Breast Cancer Specification
0.1.0 - ci-build

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

: Stanzbiopsie Mamma Pathology Report Composition - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Composition ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "CoreNeedleBiopsyComposition"] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition CoreNeedleBiopsyComposition</b></p><a name=\"CoreNeedleBiopsyComposition\"> </a><a name=\"hcCoreNeedleBiopsyComposition\"> </a><p><b>identifier</b>: Accession ID/PATH-COMP-2025-105</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://ihe-d.de/CodeSystems/IHEXDStypeCode PATH}, {http://snomed.info/sct 721967005}\">Tissue pathology biopsy report (record artifact)</span></p><p><b>encounter</b>: <a href=\"Encounter-CoreNeedleBiopsyEncounter.html\">Encounter: identifier = http://example.hospital.de/encounters#E_25_105; status = finished; class = AMB (AMB)</a></p><p><b>date</b>: 2025-01-17 17:00:00+0100</p><p><b>author</b>: <a href=\"Organization-PathologyLabOrganization.html\">Institut für Pathologie</a></p><p><b>title</b>: Histopathologischer Befundbericht - Stanzbiopsie Mamma links</p><h3>Attesters</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Mode</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td>Legal</td><td><a href=\"Organization-PathologyLabOrganization.html\">Organization Institut für Pathologie</a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-PathologyLabOrganization.html\">Organization Institut für Pathologie</a></p><h3>Events</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Code</b></td><td><b>Detail</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode PATREPE}\">pathology report entry task</span></td><td><a href=\"ServiceRequest-CoreNeedleBiopsyReportRequest.html\">ServiceRequest Breast Pathology biopsy report</a></td></tr></table></div>"^^rdf:XMLLiteral ]
  ] ; # 
  fhir:identifier [
fhir:type [
      ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/v2-0203"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/v2-0203>         ] ;
fhir:code [ fhir:v "ACSN" ] ;
fhir:display [ fhir:v "Accession ID" ]       ] )     ] ;
fhir:system [
fhir:v "http://example.hospital.de/pathology-reports"^^xsd:anyURI ;
fhir:l <http://example.hospital.de/pathology-reports>     ] ;
fhir:value [ fhir:v "PATH-COMP-2025-105" ]
  ] ; # 
  fhir:status [ fhir:v "final"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [
fhir:v "http://ihe-d.de/CodeSystems/IHEXDStypeCode"^^xsd:anyURI ;
fhir:l <http://ihe-d.de/CodeSystems/IHEXDStypeCode>       ] ;
fhir:code [ fhir:v "PATH" ]     ] [
a sct:721967005 ;
fhir:system [
fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
fhir:l <http://snomed.info/sct>       ] ;
fhir:code [ fhir:v "721967005" ] ;
fhir:display [ fhir:v "Tissue pathology biopsy report (record artifact)" ]     ] )
  ] ; # 
  fhir:subject [
fhir:l fhir:Patient/Patient4 ;
fhir:reference [ fhir:v "Patient/Patient4" ] ;
fhir:display [ fhir:v "Sabine Becker, geb. 15.03.1971 (PAT-2025-105)" ]
  ] ; # 
  fhir:encounter [
fhir:l fhir:Encounter/CoreNeedleBiopsyEncounter ;
fhir:reference [ fhir:v "Encounter/CoreNeedleBiopsyEncounter" ]
  ] ; # 
  fhir:date [ fhir:v "2025-01-17T17:00:00+01:00"^^xsd:dateTime] ; # 
  fhir:author ( [
fhir:l fhir:Organization/PathologyLabOrganization ;
fhir:reference [ fhir:v "Organization/PathologyLabOrganization" ] ;
fhir:display [ fhir:v "Institut für Pathologie" ]
  ] ) ; # 
  fhir:title [ fhir:v "Histopathologischer Befundbericht - Stanzbiopsie Mamma links"] ; # 
  fhir:attester ( [
fhir:mode [ fhir:v "legal" ] ;
fhir:party [
fhir:l fhir:Organization/PathologyLabOrganization ;
fhir:reference [ fhir:v "Organization/PathologyLabOrganization" ]     ]
  ] ) ; # 
  fhir:custodian [
fhir:l fhir:Organization/PathologyLabOrganization ;
fhir:reference [ fhir:v "Organization/PathologyLabOrganization" ]
  ] ; # 
  fhir:event ( [
    ( fhir:code [
      ( fhir:coding [
fhir:system [
fhir:v "http://terminology.hl7.org/CodeSystem/v3-ActCode"^^xsd:anyURI ;
fhir:l <http://terminology.hl7.org/CodeSystem/v3-ActCode>         ] ;
fhir:code [ fhir:v "PATREPE" ]       ] )     ] ) ;
    ( fhir:detail [
fhir:l fhir:ServiceRequest/CoreNeedleBiopsyReportRequest ;
fhir:reference [ fhir:v "ServiceRequest/CoreNeedleBiopsyReportRequest" ]     ] )
  ] ) ; # 
  fhir:section ( [
fhir:title [ fhir:v "Pathologiebefundbericht" ] ;
fhir:code [
      ( fhir:coding [
a loinc:11526-1 ;
fhir:system [
fhir:v "http://loinc.org"^^xsd:anyURI ;
fhir:l <http://loinc.org>         ] ;
fhir:code [ fhir:v "11526-1" ] ;
fhir:display [ fhir:v "Pathology study" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "additional" ] ;
fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Klinische Angaben</h3><p>Herdbefund/Architekturstörung linke Brust, BI-RADS 4b. US-gestützte Stanzbiopsie.</p><h3>Material</h3><p>HG-Stanzen/Mamma, li., 5 Uhr, 5 cm von Mamille</p><h3>Makroskopie</h3><table border=\"1\" cellpadding=\"4\" cellspacing=\"0\"><tbody><tr><td>Stanzzylinder</td><td>2 Stanzzylinder, zusammen 22 mm, mittelfest, grauweißlich, Bleistiftminenstärke</td></tr><tr><td>Paraffinblöcke</td><td>1</td></tr></tbody></table><h3>Mikroskopie</h3><p>In beiden vollständig gebetteten, mit jeweils vier Schnittstufen aufgearbeiteten Punktionszylindern lipomatös und fibrolipomatös transformiertes Brustdrüsengewebe, das zu großen Teilen eingenommen wird von Tumorstrukturen eines mittelgroßzelligen, vordergründig trabekulär, solid und dissolut einzelzellig wachsenden invasiven Mammakarzinoms mit mäßiger Zell- und Kernpolymorphie sowie ganz vereinzelt nachweisbaren Mitosen (weniger als 5/10 HPF). Im Tumorzentrum unterschiedlich ausgeprägte Stromasklerose und herdförmige -elastose. An der Tumorperipherie schüttere bis mitteldichte rundzellig entzündliche Stromareaktion.</p><h3>Diagnostische Schlussfolgerung</h3><p><b>Diagnose:</b> Invasives Mammakarzinom NST (ICD-O 8500/3)</p><table border=\"1\" cellpadding=\"4\" cellspacing=\"0\"><tbody><tr><td>ICD-O-3 Morphologie</td><td>M8500/3</td></tr><tr><td>Nottingham-Grad</td><td>Grad 2 (Score 6: Tubuli 3, Pleomorphie 2, Mitosen 1)</td></tr><tr><td>ER</td><td>Positiv (85% positive Tumorzellkerne)</td></tr><tr><td>PR</td><td>Positiv (50% positive Tumorzellkerne)</td></tr><tr><td>HER2</td><td>Negativ (nicht amplifiziert)</td></tr><tr><td>Ki-67</td><td>10%</td></tr><tr><td>B-Klassifikation</td><td>B5b (NHSBSP)</td></tr><tr><td>Relevante Mikroverkalkungen</td><td>Nein</td></tr><tr><td>Präparateradiogramm</td><td>Gesehen</td></tr><tr><td>Korrelation Mikroverkalkung</td><td>Vorliegende Verkalkung radiologisch nicht relevant (kleiner 100 Mikrometer)</td></tr></tbody></table></div>"^^rdf:XMLLiteral ]     ] ;
    ( fhir:entry [
fhir:l fhir:DiagnosticReport/CoreNeedleBiopsyReport ;
fhir:reference [ fhir:v "DiagnosticReport/CoreNeedleBiopsyReport" ]     ] )
  ] ) . #