Simone Lawson
A negative surgical margin means that no cancer cells are found at the edge of the tissue that was removed, or in other words, the rim of normal tissue is free of cancer cells. In gastric cancer, the entire gastric margin is examined using an average of six blocks, with representative sections being examined using two blocks. There is no universally accepted standard for how and when the margin should be assessed, but the recommended minimum gross distance of the tumour to the margin depends on the tumour's extent. For example, according to the Japanese Gastric Cancer Association, a gross distance of at least 2 cm from a T1 cancer, at least 3 cm for a T2 or deeper cancer, and at least 5 cm for a T3 or deeper cancer is recommended.
| Characteristics | Values |
|---|---|
| Definition of a negative margin | No cancer cells found at the edge of the tissue that was removed |
| Tumor type | Invasive or ductal carcinoma in situ (DCIS) |
| Tumor size | Greater than 2.3 cm |
| Tumor distance to margin | Greater than 4.5 cm |
| Tumor-free margin | Larger than 3 cm for type 1 or type 2 advanced cancer; larger than 5 cm for type 3, type 4, or type 5 advanced cancer |
| Resection type | R0/1 gastrectomy |
| Number of patients with positive RM | 49 (1.8%) |
| Treatment | Neoadjuvant chemotherapy and total gastrectomy |
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What You'll Learn
- A negative margin means no cancer cells are found at the edge of the tissue removed
- Tumour size and distance to the margin are factors influencing the risk of positive margins
- There is no standard definition of what constitutes an adequate negative margin
- Microscopically positive margins are linked to recurrence and decreased survival
- Complete tumour removal is essential for the treatment of resectable gastric cancer
A negative margin means no cancer cells are found at the edge of the tissue removed
When a person undergoes surgery for cancer, the surgeon removes the tumour along with a border of tissue surrounding it. This border of tissue is called the surgical margin or margin of resection. It is necessary to ensure that the tumour hasn't spread beyond this margin, as this can impact the chances of cancer recurrence.
In the context of gastric cancer, a negative margin means that no cancer cells are found at the edge of the tissue removed. This indicates that the tumour has not spread beyond the resection margin, which is crucial for achieving complete tumour removal. Complete tumour resection is essential for the effective treatment of gastric cancer.
The absence of cancer cells at the surgical margin is confirmed through microscopic examination by a pathologist. They measure the distance between the outer edge of the tumour and the outer edge of the perceived normal tissue, i.e., the surgical margin. This process helps determine if additional surgery or treatment is required. For example, if cancer cells are present in the margin, further surgery and/or radiation therapy may be recommended to ensure the cancer's complete removal.
It is important to note that there is no standard definition of what constitutes an adequate negative margin in gastric cancer. The recommended minimum distance between the tumour and the margin depends on the tumour's extent and type. For instance, the Japanese Gastric Cancer Association recommends a gross distance of at least 2 cm for T1 cancer and at least 3 cm for T2 or deeper cancer.
While achieving negative margins is crucial, it is not always possible or necessary due to the tumour's location. In some cases, cancer cells may approach but not touch the edge of the removed tissue, which is known as a close surgical margin. In such instances, the decision to perform additional surgery depends on various factors, including the type of cancer and the patient's specific circumstances.
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Tumour size and distance to the margin are factors influencing the risk of positive margins
Gastric cancer is a leading cause of cancer-related deaths worldwide. Complete tumour removal is essential for effective treatment. To achieve this, surgeons must secure a sufficient tumour-free margin, or surgical margin, which is a border of tissue surrounding and beyond the edges of the visible cancerous tumour.
The surgical margin must be examined microscopically by a pathologist to determine if cancer cells are present. The pathologist measures the distance between the outer edge of the tumour containing cancer cells and the outer edge of the perceived normal tissue (the surgical margin). The results of this examination are labelled as Negative, Positive, or Clear, and each influences treatment decisions. For example, if cancer cells are still present in the surgical margin, additional surgery and radiation may be required.
The choice of margin assessment procedure is often based on institutional tradition or surgeon preference, rather than evidence-based data. However, complete surgical resection, determined by assessment of the surgical margins, is critical for the curative treatment of patients with cancer of the oesophagus, gastroesophageal junction (GEJ), or stomach.
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There is no standard definition of what constitutes an adequate negative margin
A negative surgical margin means that no cancer cells are found at the edge of the tissue that was removed. In other words, the rim of normal tissue is free of cancer cells. The surgical margin, or margin of resection, refers to the border of tissue surrounding and beyond the edges of the visible cancerous tumour that is removed during surgery.
The recommended minimum distance between the tumour and the margin depends on the tumour's extent. For example, the Japanese Gastric Cancer Association recommends a gross distance of at least 2 cm from a T1 cancer, at least 3 cm for a T2 or deeper cancer, and at least 5 cm for more advanced cancers. However, these guidelines are not universally accepted, and the choice of margin assessment procedure often depends on institutional traditions or surgeon preferences rather than evidence-based data.
The lack of standardisation in defining an adequate negative margin highlights the complexity and individualised nature of cancer treatment. While achieving negative margins is crucial in reducing the risk of cancer recurrence and improving survival rates, the specific definition of an adequate negative margin may vary depending on the cancer type, stage, and other biological and treatment factors.
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Microscopically positive margins are linked to recurrence and decreased survival
Gastric cancer (GC) is the fourth leading cause of cancer deaths worldwide, with the fifth highest incidence among cancers. Surgery is the standard treatment for resectable GCs, and the principal goal is complete tumor resection without residual disease, known as R0 resection.
Microscopic examination of surgical margins is crucial in determining the presence of cancer cells. A positive surgical margin (also known as involved) indicates the presence of cancer cells in the tissue, requiring additional surgery to remove the remaining cancer. On the other hand, a negative surgical margin confirms the absence of cancer cells at the edge of the removed tissue.
Microscopic positive resection margins (RM) have been linked to unfavorable outcomes in patients with gastric cancer. Several studies have reported that positive RM impacts survival negatively and increases the likelihood of disease recurrence. This is particularly evident in advanced gastric cancer (AGC), where a close resection margin (CRM) of ≤0.5 cm was associated with a significant increase in locoregional recurrence and worse recurrence-free survival (RFS).
The impact of microscopically negative but close RM (CRM) is less clear and requires further evaluation. However, it is generally accepted that avoiding resection with microscopic margin involvement is essential for better prognostic outcomes. The challenge lies in securing sufficient margins, especially when aiming to preserve gastric function post-surgery.
To decrease the risk of microscopically positive RM, intraoperative frozen section diagnosis (IFSD) can be employed, although it is a time-consuming and costly procedure. Therefore, risk stratification is necessary to identify specific patients at high risk for positive RM who would benefit from IFSD.
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Complete tumour removal is essential for the treatment of resectable gastric cancer
Gastric cancer is a leading cause of cancer-related deaths worldwide. Complete tumour removal is essential for the effective treatment of resectable gastric cancer. This is achieved through a process called resection, where the surgeon removes the tumour along with a border of healthy tissue surrounding it. This border of healthy tissue is called the surgical margin or margin of resection. The adequacy of the resection is determined by assessing these surgical margins.
The surgical margin is examined microscopically by a pathologist to determine if cancer cells are present. The distance between the outer edge of the tumour and the outer edge of the healthy tissue (the surgical margin) is measured. The results of this examination are labelled as Negative, Positive, or Clear. A Negative Surgical Margin means that no cancer cells are found at the edge of the removed tissue, i.e., the rim of healthy tissue is free of cancer cells. A Positive Surgical Margin, on the other hand, indicates the presence of cancer cells in the tissue, requiring further surgery to remove the remaining cancer.
In the context of gastric cancer, the goal is to achieve R0 resection, which means that there is no evidence of cancer cells at the surgical margin. This is crucial because a positive resection margin is an independent predictor of recurrence and decreased survival. The recommended minimum distance between the tumour and the margin depends on the extent of the tumour. For example, according to the Japanese Gastric Cancer Association, a minimum distance of 2 cm is recommended for T1 cancer, 3 cm for T2 cancer, and 5 cm for deeper cancers.
However, there is no universally accepted standard for assessing gastric margins. The choice of assessment procedure is often based on institutional tradition or surgeon preference. Additionally, there is no standard definition of what constitutes an adequate negative margin. While the goal is to achieve a tumour-free margin, it is challenging because gastric tumours can spread horizontally, sometimes infiltrating the submucosa while appearing normal, misleading surgeons. Even with careful efforts to achieve complete resection, tumour cells may still be present at the resection margins, diagnosed as microscopically positive (R1).
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Frequently asked questions
A negative surgical margin means that there are no cancer cells found at the edge of the tissue that was removed. In other words, the rim of normal tissue is free of cancer cells.
A positive surgical margin means that there are cancer cells in the tissue that was perceived to be normal by the surgeon. This usually indicates the need for further surgery to remove the remaining cancer.
To achieve a negative margin in gastric cancer, a sufficient tumor-free margin must be secured, as confirmed macroscopically or endoscopically. However, there is no universally accepted standard for how and when the margin should be assessed. The choice of margin assessment procedure is often based on institutional tradition or surgeon preference.
