ISO_639-1 en false 2009-06-17 Dr Ian McNicoll Ocean Informatics, UK ian.mcnicoll@oceaninformatics.com Koray Atalag, University of Auckland, New Zealand Matt Cordell, NEHTA, Australia Sam Heard, Ocean Informatics, Australia (Editor) Heather Leslie, Ocean Informatics, Australia David McKillop, NEHTA, Australia Ian McNicoll, Ocean Informatics, United Kingdom (Editor) Cathy Richardson, NEHTA, Australia David Rowed, VAMC Clinic, Australia (Editor) Diego Bosca, IBIME Group, Spain Initial The Royal College of Pathologists, NHS Cancer Screening Programmes. Pathology Reporting of Breast Disease [Internet]. 2005 Jan ;[cited 2009 Jul 26] Available from: http://www.rcpath.org/resources/pdf/PathologyReportingOfBreastDisease-CORRECTED-lowres.pdf British Columbia Cancer Agency. Synoptic Report Form for Breast Cancer [Internet]. 2005 Dec 13;[cited 2009 Jul 26 ] Available from: http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Breast/Management/SynopticReportForm1of6/default.htm 41E10C136EAB6E4ED748035BF6D9F697

ISO_639-1 en To record detailed findings about breast cancer found on microscopic examination. breast histopathology cancer laboratory lab pathology histology malignancy To record detailed findings about microscopic examination of tissue related to breast cancer. Use as a component archetype in the context of a suite of archetypes that make up a histopathology report ie OBSERVATION.lab_test.histopathology. Not designed to be used within any other archetype other than OBSERVATION.lab_test.histopathology. © openEHR Foundation

openEHR-EHR-CLUSTER.microscopy_breast_carcinoma.v1 1.4 at0000 CLUSTER true true false false 1 1 at0000 items true true false false 1 1 CLUSTER true false true 0 at0033 items true true false false 1 1 CLUSTER true false true 0 at0036 archetype_id/value matches {/openEHR-EHR-CLUSTER\.physical_properties\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.physical_properties\.v1 constraint archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint CLUSTER true false true 0 at0037 archetype_id/value matches {/openEHR-EHR-CLUSTER\.physical_properties\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.physical_properties\.v1 constraint archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint false false true false true 1 CLUSTER true true false false 0 1 at0015 items true true false false 1 1 CLUSTER true true false false 0 1 at0020 items true true false false 1 1 ELEMENT true true false false 0 1 at0014 value true true false false 0 1 DV_COUNT true true false false 1 1 ELEMENT true true false false 0 1 at0175 value true true false false 0 1 DV_ORDINAL true true false false 1 1 1 local at0176 2 local at0177 3 local at0178 ELEMENT true true false false 0 1 at0016 value true true false false 0 1 DV_ORDINAL true true false false 1 1 1 local at0050 2 local at0051 3 local at0052 ELEMENT true true false false 0 1 at0017 value true true false false 0 1 DV_ORDINAL true true false false 1 1 1 local at0044 2 local at0045 3 local at0046 ELEMENT true true false false 0 1 at0018 value true true false false 0 1 DV_ORDINAL true true false false 1 1 1 local at0047 2 local at0048 3 local at0049 ELEMENT true true false false 0 1 at0043 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 false false true false true 1 CLUSTER true true false false 0 1 at0161 items true true false false 1 1 CLUSTER true true false false 0 1 at0159 archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_invasion\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.tumour_invasion\.v1 constraint CLUSTER true true false false 0 1 at0160 archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_invasion\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.tumour_invasion\.v1 constraint archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint false false true false true 1 CLUSTER true true false false 0 1 at0021 items true true false false 1 1 CLUSTER true true false false 0 1 at0084 archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_resection_margins\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.tumour_resection_margins\.v1 constraint archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint CLUSTER true true false false 0 1 at0113 archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_resection_margins\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.tumour_resection_margins\.v1 constraint archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint CLUSTER true true false false 0 1 at0115 archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_resection_margins\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.tumour_resection_margins\.v1 constraint archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint false false true false true 1 CLUSTER true true false false 0 1 at0054 items true true false false 1 1 ELEMENT true false true 0 at0023 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 CLUSTER true true false false 0 1 at0060 items true true false false 1 1 ELEMENT true true false false 0 1 at0061 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0167 at0168 at0169 at0170 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0055 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0109 at0110 at0152 at0153 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0058 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0171 at0172 at0173 at0174 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0056 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 CLUSTER true true false false 0 1 at0062 items true true false false 1 1 ELEMENT true true false false 0 1 at0063 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0119 at0120 at0121 false false true false true 1 CLUSTER true true false false 0 1 at0024 items true true false false 1 1 ELEMENT true true false false 0 1 at0025 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0122 at0126 at0127 at0123 at0124 ELEMENT true true false false 0 1 at0026 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 CLUSTER true true false false 0 1 at0064 items true true false false 1 1 ELEMENT true true false false 0 1 at0154 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0155 at0156 at0157 at0158 CLUSTER true true false false 0 1 at0125 items true true false false 1 1 ELEMENT true true false false 0 1 at0075 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0076 at0078 at0077 ELEMENT true true false false 0 1 at0070 value true true false false 0 1 DV_ORDINAL true true false false 1 1 1 local at0071 2 local at0072 3 local at0073 ELEMENT true true false false 0 1 at0080 value true true false false 0 1 DV_ORDINAL true true false false 1 1 1 local at0081 2 local at0082 3 local at0083 ELEMENT true true false false 0 1 at0179 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 CLUSTER true true false false 0 1 at0128 items true true false false 1 1 ELEMENT true true false false 0 1 at0130 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0132 at0133 at0134 at0135 at0136 at0137 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0131 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 false false true false true 1 CLUSTER true true false false 0 1 at0094 items true true false false 1 1 CLUSTER true true false false 0 2 at0095 items true true false false 1 1 ELEMENT true true false false 0 1 at0096 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0097 at0098 at0099 ELEMENT true true false false 0 1 at0100 value true true false false 0 1 DV_PROPORTION true true false false 1 1 ELEMENT true true false false 0 1 at0101 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0104 at0105 at0106 false false true false true 1 CLUSTER true true false false 0 1 at0102 items true true false false 1 1 ELEMENT true true false false 0 1 at0138 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0139 at0140 at0141 ELEMENT true true false false 0 1 at0162 value true true false false 0 1 DV_PROPORTION true true false false 1 1 ELEMENT true true false false 0 1 at0163 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0164 at0165 at0166 false false true false true 1 CLUSTER true true false false 0 1 at0103 items true true false false 1 1 CLUSTER true true false false 0 1 at0143 items true true false false 1 1 ELEMENT true true false false 0 1 at0107 value true true false false 0 1 DV_COUNT true true false false 1 1 magnitude true true false false 1 1 INTEGER true true false false 1 1 true false true 0 ELEMENT true true false false 0 1 at0142 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0146 at0147 at0148 false false true false true 1 CLUSTER true true false false 0 1 at0144 items true true false false 1 1 ELEMENT true true false false 0 1 at0108 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0149 at0150 at0151 ELEMENT true true false false 0 1 at0145 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 false false true false true 1 false false true false true 1 CLUSTER true true false false 0 1 at0030 items true true false false 1 1 CLUSTER true true false false 0 1 at0087 archetype_id/value matches {/openEHR-EHR-CLUSTER\.lymph_node_metastases\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.lymph_node_metastases\.v1 constraint archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint CLUSTER true true false false 0 1 at0088 archetype_id/value matches {/openEHR-EHR-CLUSTER\.lymph_node_metastases\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.lymph_node_metastases\.v1 constraint archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint false false true false true 1 CLUSTER true true false false 0 1 at0180 items true true false false 1 1 ELEMENT true false true 0 at0181 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0182 at0183 at0184 at0185 at0186 at0187 false false true false true 1 false false true false true 1 Microscopic findings - Breast cancer Microscopic anatomic pathology findings related to breast cancer. Mitosis count Mitotic frequency is calculated from the number of mitoses per 10 high-power fields. Histologic grading Histologic grading of breast cancer. Nuclear score Nuclear score. Tubular formation score Tubular formation score, representing the extent of tubular formation within invasive carcinoma cells. Histologic grade Bloom and Richardson Grade of breast cancer, derived from the total score of its components: Mitotic frequency score, Nuclear score and Tubular formation score. Bloom and Richardson Grade Bloom and Richardson Histology Grade ( with modification by Elston and Ellis) is composed of three components which are combined to produce a calculated Histology Grade. Resection margins Findings of the relation of tumour to surgical resection margins. Non-neoplastic cellular change Finding of non-neoplastic cellular change. Microcalcification Findings related to microcalcification. Microcalcification Findings of microcalcification. Associated pathology A text description of pathology associated with microcalcification. Lymph node involvement Findings related to the involvement of tumour in lymph nodes. Tumour size and extent Assessments of tumour size. Invasive tumour extent The size of the invasive aspect of the breast cancer. Total lesion extent The extent of total breast cancer lesion. Confounding issues A text description of any assessment issues which may confound the accuracy of the Bloom and Richardson histologic grade. Tubular formation score 1 Less than 75% of invasive carcinoma forming tubular or glandular structures. Tubular formation score 2 10-75% of invasive carcinoma forming tubular or glandular structures. Tubular formation score 3 Less than 10% of invasive carcinoma forming tubular or glandular structures. Grade 1 Total score of 3-5. Grade 2 Total score of 6 or 7. Grade 3 Total score of 8 or 9. Score 1 Size equivalent to 1.5–2 red blood cell diameters or normal duct epithelial nuclei; Diffuse chromatin; Inconspicuous nucleoli. Score 2 Size equivalent to 2–2.5 red blood cell diameters; Coarse chromatin; Infrequent nucleoli and mitoses. Score 3 Size > 2.5 red blood cell diameters; Pleomorphic vesicular nuclei; One or more prominent nucleoli; Frequent mitotic figures commonly present. Non-neoplastic cellular changes Findings of non-neoplastic cellular changes. Atypical lobular hyperplasia Finding of atypical lobular hyperplasia. Description A text description of finding of lobular neoplasia. Lobular carcinoma-in-situ Finding of lobular carcinoma-in-situ. Lobular neoplasia Findings of lobular neoplasia and variants. Lobular neoplasia Finding of lobular neoplasia. Paget's disease of nipple Findings related to Paget's disease of the nipple. Paget's disease of nipple Finding of Paget's disease of the nipple. DCIS features Findings related to Ductal carcinoma-in-situ (DCIS). Nuclear score Nuclear score, using the Elston and Ellis modification of the Bloom and Richardson system for grading invasive carcinoma. Score 1 Size equivalent to 1.5–2 red blood cell diameters or normal duct epithelial nuclei; Diffuse chromatin; Inconspicuous nucleoli. Score 2 Size equivalent to 2–2.5 red blood cell diameters; Coarse chromatin; Infrequent nucleoli and mitoses. Score 3 Size > 2.5 red blood cell diameters; Pleomorphic vesicular nuclei; One or more prominent nucleoli; Frequent mitotic figures commonly present. Necrosis Findings of tumour necrosis. Present (non-comedo type) Non-comedo type of tumour necrosis is present. Absent or minimal Tumour necrosis is absent or minimal. Present (Comedo type) Comedo type of tumour necrosis is present. Van Nuys Prognostic Index The Van Nuys Prognostic Index (VNPI). Van Nuys Group 1 Nuclear grade 1 or 2 and no necrosis. Van Nuys Group 2 Nuclear grade 1 or 2 and necrosis. Van Nuys Group 3 Nuclear grade 3 with or without necrosis. Invasive carcinoma at margin Details of invasive carcinoma at surgical resection margins. Sentinel nodes Details of the involvement of tumour in sentinel lymph nodes. Axillary nodes Details of the involvement of tumour in axillary lymph nodes. Hormone Receptor assays Immunohistochemical assays of oestrogen receptor (ER) and progesterone receptor (PR). Oestrogen receptor assay (ER) Oestrogen Receptor assay (ER). ER result Oestrogen Receptor assay result. Positive Oestrogen Receptor assay result is positive. Negative Oestrogen Receptor assay result is negative. Equivocal Oestrogen Receptor assay result is equivocal. Proportion of nuclei stained An estimate of the percentage of nuclei stained. Predominant staining intensity Predominant intensity of staining. Progesterone receptor assay (PR) Progesterone Receptor (PR) assay. Human Oestrogen receptor 2 assay (HER2) Human Oestrogen receptor 2 (HER2) assay. Low Predominant intensity of staining is low. Intermediate Predominant intensity of staining is intermediate. High Predominant intensity of staining is high. Immunohistochemistry score HER2 immunohistochemistry score. ISH result HER2 In situ hybridisation (ISH) result. Present - classical Classical atypical lobular neoplasia is present. Present - pleomorphic Pleomorphic atypical lobular neoplasia is present. DCIS at margin Details of DCIS (Ductal carcinoma-in-situ) at surgical resection margins. LCIS at margin Details of LCIS (Local carcinoma-in-situ) at surgical resection margins. Present Paget's disease of the nipple is present. Absent Paget's disease of the nipple is absent. Indeterminate Presence of Paget's disease of the nipple has not been determined. Present Microcalcification is present. Present - no evidence of necrosis Microcalcification is present with no evidence of necrosis. Present - with evidence of necrosis Microcalcification is present with evidence of necrosis. Histologic grade Histologic grading of DCIS. Absent Microcalcification is absent. Indeterminate Presence of microcalcification has not been determined. DCIS Architecture Findings related to architecture of the ductal carcinoma-in-situ. Dominant pattern Findingof the dominant DCIS architectural pattern. Description A text description of the architectural pattern. Solid Solid pattern of ductal carcinoma-in-situ. Cribriform Cribriform pattern of ductal carcinoma-in-situ. Micropapillary Micropapillary pattern of ductal carcinoma-in-situ. Apocrine Apocrine pattern of ductal carcinoma-in-situ. Papillary Papillary pattern of ductal carcinoma-in-situ. Indeterminate The dominant pattern of ductal carcinoma-in-situ has not been determined. PR result Progesterone Receptor assay result. Positive Progesterone Receptor assay result is positive. Negative Progesterone Receptor assay result is negative. Equivocal Progesterone Receptor assay result is equivocal. Immunohistochemistry result HER2 Immunohistochemistry result. Immunohistochemistry HER2 Immunohistochemistry result. In situ hybridisation (ISH) HER2 In situ hybridisation (ISH). Comment A text comment on HER2 In situ hybridisation (ISH) result. Positive The HER2 Immunohistochemistry result is positive. Negative The HER2 Immunohistochemistry result is negative. Equivocal The HER2 Immunohistochemistry result is equivocal. Positive The HER2 In situ hybridisation (ISH) result is positive. Negative The HER2 In situ hybridisation (ISH) result is negative. Equivocal The HER2 In situ hybridisation (ISH) result is equivocal. Absent Atypical lobular neoplasia is absent. Indeterminate The presence of atypical lobular neoplasia has not been determined. Calcification Finding of calcification in DCIS tissue. Present with necrosis Calcification with necrosis is present in DCIS tissue. Present without necrosis Calcification without necrosis is present in DCIS tissue. Absent Calcification is absent from DCIS tissue. Indeterminate Presence of calcification in DCIS tissue has not been determined. Lymphovascular invasion Details of local invasion into lymphovascular tissue. Skin / muscle invasion Details of local invasion into skin or muscle tissue. Local tumour invasion Findings of local tumour invasion. Proportion of nuclei stained An estimate of the percentage of nuclei stained. Predominant staining intensity Predominant intensity of staining. Low Predominant intensity of staining is low. Intermediate Predominant intensity of staining is intermediate. High Predominant intensity of staining is high. Present - classical Classical lobular neoplasia is present. Present - pleomorphic Pleomorphic lobular neoplasia is present. Absent Lobular neoplasia is absent. Indeterminate The presence of lobular hyperplasia has not been determined. Present - classical Classical lobular carcinoma-in-situ is present. Present - pleomorphic Pleomorphic lobular carcinoma-in-situ is present. Absent Lobular carcinoma-in-situ is absent. Indeterminate The presence of lobular carcinoma-in-situ has not been determined. Mitotic frequency score Mitotic frequency score calculated from the mitosis count and the microscopy field diameter via a lookup table. Score 1 Low mitotic frequency. Score 2 Intermediate mitotic frequency. Score 3 High mitotic frequency. Comment Comment on estimation of the histologic grade. Non-neoplastic changes Findings of non-neoplastic change. Non-neoplastic change Finding of non-neoplastic change. Columnar cell changes Columnar cell changes are present. Intraductal papilloma Intraductal papilloma is present. Radial scars Radial scars are present. Atypical ductal hyperplasia (ADH) Atypical ductal hyperplasia (ADH) is present. Absent Non-neoplastic change is absent. Indeterminate Presence of non-neoplastic changes has not been determined.