1.3.6.1.4.1.19376.1.5.3.1.1.19.1.1

Cancer Registry Pathology Report Content 1.3.6.1.4.1.19376.1.5.3.1.1.19.1.1

This message is sent by a Clinical Data Source actor that implements the V2 Care Management Update option after the completion of any of the following anatomic pathology reports:

• histopathology
• flow cytometry
• cytology
• autopsy
• bone marrow
• peripheral smear

Standards

NAACCR	North American Association of Central Cancer Registries Standards for Cancer Registries Volume V: Pathology Laboratory Electronic Reporting; Version 2.1
NAACCRMWP	NAACCR Volume V Messaging Workbench Profile
NAACCRSTL	NAACCR Search Term List
&nbsp	Chapter III. Standards for Tumor Inclusion and Reportability. NAACCR Standards for Cancer Registries Volume II: Data Standards and Data Dictionary. Twelfth Edition; Record Layout Version 11.2.
IDC-O	World Health Organization : International Classification of Diseases for Oncology (ICD-0) Third Edition

Data Element Index

[1] : Refer to NAACCR Standards for Cancer Registries Volume V: Pathology Laboratory Electronic Reporting Verison 2.1, Chapter 2.6

Message Specification

The message to send to a Cancer Registry upon completion of a qualifying pathology report is fully specified in NAACCR Standards for Cancer Registries Volume V: Pathology Laboratory Electronic Reporting Verison 2.1, Chapter 2.6. A summary of this message is listed below.

HL7 Version

HL7 2.3.1

Event Type

R01

Message Structure

ORU_R01 Unsolicited Observation Message

Conformance Profile

1.3.6.1.4.1.19376.1.5.3.1.1.19.1.1

HL7 Example of a Pathology Report HL7 Message to a Cancer Registry

Note:

Lines in the example below have been wrapped to support display of the example.

MSH|^~\&|TESTLAB1|INDEPENDENT LAB SERVICES^LABCLIANUM^CLIA|||200404281339|
  |ORU^R01|2004042813390045|P|2.3.1|||||||||2.0
PID|1||123456789^^^^SS|000039^^^^LR|McMuffin^Candy^^^Ms.||19570706|F||2106-3
  |495 East Overshoot Drive^^Delmar^NY^12054||^^^^^518^5559999|||M||
  |4442331235
ORC|RE||||||||||||||||||||General Hospital^^123456^^^AHA
  |857 Facility Lane^^Albany^NY^12205|^^^^^518^3334444
  |100 Provider St^^Albany^NY^12205
OBR|1||S91-1700|22049-1^cancer identification battery^LN|||20040720|||||||
  |^left breast mass|1234567^Myeolmus^John^^MD|(518)424-4243||||||||F|||||
  ||99999&Glance&Justin&A&MD
OBX|1|TX|22636-5^clinical history^LN|
  |47-year old white female with (L) UOQ breast mass||||||F|||20040720
OBX|2|ST|22633-2^nature of specimen^LN|1|left breast biopsy||||||F||
  |20040720
OBX|3|ST|22633-2^nature of specimen^LN|2|apical axillary tissue||||||F||
  |20040720
OBX|4|ST|22633-2^nature of specimen^LN|3
  |contents of left radical mastectomy||||||F|||20040720
OBX|5|TX|22634-0^gross pathology^LN|1
  |Part #1 is labeled "left breast biopsy" and is received fresh after frozen 
  section preparation. It consists of a single firm nodule measuring 3cm in 
  circular diameter and 1.5cm in thickness surrounded by adherent fibrofatty 
  tissue. On section a pale gray, slightly mottled appearance is revealed. 
  Numerous sections are submitted for permanent processing.||||||F|||20040720
OBX|6|TX|22634-0^gross pathology^LN|2
  |Part #2 is labeled "apical left axillary tissue" and is received fresh. It 
  consists of two amorphous fibrofatty tissue masses without grossly 
  discernible lymph nodes therein. Both pieces are rendered into numerous 
  sections and submitted in their entirety for history.||||||F|||20040720
OBX|7|TX|22634-0^gross pathology^LN|3
  |Part #3 is labeled "contents of left radical mastectomy" and is received 
  flesh. It consists of a large ellipse of skin overlying breast tissue, the 
  ellipse measuring 20cm in length and 14 cm in height. A freshly sutured 
  incision extends 3cm directly lateral from the areola, corresponding to the
  closure for removal of part #1. Abundant amounts of fibrofatty connective 
  tissue surround the entire beast and the deep aspect includes and 8cm length 
  of pectoralis minor and a generous mass of overlying pectoralis major muscle. 
  Incision from the deepest aspect of the specimen beneath the tumor mass 
  reveals tumor extension gross to within 0.5cm of muscle. Sections are 
  submitted according to the following code: DE- deep surgical resection 
  margins; SU, LA, INF, ME -- full thickness radila samplings from the center 
  of the tumor superiorly, laterally, inferiorly and medially, respectively: 
  NI- nipple and subjacent tissue. Lymph nodes dissected free from axillary 
  fibrofatty tissue from levels I, II, and III will be labeled accordingly.
  ||||||F|||20040720
OBX|8|TX|22635-7^microscopic pathology^LN|1
  |Sections of part #1 confirm frozen section diagnosis of infiltrating duct 
  carcinoma. It is to be noted that the tumor cells show considerable 
  pleomorphism, and mitotic figures are frequent (as many as 4 per high power 
  field). Many foci of calcification are present within the tumor. 
  ||||||F|||20040720
OBX|9|TX|22635-7^microscopic pathology^LN|2
  |Part #2 consists of fibrofatty tissue and single tiny lymph node free of 
  disease.||||||F|||20040720
OBX|10|TX|22635-7^microscopic pathology^LN|3
  |Part #3 includes 18 lymph nodes, three from Level III, two from Level II and
  thirteen from Level I. All lymph nodes are free of disease with the exception
  of one Level I lymph node, which contains several masses of metastatic 
  carcinoma.  All sections taken radially from the superficial center of the 
  resection site fail to include tumor, indicating the tumor to have originated
  deep within the breast parenchyma. Similarly, there is no malignancy in the 
  nipple region, or in the lactiferous sinuses.  Sections of deep surgical 
  margin demonstrate diffuse tumor infiltration of deep fatty tissues, however,
  there is no invasion of muscle. Total size of primary tumor is estimated to 
  be 4cm in greatest dimension.||||||F|||20040720
OBX|11|TX|22637-3^final diagnosis^LN|1
  |1. Infiltrating duct carcinoma, left breast. ||||||F|||20040720
OBX|12|TX|22637-3^final diagnosis^LN|2
  |2. Lymph node, no pathologic diagnosis, left axilla.||||||F|||20040720
OBX|13|TX|22637-3^final diagnosis^LN|3
  |3. Ext. of tumor into deep fatty tissue. Metastatic carcinoma, left axillary 
  lymph node (1) Level I. Free of disease 17 of 18 lymph nodes - Level I (12), 
  Level II (2) and Level III (3). ||||||F|||20040720
OBX|14|TX|22638-1^comments^LN||Clinical diagnosis: carcinoma of breast. 
  Post-operative diagnosis: same.||||||F|||20040720