Evidence Based Evidence Based Management Management

Gingivo-Buccal CancerGingivo-Buccal Cancer

Dr. A D’ CruzDr. A D’ Cruz Tata Memorial HospitalTata Memorial Hospital

Oral Cancer – Global Oral Cancer – Global Incidence Incidence

• 10th most common cancer

• 389,000 new cases annually (2000)

• 2/3rd in developing countries

• 200,000 deaths annually

• Stable or increased in last four decades

• Sharp increase in incidence in Germany, Denmark, Scotland, Central & Eastern Europe

• Same increase in Japan, Australia, New Zealand & USA ( non-whites)

Oral Cancers

Oral cancer common cancer in India – Observations reported since late 19th century

Cancer of the oral cavityCancer of the oral cavitySite DistributionSite Distribution

India

58.30%

26.60%

West

22.00%

67.0%

TONGUE & FOM

GINGIVOBUCCAL COMPLEX

[BUCCAL MUCOSA + RMT + LOWER GUM]

Biological Distinctions in Oral Biological Distinctions in Oral CancerCancer

GINGIVO – GINGIVO – BUCCAL CaBUCCAL Ca

TONGUE CaTONGUE Ca

STAGE AT STAGE AT PRESENTATIONPRESENTATION

PROPENSITY TO PROPENSITY TO NECK NECK METASTASESMETASTASES

NO – 52%NO – 52%

N+ – 48%N+ – 48%

NO – 29%NO – 29%

N+ – 71%N+ – 71%

FIRST NODAL FIRST NODAL STATIONSTATION

LEVEL ILEVEL I LEVEL II / IIILEVEL II / III

PATTERN OF PATTERN OF FAILUREFAILURE

PREDOMINANTLPREDOMINANTLY AT THE Y AT THE PRIMARY SITEPRIMARY SITE

PREDOMINANTLY IN PREDOMINANTLY IN THE NECKTHE NECK

20

80

I & II

III & IV40

60

I & II

III & IV

GINGIVOBUCCAL CANCER – THE GINGIVOBUCCAL CANCER – THE INDIAN ORAL CANCER 2275 PTS. INDIAN ORAL CANCER 2275 PTS.

(1997-99)(1997-99)

42%

28%

13%

14%3%

BUCCAL MUCOSA

LOWER ALVEOLUS

LOWER GBS

RMT

OTHERS

Gingivo-Buccal Cancers

Areca nut is the fourth most

common psychoactive

substance in the world (after

caffeine, alcohol and nicotine),

the use extending to several

hundred million people.

Tobacco chewers (with cancer) 105 AGE AND SEX MATCHED Tobacco chewers (no cancer ) 71 RELATIVE RISK = 12.5%

GHOSH S. Eur J Surg Oncol, 1996

Pre-malignant conditions n =2275 (97-99)

LEUKOPLAKIA - 8.5% (194) SMF -10.8%(245)SMF -10.8%(245)

Users

OSF Prevalence

%

R.R.

No areca nut users 3232 4 0.12 1.0

Areca nut any 1786 160 9.0 75.0

Mawa 1326 144 10.9 90.8

Areca nut with

tobacco

136 2 1.5 12.5

Mixed with smoking 324 14 4.3 35.8

5018 164 3.2

  Gupta PC et al. National Medical Journal of India; 11(3): 113-116, 1998.

Prevalence of tobacco use among oral submucous fibrosis (OSF) cases

Oral Cancers Submucous fibrosis

Hazare VK et al. National Medical Journal of India. 11(6): 299, 1998.

Relative risk of oral submucous fibrosis by the daily frequency of areca nut use - a case control study from Government Dental College, Nagpur

Frequency per day Cases Controls Relative risk

No areca nut use 5 110 1.0

1 11 24 10.1*

2-3 65 42 34.0*

4-5 61 16 83.9*

6 58 5 255.2*

Any areca nut use 195 87 49.3*

Total number 200 197

Oral Cancers Submucous fibrosis

Chemoprevention

Chemoprevention- Chemoprevention- LimitationsLimitations

• Costly• Side effects• Long duration• Lesion return on – stoppage • Exact agents not known (curcumin)

Encourage patient to stop habits

Oral / Dental Hygiene

Good Diet

TREATMENT

Early Stage I & II Late Stage III & IV

Single modalitytreatment

• SX • RT

OperableIII & IVa

In Operable

Combined modality treatment

Sx + PORT/ CT RT

Radical RT

IV cLow GC /

Symptomatic Rx

IV b

CT RT Pall CT

Gingivo - buccal cancerGingivo - buccal cancer

Gingivo – buccal cancersGingivo – buccal cancersGoals of treatmentGoals of treatment

MAXIMIZING CURE RATESMAXIMIZING CURE RATES

PRESERVING FUNCTIONPRESERVING FUNCTION

COSMESISCOSMESIS

COST EFFECTIVECOST EFFECTIVE

EXPEDITING CAREEXPEDITING CARE

Gingivobuccal Cancers Gingivobuccal Cancers Factors Affecting TreatmentFactors Affecting Treatment

TUMOR FACTORSTUMOR FACTORS T size, Location to bone, Type of lesion, Nodal diseaseT size, Location to bone, Type of lesion, Nodal disease

PATIENT FACTORSPATIENT FACTORS Performance status, Persistence of habits, PreferencePerformance status, Persistence of habits, Preference

PHYSICIAN FACTORSPHYSICIAN FACTORS Availability of Availability of MULTIDISCIPLINARY TEAMMULTIDISCIPLINARY TEAM & &

EXPERTISEEXPERTISE

GINGIVO – BUCCAL CANCERSGINGIVO – BUCCAL CANCERSEARLY T1/T2 CANCERSEARLY T1/T2 CANCERS

Cancer of the Oral Cavity – Jatin P. Shah & M J Zelefsky

SX = RT

Radiotherapy Carcinoma Buccal Radiotherapy Carcinoma Buccal MucosaMucosa

185 cases

2 years DFS - 48% RT 46% SX

Early Stage

Chaudhary, Seminars in Surgical Oncology 1989

GINGIVO – BUCCAL CANCERSGINGIVO – BUCCAL CANCERSEARLY T1/T2 CANCERS - RTEARLY T1/T2 CANCERS - RT

BOTH EXTERNAL & BOTH EXTERNAL &

INTERSTITIAL NEEDEDINTERSTITIAL NEEDED

PROLONGED TREATMENTPROLONGED TREATMENT

SIDE EFFECTS SIDE EFFECTS Xerostomia, Dental caries, ORN.Xerostomia, Dental caries, ORN.

CAN BE ONLY GIVEN CAN BE ONLY GIVEN ONCEONCE

Not suited for alveolar lesionsNot suited for alveolar lesions

“Radiotherapy is chosen when surgery not possible / functional or cosmetic problems are anticipated”

SIMPLE SIMPLE

EXPEDIOUSEXPEDIOUS

NO SIGNIFICANT FUNCTIONAL & COSMETIC NO SIGNIFICANT FUNCTIONAL & COSMETIC

DEFECTSDEFECTS

REPEATED PROCEDURE POSSIBLEREPEATED PROCEDURE POSSIBLE

COST EFFECTIVECOST EFFECTIVE

CHOICE OF TREATMENTCHOICE OF TREATMENT

GINGIVO – BUCCAL CANCERSGINGIVO – BUCCAL CANCERSEARLY T1/T2 CANCERS - SurgeryEARLY T1/T2 CANCERS - Surgery

GB Cancers – T1/T2 cancersGB Cancers – T1/T2 cancersSurgery ( margins)Surgery ( margins)

WIDE; ADEQUATE WIDE; ADEQUATE

MARGINS > 5mmMARGINS > 5mm

DEPTH – BUCCINATOR DEPTH – BUCCINATOR

MUSCLEMUSCLE

Sieczka et al Sieczka et al ( Roswell ( Roswell

Park, Am J Otolaryngol 2001)Park, Am J Otolaryngol 2001)

- - 40% local failure T1 – T240% local failure T1 – T2

Post-op ADJUVANT Post-op ADJUVANT

NECESSARYNECESSARY

Gingivo – BuccalGingivo – Buccal Cancers (T1 / T2) Cancers (T1 / T2)

M D Anderson Experience Jan 1974 – Dec1998

250 Pts ; 119 untreated

T125 - 78% (5 Yr Survival)

T245 - 66% (5 Yr Survival)

• Worse than other head & neck cancers stage matched

• Bad Prognostic factors – muscle, Stenson duct involvement, ECS

Diaz, Head & Neck ; April 2003

GBS Cancers – The TMH Experience GBS Cancers – The TMH Experience (1997-99)(1997-99)

Early Stage(I/II)Early Stage(I/II)

n 207ptsMedian follow up 2.2 yrsDFS 2yrs 65.7% 5yrs 50.33%Local Rec. rate 21%Salvage rate 37%

GINGIVO – BUCCAL CANCERSGINGIVO – BUCCAL CANCERSEARLY T1/T2 CANCERS – SURG. v/s RTEARLY T1/T2 CANCERS – SURG. v/s RT

IS A RANDOMIZED TRIAL FEASIBLE?IS A RANDOMIZED TRIAL FEASIBLE?

NO – IT WOULD BE,NO – IT WOULD BE, UNETHICAL UNETHICAL DIFFICULT OT ACCRUE PATIENTSDIFFICULT OT ACCRUE PATIENTS

Early GBS Cancers (T1/T2)Early GBS Cancers (T1/T2)Management of the Neck Management of the Neck

Low propensity to cervical metastasis [ <10% ]Low propensity to cervical metastasis [ <10% ]

7.2%7.2% Clinically N0 have occult metastasisClinically N0 have occult metastasis(Nair, Cancer 1988)(Nair, Cancer 1988)

CAN WAIT & WATCH UNLESSCAN WAIT & WATCH UNLESS Poor follow up Poor follow up Cheek flap for surgical accessCheek flap for surgical access

Marginal Mandibulectomy for GBS Marginal Mandibulectomy for GBS Cancers:Cancers:

TMH ExperienceTMH Experience

Pradhan SA et al Indian J Cancer 1987 Control Pradhan SA et al Indian J Cancer 1987 Control

rate: 79%rate: 79%

Pathak KA et al EJSO 2004Pathak KA et al EJSO 2004

1994-2001 n=831994-2001 n=83

2-year local control: 79%2-year local control: 79%

Marginal MandibulectomyMarginal MandibulectomyContraindicationsContraindications

Locoregional control influenced by soft tissue margins

(p<0.01)* - 127pts / 94 marginal mandibulectomies

O’Brien C.J., Int J Oral Maxillofac Surg 2003

GB Cancers – Locally GB Cancers – Locally advancedadvanced

T3, T4T3, T4

SURGERY FOLLOWED BY PORT

RADIOTHERAPY WITH SALVAGE SURGERY

NO RANDOMIZED CONTROL TRIALS

Radiotherapy Carcinoma Buccal Radiotherapy Carcinoma Buccal MucosaMucosa

185 cases

2 years DFS - 5% RT 33% SX

Chaudhary, Seminars in Surgical Oncology 1989

Late Stage

Gingivo – Buccal Sulcus TumorsGingivo – Buccal Sulcus TumorsRadiotherapy Radiotherapy

• 234 patients (Nair et al Cancer 1988)

• Stage I – 85%, Stage II – 63%, Stage III – 41%, Stage IV -15%

• Radium implant (28) = Small Volume ext. RT (62% Vs 64%)

• Dismal Survival with RT in advanced stage poor surgical salvage

• Compared three groups : S alone / S – PORT / RT (no survival)

Chhetri D.K., Otolaryngol Head Neck Surg 2000

Adjuvant RT (Adjuvant RT (RTOG 73.03RTOG 73.03))1973-1979 ( N=277)1973-1979 ( N=277)

Pre-opPre-op POST OP RTPOST OP RT

LR CONTROLLR CONTROL48%48% 65% [p=0.04] 65% [p=0.04]SURVIVALSURVIVAL 33%33% 38% 38%

[[p=O.1,better trend]p=O.1,better trend]

COMPLICATIONSCOMPLICATIONS SAMESAMEORAL CAVITY (43) PREOP RT PORT

SUBSET OAS 30% 36%

ANALYSIS LRC 43% 52%

Radiotherapy in head and Radiotherapy in head and neck Cancersneck Cancers

RTOG 73-03RTOG 73-03277 PATIENTS - FOLLOW UP 9-15 yrs277 PATIENTS - FOLLOW UP 9-15 yrs

PRE OP RTPRE OP RT POST OP RTPOST OP RT[ 50.0 GY ] [ 50.0 GY ] [ 60.0 GY ][ 60.0 GY ]

• LOCO REGIONAL CONTROL BETTER (p = 0.04)

• NO DIFFERENCE IN ABSOLUTE SURVIVAL (p = 0.15)

• COMPLICATIONS SAME (p - NS)

Surgery + PORTSurgery + PORT (1988 – 1994) (1988 – 1994)

n-57 – ( Sx + RT) RT 45 – 68.4 (61.2 Gy)

Poor prognostic factors – (Univariate)

- Positive Surgical Margin- Tumor invasion of cheek

Poor prognostic factors – (Multivariate)

- Tumor invasion of skin (p=0.0014)

Fu-min Fang et al Head & Neck 1997

GBS Cancers – The TMH GBS Cancers – The TMH ExperienceExperience

Prognostic factors -Prognostic factors -Late Stage Late Stage ( III / IVa)( III / IVa)

Univariate AnalysisUnivariate Analysis

Grade p=0.002Cut margins p=0.04Node positivity p=0.000Perinodal extension p=0.008Thickness > 4mm p=0.004

Multivariate AnalysisNode positivity p=0.001, HR=2.81, CI (1.5 – 5.2)Thickness >4mm p=0.002, HR=1.8, CI (1.2 – 2.8)

n 624DFS 2yrs 38.5%

5yrs 13%

Surgery v/s Surgery + PORTSurgery v/s Surgery + PORT(1989 – 1993)(1989 – 1993)

N=176 patientsN=176 patients 115(S)115(S) 61(S+R)61(S+R)LR control LR control 11%11% 48% 48% III/IV III/IV

(p=0.001)(p=0.001)

71%71% 75%75% I/II (p=NS)I/II (p=NS)

PROGNOSTIC FACTORSPROGNOSTIC FACTORS MarginsMargins ThicknessThickness Bone invasionBone invasion GradeGrade Nodal involvementNodal involvement

RT BETTER IF BEFORE 30 DAYSRT BETTER IF BEFORE 30 DAYS

- Dixit S, Vyas RK, Ann Surg - Dixit S, Vyas RK, Ann Surg Oncol. 1998Oncol. 1998

GB Sulcus Cancers – POST OP GB Sulcus Cancers – POST OP RTRT

RCTRCT

GB CANCERS (T3; T4, N0 – N2b)

SURGERY (60) SURGERY + RT (80) 58 – 65 GY

• 30 MONTHS FOLLOW UP

• DISEASE FREE SURVIVAL 38% v/s 68% ( p < 0.005)

Mishra et al (1996 – European Journal of Surgical Oncology)

RCT – Role of RT RCT – Role of RT

Peters et alPeters et al (1993) (1993) RISK GROUPSRISK GROUPSRCTRCTN = 240N = 240 LOW RISK LOW RISK HIGH RISKHIGH RISK

DOSE ADOSE A DOSE B DOSE DOSE B DOSE CC

52 – 54 Gy/ 6wks52 – 54 Gy/ 6wks 63Gy/ 7wks/35# 63Gy/ 7wks/35# 68.4Gy/7.5wks/35# 68.4Gy/7.5wks/35#Interim AnalysisInterim AnalysisHigher ReccHigher Recc

57.6Gy/ 6.5wks57.6Gy/ 6.5wks

CONCLUSIONS:CONCLUSIONS:a.a. A minimum of 57.6 Gy with boost of 63 Gy to sites of high A minimum of 57.6 Gy with boost of 63 Gy to sites of high

risk and ECS, is essentialrisk and ECS, is essentialb.b. Treatment should be started as soon as possibleTreatment should be started as soon as possiblec.c. Dose escalation above 63 Gy does not appear to improve Dose escalation above 63 Gy does not appear to improve

therapeutic ratiotherapeutic ratio

POST OP RT POST OP RT

RCT – 213 patients

Low riskn = 31

Intermediate riskn = 31

High riskn = 151

NO ADJUVANT RT 57.6 Gy/ 6.5 weeksn = 76

63 Gy / 6.5 weeksn = 75

63 Gy / 7weeks

RISK FACTORS:

•Oral cavity primary

•Margins close / positive

•Perineural invasion

2 positive lymph nodes

•Largest node > 3 cms

•Performance status 2 [WHO]

•Delay > 6 weeks

((Ang et al, 2001Ang et al, 2001))

Low risk / Intermediate risk had similar control & survivalLow risk / Intermediate risk had similar control & survival

They did better than high riskThey did better than high risk

High risk had a trend towards better control when RT High risk had a trend towards better control when RT

was given over 5 weekswas given over 5 weeks

Ang et al, 2001Ang et al, 2001

Results

POST OP CHEMORADSPOST OP CHEMORADSEORTC – NEJM 2004EORTC – NEJM 2004

Curative post surgery

167RT [66 Gy / 6.5 weeks]

167CT / RT [100mg Cispat/m2

T3;T4;Node +ve&T1/T2 adverse factors

Median follow up 60 months

I. Progression free survival 47% v/s 36% (p = 0.04)

II. Overall survival 53% v/s 40% (p = 0.02)

III. Locoregional recurrences 18% v/s 31% (p = 0.007)

IV. Toxicity [GR3] 41% v/s 21% (p = 0.001)

POST OP CHEMORADSPOST OP CHEMORADSRTOG (9501) – NEJM 2004RTOG (9501) – NEJM 2004

Curative surgery

231RT [60 – 66 Gy ]

228RT + Cisplat

[100mg/m2, Day 1,22,43]

2 nodes; ECS; +ve margins

Median follow up 60 months

I. Locoregional control 82% v/s 72% (p = 0.01)

II. Disease free survival better (p = 0.04)

III. Overall survival similar (p = 0.19)

IV. Acute toxicity [GR3] 77% v/s 34% (p < 0.001)

Gingivo – BuccalGingivo – Buccal Cancers (T3 / T4) Cancers (T3 / T4)Prospective Randomised Control TrialProspective Randomised Control Trial

135 patients ; Stage III / IV

(65) Inj. MTX 50mg / m2(day 3,10,17) (70) Observation

• DFS 61% Vs 37% (p=0.01)• Local Recurrence less in first 6 months (p=0.002)

Rao et al Am J Surg. 1994

G B Cancers - T 3 / 4G B Cancers - T 3 / 4Management of nodesManagement of nodes

1980 – 1989 - 527 patients

Extent of neck SD SOHD RND

Dissection (Level I ) (Level I – III) (Level I – V )

N0 N+ N0 N+ N0 N+

Nodes 95 71 141 42 67 111

Regional 11(12%) 24(34%) 7(5%) 8(19%) 2(3%) 20(18%)Recurrence

Pradhan S.A., D’Cruz A.K. – Eur Arch Otorhinolaryngol (1995) 252 – 143 - 145

Recurrent Oral TumorsRecurrent Oral Tumors

• 38 patients who recurred after curative treatment

• Salvage better if :-i) Initial tumor stage I / II Vs III / IV ( p < 0.001)ii) Recurring after 6 months ( p < 0.005)iii) Surgery for salvage Vs RT / CT ( p < 0.001)iv) Stage of recurrence (N S)

Overall Salvage rate 21%

Overall salvage rate whether 15% (Wheeler, 1990)

Schwatz, Head & Neck, Jan 2000

Management of Advanced Management of Advanced Unresectable Head and Unresectable Head and

Neck cancersNeck cancers

Altered fractionation radiationAltered fractionation radiation Induction chemotherapyInduction chemotherapy Alternating chemo-radiotherapyAlternating chemo-radiotherapy Concurrent CT RTConcurrent CT RT

Altered Fractionation Altered Fractionation RadiationRadiation

RTOG 9303RTOG 9303 N=1113 patientsN=1113 patientsFour armsFour arms

Standard fractionationStandard fractionationHyperfractionationHyperfractionationAccelerated hyperfractionation with SplitAccelerated hyperfractionation with SplitAccelerated fractionation with Concomitant Accelerated fractionation with Concomitant boostboost

ResultsResultsBetter locoregional control with Better locoregional control with Hyperfractionation (p=0.045) & Accelerated Hyperfractionation (p=0.045) & Accelerated fractionation with Concomitant boost (p=0.050)fractionation with Concomitant boost (p=0.050)All three Altered fractionation group had All three Altered fractionation group had increased acute toxicity and comparable late increased acute toxicity and comparable late toxic effectstoxic effects

Fu et al,Int J Radiat Oncol BiolFu et al,Int J Radiat Oncol Biol Phys 2000Phys 2000

GB cancers stage- IV B/CGB cancers stage- IV B/C

No conclusive evidence confirming the No conclusive evidence confirming the role of chemotherapy in palliation as role of chemotherapy in palliation as compared to best supportive carecompared to best supportive care

Foscan study in advanced Foscan study in advanced diseasedisease

ObjectivesObjectives

improvement in quality of lifeimprovement in quality of life

objective tumour response (complete objective tumour response (complete

and partial)and partial)

toxicity, tolerability and safetytoxicity, tolerability and safety

one-year survivalone-year survival

PDTPDTAdvanced CancersAdvanced Cancers

147 patients assessed to date147 patients assessed to date[ 109 M, 38 F][ 109 M, 38 F]

50% Caucasians, 50% Asians50% Caucasians, 50% Asians

Clinical benefitClinical benefit 24% objective response24% objective response

53% overall palliative benefit 53% overall palliative benefit

Overall study results Overall study results

Overall palliative benefit 53% (64 patients)

43 patients were optimally treated

61% showed overall palliative benefit

Palliation ( 122 patients.)

VERRUCOUS CARCINOMAVERRUCOUS CARCINOMA

5% of all SCC5% of all SCC

LOCALLY AGGRESSIVELOCALLY AGGRESSIVE DE-DIFFERENTIATION WITH RT DE-DIFFERENTIATION WITH RT

(Medina’ 84)(Medina’ 84)

Recent studies DO NOT CONFIRM Recent studies DO NOT CONFIRM

aboveabove

(Tharp, Laryngoscope 1998; (Tharp, Laryngoscope 1998;

McCafferey 1998)McCafferey 1998)

Better results with SURGERY Better results with SURGERY

compared to RTcompared to RT

Chemoradiation in Chemoradiation in Advanced Head & Neck Advanced Head & Neck

cancerscancers Induction ChemotherapyInduction Chemotherapy

Initial response rates 50 – 90% with Initial response rates 50 – 90% with Cisplatin-5FU based schedulesCisplatin-5FU based schedules

However, multiple RCT’s – Failure to However, multiple RCT’s – Failure to demonstrate a survival advantage with demonstrate a survival advantage with either Single / Multiagent either Single / Multiagent Chemotherapy Chemotherapy

Chemoradiation in Advanced Chemoradiation in Advanced Head & Neck cancersHead & Neck cancers

Alternating ChemoradiationAlternating Chemoradiation 2 RCT’s 2 RCT’s Complete response rates, Progression free survival Complete response rates, Progression free survival

and OAS – significantly better for Alternation and OAS – significantly better for Alternation chemoradiation arm as compared to Radiationchemoradiation arm as compared to Radiation

--Merlano, Cancer 1991; Merlano J Natl Cancer Inst Merlano, Cancer 1991; Merlano J Natl Cancer Inst 19961996

Concurrent ChemoradiationConcurrent Chemoradiation MACH-NC: 63 RCT’s, 10,000 patientsMACH-NC: 63 RCT’s, 10,000 patients 5 yr OAS benefit = 8% (p<0.0001)5 yr OAS benefit = 8% (p<0.0001)

-Pignon et al, Lancet 2000-Pignon et al, Lancet 2000

TMH RETROSPIVE REVIEW TMH RETROSPIVE REVIEW 3YRS [ 1997 – 1999] 3YRS [ 1997 – 1999]

Chart review of 2275 patientsChart review of 2275 patients DFS DFS Median followupMedian followup No of patients with surgery +/- RTNo of patients with surgery +/- RT Stages at presentationStages at presentation Reccurrence ratesReccurrence rates

Adjuvant Chemotherapy for stage III / Adjuvant Chemotherapy for stage III / IV IV

Head & Neck Contracts Program

Randomise

Surgery

Induction CT

Maintenance

Radiation 71 / 152 (Standard)

Induction CT Surgery RT 60 /140 (Induction)

Induction CT Surgery RT CT (Maintenance) 67 /151

1978 -1982 ; 462 patients (Median Follow-up 61 months)

• OS & DFS similar (p=0.86 & p= 0.16)

• DM less in maintenance group ( p=0.025 & p= 0.021)

• Time to 1st relapse increased ( p= 0.032 & p= 0.022)

Cancer 1980

Pts with primarytumor stage T 3 – 4 N M0

Local Recc stage T 1- 2

Local Recc stage T 3 -4

Regional recc in previously

operated neck

CT + RTSalvage SX

Treatment Failure

Pts with primary tumor stage T1-2 N0 M0

Recc < 6mths after treatment of Primary tumor

Recc > 6mths after treatment

of Primary tumor

Local Recc Stage T 3 -4

Local Recc Stage T 1 -2

Regional Recc Local recc Regional / Loco-regional

recc

Salvage SX CT + RT Salvage neck dissection

Treatment Failure

Salvage SX

GBS Cancers – The TMH GBS Cancers – The TMH Experience (1997-99)Experience (1997-99)

Late Stage(III/IVa)Late Stage(III/IVa)

n 624Median follow up 1.91 yrsDFS 2yrs 38.5% 5yrs 13%OAS 2yrs 85% 5yrs 78%Overall recc rate 37%Salvage rate 19%