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1 (loco-regional disease) (oral cavity) (circumvillae papillae) (subsite) A (upper & lower lips) B (buccal membrane) C (mouth floor) D (upper & lower gingiva) E (hard palate) F (tongue -- anterior 2/3 rds ) G (retromolar trigone) Site Distribution Site Number Percent Tongue % Buccal % Gum % Retromolar % Lip % Hard palate % Mouth floor % Overall % Cancer registration (CGMH 2002~2005) 2 TCOG

2 TNM Clinical Pathologic Primary Tumor (T) TX Primary tumor cannot be assessed. T0 No evidence of primary tumor. Tis Carcinoma in situ. T1 Tumor 2 cm or less in greatest dimension. T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension. T3 Tumor more than 4 cm in greatest dimension. T4 (Lip) Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face, i.e., chin or nose(1). T4a (Oral Cavity) Tumor invades through cortical bone, into deep [extrinsic] muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, or skin of face. T4b Tumor involves masticator space, pterygoid plates, or skull base and/or encases internal carotid artery. Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed. N0 No regional lymph node metastasis. N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension. N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. N2a Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension. N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension. N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. N3 Metastasis in a lymph node more than 6 cm in greatest dimension. Distant Metastasis (M) MX Distant metastasis cannot be assessed. M0 No distant metastasis. M1 Distant metastasis. Biopsy of metastatic site performed. Y N Source of pathologic metastatic specimen. TCOG

3 Stage Grouping 0 Tis N0 M0 I T1 N0 M0 II T2 N0 M0 III T3 N0 M0 T1 N1 M0 T2 N1 M0 T3 N1 M0 IVA T4a N0 M0 T4a N1 M0 T1 N2 M0 T2 N2 M0 T3 N2 M0 T4a N2 M0 IVB Any T N3 M0 T4b Any N M0 IVC Any T Any N M1 51% 49% Staging Number Percent I % II % III % IV % Overall % Cancer registration (CGMH 2002~2005) TNM M1 T4b N3 ( ) (oncologically sound surgical resection) (surgical margin) 1 oncologically sound surgical resection margin free (organ preservation) 4 TCOG

4 (functional surgery) 1. Surgical approach to oral cavity (1) Per os (2) Lower cheek flap (3) Upper cheek flap (4) Visor flap (5) Mandibulotomy - midline, paramidline (6) Pull through 2. Management of the neck (1) Wait & See (2) Sentinel node biopsy (3) Selective neck dissection (4) Modified radical neck dissection (5) Radical neck dissection (6) Extended radical neck dissection wait & see Sentinel node biopsy neck echo with fine needle biopsy or cytology Selective neck dissection (occult metastasis) 20% supra-omohyoid neck dissection modified radical neck dissection SAN IJV SCM m. radical neck dissection SCM IJV SAN SAN extended radical neck dissection mediastinal node occipital node 3. Management of mandible (1) Mandibulectomy - marginal, segmental (2) Mandibulotomy - midline, paramidline (3) Mandible sparing technique - pull through 80 mandible sparing technique marginal mandibulectomy (segmental mandibulectomy) segmental mandibulectomy cortex periosteum marrow root canal periodontal space marrowperiosteum cortex marrow marginal mandibulectomy Marginal mandibulectomy TCOG

5 (continuity) ( free fibular septocutaneous flap) ( free soft tissue flap) mandibulotomy () pull through (mandible sparing technique) mandibulotomy midline paramidline geniohyoid genioglossus m. midline mandibulotomy 4. Function preserving surgery marginal mandibulectomy modified radical neck dissection subtotal glossectomy s laryngectomy ( hypoglossal n. superior laryngeal n.) mouth angle preserving (preserve orbicularis oris m.) Multi-modality treatment 1993 Overall Survival Low Risk Follow Up Resectable Oral Cavity Cancer Surgery T3, T4 2 nodes Close margin RT High Risk positive margin, perineural spread, LVP, ECS CCRT 3 () 3-year Overall Survivals (1).8 (2) (3).7 (4) (5).6 (6).5 (7).4 (1) Mouth floor 87% (5) Retromolar 68%.3 (2) Buccal 76% (6) Gum 65%.2 (3) Lip 75% (7) Hard palate 56%.1 (4) Tongue 69% P = Months Cancer registration (CGMH 2002~2005) 6 TCOG

6 Overall Survival Overall Survival P < OP: 78%/3-yrs (n = 1377) Non-op: 43%/3-yrs (n = 388) Months Cancer registration (CGMH 2002~2005) (1) Stage 0 (2) Stage I (3) Stage II (4) Stage III 3-year Overall Survivals 100% 91% 79% 72% Months (5) Stage IV (6) Unknown P < (1) (2) (3) (5) (6) Cancer registration (CGMH 2002~2005) (4) 55% 49% % Dr. Jatin Shah 1998 standardized surgical principle treatment protocol 2006 Laryngoscope Treatment of squamous cell carcinoma of the retromolar trigone (22%) (18%) 26% TCOG TCOG

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