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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.

Fresh tissue received

No
- Non-routine fixation (not formalin), describe.

Yes
- Special studies required, describe.
- Ensure samples are taken prior to fixation.

Intraoperative consultation

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.

Orientation markers

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.

Options

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

Left
Right
Central

Specimen integrity

Intact
Disrupted

More detail

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

Partial
Total

Lip -see separate lip resection protocol

Bone

Not received
Received, describe specimen type and measure in three dimensions.

Maxilla
Mandible
- With inferior alveolar nerve
- Without inferior alveolar nerve
Other, specify

Teeth

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.

Salivary gland

Minor
Parotid
Submandibular
- Measure in three dimensions (mm)

See salivary gland protocol for more detail.

Neck dissection

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

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

Retromolar mucosa

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

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

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 resection

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

Mandibular resection (see illustrations provided)

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

Intraosseous lesions

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

Nerves

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

Tongue resection

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

More detail

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)

Options

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 resections

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

Maxillary resections

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

Lymph nodes

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 90^o, 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

Cassette id	Site	No. of pieces
A-B	Mucosal and soft tissue margins
E-G	Tumour, representative sections, one block per 10mm, demonstrating relationship with margins and adjacent tissue
H	Non-lesional tissue
I-K	Representative sections of other structures present e.g. glands, jugular vein, sternocleidomastoid, bone and bone margins if applicable
L+	Lymph nodes

Acknowledgements

Prof Richard Logan for his contribution in reviewing and editing this protocol.

References

Helliwell T and Woolgar J. Dataset for histopathology reporting of mucosal malignancies of the oral cavity, The Royal College of Pathologists, London, 2013.
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.
International Organization for Standardization (ISO). Dentistry -- Designation system for teeth and areas of the oral cavity. 2009.(Accessed 14 May 2014).
Slootweg PJ. Complex head and neck specimens and neck dissections. How to handle them. J Clin Pathol. 2005;58(3):243-8.
Dimenstein IB. Bone grossing techniques: helpful hints and procedures. Ann Diagn Pathol 2008;12(3):191-198.
Genden EM, Ferlito A, Bradley PJ, Rinaldo A and Scully C. Neck disease and distant metastases. Oral Oncol 20023;39(3):207-212.