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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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Veiga-San Roman P, Villanueva San Vicente V, Rodriguez-Gonzalez MA, López-Jornet P. Survival among treated tongue cancer patients: a single-center experience. Discov Oncol 2024; 15:127. [PMID: 38652185 DOI: 10.1007/s12672-024-00989-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 04/18/2024] [Indexed: 04/25/2024] Open
Abstract
OBJECTIVE To describe overall survival (OS) and disease-free survival (DFS) in a cohort of tongue cancer patients, together with the corresponding demographic, tumor and surgical characteristics. METHODS A retrospective study was made of 205 consecutive patients with primary tongue cancer subjected to surgery and adjuvant therapy according to the stage of the disease, in Hospital Clínico Universitario Virgen de la Arrixaca (HUVA) (Murcia, Spain) during the period 2000-2020. Survival was evaluated based on the Kaplan-Meier method, and the existence of significant differences between the different study variables was analyzed using the log-rank test. Cox regression analysis was performed for the identification of risk factors. RESULTS In relation to overall survival, 72.6% of the patients survived for a mean time of 14.43 years [standard error (SE) = 0.74; 95% CI: 12.98-15.87], with a cumulative survival rate of 49.8 ± 3%. Survival was reduced by the presence of tumor adjacent to resection margins [hazard ratio (HR) 2.20; 95% CI 1.09-4.43] (p = 0.028) and infiltrated resection margins (HR 3.86, 95% CI 1.56-9.57) (p = 0.004). Lymphadenectomy in turn increased survival (HR 0.15; 95% CI 0.06-0.42) (p < 0.001). In relation to disease-free survival, 55.3% of the patients suffered no relapse over a mean period of 9.91 years (SE = 0.66; 95% CI: 8.61-11.2), with a cumulative survival rate of 26.6% ± 8.4%. CONCLUSIONS In tongue cancer patients, overall and specific survival were reduced in the presence of infiltrated resection margins. Lymphadenectomy in turn improved survival compared with patients in which this procedure was not carried out.
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Affiliation(s)
- Pablo Veiga-San Roman
- Cirugía Oral y Maxilofacial del Hospital Clínico Universitario Virgen de la Arrixaca Ctra., Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Victor Villanueva San Vicente
- Cirugía Oral y Maxilofacial del Hospital Clínico Universitario Virgen de la Arrixaca Ctra., Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - M Angeles Rodriguez-Gonzalez
- Cirugía Oral y Maxilofacial del Hospital Clínico Universitario Virgen de la Arrixaca Ctra., Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Pia López-Jornet
- Pia López-Jornet Deparment Oral Medicine, University of Murcia Hospital Morales Meseguer, Clinica Odontologica Spain, Adv Marques de los Velez s/n, 30008, Murcia, Spain.
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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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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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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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Männle D, Pohlmann J, Monji-Azad S, Hesser J, Rotter N, Affolter A, Lammert A, Kramer B, Ludwig S, Huber L, Scherl C. Artificial intelligence directed development of a digital twin to measure soft tissue shift during head and neck surgery. PLoS One 2023; 18:e0287081. [PMID: 37556451 PMCID: PMC10411805 DOI: 10.1371/journal.pone.0287081] [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: 05/28/2023] [Accepted: 07/14/2023] [Indexed: 08/11/2023] Open
Abstract
Digital twins derived from 3D scanning data were developed to measure soft tissue deformation in head and neck surgery by an artificial intelligence approach. This framework was applied suggesting feasibility of soft tissue shift detection as a hitherto unsolved problem. In a pig head cadaver model 104 soft tissue resection had been performed. The surface of the removed soft tissue (RTP) and the corresponding resection cavity (RC) was scanned (N = 416) to train an artificial intelligence (AI) with two different 3D object detectors (HoloLens 2; ArtecEva). An artificial tissue shift (TS) was created by changing the tissue temperature from 7,91±4,1°C to 36,37±1,28°C. Digital twins of RTP and RC in cold and warm conditions had been generated and volumes were calculated based on 3D surface meshes. Significant differences in number of vertices created by the different 3D scanners (HoloLens2 51313 vs. ArtecEva 21694, p<0.0001) hence result in differences in volume measurement of the RTC (p = 0.0015). A significant TS could be induced by changing the temperature of the tissue of RC (p = 0.0027) and RTP (p = <0.0001). RC showed more correlation in TS by heating than RTP with a volume increase of 3.1 μl or 9.09% (p = 0.449). Cadaver models are suitable for training a machine learning model for deformable registration through creation of a digital twin. Despite different point cloud densities, HoloLens and ArtecEva provide only slightly different estimates of volume. This means that both devices can be used for the task.TS can be simulated and measured by temperature change, in which RC and RTP react differently. This corresponds to the clinical behaviour of tumour and resection cavity during surgeries, which could be used for frozen section management and a range of other clinical applications.
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Affiliation(s)
- David Männle
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jan Pohlmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sara Monji-Azad
- Mannheim Institute for Intelligent Systems in Medicine (MIISM), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jürgen Hesser
- Mannheim Institute for Intelligent Systems in Medicine (MIISM), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Interdisciplinary Center for Scientific Computing (IWR), Heidelberg University, Heidelberg, Germany
- Central Institute for Computer Engineering (ZITI), Heidelberg University, Heidelberg, Germany
- CZS Heidelberg Center for Model-Based AI, Heidelberg University, Heidelberg, Germany
- AI Health Innovation Cluster, Heidelberg-Mannheim Health and Life Science Alliance, Heidelberg University, Heidelberg, Germany
| | - Nicole Rotter
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Annette Affolter
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Lammert
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Benedikt Kramer
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sonja Ludwig
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Lena Huber
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Claudia Scherl
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- AI Health Innovation Cluster, Heidelberg-Mannheim Health and Life Science Alliance, Heidelberg University, Heidelberg, Germany
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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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Anto R, Vidya K, Thomas M, Tirkey AJ, Agarwal M, Riju J, Patil S, Bhandari S, Rekha. Worst Pattern of Invasion as an Independent Predictor of Lymph node Metastasis and Prognosis in oral Cavity Squamous cell carcinoma - A Retrospective Cohort Study. Indian J Otolaryngol Head Neck Surg 2023; 75:440-449. [PMID: 37275086 PMCID: PMC10235229 DOI: 10.1007/s12070-022-03193-z] [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: 03/13/2022] [Accepted: 09/23/2022] [Indexed: 11/28/2022] Open
Abstract
Although Worst pattern of invasion (WPOI) is one of the histopathological (HP) markers that has been utilized in risk stratification of oral squamous cell carcinoma (OSCC) patients, its potential as an independent predictive factor for lymph node metastasis (LNM) and prognosis is least analyzed. Aim of the study is to analyze the relationship of various HP parameters to WPOI, their propensity for lymph node metastasis and prognostic value. This retrospective study included 140 patients diagnosed with resectable OSCC who underwent definitive surgery. Multiparametric HP risk assessment was done on the postoperative specimen and patients were categorized as low-risk WPOI (Type 1-3), and high-risk group (type 4 and 5). After categorization, 36.1% patients had low-risk WPOI and 63.9% had high-risk WPOI. Significant association was noted between WPOI and patient's age (p = 0.001), nodal stage (p = 0.001), lymphovascular invasion (LVI) (p = 0.006) and neural invasion (p = 0.001). 87% patients with nodal metastasis had high risk WPOI. LVI (p = 0.014) and WPOI (p < 0.001) had significant predictive role in LNM. High-risk WPOI and bone involvement were found to be predictive factors for overall survival, and only high risk WPOI had strong correlation with disease free survival having significant poor prognosis. Analyzing WPOI is essential in reporting HP specimens in OSCC. High-risk WPOI can act as an independent predictor for LNM, early recurrence and poor prognosis. Incorporation of WPOI into TNM staging is recommended to improve clinician's ability to prognosticate and individualize treatment strategies.
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Affiliation(s)
| | - Konduru Vidya
- Department of head and neck surgery, Christian Medical College, Vellore, India
| | - Meera Thomas
- Department of Pathology, Christian Medical College, Vellore, India
| | - Amit Jiwan Tirkey
- Department of head and neck surgery, Christian Medical College, Vellore, India
| | - Mansi Agarwal
- Department of head and neck surgery, Christian Medical College, Vellore, India
| | - Jeyashanth Riju
- Department of head and neck surgery, Christian Medical College, Vellore, India
| | | | | | - Rekha
- Department of Biostatistics, Christian Medical College, Vellore, India
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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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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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Coutu B, Ryan E, Christensen D, Lawrence E, Bell EB, Zhen W, Sayed Z. Positive margins matter regardless of subsequent resection findings. Oral Oncol 2022; 128:105850. [DOI: 10.1016/j.oraloncology.2022.105850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/22/2022] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
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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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14
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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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15
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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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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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17
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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: 8] [Impact Index Per Article: 2.7] [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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18
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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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Toluidine blue versus frozen section for assessment of mucosal tumor margins in oral squamous cell carcinoma. BMC Cancer 2020; 20:1147. [PMID: 33238944 PMCID: PMC7691066 DOI: 10.1186/s12885-020-07644-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When the resected specimen is sent for intraoperative margin assessment, all margins are grossly checked, and selected margins undergo a frozen section (FS) examination. Therefore, there is a possibility of sampling error. This study evaluated the effectiveness of using toluidine blue (TB) as an intraoperative triage screening tool to detect positive mucosal margins of the resected specimens of oral squamous cell carcinoma (OSCC) and serve as a guide for FS sampling. METHODS Surgical samples of 30 consecutive patients with biopsy-proven OSCC were included in the study. A total of 140 mucosal margins were analyzed intraoperatively by TB and FS, the results were compared with the final histopathology. RESULTS Of the 140 examined mucosal tumor margins, 14 stained positives with TB, six were true-positives, eight were false-positives, and there were no false-negatives, as confirmed by final histopathology of the same margins. The diagnostic performance measures were sensitivity 100.0%; specificity 94.0%; positive predictive value (PPV) 42.9%; negative predictive value (NPV) 100.0%; and accuracy 94.3% (95% CI: 89.0-97.5%). For FS, there were three true-positives, three false-negatives, and no false-positives. The diagnostic performance measures were sensitivity 50.0%; specificity 100.0%; PPV 100.0%; NPV 97.8%; and accuracy 97.9% (95% CI: 93.9-99.6%). CONCLUSION TB is less specific but more sensitive than FS for detecting positive mucosal margins of resected OSCC. Screening the tumor mucosal margins with TB before FS sampling may help identify more tumor-bearing margins. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov. Registration number: NCT03554967 . Registration date: June 13, 2018.
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Muhanna N, Eu D, Chan HH, Daly M, Fricke IB, Douglas CM, Townson JL, Zheng J, Allen C, Jaffray DA, Irish JC. Assessment of a liposomal CT/optical contrast agent for image-guided head and neck surgery. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2020; 32:102327. [PMID: 33220507 DOI: 10.1016/j.nano.2020.102327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 10/22/2022]
Abstract
This study evaluates a long-acting liposomal fluorescence / CT dual-modality contrast agent (CF800) in head and neck cancer to enhance intraoperative tumor demarcation with fluorescence imaging and cone-beam computed tomography (CBCT). CF800 was administered to 12 buccal cancer-bearing rabbits. Imaging was acquired at regular time points to quantify time-dependent contrast enhancement. Surgery was performed 5-7 days after, with intraoperative near-infrared fluorescence endoscopy and CBCT, followed by histological and ex-vivo fluorescence assessment. Tumor enhancement on CT was significant at 24, 96 and 120 hours. Volumetric analysis of tumor segmentation showed high correlation between CBCT and micro-CT. Fluorescence signal was apparent in both ex-vivo and in-vivo imaging. Histological correlation showed [100%] specificity for primary tumor. Sensitivity and specificity of CF800 in detecting nodal involvement require further investigation.CF800 is long acting and has dual function for CT and fluorescence contrast, making it an excellent candidate for image-guided surgery.
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Affiliation(s)
- Nidal Muhanna
- Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada.; Department of Otolaryngology-Head and Neck Surgery-Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON, Canada.; Department of Otolaryngology-Head and Neck Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Donovan Eu
- Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada.; Department of Otolaryngology-Head and Neck Surgery-Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Harley Hl Chan
- Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada
| | - Michael Daly
- Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada
| | - Inga B Fricke
- University Health Network, TECHNA Institute, Toronto, ON, Canada
| | - Catriona M Douglas
- Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada.; Department of Otolaryngology-Head and Neck Surgery-Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jason L Townson
- Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada
| | - Jinzi Zheng
- University Health Network, TECHNA Institute, Toronto, ON, Canada
| | - Christine Allen
- University of Toronto, Pharmaceutical Sciences, Toronto, ON, Canada
| | - David A Jaffray
- Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada.; University of Toronto, Departments of Radiation Oncology and Medical Biophysics, Toronto, ON, Canada
| | - Jonathan C Irish
- Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, ON, Canada.; Department of Otolaryngology-Head and Neck Surgery-Surgical Oncology, Princess Margaret Cancer Centre/University Health Network, University of Toronto, Toronto, ON, Canada..
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21
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Smithers FAE, Haymerle G, Palme CE, Low THH, Froggatt C, Gupta R, Clark JR. A prospective study of intraoperative assessment of mucosal squamous cell carcinoma margins in the head and neck. Head Neck 2020; 43:590-600. [PMID: 33098251 DOI: 10.1002/hed.26517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In head and neck cancers, tumor margin assessment has important prognostic and therapeutic implications. Frozen section control of margins is commonly employed intraoperatively. However, this is not without limitations. The aim of this study is to determine whether intraoperative slicing of the whole specimen is feasible and what impact this may have on tumor margin assessment and the requirement for postoperative radiotherapy. METHODS From September 2016 to August 2018, we recruited 22 patients as a pilot study looking at both the practicalities and the clinical relevance of whole margin tumor analysis intraoperatively. Our project is a prospective single arm study with historical controls. RESULTS Forty-one percent of our patients required further intraoperative resection for close or involved margins. Seven of these patients who otherwise would have required adjuvant radiotherapy due to their margin status did not, after our intervention. CONCLUSIONS We found that although requiring resources, this process was feasible without unduly increasing operative times and with potential patient benefit including reduced incidence of adjuvant radiotherapy.
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Affiliation(s)
- Fiona A E Smithers
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Department of Plastic, Reconstructive and Burns Surgery, Hutt Valley Hospital, Lower Hutt, New Zealand
| | - Georg Haymerle
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Department of Otorhinolaryngology - Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Carsten E Palme
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Tsu-Hui Hubert Low
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Catriona Froggatt
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Ruta Gupta
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Department of Anatomical Pathology, Royal Prince Albert Hospital, Sydney, New South Wales, Australia
| | - Jonathan R Clark
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Department of Surgery, Royal Prince Albert Hospital, Sydney, New South Wales, Australia
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22
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Elaiwy O, El Ansari W, AlKhalil M, Ammar A. Epidemiology and pathology of oral squamous cell carcinoma in a multi-ethnic population: Retrospective study of 154 cases over 7 years in Qatar. Ann Med Surg (Lond) 2020; 60:195-200. [PMID: 33163176 PMCID: PMC7610004 DOI: 10.1016/j.amsu.2020.10.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/11/2020] [Indexed: 12/26/2022] Open
Abstract
Background Oral cancer (OC) is a neoplastic process of the oral cavity that has high mortality and significant effects on patients' aesthetics. The majority of OC is oral squamous cell carcinoma (OSCC) and resection remains the most frequent treatment. Recurrence is the main cause of tumor-related mortality. Material and methods A retrospective review of patients' charts at Hamad Medical Corporation examined 154 adults who were diagnosed as OSCC and referred to the national head and neck cancer multi-disciplinary team meetings between 2012 and 2018. The data extracted was demographic, pathologic and clinical. All patients with oral cavity tumors other than squamous cell carcinoma were excluded. Results Males comprised the majority of the sample, mean age was 46.93 years. Tongue was the most common location. The majority of the patients were diagnosed at early stages, and a small subset of patients had histologically-proven local recurrence. Conclusion The young male predominance of OSCC patients in Qatar is unprecedented worldwide. Most patients were non-Qataris, mainly from South Asia. Loss of follow-up was a challenge in assessing the long-term outcomes of OSCC. Our findings suggest the need for a more vigilant surveillance approach to oral lesions particularly in male South-Asian patients, as well as improving the follow-up strategies.
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Affiliation(s)
- Orwa Elaiwy
- Department of laboratory medicine and pathology, Hamad Medical Corporation, Doha, Qatar
| | - Walid El Ansari
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar.,School of Health and Education, University of Skövde, Skövde, Sweden
| | - Moustafa AlKhalil
- Department of Oral and Cranio-Maxillo-Facial Surgery, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine in Qatar, Doha, Qatar
| | - Adham Ammar
- Department of laboratory medicine and pathology, Hamad Medical Corporation, Doha, Qatar
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23
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Bulbul MG, Zenga J, Tarabichi O, Parikh AS, Sethi RK, Robbins KT, Puram SV, Varvares MA. Margin Practices in Oral Cavity Cancer Resections: Survey of American Head and Neck Society Members. Laryngoscope 2020; 131:782-787. [PMID: 32827312 DOI: 10.1002/lary.28976] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/20/2020] [Accepted: 07/10/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the definition of a clear margin and the use of frozen section (FS) among practicing head and neck surgeons in oral cancer management. STUDY DESIGN Cross-sectional survey. METHODS We designed a survey that was sent to American Head and Neck Society (AHNS) members via an email link. RESULTS A total of 185 (13% of 1,392) AHNS members completed our survey. Most surgeons surveyed (96.8%) use FS to supplement oral cavity squamous cell carcinoma resections. Fifty-five percent prefer a specimen-based approach. The majority of respondents believe FS is efficacious in guiding re-resection of positive margins, with 81% considering the new margin to be negative. More than half of respondents defined a distance of >5 mm on microscopic examination as a negative margin. CONCLUSIONS To avoid oral cancer resections that result in positive margins on final analysis, and thus the need for additional therapy, most surgeons surveyed use FS. A majority of surveyed surgeons now prefer a specimen-based approach to margin assessment. Although there is a debate on what constitutes a negative margin, most surgeons surveyed believe it to be >5 mm on microscopic examination. LEVEL OF EVIDENCE 4 Laryngoscope, 131:782-787, 2021.
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Affiliation(s)
- Mustafa G Bulbul
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, U.S.A
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Osama Tarabichi
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, U.S.A
| | - Anuraag S Parikh
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, U.S.A
| | - Rosh K Sethi
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - K Thomas Robbins
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University Medical School, Springfield, Illinois, U.S.A
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery and Department of Genetics, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Mark A Varvares
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, U.S.A
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24
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Brinkman D, Callanan D, O'Shea R, Jawad H, Feeley L, Sheahan P. Impact of 3 mm margin on risk of recurrence and survival in oral cancer. Oral Oncol 2020; 110:104883. [PMID: 32659737 DOI: 10.1016/j.oraloncology.2020.104883] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION While positive surgical margins in oral squamous cell carcinoma (OSCC) is generally considered an adverse prognosticator, the significance of close (≤5 mm) margins is more debatable, and has not been widely adopted as an indicator for radiotherapy. MATERIALS AND METHODS Retrospective study of 244 patients undergoing primary surgical resection of OSCC. The impact on local control (LC), disease-specific survival (DSS) and overall survival (OS) of margins at 1 mm intervals was studied. RESULTS 65 patients had involved (<1 mm), 119 close (1-5 mm), and 60 clear (>5 mm) main specimen margins. Involved margins was predictive of DSS (p = 0.04), but not LC (p = 0.20) or OS (p = 0.09). Both the 2 mm and 3 mm margin cut-offs were significantly associated with LC (p = 0.02, and p = 0.01), DSS (p = 0.02, and p = 0.007), and OS (p = 0.03. and p = 0.005). In a 3-tier model, use of 3 mm for demarcation between close and clear yielded good separation between survival curves of clear (≥3 mm), and close (1-<3 mm) or involved (<1 mm). Final margins, determined after incorporation of frozen sections and extra margins taken separately, was significant for LC (p = 0.04), but not for DSS (p = 0.05) or OS (p = 0.17). On multivariate analysis, <3 mm margin, T-classification, nodal status, extranodal spread, and postoperative radiotherapy, were independent predictors of DSS and OS. For LC, only T-classification was significant. CONCLUSION A 3 mm main specimen margin is significantly associated with survival in OSCC and may be useful for demarcation between close and clear. Further study is required to determine any impact on survival of radiotherapy for patients with <3 mm margins as sole indicator for radiotherapy.
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Affiliation(s)
- David Brinkman
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland; Department of Pathology, Cork University Hospital, Cork, Ireland; Department of Surgery, University College, Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Deirdre Callanan
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland; Department of Pathology, Cork University Hospital, Cork, Ireland; Department of Surgery, University College, Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Ross O'Shea
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland; Department of Pathology, Cork University Hospital, Cork, Ireland; Department of Surgery, University College, Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Hadeel Jawad
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland; Department of Pathology, Cork University Hospital, Cork, Ireland; Department of Surgery, University College, Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Linda Feeley
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland; Department of Pathology, Cork University Hospital, Cork, Ireland; Department of Surgery, University College, Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Patrick Sheahan
- Dept of Otolaryngology, South Infirmary Victoria University Hospital, Cork, Ireland; Department of Pathology, Cork University Hospital, Cork, Ireland; Department of Surgery, University College, Cork, Ireland; ENTO Research Unit, College of Medicine and Health, University College Cork, Cork, Ireland.
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25
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Kubik MW, Sridharan S, Varvares MA, Zandberg DP, Skinner HD, Seethala RR, Chiosea SI. Intraoperative Margin Assessment in Head and Neck Cancer: A Case of Misuse and Abuse? Head Neck Pathol 2020; 14:291-302. [PMID: 32124417 PMCID: PMC7235105 DOI: 10.1007/s12105-019-01121-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 12/19/2019] [Indexed: 12/15/2022]
Abstract
Surgical removal with negative margins is the preferred management of oral squamous cell carcinomas. This review summarizes statements by professional organizations and data supporting the specimen-driven approach to margin assessment. Practical aspects of the intraoperative margin assessment, as guided by gross examination, are presented. The most cost- and time-efficient method of intraoperative margin assessment depends on desired margin clearance and likelihood of other adverse histologic factors, such as extranodal extension, perineural invasion, which are likelier in advanced carcinomas. Intraoperative surgeon-pathologist communication can be improved by reporting to surgical team gross distances to all or selected closest margins, before choosing margins for microscopic frozen examination. Case specific mitigation strategies to minimize the negative impact of tumor-bed driven margin assessment or of suboptimal margin revision are proposed. Based on size, shape, histology, size of carcinoma at the margin, and orientation of the additional tissue, margin revision may be judged as adequate (conversion of a positive margin into a negative one), inadequate (positive margin remains positive), or indeterminate. The significance of anatomic subsite based labeling, radial margin sampling from the main resection specimen, and the relationship between the distance to closest margin and local control are highlighted. The modern definition of safe margin would account for other parameters, such as perineural invasion. An updated approach to resolution of frozen versus permanent sampling issues is outlined. Future studies are needed to design and validate risk models that would help to determine for individual patient what represents a safe margin and how to judge the quality of margin revision.
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Affiliation(s)
- Mark W. Kubik
- grid.412689.00000 0001 0650 7433Department of Otolaryngology, Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Shaum Sridharan
- grid.412689.00000 0001 0650 7433Department of Otolaryngology, Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Mark A. Varvares
- grid.38142.3c000000041936754XDepartment of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA USA
| | - Dan P. Zandberg
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, PA USA
| | - Heath D. Skinner
- grid.21925.3d0000 0004 1936 9000Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Raja R. Seethala
- grid.412689.00000 0001 0650 7433Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Simion I. Chiosea
- grid.412689.00000 0001 0650 7433Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
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26
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Huang SH, Hahn E, Chiosea SI, Xu ZY, Li JS, Shen L, O'Sullivan B. The role of adjuvant (chemo-)radiotherapy in oral cancers in the contemporary era. Oral Oncol 2020; 102:104563. [PMID: 31918174 DOI: 10.1016/j.oraloncology.2019.104563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 12/23/2019] [Accepted: 12/31/2019] [Indexed: 12/28/2022]
Abstract
Squamous cell carcinoma of oral cavity (OSCC) is predominantly managed with surgery. Post-operative radiotherapy (PORT) and chemoradiotherapy (POCRT) enhance disease control in OSCC patients with adverse anatomic and pathologic primary and nodal features. Knowledge about disease behavior, surgery and radiotherapy advances, and the emergence of new systemic agents prompt refinement of PORT volumes and POCRT regimens. Traditional and emerging prognostic models that include adverse histopathological features underpin such approaches. This review summarizes research over recent decades with emphasis on the 2015 to Feb 2019 period describing: (1) Indications for PORT and/or POCRT, addressing surgical "margin status" including the definition of a "clear" margin to permit withholding PORT/POCRT; these concepts include characterizing the specimen yielding these measurements, the optimal time point to assess these findings, and the putative value of a "revised margin" performed during the same operative procedure, (2) Emerging prognostic factors including nodal burden (total number of involved lymph nodes) and perineural invasion, (3) PORT volume design, dose/fractionation and optimal surgery-to-PORT interval, (4) Chemotherapy dose, schedule, and agents, and (5) On-going clinical trials involving systemic agents and combinations of chemotherapy with immunotherapy.
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Affiliation(s)
- Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON, Canada
| | - Ezra Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON, Canada
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, PA, USA
| | - Zhi-Yuan Xu
- Department of Clinical Oncology, The University of Hong Kong - Shenzhen Hospital, Shenzhen, PR China
| | - Ji-Shi Li
- Department of Clinical Oncology, The University of Hong Kong - Shenzhen Hospital, Shenzhen, PR China
| | - Lin Shen
- Department of Clinical Oncology, The University of Hong Kong - Shenzhen Hospital, Shenzhen, PR China
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON, Canada; Department of Clinical Oncology, The University of Hong Kong - Shenzhen Hospital, Shenzhen, PR China.
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27
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Kain JJ, Birkeland AC, Udayakumar N, Morlandt AB, Stevens TM, Carroll WR, Rosenthal EL, Warram JM. Surgical margins in oral cavity squamous cell carcinoma: Current practices and future directions. Laryngoscope 2019; 130:128-138. [PMID: 31025711 DOI: 10.1002/lary.27943] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/09/2019] [Accepted: 03/01/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To discuss the current available techniques for intraoperative margin assessment in the surgical treatment of oral squamous cell carcinoma (OSCC) through a review of the available literature. METHODS A systematic review was undertaken of the available English literature between 2008 through 2018 regarding surgical margins in OCSS. A total of 893 relevant articles were returned; 144 met criteria for review; and 64 articles were included. RESULTS In this review, we discuss the data surrounding the use of frozen section in OCSS. Additionally, alternative techniques for margin assessment are discussed, including Mohs, molecular analysis, nonfluorescent dyes, fluorescent dyes, autofluorescent imaging, narrow-band imaging, optical coherence tomography, confocal microscopy, high-resolution microendoscopy, and spectroscopy. For each technique, particular emphasis is placed on the local recurrence, disease-free survival, and overall survival rates when available. CONCLUSION This review provides support for the practice of specimen-driven margin assessment when using frozen section analysis to improve the utility of the results. Finally, several alternatives for intraoperative margin assessment currently under investigation, including pathologic, wide-field imaging and narrow-field imaging techniques, are presented. We aim to fuel further investigation into methods for margin assessment that will improve survival for patients with OSCC through a critical analysis of the available techniques. LEVEL OF EVIDENCE NA Laryngoscope, 130:128-138, 2020.
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Affiliation(s)
- Joshua J Kain
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Andrew C Birkeland
- Department of Otolaryngology, Stanford University, Stanford, California, U.S.A
| | - Neha Udayakumar
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Anthony B Morlandt
- Department of Oral & Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Todd M Stevens
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - William R Carroll
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Eben L Rosenthal
- Department of Otolaryngology, Stanford University, Stanford, California, U.S.A
| | - Jason M Warram
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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Tirelli G, Hinni ML, Fernández‐Fernández MM, Bussani R, Gatto A, Bonini P, Giudici F, Boscolo Nata F. Frozen sections and complete resection in oral cancer surgery. Oral Dis 2019; 25:1309-1317. [DOI: 10.1111/odi.13101] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/11/2019] [Accepted: 03/27/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Giancarlo Tirelli
- ENT Clinic, Head and Neck Department Azienda Sanitaria Universitaria Integrata di Trieste Trieste Italy
| | - Michael L. Hinni
- Department of Otolaryngology Mayo Clinic Phoenix Phoenix Arizona
| | | | - Rossana Bussani
- UCO Pathological Anatomy and Histopathology Unit Azienda Sanitaria Universitaria Integrata di Trieste Trieste Italy
| | - Annalisa Gatto
- ENT Clinic, Head and Neck Department Azienda Sanitaria Universitaria Integrata di Trieste Trieste Italy
| | - Pierluigi Bonini
- ENT Clinic, Head and Neck Department Azienda Sanitaria Universitaria Integrata di Trieste Trieste Italy
| | - Fabiola Giudici
- Biostatistics Unit‐Department of Medical, Surgical and Health Science Azienda Sanitaria Universitaria Integrata di Trieste Trieste Italy
| | - Francesca Boscolo Nata
- ENT Clinic, Head and Neck Department Azienda Sanitaria Universitaria Integrata di Trieste Trieste Italy
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29
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Bulbul MG, Tarabichi O, Sethi RK, Parikh AS, Varvares MA. Does Clearance of Positive Margins Improve Local Control in Oral Cavity Cancer? A Meta-analysis. Otolaryngol Head Neck Surg 2019; 161:235-244. [PMID: 30912991 DOI: 10.1177/0194599819839006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To compare local recurrence-free survival (LRFS) in early oral cavity cancer (OCC) patients with positive/close frozen section (FS) cleared with further resection (R1 to R0) or positive FS not cleared (R1) to those with negative margins on initial FS analysis (R0). DATA SOURCES PubMed, EMBASE, and Cochrane. REVIEW METHODS We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for reporting in our study. Only English-language articles that included patients with OCC and local recurrence (LR) comparisons between R0 and initially R1 to final R0 or final R1 groups were included. We requested the raw data from the corresponding authors of eligible studies and performed an individual participant data (IPD) meta-analysis of LRFS outcomes across groups. RESULTS Pooled LRFS data from 8 studies showed that patients in the R1 to R0 group had worse LRFS compared to the R0 group (hazard ratio [HR] = 2.897, P < .001). Patients in the R1 group were also found to have worse LRFS compared to the R0 group (HR = 3.795, P < .001). When compared to final R1 group, the initially R1 to final R0 only showed a trend toward better LRFS. CONCLUSION Margin revision of initially positive margins to "clear" based on FS guidance does not equate to an initially negative margin and does not significantly improve local control. These findings call into question the effectiveness of the current methodology of intraoperative FS in OCC resections and call for a prospective study to determine what system of resected specimen analysis best predicts completeness of resection.
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Affiliation(s)
- Mustafa G Bulbul
- 1 Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Osama Tarabichi
- 1 Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Rosh K Sethi
- 1 Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Anuraag S Parikh
- 1 Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- 1 Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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30
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Müller S, Boy SC, Day TA, Magliocca KR, Richardson MS, Sloan P, Tilakaratne WM, Zain RB, Thompson LDR. Data Set for the Reporting of Oral Cavity Carcinomas: Explanations and Recommendations of the Guidelines From the International Collaboration of Cancer Reporting. Arch Pathol Lab Med 2018; 143:439-446. [PMID: 30500296 DOI: 10.5858/arpa.2018-0411-sa] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The International Collaboration on Cancer Reporting is a nonprofit organization whose goal is to develop evidence-based, internationally agreed-upon standardized data sets for each cancer site for use throughout the world. Providing global standardization of pathology tumor classification, staging, and other reporting elements will lead to the objective of improved patient management and enhanced epidemiologic research. Carcinomas of the oral cavity continue to represent a significant oncologic management burden, especially as changes in alcohol and tobacco use on a global scale contribute to tumor development. Separation of oral cavity carcinomas from oropharyngeal tumors is also important, as management and outcome are quite different when human papillomavirus association is taken into consideration. Topics such as tumor thickness versus depth of invasion, pattern of invasive front, extent and size of perineural invasion, and margin assessment all contribute to accurate classification and staging of tumors. This review focuses on the data set developed for Carcinomas of the Oral Cavity Histopathology Reporting Guide, with discussion of the key elements developed for inclusion.
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Affiliation(s)
- Susan Müller
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
| | - Sonja C Boy
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
| | - Terrence A Day
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
| | - Kelly R Magliocca
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
| | - Mary S Richardson
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
| | - Philip Sloan
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
| | - Wanninayake M Tilakaratne
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
| | - Rosnah B Zain
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
| | - Lester D R Thompson
- From Atlanta Oral Pathology, Decatur, Georgia (Dr Müller); Lancet Laboratories, Pretoria, South Africa (Dr Boy); the Departments of Otolaryngology-Head and Neck Surgery (Dr Day) and Pathology and Laboratory Medicine (Dr Richardson), Medical University of South Carolina, Charleston; the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Magliocca); the Department of Cellular Pathology, Newcastle University, Newcastle upon Tyne, United Kingdom (Dr Sloan); the Department of Oral Pathology, University of Peradeniya, Sri Lanka (Dr Tilakaratne); the Department of Oral Pathology, Faculty of Dentistry, MAHSA University, Selangor, Jalan, Malaysia (Dr Zain); and the Department of Pathology, Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, California (Dr Thompson)
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Gil Z, Fridman E, Na'ara S. Reply to Patients with revised surgical resection margins are best studied as a distinct group. Cancer 2018; 124:4263-4264. [PMID: 30299539 DOI: 10.1002/cncr.31710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Ziv Gil
- The Head and Neck Center, Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, The Technion-Israel Institute of Technology, Haifa, Israel
| | - Eran Fridman
- The Head and Neck Center, Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, The Technion-Israel Institute of Technology, Haifa, Israel
| | - Shorook Na'ara
- The Head and Neck Center, Department of Otolaryngology-Head and Neck Surgery, Rambam Health Care Campus, The Technion-Israel Institute of Technology, Haifa, Israel
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CCR4 Expression Is Associated With Poor Prognosis in Patients With Early Stage (pN0) Oral Tongue Cancer. J Oral Maxillofac Surg 2018; 77:426-432. [PMID: 30395826 DOI: 10.1016/j.joms.2018.09.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/02/2018] [Accepted: 09/24/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Chemokine receptors are involved in tumor metastasis and can predict poor prognosis; however, the expression and clinicopathologic relevance of chemokine receptors in early-stage cancer remain largely unknown. This study measured the association between chemokine (C-C motif) receptor-4 (CCR4) expression and prognosis in patients with histologically node-negative (pN0) oral tongue cancer. MATERIALS AND METHODS A retrospective analysis of CCR4 expression data from a consecutive case series of patients with pN0 oral cancer tongue was conducted. The expression of CCR4 by immunohistochemistry was investigated and the association between CCR4 expression and clinicopathologic variables and overall and disease-free survivals was evaluated using Kaplan-Meier analysis and a Cox regression model. RESULTS CCR4 expression was examined in 128 human tongue cancerous samples (109 tongue squamous cell carcinomas [TSCCs] and 19 other types) and 10 normal tongue samples and was found to be highly expressed in tumor tissues compared with normal tissues. CCR4 expression was observed in 64.2% of patients with TSCC and showed a significant association with tumor stage (P = .037). Patients with CCR4-positive expression exhibited poorer overall and disease-free survivals compared with those with CCR4-negative expression (P < .001 and P = .001), and CCR4-positive expression was an independent factor of unfavorable overall and disease-free survivals (P = .002 and P = .007). CONCLUSIONS This study identified CCR4 as a potential prognostic biomarker for recurrence and survival of patients with pN0 oral tongue cancer. Thus, CCR4 might be a possible therapeutic target for patients with early-stage cancer.
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Buchakjian MR, Ginader T, Tasche KK, Pagedar NA, Smith BJ, Sperry SM. Independent Predictors of Prognosis Based on Oral Cavity Squamous Cell Carcinoma Surgical Margins. Otolaryngol Head Neck Surg 2018; 159:675-682. [PMID: 29737907 DOI: 10.1177/0194599818773070] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective To conduct a multivariate analysis of a large cohort of oral cavity squamous cell carcinoma (OCSCC) cases for independent predictors of local recurrence (LR) and overall survival (OS), with emphasis on the relationship between (1) prognosis and (2) main specimen permanent margins and intraoperative tumor bed frozen margins. Study Design Retrospective cohort study. Setting Tertiary academic head and neck cancer program. Subjects and Methods This study included 426 patients treated with OCSCC resection between 2005 and 2014 at University of Iowa Hospitals and Clinics. Patients underwent excision of OCSCC with intraoperative tumor bed frozen margin sampling and main specimen permanent margin assessment. Multivariate analysis of the data set to predict LR and OS was performed. Results Independent predictors of LR included nodal involvement, histologic grade, and main specimen permanent margin status. Specifically, the presence of a positive margin (odds ratio, 6.21; 95% CI, 3.3-11.9) or <1-mm/carcinoma in situ margin (odds ratio, 2.41; 95% CI, 1.19-4.87) on the main specimen was an independent predictor of LR, whereas intraoperative tumor bed margins were not predictive of LR on multivariate analysis. Similarly, independent predictors of OS on multivariate analysis included nodal involvement, extracapsular extension, and a positive main specimen margin. Tumor bed margins did not independently predict OS. Conclusion The main specimen margin is a strong independent predictor of LR and OS on multivariate analysis. Intraoperative tumor bed frozen margins do not independently predict prognosis. We conclude that emphasis should be placed on evaluating the main specimen margins when estimating prognosis after OCSCC resection.
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Affiliation(s)
- Marisa R Buchakjian
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Timothy Ginader
- 2 Biostatistics Core, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa, USA
| | - Kendall K Tasche
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Nitin A Pagedar
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Brian J Smith
- 2 Biostatistics Core, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa, USA
| | - Steven M Sperry
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA
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Berdugo J, Thompson LDR, Purgina B, Sturgis CD, Tuluc M, Seethala R, Chiosea SI. Measuring Depth of Invasion in Early Squamous Cell Carcinoma of the Oral Tongue: Positive Deep Margin, Extratumoral Perineural Invasion, and Other Challenges. Head Neck Pathol 2018; 13:154-161. [PMID: 29700721 PMCID: PMC6514023 DOI: 10.1007/s12105-018-0925-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/23/2018] [Indexed: 11/30/2022]
Abstract
The 8th edition of American Joint Committee on Cancer (AJCC 8th) staging manual incorporated depth of invasion (DOI) into pT stage of oral cavity cancer. The aim of this study was to characterize several histological findings that may complicate measurement of DOI in early conventional squamous cell carcinomas (SCC) of the oral tongue: (1) lack of or minimal residual carcinoma following biopsy; (2) positive deep margin; (3) extratumoral perineural invasion (PNI); and (4) lymphatic or vascular invasion. Conventional SCC of the oral tongue (n = 407) with the largest dimension of ≤ 4 cm and with a negative elective cervical lymph node dissection (pN0) were reviewed. A clear plastic ruler was used to measure DOI by dropping a "plumb line" to the deepest point of the invasive tumor from the level of the basement membrane of the normal mucosa closest to the invasive tumor. Examples of identifying reference point on the mucosal surface of oral tongue from which to measure the DOI are illustrated. In the experience of one contributing institution, the residual carcinoma was absent in 14.2% of glossectomies (34/239), while in 4.8% of cases (10/205) there was only minimal residual carcinoma. In 11.5% (21/183) of pT2 cases the deep margin was positive and thus DOI and pT may be underestimated. Of all cases with PNI, extratumoral PNI was identified in 23.1% (31/134) of cases, but represented the deepest point of invasion in only two cases. In one case, lymphatic invasion represented the deepest point of invasion and could have led to upstaging from pT1 to pT2. In conclusion, DOI measurement for SCC of the oral tongue may require re-examination of the diagnostic biopsy in up to 20% of cases due to the absence or only minimal residual carcinoma in glossectomy specimens. In 11.5% of apparently pT2 cases, DOI may be underestimated due to the positive deep margin. Rarely, extratumoral PNI or lymphatic invasion may be the deepest point of invasion. Overall, two issues (absent or minimal residual disease and positive deep margin) may confound DOI measurement in early SCCs of oral tongue.
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Affiliation(s)
- Jeremie Berdugo
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Lester D. R. Thompson
- Department of Pathology, Southern California Permanente Medical Group, Woodland Hills, CA USA
| | - Bibianna Purgina
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital/University of Ottawa, Ottawa, ON Canada
| | | | | | - Raja Seethala
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Simion I. Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA USA ,Presbyterian University Hospital, A610.3, 200 Lothrop St., Pittsburgh, PA 15213 USA
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Abstract
Neoplasms of the head and neck constitute a broad spectrum of benign and malignant entities. When treatment involves resection, assessment of the surgical margins represents an important component of the pathologic examination. Margin status is an important indicator of a complete surgical resection. The ability to generalize conclusions such as 'safe distance' measurements from work performed mSCCa or cutaneous malignancy to other types of neoplasms in the head and neck region seems limited. This article reviews conditions and considerations for reliable margin assessment and interpretation.
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Prabhu AV, Sturgis CD, Lai C, Maxwell JH, Merzianu M, Hernandez-Prera JC, Purgina B, Thompson LDR, Tuluc M, Yang X, Seethala RR, Ferris RL, Chiosea SI. Improving margin revision: Characterization of tumor bed margins in early oral tongue cancer. Oral Oncol 2017; 75:184-188. [PMID: 29074194 DOI: 10.1016/j.oraloncology.2017.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 09/24/2017] [Accepted: 10/13/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To improve margin revision, this study characterizes the number, fragmentation, and orientation of tumor bed margins (TBM) in patients with pT1-2 pN0 squamous cell carcinoma (SCC) of the oral tongue. MATERIALS AND METHODS Pathology reports (n=346) were reviewed. TBM parameters were indexed. In Group 1 patients all margins were obtained from the glossectomy specimen and there were no TBM. In Revision Group/Group 2 (n=103), tumor bed was sampled to revise suboptimal margins identified by examination of the glossectomy specimen. In Group 3 (n=124), TBM were obtained before examination of the glossectomy specimen. RESULTS AND CONCLUSIONS Fewer TBMs were obtained per patient in Group 2 compared to Group 3 (57/103, 55% of patients with <3 vs. 117/124, 94%, ≥3 TBMs, respectively). The new margin surface was more frequently indicated in Group 2 compared to Group 3 (59/103, 57%, vs. 19/124, 15%, p<.001). If glossectomy specimen margins are accepted as the reference standard, then the TBM was 15% sensitive in Group 2 (95% confidence interval [CI], 7-29) and 32% sensitive in Group 3 (95% CI, 15-55). TBM fragmentation (23/103, 22% vs. 42/124, 34%) and frozen vs. permanent discrepancies (8/103, 3% vs. 3/124, 2%) were similar between Groups 2 and 3. The new margin surface was not indicated in 6 of 11 cases with discrepant frozen vs. permanent pathology findings, precluding judgment on final margin status. To facilitate the assessment of final margins, TBM should be represented by one tissue fragment with a marked new margin surface.
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Affiliation(s)
- Arpan V Prabhu
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Chi Lai
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital/University of Ottawa, Ottawa, ON, Canada
| | - Jessica H Maxwell
- Department of Otolaryngology, Georgetown University School of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
| | - Mihai Merzianu
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | | | - Bibianna Purgina
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital/University of Ottawa, Ottawa, ON, Canada
| | - Lester D R Thompson
- Department of Pathology, Southern California Permanente Medical Group, Woodland Hills, CA, USA
| | - Madalina Tuluc
- Department of Pathology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Xiu Yang
- Department of Pathology, Hendricks Regional Health, Indianapolis, IN, USA
| | - Raja R Seethala
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Abstract
Margin assessment remains a critical component of oncologic care for head and neck cancer patients. As an integrated team, both surgeons and pathologists work together to assess margins in these complex patients. Differences in method of margin sampling can impact obtainable information and effect outcomes. Additionally, what distance is an "adequate or clear" margin for patient care continues to be debated. Ultimately, future studies and potentially secondary modalities to augment pathologic assessment of margin assessment (i.e., in situ imaging or molecular assessment) may enhance local control in head and neck cancer patients.
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Affiliation(s)
- Michelle D Williams
- Department of Pathology, Head and Neck Section, MD Anderson Cancer Center, The University of Texas, 1515 Holcombe Blvd, Unit 085, Houston, TX, 77030, USA.
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Zanoni DK, Migliacci JC, Xu B, Katabi N, Montero PH, Ganly I, Shah JP, Wong RJ, Ghossein RA, Patel SG. A Proposal to Redefine Close Surgical Margins in Squamous Cell Carcinoma of the Oral Tongue. JAMA Otolaryngol Head Neck Surg 2017; 143:555-560. [PMID: 28278337 DOI: 10.1001/jamaoto.2016.4238] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Resection of the primary tumor with negative margins is the gold standard treatment for squamous cell carcinoma of the oral tongue (SCCOT). A microscopically positive surgical margin is clearly associated with a higher risk for local recurrence, whereas a negative margin has traditionally been defined as greater than 5.0 mm clearance from the tumor, with lesser margins arbitrarily designated as close. The precise cutoff at which the risk for local recurrence with a close margin approximates that of a microscopically positive margin remains unclear. Objective To determine whether the arbitrarily defined close margin (<5.0 mm) would portend as high a risk for local recurrence as a positive margin after resection of SCCOT. Design, Setting, and Participants In this retrospective study, head and neck pathologists reviewed archived tumor specimens from 381 patients with SCCOT who underwent primary surgical resection at a tertiary care center from January 1, 2000, through December 31, 2012. Data were analyzed from November 15, 2015, to January 5, 2016. Time-dependent receiver operating characteristic curve analysis was used in patients who did not have a microscopically positive margin to determine an optimal margin cutoff for local recurrence-free survival (LRFS). Pathologic factors were assessed for LRFS in a multivariate Cox proportional hazards regression model. Main Outcomes and Measures The primary end point was evaluation of the margin distance associated with LRFS. Results Among the 381 patients included in the analysis (222 men [58.3%] and 159 women [41.7%]; mean [SD] age, 58 [14.7] years), the optimal cutoff associated with LRFS was determined to be 2.2 mm. This cutoff was compared with the traditionally accepted cutoff of 5.0 mm. Patients with a margin of 2.3 to 5.0 mm had similar LRFS as patients with a margin of greater than 5.0 mm (hazard ratio [HR], 1.31; 95% CI, 0.58-2.96), and all other comparisons were significantly different (HR for positive margin, 9.03; 95% CI, 3.45-23.67; HR for 0.01- to 2.2-mm margin, 2.83; 95% CI, 1.32-6.07). Based on this result, negative margins were redefined as those with a clearance of greater than 2.2 mm. In a multivariate model adjusting for pathologic factors, positive margins (adjusted HR, 5.73; 95% CI, 2.45-13.41) and margins of 0.01 to 2.2 mm (adjusted HR, 2.00; 95% CI, 1.13-3.55) were the variables most significantly associated with LRFS. Conclusions and Relevance In this study, local recurrence-free survival was significantly affected only with surgical margins of less than or equal to 2.2 mm in patients with SCCOT. This new definition of close margins stratifies the risk for local recurrence better than the arbitrary 5.0-mm cutoff that has been used.
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Affiliation(s)
- Daniella Karassawa Zanoni
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jocelyn C Migliacci
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bin Xu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nora Katabi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pablo H Montero
- 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
| | - Jatin P Shah
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J Wong
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ronald A Ghossein
- Department of Pathology, 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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40
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Abstract
The surgical method of margin sampling affects local control, pathologists' approach to margin sampling, and clarity of pathology reports. Studies have shown that exclusive reliance on tumor bed margins is associated with worse local control and should be avoided. En bloc resections and margins obtained from the resection specimen remain the "gold standard." Successful surgical treatment of early carcinomas of the oral cavity relies on close cooperation between surgeons and pathologists on issues of specimen orientation and margin sampling.
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Bergeron M, Gauthier P, Audet N. Decreasing loco-regional recurrence for oral cavity cancer with total Mohs margins technique. J Otolaryngol Head Neck Surg 2016; 45:63. [PMID: 27906094 PMCID: PMC5134294 DOI: 10.1186/s40463-016-0176-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/23/2016] [Indexed: 11/10/2022] Open
Abstract
Background The conventional technique for cancer resection margin analysis studies only 0.1% of the surgical margins. Complete frozen section margins - also known as Mohs margins – allows for analysis of 100% of the surgical margins. Methods The objective of our study is to compare oral cavity cancer loco-regional recurrence rates when treated by total frozen sections technique (Total Mohs margins) versus conventional margins. We conducted a multicenter retrospective cohort chart review. Loco-regional oral cancer recurrence rates were compared between patients treated with total Mohs margins (2007–2013) and patients treated with conventional margins techniques (2002–2007). Results After applying inclusion criteria, a total of 60 patients treated by total Mohs margins and 57 patients with conventional margins were identified. Patients had similar baseline cancer stages, pathological types, past head and neck cancers and comorbidities (all p > 0.05). One-year recurrence rate was lower (10.0% vs 21.1%, p = 0.019) in favor of Mohs total margins and stayed significantly lower at 5 years of follow-up. When adjusted for T grade with N0 disease, Mohs technique was still beneficial in loco-regional recurrence for Tis-T4N0 up to 2 years (10.5% vs 25.7%, z-score 1.849, p = 0.032). The Number Needed to Treat at 2 years of follow-up for this subgroup of patients (Tis-T4N0) is 6.6. Margins had to be retaken more often intra-operatively in Mohs technique (68.3% vs 12.3%, p < 0.0001), mainly for positive deep margins (48.6% of all margins, p = 0.028). Duration of surgery was not increased with Mohs vs conventional technique (380 min vs 475 min respectively, p = 0.025). Conclusions Mohs total margins may result in a significant reduction in cancer recurrence rate at 5 years compare to conventional surgery. Moreover, duration of surgery was not increased when using Mohs technique when judiciously performed. Electronic supplementary material The online version of this article (doi:10.1186/s40463-016-0176-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathieu Bergeron
- Department of Ophthalmology and Otolaryngology - Head & Neck Surgery, Faculty of Medicine, Laval University, 1050, avenue de la Médecine, Pavillon Ferdinand-Vandry, bureau 4889, Québec, Québec, G1V 0A6, Canada
| | - Pierre Gauthier
- Department of Otolaryngology- Head & Neck Surgery, Centre Hospitalier Régional de Launaudière, 1000 Boulevard Ste-Anne, St-Charles-Borromée, Québec, J6E 6J2, Canada
| | - Nathalie Audet
- Department of Otolaryngology - Head & Neck Surgery, CHU de Québec-Université Laval Hôpital de l'Enfant-Jésus, 2705, 1401 18e rue, Québec, Québec, GIJ 1Z4, Canada.
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Barroso EM, Smits RWH, van Lanschot CGF, Caspers PJ, Ten Hove I, Mast H, Sewnaik A, Hardillo JA, Meeuwis CA, Verdijk R, Noordhoek Hegt V, Baatenburg de Jong RJ, Wolvius EB, Bakker Schut TC, Koljenović S, Puppels GJ. Water Concentration Analysis by Raman Spectroscopy to Determine the Location of the Tumor Border in Oral Cancer Surgery. Cancer Res 2016; 76:5945-5953. [PMID: 27530325 DOI: 10.1158/0008-5472.can-16-1227] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 07/06/2016] [Indexed: 11/16/2022]
Abstract
Adequate resection of oral cavity squamous cell carcinoma (OCSCC) means complete tumor removal with a clear margin of more than 5 mm. For OCSCC, 85% of the surgical resections appear inadequate. Raman spectroscopy is an objective and fast tool that can provide real-time information about the molecular composition of tissue and has the potential to provide an objective and fast intraoperative assessment of the entire resection surface. A previous study demonstrated that OCSCC can be discriminated from healthy surrounding tissue based on the higher water concentration in tumor. In this study, we investigated how the water concentration changes across the tumor border toward the healthy surrounding tissue on freshly excised specimens from the oral cavity. Experiments were performed on tissue sections from 20 patients undergoing surgery for OCSCC. A transition from a high to a lower water concentration, from tumor (76% ± 8% of water) toward healthy surrounding tissue (54% ± 24% of water), takes place over a distance of about 4 to 6 mm across the tumor border. This was accompanied by an increase of the heterogeneity of the water concentration in the surrounding healthy tissue. The water concentration distributions between the regions were significantly different (P < 0.0001). This new finding highlights the potential of Raman spectroscopy for objective intraoperative assessment of the resection margins. Cancer Res; 76(20); 5945-53. ©2016 AACR.
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Affiliation(s)
- Elisa M Barroso
- Department of Oral & Maxillofacial Surgery, Special Dental Care, and Orthodontics, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Roeland W H Smits
- Department of Otorhinolaryngology & Head and Neck Surgery, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Cornelia G F van Lanschot
- Department of Otorhinolaryngology & Head and Neck Surgery, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Peter J Caspers
- Center for Optical Diagnostics & Therapy, Department of Dermatology, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands. RiverD International BV, Rotterdam, The Netherlands
| | - Ivo Ten Hove
- Department of Oral & Maxillofacial Surgery, Special Dental Care, and Orthodontics, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Hetty Mast
- Department of Oral & Maxillofacial Surgery, Special Dental Care, and Orthodontics, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology & Head and Neck Surgery, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - José A Hardillo
- Department of Otorhinolaryngology & Head and Neck Surgery, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Cees A Meeuwis
- Department of Otorhinolaryngology & Head and Neck Surgery, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Rob Verdijk
- Department of Pathology, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | | | - Robert J Baatenburg de Jong
- Department of Otorhinolaryngology & Head and Neck Surgery, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Eppo B Wolvius
- Department of Oral & Maxillofacial Surgery, Special Dental Care, and Orthodontics, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Tom C Bakker Schut
- Center for Optical Diagnostics & Therapy, Department of Dermatology, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands. RiverD International BV, Rotterdam, The Netherlands.
| | - Senada Koljenović
- Department of Pathology, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Gerwin J Puppels
- Center for Optical Diagnostics & Therapy, Department of Dermatology, Cancer Institute, Erasmus MC, Rotterdam, The Netherlands. RiverD International BV, Rotterdam, The Netherlands
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43
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Ransohoff A, Wood D, Solomon Henry A, Divi V, Colevas A. Third party assessment of resection margin status in head and neck cancer. Oral Oncol 2016; 57:27-31. [PMID: 27208841 DOI: 10.1016/j.oraloncology.2016.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 03/10/2016] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Definitive assessment of primary site margin status following resection of head and neck cancer is necessary for prognostication, treatment determination and qualification for clinical trials. This retrospective analysis determined how often an independent reviewer can assess primary tumor margin status of head and neck cancer resections based on review of the pathology report, surgical operative report, and first follow-up note alone. METHODS We extracted from the electronic medical record pathology reports, operative reports, and follow-up notes from head and neck cancer resections performed at Stanford Hospital. We classified margin status as definitive or not. We labeled any pathology report clearly indicating a positive, negative, or close (<5mm) margin as definitive. For each non-definitive pathology report, we reviewed the operative report and then the first follow-up note in an attempt to clarify margin status. We also looked for associations between non-definitive status and surgeon, year, and primary site. RESULTS 743 unique cases of head and neck cancer resection were extracted. We discarded 255 as non-head and neck cancer cases, or cases that did not involve a definitive resection of a primary tumor site. We could not definitively establish margin status in 20% of resections by independent review of the medical record. There was no correlation between margin determination and surgeon, site, or year of surgery. CONCLUSION A substantial fraction (20%) of primary site surgical margins could not be definitively determined via independent EMR review. This could have implications for subsequent patient care decisions and clinical trial options.
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Affiliation(s)
- Amy Ransohoff
- Program in Human Biology, Stanford University, United States
| | - Douglas Wood
- Biomedical Data Science, Stanford University, United States
| | | | - Vasu Divi
- Otolaryngology/Head & Neck Surgery (ENT), Stanford University, United States
| | - A Colevas
- Medicine - Med/Oncology, Stanford University, United States.
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Maxwell JH, Thompson LDR, Brandwein-Gensler MS, Weiss BG, Canis M, Purgina B, Prabhu AV, Lai C, Shuai Y, Carroll WR, Morlandt A, Duvvuri U, Kim S, Johnson JT, Ferris RL, Seethala R, Chiosea SI. Early Oral Tongue Squamous Cell Carcinoma: Sampling of Margins From Tumor Bed and Worse Local Control. JAMA Otolaryngol Head Neck Surg 2016. [PMID: 26225798 DOI: 10.1001/jamaoto.2015.1351] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Positive margins are associated with poor prognosis among patients with oral tongue squamous cell carcinoma (SCC). However, wide variation exists in the margin sampling technique. OBJECTIVE To determine the effect of the margin sampling technique on local recurrence (LR) in patients with stage I or II oral tongue SCC. DESIGN, SETTING, AND PARTICIPANTS A retrospective study was conducted from January 1, 1986, to December 31, 2012, in 5 tertiary care centers following tumor resection and elective neck dissection in 280 patients with pathologic (p)T1-2 pN0 oral tongue SCC. Analysis was conducted from June 1, 2013, to January 20, 2015. INTERVENTIONS In group 1 (n = 119), tumor bed margins were not sampled. In group 2 (n = 61), margins were examined from the glossectomy specimen, found to be positive or suboptimal, and revised with additional tumor bed margins. In group 3 (n = 100), margins were primarily sampled from the tumor bed without preceding examination of the glossectomy specimen. The margin status (both as a binary [positive vs negative] and continuous [distance to the margin in millimeters] variable) and other clinicopathologic parameters were compared across the 3 groups and correlated with LR. MAIN OUTCOMES AND MEASURES Local recurrence. RESULTS Age, sex, pT stage, lymphovascular or perineural invasion, and adjuvant radiation treatment were similar across the 3 groups. The probability of LR-free survival at 3 years was 0.9 and 0.8 in groups 1 and 3, respectively (P = .03). The frequency of positive glossectomy margins was lowest in group 1 (9 of 117 [7.7%]) compared with groups 2 and 3 (28 of 61 [45.9%] and 23 of 95 [24.2%], respectively) (P < .001). Even after excluding cases with positive margins, the median distance to the closest margin was significantly narrower in group 3 (2 mm) compared with group 1 (3 mm) (P = .008). The status (positive vs negative) of margins obtained from the glossectomy specimen correlated with LR (P = .007), while the status of tumor bed margins did not. The status of the tumor bed margin was 24% sensitive (95% CI, 16%-34%) and 92% specific (95% CI, 85%-97%) for detecting a positive glossectomy margin. CONCLUSIONS AND RELEVANCE The margin sampling technique affects local control in patients with oral tongue SCC. Reliance on margin sampling from the tumor bed is associated with worse local control, most likely owing to narrower margin clearance and greater incidence of positive margins. A resection specimen-based margin assessment is recommended.
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Affiliation(s)
- Jessica H Maxwell
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Lester D R Thompson
- Department of Pathology, Southern California Permanente Medical Group, Woodland Hills
| | - Margaret S Brandwein-Gensler
- Division of Anatomic Pathology, Department of Pathology, The University of Alabama at Birmingham4Now with the Department of Pathology and Anatomical Sciences, State University of New York at the University at Buffalo and Erie County Medical Center, Buffal
| | - Bernhard G Weiss
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Göttingen, Göttingen, Germany
| | - Martin Canis
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Göttingen, Göttingen, Germany
| | - Bibianna Purgina
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital/University of Ottawa, Ottawa, Ontario, Canada
| | - Arpan V Prabhu
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Chi Lai
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital/University of Ottawa, Ottawa, Ontario, Canada
| | - Yongli Shuai
- Biostatistics Facility, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - William R Carroll
- Department of Surgery, Head and Neck Oncology, The University of Alabama at Birmingham
| | - Anthony Morlandt
- Department of Surgery, Head and Neck Oncology, The University of Alabama at Birmingham
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania10Department of Otolaryngology, Veterans Affairs of Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Seungwon Kim
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonas T Johnson
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raja Seethala
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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45
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Baddour HM, Magliocca KR, Chen AY. The importance of margins in head and neck cancer. J Surg Oncol 2016; 113:248-55. [PMID: 26960076 DOI: 10.1002/jso.24134] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/14/2015] [Indexed: 01/30/2023]
Abstract
An estimated 200,000 deaths each year worldwide are due to cancer of the head and neck, mostly mucosal squamous cell carcinoma and nonmelanoma skin cancer. The status of surgical margins is important for prognosis and need for adjuvant therapy. We will discuss how margin status impacts outcomes and therapy, and the conundrum of determining margin status.
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Affiliation(s)
- Harry Michael Baddour
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amy Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
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46
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Positive frozen section margins predict local recurrence in R0-resected squamous cell carcinoma of the head and neck. Oral Oncol 2016; 55:17-23. [PMID: 27016013 DOI: 10.1016/j.oraloncology.2016.02.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/12/2016] [Accepted: 02/16/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The purpose of this study was to analyse the impact of surgical margins on tumour recurrence and survival of patients with carcinomas of the head and neck. MATERIAL AND METHODS A cohort of 156 patients with primary squamous cell carcinoma of the head and neck treated by local resection with negative margins and neck dissection between 2004 and 2012 was investigated. Margin status in frozen sections and permanent paraffin tissues were analysed and compared to clinical and histopathological parameters as well as to tumour recurrence (local, regional and distant) and disease-specific survival (DSS). RESULTS Close margins (<5mm) on permanent sections were correlated to high-grade differentiation (p=0.070), lymphangiosis (p=0.009) and positive neck nodes (p=0.025) implicating regional and distant recurrence (p=0.001) as well as unfavorable DSS (p=0.002). Positive margins on initial frozen section analysis revised into negative margins during further surgery were the strongest predictor for local recurrence in uni- and multivariate analysis (p<0.001, hazard ratio 3.34). However, positive frozen section margins were not significantly predictive for DSS (p=0.150). Significant predictors for DSS in univariate analysis were local recurrence (p=0.026), T-stage (p=0.02), N-stage (p<0.001), grading (p=0.02) and lymphangiosis (p=0.001). Multivariate DSS analysis revealed lymph node metastasis (p=0.005) and local recurrence (p=0.017) as significant negative predictors. CONCLUSION Close margins on permanent sections are associated with aggressive tumour characteristics, regional and distant metastasis implicating worse DSS. The accuracy of frozen section analysis seems limited as positive frozen section margins revised into negative margins bear a high risk of local recurrence.
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47
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Yamada S, Kurita H, Shimane T, Kamata T, Uehara S, Tanaka H, Yamamoto T. Estimation of the width of free margin with a significant impact on local recurrence in surgical resection of oral squamous cell carcinoma. Int J Oral Maxillofac Surg 2016; 45:147-52. [DOI: 10.1016/j.ijom.2015.09.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/11/2015] [Accepted: 09/30/2015] [Indexed: 11/30/2022]
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48
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Amit M, Na'ara S, Leider-Trejo L, Akrish S, Cohen JT, Billan S, Gil Z. Improving the rate of negative margins after surgery for oral cavity squamous cell carcinoma: A prospective randomized controlled study. Head Neck 2015; 38 Suppl 1:E1803-9. [PMID: 26685937 DOI: 10.1002/hed.24320] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND A positive margin is among the most significant factors that affects the outcome in head and neck squamous cell carcinoma (SCC). The purpose of this study was to compare the negative margin rates between 2 methods of intraoperative margin assessment in patients with oral cavity SCC. METHODS A prospective, randomized controlled trial comparing 2 methods of intraoperative margin assessment: specimen-driven margins and patient-driven margins. RESULTS The final analysis included 71 patients, 20 (29%) in the patient-driven margin arm. Frozen section analysis revealed positive/close surgical margins that led to an extension of the surgical resection in 22 of 51 patients (43%) in the specimen-driven margin arm, and 2 of 20 patients (10%) in the patient-driven margin arm (p = .01). After final pathological analysis, the wide negative margin rate was 84% in the specimen-driven margin arm, compared to 55% in the patient-driven margin arm (p = .02). Extension of the surgical resection prevented escalation of adjuvant treatment in 19 patients (38%) in the specimen-driven margin arm and 10% in the patient-driven margin arm. CONCLUSION Specimen derived margin assessment led to significant improvement in the rate of negative margins. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1803-E1809, 2016.
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Affiliation(s)
- Moran Amit
- Head and Neck Cancer Center, Department of Otolaryngology Head and Neck Surgery, Rambam Healthcare Campus, Haifa, Israel.,The Laboratory for Applied Cancer Research, The Clinical Research Institute at Rambam, Rambam Healthcare Center, Haifa, Israel
| | - Shorook Na'ara
- Head and Neck Cancer Center, Department of Otolaryngology Head and Neck Surgery, Rambam Healthcare Campus, Haifa, Israel.,The Laboratory for Applied Cancer Research, The Clinical Research Institute at Rambam, Rambam Healthcare Center, Haifa, Israel
| | | | - Sharon Akrish
- Department of Pathology, Rambam Healthcare Campus, Haifa, Israel
| | - Jacob T Cohen
- Head and Neck Cancer Center, Department of Otolaryngology Head and Neck Surgery, Rambam Healthcare Campus, Haifa, Israel.,The Laboratory for Applied Cancer Research, The Clinical Research Institute at Rambam, Rambam Healthcare Center, Haifa, Israel
| | - Salem Billan
- Institute of Radiation Oncology, Rambam Healthcare Campus, Haifa, Israel
| | - Ziv Gil
- Head and Neck Cancer Center, Department of Otolaryngology Head and Neck Surgery, Rambam Healthcare Campus, Haifa, Israel.,The Laboratory for Applied Cancer Research, The Clinical Research Institute at Rambam, Rambam Healthcare Center, Haifa, Israel.,Rappaport Faculty of Medicine and Research Institute, The Technion, Israel Institute of Technology, Haifa, Israel
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49
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Abstract
Oral cavity squamous cell carcinoma (OC-SCC) is the most common malignancy of the head and neck (excluding nonmelanoma skin cancer). Recent trends have shown a dramatic rise in the incidence of oropharyngeal squamous cell carcinoma (OP-SCC), with a marked increase in lesions related to human papillomavirus infection. This update presents the latest evidence regarding OC-SCC and OP-SCC. In particular, the authors compare and contrast tumors at these two sites with respect to epidemiology, etiopathogenesis, clinicopathologic presentation, clinical assessment, imaging, management, and prognosis. It is important for clinicians to be aware of differences between OC-SCC and OP-SCC so that appropriate patient education and multidisciplinary care can be provided to optimize outcomes.
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Affiliation(s)
- Angela C Chi
- Professor, Division of Oral Pathology, Medical University of South Carolina, Charleston, SC
| | - Terry A Day
- Professor, Wendy and Keith Wellin Endowed Chair for Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Brad W Neville
- Distinguished University Professor, Division of Oral Pathology, Medical University of South Carolina, Charleston, SC
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50
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Carrillo JF, Carrillo LC, Cano A, Ramirez-Ortega MC, Chanona JG, Avilés A, Herrera-Goepfert R, Corona-Rivera J, Ochoa-Carrillo FJ, Oñate-Ocaña LF. Retrospective cohort study of prognostic factors in patients with oral cavity and oropharyngeal squamous cell carcinoma. Head Neck 2015; 38:536-41. [DOI: 10.1002/hed.23914] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2014] [Indexed: 12/18/2022] Open
Affiliation(s)
- José F. Carrillo
- Head and Neck Department; Surgery Division; Instituto Nacional de Cancerología (INCan); Mexico City Mexico
| | - Liliana C. Carrillo
- Clinical Research Division; Surgery Division; Instituto Nacional de Cancerología (INCan); Mexico City Mexico
| | - Ana Cano
- Pathology Department; Surgery Division; Instituto Nacional de Cancerología (INCan); Mexico City Mexico
| | | | - Jorge G. Chanona
- Pathology Department; Surgery Division; Instituto Nacional de Cancerología (INCan); Mexico City Mexico
| | - Alejandro Avilés
- Pathology Department; Surgery Division; Instituto Nacional de Cancerología (INCan); Mexico City Mexico
| | - Roberto Herrera-Goepfert
- Pathology Department; Surgery Division; Instituto Nacional de Cancerología (INCan); Mexico City Mexico
| | - Jaime Corona-Rivera
- Head and Neck Department; Surgery Division; Instituto Nacional de Cancerología (INCan); Mexico City Mexico
| | | | - Luis F. Oñate-Ocaña
- Clinical Research Division; Surgery Division; Instituto Nacional de Cancerología (INCan); Mexico City Mexico
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