Wedge resection margin distances and residual adenocarcinoma in lobectomy specimens

We studied 31 T1 N0 M0 peripheral adenocarcinomas diagnosed by wedge resection and treated by lobectomy. Factors recorded were pleural surface-based, gross cut-surface, and microscopic margin distances; morphologic features of the adenocarcinomas; microscopic extension distance of beyond gross perimeter of neoplasm; and presence of residual adenocarcinoma in the lobectomy specimen. All staple-line margins in the wedge and lobectomy specimens underwent complete histologic examination. The mean pleural surface-based, gross cut-surface, and microscopic margin distances in wedge resections were 13.1, 4.1, and 2.3 mm, respectively. The mean microscopic wedge resection margin distance was 11 mm smaller than the pleural surface-based measured margin. The mean microscopic lepidic growth beyond the gross perimeter of the neoplasm was 7.4 mm. Fourteen lobectomy specimens (45%) included adenocarcinoma. The mean microscopic wedge resection specimen margin distances in cases with and without residual adenocarcinoma in the lobectomy specimens were 0.7 and 2.4 mm, respectively (P < .001). Incomplete excision may contribute to higher locoregional recurrence rates following limited resection surgery. Two processes affected wedge resection margin distances: stapling-induced parenchymal stretching, resulting in overestimation of pleural surface-based distances, and microscopic extension of adenocarcinoma beyond the gross perimeter of the neoplasm.     

Accuracy of frozen section diagnosis in soft tissue tumors

This study was undertaken to analyze the accuracy of frozen section (FS) diagnosis of 118 soft tissue tumors with respect to the reasons for which the intraoperative consultation was indicated. Fifty-seven frozen sections were performed for the diagnosis of an unknown pathologic process. Complete agreement was established in 40.3% and the correct pathologic process in 43.9%, the diagnosis was deferred in 14%, and the remaining 1.8% were diagnosed incorrectly. Examination for determination of the adequacy of resection margin (22 cases), lymph node or skip metastases (23 cases), residual or recurrent tumor after previous surgery (29 cases), viable tumor tissue after previous locoregional or systemic therapy (ten cases), and identification of the specimen (five cases) proved to be 95.5%, 95.7%, 96.6%, 90%, and 100% accurate. Considering the whole series, an erroneous answer to a question posed by a surgeon was given in four cases (two false positive and two false negative), of which two cases were a sampling error made by pathologist. Intraoperative consultation by FS in soft tissue tumors is (a) reliable for general rather than exact diagnosis in defining the previously unknown pathologic process and (b) mandatory in evaluating resection margins and any discrepancies between preoperative cytologic and intraoperative gross impression.     

The utility of intraoperative retroareolar margin frozen section assessment and the management of atypical epithelial proliferative lesions at the retroareolar margin in nipple-sparing mastectomies

ObjectivesNipple-sparing mastectomy (NSM) has become more frequently utilized due to superior psychological and cosmetic outcomes. The aim of this study was to evaluate the accuracy and utility of intraoperative frozen section evaluation of the retroareolar margin (RAM) in NSM. The management of atypical epithelial proliferative lesions at the RAM was also reviewed and discussed.MethodsA single institution, retrospective analysis was performed on all therapeutic NSM patients with intraoperative evaluation of the RAM from 2014 to 2018. Patient demographics, tumor characteristics, pathologic assessment of the RAM, surgical management, and clinical follow-up were reviewed.ResultsSeventy-four nipple-sparing mastectomies with intraoperative evaluation of RAMs were identified. Concordance was 95% between frozen and permanent section diagnoses with 4 cases representing false negatives and no false positives. There were no instances of nipple-areolar complex (NAC) recurrence in all cases with preserved NACs (mean follow up: 750 days). In the 9 cases where NACs were excised based on intraoperative RAM evaluation, the findings in the excised NACs were negative in 6 and ductal carcinoma in situ in 3 cases. Postoperative measurement of the tumor to nipple distance was the only statistically significant variable associated with a positive RAM by multivariable logistic regression (OR 0.475; 95% CI 0.238–0.946).ConclusionsIntraoperative RAM evaluation demonstrated high concordance with permanent histology. Negative RAM, including atypical epithelial proliferative lesions, led to NAC preservation without recurrence. Positive RAM alone did not predict NAC involvement, although pagetoid spread of ductal carcinoma in situ along nipple ducts may predict NAC positivity.     

Comparison of margin assessment by radial and shave sections in wide local excision specimens for invasive carcinoma of the breast

Hodi Z, Ellis I O, Elston C W, Pinder S E, Donovan G, Macmillan R D & Lee A H S
(2010) Histopathology 56 , 573–580 Comparison of margin assessment by radial and shave sections in wide local excision specimens for invasive carcinoma of the breast Aims: Standard margin assessment of breast carcinoma surgical specimens uses radial sections perpendicular to the margin. Shave sections assess a larger surface area of margin than radial sections. The aim was to assess the value of additional shave sections of the margin. Methods and results: Both types of section were used to assess 471 wide local excision specimens for invasive carcinoma. One hundred and seventy‐nine specimens had positive margins: only radial margins were involved (tumour within 5 mm of margin) in 76, only shave margins in 45, and both shave and radial margins in 58. Residual carcinoma was found in re‐excision specimens (immediate or later) in 43% when the closest distance to the radial margin was 0–1 mm, 25% for 2–4 mm, 18% for 5–9 mm and 13% for >9 mm. Residual carcinoma was found in 44% of specimens if any shave section was positive and in 9% if all shaves were negative. Residual carcinoma was found in 32% if either radial or shave sections were positive and in 4% if neither was positive. Conclusions: The combination of radial and shave sections appears to be good at separating patients into two groups with high and low risk of residual carcinoma.     

Frozen section evaluation of margins in radical prostatectomy specimens: a contemporary study and literature review

The utility of routine frozen section (FS) analysis for margin evaluation during radical prostatectomy (RP) remains controversial. A retrospective search was conducted to identify RPs evaluated by FS over a 5-year period. The potential of FS to discriminate between benign and malignant tissue and to predict final margins was evaluated. During the study period, 71 (12.3%) of 575 cases underwent FS evaluation of margins, generating 192 individual FSs. There were 8 FSs diagnosed as atypical/indeterminate because of significant freezing, crushing, and/or thermal artifacts; 11 as positive for carcinoma; and 173 as benign. Two FSs classified as benign were diagnosed as positive for carcinoma on subsequent permanent section. Frozen sections' sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for diagnosis of prostatic adenocarcinoma were 85%, 100%, 100%, 99%, and 99%, respectively. Overall RP final margin predictive accuracy was 81%. Positive FS was significantly associated with perineural invasion on biopsy and extraprostatic extension and higher stage disease on RP, but not with the overall final margin status. The high FS accuracy supports its use to guide the extent of surgery. However, FS cannot be used to predict the overall final margin status. Recognition of the histological artifacts inherent to the FS procedure is important to ensure appropriate utilization.     

Intraoperative consultation for renal lesions. Implications and diagnostic pitfalls in 324 cases

Intraoperative consultation rarely is requested for lesions in the kidney. Of 324 renal lesions submitted for gross or frozen section intraoperative consultation, 199 specimens were submitted for gross consultation only; no diagnostic pitfalls were noted. The clinical implications and diagnostic pitfalls in 125 specimens submitted for frozen section were the focus of our study. Frozen section intraoperative consultation was requested to evaluate surgical margins in partial nephrectomy specimens, solid renal mass in an unusual clinical or radiologic setting, synchronous renal and extrarenal masses, cystic renal lesion, ureteral surgical margins for transitional cell carcinoma, multiple renal masses, solid mass in a diffusely cystic kidney, and renal injury. Among the 125 cases, the diagnoses were deferred in 17 (6 renal cell carcinomas with granular cytoplasm, 7 cystic lesions, 3 metastatic tumors, 1 leiomyoma). The frozen section diagnoses were incorrect owing to limited sampling in 5 and misinterpretation in 4 (melanoma vs angiomyolipoma, lymphoma vs angiomyolipoma, benign cyst vs cystic renal cell carcinoma, metastatic renal cell carcinoma vs pheochromocytoma). Awareness of distinctive indications for frozen section intraoperative consultation and diagnostic pitfalls should improve diagnostic accuracy and facilitate proper management of these lesions.     

Factors associated with ipsilateral breast failure and distant metastases in patients with invasive breast carcinoma treated with breast-conserving therapy. A clinicopathologic study of 607 neoplasms from 583 patients

All slides from 607 consecutive invasive breast carcinomas from 583 patients were reviewed. Margin distance, composite width of invasive carcinoma, and number of ducts with intraductal carcinoma within the one-half low-power field (LPF) adjacent to the final margin were recorded. Final margin groups were positive (carcinoma at margin), near (< or = 1/2 LPF of margin), and negative (> 1/2 LPF). There were 39 ipsilateral breast failures (IBFs), and 63 patients (10.8%) developed distant metastases (DMs). Decreasing margin distance and increasing amounts of carcinoma near the margin were associated with IBF and DM. The 5-tiered composite factor of margin distance and amount of carcinoma near margin (negative margins, near least amount, near intermediate amount, near greatest amount, and positive margins) resulted in 12-year IBF rates of 9%, 6%, 18%, 24%, and 30%, respectively (P < .001). The composite factor, margin amount of carcinoma near margin, and invasive carcinoma/initial excision specimen dimension ratio were the most precise parameters assessing excision adequacy and, ultimately, IBF risk. The amount of carcinoma near the margin and volume of excised parenchyma related directly to the amount of residual carcinoma in the adjacent breast parenchyma.     

124例肺癌石蜡大切片研究

对124例肺癌石蜡大切片进行病理研完,发现大切片与常规切片对比有优越性,能准确确定大细胞癌、腺鳞癌和细支气管肺泡癌;本文纠正了24例常规切片的组织类型,大切片有利于肿瘤多中心起源观点的证实,能更有效发现血管及淋巴途径被侵和脏层胸膜穿破,用大切片作基础的肺癌WHO组织分型,能适合形态学和组织发生,为临床及科研实用的分型。     

前列腺病理大切片技术的临床应用及价值

目的探讨前列腺病理大切片技术的临床应用及价值。方法回顾性分析我院行根治性前列腺切除术的155例患者的临床资料。所有患者术后均进行病理切片分析,根据病理切片方式将其分为大切片组(45例)和常规切片组(110例)。比较2组患者切片情况、术后病理特征及Gleason评分。结果2组切片均未见收缩或褶皱,结构完整,细胞形态清晰可见。其中大切片组可多层、全面地观察到前列腺病变情况,准确定位病灶,直观辨别微小病灶、前列腺切缘是否为阳性;常规切片组无法全面观察到前列腺病变情况及其与周围组织的关系,难以明确肿瘤与切缘的距离和切缘是否为阳性。大切片组切缘阳性、微小病灶、精囊侵犯检出率高于常规切片组(P<0.05),但2组病理分期检出率比较,差异无统计学意义(P>0.05)。2组手术前后Gleason评分比较,差异无统计学意义(P>0.05),但大切片组术后Gleason评分升高比例高于常规切片组(P<0.05)。结论前列腺病理大切片技术可以全面观察到前列腺组织,提高切缘阳性、微小病灶及精囊侵犯检出率,为前列腺癌患者术后局部精准治疗提供病理依据。     

Accuracy and cost of intraoperative lymph node frozen sections at radical prostatectomy

AIM: To assess the value of intraoperative diagnostic examination of frozen sections of lymph nodes removed during radical prostatectomy. METHODS: Pelvic lymph nodes from patients with prostatic carcinoma were obtained (1) as frozen sections during radical prostatectomy, to exclude patients from non-curative surgery, and (2) as paraffin sections postoperatively from lymphadenectomy performed at radical prostatectomy, to stage the tumour and assess need for adjuvant treatment. Findings from the two approaches were used to assess the accuracy and cost of frozen section diagnosis, and to judge the results of omitting intraoperative diagnosis. RESULTS: In 82 patients frozen section revealed metastasis in six (7.3%), and metastases were found in a further four (4.9%) on paraffin sections (false negatives). Of the 195 patients undergoing staging lymphadenectomy (without frozen section), metastatic cancer was seen in nine cases (4.6%). The frozen section cost of metastatic cancer detection per patient was calculated as 7516 Pounds (550 Pounds x 82/6), with an associated false negative rate of 33%. CONCLUSIONS: Frozen section diagnosis of metastatic carcinoma in pelvic lymph nodes before radical prostatectomy has a high false negative rate and is costly. It may not be justified with the observed low incidence of lymph node metastasis.     

Comparison of margin status and lesional size between radioactive seed localized vs conventional wire localized breast lumpectomy specimens

Despite the known benefits of the use of radioactive seed localization (RSL), few studies have looked at the resultant pathologic marginal status of these lumpectomy specimens, especially in regard to different definitions of close/positive margins. We compared the marginal status of lumpectomy specimens removed by either RSL or conventional wire localization (CWL) techniques. A total of 106 lumpectomy specimens including 62 by CWL and 44 by RSL for invasive ductal and lobular carcinomas were compared. Data on gross and microscopic surgical margin status, tumor type and grade, and demographic information were retrospectively collected. There was no difference between the techniques in terms of tumor characteristics including size, histologic grade, lymph node positivity, or age. Although the distributions are very similar between CWL and RSL specimens for final marginal assessments (P = .69), there is a (modest) statistically significant difference in the distribution for margin classifications based on gross assessments (P = .040), specifically more RSL specimens exhibiting tumor within 1 mm of the closest margin. Concordance between gross and microscopic lesion measurements is highest for invasive ductal carcinoma grade 3 for both CWL and RSL lumpectomies (78.6% and 80.0%). This study shows that there were no significant marginal status differences between RSL and CWL lumpectomy specimens with invasive carcinoma. Rather, what was relevant is whether the entire specimen could be classified as having negative/close margins. Significant workflow challenges in surgical pathology laboratories are expected with the adoption of the RSL process.     

A new method of complete peripheral margin assessment in breast conservative surgery using an adjustable polygonal prism mould

Conventional margin evaluation for breast conservative surgery is usually based on the sections taken perpendicular to the inked margins and has difficulty in completeness. We have developed a new method using an adjustable mould during fixation so that the three-dimensional specimen is fixed in the shape of polygonal prism. The new method enables us to assess peripheral margins completely by examining the inner surfaces of the marginal slices cut parallel to the flat peripheral margins of the specimen. DESIGN: We have applied the new method to 59 invasive carcinomas and 10 noninvasive carcinomas of the breast, which were judged to be negative for residual tumor by conventional inked margin on the section cut through the center of the tumor. RESULTS: The new method detected 13(22.0%) and 3(30.0%) cases with positive margins in 59 invasive carcinomas and 10 noninvasive carcinomas of the breast, respectively. Nine of 13(69.2%) positive margins in invasive carcinomas were due to the intraductal components of the carcinomas. CONCLUSION: The polygon method is superior to the conventional inked margin method in sensitivity. Furthermore, it covered all the peripheral margins and pinpointed the positive sites.     

Histological margin assessment for breast ductal carcinoma in situ: precision and implications.

Local recurrence after lumpectomy for ductal carcinoma in situ (DCIS) is a major concern and is related to residual disease in the breast. We studied the predictive value of lumpectomy margins for residual DCIS and compared our results and pathological processing techniques with those published in the literature. Margin status was determined for 89 patients with screen-detected DCIS who had lumpectomy and re-excision, for the presence and extent of residual disease. Margin width was defined as the narrowest distance between tumor and any inked margin or, where margins were positive, classified into focal involvement (<1 mm of the inked surface involved), minimal (>or=1<15 mm) and extensive (>or=15 mm). The amount of residual tumor was quantified according to the number of ducts involved with tumor: small (fewer than 10 ducts) or large (10 or more ducts) residuum. The initial margin status was a significant predictor for the presence of residual tumor in re-excision specimens (P=0.006). There was residual tumor in 44 and 45% of close non-involved (>1 and 25 mm,respectively, showing residual disease. The presence of residual tumor was not significantly related to age, mammographic appearance, nuclear grade or intraductal necrosis. The initial margin status was found to predict for the amount of residual tumor. With careful margin assessment, margin status after lumpectomy for DCIS can be used to predict for the presence and amount of residual tumor in the breast and is a guide to further management decisions. A standard for margin status reporting and pathological processing of screen-detected DCIS in situ lesions will help in the interpretation of data from different institutions.     

Intra-surgical total and re-constructible pathological prostate examination for safer margins and nerve preservation (Istanbul preserve)

PurposeTo demonstrate a novel frozen section analysis technique during robot assisted radical prostatectomy with 2 distinct advantages: evaluation of the entire circumference and easier reconstruction for whole mount evaluation.Material and methodsIstanbul Preserve was performed on patients who underwent robotic prostatectomy with nerve sparing between 10/2014 and 7/2016. Gland was sectioned at 3–4 mm intervals from apex to bladder neck. Entire tissue representing margins (except for the most anterior portion) was circumferentially excised and microscopically analyzed. In margin positivity, approach was individualized based on extent of positive margin and Gleason pattern. A matched cohort was established for comparison. Retrospective analysis of a prospectively maintained database was performed. Impact of FSA on PSM rate was primarily assessed.ResultsData on 170 patients was analyzed. Positive surgical margin was reported in 56(33%) on frozen section. Neurovascular bundle was partially or totally resected in 79% and 18%. Conversion of positive margin to negative was achieved in 85%. Overall positive margin rate decreased from 22.5% to 7.5%. Nerve sparing increased from 87% to 93%. Location of positive margin at frozen was at the neurovascular bundle area in 39%; thus Istanbul Preserve detected 61% additional margin positivity compared to other techniques. Reconstruction for whole mount was easy.ConclusionIstanbul Preserve is a novel technique for intraoperative FSA during RARP allowing for microscopic examination of the entire prostate for margin status and easy re-construction for whole mount examination. It guarantees safer margins together with increased rate of nerve sparing.     

Are en face frozen sections accurate for diagnosing margin status in melanocytic lesions?

To assess the diagnostic accuracy of margin evaluation of melanocytic lesions using en face frozen sections compared with standard paraffin-embedded sections, we studied 2 sets of lesions in which en face frozen sections were used for analysis of surgical margins (13 from malignant melanomas [MMs] and 10 from nonmelanocytic lesions [NMLs]). Routine permanent sections were cut after routine processing. The slides were mixed and coded randomly. Fifteen dermatopathologists examined the cases separately. Margin status was categorized as positive, negative, or indeterminate. Kappa statistics were calculated per dermatopathologist and per case. One case from each group was excluded because epidermis was not available in the routine sections. Of 330 evaluations (22 cases, 15 dermatopathologists), there were 132 diagnostic discrepancies (40.0%): 66 each for MM and NML (mean per case for both diagnoses, 6). In 9 instances (6.8%), the change was from positive (frozen) to negative (permanent) and in 43 (32.6%), from negative (frozen) to positive (permanent). There was poor agreement between frozen and permanent sections (kappa range per dermatopathologist, -0.1282 to 0.6615). If permanent histology is considered the "gold standard" for histologic evaluation, en face frozen sections are not suitable for accurate surgical margin assessment of melanocytic lesions.     

Quantifying the extent of invasive carcinoma and margin status in partial mastectomy cases having a gross lesion: is a defined tissue processing protocol needed?

Accurate estimation of disease extent and margin status is critical when evaluating partial mastectomy cases because both are predictors of recurrence. No published standards exist for processing specimens involved by invasive carcinoma, presumably because such cases have a gross lesion. We retrospectively studied 100 partial mastectomy cases and concluded that a standardized tissue mapping protocol is needed to ensure adequate pathologic examination even when a gross lesion is present. When mapped and unmapped findings were compared, 17 cases (10 with ductal and 7 with lobular carcinoma) had an increase in carcinoma size, 12 cases (9 with ductal and 3 with lobular carcinoma) had an increase in pathologic T stage, and positive margins were found in 8 cases (7 with ductal and 1 with lobular carcinoma). We describe our tissue-mapping protocol, and advocate its use as a standardized protocol for processing all partial mastectomy specimens.     

Intraoperative evaluation of lumpectomy margins by imprint cytology with histologic correlation: a community hospital experience

BACKGROUND: Several well-controlled studies have demonstrated significantly increased local recurrence rates in patients with low-stage breast carcinoma treated with breast conservation therapy in whom focally positive margins were not reexcised. Imprint cytology is a rapid technique for evaluating surgical margins intraoperatively, thus allowing reexcisions to be performed during the initial surgery. The large majority of studies on the use of intraoperative imprint cytologic examination of breast conservation therapy margins have been performed at university-based academic centers. OBJECTIVE: To evaluate the utility of intraoperative imprint cytologic evaluation of breast conservation therapy margins in a community hospital setting. METHODS: We retrospectively reviewed the intraoperative imprint cytology margins of 141 lumpectomy specimens that had been obtained from 137 patients between May 1997 and May 2001. RESULTS: We evaluated 758 separate margins. On a patient basis, the sensitivity was 80%, the specificity was 85%, the positive predictive value was 40%, the negative predictive value was 97%, and the overall accuracy was 85%. There were no cytologically unsatisfactory margins. CONCLUSION: Imprint cytology is an accurate, simple, rapid, and cost-effective method for determining the margin status of breast conservation therapy specimens intraoperatively in the community hospital setting. This method allows a survey of the entire surface area of the lumpectomy specimen, which is not practical using frozen section evaluation.     

保乳手术标本定位全部取材病理检查的意义

目的探讨保证保乳手术标本切缘阴性的病理取材诊断方法及意义。方法（1）术中对145例保乳手术标本进行定位全切片检查,79例进行选择性取材检查;（2）术后对84例保乳手术标本进行定位全切片检查,226例进行选择性取材检查;（3）对两组手术病例进行随访观察。结果（1）术中定位全切片取材切缘阳性检出率（24．1％,35／145）明显高于选择性取材（6．3％,5／79）,差异具有统计学意义（P〈0．01）;（2）术后定位全切片取材切缘阳性检出率（29／84,34．5％）亦明显高于选择性取材（12．0％,27／226）,差异具有统计学意义（P〈0．01）;（3）经2～46个月随访,保乳手术标本选择性取材病例中有3例分别于术后6、15、28个月局部复发,定位全切片取材病例无复发。结论定位全切片取材和诊断可以降低保乳手术标本切缘阳性的漏诊率,并能够定位切缘阳性的部位,对减小二次手术和术后复发的风险,保证保乳手术的成功具有重要作用。     

Tissue preparation for MOHS’ frozen sections: a comparison of three techniques

Accurate, efficient frozen section analysis is important for tumor control. A few studies address the technical issues. More are needed, especially as new technologies become available. The objective of this study is to compare the efficiency of three techniques of flattening tissue for microscopically oriented histologic surgery (MOHS): conventional frozen sectioning, Cryocup™, and CryoHist™. Conventional chuck/heat sink-frozen section preparation were compared with Cryocup™ and CryoHist™ to determine the most efficient technique to examine 100% of the surgical margin of 4-cm diameter, full thickness, fresh autopsy cylinders of anterior abdominal skin, which were marked on their deep and peripheral margins. The specimens were frozen sectioned at 5 μm until all the marking dye was gone from the deep surface, and 95% of the perimeter epidermis could be seen. The conventional chuck required an average of 304 micrometers to clear the deep margin and four fifths did not contain 95% of the epidermal margin. The Cryocup™ required an average of 284 μm to examine the deep margin and 95% of the epidermal margin. The CryoHist™ required an average of 104 μm to examine the deep margin and 95% of the epidermal border. The new techniques improve the efficiency and presumably the accuracy of tumor margin analysis.