Choice of Adjuvant Radiotherapy Facility in Major Salivary Gland Cancer

OBJECTIVE

Undergoing surgery and adjuvant radiotherapy (aRT) at the same facility has been associated with higher overall survival (OS) in head and neck squamous cell carcinoma. Our study investigates whether undergoing surgery and aRT at the same academic facility is associated with higher OS in major salivary gland cancer (MSGC).

METHODS

The 2006-2018 National Cancer Database was queried for patients with MSGC undergoing surgery at an academic facility and then aRT. Multivariable binary logistic and Cox proportional hazards regression models were implemented.

RESULTS

Of 2801 patients satisfying inclusion criteria, 2130 (76.0%) underwent surgery and aRT at the same academic facility. Residence in a less populated area (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI] 1.16-2.45), treatment without adjuvant chemotherapy (aOR 1.97, 95% CI 1.41-2.76), and aRT duration (aOR 1.02, 95% CI 1.01-1.04) were associated with undergoing surgery and aRT at different facilities on multivariable logistic regression adjusting for patient demographics, clinicopathologic features, and adjuvant therapy (p < 0.01). Five-year OS was higher in patients undergoing surgery and aRT at the same academic facility (68.8% vs. 61.9%, p < 0.001). Undergoing surgery and aRT at different facilities remained associated with worse OS on multivariable Cox regression (aHR 1.41, 95% CI 1.10-1.81, p = 0.007).

CONCLUSION

Undergoing surgery and aRT at the same academic facility is associated with higher OS in MSGC. Although undergoing surgery and aRT at the same academic facility is impractical for all patients, academic physicians should consider same-facility treatment for complex patients who would most benefit from clear multidisciplinary communication.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3620-3632, 2024.

Facility Volume and Changing Facilities for Postoperative Radiotherapy in Salivary Gland Cancer

OBJECTIVES

Changing location of postoperative radiotherapy (PORT) after treatment at a high-volume facility (HVF) is associated with worse survival in various head and neck cancers. Our study investigates this relationship in salivary gland cancer (SGC).

METHODS

The 2004-2016 National Cancer Database was queried for all cases of adult SGC treated with surgery and PORT with or without adjuvant chemotherapy. Patients with multiple cancer diagnoses, metastatic disease, or unknown PORT facility were excluded. Reporting facilities with >95th percentile annual case volume were classified as HVFs, the remainder were classified low-volume facilities (LVFs).

RESULTS

A total of 7885 patients met inclusion criteria, of which 418 (5.3%) were treated at an HVF. Patients treated at an HVF had higher rates clinical nodal positivity (18.2% vs. 14.0%, p < 0.001) and clinical T3/T4 (27.3% vs. 20.7%, p = 0.001) disease. Patients at HVFs changed facility for PORT at lower rates (18.9% vs. 24.5%, p = 0.009). Patients treated at an HVF had higher 5-year overall survival (5-OS) than those treated at an LVF (79.0% vs. 72.0%, p = 0.042). Patients treated at an HVF that changed PORT facility had worse 5-OS (60.8% vs. 83.2%, p < 0.001). Radiation facility change was an independent predictor of worse survival in patients treated at an HVF (HR: 8.99 [3.15-25.67], p < 0.001) but not for patients treated at a LVF (HR: 1.11 [0.98-1.25], p = 0.109).

CONCLUSIONS

Patients treated at an HVF changing facility for PORT for SGC experience worse survival. Our data suggest patients treated surgically at an HVF should be counseled to continue their PORT at the same institution.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

High surgical volume is associated with improved survival in head and neck cancer

OBJECTIVES

Examine the relationship between hospital volume and overall mortality in a surgical cohort of head and neck squamous cell carcinoma (HNSCC) patients.

MATERIALS & METHODS

A retrospective review of the NCDB was completed for adults with previously untreated HNSCC diagnosed between 2004 and 2016. Mean annual hospital volume was calculated using the number of head and neck cancer cases treated at a given facility divided by the number of years the facility reported to the NCDB. Facilities were separated into three categories based on their volume percentile, informed by inflection points from a natural cubic spline: Hospital Group 1 (<50%); Hospital Group 2 (50-90%); Hospital Group 3 (90%+). Cox proportional hazard models were used to examine the association between volume percentiles (continuous or categorical) with patient overall survival, adjusting for important patient and facility variables known to impact survival.

RESULTS

Risk of death decreased by 2.97% for every 10% increase in facility percentile after adjusting for other risk factors. Patients treated at facilities in Hospital Group 1 had a 23.1% increase in risk of mortality (HR 1.231 [95% CI 1.12-1.35]) relative those at facilities in Hospital Group 3. No significant difference in mortality risk was found between Hospital Group 2 versus Hospital Group 3 (HR 1.031 [95% CI 0.97-1.10]).

CONCLUSIONS

Survival of HNSCC patients is significantly improved when treated at facilities >50th percentile in annual hospital volume. This may support the regionalization of care to high volume head and neck centers with comprehensive facilities and supportive services to maximize patient outcomes.

Effect of facility volume on giant pituitary adenoma neurosurgical outcomes

OBJECTIVE

Giant pituitary adenomas (PAs), defined as 4 cm or greater at their maximum diameter, are commonly treated with neurosurgical intervention as the first-line therapy. However, existing studies are from high-volume institutions whose outcomes may not be representative of many cancer centers. In the present study, the authors use a large cancer registry to evaluate demographics, national treatment trends, and outcomes by facility volume to address knowledge gaps for this uncommon tumor.

METHODS

The National Cancer Database was queried for adult patients with PAs who had undergone resection from 2004 to 2016. Univariate and multivariate logistic regression modeling was used to evaluate the prognostic impact of covariates on short-term outcomes including 30-day readmission (30R), 30-day mortality (30M), 90-day mortality (90M), and prolonged length of inpatient hospital stay (LOS). Propensity score matching was used for validation.

RESULTS

Among the 39,030 patients who met the study inclusion criteria, 3696 giant PAs were identified. These tumors had higher rates of subtotal resection (55% vs 24%, p < 0.001), adjunctive radiotherapy (15% vs 5%, p < 0.001), and hormonal therapy (8% vs 4%, p < 0.001) than nongiant PAs. The giant PAs also had worse 30M (0.6% vs 3.1%, p < 0.001), 90M (1.0% vs 5.0%, p < 0.001), 30R (4.0% vs 6.3%, p < 0.001), and LOS (22.2% vs 42.1%, p < 0.001). On multivariate analysis for giant PA, decreased tumor size, younger age, race other than African American, lower comorbidity score, and high-volume facility (HVF; defined as ≥ 2.5 giant PA cases per year) were statistically significant predictors of favorable outcomes. Specifically, 30M, 90M, 30R, and LOS were decreased by 50%, 43%, 55%, and 32%, respectively, when giant PAs were treated at HVFs (each p < 0.05). HVFs more often used the endoscopic approach (71% vs 46%, p < 0.001) and less adjuvant radiotherapy (11% vs 16%, p < 0.001). Propensity score matching validated 30M, 30R, and LOS outcome differences in a cohort of 1056 patients.

CONCLUSIONS

This study provides evidence of superior outcomes when giant PAs are treated at HVFs. These results likely reflect the relation between physician experience and outcomes for these uncommon tumors, which suggests the need for institutional collaboration as a potential goal in their surgical management.

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.

Results of histopathological revisions of major salivary gland neoplasms in routine clinical practice

AIMS

Salivary gland neoplasms are rare and are characterised by overlapping histopathological aspects. Therefore, the assessment of the correct histopathological diagnosis can be challenging. This study evaluated the frequency of pathology consultations and revisions for salivary gland neoplasms during routine clinical practice in the Netherlands. Furthermore, the concordance and discordance rates of these revisions are presented.

METHODS

The Dutch Pathology Registry (PALGA) was searched for patients that underwent a resection of a major salivary gland neoplasm between 2006 and 2016. Frequencies of pathology consultations and revisions are presented and, in order to calculate the rates of concordance and discordance, the results of the initial histopathological review were compared with the results of the revision.

RESULTS

Between 2006 and 2016, 13 441 major salivary gland neoplasms were resected in the Netherlands. 90% (n=12 082) of these tumours were diagnosed as benign and 10% (n=1359) as malignant. The initial pathologist requested a consultation in 3.3% of resections (n=439). Revision of the histopathological specimen was performed in 2.6% (n=350) of cases. Revisions were discordant in 8.3%; including 5.8% of the initially benign diagnosed lesions reclassified as malignant by the second expert pathologist and 8% of the revised malignant tumours that underwent a subtype change.

CONCLUSIONS

The number of discordant histopathological revisions (8.3%) emphasises the complexity of the histopathological diagnosis of salivary gland neoplasms. An increase in consultations may improve the accuracy of the initial diagnosis and thus treatment in salivary gland tumours while lowering the need for revisions and the number of discordant revisions.

Patterns of care analysis for salivary gland cancer: a survey within the German Society of Radiation Oncology (DEGRO) and recommendations for daily practice

Background

Salivary gland cancer (SGC) is rare and a heterogeneous type of cancer. Prospective randomized trials are lacking. No guideline focusing on standard procedures of radiotherapy (RT) in the treatment of SGC exists. Therefore, we surveyed the members of the German Society of Radiation Oncology (DEGRO) to gain information about current therapeutic strategies of SGC.

Methods

An anonymous questionnaire was designed and made available on the online platform umfrageonline.com. The corresponding link was sent to all DEGRO members who provided their user data for contact purposes. Alternatively, a PDF printout version was sent. Frequency distributions of responses for each question were calculated. The data were also analyzed by type of institution.

Results

Sixty-seven responses were received, including answers from 21 university departments, 22 non-university institutions, and 24 radiation oncology practices. Six participants reported that their departments (practice: n = 5, non-university hospital: n = 1) did not treat SGC, and therefore the questionnaire was not completed. Concerning radiation techniques, target volume definition, and concomitant chemotherapy, treatment strategies varied greatly among the participants. Comparing university vs. non-university institutions, university hospitals treat significantly more patients with SGC per year and initiated more molecular pathological diagnostics.

Conclusion

SGC represents a major challenge for clinicians, as reflected by the inhomogeneous survey results regarding diagnostics, RT approaches, and systemic therapy. Future prospective, multicenter clinical trials are warranted to improve and homogenize treatment of SGC and to individualize treatment according to histologic subtypes and risk factors.

Supplementary Information

The online version of this article (10.1007/s00066-021-01833-x) contains supplementary material, which is available to authorized users.

Factors predictive of 90-day mortality after surgical resection for oral cavity cancer: Development of a recursive partitioning analysis for risk stratification

BACKGROUND

Factors that influence postoperative mortality (POM) have been identified, but a predictive model to guide clinicians treating oral cavity cancer (OCC) has not been well established.

METHODS

Patients with OCC undergoing upfront surgical resection were included. Primary outcome was 90-day POM (90dPOM).

RESULTS

33 845 were identified using the National Cancer Database. Rate of 90dPOM was 3.2%. Predictors of higher 90dPOM include older age, higher comorbidity scores, nonprivate insurance, lower income, treatment in an academic facility, higher T- and N-classification, radical excision, and presence of positive margins. On RPA, two high-risk (90dPOM > 10%) patient subsets were identified: patients ≥80 years of age with T3-4 disease and patients <80 years, with any comorbidity and T3-4, N2-3 disease.

CONCLUSIONS

We identified a subset of patients in this cohort who are at high risk for 90dPOM. These patients may warrant additional perioperative and postoperative monitoring in addition to better preoperative assessment and screening.

Accuracy of parotid gland FNA cytology and reliability of the Milan System for Reporting Salivary Gland Cytopathology in clinical practice

Background

Differentiating between malignant and benign salivary gland tumors with fine‐needle aspiration cytology (FNAC) can be challenging. This study was aimed at testing the validity of the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) and at assessing possible differences in the sensitivity and specificity of parotid gland FNAC between dedicated head and neck (H&N) centers, subdivided into head and neck oncology centers (HNOCs) and head and neck oncology affiliated centers (HNOACs), and general hospitals (GHs).

Methods

The Dutch Pathology Registry (PALGA) database was searched for patients who had undergone a salivary gland resection between January 1, 2006, and January 1, 2017, and had a preoperative FNAC result. The FNAC reports were retrospectively assigned to MSRSGC categories. The risk of malignancy (ROM) was calculated for each category. The sensitivity and specificity for diagnosing malignancy were calculated and compared among HNOCs, HNOACs, and GHs.

Results

In all, 12,898 FNAC aspirates were evaluated. The ROMs for each category were as follows: 12.5% in MSRSGC I, 10.3% in MSRSGC II, 29% in MSRSGC III, 2.3% in MSRSGC IVa, 28.6% in MSRSGC IVb, 83% in MSRSGC V, and 99.3% in MSRSGC VI. The sensitivity of FNAC was highest in HNOCs (88.1%), HNOACs scored lower (79.7%), and GHs had a sensitivity of 75.0%.

Conclusions

The MSRSGC is a valid tool for reporting parotid gland FNAC; therefore, these results strongly advocate its use. On the basis of the higher sensitivity of FNAC in dedicated H&N centers, the authors recommend that GHs use the presented management strategies to help to minimize the chances of a preoperative misdiagnosis.

The Milan System for Reporting Salivary Gland Cytopathology is a valid tool for reporting parotid gland fine‐needle aspiration cytology. The sensitivity of fine‐needle aspiration cytology is higher at dedicated head and neck centers.

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.