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

## Example DiagnosticReport: Informe de Anatomía Patológica de Biopsia de Mama

Page standards status: Informative

Profile: Perfil del Reporte de Anatomía Patológica

## Informe de Biopsia de Mama (Pathology (gross & histopath, not surgical))

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:

- Carcinoma ductal infiltrante
- Mama