Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

Abstract

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 inRotterdam 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.

Ultrasound‐guided resection for squamous cell carcinoma of the buccal mucosa: A feasibility study

“…However, patients with an involved or close tumor‐free margin have a higher risk of recurrence and qualify for adjuvant treatment, which also carries a high risk of morbidity 3,4,37,38 . Furthermore, the chance of correctly re‐resecting an involved or close tumor‐free margin in a second operation is low 39 …”

Image-guided surgery in oral cancer: toward improved margin control

“…Although this method screens larger areas than frozen section, it still depends on tactile information from the surgeon, which could lead to sampling errors comparable with frozen section. Furthermore, this method is unable to detect microscopic or perineural growth of the tumor front [10 ▪ ,11 ▪ ].…”

Rational design of a self-assembling high performance organic nanofluorophore for intraoperative NIR-II image-guided tumor resection of oral cancer

“…[8][9][10] Implementation of this protocol may increase the number of adequate resections from 15% to 40%, but it has not been widely adopted because grossing fresh tissue is counterintuitive for most pathologists. [8] Another option is intraoperative imageguided resection which, for some tumor types, can significantly simplify tumor margin delineation, reduce surgical staff, and improve adequate resection outcomes. While crosssectional imaging techniques such as magnetic resonance imaging (MRI) and computed tomography can be effective preoperative imaging tools for surgical planning in OSCC cases, they are less effective for intraoperative procedures in the oral cavity due to its complicated anatomy.…”

“…To improve outcomes, a new protocol has been proposed as the standard of care in which resection margins are determined through intricate tissue tagging and sample collection by a team of surgeons and pathologists during surgery. [8][9][10] Implementation of this protocol may increase the number of adequate resections from 15% to 40%, but it has not been widely adopted because grossing fresh tissue is counterintuitive for most pathologists. [8] Another option is intraoperative imageguided resection which, for some tumor types, can significantly simplify tumor margin delineation, reduce surgical staff, and improve adequate resection outcomes.…”