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Chen Y, Zhong NN, Cao LM, Liu B, Bu LL. Surgical margins in head and neck squamous cell carcinoma: A narrative review. Int J Surg 2024; 110:3680-3700. [PMID: 38935830 PMCID: PMC11175762 DOI: 10.1097/js9.0000000000001306] [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: 12/27/2023] [Accepted: 02/26/2024] [Indexed: 06/29/2024]
Abstract
Head and neck squamous cell carcinoma (HNSCC), a prevalent and frequently recurring malignancy, often necessitates surgical intervention. The surgical margin (SM) plays a pivotal role in determining the postoperative treatment strategy and prognostic evaluation of HNSCC. Nonetheless, the process of clinical appraisal and assessment of the SMs remains a complex and indeterminate endeavor, thereby leading to potential difficulties for surgeons in defining the extent of resection. In this regard, we undertake a comprehensive review of the suggested surgical distance in varying circumstances, diverse methods of margin evaluation, and the delicate balance that must be maintained between tissue resection and preservation in head and neck surgical procedures. This review is intended to provide surgeons with pragmatic guidance in selecting the most suitable resection techniques, and in improving patients' quality of life by achieving optimal functional and aesthetic restoration.
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Affiliation(s)
- Yang Chen
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology
| | - Nian-Nian Zhong
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology
| | - Lei-Ming Cao
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology
| | - Bing Liu
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology
- Department of Oral & Maxillofacial – Head Neck Oncology, School & Hospital of Stomatology, Wuhan University, Wuhan, People’s Republic of China
| | - Lin-Lin Bu
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology
- Department of Oral & Maxillofacial – Head Neck Oncology, School & Hospital of Stomatology, Wuhan University, Wuhan, People’s Republic of China
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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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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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Puram SV, Mays AC, Bayon R, Bell D, Chung J, Fundakowski CE, Johnson BT, Massa ST, Sharma A, Varvares MA. Margins in Stage I and II Oral Cavity Squamous Cell Carcinoma: A Review From the American Head and Neck Society. JAMA Otolaryngol Head Neck Surg 2023; 149:636-642. [PMID: 37289469 DOI: 10.1001/jamaoto.2023.1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Importance The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality. Observations This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design. Conclusions and Relevance Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.
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Affiliation(s)
- Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
- Department of Genetics, Washington University in St Louis, St Louis, Missouri
| | - Ashley C Mays
- Department of Otolaryngology, Cleveland Clinic Florida, Cleveland Clinic Indian River Hospital, Vero Beach
| | - Rodrigo Bayon
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City
| | - Diana Bell
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jeffson Chung
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown
| | - Christopher E Fundakowski
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Bradley T Johnson
- Ear, Nose, Throat and Plastic Surgery Associates, AdventHealth, Winter Park, Florida
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, St Louis University, St Louis, Missouri
| | - Arun Sharma
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston
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Zhang L, Judd RT, Zhao S, Rygalski C, Li M, Briody A, Swendseid B, Blakaj DM, Agrawal A, Ozer E, Carrau RL, Teknos TN, VanKoevering K, Rocco JW, Old MO, Seim NB, Puram SV, Haring CT, Kang SY. Immediate resection of positive margins improves local control in oral tongue cancer. Oral Oncol 2023; 141:106402. [PMID: 37094500 DOI: 10.1016/j.oraloncology.2023.106402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/08/2023] [Accepted: 04/15/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVES This study investigates the impact of immediate resection of positive margins on local control of oral tongue cancer. MATERIALS AND METHODS We analyzed 273 consecutive oral tongue cancers resected from 2013 to 2018. Additional resection was performed in cases during the initial operation based on surgeon inspection of the specimen and/or frozen margins. Positive margins were defined as invasive carcinoma/high-grade dysplasia < 1 mm from the inked edge. Patients were grouped as follows: negative margin (Group 1); positive margin with immediate additional tissue resection (Group 2); and positive margin without additional tissue resection (Group 3). RESULTS Overall, the rate of local recurrence was 7.7 % (21/273), and the rate of positive main specimen margin was 17.9 %. Of these patients, 38.8 % (19/49) underwent immediate additional resection of the presumed positive margin. Group 3 had higher local recurrence rates than Group 1 after adjustment for T-stage (aHR 2.8 [95 % CI 1.0-7.7], p = 0.04). Group 2 had similar rates of local recurrence (aHR 0.45 [95 % CI 0.06-3.6], p = 0.45). Three year local recurrence free survival for Groups 1, 2, and 3 were 91 %, 92 % and 73 %, respectively. Compared to the main specimen margin, sensitivity of intraoperative frozen tumor bed margins was 17.4 %, and specificity was 95 %. CONCLUSION In patients with positive main specimen margins, anticipation and detection in real-time with immediate additional tissue resection reduced local recurrence to rates similar to those with negative main specimen margins. These findings support the use of technology to provide real-time intraoperative margin data and guide additional resection for improved local control.
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Affiliation(s)
- Lisa Zhang
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Ryan T Judd
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Songzhu Zhao
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Chandler Rygalski
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Michael Li
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | | | - Brian Swendseid
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Dukagjin M Blakaj
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Amit Agrawal
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Enver Ozer
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Ricardo L Carrau
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Theodoros N Teknos
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Kyle VanKoevering
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - James W Rocco
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Matthew O Old
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Nolan B Seim
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Sidharth V Puram
- Department of Otolaryngology, Division of Head and Neck Surgery, Washington University School of Medicine, USA
| | - Catherine T Haring
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA
| | - Stephen Y Kang
- Division of Head and Neck Oncology, Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University, 4000 Eye and Ear Institute, 915 Olentangy River Rd, Columbus, OH 43212, USA.
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Merlotti A, Alterio D, Orlandi E, Racadot S, Bonomo P, Franco P, D'Angelo E, Ursino S, Pointreau Y, Lapeyre M, Graff P, Di Rito A, Argenone A, Musio D, De Felice F, Dionisi F, Fanetti G, D'Onofrio I, Belgioia L, Maddalo M, Scricciolo M, Bourhis J, Russi E, Thariat J. AIRO GORTEC consensus on postoperative radiotherapy (PORT) in low-intermediate risk early stages oral squamous cell cancers (OSCC). Radiother Oncol 2022; 177:95-104. [PMID: 36336113 DOI: 10.1016/j.radonc.2022.10.035] [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: 07/11/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
Evidence on the efficacy of postoperative radiotherapy (PORT) in low-intermediate risk squamous cell carcinoma of the oral cavity (OSCC) remains inconclusive. Members of a task force from two national radio-oncology Associations (AIRO and GORTEC) defined 14 clinically relevant questions to identify "gray areas" pertinent to the indication for PORT in this clinical setting. Consequently, a literature review was performed on the topic. The resulting statements were then rated by an Expert Panel (EP) using a modified Delphi method. Only radiation oncologists were part of the discussion and voting on the scenarios. There was agreement on the 14 statements at the first round of voting. The task force then decided to propose clinical cases for the two more controversial statements that had received a lower agreement to better capture the Experts' attitudes. The clinical cases highlighted a more significant decisional heterogeneity. However, the good level of consensus reached among the two Associations gives relevant support in informing clinical choices while acknowledging general indications cannot fit all clinical situations and do not replace multidisciplinary discussion.
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Affiliation(s)
- Anna Merlotti
- Radiotherapy Department, S. Croce & Carle Teaching Hospital, Cuneo, Italy.
| | - Daniela Alterio
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Ester Orlandi
- Radiation Oncology, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Séverine Racadot
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Pierluigi Bonomo
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
| | - Elisa D'Angelo
- Radiation Oncology, University Hospital of Modena, Modena, Italy
| | - Stefano Ursino
- Department of Radiation Oncology, Santa Chiara University Hospital, Pisa 56126, Italy
| | - Yoann Pointreau
- Department of Radiation Oncology, Centre Jean Bernard, Le Mans, France
| | - Michel Lapeyre
- Radiation Oncology Department, Centre Jean-Perrin, Unicancer, Clermont-Ferrand, France
| | - Pierre Graff
- Department of Radiation Oncology, Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay, France
| | - Alessia Di Rito
- Radiation Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Angela Argenone
- Division of Radiation Oncology, Azienda Ospedaliera di Rilievo Nazionale San Pio, Benevento, Italy
| | - Daniela Musio
- Radiotherapy Department, Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy
| | - Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | | | - Giuseppe Fanetti
- Division of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, PN, Italy
| | - Ida D'Onofrio
- Unit of Radiation Oncology, Ospedale del Mare, ASL Napoli 1 Centro, 80147 Naples, Italy
| | - Liliana Belgioia
- Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marta Maddalo
- Department of Radiation Oncology, University of Brescia and Spedali Civili, Brescia, Italy
| | | | - Jean Bourhis
- Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Elvio Russi
- Radiotherapy Department, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Baclesse / ARCHADE, Caen, France
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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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8
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Serinelli S, Bryant SM, Williams MPA, Marzouk M, Zaccarini DJ. Frozen-Permanent Section Discrepancy Rate in Oral Cavity and Oropharyngeal Squamous Cell Carcinoma. Head Neck Pathol 2021; 16:466-475. [PMID: 34655410 PMCID: PMC9187809 DOI: 10.1007/s12105-021-01385-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
Frozen section evaluation of head and neck squamous cell carcinoma (SCC) is critical for margin status and subsequent patient therapy. In this study, we retrospectively reviewed the rate of frozen-permanent section discrepancies in blocks with two frozen section levels compared to ≥ three levels in oral cavity and oropharyngeal SCCs. A search of the cases with both intraoperative frozen sections and corresponding permanent sections for SCCs in the oral cavity and oropharynx was performed. Frozen sections and permanent slides were compared. The nature of discrepancies was assigned to one of the following: change in diagnosis, margin status, or distance of the tumor from the margin. The cause of the discrepancy was designated as one of the following: block sampling, gross sampling, interpretation, or technical error. The pathologist experience, frozen section technical experience, and intraoperative impact of each discrepancy were also evaluated. A total of 654 frozen and corresponding permanent blocks were assessed. For 532 of the frozen section blocks, two levels were cut, while 122 frozen section blocks had ≥ three levels. Thirty-five frozen-permanent section discrepancies were observed (5.4% of all blocks). Among these, 2.5% had a possible or definitive intraoperative impact. The percentage of discrepancies in the ≥ three levels group (5.7%) was slightly higher than the two-level group (5.3%), and this difference was not statistically significant. For the two-level group, the overall block sampling error rate was 4.5%. This was not significantly different from the 4.1% block sampling error rate seen in the ≥ three levels group. The rate of block sampling discrepancy did not show significant differences based on attending or frozen section technical experience. A change in margin distance (closer margin detected on permanent) occurred in 4% of the blocks and involved 16% of the patients. This review of oral cavity and oropharynx SCCs frozen/permanent section discrepancies shows that the error rate is not significantly different depending on the number of levels cut. The results suggest that always performing more than two frozen section levels may not yield a decreased discrepancy rate. A change in margin distance occurred quite frequently, but only in rare cases it had a definitive impact on the intraoperative management. Given the importance of correct intraoperative diagnosis in patient management, additional levels may be warranted depending on the clinical scenario.
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Affiliation(s)
- Serenella Serinelli
- Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
| | - Stephanie M. Bryant
- Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
| | - Michael P. A. Williams
- Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
| | - Mark Marzouk
- Department of Head and Neck Oncologic Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
| | - Daniel J. Zaccarini
- Department of Pathology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY USA
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9
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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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10
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Hashmi AA, Iftikhar SN, Haider R, Baig NN, Asif MG, Irfan M. Recurrence and Disease-Free Survival in Head and Neck Squamous Cell Carcinoma After Margin-Free Resection on Frozen Section: An Institutional Perspective. Cureus 2020; 12:e11385. [PMID: 33312786 PMCID: PMC7725211 DOI: 10.7759/cureus.11385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction The most important factor determining survival in patients with head and neck squamous cell carcinoma (HNSCC) is a disease recurrence. A high rate of recurrence was noted in previous studies conducted in Pakistan; however, these studies did not consider margin status as inadequate margin clearance leads to disease recurrence. In this study, we determined cancer recurrence in patients with HNSCC after nullifying this factor. Methods This cross-sectional observational study was conducted in Liaquat National Hospital (LNH) for a duration of three years. Data collection period was from January 2015 to December 2017. A total of 150 patients that underwent surgery at LNH for HNSCC with margin-free frozen sections were included in the study. Pathological tumor characteristics such as tumor type, size, depth of invasion and nodal status were determined. Results The mean age of the patients was 50.31±12.90 with mean tumor size of 3.38±1.76. Nodal metastases were present in 45.3% cases with 17.3% showing extranodal extension. Recurrence was observed in 66% of cases with median disease-free survival of 12 months and perineural invasion was noted in 12% cases. We found a significant association of disease recurrence with larger tumor size, depth of invasion and extranodal extension. Moreover, younger age (<30 years) and older age (>50 years) groups showed higher rates of recurrence than the middle age group (30-50 years). Similarly, univariate and multivariate analyses revealed that tumors with ≥1 cm depth of invasion and the presence of extranodal extension were more likely to have disease recurrence than tumors with <1 cm depth of invasion and without extranodal extension. Survival analysis using the Kaplan-Meier method for HNSCC revealed a significant difference in disease-free survival in patients with more than 2 cm tumor size and ≥1 cm depth of invasion than cases with ≤ 2cm tumor size and <1 cm depth of invasion. Conclusion A high rate of disease recurrence for HNSSC was noted in our study, despite margin-free primary tumor resection. Apart from tumor size and depth of invasion, extranodal extension was significantly associated with disease recurrence in HNSCC. This signifies a need for margin evaluation of neck dissection specimen in cases with extranodal extension.
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Affiliation(s)
- Atif A Hashmi
- Pathology, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Syeda N Iftikhar
- Pathology, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Rimsha Haider
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, PAK.,Emergency Medicine, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Nabeel N Baig
- Research and Development, College of Physicians and Surgeons, Karachi, PAK
| | | | - Muhammad Irfan
- Statistics, Liaquat National Hospital and Medical College, Karachi, PAK
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11
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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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12
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Wu L, Chen J, Tian T, Li N, Jiang C. Reconstruction for Various Subtypes of Unilateral Buccal Defects After Oncologic Surgery by Using Personalized Anterolateral Thigh Flaps. J Oral Maxillofac Surg 2020; 78:1203-1213. [PMID: 32277936 DOI: 10.1016/j.joms.2020.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/19/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Radical resection of buccal carcinoma frequently leads to intraoral or through-and-through buccal defects. Anterolateral thigh (ALT) flaps can be harvested to reconstruct different buccal defect subtypes. The purpose of this study was to investigate clinical outcomes after the application of personalized ALT flaps for the precise reconstruction of unilateral buccal defects. MATERIALS AND METHODS Patients with primary unilateral buccal carcinoma who underwent tumor ablation and simultaneous reconstruction of personalized ALT flaps from January 2015 to January 2018 were enrolled in this retrospective case series. Buccal defects were classified into 4 subtypes. Demographic features, defect range and reconstructive method, and perioperative characteristics were reviewed and recorded. Quality of life and mouth opening were assessed by the University of Washington Quality-of-Life questionnaire and interincisal distance (IID), respectively, during follow-up. Descriptive statistics were calculated for each study variable. RESULTS Four types of ALT flaps were harvested and used to reconstruct different buccal defects in 146 patients. Of the 193 skin paddles applied, 189 survived, and few recipient- and donor-site complications were observed. One hundred eight patients were assessed with the University of Washington Quality-of-Life questionnaire and followed until 12 months postoperatively. Our results showed that physical, functional, social, and emotional domain scores increased steadily during the follow-up period. Ninety-eight patients showed improvements in mouth opening when the IID before the operation was compared with the IID at 3 and 6 months postoperatively. CONCLUSIONS A personalized ALT flap is a suitable choice for reconstructing unilateral buccal defects after oncologic surgery given its high success rate, customizable and flexible design, low complication rate, and satisfactory esthetic and functional results.
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Affiliation(s)
- Limeng Wu
- Resident, Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Jie Chen
- Resident, Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Tian Tian
- Resident, Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Ning Li
- Associate Professor, Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Canhua Jiang
- Professor and Department Head, Department of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha, China.
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13
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Ultrasound aids in intraoperative assessment of deep resection margins of squamous cell carcinoma of the tongue. Br J Oral Maxillofac Surg 2020; 58:285-290. [DOI: 10.1016/j.bjoms.2019.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 11/15/2019] [Indexed: 11/22/2022]
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14
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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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15
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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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16
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Tian T, Chen J, Li N, Huang L, Min AJ, Chen XQ, Jian XC, Jiang CH. [Application of the nasolabial fold "smile" incision approach in posterior buccal cancer ablation]. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2019; 37:621-625. [PMID: 31875440 DOI: 10.7518/hxkq.2019.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study investigated the feasibility and clinical result of radical resection of posterior buccal carcinoma by using the facial nasolabial fold "smile" incision approach. METHODS From August 2016 to March 2017, 23 patients with posterior buccal carcinoma were included in this study and underwent radical surgery. Upon finishing the cervical lymph node dissection, an arc-shaped incision was made at 1 cm lateral to the ipsilateral angulus oris, extending along the nasolabial fold upward to the inferolateral margin of the nasal alar while downward in direct continuity with the neck dissection incision. RESULTS Satisfactory exposure and easy resection of the primary tumor with negative surgical margin were achieved in all 23 patients. After 12-22 months of follow-up (16.5 months on average), all patients recovered favorably, and no local recurrence or distant metastasis was observed. Mouth opening was restored to normal in all cases. The scars were hidden in the nasolabial fold, thus named "smile" incision. CONCLUSIONS For posterior buccal cancer patients, the facial "smile" incision approach can satisfy the need of surgical exposure, facilitate operative performance, and preserve the annular integrity of the lips without affecting the radical tumor ablation, thereby maintaining a favorable mouth opening. With these advantages, the "smile" incision approach is considered worthy of being popularized in clinical application.
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Affiliation(s)
- Tian Tian
- Dept. of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Jie Chen
- Dept. of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Ning Li
- Dept. of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Long Huang
- Dept. of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - An-Jie Min
- Dept. of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Xin-Qun Chen
- Dept. of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Xin-Chun Jian
- Dept. of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Can-Hua Jiang
- Dept. of Oral and Maxillofacial Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
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17
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Duvvuri U, Johnson JT, Chiosea SI. Standardized Margin Assessment Is Needed Before Implementing Negative Margin as a Quality Measure. JAMA Otolaryngol Head Neck Surg 2019; 144:541-542. [PMID: 29596555 DOI: 10.1001/jamaoto.2018.0074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Umamaheswar Duvvuri
- Department of Otolaryngology, Veterans Affairs of Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Jonas T Johnson
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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18
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Surgical margins in oral squamous cell cancer: intraoperative evaluation and prognostic impact. Curr Opin Otolaryngol Head Neck Surg 2019; 27:98-103. [PMID: 30844923 DOI: 10.1097/moo.0000000000000516] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW To summarize recent findings regarding surgical management of oral squamous cell cancer (OSCC) through analysis of different intraoperative techniques for assessment of margins, evaluate the pros and cons of each, and ensuing prognostic impact. RECENT FINDINGS 'En bloc' OSCC resection and histopathologic evaluation of margins on the formalin-fixed specimen remain the 'gold standard' for oral oncologic surgery, whereas assessment of intraoperative surgical margins and its overall clinical value are still questioned and debated in the literature. The commonly applied evaluation of frozen sections still raises concerns regarding its efficacy and reproducibility; therefore, several ancillary diagnostic methods have entered the field of head and neck oncology in the last decades, aiming to support the surgeon in achieving tumor-free margins during ablative procedures. SUMMARY Poor prognosis of OSCC is strongly associated with residual tumor after surgery. Negative surgical margins are one of the strongest prognosticators for disease-free survival and locoregional control, but their intraoperative determination seems still to be suboptimal and needs better refinement. The most studied techniques to assess intraoperative margins include fluorescence, Raman spectroscopy, narrow band imaging, optical coherence tomography, and cytological bone margins analysis; each has its unique characteristics that are described in detail herein.
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19
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Sridharan S, Thompson LDR, Purgina B, Sturgis CD, Shah AA, Burkey B, Tuluc M, Cognetti D, Xu B, Higgins K, Hernandez-Prera JC, Guerrero D, Bundele MM, Kim S, Duvvuri U, Ferris RL, Gooding WE, Chiosea SI. Early squamous cell carcinoma of the oral tongue with histologically benign lymph nodes: A model predicting local control and vetting of the eighth edition of the American Joint Committee on Cancer pathologic T stage. Cancer 2019; 125:3198-3207. [PMID: 31174238 DOI: 10.1002/cncr.32199] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/15/2019] [Accepted: 04/18/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND The eighth edition of the American Joint Committee on Cancer staging manual (AJCC8) added depth of invasion to the definition of pathologic T stage (pT). In the current study, the authors assess pT stage migration and the prognostic performance of the updated pT stage and compare it with other clinicopathologic variables in patients with early squamous cell carcinoma of the oral tongue (OTSCC; tumors measuring ≤4 cm) with histologically benign lymph nodes (pN0). METHODS A multi-institutional cohort of patients with early OTSCC was restaged as per AJCC8. Primary endpoints were local recurrence (LR) and locoregional recurrence (LRR). Influential variables were identified and an LR/LRR prediction model was developed. RESULTS There were a total of 494 patients, with 49 LR and 73 LRR. AJCC8 pT criteria resulted in upstaging of 37.9% of patients (187 of 494 patients), including 34.5% (64 of 185 patients) from pT2 to pT3, without improving the prognostication for LR or LRR. Both LR and LRR were found to be similar for patients with AJCC8 pT2 and pT3 disease. On multivariate analysis, LR was only found to be associated with distance to the closest margin (hazard ratio, 0.36; 95% CI, 0.20-0.64 [P = .0007]) and perineural invasion (hazard ratio, 1.92; 95% CI, 1.10-0.64 [P = .046]). Based on these 2 predictors, a final proportional hazards regression model (which may be used similar to a nomogram) was developed. The proposed model appeared to be superior to AJCC pT stage for estimating the probability of LR and LRR for individual patients with early OTSCC. CONCLUSIONS AJCC8 pT criteria resulted in pT upstaging of patients with pN0 disease without improved LR or LRR prognostication. The proposed model based on distance to the closest margin and perineural invasion, status outperformed pT as a predictor of LR and LRR in patients with early OTSCC.
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Affiliation(s)
- Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Lester D R Thompson
- Department of Pathology, Southern California Permanente Medical Group, Woodland Hills, California
| | - Bibianna Purgina
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Akeesha A Shah
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Brian Burkey
- Section of Head and Neck Surgery and Oncology, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Madalina Tuluc
- Department of Pathology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Bin Xu
- Department of Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin Higgins
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Dominick Guerrero
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Seungwon Kim
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Umamaheswar Duvvuri
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert L Ferris
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - William E Gooding
- Biostatistics Facility, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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20
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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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21
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Sperry SM, Varvares MA, Chiosea SI. Patients with revised surgical resection margins are best studied as a distinct group. Cancer 2018; 124:4262-4263. [PMID: 30299546 DOI: 10.1002/cncr.31712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Steven M Sperry
- Department of Otolaryngology and Head and Neck Surgery, University of Iowa, Iowa City, Iowa
| | - Mark A Varvares
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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22
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Fridman E, Na'ara S, Agarwal J, Amit M, Bachar G, Villaret AB, Brandao J, Cernea CR, Chaturvedi P, Clark J, Ebrahimi A, Fliss DM, Jonnalagadda S, Kohler HF, Kowalski LP, Kreppel M, Liao CT, Patel SG, Patel RS, Robbins KT, Shah JP, Shpitzer T, Yen TC, Zöller JE, Gil Z. The role of adjuvant treatment in early-stage oral cavity squamous cell carcinoma: An international collaborative study. Cancer 2018; 124:2948-2955. [PMID: 29757457 DOI: 10.1002/cncr.31531] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 04/05/2018] [Accepted: 04/10/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Up to half of patients with oral cavity squamous cell carcinoma (OCSCC) have stage I to II disease. When adequate resection is attained, no further treatment is needed; however, re-resection or radiotherapy may be indicated for patients with positive or close margins. This multicenter study evaluated the outcomes and role of adjuvant treatment in patients with stage I to II OCSCC. METHODS Overall survival (OS), disease-specific survival, local-free survival, and disease-free survival rates were calculated with Kaplan-Meier analysis. RESULTS Of 1257 patients with T1-2N0M0 disease, 33 (2.6%) had positive margins, and 205 (16.3%) had close margins. The 5-year OS rate was 80% for patients with clear margins, 52% for patients with close margins, and 63% for patients with positive margins (P < .0001). In a multivariate analysis, age, depth of invasion, and margins were independent predictors of outcome. Close margins were associated with a >2-fold increase in the risk of recurrence (P < .0001). The multivariate analysis revealed that adjuvant treatment significantly improved the outcomes of patients with close/positive margins (P = .002 to .03). CONCLUSIONS Patients with stage I to II OCSCC and positive/close margins have poor long-term outcomes. For this population, adjuvant treatment may be associated with improved survival. Cancer 2018;124:2948-55. © 2018 American Cancer Society.
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Affiliation(s)
- Eran Fridman
- Rambam Healthcare Campus, Technion-Israel Institute of Technology, Haifa, Israel.,Laboratory for Applied Cancer Research, Technion-Israel Institute of Technology, Haifa, Israel
| | - Shorook Na'ara
- Rambam Healthcare Campus, Technion-Israel Institute of Technology, Haifa, Israel.,Laboratory for Applied Cancer Research, Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Moran Amit
- Rambam Healthcare Campus, Technion-Israel Institute of Technology, Haifa, Israel.,Laboratory for Applied Cancer Research, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gideon Bachar
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petach Tikva, Israel
| | | | - Jose Brandao
- Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Claudio R Cernea
- Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Jonathan Clark
- Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Head and Neck Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Ardalan Ebrahimi
- Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Head and Neck Surgery, Liverpool Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Dan M Fliss
- Department of Otolaryngology-Head and Neck Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | | | - Hugo F Kohler
- Department of Head and Neck Surgery, A. C. Camargo Cancer Center, São Paulo, Brazil
| | | | - Matthias Kreppel
- Department of Oral and Cranio-Maxillo and Facial Plastic Surgery, University of Cologne, Cologne, Germany
| | | | - Snehal G Patel
- Head and Neck Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - K Thomas Robbins
- Southern Illinois University School of Medicine, Carbondale, Illinois
| | - Jatin P Shah
- Head and Neck Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas Shpitzer
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petach Tikva, Israel
| | | | - Joachim E Zöller
- Department of Oral and Cranio-Maxillo and Facial Plastic Surgery, University of Cologne, Cologne, Germany
| | - Ziv Gil
- Rambam Healthcare Campus, Technion-Israel Institute of Technology, Haifa, Israel.,Laboratory for Applied Cancer Research, Technion-Israel Institute of Technology, Haifa, Israel
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23
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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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24
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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: 22] [Impact Index Per Article: 3.1] [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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25
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Thavarajah R, Ranganathan K. Trends in oral squamous cell carcinoma: Diagnosis for effective, evidence-based treatment 2017. J Oral Maxillofac Pathol 2017; 21:189-191. [PMID: 28932025 PMCID: PMC5596666 DOI: 10.4103/jomfp.jomfp_97_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rooban Thavarajah
- Department of Oral Pathology, Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi, Chennai - 600 119, Tamil Nadu, India. E-mail:
| | - Kannan Ranganathan
- Department of Oral Pathology, Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi, Chennai - 600 119, Tamil Nadu, India. E-mail:
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