{
  "resourceType" : "Composition",
  "id" : "TransurethralEnucleationComposition",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition TransurethralEnucleationComposition</b></p><a name=\"TransurethralEnucleationComposition\"> </a><a name=\"hcTransurethralEnucleationComposition\"> </a><p><b>identifier</b>: Accession ID/PATH-COMP-2024-004</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}\">Pathology study</span></p><p><b>encounter</b>: <a href=\"Encounter-TransurethralEnucleationEncounter.html\">Encounter: identifier = http://example.hospital.de/encounters#E_24_004; status = finished; class = IMP (IMP)</a></p><p><b>date</b>: 2024-04-15 08:00:00+0100</p><p><b>author</b>: <a href=\"Organization-PathologyLabOrganization.html\">Pathologisches Institut</a></p><p><b>title</b>: Histopathologischer Befundbericht - Prostata Enucleation</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-TransurethralEnucleationReportRequest.html\">ServiceRequest Prostatectomy (procedure)</a></td></tr></table></div>"
  },
  "identifier" : {
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
        "code" : "ACSN",
        "display" : "Accession ID"
      }]
    },
    "system" : "http://example.hospital.de/pathology-reports",
    "value" : "PATH-COMP-2024-004"
  },
  "status" : "final",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "11526-1",
      "display" : "Pathology study"
    },
    {
      "system" : "http://ihe-d.de/CodeSystems/IHEXDStypeCode",
      "code" : "PATH"
    }]
  },
  "subject" : {
    "reference" : "Patient/Patient3",
    "display" : "Klaus Becker, geb. 10.11.1958 (PAT-2024-003)"
  },
  "encounter" : {
    "reference" : "Encounter/TransurethralEnucleationEncounter"
  },
  "date" : "2024-04-15T08:00:00+01:00",
  "author" : [{
    "reference" : "Organization/PathologyLabOrganization",
    "display" : "Pathologisches Institut"
  }],
  "title" : "Histopathologischer Befundbericht - Prostata Enucleation",
  "attester" : [{
    "mode" : "legal",
    "party" : {
      "reference" : "Organization/PathologyLabOrganization"
    }
  }],
  "custodian" : {
    "reference" : "Organization/PathologyLabOrganization"
  },
  "event" : [{
    "code" : [{
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code" : "PATREPE"
      }]
    }],
    "detail" : [{
      "reference" : "ServiceRequest/TransurethralEnucleationReportRequest"
    }]
  }],
  "section" : [{
    "title" : "Pathologiebefundbericht",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "60567-5",
        "display" : "Comprehensive pathology report panel"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h3>Klinische Angaben</h3><p>Obstruktive Miktionsbeschwerden. PSA 12,5 ng/ml. Prostata-Enukleation (HoLEP/ThuLEP). V.a. Prostatakarzinom.</p><h3>Makroskopie</h3><p>Enukleationspräparat 25 g, Maße 3,5 × 2,8 × 2,2 cm. Keine Samenblasen, keine Lymphknoten im Resektat.</p><table border=\"1\" cellpadding=\"4\" cellspacing=\"0\"><tbody><tr><td>Präparat</td><td>Prostata-Enukleationspräparat</td></tr><tr><td>Gewicht</td><td>25 g</td></tr><tr><td>Maße (L × B × T)</td><td>3,5 × 2,8 × 2,2 cm</td></tr><tr><td>Samenblasen</td><td>Nicht im Resektat</td></tr><tr><td>Lymphknoten</td><td>Nicht im Resektat</td></tr></tbody></table><h3>Mikroskopie</h3><p>Azinäres Adenokarzinom der Prostata mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration mit perineuralem und lymphovaskulärem Befall.</p><h3>Diagnostische Schlussfolgerung</h3><p>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.</p><table border=\"1\" cellpadding=\"4\" cellspacing=\"0\"><tbody><tr><td>Histologischer Typ</td><td>Azinäres Adenokarzinom mit invasiven kribriformen Anteilen (8140/3)</td></tr><tr><td>Gleason-Score</td><td>4+5=9</td></tr><tr><td>ISUP-Gradgruppe</td><td>5 (WHO 2016)</td></tr><tr><td>Tumoranteil</td><td>60%</td></tr><tr><td>Anteil Gleason 4/5</td><td>90%</td></tr><tr><td>Intraduktales Karzinom</td><td>Nachgewiesen</td></tr><tr><td>Invasives kribriformes Karzinom</td><td>Nachgewiesen</td></tr><tr><td>Extraprostatische Ausbreitung</td><td>Nachgewiesen</td></tr><tr><td>Samenblaseninfiltration</td><td>Nachgewiesen</td></tr><tr><td>Lymphovaskuläre Invasion</td><td>Nachgewiesen</td></tr><tr><td>Perineurale Infiltration</td><td>Nachgewiesen</td></tr></tbody></table><p><b>Diagnose:</b> Azinäres Adenokarzinom der Prostata (ICD-O 8140/3) – High-grade</p><p><b>Empfehlung:</b> Staging-Untersuchungen und interdisziplinäre Tumorkonferenz.</p></div>"
    },
    "entry" : [{
      "reference" : "DiagnosticReport/TransurethralEnucleationReport"
    }]
  }]
}