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.