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Bray J, Eward W, Breen M. Evaluating the relevance of surgical margins. Part one: The problems with current methodology. Vet Comp Oncol 2023; 21:1-11. [PMID: 36308442 DOI: 10.1111/vco.12865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 11/28/2022]
Abstract
The goal of cancer surgery is to achieve a "clean" microscopic resection, with no residual tumour remaining in the wound. To achieve that goal, the surgeon typically incorporates a measured buffer of grossly normal tissue about the entire circumference of the tumour. Microscopic analysis of the resection boundaries is then performed to determine if all traces of the tumour have been completely removed. This analysis is thought to provide a surrogate indication as to the likelihood for that tumour to recur after surgery. However, it is recognised that tumour recurrence may not occur even when microscopic evidence of tumour has been identified at the resection margins, and recurrence can also occur when conventional histology has considered the tumour to have been completely removed. The explanations for this dichotomy are numerous and include technical and practical limitations of the processing methodology, and also several surgeon-related and tumour-related reasons. Ultimately, the inability to confidently determine when a tumour has been removed sufficiently to prevent recurrence can impact on the ability to provide owners with confident treatment advice. In this article, the authors describe the challenges with defining the true extent of the tumour margin from the perspective of the surgeon, the pathologist and the tumour. The authors also provide an analysis of why our current efforts to ensure that all traces of the local tumour have been successfully removed may provide an imperfect assessment of the risk of recurrence.
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Affiliation(s)
| | - Will Eward
- Duke Cancer Center, Durham, North Carolina, USA
| | - Matthew Breen
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
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2
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Cockburn E, Janovec J, Solano MA, L’Eplattenier H. Marginal excision of cutaneous mast cell tumors in dogs was not associated with a higher rate of complications or prolonged wound healing than marginal excision of soft tissue sarcomas. J Am Vet Med Assoc 2022; 260:741-746. [DOI: 10.2460/javma.21.05.0235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Abstract
OBJECTIVE
To compare wound healing following planned marginal excision of cutaneous mast cell tumors (MCTs) with that of soft tissue sarcomas (STSs) and to identify risk factors for wound healing complications and delay in healing.
ANIMALS
126 dogs that underwent intentional marginal excision of cutaneous MCTs (n = 77) or subcutaneous STSs (49).
PROCEDURES
Medical records of included dogs were reviewed and signalment, tumor size, tumor location, skin closure type, time to healing, reported complications, histopathological grade, and surgical margins were recorded. These variables and outcomes (complication rate and time to complete healing) were compared between dogs in the MCT and STS groups. Potential risk factors for complications and delayed healing were analyzed.
RESULTS
No significant difference between the groups was found in any of the variables. Wound healing complication rates were 29% (22/77) for the MCT group and 31% (15/49) for the STS group. The mean ± SD time to complete healing was 16.5 ± 7.5 days for the MCT group and 17.7 ± 9.3 days for the STS group. These outcomes did not differ significantly between groups. For both groups, the use of subdermal plexus flap reconstruction was associated with the development of complications and increased time to complete healing.
CLINICAL RELEVANCE
Marginal excision of cutaneous MCTs was not associated with a higher rate of complication or prolonged wound healing, compared with marginal excision of STSs. The use of flap reconstruction in skin closure may delay healing and planned adjuvant therapy. Owners should be counseled regarding these risks and where appropriate and feasible, surgery without reconstruction should be considered.
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Affiliation(s)
- Elspeth Cockburn
- 1Davies Veterinary Specialists, Manor Farm Business Park, Hertfordshire, England
| | - Jan Janovec
- 1Davies Veterinary Specialists, Manor Farm Business Park, Hertfordshire, England
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3
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Ranganathan B, Milovancev M, Mehrkens L, Townsend KL. Intersurgeon agreement in determining 3 cm surgical margins of subcutaneous tumors in dogs. Vet Surg 2021; 50:1573-1578. [PMID: 34536030 DOI: 10.1111/vsu.13724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 08/16/2021] [Accepted: 08/26/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate intersurgeon agreement in performing a 3 cm wide surgical excision for subcutaneous malignancies in dogs. STUDY DESIGN Prospective, blinded, randomized, clinical study. ANIMALS Client-owned dogs with subcutaneous tumors undergoing curative-intent, wide surgical excision between April 2019 to March 2020. METHODS Four surgeons, instructed to perform a 3 cm wide excision, each sequentially indicated their proposed skin incision locations around subcutaneous tumors, without knowledge of the other surgeons' proposed incisions. A tripod-mounted camera and laser positioning system were used to photograph each surgeon's proposed margin length. A random-effects model was used to estimate the standard deviation of margin lengths that would be expected from a random sample of surgeons. RESULTS Each of the four surgeons provided 33 independent radial measurements from 11 tumors (six soft tissue sarcomas and five mast cell tumors), for a total of 132 radial measurements. No individual surgeon consistently proposed longer or shorter margin incision locations. The prediction interval for a future margin measurement was 6 mm, implying that the 95% confidence interval of an individual surgeon's margin length would be within ±6 mm of the mean margin length from a random sample of surgeons. CONCLUSION Ninety-five percent of surgeons would be expected to deliver a surgical dose between 2.4-3.6 cm, for a theoretically uniform surgical dose of 3 cm wide margins. CLINICAL SIGNIFICANCE Surgical doses are likely to vary at clinically relevant levels among surgeons, complicating design and interpretation of studies attempting to identify an ideal surgical dose.
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Affiliation(s)
- Bharadhwaj Ranganathan
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon, USA
| | - Milan Milovancev
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon, USA
| | - Lea Mehrkens
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon, USA
| | - Katy L Townsend
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon, USA
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Chiti LE, Ferrari R, Roccabianca P, Boracchi P, Godizzi F, Busca GA, Stefanello D. Surgical Margins in Canine Cutaneous Soft-Tissue Sarcomas: A Dichotomous Classification System Does Not Accurately Predict the Risk of Local Recurrence. Animals (Basel) 2021; 11:ani11082367. [PMID: 34438827 PMCID: PMC8388623 DOI: 10.3390/ani11082367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Histological evaluation of surgical margins is crucial for correct prognostication and adjuvant treatment recommendation after excision of soft tissue sarcoma (STS) in dogs. Incompletely excised STS have a high risk of local recurrence (LR), while completely excised STS without other negative prognostic factors are generally associated with a good prognosis. However, guidelines are lacking on how to manage STS excised with clean but close margins (CbCM), although some authors advocated their inclusion in the tumor-free margin group. This retrospective study investigates the impact of CbCM on LR of canine STS. Ninety-eight surgical excised canine STS at first presentation were included. Cumulative incidence of LR was estimated for each category of margins (tumor-free, infiltrated, CbCM), and after grouping CbCM alternatively in the tumor-free and infiltrated category. Cumulative incidence of LR at three years differed significantly between the three categories, and it was estimated to be 42% with infiltrated margins, 23% with CbCM, 7% with tumor-free margins. Both when CbCM were grouped with infiltrated margins or with tumor-free margins, the incidence of LR was statistically different. The rate of LR with CbCm was greater than with tumor-free margins. The category CbCM may be considered as a separate prognostic category. Abstract Adjuvant treatments are recommended in dogs with incompletely excised cutaneous soft-tissue sarcoma (STS) to reduce the risk of local recurrence (LR), although guidelines are lacking on how to manage clean but close margins (CbCM). This retrospective study investigates the impact of CbCM on LR of canine STS. Ninety-eight surgically excised canine STS at first presentation were included. Tissue samples were routinely trimmed and analyzed. Cumulative incidence of LR was estimated for each category of margins (tumor-free, infiltrated, CbCM), and included CbCM in the tumor-free and infiltrated category, respectively. The prognostic impact on LR was then adjusted for relevant prognostic factors. Cumulative incidence of LR at three years differed significantly between the three categories (p = 0.016), and was estimated to be 42% with infiltrated margins, 23% with CbCM, 7% with tumor-free margins. Both when CbCM were grouped with infiltrated margins (p = 0.033; HR = 5.05), and when CbCM were grouped with tumor-free margins (p = 0.011; HR = 3.13), a significant difference between groups was found. STS excised with infiltrated margins had the greatest risk of LR. The rate of LR with CbCm was greater than recurrence rate of tumor-free margins. The category CbCM may be considered as a separate prognostic category.
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Affiliation(s)
- Lavinia Elena Chiti
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
| | - Roberta Ferrari
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
- Correspondence:
| | - Paola Roccabianca
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
| | - Patrizia Boracchi
- Laboratorio di Statistica Medica, Biometrica ed Epidemiologia “A. Maccaro”, Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, 20122 Milan, Italy;
| | - Francesco Godizzi
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
| | | | - Damiano Stefanello
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
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5
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Del Magno S, Morello E, Iussich S, Gola C, Dalpozzo B, Annoni M, Martano M, Massari F, Giacobino D, Piras LA, Stefanello D, Buracco P. Evaluation of the neoplastic infiltration of the skin overlying canine subcutaneous soft tissue sarcomas: An explorative study. Vet Comp Oncol 2021; 19:304-310. [PMID: 33423367 DOI: 10.1111/vco.12676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 11/24/2022]
Abstract
Studies regarding the neoplastic infiltration of the skin overlying canine subcutaneous soft tissue sarcoma (sSTS) are lacking. In case of the absence of tumor infiltration, there would be the possibility of leaving this unaffected skin in place, thus simplifying surgery. The aim of the study was to investigate whether the skin overlying sSTSs is infiltrated by neoplastic cells. Dogs with sSTSs treated surgically were prospectively enrolled. After excision, the skin was dissected from the tumor along the natural surgical plane of cleavage and histologically evaluated. Twenty-nine dogs with an sSTS were included (22 grade I, 6 grade II, and 1 grade III). The sSTS-overlying skin was not tumor-infiltrated in 14/29 cases (48.3%). A higher frequency of infiltration was observed in higher grade sSTSs (grades II and III, 100%; P = .006); nevertheless, 8/22 grade I sSTSs (36%) also showed cutaneous infiltration. This infiltration involved the dermis of the skin directly in contact with the tumor (multifocal in 11 and diffuse in four cases). Although the cutaneous tumor infiltration is less frequent in grade I sSTSs and a wide excision may still be the safest treatment for any sSTS for a greater possibility of local control, this study opens the possibility to a less aggressive cutaneous excision, but still with a local curative intent, as only the skin directly in contact with the sSTS has been proven to be tumor-infiltrated. Additional studies are warranted to confirm that excision of only this skin may guarantee a complete local control, especially in lower-grade sSTSs.
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Affiliation(s)
- Sara Del Magno
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell'Emilia, Italy
| | - Emanuela Morello
- Department of Veterinary Science, University of Turin, Grugliasco, Italy
| | - Selina Iussich
- Department of Veterinary Science, University of Turin, Grugliasco, Italy
| | - Cecilia Gola
- Department of Veterinary Science, University of Turin, Grugliasco, Italy
| | - Boris Dalpozzo
- Clinica Veterinaria dell'Orologio, Sasso Marconi, Bologna, Italy
| | | | - Marina Martano
- Department of Veterinary-Medical Sciences, University of Parma, Parma, Italy
| | | | - Davide Giacobino
- Department of Veterinary Science, University of Turin, Grugliasco, Italy
| | - Lisa Adele Piras
- Department of Veterinary Science, University of Turin, Grugliasco, Italy
| | | | - Paolo Buracco
- Department of Veterinary Science, University of Turin, Grugliasco, Italy
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Abrams BE, Putterman AB, Ruple A, Wavreille V, Selmic LE. Variability in tumor margin reporting for soft tissue sarcoma and cutaneous mast cell tumors in dogs: A systematic review. Vet Surg 2020; 50:259-272. [DOI: 10.1111/vsu.13539] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 10/01/2020] [Accepted: 10/17/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Brittany E. Abrams
- Department of Veterinary Clinical Sciences College of Veterinary Medicine, The Ohio State University Columbus Ohio
| | - Allison B. Putterman
- Department of Veterinary Clinical Medicine College of Veterinary Medicine, University of Illinois at Urbana‐Champaign Urbana Illinois
| | - Audrey Ruple
- Department of Comparative Pathobiology College of Veterinary Medicine, Purdue University West Lafayette, Indiana
| | - Vincent Wavreille
- Department of Veterinary Clinical Sciences College of Veterinary Medicine, The Ohio State University Columbus Ohio
| | - Laura E. Selmic
- Department of Veterinary Clinical Sciences College of Veterinary Medicine, The Ohio State University Columbus Ohio
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Saunders H, Thomson MJ, O'Connell K, Bridges JP, Chau L. Evaluation of a modified proportional margin approach for complete surgical excision of canine cutaneous mast cell tumours and its association with clinical outcome. Vet Comp Oncol 2020; 19:604-615. [PMID: 32558125 DOI: 10.1111/vco.12630] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 12/27/2022]
Abstract
Canine cutaneous mast cell tumours (MCTs) represent a common neoplasm in veterinary practice. Several reported techniques are available to guide surgical excision. Our study examined one hundred cutaneous MCTs that were excised surgically using a modified proportional margin approach. A 2 cm lateral margin upper limit was applied for any tumour diameter that exceeded this size with a deep surgical margin of one fascial plane applied. A retrospective, cross-sectional study with follow-up was used to determine the clinical utility of this excision technique. Associations between explanatory variables of tumour size and grade were compared with outcomes of complete excision and size of histologic tumour-free margins (HTFM) using the appropriate Pearson's χ2 and Fisher's exact tests. Follow-up data evaluated tumour recurrence and patient survival. Ninety-five percent of MCTs (95/100) were completely excised. No significant association in the achievement of complete excision between low- and high-grade MCTs (P = .48) was noted. Tumour size was not associated with the rate of complete excision (P = .06). Tumour grade and size did not influence the size of the HTFM (P = .94 and P = .14, respectively). Overall, a recurrence rate of 3% (3/100 tumours) and de novo MCT development rate of 7.7% (5/65 dogs) was noted, with median follow-up period of 593 days (range 180-1460 days). Post-operative metastases were seen in 4.6% of dogs (3/65). Therefore, a modified proportional margin approach with 2 cm lateral margin upper limit is a suitable technique to guide surgical excision of canine cutaneous MCTs.
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Affiliation(s)
- Harvey Saunders
- Department of Oncology, Animal Referral Hospital Brisbane, Sinnamon Park, Queensland, Australia
| | - Maurine J Thomson
- Department of Oncology, Animal Referral Hospital Brisbane, Sinnamon Park, Queensland, Australia
| | - Kathleen O'Connell
- Department of Oncology, Animal Referral Hospital Brisbane, Sinnamon Park, Queensland, Australia
| | - Janis P Bridges
- Institute of Veterinary, Animal and Biomedical Sciences, Massey University, Palmerston North, New Zealand
| | - Lincoln Chau
- Department of Oncology, Animal Referral Hospital Brisbane, Sinnamon Park, Queensland, Australia
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8
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Liptak JM. Histologic margins and the residual tumour classification scheme: Is it time to use a validated scheme in human oncology to standardise margin assessment in veterinary oncology? Vet Comp Oncol 2019; 18:25-35. [DOI: 10.1111/vco.12555] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/05/2019] [Accepted: 11/08/2019] [Indexed: 12/12/2022]
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9
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Milovancev M, Townsend KL, Tuohy JL, Gorman E, Bracha S, Curran KM, Russell DS. Long-term outcomes of dogs undergoing surgical resection of mast cell tumors and soft tissue sarcomas: A prospective 2-year-long study. Vet Surg 2019; 49:96-105. [PMID: 31044443 DOI: 10.1111/vsu.13225] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 03/19/2019] [Accepted: 04/14/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Report clinical outcomes of dogs with surgically excised mast cell tumors (MCT) and soft tissue sarcomas (STS). STUDY DESIGN Prospective clinical study. SAMPLE POPULATION Fifty-three dogs with 52 MCT (50 low grade, 2 high grade) and 19 STS (12 grade I, 6 grade II, 1 grade III). METHODS All dogs were examined at 3, 6, 12, 18, and 24 months postoperatively, with cytologic or histopathologic evaluation of suspected local recurrences. Dogs euthanized because of study tumor-related causes underwent necropsy. RESULTS Median intraoperative margins were 20 mm and 30 mm wide for MCT and STS, respectively, with 1 fascial plane resected en bloc. The narrowest histologic tumor-free margins measured <1 mm in 21 of 52 (40%) MCT and 7 of 19 (37%) STS. All dogs were followed for 24 months. Two of 50 (4%) low-grade MCT were diagnosed, with local recurrence 181 and 265 days postoperatively. Two of 36 (6%) dogs with low-grade MCT developed visceral metastasis 181 and 730 days postoperatively. One of 2 dogs with high-grade MCT developed local recurrence 115 days postoperatively. No local recurrence or metastasis was diagnosed after excision of 19 STS. CONCLUSION Local recurrence rates among predominantly low- to intermediate-grade MCT and STS were low, despite a high prevalence of histologic tumor-free margins <1 mm. Surgical recommendations for high-grade tumors cannot be extrapolated from this population. CLINICAL SIGNIFICANCE Surgeons should seek to achieve microscopically complete excision for MCT and STS while minimizing patient morbidity and considering limitations of histopathology in predicting outcomes.
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Affiliation(s)
- Milan Milovancev
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon
| | - Katy L Townsend
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon
| | - Joanne L Tuohy
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Elena Gorman
- Department of Biomedical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon
| | - Shay Bracha
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon
| | - Kaitlin M Curran
- Department of Clinical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon
| | - Duncan S Russell
- Department of Biomedical Sciences, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon
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