Frequency and accuracy of intraoperative bone margin sampling for T4a cancers of the head and neck at the QEII Health Sciences Centre: a retrospective chart review

Patients

A total of 67 patients were eligible for inclusion in the study. Patient demographics are presented in Table 1. The ratio of men to women who underwent resection of a stage T4a tumor involving bone during this timeframe was approximately 2:1.

Table 1 Demographics of patients with negative and positive bone margins on final surgical pathologyFinal surgical margins

Of the 67 included patients, 62 (92.5%) had negative bone margins and 5 (7.5%) had positive margins at the time of final pathology. Of the 5 patients with positive final bone margins, two had a segmental mandibulectomy, one had a marginal mandibulectomy, one had a partial maxillectomy and one had a partial maxillectomy with resection of the sphenoid, ethmoid and orbital bones. Seven patients (10.4%) had positive soft tissue margins on final pathology, one of which also had final positive bone margins. In one patient with positive final bone margins, soft tissue margins could not be determined. Fifty patients (74.6%) had a resection involving mandible, while the remainder involved resection of maxilla, hyoid and/or other facial bones only (Table 1).

Recurrence-free survival

The median RFS was 4.03 years for patients with final negative bone margins and 3.34 years for patients with final positive bone margins (p = 0.66; Fig. 1). The 5-year RFS was 48.6% for patients with final negative bone margins and estimated to be 37.5% for patients with final positive bone margins (Fig. 1).

Fig. 1figure 1

Percent recurrence-free survival of patients with negative vs. positive bone margins on final surgical pathology measured by date of first recurrence (negative margins n = 62, positive margins n = 5)

Overall survival

The median OS was 4.56 years for patients with final negative bone margins and 3.98 years for patients with final positive bone margins (p = 0.96; Fig. 2). Five-year OS for patients with final negative bone margins was 44.3%, whereas no patients with final positive bone margins survived five years after surgery. Disease specific survival could not be determined due to a lack of consistent access to cause of death.

Fig. 2figure 2

Percent survival of patients with final negative or positive bone margins (negative margins n = 62, positive margins n = 5)

Intraoperative bone margin sampling

Of the 67 patients in the study, 50 involved resection of mandible and were therefore amenable to intraoperative bone margin sampling based on previous institution sampling practices. A total of 18 patients underwent intraoperative bone margin sampling. Intraoperative bone margin sampling occurred through analysis of curreted tissue of the medullary space including mandibular bone marrow and/or small bone fragments (13/18), and the inferior alveolar nerve (IAN) when present at resection site (7/18). Five patiets did not have sufficient bone marrow harvested and underwent analsysis of the IAN alone. Fourteen patients had negative intraoperative bone margins, all of which had negative final bone margins. Four patients had positive intraoperative bone margins, three of which had negative final bone margins. Two patients with positive intraoperative bone marrow sampling had further resection of mandible and negative final bone margins. Another patient had intraoperative sampling of the inferior alveolar nerve after the mandible had been resected, which was positive. There was further resection of soft tissue with positive final soft tissue margins and negative final bone margins. The remaining patient with positive intraoperative bone margins had a re-resection of bone intraoperatively, however the bone margins remained positive on final pathology. Sensitivity and specificity could not be determined as pathologists did not routinely assess the bone margins of initial specimens if re-resections were performed after a positive intraoperative bone margin was identified.

Adjuvant therapy

Of the patients with final negative bone margins, 10 (16.1%) received no adjuvant therapy, 38 (61.3%) received radiation therapy and 13 (21.0%) received chemoradiation (Table 2). For one (1.6%) patient in this group, there was no access to information on adjuvant therapy given. All 5 (100%) patients with final positive bone margins received adjuvant radiation therapy alone. Two of the patients did not receive chemotherapy in addition to radiation due to patient preference and one did not receive chemotherapy due to age and functional status. It is unknown why the remaining two patients did not receive adjuvant chemotherapy.

Table 2 Adjuvant therapy administered in patients with negative and positive final bone margins, absolute numbers (percent)

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