Fluorescence-Guided Surgery for Assessing Margins in Head and Neck Cancer

Importance Head and neck squamous cell cancer (HNSCC) is associated with a higher positive margin rate compared with most other cancers in surgical oncology. This rate has remained stagnant over the past 3 decades. Fluorescence-guided surgery (FGS) is a promising tool to address high positive margin rates in multiple solid tumor types, including HNSCC. This review summarizes data from a decade of FGS research in this tumor type to outline how fluorescence can help improve margin clearance, especially at the deep margin. The principles presented can be broadly applied using HNSCC as a model disease. Observations In contrast to the superficial mucosal margin, the deep margin is especially challenging for surgeons to visualize and contributes to the vast majority of positive margins and subsequent sequelae in HNSCC. Using fluorescence in vivo can highlight residual disease in the resection bed, while using fluorescence ex vivo can highlight how close the tumor margin is from the resection surface of the specimen, guiding sampling and further resection. Conclusions and Relevance Currently, there are several clinical trials investigating FGS to improve margin clearance in HNSCC, with many fluorescent agents already approved for use in other cancer types. As additional agents are brought into clinical use, it will be critical to understand how this technique will or will not improve oncological management in our patients. To address this important point, we present 2 key areas where surgeons will consider use of these FGS: to assess the peripheral mucosal margin and the deep surface of the tumor. We outline how in vivo and ex vivo fluorescence can be used for this purpose. We summarize data from multiple sources to explain how FGS is most likely to help with deep margin clearance.