Advancing Surgical Pathology Reporting in Head and Neck Cancer through 3D Visualization, Dynamic Documentation, and Optimized Communication

Summary

Head and neck cancer management requires precise intraoperative communication and documentation to achieve tumor clearance and guide postoperative care. Traditional pathology reports often fail to capture the full scope of surgical findings. We present a protocol using 3D scanning, standardized timeouts, and a novel software to enhance intraoperative communication and pathologic reporting.

Abstract

The successful surgical management of head and neck cancer relies on intraoperative communication between surgical and pathological teams to achieve oncologic clearance. Precise documentation of the actions taken and pathological information obtained during surgery is crucial for planning adjuvant treatment and to meaningfully interpret surveillance imaging. Achieving oncologic clearance of the cancer has significant implications with respect to reducing the risk of recurrence, reducing the need for multimodality adjuvant therapy, and improving quality of life. The surgical pathology report guides postoperative care, and yet it falls short of conveying the comprehensive body of information obtained at the time of surgery. We report the use of 3D scanning technology, principles of standardization, and software developments to improve the current surgical workflow and final pathology report. The approach described here integrates dynamic three-dimensional (3D) visuals, a series of intraoperative timeouts, annotated radiographs, and a novel surgical pathology reporting software to improve both intraoperative communication as well as postoperative understanding by medical and radiation oncologists. This unique methodology addresses shortcomings in the current and stagnant standard of care for pathologic documentation, paves the way for significant innovations in surgical pathology reporting, and holds the promise of improving patient outcomes.

Introduction

Head and neck cancers originate from the oral cavity, pharynx, sinonasal tract, salivary glands, skin and larynx¹. These malignancies rank in the top ten most common cancers, accounting for approximately 70,000 new diagnoses and 16,000 deaths annually in the United States, and 900,000 new diagnoses and 450,000 deaths worldwide^2,3. Head and neck cancer treatment often requires long-term multispecialty and multimodality care^4,5. Primary surgical resection followed by adjuvant radiation (RT) or chemoradiation (CRT) is recommended for most advanced stage cancers arising in the oral cavity, salivary glands, sinonasal cavities, larynx, and hypopharynx ⁶. Surgery remains the most effective treatment modality⁷. Prior research has demonstrated a significant survival benefit over definitive RT or CRT in oral cavity, HPV-negative oropharyngeal, early supraglottic, and advanced-stage laryngeal cancers^8,9,10,11,12.

The goal of surgical resection is to achieve tumor clearance documented as negative margins¹³. The status of the surgical margin is an independent prognostic factor that predicts recurrence, as well as the need for further treatment¹⁴. Positive margins have been linked to decreased survival, increased local recurrence, increased cost of care, and treatment intensification¹⁵. Intraoperative frozen section analysis remains the best practice for achieving tumor clearance and is widely employed by head and neck surgeons to help guide intraoperative decision making and the harvest of additional tissue during surgery¹⁶. Oncologic frozen section margin analysis involves analyzing tissue samples that are traditionally harvested from the resected specimen (specimen-driven) or from the tumor bed (defect-driven), the former of which is associated with superior rates of local control^{17,18,19,20,21}. However, this process has remained stagnant and unstandardized, with variable surgical approaches, communication strategies, and definitions of margin clearance^17,22. Information about the location and breadth of margins "at-risk" (<5 mm or positive) guides the harvest of additional tissue - and the pursuit of tumor clearance. However, surgeons and pathologists often rely on informal, undocumented conversations and crude two-dimensional drawings for communication²³. There is ample room for improvement; prior investigations found that supplemental margins can be off-target by as much as 1 cm in one-third of cases²⁴.

The surgical pathology report serves to convey the pathological information gathered during surgery and guide postoperative decision-making. Prior research has demonstrated that the pathology report lacks clarity and is often misinterpreted. Powsner et al. reported a 30% misinterpretation rate of pathology reports among surgeons²⁵. Mossanen et al. reviewed several articles examining the clarity of surgical pathology reports and identified calls for standardization and clearer organization²⁶. In a survey of head and neck cancer specialists, respondents reported a lack of clarity regarding whether supplemental margins reflected tumor clearance, the extent of supplemental margins harvested intraoperatively, and the final margin status. Most radiation and medical oncologists (61%) found pathology reports difficult to navigate and reported that critical information is not easily accessible²⁷. These findings emphasize the need to improve final pathology reports to ensure that postoperative providers have access to accurate, detailed information essential for optimizing care.

Given the prognostic importance of the surgical margin, it is particularly concerning that the final margin status is not made clear in pathology reports. We believe that the process of intraoperative pathologic consultation represents a modifiable target for improving the clarity of the surgical pathology report. We have spent several years identifying and implementing actionable changes in intraoperative pathologic consultation and reporting for head and neck cancer^22,23,28,29. We have published in detail about 3D optical scanning of both the surgical specimen and ablative defect^23,28. In tandem with our established 3D scanning method, we have implemented a series of structured, intraoperative "timeouts" to standardize and improve surgeon-pathologist communication during oncologic resections. We have also developed a novel pathologic reporting software, MarginView3D (MV3D), that facilitates this approach. Here, we outline an intraoperative workflow designed to improve communication and create a clear and definitive surgical pathology report. This approach can be utilized in any head and neck cancer resection for which frozen section analysis is the standard of care. It is anticipated that it will be useful in other forms of surgical oncology that utilize frozen section analysis.

Protocol

This protocol was performed at Mount Sinai West Hospital under IRB#23-0177. A schematic of the protocol is depicted in Figure 1. Scanning is performed by medical trainees and research staff, who also enter information into MV3D. All timeouts, pathological analyses, and discussions are conducted by board-certified pathologists and surgeons.

1. Three-dimensional specimen scan (Figure 2)

NOTE: Detailed instructions for using the scanning hardware and software can be found in Supplementary File 1.

1. Set up the 3D scanner and its associated turntable on a flat surface in the frozen section laboratory. Connect the scanner to the laptop and open the associated scanning software.
2. Obtain the resected specimen from the surgical team.
3. Prep the specimen by removing any excess blood using gauze or a paper tissue. Dispose of the gauze or tissue in a biohazard waste container.
   NOTE: For specimens with no notable landmarks (i.e., teeth or bone), put one pin on the edge of the specimen corresponding to a geographic marker (clip or suture) placed and labeled by the surgeon.
4. Using gloves, place the specimen in the center of the turntable. After use, dispose of the gloves in a biohazard waste container.
5. Turn off the lights and conduct the scan.
6. Flip the specimen 180° and scan the other side.
7. Align the two scans using anatomical landmarks and/or pins for guidance. Adjust the brightness as needed so that the scan closely mirrors the color of the specimen.
8. Save the scan as an .OBJ file named "SpecimenScan."

2. Three-dimensional defect scan (Figure 3)

NOTE: Detailed instructions for using the scanning hardware and software can be found in Supplementary File 1.

1. Bring the laptop and the handheld scanner into the operating room and set them up on a small cart. Connect the scanner to the laptop and open the associated scanning software.
2. Achieve hemostasis and then move the operating room overhead lights away from the defect and place sterile towels around the defect.
3. Hold the scanner directly above the defect (30-40 cm) and press the Play button to begin Preview mode.
4. Adjust the position of the scanner and brightness as needed to confirm that there is a green outline of the defect visible on the scanning software.
5. Press the Play button again to start the actual scan.
6. Scan the defect for about 2 min. Start with the scanner in place and centered above the defect for about 1 min. After 1 min, slowly move the scanner to each side in a windshield wiper motion.
   NOTE: If the message "Tracking Lost" appears on the software, go back to the original position to find the image again.
7. Save the scan as an .OBJ file named "DefectScan."

3. Three-dimensional anatomical model

1. Open the MV3D Anatomical Library.
2. Select Choose Models.
3. Select all the relevant anatomic parts from the library relevant to the specific procedure.
4. Click save and add to the specific procedure within MV3D.

4. Orientation timeout (pathology team)

1. Open MV3D and select Create Procedure, or if the procedure was already created, choose the procedure from the list of recent procedures by date.
2. Once both 3D scans have been generated, import them into MV3D by selecting Import Specimen and Import Defect.
3. Project MV3D onto the operating room monitor to display the scans and the 3D anatomical model.
4. Establish an audiovisual connection between the pathology laboratory and the operating room.
5. Together with the surgeon, select three anatomical axes for orientation.
6. Orient the specimen scan along the selected axes by rotating it until there is a mutual agreement between the surgical and pathology teams.
7. Repeat for the defect scan and the anatomical model.
8. As needed, use the 3D visuals to discuss where to take frozen section margins and identify specific areas of clinical interest.

5. Frozen section timeout (pathology team)

1. Following completion of frozen section analysis, annotate the specimen scan to indicate the locations of all sampled margins.
2. For each annotation, input a descriptive name, the margin status (positive, negative, close), diagnosis, and any pertinent notes (i.e., "2 mm from deep").
3. Project MV3D onto the operating room monitor.
4. Establish an audiovisual connection between the pathology laboratory and the operating room.
5. Report the results of frozen section analysis to the surgical team with the visual aid of the annotated specimen scan.
6. Using the 3D scans, discuss where supplemental margins should be taken from the defect to address at-risk margins from the specimen (Figure 4).
7. Harvest supplemental margins to address margins at-risk and send them with appropriate geographic orientation markers for frozen section analysis (surgeon)

6. Reconciliation timeout (surgical and pathology teams)

1. Annotate the location of supplemental margins on the defect scan (surgeon).
2. Annotate the extent of resection and the location of supplemental margins on the anatomical model (surgeon).
3. Following completion of frozen section analysis, input a descriptive name, the margin status, and any pertinent notes for each supplemental margin (pathologist).
4. Project MV3D onto the operating room monitor.
5. Establish an audiovisual connection between the pathology laboratory and the operating room.
6. Report the results of frozen section analysis of the supplemental margins to the surgical team.
7. Discuss each margin at-risk and align the specific supplemental margins that address those concerning margins.
8. Arrive at an explicit agreement that oncologic clearance has or has not been achieved.
9. Commence with the reconstruction portion of the operation.

7. Annotation of radiographs and recording of surgical narrative (surgeon)

1. Following surgery, select and annotate preoperative radiographs to demarcate the extent of surgical resection and the location of supplemental margins, indicating areas of clinical interest (Figure 5).
2. Record an audiovisual narrative providing a summary of the oncologic resection and intraoperative pathologic consultation with the visual aid of the scans and descriptive information rendered in MV3D.

8. Recording of pathological narrative (pathologist)

1. After the results of the permanent section have been obtained, record a brief audiovisual narrative to provide the pathology perspective on the case and specifically note whether permanent section results change the final oncologic clearance status.

Results

Since the implementation of this novel scanning workflow in January 2023, we have scanned 92 head and neck cancer cases. From August 2024 to April 2025, we successfully integrated MV3D into this workflow in 33 cases. Procedures included mandibulectomy (n = 29), laryngectomy/laryngopharyngectomy (n = 17), glossectomy (n = 14), palatomaxillectomy (n = 12), parotidectomy (n = 9), oral cavity soft tissue resection (n = 6), scalp resection (n = 1), lip resection (n = 1), rhinectomy (n = 1), facial cutaneous malignancy resecti...

Discussion

While the ultimate goal of oncologic resections is tumor clearance, the methods by which surgeons and pathologists communicate essential pathological information are outdated and inefficient²². The surgeon often scrubs out of the operating room to engage in informal and largely undocumented face-to-face conversations with the pathologist. The processing of surgical specimens involves slicing the tissue, which renders them virtually unrecognizable, leaving crude drawings as the only visual referenc...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
EinScan SP V2	Shining 3D	N/A	Tabletop scanner
Einscan Pro HD	Shining 3D	N/A	Handheld Scanner
EXScan Pro software	Shining 3D	N/A	Handheld scanner software
ExScan S software	Shining 3D	N/A	Tabletop scanner software
ThinkPad P1 Gen 7 Intel (16″) Mobile Workstation	Lenovo	Part Number: 21KV001EUS	Laptop (Minimum System Requirements: PC running Windows 10 with at least 8GB of RAM; Processor such as an Intel® Xeon E3-1230, i5-3470, i7-3770, i7-8700, or higher; Minimum GPU of Nvidia GTX 660 or Quadro P1000 is also recommended
ThinkStation P3 Ultra Small Form Factor Workstation	Lenovo	Part Number 30HACTO1WWUS1	Server