| ARCHETYPE ID | openEHR-EHR-CLUSTER.microscopy_breast_carcinoma.v1 |
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| Concept | Microscopic findings - Breast cancer |
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| Description | Microscopic anatomic pathology findings related to breast cancer. |
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| Use | 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. |
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| Misuse | Not designed to be used within any other archetype other than OBSERVATION.lab_test.histopathology. |
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| Purpose | To record detailed findings about breast cancer found on microscopic examination. |
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| References | 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 |
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| Copyright | © openEHR Foundation |
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| Authors | Author name: Dr Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2009-06-17
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| Other Details Language | Author name: Dr Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2009-06-17
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| Other Details (Language Independent) | - References: 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
- MD5-CAM-1.0.1: 41E10C136EAB6E4ED748035BF6D9F697
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| Keywords | breast, histopathology, cancer, laboratory, lab, pathology, histology, malignancy |
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| Lifecycle | Initial |
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| Language used | en |
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| Citeable Identifier | 1246.145.2914 |
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| items | |
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| Tumour size and extent | Tumour size and extent: Assessments of tumour size. |
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| Invasive tumour extent | Invasive tumour extent: The size of the invasive aspect of the breast cancer.
Include:
openEHR-EHR-CLUSTER.physical_properties.v1
Exclude:
All not explicitly included archetypes |
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| Total lesion extent | Total lesion extent: The extent of total breast cancer lesion.
Include:
openEHR-EHR-CLUSTER.physical_properties.v1
Exclude:
All not explicitly included archetypes |
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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: at0176::Score 1 [Low mitotic frequency.]
2: at0177::Score 2 [Intermediate mitotic frequency.]
3: at0178::Score 3 [High mitotic frequency.]
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| Nuclear score | Nuclear score: Nuclear score.
1: at0050::Score 1 [Size equivalent to 1.5–2 red blood cell diameters or normal duct epithelial nuclei; Diffuse chromatin; Inconspicuous nucleoli.]
2: at0051::Score 2 [Size equivalent to 2–2.5 red blood cell diameters; Coarse chromatin; Infrequent nucleoli and mitoses.]
3: at0052::Score 3 [Size > 2.5 red blood cell diameters; Pleomorphic vesicular nuclei; One or more prominent nucleoli; Frequent mitotic figures commonly present.]
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| Tubular formation score | Tubular formation score: Tubular formation score, representing the extent of tubular formation within invasive carcinoma cells.
1: at0044::Tubular formation score 1 [Less than 75% of invasive carcinoma forming tubular or glandular structures.]
2: at0045::Tubular formation score 2 [10-75% of invasive carcinoma forming tubular or glandular structures.]
3: at0046::Tubular formation score 3 [Less than 10% of invasive carcinoma forming tubular or glandular structures.]
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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: at0047::Grade 1 [Total score of 3-5.]
2: at0048::Grade 2 [Total score of 6 or 7.]
3: at0049::Grade 3 [Total score of 8 or 9.]
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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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| Local tumour invasion | Local tumour invasion: Findings of local tumour invasion. |
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| Lymphovascular invasion | Lymphovascular invasion: Details of local invasion into lymphovascular tissue.
Include:
All not explicitly excluded archetypes
Exclude:
openEHR-EHR-CLUSTER.tumour_invasion.v1 |
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| Skin / muscle invasion | Skin / muscle invasion: Details of local invasion into skin or muscle tissue.
Include:
openEHR-EHR-CLUSTER.tumour_invasion.v1
Exclude:
All not explicitly included archetypes |
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| Resection margins | Resection margins: Findings of the relation of tumour to surgical resection margins. |
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| Invasive carcinoma at margin | Invasive carcinoma at margin: Details of invasive carcinoma at surgical resection margins.
Include:
openEHR-EHR-CLUSTER.tumour_resection_margins.v1
Exclude:
All not explicitly included archetypes |
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| DCIS at margin | DCIS at margin: Details of DCIS (Ductal carcinoma-in-situ) at surgical resection margins.
Include:
openEHR-EHR-CLUSTER.tumour_resection_margins.v1
Exclude:
All not explicitly included archetypes |
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| LCIS at margin | LCIS at margin: Details of LCIS (Local carcinoma-in-situ) at surgical resection margins.
Include:
openEHR-EHR-CLUSTER.tumour_resection_margins.v1
Exclude:
All not explicitly included archetypes |
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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.
Choice of:
 Coded Text
- at0167::Present - classical [Classical lobular neoplasia is present.]
- at0168::Present - pleomorphic [Pleomorphic lobular neoplasia is present.]
- at0169::Absent [Lobular neoplasia is absent.]
- at0170::Indeterminate [The presence of lobular hyperplasia has not been determined.]
 Text
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| Atypical lobular hyperplasia | Atypical lobular hyperplasia: Finding of atypical lobular hyperplasia.
Choice of:
- Coded Text
- at0109::Present - classical [Classical atypical lobular neoplasia is present.]
- at0110::Present - pleomorphic [Pleomorphic atypical lobular neoplasia is present.]
- at0152::Absent [Atypical lobular neoplasia is absent.]
- at0153::Indeterminate [The presence of atypical lobular neoplasia has not been determined.]
- Text
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| Lobular carcinoma-in-situ | Lobular carcinoma-in-situ: Finding of lobular carcinoma-in-situ.
Choice of:
- Coded Text
- at0171::Present - classical [Classical lobular carcinoma-in-situ is present.]
- at0172::Present - pleomorphic [Pleomorphic lobular carcinoma-in-situ is present.]
- at0173::Absent [Lobular carcinoma-in-situ is absent.]
- at0174::Indeterminate [The presence of lobular carcinoma-in-situ has not been determined.]
- 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.
- at0119::Present [Paget's disease of the nipple is present.]
- at0120::Absent [Paget's disease of the nipple is absent.]
- at0121::Indeterminate [Presence of Paget's disease of the nipple has not been determined.]
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| Microcalcification | Microcalcification: Findings related to microcalcification. |
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| Microcalcification | Microcalcification: Findings of microcalcification.
- at0122::Present [Microcalcification is present.]
- at0126::Absent [Microcalcification is absent.]
- at0127::Indeterminate [Presence of microcalcification has not been determined.]
- at0123::Present - no evidence of necrosis [Microcalcification is present with no evidence of necrosis.]
- at0124::Present - with evidence of necrosis [Microcalcification is 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.
- at0155::Present with necrosis [Calcification with necrosis is present in DCIS tissue.]
- at0156::Present without necrosis [Calcification without necrosis is present in DCIS tissue.]
- at0157::Absent [Calcification is absent from DCIS tissue.]
- at0158::Indeterminate [Presence of calcification in DCIS tissue has not been determined.]
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| Histologic grade | Histologic grade: Histologic grading of DCIS. |
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| Necrosis | Necrosis: Findings of tumour necrosis.
- at0076::Present (non-comedo type) [Non-comedo type of tumour necrosis is present.]
- at0078::Present (Comedo type) [Comedo type of tumour necrosis is present.]
- at0077::Absent or minimal [Tumour necrosis is 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: at0071::Score 1 [Size equivalent to 1.5–2 red blood cell diameters or normal duct epithelial nuclei; Diffuse chromatin; Inconspicuous nucleoli.]
2: at0072::Score 2 [Size equivalent to 2–2.5 red blood cell diameters; Coarse chromatin; Infrequent nucleoli and mitoses.]
3: at0073::Score 3 [Size > 2.5 red blood cell diameters; Pleomorphic vesicular nuclei; One or more prominent nucleoli; Frequent mitotic figures commonly present.]
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| Van Nuys Prognostic Index | Van Nuys Prognostic Index: The Van Nuys Prognostic Index (VNPI).
1: at0081::Van Nuys Group 1 [Nuclear grade 1 or 2 and no necrosis.]
2: at0082::Van Nuys Group 2 [Nuclear grade 1 or 2 and necrosis.]
3: at0083::Van Nuys Group 3 [Nuclear grade 3 with or without necrosis.]
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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.
Choice of:
- Coded Text
- at0132::Solid [Solid pattern of ductal carcinoma-in-situ.]
- at0133::Cribriform [Cribriform pattern of ductal carcinoma-in-situ.]
- at0134::Micropapillary [Micropapillary pattern of ductal carcinoma-in-situ.]
- at0135::Apocrine [Apocrine pattern of ductal carcinoma-in-situ.]
- at0136::Papillary [Papillary pattern of ductal carcinoma-in-situ.]
- at0137::Indeterminate [The dominant pattern of ductal carcinoma-in-situ has not been determined.]
- 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.
- at0097::Positive [Oestrogen Receptor assay result is positive.]
- at0098::Negative [Oestrogen Receptor assay result is negative.]
- at0099::Equivocal [Oestrogen Receptor assay result is 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.
- at0104::Low [Predominant intensity of staining is low.]
- at0105::Intermediate [Predominant intensity of staining is intermediate.]
- at0106::High [Predominant intensity of staining is high.]
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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.
- at0139::Positive [Progesterone Receptor assay result is positive.]
- at0140::Negative [Progesterone Receptor assay result is negative.]
- at0141::Equivocal [Progesterone Receptor assay result is 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.
- at0164::Low [Predominant intensity of staining is low.]
- at0165::Intermediate [Predominant intensity of staining is intermediate.]
- at0166::High [Predominant intensity of staining is high.]
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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.
min: >=0
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| Immunohistochemistry result | Immunohistochemistry result: HER2 Immunohistochemistry result.
- at0146::Positive [The HER2 Immunohistochemistry result is positive.]
- at0147::Negative [The HER2 Immunohistochemistry result is negative.]
- at0148::Equivocal [The HER2 Immunohistochemistry result is 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.
- at0149::Positive [The HER2 In situ hybridisation (ISH) result is positive.]
- at0150::Negative [The HER2 In situ hybridisation (ISH) result is negative.]
- at0151::Equivocal [The HER2 In situ hybridisation (ISH) result is equivocal.]
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| Comment | Comment: A text comment on HER2 In situ hybridisation (ISH) result. |
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| Lymph node involvement | Lymph node involvement: Findings related to the involvement of tumour in lymph nodes. |
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| Sentinel nodes | Sentinel nodes: Details of the involvement of tumour in sentinel lymph nodes.
Include:
openEHR-EHR-CLUSTER.lymph_node_metastases.v1
Exclude:
All not explicitly included archetypes |
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| Axillary nodes | Axillary nodes: Details of the involvement of tumour in axillary lymph nodes.
Include:
openEHR-EHR-CLUSTER.lymph_node_metastases.v1
Exclude:
All not explicitly included archetypes |
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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.
- at0182::Columnar cell changes [Columnar cell changes are present.]
- at0183::Intraductal papilloma [Intraductal papilloma is present.]
- at0184::Radial scars [Radial scars are present.]
- at0185::Atypical ductal hyperplasia (ADH) [Atypical ductal hyperplasia (ADH) is present.]
- at0186::Absent [Non-neoplastic change is absent.]
- at0187::Indeterminate [Presence of non-neoplastic changes has not been determined.]
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| Other contributors | 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 |
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| Translators | |
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