Examples Index

This section provides a complete worked example of NPCR Anmälan reporting through 20 linked FHIR resource instances. Together they trace one fictional patient (Sven Svensson) from primary care referral through diagnosis to pathology report.

The example demonstrates how the profiles in this IG link via FHIR references to form a coherent record of a single Anmälan registration event.

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Patient Scenario

Sven Svensson is a 70-year-old male (born 1953-08-15, personnummer 19530815-1212) living in Karlstad, Sweden. On 2024-03-10, a routine primary care visit found his serum PSA elevated at 18.5 µg/L (P-PSA, NPU08669), prompting his general practitioner to author a referral on 2024-03-15. The referral was received at the urology specialist clinic on 2024-03-22.

At his first specialist visit on 2024-04-08 (KVÅ VJ125, Kvalitetsregisterkod 484), the urologist measured the prostate by transrectal ultrasound (TRUS) at 47 ml and ordered a multiparametric MRI.

The MRI was performed on 2024-04-22 and showed prostate volume 45 ml with a PI-RADS 4 lesion (high likelihood of clinically significant cancer). Extraprostatic extension (EPE) was assessed as Sannolikt (likely, scale 4 of 5), while seminal vesicle invasion (SVI) was assessed as Sannolikt inte (unlikely, scale 2 of 5).

On 2024-05-06, the patient underwent a combined transrectal biopsy under povidone-iodine rectal preparation. Three MR-fusion targeted biopsies (technique: fusion MR/ultraljud) were taken from the PI-RADS 4 lesion, alongside 12 systematic biopsy cores. The diagnosis method was registered as histopathology from needle biopsy (NPCR D_Vavn = 1, KVÅ KEB00).

The pathology report (PAD number P24-12345, Patologi Centralsjukhuset Karlstad) was issued on 2024-05-22 with the following findings:

• Targeted biopsy: 3 cores; longest cancer length 12 mm; the core containing the longest cancer measured 15 mm in total; Gleason 4+3=7 (NPCR convention: highest Gleason in a single biopsy)
• Systematic biopsy: 12 cores, 4 with cancer; total cancer length 22 mm; total biopsy length 160 mm; Gleason 3+3=6

The patient-level Gleason summary was set to 4+3=7, taken from the targeted biopsy. This case illustrates the clinical value of MRI-targeted biopsy: the systematic 12-core sampling alone would have suggested a lower-grade tumor (Gleason 6, grade group 1), but MRI-fusion targeting of the PI-RADS 4 lesion revealed higher-grade cancer (Gleason 7, grade group 3) that determines management decisions. Prostate cancer was confirmed (ICD-10-SE C619, Malign tumör i prostata) and clinically staged as T2 N0 M0 per UICC TNM Edition 8 (NPCR simplified clinical T classification, no T2 sub-stages).

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Timeline

Date	Event
2024-03-10	Primary care: PSA 18.5 µg/L
2024-03-15	General practitioner authors referral
2024-03-22	Specialist clinic receives referral
2024-04-08	First specialist visit (urology); prostate volume 47 ml (TRUS)
2024-04-22	Prostate MRI: PI-RADS 4, EPE Sannolikt, SVI Sannolikt inte, volume 45 ml
2024-05-06	Combined transrectal biopsy (3 targeted + 12 systematic cores)
2024-05-22	Pathology report; Gleason 4+3=7 (targeted) vs 3+3=6 (systematic); summary 4+3=7; T2 N0 M0

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Examples by Clinical Phase

A. Patient

• Patient: Sven Svensson — Demographics with personnummer 19530815-1212

B. Laboratory (pre-referral)

• Observation: S-PSA 18.5 µg/L — Elevated PSA prompting referral (NPU08669, 2024-03-10)

C. Referral and First Specialist Visit

• ServiceRequest: Referral to urology — Authored 2024-03-15, received 2024-03-22 (with NPCR Referral Receipt Date extension)
• Encounter: First specialist visit — 2024-04-08, dual-coded KVÅ VJ125 + Kvalitetsregisterkod 484
• Observation: Prostate volume 47 ml (TRUS) — Ultrasound measurement at first visit (SNOMED CT 249606000)

D. MRI Examination

• Procedure: Prostate MRI — 2024-04-22, multiparametric MRI procedure record
• Observation: MRI findings — 4 components: prostate volume MR 45 ml, PI-RADS 4, EPE Sannolikt (likely), SVI Sannolikt inte (unlikely)

E. Biopsy Procedure

• Procedure: Biopsy — 2024-05-06, transrectal biopsy with all 6 NPCR extensions: pathway (transrektal), povidone-iodine used, targeted technique (fusion), systematic biopsy (Ja), targeted biopsy (Ja), unclear biopsy (Nej)
• Procedure: Diagnosis method — Dual-coded NPCR tissue source (D_Vavn = 1, mellannålsbiopsi prostata) + KVÅ KEB00

F. Pathology Results

• Observation: Targeted biopsy results — 3 cores; longest cancer 12 mm; total biopsy of longest core 15 mm
• Observation: Systematic biopsy results — 12 cores, 4 with cancer; total cancer 22 mm; total biopsy length 160 mm
• Observation: Gleason from targeted biopsy — 4+3=7, grade group 3 (highest in single biopsy convention, with NPCR Gleason Definition Type extension)
• Observation: Gleason from systematic biopsy — 3+3=6, grade group 1
• Observation: Gleason summary (patient-level) — 4+3=7, derived from targeted (4+3=7) and systematic (3+3=6); higher grade taken

G. Diagnosis and Clinical Staging

• Condition: Prostate cancer — ICD-10-SE C619, confirmed, onset 2024-05-22
• Observation: T-stage T2 — Local tumor stage (NPCR simplified TNM 8, no T2 sub-stages)
• Observation: N-stage N0 — No regional lymph node metastasis
• Observation: M-stage M0 — No distant metastasis

H. Pathology Report

• Organization: Pathology lab — Patologi, Centralsjukhuset Karlstad
• DiagnosticReport: Pathology synoptic report — PAD P24-12345 aggregating biopsy results and Gleason scores

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Reference Graph

The 20 examples form a connected reference graph:

• Patient is referenced by all clinical resources via subject
• ServiceRequest links Encounter to the originating referral via basedOn
• Condition is referenced by T-Stage, N-Stage, M-Stage observations via focus
• Gleason summary uses derivedFrom to reference targeted and systematic Gleason observations
• Pathology DiagnosticReport uses result to aggregate 5 biopsy-derived observations and performer to reference the pathology Organization

This pattern demonstrates how NPCR Anmälan data, decomposed into discrete FHIR resources, can be reassembled into a clinically coherent registration record via standard FHIR references.

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Profile Coverage

These 20 examples exercise 19 of the 24 profiles in this IG. The 5 profiles not exercised (NPCRCauseOfDeathObservation, NPCRWHOGradeObservation, NPCRGleasonScoreUnclearBiopsyObservation, NPCRGleasonScoreTURPCystoObservation, NPCRBiopsyResultsUnclearBiopsyObservation) are clinically inapplicable to this patient scenario:

• CauseOfDeath: patient is alive
• WHO grade: only used for cytological diagnoses (Sven had histological)
• Unclear biopsy / TUR-P-Cysto Gleason: PAD distinguishes targeted from systematic; no TUR-P performed
• Unclear biopsy results: same as above

Future iterations may add example sets for additional clinical scenarios (deceased patient, cytological diagnosis, TUR-P incidental finding) to exercise these profiles.