Combined Plastic Surgery Combined Plastic Surgery ENT CasesENT Cases
Audit of Pathology Audit of Pathology UpdateUpdate
18 December 200418 December 2004
Harry PowellHarry PowellMichael BeckettMichael Beckett
David OliverDavid Oliver
The cure of head and neck SCC depends The cure of head and neck SCC depends to a great degree on the adequacy of to a great degree on the adequacy of excisionexcision
Tumour recurrences are likely if the Tumour recurrences are likely if the surgical margins are positive, within 5mm surgical margins are positive, within 5mm or contain premalignant changes.or contain premalignant changes.
The positive margin has considerable The positive margin has considerable impact.impact.
2 out of 31 patients with +ve margins in a series of 349 2 out of 31 patients with +ve margins in a series of 349 patients were alive without recurrence at 3 yearspatients were alive without recurrence at 3 years
Zieske LA et al: Squamous cell carcinoma with positive margins. Zieske LA et al: Squamous cell carcinoma with positive margins. Surgery and post operative radiation. Surgery and post operative radiation. Arch Otolaryngol Head Neck Arch Otolaryngol Head Neck Surg 112:863, 1986.Surg 112:863, 1986.
73% recurrence rate when margins +ve vs 39% when –73% recurrence rate when margins +ve vs 39% when –ve marginsve margins
Vikram B et al: Failure at the primary site following multimodality Vikram B et al: Failure at the primary site following multimodality treatment in advanced head and neck cancer. treatment in advanced head and neck cancer. Head Neck Surg Head Neck Surg 6:720, 1984.6:720, 1984.
The recommended margin of excision for Oral The recommended margin of excision for Oral Cavity and Oropharyngeal Squamous Cell Cavity and Oropharyngeal Squamous Cell Carcinoma is 2cmCarcinoma is 2cm
In order to obtain a 5mm pathologic margin an In order to obtain a 5mm pathologic margin an insitu margin of 8-10mm is required.insitu margin of 8-10mm is required.
Stage I > 80% cure Stage I > 80% cure Stage II > 60% cureStage II > 60% cureStage III or IV <30% cureStage III or IV <30% cureCervical Nodes decrease survival by 50%Cervical Nodes decrease survival by 50%
RadiotherapyRadiotherapy
For small tumour has survival rates equal to For small tumour has survival rates equal to surgery (stage I)surgery (stage I)
Indications at SCGHIndications at SCGH
Positive or close (<5mm) marginsPositive or close (<5mm) margins Large (T3/T4) tumoursLarge (T3/T4) tumours Nodes >1cmNodes >1cm Extracapsular involvementExtracapsular involvement Invasion of lymphatic, vascular, perineural tissueInvasion of lymphatic, vascular, perineural tissue
Update January 2004Update January 2004to December 2004to December 2004
10 patients10 patients
Combined ENT casesCombined ENT cases
09.01.0409.01.04
Daniel WrightDaniel Wright
Mitchell/AllenMitchell/Allen
SCC T2 N0SCC T2 N0
Stage IIStage II
Left floor Left floor mouthmouth
16 x 8mm16 x 8mm
3mm deep3mm deep
Left WLELeft WLE
Left I to III Left I to III
Neck dissectionNeck dissection
Submental A. Submental A. island flapisland flap
DxTDxT
Complete ExcisionComplete Excision
0/16 nodes –ve0/16 nodes –ve
0/3 –ve Sub Mand0/3 –ve Sub Mand
Specimen 45 x 25x 6Specimen 45 x 25x 6
Complete ExcisionComplete Excision
Frozen Frozen sectionsection
-ve-ve
30.01.0430.01.04
Donald JohnstonDonald Johnston
Mitchell/AllenMitchell/Allen
SCCSCC
Left pre-Left pre-auricularauricular
Submental A. Submental A. island flapisland flap
Sup Sup parotidectomyparotidectomy
Neck dissectionNeck dissection
DxTDxT
5mm deep, 8mm 5mm deep, 8mm radial 0/12 LNradial 0/12 LN
11.10.04 ?scc rec11.10.04 ?scc rec
10.12.04 resection10.12.04 resection
Invasive SCC pre-Invasive SCC pre-auricularauricular
Complete ExcisionComplete Excision
Frozen Frozen sectionsection
-ve-ve
11.02.0411.02.04
Waclaw Waclaw NachowiczNachowicz
Grey/BriggsGrey/Briggs
Basi-Basi-squamous Casquamous Ca
Previously Previously incomplete incomplete BCC earBCC ear
Temporal boneTemporal bone
Sup Sup parotidectomyparotidectomy
Selective Neck Selective Neck dissectiondissection
P major flapP major flap
DxT refusedDxT refused
? Clear new margins? Clear new margins
?Complete?Complete
Frozen Frozen SectionSection
Perineural Perineural involvementinvolvement
22.03.0422.03.04
Ed OszinskiEd Oszinski
Bond/copperBond/copper
TonsillarTonsillar
SCCSCC
SclerodermaScleroderma
Oropharyngeal, Oropharyngeal, nasopharyngeal nasopharyngeal resectionresection
Midline Midline mandibulotomymandibulotomy
P. Major Flap P. Major Flap Partail flap Partail flap necrosis necrosis
SSG neckSSG neck
No DXTNo DXT
CarcinosarcomaCarcinosarcoma
Deep basaloid Deep basaloid squamous cellsquamous cell
Deep +ve, second Deep +ve, second deeper specimen –vedeeper specimen –ve
Mucosal margins Mucosal margins clear clear
Incomplete ExcisionIncomplete Excision
Frozen Frozen Section Section
+ve deep +ve deep marginmargin
15.04.0415.04.04
Peter SmithPeter Smith
Mitchell/AllenMitchell/Allen
Recurrent Recurrent tumourtumour
High grade 2002High grade 2002
DxT DxT
Cavernous sinus Cavernous sinus involvementinvolvement
Adenoid cystic Adenoid cystic MaxillaMaxilla
L inferior L inferior extended extended maxillectomymaxillectomy
Free RFFFree RFF
+ve post and Lateral+ve post and Lateral
Soft pallateSoft pallate
Infra-temporal fossaInfra-temporal fossa
?palliative surgery?palliative surgery
Incomplete ExcisionIncomplete Excision
02.07.0402.07.04
Wayne Wayne GreenhalghGreenhalgh
Mitchell/AllenMitchell/Allen
SCC Floor of SCC Floor of mouthmouth
T4 N1 M0T4 N1 M0
Stage IVAStage IVA
Resection FOM, Resection FOM, Marginal Marginal mandibulectomymandibulectomyL Neck L Neck dissectiondissection
Free RFFFree RFF
DXTDXT
Poorly diff SCCPoorly diff SCC
Deep 7mm clearDeep 7mm clear
Floor <0.5Floor <0.5
Others 5mmOthers 5mm
Neck 1/29 +ve Level IINeck 1/29 +ve Level II
Incomplete ExcisionIncomplete Excision
Frozen Frozen SectionsSections
-ve-ve
False NegFalse Neg
Dominico Dominico TropianoTropiano
Right Right maxillary maxillary sinus SCCsinus SCC
T4 N2T4 N2
Right superficial Right superficial parotidectomy, parotidectomy, neck dissection, neck dissection, right radical right radical maxillectomy maxillectomy and orbital and orbital exenterationexenteration
Ref DxTRef DxT
Incomplete margins:Incomplete margins:
Posterior margin of Posterior margin of maxilla/orbital maxilla/orbital specimenspecimen
+ve LN+ve LN
Levels I – VLevels I – V
Incomplete ExcisionIncomplete Excision
22.10.0422.10.04
Rebecca Rebecca FernandezFernandez
Mitchell/AllenMitchell/Allen
SCC TongueSCC Tongue
T4 N2T4 N2
Stage IVAStage IVA
Total Total glossectomyglossectomy
R mod radicalR mod radical
L selective neckL selective neck
Free Rectus Free Rectus myocutaneous myocutaneous flapflap
Chemo / DxTChemo / DxT
Mod Diff SCCMod Diff SCC
Clear margins Clear margins
15mm lat15mm lat
30mm tongue base30mm tongue base
+ve LN+ve LN
Level I, III and IVLevel I, III and IV
Complete ExcisionComplete Excision
Frozen Frozen SectionsSections
-ve-ve
Eric KayEric Kay
05.11.0405.11.04
Mitchell/AllenMitchell/Allen
Adenoid Adenoid Cystic CaCystic Ca
T2 N0 M0T2 N0 M0
Partial resection Partial resection of maxilla, of maxilla, orbital floor. Full orbital floor. Full dental clearancedental clearance
Free RFFFree RFF
Pending Pending oncologyoncology
Incomplete margins:Incomplete margins:
Right posterior Right posterior ethmoid ethmoid
lateral nasal walllateral nasal wall
Incomplete ExcisionIncomplete Excision
Frozen Frozen Section Section
-ve-ve
Earl BoxallEarl Boxall
22.11.0422.11.04
Bond/CopperBond/Copper
SCCSCC
Floor mouthFloor mouth
25 x 28 x 25 x 28 x 10mm10mm
Dental Dental clearanceclearance
WLEWLE
Bilateral Level IBilateral Level I
Pending further Pending further surgerysurgery
Incomplete margins:Incomplete margins:
Ventral tongue Ventral tongue mucosa and adjacent mucosa and adjacent musclemuscle
Gingival mucosaGingival mucosa
Sublingual gland Sublingual gland aspectaspect
Perineural invasionPerineural invasion
Incomplete ExcisionIncomplete Excision
SummarySummary
10 combined oncology cases10 combined oncology cases3 completely excised3 completely excised
7 had inadequate margins7 had inadequate margins 1 case palliative1 case palliative Orientation one specimenOrientation one specimen
Margins involved Margins involved 77Re-excision Re-excision 11Frozen Section Frozen Section 7 (2 +ve 1 False Neg)7 (2 +ve 1 False Neg)
Previous Data (TH)Previous Data (TH)
1 year combined ENT Plastic Surgery Cases 1 year combined ENT Plastic Surgery Cases
(1(1stst October 2002 to 1 October 2002 to 1stst October 2003) October 2003)
11 cases11 cases
8 Nov 20028 Nov 2002
Mitchell/Allen Mitchell/Allen Aubrey SPEEDYAubrey SPEEDY
SCC PalateSCC Palate Full thickness soft Full thickness soft palate and partial palate and partial pharyngeal wall, pharyngeal wall, neck dissection, neck dissection, radial forearm flap.radial forearm flap.
To deep margin To deep margin along 1mmalong 1mm
Frozen Frozen section section
22 Feb 2003 22 Feb 2003 Mitchell/Allen Mitchell/Allen David ROBINSDavid ROBINS
SCC SCC Retromolar Retromolar trigonetrigone
Wide local excision, Wide local excision, neck dissection, neck dissection, radial forearm flap.radial forearm flap.
To deep resection To deep resection margin in two margin in two areas over a front areas over a front of 7mmof 7mm
No Frozen No Frozen sectionsection
4 Apr 20034 Apr 2003
Mitchell/AllenMitchell/Allen
William GEORGEWilliam GEORGE
Left retromolar Left retromolar SCCSCC
Excision floor of Excision floor of mouth, neck mouth, neck dissection, free dissection, free fibula flap.fibula flap.
Antero-medial Antero-medial margin involved. margin involved. Perineural and Perineural and vascular vascular involvement. 3 neck involvement. 3 neck nodesnodes
Frozen Frozen sectionsection
6 Jun 20036 Jun 2003
Mitchell/AllenMitchell/Allen
David David CRAWFORDCRAWFORD
SCC Floor of SCC Floor of mouthmouth
Floor of mouth Floor of mouth excision, excision, glossectomy, glossectomy, radical neck radical neck dissection, free dissection, free fibula flap.fibula flap.
Resection margins Resection margins clear, tumour clear, tumour involving medullary involving medullary cavity of bone and cavity of bone and nerve labelled base nerve labelled base of skull (incomplete)of skull (incomplete)
Frozen Frozen sectionsection
18 Jun 200318 Jun 2003
Grey/BriggsGrey/Briggs
Maria VAN DE Maria VAN DE VLAGVLAG
Parotid Parotid CarcinomaCarcinoma
Pectoralis Major Pectoralis Major flap and sural flap and sural nerve grafts.nerve grafts.
Salivary duct Salivary duct carcinoma extending carcinoma extending to deep and superior to deep and superior parotid margin over a parotid margin over a broad front. broad front. Perineural, lymphatic Perineural, lymphatic invasion. 6 nodes.invasion. 6 nodes.
Frozen Frozen sectionsection
21 Jul 200321 Jul 2003
Bond/CooperBond/Cooper
William William DELLAVANZODELLAVANZO
Right Right mandibular mandibular SCCSCC
Right Right hemimandibulechemimandibulectomy, neck tomy, neck dissection, dissection, pectoralis major pectoralis major flap.flap.
Resection margins Resection margins clear (close at clear (close at 1.5mm) 1.5mm) 9 nodes, 9 nodes, vascular and lymphatic vascular and lymphatic invasioninvasion
No frozen No frozen sectionsection
1 Aug 20031 Aug 2003
Mitchell/AllenMitchell/Allen
Leonard DUNNERLeonard DUNNER
SCC SCC preauricular preauricular skinskin
Hemiauriculectomy, Hemiauriculectomy, parotidectomy, parotidectomy, neck dissection, neck dissection, rectus abdominus rectus abdominus flap.flap.
Involved deep, Involved deep, anterior anterior margin, margin, sternomastoid sternomastoid and parotid. and parotid. 1 1 lymph nodelymph node
Frozen Frozen sectionsection
18 Aug 200318 Aug 2003
Bond/CooperBond/Cooper
Raymond BEARDRaymond BEARD
Melanoma Melanoma left upper left upper incisorincisor
Alveolus and hard Alveolus and hard palate resection, palate resection, radial forearm flap radial forearm flap with bone.with bone.
Resection Resection margins clear. margins clear. Minimum Minimum invasive invasive margin 3mm, margin 3mm, insitu 0.5mminsitu 0.5mm
No frozen No frozen section section
Re-Re-excsion excsion performed performed at one at one month (1.8 month (1.8 by 1.5cm)by 1.5cm)
12 Sept 200312 Sept 2003
Mitchell/AllenMitchell/Allen
Claire EVANSClaire EVANS
Verrucous Verrucous carcinoma carcinoma left mouthleft mouth
Excision floor of Excision floor of mouth tumour, mouth tumour, neck dissection neck dissection radial forearm flapradial forearm flap
Verrucous and Verrucous and invasive SCC. invasive SCC. Invasive SCC Invasive SCC 3mm from 3mm from margin margin
Frozen Frozen sectionsection
23 Sept 200323 Sept 2003
Bond/CooperBond/Cooper
Estelle POLLOCKEstelle POLLOCK
Left Neck SCCLeft Neck SCC Excision of Excision of tumour and tumour and deltopectoral deltopectoral flapflap
Present at deep Present at deep resection resection margins, less margins, less than 1mm from than 1mm from superior margin superior margin 1 lymph node 1 lymph node and and lymphovascular lymphovascular invasioninvasion
No frozen No frozen sectionsection
Non – Oncological Combined Non – Oncological Combined CaseCase
1 Mar 2003 1 Mar 2003
Mitchell/AllenMitchell/Allen
Robert Robert HUGHESHUGHES
Osteoradionecrosis Osteoradionecrosis of the mandibleof the mandible
Excision of Excision of osteoradionecrosis osteoradionecrosis and free fibula flapand free fibula flap
OsteradionecrosisOsteradionecrosis
10 combined oncology cases.10 combined oncology cases.
All had inadequate marginsAll had inadequate margins
Margins involved Margins involved 77
Close Close 3 (1.5mm, 3mm, 0.5mm)3 (1.5mm, 3mm, 0.5mm)
Re-excision Re-excision 11
Frozen Section Frozen Section 55
Difficult tumoursDifficult tumours
Frozen sections (70%)Frozen sections (70%)
Attention to resection marginsAttention to resection margins
Role of Radiotherapy (all referred)Role of Radiotherapy (all referred) 1 refused1 refused 11 scleroderma contra-indicated scleroderma contra-indicated 1 pending further surgery1 pending further surgery 1 still in -patient1 still in -patient 1 palliative previous DxT1 palliative previous DxT
Postoperative chemoradiotherapy for high-risk head-Postoperative chemoradiotherapy for high-risk head-and-neck SCC and-neck SCC
Peter MacCallum Centre Int J Radiat Oncol Biol Phys. 2004Peter MacCallum Centre Int J Radiat Oncol Biol Phys. 2004
July 1999 and January 2003 47. July 1999 and January 2003 47. 47 patients, 41 (87%) had Stage III-IV disease. oral 47 patients, 41 (87%) had Stage III-IV disease. oral cavity in 51%cavity in 51%27 had nodal disease with extracapsular extension 27 had nodal disease with extracapsular extension 26 had positive or close mucosal margins (<5 mm).26 had positive or close mucosal margins (<5 mm). 10 had undergone resection of recurrent disease after 10 had undergone resection of recurrent disease after previous surgery. previous surgery. The estimated 2-year The estimated 2-year
locoregional control 56%,locoregional control 56%, progression-free survival 62%progression-free survival 62% overall survival rate was 73%, overall survival rate was 73%,
Do frozen sections help achieve adequate Do frozen sections help achieve adequate
surgical margins in the resection of oral arcinoma?surgical margins in the resection of oral arcinoma?
Int J Oral Maxillofac Surg. 2003; Manchester, UKInt J Oral Maxillofac Surg. 2003; Manchester, UK
82 patients who underwent resection oro-82 patients who underwent resection oro-pharyngeal carcinoma and had frozen section pharyngeal carcinoma and had frozen section
Concordance between cryostat and paraffin Concordance between cryostat and paraffin sections was 99.5% sections was 99.5%
10 of the 12 patients with margins containing 10 of the 12 patients with margins containing invasive tumour had negative cryostat sections invasive tumour had negative cryostat sections intra-operatively, which demonstrated problems intra-operatively, which demonstrated problems with sampling which is the major drawback.with sampling which is the major drawback.
Relevance of positive margins in case of adjuvant Relevance of positive margins in case of adjuvant therapy of oral Cancer.therapy of oral Cancer.
Kovacs AF Int J Oral Maxillofac Surg. 2004. Frankfurt.Kovacs AF Int J Oral Maxillofac Surg. 2004. Frankfurt.
Positive or clean surgical margins are of great prognostic Positive or clean surgical margins are of great prognostic interest in the surgical treatment of oral and interest in the surgical treatment of oral and oropharyngeal cancer with poor survival of patients oropharyngeal cancer with poor survival of patients burdened with positive margins. burdened with positive margins. A second resection in patients with positive margins, A second resection in patients with positive margins, executed in the group with postoperative radiation with executed in the group with postoperative radiation with concurrent chemotherapy, did not result in survival concurrent chemotherapy, did not result in survival improvement. improvement. Therefore, radical resection at initial surgery in healthy Therefore, radical resection at initial surgery in healthy and clear margins remains indispensable in multi-and clear margins remains indispensable in multi-modality treatment strategies modality treatment strategies