Significance Of Margins Research Articles

Management of patients with positive surgical margins after vertical hemilaryngectomy.

To evaluate the significance of positive surgical margins after vertical hemilaryngectomy for squamous cell carcinoma of the larynx. A retrospective review of patients undergoing hemilaryngectomy over a 20-year period. A major academic medical center. Fifty-six consecutive patients who underwent hemilaryngectomy between 1970 and 1990. Seventeen patients were excluded because of insufficient data or because they received postoperative radiation therapy. Eleven (28%) of 39 patients had cancer involvement of at least one margin. Two (8%) of 28 patients with negative margins and six (55%) of 11 patients with positive margins had recurrence. This difference in tumor recurrence is statistically significant. The mean disease-free interval prior to recurrence was 25 months, with no significant difference between the two groups. The mean follow-up periods for patients with positive vs negative margins were not statistically significant. There were no significant differences in survival estimates between patients with positive margins and those with negative margins. Despite a sevenfold increase in tumor recurrence rates for patients with positive margins after hemilaryngectomy, there was no adverse effect on overall survival when these patients were managed with close follow-up and salvage surgery with or without postoperative radiation therapy for tumor recurrence.

The Prognostic Significance of Surgical Margin in Liver Resection of Patients With Hepatocellular Carcinoma

To evaluate the prognostic significance of surgical margin in liver resection of patients with hepatocellular carcinoma. Retrospective study. The Center for Adult Diseases, Osaka, Japan, between 1980 and 1989. One hundred eighty-five patients with hepatocellular carcinoma who underwent liver resection with complete extirpation. Cumulative survival rate. The patients were divided into a wide surgical margin group, in which the lesion was excised with a margin of 1.0 cm or more, and a narrow surgical margin group, in which the margin was less than 1.0 cm. No significant differences could be detected in survival rates for 3 years or longer. Mean +/- SE tumor sizes were 3.4 +/- 0.4 cm and 4.4 +/- 0.3 cm, respectively, in the wide and narrow surgical margin groups. The patients were divided into three groups according to tumor size: group 1, 2.0 cm or less in diameter; group 2, greater than 2.0 cm but 5.0 cm or less in diameter; and group 3, greater than 5.0 cm in diameter. In groups 2 and 3, no significant differences in survival rates were found between the wide and narrow surgical margin groups. In group 1, the survival rate was significantly higher in the wide surgical margin group than in the narrow surgical margin group (P < .05). Small hepatocellular carcinomas of 2.0 cm or less in diameter should be resected with an adequate surgical margin. However, surgical margin was not a significant factor in the resection of hepatocellular carcinomas larger than 2.0 cm.

Planned Segmentectomy

Some surgeons consider excisional biopsy with gross negative margins to be adequate surgical therapy for breast carcinomas, if followed by axillary dissection and radiation. To test our hypothesis that breast carcinoma necessitates planned operation, we reviewed the incidence of residual cancer tissue (RCT) and the significance of positive margins following excisional breast biopsy and segmentectomy. SETTING, PATIENTS, AND INTERVENTION/OUTCOME MEASURES: Using the clinical database of our multidisciplinary cancer center, we examined the tumor status of segmentectomy specimens from 375 patients treated for breast carcinoma during the past 10 years. All patients underwent excisional biopsy of the tumor mass before definitive treatment with segmentectomy and axillary dissection. Median follow-up was 32 months. The 284 patients (76%) whose segmentectomy specimens contained residual tumor (RCT-positive patients) had a larger median tumor diameter than RCT-negative patients (2 vs 1 cm, P < .01). Patients with tumor-positive axillary lymph nodes were more likely to be RCT positive (P < .001). Tumors of RCT-positive patients were more frequently identified by physical examination, whereas those of RCT-negative patients were more frequently identified by mammography (P < .001). Overall recurrence rate was 7% (26/384). Recurrence-free survival rates were statistically related to tumor status of the segmentectomy margins (P < .025) but not to RCT in the segmentectomy specimen. Diagnostic breast biopsy is not a substitute for planned excision to remove all malignant tissue. Anything less than a preconceived surgical procedure may leave a significant amount of malignant tissue.

Limb-preserving treatment for soft tissue sarcomas of the extremities. The significance of surgical margins.

Between 1970 and 1990, 74 patients with extremity soft tissue sarcomas began a regimen of limb-sparing surgery and irradiation. Ninety-two percent received postoperative irradiation, 7% received preoperative irradiation, and one patient was treated with radiation after an incisional biopsy only. Radiation was administered with a shrinking-field technique (median total dose, 63 Gy; range, 39.6-71 Gy), with 14 patients receiving interstitial brachytherapy as a component of treatment. Ten patients received adjuvant chemotherapy. Local control of disease was 82% at 5 years, and 95% after salvage therapy. The actuarial risk of distant disease recurrence was 27%, with an overall survival rate of 70% at 5 years. Histologic subtype, tumor grade, size of tumor, location of tumor, status of the surgical margins, use of chemotherapy, radiation dose, interval until initiation of radiation therapy, and use of a brachytherapy boost were analyzed to determine their effect on survival, local control, and freedom from distant metastasis. Microscopic involvement of the surgical margins predicted for local disease recurrence (P = 0.0002), distant disease recurrence (P = 0.008), and poorer overall survival (P = 0.02). Low histologic grade was favorably correlated with freedom from distant disease recurrence (P = 0.004) and survival (P = 0.002). Patients with liposarcomas had superior local control (P = 0.004) compared with patients with tumors of other histologic subtypes. Five patients experienced a complication of therapy, for an actuarial risk of 10% at 5 years. Only two patients required hospital admittance for treatment-related morbidity. These findings support the continued use of limb-preserving management for extremity sarcomas and emphasize the importance of the status of the surgical margins.

Immediate free flap mandibular reconstruction: significance of adequate surgical margins.

The pathologic records of 182 consecutive patients who had mandible resections were reviewed to determine the incidence of positive margins in the bone specimens and the risk factors associated with positive margins. Of the 182 cases reviewed, 82 (45%) were found to have involvement of the mandible at the time of resection and four (2%) were found to have positive margins. The predominant tumor histology was squamous cell carcinoma, 148 of 182 (81%), followed in frequency by osteosarcoma 12 of 182 (7%), salivary gland tumors 13 of 182 (7%), and miscellaneous other tumors (nine of 182 (5%). Of the four tumors with positive margins, two (50%) were squamous cell carcinomas, one (25%) was an osteosarcoma, and one (25%) was a salivary gland tumor. All four tumors were large tumors that had failed to respond to previous therapy. All obviously involved the mandible at the time of presentation. This study demonstrates that the incidence of bone margin involvement after mandibulectomy is rare and predictable and that clinical selection of candidates for immediate reconstruction is reliable in preventing inappropriate use of free bone flaps in patients at risk for positive bone margins.

The significance of cone biopsy resection margins

This 12-year retrospective study examines the significance of margin involvement with dysplasia at cone biopsy in relation to follow-up. Of 300 cone biopsies, 123 (41%) had margin involvement. These cases of margin involvement were associated with more severe dysplasia ( P < 0.0001) and a higher chance of subsequent abnormal cytological follow-up ( P < 0.0001) and residual dysplasia at subsequent surgery ( P < 0.0001). Involvement of the endocervical margin at the initial cone biopsy was a sensitive predictor of future abnormality, with an incidence of subsequent abnormal cytology of 29% and residual disease of 82% in those undergoing further surgery. In those cases where the margins had been clear, the incidence of abnormal cytological follow-up was 8%, with 12% residual disease in those undergoing subsequent surgery. Margin involvement was a better predictor of residual disease at repeat surgery than abnormal follow-up cytology (positive predictive value, 79% vs 60%, respectively).

The significance of the pathology margins of the tumor excision on the outcome of patients treated with definitive irradiation for early stage breast cancer

To evaluate the significance of the pathology margins of the tumor excision on the outcome of treatment, an analysis was performed of 697 consecutive women with clinical Stage I or II invasive carcinoma of the breast treated with breast-conserving surgery and definitive irradiation. Complete gross excision of the primary tumor was performed in all cases, and an axillary staging procedure was performed to determine pathologic axillary lymph node status. The 697 patients were divided into four groups based on the final pathology margin from the primary tumor excision or from the re-excision if performed. These four groups were: (a) 257 patients with a negative margin (>2 mm), (b) 57 patients with a positive margin, (c) 37 patients with a close margin (⪯2 mm), and (d) 346 patients with an unknown margin. The patients with positive final pathology margins were focally positive on microscopic examination. Patients with grossly positive margins or with diffusely positive microscopic margins were treated with conversion to mastectomy. There was a significant difference in the total radiation dose for the four groups (median dose of 6000 vs 6500 vs 6400 vs 6240 cGy, respectively; p < .0001). There was no significant difference among the four groups for 5-year actuarial overall survival (p = .19), no evidence of disease (NED) survival (p = .95), or relapsefree survival (p = .80). There was no significant difference among the four grous for five year actuarial local or regional control (all p ≥ .29). Subset analyses did not identify any poor outcome subgroups. These results have demonstrated that selected patients with focally positive or close microscopic pathology margins can be adequately treated with definitive breast irradiation. Patient selection and the technical delivery of radiation treatment including a boost may have been important contributing factors to the good outcome in these patients.

Significance of positive margins in oral cavity squamous carcinoma : TR Loree, EW Strong. Am J Surg 1990; 160:410–414

Significance of positive margins in oral cavity squamous carcinoma : TR Loree, EW Strong. Am J Surg 1990; 160:410–414

Significance and Treatment of Positive Margins or Seminal Vesicle Invasion After Radical Prostatectomy

The periprostatic soft-tissue involvement described in the older urologic literature differs from that now recognized; a much "earlier" pathologic stage C is being identified. Apparent microscopic extension of the cancer to the margin of the specimen yields an approximately 25% risk of local recurrence. Postoperative radiation apparently is effective in reducing this risk, and if patients are properly selected, such treatment is well tolerated. Whether adjuvant radiation affects overall survival is not known. New observations on pathologic extension of the disease need to be refined.

Significance of positive margins in oral cavity squamous carcinoma

Three hundred ninety-eight consecutive, previously untreated patients undergoing surgery for epidermoid carcinoma of the oral cavity from 1979 to 1983 were reviewed. One hundred twenty-nine patients were classified as having positive surgical margins. Of these, 83 patients had tumor within 0.5 mm of the surgical margin, 9 had premalignant changes at the margin, 9 had in situ carcinoma at the margin, and 28 had invasive cancer at the margin. The remaining 269 patients had uninvolved margins. The significance of positive margins relating to survival, subsequent clinical course, local recurrence, and patterns of treatment failure was examined, along with the impact of adjuvant postoperative radiotherapy on positive margins. The percentage of patients having positive margins progressively increased with increasing T stage: 21% in T1 versus 55% in T4 primary cancer. The overall 5-year survival for patients with negative margins was 60%. For patients with positive margins, 5-year survival was 52%. This difference was statistically significant. The incidence of local recurrence in patients having positive surgical margins was twice as much as in those with negative margins (36% versus 18%). Metastasis rates in the neck and at distant sites were not significantly influenced by the status of the surgical margin. Of the 129 patients with positive margins, 49 received postoperative radiotherapy. In those patients so treated, a trend toward lower recurrence rates was noted. Differences were not statistically significant. This retrospective review confirms the importance of adequate resection of the primary tumor as well as the relative ineffectiveness of adjuvant postoperative radiotherapy in the improvement of local control in patients with positive surgical margins.

The significance of pathologic margins of tumor excision on the outcome of patients treated with definitive irradiation for early stage breast cancer

The significance of pathologic margins of tumor excision on the outcome of patients treated with definitive irradiation for early stage breast cancer

The significance of positive endocervical curettage and endocervical margins: A review of 183 cone biopsies

The significance of positive endocervical curettage and endocervical margins: A review of 183 cone biopsies

Squamous cell carcinoma of the external ear: a review of 75 cases.

Squamous cell carcinoma of the external ear can be a potentially lethal lesion. Although it is the most common cancer involving the pinna, the variables that have the greatest impact on prognosis are still in question. We reviewed 75 cases of squamous cell carcinoma of the external ear to determine patterns of occurrence and treatment failure. Forty patients had adequate follow-up for determination of cancer control rates. Local control was successful with initial treatment in 85% of the cases. The incidence of lymph node metastases was 10%, whereas distant metastasis occurred in only one patient (2.5%). This series differs from others in that most patients were unselected and most of the lesions treated were early (less than 1 cm). The significance of positive margins after surgical excision is also analyzed.

Democracy and Social Choice

The problem ofjustifying democracy arises when a society sees the need for cooperative, collective action. Collective action may be needed to solve coordination problems, public goods problems, Prisoner's Dilemmas, and other structural problems of human interaction or perhaps to realize common ideals of justice in concrete political institutions. Once the need for collective action is established, one must ask how the goals of a cooperative endeavor are to be secured. Cooperation requires that individuals, at least over a specified range of activity, pursue a joint strategy. To assure voluntary compliance in a joint venture, cooperation must be to each person's advantage. However, each person may have an incentive to induce others to cooperate and to defect from the joint strategy in the hope of enjoying the fruits of cooperation without incurring the opportunity costs of compliance. This is the essence of the Prisoner's Dilemma, and considerations of this sort suggest that if collective action is to succeed, policies or strategies formed collectively must be coercively enforceable. Coercion, however, requires justification. Because solving the problem of rational noncompliance requires that collective decisions be coercively enforceable, the rules by which collective decisions are reached require justification. Douglas Rae neatly puts the problem of justification that emerges when political solutions are coercively enforceable as follows: "Once a political community has decided which of its members are to participate directly in the making of collective policy, an important question remains: 'How many of them must agree before a policy is imposed on the community?"" This is essentially the question to which the principle of democratic rule provides an answer: by what process are collective decisions to be made? Answering Rae's question requires a normative framework. We could say that a procedure for making collective decisions is justified if and

The nature and significance of magma chamber margins in ophiolites: examples from the Norwegian Caledonides

Large-scale intrusive contacts with associated marginal series have been encountered within Norwegian ophiolite complexes at Karmøy, Solund and Leka. The contacts limit individual magma chambers and are found at different structural levels of the plutonic suites. Examples of magma chamber margins adjacent to interlayered ultramafic and gabbroic rocks, modally-layered gabbros, high-level gabbros and sheeted dykes, are described. The nature of the intrusive boundaries and the presence of partially resorbed xenoliths in the vicinity of the intrusive margins suggest that stoping and assimilation have been important mechanisms during the development of the magma chambers. Characteristic marginal series are developed along the intrusive boundaries. The thicknesses and appearance of these series vary with depth in the complexes. Whereas the marginal series are well developed within the uppermost levels of the plutonic complexes (exhibiting rock types such as microgabbro, massive gabbro and magnetite gabbro), the marginal series observed at lower levels are thinner and also devoid of chilled facies rocks and magnetite gabbros. The marginal series may be subdivided into border and roof series. The latter are characterized by an intimate relationship with sheeted dykes, which comprise dyke swarms formed both prior to, during, and subsequent to crystallization of the roof series. Based on these relationships the dykes can be subdivided into rooted and rootless dykes. A multiple magma chamber model, with magma chambers migrating from a low to a high level within the oceanic crust, is proposed on the basis of the observed features.

The significance of laser margins when treating genital condylomata and vulvar intraepithelial neoplasia (VIN) with reference to latent human papillomavirus (HPV)

The significance of laser margins when treating genital condylomata and vulvar intraepithelial neoplasia (VIN) with reference to latent human papillomavirus (HPV)

Abashiri Tectonic line : Kimura, Gaku, 1981. Special reference to the tectonic significance of the southwestern margin of the Kurile Arc. J. Fac. Sci. Hokkaido Univ., (Ser. 4, Geol. Mineral.) 20(1):95–111

Abashiri Tectonic line : Kimura, Gaku, 1981. Special reference to the tectonic significance of the southwestern margin of the Kurile Arc. J. Fac. Sci. Hokkaido Univ., (Ser. 4, Geol. Mineral.) 20(1):95–111

The significance of positive margins in hemilaryngectomy specimens.

This clinicopathologic study was undertaken to determine the meaning of surgical margins "involved" with carcinoma. The fate of hemilaryngectomy patients whose specimens had this finding was comparared with that of patients who had "uninvolved" margins. A consecutive series of 111 hemilaryngectomies performed for previously untreated invasive epidermoid carcinoma was analyzed. Serial step sections in a longitudinal plane were available for re-examination and re-evaluation of the surgical margins in each case. Clinical follow-up on every patient was current through 1972. Thirty-nine patients had cancer involvement of a margin in the hemilaryngectomy specimen. None of these patients received any immediate therapy but were followed only. Seven of these patients (18 percent) subsequently developed a biopsy proven local recurrence. Four of the 72 patients (6 percent) with uninvolved margins developed a local recurrence. The site of the positive margin in the specimen was compared with the clinical site of recurrence. The seven local recurrences in patients with positive margins were treated with full course irradiation or total laryngectomy. All of these patients are alive and free of cancer or have died of other causes without evidence of cancer. Of the four local recurrences in patients with negative margins one died of cancer; two are living and well, and one died of other causes. This study provides evidence to support the conservative management of those hemilaryngectomy patients who have involved margins in the resection specimen. No immediate treatment is required. Careful follow-up is indicated with 18 percent chance of clinical recurrence. These biopsy proven recurrences can then be successfully treated with total laryngectomy or full course irradiation. Utilizing this approach none of the 39 patients with involved margins died of cancer in the 5 to 12-year follow-up period.

Prognostic significance of tumor margins in mammary carcinoma.

The previously suggested favorable prognostic significance of pushing tumor margins in mammary carcinoma is denied by the present report. Although tumors with margins of this sort are less likely to be associated with extensive axillary lymph nodal metastases, the ultimate prognosis for survival is no better in these cases, and is actually somewhat worse when medullary and colloid carcinomas are excluded. Since the tumors with pushing margins appear to be comparable in other respects to those with infiltrating margins, the reason for these findings remains unclear.

Rent and Price: "Alternative Use" and "Scarcity Value"

I. The alternative idea, 119. — A or price notion, 120. — Assumes distinct land-use groups and margins, 121. — II. Its alternative-utility aspect, 121. — Not significant as a long-time factor, 122. — Limited significance as a short-time factor, 123. — Classification of land utilities, 124. — III. The alternative-supply aspect, 126. — Limitations, general and particular, 126. — Costs, 127. — Return to view-point and net utility, 128. — Effect of unequal wealth distribution, 129. — IV. The relation of alternative uses to rent, 130. — Not causal or determinative, 130. — Some practical considerations, 131. — V. Mill's treatment of scarcity value and rent, 132. — Overlooks the significance of the intensive margin, 135. — Loose use of terms, 137.