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Current Treatment Options in Oncology Nov 2021Osteoradionecrosis (ORN) of the mandible is a rare but devastating complication which occurs following radiation therapy for head and neck malignancies. Left untreated,... (Review)
Review
Osteoradionecrosis (ORN) of the mandible is a rare but devastating complication which occurs following radiation therapy for head and neck malignancies. Left untreated, ORN often results in pathologic fracture of the mandible leading to pain, trismus, difficulty eating, and overall poor quality of life. Historically, early intervention relied on hyperbaric oxygen and local debridement. Patients whose disease progressed despite therapy required segmental resection of the mandible with osseous free flap reconstruction, a highly invasive operation. Patients that presented with a moderate disease without pathologic fracture were often doomed to fail non-operative management, ultimately leading to disease progression and fracture. The traditional dichotomous treatment paradigm left a void of options for patients with moderate disease. The ideal intervention for this category of patients would provide renewed vascularity to the diseased tissue bed allowing for the osteogenesis and reestablishment of strong, load-bearing bone. The innovative technique termed the vascularized fascia lata "rescue flap" has proven to be an effective treatment for moderate ORN and will likely transform dated treatment algorithms.
Topics: Anti-Bacterial Agents; Antioxidants; Bone Density Conservation Agents; Debridement; Humans; Hyperbaric Oxygenation; Mandibular Diseases; Mandibular Osteotomy; Mandibular Reconstruction; Oral Hygiene; Osteoradionecrosis; Smoking Cessation; Tooth Extraction; Ultrasonic Therapy
PubMed: 34773495
DOI: 10.1007/s11864-021-00915-3 -
Acta Oto-laryngologica Jan 2023Base of tongue cancer incidence and patient survival is increasing why treatment sequelae becomes exceedingly important. Osteoradionecrosis (ORN) is a late adverse...
BACKGROUND
Base of tongue cancer incidence and patient survival is increasing why treatment sequelae becomes exceedingly important. Osteoradionecrosis (ORN) is a late adverse effect of radiotherapy and brachytherapy (BT) could be a risk factor. Brachytherapy is used in three out of six health care regions in Sweden.
AIMS
Investigate if patients treated in regions using BT show an increased risk for ORN and whether brachytherapy has any impact on overall survival.
MATERIAL AND METHODS
We used data from the Swedish Head and Neck Cancer Register between 2008-2014. Due to the nonrandomized nature of the study and possible selection bias we compared the risk for ORN in brachy vs non-brachy regions.
RESULTS
Fifty out of 505 patients (9.9%) developed ORN; eight of these were treated in nonbrachy regions (16%), while 42 (84%) were treated in brachy regions. Neither age, sex, TNM-classification/stage, p16, smoking, neck dissection, or chemotherapy differed between ORN and no-ORN patients. The risk for ORN was significantly higher for patients treated in brachy regions compared to non-brachy regions (HR = 2,63, = .012), whereas overall survival did not differ (HR = 0.95, = .782).
CONCLUSIONS AND SIGNIFICANCE
Brachytherapy ought to be used cautiously for selected patients or within prospective randomized studies.
Topics: Humans; Osteoradionecrosis; Brachytherapy; Tongue Neoplasms; Prospective Studies; Head and Neck Neoplasms; Retrospective Studies
PubMed: 36595465
DOI: 10.1080/00016489.2022.2161627 -
JAMA Otolaryngology-- Head & Neck... Dec 2023Patients with head and neck cancer undergo extraction of teeth with poor prognoses to minimize post-radiation therapy (RT) extractions, which are known to cause...
IMPORTANCE
Patients with head and neck cancer undergo extraction of teeth with poor prognoses to minimize post-radiation therapy (RT) extractions, which are known to cause osteoradionecrosis (ORN). However, many patients are required to start RT before the extraction sites are completely healed. The role of pre-RT extractions in the development of ORN has been disputed in literature.
OBJECTIVE
To determine whether the timing of pre-RT dental extractions is associated with ORN development in patients with head and neck cancer.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study was conducted at a single institution (Princess Margaret Cancer Centre, Toronto, Canada) between January 1, 2011, and January 1, 2018, and included 879 patients with head and neck cancer who underwent pre-RT dental extractions before curative RT of 45 Gy or greater. Patient demographic information and clinical characteristics (eg, primary cancer site, nodal involvement, chemotherapy, smoking status, dental pathology) were considered. Data analyses were performed from July to December 2022.
MAIN OUTCOMES AND MEASURES
Timing (number of days) from dental extractions to RT start date and pre-RT extractions categorized as healed, minor bone spicules (MBS), or ORN.
RESULTS
The study population consisted of 879 patients with a median (range) age of 62 (20-96) years, with 685 men (78%) and 194 women (22%). Of these, 847 (96.3%) healed from pre-RT dental extractions, 16 (1.8%) developed MBS, and 16 (1.8%) developed ORN. The median (range) time in number of days from pre-RT extraction(s) to start of RT was 9 (0-98) days in the healed cohort, 6 (3-23) days in the MBS cohort, and 6 (0-12) days in the ORN cohort. There was a large difference in the timing of pre-RT extractions between the healed and the MBS cohorts (mean 11.9 vs 7.4 days to radiation; difference 4.4; 95% CI, 1.5-7.3), and the healed and the ORN cohorts (mean 11.9 vs 7.1 days; difference 4.8 days; 95% CI, 2.6-7.1).
CONCLUSION
The findings of this retrospective cohort study suggest that there was an important association between the timing of pre-RT dental extractions and ORN when extractions occurred within 7 days of the RT start date. Despite this, ORN after pre-RT extractions is relatively rare. These findings indicate that patients with head and neck cancer who are to undergo RT should not delay treatment for extractions when it might compromise oncologic control.
Topics: Male; Humans; Female; Middle Aged; Aged; Aged, 80 and over; Retrospective Studies; Osteoradionecrosis; Head and Neck Neoplasms; Smoking; Tooth Extraction
PubMed: 37856115
DOI: 10.1001/jamaoto.2023.3429 -
Clinical Radiology Feb 2015Head and neck malignancies constitute a major cause of morbidity and mortality all over the world. Radiotherapy plays a pivotal role in the management of these tumours;... (Review)
Review
Head and neck malignancies constitute a major cause of morbidity and mortality all over the world. Radiotherapy plays a pivotal role in the management of these tumours; however, it has associated complications, with mandibular osteoradionecrosis (ORN) being one of the gravest orofacial complications. Early diagnosis, extent evaluation, and detection of complications of ORN are imperative for instituting an appropriate management protocol. ORN can closely mimic tumour recurrence, the differentiation of which has obvious clinical implications. The purpose of the present review is to acquaint the radiologist with the imaging features of mandibular ORN and the ways to differentiate ORN from tumour recurrence.
Topics: Fluorodeoxyglucose F18; Humans; Magnetic Resonance Imaging; Mandible; Mandibular Diseases; Osteoradionecrosis; Positron-Emission Tomography; Radiopharmaceuticals; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed
PubMed: 25446325
DOI: 10.1016/j.crad.2014.09.012 -
Oral and Maxillofacial Surgery Clinics... Aug 2017Bone margin analysis in cases of osteomyelitis, osteoradionecrosis, and medication-related osteonecrosis of the jaw is a controversial topic. There is little evidence to... (Review)
Review
Bone margin analysis in cases of osteomyelitis, osteoradionecrosis, and medication-related osteonecrosis of the jaw is a controversial topic. There is little evidence to guide treatment and the interpretation of bone margin results. This article examines the significance of margin status and any possible effect on progression of the disease process. A review of various treatment adjuncts used for intraoperative margin analysis during removal of affected tissue is provided. Literature on the role of imaging is also discussed with regards to treatment planning for surgical resection. The histology of the three separate entities including the approach to surgical and pathologic evaluation of margins is also discussed.
Topics: Bisphosphonate-Associated Osteonecrosis of the Jaw; Humans; Jaw Diseases; Margins of Excision; Osteomyelitis; Osteonecrosis; Osteoradionecrosis
PubMed: 28709531
DOI: 10.1016/j.coms.2017.03.007 -
Practical Radiation Oncology 2024Osteoradionecrosis (ORN) is a severe late complication of head and neck radiation therapy shown to have profound negative effect on the quality of life of cancer... (Review)
Review
PURPOSE
Osteoradionecrosis (ORN) is a severe late complication of head and neck radiation therapy shown to have profound negative effect on the quality of life of cancer survivors. Over the past few decades, improvements in radiation delivery techniques have resulted in a decrease in the incidence of ORN. However, even with modern radiation therapy techniques, ORN remains an important clinical concern. In recent literature, there is a wide range of reported ORN rates from 0% to as high as 20%. With such a high level of variability in the reported incidence of ORN, oncologists often encounter difficulties estimating the risk of this serious radiation therapy toxicity.
METHODS AND MATERIALS
In this review, the authors present a summary of the factors that contribute to the high level of variability in the reported incidence of ORN.
RESULTS
Variable definition, variable grading, and heterogeneity of both study inclusion criteria and treatment parameters can each significantly influence the reporting of ORN rates.
CONCLUSIONS
Given numerous factors can affect the reported incidence of ORN, a thorough understanding of the clinical context behind the reported ORN rates is needed to comprehend the true risk of this important radiation therapy toxicity.
Topics: Humans; Osteoradionecrosis; Head and Neck Neoplasms; Incidence; Quality of Life
PubMed: 38649030
DOI: 10.1016/j.prro.2024.02.008 -
Cancer Radiotherapie : Journal de La... Sep 2023Efforts have been made to reduce epidemiological indicators of osteoradionecrosis in patients with head and neck cancer over recent years. This umbrella review aims to... (Review)
Review
OBJECTIVE
Efforts have been made to reduce epidemiological indicators of osteoradionecrosis in patients with head and neck cancer over recent years. This umbrella review aims to synthesize the information of the systematic reviews/meta-analyses investigating the effect of radiotherapy in patients with head and neck cancer on the frequency of osteoradionecrosis and to identify and analyze the gaps in current scientific literature.
MATERIAL AND METHODS
A systematic review of systematic reviews with and without meta-analysis of intervention studies was conducted. Qualitative analysis of the reviews and their quality evaluation were performed.
RESULTS
A total of 152 articles were obtained, and ten of them were selected for the final analysis, where six were systematic reviews and four were meta-analysis. According to the guide Assessing the Methodological Quality of Systematic Reviews (Amstar), eight articles included were of high quality and two of medium quality. These descriptive systematic reviews/meta-analyses included a total of 25 randomized clinical trials, showing that radiotherapy has positive effects on the frequency of osteoradionecrosis. Even though a reduction in the incidence of osteoradionecrosis was observed back in the history, in systematic reviews with meta-analysis, overall effect estimators were not significant.
CONCLUSIONS
Differential findings are not enough to demonstrate that there is a significant reduction in the frequency of osteoradionecrosis in patients with head and neck cancer treated by radiation. Possible explanations are related to factors such as the type of studies analyzed, indicator of irradiated complication considered, and specific variables included in the analysis. Many systematic reviews did not address publication bias and did identify gaps in knowledge that require further clarification.
Topics: Humans; Head and Neck Neoplasms; Jaw; Jaw Diseases; Osteoradionecrosis; Systematic Reviews as Topic; Meta-Analysis as Topic
PubMed: 37268457
DOI: 10.1016/j.canrad.2023.01.009 -
Oral Surgery, Oral Medicine, Oral... Jul 2023This systematic review aimed to determine whether the pentoxifylline and tocopherol (PENTO) protocol effectively reduce the risk of osteoradionecrosis (ORN) in patients... (Review)
Review
PURPOSE
This systematic review aimed to determine whether the pentoxifylline and tocopherol (PENTO) protocol effectively reduce the risk of osteoradionecrosis (ORN) in patients undergoing tooth extraction after head and neck radiotherapy.
METHODS
We searched PubMed, SCOPUS, LILACS, EMBASE, Web of Science, and Cochrane databases up to August 2022. We considered only studies that included patients diagnosed with head and neck cancer undergoing tooth extraction with PENTO prophylaxis after radiotherapy.
RESULTS
Of the 642 studies identified, 4 were included. Across the included studies, 387 patients had 1871 teeth extracted while on PENTO prophylaxis. The interval of the PENTO protocol differed among the studies included. Overall, a total of 12 (3.1%) patients had ORN, whereas at the individual tooth level analysis the ORN rate was 0.9%.
CONCLUSIONS
Insufficient evidence exists to promote using the PENTO protocol before dental extractions to prevent ORN.
Topics: Humans; Tocopherols; Pentoxifylline; Osteoradionecrosis; Head and Neck Neoplasms; Tooth Extraction; Retrospective Studies
PubMed: 36882364
DOI: 10.1016/j.oooo.2023.01.005 -
The Laryngoscope Nov 2020PENTOCLO treatment, associating pentoxifylline, tocopherol, and clodronate, resolves radiation-induced fibrosis. The main aim of the present study was to prospectively...
OBJECTIVES/HYPOTHESIS
PENTOCLO treatment, associating pentoxifylline, tocopherol, and clodronate, resolves radiation-induced fibrosis. The main aim of the present study was to prospectively assess efficacy in mandibular osteoradionecrosis (ORN).
STUDY DESIGN
Prospective cohort study.
METHODS
Twenty-seven patients with mandibular ORN were included in the Pentoclauvergne Study between January 2014 and February 2016. After an initial 28-day phase of antibiotic, antifungal, and corticosteroid therapy, they received the PENTOCLO association daily until cure or a maximum of 24 months. The main assessment criterion was exposed bone area (EBA); secondary criteria comprised the Subjective, objective, management, and analytic (SOMA) score.
RESULTS
Under PENTOCLO, EBA decreased by 28% at 2 months, 55% at 6 months, and 92% at 24 months; the SOMA score decreased by 23%, 38%, and 50%, respectively. A complete treatment course cured 76.5% of patients at a mean 9.6 months.
CONCLUSIONS
PENTOCLO is a simple, well-tolerated, and effective treatment for mandibular ORN.
LEVEL OF EVIDENCE
4 Laryngoscope, 130:E559-E566, 2020.
Topics: Aged; Aged, 80 and over; Bone Density Conservation Agents; Clodronic Acid; Drug Combinations; Female; Humans; Male; Mandibular Diseases; Middle Aged; Osteoradionecrosis; Pentoxifylline; Prospective Studies; Tocopherols; Treatment Outcome
PubMed: 31747060
DOI: 10.1002/lary.28399 -
JAMA Otolaryngology-- Head & Neck... Feb 2023Proton radiation therapy (PRT) has reduced radiation-induced toxic effects, such as mucositis and xerostomia, over conventional photon radiation therapy, leading to...
IMPORTANCE
Proton radiation therapy (PRT) has reduced radiation-induced toxic effects, such as mucositis and xerostomia, over conventional photon radiation therapy, leading to significantly improved quality of life in patients with head and neck cancers. However, the prevalence of osteoradionecrosis (ORN) of the jaw following PRT in these patients is less clear.
OBJECTIVE
To report the prevalence and clinical characteristics of ORN in patients with oral and oropharyngeal cancer (OOPC) treated with PRT.
DESIGN, SETTING, AND PARTICIPANTS
This case series reports a single-institution experience (Memorial Sloan Kettering Cancer Center, New York, New York) between November 2013 and September 2019 and included 122 radiation therapy-naive patients with OOPC treated with PRT. Data were analyzed from 2013 to 2019.
MAIN OUTCOMES AND MEASURES
Clinical parameters, including sex, age, comorbidities, tumor histology, concurrent chemotherapy, smoking, comorbidities, and preradiation dental evaluation, were obtained from the medical record. Patients with clinical or radiographic signs of ORN were identified and graded using the adopted modified Glanzmann and Grätz grading system. Characteristics of ORN, such as location, clinical presentation, initial stage at diagnosis, etiology, time to diagnosis, management, and clinical outcome at the last follow-up, were also collected.
RESULTS
Of the 122 patients (mean [SD] age, 63 [13] years; 45 [36.9%] women and 77 [63.1%] men) included in this study, 13 (10.6%) developed ORN following PRT during a median (range) follow-up time of 40.6 (<1-101) months. All patients had spontaneous development of ORN. At the time of initial diagnosis, grade 0, grade 1, grade 2, and grade 3 ORN were seen in 2, 1, 9, and 1 patient, respectively. The posterior ipsilateral mandible within the radiation field that received the full planned PRT dose was the most involved ORN site. At a median (range) follow-up of 13.5 (0.2-58.0) months from the time of ORN diagnosis, complete resolution, stable condition, and progression of ORN were seen in 3, 6, and 4 patients, respectively. The 3-year rates of ORN and death in the total cohort were 5.2% and 21.5%, while the 5-year rates of ORN and death were 11.5% and 34.4%, respectively.
CONCLUSIONS AND RELEVANCE
In this case series, the prevalence of ORN following PRT was found to be 10.6%, indicating that ORN remains a clinical challenge even in the era of highly conformal PRT. Clinicians treating patients with OOPC with PRT should be mindful of this complication.
Topics: Male; Humans; Female; Middle Aged; Osteoradionecrosis; Protons; Quality of Life; Head and Neck Neoplasms; Oropharyngeal Neoplasms; Mouth Neoplasms; Retrospective Studies
PubMed: 36547968
DOI: 10.1001/jamaoto.2022.4165