Surgical margins in head and neck cancer: A contemporary review

Intraoperative imaging in pathology-assisted surgery

The pathological assessment of surgical specimens during surgery can reduce the incidence of positive resection margins, which otherwise can result in additional surgeries or aggressive therapeutic regimens. To improve patient outcomes, intraoperative spectroscopic, fluorescence-based, structural, optoacoustic and radiological imaging techniques are being tested on freshly excised tissue. The specific clinical setting and tumour type largely determine whether endogenous or exogenous contrast is to be detected and whether the tumour specificity of the detected biomarker, image resolution, image-acquisition times or penetration depth are to be prioritized. In this Perspective, we describe current clinical standards for intraoperative tissue analysis and discuss how intraoperative imaging is being implemented. We also discuss potential implementations of intraoperative pathology-assisted surgery for clinical decision-making.

Robotic vs. transoral laser surgery of malignant oropharyngeal tumors-what is best for the patient? : A contemporary review

Human papillomavirus (HPV)-associated squamous cell carcinoma of the oropharynx is a malignancy of increasing prevalence. The oncologic community is currently evaluating the safety and efficacy of de-intensifying treatment without compromising oncologic outcomes. Paramount to these treatment algorithms is primary surgery through transoral approaches. This article reviews the literature and concepts pertaining to transoral surgery and describes the two most common techniques, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS).

Multicentre study on resection margins in carcinoma of the oral cavity, oro-hypopharynx and larynx

Objective

The prognostic significance of the resection margins is still subject of conflicting opinions. The purpose of this paper is to report the results of a study on the margins in carcinoma of the oral cavity, oro-hypopharynx and larynx.

Methods

A multicentre prospective study was carried out between 2015 and 2018 with the participation of 10 Italian reference hospitals. The primary objective was to evaluate local control in patients with well-defined clinical characteristics and comprehensive histopathological information.

Results

During the study period, 455 patients were enrolled; the minimum follow-up was 2 years. Previous treatment, grading and fresh specimen examination were identified as risk factors for local control in multivariate analysis. On the basis of these results, it seems possible to delineate “risk profiles” for different oncological outcomes.

Discussion

The prognostic significance of the margins is reduced, and other risk factors emerge, which require diversified treatment and follow-up.

Conclusions

Multidisciplinary treatment with adjuvant therapy, if indicated, reduces the prognostic importance of margins. Collaboration with a pathologist is an additional favourable prognostic factor and quality indicator.

An appendix with literature review is present in the online version.

Surgical Margins After Computer-Assisted Mandibular Reconstruction: A Retrospective Study

Purpose: The use of virtual surgical planning in head and neck surgery is growing strongly. In the literature, its validity, accuracy and clinical utility for mandibular reconstruction are widely documented. Virtual planning of surgical bone resection and reconstruction takes place several days before surgery and its very sensitive nature can negatively affect an intervention aimed at maximum precision in term of oncological safety. Methods: The study focuses on a retrospective evaluation of the surgical margins in 26 consecutive cases with oral cavity malignancy and who underwent computer-assisted mandibular resection/reconstruction guided by the different types of bone, periosteal and peri-mandibular tissue involvement. The goal was to analyze the strategic and technical aspects useful to minimize the risk of positive or close margins and to vary the reconstructive strategy in the case of intraoperative findings of a non-radical planned resection. Results: No intraoperative or perioperative complications occurred. In 20 patients, virtual surgical planning permitted mandibular reconstruction to be performed using composite fibular free flaps, characterized by high accuracy and negative bone margins. In the remaining 6 patients, also virtually planned but otherwise reconstructed due to poor general condition (advanced age, severe comorbidity), negative bone margins were obtained. Intraoperative enlargement of the resection was carried out in one case and positive soft tissue margins were observed in another case. Conclusion: The results were satisfactory in terms of oncological radicality and precision. The functional benefits and reduction in operating times, previously demonstrated in other articles also by the authors, seem to justify the side effects related to the risk of modifying the planned surgery. During virtual planning, the surgeons must bear in mind that an unexpected progression of the tumor or a limited planned resection will entail modifying the extent of the resection intraoperatively and nullifying the virtual planning on which the reconstruction was based. Further investigations are necessary to clarify all aspects of virtual surgical planning in this setting.

Frozen Section Analysis and Real-Time Magnetic Resonance Imaging of Surgical Specimen Oriented on 3D Printed Tongue Model to Assess Surgical Margins in Oral Tongue Carcinoma: Preliminary Results

Background

A surgical margin is the apparently healthy tissue around a tumor which has been removed. In oral cavity carcinoma, a negative margin is considered ≥ 5 mm, a close margin between 1 and 5 mm, and a positive margin ≤ 1 mm. Currently, the intraoperative surgical margin status is based on the visual inspection and tissue palpation by the surgeon and intraoperative histopathological assessment of the resection margins by frozen section analysis (FSA). FSA technique is limited and susceptible to sampling errors. Definitive information on the deep resection margins requires postoperative histopathological analysis.

Methods

We described a novel approach for the assessment of intraoperative surgical margins by examining a surgical specimen oriented through a 3D-printed specific patient tongue with real-time Magnetic Resonance Imaging (MRI). We reported the preliminary results of a case series of 10 patients, prospectively enrolled, with oral tongue carcinoma who underwent surgery between February 2020 and April 2021. Two radiologists with 5 and 10 years of experience, respectively, in Head and Neck radiology in consensus evaluated specimen MRI and measured the distance between the tumor and the specimen surface. We performed intraoperative bedside FSA. To compare the performance of bedside FSA and MRI in predicting definitive margin status we computed the weighted sensitivity (SE), specificity (SP), accuracy (ACC), area under the ROC curve (AUC), F1-score, Positive Predictive Value (PPV), and Negative Predictive Value (NPV). To express the concordance between FSA and ex-vivo MRI we reported the jaccard index.

Results

Intraoperative bedside FSA showed SE of 90%, SP of 100%, F1 of 95%, ACC of 0.9%, PPV of 100%, NPV (not a number), and jaccard of 90%, and ex-vivo MRI showed SE of 100%, SP of 100%, F1 of 100%, ACC of 100%, PPV of 100%, NPV of 100%, and jaccard of 100%. These results needed to be validated in a larger sample size of 21- 44 patients.

Conclusion

The presented method allows a more accurate evaluation of surgical margin status, and the first clinical experiences underline the high potential of integrating FSA with ex-vivo MRI of the fresh surgical specimen.

Diagnostic Accuracy of Confocal Laser Endomicroscopy for the Diagnosis of Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Background: Advances in treatment approaches for patients with oral squamous cell carcinoma (OSCC) have been unsuccessful in preventing frequent recurrences and distant metastases, leading to a poor prognosis. Early detection and prevention enable an improved 5-year survival and better prognosis. Confocal Laser Endomicroscopy (CLE) is a non-invasive imaging instrument that could enable an earlier diagnosis and possibly help in reducing unnecessary invasive surgical procedures. Objective: To present an up to date systematic review and meta-analysis assessing the diagnostic accuracy of CLE in diagnosing OSCC. Materials and Methods. PubMed, Scopus, and Web of Science databases were explored up to 30 June 2021, to collect articles concerning the diagnosis of OSCC through CLE. Screening: data extraction and appraisal was done by two reviewers. The quality of the methodology followed by the studies included in this review was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. A random effects model was used for the meta-analysis. Results: Six studies were included, leading to a total number of 361 lesions in 213 patients. The pooled sensitivity and specificity were 95% (95% CI, 92–97%; I² = 77.5%) and 93% (95% CI, 90–95%; I² = 68.6%); the pooled positive likelihood ratios and negative likelihood ratios were 10.85 (95% CI, 5.4–21.7; I² = 55.9%) and 0.08 (95% CI, 0.03–0.2; I² = 83.5%); and the pooled diagnostic odds ratio was 174.45 (95% CI, 34.51–881.69; I² = 73.6%). Although risk of bias and heterogeneity is observed, this study validates that CLE may have a noteworthy clinical influence on the diagnosis of OSCC, through its high sensitivity and specificity. Conclusions: This review indicates an exceptionally high sensitivity and specificity of CLE for diagnosing OSCC. Whilst it is a promising diagnostic instrument, the limited number of existing studies and potential risk of bias of included studies does not allow us to draw firm conclusions. A conclusive inference can be drawn when more studies, possibly with homogeneous methodological approach, are performed.

Total Laryngectomy: A Review of Surgical Techniques

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end.

Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

A pre-screening strategy to assess resected tumor margins by imaging cytoplasmic viscosity and hypoxia

To assure complete tumor removal, frozen section analysis is the most common procedure for intraoperative pathological assessment of resected tumor margins. However, during one operation, multiple biopsies may be sent for examination, but only few of them are made into cryosections because of the complex preparation protocols and time-consuming pathological analysis, which potentially increases the risk of overlooking tumor involvement. Here, we propose a fluorescence-based pre-screening strategy that allows high-throughput, convenient, and fast gross assessment of resected tumor margins. A dual-activatable cationic fluorescent molecular rotor was developed to specifically illuminate live tumor cells’ cytoplasm by emitting two different fluorescence signals in response to elevations in hypoxia-induced nitroreductase (a biochemical marker) and cytoplasmic viscosity (a biophysical marker), two characteristics of cancer cells. The ability of the fluorescent molecular rotor in detecting tumor cells was evaluated in mouse and human specimens of multiple tissues by comparing with hematoxylin and eosin staining. Importantly, the fluorescent molecular rotor achieved 100 % specificity in discriminating lung and liver cancers from normal tissue, allowing pre-screening of the tumor-free surgical margins and promoting clinical decision. Altogether, this type of fluorescent molecular rotor and the proposed strategy may serve as a new option to facilitate intraoperative assessment of resected tumor margins.

Targeting Nanomaterials to Head and Neck Cancer Cells Using a Fragment of the Shiga Toxin as a Potent Natural Ligand

Head and Neck Cancer (HNC) is the seventh most common cancer worldwide with a 5-year survival from diagnosis of 50%. Currently, HNC is diagnosed by a physical examination followed by an histological biopsy, with surgery being the primary treatment. Here, we propose the use of targeted nanotechnology in support of existing diagnostic and therapeutic tools to prevent recurrences of tumors with poorly defined or surgically inaccessible margins. We have designed an innocuous ligand-protein, based on the receptor-binding domain of the Shiga toxin (ShTxB), that specifically drives nanoparticles to HNC cells bearing the globotriaosylceramide receptor on their surfaces. Microscopy images show how, upon binding to the receptor, the ShTxB-coated nanoparticles cause the clustering of the globotriaosylceramide receptors, the protrusion of filopodia, and rippling of the membrane, ultimately allowing the penetration of the ShTxB nanoparticles directly into the cell cytoplasm, thus triggering a biomimetic cellular response indistinguishable from that triggered by the full-length Shiga toxin. This functionalization strategy is a clear example of how some toxin fragments can be used as natural biosensors for the detection of some localized cancers and to target nanomedicines to HNC lesions.

The impact of positive margin on survival in oral cavity squamous cell carcinoma

BACKGROUND

Positive margins are known to impact survival in oral cavity squamous cell carcinoma (OCSCC). We aimed to determine the impact of positive margins on survival and whether radiation improves survival following positive margins.

METHODS

Data was obtained from the National Cancer Database and included patients with cT1T2N0 OCSCC. Survival outcomes were assessed via log-rank test. Cox-regression analysis was performed to determine if positive margins or radiation, when applicable, correlated with survival after accounting for covariates.

RESULTS

Positive margin patients had worse overall survival compared to negative margin control (HR = 1.76, p < 0.001) and reduced survival by 13%. On multivariate analysis, positive margins correlated with survival (HR = 1.60, p < 0.001). Radiation did not improve survival in positive margin patients (HR = 0.99, p = 0.55).

CONCLUSIONS

Patients with positive margins have an 11-15% worse overall survival. Radiation does not appear to impact survival in patients with a positive margin.

An overview of the current clinical status of optical imaging in head and neck cancer with a focus on Narrow Band imaging and fluorescence optical imaging

Early and accurate identification of head and neck squamous cell carcinoma (HNSCC) is important to improve treatment outcomes and prognosis. New optical imaging techniques may assist in both the diagnostic process as well as in the operative setting by real-time visualization and delineation of tumor. Narrow Band Imaging (NBI) is an endoscopic technique that uses blue and green light to enhance mucosal and submucosal blood vessels, leading to better detection of (pre)malignant lesions showing aberrant blood vessel patterns. Fluorescence optical imaging makes use of near-infrared fluorescent agents to visualize and delineate HNSCC, resulting in fewer positive surgical margins. Targeted fluorescent agents, such as fluorophores conjugated to antibodies, show the most promising results. The aim of this review is: (1) to provide the clinical head and neck surgeon an overview of the current clinical status of various optical imaging techniques in head and neck cancer; (2) to provide an in-depth review of NBI and fluorescence optical imaging, as these techniques have the highest potential for clinical implementation; and (3) to describe future improvements and developments within the field of these two techniques.

High-Resolution 18F-FDG PET/CT for Assessing Three-Dimensional Intraoperative Margins Status in Malignancies of the Head and Neck, a Proof-of-Concept

The surgical treatment of head and neck malignancies relies on the complete removal of tumoral tissue, while inadequate margins necessitate the use of adjuvant therapy. However, most positive margins are identified postoperatively as deep margins, and intraoperative identification of the deep positive margins could help achieve adequate surgical margins and decrease adjuvant therapies. To improve deep-margin identification, we investigated whether the use of high-resolution preclinical PET and CT could increase certainty about the surgical margins in three dimensions. Patients with a malignancy of the head and neck planned for surgical resection were administered a clinical activity of 4MBq/kg ¹⁸F-FDG approximately one hour prior to surgical initiation. Subsequently, the resected specimen was scanned with a micro-PET-CT imaging device, followed by histopathological assessment. Eight patients were included in the study and intraoperative PET/CT-imaging of 11 tumoral specimens and lymph nodes of three patients was performed. As a result of the increased resolution, differentiation between inflamed and dysplastic tissue versus malignant tissue was complicated in malignancies with increased peritumoral inflammation. The current technique allowed the three-dimensional delineation of ¹⁸F-FDG using submillimetric PET/CT imaging. While further optimization and patient stratification is required, clinical implementation could enable deep margin assessment in head and neck resection specimens.

Robotic surgery may improve overall survival for T1 and T2 tumors of the hypopharynx: An NCDB cohort study

BACKGROUND

Hypopharyngeal cancer is associated with poor survival. Robotic surgery is emerging as a treatment for hypopharyngeal tumors, but no rigorous data are available to assess its effect on survival.

METHODS

The National Cancer Database (NCDB) was used to identify patients with T1 and T2 hypopharyngeal tumors undergoing robotic surgery, laser surgery, and primary radiation with or without chemotherapy from 2010 to 2016. All adult patients with available staging and no distant metastasis were included.

RESULTS

We compared 57 patients undergoing robotic surgery, 236 undergoing laser surgery, and 5,742 undergoing primary radiation. Compared to laser surgery, patients undergoing robotic surgery were significantly more likely to have negative margins, neck dissection, lower incomes, and care at an academic center. Rates of robotic surgery also significantly increased from 2010 to 2015. After multivariate regression, robotic surgery was associated with significantly improved overall survival compared to laser surgery and primary radiation.

CONCLUSION

Robotic surgery improves overall survival for T1 and T2 hypopharyngeal tumors compared to laser surgery and primary radiation in this NCDB cohort. This effect may be mediated by decreased positive margin rates relative to laser surgery. Rates of hypopharyngeal robotic surgery are expected to increase with wider adoption of robotic platforms and may improve overall survival rates for hypopharyngeal cancer.

The impact of lymph node density as a predictive factor for survival and recurrence of tongue squamous cell carcinoma

The oral tongue is considered the most frequently involved site in cases of oral squamous cell carcinoma (OSCC). Lymph node (LN) density, defined as the number of positive LNs divided by the total number of resected LNs, is considered an important prognostic factor in OSCC; however the cut-off point remains uncertain. A retrospective study was performed involving 104 patients who underwent a glossectomy procedure for oral tongue squamous cell carcinoma (OTSCC) between the years 2008 and 2018. LN density and other related prognostic factors, including pathological N-stage (pN), extranodal extension (ENE), perineural invasion (PNI), and depth of invasion (DOI), were investigated in relation to survival and recurrence rates. pN + stage, the presence of ENE, the presence of PNI, and increased DOI were found to be associated with increased LN density values, as well as lower patient survival and higher recurrence rates. The statistical analysis identified a cut-off point for LN density of 2.5%. In advanced stage disease, LN density values above 2.5% had a significant impact on the survival rate (P = 0.005), as well as the recurrence rate (P = 0.038). In conclusion, in addition to other previously known prognostic factors, LN density may serve as a strong prognostic factor for survival and recurrence in patients with advanced- and early-stage OTSCC.

Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma

OBJECTIVE

Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective case series and subsequent prospective cohort study SETTING: Tertiary care academic teaching hospital SUBJECTS AND METHODS: Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 - December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 - December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost.

RESULTS

Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD.

CONCLUSION

Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments.

Impact of Planning Method (Conventional versus Virtual) on Time to Therapy Initiation and Resection Margins: A Retrospective Analysis of 104 Immediate Jaw Reconstructions

Simple Summary

Computer-aided design and manufacturing of osseous reconstructions are currently widely used in jaw reconstructive surgery, providing an improved surgical outcome and decreased procedural stumbling block. However, data on the influence of planning time on the time-to-surgery initiation and resection margin are missing in the literature. This retrospective, monocentric study compares process times from the first patient contact in hospital, time of in-house or out-of-house biopsy for tumor diagnosis and surgical therapy of tumor resection, and immediate reconstruction of the jaw with free fibula flaps (FFF). Two techniques for reconstruction are used: Virtual surgical planning (VSP) and non-VSP. A total of 104 patients who underwent FFF surgery for immediate jaw reconstruction from 2002 to 2020 are included. The study findings fill the gaps in the literature and obtain clear insights based on the investigated study subjects.

Abstract

Virtual surgical planning (VSP) and patient-specific implants are currently increasing for immediate jaw reconstruction after ablative oncologic surgery. This technique contributes to more accurate and efficient preoperative planning and shorter operation time. The present retrospective, single-center study analyzes the influence of time delay caused by VSP vs. conventional (non-VSP) reconstruction planning on the soft and hard tissue resection margins for necessary oncologic safety. A total number of 104 cases of immediate jaw reconstruction with free fibula flap are included in the present study. The selected method of reconstruction (conventionally, non-VSP: n = 63; digitally, VSP: n = 41) are analyzed in detail. The study reveals a statistically significant (p = 0.008) prolonged time to therapy initiation with a median of 42 days when the VSP method compared with non-VSP (31.0 days) is used. VSP did not significantly affect bony or soft tissue resection margin status. Apart from this observation, no significant differences concerning local tumor recurrence, lymph node, and distant metastases rates are found according to the reconstruction method, and affect soft or bone tissue resection margins. Thus, we conclude that VSP for immediate jaw reconstruction is safe for oncological purposes.

The impact of intraoperative frozen section analysis on final resection margin status, recurrence, and patient outcome with oral squamous cell carcinoma

Background

The objective of this study was to evaluate the diagnostic value of intraoperative frozen section analysis (IFSA) of tumor bed margins in patients with oral squamous cell carcinoma (OSCC).

Methods

This retrospective study includes 194 primary OSCC cases. The impact of intraoperative information by IFSA on final margin status, local recurrence, and disease-specific survival were analyzed.

Results

IFSA revealed a 50% sensitivity and a 100% specificity, with a positive and negative predictive value of 100% and 89.1%, respectively. In 19 cases, margins were rated positive by IFSA and remained positive in eight cases (42.1%), despite immediate re-resection. This constellation led to higher recurrence and lower survival rates than in cases with consecutive R0 status (each p = 0.046). Positive margins in IFSA were associated with closer final margins (p = 0.022) and early recurrences (p = 0.050).

Conclusions

Achieving instant R0 status has a crucial impact on disease recurrence and patient survival. IFSA falls short to ensure secure definite surgical margins. Thus, improved intraoperative diagnostic information on the location and extent of OSCC could support patient treatment.

Clinical relevance

Considering that patient survival has not improved despite progress in surgical and adjuvant therapy, the process and outcome of IFSA was scrutinized as one part of the treatment concept.

Full-Thickness Tumor Resection of Oral Cancer Involving the Facial Skin-Microsurgical Reconstruction of Extensive Defects after Radical Treatment of Advanced Squamous Cell Carcinoma

Simple Summary

Advanced malignant tumors of the oral cavity are challenging because they impose serious oncological and functional requirements on the treatment specialist. Depending on the localization and the extent of the primary tumor, a full-thickness resection affecting the facial skin may be necessary to achieve a complete tumor resection. The resulting defects need adequate reconstruction in order to restore the aesthetics and functionality of the orofacial system. In this retrospective analysis, the authors aimed to evaluate treatment techniques for these tumors and analyze the clinical outcome of the related procedures. Full-thickness tumor resection with free flap reconstruction due to advanced cancer was performed in 33 patients.

Abstract

Advanced tumors of the head and neck are challenging for the treatment specialist due to the need to synergize oncological and functional requirements. Free flap reconstruction has been established as the standard of care for defects following tumor resection. However, depending on the affected anatomic subsite, advanced tumors may impose specific difficulties regarding reconstruction, especially when full-thickness resection is required. This study aimed to evaluate reconstructive strategies and oncological outcomes in patients with full-thickness resection of the oral cavity. A total of 33 patients with extensive defects due to squamous cell carcinoma of the oral cavity were identified. Indications, reconstructive procedures, and clinical outcome were evaluated. Thirty-two patients (97%) presented locally advanced tumors (T3/T4). Complete tumor resection was achieved in 26 patients (78.8%). The anterolateral thigh flap was the most frequently used flap (47.1%), and the primary flap success rate was 84.8%. The cohort demonstrated a good local control rate and moderate overall and progression-free survival rates. Most patients regained full competence regarding oral alimentation and speech. Full-thickness tumor resections of the head and neck area may be necessary due to advanced tumors in critical anatomic areas. In many cases, radical surgical treatment leads to good oncological results. Free flap reconstruction has been shown to be a suitable option for extensive defects in aesthetically challenging regions.

Are the oxidative stress levels in the tumor center and tumor boundary different from those in healthy tissue?

PURPOSE

This study aimed to investigate the relationship between oxidative stress levels in the tumor center, tumor edge, and healthy tissue.

METHODS

This study included a total of 53 patients with head and neck cancer. Samples of 5 × 5 × 5 mm were collected from the tumor center, tumor edge, and the healthy tissue. Total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) values were evaluated. (1) Oxidative stress values in the center and edge of all tumors and in healthy tissues were compared according to localization. (2) Tumors were divided into two groups as malignant (Group 1 [n = 28]: Laryngeal and tongue squamous cell cancers) and benign (Group 2 [n = 25]: Pleomorphic adenoma and Warthin tumors). The groups were compared according to the localization of the tissues.

RESULTS

The TOS value in the tumor edge was significantly higher than those in the tumor center and the healthy tissue. The TAS value in tissue located in the tumor edge was significantly higher than in the healthy tissue. The OSI value in the tumor edge was significantly higher than those in the tumor center and the healthy tissue. In all three localizations (tumor center, tumor edge, and healthy tissue), TOS and OSI values in Group 1 were significantly higher than Group 2.

CONCLUSION

Oxidative stress values in the tumor edge are significantly higher than the center of the tumor and healthy tissue. In malignant tumors, oxidative stress values are significantly higher in all localizations compared to benign tumors.

Operational Impacts of the Coronavirus Disease 2019 (COVID-19) Pandemic and Early Recovery Trends: University of Washington Anatomic Pathology Experience

CONTEXT.—

The coronavirus disease 2019 pandemic, caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2, has resulted in worldwide disruption to the delivery of patient care. The Seattle, Washington metropolitan area was one of the first in the United States affected by the pandemic. As a result, the anatomic pathology services at the University of Washington experienced significant changes in operational volumes early in the pandemic.

OBJECTIVE.—

To assess the impact of coronavirus disease 2019 and both state and institutional policies implemented to mitigate viral transmission (including institutional policies on nonurgent procedures) on anatomic pathology volumes.

DESIGN.—

Accessioned specimens from January to June 2020 were evaluated as coronavirus disease 2019 and institutional policies changed. The data were considered in these contexts: subspecialty, billable Current Procedural Terminology codes, and intraoperative consultation. Comparable data were retrieved from 2019 as a historical control.

RESULTS.—

There was a significant reduction in overall accessioned volume (up to 79%) from prepandemic levels during bans on nonurgent procedures when compared with 2020 pre-coronavirus disease 2019 volumes and historical controls. The gastrointestinal and dermatopathology services were most impacted, and breast and combined head and neck/pulmonary services were least impacted. Current Procedural Terminology code 88305, for smaller/biopsy specimens, had a 63% reduction during nonurgent procedure bans. After all bans on procedures were lifted, the overall volume plateaued at 89% of prepandemic levels.

CONCLUSIONS.—

A significant decrease in specimen volume was most strongly associated with bans on nonurgent procedures. Although all departmental areas had a decrease in volume, the extent of change varied across subspecialty and specimen types. Even with removal of all bans, service volume did not reach prepandemic levels.

Intraoperative Fluorescence-Guided Surgery in Head and Neck Squamous Cell Carcinoma

The rate of positive margins in head and neck cancers has remained stagnant over the past three decades and is consistently associated with poor overall survival. This suggests that significant improvements must be made intraoperatively to ensure negative margins. We discuss the important role of fluorescence imaging to guide surgical oncology in head and neck cancer. This review includes a general overview of the principles of fluorescence, available fluorophores used for fluorescence imaging, and specific clinical applications of fluorescence-guided surgery, as well as challenges and future directions in head and neck surgical oncology. Laryngoscope, 131:529-534, 2021.

Primary intraosseous malignancies: A 10-year retrospective cohort study

OBJECTIVE

This study aimed to explore the characteristics and prognoses of primary jaw malignancies and identify valuable prognostic factors.

STUDY DESIGN

Patients who were primarily diagnosed with jaw malignancies at Beijing Stomatological Hospital between 2006 and 2016 were retrospectively reviewed.

RESULTS

Eighty patients with malignant jaw tumors were enrolled in the study. Squamous cell carcinoma was the most common type (56.2%). The age range of patients varied from 11 to 92 years old (mean age = 51.5 years), and the male-to-female ratio was 2.1:1. Anatomically, the mandible was involved in 82.5% of cases. The estimated disease-free survival and overall survival (OS) rates were 60.6% and 73.2%, respectively. Cox multivariate analysis showed that a smoking history (hazard ratio = 5.015, 95% confidence interval, 1.900-13.235, P = .001) and advanced age (≥60 years; hazard ratio = 2.464, 95% confidence interval, 0.987-6.155, P = .046) were independent prognostic factors for poor OS.

CONCLUSION

Primary jaw malignancies were more prevalent in the mandible and among males and middle-aged patients. Radical resection of the primary surgery was the basis of a good prognosis, and the choice of postoperative adjuvant therapy may not ultimately affect OS. Patients with a history of smoking and advanced age were at high risk for poor prognosis.

Optical diagnosis of oral cavity lesions by label-free Raman spectroscopy

Oral squamous cell carcinoma (OSCC) is one of the most prevalent cancers and frequently preceded by non-malignant lesions. Using Shifted-Excitation Raman Difference Spectroscopy (SERDS), principal component and linear discriminant analysis in native tissue specimens, 9500 raw Raman spectra of OSCC, 4300 of non-malignant lesions and 4200 of physiological mucosa were evaluated. Non-malignant lesions were distinguished from physiological mucosa with a classification accuracy of 95.3% (95.4% sensitivity, 95.2% specificity, area under the curve (AUC) 0.99). Discriminating OSCC from non-malignant lesions showed an accuracy of 88.4% (93.7% sensitivity, 76.7% specificity, AUC 0.93). OSCC was identified against physiological mucosa with an accuracy of 89.8% (93.7% sensitivity, 81.0% specificity, AUC 0.90). These findings underline the potential of SERDS for the diagnosis of oral cavity lesions.

Tumor dimension-dependent microscopic extensions of hypopharyngeal cancer: Therapeutic implications for larynx-preserving hypopharyngectomy

INTRODUCTION

Hypopharyngeal cancer (HPC) is well characterized by the early submucosal spread of cancer cells into adjacent subsites of the hypopharynx and deep tissues, advocating a wide extent of treatment. However, the microscopic extensions (ME) from gross tumors, according to the primary tumor dimensions, has not been reported in detail.

METHODS

We included patients who underwent upfront curative surgery, and retrospectively reviewed pathology specimens from 45 HPC cases. The distance of the MEs, defined as tumor infiltration beyond the gross tumor border on the submucosal and deep sides, was measured. We analyzed potential correlations between MEs and various physical tumor factors.

RESULTS

A rough linear correlation between the submucosal ME and the maximal diameter of tumors was found (p < .001, r²  = 0.225). Deep MEs did not correlate with tumor physical factors. However, the MEs differed significantly by the T status (p = .033 and .015 in submucosal and deep sides). In T1-2 tumors, the submucosal MEs were less than 0.5 cm, whereas those of T3-4 tumors were 1.5-2.0 cm.

CONCLUSION

In HPC, local MEs beyond the gross tumor border correlated with primary tumor T status. Our findings support that the surgical safety margin for HPC can be adjusted according to tumor dimension.

HPV/p16-positive oropharyngeal cancer treated with transoral robotic surgery: The roles of margins, extra-nodal extension and adjuvant treatment

PURPOSE

Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) treatment outcomes are re-defining management. Traditional margins, the role of extranodal extension (ENE) and adjuvant treatment intensity continue to be debated. This study aimed to determine the impact of margins, ENE and adjuvant therapy on survival following transoral robotic surgery (TORS).

METHODS

Patients treated with TORS at an academic center were retrospectively identified (2013-2019). Survival outcomes were evaluated using Kaplan-Meier curves.

RESULTS

48 patients were included. 40 (83%) were male. Mean age was 61.2 years. 43 (90%) were stage I. 22 (45.8%) had ENE. 31 (65%) had margins >1 mm. 38 (79%) had indications for radiation therapy; 9 (24%) refused. Chemotherapy was recommended in 36 (75%) patients; 24 (67%) refused. Locoregional control was 98%, metastasis-free survival was 96%, and disease-specific survival was 100% at 5-years. Overall survival was 95%.

CONCLUSIONS

Given the high survival rate seen after TORS, it is likely that margins, ENE and adjuvant treatment may not significantly contribute to outcomes.

Intraoperative Assessment of the Resection Specimen Facilitates Achievement of Adequate Margins in Oral Carcinoma

Background

Inadequate resection margins in oral cavity squamous cell carcinoma have an adverse effect on patient outcome. Intraoperative assessment provides immediate feedback enabling the surgeon to achieve adequate resection margins. The goal of this study was to evaluate the value of specimen-driven intraoperative assessment by comparing the margin status in the period before and the period after the introduction of specimen-driven assessment as a standard of care (period 2010-2012 vs period 2013-2017).

Methods

A cohort of patients surgically treated for oral squamous cell carcinoma at the Erasmus MC Cancer Institute, Rotterdam, between 2010-2012 was studied retrospectively and compared to results of a prospectively collected cohort between 2013-2017. The frequency, type and results of intraoperative assessment of resection margins were analyzed.

Results

One hundred seventy-four patients were included from 2010-2012, 241 patients were included from 2013-2017. An increase in the frequency of specimen-driven assessment was seen between the two periods, from 5% in 2010-2012 to 34% in 2013-2017. When performing specimen-driven assessment, 16% tumor-positive resection margins were found in 2013-2017, compared to 43% tumor-positive resection margins overall in 2010-2012. We found a significant reduction of inadequate resection margins for specimen-driven intraoperative assessment (p < 0.001). Also, tumor recurrence significantly decreased, and disease-specific survival improved when performing specimen-driven intraoperative assessment.

Conclusions

Specimen-driven intraoperative assessment improves resection margins and consequently, the outcome of oral cancer patients. We advocate this method as standard of care.

Accuracy of Frozen Section Examination in Oral Cavity Cancers

PURPOSE

This study aimed to compare the intraoperative frozen section with the surgical margin in the postoperative surgical margins of the postoperative pathology of oral squamous cell carcinomas in order to examine the reliability of the frozen section.

METHODS

A retrospective analysis was conducted for patients who underwent surgery for oral squamous cell carcinoma in a tertiary hospital between January 2018 and 2019. The intraoperative frozen section examinations, grade of the tumor, number of lymph nodes, number of affected lymph nodes, depth of invasion, perineural invasion, lymphovascular invasion, and extranodal extension were recorded from the pathological records. The concordance between the frozen section examination and postoperative pathology 2 methods was examined using the Cronbach α coefficient. Sensitivity, specificity, positive predictive value, negative predictive value regarding surgical margins, and accuracy were calculated and reported.

RESULTS

Overall, 181patients who underwent surgery for oral cavity cancers were included; 118 (65.2%) were males. The mean (± standard deviation) age of the included participants was 57.4 ± 16.1 years. The most common tumour subsite was the tongue (n = 71, 39.2%). There was concordancy between the frozen, positive intraoperative malignancy and the postoperative pathology malignancy. The frozen, negative intraoperative malignancy and postoperative safe surgical margin did not significantly differ.

CONCLUSION

As a result of intraoperative frozen examination, we found conformity between the postoperative pathology results of patients with positive and negative surgical margins. Frozen section examination could be used safely to examine intraoperative surgical margins of oral squamous cell carcinoma.

The Effect of Diathermy Power Settings on Oral Cavity Mucosal Contraction: A Rat Model

OBJECTIVES/HYPOTHESIS

The effects of different electrocautery power settings on mucosal contraction and margin status in the oral cavity have not been well established. The aim of this study was to examine how different levels of electrocautery energy outputs affect oral mucosal tissue margins.

STUDY DESIGN

Animal model.

METHODS

A model of 23 adult rats was used (two specimens per rat). After anesthetizing the animals, a 6-mm biopsy punch marked the resection margin on the buccal mucosa (one per cheek). The specimens were excised by means of three energy levels, a cold knife, and monopolar diathermy that was set on either 20 W or 30 W cut modes. The specimens were evaluated for extent of contraction.

RESULTS

A total of 45 samples were obtained and measured, including 15 specimens in the cold-knife group, 15 specimens in the 20 W group, and 15 specimens in the 30 W group. The median diameters of the specimens after resection were 4.5 mm for the cold-knife group (interquartile range [IQR] = 4.0-5.0), 3.5 mm for the 20 W group (IQR = 3.5-4.0), and 2.8 mm for the 30 W group (IQR = 2.5-3.0). Specimen contraction was 25.0%, 41.7%, and 53.3%, respectively. The difference in shrinkage between each pair was statistically significant: cold knife versus 20 W, P = .001; cold knife versus 30 W, P < .0001; and 20 W versus 30 W, P < .001.

CONCLUSIONS

Diathermy power settings result in a significant difference of mucosal tissue contraction, with higher outputs resulting in a narrower mucosal margin. It is imperative that the surgical team take into consideration the diathermy settings during initial resection planning. Laryngoscope, 131:E1514-E1518, 2021.

Clinical behavior of T1-T2 squamous cell carcinoma of the oral cavity

OBJECTIVES

The main aim of the present study is to analyze the differences in the clinical behavior of pT1 and pT2 oral squamous cell carcinoma of the oral cavity and the importance of tumor thickness in these groups of patients.

METHODS

A retrospective analysis was conducted using the records of patients diagnosed with pT1 and pT2 oral squamous cell carcinoma between 2006 and 2015 to identify significant differences between these two groups of patients. Several pathological features such as T-stage, N-stage, tumor thickness, surgical margins, and locoregional failure were analyzed.

RESULTS

194 patients were included in this study. Tumor thickness >0.4 cm was significantly related with nodal involvement and overall survival (p < 0.001). T and N stage, tumor thickness, extracapsular spread and surgical margins were associated with poorer outcomes in terms of overall survival (p < 0.001).

CONCLUSION

Tumor thickness represents an extremely important prognostic factor and to include depth of invasion (DOI) in the staging of oral squamous cell carcinoma will help in the choice of better treatment strategies and to improve overall survival.

Margin Practices in Oral Cavity Cancer Resections: Survey of American Head and Neck Society Members

OBJECTIVES/HYPOTHESIS

To investigate the definition of a clear margin and the use of frozen section (FS) among practicing head and neck surgeons in oral cancer management.

STUDY DESIGN

Cross-sectional survey.

METHODS

We designed a survey that was sent to American Head and Neck Society (AHNS) members via an email link.

RESULTS

A total of 185 (13% of 1,392) AHNS members completed our survey. Most surgeons surveyed (96.8%) use FS to supplement oral cavity squamous cell carcinoma resections. Fifty-five percent prefer a specimen-based approach. The majority of respondents believe FS is efficacious in guiding re-resection of positive margins, with 81% considering the new margin to be negative. More than half of respondents defined a distance of >5 mm on microscopic examination as a negative margin.

CONCLUSIONS

To avoid oral cancer resections that result in positive margins on final analysis, and thus the need for additional therapy, most surgeons surveyed use FS. A majority of surveyed surgeons now prefer a specimen-based approach to margin assessment. Although there is a debate on what constitutes a negative margin, most surgeons surveyed believe it to be >5 mm on microscopic examination.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:782-787, 2021.

Novel induction therapy transoral surgery treatment paradigm with risk-adapted adjuvant therapy for squamous cell carcinoma of the head and neck - Mature clinical and functional outcomes

OBJECTIVE

Induction chemotherapy in head and neck squamous cell carcinoma (HNSCCA) has principally been studied prior to radiation therapy. We evaluated pre-operative induction therapy followed by surgery followed by risk-adapted adjuvant therapy. This report details the mature 5-year survival statistics, clinical and functional outcomes.

METHODS

An IRB-approved single institution prospective phase II clinical trial from October 2012 to November 2016 was conducted for patients with transorally-resectable American Joint Committee on Cancer 7th ed. stage III/IV HNSCCA. Patients were treated once weekly for six weeks with a multi-drug induction regimen of carboplatin, paclitaxel and daily lapatinib followed by transoral surgery and neck dissection. Patients were then stratified based on pathologic response to either observation or adjuvant therapy. Survival statistics and functional patient outcomes were analyzed. Specifically, peri-operative outcomes were analyzed and compared to a matched surgical cohort.

RESULTS

38/40 enrolled patients completed trial therapy. Median hospital stay was 3 days with 9/38 patients receiving a PEG (median 46 days). Median NPO status was 1 day, with a median return to a regular diet in 16 days. Mean patient weight was well preserved from pretreatment to 1 year after surgery (85.1 kg (95% CI 79.6-90.7) vs 83.1 kg (95% CI 77.7-88.6 kg) respectively). Of the 38 patients who completed trial therapy; DSS, PFS and OS were 100%, 97% and 97% respectively with median follow up of 4.9 years (3.33-7.25).

CONCLUSION

Transoral surgery was feasible following this novel induction regimen with excellent peri-operative, functional and longterm survival outcomes.

An Update on Surgical Margins in the Head Neck Squamous Cell Carcinoma: Assessment, Clinical Outcome, and Future Directions

PURPOSE OF REVIEW

Failure to achieve tumor-free margins is the single largest cause of death for head neck cancer patients. At the same time, it is the only factor that is in complete control of the surgeon. This review summarizes evidence for the definition, clinical implications, and methods to achieve optimal margins.

RECENT FINDINGS

The previous universally followed definition of adequate margin (5 mm in final histopathology) has been disputed. Various biological, optical, and imaging adjuncts can aid in achieving optimal margins. Extent of resection and margins in human papilloma virus (HPV)-positive oropharyngeal cancers and following induction chemotherapy remain controversial. Though practiced widely, frozen section-guided margin revision has not conclusively shown improved local control rates. The role of molecular assessment of margins is promising but not established. The definition of adequate margin differs according to the site in the head neck region. Currently, the 5-mm margin at final histopathology is the most commonly accepted definition of an "adequate" margin.

Prognostic impact of resection margin involvement in surgically managed HPV-positive tonsil cancer

OBJECTIVES

To find out the role of resection margin involvement in surgically managed HPV-positive tonsil cancer.

MATERIALS AND METHODS

The study included 94 subjects with HPV-positive tonsil cancer undergoing surgical treatment. We evaluated the relationships between the resection margin status, clinicopathological factors, and oncological outcome.

RESULTS

The rate of resection margin involvement was 22.3% (21/94) after ablative surgery. Margin involvement, lymphatic invasion, and extracapsular spread were associated with the 5-year disease-free survival (DFS) and disease-specific survival (DSS) rate in univariate analysis. Multivariate Cox regression analysis confirmed a significant association between the margin involvement and 5-year DFS rate (HR = 4.602; 95% CI = 1.202-17.620; p = 0.026) and 5-year DSS rate (HR = 12.826; 95% CI = 1.399-117.593; p = 0.024). The incidence of resection margin involvement was significantly higher in patients with larger tumors (35.19 ± 15.07 mm vs. 25.53 ± 10.32 mm, p = 0.011) and more invasive tumors (17.84 ± 7.90 mm vs. 13.46 ± 6.88 mm, p = 0.037). The cutoff value of tumor size and depth of invasion for resection margin involvement was 29.5 mm (74% sensitivity and 63% specificity) and 14.5 mm (74% sensitivity and 61% specificity), respectively.

CONCLUSION

Resection margin involvement was significantly correlated with tumor size and the depth of invasion in HPV-positive tonsil cancer. Furthermore, resection margin involvement was associated with adverse outcomes.

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO₂, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.

Clinical label-free biochemical and metabolic fluorescence lifetime endoscopic imaging of precancerous and cancerous oral lesions

INTRODUCTION

Incomplete head and neck cancer resection occurs in up to 85% of cases, leading to increased odds of local recurrence and regional metastases; thus, image-guided surgical tools for accurate, in situ and fast detection of positive margins during head and neck cancer resection surgery are urgently needed. Oral epithelial dysplasia and cancer development is accompanied by morphological, biochemical, and metabolic tissue and cellular alterations that can modulate the autofluorescence properties of the oral epithelial tissue.

OBJECTIVE

This study aimed to test the hypothesis that autofluorescence biomarkers of oral precancer and cancer can be clinically imaged and quantified by means of multispectral fluorescence lifetime imaging (FLIM) endoscopy.

METHODS

Multispectral autofluorescence lifetime images of precancerous and cancerous lesions from 39 patients were imaged in vivo using a novel multispectral FLIM endoscope and processed to generate widefield maps of biochemical and metabolic autofluorescence biomarkers of oral precancer and cancer.

RESULTS

Statistical analyses applied to the quantified multispectral FLIM endoscopy based autofluorescence biomarkers indicated their potential to provide contrast between precancerous/cancerous vs. healthy oral epithelial tissue.

CONCLUSION

To the best of our knowledge, this study represents the first demonstration of label-free biochemical and metabolic clinical imaging of precancerous and cancerous oral lesions by means of widefield multispectral autofluorescence lifetime endoscopy. Future studies will focus on demonstrating the capabilities of endogenous multispectral FLIM endoscopy as an image-guided surgical tool for positive margin detection during head and neck cancer resection surgery.

Assessment of surgical tumor-free resection margins in fresh squamous-cell carcinoma resection specimens of the tongue using a clinical MRI system

BACKGROUND

Current intraoperative methods of visual inspection and tissue palpation by the surgeon, and frozen section analysis cannot reliably prevent inadequate surgical margins in patients treated for oral squamous-cell carcinoma (OSCC). This study assessed feasibility of MRI for the assessment of surgical resection margins in fresh OSCC specimens.

METHODS

Ten consecutive tongue specimens containing OSCC were scanned using 3 T clinical whole-body MRI. Two radiologists independently annotated OSCC location and minimal tumor-free margins. Whole-mount histology was the reference standard.

RESULTS

The positive predictive values (PPV) and negative predictive values (NPV) for OSCC localization were 96% and 75%, and 87% and 79% for reader 1 and 2, respectively. The PPV and NPV for identification of margins <5 mm were 38% and 91%, and 5% and 87% for reader 1 and 2, respectively.

CONCLUSIONS

MRI accurately localized OSCC with high inter-reader agreement in fresh OSCC specimens, but it seemed not yet feasible to accurately assess the surgical margin status.

Implications of Tumor Size, Subsite, and Adjuvant Therapy on Outcomes in pT4aN0 Oral Cavity Carcinoma

Objective

To determine if tumor size, subsite, and adjuvant radiation therapy (AXRT) are associated with overall survival (OS) in patients with pT4aN0 oral cavity squamous cell carcinoma (OSCC) who underwent mandibulectomy with negative surgical margins (NSMs).

Study Design

Retrospective cohort study.

Setting

National Cancer Database (NCDB).

Subjects and Methods

Retrospective analysis of the NCDB that included patients diagnosed with pT4aN0 OSCC who underwent mandibulectomy with NSMs between 2004 and 2015. The association of age, Charlson-Deyo score (CDS), tumor size, subsite, and AXRT with OS was analyzed. The cases were divided into 3 subgroups based on maximal tumor dimension for subgroup analysis; tumors ≤2.0 cm, tumors 2.1 to 4.0 cm, and tumors >4.0 cm.

Results

For the entire cohort; age ( P < .001; hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.02-1.03), CDS ( P = .013; HR, 0.57; 95% CI, 0.37-0.89), tongue subsite ( P = .003; HR, 2.01; 95% CI, 1.27-3.40), floor of mouth subsite ( P = .001; HR, 1.76; 95% CI, 1.28-2.42), tumor size ( P < .001; HR, 0.57; 95% CI, 0.45-0.72), and AXRT ( P < .001; HR, 1.46; 95% CI, 1.24-1.72) were associated with OS on multivariate analysis. On subgroup analysis, AXRT not significantly associated with OS in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm ( P = .323; HR, 1.29; 95% CI, 0.78-2.15).

Conclusions

In patients with pT4aN0 OSCC who underwent mandibulectomy with NSMs, age, CDS, tongue subsite, floor of mouth subsite, tumor size, and AXRT are associated with OS. AXRT was not significantly associated with overall survival in patients with gingival, hard palate, retromolar trigone, and not specified tumors ≤2.0 cm.

Value of Full-Field Optical Coherence Tomography Imaging for the Histological Assessment of Head and Neck Cancer

BACKGROUND AND OBJECTIVES

In head and neck surgery, intraoperative and postoperative evaluation of tumor margins is achieved by histopathological assessment, which is a multistep process. Intraoperative analysis of tumor margins to obtain a preliminary diagnosis is usually carried out on frozen sections. Analysis of frozen sections is challenging due to technical difficulties in processing. Full-field optical coherence tomography (FFOCT) provides ex vivo images of fresh tissue samples at a microscopic scale without tissue processing. The objectives of our study were to define the diagnostic criteria required to interpret head and neck FFOCT images and to evaluate the reliability of a histological diagnosis made on an "optical biopsy" produced by head and neck FFOCT imaging compared with conventional histology.

STUDY DESIGN/MATERIALS AND METHODS

First, we established an atlas of comparative images (FFOCT/standard histology) and defined the diagnostic criteria based on FFOCT images. Two pathologists subsequently performed a blinded review on 57 FFOCT images (32 patients). Specificity and sensitivity were measured by comparison with the standard histological diagnosis. The primary endpoint was major concordance, defined as two classifications leading to the same therapeutic decision (treatment/no treatment).

RESULTS

Pathologists identified four main criteria for tissue diagnosis on FFOCT images: heterogeneous cell distribution, stromal reaction, coiling, and keratinization abnormalities. The correlation study showed good results, with sensitivity from 88% to 90% and specificity from 81% to 87%, regardless of whether the FFOCT image review was performed by a pathologist with or without previous experience in optical imaging.

CONCLUSIONS

Our results demonstrate that FFOCT images can be used by pathologists for differential diagnosis, and that high-resolution FFOCT imaging can provide an assessment of microscopic architecture in head and neck tissues without tissue processing requirements. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Defining secure surgical bone margins in head and neck squamous cell carcinomas: The diagnostic impact of intraoperative cytological assessment of bone resection margins compared with preoperative imaging

BACKGROUND

Imaging provides crucial staging information for treatment planning of head and neck squamous cell carcinomas (HNSCCs). Despite technical progress in imaging techniques, defining the extent of bone involvement preoperatively remains challenging and requires intraoperative information to control for adequate resection. The intraoperative cytological assessment of the bone resection margins (ICAB) provides information whether bone is infiltrated by carcinoma. The aim of this study was to assess the diagnostic value of preoperative imaging compared with ICAB in order to achieve carcinoma-free bone margins.

MATERIALS AND METHODS

108 HNSCC patients underwent preoperative computed tomography (CT), magnetic resonance imaging (MRI) and orthopantomogram (OPG) for staging and surgical planning. Curative resection was planned based on imaging. Intraoperatively, the resection margins were controlled by ICAB. The diagnostic value of preoperative imaging and ICAB was assessed with reference to the histological findings.

RESULTS

CT showed a sensitivity of 89.7%, specificity of 63.0%, positive predictive value (PPV) of 85.9%, and negative predictive value (NPV) of 70.8%. MRI revealed a sensitivity of 45.5%, specificity of 66.7%, PPV of 71.4% and NPV of 40.0%. OPG-imaging had a sensitivity of 64.7%, specificity of 76.2%, PPV of 81.5%, NPV 57.1%. In comparison, ICAB provided a sensitivity of 78.6%, specificity of 95.7%, PPV 73.3%, and NPV 96.7%. The accuracy was 82.1%, 52.9%, 69.0%, and 93.5% for CT, MRI, OPG, and ICAB, respectively.

CONCLUSION

Preoperative imaging lacks accuracy in defining adequate bone resection margins, compared with ICAB. ICAB supports preoperative imaging and intraoperative frozen sections to improve bone margin control.

Anatomically-based transoral surgical approach to early-stage oral tongue squamous cell carcinoma

The mainstream of treatment of early-stage oral tongue squamous cell carcinoma (OTSCC) is represented by transoral resection with "adequate" free margins. Despite that, a precise and shared definition of "adequate margin" is lacking, and so is a standardized transoral surgical technique.The tongue is a symmetrically paired organ, consisting of intertwining intrinsic and extrinsic muscles, which can be distinguished during dissection. Routes of tumoral spread in oral tongue cancer are well-known and should be taken into account during resection. We propose herein a standardized and replicable surgical technique to resect early-stage OTSCC, based on rational anatomical considerations.

Intraoperative Primary Tumor Identification and Margin Assessment in Head and Neck Unknown Primary Tumors

OBJECTIVE

Surgical management of the unknown primary head and neck squamous cell carcinoma (UP HNSCC) remains controversial due to challenging clinical diagnosis. This study compares positron emission tomography-computed tomography (PET-CT) findings with intraoperative identification of primary tumors and compares intraoperative frozen-section margins to final histopathology. In addition, adjuvant therapy indications are provided.

STUDY DESIGN

Prospective cohort study.

SETTING

Academic university hospital.

SUBJECTS AND METHODS

Sixty-one patients with UP HNSCC were included. Patients received PET-CT, followed by oropharyngeal transoral laser microsurgery (TLM). Margins were assessed intraoperatively using frozen sections and afterward by final histopathology. Adjuvant treatment was based on final histopathology.

RESULTS

The sensitivity of localizing the primary tumor with PET-CT was 50.9% with a specificity of 82.5%. The primary tumor was found intraoperatively on frozen sections in 82% (n = 50) of patients. Five more tumors were identified on final histopathology, leading to a total of 90% (n = 55). Of the 50 intraoperatively found tumors, 98% (n = 49) had negative margins on frozen sections, and 90% (n = 45) were truly negative on final histopathology. Eighteen patients (29.5%) avoided adjuvant treatment.

CONCLUSION

PET-CT localized the primary tumor in fewer than half the cases. This protocol identified 90% of primary tumors. Intraoperative frozen-section margin assessment has shown potential with a specificity of 92% compared to final histopathology. As a result, adjuvant therapy was avoided in almost one-third of our patients.

A Self-Assembled "Albumin-Conjugate" Nanoprobe for Near Infrared Optical Imaging of Subcutaneous and Metastatic Tumors

The need for in situ accurate identification of tumor assisted real-time image-guided surgical resection calls for new near-infrared fluorescence agents with high tumor-sensitivity and excellent biocompatibility. Here, an albumin-conjugate nanoparticle system HSA-Er-RI-Cl was designed, synthesized, and applied in cancer imaging, which simultaneously achieved the EPR effect, hypoxia-targeting, and EGFR-targeting property. Our novel nanoprobe is composed of human serum albumin (HSA) and double-targeting small molecule conjugate (Er-RI-Cl): a hypoxia-targeting heptamethine carbocyanine dye (RI-Cl) conjugated with a clinic anti-EGFR antagonist (Erlotinib) by covalent bonding. This conjugate could bind to albumin proteins, forming albumin-conjugate complexes, and those complexes self-assemble into particles with diameters of approximately 100 nm in the aqueous solution. The tumor hypoxia and EGFR targeting specificity of HSA-Er-RI-Cl was, respectively, evaluated in vitro and in vivo. Using murine xenograft subcutaneous and brain metastatic tumor models, we demonstrated that HSA-Er-RI-Cl is a highly potent tumor-targeting NIR agent for noninvasive imaging with remarkable tumor localization and excellent pharmacokinetic properties.

Hypoxia-Targeting Multifunctional Nanoparticles for Sensitized Chemotherapy and Phototherapy in Head and Neck Squamous Cell Carcinoma

Purpose

Chemotherapy in head and neck squamous cell carcinoma (HNSCC) has many systemic side effects, as well as hypoxia-induced chemoresistance. To reduce side effects and enhance chemosensitivity are urgently needed.

Methods

We synthesized a drug delivery system (named CECMa NPs) based on cisplatin (CDDP) and metformin (chemotherapeutic sensitizer), of which chlorin e6 (Ce6) and polyethylene glycol diamine (PEG) were synthesized as the shell, an anti-LDLR antibody (which can target to hypoxic tumor cells) was modified on the surface to achieve tumor targeting.

Results

The NPs possessed a great synergistic effect of chemotherapy and phototherapy. After laser stimulation, both CDDP and metformin can be released in situ to achieve anti-tumor effects. Meanwhile, PDT and PTT triggered by a laser have anticancer effects. Furthermore, compared with free cisplatin, CECMa exhibits less systemic toxicity with laser irradiation in the xenograft mouse tumor model.

Conclusion

CECMa effectively destroyed the tumors via hypoxia targeting multimodal therapy both in vitro and in vivo, thereby providing a novel strategy for targeting head and neck squamous cell carcinoma.

Intraoperative Molecular Imaging for ex vivo Assessment of Peripheral Margins in Oral Squamous Cell Carcinoma

Objective: Complete surgical resection is the standard of care for treatment of oral cancer although the positive margin rate remains 15–30%. Tissue sampling from the resected specimen and from the wound bed for frozen section analysis (FSA) remains the mainstay for intraoperative margin assessment but is subject to sampling error and can require the processing of multiple samples. We sought to understand if an ex vivo imaging strategy using a tumor-targeted fluorescently labeled antibody could accurately identify the closest peripheral margin on the mucosal surface of resected tumor specimen, so that this “sentinel margin” could be used to guide pathological sampling.

Materials and Methods: Twenty-nine patients with oral squamous cell carcinoma scheduled for surgical resection were consented for the study and received systemic administration of a tumor-targeted fluorescently labeled antibody (Panitumumab IRDye800CW). After surgical resection, the tumor specimen was imaged using a closed-field fluorescent imaging device. Relevant pathological data was available for five patients on retrospective review. For each of these five patients, two regions of highest fluorescence intensity at the peripheral margin and one region of lowest fluorescence intensity were identified, and results were correlated with histology to determine if the region of highest fluorescence intensity along the mucosal margin (i.e., the sentinel margin) was truly the closest margin.

Results: Imaging acquisition of the mucosal surface of the specimen immediately after surgery took 30 s. In all of the specimens, the region of highest fluorescence at the specimen edge had a significantly smaller margin distance than other sampled regions. The average margin distance at the closest, “sentinel,” margin was 3.2 mm compared to a margin distance of 8.0 mm at other regions (p < 0.0001).

Conclusions: This proof-of-concept study suggests that, when combined with routine FSA, ex vivo fluorescent specimen imaging can be used to identify the closest surgical margin on the specimen. This approach may reduce sampling error of intraoperative evaluation, which should ultimately improve the ability of the surgeon to identify the sentinel margin. This rapid sentinel margin identification improves the surgeon's orientation to areas most likely to be positive in the surgical wound bed and may expedite pathology workflow.

Redefining adequate margins in oral squamous cell carcinoma: outcomes from close and positive margins

PURPOSE

Adequacy of surgical margins impacts outcomes in oral cancer. We sought to determine whether close and positive margins have different outcomes in patients with oral cancer.

METHODS

Retrospective data from 612 patients with oral carcinoma were analyzed for the effect of margin status on locoregional recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival (OS).

RESULTS

A total of 90 cases (14.7%) had close margins and 26 patients (4.2%) had positive margins. Recurrences were documented in 173 patients (28%), of which 137 (22% of the study sample) were locoregional, and 164 patients (27%) had died. Among patients with close or positive margins, a cutoff of 1 mm optimally separated LRFS (adjusted p = 0.0190) and OS curves (adjusted p = 0.0168) whereas a cutoff of 2 mm was sufficient to significantly separate DFS curves (adjusted p = 0.0281).

CONCLUSIONS

Patients with oral carcinoma with positive margins (< 1 mm) had poorer outcomes compared to those with close margins (1-5 mm) in terms of LRFS, DFS and OS. There is a suggestion that a cutoff of < 2 mm might provide slightly more separation for DFS.