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Zheng M, Liu Z, He Y. Radiation-induced fibrosis: Mechanisms and therapeutic strategies from an immune microenvironment perspective. Immunology 2024; 172:533-546. [PMID: 38561001 DOI: 10.1111/imm.13788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
Radiation-induced fibrosis (RIF) is a severe chronic complication of radiotherapy (RT) manifested by excessive extracellular matrix (ECM) components deposition within the irradiated area. The lung, heart, skin, jaw, pelvic organs and so on may be affected by RIF, which hampers body functions and quality of life. There is accumulating evidence suggesting that the immune microenvironment may play a key regulatory role in RIF. This article discussed the synergetic or antagonistic effects of immune cells and mediators in regulating RIF's development. Several potential preventative and therapeutic strategies for RIF were proposed based on the immunological mechanisms to provide clinicians with improved cognition and clinical treatment guidance.
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Affiliation(s)
- Mengting Zheng
- Department of Oral Maxillofacial & Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
| | - Zhonglong Liu
- Department of Oral Maxillofacial & Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
| | - Yue He
- Department of Oral Maxillofacial & Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, Shanghai, China
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Sweeny L, Long SM, Pipkorn P, Wax MK, Thomas CM, Curry JM, Yang S, Lander D, Chowdhury F, Amin D, Kane AC, Miles BA, Salama A, Cannady SB, Tasche K, Mann D, Jackson R. Microvascular reconstruction of medication related osteonecrosis of the head and neck. Head Neck 2024; 46:1902-1912. [PMID: 38294050 DOI: 10.1002/hed.27653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/04/2024] [Accepted: 01/13/2024] [Indexed: 02/01/2024] Open
Abstract
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.
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Affiliation(s)
- Larissa Sweeny
- Department of Otolaryngology-Head and Neck Surgery, University of Miami, Miami, Florida, USA
- Surgical Care Division, Miami Veterans Affairs Health Care System, Miami, Florida, USA
| | - Sallie M Long
- Department of Otolaryngology-Head and Neck Surgery, University of Miami, Miami, Florida, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, Missouri, USA
| | - Mark K Wax
- Oregon Health and Science University School of Medicine, Oregon, Portland, USA
| | - Carissa M Thomas
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sara Yang
- Oregon Health and Science University School of Medicine, Oregon, Portland, USA
| | - Daniel Lander
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, Missouri, USA
| | - Farshad Chowdhury
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Dev Amin
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Anne C Kane
- Department of Otolaryngology, University of Mississippi, Jackson, Mississippi, USA
| | - Brett A Miles
- Department Otolaryngology Head and Neck Oncology, Northwell Health System, New York, New York, USA
| | - Andrew Salama
- Division Oral and Maxillofacial Surgery, Northwell Health System, New York, New York, USA
| | - Steven B Cannady
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kendall Tasche
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Derek Mann
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, Missouri, USA
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de Morais RPL, de Aguiar AWPB, da Hora Sales PH, Carvalho ADAT, Vescovi P, Meleti M, Leão JC. Is the use of Pentoxifylline and Tocopherol effective in the treatment of Osteoradionecrosis of the jaws or for the treatment of medicationosteonecrosis of the jaw? An overview. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024:101959. [PMID: 38964469 DOI: 10.1016/j.jormas.2024.101959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 06/30/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE The aim of the present study was to determine the methodological quality of systematic reviews that evaluated the effectiveness of pentoxifylline and tocopherol (PENTO) in the treatment of osteoradionecrosis of the jaw (ORNJ) and medication-related osteonecrosis of the jaw (MRONJ). METHODS Searches were performed in Databases including PubMed, Scopus, LILACS, DARE, Cochrane Library, and SIGLE through OpenGrey until March 2024, were evaluated by two independent reviewers to answer the following question: Is the use of PENTO protocol effective in the treatment of ORNJ or for the treatment of MRONJ? RESULTS A total of 256 articles were initially identified; however, following the use of appropriate inclusion and exclusion criteria, five systematic reviews were identified for detailed analysis. The final study sample comprised 588 patients: 397 patients with ORN and 197 patients with MRONJ who were treated with PENTO. The total recovery of individuals who used the PENTO protocol was 62,2 % for ORN and 100 % for MRONJ, with a follow-up period of 1 month to 10 years. The methodological quality of the studies was assessed using the AMSTAR 2 tool, in which four were of low quality and 1 moderate quality. CONCLUSION The treatment of ORN and MRONJ with pentoxifylline and tocopherol has shown good results in the studies presented, with a partial or total reduction in bone exposure. However, the low quality of the relevant reports highlights the need for primary and secondary studies with better methodological rigor to reduce bias and provide reassurance for this treatment option.
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Affiliation(s)
- Rayane Portela Lima de Morais
- Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235, Recife, Brazil
| | | | | | | | - Paolo Vescovi
- Department of Medicine and Surgery, Università degli Studi di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Marco Meleti
- Department of Medicine and Surgery, Università degli Studi di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Jair Carneiro Leão
- Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235, Recife, Brazil.
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Hurrell MJL, Leinkram D, Stokan MJ, Clark JR. Medial Femoral Condyle Periosteal Free Flap for Bone Coverage Following Debridement of Intermediate-Stage Osteoradionecrosis of the Jaw. J Craniofac Surg 2024; 35:1174-1176. [PMID: 38635500 DOI: 10.1097/scs.0000000000010059] [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: 12/18/2023] [Accepted: 01/11/2024] [Indexed: 04/20/2024] Open
Abstract
STUDY DESIGN Case report. Osteoradionecrosis (ORN) of the jaw is a potentially devastating consequence of head and neck irradiation. The progression of ORN can lead to loss of bone, teeth, soft tissue necrosis, pathologic fracture, and oro-cutaneous fistula. Reconstructive surgery has mostly been reserved for late-stage disease where segmental resections are frequently necessary. Evidence is emerging to support earlier treatment in the form of debridement in combination with soft tissue free flaps for intermediate-stage ORN. The authors present a case of a 76-year-old male with persistent Notani 2 ORN of the mandible, treated with surgical removal of all remaining mandibular teeth, transoral debridement of all necrotic mandibular bone, and bone coverage with a left medial femoral condyle (MFC) periosteal free flap based on the descending genicular artery. Treatment was uneventful both intraoperatively and postoperatively. Since surgery (15 mo) the patient has remained free from clinical and radiologic signs of ORN. The MFP periosteal free flap provided an excellent result with minimal surgical complexity and morbidity in this case. Such treatment at an intermediate stage likely results in a reduction in segmental resections, less donor site morbidity, less operative time, less overall treatment time, and possibly fewer postoperative complications compared with the status quo.
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Affiliation(s)
- Michael J L Hurrell
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, NSW
- Maxillofacial Surgery Unit, Gold Coast Hospital and Health Service, Gold Coast University Hospital
- School of Medicine and Dentistry, Griffith University, Southport, QLD
| | - David Leinkram
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, NSW
| | - Murray J Stokan
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, NSW
| | - Jonathan R Clark
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, NSW
- Sydney Medical School, Faculty of Medicine and Health Sciences, University of Sydney
- Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, NSW, Australia
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Peterson DE, Koyfman SA, Yarom N, Lynggaard CD, Ismaila N, Forner LE, Fuller CD, Mowery YM, Murphy BA, Watson E, Yang DH, Alajbeg I, Bossi P, Fritz M, Futran ND, Gelblum DY, King E, Ruggiero S, Smith DK, Villa A, Wu JS, Saunders D. Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline. J Clin Oncol 2024; 42:1975-1996. [PMID: 38691821 DOI: 10.1200/jco.23.02750] [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: 12/20/2023] [Accepted: 01/22/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer. METHODS The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008. RESULTS A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation. RECOMMENDATIONS Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.
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Affiliation(s)
| | | | - Noam Yarom
- Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Charlotte Duch Lynggaard
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Lone E Forner
- Department of Oral and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark
| | | | - Yvonne M Mowery
- UPMC Hillman Cancer Center, Pittsburgh, PA
- University of Pittsburgh, Pittsburgh, PA
| | | | - Erin Watson
- Department of Dental Oncology, Princess Margaret Cancer Center/Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - David H Yang
- BC Cancer/University of British Columbia, Vancouver, Canada
| | - Ivan Alajbeg
- University of Zagreb School of Dental Medicine, Zagreb, Croatia
| | - Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Neal D Futran
- University of Washington School of Medicine, Seattle, WA
| | | | - Edward King
- Northern Colorado Head and Neck Cancer Support Group, Windsor, CO
| | - Salvatore Ruggiero
- New York Center for Orthognathic and Maxillofacial Surgery, New York, NY
| | | | | | - Jonn S Wu
- BC Cancer/University of British Columbia, Vancouver, Canada
| | - Deborah Saunders
- Health Sciences North Research Institute, Northern Ontario School of Medicine, Health Sciences North, Sudbury, Ontario, Canada
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Grasl S, Wassipaul C, Fischer G, Arnoldner C, Janik S. An Unknown Foreign laryngeal Object: an exotic complication of skull base osteoradionecrosis. Eur Arch Otorhinolaryngol 2024; 281:2755-2759. [PMID: 38381152 PMCID: PMC11023982 DOI: 10.1007/s00405-024-08507-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Osteoradionecrosis (ORN) of the skull base is a rare complication after head and neck radiation with a broad variety of subsequent complications. METHODS A 68-year-old woman with a complex oncological history (right-sided sphenoid meningioma; left-sided neck metastasis of a Cancer of Unknown Primary-CUP) was admitted with a right-sided epi-/ oropharyngeal mass and severe pain exacerbations for further evaluation. CT scan revealed an advanced ORN of the skull base with subsequent abruption of the ventral part of the clivus. This dislocated part of the clivus wedged in the oropharynx for 48 h and then moved towards the larynx, resulting in dyspnea and almost complete airway obstruction. RESULTS Due to the dangerous airway situation, an urgent exploration and removal of the dislocated clivus was necessary. After a potential cervical spine instability was ruled out, the patient's airway was initially secured with an awake tracheotomy and the clivus was removed transorally. The tracheostomy tube was removed during the ongoing inpatient stay, and the patient was discharged with significant pain relief. CONCLUSIONS The present case illustrates an orphan complication of skull base ORN resulting in a major airway emergency situation.
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Affiliation(s)
- Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Wassipaul
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Gregor Fischer
- Department of Otolaryngology, Karl Landsteiner University Hospital, Krems, Austria
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria.
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Owosho AA, DeColibus KA, Okhuaihesuyi O, Levy LC. Prophylactic Use of Pentoxifylline and Tocopherol for Prevention of Osteoradionecrosis of the Jaw after Dental Extraction in Post-Radiated Oral and Oropharyngeal Cancer Patients: An Initial Case Series. Dent J (Basel) 2024; 12:83. [PMID: 38667995 PMCID: PMC11049290 DOI: 10.3390/dj12040083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Osteoradionecrosis of the jaw is a morbid complication of radiotherapy in patients with oral and oropharyngeal cancers that may be precipitated by dental extractions. Pentoxifylline and tocopherol (PENTO) has been utilized in the management of osteoradionecrosis and as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. This observational study aims to report the outcome of the prophylactic use of PENTO in the prevention of osteoradionecrosis of the jaw after dental extractions in post-radiated oral and oropharyngeal cancer patients and to review the current literature on this topic. Four post-radiated oral and oropharyngeal oncology patients were referred to the dental oncology clinic of the University Dental Practice, University of Tennessee Health Sciences Center for dental extractions. All four patients were prescribed pentoxifylline 400 mg BID (twice a day) and tocopherol 400 IU BID (oral tablets) for 2 weeks before extraction(s) and for 6 weeks after extraction(s). All patients were followed up every week after the second week post-extraction if feasible until the extraction site(s) healed (covered by mucosa). The assessment endpoint was defined as 6 weeks post-extraction with the outcomes assessed as using four categories determined by the area of exposed bone: complete healing (complete mucosal coverage of extraction site); partial healing (reduction in size of extraction site); no change; and progression (increase in size of the extraction site). At the assessment endpoint, all patients had complete healing of all extraction sites. The ORN rate at the patient level (0/4) and individual tooth level (0/8) was 0%. All patients tolerated the PENTO medications and no adverse effects from the use of these medications were reported. This limited study in addition to the other reviewed studies estimates the rate of ORN at the patient level as 3.2% (14/436) for post-radiated head and neck oncology patients after dental extractions/invasive oral procedures. In conclusion, this PENTO regimen can reduce/prevent the incidence of ORN in post-radiated head and neck oncology patients. This safe and cost-effective protocol (PENTO regimen) should be further evaluated as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. We recommend large prospective studies to be carried out to further validate these findings.
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Affiliation(s)
- Adepitan A. Owosho
- Department of Diagnostic Sciences, College of Dentistry/Department of Otolaryngology—Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, 875 Union Avenue, Memphis, TN 38163, USA
| | - Katherine A. DeColibus
- Department of Diagnostic Sciences, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Osariemen Okhuaihesuyi
- Missouri School of Dentistry and Oral Health, A.T. Still University, Kirksville, MO 63501, USA
| | - Layne C. Levy
- Advanced Education in General Dentistry, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
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Quah B, Yong CW, Lai CWM, Islam I. Efficacy of adjunctive modalities during tooth extraction for the prevention of osteoradionecrosis: A systematic review and meta-analysis. Oral Dis 2024. [PMID: 38396363 DOI: 10.1111/odi.14902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/18/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Jaw osteoradionecrosis (ORN) is a complication in patients with previous head and neck radiotherapy. Its incidence increases with dental extractions. Hence, this review aimed to evaluate the efficacy of adjunctive treatment modalities undertaken at the time of extraction in previous head and neck radiotherapy patients in preventing ORN. METHODS A systematic review was conducted, where studies with data on ORN incidence after extraction with or without adjunctive interventions were included. Meta-analyses were conducted to estimate the pooled prevalence of ORN per intervention and the pooled odds ratio for incidence of ORN between interventions. RESULTS In total, 1520 patients in 29 studies were included. Interventions identified were hyperbaric oxygen (HBO), pentoxifylline-tocopherol (PENTO), antibiotics (ABX), platelet-rich fibrin and photobiomodulation. The pooled prevalence of ORN for HBO (4.6%), PENTO (3.4%) and ABX (3.8%) was significantly lower than the Control (17.6%). For studies with direct comparisons between groups, HBO had lower but not significant odds of developing ORN than the Control (OR 0.27) and ABX (OR 0.57). CONCLUSIONS HBO, PENTO and ABX may reduce the incidence of ORN compared to no intervention. Given that all three have similar incidences of ORN, ABX may be the most cost-effective and accessible adjunctive modality.
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Affiliation(s)
- Bernadette Quah
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
| | - Chee Weng Yong
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
| | - Clement Wei Ming Lai
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
| | - Intekhab Islam
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
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Patel V, Young H, Mellor A, Sproat C, Kwok J, Cape A, Mahendran K. The use of liquid formulation pentoxifylline and vitamin E in both established and as a prophylaxis for dental extractions "at risk" of osteoradionecrosis. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 136:404-409. [PMID: 37316424 DOI: 10.1016/j.oooo.2023.02.012] [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: 01/17/2023] [Revised: 02/08/2023] [Accepted: 02/19/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Osteoradionecrosis (ORN) of the jaws remains one of the most debilitating complications of radiotherapy (RT) in patients with head and neck cancer (HNC). Liquid pentoxifylline and vitamin E (PVe) presents an alternative formulation to tablets for patients with dysphagia or enteric feeding. OBJECTIVE This study aimed to assess the clinical outcomes of using a liquid formulation of PVe for both established ORN and as a prophylaxis to avoid its occurrence after dental extractions. A secondary objective was to determine patient-reported side effects in relation to the liquid formulation of PVe. STUDY DESIGN The clinical records of 111 patients with HNC who were prescribed liquid PVe were reviewed retrospectively (66 with established ORN and 45 as prophylaxis before an invasive dental procedure). RESULTS In established ORN, 44% healed, and 41% were stable. In the prophylaxis group, 96% of surgical sites healed completely, with 4% (n = 2) developing ORN. Most patients (89%) were able to tolerate liquid PVe. Of the 11% (n = 12) who could not tolerate this regime, the most commonly reported side effect was gastric irritation (n = 5/12), whereas no more than 1 patient reported dizziness, malaise, and bleeding. CONCLUSIONS This retrospective review suggests that liquid PVe is efficacious for both established ORN and as a prophylaxis. Side effects reported were similar to those recognized for the tablet formulation.
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Affiliation(s)
- Vinod Patel
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Helen Young
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Amy Mellor
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Chris Sproat
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jerry Kwok
- Oral Surgery Department, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Angela Cape
- King's College London, London, United Kingdom
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Kosaraju N, Zhang H, Qi S, Chin R, Wang MB. Anterior Skull Base Osteoradionecrosis in the Age of Intensity-Modulated Radiation Therapy: A Case Series. J Neurol Surg Rep 2023; 84:e109-e112. [PMID: 37771656 PMCID: PMC10533358 DOI: 10.1055/a-2164-8637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
Background Despites advances in radiation technology, skull base osteoradionecrosis (ORN) continues to be a rare, devastating, and hard to treat complication of radiotherapy. We present three cases of anterior skull base ORN in a cohort treated with intensity-modulated radiation therapy (IMRT). Case Series Three patients developed anterior skull base ORN after receiving at least one round of IMRT. ORN was diagnosed through either nasal endoscopy or imaging findings. The first was a 59-year-old woman with a sinonasal squamous cell carcinoma. Her chemoradiation history was notable for reirradiation and a high dose of radiation (143.3 Gy). The second was a 55-year-old man with recurrent nasopharyngeal carcinoma, whose history was notable for a high dose of radiation (∼140 Gy) and for being reirradiated. The final patient was a 37-year-old woman with an unremarkable history who received radiotherapy (65.0 Gy) for an esthesioneuroblastoma. One patient was asymptomatic and did not receive ORN-specific therapy. The other two were treated with a combination of medical and surgical intervention with successful short-term outcomes (no evidence of infection). Conclusion Anterior skull base ORN can be treated through conservative and surgical means to achieve successful short-term outcomes. Further investigation of long-term outcomes is warranted.
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Affiliation(s)
- Nikitha Kosaraju
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States
| | - Huan Zhang
- Department of Head and Neck Surgery, UCLA Medical Center, Los Angeles, California, United States
| | - Sharon Qi
- Department of Radiation Oncology, UCLA Medical Center, Los Angeles, California, United States
| | - Robert Chin
- Department of Radiation Oncology, UCLA Medical Center, Los Angeles, California, United States
| | - Marilene B. Wang
- Department of Head and Neck Surgery, UCLA Medical Center, Los Angeles, California, United States
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Tang J, Li XW, Wu Y, Su Z, He Y, Sun XW, Cao XL, Li YH, Wang BC, Zou GR. Treating radiation‑related nasopharyngeal necrosis with endostar in patient with nasopharyngeal carcinoma: A report of two cases and a literature review. Mol Clin Oncol 2023; 19:57. [PMID: 37359714 PMCID: PMC10288433 DOI: 10.3892/mco.2023.2653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Radiation-related nasopharyngeal necrosis (RRNN) is a rare and often fatal complication in patients with nasopharyngeal carcinoma (NPC). Currently, no standard treatments are recommended for RRNN. The effects of traditional conservative treatments are suboptimal, and surgery for RRNN cannot be performed by inexperienced doctors. In the present study, the use of Endostar in two patients with RRNN was evaluated. Two patients with RRNN were treated at the Department of Oncology, Panyu Central Hospital (Guangzhou, China). Endostar was administrated (15 mg/day from day 1 to day 7, every three weeks) intravenously for four and seven cycles in a male and a female patient, respectively. The effects of Endostar were assessed using magnetic resonance imaging (MRI) and a nasopharyngoscope. The symptoms of RRNN in both patients were relieved after treatment with Endostar. MRI and nasopharyngoscope analysis revealed that necrosis of the nasopharynx was substantially decreased and nasopharyngeal ulcers were healed. Endostar has the potential to be a novel, effective therapy for the treatment of patients with RRNN. However, clinical trials are required to confirm the results of the present study.
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Affiliation(s)
- Jie Tang
- Department of Oncology, Panyu Central Hospital, Cancer Institute of Panyu, Guangzhou, Guangdong 511400, P.R. China
| | - Xiu-Wen Li
- Department of Cardiology, Panyu Central Hospital, Guangzhou, Guangdong 511400, P.R. China
| | - Yong Wu
- Department of Oncology, The Second Affiliated Hospital, School of Medicine, South China University of Technology Guangzhou, Guangdong 510180, P.R. China
- Guangzhou First People's Hospital, Guangzhou, Guangdong 510180, P.R. China
| | - Zhen Su
- Department of Oncology, Panyu Central Hospital, Cancer Institute of Panyu, Guangzhou, Guangdong 511400, P.R. China
| | - Yan He
- Department of Oncology, Panyu Central Hospital, Cancer Institute of Panyu, Guangzhou, Guangdong 511400, P.R. China
| | - Xue-Wen Sun
- Department of Oncology, Panyu Central Hospital, Cancer Institute of Panyu, Guangzhou, Guangdong 511400, P.R. China
| | - Xiao-Long Cao
- Department of Oncology, Panyu Central Hospital, Cancer Institute of Panyu, Guangzhou, Guangdong 511400, P.R. China
| | - Yi-Hua Li
- Department of Oncology, Panyu Central Hospital, Cancer Institute of Panyu, Guangzhou, Guangdong 511400, P.R. China
| | - Bi-Cheng Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Guo-Rong Zou
- Department of Oncology, Panyu Central Hospital, Cancer Institute of Panyu, Guangzhou, Guangdong 511400, P.R. China
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12
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Goh EZ, Beech N, Johnson NR, Batstone M. The dental management of patients irradiated for head and neck cancer. Br Dent J 2023; 234:800-804. [PMID: 37291302 PMCID: PMC10250190 DOI: 10.1038/s41415-023-5864-z] [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: 11/10/2022] [Revised: 02/10/2023] [Accepted: 03/03/2023] [Indexed: 06/10/2023]
Abstract
Patients undergoing radiotherapy for head and neck cancers are prone to a range of dental complications, including mucositis, trismus, xerostomia, radiation caries and osteoradionecrosis. Specific considerations include the preventive, restorative and rehabilitative management of such patients, and the prevention and treatment of complications. This article aims to highlight the current understanding and management of dental needs for patients who have had or will undergo radiotherapy.
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Affiliation(s)
- Elizabeth Z Goh
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
| | - Nicholas Beech
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nigel R Johnson
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; School of Dentistry, University of Queensland, Brisbane, Queensland, Australia; Oral and Maxillofacial Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Martin Batstone
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Oral and Maxillofacial Department, Royal Brisbane and Women´s Hospital, Brisbane, Queensland, Australia
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13
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The Progress in Reconstruction of Mandibular Defect Caused by Osteoradionecrosis. JOURNAL OF ONCOLOGY 2023; 2023:1440889. [PMID: 36968640 PMCID: PMC10033216 DOI: 10.1155/2023/1440889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/17/2023]
Abstract
Osteoradionecrosis (ORN) is described as a disease with exposed, nonviable bone that fails to heal spontaneously or by means of conservative treatment after radiotherapy in at least 3 months. Though traditional theories in the early stage including hypoxic-hypocellular-hypovascular and fibro-atrophic in addition to new findings such as ferroptosis were put forward to explain the mechanisms of the osteoradionecrosis, the etiology of ORN is still unclear. With the high rate of occurrence in the head and neck area, especially in the mandible, this disease can disrupt the shape and function of the irradiated area, leading to a clinical presentation ranging from stable small areas of asymptomatic exposed bone to severe progressive necrosis. In severe cases, patients may experience pain, xerostomia, dysphagia, facial fistulas, and even a jaw defect. Consequently, sequence therapy and sometimes extensive surgery and reconstructions are needed to manage these sequelae. Treatment options may include pain medication, antibiotics, the removal of sequesters, hyperbaric oxygen therapy, segmental resection of the mandible, and free flap reconstruction. Microanastomosed free-flaps are considered to be promising choice for ORN reconstruction in recent researches, and new methods including three-dimensional (3-D) printing, pentoxifylline, and amifostine are used nowadays in trying increase the success rates and improve quality of the reconstruction. This review summarizes the main research progress in osteoradionecrosis and reconstruction treatment of osteoradionecrosis with mandibular defect.
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14
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Lombardi N, Varoni E, Villa G, Salis A, Lodi G. Pentoxifylline and tocopherol for prevention of osteoradionecrosis in patients who underwent oral surgery: A clinical audit. SPECIAL CARE IN DENTISTRY 2023; 43:136-143. [PMID: 35895902 DOI: 10.1111/scd.12759] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/09/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Osteoradionecrosis (ORN) of the jaw is a severe and debilitating complication of the head and neck radiotherapy which frequently occurrs after oral surgery. This clinical audit aims aevaluate the effectiveness of combined use of pentoxifylline and tocopherol (PENTO) in prevention ORN onset in patient who underwent oral surgery after head and neck radiotherapy (RT). MATERIAL METHOD In this clinical audit Pentoxifylline 400 mg, twice a day, and Tocopherol 800 IU once a day (PENTO protocol) have been prescribed. Patients started the protocol 1 week before the surgical procedure and continued for 8 weeks after. RESULTS Twenty-nine patients were included. They received 75 surgical interventions under PENTO protocol: 71 surgical procedures of dental extraction (single or multiple dental extractions in each session) and four implant placements. A total of 152 dental extractions were carried out: 64 surgical extractions which required the raising of mucoperiosteal flap, and 88 simple extractions. Four out of 29 patients developed ORN after surgical procedures: four cases of ORN occurred after dental extractions (5.6%) and one case of ORN after implant placement (25%). CONCLUSION PENTO is a useful ORN preventive protocol, low-cost and clinically feasible, safe and well tolerated by patients. Further studies should focus on better defining the effectiveness PENTO, independently from the antibiotic therapy.
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Affiliation(s)
- Niccolò Lombardi
- Università degli Studi di Milano, Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Milan, Italy
- ASST Santi paolo e Carlo, Ospedale San Paolo, Milan, Italy
| | - Elena Varoni
- Università degli Studi di Milano, Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Milan, Italy
- ASST Santi paolo e Carlo, Ospedale San Paolo, Milan, Italy
| | - Giulio Villa
- Università degli Studi di Milano, Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Milan, Italy
| | - Annalisa Salis
- Università degli Studi di Milano, Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Milan, Italy
| | - Giovanni Lodi
- Università degli Studi di Milano, Dipartimento di Scienze Biomediche Chirurgiche e Odontoiatriche, Milan, Italy
- ASST Santi paolo e Carlo, Ospedale San Paolo, Milan, Italy
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15
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Sreenath SB, Grafmiller KT, Tang DM, Roof SA, Woodard TD, Kshettry VR, Recinos PF, Sindwani R, Fritz MA. Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era. Laryngoscope 2023; 133:562-568. [PMID: 35920134 DOI: 10.1002/lary.30315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/17/2022] [Accepted: 07/07/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Osteoradionecrosis (ORN) of the skull base and craniovertebral junction is a challenging complication of radiation therapy (RT). Severe cases often require surgical intervention through a multi-modal approach. With the evolution in endoscopic surgery and advances in skull base reconstruction, there is an increasing role for microvascular free tissue transfer (MFTT). We describe an endoscopic-assisted approach for the management of ORN of the skull base using fascia lata for MFTT. STUDY DESIGN Retrospective case series. METHODS Between 2017 and 2021, a review of all cases in which fascia lata MFTT was utilized for skull base ORN was performed. Patient demographics, preoperative characteristics, and postoperative outcomes with long-term follow-up were reviewed. RESULTS Five patients were identified. Mean duration to onset of ORN was 17 months following RT. A trial of antibiotics, hyperbaric oxygen (HBO), and/or limited debridement was attempted without success. Refractory pain and progressive osteomyelitis were unifying symptoms. All patients underwent endoscopic debridement of the affected region of ORN prior to MFTT. Vascularized fascia lata was inset through a combined endonasal and transoral corridor. There was improvement in chronic pain in the postop setting with no patients requiring continued antibiotics or HBO therapy. Mean post-op follow-up was 23 months. CONCLUSIONS With continued evolution in endoscopic, minimally invasive approaches, there is an expanding indication for early surgical management in refractory ORN. Fascia lata MFTT is a novel and effective strategy for the management of ORN of the skull base and upper cervical spine with excellent postoperative outcomes and limited patient morbidity. LEVEL OF EVIDENCE 4 Laryngoscope, 133:562-568, 2023.
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Affiliation(s)
- Satyan B Sreenath
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Kevin T Grafmiller
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Dennis M Tang
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Scott A Roof
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mt. Sinai, New York, New York, U.S.A
| | - Troy D Woodard
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Varun R Kshettry
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Pablo F Recinos
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Michael A Fritz
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A
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16
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Fascio-cutaneous and fascio-periosteal free flaps for treatment of intermediate stage osteoradionecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol 2022:S2212-4403(22)01298-6. [PMID: 36804836 DOI: 10.1016/j.oooo.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/09/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Osteoradionecrosis (ORN) of the jaw is a potentially devastating consequence of head and neck irradiation. Despite recent advances, there are patients who fail to respond to conventional therapies. Historically, free flaps were reserved for advanced cases requiring segmental resection and composite reconstruction, with early and intermediate disease treated more conservatively. We have adopted a more active surgical approach in selected intermediate cases. STUDY DESIGN A retrospective review of patients with intermediate stage ORN who received debridement and either fascio-cutaneous or fascio-periosteal free flap reconstruction was performed. Demographic data, ORN severity, treatment, and outcomes are described. RESULTS From 2019, 9 cases in 7 patients were identified. All cases were Notani grade II. There were 6 Epstein stage IIa and 3 Epstein stage IIIa. The mandible was the most common site (n = 8). Of the 7 patients, 2 had oropharyngeal primaries treated with chemoradiation, and 5 had oral cavity primaries treated with surgery and adjuvant radiation therapy. Three patients had prior hyperbaric oxygen therapy, and 2 had pentoxifylline/tocopherol therapy. After debridement, the radial forearm, ulnar artery perforator, and antero-lateral thigh fascio-cutaneous free flaps were each used in 1 case and the temporoparietal fascio-periosteal free flap was used in 6 cases. There was no recurrence or progression of ORN at the site of surgery, but 2 patients developed additional sites of ORN. CONCLUSIONS For patients with unresponsive intermediate ORN, debridement and soft tissue free flap reconstruction is an alternative to ongoing conservative management or composite resection and reconstruction.
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17
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Kim LN, Rubenstein RN, Chu JJ, Allen RJ, Mehrara BJ, Nelson JA. Noninvasive Systemic Modalities for Prevention of Head and Neck Radiation-Associated Soft Tissue Injury: A Narrative Review. J Reconstr Microsurg 2022; 38:621-629. [PMID: 35213927 PMCID: PMC9402815 DOI: 10.1055/s-0042-1742731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Radiation-associated soft tissue injury is a potentially devastating complication for head and neck cancer patients. The damage can range from minor sequelae such as xerostomia, which requires frequent daily maintenance, to destructive degenerative processes such as osteoradionecrosis, which can contribute to flap failure and delay or reverse oral rehabilitation. Despite the need for effective radioprotectants, the literature remains sparse, primarily focused on interventions beyond the surgeon's control, such as maintenance of good oral hygiene or modulation of radiation dose. METHODS This narrative review aggregates and explores noninvasive, systemic treatment modalities for prevention or amelioration of radiation-associated soft tissue injury. RESULTS We highlighted nine modalities with the most clinical potential, which include amifostine, melatonin, palifermin, hyperbaric oxygen therapy, photobiomodulation, pentoxifylline-tocopherol-clodronate, pravastatin, transforming growth factor-β modulators, and deferoxamine, and reviewed the benefits and limitations of each modality. Unfortunately, none of these modalities are supported by strong evidence for prophylaxis against radiation-associated soft tissue injury. CONCLUSION While we cannot endorse any of these nine modalities for immediate clinical use, they may prove fruitful areas for further investigation.
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Affiliation(s)
- Leslie N. Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robyn N. Rubenstein
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jacqueline J. Chu
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J. Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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18
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Raj R, Nair AH, Krishnan NA, Balasubramanian D, Iyer S, Thankappan K. Advances and Controversies in the Management of Osteoradionecrosis After Head and Neck Cancer Treatment: A Narrative Review. J Maxillofac Oral Surg 2022; 21:836-844. [PMID: 36274865 PMCID: PMC9475005 DOI: 10.1007/s12663-021-01680-4] [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: 07/17/2021] [Accepted: 12/08/2021] [Indexed: 01/09/2023] Open
Abstract
Osteoradionecrosis (ORN) is a painful and debilitating serious late complication following treatment for head and neck cancer (HNC) often requiring surgical resection of the jaw and complex multidisciplinary management. An important aggravating factor for mandibular ORN is surgical trauma, commonly dental extractions or implant placement following head and neck radiotherapy. The evidence on the treatment protocols ranges from conservative management to more radical surgical strategies including the use of hyperbaric oxygen therapy. The available evidence on the preventive approaches for ORN includes prophylactic dental care prior to radiotherapy, the use of hyperbaric oxygen (HBO) treatment and prophylactic antibiotics for post-radiotherapy extractions. However, the efficacy of hyperbaric oxygen therapy has been questioned recently signifying poor understanding of the pathophysiology of the condition and therapies targeting the fibroatrophic process have become a focus of ORN treatment. Implementing recent IMRT radiation techniques has also shown evidence to reduce the incidence of ORN. This review provides an insight into the variations in definition and classification of the ORN, the controversies in its pathophysiology and the advances in the prevention and management.
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Affiliation(s)
- Radhu Raj
- Department of Prosthodontics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Aarya Haridasan Nair
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
| | - Nitin Anand Krishnan
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
| | - Deepak Balasubramanian
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
| | - Subramania Iyer
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
| | - Krishnakumar Thankappan
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
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Dinnoo A, Benmoussa N, Bidault F, Brau JJ, Tissot H, Temam S, Janot F, Henry T. 18F-FDG PET/CT for early response assessment of jaw osteoradionecrosis after the PENTOCLO protocol: A promising imaging modality. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e192-e198. [PMID: 34826634 DOI: 10.1016/j.jormas.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/25/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The Pentoxifylline, Tocopherol and Clodronate protocol (PENTOCLO) showed promising results for jaw osteoradionecrosis (ORN) management. However, the clinical and radiological improvements are often delayed, leading to unwanted long-term treatment, with potential loss of opportunity for more radical surgical treatments. Our objective was to assess the diagnosis performance of 18F-FDG PET/CT to early predict ORN response to the PENTOCLO protocol. MATERIALS AND METHODS All patients from our center who were treated with the PENTOCLO protocol and with a 18F-FDG PET/CT performed at diagnosis and three months after the end of antibiotherapy were retrospectively included. The PENTOCLO protocol was always combined with prior appropriate antibiotherapy for six weeks. The healing endpoint was divided into healing, stability or worsening, according to the combination of clinical and radiological assessments at the date of last follow-up. For each patient, the difference between the maximal standardized uptake value (ΔSUVmax) of the ORN lesion at three months and baseline were computed. Diagnostic performance of 18F-FDG PET/CT was evaluated by sensitivity, specificity and the area under the receiver operating characteristic curve (ROC-AUC) of ΔSUVmax. RESULTS 24 patients were included with an average follow-up of 29.3 months. The healing, stability and worsening rate were 25%, 62.5% and 12.5% respectively. The AUC for discriminating worsening vs stability or healing was 0.92 (IC95 [0.81-1.00]). A ΔSUVmax greater than or equal to 0 was predictive of a worsening with a sensitivity and specificity of 84 and 66% respectively. CONCLUSION 18F-FDG PET/CT imaging could be useful for early prediction of PENTOCLO treatment resistance with appropriate antibiotherapy.
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Affiliation(s)
- Aina Dinnoo
- Gustave Roussy, Paris-Saclay University, Department of Head and Neck Surgical Oncology, Villejuif, F-94805, France
| | - Nadia Benmoussa
- Gustave Roussy, Paris-Saclay University, Department of Head and Neck Surgical Oncology, Villejuif, F-94805, France.
| | - François Bidault
- Gustave Roussy, Department of Diagnostic Radiology, Villejuif, F-94805, France.; BioMaps (UMR1281), Université Paris-Saclay, CNRS, INSERM, CEA, Orsay, 91471, France
| | | | - Hubert Tissot
- Gustave Roussy, Paris-Saclay University, Department of Nuclear Medicine, Villejuif, F-94805, France
| | - Stephane Temam
- Gustave Roussy, Paris-Saclay University, Department of Head and Neck Surgical Oncology, Villejuif, F-94805, France
| | - François Janot
- Gustave Roussy, Paris-Saclay University, Department of Head and Neck Surgical Oncology, Villejuif, F-94805, France
| | - Théophraste Henry
- Gustave Roussy, Paris-Saclay University, Department of Nuclear Medicine, Villejuif, F-94805, France
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20
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Lin Y, Xu Z, Zhou B, Ma K, Jiang M. Pentoxifylline Inhibits Pulmonary Fibrosis by Regulating Cellular Senescence in Mice. Front Pharmacol 2022; 13:848263. [PMID: 35662697 PMCID: PMC9160723 DOI: 10.3389/fphar.2022.848263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic progressive disease, and its occurrence and development are mediated by cellular senescence. Drugs targeting senescent cells seem like a promising and efficacious strategy for IPF treatment. Previous studies have illustrated that pentoxifylline (PTX) may play a certain role in inhibiting pulmonary fibrosis and combating cellular senescence. In this study, we demonstrated that PTX administration inhibits pulmonary fibrosis development and cellular senescence in the bleomycin (BLM)-induced IPF mice model. Moreover, the expression levels of fibrosis-related genes and senescence-related genes in mice lung tissue and primary pulmonary fibroblasts illustrated lung fibroblasts' vital role in these two processes. And the curative effect of PTX was completed mainly by acting on lung fibroblasts. Besides, during the whole treatment, delayed initiation or advanced halt of PTX administration would influence its effectiveness in reducing fibrotic and senescent traits in various degrees, and the latter influenced more. We further determined that a long period of PTX administration could bring noticeable benefits to mice in recovering BLM-induced lung fibrosis and suppressing age-associated cellular senescence. Moreover, it was still effective when PTX administration was used to treat senescent human fibroblasts. Thus, our findings manifested that PTX therapy is an efficient remedy for pulmonary fibrosis by suppressing cellular senescence.
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Affiliation(s)
- Yifan Lin
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Zhihao Xu
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Beibei Zhou
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Keer Ma
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Mengyi Jiang
- Department of Respiratory and Critical Care Medicine, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
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21
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Cho SW, Han SY, Song Y, Kim JW, Kim HJ, Kim DY, Rhee CS, Bae YJ, Kim JH, Wu HG, Bang JS, Won TB. Aggressive Treatment Including Endonasal Surgical Sequestrectomy with Vascularized Nasoseptal Flap Can Improve Outcomes of Skull Base Osteoradionecrosis. J Neurol Surg B Skull Base 2022; 83:e15-e23. [PMID: 35832995 PMCID: PMC9272258 DOI: 10.1055/s-0040-1722669] [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: 05/17/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022] Open
Abstract
Objective Skull base osteoradionecrosis (SB-ORN) is a serious, potentially lethal complication of radiation therapy. We aimed to review the clinical characteristics and outcomes of SB-ORN according to the extent of treatment. Design Retrospective analysis design was used for this study. Setting The study was conducted in two tertiary care hospitals. Participants Patients included who had been clinically diagnosed with SB-ORN from January 2006 to 2017. Main Outcome Measures Clinical characteristics, including demographics, predisposing factors, presenting symptoms, radiological findings, treatment modalities, and treatment outcomes, were reviewed. Treatment was classified into conservative and aggressive types. Aggressive treatment included radical surgical removal of soft tissue and bony sequestrum with the placement of vascularized tissue. Treatment outcome was analyzed in terms of clinical control, survival, and carotid artery blow out. Results Fifteen patients (11 males and 4 females) were identified during the study period. Eight patients were managed conservatively, whereas seven patients were managed with aggressive treatment. The 2-year survival was 75% in the aggressive treatment group and 15% in the conservative group (log-rank, p = 0.049). The estimated 2-year blow out free rate was 46.7% for the conservative group and 100% for the aggressive group (log-rank, p = 0.100). Conclusion In patients with SB-ORN, aggressive management, including surgical removal of sequestrum and coverage with a pedicled flap, is associated with increased survival.
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Affiliation(s)
- Sung-Woo Cho
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Sang Y. Han
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Yoonjae Song
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Jeong-Whun Kim
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Hyun J. Kim
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Young Kim
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Chae-Seo Rhee
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Yun J. Bae
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Ji-hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae S. Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Tae-Bin Won
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
- Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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22
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Willcocks EJ, Lim YBY, Rogers SN. Patients' experience and perceived concerns regarding obtaining and taking prescriptions for head and neck osteoradionecrosis. Br J Oral Maxillofac Surg 2022; 60:459-464. [PMID: 35351326 DOI: 10.1016/j.bjoms.2021.07.019] [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: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
The main components of the medical management of osteoradionecrosis (ORN) are combinations of clodronate, pentoxifylline, tocopherol, sometimes with antibiotics or chlorhexidine rinses. Anecdotally in the Cheshire and Merseyside network, patients report having difficulties getting and taking their prescription, hence the aim was to survey patient experience of obtaining prescriptions, administration of the medications, and side effects. Patients prescribed tocopherol and pentoxifylline from the pharmacy department's record database from the period of January 2019 to June 2020 were invited to take part in a semi-structured telephone survey. Sixteen patients out of a total 33 (48%) responded. 11 patients (69%) reported some issue collecting their repeat prescriptions, commonly low stock of medicines in community or unwillingness of GPs to prescribe. One patient permanently stopped treatment owing to difficulties obtaining medication, whilst for three there were temporary gaps in treatment. Difficulty in administration of the medications was reported in 7 patients (44%) patients, most commonly in those with pre-existing dysphagia. Issues related to difficulties in swallowing the large pentoxifylline tablet or with the vitamin E capsules. Patients crushed the medications, but this was associated with gastrointestinal side-effects in one patient who had to stop treatment. One patient stopped chlorhexidine mouthwash due to oral soreness. In conclusion, medical management of ORN is well tolerated by patients. There is difficulty for patients getting prescriptions in primary care. Few patients need to stop taking the medication due to difficulty in administration or side-effects. More patient information would be useful for all concerned.
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Affiliation(s)
- Edward J Willcocks
- Liverpool Head and Neck Centre, Liverpool University Hospital Foundation Trust, Liverpool L9 7AL, UK.
| | - Yvonne B Y Lim
- Pharmacist Liverpool University Hospital Foundation Trust, Liverpool L9 7AL, UK.
| | - Simon N Rogers
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk L39 4QP, UK; Liverpool Head and Neck Centre, Liverpool University Hospital Foundation Trust, Liverpool L9 7AL, UK.
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23
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Xu SH, Tang JS, Shen XY, Niu ZX, Xiao JL. Osteoradionecrosis of the Hip, a Troublesome Complication of Radiation Therapy: Case Series and Systematic Review. Front Med (Lausanne) 2022; 9:858929. [PMID: 35402457 PMCID: PMC8990133 DOI: 10.3389/fmed.2022.858929] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Osteoradionecrosis of the hip is a serious complication of radiotherapy that is easily overlooked by physicians and patients in the early stages. There are relatively few reports on this subject, so there is no clear scientific consensus for the pathogenesis, early diagnosis, and clinical treatment of hip osteoradionecrosis. In this paper, we report two cases of hip osteoradionecrosis and systematically review the related literature. Case Presentation We report two cases of hip osteoradionecrosis. One patient successfully underwent total hip arthroplasty in our hospital and recovered well postoperatively. Another patient although we offered a variety of surgical options for this patient, the patient was worried that the bone loss would lead to poor prosthesis fixation, resulting in prosthesis loosening and infection, and therefore ultimately refused surgical treatment. Conclusion With the development of radiological techniques, the incidence of hip osteoradionecrosis is decreasing year by year, but early diagnosis and rational treatment remain challenging. The effects of non-surgical treatment are limited. Early prevention, early detection, and early intervention are crucial to delay or prevent the emergence of more serious complications.
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Affiliation(s)
- Sheng-hao Xu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jin-shuo Tang
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Xian-yue Shen
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhi-xin Niu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jian-lin Xiao
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Jian-lin Xiao, ; orcid.org/0000-0001-7175-2726
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24
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Ramia P, Bodgi L, Mahmoud D, Mohammad MA, Youssef B, Kopek N, Al-Shamsi H, Dagher M, Abu-Gheida I. Radiation-Induced Fibrosis in Patients with Head and Neck Cancer: A Review of Pathogenesis and Clinical Outcomes. CLINICAL MEDICINE INSIGHTS: ONCOLOGY 2022; 16:11795549211036898. [PMID: 35125900 PMCID: PMC8808018 DOI: 10.1177/11795549211036898] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/15/2021] [Indexed: 01/08/2023] Open
Abstract
Radiotherapy-related fibrosis remains one of the most challenging treatment related side effects encountered by patients with head and neck cancer. Several established and ongoing novel therapies have been studied with paucity of data in how to best treat these patients. This review aims to provide researchers and health care providers with a comprehensive review on the presentation, etiology, and therapeutic options for this serious condition.
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Affiliation(s)
- Paul Ramia
- McGill University Health Centre, Montreal, QC, Canada
| | - Larry Bodgi
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Dima Mahmoud
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohammad A Mohammad
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bassem Youssef
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Neil Kopek
- McGill University Health Centre, Montreal, QC, Canada
| | - Humaid Al-Shamsi
- Burjeel Cancer Institute, Abu-Dhabi, United Arab Emirates.,Emirates Oncology Society, Dubai, United Arab Emirates.,University of Sharjah, Sharjah, United Arab Emirates
| | - Mona Dagher
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ibrahim Abu-Gheida
- Burjeel Cancer Institute, Abu-Dhabi, United Arab Emirates.,Emirates Oncology Society, Dubai, United Arab Emirates.,United Arab Emirates University, Al Ain, United Arab Emirates
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25
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The Potential Therapeutic Role of Mesenchymal Stem Cells-Derived Exosomes in Osteoradionecrosis. JOURNAL OF ONCOLOGY 2021; 2021:4758364. [PMID: 34899907 PMCID: PMC8660232 DOI: 10.1155/2021/4758364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/07/2021] [Accepted: 11/12/2021] [Indexed: 02/05/2023]
Abstract
As one of the most serious complications of radiotherapy, osteoradionecrosis (ORN) seriously affects the quality of life of patients and even leads to death. Vascular injury and immune disorders are the main causes of bone lesions. The traditional conservative treatment of ORN has a low cure rate and high recurrent. Exosomes are a type of extracellular bilayer lipid vesicles secreted by almost all cell types. It contains cytokines, proteins, mRNA, miRNA, and other bioactive cargos, which contribute to several distinct processes. The favorable biological functions of mesenchymal stem cells-derived exosomes (MSC exosomes) include angiogenesis, immunomodulation, bone regeneration, and ferroptosis regulation. Exploring the characteristic of ORN and MSC exosomes can promote bone regeneration therapies. In this review, we summarized the current knowledge of ORN and MSC exosomes and highlighted the potential application of MSC exosomes in ORN treatment.
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26
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Imaging of Complications of Chemoradiation. Neuroimaging Clin N Am 2021; 32:93-109. [PMID: 34809846 DOI: 10.1016/j.nic.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chemoradiation for head and neck cancer is associated with a variety of early and late complications. Toxicities may affect the aero-digestive tract (mucositis, salivary gland injury), regional osseous and cartilaginous structures (osteoradionecrosis (ORN) and chondronecrosis), vasculature (progressive radiation vasculopathy and carotid blow out syndromes), and neural structures (optic neuritis, myelitis, and brain injury). These may be difficult to distinguish from tumor recurrence on imaging, and may necessitate the use of advanced MRI and molecular imaging techniques to reach the correct diagnosis. Secondary radiation-induced malignancies include thyroid cancer and a variety of sarcomas that may manifest several years after treatment. Checkpoint inhibitors can cause a variety of adverse immune events, including autoimmune hypophysitis and encephalitis.
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27
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Overview and Emerging Trends in the Treatment of Osteoradionecrosis. Curr Treat Options Oncol 2021; 22:115. [PMID: 34773495 DOI: 10.1007/s11864-021-00915-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 10/19/2022]
Abstract
OPINION STATEMENT Osteoradionecrosis (ORN) of the mandible is a rare but devastating complication which occurs following radiation therapy for head and neck malignancies. Left untreated, ORN often results in pathologic fracture of the mandible leading to pain, trismus, difficulty eating, and overall poor quality of life. Historically, early intervention relied on hyperbaric oxygen and local debridement. Patients whose disease progressed despite therapy required segmental resection of the mandible with osseous free flap reconstruction, a highly invasive operation. Patients that presented with a moderate disease without pathologic fracture were often doomed to fail non-operative management, ultimately leading to disease progression and fracture. The traditional dichotomous treatment paradigm left a void of options for patients with moderate disease. The ideal intervention for this category of patients would provide renewed vascularity to the diseased tissue bed allowing for the osteogenesis and reestablishment of strong, load-bearing bone. The innovative technique termed the vascularized fascia lata "rescue flap" has proven to be an effective treatment for moderate ORN and will likely transform dated treatment algorithms.
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28
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Banjar A, Patel V, Abed H. Pentoxifylline and tocopherol (vitamin E) with/without clodronate for the management of osteoradionecrosis: A scoping review. Oral Dis 2021; 29:29-39. [PMID: 34695271 DOI: 10.1111/odi.14058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/10/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment of osteoradionecrosis (ORN) is not a straightforward task, and it is unpredictable. However, a combination of pentoxifylline; an antioxidant drug, and tocopherol (vitamin E) works as a potent antifibrotic agent and have shown recently both significant and impressive results. AIMS This scoping review aims to investigate the most prescribed regimen of pentoxifylline and tocopherol with/without clodronate for the management of ORN. METHODS Ovid MEDLINE and EMBASE databases were used to retrieve eligible studies using planned search keywords. PROSPERO and Cohcarne library were also searched for ongoing or published systematic reviews, respectively. Included articles were grouped thematically according to the type of studies and accordingly they were summarized. RESULTS A total of 27 articles met the inclusion criteria and included in the data analyses. All the included articles were published between 1997 and 2020. Of these 27 included studies, two were randomized control trials, two were systematic reviews, six were retrospective studies, five were observational studies, seven were narrative reviews, four were case reports, and lastly one was an in-vitro study. CONCLUSIONS Treatment by PENTO (800 mg of pentoxifylline + 1000 IU of tocopherol) once daily for an early established ORN or PENTOCLO (PENTO regimen + 1600 mg of clodronate) once daily for the refractory/severe cases of ORN appears to be the most prescribed regimen used for the treatment of ORN using these drugs. These drugs appear safe, effective and inexpensive for the treatment of ORN.
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Affiliation(s)
- Assim Banjar
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Vinod Patel
- Department of Oral Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Hassan Abed
- Department of Basic and Clinical Oral Sciences, Faculty of Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia
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29
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Review of Myeloma Therapies and Their Potential for Oral and Maxillofacial Side Effects. Cancers (Basel) 2021; 13:cancers13174479. [PMID: 34503289 PMCID: PMC8431464 DOI: 10.3390/cancers13174479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/29/2021] [Accepted: 09/02/2021] [Indexed: 02/08/2023] Open
Abstract
Simple Summary Myeloma is a common cancer involving the bone marrow. Some of the medications used in the treatment of myeloma, including those that reduce the risk of bone fractures, can increase the chance of side effects occurring in the jawbone. The most serious complication in the jawbone is called medication-related osteonecrosis, meaning part of the jawbone dies. The aim of this review is to highlight some of the medications that are implicated and other risk factors that can contribute to osteonecrosis. Suggestions to prevent this complication from occurring are described. Conventional methods of treating established medication-related osteonecrosis of the jawbone are outlined as well as emerging new treatments. Abstract Myeloma is a common haematological malignancy in which adverse skeletal related events are frequently seen. Over recent years, treatment for myeloma has evolved leading to improved survival. Antiresorptive therapy is an important adjunct therapy to reduce the risk of bone fractures and to improve the quality of life for myeloma patients; however, this has the potential for unwanted side effects in the oral cavity and maxillofacial region. Osteonecrosis of the jaw related to antiresorptive medications and other myeloma therapies is not uncommon. This review serves to highlight the risk of osteonecrosis of the jaw for myeloma patients, with some suggestions for prevention and management.
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30
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Tso TV, Blackwell KE, Sung EC. Predictive factors of osteoradionecrosis necessitating segmental mandibulectomy-A descriptive study. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 134:e8-e13. [PMID: 34758937 DOI: 10.1016/j.oooo.2021.08.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of this study was to assess characteristics of patients with mandibular osteoradionecrosis (ORN) of severity necessitating segmental mandibulectomy and osteocutaneous free flap reconstruction. STUDY DESIGN This study is a retrospective review of patients who underwent free flap reconstruction of the mandible at the UCLA Medical Center between January 2016 and February 2020 secondary to ORN. RESULTS Twenty-nine charts with detailed dental and medical records were identified. Hypertension was reported in 14 of 29 patients, diabetes in 2 of 29, osteoporosis in 2 of 29, antiresorptive use in 3 of 29, tobacco use in 15 of 29, and alcohol use in 19 of 29. Twenty-three patients initially had stage III-IV cancer. The median radiation dose was 68 Gy and median time to ORN was 5.2 years. Chemotherapy was given in 21 patients and 4 had previous mandibular surgery. Twelve of 29 patients had surgical procedures identified as the causative factor and 17 of 29 occurred spontaneously. Median decayed, missing, and filled teeth score was 17 and 17 of 29 patients had grade II-IV periodontitis. Periodontitis was present in 8 of 17 of spontaneous and 1 of 12 of surgery cases. Twenty-five of 29 cases occurred in the same oral sextant as the tumor. CONCLUSION Severe ORN occurred at doses >60 Gy in most cases. Location of the primary tumor was predictive of site of ORN and only molars were involved when precipitated by tooth extraction. Risk of ORN persists indefinitely.
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Affiliation(s)
- Theodore V Tso
- Attending Staff, Division of Maxillofacial Surgery & Hospital Dentistry, Harbor-UCLA Medical Center, Torrance, CA, USA; Lecturer, UCLA School of Dentistry, Los Angeles, CA, USA.
| | - Keith E Blackwell
- Professor, Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Eric C Sung
- Professor of Clinical Dentistry, UCLA School of Dentistry, Los Angeles, CA, USA
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31
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Wang K, Tepper JE. Radiation therapy-associated toxicity: Etiology, management, and prevention. CA Cancer J Clin 2021; 71:437-454. [PMID: 34255347 DOI: 10.3322/caac.21689] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) is a curative treatment for many malignancies and provides effective palliation in patients with tumor-related symptoms. However, the biophysical effects of RT are not specific to tumor cells and may produce toxicity due to exposure of surrounding organs and tissues. In this article, the authors review the clinical context, pathophysiology, risk factors, presentation, and management of RT side effects in each human organ system. Ionizing radiation works by producing DNA damage leading to tumor death, but effects on normal tissue may result in acute and/or late toxicity. The manifestation of toxicity depends on both cellular characteristics and affected organs' anatomy and physiology. There is usually a direct relationship between the radiation dose and volume to normal tissues and the risk of toxicity, which has led to guidelines and recommended dose limits for most tissues. Side effects are multifactorial, with contributions from baseline patient characteristics and other oncologic treatments. Technological advances in recent decades have decreased RT toxicity by dramatically improving the ability to deliver RT that maximizes tumor dose and minimizes organ dose. Thus the study of RT-associated toxicity is a complex, core component of radiation oncology training that continues to evolve alongside advances in cancer management. Because RT is used in up to one-half of all patients with cancer, an understanding of its acute and late effects in different organ systems is clinically pertinent to both oncologists and nononcologists.
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Affiliation(s)
- Kyle Wang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Joel E Tepper
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
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32
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Grammatis AL, Georgiou EX, Becker CM. Pentoxifylline for the treatment of endometriosis-associated pain and infertility. Cochrane Database Syst Rev 2021; 8:CD007677. [PMID: 34431079 PMCID: PMC8407096 DOI: 10.1002/14651858.cd007677.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Endometriosis is a chronic inflammatory condition that occurs during the reproductive years. It is characterised by endometrium-like tissue developing outside the uterine cavity. This endometriotic tissue development is dependent on oestrogen produced primarily by the ovaries and partially by the endometriotic tissue itself, therefore traditional management has focused on ovarian suppression. In this review we considered the role of modulation of the immune system as an alternative approach. This is an update of a Cochrane Review previously published in 2012. OBJECTIVES To determine the effectiveness and safety of pentoxifylline in the management of endometriosis. SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility (CGF) Group Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED on 16 December 2020, together with reference checking and contact with study authors and experts in the field to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing pentoxifylline with placebo or no treatment, other medical treatment, or surgery in women with endometriosis. The primary outcomes were live birth rate and overall pain (as measured by a visual analogue scale (VAS) of pain, other validated scales, or dichotomous outcomes) per woman randomised. Secondary outcomes included clinical pregnancy rate, miscarriage rate, rate of recurrence, and adverse events resulting from the pentoxifylline intervention. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies against the inclusion criteria, extracted data, and assessed risk of bias, consulting a third review author where required. We contacted study authors as needed. We analysed dichotomous outcomes using Mantel-Haenszel risk ratios (RRs), 95% confidence intervals (CIs), and a fixed-effect model. For small numbers of events, we used a Peto odds ratio (OR) with 95% CI instead. We analysed continuous outcomes using the mean difference (MD) between groups presented with 95% CIs. We used the I2 statistic to evaluate heterogeneity amongst studies. We employed the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included five parallel-design RCTs involving a total of 415 women. We included one additional RCT in this update. Three studies did not specify details relating to allocation concealment, and two studies were not blinded. There were also considerable loss to follow-up, with four studies not conducting intention-to-treat analysis. We judged the quality of the evidence as very low. Pentoxifylline versus placebo No trials reported on our primary outcomes of live birth rate and overall pain. We are uncertain as to whether pentoxifylline treatment affects clinical pregnancy rate when compared to placebo (RR 1.38, 95% CI 0.91 to 2.10; 3 RCTs, n = 285; I2 = 0%; very low-quality evidence). The evidence suggests that if the clinical pregnancy rate with placebo is estimated to be 20%, then the rate with pentoxifylline is estimated as between 18% and 43%. We are also uncertain as to whether pentoxifylline affects the recurrence rate of endometriosis (RR 0.84, 95% CI 0.30 to 2.36; 1 RCT, n = 121; very low-quality evidence) or miscarriage rate (Peto OR 1.99, 95% CI 0.20 to 19.37; 2 RCTs, n = 164; I2 = 0%; very low-quality evidence). No trials reported on the effect of pentoxifylline on improvement of endometriosis-related symptoms other than pain or adverse events. Pentoxifylline versus no treatment No trials reported on live birth rate. We are uncertain as to whether pentoxifylline treatment affects overall pain when compared to no treatment at one month (MD -0.36, 95% CI -2.12 to 1.40; 1 RCT, n = 34; very low-quality evidence), two months (MD -1.25, 95% CI -2.67 to 0.17; 1 RCT, n = 34; very low-quality evidence), or three months (MD -1.60, 95% CI -3.32 to 0.12; 1 RCT, n = 34; very low-quality evidence). No trials reported on adverse events caused by pentoxifylline or any of our other secondary outcomes. Pentoxifylline versus other medical therapies One study (n = 83) compared pentoxifylline to the combined oral contraceptive pill after laparoscopic surgery to treat endometriosis, but could not be included in the meta-analysis as it was unclear if the data were presented as +/- standard deviation and what the duration of treatment was. No trials reported on adverse events caused by pentoxifylline or any of our other secondary outcomes. Pentoxifylline versus conservative surgical treatment No study reported on this comparison. AUTHORS' CONCLUSIONS No studies reported on our primary outcome of live birth rate. Due to the very limited evidence, we are uncertain of the effects of pentoxifylline on clinical pregnancy rate, miscarriage rate, or overall pain. There is currently insufficient evidence to support the use of pentoxifylline in the management of women with endometriosis with respect to subfertility and pain relief outcomes.
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Affiliation(s)
| | | | - Christian M Becker
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
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33
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Samani M, Beheshti S, Cheng H, Sproat C, Kwok J, Patel V. Prophylactic pentoxifylline and vitamin E use for dental extractions in irradiated patients with head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 133:e63-e71. [PMID: 34753695 DOI: 10.1016/j.oooo.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/14/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Osteoradionecrosis (ORN) of the jaw is preceded by dental extractions in up to 10% of cases. We present a case series of post-radiotherapy patients undergoing dental extractions who have received the prophylactic antifibrotic agents pentoxifylline and vitamin E (PVe) to prevent ORN. STUDY DESIGN A retrospective review was conducted of 219 patients with head and neck cancer (HNC) undergoing 1079 dental extractions between 2009 and 2020. Data regarding oncological treatment, prophylactic drug regimen, dental history, and clinical outcome was collected. RESULTS Twelve patients developed ORN at 17 extraction sites (ORN rates, 1.6% and 5.5% at tooth level and patient level, respectively). PVe regimen compliance significantly decreased ORN rates at the patient level (3.4% vs 11.5%; P < .03) and the tooth level (1.0% vs 3.5%; P < .01) compared with no PVe. Regimen compliance significantly reduced ORN rates in patients with oropharyngeal cancer (P < .01); in those with mandibular (P < .005) molar (P < .003), and flapless extractions (P < .04); in patients with radiation regions >40 Gy (P < .0009); and in those who underwent primary closure (P < .03). Machine learning analysis identified almost all these factors as influential at a tooth level for ORN. CONCLUSIONS PVe regimen compliance decreased dental extraction ORN rates more than the literature base rates of 7% at the patient level and 2% at the tooth level. Given its success in managing existing ORN, PVe could be extended prophylactically for dental extractions in irradiated patients with head and neck cancer.
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Affiliation(s)
- Meera Samani
- Associate Specialist (Oral Surgery), Oral Surgery Department, Guy's Dental Hospital, London, United Kingdom
| | - Shahryar Beheshti
- Speciality Dentist (Oral Surgery), Oral Surgery Department, Guy's Dental Hospital, London, United Kingdom
| | - Hilary Cheng
- Dental Core Trainee (Oral Surgery), Oral Surgery Department, Guy's Dental Hospital, London, United Kingdom
| | - Chris Sproat
- Consultant (Oral Surgery), Oral Surgery Department, Guy's Dental Hospital, London, United Kingdom
| | - Jerry Kwok
- Consultant (Oral Surgery), Oral Surgery Department, Guy's Dental Hospital, London, United Kingdom
| | - Vinod Patel
- Consultant (Oral Surgery), Oral Surgery Department, Guy's Dental Hospital, London, United Kingdom.
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Shaikh N, Makary CA, Ryan L, Reyes C. Treatment Outcomes for Osteoradionecrosis of the Central Skull Base: A Systematic Review. J Neurol Surg B Skull Base 2021; 83:e521-e529. [PMID: 35832934 DOI: 10.1055/s-0041-1733973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 07/11/2021] [Indexed: 10/20/2022] Open
Abstract
Abstract
Objective Osteoradionecrosis (ORN) of the skull base can have catastrophic consequences if not detected early and managed appropriately. This is a systematic review of the different treatment modalities for skull base ORN and their outcomes.
Study Design This study is a systematic review.
Materials and Methods Two researchers extracted information including patient population, surgical technique, outcomes of interest, and study design. A computerized search of Medline, Embase, and the Cochrane library (January 1990–June 2020) looked for several papers on the subject of skull base ORN.
Results A total of 29 studies had met inclusion criteria, including data from 333 patients. Nasopharyngeal carcinoma was the most common primary tumor (85%). Average age at diagnosis of ORN was 55.9 years (range = 15–80 years) and 72.3% of patients were males. The average time to diagnosis of ORN after radiation therapy was 77 months with an average radiation dose of 76.2 Gy (range = 46–202 Gy). Nighty-eight patients (29.4%) also had chemotherapy as part of their treatment regimen. Although all parts of the central skull base were reported to be involved, the clivus and sphenoid bone were the most commonly reported subsites. Trial of medical treatment had a success rate of 41.1%. About 66% of patients needed surgical treatment, either primarily or after failing medical treatment. Success rate was 77.3%. Overall, the surgical treatment was superior to medical treatment (p < 0.0001).
Conclusion ORN is a rare complication of the treatment of skull base tumors. Most cases require surgical treatment, including endoscopic debridement or free flap reconstruction, which has a high success rate.
Level of Evidence Level 3 evidence as a systematic review of case studies, case reports, retrospective, and prospective trials with no blinding or controls.
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Affiliation(s)
- Noah Shaikh
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
| | - Chadi A. Makary
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
| | - Lindsey Ryan
- Department of Otolaryngology, Augusta University, Augusta, Georgia, United States
| | - Camilo Reyes
- Department of Otolaryngology, Augusta University, Augusta, Georgia, United States
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Lovin BD, Hernandez M, Elms H, Choi JS, Lindquist NR, Moreno AC, Nader ME, Gidley PW. Temporal Bone Osteoradionecrosis: An 18-year, Single-Institution Experience. Laryngoscope 2021; 131:2578-2585. [PMID: 34287898 DOI: 10.1002/lary.29758] [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: 04/05/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To report the largest single-institution review of temporal bone osteoradionecrosis (TBORN), and characterize the disease's natural history, prognostic factors, management, and outcomes. STUDY DESIGN Retrospective chart review. METHODS Retrospective review was conducted to identify patients with TBORN. Pertinent data were extracted. Descriptive statistics were used to summarize patient, tumor, and treatment characteristics. Multivariable analyses were conducted to explore associations between these characteristics and time to TBORN diagnosis and risk of developing diffuse disease. RESULTS TBORN was identified in 145 temporal bones from 128 patients. Mean age at diagnosis was 62 years, and mean time to diagnosis after radiotherapy was 10 years. Age greater than 50 years was associated with earlier diagnosis. According to the Ramsden criteria, 76% of TBs had localized and 24% had diffuse disease at initial diagnosis; 37% had diffuse disease at last follow-up. On multivariable analysis, diabetes, three-dimensional conformal radiotherapy (3D-CRT), and periauricular skin malignancy were significant risk factors for developing diffuse disease. Localized disease was successfully managed with conservative measures, whereas surgery was often necessary for diffuse disease. When TBORN spread outside the mastoid or infratemporal fossa, conservative measures were always unsuccessful. CONCLUSIONS TBORN occurs earlier in older patients. While diffuse disease is less common than localized disease, it occurs more frequently in patients with diabetes, history of 3D-CRT, and periauricular skin malignancies. Conservative management is appropriate for localized disease, while surgery is often necessary for diffuse disease. The prognostic factors identified helped propose a TBORN staging system and treatment guidelines which may improve patient risk stratification and disease management. LEVEL OF EVIDENCE IV Laryngoscope, 2021.
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Affiliation(s)
- Benjamin D Lovin
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Hunter Elms
- Department of Otolaryngology-Head and Neck Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Jonathan S Choi
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Nathan R Lindquist
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Amy C Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Marc-Elie Nader
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Paul W Gidley
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
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Platelet-rich fibrin as a treatment option for osteoradionecrosis: A literature review. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2021; 123:e20-e27. [PMID: 34171527 DOI: 10.1016/j.jormas.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/11/2021] [Accepted: 06/07/2021] [Indexed: 11/20/2022]
Abstract
The aim of this review is to establish the usefulness and effectiveness of using platelet-rich fibrin (PRF) in the treatment of osteoradionecrosis (ORN) lesions. A review of the literature was performed using keywords through the PubMed-Medline and Cochrane Library search engine. Inclusion criteria were: (1) original publication in either the French or the English language, (2) studies conducted in humans, (3) presence of ORN lesions following head and neck radiotherapy (RT), (4) use of PRF or derivates in the treatment of ORN lesions, (5) clinical variables and outcomes mentioned in the study. Overall, four case reports were retained. Two publications were removed from the initial seven results after application of the inclusion criteria. A recent randomised clinical trial was not considered since the group analysed the effectiveness of leukocyte-enriched Plasmas-Rich-Fibrin (LPRF) in preventing ORN, but not in treating it. Therefore, four publications were retained for analysis. Results suggest that using PRF as an adjunct to surgical therapy is beneficial in treating ORN lesions although no controlled studies were found. Therefore, additional controlled clinical studies are warranted to better define the effectiveness and recommendation of this approach.
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Habib A, Hanasono MM, DeMonte F, Haider A, Breshears JD, Nader ME, Gidley PW, Su SY, Hanna EY, Raza SM. Surgical Management of Skull Base Osteoradionecrosis in the Cancer Population - Treatment Outcomes and Predictors of Recurrence: A Case Series. Oper Neurosurg (Hagerstown) 2021; 19:364-374. [PMID: 32324878 DOI: 10.1093/ons/opaa082] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 02/10/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Skull base osteoradionecrosis (ORN) is a challenging treatment-related complication sometimes seen in patients with cancer. Although ORN management strategies for other anatomic sites have been reported, there is a paucity of data guiding the management of skull base ORN. OBJECTIVE To report a single-center tertiary care series of skull base ORN and to better understand the factors affecting ORN recurrence after surgical management. METHODS We conducted a retrospective cohort study of patients with skull base ORN treated at our center between 2003 and 2017. Univariate and multivariate binary logistic regressions were performed to identify predictors of recurrence. RESULTS A total of 31 patients were included in this study. The median age at ORN diagnosis was 61.1 yr (range, 32.8-84.9 yr). Of these 31 patients, 15 (48.4%) patients were initially treated medically. All 31 patients underwent surgery. Three (14.3%) of 21 patients treated with a free flap and 4 (50.0%) of 8 patients who underwent primary closure experienced recurrence. Cox regression analysis revealed that reconstruction with local tissue closure (P = .044) and ongoing treatment for active primary cancer (P = .022) were significant predictors of recurrence. The median overall survival from index surgery for ORN treatment was 83.9 mo. At 12-mo follow-up, 78.5% of patients were alive. CONCLUSION In this study, we assess the outcomes of our treatment approach, surgical debridement with vascularized reconstruction, on recurrence-free survival in patients with skull base ORN. Further studies with larger cohorts are needed to assess current treatment paradigms.
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Affiliation(s)
- Ahmed Habib
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew M Hanasono
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ali Haider
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jonathan D Breshears
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marc-Elie Nader
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul W Gidley
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Hato H, Sakata KI, Sato J, Satoh A, Hayashi T, Kitagawa Y. Clinical study of treatment methods and associated factors in mandibular osteoradionecrosis. J Oral Sci 2021; 63:289-291. [PMID: 34092776 DOI: 10.2334/josnusd.21-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This study aimed to determine the appropriate treatment methods and evaluate associated factors by comparing nonoperative treatment alone with a combination of both nonoperative and surgical treatment in 34 patients with mandibular osteoradionecrosis (mORN). The associated cure factors were analyzed by Cox regression. Propensity scores were calculated from factors that were not significant in the univariate analysis and used as covariates in the multivariate analysis. The cure rate among patients who received nonoperative and surgical treatment was higher than that observed with nonoperative treatment alone. Only the treatment method was associated with cure in both univariate and multivariate analyses.
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Affiliation(s)
- Hiroyuki Hato
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
| | - Ken-Ichiro Sakata
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
| | - Jun Sato
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
| | - Akira Satoh
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
| | - Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery, Asahikawa Medical University
| | - Yoshimasa Kitagawa
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
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Late radiation effects in survivors of head and neck cancer: State of the science. Crit Rev Oncol Hematol 2021; 162:103335. [PMID: 33992801 DOI: 10.1016/j.critrevonc.2021.103335] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 01/15/2023] Open
Abstract
Head and neck squamous cell carcinoma is one of the most common neoplasms. Radiotherapy (RT) plays an essential role in the management of such cases. Despite advances in the technique, hyposalivation, xerostomia, dysphagia, trismus, radiation caries, and osteoradionecrosis remain significant late complications of RT. The aim of this narrative review was to summarize and update the main findings related to late side effects of radiotherapy in survivors of head and neck cancer (HNC). Such effects limit the ability to speak, ingest food and medications, and breathe and also exert a negative impact on social well-being and quality of life. This review highlights research in the field for both researchers and clinicians, assisting in the prevention and management of these adverse conditions. The findings can contribute to improving preventive management and multidisciplinary interventions for HNC patients.
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Ricketts TD, Prieto-Dominguez N, Gowda PS, Ubil E. Mechanisms of Macrophage Plasticity in the Tumor Environment: Manipulating Activation State to Improve Outcomes. Front Immunol 2021; 12:642285. [PMID: 34025653 PMCID: PMC8139576 DOI: 10.3389/fimmu.2021.642285] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/16/2021] [Indexed: 12/12/2022] Open
Abstract
Macrophages are a specialized class of innate immune cells with multifaceted roles in modulation of the inflammatory response, homeostasis, and wound healing. While developmentally derived or originating from circulating monocytes, naïve macrophages can adopt a spectrum of context-dependent activation states ranging from pro-inflammatory (classically activated, M1) to pro-wound healing (alternatively activated, M2). Tumors are known to exploit macrophage polarization states to foster a tumor-permissive milieu, particularly by skewing macrophages toward a pro-tumor (M2) phenotype. These pro-tumoral macrophages can support cancer progression by several mechanisms including immune suppression, growth factor production, promotion of angiogenesis and tissue remodeling. By preventing the adoption of this pro-tumor phenotype or reprogramming these macrophages to a more pro-inflammatory state, it may be possible to inhibit tumor growth. Here, we describe types of tumor-derived signaling that facilitate macrophage reprogramming, including paracrine signaling and activation of innate immune checkpoints. We also describe intervention strategies targeting macrophage plasticity to limit disease progression and address their implications in cancer chemo- and immunotherapy.
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Affiliation(s)
| | | | | | - Eric Ubil
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, United States
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Camolesi GC, Ortega KL, Medina JB, Campos L, Lorenzo Pouso AI, Gándara Vila P, Pérez Sayáns M. Therapeutic alternatives in the management of osteoradionecrosis of the jaws. Systematic review. Med Oral Patol Oral Cir Bucal 2021; 26:e195-e207. [PMID: 33037800 PMCID: PMC7980297 DOI: 10.4317/medoral.24132] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/28/2020] [Indexed: 01/11/2023] Open
Abstract
Background to systematically review the literature, comparing the healing of osteoradionecrosis (ORN) among the therapeutic alternatives: surgical, pharmacological and combined.
Material and Methods The review was organized according to the PRISMA protocol with regards to the following PICO question: patients with ORN of the jaws (P=Patient); all interventions reported (I = intervention); between all therapies (C=Comparison); healing of lesions (O=outcome).
Results Surgical treatment was the most common choice (46.3%) followed by pharmacological treatment, exclusively (25.9%) or combined (26.9%). Treatment exclusively by surgical intervention seems to be most effective option, with 51.2% of the lesions healed, OR for healing of 5.7 (CI95% 1.9-16.9, p=0.002). Only 1 case (0.9%) corresponded to low level laser therapy.
Conclusions It seems clear that early intervention with conservative surgical combined with pharmacological methods improves the prognosis of ORN. Key words:Osteoradionecrosis, radiotherapy bone necrosis, hyperbaric oxygen, pentoxifylline, teriparatide, low level laser therapy.
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Affiliation(s)
- G-C Camolesi
- Entrerríos s/n, Santiago de Compostela C.P. 15782, Spain +
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Sweeny L, Mayland E, Swendseid BP, Curry JM, Kejner AE, Thomas CM, Kain JJ, Cannady SB, Tasche K, Rosenthal EL, DiLeo M, Luginbuhl AJ, Theeuwen H, Sarwary JR, Petrisor D, Wax MK. Microvascular Reconstruction of Osteonecrosis: Assessment of Long-term Quality of Life. Otolaryngol Head Neck Surg 2021; 165:636-646. [PMID: 33618563 DOI: 10.1177/0194599821990682] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Larissa Sweeny
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana, USA
| | - Erica Mayland
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana, USA
| | - Brian P Swendseid
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexandra E Kejner
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Carissa M Thomas
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joshua J Kain
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Steve B Cannady
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kendall Tasche
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Eben L Rosenthal
- Department of Otolaryngology, Stanford University, Palo Alto, California, USA
| | - Michael DiLeo
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana, USA
| | - Adam J Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Juliana R Sarwary
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Daniel Petrisor
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Mark K Wax
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Is radiation-induced arteriopathy in long-term breast cancer survivors an underdiagnosed situation?: Critical and pragmatic review of available literature. Radiother Oncol 2021; 157:163-174. [PMID: 33515666 DOI: 10.1016/j.radonc.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Although considered exceptional, radiation-induced arteriopathy in long-term breast cancer survivors involves three main arterial domains in the irradiated volume, namely axillary-subclavian, coronary, and carotid. Stenosis of medium-large arteries is caused by "accelerated" atherosclerosis, particularly beyond 10 years after long-forgotten radiotherapy. The present review aims at summarizing what is known about arteriopathy, as well as the state of the art in terms of diagnosis and therapeutic management. DIAGNOSIS Pauci-symptomatic over years, the usual clinical presentation of arteriopathy involves arm pain with coldness due to subacute or critical ischemia (arterial occlusion), wrongly attributed to an exclusive neurological disorder, and more rarely transient ischemic accident or angina. Evaluation of the supra-aortic trunks by computed tomography and/or magnetic resonance angiography visualizes artery lesions, while Doppler ultrasonography in expert hands assesses diagnosis and downstream functional impact. In severe cases, more invasive angiography directly visualizes long irregular arterial stenosis (full-field radiotherapy), allowing accurate prognosis and treatment. MANAGEMENT Requires early diagnosis to enable initiation of medical treatment that increases blood flow (aspirin) as soon as moderate stenosis is detected, combined with correction of vascular risk factors. In intermediate cases, these therapeutic measures are completed by revascularization strategies using transluminal angioplasty-stenting (wall thickness). Antifibrotic treatment is useful in advanced cases with combined radiation injuries. CONCLUSION In follow-up of long-term breast cancer survivors with node irradiation, myocardial infarction is treated even if radiotherapy is forgotten, while recognition and diagnosis of chronic arm ischemia due to subclavian artery stenosis needs to be improved for appropriate therapeutic management.
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Venkat P, Han J, Demanes DJ. Brachytherapy of the head and neck: An University of California Los Angeles guide to morbidity reduction. Brachytherapy 2021; 20:1014-1040. [PMID: 33487561 DOI: 10.1016/j.brachy.2020.12.002] [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: 07/15/2020] [Revised: 11/30/2020] [Accepted: 12/06/2020] [Indexed: 11/16/2022]
Abstract
The head and neck (H&N) region is among the most intricate and functional part of our anatomy. Major functional nerves and blood vessels with importance that affect the entire body emanate from the base of skull. Brachytherapy plays an important role as a single modality therapy in early cancer of the lip and oral cavity and a supplemental role in the pharynx or in advanced or recurrent disease. Morbidity in the H&N is intensely personal and disabling. Its avoidance is critical in determining the success or failure of a treatment program, and it is essential to preservation of quality of life. This article summarizes the current literature regarding morbidity related to H&N brachytherapy to aid patients and physicians to achieve optimal outcomes.
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Affiliation(s)
- Puja Venkat
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA.
| | - James Han
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - D Jeffrey Demanes
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
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Frankart AJ, Frankart MJ, Cervenka B, Tang AL, Krishnan DG, Takiar V. Osteoradionecrosis: Exposing the Evidence Not the Bone. Int J Radiat Oncol Biol Phys 2021; 109:1206-1218. [PMID: 33412258 DOI: 10.1016/j.ijrobp.2020.12.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/17/2020] [Accepted: 12/24/2020] [Indexed: 12/25/2022]
Abstract
Osteoradionecrosis is a relatively rare but potentially morbid and costly complication of radiation therapy for head and neck cancer. Multidisciplinary diagnosis and treatment are essential. Despite evidence guiding individual aspects of care for osteoradionecrosis, there is a lack of broad consensus on the overall diagnosis and management of this condition. This study comprehensively reviews the literature, with a focus on the past 10 years, to guide evaluation and treatment.
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Affiliation(s)
- Andrew J Frankart
- Department of Radiation Oncology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | | | - Brian Cervenka
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Alice L Tang
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Deepak G Krishnan
- Department of Surgery, Division of Oral and Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Vinita Takiar
- Department of Radiation Oncology, University of Cincinnati Medical Center, Cincinnati, Ohio; Cincinnati VA Medical Center, Cincinnati, Ohio.
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Patel S, Patel N, Sassoon I, Patel V. The use of pentoxifylline, tocopherol and clodronate in the management of osteoradionecrosis of the jaws. Radiother Oncol 2020; 156:209-216. [PMID: 33385466 DOI: 10.1016/j.radonc.2020.12.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
AIMS Medical management of osteoradionecrosis (ORN) via pentoxifylline, tocopherol (PENTO) and clodronate (PENTOCLO) has shown both promise and early positive outcomes. We aimed to determine clinical outcomes for patients with established ORN managed solely via PENTO or PENTOCLO. METHODS The study retrospectively reviewed and collected data from the medical records of 169 patients diagnosed with ORN and treated via medical management. Patients that received any additional interventions such as surgery or hyperbaric oxygen were not included. RESULTS Medical management led to healed ORN in 54.4% (n = 92/169) of patients after an average of 12.9 months. Outcome comparison between PENTO and PENTOCLO identified the former regime to be significantly superior (p = 0.0001). There is an inverse relationship with increasing ORN severity and healing with medical management (p < 0.0001) with oropharyngeal cancer (p = 0.0347) patients responding favourably via this approach. Infection had a critical role in the final outcome with those healing requiring 1.3 antibiotic prescriptions, while those that had disease progression requiring 4.3 prescriptions. CONCLUSION Medical management is a viable treatment option for ORN. It appears to be most effective in Notani I and non-infected ORN. When healing was not achieved the regime was able to stabilise the condition.
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Affiliation(s)
- Sagar Patel
- DCT2 (Oral & Maxillofacial Surgery), Northwick Park Hospital, United Kingdom.
| | - Nisma Patel
- Fl 23 Guys Dental Hospital, London, United Kingdom.
| | - Isabel Sassoon
- Dept of Computer Science, Brunel University, United Kingdom.
| | - Vinod Patel
- Fl 23 Guys Dental Hospital, London, United Kingdom.
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Vahidi N, Lee TS, Daggumati S, Shokri T, Wang W, Ducic Y. Osteoradionecrosis of the Midface and Mandible: Pathogenesis and Management. Semin Plast Surg 2020; 34:232-244. [PMID: 33380908 DOI: 10.1055/s-0040-1721759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Radiation therapy is an important and commonly used treatment modality for head and neck cancers. Osteoradionecrosis (ORN) is a potential debilitating complication of treatment, which most commonly affects the mandible. Management strategies are tailored to the severity of disease. Medical management including oral rinses, irrigations, antibiotics, and pharmacological treatments is viable for mild-to-moderate ORN. More severe disease is best addressed with a combination of medical management and surgical intervention aimed at aggressively removing devitalized tissue until bleeding bone is encountered and reconstructing the soft tissue and bone defect. Reconstruction with either regional vascularized flaps or vascularized osteocutaneous free flaps in case of larger full-thickness bone defects (greater than 6 cm) or anterior mandible (medial to mental foramen) is most appropriate. Maxillary ORN complications can present with a wide range of functional problems and facial disfigurement. Life-threatening and time-sensitive problems should be treated first, such as skull base bone coverage or correction of severe ectropion, to avoid blindness from exposure keratopathy. Then, less time-sensitive issues can be addressed next, such as nasal obstruction, velopharyngeal insufficiency, and chronic tearing. It may require a combination of specialists from different disciplines to address various issues that can arise from maxillary ORN.
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Affiliation(s)
- Nima Vahidi
- Department of Otolaryngology, Virginia Commonwealth University, Richmond, Virginia
| | - Thomas S Lee
- Department of Otolaryngology, Virginia Commonwealth University, Richmond, Virginia
| | - Srihari Daggumati
- Department of Otolaryngology, Virginia Commonwealth University, Richmond, Virginia
| | - Tom Shokri
- Otolaryngology and Facial Plastic Surgery Associates, Facial Plastics, Fort Worth, Texas
| | - Weitao Wang
- Otolaryngology and Facial Plastic Surgery Associates, Facial Plastics, Fort Worth, Texas.,Department of Otolaryngology, University of Rochester, Rochester, New York
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Facial Plastics, Fort Worth, Texas
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Zhou LY, Lin SN, Rieder F, Chen MH, Zhang SH, Mao R. Noncoding RNAs as Promising Diagnostic Biomarkers and Therapeutic Targets in Intestinal Fibrosis of Crohn's Disease: The Path From Bench to Bedside. Inflamm Bowel Dis 2020; 27:971-982. [PMID: 33324986 PMCID: PMC8344842 DOI: 10.1093/ibd/izaa321] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Indexed: 12/12/2022]
Abstract
Fibrosis is a major pathway to organ injury and failure, accounting for more than one-third of deaths worldwide. Intestinal fibrosis causes irreversible and serious clinical complications, such as strictures and obstruction, secondary to a complex pathogenesis. Under the stimulation of profibrotic soluble factors, excessive activation of mesenchymal cells causes extracellular matrix deposition via canonical transforming growth factor-β/Smads signaling or other pathways (eg, epithelial-to-mesenchymal transition and endothelial-to-mesenchymal transition) in intestinal fibrogenesis. In recent studies, the importance of noncoding RNAs (ncRNAs) stands out in fibrotic diseases in that ncRNAs exhibit a remarkable variety of biological functions in modulating the aforementioned fibrogenic responses. In this review, we summarize the role of ncRNAs, including the emerging long ncRNAs and circular RNAs, in intestinal fibrogenesis. Notably, the translational potential of ncRNAs as diagnostic biomarkers and therapeutic targets in the management of intestinal fibrosis is discussed based on clinical trials from fibrotic diseases in other organs. The main points of this review include the following: • Characteristics of ncRNAs and mechanisms of intestinal fibrogenesis • Wide participation of ncRNAs (especially the emerging long ncRNAs and circular RNAs) in intestinal fibrosis, including transforming growth factor-β signaling, epithelial-to-mesenchymal transition/endothelial-to-mesenchymal transition, and extracellular matrix remodeling • Translational potential of ncRNAs in the diagnosis and treatment of intestinal fibrosis based on clinical trials from fibrotic diseases in other organs.
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Affiliation(s)
- Long-Yuan Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Si-Nan Lin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Min-Hu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Sheng-Hong Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China,Address correspondence to: Ren Mao, MD, Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, People’s Republic of China; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH (); and Sheng-Hong Zhang, MD, Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, People’s Republic of China ()
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA,Address correspondence to: Ren Mao, MD, Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, People’s Republic of China; Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH (); and Sheng-Hong Zhang, MD, Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, People’s Republic of China ()
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Jia AY, Viswanathan AN. Vaginal necrosis: A rare late toxicity after radiation therapy. Gynecol Oncol 2020; 160:602-609. [PMID: 33303211 DOI: 10.1016/j.ygyno.2020.11.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/23/2020] [Indexed: 01/22/2023]
Abstract
Vaginal necrosis is a late radiation tissue injury with serious morbidity complications. It is rare, and its incidence is not well assessed in prospective trials. Patient comorbidities and radiation dose can significantly increase the risk. As treatment of gynecologic malignancies often involve a multidisciplinary approach, timely diagnosis and appropriate management by physicians of the team are crucial. Untreated vaginal necrosis can lead to infection, hemorrhage, necrosis-related fistulation to the bladder or rectum, perforation, and death. In this review, we describe the pathophysiology of vaginal necrosis, its clinical course, and management options.
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Affiliation(s)
- Angela Y Jia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, United States of America
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, United States of America.
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Kün-Darbois JD, Fauvel F. Medication-related osteonecrosis and osteoradionecrosis of the jaws: Update and current management. Morphologie 2020; 105:170-187. [PMID: 33281055 DOI: 10.1016/j.morpho.2020.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 12/19/2022]
Abstract
Medication related osteonecrosis of the jaws (MRONJ) and osteoradionecrosis of the jaws (ORNJ) are two different diseases of quite similar appearance. MRONJ is mainly due to antiresorptive or antiangiogenic drug therapy and ORNJ to radiotherapy. The present work aimed at presenting and comparing the current knowledge on MRONJ and ORNJ. They both present as an exposure of necrotic bone and differ in some clinical or radiological characteristics, clinical course and mostly in treatment. They share similar risk factors. A tooth extraction is more frequently found as a triggering factor in MRONJ. The frequency of a maxillary localisation seems higher for MRONJ. On computed tomographic images, a periosteal reaction seems characteristic of MRONJ. More frequent pathological fractures seem to occur in ORNJ. It is mandatory, for ORNJ diagnosis, to exclude a residual or recurrent tumour using histological examination. Both MRONJ and ORNJ are challenging to treat and cannot be managed similarly. For both, it would still be worth to optimise awareness within the medical community, patients' oral hygiene and dental cares to improve their prevention and make their incidences decrease. Conservative therapy is more frequently achieved for MRONJ than ORNJ and surgical resection is more often performed for ORNJ. For both diseases, the last treatment possible in refractory cases is a surgical extensive resection with free flap reconstruction. A MRONJ classification is widely used today, whereas no consensus exists to date for ORNJ classification. We propose a classification that could play this role.
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Affiliation(s)
- J-D Kün-Darbois
- Department of oral and maxillofacial surgery, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex, France; Groupe études remodelage osseux et bioMatériaux, GEROM, SFR 4208, UNIV Angers, IRIS-IBS institut de biologie en Santé, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex, France.
| | - F Fauvel
- Department of oral and maxillofacial surgery, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France; Department of oral and maxillofacial surgery, CH de Saint-Nazaire, 11, boulevard Georges-Charpak, 44606 Saint-Nazaire cedex, France
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