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
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<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Composition CoreNeedleBiopsyComposition</b></p><a name="CoreNeedleBiopsyComposition"> </a><a name="hcCoreNeedleBiopsyComposition"> </a><p><b>identifier</b>: Accession ID/PATH-COMP-2024-001</p><p><b>status</b>: Final</p><p><b>type</b>: <span title="Codes:{http://loinc.org 11526-1}, {http://ihe-d.de/CodeSystems/IHEXDStypeCode PATH}, {http://snomed.info/sct 721967005}">Pathology study</span></p><p><b>encounter</b>: <a href="Encounter-CoreNeedleBiopsyEncounter.html">Encounter: identifier = http://example.hospital.de/encounters#E_24_001; status = finished; class = IMB (IMB)</a></p><p><b>date</b>: 2024-01-20 15:30:00+0100</p><p><b>author</b>: <a href="Organization-PathologyLabOrganization.html">Pathologisches Institut</a></p><p><b>title</b>: Histopathologischer Befundbericht - Prostatabiopsie</p><h3>Attesters</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Mode</b></td><td><b>Party</b></td></tr><tr><td style="display: none">*</td><td>Legal</td><td><a href="Organization-PathologyLabOrganization.html">Organization Pathologielabor</a></td></tr></table><p><b>custodian</b>: <a href="Organization-PathologyLabOrganization.html">Organization Pathologielabor</a></p><h3>Events</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Code</b></td><td><b>Detail</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://terminology.hl7.org/CodeSystem/v3-ActCode PATREPE}">pathology report entry task</span></td><td><a href="ServiceRequest-CoreNeedleBiopsyReportRequest.html">ServiceRequest Prostate Pathology biopsy report</a></td></tr></table></div>
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<code value="ACSN"/>
<display value="Accession ID"/>
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<system value="http://example.hospital.de/pathology-reports"/>
<value value="PATH-COMP-2024-001"/>
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<status value="final"/>
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<system value="http://loinc.org"/>
<code value="11526-1"/>
<display value="Pathology study"/>
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<code value="PATH"/>
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<system value="http://snomed.info/sct"/>
<code value="721967005"/>
<display value="Tissue pathology biopsy report"/>
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<subject>🔗
<reference value="Patient/Patient1"/>
<display value="Hans Mueller, geb. 15.08.1955 (PAT-2024-001)"/>
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<encounter>🔗
<reference value="Encounter/CoreNeedleBiopsyEncounter"/>
</encounter>
<date value="2024-01-20T15:30:00+01:00"/>
<author>🔗
<reference value="Organization/PathologyLabOrganization"/>
<display value="Pathologisches Institut"/>
</author>
<title value="Histopathologischer Befundbericht - Prostatabiopsie"/>
<attester>
<mode value="legal"/>
<party>🔗
<reference value="Organization/PathologyLabOrganization"/>
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<custodian>🔗
<reference value="Organization/PathologyLabOrganization"/>
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<event>
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<coding>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="PATREPE"/>
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<detail>🔗
<reference value="ServiceRequest/CoreNeedleBiopsyReportRequest"/>
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<section>
<title value="Pathologiebefundbericht"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="60567-5"/>
<display value="Comprehensive pathology report panel"/>
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<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml"><h3>Klinische Angaben</h3><p>Erhöhter PSA-Wert (8,5 ng/ml). V.a. Prostatakarzinom. Bitte histologische Abklärung.</p><h3>Makroskopie</h3><p>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).</p><table border="1" cellpadding="4" cellspacing="0"><thead><tr><th>Stanze</th><th>Lokalisation</th><th>Stanzenlänge (cm)</th><th>Zylinderanzahl im Gefäß</th></tr></thead><tbody><tr><td>01</td><td>Rechts lateral basal</td><td>1.8</td><td>1</td></tr><tr><td>02</td><td>Rechts lateral mid</td><td>1.6</td><td>1</td></tr><tr><td>03</td><td>Rechts lateral apikal</td><td>1.5</td><td>1</td></tr><tr><td>04</td><td>Rechts medial basal</td><td>1.9</td><td>1</td></tr><tr><td>05</td><td>Rechts medial mid</td><td>1.4</td><td>1</td></tr><tr><td>06</td><td>Rechts medial apikal</td><td>1.7</td><td>1</td></tr><tr><td>07</td><td>Links lateral basal</td><td>1.6</td><td>1</td></tr><tr><td>08</td><td>Links lateral mid</td><td>1.5</td><td>1</td></tr><tr><td>09</td><td>Links lateral apikal</td><td>1.8</td><td>1</td></tr><tr><td>10</td><td>Links medial basal</td><td>1.3</td><td>1</td></tr><tr><td>11</td><td>Links medial mid</td><td>1.7</td><td>1</td></tr><tr><td>12</td><td>Links medial apikal</td><td>1.4</td><td>1</td></tr></tbody></table><h3>Mikroskopie</h3><p>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.</p><table border="1" cellpadding="4" cellspacing="0"><thead><tr><th>Stanze</th><th>Befund</th><th>Gleason-Score</th><th>Tumoranteil</th></tr></thead><tbody><tr><td>01</td><td>Adenokarzinom</td><td>3+4=7</td><td>40%</td></tr><tr><td>02</td><td>Adenokarzinom</td><td>4+3=7</td><td>60%</td></tr><tr><td>03</td><td>Benigne</td><td>-</td><td>-</td></tr><tr><td>04</td><td>Adenokarzinom</td><td>4+4=8</td><td>80%</td></tr><tr><td>05</td><td>Benigne</td><td>-</td><td>-</td></tr><tr><td>06</td><td>Adenokarzinom</td><td>3+3=6</td><td>20%</td></tr><tr><td>07</td><td>Adenokarzinom</td><td>4+5=9</td><td>95%</td></tr><tr><td>08</td><td>Benigne</td><td>-</td><td>-</td></tr><tr><td>09</td><td>Adenokarzinom</td><td>3+4=7</td><td>35%</td></tr><tr><td>10</td><td>Benigne</td><td>-</td><td>-</td></tr><tr><td>11</td><td>Adenokarzinom</td><td>3+4=7</td><td>25%</td></tr><tr><td>12</td><td>Benigne</td><td>-</td><td>-</td></tr></tbody></table><h3>Diagnostische Schlussfolgerung</h3><p>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.</p><table border="1" cellpadding="4" cellspacing="0"><tbody><tr><td>Histologischer Typ</td><td>Azinäres Adenokarzinom (8140/3)</td></tr><tr><td>Gleason-Score</td><td>4+5=9 (höchster Score)</td></tr><tr><td>ISUP-Gradgruppe</td><td>5 (WHO 2016)</td></tr><tr><td>Positive Stanzen</td><td>7 von 12 (4 rechts, 3 links)</td></tr><tr><td>Tumoranteil gesamt</td><td>51%</td></tr><tr><td>Tumorlänge gesamt</td><td>52,7 mm</td></tr><tr><td>Anteil Gleason 4/5</td><td>77%</td></tr><tr><td>Perineurale Infiltration</td><td>Nachgewiesen</td></tr><tr><td>Periprostatische Fettinvasion</td><td>Nachgewiesen (apikal)</td></tr><tr><td>Samenblaseninfiltration</td><td>Nicht nachgewiesen</td></tr><tr><td>Lymphovaskuläre Invasion</td><td>Nicht nachgewiesen</td></tr><tr><td>Intraduktales Karzinom</td><td>Nicht nachgewiesen</td></tr><tr><td>ASAP</td><td>Nicht nachgewiesen</td></tr><tr><td>High-grade-PIN</td><td>Nicht nachgewiesen</td></tr></tbody></table><p><b>Diagnose:</b> Azinäres Adenokarzinom der Prostata (ICD-O 8140/3)</p></div>
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<entry>🔗
<reference value="DiagnosticReport/CoreNeedleBiopsyReport"/>
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