To evaluate trends in contemporary positive surgical margin incidence in cT1-T2 oral cavity squamous cell carcinoma and to evaluate factors associated with surgical margin status.Retrospective analysis of large dataset.Retrospective analysis of the National Cancer Database.Between 2004 and 2016, 39,818 patients with cT1 or cT2 oral cavity squamous cell carcinoma received primary curative-intent surgery. Positive surgical margins were present in 7.95% of patients, and univariable adjusted probability of positive surgical margins over the study period declined by 1% per year (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-1.0; P = .049). Multivariable regression revealed the annual rate of positive surgical margins declined significantly (OR, 0.95 per year; 95% CI, 0.92-0.97; P < .001). Factors associated with increased odds of positive surgical margins included cT2 disease, subsite, understaged disease, lymphovascular invasion, tumor grade, and positive lymph nodes. Race and socioeconomic status were not associated with surgical margin status. Treatment at an academic center was associated with increased time to definitive surgery (median 35 days IQR 22-50 vs. median 27 days IQR 14-42; P < .001) and a 20% reduction in positive surgical margin rate (OR, 0.80; 95% CI, 0.71-0.90; P < .001). Treatment at high-volume centers was less likely to be associated with positive surgical margins (OR, 0.85; 95% CI, 0.74-0.98; P = .02).Surgical subsite, clinical T and N category, presence of lymphovascular invasion, and histologic grade were independent predictors of positive surgical margins. Patients are increasingly being treated at high-volume and academic centers. Overall, the rate of positive surgical margins in cT1-T2 oral cavity squamous cell carcinoma is decreasing.4 Laryngoscope, 132:1962-1970, 2022.
The aim of this study was to compare the incidence of positive surgical margins (PSMs) between different races and sexes in a national cohort. In this study, we analyzed the association between race and sex disparities and the incidence of PSMs based on data from the 2004-2016 National Cancer Database (NCDB). The NCDB includes deidentified data collected from over 1500 hospitals as part of the Commission on Cancer approvals program and represents over 70% of new cancer cases in the United States. This analysis provides minimally adjusted and further adjusted multivariate analyses of the incidence of positive surgical margins in OCSCC stratified by sex and race, disease characteristics, other demographics, comorbidities, and social determinants of health (SDOH). The incidence of PSMs was found to be elevated in black males of any age, black males under the age of 45, and in Indigenous American and native Alaskan males under the age of 45, independent of clinicopathologic factors. Specifically, black patients had a significantly higher incidence of PSMs when controlling for age, subsite, stage, grade, LVI, and CDCS. Our results remained unchanged after adjusting for the SDOH variables of insurance coverage, level of education, income, metropolitan versus urban versus rural location, distance from treatment center, and facility type. The findings of this study suggest that black males of any age, black males under 45, and Indigenous American and native Alaskan males under 45 have a higher incidence of PSMs, independent of clinicopathologic factors and SDOH. Our findings may help inform clinicians and hospitals of lapses in our healthcare system that perpetuate these inequities and further the goal of tackling disparities in surgical care.
Background Endoscopic sinus surgery (ESS) has become the treatment of choice for a variety of nasal conditions. The purpose of this study was to analyze the effect of diabetes mellitus (DM) on postoperative outcomes in ESS. Methods Data on endoscopic sinus surgery performed from 2005 to 2013 were collected from the American College of Surgeons National Surgical Quality Improvement (ACS‐NSQIP) database. Two groups were created, based on the presence of a DM diagnosis, and were analyzed for preoperative variables, comorbidities, and postoperative complications using SPSS statistical software. Results There were 644 patients included in the analysis, 85 of whom (13.2%) had a diagnosis of DM. Patients with DM were more likely to have higher rates of preoperative dyspnea and hypertension. After accounting for confounding factors, DM patients undergoing ESS were at higher risk of overall medical complications, pneumonia, unplanned reintubation, ventilator use of >48 hours, and mortality. However, after separating patients into outpatient and inpatient groups, DM was found to be an independent predictor of urinary tract infection in outpatients and of ventilator use >48 hours in inpatients. Conclusion DM patients undergoing ESS are at increased risk for postoperative medical complications. However, DM does not appear to increase the postoperative surgical complication rate in this population. Furthermore, DM does not appear to have an impact on ESS mortality, readmission, or reoperation rates.
Objective This study is designed to analyze the survival benefits of elective neck dissection (END) in the treatment of squamous cell carcinoma of the maxillary sinus (MS‐SCC) with clinically negative neck lymph nodes (N0) and no metastasis (M0). Study Design The aim of this study was to evaluate whether END improves survival in patients with MS‐SCC. Methods This study is a population‐based, concurrent retrospective database analysis of patients diagnosed with N0M0 MS‐SCC from 2004 to 2013. Data were acquired from the Surveillance, Epidemiology, and End Results database. Frequency functions, Kaplan‐Meier and Cox regression models were queried to analyze demographics, treatment status, and survival outcomes. Results There were a total of 927 MS‐SCC cases in the database between 2004 and 2013. This analysis revealed that for the overall cohort, END significantly and independently reduces the 5‐year hazard of death in MS‐SCC (hazard ratio [HR] = 0.646, 95% confidence interval [CI] = 0.419–0.873, P = 0.047). For early tumor (T)1/T2 tumors and T4 tumors, END did not independently improve 5‐year survival. However, for T3 disease, END significantly reduced the 5‐year hazard of death in MS‐SCC (HR = 0.471, 95% CI = 0.261–0.680, P = 0.001), regardless of other covariates, including adjuvant radiation. There has been an increase in the percentage of MS‐SCC surgeries that have been accompanied by END since SEER started collecting this data, although this did not demonstrate significance (R 2 = 0.622). Conclusion END improves disease‐specific survival in patients with MS‐SCC size > 4 cm and advanced T‐stage (American Joint Committee on Cancer AJCC TIII). Therefore, surgeons performing maxillectomies should consider conducting an END concurrent with maxillectomy for those with size > 4 cm advanced stage cancer. Level of Evidence 4. Laryngoscope , 1835–1841, 2018
Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking.To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck.The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016.Microvascular reconstructive surgery of the head and neck.Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality.A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16).Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery.3.
Objectives/Hypothesis Analyze the characteristics of second primary lung malignancies (SPLMs) following an index head and neck squamous cell carcinoma (HNSCC). Study Design Retrospective cohort study. Methods The Surveillance, Epidemiology and End Results database was queried for all cases of HNSCC between 1973 and 2014 (N = 101,856). This population was compared to a standard population to assess relative risk for lung cancer, calculated as the standardized incidence ratio (SIR). Patients who developed SPLMs were extracted (N = 8,116) and compared to all other cases of lung cancer (N = 1,160,853) to assess histopathological differences. SPLM subpopulations divided by head and neck primary site were compared for lung cancer histology and time interval between cancer diagnoses. Results Overall, 8.0% of HNSCC patients developed SPLMs (SIR = 4.22, P < .001), diagnosed an average of 6.7 years later. Patients with HNSCC of the supraglottis and hypopharynx were at the highest risk relative to a standard population, with SIRs of 8.10 and 6.34, respectively. When comparing SPLMs to all other lung cancers, there was no difference in the distribution of lung lobe affected, but SPLMs were significantly more likely to be of squamous cell carcinoma histology (42.0% vs. 21.0%, P < .001). Among head and neck subsites, lung cancers following larynx tumors had a significantly higher proportion of small cell histology, and those following oropharyngeal or hypopharyngeal tumors had significantly higher proportions of squamous cell histology. Conclusions Patients who undergo curative treatment of HNSCC are at high risk for developing SPLMs. Subsite‐specific differences may help elucidate the degree of risk attributable to smoking, genetic susceptibility, human papillomavirus infection, or metastasis masquerading as an SPLM. Level of Evidence 4 Laryngoscope , 129:903–909, 2019
Diabetes is associated with microvascular pathology and may predispose patients undergoing microvascular surgery to complications. This study assesses diabetes as a risk factor for complications following free flap surgery of the head and neck.In this retrospective cohort study, data on free flap surgeries of the head and neck between 2005 and 2014 was collected from the National Surgical Quality Improvement Program (NSQIP) database. A propensity-matching algorithm (PSM) was used to equilibrate distribution of numerous covariates between the diabetic and nondiabetic cohorts. A sub-analysis was performed to examine the impact of insulin-dependency.The initial dataset contained 2187 free flaps of the head and neck. After implementing PSM, a new population was created containing 506 total cases with 253 DM patients. The majority of cases were male and white. The matched cohort did not contain any demographics or comorbidities associated with DM. Complications significantly elevated in the DM group were severe bleeding (P = .046), postoperative ventilation greater than 48 hours (P < .001), and pneumonia (P < .048). In patients with insulin-dependent diabetes, reintubation (P = .005), cardiac arrest (P = .010), severe bleeding (P = .006), overall surgical complications (P = .015), and overall complications (P = .005) were significantly increased.This study examines the impact of diabetes on postoperative complications following free flap reconstruction of the head and neck. Propensity score matching was utilized. Analysis of the PSM cohort suggests that diabetic patients have elevated rates of postoperative pulmonary complications. Additionally, patients with insulin-dependent diabetes have significantly elevated rates of medical and surgical complications.
Objective Laryngeal cancer most commonly arises from the glottis. Comparable outcomes in survival have been shown in patients with early glottic squamous cell carcinoma treated with either surgery or radiotherapy. Study Design and Setting Administrative database study. Subjects and Methods The US National Cancer Institute’s SEER database (Surveillance, Epidemiology, and End Results) was queried for cases of early glottic cancer (T1‐T2N0M0, 1988‐2012). We identified 13,312 qualifying cases. Patient demographics, therapeutic measures, and survival outcomes were examined with appropriate univariate and multivariate analyses. Results Early glottic cancer has a mean age at diagnosis of 64.8 ± 11.6 years and a male:female ratio of 6.9:1. The most common treatment modality was radiotherapy alone (51.6%), followed by combination therapy with surgery first (31.5%). Overall, the 5‐year disease‐specific survival (DSS) rate was 88.4%. When stratified by treatment modality and stage, 5‐year DSS for T1 tumors was 93.2% with surgery alone and 89.0% with radiation alone ( P <. 0001). With combination therapy, the 5‐year DSS was 91.3% for surgery first and 84.9% for radiation first ( P =. 0239). In T2 tumors, 5‐year DSS was improved with single‐modality therapy versus multimodality therapy (81.1% vs 76.4; P =. 0255). Conclusion In T1 disease, surgery alone shows improved 5‐year DSS versus radiation alone, but this difference was not observed in T2 tumors. Additionally, surgery, rather than radiation, shows improved 5‐year DSS when implemented as a first‐line therapy. Combination therapy does not show improved 5‐year DSS for early glottic cancer.
