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Cheng M, Jiang Y, Wang Y, Wu Y, Zhu Y. Enhancing osteosarcoma therapy through aluminium hydroxide nanosheets-enabled macrophage modulation. Int J Pharm 2024; 649:123640. [PMID: 38043749 DOI: 10.1016/j.ijpharm.2023.123640] [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: 10/12/2023] [Revised: 11/21/2023] [Accepted: 11/25/2023] [Indexed: 12/05/2023]
Abstract
Chemotherapy in osteosarcoma treatment has long been stagnating, leaving challenges in the treatment of patients with metastatic and recurrent osteosarcoma. Modulation of macrophages in the tumour microenvironment offers great opportunities to elicit a durable antitumour effect. Here, we employed aluminium hydroxide nanosheets (nAl) to co-deliver the chemotherapy drug doxorubicin (DOX) and immune modulator zoledronic acid (ZA). The hexagon nAl was obtained by a facile approach, with a high positive surface charge for the loading of ZA. With 37% and 8.5% payloads to ZA and DOX, the formed nAl/ZD showed efficient cell growth inhibition to LM8 osteosarcoma cells, and preferential M1 polarization induction to RAW 264.7 macrophage cells. Furthermore, enhanced antitumour effect was observed with nAl/ZD-enabled macrophage activation in the LM8/RAW 264.7 co-culture model. Our results may inspire new treatment strategies for osteosarcoma.
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Affiliation(s)
- Min Cheng
- College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing 211816, China
| | - Yi Jiang
- College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing 211816, China
| | - Ying Wang
- College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing 211816, China
| | - Yilun Wu
- College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing 211816, China.
| | - Yishen Zhu
- College of Biotechnology and Pharmaceutical Engineering, Nanjing Tech University, Nanjing 211816, China.
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Kasper R, Scheurer M, Pietzka S, Sakkas A, Schramm A, Wilde F, Ebeling M. MRONJ of the Mandible—From Decortication to a Complex Jaw Reconstruction Using a CAD/CAM-Guided Bilateral Scapula Flap. Medicina (B Aires) 2023; 59:medicina59030535. [PMID: 36984535 PMCID: PMC10052135 DOI: 10.3390/medicina59030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 03/12/2023] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) has been an integral part of the maxillofacial patient population for some time. The therapeutic concept ranges from conservative approaches over less extended decortications to major jaw resections, which can result in a considerable loss of quality of life. Based on three case reports, this paper presents the long-term history of patients with MRONJ of the mandible, whose disease ultimately resulted in partial or total mandibular resection and subsequent multisegmental reconstruction using a microvascular anastomosed bone flap. Furthermore, a suitable alternative for complex mandibular reconstruction is demonstrated when using a free fibula flap is not possible. The options are limited, particularly when multisegmental restoration of mandibular continuity is required. One case presents a mandible reconstruction using a CAD/CAM-guided bilateral scapular free flap (CAD/CAM = Computer-Aided Design and Manufacturing), which has not been described for this purpose before. Due to the complexity, computer-assisted surgery and patient-specific implants seem reasonable, which is why a special focus was applied to this topic.
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Affiliation(s)
- Robin Kasper
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Correspondence:
| | - Mario Scheurer
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
| | - Sebastian Pietzka
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Andreas Sakkas
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Alexander Schramm
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Frank Wilde
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Marcel Ebeling
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
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Yanni A, Bouland C, Monteiro R, Rodriguez A, Loeb I, Javadian R, Dequanter D. Contribution of Antiangiogenic Agents to the Risk of Medication-related Osteonecrosis of the Jaw in Combination with Antiresorptive Agents: Preliminary Results in a Comparative Prospective Report of 59 Oncologic Cases. J Int Soc Prev Community Dent 2022; 12:564-570. [PMID: 36532328 PMCID: PMC9753918 DOI: 10.4103/jispcd.jispcd_110_22] [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: 05/02/2022] [Revised: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023] Open
Abstract
AIM The aim of this preliminary study was to evaluate in an oncological population the association risk of antiangiogenic (AA) agents to antiresorptive (AR) agents on the incidence and the severity of medication-related osteonecrosis of the jaw (MRONJ). MATERIALS AND METHODS In this prospective study, we reviewed the medical records and clinical variables of 59 consecutive oncologic patients who developed MRONJ. For all patients, we retrieved the following variables: age, gender, alcohol and tobacco use, type of cancer, use of corticosteroids for >3 months, history of diabetes, MRONJ staging, combination of AR and AA agents, dental history (surgery, prosthesis) or spontaneous, site of MRONJ, delay between AR and AA first intake, and MRONJ development. Patients were divided into two groups according to drugs therapy they underwent: group 1 (G1) including patients treated with AR agents alone and group 2 (G2) including patients receiving antiresorptive-antiangiogenic drugs (AR+AA). The degree and the therapeutical success were defined as primary outcomes and the number, the localization, and the delay in onset of the lesions as secondary outcomes. In order to identify predictive factors of osteonecrosis-free interval time, univariate and multivariate Cox regression was performed. Statistical tests were carried out using the IBM® SPSS® Statistics software. All reported P-values are two-tailed and were considered to be significant when less than 0.05. RESULTS Among the 47 patients who received AR agent alone (group 1), the mean treatment duration before diagnosis of MRONJ was 39.2 months. In the second group (n = 12), patients developed MRONJ with a comparable mean time of 55 months (P = 0.16). According to the staging of MRONJ at the time of diagnosis, no significant difference (P = 0.736) was observed between the two groups. Moreover, the treatment applied was not statistically different in both the groups and was successful in 36.17% of the patients in group 1 and 58.33% of the patients in group 2. No statistically difference was reported in both the groups (P = 0.16). After statistical analysis, no significant difference in terms of MRONJ localization (P = 0.13) was observed. Finally, the incidence of spontaneous MRONJ was comparable in both the groups. Statistical analysis revealed that total time of treatment was the only factor associated with poor osteonecrosis-free interval time (hazard ratio 0.99; P = 0.001). Interestingly, the combination of an AA and AR agent was not a significant predictor factor of the interval time before the diagnosis of osteonecrosis. Additionally, corticosteroid use, diabetes mellitus, and dental consultation before treatment were not statistically related to poorer osteonecrosis-free interval time rates. CONCLUSION In our preliminary study, neither the mean treatment time duration before the diagnosis of MRONJ nor the dose delivered was different in both the groups (AR vs. AR+AA). Moreover, no significant difference was observed between both the groups regarding the localization and the staging of MRONJ at the time of diagnosis. Interestingly, our results demonstrated that the risk of spontaneous MRONJ is statistically comparable in the AR and AR-AA groups. Additionally, the addition of an AA agent did not influence the treatment applied in the two groups of patients.
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Affiliation(s)
- Antoine Yanni
- Department of Stomatology—Maxillofacial Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Cyril Bouland
- Department of Stomatology—Maxillofacial Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Raquel Monteiro
- Department of Stomatology—Maxillofacial Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Alexandra Rodriguez
- Department of Otolaryngolology—Head and Neck Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Isabelle Loeb
- Department of Stomatology—Maxillofacial Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Rokneddine Javadian
- Department of Stomatology—Maxillofacial Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Didier Dequanter
- Department of Stomatology—Maxillofacial Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium,Department of Otolaryngolology—Head and Neck Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium,Address for correspondence: Prof. Didier Dequanter, Department of Stomatology-Maxillofacial Surgery, CHU Saint Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium. E-mail:
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4
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Williams DW, Ho K, Lenon A, Kim S, Kim T, Gwack Y, Kim RH. Long-Term Ligature-Induced Periodontitis Exacerbates Development of Bisphosphonate-Related Osteonecrosis of the Jaw in Mice. J Bone Miner Res 2022; 37:1400-1410. [PMID: 35598324 PMCID: PMC9386631 DOI: 10.1002/jbmr.4614] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 04/12/2022] [Accepted: 04/24/2022] [Indexed: 11/07/2022]
Abstract
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a detrimental intraoral lesion that occurs in patients with long-term or high-dose use of anti-resorptive agents such as bisphosphonates. Tooth extraction is a known risk factor for BRONJ, and such intervention is often performed to eliminate existing pathological inflammatory conditions. Previously, we determined that ligature-induced periodontitis (LIP) is a risk factor for the development of osteonecrosis in mice, but it remains unclear whether the chronicity of LIP followed by extraction influences osteonecrosis development. In this study, we assess the effect of short-term and long-term LIP (ligature placed for 3 weeks [S-LIP] or 10 weeks [L-LIP], respectively) on osteonecrosis development in mice receiving 250 μg/kg/week zoledronic acid (ZOL). When compared to S-LIP, L-LIP caused 70% (p ≤ 0.0014) more bone loss without altering microbe composition. In the presence of ZOL, bone loss mediated by LIP was prevented and bone necrosis was induced. When the ligated tooth was extracted, histologic hallmarks of osteonecrosis including empty lacunae and necrotic bone were increased by 88% (p = 0.0374) and 114% (p = 0.0457), respectively, in L-LIP compared to S-LIP. We also observed significant increases in serum platelet factor 4 (PF4) and macrophage inflammatory factor 1 γ (MIP1γ) in mice that received ZOL treatment and had tooth extractions compared to controls, which may be systemic markers of inflammation-associated osteonecrosis development. Additionally, CD3+ T cells were identified as the major immune population in both health and disease, and we observed a 116% (p = 0.0402) increase in CD3+IL23R+ T cells in L-LIP compared to S-LIP lesions following extraction. Taken together, our study reveals that extracting a periodontally compromised tooth increases the formation of necrotic bone compared to extracting a periodontally healthy tooth and that osteonecrosis may be associated with the duration of the preexisting pathological inflammatory conditions. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Drake Winslow Williams
- The Shapiro Family Laboratory of Viral Oncology and Aging Research, Los Angeles, CA, USA.,Section of Restorative Dentistry, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Katie Ho
- The Shapiro Family Laboratory of Viral Oncology and Aging Research, Los Angeles, CA, USA
| | - Allison Lenon
- The Shapiro Family Laboratory of Viral Oncology and Aging Research, Los Angeles, CA, USA
| | - Sol Kim
- The Shapiro Family Laboratory of Viral Oncology and Aging Research, Los Angeles, CA, USA.,Section of Restorative Dentistry, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Terresa Kim
- The Shapiro Family Laboratory of Viral Oncology and Aging Research, Los Angeles, CA, USA
| | - Yousang Gwack
- Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Reuben H Kim
- The Shapiro Family Laboratory of Viral Oncology and Aging Research, Los Angeles, CA, USA.,Section of Restorative Dentistry, UCLA School of Dentistry, Los Angeles, CA, USA.,UCLA Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, USA
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5
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Patel V, Patel S, Grossman S, Wali R, Burns M, Zebic L, Enting D, Henien M. The presenting dental status of solid tumours with bone metastases requiring bone-targeting agents - part 4: miscellaneous cancers. Br Dent J 2022; 232:213-218. [PMID: 35217738 DOI: 10.1038/s41415-022-3983-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/25/2021] [Indexed: 11/09/2022]
Abstract
This article discusses relevant information for the dental sector regarding metastatic cancers beyond breast and prostate cancer. Typically, tumour sites such as lung, renal, colorectal, gastrointestinal, thyroid, hepatic and pancreatic cancers are increasingly being referred for bone-targeting agents upon evidence of bone metastases.The current article explores the presenting dental status of these tumour groups on the background of survival outcomes. In addition, the article provides insight towards the complexity in achieving 'dental fitness' and whether 'dental stability' could be an alternative to consider via palliative dentistry in certain cases.
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Affiliation(s)
- Vinod Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK.
| | - Sheelen Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | | | - Rana Wali
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Megan Burns
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Lara Zebic
- Oral Surgery Department, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Deborah Enting
- Medical Oncology, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
| | - Marianne Henien
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, UK
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6
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Srivastava A, Gonzalez GMN, Geng Y, Won AM, Myers J, Li Y, Chambers MS. Medication-Related Osteonecrosis of the Jaw in Patients Treated Concurrently with Antiresorptive and Antiangiogenic Agents: Systematic Review and Meta-Analysis. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2021; 4:196-207. [PMID: 35665023 PMCID: PMC9138478 DOI: 10.36401/jipo-21-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/26/2021] [Accepted: 08/13/2021] [Indexed: 11/09/2022]
Abstract
ABSTRACT
Introduction
Medication-related osteonecrosis of the jaws (MRONJ) is a known adverse event related to the use of antiresorptive (AR) drugs. More recently, an association between antiangiogenic (AA) drugs and MRONJ has been suggested. This review aimed to investigate the overall prevalence and relative risk of MRONJ in patients treated concurrently with AA and AR agents in comparison with a single AA or AR drug.
Methods
A review protocol was registered with PROSPERO (ID: CRD42020214244). A systematic literature search, study selection, quality assessment, and data extraction were carried out following PRISMA guidelines. Random-effects meta-analysis models were used to summarize relative estimates for the outcomes, namely prevalence and relative risk of MRONJ. Exposure variable included type of drug, specifically AA and AR agents administered either concurrently or individually.
Results
Eleven studies were included in the final qualitative and quantitative syntheses. The overall pooled weighted prevalence of MRONJ with concurrent AA-AR drugs was 6% (95% CI: 3–8%), compared with 0% (95% CI: 0–0%) for AA only and 5% (95% CI: 0–10%) for AR only. However, high heterogeneity was noted among included studies. Retrospective cohort studies showed a higher pooled prevalence of 13% (95% CI: 10–17%) for concurrent AA-AR therapy. The pooled risk ratio for MRONJ revealed a risk with concurrent AA-AR drugs 2.57 times as high as with AR only (95% CI: 0.84–7.87); however, this difference was not statistically significant. Concurrent AA-AR drugs had a risk for MRONJ 23.74 times as high as with AA only (95% CI: 3.71–151.92).
Conclusions
High-quality, representative studies are needed for accurate estimation of relative risk of MRONJ with concurrent AA and AR therapy.
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Affiliation(s)
- Akanksha Srivastava
- Department of Restorative Dentistry and Prosthodontics, University of Texas Health Science Center at Houston School of Dentistry, Houston, TX, USA
- Present: Department of Surgery, College of Medicine, The University of Illinois at Chicago, Chicago, IL, USA
| | - Graciela M. Nogueras Gonzalez
- Department of Biostatistics, Division of Basic Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yimin Geng
- Research Medical Library, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Alexander M. Won
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Myers
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yisheng Li
- Department of Biostatistics, Division of Basic Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark S. Chambers
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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7
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Is Medication-Related Osteonecrosis of the Jaws (MRONJ) Associated to Cyclin-Dependent Kinase (CDK) 4/6 Inhibitors? A Word of Cautiousness. Comment on Marcianò et al. Medication-Related Osteonecrosis of the Jaws and CDK4/6 Inhibitors: A Recent Association. Int. J. Environ. Res. Public Health 2020, 17, 9509. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910143. [PMID: 34639444 PMCID: PMC8508584 DOI: 10.3390/ijerph181910143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/16/2021] [Indexed: 01/06/2023]
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8
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Sakkas A, Heil S, Kargus S, Rebel M, Mischkowski RA, Thiele OC. Tocilizumab: Another medication related to osteonecrosis of the jaws? A case report and literature review. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2021; 10:Doc03. [PMID: 33928006 PMCID: PMC8054499 DOI: 10.3205/iprs000153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients receiving antiresorptive medication, such as bisphosphonates and denosumab, for different oncologic and non-oncologic diseases. Here, we report a case of MRONJ in a patient treated with tocilizumab, a humanized anti-interleukin-6 receptor antibody that effectively treats moderate to severe rheumatoid arthritis in adults. Case description: A 45-year-old female patient diagnosed with severe rheumatoid arthritis, who had been undergoing intravenous tocilizumab therapy for three years without history of bisphosphonate use, was referred to our department. Four weeks previously, several teeth in the maxilla and mandible were removed under local anesthesia by her dentist. Two weeks after the extractions, she felt pain in both jaws. We diagnosed wound dehiscence and delayed healing of the alveolar bone after the tooth extractions. Digital volume tomography showed persistent dry alveolar sockets. The patient underwent surgical debridement of necrotic bone, and intravenous antibiotics were administered in hospital. Five months later, wound dehiscence reoccurred in the same regions. Histopathological analysis of bone biopsies revealed a diagnosis of MRONJ. Four months later, wound dehiscence occurred in the left maxillary alveolar ridge, and local bone resection was performed under antibiotic treatment. Twenty-four months after the last surgery, wound dehiscence had healed completely without signs of recurrence. Discussion: Osteomyelitis of the jaw in patients treated with tocilizumab has not been reported often. This case confirms the potential role of this interleukin-6 receptor inhibitor in the pathogenesis of MRONJ and shows that patients who receive tocilizumab with MRONJ-like symptoms should be closely monitored. The pathomechanism of MRONJ under tocilizumab therapy remains unclear, so dental practitioners, maxillofacial surgeons, and rheumatologists should look for signs of MRONJ in patients receiving tocilizumab to prevent MRONJ onset.
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Affiliation(s)
- Andreas Sakkas
- Department of Oral, Maxillofacial and Facial Plastic Surgery, Ludwigshafen Hospital, Ludwigshafen, Germany
| | - Sebastian Heil
- Department of Oral, Maxillofacial and Facial Plastic Surgery, Ludwigshafen Hospital, Ludwigshafen, Germany
| | - Steffen Kargus
- Department of Oral, Maxillofacial and Facial Plastic Surgery, Ludwigshafen Hospital, Ludwigshafen, Germany
| | - Martin Rebel
- Department of Pathology, Ludwigshafen Hospital, Ludwigshafen, Germany
| | - Robert A Mischkowski
- Department of Oral, Maxillofacial and Facial Plastic Surgery, Ludwigshafen Hospital, Ludwigshafen, Germany
| | - Oliver C Thiele
- Department of Oral, Maxillofacial and Facial Plastic Surgery, Ludwigshafen Hospital, Ludwigshafen, Germany
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9
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Kanwar N, Bakr MM, Meer M, Siddiqi A. Emerging therapies with potential risks of medicine-related osteonecrosis of the jaw: a review of the literature. Br Dent J 2021; 228:886-892. [PMID: 32541753 DOI: 10.1038/s41415-020-1642-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In the past, osteonecrosis of the jaw (ONJ) was generally reported with bisphosphonate drugs; hence, the term BRONJ (bisphosphonate-related osteonecrosis of the jaw) was initially proposed. This was followed by the term ARONJ (antiresorptive osteonecrosis of the jaw). More recently, other novel medications such as vascular endothelial growth factor (VEGF) inhibitors, tyrosine kinase inhibitors and humanised antibodies that affect osteoclastic action have been reported to initiate ONJ in several cases. For this reason, in 2014, the American Association of Oral and Maxillofacial Surgeons (AAOMS) changed the term to MRONJ - medication-related osteonecrosis of the jaw. The review primarily focuses on ONJ associated with emerging therapies for the management of bone disorders. This article sheds some light on the risk factors that predispose dental patients to the development of osteonecrosis, the mechanisms of drug therapies associated with MRONJ, and potential treatment and management regimes for MRONJ patients. The current review noted that the incidence and associated risk of MRONJ is significant with the new therapeutic agents discussed. Therefore, for optimised patient care, pharmacovigilance with the new medications is essential for dental professionals.
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Affiliation(s)
- Nupur Kanwar
- General Dentist, School of Dentistry and Oral Health, Griffith University, Queensland, 4222, Australia
| | - Mahmoud M Bakr
- Director of Clinical Education (Dentistry), Senior Lecturer, General Dental Practice, School of Dentistry and Oral Health, Griffith University Queensland, 4222, Australia
| | - Mohammed Meer
- Senior Lecturer, Oral and Maxillofacial Surgery, School of Dentistry and Oral Health, Griffith University, Queensland, 4222, Australia
| | - Allauddin Siddiqi
- Department of Periodontics, School of Dentistry and Oral Health, Griffith University, Queensland, 4222, Australia.
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10
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Awareness among patient at risk of developing Medication Related Osteonecrosis of the Jaw (MRONJ) - A primary prevention strategy. Saudi Pharm J 2020; 28:771-778. [PMID: 32550810 PMCID: PMC7292880 DOI: 10.1016/j.jsps.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/06/2020] [Indexed: 12/26/2022] Open
Abstract
The quality of life, in itself, in cancer patients or in osteoporotic individuals, without even considering the side effects of the medication in the first place, has a considerable negative impact on the clinical outcome. The Medication Related Osteonecrosis of the Jaw (MRONJ), in the maxillofacial region, although rare, needs to be addressed with the prime importance. One of the key components of any given preventive treatment strategy is to, create awareness about the medication related unwanted effects, among health care professionals and patients. Objective This study is aimed to explore and assess the awareness level among dental patients about MRONJ, the risk factors, and the high-risk category (who are prone to develop MRONJ). Material and methods This is a prospective interviewer administered research electronic data capture (REDCap) survey. The sample included 68 patients, who are currently taking or will be taking Bisphosphonate (BP), and/or Denosumab, and anti-Angiogenic agent. Data have been analyzed using IBM SPSS software, Results Sixty-eight patients (18 males and 50 females), participated in this study. Only 23 subjects (33.82%) were aware about the MRONJ. Females were more aware about the complications than males. The awareness among the subjects with education at college level appears to be higher than the subjects having education less than high school level. Even though, a dental check- up, is mandatory, prior to starting these medications, to see if any dental treatment is required, only slightly more than half of the patients (54.72%) had a dental checkup. Conclusion This is a novel study in the Middle- East, used to assess awareness about the MRONJ including three type of related medications. Low awareness of MRONJ is alarming. The results of the study will help to initiate the process of providing the education materials, about the side effects and importance of oral hygiene maintenance, giving priority to improve the quality of life in such patients. Awareness of patients regarding the complications must be an important part of health care practice guidelines.
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11
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Messer JG, Castillo EJ, Abraham AM, Jiron JM, Israel R, Yarrow JF, Thomas S, Reynolds MC, Wnek RD, Jorgensen M, Wanionok N, Van Poznak C, Bhattacharyya I, Kimmel DB, Aguirre JI. Anti-vascular endothelial growth factor antibody monotherapy causes destructive advanced periodontitis in rice rats (Oryzomys palustris). Bone 2020; 130:115141. [PMID: 31707108 PMCID: PMC6941430 DOI: 10.1016/j.bone.2019.115141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/15/2019] [Accepted: 11/04/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Angiogenesis inhibitors (AgI) are commonly used in combination chemotherapy protocols to treat cancer, and have been linked to osteonecrosis of the jaw (ONJ). However, it is unknown if AgI therapy alone is sufficient to induce ONJ. We have previously established an ONJ model in rice rats with localized periodontitis that receive zoledronic acid (ZOL). The purpose of this study was to use this model to determine the role of anti-vascular endothelial growth factor A (anti-VEGF) antibody treatment of rice rats with localized maxillary periodontitis. We hypothesized that rice rats with localized maxillary periodontitis given anti-VEGF monotherapy will develop oral lesions that resemble ONJ, defined by exposed, necrotic alveolar bone. METHODS At age 4 weeks, 45 male rice rats were randomized into three groups (n = 15): 1) VEH (saline), 2) ZOL (80 μg/kg body weight, intravenously once monthly), and 3) anti-VEGF (5 mg B20-4.1.1/kg body weight, subcutaneously twice weekly). After 24 weeks, rats were euthanized, jaws were excised and a high-resolution photograph of each quadrant was taken to assign a severity grade based on gross appearance. Jaws were then fixed, scanned by MicroCT, decalcified and sectioned for histopathologic and immunohistochemical analyses. RESULTS 40-80% of the rats in the three groups developed gross oral lesions. 50% of ZOL rats developed ONJ. In contrast, 80% of the anti-VEGF rats developed destructive advanced periodontitis that was characterized by extreme alveolar bone loss and fibrosis. Anti-VEGF rats never developed exposed, necrotic bone. Furthermore, only anti-VEGF rats developed mild to severe mandibular periodontitis. Compared to VEH rats, more T-cells were found in periodontal lesions of anti-VEGF rats and more cells of the monocyte lineage were found in ONJ lesions of ZOL rats. CONCLUSIONS Anti-VEGF monotherapy administered to a validated rodent model of ONJ caused a destructive advanced form of periodontitis that differed significantly from ONJ.
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Affiliation(s)
- J G Messer
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - E J Castillo
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - A M Abraham
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - J M Jiron
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - R Israel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - J F Yarrow
- Research Service, VA Medical Center, Gainesville, FL, United States of America; Division of Endocrinology, Diabetes, and Metabolism, University of Florida College of Medicine, Gainesville, FL, United States of America.
| | - S Thomas
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - M C Reynolds
- Research Service, VA Medical Center, Gainesville, FL, United States of America
| | - R D Wnek
- Research Service, VA Medical Center, Gainesville, FL, United States of America
| | - M Jorgensen
- Department of Pediatrics, College of Medicine, UF, United States of America.
| | - N Wanionok
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America
| | - C Van Poznak
- University of Michigan, Ann Arbor, MI, United States of America.
| | - I Bhattacharyya
- Department of Oral & Maxillofacial Diagnostic Sciences, College of Dentistry, UF, United States of America.
| | - D B Kimmel
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
| | - J I Aguirre
- Department of Physiological Sciences, University of Florida (UF), Gainesville, FL, United States of America.
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Oliveira LJC, Canedo FSNA, Sacardo KP, Alessi JVM, Barbosa FG, Shimada AK, Katz A. Bevacizumab-associated osteonecrosis of the femur and tibia. Oxf Med Case Reports 2019; 2019:omz040. [PMID: 31198576 PMCID: PMC6544424 DOI: 10.1093/omcr/omz040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/27/2019] [Accepted: 04/05/2019] [Indexed: 11/13/2022] Open
Abstract
Osteonecrosis is a multifactorial process that can affect different skeletal structures of the body. Osteonecrosis of the jaw associated with bevacizumab, steroids and bisphosphonates, alone or in combination, is a well-documented phenomenon. There are few cases of involvement of the appendicular skeleton. Magnetic resonance imaging is the most sensitive method for diagnosis. We hereby report two cases of osteonecrosis in the right tibia and in bilateral femoral heads in patients with adenocarcinoma of the lung and ovarian papillary serous carcinoma, respectively, that developed the complication after long-term bevacizumab exposure. Long-term exposure to antiangiogenic treatment may be a potential risk factor. Oncologists should be aware that osteonecrosis is a rare but real toxicity associated with bevacizumab and other antiangiogenics, which can occur in locations different from the jaw.
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Affiliation(s)
| | | | | | | | - Felipe G Barbosa
- Radiology and Nuclear Medicine Service, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Artur Katz
- Oncology Center, Hospital Sírio-Libanês, São Paulo, Brazil
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13
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Affiliation(s)
- Lara Zebic
- Oral Surgery Department, Birmingham Dental Hospital, Birmingham B5 7EG, UK
| | - Vinod Patel
- Oral Surgery Department, Guy's Dental Hospital, London SE1 9RT, UK
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Wang QZ, Liu JY, Pan J. [Progress on medication-related osteonecrosis of the jaw]. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2019; 36:568-572. [PMID: 30465354 DOI: 10.7518/hxkq.2018.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a severe complication of bisphosphonates (BPs) or other targeted agent therapies. MRONJ appears as exposed bone, pus, and swelling in the oral and maxillofacial regions. However, neither surgery nor conservative therapy can eliminate symptoms thoroughly. In addition to BPs, several antiresorptive and antiangiogenic agents, such as denosumab and bevacizumab, as well as targeted agents, such as sunitinib and temsirolimus, can cause osteonecrosis of the jaw according to the literature. This review aims to summarize the research progress on these new drugs.
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Affiliation(s)
- Qi-Zhang Wang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Ji-Yuan Liu
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Jian Pan
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
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15
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King R, Tanna N, Patel V. Medication-related osteonecrosis of the jaw unrelated to bisphosphonates and denosumab-a review. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 127:289-299. [PMID: 30713092 DOI: 10.1016/j.oooo.2018.11.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/22/2018] [Accepted: 11/23/2018] [Indexed: 01/23/2023]
Abstract
The link between medication-related osteonecrosis of the jaw (MRONJ) and bone modulating drugs, such as bisphosphonates and denosumab, is well established, and the number of reported cases is increasing. The development of novel medications used in the treatment of cancer, as well as autoimmune and bone conditions, has led to more cases of MRONJ being reported. However, in addition to this group of medications, increasing numbers of new agents in cancer therapy, such as antiangiogenic agents, have also been implicated in the development of MRONJ. As these newer agents with similar mechanisms are routinely used, the numbers of reported cases will likely rise further. This article aims to identify and summarize the drugs implicated in MRONJ, besides bisphosphonates and denosumab. A wide range of medications classified as tyrosine kinase inhibitors, monoclonal antibodies, mammalian target of rapamycin inhibitors, radiopharmaceuticals, selective estrogen receptor modulators, and immunosuppressants have been implicated in MRONJ. It remains crucial that oral health care providers are aware of these new medications and their associated risks to manage their patients appropriately.
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Affiliation(s)
- Rebecca King
- DCT2 (Oral Surgery), Oral Surgery Department, Guys Dental Institute, Guys & St. Thomas NHS Foundation Trust, London, UK
| | - Nikki Tanna
- Consultant (Oral Surgery), Oral Surgery Department, Eastman Dental Hospital, London, UK
| | - Vinod Patel
- Consultant (Oral Surgery), Oral Surgery Department, Guys Dental Institute, Guys & St. Thomas NHS Foundation Trust, London, UK.
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Khominsky A, Lim MAWT. “Spontaneous” medication-related osteonecrosis of the jaw; two case reports and a systematic review. Aust Dent J 2018; 63:441-454. [DOI: 10.1111/adj.12648] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2018] [Indexed: 11/30/2022]
Affiliation(s)
- A Khominsky
- Dental Unit; The Alfred Hospital; Prahran Victoria Australia
| | - MAWT Lim
- Dental Unit; The Alfred Hospital; Prahran Victoria Australia
- Melbourne Dental School; Royal Dental Hospital of Melbourne; Carlton Victoria Australia
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Favia G, Tempesta A, Limongelli L, Crincoli V, Iannone F, Lapadula G, Maiorano E. A Case of Osteonecrosis of the Jaw in a Patient with Crohn's Disease Treated with Infliximab. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1351-1356. [PMID: 29257800 PMCID: PMC5737229 DOI: 10.12659/ajcr.905355] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Gianfranco Favia
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, "Aldo Moro" University, Bari, Italy
| | - Angela Tempesta
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, "Aldo Moro" University, Bari, Italy
| | - Luisa Limongelli
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, "Aldo Moro" University, Bari, Italy
| | - Vito Crincoli
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, "Aldo Moro" University, Bari, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantation, Operating Unit of Rheumatology, "Aldo Moro" University, Bari, Italy
| | - Giovanni Lapadula
- Department of Emergency and Organ Transplantation, Operating Unit of Rheumatology, "Aldo Moro" University, Bari, Italy
| | - Eugenio Maiorano
- Department of Emergency and Organ Transplantation, Operating Unit of Pathological Anatomy, "Aldo Moro" University, Bari, Italy
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Patel V, Sproat C, Kwok J, Tanna N. Axitinib-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 124:e257-e260. [DOI: 10.1016/j.oooo.2017.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 11/16/2022]
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19
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Incidence of medication-related osteonecrosis of the jaw in patients treated with both bone resorption inhibitors and vascular endothelial growth factor receptor tyrosine kinase inhibitors. Support Care Cancer 2017; 26:869-878. [DOI: 10.1007/s00520-017-3903-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
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20
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Berquet A, Louvrier A, Denis F, Bornert F, Weber E, Meyer C. [Evaluation of healing time of osteochemonecrosis of the jaw after surgery: Single-center retrospective study and review of the literature]. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017; 118:11-19. [PMID: 28330568 DOI: 10.1016/j.jormas.2016.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 10/17/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Osteochemonecrosis of the jaw (ONJ) is a chronic ischemic bone exposure. It has an increasing incidence. ONJ is mainly related to bisphosphonate and denosumab therapies in oncologic settings. Healing is considered uncertain ad as occurring slowly. International recommendations suggest to treat ONJ symptomatically in a first attempt. A surgical procedure, potentially aggressive, should be carefully weight up in patients in poor condition and whose life expectancy is often limited. However, surgical treatment seems to allow for a high rate of clinical remission. Postoperative remission periods, when mentioned in the studies, are disparate. The aim of our study was to clarify the remission period of ONJ after surgical management. METHOD A retrospective study was conducted on all patients operated for an ONJ at stage 2 and 3 in the Department for Oral and Maxillofacial Surgery - University Hospital of Besançon (France) from January 2006 to September 2015. Healing was defined as complete mucosal closure and asymptomatic site. Stage of the disease, the number and the type of surgery and the time between the last operation and the healing was noticed. These data were compared to an exhaustive review of the literature on PubMed with the following key-words: "osteonecrosis" AND "jaw" AND "surgery" AND "management". Only the articles giving the healing period were included. RESULTS Regarding the single-center retrospective study, the files of 23 patients could be included. Fifteen percent of the patients benefited from several procedures under general anesthesia. Twenty percent had a stage 3 ONJ and 80 % had a stage 2 ONJ. Twenty-five interventions were performed on 23 sites in 20 patients. Immediate healing after surgery occurred in 35 % of the patients. At 6 months after surgery, 57 % of the treated areas were healed. Twenty percent of the patients had died. The healing rate did not improve further after 6 months postoperatively. Regarding the review of the literature, 7 articles could be included. The mean postoperative healing period was 60.7 % at 6 months, 71.1 % at 12 months and 69.5 % at 18 months. DISCUSSION Our study shows that the postoperative healing rate of ONJ lies between 57 and 66.7 % at 6 months and that this rate was optimized in the order of 10 % to 12months and stable at 18months postoperatively. The ONJ of our series were partially or fully linked to other drugs than bisphosphonates in 70 % of the cases: 50 % were related to denosumab, alone or in combination and 35 % were related to an association with antiangiogenics, bevacizumab mainly.
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Affiliation(s)
- A Berquet
- Département d'odontologie et de chirurgie orale, CHU François Mitterrand, Dijon, France; Département de chirurgie maxillo-faciale, stomatologie et odontologie hospitalière, CHRU Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25030 Besançon, France.
| | - A Louvrier
- Faculté de médecine, université de Franche-Comté, Besançon, France; Département de chirurgie maxillo-faciale, stomatologie et odontologie hospitalière, CHRU Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25030 Besançon, France
| | - F Denis
- Département de chirurgie orale, service d'odontologie, hôpital de la Maison-Blanche, université Champagne-Ardennes, Reims, France; EA 481 neurosciences intégratives et cliniques, Besançon, France; Centre hospitalier La Chartreuse, 21033 Dijon, France
| | - F Bornert
- Inserm (French National Institute of Health and Medical Research), "Osteoarticular and Dental Regenerative Nanomedicine" laboratory, UMR 1109, faculté de médecine, FMTS, 67085 Strasbourg cedex, France; Université de Strasbourg, faculté de chirurgie dentaire, Strasbourg, France; Pôle de médecine et de chirurgie bucco-dentaires, unité de pathologie-chirurgie buccale, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - E Weber
- Département de chirurgie maxillo-faciale, stomatologie et odontologie hospitalière, CHRU Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25030 Besançon, France; EA 4662 Nanomedicine Lab, université de Franche-Comté, 25000 Besançon, France
| | - C Meyer
- Département d'odontologie et de chirurgie orale, CHU François Mitterrand, Dijon, France; Département de chirurgie maxillo-faciale, stomatologie et odontologie hospitalière, CHRU Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25030 Besançon, France; EA 4662 Nanomedicine Lab, université de Franche-Comté, 25000 Besançon, France
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Ruhin B. [Not Available]. REVUE DE STOMATOLOGIE, DE CHIRURGIE MAXILLO-FACIALE ET DE CHIRURGIE ORALE 2016; 117:363-365. [PMID: 27364432 DOI: 10.1016/j.revsto.2016.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/03/2016] [Indexed: 06/06/2023]
Affiliation(s)
- B Ruhin
- Pathologies osseuses des mâchoires, service de chirurgie maxillo-faciale et de stomatologue, hôpital de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris, France.
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Current Controversies on the Pathogenesis of Medication-Related Osteonecrosis of the Jaw. Dent J (Basel) 2016; 4:dj4040038. [PMID: 29563480 PMCID: PMC5806951 DOI: 10.3390/dj4040038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 10/11/2016] [Accepted: 10/21/2016] [Indexed: 11/17/2022] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) was first reported more than a decade ago. Since then, numerous cases have been diagnosed. Currently, there are three groups of drugs related to MRONJ: bisphosphonates, denosumab and anti-angiogenic drugs. As MRONJ can lead to debilitating clinical sequels and limited effective treatment options are available, much research has been done in understanding its pathophysiology. Until now, the exact pathogenesis of MRONJ has not been fully elucidated. While history of invasive dental procedures or local trauma may be present, some cases occur spontaneously without any preceding factors. This review aims to examine and discuss the three main hypotheses for the pathogenesis of MRONJ, namely suppressed bone turnover, cellular toxicity and infection.
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Fantasia JE. The Role of Antiangiogenic Therapy in the Development of Osteonecrosis of the Jaw. Oral Maxillofac Surg Clin North Am 2016; 27:547-53. [PMID: 26515736 DOI: 10.1016/j.coms.2015.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There is an increasing use of established and newer medications that have antiangiogenic properties. Inhibition of angiogenesis likely has either a primary or secondary role in the development of osteonecrosis of the jaw (ONJ). These medications are being used in the treatment of various cancers and in the treatment of several non-oncologic conditions. Antiangiogenic medications when used in combination with antiresorptive medications, such as nitrogen-containing bisphosphonates or denosumab, seem to increase the likelihood of osteonecrosis of the jaw. This review highlights the role of inhibitors of angiogenesis and their role in the development of osteonecrosis of the jaws.
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Affiliation(s)
- John E Fantasia
- Division of Oral and Maxillofacial Pathology, Department of Dental Medicine, Hofstra North Shore-LIJ School of Medicine, 270-05 76th Avenue, New Hyde Park, NY 11040, USA.
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Córdova LA, Guilbaud F, Amiaud J, Battaglia S, Charrier C, Lezot F, Piot B, Redini F, Heymann D. Severe compromise of preosteoblasts in a surgical mouse model of bisphosphonate-associated osteonecrosis of the jaw. J Craniomaxillofac Surg 2016; 44:1387-94. [PMID: 27519659 DOI: 10.1016/j.jcms.2016.07.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 06/06/2016] [Accepted: 07/15/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The effect of amino-bisphosphonates on osteoblastic lineage and its potential contribution to the pathogenesis of bisphosphonate-associated osteonecrosis of the jaw (BONJ) remain controversial. We assessed the effects of zoledronic acid (ZOL) on bone and vascular cells of the alveolar socket using a mouse model of BONJ. MATERIAL AND METHODS Thirty-two mice were treated twice a week with either 100 μg/kg of ZOL or saline for 12 weeks. The first left maxillary molar was extracted at the third week. Alveolar sockets were assessed at both 3 weeks (intermediate) and 9 weeks (long-term) after molar extraction by semi-quantitative histomorphometry for empty lacunae, preosteoblasts (Osterix), osteoclasts (TRAP), and pericyte-like cells (CD146). Also, the bone microarchitecture was assessed by micro-CT. RESULTS Osteonecrotic-like lesions were observed in 21% of mice. Moreover, a decreased number of preosteoblasts contrasted with the increased number of osteoclasts at both time points. In addition, osteoclasts display multinucleation and detachment from the endosteal surface. Furthermore, the number of pericyte-like cells increased at the intermediate time point. The alveolar bone mass increased exclusively with long-term ZOL treatment. CONCLUSION The severe imbalance between bone-forming cells and bone-resorbing cells shown in this study could contribute to the pathogenesis of BONJ.
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Affiliation(s)
- Luis A Córdova
- INSERM, UMR 957, Equipe Ligue Contre le Cancer 2012, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; University of Nantes, Nantes Atlantique Universities, Pathophysiology of Bone Resorption and Therapy of Primary Bone Tumours Laboratory, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; Department of Oral and Maxillofacial Surgery, San Borja Arriarán University Hospital - Faculty of Dentistry, University of Chile, Sergio Livingstone Polhammer 943, Independencia, Santiago, Chile.
| | - Florian Guilbaud
- INSERM, UMR 957, Equipe Ligue Contre le Cancer 2012, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; University of Nantes, Nantes Atlantique Universities, Pathophysiology of Bone Resorption and Therapy of Primary Bone Tumours Laboratory, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France.
| | - Jérôme Amiaud
- INSERM, UMR 957, Equipe Ligue Contre le Cancer 2012, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; University of Nantes, Nantes Atlantique Universities, Pathophysiology of Bone Resorption and Therapy of Primary Bone Tumours Laboratory, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France.
| | - Séverine Battaglia
- INSERM, UMR 957, Equipe Ligue Contre le Cancer 2012, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; University of Nantes, Nantes Atlantique Universities, Pathophysiology of Bone Resorption and Therapy of Primary Bone Tumours Laboratory, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France.
| | - Céline Charrier
- INSERM, UMR 957, Equipe Ligue Contre le Cancer 2012, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; University of Nantes, Nantes Atlantique Universities, Pathophysiology of Bone Resorption and Therapy of Primary Bone Tumours Laboratory, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France.
| | - Frédéric Lezot
- INSERM, UMR 957, Equipe Ligue Contre le Cancer 2012, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; University of Nantes, Nantes Atlantique Universities, Pathophysiology of Bone Resorption and Therapy of Primary Bone Tumours Laboratory, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France.
| | - Benoît Piot
- Department of Stomatology and Maxillofacial Surgery, Nantes University Hospital, 1 Place Alexis-Ricordeau, 44093, Nantes Cedex 1, France; Nantes University Hospital, 1 Place Alexis-Ricordeau, 44093, Nantes Cedex 1, France.
| | - Françoise Redini
- INSERM, UMR 957, Equipe Ligue Contre le Cancer 2012, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; University of Nantes, Nantes Atlantique Universities, Pathophysiology of Bone Resorption and Therapy of Primary Bone Tumours Laboratory, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France.
| | - Dominique Heymann
- INSERM, UMR 957, Equipe Ligue Contre le Cancer 2012, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; University of Nantes, Nantes Atlantique Universities, Pathophysiology of Bone Resorption and Therapy of Primary Bone Tumours Laboratory, 1 rue Gaston Veil, Nantes Cedex 1, 44035, Nantes, France; Nantes University Hospital, 1 Place Alexis-Ricordeau, 44093, Nantes Cedex 1, France; Department of Oncology and Metabolism, Medical School, Beech Hill Road, S10 2RX, Sheffield, UK.
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de Barros Silva PG, de Oliveira CC, Brizeno L, Wong D, Lima Júnior R, Gonçalves RP, Sousa FB, Mota M, de Albuquerque Ribeiro R, Alves A. Immune cellular profile of bisphosphonate-related osteonecrosis of the jaw. Oral Dis 2016; 22:649-57. [PMID: 27232600 DOI: 10.1111/odi.12513] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/09/2016] [Accepted: 05/02/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Characterize the cell profile and immunostaining of proinflammatory markers in an experimental model of bisphosphonate-related osteonecrosis of the jaw (BRONJ). MATERIALS AND METHODS Male Wistar rats (n = 6-7) were treated chronically with saline solution or zoledronic acid (ZA) at 0.04, 0.20, and 1.00 mg kg(-1) (1.4 × 10(-7) , 6.9 × 10(-6) , and 3.4 × 10(-5) mol kg(-1) ), and subsequently, the first left inferior molar was extracted. Were performed counting of viable and empty osteocyte lacunae, viable and apoptotic osteoclasts, polymorphonuclear neutrophil, mast cells (toluidine blue), and the positive presence cells for CD68, tumor necrosis factor-alpha (TNF-α), IL (interleukin)-1β, inducible nitric oxide synthase (iNOS), nuclear factor-kappa B (NF-kB) and IL-18 binding protein (IL-18 bp). RESULTS BRONJ was showed in ZA treated with 0.20 and 1.00 mg kg(-1) . There is a dose dependent increase in percentage of empty osteocyte lacunae (P < 0.001) and apoptotic osteoclasts (P < 0.001), counting of total osteoclasts (P = 0.003), polymorphonuclear neutrophil cells (P = 0.009), cytoplasmic-positive cells of CD68 (P < 0.001), TNF-α (P = 0.001), IL-1β (P = 0.001), iNOS (P < 0.001), NF-kB (P = 0.006), and nuclear-positive cells of NF-kB (P = 0.011). Consequently, there is no difference in mast cells (P = 0.957), and IL-18 bp immunostaining decreases dose dependently (P = 0.005). CONCLUSIONS BRONJ is characterized by increases in immunostaining for proinflammatory markers and NF-kB and inversely associated with cells exhibiting IL-18 bp.
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Affiliation(s)
- P G de Barros Silva
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceara, Fortaleza, Ceara, Brazil.
| | - C C de Oliveira
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - Lac Brizeno
- Department of Biotechnology, Faculty of Biotechnology, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - Dvt Wong
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - Rcp Lima Júnior
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - R P Gonçalves
- Department of Clinical Analysis, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - F B Sousa
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - Mrl Mota
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - R de Albuquerque Ribeiro
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - Apnn Alves
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceara, Fortaleza, Ceara, Brazil
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Abu-Sirhan S, Hertel M, Preissner S, Wirtz HC, Herbst SR, Pierdzioch P, Raguse JD, Hartwig S. Bactericidal efficacy of cold plasma in processed bone. A new approach for adjuvant therapy of medication-related osteonecrosis of the jaw? CLINICAL PLASMA MEDICINE 2016. [DOI: 10.1016/j.cpme.2015.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fusco V, Santini D, Armento G, Tonini G, Campisi G. Osteonecrosis of jaw beyond antiresorptive (bone-targeted) agents: new horizons in oncology. Expert Opin Drug Saf 2016; 15:925-35. [PMID: 27074901 DOI: 10.1080/14740338.2016.1177021] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Metwally T, Burke A, Tsai JY, Collins MT, Boyce AM. Fibrous Dysplasia and Medication-Related Osteonecrosis of the Jaw. J Oral Maxillofac Surg 2016; 74:1983-99. [PMID: 27137436 DOI: 10.1016/j.joms.2016.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/01/2016] [Accepted: 04/01/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Osteonecrosis of the jaw (ONJ) is an established side effect of intravenous bisphosphonates and other antiresorptive medications. Although bisphosphonates are frequently prescribed for patients with the skeletal disorder fibrous dysplasia (FD), there are no reports of ONJ in this population. This has led some to conclude that patients with FD are at low risk for the development of bisphosphonate-related ONJ. PATIENTS AND METHODS Patients were evaluated as part of a longstanding FD natural history study at the National Institutes of Health. RESULTS Of 76 patients with FD who were treated with bisphosphonates, 4 developed ONJ (5.4%). Three patients developed ONJ in areas of FD-affected bone and 1 in an area of normal bone. All 4 patients had features known to be associated with ONJ in the general population, including long-term high-dose intravenous bisphosphonate treatment, periodontal and endodontic infections, and dentoalveolar surgical procedures. CONCLUSIONS These cases establish ONJ as a potential complication of bisphosphonate treatment in patients with FD. The presence of established risk factors for ONJ in this group of patients with FD suggests that high-risk patients could be identified before the development of ONJ. Clinicians should use caution in prescribing bisphosphonates to patients with FD and should do so only for established indications.
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Affiliation(s)
- Tarek Metwally
- Medical Research Scholar, Section on Skeletal Disorders and Mineral Homeostasis, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD; Dental Student, University of Michigan School of Dentistry, Ann Arbor, MI
| | - Andrea Burke
- Clinical Research Fellow, Section on Skeletal Disorders and Mineral Homeostasis, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Jeffrey Y Tsai
- Resident, Department of Oral and Maxillofacial Surgery, School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY
| | - Michael T Collins
- Chief, Section on Skeletal Disorders and Mineral Homeostasis, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Alison M Boyce
- Attending Physician, Section on Skeletal Disorders and Mineral Homeostasis, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD; Adjunct Assistant Professor, Division of Endocrinology and Diabetes, and Attending Physician, Bone Health Program, Division of Orthopaedics and Sports Medicine, Children's National Health System, Washington, DC.
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Patel V, Kelleher M, Sproat C, Kwok J, McGurk M. New cancer therapies and jaw necrosis. Br Dent J 2015; 219:203-7. [DOI: 10.1038/sj.bdj.2015.680] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 12/12/2022]
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Long term exposure to antiangiogenic therapy, bevacizumab, induces osteonecrosis. Invest New Drugs 2015; 33:1144-7. [PMID: 26311072 DOI: 10.1007/s10637-015-0283-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 08/20/2015] [Indexed: 01/22/2023]
Abstract
PURPOSE Bevacizumab, a monoclonal VEGF-A antibody, has been identified as an aetiology of osteonecrosis of the femoral head. Long exposure to anti VEGF therapy induced chronic hypoperfusion of normal tissues. Osteonecrosis is a musculo-skeletal disease secondary to cellular death of bone component mainly induced by corticosteroids, alcohol use, or connective tissue disorders. METHODS The medical records of patients with metastatic colorectal carcinoma receiving Bevacizumab between January 2006 and November 2013 were retrospectively reviewed and we had looked for osteonecrosis. Every disorder of musculoskeletal mobility were examined by orthopaedist and evaluated by imaging. RESULTS We report on osteonecrosis of humeral and femoral head in patient with metastatic colon adenocarcinoma receiving a long-term exposure to anti angiogenic based treatment (>6 months), lack of other factors predisposing to osteonecrosis. These observations, according to literature, suggests that long exposure to anti VEGF-A, Bevacizumab, promote bone hypoperfusion and may induced osteonecrosis either on the femoral head or the humeral head with an incidence of 4 out of 1000 patients. CONCLUSIONS With an incidence of 4 out of 1000 patients osteonecrosis is a rare side effect of anti-angiogenic agent. With the increasing utilisation and duration of exposure of anti-VEGF therapy some rare side effect due to chronic ischemia may appear. The clinician should be aware about uncommon symptoms.
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Günaldi M, Afsar CU, Duman BB, Kara IO, Tatli U, Sahin B. Effect of the cumulative dose of zoledronic acid on the pathogenesis of osteonecrosis of the jaws. Oncol Lett 2015; 10:439-442. [PMID: 26171047 DOI: 10.3892/ol.2015.3156] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 03/24/2015] [Indexed: 11/06/2022] Open
Abstract
Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a severe bone disease for which the pathogenetic mechanisms and risk factors are not fully understood. The present study evaluated the data of 652 patients with bone metastasis that had undergone treatment with biphosphonates. Subsequently, 24 patients with BRONJ and 20 control patients without BRONJ that were treated with zoledronic acid were enrolled. It was found that BRONJ occurred in 3.6% of patients. The mean age and the administration of dental treatment were found to be significantly associated with BRONJ development (P=0.049 and P=0.013, respectively). The cumulative dose median in the BRONJ group was found to be significantly higher compared with the cumulative dose average in the control group (P=0.037). In addition, at the time of BRONJ development, improvement in the disease was determined to be better in the BRONJ group than in the control group (P=0.031). The present study determined that age, the existence of dental extraction and the cumulative dose of zoledronate were all important risk factors in BRONJ development.
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Affiliation(s)
- Meral Günaldi
- Department of Medical Oncology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Cigdem Usul Afsar
- Department of Medical Oncology, Cukurova University Medical School, Adana, Adana, Turkey
| | - Berna Bozkurt Duman
- Department of Medical Oncology, Adana Research and Training Hospital, Adana, Adana, Turkey
| | - Ismail Oguz Kara
- Department of Medical Oncology, Cukurova University Medical School, Adana, Adana, Turkey
| | - Ufuk Tatli
- Faculty of Dentistry, Cukurova University, Adana, Adana, Turkey
| | - Berksoy Sahin
- Department of Medical Oncology, Cukurova University Medical School, Adana, Adana, Turkey
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Foster KA, Ares WJ, Pollack IF, Jakacki RI. Bevacizumab for symptomatic radiation-induced tumor enlargement in pediatric low grade gliomas. Pediatr Blood Cancer 2015; 62:240-245. [PMID: 25382690 DOI: 10.1002/pbc.25277] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 08/25/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Radiation therapy (RT)-induced effects in children treated for low grade glioma (LGG) can result in worsening of neurologic symptoms and clinical and radiographic deterioration. Treatment for radiation-induced tumor enlargement is based on symptom control and usually involves steroids. PROCEDURE We conducted a retrospective review of children with LGG treated with RT who developed symptomatic radiation-induced tumor enlargement and were managed with bevacizumab. Charts were abstracted for onset and duration of RT changes, toxicity and doses of dexamethasone and bevacizumab. Tumor volumes prior to RT, at maximal size following RT, after bevacizumab administration, and at follow-up were evaluated. RESULTS Five children were treated with bevacizumab for symptomatic radiation-induced tumor enlargement following RT for LGG at a median of 4.2 months (range, 1-11 months) after completion of RT. The median increase in volume of tumor was 195.4% (range, 115.5-309%) compared to the pre-RT volume. Bevacizumab 5-10 mg/kg was administered IV q 2-4 weeks as primary treatment (n = 1) or to assist in weaning patients off steroids (n = 4). All children on high dose steroids (n = 4) were weaned off or to physiologic doses of hydrocortisone. Two children developed avascular necrosis after prolonged steroid use and while on bevacizumab. Radiographically, all children showed significant improvement and are now a median of 31 months (range, 18-50 months) from the completion of radiation without requiring additional tumor-related therapy. CONCLUSIONS Bevacizumab can play an important role in children with symptomatic radiation changes following LGG treatment, allowing patients to avoid or minimize the toxicity of long-term steroid use. Pediatr Blood Cancer 2015;62:240-245. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Kimberly A Foster
- Department of Neurosurgery, Children's Hospital of Pittsburgh, Neurosurgery/Faculty Pavilion, Pittsburgh, Pennsylvania
| | - William J Ares
- Department of Neurosurgery, Children's Hospital of Pittsburgh, Neurosurgery/Faculty Pavilion, Pittsburgh, Pennsylvania
| | - Ian F Pollack
- Department of Neurosurgery, Children's Hospital of Pittsburgh, Neurosurgery/Faculty Pavilion, Pittsburgh, Pennsylvania
| | - Regina I Jakacki
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Osteonecrosis of the jaw (ONJ) in renal cell cancer patients after treatment including zoledronic acid or denosumab. Support Care Cancer 2014; 22:1737-8. [PMID: 24570104 DOI: 10.1007/s00520-014-2159-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
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