Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois.
Pritzker School of Medicine, The University of Chicago, Chicago, Illinois.
JAMA Otolaryngol Head Neck Surg. 2018 Dec 1;144(12):1090-1097. doi: 10.1001/jamaoto.2018.2421.
The achievement of complete tumor resection with tumor-free margins is one of the main principles of oncologic surgery for head and neck squamous cell carcinoma (HNSCC). The negative prognostic influence of a positive margin (PM) across all head and neck subsites has been well established. National guidelines recommend the use of adjuvant chemoradiation therapy (CRT) in the setting of PM.
To determine the incidence of PM in HNSCC across multiple subsites, as well as the factors associated with its occurrence.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used the National Cancer Database to identify patients diagnosed with HNSCC between 2010 and 2014 and who underwent surgical resection (n = 28 840).
Predictors of PM rate and likelihood to receive adjuvant CRT.
Among the 28 840 patients included in this study, 19 727 (68.4 %) were men, and the average age was 62.4 years (range, 40 to ≥90 years). In univariable analysis, a lower PM rate was associated with higher facility volume (26.3% for the lowest volume quartile, 16.5% for the middle 2 quartiles, and 10.8% for the highest volume quartile) and treatment at academic vs nonacademic facilities (14.0% vs 22.7%). In multivariate analysis, those treated at higher-volume facilities remained significantly less likely to have PM (adjusted odds ratio, 0.85; 95% CI, 0.83-0.88). The trend of decreasing PM rate with increasing facility volume was observed in both academic (aOR, 0.88 per 10-case volume increase [95% CI, 0.85-0.91]) and nonacademic (aOR, 0.73 per 10-case volume increase [95% CI, 0.68-0.80]) facilities. There was no association between facility volume and patient likelihood of receiving adjuvant CRT in the setting of PM (compared with CCPs: aOR, 0.98 per 10-case volume increase [95% CI, 0.84-1.14] for CCCPs; and aOR, 1.24 [95% CI, 0.99-1.55] for INCPs).
These findings suggest that high-volume facilities are associated with lower rates of PM in the surgical treatment of HNSCC in both academic and nonacademic settings. Facility volume for head and neck oncologic surgeries may be considered a benchmark for quality of care.
对于头颈部鳞状细胞癌（HNSCC），实现肿瘤完全切除和无肿瘤边缘是肿瘤外科的主要原则之一。所有头颈部亚部位的阳性切缘（PM）的负面预后影响已经得到充分证实。国家指南建议在 PM 情况下使用辅助放化疗（CRT）。
确定 HNSCC 在多个亚部位的 PM 发生率，以及与 PM 发生相关的因素。
设计、地点和参与者：这项回顾性队列研究使用国家癌症数据库确定了 2010 年至 2014 年间诊断为 HNSCC 并接受手术切除的患者（n=28840）。
PM 发生率和接受辅助 CRT 可能性的预测因素。
在这项研究的 28840 名患者中，19727 名（68.4%）为男性，平均年龄为 62.4 岁（范围，40 至≥90 岁）。在单变量分析中，较低的 PM 发生率与较高的设施容量（最低容量四分位数为 26.3%，中间两个四分位数为 16.5%，最高容量四分位数为 10.8%）和在学术与非学术设施治疗（14.0%与 22.7%）相关。在多变量分析中，在高容量设施接受治疗的患者发生 PM 的可能性显著降低（调整后的优势比，0.85；95%置信区间，0.83-0.88）。在学术（aOR，每增加 10 例病例体积增加 0.88[95%置信区间，0.85-0.91]）和非学术设施（aOR，每增加 10 例病例体积增加 0.73[95%置信区间，0.68-0.80]）中均观察到设施容量与 PM 发生率降低的趋势。设施容量与 PM 患者接受辅助 CRT 的可能性之间没有关联（与 CCPs 相比：每增加 10 例病例体积，CCCPs 的 aOR 为 0.98[95%CI，0.84-1.14]；INCPs 的 aOR 为 1.24[95%CI，0.99-1.55]）。
这些发现表明，在学术和非学术环境中，高容量设施与 HNSCC 手术治疗中 PM 发生率较低相关。头颈部肿瘤手术的设施容量可被视为护理质量的基准。
