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. 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", are non-optimal. For example, in locally advanced rectal cancer, in one study, 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; definitions of positive margin are dependent on the anatomical site.
Types of margins
- En face (formally en face margin).
- Sample the complete surface.
- 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.
- Sample a subset of the surface.
- The distance between the margin and lesion can be measured at microscopy, i.e. on the glass slide.
- What constitutes an adequate margin is dependent on the tumour type, as different tumours have different behaviours.
Adequate margins by tumour
|Tumour||Adequate pathologic margin||Adequate clinical margin||System|
|Colorectal carcinoma||>=1 mm; circumferential margin (esp. in rectal carcinoma) most important||1 cm||Gastrointestinal pathology|
|Vulvar carcinoma||0.8 cm (fixed)||1.0 cm (fresh)||Gynecologic pathology|
|Malignant melanoma||same as clinical (interesting is that CAP says "no minimum safe distance established")||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)||Breast pathology|
|Invasive breast carcinoma||ink cannot be on tumour - consensus of Society of Surgical Oncology-American Society for Radiation Oncology (for low stage tumours)||Breast pathology|
|Sarcoma||>= 1 cm||Sarcoma|
|Prostate carcinoma||tumour not touching ink - "close" margins have a higher biochemical recurrence||Genitourinary pathology|
|Renal cell carcinoma||tumour not touching ink; positive margins get clinical follow-up as recurrences are uncommon||Genitourinary pathology|
|Squamous cell carcinoma of the skin||4 mm, 6 mm for high risk||Dermatopathology|
|Urothelial carcinoma||tumour not touching ink||Genitourinary pathology|
Stray ink versus true positive
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.
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.
A re-excised (previously) positive margin is negative for tumour
It occasionally happens that a re-excised margin specimen is negative for tumour.
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.
- One should review the positive margin call to ensure it isn't an overall.
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