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Fitzgerald KT, Lyons C, England A, McEntee MF, Devine A, O'Donovan T, O'Sullivan E. Risk factors associated with the development of osteoradionecrosis (ORN) in Head and Neck cancer patients in Ireland: A 10-year retrospective review. Radiother Oncol 2024; 196:110286. [PMID: 38641259 DOI: 10.1016/j.radonc.2024.110286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/21/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND AND PURPOSES To assess osteoradionecrosis (ORN) incidence in a population of Irish Head and Neck cancer (HNC) patients, and assess precipitating factors that may contribute to ORN development to aid prevention. MATERIALS AND METHODS Review of 1050 HNC patients attending the Dental Oncology Clinic, CUDSH between 2010 and 2021 identified 47 cases of ORN. Medical, dental and radiotherapy records of these forty-seven patients were retrospectively reviewed. Patient-, tumour-, and treatment-related variables were investigated in association with osteoradionecrosis development. Analysis conducted using SPSS, Pearson's Chi-square test (p < 0.05), and ordinal regression model. RESULTS ORN incidence was 4.4 %. Median time from radiotherapy (RT) to ORN development was 9.5 months (range 1-98.5 months). ORN development within the mandibular surgical site was significant (p <.001), presenting at a higher Notani grade (p =.002), in mid-mandibular body region (p =.028), at radiation doses ≥ 60 Gy (p =.035), due to induced causes (p =.029), and without resolution (p =.019). CONCLUSION This is the first retrospective study of ORN in HNC patients in Ireland over 10-year period. ORN incidence was extremely low (4.4%). As patients reported high smoking/alcohol use and poor dental attendance pre-diagnosis, this suggests intensive dental intervention pre/post-diagnosis contributed to low ORN rates. Mandibular surgery pre-RT increased risk of developing ORN at the surgical site. Therefore, we recommend future treatment planning should contour the surgical site, designating it an organ at risk (OAR), assigning a dose constraint, where oncologically possible, with emphasis on reducing the hot-spot to this region; findings reinforce importance of life-long expert dental care to reduce ORN incidence.
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Affiliation(s)
| | - Ciara Lyons
- Radiation Therapy Dept., Glandore Centre, Cork University Hospital, Cork, Ireland
| | - Andrew England
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Mark F McEntee
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Annemarie Devine
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Theresa O'Donovan
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Eleanor O'Sullivan
- Radiation Therapy Dept., Glandore Centre, Cork University Hospital, Cork, Ireland; ENTO Research Unit, Cork University Dental School & Hospital, Cork, Ireland.
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Carsuzaa F, Dore M, Falek S, Delpon G, Drouet J, Thariat J. [Prevention, diagnosis and management of osteoradionecrosis: Where do we stand?]. Bull Cancer 2024; 111:525-536. [PMID: 38480057 DOI: 10.1016/j.bulcan.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 05/13/2024]
Abstract
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.
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Affiliation(s)
- Florent Carsuzaa
- Service d'ORL et chirurgie cervico-faciale, centre hospitalo-universitaire de Poitiers, Poitiers, France.
| | - Mélanie Dore
- Service de radiothérapie, institut de cancérologie de l'Ouest, Nantes, France
| | - Sabah Falek
- Service de chirurgie maxillofaciale et stomatologie, centre François-Baclesse, Caen, France
| | - Grégory Delpon
- Service de radiothérapie, institut de cancérologie de l'Ouest, Nantes, France
| | - Julien Drouet
- Service de chirurgie maxillofaciale et stomatologie, centre François-Baclesse, Caen, France
| | - Juliette Thariat
- Service de radiothérapie, centre François-Baclesse, Caen, France; Laboratoire de physique corpusculaire, IN2P3/ENSICAEN/CNRS, UMR 6534, Normandie université, Caen, France; GORTEC, Intergroupe ORL France, France
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3
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Somay E, Topkan E, Selek U. Re: Minimum detectable change in occlusal load - Normative data for healthy and head and neck cancer populations. Br J Oral Maxillofac Surg 2024; 62:314-315. [PMID: 38458908 DOI: 10.1016/j.bjoms.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey; Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kyrenia University, Girne, Cyprus.
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey.
| | - Ugur Selek
- Department of Radiation Oncology, Faculty of Medicine, Koc University, Istanbul, Turkey.
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Owosho AA, DeColibus KA, Okhuaihesuyi O, Levy LC. Prophylactic Use of Pentoxifylline and Tocopherol for Prevention of Osteoradionecrosis of the Jaw after Dental Extraction in Post-Radiated Oral and Oropharyngeal Cancer Patients: An Initial Case Series. Dent J (Basel) 2024; 12:83. [PMID: 38667995 PMCID: PMC11049290 DOI: 10.3390/dj12040083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Osteoradionecrosis of the jaw is a morbid complication of radiotherapy in patients with oral and oropharyngeal cancers that may be precipitated by dental extractions. Pentoxifylline and tocopherol (PENTO) has been utilized in the management of osteoradionecrosis and as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. This observational study aims to report the outcome of the prophylactic use of PENTO in the prevention of osteoradionecrosis of the jaw after dental extractions in post-radiated oral and oropharyngeal cancer patients and to review the current literature on this topic. Four post-radiated oral and oropharyngeal oncology patients were referred to the dental oncology clinic of the University Dental Practice, University of Tennessee Health Sciences Center for dental extractions. All four patients were prescribed pentoxifylline 400 mg BID (twice a day) and tocopherol 400 IU BID (oral tablets) for 2 weeks before extraction(s) and for 6 weeks after extraction(s). All patients were followed up every week after the second week post-extraction if feasible until the extraction site(s) healed (covered by mucosa). The assessment endpoint was defined as 6 weeks post-extraction with the outcomes assessed as using four categories determined by the area of exposed bone: complete healing (complete mucosal coverage of extraction site); partial healing (reduction in size of extraction site); no change; and progression (increase in size of the extraction site). At the assessment endpoint, all patients had complete healing of all extraction sites. The ORN rate at the patient level (0/4) and individual tooth level (0/8) was 0%. All patients tolerated the PENTO medications and no adverse effects from the use of these medications were reported. This limited study in addition to the other reviewed studies estimates the rate of ORN at the patient level as 3.2% (14/436) for post-radiated head and neck oncology patients after dental extractions/invasive oral procedures. In conclusion, this PENTO regimen can reduce/prevent the incidence of ORN in post-radiated head and neck oncology patients. This safe and cost-effective protocol (PENTO regimen) should be further evaluated as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. We recommend large prospective studies to be carried out to further validate these findings.
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Affiliation(s)
- Adepitan A. Owosho
- Department of Diagnostic Sciences, College of Dentistry/Department of Otolaryngology—Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, 875 Union Avenue, Memphis, TN 38163, USA
| | - Katherine A. DeColibus
- Department of Diagnostic Sciences, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Osariemen Okhuaihesuyi
- Missouri School of Dentistry and Oral Health, A.T. Still University, Kirksville, MO 63501, USA
| | - Layne C. Levy
- Advanced Education in General Dentistry, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
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Naseer A, Goode F, Doyle T. Osteoradionecrosis - an old problem with new consequences. Curr Opin Support Palliat Care 2024; 18:39-46. [PMID: 38170197 DOI: 10.1097/spc.0000000000000690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Osteoradionecrosis (ORN) is a devasting complication of radiation therapy (RT), especially in head and neck cancers (HNC), and is still poorly understood. The aim of this review is to report its incidence and consider the risk factors associated with ORN to highlight prevention strategies to decrease its incidence. RECENT FINDINGS The average incidence of ORN is between 2% and 23%, with incidence decreasing in more recent years with the introduction of modern RT technology and better oral health care. Smoking, diabetes mellitus, oropharyngeal and oral cavity cancers, pre- and post-RT dental extractions and a total radiation dose of over 60 Gy were all identified as risk factors for ORN. In prevention, strategies were mainly structured around minimising risk factors or targeting possible mechanisms of ORN's pathophysiology. SUMMARY At present, the controversy surrounding the risk factors and pathogenesis of ORN makes it difficult to establish a set of prevention guidelines for its incidence. In order to achieve this, more research examining its aetiology must be conducted as well as a universal staging system within which ORN may be classified.
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Affiliation(s)
- Amara Naseer
- School of Medicine, Discipline of Radiation Therapy, Trinity College Dublin, The University of Dublin
| | - Fiona Goode
- Trinity College: The University of Dublin Trinity College, Dublin, Republic of Ireland
| | - Tia Doyle
- Trinity College: The University of Dublin Trinity College, Dublin, Republic of Ireland
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Yilmaz B, Somay E, Topkan E, Pehlivan B, Besen AA, Mertsoylu H, Selek U. Predictive potential of pan-immune-inflammation value / hemoglobin index as biomarker for osteoradionecrosis risk in locally advanced nasopharyngeal carcinomas. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101786. [PMID: 38286220 DOI: 10.1016/j.jormas.2024.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/10/2024] [Accepted: 01/25/2024] [Indexed: 01/31/2024]
Abstract
OBJECTIVE We aimed to investigate whether the Pan-Immune-Inflammation-Value/Hemoglobin (PIV/Hb) index could predict the risk of osteoradionecrosis (ORN) in patients receiving concurrent chemoradiotherapy (CCRT) for locally advanced nasopharyngeal cancer (LA-NPC). MATERIALS AND METHODS This retrospective analysis included LA-NPC patients who underwent CCRT and pre-CCRT oral exams at our institution's Departments of Radiation Oncology and Dentistry between January 2010 and December 2022. The relationship between ORN rates and PIV-Hb levels was explored using receiver operating characteristic curve analysis. The primary objective was to establish a correlation between pre-CCRT PIV-Hb levels and ORN rates, while the secondary objective was to identify other risk factors for ORN. RESULTS Of 249 eligible patients, 21 (8.4 %) were diagnosed with ORN. The optimal pre-CCRT PIV/Hb cutoff was 73.8, which divided patients into two subgroups with distinctive ORN risk estimates: Group 1: PIV/Hb < 73.8 (N = 206), and Group 2: PIV/Hb ≥ 73.8 (N = 43). The results of the comparative analysis indicated that the cohort with PIV/Hb ≥ 73.8 exhibited substantially higher rates of ORN than the PIV/Hb < 73.8 cohort (44.2 % vs. 1.0 %; P < 0.001). The multivariate logistic regression analysis indicated that the pretreatment PIV/Hb ≥ 73.8 was independently associated with higher ORN rates (P < 0.001). CONCLUSION The results of our current investigation indicate that higher levels of pretreatment PIV/Hb were associated with a significant independent increase in ORN rates in LA-NPC patients who received CCRT.
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Affiliation(s)
- Busra Yilmaz
- Department of Oral and Maxillofacial Radiology, School of Dental Medicine, Bahcesehir University, Balmumcu Campus, Gayrettepe, Barbaros Blv., No:153 Beşiktaş, Istanbul 34349, Turkey.
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, School of Medicine, Bahcesehir University, Istanbul, Turkey
| | - Ali Ayberk Besen
- Clinics of Medical Oncology, Adana Seyhan Medical Park Hospital, Adana, Turkey
| | - Huseyin Mertsoylu
- Clinics of Medical Oncology, Istinye University, Adana Medical Park Hospital, Adana, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey
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7
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Corrao G, Mazzola GC, Lombardi N, Marvaso G, Pispero A, Baruzzi E, Decani S, Tarozzi M, Bergamaschi L, Lorubbio C, Repetti I, Starzyńska A, Alterio D, Ansarin M, Orecchia R, D’Amore F, Franchini R, Nicali A, Castellarin P, Sardella A, Lodi G, Varoni EM, Jereczek-Fossa BA. Oral Surgery and Osteoradionecrosis in Patients Undergoing Head and Neck Radiation Therapy: An Update of the Current Literature. Biomedicines 2023; 11:3339. [PMID: 38137559 PMCID: PMC10742198 DOI: 10.3390/biomedicines11123339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Osteoradionecrosis (ORN) is a serious long-term complication of head and neck radiotherapy (RT), which is often triggered by dental extractions. It results from avascular aseptic necrosis due to irradiated bone damage. ORN is challenging to treat and can lead to severe complications. Furthermore, ORN causes pain and distress, significantly reducing the patient's quality of life. There is currently no established preventive strategy. This narrative review aims to provide an update for the clinicians on the risk of ORN associated with oral surgery in head and neck RT patients, with a focus on the timing suitable for the oral surgery and possible ORN preventive treatments. An electronic search of articles was performed by consulting the PubMed database. Intervention and observational studies were included. A multidisciplinary approach to the patient is highly recommended to mitigate the risk of RT complications. A dental visit before commencing RT is highly advised to minimize the need for future dental extractions after irradiation, and thus the risk of ORN. Post-RT preventive strategies, in case of dento-alveolar surgery, have been proposed and include antibiotics, hyperbaric oxygen (HBO), and the combined use of pentoxifylline and tocopherol ("PENTO protocol"), but currently there is a lack of established standards of care. Some limitations in the use of HBO involve the low availability of HBO facilities, its high costs, and specific clinical contraindications; the PENTO protocol, on the other hand, although promising, lacks clinical trials to support its efficacy. Due to the enduring risk of ORN, removable prostheses are preferable to dental implants in these patients, as there is no consensus on the appropriate timing for their safe placement. Overall, established standards of care and high-quality evidence are lacking concerning both preventive strategies for ORN as well as the timing of the dental surgery. There is an urgent need to improve research for more efficacious clinical decision making.
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Affiliation(s)
- Giulia Corrao
- Division of Radiation Oncology, IEO—European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.C.); (G.C.M.); (G.M.); (L.B.); (C.L.); (I.R.); (D.A.); (B.A.J.-F.)
| | - Giovanni Carlo Mazzola
- Division of Radiation Oncology, IEO—European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.C.); (G.C.M.); (G.M.); (L.B.); (C.L.); (I.R.); (D.A.); (B.A.J.-F.)
| | - Niccolò Lombardi
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Giulia Marvaso
- Division of Radiation Oncology, IEO—European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.C.); (G.C.M.); (G.M.); (L.B.); (C.L.); (I.R.); (D.A.); (B.A.J.-F.)
| | - Alberto Pispero
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Elisa Baruzzi
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Sem Decani
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Marco Tarozzi
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Luca Bergamaschi
- Division of Radiation Oncology, IEO—European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.C.); (G.C.M.); (G.M.); (L.B.); (C.L.); (I.R.); (D.A.); (B.A.J.-F.)
| | - Chiara Lorubbio
- Division of Radiation Oncology, IEO—European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.C.); (G.C.M.); (G.M.); (L.B.); (C.L.); (I.R.); (D.A.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Ilaria Repetti
- Division of Radiation Oncology, IEO—European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.C.); (G.C.M.); (G.M.); (L.B.); (C.L.); (I.R.); (D.A.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Anna Starzyńska
- Department of Oral Surgery, Medical University of Gdańsk, 7 Dębinki Street, 80-211 Gdańsk, Poland;
| | - Daniela Alterio
- Division of Radiation Oncology, IEO—European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.C.); (G.C.M.); (G.M.); (L.B.); (C.L.); (I.R.); (D.A.); (B.A.J.-F.)
| | - Mohseen Ansarin
- Division of Otolaryngology and Head and Neck Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy;
| | - Roberto Orecchia
- Scientific Directorate, IEO-European Institute of Oncology, IRCCS, 20141 Milan, Italy;
| | - Fiorella D’Amore
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Roberto Franchini
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Andrea Nicali
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Paolo Castellarin
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Andrea Sardella
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Giovanni Lodi
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Elena Maria Varoni
- Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Via Beldiletto 1, 20142 Milan, Italy; (N.L.); (A.P.); (E.B.); (S.D.); (M.T.); (F.D.); (R.F.); (A.N.); (P.C.); (A.S.); (G.L.)
- ASST Santi Paolo e Carlo, SC Odontostomatology II, San Paolo Hospital, 20142, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO—European Institute of Oncology, IRCCS, 20141 Milan, Italy; (G.C.); (G.C.M.); (G.M.); (L.B.); (C.L.); (I.R.); (D.A.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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8
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Yilmaz B, Somay E, Topkan E, Kucuk A, Pehlivan B, Selek U. Utility of pre-chemoradiotherapy Pan-Immune-Inflammation-Value for predicting the osteoradionecrosis rates in locally advanced nasopharyngeal cancers. Strahlenther Onkol 2023; 199:910-921. [PMID: 37566126 DOI: 10.1007/s00066-023-02119-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE The aim of this retrospective study was to explore whether pretreatment Pan-Immune-Inflammation-Value (PIV) measurements might predict the risk of mandibular osteoradionecrosis (ORN) in patients receiving concurrent chemoradiotherapy (CCRT) for locally advanced nasopharyngeal cancer (LA-NPC). METHODS The platelet, monocyte, neutrophil, and lymphocyte counts acquired on the first day of CCRT were used to compute pretreatment PIV levels: PIV = (Platelets × Monocytes × Neutrophils) ÷ Lymphocytes. Receiver operating characteristic curve analysis was used to determine the association between ORN rates and PIV levels. Spearman correlation analysis was used to examine the probable intergroup correlations. The potential link between the pretreatment PIV levels and the post-treatment ORN rates was determined as the primary objective. RESULTS 21 (10.0%) of 210 eligible patients were diagnosed with ORN. The optimal pre-CCRT PIV cutoff was 833, which separated patients into two PIV groups with divergent ORN prevalence estimates: Group 1: PIV < 833 (N = 153), and Group 2: PIV ≥ 833 (N = 57). The comparison analysis found that the PIV ≥ 833 cohort had significantly higher ORN rates than the PIV < 833 cohort (29.8% vs. 2.6%; P < 0.001). Other characteristics linked to significantly higher ORN rates were the patient's continuing smoking, the use of the Three-dimensional conformal radiation therapy technique, the mean mandibular dose of ≥ 58.1 Gy, the number of tooth extractions before CCRT ≥ 4, and the presence of tooth extractions after CCRT. The independent importance of all factors on higher ORN occurrence rates were retained in multivariate analysis (P < 0.05). CONCLUSIONS Our findings revealed a strong link between aggravated inflammatory response and ORN genesis, with high pretreatment PIV levels related to significantly higher ORN rates.
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Affiliation(s)
- Busra Yilmaz
- Department of Oral and Maxillofacial Radiology, School of Dental Medicine, Bahcesehir University, Istanbul, Turkey.
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Ahmet Kucuk
- Department of Radiation Oncology, Mersin City Hospital, Mersin, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey
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9
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Li CX, Sun JL, Gong ZC, Liu H, Ding MC, Zhao HR. An umbrella review exploring the effect of radiotherapy for head and neck cancer patients on the frequency of jaws osteoradionecrosis. Cancer Radiother 2023; 27:434-446. [PMID: 37268457 DOI: 10.1016/j.canrad.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 06/04/2023]
Abstract
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.
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Affiliation(s)
- C X Li
- Department of Oral and Maxillofacial Oncology & Surgery, Xinjiang Medical University Affiliated First Hospital, Urumqi 830054, China; School/Hospital of Stomatology, Xinjiang Medical University, Urumqi 830011, China; Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi 830054, China.
| | - J-L Sun
- Department of Preventive Medicine, School of Medicine, Shihezi University, Shihezi 832003, China
| | - Z-C Gong
- Department of Oral and Maxillofacial Oncology & Surgery, Xinjiang Medical University Affiliated First Hospital, Urumqi 830054, China; School/Hospital of Stomatology, Xinjiang Medical University, Urumqi 830011, China; Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi 830054, China.
| | - H Liu
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai 200003, China; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai 200433, China
| | - M-C Ding
- State Key Laboratory of Military Stomatology, National Clinical Research Center for Oral Diseases, Shaanxi Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, School of Stomatology, The Fourth Military Medical University, Xi'an 710032, China
| | - H-R Zhao
- The First Ward of Oncological Department, Cancer Center, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China.
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10
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Sijtsema ND, Verduijn GM, Nasserinejad K, van Norden Y, Mast H, van der Lugt A, Hoogeman MS, Petit SF. Development of a local dose-response relationship for osteoradionecrosis within the mandible. Radiother Oncol 2023; 186:109736. [PMID: 37315578 DOI: 10.1016/j.radonc.2023.109736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE Osteoradionecrosis (ORN) of the mandible is a severe complication following radiotherapy of the head and neck, but not all regions of the mandible may be equally at risk. Therefore our goal was to explore a local dose response relationship for subregions of the mandible. MATERIALS AND METHODS All oropharyngeal cancer patients treated at our hospital between 2009 and 2016 were reviewed. Follow-up was cut-off at 3 years. For patients that developed ORN, the ORN volume was delineated on the planning CT. Each mandible was divided into 16 volumes of interest (VOIs) based on the location of the dental elements and the presence of ORN in each was scored. Generalized estimating equations were used to build a model for the probability of developing ORN in an element VOI. RESULTS Of the 219 included patients, 22 developed ORN in 89 element VOIs. Mean dose to the element VOI (odds ratio (OR) = 1.05 per Gy, 95% confidence interval (CI): (1.04,1.07)), pre-radiotherapy extractions of an element ipsilateral to element of interest (OR = 2.81, 95% CI: (1.12,7.05)), and smoking at start of radiotherapy (OR = 3.37, 95% CI: (1.29,8.78)) were significantly associated with an increased probability of ORN in the VOI. CONCLUSION The developed dose-response model indicates that the probability of ORN varies within the mandible and strongly depends on the local dose, the location of extractions, and smoking.
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Affiliation(s)
- Nienke D Sijtsema
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Gerda M Verduijn
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Kazem Nasserinejad
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Innovative Statistical Consulting, Therapeutics Development Team, Cytel Inc., Cambridge, MA, USA
| | - Yvette van Norden
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hetty Mast
- Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mischa S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics and Informatics, HollandPTC, Delft, The Netherlands
| | - Steven F Petit
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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11
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Topkan E, Kucuk A, Somay E, Yilmaz B, Pehlivan B, Selek U. Review of Osteoradionecrosis of the Jaw: Radiotherapy Modality, Technique, and Dose as Risk Factors. J Clin Med 2023; 12:3025. [PMID: 37109361 PMCID: PMC10143049 DOI: 10.3390/jcm12083025] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
Radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) is the cornerstone of organ-sparing or adjuvant therapy for nearly all head and neck cancers. Unfortunately, aggressive RT or CCRT can result in severe late toxicities, such as osteoradionecrosis of the jaws (ORNJ). The incidence of ORNJ is currently less than 5-6% due to advances in dental preventive care programs, RT planning systems, and RT techniques. Although numerous patient-, tumor-, and treatment-related factors may influence the incidence rates of ORNJ, RT modality (equipment), technique, and dose-volume-related factors are three of the most influential factors. This is mainly because different RT equipment and techniques have different levels of success at delivering the prescribed dose to the focal volume of the treatment while keeping the "organ at risk" safe. ORNJ risk is ultimately determined by mandibular dose, despite the RT technique and method being known predictors. Regardless of the photon delivery method, the radiobiological effects will be identical if the total dose, dose per fraction, and dose distribution within the tissue remain constant. Therefore, contemporary RT procedures mitigate this risk by reducing mandibular dosages rather than altering the ionizing radiation behavior in irradiated tissues. In light of the paucity of studies that have examined the impact of RT modality, technique, and dose-volume-related parameters, as well as their radiobiological bases, the present review aims to provide a comprehensive overview of the published literature on these specific issues to establish a common language among related disciplines and provide a more reliable comparison of research results.
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Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Medical Faculty, Baskent University, Adana 01120, Turkey
| | - Ahmet Kucuk
- Clinics of Radiation Oncology, Mersin City Education and Research Hospital, Mersin 33160, Turkey
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara 06490, Turkey
| | - Busra Yilmaz
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Baskent University, Ankara 06490, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul 34349, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul 34450, Turkey
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, TX 77030, USA
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12
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Yilmaz B, Somay E, Topkan E, Kucuk A, Pehlivan B, Selek U. The predictive value of pretreatment hemoglobin-to-platelet ratio on osteoradionecrosis incidence rates of locally advanced nasopharyngeal cancer patients managed with concurrent chemoradiotherapy. BMC Oral Health 2023; 23:231. [PMID: 37081475 PMCID: PMC10116666 DOI: 10.1186/s12903-023-02937-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 04/04/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND This retrospective study aimed to investigate whether the pretreatment hemoglobin-to-platelet ratio (HPR) could predict the risk of osteoradionecrosis (ORN) in patients receiving concurrent chemoradiotherapy (C-CRT) for locally advanced nasopharyngeal carcinoma (LA-NPC). METHODS ORN cases were reported from the records of LA-NPC patients who had oral examinations before and after C-CRT. The pretreatment HPR values were calculated on the first day of C-CRT. The connection between HPR values and ORN occurrences was determined using receiver operating characteristic curve analysis. The primary endpoint was the relationship between the pretreatment HPR values and post-C-CRT ORN incidence rates, while secondary endpoints included the identification of other putative ORN risk factors. RESULTS We distinguished 10.9% incidences of ORN during the post-C-CRT follow-up period among 193 LA-NPC patients. The optimal cutoff for pre-C-CRT HPR was 0.48 that grouped the patients into two HPR groups with fundamentally different post-C-CRT ORN incidence rates: Group 1: HPR ≤ 0.48 (N = 60), and Group 2: HPR > 0.48 (N = 133). The comparative analysis indicated a significantly higher ORN incidence in HPR ≤ 0.48 group (30%; P < 0.001). The other factors associated with meaningfully increased ORN rates included the presence of pre-C-CRT ≥ 5 teeth extractions, mandibular volume receiving ≥ 64 Gy, post-C-CRT tooth extractions, mean mandibular dose ≥ 50.6 Gy, and C-CRT to tooth extraction interval > 5.5 months. CONCLUSION Low pretreatment HPR levels were independently and unequivocally linked to significantly increased incidence of ORN post-C-CRT. Pre-C-CRT HPR levels may be used to estimate the incidence of ORN and be useful for taking preventive and therapeutic measures in these patients such as monitoring oral hygiene with strict follow-up, avoidance of unnecessary tooth extractions, particularly after C-CRT, and use of more rigorous mandibular RT dose limits.
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Affiliation(s)
- Busra Yilmaz
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, 01120, Turkey.
| | - Ahmet Kucuk
- Department of Radiation Oncology, Mersin City Hospital, Mersin, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey
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Topkan E, Yilmaz B, Somay E, Kucuk A. RE: Is Dose Volume a Better Predictor of Osteoradionecrosis Risk Than Total Dose for Patients Who Have Received Head and Neck Radiation? J Oral Maxillofac Surg 2023; 81:3. [PMID: 36596618 DOI: 10.1016/j.joms.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 08/27/2022] [Indexed: 01/02/2023]
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14
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Singh A, Huryn JM, Kronstadt KL, Yom SK, Randazzo JR, Estilo CL. Osteoradionecrosis of the jaw: A mini review. FRONTIERS IN ORAL HEALTH 2022; 3:980786. [PMID: 35967463 PMCID: PMC9366306 DOI: 10.3389/froh.2022.980786] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/11/2022] [Indexed: 11/29/2022] Open
Abstract
Osteoradionecrosis (ORN) of the jaw is one of the most dreaded complications of head and neck radiation therapy. Despite the evolution of radiation treatment modalities, ORN continues to remain a therapeutic challenge and its etiopathogenesis still remains unclear. It is clinically characterized by exposed necrotic bone within the head and neck radiation field. Over the past years, several studies have reported on the definition, staging, incidence, etiology, and management of this oral complication. In this review, we summarize the literature on ORN and discuss our institutional experience and management strategies that aim to predict and mitigate risk for ORN.
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