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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. | ||
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 surgical margin is dependent on the tumour and its biology. | 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== | ||
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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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| 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> | | 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]] | | [[Genitourinary pathology]] | ||
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==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== | ||