ARCHETYPE Microscopic findings - Colorectal cancer (openEHR-EHR-CLUSTER.microscopy_colorectal_carcinoma.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.microscopy_colorectal_carcinoma.v0
ConceptMicroscopic findings - Colorectal cancer
DescriptionMicroscopic anatomical pathology findings related to colorectal cancer.
UseTo 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.
MisuseNot designed to be used within any other archetype other than OBSERVATION.lab_test.histopathology.
PurposeTo record detailed findings about colorectal cancer found on microscopic histopathological examination.
ReferencesCollege 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


Copyright© openEHR Foundation
AuthorsAuthor name: Dr Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 17/06/2009
Other Details LanguageAuthor name: Dr Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 17/06/2009
Other Details (Language Independent)
  • Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.
  • Custodian Organisation: openEHR Foundation
  • 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
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • MD5-CAM-1.0.1: 562FF5B73E28BB984DD5618541281CE0
  • Build Uid: d137e74a-641c-4979-ae77-2bb2d80b296e
  • Revision: 0.0.1-alpha
Keywordshistopathology, cancer, laboratory, lab, malignancy, pathology, colonic, rectal, anal, GI, gastrointestinal, bowel
Lifecyclein_development
UIDd5de7428-4df0-4cb1-a609-53210acbbabd
Language useden
Citeable Identifier1246.145.2791
Revision Number0.0.1-alpha
items
Histological gradingHistological grading: Histological grading.
GradeGrade: Histological grade of the tumour.
  • Well differentiated [Tumour is well differentiated.]
  • Moderately differentiated [Tumour is moderately differentiated.]
  • Poorly differentiated [Tumour is poorly differentiated.]
  • Undifferentiated [Tumour is undifferentiated.]
  • Low-grade [Well or moderately differentiated]
  • High grade [Poorly differentiated or undifferentiated]
CommentComment: A text comment on histological grading.
Local invasionLocal invasion: Direct invasion of local tissue by tumour.
Local invasion classificationLocal invasion classification: Local invasion of tumour. Scored using the pT element of the TNM classification.
  • pT0 [No evidence of primary tumour.]
  • pT1 [Tumour invades submucosa.]
  • pT2 [Tumour invades muscularis propria.]
  • pT3 [Tumour invades through muscularis propria into subserosa, or into non-peritonealised pericolic or perirectal tissues.]
  • pT4a [Tumour directly invades other organs or structures.]
  • pT4b [Tumour perforates visceral peritoneum.]
  • pTX [Primary tumour cannot be assessed.]
  • pTis [Carcinoma in-situ: intraepithelial or invasion of lamina propria.]
Depth of invasionDepth of invasion: The subdivision of pT3 that applies to the tumour.
  • pT3a [Minimal invasion: <1 mm beyond the border of the muscularis propria.]
  • pT3b [Slight invasion: 1-5 mm beyond the border of the muscularis propria.]
  • pT3c [Moderate invasion: >5 mm and <= 15mm beyond the border of the muscularis propria.]
  • pT3d [Extensive invasion: > 15 mm beyond the border of the muscularis propria.]
Distance of invasionDistance of invasion: Distance of tumour invasion beyond the muscularis propria.
Property: Length
Units: >=0.0 mm
Surgical resection marginsSurgical resection margins: Findings related to surgical resection margins.
Surgical resection marginSurgical resection margin: Details of a single surgical resection margin.
Include:
openEHR-EHR-CLUSTER.tumour_resection_margins.v1
Exclude:
All not explicitly included archetypes
In-situ carcinoma findingsIn-situ carcinoma findings: Findings related to in-situ carcinoma.
In-situ carcinomaIn-situ carcinoma: Findings of in-situ carcinoma.
  • Present [In-situ carcinoma is present.]
  • Absent [In-situ carcinoma is absent.]
  • Indeterminate [Presence of in-situ carcinoma has not been determined.]
DescriptionDescription: A text description of in-situ carcinoma.
Lymph node findingsLymph node findings: Findings related to the involvement of tumour in lymph nodes.
Lymph node detailLymph node detail: Findings related to the involvement of tumour in lymph nodes.
Include:
openEHR-EHR-CLUSTER.lymph_node_metastases.v1
Nodal involvement classificationNodal involvement classification: An estimate of nodal involvement using the pN element of TNM classification.
Choice of:
  •  Coded Text
    • pN0 [No regional lymph node metastasis.]
    • pN1 [Metastasis in 1-3 regional lymph nodes.]
    • pN2 [Metastasis in 4 or more regional lymph nodes.]
    • pNx [Regional lymph nodes cannot be assessed.]
  •  Text
Distance from marginDistance from margin: Distance of nearest involved node to the circumferential margin.
Property: Length
Units: >=0.0 mm
CommentComment: An additional text comment on lymph node findings.
Status of apical lymph nodeStatus of apical lymph node: Status of the apical lymph node.
Local tissue invasionLocal tissue invasion: Findings related to local tissue invasion by tumour.
Venous (large vessel) invasionVenous (large vessel) invasion: Details of venous (large vessel) invasion by tumour.
Include:
openEHR-EHR-CLUSTER.tumour_invasion.v1
Exclude:
All not explicitly included archetypes
Lymphatic (small vessel) invasionLymphatic (small vessel) invasion: Details of lymphatic (small vessel) invasion by tumour.
Include:
openEHR-EHR-CLUSTER.tumour_invasion.v1
Exclude:
All not explicitly included archetypes
Perineural invasionPerineural invasion: Details of perineural invasion by tumour.
Include:
openEHR-EHR-CLUSTER.tumour_invasion.v1
Discontinuous extramural deposit findingsDiscontinuous extramural deposit findings: Findings related to discontinuous extramural tumour deposits.
Discontinuous extramural tumour depositsDiscontinuous extramural tumour deposits: Findings of discontinuous extramural tumour deposits.
  • Present [Discontinuous extramural tumour deposits are present.]
  • Absent [Discontinuous extramural tumour deposits are absent.]
  • Indeterminate [Presence of discontinuous extramural tumour deposits has not been determined.]
Discontinuous extramural depositsDiscontinuous extramural deposits: Details of discontinuous extramural tumour deposits.
Include:
openEHR-EHR-CLUSTER.tumour_invasion.v1
Exclude:
All not explicitly included archetypes
Distance from marginDistance from margin: Distance from circumferential margin to extramural deposits.
Property: Length
Units: >=0.0 mm
Distant metastasis findingsDistant metastasis findings: Findings related to distant metastasis.
Distant metastasisDistant metastasis: Findings of distant metastasis.
  • Present [Evidence of distant metastasis.]
  • Absent [No evidence of distant metastasis.]
  • Indeterminate [Evidence of metastasis has not been determined.]
Sites Sites : Details of sites of proven distant metastases.
Include:
openEHR-EHR-CLUSTER.anatomical_location-precise.v1
Exclude:
All not explicitly included archetypes
DescriptionDescription: A text description of distant metastases.
Adenomatous polypsAdenomatous polyps: Findings of adenoatous polyps.
Type of polypType of polyp: Type of adenomatous polyp
Number of polypsNumber of polyps: Number of adenomatous polyps.
min: >=0

Polyposis syndromePolyposis syndrome: Evidence of polyposis syndrome.
  • Present [There is evidence of polyposis syndrome.]
  • Absent [There is no evidence of polyposis syndrome.]
  • Indeterminate [Evidence of polyposis syndrome has not been determined.]
CommentComment: Comment concerning adenomatous polyps.
Additional findingsAdditional findings: Additional histopathological findings.
Additional findingAdditional finding: A single additional histopathological finding.
Choice of:
  •  Coded Text
    • Synchronous carcinoma [Synchronous carcinoma is present.]
    • Ulcerative colitis [Ulcerative colitis is present.]
    • Ulcerative colitis with dysplasia [Ulcerative colitis with dysplasia is present.]
    • Crohn's disease [Crohn's disease is present.]
    • Crohn's disease with dysplasia [Crohn's disease with dysplasia is present.]
    • Diverticulosis [Diverticulosis is present.]
  •  Text
DescriptionDescription: A text description of additional findings.
Residual tumour statusResidual tumour status: Estimate of the completeness of surgical resection.
  • R0 [No residual tumour - as per AJCC TNM classification 7th Edition.]
  • R1 [R1 - as per AJCC TNM classification 7th Edition.]
  • R2 [R2 - as per AJCC TNM classification 7th Edition.]
  • RX [Residual tumour cannot be assessed - as per AJCC TNM classification 7th Edition.]
Response to neoadjuvant therapyResponse to neoadjuvant therapy: Details of the response to neoadjuvant therapy.
Neoadjuvant therapy givenNeoadjuvant therapy given: Has neoadjuvant therapy been given?
  • Yes [Neoadjuvant therapy has been given.]
  • No [Neoadjuvant therapy has not been given.]
  • Not known [It is not known if neoadjuvant therapy has been given.]
Grade of responseGrade of response: Alternative assessment grades of response to neoadjuvant therapy.
Grade (AJCC)Grade (AJCC): An estimate of the response to neoadjuvant therapy. (AJCC score).
  • Grade 0 - complete response [Complete response to neoadjuvant therapy.]
  • Grade 1 - moderate response [Moderate response to neoadjuvant therapy.]
  • Grade 2 - minimal response [Minimal response to neoadjuvant therapy.]
  • Grade 3 - poor response [Poor response to neoadjuvant therapy.]
Grade (CAP)Grade (CAP): An estimate of the response to neoadjuvant therapy. (CAP) College of American Pathologists.
  • No residual tumour [Complete response to treatment; Grade 0.]
  • Marked response [Minimal residual cancer persists; Grade 1.]
  • Moderate response [Grade 2.]
  • No definite response [Poor or no response; Grade 3.]
  • Response not known [Response to treatment is unknown.]
Grade (RCP)Grade (RCP): An estimate of the response to neoadjuvant therapy. (RCP) Royal College of Pathologists (UK).
  • No residual tumour cells or mucous lakes only [No residual tumour cells or mucous lakes only.]
  • Minimal residual tumour [Minimal residual tumour is present.]
  • No marked regression [Marked regression is absent.]
CommentComment: A text comment on the response to neoadjuvant therapy.
Other contributorsKoray Atalag, University of Auckland, New Zealand
Matt Cordell, NEHTA, Australia
David McKillop, NEHTA, Australia
Cathy Richardson, NEHTA, Australia
David Rowed, Ocean Informatics, Australia
Translators
  • Arabic (Syria): Mona Saleh