Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

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.