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HdBe-TNMTumorClassification

WARNING This page contains a draft CBB, as raw output from the zib export and automatic conversion to CBB. It requires thorough review and adaption to the Belgian realm. This CBB is merely added for informative use.

CBB	Description	Status
HdBe-TNMTumorClassification	TNM Classification of Malignant Tumors (TNM) is the cancer staging system developed and is maintained by the Union for International Cancer Control (UICC). It is also used by the American Joint Committee on Cancer (AJCC) and the International Federation of Gynecology and Obstetrics (FIGO). In 1987, the UICC and AJCC staging systems were unified into the single TNM staging system. Nevertheless, there are still some differences between the two systems. The TNM-classification is developed for solid tumors. TNM is a notation system that describes the stage of a cancer, which originates from a solid tumor, using alphanumeric codes; T describes the size of the original (primary) tumor and whether it has invaded nearby tissue, N describes nearby (regional) lymph nodes that are involved, and M describes distant metastasis (spread of cancer from one part of the body to another). In addition to T, N and M, the classification also contains other parameters that may be relevant. Purpose TNM classification is a major determinant of appropriate treatment and prognosis. Stage is an increasingly important component of cancer surveillance and cancer control and an endpoint for the evaluation of the population-based screening and early detection efforts. The TNM staging system is the common language in which oncology health professionals can communicate on the cancer extent for individual patients as a basis for decision making on treatment management and individual prognosis but can also be used, to inform and evaluate treatment guidelines, national cancer planning and research. The objectives of the TNM classification are the following: Aid treatment planning, Provide an indication of prognosis based on historical outcome data, Assist in the evaluation of treatment results, Facilitate the exchange of information between treatment centers, Contribute to continuing investigations of human malignancies, Support cancer control activities, including through cancer registries. The TNM classification is a unified standard. It goes beyond clinician practice and constitutes vital information for policy-makers developing or implementing cancer control and prevention plans. Instructions From a generic TNM Classification towards a disease-specific TNM Classification Development or implementation of a tumor-specific information model of the TNM Classification standard requires insight into how values sets can be restricted, expanded, and applied. Restriction of a value list means either leaving out items or making items more specific by choosing other terms within the official code system. The aim for the future is to have available ready-to-use value sets per type of malignancy. Codes systems This clinical model uses 2 international code systems: SNOMED CT (managed by SNOMED international, Dutch management by Nictiz) International Classification of Diseases for Oncology, version 3 (ICD-O-3), managed by the WHO. For items where neither of these 2 code systems were considered useful or satisfactory, we chose to manage the value sets as part of the management of the HCIMs (Health and Care Information Models). When a unique and international reference to the TNM Classification standard as codesystem and the valuesets becomes availble these can be amended in a next version of the HCIM . Starting points from the perspective of the TNM Classification standard One TNM-classification per single organ, and one classification per side for paired organs. For example: when breast cancer involves a primary tumor in both breasts, there will be two instances of the HCIM with laterality ‘left’ for one breast and laterality ‘right’ for the other (‘bilateral’ is not allowed for paired organs). The HCIM does not only encompass the outcome of the TNM classification, but also the exact localization of the primary tumor(s), the positive lymph nodes, and metastases. In case of multiple primary tumors in the same organ, one should classify the tumor with the highest T-category, and mention the multiple presence or number of tumors between brackets. For example: T2 (m) or T2 (5). The lesion with the highest T-category determines the classification of the tumor. In order to distinguish between lesions and to represent each individual lesion, the HCIM has the container ‘Lesion’. Each lesion has a number. The HCIM does not represent which lesion (e.g. 1, 2, or 4) has the highest T-category, since this is only clear after judgment by the health professional on the basis of morphology and/or imaging. Use of the UICC (http://www.uicc.org/resources/tnm) **/ AJCC (http://cancerstaging.org/references-tools/deskreferences/Pages/default.aspx )** version of the TNM Classification of Malignant Tumours. Although definitions and wording should not differ between the AJCC and UICC TNM classifications, some differences have regrettably crept in (for example: the definition of regional lymph nodes associated with carcinomas of the esophagus and endometrium). Therefore, the HCIM allows for choosing between the UICC or AJCC version. Criteria within the TNM-classification system have changed over the years and resulted in various editions. As a result, a specific tumor stage may have a completely different prognosis, depending on the edition used. Furthermore, it is important to consider the consequences of improved treatment over time. Beside staging based on the UICC or AJCC classifications there is the ‘Essential TNM’. This is a simplified version of the TNM, specifically developed for the representation of the occurrence of cancer in low wage countries. These countries often lack the resources for early diagnosis, and make limited use of the TNM classification system (in these countries, cancer is generally detected in a very late stage). This special version of the TNM has not been taken into account while developing this HCIM. Furthermore, the use of the ‘Essential TNM’ is generally limited to acquire data for statistics related to the prevalence of certain malignancies in these countries. Prefix and suffix are integrated in value sets Although it would be possible to create separate value sets for the potential prefixes and suffixes associated with the T, N, and M items, we chose to facilitate the use of the model by integrating them in the T, N, and M value sets. This decision is based on the current insight that it prevents the creation of invalid combinations. Prefix c: Clinical classification, based on data prior to treatment, such as clinical examination, imaging, endoscopy, biopsies, surgical exploration or examination under anesthesia, and other types of examination. yc: Classification performed during or following initial multimodal therapy (non-surgical). p: Post-surgical histopathological classification. This is based on data prior to treatment, supplemented with pathological examination after surgical treatment. yp: Classification performed during or after multimodal treatment (including surgical treatment). rc: Clinical classification in case of a recurrent tumor (after a disease-free interval). rp: Postoperative pathological classificationin case of a recurrent tumor (after a disease-free interval). a: Classification determined during autopsy. Suffix (mi): Cases with micrometastasis only (sn): Cases after sentinel lymph node assessment (f): Cases where FNA or a core biopsy is performed on regional lymph nodes (i-): negative morphological findings for isolated tumor cells (ITC) (i+): positive morphological findings for isolated tumor cells (ITC) (mol-): negative non-morphological findings for isolated tumor cells (ITC) (mol+): positive non-morphological findings for isolated tumor cells (ITC) (0): without elevated (LDH) (1): with elevated (LDH) Patient Population Adult patients with a solid tumor on which the TNM-classifications can be applied. Issues Usability of this HCIM as well as disease-specific code lists are created in the first pilot(s), planned in the summer of 2020. During these projects, IKNL will provide the maintenance for these code lists. When these pilot projects are completed, the findings will be included as change requests in the regular maintenance process of the HCIM center.	draft

CBB

Description

Status

HdBe-TNMTumorClassification

TNM Classification of Malignant Tumors (TNM) is the cancer staging system developed and is maintained by the Union for International Cancer Control (UICC). It is also used by the American Joint Committee on Cancer (AJCC) and the International Federation of Gynecology and Obstetrics (FIGO). In 1987, the UICC and AJCC staging systems were unified into the single TNM staging system. Nevertheless, there are still some differences between the two systems. The TNM-classification is developed for solid tumors. TNM is a notation system that describes the stage of a cancer, which originates from a solid tumor, using alphanumeric codes; T describes the size of the original (primary) tumor and whether it has invaded nearby tissue, N describes nearby (regional) lymph nodes that are involved, and M describes distant metastasis (spread of cancer from one part of the body to another). In addition to T, N and M, the classification also contains other parameters that may be relevant.

Purpose

TNM classification is a major determinant of appropriate treatment and prognosis. Stage is an increasingly important component of cancer surveillance and cancer control and an endpoint for the evaluation of the population-based screening and early detection efforts. The TNM staging system is the common language in which oncology health professionals can communicate on the cancer extent for individual patients as a basis for decision making on treatment management and individual prognosis but can also be used, to inform and evaluate treatment guidelines, national cancer planning and research. The objectives of the TNM classification are the following:

Aid treatment planning,
Provide an indication of prognosis based on historical outcome data,
Assist in the evaluation of treatment results,
Facilitate the exchange of information between treatment centers,
Contribute to continuing investigations of human malignancies,
Support cancer control activities, including through cancer registries.

The TNM classification is a unified standard. It goes beyond clinician practice and constitutes vital information for policy-makers developing or implementing cancer control and prevention plans.

Instructions

From a generic TNM Classification towards a disease-specific TNM Classification Development or implementation of a tumor-specific information model of the TNM Classification standard requires insight into how values sets can be restricted, expanded, and applied. Restriction of a value list means either leaving out items or making items more specific by choosing other terms within the official code system. The aim for the future is to have available ready-to-use value sets per type of malignancy. Codes systems This clinical model uses 2 international code systems:

SNOMED CT (managed by SNOMED international, Dutch management by Nictiz)
International Classification of Diseases for Oncology, version 3 (ICD-O-3), managed by the WHO.

For items where neither of these 2 code systems were considered useful or satisfactory, we chose to manage the value sets as part of the management of the HCIMs (Health and Care Information Models). When a unique and international reference to the TNM Classification standard as codesystem and the valuesets becomes availble these can be amended in a next version of the HCIM . Starting points from the perspective of the TNM Classification standard

One TNM-classification per single organ, and one classification per side for paired organs. For example: when breast cancer involves a primary tumor in both breasts, there will be two instances of the HCIM with laterality ‘left’ for one breast and laterality ‘right’ for the other (‘bilateral’ is not allowed for paired organs).
The HCIM does not only encompass the outcome of the TNM classification, but also the exact localization of the primary tumor(s), the positive lymph nodes, and metastases.
In case of multiple primary tumors in the same organ, one should classify the tumor with the highest T-category, and mention the multiple presence or number of tumors between brackets. For example: T2 (m) or T2 (5). The lesion with the highest T-category determines the classification of the tumor. In order to distinguish between lesions and to represent each individual lesion, the HCIM has the container ‘Lesion’. Each lesion has a number. The HCIM does not represent which lesion (e.g. 1, 2, or 4) has the highest T-category, since this is only clear after judgment by the health professional on the basis of morphology and/or imaging.

Use of the ****UICC (http://www.uicc.org/resources/tnm) ****/ ****AJCC (http://cancerstaging.org/references-tools/deskreferences/Pages/default.aspx** )**** version of the TNM Classification of Malignant Tumours.**

Although definitions and wording should not differ between the AJCC and UICC TNM classifications, some differences have regrettably crept in (for example: the definition of regional lymph nodes associated with carcinomas of the esophagus and endometrium). Therefore, the HCIM allows for choosing between the UICC or AJCC version. Criteria within the TNM-classification system have changed over the years and resulted in various editions. As a result, a specific tumor stage may have a completely different prognosis, depending on the edition used. Furthermore, it is important to consider the consequences of improved treatment over time.
Beside staging based on the UICC or AJCC classifications there is the ‘Essential TNM’. This is a simplified version of the TNM, specifically developed for the representation of the occurrence of cancer in low wage countries. These countries often lack the resources for early diagnosis, and make limited use of the TNM classification system (in these countries, cancer is generally detected in a very late stage). This special version of the TNM has not been taken into account while developing this HCIM. Furthermore, the use of the ‘Essential TNM’ is generally limited to acquire data for statistics related to the prevalence of certain malignancies in these countries.

Prefix and suffix are integrated in value sets Although it would be possible to create separate value sets for the potential prefixes and suffixes associated with the T, N, and M items, we chose to facilitate the use of the model by integrating them in the T, N, and M value sets. This decision is based on the current insight that it prevents the creation of invalid combinations. **Prefix **

**c: **Clinical classification, based on data prior to treatment, such as clinical examination, imaging, endoscopy, biopsies, surgical exploration or examination under anesthesia, and other types of examination.
yc: Classification performed during or following initial multimodal therapy (non-surgical).
p: Post-surgical histopathological classification. This is based on data prior to treatment, supplemented with pathological examination after surgical treatment.
yp: Classification performed during or after multimodal treatment (including surgical treatment).
rc: Clinical classification in case of a recurrent tumor (after a disease-free interval).
rp: Postoperative pathological classificationin case of a recurrent tumor (after a disease-free interval).
a: Classification determined during autopsy.

Suffix

(mi): Cases with micrometastasis only
(sn): Cases after sentinel lymph node assessment
(f): Cases where FNA or a core biopsy is performed on regional lymph nodes
(i-): negative morphological findings for isolated tumor cells (ITC)
(i+): positive morphological findings for isolated tumor cells (ITC)
(mol-): negative non-morphological findings for isolated tumor cells (ITC)
(mol+): positive non-morphological findings for isolated tumor cells (ITC)
(0): without elevated (LDH)
(1): with elevated (LDH)

Patient Population

Adult patients with a solid tumor on which the TNM-classifications can be applied. Issues Usability of this HCIM as well as disease-specific code lists are created in the first pilot(s), planned in the summer of 2020. During these projects, IKNL will provide the maintenance for these code lists. When these pilot projects are completed, the findings will be included as change requests in the regular maintenance process of the HCIM center.

draft

TNMTumorClassification			TNMTumorClassification	Element id TNMTumorClassification Short description TNMTumorClassification Definition Root concept of the TNMTumorClassification information model.This root concept contains all data elements of the TNMTumorClassification information model. Data type TNMTumorClassification Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id TNMTumorClassification.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
PrimaryTumor		0..1	BackboneElement	Element id TNMTumorClassification.PrimaryTumor Short description PrimaryTumor Definition Container of the PrimaryTumor concept.This container contains all data elements of the PrimaryTumor concept. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id TNMTumorClassification.PrimaryTumor.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.PrimaryTumor.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.PrimaryTumor.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
MNumberOfPrimaryTumors		0..1	CodeableConcept	Element id TNMTumorClassification.PrimaryTumor.MNumberOfPrimaryTumors Short description m_NumberOfPrimaryTumors Definition Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TPrimaryTumor		0..1	CodeableConcept	Element id TNMTumorClassification.PrimaryTumor.TPrimaryTumor Short description T_PrimaryTumor Definition Staging result of the size extension of the primary tumor, the T-category of the TNM classification including the prefix and suffix. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
Abnormality		1..*	BackboneElement	Element id TNMTumorClassification.PrimaryTumor.Abnormality Short description Abnormality Definition Container of the Abnormality concept.This container contains all data elements of the Abnormality concept. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id TNMTumorClassification.PrimaryTumor.Abnormality.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.PrimaryTumor.Abnormality.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.PrimaryTumor.Abnormality.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
AbnormalityNumber		0..1	positiveInt	Element id TNMTumorClassification.PrimaryTumor.Abnormality.AbnormalityNumber Short description AbnormalityNumber Definition The number assigned to the abnormality, which is necessary in order to be able to clearly indicate to which abnormality the information relates in various examinations. In the case of multiple primary tumors in one organ, the tumor with the highest T category should be classified. Comments 32 bit number; for values larger than this, use decimal Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Morphology		0..1	CodeableConceptBinding	Element id TNMTumorClassification.PrimaryTumor.Abnormality.Morphology Short description Morphology Definition Behavior of a tumor and cell type expressed in ICD-O-3 morphological or histology code. Describes the cell type (or histology) of the tumor, together with the behavior (malignant or benign). This is determined by a pathologist. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding Morphology codes Morphology (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
GHistopathologicalGrading		0..1	CodeableConcept	Element id TNMTumorClassification.PrimaryTumor.Abnormality.GHistopathologicalGrading Short description G_HistopathologicalGrading Definition Staging result of the histopathological grading, the G-category of theTNM classification. The differentiation grade of a tumor is determined by a pathologist. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TumorLocalization	I	0..*	Reference(HdBe-AnatomicalLocation)	Element id TNMTumorClassification.PrimaryTumor.Abnormality.TumorLocalization Short description TumorLocalization Definition Container of the TumorLocalization concept.This container contains all data elements of the TumorLocalization concept. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(HdBe-AnatomicalLocation) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
RegionalLymphnodes		0..1	BackboneElement	Element id TNMTumorClassification.RegionalLymphnodes Short description RegionalLymphnodes Definition Container of the RegionalLymphnodes concept.This container contains all data elements of the RegionalLymphnodes concept. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id TNMTumorClassification.RegionalLymphnodes.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.RegionalLymphnodes.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.RegionalLymphnodes.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
NRegionalLymphnodes		0..1	CodeableConcept	Element id TNMTumorClassification.RegionalLymphnodes.NRegionalLymphnodes Short description N_RegionalLymphnodes Definition Staging result of the presence or absence of regional lymph nodes metastasis, the N-category of the TNM classification. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
RegionalLymphNodesLocalization	I	0..*	Reference(HdBe-AnatomicalLocation)	Element id TNMTumorClassification.RegionalLymphnodes.RegionalLymphNodesLocalization Short description RegionalLymphNodesLocalization Definition Container of the RegionalLymphNodesLocalization concept.This container contains all data elements of the RegionalLymphNodesLocalization concept. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(HdBe-AnatomicalLocation) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
DistantMetastasis		0..1	BackboneElement	Element id TNMTumorClassification.DistantMetastasis Short description DistantMetastasis Definition Container of the DistantMetastasis concept.This container contains all data elements of the DistantMetastasis concept. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id TNMTumorClassification.DistantMetastasis.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.DistantMetastasis.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id TNMTumorClassification.DistantMetastasis.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
MDistantMetastasis		0..1	CodeableConcept	Element id TNMTumorClassification.DistantMetastasis.MDistantMetastasis Short description M_DistantMetastasis Definition Staging result of the presence or absence of distant metastasis, the M-category of the TNM classification. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
DistantMetastasisLocalization	I	0..*	Reference(HdBe-AnatomicalLocation)	Element id TNMTumorClassification.DistantMetastasis.DistantMetastasisLocalization Short description DistantMetastasisLocalization Definition Container of the DistantMetastasisLocalization concept.This container contains all data elements of the DistantMetastasisLocalization concept. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(HdBe-AnatomicalLocation) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
DateOfTnmclassification		0..1	dateTime	Element id TNMTumorClassification.DateOfTnmclassification Short description DateOfTNMClassification Definition The date at which the TNM Classification (the value) has been assigned. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Tnmversion		0..1	CodeableConceptBinding	Element id TNMTumorClassification.Tnmversion Short description TNMVersion Definition TNM classification version (AJCC or UICC) and edition used (7th, 8th etc.). Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding TNMVersion codes TNMVersion (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
IntegratedTnmvalue		0..1	string	Element id TNMTumorClassification.IntegratedTnmvalue Short description IntegratedTNMValue Definition The assigned TNM classification (the value), based on each T, N and M category (optional incl. multiple primary tumors (m) and/or the localization of M). Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Explanation		0..1	string	Element id TNMTumorClassification.Explanation Short description Explanation Definition Remark regarding interpretation of the integrated TNM value as is classified. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
TlLymphaticInvasion		0..1	CodeableConceptBinding	Element id TNMTumorClassification.TlLymphaticInvasion Short description TL_LymphaticInvasion Definition Presence or absence of tissue invasion absence of lymphatic invasion, the L-category. It concerns an additional description within the TNM classification that is determined by a pathologist. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding TL-LymphaticInvasion codes InfusionCatheterType (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
PnPerineuralInvasion		0..1	CodeableConcept	Element id TNMTumorClassification.PnPerineuralInvasion Short description Pn_PerineuralInvasion Definition Presence or absence of perineural invasion, the Pn-category. It concerns an additional description within the TNM classification that is determined by a pathologist. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
VVenousInvasion		0..1	CodeableConceptBinding	Element id TNMTumorClassification.VVenousInvasion Short description V_VenousInvasion Definition Presence or absence of venous invasion, the V-category. It concerns an additional description within the TNM classification that is determined by a pathologist. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding V-VenousInvasion codes V-VenousInvasion (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
AnatomicalStage		0..1	CodeableConceptBinding	Element id TNMTumorClassification.AnatomicalStage Short description AnatomicalStage Definition The stage of the disease is the grouping based on the anatomical extent of the disease. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding AnatomicalStage codes AnatomicalStage (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
PrognosticStage		0..1	CodeableConceptBinding	Element id TNMTumorClassification.PrognosticStage Short description PrognosticStage Definition The Prognostic Stage group of the disease. Next to the anatomic extent of the disease additional prognostic factors are included in the grouping. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding PrognosticStage codes PrognosticStage (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
RResidualTumor		0..1	CodeableConcept	Element id TNMTumorClassification.RResidualTumor Short description R_ResidualTumor Definition Presence or absence of Residual Tumor after treatment, the R-category. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

TNMTumorClassification		0..*
TNMTumorClassification.PrimaryTumor	BackboneElement	0..1
TNMTumorClassification.PrimaryTumor.MNumberOfPrimaryTumors	CodeableConcept	0..1
TNMTumorClassification.PrimaryTumor.TPrimaryTumor	CodeableConcept	0..1
TNMTumorClassification.PrimaryTumor.Abnormality	BackboneElement	1..*
TNMTumorClassification.PrimaryTumor.Abnormality.AbnormalityNumber	positiveInt	0..1
TNMTumorClassification.PrimaryTumor.Abnormality.Morphology	CodeableConcept	0..1
TNMTumorClassification.PrimaryTumor.Abnormality.GHistopathologicalGrading	CodeableConcept	0..1
TNMTumorClassification.PrimaryTumor.Abnormality.TumorLocalization	Reference(HdBe-AnatomicalLocation)	0..*
TNMTumorClassification.RegionalLymphnodes	BackboneElement	0..1
TNMTumorClassification.RegionalLymphnodes.NRegionalLymphnodes	CodeableConcept	0..1
TNMTumorClassification.RegionalLymphnodes.RegionalLymphNodesLocalization	Reference(HdBe-AnatomicalLocation)	0..*
TNMTumorClassification.DistantMetastasis	BackboneElement	0..1
TNMTumorClassification.DistantMetastasis.MDistantMetastasis	CodeableConcept	0..1
TNMTumorClassification.DistantMetastasis.DistantMetastasisLocalization	Reference(HdBe-AnatomicalLocation)	0..*
TNMTumorClassification.DateOfTnmclassification	dateTime	0..1
TNMTumorClassification.Tnmversion	CodeableConcept	0..1
TNMTumorClassification.IntegratedTnmvalue	string	0..1
TNMTumorClassification.Explanation	string	0..1
TNMTumorClassification.TlLymphaticInvasion	CodeableConcept	0..1
TNMTumorClassification.PnPerineuralInvasion	CodeableConcept	0..1
TNMTumorClassification.VVenousInvasion	CodeableConcept	0..1
TNMTumorClassification.AnatomicalStage	CodeableConcept	0..1
TNMTumorClassification.PrognosticStage	CodeableConcept	0..1
TNMTumorClassification.RResidualTumor	CodeableConcept	0..1

TNMTumorClassification
Definition	Root concept of the TNMTumorClassification information model.This root concept contains all data elements of the TNMTumorClassification information model.
Cardinality	0...*
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0...1
Type	string
Mappings	rim: n/a
TNMTumorClassification.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality	0...*
Type	Extension
Alias	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Slicing	Unordered, Open, by url(Value)
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.PrimaryTumor
Definition	Container of the PrimaryTumor concept.This container contains all data elements of the PrimaryTumor concept.
Cardinality	0...1
Type	BackboneElement
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.PrimaryTumor.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0...1
Type	string
Mappings	rim: n/a
TNMTumorClassification.PrimaryTumor.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality	0...*
Type	Extension
Alias	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Slicing	Unordered, Open, by url(Value)
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.PrimaryTumor.modifierExtension
Definition	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality	0...*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, user content, modifiers
Requirements	Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.PrimaryTumor.MNumberOfPrimaryTumors
Definition	-
Cardinality	0...1
Type	CodeableConcept
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.PrimaryTumor.TPrimaryTumor
Definition	Staging result of the size extension of the primary tumor, the T-category of the TNM classification including the prefix and suffix.
Cardinality	0...1
Type	CodeableConcept
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.PrimaryTumor.Abnormality
Definition	Container of the Abnormality concept.This container contains all data elements of the Abnormality concept.
Cardinality	1...*
Type	BackboneElement
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.PrimaryTumor.Abnormality.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0...1
Type	string
Mappings	rim: n/a
TNMTumorClassification.PrimaryTumor.Abnormality.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality	0...*
Type	Extension
Alias	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Slicing	Unordered, Open, by url(Value)
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.PrimaryTumor.Abnormality.modifierExtension
Definition	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality	0...*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, user content, modifiers
Requirements	Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.PrimaryTumor.Abnormality.AbnormalityNumber
Definition	The number assigned to the abnormality, which is necessary in order to be able to clearly indicate to which abnormality the information relates in various examinations. In the case of multiple primary tumors in one organ, the tumor with the highest T category should be classified.
Cardinality	0...1
Type	positiveInt
Comments	32 bit number; for values larger than this, use decimal
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.PrimaryTumor.Abnormality.Morphology
Definition	Behavior of a tumor and cell type expressed in ICD-O-3 morphological or histology code. Describes the cell type (or histology) of the tumor, together with the behavior (malignant or benign). This is determined by a pathologist.
Cardinality	0...1
Type	CodeableConcept
Binding	Morphology codes Morphology (extensible)
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.PrimaryTumor.Abnormality.GHistopathologicalGrading
Definition	Staging result of the histopathological grading, the G-category of theTNM classification. The differentiation grade of a tumor is determined by a pathologist.
Cardinality	0...1
Type	CodeableConcept
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.PrimaryTumor.Abnormality.TumorLocalization
Definition	Container of the TumorLocalization concept.This container contains all data elements of the TumorLocalization concept.
Cardinality	0...*
Type	Reference(HdBe-AnatomicalLocation)
Comments	References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))`
Mappings	rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
TNMTumorClassification.RegionalLymphnodes
Definition	Container of the RegionalLymphnodes concept.This container contains all data elements of the RegionalLymphnodes concept.
Cardinality	0...1
Type	BackboneElement
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.RegionalLymphnodes.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0...1
Type	string
Mappings	rim: n/a
TNMTumorClassification.RegionalLymphnodes.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality	0...*
Type	Extension
Alias	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Slicing	Unordered, Open, by url(Value)
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.RegionalLymphnodes.modifierExtension
Definition	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality	0...*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, user content, modifiers
Requirements	Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.RegionalLymphnodes.NRegionalLymphnodes
Definition	Staging result of the presence or absence of regional lymph nodes metastasis, the N-category of the TNM classification.
Cardinality	0...1
Type	CodeableConcept
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.RegionalLymphnodes.RegionalLymphNodesLocalization
Definition	Container of the RegionalLymphNodesLocalization concept.This container contains all data elements of the RegionalLymphNodesLocalization concept.
Cardinality	0...*
Type	Reference(HdBe-AnatomicalLocation)
Comments	References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))`
Mappings	rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
TNMTumorClassification.DistantMetastasis
Definition	Container of the DistantMetastasis concept.This container contains all data elements of the DistantMetastasis concept.
Cardinality	0...1
Type	BackboneElement
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.DistantMetastasis.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0...1
Type	string
Mappings	rim: n/a
TNMTumorClassification.DistantMetastasis.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality	0...*
Type	Extension
Alias	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Slicing	Unordered, Open, by url(Value)
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.DistantMetastasis.modifierExtension
Definition	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality	0...*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, user content, modifiers
Requirements	Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()`
Mappings	rim: n/a rim: N/A
TNMTumorClassification.DistantMetastasis.MDistantMetastasis
Definition	Staging result of the presence or absence of distant metastasis, the M-category of the TNM classification.
Cardinality	0...1
Type	CodeableConcept
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.DistantMetastasis.DistantMetastasisLocalization
Definition	Container of the DistantMetastasisLocalization concept.This container contains all data elements of the DistantMetastasisLocalization concept.
Cardinality	0...*
Type	Reference(HdBe-AnatomicalLocation)
Comments	References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))`
Mappings	rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
TNMTumorClassification.DateOfTnmclassification
Definition	The date at which the TNM Classification (the value) has been assigned.
Cardinality	0...1
Type	dateTime
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.Tnmversion
Definition	TNM classification version (AJCC or UICC) and edition used (7th, 8th etc.).
Cardinality	0...1
Type	CodeableConcept
Binding	TNMVersion codes TNMVersion (extensible)
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.IntegratedTnmvalue
Definition	The assigned TNM classification (the value), based on each T, N and M category (optional incl. multiple primary tumors (m) and/or the localization of M).
Cardinality	0...1
Type	string
Comments	Note that FHIR strings SHALL NOT exceed 1MB in size
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.Explanation
Definition	Remark regarding interpretation of the integrated TNM value as is classified.
Cardinality	0...1
Type	string
Comments	Note that FHIR strings SHALL NOT exceed 1MB in size
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a
TNMTumorClassification.TlLymphaticInvasion
Definition	Presence or absence of tissue invasion absence of lymphatic invasion, the L-category. It concerns an additional description within the TNM classification that is determined by a pathologist.
Cardinality	0...1
Type	CodeableConcept
Binding	TL-LymphaticInvasion codes InfusionCatheterType (extensible)
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.PnPerineuralInvasion
Definition	Presence or absence of perineural invasion, the Pn-category. It concerns an additional description within the TNM classification that is determined by a pathologist.
Cardinality	0...1
Type	CodeableConcept
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.VVenousInvasion
Definition	Presence or absence of venous invasion, the V-category. It concerns an additional description within the TNM classification that is determined by a pathologist.
Cardinality	0...1
Type	CodeableConcept
Binding	V-VenousInvasion codes V-VenousInvasion (extensible)
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.AnatomicalStage
Definition	The stage of the disease is the grouping based on the anatomical extent of the disease.
Cardinality	0...1
Type	CodeableConcept
Binding	AnatomicalStage codes AnatomicalStage (extensible)
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.PrognosticStage
Definition	The Prognostic Stage group of the disease. Next to the anatomic extent of the disease additional prognostic factors are included in the grouping.
Cardinality	0...1
Type	CodeableConcept
Binding	PrognosticStage codes PrognosticStage (extensible)
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
TNMTumorClassification.RResidualTumor
Definition	Presence or absence of Residual Tumor after treatment, the R-category.
Cardinality	0...1
Type	CodeableConcept
Comments	Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
Invariants	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Mappings	rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

Example instances

[CBB name]
[Concept name ]	[example value]

// example of NameInformation

## Example instances

| NameInformation      |                   |
|----------------------|-------------------|
| FirstNames | Johanna Petronella Maria   
| Initials | J.P.M. 
| GivenName | Jo 
| NameUsage | Geslachtsnaam partner gevolgd door eigen geslachtsnaam
| LastName.Prefix | van
| LastName.LastName | Putten
| LastNamePartner.PartnerPrefix | van der
| LastNamePartner.PartnerLastName | Giessen
| Titles |

zib [zib name + version](https://zibs.nl/wiki/[zib name + version(release)]) difference

Concept	Category	Description
`[element.path]`	[category of change]	[Description of change]([Reference to ticket/issue/zulip chat using MarkDown link])

Terminology Bindings

Path	Name	Strength	URL
PrimaryTumor.Abnormality.Morphology	Morphology	extensible	https://fhir.healthdata.be/ValueSet/Morphology
Tnmversion	TNMVersion	extensible	https://fhir.healthdata.be/ValueSet/TNMVersion
TlLymphaticInvasion	InfusionCatheterType	extensible	https://fhir.healthdata.be/ValueSet/InfusionCatheterType
VVenousInvasion	V-VenousInvasion	extensible	https://fhir.healthdata.be/ValueSet/V-VenousInvasion
AnatomicalStage	AnatomicalStage	extensible	https://fhir.healthdata.be/ValueSet/AnatomicalStage
PrognosticStage	PrognosticStage	extensible	https://fhir.healthdata.be/ValueSet/PrognosticStage