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Forex margin vs free margin of the posterior

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In contrast to several earlier studies, our data indicate that the technique is associated with a relatively low false negative rate of 8. In other words, if a margin is deemed grossly negative, it is likely to also be microscopically negative. We therefore believe the technique is clinically useful, and can spare patients future additional surgery to achieve clear margins.

In order to optimize cosmesis, breast surgeons are usually interested in removing the minimal amount of tissue required to achieve clear margins. It would therefore be useful to establish a gross margin distance at which re-excision can be confidently avoided. At our institution, there is no agreed upon standard, and the decision to re-excise is left to the judgement of the individual surgeon. Other institutions do appear to implement a universal standard—e.

As seen in Fig. These data suggest that if the gross margin distance is at least 4 mm, re-excision can be avoided in order to optimize cosmesis without risking positive margins. Are there any clinicopathologic variables that affect the accuracy of gross intraoperative assessment? In particular, are there any variables collected pre-operatively which could guide the surgeon when requesting gross assessment?

In our multivariate logistic regression model Table 2 only multifocality on final pathology was associated with a false negative intraoperative assessment. Somewhat surprisingly, no other tumor characteristics had a significant effect on the performance of gross assessment e. We did not incorporate pre-operative imaging features into our model; intuitively, such features may affect the results of gross assessment, and would be interesting to explore in a future study.

In our practice, pathologists perform the gross exam and communicate the results to the surgeon. This appears to be a relatively common practice per the CAP survey cited above However, the surgeon could perform the procedure themselves, or could examine the specimen in conjunction with the pathologist, as was done in the Balch study Previous studies examining the accuracy of gross intraoperative margin assessment have shown varying results.

For example, a study by Balch et al. The authors concluded that the technique was not sufficiently accurate, and that other methods were needed. In the study by Fleming et al. The technique reduced the rate of future re-operation from The authors concluded that the technique was effective.

A study by Uecker et al. The publication of the consensus guidelines appears to have markedly decreased the rate of re-excision for positive margins 27 , 28 , 29 , 30 , and has thereby somewhat decreased the necessity of an intraoperative margin assessment technique. Given the high cost in terms of patient distress, potential morbidity, cosmesis, and financial burden, we still believe a rapid and accurate intraoperative tool for margin analysis is needed. Besides the well-established pathology-assisted intraoperative methods discussed above, various radiographic and surgical tools and techniques have been shown to reduce positive margins These include pre-operative localization of the lesion via wires or newer localization devices, as well as intraoperative ultrasound.

In a randomized clinical trial by Chagpar et al. Several novel techniques have been proposed for margin assessment, including Raman spectroscopy 34 , 35 , optical coherence tomography 36 , 37 , and confocal and multiphoton microscopy 38 , The MarginProbe Dune Medical Devices, Alpharetta, GA is a commercially available spectroscopy-based device that has been shown to reduce positive margin rates 40 , 41 , The Lumicell Lumicell, Inc.

Since our data was collected after the adoption of the SSO-ASTRO margin consensus guidelines, we believe our results are more generalizable than previous studies. However, we have not controlled for institution-specific surgical or pathology-related practices e. In addition, while our cohort of patients is one of the largest amongst the existing studies, a significantly larger cohort perhaps from multiple institutions would be ideal for bolstering our conclusions.

In our cohort of patients, 27 8. The technique was associated with a false negative rate of 8. Our data suggest that for gross margin distances of at least 4 mm, re-excision can safely be avoided in order to optimize cosmesis. To our knowledge, this is the only study of the gross intraoperative technique performed since , and thus contributes substantially to the relatively scant existing literature.

We anticipate and encourage the establishment of more evidence-based best practice guidelines for BCS, including pathologic assessment, in order to alleviate the persistent problem of positive margins and create more uniform care. Ultimately some of the novel techniques outlined above may play a role. We retrospectively identified all patients at our institution who underwent breast conserving surgery for a preoperative diagnosis of invasive carcinoma with or without accompanying in situ carcinoma , and for whom a gross intraoperative examination was requested at the time of surgery.

Excisions performed only for ductal carcinoma in situ DCIS were excluded, since margin guidelines differ for DCIS 46 and intraoperative assessment is not routinely requested at our institution for these specimens. Specimens from patients underwent gross intraoperative evaluation during the study period. These specimens were excluded from the analysis. There were 55 patients who had received neoadjuvant chemotherapy NAC prior to gross examination. Surgeons at our institution less commonly request gross examination for NAC-treated cases since the treated tumor mass can be difficult to grossly identify in cases with a complete or near-complete pathologic response.

Additionally, NAC-treated patients are likely to differ from non-NAC patients in terms of clinico-pathologic characteristics. These 55 patients were therefore excluded from the main analysis in an effort to achieve a more homogenous cohort. The clinico-pathologic features of these 55 patients are separately presented in Table S1. The final cohort comprised patients. Use of intraoperative ultrasonography is surgeon-dependent and is generally used selectively.

Sentinel lymph node biopsy is performed in the clinically negative axilla, and frozen sections of sentinel lymph nodes are not performed in the setting of breast conserving surgery. Many patients with clinically positive axillary nodes receive neoadjuvant systemic therapy. Per our standard workflow, specimen radiographs with two views were obtained and interpreted by the breast surgeon and a radiologist.

They are correlated with the gross intraoperative examination findings, but the latter method is generally used to assess margin status since it is assumed to be more sensitive. Occasionally, surgeons will excise additional tissue based only on the specimen radiograph findings e. However, radiographic margin assessment is not routinely performed. Gross examination was carried out as follows Fig. The pathologist was ultimately responsible for determining the closest gross margin, which was communicated to the surgeon via telephone and was also documented via a written diagnosis.

The written diagnosis was incorporated into the final pathology report. Although the exact wording of the intraoperative diagnosis was left to the discretion of the individual pathologist, in practice nearly all the diagnoses included an estimated measurement in millimeters, as well as an indication of which specific margin appeared closest e. For 23 specimens in our cohort, a distance to the closest margin was not recorded by the pathologist e.

The decision to re-excise, and the amount of tissue to remove during the re-excision, was left to the discretion of the surgeon. Gross intraoperative assessment workflow with example specimen. A Radiograph of a freshly excised breast lumpectomy specimen. B Excised specimen with orienting sutures and a localization wire. Dye from the sentinel node localization procedure is present. C The specimen has been inked in six colors to designate the surgical margins inferior, superior, anterior, posterior, medial, lateral.

D Representative serial sections. A centrally located tumor is visible as a vaguely defined area of whitish discoloration. E A close-up with the region of tumor annotated black circle , as well as the grossly identified closest margin red ruler. In this case the green-inked inferior margin was closest, and grossly measured 1 mm to the tumor. F Microscopic pathology showing invasive ductal carcinoma. The microscopic distance to the inferior margin was 1 mm red ruler. Gross intraoperative assessment prompted immediate re-excision of this margin, and the re-excised margin was negative for carcinoma.

The diagnosis rendered during gross assessment was compared with the final microscopic pathologic diagnosis for concordance, which was considered the gold standard. Otherwise, the gross diagnosis was considered negative. For all final pathology reports, preliminary margins for the initially excised specimen and final margins including any additionally excised tissue were reported.

A patient was deemed to have been successfully converted from positive to negative margin status if the preliminary margin was positive, but the final margins were negative after additional tissue was excised due to gross examination findings. Test performance metrics were computed to summarize the overall performance of the gross intraoperative assessment technique, and the following clinicopathologic variables were retrieved for each specimen: tumor histologic type, grade, stage, presence of lymphovascular invasion, tumor focality, receipt of neoadjuvant therapy, and biomarker status ER, PR, and HER2.

Tumor focality was based on the final pathologic assessment as defined in the American Joint Committee on Cancer AJCC staging manual, 8th edition 48 , and not a gross assessment of focality. Table 3 displays the clinicopathologic variables for our patient cohort. Multivariate logistic regression models were used to examine the impact of clinicopathologic covariates on discordance. All statistics were performed using the R software package The study was approved by the City of Hope institutional review board, and a waiver of informed consent was obtained IRB All methods were carried out in accordance with relevant guidelines and regulations.

Veronesi, U. Breast conservation is the treatment of choice in small breast cancer: Long-term results of a randomized trial. Cancer Clin. Breast conservation is a safe method in patients with small cancer of the breast. Long-term results of three randomised trials on 1, patients. Cancer 31 , — Article Google Scholar. Jacobson, J. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer.

Poggi, M. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: The National Cancer Institute randomized trial. Cancer 98 , — Article PubMed Google Scholar. Houssami, N. Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy.

Cancer 46 , — Schnitt, S. The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy. Cancer 74 , — Park, C. Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: Influence of margin status and systemic therapy on local recurrence. Abe, S. Margin re-excision and local recurrence in invasive breast cancer: A cost analysis using a decision tree model.

Lester, S. Protocol for the examination of specimens from patients with invasive carcinoma of the breast. Fleming, F. Intraoperative margin assessment and re-excision rate in breast conserving surgery. EJSO 30 , — Balch, G. Accuracy of intraoperative gross examination of surgical margin status in women undergoing partial mastectomy for breast malignancy. Uecker, J. Intraoperative assessment of breast cancer specimens decreases cost and number of reoperations.

Olson, T. Frozen section analysis for intraoperative margin assessment during breast-conserving surgery results in low rates of re-excision and local recurrence. Esbona, K. Intraoperative imprint cytology and frozen section pathology for margin assessment in breast conservation surgery: A systematic review. Osako, T. Efficacy of intraoperative entire-circumferential frozen section analysis of lumpectomy margins during breast-conserving surgery for breast cancer.

Jorns, J. Intraoperative frozen section analysis of margins in breast conserving surgery significantly decreases reoperative rates: One-year experience at an ambulatory surgical center. Weber, W. Accuracy of frozen section analysis versus specimen radiography during breast-conserving surgery for nonpalpable lesions.

World J. Cox, C. Touch preparation cytology of breast lumpectomy margins with histologic correlation. Muttalib, M. Intra-operative assessment of excision margins using breast imprint and scrape cytology. The Breast 14 , 42—50 Bakhshandeh, M.

Use of imprint cytology for assessment of surgical margins in lumpectomy specimens of breast cancer patients. Valdes, E. Intra-operative touch preparation cytology; does it have a role in re-excision lumpectomy?. Landercasper, J. Toolbox to reduce lumpectomy reoperations and improve cosmetic outcome in breast cancer patients: The American Society of breast surgeons consensus conference. Guidi, A.

Breast specimen processing and reporting with an emphasis on margin evaluation: A College of American Pathologists survey of laboratories. McCahill, L. King, T. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy. Smith, B. Paravati, A. Luryi, A. Positive surgical margins in early stage oral cavity cancer: an analysis of 20, cases. Binahmed, A. The clinical significance of the positive surgical margin in oral cancer.

Chen, T. The clinical significance of pathological findings in surgically resected margins of the primary tumor in head and neck carcinoma. Jacobs, J. Implications of positive surgical margins. Jones, A. Prognosis in mouth cancer: tumour factors. Sutton, D. The prognostic implications of the surgical margin in oral squamous cell carcinoma.

Acevedo, J. Divrik, R. Impact of routine second transurethral resection on the long-term outcome of patients with newly diagnosed pT1 urothelial carcinoma with respect to recurrence, progression rate, and disease-specific survival: a prospective randomised clinical trial. Hellenthal, N. Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

Dotan, Z. Positive surgical margins in soft tissue following radical cystectomy for bladder cancer and cancer specific survival. Stevenson, S. Cost-effectiveness of neoadjuvant chemotherapy before radical cystectomy for muscle-invasive bladder cancer. Kanters, A. Colorectal cancer: Quality of surgical care in Michigan. Chu, Q. Peeters, K. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma.

Lin, H. Circumferential margin plays an independent impact on the outcome of rectal cancer patients receiving curative total mesorectal excision. Sasikumar, A. PubMed Google Scholar. Schrag, D. The price tag on progress—chemotherapy for colorectal cancer. Borghesi, M. Positive surgical margins after nephron-sparing surgery for renal cell carcinoma: incidence, clinical impact, and management.

Marszalek, M. Positive surgical margins after nephron-sparing surgery. Lee, D. Renal function and oncologic outcomes in nephron sparing surgery for renal masses in solitary kidneys. Raz, O. Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron sparing surgery. Khalifeh, A. Positive surgical margins in robot-assisted partial nephrectomy: a multi-institutional analysis of oncologic outcomes leave no tumor behind.

Little, A. Patterns of surgical care of lung cancer patients. Osarogiagbon, R. Thomas, A. Improving lung cancer outcomes by improving the quality of surgical care. Uramoto, H. Pfannschmidt, J. Prognostic assessment after surgical resection for non-small cell lung cancer: experiences in patients.

Arriagada, R. Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung cancer. Riquet, M. Microscopic residual disease after resection for lung cancer: a multifaceted but poor factor of prognosis. Wind, J. Residual disease at the bronchial stump after curative resection for lung cancer. Predina, J. Clinical implications of positive margins following non-small cell lung cancer surgery.

Orbay, H. Intraoperative targeted optical imaging: a guide towards tumor-free margins in cancer surgery. Curr Pharm Biotechnol 14 , — Bu, L. Fluorescent imaging of cancerous tissues for targeted surgery. Woo, T. Wang, L. Rahbari, R. Thyroid cancer gender disparity. Hartl, D.

Resection margins and prognosis in locally invasive thyroid cancer. Bilimoria, K. Extent of surgery affects survival for papillary thyroid cancer. Adam, M. Extent of surgery for papillary thyroid cancer is not associated with survival: an analysis of 61, patients.

Hong, C. Prognostic implications of microscopic involvement of surgical resection margin in patients with differentiated papillary thyroid cancer after high-dose radioactive iodine ablation. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Andersen, P. Differentiated carcinoma of the thyroid with extrathyroidal extension. Am J Surg , — Shah, J.

Lobectomy versus total thyroidectomy for differentiated carcinoma of the thyroid: a matched-pair analysis. Sipos, J. Thyroid cancer epidemiology and prognostic variables. Marino, M. Cookson, M. Margin control in open radical prostatectomy: what are the real outcomes? Silberstein, J. Significance and management of positive surgical margins at the time of radical prostatectomy. Yossepowitch, O. Positive surgical margins after radical prostatectomy: a systematic review and contemporary update.

Preston, M. The association between nerve sparing and a positive surgical margin during radical prostatectomy. Google Scholar. Novara, G. Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy. Wright, J. Positive surgical margins at radical prostatectomy predict prostate cancer specific mortality. Mauermann, J. The impact of solitary and multiple positive surgical margins on hard clinical end points in adjuvant treatment-naive pT N0 radical prostatectomy patients.

Retel, V. Determinants and effects of positive surgical margins after prostatectomy on prostate cancer mortality: a population-based study. Jacobs, B. Growth of high-cost intensity-modulated radiotherapy for prostate cancer raises concerns about overuse. Schorge, J. Surgical debulking of ovarian cancer: what difference does it make?

Rev Obstet Gynecol 3 , — Bristow, R. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. Hoskins, W. The effect of diameter of largest residual disease on survival after primary cytoreductive surgery in patients with suboptimal residual epithelial ovarian carcinoma. Am J Obstet Gynecol , — discussion Chi, D. Winter, W. Tumor residual after surgical cytoreduction in prediction of clinical outcome in stage IV epithelial ovarian cancer: a Gynecologic Oncology Group Study.

Creasman, W. Carcinoma of the corpus uteri. Odicino, F. Controversies in the Surgery of Endometrial Cancer. InTech Sartori, E. Clinical behavior of stage II endometrial cancer cases: the impact of primary surgical approach and of adjuvant radiation therapy. Int J Gynecol Cancer 11 , — Gadducci, A.

Treatment Planning in Endometrial Cancer. Cancer Therapy. Seagle, B. Lachance, J. A cost-effective analysis of adjuvant therapies for the treatment of stage I endometrial adenocarcinoma. Download references. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Ryan K. Orosco, Viridiana J. Tapia, Joseph A. Califano, John Pang, Kathryn R.

Joseph A. Califano, Ezra E. Cohen, Christopher Kane, Scott M. Ezra E. Cohen, Scott M. You can also search for this author in PubMed Google Scholar. Figures were prepared by V. Correspondence to Quyen T. Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Reprints and Permissions. Orosco, R. Sci Rep 8, Download citation. Received : 06 November Accepted : 05 March Published : 09 April Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. By submitting a comment you agree to abide by our Terms and Community Guidelines.

If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate. Advanced search. Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily. Skip to main content Thank you for visiting nature. Download PDF. Subjects Cancer Cancer epidemiology. Abstract A positive surgical margin PSM following cancer resection oftentimes necessitates adjuvant treatments and carries significant financial and prognostic implications.

Methods The ten most common solid organ cancers in the US are: prostate, breast, lung and bronchus, colon and rectal, urinary bladder, thyroid, kidney and renal pelvis, uterine corpus, oral cavity, ovarian 3. Disclosure The American College of Surgeons and the CoC have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator.

Results and Discussion Most patients were women Table 1 Prevalence of PSM for individual tumor sites as a function of gender, race, age, tumor category, tumor grade. Analysis of PSM change over study period comparing unadjusted rate from the last 5 years of the study period — to the first 5 years of the study period — Full size table.

Figure 1. Full size image. Table 2 Summary of the prognostic implications, adjuvant treatment recommendations, and associated cost estimates of PSM for individual tumor sites: breast, prostate, bladder, colon and rectum, thyroid, oral cavity, lung and bronchus, uterine.

Conclusion This work serves to define the magnitude of PSM as a surgical challenge in the most common solid cancers in the US. References Siegel, R. Google Scholar Novara, G. Google Scholar Seagle, B. Murphy Authors Ryan K.

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Initial margin is the amount required to buy a stock on margin, while maintenance margin is the equity needed to keep the position open. A margin call is when money must be added to a margin account after a trading loss to meet minimum capital requirements. The “ask” is the price at which you can BUY the base currency. The difference between these two prices is known as the spread. Also known as the “bid/ask.