Cancer treatment—surgical margin status, positive/negative/unknown code N
Data Element Attributes
Identifying and definitional attributes
|Metadata item type:||Data Element|
|Short name:||Surgical margin status|
Health, Standard 14/05/2015
|Definition:||The status of the closest surgical margin from the invasive or in situ carcinoma after surgical treatment for cancer, as represented by a code.|
|Data Element Concept:||Cancer treatment—surgical margin status|
|Value Domain:||Positive/negative/unknown code N|
Value domain attributes
|Maximum character length:||1|
Collection and usage attributes
|Guide for use:|
Surgical margins represent sites that have either been cut or bluntly dissected by the surgeon to resect the specimen.
Record whether the surgical margin to the invasive or in situ carcinoma was positive, negative or unknown as described in the pathology report. Where two or more margins are reported, only the closest should be recorded (ie if any margin is reported positive, positive should be recorded).
Record only for the most definitive surgical procedure performed. For instance, if a surgical procedure to remove a portion of tumour at the primary site is followed by additional surgery to remove the remainder of the tumour at that site, code the distance of the margin for the final surgical procedure.
Record for the primary tumour site only, not for metastatic sites.
Negative (also outlined as clear) should be recorded when no cancer cells are seen at the outer edge of the tissue that was removed. Positive should be recorded when cancer cells come right out to the edge of the removed tissue. Unknown should be recorded when the pathology report does not define the surgical margin.
|Collection methods:||This information should be sought from the patient's pathology report under microscopic findings.|
|Comments:||The distance of the closest margin is useful for surgical audit and for assessing the completeness of surgical resection. Margin involvement may influence treatment decisions and is a prognostic indicator.|
Source and reference attributes
Royal College of Pathologists of Australasia 2010. Lung cancer structured reporting protocol. 1st Edition (Version 1.0). Surry Hills, NSW: Royal College of Pathologists of AustralasiaAmerican College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2011 revision. Commission on Cancer, page 211
|Related metadata references:|
See also Cancer treatment—lung cancer surgical margin qualifier, code N[N]
Health, Standard 08/05/2014
|Implementation in Data Set Specifications:|