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Difference between revisions of "Surgical margins"
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[[Image:Urothelial_carcinoma_positive_margin_-_alt_--_high_mag.jpg|thumb|right|200px|A positive surgical margin ([[ink]] on tumour) in [[urothelial carcinoma]]. [[H&E stain]].]] | |||
[[Image:Positive_margin_with_cautery_artefact_-_adenocarcinoma_-_high_mag.jpg|right|thumb|200px|A positive surgical margin (tumour with [[cautery artifact]]) in [[colorectal carcinoma]]. [[H&E stain]].]] | |||
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''.<ref name=pmid8443747>{{Cite journal | last1 = Ng | first1 = IO. | last2 = Luk | first2 = IS. | last3 = Yuen | first3 = ST. | last4 = Lau | first4 = PW. | last5 = Pritchett | first5 = CJ. | last6 = Ng | first6 = M. | last7 = Poon | first7 = GP. | last8 = Ho | first8 = J. | title = Surgical lateral clearance in resected rectal carcinomas. A multivariate analysis of clinicopathologic features. | journal = Cancer | volume = 71 | issue = 6 | pages = 1972-6 | month = Mar | year = 1993 | doi = | PMID = 8443747 }}</ref> Margins are important as an incompletely removed disease process may lead to re-occurrence. | 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''.<ref name=pmid8443747>{{Cite journal | last1 = Ng | first1 = IO. | last2 = Luk | first2 = IS. | last3 = Yuen | first3 = ST. | last4 = Lau | first4 = PW. | last5 = Pritchett | first5 = CJ. | last6 = Ng | first6 = M. | last7 = Poon | first7 = GP. | last8 = Ho | first8 = J. | title = Surgical lateral clearance in resected rectal carcinomas. A multivariate analysis of clinicopathologic features. | journal = Cancer | volume = 71 | issue = 6 | pages = 1972-6 | month = Mar | year = 1993 | doi = | PMID = 8443747 }}</ref> Margins are important as an incompletely removed disease process may lead to re-occurrence. | ||
What defines a positive surgical margin is dependent on the tumour and its biology; the definitions for a positive margin are often dependent on (1) the anatomical [[site]] of the tumour and (2) the tumour type. | |||
==Significance== | |||
Most often, positive margins, i.e. surgical margins with disease present ''or'' "very close", are non-optimal. For example, in locally advanced [[rectal cancer]], in one study,<ref name=pmid17614249>{{cite journal |author=Larsen SG, Wiig JN, Dueland S, Giercksky KE |title=Prognostic factors after preoperative irradiation and surgery for locally advanced rectal cancer |journal=Eur J Surg Oncol |volume=34 |issue=4 |pages=410–7 |year=2008 |month=April |pmid=17614249 |doi=10.1016/j.ejso.2007.05.012 |url=}}</ref> 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. | |||
==Types of margins== | ==Types of margins== | ||
*''En face'' (formally ''en face margin''). | *''En face'' (formally ''en face margin''). | ||
**Sample the complete surface. | **Sample the complete surface. | ||
**No information about the distance between the margin and lesion can be obtained | **No information about the distance between the margin and lesion can be obtained at microscopy, i.e. from the glass slide. | ||
*''On edge'' (formally ''on edge margin''), [[AKA]] ''perpendicular margin'', as the cut to prepare the tissue for microscopic examination is perpendicular to the cut from the surgeon. | *''On edge'' (formally ''on edge margin''), [[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. | **Sample a subset of the surface. | ||
**The distance between the margin and lesion can be measured | **The distance between the margin and lesion can be measured at microscopy, i.e. on the glass slide. | ||
Note: | |||
*It should ''always'' be clear from the ''[[Principles of grossing|gross description]]'' which type of margin was taken; this is especially important for cases that were not [[submitted in total]]. | |||
==Positive margin definition== | |||
Unfortunately, there is no universal definition for ''positive margin''. | |||
Definitionally, there is agreement that "tumour touching the edge of the specimen" is a ''positive margin''.<ref name=pmid26028131>{{cite journal |authors=Chagpar AB, Killelea BK, Tsangaris TN, Butler M, Stavris K, Li F, Yao X, Bossuyt V, Harigopal M, Lannin DR, Pusztai L, Horowitz NR |title=A Randomized, Controlled Trial of Cavity Shave Margins in Breast Cancer |journal=N Engl J Med |volume=373 |issue=6 |pages=503–10 |date=August 2015 |pmid=26028131 |pmc=5584380 |doi=10.1056/NEJMoa1504473 |url=}}</ref><ref name=pmid16509840/> | |||
It may be useful to differentiate ''pathologic margin [status]'' (tumour touching inked margin) and ''oncologic margin [status]'' (tumour sufficiently clear of margin to not significantly affect the prognosis). Oncologists, surgeons and patients really only care about ''oncologic margin [status]'' for relatively obvious reasons. | |||
Perhaps confusing is that: ''a [pathologically] clear margin'' may be defined as being ''[oncologically] a positive margin'', e.g. tumour ''not'' touching the ink of an inked margin - but less than 1 mm from the ink - may be a "positive margin".<ref name=pmid16509840>{{cite journal |authors=Scopa CD, Aroukatos P, Tsamandas AC, Aletra C |title=Evaluation of margin status in lumpectomy specimens and residual breast carcinoma |journal=Breast J |volume=12 |issue=2 |pages=150–3 |date=2006 |pmid=16509840 |doi=10.1111/j.1075-122X.2006.00223.x |url=}}</ref> | |||
==Adequate margin== | ==Adequate margin== | ||
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|- | |- | ||
| [[Colorectal carcinoma]] | | [[Colorectal carcinoma]] | ||
| > | | >1 mm;<ref name=pmid37722286>{{cite journal |authors=Smith HG, Schlesinger NH, Qvortrup C, Chiranth D, Lundon D, Ben-Yaacov A, Caballero C, Suppan I, Kok JH, Holmberg CJ, Mohan H, Montagna G, Santrac N, Sayyed R, Schrage Y, Sgarbura O, Ceelen W, Lorenzon L, Brandl A |title=Variations in the definition and perceived importance of positive resection margins in patients with colorectal cancer - an EYSAC international survey |journal=Eur J Surg Oncol |volume=49 |issue=11 |pages=107072 |date=November 2023 |pmid=37722286 |doi=10.1016/j.ejso.2023.107072 |url=}}</ref> circumferential margin (esp. in rectal carcinoma) most important<ref name=pmid7915774>{{Cite journal | last1 = Adam | first1 = IJ. | last2 = Mohamdee | first2 = MO. | last3 = Martin | first3 = IG. | last4 = Scott | first4 = N. | last5 = Finan | first5 = PJ. | last6 = Johnston | first6 = D. | last7 = Dixon | first7 = MF. | last8 = Quirke | first8 = P. | title = Role of circumferential margin involvement in the local recurrence of rectal cancer. | journal = Lancet | volume = 344 | issue = 8924 | pages = 707-11 | month = Sep | year = 1994 | doi = | PMID = 7915774 }}</ref> | ||
| 1 cm<ref name=pmid18766404>{{Cite journal | last1 = Rutkowski | first1 = A. | last2 = Bujko | first2 = K. | last3 = Nowacki | first3 = MP. | last4 = Chmielik | first4 = E. | last5 = Nasierowska-Guttmejer | first5 = A. | last6 = Wojnar | first6 = A. | title = Distal bowel surgical margin shorter than 1 cm after preoperative radiation for rectal cancer: is it safe? | journal = Ann Surg Oncol | volume = 15 | issue = 11 | pages = 3124-31 | month = Nov | year = 2008 | doi = 10.1245/s10434-008-0125-6 | PMID = 18766404 }}</ref> | | 1 cm<ref name=pmid18766404>{{Cite journal | last1 = Rutkowski | first1 = A. | last2 = Bujko | first2 = K. | last3 = Nowacki | first3 = MP. | last4 = Chmielik | first4 = E. | last5 = Nasierowska-Guttmejer | first5 = A. | last6 = Wojnar | first6 = A. | title = Distal bowel surgical margin shorter than 1 cm after preoperative radiation for rectal cancer: is it safe? | journal = Ann Surg Oncol | volume = 15 | issue = 11 | pages = 3124-31 | month = Nov | year = 2008 | doi = 10.1245/s10434-008-0125-6 | PMID = 18766404 }}</ref> | ||
| [[Gastrointestinal pathology]] | | [[Gastrointestinal pathology]] | ||
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|- | |- | ||
| [[Ductal carcinoma in situ]] | | [[Ductal carcinoma in situ]] | ||
| | | [[ink]] cannot be on tumour - consensus of Society of Surgical Oncology-American Society for Radiation Oncology (for low stage tumours)<ref name=pmid24521674>{{Cite journal | last1 = Moran | first1 = MS. | last2 = Schnitt | first2 = SJ. | last3 = Giuliano | first3 = AE. | last4 = Harris | first4 = JR. | last5 = Khan | first5 = SA. | last6 = Horton | first6 = J. | last7 = Klimberg | first7 = S. | last8 = Chavez-MacGregor | first8 = M. | last9 = Freedman | first9 = G. | title = Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. | journal = Int J Radiat Oncol Biol Phys | volume = 88 | issue = 3 | pages = 553-64 | month = Mar | year = 2014 | doi = 10.1016/j.ijrobp.2013.11.012 | PMID = 24521674 }}</ref> | ||
| | | | ||
| [[Breast pathology]] | | [[Breast pathology]] | ||
|- | |- | ||
| [[Invasive breast cancer|Invasive breast carcinoma]] | | [[Invasive breast cancer|Invasive breast carcinoma]] | ||
| cannot be | | ink cannot be on tumour - consensus of Society of Surgical Oncology-American Society for Radiation Oncology (for low stage tumours)<ref name=pmid24521674>{{Cite journal | last1 = Moran | first1 = MS. | last2 = Schnitt | first2 = SJ. | last3 = Giuliano | first3 = AE. | last4 = Harris | first4 = JR. | last5 = Khan | first5 = SA. | last6 = Horton | first6 = J. | last7 = Klimberg | first7 = S. | last8 = Chavez-MacGregor | first8 = M. | last9 = Freedman | first9 = G. | title = Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. | journal = Int J Radiat Oncol Biol Phys | volume = 88 | issue = 3 | pages = 553-64 | month = Mar | year = 2014 | doi = 10.1016/j.ijrobp.2013.11.012 | PMID = 24521674 }}</ref> | ||
| | | | ||
| [[Breast pathology]] | | [[Breast pathology]] | ||
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|System --> | |System --> | ||
|} | |} | ||
==Fragmented and incised specimens== | |||
There is limited advice on how to deal with a fragmented or incised specimen. | |||
If the specimen can be "put back together", it is reasonable to assess the margin and comment on the limitation. | |||
The ''College of American Pathologists'' synoptic for invasive breast carcinoma (version 4.3.0.1) states:<ref>URL: [https://documents.cap.org/protocols/cp-breast-invasive-resection-19-4301.pdf https://documents.cap.org/protocols/cp-breast-invasive-resection-19-4301.pdf]. Accessed on: 2022 January 12.</ref> | |||
:''If the specimen is received sectioned or fragmented, this should be noted, as this will limit the ability to evaluate the status of margins.'' | |||
==Microscopic== | |||
Features of the true margin: | |||
*Irregular/non-linear appearance. | |||
DDx: | |||
*Cut at the grossing bench (by the pathologist/pathology assistant/pathology resident) post-[[fixation]] - these are usually straight. | |||
*Artifactal cleft/separation. | |||
Note: | |||
*The surgeon's cut is irregular due to loading during extraction and fixation effects. | |||
===Images=== | |||
<gallery> | |||
Image: Surgeons cut at microscopy - extremely low mag.jpg | True margin - surgeon's cut (left of image) - extremely low mag. (WC) | |||
Image: PAs cut at microscopy - extremely low mag.jpg | Pathology assistant's cut (right of image) - extremely low mag. (WC) | |||
</gallery> | |||
==Sign out== | ==Sign out== | ||
===Stray ink versus true positive=== | ===Stray ink versus true positive=== | ||
====True positive==== | |||
<pre> | <pre> | ||
COMMENT: | COMMENT: | ||
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positive margin; this essentially excludes that what is interpreted as a | positive margin; this essentially excludes that what is interpreted as a | ||
positive margin could represent stray ink. | positive margin could represent stray ink. | ||
</pre> | |||
====Stray ink==== | |||
<pre> | |||
COMMENT: | |||
The margin assessment is suboptimal as the specimen was cut prior to | |||
inking. Ink on tumour in this context may represent stray ink on tumour | |||
or a true positive margin. | |||
Ink is focally present on tumour in this case and it is favoured to | |||
represent stray ink, as the quantity of ink is minimal; however, margin | |||
positivity cannot be completely excluded. | |||
</pre> | |||
===A re-excised (previously) positive margin is negative for tumour=== | |||
It occasionally happens that a re-excised margin specimen is negative for tumour. | |||
<pre> | |||
The lack of tumour in Part B may be explained by either of the following: | |||
(1) There was minimal clearance (<1 mm) in Part A that was not sampled. | |||
(2) The sampling of Part B missed minimal tumour involvement. | |||
</pre> | |||
Note: | |||
*One should review the positive margin call to ensure it isn't an overall. | |||
===Tumour in tip - flipped block=== | |||
<pre> | |||
Lesion, Right Upper Lid, Excision: | |||
- BASAL CELL CARCINOMA, favour clear margin (see comment). | |||
Comment: | |||
Basal cell carcinoma (BCC) is present in the block 3 tip, on the initial cut. The tissue was re-embedded and BCC is seen on the recut. BCC is clear of the inked margin. Thus, the margin is favoured to be clear; however, out-of-plane margin involvement cannot be excluded. | |||
</pre> | |||
===Alternate=== | |||
<pre> | |||
Lesion, Right Lower Eyelid, Excision: | |||
- BASAL CELL CARCINOMA (BCC), cannot exclude positive margin, see comment. | |||
Comment: | |||
BCC was found in block 1 (one of the tips) on the initial cut. | |||
In block 1, BCC is present but distant from the inked margin in the plane | |||
of section. The margin is not completely in the plane of section; thus, | |||
trimming of a negative margin cannot be entirely excluded. As BCC is seen | |||
on both sides of the block, a positive cannot be excluded. | |||
</pre> | </pre> | ||
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*[[Frozen section]]. | *[[Frozen section]]. | ||
*[[Crush artifact]]. | *[[Crush artifact]]. | ||
*[[Marking ink]]. | |||
==References== | ==References== | ||