Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way
May 10th, 2021
The goal of this protocol is to provide a clear overview of specimen-driven intraoperative assessment of resection margins. It is encouraged to implement this protocol to improve patient care at other institutes.
This protocol describes a specimen-driven method of intraoperative assessment of resection margins in oral cancer and this method allows physicians to improve the number of adequate resections. This protocol can be implemented easily in any institute. It does not interfere with the duration of surgical procedure nor it does interfere or disturb final pathology.
To begin, put the chlorhexadine pre-wetted tags paired on the sides of the intended lines of resection so that one tag remains on the resection specimen and the other remains at the corresponding spot in the wound bed. Cut between each pair of tags and remove the specimen with the tumor. Next, transfer the specimen to the grossing room.
Once the pathologist receives the specimen, rinse the specimen with water and gently pat it dry with gauze or paper. Record the general information and indicate the locations of the tags on the anatomical template. Place the specimen on the printed anatomical template, then ink the superior surface black and inferior surface blue, according to the standard protocol.
Indicate the location of any suspicious region on the anatomical template and relate it to the numbered tags. Depending on the size of the specimen and suspicious regions, make one or more incisions perpendicular to the resection surface of the suspicious regions at a distance of about five millimeters. Measure the margins on the cross sections and record the exact values in millimeters in the anatomical template.
If an inadequate margin is detected, indicate the exact location based on the tags and record it in the template. If an additional resection is not achievable, annotate the reason on the template in the additional comments section. If an additional resection is achievable, mention the exact location and indicate the thickness needed to achieve an adequate resection in the recommended section.
Relocate to perform the additional resection. Keep the main resection specimen in the refrigerator until the additional resection is received, then verify the accuracy of the location and size of the additional resection. Reassemble the specimen by the correct orientation of the cross sections and the polar ends sections of the tissue based on the tags and the photographs recorded during IOARM.
Cut the pieces of cork slightly larger than the tissue sections and place each tissue section on a piece of cork. Draw a line on the cork around the tissue section with a permanent marker and capture the image. Insert the pins through the corks next to the edge of the tissue section to keep the tissue sections attached to the cork.
To reassemble the whole specimen, put all the cork embedded tissue sections, including the polar ends, together in the correct anatomical orientation. Keep all the tissue sections together by puncturing the adjacent corks. Place the correctly oriented specimen on the anatomical template and capture the image.
Submerge the specimen in 4%formalin solution and stick a clear invisible warning note on the container with the specimen to avoid accidents. The specimen-driven intraoperative assessment of resection margins resulted in the successful identification of all inadequate margins. The final pathology report showed the presence of a well to moderately differentiated PT3 squamous cell carcinoma on the left side of the tongue.
The minimal margins were recorded and the IOARM was found to be in concordance with the final pathology. Based on this protocol for oral cancer surgery, the protocols for intraoperative assessment of all other surgical procedures that are dealing with solid cancers can easily be developed.
Overview
This article details a specimen-driven protocol for intraoperative assessment of resection margins (IOARM) in oral cancer surgery, specifically oral cavity squamous cell carcinoma (OCSCC). The method aims to improve the rate of adequate tumor resections by enabling real-time identification and correction of inadequate margins during surgery. The protocol is designed to be easily implemented without interfering with surgical duration or final pathology assessment.
Key Study Components
Area of Science
- Oncological surgery
- Pathology
- Head and neck cancer
Background
- Complete tumor resection with adequate margins is critical in oral cancer surgery.
- Historically, only 15%-26% of OCSCC resections are adequate due to lack of intraoperative margin information.
- Margin status is typically determined days after surgery via final histopathology.
- Specimen-driven IOARM was implemented at Erasmus MC to address this gap.
Purpose of Study
- To present a detailed protocol for specimen-driven IOARM in oral cancer surgery.
- To demonstrate how intraoperative margin assessment can improve resection adequacy.
- To provide a reproducible method for other institutions.
Methods Used
- Placement of paired chlorhexidine pre-wetted tags on both sides of intended resection lines for orientation.
- Specimen removal and transfer to the grossing room.
- Specimen rinsing, drying, and inking of surfaces for orientation.
- Recording of tag locations and suspicious regions on an anatomical template.
- Incision and measurement of margins at suspicious regions; documentation of findings.
- Recommendation and execution of additional resections if inadequate margins are found.
- Reassembly and orientation of tissue sections using cork, pins, and photographic documentation.
- Specimen fixation in formalin and final pathology correlation.
Main Results
- Successful identification of all inadequate margins intraoperatively.
- IOARM findings were concordant with final pathology results.
- Implementation improved adequate resection rates from 15%-40%.
- The protocol did not interfere with surgical duration or final pathology assessment.
Conclusions
- Specimen-driven IOARM is effective for improving margin adequacy in oral cancer surgery.
- The protocol is practical and can be adopted by other institutions.
- This approach can be adapted for intraoperative assessment in other solid cancer surgeries.
Frequently Asked Questions
Executive Industry Relevance
Intraoperative assessment of resection margins (IOARM) addresses a critical gap in surgical oncology by enabling real-time margin evaluation and correction during oral cavity cancer resections. This protocol enhances predictive confidence in surgical outcomes and reduces the risk of inadequate resections, directly impacting downstream pathology and therapeutic decision-making. Its adoption supports risk-adjusted advancement and portfolio prioritization in translational oncology programs.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables precise anatomical mapping and margin quantification for biological de-risking.
- Supports functional validation of surgical endpoints relevant to tumor clearance.
- Improves predictive confidence in tissue-based translational models.
Screening & Assay Development
- Standardizes specimen orientation and documentation for reproducible downstream analysis.
- Facilitates quantitative measurement of resection margins for assay calibration.
- Prepares validated tissue samples for molecular or histopathological screening workflows.
Translational & Preclinical Research
- Aligns surgical margin assessment with disease-relevant translational biomarkers.
- Ensures continuity from intraoperative findings to preclinical model validation.
- Reduces mechanistic ambiguity in tumor margin status for risk-adjusted studies.
Pipeline & Workflow Integration
This specimen-driven IOARM protocol integrates at the interface of surgical intervention and pathology, bridging early clinical discovery with translational research and preclinical validation.
- Discovery Biology: Provides real-time hypothesis testing of margin adequacy and anatomical localization.
- Screening: Delivers reproducible, quantitative margin data for comparative analytics.
- Analytics: Enables precise measurement and documentation of margin distances for statistical review.
- Translational Research: Supports biomarker alignment and continuity from surgical to preclinical endpoints.
- Enterprise Reuse: Offers a standardized, adaptable protocol for broader solid tumor applications.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence and reduces biological risk in surgical oncology pipelines.
- Operational Value: Standardizes intraoperative and pathology workflows without extending surgical time.
- Strategic Value: Improves go/no-go decision quality and capital efficiency by reducing inadequate resections.
- Portfolio Impact: Enables risk-adjusted prioritization and advancement of surgical and translational oncology assets.
Implementation Considerations
- Requires cross-disciplinary expertise in surgical oncology and pathology.
- Needs infrastructure for specimen tagging, anatomical mapping, and photographic documentation.
- Demands standardized protocols for intraoperative and pathology team collaboration.
- Adaptable to other solid tumor models with protocol modifications as needed.
- Potential concerns about specimen orientation are addressed by the protocol's documentation steps.
