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.

Surgical margins in head and neck cancer: A contemporary review

The primary treatment modality of oral cancer is generally determined according to the stage of the disease, with surgical treatment remaining the mainstay of multimodal treatment. When selecting the treatment, many factors are taken into consideration, and the treatment should be tailored individually to the patient’s needs and consider the quality of life as well as the survival of the patient. Early-stage disease is primarily managed with surgery or brachytherapy without functional morbidity, whereas for advanced-stage disease multidisciplinary treatment is recommended, not only for enhanced survival but also for improved quality of life. After resection of large primary tumors, reconstructive surgery is required. Free tissue transfer currently represents one of the most popular and reliable techniques for oral reconstruction. For cN0 neck, elective neck dissection is recommended when the risk of occult metastases is >20 %, when the neck is entered either for resection of the primary tumor or for reconstruction, or when the patient is unlikely to return for a close follow-up. Sentinel node biopsy is performed investigationally. Modified radical neck dissection is the gold standard for cN+ neck. For patients with multiple node metastases or extracapsular spread, postoperative radiotherapy or chemoradiotherapy is recommended, with the lymph nodes situated outside the confines of the radical neck dissection, such as the lingual and retropharyngeal nodes, receiving considerable attention. Targeted therapy for oral cancer is still a relatively new concept, and more studies are needed to confirm the clinical effectiveness of these drugs.

Current status of oral cancer treatment strategies: surgical treatments for oral squamous cell carcinoma

BACKGROUND.

The role of elective and therapeutic selective neck dissection in patients with early stage cancer of the oral tongue remains controversial. The purpose was to investigate the role of neck treatment in the management of this condition.



METHODS.

A total of 380 patients with cT1-2N0 oral tongue cancer were retrospectively reviewed. Patients were staged by means of computed tomography (CT) or magnetic resonance imaging (MRI) scans. A total of 324 patients received elective neck dissection (END), whereas 56 participants received observation (OBS). In all, 287 patients received supraomohyoid neck dissection (SOND), whereas 37 patients received modified radical neck dissection (MRND). Overall survival (OS) and neck control rates (NCR) were investigated according to the treatment modality.



RESULTS.

In the END group the occult metastasis (OM) rates in cervical lymph nodes were 5.2% for cT1 lesions and 14.6% for cT2 lesion (P = .005). The 5-year OS (P = .029) and NCR rates (P = .001) were significantly better in the END group compared with the OBS group. Patients who received MRND had a better 5-year NCR compared with SOND, albeit not significantly (91.4% vs 85.3%, P = .415). Multivariate analysis showed that END and stage were independent predictors of both NCR and OS.



CONCLUSIONS.

END should be performed routinely in patients with early-stage oral tongue cancer, even in the presence of negative neck by CT scans and MRI. Cancer 2008. © 2008 American Cancer Society

Neck Treatment of Patients With Early Stage Oral Tongue Cancer : Comparison Between Observation, Supraomohyoid Dissection, and Extended Dissection

A meta-analysis of margin size and local recurrence in oral squamous cell carcinoma.

Diagnostic accuracy of magnetic resonance imaging (MRI) in the assessment of tumor invasion depth in oral/oropharyngeal cancer

Background: The importance of tumor free margins in outcome of cancer surgery is well known. Often the pathological margins are reported to be significantly smaller than the in situ margins. This discrepancy is due to margin shrinkage the quantum of which has not been studied in patients with oral cancers. Objectives: To quantify the shrinkage of mucosal margin following excision for carcinoma of the oral tongue and buccal mucosa. Methods: Mucosal margins were measured prior to resection and half an hour after excision in 27 patients with carcinoma of the tongue and buccal mucosa. The mean margin shrinkage was assessed and the variables affecting the quantum of shrinkage analyzed. Results: The mean shrinkage from the in situ to the post resection margin status was 22.7% (P < 0.0001). The mean shrinkage of the tongue margins was 23.5%, compared to 21.2% for buccal mucosa margins. The mean shrinkage in T1/T2 tumors (25.6%) was significantly more than in T3/T4 (9.2%, P < 0.011). Conclusions: There is significant shrinkage of mucosal margins after surgery. Hence this should be considered and appropriate margins should be taken at initial resection to prevent the agony of post-operative positive surgical margins.

C. Kumaran

Papers

Post-resection mucosal margin shrinkage in oral cancer: quantification and significance.