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Evidence Based Management Gingivo-Buccal Cancer

Oral Cancer ? Global 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

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Evidence Based Management Gingivo-Buccal Cancer

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    1. Evidence Based Management Gingivo-Buccal Cancer Dr. A D’ Cruz Tata Memorial Hospital

    2. Oral Cancer – Global Incidence

    4. Cancer of the oral cavity Site Distribution

    5. Biological Distinctions in Oral Cancer

    6. GINGIVOBUCCAL CANCER – THE INDIAN ORAL CANCER 2275 PTS. (1997-99)

    13. Chemoprevention- Limitations

    15. Gingivo – buccal cancers Goals of treatment MAXIMIZING CURE RATES PRESERVING FUNCTION COSMESIS COST EFFECTIVE EXPEDITING CARE

    16. Gingivobuccal Cancers Factors Affecting Treatment TUMOR FACTORS T size, Location to bone, Type of lesion, Nodal disease PATIENT FACTORS Performance status, Persistence of habits, Preference PHYSICIAN FACTORS Availability of MULTIDISCIPLINARY TEAM & EXPERTISE

    17. GINGIVO – BUCCAL CANCERS EARLY T1/T2 CANCERS

    18. Radiotherapy Carcinoma Buccal Mucosa

    19. GINGIVO – BUCCAL CANCERS EARLY T1/T2 CANCERS - RT BOTH EXTERNAL & INTERSTITIAL NEEDED PROLONGED TREATMENT SIDE EFFECTS Xerostomia, Dental caries, ORN. CAN BE ONLY GIVEN ONCE Not suited for alveolar lesions “Radiotherapy is chosen when surgery not possible / functional or cosmetic problems are anticipated”

    20. SIMPLE EXPEDIOUS NO SIGNIFICANT FUNCTIONAL & COSMETIC DEFECTS REPEATED PROCEDURE POSSIBLE COST EFFECTIVE CHOICE OF TREATMENT GINGIVO – BUCCAL CANCERS EARLY T1/T2 CANCERS - Surgery

    21. GB Cancers – T1/T2 cancers Surgery ( margins) WIDE; ADEQUATE MARGINS > 5mm DEPTH – BUCCINATOR MUSCLE Sieczka et al ( Roswell Park, Am J Otolaryngol 2001) - 40% local failure T1 – T2 Post-op ADJUVANT NECESSARY

    22. Gingivo – Buccal Cancers (T1 / T2)

    23. GBS Cancers – The TMH Experience (1997-99) Early Stage(I/II) n 207pts Median follow up 2.2 yrs DFS 2yrs 65.7% 5yrs 50.33% Local Rec. rate 21% Salvage rate 37%

    24. GINGIVO – BUCCAL CANCERS EARLY T1/T2 CANCERS – SURG. v/s RT IS A RANDOMIZED TRIAL FEASIBLE? NO – IT WOULD BE, UNETHICAL DIFFICULT OT ACCRUE PATIENTS

    25. Early GBS Cancers (T1/T2) Management of the Neck Low propensity to cervical metastasis [ <10% ] 7.2% Clinically N0 have occult metastasis (Nair, Cancer 1988) CAN WAIT & WATCH UNLESS Poor follow up Cheek flap for surgical access

    26. Marginal Mandibulectomy for GBS Cancers: TMH Experience Pradhan SA et al Indian J Cancer 1987 Control rate: 79% Pathak KA et al EJSO 2004 1994-2001 n=83 2-year local control: 79%

    27. Marginal Mandibulectomy Contraindications Locoregional control influenced by soft tissue margins (p<0.01)* - 127pts / 94 marginal mandibulectomies

    28. GB Cancers – Locally advanced T3, T4

    29. Radiotherapy Carcinoma Buccal Mucosa

    30. Gingivo – Buccal Sulcus Tumors Radiotherapy

    31. Adjuvant RT (RTOG 73.03) 1973-1979 ( N=277) Pre-op POST OP RT LR CONTROL 48% 65% [p=0.04] SURVIVAL 33% 38% [p=O.1,better trend] COMPLICATIONS SAME

    32. Radiotherapy in head and neck Cancers RTOG 73-03 277 PATIENTS - FOLLOW UP 9-15 yrs PRE OP RT POST OP RT [ 50.0 GY ] [ 60.0 GY ]

    33. Surgery + PORT (1988 – 1994)

    34. GBS Cancers – The TMH Experience Prognostic factors -Late Stage ( III / IVa) Univariate Analysis Grade p=0.002 Cut margins p=0.04 Node positivity p=0.000 Perinodal extension p=0.008 Thickness > 4mm p=0.004 Multivariate Analysis Node 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)

    35. Surgery v/s Surgery + PORT (1989 – 1993) N=176 patients 115(S) 61(S+R) LR control 11% 48% III/IV (p=0.001) 71% 75% I/II (p=NS) PROGNOSTIC FACTORS Margins Thickness Bone invasion Grade Nodal involvement RT BETTER IF BEFORE 30 DAYS - Dixit S, Vyas RK, Ann Surg Oncol. 1998

    36. GB Sulcus Cancers – POST OP RT RCT

    37. RCT – Role of RT Peters et al (1993) RISK GROUPS RCT N = 240 LOW RISK HIGH RISK DOSE A DOSE B DOSE C 52 – 54 Gy/ 6wks 63Gy/ 7wks/35# 68.4Gy/7.5wks/35# Interim Analysis Higher Recc 57.6Gy/ 6.5wks CONCLUSIONS: A minimum of 57.6 Gy with boost of 63 Gy to sites of high risk and ECS, is essential Treatment should be started as soon as possible Dose escalation above 63 Gy does not appear to improve therapeutic ratio

    38. POST OP RT

    39. Low risk / Intermediate risk had similar control & survival They did better than high risk High risk had a trend towards better control when RT was given over 5 weeks

    40. POST OP CHEMORADS EORTC – NEJM 2004

    41. POST OP CHEMORADS RTOG (9501) – NEJM 2004

    42. Gingivo – Buccal Cancers (T3 / T4) Prospective Randomised Control Trial

    43. G B Cancers - T 3 / 4 Management of nodes

    44. Recurrent Oral Tumors

    45. Management of Advanced Unresectable Head and Neck cancers Altered fractionation radiation Induction chemotherapy Alternating chemo-radiotherapy Concurrent CT RT

    46. Altered Fractionation Radiation RTOG 9303 N=1113 patients Four arms Standard fractionation Hyperfractionation Accelerated hyperfractionation with Split Accelerated fractionation with Concomitant boost Results Better locoregional control with Hyperfractionation (p=0.045) & Accelerated fractionation with Concomitant boost (p=0.050) All three Altered fractionation group had increased acute toxicity and comparable late toxic effects Fu et al,Int J Radiat Oncol Biol Phys 2000

    47. GB cancers stage- IV B/C No conclusive evidence confirming the role of chemotherapy in palliation as compared to best supportive care

    48. Foscan study in advanced disease Objectives improvement in quality of life objective tumour response (complete and partial) toxicity, tolerability and safety one-year survival

    49. PDT Advanced Cancers 147 patients assessed to date [ 109 M, 38 F] 50% Caucasians, 50% Asians Clinical benefit 24% objective response 53% overall palliative benefit

    50. Overall study results

    51. VERRUCOUS CARCINOMA 5% of all SCC LOCALLY AGGRESSIVE DE-DIFFERENTIATION WITH RT (Medina’ 84) Recent studies DO NOT CONFIRM above (Tharp, Laryngoscope 1998; McCafferey 1998) Better results with SURGERY compared to RT

    53. Chemoradiation in Advanced Head & Neck cancers Induction Chemotherapy Initial response rates 50 – 90% with Cisplatin-5FU based schedules However, multiple RCT’s – Failure to demonstrate a survival advantage with either Single / Multiagent Chemotherapy

    54. Chemoradiation in Advanced Head & Neck cancers Alternating Chemoradiation 2 RCT’s Complete response rates, Progression free survival and OAS – significantly better for Alternation chemoradiation arm as compared to Radiation -Merlano, Cancer 1991; Merlano J Natl Cancer Inst 1996 Concurrent Chemoradiation MACH-NC: 63 RCT’s, 10,000 patients 5 yr OAS benefit = 8% (p<0.0001) -Pignon et al, Lancet 2000

    55. TMH RETROSPIVE REVIEW 3YRS [ 1997 – 1999] Chart review of 2275 patients DFS Median followup No of patients with surgery +/- RT Stages at presentation Reccurrence rates

    56. Adjuvant Chemotherapy for stage III / IV

    59. GBS Cancers – The TMH Experience (1997-99) Late Stage(III/IVa) n 624 Median follow up 1.91 yrs DFS 2yrs 38.5% 5yrs 13% OAS 2yrs 85% 5yrs 78% Overall recc rate 37% Salvage rate 19%

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