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
Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)
Document Content
Obstruktive Miktionsbeschwerden. PSA 12,5 ng/ml. Prostata-Enukleation (HoLEP/ThuLEP). V.a. Prostatakarzinom.
Enukleationspräparat 25 g, Maße 3,5 × 2,8 × 2,2 cm. Keine Samenblasen, keine Lymphknoten im Resektat.
| Präparat | Prostata-Enukleationspräparat |
| Gewicht | 25 g |
| Maße (L × B × T) | 3,5 × 2,8 × 2,2 cm |
| Samenblasen | Nicht im Resektat |
| Lymphknoten | Nicht im Resektat |
Azinäres Adenokarzinom der Prostata mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration mit perineuralem und lymphovaskulärem Befall.
Gleason-Score 4+5=9, ISUP-Gradgruppe 5 (WHO 2016). Anteil Gleasonmuster 4/5: 90%. Tumorinfiltration ca. 60% des Prostatagewebes. Intraduktales Karzinom und invasive kribriforme Anteile nachgewiesen. Extraprostatische Ausbreitung, Samenblaseninvasion, lymphovaskuläre Invasion und perineurale Infiltration nachgewiesen.
| Histologischer Typ | Azinäres Adenokarzinom mit invasiven kribriformen Anteilen (8140/3) |
| Gleason-Score | 4+5=9 |
| ISUP-Gradgruppe | 5 (WHO 2016) |
| Tumoranteil | 60% |
| Anteil Gleason 4/5 | 90% |
| Intraduktales Karzinom | Nachgewiesen |
| Invasives kribriformes Karzinom | Nachgewiesen |
| Extraprostatische Ausbreitung | Nachgewiesen |
| Samenblaseninfiltration | Nachgewiesen |
| Lymphovaskuläre Invasion | Nachgewiesen |
| Perineurale Infiltration | Nachgewiesen |
Diagnose: Azinäres Adenokarzinom der Prostata (ICD-O 8140/3) – High-grade
Empfehlung: Staging-Untersuchungen und interdisziplinäre Tumorkonferenz.
Entry 2 - fullUrl = http://prostatecancerspec.org/Patient/Patient3
Resource Patient:
Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)
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/TransurethralEnucleationReport
Resource DiagnosticReport:
Profile: MII PR Patho Report version: 2026.0.0
Pathology Synoptic report (Surgical Pathology)
Subject Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003) Relevant Time 2024-05-12 17:00:00+0100 Reported 2024-05-13 08:00:00+0100 Performer Practitioner Maria Schneider Identifier Accession ID/E_24_004 Report Details
Code Value Flags Relevant Time Pathology report gross observation Narrative (Prostate) Final 2024-04-11 14:00:00+0100 Pathology report final diagnosis Narrative Final 2024-05-12 Prostata Enucleation: Azinäres Adenokarzinom, Gleason Score 4+5=9 (ISUP Grade Group 5), mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration (60% des Gewebes) mit extraprostatischer Extension, Samenblaseninvasion, perineuralem und lymphovaskulärem Befall.
Entry 5 - fullUrl = http://prostatecancerspec.org/Observation/TransurethralEnucleationDiagnosticConclusionGrouper
Resource Observation:
Profile: MII PR Patho Diagnostic Conclusion Grouper version: 2026.0.0
basedOn: ServiceRequest Prostatectomy (procedure)
status: Final
category: Laboratory
code: Pathology report final diagnosis Narrative
subject: Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)
effective: 2024-05-12
performer: Practitioner Maria Schneider
hasMember:
- Observation Histology and Behavior ICD-O-3 Cancer
- Observation Histology type in Cancer specimen Narrative
- 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 Tissue cores.positive.carcinoma in Tissue core
- 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
Entry 6 - fullUrl = http://prostatecancerspec.org/Observation/TransurethralEnucleationMacroscopicGrouper
Resource Observation:
Profile: MII PR Patho Macroscopic Grouper version: 2026.0.0
status: Final
category: Laboratory
code: Pathology report gross observation Narrative
subject: Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)
effective: 2024-04-11 14:00:00+0100
performer: Practitioner Maria Schneider
bodySite: Prostate
hasMember:
Entry 7 - fullUrl = http://prostatecancerspec.org/Encounter/TransurethralEnucleationEncounter
Resource Encounter:
identifier:
http://example.hospital.de/encounters/E_24_004status: completed
class: IMP
subject: Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)
Entry 8 - fullUrl = http://prostatecancerspec.org/ServiceRequest/TransurethralEnucleationReportRequest
Resource ServiceRequest:
Profile: MII PR Patho Service Request version: 2026.0.0
identifier: Placer Identifier/PATH-RPT-2024-004
status: Completed
intent: Order
category: Pathology consultation, comprehensive, records and specimen with report (procedure)
code: No display for ServiceRequest.code (concept: Prostatectomy (procedure))
subject: Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)
requester: Practitioner Andreas Weber
performer: Practitioner Maria Schneider
supportingInfo:
- No display for ServiceRequest.supportingInfo (reference: ->Observation Prostate specific Ag [Mass/volume] in Serum or Plasma)
- No display for ServiceRequest.supportingInfo (reference: ->Procedure Enukleation der Prostata)
- No display for ServiceRequest.supportingInfo (reference: ->Condition Prostatahyperplasie ohne Beschwerden beim Wasserlassen)