Prostate Cancer Specification
0.1.0 - ci-build
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
Document Subject
Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)
Document Content
Z.n. Prostata-Stanzbiopsie mit Nachweis eines Prostatakarzinoms (höchster Gleason 4+5=9, ISUP-Gradgruppe 5). Radikale Prostatektomie mit pelviner Lymphadenektomie.
Prostatektomiepräparat 55 g, Maße 4,5 × 4,0 × 3,5 cm. Samenbläschen beidseits 2,5 cm. Lymphknoten bilateral vorhanden.
| Präparat | Radikale Prostatektomie mit Samenblasen und pelvinen Lymphknoten |
| Gewicht | 55 g |
| Maße (B × H × T) | 4,5 × 4,0 × 3,5 cm |
| Samenblasen | Vorhanden, beidseits 2,5 cm |
| Lymphknoten | Bilateral vorhanden |
Azinäres Adenokarzinom der Prostata mit gemischten, überwiegend klein- bis mitteltubulären, mäßig irregulären Drüsen sowie einem geringeren Anteil an kribriformen Wachstumsmustern. Tumorgewebe in beiden Seitenlappen nachweisbar. Kein kapselüberschreitendes Wachstum. Samenblasen und Lymphknoten tumorgewebsfrei.
Gleason-Score 3+4=7, ISUP-Gradgruppe 2 (WHO 2016). Maximaler Tumordurchmesser 18 mm, 25% des Prostatagewebes tumorbefallen. Anteil Gleasonmuster 4/5: 30%. Kein intraduktales Karzinom, kein invasives kribriformes Karzinom. Keine extraprostatische Ausbreitung, keine Samenblaseninfiltration, keine lymphovaskuläre Invasion, keine perineurale Infiltration, keine Blasenhalsinvasion. Absetzungsränder tumorfrei (R0). 12 Lymphknoten untersucht, 0 positiv. Staging: pT2 pN0.
| Histologischer Typ | Azinäres Adenokarzinom (8140/3) |
| Gleason-Score | 3+4=7 |
| ISUP-Gradgruppe | 2 (WHO 2016) |
| Maximaler Tumordurchmesser | 18 mm |
| Tumoranteil | 25% |
| Anteil Gleason 4/5 | 30% |
| Intraduktales Karzinom | Nicht nachgewiesen |
| Invasives kribriformes Karzinom | Nicht nachgewiesen |
| Extraprostatische Ausbreitung | Nicht nachgewiesen |
| Samenblaseninfiltration | Nicht nachgewiesen |
| Lymphovaskuläre Invasion | Nicht nachgewiesen |
| Perineurale Infiltration | Nicht nachgewiesen |
| Blasenhalsinvasion | Nicht nachgewiesen |
| Absetzungsränder | Tumorfrei (R0) |
| Lymphknoten untersucht | 12 |
| Lymphknoten positiv | 0 |
| pT-Stadium | pT2 |
| pN-Stadium | pN0 |
Diagnose: Azinäres Adenokarzinom der Prostata (ICD-O 8140/3)
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:
identifier:
http://example.hospital.de/organization-ids/ORG-PATH-001name: Pathologielabor
Entry 4 - fullUrl = http://prostatecancerspec.org/DiagnosticReport/RadicalProstatectomyReport
Resource DiagnosticReport:
Profile: MII PR Patho Report version: 2026.0.0
Pathology Synoptic report (Surgical Pathology)
Subject Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001) Relevant Time 2024-03-20 17:00:00+0100 Reported 2024-03-21 08:00:00+0100 Performer Practitioner Maria Schneider Identifier Accession ID/E_24_002 Report Details
Code Value Flags Relevant Time Pathology report gross observation Narrative (Prostate) Makroskopische Messungen des Prostatektomiepräparats Final 2024-03-16 14:00:00+0100 Pathology report final diagnosis Narrative Final 2024-03-20 Adenokarzinom der Prostata, Gleason Score 3+4=7, pT2 pN0 (0/12) R0. Maximaler Tumordurchmesser 18 mm (ca. 25% der Prostata). Keine extrakapsuläre Extension, keine Samenblaseninvasion, alle Resektionsränder tumorfrei.
Entry 5 - fullUrl = http://prostatecancerspec.org/Observation/RadicalProstatectomyDiagnosticConclusionGrouper
Resource Observation:
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: Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)
effective: 2024-03-20
performer: Practitioner Maria Schneider
hasMember:
- Observation Histology and Behavior ICD-O-3 Cancer
- Observation Histology type in Cancer specimen Narrative
- Observation World Health Organization tumor classification (observable entity)
- Observation Gleason pattern.primary in Prostate tumor
- Observation Gleason pattern.secondary in Prostate tumor
- Observation Gleason score in Specimen Qualitative
- Observation Prostate tumor area with Gleason pattern 4+5/Total tumor area [Area Fraction] in Prostate tumor by Microscopy
- Observation Histologic grade of primary malignant neoplasm of prostate by International Society of Urological Pathology technique (observable entity)
- Observation Non-infiltrating intraductal carcinoma (morphologic abnormality)
- Observation Cribriform carcinoma
- Observation Size.maximum dimension in Tumor
- Observation Tissue involved by tumor in Prostate tumor
- Observation Periprostatic fat invasion [Identifier] in Specimen by CAP cancer protocols
- Observation Seminal vesicle invasion [Identifier] in Specimen by CAP cancer protocols
- Observation Venous + Lymphatic small vessel invasion in Specimen by CAP cancer protocols
- Observation Perineural invasion [Presence] in Cancer specimen
- Observation Bladder neck involvement of Prostate tumor
- Observation Margin involvement [Type] in Prostate tumor
- Observation Regional lymph nodes examined [#] Specimen
- Observation Regional lymph nodes positive [#] Specimen
- Observation Primary tumor.pathology Cancer
- Observation Regional lymph nodes.pathology [Class] Cancer
Entry 6 - fullUrl = http://prostatecancerspec.org/Observation/RadicalProstatectomyMacroscopicGrouper
Resource Observation:
Profile: MII PR Patho Macroscopic Grouper version: 2026.0.0
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: 2024-03-16 14:00:00+0100
performer: Practitioner Maria Schneider
value: Makroskopische Messungen des Prostatektomiepräparats
bodySite: Prostate
hasMember:
- Observation Weight of Tissue
- Observation Dimension [Length] of Specimen
- Observation Dimension [Length] of Specimen
- Observation Dimension [Length] of Specimen
- Observation Tumor finding
- Observation Anatomic part Laterality
- Observation Seminal vesicles [Presence] in Specimen
- Observation Dimension [Length] of Specimen
Entry 7 - fullUrl = http://prostatecancerspec.org/Encounter/RadicalProstatectomyEncounter
Resource Encounter:
identifier:
http://example.hospital.de/encounters/E_24_002status: completed
class: IMP
subject: Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)
Entry 8 - fullUrl = http://prostatecancerspec.org/ServiceRequest/RadicalProstatectomyReportRequest
Resource ServiceRequest:
Profile: MII PR Patho Service Request version: 2026.0.0
identifier: Placer Identifier/PATH-RPT-2024-002
status: Completed
intent: Order
category: Pathology consultation, comprehensive, records and specimen with report (procedure)
code: No display for ServiceRequest.code (concept: Pathology synoptic report)
subject: Hans Mueller Male, DoB: 1955-08-15 ( http://example.hospital.de/patient-ids#PAT-2024-001)
requester: Practitioner Andreas Weber
performer: Practitioner Maria Schneider
supportingInfo: No display for ServiceRequest.supportingInfo (reference: ->Condition Bösartige Neubildung der Prostata)