IDEA4RC FHIR Implementation Guide
0.1.0 - CI Build
150
IDEA4RC FHIR Implementation Guide
0.1.0 - CI Build
150
IDEA4RC FHIR Implementation Guide, published by IDEA4RC Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/idea4rc/ and changes regularly. See the Directory of published versions
| Draft as of 2025-07-25 |
Definitions for the Diagnosis logical model.
Guidance on how to interpret the contents of this table can be foundhere
| 0. Diagnosis | |||||||
| Definition | Diagnosis Maturity Level: 0 Draft | ||||||
| Short | Diagnosis | ||||||
| Control | 0..* | ||||||
| Is Modifier | false | ||||||
| Logical Model | Instances of this logical model are not marked to be the target of a Reference | ||||||
| 2. Diagnosis.cancerepisode | |||||||
| Definition | CancerEpisode reference where the diagnosis was performed | ||||||
| Short | CancerEpisode (M) | ||||||
| Control | 1..* | ||||||
| Type | http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/CancerEpisode | ||||||
| Obligations |
| ||||||
| 4. Diagnosis.dateOfDiagnosis | |||||||
| Definition | Date of the procedure performed to obtain the specimen for the histological diagnosis, regardless of the institution that performed it. | ||||||
| Short | Date of diagnosis (biopsy or surgical piece) (M) | ||||||
| Control | 1..* | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 6. Diagnosis.typeOfBiopsy | |||||||
| Definition | Type of biopsy performed to the patient. Information coming from the biopsy data. | ||||||
| Short | Type of biopsy (M) | ||||||
| Comments | Fine needle biopsy - 4171863 Core needle biopsy - 4321878 Incisional biopsy - 4321986 Excisional biopsy - 4228202 Excision - 4279903 | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 8. Diagnosis.biopsyDoneBy | |||||||
| Definition | Describes the institution where diagnostic procedure was performed. A pseudonym for a hospital. It could be the ID assigned from the original hospital. | ||||||
| Short | Biopsy done by (M) | ||||||
| Control | 1..* | ||||||
| Type | string | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 10. Diagnosis.ageAtDiagnosis | |||||||
| Definition | Age of the patient at the time of the diagnosis. | ||||||
| Short | Age at diagnosis (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 12. Diagnosis.radiotherapyInducedSarcoma | |||||||
| Definition | radiotherapy induced if the new tumour is in the field or marginal the anatomical area that received high radiation dose; please specify the interval time from the radiotherapy treatment | ||||||
| Short | Radiotherapy induced sarcoma (M) | ||||||
| Comments | Radiation-induced sarcoma - 2000100003 | ||||||
| Control | 1..* | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 14. Diagnosis.biopsyGrading | |||||||
| Definition | Grading of the cancer given by the biopsy | ||||||
| Short | Biopsy grading (O) | ||||||
| Comments | Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 16. Diagnosis.histologyGroup | |||||||
| Definition | HNC: Describes the histology of primary tumour according to WHO 2017 clasification. | ||||||
| Short | Histology group (O) | ||||||
| Comments | Squamous cell carcinoma - 37156145 Adenocarcinoma - 37152526 Neuroendocrine carcinoma - 1242310 Undifferentiated carcinoma of nasal sinus - 44783808 Adenosquamous carcinoma - 4241843 Teratocarcinoma - 4284401 Nuclear protein in testis associated carcinoma - 37116896 HPV-related Multiphenotypic Sinonasal Carcinoma - 2000100004 Olfactory neuroblastoma - 4295574 Odontogenic tumor, malignant - 4098585 Lipomatous neoplasm (Adipocytic tumours) - 4019487 Fibromatous neoplasm of borderline malignancy - 4266648 So-called fibrohistiocytic tumours - 2000100005 Vascular tumours - 2000100006 Pericytic (perivascular) tumours - 2000100007 Smooth muscle tumor - 4327493 Osseous AND/OR chondromatous neoplasm - 4019107 Nerve sheath tumor - 4017276 Neoplasm of uncertain behavior - 4313421 Undifferentiated small round cell sarcomas of bone and soft tissue - 2000100008 Endometrial stromal sarcoma - 2000100009 Miscellanious mesenchimal tumors - 2000100010 Mixed epithelial and mesenchymal tumours - 2000100011 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 18. Diagnosis.site | |||||||
| Definition | Describes the primary tumor site. For head and neck, according to AJCC . | ||||||
| Short | Site (O) | ||||||
| Comments | Nasal cavity and paranasal sinus - 2000000067 Nasopharynx - 36769745 Parotid gland - 36769263 Submandibular gland - 36770243 Sublingual gland - 36769383 Middle ear - 2000100020 Hypopharynx - 36770295 Oropharynx - 36769199 Larynx - 2000000037 Oral cavity - 2000100021 Lip - 36769197 Pharynx - 2000000057 Sinonasal - 2000000067 Larynx - 2000000037 Head, face, and neck - 36769894 Upper limb and shoulder - 36769192 Lower limb and hip - 36769168 Trunk - 36768213 Thorax - 36770344 Abdomen - 36769612 Retroperitoneum - 36770706 Peritoneum - 36768774 Pelvis - 36768752 Breast - 2000000012 Genitourinary (not bladder / prostate) - 36768087 Urinary tract - 36769378 Central Nervous System - 2000000015 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 20. Diagnosis.histologySubgroup | |||||||
| Definition | Histology subgroup value for the cancer diagnosis. | ||||||
| Short | Histology subgroup (O) | ||||||
| Comments | Squamous cell carcinoma, keratinizing - 4078953 Squamous cell carcinoma, large cell, nonkeratinizing - 4166826 Schneiderian carcinoma - 4206785 Non-keratinizing squamous cell carcinoma: SMARCB1 (INI-1)-deficient Sinonasal Carcinoma - 2000100012 Non-keratinizing squamous cell carcinoma: Transitional (cylindrical cell, Schneiderian) carcinoma - 2000100013 Squamous cell carcinoma, spindle cell - 4009590 Spindle cell (sarcomatoid) squamous cell carcinoma: SMARCB1 (INI-1) - 2000100014 Lymphoepithelial carcinoma - 4247661 Basaloid squamous cell carcinoma - 4029973 Squamous cell carcinoma - 37156145 Adenoid squamous cell carcinoma - 4312219 Squamous cell carcinoma, microinvasive - 4052146 Giant cell carcinoma - 4175678 Verrucous carcinoma - 4233949 Papillary squamous cell carcinoma - 4191609 Squamous cell carcinoma - 37156145 Human papillomavirus positive squamous cell carcinoma - 37204531 Human papillomavirus negative squamous cell carcinoma - 37204532 Squamous cell carcinoma - 37156145 Adenocarcinoma, intestinal type - 4097305 Adenocarcinoma - 37152526 Cystoadenocarcinoma - 4050978 Mucinous adenocarcinoma - 4247921 Ceruminous adenocarcinoma - 4238334 Papillary adenocarcinoma - 4172953 Adenoid cystic carcinoma - 4022895 Mucoepidermoid carcinoma - 4253608 Polymorphous low grade adenocarcinoma - 4030121 Acinar cell carcinoma - 4164740 Clear cell adenocarcinoma - 4148292 Basal cell adenocarcinoma - 4146684 Infiltrating duct carcinoma - 4221403 Juvenile carcinoma of the breast - 4224593 Paget's disease, extramammary (except Paget's disease of bone) - 4323699 Malignant myoepithelioma - 4029680 Epithelial-myoepithelial carcinoma - 4321002 Carcinoma ex pleomorphic adenoma - 4066512 Sebaceous adenocarcinoma - 4182993 Carcinosarcoma - 4271564 Oxyphilic adenocarcinoma - 4212379 Cystadenocarcinoma - 4050978 Small cell neuroendocrine carcinoma (SmCC) - 36714029 Malignant poorly differentiated neuroendocrine carcinoma - 37018672 Large cell neuroendocrine carcinoma (LCNEC) - 4029971 Neuroendocrine tumor grade 1 - 4133828 Neuroendocrine tumor grade 2 - 4133297 Neuroendocrine carcinoma - 1242310 Odontogenic tumor, malignant - 4098585 Clear cell odontogenic carcinoma - 37116966 Malignant odontogenic ghost cell tumor
SMARCB1 (INI-1)-deficient Sinonasal undifferentiated Carcinoma - 2000100015 Sinonasal SMARCA4 deficient carcinoma; - 2000100016 IDH2-mutated sinonasal undifferentiated neoplasm - 2000100017 Undifferentiated carcinoma of nasal sinus - 44783808 Carcinoma, undifferentiated - 4243327 Adenosquamous carcinoma - 4241843 Teratocarcinoma - 4284401 Nuclear protein in testis associated carcinoma - 37116896 HPV-related Multiphenotypic Sinonasal Carcinoma - 2000100018 Olfactory neuroblastoma - 4295574 Atypical lipomatous tumor - 4021372 Liposarcoma, well differentiated - 4102790 Dedifferentiated liposarcoma - 4284833 Myxoid liposarcoma - 4101123 Pleomorphic liposarcoma - 4010104 Myxoid pleomorphic liposarcoma - 1243142 Palmar/plantar-type fibromatosis - 45766452 Aggressive fibromatosis - 4264204 Lipofibromatosis - 45766468 Giant cell fibroblastoma - 4030132 Dermatofibrosarcoma protuberans - 4295283 Solitary fibrous tumor and hemangiopericytoma grade 1 - 37116995 Solitary fibrous tumor and hemangiopericytoma grade 2 - 37116996 Solitary fibrous tumor and hemangiopericytoma grade 3 - 37116997 Myofibroblastic tumour - 4021373 Low-grade myofibroblastic sarcoma - 45766454 Cellular fibroma - 4029679 Myxoinflammatory fibroblastic sarcoma - 45766450 Fibrosarcoma - 4202374 Myxofibrosarcoma - 45771359 Low-grade fibromyxoid sarcoma - 45771361 Sclerosing epithelioid fibrosarcoma - 45766456 Plexiform fibrohistiocytic tumour - 4029525 Giant cell tumour of soft parts - 4218898 Tenosynovial giant cell tumor - 4030140 Tenosynovial giant cell tumor, diffuse - 45766525 Malignant tenosynovial giant cell tumor - 4029655 Epithelioid haemangioendothelioma - 4207381 Angiosarcoma - 3661612 Hemangioendothelioma - 4281384 Spindle cell hemangioendothelioma - 4030139 Retiform haemangioendothelioma - 45766493 Papillary intralymphatic angioendothelioma - 4030138 Composite haemangioendothelioma - 45766494 Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma - 45766492 Glomus tumor - 4014760 Glomus tumor, malignant - 4028856 Smooth muscle tumour - 4327493 Epithelioid smooth muscle tumor of uncertain malignant potential - 607803 Myxoid smooth muscle tumour of uncertain mailgnant potential - 600675 Metastasizing leiomyoma - 4029023 Leiomyosarcoma - 37151903 Epithelioid leiomyosarcoma - 4173148 Myxoid leiomyosarcoma - 4059632 Embryonal rhabdomyosarcoma - 4031038 Alveolar rhabdomyosarcoma - 4272931 Pleomorphic rhabdomyosarcoma - 4298312 Spindle cell rhabdomyosarcoma - 4029528 Ectomesenchymoma - 4029024 Extraskeletal osteosarcoma - 4298240 Malignant peripheral nerve sheath tumour - 4062426 Melanotic malignant peripheral nerve sheath tumor - 4102399 Granular cell tumour - 4005360 Granular cell tumour, malignant - 4027842 Atypical fibrous histiocytoma - 4096931 Angiomatoid fibrous histiocytoma - 4029526 Pleomorphic hyalinizing angiectatic tumour - 45766448 Hemosiderotic fibrolipomatous tumor - 1243125 NTRK-rearranged spindle cell neoplasm - 1243130 Synovial sarcoma - 4268491 Epithelioid sarcoma - 4244886 Alveolar soft part sarcoma - 4339208 Clear cell sarcoma - 4155072 Extraskeletal myxoid chondrosarcoma - 4297345 Desmoplastic small round cell tumor - 4029522 Extrarenal rhabdoid tumor - 4299132 Perivascular epithelioid tumor, benign - 45771358 Perivascular epithelioid tumor, malignant - 45766447 Perivascular epithelioid cell tumor - 4304780 Intimal sarcoma - 45766495 Undifferentiated sarcoma - 4029021 Myoepithelioma - 4239519 Myoepithelial carcinoma - 4029680 Ossifying fibromyxoid tumour - 4028565 Ossifying fibromyxoid tumor, malignant - 45766467 Mesenchymoma - 4195947 Phosphaturic mesenchymal tumor, benign - 45766484 Phosphaturic mesenchymal tumour, malignant - 45766485 Angiomyxoma - 4239956 Angiomatoid fibrous histiocytoma - 4029526 NTRK-rearranged spindle cell neoplasm (emerging) - 2000100019 Ewing sarcoma / peripheral neuroectodermal tumor - 45766528 Round cell sarcoma with EWSR1–non-ETS fusions - 37155974 CIC-rearranged sarcoma - 37152438 Sarcoma with BCOR genetic alterations - 37152440 Endometrial stromal sarcoma, high grade - 4290926 Endometrial stromal sarcoma, low grade - 4028557 Uterine tumour resembling ovarian sex cord tumour - 45771357 Benign phyllodes tumor - 4040991 Borderline phyllodes tumor - 4323562 Malignant phyllodes tumor - 4337106 Follicular dendritic cell sarcoma - 4028710 Histiocytic sarcoma - 4029172 Interdigitating dendritic cell sarcoma - 4028709 Langherans cell sarcoma - 4029173 Fibroblastic reticular cell tumour - 42872917 Biphenotypic sinonasal sarcoma - 37311513 Adenosarcoma - 4135215 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 22. Diagnosis.subsite | |||||||
| Definition | Topography subsite value for the cancer diagnosis | ||||||
| Short | Subsite (O) | ||||||
| Comments | Nasal cavity structure - 4088327 Maxillary sinus structure - 4050631 Ethmoid sinus structure - 4182234 Frontal sinus structure - 4204534 Sphenoid sinus structure - 4097172 Nasal sinus structure - 4051578 Structure of superior wall of nasopharynx - 4068978 Structure of posterior wall of nasopharynx - 4146741 Structure of lateral wall of nasopharynx - 4323979 Structure of anterior wall of nasopharynx - 4220236 Nasopharyngeal structure - 4216712 Structure of postcricoid region - 4147741 Structure of hypopharyngeal aspect of aryepiglottic fold - 4262980 Structure of posterior wall of hypopharynx - 4102600 Structure of piriform recess - 4268741 Hypopharyngeal structure - 4218592 Parotid gland structure - 4166063 Submandibular salivary gland structure - 4299196 Sublingual gland structure - 4229131 Middle ear structure - 4100253 Structure of root of tongue - 4169910 Soft palate structure - 4177005 Uvula palatina structure - 4095284 Tonsillar fossa structure - 4138234 Lingual tonsil structure - 4068841 Palatine arch structure - 4065073 Structure of vallecula of epiglottis - 4173123 Structure of anterior surface of epiglottis - 4283238 Structure of lateral wall of oropharynx - 4078066 Structure of posterior wall of oropharynx - 4045435 Embryonic branchial cleft - 4235649 Palatine tonsillar structure - 4327174 Oropharyngeal structure - 4151149 Glottis structure - 4047227 Supraglottis structure - 4001049 Subglottis structure - 4002724 Laryngeal cartilage structure - 4279711 Laryngeal structure - 4262229 Structure of dorsum of tongue - 4284551 Structure of border of tongue - 4077986 Structure of inferior surface of tongue - 4172794 Anterior 2/3 of tongue NOS - 2000100024 Overlapping lesion of tongue - 44498031 Structure of gum of maxilla - 4047029 Structure of gum of mandible - 4210919 Structure of anterior floor of mouth - 4181419 Structure of lateral floor of mouth - 4103066 Overlapping lesion of floor of mouth - 44498040 Hard palate structure - 4234542 Buccal mucosa - 4057160 Structure of vestibule of mouth - 4144069 Structure of retromolar area of mouth - 4312102 Overlapping lesion of other and unspecified parts of mouth - 44498052 Oral cavity structure - 4253672 Structure of vermilion border of upper lip - 4134589 Structure of vermilion border of lower lip - 4027546 Structure of vermilion border of lip - 4027545 Structure of mucous membrane of upper lip - 4086480 Structure of mucous membrane of lip - 4245168 Commissure of lips - 4307358 Lip structure - 4168155 Hand structure - 4310976 Wrist region structure - 4220073 Forearm structure - 4032953 Elbow region structure - 4027910 Antecubital fossa (surface region) - 4348994 Upper arm structure - 4165266 Foot structure- 4211098 Ankle region structure - 4142359 Lower leg structure - 4107527 Knee region structure - 4217806 popliteal fossa structure - 4138531 Upper leg - 4090445 Deltoid - 4291935 Supraclavicular - 4088464 Periscapular - 2000100022 Trapezius - 4136969 Groin Flap - 2000100023 Buttock - 4263335 Pectoral - 4096078 Axilla - 4157836 Joint structure of thoracic wall - 4088614 Anterior abdominal wall structure - 4244412 Posterior abdominal wall structure - 4330865 Paravertebral region - 4348976 Structure of thoracolumbar region of back - 4289613 Structure of thoracolumbar junction of vertebral column - 606482 Structure of cervical vertebral column - 4046743 Retroperitoneal fascia - 4075118 Retroperitoneal compartment structure - 4220536 Inferior vena cava structure - 4271699 Iliac vessel - 4193451 Aorta and aorta, CS - 4004831 Structure of renal artery - 4154880 Gonadal artery - 4157844 Structure of mesenteric artery - 4314264 Other vessels - Subsume (CHILDREN) Pelvic region - 4044034 Region of esophagus - 4075991 Stomach structure - 4288283 Duodenal structure - 4302112 Jejunal structure - 4065077 Stricture of ileum - 4316356 Colon structure - 4215634 Rectum structure - 4144541 Mesentery - 4233095 Lung structure - 4213162 Heart structure - 4217142 Pleura structure - 4150673 Region of mediastinum - 4088610 Superior vena cava structure - 4167648 Aorta and aorta, CS - 4004831 Stricture of pulmonary vessel - 4035327 Structure of subclavian artery - 4272388 Adrenal structure - 4051774 Kidney structure - 4271678 Region of ureter - 4078617 Urinary bladder structure - 4232481 Prostatic structure - 4165732 Seminal Vescicle structure - 4277442 Spermatic Cord structure - 4172591 Testis structure - 4238088 Penile structure - 4077311 Uterine structure - 4149192 Ovarian structure - 4049448 Fallopian tube structure - 4151444 Vaginal structure - 4296022 Vulval structure - 4166066 Face and/or neck structure - 4122633 Breast structure - 4298444 Any Domain=Spec Anatomic Site and Standard code | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 24. Diagnosis.diagnosisCode | |||||||
| Definition | Histology/Topography code combination for the cancer diagnosis | ||||||
| Short | Diagnosis code (M) | ||||||
| Comments | The codes lists are in the spreadsheets "HNC Conditions List" and "Sarcoma Conditions List" of the file | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 26. Diagnosis.tumorSize | |||||||
| Definition | Describes the tumor size in CM. (the longest diameter; longest dimension between pre operatory imaging and pathological specimen) cm | ||||||
| Short | Tumor Size (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 28. Diagnosis.superficialDepth | |||||||
| Definition | Provides the superficial depth of the tumour (for upper and lower limbs and superficial trunk) superficial (superficial tumour is located exclusively above the investing fascia without invasion of the fascia), deep (deep tumour is located beneath or invade the investing fascia). All the others are deep by definition. | ||||||
| Short | Superficial depth (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 30. Diagnosis.deepDepth | |||||||
| Definition | Provides the deep depth of the tumour (for upper and lower limbs and superficial trunk) superficial (superficial tumour is located exclusively above the investing fascia without invasion of the fascia), deep (deep tumour is located beneath or invade the investing fascia). All the others are deep by definition | ||||||
| Short | Deep depth (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 32. Diagnosis.biopsyMitoticCount | |||||||
| Definition | Mitotic count reported from the biopsy (Number/10HPF/1mm2, 50HPF/5mm2). Reported as Number of mitoses per 10 high power fields. | ||||||
| Short | Biopsy Mitotic count (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 34. Diagnosis.mitoticIndex | |||||||
| Definition | Mitotic index derived from the mitotic count. Information coming from the biopsy and derived. M1 for less than 10HPF, M2 for range 10-20 HPF and M3 for greater than 20 HPF. | ||||||
| Short | Mitotic Index (M) | ||||||
| Comments | Less than 10 mitoses per 10 HPF (score = 1) - 4240574 10-20 mitoses per 10 HPF (score = 2) - 4241298 Greater than 10 mitoses per 10 HPF (score = 3) - 4240069 | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 36. Diagnosis.plasmaticEbvDnaAtBaseline | |||||||
| Definition | Describes the result of EBV DNA plasmatic test before treatment for Lymphoepithelial carcinoma, lymphoepithelioma like carcinoma (Nasal cavity and Paranasal Sinuses) or Nasopharynx | ||||||
| Short | Plasmatic EBV DNA at baseline (R) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 38. Diagnosis.hpvStatus | |||||||
| Definition | Describes the result of HPV tumor tested in Nasal Cavity and Paranasal Sinuses, Nasopharnx or Oropharynx carcinoma | ||||||
| Short | HPV status (M for OROPHARYNGEAL (not oral cavity) carcinomas) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 40. Diagnosis.crpTested | |||||||
| Definition | Describes the result of C reactive protein tested | ||||||
| Short | CRP – C reactive protein tested (O) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
Guidance on how to interpret the contents of this table can be foundhere
| 0. Diagnosis | |||||||
| Definition | Diagnosis Maturity Level: 0 Draft | ||||||
| Short | Diagnosis | ||||||
| Logical Model | Instances of this logical model are not marked to be the target of a Reference | ||||||
| 2. Diagnosis.cancerepisode | |||||||
| Definition | CancerEpisode reference where the diagnosis was performed | ||||||
| Short | CancerEpisode (M) | ||||||
| Control | 1..* | ||||||
| Type | http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/CancerEpisode | ||||||
| Obligations |
| ||||||
| 4. Diagnosis.dateOfDiagnosis | |||||||
| Definition | Date of the procedure performed to obtain the specimen for the histological diagnosis, regardless of the institution that performed it. | ||||||
| Short | Date of diagnosis (biopsy or surgical piece) (M) | ||||||
| Control | 1..* | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 6. Diagnosis.typeOfBiopsy | |||||||
| Definition | Type of biopsy performed to the patient. Information coming from the biopsy data. | ||||||
| Short | Type of biopsy (M) | ||||||
| Comments | Fine needle biopsy - 4171863 Core needle biopsy - 4321878 Incisional biopsy - 4321986 Excisional biopsy - 4228202 Excision - 4279903 | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 8. Diagnosis.biopsyDoneBy | |||||||
| Definition | Describes the institution where diagnostic procedure was performed. A pseudonym for a hospital. It could be the ID assigned from the original hospital. | ||||||
| Short | Biopsy done by (M) | ||||||
| Control | 1..* | ||||||
| Type | string | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 10. Diagnosis.ageAtDiagnosis | |||||||
| Definition | Age of the patient at the time of the diagnosis. | ||||||
| Short | Age at diagnosis (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 12. Diagnosis.radiotherapyInducedSarcoma | |||||||
| Definition | radiotherapy induced if the new tumour is in the field or marginal the anatomical area that received high radiation dose; please specify the interval time from the radiotherapy treatment | ||||||
| Short | Radiotherapy induced sarcoma (M) | ||||||
| Comments | Radiation-induced sarcoma - 2000100003 | ||||||
| Control | 1..* | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 14. Diagnosis.biopsyGrading | |||||||
| Definition | Grading of the cancer given by the biopsy | ||||||
| Short | Biopsy grading (O) | ||||||
| Comments | Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 16. Diagnosis.histologyGroup | |||||||
| Definition | HNC: Describes the histology of primary tumour according to WHO 2017 clasification. | ||||||
| Short | Histology group (O) | ||||||
| Comments | Squamous cell carcinoma - 37156145 Adenocarcinoma - 37152526 Neuroendocrine carcinoma - 1242310 Undifferentiated carcinoma of nasal sinus - 44783808 Adenosquamous carcinoma - 4241843 Teratocarcinoma - 4284401 Nuclear protein in testis associated carcinoma - 37116896 HPV-related Multiphenotypic Sinonasal Carcinoma - 2000100004 Olfactory neuroblastoma - 4295574 Odontogenic tumor, malignant - 4098585 Lipomatous neoplasm (Adipocytic tumours) - 4019487 Fibromatous neoplasm of borderline malignancy - 4266648 So-called fibrohistiocytic tumours - 2000100005 Vascular tumours - 2000100006 Pericytic (perivascular) tumours - 2000100007 Smooth muscle tumor - 4327493 Osseous AND/OR chondromatous neoplasm - 4019107 Nerve sheath tumor - 4017276 Neoplasm of uncertain behavior - 4313421 Undifferentiated small round cell sarcomas of bone and soft tissue - 2000100008 Endometrial stromal sarcoma - 2000100009 Miscellanious mesenchimal tumors - 2000100010 Mixed epithelial and mesenchymal tumours - 2000100011 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 18. Diagnosis.site | |||||||
| Definition | Describes the primary tumor site. For head and neck, according to AJCC . | ||||||
| Short | Site (O) | ||||||
| Comments | Nasal cavity and paranasal sinus - 2000000067 Nasopharynx - 36769745 Parotid gland - 36769263 Submandibular gland - 36770243 Sublingual gland - 36769383 Middle ear - 2000100020 Hypopharynx - 36770295 Oropharynx - 36769199 Larynx - 2000000037 Oral cavity - 2000100021 Lip - 36769197 Pharynx - 2000000057 Sinonasal - 2000000067 Larynx - 2000000037 Head, face, and neck - 36769894 Upper limb and shoulder - 36769192 Lower limb and hip - 36769168 Trunk - 36768213 Thorax - 36770344 Abdomen - 36769612 Retroperitoneum - 36770706 Peritoneum - 36768774 Pelvis - 36768752 Breast - 2000000012 Genitourinary (not bladder / prostate) - 36768087 Urinary tract - 36769378 Central Nervous System - 2000000015 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 20. Diagnosis.histologySubgroup | |||||||
| Definition | Histology subgroup value for the cancer diagnosis. | ||||||
| Short | Histology subgroup (O) | ||||||
| Comments | Squamous cell carcinoma, keratinizing - 4078953 Squamous cell carcinoma, large cell, nonkeratinizing - 4166826 Schneiderian carcinoma - 4206785 Non-keratinizing squamous cell carcinoma: SMARCB1 (INI-1)-deficient Sinonasal Carcinoma - 2000100012 Non-keratinizing squamous cell carcinoma: Transitional (cylindrical cell, Schneiderian) carcinoma - 2000100013 Squamous cell carcinoma, spindle cell - 4009590 Spindle cell (sarcomatoid) squamous cell carcinoma: SMARCB1 (INI-1) - 2000100014 Lymphoepithelial carcinoma - 4247661 Basaloid squamous cell carcinoma - 4029973 Squamous cell carcinoma - 37156145 Adenoid squamous cell carcinoma - 4312219 Squamous cell carcinoma, microinvasive - 4052146 Giant cell carcinoma - 4175678 Verrucous carcinoma - 4233949 Papillary squamous cell carcinoma - 4191609 Squamous cell carcinoma - 37156145 Human papillomavirus positive squamous cell carcinoma - 37204531 Human papillomavirus negative squamous cell carcinoma - 37204532 Squamous cell carcinoma - 37156145 Adenocarcinoma, intestinal type - 4097305 Adenocarcinoma - 37152526 Cystoadenocarcinoma - 4050978 Mucinous adenocarcinoma - 4247921 Ceruminous adenocarcinoma - 4238334 Papillary adenocarcinoma - 4172953 Adenoid cystic carcinoma - 4022895 Mucoepidermoid carcinoma - 4253608 Polymorphous low grade adenocarcinoma - 4030121 Acinar cell carcinoma - 4164740 Clear cell adenocarcinoma - 4148292 Basal cell adenocarcinoma - 4146684 Infiltrating duct carcinoma - 4221403 Juvenile carcinoma of the breast - 4224593 Paget's disease, extramammary (except Paget's disease of bone) - 4323699 Malignant myoepithelioma - 4029680 Epithelial-myoepithelial carcinoma - 4321002 Carcinoma ex pleomorphic adenoma - 4066512 Sebaceous adenocarcinoma - 4182993 Carcinosarcoma - 4271564 Oxyphilic adenocarcinoma - 4212379 Cystadenocarcinoma - 4050978 Small cell neuroendocrine carcinoma (SmCC) - 36714029 Malignant poorly differentiated neuroendocrine carcinoma - 37018672 Large cell neuroendocrine carcinoma (LCNEC) - 4029971 Neuroendocrine tumor grade 1 - 4133828 Neuroendocrine tumor grade 2 - 4133297 Neuroendocrine carcinoma - 1242310 Odontogenic tumor, malignant - 4098585 Clear cell odontogenic carcinoma - 37116966 Malignant odontogenic ghost cell tumor
SMARCB1 (INI-1)-deficient Sinonasal undifferentiated Carcinoma - 2000100015 Sinonasal SMARCA4 deficient carcinoma; - 2000100016 IDH2-mutated sinonasal undifferentiated neoplasm - 2000100017 Undifferentiated carcinoma of nasal sinus - 44783808 Carcinoma, undifferentiated - 4243327 Adenosquamous carcinoma - 4241843 Teratocarcinoma - 4284401 Nuclear protein in testis associated carcinoma - 37116896 HPV-related Multiphenotypic Sinonasal Carcinoma - 2000100018 Olfactory neuroblastoma - 4295574 Atypical lipomatous tumor - 4021372 Liposarcoma, well differentiated - 4102790 Dedifferentiated liposarcoma - 4284833 Myxoid liposarcoma - 4101123 Pleomorphic liposarcoma - 4010104 Myxoid pleomorphic liposarcoma - 1243142 Palmar/plantar-type fibromatosis - 45766452 Aggressive fibromatosis - 4264204 Lipofibromatosis - 45766468 Giant cell fibroblastoma - 4030132 Dermatofibrosarcoma protuberans - 4295283 Solitary fibrous tumor and hemangiopericytoma grade 1 - 37116995 Solitary fibrous tumor and hemangiopericytoma grade 2 - 37116996 Solitary fibrous tumor and hemangiopericytoma grade 3 - 37116997 Myofibroblastic tumour - 4021373 Low-grade myofibroblastic sarcoma - 45766454 Cellular fibroma - 4029679 Myxoinflammatory fibroblastic sarcoma - 45766450 Fibrosarcoma - 4202374 Myxofibrosarcoma - 45771359 Low-grade fibromyxoid sarcoma - 45771361 Sclerosing epithelioid fibrosarcoma - 45766456 Plexiform fibrohistiocytic tumour - 4029525 Giant cell tumour of soft parts - 4218898 Tenosynovial giant cell tumor - 4030140 Tenosynovial giant cell tumor, diffuse - 45766525 Malignant tenosynovial giant cell tumor - 4029655 Epithelioid haemangioendothelioma - 4207381 Angiosarcoma - 3661612 Hemangioendothelioma - 4281384 Spindle cell hemangioendothelioma - 4030139 Retiform haemangioendothelioma - 45766493 Papillary intralymphatic angioendothelioma - 4030138 Composite haemangioendothelioma - 45766494 Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma - 45766492 Glomus tumor - 4014760 Glomus tumor, malignant - 4028856 Smooth muscle tumour - 4327493 Epithelioid smooth muscle tumor of uncertain malignant potential - 607803 Myxoid smooth muscle tumour of uncertain mailgnant potential - 600675 Metastasizing leiomyoma - 4029023 Leiomyosarcoma - 37151903 Epithelioid leiomyosarcoma - 4173148 Myxoid leiomyosarcoma - 4059632 Embryonal rhabdomyosarcoma - 4031038 Alveolar rhabdomyosarcoma - 4272931 Pleomorphic rhabdomyosarcoma - 4298312 Spindle cell rhabdomyosarcoma - 4029528 Ectomesenchymoma - 4029024 Extraskeletal osteosarcoma - 4298240 Malignant peripheral nerve sheath tumour - 4062426 Melanotic malignant peripheral nerve sheath tumor - 4102399 Granular cell tumour - 4005360 Granular cell tumour, malignant - 4027842 Atypical fibrous histiocytoma - 4096931 Angiomatoid fibrous histiocytoma - 4029526 Pleomorphic hyalinizing angiectatic tumour - 45766448 Hemosiderotic fibrolipomatous tumor - 1243125 NTRK-rearranged spindle cell neoplasm - 1243130 Synovial sarcoma - 4268491 Epithelioid sarcoma - 4244886 Alveolar soft part sarcoma - 4339208 Clear cell sarcoma - 4155072 Extraskeletal myxoid chondrosarcoma - 4297345 Desmoplastic small round cell tumor - 4029522 Extrarenal rhabdoid tumor - 4299132 Perivascular epithelioid tumor, benign - 45771358 Perivascular epithelioid tumor, malignant - 45766447 Perivascular epithelioid cell tumor - 4304780 Intimal sarcoma - 45766495 Undifferentiated sarcoma - 4029021 Myoepithelioma - 4239519 Myoepithelial carcinoma - 4029680 Ossifying fibromyxoid tumour - 4028565 Ossifying fibromyxoid tumor, malignant - 45766467 Mesenchymoma - 4195947 Phosphaturic mesenchymal tumor, benign - 45766484 Phosphaturic mesenchymal tumour, malignant - 45766485 Angiomyxoma - 4239956 Angiomatoid fibrous histiocytoma - 4029526 NTRK-rearranged spindle cell neoplasm (emerging) - 2000100019 Ewing sarcoma / peripheral neuroectodermal tumor - 45766528 Round cell sarcoma with EWSR1–non-ETS fusions - 37155974 CIC-rearranged sarcoma - 37152438 Sarcoma with BCOR genetic alterations - 37152440 Endometrial stromal sarcoma, high grade - 4290926 Endometrial stromal sarcoma, low grade - 4028557 Uterine tumour resembling ovarian sex cord tumour - 45771357 Benign phyllodes tumor - 4040991 Borderline phyllodes tumor - 4323562 Malignant phyllodes tumor - 4337106 Follicular dendritic cell sarcoma - 4028710 Histiocytic sarcoma - 4029172 Interdigitating dendritic cell sarcoma - 4028709 Langherans cell sarcoma - 4029173 Fibroblastic reticular cell tumour - 42872917 Biphenotypic sinonasal sarcoma - 37311513 Adenosarcoma - 4135215 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 22. Diagnosis.subsite | |||||||
| Definition | Topography subsite value for the cancer diagnosis | ||||||
| Short | Subsite (O) | ||||||
| Comments | Nasal cavity structure - 4088327 Maxillary sinus structure - 4050631 Ethmoid sinus structure - 4182234 Frontal sinus structure - 4204534 Sphenoid sinus structure - 4097172 Nasal sinus structure - 4051578 Structure of superior wall of nasopharynx - 4068978 Structure of posterior wall of nasopharynx - 4146741 Structure of lateral wall of nasopharynx - 4323979 Structure of anterior wall of nasopharynx - 4220236 Nasopharyngeal structure - 4216712 Structure of postcricoid region - 4147741 Structure of hypopharyngeal aspect of aryepiglottic fold - 4262980 Structure of posterior wall of hypopharynx - 4102600 Structure of piriform recess - 4268741 Hypopharyngeal structure - 4218592 Parotid gland structure - 4166063 Submandibular salivary gland structure - 4299196 Sublingual gland structure - 4229131 Middle ear structure - 4100253 Structure of root of tongue - 4169910 Soft palate structure - 4177005 Uvula palatina structure - 4095284 Tonsillar fossa structure - 4138234 Lingual tonsil structure - 4068841 Palatine arch structure - 4065073 Structure of vallecula of epiglottis - 4173123 Structure of anterior surface of epiglottis - 4283238 Structure of lateral wall of oropharynx - 4078066 Structure of posterior wall of oropharynx - 4045435 Embryonic branchial cleft - 4235649 Palatine tonsillar structure - 4327174 Oropharyngeal structure - 4151149 Glottis structure - 4047227 Supraglottis structure - 4001049 Subglottis structure - 4002724 Laryngeal cartilage structure - 4279711 Laryngeal structure - 4262229 Structure of dorsum of tongue - 4284551 Structure of border of tongue - 4077986 Structure of inferior surface of tongue - 4172794 Anterior 2/3 of tongue NOS - 2000100024 Overlapping lesion of tongue - 44498031 Structure of gum of maxilla - 4047029 Structure of gum of mandible - 4210919 Structure of anterior floor of mouth - 4181419 Structure of lateral floor of mouth - 4103066 Overlapping lesion of floor of mouth - 44498040 Hard palate structure - 4234542 Buccal mucosa - 4057160 Structure of vestibule of mouth - 4144069 Structure of retromolar area of mouth - 4312102 Overlapping lesion of other and unspecified parts of mouth - 44498052 Oral cavity structure - 4253672 Structure of vermilion border of upper lip - 4134589 Structure of vermilion border of lower lip - 4027546 Structure of vermilion border of lip - 4027545 Structure of mucous membrane of upper lip - 4086480 Structure of mucous membrane of lip - 4245168 Commissure of lips - 4307358 Lip structure - 4168155 Hand structure - 4310976 Wrist region structure - 4220073 Forearm structure - 4032953 Elbow region structure - 4027910 Antecubital fossa (surface region) - 4348994 Upper arm structure - 4165266 Foot structure- 4211098 Ankle region structure - 4142359 Lower leg structure - 4107527 Knee region structure - 4217806 popliteal fossa structure - 4138531 Upper leg - 4090445 Deltoid - 4291935 Supraclavicular - 4088464 Periscapular - 2000100022 Trapezius - 4136969 Groin Flap - 2000100023 Buttock - 4263335 Pectoral - 4096078 Axilla - 4157836 Joint structure of thoracic wall - 4088614 Anterior abdominal wall structure - 4244412 Posterior abdominal wall structure - 4330865 Paravertebral region - 4348976 Structure of thoracolumbar region of back - 4289613 Structure of thoracolumbar junction of vertebral column - 606482 Structure of cervical vertebral column - 4046743 Retroperitoneal fascia - 4075118 Retroperitoneal compartment structure - 4220536 Inferior vena cava structure - 4271699 Iliac vessel - 4193451 Aorta and aorta, CS - 4004831 Structure of renal artery - 4154880 Gonadal artery - 4157844 Structure of mesenteric artery - 4314264 Other vessels - Subsume (CHILDREN) Pelvic region - 4044034 Region of esophagus - 4075991 Stomach structure - 4288283 Duodenal structure - 4302112 Jejunal structure - 4065077 Stricture of ileum - 4316356 Colon structure - 4215634 Rectum structure - 4144541 Mesentery - 4233095 Lung structure - 4213162 Heart structure - 4217142 Pleura structure - 4150673 Region of mediastinum - 4088610 Superior vena cava structure - 4167648 Aorta and aorta, CS - 4004831 Stricture of pulmonary vessel - 4035327 Structure of subclavian artery - 4272388 Adrenal structure - 4051774 Kidney structure - 4271678 Region of ureter - 4078617 Urinary bladder structure - 4232481 Prostatic structure - 4165732 Seminal Vescicle structure - 4277442 Spermatic Cord structure - 4172591 Testis structure - 4238088 Penile structure - 4077311 Uterine structure - 4149192 Ovarian structure - 4049448 Fallopian tube structure - 4151444 Vaginal structure - 4296022 Vulval structure - 4166066 Face and/or neck structure - 4122633 Breast structure - 4298444 Any Domain=Spec Anatomic Site and Standard code | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 24. Diagnosis.diagnosisCode | |||||||
| Definition | Histology/Topography code combination for the cancer diagnosis | ||||||
| Short | Diagnosis code (M) | ||||||
| Comments | The codes lists are in the spreadsheets "HNC Conditions List" and "Sarcoma Conditions List" of the file | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 26. Diagnosis.tumorSize | |||||||
| Definition | Describes the tumor size in CM. (the longest diameter; longest dimension between pre operatory imaging and pathological specimen) cm | ||||||
| Short | Tumor Size (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 28. Diagnosis.superficialDepth | |||||||
| Definition | Provides the superficial depth of the tumour (for upper and lower limbs and superficial trunk) superficial (superficial tumour is located exclusively above the investing fascia without invasion of the fascia), deep (deep tumour is located beneath or invade the investing fascia). All the others are deep by definition. | ||||||
| Short | Superficial depth (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 30. Diagnosis.deepDepth | |||||||
| Definition | Provides the deep depth of the tumour (for upper and lower limbs and superficial trunk) superficial (superficial tumour is located exclusively above the investing fascia without invasion of the fascia), deep (deep tumour is located beneath or invade the investing fascia). All the others are deep by definition | ||||||
| Short | Deep depth (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 32. Diagnosis.biopsyMitoticCount | |||||||
| Definition | Mitotic count reported from the biopsy (Number/10HPF/1mm2, 50HPF/5mm2). Reported as Number of mitoses per 10 high power fields. | ||||||
| Short | Biopsy Mitotic count (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 34. Diagnosis.mitoticIndex | |||||||
| Definition | Mitotic index derived from the mitotic count. Information coming from the biopsy and derived. M1 for less than 10HPF, M2 for range 10-20 HPF and M3 for greater than 20 HPF. | ||||||
| Short | Mitotic Index (M) | ||||||
| Comments | Less than 10 mitoses per 10 HPF (score = 1) - 4240574 10-20 mitoses per 10 HPF (score = 2) - 4241298 Greater than 10 mitoses per 10 HPF (score = 3) - 4240069 | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 36. Diagnosis.plasmaticEbvDnaAtBaseline | |||||||
| Definition | Describes the result of EBV DNA plasmatic test before treatment for Lymphoepithelial carcinoma, lymphoepithelioma like carcinoma (Nasal cavity and Paranasal Sinuses) or Nasopharynx | ||||||
| Short | Plasmatic EBV DNA at baseline (R) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 38. Diagnosis.hpvStatus | |||||||
| Definition | Describes the result of HPV tumor tested in Nasal Cavity and Paranasal Sinuses, Nasopharnx or Oropharynx carcinoma | ||||||
| Short | HPV status (M for OROPHARYNGEAL (not oral cavity) carcinomas) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 40. Diagnosis.crpTested | |||||||
| Definition | Describes the result of C reactive protein tested | ||||||
| Short | CRP – C reactive protein tested (O) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
Guidance on how to interpret the contents of this table can be foundhere
| 0. Diagnosis | |||||||
| Definition | Diagnosis Maturity Level: 0 Draft | ||||||
| Short | Diagnosis | ||||||
| Control | 0..* | ||||||
| Is Modifier | false | ||||||
| Logical Model | Instances of this logical model are not marked to be the target of a Reference | ||||||
| 2. Diagnosis.cancerepisode | |||||||
| Definition | CancerEpisode reference where the diagnosis was performed | ||||||
| Short | CancerEpisode (M) | ||||||
| Control | 1..* | ||||||
| Type | http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/CancerEpisode | ||||||
| Obligations |
| ||||||
| 4. Diagnosis.dateOfDiagnosis | |||||||
| Definition | Date of the procedure performed to obtain the specimen for the histological diagnosis, regardless of the institution that performed it. | ||||||
| Short | Date of diagnosis (biopsy or surgical piece) (M) | ||||||
| Control | 1..* | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 6. Diagnosis.typeOfBiopsy | |||||||
| Definition | Type of biopsy performed to the patient. Information coming from the biopsy data. | ||||||
| Short | Type of biopsy (M) | ||||||
| Comments | Fine needle biopsy - 4171863 Core needle biopsy - 4321878 Incisional biopsy - 4321986 Excisional biopsy - 4228202 Excision - 4279903 | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 8. Diagnosis.biopsyDoneBy | |||||||
| Definition | Describes the institution where diagnostic procedure was performed. A pseudonym for a hospital. It could be the ID assigned from the original hospital. | ||||||
| Short | Biopsy done by (M) | ||||||
| Control | 1..* | ||||||
| Type | string | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 10. Diagnosis.ageAtDiagnosis | |||||||
| Definition | Age of the patient at the time of the diagnosis. | ||||||
| Short | Age at diagnosis (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 12. Diagnosis.radiotherapyInducedSarcoma | |||||||
| Definition | radiotherapy induced if the new tumour is in the field or marginal the anatomical area that received high radiation dose; please specify the interval time from the radiotherapy treatment | ||||||
| Short | Radiotherapy induced sarcoma (M) | ||||||
| Comments | Radiation-induced sarcoma - 2000100003 | ||||||
| Control | 1..* | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 14. Diagnosis.biopsyGrading | |||||||
| Definition | Grading of the cancer given by the biopsy | ||||||
| Short | Biopsy grading (O) | ||||||
| Comments | Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 16. Diagnosis.histologyGroup | |||||||
| Definition | HNC: Describes the histology of primary tumour according to WHO 2017 clasification. | ||||||
| Short | Histology group (O) | ||||||
| Comments | Squamous cell carcinoma - 37156145 Adenocarcinoma - 37152526 Neuroendocrine carcinoma - 1242310 Undifferentiated carcinoma of nasal sinus - 44783808 Adenosquamous carcinoma - 4241843 Teratocarcinoma - 4284401 Nuclear protein in testis associated carcinoma - 37116896 HPV-related Multiphenotypic Sinonasal Carcinoma - 2000100004 Olfactory neuroblastoma - 4295574 Odontogenic tumor, malignant - 4098585 Lipomatous neoplasm (Adipocytic tumours) - 4019487 Fibromatous neoplasm of borderline malignancy - 4266648 So-called fibrohistiocytic tumours - 2000100005 Vascular tumours - 2000100006 Pericytic (perivascular) tumours - 2000100007 Smooth muscle tumor - 4327493 Osseous AND/OR chondromatous neoplasm - 4019107 Nerve sheath tumor - 4017276 Neoplasm of uncertain behavior - 4313421 Undifferentiated small round cell sarcomas of bone and soft tissue - 2000100008 Endometrial stromal sarcoma - 2000100009 Miscellanious mesenchimal tumors - 2000100010 Mixed epithelial and mesenchymal tumours - 2000100011 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 18. Diagnosis.site | |||||||
| Definition | Describes the primary tumor site. For head and neck, according to AJCC . | ||||||
| Short | Site (O) | ||||||
| Comments | Nasal cavity and paranasal sinus - 2000000067 Nasopharynx - 36769745 Parotid gland - 36769263 Submandibular gland - 36770243 Sublingual gland - 36769383 Middle ear - 2000100020 Hypopharynx - 36770295 Oropharynx - 36769199 Larynx - 2000000037 Oral cavity - 2000100021 Lip - 36769197 Pharynx - 2000000057 Sinonasal - 2000000067 Larynx - 2000000037 Head, face, and neck - 36769894 Upper limb and shoulder - 36769192 Lower limb and hip - 36769168 Trunk - 36768213 Thorax - 36770344 Abdomen - 36769612 Retroperitoneum - 36770706 Peritoneum - 36768774 Pelvis - 36768752 Breast - 2000000012 Genitourinary (not bladder / prostate) - 36768087 Urinary tract - 36769378 Central Nervous System - 2000000015 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 20. Diagnosis.histologySubgroup | |||||||
| Definition | Histology subgroup value for the cancer diagnosis. | ||||||
| Short | Histology subgroup (O) | ||||||
| Comments | Squamous cell carcinoma, keratinizing - 4078953 Squamous cell carcinoma, large cell, nonkeratinizing - 4166826 Schneiderian carcinoma - 4206785 Non-keratinizing squamous cell carcinoma: SMARCB1 (INI-1)-deficient Sinonasal Carcinoma - 2000100012 Non-keratinizing squamous cell carcinoma: Transitional (cylindrical cell, Schneiderian) carcinoma - 2000100013 Squamous cell carcinoma, spindle cell - 4009590 Spindle cell (sarcomatoid) squamous cell carcinoma: SMARCB1 (INI-1) - 2000100014 Lymphoepithelial carcinoma - 4247661 Basaloid squamous cell carcinoma - 4029973 Squamous cell carcinoma - 37156145 Adenoid squamous cell carcinoma - 4312219 Squamous cell carcinoma, microinvasive - 4052146 Giant cell carcinoma - 4175678 Verrucous carcinoma - 4233949 Papillary squamous cell carcinoma - 4191609 Squamous cell carcinoma - 37156145 Human papillomavirus positive squamous cell carcinoma - 37204531 Human papillomavirus negative squamous cell carcinoma - 37204532 Squamous cell carcinoma - 37156145 Adenocarcinoma, intestinal type - 4097305 Adenocarcinoma - 37152526 Cystoadenocarcinoma - 4050978 Mucinous adenocarcinoma - 4247921 Ceruminous adenocarcinoma - 4238334 Papillary adenocarcinoma - 4172953 Adenoid cystic carcinoma - 4022895 Mucoepidermoid carcinoma - 4253608 Polymorphous low grade adenocarcinoma - 4030121 Acinar cell carcinoma - 4164740 Clear cell adenocarcinoma - 4148292 Basal cell adenocarcinoma - 4146684 Infiltrating duct carcinoma - 4221403 Juvenile carcinoma of the breast - 4224593 Paget's disease, extramammary (except Paget's disease of bone) - 4323699 Malignant myoepithelioma - 4029680 Epithelial-myoepithelial carcinoma - 4321002 Carcinoma ex pleomorphic adenoma - 4066512 Sebaceous adenocarcinoma - 4182993 Carcinosarcoma - 4271564 Oxyphilic adenocarcinoma - 4212379 Cystadenocarcinoma - 4050978 Small cell neuroendocrine carcinoma (SmCC) - 36714029 Malignant poorly differentiated neuroendocrine carcinoma - 37018672 Large cell neuroendocrine carcinoma (LCNEC) - 4029971 Neuroendocrine tumor grade 1 - 4133828 Neuroendocrine tumor grade 2 - 4133297 Neuroendocrine carcinoma - 1242310 Odontogenic tumor, malignant - 4098585 Clear cell odontogenic carcinoma - 37116966 Malignant odontogenic ghost cell tumor
SMARCB1 (INI-1)-deficient Sinonasal undifferentiated Carcinoma - 2000100015 Sinonasal SMARCA4 deficient carcinoma; - 2000100016 IDH2-mutated sinonasal undifferentiated neoplasm - 2000100017 Undifferentiated carcinoma of nasal sinus - 44783808 Carcinoma, undifferentiated - 4243327 Adenosquamous carcinoma - 4241843 Teratocarcinoma - 4284401 Nuclear protein in testis associated carcinoma - 37116896 HPV-related Multiphenotypic Sinonasal Carcinoma - 2000100018 Olfactory neuroblastoma - 4295574 Atypical lipomatous tumor - 4021372 Liposarcoma, well differentiated - 4102790 Dedifferentiated liposarcoma - 4284833 Myxoid liposarcoma - 4101123 Pleomorphic liposarcoma - 4010104 Myxoid pleomorphic liposarcoma - 1243142 Palmar/plantar-type fibromatosis - 45766452 Aggressive fibromatosis - 4264204 Lipofibromatosis - 45766468 Giant cell fibroblastoma - 4030132 Dermatofibrosarcoma protuberans - 4295283 Solitary fibrous tumor and hemangiopericytoma grade 1 - 37116995 Solitary fibrous tumor and hemangiopericytoma grade 2 - 37116996 Solitary fibrous tumor and hemangiopericytoma grade 3 - 37116997 Myofibroblastic tumour - 4021373 Low-grade myofibroblastic sarcoma - 45766454 Cellular fibroma - 4029679 Myxoinflammatory fibroblastic sarcoma - 45766450 Fibrosarcoma - 4202374 Myxofibrosarcoma - 45771359 Low-grade fibromyxoid sarcoma - 45771361 Sclerosing epithelioid fibrosarcoma - 45766456 Plexiform fibrohistiocytic tumour - 4029525 Giant cell tumour of soft parts - 4218898 Tenosynovial giant cell tumor - 4030140 Tenosynovial giant cell tumor, diffuse - 45766525 Malignant tenosynovial giant cell tumor - 4029655 Epithelioid haemangioendothelioma - 4207381 Angiosarcoma - 3661612 Hemangioendothelioma - 4281384 Spindle cell hemangioendothelioma - 4030139 Retiform haemangioendothelioma - 45766493 Papillary intralymphatic angioendothelioma - 4030138 Composite haemangioendothelioma - 45766494 Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma - 45766492 Glomus tumor - 4014760 Glomus tumor, malignant - 4028856 Smooth muscle tumour - 4327493 Epithelioid smooth muscle tumor of uncertain malignant potential - 607803 Myxoid smooth muscle tumour of uncertain mailgnant potential - 600675 Metastasizing leiomyoma - 4029023 Leiomyosarcoma - 37151903 Epithelioid leiomyosarcoma - 4173148 Myxoid leiomyosarcoma - 4059632 Embryonal rhabdomyosarcoma - 4031038 Alveolar rhabdomyosarcoma - 4272931 Pleomorphic rhabdomyosarcoma - 4298312 Spindle cell rhabdomyosarcoma - 4029528 Ectomesenchymoma - 4029024 Extraskeletal osteosarcoma - 4298240 Malignant peripheral nerve sheath tumour - 4062426 Melanotic malignant peripheral nerve sheath tumor - 4102399 Granular cell tumour - 4005360 Granular cell tumour, malignant - 4027842 Atypical fibrous histiocytoma - 4096931 Angiomatoid fibrous histiocytoma - 4029526 Pleomorphic hyalinizing angiectatic tumour - 45766448 Hemosiderotic fibrolipomatous tumor - 1243125 NTRK-rearranged spindle cell neoplasm - 1243130 Synovial sarcoma - 4268491 Epithelioid sarcoma - 4244886 Alveolar soft part sarcoma - 4339208 Clear cell sarcoma - 4155072 Extraskeletal myxoid chondrosarcoma - 4297345 Desmoplastic small round cell tumor - 4029522 Extrarenal rhabdoid tumor - 4299132 Perivascular epithelioid tumor, benign - 45771358 Perivascular epithelioid tumor, malignant - 45766447 Perivascular epithelioid cell tumor - 4304780 Intimal sarcoma - 45766495 Undifferentiated sarcoma - 4029021 Myoepithelioma - 4239519 Myoepithelial carcinoma - 4029680 Ossifying fibromyxoid tumour - 4028565 Ossifying fibromyxoid tumor, malignant - 45766467 Mesenchymoma - 4195947 Phosphaturic mesenchymal tumor, benign - 45766484 Phosphaturic mesenchymal tumour, malignant - 45766485 Angiomyxoma - 4239956 Angiomatoid fibrous histiocytoma - 4029526 NTRK-rearranged spindle cell neoplasm (emerging) - 2000100019 Ewing sarcoma / peripheral neuroectodermal tumor - 45766528 Round cell sarcoma with EWSR1–non-ETS fusions - 37155974 CIC-rearranged sarcoma - 37152438 Sarcoma with BCOR genetic alterations - 37152440 Endometrial stromal sarcoma, high grade - 4290926 Endometrial stromal sarcoma, low grade - 4028557 Uterine tumour resembling ovarian sex cord tumour - 45771357 Benign phyllodes tumor - 4040991 Borderline phyllodes tumor - 4323562 Malignant phyllodes tumor - 4337106 Follicular dendritic cell sarcoma - 4028710 Histiocytic sarcoma - 4029172 Interdigitating dendritic cell sarcoma - 4028709 Langherans cell sarcoma - 4029173 Fibroblastic reticular cell tumour - 42872917 Biphenotypic sinonasal sarcoma - 37311513 Adenosarcoma - 4135215 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 22. Diagnosis.subsite | |||||||
| Definition | Topography subsite value for the cancer diagnosis | ||||||
| Short | Subsite (O) | ||||||
| Comments | Nasal cavity structure - 4088327 Maxillary sinus structure - 4050631 Ethmoid sinus structure - 4182234 Frontal sinus structure - 4204534 Sphenoid sinus structure - 4097172 Nasal sinus structure - 4051578 Structure of superior wall of nasopharynx - 4068978 Structure of posterior wall of nasopharynx - 4146741 Structure of lateral wall of nasopharynx - 4323979 Structure of anterior wall of nasopharynx - 4220236 Nasopharyngeal structure - 4216712 Structure of postcricoid region - 4147741 Structure of hypopharyngeal aspect of aryepiglottic fold - 4262980 Structure of posterior wall of hypopharynx - 4102600 Structure of piriform recess - 4268741 Hypopharyngeal structure - 4218592 Parotid gland structure - 4166063 Submandibular salivary gland structure - 4299196 Sublingual gland structure - 4229131 Middle ear structure - 4100253 Structure of root of tongue - 4169910 Soft palate structure - 4177005 Uvula palatina structure - 4095284 Tonsillar fossa structure - 4138234 Lingual tonsil structure - 4068841 Palatine arch structure - 4065073 Structure of vallecula of epiglottis - 4173123 Structure of anterior surface of epiglottis - 4283238 Structure of lateral wall of oropharynx - 4078066 Structure of posterior wall of oropharynx - 4045435 Embryonic branchial cleft - 4235649 Palatine tonsillar structure - 4327174 Oropharyngeal structure - 4151149 Glottis structure - 4047227 Supraglottis structure - 4001049 Subglottis structure - 4002724 Laryngeal cartilage structure - 4279711 Laryngeal structure - 4262229 Structure of dorsum of tongue - 4284551 Structure of border of tongue - 4077986 Structure of inferior surface of tongue - 4172794 Anterior 2/3 of tongue NOS - 2000100024 Overlapping lesion of tongue - 44498031 Structure of gum of maxilla - 4047029 Structure of gum of mandible - 4210919 Structure of anterior floor of mouth - 4181419 Structure of lateral floor of mouth - 4103066 Overlapping lesion of floor of mouth - 44498040 Hard palate structure - 4234542 Buccal mucosa - 4057160 Structure of vestibule of mouth - 4144069 Structure of retromolar area of mouth - 4312102 Overlapping lesion of other and unspecified parts of mouth - 44498052 Oral cavity structure - 4253672 Structure of vermilion border of upper lip - 4134589 Structure of vermilion border of lower lip - 4027546 Structure of vermilion border of lip - 4027545 Structure of mucous membrane of upper lip - 4086480 Structure of mucous membrane of lip - 4245168 Commissure of lips - 4307358 Lip structure - 4168155 Hand structure - 4310976 Wrist region structure - 4220073 Forearm structure - 4032953 Elbow region structure - 4027910 Antecubital fossa (surface region) - 4348994 Upper arm structure - 4165266 Foot structure- 4211098 Ankle region structure - 4142359 Lower leg structure - 4107527 Knee region structure - 4217806 popliteal fossa structure - 4138531 Upper leg - 4090445 Deltoid - 4291935 Supraclavicular - 4088464 Periscapular - 2000100022 Trapezius - 4136969 Groin Flap - 2000100023 Buttock - 4263335 Pectoral - 4096078 Axilla - 4157836 Joint structure of thoracic wall - 4088614 Anterior abdominal wall structure - 4244412 Posterior abdominal wall structure - 4330865 Paravertebral region - 4348976 Structure of thoracolumbar region of back - 4289613 Structure of thoracolumbar junction of vertebral column - 606482 Structure of cervical vertebral column - 4046743 Retroperitoneal fascia - 4075118 Retroperitoneal compartment structure - 4220536 Inferior vena cava structure - 4271699 Iliac vessel - 4193451 Aorta and aorta, CS - 4004831 Structure of renal artery - 4154880 Gonadal artery - 4157844 Structure of mesenteric artery - 4314264 Other vessels - Subsume (CHILDREN) Pelvic region - 4044034 Region of esophagus - 4075991 Stomach structure - 4288283 Duodenal structure - 4302112 Jejunal structure - 4065077 Stricture of ileum - 4316356 Colon structure - 4215634 Rectum structure - 4144541 Mesentery - 4233095 Lung structure - 4213162 Heart structure - 4217142 Pleura structure - 4150673 Region of mediastinum - 4088610 Superior vena cava structure - 4167648 Aorta and aorta, CS - 4004831 Stricture of pulmonary vessel - 4035327 Structure of subclavian artery - 4272388 Adrenal structure - 4051774 Kidney structure - 4271678 Region of ureter - 4078617 Urinary bladder structure - 4232481 Prostatic structure - 4165732 Seminal Vescicle structure - 4277442 Spermatic Cord structure - 4172591 Testis structure - 4238088 Penile structure - 4077311 Uterine structure - 4149192 Ovarian structure - 4049448 Fallopian tube structure - 4151444 Vaginal structure - 4296022 Vulval structure - 4166066 Face and/or neck structure - 4122633 Breast structure - 4298444 Any Domain=Spec Anatomic Site and Standard code | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 24. Diagnosis.diagnosisCode | |||||||
| Definition | Histology/Topography code combination for the cancer diagnosis | ||||||
| Short | Diagnosis code (M) | ||||||
| Comments | The codes lists are in the spreadsheets "HNC Conditions List" and "Sarcoma Conditions List" of the file | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 26. Diagnosis.tumorSize | |||||||
| Definition | Describes the tumor size in CM. (the longest diameter; longest dimension between pre operatory imaging and pathological specimen) cm | ||||||
| Short | Tumor Size (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 28. Diagnosis.superficialDepth | |||||||
| Definition | Provides the superficial depth of the tumour (for upper and lower limbs and superficial trunk) superficial (superficial tumour is located exclusively above the investing fascia without invasion of the fascia), deep (deep tumour is located beneath or invade the investing fascia). All the others are deep by definition. | ||||||
| Short | Superficial depth (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 30. Diagnosis.deepDepth | |||||||
| Definition | Provides the deep depth of the tumour (for upper and lower limbs and superficial trunk) superficial (superficial tumour is located exclusively above the investing fascia without invasion of the fascia), deep (deep tumour is located beneath or invade the investing fascia). All the others are deep by definition | ||||||
| Short | Deep depth (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 32. Diagnosis.biopsyMitoticCount | |||||||
| Definition | Mitotic count reported from the biopsy (Number/10HPF/1mm2, 50HPF/5mm2). Reported as Number of mitoses per 10 high power fields. | ||||||
| Short | Biopsy Mitotic count (M) | ||||||
| Control | 1..* | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 34. Diagnosis.mitoticIndex | |||||||
| Definition | Mitotic index derived from the mitotic count. Information coming from the biopsy and derived. M1 for less than 10HPF, M2 for range 10-20 HPF and M3 for greater than 20 HPF. | ||||||
| Short | Mitotic Index (M) | ||||||
| Comments | Less than 10 mitoses per 10 HPF (score = 1) - 4240574 10-20 mitoses per 10 HPF (score = 2) - 4241298 Greater than 10 mitoses per 10 HPF (score = 3) - 4240069 | ||||||
| Control | 1..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 36. Diagnosis.plasmaticEbvDnaAtBaseline | |||||||
| Definition | Describes the result of EBV DNA plasmatic test before treatment for Lymphoepithelial carcinoma, lymphoepithelioma like carcinoma (Nasal cavity and Paranasal Sinuses) or Nasopharynx | ||||||
| Short | Plasmatic EBV DNA at baseline (R) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 38. Diagnosis.hpvStatus | |||||||
| Definition | Describes the result of HPV tumor tested in Nasal Cavity and Paranasal Sinuses, Nasopharnx or Oropharynx carcinoma | ||||||
| Short | HPV status (M for OROPHARYNGEAL (not oral cavity) carcinomas) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 40. Diagnosis.crpTested | |||||||
| Definition | Describes the result of C reactive protein tested | ||||||
| Short | CRP – C reactive protein tested (O) | ||||||
| Comments | Positive - 9191 Negative - 9189 not tested - 45878602 | ||||||
| Control | 0..* | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
IG © 2022+ IDEA4RC Project. Package hl7.eu.fhir.idea4rc#0.1.0 based on FHIR 4.0.1. Generated 2025-07-25
Links: Table of Contents |
QA Report
The IDEA4RC project has received funding from the European Union's Horizon 2020
research and innovation programme under grant agreement No. 101057048.
