VI.2.7 Surgical Margins of the Primary Site

VI.2.7 Surgical Margins of the Primary Site

This field describes the final status of the surgical margins after resection of the primary tumor. It is used in staging, for quality assurance measures, and may be a prognostic factor in recurrence.

Coding Instructions:

Surgical margins are required by the CCR to be coded for all primary sites. This applies to cases diagnosed January 1, 2016 and forward.
Record the margin status as it appears in the pathology report.
Codes 0-3 are hierarchical.

If two codes describe the margin status, use the numerically higher code.

Code 1 for involved margins not otherwise specified.
Code 2 for involved margins seen microscopically but not macroscopically (grossly, with the naked eye).
Code 3 for involved margins seen macroscopically.
Code 7 if the pathology report indicates the margin could not be determined.
Code 8 when no surgery is performed on the primary site.
Code 9 in the following scenarios:

Pathology report makes no mention of the margins.
No tissue was sent to pathology.
For lymphomas/lymphoid neoplasms with a lymph node primary site.
For an unknown or ill-defined primary site.
For Hematopoietic, Reticuloendothelial, Immunoproliferative, or Myeloproliferative diseases.

Codes:

Code	Label	Description
0	No residual tumor	All margins are grossly and microscopically negative.
1	Residual tumor, NOS	Involvement is indicated, but not otherwise specified.
2	Microscopic residual tumor	Cannot be seen by the naked eye.
3	Macroscopic residual tumor	Gross tumor of the primary site which is visible to the naked eye.
7	Margins not evaluable	Cannot be assessed (indeterminate).
8	No primary site surgery	No surgical procedure of the primary site. Diagnosed at autopsy.
9	Unknown or not applicable	It is unknown whether a surgical procedure to the primary site was performed; death certificate-only; for lymphomas with lymph node primary site; an unknown or ill-defined primary; or for Hematopoietic, Reticuloendothelial, Immunoproliferative, or Myeloproliferative disease.

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