Michelle M. Chen

Transoral Robotic Surgery A Population-Level Analysis

Objective (1) To determine baseline demographic, geographic, clinical, and pathologic characteristics of patients who had transoral robotic surgery (TORS) for oropharyngeal cancer. (2) To analyze margin status and unplanned readmission after TORS versus nonrobotic surgery. Study Design Retrospective database review. Setting National Cancer Database (2010-2011). Subjects and Methods Searching the National Cancer Database for adults with oropharyngeal cancer, we identified 877 patients who had TORS and 4269 patients who had nonrobotic surgery. Outcomes of interest included likelihood of adjuvant therapy, margin status, and unplanned readmission. Statistical analysis included chi-square, t tests, and multivariate regression. Results From 2010 to 2011, there was a 67% increase in the use of TORS for oropharyngeal cancer. Compared with patients who had nonrobotic surgery, TORS patients were more likely to be at academic centers (80.8% vs 49.1%, P < .001), to have private insurance (62.2% vs 57.4%, P < .001), and to have human papilloma virus (HPV)–positive tumors (48.3% vs 27.1%, P < .001). TORS (odds ratio, 0.50; 95% CI, 0.39-0.63) and HPV positivity (odds ratio, 0.73; 95% CI, 0.53-0.99) were independently associated with decreased likelihood of adjuvant chemoradiation versus radiation therapy. TORS patients were less likely to have positive margins than were patients who had nonrobotic surgery (20.2% vs 31.0%, P < .001). High-volume TORS centers had lower rates of positive margins (15.8% vs 26.1%, P < .001) and unplanned readmissions (3.1% vs 6.1%, P < .03) than did low-volume centers. Conclusions TORS is being rapidly adopted by academic and community cancer centers. TORS is associated with a lower rate of positive margins than nonrobotic surgery, and high-volume centers have the lowest rates of positive margins and unplanned readmissions.

Histologic grade as prognostic indicator for mucoepidermoid carcinoma: A population-level analysis of 2400 patients

Mucoepidermoid carcinoma (MEC) is an uncommon malignancy. To the best of our knowledge, this is the largest study investigating disease‐specific survival (DSS) of parotid MEC and the first population‐level study of the distribution of nodal metastases.

The Role of Adjuvant Therapy in the Management of Head and Neck Merkel Cell Carcinoma: An Analysis of 4815 Patients

IMPORTANCE Merkel cell carcinoma (MCC) is a rare neuroendocrine malignant neoplasm that most commonly occurs in the head and neck and is rapidly increasing in incidence. The role of adjuvant chemoradiotherapy (CRT) in the management of head and neck MCC remains controversial. OBJECTIVE To evaluate the association between different adjuvant therapies and survival in head and neck MCC. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of adult patients with head and neck MCC who had surgery recorded in the National Cancer Data Base from 1998 to 2011. INTERVENTIONS Surgical excision, adjuvant radiation therapy (RT), or adjuvant CRT. MAIN OUTCOMES AND MEASURES Our main outcome was overall survival (OS). Statistical analysis included χ2, t tests, Kaplan-Meier survival analysis, and Cox proportional hazards regression analysis. RESULTS We identified 4815 patients; 92.0% underwent standard surgical excision, and 8.0% underwent Mohs surgery. On multivariate analysis, age at least 75 years (hazard ratio [HR], 2.83 [95% CI, 1.82-4.41]), larger tumor size, positive margins (HR, 1.52 [95% CI, 1.25-1.85]), and metastatic lymph nodes (HR, 2.29 [95% CI, 1.84-2.85]) were independently associated with decreased OS. Postoperative CRT (HR, 0.62 [95% CI, 0.47-0.81]) and RT (HR, 0.80 [95% CI, 0.70-0.92]) provided a survival benefit over surgery alone. Adjuvant CRT was associated with improved OS over adjuvant RT in patients with positive margins (HR, 0.48 [95% CI, 0.25-0.93]), tumor size at least 3 cm (HR, 0.52 [95% CI, 0.30-0.90]), and male sex (HR, 0.69 [95% CI, 0.50-0.94]). CONCLUSIONS AND RELEVANCE To our knowledge, this the first study examining the role of adjuvant CRT in head and neck MCC. Results suggest that adjuvant CRT may help improve survival in high-risk patients, such as males and those with positive margins and larger tumors.

Treatment Factors Associated With Survival in Early-Stage Oral Cavity Cancer: Analysis of 6830 Cases From the National Cancer Data Base

IMPORTANCE Most patients with oral cavity squamous cell cancer (OCSCC) are initially seen at an early stage (I and II). Although patient and tumor prognostic features have been analyzed extensively, population-level data examining how variations in treatment factors impact survival are lacking to date. OBJECTIVE To analyze associations between treatment variables and survival in stages I and II oral cavity squamous cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of cases in the National Cancer Data Base. Patients diagnosed as having stage I or II OCSCC between January 1, 2003, and December 31, 2006, and treated with surgery were identified. Univariate and multivariable analyses of overall survival based on patient, disease, and treatment characteristics were conducted. MAIN OUTCOMES AND MEASURES Overall survival and survival at 5 years. RESULTS In total, 6830 patients were included. Survival at 5 years was 69.7% (4760 patients). On univariate analysis, treatment factors associated with improved survival included treatment at academic or research institutions, no radiation therapy, no chemotherapy, and negative margins (P < .001 for all). Neck dissection was associated with improved survival (P = .001), reflecting pathologic restaging and elimination of patients with occult nodal disease. Patients treated at academic or research institutions were more likely to receive neck dissection and less likely to receive radiation therapy or have positive margins. On multivariable analysis, neck dissection (hazard ratio [HR], 0.85; 95% CI, 0.76-0.94; P = .003) and treatment at academic or research institutions (HR, 0.88; 95% CI, 1.01-1.26; P = .03) were associated with improved survival, whereas positive margins (HR, 1.27; 95% CI, 1.08-1.49; P = .005), insurance through Medicare (HR, 1.45; 95% CI, 1.25-1.69; P < .001) or Medicaid (HR, 1.96; 95% CI, 1.60-2.39; P < .001), and adjuvant radiation therapy (HR, 1.31; 95% CI, 1.16-1.49; P < .001) or adjuvant chemotherapy (HR, 1.34; 95% CI, 1.03-1.75; P = .03) were associated with compromised survival. CONCLUSIONS AND RELEVANCE Prognostic impacts of treatment factors in early OCSCC are presented. Overall survival for early OCSCC varies with demographic and tumor characteristics but also varies with treatment and system factors, which may represent targets for improving outcomes in this disease.

Postdischarge Complications Predict Reoperation and Mortality after Otolaryngologic Surgery

Objectives (1) Determine procedure-specific rates of postdischarge complications (PDCs) and their risk factors in the first 30 days following inpatient otolaryngologic surgery. (2) Evaluate association between PDCs and risk of reoperation and mortality. Study Design Retrospective cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program (2005-2011). Subjects and Methods We identified 48,028 adult patients who underwent inpatient otolaryngologic surgery. Outcomes of interest included complications, reoperation, and mortality in the first 30 days following surgery. Statistical analysis included chi-square, t tests, and multivariate regression. Results Laryngectomy, lip, and tongue/floor of mouth surgery had the highest PDC rates (8.0%, 7.4%, and 4.1%, respectively). Within the first 48 hours, week, and 2 weeks post discharge, 10%, 44%, and 73% of PDCs occurred, respectively. Common PDCs included surgical site infections (53.6%), other infections (37.4%), and venous thromboembolic events (7.4%). Multivariate analysis demonstrated that increasing age (odds ratio [OR] = 1.01; 95% confidence interval [CI], 1.01-1.02), prolonged operative time (OR = 1.68; 95% CI, 1.39-2.03), hospital stay >1 day (OR = 1.49; 95% CI, 1.18-1.86), and American Society of Anesthesiologists (ASA) class ≥3 (OR = 1.45; 95% CI, 1.18-1.78) were independently associated with PDCs. Patients with PDCs were more likely to die (0.9% vs 0.1%, P < .001) or have a reoperation (10.4% vs 1.2%, P < .001). Conclusion This is the first study of overall postdischarge events after otolaryngologic surgery. PDC rates in otolaryngology occur soon after discharge, are procedure specific, and are associated with reoperation and mortality. Targeted procedure-specific triage and follow-up plans for high-risk patients may improve outcomes.

Lymph Node Count From Neck Dissection Predicts Mortality in Head and Neck Cancer

Purpose Multiple smaller studies have demonstrated an association between overall survival and lymph node (LN) count from neck dissection in patients with head and neck cancer. This is a large cohort study to examine these associations by using a national cancer database. Patients and Methods The National Cancer Database was used to identify patients who underwent upfront nodal dissection for mucosal head and neck squamous cell carcinoma between 2004 and 2013. Patients were stratified by LN count into those with < 18 nodes and those with ≥ 18 nodes on the basis of prior work. A multivariable Cox proportional hazards regression model was constructed to predict hazard of mortality. Stratified models predicted hazard of mortality both for patients who were both node negative and node positive. Results There were 45,113 patients with ≥ 18 LNs and 18,865 patients with < 18 LNs examined. The < 18 LN group, compared with the ≥ 18 LN group, had more favorable tumor characteristics, with a lower proportion of T3 and T4 lesions (27.9% v 39.8%), fewer patients with positive nodes (46.6% v 60.5%), and lower rates of extracapsular extension (9.3% v 15.1%). Risk-adjusted Cox models predicting hazard of mortality by LN count showed an 18% increased hazard of death for patients with < 18 nodes examined (hazard ratio [HR] 1.18; 95% CI, 1.13 to 1.22). When stratified by clinical nodal stage, there was an increased hazard of death in both groups (node negative: HR, 1.24; 95% CI, 1.17 to 1.32; node positive: HR, 1.12; 95% CI, 1.05 to 1.19). Conclusion The results of our study demonstrate a significant overall survival advantage in both patients who are clinically node negative and node positive when ≥ 18 LNs are examined after neck dissection, which suggests that LN count is a potential quality metric for neck dissection.

Hypopharyngeal cancer incidence, treatment, and survival: temporal trends in the United States.

The objective was to characterize incidence, treatment, and survival for hypopharyngeal cancer in the United States between 1988 and 2010, and to analyze associations between changes in treatment modality and survival.

Prognostic factors for squamous cell cancer of the parotid gland: An analysis of 2104 patients

Parotid gland squamous cell cancer (SCC) occurs as metastasis from cutaneous SCC or primary malignancy. There is limited data on incidence, prognosis, and treatment outcomes.

Hospital readmission and 30‐day mortality after surgery for oral cavity cancer: Analysis of 21,681 cases

Oral cavity squamous cell cancer (SCC) is treated primarily with surgery. Rates of 30‐day hospital readmission and mortality after surgery for oral cavity SCC are unknown.

Safety of Adult Tonsillectomy: A Population-Level Analysis of 5968 Patients

IMPORTANCE Tonsillectomy is one of the most commonly performed otolaryngology procedures. The safety of this procedure in adults is based on small case series. To our knowledge, we report the first population-level analysis of the safety of adult tonsillectomies in the United States. OBJECTIVE To characterize the mortality, complication, and reoperation rate in adult tonsillectomy. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 5968 adult patients who underwent tonsillectomy with records in the database of the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2011). INTERVENTION Tonsillectomy. MAIN OUTCOMES AND MEASURES Outcomes of interest included mortality, complications, and reoperation in the 30-day postoperative period. Statistical analysis included χ² test, t test, and multivariate logistic regression. RESULTS The 30-day mortality rate was 0.03%, the complication rate was 1.2%, and the reoperation rate was 3.2%. Most patients had a primary diagnosis of chronic tonsillitis and/or adenoiditis (82.9%), and the most common complications were pneumonia (27% of all complications), urinary tract infection (27%), and superficial site infections (16%). Patients who underwent reoperation were more likely to be male (54.0% vs 32.4%; P < .001), white (84.8% vs 75.3%; P = .02), or inpatients (24.3% vs 14.3%; P < .001) and to have postoperative complications (5.3% vs 1.1%; P < .001) than those who did not return to the operating room. On multivariate analysis, male sex (odds ratio [OR], 2.30 [95% CI, 1.67-3.15]), inpatient status (OR, 1.52 [95% CI, 1.04-2.22]), and the presence of a postoperative complication (OR, 4.58 [95% CI, 2.11-9.93]) were independent risk factors for reoperation. CONCLUSIONS AND RELEVANCE In the United States, adult tonsillectomy is a safe procedure with low rates of mortality and morbidity. The most common posttonsillectomy complications were infectious in etiology, and complications were independently associated with the need for reoperation.