Surgical margins

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The surgical margins, often simply referred to as margins, are the set of surfaces that were cut by the surgeon in order to remove the specimen from the body. The distance between the tumour and the margin is called the surgical clearance, a term that may be used interchangeably with the term surgical margin.[1] Margins are important as an incompletely removed disease process may lead to re-occurrence.

Most often, positive margins, i.e. surgical margins with disease present or "very close", suck. For example, in locally advanced rectal cancer, in one study,[2] five year survival was found to be 60%, 31% and 0% for R0 (no tumour at the margin), R1 (microscopic tumour at the margin), and R2 (macroscopic tumour at the margin) resections respectively.

What defines a positive surgical margin is dependent on the tumour and its biology.

Types of margins

  • En face.
    • Sample the complete surface.
    • No information about the distance between the margin and lesion can be obtained.
  • On edge, AKA perpendicular margin, as the cut to prepare the tissue for microscopic examination is perpendicular to the cut from the surgeon.
    • Sample a subset of the surface.
    • The distance between the margin and lesion can be measured.

Adequate margin

  • What constitutes an adequate margin is dependent on the tumour type, as different tumours have different behaviours.

Adequate margins by tumour

Tumour Pathologic margin Clinical margin System
Colorectal carcinoma >1 mm[3] 1 cm[4] Gastrointestinal pathology
Vulvar carcinoma 0.8 cm (fixed)[5] 1.0 cm (fresh)[5] Gynecologic pathology
Malignant melanoma same as clinical (interesting is that CAP says "no minimum safe distance established"[6])
  • MIS: 5 mm[7] considered inadequate by some[8]
  • <2 mm invasion: 10 mm[9][10]
  • >2 mm invasion: 20 mm[11]
 Dermatopathology
Ductal carcinoma in situ > 2mm[12]; if < 1 mm patient benefit from radiation[13] Breast pathology
Invasive breast carcinoma cannot be at margin - no concensus[14]
Sarcoma >= 1 cm[15] Sarcoma

See also

References

  1. ↑ Ng, IO.; Luk, IS.; Yuen, ST.; Lau, PW.; Pritchett, CJ.; Ng, M.; Poon, GP.; Ho, J. (Mar 1993). "Surgical lateral clearance in resected rectal carcinomas. A multivariate analysis of clinicopathologic features.". Cancer 71 (6): 1972-6. PMID 8443747.
  2. ↑ Larsen SG, Wiig JN, Dueland S, Giercksky KE (April 2008). "Prognostic factors after preoperative irradiation and surgery for locally advanced rectal cancer". Eur J Surg Oncol 34 (4): 410–7. doi:10.1016/j.ejso.2007.05.012. PMID 17614249.
  3. ↑ Fitzgerald, TL.; Brinkley, J.; Zervos, EE. (Nov 2011). "Pushing the envelope beyond a centimeter in rectal cancer: oncologic implications of close, but negative margins.". J Am Coll Surg 213 (5): 589-95. doi:10.1016/j.jamcollsurg.2011.07.020. PMID 21856181.
  4. ↑ Rutkowski, A.; Bujko, K.; Nowacki, MP.; Chmielik, E.; Nasierowska-Guttmejer, A.; Wojnar, A. (Nov 2008). "Distal bowel surgical margin shorter than 1 cm after preoperative radiation for rectal cancer: is it safe?". Ann Surg Oncol 15 (11): 3124-31. doi:10.1245/s10434-008-0125-6. PMID 18766404.
  5. ↑ 5.0 5.1 Palaia, I.; Bellati, F.; Calcagno, M.; Musella, A.; Perniola, G.; Panici, PB. (Aug 2011). "Invasive vulvar carcinoma and the question of the surgical margin.". Int J Gynaecol Obstet 114 (2): 120-3. doi:10.1016/j.ijgo.2011.02.012. PMID 21669423.
  6. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2012/SkinMelanoma_12protocol.pdf. Accessed on: 19 August 2012.
  7. ↑ Kunishige, JH.; Brodland, DG.; Zitelli, JA. (Mar 2012). "Surgical margins for melanoma in situ.". J Am Acad Dermatol 66 (3): 438-44. doi:10.1016/j.jaad.2011.06.019. PMID 22196979.
  8. ↑ Möller, MG.; Pappas-Politis, E.; Zager, JS.; Santiago, LA.; Yu, D.; Prakash, A.; Kinal, A.; Clark, GS. et al. (Jun 2009). "Surgical management of melanoma-in-situ using a staged marginal and central excision technique.". Ann Surg Oncol 16 (6): 1526-36. doi:10.1245/s10434-008-0239-x. PMID 19050971.
  9. ↑ Cohn-Cedermark, G.; Rutqvist, LE.; Andersson, R.; Breivald, M.; Ingvar, C.; Johansson, H.; Jönsson, PE.; Krysander, L. et al. (Oct 2000). "Long term results of a randomized study by the Swedish Melanoma Study Group on 2-cm versus 5-cm resection margins for patients with cutaneous melanoma with a tumor thickness of 0.8-2.0 mm.". Cancer 89 (7): 1495-501. PMID 11013363.
  10. ↑ Veronesi, U.; Cascinelli, N. (Apr 1991). "Narrow excision (1-cm margin). A safe procedure for thin cutaneous melanoma.". Arch Surg 126 (4): 438-41. PMID 2009058.
  11. ↑ Balch, CM.; Soong, SJ.; Smith, T.; Ross, MI.; Urist, MM.; Karakousis, CP.; Temple, WJ.; Mihm, MC. et al. (Mar 2001). "Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas.". Ann Surg Oncol 8 (2): 101-8. PMID 11258773.
  12. ↑ Dunne, C.; Burke, JP.; Morrow, M.; Kell, MR. (Apr 2009). "Effect of margin status on local recurrence after breast conservation and radiation therapy for ductal carcinoma in situ.". J Clin Oncol 27 (10): 1615-20. doi:10.1200/JCO.2008.17.5182. PMID 19255332.
  13. ↑ Silverstein, MJ.; Lagios, MD.; Groshen, S.; Waisman, JR.; Lewinsky, BS.; Martino, S.; Gamagami, P.; Colburn, WJ. (May 1999). "The influence of margin width on local control of ductal carcinoma in situ of the breast.". N Engl J Med 340 (19): 1455-61. doi:10.1056/NEJM199905133401902. PMID 10320383.
  14. ↑ Singletary, SE. (Nov 2002). "Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy.". Am J Surg 184 (5): 383-93. PMID 12433599.
  15. ↑ Baldini, EH.; Goldberg, J.; Jenner, C.; Manola, JB.; Demetri, GD.; Fletcher, CD.; Singer, S. (Oct 1999). "Long-term outcomes after function-sparing surgery without radiotherapy for soft tissue sarcoma of the extremities and trunk.". J Clin Oncol 17 (10): 3252-9. PMID 10506627.
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