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Difference between revisions of "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''.<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. | 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== | ||
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Note: | 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]]. | *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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|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== | ||
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===Tumour in tip - flipped block=== | ===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> | <pre> | ||
Lesion, Right Lower Eyelid, Excision: | Lesion, Right Lower Eyelid, Excision: | ||
- BASAL CELL CARCINOMA (BCC), | - BASAL CELL CARCINOMA (BCC), cannot exclude positive margin, see comment. | ||
Comment: | Comment: | ||
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of section. The margin is not completely in the plane of section; thus, | 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 | trimming of a negative margin cannot be entirely excluded. As BCC is seen | ||
on both sides of the block, a positive | on both sides of the block, a positive cannot be excluded. | ||
</pre> | </pre> | ||