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Philips R, Yalamanchi P, Topf MC. Trends and Future Directions in Margin Analysis for Head and Neck Cancers. Surg Oncol Clin N Am 2024; 33:651-667. [PMID: 39244285 DOI: 10.1016/j.soc.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2024]
Abstract
Margin status in head and neck cancer has important prognostic implications. Currently, resection is based on manual palpation and gross visualization followed by intraoperative specimen or tumor bed-based margin analysis using frozen sections. While generally effective, this protocol has several limitations including margin sampling and close and positive margin re-localization. There is a lack of evidence on the association of use of frozen section analysis with improved survival in head and neck cancer. This article reviews novel technologies in head and neck margin analysis such as 3-dimensional scanning, augmented reality, molecular margins, optical imaging, spectroscopy, and artificial intelligence.
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Affiliation(s)
- Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA.
| | - Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA; Vanderbilt University School of Engineering, 1211 Medical Center Drive, Nashville, TN 37232, USA
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Neumann F, Straub X, Mrosk F, Rubarth K, Wolfsberg J, Piwonski I, Doll C, Voss J, Heiland M, Kreutzer K, Koerdt S. Resection status and margin control in intraoperative frozen sectioning analysis of oral squamous cell carcinoma. Oral Maxillofac Surg 2024; 28:1209-1218. [PMID: 38532169 PMCID: PMC11330392 DOI: 10.1007/s10006-024-01238-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 03/11/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Intraoperative frozen section analysis (IFSA) is a well-established procedure for determining the intraoperative soft tissue resection status in patients with oral squamous cell carcinoma (OSCC). Margin status is a major predictor of the patient´s outcome, histologically free margins of ≥ 5 mm are demanded. This study evaluates the accuracy of IFSA, the impact of margin status and the impact of intraoperative margin revision on disease-free survival (DFS) and overall survival (OS). METHODS This retrospective study included 213 patients with OSCC. IFSA results were compared with definitive histopathological reports, Kaplan-Meier analysis was performed. Cut-off values were calculated for resection margins considering known risk factors. RESULTS IFSA showed positive margins in 8 cases (3.8%). Kaplan-Meier analysis revealed no significant differences for OS or DFS if R0-status was achieved by initial resection or immediate re-resection. Final histopathological evaluation revealed false-positive IFSA in 3/8 cases (37.5%) and false-negative IFSA in 1/205 cases (0.5%). Sensitivity was 83.3% and specificity was 98.6%. Analysis of optimal cut-off values showed no general need for larger resection margins in patients with risk factors. Cut-off values were slightly higher for patients with the risk factor alcohol consumption (7 mm for OS and DFS) or pN + ECS- disease (7 mm for DFS). Optimal cut-off values for tumour-margin-distance were around 6 mm. CONCLUSION IFSA provides a valuable assessment method for intraoperative soft tissue resection margins. Risk factors seemingly do not significantly influence the extent of tumour resection.
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Affiliation(s)
- Felix Neumann
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin, Corporate Memberember of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Xenia Straub
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin, Corporate Memberember of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Friedrich Mrosk
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin, Corporate Memberember of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kerstin Rubarth
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Institute of Biometry and Clinical Epidemiology, Charitéplatz 1, 10117, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Institute of Medical Informatics, Charitéplatz 1, 10117, Berlin, Germany
| | - Johanna Wolfsberg
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Institute of Medical Informatics, Charitéplatz 1, 10117, Berlin, Germany
| | - Iris Piwonski
- Department of Pathology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Christian Doll
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin, Corporate Memberember of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jan Voss
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin, Corporate Memberember of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin, Corporate Memberember of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kilian Kreutzer
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin, Corporate Memberember of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Steffen Koerdt
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin, Corporate Memberember of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Luna-Ortiz K, Guillén-Hernández GA, Caro-Sanchez CH, Luna-Peteuil Z, Cano-Valdez AM, Garcia-Ortega DY. Transtumoral approach and piecemeal resection (Steiner principle) for the treatment of tongue cancer at stage T1-T2: A pilot study. Med Oral Patol Oral Cir Bucal 2024; 29:e704-e710. [PMID: 39088717 PMCID: PMC11365059 DOI: 10.4317/medoral.26696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 06/03/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND To assess the feasibility of maximizing negative margins with minimal resection of healthy tissue, as confirmed by intraoperative assessment. This approach aims to be safe, effective, and to be considered a standard procedure. MATERIAL AND METHODS A prospective pilot study. Peritumoral ink marking aided in identifying margins. Transtumoral incisions were made along the central line until healthy tissue was visible. If positive or close margins were identified, an extension was performed only in the involved area. The tumor bed and outer part of the tumor were inked to determine margins for intraoperative assessment of the specimen. RESULTS Twelve patients with oral squamous cell carcinoma participated in the study, comprising 3 men and 9 women, with a mean age of 58 years. Four patients were diagnosed with clinical stage I (T1N0), while eight were classified as stage II (T2 N0). All patients underwent ipsilateral neck dissection (levels I-III). Intraoperative outcomes included negative, positive, or close margins. The number of tissue blocks varied based on the size of the tongue tumor and the segments that required expansion to ensure a tumor-free margin (>1 mm), which was necessary in 8 patients. All final pathological reports indicated negative margins of >1 mm. CONCLUSIONS Piecemeal resection emerges as a feasible and oncologically sound procedure for achieving margins >1mm, which are deemed safe. Precisely identifying positive areas within the tumor proves significantly safer than en bloc resections. The prognoses observed in this series depended more on regional disease factors than on specific characteristics of the primary tumor.
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Affiliation(s)
- K Luna-Ortiz
- Departmet of Head and Neck Surgery Instituto Nacional de Cancerología Av. San Fernando #22, Col. Sección XVI Tlalpan 14080, CDMX, México
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Kamalakkannan S, Rajan F, Shanmugam J, Ramachandran S, Muthusamy R, Selvan E, Sakthivel P, Chidambaranathan N, Dhiwakar M. Margin status, adjuvant treatment and recurrence in buccal cancer. Oral Oncol 2024; 156:106927. [PMID: 38943869 DOI: 10.1016/j.oraloncology.2024.106927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 06/15/2024] [Accepted: 06/25/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE To assess the prognostic importance of margin in resected buccal cancer within a framework of risk factor-driven postoperative adjuvant treatment. MATERIALS AND METHODS Consecutive, treatment naïve patients undergoing primary surgical treatment for buccal cancer. Margin was defined as clear (≥5 mm), close (1-4 mm) and involved (<1 mm). Main outcome was association of margin with local recurrence free survival (LRFS). Subgroup analysis of close margin was performed according to receipt or no receipt of adjuvant treatment. A numerical margin cut-off in mm that could independently predict LRFS was sought to be identified. RESULTS Of the 167 patients included, the frequency of clear, close and involved margins was 50 (30 %), 78 (47 %) and 39 (23 %) respectively, among whom 52 %, 44 % and 98 % received postoperative adjuvant treatment respectively. Clear and close margins had similar 3-year LRFS (89 % and 96 % respectively), while involved margin had worse 3-year LRFS at 65 %. Involved margin was confirmed to be strongly and independently associated with worse LRFS. Within close margin, receipt and no receipt of adjuvant treatment had similar 3-year LRFS (92 % and 100 % respectively). A margin cut-off of 2 mm was identified at or above which LRFS approximated that of clear margin. CONCLUSIONS This single center cohort study of patients with resected buccal cancer suggests that close margin is distinct from and has a better LRFS than involved margin. A subset of close margin, with margin size ≥ 2 mm and no other adverse features, might be spared adjuvant treatment without compromising outcomes.
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Affiliation(s)
- Sneha Kamalakkannan
- Departments of Otolaryngology-Head and Neck Surgery, Kovai Medical Center and Hospital, Coimbatore 641014, India
| | - Firoz Rajan
- surgical oncology, Kovai Medical Center and Hospital, Coimbatore 641014, India
| | - Jeevithan Shanmugam
- Community Medicine and Epidemiology, Kovai Medical Center and Hospital, Coimbatore 641014, India
| | | | | | - Ezhir Selvan
- surgical oncology, Kovai Medical Center and Hospital, Coimbatore 641014, India
| | - Pirabu Sakthivel
- Departments of Otolaryngology-Head and Neck Surgery, Kovai Medical Center and Hospital, Coimbatore 641014, India
| | - Nithyanand Chidambaranathan
- Departments of Otolaryngology-Head and Neck Surgery, Kovai Medical Center and Hospital, Coimbatore 641014, India
| | - Muthuswamy Dhiwakar
- Departments of Otolaryngology-Head and Neck Surgery, Kovai Medical Center and Hospital, Coimbatore 641014, India.
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Yun J, Kapustin D, Joseph J, Su V, Ramirez RJ, Khan MN, Chai R, Karasick M, Wiedmer C, Brandwein-Weber M, Urken ML. Improving Interdisciplinary Communication and Pathology Reporting for Head and Neck Cancer Resections: 3D Visualizations and Margin Reconciliation. Head Neck Pathol 2024; 18:78. [PMID: 39153096 PMCID: PMC11330424 DOI: 10.1007/s12105-024-01684-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 08/02/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE Surgical pathology reports play an integral role in postoperative management of head and neck cancer patients. Pathology reports of complex head and neck resections must convey critical information to all involved clinicians. Previously, we demonstrated the utility of 3D specimen and defect scanning for communicating margin status and documenting the location of supplemental margins. We introduce a newly designed permanent pathology report which improves documentation of intraoperative margin mapping and extent of corresponding supplemental margins harvested. METHODS We test the hypothesis that gaps in understanding exist for head and neck resection pathology reports across providers. A cross-sectional exploratory study using human-centered design was implemented to evaluate the existing permanent pathology report with respect to understanding margin status. Pathologists, surgeons, radiation oncologists, and medical oncologists from United States-based medical institutions were surveyed. The results supported a redesign of our surgical pathology template, incorporating 3D specimen / defect scans and annotated radiographic images indicating the location of inadequate margins requiring supplemental margins, or indicating frankly positive margins discovered on permanent section. RESULTS Forty-seven physicians completed our survey. Analyzing surgical pathology reports, 28/47 (60%) respondents reported confusion whether re-excised supplemental margins reflected clear margins, 20/47 (43%) reported uncertainty regarding final margin status, and 20/47 (43%) reported the need for clarity regarding the extent of supplemental margins harvested intraoperatively. From this feedback, we designed a new pathology report template; 61 permanent pathology reports were compiled with this new template over a 12-month period. CONCLUSION Feedback from survey respondents led to a redesigned permanent pathology report that offers detailed visual anatomic information regarding intraoperative margin findings and exact location/size of harvested supplemental margins. This newly designed report reconciles frozen and permanent section results and includes annotated radiographic images such that clinicians can discern precise actions taken by surgeons to address inadequate margins, as well as to understand the location of areas of concern that may influence adjuvant radiation planning.
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Affiliation(s)
- Jun Yun
- THANC (Thyroid, Head & Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
| | - Danielle Kapustin
- THANC (Thyroid, Head & Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
| | - Justin Joseph
- THANC (Thyroid, Head & Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
| | - Vivian Su
- THANC (Thyroid, Head & Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
| | - Ricardo J Ramirez
- THANC (Thyroid, Head & Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
| | - Mohemmed N Khan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
| | - Raymond Chai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
| | - Michael Karasick
- THANC (Thyroid, Head & Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA
| | - Christina Wiedmer
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Mark L Urken
- THANC (Thyroid, Head & Neck Cancer) Foundation, 10 Union Square East, Suite 5B, New York, NY, 10003, USA.
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 10 Union Square East, Suite 5B, New York, NY, 10003, USA.
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Poissonnet V, Segier B, Lopez R, Siegfried A, Dupret-Bories A, Sarini J, Poulet V, Delanoë F, Vergez S, Chabrillac E. Prognostic implications of mucosal and deep margin distances according to T-status in oral tongue squamous cell carcinoma: A single-center retrospective study. Head Neck 2024. [PMID: 38884458 DOI: 10.1002/hed.27844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/18/2024] Open
Abstract
OBJECTIVE To elucidate the prognostic implications of mucosal and deep margin distances in oral tongue squamous cell carcinoma (OTSCC), and to assess a different margin cut-off value in T1-T2 versus T3-T4 tumors. METHODS This single-center retrospective study included 223 patients who received surgery for a primary OTSCC between January 2017 and December 2021. RESULTS Multivariable analysis showed that deep margin distance ≥3 mm in T1-T2 tumors and ≥5 mm in T3-T4 tumors was significantly associated with better RFS and OS. Mucosal and deep margin distances were globally clinically useful for 2-year RFS prediction of T1-T2 tumors, for which deep margins seemed to have more clinical utility than mucosal margins. The influence of margin distances on 2-year RFS seemed greater for T1-T2 tumors than T3-T4 tumors. CONCLUSION Mucosal and deep margin distances were associated with OS and RFS in OTSCC. Shorter deep margin distances may be aimed for in T1-T2 versus T3-T4 tumors.
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Affiliation(s)
- Valentine Poissonnet
- Department of Surgery, University Cancer Institute of Toulouse - Oncopole, Toulouse, France
- Department of Ear, Nose & Throat Surgery, Toulouse University Hospital - Larrey Hospital, Toulouse, France
| | - Bertille Segier
- Department of Biostatistics, Claudius Regaud Institute, University Cancer Institute of Toulouse - Oncopole, Toulouse, France
| | - Raphaël Lopez
- Department of Maxillofacial Surgery, Toulouse University Hospital - Pierre Paul Riquet Hospital, Toulouse, France
| | - Aurore Siegfried
- Department of Pathology, University Cancer Institute Oncopole and Toulouse University Hospital, Toulouse, France
| | - Agnès Dupret-Bories
- Department of Surgery, University Cancer Institute of Toulouse - Oncopole, Toulouse, France
- Department of Ear, Nose & Throat Surgery, Toulouse University Hospital - Larrey Hospital, Toulouse, France
| | - Jérôme Sarini
- Department of Surgery, University Cancer Institute of Toulouse - Oncopole, Toulouse, France
| | - Vinciane Poulet
- Department of Maxillofacial Surgery, Toulouse University Hospital - Pierre Paul Riquet Hospital, Toulouse, France
| | - Franck Delanoë
- Department of Maxillofacial Surgery, Toulouse University Hospital - Pierre Paul Riquet Hospital, Toulouse, France
| | - Sébastien Vergez
- Department of Surgery, University Cancer Institute of Toulouse - Oncopole, Toulouse, France
- Department of Ear, Nose & Throat Surgery, Toulouse University Hospital - Larrey Hospital, Toulouse, France
| | - Emilien Chabrillac
- Department of Surgery, University Cancer Institute of Toulouse - Oncopole, Toulouse, France
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Dedivitis RA, de Matos LL, de Castro MAF, Kowalski LP. Association of the Specimen and Tumor Bed Margin Status with Local Recurrence and Survival in Open Partial Laryngectomy. J Clin Med 2024; 13:2491. [PMID: 38731017 PMCID: PMC11084571 DOI: 10.3390/jcm13092491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/21/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background/Objectives: Positive margins are associated with locoregional recurrence in early laryngeal cancer. The aim of this study was to evaluate the impacts of specimen-driven (ex vivo) positive margins on patients with early-stage laryngeal cancer whose tumor bed (defect-driven) margins had been negative. Methods: A retrospective study was performed on 60 consecutive T1b/T2 glottic cancer patients who underwent open frontolateral laryngectomy. The intraoperative margins were obtained from the tumor bed. Their recurrence and disease-free survival were evaluated. In all cases, negative margins were obtained from the surgical bed. The impact of positive margins from the specimen was evaluated in a paraffin study. Results: Among 10 patients with positive margins in the specimen, six experienced local relapse, and among 50 patients with negative margins in the specimen, three developed recurrence. The 5-year disease-free survival rates were 37.5% and 93.9%, respectively (p < 0.001; log-rank). Even with negative margins in the surgical bed, patients with positive margins in the specimen at the final histopathological examination had a 3.5-fold higher chance of developing local recurrence than those with negative margins (HR = 13.993; 95% CI: 3.479-56.281; p < 0.001; univariate Cox regression). Conclusions: Specimen-driven positive margins represent a significant risk factor for local recurrence, even under negative margins at the tumor bed.
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Affiliation(s)
| | - Leandro Luongo de Matos
- School of Medicine, University of São Paulo, São Paulo 05508-220, Brazil; (R.A.D.); (L.L.d.M.); (L.P.K.)
| | | | - Luiz Paulo Kowalski
- School of Medicine, University of São Paulo, São Paulo 05508-220, Brazil; (R.A.D.); (L.L.d.M.); (L.P.K.)
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Barry B, Dolivet G, Clatot F, Huguet F, Abdeddaim C, Baujat B, Blanchard N, Calais G, Carrat X, Chatellier A, Coste F, Cupissol D, Cuvelier P, De Mones Del Pujol E, Deneuve S, Duffas O, Dupret-Bories A, Even C, Evrard C, Evrard D, Faivre S, Fakhry N, Garrel R, Gorphe P, Houliat T, Kaminsky MC, Krebs L, Lapeyre M, Lindas P, Malard O, Mirghani H, Mondina M, Moriniere S, Mouawad F, Pestre-Munier J, Pham Dang N, Picard A, Ramin L, Renard S, Salvan D, Schernberg A, Sire C, Thariat J, Vanbockstael J, Vo Tan D, Wojcik T, Klein I, Block V, Baumann-Bouscaud L, De Raucourt D. [French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]. Bull Cancer 2024; 111:393-415. [PMID: 38418334 DOI: 10.1016/j.bulcan.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/14/2023] [Accepted: 12/31/2023] [Indexed: 03/01/2024]
Abstract
OBJECTIVES The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations. METHODOLOGY To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS). RESULTS The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey. CONCLUSION All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.
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Affiliation(s)
- Béatrix Barry
- AP-HP, hôpital Bichat-Claude-Bernard, ORL et CCF, Paris (75), France
| | - Gilles Dolivet
- Institut de cancérologie de Lorraine, ORL et CCF, Nancy (54), France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Olivier Duffas
- Centre hospitalier de Libourne, ORL et CMF, Libourne, France
| | | | | | | | - Diane Evrard
- AP-HP, hôpital Bichat-Claude-Bernard, ORL et CCF, Paris (75), France
| | | | - Nicolas Fakhry
- Assistance publique-Hôpitaux de Marseille, ORL et CCF, Marseille, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Didier Salvan
- Centre hospitalier Sud Francilien, ORL et CCF, Corbeil-Essonnes, France
| | | | | | | | | | | | | | - Isabelle Klein
- Dispositif Spécifique Régional du Cancer Grand Est - NEON, Nancy (54), France
| | - Véronique Block
- Dispositif Spécifique Régional du Cancer Grand Est - NEON, Nancy (54), France
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Tessler I, Marilena V, Alon EE, Gecel NA, Remer E, Gluck I, Yoffe T, Dobriyan A. Paradigm Change for Intraoperative Surgical Margin Assessment for Oral Squamous Cell Carcinoma. Laryngoscope 2024; 134:1725-1732. [PMID: 37929854 DOI: 10.1002/lary.31126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Achieving clear surgical margins is one of the primary surgical goals in treating oral squamous cell carcinoma (OSCC) and thus aiming to improve overall and disease-specific survival. Therefore, we developed the Goal-Oriented Assessment for Intraoperative Margin ('GAIM') protocol, a novel intraoperative approach for margin assessment, and present here our 5-year experience and outcomes. METHODS 'GAIM' is a 7-step procedure comprising systematic ruler-aided resection of labeled tumor-bed margins, frozen section (FS) co-produced by both pathologists and operating surgeons, and immediate extension of resection according to FS findings. Data from all patients operated using the 'GAIM' protocol at a single tertiary center between 2018 to 2022 were analyzed, including margin status on FS and final pathology (FP) records, recurrence, and mortality. RESULTS A total of 196 patients were included, 56.6% (n = 111) stages I-II, and 43.4% (n = 85) stages III-IV. Using the 'GAIM' protocol, we achieved an overall 94.4% of clean and revised clean surgical margins. Patients with a 2-year and longer follow-up (n = 141) had local recurrence in 3.5% when both FS and final margins were clean, 8.1% when FP margins were clean, and 16.7% with close/positive final margins. CONCLUSIONS The proposed 'GAIM' protocol is a novel, effective, reproducible, and safe approach for margin evaluation that can be systematically applied. It can increase the rate of final clean surgical margins and potentially improve patients' outcomes. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1725-1732, 2024.
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Affiliation(s)
- Idit Tessler
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Otolaryngology Head and Neck Surgery, Sheba Medical Center, Ramat Gan, Israel
| | - Vered Marilena
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pathology, Sheba Medical Center, Ramat Gan, Israel
| | - Eran E Alon
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Otolaryngology Head and Neck Surgery, Sheba Medical Center, Ramat Gan, Israel
| | - Nir A Gecel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eric Remer
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Otolaryngology Head and Neck Surgery, Sheba Medical Center, Ramat Gan, Israel
| | - Iris Gluck
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Tal Yoffe
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Oral and Maxillofacial Surgery, Sheba Medical Center, Ramat Gan, Israel
| | - Alex Dobriyan
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Oral and Maxillofacial Surgery, Sheba Medical Center, Ramat Gan, Israel
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10
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Matos LL, Kowalski LP, Chaves ALF, de Oliveira TB, Marta GN, Curado MP, de Castro Junior G, Farias TP, Bardales GS, Cabrera MA, Capuzzo RDC, de Carvalho GB, Cernea CR, Dedivitis RA, Dias FL, Estefan AM, Falco AH, Ferraris GA, Gonzalez-Motta A, Gouveia AG, Jacinto AA, Kulcsar MAV, Leite AK, Lira RB, Mak MP, De Marchi P, de Mello ES, de Matos FCM, Montero PH, de Moraes ED, de Moraes FY, Morais DCR, Poenitz FM, Poitevin A, Riveros HO, Sanabria Á, Ticona-Castro M, Vartanian JG, Viani G, Vines EF, William Junior WN, Conway D, Virani S, Brennan P. Latin American Consensus on the Treatment of Head and Neck Cancer. JCO Glob Oncol 2024; 10:e2300343. [PMID: 38603656 DOI: 10.1200/go.23.00343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 04/13/2024] Open
Abstract
Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.
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Affiliation(s)
- Leandro Luongo Matos
- Head and Neck Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | - Gilberto de Castro Junior
- Clinical Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Andrés Munyo Estefan
- Profesor Adjunto Catedra de Otorrinolaringologia del Hospital de Clínicas, Montevidéu, Uruguay
| | | | | | | | - Andre Guimarães Gouveia
- Juravinski Cancer Centre, Department of Oncology, Division of Radiation Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Marco Aurelio Vamondes Kulcsar
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | - Ana Kober Leite
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | - Renan Bezerra Lira
- AC Camargo Cancer Center and Hospital Albert Einstein, São Paulo, Brazil
| | - Milena Perez Mak
- 3Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil
| | | | | | | | - Pablo H Montero
- Department of Surgical Oncology and Head and Neck Surgery, Division of Surgery, P. Universidad Católica de Chile, Santiago, Chile
| | | | | | | | | | | | | | - Álvaro Sanabria
- 4Department of Surgery, Universidad de Antioquia, Hospital Alma Mater, Medellin, Colombia
| | - Miguel Ticona-Castro
- 5ESMO Member, Peruvian Society of Medical Oncology (S.P.O.M.) Member, La Molina, Peru
| | - José Guilherme Vartanian
- 6Head and Neck Surgery and Otorhinolaryngology Department, A. C. Camargo Cancer Center, São Paulo, Brazil
| | - Gustavo Viani
- 7Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, Brazil
| | - Eugenio F Vines
- Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | | | - Shama Virani
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
| | - Paul Brennan
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
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11
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Spence RN, Au VH, Zhao Y, Feng AL, Juliano AF, Goss D, Varvares MA. Intraoperative Ultrasound for the Management of Oral Tongue Cancer: a Systematic Review and Meta-Analysis. OTO Open 2024; 8:e147. [PMID: 38846015 PMCID: PMC11154832 DOI: 10.1002/oto2.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/17/2024] [Accepted: 05/09/2024] [Indexed: 06/09/2024] Open
Abstract
Objective To evaluate for correlation between intraoperative ultrasound (IOUS)-measured tumor thickness (TT) (uTT) and histopathological TT (hTT), and to compare IOUS-assisted resection with conventional resection in patients with oral tongue cancers. Data Sources Ovid MEDLINE (1946-2023), Embase.com (1947-2023), and Web of Science (All Databases 1900-2023). Review Methods Inclusion criteria were the use of IOUS for the management of oral tongue cancer. Studies that did not report quantitative data were excluded. Additionally, studies that were not contributory to meta-analysis, or a narrative analysis of pooled results were excluded. Selection was carried out by 2 reviewers. A total of 2417 studies were initially identified, with 12 ultimately being included in this review, and 7 included in the meta-analysis. Data were extracted by 2 investigators and were pooled using a random-effects model. Results Our meta-analysis reveals a pooled correlation coefficient of 0.92 (95% confidence interval: 0.80-0.96) for studies comparing uTT to hTT. Studies comparing IOUS-assisted resection to conventional resection found IOUS-assisted resection yielded wider nearest margins in all studies reporting this outcome. Conclusion IOUS reliably measures TT, similarly to that of histopathology measurement. IOUS-assisted resection, which allows the surgeon to view the deep extent of tumor invasion, may increase closest radial margin distance compared to conventional resection. IOUS-assisted resection may represent a more reliable approach to achieving clear margins than conventional resection.
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Affiliation(s)
- Ryland N. Spence
- The Warren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Vivienne H. Au
- Department of Otolaryngology–Head and Neck SurgeryNew York‐Presbyterian Hospital, Columbia University and Weill Cornell Schools of MedicineNew YorkNew YorkUSA
| | - Yan Zhao
- Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and EarBostonMassachusettsUSA
| | - Allen L. Feng
- Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and EarBostonMassachusettsUSA
| | - Amy F. Juliano
- Department of RadiologyMassachusetts Eye and Ear, Harvard Medical SchoolBostonMassachusettsUSA
| | - Deborah Goss
- Library Services, Massachusetts Eye and EarBostonMassachusettsUSA
| | - Mark A. Varvares
- Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and EarBostonMassachusettsUSA
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12
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Prasad K, Sharma R, Habib D, Sinard R, Mannion K, Rohde S, Langerman A, Netterville J, Rosenthal E, Lewis J, Topf MC. How Often is Cancer Present in Oral Cavity Re-resections After Initial Positive Margins? Laryngoscope 2024; 134:717-724. [PMID: 37584332 PMCID: PMC10947549 DOI: 10.1002/lary.30959] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVE To evaluate the rate at which carcinoma is present in the re-resection specimen following initial positive margins during head and neck cancer surgery and its impact on oncologic outcomes. STUDY DESIGN Retrospective chart review. METHODS A single institution retrospective chart review of patients that underwent curative-intent surgery for oral cavity cancer was performed. Final pathology reports were reviewed to identify patients with initial positive margins who underwent re-resection during the same operation. Initial positive margin was defined as severe dysplasia, carcinoma in situ (CIS), or carcinoma. Cox proportional hazards and Kaplan-Meier analyses were used to assess for associations with survival outcomes. RESULTS Among 1873 total patients, 190 patients (10.1%) had initial positive margins and underwent re-resection during the same surgery. Additional carcinoma, CIS, or severe dysplasia was found in 29% of re-resections, and 31% of patients with initial positive margins had final positive margins. Half of the patients with a final positive margin had a positive margin at an anatomic site different than the initial positive margin that was re-resected. The median follow-up was 636 days (range 230-1537). Re-resection with cancer and final positive margin status was associated with worse overall survival (OS; p = 0.044 and p = 0.05, respectively). However, only age, T4 disease, and surgery for recurrent oral cavity cancer were independently associated with OS (p < 0.001, p = 0.005, and p = 0.001, respectively). CONCLUSIONS Fewer than a third of oral cavity re-resections contain further malignancy, which may suggest that surgeons have difficulty relocating the site of initial positive margin. Final positive margins are often at anatomic sites different than the initial positive margin. LEVEL OF EVIDENCE 4 Laryngoscope, 134:717-724, 2024.
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Affiliation(s)
- Kavita Prasad
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Rahul Sharma
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Daniel Habib
- Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Robert Sinard
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Kyle Mannion
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Sarah Rohde
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Alexander Langerman
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - James Netterville
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Eben Rosenthal
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - James Lewis
- Department of Pathology, Microbiology, & Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Michael C Topf
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
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13
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Suhaym O, Moles L, Callahan N. Cutting guides in mandibular tumor ablation: Are we as accurate as we think? Saudi Dent J 2024; 36:340-346. [PMID: 38420006 PMCID: PMC10897611 DOI: 10.1016/j.sdentj.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 03/02/2024] Open
Abstract
Purpose Tumor margin status is critical in local tumor recurrence and is a significant prognostic factor in head and neck cancer survival. With the introduction of computer-assisted surgical planning, one of the main challenges is the accurate positioning of the surgical cutting guide but there is limited evidence of the accuracy of the 3D cutting guides in mimicking virtually planned osteotomy. This study evaluates the accuracy of osteotomy lines produced by 3D-printed cutting guides and assesses the overall accuracy of mandibular reconstruction. Material and Methods The pre and postoperative 3D models were aligned using an automated surface registration feature based on the iterative closest point algorithm. The differences in osteotomy line deviation, linear and angle measurements, and 3D volume quantification of the pre and post models were measured. Results We included 14 patients (8 men and 6 women with ages ranging from 13 to 75 years) with a segmental mandibular resection who met all of the inclusion criteria. The smallest defect size was 4.4 cm, the largest defect was 12.2 cm, and the average was 7.30 cm +/- 2.80 cm. The average deviation between virtually planned osteotomy and actual surgical osteotomy was 1.52 +/-1.02 mm. No covariates were associated with increased inaccuracy of the 3D-printed cutting guides. Conclusion The finding of this study suggests that virtual surgical planning is an unambiguous paradigm shift in the predictability of the surgical plan and achievement of the reconstruction goals. The 3D-printed cutting guides are a very accurate and reliable tool in translating virtual ablation plans to an actual surgical resection margin.
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Affiliation(s)
- Omar Suhaym
- Maxillofacial Surgery and Diagnostic Sciences, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center (KAIMRC), Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Ar Rimayah, 14611 Riyadh, Saudi Arabia
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14
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Villemure-Poliquin N, Roy ÈM, Nguyen S, Beauchemin M, Audet N. Tumor Bed Margins Versus Specimen Margins in Oral Cavity Cancer: Too Close to Call? J Otolaryngol Head Neck Surg 2024; 53:19160216241278653. [PMID: 39248608 PMCID: PMC11384533 DOI: 10.1177/19160216241278653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION The routine assessment of intraoperative margins has long been the standard of care for oral cavity cancers. However, there is a controversy surrounding the best method for sampling surgical margins. The aim of our study is to determine the precision of a new technique for sampling tumor bed margins (TBMs), to evaluate the impact on survival and the rate of free flap reconstructions. METHODS This retrospective cohort study involved 156 patients with primary cancer of the tongue or floor of the mouth who underwent surgery as initial curative treatment. Patients were separated into 2 groups: one using an oriented TBM derived from Mohs' technique, where the margins are taken from the tumor bed and identified with Vicryl sutures on both the specimen and the tumor bed, and the other using a specimen margins (SMs) driven technique, where the margins are taken from the specimen after the initial resection. Clinicopathologic features, including margin status, were compared for both groups and correlated with locoregional control. Precision of per-operative TBM sampling method was obtained. RESULTS A total of 156 patients were included in the study, of which 80 were in TBM group and 76 were in SM group. Precision analysis showed that the oriented TBM technique pertained a 50% sensitivity, 96.6% specificity, 80% positive predictive value, and an 87.5% negative predictive value. Survival analysis revealed nonstatistically significant differences in both local control (86.88% vs 83.50%; P = .81) as well as local-regional control (82.57% vs 72.32%; P = .21). There was a significant difference in the rate of free flap-surgeries between the 2 groups (30% vs 64.5%; P < .001). CONCLUSION Our described oriented TBM technique has demonstrated reduced risk of free flap reconstructive surgery, increased precision, and similar prognostic in terms of local control, locoregional control, and disease-free survival when compared to the SM method.
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Affiliation(s)
- Noémie Villemure-Poliquin
- Département d'ophtalmologie et d'oto-rhino-laryngologie - chirurgie cervico-faciale, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Ève-Marie Roy
- Département d'ophtalmologie et d'oto-rhino-laryngologie - chirurgie cervico-faciale, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Sally Nguyen
- Département de chirurgie, Service d'oto-rhino-laryngologie - chirurgie cervico-faciale, CISSS de l'Outaouais, Centre affilié universitaire avec l'Université McGill, Gatineau, QC, Canada
| | - Michel Beauchemin
- Département d'anatomo-pathologie, Faculté de Médecine, Université Laval, Quebec City, QC, Canada
| | - Nathalie Audet
- Département d'ophtalmologie et d'oto-rhino-laryngologie - chirurgie cervico-faciale, Faculté de Médecine, Université Laval, Québec, QC, Canada
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15
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Miller A, Prasad K, Sharif KF, Adams DJ, Garbow L, Roberts E, Lewis JS, Ely KA, Mehrad M, Rohde SL, Langerman AJ, Mannion K, Sinard RJ, Netterville JL, Rosenthal EL, Topf MC. Virtual 3D Specimen Mapping in Head & Neck Oncologic Surgery. Laryngoscope 2024; 134:191-197. [PMID: 37466329 PMCID: PMC10796840 DOI: 10.1002/lary.30881] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/15/2023] [Accepted: 06/29/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Virtual 3D specimen mapping of oncologic surgical specimens provides a visual record of the specimen and margin sampling sites which can be utilized in a variety of cancer care settings. Our objective was to perform a retrospective review of head and neck surgical oncology cases where the specimen was mapped post-operatively and to evaluate the utility of these 3D specimen maps amongst the multidisciplinary cancer care team. METHODS A retrospective review of our 3D specimen model biorepository was performed. Surgical specimens were 3D scanned and then graphically annotated (or "mapped") during routine pathologic processing. The resulting 3D specimen maps were distributed to the multidisciplinary oncologic care team. Final margin status and any use of the 3D specimen maps were recorded. RESULTS A total of 28 cases were included. Virtual 3D specimen maps were utilized by the cancer care team in 8 cases (29%), including 2 positive margin cases, 2 close margin cases, and 4 indeterminate margin cases. 3D specimen maps were used to visualize positive margin sites for pathologist-surgeon communication as a visual reference during tumor board discussions and to inform radiation treatment planning. CONCLUSION Post-operative virtual 3D specimen mapping of oncologic specimens creates a permanent visual record of the specimen and the margins sampled and may serve as a beneficial tool for communication amongst the multidisciplinary cancer care team. LEVEL OF EVIDENCE 4 Laryngoscope, 134:191-197, 2024.
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Affiliation(s)
- Alexis Miller
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - Kavita Prasad
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | | | - Destinee J. Adams
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - Lily Garbow
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - Emily Roberts
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - James S. Lewis
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - Kim A. Ely
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - Mitra Mehrad
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - Sarah L. Rohde
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - Alexander J. Langerman
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - Kyle Mannion
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - Robert J. Sinard
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - James L. Netterville
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - Eben L. Rosenthal
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
| | - Michael C. Topf
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center
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16
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Reale M, Bardon ML, Ciavarro G, Pedrazzi G, Santoro GP. Value and role of surgical margins in transoral laser microsurgery of the larynx, literature review and clinical considerations. Eur Arch Otorhinolaryngol 2024; 281:23-30. [PMID: 37740744 DOI: 10.1007/s00405-023-08238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/10/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE There is no agreement on the most appropriate post-operative pathway for the management of positive margins after laser cordectomy for early stage glottic tumours (T1-2N0M0). This literature review and meta-analysis aim to evaluate the post-operative treatment with the best oncological results among follow-up, radiotherapy (RT) and surgical second look. The parameters utilized were incidence of recurrence, overall (OS), disease-specific (DSS) and disease-free (DFS) survival and larynx preservation (LP). METHODS The articles were found through a string typed into PubMed from 2007 to 2022. The studies with detailed oncological results were selected according to inclusion criteria, and then the meta-analysis was carried out. RESULTS Sixteen studies met the inclusion criteria for 2808 patients. The positive margin was found in 748 patients (26.6%), of which 416 were referred to follow-up, 89 to RT and 242 to a surgical second look. A false positive margin was found in 58/104 patients (56%). The recurrence rate in patients with positive margins was significantly higher (p = 0.003). In OS, DSS, DFS and LP, the odds ratio (OR) value was always greater than 1, assessing the role of the positive margin as a risk factor. CONCLUSIONS Prospective studies will be necessary to establish the role of positive margin as a prognostic factor. A surgical second look in case of positive margin seems to be the best option for the patient in terms of lower risk of recurrence and better oncological results. Better collaboration between surgeon and pathologist would be desirable to limit the real and false positive margins.
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Affiliation(s)
- M Reale
- Department of Otolaryngology and Otoneurosurgery, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - M L Bardon
- Department of Otolaryngology and Otoneurosurgery, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy.
| | - G Ciavarro
- Department of Otolaryngology and Otoneurosurgery, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - G Pedrazzi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - G P Santoro
- Department of Otolaryngology and Otoneurosurgery, University Hospital of Parma, Via Gramsci 14, 43126, Parma, Italy
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Vlocskó M, Piffkó J, Janovszky Á. Intraoperative Assessment of Resection Margin in Oral Cancer: The Potential Role of Spectroscopy. Cancers (Basel) 2023; 16:121. [PMID: 38201548 PMCID: PMC10777979 DOI: 10.3390/cancers16010121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
In parallel with the increasing number of oncological cases, the need for faster and more efficient diagnostic tools has also appeared. Different diagnostic approaches are available, such as radiological imaging or histological staining methods, but these do not provide adequate information regarding the resection margin, intraoperatively, or are time consuming. The purpose of this review is to summarize the current knowledge on spectrometric diagnostic modalities suitable for intraoperative use, with an emphasis on their relevance in the management of oral cancer. The literature agrees on the sensitivity, specificity, and accuracy of spectrometric diagnostic modalities, but further long-term prospective, multicentric clinical studies are needed, which may standardize the intraoperative assessment of the resection margin and the use of real-time spectroscopic approaches.
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Affiliation(s)
| | | | - Ágnes Janovszky
- Department of Oral and Maxillofacial Surgery, Albert Szent-Györgyi Medical School, University of Szeged, Kálvária 57, H-6725 Szeged, Hungary; (M.V.); (J.P.)
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18
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Prasad K, Topf MC, Clookey S, Philips R, Curry J, Tassone P. Trends in Positive Surgical Margins in cT3-T4 Oral Cavity Squamous Cell Carcinoma. Otolaryngol Head Neck Surg 2023; 169:1200-1207. [PMID: 37232479 DOI: 10.1002/ohn.377] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/11/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Positive surgical margins in oral cavity squamous cell carcinoma are associated with cost escalation, treatment intensification, and greater risk of recurrence and mortality. The positive margin rate has been decreasing for cT1-T2 oral cavity cancer over the past 2 decades. We aim to evaluate positive margin rates in cT3-T4 oral cavity cancer over time, and determine factors associated with positive margins. STUDY DESIGN Retrospective analysis of a national database. SETTING National Cancer Database 2004 to 2018. METHODS All adult patients diagnosed between 2004 and 2018 who underwent primary curative intent surgery for previously untreated cT3-T4 oral cavity cancer with known margin status were included. Logistic univariable and multivariable regression analyses were performed to identify factors associated with positive margins. RESULTS Among 16,326 patients with cT3 or cT4 oral cavity cancer, positive margins were documented in 2932 patients (18.1%). Later year of treatment was not significantly associated with positive margins (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.96-1.00). The proportion of patients treated at academic centers increased over time (OR 1.02, 95% CI 1.01-1.03). On multivariable analysis, positive margins were significantly associated with hard palate primary, cT4 tumors, advancing N stage, lymphovascular invasion, poorly differentiated histology, and treatment at nonacademic or low-volume centers. CONCLUSION Despite increased treatment at academic centers for locally advanced oral cavity cancer, there has been no significant decrease in positive margin rates which remains high at 18.1%. Novel techniques for margin planning and assessment may be required to decrease positive margin rates in locally advanced oral cavity cancer.
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Affiliation(s)
- Kavita Prasad
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael C Topf
- Department of Otolaryngology-Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Patrick Tassone
- Department of Otolaryngology-Head & Neck Surgery, University of Missouri, Columbia, Missouri, USA
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Wu SS, Woody N, Hesse J, Cook S, Cracolici V, Ku JA, Prendes B, Silver N, Scharpf J, Brauer PR, Reddy CA, Campbell SR, Koyfman SA, Burkey B, Lamarre ED. Margin Assessment Methods in Oral Cavity Squamous Cell Carcinoma and Recurrence: Tumor Bed vs Resection Specimen Sampling. JAMA Otolaryngol Head Neck Surg 2023; 149:1011-1020. [PMID: 37768650 PMCID: PMC10540056 DOI: 10.1001/jamaoto.2023.2982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/05/2023] [Indexed: 09/29/2023]
Abstract
Importance Positive margins and margin clearance are risk factors for recurrence in oral cavity squamous cell carcinoma (OCSCC), and these features are used to guide decisions regarding adjuvant radiation treatment. However, the prognostic value of intraoperative tumor bed vs resection specimen sampling is not well defined. Objective To determine the prognostic implications of intraoperative margin assessment methods (tumor bed vs resection specimen sampling) with recurrence among patients who undergo surgical resection for OCSCC. Design, Setting, and Participants This was a retrospective study of patients who had undergone surgical resection of OCSCC between January 1, 2000, and December 31, 2021, at a tertiary-level academic institution. Patients were grouped by margin assessment method (tumor bed [defect] or resection specimen sampling). Of 223 patients with OCSCC, 109 patients had localized tumors (pT1-T2, cN0), 154 had advanced tumors, and 40 were included in both cohorts. Disease recurrence after surgery was estimated by the cumulative incidence method and compared between cohorts using hazard ratios (HRs). Data analyses were performed from January 5, 2023, to April 30, 2023. Main Outcome and Measures Recurrence-free survival (RFS). Results The study population comprised 223 patients (mean [SD] age, 62.7 [12.0] years; 88 (39.5%) female and 200 [90.0%] White individuals) of whom 158 (70.9%) had defect-driven and 65 (29.1%) had specimen-driven margin sampling. Among the 109 patients with localized cancer, intraoperative positive margins were found in 5 of 67 (7.5%) vs 8 of 42 (19.0%) for defect- vs specimen-driven sampling, respectively. Final positive margins were 3.0% for defect- (2 of 67) and 2.4% for specimen-driven (1 of 42) margin assessment. Among the 154 patients with advanced cancer, intraoperative positive margins were found in 29 of 114 (25.4%) vs 13 of 40 (32.5%) for defect- and specimen-driven margins, respectively. Final positive margins were higher in the defect-driven group (9 of 114 [7.9%] vs 1 of 40 [2.5%]). When stratified by margin assessment method, the 3-year rates of local recurrence (9.7% vs 5.1%; HR, 1.37; 95% CI, 0.51-3.66), regional recurrence (11.0% vs 10.4%; HR, 0.85; 95% CI, 0.37-1.94), and distant recurrence (6.4% vs 5.0%; HR, 1.10; 95% CI, 0.36-3.35) were not different for defect- vs specimen-driven sampling cohorts, respectively. The 3-year rate of any recurrence was 18.9% in the defect- and 15.2% in the specimen-driven cohort (HR, 0.93; 95% CI, 0.48-1.81). There were no differences in cumulative incidence of disease recurrence when comparing defect- vs specimen-driven cases. Conclusions and Relevance The findings of this retrospective cohort study indicate that margin assessment methods using either defect- or specimen-driven sampling did not demonstrate a clear association with the risk of recurrence after OCSCC resection. Specimen-driven sampling may be associated with reduced surgical margin positivity rates, which often necessitate concurrent chemotherapy with adjuvant radiation therapy.
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Affiliation(s)
- Shannon S. Wu
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Neil Woody
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer Hesse
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Samantha Cook
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Jamie A. Ku
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brandon Prendes
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Natalie Silver
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph Scharpf
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Philip R. Brauer
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Chandana A. Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shauna R. Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shlomo A. Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Burkey
- Department of Otolaryngology, Head and Neck Institute, Head and Neck Institute, Cleveland Clinic, Vero Beach, Florida
| | - Eric D. Lamarre
- Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
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20
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Yun J, Su V, Kapustin D, Rubin SJ, Brandwein-Weber M, Khan MN, Chai R, Doyle S, Karasick M, Urken ML. Intraoperative three-dimensional scanning of head and neck surgical defects: Enhanced communication and documentation of harvested supplemental margins. Head Neck 2023; 45:2690-2699. [PMID: 37638591 DOI: 10.1002/hed.27498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/11/2023] [Accepted: 08/19/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND We have demonstrated the effectiveness of 3D resection specimen scanning for communicating margin results. We now address the corresponding surgical defect by debuting 3D defect models, which allow for accurate annotations of harvested supplemental margins. METHODS Surgical defects were rendered into 3D models, which were annotated to document the precise location of harvested supplemental margins. 3D defect scans were also compared with routine 2D photography and were analyzed for quality, clarity, and the time required to complete the scan. RESULTS Forty defects were scanned from procedures including segmental mandibulectomy, maxillectomy, and laryngopharyngectomy. Average duration of defect scan was 6 min, 45 s. In six of ten 2D photographs, the surgeon was unable to precisely annotate the extent of at least one supplemental margin. CONCLUSION 3D defect scanning offers advantages in that this technique enables documentation of the precise location and breadth of supplemental margins harvested to address margins at-risk.
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Affiliation(s)
- Jun Yun
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, USA
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vivian Su
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, USA
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Danielle Kapustin
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, USA
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel J Rubin
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, USA
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Mohemmed N Khan
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raymond Chai
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Scott Doyle
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine & Biomedical Sciences, Buffalo, New York, USA
| | - Michael Karasick
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, USA
| | - Mark L Urken
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, New York, USA
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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21
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Inoue K, Ito H, Iwai M, Tanaka M, Mori Y, Todo T. Neoadjuvant use of oncolytic herpes virus G47Δ prevents local recurrence after insufficient resection in tongue cancer models. Mol Ther Oncolytics 2023; 30:72-85. [PMID: 37583387 PMCID: PMC10423690 DOI: 10.1016/j.omto.2023.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 07/17/2023] [Indexed: 08/17/2023] Open
Abstract
A complete resection of tongue cancer is often difficult. We investigate the usefulness of administering G47Δ (teserpaturev), a triple-mutated oncolytic herpes simplex virus type 1, prior to resection. G47Δ exhibits good cytopathic effects and replication capabilities in all head and neck cancer cell lines tested. In an orthotopic SCCVII tongue cancer model of C3H/He mice, an intratumoral inoculation with G47Δ significantly prolongs the survival. Further, mice with orthotopic tongue cancer received neoadjuvant G47Δ (or mock) therapy with or without "hemilateral" resection, the maximum extent avoiding surgical deaths. Neoadjuvant G47Δ and resection led to 10/10 survival (120 days), whereas the survivals for G47Δ alone and resection alone were 6/10 and 5/10, respectively: all control animals died by day 11. Furthermore, 100% survival was achieved with neoadjuvant G47Δ therapy even when the resection area was narrowed to "partial," providing insufficient resection margins, whereas hemilateral resection alone caused death by local recurrence in half of the animals. G47Δ therapy caused increased number of tumor-infiltrating CD8+ and CD4+ cells, increased F4/80+ cells within the residual tongues, and increased expression of immune-related genes in and around the tumor. These results imply that neoadjuvant use of G47Δ is useful for preventing local recurrence after tongue cancer surgery.
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Affiliation(s)
- Kosuke Inoue
- Division of Innovative Cancer Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
- Department of Oral and Maxillofacial Surgery, Jichi Medical University Hospital, Tochigi 329-0498, Japan
| | - Hirotaka Ito
- Division of Innovative Cancer Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
| | - Miwako Iwai
- Division of Innovative Cancer Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
| | - Minoru Tanaka
- Division of Innovative Cancer Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
- Project Division of Oncolytic Virus Development, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
| | - Yoshiyuki Mori
- Department of Oral and Maxillofacial Surgery, Jichi Medical University Hospital, Tochigi 329-0498, Japan
| | - Tomoki Todo
- Division of Innovative Cancer Therapy, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
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22
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Warshavsky A, Dorman A, Carmel-Neiderman NN, Leider-Trejo L, Muhanna N, Kampel L, Ianculovici C, Horowitz G. Pre-resection Intraoperative Core Biopsies in Oral Tongue Cancer-A Pilot Study. Laryngoscope 2023; 133:2232-2236. [PMID: 36576073 DOI: 10.1002/lary.30546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/14/2022] [Accepted: 12/03/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess a novel intraoperative core biopsy technique to provide enhanced guidance in partial glossectomies. METHODS All patients diagnosed with squamous cell carcinoma of the oral tongue were eligible for study participation. Following anesthesia, the planned resection and three points midway between the gross tumor and the intended ablation were marked. A core biopsy was performed with a needle spring on each point and sent for frozen sections. The initially planned resection was executed if the cores returned free of tumor. In case of a positive core biopsy, a new 1-1.5 cm margin was marked around that point. The main outcome measure was the closest final margin diameter, especially the deep ones. Other outcome measures were the core biopsies' sensitivity, specificity, and negative predictive value. Complications were recorded. RESULTS The final margins of 10 patients undergoing intraoperative core biopsies and 20 matched controls were analyzed. One patient had two positive cores and final negative margins after modifying the resection accordingly. Another patient had a positive biopsy diagnosed only on final pathology, and one close final margin. Patients that were operated with the new technique had larger margins compared to the controls: median (interquartile range) closest margin 5.95 (3.97; 9.63) mm versus 4 (2.25; 5) mm (p = 0.074) and median deep margin 8.6 (6.16; 10) mm versus 5 (3;10) mm (p = 0.411), respectively. There were no complications. CONCLUSION A novel pre-resection intraoperative biopsy technique is presented. Core biopsies taken during glossectomies have the potential to prevent inadequate margins. LEVEL OF EVIDENCE 3 Laryngoscope, 133:2232-2236, 2023.
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Affiliation(s)
- Anton Warshavsky
- The Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alexandra Dorman
- The Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Narin Nard Carmel-Neiderman
- The Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Leonora Leider-Trejo
- The Department of Pathology, Tel-Aviv Sourasky Medical Center, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nidal Muhanna
- The Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Liyona Kampel
- The Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Clariel Ianculovici
- The Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gilad Horowitz
- The Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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23
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Kowalski LP. Eugene Nicholas Myers' Lecture on Head and Neck Cancer, 2020: The Surgeon as a Prognostic Factor in Head and Neck Cancer Patients Undergoing Surgery. Int Arch Otorhinolaryngol 2023; 27:e536-e546. [PMID: 37564472 PMCID: PMC10411134 DOI: 10.1055/s-0043-1761170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/26/2022] [Indexed: 08/12/2023] Open
Abstract
This paper is a transcript of the 29 th Eugene N. Myers, MD International Lecture on Head and Neck Cancer presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2020. By the end of the 19 th century, the survival rate in treated patients was 10%. With the improvements in surgical techniques, currently, about two thirds of patients survive for > 5 years. Teamwork and progress in surgical reconstruction have led to advancements in ablative surgery; the associated adjuvant treatments have further improved the prognosis in the last 30 years. However, prospective trials are lacking; most of the accumulated knowledge is based on retrospective series and some real-world data analyses. Current knowledge on prognostic factors plays a central role in an efficient treatment decision-making process. Although the influence of most tumor- and patient-related prognostic factors in head and neck cancer cannot be changed by medical interventions, some environmental factors-including treatment, decision-making, and quality-can be modified. Ideally, treatment strategy decisions should be taken in dedicated multidisciplinary team meetings. However, evidence suggests that surgeons and hospital volume and specialization play major roles in patient survival after initial or salvage head and neck cancer treatment. The metrics of surgical quality assurance (surgical margins and nodal yield) in neck dissection have a significant impact on survival in head and neck cancer patients and can be influenced by the surgeon's expertise. Strategies proposed to improve surgical quality include continuous performance measurement, feedback, and dissemination of best practice measures.
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Affiliation(s)
- Luiz P. Kowalski
- Head and Neck Surgery Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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24
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Puram SV, Mays AC, Bayon R, Bell D, Chung J, Fundakowski CE, Johnson BT, Massa ST, Sharma A, Varvares MA. Margins in Stage I and II Oral Cavity Squamous Cell Carcinoma: A Review From the American Head and Neck Society. JAMA Otolaryngol Head Neck Surg 2023; 149:636-642. [PMID: 37289469 DOI: 10.1001/jamaoto.2023.1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Importance The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality. Observations This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design. Conclusions and Relevance Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.
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Affiliation(s)
- Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
- Department of Genetics, Washington University in St Louis, St Louis, Missouri
| | - Ashley C Mays
- Department of Otolaryngology, Cleveland Clinic Florida, Cleveland Clinic Indian River Hospital, Vero Beach
| | - Rodrigo Bayon
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City
| | - Diana Bell
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jeffson Chung
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown
| | - Christopher E Fundakowski
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Bradley T Johnson
- Ear, Nose, Throat and Plastic Surgery Associates, AdventHealth, Winter Park, Florida
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, St Louis University, St Louis, Missouri
| | - Arun Sharma
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston
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25
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Urken ML, Yun J, Saturno MP, Greenberg LA, Chai RL, Sharif K, Brandwein-Weber M. Frozen Section Analysis in Head and Neck Surgical Pathology: A Narrative Review of the Past, Present, and Future of Intraoperative Pathologic Consultation. Oral Oncol 2023; 143:106445. [PMID: 37285683 DOI: 10.1016/j.oraloncology.2023.106445] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/13/2023] [Accepted: 05/30/2023] [Indexed: 06/09/2023]
Abstract
Frozen section has remained the diagnostic gold standard for intraoperative pathological evaluation of surgical margins for head and neck specimens. While achieving tumor-free margins is of utmost importance to all head and neck surgeons, in practice, there are numerous debates and a lack of standardization for the role and method of intraoperative pathologic consultation. This review serves as a summary guide to the historical and contemporary practice of frozen section analysis and margin mapping in head and neck cancer. In addition, this review discusses current challenges in head and neck surgical pathology, and introduces 3D scanning as a groundbreaking technology to bypass many of the pitfalls in the current frozen section workflow. The ultimate goal for all head and neck pathologists and surgeons should be to modernize practices and take advantage of new technology, such as virtual 3D specimen mapping techniques, that improves the workflow for intraoperative frozen section analysis.
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Affiliation(s)
- Mark L Urken
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, NY, USA; Dept. of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Jun Yun
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, NY, USA; Dept. of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, USA
| | | | - Lily A Greenberg
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, NY, USA
| | - Raymond L Chai
- Dept. of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Kayvon Sharif
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Margaret Brandwein-Weber
- THANC (Thyroid, Head & Neck Cancer) Foundation, New York, NY, USA; Dept. of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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26
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Higginson JA, Breik O, Thompson AH, Ashrafian H, Hardman JC, Takats Z, Paleri V, Dhanda J. Diagnostic accuracy of intraoperative margin assessment techniques in surgery for head and neck squamous cell carcinoma: A meta-analysis. Oral Oncol 2023; 142:106419. [PMID: 37178655 DOI: 10.1016/j.oraloncology.2023.106419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/18/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Positive margins following head and neck squamous cell carcinoma (HNSCC) surgery lead to significant morbidity and mortality. Existing Intraoperative Margin Assessment (IMA) techniques are not widely used due to limitations in sampling technique, time constraints and resource requirements. We performed a meta-analysis of the diagnostic performance of existing IMA techniques in HNSCC, providing a benchmark against which emerging techniques may be judged. METHODS The study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Studies were included if they reported diagnostic metrics of techniques used during HNSCC surgery, compared with permanent histopathology. Screening, manuscript review and data extraction was performed by multiple independent observers. Pooled sensitivity and specificity were estimated using the bivariate random effects model. RESULTS From an initial 2344 references, 35 studies were included for meta-analysis. Sensitivity (Sens), specificity (Spec), diagnostic odds ratio (DOR) and area under the receiver operating characteristic curve (AUROC) were calculated for each group (n, Sens, Spec, DOR, AUROC): frozen section = 13, 0.798, 0.991, 309.8, 0.976; tumour-targeted fluorescence (TTF) = 5, 0.957, 0.827, 66.4, 0.944; optical techniques = 10, 0.919, 0.855, 58.9, 0.925; touch imprint cytology = 3, 0.925, 0.988, 51.1, 0.919; topical staining = 4, 0.918, 0.759, 16.4, 0.833. CONCLUSIONS Frozen section and TTF had the best diagnostic performance. Frozen section is limited by sampling error. TTF shows promise but involves administration of a systemic agent. Neither is currently in widespread clinical use. Emerging techniques must demonstrate competitive diagnostic accuracy whilst allowing rapid, reliable, cost-effective results.
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Affiliation(s)
| | - Omar Breik
- School of Dentristy, University of Queensland, Australia
| | | | | | - John C Hardman
- International Centre for Recurrent Head and Neck Cancer, The Royal Marsden NHS Foundation Trust, UK
| | | | - Vinidh Paleri
- International Centre for Recurrent Head and Neck Cancer, The Royal Marsden NHS Foundation Trust, UK; Institute of Cancer Research, UK
| | - Jagtar Dhanda
- Department of Surgery, Brighton and Sussex Medical School, UK
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27
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Young K, Bulosan H, Kida CC, Bewley AF, Abouyared M, Birkeland AC. Stratification of surgical margin distances by the millimeter on local recurrence in oral cavity cancer: A systematic review and meta-analysis. Head Neck 2023; 45:1305-1314. [PMID: 36891759 PMCID: PMC10079646 DOI: 10.1002/hed.27339] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/30/2023] [Accepted: 02/22/2023] [Indexed: 03/10/2023] Open
Abstract
There are limited data supporting the commonly suggested 5 mm margin cutoff as the optimum value in defining clear margins in oral cancer. A database search of Pubmed/Medline, Web of Science, and EBSCOhost was performed from inception to June 2022. A random-effects model was chosen for this meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed throughout this study. Seven studies met study criteria (2215 patients). The risk ratio was significantly higher for margins <5 mm when compared to those ≥5 mm (2.09 (95%CI: 1.53-2.86, I2 = 0.47)). Subgroup analysis (I2 = 0.15) of margin distances of 0.0-0.9, 1.0-1.9, 2.0-2.9, 3.0-3.9, and 4.0-4.9 mm calculated risk ratios for local recurrence of 2.96, 2.01, 2.17, 1.8, and 0.98, respectively. Margins between 4.0 and 4.9 mm had similar risk ratios for local recurrence compared to ≥5 mm, while margins <4.0 were significantly higher.
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Affiliation(s)
- Kurtis Young
- University of Hawaii at Manoa, John A. Burns School of Medicine
| | - Hannah Bulosan
- University of Hawaii at Manoa, John A. Burns School of Medicine
| | - Carley C. Kida
- University of Hawaii at Manoa, John A. Burns School of Medicine
| | - Arnaud F. Bewley
- Department of Otolaryngology - Head and Neck Surgery, University of California, Davis
| | - Marianne Abouyared
- Department of Otolaryngology - Head and Neck Surgery, University of California, Davis
| | - Andrew C. Birkeland
- Department of Otolaryngology - Head and Neck Surgery, University of California, Davis
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28
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Zhang L, Judd RT, Zhao S, Rygalski C, Li M, Briody A, Swendseid B, Blakaj DM, Agrawal A, Ozer E, Carrau RL, Teknos TN, VanKoevering K, Rocco JW, Old MO, Seim NB, Puram SV, Haring CT, Kang SY. Immediate resection of positive margins improves local control in oral tongue cancer. Oral Oncol 2023; 141:106402. [PMID: 37094500 DOI: 10.1016/j.oraloncology.2023.106402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/08/2023] [Accepted: 04/15/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVES This study investigates the impact of immediate resection of positive margins on local control of oral tongue cancer. MATERIALS AND METHODS We analyzed 273 consecutive oral tongue cancers resected from 2013 to 2018. Additional resection was performed in cases during the initial operation based on surgeon inspection of the specimen and/or frozen margins. Positive margins were defined as invasive carcinoma/high-grade dysplasia < 1 mm from the inked edge. Patients were grouped as follows: negative margin (Group 1); positive margin with immediate additional tissue resection (Group 2); and positive margin without additional tissue resection (Group 3). RESULTS Overall, the rate of local recurrence was 7.7 % (21/273), and the rate of positive main specimen margin was 17.9 %. Of these patients, 38.8 % (19/49) underwent immediate additional resection of the presumed positive margin. Group 3 had higher local recurrence rates than Group 1 after adjustment for T-stage (aHR 2.8 [95 % CI 1.0-7.7], p = 0.04). Group 2 had similar rates of local recurrence (aHR 0.45 [95 % CI 0.06-3.6], p = 0.45). Three year local recurrence free survival for Groups 1, 2, and 3 were 91 %, 92 % and 73 %, respectively. Compared to the main specimen margin, sensitivity of intraoperative frozen tumor bed margins was 17.4 %, and specificity was 95 %. CONCLUSION In patients with positive main specimen margins, anticipation and detection in real-time with immediate additional tissue resection reduced local recurrence to rates similar to those with negative main specimen margins. These findings support the use of technology to provide real-time intraoperative margin data and guide additional resection for improved local control.
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Affiliation(s)
- Lisa Zhang
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Ryan T Judd
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Songzhu Zhao
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Chandler Rygalski
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Michael Li
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | | | - Brian Swendseid
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Dukagjin M Blakaj
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Amit Agrawal
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Enver Ozer
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Ricardo L Carrau
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Theodoros N Teknos
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Kyle VanKoevering
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - James W Rocco
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Matthew O Old
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Nolan B Seim
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Sidharth V Puram
- Department of Otolaryngology, Division of Head and Neck Surgery, Washington University School of Medicine, USA
| | - Catherine T Haring
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Stephen Y Kang
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA.
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29
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Banoub RG, Crippen MM, Fiorella MA, Ross HM, Sagalow ES, Bar-Ad V, Cohen D, Gargano SM, Tuluc M, Selman Y, Goldman R, Cottrill E, Luginbuhl A, Fundakowski C, Mady LJ, Cognetti D, Topf MC, Curry JM. Variance in 3D anatomic localization of surgical margins based on conventional margin labeling in head and neck squamous cell carcinoma. Oral Oncol 2023; 139:106360. [PMID: 36924699 PMCID: PMC10947562 DOI: 10.1016/j.oraloncology.2023.106360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/31/2023] [Accepted: 02/28/2023] [Indexed: 03/15/2023]
Abstract
OBJECTIVE In head and neck cancer (HNC), positive margins are strongly predictive of treatment failure. We sought to measure the accuracy of localization of margin sampling sites based on conventional anatomic labels using a digital 3D-model. METHODS Preoperative CT scans for 9 patients with HNC treated operatively at our institution were imported into a multiplanar radiology software, which was used to render a digital 3D model of each tumor intended to represent the resection specimen. Surgical margin labels recorded during the operative case were collected from pathology records. Margin labels (N = 64) were presented to participating physicians.Participants were asked to mark the anatomic location of each surgical margin using the 3D-model and corresponding radiographic planes for reference.For each individual margin, the 3D coordinates of each participant's marker were used to calculate a mean localization point called the geometric centroid. Mean distance from individual markers to the centroid was compared between participantsand margin types. RESULTS Amongst 7 surgeons, markers were placed a mean distance of 12.6 mm ([SD] = 7.5) from the centroid.Deep margins were marked with a greater mean distance than mucosal/skin margins (19.6 [24.8] mm vs. 15.3 [14.9] mm, p = 0.034). When asked to relocate a margin following re-resection, surgeons marked a point an average of 20.6 [12.4] mm from their first marker with a range of 3.9- 45.1 mm. CONCLUSIONS Retrospective localization of conventionally labeled margins is an imprecise process with variability across the care team. Future interventions targeting margin documentation and communication may improve sampling precision.
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Affiliation(s)
- Raphael G Banoub
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Meghan M Crippen
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Michele A Fiorella
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Heather M Ross
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Emily S Sagalow
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Voichita Bar-Ad
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Dane Cohen
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Stacey M Gargano
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Madalina Tuluc
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Yamil Selman
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Richard Goldman
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Elizabeth Cottrill
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Adam Luginbuhl
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Christopher Fundakowski
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Leila J Mady
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - David Cognetti
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Michael C Topf
- Department of Otolaryngology - Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Joseph M Curry
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
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30
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Sivrice ME, Akın V, Erkılınç G, Yasan H, Tüz M, Okur E, Kumbul YÇ, Çiriş İM. Frozen Section Evaluation for Surgical Margins in Laryngeal Squamous Cell Carcinoma: Is it a Reliable Method for Partial and Total Laryngectomies? Head Neck Pathol 2023; 17:172-177. [PMID: 36171534 PMCID: PMC10063756 DOI: 10.1007/s12105-022-01485-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/24/2022] [Accepted: 08/02/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND In this study, we aimed to compare the accuracy of frozen section evaluation in partial and total laryngectomies performed to treat laryngeal squamous cell carcinoma . METHODS A retrospective study was conducted to evaluate the efficacy and accuracy of frozen section analysis for laryngeal squamous cell carcinoma of 65 patients, operated at a tertiary hospital. Two groups were recruited according to the surgical procedure. RESULTS The sensitivity and specificity of frozen section diagnosis in laryngeal cancer were 20% and 99.73%, respectively. For partial laryngectomy, the sensitivity was 16.66% and specificity was 100%. For total laryngectomy, sensitivity was 22.2% and specificity 99.13%. Discordances between the initial frozen section diagnosis and the subsequent permanent section diagnosis were found in 13 (3.35%) pairs (3.37% partial laryngectomy and 3.33% total laryngectomy). CONCLUSION Our study shows that the surgical method applied has no effect on discordances. However, sampling errors are likely to be more common in partial laryngectomy procedures. It should be kept in mind that the sensitivity of frozen section evaluation is low.
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Affiliation(s)
- Mehmet Emre Sivrice
- Department of Oto-Rhino-Laryngology and Head&Neck Surgery, Faculty of Medicine, Süleyman Demirel University, 32200 Isparta, Isparta Turkey
| | - Vural Akın
- Department of Oto-Rhino-Laryngology and Head&Neck Surgery, Faculty of Medicine, Süleyman Demirel University, 32200 Isparta, Isparta Turkey
| | - Gamze Erkılınç
- Department of Pathology, Urla State Hospital, İzmir, Turkey
| | - Hasan Yasan
- Department of Oto-Rhino-Laryngology and Head&Neck Surgery, Faculty of Medicine, Süleyman Demirel University, 32200 Isparta, Isparta Turkey
| | - Mustafa Tüz
- Department of Oto-Rhino-Laryngology and Head&Neck Surgery, Faculty of Medicine, Süleyman Demirel University, 32200 Isparta, Isparta Turkey
| | - Erdoğan Okur
- Department of Oto-Rhino-Laryngology and Head&Neck Surgery, Faculty of Medicine, Süleyman Demirel University, 32200 Isparta, Isparta Turkey
| | - Yusuf Çağdaş Kumbul
- Department of Oto-Rhino-Laryngology and Head&Neck Surgery, Faculty of Medicine, Süleyman Demirel University, 32200 Isparta, Isparta Turkey
| | - İbrahim Metin Çiriş
- Department of Pathology, Faculty of Medicine, Süleyman Demirel University, Isparta, Turkey
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31
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Brandwein-Weber M, Urken ML, Topf MC, Lewis JS, Kang SY, Curry JM, Chai R, Khan M, Modica I, Chung D, Rosenthal EL. Radical shift in the communication paradigm in head and neck frozen section analysis: Intraoperative three-dimensional specimen scanning. Head Neck 2023; 45:7-9. [PMID: 36377564 DOI: 10.1002/hed.27247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Margaret Brandwein-Weber
- Department of Pathology, Mount Sinai West, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mark L Urken
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York, USA.,Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael C Topf
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James S Lewis
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Y Kang
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Raymond Chai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohammed Khan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ippolito Modica
- Department of Pathology, Mount Sinai West, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dan Chung
- Department of Pathology, Mount Sinai West, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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32
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Sharif KF, Lewis JS, Ely KA, Mehrad M, Pruthi S, Netterville JL, Rohde SL, Langerman A, Mannion K, Sinard RJ, Rosenthal EL, Topf MC. The computer-aided design margin: Ex vivo 3D specimen mapping to improve communication between surgeons and pathologists. Head Neck 2023; 45:22-31. [PMID: 36156327 PMCID: PMC9885304 DOI: 10.1002/hed.27201] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/09/2022] [Accepted: 09/09/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Numerous challenges exist in determining surgical margin status. Communication between surgeons and pathologists is crucial for specimen orientation and accurate margin assessment. METHODS A prospective study to determine feasibility of incorporating three-dimensional (3D) scanning into surgical pathology workflow was performed. A structured-light 3D scanner captured the photorealistic surface topography of fresh surgical specimens. Computer-aided design (CAD) software was used to document sites of margin sampling and sectioning. Surveys were distributed among faculty and staff stakeholders to assess feasibility. RESULTS A series of 40 cases were 3D-scanned. Median image acquisition time was 8 min. The majority of respondents agreed that the experimental 3D system helped achieve clearer communication. 3D specimen maps assisted in the communication of a focally positive or close margin in 4 of 17 cases. CONCLUSIONS Routine 3D scanning and specimen mapping is feasible and represents an innovative approach to intraoperative and final pathology documentation, margin analysis, and surgeon-pathologist communication.
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Affiliation(s)
- Kayvon F. Sharif
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - James S. Lewis
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA,Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kim A. Ely
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mitra Mehrad
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sumit Pruthi
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James L. Netterville
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L. Rohde
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexander Langerman
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kyle Mannion
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert J. Sinard
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eben L. Rosenthal
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael C. Topf
- Department of Otolaryngology – Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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33
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Saturno MP, Brandwein-Weber M, Greenberg L, Silberzweig A, Buchbinder D, Dowling EM, Khan MN, Chai R, Urken ML. Utilizing 3D head and neck specimen scanning for intraoperative margin discussions: Proof of concept of our novel approach. Head Neck 2023; 45:10-21. [PMID: 36065715 DOI: 10.1002/hed.27171] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/11/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The current standard of documenting and communicating frozen section margin results is inefficient. We present a novel method of generating 3D digital models of gross tumor specimens to more clearly visualize histopathological margin results. METHODS Fifty-five head and neck specimens were scanned and virtually "inked" using 3D software. These 3D specimen maps were displayed in the operating room to provide the surgeon with a real-time specimen-to-defect relationship by which further resections could be guided. RESULTS Margin results were reported within an average of 34 min using the proposed workflow. The scanner rendered accurate models of specimens that exceeded 3.0 × 3.0 × 3.0 cm. Critical specimen features to consider were size, color, textural complexity, and the presence of discernible anatomic landmarks. CONCLUSIONS Optical 3D scanning technology can improve the quality of head and neck margin documentation and the efficiency with which results are communicated between the pathologist and surgeon.
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Affiliation(s)
- Michael P Saturno
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York, USA
| | - Margaret Brandwein-Weber
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lily Greenberg
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York, USA
| | - Alex Silberzweig
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York, USA
| | - Daniel Buchbinder
- Division of Oral and Maxillofacial Surgery, Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - Eric M Dowling
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York, USA.,Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohemmed N Khan
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raymond Chai
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mark L Urken
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, New York, USA.,Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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34
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Gupta P, Chattopadhyay T, Mallick B. miRNome-transcriptome analysis unveils the key regulatory pathways involved in the tumorigenesis of tongue squamous cell carcinoma. Brief Funct Genomics 2022; 21:466-477. [PMID: 36255066 DOI: 10.1093/bfgp/elac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/11/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022] Open
Abstract
Tongue squamous cell carcinoma (TSCC) is considered the most common malignant tumor among the oral squamous cell carcinomas with a poor prognosis. Understanding the underlying molecular mechanisms that underpin TSCC and its treatments is the focus of the research. Deregulated expression of microRNAs (miRNAs) has recently been implicated in various biological processes linked to cancer. Therefore, in this study, we attempted to investigate miRNAs and their targets expressed in TSCC, which could be involved in its oncogenesis. We performed next-generation sequencing of small RNAs and transcriptomes in H357 TSCC cell line and human oral keratinocytes as a control to find miRNAs and mRNAs that are differentially expressed (DE), which were then supplemented with additional expression datasets from databases, yielding 269 DE miRNAs and 2094 DE genes. The target prediction followed by pathway and disease function analysis revealed that the DE targets were significantly associated with the key processes and pathways, such as apoptosis, epithelial-mesenchymal transition, endocytosis and vascular endothelial growth factor signaling pathways. Furthermore, the top 12 DE targets were chosen based on their involvement in more than one cancer-related pathway, of which 6 genes are targeted by miR-128-3p. Real-time quantitative PCR validation of this miRNA and its targets in H357 and SCC9 TSCC cells confirmed their possible targeting from their reciprocal expression, with MAP2K7 being a critical target that might be involved in oncogenesis and progression of TSCC by acting as a tumor suppressor. Further research is underway to understand how miR-128-3p regulates oncogenesis in TSCC via MAP2K7 and associated pathways.
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Affiliation(s)
- Pooja Gupta
- RNAi and Functional Genomics Lab., Department of Life Science, National Institute of Technology, Rourkela 769008, Odisha, India
| | - Trisha Chattopadhyay
- RNAi and Functional Genomics Lab., Department of Life Science, National Institute of Technology, Rourkela 769008, Odisha, India
| | - Bibekanand Mallick
- RNAi and Functional Genomics Lab., Department of Life Science, National Institute of Technology, Rourkela 769008, Odisha, India
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35
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Long SM, Mclean T, Valero Mayor C, Fitzgerald CWR, Feit NZ, Katabi N, Xu B, Cohen MA, Ganly I, Ghossein RA, Patel SG. Use of Intraoperative Frozen Section to Assess Final Tumor Margin Status in Patients Undergoing Surgery for Oral Cavity Squamous Cell Carcinoma. JAMA Otolaryngol Head Neck Surg 2022; 148:911-917. [PMID: 35925571 PMCID: PMC9353701 DOI: 10.1001/jamaoto.2022.2131] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Methods of assessing final margin status in patients undergoing surgery for oral cavity squamous cell carcinoma, such as intraoperative frozen section histopathology (IFSH) taken from the tumor bed, may have limitations in accuracy. Objective To evaluate the accuracy and implications of using IFSH samples to assess tumor bed margins in patients undergoing surgery for oral cavity squamous cell carcinoma (SCC). Design, Setting, and Participants This cross-sectional study included 1257 patients who underwent surgery for oral cavity SCC between January 1, 2000, and December 31, 2015, at an academic cancer center. A total of 4821 IFSH samples were examined from 1104 patients (87.8%) who had at least 1 IFSH sample. Institutional practice is to harvest margins for IFSH from the tumor bed. Statistical analysis was performed from August 1, 2021, to April 4, 2022. Main Outcomes and Measures Sensitivity and specificity were calculated for IFSH samples of margins compared with the permanent pathology samples of the same tissue and for IFSH compared with the final tumor specimen histopathology (FTSH). Results were classified using a binary method, with histopathologic reports interpreted as either negative (including negative or atypia or dysplasia) or positive (including carcinoma in situ, suspicious, or positive). Results A total of 1257 patients met the inclusion criteria, including 709 men (56.4%), with a median age of 62 years (IQR, 52-73 years); 1104 patients (627 men [56.8%]; median age, 62 years [IQR, 52-72 years]) had IFHS samples. For IFSH relative to permanent sections of the IFSH tissue, sensitivity and specificity of IFSH were high (sensitivity, 76.5% [95% CI, 67.5%-85.5%]; specificity, 99.9% [95% CI, 99.8%-100%]), with discordant results in 24 of 4821 total specimens (0.5%). Final specimen margins were positive in 11.7% of patients (147 of 1257). Compared with FTSH, the sensitivity of IFSH for defining margin status was 10.8% (95% CI, 5.8%-15.8%), and the specificity was 99.1% (95% CI, 98.8%-99.4%). The rate of discordance was 4.0% (171 of 4284 specimens) between IFSH and FTSH. Conclusions and Relevance The findings of this cross-sectional study suggest that IFSH is accurate compared with permanent pathologic characteristics of the same tissue, but less reliable at assessing final margin status on the tumor specimen. Despite a high specificity, the sensitivity of IFSH compared with FTSH is low, which may be associated with the inherent inability of tumor bed IFSH margin analysis to accurately account for the 3-dimensional association of tumor margins with the periphery of the specimen and the overall low rate of positive final tumor margins. Although tumor bed IFSH is widely used in the management of oral cavity cancer, this study suggests that there are limitations of this modality in assessing the final surgical margin status.
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Affiliation(s)
- Sallie M Long
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Otolaryngology-Head and Neck Surgery, NewYork-Presbyterian Hospital-Columbia and Cornell, New York, New York
| | - Timothy Mclean
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cristina Valero Mayor
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Conall W R Fitzgerald
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Noah Z Feit
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Nora Katabi
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bin Xu
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ronald A Ghossein
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G Patel
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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36
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Krishnan G, van den Berg NS, Nishio N, Kapoor S, Pei J, Freeman L, Lee YJ, Zhou Q, van Keulen S, Farkurnejad S, Condon J, Baik FM, Martin BA, Rosenthal EL. Fluorescent Molecular Imaging Can Improve Intraoperative Sentinel Margin Detection in Oral Squamous Cell Carcinoma. J Nucl Med 2022; 63:1162-1168. [PMID: 35027369 PMCID: PMC9364343 DOI: 10.2967/jnumed.121.262235] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023] Open
Abstract
In head and neck cancer, a major limitation of current intraoperative margin analysis is the ability to detect areas most likely to be positive based on specimen palpation, especially for larger specimens where sampling error limits detection of positive margins. This study aims to prospectively examine the clinical value of fluorescent molecular imaging to accurately identify "the sentinel margin," the point on a specimen at which the tumor lies closest to the resected edge in real-time during frozen section analysis. Methods: Eighteen patients with oral squamous cell carcinoma were enrolled into a prospective clinical trial and infused intravenously with 50 mg of panitumumab-IRDye800CW 1-5 d before surgery. Resected specimens were imaged in a closed-field near-infrared optical imaging system in near real-time, and custom-designed software was used to identify locations of highest fluorescence on deep and peripheral margins. The surgeon identified the sentinel margin masked to optical specimen mapping, and then the regions of highest fluorescence were identified and marked for frozen analysis. Final pathology based on specimen reconstruction was used as reference standard. Results: Resected specimens were imaged in the operating room, and fluorescence had a higher interobserver agreement with pathology (Cohen κ value 0.96) than the surgeon (Cohen κ value of 0.82) for the location of the closest margin. Plotting margin distance at the predicted sentinel margin location of each observer versus the actual closest margin distance at pathology demonstrated best correlation between fluorescence and pathology (R2 = 0.98) with surgeon (R2 = 0.75). Conclusion: Fluorescence imaging can improve identification of the sentinel margin in head and neck cancer resections, holding promise for rapid identification of positive margins and improved oncologic outcomes.
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Affiliation(s)
- Giri Krishnan
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California;,Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Nynke S. van den Berg
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Naoki Nishio
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California;,Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shrey Kapoor
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Jaqueline Pei
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Laura Freeman
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Yu-Jin Lee
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Quan Zhou
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Stan van Keulen
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Shayan Farkurnejad
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - James Condon
- Department of Public Health, School of Medicine, The University of Adelaide, Adelaide, SA, Australia; and
| | - Fred M. Baik
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Brock A. Martin
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Eben L. Rosenthal
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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MacKay C, Turner B, Bullock M, Taylor SM, Trites J, Corsten M, Geldenhuys L, Rigby MH. Margin Sampling and Survival Outcomes in Oral Cavity and p16-Positive Oropharyngeal Squamous Cell Carcinoma. OTO Open 2022; 6:2473974X221101024. [PMID: 36160933 PMCID: PMC9500292 DOI: 10.1177/2473974x221101024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/28/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To compare the association of margin sampling technique on survival outcomes in surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. Study Design A prospective longitudinal cohort study. Setting Tertiary care academic teaching hospital in Halifax, Nova Scotia. Methods All cases of surgically treated cT1-2 oral cavity and oropharyngeal cancer undergoing specimen-oriented margin analysis between January 1, 2017, and December 31, 2018 were analyzed. The specimen-oriented cohort was compared with a cohort of patients from January 1, 2009, to December 31, 2014, where a defect-oriented margin sampling protocol was used. Kaplan-Meier survival curves were used to estimate 2-year overall survival, disease-specific survival, local control, and recurrence-free survival rates in oral cavity and p16-positive oropharyngeal squamous cell carcinoma. Cox proportional hazards models were used to assess the effect of margin sampling method on disease-specific survival and local control. Results There was no significant association between margin sampling technique and 2-year survival outcomes for surgically treated cT1-2 oral cavity and oropharyngeal squamous cell carcinoma. In the multivariate Cox proportional hazard model, the hazard ratio (HR) of specimen-oriented sampling was not significantly different for disease-specific survival (HR, 1.32; 95% CI, 0.3032-5.727; P = .713) or local control (HR, 0.4087; 95% CI, 0.0795-2.099; P = .284). Conclusion Intraoperative margin sampling method was not associated with a significant change in 2-year survival outcomes. Despite no effect on survival outcomes, implementation of a specimen-oriented sampling method has potential for cost avoidance by decreasing the number of re-resections for positive or close margins.
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Affiliation(s)
- Colin MacKay
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Canada
| | - Brooke Turner
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Canada
| | - Martin Bullock
- Division of Anatomical Pathology, Department of Pathology, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Canada
| | - S. Mark Taylor
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Canada
| | - Jonathan Trites
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Canada
| | - Martin Corsten
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Canada
| | - Laurette Geldenhuys
- Division of Anatomical Pathology, Department of Pathology, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Canada
| | - Matthew H. Rigby
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Canada
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Brinkman D, Callanan D, Jawad H, O'Sullivan R, O'Shea R, Dias A, Feeley L, Sheahan P. Comparison of royal college of pathologists and college of american pathologists definition for positive margins in oral cavity squamous cell carcinoma. Oral Oncol 2022; 127:105797. [PMID: 35272227 DOI: 10.1016/j.oraloncology.2022.105797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/13/2022] [Accepted: 02/24/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pathological margin assessment is an essential component of surgical management of oral cavity squamous cell carcinoma (OCSCC), however, in many studies, variable definitions of involved margins have been used. The purpose of the present study was to compare the prognostic ability of involved margins according to Royal College of Pathologists (RCPath) and College of American Pathologists (CAP) guidance. METHODS Retrospective study of 300 patients with previously untreated OCSCC undergoing definitive surgical management. Main specimen margin status was defined according to RCPath guidance and CAP guidance. "Final margin status", incorporated the results of frozen sections and extra tumour bed resections. The prognostic impact of each margin definition was studied using univariate analysis, and in multivariate models including T-stage (AJCC 8th edition), nodal status (pN+), extranodal extension (ENE), and use of adjuvant radiotherapy. RESULTS Both RCPath and CAP positive margins were associated with local recurrence (LR), disease-specific survival (DSS), and overall survival (OS) on univariate analysis, while final margin status was associated with LR and DSS, but not OS. On multivariate analysis, only CAP positive main specimen margin status was independently associated with LR (odds ratio 2.44, 95% CI 1.37, 4.34), DSS (odds ratio 2.28, 95% CI 1.31, 3.82), and OS (odds ratio 1.59, 95% CI 1.04, 2.42). CONCLUSIONS Involved main specimen margin as defined by CAP guidance has the advantage of being an independent prognosticator of LR and survival in our cohort.
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Affiliation(s)
- David Brinkman
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Deirdre Callanan
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Ireland
| | - Hadeel Jawad
- Department of Pathology, Cork University Hospital, Cork, Ireland
| | - Ryan O'Sullivan
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Ross O'Shea
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Andrew Dias
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland
| | - Linda Feeley
- Department of Pathology, Cork University Hospital, Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Ireland
| | - Patrick Sheahan
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland; Department of Surgery, University College Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Ireland.
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Köhler HF, Vartanian JG, Pinto CAL, da Silva Rodrigues IFP, Kowalski LP. The impact of worst pattern of invasion on the extension of surgical margins in oral squamous cell carcinoma. Head Neck 2021; 44:691-697. [PMID: 34904762 DOI: 10.1002/hed.26956] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/28/2021] [Accepted: 12/03/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND To evaluate margins for oral carcinoma according to types of invasion front. METHODS Retrospective cohort of 772 patients with worst pattern of invasion (WPOI) graded 1-5. Local recurrence was the outcome of interest. RESULTS Local recurrences occurred in 164 patients (21.2%) and was affected by WPOI type 4/5, margin distance, perineural invasion, and adjuvant radiotherapy. In patients with WPOI types 1/2/3, a cutoff of 1.7 mm was considered ideal margin extent and in patients with WPOI types 4/5, the cutoff was 7.8 mm. Patients below these thresholds had a significantly higher incidence of local recurrence. CONCLUSIONS Different WPOI determine the ideal extent of surgical margins as 1.7 mm for patients with types 1-3, and 7.8 mm in patients with types 4/5.
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Affiliation(s)
- Hugo Fontan Köhler
- Department of Head and Neck Surgery and Otolaryngology, A C Camargo Cancer Center, São Paulo, Brazil
| | - José Guilherme Vartanian
- Department of Head and Neck Surgery and Otolaryngology, A C Camargo Cancer Center, São Paulo, Brazil
| | | | | | - Luiz Paulo Kowalski
- Department of Head and Neck Surgery and Otolaryngology, A C Camargo Cancer Center, São Paulo, Brazil.,Department of Surgery, São Paulo University Medical School, São Paulo, Brazil
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40
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Maharaj D, Thaduri A, Jat B, Poonia D, Durgapal P, Rajkumar K. Performance and survival outcomes of defect-driven versus specimen-driven method of frozen section intraoperative margin assessment in oral cancers. Int J Oral Maxillofac Surg 2021; 51:1131-1137. [DOI: 10.1016/j.ijom.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 11/14/2021] [Accepted: 11/17/2021] [Indexed: 11/15/2022]
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41
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Asoda S, Miyashita H, Soma T, Munakata K, Yamada Y, Yasui Y, Kudo Y, Usuda S, Hasegawa T, Nakagawa T, Kawana H. Clinical value of entire-circumferential intraoperative frozen section analysis for the complete resection of superficial squamous cell carcinoma of the tongue. Oral Oncol 2021; 123:105629. [PMID: 34784507 DOI: 10.1016/j.oraloncology.2021.105629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/09/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES We aimed to evaluate the clinical value of an entire-circumferential intraoperative frozen section analysis (e-IFSA) for the complete resection of superficial squamous cell carcinoma (SCC) of the tongue. MATERIALS AND METHODS A total 276 specimens from 51 patients with pT1-2, N0, mucosal or submucosal invasion SCC were analyzed to evaluate the diagnostic accuracy of the e-IFSA and the added value of the e-IFSA to iodine staining. The e-IFSA results were compared with the final histologic results obtained using permanent sections. All specimens for the e-IFSA were taken over the entire circumference 5 mm outside from the iodine unstained areas. The outline of the main resected specimen after taking these outer mucosal specimens were defined as the surgical margins determined by iodine staining alone. RESULTS The e-IFSA results were in excellent agreement with final histological results (Cohen's kappa value: 0.85) and the e-IFSA showed high sensitivity (100%) and high negative predictive value (100%). The actual complete resection rate with an e-IFSA was 100% (51/51), and no patient required additional resection after surgery. In contrast, 10/51 patients (20%) patients showed residual atypical mucosal epithelium at or beyond the margin determined by iodine staining alone; this difference was statistically significant (P = 0.002). The 5-year local control rate and 5-year overall survival rate after this procedure were both 100%. CONCLUSION An e-IFSA has additional value when performed in conjunction with iodine staining. An e-IFSA would be useful for achieving complete resection of superficial SCC of the tongue.
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Affiliation(s)
- Seiji Asoda
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hidetaka Miyashita
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomoya Soma
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kanako Munakata
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuka Yamada
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Yasui
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Kudo
- Department of Dent-oral Anesthesiology, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | - Shin Usuda
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiro Hasegawa
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taneaki Nakagawa
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiromasa Kawana
- Department of Dentistry and Oral Surgery, Keio University School of Medicine, Tokyo, Japan; Department of Oral and Maxillofacial Implantology, Kanagawa Dental University, Yokosuka, Japan.
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42
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Lim YJ, Kong M. Population-based comparative survival analysis of surgery with or without adjuvant radiotherapy and non-operative primary radiotherapy in patients with early-stage oral tongue squamous cell carcinoma. PLoS One 2021; 16:e0259384. [PMID: 34762670 PMCID: PMC8584751 DOI: 10.1371/journal.pone.0259384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Although recent clinical guidelines do allow primary radiotherapy for selected patients with early-stage oral tongue cancer, there has been little knowledge on the treatment outcomes of non-operative radiotherapy using modern treatment techniques. This study evaluated recent prognostic differences between primary radiotherapy and surgical resection in T1‒2N0 oral tongue squamous cell carcinoma. Methods Patients diagnosed with T1‒2N0 oral tongue squamous cell carcinoma were identified from the Surveillance, Epidemiology, and End Results database. After propensity score matching, the disease-specific survival of primary radiotherapy and surgery was compared. Results From a total of 8,458 patients initially identified, we defined matched cohorts: cohort A, comparing surgery alone vs. primary radiotherapy (n = 230 vs. 230), and cohort B, comparing surgery plus adjuvant radiotherapy vs. primary radiotherapy (n = 230 vs. 230). The 7-year disease-specific survival rates were 77% vs. 35% (cohort A) and 65% vs. 35% (cohort B) (P < 0.001 for all comparisons). Primary radiotherapy was independently associated with worse disease-specific survival in both cohorts A (hazard ratio 4.06; 95% confidence interval 2.53‒6.52) and B (hazard ratio 2.81; 95% confidence interval 1.96‒4.04). Time-course hazard rate function plots showed a distinct short-term risk increment in disease-specific mortality in the primary radiotherapy group. Conclusion In the contemporary treatment era, the use of radiotherapy as a definitive treatment resulted in an inferior prognosis in patients with T1‒2N0 oral tongue squamous cell carcinoma. The present population-based data suggest that primary radiotherapy cannot be used as an alternative to surgical management and it needs to be avoided as much as possible in early-stage tumors.
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Affiliation(s)
- Yu Jin Lim
- Department of Radiation Oncology, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Moonkyoo Kong
- Department of Radiation Oncology, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
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43
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Serinelli S, Bryant SM, Williams MPA, Marzouk M, Zaccarini DJ. Frozen-Permanent Section Discrepancy Rate in Oral Cavity and Oropharyngeal Squamous Cell Carcinoma. Head Neck Pathol 2021; 16:466-475. [PMID: 34655410 PMCID: PMC9187809 DOI: 10.1007/s12105-021-01385-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
Frozen section evaluation of head and neck squamous cell carcinoma (SCC) is critical for margin status and subsequent patient therapy. In this study, we retrospectively reviewed the rate of frozen-permanent section discrepancies in blocks with two frozen section levels compared to ≥ three levels in oral cavity and oropharyngeal SCCs. A search of the cases with both intraoperative frozen sections and corresponding permanent sections for SCCs in the oral cavity and oropharynx was performed. Frozen sections and permanent slides were compared. The nature of discrepancies was assigned to one of the following: change in diagnosis, margin status, or distance of the tumor from the margin. The cause of the discrepancy was designated as one of the following: block sampling, gross sampling, interpretation, or technical error. The pathologist experience, frozen section technical experience, and intraoperative impact of each discrepancy were also evaluated. A total of 654 frozen and corresponding permanent blocks were assessed. For 532 of the frozen section blocks, two levels were cut, while 122 frozen section blocks had ≥ three levels. Thirty-five frozen-permanent section discrepancies were observed (5.4% of all blocks). Among these, 2.5% had a possible or definitive intraoperative impact. The percentage of discrepancies in the ≥ three levels group (5.7%) was slightly higher than the two-level group (5.3%), and this difference was not statistically significant. For the two-level group, the overall block sampling error rate was 4.5%. This was not significantly different from the 4.1% block sampling error rate seen in the ≥ three levels group. The rate of block sampling discrepancy did not show significant differences based on attending or frozen section technical experience. A change in margin distance (closer margin detected on permanent) occurred in 4% of the blocks and involved 16% of the patients. This review of oral cavity and oropharynx SCCs frozen/permanent section discrepancies shows that the error rate is not significantly different depending on the number of levels cut. The results suggest that always performing more than two frozen section levels may not yield a decreased discrepancy rate. A change in margin distance occurred quite frequently, but only in rare cases it had a definitive impact on the intraoperative management. Given the importance of correct intraoperative diagnosis in patient management, additional levels may be warranted depending on the clinical scenario.
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Affiliation(s)
- Serenella Serinelli
- Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
| | - Stephanie M. Bryant
- Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
| | - Michael P. A. Williams
- Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
| | - Mark Marzouk
- Department of Head and Neck Oncologic Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
| | - Daniel J. Zaccarini
- Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
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Bulbul MG, Tarabichi O, Parikh AS, Yoon BC, Juliano A, Sadow PM, Faquin W, Gropler M, Walker R, Puram SV, Varvares MA. The utility of intra-oral ultrasound in improving deep margin clearance of oral tongue cancer resections. Oral Oncol 2021; 122:105512. [PMID: 34564016 DOI: 10.1016/j.oraloncology.2021.105512] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 08/10/2021] [Accepted: 08/23/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To investigate the potential utility of intra-oral ultrasound (IOUS) in guiding deep margin clearance and measuring depth of invasion (DOI) of oral tongue carcinomas (OTC). MATERIALS AND METHODS Retrospective chart review of consecutive patients with T1-T3 OTC who underwent intraoperative ultrasound-guided resection and a comparator group that had undergone resection without the use of IOUS both by a single surgeon. Data was extracted from operative, pathology and radiology reports. Deep margins and DOI were reviewed by a dedicated head and neck pathologist. Correlation between histologic and ultrasound DOI was assessed using Pearson correlation. RESULTS A total of 23 patients were included in the study cohort with a comparator group of 21 patients in the control group. None of the patients in the study cohort had a positive (cut-through) deep margin and the mean deep margin clearance was 8.5 ± 4.9 and 6.7 ± 3.8 for the IOUS and non-IOUS groups respectively (p-value 0.18) showing a non-significant improvement in the IOUS group. As a secondary outcome, there was a strong correlation between histologic and ultrasound DOI (0.9449). CONCLUSION Ultrasound appears to be a potentially effective tool in guiding OTC resections. In this small series, IOUS facilitated deep margin clearance and resulted in a non-statistically significant increase in deep margin clearance. Intraoral ultrasound can accurately measure lesional DOI.
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Affiliation(s)
- Mustafa G Bulbul
- Department of Otolaryngology - Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Osama Tarabichi
- Department of Otolaryngology - Head and Neck Surgery, University of Iowa, Iowa City, IA, USA
| | - Anuraag S Parikh
- Department of Otolaryngology, Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Byung C Yoon
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Juliano
- Department of Radiology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - William Faquin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Gropler
- Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Denver, CO, USA
| | - Ronald Walker
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sidharth V Puram
- Department of Otolaryngology - Head and Neck Surgery and Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.
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45
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Holcomb AJ, Richmon JD. Surgical margins in a single-modality transoral robotic surgery: A conundrum-Reply. Head Neck 2021; 43:3219-3221. [PMID: 34351028 DOI: 10.1002/hed.26831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/26/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
- Andrew J Holcomb
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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46
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Horwich P, MacKay C, Bullock M, Taylor SM, Hart R, Trites J, Geldenhuys L, Williams B, Rigby MH. Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma. J Otolaryngol Head Neck Surg 2021; 50:37. [PMID: 34154663 PMCID: PMC8218466 DOI: 10.1186/s40463-021-00501-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 02/22/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- P Horwich
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, 3rd Floor Dickson Building, VG Site, 5820 University Avenue, Halifax, Nova Scotia, B3H 2Y9, Canada.
| | - C MacKay
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, 3rd Floor Dickson Building, VG Site, 5820 University Avenue, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - M Bullock
- Department of Pathology, Division of Anatomical Pathology, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - S M Taylor
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, 3rd Floor Dickson Building, VG Site, 5820 University Avenue, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - R Hart
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, 3rd Floor Dickson Building, VG Site, 5820 University Avenue, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - J Trites
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, 3rd Floor Dickson Building, VG Site, 5820 University Avenue, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - L Geldenhuys
- Department of Pathology, Division of Anatomical Pathology, Queen Elizabeth II Health Science Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - B Williams
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, 3rd Floor Dickson Building, VG Site, 5820 University Avenue, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - M H Rigby
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Queen Elizabeth II Health Science Centre and Dalhousie University, 3rd Floor Dickson Building, VG Site, 5820 University Avenue, Halifax, Nova Scotia, B3H 2Y9, Canada
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47
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Impact of Planning Method (Conventional versus Virtual) on Time to Therapy Initiation and Resection Margins: A Retrospective Analysis of 104 Immediate Jaw Reconstructions. Cancers (Basel) 2021; 13:cancers13123013. [PMID: 34208555 PMCID: PMC8235255 DOI: 10.3390/cancers13123013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/24/2022] Open
Abstract
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.
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Nentwig K, Unterhuber T, Wolff KD, Ritschl LM, Nieberler M. The impact of intraoperative frozen section analysis on final resection margin status, recurrence, and patient outcome with oral squamous cell carcinoma. Clin Oral Investig 2021; 25:6769-6777. [PMID: 33956217 PMCID: PMC8602179 DOI: 10.1007/s00784-021-03964-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Katharina Nentwig
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Tobias Unterhuber
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
| | - Markus Nieberler
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
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49
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Holcomb AJ, Herberg M, Strohl M, Ochoa E, Feng AL, Abt NB, Mokhtari TE, Suresh K, McHugh CI, Parikh AS, Sadow P, Faquin W, Faden D, Deschler DG, Varvares MA, Lin DT, Fakhry C, Ryan WR, Richmon JD. Impact of surgical margins on local control in patients undergoing single-modality transoral robotic surgery for HPV-related oropharyngeal squamous cell carcinoma. Head Neck 2021; 43:2434-2444. [PMID: 33856083 DOI: 10.1002/hed.26708] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/17/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The impact of close surgical margins on oncologic outcomes in HPV-related oropharyngeal squamous cell carcinoma (HPV + OPSCC) is unclear. METHODS Retrospective case series including patients undergoing single modality transoral robotic surgery (TORS) for HPV + OPSCC at three academic medical centers from 2010 to 2019. Outcomes were compared between patients with close surgical margins (<1 mm or requiring re-resection) and clear margins using the Kaplan-Meier method. RESULTS Ninety-nine patients were included (median follow-up 21 months, range 6-121). Final margins were close in 22 (22.2%) patients, clear in 75 (75.8%), and positive in two (2.0%). Eight patients (8.1%) recurred, including two local recurrences (2.0%). Four patients died during the study period (4.0%). Local control (p = 0.470), disease-free survival (p = 0.513), and overall survival (p = 0.064) did not differ between patients with close and clear margins. CONCLUSIONS Patients with close surgical margins after TORS for HPV + OPSCC without concurrent indications for adjuvant therapy may be considered for observation alone.
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Affiliation(s)
- Andrew J Holcomb
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Herberg
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Madeleine Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Edgar Ochoa
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas B Abt
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Tara E Mokhtari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Krish Suresh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher I McHugh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Anuraag S Parikh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Sadow
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - William Faquin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Faden
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - William R Ryan
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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50
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Barroso EM, Aaboubout Y, van der Sar LC, Mast H, Sewnaik A, Hardillo JA, Ten Hove I, Nunes Soares MR, Ottevanger L, Bakker Schut TC, Puppels GJ, Koljenović S. Performance of Intraoperative Assessment of Resection Margins in Oral Cancer Surgery: A Review of Literature. Front Oncol 2021; 11:628297. [PMID: 33869013 PMCID: PMC8044914 DOI: 10.3389/fonc.2021.628297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/15/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Achieving adequate resection margins during oral cancer surgery is important to improve patient prognosis. Surgeons have the delicate task of achieving an adequate resection and safeguarding satisfactory remaining function and acceptable physical appearance, while relying on visual inspection, palpation, and preoperative imaging. Intraoperative assessment of resection margins (IOARM) is a multidisciplinary effort, which can guide towards adequate resections. Different forms of IOARM are currently used, but it is unknown how accurate these methods are in predicting margin status. Therefore, this review aims to investigate: 1) the IOARM methods currently used during oral cancer surgery, 2) their performance, and 3) their clinical relevance. Methods A literature search was performed in the following databases: Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar (from inception to January 23, 2020). IOARM performance was assessed in terms of accuracy, sensitivity, and specificity in predicting margin status, and the reduction of inadequate margins. Clinical relevance (i.e., overall survival, local recurrence, regional recurrence, local recurrence-free survival, disease-specific survival, adjuvant therapy) was recorded if available. Results Eighteen studies were included in the review, of which 10 for soft tissue and 8 for bone. For soft tissue, defect-driven IOARM-studies showed the average accuracy, sensitivity, and specificity of 90.9%, 47.6%, and 84.4%, and specimen-driven IOARM-studies showed, 91.5%, 68.4%, and 96.7%, respectively. For bone, specimen-driven IOARM-studies performed better than defect-driven, with an average accuracy, sensitivity, and specificity of 96.6%, 81.8%, and 98%, respectively. For both, soft tissue and bone, IOARM positively impacts patient outcome. Conclusion IOARM improves margin-status, especially the specimen-driven IOARM has higher performance compared to defect-driven IOARM. However, this conclusion is limited by the low number of studies reporting performance results for defect-driven IOARM. The current methods suffer from inherent disadvantages, namely their subjective character and the fact that only a small part of the resection surface can be assessed in a short time span, causing sampling errors. Therefore, a solution should be sought in the field of objective techniques that can rapidly assess the whole resection surface.
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Affiliation(s)
- Elisa M Barroso
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Yassine Aaboubout
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lisette C van der Sar
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Hetty Mast
- Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jose A Hardillo
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ivo Ten Hove
- Department of Oral and Maxillofacial Surgery, Leiden UMC, Leiden University Medical Center, Leiden, Netherlands
| | - Maria R Nunes Soares
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lars Ottevanger
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Tom C Bakker Schut
- Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Gerwin J Puppels
- Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Senada Koljenović
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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