Repositorio de Reportes de Biopsias Oncológicas
0.1.1-draft - STU1
Repositorio de Reportes de Biopsias Oncológicas
0.1.1-draft - STU1
Repositorio de Reportes de Biopsias Oncológicas, published by Unidad de Interoperabilidad - MINSAL. This guide is not an authorized publication; it is the continuous build for version 0.1.1-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Minsal-CL/R2BO/ and changes regularly. See the Directory of published versions
| Page standards status: Informative |
| Subject | Javiera Castilla (official) Female, DoB: 1995-12-12 ( PPN: ACL123456789876 (use: official, )) |
| Reported | 2021-08-01 10:00:00-0400 |
| Performer | PractitionerRole MÉDICO CIRUJANO |
| Identifier | r2bo-2020-0001 |
Report Details
| Code | Value | Flags | When For |
| Pathology report microscopic observation in Specimen | Se observa tejido mamario con células epiteliales y estromales, con signos de malignidad con metastasis en ganglios linfáticos | Final | 2021-06-01 12:00:00-0400 |
| Macroscopic observation [Interpretation] in Specimen Narrative | Muestra de biopsia de tejido mamario, de 2x2x1 cm, de color blanco, consistencia firme, bordes irregulares, sin lesiones visibles a simple vista | Final | 2021-06-01 12:00:00-0400 |
| Pathologic TNM stage grouping | Final | 2021-06-01 12:00:00-0400 | |
| Lymph nodes with metastasis [#] in Cancer specimen | true | Final | 2021-06-01 12:00:00-0400 |
| Presence of direct invasion by primary malignant neoplasm to nerve | Perineural invasion by tumour not identified | Final | 2021-06-01 12:00:00-0400 |
| Status of peritumoral lymphocyte response | Marked peritumoral lymphocytic response | Final | 2021-06-01 12:00:00-0400 |
| Lymphatic.small vessel.invasion [Identifier] in Specimen by CAP cancer protocols | Present | Final | 2021-06-01 12:00:00-0400 |
| Venous.large vessel.invasion [Identifier] in Specimen by CAP cancer protocols | Present | Final | 2021-06-01 12:00:00-0400 |
| Surgical margin observable | Final | 2021-06-01 12:00:00-0400 | |
| Multiple tumors reported as single primary Cancer | true | Final | 2021-06-01 12:00:00-0400 |
| Status of specimen involvement by multifocal invasion | true | Final | 2021-06-01 12:00:00-0400 |
| Percentage of tumour involved by necrosis | 5 % (Details: UCUM code% = 'percent') | Final | 2021-06-01 12:00:00-0400 |
| Tumor response to neoadjuvant therapy | El tratamiento entregado no ha sido efectivo para reducir el tamaño del tumor, por lo que se recomienda un nuevo tratamiento. | Final | 2021-06-01 12:00:00-0400 |
| Size Tumor | Final | 2021-06-01 12:00:00-0400 |
Carcinoma ductal infiltrante de mama, grado histológico 2, estadio pT2N2M1, con márgenes quirúrgicos positivos y con evidencia de necrosis tumoral
Coded Conclusions: