STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

??.?? Logical Model nehta-colorectal - Content

Colorectal cancer.

??.??.1 Scope and Usage

TODO

??.??.2 Boundaries and Relationships

TODO

??.??.3 Background and Context

TOGO

??.??.4 Logical Model Content

Structure

NameFlagsCard.TypeDescription & ConstraintsImplemented Asdoco
.. Colorectal LogicalColorectaldr := DiagnosticReport
... subject Σ1..1Reference(Patient | Group)The subject of the report, usually, but not always, the patientdr.subject
... requester Σ0..1Reference(Practitioner)Who ordered the test!req := dr.request->DiagnosticOrder; req[orderer := $value]
... performer Σ0..1Reference(Practitioner | Organization)Responsible Diagnostic Servicedr[performer := $value]
... preAnalytic I0..1ElementPre Analytic
If there is a perforation, the perforation type must be indicated.		req := dr.request->DiagnosticOrder; req[orderer := $value]
.... clinicalInformation 0..1stringClinical informationreq.reason[text := $value]
.... operatingSurgeonDetails Σ0..1Reference(Practitioner)Operating surgeon detailssp := dr.specimen->Specimen; sp.collection[collector := $value]
.... perforation I0..1codePerforation
PresentAbsentNotstated (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... natureOfPerforation 0..*codeNature of perforation
NehtaNatureOfPerforation (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... clinicalObstruction 0..1codeClinical obstruction
PresentAbsentNotstated (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... tumourLocation I0..*codeTumour location
ColorectalCancerTumourLocation (Required)
If the tumour location is rectum, then the distance from the anal verge must be recorded.		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... synchronousTumours 0..1stringSynchronous tumours - other sitereq.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... distanceAnalVerge 0..1SimpleQuantityDistance from anal vergereq.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... typeOfOperation I0..1code*
ColorectalCancerOperationType (Required)
If other procedure(s) is selected, then record the type of procedure.
If anterior resection is selected, record anterior resection type.		too := req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... typeOfProcedure 0..1stringProcedure typetoo.text
.... anteriorResectionType 0..1codeAnterior resection type
HiLowUltralow (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... preoperativeRadiotherapy I0..1codePre-operative radiotherapy
YesNoNotStated (Required)
If pre-operative radiotherapy is done, then the type of course is to be recorded.		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... typeOfCourse 0..1codeType of course
TypeOfCourse (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... surgeonsOpinion 0..1stringSurgeons opinion of residual cancerreq.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... adjacentOrgans 0..1stringAdjacent organ involvementreq.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... newPrimaryOrRecurrence I0..1codeNew primary cancer or recurrence
NehtaCancerPrimaryOrRecurrence (Required)
If regional (local) recurrence or distant metastasis describe.		pno := req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... RecurrenceDescription 0..1stringDescribepno.component[code := %map-codes; value[x] := $value]
.... pathologyAccessionNumber 0..1stringPathology numberdr[identifier := $value]
.... otherRelevantDetails 0..1stringOther detailsreq.note[text := $value]
... macro I0..1ElementMacroscopy
If lymph nodes have been received the tumour inolvement in the lymph nodes is to be recorded.
If lymph nodes are received, record the number of nodes		macro := dr.result->Observation[code := %map-codes]
.... specimenLength 1..1SimpleQuantitySpecimen lengthsp1 := dr.specimen->Specimen; sp1.collection[quantity := $value]
.... tumourSite I1..1codeTumour site
ColorectalCancerTumourLocation (Required)
If the tumour is a rectal tumour the status of the nonperitonealised circumferential margin (rectal tumours) is to be recorded.
If tumour site is rectum, the intactness of mesorectum is to be recorded.
If tumour site is rectum, the relationship to anterior peritoneal reflection is to be recorded.		sp2 := dr.specimen->Specimen; sp2.collection[bodySite := $value]
.... maxTumourDiameter 1..1SimpleQuantityMax. tumour diametermacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... distanceNearerProxOrDistal 1..*SimpleQuantityDist. of tumour to the nearer proximal or distal "cut end"macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... distNonperitonCircumMargin 1..1SimpleQuantityDist. of tumour to the nonperitonealised circumferential marginmacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourPerforation 1..1codeTumour perforation
PresentAbsent (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... relToAntPeritonealReflection 0..1codeRelationship to anterior peritoneal reflection
NehtaRelAnteriorPeritonealReflection (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... intactnessOfMesorectum 0..1codeIntactness of mesorectum
MesorectumIntactness (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... peritoneum 0..1codePeritoneum
NehtaPeritoneumInvasion (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... lymphNodes I0..1codeLymph nodes
ReceivedNotreceived (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... noLymphNodesPerCassette 0..*stringNumber of lymph nodes in each cassettemacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... polyps I0..1codePolyps
PresentAbsent (Required)
If polyps are present, provide a polyp summary.		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... polypSummary 0..1stringThe number, diameter and gross configuration of polyps should be summarisedmacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... otherMacroComments 0..1stringOther macroscopic commentsmacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... natureAndSiteOfBlocks 1..*stringNature and site of blocksmacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
... micro 0..1ElementMicroscopymicro := dr.result->Observation[code := %map-codes]
.... tumourType 1..1codeTumour type
TumourType (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... histologicalGrade 1..1codeHistological grade
HistologicalGrade (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... maxDegreeLocalInvasion 1..1codeMaximum degree of local invasion into or through the bowel wall
DegreeInvasionBowelWall (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... proximalOrDistalResectionMargins I0..1codeInvolvement of the proximal or distal resection (cut-end) margins
CRCInvolvedNotinvolved (Required)
If the tumour is not involved in the proximal or distal resection (‘cut-end’) margins, then record the microscopic clearance.
If the tumour is involved in the proximal or distal resection (‘cut-end’) margins, then record invovled margin(s).		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... involvedMargins 1..*codeInvolved margin(s)
DistalProximal (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... marginsMicroClearance 0..1SimpleQuantityMicroscopic Clearancemicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... nonperitonealisedCircumMargin I0..1codeStatus of the nonperitonealised circumferential margin (rectal tumours)
InvolvedNotinvolved (Required)
If the tumour is a rectal tumour and the status of the nonperitonealised circumferential margin (rectal tumours) is not involved, then the clearance is to be recorded.		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... microClearanceRectum 0..1SimpleQuantityMicroscopic Clearancemicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... lymphNodeInvolvement I0..1codeLymph node involvement
PresentAbsent (Required)
If tumour positive lymph nodes are present then record the site(s) and numbers of lymph nodes.		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... lymphNodesDetails 0..*stringSite(s) and numbers of lymph nodesmicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... extramuralTumourDeposits 0..1codeIsolated extra-mural tumour deposits
PresentAbsent (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... apicalNodeInvolvement 0..1codeApical node involvement
PresentAbsent (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... venousSmallVesselInvasion 0..1stringVenous and small vessel invasionmicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... intramuralVeinInvasion 1..1codeIntramural vein invasion
NotIdentifiedPresent (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... extramuralVeinInvasion 1..1codeExtramural vein invasion
NotIdentifiedPresent (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... smallVesselInvasion 1..1codeSmall vessel invasion
NotIdentifiedPresentPresentExtensive (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... perineuralInvasion 1..1codePerineural invasion
NotIdentifiedPresentPresentExtensive (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... histoConfDistMetastases I1..1codeHistologically confirmed distant metastases
PresentAbsent (Required)
If histologically confirmed distant metastases are present then the sites are to be recorded.		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... histoConfDistMetastasesSite 0..1stringHistologically confirmed distant metastases - sitemicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... relCoexistPathabnorm I1..*codeRelevant coexistent pathological abnormalities
CoexistentPathologicalAbnormalities (Required)
If polyps are present as relevant coexistent pathological abnormalities, then polyp details are to be recorded.
If Ulcerative colitis is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded.
If Crohn's disease is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded.
If other abnormalities is selected as relevant coexistent pathological abnormality, then other abnormaily details are to be recorded.		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... polypDetails 0..1stringPolyp details (type, number, polyposis syndrome criteria met etc)micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... dysplasia 0..1codeDysplasia
Dysplasia (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... otherAbnormality 0..1stringOther abnormalitymicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... microResidualTumourStatus 1..1stringMicroscopic residual tumour status (completeness of resection)micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... neoadjuvantTherapy 0..1codeResponse to neoadjuvant therapy
ResponseToNeoadjuvantTherapy (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... microComments 0..1stringMicroscopic commentsmicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
... ancillaryTests 0..1ElementAncillary test findingsancillary := dr.result->Observation[code := %map-codes]
.... mismatchRepairEnz 1..1Mismatch repair enzymes
.... mlh1 0..1codeMLH-1
StainType (Required)		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... pms2 0..1codePMS-2
StainType (Required)		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... msh2 0..1codeMSH-2
StainType (Required)		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... msh6 0..1codeMSH-6
StainType (Required)		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... comments 0..1stringMismatch repair enzyme commentsancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... msi I0..1ElementMicrosatellite instability (MSI)
..... code I0..1codeMicrosatellite instability (MSI)
UnstableStable (Required)
If MSI unstable, record laboratory performing test and report number
If MSI stable, record laboratory performing test and report number		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... comments 0..1stringMicrosatellite instability (MSI) commentsancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... labDetails 0..1stringMSI laboratory performing test and report numberancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... braf I0..1ElementBRAF (V600E mutation)
..... code I0..1codeBRAF (V600E mutation)
MutatedWildtype (Required)
If BRAF mutated, record laboratory performing test and report number
If BRAF wild type, record laboratory performing test and report number		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... comments 0..1stringBRAF (V600E mutation) commentsancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... labDetails 0..1stringBRAF (V600E mutation) laboratory performing test and report numberancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... kras I0..1ElementKRAS gene mutation (codons 12 and 13)
..... code I0..1codeKRAS gene mutation (codons 12 and 13)
MutatedWildtype (Required)
If KRAS wild type, record laboratory performing test and report number
If KRAS mutated, record laboratory performing test and report number		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... comments 0..1stringKRAS gene mutation (codons 12 and 13) commentsancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... labDetails 0..1stringKRAS gene mutation (codons 12 and 13) laboratory performing test and report numberancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
... synthesisOverview 0..1ElementSynthesis and Overviewsynthesis := dr.result->Observation[code := %map-codes]
.... tumourStage 1..1stringTumour stagesynthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStageT 0..1codeT
CrcTumourStageT (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStageN 0..1codeN
CrcTumourStageN (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStageM 0..1codeM
CrcTumourStageM (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStageGrouping 1..1codeStage grouping
TumourStageGrouping (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStagingSystem 1..1stringYear and/or edition of staging systemsynthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... residualTumourStatus 1..1stringResidual tumour status
ResidualTumourStatus (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... diagnosticSummary Σ0..1stringDiagnostic summarydr[conclusion := $value]
.... newPrimaryOrRecurrence 0..1codeNew primary cancer or recurrence
NewCancerOrRecurrence (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... newDescription 0..1stringDescribe
.... overarchingComment 0..1stringOverarching commentsynthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]

doco Documentation for this format

UML Diagram

Colorectal (Logical)The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sourcessubject : Reference [1..1] « Patient|Group »The practitioner that holds legal responsibility for ordering the investigationrequester : Reference [0..1] « Practitioner »The diagnostic service that is responsible for issuing the reportperformer : Reference [0..1] « Practitioner|Organization »PreAnalyticClinical information provided on request formclinicalInformation : string [0..1]The operating surgeon name and contact detailsoperatingSurgeonDetails : Reference [0..1] « Practitioner »Presence or absence of a perforationperforation : code [0..1] « A code that indicates whether perforation is present (Strength=Required)PresentAbsentNotstated! »The type of perforationnatureOfPerforation : code [0..*] « A code that indicates the type of perforation (Strength=Required)NehtaNatureOfPerforation! »Whether a clinical obstruction is present or absentclinicalObstruction : code [0..1] « A code that indicates whether a clinical obstruction is present (Strength=Required)PresentAbsentNotstated! »Anatomical location of the tumour from a given listtumourLocation : code [0..*] « A code that indicates the antomical location of the tumour from a given list (Strength=Required)ColorectalCancerTumourLocation! »For synchronous tumours indicate each other sitesynchronousTumours : string [0..1]Quantitative measurement of distance from anal vergedistanceAnalVerge : Quantity(SimpleQuantity) [0..1]The type of operation selected from a listtypeOfOperation : code [0..1] « A code that indicates the type of operation (Strength=Required)ColorectalCancerOperationType! »Type of proceduretypeOfProcedure : string [0..1]The type of anterior resectionanteriorResectionType : code [0..1] « A code that idicates the type of anterior resection (Strength=Required)HiLowUltralow! »An indication of pre-operative radiotherapypreoperativeRadiotherapy : code [0..1] « A code that indicates whether pre-operative radiotherapy was used (Strength=Required)YesNoNotStated! »The type of course of pre-operative radiotherapytypeOfCourse : code [0..1] « A code that indicates the type of course of pre-operative radiotherapy (Strength=Required)TypeOfCourse! »Surgeons opinion on the existence of local residual cancer postsurgerysurgeonsOpinion : string [0..1]Involvement of adjacent organsadjacentOrgans : string [0..1]An indication of whether a new primary cancer or a recurrencenewPrimaryOrRecurrence : code [0..1] « A code that indicates whether a new primary cancer or an recurrence (Strength=Required) NehtaCancerPrimaryOrRecurrence! »Description of regional (local) recurrence or distant metastasesRecurrenceDescription : string [0..1]Pathology accession numberpathologyAccessionNumber : string [0..1]Other relevant detailsotherRelevantDetails : string [0..1]MacroThe length of the specimenspecimenLength : Quantity(SimpleQuantity) [1..1]The site of the tumourtumourSite : code [1..1] « A code that indicates the site of the tumour (Strength=Required)ColorectalCancerTumourLocation! »Maximum tumour diametermaxTumourDiameter : Quantity(SimpleQuantity) [1..1]Distance of tumour to the nearer proximal or distal "cut end"distanceNearerProxOrDistal : Quantity(SimpleQuantity) [1..*]Distance of tumour to the nonperitonealised circumferential margindistNonperitonCircumMargin : Quantity(SimpleQuantity) [1..1]The presence or absence of tumour perforationtumourPerforation : code [1..1] « A code that indicates the presence or absence of a tumour perforation (Strength=Required)PresentAbsent! »Site of tumour in relation to the anterior level of the peritoneal reflectionrelToAntPeritonealReflection : code [0..1] « A code that indicates the site of tumour in relation to the anterior level of the peritoneal reflection (Strength=Required) NehtaRelAnteriorPeritonealRef...! »For rectal resections the intactness of the mesorectum must be recordedintactnessOfMesorectum : code [0..1] « A code that indicates the intactness of the mesorectum (Strength=Required)MesorectumIntactness! »Any involvement of the peritoneum should be recordedperitoneum : code [0..1] « A code that indicates the tumour invovlement in the peritoneum (Strength=Required)NehtaPeritoneumInvasion! »If lymph nodes are received, then they should be recordedlymphNodes : code [0..1] « A code that indicates if lymph nodes were received (Strength=Required)ReceivedNotreceived! »The number of lymph nodes placed in each cassette should be recordednoLymphNodesPerCassette : string [0..*]The presence or absence of polyps should be recordedpolyps : code [0..1] « A code that indicates the presence or absence of polyp(s) (Strength=Required)PresentAbsent! »The polyp summary should include the numbers, diameter range and gross appearancepolypSummary : string [0..1]A descriptive or narrative field should be provided to record any macroscopic information that is not recorded in the above standards and guidelines, and that would normally form part of the macroscopic descriptionotherMacroComments : string [0..1]The nature and sites of all blocks must be recordednatureAndSiteOfBlocks : string [1..*]MicroA single selection value list from WHO Classification of TumourstumourType : code [1..1] « A code from the WHO Calssification that indicates the tumour type (Strength=Required)TumourType! »The histological grading of the tumour must be recordedhistologicalGrade : code [1..1] « A code that indicates the histological grade of the tumour (Strength=Required)HistologicalGrade! »The maximum degree of local invasion into or through the bowel wall must be recordedmaxDegreeLocalInvasion : code [1..1] « A code that indicates the maximum degree of local invasion into or through the bowel wall (Strength=Required)DegreeInvasionBowelWall! »Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recordedproximalOrDistalResectionMargins : code [0..1] « A code that indicates involvement of the proximal or distal resection (cut-end) margins (Strength=Required) CRCInvolvedNotinvolved! »Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recordedinvolvedMargins : code [1..*] « A code that indicates the involvement at the margins (Strength=Required)DistalProximal! »If the margin is less than 10 mm, the clearance must be recordedmarginsMicroClearance : Quantity(SimpleQuantity) [0..1]The status of the nonperitonealised circumferential margin in rectal tumours must be recordednonperitonealisedCircumMargin : code [0..1] « A code that indicates the status of the nonperitonealised circumferential margin in rectal tumours (Strength=Required)InvolvedNotinvolved! »In rectal tumours, the minimum distance in millimetres between the tumour and the nonperitonealised (circumferential, radial) margin must be recorded from the histological slidesmicroClearanceRectum : Quantity(SimpleQuantity) [0..1]Results of lymph node histopathology must be recordedlymphNodeInvolvement : code [0..1] « A code that indicates lymph node involvement (Strength=Required)PresentAbsent! »If lymph node(s) received then the site(s) and numbers of lymph nodes must be recordedlymphNodesDetails : string [0..*]The presence or absence of isolated extra-mural tumour deposits is to be recordedextramuralTumourDeposits : code [0..1] « A code that indicates the presence or absence of isolated extra-mural tumour deposits. (Strength=Required)PresentAbsent! »Involvement of the apical lymph node should be recordedapicalNodeInvolvement : code [0..1] « A code that indicates apical node involvement (Strength=Required)PresentAbsent! »For all tumours, venous and small vessel invasion must be reported and its anatomic location specified as intramural or extramuralvenousSmallVesselInvasion : string [0..1]Intramural invasion must be reported onintramuralVeinInvasion : code [1..1] « A code that indicates intramural vein invasion (Strength=Required)NotIdentifiedPresent! »Extramural invasion must be reported onextramuralVeinInvasion : code [1..1] « A code that indicates extramural vein invasion (Strength=Required)NotIdentifiedPresent! »Small vessel invasion must be reported onsmallVesselInvasion : code [1..1] « A code that indicates small vessel invasion (Strength=Required)NotIdentifiedPresentPresentEx...! »Perineural invasion must be reported onperineuralInvasion : code [1..1] « A code that indicates perineural invasion (Strength=Required)NotIdentifiedPresentPresentEx...! »The presence or absence of histologically confirmed distant metastases must be recordedhistoConfDistMetastases : code [1..1] « A code that indicates the presence or absence of histologically confirmed distant metastases (Strength=Required)PresentAbsent! »The site of histologically confirmed distant metastases must be recordedhistoConfDistMetastasesSite : string [0..1]The relevant coexistent pathological abnormalities must be recordedrelCoexistPathabnorm : code [1..*] « A code that indicates the relevant coexistent pathological abnormalities (Strength=Required) CoexistentPathologicalAbnorma...! »The polyp details (type, number, polyposis syndrome criteria met etc) is to be recordedpolypDetails : string [0..1]If Ulcerative colitis or Crohns disease is selected for relevant coexistent pathological abnormalities record dysplasiadysplasia : code [0..1] « A code that indicates dysplasia if Ulcerative colitis or Crohn's disease is selected for relevant coexistent pathological abnormalities (Strength=Required)Dysplasia! »Record any other abnormalityotherAbnormality : string [0..1]The microscopic residual tumour status (completeness of resection) is to be recordedmicroResidualTumourStatus : string [1..1]The response to neoadjuvant therapy should be recordedneoadjuvantTherapy : code [0..1] « A code that indicates the response to neoadjuvant therapy (Strength=Required)ResponseToNeoadjuvantTherapy! »Other Microscopic comments should be recordedmicroComments : string [0..1]AncillaryTestsMismatch repair enzymes are to be recordedmismatchRepairEnz : ?? [1..1]MLH-1 testingmlh1 : code [0..1] « A code that indicates MLH-1 testing (Strength=Required)StainType! »PMS-2 testingpms2 : code [0..1] « A code that indicates PMS-2 testing (Strength=Required)StainType! »MSH-2 testingmsh2 : code [0..1] « A code that indicates MSH-2 testing (Strength=Required)StainType! »MSH-6 testingmsh6 : code [0..1] « A code that indicates MSH-6 testing (Strength=Required)StainType! »Mismatch repair enzyme comments can be recordedcomments : string [0..1]MsiMicrosatellite instability (MSI) to be recordedcode : code [0..1] « A code that indicates Microsatellite instability (MSI) (Strength=Required)UnstableStable! »Microsatellite instability (MSI) comments can be recordedcomments : string [0..1]Microsatellite instability (MSI) laboratory performing test and report number can be recordedlabDetails : string [0..1]BrafBRAF (V600E mutation) testingcode : code [0..1] « A code that indicates the BRAF (V600E mutation) (Strength=Required)MutatedWildtype! »BRAF (V600E mutation) comments can be recordedcomments : string [0..1]BRAF (V600E mutation) laboratory performing test and report number can be recordedlabDetails : string [0..1]KrasKRAS gene mutation (codons 12 and 13) testingcode : code [0..1] « A code that indicates the KRAS gene mutation (codons 12 and 13) (Strength=Required)MutatedWildtype! »KRAS gene mutation (codons 12 and 13) comments can be recordedcomments : string [0..1]KRAS gene mutation (codons 12 and 13) laboratory performing test and report number can be recordedlabDetails : string [0..1]SynthesisOverviewTumour stage is to be recordedtumourStage : string [1..1]Tumour stage T is to be recordedtumourStageT : code [0..1] « A code that records tumour stage T (Strength=Required)CrcTumourStageT! »Tumour stage N is to be recordedtumourStageN : code [0..1] « A code that records tumour stage N (Strength=Required)CrcTumourStageN! »Tumour stage M is to be recordedtumourStageM : code [0..1] « A code that records tumour stage M (Strength=Required)CrcTumourStageM! »Tumour stage grouping is to be recordedtumourStageGrouping : code [1..1] « A code that records tumour stage grouping (Strength=Required)TumourStageGrouping! »Year and/or edition of staging system is to be recordedtumourStagingSystem : string [1..1]The residual tumour status must be recorded according to the AJCC Cancer Staging Manual (7th Edition)residualTumourStatus : string [1..1] « An R code that records the residual tumour status (Strength=Required)ResidualTumourStatus! »Diagnostic summary is to be recordeddiagnosticSummary : string [0..1]New primary cancer or recurrence is to be recordednewPrimaryOrRecurrence : code [0..1] « A code that records whether a new primary cancer or a recurrence (Strength=Required)NewCancerOrRecurrence! »Description of regional (local) recurrence or distant metastasesnewDescription : string [0..1]Synthesis and overview overarching commentoverarchingComment : string [0..1]Pre Analytic component - information collection prior to specimen receipt at laboratorypreAnalytic[0..1]Macroscopic findingsmacro[0..1]Microscopy of the samplemicro[0..1]Microsatellite instability (MSI) to be recordedmsi[0..1]BRAF (V600E mutation) testingbraf[0..1]KRAS gene mutation (codons 12 and 13) testingkras[0..1]Ancillary test findings are to be recordedancillaryTests[0..1]Synthesis and Overview are to be recordedsynthesisOverview[0..1]

Structure

NameFlagsCard.TypeDescription & ConstraintsImplemented Asdoco
.. Colorectal LogicalColorectaldr := DiagnosticReport
... subject Σ1..1Reference(Patient | Group)The subject of the report, usually, but not always, the patientdr.subject
... requester Σ0..1Reference(Practitioner)Who ordered the test!req := dr.request->DiagnosticOrder; req[orderer := $value]
... performer Σ0..1Reference(Practitioner | Organization)Responsible Diagnostic Servicedr[performer := $value]
... preAnalytic I0..1ElementPre Analytic
If there is a perforation, the perforation type must be indicated.		req := dr.request->DiagnosticOrder; req[orderer := $value]
.... clinicalInformation 0..1stringClinical informationreq.reason[text := $value]
.... operatingSurgeonDetails Σ0..1Reference(Practitioner)Operating surgeon detailssp := dr.specimen->Specimen; sp.collection[collector := $value]
.... perforation I0..1codePerforation
PresentAbsentNotstated (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... natureOfPerforation 0..*codeNature of perforation
NehtaNatureOfPerforation (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... clinicalObstruction 0..1codeClinical obstruction
PresentAbsentNotstated (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... tumourLocation I0..*codeTumour location
ColorectalCancerTumourLocation (Required)
If the tumour location is rectum, then the distance from the anal verge must be recorded.		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... synchronousTumours 0..1stringSynchronous tumours - other sitereq.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... distanceAnalVerge 0..1SimpleQuantityDistance from anal vergereq.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... typeOfOperation I0..1code*
ColorectalCancerOperationType (Required)
If other procedure(s) is selected, then record the type of procedure.
If anterior resection is selected, record anterior resection type.		too := req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... typeOfProcedure 0..1stringProcedure typetoo.text
.... anteriorResectionType 0..1codeAnterior resection type
HiLowUltralow (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... preoperativeRadiotherapy I0..1codePre-operative radiotherapy
YesNoNotStated (Required)
If pre-operative radiotherapy is done, then the type of course is to be recorded.		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... typeOfCourse 0..1codeType of course
TypeOfCourse (Required)		req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... surgeonsOpinion 0..1stringSurgeons opinion of residual cancerreq.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... adjacentOrgans 0..1stringAdjacent organ involvementreq.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... newPrimaryOrRecurrence I0..1codeNew primary cancer or recurrence
NehtaCancerPrimaryOrRecurrence (Required)
If regional (local) recurrence or distant metastasis describe.		pno := req.supportingInformation -> Observation[code := %map-codes; value[x] := $value]
.... RecurrenceDescription 0..1stringDescribepno.component[code := %map-codes; value[x] := $value]
.... pathologyAccessionNumber 0..1stringPathology numberdr[identifier := $value]
.... otherRelevantDetails 0..1stringOther detailsreq.note[text := $value]
... macro I0..1ElementMacroscopy
If lymph nodes have been received the tumour inolvement in the lymph nodes is to be recorded.
If lymph nodes are received, record the number of nodes		macro := dr.result->Observation[code := %map-codes]
.... specimenLength 1..1SimpleQuantitySpecimen lengthsp1 := dr.specimen->Specimen; sp1.collection[quantity := $value]
.... tumourSite I1..1codeTumour site
ColorectalCancerTumourLocation (Required)
If the tumour is a rectal tumour the status of the nonperitonealised circumferential margin (rectal tumours) is to be recorded.
If tumour site is rectum, the intactness of mesorectum is to be recorded.
If tumour site is rectum, the relationship to anterior peritoneal reflection is to be recorded.		sp2 := dr.specimen->Specimen; sp2.collection[bodySite := $value]
.... maxTumourDiameter 1..1SimpleQuantityMax. tumour diametermacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... distanceNearerProxOrDistal 1..*SimpleQuantityDist. of tumour to the nearer proximal or distal "cut end"macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... distNonperitonCircumMargin 1..1SimpleQuantityDist. of tumour to the nonperitonealised circumferential marginmacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourPerforation 1..1codeTumour perforation
PresentAbsent (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... relToAntPeritonealReflection 0..1codeRelationship to anterior peritoneal reflection
NehtaRelAnteriorPeritonealReflection (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... intactnessOfMesorectum 0..1codeIntactness of mesorectum
MesorectumIntactness (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... peritoneum 0..1codePeritoneum
NehtaPeritoneumInvasion (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... lymphNodes I0..1codeLymph nodes
ReceivedNotreceived (Required)		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... noLymphNodesPerCassette 0..*stringNumber of lymph nodes in each cassettemacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... polyps I0..1codePolyps
PresentAbsent (Required)
If polyps are present, provide a polyp summary.		macro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... polypSummary 0..1stringThe number, diameter and gross configuration of polyps should be summarisedmacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... otherMacroComments 0..1stringOther macroscopic commentsmacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... natureAndSiteOfBlocks 1..*stringNature and site of blocksmacro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
... micro 0..1ElementMicroscopymicro := dr.result->Observation[code := %map-codes]
.... tumourType 1..1codeTumour type
TumourType (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... histologicalGrade 1..1codeHistological grade
HistologicalGrade (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... maxDegreeLocalInvasion 1..1codeMaximum degree of local invasion into or through the bowel wall
DegreeInvasionBowelWall (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... proximalOrDistalResectionMargins I0..1codeInvolvement of the proximal or distal resection (cut-end) margins
CRCInvolvedNotinvolved (Required)
If the tumour is not involved in the proximal or distal resection (‘cut-end’) margins, then record the microscopic clearance.
If the tumour is involved in the proximal or distal resection (‘cut-end’) margins, then record invovled margin(s).		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... involvedMargins 1..*codeInvolved margin(s)
DistalProximal (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... marginsMicroClearance 0..1SimpleQuantityMicroscopic Clearancemicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... nonperitonealisedCircumMargin I0..1codeStatus of the nonperitonealised circumferential margin (rectal tumours)
InvolvedNotinvolved (Required)
If the tumour is a rectal tumour and the status of the nonperitonealised circumferential margin (rectal tumours) is not involved, then the clearance is to be recorded.		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... microClearanceRectum 0..1SimpleQuantityMicroscopic Clearancemicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... lymphNodeInvolvement I0..1codeLymph node involvement
PresentAbsent (Required)
If tumour positive lymph nodes are present then record the site(s) and numbers of lymph nodes.		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... lymphNodesDetails 0..*stringSite(s) and numbers of lymph nodesmicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... extramuralTumourDeposits 0..1codeIsolated extra-mural tumour deposits
PresentAbsent (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... apicalNodeInvolvement 0..1codeApical node involvement
PresentAbsent (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... venousSmallVesselInvasion 0..1stringVenous and small vessel invasionmicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... intramuralVeinInvasion 1..1codeIntramural vein invasion
NotIdentifiedPresent (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... extramuralVeinInvasion 1..1codeExtramural vein invasion
NotIdentifiedPresent (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... smallVesselInvasion 1..1codeSmall vessel invasion
NotIdentifiedPresentPresentExtensive (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... perineuralInvasion 1..1codePerineural invasion
NotIdentifiedPresentPresentExtensive (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... histoConfDistMetastases I1..1codeHistologically confirmed distant metastases
PresentAbsent (Required)
If histologically confirmed distant metastases are present then the sites are to be recorded.		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... histoConfDistMetastasesSite 0..1stringHistologically confirmed distant metastases - sitemicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... relCoexistPathabnorm I1..*codeRelevant coexistent pathological abnormalities
CoexistentPathologicalAbnormalities (Required)
If polyps are present as relevant coexistent pathological abnormalities, then polyp details are to be recorded.
If Ulcerative colitis is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded.
If Crohn's disease is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded.
If other abnormalities is selected as relevant coexistent pathological abnormality, then other abnormaily details are to be recorded.		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... polypDetails 0..1stringPolyp details (type, number, polyposis syndrome criteria met etc)micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... dysplasia 0..1codeDysplasia
Dysplasia (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... otherAbnormality 0..1stringOther abnormalitymicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... microResidualTumourStatus 1..1stringMicroscopic residual tumour status (completeness of resection)micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... neoadjuvantTherapy 0..1codeResponse to neoadjuvant therapy
ResponseToNeoadjuvantTherapy (Required)		micro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... microComments 0..1stringMicroscopic commentsmicro.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
... ancillaryTests 0..1ElementAncillary test findingsancillary := dr.result->Observation[code := %map-codes]
.... mismatchRepairEnz 1..1Mismatch repair enzymes
.... mlh1 0..1codeMLH-1
StainType (Required)		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... pms2 0..1codePMS-2
StainType (Required)		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... msh2 0..1codeMSH-2
StainType (Required)		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... msh6 0..1codeMSH-6
StainType (Required)		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... comments 0..1stringMismatch repair enzyme commentsancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... msi I0..1ElementMicrosatellite instability (MSI)
..... code I0..1codeMicrosatellite instability (MSI)
UnstableStable (Required)
If MSI unstable, record laboratory performing test and report number
If MSI stable, record laboratory performing test and report number		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... comments 0..1stringMicrosatellite instability (MSI) commentsancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... labDetails 0..1stringMSI laboratory performing test and report numberancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... braf I0..1ElementBRAF (V600E mutation)
..... code I0..1codeBRAF (V600E mutation)
MutatedWildtype (Required)
If BRAF mutated, record laboratory performing test and report number
If BRAF wild type, record laboratory performing test and report number		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... comments 0..1stringBRAF (V600E mutation) commentsancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... labDetails 0..1stringBRAF (V600E mutation) laboratory performing test and report numberancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... kras I0..1ElementKRAS gene mutation (codons 12 and 13)
..... code I0..1codeKRAS gene mutation (codons 12 and 13)
MutatedWildtype (Required)
If KRAS wild type, record laboratory performing test and report number
If KRAS mutated, record laboratory performing test and report number		ancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... comments 0..1stringKRAS gene mutation (codons 12 and 13) commentsancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
..... labDetails 0..1stringKRAS gene mutation (codons 12 and 13) laboratory performing test and report numberancillary.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
... synthesisOverview 0..1ElementSynthesis and Overviewsynthesis := dr.result->Observation[code := %map-codes]
.... tumourStage 1..1stringTumour stagesynthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStageT 0..1codeT
CrcTumourStageT (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStageN 0..1codeN
CrcTumourStageN (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStageM 0..1codeM
CrcTumourStageM (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStageGrouping 1..1codeStage grouping
TumourStageGrouping (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... tumourStagingSystem 1..1stringYear and/or edition of staging systemsynthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... residualTumourStatus 1..1stringResidual tumour status
ResidualTumourStatus (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... diagnosticSummary Σ0..1stringDiagnostic summarydr[conclusion := $value]
.... newPrimaryOrRecurrence 0..1codeNew primary cancer or recurrence
NewCancerOrRecurrence (Required)		synthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]
.... newDescription 0..1stringDescribe
.... overarchingComment 0..1stringOverarching commentsynthesis.related[type:='has-member'].target->Observation[code:=%map-codes; value[x] := $value]

doco Documentation for this format

UML Diagram

Colorectal (Logical)The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sourcessubject : Reference [1..1] « Patient|Group »The practitioner that holds legal responsibility for ordering the investigationrequester : Reference [0..1] « Practitioner »The diagnostic service that is responsible for issuing the reportperformer : Reference [0..1] « Practitioner|Organization »PreAnalyticClinical information provided on request formclinicalInformation : string [0..1]The operating surgeon name and contact detailsoperatingSurgeonDetails : Reference [0..1] « Practitioner »Presence or absence of a perforationperforation : code [0..1] « A code that indicates whether perforation is present (Strength=Required)PresentAbsentNotstated! »The type of perforationnatureOfPerforation : code [0..*] « A code that indicates the type of perforation (Strength=Required)NehtaNatureOfPerforation! »Whether a clinical obstruction is present or absentclinicalObstruction : code [0..1] « A code that indicates whether a clinical obstruction is present (Strength=Required)PresentAbsentNotstated! »Anatomical location of the tumour from a given listtumourLocation : code [0..*] « A code that indicates the antomical location of the tumour from a given list (Strength=Required)ColorectalCancerTumourLocation! »For synchronous tumours indicate each other sitesynchronousTumours : string [0..1]Quantitative measurement of distance from anal vergedistanceAnalVerge : Quantity(SimpleQuantity) [0..1]The type of operation selected from a listtypeOfOperation : code [0..1] « A code that indicates the type of operation (Strength=Required)ColorectalCancerOperationType! »Type of proceduretypeOfProcedure : string [0..1]The type of anterior resectionanteriorResectionType : code [0..1] « A code that idicates the type of anterior resection (Strength=Required)HiLowUltralow! »An indication of pre-operative radiotherapypreoperativeRadiotherapy : code [0..1] « A code that indicates whether pre-operative radiotherapy was used (Strength=Required)YesNoNotStated! »The type of course of pre-operative radiotherapytypeOfCourse : code [0..1] « A code that indicates the type of course of pre-operative radiotherapy (Strength=Required)TypeOfCourse! »Surgeons opinion on the existence of local residual cancer postsurgerysurgeonsOpinion : string [0..1]Involvement of adjacent organsadjacentOrgans : string [0..1]An indication of whether a new primary cancer or a recurrencenewPrimaryOrRecurrence : code [0..1] « A code that indicates whether a new primary cancer or an recurrence (Strength=Required) NehtaCancerPrimaryOrRecurrence! »Description of regional (local) recurrence or distant metastasesRecurrenceDescription : string [0..1]Pathology accession numberpathologyAccessionNumber : string [0..1]Other relevant detailsotherRelevantDetails : string [0..1]MacroThe length of the specimenspecimenLength : Quantity(SimpleQuantity) [1..1]The site of the tumourtumourSite : code [1..1] « A code that indicates the site of the tumour (Strength=Required)ColorectalCancerTumourLocation! »Maximum tumour diametermaxTumourDiameter : Quantity(SimpleQuantity) [1..1]Distance of tumour to the nearer proximal or distal "cut end"distanceNearerProxOrDistal : Quantity(SimpleQuantity) [1..*]Distance of tumour to the nonperitonealised circumferential margindistNonperitonCircumMargin : Quantity(SimpleQuantity) [1..1]The presence or absence of tumour perforationtumourPerforation : code [1..1] « A code that indicates the presence or absence of a tumour perforation (Strength=Required)PresentAbsent! »Site of tumour in relation to the anterior level of the peritoneal reflectionrelToAntPeritonealReflection : code [0..1] « A code that indicates the site of tumour in relation to the anterior level of the peritoneal reflection (Strength=Required) NehtaRelAnteriorPeritonealRef...! »For rectal resections the intactness of the mesorectum must be recordedintactnessOfMesorectum : code [0..1] « A code that indicates the intactness of the mesorectum (Strength=Required)MesorectumIntactness! »Any involvement of the peritoneum should be recordedperitoneum : code [0..1] « A code that indicates the tumour invovlement in the peritoneum (Strength=Required)NehtaPeritoneumInvasion! »If lymph nodes are received, then they should be recordedlymphNodes : code [0..1] « A code that indicates if lymph nodes were received (Strength=Required)ReceivedNotreceived! »The number of lymph nodes placed in each cassette should be recordednoLymphNodesPerCassette : string [0..*]The presence or absence of polyps should be recordedpolyps : code [0..1] « A code that indicates the presence or absence of polyp(s) (Strength=Required)PresentAbsent! »The polyp summary should include the numbers, diameter range and gross appearancepolypSummary : string [0..1]A descriptive or narrative field should be provided to record any macroscopic information that is not recorded in the above standards and guidelines, and that would normally form part of the macroscopic descriptionotherMacroComments : string [0..1]The nature and sites of all blocks must be recordednatureAndSiteOfBlocks : string [1..*]MicroA single selection value list from WHO Classification of TumourstumourType : code [1..1] « A code from the WHO Calssification that indicates the tumour type (Strength=Required)TumourType! »The histological grading of the tumour must be recordedhistologicalGrade : code [1..1] « A code that indicates the histological grade of the tumour (Strength=Required)HistologicalGrade! »The maximum degree of local invasion into or through the bowel wall must be recordedmaxDegreeLocalInvasion : code [1..1] « A code that indicates the maximum degree of local invasion into or through the bowel wall (Strength=Required)DegreeInvasionBowelWall! »Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recordedproximalOrDistalResectionMargins : code [0..1] « A code that indicates involvement of the proximal or distal resection (cut-end) margins (Strength=Required) CRCInvolvedNotinvolved! »Involvement of the proximal or distal resection margins (cut-end margins) by tumour must be recorded. If the margin is less than 10 mm, the clearance must be recordedinvolvedMargins : code [1..*] « A code that indicates the involvement at the margins (Strength=Required)DistalProximal! »If the margin is less than 10 mm, the clearance must be recordedmarginsMicroClearance : Quantity(SimpleQuantity) [0..1]The status of the nonperitonealised circumferential margin in rectal tumours must be recordednonperitonealisedCircumMargin : code [0..1] « A code that indicates the status of the nonperitonealised circumferential margin in rectal tumours (Strength=Required)InvolvedNotinvolved! »In rectal tumours, the minimum distance in millimetres between the tumour and the nonperitonealised (circumferential, radial) margin must be recorded from the histological slidesmicroClearanceRectum : Quantity(SimpleQuantity) [0..1]Results of lymph node histopathology must be recordedlymphNodeInvolvement : code [0..1] « A code that indicates lymph node involvement (Strength=Required)PresentAbsent! »If lymph node(s) received then the site(s) and numbers of lymph nodes must be recordedlymphNodesDetails : string [0..*]The presence or absence of isolated extra-mural tumour deposits is to be recordedextramuralTumourDeposits : code [0..1] « A code that indicates the presence or absence of isolated extra-mural tumour deposits. (Strength=Required)PresentAbsent! »Involvement of the apical lymph node should be recordedapicalNodeInvolvement : code [0..1] « A code that indicates apical node involvement (Strength=Required)PresentAbsent! »For all tumours, venous and small vessel invasion must be reported and its anatomic location specified as intramural or extramuralvenousSmallVesselInvasion : string [0..1]Intramural invasion must be reported onintramuralVeinInvasion : code [1..1] « A code that indicates intramural vein invasion (Strength=Required)NotIdentifiedPresent! »Extramural invasion must be reported onextramuralVeinInvasion : code [1..1] « A code that indicates extramural vein invasion (Strength=Required)NotIdentifiedPresent! »Small vessel invasion must be reported onsmallVesselInvasion : code [1..1] « A code that indicates small vessel invasion (Strength=Required)NotIdentifiedPresentPresentEx...! »Perineural invasion must be reported onperineuralInvasion : code [1..1] « A code that indicates perineural invasion (Strength=Required)NotIdentifiedPresentPresentEx...! »The presence or absence of histologically confirmed distant metastases must be recordedhistoConfDistMetastases : code [1..1] « A code that indicates the presence or absence of histologically confirmed distant metastases (Strength=Required)PresentAbsent! »The site of histologically confirmed distant metastases must be recordedhistoConfDistMetastasesSite : string [0..1]The relevant coexistent pathological abnormalities must be recordedrelCoexistPathabnorm : code [1..*] « A code that indicates the relevant coexistent pathological abnormalities (Strength=Required) CoexistentPathologicalAbnorma...! »The polyp details (type, number, polyposis syndrome criteria met etc) is to be recordedpolypDetails : string [0..1]If Ulcerative colitis or Crohns disease is selected for relevant coexistent pathological abnormalities record dysplasiadysplasia : code [0..1] « A code that indicates dysplasia if Ulcerative colitis or Crohn's disease is selected for relevant coexistent pathological abnormalities (Strength=Required)Dysplasia! »Record any other abnormalityotherAbnormality : string [0..1]The microscopic residual tumour status (completeness of resection) is to be recordedmicroResidualTumourStatus : string [1..1]The response to neoadjuvant therapy should be recordedneoadjuvantTherapy : code [0..1] « A code that indicates the response to neoadjuvant therapy (Strength=Required)ResponseToNeoadjuvantTherapy! »Other Microscopic comments should be recordedmicroComments : string [0..1]AncillaryTestsMismatch repair enzymes are to be recordedmismatchRepairEnz : ?? [1..1]MLH-1 testingmlh1 : code [0..1] « A code that indicates MLH-1 testing (Strength=Required)StainType! »PMS-2 testingpms2 : code [0..1] « A code that indicates PMS-2 testing (Strength=Required)StainType! »MSH-2 testingmsh2 : code [0..1] « A code that indicates MSH-2 testing (Strength=Required)StainType! »MSH-6 testingmsh6 : code [0..1] « A code that indicates MSH-6 testing (Strength=Required)StainType! »Mismatch repair enzyme comments can be recordedcomments : string [0..1]MsiMicrosatellite instability (MSI) to be recordedcode : code [0..1] « A code that indicates Microsatellite instability (MSI) (Strength=Required)UnstableStable! »Microsatellite instability (MSI) comments can be recordedcomments : string [0..1]Microsatellite instability (MSI) laboratory performing test and report number can be recordedlabDetails : string [0..1]BrafBRAF (V600E mutation) testingcode : code [0..1] « A code that indicates the BRAF (V600E mutation) (Strength=Required)MutatedWildtype! »BRAF (V600E mutation) comments can be recordedcomments : string [0..1]BRAF (V600E mutation) laboratory performing test and report number can be recordedlabDetails : string [0..1]KrasKRAS gene mutation (codons 12 and 13) testingcode : code [0..1] « A code that indicates the KRAS gene mutation (codons 12 and 13) (Strength=Required)MutatedWildtype! »KRAS gene mutation (codons 12 and 13) comments can be recordedcomments : string [0..1]KRAS gene mutation (codons 12 and 13) laboratory performing test and report number can be recordedlabDetails : string [0..1]SynthesisOverviewTumour stage is to be recordedtumourStage : string [1..1]Tumour stage T is to be recordedtumourStageT : code [0..1] « A code that records tumour stage T (Strength=Required)CrcTumourStageT! »Tumour stage N is to be recordedtumourStageN : code [0..1] « A code that records tumour stage N (Strength=Required)CrcTumourStageN! »Tumour stage M is to be recordedtumourStageM : code [0..1] « A code that records tumour stage M (Strength=Required)CrcTumourStageM! »Tumour stage grouping is to be recordedtumourStageGrouping : code [1..1] « A code that records tumour stage grouping (Strength=Required)TumourStageGrouping! »Year and/or edition of staging system is to be recordedtumourStagingSystem : string [1..1]The residual tumour status must be recorded according to the AJCC Cancer Staging Manual (7th Edition)residualTumourStatus : string [1..1] « An R code that records the residual tumour status (Strength=Required)ResidualTumourStatus! »Diagnostic summary is to be recordeddiagnosticSummary : string [0..1]New primary cancer or recurrence is to be recordednewPrimaryOrRecurrence : code [0..1] « A code that records whether a new primary cancer or a recurrence (Strength=Required)NewCancerOrRecurrence! »Description of regional (local) recurrence or distant metastasesnewDescription : string [0..1]Synthesis and overview overarching commentoverarchingComment : string [0..1]Pre Analytic component - information collection prior to specimen receipt at laboratorypreAnalytic[0..1]Macroscopic findingsmacro[0..1]Microscopy of the samplemicro[0..1]Microsatellite instability (MSI) to be recordedmsi[0..1]BRAF (V600E mutation) testingbraf[0..1]KRAS gene mutation (codons 12 and 13) testingkras[0..1]Ancillary test findings are to be recordedancillaryTests[0..1]Synthesis and Overview are to be recordedsynthesisOverview[0..1]

 

??.??.4.1 Terminology Bindings

PathDefinitionTypeReference
Colorectal.preAnalytic.perforation A code that indicates whether perforation is presentRequiredPresentAbsentNotstated
Colorectal.preAnalytic.natureOfPerforation A code that indicates the type of perforationRequiredNehtaNatureOfPerforation
Colorectal.preAnalytic.clinicalObstruction A code that indicates whether a clinical obstruction is presentRequiredPresentAbsentNotstated
Colorectal.preAnalytic.tumourLocation A code that indicates the antomical location of the tumour from a given listRequiredColorectalCancerTumourLocation
Colorectal.preAnalytic.typeOfOperation A code that indicates the type of operationRequiredColorectalCancerOperationType
Colorectal.preAnalytic.anteriorResectionType A code that idicates the type of anterior resectionRequiredHiLowUltralow
Colorectal.preAnalytic.preoperativeRadiotherapy A code that indicates whether pre-operative radiotherapy was usedRequiredYesNoNotStated
Colorectal.preAnalytic.typeOfCourse A code that indicates the type of course of pre-operative radiotherapyRequiredTypeOfCourse
Colorectal.preAnalytic.newPrimaryOrRecurrence A code that indicates whether a new primary cancer or an recurrenceRequiredNehtaCancerPrimaryOrRecurrence
Colorectal.macro.tumourSite A code that indicates the site of the tumourRequiredColorectalCancerTumourLocation
Colorectal.macro.tumourPerforation A code that indicates the presence or absence of a tumour perforationRequiredPresentAbsent
Colorectal.macro.relToAntPeritonealReflection A code that indicates the site of tumour in relation to the anterior level of the peritoneal reflectionRequiredNehtaRelAnteriorPeritonealReflection
Colorectal.macro.intactnessOfMesorectum A code that indicates the intactness of the mesorectumRequiredMesorectumIntactness
Colorectal.macro.peritoneum A code that indicates the tumour invovlement in the peritoneumRequiredNehtaPeritoneumInvasion
Colorectal.macro.lymphNodes A code that indicates if lymph nodes were receivedRequiredReceivedNotreceived
Colorectal.macro.polyps A code that indicates the presence or absence of polyp(s)RequiredPresentAbsent
Colorectal.micro.tumourType A code from the WHO Calssification that indicates the tumour typeRequiredTumourType
Colorectal.micro.histologicalGrade A code that indicates the histological grade of the tumourRequiredHistologicalGrade
Colorectal.micro.maxDegreeLocalInvasion A code that indicates the maximum degree of local invasion into or through the bowel wallRequiredDegreeInvasionBowelWall
Colorectal.micro.proximalOrDistalResectionMargins A code that indicates involvement of the proximal or distal resection (cut-end) marginsRequiredCRCInvolvedNotinvolved
Colorectal.micro.involvedMargins A code that indicates the involvement at the marginsRequiredDistalProximal
Colorectal.micro.nonperitonealisedCircumMargin A code that indicates the status of the nonperitonealised circumferential margin in rectal tumoursRequiredInvolvedNotinvolved
Colorectal.micro.lymphNodeInvolvement A code that indicates lymph node involvementRequiredPresentAbsent
Colorectal.micro.extramuralTumourDeposits A code that indicates the presence or absence of isolated extra-mural tumour deposits.RequiredPresentAbsent
Colorectal.micro.apicalNodeInvolvement A code that indicates apical node involvementRequiredPresentAbsent
Colorectal.micro.intramuralVeinInvasion A code that indicates intramural vein invasionRequiredNotIdentifiedPresent
Colorectal.micro.extramuralVeinInvasion A code that indicates extramural vein invasionRequiredNotIdentifiedPresent
Colorectal.micro.smallVesselInvasion A code that indicates small vessel invasionRequiredNotIdentifiedPresentPresentExtensive
Colorectal.micro.perineuralInvasion A code that indicates perineural invasionRequiredNotIdentifiedPresentPresentExtensive
Colorectal.micro.histoConfDistMetastases A code that indicates the presence or absence of histologically confirmed distant metastasesRequiredPresentAbsent
Colorectal.micro.relCoexistPathabnorm A code that indicates the relevant coexistent pathological abnormalitiesRequiredCoexistentPathologicalAbnormalities
Colorectal.micro.dysplasia A code that indicates dysplasia if Ulcerative colitis or Crohn's disease is selected for relevant coexistent pathological abnormalitiesRequiredDysplasia
Colorectal.micro.neoadjuvantTherapy A code that indicates the response to neoadjuvant therapyRequiredResponseToNeoadjuvantTherapy
Colorectal.ancillaryTests.mlh1 A code that indicates MLH-1 testingRequiredStainType
Colorectal.ancillaryTests.pms2 A code that indicates PMS-2 testingRequiredStainType
Colorectal.ancillaryTests.msh2 A code that indicates MSH-2 testingRequiredStainType
Colorectal.ancillaryTests.msh6 A code that indicates MSH-6 testingRequiredStainType
Colorectal.ancillaryTests.msi.code A code that indicates Microsatellite instability (MSI)RequiredUnstableStable
Colorectal.ancillaryTests.braf.code A code that indicates the BRAF (V600E mutation)RequiredMutatedWildtype
Colorectal.ancillaryTests.kras.code A code that indicates the KRAS gene mutation (codons 12 and 13)RequiredMutatedWildtype
Colorectal.synthesisOverview.tumourStageT A code that records tumour stage TRequiredCrcTumourStageT
Colorectal.synthesisOverview.tumourStageN A code that records tumour stage NRequiredCrcTumourStageN
Colorectal.synthesisOverview.tumourStageM A code that records tumour stage MRequiredCrcTumourStageM
Colorectal.synthesisOverview.tumourStageGrouping A code that records tumour stage groupingRequiredTumourStageGrouping
Colorectal.synthesisOverview.residualTumourStatus An R code that records the residual tumour statusRequiredResidualTumourStatus
Colorectal.synthesisOverview.newPrimaryOrRecurrence A code that records whether a new primary cancer or a recurrenceRequiredNewCancerOrRecurrence

??.??.4.2 Constraints

  • inv-01: On nehta-colorectal.preAnalytic: If there is a perforation, the perforation type must be indicated. (expression on nehta-colorectal.preAnalytic: )
  • inv-02: On nehta-colorectal.preAnalytic.tumourLocation: If the tumour location is rectum, then the distance from the anal verge must be recorded. (expression on nehta-colorectal.preAnalytic.tumourLocation: )
  • inv-03: On nehta-colorectal.preAnalytic.typeOfOperation: If other procedure(s) is selected, then record the type of procedure. (expression on nehta-colorectal.preAnalytic.typeOfOperation: )
  • inv-04: On nehta-colorectal.preAnalytic.typeOfOperation: If anterior resection is selected, record anterior resection type. (expression on nehta-colorectal.preAnalytic.typeOfOperation: )
  • inv-05: On nehta-colorectal.preAnalytic.preoperativeRadiotherapy: If pre-operative radiotherapy is done, then the type of course is to be recorded. (expression on nehta-colorectal.preAnalytic.preoperativeRadiotherapy: )
  • inv-06: On nehta-colorectal.preAnalytic.newPrimaryOrRecurrence: If regional (local) recurrence or distant metastasis describe. (expression on nehta-colorectal.preAnalytic.newPrimaryOrRecurrence: )
  • inv-07: On nehta-colorectal.macro.tumourSite: If tumour site is rectum, the relationship to anterior peritoneal reflection is to be recorded. (expression on nehta-colorectal.macro.tumourSite: )
  • inv-08: On nehta-colorectal.macro.tumourSite: If tumour site is rectum, the intactness of mesorectum is to be recorded. (expression on nehta-colorectal.macro.tumourSite: )
  • inv-09: On nehta-colorectal.macro: If lymph nodes are received, record the number of nodes (expression on nehta-colorectal.macro: )
  • inv-10: On nehta-colorectal.macro.polyps: If polyps are present, provide a polyp summary. (expression on nehta-colorectal.macro.polyps: )
  • inv-11: On nehta-colorectal.micro.proximalOrDistalResectionMargins: If the tumour is involved in the proximal or distal resection (‘cut-end’) margins, then record invovled margin(s). (expression on nehta-colorectal.micro.proximalOrDistalResectionMargins: )
  • inv-12: On nehta-colorectal.micro.proximalOrDistalResectionMargins: If the tumour is not involved in the proximal or distal resection (‘cut-end’) margins, then record the microscopic clearance. (expression on nehta-colorectal.micro.proximalOrDistalResectionMargins: )
  • inv-13: On nehta-colorectal.macro.tumourSite: If the tumour is a rectal tumour the status of the nonperitonealised circumferential margin (rectal tumours) is to be recorded. (expression on nehta-colorectal.macro.tumourSite: )
  • inv-14: On nehta-colorectal.micro.nonperitonealisedCircumMargin: If the tumour is a rectal tumour and the status of the nonperitonealised circumferential margin (rectal tumours) is not involved, then the clearance is to be recorded. (expression on nehta-colorectal.micro.nonperitonealisedCircumMargin: )
  • inv-15: On nehta-colorectal.macro: If lymph nodes have been received the tumour inolvement in the lymph nodes is to be recorded. (expression on nehta-colorectal.macro: )
  • inv-16: On nehta-colorectal.micro.lymphNodeInvolvement: If tumour positive lymph nodes are present then record the site(s) and numbers of lymph nodes. (expression on nehta-colorectal.micro.lymphNodeInvolvement: )
  • inv-17: On nehta-colorectal.micro.histoConfDistMetastases: If histologically confirmed distant metastases are present then the sites are to be recorded. (expression on nehta-colorectal.micro.histoConfDistMetastases: )
  • inv-18: On nehta-colorectal.micro.relCoexistPathabnorm: If polyps are present as relevant coexistent pathological abnormalities, then polyp details are to be recorded. (expression on nehta-colorectal.micro.relCoexistPathabnorm: )
  • inv-19: On nehta-colorectal.micro.relCoexistPathabnorm: If Ulcerative colitis is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded. (expression on nehta-colorectal.micro.relCoexistPathabnorm: )
  • inv-20: On nehta-colorectal.micro.relCoexistPathabnorm: If Crohn's disease is present as relevant coexistent pathological abnormality, then dysplasia is to be recorded. (expression on nehta-colorectal.micro.relCoexistPathabnorm: )
  • inv-21: On nehta-colorectal.micro.relCoexistPathabnorm: If other abnormalities is selected as relevant coexistent pathological abnormality, then other abnormaily details are to be recorded. (expression on nehta-colorectal.micro.relCoexistPathabnorm: )
  • inv-22: On nehta-colorectal.ancillaryTests.msi.code: If MSI unstable, record laboratory performing test and report number (expression on nehta-colorectal.ancillaryTests.msi.code: )
  • inv-23: On nehta-colorectal.ancillaryTests.msi.code: If MSI stable, record laboratory performing test and report number (expression on nehta-colorectal.ancillaryTests.msi.code: )
  • inv-24: On nehta-colorectal.ancillaryTests.braf.code: If BRAF mutated, record laboratory performing test and report number (expression on nehta-colorectal.ancillaryTests.braf.code: )
  • inv-25: On nehta-colorectal.ancillaryTests.braf.code: If BRAF wild type, record laboratory performing test and report number (expression on nehta-colorectal.ancillaryTests.braf.code: )
  • inv-26: On nehta-colorectal.ancillaryTests.kras.code: If KRAS mutated, record laboratory performing test and report number (expression on nehta-colorectal.ancillaryTests.kras.code: )
  • inv-27: On nehta-colorectal.ancillaryTests.kras.code: If KRAS wild type, record laboratory performing test and report number (expression on nehta-colorectal.ancillaryTests.kras.code: )

??.??.5 Notes:

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