Lithuanian Breast Diagnostics Implementation Guide
0.0.1 - ci-build Lithuania vėliava

Lithuanian Breast Diagnostics Implementation Guide, published by Lithuanian Medical Library. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7LT/ig-lt-breast/ and changes regularly. See the Directory of published versions

Pavyzdys QuestionnaireResponse: QuestionnaireResponse: Pathological Histological Examination (example)

Lithuanian

Language: en

LinkIDTextDefinitionAnswerdoco
.. questionnaireresponse-pathology-exampleQuestionnaire:Questionnaire: Pathological Histological Examination ESPBI Form (LT Breast)
... grp-referralReferral to perform pathology test
... grp-patientPatient information
.... patient-personal-codePersonal code48501019999
.... patient-nameNameJanette
.... patient-surnameSurnamePetrauskaite
.... patient-birth-dateDate of birth1985-01-01
.... patient-ageAge40
.... patient-genderGenderAdministrativeGender: female (Female)
... grp-specimen-datesSpecimen dates
.... specimen-collection-dateDate of material collection2025-03-07T09:15:00+02:00
.... specimen-shipment-dateShipment / formation date2025-03-07T10:00:00+02:00
... grp-clinical-diagnosisClinical diagnosis
.... diagnosis-icd10-codeClinical diagnosis ICD-10-AM codeC50.4
.... diagnosis-nameClinical diagnosis nameMalignant neoplasm of upper-outer quadrant of breast
... grp-materialMaterial fixation
.... fixation-typeMaterial fixation typeBreast questionnaire answer options (illustrative): fixation-formalin (Fixed (10% formalin buffered solution))
... grp-previous-proceduresPrevious procedures and key clinical data
.... previous-proceduresKey clinical dataBreast questionnaire answer options (illustrative): proc-none (No important information)
.... previous-procedures-otherOther information
... grp-special-testsSpecial tests
.... special-tests-requiredSpecial tests requiredIHC panel (ER, PR, HER2, Ki67)
... grp-radiological-dataRadiological examination data
.... radiology-performedRadiological examination performedBreast questionnaire answer options (illustrative): yes (Yes)
.... radiology-exam-typeExamination type
.... radiology-exam-dateExamination date2025-03-05
.... birads-rightBI-RADS right breastBreast questionnaire answer options (illustrative): birads-1 (BI-RADS 1 – No changes found)
.... birads-leftBI-RADS left breastBreast questionnaire answer options (illustrative): birads-4 (BI-RADS 4 – Suspicious malignant finding)
... grp-operationOperation details
.... operation-natureNature of operationBreast questionnaire answer options (illustrative): op-thick-needle-biopsy (Thick needle biopsy)
.... operation-other-detailsOther operation details
... grp-histological-sampleDescription of histological sample / object
.... sample-container-infoContainer information1 container, labelled 'Left breast UOQ, CNB'
.... sample-biopsy-locationBiopsy locationLeft breast, upper-outer quadrant, 2 o'clock position, 5 cm from nipple
... grp-macroscopicDescription of macroscopic examination
.... macro-biopsy-sizeBiopsy size (mm)15 mm (Details: UCUM codemm = 'mm')
.... macro-fragment-detailsFragment details4 tissue cores, pale grey, firm, longest 15 mm
.... macro-notesNotesEntirely submitted in 2 cassettes
... grp-microscopicDescription of microscopic examination
.... microscopic-descriptionMicroscopic examination descriptionCore biopsy fragments showing invasive carcinoma of no special type (NST). Tumour cells arranged in nests, cords and tubular structures, surrounded by desmoplastic stroma. Moderate nuclear pleomorphism, mitotic count 8/10 HPF. No definite in-situ component identified in this limited sample.
... grp-ihcImmunohistochemistry (IHC)
.... ihc-er-statusEstrogen receptors ERBreast questionnaire answer options (illustrative): ihc-strong (Strong (+++))
.... ihc-er-percentER expression in nuclei (%)90 % (Details: UCUM code% = '%')
.... ihc-pr-statusProgesterone receptors PRBreast questionnaire answer options (illustrative): ihc-moderate (Moderate (++))
.... ihc-pr-percentPR expression in nuclei (%)60 % (Details: UCUM code% = '%')
.... ihc-her2-statusHER2 statusBreast questionnaire answer options (illustrative): her2-borderline (HER2: expression borderline (2+))
.... ihc-her2-evaluationHER2 evaluationBreast questionnaire answer options (illustrative): her2-eval-2 (HER2 evaluation: 2+)
.... ihc-ki67Ki67 proliferation index (%)25 % (Details: UCUM code% = '%')
... grp-molecularMolecular studies
.... fish-resultFISH resultBreast questionnaire answer options (illustrative): fish-not-evaluated (FISH: not to be evaluated)
.... fish-her2-averageHER2 average
.... fish-cep17-averageAverage CEP17
.... fish-her2-cep17-ratioHER2/CEP17 ratio
.... cish-sish-resultCISH/SISH resultBreast questionnaire answer options (illustrative): cish-not-evaluated (CISH/SISH: not to be evaluated)
... grp-conclusionConclusion
.... conclusion-who-diagnosisWHO Classification diagnosisInvasive breast carcinoma of no special type (NST) (ICD-O 8500/3)
.... conclusion-tumour-gradeTumour gradeBreast questionnaire answer options (illustrative): grade-g2 (G2 (moderately differentiated))
.... conclusion-tumour-sizeTumour size (mm)18 mm (Details: UCUM codemm = 'mm')
.... conclusion-lviLymphovascular invasionBreast questionnaire answer options (illustrative): lvi-0 (pLVI-0: not detected)

doco Documentation for this format