Managment Of N+Neck

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Managment Of N+Neck

  1. 1. Management of the Neck (N 0 and N + ) Dr. A D’Cruz Tata Memorial Hospital
  2. 2. Cervical Metastasis <ul><li>Single most important prognostic factor </li></ul><ul><li>50% decrease in survival </li></ul><ul><li>Paradigm shift in the management in last 20 years </li></ul><ul><li>Treatment usually influenced by choice of treatment for primary </li></ul>
  3. 3. Management of the neck Surgery <ul><li>Should the N 0 neck be addressed </li></ul><ul><li>What should be the extent of dissection N 0 </li></ul><ul><li>What should be the extent of dissection for the N + neck </li></ul><ul><li>When & what adjuvant treatment is indicated after neck dissection </li></ul>
  4. 4. 1. Should the neck be addressed in a N0 neck? <ul><li>No debate - T3,T4 </li></ul><ul><li>- Cheek flap </li></ul><ul><li>- Site </li></ul><ul><li> Glottis (low risk) </li></ul><ul><li> BOT, PFS, SGL (high risk) </li></ul><ul><li>Debate </li></ul><ul><li>T1,T2 oral cavity, which can be treated per orally </li></ul>
  5. 5. END v/s Observe <ul><li>END </li></ul><ul><li>Trend towards better survival </li></ul><ul><li>Single surgery </li></ul><ul><li>? Diversion of lymphatics </li></ul><ul><li>Observe </li></ul><ul><li>No compromise on survival </li></ul><ul><li>Sx avoided in upto 80% </li></ul><ul><li>Low salvage rates </li></ul>“ It must be shown that neck dissection performed for clinically palpable metastases (cN+) is less successful than a similar operation for involved but not palpable nodes (cN0 but pN+)”
  6. 6. N0 Current Management Policies – I Mathematical Models <ul><li>Weiss et al </li></ul><ul><li>A patient with a N0 neck status should be observed if the </li></ul><ul><li>probability of occult cervical metastasis is less than 20% </li></ul><ul><li>If the probability is greater than 20%, treatment of </li></ul><ul><li>the neck is warranted (quality adjusted survival) </li></ul><ul><li>Arch Otolaryngol H & N Surg. 1994;120:699 -702 </li></ul>
  7. 7. N 0 Current Management Policies - II Historical evidence <ul><li>Site % nodal metastases </li></ul><ul><li>T1 T2 T3 </li></ul><ul><li>Oral tongue 14 30 47 </li></ul><ul><li>Floor of mouth 11 29 43 </li></ul><ul><li>RMT 11.5 37 54 </li></ul><ul><li>Lindberg et al, Byers et al, Shah et al. </li></ul>
  8. 8. <ul><li>Author (n) DFS OAS </li></ul><ul><li>Haddadin - p = 0.01 * </li></ul><ul><li>(137) </li></ul><ul><li>Lydiatt ns ns </li></ul><ul><li>(156) </li></ul><ul><li>Yuen p < 0.05 * - </li></ul><ul><li>(63) </li></ul><ul><li>Piedbois(1991) - p < 0.04 </li></ul><ul><li>(233) </li></ul><ul><li>* in favour of elective neck dissection </li></ul>N0 Current Management Policies - III Retrospective
  9. 9. <ul><li>Author (n) DFS OAS </li></ul><ul><li>Vandenbrouck (1980) ns ns </li></ul><ul><li>(75) </li></ul><ul><li>Fakih (1989) ns ns </li></ul><ul><li>(70) </li></ul><ul><li>Kligerman (1994) p = 0.04 * - </li></ul><ul><li>(67) </li></ul><ul><li> * in favour of elective neck dissection </li></ul>N 0 Current Management Policies - IV Trials – Prospective
  10. 10. Tongue cancer Retrospective analysis (1997 – 2001) <ul><li>359 patients </li></ul><ul><li>Observe Operate </li></ul><ul><li>(200 patients) (159 patients) </li></ul><ul><li>SOHD (89) MND (70) </li></ul><ul><li>Previously untreated pts </li></ul><ul><li>Per oral excisions </li></ul>
  11. 11. Tumor characteristics Observe Operate T Stage T1 118(59%) 69(43.4%) T2 82(41%) 90(56.6%) Grade I 48(24%) 30(18.9%) II 132(66%) 109(68.6%) III 20(10%) 20(12.6%) PNI No 181(90.5%) 145(91.2%) Yes 19(9.5%) 14(8.8%) Thickness <=3 39(19.5%) 13(8.2%) 4-9 115(57.5%) 89(56%) >=10 37(18.5%) 52(32.7%) Cut margin +ve 7(3.5%) 4(2.5%) -ve 184(92%) 146(91.8%) close 9(4.5%) 9(5.7%)
  12. 12. Status at last follow -up <ul><li> Observe Operate </li></ul><ul><li>Disease free 131(65.5%) 117(73.6%) </li></ul><ul><li>Alive with Disease 38(19%) 25(15.7%) </li></ul><ul><li>Died of Disease 8(4%) 5(3.1%) </li></ul><ul><li>Died of other cause 6(3%) 1(0.6%) </li></ul><ul><li>Lost to follow-up 17(8.5%) 11(6.9%) </li></ul>
  13. 13. Views on management of N0 neck Questionnaire <ul><li>Werning et al, </li></ul><ul><li>Random survey of 763 otolaryngologists </li></ul><ul><li>To determine the variability of Mx of the N0 neck </li></ul><ul><li>13% Observe </li></ul><ul><li>66% END </li></ul><ul><li>19% Radiotherapy to neck </li></ul><ul><li>Arch Otolaryngol Head Neck Surg 2003 </li></ul>
  14. 14. 2. Extent of neck dissection (N0 neck) <ul><li>Location: Oral BOT Hypopharynx Larynx </li></ul><ul><li>Level of : I-III II-III II-IV II-IV </li></ul><ul><li>Neck </li></ul><ul><li>SOHD ( I – III) - Oral cavity </li></ul><ul><li>Lateral neck (II – IV) - Oropharynx, Larynx, Hypopharynx </li></ul>- Lindberg, Byers, Shah
  15. 15. SOHD (Oral Cavity) Recurrences in dissected neck [Primary controlled; 2 YR follow up] <ul><li>Path Surgery only Sx + RT </li></ul><ul><li>Staging </li></ul><ul><li> Medina 1 Byers 2 Medina 1 Byers 2 </li></ul><ul><li>N0 0 / 51 7/130(5%) 1/29(3.45%) 2/24(8%) </li></ul><ul><li>N1 - 1/10(10%) 1/3 0/8 </li></ul><ul><li>Multiple 0 / 1 5/21(24%) 2/16(12.5%) 6/14(15%) </li></ul><ul><li>Nodes </li></ul><ul><li>1 Hawai 1991 , 2 Head & Neck 11; 1989 </li></ul>
  16. 16. Lateral Neck Dissection – Reccurences in dissected neck [Primary controlled; 2 YR follow up] <ul><li>Path Staging Surgery only Sx + RT </li></ul><ul><li> Medina 1 Byers 2 Medina 1 Byers 2 </li></ul><ul><li>N0 0 / 15(0) 10/130(8) 1/19(5.2) 1/126(1) </li></ul><ul><li>N1 - 0/4(0) 0/3(0) 0/17(0) </li></ul><ul><li>Multiple - - 0 /6(0) 3/20(15) </li></ul><ul><li>Nodes </li></ul><ul><li>1 University of Oklahoma experience , 2 Am J Surg 1986;150: 414-421 </li></ul>
  17. 17. Critical Assessment of SOHD 94 Patients / 107 SOHD’s Spiro Am J surgery 1998 94 Patients / 107 SOHD’s 24 Clinical N + 83 Clinical N - 26 Path +ve 17 Path +ve 64 Path -ve 4 (15%) Neck Fail 3 (5%) Neck Fail 5 (29%) Neck Fail
  18. 18. ORAL SCC T2 – T4 N0) RCT (148 patients) <ul><li>Rec 5Yr Survival Comp </li></ul><ul><li>MND 19 63% 41% </li></ul><ul><li>SOHD 16 67% 25% </li></ul><ul><li> p0.7150 p0.043 </li></ul><ul><li>Am J Surg 1998 Brazilian H & N group </li></ul>
  19. 19. 3. What should be the extent of dissection for the N + neck <ul><li>“ IS SELECTIVE NECK DISSECTION A VALID PROCEDURE FOR N+ NECK?” </li></ul>
  20. 20. Management of the neck <ul><li>Crile 1906, Martin 1950 </li></ul>
  21. 21. Management of the neck Bocca 1984 Laryngoscope 843 Cases Byers 1985 Am J Surg 967 Cases Anderson 1994 Am J Surg 366 Cases RND 63% 12% MRND 71% 8% p (NS) 5 year Survival Neck Failure MND = RND Same control  Less Morbid
  22. 22. Level V Metastases Overall 3 % Hypopharynx 7 % Oropharynx 6 % Oral Cavity 1 % Larynx 2 % Davidson et al, Am J Surg, Oct. 93. N = 1277
  23. 23. SND in N+ Neck Kowalski 1993 164 / 95 +ve Kolli 2000 69 / 39 +ve Traynor 1996 29 patients +ve Safe
  24. 24. Therapeutic Neck Dissection – 25 Yr Review <ul><li>Median follow up – 4.3yrs </li></ul><ul><li>SND MND RND </li></ul><ul><li>(61) (54) (61) </li></ul><ul><li>Regional Control 2(3.3%) 3(5.6%) 3(4.9%) </li></ul><ul><li>( p = NS) </li></ul><ul><li>DFS at 2yrs 80% 64% 64% </li></ul><ul><li>Comparable </li></ul>- K. Muzzafar, Laryngoscope: 2003
  25. 25. SND in N+ Neck Anderson (106 patients/ 129 necks) Oral Cavity 42 (39.6%) Oropharynx 37 (34.9%) Larynx 20 (18.9%) Hypopharynx 7 ( 6.6%) T0 1 (0.9%) T1 9 (8.5%) T2 28 (26.4%) T3 36 (34.0%) T4 32 (30.2%) Post Op RT 71.7% N1 58(54.7%) N2a 5(4.7%) N2b 28(26.4%) N2c 14(13.2%) N3 1(0.9%) ECS 30(34%) Regional failures 9 (5.7%) 6 within fields Archives 2002
  26. 26. SND in N+ Neck Medina & Byers ; Head & Neck 1989 114 patients node +ve - 91(79.8%) pathologic evidence of mets N1 / No ECS Surgery Only - 10% recc Multiple / ECS - 24% SX + RT - 15%
  27. 27. SND in N+ Neck <ul><li>Only in pts without massive adenopathy </li></ul><ul><li>No nodal fixation </li></ul><ul><li>Obvious gross ECS </li></ul><ul><li>No prior neck surgery / RT </li></ul>
  28. 28. AHNS - Procedures Studied <ul><li>Selective neck dissection </li></ul><ul><li>Total thyroidectomy </li></ul><ul><li>Parotidectomy </li></ul><ul><li>Endoscopic laryngeal surgery </li></ul>
  29. 29. Evidence-Based Review <ul><li>Thorough, systematic review of literature </li></ul><ul><li>Each relevant paper reviewed by explicit guidelines and assigned a ‘level of evidence’ </li></ul><ul><li>All papers compiled and topic is assigned ‘grade of recommendation’ </li></ul>
  30. 30. Results Expert opinion 5 D Case series (no control group) 4 C Case control studies 3 Cohort studies, Low quality RCT 2b B Meta-analysis of cohort studies 2a High quality RCT 1b A Meta-analysis of RCT’s 1a Study Design Level of Evidence Grade of Recommendation
  31. 31. 4. Adjuvant treatment after neck dissection PROGNOSTIC IMPLICATIONS <ul><li>Extracapsular spread </li></ul><ul><ul><li>Johnson (Arch 1981) < 40% Survival </li></ul></ul><ul><ul><li>Steinhart 1994 – ECS 28% v/s NO ECS 70% </li></ul></ul><ul><ul><li>Carter (Am J Surg 1985) – </li></ul></ul><ul><ul><li>“ Macroscopic ECS worse than Microscopic” </li></ul></ul><ul><li>Desmoplastic stromal pattern </li></ul><ul><ul><li>284 Patients (no RT) – 7 fold increase in regional recurrences </li></ul></ul><ul><ul><li>OLSEN (Archives 1994) </li></ul></ul><ul><li>Number of lymph nodes </li></ul><ul><ul><li>O’BRIEN ( Am J Surg 1986) - No. of nodes Recurrences </li></ul></ul><ul><ul><li>KALNINS (Am J Surg 1977) </li></ul></ul><ul><ul><li>N0 75%, 1 node 49%, 3 nodes 30%, >3 13% </li></ul></ul>Level of Lymph nodes Lower nodes have worse prognosis Spiro Am J Surg 1974, Tulenko Am J Surg 1966, Mendelson 1976
  32. 32. RCT – Role of RT in management of Neck <ul><li>Peters et al (1993) RISK GROUPS </li></ul><ul><li>RCT </li></ul><ul><li>N = 240 LOW RISK HIGH RISK </li></ul><ul><li> DOSE A DOSE B DOSE C </li></ul><ul><li>52 – 54 Gy/ 6wks 63Gy/ 7wks/35# 68.4Gy/7.5wks/35# </li></ul><ul><li>Interim Analysis </li></ul><ul><li>Higher Recc </li></ul><ul><li>57.6Gy/ 6.5wks </li></ul><ul><li>CONCLUSIONS: </li></ul><ul><li>A minimum of 57.6 Gy with boost of 63 Gy to sites of high risk and ECS, is essential </li></ul><ul><li>Treatment should be started as soon as possible </li></ul><ul><li>Dose escalation above 63 Gy does not appear to improve therapeutic ratio </li></ul>
  33. 33. POST OP RT <ul><li>RISK FACTORS: </li></ul><ul><li>Oral cavity primary </li></ul><ul><li>Margins close / positive </li></ul><ul><li>Perineural invasion </li></ul><ul><li> 2 positive lymph nodes </li></ul><ul><li>Largest node > 3 cms </li></ul><ul><li>Performance status  2 [WHO] </li></ul><ul><li>Delay > 6 weeks </li></ul>( Ang et al, 2001 ) RCT – 213 patients Low risk n = 31 Intermediate risk n = 31 High risk n = 151 NO ADJUVANT RT 57.6 Gy/ 6.5 weeks n = 76 63 Gy / 5 weeks n = 75 63 Gy / 7weeks
  34. 34. <ul><li>Low risk / Intermediate risk had similar control & survival </li></ul><ul><li>They did better than high risk </li></ul><ul><li>High risk had a trend towards better control when RT was given over 5 weeks </li></ul><ul><li>NO DATA about the ROLE FOR RT with A SINGLE NODE </li></ul>Ang et al, 2001 Results
  35. 35. Management of Neck - Single node, NO ECS <ul><li> Rec. </li></ul><ul><li> SURGERY 11% 5/47 </li></ul><ul><li>SURGERY + PORT 0% 0/21 </li></ul><ul><li>[Retrospective] </li></ul>Barkley Am j Surg 1972
  36. 36. Single node ECS -Ve M D Anderson Data
  37. 37. POST OP CHEMORADS EORTC – NEJM 2004 <ul><li>Median follow up 60 months </li></ul><ul><li>Progression free survival 47% v/s 36% (p = 0.04) </li></ul><ul><li>Overall survival 53% v/s 40% (p = 0.02) </li></ul><ul><li>Locoregional recurrences 18% v/s 31% (p = 0.007) </li></ul><ul><li>Toxicity [GR  3] 41% v/s 21% (p = 0.001) </li></ul>Curative post surgery 167 RT [66 Gy / 6.5 weeks] 167 CT / RT [100mg Cispat/m2 T3;T4;Node +ve &T1/T2 adverse factors
  38. 38. POST OP CHEMORADS RTOG (9501) – NEJM 2004 <ul><li>Median follow up 60 months </li></ul><ul><li>Locoregional control 82% v/s 72% (p = 0.01) </li></ul><ul><li>Disease free survival better (p = 0.04) </li></ul><ul><li>Overall survival similar ( p = 0.19) </li></ul><ul><li>Acute toxicity [GR  3] 77% v/s 34% (p < 0.001) </li></ul>Curative surgery 231 RT [60 – 66 Gy ] 228 RT + Cisplat [100mg/m2, Day 1,22,43]  2 nodes; ECS; +ve margins
  39. 39. Management of the neck RT / Chemo-Rads <ul><li>Should the N0 neck be radiated </li></ul><ul><li>Do we need chemo-rads for an N1 neck </li></ul><ul><li>How is an N2 / N3 node ideally managed with chemo-rads </li></ul><ul><li>Does an N2 / N3 node influence the choice of treatment of the primary </li></ul>
  40. 40. 2. Do we need chemo-rads for an N1 neck <ul><li>No proof that N1 node with T1 / T2 primary needs to be treated with chemo-rads </li></ul>Daily Fractionated RT = Chemo-rads 92% control at 3 years for <3cms node with daily RT * Mendelhall, Int J Radiation Onco 1986
  41. 41. 3. How is an N2 / N3 node ideally managed with chemo-rads <ul><li>SIZE CONTROL </li></ul><ul><li>1.5 – 2.0 88% - 92% </li></ul><ul><li>2.5 – 3.0 74% </li></ul><ul><li>3.5 – 6.0 70% </li></ul><ul><li>>7.0 0% </li></ul>Menderhall, In J. Rad Oncol 1984 (110 patients) McComs & Fletcher – Am J. Roentgenol 1957 Berkley & Fletcher – Am J. of Surgery 1972 RT + NECK DISSECTION
  42. 42. N2/N3 nodes: Planned Neck dissection <ul><li>ADVANTAGES </li></ul><ul><li>30% of specimens have occult metastasis </li></ul><ul><li>Better regional control rates </li></ul><ul><li>Poor salvage rates if picked up later (14-22%) </li></ul><ul><li>DISADVANTAGES </li></ul><ul><li>Unnecessary surgery in 70% of cases </li></ul><ul><li>Better imaging like PET </li></ul><ul><li>Complication rates </li></ul>- Menderhall 1986, Peters 1996
  43. 43. CHEMORADIOTHERAPY:N2/N3 Node <ul><li>69 of 237 patients treated on CT/RT protocols </li></ul><ul><li>35% of neck specimens pathologically positive </li></ul><ul><li>26% total complications </li></ul><ul><li>10% wound complications </li></ul><ul><li>CONCLUSIONS: </li></ul><ul><li>Feasible </li></ul><ul><li>Acceptable complication rates </li></ul><ul><li>May be overtreatment in 65-70% of patients </li></ul>STENSON et al, Archives 2000
  44. 44. CT RT – RCT (LAVERTU et al , Head Neck 1997) <ul><li>2 cycles Cisplat + 5 FU + RT </li></ul><ul><li> Assessed at 50 – 55 Gy </li></ul><ul><li>Non responders Responders </li></ul><ul><li>Progressive disease </li></ul><ul><li>65 – 72 Gy </li></ul><ul><li>SURGERY </li></ul><ul><li>Persistent CR Planned </li></ul><ul><li>adenopathy No dissection dissection </li></ul><ul><li> (17) 3/12 relapsed (35) </li></ul><ul><li>8/17+ve – 1 relapsed (25%) 4/18+ve </li></ul><ul><li>no relapsed </li></ul>NO SIGNIFICANT COMPLICATIONS  NOT STATISTICALLY SIGNIFICANT
  45. 45. N2/N3 nodes Oro/laryngopharynx Early disease - RT Locally advanced - Chemorads/RT Sx+PORT Small Primary Large Neck Node - ? ? T4 T3 II T2 I T1 N3 N2 N1 N0
  46. 46. Node excision followed by RT <ul><li>T1/T2 lesions of the PFS, Oropharynx, SGL </li></ul><ul><li>N2/N3 operable adenopathy </li></ul><ul><li>Schema </li></ul><ul><li>Appropriate nodal debulking </li></ul><ul><li>Radical RT to neck and primary (66-70Gy;7 wks) </li></ul>
  47. 47. SPLIT THERAPY - COMPARISON OF STUDIES WITH SURGERY FOLLOWED BY RT LR- Local Recurrence; RR- Regional Recurrence, OAS- Overall Survival; DFS- Disease free Survival DSS – Disease specific survival T/N criteria T1-2, N1-3 T1-3, N2-3 T1-3N2-3 T1-3N2-3 T1-2N2-3 T1-2N2-3 Survival statistics Median survival 19mths DSS at 2yrs-49% 5yr OAS-55% 3yrOAS-37%, DFS-60% 73% alive at 60mth 5yr OAS-60% 5yr DFS-59.4% RR 4% 15% 11% 8% Nil 13% LR 9% 28% 28% - 20% 7% No. of pts. 65 32 35 24 15 52 Trial Design Retrospective Retrospective/ Prospective Retrospective Retrospective Retrospective Retrospective Prospective Author/ Institute French Head And Neck Study group 2 Smeele Byers Allal Verschur TMH
  48. 48. 4. Does an N2 / N3 node influence the choice of treatment of the primary Concurrent CTRT- 9303 RTOG <ul><li>N Stage Cisplat+5FU RT-Concurrent RT alone </li></ul><ul><li> -RT [N=173] Cisplat [N=172] [N=173] </li></ul><ul><li>N0 87(50) 86(50) 87(50) </li></ul><ul><li>N1 38(22) 39(23) 32(18) </li></ul><ul><li>N2a 02(01) 07(04) 03(02) </li></ul><ul><li>N2b 17(10) 13(08) 13(8) </li></ul><ul><li>N2c 26(05) 23(13) 36(21) </li></ul><ul><li>N3 03(02) 04(02) 02(01) </li></ul>87(50) 86(50) 87(50) 38(22) 39(23) 32(18)
  49. 49. Management of the neck Surgery N Stage N 0 N 2 -3 Neck Treatment N 1 SND / Wait & Watch MND / RND SND / MND Histology of LN pN 2 – 3 ECS pN1 pNO Further Treatment ? RT RT / ? CT / RT None
  50. 50. Management of the neck * Except T1 glottis, Bracytherapy alone treating primaries RT CT / RT N 0 N 1 N 2 -3 N Stage Neck Treatment Histology of LN Elective neck * Irradiation Neck RT Neck RT No residual tumor on completion of treatment Observe Residual tumor on completion Neck dissection Imaging Neck dissection Residual tumor No residual tumor on completion Observe END 4 – 6 weeks
  51. 51. Thank you
  52. 52. Management of Neck N 2b (Multiple levels) <ul><li>Failures with multiple nodes </li></ul><ul><li>RT + neck better </li></ul><ul><li>< 6cms 50Gy + Neck </li></ul><ul><li>> 6cms 60Gy + neck </li></ul>Mendenhall 1986, Int J Radiation Oncology
  53. 53. Cervical Metastasis Chemotherapy <ul><li>Debatable role </li></ul><ul><li>VA trial (N2 / N3) [ 46 / 166 patients ] </li></ul><ul><li>61% did not receive a ‘CR’ </li></ul><ul><li>33% unresectable at salvage surgery </li></ul>Responders 60 - 70 % survival Non responders 20 - 30% survival
  54. 54. Dagum - - - 58% 5yrs Actuarial Survival (48) Wang 9.8 9.8 - 67% DFS (71) Narayan 19.2 17.3 15.3 38% 5yrs OAS (52) SPLIT THERAPY - Comparison of results of studies with RT followed by Surgery LR RR DM Survival Statistics LR- Local Recurrence RR- Regional Recurrence DM- Distant Metastasis; OAS- Overall Survival
  55. 55. 3. How is an N2 / N3 node ideally managed with chemo-rads Radio-curability proportional to volume of tumor Occult 4500 rad 1 cms 6000 ” 3 cms 7000 ” 6 cms 8000 ” McComs & Fletcher – Am J. Roentgenol 1957 Berkley & Fletcher – Am J. of Surgery 1972 RT + NECK DISSECTION
  56. 56. Management of the neck Surgery N Stage N 0 N 2 -3 Neck Treatment N 1 SND / Wait & Watch MND / RND SND / MND Histology of LN pN 2 – 3 ECS pN1 pNO Further Treatment ? RT RT / ? CT / RT None
  57. 57. Patterns of recurrence <ul><li>Site Observe Operate </li></ul><ul><li>Primary 9(4.5%) 18(11.3%) </li></ul><ul><li>Neck 94(47%) 9(5.7%) </li></ul><ul><li>Neck+primary 3(1.5%) 1(0.6%) </li></ul><ul><li>2nd Primary 1(0.5%) 2(1.3%) </li></ul>
  58. 58. Patterns of recurrence <ul><li>59.5% recurrences - Within 6 months </li></ul><ul><li>Median time to recurrence - 6.18 months </li></ul><ul><li>Observe </li></ul><ul><li>Ipsilateral – 91, Contralateral – 1, Bilateral – 2 </li></ul>Recurrences-Nodal Stage Total recurrences = 94 N1 47(50%) N2a 14(14.9%) N2b 22(23.4%) N2c 4(4.3%) N3 7(7.4%) ECS 55(58.5%)
  59. 59. Adjuvant radiotherapy- Is it a confounding factor? <ul><li>Observe Operate </li></ul><ul><li>21/200 55/159 </li></ul><ul><li>C/M +ve 3 5 </li></ul><ul><li>Poor diff 6 12 </li></ul><ul><li>PNI 7 6 </li></ul><ul><li>T size 5 12 </li></ul><ul><li>+ve nodes - 20 </li></ul>

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