Oral resection
Background
Malignancies of the oral mucosa are most commonly squamous cell carcinomas but salivary gland neoplasms and neuroendocrine epithelial neoplasms can also occur.1 The extent of resection will depend on the size and location of the lesion. A separate protocol is provided for lip resections.
Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.
- No
- Non-routine fixation (not formalin), describe.
- Yes
- Special studies required, describe.
- Ensure samples are taken prior to fixation.
- Not performed
- Performed, describe type and result
- Frozen section
- Imprints
- Other, describe
See general information for more detail on specimen handling procedures.
Inspect the specimen and dictate a macroscopic description.
External Inspection
Orientate and identify the anatomical features of the specimen.
Record additional orientation or designation provided by operating clinician:
- Absent
- Present
- Method of designation (e.g. suture, incision)
- Describe orientation of the marker at cut-up (e.g. 12 o'clock)
- Record any coloured inks applied and to which margin
Photograph the intact specimen if required.
Describe the following features of the specimen:
Procedure
Record as stated by the clinician.
- Incisional biopsy
- Excisional biopsy
- Hemi-glossectomy
- Partial glossectomy
- Hemi-mandibulectomy
- Marginal mandibulectomy
- Segmental mandibulectomy
- Partial/hemi-maxillectomy
- Total maxillectomy
- Selective neck dissection*
- Modified radical neck dissection*
- Radical neck dissection*
- Extended radical neck dissection*
*See specific protocol for more detail on neck dissection specimens
Specimen laterality
Specimen integrity
Trans-oral laser resection specimens may be received with the main tumour in one or more pieces and the resection margins in separate pots.1
Anatomical components included (more than one may apply) and specimen size (mm)
Describe and measure the anatomical components present.2
- Total specimen size in three dimensions, length x width x thickness
Mucosa
- Not received
- Received
- Measure in three dimensions
Tongue
Lip -see separate lip resection protocol
- Not received
- Received, describe specimen type and measure in three dimensions.
- Maxilla
- Mandible
- With inferior alveolar nerve
- Without inferior alveolar nerve
- Other, specify
- Not received
- Received,record number; if more than one, designate and describe each separately (size not required)
- Fédération Dentaire Internationale (FDI) designation3
- Mobility
- Periodontal ligament involvement
- Root resorption
See head and neck small biopsies and teeth protocol and anatomical terms for more detail.
- Minor
- Parotid
- Submandibular
- Measure in three dimensions (mm)
See salivary gland protocol for more detail.
- Selective
- Modified
- Radical
- Extended
See neck dissection protocol for more detail.
Dissection
After sufficient fixation, paint the relevant surgical margins with ink and record the colours applied. A single colour is usually sufficient but multiple colours may be needed to identify different margins. Ensure ink is dry before dissecting to prevent artefactual false margins.
If a neck dissection is included, separate from the rest of the specimen along an anatomical plane4 and refer to the specific protocol provided.
Generally, oral resection specimens are sectioned into 2-4mm slices radially, perpendicular to the border of the specimen.
See Slootweg4 reference for excellent diagrams to assist with complex head and neck specimens.
Buccal mucosa extends from the retromolar trigone posteriorly to the lips anteriorly. Most specimens are composed of mucosa with underlying muscle and fat. Occasionally full thickness resections would include the overlying skin.4
- Cut the specimen antero-posteriorly into parallel 2-4mm radial slices perpendicular to the border of the specimen.4
The retromolar trigone is the portion of mucosa overlying the ventral aspect of the ascending mandibular ramus. It extends from the posterior surface of the last mandibular molar tooth and extends superiorly to the maxillary tuberosity. Its medial and lateral borders are buccal mucosa and anterior faucial pillar respectively. The specimen frequently consists of a rectangular portion of mucosa with the underlying mandibular ramus.4
- Section the specimen into parallel 2-4mm radial slices, perpendicular to the border of the specimen. A short period of decalcification should be undertaken with the affected mucosa still attached to the underlying bone.
Floor of mouth is the horse-shoe shaped mucosa-covered area between the lateral border of the tongue medially and the lingual gingiva of the mandibular alveolar ridge. The submandibular and sublingual ducts open onto the floor of the mouth anteriorly.
- Cut the specimen in parallel 2-4mm radial slices perpendicular to the border of the floor of the mouth specimen or perpendicular to their long axis.
Bone specimens will require more specialised cut-up techniques.4,5
- Maxillary specimens –section (with a diamond saw) at 10mm intervals perpendicular to the long axis of the alveolar process of the maxilla into mediolateral parallel slices
- Mandibular specimens –section (with a diamond saw) at 10mm intervals perpendicularly to the long axis of the mandibular body
Sections will then require decalcification prior to further dissection.
If it is not feasible to dissect the mandibular or maxillary specimens as described, section the attached mucosa radially from the centre of the specimen to the margin. Then decalcify the entire specimen prior to dissection of the bone.
More detail
Maxillary resections will vary in size and extent. The specimen will have an oral surface which includes the palate, alveolar ridge with or without teeth as well as the maxillary gingiva. The opposite aspect represents the floor of the nose and maxillary sinus. The specimen may include the lateral nasal wall and inferior turbinate and if the specimen crosses the midline, the nasal septum will also be included. Surgical margins lie across the bony palate, nasal septum, lateral nasal wall, lateral wall of maxillary sinus and pterygoid plates dorsally.4
- Section these specimens in mediolateral parallel slices, allowing comparison with computed tomography scans or magnetic resonance imaging scans performed in the same plane.4
Two types of mandibular resections are undertaken:
-
Mandibular osteotomy:
Segments of the mandible are removed completely, disrupting the continuity of the mandible (“through and through” resections). In these specimens, both the anterior and posterior vertical bone margins must be assessed in addition to the soft tissue/mucosal (buccal/lingual) margins.
-
Mandibular segmental resection:
Segments of the mandible are removed but the lower border is preserved, retaining the continuity of the mandible. In these specimens, the alveolar ridge and inferior/caudal horizontal bone margin must be assessed in addition to the anterior and posterior vertical bone margins.4 The inferior alveolar nerve may or may not be present in continuity-maintained resection specimens. Clarification should be sought from the surgeon if this is unclear.
Section mandibular specimens perpendicularly to the long axis of the mandibular body.4
Record whether the lesion has affected the adjacent cortical bone:
Cortical bone (more than one may apply)4
- Expansion
- Attenuation
- Perforation
Surgeons are concerned with conserving as much bone as possible when resecting facial tumours and preoperative assessment of bone involvement is an important consideration. Therefore, it is important to assess the relationship between the tumour and the underlying mandibular bone. In squamous cell cancer of the oral mucosa, bone resorption may occur over a wide area or tumour may penetrate diffusely into the bone marrow.4
The specimen should be dissected in a manner that best demonstrates the extent of bone involvement and enable correlation with the preoperative assessment.4
- Tumour in the region of the lower alveolar nerve should be sought and examined closely in mandibular specimens.
- In specimens from the mandibular body, examine the cut surface of the nerve in the posterior bone margin.4
- In specimens containing the mandibular foramen, identify the nerve entering the foramen and dissect cranially and sample the extraosseous cranial cut surface.4
- Section tongue resection specimens in parallel slices perpendicular to the lateral border of the tongue.
- Where the tumour is situated dorsally on the tongue, identify and sample the lingual nerve margin (at the dorsolateral surgical margin) to enable assessment of perineural spread.4
After opening the specimens may require longer fixation in larger quantity of formalin.
Internal Inspection
Describe the internal or cut surface appearance including the following items:2
Tumour/lesion
- Absent
- Present
- Number; if more than one, designate and describe each separately
Tumour site
- Describe location with reference to anatomical landmarks. Use a photograph, if necessary, to record the tumour site.
Tumour size (mm)
- In three dimensions, length x width x thickness
- Macroscopic depth of invasion
This is the depth of invasion below the luminal surface not the thickness of tumour. Ulcerated tumours should be measured from an estimate of the reconstructed surface.1
Involvement of adjacent structures
- Absent
- Present, specify site(s)
- Large nerve e.g. inferior alveolar nerve
- Large blood vessels
- Bone/part of bone
- Salivary gland, specify type if possible
- Nose
- Sinus
- Other (e.g. floor of mouth, skin of face, deep muscle of tongue, pterygoid plates, encasing internal carotid artery, internal jugular vein, sternocleidomastoid muscle)
Distance of tumour to each margin (mm)
- Distance to the radial and soft tissue resection margins1
- Mandibular osteotomy (maintaining continuity)
- Inferior/caudal horizontal bone margin
- Anterior and posterior vertical bony margins
- Alveolar nerve margin, if present
- Mandibular segmental resection (continuity-sacrificed)
- Anterior and posterior vertical bone margins
- Inferior/caudal alveolar nerve margin
- Mandibular resection including the posterior body
- Inferior/caudal alveolar nerve resection margin
- All bony resection margins (may include lateral nasal wall, nasal septum, lateral sinus wall, zygomatic bone laterally, alveolar ridge anteriorly, hard palate medially and posterior palate/alveolar ridge)
Distant metastases6
- Absent
- Present, describe site(s)
Photograph the dissected specimen.
Note photographs taken, diagrams recorded and markings used for identification.
Processing
Dissect the specimen further and submit sections for processing according to the diagram provided.
Submit representative sections of:1
- All mucosal, buccal, lingual, anterior, posterior bone and soft tissue margins
- Tumour/ lesion at least one block per 10mm of tumour, demonstrating:
- Relationship with adjacent tissue/teeth
- Maximum depth of invasion
- Non-lesional tissue, one block
- If present
- Submandibular gland
- Jugular vein
- Sternocleidomastoid
- Bone and bone margins
Submit all lymph nodes and identify the site of each.2 See neck dissection protocol for more detail.
- Nodes < 6mm submit whole
- Nodes 6-15mm bisect longitudinally, submit both in one cassette
- Nodes >15mm bisect, then bisect one piece at 90o, submit all
- Nodes >10mm or macroscopically involved, submit blocks from the surrounding resection margin
Record details of each cassette.
An illustrated block key similar to the one provided may be useful.
Block allocation key
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Cassette id
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Site
|
No. of pieces
|
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A-B
|
Mucosal and soft tissue margins
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E-G
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Tumour, representative sections, one block per 10mm, demonstrating relationship with margins and adjacent tissue
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H
|
Non-lesional tissue
|
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I-K
|
Representative sections of other structures present e.g. glands, jugular vein, sternocleidomastoid, bone and bone margins if applicable
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L+
|
Lymph nodes
|
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Acknowledgements
Prof Richard Logan for his contribution in reviewing and editing this protocol.
References
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Dahlstrom J, Coleman H, Johnson N, Salisbury E, Veness M and Morgan G.
Oral structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2012.
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