Specimen‐driven intraoperative assessment of resection margins should be standard of care for oral cancer patients

Aaboubout, Yassine; Hove, Ivo ten; Smits, Roeland W.H.; Hardillo, José A.; Puppels, Gerwin J.; Koljenović, Senada

doi:10.1111/odi.13619

Cited by 35 publications

(39 citation statements)

References 36 publications

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“…Moreover, for the old cohort the reliable data for LVI, PNI, tumor diameter and margin status were missing and therefore not further analyzed and compared with the newer cohort. Finally, the patient outcome (locoregional recurrence and survival) in the previously published study may be influenced by the fact that our institute started with intra-operative assessment of resection margins in 2013 (22,37,38).…”

Section: Discussionmentioning

confidence: 99%

Is the Depth of Invasion a Marker for Elective Neck Dissection in Early Oral Squamous Cell Carcinoma?

et al. 2021

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ObjectiveThe depth of invasion (DOI) is considered an independent risk factor for occult lymph node metastasis in oral cavity squamous cell carcinoma (OCSCC). It is used to decide whether an elective neck dissection (END) is indicated in the case of a clinically negative neck for early stage carcinoma (pT1/pT2). However, there is no consensus on the cut-off value of the DOI for performing an END. The aim of this study was to determine a cut-off value for clinical decision making on END, by assessing the association of the DOI and the risk of occult lymph node metastasis in early OCSCC.MethodsA retrospective cohort study was conducted at the Erasmus MC, University Medical Centre Rotterdam, The Netherlands. Patients surgically treated for pT1/pT2 OCSCC between 2006 and 2012 were included. For all cases, the DOI was measured according to the 8th edition of the American Joint Committee on Cancer guideline. Patient characteristics, tumor characteristics (pTN, differentiation grade, perineural invasion, and lymphovascular invasion), treatment modality (END or watchful waiting), and 5-year follow-up (local recurrence, regional recurrence, and distant metastasis) were obtained from patient files.ResultsA total of 222 patients were included, 117 pT1 and 105 pT2. Occult lymph node metastasis was found in 39 of the 166 patients who received END. Univariate logistic regression analysis showed DOI to be a significant predictor for occult lymph node metastasis (odds ratio (OR) = 1.3 per mm DOI; 95% CI: 1.1–1.5, p = 0.001). At a DOI of 4.3 mm the risk of occult lymph node metastasis was >20% (all subsites combined).ConclusionThe DOI is a significant predictor for occult lymph node metastasis in early stage oral carcinoma. A NPV of 81% was found at a DOI cut-off value of 4 mm. Therefore, an END should be performed if the DOI is >4 mm.

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Section: Discussionmentioning

confidence: 99%

Is the Depth of Invasion a Marker for Elective Neck Dissection in Early Oral Squamous Cell Carcinoma?

et al. 2021

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“…This will continue to stand in the way of IOARM widespread adoption, despite the significant improvement in OCSCC resection results, unless standard protocols and educational programs exist. At our institute we have a comprehensive IOARM protocol including a relocation protocol (6,40). The development of objective technology is needed to address these practical hurdles and key to facilitating specimen-driven IOARM in OCSCC.…”

Section: Discussionmentioning

confidence: 99%

“…The goal of surgery is the complete resection of the tumor with an adequate resection margin (i.e., the shortest distance between the tumor border and the resection surface is > 5 mm) while preserving as much healthy tissue as possible to minimize the loss of function (such as, mastication and swallowing) and facial disfigurement. The resection margin is an important predictor for patient outcome and is the only oncological prognostic factor that pathologists and surgeons can influence (5)(6)(7).…”

Section: Introductionmentioning

confidence: 99%

Performance of Intraoperative Assessment of Resection Margins in Oral Cancer Surgery: A Review of Literature

et al. 2021

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IntroductionAchieving adequate resection margins during oral cancer surgery is important to improve patient prognosis. Surgeons have the delicate task of achieving an adequate resection and safeguarding satisfactory remaining function and acceptable physical appearance, while relying on visual inspection, palpation, and preoperative imaging. Intraoperative assessment of resection margins (IOARM) is a multidisciplinary effort, which can guide towards adequate resections. Different forms of IOARM are currently used, but it is unknown how accurate these methods are in predicting margin status. Therefore, this review aims to investigate: 1) the IOARM methods currently used during oral cancer surgery, 2) their performance, and 3) their clinical relevance.MethodsA literature search was performed in the following databases: Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar (from inception to January 23, 2020). IOARM performance was assessed in terms of accuracy, sensitivity, and specificity in predicting margin status, and the reduction of inadequate margins. Clinical relevance (i.e., overall survival, local recurrence, regional recurrence, local recurrence-free survival, disease-specific survival, adjuvant therapy) was recorded if available.ResultsEighteen studies were included in the review, of which 10 for soft tissue and 8 for bone. For soft tissue, defect-driven IOARM-studies showed the average accuracy, sensitivity, and specificity of 90.9%, 47.6%, and 84.4%, and specimen-driven IOARM-studies showed, 91.5%, 68.4%, and 96.7%, respectively. For bone, specimen-driven IOARM-studies performed better than defect-driven, with an average accuracy, sensitivity, and specificity of 96.6%, 81.8%, and 98%, respectively. For both, soft tissue and bone, IOARM positively impacts patient outcome.ConclusionIOARM improves margin-status, especially the specimen-driven IOARM has higher performance compared to defect-driven IOARM. However, this conclusion is limited by the low number of studies reporting performance results for defect-driven IOARM. The current methods suffer from inherent disadvantages, namely their subjective character and the fact that only a small part of the resection surface can be assessed in a short time span, causing sampling errors. Therefore, a solution should be sought in the field of objective techniques that can rapidly assess the whole resection surface.

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“…The current issue of Oral Diseases contains contributions that address some of the challenges in Head & Neck Oncology. One of the issues under debate is the necessity of a 5 mm width of the surgical margin (Aaboubout et al., 2020). It is clear that local control is best achieved when at least a margin of 5mm is obtained.…”

Section: Figurementioning

confidence: 99%

Cooperation as core value in an innovative era

Witjes

Vissink

2020

Oral Diseases

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Cooperation as core value in an innovative era Diagnosis, treatment, and rehabilitation of patients suffering from oral cancer are shared responsibilities of primary care givers like dentists, physicians and oral medicine specialists, and intramural secondary care specialties. Because of the complex nature of treatment and the necessity of long-term care in most patients, the treatment and follow-up of head and neck cancer patients are confined to centers with dedicated teams in most countries. Early referral of patients suspected for oral cancer is considered important because survival is related to tumor stage and primary care givers play a pivotal role in that respect (Grafton-Clarke et al., 2019). Where health care is organized with possibilities of a quick and easy referral, the risk of delayed referral is greatly reduced. dental rehabilitation after oncological surgery. Several practical issues remain to be resolved, however, such as the timing of placement of dental implants as well as the placement of dental implants in free flaps. Like for surgical planning, planning of an oral rehabilitation is supported by 3D technology. This technology supports precise placement of implants and design of prosthetic devices. Notwithstanding the long experience with dental implants, new ideas based on implant technology still emerge and become implemented in clinical practice. The application of zygoma implants after maxillectomy in combination with soft tissue flaps is an example of a creative idea finding its way into the clinic (Hackett et al., 2020). Treatment of cancer in the head and neck area is commonly accompanied by damage to the salivary glands (Barazzuol et al., 2020; Vissink et al., 2015). Damage to the salivary glands is unavoidable as the salivary glands are located superficially and the ionizing radiation has to pass salivary gland tissue to reach the tumor. While there is many approach to minimize this radiation damage to salivary gland tissue, there is yet no satisfactory therapy to treat radiation-induced salivary gland damage. A feasible option might be harvesting salivary gland tissue during, for example, a head and neck dissection procedure, isolate and proliferate stem cells from this tissue and return these stem cells to the salivary glands that are damaged by the postoperative radiotherapy. Such stem cell therapy is an attractive option for the long-term treatment of hyposalivation related xerostomia induced by irradiation, but is in need of further study in animals and preliminary studies in human before it can evolve into a clinically applicable method. Future studies should also focus on a better understanding of the radiosensitivity of parotid and submandibular salivary gland tissue (Serrano Martinez et al., 2020). All these developments show the benefits for patients of a good cooperation between primary and secondary caregivers. The good cooperation also demonstrates what can be achieved if efforts are focused and put into practice.

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Specimen‐driven intraoperative assessment of resection margins should be standard of care for oral cancer patients

Cited by 35 publications

References 36 publications

Is the Depth of Invasion a Marker for Elective Neck Dissection in Early Oral Squamous Cell Carcinoma?

Is the Depth of Invasion a Marker for Elective Neck Dissection in Early Oral Squamous Cell Carcinoma?

Performance of Intraoperative Assessment of Resection Margins in Oral Cancer Surgery: A Review of Literature

Cooperation as core value in an innovative era

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