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Journal of Surgical Oncology Sep 2016Osteoradionecrosis may develop on the residual mandible or reconstructed fibula because of inadequate soft tissue coverage and compromised tissue perfusion post...
BACKGROUND
Osteoradionecrosis may develop on the residual mandible or reconstructed fibula because of inadequate soft tissue coverage and compromised tissue perfusion post mandibular reconstruction, and radiation. This study was to investigate the incidence of osteoradionecrosis following class III mandibular defect reconstructions with an OPAC flap versus a fibula OSC flap.
METHODS
A retrospective review of a consecutive series of mandibular reconstructions between 1999 and 2010 was performed. Mandibular defects and corresponding flap types were analyzed with emphasis on outcome, complications, and rates of osteoradionecrosis among the two subgroups.
RESULTS
A total of 121 fibula flaps were performed, consisting of 53 OPAC and 68 fibula OSC flaps. Complications trended higher for OPAC flaps in partial and total flap loss rates as well as venous congestion when compared with the OSC flap cohort. The OPAC group had statistically significant lower rates of osteoradionecrosis and plate exposure than the OSC group (P = 0.04).
CONCLUSION
The OPAC flap may be preferable to fibula OSC flap in mandibular reconstruction given its lower rates of osteoradionecrosis and plate exposure. This flap type may be the flap of choice for class III defects where additional vascularized tissue may be critical for addressing significant soft tissue deficiency. J. Surg. Oncol. 2016;114:399-404. © 2016 Wiley Periodicals, Inc.
Topics: Adult; Aged; Aged, 80 and over; Female; Fibula; Head and Neck Neoplasms; Humans; Male; Mandibular Reconstruction; Middle Aged; Osteoradionecrosis; Retrospective Studies; Surgical Flaps
PubMed: 27545968
DOI: 10.1002/jso.24321 -
Tissue Engineering. Part A Sep 2022Extracellular vesicles (EVs) are considered essential mediators of regenerative roles of autologous platelet- and extracellular vesicle-rich plasma (PVRP) and platelet-...
Extracellular vesicles (EVs) are considered essential mediators of regenerative roles of autologous platelet- and extracellular vesicle-rich plasma (PVRP) and platelet- and extracellular vesicle-rich gel (PVRG). PVRP and PVRG are novel blood-derived products gaining attraction in regenerative medicine. However, despite their reported good efficacy, their preparation protocols are too time-consuming. Moreover, patient-tailored preparation protocols are desired to optimize platelet and EV count in PVRP and PVRG. This article presents the clinical implementation of one-step, patient-tailored erythrocyte sedimentation rate (ESR)-based, PVRP and PVRG preparation protocols through the presentation of three cases: (1) large chronic tympanic membrane (TM) perforation, (2) osteoradionecrosis of the lateral skull base, and (3) cerebrospinal fluid (CSF) leak in the sphenoid sinus. These were treated with PVRP and PVRG, prepared according to our preclinically constructed mathematical sedimentation model of cells and EVs based on the patient's ESR. (1) TM healed completely after the treatment with 3.6 mL of PVRP and PVRG (high platelet and EV protocol). The speech discrimination score and air conduction pure tone average improved from 75% to 95% and from 65 to 25 dB, respectively. (2) The osteoradionecrotic surface area decreased from 46 to 18 cm, and infection was eradicated after six applications of 13-65 mL of PVRG ("half-volume" protocol). (3) No CSF leak recurrence was detected after surgical closure with 30 mL of PVRG postoperatively. Reproducible preparation protocols proved effective, safe, fast, and straightforward enough for the surgical staff to prepare PVRP and PVRG intraoperatively. To alleviate preparation, a calculator is provided. This pilot study presents a sound basis for further studies, which are needed to assess the therapeutic effect of PVRP and PVRG. Impact statement We introduce a clinical implementation of a patient-tailored, erythrocyte sedimentation rate-based platelet- and extracellular vesicle-rich plasma (PVRP) and gel (PVRG) preparation protocol based on a mathematical model. Products proved beneficial in wound healing and were, to our knowledge, used for the first time in the treatment of osteoradionecrosis of the lateral skull base. Furthermore, this reproducible preparation protocol is fast and straightforward to implement in clinical practice. A calculator is provided to alleviate PVRP and PVRG preparation for various clinical scenarios.
Topics: Blood Platelets; Extracellular Vesicles; Humans; Osteoradionecrosis; Pilot Projects; Tympanic Membrane Perforation
PubMed: 35373605
DOI: 10.1089/ten.TEA.2022.0024 -
Special Care in Dentistry : Official... 2024Evaluate the existing evidence of osteoradionecrosis (ORN) treatment in adults with head and neck cancer, the methodological quality and the evidence grade within... (Review)
Review
AIMS
Evaluate the existing evidence of osteoradionecrosis (ORN) treatment in adults with head and neck cancer, the methodological quality and the evidence grade within systematic reviews (SRs).
METHODS
An extensive systematic literature search of SRs that addressed ORN in head and neck cancer patients was conducted with screening of eligible studies, data extraction, methodological (AMSTAR 2) and evidence quality assessment (GRADE) of the SRs by independent and calibrated authors.
RESULTS
A total of six SRs were enrolled. Based primarily on studies from the 1990s, there is critically low- or moderate-quality evidence that hyperbaric oxygen therapy (HBO) improves ORN healing. From 2005 onward, evidence has been discovered in relation to treatment with pentoxifylline and tocopherol (PENTO). The SRs indicate that the management of ORN with PENTO appears to be promising. The greatest rates of healing are seen in mild and moderate stages of ORN. However, the quality of evidence regarding PENTO, surgery and other treatments remains critically low.
CONCLUSION
There is no standardized protocol to treat ORN. PENTO appears to be the most promising conservative treatment; however, the current level of evidence regarding PENTO is still critically low. More robust clinical studies are needed to establish the best treatment for ORN.
Topics: Humans; Osteoradionecrosis; Head and Neck Neoplasms; Hyperbaric Oxygenation; Pentoxifylline; Tocopherols; Systematic Reviews as Topic
PubMed: 37534945
DOI: 10.1111/scd.12910 -
Journal of Clinical Oncology : Official... Jun 2024Osteoradionecrosis of the jaw (ORN) can manifest in varying severity. The aim of this study is to identify ORN risk factors and develop a novel classification to depict...
PURPOSE
Osteoradionecrosis of the jaw (ORN) can manifest in varying severity. The aim of this study is to identify ORN risk factors and develop a novel classification to depict the severity of ORN.
METHODS
Consecutive patients with head and neck cancer (HNC) treated with curative-intent intensity-modulated radiation therapy (IMRT) (≥45 Gy) from 2011 to 2017 were included. Occurrence of ORN was identified from in-house prospective dental and clinical databases and charts. Multivariable logistic regression model was used to identify risk factors and stratify patients into high-risk and low-risk groups. A novel ORN classification system was developed to depict ORN severity by modifying existing systems and incorporating expert opinion. The performance of the novel system was compared with 15 existing systems for their ability to identify and predict serious ORN event (jaw fracture or requiring jaw resection).
RESULTS
ORN was identified in 219 of 2,732 (8%) consecutive patients with HNC. Factors associated with high risk of ORN were oral cavity or oropharyngeal primaries, received IMRT dose ≥60 Gy, current/ex-smokers, and/or stage III to IV periodontal condition. The ORN rate for high-risk versus low-risk patients was 12.7% versus 3.1% ( < .001) with an AUC of 0.71. Existing ORN systems overclassified serious ORN events and failed to recognize maxillary ORN. A novel ORN classification system, ClinRad, was proposed on the basis of vertical extent of bone necrosis and presence/absence of exposed bone/fistula. This system detected serious ORN events in 5.7% of patients and statistically outperformed existing systems.
CONCLUSION
We identified risk factors for ORN and proposed a novel ORN classification system on the basis of vertical extent of bone necrosis and presence/absence of exposed bone/fistula. It outperformed existing systems in depicting the seriousness of ORN and may facilitate clinical care and clinical trials.
Topics: Humans; Osteoradionecrosis; Male; Head and Neck Neoplasms; Female; Middle Aged; Aged; Radiotherapy, Intensity-Modulated; Risk Factors; Risk Assessment; Severity of Illness Index
PubMed: 38691822
DOI: 10.1200/JCO.23.01951 -
Radiotherapy and Oncology : Journal of... Nov 2022
Protocol Letter: A multi-institutional retrospective case-control cohort investigating PREDiction models for mandibular OsteoRadioNecrosis in head and neck cancer (PREDMORN).
Topics: Humans; Osteoradionecrosis; Retrospective Studies; Head and Neck Neoplasms; Mandible; Case-Control Studies; Multicenter Studies as Topic
PubMed: 36179801
DOI: 10.1016/j.radonc.2022.09.014 -
The British Journal of Oral &... Apr 2017Pentoxifylline has been used to treat complications related to fibrosis for over 20 years. Formerly used to treat those after radiotherapy such as osteoradionecrosis... (Review)
Review
Pentoxifylline has been used to treat complications related to fibrosis for over 20 years. Formerly used to treat those after radiotherapy such as osteoradionecrosis (ORN), it is now being tried for medication-related osteonecrosis of the jaw (MRONJ), which can occur after prolonged use of bisphosphonates. We review theories on the formation of fibrosis in patients with ORN, discuss the pharmacology of pentoxifylline and vitamin E, and report published outcomes. To our knowledge no prospective randomised controlled trial has investigated the benefits of these agents in cases of ORN, but reported outcomes in many published case series are encouraging.
Topics: Humans; Jaw Diseases; Osteoradionecrosis; Pentoxifylline
PubMed: 28034471
DOI: 10.1016/j.bjoms.2016.12.006 -
Medicina Oral, Patologia Oral Y Cirugia... Sep 2018To review and discuss important topics regarding periodontal treatment pre- and post-radiotherapy for head and neck cancer in human patients; to discuss the references... (Review)
Review
BACKGROUND
To review and discuss important topics regarding periodontal treatment pre- and post-radiotherapy for head and neck cancer in human patients; to discuss the references for adequate techniques, the appropriate moment for tooth extractions and periodontal management; and to discuss the prevention of osteoradionecrosis.
MATERIAL AND METHODS
Thirty-nine studies including original studies, randomized clinical trials (RCTs) and reviews were searched in online databases MEDLINE (PubMed) and the Cochrane library. No year of publication restriction was applied.
RESULTS
Language was restricted to English, and the following Medical Subject Heading terms were used: radiotherapy, radiation therapy and periodontal treatment. Studies regarding periodontal treatment and tooth extraction that involved clinical management of irradiated patients were selected.
CONCLUSIONS
The treatment of periodontal diseases before radiotherapy is mainly required to avoid future dental extraction and to reduce the development of osteoradionecrosis. Periodontal treatment in irradiated patients mostly includes scaling and root planing, extraction of condemned teeth and topical and systemic antimicrobial therapy. Tooth removal should be planned at least 14 days before the first day of radiation treatment. Particular care and mouthwashes should be taken during and after radiation.
CLINICAL SIGNIFICANCE
The management of irradiated patients represents a challenge for health professionals, including dentists. It is important to establish recommendations for clinicians concerning dental and periodontal management in irradiated patients before, during and after treatment.
Topics: Dental Care; Head and Neck Neoplasms; Humans; Osteoradionecrosis; Periodontal Diseases
PubMed: 30148466
DOI: 10.4317/medoral.22474 -
Bulletin Du Cancer May 2024Osteoradionecrosis (ORN) is a late secondary iatrogenic complication of external radiotherapy for cancers of the upper aero-digestive tract. Despite the systematization... (Review)
Review
Osteoradionecrosis (ORN) is a late secondary iatrogenic complication of external radiotherapy for cancers of the upper aero-digestive tract. Despite the systematization of intensity-modulated radiotherapy and its potential for preserving salivary secretion and limiting the dose delivered to the supporting bone, ORN remains a feared and frequent complication. The objective of this literature review was to provide an overview of the management of ORN and to determine the key points that would make it possible to improve patient care. The diagnosis of ORN requires to eliminate tumor recurrence then is based on clinical arguments and imaging by CT or Cone Beam evolving in a chronic mode (more than 3-6 months). The harmonization of its classifications aims to offer comprehensive and multidisciplinary care as early as possible. Primary prevention is based on pre-therapeutic oral and dental preparation, then associated with fluoroprophylaxis if salivary recovery is insufficient and requires supervision of invasive dental care and prosthetic rehabilitation. Semi-automatic contouring tools make it possible to identify doses delivered to dental sectors and guide dental care with personalized dosimetric mapping. Conservative medical treatment is offered at an early stage where innovative medical treatments, highlighted by early studies, could be of interest in the future. In the event of advanced ORN, a non-conservative treatment is then proposed and frequently consists of interruptive mandibulectomy associated with reconstruction by bony free flap, the conditions of implantation remaining to be defined with the support of prospective clinical trials.
Topics: Humans; Osteoradionecrosis; Radiotherapy, Intensity-Modulated; Head and Neck Neoplasms; Primary Prevention; Dental Care; Neoplasm Recurrence, Local
PubMed: 38480057
DOI: 10.1016/j.bulcan.2024.01.008 -
Medical Science Monitor : International... Jun 2023Osteoradionecrosis (ORN) of the femoral head is an important issue for orthopedists and radiologists in clinical practice. With the rapid development of technological...
Osteoradionecrosis (ORN) of the femoral head is an important issue for orthopedists and radiologists in clinical practice. With the rapid development of technological advances in radiation therapy and the improvement in cancer survival rates, the incidence of ORN is rising, and there is an unmet need for basic and clinical research. The pathogenesis of ORN is complex, and includes vascular injury, mesenchymal stem cell injury, bone loss, reactive oxygen species, radiation-induced fibrosis, and cell senescence. The diagnosis of ORN is challenging and requires multiple considerations, including exposure to ionizing radiation, clinical manifestations, and findings on physical examination and imaging. Differential diagnosis is essential, as clinical symptoms of ORN of the femoral head can resemble many other hip conditions. Hyperbaric oxygen therapy, total hip arthroplasty, and Girdlestone resection arthroplasty are effective treatments, each with their own advantages and disadvantages. The literature on ORN of the femoral head is incomplete and there is no criterion standard or clear consensus on management. Clinicians should gain a better and more comprehensive understanding on this disease to facilitate its early and better prevention, diagnosis, and treatment. This article aims to review the pathogenesis, diagnosis, and management of osteoradionecrosis of the femoral head.
Topics: Humans; Osteoradionecrosis; Femur Head; Diagnosis, Differential; Radiation, Ionizing; Arthroplasty, Replacement, Hip
PubMed: 37310931
DOI: 10.12659/MSM.940264 -
International Journal of Oral and... Dec 2016The purpose of this study was to compare medication-related osteonecrosis of the jaw (MRONJ) with osteoradionecrosis (ORN). Group 1 comprised 74 MRONJ patients (93... (Comparative Study)
Comparative Study
The purpose of this study was to compare medication-related osteonecrosis of the jaw (MRONJ) with osteoradionecrosis (ORN). Group 1 comprised 74 MRONJ patients (93 lesions) and group 2 comprised 59 ORN patients (69 lesions). Patient characteristics, clinical presentation of the lesions, the presence of complications, and the relationship with previous dental extractions were analyzed for both groups. Significant differences were found between the groups with regard to the characteristics of the patient populations, extraction as the precipitating event, the type of initial complaint, the prevalence of pain, and the location of the lesions. In the ORN group, significantly more patients complained of pain (P=0.0108) compared with the MRONJ group. Furthermore, significantly more pathological fractures (P<0.0001) and skin fistulae (P<0.0001) occurred in the ORN group. The treatment was more often conservative in the MRONJ group than in the ORN group (61.3% vs. 36.2%). Despite similarities in terms of imaging, risk factors, prevention, and treatment, MRONJ and ORN are two distinct pathological entities, as highlighted by the differences in patient characteristics, the initial clinical presentation, course of the disease, and outcome.
Topics: Aged; Antineoplastic Agents; Female; Fractures, Spontaneous; Humans; Jaw Diseases; Male; Middle Aged; Neoplasms; Osteonecrosis; Osteoradionecrosis; Tooth Extraction
PubMed: 27427547
DOI: 10.1016/j.ijom.2016.06.016