00:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe III 2025-02-06 08:00:00+0100
container

Entry 19 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSpecimenBlock02

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_300_A_2
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
Collections
- Collected[x] Method
* 2025-02-06 08:10:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe V 2025-02-06 08:10:00+0100
container

Entry 20 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSpecimenBlock03

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_300_A_3
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
Collections
- Collected[x] Method
* 2025-02-06 08:20:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung - RR superior 2025-02-06 08:20:00+0100
container

Entry 21 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSpecimenBlock04

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_300_A_4
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
Collections
- Collected[x] Method
* 2025-02-06 08:30:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung - RR inferior 2025-02-06 08:30:00+0100
container

Entry 22 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSpecimenBlock05

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_300_A_5
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
Collections
- Collected[x] Method
* 2025-02-06 08:40:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung - RR medial, Scheibe I 2025-02-06 08:40:00+0100
container

Entry 23 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSpecimenBlock06

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_300_A_6
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
Collections
- Collected[x] Method
* 2025-02-06 08:50:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung - RR lateral, Scheibe VIII 2025-02-06 08:50:00+0100
container

Entry 24 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideHE01

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_300_A_1_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 1)
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 25 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideHE02

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_300_A_1_1_HE_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 2)
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 26 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideER01

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_300_A_1_1_ER_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: ER-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-02-06 10:00:00+0100
container

Entry 27 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlidePR01

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_300_A_1_1_PR_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: PR-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-02-06 10:00:00+0100
container

Entry 28 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideHER2IHC01

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_300_A_1_1_HER2_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HER2-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-02-06 10:00:00+0100
container

Entry 29 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideKi67-01

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_300_A_1_1_Ki67_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Ki-67-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-02-06 10:00:00+0100
container

Entry 30 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideCK18-01

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_300_A_1_1_CK18_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: CK18-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-02-06 10:00:00+0100
container

Entry 31 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlidep40-01

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_300_A_1_1_p40_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: p40-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-02-06 10:00:00+0100
container

Entry 32 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideECad-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_300_A_1_1_ECad_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:30:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:30:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: E-Cadherin-Immunhistochemie
additive: Substance Tissue stain (substance)
time: 2025-02-06 10:00:00+0100
container

Entry 33 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideBlock02-HE01

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_300_A_2_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 1)
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 34 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideBlock02-HE02

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_300_A_2_1_HE_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 2)
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 35 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideRR-Superior-HE01

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_300_A_3_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_3; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 36 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideRR-Inferior-HE01

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_300_A_4_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_4; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 37 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideRR-Medial-HE01

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_300_A_5_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_5; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 38 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedBETSlideRR-Lateral-HE01

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_300_A_6_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_A_6; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 39 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedSLNSpecimenPart

Resource Specimen:

Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0
identifier: Placer Identifier/OP25_300_B, Filler Identifier/E_25_300_B
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
status: Available
type: Lymph node specimen (specimen)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
request: ServiceRequest Pathology synoptic report
Collections
- Collector Collected[x] Method BodySite
* Practitioner Thomas Richter 2025-02-05 10:30:00+0100 Sentinel lymph node biopsy (procedure) No display for Specimen.collection.bodySite (concept: Axillary lymph node structure (body structure))
container
note:
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Entry 40 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedSLNSpecimenBlock01

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_300_B_1
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
Collections
- Collected[x] Method
* 2025-02-06 08:00:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung - SLN #1 (halbiert) 2025-02-06 08:00:00+0100
container

Entry 41 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedSLNSpecimenBlock02

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_300_B_2
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
Collections
- Collected[x] Method
* 2025-02-06 08:10:00+0100 Gross examination and sampling of tissue specimen (procedure)
Processings
- Extension Description Time[x]
* Zuschnitt und Paraffineinbettung - SLN #2 (halbiert) 2025-02-06 08:10:00+0100
container

Entry 42 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedSLNSlideHE01

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_300_B_1_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_B_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 1)
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 43 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedSLNSlideHE02

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_300_B_1_1_HE_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_B_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 2)
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 44 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedSLNSlideHE03

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_300_B_2_1_HE_01
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_B_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 1)
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 45 - fullUrl = http://breastcancerspec.org/Specimen/IntegratedSLNSlideHE04

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_300_B_2_1_HE_02
accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_300
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_300_B_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
Collections
- Collected[x] Method
* 2025-02-06 09:00:00+0100 Tissue processing technique (procedure)
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: Schnittherstellung (Schnittstufe 2)
time: 2025-02-06 09:00:00+0100
processing
MII EX Biobank Temperaturbedingungen: 20-25 °C
description: HE-Färbung
time: 2025-02-06 09:15:00+0100
container

Entry 46 - fullUrl = http://breastcancerspec.org/Substance/IntegratedSubstanceER

Resource Substance:

Profile: MII PR Biobank Substance Additiv version: 2026.0.0
status: Active
category: Chemical
code: No display for Substance.code (concept: Tissue stain (substance))
description:
Estrogen Receptor (Dako Omnis)

Entry 47 - fullUrl = http://breastcancerspec.org/Substance/IntegratedSubstancePR

Resource Substance:

Profile: MII PR Biobank Substance Additiv version: 2026.0.0
status: Active
category: Chemical
code: No display for Substance.code (concept: Tissue stain (substance))
description:
Progesterone Receptor (Dako Omnis)

Entry 48 - fullUrl = http://breastcancerspec.org/Substance/IntegratedSubstanceHER2IHC

Resource Substance:

Profile: MII PR Biobank Substance Additiv version: 2026.0.0
status: Active
category: Chemical
code: No display for Substance.code (concept: Tissue stain (substance))
description:
VENTANA HER2 (4B5), Roche

Entry 49 - fullUrl = http://breastcancerspec.org/Substance/IntegratedSubstanceKi67

Resource Substance:

Profile: MII PR Biobank Substance Additiv version: 2026.0.0
status: Active
category: Chemical
code: No display for Substance.code (concept: Tissue stain (substance))
description:
Ki-67 Antigen (Dako Omnis)

Entry 50 - fullUrl = http://breastcancerspec.org/Substance/IntegratedSubstanceCK18

Resource Substance:

Profile: MII PR Biobank Substance Additiv version: 2026.0.0
status: Active
category: Chemical
code: No display for Substance.code (concept: Tissue stain (substance))
description:
Cytokeratin 18 (DC10), Dako Omnis

Entry 51 - fullUrl = http://breastcancerspec.org/Substance/IntegratedSubstancep40

Resource Substance:

Profile: MII PR Biobank Substance Additiv version: 2026.0.0
status: Active
category: Chemical
code: No display for Substance.code (concept: Tissue stain (substance))
description:
p40 (BC28), Biocare Medical

Entry 52 - fullUrl = http://breastcancerspec.org/Substance/IntegratedSubstanceECadherin

Resource Substance:

Profile: MII PR Biobank Substance Additiv version: 2026.0.0
status: Active
category: Chemical
code: No display for Substance.code (concept: Tissue stain (substance))
description:
E-Cadherin (NCH-38), Dako Omnis

Entry 53 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroscopicGrouper

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: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
hasMember:
Observation Specimen size.maximum dimension in Breast tumor
Observation Specimen size additional dimension 1 in Breast tumor
Observation Specimen size additional dimension 2 in Breast tumor
Observation Specimen wt Tiss Qn
Observation Quadrant Breast
Observation Radial position in breast [Angle] in Breast cancer specimen
Observation Distance of primary malignant neoplasm of breast to nipple in excised breast specimen (observable entity)
Observation Number of paraffin embedded tissue blocks examined from excised specimen (observable entity)
Observation Length of tissue core(s)
Observation Length of tissue core(s)
derivedFrom:
Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 54 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroLength

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: ProbeGröße1
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 42 mm (Details: UCUM codemm = 'mm')
bodySite: Breast structure (body structure)
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 55 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroWidth

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: ProbeGröße2
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 35 mm (Details: UCUM codemm = 'mm')
bodySite: Breast structure (body structure)
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 56 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroDepth

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: ProbeGröße3
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 18 mm (Details: UCUM codemm = 'mm')
bodySite: Breast structure (body structure)
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 57 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroWeight

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: Gewicht der Probe
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 10 g (Details: UCUM codeg = 'g')
bodySite: Breast structure (body structure)
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 58 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroQuadrant

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: Quadrantenlokalisaion
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: Unterer äußerer Quadrant
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 59 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroClock

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: Zifferblattlokalisation
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 5 o'clock (Details: UCUM code{clock position} = '{clock position}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 60 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroDistanceNipple

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: Abstand von der Mamille
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 50 mm (Details: UCUM codemm = 'mm')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 61 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroBlockCount

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: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 6 Blöcke (Details: UCUM code{blocks} = '{blocks}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 62 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroSLN1Size

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: SLN #1 Größe
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 12 x 8 x 6 mm, Patentblau-markiert
bodySite: Axillary lymph node structure (body structure)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_B_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 63 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroSLN2Size

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
status: Final
category: Laboratory, Pathology report gross observation Narrative
code: SLN #2 Größe
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-06 08:30:00+0100
performer: Practitioner Elisabeth Hoffmann
value: 10 x 7 x 5 mm, Patentblau-markiert
bodySite: Axillary lymph node structure (body structure)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_B_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue block specimen (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 64 - fullUrl = http://breastcancerspec.org/Observation/IntegratedDiagnosticConclusionGrouper

Resource Observation:

Profile: MII PR Patho Diagnostic Conclusion Grouper version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory
code: Pathology report final diagnosis Narrative
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
hasMember:
Observation Surgery procedure
Observation Specimen type
Observation Specimen laterality (observable entity)
Observation Body structure included in specimen [Anatomy] in Specimen
Observation Qualitative distribution of primary malignant neoplasm of breast in excised breast specimen (observable entity)
Observation Inv comp size max dim BT
Observation Size.maximum dimension in Tumor
Observation Histo type BT
Observation Histology type in Cancer specimen Narrative
Observation Histologic grade [Score] in Breast cancer specimen by Nottingham
Observation Glandular differentiation [Score] in Breast cancer specimen by Nottingham
Observation Nuclear pleomorphism in Breast tumor by Nottingham
Observation Number of mitoses per 10 high power fields (observable entity)
Observation Mitotic rate [Score] in Breast cancer specimen by Nottingham
Observation Nottingham total score of primary malignant neoplasm of breast (observable entity)
Observation DCIS intraduct ext Br ca spec Ql Micro
Observation Nuclear grade of ductal carcinoma in situ of breast (observable entity)
Observation Growth pattern of DCIS [Type] in Breast cancer specimen by Light microscopy
Observation DCIS necrosis [Type] in Breast cancer specimen by Light microscopy
Observation Adjacent structure invaded by tumor [Anatomy] in Breast cancer specimen by Light microscopy
Observation Margin involved BT
Observation IC uninv marg closest BT
Observation IC uninv marg dist closest BT
Observation Surgical margin DCIS involvement [Presence] in Breast cancer specimen by Light microscopy
Observation DCIS.uninv marg dist.closest BT
Observation Lymph-vascular invasion Ca spec
Observation Presence of microcalcification in excised breast specimen (observable entity)
Observation Estrogen receptor [Interpretation] in Tissue
Observation Cells.estrogen receptor/cells in Breast cancer specimen by Immune stain
Observation Estrogen receptor fluorescence intensity [Type] in Breast cancer specimen by Immune stain
Observation Progesterone receptor [Interpretation] in Tissue
Observation Cells.progesterone receptor/cells in Breast cancer specimen by Immune stain
Observation Progesterone receptor fluorescence intensity [Type] in Breast cancer specimen by Immune stain
Observation HER2 [Presence] in Breast cancer specimen by Immune stain
Observation ERBB2 gene duplication [Presence] in Breast cancer specimen by FISH
Observation HER2 [Interpretation] in Tissue
Observation Cells.Ki-67 nuclear Ag/cells in Breast cancer specimen by Immune stain
Observation pT category (observable entity)
Observation Pathology report comments [Interpretation] Narrative
Observation Surgery procedure for regional nodes at facility.YYY Cancer
Observation Anatomic part Laterality
Observation Regional lymph nodes examined [#] Specimen
Observation Regional lymph nodes positive [#] Specimen
Observation Sentinel lymph nodes examined [#] in Cancer specimen by Light microscopy
Observation Number of sentinel lymph nodes containing metastatic neoplasm in excised specimen (observable entity)
Observation Lymph nodes examined [#] in Cancer specimen by Light microscopy
Observation Lymph nodes with metastasis [#] in Cancer specimen
Observation Lymph nodes with macrometastases [#] in Cancer specimen by Light microscopy
Observation Lymph nodes with micrometastases [#] in Cancer specimen by Light microscopy
Observation Lymph nodes with isolated tumor cells [#] in Cancer specimen by Light microscopy
Observation Lymph node metastatic deposit.max dimension [Length] in Cancer specimen by Light microscopy
Observation Extranodal extension of carcinoma [Presence] in Cancer specimen by Light microscopy
Observation pN category (observable entity)
Observation Pathology report comments [Interpretation] Narrative
derivedFrom:
Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 65 - fullUrl = http://breastcancerspec.org/Observation/IntegratedOperativeProcedure

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Operatives Verfahren
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Brusterhaltende Therapie (BET)
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 66 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMaterialType

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Materialart
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Exzisionspräparat
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 67 - fullUrl = http://breastcancerspec.org/Observation/IntegratedLaterality

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Seitenlokalisation der Probe
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Links
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 68 - fullUrl = http://breastcancerspec.org/Observation/IntegratedAttachedTissue

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Material/anhängendes Gewebe
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Haut
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Specimen from breast obtained by excision (specimen); note = BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 42 × 35 × 18 mm, 10 g. Haut anhängend, Drahthäkchen in situ. Lamellierung in 8 Scheiben à 5 mm. Schnittfläche: grau-weißlicher Herdbefund zentral in Scheibe III–V, ca. 18 mm.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 69 - fullUrl = http://breastcancerspec.org/Observation/IntegratedFocality

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: (Multi)fokalität
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Unifokal
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 70 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMaxDiameterInvasive

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Maximaler Durchmesser invasives Karzinom
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 18 mm (Details: UCUM codemm = 'mm')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 71 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMaxOverallDiameter

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Maximaler Gesamtdurchmesser der Läsion
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 22 mm (Details: UCUM codemm = 'mm')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 72 - fullUrl = http://breastcancerspec.org/Observation/IntegratedHistologicalType

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Histologischer Tumortyp WHO
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Invasives duktales Karzinom (NST)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 73 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMorphologyFreeText

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Morphologie Freitext
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Invasives Mammakarzinom des NST (kein spezieller Typ), maximal 18 mm messend. Das Karzinom zeigt ein überwiegend trabekuläres und solides Wachstumsmuster mit mäßiger Kern- und Zellpolymorphie. Mitosen sind vereinzelt nachweisbar (4/10 HPF). In der Tumorperipherie zeigt sich ein begleitendes duktales Carcinoma in situ (DCIS) mit intermediärem Kerngrad und überwiegend kribriformem Wachstumsmuster, maximal 8 mm. Fokale Komedo-Nekrosen. Assoziierte Mikroverkalkungen im DCIS-Areal. Alle Resektionsränder tumorfrei. Mindestabstand invasiv: 5 mm (posterior), DCIS: 3 mm. Keine Lymphgefäßinvasion.
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 74 - fullUrl = http://breastcancerspec.org/Observation/IntegratedNottinghamGrade

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Histologischer Tumorgrad (Elston-Ellis-Grad)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Nottingham Grad 2 (Score 6)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 75 - fullUrl = http://breastcancerspec.org/Observation/IntegratedTubuleScore

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Tubulus Scorewert
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 3 score (Details: UCUM code{score} = '{score}')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 76 - fullUrl = http://breastcancerspec.org/Observation/IntegratedNuclearPleomorphism

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Kernpleomorphie Scorewert
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 2 score (Details: UCUM code{score} = '{score}')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 77 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMitosisCount

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Mitosezahl
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 4 per 10 HPF (Details: UCUM code{HPF} = '{HPF}')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 78 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMitoticRateScore

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Mitoserate Scorewert
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 1 score (Details: UCUM code{score} = '{score}')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 79 - fullUrl = http://breastcancerspec.org/Observation/IntegratedElstonEllisScore

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Elston-Ellis-Summenscore
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 6 score (Details: UCUM code{score} = '{score}')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 80 - fullUrl = http://breastcancerspec.org/Observation/IntegratedAssociatedDCIS

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Klassifikation eines assoziiertes DCIS
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: DCIS vorhanden
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 81 - fullUrl = http://breastcancerspec.org/Observation/IntegratedDCISGrade

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Kerngrading / WHO-Grading nichtinvasiv
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Intermediär (Grad 2)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 82 - fullUrl = http://breastcancerspec.org/Observation/IntegratedDCISArchitecture

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: DCIS Architektur
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: kribriformer Typ
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 83 - fullUrl = http://breastcancerspec.org/Observation/IntegratedDCISNecrosis

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Nekrosen
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Fokal (Komedo-Nekrosen)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 84 - fullUrl = http://breastcancerspec.org/Observation/IntegratedTumorExtent

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Tumorausdehnung
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Auf Brustdrüse beschränkt
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 85 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMarginStatusInvasive

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Resektionsrandstatus invasiv
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Nicht befallen (R0)
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_3_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 86 - fullUrl = http://breastcancerspec.org/Observation/IntegratedClosestMargin

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Richtung des nächsten tumorfreien RR
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Posterior
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_3_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 87 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMinDistanceInvasive

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Mindestabstand des invasiven Tumor zum nächstgelegenen Resektionsrand
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 5 mm (Details: UCUM codemm = 'mm')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_3_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 88 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMarginStatusNonInvasive

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Resektionsrandstatus nichtinvasiv
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Nicht befallen
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_3_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 89 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMinDistanceNonInvasive

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Mindestabstand vom RR zum nichtinvasiven Tumor
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 3 mm (Details: UCUM codemm = 'mm')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_3_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 90 - fullUrl = http://breastcancerspec.org/Observation/IntegratedLVI

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Peritumorale Gefäßinvasion
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Nicht nachgewiesen
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 91 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMicrocalcification

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Presence of microcalcification in excised breast specimen (observable entity)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Microcalcifications present in DCIS
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 92 - fullUrl = http://breastcancerspec.org/Observation/IntegratedERStatus

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Hormonrezeptorstatus Östrogen
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Positiv
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_ER_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 93 - fullUrl = http://breastcancerspec.org/Observation/IntegratedERPercentage

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: PP ER
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 90 % (Details: UCUM code% = '%')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_ER_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 94 - fullUrl = http://breastcancerspec.org/Observation/IntegratedERIntensity

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Färbeintensität ER
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Stark
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_ER_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 95 - fullUrl = http://breastcancerspec.org/Observation/IntegratedPRStatus

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Hormonrezeptorstatus Progesteron
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Positiv
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_PR_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 96 - fullUrl = http://breastcancerspec.org/Observation/IntegratedPRPercentage

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: PP PR
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 60 % (Details: UCUM code% = '%')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_PR_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 97 - fullUrl = http://breastcancerspec.org/Observation/IntegratedPRIntensity

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Färbeintensität PR
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Mäßig
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_PR_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 98 - fullUrl = http://breastcancerspec.org/Observation/IntegratedHER2IHC

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Her2 Score
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 1+
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HER2_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 99 - fullUrl = http://breastcancerspec.org/Observation/IntegratedHER2ISH

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Her2 Amplifikation
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Nicht amplifiziert
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HER2_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 100 - fullUrl = http://breastcancerspec.org/Observation/IntegratedHER2Overall

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Her2neuStatus
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Negativ
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_HER2_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 101 - fullUrl = http://breastcancerspec.org/Observation/IntegratedKi67

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Ki67-Index
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 15 % (Details: UCUM code% = '%')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_A_1_1_Ki67_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' 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 102 - fullUrl = http://breastcancerspec.org/Observation/IntegratedPT

Resource Observation:

Profile: MII PR Onkologie TNM T-Kategorie version: 2026.0.0
status: Final
code: pT category (observable entity)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
value: T1
method: 8. Auflage

Entry 103 - fullUrl = http://breastcancerspec.org/Observation/IntegratedBETComment

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Kommentar
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_Mamma_GH' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 104 - fullUrl = http://breastcancerspec.org/Observation/IntegratedLymphNodeProcedure

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: LK OP Prozedur
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Sentinel-Lymphknoten-Biopsie
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 105 - fullUrl = http://breastcancerspec.org/Observation/IntegratedLymphNodeLaterality

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Seitenangabe
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Links
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 106 - fullUrl = http://breastcancerspec.org/Observation/IntegratedNonSLNExamined

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Anzahl untersuchter Non-SLN-axillärer LK
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 0 {count} (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 107 - fullUrl = http://breastcancerspec.org/Observation/IntegratedNonSLNPositive

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Anzahl befallener Non-SLN-axillärer LK
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 0 {count} (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 108 - fullUrl = http://breastcancerspec.org/Observation/IntegratedSLNExamined

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Anzahl untersuchter Sentinel-LK
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 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_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 109 - fullUrl = http://breastcancerspec.org/Observation/IntegratedSLNPositive

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Anzahl befallener Sentinel-LK
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 1 {count} (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 110 - fullUrl = http://breastcancerspec.org/Observation/IntegratedTotalExamined

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Gesamtzahl untersuchter Lymphknoten
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 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_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 111 - fullUrl = http://breastcancerspec.org/Observation/IntegratedTotalPositive

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Gesamtzahl befallener Lymphknoten
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 1 {count} (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 112 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMacroMetCount

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Gesamtzahl makrometastatisch befallener LK
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 0 {count} (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 113 - fullUrl = http://breastcancerspec.org/Observation/IntegratedMicroMetCount

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Gesamtzahl mikrometastatisch befallener LK
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 1 {count} (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 114 - fullUrl = http://breastcancerspec.org/Observation/IntegratedITCCount

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Gesamtzahl ausschließlich ITC-befallener LK
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 0 {count} (Details: UCUM code{count} = '{count}')
specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Lymph node specimen (specimen); note = Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert). SLN #1: 12 x 8 x 6 mm, SLN #2: 10 x 7 x 5 mm. Beide halbiert und vollständig eingebettet.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 115 - fullUrl = http://breastcancerspec.org/Observation/IntegratedLargestMetSize

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Ausdehnung der größten metastatischen Infiltration
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: 1.2 mm (Details: UCUM codemm = 'mm')
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_B_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 116 - fullUrl = http://breastcancerspec.org/Observation/IntegratedExtranodalExtension

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Extranodale Infiltration durch LK-Metastase
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: Nicht vorhanden
specimen: Specimen: identifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300_B_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_300; status = available; type = Tissue section (specimen)
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 117 - fullUrl = http://breastcancerspec.org/Observation/IntegratedPN

Resource Observation:

Profile: MII PR Onkologie TNM N-Kategorie version: 2026.0.0
status: Final
code: pN category (observable entity)
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
value: N1mi(sn)
method: 8. Auflage

Entry 118 - fullUrl = http://breastcancerspec.org/Observation/IntegratedSLNComment

Resource Observation:

Profile: MII PR Patho Finding version: 2026.0.0
basedOn: ServiceRequest Pathology synoptic report
status: Final
category: Laboratory, Pathology report final diagnosis Narrative
code: Kommentar
subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
effective: 2025-02-10
performer: Practitioner Elisabeth Hoffmann
value: In SLN #1 Nachweis einer Mikrometastase (1,2 mm) im Randsinus. SLN #2 tumorfrei in allen Schnittstufen. Keine extranodale Infiltration. Klassifikation: pN1mi(sn). Empfehlung: Besprechung in Tumorkonferenz bzgl. weiterer axillärer Therapie.
derivedFrom: Response to Questionnaire 'http://breastcancerspec.org/Questionnaire/OP_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'

Entry 119 - fullUrl = http://breastcancerspec.org/QuestionnaireResponse/IntegratedQRBreastResection

Resource QuestionnaireResponse:

LinkID Text Definition Answer
IntegratedQRBreastResection Questionnaire:http://breastcancerspec.org/Questionnaire/OP_Mamma_GH

bet.root BET Mamma

bet.clinical Klinische Angaben

11951 Proben limitiert auswertbar SNOMED CT: 373067005 (No (qualifier value))

11912 Präsentationsmodus Frisch

11147 Klinische Befunde / Anlass Z.n. Stanzbiopsie mit Nachweis eines invasiven Mammakarzinoms NST, G2

11923 Brustkrebsvorgeschichte Ersterkrankung

11952 Vorchirurgische Therapie SNOMED CT: 373067005 (No (qualifier value))

11918 Bildgebungsmodalität Mammografie, Ultraschall

11953 Radiologische Ausdehnung 15 mm (Details: UCUM codemm = 'mm')

10160 Befundmarkierung Drahthäkchen

10130 Präparateradiographie Ja, beigelegt

11954 Genetische Prädisposition Nicht bekannt

bet.macro Makroskopie

10900 Probengröße 1 (Länge) 65 mm (Details: UCUM codemm = 'mm')

10910 Probengröße 2 (Breite) 45 mm (Details: UCUM codemm = 'mm')

10920 Probengröße 3 (Tiefe) 30 mm (Details: UCUM codemm = 'mm')

10890 Gewicht 55 g (Details: UCUM codeg = 'g')

10030 Quadrant SNOMED CT: 33564002 (Structure of lower outer quadrant of breast (body structure))

10040 Zifferblattlokalisation 5 Uhr

10070 Abstand Mamille 50 mm (Details: UCUM codemm = 'mm')

bet.general Allgemeine Befunde

11130 Nichtinvasive Läsion SNOMED CT: 52101004 (Present (qualifier value))

11270 Invasives Karzinom SNOMED CT: 52101004 (Present (qualifier value))

11919 Operatives Verfahren SNOMED CT: 237371007 (Wide local excision of breast lesion (procedure))

10140 Materialart Exzisionspräparat

10800 Seitenlokalisation SNOMED CT: 7771000 (Left (qualifier value))

11040 Anhängendes Gewebe Haut

11440 Fokalität Unifokal

bet.invasive Invasives Karzinom

11400 Max Durchmesser invasiv 18 mm (Details: UCUM codemm = 'mm')

11420 Max Gesamtdurchmesser 22 mm (Details: UCUM codemm = 'mm')

11280 Histologischer Tumortyp unknown: 8500/3 (Invasives duktales Karzinom (NST))

11290 Morphologie Freitext Invasives Mammakarzinom des NST, überwiegend trabekuläres und solides Wachstumsmuster

11330 Nottingham-Grad G2

11340 Tubulus-Score 3

11350 Kernpleomorphie-Score 2

11925 Mitosezahl 4/10 HPF

11360 Mitoserate-Score 1

11390 Elston-Ellis-Summenscore 6

11300 Assoziiertes DCIS SNOMED CT: 52101004 (Present (qualifier value))

149 DCIS Kerngrading Intermediär (Grad 2)

150 DCIS Architektur Kribriform

151 DCIS Nekrosen Fokal (Komedo-Nekrosen)

11926 Tumorausdehnung Auf Brustdrüse beschränkt

bet.margins Resektionsränder

11470 RR-Status invasiv SNOMED CT: 2667000 (Absent (qualifier value))

11490 Nächster tumorfreier RR Posterior

11480 Mindestabstand invasiv 5 mm (Details: UCUM codemm = 'mm')

11968 RR-Status nichtinvasiv SNOMED CT: 2667000 (Absent (qualifier value))

11970 Mindestabstand nichtinvasiv 3 mm (Details: UCUM codemm = 'mm')

bet.additional Weitere Befunde

11430 LVI SNOMED CT: 2667000 (Absent (qualifier value))

10880 Mikrokalzifikationen In DCIS assoziiert

bet.biomarkers Biomarker

11750 ER-Status SNOMED CT: 52101004 (Present (qualifier value))

11720 ER Prozent 90

11730 ER Färbeintensität Stark

11790 PR-Status SNOMED CT: 52101004 (Present (qualifier value))

11760 PR Prozent 60

11770 PR Färbeintensität Mäßig

11810 HER2-Score (IHC) 1+

11820 HER2-Amplifikation (ISH) Nicht amplifiziert

11830 HER2-Gesamtstatus Negativ

11840 Ki-67-Index 15

bet.tnm TNM

169 pT-Kategorie pT1c

bet.comment Kommentar

11900 Kommentar Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung.

Documentation for this format

Entry 120 - fullUrl = http://breastcancerspec.org/QuestionnaireResponse/IntegratedQRLymphNode

Resource QuestionnaireResponse:

LinkID Text Definition Answer
IntegratedQRLymphNode Questionnaire:http://breastcancerspec.org/Questionnaire/OP_LN-Mamma

sln.root SLN-Biopsie Axilla

sln.clinical Klinische Angaben

11951 Proben limitiert auswertbar SNOMED CT: 373067005 (No (qualifier value))

11950 LK-Biopsie veranlassende klinische/bildgebende Befunde Invasives Mammakarzinom NST links, cN0

11148 Bildgebende Befunde Mammografie, Sonographie: Axilla klinisch unauffällig

10210 Neoadjuvante Therapie SNOMED CT: 373067005 (No (qualifier value))

sln.macro Makroskopie

sln.macro.sln1 SLN #1 Größe 12 x 8 x 6 mm, Patentblau-markiert

sln.macro.sln2 SLN #2 Größe 10 x 7 x 5 mm, Patentblau-markiert

sln.findings Axilläre Lymphknotenpräparate

11540 LK OP Prozedur SNOMED CT: 396487001 (Sentinel lymph node biopsy (procedure))

11620 Seitenangabe SNOMED CT: 7771000 (Left (qualifier value))

11630 Anzahl der untersuchten (nonSLN)-axillären LK 0

11640 Anzahl der befallenen (nonSLN)-axillären LK 0

11650 Anzahl der untersuchten Sentinel-LK 2

11660 Anzahl der befallenen Sentinel-LK 1

11944 Gesamtzahl untersuchter Lymphknoten 2

11945 Gesamtzahl befallener Lymphknoten 1

11947 Gesamtzahl makrometastatisch befallener Lymphknoten 0

11948 Gesamtzahl mikrometastatisch befallener Lymphknoten 1

11946 Gesamtzahl ausschließlich ITC-befallener Lymphknoten 0

11690 Ausdehnung der größten metastatischen Infiltration 1.2 mm (Details: UCUM codemm = 'mm')

11700 Extranodale Infiltration durch LK-Metastase SNOMED CT: 2667000 (Absent (qualifier value))

sln.tnm Pathologisches TNM-Staging

175 Regionäre Lymphknoten (pN-Kategorie) pN1mi(sn)

Documentation for this format

LinkID	Text	Answer
IntegratedQRBreastResection		Questionnaire:http://breastcancerspec.org/Questionnaire/OP_Mamma_GH
bet.root	BET Mamma
bet.clinical	Klinische Angaben
11951	Proben limitiert auswertbar	SNOMED CT: 373067005 (No (qualifier value))
11912	Präsentationsmodus	Frisch
11147	Klinische Befunde / Anlass	Z.n. Stanzbiopsie mit Nachweis eines invasiven Mammakarzinoms NST, G2
11923	Brustkrebsvorgeschichte	Ersterkrankung
11952	Vorchirurgische Therapie	SNOMED CT: 373067005 (No (qualifier value))
11918	Bildgebungsmodalität	Mammografie, Ultraschall
11953	Radiologische Ausdehnung	15 mm (Details: UCUM codemm = 'mm')
10160	Befundmarkierung	Drahthäkchen
10130	Präparateradiographie	Ja, beigelegt
11954	Genetische Prädisposition	Nicht bekannt
bet.macro	Makroskopie
10900	Probengröße 1 (Länge)	65 mm (Details: UCUM codemm = 'mm')
10910	Probengröße 2 (Breite)	45 mm (Details: UCUM codemm = 'mm')
10920	Probengröße 3 (Tiefe)	30 mm (Details: UCUM codemm = 'mm')
10890	Gewicht	55 g (Details: UCUM codeg = 'g')
10030	Quadrant	SNOMED CT: 33564002 (Structure of lower outer quadrant of breast (body structure))
10040	Zifferblattlokalisation	5 Uhr
10070	Abstand Mamille	50 mm (Details: UCUM codemm = 'mm')
bet.general	Allgemeine Befunde
11130	Nichtinvasive Läsion	SNOMED CT: 52101004 (Present (qualifier value))
11270	Invasives Karzinom	SNOMED CT: 52101004 (Present (qualifier value))
11919	Operatives Verfahren	SNOMED CT: 237371007 (Wide local excision of breast lesion (procedure))
10140	Materialart	Exzisionspräparat
10800	Seitenlokalisation	SNOMED CT: 7771000 (Left (qualifier value))
11040	Anhängendes Gewebe	Haut
11440	Fokalität	Unifokal
bet.invasive	Invasives Karzinom
11400	Max Durchmesser invasiv	18 mm (Details: UCUM codemm = 'mm')
11420	Max Gesamtdurchmesser	22 mm (Details: UCUM codemm = 'mm')
11280	Histologischer Tumortyp	unknown: 8500/3 (Invasives duktales Karzinom (NST))
11290	Morphologie Freitext	Invasives Mammakarzinom des NST, überwiegend trabekuläres und solides Wachstumsmuster
11330	Nottingham-Grad	G2
11340	Tubulus-Score	3
11350	Kernpleomorphie-Score	2
11925	Mitosezahl	4/10 HPF
11360	Mitoserate-Score	1
11390	Elston-Ellis-Summenscore	6
11300	Assoziiertes DCIS	SNOMED CT: 52101004 (Present (qualifier value))
149	DCIS Kerngrading	Intermediär (Grad 2)
150	DCIS Architektur	Kribriform
151	DCIS Nekrosen	Fokal (Komedo-Nekrosen)
11926	Tumorausdehnung	Auf Brustdrüse beschränkt
bet.margins	Resektionsränder
11470	RR-Status invasiv	SNOMED CT: 2667000 (Absent (qualifier value))
11490	Nächster tumorfreier RR	Posterior
11480	Mindestabstand invasiv	5 mm (Details: UCUM codemm = 'mm')
11968	RR-Status nichtinvasiv	SNOMED CT: 2667000 (Absent (qualifier value))
11970	Mindestabstand nichtinvasiv	3 mm (Details: UCUM codemm = 'mm')
bet.additional	Weitere Befunde
11430	LVI	SNOMED CT: 2667000 (Absent (qualifier value))
10880	Mikrokalzifikationen	In DCIS assoziiert
bet.biomarkers	Biomarker
11750	ER-Status	SNOMED CT: 52101004 (Present (qualifier value))
11720	ER Prozent	90
11730	ER Färbeintensität	Stark
11790	PR-Status	SNOMED CT: 52101004 (Present (qualifier value))
11760	PR Prozent	60
11770	PR Färbeintensität	Mäßig
11810	HER2-Score (IHC)	1+
11820	HER2-Amplifikation (ISH)	Nicht amplifiziert
11830	HER2-Gesamtstatus	Negativ
11840	Ki-67-Index	15
bet.tnm	TNM
169	pT-Kategorie	pT1c
bet.comment	Kommentar
11900	Kommentar	Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung.
Documentation for this format

LinkID	Text	Answer
IntegratedQRLymphNode		Questionnaire:http://breastcancerspec.org/Questionnaire/OP_LN-Mamma
sln.root	SLN-Biopsie Axilla
sln.clinical	Klinische Angaben
11951	Proben limitiert auswertbar	SNOMED CT: 373067005 (No (qualifier value))
11950	LK-Biopsie veranlassende klinische/bildgebende Befunde	Invasives Mammakarzinom NST links, cN0
11148	Bildgebende Befunde	Mammografie, Sonographie: Axilla klinisch unauffällig
10210	Neoadjuvante Therapie	SNOMED CT: 373067005 (No (qualifier value))
sln.macro	Makroskopie
sln.macro.sln1	SLN #1 Größe	12 x 8 x 6 mm, Patentblau-markiert
sln.macro.sln2	SLN #2 Größe	10 x 7 x 5 mm, Patentblau-markiert
sln.findings	Axilläre Lymphknotenpräparate
11540	LK OP Prozedur	SNOMED CT: 396487001 (Sentinel lymph node biopsy (procedure))
11620	Seitenangabe	SNOMED CT: 7771000 (Left (qualifier value))
11630	Anzahl der untersuchten (nonSLN)-axillären LK	0
11640	Anzahl der befallenen (nonSLN)-axillären LK	0
11650	Anzahl der untersuchten Sentinel-LK	2
11660	Anzahl der befallenen Sentinel-LK	1
11944	Gesamtzahl untersuchter Lymphknoten	2
11945	Gesamtzahl befallener Lymphknoten	1
11947	Gesamtzahl makrometastatisch befallener Lymphknoten	0
11948	Gesamtzahl mikrometastatisch befallener Lymphknoten	1
11946	Gesamtzahl ausschließlich ITC-befallener Lymphknoten	0
11690	Ausdehnung der größten metastatischen Infiltration	1.2 mm (Details: UCUM codemm = 'mm')
11700	Extranodale Infiltration durch LK-Metastase	SNOMED CT: 2667000 (Absent (qualifier value))
sln.tnm	Pathologisches TNM-Staging
175	Regionäre Lymphknoten (pN-Kategorie)	pN1mi(sn)
Documentation for this format