| TEMPLATE ID | British Columbia Cancer agency Breast Cancer Synoptic Report |
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| Concept | British Columbia Cancer agency Breast Cancer Synoptic Report |
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| Description | This template demonstrates representation of a NEHTA Synoptic report for Melanoma histopathology |
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| Purpose | This template demonstrates representation of a NEHTA Synoptic report for Melanoma histopathology |
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| References | |
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| Other Details (Language Independent) | - MetaDataSet:Sample Set : Template metadata sample set
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| Language used | en |
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| Citeable Identifier | 1013.26.199 |
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| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
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| British Columbia Cancer agency Breast Cancer Synoptic Report | British Columbia Cancer agency Breast Cancer Synoptic Report: Document to communicate information to others, commonly in response to a request from another party. |
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| Other Context | |
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| Report ID | Report ID: Identification information about the report. |
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| Status | Status: The status of the entire report. Note: This is not the status of any of the report components. |
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| Patient Identity | Patient Identity: A generic section header which should be renamed in a template to suit a specific clinical context.
Annotations- Default: Basic patient identifier e.g. Name, address and ID are presumed to be held separately
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| Diagnostic Summary | Diagnostic Summary: A generic section header which should be renamed in a template to suit a specific clinical context.
Annotations- Default: From the generic framework recommendation
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| Diagnosis | Diagnosis: A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria |
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| Diagnosis | Diagnosis: The index diagnosis
Value set: ac0.1 |
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| Clinical description | Clinical description: Description of the clinical aspects of the problem |
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| Date clinically recognised | Date clinically recognised: Date the problem was recognised by clinicians |
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| 2. Current biopsy findings | 2. Current biopsy findings: A generic section header which should be renamed in a template to suit a specific clinical context. |
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| Breast cancer biopsy result | Breast cancer biopsy result: Simple histopathology lab test result. |
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| Data | |
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| Any event | Any event: * |
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| Data | |
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| Test name | Test name: Specific identifier for this lab test. e.g. Full blood count , blood glucose, urine microbiology. May equate to the result name for a single value result. Commonly a coded term e.g from LOINC or SNOMED-CT.
Default value: Breast Biopsy |
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| Diagnostic service | Diagnostic service: The type of high-level diagnostic service e.g. biochemistry, haematology. |
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| Macroscopic | Macroscopic: Macroscopic findings - more than one set of findings may be recorded. |
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| Macroscopic finding | Macroscopic finding: A single set of macroscopic pathology findings. |
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| Tissue present | Tissue present: Confirmation, or otherwise, that the tissue or structure referred to by this macroscopic finding is present in the specimen for analysis.
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| Description | Description: Narrative text recorded at the time of specimen macroscopic dissection. |
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| Overall macroscopic description | Overall macroscopic description: General comment or description about macroscopy findings. |
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| Microscopic | Microscopic: Microscopic findings - more than one set of findings may be recorded. |
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| Histopathological result | Histopathological result: A conclusion or 'pathological diagnosis' for this individual microscopic finding. |
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| Specimen | Specimen: To record details of a laboratory specimen. |
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| Specimen type | Specimen type: The type of specimen to be collected e.g venous blood, prostatic biopsy.
Optional[{fhir_mapping=Specimen.type}] |
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| Datetime collected | Datetime collected: The date and time that collection has been ordered to take place or has taken place. |
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| Sampling conditions | Sampling conditions: Any conditions to be met before the sample should be taken.
e.g. fasting, 'full bladder', 'sterile field' or any special instructions on the handling or immediate processing of the sample e.g. centrifuge on receipt.
Can also be used to document any known deviations from collection or handling instructions e.g patient was not fasted. |
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| Collection method | Collection method: The method of collection to be used eg Venepuncture, biopsy, resection.
Optional[{fhir_mapping=Specimen.collection.method}] |
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| Collection method description | Collection method description: Additional detailed description of method of sample collection. |
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| Potential risk | Potential risk: Any risk or biohazard associated with collecting or handling the specimen. |
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| Collection setting | Collection setting: Identification of the setting at which the specimen was collected
from a subject of care. The specimen is often collected by a
healthcare provider, but may be collected directly by the patient or carer at home.
This specifies the specimen collection location within the healthcare
environment. It enables the laboratory to ask questions about the
collection of the specimen, if required. The specimen collection
setting may provide additional information relevant to the analysis
of the result. |
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| Specimen collector identifier | Specimen collector identifier: Identifier of the person or agency responsible for collecting the specimen.
Optional[{fhir_mapping=Specimen.collection.collector}] |
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| Number of containers | Number of containers: The total number of containers holding this specimen.
>=0 |
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| Specimen quality | Specimen quality: Problems with the received specimen. |
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| Specimen received issues | Specimen received issues: Specific issue with a received specimen.
 Coded Text- Haemolysed
- Lipaemic
- Incorrect transport medium
- Insufficient sample
 Text
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| Laboratory handling issues | Laboratory handling issues: Issue arising with handling or processing of the specimen within the laboratory.
- Coded Text
- Handling error
- Age
- Laboratory accident
- Technical failure
- Text
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| Adequacy for testing | Adequacy for testing: Is the specimen adequate for testing?
- Coded Text
- Satisfactory
- Unsatisfactory - processed
- Unsatisfactory - not processed
- Text
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| Comment | Comment: An additional text comment on the quality of the received specimen. |
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| Related specimen | Related specimen: Details of a related specimen. |
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| Parent specimen identifier | Parent specimen identifier: Unique identifier of the parent specimen, where the specimen is split into sub-samples. |
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| Microscopic findings - Breast cancer | Microscopic findings - Breast cancer: Microscopic anatomic pathology findings related to breast cancer. |
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| Histologic grading | Histologic grading: Histologic grading of breast cancer. |
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| Bloom and Richardson Grade | 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. |
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| Mitosis count | Mitosis count: Mitotic frequency is calculated from the number of mitoses per 10 high-power fields. |
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| Mitotic frequency score | Mitotic frequency score: Mitotic frequency score calculated from the mitosis count and the microscopy field diameter via a lookup table.
- 1: Score 1
- 2: Score 2
- 3: Score 3
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| Nuclear score | Nuclear score: Nuclear score.
- 1: Score 1
- 2: Score 2
- 3: Score 3
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| Tubular formation score | Tubular formation score: Tubular formation score, representing the extent of tubular formation within invasive carcinoma cells.
- 1: Tubular formation score 1
- 2: Tubular formation score 2
- 3: Tubular formation score 3
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| Histologic grade | 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.
- 1: Grade 1
- 2: Grade 2
- 3: Grade 3
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| Confounding issues | Confounding issues: A text description of any assessment issues which may confound the accuracy of the Bloom and Richardson histologic grade. |
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| Non-neoplastic cellular changes | Non-neoplastic cellular changes: Findings of non-neoplastic cellular changes. |
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| Non-neoplastic cellular change | Non-neoplastic cellular change: Finding of non-neoplastic cellular change. |
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| Lobular neoplasia | Lobular neoplasia: Findings of lobular neoplasia and variants. |
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| Lobular neoplasia | Lobular neoplasia: Finding of lobular neoplasia.
- Coded Text
- Present - classical
- Present - pleomorphic
- Absent
- Indeterminate
- Text
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| Atypical lobular hyperplasia | Atypical lobular hyperplasia: Finding of atypical lobular hyperplasia.
- Coded Text
- Present - classical
- Present - pleomorphic
- Absent
- Indeterminate
- Text
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| Lobular carcinoma-in-situ | Lobular carcinoma-in-situ: Finding of lobular carcinoma-in-situ.
- Coded Text
- Present - classical
- Present - pleomorphic
- Absent
- Indeterminate
- Text
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| Description | Description: A text description of finding of lobular neoplasia. |
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| Paget's disease of nipple | Paget's disease of nipple: Findings related to Paget's disease of the nipple. |
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| Paget's disease of nipple | Paget's disease of nipple: Finding of Paget's disease of the nipple.
- Present
- Absent
- Indeterminate
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| Microcalcification | Microcalcification: Findings related to microcalcification. |
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| Microcalcification | Microcalcification: Findings of microcalcification.
- Present
- Absent
- Indeterminate
- Present - no evidence of necrosis
- Present - with evidence of necrosis
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| Associated pathology | Associated pathology: A text description of pathology associated with microcalcification. |
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| DCIS features | DCIS features: Findings related to Ductal carcinoma-in-situ (DCIS). |
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| Calcification | Calcification: Finding of calcification in DCIS tissue.
- Present with necrosis
- Present without necrosis
- Absent
- Indeterminate
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| Histologic grade | Histologic grade: Histologic grading of DCIS. |
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| Necrosis | Necrosis: Findings of tumour necrosis.
- Present (non-comedo type)
- Present (Comedo type)
- Absent or minimal
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| Nuclear score | Nuclear score: Nuclear score, using the Elston and Ellis modification of the Bloom and
Richardson system for grading invasive carcinoma.
- 1: Score 1
- 2: Score 2
- 3: Score 3
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| Van Nuys Prognostic Index | Van Nuys Prognostic Index: The Van Nuys Prognostic Index (VNPI).
- 1: Van Nuys Group 1
- 2: Van Nuys Group 2
- 3: Van Nuys Group 3
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| Comment | Comment: Comment on estimation of the histologic grade. |
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| DCIS Architecture | DCIS Architecture: Findings related to architecture of the ductal carcinoma-in-situ. |
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| Dominant pattern | Dominant pattern: Findingof the dominant DCIS architectural pattern.
- Coded Text
- Solid
- Cribriform
- Micropapillary
- Apocrine
- Papillary
- Indeterminate
- Text
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| Description | Description: A text description of the architectural pattern. |
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| Hormone Receptor assays | Hormone Receptor assays: Immunohistochemical assays of oestrogen receptor (ER) and progesterone receptor (PR). |
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| Oestrogen receptor assay (ER) | Oestrogen receptor assay (ER): Oestrogen Receptor assay (ER). |
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| ER result | ER result: Oestrogen Receptor assay result.
- Positive
- Negative
- Equivocal
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| Proportion of nuclei stained | Proportion of nuclei stained: An estimate of the percentage of nuclei stained. |
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| Predominant staining intensity | Predominant staining intensity: Predominant intensity of staining.
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| Progesterone receptor assay (PR) | Progesterone receptor assay (PR): Progesterone Receptor (PR) assay. |
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| PR result | PR result: Progesterone Receptor assay result.
- Positive
- Negative
- Equivocal
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| Proportion of nuclei stained | Proportion of nuclei stained: An estimate of the percentage of nuclei stained. |
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| Predominant staining intensity | Predominant staining intensity: Predominant intensity of staining.
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| Human Oestrogen receptor 2 assay (HER2) | Human Oestrogen receptor 2 assay (HER2): Human Oestrogen receptor 2 (HER2) assay. |
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| Immunohistochemistry | Immunohistochemistry: HER2 Immunohistochemistry result. |
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| Immunohistochemistry score | Immunohistochemistry score: HER2 immunohistochemistry score.
>=0 |
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| Immunohistochemistry result | Immunohistochemistry result: HER2 Immunohistochemistry result.
- Positive
- Negative
- Equivocal
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| In situ hybridisation (ISH) | In situ hybridisation (ISH): HER2 In situ hybridisation (ISH). |
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| ISH result | ISH result: HER2 In situ hybridisation (ISH) result.
- Positive
- Negative
- Equivocal
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| Comment | Comment: A text comment on HER2 In situ hybridisation (ISH) result. |
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| Non-neoplastic changes | Non-neoplastic changes: Findings of non-neoplastic change. |
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| Non-neoplastic change | Non-neoplastic change: Finding of non-neoplastic change.
- Columnar cell changes
- Intraductal papilloma
- Radial scars
- Atypical ductal hyperplasia (ADH)
- Absent
- Indeterminate
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| Comments | Comments: Narrative text recorded at the time of specimen microscopic examination. |
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| Overall microscopic description | Overall microscopic description: General comment or description about microscopy findings as a whole. |
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| Histopathological result | Histopathological result: Conclusions or 'pathological diagnoses' for the whole test. |
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| Histopathological subtype | Histopathological subtype: A subtype of the histopthological result. |
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| Overall interpretation | Overall interpretation: An overall interpretative comment on this test. |
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| Test identification | Test identification: Unique identifiers used in delivery of the care process. |
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| Placer order identifier | Placer order identifier: The ID assigned to the order by the order requester. Equivalent to the NEHTA Requester Order Identifier. |
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| Filler order Identifier | Filler order Identifier: The ID assigned to the test order by the order filler, usually by the (LIS) Laboratory Information System. Equivalent to the DICOM Accession Number and NEHTA Laboratory Request Identifier. |
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| Laboratory test result identifier | Laboratory test result identifier: The identifier given to the laboratory test result of a pathology
investigation. |
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