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Somay E, Topkan E, Kucuk A, Ozturk D, Ozkan EE, Ozdemir BS, Besen AA, Mertsoylu H, Pehlivan B, Selek U. Pre-chemoradiotherapy high platelet counts predict jaw osteoradionecrosis in locally advanced nasopharyngeal carcinoma patients. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101838. [PMID: 38518893 DOI: 10.1016/j.jormas.2024.101838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION This retrospective study aimed to investigate if pretreatment platelet (PLT) levels can predict the risk of osteoradionecrosis of the jaw (ORNJ) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) who received concurrent chemoradiotherapy (CCRT). MATERIAL &METHODS ORNJ instances were identified from LA-NPC patients' pre- and post-CCRT oral exam records. All pretreatment PLT values were acquired on the first day of CCRT. Receiver operating characteristic curve analysis was used to determine the optimal PLT cutoff that divides patients into two subgroups with distinctive ORNJ rates. The primary outcome measure was the association between pretreatment PLT values and ORNJ incidence rates. RESULTS The incidence of ORNJ was 8.8 % among the 240 LA-NPC patients analyzed. The ideal pre-CCRT PLT cutoff which divided the patients into two significantly different ORNJ rate groups was 285,000 cells/µL (PLT ≤ 285,000 cells/µL (N = 175) vs. PLT > 285,000 cells/µL (N = 65)). A comparison of the two PLT groups revealed that the incidence of ORNJ was substantially higher in patients with PLT > 285,000 cells/L than in those with PLT≤285,000 cells/L (26.2% vs. 2.3 %; P < 0.001). The presence of pre-CCRT ≥3 tooth extractions, any post-CCRT tooth extractions, mean mandibular dose ≥ 34.1 Gy, mandibular V57.5 Gy ≥ 34.7 %, and post-CCRT tooth extractions > 9 months after CCRT completion were also associated with significantly increased ORNJ rates. A multivariate Cox regression analysis demonstrated that each characteristic had an independent significance on ORNJ rates after CCRT. CONCLUSION An affordable and easily accessible novel biomarker, PLT> 285,000 cells/L, may predict substantially higher ORNJ rates after definitive CCRT in individuals with LA-NPC.
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Affiliation(s)
- 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
- Clinics of Radiation Oncology, Mersin City Education and Research Hospital, Mersin, Turkey
| | - Duriye Ozturk
- Department of Radiation Oncology, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Emine Elif Ozkan
- Department of Radiation Oncology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
| | | | - Ali Ayberk Besen
- Clinics of Medical Oncology, Istinye University, Adana Medical Park Hospital, Turkey
| | - Huseyin Mertsoylu
- Clinics of Medical Oncology, Istinye University, Adana Medical Park Hospital, 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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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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Renouf M, Auger S, Campion L, Delpon G, Longis J, Dupas C, Blery P, Thariat J, Doré M. Prognostic Factors of Mandibular Osteoradionecrosis Including Accurate Colocalization of Avulsions and Dosimetric Dental Mapping Software, a Case-control Study. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00518-2. [PMID: 38685504 DOI: 10.1016/j.ijrobp.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Osteoradionecrosis (ORN) of the mandible remains a significant complication in the intensity modulated radiation therapy (IMRT) era. Dental dose cannot be predicted from heterogeneous IMRT dose distributions; mandibular dose metrics cannot guide dentist avulsion decisions in high-risk ORN situations. Using a mapping tool to report dental root dose, avulsions, and ORN sites, we re-examined ORN risk factors in a case-control study. METHODS AND MATERIALS From 2008 to 2019, 897 consecutive patients with oral cavity/oropharynx or unknown primary cancer undergoing IMRT were analyzed to identify ORN cases. These were matched (1 ORN/2 controls) retrospectively for tumor location, surgery, and tobacco consumption in a monocentric case-control study. Univariate and multivariate analyses integrated ORN factors and accurate dental dose data (grouped into 4 mandibular sectors). Generalizability was investigated in a simulated population database. RESULTS A total of 171 patients were included. The median follow-up was 5.2 and 4.5 years in the ORN and control groups, respectively. The median time to ORN was 12 months. In univariate analysis, post-IMRT avulsions at the ORN site (hazard ratio [HR] = 3.6; 95% confidence interval [CI] = 1.5-8.9; P = .005), tumor laterality (HR, 4.4; 95% CI, = 1.4-14, P = .01), mean mandibular dose (HR, 1.1; 95% CI, = 1.01-1.1; P = .018) and mean dose to the ORN site (HR, 1.1; 95% CI, = 1.1-1.2; P < .001) correlated with higher ORN risk. In multivariate analysis, mean dose to the ORN site (HR, 1.1; 95% CI, = 1.1-1.2; P < .001) and post-IMRT avulsions at the ORN site (HR, 4.6; 95% CI, = 1.5-14.7; P = .009) were associated with ORN. For each increase in gray in dental dose, the ORN risk increased by 12%. Simulations confirmed study observations. CONCLUSIONS Dental dose and avulsions are associated with ORN, with a 12% increase in risk with each additional gray. Accurate dose information can help dentists in their decisions after IMRT.
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Affiliation(s)
- Marion Renouf
- Institut de Cancérologie de l'Ouest, Nantes, France; Centre Hospitalier Départemental Vendée, La Roche Sur Yon, France.
| | - Simon Auger
- Centre Hospitalier Universitaire, Nantes, France
| | - Loïc Campion
- Institut de Cancérologie de l'Ouest, Nantes, France; Nantes Université, INSERM 1307, CNRS 6075, Université d'Angers, CRCI2NA, Nantes, France
| | - Grégory Delpon
- Institut de Cancérologie de l'Ouest, Nantes, France; Laboratoire SUBATECH, UMR 6457 CNRS-IN2P3, IMT Atlantique, Nantes, France
| | - Julie Longis
- Maxillofacial Surgery Department, Centre Hospitalier Universitaire, Nantes, France
| | - Cécile Dupas
- Centre Hospitalier Universitaire, Nantes, France
| | - Pauline Blery
- Centre Hospitalier Universitaire, Nantes, France; INSERM UMRS 1229, France
| | - Juliette Thariat
- Centre François Baclesse, Caen, France; Laboratoire de Physique Corpusculaire IN2P3/ENSICAEN/CNRS UMR 6534, Normandie Université, Caen, France
| | - Mélanie Doré
- Institut de Cancérologie de l'Ouest, Nantes, France
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Yilmaz B, Somay E, Topkan E, Pehlivan B, Selek U. Pre-chemoradiotherapy low hemoglobin levels indicate increased osteoradionecrosis risk in locally advanced nasopharyngeal cancer patients. Eur Arch Otorhinolaryngol 2023; 280:2575-2584. [PMID: 36749372 DOI: 10.1007/s00405-023-07864-7] [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: 01/02/2023] [Accepted: 01/27/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE We aimed to determine whether pretreatment hemoglobin (Hb) levels can predict the risk of osteoradionecrosis (ORN) in patients receiving concurrent chemoradiotherapy (CCRT) for locally advanced nasopharyngeal carcinoma (LA-NPC). METHODS ORN cases were identified from the records of LA-NPCs who had oral exams before and after CCRT. All Hb measurements were obtained on the first day of treatment. Receiving operating characteristic curve analysis was used to determine the relationship between Hb levels and ORN rates. The relationship between pretreatment Hb levels and ORN rates served as the primary endpoint, and secondary endpoints included the discovery of additional potential ORN risk factors. RESULTS Among the 263 eligible LA-NPCs, we identified 8.7% ORN cases. The ideal cutoff Hb before CCRT was 10.6 g/dL. It was revealed that HPR ≤ 10.6 group had a significantly higher ORN rate (32.5% vs. 1.5% for Hb > 10.6; P < 0.001). The mandibular V59.8 ≥ 36% Gy, pre-CCRT ≥ 4 tooth extractions, the presence of post-CCRT tooth extractions, and the time of post-CCRT tooth extractions > 8 months were the other factors associated with significantly increased ORN rates (P < 0.05 for each). CONCLUSION Low pre-CCRT Hb levels appeared to be independently linked to significantly higher ORN rates. Pretreatment Hb levels may be used to establish preventive measures and predict ORN.
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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, Adana, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey.,Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
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Delpon G, Renouf M, Langé M, Blery P, Dupas C, Longis J, Thariat J, Doré M. Systematic dosimetric evaluation of risk of osteoradionecrosis (DERO): First results of dose reporting for preventing teeth osteoradionecrosis after head and neck irradiation. Cancer Radiother 2023; 27:103-108. [PMID: 36739196 DOI: 10.1016/j.canrad.2022.08.003] [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: 08/02/2022] [Revised: 08/11/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE OsteoRadioNecrosis (ORN) is a late complication of radiation for head and neck cancer. Predicting ORN is a major challenge. We developed DERO (Dosimetric Evaluation of Risk of ORN), a semi-automatic tool which reports doses delivered to tooth-bearing sectors, to guide post-therapeutic dental care. We present the method and the first results of a 125-patient prospective cohort. MATERIAL AND METHODS Dosimetric data of patients treated with IMRT for head and neck cancer were prospectively segmented to the DERO algorithm. Four arches corresponding to 8-tooth sectors were semi-automatically generated. Thirty-two cylindrical Regions Of Interest (ROI) corresponding to each tooth and surrounding periodontium were created by linear interpolation. Mean doses (Dmean) of ROI were extracted and included in a database, along with data about primary tumor site, laterality and dose values from organs at risk. Dmean to tooth sectors were computed for molar sectors, (teeth X5 to X8) and anterior sectors (teeth X1 to X4). An individual dose map was generated and delivered to patients and dentists. RESULTS Dosimetric data from 125 patients treated with Tomotherapy® were prospectively collected and analyzed: 9 parotid tumors (PA), 41 Sub-Hyoid tumors (larynx, hypopharynx) (SH), 43 Oropharynx tumors (OR), 32 Oral Cavity tumors (OC). Irradiation was unilateral for 100% of PA tumors (9), 12% of OR tumors (5) and 47% of OC tumors (15). For unilateral cervical irradiation, Dmean in ipsilateral molar sectors was 54Gy for OC tumors, 45Gy for OR tumors, 20Gy for PA tumors. For Oral Cavity bilateral irradiation, Dmean was high in all tooth sectors, 49 to 55Gy. For SH tumors, Dmean in molar sectors was 27Gy. A dose gradient of 10 to 20Gy was observed between molar and anterior sectors whether radiation was uni or bilateral. CONCLUSION Mandibular molar sectors of Oropharynx and Oral Cavity tumors were exposed to high Dmean of 40 to 50Gy. On the other hand, tooth sectors received lower doses for SH radiation. The DERO tool guide post-radiation dental care with a personalized dosimetric cartography to patient. With data update and patient follow-up, we will be able to determine ORN risk after head and neck radiation.
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Affiliation(s)
- G Delpon
- Medical physics department, institut de cancérologie de l'Ouest, Saint-Herblain, France; IMT atlantique, Nantes université, CNRS/IN2P3, Subatech, Nantes, France
| | - M Renouf
- Radiation oncology department, institut de cancérologie de l'Ouest, Saint-Herblain, France
| | - M Langé
- Radiation oncology department, institut de cancérologie de l'Ouest, Saint-Herblain, France
| | - P Blery
- Nantes université, Oniris, Inserm, regenerative medicine and skeleton, RMeS, UMR 1229, Nantes, France; Odontology department, centre hospitalo-universitaire, Nantes, France
| | - C Dupas
- Odontology department, centre hospitalo-universitaire, Nantes, France
| | - J Longis
- Maxillofacial surgery department, centre hospitalo-universitaire, Nantes, France
| | - J Thariat
- Radiation oncology department, Centre François-Baclesse, Caen, France; Laboratoire de physique corpusculaire, IN2P3/ENISAEN-CNRS, Caen, France; Normandie université, Caen, France
| | - M Doré
- Radiation oncology department, institut de cancérologie de l'Ouest, Saint-Herblain, France.
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Leboucher A, Sotton S, Gambin Flandrin I, Magné N. Head and neck radiotherapy-induced carotid toxicity: Pathophysiological concepts and clinical syndromes. Oral Oncol 2022; 129:105868. [DOI: 10.1016/j.oraloncology.2022.105868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 03/27/2022] [Accepted: 04/12/2022] [Indexed: 01/17/2023]
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