Presentation on theme: "Combined Plastic Surgery ENT Cases"— Presentation transcript:
1Combined Plastic Surgery ENT Cases Audit of PathologyUpdate18 December 2004Harry PowellMichael BeckettDavid Oliver
2The 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.
373% 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 yearsZieske 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 marginsVikram B et al: Failure at the primary site following multimodality treatment in advanced head and neck cancer. Head Neck Surg 6:720, 1984.
4The 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% cureStage II > 60% cureStage III or IV <30% cureCervical Nodes decrease survival by 50%
5RadiotherapyFor small tumour has survival rates equal to surgery (stage I)Indications at SCGHPositive or close (<5mm) marginsLarge (T3/T4) tumoursNodes >1cmExtracapsular involvementInvasion of lymphatic, vascular, perineural tissue
6Update January 2004 to December 2004 10 patientsCombined ENT cases
7Daniel WrightMitchell/AllenSCC T2 N0Stage IILeft floor mouth16 x 8mm3mm deepLeft WLELeft I to IIINeck dissectionSubmental A. island flapDxTComplete Excision0/16 nodes –ve0/3 –ve Sub MandSpecimen 45 x 25x 6Frozen section-veDonald JohnstonSCCLeft pre-auricularSup parotidectomy5mm deep, 8mm radial 0/12 LN?scc recresectionInvasive SCC pre-auricularWaclaw NachowiczGrey/BriggsBasi-squamous CaPreviously incomplete BCC earTemporal boneSup parotidectomySelective Neck dissectionP major flapDxT refused? Clear new margins?CompleteFrozen SectionPerineural involvement
8Ed OszinskiBond/copperTonsillarSCCSclerodermaOropharyngeal, nasopharyngeal resectionMidline mandibulotomyP. Major Flap Partail flap necrosisSSG neckNo DXTCarcinosarcomaDeep basaloid squamous cellDeep +ve, second deeper specimen –veMucosal margins clearIncomplete ExcisionFrozen Section+ve deep marginPeter SmithMitchell/AllenRecurrent tumourHigh grade 2002DxTCavernous sinus involvementAdenoid cystic MaxillaL inferior extended maxillectomyFree RFF+ve post and LateralSoft pallateInfra-temporal fossa?palliative surgery
9Wayne GreenhalghMitchell/AllenSCC Floor of mouthT4 N1 M0Stage IVAResection FOM, Marginal mandibulectomyL Neck dissectionFree RFFDXTPoorly diff SCCDeep 7mm clearFloor <0.5Others 5mmNeck 1/29 +ve Level IIIncomplete ExcisionFrozen Sections-veFalse NegDominico TropianoRight maxillary sinus SCCT4 N2Right superficial parotidectomy, neck dissection, right radical maxillectomy and orbital exenterationRef DxTIncomplete margins:Posterior margin of maxilla/orbital specimen+ve LNLevels I – VRebecca FernandezSCC TongueTotal glossectomyR mod radicalL selective neckFree Rectus myocutaneous flapChemo / DxTMod Diff SCCClear margins15mm lat30mm tongue baseLevel I, III and IVComplete Excision
10Eric KayMitchell/AllenAdenoid Cystic CaT2 N0 M0Partial resection of maxilla, orbital floor. Full dental clearanceFree RFFPending oncologyIncomplete margins:Right posterior ethmoidlateral nasal wallIncomplete ExcisionFrozen Section-veEarl BoxallBond/CopperSCCFloor mouth25 x 28 x 10mmDental clearanceWLEBilateral Level IPending further surgeryVentral tongue mucosa and adjacent muscleGingival mucosaSublingual gland aspectPerineural invasion
11Summary 10 combined oncology cases 3 completely excised 7 had inadequate margins1 case palliativeOrientation one specimenMargins involved 7Re-excision 1Frozen Section 7 (2 +ve 1 False Neg)
131 year combined ENT Plastic Surgery Cases (1st October 2002 to 1st October 2003)11 cases
148 Nov 2002Mitchell/Allen Aubrey SPEEDYSCC PalateFull thickness soft palate and partial pharyngeal wall, neck dissection, radial forearm flap.To deep margin along 1mmFrozen section22 Feb Mitchell/Allen David ROBINSSCC Retromolar trigoneWide local excision, neck dissection, radial forearm flap.To deep resection margin in two areas over a front of 7mmNo Frozen section4 Apr 2003Mitchell/AllenWilliam GEORGELeft retromolar SCCExcision floor of mouth, neck dissection, free fibula flap.Antero-medial margin involved. Perineural and vascular involvement. 3 neck nodes
156 Jun 2003Mitchell/AllenDavid CRAWFORDSCC Floor of mouthFloor 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 section18 Jun 2003Grey/BriggsMaria VAN DE VLAGParotid CarcinomaPectoralis 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 2003Bond/CooperWilliam DELLAVANZORight mandibular SCCRight hemimandibulectomy, neck dissection, pectoralis major flap.Resection margins clear (close at 1.5mm) 9 nodes, vascular and lymphatic invasionNo frozen section
161 Aug 2003Mitchell/AllenLeonard DUNNERSCC preauricular skinHemiauriculectomy, parotidectomy, neck dissection, rectus abdominus flap.Involved deep, anterior margin, sternomastoid and parotid. 1 lymph nodeFrozen section18 Aug 2003Bond/CooperRaymond BEARDMelanoma left upper incisorAlveolus and hard palate resection, radial forearm flap with bone.Resection margins clear. Minimum invasive margin 3mm, insitu 0.5mmNo frozen sectionRe-excsion performed at one month (1.8 by 1.5cm)12 Sept 2003Claire EVANSVerrucous carcinoma left mouthExcision floor of mouth tumour, neck dissection radial forearm flapVerrucous and invasive SCC. Invasive SCC 3mm from margin
1723 Sept 2003Bond/CooperEstelle POLLOCKLeft Neck SCCExcision of tumour and deltopectoral flapPresent at deep resection margins, less than 1mm from superior margin lymph node and lymphovascular invasionNo frozen section
18Non – Oncological Combined Case 1 Mar 2003Mitchell/AllenRobert HUGHESOsteoradionecrosis of the mandibleExcision of osteoradionecrosis and free fibula flapOsteradionecrosis
1910 combined oncology cases. All had inadequate margins Margins involved 7Close 3 (1.5mm, 3mm, 0.5mm)Re-excision 1Frozen Section 5
20Attention to resection margins Role of Radiotherapy (all referred) Difficult tumoursFrozen sections (70%)Attention to resection marginsRole of Radiotherapy (all referred)1 refused1 scleroderma contra-indicated1 pending further surgery1 still in -patient1 palliative previous DxT
22Postoperative chemoradiotherapy for high-risk head-and-neck SCC Peter MacCallum Centre Int J Radiat Oncol Biol Phys. 2004July 1999 and January47 patients, 41 (87%) had Stage III-IV disease. oral cavity in 51%27 had nodal disease with extracapsular extension26 had positive or close mucosal margins (<5 mm).10 had undergone resection of recurrent disease after previous surgery.The estimated 2-yearlocoregional control 56%,progression-free survival 62%overall survival rate was 73%,
23Do frozen sections help achieve adequate surgical margins in the resection of oral arcinoma? Int J Oral Maxillofac Surg. 2003; Manchester, UK82 patients who underwent resection oro-pharyngeal carcinoma and had frozen sectionConcordance 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.
24Relevance 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