We thank Bas J. van Brakel and Roxanna Haak for their help in performing IOARM. Klara A. Bouman-Zevenbergen, Ian Overduin, and Silvy L. Sabiran - Singoredjo for their assistance and supportive role in ensuring logistics, equipment, and availability of personnel at the pathology department.

This study was approved by the institutional Medical Ethics Committee (MEC-2015-150).
NOTE: All the patient and personnel information in the figures or examples are fictional (i.e., XXXXX and YYYYY).
1. Before surgery
<ol>
	<li>Surgery department: Request for IOARM during the planning of surgery.</li>
	<li>Pathology department: Ensure logistics/equipment (see Table of Materials) and the availability of personnel (pathologist/pathology resident and assistant).</li>
</ol>
2. During surgery
<ol>
	<li>Operation room (OR)
	<ol>
		<li>Ensure that all involved personnel are familiar with the relocation protocol12.</li>
		<li>Follow the relocation protocol.</li>
		<li>Submerge the tags in chlorhexidine for at least 30 min before the start of the surgery.</li>
		<li>Place the tags paired on either side of the intended line of resection (both superficial and deep), so that one tag is on the resection specimen and the other remains at the corresponding spot in the wound bed (Figure 1A) as described by Van Lanschot et al.12.</li>
		<li>Cut between each pair of tags.</li>
		<li>Remove the specimen with the tumor (one tag from each pair remains in the wound bed, Figure 1B).</li>
		<li>Fill out the pathology request form with a clear indication of the anatomical location of the tags (e.g., tag 1 = anterior, tag 2 = superior).</li>
		<li>Record the surgical procedure-related defects of the specimen and their location in relation to the tags, on the pathology request form. 
		NOTE: Procedure-related defects create false resection surfaces and can lead to incorrect allocation of inadequate margins during both IOARM and final pathology.</li>
		<li>Bring the specimen to the pathology department.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62446/62446fig01.jpg" /> 
Figure 1: Illustration of the relocation protocol. (A) Application of tags in a pair-wise manner. (B) Wound bed and specimen both with one tag of each pair. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62446/62446fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="2">
	<li>IOARM - Grossing room (GR), pathology department
	<ol>
		<li>Rinse the specimen with water and gently pat it dry with gauze or paper. 
		&#8203;NOTE: Register every next step with photographs and store them in the Electronic Patient File (EPF).</li>
		<li>Record the general information (date, patient id, pathology number, surgeon, pathologist, type of specimen, and tags used) on the anatomical template.</li>
		<li>Indicate the locations of the tags on the anatomical template (Figure 2).</li>
		<li>Place the specimen on the anatomical template.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/62446/62446fig02.jpg" /> 
Figure 2: Example of anatomical template for IOARM. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62446/62446fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="5">
	<li>Ink the resection surface according to standard protocol (e.g., superior blue and inferior green).</li>
	<li>Inspect the specimen visually and by palpation (pathologist and surgeon).</li>
	<li>Indicate the location of any suspicious region (i.e., margin &#60;5 mm) on the anatomical template and relate it to the numbered tags (section Result of IOARM, Figure 2).</li>
	<li>Perform an incision perpendicular to the resection surface at the suspicious region (Figure 3A). Depending on the size of the specimen and/or suspicious regions, make one or more incisions with a distance of about 5 mm. In case of more than one incision, number the incisions as IOA1, IOA2, etc.</li>
	<li>Measure the margins (i.e., the distance between resection surface and tumor border) on the tissue sections (Figure 3B) and record the exact values in mm on the anatomical template (section Result of IOARM, Figure 3C). 
	&#8203;NOTE: If the tumor border is macroscopically not distinguishable (e.g., the tumor cannot be distinguished from surrounding fibrotic or salivary gland tissue), microscopic analysis by frozen section is indicated.</li>
</ol>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/62446/62446fig03.jpg" /> 
Figure 3: Illustration of IOARM. (A) Perpendicular incision performed after identification of suspicious region by palpation. (B) The margin is measured. (C) The result of IOARM and the recommendation are recorded. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62446/62446fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="10">
	<li>Proceed with the completion of the operation, step 2.2.19. If an adequate margin is detected (i.e., additional resection is not needed).</li>
	<li>Indicate the exact location based on the tags if an inadequate margin is detected and record it on the template. Proceed with an additional resection if surgically/technically achievable, step 2.2.13.</li>
	<li>Annotate the reason on the template, if an additional resection is not achievable (section Additional comments, Figure 2).</li>
	<li>Recommend (pathologist/surgeon) the additional resection based on the exact location and indicate the thickness needed to achieve an adequate resection (Figure 3C). 
	NOTE: If the inadequate margin concerns a positive margin, a minimal thickness of 6 mm should be recommended for the additional resection.</li>
	<li>Keep (pathologist) the main resection specimen in the refrigerator until the additional resection is received.</li>
	<li>Relocate (surgeon) the area of additional resection in relation to the tags, in the wound bed, based on the record of IOARM (Figure 3C).</li>
	<li>Perform the additional resection.</li>
	<li>Send the additional resection to the GR.</li>
	<li>Verify (pathologist) the accuracy of the additional resection regarding its location (based on tags) and its size. 
	NOTE: The above steps are applicable in the case of a close margin. In the case of a positive margin, an IOARM of the additional resection is necessary (pathologist). The surgeon waits for the result of the second IOARM before completing the operation.</li>
	<li>Remove (surgeon) the remaining tags from the wound bed and complete the operation.</li>
	<li>Copy (pathologist) all data from the anatomical template to the EPF.</li>
</ol>
3. After IOARM - Grossing room (GR), pathology department
NOTE: To preserve the anatomical orientation and shape of the specimen the following steps are performed.
<ol>
	<li>Reassemble the specimen by the correct orientation of all tissue sections (cross-sections and the polar ends) based on the tags and the photographs recorded during IOARM. 
	&#8203;NOTE: Cross-sections are in the middle of the specimen and the polar ends are the outer parts of the specimen.</li>
	<li>Cut the pieces of cork slightly larger than the tissue sections.</li>
	<li>Place each tissue section on a piece of cork.</li>
	<li>Draw a line on the cork around the tissue section with a permanent marker and take a photograph (Figure 4A).</li>
	<li>Place another piece of cork on top of all tissue sections except the polar ends (Figure 4B).</li>
	<li>Keep the upper and lower cork together, with the tissue section in between, by placing pins through both corks next to the edge of the tissue section, but not through the tissue section (Figure 4B).</li>
</ol>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/62446/62446fig04.jpg" /> 
Figure 4: Illustration of the method to preserve the anatomical orientation and shape of tissue sections. (A) Tissue sections are placed on a piece of cork with a line drawn on the cork around the tissue section with a permanent marker. (B) Pins are obliquely placed over the polar ends and another piece of cork is placed over the tissue section. (C) Illustration of a reassembled fresh specimen kept together with pins that puncture the adjacent corks. (D) Illustration of a reassembled fixed specimen kept together with pins that puncture adjacent corks. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62446/62446fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="7">
	<li>Place the polar ends on a separate piece of cork (Figure 4A).</li>
	<li>Keep the polar ends attached to the cork by obliquely placing pins over the tissue and piercing the cork just beside the edge of the tissue (Figure 4B). 
	CAUTION: Do not puncture the specimen with the pins.</li>
	<li>Reassemble the whole specimen: put all the tissue sections including the polar ends together in the correct anatomical orientation.</li>
	<li>Keep all the tissue sections together by puncturing the adjacent corks (Figure 4C).</li>
	<li>Position the specimen with the correct orientation on the anatomical template and take a photograph.</li>
	<li>Place the specimen in formaldehyde solution (formalin 4%). 
	NOTE: For proper fixation, pieces of paper can be placed on top of the specimen to keep it submerged in formalin.</li>
	<li>Make a clear and visible warning note on the container with the specimen (e.g., caution needles/pins), to avoid accidents.</li>
	<li>Store the container with the specimen for further processing, according to the standard pathology protocol.</li>
</ol>
4. Grossing of the fixed specimen after IOARM
NOTE: After formalin fixation, the specimen should be grossed preferably by the pathologist/resident/assistant, who performed the IOARM.
CAUTION: Be careful with the needles/pins when removing the specimen from the container.
<ol>
	<li>Follow the institutional grossing protocol. 
	&#8203;NOTE: Take additional measures to ensure the correct orientation and to facilitate the comparison of the margin status between IOARM and final pathologic assessment.
	<ol>
		<li>Consult the pictures of the IOARM.</li>
		<li>Take the specimen out of the container.</li>
		<li>Check whether all the tissue sections are present.</li>
		<li>Position the specimen with the correct orientation on the anatomical template and take a photograph (Figure 4D).</li>
		<li>Remove the pins.</li>
		<li>Separate the individual tissue sections with corresponding cork.</li>
		<li>Take photographs of each tissue section with their corresponding corks, focusing on the lines that were drawn around the tissue section to assess possible shrinkage of tissue after fixation (Figure 5).</li>
	</ol>
	</li>
</ol>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/62446/62446fig05.jpg" /> 
Figure 5: Illustration of a polar end with the cut surface facing the cork, held against the cork by tilted pins. (A) Fresh specimen. (B) After fixation. (C) The cut surface of the polar end is flat after fixation. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62446/62446fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="8">
	<li>Detach all tissue sections systematically from the cork (e.g., start from anterior to posterior or left to right).</li>
	<li>Gross the IOARM-tissue sections to the standard final tissue sections (2-3 mm thick).</li>
	<li>Place all final tissue sections, in the correct anatomical orientation (e.g., from anterior to posterior), on a paper on the grossing table.</li>
	<li>Number all the final tissue sections consecutively with a permanent marker on the paper (Figure 6).</li>
	<li>Annotate the location of IOARM with a permanent marker (Figure 6).</li>
	<li>Take photographs, including all final tissue sections and store them in the EPF (Figure 6).</li>
	<li>Select the relevant final tissue sections and IOARM sections to be further processed for final pathologic assessment.</li>
</ol>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/62446/62446fig06.jpg" /> 
Figure 6: Grossed specimen with the location of the IOARM marked. Corresponding numbers 1-5 refer to tissue sections from left to right. A-E corresponds with tissue sections included for histopathologic evaluation. Note that the remaining piece of tissue that was evaluated by frozen section (FS) is indicated to enable direct comparison with the permanent HE-stained section. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62446/62446fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
5. The final pathologic assessment - Impact of IOARM on final margin status
<ol>
	<li>Follow the local standardized protocol. The protocol followed here is the PALGA (Pathologisch-Anatomisch Landelijk Geautomatiseerd Archief, the nationwide network and registry of histo- and cytopathology in the Netherlands) national Head-Neck protocol for the final standardized structured pathology report. 
	NOTE: This protocol is based on the up-to-date standards of the American Joint Committee on Cancer (AJCC), Union for International Cancer Control (UICC), and the World Health Organisation (WHO).
	<ol>
		<li>Assess all the margins in millimeters, including mucosa, submucosa, and bone.</li>
		<li>If an inadequate margin is found, annotate its extent (e.g., submucosal margin anterior is 3.5 mm, extending over a trajectory of 6 mm).</li>
		<li>Assess the presence of dysplasia and its grade for mucosal resection margins.</li>
		<li>Indicate the final margin by adding the dimensions of the additional resection (if performed) to the margin measured on the main specimen.</li>
		<li>Record the unique pathology number of the additional resection in the pathology report of the main specimen (e.g., Margins: anterior 6 mm, posterior 8 mm, superior 6 mm (including 3mm of the additional resection, H20-2021), inferior 7 mm, medial 5.3 mm).</li>
		<li>Verify the margins found during IOARM.</li>
		<li>Annotate the result of this verification (e.g., NB Margins found during the intraoperative assessment are in concordance with margins based on the final pathology). 
		NOTE: The time needed for IOARM should be limited in order to not interfere with the surgical workflow. At the institute, the IOARM takes about 10 min. The surgeon and pathologist perform the IOARM together. For the relocation method (placing the tags during surgery) an additional time of 5 min is needed. This will differ for each institute depending on the logistics.</li>
	</ol>
	</li>
</ol>

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The authors have nothing to disclose.

The goal of surgical treatment of OCSCC patients is the complete removal of the tumor with adequate margins. This is too often not achieved, which inspired to design an adjusted approach to oral cancer surgery with a focus on intraoperative assessment of resection margins. Aside from resection margins, other adverse tumor factors such as the pattern of invasion, perineural invasion, and lymphovascular invasion also affect the local recurrence. However, of all adverse tumor factors, surgeons and pathologists can only influence the resection margins7,8,11.
The specimen-driven IOARM method was implemented in 2013; this was eventually supported by the evidence that specimen-driven IOARM is superior to defect-driven IOARM7,13,14,15,16,17. This resulted in its recommendation by AJCC in 201718. Noteworthy, the specimen-driven IOARM method became the standard of care in the institute in 2015. From 2013 until 2020 the IOARM was performed in 304 cases with a steep increase from 2018.
It is important to realize that developing and implementing an IOARM method involves many personnel (pathologists/surgeons/assistants/trainees/researchers), in order to make it standard of care. Many professionals were involved, during many years, in the development of this protocol, which is actually the strength of the method. The development of this method started in 2013 and reached a consensus in 2015. This was achieved based on the two-weekly meetings during which discussions regarding all the patients treated with surgery, including IOARM, took place. In this way, it was possible to timely adjust and refine the procedure. Besides, the two-weekly meetings enabled prospective data collection, which provides the basis for the performance and follow-up studies9. Moreover, for every case, the team ensured that the final pathology was not compromised due to IOARM. Finally, it is important to realize that this kind of assessment is a dynamic process and will always undergo changes toward improvement.
With the specimen-driven IOARM method, the margins are assessed by inspection, palpation, and perpendicular incisions (grossing). This approach provides an as accurate as possible estimation of margins in millimeters and enables feedback on whether an additional resection is needed and what the dimensions should be. Kubik et al. described several reasons (e.g., additional resection at an incorrect location, the incorrect orientation of the additional resection, incorrect dimensions of the additional resection) for additional resections to be inadequate17. The IOARM is a valuable method but only when accompanied by an as accurate as possible relocation method of inadequate margins to enable the surgeon to perform an adequate additional resection. The spatial relationship between the additional resection and the main specimen is the key factor. Therefore, a simple but elegant relocation method as shown in Figure 1 was developed and described in detail by Van Lanschot et al.12. This method allows the surgeon to perform an additional resection based on the relocation of the inadequate margin defined by the tags in the wound bed. For example, a margin of 2 mm is found between tags 1-2-3, the surgeon performs an additional resection around tags 1-2-3 with a thickness of 4 mm. This relocation method is shown to be effective by the results of Smits et al.9.
This IOARM method is supported by frozen section procedure only if the tumor cannot be distinguished macroscopically from surrounding tissue (e.g., fibrosis of tissue after radiotherapy or scar formation after previous surgery, or salivary gland tissue). Some institutes use another approach, in which frozen sections are taken from the specimen from all quadrants13,19. This method enables a more standardized protocol. However, the comprehensiveness of this method might not be always efficient. Moreover, multiple frozen sections are needed which is costly, time-consuming, and not accessible for all institutes. The described method is more efficient because the region of interest is preselected (i.e., region of suspicious inadequate margin) and is therefore cheaper, faster, and available for every institute. This is in accordance with previous findings that frozen section analysis does not improve the accuracy of specimen-driven IOARM based on grossing in most cases and is not cost-effective20,21,22.
According to the literature &#62;93% of all inadequate margins are found at the submucosal resection margins23. This is in line with the findings of the institute. Mucosal alterations with high-grade dysplasia/CIS are often easy to detect during IOARM, only in a few cases, a frozen section is recommended. Until now in the IOARM cohort, any mucosal positive margins regarding cancer or high-grade dysplasia/CIS have not been encountered.
Even though specimen-driven IOARM significantly improves the rate of adequate resections in OCSCC patients and consequently improves patient outcome7,9,22,21, its wide implementation is lagging. The main cause of this is the fact that the grossing of fresh tissue is counter-intuitive for pathologists. The pathologists are fearful that grossing fresh tissue will deteriorate the anatomical orientation, shape, and size of the specimen, and therefore will affect the final histopathologic assessment24,25. However, the measures prescribed in the protocol prevent these possible negative effects. Since the implementation of this protocol, the anatomical orientation, shape, and size of the specimen have never been altered nor was the final pathologic assessment ever compromised (manuscript in preparation).
Although little additional time is required to perform IOARM, it is clear that no real obstacles exist to implement IOARM, but there must be a willingness to go through a learning curve, regarding the grossing of fresh tissue and identifying inadequate margins. The most important prerequisite is a dedicated and cooperative team of surgeons and pathologists. In this study, an IOARM method for head and neck cancer surgery has been described, that can easily be implemented in every institute and during any other cancer surgery. This protocol significantly improves the rate of adequate resections while concomitantly reducing the need for postoperative radiotherapy and improving the patient outcome. The specimen-driven IOARM method will help surgeons to achieve first-time-right surgery and patients will benefit.

Every year, around 350,000 new patients are diagnosed worldwide with cancer in the oral cavity; 90% of cases are squamous cell carcinoma1. The mortality rate is 175,000 worldwide per year and the 5-year survival is 50% to 64.8%1,2,3,4.
The primary treatment of oral cavity squamous cell carcinoma (OCSCC) is surgery5. The goal of the surgery is the complete removal of the tumor with adequate margins, according to the Royal College of Pathologists6. Margins &#62;5 mm (clear) are regarded as adequate, whereas margins from 0-5 mm are regarded as inadequate.
Adequate resection margins lead to higher survival and a reduction in local recurrence-rates of OCSCC7,8,9. Tumor resections with inadequate margins result in the need for adjuvant therapy (postoperative radiotherapy and/or chemotherapy). This brings an additional burden for the patient, increasing morbidity and reducing the quality of life10. The resection margin is the only oncological prognostic factor that the surgeon and pathologist can influence.
Recent reports have shown that adequate resections are only achieved in 15%-26% of cases7,8,11. These poor results are caused by the complex anatomy of the oral cavity and the lack of intraoperative guidance. During surgery, the surgeon can only rely on inspection, palpation, and preoperative imaging.
The final margin status follows only several days after the operation. If an inadequate margin is encountered at the final pathologic assessment, a second operation is usually not an option, because the wound bed reconstruction has usually healed by that time. Moreover, a second operation is mostly not effective, because the relocation of the inadequate margin is even more difficult in the postoperative setting.
To overcome the lack of intraoperative information about margin status, specimen-driven intraoperative assessment of resection margins (IOARM) was implemented in 20139. It became the standard of care in the institute in 2015. Described here is the IOARM method in detail to enable colleagues at other institutes to implement this protocol.

<table><tbody><tr><td>Anatomical templates</td><td></td><td></td><td>https://www.palga.nl/assets/uploads/Protocollen/HoofdHalstumoren.pdf</td></tr><tr><td>Anatomical tweezers</td><td></td><td></td><td></td></tr><tr><td>Brush</td><td></td><td></td><td>to apply the inc to the tissue</td></tr><tr><td>Bucket for formalin fixation</td><td></td><td></td><td>Size of the container depends on the size fo the tissue</td></tr><tr><td>Buffered formalin 4%</td><td></td><td></td><td></td></tr><tr><td>Camera</td><td></td><td></td><td></td></tr><tr><td>Computer</td><td></td><td></td><td></td></tr><tr><td>Cork</td><td></td><td></td><td>Thin plates of cork</td></tr><tr><td>Ethanol 70%</td><td></td><td></td><td></td></tr><tr><td>Examination gloves</td><td></td><td></td><td></td></tr><tr><td>Gauze or Paper</td><td></td><td></td><td>That wont leave particles on the specimen</td></tr><tr><td>Grossing knife 15cm</td><td></td><td></td><td></td></tr><tr><td>Grossing knife 30cm</td><td></td><td></td><td></td></tr><tr><td>Grossing tabel</td><td></td><td></td><td></td></tr><tr><td>Inc for tissue</td><td></td><td></td><td>3 or more different colors</td></tr><tr><td>Labcoat</td><td></td><td></td><td></td></tr><tr><td>Long pins/Sewing pins</td><td></td><td></td><td></td></tr><tr><td>Paper</td><td></td><td></td><td>To place the tissue sections on during the grossing</td></tr><tr><td>Permanent markers</td><td></td><td></td><td>Different colors (black/blue/red/green)</td></tr><tr><td>Relocation tags</td><td>Premier Farnell Limited BV, Utrecht, The Netherlands</td><td></td><td>Numbered from 0-9, cut to a size of 5 mm x 7 mm x 2 mm</td></tr><tr><td>Scalpel</td><td></td><td></td><td></td></tr><tr><td>Surgical tweezers</td><td></td><td></td><td></td></tr><tr><td>Sutures</td><td>Ethicon</td><td>Ethilon 3.0</td><td>To suture in the tags</td></tr><tr><td>Tap water</td><td></td><td></td><td></td></tr><tr><td>Transparant ruler 30 cm</td><td></td><td></td><td>2 rulers needed</td></tr></tbody></table>

intraoperative assessment of resection margins in oral cavity cancer: this is the way

The goal of head and neck oncological surgery is complete tumor resection with adequate resection margins while preserving acceptable function and appearance. For oral cavity squamous cell carcinoma (OCSCC), different studies showed that only 15%-26% of all resections are adequate. A major reason for the low number of adequate resections is the lack of information during surgery; the margin status is only available after the final histopathologic assessment, days after surgery.
The surgeons and pathologists at the Erasmus MC University Medical Center in Rotterdam started the implementation of specimen-driven intraoperative assessment of resection margins (IOARM) in 2013, which became the standard of care in 2015. This method enables the surgeon to turn an inadequate resection into an adequate resection by performing an additional resection during the initial surgery. Intraoperative assessment is supported by a relocation method procedure that allows accurate identification of inadequate margins (found on the specimen) in the wound bed.
The implementation of this protocol resulted in an improvement of adequate resections from 15%-40%. However, the specimen-driven IOARM is not widely adopted because grossing fresh tissue is counter-intuitive for pathologists. The fear exists that grossing fresh tissue will deteriorate the anatomical orientation, shape, and size of the specimen and therefore will affect the final histopathologic assessment. These possible negative effects are countered by the described protocol. Here, the protocol for specimen-driven IOARM is presented in detail, as performed at the institute.

Example of IOARM resulting in an adequate resection 
The patient presents with a cT2N0M0 SCC of the left side of the tongue with no medical history. The patient undergoes hemiglossectomy supported by IOARM. The specimen is inspected and palpated; the mucosal margins are measured as &#62;5 mm. One area in the submucosal resection surface is suspicious for an inadequate margin, located around tag 5. The submucosal margin is 3-4 mm at tag 5. All the information is recorded on the template and copied to the EPF (Figure 7A).
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/62446/62446fig07.jpg" /> 
Figure 7: Examples of two different IOARMs recorded on the anatomical template. (A) IOARM resulting in an adequate resection. (B) IOARM not resulting in an adequate resection. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62446/62446fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
The surgeon returns to the OR and performs the additional resection. The pathologist verifies the accuracy and dimensions, including the thickness of the additional resection.
The final pathology report shows the presence of moderately differentiated pT2 squamous cell carcinoma on the left side of tongue. The tumor diameter is 2.5 cm and the depth of invasion is 6.0 mm. The worst pattern of invasion (WPOI) is category 3. Perineural invasion (PNI) is not present and the lymphovascular invasion (LVI) is present. The minimal margins (mucosal and submucosal) at the inferior, superior, anterior, and posterior location are 5.8 mm (including additional resection (PA number: XXXXX) of 3 mm thickness), 6.2 mm (including additional resection (PA number: XXXXX) of 3 mm thickness), 5.2 mm, and 5.5 mm, respectively. IOARM is in concordance with final pathology.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="4">Margins (mm)</td>
		</tr>
		<tr>
			<td>Location</td>
			<td>Based on IOARM</td>
			<td>After additional resection</td>
			<td>Based on Final pathology</td>
		</tr>
		<tr>
			<td>Inferior</td>
			<td>3-4</td>
			<td>6-7</td>
			<td>5.8</td>
		</tr>
		<tr>
			<td>Superior</td>
			<td>3-4</td>
			<td>6-7</td>
			<td>6.2</td>
		</tr>
		<tr>
			<td>Anterior</td>
			<td>&#62;5</td>
			<td></td>
			<td>5.2</td>
		</tr>
		<tr>
			<td>Posterior</td>
			<td>&#62;5</td>
			<td></td>
			<td>5.5</td>
		</tr>
	</tbody>
</table>
Table 1: Example of resection margins during IOARM resulting in an adequate resection at final pathology, after additional resection.
Example of IOARM not resulting in an adequate resection 
The patient presents with a cT1N0M0 SCC of the right side of the tongue with no medical history. The patient underwent a resection supported by IOARM. The surgeon takes the specimen to the pathologist at the pathology department. The mucosa is visually inspected, and the mucosal margins are measured with a transparent ruler, all mucosal margins are &#62;5 mm. The submucosal margins are visually inspected and palpated and all margins seem &#62;5 mm. A suspicious area is found at tag 1 (anterior resection surface) and tag 3 (posterior resection surface). A grossing knife is placed perpendicular to the resection surface from anterior to posterior (tag 1 to tag 3) and an incision is made. The pathologist measures the margin on the cross-section and the margins are &#62;5 mm. All the information is recorded on the template and copied to the EPF (Figure 7B).
The final pathology report shows a well-differentiated pT1 squamous cell carcinoma on the right side of the tongue. The diameter of the tumor is 1.8 cm, and the depth of invasion is 3.8 mm. The worst pattern of invasion (WPOI) is category 2. Perineural invasion (PNI), lymphovascular invasion (LVI), and dysplasia are not present. The minimal margins (mucosal and submucosal) at the inferior, superior, anterior, and posterior locations are 4.0 mm, 6.1 mm, 6.4 mm, and 7.8 mm, respectively. IOARM is not in concordance with final pathology, margin inferior was missed.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="4">Margins (mm)</td>
		</tr>
		<tr>
			<td>Location</td>
			<td>Based on IOARM</td>
			<td>After additional resection</td>
			<td>Based on Final pathology</td>
		</tr>
		<tr>
			<td>Inferior</td>
			<td>&#62;5</td>
			<td rowspan="4">Not recommended all margins &#62; 5mm</td>
			<td>4.0</td>
		</tr>
		<tr>
			<td>Superior</td>
			<td>&#62;5</td>
			<td>6.1</td>
		</tr>
		<tr>
			<td>Anterior</td>
			<td>6</td>
			<td>6.4</td>
		</tr>
		<tr>
			<td>Posterior</td>
			<td>8</td>
			<td>7.8</td>
		</tr>
	</tbody>
</table>
Table 2: Example of resection margins during IOARM not resulting in an adequate resection at final pathology.

Watch this Scientific Journal Video about Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way at JoVE.com

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

The goal of this protocol is to provide a clear overview of specimen-driven intraoperative assessment of resection margins. It is encouraged to implement this protocol to improve patient care at other institutes.

The goal of head and neck oncological surgery is complete tumor resection with adequate resection margins while preserving acceptable function and ...

intraoperative-assessment-resection-margins-oral-cavity-cancer-this

Nanyang Technological University

Research

JoVE Journal

Medicine

3.7K Views.  Erasmus MC University Medical Center. Dit protocol beschrijft een specimen-gedreven methode van intraoperatieve beoordeling van resectiemarges bij mondkanker en deze methode stelt artsen in staat om het aantal adequate resecties te verbeteren. Dit protocol kan eenvoudig in elk instituut worden geïmplementeerd. Het interfereert niet met de duur van de chirurgische procedure en interfereert of verstoort de uiteindelijke pathologie niet.Plaats om te beginnen de chloorhexadine voorbevochtigde tags gekoppeld aan de zijkanten v...

Video: Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

DIPLOMA Approach for Standardized Pathology Assessment of Distal Pancreatectomy Specimens

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. Accurate pathology assessment of the pancreatic specimen is essential for providing prognostic information and it may guide further treatment strategies. The recent 8th edition of the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system for pancreatic tumors has incorporated significant changes to tumor (pT) stage, which is predominantly based on tumor size. This change emphasizes the importance of careful block selection. Owing to the greater prevalence of tumors in the head of the pancreas, efforts are made to standardize the assessment of pancreatoduodenectomy specimens. However, consensus regarding the macroscopic assessment of distal (i.e., left) pancreatectomy specimens is lacking. The DIPLOMA approach includes the standardized measurement of pancreas and other resected organs, inking of relevant surgical margins and anatomical surfaces without removing covering layers of fat, measurement of tumor size (for T-stage), together with assessment of splenic vessel involvement (and other organs if present). All relevant margins are assessed, and relevant blocks are selected to confirm these parameters microscopically. The current protocol describes a standardized approach to the macroscopic assessment of distal pancreatectomy specimens. This approach was developed during several meetings with pathologists and surgeons during the preparation phase for an international multicenter trial (DIPLOMA, ISRCTN44897265), which focuses on radicality of distal pancreatectomy for pancreatic ductal adenocarcinoma. This standardized approach can be instrumental in the design of studies and will uniform reporting on the outcomes of distal pancreatectomy. The described technique is used in the DIPLOMA trial for pancreatic ductal adenocarcinoma but may also be useful for other indications.

The current study highlights a standardized approach to the macroscopic assessment of distal pancreatectomy specimens for pancreatic ductal adenocarcinoma, with special emphasis on the measurement of pancreatic dimensions and those of other organs, inking of margins, measurement of tumor size and proximity to margins, lymph node sampling and block selection.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant cancers. A minority (20%) of PDACs are found in the pancreatic body and tail. ...

A Postoperative Evaluation Guideline for Computer-Assisted Reconstruction of the Mandible

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging modalities, mandibular defect classification, and evaluation methodologies between studies. This guideline uses a step-by-step approach guiding the process of imaging, classification of mandibular defects and volume assessment of three-dimensional (3D) models, after which a legitimized quantitative accuracy evaluation method can be performed between the postoperative clinical situation and the preoperative virtual plan. The condyles and the vertical and horizontal corners of the mandible are used as bony landmarks to define virtual lines in the computer-assisted surgery (CAS) software. Between these lines the axial, coronal, and both sagittal mandibular angles are calculated on both pre- and postoperative 3D models of the (neo)mandible and subsequently the deviations are calculated. By superimposing the postoperative 3D model to the preoperative virtually planned 3D model, which is fixed to the XYZ axis, the deviation between pre- and postoperative virtually planned dental implant positions can be calculated. This protocol continues and specifies an earlier publication of this evaluation guideline.

Here, we propose a practical, feasible and reproducible evaluation guideline for computer-assisted reconstruction of the mandible in order to create uniformity between studies regarding postoperative accuracy evaluation. This protocol continues and specifies an earlier publication of this evaluation guideline.

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging ...

A Mouse Model of Incompletely Resected Soft Tissue Sarcoma for Testing (Neo)adjuvant Therapies

Surgery is often the first treatment for many solid tumors. However, local relapses frequently occur following primary tumor resection, despite adjuvant or neo-adjuvant therapies. This occurs when surgical margins are insufficiently tumor-free, resulting in residual cancer cells. From a biological and immunological perspective, surgery is not a null event; the wound healing environment is known to induce both pro- and anti-tumorigenic pathways. As a consequence, preclinical models for drug development aimed at preventing local relapse should incorporate surgical resection when testing new (neo)adjuvant therapies, to model the clinical settings in patients treated with surgery.
Here, we describe a mouse model of incomplete surgical resection of WEHI 164 soft tissue sarcoma that allows testing of (neo)adjuvant therapies in the setting of a wound healing response. In this model, 50% or 75% of the tumor is removed, leaving behind some cancer tissue in situ to model gross residual disease after surgery in the clinical setting. This model allows testing therapies in the context of surgery while also considering the wound healing response, which may affect the efficacy of (neo)adjuvant treatments. The incomplete surgical resection results in reproducible regrowth of the tumor in all mice in the absence of adjuvant therapy. Adjuvant treatment with checkpoint blockade results in reduced tumor regrowth. This model is thus appropriate for testing therapies in the context of debulking surgery and its associated wound healing response and can be extended to other types of solid cancer.

A Mouse Model of Incompletely Resected Soft Tissue Sarcoma for Testing Neoadjuvant Therapies

In this protocol, we describe a mouse model of incomplete surgical resection of soft tissue sarcoma for testing (neo)adjuvant therapies.

Surgery is often the first treatment for many solid tumors. However, local relapses frequently occur following primary tumor resection, despite adjuvant ...

An In Vivo Mouse Model of Total Intravenous Anesthesia During Cancer Resection Surgery

Anesthesia is a routine component of cancer care that is used for diagnostic and therapeutic procedures. The anesthetic technique has recently been implicated in impacting long-term cancer outcomes, possibly through modulation of adrenergic-inflammatory responses that impact cancer cell behavior and immune cell function. Emerging evidence suggests that propofol-based total intravenous anesthesia (TIVA) may be beneficial for long-term cancer outcomes when compared to inhaled volatile anesthesia. However, the available clinical findings are inconsistent. Preclinical studies that identify the underlying mechanisms involved are critically needed to guide the design of clinical studies that will expedite insight. Most preclinical models of anesthesia have been extrapolated from the use of anesthesia in in vivo research and are not optimally designed to study the impact of anesthesia itself as the primary endpoint. This paper describes a method for delivering propofol-TIVA anesthesia in a mouse model of breast cancer resection that replicates key aspects of clinical delivery in cancer patients. The model can be used to study mechanisms of action of anesthesia on cancer outcomes in diverse cancer types and can be extrapolated to other non-cancer areas of preclinical anesthesia research.

An In Vivo Mouse Model of Total Intravenous Anesthesia During Cancer Resection Surgery

This paper describes a method for modeling total intravenous anesthesia (TIVA) during cancer resection surgery in mice. The goal is to replicate key features of anesthesia delivery to patients with cancer. The method allows investigation of how anesthetic technique affects cancer recurrence after resection surgery.

Anesthesia is a routine component of cancer care that is used for diagnostic and therapeutic procedures. The anesthetic technique has recently been ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Capturing Oral Submucous Fibrosis Tissue Samples for Spatial-Omics Analysis

Isolation of Cells with Morphological and Spatial Information from Oral Submucous Fibrosis Samples by Laser Capture Microdissection

Oral submucous fibrosis (OSF) is a common type of potentially malignant disorder in the oral cavity. The atrophy of epithelium and fibrosis of the lamina propria and the submucosa are often found on histopathological slides. Epithelial dysplasia, epithelial atrophy, and senescent fibroblasts have been proposed to be associated with the malignant transformation of OSF. However, because of the heterogeneity of potentially malignant oral disorders and oral squamous cell carcinoma, it is difficult to identify the specific molecular mechanisms of malignant transformation in OSF. Here, we present a method to obtain a small number of epithelial or mesenchymal cells carrying morphological data and spatial information by laser capture microdissection on formalin-fixed paraffin-embedded tissue slides. Using a microscope, we can precisely capture microscale (~500 cells) dysplastic or atrophic epithelial tissue and fibrotic subepithelial tissue. The extracted cells can be evaluated by genome or transcriptome sequencing to acquire genomic and transcriptomic data with morphological and spatial information. This approach removes the heterogeneity of bulk OSF tissue sequencing and the interference caused by cells in non-lesioned areas, allowing for precise spatial-omics analysis of OSF tissue.

Author Spotlight: Unlocking the Mysteries of Oral Potential Malignancies 

Laser capture microdissection of oral submucous fibrosis tissues allows for precise extraction of cells from histological regions of interest for the analysis of multi-omics data with morphological and spatial information.

Oral submucous fibrosis (OSF) is a common type of potentially malignant disorder in the oral cavity. The atrophy of epithelium and fibrosis of the lamina ...

Advanced CAD Imaging for Surgical Margin Analysis in Cancer Care

Enhanced Communication of Tumor Margins Using 3D Scanning and Mapping

After oncologic resection of malignant tumors, specimens are sent to pathology for processing to determine the surgical margin status. These results are communicated in the form of a written pathology report. The current standard-of-care pathology report provides a written description of the specimen and the sites of margin sampling without any visual representation of the resected tissue. The specimen itself is typically destroyed during sectioning and analysis. This often leads to challenging communication between pathologists and surgeons when the final pathology report is confirmed. Furthermore, surgeons and pathologists are the only members of the multidisciplinary cancer care team to visualize the resected cancer specimen. We have developed a 3D scanning and specimen mapping protocol to address this unmet need. Computer-aided design (CAD) software is used to annotate the virtual specimen clearly showing sites of inking and margin sampling. This map can be utilized by various members of the multidisciplinary cancer care team.

Author Spotlight: 3D Scanning and Augmented Reality for Enhanced Cancer Surgery Communication

A novel method for 3D scanning and virtual mapping of cancer resections is proposed with the goal of improving communication among the multidisciplinary cancer care team.

After oncologic resection of malignant tumors, specimens are sent to pathology for processing to determine the surgical margin status. These results are ...

Improving Outcomes in Anteromesial Temporal Lobe Resections - A Demonstration of Resecting the Temporal Piriform Cortex

Anteromesial temporal lobe resection (ATLR) is a useful treatment option for drug-resistant mesial temporal lobe epilepsy (DRmTLE). Growing evidence suggests the piriform cortex plays a crucial role in the generation and propagation of seizures in DRmTLE - and that the resection of the temporal portion of the piriform cortex is associated with significantly improved rates of seizure freedom. 
Here, we present the resection of the temporal portion of the piriform cortex in ATLR, using high-resolution preoperative probabilistic tractography algorithms and fused anatomical masks of the structures of interest into the intraoperative neuronavigation and microscope head-up display (HUD). 
All patients undergoing comprehensive preoperative assessment and investigations for DRmTLE provided informed, written consent to record an intraoperative video of the procedure. Patients were identified by an expert multidisciplinary team of epileptologists, epilepsy neurosurgeons, neuropsychologists, neuropsychiatrists, and electrophysiologists at a large epilepsy surgery center. The preoperative imaging pipeline included the delineation of critical structures. This included the temporal piriform cortex, and high-resolution probabilistic tractography for essential tracts at risk (e.g., optic radiation and inferior fronto-occipital fasciculus). These were co-registered to the preoperative volumetric neuronavigation scan and uploaded to the intra-operative neuronavigation system. 
Presented here is a step-by-step procedure of ATLR, including the resection of the temporal portion of the piriform cortex. The protocol combines Advanced structural and diffusion MR imaging and intraoperative visual aids to integrate anatomical masks of critical grey matter structures and white matter tracts into the surgical workflow in the operating room.

Here, we demonstrate an approach to intraoperative neurosurgical guidance in anteromesial temporal lobe resections, specifically highlighting the use of tractography and anatomical masks to aid safe resection of the temporal portion of the piriform cortex - an area increasingly regarded as a crucial surgical target in drug-resistant mesial temporal lobe epilepsy.

Anteromesial temporal lobe resection (ATLR) is a useful treatment option for drug-resistant mesial temporal lobe epilepsy (DRmTLE). Growing evidence ...

Neuroscience

Assessment of the Mouth

A thorough mouth assessment, including inspection and palpation of the lips, gums, tongue, tonsils, uvula, and pharynx, is crucial in detecting potential health issues. Diseases ranging from oral cancer to systemic conditions like diabetes could be identified early through careful oral examination. This article provides a detailed guide on conducting a comprehensive mouth assessment.
Mouth Inspection
The inspection begins with visually examining the mouth for symmetry, color, and size. Attention should be paid to abnormalities such as pallor or cyanosis, cracking, ulcers, or fissures.
Lips
Lips should be inspected for moisture, hydration, color, texture, symmetry, and possible ulcerations or fissures. Healthy lips are generally moist, pink, smooth, and symmetric.
Gums
Gums should be carefully inspected for signs of inflammation, bleeding, retraction, discoloration, and odors from the breath. Any abnormal shape and position of teeth, swelling, bleeding, discoloration, or gingival inflammation should be noted.
Tongue
The dorsum (top) of the tongue could have a thin white coating, which is harmless, while the undersurface should be smooth and free of lesions. Assess the tongue&#39;s size, symmetry, and strength by requesting the patient to protrude and move it sideways.
Tonsils, Uvula, and Pharynx
The tonsils, uvula, soft palate, and anterior and posterior pillars are inspected by tilting the patient&#39;s head and depressing the tongue with a blade. When the patient says &#8220;ah,&#8221; the uvula and soft palate should rise and remain in the midline.
Palpation of the Mouth
Following inspection, palpation is performed to assess any suspicious areas in the mouth. It involves using gloved fingers to feel for abnormalities such as ulcers, nodules, indurations, and areas of tenderness.
Lips, Gums, and Tongue
The lips, gums, and tongue are palpated for lesions or abnormalities. Special attention should be given to the fit and condition of dentures, swallowing ability, and potential mouth lesions in older adults and those with dentures. Patients with dentures should remove them during an oral exam to allow for better visualization and palpation of the area.
Floor of the Mouth
The floor of the mouth is also assessed by asking the patient to touch the roof of the mouth with the tip of their tongue. It allows the clinician to look for any mucosal lesions or abnormalities involving the frenulum or superficial veins on the undersurface of the tongue.
A comprehensive mouth assessment is essential for early detection of many disorders. Healthcare professionals must be adept at inspection and palpation techniques to ensure a thorough examination, leading to a more accurate diagnosis. Regular mouth assessments are vital, as many disorders, including cancer, diabetes, and immunosuppressive conditions, can manifest through changes in the oral cavity.

The oral cavity assessment starts with the lips, checking for symmetry, moisture, color, and overall appearance.
Healthy lips are usually pink, smooth, ...

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

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