Diagnostic Conclusion Grouper - Integrated BET + SLN - Breast Cancer Specification v0.1.0

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

Example Observation: Diagnostic Conclusion Grouper - Integrated BET + SLN

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)'