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Combined Plastic Surgery ENT Cases

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1 Combined Plastic Surgery ENT Cases
Audit of Pathology Update 18 December 2004 Harry Powell Michael Beckett David Oliver

2 The cure of head and neck SCC depends to a great degree on the adequacy of excision
Tumour recurrences are likely if the surgical margins are positive, within 5mm or contain premalignant changes. The positive margin has considerable impact.

3 73% recurrence rate when margins +ve vs 39% when –ve margins
2 out of 31 patients with +ve margins in a series of 349 patients were alive without recurrence at 3 years Zieske LA et al: Squamous cell carcinoma with positive margins. Surgery and post operative radiation. Arch Otolaryngol Head Neck Surg 112:863, 1986. 73% recurrence rate when margins +ve vs 39% when –ve margins Vikram B et al: Failure at the primary site following multimodality treatment in advanced head and neck cancer. Head Neck Surg 6:720, 1984.

4 The recommended margin of excision for Oral Cavity and Oropharyngeal Squamous Cell Carcinoma is 2cm
In order to obtain a 5mm pathologic margin an insitu margin of 8-10mm is required. Stage I > 80% cure Stage II > 60% cure Stage III or IV <30% cure Cervical Nodes decrease survival by 50%

5 Radiotherapy For small tumour has survival rates equal to surgery (stage I) Indications at SCGH Positive or close (<5mm) margins Large (T3/T4) tumours Nodes >1cm Extracapsular involvement Invasion of lymphatic, vascular, perineural tissue

6 Update January 2004 to December 2004
10 patients Combined ENT cases

7 Daniel Wright Mitchell/Allen SCC T2 N0 Stage II Left floor mouth 16 x 8mm 3mm deep Left WLE Left I to III Neck dissection Submental A. island flap DxT Complete Excision 0/16 nodes –ve 0/3 –ve Sub Mand Specimen 45 x 25x 6 Frozen section -ve Donald Johnston SCC Left pre-auricular Sup parotidectomy 5mm deep, 8mm radial 0/12 LN ?scc rec resection Invasive SCC pre-auricular Waclaw Nachowicz Grey/Briggs Basi-squamous Ca Previously incomplete BCC ear Temporal bone Sup parotidectomy Selective Neck dissection P major flap DxT refused ? Clear new margins ?Complete Frozen Section Perineural involvement

8 Ed Oszinski Bond/copper Tonsillar SCC Scleroderma Oropharyngeal, nasopharyngeal resection Midline mandibulotomy P. Major Flap Partail flap necrosis SSG neck No DXT Carcinosarcoma Deep basaloid squamous cell Deep +ve, second deeper specimen –ve Mucosal margins clear Incomplete Excision Frozen Section +ve deep margin Peter Smith Mitchell/Allen Recurrent tumour High grade 2002 DxT Cavernous sinus involvement Adenoid cystic Maxilla L inferior extended maxillectomy Free RFF +ve post and Lateral Soft pallate Infra-temporal fossa ?palliative surgery

9 Wayne Greenhalgh Mitchell/Allen SCC Floor of mouth T4 N1 M0 Stage IVA Resection FOM, Marginal mandibulectomyL Neck dissection Free RFF DXT Poorly diff SCC Deep 7mm clear Floor <0.5 Others 5mm Neck 1/29 +ve Level II Incomplete Excision Frozen Sections -ve False Neg Dominico Tropiano Right maxillary sinus SCC T4 N2 Right superficial parotidectomy, neck dissection, right radical maxillectomy and orbital exenteration Ref DxT Incomplete margins: Posterior margin of maxilla/orbital specimen +ve LN Levels I – V Rebecca Fernandez SCC Tongue Total glossectomy R mod radical L selective neck Free Rectus myocutaneous flap Chemo / DxT Mod Diff SCC Clear margins 15mm lat 30mm tongue base Level I, III and IV Complete Excision

10 Eric Kay Mitchell/Allen Adenoid Cystic Ca T2 N0 M0 Partial resection of maxilla, orbital floor. Full dental clearance Free RFF Pending oncology Incomplete margins: Right posterior ethmoid lateral nasal wall Incomplete Excision Frozen Section -ve Earl Boxall Bond/Copper SCC Floor mouth 25 x 28 x 10mm Dental clearance WLE Bilateral Level I Pending further surgery Ventral tongue mucosa and adjacent muscle Gingival mucosa Sublingual gland aspect Perineural invasion

11 Summary 10 combined oncology cases 3 completely excised
7 had inadequate margins 1 case palliative Orientation one specimen Margins involved 7 Re-excision 1 Frozen Section 7 (2 +ve 1 False Neg)

12 Previous Data (TH)

13 1 year combined ENT Plastic Surgery Cases
(1st October 2002 to 1st October 2003) 11 cases

14 8 Nov 2002 Mitchell/Allen Aubrey SPEEDY SCC Palate Full thickness soft palate and partial pharyngeal wall, neck dissection, radial forearm flap. To deep margin along 1mm Frozen section 22 Feb Mitchell/Allen David ROBINS SCC Retromolar trigone Wide local excision, neck dissection, radial forearm flap. To deep resection margin in two areas over a front of 7mm No Frozen section 4 Apr 2003 Mitchell/Allen William GEORGE Left retromolar SCC Excision floor of mouth, neck dissection, free fibula flap. Antero-medial margin involved. Perineural and vascular involvement. 3 neck nodes

15 6 Jun 2003 Mitchell/Allen David CRAWFORD SCC Floor of mouth Floor of mouth excision, glossectomy, radical neck dissection, free fibula flap. Resection margins clear, tumour involving medullary cavity of bone and nerve labelled base of skull (incomplete) Frozen section 18 Jun 2003 Grey/Briggs Maria VAN DE VLAG Parotid Carcinoma Pectoralis Major flap and sural nerve grafts. Salivary duct carcinoma extending to deep and superior parotid margin over a broad front. Perineural, lymphatic invasion. 6 nodes. 21 Jul 2003 Bond/Cooper William DELLAVANZO Right mandibular SCC Right hemimandibulectomy, neck dissection, pectoralis major flap. Resection margins clear (close at 1.5mm) 9 nodes, vascular and lymphatic invasion No frozen section

16 1 Aug 2003 Mitchell/Allen Leonard DUNNER SCC preauricular skin Hemiauriculectomy, parotidectomy, neck dissection, rectus abdominus flap. Involved deep, anterior margin, sternomastoid and parotid. 1 lymph node Frozen section 18 Aug 2003 Bond/Cooper Raymond BEARD Melanoma left upper incisor Alveolus and hard palate resection, radial forearm flap with bone. Resection margins clear. Minimum invasive margin 3mm, insitu 0.5mm No frozen section Re-excsion performed at one month (1.8 by 1.5cm) 12 Sept 2003 Claire EVANS Verrucous carcinoma left mouth Excision floor of mouth tumour, neck dissection radial forearm flap Verrucous and invasive SCC. Invasive SCC 3mm from margin

17 23 Sept 2003 Bond/Cooper Estelle POLLOCK Left Neck SCC Excision of tumour and deltopectoral flap Present at deep resection margins, less than 1mm from superior margin lymph node and lymphovascular invasion No frozen section

18 Non – Oncological Combined Case
1 Mar 2003 Mitchell/Allen Robert HUGHES Osteoradionecrosis of the mandible Excision of osteoradionecrosis and free fibula flap Osteradionecrosis

19 10 combined oncology cases. All had inadequate margins
Margins involved 7 Close 3 (1.5mm, 3mm, 0.5mm) Re-excision 1 Frozen Section 5

20 Attention to resection margins Role of Radiotherapy (all referred)
Difficult tumours Frozen sections (70%) Attention to resection margins Role of Radiotherapy (all referred) 1 refused 1 scleroderma contra-indicated 1 pending further surgery 1 still in -patient 1 palliative previous DxT


22 Postoperative chemoradiotherapy for high-risk head-and-neck SCC Peter MacCallum Centre Int J Radiat Oncol Biol Phys. 2004 July 1999 and January 47 patients, 41 (87%) had Stage III-IV disease. oral cavity in 51% 27 had nodal disease with extracapsular extension 26 had positive or close mucosal margins (<5 mm). 10 had undergone resection of recurrent disease after previous surgery. The estimated 2-year locoregional control 56%, progression-free survival 62% overall survival rate was 73%,

23 Do frozen sections help achieve adequate surgical margins in the resection of oral arcinoma? Int J Oral Maxillofac Surg. 2003; Manchester, UK 82 patients who underwent resection oro-pharyngeal carcinoma and had frozen section Concordance between cryostat and paraffin sections was 99.5% 10 of the 12 patients with margins containing invasive tumour had negative cryostat sections intra-operatively, which demonstrated problems with sampling which is the major drawback.

24 Relevance of positive margins in case of adjuvant therapy of oral Cancer Kovacs AF Int J Oral Maxillofac Surg Frankfurt. Positive or clean surgical margins are of great prognostic interest in the surgical treatment of oral and oropharyngeal cancer with poor survival of patients burdened with positive margins. A second resection in patients with positive margins, executed in the group with postoperative radiation with concurrent chemotherapy, did not result in survival improvement. Therefore, radical resection at initial surgery in healthy and clear margins remains indispensable in multi-modality treatment strategies


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