FHIR IG analytics| Package | medmij.fhir.nl.r4.pathology |
| Resource Type | DiagnosticReport |
| Id | DiagnosticReport-Pathology-Report-1-Smalhart.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "DiagnosticReport",
"id": "Pathology-Report-1-Smalhart",
"meta": {
"tag": [
{
"code": "0388",
"system": "urn:oid:2.16.840.1.113883.2.4.6.7",
"display": "Medisch specialisten, pathologische anatomie"
}
],
"profile": [
"http://medmij.nl/fhir/StructureDefinition/path-Report"
]
},
"status": "final",
"category": [
{
"coding": [
{
"code": "108257001",
"system": "http://snomed.info/sct",
"display": "pathologisch-anatomische verrichting"
}
]
}
],
"code": {
"coding": [
{
"code": "252416005",
"system": "http://snomed.info/sct",
"display": "Histopathology test"
}
]
},
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": [
{
"system": "urn:oid:2.16.840.1.113883.2.4.3.23.3.934.1",
"value": "T26-61237"
}
],
"basedOn": [
{
"reference": "ServiceRequest/Pathology-Request-1-Smalhart",
"display": "Request for Histopathology test"
}
],
"subject": {
"reference": "Patient/Pathology-Patient-Smalhart",
"display": "G. Smalhart"
},
"effectivePeriod": {
"start": "2026-06-13",
"end": "2026-06-14"
},
"resultsInterpreter": [
{
"reference": "PractitionerRole/Pathology-PractitionerRole-Tholoog",
"display": "P.A. Tholoog, St. Holisto's Hospitaal, patholoog"
}
],
"specimen": [
{
"reference": "Specimen/Pathology-Specimen-1-Smalhart",
"display": "Colon Resectie"
}
],
"result": [
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-1",
"display": "Type resectie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-2",
"display": "obstructie-ileus van dunne darm gelijktijdig met en door impactie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-3",
"display": "locatie van metastase op afstand"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-4",
"display": "Status metastasen"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-5",
"display": "Type tumor"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-6",
"display": "Ki-67 index NEN"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-7",
"display": "Diameter grootste metastase NET"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-8",
"display": "vaststellen DNA mismatch repair eiwit in kwaadaardige tumor met immunohistochemie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-9",
"display": "DNA mismatch repair eiwit MLH1"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-10",
"display": "Aspect tumor"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-11",
"display": "status van invasie van tumor in bloedvat"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-12",
"display": "Angio-invasie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-13",
"display": "vaststellen DNA mismatch repair eiwit in kwaadaardige tumor met immunohistochemie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-14",
"display": "DNA mismatch repair eiwit MSH6"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-15",
"display": "bepalen van marker proteïne Ki-67 voor snelle celproliferatie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-16",
"display": "Type tumor"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-17",
"display": "vaststellen DNA mismatch repair eiwit in kwaadaardige tumor met immunohistochemie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-18",
"display": "DNA mismatch repair eiwit PMS2"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-19",
"display": "vaststellen DNA mismatch repair eiwit in kwaadaardige tumor met immunohistochemie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-20",
"display": "DNA mismatch repair eiwit MSH2"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-21",
"display": "Mesenteriale massa aanwezig"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-22",
"display": "Lengte preparaat"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-23",
"display": "Poliep(en)"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-24",
"display": "aantal slijmvliesbiopten"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-25",
"display": "plaats van primaire tumor"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-26",
"display": "grootste lengte van tumor in preparaat verkregen door resectie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-27",
"display": "vaststellen DNA mismatch repair eiwit in kwaadaardige tumor met immunohistochemie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-28",
"display": "status van invasie van tumor in bloedvat"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-29",
"display": "immunohistochemische verrichting"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-30",
"display": "Respons op eerdere therapie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-31",
"display": "Mitosen per 2mm2"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-32",
"display": "status van intactheid van preparaat verkregen door resectie van mesocolon"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-33",
"display": "tumor in anamnese"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-34",
"display": "histologische graad van neuro-endocrien neoplasma"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-35",
"display": "zegelringcelcarcinoom"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-36",
"display": "Tumor budding"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-37",
"display": "Perforatie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-38",
"display": "afstand van tumor tot proximaal snijvlak in biopt"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-39",
"display": "Retroperitoneaal klievingsvlak/radiaire snijvlak"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-40",
"display": "Lokalisatie dichtstbijzijnde darmsnijvlak"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-41",
"display": "terugkerende tumor"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-42",
"display": "status van ingroei van tumor rondom zenuw"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-43",
"display": "aanwezigheid van neoplasma op het mesenteriale snijvlak in in preparaat van weefsel verkregen door excisie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-44",
"display": "grootste lengte van tumor in preparaat verkregen door resectie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-45",
"display": "Proximaal darmsnijvlak"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-46",
"display": "Distaal darmsnijvlak"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-47",
"display": "moleculaire diagnostiek"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-48",
"display": "Diepste tumordoorgroei"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-49",
"display": "Eerdere therapie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-50",
"display": "Eerdere therapie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-51",
"display": "plaats van primaire tumor"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-52",
"display": "status van ingroei van tumor rondom zenuw"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-53",
"display": "Lymfocytaire infiltratie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-54",
"display": "diagnose"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-55",
"display": "Tumor aanwezig"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-56",
"display": "aantal tumoren"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-57",
"display": "aantal lymfeklieren aangedaan door maligniteit"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-58",
"display": "Dichtstbijzijnde darmsnijvlak"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-59",
"display": "anatomische locatie van directe invasie door goed gedifferentieerde neuro-endocriene tumor"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-60",
"display": "Aspect tumor"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-61",
"display": "Onderzoek vermelden als"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-62",
"display": "afstand van tumor tot distaal snijvlak in biopt"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-63",
"display": "afstand van neoplasma tot dichtstbijzijnde radiaal snijvlak in biopt"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-64",
"display": "Histologisch respons op (neo-adjuvante) therapie in de lymfklieren"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-65",
"display": "Respons op eerdere therapie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-66",
"display": "diameter van massa"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-67",
"display": "Aantal mitosen per 2mm2"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ProtocolDataItem-1-68",
"display": "percentage celkernen positief voor INSM1 in primair maligne neoplasma volgens immunohistochemie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-ClinicalInformation-1",
"display": "Klinische gegevens"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-Macroscopy-1",
"display": "Macroscopie"
},
{
"reference": "Observation/Pathology-Observation-Smalhart-Microscopy-1",
"display": "Microscopie"
}
],
"conclusion": "<div>Hemicolectomie rechts, 2 tumoren.</div><div>type 1ste tumor (WHO): zegelringcelcarcinoom; maximale diameter tumor 0,6 cm; lokalisatie: coecum; diepste tumor doorgroei: submucosa; eerdere neo-adjuvante therapie: chemotherapie en radiotherapie kort, respons op eerdere neo-adjuvante therapie: partiele regressie (pT1).</div><div>Dichtstbijzijnde darmsnijvlak niet vrij; retroperitoneaal klievingsvlak/radiaire snijvlak vrij (afstand > 0,1 cm < 0,2 cm).</div><div>Angio-invasie: lymfvat invasie en intramurale veneuze invasie.</div><div>Perineurale invasie: aangetroffen.</div><div/><div>type 2de tumor (WHO): neuroendocriene tumor graad 1; maximale diameter tumor 0,7 cm; lokalisatie: ileum; diepste tumordoorgroei (NET) (ileum/jejunum): invasie in muscularis propria; eerdere neo-adjuvante therapie: chemotherapie en radiotherapie kort, respons op eerdere neo-adjuvante therapie: geen regressie (pT2).</div><div>Proximaal darmsnijvlak vrij (afstand 0,2 cm); distaal darmsnijvlak vrij (afstand 0,2 cm); Mesenteriaal snijvlak: niet vrij.</div><div>Angio-invasie: geen lymfvat invasie of extramurale veneuze invasie aangetroffen.</div><div>Perineurale invasie: niet aangetroffen.</div><div/><div>Aantal lymfklieren: 23 waarvan met metastasen: 18. Aantal tumordeposits: 1.</div><div/><div>Histologisch bevestigde metastase(n) in lever.</div><div/><div>TNM classificatie Colon en Rectum (9e editie UICC): rypT1N2b(mi)M1a.</div><div/><div>TNM classificatie Dunne darm GD-NET (9e editie UICC): ypT2N2(mi)M1a.</div><div>Patient is bekend met: MUTYH geassocieerde polyposis (MAP).</div><div/><div>MMR-status: MMR-deficiënt (dMMR), zie specificatie in het protocollair verslag. Advies m.b.t. erfelijkheid: de leeftijd en MMR-deficiëntie is een reden voor nader onderzoek naar aanleg voor Lynch syndroom en daarmee verwijzing naar een klinisch geneticus te overwegen.</div>"
}