Generated Narrative: Composition IntegratedComposition identifier: Accession ID/PATH-COMP-2025-300 status: Final type: Pathology report (record artifact) encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_300; status = finished; class = IMP (IMP) date: 2025-02-10 17:00:00+0100 author: Institut für Pathologie title: Histopathologischer Befundbericht — BET Mamma links mit SLN-Biopsie Axilla Attesters - Mode Party * Legal Organization Institut für Pathologie custodian: Organization Institut für Pathologie Events - Code Detail * pathology report entry task ServiceRequest Pathology synoptic report
Histopathologischer Befundbericht — BET Mamma links mit SLN-Biopsie Axilla
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.
Generated Narrative: Patient Patient4 Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
Generated Narrative: Organization PathologyLabOrganization identifier: http://example.hospital.de/organization-ids/ORG-PATH-001 name: Institut für Pathologie
Generated Narrative: Practitioner PathologistPractitioner identifier: http://example.hospital.de/practitioner-ids/PATH-001 name: Elisabeth Hoffmann Qualifications - Code * Pathology
Generated Narrative: Practitioner BreastSurgeonPractitioner identifier: http://example.hospital.de/practitioner-ids/GYN-001 name: Thomas Richter Qualifications - Code * Gynecology
Generated Narrative: Encounter IntegratedEncounter identifier: http://example.hospital.de/encounters/E_25_300 status: Finished class: [not stated]: IMP (IMP) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)
Generated Narrative: Condition IntegratedDiagnosisConfirmed 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.
Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse
Z.n. Stanzbiopsie (E_25_105) mit Nachweis eines invasiven Mammakarzinoms NST, G2. BI-RADS 4b. BET links mit SLN-Biopsie Axilla indiziert.
Generated Narrative: ServiceRequest IntegratedReportRequest 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: 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 reasonCode: Malignant neoplasm of breast (disorder) supportingInfo: Condition Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse Diagnostic Report for 'MG Breast Screening' for '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)' Observation Personal history of primary malignant neoplasm of breast (situation) Observation Cancer treatment --preoperative Observation Lesion size, largest dimension (observable entity) Observation Insertion of marker into breast using X-ray guidance (procedure) Observation 80865008|Specimen mammography|:363702006|Has focus|=185008008|Medical reports sent| Observation Diathesis, function (observable entity) 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.
Pathology consultation, comprehensive, records and specimen with report (procedure)
Generated Narrative: DiagnosticReport IntegratedImagingReport 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.
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.
Generated Narrative: Observation IntegratedCancerHistory status: Final code: Brustkrebsvorgeschichte subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Ersterkrankung
Personal history of primary malignant neoplasm of breast (situation)
Generated Narrative: Observation IntegratedPriorTherapy status: Final code: Vorchirurgische Therapie bei invasivem Karzinom subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Keine neoadjuvante Therapie
Vorchirurgische Therapie bei invasivem Karzinom
Generated Narrative: Observation IntegratedRadiologicalExtent status: Final code: Radiologische Ausdehnung subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: 15 mm (Details: UCUM codemm = 'mm')
Lesion size, largest dimension (observable entity)
Generated Narrative: Observation IntegratedSpecimenMarking status: Final code: Befundmarkierung subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Drahthäkchen
Insertion of marker into breast using X-ray guidance (procedure)
Generated Narrative: Observation IntegratedSpecimenRadiographyClinical status: Final code: Präparateradiographie beigelegt subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Ja, beigelegt
80865008|Specimen mammography|:363702006|Has focus|=185008008|Medical reports sent|
Generated Narrative: Observation IntegratedGeneticPredisposition status: Final code: Genetische Prädisposition subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) value: Nicht bekannt
Generated Narrative: DiagnosticReport IntegratedReport 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.
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.
Generated Narrative: Specimen IntegratedBETSpecimenPart 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) Structure of lower outer quadrant of breast (body structure) Containers - Type Additive[x] * Specimen vial (physical object) Neutral buffered formalin (substance) note: BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 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 from breast obtained by excision (specimen)
Wide local excision of breast lesion (procedure)
Structure of lower outer quadrant of breast (body structure)
BET-Exzisionspräparat Mamma links, unterer äußerer Quadrant, 5 Uhr, 50 mm von Mamille. 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.
Generated Narrative: Specimen IntegratedBETSpecimenBlock01 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe III Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:00:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Gross examination and sampling of tissue specimen (procedure)
Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe III
Preparation of formalin fixed paraffin embedded tissue specimen (procedure)
General specimen container (physical object)
Generated Narrative: Specimen IntegratedBETSpecimenBlock02 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe V Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:10:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - Tumor zentral, Scheibe V
Generated Narrative: Specimen IntegratedBETSpecimenBlock03 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung - RR superior Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:20:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - RR superior
Generated Narrative: Specimen IntegratedBETSpecimenBlock04 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung - RR inferior Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:30:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - RR inferior
Generated Narrative: Specimen IntegratedBETSpecimenBlock05 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung - RR medial, Scheibe I Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:40:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - RR medial, Scheibe I
Generated Narrative: Specimen IntegratedBETSpecimenBlock06 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung - RR lateral, Scheibe VIII Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:50:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - RR lateral, Scheibe VIII
Generated Narrative: Specimen IntegratedBETSlideHE01 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) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Hematoxylin and eosin stain method (procedure)
Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideHE02 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) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideER01 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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: ER-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Immunohistochemistry procedure (procedure)
Generated Narrative: Specimen IntegratedBETSlidePR01 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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: PR-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideHER2IHC01 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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HER2-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideKi67-01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Ki-67-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideCK18-01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: CK18-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlidep40-01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: p40-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideECad-01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: E-Cadherin-Immunhistochemie procedure: Immunohistochemistry procedure (procedure) additive: Substance Tissue stain (substance) time: 2025-02-06 10:00:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideBlock02-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideBlock02-HE02 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideRR-Superior-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideRR-Inferior-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideRR-Medial-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedBETSlideRR-Lateral-HE01 Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_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 procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedSLNSpecimenPart 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) Axillary lymph node structure (body structure) Containers - Type Additive[x] * Specimen vial (physical object) Neutral buffered formalin (substance) 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.
Axillary lymph node structure (body structure)
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.
Generated Narrative: Specimen IntegratedSLNSpecimenBlock01 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung - SLN #1 (halbiert) Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:00:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - SLN #1 (halbiert)
Generated Narrative: Specimen IntegratedSLNSpecimenBlock02 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 Procedure Time[x] * Zuschnitt und Paraffineinbettung - SLN #2 (halbiert) Preparation of formalin fixed paraffin embedded tissue specimen (procedure) 2025-02-06 08:10:00+0100 Containers - Type Additive[x] * General specimen container (physical object) Paraffin wax (substance)
Zuschnitt und Paraffineinbettung - SLN #2 (halbiert)
Generated Narrative: Specimen IntegratedSLNSlideHE01 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) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedSLNSlideHE02 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) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedSLNSlideHE03 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) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen IntegratedSLNSlideHE04 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) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:00:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:15:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Substance IntegratedSubstanceER Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: Estrogen Receptor (Dako Omnis)
Generated Narrative: Substance IntegratedSubstancePR Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: Progesterone Receptor (Dako Omnis)
Generated Narrative: Substance IntegratedSubstanceHER2IHC Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: VENTANA HER2 (4B5), Roche
Generated Narrative: Substance IntegratedSubstanceKi67 Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: Ki-67 Antigen (Dako Omnis)
Generated Narrative: Substance IntegratedSubstanceCK18 Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: Cytokeratin 18 (DC10), Dako Omnis
Generated Narrative: Substance IntegratedSubstancep40 Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: p40 (BC28), Biocare Medical
Generated Narrative: Substance IntegratedSubstanceECadherin Profile: MII PR Biobank Substance Additiv version: 2026.0.0 status: Active category: Chemical code: Tissue stain (substance) description: E-Cadherin (NCH-38), Dako Omnis
Generated Narrative: Observation IntegratedMacroscopicGrouper 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)'
Generated Narrative: Observation IntegratedMacroLength 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)'
Specimen size.maximum dimension in Breast tumor
Generated Narrative: Observation IntegratedMacroWidth 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)'
Specimen size additional dimension 1 in Breast tumor
Generated Narrative: Observation IntegratedMacroDepth 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)'
Specimen size additional dimension 2 in Breast tumor
Generated Narrative: Observation IntegratedMacroWeight 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)'
Generated Narrative: Observation IntegratedMacroQuadrant 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)'
Generated Narrative: Observation IntegratedMacroClock 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)'
Radial position in breast [Angle] in Breast cancer specimen
Radial location of primary malignant neoplasm in excised breast specimen (observable entity)
Generated Narrative: Observation IntegratedMacroDistanceNipple 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)'
Distance of primary malignant neoplasm of breast to nipple in excised breast specimen (observable entity)
Generated Narrative: Observation IntegratedMacroBlockCount 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)'
Number of paraffin embedded tissue blocks examined from excised specimen (observable entity)
Generated Narrative: Observation IntegratedMacroSLN1Size 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)'
Generated Narrative: Observation IntegratedMacroSLN2Size 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)'
Generated Narrative: Observation IntegratedDiagnosticConclusionGrouper 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)'
Generated Narrative: Observation IntegratedOperativeProcedure 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)'
Specimen collection procedure (observable entity)
Generated Narrative: Observation IntegratedMaterialType 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)'
Generated Narrative: Observation IntegratedLaterality 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)'
Generated Narrative: Observation IntegratedAttachedTissue 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)'
Body structure included in specimen [Anatomy] in Specimen
Generated Narrative: Observation IntegratedFocality 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)'
Qualitative distribution of primary malignant neoplasm of breast in excised breast specimen (observable entity)
Generated Narrative: Observation IntegratedMaxDiameterInvasive 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)'
Greatest length dimension of excised primary malignant neoplasm (observable entity)
Maximaler Durchmesser invasives Karzinom
Generated Narrative: Observation IntegratedMaxOverallDiameter 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)'
Generated Narrative: Observation IntegratedHistologicalType 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)'
Histologic type of primary malignant neoplasm of breast (observable entity)
Generated Narrative: Observation IntegratedMorphologyFreeText 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)'
Histology type in Cancer specimen Narrative
Invasives Mammakarzinom des NST (kein spezieller Typ), maximal 18 mm messend. Das Karzinom zeigt ein überwiegend trabekuläres und solides Wachstumsmuster mit mäßiger Kern- und Zellpolymorphie. Mitosen sind vereinzelt nachweisbar (4/10 HPF). In der Tumorperipherie zeigt sich ein begleitendes duktales Carcinoma in situ (DCIS) mit intermediärem Kerngrad und überwiegend kribriformem Wachstumsmuster, maximal 8 mm. Fokale Komedo-Nekrosen. Assoziierte Mikroverkalkungen im DCIS-Areal. Alle Resektionsränder tumorfrei. Mindestabstand invasiv: 5 mm (posterior), DCIS: 3 mm. Keine Lymphgefäßinvasion.
Generated Narrative: Observation IntegratedNottinghamGrade 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)'
Histologic grade [Score] in Breast cancer specimen by Nottingham
Histologischer Tumorgrad (Elston-Ellis-Grad)
G2: Moderately differentiated histologic grade (qualifier value)
Generated Narrative: Observation IntegratedTubuleScore 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)'
Glandular differentiation [Score] in Breast cancer specimen by Nottingham
Generated Narrative: Observation IntegratedNuclearPleomorphism 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)'
Nuclear pleomorphism in Breast tumor by Nottingham
Generated Narrative: Observation IntegratedMitosisCount 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)'
Number of mitoses per 10 high power fields (observable entity)
Generated Narrative: Observation IntegratedMitoticRateScore 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)'
Mitotic rate [Score] in Breast cancer specimen by Nottingham
Generated Narrative: Observation IntegratedElstonEllisScore 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)'
Nottingham total score of primary malignant neoplasm of breast (observable entity)
Generated Narrative: Observation IntegratedAssociatedDCIS 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)'
Generated Narrative: Observation IntegratedDCISGrade 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)'
Nuclear grade of ductal carcinoma in situ of breast (observable entity)
Generated Narrative: Observation IntegratedDCISArchitecture 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)'
Growth pattern of DCIS [Type] in Breast cancer specimen by Light microscopy
Architectural pattern of ductal carcinoma in situ in breast (observable entity)
Generated Narrative: Observation IntegratedDCISNecrosis 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)'
DCIS necrosis [Type] in Breast cancer specimen by Light microscopy
Generated Narrative: Observation IntegratedTumorExtent 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)'
Adjacent structure invaded by tumor [Anatomy] in Breast cancer specimen by Light microscopy
Status of extension by tumor (observable entity)
Anatomic location directly invaded by primary malignant neoplasm of breast (observable entity)
Generated Narrative: Observation IntegratedMarginStatusInvasive 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)'
Presence of neoplasm at excised surgical margin (observable entity)
Surgical margin involved by primary malignant neoplasm of breast in excised breast specimen (observable entity)
Generated Narrative: Observation IntegratedClosestMargin 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)'
Surgical margin closest to malignant neoplasm in excised specimen of breast (observable entity)
Generated Narrative: Observation IntegratedMinDistanceInvasive 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)'
Distance of invasive carcinoma of breast from closest surgical margin in excised breast specimen (observable entity)
Mindestabstand des invasiven Tumor zum nächstgelegenen Resektionsrand
Generated Narrative: Observation IntegratedMarginStatusNonInvasive 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)'
Surgical margin DCIS involvement [Presence] in Breast cancer specimen by Light microscopy
Presence of ductal carcinoma in situ at surgical margin in excised specimen of breast (observable entity)
Generated Narrative: Observation IntegratedMinDistanceNonInvasive 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)'
Mindestabstand vom RR zum nichtinvasiven Tumor
Generated Narrative: Observation IntegratedLVI 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)'
Presence of direct invasion by primary malignant neoplasm to lymphatic vessel and/or small blood vessel (observable entity)
Generated Narrative: Observation IntegratedMicrocalcification 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)'
Presence of microcalcification in excised breast specimen (observable entity)
Generated Narrative: Observation IntegratedERStatus 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
Estrogen receptor [Interpretation] in Tissue
Observation using immunohistochemistry (observable entity)
Generated Narrative: Observation IntegratedERPercentage 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
Cells.estrogen receptor/cells in Breast cancer specimen by Immune stain
Percent of cells with estrogen receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Generated Narrative: Observation IntegratedERIntensity 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
Estrogen receptor fluorescence intensity [Type] in Breast cancer specimen by Immune stain
Intensity of stain of estrogen receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Severe (severity modifier) (qualifier value)
Generated Narrative: Observation IntegratedPRStatus 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
Progesterone receptor [Interpretation] in Tissue
Generated Narrative: Observation IntegratedPRPercentage 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
Cells.progesterone receptor/cells in Breast cancer specimen by Immune stain
Percent of cells with progesterone receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Generated Narrative: Observation IntegratedPRIntensity 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
Progesterone receptor fluorescence intensity [Type] in Breast cancer specimen by Immune stain
Intensity of stain of progesterone receptor in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Moderate (severity modifier) (qualifier value)
Generated Narrative: Observation IntegratedHER2IHC 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
HER2 [Presence] in Breast cancer specimen by Immune stain
Presence of receptor tyrosine-protein kinase erbB-2 in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Generated Narrative: Observation IntegratedHER2ISH 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
ERBB2 gene duplication [Presence] in Breast cancer specimen by FISH
Generated Narrative: Observation IntegratedHER2Overall 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
Generated Narrative: Observation IntegratedKi67 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
Cells.Ki-67 nuclear Ag/cells in Breast cancer specimen by Immune stain
Percent of cell nuclei positive for proliferation marker protein Ki-67 in primary malignant neoplasm of breast by immunohistochemistry (observable entity)
Generated Narrative: Observation IntegratedPT Profile: MII PR Onkologie TNM T-Kategorie version: 2026.0.0 status: Final code: pT category (observable entity) subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-10 value: T1 method: 8. Auflage
Generated Narrative: Observation IntegratedBETComment 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)'
Pathology report comments [Interpretation] Narrative
Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung.
Generated Narrative: Observation IntegratedLymphNodeProcedure 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)'
Surgery procedure for regional nodes at facility.YYY Cancer
Generated Narrative: Observation IntegratedLymphNodeLaterality 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)'
Generated Narrative: Observation IntegratedNonSLNExamined 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)'
Regional lymph nodes examined [#] Specimen
Anzahl untersuchter Non-SLN-axillärer LK
Generated Narrative: Observation IntegratedNonSLNPositive 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)'
Regional lymph nodes positive [#] Specimen
Generated Narrative: Observation IntegratedSLNExamined 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)'
Sentinel lymph nodes examined [#] in Cancer specimen by Light microscopy
Generated Narrative: Observation IntegratedSLNPositive 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)'
Number of sentinel lymph nodes containing metastatic neoplasm in excised specimen (observable entity)
Generated Narrative: Observation IntegratedTotalExamined 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)'
Lymph nodes examined [#] in Cancer specimen by Light microscopy
Generated Narrative: Observation IntegratedTotalPositive 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)'
Lymph nodes with metastasis [#] in Cancer specimen
Generated Narrative: Observation IntegratedMacroMetCount 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)'
Lymph nodes with macrometastases [#] in Cancer specimen by Light microscopy
Gesamtzahl makrometastatisch befallener LK
Generated Narrative: Observation IntegratedMicroMetCount 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)'
Lymph nodes with micrometastases [#] in Cancer specimen by Light microscopy
Gesamtzahl mikrometastatisch befallener LK
Generated Narrative: Observation IntegratedITCCount 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)'
Lymph nodes with isolated tumor cells [#] in Cancer specimen by Light microscopy
Gesamtzahl ausschließlich ITC-befallener LK
Generated Narrative: Observation IntegratedLargestMetSize 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)'
Lymph node metastatic deposit.max dimension [Length] in Cancer specimen by Light microscopy
Ausdehnung der größten metastatischen Infiltration
Generated Narrative: Observation IntegratedExtranodalExtension 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)'
Extranodal extension of carcinoma [Presence] in Cancer specimen by Light microscopy
Extranodale Infiltration durch LK-Metastase
Generated Narrative: Observation IntegratedPN 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
Generated Narrative: Observation IntegratedSLNComment 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)'
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.
Generated Narrative: QuestionnaireResponse IntegratedQRBreastResection LinkID Text Definition Answer IntegratedQRBreastResection Questionnaire:http://breastcancerspec.org/Questionnaire/OP_Mamma_GH #xD; bet.root BET Mamma #xD; bet.clinical Klinische Angaben #xD; 11951 Proben limitiert auswertbar SNOMED CT: 373067005 (No (qualifier value)) #xD; 11912 Präsentationsmodus Frisch #xD; 11147 Klinische Befunde / Anlass Z.n. Stanzbiopsie mit Nachweis eines invasiven Mammakarzinoms NST, G2 #xD; 11923 Brustkrebsvorgeschichte Ersterkrankung #xD; 11952 Vorchirurgische Therapie SNOMED CT: 373067005 (No (qualifier value)) #xD; 11918 Bildgebungsmodalität Mammografie, Ultraschall #xD; 11953 Radiologische Ausdehnung 15 mm (Details: UCUM codemm = 'mm') #xD; 10160 Befundmarkierung Drahthäkchen #xD; 10130 Präparateradiographie Ja, beigelegt #xD; 11954 Genetische Prädisposition Nicht bekannt #xD; bet.macro Makroskopie #xD; 10900 Probengröße 1 (Länge) 65 mm (Details: UCUM codemm = 'mm') #xD; 10910 Probengröße 2 (Breite) 45 mm (Details: UCUM codemm = 'mm') #xD; 10920 Probengröße 3 (Tiefe) 30 mm (Details: UCUM codemm = 'mm') #xD; 10890 Gewicht 55 g (Details: UCUM codeg = 'g') #xD; 10030 Quadrant SNOMED CT: 33564002 (Structure of lower outer quadrant of breast (body structure)) #xD; 10040 Zifferblattlokalisation 5 Uhr #xD; 10070 Abstand Mamille 50 mm (Details: UCUM codemm = 'mm') #xD; bet.general Allgemeine Befunde #xD; 11130 Nichtinvasive Läsion SNOMED CT: 52101004 (Present (qualifier value)) #xD; 11270 Invasives Karzinom SNOMED CT: 52101004 (Present (qualifier value)) #xD; 11919 Operatives Verfahren SNOMED CT: 237371007 (Wide local excision of breast lesion (procedure)) #xD; 10140 Materialart Exzisionspräparat #xD; 10800 Seitenlokalisation SNOMED CT: 7771000 (Left (qualifier value)) #xD; 11040 Anhängendes Gewebe Haut #xD; 11440 Fokalität Unifokal #xD; bet.invasive Invasives Karzinom #xD; 11400 Max Durchmesser invasiv 18 mm (Details: UCUM codemm = 'mm') #xD; 11420 Max Gesamtdurchmesser 22 mm (Details: UCUM codemm = 'mm') #xD; 11280 Histologischer Tumortyp unknown: 8500/3 (Invasives duktales Karzinom (NST)) #xD; 11290 Morphologie Freitext Invasives Mammakarzinom des NST, überwiegend trabekuläres und solides Wachstumsmuster #xD; 11330 Nottingham-Grad G2 #xD; 11340 Tubulus-Score 3 #xD; 11350 Kernpleomorphie-Score 2 #xD; 11925 Mitosezahl 4/10 HPF #xD; 11360 Mitoserate-Score 1 #xD; 11390 Elston-Ellis-Summenscore 6 #xD; 11300 Assoziiertes DCIS SNOMED CT: 52101004 (Present (qualifier value)) #xD; 149 DCIS Kerngrading Intermediär (Grad 2) #xD; 150 DCIS Architektur Kribriform #xD; 151 DCIS Nekrosen Fokal (Komedo-Nekrosen) #xD; 11926 Tumorausdehnung Auf Brustdrüse beschränkt #xD; bet.margins Resektionsränder #xD; 11470 RR-Status invasiv SNOMED CT: 2667000 (Absent (qualifier value)) #xD; 11490 Nächster tumorfreier RR Posterior #xD; 11480 Mindestabstand invasiv 5 mm (Details: UCUM codemm = 'mm') #xD; 11968 RR-Status nichtinvasiv SNOMED CT: 2667000 (Absent (qualifier value)) #xD; 11970 Mindestabstand nichtinvasiv 3 mm (Details: UCUM codemm = 'mm') #xD; bet.additional Weitere Befunde #xD; 11430 LVI SNOMED CT: 2667000 (Absent (qualifier value)) #xD; 10880 Mikrokalzifikationen In DCIS assoziiert #xD; bet.biomarkers Biomarker #xD; 11750 ER-Status SNOMED CT: 52101004 (Present (qualifier value)) #xD; 11720 ER Prozent 90 #xD; 11730 ER Färbeintensität Stark #xD; 11790 PR-Status SNOMED CT: 52101004 (Present (qualifier value)) #xD; 11760 PR Prozent 60 #xD; 11770 PR Färbeintensität Mäßig #xD; 11810 HER2-Score (IHC) 1+ #xD; 11820 HER2-Amplifikation (ISH) Nicht amplifiziert #xD; 11830 HER2-Gesamtstatus Negativ #xD; 11840 Ki-67-Index 15 #xD; bet.tnm TNM #xD; 169 pT-Kategorie pT1c #xD; bet.comment Kommentar #xD; 11900 Kommentar Korrelation mit dem Vorbefund der Stanzbiopsie (E_25_105): Übereinstimmende Histologie (invasives Mammakarzinom NST, G2). Biomarkerprofil bestätigt: ER+, PR+, HER2-, Luminal-A-like. Empfehlung: Tumorkonferenz zur weiteren Therapieplanung. #xD; Documentation for this format
Z.n. Stanzbiopsie mit Nachweis eines invasiven Mammakarzinoms NST, G2
Invasives Mammakarzinom des NST, überwiegend trabekuläres und solides Wachstumsmuster
Generated Narrative: QuestionnaireResponse IntegratedQRLymphNode LinkID Text Definition Answer IntegratedQRLymphNode Questionnaire:http://breastcancerspec.org/Questionnaire/OP_LN-Mamma #xD; sln.root SLN-Biopsie Axilla #xD; sln.clinical Klinische Angaben #xD; 11951 Proben limitiert auswertbar SNOMED CT: 373067005 (No (qualifier value)) #xD; 11950 LK-Biopsie veranlassende klinische/bildgebende Befunde Invasives Mammakarzinom NST links, cN0 #xD; 11148 Bildgebende Befunde Mammografie, Sonographie: Axilla klinisch unauffällig #xD; 10210 Neoadjuvante Therapie SNOMED CT: 373067005 (No (qualifier value)) #xD; sln.macro Makroskopie #xD; sln.macro.sln1 SLN #1 Größe 12 x 8 x 6 mm, Patentblau-markiert #xD; sln.macro.sln2 SLN #2 Größe 10 x 7 x 5 mm, Patentblau-markiert #xD; sln.findings Axilläre Lymphknotenpräparate #xD; 11540 LK OP Prozedur SNOMED CT: 396487001 (Sentinel lymph node biopsy (procedure)) #xD; 11620 Seitenangabe SNOMED CT: 7771000 (Left (qualifier value)) #xD; 11630 Anzahl der untersuchten (nonSLN)-axillären LK 0 #xD; 11640 Anzahl der befallenen (nonSLN)-axillären LK 0 #xD; 11650 Anzahl der untersuchten Sentinel-LK 2 #xD; 11660 Anzahl der befallenen Sentinel-LK 1 #xD; 11944 Gesamtzahl untersuchter Lymphknoten 2 #xD; 11945 Gesamtzahl befallener Lymphknoten 1 #xD; 11947 Gesamtzahl makrometastatisch befallener Lymphknoten 0 #xD; 11948 Gesamtzahl mikrometastatisch befallener Lymphknoten 1 #xD; 11946 Gesamtzahl ausschließlich ITC-befallener Lymphknoten 0 #xD; 11690 Ausdehnung der größten metastatischen Infiltration 1.2 mm (Details: UCUM codemm = 'mm') #xD; 11700 Extranodale Infiltration durch LK-Metastase SNOMED CT: 2667000 (Absent (qualifier value)) #xD; sln.tnm Pathologisches TNM-Staging #xD; 175 Regionäre Lymphknoten (pN-Kategorie) pN1mi(sn) #xD; Documentation for this format
LK-Biopsie veranlassende klinische/bildgebende Befunde
Mammografie, Sonographie: Axilla klinisch unauffällig
Anzahl der untersuchten (nonSLN)-axillären LK
Anzahl der befallenen (nonSLN)-axillären LK
Gesamtzahl makrometastatisch befallener Lymphknoten
Gesamtzahl mikrometastatisch befallener Lymphknoten
Gesamtzahl ausschließlich ITC-befallener Lymphknoten