Redefining Adequate Surgical Resection Margins for Oral Squamous Cell Carcinoma: Our Institutional Experience in 5 Consecutive Years (original) (raw)
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BJSTR, 2017
Aim: Surgical margin status in the resection of oral squamous cell carcinoma (OSCC) is a significant prognostic indicator of recurrence and long term outcome. We sought to investigate the factors (patient, tumour and surgical) at time of surgery that influenced the ability to achieve adequate surgical margins. Method: We retrospectively reviewed patients who had undergone primary resection of OSCC. Over a 4-year period (2012-2015) 100 patients were surgically treated. Histological derived margins were classified as clear (≥5mm), close (<5mm) or involved (tumour present at resection margin). Results: Overall, 49%, 45% and 6% had clear, close and involved margins respectively. Of the 100 patients, 28 had stage I, 21 stages II, 7 stages III and 44 stage IV diseases. No relationship was evident between margin status and sex, age (<65), surgical access or individual surgeon. Maximum tumour diameter and depth of invasion were significant factors relating to poorer margins (p=0.015 and 0.021). Tumour site appeared to have no impact upon margin status. The histological feature of bone invasion had a significant impact upon poorer margins (p=0.015), as did a positive node status (p=0.0054). We were unable to correlate lymphovascular or perineural invasion with margin status. Discussion: We highlight tumour factors which appear to influence the margin status of resected OSCC, notably tumour size and depth, nodal spread and bone invasion. These all correlate to advanced stage disease being more difficult to treat. Our findings further stress the importance of being able to identify and delineate tumour mass intra-operatively to facilitate a clear resection margin.
The impact of close surgical margins on recurrence in oral squamous cell carcinoma
Journal of Otolaryngology - Head & Neck Surgery, 2021
Background Close margins influence treatment and outcome in patients with oral squamous cell carcinoma (OSCC). This study evaluates 187 cases of surgically treated OSCC regarding the impact of close margins on recurrence-free survival (RFS) and disease-specific survival (DSS). Methods Predictors of worsened outcome were identified using Kaplan-Meier analysis and multivariate Cox regression analysis. Results Tumour size [HR:1.70(0.95–3.08)], nodal status [HR:2.15(1.00–4.64)], presence of extracapsular spread (ECS) [HR:6.36(2.41–16.74)] and smoking history [HR:2.87(1.19–6.86)] were associated with worsened RFS. Similar factors were associated with worsened DSS. Close margins did not influence RFS or DSS. Conclusions While most conventional risk factors for OSCC conferred a worsened outcome, close margins did not. One explanation for this would be that close margins (< 5 mm) are equivalent to clear margins and the cutoff definition for a close margin should be re-evaluated. Lack of ...
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...
What is the adequate margin of surgical resection in oral cancer?
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 2009
Objective. The "adequate surgical margin" has always remained an enigma in the minds of head and neck surgeons. This study systematically analyses the impact of the width of the clear surgical margin on survival in oral cancer. Study design. A historical cohort of 277 surgically treated patients with oral cancer were followed for a median period of 36 months. Cox proportional hazard models were used to determine the independent effect of the clear surgical margin, in millimeters, on 5-year survival. Results. Patients with margins of 5 mm or more had a 5-year survival rate of 73% when compared to those with margins of 3 to 4 mm (69%) , 2 mm or less (62%), and involved margins (39%, P ϭ .000). After controlling for confounding variables (age, gender, stage) each 1-mm increase in clear surgical margin decreased the risk of death at 5 years by 8% (HR 0.92; 95% CI 0.86, 0.99; P ϭ .021). Based on this model, patients with positive surgical margins had a 2.5-fold increase in risk of death at 5 years and those with close (Յ 3 mm) margins had a 1.5-fold increase in risk of death (P ϭ 0.076) when compared to patients with margins greater than 3 mm (P ϭ .000). Conclusions. Survival improves with each additional millimeter of clear surgical margin. This systematic evaluation of surgical margins suggests that an adequate resection in oral cancer should provide a margin of greater than 3 mm on permanent pathology section.
British Journal of Oral and Maxillofacial Surgery, 2012
There is a lack of consistency among published reports in the definition of what constitutes close resection margins (1-5 mm) in the surgical treatment of oral and oropharyngeal squamous cell carcinoma (SCC). Our aim was to define what would constitute close resection margins in predicting local recurrence and disease-specific survival. The study comprised 192 previously untreated patients with oral and oropharyngeal SCC who were recruited at the Southern General Hospital, Glasgow, from 2001 to 2007 with a minimum follow-up of 2 years. Resection was the primary treatment and the surgical margins were recorded for all patients. Statistical analyses were aided by the Statistical Package for the Social Sciences, version 15.0, and MedCalc software. The status of the surgical margins was evaluated using a receiver operating characteristic (ROC) curve to define the cut-off point. Cox's proportional hazard model was used to establish predictive factors for local recurrence and disease-specific survival. Of 192 patients, 23 (12%) had involved margins (<1.0 mm), 107 (56%) had close margins (1.0-2.0 mm (16.1%); 2.1-3.0 mm (12%); 3.1-4.0 mm (10.4%); 4.1-5.0 mm (17.2%), and 62 (32.3%) had clear margins (>5 mm). No predictive cut-off point was found that related close surgical margins to local recurrence. However, there was a significant adverse association between surgical margins ≤1.6 mm and disease-specific survival. In recommending postoperative adjuvant treatment for oral and oropharyngeal SCC, we suggest that surgical margins within 2 mm should be considered as the cut-off. However, other clinical and pathological prognostic factors should also be taken into consideration when recommending further treatment.
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.
Oral Oncology, 2012
Pathologic positive margin (PPM) has been proved to be an adverse prognostic factor for patients with oral squamous cell carcinoma (OSCC). Pathologic close margin (PCM) may occur as a result of limited resection. However, it's impact on the survival of early stage OSCC patients is relatively unclear. The medical records of all patients with early stage OSCC between 1999 and 2006 were reviewed. We analyzed 407 early stage OSCC patients, including 362 patients with pathologic safe margin (PSM), 14 patients with PPM and 31 patients with PCM. All patients with PCM didn't receive adjuvant radiotherapy, while 11 patients with PPM received adjuvant radiotherapy. The 5-year disease-free survival rates of patients with PSM, PPM and PCM were 78.2%, 61.4% and 50.8%, respectively (p = .002). The 5-year overall survival rates of patients with PSM, PPM and PCM were 91.2%, 85.1% and 70.1%, respectively (p = .001). On multivariate analyses using the Cox logistic regression method, PCM was the independent adverse prognostic factor for disease-free survival and overall survival (p = .002 and .006, respectively). Pathologic close margin is a poor prognostic factor for disease-free and overall survivals of patients with early stage OSCC. Postoperative adjuvant radiotherapy or revised surgery with a wider margin might be necessary for early stage OSCC patients with PCM.
Margins and survival in oral cancer
British Journal of Oral and Maxillofacial Surgery, 2018
In the surgical management of oral squamous cell carcinoma (SCC) we aim to resect the tumour with clear margins in all planes. The aim of this study was to identify and compare overall survival in a group of 591 patients who had resections, and to relate this to the clearance of margins at the tumour bed. We used life tables to calculate survival at one, two, three, five, and 10 years after diagnosis by margin (clear = 5 mm or more; close = 2-5 mm; and involved = less than 2 mm). Kaplan-Meier curves were produced for the margins alone, which were defined as clear in 480 patients (81%), close in 63 (11%), and involved in 48 (8%). Five-year survival was 81%, 75%, and 54% for clear, close, and involved margins, respectively, which highlights the importance of clear margins for survival. There is a significant prognostic implication associated with close, and particularly with involved, margins.
Surgical margins and its evaluation in oral cancer: a review
Journal of clinical and diagnostic research : JCDR, 2014
The main surgical goal while treating cancer is to remove all local malignant disease with no residual malignant cells left. Overall benefits of achieving negative resection margins in terms of disease free local recurrence and overall survival has been discussed in many studies. The quantity of normal tissue to be removed during surgical procedure has not been standardised. Local recurrence can also occur among tumours with extensive histological demonstration of adequate resection margins. Oral cavity, submandibular region, tonsil and pharynx are the sites which have high chances of recurrence, even after showing negative margins. Therefore, the current approaches for histological risk assessment and various methods of evaluation of the surgical margins with their limitations are briefed in the present article.
British Journal of Oral & Maxillofacial Surgery, 2009
Background: The clearance of surgical margins at the primary site is widely thought to influence the subsequent course of the disease in patients operated on for oral and oropharyngeal carcinoma. In some reports the adverse impact of close or involved margins was not negated by postoperative radiotherapy. These findings, in addition to descriptive histopathological studies, have led some authors to recommend margins of more than a macroscopic clearance of 1 cm at certain subsites. We have therefore examined the relation between the condition of surgical margins and local recurrence and disease-specific survival. Methods: Identical treatment protocols were used to treat two independent groups of patients (Sydney, Australia, n = 237; Lanarkshire, n = 95) who presented with previously untreated carcinoma of the mouth or oropharynx. All patients were operated on with the primary objective of achieving a macroscopic clearance of 1 cm. Postoperative radiotherapy was used according to a protocol. Data about patients were entered into comprehensive computerised databases prospectively. Known clinical and pathological prognostic indicators, in addition to the condition of surgical margins, were analysed to find out if they were predictive of local recurrence and disease-specific survival using the Cox proportional hazard model. Results: Local recurrence was predicted by the presence of perineural invasion at the primary site in both groups. Disease-specific survival was predicted by the presence and extent of regional lymph node metastases in both groups. The condition of surgical margins (clear, close, or involved) did not predict local recurrence, or disease-specific survival on multivariate analysis. Conclusions: A macroscopic margin of 1 cm seems adequate in the surgical management of oral and oropharyngeal carcinoma. For most patients who have close or involved margins the biology of the disease influences the subsequent course irrespective of the width of clearance of tumour.