Cancer Pathology Data Sharing
2.0.0-ballot - STU 2 Ballot
Cancer Pathology Data Sharing
2.0.0-ballot - STU 2 Ballot
This page is part of the Sharing eCC Data from Pathology Labs to EHR (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This version is a pre-release. The current official version is 1.0.1. For a full list of available versions, see the Directory of published versions
| Page standards status: Informative |
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <https://loinc.org/rdf/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:Composition ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "composition-invasive-carcinoma-of-the-breast"] ; # fhir:meta [ ( fhir:profile [ fhir:v "http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/us-pathology-composition"^^xsd:anyURI ; fhir:link <http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/us-pathology-composition> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "extensions" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition composition-invasive-carcinoma-of-the-breast</b></p><a name=\"composition-invasive-carcinoma-of-the-breast\"> </a><a name=\"hccomposition-invasive-carcinoma-of-the-breast\"> </a><a name=\"composition-invasive-carcinoma-of-the-breast-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-us-pathology-composition.html\">US Pathology Composition Laboratory Report</a></p></div><p><b>Document DiagnosticReport Reference</b>: <a href=\"DiagnosticReport-diagnosticreport-breast-invasive-carcinoma.html\">Diagnostic Report for 'Pathology Synoptic report' for '->Annie Oakley'</a></p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{https://cap.org/eCC Breast.Invasive.Res.189_4.009.021.REL_sdcFDF}\">INVASIVE CARCINOMA OF THE BREAST: Biopsy</span></p><p><b>encounter</b>: <a href=\"Bundle-bundle-us-pathology-exchange.html#http-//hl7.org/fhir/us/cancer-reporting/Encounter/encounter-uspath-specimen-collection\">Bundle: identifier = UUID:1e518c9a-b9a2-4ee6-a350-8965b7924311; type = document; timestamp = 2024-12-05 18:05:57+0000</a></p><p><b>date</b>: 2025-01-01 21:39:30+0000</p><p><b>author</b>: <a href=\"PractitionerRole-practitionerrole-uspath-practitioner-oncologist.html\">Wise Owl</a></p><p><b>title</b>: INVASIVE CARCINOMA OF THE BREAST: Resection</p></div>"^^rdf:XMLLiteral ] ; # fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference"^^xsd:anyURI ] ; fhir:value [ a fhir:Reference ; fhir:reference [ fhir:v "DiagnosticReport/diagnosticreport-breast-invasive-carcinoma" ] ] ] ) ; # fhir:status [ fhir:v "final"] ; # fhir:type [ ( fhir:coding [ fhir:system [ fhir:v "https://cap.org/eCC"^^xsd:anyURI ] ; fhir:code [ fhir:v "Breast.Invasive.Res.189_4.009.021.REL_sdcFDF" ] ; fhir:display [ fhir:v "INVASIVE CARCINOMA OF THE BREAST: Biopsy" ] ] ) ] ; # fhir:subject [ fhir:link <http://hl7.org/fhir/us/cancer-reporting/Patient/patient-OakleyAnnie> ; fhir:reference [ fhir:v "http://hl7.org/fhir/us/cancer-reporting/Patient/patient-OakleyAnnie" ] ; fhir:display [ fhir:v "Annie Oakley" ] ] ; # fhir:encounter [ fhir:link <http://hl7.org/fhir/us/cancer-reporting/Encounter/encounter-uspath-specimen-collection> ; fhir:reference [ fhir:v "http://hl7.org/fhir/us/cancer-reporting/Encounter/encounter-uspath-specimen-collection" ] ] ; # fhir:date [ fhir:v "2025-01-01T21:39:30.000Z"^^xsd:dateTime] ; # fhir:author ( [ fhir:reference [ fhir:v "PractitionerRole/practitionerrole-uspath-practitioner-oncologist" ] ; fhir:display [ fhir:v "Wise Owl" ] ] ) ; # fhir:title [ fhir:v "INVASIVE CARCINOMA OF THE BREAST: Resection"] ; # fhir:section ( [ fhir:title [ fhir:v "INVASIVE CARCINOMA OF THE BREAST: Resection" ] ; fhir:code [ ( fhir:coding [ a loinc:26436-6 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "26436-6" ] ; fhir:display [ fhir:v "Laboratory Studies (set)" ] ] ) ] ; fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Specimen</b></p><p><b>Procedure</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Needle biopsy<br/><span style=\"display: inline-block; width: 20px;\">__</span> Fine needle aspiration<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ___________________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Not specified</p><p><b>Specimen Laterality</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Right<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Left<br/><span style=\"display: inline-block; width: 20px;\">__</span> Not specified</p><p><b>+Tumor Site (select all that apply)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Upper outer quadrant<br/><span style=\"display: inline-block; width: 20px;\">__</span> Lower outer quadrant<br/><span style=\"display: inline-block; width: 20px;\">__</span> Upper inner quadrant<br/><span style=\"display: inline-block; width: 20px;\">__</span> Lower inner quadrant<br/><span style=\"display: inline-block; width: 20px;\">__</span> Central<br/><span style=\"display: inline-block; width: 20px;\">__</span> Nipple<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Clock position</p><p style=\"margin-left: 40px;\"><b>Specify Clock Position (select all that apply)</b></p><p style=\"margin-left: 60px;\"><span style=\"display: inline-block; width: 20px;\">__</span> 1 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 2 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 3 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 4 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 5 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 6 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 7 o'clock<br/><span style=\"display: inline-block; width: 20px;\">✓</span> 8 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 9 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 10 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 11 o'clock<br/><span style=\"display: inline-block; width: 20px;\">__</span> 12 o'clock</p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Specify distance from nipple in Centimeters (cm): _______________ cm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ___________________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Not specified</p><p><b>Histologic Type (Note A)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> No residual invasive carcinoma<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Invasive carcinoma of no special type (ductal)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Micro-invasive carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Invasive lobular carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Invasive carcinoma with mixed ductal and lobular features<br/><span style=\"display: inline-block; width: 20px;\">__</span> Invasive carcinoma with features of (specify): ___________________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Tubular carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Invasive cribriform carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Mucinous carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Invasive micropapillary carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Apocrine adenocarcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Metaplastic carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Encapsulated papillary carcinoma with invasion<br/><span style=\"display: inline-block; width: 20px;\">__</span> Solid papillary carcinoma with invasion<br/><span style=\"display: inline-block; width: 20px;\">__</span> Intraductal papillary adenocarcinoma with invasion<br/><span style=\"display: inline-block; width: 20px;\">__</span> Adenoid cystic carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Neuroendocrine tumor<br/><span style=\"display: inline-block; width: 20px;\">__</span> Neuroendocrine carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Invasive carcinoma, type cannot be determined: ___________________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other histologic type not listed (specify): ___________________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Histologic Type Comment: ___________________</p><p><b>Histologic Grade (Nottingham Histologic Score) (required only if applicable) (Note B)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Not applicable (no residual carcinoma or microinvasion only)<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Nottingham Score</p><p style=\"margin-left: 40px;\"><b>Glandular (Acinar) / Tubular Differentiation</b></p><p style=\"margin-left: 60px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Score 1 (greater than 75% of tumor area forming glandular / tubular structures)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Score 2 (10% to 75% of tumor area forming glandular / tubular structures)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Score 3 (less than 10% of tumor area forming glandular / tubular structures)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Score cannot be determined</p><p style=\"margin-left: 40px;\"><b>Nuclear Pleomorphism</b></p><p style=\"margin-left: 60px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Score 1 (Nuclei small with little increase in size in comparison with normal breast epithelial cells, regular outlines, uniform nuclear chromatin, little variation in size)<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Score 2 (Cells larger than normal with open vesicular nuclei, visible nucleoli, and moderate variability in both size and shape)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Score 3 (Vesicular nuclei, often with prominent nucleoli, exhibiting marked variation in size and shape, occasionally with very large and bizarre forms)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Score cannot be determined</p><p style=\"margin-left: 40px;\"><b>Mitotic Rate</b></p><p style=\"margin-left: 60px;\"><span>See Table 1 in <i>CAP Protocol</i></span><br/><span style=\"display: inline-block; width: 20px;\">✓</span> Score 1<br/><span style=\"display: inline-block; width: 20px;\">__</span> Score 2<br/><span style=\"display: inline-block; width: 20px;\">__</span> Score 3<br/><span style=\"display: inline-block; width: 20px;\">__</span> Score cannot be determined: ___________________</p><p style=\"margin-left: 40px;\"><b>Overall Grade</b></p><p style=\"margin-left: 60px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Grade 1 (scores of 3, 4, or 5)</p><p><b>Tumor Size (Note E)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> No residual invasive carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Microinvasion only (less than or equal to 1 mm)<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Greatest dimension of largest invasive focus greater than 1 mm (specify exact measurement in Millimeters (mm)): <b>13.0</b> mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Additional Dimension in Millimeters (mm): ____ × ____ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Size of largest invasive focus cannot be determined (explain): ___________________</p><p><b>+Tumor Focality (Note F)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Single focus of invasive carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Multiple foci of invasive carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> Number of Foci<br/><span style=\"display: inline-block; width: 20px;\">__</span> Specify number: ___________________<br/><span style=\"display: inline-block; width: 20px;\">__</span> At least: ___________________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined</p><p><b>Ductal Carcinoma In Situ (DCIS) (Note G)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Not identified<br/><span style=\"display: inline-block; width: 20px;\">__</span> Present<br/><span style=\"display: inline-block; width: 20px;\">__</span> Present (in close proximity to invasive carcinoma)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Present only after presurgical therapy and prior to therapy the cancer is classified as pTis<br/><span style=\"display: inline-block; width: 20px;\">__</span> Negative for extensive intraductal component (EIC)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Positive for extensive intraductal component (EIC)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Only DCIS is present after presurgical (neoadjuvant) therapy</p><p><b>+Size (Extent) of DCIS</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Estimated size (extent) of DCIS is at least in Millimeters (mm): _____ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Additional Dimension in Millimeters (mm): _____ × _____ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined</p><p><b>Tumor Extent (Note H)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Tumor Extent (required only if skin, nipple, or skeletal muscle are present and involved) (select all that apply)<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Not applicable (skin, nipple, and skeletal muscle are absent OR are uninvolved)</p><p><b>Margin Status for Invasive Carcinoma (required only if residual invasive carcinoma is present in specimen)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Not applicable (residual invasive carcinoma in specimen is absent)<br/><span style=\"display: inline-block; width: 20px;\">✓</span> All margins negative for invasive carcinoma</p><p><b>Distance from Invasive Carcinoma to Closest Margin</b></p><p style=\"margin-left: 20px;\"><span>Specify in Millimeters (mm):</span></p><p style=\"margin-left: 40px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Exact distance: ______________ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Less than: ______________ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Greater than: ______________ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>+Closest Margin(s) to Invasive Carcinoma (select all that apply)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Anterior<br/><span style=\"display: inline-block; width: 20px;\">__</span> Posterior<br/><span style=\"display: inline-block; width: 20px;\">__</span> Superior<br/><span style=\"display: inline-block; width: 20px;\">__</span> Inferior<br/><span style=\"display: inline-block; width: 20px;\">__</span> Medial<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Lateral<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Margin(s) Involved by Invasive Carcinoma (select all that apply)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Anterior (specify extent): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Posterior (specify extent): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Superior (specify extent): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Inferior (specify extent): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Medial (specify extent): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Lateral (specify extent): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify margin(s) and extent): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Regional Lymph Node Status</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Not applicable (no regional lymph nodes submitted or found)<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Regional lymph nodes present<br/><span style=\"display: inline-block; width: 20px;\">__</span> All regional lymph nodes negative for tumor<br/><span style=\"display: inline-block; width: 20px;\">__</span> Tumor present in regional lymph node(s)</p><p><b>Number of Lymph Nodes with Macrometastases (greater than 2 mm)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Exact number (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> At least (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Number of Lymph Nodes with Micrometastases (greater than 0.2 mm to 2 mm and / or greater than 200 cells)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Exact number (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> At least (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Number of Lymph Nodes with Isolated Tumor Cells (0.2 mm or less OR 200 cells or less) (required only if applicable)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Not applicable<br/><span style=\"display: inline-block; width: 20px;\">__</span> Exact number (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> At least (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Size of Largest Nodal Metastatic Deposit</b></p><p style=\"margin-left: 20px;\"><span>Specify in Millimeters (mm):</span></p><p style=\"margin-left: 40px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Exact size: ______________ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Less than: ______________ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Greater than: ______________ mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Extranodal Extension</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Not identified<br/><span style=\"display: inline-block; width: 20px;\">__</span> Present, 2 mm or less<br/><span style=\"display: inline-block; width: 20px;\">__</span> Present, greater than 2 mm</p><p style=\"margin-left: 20px;\"><b>+Specify Amount:</b></p><p style=\"margin-left: 40px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Present<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined: ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Total Number of Lymph Nodes Examined (sentinel and non-sentinel)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Exact number (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> At least (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Number of Sentinel Nodes Examined (if applicable)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Not applicable<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Exact number (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> At least (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (explain): ______________</p><p><b>Distant Site(s) Involved, if applicable (select all that apply)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Not applicable<br/><span style=\"display: inline-block; width: 20px;\">__</span> Non-regional lymph node(s) (specify, if possible): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Lung: ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Liver: ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Bone: ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Brain: ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Other (specify): ______________<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined</p><p><b>Modified Classification (required only if applicable) (select all that apply)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Not applicable<br/><span style=\"display: inline-block; width: 20px;\">__</span> y (post-neoadjuvant therapy)<br/><span style=\"display: inline-block; width: 20px;\">__</span> r (recurrence)</p><p><b>pT Category</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> pT not assigned (cannot be determined based on available pathological information)<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT0: No evidence of primary tumor<br/><span style=\"display: inline-block; width: 20px;\">__</span> pTis (DCIS): Ductal carcinoma in situ<br/><span style=\"display: inline-block; width: 20px;\">__</span> pTis (Paget): Paget disease NOT associated with invasive carcinoma and / or carcinoma in situ (DCIS) in the underlying breast parenchyma<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT1: Tumor less than or equal to 20 mm in greatest dimension<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT1mi: Tumor less than or equal to 1 mm in greatest dimension<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT1a: Tumor greater than 1 mm but less than or equal to 5 mm in greatest dimension<br/><span style=\"display: inline-block; width: 20px;\">✓</span> pT1b: Tumor greater than 5 mm but less than or equal to 10 mm in greatest dimension<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT1c: Tumor greater than 10 mm but less than or equal to 20 mm in greatest dimension<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT2: Tumor greater than 20 mm but less than or equal to 50 mm in greatest dimension<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT3: Tumor greater than 50 mm in greatest dimension<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT4: Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules)<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT4a: Extension to the chest wall; invasion of or adherence to pectoralis muscle in the absence of invasion of chest wall structures does not qualify as T4<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT4b: Ulceration and/or ipsilateral satellite nodules and/or edema (including peau d'orange) of the skin which do not meet the criteria for inflammatory carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT4c: Both T4a and T4b are present<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT4d: Inflammatory carcinoma<br/><span style=\"display: inline-block; width: 20px;\">__</span> pT4 (subcategory cannot be determined)</p><p><b>pN Category</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> pN not assigned (no nodes submitted or found)<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN not assigned (cannot be determined based on available pathological information)<br/><span style=\"display: inline-block; width: 20px;\">✓</span> pN0: No regional lymph node metastasis identified or ITCs only<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN0 (i+): ITCs only (malignant cell clusters no larger than 0.2 mm) in regional lymph node(s)<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN0 (mol+): Positive molecular findings by reverse transcriptase polymerase chain reaction (RT-PCR); no ITCs detected<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN1: Metastases in 1 to 3 axillary lymph nodes, at least one metastasis larger than 2.0 mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN1mi: Micrometastases (approximately 200 cells, larger than 0.2 mm, but none larger than 2.0 mm)<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN1a: Metastases in 1 to 3 axillary lymph nodes, at least one metastasis larger than 2.0 mm<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN1b: Metastases in internal mammary sentinel nodes, excluding ITCs<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN1c: pN1a and pN1b combined<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN2: Metastases in 4-9 axillary lymph nodes; or in clinically detected internal mammary lymph nodes with negative axillary nodes<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN2a: Metastases in 4-9 axillary lymph nodes (at least one tumor deposit larger than 2.0 mm)<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN2b: Metastases in clinically detected internal mammary lymph nodes with or without microscopic confirmation; with pathologically negative axillary lymph nodes<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN3: Metastases in 10 or more axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes; or in clinically detected ipsilateral internal mammary lymph nodes with one or more positive level I, II axillary lymph nodes; or in more than 3 axillary lymph nodes and in internal mammary lymph nodes with microscopic disease or macroscopic disease detected by sentinel lymph node biopsy but not clinically detected; or in ipsilateral supraclavicular lymph nodes<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN3a: Metastases in 10 or more axillary lymph nodes (at least one tumor deposit larger than 2.0 mm); or metastases to the infraclavicular (level III axillary lymph) nodes<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN3b: pN1a or pN2a in the presence of cN2b (positive internal mammary nodes by imaging); or pN2a in the presence of pN1b<br/><span style=\"display: inline-block; width: 20px;\">__</span> pN3c: Metastases in ipsilateral supraclavicular lymph nodes</p><p><b>N Suffix (required only if applicable)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Not applicable<br/><span style=\"display: inline-block; width: 20px;\">__</span> (sn) Sentinel node(s) evaluated. If 6 or more nodes (sentinel or nonsentinel) are removed, this modifier should not be used<br/><span style=\"display: inline-block; width: 20px;\">__</span> (f) Nodal metastasis confirmed by fine needle aspiration or core needle biopsy<br/><span style=\"display: inline-block; width: 20px;\">__</span> (m) Multiple primary synchronous tumors in a single organ</p><p><b>ADDITIONAL FINDINGS (Note O)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">+</span>Additional Findings (specify): ________________</p><p><b>SPECIAL STUDIES</b></p><p style=\"margin-left: 20px;\">The CAP Breast Biomarker Template should be used for reporting biomarkers requested for this resection specimen. Pending biomarker studies should be listed in the Comments section of this report.</p><p><b>+Breast Biomarker Studies Performed on Previous Biopsy (select all that apply)</b></p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Estrogen Receptor (ER)</p><p style=\"margin-left: 40px;\"><b>Estrogen Receptor (ER) Status</b></p><p style=\"margin-left: 60px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Positive (greater than 10% of cells demonstrate nuclear positivity)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Low Positive (1-10% of cells with nuclear positivity)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Negative<br/><span style=\"display: inline-block; width: 20px;\">✓</span> Cannot be determined (indeterminate)</p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> Progesterone Receptor (PgR)</p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> HER2 (by immunohistochemistry)</p><p style=\"margin-left: 40px;\"><span style=\"display: inline-block; width: 20px;\">✓</span> Negative (Score 0)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Negative (Score 1+)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Equivocal (Score 2+)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Positive (Score 3+)<br/><span style=\"display: inline-block; width: 20px;\">__</span> Cannot be determined (indeterminate)</p><p style=\"margin-left: 20px;\"><span style=\"display: inline-block; width: 20px;\">__</span> HER2 (by in situ hybridization)</p></div>"^^rdf:XMLLiteral ] ; ( fhir:entry [ fhir:reference [ fhir:v "Observation/observation-section-specimen" ] ] ) ] ) . # <http://hl7.org/fhir/us/cancer-reporting/Patient/patient-OakleyAnnie> a fhir:us . <http://hl7.org/fhir/us/cancer-reporting/Encounter/encounter-uspath-specimen-collection> a fhir:us .
IG © 2025+ HL7 International / Orders and Observations and College of American Pathologists. Package hl7.fhir.us.cancer-reporting#2.0.0-ballot based on FHIR 4.0.1. Generated 2025-03-31
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