Influence of condition of surgical margins on local recurrence and disease-specific survival in oral and oropharyngeal cancer

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Abstract

Background: The clearance of surgical margins at the primary site is widely thought to influence the subsequent course of the disease in patients operated on for oral and oropharyngeal carcinoma. In some reports the adverse impact of close or involved margins was not negated by postoperative radiotherapy. These findings, in addition to descriptive histopathological studies, have led some authors to recommend margins of more than a macroscopic clearance of 1 cm at certain subsites. We have therefore examined the relation between the condition of surgical margins and local recurrence and disease-specific survival. Methods: Identical treatment protocols were used to treat two independent groups of patients (Sydney, Australia, n=237; Lanarkshire, n=95) who presented with previously untreated carcinoma of the mouth or oropharynx. All patients were operated on with the primary objective of achieving a macroscopic clearance of 1 cm. Postoperative radiotherapy was used according to a protocol. Data about patients were entered into comprehensive computerised databases prospectively. Known clinical and pathological prognostic indicators, in addition to the condition of surgical margins, were analysed to find out if they were predictive of local recurrence and disease-specific survival using the Cox proportional hazard model. Results: Local recurrence was predicted by the presence of perineural invasion at the primary site in both groups. Disease-specific survival was predicted by the presence and extent of regional lymph node metastases in both groups. The condition of surgical margins (clear, close, or involved) did not predict local recurrence, or disease-specific survival on multivariate analysis. Conclusions: A macroscopic margin of 1 cm seems adequate in the surgical management of oral and oropharyngeal carcinoma. For most patients who have close or involved margins the biology of the disease influences the subsequent course irrespective of the width of clearance of tumour.

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INTRODUCTION

The width of margins of clearance in the surgical management of oral and oropharyngeal cancer is widely thought to have an important adverse influence on the subsequent course of the disease.1 Several reports have indicated that the presence of tumour at surgical margins implies a worse prognosis.2., 3. While postoperative radiotherapy decreases the likelihood of local recurrence, it does not reduce the rate to that seen in patients with clear surgical margins.3 Additional work that describes

PATIENTS AND METHODS

Previously untreated patients who presented with oral and oropharyngeal squamous cell carcinoma at two centres (Royal Prince Alfred Hospital Sydney, Australia n=237; and Monklands Hospital, Lanarkshire, Scotland n=95), and managed according to identical treatment protocols were included. Comprehensive data for each patient was entered prospectively onto a computerised database at each centre. Data was collected in Sydney during the period 1987–1997. The opportunity to confirm or refute the

Characteristics of patients, site, and stage distribution of tumours

The Sydney group comprised 237 patients with all survivors having a minimum of one year follow-up and 177 (92%) of survivors having greater than two years follow-up (range 12–120 months). The Lanarkshire cohort comprised 95 patients with a minimum of 15 months follow-up (range 15–60 months). Amongst the 75 patients who were disease free at the last point of contact 64 (87%) had greater than two years follow-up. Previous reports indicate that 78–88% of recurrence events occur within two years of

DISCUSSION

Using multivariate analysis we have failed to demonstrate that the condition of surgical margins had an independent predictive effect on either local recurrence or disease-specific survival. The consistency of findings across two independent samples adds credence to the results. Tumours with more aggressive biology are recognizable in many, but not all, cases by their clinical and pathological presenting features. Metastatic deposits in the regional nodes are clearly the most important, but

CONCLUSIONS

A 1-cm macroscopic margin seems adequate in the surgical management of oral and oropharyngeal carcinoma. For most patients who have unsatisfactory margins despite this therapeutic goal, the biology of the disease influences the subsequent course irrespective of the condition of the surgical margins. The use of wider resection margins is unlikely to influence local recurrence or disease-specific survival, and is likely to have an adverse effect on functional outcome.

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