Surgical Margins if Oral Cavity Squamous Cell Carcinoma

  • The ultimate aim of surgical resection is:
    • Adequate clearance of the tumor
  • Inadequate clearance of the tumor results in:
    • Increased local recurrence and decreased long-term prognosis
  • Indications for postoperative radiotherapy (PORT) include:
    • Positive or close margins:
      • However despite PORT:
        • Local recurrence rates do not approach those in which adequate clearance is achieved at the primary operation
  • Increasing resection margins in the region of the head and neck:
    • Potentially results in increased functional and cosmetic deficit
  • Resection margins of up to 2 cm have been advocated:
    • However such margins result in significant functional deficit following the resection of even the smallest of tumors
  • Three-dimensional, 1 cm resection margins:
    • Have been demonstrated as acceptable when dealing with oral and oropharyngeal tumor:
      • Adopting 1 cm surgical margins:
        • Account is taken of the shrinkage that occurs post-resection:
          • So ensuring greater than 5 mm pathological margins
      • It should be remembered that the use of 5 mm as a cut-off point for ‘clear’ margins is arbitrary and purely represents a margin that is considered acceptable
      • It is vitally important to continually reassess margins visually and by palpation during tumor resection
      • If approaching the resection of a tumor with curative intent:
        • Then reconstructive considerations should not influence the tumor resection
  • Comparison of published data regarding the incidence of positive margins and their influence on survival or local recurrence is complicated by the variable definition of a positive margin:
    • The definition of a positive margin ranges from:
      • Invasive tumor at the margin, tumor within 1 mm and tumor within 5 mm
    • The UK Royal College of Pathologists have issued guidelines:
      • Suggesting clear margins if the histological clearance is 45 mm
      • Close margins if 1 mm to 5 mm
      • Positive margins if less than 1mm
  • The incidence of positive margins for tumors of the oral cavity:
    • Has been demonstrated as being higher than other head and neck sites:
      • Potentially due to its complex anatomy and three-dimensional shape
    • Large tumors, perineural spread, vascular permeation, a noncohesive invasive front or cervical metastasis:
      • Are all associated with a greater risk of failing to achieve clear margins:
        • These features suggest that close or involved margins:
          • Potentially reflect a more aggressive tumor
  • The incidence of close or involved margins following tumor resection may be greater than 60% depending on tumor site and size:
    • Invariably, it is the deep margin that is close or positive:
      • However close deep margins do not necessarily require adjunctive treatment:
        • The use of ultrasonography to aid in determining deep margin resection has been described
  • Frozen sections are not routinely used by many surgeons:
    • Reasons cited being potential cost
    • Inability to reliably prevent positive final margins
    • Poor relocation of biopsy site should the result be positive
  • Ninety-nine percent of American head and neck surgeons:
    • Routinely use frozen section intraoperatively:
      • However overreliance on frozen section may result in undertreatment of tumors
  • When conducting a bony resection:
    • A 1 cm margin should be achieved:
      • It has been demonstrated that it is unusual for extension of tumor in bone to exceed the overlying soft tissue extension
#Arrangoiz #CancerSurgeon #HeadandNeckSurgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico #SurgicalOncologist #OralCavityCancer

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s