Prostate Cancer Specification
0.1.0 - ci-build

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

Example Bundle: Document Bundle - Prostatabiopsie

Document Details

Document Subject

Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)

Document Content

Pathologiebefundbericht

Klinische Angaben

Erhöhter PSA-Wert (8,5 ng/ml). V.a. Prostatakarzinom. Bitte histologische Abklärung.

Makroskopie

Makroskopie

Makroskopische Messungen für alle 12 Prostatastanzen: Längen 1,3–1,9 cm, je 1 Zylinder pro Specimen. Stanzen 01–06 aus rechter Prostataregion (lateral basal/mid/apikal, medial basal/mid/apikal), Stanzen 07–12 aus linker Prostataregion (lateral basal/mid/apikal, medial basal/mid/apikal).

StanzeLokalisationStanzenlänge (cm)Zylinderanzahl im Gefäß
01Rechts lateral basal1.81
02Rechts lateral mid1.61
03Rechts lateral apikal1.51
04Rechts medial basal1.91
05Rechts medial mid1.41
06Rechts medial apikal1.71
07Links lateral basal1.61
08Links lateral mid1.51
09Links lateral apikal1.81
10Links medial basal1.31
11Links medial mid1.71
12Links medial apikal1.41

Mikroskopie

Mikroskopie

Adenokarzinom in 7 von 12 Stanzen nachgewiesen (01, 02, 04, 06, 07, 09, 11). Gleason-Scores: Stanze 01 (3+4=7), Stanze 02 (4+3=7), Stanze 04 (4+4=8), Stanze 06 (3+3=6), Stanze 07 (4+5=9), Stanze 09 (3+4=7), Stanze 11 (3+4=7). Höchster Gleason-Score 4+5=9, ISUP-Gradgruppe 5. Benigne Befunde in Stanzen 03, 05, 08, 10, 12.

StanzeBefundGleason-ScoreTumoranteil
01Adenokarzinom3+4=740%
02Adenokarzinom4+3=760%
03Benigne--
04Adenokarzinom4+4=880%
05Benigne--
06Adenokarzinom3+3=620%
07Adenokarzinom4+5=995%
08Benigne--
09Adenokarzinom3+4=735%
10Benigne--
11Adenokarzinom3+4=725%
12Benigne--

Diagnostische Schlussfolgerung

Diagnostische Schlussfolgerung

7 von 12 Stanzen tumorbefallen (4 rechts: 01, 02, 04, 06; 3 links: 07, 09, 11). Prozentualer Tumoranteil 51%, Tumorlänge gesamt 52,7 mm. Perineurale Infiltration und Infiltration des periprostatischen Fettgewebes apikal nachgewiesen. Samenblaseninfiltration, lymphovaskuläre Invasion, intraduktales Karzinom, ASAP, High-grade-PIN und granulomatöse Prostatitis nicht nachgewiesen.

Histologischer TypAzinäres Adenokarzinom (8140/3)
Gleason-Score4+5=9 (höchster Score)
ISUP-Gradgruppe5 (WHO 2016)
Positive Stanzen7 von 12 (4 rechts, 3 links)
Tumoranteil gesamt51%
Tumorlänge gesamt52,7 mm
Anteil Gleason 4/577%
Perineurale InfiltrationNachgewiesen
Periprostatische FettinvasionNachgewiesen (apikal)
SamenblaseninfiltrationNicht nachgewiesen
Lymphovaskuläre InvasionNicht nachgewiesen
Intraduktales KarzinomNicht nachgewiesen
ASAPNicht nachgewiesen
High-grade-PINNicht nachgewiesen

Diagnose: Azinäres Adenokarzinom der Prostata (ICD-O 8140/3)

Additional Resources Included in Document

Entry 2 - fullUrl = http://prostatecancerspec.org/Patient/Patient1

Resource Patient:

Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)

Entry 3 - fullUrl = http://prostatecancerspec.org/Organization/PathologyLabOrganization

Resource Organization:

Pathologielabor (http://example.hospital.de/organization-ids#ORG-PATH-001)

Entry 4 - fullUrl = http://prostatecancerspec.org/DiagnosticReport/CoreNeedleBiopsyReport

Resource DiagnosticReport:

Profile: MII PR Patho Report version: 2027.0.0-ballot

Pathology Synoptic report (Surgical Pathology)

SubjectHans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)
Relevant Time2024-01-20 15:00:00+0100
Reported2024-01-20 15:30:00+0100
Performer Maria Schneider (http://example.hospital.de/practitioner-ids#PATH-001)
Identifier Accession ID/E_24_001

Report Details

CodeValueFlagsRelevant Time
Pathology report gross observation Narrative (Prostate)Makroskopische Messungen aller 12 ProstatastanzenFinal2024-01-15 14:00:00+0100
Pathology report microscopic observation Narrative Other stain (Prostate)Mikroskopische Befunde aller 12 ProstatastanzenFinal2024-01-17 10:00:00+0100
Pathology report final diagnosis NarrativeFinal2023-03-15

Adenokarzinom der Prostata, Gleason-Score 7a (3+4) in 7 von 12 Stanzen, mit perineuralem Befall.

Entry 5 - fullUrl = http://prostatecancerspec.org/Observation/CoreNeedleBiopsyDiagnosticConclusionGrouper

Resource Observation:

Profile: MII PR Patho Diagnostic Conclusion Grouper version: 2027.0.0-ballot

basedOn: ServiceRequest Prostate Pathology biopsy report

status: Final

category: Laboratory

code: Pathology report final diagnosis Narrative

subject: Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)

effective: 2023-03-15

performer: Maria Schneider (http://example.hospital.de/practitioner-ids#PATH-001)

hasMember:

derivedFrom:

Entry 6 - fullUrl = http://prostatecancerspec.org/Observation/CoreNeedleBiopsyMacroscopicGrouper

Resource Observation:

Profile: MII PR Patho Macroscopic Grouper version: 2027.0.0-ballot

status: Final

category: Laboratory

code: Pathology report gross observation Narrative

subject: Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)

effective: 2024-01-15 14:00:00+0100

performer: Maria Schneider (http://example.hospital.de/practitioner-ids#PATH-001)

value: Makroskopische Messungen aller 12 Prostatastanzen

bodySite: Prostate

derivedFrom:

Entry 7 - fullUrl = http://prostatecancerspec.org/Observation/CoreNeedleBiopsyMicroscopicGrouper

Resource Observation:

Profile: MII PR Patho Microscopic Grouper version: 2027.0.0-ballot

status: Final

category: Laboratory

code: Pathology report microscopic observation Narrative Other stain

subject: Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)

effective: 2024-01-17 10:00:00+0100

performer: Maria Schneider (http://example.hospital.de/practitioner-ids#PATH-001)

value: Mikroskopische Befunde aller 12 Prostatastanzen

bodySite: Prostate

derivedFrom:

Entry 8 - fullUrl = http://prostatecancerspec.org/Encounter/CoreNeedleBiopsyEncounter

Resource Encounter:

identifier: http://example.hospital.de/encounters/E_24_001

status: completed

class: IMB

subject: Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)

Entry 9 - fullUrl = http://prostatecancerspec.org/ServiceRequest/CoreNeedleBiopsyReportRequest

Resource ServiceRequest:

Profile: MII PR Patho Service Request version: 2027.0.0-ballot

identifier: Placer Identifier/PATH-RPT-2024-001

requisition: Placer Group Number/BX24_001

status: Completed

intent: Order

category: Pathology consultation, comprehensive, records and specimen with report

code: No display for ServiceRequest.code (concept: Prostate Pathology biopsy report)

subject: Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)

encounter: Encounter: identifier = http://example.hospital.de/encounters#E_24_001; status = finished; class = IMB (IMB)

requester: Andreas Weber (http://example.hospital.de/practitioner-ids#URO-001)

performer: Maria Schneider (http://example.hospital.de/practitioner-ids#PATH-001)

supportingInfo:

  • No display for ServiceRequest.supportingInfo (reference: ->Observation Prostate specific Ag [Mass/volume] in Serum or Plasma)
  • No display for ServiceRequest.supportingInfo (reference: ->Condition Bösartige Neubildung der Prostata)