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Macroscopic involvement is gross tumor which is visible to the naked eye. It may However, it must be documented in the operative report or in the gross portion of the pathology report.

The code is hierarchical; if two codes describe the margin status, use the numerically higher code.

Code the margin status for each individual surgical event.

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For an unknown or ill-defined primary (C76.0-C76.8, C80.9) or for hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease (C42.0, C42.1, C42.3, C42.4, or M-9750, 9760-9764, 9800-99820, 9826, 9831-9920, 9931-9964, 9980-9989), code 9.   

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the pathology report

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.

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   

Unknown whether a surgical procedure to the primary site was performed; DCO; for lymphomas with a lymph node primary site; an unknown or ill-defined primary; or for hematopoietic diseases.

Coding Instructions

• 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 7 if the pathology report indicates the margins could not be determined.

• If no surgery of the primary site was performed, code 8.

• Code 9 if the pathology report makes no mention of margins or no tissue was sent to pathology.

• For lymphomas (M-9590-9726, 9728-9732, 9734-9740, 9750-9762, 9811-9831, 9940, 9948 and 9971) with a lymph node primary site (C77.0–C77.9), code 9.

• For an unknown or ill-defined primary site (C76.0–C76.8, C80.9) or for hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease (C42.0, C42.1, C42.3, C42.4, or M-9727, 9733, 9741-9742, 9764-9809, 9832, 9840-9931, 9945-9946, 9950-9967, and 9975-9992), code 9.