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

: Enucleation Pathology Report Composition - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/Composition/TransurethralEnucleationComposition> a fhir:Composition ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "TransurethralEnucleationComposition"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ] ;
     fhir:Narrative.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>"
  ] ;
  fhir:Composition.identifier [
     fhir:Identifier.type [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ;
         fhir:Coding.code [ fhir:value "ACSN" ] ;
         fhir:Coding.display [ fhir:value "Accession ID" ]
       ]
     ] ;
     fhir:Identifier.system [ fhir:value "http://example.hospital.de/pathology-reports" ] ;
     fhir:Identifier.value [ fhir:value "PATH-COMP-2024-004" ]
  ] ;
  fhir:Composition.status [ fhir:value "final"] ;
  fhir:Composition.type [
     fhir:CodeableConcept.coding [
       fhir:index 0 ;
       a loinc:11526-1 ;
       fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
       fhir:Coding.code [ fhir:value "11526-1" ] ;
       fhir:Coding.display [ fhir:value "Pathology study" ]
     ], [
       fhir:index 1 ;
       fhir:Coding.system [ fhir:value "http://ihe-d.de/CodeSystems/IHEXDStypeCode" ] ;
       fhir:Coding.code [ fhir:value "PATH" ]
     ]
  ] ;
  fhir:Composition.subject [
     fhir:link <http://hl7.org/fhir/Patient/Patient3> ;
     fhir:Reference.reference [ fhir:value "Patient/Patient3" ] ;
     fhir:Reference.display [ fhir:value "Klaus Becker, geb. 10.11.1958 (PAT-2024-003)" ]
  ] ;
  fhir:Composition.encounter [
     fhir:link <http://hl7.org/fhir/Encounter/TransurethralEnucleationEncounter> ;
     fhir:Reference.reference [ fhir:value "Encounter/TransurethralEnucleationEncounter" ]
  ] ;
  fhir:Composition.date [ fhir:value "2024-04-15T08:00:00+01:00"^^xsd:dateTime] ;
  fhir:Composition.author [
     fhir:index 0 ;
     fhir:link <http://hl7.org/fhir/Organization/PathologyLabOrganization> ;
     fhir:Reference.reference [ fhir:value "Organization/PathologyLabOrganization" ] ;
     fhir:Reference.display [ fhir:value "Pathologisches Institut" ]
  ] ;
  fhir:Composition.title [ fhir:value "Histopathologischer Befundbericht - Prostata Enucleation"] ;
  fhir:Composition.attester [
     fhir:index 0 ;
     fhir:Composition.attester.mode [ fhir:value "legal" ] ;
     fhir:Composition.attester.party [
       fhir:link <http://hl7.org/fhir/Organization/PathologyLabOrganization> ;
       fhir:Reference.reference [ fhir:value "Organization/PathologyLabOrganization" ]
     ]
  ] ;
  fhir:Composition.custodian [
     fhir:link <http://hl7.org/fhir/Organization/PathologyLabOrganization> ;
     fhir:Reference.reference [ fhir:value "Organization/PathologyLabOrganization" ]
  ] ;
  fhir:Composition.event [
     fhir:index 0 ;
     fhir:Composition.event.code [
       fhir:index 0 ;
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ] ;
         fhir:Coding.code [ fhir:value "PATREPE" ]
       ]
     ] ;
     fhir:Composition.event.detail [
       fhir:index 0 ;
       fhir:link <http://hl7.org/fhir/ServiceRequest/TransurethralEnucleationReportRequest> ;
       fhir:Reference.reference [ fhir:value "ServiceRequest/TransurethralEnucleationReportRequest" ]
     ]
  ] ;
  fhir:Composition.section [
     fhir:index 0 ;
     fhir:Composition.section.title [ fhir:value "Pathologiebefundbericht" ] ;
     fhir:Composition.section.code [
       fhir:CodeableConcept.coding [
         fhir:index 0 ;
         a loinc:60567-5 ;
         fhir:Coding.system [ fhir:value "http://loinc.org" ] ;
         fhir:Coding.code [ fhir:value "60567-5" ] ;
         fhir:Coding.display [ fhir:value "Comprehensive pathology report panel" ]
       ]
     ] ;
     fhir:Composition.section.text [
       fhir:Narrative.status [ fhir:value "additional" ] ;
       fhir:Narrative.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>"
     ] ;
     fhir:Composition.section.entry [
       fhir:index 0 ;
       fhir:link <http://hl7.org/fhir/DiagnosticReport/TransurethralEnucleationReport> ;
       fhir:Reference.reference [ fhir:value "DiagnosticReport/TransurethralEnucleationReport" ]
     ]
  ] .

<http://hl7.org/fhir/Patient/Patient3> a fhir:Patient .

<http://hl7.org/fhir/Encounter/TransurethralEnucleationEncounter> a fhir:Encounter .

<http://hl7.org/fhir/Organization/PathologyLabOrganization> a fhir:Organization .

<http://hl7.org/fhir/ServiceRequest/TransurethralEnucleationReportRequest> a fhir:ServiceRequest .

<http://hl7.org/fhir/DiagnosticReport/TransurethralEnucleationReport> a fhir:DiagnosticReport .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/Composition/TransurethralEnucleationComposition.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/Composition/TransurethralEnucleationComposition.ttl> .