Generated Narrative: Observation IntegratedDiagnosticConclusionGrouper

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)'