Cancer Pathology Data Sharing
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Cancer Pathology Data Sharing, published by HL7 International / Orders and Observations. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cancer-reporting/ and changes regularly. See the Directory of published versions

Example Bundle: US Pathology Exchange bundle example

Document Subject

Annie Oakley Female, DoB: 1990-06-01 ( SHID: 12446 (use: usual, ))

Other Ids:
  • CaliforniaDLN/patient-OakleyAnnie
  • FHIR/66574567 (use: usual, )
  • MRN/abc123 (use: usual, )
Contact Detail
Links:

Document Content

INVASIVE CARCINOMA OF THE BREAST: Resection

Specimen

Procedure

✓ Needle biopsy
__ Fine needle aspiration
__ Other (specify): ___________________
__ Not specified

Specimen Laterality

__ Right
✓ Left
__ Not specified

+Tumor Site (select all that apply)

__ Upper outer quadrant
__ Lower outer quadrant
__ Upper inner quadrant
__ Lower inner quadrant
__ Central
__ Nipple
✓ Clock position

Specify Clock Position (select all that apply)

__ 1 o'clock
__ 2 o'clock
__ 3 o'clock
__ 4 o'clock
__ 5 o'clock
__ 6 o'clock
__ 7 o'clock
✓ 8 o'clock
__ 9 o'clock
__ 10 o'clock
__ 11 o'clock
__ 12 o'clock

__ Specify distance from nipple in Centimeters (cm): _______________ cm
__ Other (specify): ___________________
__ Not specified

Histologic Type (Note A)

__ No residual invasive carcinoma
✓ Invasive carcinoma of no special type (ductal)
__ Micro-invasive carcinoma
__ Invasive lobular carcinoma
__ Invasive carcinoma with mixed ductal and lobular features
__ Invasive carcinoma with features of (specify): ___________________
__ Tubular carcinoma
__ Invasive cribriform carcinoma
__ Mucinous carcinoma
__ Invasive micropapillary carcinoma
__ Apocrine adenocarcinoma
__ Metaplastic carcinoma
__ Encapsulated papillary carcinoma with invasion
__ Solid papillary carcinoma with invasion
__ Intraductal papillary adenocarcinoma with invasion
__ Adenoid cystic carcinoma
__ Neuroendocrine tumor
__ Neuroendocrine carcinoma
__ Invasive carcinoma, type cannot be determined: ___________________
__ Other histologic type not listed (specify): ___________________
__ Histologic Type Comment: ___________________

Histologic Grade (Nottingham Histologic Score) (required only if applicable) (Note B)

__ Not applicable (no residual carcinoma or microinvasion only)
✓ Nottingham Score

Glandular (Acinar) / Tubular Differentiation

✓ Score 1 (greater than 75% of tumor area forming glandular / tubular structures)
__ Score 2 (10% to 75% of tumor area forming glandular / tubular structures)
__ Score 3 (less than 10% of tumor area forming glandular / tubular structures)
__ Score cannot be determined

Nuclear Pleomorphism

__ 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)
✓ Score 2 (Cells larger than normal with open vesicular nuclei, visible nucleoli, and moderate variability in both size and shape)
__ Score 3 (Vesicular nuclei, often with prominent nucleoli, exhibiting marked variation in size and shape, occasionally with very large and bizarre forms)
__ Score cannot be determined

Mitotic Rate

See Table 1 in CAP Protocol
✓ Score 1
__ Score 2
__ Score 3
__ Score cannot be determined: ___________________

Overall Grade

✓ Grade 1 (scores of 3, 4, or 5)

Tumor Size (Note E)

__ No residual invasive carcinoma
__ Microinvasion only (less than or equal to 1 mm)
✓ Greatest dimension of largest invasive focus greater than 1 mm (specify exact measurement in Millimeters (mm)): 13.0 mm
__ Additional Dimension in Millimeters (mm): ____ × ____ mm
__ Size of largest invasive focus cannot be determined (explain): ___________________

+Tumor Focality (Note F)

✓ Single focus of invasive carcinoma
__ Multiple foci of invasive carcinoma
__ Number of Foci
__ Specify number: ___________________
__ At least: ___________________
__ Cannot be determined

Ductal Carcinoma In Situ (DCIS) (Note G)

✓ Not identified
__ Present
__ Present (in close proximity to invasive carcinoma)
__ Present only after presurgical therapy and prior to therapy the cancer is classified as pTis
__ Negative for extensive intraductal component (EIC)
__ Positive for extensive intraductal component (EIC)
__ Only DCIS is present after presurgical (neoadjuvant) therapy

+Size (Extent) of DCIS

__ Estimated size (extent) of DCIS is at least in Millimeters (mm): _____ mm
__ Additional Dimension in Millimeters (mm): _____ × _____ mm
__ Cannot be determined

Tumor Extent (Note H)

__ Tumor Extent (required only if skin, nipple, or skeletal muscle are present and involved) (select all that apply)
✓ Not applicable (skin, nipple, and skeletal muscle are absent OR are uninvolved)

Margin Status for Invasive Carcinoma (required only if residual invasive carcinoma is present in specimen)

__ Not applicable (residual invasive carcinoma in specimen is absent)
✓ All margins negative for invasive carcinoma

Distance from Invasive Carcinoma to Closest Margin

Specify in Millimeters (mm):

✓ Exact distance: ______________ mm
__ Less than: ______________ mm
__ Greater than: ______________ mm
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

+Closest Margin(s) to Invasive Carcinoma (select all that apply)

__ Anterior
__ Posterior
__ Superior
__ Inferior
__ Medial
✓ Lateral
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Margin(s) Involved by Invasive Carcinoma (select all that apply)

__ Anterior (specify extent): ______________
__ Posterior (specify extent): ______________
__ Superior (specify extent): ______________
__ Inferior (specify extent): ______________
__ Medial (specify extent): ______________
__ Lateral (specify extent): ______________
__ Other (specify margin(s) and extent): ______________
__ Cannot be determined (explain): ______________
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Regional Lymph Node Status

__ Not applicable (no regional lymph nodes submitted or found)
✓ Regional lymph nodes present
__ All regional lymph nodes negative for tumor
__ Tumor present in regional lymph node(s)

Number of Lymph Nodes with Macrometastases (greater than 2 mm)

__ Exact number (specify): ______________
__ At least (specify): ______________
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Number of Lymph Nodes with Micrometastases (greater than 0.2 mm to 2 mm and / or greater than 200 cells)

__ Exact number (specify): ______________
__ At least (specify): ______________
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Number of Lymph Nodes with Isolated Tumor Cells (0.2 mm or less OR 200 cells or less) (required only if applicable)

__ Not applicable
__ Exact number (specify): ______________
__ At least (specify): ______________
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Size of Largest Nodal Metastatic Deposit

Specify in Millimeters (mm):

__ Exact size: ______________ mm
__ Less than: ______________ mm
__ Greater than: ______________ mm
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Extranodal Extension

__ Not identified
__ Present, 2 mm or less
__ Present, greater than 2 mm

+Specify Amount:

__ Present
__ Cannot be determined: ______________
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Total Number of Lymph Nodes Examined (sentinel and non-sentinel)

✓ Exact number (specify): ______________
__ At least (specify): ______________
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Number of Sentinel Nodes Examined (if applicable)

__ Not applicable
✓ Exact number (specify): ______________
__ At least (specify): ______________
__ Other (specify): ______________
__ Cannot be determined (explain): ______________

Distant Site(s) Involved, if applicable (select all that apply)

✓ Not applicable
__ Non-regional lymph node(s) (specify, if possible): ______________
__ Lung: ______________
__ Liver: ______________
__ Bone: ______________
__ Brain: ______________
__ Other (specify): ______________
__ Cannot be determined

Modified Classification (required only if applicable) (select all that apply)

__ Not applicable
__ y (post-neoadjuvant therapy)
__ r (recurrence)

pT Category

__ pT not assigned (cannot be determined based on available pathological information)
__ pT0: No evidence of primary tumor
__ pTis (DCIS): Ductal carcinoma in situ
__ pTis (Paget): Paget disease NOT associated with invasive carcinoma and / or carcinoma in situ (DCIS) in the underlying breast parenchyma
__ pT1: Tumor less than or equal to 20 mm in greatest dimension
__ pT1mi: Tumor less than or equal to 1 mm in greatest dimension
__ pT1a: Tumor greater than 1 mm but less than or equal to 5 mm in greatest dimension
✓ pT1b: Tumor greater than 5 mm but less than or equal to 10 mm in greatest dimension
__ pT1c: Tumor greater than 10 mm but less than or equal to 20 mm in greatest dimension
__ pT2: Tumor greater than 20 mm but less than or equal to 50 mm in greatest dimension
__ pT3: Tumor greater than 50 mm in greatest dimension
__ pT4: Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules)
__ 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
__ 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
__ pT4c: Both T4a and T4b are present
__ pT4d: Inflammatory carcinoma
__ pT4 (subcategory cannot be determined)

pN Category

__ pN not assigned (no nodes submitted or found)
__ pN not assigned (cannot be determined based on available pathological information)
✓ pN0: No regional lymph node metastasis identified or ITCs only
__ pN0 (i+): ITCs only (malignant cell clusters no larger than 0.2 mm) in regional lymph node(s)
__ pN0 (mol+): Positive molecular findings by reverse transcriptase polymerase chain reaction (RT-PCR); no ITCs detected
__ pN1: Metastases in 1 to 3 axillary lymph nodes, at least one metastasis larger than 2.0 mm
__ pN1mi: Micrometastases (approximately 200 cells, larger than 0.2 mm, but none larger than 2.0 mm)
__ pN1a: Metastases in 1 to 3 axillary lymph nodes, at least one metastasis larger than 2.0 mm
__ pN1b: Metastases in internal mammary sentinel nodes, excluding ITCs
__ pN1c: pN1a and pN1b combined
__ pN2: Metastases in 4-9 axillary lymph nodes; or in clinically detected internal mammary lymph nodes with negative axillary nodes
__ pN2a: Metastases in 4-9 axillary lymph nodes (at least one tumor deposit larger than 2.0 mm)
__ pN2b: Metastases in clinically detected internal mammary lymph nodes with or without microscopic confirmation; with pathologically negative axillary lymph nodes
__ 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
__ 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
__ pN3b: pN1a or pN2a in the presence of cN2b (positive internal mammary nodes by imaging); or pN2a in the presence of pN1b
__ pN3c: Metastases in ipsilateral supraclavicular lymph nodes

N Suffix (required only if applicable)

__ Not applicable
__ (sn) Sentinel node(s) evaluated. If 6 or more nodes (sentinel or nonsentinel) are removed, this modifier should not be used
__ (f) Nodal metastasis confirmed by fine needle aspiration or core needle biopsy
__ (m) Multiple primary synchronous tumors in a single organ

ADDITIONAL FINDINGS (Note O)

+Additional Findings (specify): ________________

SPECIAL STUDIES

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.

+Breast Biomarker Studies Performed on Previous Biopsy (select all that apply)

✓ Estrogen Receptor (ER)

Estrogen Receptor (ER) Status

__ Positive (greater than 10% of cells demonstrate nuclear positivity)
__ Low Positive (1-10% of cells with nuclear positivity)
__ Negative
✓ Cannot be determined (indeterminate)

__ Progesterone Receptor (PgR)

✓ HER2 (by immunohistochemistry)

✓ Negative (Score 0)
__ Negative (Score 1+)
__ Equivocal (Score 2+)
__ Positive (Score 3+)
__ Cannot be determined (indeterminate)

__ HER2 (by in situ hybridization)

Additional Resources Included in Document

Entry 2 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/DiagnosticReport/diagnosticreport-breast-invasive-carcinoma

Resource DiagnosticReport:

Pathology Synoptic report (Pathology)

SubjectAnnie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))
When For2025-03-18 21:39:30+0000
Performer PractitionerRole Primary Interpreter
Identifier CAPeCC/urn:uuid:7c9139fe-ddd5-49d9-b649-f37344e8b995

Report Details

CodeValueFlagsWhen For
SPECIMENFinal2025-03-18
TUMORFinal2024-12-05
Tumor Extent (Note H)Final2025-03-18 14:52:02+0000 --> (ongoing)
Lymph NodesFinal2025-03-18
MARGINS (Note L)Final2025-03-18
REGIONAL LYMPH NODES (Note M)Final2025-03-18
Distant MetastasisFinal2025-03-18
PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition) (Note M)Final2025-03-18
ADDITIONAL FINDINGS (Note N)Final2025-03-18
SPECIAL STUDIESFinal2025-03-18
COMMENTSFinal2025-03-18

Entry 3 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-specimen

Resource Observation:

identifier: CAPeCC/urn:uuid:6ac70450-cc74-4a8e-8699-9ffab1e0ac24

status: Final

category: Section

code: SPECIMEN

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember:

Entry 4 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-tumor

Resource Observation:

identifier: CAPeCC/urn:uuid:cb7657fb-8127-41ef-9912-8f6fc52a5f85

status: Final

category: Section

code: TUMOR

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2024-12-05

performer: Practitioner Wise Owl

hasMember:

Entry 5 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-lymph-nodes

Resource Observation:

identifier: CAPeCC/urn:uuid:a0d2cb8e-ab6f-4efe-ad2b-03c20d625a9f

status: Final

category: Section

code: Lymph Nodes

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

Entry 6 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-margins

Resource Observation:

identifier: CAPeCC/urn:uuid:a0d2cb8e-ab6f-4efe-ad2b-03c20d625a9f

status: Final

category: Section

code: MARGINS (Note L)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember: Observation Margin Status for Invasive Carcinoma

Entry 7 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-regional-lymph-nodes

Resource Observation:

identifier: CAPeCC/urn:uuid:a0d2cb8e-ab6f-4efe-ad2b-03c20d625a9f

status: Final

category: Section

code: REGIONAL LYMPH NODES (Note M)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember: Observation Regional Lymph Node Status

Entry 8 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-distant-metastasis

Resource Observation:

identifier: CAPeCC/urn:uuid:a0d2cb8e-ab6f-4efe-ad2b-03c20d625a9f

status: Final

category: Section

code: Distant Metastasis

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember: Observation DISTANT METASTASIS

Entry 9 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-ptnm-classification

Resource Observation:

identifier: CAPeCC/urn:uuid:4958b036-f88e-470b-b225-38e9fe6b6541

status: Final

category: Section

code: PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition) (Note M)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember:

Entry 10 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-additional-findings

Resource Observation:

identifier: CAPeCC/urn:uuid:7c9139fe-ddd5-49d9-b649-f37344e8b995

status: Final

category: Section

code: ADDITIONAL FINDINGS (Note N)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember: Observation Additional Findings (specify)

Entry 11 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-additional-findings-specify

Resource Observation:

identifier: CAPeCC/urn:uuid:9cfaa1f6-f0af-4e66-8fe0-130b2143b135

status: Final

category: Question

code: Additional Findings (specify)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

derivedFrom: Observation ADDITIONAL FINDINGS (Note N)

Entry 12 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-special-studies

Resource Observation:

identifier: CAPeCC/urn:uuid:87335ed1-f468-4061-a401-8b8e3b54cf4c

status: Final

category: Section

code: SPECIAL STUDIES

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember: Observation Breast Biomarker Testing Performed on Previous Biopsy

Entry 13 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-comments

Resource Observation:

identifier: CAPeCC/uuid:c3189cd4-33a0-447f-9bbf-2b225e2aa305

status: Final

category: Section

code: COMMENTS

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

Entry 14 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-procedure-breast-excision

Resource Observation:

identifier: CAPeCC/urn:uuid:7c9139fe-ddd5-49d9-b649-f37344e8b995

status: Final

category: Question

code: Procedure (Note A)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Excision (less than total mastectomy)

derivedFrom: Observation SPECIMEN

Entry 15 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-specimen-laterality

Resource Observation:

identifier: CAPeCC/urn:uuid:4bcd147c-ff3d-4eb3-bcd3-9d679bd1ad1b

status: Final

category: Question

code: Specimen Laterality

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Right

derivedFrom: Observation SPECIMEN

Entry 16 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-tumor-site

Resource Observation:

identifier: CAPeCC/urn:uuid:79ab15c8-4b0e-48e5-a477-7f72e62c002b

status: Final

category: Question

code: Tumor Site (Note B)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

hasMember: Observation Clock position

derivedFrom: Observation TUMOR

Entry 17 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-clock-position

Resource Observation:

identifier: CAPeCC/urn:uuid:ab9326c2-e1fe-4ba0-873c-41c923c7f772

status: Final

category: Question

code: Clock position

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Clock position

hasMember: Observation Specify Clock Position

derivedFrom: Observation Tumor Site (Note B)

Entry 18 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-clock-position-8

Resource Observation:

identifier: CAPeCC/urn:uuid:bf778f95-b1a8-4674-a73e-1f2dc0bfbdc4

status: Final

category: Question

code: Specify Clock Position

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-13 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: 8 o'clock

Entry 19 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-histologic-type

Resource Observation:

identifier: CAPeCC/urn:uuid:cb7657fb-8127-41ef-9912-8f6fc52a5f85

status: Final

category: Question

code: Histologic Type (Note C)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: Invasive carcinoma of no special type (ductal)

Entry 20 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-histologic-grade

Resource Observation:

identifier: CAPeCC/urn:uuid:cb7657fb-8127-41ef-9912-8f6fc52a5f85

status: Final

category: Question

code: Histologic Grade (Nottingham Histologic Score) (required only if applicable) (Note D)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Nottingham Score

hasMember:

derivedFrom: Observation TUMOR

Entry 21 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-glandular-differentiation

Resource Observation:

identifier: CAPeCC/urn:uuid:f0d0b23b-f6a0-44d4-bfaf-ade1b485c0b0

status: Final

category: Question

code: Glandular (Acinar) / Tubular Differentiation

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Score 2 (10 to 75% of tumor area forming glandular / tubular structures)

derivedFrom: Observation Histologic Grade (Nottingham Histologic Score) (required only if applicable) (Note D)

Entry 22 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-nuclear-pleomorphism

Resource Observation:

identifier: CAPeCC/urn:uuid:77d0563d-3685-4316-9a81-fa7d04d0d8d2

status: Final

category: Question

code: Nuclear Pleomorphism

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Score 2 (Cells larger than normal with open vesicular nuclei, visible nucleoli, and moderate variability in both size and shape)

derivedFrom: Observation Histologic Grade (Nottingham Histologic Score) (required only if applicable) (Note D)

Entry 23 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-mitotic-rate

Resource Observation:

identifier: CAPeCC/urn:uuid:814dd523-9284-4edb-8831-fc1c440e4979

status: Final

category: Question

code: Mitotic Rate

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Score 1

derivedFrom: Observation Histologic Grade (Nottingham Histologic Score) (required only if applicable) (Note D)

Entry 24 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-overall-grade

Resource Observation:

identifier: CAPeCC/urn:uuid:ddea4bbc-a3e7-477b-b279-57cf5071e0b9

status: Final

category: Question

code: Overall Grade

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2024-12-05 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Grade 1 (scores of 3, 4 or 5)

derivedFrom: Observation Histologic Grade (Nottingham Histologic Score) (required only if applicable) (Note D)

Entry 25 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-tumor-size

Resource Observation:

identifier: CAPeCC/urn:uuid:66153175-f304-443e-99cb-4058f350248b

status: Final

category: Question

code: Tumor Size (Note E)

subject: Annie Oakley

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: PractitionerRole Primary Interpreter

value: Greatest dimension of largest invasive focus greater than 1 mm (specify exact measurement in Millimeters (mm))

hasMember: Observation Additional Dimension in Millimeters (mm)

derivedFrom: Observation TUMOR

Entry 26 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-additional-dimension

Resource Observation:

identifier: CAPeCC/urn:uuid:18c9ea9c-ddf2-400d-adea-07c97dd7b016

status: Final

category: Question

code: Additional Dimension in Millimeters (mm)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: 13

derivedFrom: Observation Tumor Size (Note E)

Entry 27 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-tumor-focality

Resource Observation:

identifier: CAPeCC/urn:uuid:309f8a1c-8311-4751-8718-4b2573a09633

status: Final

category: Question

code: Tumor Focality (Note F)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Single focus of invasive carcinoma

derivedFrom: Observation TUMOR

Entry 28 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-ductal-carcinoma

Resource Observation:

identifier: CAPeCC/urn:uuid:c2f916f9-7438-4ba6-9cba-9e9064edbe3c

status: Final

category: Question

code: Ductal Carcinoma In Situ (DCIS) (Note G)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Not identified

derivedFrom: Observation TUMOR

Entry 29 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-section-tumor-extent

Resource Observation:

identifier: CAPeCC/urn:uuid:1dc64a64-e4f1-4996-87df-28b76446c35a

status: Final

category: Section

code: Tumor Extent (Note H)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

derivedFrom: Observation TUMOR

Entry 30 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-margins-margin-status-for-invasive-carcinoma

Resource Observation:

identifier: CAPeCC/urn:uuid:ee170d9a-d5b5-481a-ac58-52dea11955b4

status: Final

category: Question

code: Margin Status for Invasive Carcinoma

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: All margins negative for invasive carcinoma

hasMember:

derivedFrom: Observation MARGINS (Note L)

Entry 31 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-margins-distance-to-closest-margin

Resource Observation:

identifier: CAPeCC/urn:uuid:7069b59e-9414-4838-bd6d-674ef97c414c

status: Final

category: Question

code: Distance from Invasive Carcinoma to Closest Margin

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Exact distance

derivedFrom: Observation Margin Status for Invasive Carcinoma

Entry 32 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-margins-closest-margin-to-invasive-carcinoma

Resource Observation:

identifier: CAPeCC/urn:uuid:c12982a8-541c-469a-b016-9468d58eb858

status: Final

category: Question

code: Closest Margin(s) to Invasive Carcinoma

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18 14:52:02+0000 --> (ongoing)

performer: Practitioner Wise Owl

value: Lateral

derivedFrom: Observation MARGINS (Note L)

Entry 33 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-regional-lymph-node-status

Resource Observation:

identifier: CAPeCC/urn:uuid:a0d2cb8e-ab6f-4efe-ad2b-03c20d625a9f

status: Final

category: Question

code: Regional Lymph Node Status

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: Regional lymph nodes present

hasMember:

derivedFrom: Observation REGIONAL LYMPH NODES (Note M)

Entry 34 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-regional-lymph-nodes-number-examined

Resource Observation:

identifier: CAPeCC/urn:uuid:a903ae85-913a-4c9b-94cb-c6a1e00340e3

status: Final

category: Question

code: Total Number of Lymph Nodes Examined (sentinel and non-sentinel)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: Exact number (specify)

derivedFrom: Observation Regional Lymph Node Status

Entry 35 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-regional-lymph-nodes-number-sentinel

Resource Observation:

identifier: CAPeCC/urn:uuid:25b43d87-bad0-4779-91c8-352ad2f778ce

status: Final

category: Question

code: Number of Sentinel Nodes Examined

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: Exact number (specify)

derivedFrom: Observation Regional Lymph Node Status

Entry 36 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-distant-metastasis

Resource Observation:

identifier: CAPeCC/urn:uuid:a0d2cb8e-ab6f-4efe-ad2b-03c20d625a9f

status: Final

category: Section

code: DISTANT METASTASIS

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember: Observation Distant Site(s) Involved, if applicable

Entry 37 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-distant-metastasis-distant-sites

Resource Observation:

identifier: CAPeCC/urn:uuid:a0d2cb8e-ab6f-4efe-ad2b-03c20d625a9f

status: Final

category: Question

code: Distant Site(s) Involved, if applicable

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: Not applicable

derivedFrom: Observation DISTANT METASTASIS

Entry 38 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-ptnm-classification-pT-Category

Resource Observation:

identifier: CAPeCC/urn:uuid:4958b036-f88e-470b-b225-38e9fe6b6541

status: Final

category: Question

code: pT Category

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: pT1b: Tumor greater than 5 mm but less than or equal to 10 mm in greatest dimension

derivedFrom: Observation PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition) (Note M)

Entry 39 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-ptnm-classification-pN-Category

Resource Observation:

identifier: CAPeCC/urn:uuid:7164b3a9-3061-4f7f-9bbb-2a4e6980d665

status: Final

category: Question

code: pN Category

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: pN0: No regional lymph node metastasis identified or ITCs only#

derivedFrom: Observation PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition) (Note M)

Entry 40 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-special-studies-breast-biomarker

Resource Observation:

identifier: CAPeCC/urn:uuid:3a313831-c8c5-44e7-8df2-af1b47b9879f

status: Final

category: Question

code: Breast Biomarker Testing Performed on Previous Biopsy

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

hasMember:

derivedFrom: Observation SPECIAL STUDIES

Entry 41 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-special-studies-estrogen-receptor

Resource Observation:

identifier: CAPeCC/urn:uuid:8e615e45-6a49-46d9-8dfe-e84f19c29a92

status: Final

category: Question

code: Estrogen Receptor (ER)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-05

performer: Practitioner Wise Owl

value: Estrogen Receptor (ER)

hasMember: Observation Estrogen Receptor (ER) Status

derivedFrom: Observation Breast Biomarker Testing Performed on Previous Biopsy

Entry 42 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-special-studies-estrogen-receptor-status

Resource Observation:

identifier: CAPeCC/urn:uuid:32bd9a78-878b-4fda-a6bd-c0bc58109fe7

status: Final

category: Question

code: Estrogen Receptor (ER) Status

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: Cannot be determined (indeterminate)

derivedFrom: Observation Estrogen Receptor (ER)

Entry 43 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-special-studies-her2

Resource Observation:

identifier: CAPeCC/urn:uuid:deacb965-18d3-4451-a27f-0e26e7a9e5a2

status: Final

category: Question

code: HER2 (by immunohistochemistry)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Stains Alot

hasMember: Observation HER2 (by immunohistochemistry)

derivedFrom: Observation Breast Biomarker Testing Performed on Previous Biopsy

Entry 44 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Observation/observation-special-studies-negative

Resource Observation:

identifier: CAPeCC/urn:uuid:1ca2fb51-1752-4489-a4b0-5c0dccc043e5

status: Final

category: Question

code: HER2 (by immunohistochemistry)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

effective: 2025-03-18

performer: Practitioner Wise Owl

value: Negative (Score 0)

derivedFrom: Observation HER2 (by immunohistochemistry)

Entry 45 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Specimen/specimen-breast

Resource Specimen:

identifier: https://www.example.org/some-lis/fhir/specimen-identifier-provisioner/987654321

accessionIdentifier: https://www.example.org/some-lis/fhir/specimen-identifier-provisioner/987654321X

type: Tissue specimen (specimen)

request: ServiceRequest Surgical pathology study

Collections

-Collected[x]MethodBodySite
*2025-03-18 17:00:14-0500Excision (procedure)No display for Specimen.collection.bodySite (concept: Breast structure (body structure))

container

Entry 46 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Patient/patient-OakleyAnnie

Resource Patient:

Annie Oakley Female, DoB: 1990-06-01 ( SHID: 12446 (use: usual, ))

Other Ids:
  • CaliforniaDLN/patient-OakleyAnnie
  • FHIR/66574567 (use: usual, )
  • MRN/abc123 (use: usual, )
Contact Detail
Links:

Entry 47 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Encounter/encounter-uspath-specimen-collection

Resource Encounter:

identifier: http://example.com/fhir/encounters/123

status: completed

class: inpatient encounter

type: Pathology consultation, comprehensive, records and specimen with report

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

basedOn: ServiceRequest Surgical pathology study

participant

participant

Entry 48 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/ServiceRequest/servicerequest-cancer-path

Resource ServiceRequest:

status: Active

intent: Order

category: Pathology

code: No display for ServiceRequest.code (concept: Surgical pathology study)

subject: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

encounter: Encounter: identifier = http://example.com/fhir/encounters#123; status = finished; class = inpatient encounter (ActCode[3.0.0]#IMP); type = Pathology consultation, comprehensive, records and specimen with report

occurrence: 2025-03-18 17:00:14-0500

requester: PractitionerRole Ordering Provider

specimen: Specimen: identifier = https://www.example.org/some-lis/fhir/specimen-identifier-provisioner#987654321; accessionIdentifier = https://www.example.org/some-lis/fhir/specimen-identifier-provisioner#987654321X; type = Tissue specimen (specimen)

Entry 49 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/PractitionerRole/practitionerrole-uspath-practitioner-oncologist

Resource PractitionerRole:

practitioner: Practitioner Wise Owl

organization: Organization Redwood Women's Center, P.C.

code: Ordering Provider

Entry 50 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/PractitionerRole/practitionerrole-uspath-pathologist

Resource PractitionerRole:

practitioner: Practitioner Stains Alot

organization: Organization Some Pathology Lab Name

code: Primary Interpreter

Entry 51 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/PractitionerRole/practitionerrole-uspath-surgeon

Resource PractitionerRole:

practitioner: Practitioner Cuts Alot

organization: Organization Redwood Women's Center, P.C.

code: Ordering Provider

Entry 52 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Organization/organization-Redwood-Womens-Center-PC

Resource Organization:

active: true

name: Redwood Women's Center, P.C.

Contacts

-Address
*3307 Renner Drive Fortuna CA 95540 USA

Entry 53 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Organization/organization-principal-pathology-lab

Resource Organization:

active: true

name: Some Pathology Lab Name

Contacts

-Address
*Any City CA 95540 USA

Entry 54 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Practitioner/practitioner-pathologist

Resource Practitioner:

identifier: NPI/1234567893

name: Stains Alot

Entry 55 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Practitioner/practitioner-oncologist

Resource Practitioner:

identifier: NPI/1234567893

name: Wise Owl

Entry 56 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/Practitioner/practitioner-surgeon

Resource Practitioner:

identifier: NPI/1234567893

name: Cuts Alot

Entry 57 - fullUrl = http://hl7.org/fhir/us/cancer-reporting/RelatedPerson/relatedperson-pathology-next-of-kin

Resource RelatedPerson:

active: true

patient: Annie Oakley Female, DoB: 1990-06-01 ( MRN: AlaskaDLN#abc123 (use: usual, ))

relationship: Next-of-Kin

name: Bill Hickok

telecom: ph: 1-989-654-7896