Panel deliberation.
Complete resection with negative margin is associated with improved local control and survival. However, negative margin resection is not the goal for orbital RMS or for large tumors where morbidity would be significant38,39. Although the choice of a 0.5 cm margin is somewhat arbitrary, such a narrow margin may be more feasible and simultaneously enable pathological confirmation of R0 resection. At the time of surgical local control, the fundamental principle of complete excision with a surrounding ”cuff” of normal tissue should be followed to ascertain pathological negative margins, provided there is no loss of function or cosmetic appearance. The surgical team should ensure that the specimen is handed to pathology intact and abstain from any “on-table” dissection of the specimen that may violate the surrounding cuff of normal tissue. To ensure accurate margin evaluation, the specimen should be oriented, and margins labeled. It is inevitable to have narrow margins in some cases with complex tumor anatomy. In such cases, the surgeon ought to obtain biopsies of the resection bed especially adjacent to areas with questionable margins. These biopsies ought to be accurately labeled and sent for pathologic examination. To guarantee the accuracy of the margin inspection, communication with the local pathologist is required. A narrow margin of <1 mm is acceptable for sites with anatomic restrictions like non-parameningeal head and neck RMS to preserve form and function. Similarly, very aggressive resection is not warranted for RMS of the perineum or anus because of the proximity to urethra and anus that limits the feasibility of complete resection without compromising function preservation40. Neurovascular and other critical structures should not be resected to achieve arbitrary margin widths.
The panel suggests intraoperative tumor-bed marking with surgical clips for patients with RMS. (Weak recommendation, Certainty of evidence: Very Low)
We identified no comparative studies that assessed marking of tumor bed with surgical clips versus no marking.