MPMMCC VARANASI CASE DISCUSSION MEETING TO BE HELD FROM 5.10 PM 11/06/2026

[00:00:55]Yo, Best driver.

[00:01:20]Okay.

[00:01:22]Okay.

[00:01:40]Okay, man.

[00:01:42][clears throat] Opening ID connect.

[00:02:40]It's really clear.

[00:03:09]Okay. Does Who's clean?

[00:05:04]follow.

[00:05:24]Mary Uh dispatch Follow.

[00:20:23]set up for you.

[00:20:37]Don't fight.

[00:22:43]Sir, are you uh ready? Can we start?

[00:22:50]>> Are you asking me? Uh >> yes, sir. Yes, sir.

[00:23:04]Good evening everyone. Welcome to Mahana case discussion series. Today it's my privilege to introduce Dr. Moni Abraham Kuryos. He's a worldrenowned headneck cancer surgeon and he has uh more than 200 publications and also authored contemporary in oral oncology uh textbook. He is a co-founder and medical director of Cartinos Healthcare and also a vice chairman of Headneck Cancer Surgery at Roseville Park Comprehensive Cancer Center. Um, welcome, welcome, sir. It's a privilege to have you here.

[00:23:42]>> Thank you. Thank you very much for the kind invitation.

[00:23:47]I hope you can see my slides and you can hear me.

[00:23:51]>> Yes, sir. We're able to see your slides and we can hear you.

[00:23:54]>> Thank you. Thank you so much. I'm really happy that you asked me to speak on a topic which I'm very passionate about.

[00:24:01]Uh so I will take about 20 minutes of your time and try to cover the topic which is assigned to me that is uh management of uh the advanced gingerbuckle carcinoma. particularly relevant is the uh we'll talk about the anatomy because anatomy is the basis for surgical management of uh these tumors and talk about the the technique of uh compartmental uh resection.

[00:24:32]So this is what I'm going to cover. uh we're going to look at uh how these tumors spread into the infatal fossa very briefly look up uh the we'll talk about the concept of compartmental resection started in saroma and increasingly be applied in head and neck then I will go into anatomy of infatal form and then we'll talk about the surgical technique there are two types type one and type two I'll go into details step by step and if time permits I will uh discuss the oncological outcome and I want to acknowledge Manish Tiwari who has done most of the illustration of this presentation. Uh thank you Manish.

[00:25:16]Uh so first of all this is a very much an Indian cancer you know the the Indian cancer particularly northern part of India where I come from that is coin we don't see that many buckle cancer mostly tongue and floral mouth cancers we see when we I had the opportunity to work in Bangalore and northern part of the the Karnataka uh we have seen a number of these cases okay uh that was a revelation for Okay. Now what is unique about this tumor is that uh this is one tumor you can see in that picture on the on your right side. uh then you can if it it invades about 1 cm it gets into poxinator mess and if it's a medial to the mandible the the middle terod will be affected and uh we call this as a T4B cancer not because of any biology but just happened that that tumor happened to be there okay and then uh unfortunately the people who developed the staging system we don't see these tumors and unfortunately they put them into this T4B category and uh we lost lot of life because of that. I'm going to uh to contradict that and try to see that these tumors can be managed like just like any other T4 tumors.

[00:26:41]Now way back we have seen a lot of failures when we tried to manage these tumors. Way back in 2009 uh Navdi and myself and few of us together uh tried to understand how these tumors get into infatal force. So we resected, sent the specimen to the pathologist, tagged various muscles and bony structures and then we uh looked at how this tumor uh spread into the infatal fossa and we have observed that there are two pattern of uh spread based on the epicenter of the tumor. If the tumor happens to have to originate from the tuberosity maxilla they go directly to that upper gingle culpus go directly to tergo maxel fish.

[00:27:30]However, a lower gingerbuckle tumors or retromoral trigon tumors get into the mesa or medial terragoid or or go along the oralis muscle and once get a tumor gets access to infotal force from the medial tergoid it can get into the lateral tergoid muscle. But the term maxel fissure area that is very dangerous area because just at the top is the inferior orbital fissure and then the the forammen rotundum and and so on and get access direct access to to the intraranal compartment and we lose a lot of patients uh uh in that uh location.

[00:28:11]Now based on that we uh try to classify the tumor. Traditionally we were taught to group this tumor into the supra notch and infra notch that unfortunately an error has gone into our uh uh and to the literature and correcting that error is a challenge. I will try to explain why that should be corrected. Now based on the pattern of spread we classify them into three classes. One is the class one that is tumor involving the mess or medial terraord or lower part of the the temporalis and class two are those tumors go into the lateral teroid the dangerous tumors are the terug maxel fissure that doesn't matter that some of them are can be infra but that can gain access to the inferior orbital fissure and uh can cause trouble for us to get uh get the adequate clearance. Then we develop a technique of what we call compartmental resection of of these tumors irrespective of uh the location of tumor we just remove that end compartment I will go into details of that later and when we talk about compartment resection the the idea came up in the in the saroma as I mentioned in saroma we when there is a tumor of the of one compartment we don't go and resect the the amputation of the leg is not carried out nowadays we preserve the the leg by understanding that tumor spread along the muscles or nerve. So you just have to remove that compartment. Now if you in within the compartment they need to get about 5 cm margin. But if the periodium of fascia comes there if you just get few millimeters margin it is as good as a 5 cm margin. So same principle we adopt. I request you to read up this NA king's article way back in 83 talk about this concept of compartmental section. I will not go into details of that. Okay. Now let's get into the anatomy of infraal for the reason why we are shying away from resecting that area is because normally we don't venture into that area very frequently and it's an unknown territory. So we don't operate uh we try to shy away from operating. So I'm going to take you very briefly a surgeon's perspective about the surgery of anatomy of infatal fossa at a cross-section uh around the parotted area. uh infertile fossa has got a masticatory space as well as the paraphern space which can be a pre-sty or prostyloid post styloid and when we talking about uh and the combination of the pre the parapharings and mastigative space combines together forms the uh infraal for now I'm going to take show you some illustration from Albert Rotten a beautiful illustration journal of neurosurgery published sometime time in mid '90s. Again look up that article the series of article showing the anatomy.

[00:31:17]So if you look at this is a the axial section at the level of the floor of the orbit. Clus here nasal septum here and the skin here. So let's take you from one and skin to the clus area. As you can see it's a very clouded crowded area. There are lot of blue oceans here.

[00:31:36]that is the the in the parap the the the the vascular channels. So outside the the skin then there is a condile and coronoid. Lateral to that is a mass meter. Medal to that is a medial tergoid and then we have the ustation tube.

[00:31:53]Medial to the ustation tube is the clus and the coroted artery and so on. Okay let's go into each area in more detail.

[00:32:03]If you look at the back again just to orient here this is the clus here this the the paraphering fat here red part is the pre-stylo and the yellow is the post styloid area and when we are talking about the the buck ginger buckle tumor we are addressing only the paraphern space pre-styloid not post styloid is not involved now one important anatomical feature we need to appreciate is that we are worried about internal coroted artery in this area but at the skull base the internal coroted artery is always medial medial to the ustation tube. So once you understand the anatomy of the ustation tube internal coroted artery styloid process internal jugular vein we can be very confident uh about the the the navigating that area. Now if you uh go and expose that area clearly this a clus here okay and this is a tergoid plate here floor of the orbit.

[00:33:05]Now in tumor the tumor displace the the the uh the soft tissue but it tends to not to displace or uh uh cause affect the bony structure. Now one of the area the structure we need to identify the foramina valley. To identify that structure, you need to just follow the posterior border of the lateral tergoid plate. At the end of that is paramino valley. Then you have the ustation tube and there's a thick fingo basela fascia.

[00:33:36]So if you have to put your finger at the skull base, you will not be able to feel the corroted art pulsation because of this thick fascia. Then deep to that is a carroted artery there. Okay. Now if you go and remove that ustation tube.

[00:33:50]Okay. Then you will expose the caroted artery in the within the skull base in intraranial skull base. Now this is a posterior genu of the posterior genu of the caroted artery and carotal artery runs uh the anterior and medial over the foram and le serum and then uh then further get into the cover sinus and so on. Now karate daughter is always medial to that as I mentioned ustation tube which is removed here and just lateral to the ustation tube is the foramina valley and here's a foram rotundum where through which the maxi artery uh uh travels.

[00:34:31]Now this is a look of on a on a sagittal plane just to orient yourself here the sigomatic bone is removed and uh this is a nasal cavity is exposed. This is a ustation tube and foram oval here as I me mentioned you earlier if you follow the posterior border of the lateral teroid plate that will expose to the the the foramino valley. Okay. And here that the forammen uh the rotundum will travel along the floor of the the orbit and here the tero max fissure uh that will extend as a inferior oral fissure continues as superior orbital fissure and continues to the cover sinus. And now if you were to go and do an orbit of saggyatic osteotomy remove the saggyatic bone lateral wall of the orbit and then you can uh uh retract the temporal lobe then you can get in the cover sinus area and this is the maxillary nerve mandibular nerve further medial is the carotened artery. Okay.

[00:35:34]So once we understood the the anatomy and the pattern of spread we can essentially as I mentioned at the beginning we can classify into three groups the the tumors. Class one is the low infertal fossa. Most of time start from the lower gingal sulcus involves the mess or medial terragoid. Class two are the tumors go into the lateral terragoid. Class three are the term maxel fissure or the inferior fissure get involved. So these are the three classes. Okay. Now this dotted line is the that uh sigmoid notch line. Okay.

[00:36:14]Supra sigmoid infras notch type of tumor. As you can see that some of the tumors averting the the lateral tragoid they behave not as good as the low class one but can be fairly uh uh well managed surgically but the class three are dangerous one that needs a different approach. Now based on that uh not all the tumor need compartment or entire structure need to be removed. uh there are two types of infotal fossa resection. The red one is a type one resection and the blue green one is the type two resection. Now the difference between the type one and type two are shown here. Type one are the tumors of the upper gingiobuckle sulcus and in this case the mandible is not involved. So we can preserve the mandible and lateral tid definitely needs to be removed and the incision has to be done by a lower lip split incision. Now type two where the lower gingerbuckle sulcus tumors that the skin is involved or the manduple is involved where the mandible needs to be sacrificed the lateral teroid we may be able to preserve it. Okay. Uh the incision normally made around the skin uh around the tumor invading the the skin. Uh uh that's how the incision is made. Now case in point is a tumor like this tumor of the tuborosium maxilla axial section showing the tumor invading that the media trogoid muscle tumaxel fissure is involved. Okay. Now how do you manage that? There are 15 steps involved in the type one resection. We published that uh last year in the journal of maxel facial surgery. I request you to uh just take a note of that uh the the uh the reference. You can get all the details from that. The uh the technique has to be uh standardized. If we don't standardize the technique uh I can do the operation, few expert surgeon can do surgeon but we cannot scalable the the operation. So we have developed a stepwise approach almost like a neck dissection. Neck dissection we all do we don't discover a new operation. We follow a 1 2 3 four kind of steps. Now type one I will go into details of each one each of the step incision exposure angle osteotomy various structures needs to be identified various structures need to be dissected and so on. The the idea is that the the the deeper the the the dissection go the deeper structure will be exposed. So safely and without bleeding we can excise this uh uh these uh these tumors without causing much uh bleeding. Now type one the incision as I mentioned lower lip split incision.

[00:39:07]Okay. then expose the messa then go uh just over the over the muscle uh so that the the facial nerve branches are uh kept intact and you expose the entire lateral side of the face. Then after that you have to make an angle osteotomy. We make that osteotomy within the attachment of the mesa. Detach the mesa. Do a angle osteotomy. Try to preserve the lingual nerve and try to preser protect the lingual nerve. Then you go and detach the medial terot.

[00:39:40]Attach the lateral the medial side of the the ramis of the mandib. That is step two, three and four. Then step four is detaching that meita from the sigumatic bone. Either you can detach.

[00:39:54]We prefer to take a sliver of the saggy bone. So you get get exposure of the the upper part of the infatal fossa particularly important in type one resection where you have to remove the root of the the the tergoid. Okay. So that is step five. Now step six the after once you remove that meita the next muscle you will see will be lateral tragoid. You just go and divide the lateral tragoid muscle. Then the next step is to to identify the stylo mandibular ligament that is attached to the posterior border of the mandible.

[00:40:30]You go and detach and the step eight is identifying the internal maxillary artery. Okay. Now that is fairly easy to identify. Sometime we we may we miss it but always have a deliberate attempt to identify the maxillary artery that always get into the infotal forcer between the medial tergoid and lateral tergoid. We learned that lateral terragoid is inserted to the condile. So there is a the triangular space between that uh the posterior border the ramis of mandible medial tergoid lateral tergoid within that fat plane we should and medial to the condile we can almost always we can identify the maxi atney liate them the idea is to to divide the structures the vascular structures before we actually encounter some people say you divide let it bleed and then catch that I believe is the wrong technique so here you go around that uh the the the the uh the in muscles of mastigation liate the feeder vessels.

[00:41:33]Now after that you go into the maxlectomy that we all know how to do that that is step number nine and step number 10 is the dividing the lateral teroid lateral terod as we all know inserted to the condile. So you go and divide that and then the origin of the lateral teroid the superior belly is attached to the terot crest of temple bone you go and detach that is the step 10 and 11.

[00:42:01]Now 12 13 is a critical step that is dividing the root of the tergoid and in this picture the the angle of the so is shown in the wrong direction. Uh so you start from the anterior to the posterior. So the maxul is divided downwards. Turaxal fissure is exposed and you go from the anterior to the posterior. As we learned earlier posterior to the posterior uh to the to the lateral the the the uh the posterior border of the lateral teroid plate will be the foramina valley that bleeds. So you come from anterior to posterior. The blade should be parall to the occlusal plane. So you don't accidentally direct your soul into the intraranial uh space.

[00:42:45]So once you divide that then you can remove the entire structure and the the only structure which going to bleed will be forina valley. You take a piece of uh gel foam into the plug it into the foramina valley and seal with the bone wax. Almost always we should be able to control the bleeding. Okay. So this is a quick case uh showing that uh the this is actually s Minus salivary gland tumor expose that tumor angle osteotomy is done. Lingal nerve is identified and then resect the tumor and then nasop fairings here. Skull base is exposed here and the alt flap was used for reconstruction. Postop scan showing the root of the tgo divided alt flap here.

[00:43:34]some blood in the istration tube sorry in of the spinoid sinus now the the next is type two type two as I mentioned you have to this is shown the green uh since it started from the lower ginger buckle culcus we'll have to sacrifice the the mandible and mess and most of the time the skin two so I'm going to show only what are the the variation from the type type one you can read up as I said the the the from that previous publications The incision has to be made along that area of skin we have to remove. And then you do a curved incision from that most dependent part to the the posterior part of the neck. expose that the the mantle and the mesa area and then the next is uh do that osteotomy around the oh before that you have to identify the uh the facial nerve preserve the upper branch of the facial nerve quick parottomy parotctomy need to be done divide the mea from the psychatic bone you can take a sliver of sygumatic bone as I mentioned before then here the difference of identifying the internal maxillary artery is You don't identify, you can't identify from the medial side.

[00:44:49]You identify in the posteriorly. So you do a uh subscid conttomy you need to do. Before that you do anterior the mandible osteotomy. pull the entire mandible forward and then you can identify the intel maxillary artery posterior to the mandible. liate that and then you go and do the maxlectomy as we discussed earlier and then you down fracture the the maxilla downwards and then go and divide the lateral terrigoid uh then the measa also divided from the sidatic bone uh then divide the temporalis muscle insertion of the lateral tergoid sometime you can keep the lateral throgo because it's lower the tumor is on the lower side and then go and divide the uh the teroid plate from the skull base. Here the orientation is correct anterior to the posterior and the final structure identifying will be the foramino valley that bleeds. So take that tumor out and then plug that foramino valley. Okay. So case in point is a tumor such as this one start in the lower gingerbuckle sulcus mandib is involved medial terod is involved skin is involved. So at the end of the operation this should be the the the the defect should look like skull base will be the the margin superiorly air should be the margin laterally air should be the margin superiorly keroted artery which should be the margin in posteriorly and we reconstructed using an alt fl. Okay.

[00:46:25]Now doing surgery is one thing but uh showing oncological result is another thing. Okay. Now uh we are very fortunate that there is a metaanalysis published two years ago out of that 20 odd public 16 odd publications I'm very very happy to see that 10 of them came from India two from our group and showing that if you uh do manage the patient like this is about 11,000 odd patients about over thousand are T4B 10,000 T4A T4B the outcome is 61% T4A A 64%.

[00:47:03]Uh so that that's a dis overall survival disease survival also comparable showing that the T4B is not oncologically different significant different from T4A. So don't please don't condemn this patient on a palative mode treatment. So this is a the the the work workflow we follow patient with T4A or T4B tumors. uh we based on the if the poor performance status of course best supported care if the class three that maxel fissure involved in the infidop fissure or something we give induction chemotherapy that's the only case where we will give induction chemotherapy the other cases we go for primary surgery and then we subject the patient chemo radiotherapy and then if the recurrence of course the best support is okay I just want to make a plea to the to all of us that same tumor of the paranasal sinus if tumor invades that tergoid plate or infertal force it's T4A but our tumor of ging buckle tumor when involves this area we call for some reason T4B that is totally wrong I do hope that uh the staging committee will change uh uh in this uh uh in the staging system. I think I've taken enough of your time. I will pause here and uh happy to take a post.

[00:48:42]>> Thank you sir. That was till day the most um beautiful and explicit lecture on ITF anatomy and the management of uh oral cancers involving the ITF region. And um it was uh you even showed the excellent anatomical images which made things even clearer for everyone. So are there any questions to sir? Sir >> morning I'm going to ask you a question Dr. Druz. I'm operating your lecture.

[00:49:15]Can you hear me? Mo >> yes. Yes very much sir. Anil I'm really honored that you're participating.

[00:49:21]>> Firstly firstly congratulations. You put in a lot of effort. Your your your photograph illustrations were outstanding. The boy Manish who you said you thanked him has really done a great job. Someday if someone asked me to give a talk I'll borrow few of your slides.

[00:49:40]That's point one. The second thing is that you made it like a walk in the park. Can you tell me uh on an average if all of us had to do it like this, what's the average blood loss across these cases?

[00:49:55]>> Maximum 100 ml.

[00:49:58]>> Seriously?

[00:49:58]>> Yeah. 100 100. If I lose more than 100 ml, I will have to go back to my anatomy dissection call and learn anatomy.

[00:50:07]>> So for my my experiences even I do this but it's very very unpredictable. It could be 100 ml but I cannot say with confidence that it's 100. I would like some others to also give their view and really if everybody's getting 100 and mine is unpredictable I'm stopping by lakes shore in the next couple of weeks.

[00:50:28]>> Oh no no >> and spending a few days with you.

[00:50:31]>> No no no the basic principle about this surgery is that this is a see the you have to consider this as a vascular manformation.

[00:50:40]Okay. If you >> I've heard that. Yeah.

[00:50:42]>> Yeah. So if you go and go into the muscle and try to operate it to bleed and the venus channels are unpredictable. Okay. So that is why sometime you get bad bleeding particularly if you get divide that lateral teroid. So medial ter you hug the mandible. Okay.

[00:51:01]>> Medial tergoid is not the problem. Yeah.

[00:51:03]>> Lateral is the problem when you go up.

[00:51:06]Yeah.

[00:51:07]>> Yeah. So you go and divide the lateral teroid origin from the temporal bone.

[00:51:13]Don't divide inferiorly then it bleeds.

[00:51:16]So almost like how you detach the medial teroid from the medial ter mandible you detach the lateral teroid from the from the temporal bone to do that to access that sigmatic bone comes in the place.

[00:51:30]So that is why you take a sliver of the body of sigmatic bone then you get a very good exposure at the top. So don't be in a hurry to do that. Go and divide the lateral the temporalis muscle then you get enough exposure. So giving good exposure is a key. But having said that having said that the about you know overconfidence is always bad. Okay. The about a month or two ago I made a cut into the middle fossa. Okay. So that I lost got into the governor sinus blood a lot and so on that do happen that because of all confidence that's a technical error not because I didn't follow my my my steps >> thanks money thank you >> professor money may I ask a question this is Abhishek V here >> so uh so I wanted to ask when would you uh include the lateral tergoid plate in your resection such that both the attachments of the medial and the lateral tergoid both the insertion and the origin are within the specimen. So I find myself doing that only when the lateral terragoid muscle is involved close to its uh tergoid plate origin.

[00:52:44]Would you always include the lateral terragoid plate in your resection >> class one? No, I will try not to because as the as Dr. Druz mentioned that's area it's going to bleed a lot. So lateral the the the class one that is a mess and medial ter only involved from the lower gingio buckle culcus. No a class two and class three definitely. Yes.

[00:53:07]>> And for you what would be the limits of uh infrmpal resection on a CT scan. So we know now that there is a poster medial compartment which kind of opens into the tero maxillary fissure and then communicates into the inferior orbital fissure. So where would you call it a limit?

[00:53:27]>> So that is why we have to study the scan very very carefully. Most of the time tumor get in the inferior orital fissure through the posterior superior alvular nerve. If you uh study the scan properly either CT or MRI if there is enhancement on the posterior side of the the ramis the me the maxilla and then there is a loss of fat in the u fissure area that is no no having said that uh there is a meta analys there's a the analysis from the co sorry the head corporated group going to be published very soon almost 700 odd uh patients from multiple centers within the country 50% of the scans overread 50% 49 something okay so scan overs infatal force and extent of the tumor okay so that we have to be careful but if there's a loss of fat within the that inferior orbital fissure then no no and if there's thickening of the foramino valley okay sometime we see perural spread along that uh mandibular nerve then uh I will not operate.

[00:54:39]>> Any chance I'm going to get a positive margin means it's like a biopsy. I've said that several time before the surgery with a positive margin is a grand biopsy.

[00:54:49]>> And how about tergo a maxillary ferial involvement >> because yeah because there is no medial margin to that.

[00:54:56]>> No no the low in fact I I'm going to operate on a case on Tuesday. My colleague said no don't operate sir either is you're going to get post margin and so on. So the but if there's a that's a almost all the tubros maxilla there will be lower taxial fish involvement you study whether the tumor has gone along the posterior alvular nerve then no but if the fat within the inferior fissure is intact I operate are there any more questions for sir Okay, now we'll proceed with the case discussion.

[00:55:48]I would like to um welcome Dr. Anil Cruz.

[00:55:53]>> Hello.

[00:55:54]>> Yes. Yes.

[00:55:55]>> I have a question for sir.

[00:55:58]Sir especially we sir I I could not go to first inial your class your lecture at end I saw your picture and it clearance I'm Dr. Sudha from Kiddway.

[00:56:12]Sir, we are we do similarly in kidway lot of cases 100 cases we do every month every year. ITF clearance and ITF involvement is not a contra indicate even though T4B they got a very good prognosis actually.

[00:56:31]So usually my blood loss is around 300 to 500 ml because especially when you go to overlay and I think the bleeding is even though it's high so when you find a breeding from far overlay what is how do you control actually >> yeah so the first thing is that you address that lastly don't don't make a cut in involve the phamina value at the beginning so you do all the research ction. The last cut is a tid plate cut.

[00:57:03]>> Right. Right. Right sir. Yeah. Last test will be the perman will be out. Okay.

[00:57:08]>> Yes.

[00:57:08]>> And then what you do you put a some you ask your colleague to put a finger and with the pressure you control you go and inspect the specimen and everything.

[00:57:18]Then after that but by that time it takes about two or three minutes. Then I put a gel foam into the foram. Okay.

[00:57:26]>> Okay.

[00:57:26]>> Field it with the bone wax.

[00:57:28]>> Okay.

[00:57:30]So, so I said my experience also and I do gel for I2 or bone w I take some muscles like me thing plug it in the in the overlay for overlay that's also actually if you don't have gel foam or bone wax the alternative is what we do in kit is take a piece of muzzle plug it hold for five minutes it will stop automatically this my personal experience that's what I wanted to share thank you sir Yeah, that that is that is quite yeah useful technique.

[00:58:12]>> So now we'll proceed with the case discussion.

[00:58:14]>> Uh I would like to welcome Dr. Anil Cruz. He's a director uh oncology Apollo hospitals Mumbai, Chennai and Delhi.

[00:58:24]Welcome sir. Uh Dr. Sarbani Goos Laskar.

[00:58:27]She's a professor in radiation oncology, TMH Mumbai. Welcome ma'am. And Dr. Deepak Serin, he's a chairman headneck surgery, Maidanta Gorga. And today's case presentation will be done by Dr. Rizel Goyel. He is a headneck cancer resident from Mahavir Cancer Santan Patna.

[00:58:50]And today's case presentation will be on locally advanced oral cavity cancer.

[00:58:57]Uh Deepak, you'll be the lead examiner.

[00:59:02]>> Um sir, I think he'll be joining a little late as he's stuck in a surgery.

[00:59:06]So I think you will be taking >> Even I'm in a surgery. I put a mop on the wound and I'm sitting. Anyway, go ahead. No problem. Sharbani is there.

[00:59:17]>> Yes sir, she's here.

[00:59:18]>> Okay, lovely. Okay, let's go.

[00:59:21]>> And I also request Dr. Moni sir to join as a examiner in the case presentation.

[00:59:30]>> Joshua yes just quickly before he starts presenting you all have done oral cavity before right in the series.

[00:59:38]>> Yes sir.

[00:59:40]>> So then we won't do we spend lot of time quizzing on the history and all or just move on. How do you want it done? It shouldn't be a repetition. Uh sir as you wish uh the things that you would want to discuss.

[00:59:53]>> Okay fine.

[00:59:54]>> Yes. Thank you Dr. Rizul. You can share your screen.

[01:00:31]Dr. Rizle, >> can you please unmute yourself?

[01:00:39]>> Yes, ma'am. Audible, ma'am.

[01:00:41]>> Yes, you're audible. Please share your screen.

[01:00:57]Ma'am, my screen is visible or not?

[01:00:59]Ma'am, >> visible but only one big R is being seen.

[01:01:14]>> Please share your screens. One minute, ma'am.

[01:02:12]Is there a problem?

[01:02:14]>> Yes ma'am. Uh just uh sharing ma'am I'm just trying but show visible presentation ma'am >> stop sharing and start again >> stop sharing and start again it should book.

[01:02:50]>> Dr. Rizul, you can do one thing. You can start your presentation. Meanwhile, you can ask somebody to mail your presentation to us so that we can share it from here.

[01:03:00]>> Okay, ma'am. Okay.

[01:03:25]Just five minutes. Huh?

[01:03:38]And she meat.

[01:05:19]Easy trick.

[01:05:53]Dr. Rizzle please share it with us so that uh we can share it from Huh?

[01:06:26]Ma'am, I have shared my uh like >> uh it's not visible but you're not able to see.

[01:06:40]>> Yes, I got your presentation. We'll share it from here.

[01:06:43]>> Yes, ma'am.

[01:06:52]screen ma'am. Uh I think now it will be visible ma'am my presentation.

[01:06:59]>> Let me just see uh >> yes it's visible. It's visible.

[01:07:07]>> Okay ma'am. Thank you ma'am. Should I start ma'am?

[01:07:09]>> Yes. Yes.

[01:07:11]>> Okay ma'am. Thank you. So uh good evening everyone. Uh today I'm presenting my case on locally advanced oral cancer.

[01:07:20]So um starting with my presentation uh patient Mr. X 44 year old male he is a manual liver by profession from Mongir Bihar with chief complaint of ulcerative growth inner side of cheek for past 5 months and pain in the right side of cheek for 3 months.

[01:07:40]History of present illness. Patient was apparently well 5 months back when he noticed ulcer in the left side retroolar trione area which was insidious in onset and gradually progressive to the present size associated with pain uh [clears throat] localized to the site the leaking in nature aggravated while eating and partially relieved with energetics and associated with the decreased mouth opening.

[01:08:04]There is no history of any sharp tooth.

[01:08:06]No history of any loosening of teeth. No history of any oral bleeding. No history of any referred earache. No history of any similar leion in the other side of the oral cavity. No history of any change in voice. No history of any difficulty in swallowing. And no history of any bone pain, cuff, hemoptasis then weight loss.

[01:08:24]Coming to the past history, uh not a known case of hypertension, diabetes, asthma, TB losses and seizure. There is no history of any drug allergy and no previous history of any surgery or any kind of radiation exposure.

[01:08:40]Then personal history patient is a chronic uh tobacco tuber with a reconet for the last 15 years with peculiar habit of keeping it in over the left side of the mouth throughout the day.

[01:08:51]Quitting 3 months back. There is no history of any smoking and alcohol abuse. Uh patient is having the mixed diet, normal sleep cycle pattern and normal bowel bladder habit.

[01:09:04]Family history, patient is married having the two children and there is no history of any cancer in the family.

[01:09:12]So my summary is patient is a 45 yearear-old male with no known corobities with the chronic tobacco or recon tumor for the past 15 years presented with progressive non-healing ulcer over the right side inner side of cheek associated with pain and reduced mouth opening for 5 months should I continue ma'am hello is audible >> yeah it's okay The history is okay.

[01:09:43]There's only one point. Why did you ask history of bone pain and some various hemoptises? How common is it in oral cavity?

[01:09:52]Sir uh I have asked about that bone pain uh cuff and hemoptitis to rule out any uh distinct metastases any lung metastases and the risk of because in oral cancers most common sight of distant metastasis is primarily over the lung uh with the present of any other extra thoracic extension is less than 4%. So um just to rule out any kind of uh >> so how often have you seen hemopasis in an oral cavity with metastasis?

[01:10:26]>> Uh sir >> so I'm going to ask you one I'm just going to ask you one quick question.

[01:10:33]What is the difference between a primary in the lung and metastatic disease in the lung >> in presentation?

[01:10:47]So I'll tell you the first the primary is usually central the metastasis are peripheral.

[01:10:54]>> Yes sir.

[01:10:56]>> Second metastasis could be multiple.

[01:10:59]And the most important point is metastasis are usually silent. They don't have demopasis.

[01:11:06]So you've copied something from kas and you're just telling me about himopasis.

[01:11:12]>> Yes sir. and and and you're going for an MCH exam, you should be able to justify what you're saying. I'm not saying you're wrong, but you should be able to tell me not because someone told you to say opticis. It doesn't matter. It's a small point, but I always find when I was an examiner, many youngsters just present rut and they're not able to understand why they telling the answer.

[01:11:37]MCH level, you must say why. Okay, go ahead. Smani you want to ask anything?

[01:11:45]>> Nothing now sir.

[01:11:46]>> Okay lovely. You're getting ready with proton is it?

[01:11:52]>> No sir.

[01:11:53]>> Okay cho. Okay go ahead. Come on.

[01:11:55]>> Yes sir.

[01:11:56]>> Rul.

[01:11:57]>> Yes sir.

[01:11:59]Uh going for the general physical examination. Patient is uh well oriented to time place person built well nourished hydrated. Patient performance status is eco score is zero um height appro 165 cm weight 80 kg BMI is 29.5 uh vitals they are within normal limits and as such palaric terroris clubbing and generalized lymphopathy and edema is absent.

[01:12:30]Coming to the local examination starting with the extraorally with the face examination on inspection and palpation there is just a diffused swelling present over the left side of face with overlying skin free skin is pinchable there is no such suspicious growth or ulcerative lesion present and uh seventh nerve examination is normal.

[01:12:54]Coming to the intraoral examination uh on inspection first of all the lips they are normal mouth opening um is appro 18 mm incizer distance oral dental hygiene is poor uh there is a heltosis present teeth they are patient is dented all teeth are present and they are tobacco stained with no sharp teeth present then um on inspection there is a irregular ufiltrative Growth size 3.5 into 3 cm over the left side of retrooar triion withverted margins and with surrounding area of arythma growth is extending anteriorly from the second last mer posteriorly to the retroolar trione superiorly and inferiorly extending to upper and lower abs on palpation in uh confirming the inspector findings mouth opening is 18 mm uh entrance as a distance uh there's plenching of submosal fibrosis present involving the pallet and the left side of buckle migosa. Tendon is present at the sight of growth uh bleeds on touch.

[01:14:02]There is also the lupopleia present over the dorsal surface of tongue. There is a loss of sensation over the chin region and tongue movements are normal and full.

[01:14:14]Then coming to the orophenial examination uh on inspection and palpation base of tongue normal bilateral tonsular fora normal posterior fangial wall normal and Hopkins examination this is normal.

[01:14:27]>> Why did you examine all this >> sir? Uh to rule out any second primary and any kind of uh um like multiple synchronous lesions over the other side.

[01:14:40]So that's why we did the Hopkins examination and the oral financial examination.

[01:14:45]>> Two quick questions. Tell me a little bit about second primaries. What are the types?

[01:14:52]Sir uh second primary tumor uh means when there are multif focal areas of u tumors which are uh present due to the chronic carcinogen exposure leading to the um proliferation or because of genetic alteration at >> you're making it to multif focal areas is field carnogenesis >> I am asking sir >> I I am asking if what are the types of second primary tumors You said second primary tumor that's >> it can be synchronous or it can be metacronis uh depending if it is a synchronous then uh the second legion if it is within the 6 months of duration and metacronis if it is more than 6 months of duration.

[01:15:35]>> Yeah some people call them simultaneous synchronous metacronis simultaneous is at the same time synchronous uh within 6 months and metacronis subsequently. If you have an oral cavity cancer, which is the most probable site of having a second primary cancer?

[01:15:57]>> Uh sir, um it would be um or ferings and like um hypoparrenx oral cavity. If it is a oral cavity cancer, yes, >> if it's an oral cavity cancer, the second primary is usually in the oral cavity. Oops.

[01:16:20]>> Do you know anything about axis of second primary?

[01:16:26]>> First described by someone called Bruce Harvey. So if the primary is somewhere, the sec the second primary will be somewhere. It it's basically on the eeology. I'll tell you to save time. If you're a smoker, you'll get a glottic cancer. The second will be in the lung because it goes that way. If you're a chewer or an alcohol, it'll be in the floor of mouth and then it'll come into the hypoparrenx and esophagus because the carcinogens go along that way. But in oral cavity, the second primary is always in the oral cavity. Most often, I mean, I'm sure you'll suddenly say you saw a case, but most often it's in the oral cavity. How do you know it's not a recurrence and it's in second primary?

[01:17:10]Or if they're two cancers together, how do you know it's not met meta? I mean, uh it's the same cancer.

[01:17:18]>> Sir, uh according to that Warren and Gates criteria, we uh first of all the biopsy. We will uh do the biopsy and prove it that >> just tell me the distance. Tell me the distance.

[01:17:29]>> 2 cm 2 cm of distance between the two.

[01:17:34]>> Okay.

[01:17:34]>> Yes sir.

[01:17:35]>> Okay. And the other thing is the intervening mucosa should not have displasia or carnoma C2. Sometime you might have a 2 cm but the in between mucosa if it's all displastic and unhealthy it may not be carcinoma it's part of the same cancer.

[01:17:56]>> Yes sir.

[01:17:57]>> Okay go ahead.

[01:18:00]Uh then going to the neck examination on inspection there is a single uh solitary swelling which is present over the left level 1B submandibular region. Uh there's a single isolated node size 1.5 into 1.5 cm firm mobile non- tender with normal overlying skin and the left level 1B over the right side neck examination it's normal and other thyroid examination is normal.

[01:18:26]going for the systemic examination u all within the normal limit CVS respiratory abdominal CNS.

[01:18:33]So my summary is uh 45 year old male with no known coorbidities with chronic tobacco and econ for the past 15 years presented with ultra proliferative growth over the left side retroolar trione size 3.5 into 3 cm extending to upper and lower GBS associated with pain since past 3 months reduced mouth opening and oral submucosal fibrosis present with epsilateral neck node size 1.5 into 1.5 cm left 1b with no signs of any distant metastasis So my uh probable diagnosis would be carcinoma left side retroo clinically T4B N1 M0 stage 4B.

[01:19:15]>> Why T4B?

[01:19:17]>> Sir because the lesion is involving as such the retroar trione area with the presence of tresmas that is involvement of mastigator space. So uh >> my friend you have told me the patient has submucous fibrosis. How do you know that it is because of your tismas?

[01:19:36]You have said so loudly he has got sub mucus blanching in a patient with submucous fibrosis and clinically T4B.

[01:19:47]>> Yes sir. Uh sir um patient is having the tismas within the short duration.

[01:19:54]>> Sub mucus fibrosis.

[01:19:57]Sub mucus fibrosis didn't didn't cause him any Christmas is it and his mouth opening was 18 mm.

[01:20:03]>> Yes sir.

[01:20:05]>> So how did he have done >> duration is one factor sir because it's an acute duration of short duration sir.

[01:20:12]So uh most probably the legion the cause of the lesion being at the site is the direct involvement of mast.

[01:20:19]>> Anyway theoretically you're correct but it's unlikely to be acute. acute is uh uh I agree with you that if it's a short duration acute duration is usually because of pain when you give them anesthesia that Christmas gets relieved but uh uh uh uh in a submucous fibrosis I would just say you can say locally advanced you can clinically say T4 don't quantify to T4B or T3 could be T4 sir the qualify don't get into so confidently that the infrar temporal is involved. The mouth opening is pretty good for this man with some mucus fibrosis.

[01:21:00]>> Sir, good evening sir. He told one point I did correct I don't know loss of sensation in the submental reason he mentioned >> that is indicate involvement even the mandible erosion can also involvement also can lead to loss of tension because nerve dysfunction since he telling RMT that one point in in favor of T4B >> anyway I I have got lot of senior people Sarbani Mooney Abishek Vidya if they're still around and Deepak Sarin how many of yall examine for submental sensation in an oral cavity?

[01:21:45]No that >> yeah that's that is an important uh finding to elicit particularly if there is a mandibular uh suspect a mandula involvement in addition to that we need to you mention about facial nerve you man examined but you all the trigeminal nerve divisions whether the nerve has gone through the the trunk of the facial mandibular nerve is involved or not or trigeminal nerve is involved so you can you could have examined all the other >> cranial nerves Yes sir. All of the pain.

[01:22:17]Yes.

[01:22:17]>> And the patient nerve also uh there should be some reason why why did you examine the patient nerve or why did you say it's it's not involved >> sir? uh because um the as such the feroted uh node because in uh in these such type of cases where the uh lesion is over the RMT retroar trione area and we could possibly be uh ruling out the lesion involving the masticator space or towards the infrmporal fossa. So um while uh doing the surgery intraoperatively um while raising the cheek flap and uh that uh separating that uh uh massetric uh bcometric region. So at that site sometimes there are chances of um facial nerve injury or nerve um injury that will be involved at the direct involvement at the at the local tumors at the the sight of the tumor. Is that right? Not at the at the the facial facial foraminis. All right.

[01:23:23]>> Yes. Yes.

[01:23:25]>> On the face. I think that's his concern.

[01:23:29]But uh Mooney if we examine all these nerves what is the accuracy visav imaging since you're insisting on examining result you can tell me >> um sir can you sir please >> if there's if there's gross invasion of the bone and the nerve involvement will you need to elicit submental uh loss of sensation. Would you need to examine all the divisions of the trigeminal or would you bank on imaging to get a more accurate assessment? So all >> yeah all these nerves would have been examined including mouth opening side to side of the jaw and all much before fine imaging came into view. Unless you have gross facial involvement like a bell's phenomenon that may s signify inoperability. Apart from that most of the other nerve involvement unless it's gross it's assessed on imaging rather than on clinical examination. At least in my practice I never go and examine the submental. I'll just ask for an X-ray and know whether the mandible is involved. But respond there are doctors like me also there as you at seminar they will ask that question we will ask you to do the your investigation should find the clinical finding or reconfirmation of your clinical finding.

[01:25:03]So it should be a targeted uh examination of uh possible areas of invasion.

[01:25:12]>> Yes sir. Yes sir.

[01:25:14]So um sir once u we are uh going for the clinical and examination part we will have that uh confirmation over the biopsy that [clears throat] uh uh after taking the veg biopsy from that site it was came out as biopsy proven squamous cell carcinoma and we did the imaging that is uh contrast enhanced city imaging of face and neck including the um uh city thorax to rule out for any lung metastasis.

[01:25:51]So should I uh play that imaging part sir?

[01:25:54]>> No. Why did you do CT of the local area and CT thorax and not a pet CT?

[01:26:01]Sir uh one cause is because uh as such city thorax is uh enough because chances of extra thoracic extension is in less than >> that that I understand but instead of doing two investigations just do a pet CT why don't why did you want a CT thorax and a CT contrast is it cheaper is it more accurate >> yes sir sir um >> but these days >> yes These days you get pet city for 10,000 rupees. If you do two it's two investigations. It comes to 12 in corporate.

[01:26:40]>> You may be right. I just need to know your logic.

[01:26:43]>> Sir u one reason at my center is that uh logistics issue because of u patient load and all of that the there's a long waiting list for pet city at my center.

[01:26:56]So we usually go for CCT face and neck with NCC thorax although we have that availability of pet city at our center also but uh seeing the cost and seeing that long waiting list we go for CCT.

[01:27:10]While your answer may be uh uh okay for your setup, for me I do exactly like you do a high resolution CT and I do a CT thorax for the same reason you said that the metastasis is usually to the lung and the enough studies to show that it is fine. But the reason I do a high resolution CT is usually the cuts of the CT are better. the the the the interpretation of the disease as compared to a pet. Unless you have a very dedicated CT study done on a pet, usually those are not as accurate the cuts also which the the the PET is usually reviewed by a nuclear physician who may not be as adept to a radiologist to report on the cuts of your uh of your CT or PET. So I always do a high resolution CT the resolution is much better you see it much better and I just follow it with a non-contrast uh examination of the chest but if you do a dedicated PET CT and you have someone who is dedicated and doing proper cuts to supplement the CT it's fine to do a PET.

[01:28:31]>> Yes. Yes sir.

[01:28:33]>> Okay. Go ahead.

[01:28:35]Um so this is the uh CT scan the imaging of the patient.

[01:28:43]Sir um just want to play over this part.

[01:28:49]Is it visible sir? My screen is visible now.

[01:28:52]>> Just stop at the right relevance and tell us the findings.

[01:28:56]>> Yes sir.

[01:29:06]So um this is the contrast enhanced city scan of uh face and neck with puff cheek appearance. Um in this uh we can see clearly that there is a heterogeneous uh enhanced lesion present over the left uh left side involving the uh as such the retroar trione area. So uh in this uh studies just I'm telling first of all on the looking at the normal side there is uh one coronoid and condile area and uh comparing it uh to towards the left side we see there is a as such erosion of the ramis of the mantiple also along with that uh we can see that there are involvement of uh all the masticator muscles that they are eroded.

[01:29:55]One minute. Can you please come to the cuts which have the ramis of the mandible? I don't think this cut has the ramis of the mandible in it.

[01:30:02]>> Yes. Yes. Yes. Yes. M. One minute.

[01:30:08]Let me come to that part also. Yes ma'am.

[01:30:12]So in this part u we can see clearly that uh the ramis of the mandible is involved uh over the left side. There's the erosion of the ramis of the mandible and also along with that uh we can see that uh like comparing to the left side that is the masset muscle the mass muscle is involved also the medial tergoid which is involved over the left side um with this and there is a involvement of tero mandicular rafi which is involved uh over the left side area the lesion uh if we go to towards just uh uppercut So uh it clearly shows that how the lesion is going well into the high higher ITF region uh because there is a involvement of uh the temporalis muscle along with that uh lateral tergoid muscle. So uh looking like the uh imaging the lesion is going towards the posterior high and ITF region that is it is involving um the all the four mastigator muscles including the lateral tergoid muscle temporalist muscle mass and the medial tergoid muscle and just showing that um nodal neck nodal level also at the levels 1B.

[01:31:55]>> AJ, forget all that. What will you do to the patient?

[01:31:58]>> This is a 1B nodal disease, >> sir. Um, seeing uh >> Okay, since you're showing you're showing the neck node, what is the sensitivity of CT MR PET for neck nodes?

[01:32:14]Sir sensitivity uh according to the one le article sensitivity of uh city scan is uh appro u 54 to 55% compared to um like other like USG and pet city which is 66%. Whereas specificity of CT scan is very high that is uh uh like 93 to 95%.

[01:32:38]>> Of what or what of what is very high >> sir? Specificity specificity of city scan is very high uh like 9 3 to 95%.

[01:32:49]>> For for for N0 or for N plus >> um that is for >> very first result >> whenever whenever you answer the examiner okay LEO's meta analysis is okay but never give 66 55 always give a range.

[01:33:07]>> Yes sir. Yes. So the the accuracy or the sensitivity of any imaging that you do whether it's sono CT MR PET cover ours around 70%. There's a big range from 55 to 70 88 80 you can quote anything but it's normally taken around 70.

[01:33:30]>> Yes sir.

[01:33:31]>> Okay.

[01:33:33]Go ahead sir. um uh for my the management part I am for this specific patient I'm going to have one tumor board discussion that is with the discussion with all the medical oncologist with the radiation oncologist as well as with my uh consultants and um after the discussion if um from our point of view we will send this patient for new adjubant chemotherapy followed by reassessment for surgery.

[01:34:04]>> Dr. Armani wants to give radiotherapy first. Right or wrong?

[01:34:14]>> Hello. Rizul.

[01:34:16]>> Yes sir.

[01:34:18]>> Dr. Smani texted me. She wants to give paliative radiotherapy. Right or wrong?

[01:34:25]Sir um I think uh the disease is looking like it can be uh borderline reectable.

[01:34:36]Um so giving the two cycles of nicity and then reassessment would be the one choice because I think we can go for the uh up like surgery also upfront surgery followed by n we have some articles.

[01:34:54]Yes.

[01:34:55]The common question an examiner like me will ask you is that you gave neojuven chemotherapy what will be your margins will they be less or the same >> sir um it would be the same sir margin would be >> operate now >> sir the only um the thing is uh if we operate right now the disease is very much close to the tergoid plates so there are chances that we will not going to get enough margin because uh we may go to the like entering the base of skull area or >> you can remove the plates not in this type of tumor plates you can remove >> you can even remove the teride plates you can remove the base of the ter plates it has to be removed in this type of cases actually because when you want to remove a compartment and medial ter is involved from the origin because in between the two posa the T the will be left over. So it has to you have to remove the tide P along with med in this case M and temporal actually in this case as I said NC is better then you can take up for S.

[01:36:11]So Tide plate has to be removed in this case >> sir. Yes sir. Yes sir. But um just uh looking for that u why we want to give the two or three cycles of new adjint chemotherapy is so um the disease the tumor burden can get a decreased and um like we can go for the surgery after the two to three cycles if uh followed by that uh complete resection with steroid plates removal. Sir Rul the answer you should give your examiner is that sir I'm unsure about the operability it looks borderline operable if you feel it is operable for me this is an inoperable case but I if you if you want to give the answer sir I'll give two cycles of neoaduvent therapy if the tumor shrinks probably this will tell me biologically that this patient is in a good group and you can quote data data article that those that had response did well 40% two-year survival and also because it is shrunk it'll make I'll be a little more secure on my margins even though I'll go as wide and do the entire compartmental exition that's the way you should answer the examiner >> yes sir yes >> if they don't respond then biologically this is not a good tumor and you're not going to operate the patient Sir, >> can I >> Yeah, go ahead. Sorry, Mon. Go ahead.

[01:37:46]>> Brussell, what's the correlation between radiological extended tumor and pathological uh staging specifically about infertal force? Do you have any date? Do you know about any data?

[01:38:00]>> Sir, uh radiological and pathological correlation you're asking. So let's say that you have done a not this question done a resection of a T4B tumor >> and get the specimen out and then look at the path.

[01:38:19]>> What's the correlation between the two radiological versus pathological?

[01:38:26]>> So sorry actually your voice will get little bit disturb I don't know whether you can you hear me now.

[01:38:32]>> Yes sir. Yes sir. Yes sir. So what's the correl what's the the the the accuracy of radiology to predict the pathological extent of the tumor in when it comes to infatal force >> huh >> any studies out there >> some uh one there is one article >> uh sir like there is one article by Abhishek Mahajan at all where he has already shown like on basis of radiology how we divide that infrmporal fossa region into the three parts like um the low ITF that is the involvement of medial teroid this man is asking you a different question what is the correlation between radiologically and path pathology you didn't listen to his talk you answering something else am I correct moni is that what you is is that the >> that's correct almost 50% overreading happens with the with the radiology not this case. This is of course there is a lateral the lateral terod and temporalis muscle is involved but there is a 50% overreading.

[01:39:46]>> Oops. Oops.

[01:39:48]>> Okay. So quickly we going to give two cycles of chemotherapy. Name the chemotherapy. 1 2 3 jali bolo. Uh sir uh we'll give satin with the five urasil with the uh tax >> with taxense. What about just giving two sir? Um we have seen that uh some articles where they have quoted that three drug regimen has a overall survival rate better. one article by uh VM Partil that have shown that um three drug regime >> no no VM partil didn't show that VM parts gave various regimes no one VM the two studies that showed that three drugs is better than true drugs is tax 323 or 324 not VM partil's article only abstract VMI has he done three drug versus two drug.

[01:40:46]>> So that has been done recently that is DC versus DCF.

[01:40:51]>> So that DCF is better than DC.

[01:40:54]>> So we have evidence for that. But with but F but why don't you give F?

[01:41:00]>> Yes sir. I I was telling >> why don't you give >> sorry >> what is the problem with F?

[01:41:08]>> Uh say say fluo F sounds a little vulgar on this.

[01:41:13]>> Okay okay okay. Sorry, I and you're a stern. Okay, but tell us what's the problem and what do you do to predict that you won't have that problem?

[01:41:22]>> The F problem >> sir. U the problem enzyme enzyme >> dihydropyramidine dehydrogenous deficiency is that one enzyme is related to >> and madam kolo because the toxicity is very high of that. Can I add can I add kruda with these three drugs? I want to give Krua. Should I add Kruda?

[01:41:52]>> Sir like already told >> what is Kruda?

[01:42:03]Sorry, I haven't heard book e k e y t r u d a kruda.

[01:42:18]Sir yes sir. So tell tell us what is the current level one evidence of not giving chemotherapy and only giving immunotherapy on patients with locally advanced.

[01:42:38]Sir um like one article of that keynote 689 trial with where we have that use of neojuvent and adjuventismab along with that chemotherapy and we have seen uh the results of uh uh like comparing uh comparing to that uh use of pimrollism in one arm. uh we have given uh the dosage that is approx 200 mg 2 weekly followed by surgery.

[01:43:07]>> Forget that just tell me what did they do in one arm.

[01:43:11]>> Sir in one arm they take peismab along with the uh uh cysplatin and uh radiation therapy. No they had given they had given neojument femorismab then they did the therapy and then in the maintenance phase they had given cisplatin with radiotherapy with femoralism and then uh in maintenance phase also they have given another uh some cycles of >> okay okay don't worry I just want to listen understand your thinking so why don't you only give your patient two cycles of immuno ketruda why do you want to give three drugs or Why do you want to add three drugs with Kruda?

[01:43:52]>> Sir, uh because um in that study only they have shown that uh the survival event free survival rate and the um overall survival based on >> eventfree survival rate to you are giving three drugs. You should have given kruda. Why did you tell me three drugs >> sir? um because of uh adding that um um based on that CPS score sir uh that is uh 10 more than 10 or more than one we have seen that the results were much better. No my friend I I know you've read little bit of that article. I'm not troubling you on the article. My question is just to understand you said you'll give neoaguent chemo. I agree with you. I am asking you why don't you add immunoccology ketruda in light of level one evidence. That's all I'm asking you. Good idea not good idea.

[01:44:53]Uh >> si you take over si >> where's Deepak?

[01:45:01]>> I actually have to leave for another Aoy meeting sir.

[01:45:04]>> Okay. Okay. Go ahead. Tell us the reason. Mon is very fond of imuno imunotherapy. Mooney will justify.

[01:45:14]>> What was the end point in that study?

[01:45:19]Sorry. What was that point in that study?

[01:45:24]>> Sir, end point was that um adding that pimrollism map gives that u uh survival over the survival rate and over that inventory survival rate was better.

[01:45:35]>> Okay, disease free survival was better.

[01:45:37]But what about did they look at the overall survival?

[01:45:42]>> Yeah, sir. overall survival rate was um like I think >> it's okay. Okay, you can read up that simple >> where did it show a difference this thing what you call keynote 689 where was the statistically significant difference in this experimental arm versus the standard arm >> ma'am one difference was over that uh uh like uh disease free survival rate and second was of uh that uh based on >> less in the patients that received ketruda along with kruda versus no ketruda call the uh uh smani we won't quiz him too much on the paper he can read it but as a senior going MCH you should know but sbani wants you to say that it was pard and moan on eventfree survival and distant meta spaces were less in the arm that got kruda >> sir and just a point abhishek here >> yeah bolo abhishek But for the 689 the inclusion criteria clearly stated reectable cancers.

[01:46:55]>> Granted granted I want I want >> I are you jogging or testing my memory.

[01:47:01]I wanted the boy to answer. Thank you for coming to us. Normally those little invigilators around come to their rescue. Absolutely correct >> so you need to read this paper because these are contemporary topics with imunotherapy. So you need to know what is the difference between the keynote 689 and the neotusumap and the adu neoposttop. Now it is important for you to know that also was it used in these patients? No, not in these kinds of patients. It was used in a in the usual run-of-the-mill patients who were thought to be at high risk.

[01:47:38]So you have to be able to justify why you are not talking about imunotherapy in these patients. Look at the kind of patient you're presenting, right?

[01:47:47]>> Yes.

[01:47:51]>> But but Rizzul the answer I was looking from from you was exactly what Abishek said that this was not the subgroup >> but yes sir in light of other data that is coming up. Many people are now adding IO along with chemotherapy and it's downsizing. They're doing response adaptive surgery and it's also conceptually supposed to help in better control. There's no level one data but it's evolving. You can you could also justify by saying sir there's no level one data but I'll talk to my patients.

[01:48:26]I'll explain them. I wouldn't mind adding an examiner just wants to see your understanding. I mean there's no always a right or wrong answer in these kind of cases.

[01:48:38]>> Yes. Yes. Go ahead.

[01:48:42]Um sir um so after having the like already discussed with my uh like in the teamer board that after giving the two cycles of n based on the uh again we will going to have a reassessment. So uh if there is uh the response based on that u resist [clears throat] criteria that uh the disease has partial response or uh like um this response then we will going to go for the uh surgery that is uh in this case uh if we go for the surgery then that would be uh like um arch preserving hammy mandiblectomy with >> before before you go for surgery How do you eval? How do you do the response evaluation? What's the ideal method of >> sir? Ideal method for response evaluation is the resist criteria that is the response valuation in solid tumors where we look whether there is a complete response partial response the disease is stable or there is a progressive disease. So if there is a partial response uh based on that uh more than u 30% uh response uh with the we will look for the the diameter of the excess of the some of the lesions. So if the response is more than 30% then that would be counted as a partial response.

[01:50:05]If there is neither a the disease has progressed or neither there's a shrinkage then that is a stable disease or if the disease has gone for the progressive disease that is 20% at least there is a increase in diameter of the some of the lesions then u that is a progressive disease. So based on this criteria uh on seeing over the clinical radological correlation uh we decide whether what would be the outcome of And if not to use a PET scan, how would you evaluate the response?

[01:50:42]>> Sir, >> scan sir. Based on the PET scan uh um we will see for the uh PET resist criteria that is uh the response is completely uh metabolic or is it uh partial metabolic response or is it progressive metabolic response or a stable metabolic response. So complete metabolic response means complete resolution of the uh disease. Thank you.

[01:51:13]That's one. That's one.

[01:51:17]>> So, do you know what happened to this patient after the two cycles?

[01:51:22]>> Sir, uh right now the we have the patient is already on chemotherapy. So, um although uh we haven't reassessed this patient uh the patient is already ongoing chemotherapy. But if uh likewise we have if we see that there is some uh partial response then we will go for the uh upon surgery followed by this new chemotherapy and let's say that you have done the surgery okay the chemotherapy and then surgery was done and let's say that the tumor came back as T3 just hypothetically PT3 N1 how will you manage the patient sir >> uh then we will go for the adjument radiotherapy uh because the the disease is first of all uh T3 and uh there is also nodal positive so we will go for u based on other hisystopathological features also uh we will give this patient adjument radiotherapy What's the let's say that I want to give chemo radio at joint okay can you justify or can you say that what I'm saying is wrong if so why >> did induction chemotherapy good response you did surgery pathologically 3 N1 I would I'm going to argue for chemo radio am I wrong or Right sir um based on the pathologically looking for like it would be adjuant RT but I don't know sir why we will go for new adjuant why we will go for adjuant chemo radiotherapy or I'm not sure because uh chemotherapy is only given when we would see that there the margins positivity or some extra nodal extension or number of uh like uh number of nodes like five or more than nodes then maybe we can consider for chemotherapy along with the radiotherapy or N3B positive disease but otherwise in this patient specific if the like you have given the pathologically T3 N1 um I will look for these features also sir what about the margins what about the n extra noodle or is extra noodle but what about the margins positivity and the number of nodes.

[01:54:04]Okay, I'll pause. Yeah. Yeah.

[01:54:12]Any other any other comments, thoughts?

[01:54:15]Anyone?

[01:54:21]>> Mon?

[01:54:23]>> Yeah. The point you were making is whether you want to give the pre-staging adjuvent or you wanted to give lesser adjuvent. What was the point that was being discussed?

[01:54:35]>> If there's induction chemo response about followup with a chemo radiotherapy rather than uh uh because of the the uh uh >> yeah initial staging.

[01:54:48]>> Yeah. Yeah. Okay.

[01:54:55]Hello.

[01:54:56]>> Yes sir.

[01:54:57]>> Sir, I'm Dr. Div Sam from Bhubnesur.

[01:55:00]Sir, can I add something?

[01:55:04]>> Sure. Sure, sir. Sure.

[01:55:06]>> Sir, actually the patient ideally should require a post of chemotherapy. I think because the patient has responded well to chemotherapy.

[01:55:16]>> Yeah.

[01:55:16]>> And also chemo will act as a sensitizer, radio sensitizer. So I think patient we should give chemotherapy postoperatively rather than simply radiotherapy based on the posttop finding because postoperatively because of the new chemotherapy the tumor size gets synced by seeing the CT scan preoperatively it's definitely it was a T4B disease I think we should go ahead with chemotherapy postoperatively rather than only radiotherapy sir kindly sir ban >> yeah sir bani you want to make any comments then I can make one comment Right.

[01:55:54]>> Where is >> uh hello?

[01:55:58]>> Yeah, I think Sarbani has left I think.

[01:56:01]>> Okay. So, quickly I'll tell you that uh my philosophy and I think most of literature supports that you would give chemo you would give the adjuven treatment based on your pre uh chemotherapy staging.

[01:56:16]At least I would do that. Though there are some studies that show that when you downsize the tumor, you may be able to save and the keynote 689 study is a case in point where they show that the need for adjuvent is probably less in those that responded with the IO because the there was path downstaging but generally the dictim and I agree with the person who made the comment that you should give this patient chemo. It depends of course on the margins and the extra nodal spread.

[01:56:53]>> Yes.

[01:56:55]>> Okay. Go ahead.

[01:56:58]Any other points?

[01:57:05]>> Okay. Great.

[01:57:08]Abishek. Any any points you want to add?

[01:57:17]Okay, I think Moni uh we are well past the time. I think this has to end at 7.

[01:57:22]I also am called back into the operating rooms. So uh if there are no more points, Aim, with your permission, can we call this uh uh conclude the the presentation?

[01:57:34]>> Yes sir. Uh we can conclude the presentation.

[01:57:38]>> Okay, great. Okay, Rul, well done. But my only suggestion to you is that you should be able to justify the answer we give. Your knowledge is good but just justify. So when I ask you certain questions, Dr. Mooney asks you certain questions, you should be able to tell the the the rational why you are doing it. At the MCH level, we expect that because the moment you get your degree, you're going to be a consultant. So you should be able to justify what you're doing rather than just warm it out. So and so did one study it was 70%. More the understanding of the science. But well done and thank you folks for having us. It was a little rushed. I also was a little preoccupied with surgery but thank you very much.

[01:58:26]>> Thank you sir. Thank you sir. Thank you ma'am.

[01:58:28]>> Thank you sir. Thank you everyone. Uh thank you Mon. Thank you uh Deus sir for joining us. Thank you si ma'am. Thank you everyone and um we'll conclude here.