The illusion of conventional histological resection margin control

Delft, Lieke C.J. van; Nelemans, Patty J.; Loo, Eva van; Hamid, Myrurgia Abdul; Kelleners‐Smeets, Nicole W.J.

doi:10.1111/bjd.17510

Cited by 18 publications

(22 citation statements)

References 8 publications

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“…Further selection bias through the differential use of Mohs micrographic surgery by specialty and country will remove lesions that are at the highest risk of incomplete excision. Finally, standard histology using ‘bread‐loaf’ techniques only assesses between 0·19% and 2% of specimen margins 137–139 consequently, the actual incomplete excision rate in the population is likely to be higher than our estimates suggest. Prospective studies were found to be at a lower risk of incomplete excision than retrospective studies, which may be due to selection bias caused by stricter inclusion criteria of randomized controlled trials than retrospective studies.…”

Section: Discussionmentioning

confidence: 76%

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta‐analysis*

et al. 2020

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Summary Background Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates. Objectives We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta‐analysis of primary clinical studies. Methods A PRISMA‐compliant systematic review and meta‐analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000–27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random‐effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta‐analysis and meta‐regression, which were presented as risk ratios (RRs). Results Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7–12·4] and for SCC 9·4% (95% CI 7·6–11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0–7·3) and SCCs (RR 4·8, 95% CI 1·0–22·8). Studies were heterogeneous (I2 = 98%) and at high risk of bias. Conclusions The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.

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Section: Discussionmentioning

confidence: 76%

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta‐analysis*

et al. 2020

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“…This is believed to be due to its infiltrative growth pattern and sampling error from standard histological processing, 5 for which the specimen margin evaluated can range from 0Á5% 6 to 2%. 7 The amount of tissue visualized depends on the number of sections read. Surgical techniques utilizing margin control such as Mohs micrographic surgery (MMS) may reduce the risk of sampling error.…”

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confidence: 99%

“…However, after excision with apparently uninvolved histological margins, local recurrence within or adjacent to the primary site can occur. This is believed to be due to its infiltrative growth pattern and sampling error from standard histological processing, 5 for which the specimen margin evaluated can range from 0·5% 6 to 2% 7 . The amount of tissue visualized depends on the number of sections read.…”

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confidence: 99%

A 10‐year review of surgical management of dermatofibrosarcoma protuberans*

et al. 2020

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Summary Background Dermatofibrosarcoma protuberans (DFSP) is a rare skin cancer. Standard treatment in the UK is either wide local excision (WLE) or Mohs micrographic surgery (MMS). It is unclear which approach has the lower recurrence rate. Objectives We undertook a retrospective comparative review of surgical management of DFSP in the UK National Health Service in order to define (i) current surgical practice for primary and recurrent DFSP, (ii) local recurrence rates for primary DFSP and (iii) survival outcomes for DFSP. Methods A retrospective clinical case‐note review of patients with histologically confirmed DFSP (January 2004 to December 2013) who have undergone surgical treatment. Results The surgical management of 483 primary and 64 recurrent DFSP in 11 plastic surgery and 15 dermatology departments was analysed. Almost 75% of primary DFSP (n = 362) were treated with WLE and 20% (n = 97) with MMS. For recurrent DFSP, 69% (n = 44) and 23% (n = 15) of patients underwent WLE and MMS, respectively. Recurrent primary DFSP occurred in six patients after WLE and none after MMS. The median follow‐up time was 25·5 months (interquartile range 6·8–45·1) for new and 19·8 (IQR 4·5–44·5) for recurrent DFSP [Correction added on 1 Feb 2021, after first online publication: 4.8 years (interquartile range 3.5‐5.8) was incorrect], with eight reported deaths during the follow‐up analysis period (one confirmed to be DFSP related). Conclusions WLE was the most common surgical modality used to treat DFSP across the UK. The local recurrence rate was very low, occurring only after WLE. Although a prospective randomized controlled trial may provide more definitive outcomes, in the absence of a clearly superior surgical modality, treatment decisions should be based on patient preference, clinical expertise and cost.

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“…Standard excisions and POMA for the treatment of skin cancer reveals a combined positive margin or tumor recurrence rate of at least 20% [1][2][3][4] . Either of these outcomes (i.e., post-operative positive margins or false negative margins) requires additional surgery, radiation, chemotherapy, or some combination thereof, resulting in patient morbidity, mortality, and a significant cost to our healthcare system [5][6][7][8][9][10] . These pitfalls have been addressed in some settings through the use of intraoperative frozen sections or analyzing a larger percentage of tissue margins, which, in comparison to standard excisions and POMA, can reduce positive margin or recurrence rates to less than 1-2% in certain surgical subspecialties 3,[11][12][13] .…”

Section: Introductionmentioning

confidence: 99%

ArcticAI: A Deep Learning Platform for Rapid and Accurate Histological Assessment of Intraoperative Tumor Margins

Levy

Davis

Chacko

et al. 2022

Preprint

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Successful treatment of solid cancers relies on complete surgical excision of the tumor either for definitive treatment or before adjuvant therapy. Radial sectioning of the resected tumor and surrounding tissue is the most common form of intra-operative and post-operative margin assessment. However, this technique samples only a tiny fraction of the available tissue and therefore may result in incomplete excision of the tumor, increasing the risk of recurrence and distant metastasis and decreasing survival. Repeat procedures, chemotherapy, and other resulting treatments pose significant morbidity, mortality, and fiscal costs for our healthcare system. Mohs Micrographic Surgery (MMS) is used for the removal of basal cell and squamous cell carcinoma utilizing frozen sections for real-time margin assessment while assessing 100% of the peripheral and deep margins, resulting in a recurrence rate of less than one percent. Real-time assessment in many tumor types is constrained by tissue size and complexity and the time to process tissue and evaluate slides while a patient is under general anesthesia. In this study, we developed an artificial intelligence (AI) platform, ArcticAI, which augments the surgical workflow to improve efficiency by reducing rate-limiting steps in tissue preprocessing and histological assessment through automated mapping and orientation of tumor to the surgical specimen. Using basal cell carcinoma (BCC) as a model system, the results demonstrate that ArcticAI can provide effective grossing recommendations, accurately identify tumor on histological sections, map tumor back onto the surgical resection map, and automate pathology report generation resulting in seamless communication between the surgical pathology laboratory and surgeon. AI-augmented-surgical excision workflows may make real-time margin assessment for the excision of more complex and challenging tumor types more accessible, leading to more streamlined and accurate tumor removal while increasing healthcare delivery efficiency.

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The illusion of conventional histological resection margin control

Cited by 18 publications

References 8 publications

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta‐analysis*

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta‐analysis*

A 10‐year review of surgical management of dermatofibrosarcoma protuberans*

ArcticAI: A Deep Learning Platform for Rapid and Accurate Histological Assessment of Intraoperative Tumor Margins

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