Routine Intraoperative Frozen Section Represents a "Very Costly" Soft Tissue Sarcoma Procedure

The utility of routine peripheral margin sampling in soft tissue sarcoma resection may be considered a questionable approach with added cost, according to R. Lor Randall, MD, FACS.

In a study assessing peripheral margin sampling patterns in patients with soft tissue sarcoma (n = 179), 66% had peripheral margins sampled, of which frozen margins were analyzed in 23%.1 The findings demonstrated that 10 patients had positive margins (5.5% of all patients; 8.4% of those with margins sampled) and 15 patients (8.4%) had R1 margins on the final tumor specimen.

Surveys regarding intraoperative peripheral margins were sent to 320 members of the Musculoskeletal Tumor Society, and 108 responses were collected.2 Of note, 51% (n = 55) of responding members reported that they routinely send intraoperative margins; specifically, members who routinely send frozen margins send 4 to 6 specimens on average.

“[This is] relevant to all medical, radiation, and surgical oncologists who are interested in sarcoma and solid tumors because it does have some bearing on treatment algorithms, as well as the value proposition with health care and the cost of delivering quality care,” Randall said during an interview with OncLive®.

In the interview, Randall discussed the role of intraoperative frozen sections in soft tissue sarcoma and the utility of this approach.

Randall is the David Linn Endowed Chair for Orthopedic Surgery, chair in the Department of Orthopedic Surgery, and professor in the Department of Orthopedic Surgery at the University of California, Davis in Sacramento.

OncLive: What is the role of intraoperative frozen sections in soft tissue sarcoma?

Randall: We did a couple of studies looking at intraoperative frozen sections and resections of soft tissue sarcomas; [these studies] primarily [included] adults, but there were a few [children] here. This was a study looking at soft tissue sarcomas, not bone sarcomas.

When we remove the tumor, some surgical oncologists will take samplings outside of the tumor bed. For example, you remove the tumor, but then you're left with the sarcoma bed; you take sampling margins to look for any atypical cells, and that's called a frozen section. You get some real-time feedback, and sometimes they'll say this area is a little bit suspicious, and then the surgeon will take a little bit more.

What is the utility of intraoperative frozen sections in soft tissue sarcomas?

When you do a frozen section, it's approximately $500. Then, they will also do i definitive analysis, and they can charge about $500 for that, as well. On average, that's approximately $1000, and I think that's true at most centers. If you take more than 1, say you take up to 5 or 6, you're talking about $5000 or $6000 of added cost.

What's the utility of that? We [looked at] 2 things [in our studies]. We looked at our own institutional experience and the yield therein. We also surveyed the Musculoskeletal Tumor Society to see their practices because these were the content experts. What we did with our center is we looked at 179 patients [with] soft tissue extremity sarcomas, and two-thirds of them had peripheral margins sampled with frozen sections, and we found some with positive margins. We found the vast majority were not. What was interesting was that if we had a positive peripheral margin identified, there was about a 50% chance that the final resection margin would be positive, or what we call R1. However, if the margins we sampled were negative, there was only a 4.6% chance of the margins being positive, and this was statistically significant. There was also a weak-to-moderate agreement between the peripheral margin and the final specimen margin.

What this is basically telling us is that if [patients] get a frozen section, but the vast frozen section is positive, that may mean you need to do a little bit more resection, but that positive margin is pretty infrequent, and it's very costly to do it.

What are the key take-home messages regarding this research?

We wanted to do was take this information and discuss it with the Musculoskeletal Tumor Society and see what they thought about it. We sent out a survey, and at the end of it, only 51% of surgeons said that they felt doing this sampling of peripheral margins as frozen sections at the time of surgery was worth it, and 49% said it was not worth it, so [results were] right down the middle.

However, the take-home message for us is that we need to be pretty critical of this. The message for the surgical oncologists is there is a good reason to do a sampling peripheral margin when there is a clinical suspicion that that margin will be positive. For example, if you've got a tumor and you're dissecting off critical structures, or it's near the bone, maybe then you want to get a peripheral margin and send that for a frozen section. However, to do it carte blanche and say we're going to say, 'You got this big tumor we've just taken out, now we're just going to take random sections around the perimeter and sample them.' That very often leads to negativity and high costs, so we should probably tailor our practice and use it on a much more discretionary basis.

What does it mean to the nonsurgical oncologist? Well, the radiation therapist certainly will care about local control. In an era of cost containment, with increased health care demands, and challenges of access to increased costs, we need to think about driving down the surgical costs, which will not directly impact the radiation therapist, but they do want to be aware of the areas where the surgeon is potentially, at their discretion, taking more tissue and looking at it and doing that additional peripheral margin. The radiation therapist might say those are areas where you want to lay clips so that I know that's an area of concern so that I can boost my therapy to that area. The clips will allow for the radiation therapist to boost that area on CT scans and or conventional radiographs. For the medical oncologists, although they may [provide] care on the day-to-day a little bit less for this, it's important to realize that the surgeons do want to be part of the value equation here and drive down costs. Not just doing things as defensive medicine but doing them for a reason.

What are some of the next steps in this domain that will be explored?

In the consensus of guidelines around soft tissue sarcoma, we need to make sure that this is entrenched. The opinion and science inform us that we shouldn't just be getting additional margins all the time, and whether it's just for optimal health care or part of the value of health care, we need to get those into guidelines [to] be helpful. So [this could be] NCCN guidelines, or other consensus statements around the management of soft tissue sarcoma, where say if the surgeon determines that a margin is at risk, one should consider doing a select peripheral margin sampling in that area, but not globally across the field, would be something that would be helpful.

References

1. Zeitlinger L, Chavez GM, Wilson MD, et al. Intraoperative Peripheral Frozen Margin Assessment in Soft Tissue Sarcoma. J Surg Oncol. Published online November 11, 2024. doi:10.1002/jso.27935
2. Zeitlinger L, Chavez GM, Darrow M, Canter RJ, Randall RL, Thorpe SW. Musculoskeletal Tumor Society Member Survey: Intra-Operative Peripheral Margins in Soft Tissue Sarcoma. J Surg Oncol. Published online November 11, 2024. doi:10.1002/jso.27936