archetype (adl_version=1.4) openEHR-EHR-CLUSTER.microscopy_colorectal_carcinoma.v1 concept [at0000] -- Microscopic findings - Colorectal cancer language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Dr Ian McNicoll"> ["organisation"] = <"Ocean Informatics, UK"> ["email"] = <"ian.mcnicoll@oceaninformatics.com"> ["date"] = <"17/06/2009"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record detailed findings about colorectal cancer found on microscopic histopathological examination."> use = <"To record detailed findings about microscopic examination of tissue related to colorecal cancer. Use as a component archetype in the context of a suite of archetypes that make up a histopathology report i.e. OBSERVATION.lab_test.histopathology and CLUSTER.macroscopy.colorectal_carcinoma."> keywords = <"histopathology", "cancer", "laboratory", "lab", "malignancy", "pathology", "colonic", "rectal", "anal", "GI", "gastrointestinal", "bowel"> misuse = <"Not designed to be used within any other archetype other than OBSERVATION.lab_test.histopathology."> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <"Koray Atalag, University of Auckland, New Zealand", "Matt Cordell, NEHTA, Australia", "David McKillop, NEHTA, Australia", "Cathy Richardson, NEHTA, Australia", "David Rowed, Ocean Informatics, Australia"> other_details = < ["references"] = <"College of American Pathologists. Protocol for the Examination of Specimens from Patients with Primary Carcinomas of the Colon and Rectum [Internet]. 2009 Mar ;[cited 2009 Jul 28 ] Available from: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2008/colonrectum08_pw.pdf Royal College of Pathologists. Dataset for colorectal cancer (2nd edition) [Internet]. 2007 Dec 4;[cited 2009 Jul 29 ] Available from: http://www.rcpath.org/index.asp?PageID=1153 Royal College of Pathologists of Australasia. Colorectal Cancer Structured Reporting Protocol (1st Edition 2010). [Internet]. 2010;[cited 2010 Mar 21 ] Available from: http://www.rcpa.edu.au//static/File/Asset%20library/public%20documents/Publications/StructuredReporting/COLORECTAL%20CANCER%20STRUCTURED%20REPORTING%20PROTOCOL%20for%20web.pdf"> ["MD5-CAM-1.0.1"] = <"45150B03A2A6EFB7E8B8B329C55E4A3E"> > definition CLUSTER[at0000] matches { -- Microscopic findings - Colorectal cancer items cardinality matches {1..*; unordered} matches { CLUSTER[at0269] occurrences matches {0..1} matches { -- Histological grading items cardinality matches {1..*; unordered} matches { ELEMENT[at0270] occurrences matches {0..1} matches { -- Grade value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0272, -- Well differentiated at0273, -- Moderately differentiated at0341, -- Poorly differentiated at0342, -- Undifferentiated at0360, -- Low-grade at0361] -- High grade } } } } ELEMENT[at0271] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } CLUSTER[at0236] occurrences matches {0..1} matches { -- Local invasion items cardinality matches {1..*; unordered} matches { ELEMENT[at0310] occurrences matches {0..1} matches { -- Local invasion classification value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0311, -- pT0 at0312, -- pT1 at0313, -- pT2 at0314, -- pT3 at0315, -- pT4a at0316, -- pT4b at0317, -- pTX at0343] -- pTis } } } } ELEMENT[at0318] occurrences matches {0..1} matches { -- Depth of invasion value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0319, -- pT3a at0320, -- pT3b at0321, -- pT3c at0322] -- pT3d } } } } ELEMENT[at0323] occurrences matches {0..1} matches { -- Distance of invasion value matches { C_DV_QUANTITY < property = <[openehr::122]> list = < ["1"] = < units = <"mm"> magnitude = <|>=0.0|> > > > } } } } CLUSTER[at0244] occurrences matches {0..1} matches { -- Surgical resection margins items cardinality matches {1..*; unordered} matches { allow_archetype CLUSTER[at0246] occurrences matches {0..*} matches { -- Surgical resection margin include archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_resection_margins\.v1/} exclude archetype_id/value matches {/.*/} } } } CLUSTER[at0252] occurrences matches {0..1} matches { -- In-situ carcinoma findings items cardinality matches {1..*; unordered} matches { ELEMENT[at0251] occurrences matches {0..1} matches { -- In-situ carcinoma value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0253, -- Present at0254, -- Absent at0255] -- Indeterminate } } } } ELEMENT[at0256] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } CLUSTER[at0030] occurrences matches {0..1} matches { -- Lymph node findings items cardinality matches {1..*; unordered} matches { allow_archetype CLUSTER[at0087] occurrences matches {0..1} matches { -- Lymph node detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.lymph_node_metastases\.v1/} } ELEMENT[at0324] occurrences matches {0..1} matches { -- Nodal involvement classification value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0325, -- pN0 at0326, -- pN1 at0327, -- pN2 at0344] -- pNx } } DV_TEXT matches {*} } } ELEMENT[at0276] occurrences matches {0..1} matches { -- Distance from margin value matches { C_DV_QUANTITY < property = <[openehr::122]> list = < ["1"] = < units = <"mm"> magnitude = <|>=0.0|> > > > } } ELEMENT[at0348] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } ELEMENT[at0365] occurrences matches {0..1} matches { -- Status of apical lymph node value matches { DV_TEXT matches {*} } } CLUSTER[at0278] occurrences matches {0..1} matches { -- Local tissue invasion items cardinality matches {1..*; unordered} matches { allow_archetype CLUSTER[at0277] occurrences matches {0..*} matches { -- Venous (large vessel) invasion include archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_invasion\.v1/} exclude archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0279] occurrences matches {0..*} matches { -- Lymphatic (small vessel) invasion include archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_invasion\.v1/} exclude archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0286] occurrences matches {0..*} matches { -- Perineural invasion include archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_invasion\.v1/} } CLUSTER[at0280] occurrences matches {0..1} matches { -- Discontinuous extramural deposit findings items cardinality matches {1..*; unordered} matches { ELEMENT[at0281] occurrences matches {0..1} matches { -- Discontinuous extramural tumour deposits value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0282, -- Present at0283, -- Absent at0284] -- Indeterminate } } } } allow_archetype CLUSTER[at0346] occurrences matches {0..1} matches { -- Discontinuous extramural deposits include archetype_id/value matches {/openEHR-EHR-CLUSTER\.tumour_invasion\.v1/} exclude archetype_id/value matches {/.*/} } ELEMENT[at0285] occurrences matches {0..1} matches { -- Distance from margin value matches { C_DV_QUANTITY < property = <[openehr::122]> list = < ["1"] = < units = <"mm"> magnitude = <|>=0.0|> > > > } } } } } } CLUSTER[at0263] occurrences matches {0..1} matches { -- Distant metastasis findings items cardinality matches {1..*; unordered} matches { ELEMENT[at0264] occurrences matches {0..1} matches { -- Distant metastasis value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0362, -- Present at0363, -- Absent at0364] -- Indeterminate } } } } allow_archetype CLUSTER[at0287] occurrences matches {0..*} matches { -- Sites include archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location-precise\.v1/} exclude archetype_id/value matches {/.*/} } ELEMENT[at0265] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } CLUSTER[at0366] occurrences matches {0..1} matches { -- Adenomatous polyps items cardinality matches {1..*; unordered} matches { ELEMENT[at0359] occurrences matches {0..1} matches { -- Type of polyp value matches { DV_TEXT matches {*} } } ELEMENT[at0338] occurrences matches {0..1} matches { -- Number of polyps value matches { DV_COUNT matches { magnitude matches {|>=0|} } } } ELEMENT[at0367] occurrences matches {0..1} matches { -- Polyposis syndrome value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0368, -- Present at0369, -- Absent at0370] -- Indeterminate } } } } ELEMENT[at0371] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } CLUSTER[at0179] occurrences matches {0..1} matches { -- Additional findings items cardinality matches {1..*; unordered} matches { ELEMENT[at0250] occurrences matches {0..*} matches { -- Additional finding value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0293, -- Synchronous carcinoma at0294, -- Ulcerative colitis at0295, -- Ulcerative colitis with dysplasia at0296, -- Crohn's disease at0297, -- Crohn's disease with dysplasia at0340] -- Diverticulosis } } DV_TEXT matches {*} } } ELEMENT[at0220] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } ELEMENT[at0262] occurrences matches {0..1} matches { -- Residual tumour status value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0298, -- R0 at0299, -- R1 at0300, -- R2 at0301] -- RX } } } } CLUSTER[at0308] occurrences matches {0..1} matches { -- Response to neoadjuvant therapy items cardinality matches {1..*; unordered} matches { ELEMENT[at0330] occurrences matches {0..1} matches { -- Neoadjuvant therapy given value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0331, -- Yes at0332, -- No at0333] -- Not known } } } } CLUSTER[at0347] occurrences matches {0..1} matches { -- Grade of response items cardinality matches {1; unordered} matches { ELEMENT[at0302] occurrences matches {0..1} matches { -- Grade (AJCC) value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0349, -- Grade 0 - complete response at0350, -- Grade 1 - moderate response at0351, -- Grade 2 - minimal response at0352] -- Grade 3 - poor response } } } } ELEMENT[at0329] occurrences matches {0..1} matches { -- Grade (CAP) value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0354, -- No residual tumour at0355, -- Marked response at0356, -- Moderate response at0357, -- No definite response at0358] -- Response not known } } } } ELEMENT[at0334] occurrences matches {0..1} matches { -- Grade (RCP) value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0335, -- No residual tumour cells or mucous lakes only at0336, -- Minimal residual tumour at0337] -- No marked regression } } } } } } ELEMENT[at0309] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Microscopic findings - Colorectal cancer"> description = <"Microscopic anatomical pathology findings related to colorectal cancer."> > ["at0030"] = < text = <"Lymph node findings"> description = <"Findings related to the involvement of tumour in lymph nodes."> > ["at0087"] = < text = <"Lymph node detail"> description = <"Findings related to the involvement of tumour in lymph nodes."> > ["at0179"] = < text = <"Additional findings"> description = <"Additional histopathological findings."> > ["at0220"] = < text = <"Description"> description = <"A text description of additional findings."> > ["at0236"] = < text = <"Local invasion"> description = <"Direct invasion of local tissue by tumour."> > ["at0244"] = < text = <"Surgical resection margins"> description = <"Findings related to surgical resection margins."> > ["at0246"] = < text = <"Surgical resection margin"> description = <"Details of a single surgical resection margin."> > ["at0250"] = < text = <"Additional finding"> description = <"A single additional histopathological finding."> > ["at0251"] = < text = <"In-situ carcinoma"> description = <"Findings of in-situ carcinoma."> > ["at0252"] = < text = <"In-situ carcinoma findings"> description = <"Findings related to in-situ carcinoma."> > ["at0253"] = < text = <"Present"> description = <"In-situ carcinoma is present."> > ["at0254"] = < text = <"Absent"> description = <"In-situ carcinoma is absent."> > ["at0255"] = < text = <"Indeterminate"> description = <"Presence of in-situ carcinoma has not been determined."> > ["at0256"] = < text = <"Description"> description = <"A text description of in-situ carcinoma."> > ["at0262"] = < text = <"Residual tumour status"> description = <"Estimate of the completeness of surgical resection."> > ["at0263"] = < text = <"Distant metastasis findings"> description = <"Findings related to distant metastasis."> > ["at0264"] = < text = <"Distant metastasis"> description = <"Findings of distant metastasis."> > ["at0265"] = < text = <"Description"> description = <"A text description of distant metastases."> > ["at0269"] = < text = <"Histological grading"> description = <"Histological grading."> > ["at0270"] = < text = <"Grade"> description = <"Histological grade of the tumour."> > ["at0271"] = < text = <"Comment"> description = <"A text comment on histological grading."> > ["at0272"] = < text = <"Well differentiated"> description = <"Tumour is well differentiated."> > ["at0273"] = < text = <"Moderately differentiated"> description = <"Tumour is moderately differentiated."> > ["at0276"] = < text = <"Distance from margin"> description = <"Distance of nearest involved node to the circumferential margin."> > ["at0277"] = < text = <"Venous (large vessel) invasion"> description = <"Details of venous (large vessel) invasion by tumour."> > ["at0278"] = < text = <"Local tissue invasion"> description = <"Findings related to local tissue invasion by tumour."> > ["at0279"] = < text = <"Lymphatic (small vessel) invasion"> description = <"Details of lymphatic (small vessel) invasion by tumour."> > ["at0280"] = < text = <"Discontinuous extramural deposit findings"> description = <"Findings related to discontinuous extramural tumour deposits."> > ["at0281"] = < text = <"Discontinuous extramural tumour deposits"> description = <"Findings of discontinuous extramural tumour deposits."> > ["at0282"] = < text = <"Present"> description = <"Discontinuous extramural tumour deposits are present."> > ["at0283"] = < text = <"Absent"> description = <"Discontinuous extramural tumour deposits are absent."> > ["at0284"] = < text = <"Indeterminate"> description = <"Presence of discontinuous extramural tumour deposits has not been determined."> > ["at0285"] = < text = <"Distance from margin"> description = <"Distance from circumferential margin to extramural deposits."> > ["at0286"] = < text = <"Perineural invasion"> description = <"Details of perineural invasion by tumour."> > ["at0287"] = < text = <"Sites"> description = <"Details of sites of proven distant metastases."> > ["at0293"] = < text = <"Synchronous carcinoma"> description = <"Synchronous carcinoma is present."> > ["at0294"] = < text = <"Ulcerative colitis"> description = <"Ulcerative colitis is present."> > ["at0295"] = < text = <"Ulcerative colitis with dysplasia"> description = <"Ulcerative colitis with dysplasia is present."> > ["at0296"] = < text = <"Crohn's disease"> description = <"Crohn's disease is present."> > ["at0297"] = < text = <"Crohn's disease with dysplasia"> description = <"Crohn's disease with dysplasia is present."> > ["at0298"] = < text = <"R0"> description = <"No residual tumour - as per AJCC TNM classification 7th Edition."> > ["at0299"] = < text = <"R1"> description = <"R1 - as per AJCC TNM classification 7th Edition."> > ["at0300"] = < text = <"R2"> description = <"R2 - as per AJCC TNM classification 7th Edition."> > ["at0301"] = < text = <"RX"> description = <"Residual tumour cannot be assessed - as per AJCC TNM classification 7th Edition."> > ["at0302"] = < text = <"Grade (AJCC)"> description = <"An estimate of the response to neoadjuvant therapy. (AJCC score)."> > ["at0308"] = < text = <"Response to neoadjuvant therapy"> description = <"Details of the response to neoadjuvant therapy."> > ["at0309"] = < text = <"Comment"> description = <"A text comment on the response to neoadjuvant therapy."> > ["at0310"] = < text = <"Local invasion classification"> description = <"Local invasion of tumour. Scored using the pT element of the TNM classification."> > ["at0311"] = < text = <"pT0"> description = <"No evidence of primary tumour."> > ["at0312"] = < text = <"pT1"> description = <"Tumour invades submucosa."> > ["at0313"] = < text = <"pT2"> description = <"Tumour invades muscularis propria."> > ["at0314"] = < text = <"pT3"> description = <"Tumour invades through muscularis propria into subserosa, or into non-peritonealised pericolic or perirectal tissues."> > ["at0315"] = < text = <"pT4a"> description = <"Tumour directly invades other organs or structures."> > ["at0316"] = < text = <"pT4b"> description = <"Tumour perforates visceral peritoneum."> > ["at0317"] = < text = <"pTX"> description = <"Primary tumour cannot be assessed."> > ["at0318"] = < text = <"Depth of invasion"> description = <"The subdivision of pT3 that applies to the tumour."> > ["at0319"] = < text = <"pT3a"> description = <"Minimal invasion: <1 mm beyond the border of the muscularis propria."> > ["at0320"] = < text = <"pT3b"> description = <"Slight invasion: 1-5 mm beyond the border of the muscularis propria."> > ["at0321"] = < text = <"pT3c"> description = <"Moderate invasion: >5 mm and <= 15mm beyond the border of the muscularis propria."> > ["at0322"] = < text = <"pT3d"> description = <"Extensive invasion: > 15 mm beyond the border of the muscularis propria."> > ["at0323"] = < text = <"Distance of invasion"> description = <"Distance of tumour invasion beyond the muscularis propria."> > ["at0324"] = < text = <"Nodal involvement classification"> description = <"An estimate of nodal involvement using the pN element of TNM classification."> > ["at0325"] = < text = <"pN0"> description = <"No regional lymph node metastasis."> > ["at0326"] = < text = <"pN1"> description = <"Metastasis in 1-3 regional lymph nodes."> > ["at0327"] = < text = <"pN2"> description = <"Metastasis in 4 or more regional lymph nodes."> > ["at0329"] = < text = <"Grade (CAP)"> description = <"An estimate of the response to neoadjuvant therapy. (CAP) College of American Pathologists."> > ["at0330"] = < text = <"Neoadjuvant therapy given"> description = <"Has neoadjuvant therapy been given?"> > ["at0331"] = < text = <"Yes"> description = <"Neoadjuvant therapy has been given."> > ["at0332"] = < text = <"No"> description = <"Neoadjuvant therapy has not been given."> > ["at0333"] = < text = <"Not known"> description = <"It is not known if neoadjuvant therapy has been given."> > ["at0334"] = < text = <"Grade (RCP)"> description = <"An estimate of the response to neoadjuvant therapy. (RCP) Royal College of Pathologists (UK)."> > ["at0335"] = < text = <"No residual tumour cells or mucous lakes only"> description = <"No residual tumour cells or mucous lakes only."> > ["at0336"] = < text = <"Minimal residual tumour"> description = <"Minimal residual tumour is present."> > ["at0337"] = < text = <"No marked regression"> description = <"Marked regression is absent."> > ["at0338"] = < text = <"Number of polyps"> description = <"Number of adenomatous polyps."> > ["at0340"] = < text = <"Diverticulosis"> description = <"Diverticulosis is present."> > ["at0341"] = < text = <"Poorly differentiated"> description = <"Tumour is poorly differentiated."> > ["at0342"] = < text = <"Undifferentiated"> description = <"Tumour is undifferentiated."> > ["at0343"] = < text = <"pTis"> description = <"Carcinoma in-situ: intraepithelial or invasion of lamina propria."> > ["at0344"] = < text = <"pNx"> description = <"Regional lymph nodes cannot be assessed."> > ["at0346"] = < text = <"Discontinuous extramural deposits"> description = <"Details of discontinuous extramural tumour deposits."> > ["at0347"] = < text = <"Grade of response"> description = <"Alternative assessment grades of response to neoadjuvant therapy."> > ["at0348"] = < text = <"Comment"> description = <"An additional text comment on lymph node findings."> > ["at0349"] = < text = <"Grade 0 - complete response"> description = <"Complete response to neoadjuvant therapy."> > ["at0350"] = < text = <"Grade 1 - moderate response"> description = <"Moderate response to neoadjuvant therapy."> > ["at0351"] = < text = <"Grade 2 - minimal response"> description = <"Minimal response to neoadjuvant therapy."> > ["at0352"] = < text = <"Grade 3 - poor response"> description = <"Poor response to neoadjuvant therapy."> > ["at0354"] = < text = <"No residual tumour"> description = <"Complete response to treatment; Grade 0."> > ["at0355"] = < text = <"Marked response"> description = <"Minimal residual cancer persists; Grade 1."> > ["at0356"] = < text = <"Moderate response"> description = <"Grade 2."> > ["at0357"] = < text = <"No definite response"> description = <"Poor or no response; Grade 3."> > ["at0358"] = < text = <"Response not known"> description = <"Response to treatment is unknown."> > ["at0359"] = < text = <"Type of polyp"> description = <"Type of adenomatous polyp"> > ["at0360"] = < text = <"Low-grade"> description = <"Well or moderately differentiated"> > ["at0361"] = < text = <"High grade"> description = <"Poorly differentiated or undifferentiated"> > ["at0362"] = < text = <"Present"> description = <"Evidence of distant metastasis."> > ["at0363"] = < text = <"Absent"> description = <"No evidence of distant metastasis."> > ["at0364"] = < text = <"Indeterminate"> description = <"Evidence of metastasis has not been determined."> > ["at0365"] = < text = <"Status of apical lymph node"> description = <"Status of the apical lymph node."> > ["at0366"] = < text = <"Adenomatous polyps"> description = <"Findings of adenoatous polyps."> > ["at0367"] = < text = <"Polyposis syndrome"> description = <"Evidence of polyposis syndrome."> > ["at0368"] = < text = <"Present"> description = <"There is evidence of polyposis syndrome."> > ["at0369"] = < text = <"Absent"> description = <"There is no evidence of polyposis syndrome."> > ["at0370"] = < text = <"Indeterminate"> description = <"Evidence of polyposis syndrome has not been determined."> > ["at0371"] = < text = <"Comment"> description = <"Comment concerning adenomatous polyps."> > > > >