Transcript Combined Plastic Surgery ENT Cases

Combined Plastic Surgery
ENT Cases
Audit of Pathology
Update
18 December 2004
Harry Powell
Michael Beckett
David Oliver
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.
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.
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%
Radiotherapy
For small tumour has survival rates equal to
surgery (stage I)
Indications at SCGH
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Positive or close (<5mm) margins
Large (T3/T4) tumours
Nodes >1cm
Extracapsular involvement
Invasion of lymphatic, vascular, perineural tissue
Update January 2004
to December 2004
10 patients
Combined ENT cases
09.01.04
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
30.01.04
Donald Johnston
Mitchell/Allen
SCC
Left preauricular
Submental A.
island flap
Sup
parotidectomy
Neck dissection
DxT
5mm deep, 8mm
radial 0/12 LN
11.10.04 ?scc rec
10.12.04 resection
Invasive SCC preauricular
Complete Excision
Frozen
section
-ve
11.02.04
Waclaw
Nachowicz
Grey/Briggs
Basisquamous Ca
Previously
incomplete
BCC ear
Temporal bone
Sup
parotidectomy
Selective Neck
dissection
P major flap
DxT refused
? Clear new margins
Frozen
Section
Perineural
involvement
Complete Excision
?Complete
22.03.04
Ed Oszinski
Bond/copper
15.04.04
Peter Smith
Mitchell/Allen
Tonsillar
SCC
Scleroderma
Recurrent
tumour
High grade 2002
DxT
Cavernous sinus
involvement
Adenoid cystic
Maxilla
Oropharyngeal,
nasopharyngeal
resection
Midline
mandibulotomy
P. Major Flap
Partail flap
necrosis
SSG neck
No DXT
Carcinosarcoma
Deep basaloid
squamous cell
L inferior
extended
maxillectomy
+ve post and Lateral
Soft pallate
Infra-temporal fossa
?palliative surgery
Deep +ve, second
deeper specimen –ve
Mucosal margins
clear
Incomplete Excision
Free RFF
Incomplete Excision
Frozen
Section
+ve deep
margin
02.07.04
Wayne
Greenhalgh
Mitchell/Allen
SCC Floor of
mouth
T4 N1 M0
Stage IVA
Resection FOM,
Marginal
mandibulectomy
L Neck
dissection
Free RFF
DXT
Poorly diff SCC
Deep 7mm clear
Floor <0.5
Others 5mm
Neck 1/29 +ve Level II
Incomplete Excision
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
Incomplete Excision
22.10.04
Rebecca
Fernandez
Mitchell/Allen
SCC Tongue
T4 N2
Stage IVA
Total
glossectomy
R mod radical
L selective neck
Free Rectus
myocutaneous
flap
Chemo / DxT
Mod Diff SCC
Clear margins
15mm lat
30mm tongue base
+ve LN
Level I, III and IV
Complete Excision
Frozen
Sections
-ve
False Neg
Frozen
Sections
-ve
Eric Kay
05.11.04
Mitchell/Allen
Earl Boxall
22.11.04
Bond/Copper
Adenoid
Cystic Ca
T2 N0 M0
SCC
Floor mouth
25 x 28 x
10mm
Partial resection
of maxilla,
orbital floor. Full
dental clearance
Free RFF
Pending
oncology
Incomplete margins:
Right posterior
ethmoid
lateral nasal wall
Dental
clearance
WLE
Bilateral Level I
Pending further
surgery
Incomplete margins:
Ventral tongue
mucosa and adjacent
muscle
Gingival mucosa
Sublingual gland
aspect
Perineural invasion
Incomplete Excision
Incomplete Excision
Frozen
Section
-ve
Summary
10 combined oncology cases
3 completely excised
7 had inadequate margins
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1 case palliative
Orientation one specimen
Margins involved
Re-excision
Frozen Section
7
1
7 (2 +ve 1 False Neg)
Previous Data (TH)
1 year combined ENT Plastic Surgery Cases
(1st October 2002 to 1st October 2003)
11 cases
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 2003
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
Frozen
margin involved.
section
Perineural and
vascular
involvement. 3 neck
nodes
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.
Frozen
section
21 Jul 2003
Bond/Cooper
William
DELLAVANZO
Right
mandibular
SCC
Right
hemimandibulec
tomy, neck
dissection,
pectoralis major
flap.
Resection margins
clear (close at
1.5mm) 9 nodes,
vascular and lymphatic
invasion
No frozen
section
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
Reexcsion
performed
at one
month (1.8
by 1.5cm)
12 Sept 2003
Mitchell/Allen
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
Frozen
section
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
1 lymph node and
lymphovascular
invasion
No frozen
section
Non – Oncological Combined
Case
1 Mar 2003
Mitchell/Allen
Robert
HUGHES
Osteoradionecrosis
of the mandible
Excision of
osteoradionecrosis
and free fibula flap
Osteradionecrosis
10 combined oncology cases.
All had inadequate margins
Margins involved
Close
Re-excision
Frozen Section
7
3 (1.5mm, 3mm, 0.5mm)
1
5
Difficult tumours
Frozen sections (70%)
Attention to resection margins
Role of Radiotherapy (all referred)
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1 refused
1 scleroderma contra-indicated
1 pending further surgery
1 still in -patient
1 palliative previous DxT
Postoperative chemoradiotherapy for high-risk headand-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
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locoregional control 56%,
progression-free survival 62%
overall survival rate was 73%,
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 oropharyngeal 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.
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 multimodality treatment strategies