Quality of life after management of advanced osteoradionecrosis of the mandible

Microvascular reconstruction of medication related osteonecrosis of the head and neck

BACKGROUND

Medication related osteonecrosis of the jaw (MRONJ) requiring free flap (FF) reconstruction is uncommon with limited reported findings.

METHODS

Multicenter, retrospective case series of 49 consecutive adult patients presenting with advanced MRONJ requiring FF reconstruction from 2010 to 2022. Perioperative complications and outcomes were analyzed.

RESULTS

Eighty-two percent (n = 40) of cases were of the mandible and 18% (n = 9) were of the maxilla. The mean follow-up was 15 months (±19.6). The majority of FF survived (96%, n = 47). FF reconstructions of the maxilla were more likely to require postoperative debridement (56%, 95% CI [27, 81%] vs. 15%, 95% CI [7, 25%], p = 0.008) or develop intraoral bone exposure (56%, 95% CI [27, 81%] vs. 18%, 95% CI [9, 27%], p = 0.02). Most patients (71%, n = 35) received preoperative antibiotics which was associated with a higher rate of FF survival (100% vs. 86%, 95% CI [60, 96%], p = 0.02) and fewer complications.

CONCLUSIONS

Patients undergoing FF reconstruction for MRONJ do well with high rates of FF success. MRONJ of the maxilla have a higher rate of some complications. Preoperative antibiotics correlated with higher FF survival and fewer postoperative complications.

Osteoradionecrosis Rates After Head and Neck Radiation Therapy: Beyond the Numbers

PURPOSE

Osteoradionecrosis (ORN) is a severe late complication of head and neck radiation therapy shown to have profound negative effect on the quality of life of cancer survivors. Over the past few decades, improvements in radiation delivery techniques have resulted in a decrease in the incidence of ORN. However, even with modern radiation therapy techniques, ORN remains an important clinical concern. In recent literature, there is a wide range of reported ORN rates from 0% to as high as 20%. With such a high level of variability in the reported incidence of ORN, oncologists often encounter difficulties estimating the risk of this serious radiation therapy toxicity.

METHODS AND MATERIALS

In this review, the authors present a summary of the factors that contribute to the high level of variability in the reported incidence of ORN.

RESULTS

Variable definition, variable grading, and heterogeneity of both study inclusion criteria and treatment parameters can each significantly influence the reporting of ORN rates.

CONCLUSIONS

Given numerous factors can affect the reported incidence of ORN, a thorough understanding of the clinical context behind the reported ORN rates is needed to comprehend the true risk of this important radiation therapy toxicity.

Pre- and Post-Operative Quality of Life in Patients with Osteoradionecrosis of the Jaw

Osteoradionecrosis of the jaw (ORNJ) is a feared complication following radiation therapy performed for oncological treatment of head and neck cancers (HNC). To date, there is no clear evidence regarding the impact of surgical treatment of ORNJ on the quality of life (QoL) of affected patients. However, understanding the significance of the surgical treatment approach and its effects on QoL is an essential factor in the decision-making process for optimal, individualized therapy. In this prospective clinical study, QoL was assessed in relation to health related QoL (HRQoL) and oral health related QoL (OHQoL) before and after surgical treatment of ORNJ using standardized questionnaires (EORTC QLQ-C30, QLQ-HN35, OHIP-14). The overall QoL scores as well as individual domains of the collected scales regarding functional and symptom-related complaints were statistically analyzed. Subgroups concerning age, gender, different risk factors and type of ORNJ therapy were compared using Kruskal Wallis test. In addition, clinical and demographic patient data were collected and analyzed. QoL improvement correlated with the type of surgical ORNJ and the length of hospitalization. Better QoL scores were achieved post-operatively regarding different symptoms like pain, swallowing and mouth opening. Long-term effects of radiation therapy remained visibly restrictive to QoL and worsen over time.

Review of Osteoradionecrosis of the Jaw: Radiotherapy Modality, Technique, and Dose as Risk Factors

Radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) is the cornerstone of organ-sparing or adjuvant therapy for nearly all head and neck cancers. Unfortunately, aggressive RT or CCRT can result in severe late toxicities, such as osteoradionecrosis of the jaws (ORNJ). The incidence of ORNJ is currently less than 5-6% due to advances in dental preventive care programs, RT planning systems, and RT techniques. Although numerous patient-, tumor-, and treatment-related factors may influence the incidence rates of ORNJ, RT modality (equipment), technique, and dose-volume-related factors are three of the most influential factors. This is mainly because different RT equipment and techniques have different levels of success at delivering the prescribed dose to the focal volume of the treatment while keeping the "organ at risk" safe. ORNJ risk is ultimately determined by mandibular dose, despite the RT technique and method being known predictors. Regardless of the photon delivery method, the radiobiological effects will be identical if the total dose, dose per fraction, and dose distribution within the tissue remain constant. Therefore, contemporary RT procedures mitigate this risk by reducing mandibular dosages rather than altering the ionizing radiation behavior in irradiated tissues. In light of the paucity of studies that have examined the impact of RT modality, technique, and dose-volume-related parameters, as well as their radiobiological bases, the present review aims to provide a comprehensive overview of the published literature on these specific issues to establish a common language among related disciplines and provide a more reliable comparison of research results.

Osteoradionecrosis rate in oropharynx cancer treated with dose volume histogram based constraints

OBJECTIVES

Mandibular dose constraints are designed to limit high dose to small volumes to avoid osteoradionecrosis (ORN). Based upon a published experience, intermediate-dose constraints were introduced but have not been independently validated. We hypothesize that these constraints lower ORN rate without compromising other organs at risk (OAR).

METHODS

Oropharyngeal cancer patients treated with standard fractionation adjuvant/definitive VMAT from 01/2014-08/2020 were included. In 09/2017, mandibular dose constraint was changed from historical constraint (HC) of D 0.1 cc < 70 Gy to modified constraints (MC) of V 44 Gy < 42%, V 58 Gy < 25%, D 0.5 cc < 70 Gy. OAR dosimetric changes and ORN development were evaluated. Regression modelling predicted long-term ORN cases in MC group.

RESULTS

There were 174 patients, 71 in MC group. Seven cases of ORN in HC group at a median follow up (FU) of 39 months and 1 case of ORN in MC group at a median FU of 11 months were observed. More patients in the MC group met V 44 Gy (87% vs 62%, p < 0.01) and V 58 Gy constraints (92% vs 73%, p < 0.01). Mean doses to OARs did not rise. Mandible V 44 Gy and V 58 Gy were significantly associated with ORN (p < 0.01 and p = 0.03, respectively) across all patients. In the HC group, V 44 Gy was independently associated with ORN (p = 0.01). To account for shorter FU in MC group, logistic regression of ORN based on V 44 Gy in HC patients was performed. This predicts 3.2 ORN cases in the MC group (95% CI: 0.00-6.4).

CONCLUSION

Achieving V 44 Gy and V 58 Gy was successful in 87% of cases without sacrificing target coverage or OARs and resulted in non-significant ORN decrease.

Effect of Radiotherapy on Functional and Health-Related Quality of Life Outcomes after Jaw Reconstruction

Simple Summary

Reconstructive surgery is critical to restore form and function after treatment for head and neck cancer (HNC). The aim of this cross-sectional study was to describe long-term quality of life (QoL) and functional outcomes among patients with a history of HNC who underwent reconstruction of the mandible and/or maxilla. Patients who had radiotherapy either before or after their index reconstruction reported significantly worse functional and QoL outcomes, including speech, swallowing, eating and drinking, appearance, smiling, and satisfaction with information. Swallowing, salivation, oral competence, and satisfaction with information worsened with increasing time since surgery. Women and younger patients also reported worse functional and QoL outcomes, especially speech and facial aesthetics. Understanding long-term outcomes of jaw reconstruction is important for both patients and clinicians to make evidence-based decisions about treatment options. We have identified several groups at risk of poorer outcomes that may benefit from enhanced pre-operative counselling and post-operative monitoring.

Abstract

Long-term health-related quality of life (HRQOL) and functional outcomes following mandibular and maxillary reconstruction are lacking. To determine these outcomes, a cross-sectional study of patients with a history of cancer who underwent jaw reconstruction was undertaken. Participants were identified from a database of jaw reconstruction procedures at the Chris O’Brien Lifehouse (Sydney, Australia). Eligible patients had at least one month follow-up, were aged ≥18 years at surgery, and had history of malignancy. HRQOL was measured using the FACE-Q Head and Neck Cancer Module (FACE-Q H&N). Functional outcomes were measured using the FACE-Q H&N, MD Anderson Dysphagia Inventory (MDADI) and Speech Handicap Index (SHI). Ninety-seven questionnaires were completed (62% response rate). Mean age of respondents was 63.7 years, 61% were male, and 64% underwent radiotherapy. Treatment with radiotherapy was associated with worse outcomes across 10/14 FACE-Q H&N scales, three MDADI subscales and one composite score, and the SHI. Mean differences in scores between irradiated and non-irradiated patients exceeded clinically meaningful differences for the MDADI and SHI. Issues with oral competence, saliva, speaking, and swallowing worsened with increasing time since surgery. Younger patients reported greater concerns with appearance, smiling, speaking, and cancer worry. Women reported greater concerns regarding appearance and associated distress. History of radiotherapy substantially impacts HRQOL and function after jaw reconstruction. Age at surgery and gender were also predictors of outcomes and associated distress. Pre-treatment counselling of patients requiring jaw reconstruction may lead to improved survivorship for patients with head and neck cancer.

Quality of life after segmental mandibulectomy and free flap for mandibular osteonecrosis: Systematic review

OBJECTIVE

Review QOL outcomes among patients undergoing segmental mandibulectomy and bony free flap reconstruction for ONJ.

DATA SOURCES

PubMed was searched for MeSH terms "Quality of life," "Osteonecrosis," "Osteoradionecrosis," "Bisphosphonate-associated osteonecrosis of the jaw," "Free tissue flaps," and "Mandibular reconstruction."

REVIEW METHODS

English language studies with QOL outcomes data for patients undergoing free flap reconstruction for advanced ONJ were included. 197 records were initially screened; 18 full texts assessed; 10 full texts included. PRISMA guidelines were followed.

RESULTS

Ten studies were included in this systematic review: six retrospective, three retrospective with comparison groups, and one prospective. In studies with comparison groups, ONJ patients have worse self-reported QOL than the general population as well as head and neck cancer patients without ONJ. Nearly all patients with QOL measurements (220/235 patients) had ONJ from prior radiation. Segmental mandibulectomy and bony free flap improved overall QOL in over half of patients, as well as pain associated with ONJ in 70-75 % of patients. Surgery did not improve long-term effects of radiation such as chewing, swallowing, and salivary production. Donor site morbidity rarely affects QOL.

CONCLUSIONS

Osteonecrosis of the jaw (ONJ) worsens quality-of-life, and advanced disease often requires segmental mandibulectomy and bony free flap reconstruction. Patients and surgeons may expect improvement in some, but not all, domains of patient-reported QOL by the use of segmental mandibulectomy and reconstruction for advanced ONJ.

Osteoradionecrosis of the jaw: A mini review

Osteoradionecrosis (ORN) of the jaw is one of the most dreaded complications of head and neck radiation therapy. Despite the evolution of radiation treatment modalities, ORN continues to remain a therapeutic challenge and its etiopathogenesis still remains unclear. It is clinically characterized by exposed necrotic bone within the head and neck radiation field. Over the past years, several studies have reported on the definition, staging, incidence, etiology, and management of this oral complication. In this review, we summarize the literature on ORN and discuss our institutional experience and management strategies that aim to predict and mitigate risk for ORN.

Free vascularized flap reconstruction for osteoradionecrosis of the mandible: a 25-year retrospective cohort study

Background

Osteoradionecrosis of the jaw is a severe complication of radiotherapy in head and neck cancer patients. If conservative treatment and surgical debridement have been unsuccessful, the preferred treatment for symptomatic mandibular osteoradionecrosis (mORN) is radical surgery and subsequent reconstruction with a free vascularized flap. This study aims to assess the outcomes of free vascularized flap reconstruction in mORN.

Methods

A retrospective study was conducted on all patients who underwent a free vascularized flap reconstruction for mORN between 1995 and 2021 in Amsterdam UMC – VUmc, The Netherlands.

Results

In our cohort study, three of the twenty-eight flap reconstructions failed (10.7%). No recurrences of mORN were observed during a mean follow-up of 8 years.

Conclusions

The success rate of free vascularized flap reconstruction for mORN is high. The fibula is the preferred free flap for mandibular reconstruction in mORN cases. However, this type of surgery is at risk for complications and patients need to be informed that these complications may require surgical re-intervention.

Level of evidence: Level IV, Therapeutic; Risk/Prognostic.

The impact of hyperbaric oxygen therapy on late irradiation injury in oral microcirculation

BACKGROUND

Late side effects of radiotherapy in patients with head and neck cancer (HNCPs) result in decreased tissue vascularity, a compromised healing capacity and spontaneous breakdown of tissue. The aim of this study was to examine the in vivo effect of hyperbaric oxygen therapy (HBOT) on the microcirculation in irradiated oral tissue.

METHODS

Using a handheld microscope, the effect of HBOT on oral mucosal microcirculation parameters was measured in 34 previously irradiated HNCPs prior to HBOT and at 4 weeks and 6 months posttreatment.

RESULTS

A significant increase in mean buccal vessel density and decrease in buccal vessel diameter was found 6 months after HBOT compared to baseline, 22 ± 11 versus 25 ± 7 cpll/mm2 (p < 0.05) and 20 ± 4 versus 16 ± 5 μm (p < 0.05), respectively.

CONCLUSION

Our results indicate that oral microcirculation histopathology associated with irradiation is able to respond to HBOT by redirecting oral microcirculation parameters towards values consistent with healthy tissue.

Impact of Anti-Diabetic Medications on Quality of Life in Persons with Type 2 Diabetes Mellitus

INTRODUCTION

Type 2 diabetes mellitus (T2DM) has been found to be associated with poor quality of life (QOL). The aim of this study was to measure QOL in T2DM patients and examine if the patients' socio demographic, diabetes-related clinical characteristics and insulin usage are associated with better quality of life.

MATERIALS AND METHODS

This clinic based cross-sectional study analyzed data from outpatients with T2DM attending a referral clinic between January and June 2016. Association between Diabetes Attitudes, Wishes and Needs (DAWN) QOL and few demographic, socioeconomic, clinical and biochemical predictors were examined using multivariate logistic regression model. A total of 518 patients completed the interview.

RESULTS

The HbA1c level of insulin ± oral anti-diabetic (OAD) cohort was significantly lower (7.89 ± 1.98) than the OAD cohort (8.79 ± 1.96), P < 0.001. Compared to their counterparts in the OAD cohort, patients on insulin were older with longer duration of diabetes mellitus. Co-morbid confounders like obesity, hypoglycemia, and blood pressure control or socio demographic confounders like income, education were almost similar in both the cohorts. The incidence of hypertension, coronary artery disease (CAD) and statin usage was significantly higher in the insulin cohort. The overall composite DAWN QOL scores of the insulin ± OAD cohort (25.42 ± 4.35) was marginally higher than that of the OAD cohort (23.62 ± 5.06) (P = 0.067). Analog insulin users were also found to have significantly higher composite DAWN QOL scores compared to human insulin users (25.77 ± 5.73 vs.24.13 ± 4.88, P = 0.037).

CONCLUSIONS

The insulin cohort, despite being older and having longer duration of diabetes, had significantly higher diet compliance score, and enhanced QOL owing to better diabetes-related knowledge and treatment adherence characteristics than non-insulin users. Questionnaires-based evaluation of QOL can provide better understanding of the patient's experience of the illness, self-care, psychological and emotional functioning, and choice of therapeutic modality enhancing the quality of care.

Occurrence and Treatment Outcome of Late Complications After Free Fibula Flap Reconstruction for Mandibular Osteoradionecrosis

PURPOSE

This study aimed to evaluate the occurrence and treatment outcome of late complications after free fibula osteocutaneous flap reconstruction for mandibular osteoradionecrosis (ORN).

METHODS

We enrolled 15 consecutive patients (14 men, one woman; median age 65 years, range 57-80 years) who underwent free fibula reconstruction for advanced mandibular ORN during 2013-2017 with two or more years of follow-up. Late complications included infection, plate exposure, and recurrence at the resection margin. The effect of perioperative antibiotic administration on late complications was also assessed.

RESULTS

Late complications occurred in 33.3% (5/15) of patients, including two infections (local and distant), two plate exposures, and two recurrences (plate exposure and recurrence occurred in one patient). Perioperative antibiotic administration duration did not significantly affect the occurrence of postoperative late complications. All late complications were treated without problems.

CONCLUSIONS

Late complications after ORN reconstructive surgery are not uncommon, but can be treated properly.

Health related quality of life and patient concerns in patients with osteoradionecrosis

The number of patients presenting with osteoradionecrosis (ORN) is likely to increase in future and health related quality of life (HRQOL) is a key outcome. This study aimed to report patient concerns and HRQOL in an osteoradionecrosis cohort over 12 years. Patients attended routine follow-up clinics between 2008 to 2020, where patient reported outcome (PRO) assessment was used before consultations as standard practice. The two PROs were the Patient Concerns Inventory (PCI) and the University of Washington quality of life questionnaire (UW-QOL v4). The study sample comprised 109 patients with ORN seen in 445 clinics when PCI and UW-QOL were used. At clinic, patients were in one of six ORN states: before ORN (26 with data), at diagnosis (12), and following treatment either improved (27), progressed (46), stable (63) or resolved (37). Worst HRQOL outcomes were reported in the progressive group with 50% reporting overall QOL as less than good. Pain was a major dysfunction (63%) as was physical and social-emotional functioning and this group reported many PCI issues, median (IQR) 7 (4-11). Kaplan-Meier estimates of survival with 95% CI after diagnosis with ORN were 96% (90-99%) at 12 months, 89% (81-94%) at 24 months and 73% (61-82%) at 60 months. This study indicates that ORN is a chronic condition with long-term survivorship consequences. More data through cohort studies and trials are needed to assist in decision making for individual patients.

Microvascular Reconstruction of Osteonecrosis: Assessment of Long-term Quality of Life

OBJECTIVE

Review long-term clinical and quality-of-life outcomes following free flap reconstruction for osteonecrosis.

STUDY DESIGN

Retrospective multi-institutional review.

SETTING

Tertiary care centers.

METHODS

Patients included those undergoing free flap reconstructions for osteonecrosis of the head and neck (N = 232). Data included demographics, defect, donor site, radiation history, perioperative management, diet status, recurrence rates, and long-term quality-of-life outcomes. Quality-of-life outcomes were measured using the University of Washington Quality of Life (UW-QOL) survey.

RESULTS

Overall flap success rate was 91% (n = 212). Relative to preoperative diet, 15% reported improved diet function at 3 months following reconstruction and 26% at 5 years. Osteonecrosis recurred in 14% of patients (32/232); median time to onset was 11 months. Cancer recurrence occurred in 13% of patients (29/232); median time to onset was 34 months. Results from the UW-QOL questionnaire were as follows: no pain (45%), minor or no change in appearance (69%), return to baseline endurance level (37%), no limitations in recreation (40%), no changes in swallowing following reconstruction (28%), minor or no limitations in mastication (29%), minor or no speech difficulties (93%), no changes in shoulder function (84%), normal taste function (19%), normal saliva production (27%), generally excellent mood (44%), and no or minimal anxiety about cancer (94%).

CONCLUSION

The majority of patients maintained or had advancement in diet following reconstruction, with low rates of osteonecrosis or cancer recurrence and above-average scores on UW-QOL survey suggesting good return of function and quality of life.

Labiomental sensation after segmental mandibulectomy and inferior alveolar nerve preservation for osteoradionecrosis

Advanced mandibular osteoradionecrosis requires a segmental mandibulectomy with reconstruction using a free fibular flap. The conservation of labiomental sensation by lateralization of the inferior alveolar nerve is unusual during a segmental mandibulectomy. A protocol for the evaluation of labiomental sensation has been created for the clinical follow-up of operated patients. The patients included were patients with mandibular osteoradionecrosis who underwent a segmental mandibulectomy with reconstruction by free fibular flap and whose pre-operative labiomental sensation was preserved. All patients were followed-up by the same examiner and operated on by the same surgeon. The neuro-sensitive examination analyses the different forms of sensation at 1 week and at 12 months postoperatively. Between May 2017 and May 2018, 3 consecutive patients were assessed. The results of the labiomental sensitive evaluation using our evaluation protocol attest to the preservation of labiomental sensation. The operating time was increased by an average of 35 min per surgical procedure. The conservation and re-routing of the inferior alveolar nerve in segmental mandibulectomy with fibula free flap reconstruction in patients with osteoradionecrosis allows for the preservation of labiomental sensation, which improves the quality of life of patients. Our protocol can be used in all surgical procedure that affect sensibility.

Timing of dental extractions in patients undergoing radiotherapy and the incidence of osteoradionecrosis: a systematic review and meta-analysis

This systematic review aimed to examine whether the incidence of osteonecrosis differed between patients who have dental extractions before or after radiotherapy (RT). The reported incidence of osteoradionecrosis (ORN) of the jaws following RT to the head and neck varies widely in the literature. Currently, for patients with head and neck cancer there are no universally accepted guidelines on the optimal timing of dental surgery relative to RT to minimise incident ORN. A literature review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) criteria. A search of PubMed, EMBASE, Evidence-Based Medicine, and Web of Science databases targeted literature published up to and including 10 April 2020. Two independent reviewers assessed studies for eligibility against inclusion criteria. An assessment of bias was conducted for each of the included studies and relevant data extracted. A meta-analysis was undertaken using the statistical methods described. Twenty-four of 708 studies were included. They were heterogeneous and included a wide variation of RT methods, head and neck malignancies, and comorbidities. While some concluded that the incidence of ORN was dependent on the timing of dental extractions in relation to RT, with regard to the risk of its development, others reported additional factors such as age, comorbidities, extent of surgical resection, and dose and field of radiation, as more important predictors than timing. In many there was consistent lack of detail around the timing of dental procedures in relation to the delivery of RT. From 21 studies including 36,294 patients, of whom 14,389 had extractions before RT, the pooled incidence of ORN was 5.5% (95% CI: 2.1% to 10.1%). Significant heterogeneity was found in Cochran's Q-test (p<0.001) and Higgins I²=98.0%. From 21 studies including 37,805 patients, of whom 6030 had extractions after RT, the pooled incidence of ORN was 5.3% (95% CI: 2.9% to 8.2%). Significant heterogeneity was found in Cochran's Q-test (p<0.001) and Higgins I²=80.0%. There was no statistically significant difference between these two groups (random-effects model Q=0.12, p=0.73). Large, longitudinal studies with a priori-specified methods are needed to identify, recruit, and prospectively follow patients with head and neck cancer for the onset of ORN after dental surgery. This will allow clinical guidelines to be established to assist clinicians to plan treatment when extractions are indicated in patients undergoing RT to the head and neck.

Primary vs Secondary Endosseous Implantation After Fibular Free Tissue Reconstruction of the Mandible for Osteoradionecrosis

Importance

The clinical and financial implications of the timing of dental rehabilitation after a fibula free tissue transfer (FFTT) for osteoradionecrosis (ORN) and osteonecrosis (ON) of the mandible have yet to be established.

Objective

To compare the outcomes of primary implantation vs secondary implantation after FFTT for ORN and ON of the mandible.

Design, Setting, and Participants

A retrospective review was conducted of 23 patients at a single tertiary academic referral center undergoing primary implantation or secondary implantation after FFTT for ORN and ON from January 1, 2006, to November 10, 2015.

Interventions

All patients underwent FFTT with primary implantation (n = 12) or secondary implantation (n = 11).

Main Outcomes and Measures

Outcomes of FFTT, dental implantation, implant use, diet, speech, and disease-free survival were reviewed. Fixed unit costs were estimated based on the mean cost analysis.

Results

Twenty-three patients (7 women and 16 men; mean [SD] age, 62.4 [8.2] years [range, 24-81 years]) met the inclusion criteria. Of these, 18 had ORN and 5 had ON. Dental implantation was performed at the time of FFTT for 12 patients and was performed secondarily for 11 patients. There were a mean of 5.2 implants per patient performed, for a total of 121 implants. There was 1 complete flap failure in the primary implantation group. Neither flap nor implant complications were affected by the timing of the implantation. Overall, the implant survival rate was 95% (55 of 58) in the primary implantation group and 98% (62 of 63) in the secondary implantation group. Time from FFTT to abutment placement (primary implantation, 19.6 weeks; secondary implantation, 61.0 weeks) was significantly shorter after primary implantation (P < .001). There was no clinical difference in postoperative complications and implant outcomes for ORN vs ON. Improvement in speech and oral competence in the primary implantation group vs the secondary implantation group was not statistically significant, given an experiment-adjusted P = .001 set as significant (normal speech, 9 vs 3; P = .02; and normal oral competence, 9 vs 3; P = .02). Disease-free survival was 91% (20 of 22 patients) overall. Fixed unit (U) costs were 1.0 U for primary implantation and 1.24 U for secondary implantation.

Conclusions and Relevance

Patients undergoing primary implantation after FFTT for ORN and ON had a similar rate of complications compared with those undergoing secondary implantation. However, primary implantation allowed a faster return than secondary implantation to oral nutrition and prosthesis use. The fixed unit cost was reduced for those undergoing primary implantation. Although dental implantation was safe and effective in both groups, the decreased time to use and the decreased overall cost should prompt surgeons to consider primary implantation after FFTT for ORN and ON.

Level of Evidence

3.

Symptom distress and interference among cancer patients with osteoradionecrosis of jaw: A cross-sectional study

Objective

Osteoradionecrosis of the jaws (ORNJ) is among the most serious oral complications of head and neck cancer treatment with radiation therapy. This study aimed to examine the level of symptom distress and interference of ORNJ in head and neck cancer patients in China.

Methods

A cross-sectional study was conducted to profile patient reported symptom severity. Ninety-five hospitalized ORNJ patients were recruited. Participants completed the MD Anderson Symptom Inventory–Head and Neck Module-Chinese version.

Results

The percentage of participants who reported that they experienced at least one type of symptom was 97.9%, and 85.2% patients reported interference. The 10 most severe symptoms were as follows: limited mouth opening, problem with teeth/gums, difficulty swallowing/chewing, dry mouth, oral malodor, difficulty with voice/speech, dental ulcer, tinnitus/ear obstruction, skin pain/burning/rash, and difficulty hearing. The problem of limited mouth opening was more severe in patients with longer time to onset of ORNJ after radiotherapy. The interference of patients positively correlated with core symptoms (r = 0.612), head and neck symptoms (r = 0.709), and ORNJ symptoms (r = 0.440) (P < 0.01). The longer time to the onset of ORNJ after radiotherapy was positively and significantly correlated with symptom distress (r = 0.479, P < 0.001), and mouth opening correlated negatively with symptom distress (r = −0.298, P = 0.003).

Conclusions

ORNJ patients suffered mainly from limited mouth opening and other maxillofacial symptoms. The problem of limited mouth opening was more severe in patients with longer time to onset of ORNJ after radiotherapy. ORNJ patients commonly had symptom distress, which influenced their quality of life.

Quality of life after microvascular mandibular reconstruction for osteoradionecrosis-A prospective study

BACKGROUND

Reconstructive surgery for mandibular osteoradionecrosis is increasing; however, evidence regarding the impact on health-related quality of life is lacking. The current exploratory study prospectively investigates whether resection with reconstruction is associated with changes in HRQoL parameters for these patients.

METHODS

Seventeen patients underwent microvascular reconstruction for mandibular osteoradionecrosis between 2012 and 2015, and 16 completed the EORTC quality of life questionnaires QLQ-C30 and QLQ-H&N35 1 month before and 1 year after surgery.

RESULTS

Increases in emotional (P = 0.01) and social functioning (P = 0.004) were observed, together with improvements in the fatigue (P = 0.04), appetite loss (P = 0.02) and pain (P = 0.02) scores, as evaluated by the QLQ-C30. Pain reduction was further confirmed by the QLQ-H&N35 (P = 0.04), which also showed improved scores for feeling ill (P = 0.001) and sexual difficulties (P = 0.04).

CONCLUSION

This exploratory study suggests that microvascular reconstruction after mandibular osteoradionecrosis may improve HRQoL, with an emphasis on pain reduction; however, further studies are needed.

Modern management of osteoradionecrosis

PURPOSE OF REVIEW

Despite recent advances in radiotherapy, osteoradionecrosis (ORN) remains a common and difficult complication of radiation therapy in head and neck cancer patients. Available treatment options are complementary to its complex pathophysiology and the currently available theories of ORN development. The efficacy of hyperbaric oxygen therapy has recently been questioned, and therapies targeting the fibroatrophic process have become a focus of ORN treatment. The objective of this review is to evaluate the literature regarding ORN of the mandible, with a focus on available treatment options.

RECENT FINDINGS

The recently proposed fibroatrophic theory has challenged the traditional hypovascular-hypoxic-hypocellular theory as the mechanism of ORN. Medical management targeting this fibroatrophic process offers promising results, but has yet to be confirmed with robust clinical trials. The routine use of hyperbaric oxygen therapy is not substantiated in the literature, but may be justified for select patients. Systemic steroids may also have a role, though data are limited.

SUMMARY

The fibroatrophic process has gained acceptance as a main mechanism of ORN. No gold standard treatment or consensus guidelines exist, though a combination of therapeutic strategies should be considered, taking into account the severity of disease and individual patient characteristics.

Management of incidental discovery of microscopic squamous cell carcinoma in zones of osteoradionecrosis of the mandible

OBJECTIVES

Osteoradionecrosis (ORN) of the mandible is a common complication of head and neck radiotherapy and often requires surgical treatment. Squamous cell carcinoma (SCC) can be exceptionally discovered within zones of ORN on histological examination of the operative specimen. The authors discuss the management of these lesions based on a short patient series.

MATERIALS AND METHODS

This single-centre retrospective study was based on patients managed between 2012 and 2014 for ORN with incidental discovery of microscopic SCC.

RESULTS

Five patients with incidental discovery of microscopic SCC in a zone of ORN of the mandible were included in this study. The mean time to onset of ORN after the end of radiotherapy for locally advanced SCC of the oral cavity or oropharynx was 42 months. Surgical treatment consisted of marginal or segmental mandibulectomy with free flap reconstruction. No recurrence was observed with a mean follow-up of 35 months [24-46].

CONCLUSION

The incidental discovery of microscopic SCC in a zone of ORN of the mandible is a rare event and has not been reported in the literature. Optimal management cannot be reliably defined due to the lack of data in the literature, but the present study supports careful histological examination of ORN specimens. Treatment must be as conservative as possible to avoid excessively invasive surgery.

Efficacy of Adjunctive Hyperbaric Oxygen Therapy in Osteoradionecrosis

Osteoradionecrosis (ORN) is a common consequence resulting from radiation in patients with cancer. Presently, hyperbaric oxygen therapy (HBOT) is proposed to have a role in improving wound healing in ORN patients. There is no strong scientific evidence to confirm the benefits of HBOT for treatment of ORN as an adjunctive treatment. This study aimed to determine the benefits of adjunctive treatment of HBOT in ORN. A retrospective study was conducted at the Srinagarind Hospital, the Faculty of Medicine, Khon Kaen University, Thailand, between 2011 and 2017. The patients diagnosed with ORN, who received adjunctive HBOT before the operation, were enrolled. Complete healing of wounds was the primary outcome. There were 84 ORN patients with a mean age of 58.78 years; 54.76% were male and 45.24% were female. HBOT had a role significant in improving wound healing of ORN patients with stages 1 and 2. Poisson regression analysis showed that stage 3 of ORN negatively correlated with the number of HBOT dives (p = 0.001, incidence rates ratio = 0.85). In conclusion, HBOT improved wound healing of ORN patients with stages 1 and 2. In addition, stage 2 of ORN patients significantly required the highest number of HBOT dives compared to other types of ORN to promote wound healing, whereas stage 3 patients, who underwent bone debridement combined with HBOT, initiated to success of treatment process and required a smaller number of dives.

Association between pain severity and clinicohistopathologic findings in the mandibular canal and inferior alveolar nerve of patients with advanced mandibular osteoradionecrosis

OBJECTIVE

Pain is one of the most problematic symptoms in patients with osteoradionecrosis of the jaws. This study investigated the associations between pain severity and morphologic alterations of the mandibular canal and inferior alveolar nerve, in respective computerized tomography images and resected specimens of mandibular osteoradionecrosis.

STUDY DESIGN

We assessed 14 lesions in 13 patients who underwent segmental mandibulectomy for surgical debridement and simultaneous reconstruction with free fibula flap (1 patient exhibited bilateral lesions). The extent of the mandibular canal bone defect on preoperative coronal computerized tomography images and the number of inferior alveolar nerve fascicles in resected specimens were evaluated. Comparisons were made between the slight pain and extreme pain groups. In most of the patients in the extreme pain group, either mandibular canal bone defects were absent or entire circumferential defects were present; inferior alveolar nerve fascicles were either distinguishable or completely absent in the resected specimens.

RESULTS

Although there was no statistically significant association between extreme pain and computerized tomography or histopathologic findings, the histopathologically indistinguishable inferior alveolar nerve fascicles was significantly associated with slight pain.

CONCLUSIONS

The degree of degeneration of mandibular canal and inferior alveolar nerve may be associated with pain severity in patients with mandibular osteoradionecrosis.

Using PROMs to guide patients and practitioners through the head and neck cancer journey

The measurement of patient-reported outcome measures (PROMs) following head and neck cancer (HNC) has the capacity to substantially enhance the care of patients and their care-givers following the diagnosis and treatment of HNC. Literature concerning PROMs has increased exponentially in the past 2 decades, producing a vast array of data upon which the multidisciplinary team can reflect. For this review, “Handle On QOL” has been used as a source of references to illustrate the points raised. PROMs are contextualized by considering the clinically-distinct key stages that cancer patients endure: diagnosis, treatment, acute toxicity, early recovery, late effects, recurrence, and palliation. The PROMs are considered in six main categories: 1) those addressing cornucopia of issues not specific to cancer; 2) those addressing issues common to all cancers; 3) questionnaires with items specific to HNC; 4) questionnaires that focus on a particular aspect of head and neck function; 5) those measuring psychological concerns, such as depression, anxiety, or self-esteem; and 6) item prompt lists. Potential benefits of PROMs in clinical practice are discussed, as are barriers to use. The way forward in integrating PROMs into routine HNC care is discussed with an emphasis on information technology.

Treatment of late sequelae after radiotherapy for head and neck cancer

Radiotherapy (RT) is used to treat approximately 80% of patients with cancer of the head and neck. Despite enormous advances in RT planning and delivery, a significant number of patients will experience radiation-associated toxicities, especially those treated with concurrent systemic agents. Many effective management options are available for acute RT-associated toxicities, but treatment options are much more limited and of variable benefit among patients who develop late sequelae after RT. The adverse impact of developing late tissue damage in irradiated patients may range from bothersome symptoms that negatively affect their quality of life to severe life-threatening complications. In the region of the head and neck, among the most problematic late effects are impaired function of the salivary glands and swallowing apparatus. Other tissues and structures in the region may be at risk, depending mainly on the location of the irradiated tumor relative to the mandible and hearing apparatus. Here, we review the available evidence on the use of different therapeutic strategies to alleviate common late sequelae of RT in head and neck cancer patients, with a focus on the critical assessment of the treatment options for xerostomia, dysphagia, mandibular osteoradionecrosis, trismus, and hearing loss.

Symptom burden and dysphagia associated with osteoradionecrosis in long-term oropharynx cancer survivors: A cohort analysis

OBJECTIVE

The purpose is to examine the relationship between mandibular osteoradionecrosis (ORN) and chronic dysphagia in long-term oropharynx cancer (OPC) survivors, and to determine the perceived symptom burden associated with ORN.

MATERIALS AND METHODS

Medical records of 349 OPC patients treated with bilateral IMRT and systemic therapy were reviewed. ORN was graded using a published 4-point classification schema. Patients were considered to have chronic dysphagia if they had aspiration pneumonia, stricture or aspiration detected by fluoroscopy or endoscopy, and/or feeding tube dependence in long-term follow-up ⩾1year following radiotherapy. MD Anderson Symptom Inventory - Head and Neck Module (MDASI-HN) scores were analyzed in a nested cross-sectional survey sample of 118 patients.

RESULTS

34 (9.7%, 95% CI: 6.8-13.3%) patients developed ORN and 45 (12.9%, 95% CI: 9.6-16.9%) patients developed chronic dysphagia. Prevalence of chronic dysphagia was significantly higher in ORN cases (12/34, 35%) compared to those who did not develop ORN (33/315, 11%, p<0.001). ORN grade was also significantly associated with prevalence of dysphagia (p<0.001); the majority of patients with grade 4 ORN requiring major surgery (6 patients, 75%) were found to have chronic dysphagia. Summary MDASI-HN symptom scores did not significantly differ by ORN grade. Significantly higher symptom burden was reported, however, among ORN cases compared to those without ORN for MDASI-HN swallowing (p=0.033), problems with teeth and/or gums (p=0.016) and change in activity (p=0.015) item scores.

CONCLUSIONS

ORN is associated with excess burden of chronic dysphagia and higher symptom severity related to swallowing, dentition and activity limitations.

Potential risk factors for jaw osteoradionecrosis after radiotherapy for head and neck cancer

INTRODUCTION

To identify potential risk factors for the development of jaw osteoradionecrosis (ORN) after 3D-conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) among patients with newly diagnosed head and neck cancer.

MATERIAL AND METHODS

This study included 776 patients who underwent 3D-CRT or IMRT for head and neck cancer at the Department of Radiotherapy at the University Hospital Halle-Wittenberg between 2003 and 2013. Sex, dental status prior to radiotherapy, tumor site, bone surgery during tumor resection, concomitant chemotherapy, and the development of advanced ORN were documented for each patient. ORN was classified as grade 3, 4, or 5 according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer classification or grade 3 or 4 according to the late effects in normal tissues/subjective, objective, management, and analytic scale. The cumulative incidence of ORN was estimated. Cox regression analysis was used to identify prognostic risk factors for the development of ORN.

RESULTS

Fifty-one patients developed advanced ORN (relative frequency 6.6 %, cumulative incidence 12.4 %). The highest risk was found in patients who had undergone primary bone surgery during tumor resection (hazard ratio [HR] = 5.87; 95 % confidence interval [CI]: 3.09-11.19) and in patients with tumors located in the oral cavity (HR = 4.69; 95 % CI: 1.33-16.52). Sex, dentition (dentulous vs. edentulous), and chemotherapy had no clinically relevant influence.

DISCUSSION AND CONCLUSION

In contrast to most previous studies, we noted a low cumulative incidence of advanced ORN. Patients with tumors located in the oral cavity and those who undergo bone surgery during tumor resection prior to RT may be considered a high-risk group for the development of ORN.

Reconstruction of composite oral cavity defects with temporalis flaps after prior treatment

BACKGROUND

Reconstruction of composite oral cavity defects in the setting of prior surgery and radiotherapy presents a significant challenge. Although free tissue transfer has shown success in such situations, it is not without considerable risk. Regional pedicled flaps may provide a more suitable alternative. In certain patients, however, severe soft tissue fibrosis makes more conventional regional flaps impractical or impossible. In these situations, temporalis flaps (temporalis muscle and temporoparietal fascia flaps) are versatile options for coverage of complex defects.

OBJECTIVE

To report our experience using pedicled temporalis flaps for reconstruction of composite oral cavity defects in patients with significant co-morbidities and prior treatment.

METHODS

Three patients were identified and their medical records were reviewed. Their clinical courses and functional outcomes are described. We include a discussion of the operative technique and relevant literature.

RESULTS

All patients had previously undergone extensive treatment. One patient needed reconstruction after resection of a third head and neck malignancy and two patients presented for treatment of osteoradionecrosis. A temporalis muscle flap was used to reconstruct composite oral cavity defects in two patients and a combined temporalis muscle and temporoparietal fascia flap was used for independent defects in one patient. All flaps survived. Functional status and pain improved or stabilized in all patients. There were no major or minor complications.

CONCLUSION

In previously treated fields, where more conventional flaps are impractical, temporalis flaps are a suitable alternative to achieve a stable healing wound and prevent worsening of functional status.

Biomaterial scaffolds for treating osteoporotic bone

Healing fractures resulting from osteoporosis or cancer remains a significant clinical challenge. In these populations, healing is often impaired not only due to age and disease, but also by other therapeutic interventions such as radiation, steroids, and chemotherapy. Despite substantial improvements in the treatment of osteoporosis over the last few decades, osteoporotic fractures are still a major clinical challenge in the elderly population due to impaired healing. Similar fractures with impaired healing are also prevalent in cancer patients, especially those with tumor growing in bone. Treatment options for cancer patients are further complicated by the fact that bone anabolic therapies are contraindicated in patients with tumors. Therefore, many patients undergo surgery to repair the fracture, and bone grafts are often used to stabilize orthopedic implants and provide a scaffold for ingrowth of new bone. Both synthetic and naturally occurring biomaterials have been investigated as bone grafts for repair of osteoporotic fractures, including calcium phosphate bone cements, resorbable polymers, and allograft or autograft bone. In order to re-establish normal bone repair, bone grafts have been augmented with anabolic agents, such as mesenchymal stem cells or recombinant human bone morphogenetic protein-2. These developing approaches to bone grafting are anticipated to improve the clinical management of osteoporotic and cancer-induced fractures.