Generated Narrative: Composition LymphNodeComposition identifier: Accession ID/PATH-COMP-2025-211 status: Final type: Pathology report (record artifact) encounter: Encounter: identifier = http://example.hospital.de/encounters#E_25_211; status = finished; class = IMP (IMP) date: 2025-02-10 17:00:00+0100 author: Institut für Pathologie title: Histopathologischer Befundbericht - SLN-Biopsie Axilla links 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 - SLN-Biopsie Axilla links
Klinische Angaben Invasives Mammakarzinom NST links, G2. Klinisch unauffällige Axilla (cN0). SLN-Biopsie indiziert. Keine neoadjuvante Therapie. Material Sentinel-Lymphknoten-Exzisat linke Axilla, 2 SLN identifiziert (Patentblau-markiert) Makroskopie Zwei, 12 × 8 × 6 mm (A_1) bzw. 10 × 7 × 5 mm (A_2) durchmessende Sentinellymphknoten werden jeweils halbiert und separat eingebettet (je 1 Paraffinblock). Makroskopisch zeigen sich leicht fleckige rötlich-weiße Schnittflächen ohne Herdbefund. Mikroskopie Nach Anfertigung von jeweils 5, im Abstand von 1 mm zueinander liegenden HE-gefärbten Schnittstufen der Lymphknotenhälften zeigt sich eine ausgeprägte Sinushistiozytose und mäßiggradige Follikelhyperplasie. Im Sentinellymphknoten A_1 findet sich in Schnittstufe 3 eine 1,3 mm große metastatische Absiedlung des bekannten Mammakarzinoms ohne Kapselbeziehung. Im Sentinellymphknoten A_2 sind alle Schnittstufen tumorfrei. Kein Anhalt für isolierte Tumorzellen (ITC). Diagnostische Schlussfolgerung Prozedur Sentinel-Lymphknoten-Biopsie Seitenlokalisation Links 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 pN-Staging pN1mi(sn) — Mikrometastase in Sentinel-Lymphknoten Kommentar: In SLN #1 Nachweis einer Mikrometastase (1,2 mm) im Randsinus. SLN #2 tumorfrei in allen Schnittstufen. Keine extranodale Infiltration. Empfehlung: Besprechung in Tumorkonferenz bzgl. weiterer axillärer Therapie.
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 LymphNodeEncounter identifier: http://example.hospital.de/encounters/E_25_211 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 LymphNodeDiagnosisConfirmed 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_211; status = finished; class = IMP (IMP) onset: 2025-01-15 recordedDate: 2025-02-05 note: Invasives Mammakarzinom NST links, G2. SLN-Biopsie indiziert bei klinisch unauffälliger Axilla (cN0).
Bösartige Neubildung: Unterer äußerer Quadrant der Brustdrüse
Invasives Mammakarzinom NST links, G2. SLN-Biopsie indiziert bei klinisch unauffälliger Axilla (cN0).
Generated Narrative: ServiceRequest LymphNodeReportRequest Profile: MII PR Patho Service Request version: 2026.0.0 identifier: Placer Identifier/PATH-RPT-2025-211 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_211; status = finished; class = IMP (IMP) requester: Practitioner Thomas Richter performer: Practitioner Elisabeth Hoffmann reasonCode: Carcinoma 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)' specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeImagingReport 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 Mammografie und Sonographie: Klinisch unauffällige Axilla links (cN0). Kein Hinweis auf pathologische axilläre Lymphknoten.
Mammografie und Sonographie: Klinisch unauffällige Axilla links (cN0). Kein Hinweis auf pathologische axilläre Lymphknoten.
Generated Narrative: DiagnosticReport LymphNodeReport 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_211 Report Details Code Value Flags When For Pathology report gross observation Narrative (Axillary lymph node structure (body structure)) Final 2025-02-06 08:30:00+0100 Pathology report final diagnosis Narrative Final 2025-02-10 Sentinel-Lymphknoten-Biopsie linke Axilla: 2 SLN untersucht, 1x Mikrometastase (1,2 mm) in SLN #1, 1x tumorfrei (SLN #2). Keine extranodale Infiltration. pN1mi(sn).
Sentinel-Lymphknoten-Biopsie linke Axilla: 2 SLN untersucht, 1x Mikrometastase (1,2 mm) in SLN #1, 1x tumorfrei (SLN #2). Keine extranodale Infiltration. pN1mi(sn).
Generated Narrative: Specimen LymphNodeSpecimenPart Profiles: MII PR Patho Specimen version: 2026.0.0, MII PR Biobank Specimen Bioprobe Core version: 2026.0.0 identifier: Placer Identifier/OP25_211_A, Filler Identifier/E_25_211_A accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 status: Available type: Specimen from sentinel lymph node of breast (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) Lymph node group of left axilla (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.
Specimen from sentinel lymph node of breast (specimen)
Lymph node group of left axilla (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 LymphNodeSpecimenBlock01 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_211_A_1 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211; status = available; type = Specimen from sentinel lymph node of breast (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)
Gross examination and sampling of tissue specimen (procedure)
Zuschnitt und Paraffineinbettung - SLN #1 (halbiert)
Preparation of formalin fixed paraffin embedded tissue specimen (procedure)
General specimen container (physical object)
Generated Narrative: Specimen LymphNodeSpecimenBlock02 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_211_A_2 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeSpecimenSlideHE01 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_211_A_1_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; 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 LymphNodeSpecimenSlideHE02 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_211_A_1_1_HE_02 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:05:00+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 09:05:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:20:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen LymphNodeSpecimenSlideHE03 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_211_A_1_1_HE_03 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:10:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 3) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:10:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:25:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen LymphNodeSpecimenSlideHE04 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_211_A_1_1_HE_04 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:15:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 4) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:15:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:30:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen LymphNodeSpecimenSlideHE05 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_211_A_1_1_HE_05 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:20:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 5) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:20:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:35:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen LymphNodeSpecimenSlideHE06 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_211_A_2_1_HE_01 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:10:00+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 09:10:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:25:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen LymphNodeSpecimenSlideHE07 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_211_A_2_1_HE_02 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:15:00+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 09:15:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:30:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen LymphNodeSpecimenSlideHE08 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_211_A_2_1_HE_03 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:20:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 3) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:20:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:35:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen LymphNodeSpecimenSlideHE09 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_211_A_2_1_HE_04 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Tissue block specimen (specimen) Collections - Collected[x] Method * 2025-02-06 09:25:00+0100 Tissue processing technique (procedure) processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: Schnittherstellung (Schnittstufe 4) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:25:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:40:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Specimen LymphNodeSpecimenSlideHE10 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_211_A_2_1_HE_05 accessionIdentifier: https://pathologie.example-hospital.de/fhir/fn/befundbericht/E_25_211 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_211_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; 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 (Schnittstufe 5) procedure: Sectioning of tissue block (procedure) time: 2025-02-06 09:30:00+0100 processing MII EX Biobank Temperaturbedingungen: 20-25 °C description: HE-Färbung procedure: Hematoxylin and eosin stain method (procedure) time: 2025-02-06 09:45:00+0100 Containers - Type Additive[x] * Microscope slide (physical object) Microscope slide mounting medium (substance)
Generated Narrative: Observation LymphNodeMacroscopicGrouper Profile: MII PR Patho Macroscopic Grouper version: 2026.0.0 status: Final category: Laboratory code: Pathology report gross observation Narrative subject: Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105) effective: 2025-02-06 08:30:00+0100 performer: Practitioner Elisabeth Hoffmann bodySite: Axillary lymph node structure (body structure) hasMember: Observation Sentinel lymph nodes examined [#] in Cancer specimen by Light microscopy Observation Lymph nodes examined [#] in Cancer specimen by Light microscopy Observation Length of lymph node in excised specimen (observable entity) Observation Length of lymph node in excised specimen (observable entity) 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)'
Axillary lymph node structure (body structure)
Generated Narrative: Observation LymphNodeMacroSLNExamined Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: Sentinel lymph nodes examined [#] in Cancer specimen by Light microscopy 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: 2 nodes (Details: UCUM code{nodes} = '{nodes}') specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeMacroTotalExamined Profile: MII PR Patho Finding version: 2026.0.0 status: Final category: Laboratory, Pathology report gross observation Narrative code: Lymph nodes examined [#] in Cancer specimen by Light microscopy 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: 2 nodes (Details: UCUM code{nodes} = '{nodes}') specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeMacroSLN1Size 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_211_A_1; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; 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)'
Length of lymph node in excised specimen (observable entity)
Generated Narrative: Observation LymphNodeMacroSLN2Size 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_211_A_2; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; 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 LymphNodeDiagnosticConclusionGrouper 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 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_LN-Mamma' about '->Sabine Becker Female, DoB: 1971-03-15 ( http://example.hospital.de/patient-ids#PAT-2025-105)'
Generated Narrative: Observation LymphNodeProcedure 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeLaterality 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeNonSLNExamined 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeNonSLNPositive 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeSLNExamined 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeSLNPositive 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeTotalExamined 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeTotalPositive 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeMacroMetCount 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeMicroMetCount 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeITCCount 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_211; status = available; type = Specimen from sentinel lymph node of breast (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 LymphNodeLargestMetSize 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_211_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; 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 LymphNodeExtranodalExtension 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_211_A_1_1_HE_01; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_25_211; 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 LymphNodePN 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 LymphNodeComment 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)'
Pathology report comments [Interpretation] Narrative
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 QuestionnaireResponseLymphNode LinkID Text Definition Answer QuestionnaireResponseLymphNode 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