Case Reporting Form (CRF)

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Demography

Trial ID: T-002
Initials: AB
Gender: Male
Age: 34
Date of Entry: 06/12/2025

Habit Details

Habit Name Status From Age To Age Frequency/Day
Smoking Stopped a year ago 23 34 3
Alcohol Occasional user 23 34 1

Clinical Course Details

Diagnosis & Staging

Site: Oral Cavity

Subsite: GB Sulcus

TNM: T:T4a N:N1 M:M0

Dimensions: Max: 5 cm, Min: 2 cm

Biopsy Report: MDSCC

Treatment History

Prior Radiotherapy: No

Prior Chemotherapy: Yes (Cisplatin weekly Paclitaxel Weekly)

Treatment Plan: Surgery followed by adjuvant CTRT


Surgery & Hospital Course

Admission Date: 01/11/2025

Surgery Date: 02/11/2025

Primary Surgery: WLE

Neck Dissection: Level I, Level II, Level III, Level IV, Level V

Reconstruction: Regional flap

Post-Op & Discharge

Course in Hospital: Uneventful

Tracheostomy: Yes

NG Tube: Yes

NG Tube Removal Date: 30/11/2025

Discharge Date: 12/11/2025