Combined Plastic Surgery ENT Cases

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. 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 2004to December 2004 10 patients Combined ENT cases

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

18. Non – Oncological Combined Case

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. 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 2003 47. • 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. 2004. 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