Impact of histological Oral Tongue Cancer margins on locoregional recurrence: A multi-centre retrospective analysis
Introduction
Globally, cancer of the oral cavity represents 2.1% of all new cancer diagnoses, of which 90% are of squamous cell origin [1], [2], [3], [4]. In the Australian population, the tongue is the second most common site of oral cancer preceded by cancers of the lip, reflective of the high ultraviolet radiation exposure in Australia [1], [2], [3], [4]. In 2015, there were approximately 4500 cases of head and neck cancer (HNC; including lip) diagnosed in Australia of which 526 were oral tongue [5].
The standard treatment of oral tongue squamous cell carcinoma (OTSCC) involves primary surgical resection, with or without cervical lymph node dissection and adjuvant radiotherapy (aRT) or chemoradiotherapy (aCRT) when indicated [6], [7], [8]. Cervical lymph node dissection is typically undertaken if nodes are assessed as being involved or prophylactically if the tumour depth of invasion (DOI) is ≥4 mm, the role of dissection for DOI between 2 and 4 mm is debated [9], [10], [11], [12], [13]. This is in accordance with standard protocols of the US National Comprehensive Cancer Network (NCCN) guidelines [14]. The overarching goal of oncologic surgery in oral cancer must be complete tumour resection with histological verification of tumour-free margins. An involved tumour histological margin (HM)1 has been demonstrated to have a significant impact on locoregional failure (LRF) and overall survival (OS) [15], [16], [17], [18], [19].
There is ongoing conjecture regarding the optimal HM to deliver an acceptable rate of local recurrence whilst minimising surgical morbidity [20]. The Royal College of Pathologists classifies HM of oral cavity cancers of <1 mm as involved, 1–5 mm as close and >5 mm as clear, this classification is also the position of the Royal Australasian Royal College of Pathologists and the NCCN [21], [22].
There have been a range of HM suggested as delivering adequate reduction in risk for LRF in the literature, ranging from 1 mm to 10 mm [18], [19], [20], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33]. Whilst the literature is not entirely congruent on the acceptable margin for achieving acceptable local recurrence rates, the NCCN recommends a surgical margin (SM) of between 10 and 15 mm to facilitate a minimum 5 mm HM, allowing for specimen shrinkage during formalin fixation [14], [34].
Section snippets
Patients and methods
In this study the medical records of consecutive patients who underwent surgical resection for OTSCC at the Royal Melbourne Hospital and Peter MacCallum Cancer Centre between January 2007 and December 2016 were retrospectively reviewed. A total of 258 patients were included in the study. The study received multisite ethics approval (HREC/17/PMCC/220). The exclusion criteria were patients who had previous or a concurrent HNSCC. HM were classified as: involved (<1 mm; SCC in-situ was classified
Results
In total, 258 patients were eligible for inclusion in the study with a median follow-up period of 4.8 years. The baseline characteristics are described in Table 1. The mean age was 61 years old with an equal sex distribution. Current or ex-smokers comprised 55% (n = 141) of the study population and the majority (53%) of patients had T1 disease, 35% T2 and a combined 12% for T3 and T4 disease according to AJCC 7th edition staging. In total, 135 (52%) of the patients had adjuvant treatment with
Discussion
We present the findings of a large, retrospective, multi-institutional study on the adequacy of HM in OTSCC. Surgery is the preferred initial treatment of choice for OTSCC of any T stage. This large contemporary consecutive series of OTSCC patients with a majority of early stage T1/2 were treated in two tertiary referral head and neck cancer centers. Our results suggest worse local control and OS for patients having close or involved HM after initial surgical treatment, independent of age, DOI,
Conclusion
Initial surgical resection of oral tongue SCC (OTSCC) is preferred. An HM of the primary tumour >5 mm is recommended for improved locoregional control and OS regardless of subsequent revision surgery and/or aRT/aCRT. The oncologic aim of OTSCC surgery is to achieve >5 mm HM to maximise locoregional control and OS.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We would like to thank the patients whose data contributed to this study.
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