Surgical margins in head and neck cancer: A contemporary review (original) (raw)
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Surgical margins in head and neck cancer: Intra- and postoperative considerations
Auris, nasus, larynx, 2018
To provide a perspective on the significance of recent reports for optimizing cancer free surgical margins that have challenged standard practices. We conducted a review of the recent literature (2012-2018) using the keywords surgical margin analysis, frozen and paraffin section techniques, head and neck cancer, spectroscopy and molecular markers. Of significance are the reports indicating superiority of tumor specimen directed sampling of margins compared to patient directed (tumor bed) sampling for frozen section control of oral cancers. With reference to optimal distance between tumor and the surgical margin, recent reports recommended cutoffs less than 5mm. Employment of new technologies such as light spectroscopy and molecular analysis of tissues, provide opportunities for a "real time" assessment of surgical margins. The commonly practiced method of patient directed margin sampling involving previous studies raises concern over conclusions made regarding the efficacy...
Cancers, 2021
Surgery is one of the mainstays of head and neck cancer treatment, and aims at radical resection of the tumor with 1 cm tumor-free margins to obtain locoregional control. Surgical margins are evaluated by histopathological examination of the resection specimen. It has been long an enigma that approximately 10–30% of surgically treated head and neck cancer patients develop locoregional recurrences even though the resection margins were microscopically tumor-free. However, the origins of these recurrences have been elucidated by a variety of molecular studies. Recurrences arise either from minimal residual disease, cancer cells in the surgical margins that escape detection by the pathologist when examining the specimen, or from precancerous mucosal changes that may remain unnoticed. Head and neck tumors develop in mucosal precursor changes that are sometimes visible but mostly not, fueling research into imaging modalities such as autofluorescence, to improve visualization. Mostly unno...
Assessment of margins in resection specimens for head and neck malignancies
The study was carried out from January 2008 to December 2010 as a retrospective observational study. Tumour registers and computer data bases from the Department of Histopathology were analyzed for the cases of malignancies involving various head and neck sites (both extra oral and intra oral), that were sent for histopathological analysis after complete resection during the above mentioned 3 years.
Third party assessment of resection margin status in head and neck cancer
Oral Oncology, 2016
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 (<5 mm) 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 nonhead 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.
Cancer biology & medicine, 2012
To assess the impact of close or positive surgical margins on the outcome, and to determine whether margin status influence the recurrence rate and the overall survival for patients with head and neck cancers. Records from 1996 to 2001 of 413 patients with primary head and neck squamous cell carcinoma (SCC) treated with surgery as the first line treatment were analysed. Of these patients, 82 were eligible for the study. Patients were followed up for 5 years. Patients with margins between 5-10 mm had 50% recurrence rate (RR), those with surgical margins between 1-5 mm had RR of 59% and those with positive surgical margins had RR of 90% (P=0.004). The 5-year survival rates were 54%, 39% and 10%, respectively (P=0.002). Unsatisfactory surgical margin is an independent risk factor for recurrence free survival as well as overall survival regardless of the other tumor and patient characteristics.
Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way
Journal of Visualized Experiments, 2021
The goal of head and neck oncological surgery is complete tumor resection with adequate resection margins while preserving acceptable function and appearance. For oral cavity squamous cell carcinoma (OCSCC), different studies showed that only 15%-26% of all resections are adequate. A major reason for the low number of adequate resections is the lack of information during surgery; the margin status is only available after the final histopathologic assessment, days after surgery. The surgeons and pathologists at the Erasmus MC University Medical Center in Rotterdam started the implementation of specimen-driven intraoperative assessment of resection margins (IOARM) in 2013, which became the standard of care in 2015. This method enables the surgeon to turn an inadequate resection into an adequate resection by performing an additional resection during the initial surgery. Intraoperative assessment is supported by a relocation method procedure that allows accurate identification of inadequate margins (found on the specimen) in the wound bed. The implementation of this protocol resulted in an improvement of adequate resections from 15%-40%. However, the specimen-driven IOARM is not widely adopted because grossing fresh tissue is counter-intuitive for pathologists. The fear exists that grossing fresh tissue will deteriorate the anatomical orientation, shape, and size of the specimen and therefore will affect the final histopathologic assessment. These possible negative effects are countered by the described protocol. Here, the protocol for specimen-driven IOARM is presented in detail, as performed at the institute.
Molecular analysis of surgical margins in head and neck cancer: more than a marginal issue
Oral oncology, 2010
The relatively modest survival of patients surgically treated for advanced HNSCC can partly be explained by the development of local relapse. It is important that surgeons are able to predict which patients are at high risk to develop local relapse, since clinical management can be tailored. Local relapse after resection of a primary HNSCC is easily explained, when tumour is detected in the surgical margins and thus residual tumour is likely to remain in the patient, but the pathobiology is more complex in cases where the margins are histologically tumour-free. Molecular studies indicate that there are two different mechanisms responsible in these cases. First, small clusters of residual tumour cells that are undetectable on routine histopathological examination (known as minimal residual cancer: MRC) proliferate and this forms the basis of recurring cancer. A second cause of relapse is a remaining field of preneoplastic cells that is struck by additional genetic hits leading to inv...
Critical evaluation of frozen section margins in head and neck cancer resections
Cancer, 2006
BACKGROUND.Negative resection margins are likely the most important prognostic factor for a patient with a head and neck squamous cell carcinoma. Frozen-section evaluation allows a positive margin to be corrected before surgical closure and reconstruction. A final pathology report is later issued after examination of all resected tissues. The accuracy of the final pathology report relies on accuracy in the preceding steps. The current process of margin reporting in head and neck cancer resections was studied to reveal possible waste and error in the system.Negative resection margins are likely the most important prognostic factor for a patient with a head and neck squamous cell carcinoma. Frozen-section evaluation allows a positive margin to be corrected before surgical closure and reconstruction. A final pathology report is later issued after examination of all resected tissues. The accuracy of the final pathology report relies on accuracy in the preceding steps. The current process of margin reporting in head and neck cancer resections was studied to reveal possible waste and error in the system.METHODS.Two hundred pathologists were surveyed about their center's current process of frozen-section margin evaluation. The authors of the current study used the membership log of the North American Society of Head and Neck Pathology and the list of the top 50 US cancer centers according to US News and World Report. The authors analyzed the process of frozen-section procedure using Toyota industry principles of quality improvement.Two hundred pathologists were surveyed about their center's current process of frozen-section margin evaluation. The authors of the current study used the membership log of the North American Society of Head and Neck Pathology and the list of the top 50 US cancer centers according to US News and World Report. The authors analyzed the process of frozen-section procedure using Toyota industry principles of quality improvement.RESULTS.The majority of surgeons send small fragments of tissue from the surgical defect cavity. Many pathologists receive small unoriented tissue fragments. Many resample all or most of the margins for the final pathology report without anatomic orientation from the surgeon. Other pathologists do not sample any margins.The majority of surgeons send small fragments of tissue from the surgical defect cavity. Many pathologists receive small unoriented tissue fragments. Many resample all or most of the margins for the final pathology report without anatomic orientation from the surgeon. Other pathologists do not sample any margins.CONCLUSIONS.Final margin reporting redundancy and waste is due mainly to lack of anatomic correlation at interdisciplinary hand-offs. Oversampling and undersampling of margins may be occurring, and the accuracy of the final pathology report may be compromised. There is currently no consensus on how to best submit tissue for frozen-section evaluation of head and neck resection margins. Cancer 2006. © 2006 American Cancer Society.Final margin reporting redundancy and waste is due mainly to lack of anatomic correlation at interdisciplinary hand-offs. Oversampling and undersampling of margins may be occurring, and the accuracy of the final pathology report may be compromised. There is currently no consensus on how to best submit tissue for frozen-section evaluation of head and neck resection margins. Cancer 2006. © 2006 American Cancer Society.
Frontiers in Oncology, 2020
BackgroundInadequate resection margins in oral cavity squamous cell carcinoma have an adverse effect on patient outcome. Intraoperative assessment provides immediate feedback enabling the surgeon to achieve adequate resection margins. The goal of this study was to evaluate the value of specimen-driven intraoperative assessment by comparing the margin status in the period before and the period after the introduction of specimen-driven assessment as a standard of care (period 2010–2012 vs period 2013–2017).MethodsA cohort of patients surgically treated for oral squamous cell carcinoma at the Erasmus MC Cancer Institute, Rotterdam, between 2010–2012 was studied retrospectively and compared to results of a prospectively collected cohort between 2013–2017. The frequency, type and results of intraoperative assessment of resection margins were analyzed.ResultsOne hundred seventy-four patients were included from 2010–2012, 241 patients were included from 2013–2017. An increase in the freque...
Multicentre study on resection margins in carcinoma of the oral cavity, oro-hypopharynx and larynx
Acta Otorhinolaryngologica Italica, 2022
Objective. The prognostic significance of the resection margins is still subject of conflicting opinions. The purpose of this paper is to report the results of a study on the margins in carcinoma of the oral cavity, oro-hypopharynx and larynx. Methods. A multicentre prospective study was carried out between 2015 and 2018 with the participation of 10 Italian reference hospitals. The primary objective was to evaluate local control in patients with well-defined clinical characteristics and comprehensive histopathological information. Results. During the study period, 455 patients were enrolled; the minimum follow-up was 2 years. Previous treatment, grading and fresh specimen examination were identified as risk factors for local control in multivariate analysis. On the basis of these results, it seems possible to delineate "risk profiles" for different oncological outcomes. Discussion. The prognostic significance of the margins is reduced, and other risk factors emerge, which require diversified treatment and follow-up. Conclusions. Multidisciplinary treatment with adjuvant therapy, if indicated, reduces the prognostic importance of margins. Collaboration with a pathologist is an additional favourable prognostic factor and quality indicator. An appendix with literature review is present in the online version. KEY WORDS: resection margins, oral-pharyngeal-laryngeal cancer RIASSUNTO Obiettivo. Il significato prognostico dei margini di resezione è ancora oggetto di pareri discordanti. Scopo di questo scritto è riportare i risultati di uno studio sui margini nel carcinoma del cavo orale, oro-ipofaringe e laringe. Metodi. È stato condotto uno studio prospettico multicentrico con la partecipazione di 10 Centri italiani, nel periodo 2015-2018, con l'obiettivo primario di valutare il controllo locale in pazienti con ben determinate caratteristiche cliniche e con disponibilità di esaurienti informazioni istopatologiche. Risultati. Nel periodo in studio sono stati arruolati 455 pazienti con un follow-up minimo di 2 anni. All'analisi multivariata per il controllo locale sono risultati fattori di rischio il trattamento precedente, il grading e l'esame a fresco dello specimen. Sulla base dei risultati ottenuti è possibile delineare un "profilo di rischio" per tutti i diversi outcomes oncologici. Discussione. Il significato prognostico dei margini è ridotto, altri fattori emergono come profili di rischio, che richiederebbero trattamento e follow-up diversificati.