| 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 | copyright (c) 2010 openEHR Foundation |
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| Authors | Author name: Dr Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 17/06/2009
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| Other Details Language | Author name: Dr Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 17/06/2009
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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: C53E5BC4751A2B3B3B762DEB226400D2
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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 | 1013.1.381 |
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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 [> 75% of invasive carcinoma forming tubular or glandular structures.]
2: at0045::Tubular formation score 2 [1075% of invasive carcinoma forming tubular or glandular structures.]
3: at0046::Tubular formation score 3 [< 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 35.]
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 | David Rowed, Ocean Informatics, Australia
Heather Leslie, Ocean Informatics, Australia
Cathy Richardson, NEHTA, Australia
David McKillop, NEHTA, Australia
Koray Atalag, University of Auckland, New Zealand
Matt Cordell, NEHTA, Australia |
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| Translators | |
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