Surgical margins in head and neck cancer: A contemporary review

Abstract

Adequate resection margins are critical to the treatment decisions and prognosis of patients with head and neck squamous cell carcinoma (HNSCC). However, there are numerous controversies regarding reporting and interpretation of the status of resection margins. Fundamental issues relating to the basic definition of margin adequacy, uniform reporting standards for margins, optimal method of specimen dissection, and the role of intraoperative frozen section evaluation, all require further clarification and standardization. Future horizons for margin surveillance offer the possible use of novel methods such as "molecular margins" and contact microscopic endoscopy, However, the limitations of these approaches need to be understood. The goal of this review was to evaluate these issues to define a more rational, standardized approach for achieving resection margin adequacy for patients with HNSCC undergoing curative resection.

Modeling the Laser Ablation Process

“…Considering the resection margins typically employed during TLM, we observe that the accuracy of the model is compatible with the requirements of these interventions. Surgeons aim to reach a minimum of 5 mm in resection depth to achieve surgical radicality [17,18], i.e. to ensure the removal of the whole tumor.…”

“…to ensure the removal of the whole tumor. Smaller margins, down to 1 mm, are used in those cases where function preservation is considered, including the treatment of glottic cancer [17,18]. However, it is important to point out that the reported accuracy was obtained on muscle tissue.…”

Role of Extracapsular Nodal Spread and Surgical Margin Status in defining High-risk Head and Neck Squamous Cell Carcinoma and its Treatment Intensity

“…18 Local recurrence is not only a result of the mere persistence of cancer cells in the surgical field, but also results from their increased survival chances in a postsurgical environment marked by abundant growth factors and increased delivery of oxygen and nutrients. 19 Postsurgical persistence of cancer cells may also be an indirect reflection of aggressive tumor biology, as it is frequently associated with high-stage tumors, perineural invasion, infiltrative tumor margins, and other highrisk factors that decrease chances for successful surgical resection. 19 Finally, survival decrease associated with persistence of cancer cells in the wound bed may result from increased chances of distant metastasis due to inflammatory vasodilatation.…”

“…19 Postsurgical persistence of cancer cells may also be an indirect reflection of aggressive tumor biology, as it is frequently associated with high-stage tumors, perineural invasion, infiltrative tumor margins, and other highrisk factors that decrease chances for successful surgical resection. 19 Finally, survival decrease associated with persistence of cancer cells in the wound bed may result from increased chances of distant metastasis due to inflammatory vasodilatation. For these reasons, postoperative histopathological assessment of surgical tumor margins provides a paramount piece of information to improve risk stratification and determination of adjuvant treatment requirement.…”

“…Although the subsequent steps leading up to the microscopic assessment of the surgical margins, including the fabrication and processing of paraffin embedded tissue blocks, are a fairly standardized and automated process, the actual microscopic assessment of surgical margins is associated with significant intra-and interobserver variability. 19 In cases where microscopic analysis clearly shows that a tumor extends into the ink-colored specimen margin, it is obvious that a positive surgical margin is present, and the chances for persistence of cancer cells within the surgical wound are increased sharply. In these cases, little discussion typically exists, unless the surgeon has provided clearly defined additional resection margins which correspond to the exact anatomical location at which the positive surgical margin was identified.…”