combined plastic surgery ent cases

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


Frozen Frozen sectionsection

-ve-ve

30.01.0430.01.04

Donald JohnstonDonald Johnston


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



-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


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


02.07.0402.07.04

Wayne Wayne GreenhalghGreenhalgh


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


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


22.10.0422.10.04

Rebecca Rebecca FernandezFernandez


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


Frozen Frozen SectionsSections

-ve-ve

Eric KayEric Kay

05.11.0405.11.04


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


Right posterior Right posterior ethmoid ethmoid

lateral nasal walllateral nasal wall


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


Ventral tongue Ventral tongue mucosa and adjacent mucosa and adjacent musclemuscle

Gingival mucosaGingival mucosa

Sublingual gland Sublingual gland aspectaspect

Perineural invasionPerineural invasion


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


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


6 Jun 20036 Jun 2003


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)


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.


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


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


18 Aug 200318 Aug 2003


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


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


23 Sept 200323 Sept 2003


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


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

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