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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 | [[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. | |||
Most often, positive margins, i.e. surgical margins with disease present ''or'' "very close", | 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. | ||
What defines a positive margin | What defines a positive surgical margin is dependent on the tumour and its biology; definitions of positive margin are dependent on the anatomical [[site]]. | ||
==Types of margins== | ==Types of margins== | ||
*''En face''. | *''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'', [[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]]. | |||
==Adequate margin== | ==Adequate margin== | ||
*What constitutes an adequate margin is dependent on the tumour type, as different tumours have different behaviours. | *What constitutes an adequate margin is dependent on the tumour type, as different tumours have different behaviours. | ||
===Adequate margins by tumour=== | |||
{| class="wikitable sortable" | |||
!Tumour | |||
!Adequate pathologic margin | |||
!Adequate clinical margin | |||
!System | |||
|- | |||
| [[Colorectal carcinoma]] | |||
| >=1 mm;<ref name=pmid12077094>{{Cite journal | last1 = Petersen | first1 = VC. | last2 = Baxter | first2 = KJ. | last3 = Love | first3 = SB. | last4 = Shepherd | first4 = NA. | title = Identification of objective pathological prognostic determinants and models of prognosis in Dukes' B colon cancer. | journal = Gut | volume = 51 | issue = 1 | pages = 65-9 | month = Jul | year = 2002 | doi = | PMC = 1773289 | PMID = 12077094 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1773289/ }}</ref><ref>{{Cite journal | last1 = Fitzgerald | first1 = TL. | last2 = Brinkley | first2 = J. | last3 = Zervos | first3 = EE. | title = Pushing the envelope beyond a centimeter in rectal cancer: oncologic implications of close, but negative margins. | journal = J Am Coll Surg | volume = 213 | issue = 5 | pages = 589-95 | month = Nov | year = 2011 | doi = 10.1016/j.jamcollsurg.2011.07.020 | PMID = 21856181 }}</ref><ref name=pmid2430152>{{Cite journal | last1 = Quirke | first1 = P. | last2 = Durdey | first2 = P. | last3 = Dixon | first3 = MF. | last4 = Williams | first4 = NS. | title = Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. | journal = Lancet | volume = 2 | issue = 8514 | pages = 996-9 | month = Nov | year = 1986 | doi = | PMID = 2430152 }}</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> | |||
| [[Gastrointestinal pathology]] | |||
|- | |||
|[[Vulvar carcinoma]] | |||
| 0.8 cm (fixed)<ref name=pmid21669423/> | |||
| 1.0 cm (fresh)<ref name=pmid21669423>{{Cite journal | last1 = Palaia | first1 = I. | last2 = Bellati | first2 = F. | last3 = Calcagno | first3 = M. | last4 = Musella | first4 = A. | last5 = Perniola | first5 = G. | last6 = Panici | first6 = PB. | title = Invasive vulvar carcinoma and the question of the surgical margin. | journal = Int J Gynaecol Obstet | volume = 114 | issue = 2 | pages = 120-3 | month = Aug | year = 2011 | doi = 10.1016/j.ijgo.2011.02.012 | PMID = 21669423 }}</ref> | |||
| [[Gynecologic pathology]] | |||
|- | |||
|[[Malignant melanoma]] | |||
| same as clinical (interesting is that CAP says "no minimum safe distance established"<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2012/SkinMelanoma_12protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2012/SkinMelanoma_12protocol.pdf]. Accessed on: 19 August 2012.</ref>) | |||
| | |||
*[[MIS]]: 5 mm<ref name=pmid22196979>{{Cite journal | last1 = Kunishige | first1 = JH. | last2 = Brodland | first2 = DG. | last3 = Zitelli | first3 = JA. | title = Surgical margins for melanoma in situ. | journal = J Am Acad Dermatol | volume = 66 | issue = 3 | pages = 438-44 | month = Mar | year = 2012 | doi = 10.1016/j.jaad.2011.06.019 | PMID = 22196979 }}</ref> considered inadequate by some<ref name=pmid19050971>{{Cite journal | last1 = Möller | first1 = MG. | last2 = Pappas-Politis | first2 = E. | last3 = Zager | first3 = JS. | last4 = Santiago | first4 = LA. | last5 = Yu | first5 = D. | last6 = Prakash | first6 = A. | last7 = Kinal | first7 = A. | last8 = Clark | first8 = GS. | last9 = Zhu | first9 = W. | title = Surgical management of melanoma-in-situ using a staged marginal and central excision technique. | journal = Ann Surg Oncol | volume = 16 | issue = 6 | pages = 1526-36 | month = Jun | year = 2009 | doi = 10.1245/s10434-008-0239-x | PMID = 19050971 }}</ref> | |||
*<2 mm invasion: 10 mm<ref name=pmid11013363>{{Cite journal | last1 = Cohn-Cedermark | first1 = G. | last2 = Rutqvist | first2 = LE. | last3 = Andersson | first3 = R. | last4 = Breivald | first4 = M. | last5 = Ingvar | first5 = C. | last6 = Johansson | first6 = H. | last7 = Jönsson | first7 = PE. | last8 = Krysander | first8 = L. | last9 = Lindholm | first9 = C. | title = 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. | journal = Cancer | volume = 89 | issue = 7 | pages = 1495-501 | month = Oct | year = 2000 | doi = | PMID = 11013363 }}</ref><ref name=pmid2009058>{{Cite journal | last1 = Veronesi | first1 = U. | last2 = Cascinelli | first2 = N. | title = Narrow excision (1-cm margin). A safe procedure for thin cutaneous melanoma. | journal = Arch Surg | volume = 126 | issue = 4 | pages = 438-41 | month = Apr | year = 1991 | doi = | PMID = 2009058 }}</ref> | |||
*>=2 mm invasion: 20 mm<ref name=pmid11258773>{{Cite journal | last1 = Balch | first1 = CM. | last2 = Soong | first2 = SJ. | last3 = Smith | first3 = T. | last4 = Ross | first4 = MI. | last5 = Urist | first5 = MM. | last6 = Karakousis | first6 = CP. | last7 = Temple | first7 = WJ. | last8 = Mihm | first8 = MC. | last9 = Barnhill | first9 = RL. | title = Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas. | journal = Ann Surg Oncol | volume = 8 | issue = 2 | pages = 101-8 | month = Mar | year = 2001 | doi = | PMID = 11258773 }}</ref> | |||
| [[Dermatopathology]] | |||
|- | |||
| [[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]] | |||
|- | |||
| [[Invasive breast cancer|Invasive breast carcinoma]] | |||
| 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]] | |||
|- | |||
| [[Sarcoma]] | |||
| >= 1 cm<ref name=pmid10506627>{{Cite journal | last1 = Baldini | first1 = EH. | last2 = Goldberg | first2 = J. | last3 = Jenner | first3 = C. | last4 = Manola | first4 = JB. | last5 = Demetri | first5 = GD. | last6 = Fletcher | first6 = CD. | last7 = Singer | first7 = S. | title = Long-term outcomes after function-sparing surgery without radiotherapy for soft tissue sarcoma of the extremities and trunk. | journal = J Clin Oncol | volume = 17 | issue = 10 | pages = 3252-9 | month = Oct | year = 1999 | doi = | PMID = 10506627 }}</ref> | |||
| | |||
| [[Sarcoma]] | |||
|- | |||
| [[Prostate carcinoma]] | |||
| tumour not touching ink - "close" margins have a higher biochemical recurrence<ref name=pmid22578729>{{Cite journal | last1 = Lu | first1 = J. | last2 = Wirth | first2 = GJ. | last3 = Wu | first3 = S. | last4 = Chen | first4 = J. | last5 = Dahl | first5 = DM. | last6 = Olumi | first6 = AF. | last7 = Young | first7 = RH. | last8 = McDougal | first8 = WS. | last9 = Wu | first9 = CL. | title = A close surgical margin after radical prostatectomy is an independent predictor of recurrence. | journal = J Urol | volume = 188 | issue = 1 | pages = 91-7 | month = Jul | year = 2012 | doi = 10.1016/j.juro.2012.02.2565 | PMID = 22578729 }}</ref> | |||
| | |||
| [[Genitourinary pathology]] | |||
|- | |||
| [[Renal cell carcinoma]] | |||
| tumour not touching ink; positive margins get clinical follow-up as recurrences are uncommon<ref name=pmid22136987>{{Cite journal | last1 = Marszalek | first1 = M. | last2 = Carini | first2 = M. | last3 = Chlosta | first3 = P. | last4 = Jeschke | first4 = K. | last5 = Kirkali | first5 = Z. | last6 = Knüchel | first6 = R. | last7 = Madersbacher | first7 = S. | last8 = Patard | first8 = JJ. | last9 = Van Poppel | first9 = H. | title = Positive surgical margins after nephron-sparing surgery. | journal = Eur Urol | volume = 61 | issue = 4 | pages = 757-63 | month = Apr | year = 2012 | doi = 10.1016/j.eururo.2011.11.028 | PMID = 22136987 }}</ref> | |||
| | |||
| [[Genitourinary pathology]] | |||
|- | |||
| [[Squamous cell carcinoma of the skin]] | |||
| | |||
| 4 mm, 6 mm for high risk<ref name=pmid1430364>{{Cite journal | last1 = Brodland | first1 = DG. | last2 = Zitelli | first2 = JA. | title = Surgical margins for excision of primary cutaneous squamous cell carcinoma. | journal = J Am Acad Dermatol | volume = 27 | issue = 2 Pt 1 | pages = 241-8 | month = Aug | year = 1992 | doi = | PMID = 1430364 }}</ref> | |||
| [[Dermatopathology]] | |||
|- | |||
| [[Urothelial carcinoma]] | |||
| tumour not touching ink<ref name=pmid17936804>{{Cite journal | last1 = Dotan | first1 = ZA. | last2 = Kavanagh | first2 = K. | last3 = Yossepowitch | first3 = O. | last4 = Kaag | first4 = M. | last5 = Olgac | first5 = S. | last6 = Donat | first6 = M. | last7 = Herr | first7 = HW. | title = Positive surgical margins in soft tissue following radical cystectomy for bladder cancer and cancer specific survival. | journal = J Urol | volume = 178 | issue = 6 | pages = 2308-12; discussion 2313 | month = Dec | year = 2007 | doi = 10.1016/j.juro.2007.08.023 | PMID = 17936804 }}</ref> | |||
| | |||
| [[Genitourinary pathology]] | |||
|- <!-- | |||
|Tumour | |||
|Pathologic margin | |||
|Clinical margin | |||
|System --> | |||
|} | |||
==Sign out== | |||
===Stray ink versus true positive=== | |||
====True positive==== | |||
<pre> | |||
COMMENT: | |||
Ink is seen very focally on a fragment of tumour in A21-1. Inspection of | |||
the tissue block shows ink on the surface of the tissue fragment with the | |||
positive margin; this essentially excludes that what is interpreted as a | |||
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 Lower Eyelid, Excision: | |||
- BASAL CELL CARCINOMA (BCC), favour 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 margin is favoured. | |||
</pre> | |||
==See also== | ==See also== | ||
*[[Basics]]. | *[[Basics]]. | ||
*[[Frozen section]]. | *[[Frozen section]]. | ||
*[[Crush artifact]]. | |||
*[[Marking ink]]. | |||
==References== | ==References== | ||