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 …”

“…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 Because US is non-invasive, affordable, widely available, and easy to insert in the surgical workflow, it is a suitable tool for every head and neck surgeon to guide their resection. This study gives surgeons a guideline for using intraoperative US and a US tumor-free margin to strive for during surgery.…”

A closer look at the resection margins of buccal mucosa cancer: Their influence on local recurrence free survival

“…Adjuvant PO(ch)RT was more effective than adjuvant re-resection in lowering the risk for local recurrence, probably because relocating an involved or close tumor-free margin in a postoperative setting can often be inadequate. 5,21 Patients with ≥5.0 mm tumor-free margin have a very low risk of local recurrence and seem to have a better DSS and OS compared to patients with <5.0 mm tumor-free margins. Adjuvant PO(ch)RT results in better LRFS, however, it can also increase morbidity due to mucositis, xerostomia, and ulceration.…”

“…However, besides the inconvenience of a second operation under general anesthesia and hospital admission, re‐resection entails additional risks associated with surgery, such as bleeding, infection, wound healing problems, and impairment of mouth opening due to scar formation. Also, re‐resections may be inaccurate in determining the exact location of the tumor residue, especially in a postoperative setting 21 . Furthermore, PO(ch)RT could result in the development of radiotherapy‐related acute and late morbidity, that is, mucositis, xerostomia, fibrosis, and osteoradionecrosis 22,23 …”

“…Also, re-resections may be inaccurate in determining the exact location of the tumor residue, especially in a postoperative setting. 21 Furthermore, PO(ch)RT could result in the development of radiotherapy-related acute and late morbidity, that is, mucositis, xerostomia, fibrosis, and osteoradionecrosis. 22,23 Given that BMSCC appears to behave more aggressively than SCC of other oral cavity subsites, it is important to identify factors associated with local recurrence.…”