The clinical significance of pathological findings in surgically resected margins of the primary tumor in head and neck carcinoma

doi:10.1016/0360-3016(87)90095-2

International Journal of Radiation OncologyBiologyPhysics

Volume 13, Issue 6, June 1987, Pages 833-837

https://doi.org/10.1016/0360-3016(87)90095-2 Get rights and content

Abstract

Two hundred seventy (270) consecutive surgical patients treated at Roswell Park Memorial Institute for carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx between 1977 and 1982 were reviewed to determine the relationship between pathological findings at the surgical margins of the primary tumor and the incidence of local recurrence and clinical outcome. The estimated 5-year disease-free survival rate was 39% for patients with free surgical margins (10%—hypopharynx, 30%—oropharynx, 40%—oral cavity, and 53%—larynx) and 7% for not-free surgical margins. Patients with free surgical margins and with well-differentiated squamous cell carcinoma had better prognosis than those patients with moderately- and poorly-differentiated carcinomas. The local recurrence rate for Stage T1 and T2 lesions with free surgical margins was 17%, compared with 27% for Stages T3 and T4. The results of this study indicate that pathological evidence of complete excision of the primary tumor is important and attempts should be made to obtain pathological clearance. The local recurrence rate for Stage T3 and T4 lesions is high. Adjuvant therapy is indicated and post-operative radiotherapy is recommended.

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The impact of surgical resection margins on outcomes for adults with head and neck osteosarcomas: A Canadian sarcoma research and Clinical Collaboration (CanSaRCC) study
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The aim of the study is to describe the factors that influence outcome in adults with head and neck osteosarcoma (HNO) with a specific focus on the margin status.
Patients with a diagnosis of HNO between the years 1996–2021 were reviewed from the Canadian Sarcoma Research and Clinical Collaboration (CanSaRCC) Database. Baseline characteristics, pathology, treatment, and outcomes were analyzed. Univariable (UVA) and multivariable (MVA) Cox regression models were performed. 5-year locoregional control rate and overall survival (OS) were estimated using Kaplan-Meier method and Log-Rank test.
Of 50 patients with a median age of 40 years (range 16–80), 27 (54%) were male. HNO commonly involved the mandible (n = 21, 42%) followed by maxilla (n = 15, 30%). Thirteen (33.3%) had low-intermediate grade and 26 (66.6%) had high grade tumors. Three patients (6%) had negative resection margins (>5 mm), 24 (48%) had close margins (1–5 mm), 15 (30%) had positive margins (<1mm) and 7 (16%) had unknown margin status. In total, 39 (78%) received chemotherapy – 22 (44%) received neoadjuvant chemotherapy while 17 (34%) received adjuvant chemotherapy. A total of 12 (24%) patients received radiotherapy, of whom 8 (16%) had adjuvant and 3 (6%) had neo-adjuvant. Median follow-up time was 6.3 years (range 0.26–24.9). Disease recurred in 21 patients (42%), of whom 15 (30%) had local recurrence only, 4 (8%) had distant metastasis, and 2 (4%) had both local and distant recurrence. 5-year locoregional control rate and OS was 62% and 79.2% respectively. Resection margins <3 mm was associated with lower 5 years OS and locoregional control rate (Log-Rank p = 0.02, p = 0.01 respectively).
Osteosarcomas of the head and neck are rare and local recurrence remains a concern. Surgical resection with negative resection margins may improve survival, and a 3 mm resection margin threshold may optimize survival. Radiotherapy and/or chemotherapy should be considered in a multidisciplinary setting based on risk-features.
Squamous Cell Carcinoma of the Upper Aerodigestive System
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Target delineation for postoperative treatment of head and neck cancer
2018, Oral Oncology
Citation Excerpt :
However, it is important to point out that patients with known macroscopic residual disease in the tumour bed (R2 resections) are not candidates for PORT or POCRT and should undergo re-resection or definitive RT/CRT. A number of other pathological risk factors have also been associated with an increased risk of loco-regional recurrence after surgery and are indicators for recommending PORT: ≥ 2 or involved lymph nodes [11,18], a single node >3 cm [11], perineural invasion [11,19], close mucosal margins [11] and T3-4 stage [20], particularly when clusters of 2 or more of these risk factors occur together [11]. Grade of the primary tumour and presence of lympho-vascular invasion have also been identified as possible risk factors for recurrence [21], but their individual significance remains unclear.
Patients who undergo primary surgical resection for a Head and Neck Squamous Cell Carcinoma (HNSCC) are stratified post-operatively, based on the presence or absence of pathological risk factors for recurrence, to estimate their risk of treatment failure. Post-operative radiotherapy, with or without concurrent chemotherapy, is offered if there is a significant risk of recurrence, in order to eradicate potential microscopic residual cancer cells and ultimately improve loco-regional control and survival.
This review will offer practical guidelines for delineation of the post-operative primary and nodal Clinical Target Volumes (CTVs) based on a geometric expansion of the pre-operative primary and nodal Gross Tumour Volumes (GTVs), as already implemented in the definitive radiotherapy setting. Nodal levels requiring elective treatment are defined for inclusion in the prophylactic CTV. Optimising patient selection for post-operative treatment is discussed as well as areas of controversy, relating to the dose prescription and extent of nodal volumes to be included in the CTV. Finally, clinical trials exploring the prospect of adjuvant treatment de-intensification after transoral surgery for HPV-positive oropharyngeal cancer are outlined. The aim is to improve consensus amongst clinicians and contribute towards improving outcomes for surgically treated patients with HNSCC.
Margin Analysis: Squamous Cell Carcinoma of the Oral Cavity
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Adverse pathologic features in early oral squamous cell carcinoma and the role of postoperative radiotherapy—a review
2017, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
The use of postoperative radiotherapy (PORT) in early stage oral cancer with adverse pathologic features (APFs) is controversial. Prognostically relevant APFs reviewed were perineural invasion, lymphovascular invasion, depth of invasion, worst pattern of invasion, and margin status. The current literature remains divided with regard to the benefit of treatment escalation in these patients; although these patients are at high risk for recurrence, the morbidity of PORT needs to be balanced against the likely benefit in disease control. A wide heterogeneity in the literature exists, likely as a result of differences in treatment protocols. We performed a literature review of the role of PORT in early-stage oral cancer with APFs. Based on the current evidence, the decision to administer adjuvant therapy needs to be made on an individual basis; patients with >1 APF are likely to benefit from PORT, and the use of risk-scoring systems may help in decision making.
Intraoperative gross examination vs frozen section for achievement of adequate margin in oral cancer surgery
2017, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Surgical margin status is an important prognostic factor in oral squamous cell carcinoma. The primary aim of the surgeon is to achieve a microscopically complete surgical resection during initial surgery. As there are no definite guidelines, a few surgeons use frozen section (FS) for margin assessment whereas others use gross examination (GE).
This is a retrospective analysis of prospectively collected data from the electronic medical records of 435 oral cavity cancer patients. As per the operating surgeon's preference, margin assessment was done using GE in 239 (54.94%) specimens, and FS was used in 196 (45.05%) specimens. Surgery was the primary modality of treatment for all patients, followed by adjuvant therapy.
Close/positive margins were seen in 6.63% of patients in the FS group and in 6.69% of patients in the GE group (P = .855). The sensitivity and specificity were 45.45% and 98.8%, respectively, for FS and 61.9% and 88.32% for GE. We found no survival benefit when FS was used for margin assessment (disease-free survival: P = .469; overall survival: 0.325). Incidence of inadequate margins was similar in both the groups (P = .608) even in patients with some form of previous treatment.
We propose the judicious use of FS rather than routine use for margin assessment. The study reports that GE is an well-tolerated oncologic alternative to FS.

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^☆: This paper was presented to the American Society of Therapeutic Radiology and Oncology on October 3, 1985 in Miami, Florida.

^∗: Department of Radiation Medicine

^†: Department of Biomathematics

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Original contributionThe clinical significance of pathological findings in surgically resected margins of the primary tumor in head and neck carcinoma☆

Abstract

Manual for Staging of Cancer

The significance of positive margins in hemilaryngectomy

Laryngoscopy

Regression models and life-tables

J. Royal Stat. Soc. B.

Original contribution
The clinical significance of pathological findings in surgically resected margins of the primary tumor in head and neck carcinoma☆