Recurrence after primary salivary gland carcinoma: Frequency, survival, and risk factors

BACKGROUND

Primary salivary gland carcinomas (SGC) are rare neoplasms that present therapeutic challenges especially in recurrent tumors. The aim of this study was to investigate the incidence and distribution of tumor recurrence, associated risk factors, and survival.

METHODS

This analysis includes data from 318 patients treated for SGC between 1992 and 2020. Survival analysis was performed using the Kaplan-Meier method. Univariate and multivariate analyses were used to identify risk factors associated with recurrence.

RESULTS

21.7% of the patients developed recurrent disease after a mean of 38.2 months. In multivariate analysis, positive-resection margins, vascular invasion, and tumor localization in the submandibular gland and small salivary glands were independent factors for recurrence. The 5-year overall survival was 67%, the 5-year disease-free survival was 54%.

CONCLUSION

Tumor recurrence in SGC occurred in one out of five patients. In highly aggressive entities and patients with risk factors, treatment intensification should be considered.

Particle Beam Therapy and Surgery as Radical Treatments for Parotid Malignancies-A Single-Center Preliminary Case Study

Background/Objectives: Particle beam therapy (PBT) was approved in April 2018 for head and neck malignancies and has since been introduced as a radical therapy for parotid malignancies. However, its prevalence and effectiveness in relation to surgical treatment have not been investigated. Methods: In this study, we evaluated 36 patients with parotid malignancy who underwent surgery (n = 26) or PBT (n = 10) and then analyzed the annual changes in the number of patients, survival rates, and clinical factors affecting prognosis. Results: Of the ten patients who opted for PBT, two and eight patients underwent PBT before and after 2018, respectively. There was a significant difference between these two groups of patients (p = 0.04). Of the ten patients who underwent PBT, five patients were recurrent cases; meanwhile, all twenty-six patients who underwent surgery were receiving initial treatment. Only one patient in each group had local recurrence after the treatment. Conclusions: The use of PBT as a radical therapy for parotid malignancies has been increasing since 2018, and patients with recurrent tumors tended to choose PBT. The outcome of the patients who underwent PBT did not seem to be inferior compared with those of the patients who underwent surgery. The histopathological type was a crucial issue in the outcomes of patients who underwent radical therapy for parotid malignancies.

Radical Resection of Malignant Tumors of Major Salivary Glands: Is This Possible?

In primary therapy, a universally recognized surgical indication applies to all tumors of the salivary glands. According to the classic rule, radical resection of a head and neck tumor requires clean margins of at least 5 mm, although recent studies have shown that for certain locations, 1 mm may be sufficient. In the surgical resection of a tumor of the salivary glands, especially of the parotid gland, can these rules be respected? Owing to the complex branching and connections of the facial nerve within the parotid gland, even a medium-sized malignant tumor may be in contact with a branch of the nerve, thus raising the question of its preservation. The facial nerve is so important from a functional and aesthetic point of view that it is commonly believed that it should be preserved unless it is incorporated into the tumor. This is a compromise between an oncological resection, that is, the complete excision of the tumor with no residual cancer cells left behind, and quality of life. Almost all authors try to overcome this lack of radicality by indicating postoperative (chemo)radiotherapy. In this article, the pros and cons of nerve preservation will be analyzed by examining the published studies on this topic.

Association between factor of parotid lymph node and prognosis in parotid cancer

INTRODUCTION

Survival significance of parotid lymph node (LN) factors in parotid cancer remains unclear, our goal was to assess the impact of number, size, and extranodal extension (ENE) of metastatic parotid LNs on prognosis in parotid cancer.

MATERIALS AND METHODS

Patients with surgically treated parotid cancer were retrospectively enrolled. Primary outcome variable was recurrence-free survival (RFS) and overall survival (OS). The hazard ratios (HRs) of main predictive variables including the number, size, and ENE of positive parotid LNs on RFS and OS were analyzed using Cox model. The secondary outcome variable was ENE of metastatic parotid LN, its association with clinicopathologic variables were evaluated using Chi-square test.

RESULTS

In total, 453 patients (186 male and 267 female) were included. The 10-year RFS and OS rates were 73% (95%CI: 69%-77%) and 61% (95%CI: 55%-67%), respectively. In Cox model, compared none parotid LN metastasis, one metastatic parotid LN did not offer additional compromise of RFS (p = 0.224) or OS (p = 0.135), but two or more positive LNs decreased the control of RFS (HR: 2.017; 95%CI: 1.378-4.632) and OS (HR: 2.173; 95%CI: 1.367-4.275). When accounting for the number of metastatic LNs, LN size or ENE was no longer related to RFS or OS. ENE of parotid LN tended to develop if there was presence of T3/4 stage, lymphovascular invasion, high histologic grade, N2/3 stage, and three or more positive parotid LNs.

CONCLUSION

Quantitative parotid LN burden but not ENE or LN size is an important determinant of survival in patients with parotid cancer.

Clinicopathological Predictors of Survival for Parotid Mucoepidermoid Carcinoma: A Systematic Review

OBJECTIVE

Various prognostic factors are associated with the survival of patients with parotid mucoepidermoid carcinoma (MEC). The aim of this systematic review is to summarize the clinical and pathologic prognostic factors on survival outcomes in patients with parotid MEC.

DATA SOURCES

Articles published from database inception to July 2020 on OVID Medline, OVID Embase, Cochrane Central, and Scopus.

REVIEW METHODS

Studies were included that reported clinical or pathologic prognostic factors on survival outcomes for adult patients with parotid MEC. Data extraction, risk of bias, and quality assessment were conducted by 2 independent reviewers.

RESULTS

A total of 4290 titles were reviewed, 396 retrieved for full-text screening, and 18 included in the review. The average risk of bias was high, and quality assessment for the prognostic factors ranged from very low to moderate. Prognostic factors that were consistently associated with negative survival outcomes on multivariate analysis included histologic grade (hazard ratio [HR], 5.66), nodal status (HR, 2.86), distant metastasis (HR, 3.10-5.80), intraparotid metastasis (HR, 13.52), and age (HR, 1.02-6.86). Prognostic factors that inconsistently reported associations with survival outcomes were TNM stage, T classification, and N classification.

CONCLUSION

Histologic grade, nodal status, distant metastasis, intraparotid metastasis, and age were associated with worse survival outcomes. These prognostic factors should be considered when determining the most appropriate treatment and follow-up plan for patients with parotid MEC.

Facility volume and survival: Human papilloma virus positive oropharyngeal squamous cell carcinoma

BACKGROUND

To analyze the impact of facility volume on survival for human papilloma virus positive oropharyngeal squamous cell carcinoma (HPV+ OPSCC) patients.

METHODS

Patients treated for HPV+ OPSCC from 2010 to 2017 were queried from the National Cancer Database. Facilities of average annual case volume <50th percentile were categorized as low-volume (LV) and >95th percentile as high-volume (HV).

RESULTS

11,546 were included, with 10,305 patients (89.3 %) treated at LV and 1241 (10.7 %) at HV facilities. A greater proportion of cases involving resection of base of tongue and lingual tonsil were treated at HV (30.3 %) compared to LV (22.3 %) facilities (p < 0.001). Patients treated at a HV facility had greater percentage of clinical T4 (11.2 % vs. 8.6 %, p = 0.001) and N+ disease (90.5 % vs. 85.7 %, p < 0.001) patients. Survival analysis showed no statistically significant difference between five-year overall survival rates by facility volume (p = 0.388) for all patients. On multivariable analysis, facility volume was not associated with survival (HR: 0.968 [0.758-1.235], p = 0.791). These trends were found for both patients undergoing primary surgery or chemoradiotherapy.

CONCLUSION

Our data indicates that patients with HPV+ OPSCC do not experience a survival benefit with treatment at HV facility, suggesting these patients may be adequately treated at LV centers.

Nodal Metastases in Pediatric and Adult Acinic Cell Carcinoma of the Major Salivary Glands

OBJECTIVE

Acinic cell carcinoma (AciCC) is a rare, usually low-grade salivary malignancy. Evidence on rates of lymph node metastases (LNMs) is limited in pediatric patients and varies significantly (4%-45%) in adults. We set out to determine and compare rates of LNMs in pediatric and adult AciCC and to analyze their impact on survival, using the National Cancer Database.

STUDY DESIGN

Historical cohort study.

SETTING

National Cancer Database.

METHODS

All AciCCs of the major salivary glands with complete clinical and pathologic nodal staging were selected between 2010 and 2016. Patient demographics, tumor characteristics, treatment, and survival were analyzed. Univariable and multivariable regression were performed to determine factors associated with LNMs and survival.

RESULTS

We identified 57 (4.6%) pediatric patients (<18 years) and 1192 (95.4%) adults with AciCC. Clinical LNMs were rare in pediatric patients (n < 10) and adults (n = 88, 7.4%). Occult LNMs were uncommon in pediatric patients (n < 5) and adults (n = 41, 4.6%). Three-year overall survival for pediatric patients was 97.8%. Adults with LNM had worse 3-year overall survival than those without (66.0% vs 96.3%, P < .001). In multivariable regression, high-grade disease (hazard ratio, 10.15 [95% CI, 5.60-18.80]; P < .001) and T3-T4 tumors (hazard ratio, 2.80 [95% CI, 1.56-4.97]; P < .001) were associated with LNM in adult patients.

CONCLUSION

LNMs in AciCC of the major salivary glands are rare in children and adults. However, high-grade and T3-T4 tumors are associated with an increased risk of LNM. LNM is associated with worse survival.

National analysis of positive surgical margins in oropharyngeal salivary gland malignancies

OBJECTIVE

Positive surgical margins (PSM) are associated with worse survival in oropharyngeal salivary gland malignancies (OPSGM), but existing literature is limited to small series. Our objective was to identify risk factors for PSM using the national cancer database (NCDB), including a transoral robotic surgical (TORS) approach.

METHODS

NCDB was queried for patients with T1-T4a OPSGM undergoing resection between 2010 and 2017. Risk factors for PSM were determined using logistic regression. Overall survival (OS) was analyzed using Kaplan-Meier and Cox proportional hazards models.

RESULTS

Of 785 patients, 165 (21.0 %) had PSM. Age, stage T4a tumors (OR 2.00, 95 % Confidence Interval [CI]: 1.03-3.88), adenoid cystic carcinoma (OR 2.02, 95 % CI: 1.29-3.18), and treatment at lower volume institutions (OR 1.68, 95 % CI: 1.09-2.59) were all independently associated with PSM. TORS versus a non-robotic approach was not associated with PSM (23.9 % vs 20.4 %, p 0.358), respectively. Positive margins were independently associated with a worse OS than negative margins (HR 1.63, 95 % CI: 1.03-2.59). Adjuvant radiation therapy was associated with improved survival in high grade tumors with positive margins.

CONCLUSION

This study represents the largest review assessing risk factors for positive margins in OPSGM. Histologic type (adenoid cystic carcinoma), age, T4a tumor stage and treatment at a lower volume institution were all predictive of positive margins. With increasing use of TORS over the last decade, there does not appear to be a greater risk of positive margins using this modality in select patients.

LEVEL OF EVIDENCE

N/A.

Clinical target volume design of postoperative intensity-modulated radiotherapy for major salivary gland tumours according to surgical principles: an innovative method

BACKGROUND

No international consensus has been reached regarding delineation of postoperative intensity-modulated radiotherapy (PO-IMRT) clinical target volumes (CTV) for major salivary gland carcinoma (SGC). The purpose of this article was to report our experience according to surgical principles.

METHODS

Between June 2010 and June 2018, 54 consecutive patients were enrolled. Reserved tissues around the margin of resection that were less than 5 mm from the invasive tumour edge before surgery were defined as high-risk clinical target volumes (CTV-HD), those less than 10 mm away were defined as medium-risk CTV (CTV1), and those 10-20 mm away were defined as low-risk CTV (CTV2), and were irradiated with 63-65 Gy, 59.5-61 Gy, and 45-54 Gy, respectively. Target volume distributions of reserved tissues were analysed and actuarial estimates of overall survival (OS), recurrence-free survival (RFS) and distant metastasis-free survival (DMFS) were obtained with the Kaplan-Meier method.

RESULTS

In parotid gland tumours, the percentages of defined CTV-HD in the styloid process, mandibular ramus, posterior venter of the digastric muscle, carotid sheath and stylomastoid foramen reached 34.29%, 25.71%, 54.29%, 40.00%, and 37.10%, respectively. The median follow-up was 33 months (range, 5-98 months). The 3-year and 5-year Kaplan-Meier estimates of OS, RFS and DMFS were 85.4% and 77.8%, 97.4%, and 97.4%, and 82.0% and 82.0%, respectively.

CONCLUSIONS

It is feasible to delineate CTVs according to distances between various reserved tissues and the primary tumour edge before operation.

Margin status, local control, and disease-specific survival in surgically resected parotid carcinomas with parapharyngeal extension

BACKGROUND

Resection of parotid carcinomas involving the parapharyngeal space is challenging. How this affects tumor margin control, recurrence, and survival is unclear.

METHODS

Patients who underwent resection of parotid carcinomas between 1985 and 2015 at Memorial Sloan Kettering Cancer Center were evaluated for the impact of parapharyngeal extension (PPE) on margin status, local recurrence-free probability (LRFP), and disease-specific survival (DSS).

RESULTS

Out of 214 patients in whom preoperative imaging was available for review, 22 (10.3%) had PPE. Matched by histotypes, carcinomas with PPE had comparable margin positivity (p = 0.479), T classification (p = 0.316), pathologic risk (p = 0.936), and adjuvant therapy (p = 0.617) to those without PPE. The 3-year LRFP was 88.9% versus 95.4% (hazard ratio [HR] 2.23 after adjusting for pT classification, p = 0.342) and the 5-year DSS was 74.2% versus 69.5% (adjusted HR 0.45, p = 0.232) in patients with and without PPE.

CONCLUSION

PPE does not appear to worsen oncologic outcomes in the resection of parotid carcinomas.

Management of Salivary Gland Malignancy: ASCO Guideline

PURPOSE

To provide evidence-based recommendations for practicing physicians and other healthcare providers on the management of salivary gland malignancy.

METHODS

ASCO convened an Expert Panel of medical oncology, surgical oncology, radiation oncology, neuroradiology, pathology, and patient advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2000 through 2020. Outcomes of interest included survival, diagnostic accuracy, disease recurrence, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 293 relevant studies to inform the evidence base for this guideline. Six main clinical questions were addressed, which included subquestions on preoperative evaluations, surgical diagnostic and therapeutic procedures, appropriate radiotherapy techniques, the role of systemic therapy, and follow-up evaluations.

RECOMMENDATIONS

When possible, evidence-based recommendations were developed to address the diagnosis and appropriate preoperative evaluations for patients with a salivary gland malignancy, therapeutic procedures, and appropriate treatment options in various salivary gland histologies.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Diagnostic and Prognostic Utility of 18F-FDG PET/CT in Recurrent Salivary Gland Cancers

OBJECTIVE. The role of ¹⁸F-FDG PET/CT in the evaluation of recurrent salivary gland tumors remains poorly defined. We investigated the diagnostic and prognostic utility of PET in this setting. MATERIALS AND METHODS. A total of 146 patients with recurrent salivary gland cancer were treated at our institution between January 2002 and December 2015. Patients who underwent FDG PET/CT and conventional imaging (CT or MRI) within 3 months of recurrence (n = 78) were included in this retrospective analysis. On FDG PET/CT, we measured the SUV_max, total body metabolic tumor volume of all lesions, and total lesion glycolysis of all lesions to determine the intensity and extent of FDG-avid disease. We assessed the correlation of FDG PET/CT findings with clinicopathologic features, progression-free survival, and overall survival. RESULTS. FDG PET/CT was positive for recurrence in 74 of 78 patients (94.9%) and falsely negative in four patients (5.1%). In comparison with conventional imaging, FDG PET/CT performed for restaging detected additional recurrent lesions in 14 patients (17.9%). The median SUV_max was 7.4, the median total body metabolic tumor volume was 30.1 cm³, and median total lesion glycolysis was 97.3 g/mL × cm³. Sixty-six patients had progressive disease, and 54 died. Univariate and multivariate Cox hazards analysis identified pathologic risk group (p = .04), total body metabolic tumor volume (p < .001), and total lesion glycolysis (p < .001) as independent prognostic factors for progression-free survival and identified age (p = .05), total body metabolic tumor volume (p < .001), and total lesion glycolysis (p < .001) as independent prognostic factors for overall survival. CONCLUSION. In patients with recurrent salivary gland cancer, FDG PET/CT is useful as a single test for defining the extent of disease and providing prognostic information, which may help in selecting appropriate treatment strategies.

Factors and Outcomes Associated With Temporal Bone Resection for Primary Parotid Malignancy

OBJECTIVE(S)

Although parotid cancer invading into the temporal bone makes up only a small fraction of all parotid cancers, it is more common and relatively understudied compared with primary cancer of the external auditory canal. The objective of this study was to determine what factors are associated with receiving parotidectomy with temporal bone resection (TBR) and the immediate postoperative outcomes.

METHODS

We reviewed the National Cancer Database (2004-2015) for patients with primary parotid malignancy who received parotidectomy with or without TBR. Patient demographic, clinical, and perioperative variables were collected and then compared. Multivariate logistic regression was performed to determine factors associated with receiving TBR.

RESULTS

We identified 134 patients who received parotidectomy with TBR and 16,595 who received parotidectomy only. Reported in terms of odds ratios (95% confidence interval), our multivariate model showed having surgery at an academic facility (1.91 [1.34-2.71], P < .001), clinical stage III or IV (7.48 [1.65-33.96] and 31.37 [7.61-129.32], P = .009 and P < .001, respectively), histologic grade II to IV (4.36 [1.51-12.57], 4.31 [1.53-12.15], and 6.74 [2.26-20.13], P = .006, .006, and .001, respectively), and adenoid cystic histology (3.23 [2.02-5.17], P < .001) were significantly and independently associated with receiving TBR. There was no significant difference in 30-day readmission, or 30-day or 90-day mortality, but the rate of positive surgical margins was significantly higher in those who underwent TBR.

CONCLUSION

Demographic variables are not significant factors for receiving TBR. Tumor characteristics, such as clinical stage and histologic type, and receiving surgical treatment at an academic facility were more strongly associated with receiving TBR.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2461-E2468, 2021.

Role of concurrent chemoradiation on locally advanced unresectable adenoid cystic carcinoma

BACKGROUND/AIMS

Adenoid cystic carcinoma (ACC) is a rare salivary gland tumor characterized by indolence, with a high rate of local recurrence and distant metastasis. This study aimed to investigate the effect of concurrent chemoradiation (CCRT) on locally advanced unresectable ACC.

METHODS

We retrospectively analyzed clinical data from 10 patients with pathologically confirmed ACC of the head and neck who received CCRT with cisplatin in Seoul National University Hospital between 2013 and 2018.

RESULTS

Ten patients with unresectable disease at the time of diagnosis or with positive margins after surgical resection received CCRT with weekly cisplatin. Eight patients (80%) achieved complete remission, of which three later developed distant metastases without local relapse; one patient developed distant metastasis and local relapse. Two patient achieved partial remission without progression. Patients experienced several toxicities, including dry mouth, radiation dermatitis, nausea, and salivary gland inflammation of mostly grade 1 to 2. Only one patient showed grade 3 oral mucositis. Median relapse-free survival was 34.5 months (95% confidence interval, 22.8 months to not reached).

CONCLUSION

CCRT with cisplatin is effective for local control of ACC with manageable toxicity and may be an effective treatment option for locally advanced unresectable ACC.

Value and Quality of Care in Head and Neck Oncology

PURPOSE OF REVIEW

The concept of value-based health care (VBHC) was articulated more than a decade ago. However, its clinical implementation remains an on-going process and a particularly demanding one for the domain of head and neck cancer (HNC). These cancers often present with fast growing tumors in functionally and cosmetically sensitive sites and afflict patients with differing circumstances and comorbidity. Moreover, the various treatment modalities and protocols have different effects on functional outcomes. Hence, the interpretation of what constitutes VBHC in head and neck oncology remains challenging.

RECENT FINDINGS

This monograph reviews developments in specific aspects of VBHC for HNC patients, including establishment of registries and quality indices (such as infrastructure, process, and outcome indicators). It emphasizes the importance of the multidisciplinary team, "time to treatment intervals," and adherence to guidelines. The discussion addresses major indicators including survival, quality of life and functional outcomes, and adverse events. Also, strengths and weaknesses of nomograms, prognostic and decision models, and variation of care warrant attention. Health care professionals, together with patients, must properly define quality and relevant outcomes, both for the individual patient as well as the HNC population. It is essential to capture and organize the relevant data so that they can be analyzed and the results used to improve both outcomes and value.

Clinical characteristics and treatment-associated survival of head and neck Ewing sarcoma

OBJECTIVES

Ewing sarcoma of the head and neck (ESHN) is a rare malignancy for which limited data exists. Herein we examine anatomic distribution of ESHN, demographic characteristics, and multi-modal therapy as potential determinants in the overall survival (OS) of patients with ESHN.

METHODS

A retrospective study of the National Cancer Database (NCDB) from 2004-2016 was performed. A multivariate Cox regression and univariate Kaplan-Meier survival analyses were conducted.

RESULTS

We identified 284 patients with ESHN eligible for demographic analysis and 223 for survival analysis. Approximately half (50.3%) of patients with ESHN were under the age of 18. Pediatric patients (<18) were less likely to present with distant metastases (≤8.0% vs. 9.5-19.0%, P = .006) and more likely to present with osseous disease (90.2% vs. 75.2%, P = .001) than adults. Adult age (HR: 2.727, 95% CI, 1.381-5.384, P = .004) and distant metastatic disease at the time of presentation (HR: 8.161, 95% CI, 2.922-22.790, P < .001) were independently associated with worse OS. The addition of local therapy (either surgery, radiotherapy, or both) to chemotherapy was not associated with improved survival when compared to treatment with chemotherapy alone.

CONCLUSION

Predictors of OS in patients with ESHN included age < 18 years and non-metastatic disease at the time of diagnosis. Tumor site of origin (osseous vs. extraosseous primary) or the addition of local therapy to chemotherapy had no impact on OS. Our analysis suggests that chemotherapy serves as the primary modality in treating ESHN, while further study of this rare malignancy is required to discern the utility of combined systemic and local therapy. Laryngoscope, 130:2385-2392, 2020.

Margins in Sinonasal Squamous Cell Carcinoma: Predictors, Outcomes, and the Endoscopic Approach

OBJECTIVES

To identify factors associated with positive margins following surgical management of sinonasal squamous cell carcinoma (SNSCC), especially with regard to endoscopic treatment.

METHODS

In a retrospective analysis of adult patients with clinically staged tumor (T)1 to T4a SNSCC within the National Cancer Database (NCDB) from 2004 to 2014, factors were associated with positive margins using multivariable binary logistic regression. Cases from 2010 to 2014 had surgical approach (open vs. endoscopic) available and were analyzed in a subgroup to assess the association of surgical approach with margin status. The association of margin status with overall survival (OS) and additional therapy administration was also assessed.

RESULTS

We identified 2,968 cases, of which 807 (27.2%) had positive margins. On multivariable analysis, factors associated with positive margins included higher T stage (T4a vs. T1: odds ratio [OR] 2.768 [95% CI 2.143-3.577]), less differentiated tumors (poorly differentiated vs. well differentiated: OR 1.403 [95% CI 1.060-1.856]), and tumors in the ethmoid sinus (vs. nasal cavity; OR 1.889 [95% CI 1.305-2.734]). Cases treated at higher volume facilities (HVFs) were associated with a lower likelihood of positive margins (OR 0.716 [95% CI 0.582-0.881]). Positive margins were associated with decreased OS (hazard ratio 1.672 [95% CI 1.464-1.908]) and an increased rate of additional therapy (OR 1.966 [95% confidence interval 1.597-2.421]). An endoscopic approach was not associated with an increased likelihood of obtaining positive margins (vs. open; OR 1.151 [0.903-1.651]).

CONCLUSION

Positive margins were less likely when performed at HVFs and more likely in the ethmoid sinus than other subsites. Importantly, there was no association between positive margins and surgical approach. Endoscopic surgery may offer a safe, less invasive alternative to open surgery for select patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:E388-E396, 2020.

Intermediate-grade carcinoma of the parotid and the impact of adjuvant radiation

PURPOSE

To determine the influence of adjuvant radiotherapy on survival in surgically-managed early stage intermediate-grade mucoepidermoid and acinic cell carcinoma of the parotid.

MATERIALS AND METHODS

The National Cancer Database was reviewed between 2004 and 2015 to identify patients with intermediate-grade, early T-stage, node-negative parotid carcinoma who underwent parotidectomy ± radiotherapy.

RESULTS

There were 744 patients identified of which 81% had mucoepidermoid carcinoma and 19% had acinic cell carcinoma. Positive surgical margins were identified in 21% and adjuvant radiotherapy was administered in 38% of cases. Of the 159 patients with positive margins, 113 (71%) received adjuvant radiotherapy. Of the 585 patients with negative margins, 173 (30%) underwent adjuvant radiotherapy. In multivariable analysis, age (over 52 years: HR 5.19, 95%CI 2.33-11.57), insurance status (private insurance: HR 0.24 95%CI 0.13-0.43), and extent of parotidectomy (total parotidectomy: HR 2.02 95%CI 1.23-3.31) were significantly associated with overall survival, while adjuvant radiotherapy was not a significant predictive factor (HR 0.81, 95%CI 0.49-1.36). In patients with positive margin resections, however, adjuvant radiation was an independent predictor of improved survival when adjusted for age, insurance status, and extent of parotidectomy (HR 0.34, 95%CI 0.13-0.88). Conversely, in patients with negative margin resections, adjuvant radiation did not influence survival outcomes when adjusted for these covariates (HR 1.02, 95%CI 0.53-1.93).

CONCLUSIONS AND RELEVANCE

In patients with early stage intermediate-grade parotid carcinoma, adjuvant radiotherapy significantly and independently improves survival in those with post-operative positive margins. Adjuvant therapy, however, does not appear to improve survival outcomes in those with negative margin resections.

Positive surgical margins at radical prostatectomy in the United States: Institutional variations and predictive factors

INTRODUCTION

Positive surgical margins (PSMs) are associated with treatment failure after radical prostatectomy (RP) for patients with prostate cancer (CaP). We investigated institutional variations in PSM after RP, as well as clinical and demographic factors predicting PSM.

PATIENTS AND METHODS

Patients undergoing RP for clinically localized CaP were identified in the National Cancer Database in 2010 to 2013 and clinicodemographics were recorded. Treating institution was defined as academic (AMC) or nonacademic medical centers (nAMC). The primary outcome was the PSM rate. Multivariable logistic regression and propensity matching with inverse probability treatment weighing were used to both compare outcomes between AMC and nAMC and to identify predictors of PSM following RP.

RESULTS

A total of 167,260 patients met our inclusion criteria. PSM rate was significantly lower in patients treated at AMC (13,435, 18.9%) compared with 22,145 (23.0%) in those treated at nAMC (P < 0.01). The difference between PSM rate in AMC and nAMC was more pronounced in lower volume centers while it was not significant in higher volume centers. On multivariable analysis, age, race, prostate-specific antigen (PSA), biopsy Gleason score, comorbidity profile, insurance type, income, and treatment facility were significantly associated with PSM rate.

CONCLUSION

PSM rates appear to be lower at AMC and higher volume facilities, which can potentially reflect institutional differences in surgical quality. In addition, we identified several socioeconomic and demographic factors that contribute to the likelihood of PSM following RP for localized CaP, suggesting potential systematic variation in the quality of surgical care. The cause of this variation warrants further investigation and evaluation.

Preoperative biopsy in parotid malignancies: Variation in use and impact on surgical margins

OBJECTIVES

Determine rate of preoperative biopsy in parotid malignancies, identify factors associated with its use, and its association with surgical margins.

STUDY DESIGN

Retrospective cohort.

SETTING

Commission on Cancer-Accredited Institutions.

SUBJECTS AND METHODS

We included 5533 patients treated surgically for a parotid malignancy 2004-2014 in the National Cancer Database. Chi-squared tests, univariable, and multivariable logistic regressions were used to evaluate predictors of preoperative biopsy (defined as needle, aspiration, or incisional), and associate biopsy with surgical margins.

RESULTS

Preoperative biopsy was utilized in 26.0% of patients. Biopsy was more likely in patients >60 years (odds ratio [OR]: 1.19, P = .035), advanced clinical T stage (vs. T1,T2 OR: 1.23, P = .009; T3 OR: 1.26, P = .026; T4A OR: 2.05, P < .001), advanced clinical N stage (vs. N0, N1: OR: 1.39, P = .013; N2/3: OR: 1.63, P < .001), in academic centers (OR: 1.18, P < .024), and in higher volume centers (vs. low, medium OR: 1.28, P = .002; high OR: 2.16, P < .001). Biopsy use increased over time (vs. 2004-2006, 2007-2010 OR: 1.20, P = .047; 2011-2014 OR: 1.39, P < .001). Biopsy was associated with a reduced risk of positive margins in patients with clinical T1 stage (OR: 0.70, P = .012), and younger than 61 (OR: 0.79, P = .036).

CONCLUSION

The national rate of preoperative biopsy in parotid malignancy is low at 26.0%, but has increased over time. Preoperative biopsy is associated with a reduced risk of positive margins in younger patients and those with early clinical stage, suggesting its increased use may improve surgical outcomes and decrease reoperation or adjuvant therapy in these subgroups of patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:1450-1458, 2020.

Prognostic Case Volume Thresholds in Patients With Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Though described as an important prognostic indicator, facility case volume thresholds for patients with head and neck squamous cell carcinoma (HNSCC) have not been previously developed to date.

OBJECTIVE

To identify prognostic case volume thresholds of facilities that manage HNSCC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of 351 052 HNSCC cases reported from January 1, 2004, through December 31, 2014, by Commission of Cancer-accredited cancer centers from the US National Cancer Database. Data were analyzed from August 1, 2018, to April 5, 2019.

EXPOSURES

Treatment of HNSCC at facilities with varying case volumes.

MAIN OUTCOMES AND MEASURES

Using all-cause mortality outcomes among adult patients with HNSCC, 10 groups with increasing facility case volume were created and thresholds were identified where group survival differed compared with each of the 2 preceding groups (univariate log-rank analysis). Groups were collapsed at these thresholds and the prognostic value was confirmed using multivariable Cox regression. Prognostic meaning of these thresholds was assessed in subgroups by category (localized [I/II] and advanced [III/IV]), without metastasis (M0), with metastasis (M1), and anatomic subsites (nonoropharyngeal HNSCC and oropharyngeal HNSCC with known human papillomavirus status).

RESULTS

Of 250 229 eligible patients treated at 1229 facilities in the United States, there were 185 316 (74.1%) men and 64 913 (25.9%) women and the mean (SD) age was 62.8 (12.1) years. Three case volume thresholds were identified (low: ≤54 cases per year; moderate: >54 to ≤165 cases per year; and high: >165 cases per year). Compared with the moderate-volume group, multivariate analysis found that treatment at low-volume facilities (LVFs) was associated with a higher risk of mortality (hazard ratio [HR], 1.09; 99% CI, 1.07-1.11), whereas treatment at high-volume facilities (HVFs) was associated with a lower risk of mortality (HR, 0.92; 99% CI, 0.89-0.94). Subgroup analysis with Bonferroni correction revealed that only the moderate- vs low- threshold had meaningful differences in outcomes in localized stage (I/II) cancers, (LVFs vs moderate-volume facilities [MVFs]: HR, 1.09 [99% CI, 1.05-1.13]; HVF vs MVF: HR, 0.95 [99% CI, 0.90-1.00]), whereas both thresholds were meaningful in advanced stage (III/IV) cancers (LVF vs MVF: HR, 1.09 [99% CI, 1.06-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.88-0.94]). Survival differed by prognostic thresholds for both M0 (LVF vs MVF: HR, 1.09 [99% CI, 1.07-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.89-0.94]) and nonoropharyngeal HNSCC (LVF vs MVF: HR, 1.10 [99% CI, 1.07-1.13]; HVF vs MVF: HR, 0.93 [99% CI, 0.90-0.97]) site cases, but not for M1 (LVF vs MVF: HR, 1.00 [99% CI, 0.92-1.09]; HVF vs MVF: HR, 0.94 [99% CI, 0.83-1.07]) or oropharyngeal HNSCC cases (when controlling for human papillomavirus status) (LVF vs MVF: HR, 1.10 [99% CI, 0.99-1.23]; HVF vs MVF: HR, 1.07 [99% CI, 0.94-1.22]).

CONCLUSIONS AND RELEVANCE

Higher volume facility threshold results appear to be associated with increases in survival rates for patients treated for HNSCC at MVFs or HVFs compared with LVFs, which suggests that these thresholds may be used as quality markers.

A nomogram to estimate the risk of developing distant metastases in parotid cancer

BACKGROUND

Parotid cancer (PC) is a heterogeneous group of malignant tumors whose management mainly focuses on locoregional control. However, distant metastases (DM) can represent the most common cause of treatment failure. We have defined the predictors and developed a model that can predict a single patient's risk to develop DM.

METHODS

We have analyzed our institutional database of 259 patients with PC and use it to develop a nomogram. C-index and calibration curves were used to assess performance of our model.

RESULTS

DM appeared in 18.9% of patients. Age, cT, pN, perineural invasion, and adenoid cystic carcinoma were significantly associated with distant failure.

CONCLUSIONS

We here present the first model to identify patients with PC at high risk of DM. Such tool can be of great value in managing these rare cancers in terms of a more precise prognosis and follow-up while waiting for better systemic therapies to come in the future.

Positive Surgical Margins in Submandibular Malignancies: Facility and Practice Variation

OBJECTIVES

Identify positive margin rate in a national cohort of patients with submandibular carcinoma, identify predictors of positive margins, and associate margins with overall survival.

STUDY DESIGN

Retrospective cohort.

SETTING

Commission on Cancer-accredited hospitals.

SUBJECTS AND METHODS

We included patients in the National Cancer Database from 2004 to 2014 who were diagnosed with submandibular carcinoma and underwent primary surgical resection. We determined the rate of positive surgical margins and associated patient, tumor, and treatment factors with positive margins via univariable and multivariable logistic regression analysis. We associated margin status with overall survival by Kaplan-Meier curve and Cox proportional hazards regression.

RESULTS

We identified 1150 patients with submandibular malignancy undergoing surgical resection. Positive margin rate was 41.0%. Increased odds of positive margins were seen in patients with advanced T stage (vs T1, T3: odds ratio [OR] = 3.04, P < .001; T4a: OR = 2.89, P < .001), adenoid cystic carcinoma histology (OR = 1.54, P = .020), and those treated at nonacademic facilities (OR = 1.41, P = .008). Patients who underwent a preoperative diagnostic biopsy had decreased odds of positive margins (OR = 0.72, P = .014). Positive margins were associated with reduced overall survival (58% vs 69% 5-year overall survival, P < .001; hazard ratio = 1.49, P = .001) when controlling for patient, tumor, and management factors.

CONCLUSIONS

The national positive margin rate of submandibular carcinoma is 41.0%. Preoperative biopsy and treatment at academic institutions independently decreased the risk of positive margins, and positive margins were independently associated with diminished overall survival. Positive margin rate for submandibular carcinoma may be considered a benchmark for quality of care.