Performance of Intraoperative Assessment of Resection Margins in Oral Cancer Surgery: A Review of Literature

Abstract

Introduction: Achieving adequate resection margins during oral cancer surgery is important to improve patient prognosis. Surgeons have the delicate task of achieving an adequate resection and safeguarding satisfactory remaining function and acceptable physical appearance, while relying on visual inspection, palpation, and preoperative imaging. Intraoperative assessment of resection margins (IOARM) is a multidisciplinary effort, which can guide towards adequate resections. Different forms of IOARM are currently used, but it is unknown how accurate these methods are in predicting margin status. Therefore, this review aims to investigate: 1) the IOARM methods currently used during oral cancer surgery, 2) their performance, and 3) their clinical relevance.

Methods: A literature search was performed in the following databases: Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar (from inception to January 23, 2020). IOARM performance was assessed in terms of accuracy, sensitivity, and specificity in predicting margin status, and the reduction of inadequate margins. Clinical relevance (i.e., overall survival, local recurrence, regional recurrence, local recurrence-free survival, disease-specific survival, adjuvant therapy) was recorded if available.

Results: Eighteen studies were included in the review, of which 10 for soft tissue and 8 for bone. For soft tissue, defect-driven IOARM-studies showed the average accuracy, sensitivity, and specificity of 90.9%, 47.6%, and 84.4%, and specimen-driven IOARM-studies showed, 91.5%, 68.4%, and 96.7%, respectively. For bone, specimen-driven IOARM-studies performed better than defect-driven, with an average accuracy, sensitivity, and specificity of 96.6%, 81.8%, and 98%, respectively. For both, soft tissue and bone, IOARM positively impacts patient outcome.

Conclusion: IOARM improves margin-status, especially the specimen-driven IOARM has higher performance compared to defect-driven IOARM. However, this conclusion is limited by the low number of studies reporting performance results for defect-driven IOARM. The current methods suffer from inherent disadvantages, namely their subjective character and the fact that only a small part of the resection surface can be assessed in a short time span, causing sampling errors. Therefore, a solution should be sought in the field of objective techniques that can rapidly assess the whole resection surface.

Keywords: bone tissue; defect-driven; intraoperative assessment (IOA); margin status; oral cancer; soft tissue; specimen-driven; squamous cell carcinoma.

Figure 1

Flow diagram of the study selection process.