Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
JAMA Otolaryngol Head Neck Surg. 2017 Dec 1;143(12):1220-1227. doi: 10.1001/jamaoto.2017.2011.
Sinonasal mucosal melanoma (SMM) is a rare malignant neoplasm characterized by a poor prognosis despite aggressive intervention including wide surgical resection. Margin status has previously been cited as an important prognostic factor for local control and overall survival (OS) in patients who undergo either an open or endoscopic surgical approach. No comparisons have been made, however, in patients who have undergone gross total resection with or without positive margins.
To assess the association of margin status and surgical approach with oncologic outcomes in patients with SMM undergoing gross total resection.
DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, patients with SMM without evidence of regional or distant disease treated with curative intent in part or full at Memorial Sloan Kettering Cancer Center from 1998 through 2016 were retrospectively assessed. Demographic data, prognostic information, and surgical pathology were reviewed. Operative reports and imaging were used to confirm gross total resection of local disease.
Surgical techniques including open maxillectomy, craniofacial resection, and endoscopic resection.
Three-year local recurrence-free survival (LRFS), disease-free survival (DFS), and OS were calculated using the Kaplan-Meier method. Univariate and multivariable analyses of outcomes were carried out using the Cox proportional hazard regression method.
Seventy-two patients (39 [54%] female; mean [SD] age, 67 [12] years) met the eligibility criteria. Thirty-eight patients (53%) underwent open partial or total maxillectomy with or without ethmoidectomy or sphenoidectomy via a transfacial approach. Fourteen patients (19%) had a more extensive craniofacial approach, and 20 patients (28%) underwent endoscopic resection. The 3-year OS for all patients was 52%. The absolute 3-year difference between patients with open/craniofacial resection vs endoscopic resection for LRFS, DFS, and OS was 11% (95% CI, −21% to 43%), 16% (95% CI, −7% to 39%), and 12% (95% CI, −18% to 41%), respectively. The absolute 3-year difference between patients with a negative margin and patients with a positive margin for LRFS, DFS, and OS was 18% (95% CI, −9% to 45%), 5% (95% CI, −17% to 27%), and 15% (95% CI, −9% to 39%), respectively. Multivariable analysis revealed that none of the adjusted variables (margin status, tumor stage, or surgical approach) were significantly associated with OS.
Outcomes for patients with SMM remain poor regardless of operative approach or postoperative margin status.
尽管采用了包括广泛手术切除在内的积极干预措施，但是鼻窦黏膜黑色素瘤（SMM）仍是一种预后不良的罕见恶性肿瘤。在接受开放式或内镜手术治疗的患者中，切缘状态先前被认为是局部控制和总生存（OS）的重要预后因素。然而，尚未在接受完全手术切除且切缘阳性或阴性的患者中进行比较。
评估 SMM 患者在接受完全手术切除时切缘状态和手术方法与肿瘤学结果的关系。
设计、设置和参与者：在这项回顾性队列研究中，对 1998 年至 2016 年期间在 Memorial Sloan Kettering 癌症中心接受根治性治疗的局部疾病部分或全部接受治疗的无区域或远处疾病证据的 SMM 患者进行评估。回顾性评估了患者的人口统计学数据、预后信息和手术病理学资料。使用手术报告和影像学检查来确认局部疾病的完全手术切除。
包括开放式上颌骨切除术、颅面切除术和内镜切除术在内的手术技术。
使用 Kaplan-Meier 法计算 3 年局部无复发生存率（LRFS）、无病生存率（DFS）和 OS。使用 Cox 比例风险回归法进行单变量和多变量分析。
72 名患者（39 [54%] 名女性；平均[SD]年龄，67 [12] 岁）符合入选标准。38 名患者（53%）接受了开放式部分或全部上颌骨切除术，联合或不联合经面入路的鼻旁窦切除术或蝶窦切除术。14 名患者（19%）采用了更广泛的颅面入路，20 名患者（28%）接受了内镜切除术。所有患者的 3 年 OS 为 52%。在接受开放式/颅面切除术与内镜切除术的患者中，LRFS、DFS 和 OS 的 3 年绝对差异分别为 11%（95%CI，-21%至 43%）、16%（95%CI，-7%至 39%）和 12%（95%CI，-18%至 41%）。LRFS、DFS 和 OS 的阴性切缘与阳性切缘患者的 3 年绝对差异分别为 18%（95%CI，-9%至 45%）、5%（95%CI，-17%至 27%）和 15%（95%CI，-9%至 39%）。多变量分析显示，调整后的变量（切缘状态、肿瘤分期或手术方法）均与 OS 无显著相关性。
无论手术方法还是术后切缘状态如何，SMM 患者的预后仍然较差。
