Scarberry Kyle, Berger Nicholas G, Scarberry Kelly B, Agrawal Shree, Francis John J, Yih Jessica M, Gonzalez Christopher M, Abouassaly Robert
Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH.
Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI.
Urol Oncol. 2018 Jun;36(6):308.e11-308.e17. doi: 10.1016/j.urolonc.2018.03.007. Epub 2018 Apr 5.
Positive surgical margins (PSM) and lymph node yield (LNY) following radical cystectomy (RC) for urothelial carcinoma of the bladder affect survival. Variations in PSM or LNY at different care facilities are poorly described. We evaluated the relationship between hospital surgical volume and academic hospital status with these surgical outcomes and overall survival (OS).
Patients with nonmetastatic urothelial carcinoma of the bladder who underwent RC were identified from the National Cancer Database (2004-2013). Treatment centers were categorized as academic (ACC) and community cancer centers (CCC). Logistic regression was used to identify factors associated with PSM status and LNY, and a multivariate Cox proportional hazards model was used to determine factors associated with OS.
In our cohort, 39,274 patients underwent RC. A lower proportion of PSMs (10% vs.12%; P<0.001) and higher median LNY (14 vs. 8, P<0.001) was observed at ACCs compared to CCCs. On logistic regression, there were lower odds of PSM (OR = 0.89, 95% CI: 0.81-0.97) and higher odds of LNY ≥ 10 nodes (OR = 1.84, 95% CI: 1.74-1.96) among patients at ACCs compared to CCCs. Cox proportional hazards analysis demonstrated benefit to OS at high-volume centers (HR = 0.91, 95% CI: 0.87-0.95) but not based on ACC designation. The OS advantage at high-volume centers is attenuated (HR = 0.95, 95% CI: 0.91-0.99) by PSM status and LNY.
ACCs demonstrate improved surgical outcomes following RC, and a survival advantage attributable to high surgical volume is identified. Centralization of care may lead to improved outcomes in this lethal malignancy.
膀胱尿路上皮癌根治性膀胱切除术（RC）后的阳性手术切缘（PSM）和淋巴结获取数量（LNY）会影响生存率。不同医疗机构中PSM或LNY的差异鲜有描述。我们评估了医院手术量和学术医院地位与这些手术结果及总生存期（OS）之间的关系。
从国家癌症数据库（2004 - 2013年）中识别出接受RC的非转移性膀胱尿路上皮癌患者。治疗中心分为学术癌症中心（ACC）和社区癌症中心（CCC）。采用逻辑回归确定与PSM状态和LNY相关的因素，采用多变量Cox比例风险模型确定与OS相关的因素。
在我们的队列中，39274例患者接受了RC。与CCC相比，ACC的PSM比例更低（10%对12%；P<0.001），LNY中位数更高（14对8，P<0.001）。逻辑回归显示，与CCC患者相比，ACC患者出现PSM的几率更低（OR = 0.89，95%CI：0.81 - 0.97），LNY≥10个淋巴结的几率更高（OR = 1.84，95%CI：1.74 - 1.96）。Cox比例风险分析表明，高手术量中心对OS有获益（HR = 0.91，95%CI：0.87 - 0.95），但并非基于ACC的指定。高手术量中心的OS优势因PSM状态和LNY而减弱（HR = 0.95，95%CI：0.91 - 0.99）。
ACC在RC后显示出更好的手术结果，并且确定了高手术量带来的生存优势。集中治疗可能会改善这种致命恶性肿瘤的治疗结果。
