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Fitzgerald KT, Lyons C, England A, McEntee MF, Devine A, O'Donovan T, O'Sullivan E. Response to letter to the editor by Somay et al., re: "Risk factors associated with the development of osteoradionecrosis (ORN) in head and neck cancer patients in Ireland: A 10-year retrospective review". Radiother Oncol 2024; 198:110412. [PMID: 38960325 DOI: 10.1016/j.radonc.2024.110412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/17/2024] [Indexed: 07/05/2024]
Affiliation(s)
| | - Ciara Lyons
- Radiation Therapy Dept., Glandore Centre, Cork University Hospital, Cork, Ireland
| | - Andrew England
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Mark F McEntee
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Annemarie Devine
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Theresa O'Donovan
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Eleanor O'Sullivan
- Radiation Therapy Dept., Glandore Centre, Cork University Hospital, Cork, Ireland; ENTO Research Unit, Cork University Dental School & Hospital, Cork, Ireland.
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Margalit DN, Anker CJ, Aristophanous M, Awan M, Bajaj GK, Bradfield L, Califano J, Caudell JJ, Chapman CH, Garden AS, Harari PM, Helms A, Lin A, Maghami E, Mehra R, Parker L, Shnayder Y, Spencer S, Swiecicki PL, Tsai JC, Sher DJ. Radiation Therapy for HPV-Positive Oropharyngeal Squamous Cell Carcinoma: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:398-425. [PMID: 39078350 DOI: 10.1016/j.prro.2024.05.007] [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: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a distinct disease from other head and neck tumors. This guideline provides evidence-based recommendations on the critical decisions in its curative treatment, including both definitive and postoperative radiation therapy (RT) management. METHODS ASTRO convened a task force to address 5 key questions on the use of RT for management of HPV-associated OPSCC. These questions included indications for definitive and postoperative RT and chemoradiation; dose-fractionation regimens and treatment volumes; preferred RT techniques and normal tissue considerations; and posttreatment management decisions. The task force did not address indications for primary surgery versus RT. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Concurrent cisplatin is recommended for patients receiving definitive RT with T3-4 disease and/or 1 node >3 cm, or multiple nodes. For similar patients who are ineligible for cisplatin, concurrent cetuximab, carboplatin/5-fluorouracil, or taxane-based systemic therapy are conditionally recommended. In the postoperative setting, RT with concurrent cisplatin (either schedule) is recommended for positive surgical margins or extranodal extension. Postoperative RT alone is recommended for pT3-4 disease, >2 nodes, or a single node >3 cm. Observation is conditionally recommended for pT1-2 disease and a single node ≤3 cm without other risk factors. For patients treated with definitive RT with concurrent systemic therapy, 7000 cGy in 33 to 35 fractions is recommended, and for patients receiving postoperative RT without positive surgical margins and extranodal extension, 5600 to 6000 cGy is recommended. For all patients receiving RT, intensity modulated RT over 3-dimensional techniques with reduction in dose to critical organs at risk (including salivary and swallowing structures) is recommended. Reassessment with positron emission tomography-computed tomography is recommended approximately 3 months after definitive RT/chemoradiation, and neck dissection is recommended for convincing evidence of residual disease; for equivocal positron emission tomography-computed tomography findings, either neck dissection or repeat imaging is recommended. CONCLUSIONS The role and practice of RT continues to evolve for HPV-associated OPSCC, and these guidelines inform best clinical practice based on the available evidence.
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Affiliation(s)
- Danielle N Margalit
- Department of Radiation Oncology, Brigham & Women's/Dana-Farber Cancer Center, Harvard Medical School, Boston, Massachusetts.
| | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | - Michalis Aristophanous
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gopal K Bajaj
- Department of Advanced Radiation Oncology and Proton Therapy, Inova Schar Cancer Institute, Fairfax, Virginia
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Joseph Califano
- Department of Surgery, University of California San Diego Health, San Diego, California
| | - Jimmy J Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Christina H Chapman
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas
| | - Adam S Garden
- Department of Radiation Oncology, University of Texas - MD Anderson Cancer Center, Houston, Texas
| | - Paul M Harari
- Department of Human Oncology, University of Wisconsin, Madison, Wisconsin
| | - Amanda Helms
- American Society for Radiation Oncology, Arlington, Virginia
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellie Maghami
- Department of Surgery, City of Hope, Duarte, California
| | - Ranee Mehra
- Department of Medical Oncology, University of Maryland Medical School and Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | | | - Yelizaveta Shnayder
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Sharon Spencer
- Department of Radiation Oncology, University of Alabama Heersink School of Medicine, Birmingham, Alabama
| | - Paul L Swiecicki
- Department of Medical Oncology, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan
| | | | - David J Sher
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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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; 30:3732-3744. [PMID: 38396363 DOI: 10.1111/odi.14902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [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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Hosseinian S, Hemmati M, Dede C, Salzillo TC, van Dijk LV, Mohamed ASR, Lai SY, Schaefer AJ, Fuller CD. Cluster-Based Toxicity Estimation of Osteoradionecrosis Via Unsupervised Machine Learning: Moving Beyond Single Dose-Parameter Normal Tissue Complication Probability by Using Whole Dose-Volume Histograms for Cohort Risk Stratification. Int J Radiat Oncol Biol Phys 2024; 119:1569-1578. [PMID: 38462018 PMCID: PMC11262961 DOI: 10.1016/j.ijrobp.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 01/13/2024] [Accepted: 02/08/2024] [Indexed: 03/12/2024]
Abstract
PURPOSE Given the limitations of extant models for normal tissue complication probability estimation for osteoradionecrosis (ORN) of the mandible, the purpose of this study was to enrich statistical inference by exploiting structural properties of data and provide a clinically reliable model for ORN risk evaluation through an unsupervised-learning analysis that incorporates the whole radiation dose distribution on the mandible. METHODS AND MATERIALS The analysis was conducted on retrospective data of 1259 patients with head and neck cancer treated at The University of Texas MD Anderson Cancer Center between 2005 and 2015. During a minimum 12-month posttherapy follow-up period, 173 patients in this cohort (13.7%) developed ORN (grades I to IV). The (structural) clusters of mandibular dose-volume histograms (DVHs) for these patients were identified using the K-means clustering method. A soft-margin support vector machine was used to determine the cluster borders and partition the dose-volume space. The risk of ORN for each dose-volume region was calculated based on incidence rates and other clinical risk factors. RESULTS The K-means clustering method identified 6 clusters among the DVHs. Based on the first 5 clusters, the dose-volume space was partitioned by the soft-margin support vector machine into distinct regions with different risk indices. The sixth cluster entirely overlapped with the others; the region of this cluster was determined by its envelopes. For each region, the ORN incidence rate per preradiation dental extraction status (a statistically significant, nondose related risk factor for ORN) was reported as the corresponding risk index. CONCLUSIONS This study presents an unsupervised-learning analysis of a large-scale data set to evaluate the risk of mandibular ORN among patients with head and neck cancer. The results provide a visual risk-assessment tool for ORN (based on the whole DVH and preradiation dental extraction status) as well as a range of constraints for dose optimization under different risk levels.
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Affiliation(s)
| | - Mehdi Hemmati
- School of Industrial and Systems Engineering, University of Oklahoma, Norman, Oklahoma
| | - Cem Dede
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Travis C Salzillo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lisanne V van Dijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Abdallah S R Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew J Schaefer
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas.
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Ito M, Hayashi T, Takeuchi A, Abe S, Adachi S, Oshima Y, Kazaoka Y, Suzuki K. Intra-arterial chemoradiotherapy for oral cancer: Superiority of intensity-modulated radiation therapy over three-dimensional conformal radiation therapy. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024:101981. [PMID: 39067639 DOI: 10.1016/j.jormas.2024.101981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE To determine the superiority of intensity-modulated radiation therapy (IMRT) over three-dimensional conformal radiation therapy (3DCRT) in patients who underwent intra-arterial chemoradiotherapy for oral cancer. METHODS We retrospectively analyzed patients with locally advanced oral cancer curatively treated with intra-arterial chemoradiotherapy at a single institution between 2010 and 2021. All patients treated after May 2015 underwent IMRT. Docetaxel (12 mg/m2/week) and nedaplatin (5 mg/m2/day) were administered through a shallow temporal artery using a catheter. RESULTS In total, 143 patients (IMRT: 71; 3DCRT: 72) were included in this study. The 5-year overall survival (OS) and progression-free survival (PFS) rates were 75.7 % and 59.8 %, respectively, with no significant differences between the irradiation methods. In multivariate analysis, cervical lymph node metastasis (LNM) was the only significant poor prognostic factor contributing to OS, PFS, locoregional control (LRC), and local control (LC). In multivariate subgroup analysis of LNM cases (n = 90), IMRT contributed to favorable LRC (hazard ratio [HR]=0.4, P = 0.01) and LC (HR=0.4, P = 0.006). There was no difference in the incidence of grade ≥2 osteonecrosis of the jaw (4.2 % vs. 12.5 %, P = 0.13), xerostomia (75 % vs. 82 %, P = 0.316), or dysgeusia (80 % vs. 82 %, P = 0.834) between the IMRT and 3DCRT groups. However, the rates of xerostomia at 6 months and dysgeusia at 3 months were lower in the IMRT group (both P < 0.001). CONCLUSION IMRT neither improved patient survival nor significantly reduced the incidence of osteonecrosis of the jaw. However, it demonstrated favorable LRC and LC in patients with LNM, suggesting an advantage in early recovery from xerostomia and dysgeusia.
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Affiliation(s)
- Makoto Ito
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan.
| | - Tomio Hayashi
- Department of Oral and Maxillofacial Surgery, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan
| | - Arisa Takeuchi
- Department of Radiation Oncology, Anjo Kosei Hospital, 28 Higashihirokute, Anjo-cho, Anjo, Aichi 446-8602, Japan
| | - Souichirou Abe
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan
| | - Sou Adachi
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan
| | - Yukihiko Oshima
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan
| | - Yoshiaki Kazaoka
- Department of Oral and Maxillofacial Surgery, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan
| | - Kojiro Suzuki
- Department of Radiology, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan
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Kishida K, Jingu K, Ito K, Umezawa R, Yamamoto T, Takahashi N, Suzuki Y, Omata S, Harada H, Seki Y, Chiba N, Okuda S. Impact of dose distribution by a 3D planning system for brachytherapy with 198Au grains for head and neck cancer. Head Neck 2024. [PMID: 39011775 DOI: 10.1002/hed.27874] [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: 03/21/2024] [Revised: 06/30/2024] [Accepted: 07/07/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND There has been no study in which the correlation between clinical results and dosimetry based on a 3D treatment planning system in patients with 198Au grains for head and neck cancer was evaluated. METHODS Thirty-two patients who were treated with 198Au grains for head and neck cancer were reviewed. Twenty-five patients were treated with brachytherapy alone and seven patients were treated with a combination of brachytherapy and neoadjuvant external beam radiation therapy. RESULTS With a median observation period of 60 months, the 5-year local control rate was 82.9%. V85Gy of CTV in patients with local recurrence tended to be lower than that in patients without local recurrence (p = 0.07). The maximum dose of the keratinized gingiva in patients in whom bone exposure occurred was significantly higher than that in patients in whom bone exposure did not occur (p = 0.001). CONCLUSIONS Dose distribution with 198Au grains can predict local control and late adverse events.
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Affiliation(s)
- Keita Kishida
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kengo Ito
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - So Omata
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hinako Harada
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Seki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nanae Chiba
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shinsaku Okuda
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Fitzgerald KT, Lyons C, England A, McEntee MF, Devine A, O'Donovan T, O'Sullivan E. Risk factors associated with the development of osteoradionecrosis (ORN) in Head and Neck cancer patients in Ireland: A 10-year retrospective review. Radiother Oncol 2024; 196:110286. [PMID: 38641259 DOI: 10.1016/j.radonc.2024.110286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/21/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND AND PURPOSES To assess osteoradionecrosis (ORN) incidence in a population of Irish Head and Neck cancer (HNC) patients, and assess precipitating factors that may contribute to ORN development to aid prevention. MATERIALS AND METHODS Review of 1050 HNC patients attending the Dental Oncology Clinic, CUDSH between 2010 and 2021 identified 47 cases of ORN. Medical, dental and radiotherapy records of these forty-seven patients were retrospectively reviewed. Patient-, tumour-, and treatment-related variables were investigated in association with osteoradionecrosis development. Analysis conducted using SPSS, Pearson's Chi-square test (p < 0.05), and ordinal regression model. RESULTS ORN incidence was 4.4 %. Median time from radiotherapy (RT) to ORN development was 9.5 months (range 1-98.5 months). ORN development within the mandibular surgical site was significant (p <.001), presenting at a higher Notani grade (p =.002), in mid-mandibular body region (p =.028), at radiation doses ≥ 60 Gy (p =.035), due to induced causes (p =.029), and without resolution (p =.019). CONCLUSION This is the first retrospective study of ORN in HNC patients in Ireland over 10-year period. ORN incidence was extremely low (4.4%). As patients reported high smoking/alcohol use and poor dental attendance pre-diagnosis, this suggests intensive dental intervention pre/post-diagnosis contributed to low ORN rates. Mandibular surgery pre-RT increased risk of developing ORN at the surgical site. Therefore, we recommend future treatment planning should contour the surgical site, designating it an organ at risk (OAR), assigning a dose constraint, where oncologically possible, with emphasis on reducing the hot-spot to this region; findings reinforce importance of life-long expert dental care to reduce ORN incidence.
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Affiliation(s)
| | - Ciara Lyons
- Radiation Therapy Dept., Glandore Centre, Cork University Hospital, Cork, Ireland
| | - Andrew England
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Mark F McEntee
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Annemarie Devine
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Theresa O'Donovan
- Medical Imaging & Radiation Therapy, School of Medicine, University College Cork, Ireland
| | - Eleanor O'Sullivan
- Radiation Therapy Dept., Glandore Centre, Cork University Hospital, Cork, Ireland; ENTO Research Unit, Cork University Dental School & Hospital, Cork, Ireland.
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de Almeida-Silva LA, Lupp JDS, Sobral-Silva LA, Dos Santos LAR, Marques TO, da Silva DBR, Caneppele TMF, Bianchi-de-Moraes M. The incidence of osteoradionecrosis of the jaws in oral cavity cancer patients treated with intensity-modulated radiotherapy: a systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 2024; 138:66-78. [PMID: 38772792 DOI: 10.1016/j.oooo.2024.04.008] [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: 11/24/2023] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE A systematic review with meta-analysis was conducted to define the incidence of osteoradionecrosis (ORN) in patients with oral cavity cancer (OCC) treated with intensity-modulated radiotherapy (IMRT), and to identify the risk factors influencing its development. STUDY DESIGN Six databases were searched systematically. A meta-analysis was performed to determine overall, spontaneous, and dental extraction-attributed incidences of ORN. The Grading of Recommendations Assessment, Development, and Evaluation tool evaluated evidence certainty. RESULTS Out of 11 eligible studies, 6 underwent meta-analysis for the overall aggregated ORN incidence in OCC patients receiving IMRT, resulting in an incidence rate of 8% (95% CI: 6%-11%). Regarding development reasons, 2 studies were assessed, revealing an incidence of 36% (95% CI: 1%-98%) for spontaneous ORN, and 17% (95% CI: 5%-44%) ensued from dental extraction exclusively pre-RT. All rates had very low certainty of evidence. Factors significantly correlated with ORN development included postoperative RT use (78%), employment of therapeutic doses above 50 Gy, and mandibular involvement (80.5%). CONCLUSION The findings suggest that IMRT alone is not sufficient to decrease ORN rates in OCC patients, underscoring the importance of precisely identifying the involved risk factors. However, further detailed primary studies will be necessary.
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Affiliation(s)
- Luis Augusto de Almeida-Silva
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, São Paulo State University (Unesp), São José dos Campos, Brazil.
| | - Juliana Dos Santos Lupp
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, São Paulo State University (Unesp), São José dos Campos, Brazil
| | - Leonardo Alvares Sobral-Silva
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, São Paulo State University (Unesp), São José dos Campos, Brazil
| | - Luiz Augusto Rodrigues Dos Santos
- Department of Surgery and Diagnosis, Institute of Science and Technology, São Paulo State University (Unesp), São José dos Campos, Brazil
| | - Thays Oliveira Marques
- Department of Bioscience and Oral Diagnosis, Institute of Science and Technology, São Paulo State University (Unesp), São José dos Campos, Brazil
| | - Danillo Babinskas Ribeiro da Silva
- Department of Surgery and Diagnosis, Institute of Science and Technology, São Paulo State University (Unesp), São José dos Campos, Brazil
| | - Taciana Marco Ferraz Caneppele
- Department of Restorative Dentistry, Institute of Science and Technology, São Paulo State University (Unesp), São José dos Campos, Brazil
| | - Michelle Bianchi-de-Moraes
- Department of Surgery and Diagnosis, Institute of Science and Technology, São Paulo State University (Unesp), São José dos Campos, Brazil
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Yang F, Wong RJ, Zakeri K, Singh A, Estilo CL, Lee NY. Osteoradionecrosis Rates After Head and Neck Radiation Therapy: Beyond the Numbers. Pract Radiat Oncol 2024; 14:e264-e275. [PMID: 38649030 DOI: 10.1016/j.prro.2024.02.008] [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: 11/11/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Osteoradionecrosis (ORN) is a severe late complication of head and neck radiation therapy shown to have profound negative effect on the quality of life of cancer survivors. Over the past few decades, improvements in radiation delivery techniques have resulted in a decrease in the incidence of ORN. However, even with modern radiation therapy techniques, ORN remains an important clinical concern. In recent literature, there is a wide range of reported ORN rates from 0% to as high as 20%. With such a high level of variability in the reported incidence of ORN, oncologists often encounter difficulties estimating the risk of this serious radiation therapy toxicity. METHODS AND MATERIALS In this review, the authors present a summary of the factors that contribute to the high level of variability in the reported incidence of ORN. RESULTS Variable definition, variable grading, and heterogeneity of both study inclusion criteria and treatment parameters can each significantly influence the reporting of ORN rates. CONCLUSIONS Given numerous factors can affect the reported incidence of ORN, a thorough understanding of the clinical context behind the reported ORN rates is needed to comprehend the true risk of this important radiation therapy toxicity.
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Affiliation(s)
- Fan Yang
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J Wong
- Departments of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kaveh Zakeri
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annu Singh
- Departments of Dentistry, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cherry L Estilo
- Departments of Dentistry, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Kovarik PD, Cvek J, Patil R, Macdougall C, Kelly C, Jackson M, McKenzie L, West N, Willis N, Kovarik JP, Anwar MN, Ellabban I, Shahid Iqbal M. Timing of development of osteoradionecrosis post head and neck radiotherapy: does a safe time interval exist for dental extraction? Strahlenther Onkol 2024:10.1007/s00066-024-02251-5. [PMID: 38918259 DOI: 10.1007/s00066-024-02251-5] [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: 02/25/2024] [Accepted: 05/26/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Risk factors for developing osteoradionecrosis (ORN) are well known, but less is known about factors influencing the interval between radiotherapy and the onset of ORN. Also, it is unknown whether there is any specific period post-radiotherapy with a reduced probability of ORN when irradiated teeth require extraction. PURPOSE The primary aim of this study was to identify factors influencing the interval in developing ORN in the following subgroups of patients: (1) patients who spontaneously developed ORN, (2) surgical-intervention-related ORN with a particular focus on patients after mandibulectomy. The secondary aim was to attempt to identify a possible time for safer dental intervention after primary treatment. MATERIALS AND METHODS The authors retrospectively analysed 1608 head and neck cancer (HNC) patients treated in a single centre. Time intervals were measured from the end of radiotherapy to the development of ORN and further analysed in the subgroups listed above. RESULTS In all, 141 patients (8.8%) developed intra-oral ORN. Median time from radiotherapy to ORN development in the whole cohort was 9 months. Median interval for spontaneous ORN was 8 months, 6.5 months for intervention-related ORN, and 15 months for patients post-mandibulectomy. In patients who required dental extraction preradiotherapy, median interval of ORN onset was 5 months. CONCLUSION In our study, a slightly higher proportion of patients with intervention developed ORN earlier in comparison with spontaneous ORN. The period from 12-18 months after radiotherapy was identified as having the highest probability of developing ORN in patients after mandibulectomy. A time for safer dental intervention after primary treatment was not identified.
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Affiliation(s)
- Petr Daniel Kovarik
- Department of Trauma and Orthopaedics, Northumbria Specialist Emergency Care Hospital, Cramlington, UK
- Department of Oncology, University of Ostrava, Ostrava, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University of Ostrava, Ostrava, Czech Republic
| | - Rahul Patil
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - Craig Macdougall
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - Charles Kelly
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
- Newcastle university, Newcastle upon Tyne, UK
| | - Malcolm Jackson
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - Laura McKenzie
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - Nick West
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - Nicholas Willis
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK
| | - Josef Paul Kovarik
- Institute of Dentistry and Oral Sciences, Palacky University Olomouc, Olomouc, Czech Republic
| | - Muhammad Naveed Anwar
- Department of Computer & Information Sciences, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne, UK
| | | | - Muhammad Shahid Iqbal
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne, UK.
- Newcastle university, Newcastle upon Tyne, UK.
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11
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Watson EE, Hueniken K, Lee J, Huang SH, El Maghrabi A, Xu W, Moreno AC, Tsai CJ, Hahn E, McPartlin AJ, Yao CMKL, Goldstein DP, De Almeida JR, Waldon JN, Fuller CD, Hope AJ, Ruggiero SL, Glogauer M, Hosni AA. Development and Standardization of an Osteoradionecrosis Classification System in Head and Neck Cancer: Implementation of a Risk-Based Model. J Clin Oncol 2024; 42:1922-1933. [PMID: 38691822 DOI: 10.1200/jco.23.01951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/01/2023] [Accepted: 02/26/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE Osteoradionecrosis of the jaw (ORN) can manifest in varying severity. The aim of this study is to identify ORN risk factors and develop a novel classification to depict the severity of ORN. METHODS Consecutive patients with head and neck cancer (HNC) treated with curative-intent intensity-modulated radiation therapy (IMRT) (≥45 Gy) from 2011 to 2017 were included. Occurrence of ORN was identified from in-house prospective dental and clinical databases and charts. Multivariable logistic regression model was used to identify risk factors and stratify patients into high-risk and low-risk groups. A novel ORN classification system was developed to depict ORN severity by modifying existing systems and incorporating expert opinion. The performance of the novel system was compared with 15 existing systems for their ability to identify and predict serious ORN event (jaw fracture or requiring jaw resection). RESULTS ORN was identified in 219 of 2,732 (8%) consecutive patients with HNC. Factors associated with high risk of ORN were oral cavity or oropharyngeal primaries, received IMRT dose ≥60 Gy, current/ex-smokers, and/or stage III to IV periodontal condition. The ORN rate for high-risk versus low-risk patients was 12.7% versus 3.1% (P < .001) with an AUC of 0.71. Existing ORN systems overclassified serious ORN events and failed to recognize maxillary ORN. A novel ORN classification system, ClinRad, was proposed on the basis of vertical extent of bone necrosis and presence/absence of exposed bone/fistula. This system detected serious ORN events in 5.7% of patients and statistically outperformed existing systems. CONCLUSION We identified risk factors for ORN and proposed a novel ORN classification system on the basis of vertical extent of bone necrosis and presence/absence of exposed bone/fistula. It outperformed existing systems in depicting the seriousness of ORN and may facilitate clinical care and clinical trials.
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Affiliation(s)
- Erin E Watson
- Department of Dental Oncology, Princess Margaret Cancer Centre, Toronto, ON
- Faculty of Dentistry, University of Toronto, Toronto, ON
| | - Katrina Hueniken
- Department of Biostatistics, University Health Network, Toronto, ON
| | - Junhyung Lee
- Department of Dental Oncology, Princess Margaret Cancer Centre, Toronto, ON
| | - Shao Hui Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON
| | - Amr El Maghrabi
- Department of Dental Oncology, Princess Margaret Cancer Centre, Toronto, ON
| | - Wei Xu
- Department of Biostatistics, University Health Network, Toronto, ON
| | | | - C Jillian Tsai
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON
| | - Ezra Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON
| | - Andrew J McPartlin
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON
| | - Christopher M K L Yao
- Department of Otolaryngology-Head & Neck Surgery, University Health Network/University of Toronto, Toronto, ON
| | - David P Goldstein
- Department of Otolaryngology-Head & Neck Surgery, University Health Network/University of Toronto, Toronto, ON
| | - John R De Almeida
- Department of Otolaryngology-Head & Neck Surgery, University Health Network/University of Toronto, Toronto, ON
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - John N Waldon
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON
| | - Clifton D Fuller
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON
| | - Andrew J Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON
| | - Salvatore L Ruggiero
- Department of Oral and Maxillofacial Surgery, Stony Brook University, Stony Brook, NY
- Hofstra North Shore-LIJ School of Medicine, Uniondale, NY
| | | | - Ali A Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON
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12
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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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13
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Somay E, Topkan E, Kucuk A, Ozturk D, Ozkan EE, Ozdemir BS, Besen AA, Mertsoylu H, Pehlivan B, Selek U. Pre-chemoradiotherapy high platelet counts predict jaw osteoradionecrosis in locally advanced nasopharyngeal carcinoma patients. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101838. [PMID: 38518893 DOI: 10.1016/j.jormas.2024.101838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION This retrospective study aimed to investigate if pretreatment platelet (PLT) levels can predict the risk of osteoradionecrosis of the jaw (ORNJ) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) who received concurrent chemoradiotherapy (CCRT). MATERIAL &METHODS ORNJ instances were identified from LA-NPC patients' pre- and post-CCRT oral exam records. All pretreatment PLT values were acquired on the first day of CCRT. Receiver operating characteristic curve analysis was used to determine the optimal PLT cutoff that divides patients into two subgroups with distinctive ORNJ rates. The primary outcome measure was the association between pretreatment PLT values and ORNJ incidence rates. RESULTS The incidence of ORNJ was 8.8 % among the 240 LA-NPC patients analyzed. The ideal pre-CCRT PLT cutoff which divided the patients into two significantly different ORNJ rate groups was 285,000 cells/µL (PLT ≤ 285,000 cells/µL (N = 175) vs. PLT > 285,000 cells/µL (N = 65)). A comparison of the two PLT groups revealed that the incidence of ORNJ was substantially higher in patients with PLT > 285,000 cells/L than in those with PLT≤285,000 cells/L (26.2% vs. 2.3 %; P < 0.001). The presence of pre-CCRT ≥3 tooth extractions, any post-CCRT tooth extractions, mean mandibular dose ≥ 34.1 Gy, mandibular V57.5 Gy ≥ 34.7 %, and post-CCRT tooth extractions > 9 months after CCRT completion were also associated with significantly increased ORNJ rates. A multivariate Cox regression analysis demonstrated that each characteristic had an independent significance on ORNJ rates after CCRT. CONCLUSION An affordable and easily accessible novel biomarker, PLT> 285,000 cells/L, may predict substantially higher ORNJ rates after definitive CCRT in individuals with LA-NPC.
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Affiliation(s)
- Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey.
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Ahmet Kucuk
- Clinics of Radiation Oncology, Mersin City Education and Research Hospital, Mersin, Turkey
| | - Duriye Ozturk
- Department of Radiation Oncology, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Emine Elif Ozkan
- Department of Radiation Oncology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
| | | | - Ali Ayberk Besen
- Clinics of Medical Oncology, Istinye University, Adana Medical Park Hospital, Turkey
| | - Huseyin Mertsoylu
- Clinics of Medical Oncology, Istinye University, Adana Medical Park Hospital, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey
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14
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Merring-Mikkelsen L, Brincker MH, Andersen M, Kesmez Ö, Nielsen MS. Mandible osteoradionecrosis after high-dose radiation therapy for head and neck cancers: risk factors and dosimetric analysis. Acta Oncol 2024; 63:273-276. [PMID: 38711314 PMCID: PMC11332527 DOI: 10.2340/1651-226x.2024.35222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/08/2024] [Indexed: 05/08/2024]
Affiliation(s)
| | - Mads Høyrup Brincker
- Department of Medical Physics, Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Maria Andersen
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Özlem Kesmez
- Department of Oral and Maxillofacial, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Skovmos Nielsen
- Department of Medical Physics, Oncology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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15
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Carsuzaa F, Dore M, Falek S, Delpon G, Drouet J, Thariat J. [Prevention, diagnosis and management of osteoradionecrosis: Where do we stand?]. Bull Cancer 2024; 111:525-536. [PMID: 38480057 DOI: 10.1016/j.bulcan.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 05/13/2024]
Abstract
Osteoradionecrosis (ORN) is a late secondary iatrogenic complication of external radiotherapy for cancers of the upper aero-digestive tract. Despite the systematization of intensity-modulated radiotherapy and its potential for preserving salivary secretion and limiting the dose delivered to the supporting bone, ORN remains a feared and frequent complication. The objective of this literature review was to provide an overview of the management of ORN and to determine the key points that would make it possible to improve patient care. The diagnosis of ORN requires to eliminate tumor recurrence then is based on clinical arguments and imaging by CT or Cone Beam evolving in a chronic mode (more than 3-6 months). The harmonization of its classifications aims to offer comprehensive and multidisciplinary care as early as possible. Primary prevention is based on pre-therapeutic oral and dental preparation, then associated with fluoroprophylaxis if salivary recovery is insufficient and requires supervision of invasive dental care and prosthetic rehabilitation. Semi-automatic contouring tools make it possible to identify doses delivered to dental sectors and guide dental care with personalized dosimetric mapping. Conservative medical treatment is offered at an early stage where innovative medical treatments, highlighted by early studies, could be of interest in the future. In the event of advanced ORN, a non-conservative treatment is then proposed and frequently consists of interruptive mandibulectomy associated with reconstruction by bony free flap, the conditions of implantation remaining to be defined with the support of prospective clinical trials.
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Affiliation(s)
- Florent Carsuzaa
- Service d'ORL et chirurgie cervico-faciale, centre hospitalo-universitaire de Poitiers, Poitiers, France.
| | - Mélanie Dore
- Service de radiothérapie, institut de cancérologie de l'Ouest, Nantes, France
| | - Sabah Falek
- Service de chirurgie maxillofaciale et stomatologie, centre François-Baclesse, Caen, France
| | - Grégory Delpon
- Service de radiothérapie, institut de cancérologie de l'Ouest, Nantes, France
| | - Julien Drouet
- Service de chirurgie maxillofaciale et stomatologie, centre François-Baclesse, Caen, France
| | - Juliette Thariat
- Service de radiothérapie, centre François-Baclesse, Caen, France; Laboratoire de physique corpusculaire, IN2P3/ENSICAEN/CNRS, UMR 6534, Normandie université, Caen, France; GORTEC, Intergroupe ORL France, France
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16
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Renouf M, Auger S, Campion L, Delpon G, Longis J, Dupas C, Blery P, Thariat J, Doré M. Prognostic Factors of Mandibular Osteoradionecrosis Including Accurate Colocalization of Avulsions and Dosimetric Dental Mapping Software, a Case-control Study. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00518-2. [PMID: 38685504 DOI: 10.1016/j.ijrobp.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Osteoradionecrosis (ORN) of the mandible remains a significant complication in the intensity modulated radiation therapy (IMRT) era. Dental dose cannot be predicted from heterogeneous IMRT dose distributions; mandibular dose metrics cannot guide dentist avulsion decisions in high-risk ORN situations. Using a mapping tool to report dental root dose, avulsions, and ORN sites, we re-examined ORN risk factors in a case-control study. METHODS AND MATERIALS From 2008 to 2019, 897 consecutive patients with oral cavity/oropharynx or unknown primary cancer undergoing IMRT were analyzed to identify ORN cases. These were matched (1 ORN/2 controls) retrospectively for tumor location, surgery, and tobacco consumption in a monocentric case-control study. Univariate and multivariate analyses integrated ORN factors and accurate dental dose data (grouped into 4 mandibular sectors). Generalizability was investigated in a simulated population database. RESULTS A total of 171 patients were included. The median follow-up was 5.2 and 4.5 years in the ORN and control groups, respectively. The median time to ORN was 12 months. In univariate analysis, post-IMRT avulsions at the ORN site (hazard ratio [HR] = 3.6; 95% confidence interval [CI] = 1.5-8.9; P = .005), tumor laterality (HR, 4.4; 95% CI, = 1.4-14, P = .01), mean mandibular dose (HR, 1.1; 95% CI, = 1.01-1.1; P = .018) and mean dose to the ORN site (HR, 1.1; 95% CI, = 1.1-1.2; P < .001) correlated with higher ORN risk. In multivariate analysis, mean dose to the ORN site (HR, 1.1; 95% CI, = 1.1-1.2; P < .001) and post-IMRT avulsions at the ORN site (HR, 4.6; 95% CI, = 1.5-14.7; P = .009) were associated with ORN. For each increase in gray in dental dose, the ORN risk increased by 12%. Simulations confirmed study observations. CONCLUSIONS Dental dose and avulsions are associated with ORN, with a 12% increase in risk with each additional gray. Accurate dose information can help dentists in their decisions after IMRT.
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Affiliation(s)
- Marion Renouf
- Institut de Cancérologie de l'Ouest, Nantes, France; Centre Hospitalier Départemental Vendée, La Roche Sur Yon, France.
| | - Simon Auger
- Centre Hospitalier Universitaire, Nantes, France
| | - Loïc Campion
- Institut de Cancérologie de l'Ouest, Nantes, France; Nantes Université, INSERM 1307, CNRS 6075, Université d'Angers, CRCI2NA, Nantes, France
| | - Grégory Delpon
- Institut de Cancérologie de l'Ouest, Nantes, France; Laboratoire SUBATECH, UMR 6457 CNRS-IN2P3, IMT Atlantique, Nantes, France
| | - Julie Longis
- Maxillofacial Surgery Department, Centre Hospitalier Universitaire, Nantes, France
| | - Cécile Dupas
- Centre Hospitalier Universitaire, Nantes, France
| | - Pauline Blery
- Centre Hospitalier Universitaire, Nantes, France; INSERM UMRS 1229, France
| | - Juliette Thariat
- Centre François Baclesse, Caen, France; Laboratoire de Physique Corpusculaire IN2P3/ENSICAEN/CNRS UMR 6534, Normandie Université, Caen, France
| | - Mélanie Doré
- Institut de Cancérologie de l'Ouest, Nantes, France
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Moreno AC, Watson EE, Humbert-Vidan L, Peterson DE, van Dijk LV, Urbano TG, Van den Bosch L, Hope AJ, Katz MS, Hoebers FJ, Aponte Wesson RA, Bates JE, Bossi P, Dayo AF, Doré M, Fregnani ER, Galloway TJ, Gelblum DY, Hanna IA, Henson CE, Kiat-amnuay S, Korfage A, Lee NY, Lewis CM, Lynggaard CD, Mäkitie AA, Magalhaes M, Mowery YM, Muñoz-Montplet C, Myers JN, Orlandi E, Patel J, Rigert JM, Saunders D, Schoenfeld JD, Selek U, Somay E, Takiar V, Thariat J, Verduijn GM, Villa A, West N, Witjes MJ, Won A, Wong ME, Yao CM, Young SW, Al-eryani K, Barbon CE, Buurman DJ, Dieleman FJ, Hofstede TM, Khan AA, Otun AO, Robinson JC, Hum L, Johansen J, Lalla R, Lin A, Patel V, Shaw RJ, Chambers MS, Ma D, Singh M, Yarom N, Mohamed ASR, Hutcheson KA, Lai SY, Fuller CD. International Expert-Based Consensus Definition, Staging Criteria, and Minimum Data Elements for Osteoradionecrosis of the Jaw: An Inter-Disciplinary Modified Delphi Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.07.24305400. [PMID: 38645105 PMCID: PMC11030490 DOI: 10.1101/2024.04.07.24305400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Purpose Osteoradionecrosis of the jaw (ORNJ) is a severe iatrogenic disease characterized by bone death after radiation therapy (RT) to the head and neck. With over 9 published definitions and at least 16 diagnostic/staging systems, the true incidence and severity of ORNJ are obscured by lack of a standard for disease definition and severity assessment, leading to inaccurate estimation of incidence, reporting ambiguity, and likely under-diagnosis worldwide. This study aimed to achieve consensus on an explicit definition and phenotype of ORNJ and related precursor states through data standardization to facilitate effective diagnosis, monitoring, and multidisciplinary management of ORNJ. Methods The ORAL Consortium comprised 69 international experts, including representatives from medical, surgical, radiation oncology, and oral/dental disciplines. Using a web-based modified Delphi technique, panelists classified descriptive cases using existing staging systems, reviewed systems for feature extraction and specification, and iteratively classified cases based on clinical/imaging feature combinations. Results The Consortium ORNJ definition was developed in alignment with SNOMED-CT terminology and recent ISOO-MASCC-ASCO guideline recommendations. Case review using existing ORNJ staging systems showed high rates of inability to classify (up to 76%). Ten consensus statements and nine minimum data elements (MDEs) were outlined for prospective collection and classification of precursor/ORNJ stages. Conclusion This study provides an international, consensus-based definition and MDE foundation for standardized ORNJ reporting in cancer survivors treated with RT. Head and neck surgeons, radiation, surgical, medical oncologists, and dental specialists should adopt MDEs to enable scalable health information exchange and analytics. Work is underway to develop both a human- and machine-readable knowledge representation for ORNJ (i.e., ontology) and multidisciplinary resources for dissemination to improve ORNJ reporting in academic and community practice settings.
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18
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Watson E, Lee JH, Hosni A. Tooth Extraction and Osteoradionecrosis-Reply. JAMA Otolaryngol Head Neck Surg 2024; 150:355-356. [PMID: 38358736 DOI: 10.1001/jamaoto.2023.4680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Erin Watson
- Department of Dental Oncology and Maxillofacial Prosthetics, Princess Margaret Cancer Centre, Toronto, Canada
- Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - Jun Hyung Lee
- Department of Dental Oncology and Maxillofacial Prosthetics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Ali Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
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19
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Barry B, Dolivet G, Clatot F, Huguet F, Abdeddaim C, Baujat B, Blanchard N, Calais G, Carrat X, Chatellier A, Coste F, Cupissol D, Cuvelier P, De Mones Del Pujol E, Deneuve S, Duffas O, Dupret-Bories A, Even C, Evrard C, Evrard D, Faivre S, Fakhry N, Garrel R, Gorphe P, Houliat T, Kaminsky MC, Krebs L, Lapeyre M, Lindas P, Malard O, Mirghani H, Mondina M, Moriniere S, Mouawad F, Pestre-Munier J, Pham Dang N, Picard A, Ramin L, Renard S, Salvan D, Schernberg A, Sire C, Thariat J, Vanbockstael J, Vo Tan D, Wojcik T, Klein I, Block V, Baumann-Bouscaud L, De Raucourt D. [French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]. Bull Cancer 2024; 111:393-415. [PMID: 38418334 DOI: 10.1016/j.bulcan.2023.12.007] [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: 07/03/2023] [Revised: 12/14/2023] [Accepted: 12/31/2023] [Indexed: 03/01/2024]
Abstract
OBJECTIVES The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations. METHODOLOGY To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS). RESULTS The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey. CONCLUSION All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.
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Affiliation(s)
- Béatrix Barry
- AP-HP, hôpital Bichat-Claude-Bernard, ORL et CCF, Paris (75), France
| | - Gilles Dolivet
- Institut de cancérologie de Lorraine, ORL et CCF, Nancy (54), France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Olivier Duffas
- Centre hospitalier de Libourne, ORL et CMF, Libourne, France
| | | | | | | | - Diane Evrard
- AP-HP, hôpital Bichat-Claude-Bernard, ORL et CCF, Paris (75), France
| | | | - Nicolas Fakhry
- Assistance publique-Hôpitaux de Marseille, ORL et CCF, Marseille, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Didier Salvan
- Centre hospitalier Sud Francilien, ORL et CCF, Corbeil-Essonnes, France
| | | | | | | | | | | | | | - Isabelle Klein
- Dispositif Spécifique Régional du Cancer Grand Est - NEON, Nancy (54), France
| | - Véronique Block
- Dispositif Spécifique Régional du Cancer Grand Est - NEON, Nancy (54), France
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Topkan E, Somay E, Selek U. Tooth Extraction and Osteoradionecrosis. JAMA Otolaryngol Head Neck Surg 2024; 150:354-355. [PMID: 38358747 DOI: 10.1001/jamaoto.2023.4679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, Faculty of Medicine, Koc University, Istanbul, Turkey
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Owosho AA, DeColibus KA, Okhuaihesuyi O, Levy LC. Prophylactic Use of Pentoxifylline and Tocopherol for Prevention of Osteoradionecrosis of the Jaw after Dental Extraction in Post-Radiated Oral and Oropharyngeal Cancer Patients: An Initial Case Series. Dent J (Basel) 2024; 12:83. [PMID: 38667995 PMCID: PMC11049290 DOI: 10.3390/dj12040083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Osteoradionecrosis of the jaw is a morbid complication of radiotherapy in patients with oral and oropharyngeal cancers that may be precipitated by dental extractions. Pentoxifylline and tocopherol (PENTO) has been utilized in the management of osteoradionecrosis and as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. This observational study aims to report the outcome of the prophylactic use of PENTO in the prevention of osteoradionecrosis of the jaw after dental extractions in post-radiated oral and oropharyngeal cancer patients and to review the current literature on this topic. Four post-radiated oral and oropharyngeal oncology patients were referred to the dental oncology clinic of the University Dental Practice, University of Tennessee Health Sciences Center for dental extractions. All four patients were prescribed pentoxifylline 400 mg BID (twice a day) and tocopherol 400 IU BID (oral tablets) for 2 weeks before extraction(s) and for 6 weeks after extraction(s). All patients were followed up every week after the second week post-extraction if feasible until the extraction site(s) healed (covered by mucosa). The assessment endpoint was defined as 6 weeks post-extraction with the outcomes assessed as using four categories determined by the area of exposed bone: complete healing (complete mucosal coverage of extraction site); partial healing (reduction in size of extraction site); no change; and progression (increase in size of the extraction site). At the assessment endpoint, all patients had complete healing of all extraction sites. The ORN rate at the patient level (0/4) and individual tooth level (0/8) was 0%. All patients tolerated the PENTO medications and no adverse effects from the use of these medications were reported. This limited study in addition to the other reviewed studies estimates the rate of ORN at the patient level as 3.2% (14/436) for post-radiated head and neck oncology patients after dental extractions/invasive oral procedures. In conclusion, this PENTO regimen can reduce/prevent the incidence of ORN in post-radiated head and neck oncology patients. This safe and cost-effective protocol (PENTO regimen) should be further evaluated as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. We recommend large prospective studies to be carried out to further validate these findings.
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Affiliation(s)
- Adepitan A. Owosho
- Department of Diagnostic Sciences, College of Dentistry/Department of Otolaryngology—Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, 875 Union Avenue, Memphis, TN 38163, USA
| | - Katherine A. DeColibus
- Department of Diagnostic Sciences, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Osariemen Okhuaihesuyi
- Missouri School of Dentistry and Oral Health, A.T. Still University, Kirksville, MO 63501, USA
| | - Layne C. Levy
- Advanced Education in General Dentistry, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
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22
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Naseer A, Goode F, Doyle T. Osteoradionecrosis - an old problem with new consequences. Curr Opin Support Palliat Care 2024; 18:39-46. [PMID: 38170197 DOI: 10.1097/spc.0000000000000690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Osteoradionecrosis (ORN) is a devasting complication of radiation therapy (RT), especially in head and neck cancers (HNC), and is still poorly understood. The aim of this review is to report its incidence and consider the risk factors associated with ORN to highlight prevention strategies to decrease its incidence. RECENT FINDINGS The average incidence of ORN is between 2% and 23%, with incidence decreasing in more recent years with the introduction of modern RT technology and better oral health care. Smoking, diabetes mellitus, oropharyngeal and oral cavity cancers, pre- and post-RT dental extractions and a total radiation dose of over 60 Gy were all identified as risk factors for ORN. In prevention, strategies were mainly structured around minimising risk factors or targeting possible mechanisms of ORN's pathophysiology. SUMMARY At present, the controversy surrounding the risk factors and pathogenesis of ORN makes it difficult to establish a set of prevention guidelines for its incidence. In order to achieve this, more research examining its aetiology must be conducted as well as a universal staging system within which ORN may be classified.
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Affiliation(s)
- Amara Naseer
- School of Medicine, Discipline of Radiation Therapy, Trinity College Dublin, The University of Dublin
| | - Fiona Goode
- Trinity College: The University of Dublin Trinity College, Dublin, Republic of Ireland
| | - Tia Doyle
- Trinity College: The University of Dublin Trinity College, Dublin, Republic of Ireland
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23
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Topkan E, Somay E, Yilmaz B. In reply to Shih YJ et.al. (doi: 10.1111/odi.14349). Oral Dis 2024; 30:814-815. [PMID: 36114821 DOI: 10.1111/odi.14380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/13/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Busra Yilmaz
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Baskent University, Ankara, Turkey
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24
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Boromand G, Haugen-Cange H, Asparusova M, Ekestubbe A, Kjeller G. Long-term follow-up of osteoradionecrosis of the mandible. Acta Odontol Scand 2024; 82:48-54. [PMID: 37772879 DOI: 10.1080/00016357.2023.2257316] [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: 03/01/2023] [Accepted: 09/05/2023] [Indexed: 09/30/2023]
Abstract
AIM Investigating the prevalence of mandibular ORN in a single Swedish Oncology Center. METHODS A total of 450 patients, treated with radiotherapy for squamous cell carcinoma in the oropharynx between 2004 and 2014 were included. Three different techniques of radiotherapy were studied. ORN diagnosis was set when clinical signs according to Marx were observed, or if radiological signs were staged according to Schwartz and Kagan. RESULTS Using the staging system, 90 patients (20%) were diagnosed with ORN. The mean age of the ORN patients was 56.6 years, the older the patient the lower the risk of developing ORN (p = .01). The risk of developing ORN for patients receiving Intensity Modulated Radiotherapy was lower compared to patients treated with the other techniques in the multivariable analysis. Brachytherapy significantly increases the risk of ORN. The risk of ORN increased by 8% each year after radiation (p = .04). The mean time to the ORN diagnosis was 3.9 years. In the multivariate analysis, the risk of ORN increased by 13% each year after radiation (p = .0013). CONCLUSION The mean radiation dose was of greater importance for the risk of ORN than the maximum dose. Elderly people with oropharyngeal cancer were less prone to develop ORN.
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Affiliation(s)
- Ghazaleh Boromand
- Department of Oral and Maxillofacial Surgery, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hedda Haugen-Cange
- Department of Oncology, Institute of Clinical Sciences at Gothenburg University and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Asparusova
- Department of Oral and Maxillofacial Surgery, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Ekestubbe
- Department of Oral and Maxillofacial Radiology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Goran Kjeller
- Department of Oral and Maxillofacial Surgery, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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All S, Zhong X, Choi B, Kim JS, Zhuang T, Avkshtol V, Sher D, Lin MH, Moon DH. In Silico Analysis of Adjuvant Head and Neck Online Adaptive Radiation Therapy. Adv Radiat Oncol 2024; 9:101319. [PMID: 38260220 PMCID: PMC10801641 DOI: 10.1016/j.adro.2023.101319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/13/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose Recently developed online adaptive radiation therapy (OnART) systems enable frequent treatment plan adaptation, but data supporting a dosimetric benefit in postoperative head and neck radiation therapy (RT) are sparse. We performed an in silico dosimetric study to assess the potential benefits of a single versus weekly OnART in the treatment of patients with head and neck squamous cell carcinoma in the adjuvant setting. Methods and Materials Twelve patients receiving conventionally fractionated RT over 6 weeks and 12 patients receiving hypofractionated RT over 3 weeks on a clinical trial were analyzed. The OnART emulator was used to virtually adapt either once midtreatment or weekly based on the patient's routinely performed cone beam computed tomography. The planning target volume (PTV) coverage, dose heterogeneity, and cumulative dose to the organs at risk for these 2 adaptive approaches were compared with the nonadapted plan. Results In total, 13, 8, and 3 patients had oral cavity, oropharynx, and larynx primaries, respectively. In the conventionally fractionated RT cohort, weekly OnART led to a significant improvement in PTV V100% coverage (6.2%), hot spot (-1.2 Gy), and maximum cord dose (-3.1 Gy), whereas the mean ipsilateral parotid dose increased modestly (1.8 Gy) versus the nonadapted plan. When adapting once midtreatment, PTV coverage improved with a smaller magnitude (0.2%-2.5%), whereas dose increased to the ipsilateral parotid (1.0-1.1 Gy) and mandible (0.2-0.7 Gy). For the hypofractionated RT cohort, similar benefit was observed with weekly OnART, including significant improvement in PTV coverage, hot spot, and maximum cord dose, whereas no consistent dosimetric advantage was seen when adapting once midtreatment. Conclusions For head and neck squamous cell carcinoma adjuvant RT, there was a limited benefit of single OnART, but weekly adaptations meaningfully improved the dosimetric criteria, predominantly PTV coverage and dose heterogeneity. A prospective study is ongoing to determine the clinical benefit of OnART in this setting.
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Affiliation(s)
- Sean All
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Xinran Zhong
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Byongsu Choi
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Tingliang Zhuang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vladimir Avkshtol
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David Sher
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mu-Han Lin
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dominic H. Moon
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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de Rabello DGD, Valera MC, Corazza BJM, Dos Santos LM, Carvalho CAT. Clinical efficacy of endodontic protocols on reducing cultivable bacteria and endotoxin in infected root canal in patients submitted to head and neck radiotherapy: a randomised clinical trial. Clin Oral Investig 2023; 27:7199-7207. [PMID: 38038750 DOI: 10.1007/s00784-023-05283-w] [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: 11/04/2021] [Accepted: 11/10/2022] [Indexed: 12/02/2023]
Abstract
OBJECTIVES Assess the efficacy of biomechanical preparation using a reciprocating system followed by final irrigation protocols, then intracanal medication, on reducing endotoxins and cultivable bacteria of infected teeth in irradiated patients. MATERIALS AND METHODS Twenty-two infected single-rooted canals in patients submitted to head and neck radiotherapy were prepared by reciprocating motion and 2.5% NaOCl. Patients were randomly divided into two groups of 11 patients before the final irrigation protocol: apical positive pressure (APP) or passive ultrasonic activation (PUA). Both groups were treated in two sessions, using Ca(OH)2 as intracanal medication for 14 days. Root canal content sampling was performed after canal access (S1), after biomechanical preparation plus the irrigation protocol (S2), and after intracanal medication (S3). Chromogenic limulus amoebocyte lysate assay measured endotoxin levels (EU/mL), and bacterial load was determined by culture techniques (CFU/mL). RESULTS Treatment protocols reduced bacterial counts after S2 in both groups (p = 0.01). S3 differed from S1 (p = 0.01), but not from S2 (p = 0.4). Endotoxin levels were reduced in both groups after S2 (P = 0.03) and were lower in S3 than in S2, with significant differences in the APP group (p = 0.03). CONCLUSIONS Biomechanical preparation using a reciprocating system and 2.5% NaOCl in irradiated teeth, followed by the irrigation protocol (APP or PUA), demonstrated efficacy in reducing endodontic contaminants. Ca(OH)2 as intracanal medication should be performed in irradiated patients with infected root canals. CLINICAL RELEVANCE This clinical study demonstrated that endodontic treatment in irradiated patients is efficacious at reducing bacterial load and endotoxin levels.
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Affiliation(s)
- Diego Guilherme Dias de Rabello
- Department of Restorative Dentistry, Endodontic Division, Institute of Science and Technology, São Paulo State University - UNESP, Av. Eng. Francisco José Longo, 777, São José dos Campos, São Paulo, Brazil
| | - Marcia Carneiro Valera
- Department of Restorative Dentistry, Endodontic Division, Institute of Science and Technology, São Paulo State University - UNESP, Av. Eng. Francisco José Longo, 777, São José dos Campos, São Paulo, Brazil.
| | - Bruna Jordão Motta Corazza
- Department of Restorative Dentistry, Endodontic Division, Institute of Science and Technology, São Paulo State University - UNESP, Av. Eng. Francisco José Longo, 777, São José dos Campos, São Paulo, Brazil
| | - Lúcio Murilo Dos Santos
- Department of Diagnosis and Surgery, Maxillofacial Surgery Division, Institute of Science and Technology, São Paulo State University - UNESP, São José dos Campos, São Paulo, 12245-000, Brazil
| | - Claudio Antônio Talge Carvalho
- Department of Restorative Dentistry, Endodontic Division, Institute of Science and Technology, São Paulo State University - UNESP, Av. Eng. Francisco José Longo, 777, São José dos Campos, São Paulo, Brazil
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Verduijn GM, Sijtsema ND, van Norden Y, Heemsbergen WD, Mast H, Sewnaik A, Chin D, Baker S, Capala ME, van der Lugt A, van Meerten E, Hoogeman MS, Petit SF. Accounting for fractionation and heterogeneous dose distributions in the modelling of osteoradionecrosis in oropharyngeal carcinoma treatment. Radiother Oncol 2023; 188:109889. [PMID: 37659662 DOI: 10.1016/j.radonc.2023.109889] [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: 05/03/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND AND PURPOSE Osteoradionecrosis (ORN) of the mandible is a severe complication following radiotherapy (RT). With a renewed interest in hypofractionation for head and neck radiotherapy, more information concerning ORN development after high fraction doses is important. The aim of this explorative study was to develop a model for ORN risk prediction applicable across different fractionation schemes using Equivalent Uniform Doses (EUD). MATERIAL AND METHODS We performed a retrospective cohort study in 334 oropharyngeal squamous cell carcinoma (OPSCC) patients treated with either a hypofractionated Stereotactic Body Radiation Therapy (HF-SBRT) boost or conventional Intensity Modulated Radiation Therapy (IMRT). ORN was scored with the CTCAE v5.0. HF-SBRT and IMRT dose distributions were converted into equivalent dose in 2 Gy fractions (α/β = 0.85 Gy) and analyzed using EUD. The parameter a that led to an EUD that best discriminated patients with and without grade ≥ 2 ORN was selected. Patient and treatment-related risk factors of ORN were analyzed with uni- and multivariable regression analysis. RESULTS A total of 32 patients (9.6%) developed ORN grade ≥ 2. An EUD(a = 8) best discriminated between ORN and non-ORN (AUC = 0.71). In multivariable regression, pre-RT extractions (SHR = 2.34; p = 0.012), mandibular volume (SHR = 1.04; p = 0.003), and the EUD(a = 8) (SHR = 1.14; p < 0.001) were significantly associated with ORN. CONCLUSION Risk models for ORN based on conventional DVH parameters cannot be directly applied to HF-SBRT fractionation schemes and dose distributions. However, after correcting for fractionation and non-uniform dose distributions using EUD, a single model can distinguish between ORN and non-ORN after conventionally fractionated radiotherapy and hypofractionated boost treatments.
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Affiliation(s)
- Gerda M Verduijn
- Departments of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands.
| | - Nienke D Sijtsema
- Departments of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands; Departments of Radiology and Nuclear Medicine, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Yvette van Norden
- Departments of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Wilma D Heemsbergen
- Departments of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Hetty Mast
- Departments of Oral and Maxillofacial Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Aniel Sewnaik
- Departments of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Denzel Chin
- Departments of Oral and Maxillofacial Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Sarah Baker
- Departments of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Marta E Capala
- Departments of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Aad van der Lugt
- Departments of Radiology and Nuclear Medicine, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Esther van Meerten
- Departments of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Mischa S Hoogeman
- Departments of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Steven F Petit
- Departments of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
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Akino Y, Shiomi H, Tsujimoto T, Hamatani N, Hirata T, Oda M, Takeshita A, Shimamoto H, Ogawa K, Murakami S. Inverse planning optimization with lead block effectively suppresses dose to the mandible in high-dose-rate brachytherapy for tongue cancer. Jpn J Radiol 2023; 41:1290-1297. [PMID: 37273111 PMCID: PMC10613594 DOI: 10.1007/s11604-023-01451-w] [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: 02/22/2023] [Accepted: 05/14/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE In this study, we developed in-house software to evaluate the effect of the lead block (LB)-inserted spacer on the mandibular dose in interstitial brachytherapy (ISBT) for tongue cancer. In addition, an inverse planning algorithm for LB attenuation was developed, and its performance in mandibular dose reduction was evaluated. METHODS Treatment plans of 30 patients with tongue cancer treated with ISBT were evaluated. The prescribed dose was 54 Gy/9 fractions. An in-house software was developed to calculate the dose distribution based on the American Association of Physicists in Medicine (AAPM) Task Group No.43 (TG-43) formalism. The mandibular dose was calculated with consideration of the LB attenuation. The attenuation coefficient of the lead was computed using the PHITS Monte Carlo simulation. The software further optimized the treatment plans using an attraction-repulsion model (ARM) to account for the LB attenuation. RESULTS Compared to the calculation in water, the D2 cc of the mandible changed by - 2.4 ± 2.3 Gy (range, - 8.6 to - 0.1 Gy) when the LB attenuation was considered. The ARM optimization with consideration of the LB resulted in a - 2.4 ± 2.4 Gy (range, - 8.2 to 0.0 Gy) change in mandibular D2 cc. CONCLUSIONS This study enabled the evaluation of the dose distribution with consideration of the LB attenuation. The ARM optimization with lead attenuation further reduced the mandibular dose.
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Affiliation(s)
- Yuichi Akino
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
- Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan.
| | - Hiroya Shiomi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan
| | - Tomomi Tsujimoto
- Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan
| | - Noriaki Hamatani
- Department of Medical Physics, Osaka Heavy-Ion Therapy Center, Osaka, Japan
| | - Takero Hirata
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Michio Oda
- Department of Medical Technology, Osaka University Hospital, Suita, Osaka, Japan
| | - Ami Takeshita
- Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan
| | - Hiroaki Shimamoto
- Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shumei Murakami
- Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry, Suita, Osaka, Japan
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Wang X, Zheng L, Zhang J, Zhang J. Evaluation of outcomes after conservative mandibular surgery in patients with oral squamous cell carcinoma. Int J Oral Maxillofac Surg 2023; 52:1111-1119. [PMID: 37271626 DOI: 10.1016/j.ijom.2023.05.007] [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: 02/13/2022] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 06/06/2023]
Abstract
This study aimed to assess preoperative radiological and clinical examinations for identifying bone status and to evaluate survival outcomes in patients undergoing marginal mandibulectomy for the primary treatment of oral squamous cell carcinoma. The medical records, enhanced computed tomography (CT) scans, and pathological specimens of these patients were reviewed. Disease-free (DFS), local recurrence-free (LRFS), and osteoradionecrosis-free (ORNFS) survival were analysed. The study included 104 patients. The preoperative CT and clinical examinations achieved a sensitivity of 45.8% and specificity of 100% for judging bone condition. LRFS was 79.6% and DFS was 68.8%. Pathological bone invasion in significantly affected DFS (P = 0.597), while DFS was significantly higher for those with a lower clinical tumour stage (1/2 vs 3/4; P = 0.005) and postoperative radiotherapy (P = 0.011). Among 39 patients receiving postoperative radiotherapy, ORNFS was 75.2%. Postoperative chemotherapy significantly decreased ORNFS (P = 0.009). Tumour subsite (P = 0.003) and the resection site (P = 0.035) significantly affected the remaining bone height. The results indicate that CT and clinical examinations cannot precisely identify superficial bone damage, but work well in selecting patients for marginal resection. Adhering to current indications, this resection approach can guarantee safe bone margins in terms of survival outcomes.
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Affiliation(s)
- X Wang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - L Zheng
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China.
| | - J Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - J Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
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Watson EE, Hueniken K, Lee J, Huang SH, Maghrabi A AE, Xu W, Moreno AC, Tsai CJ, Hahn E, McPartlin AJ, Yao CM, Goldstein DP, De Almeida JR, Waldon JN, Fuller CD, Hope AJ, Ruggiero SL, Glogauer M, Hosni AA. Development and Standardization of a Classification System for Osteoradionecrosis: Implementation of a Risk-Based Model. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.12.23295454. [PMID: 37745576 PMCID: PMC10516072 DOI: 10.1101/2023.09.12.23295454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Purpose Osteoradionecrosis of the jaw (ORN) can manifest in varying severity. The aim of this study is to identify ORN risk factors and develop a novel classification to depict the severity of ORN. Methods Consecutive head-and-neck cancer (HNC) patients treated with curative-intent IMRT (≥ 45Gy) in 2011-2018 were included. Occurrence of ORN was identified from in-house prospective dental and clinical databases and charts. Multivariable logistic regression model was used to identify risk factors and stratify patients into high-risk and low-risk groups. A novel ORN classification system was developed to depict ORN severity by modifying existing systems and incorporating expert opinion. The performance of the novel system was compared to fifteen existing systems for their ability to identify and predict serious ORN event (jaw fracture or requiring jaw resection). Results ORN was identified in 219 out of 2732 (8%) consecutive HNC patients. Factors associated with high-risk of ORN were: oral-cavity or oropharyngeal primaries, received IMRT dose ≥60Gy, current/ex-smokers, and/or stage III-IV periodontal disease. The ORN rate for high-risk vs low-risk patients was 12.7% vs 3.1% (p<0.001) with an area-under-the-receiver-operating-curve (AUC) of 0.71. Existing ORN systems overclassified serious ORN events and failed to recognize maxillary ORN. A novel ORN classification system, RadORN, was proposed based on vertical extent of bone necrosis and presence/absence of exposed bone/fistula. This system detected serious ORN events in 5.7% of patients and statistically outperformed existing systems. Conclusion We identified risk factors for ORN, and proposed a novel ORN classification system based on vertical extent of bone necrosis and presence/absence of exposed bone/fistula. It outperformed existing systems in depicting the seriousness of ORN, and may facilitate clinical care and clinical trials.
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Affiliation(s)
- Erin E Watson
- Department of Dental Oncology, Princess Margaret Cancer Centre
- Faculty of Dentistry, University of Toronto
| | | | - Junhyung Lee
- Department of Dental Oncology, Princess Margaret Cancer Centre
| | - Sophie H Huang
- Department of Radiation Oncology, Princess Margaret Cancer Centre; University of Toronto
| | | | - Wei Xu
- Department of Biostatistics, University Health Network
| | - Amy C Moreno
- The University of Texas MD Anderson Cancer Center, Department of Radiaion Oncology
| | - C Jillian Tsai
- Department of Radiation Oncology, Princess Margaret Cancer Centre; University of Toronto
| | - Ezra Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre; University of Toronto
| | - Andrew J McPartlin
- Department of Radiation Oncology, Princess Margaret Cancer Centre; University of Toronto
| | - Christopher Mkl Yao
- Department of Otolaryngology - Head & Neck Surgery, University Health Network; University of Toronto
| | - David P Goldstein
- Department of Otolaryngology - Head & Neck Surgery, University Health Network; University of Toronto
| | - John R De Almeida
- Department of Otolaryngology - Head & Neck Surgery, University Health Network; University of Toronto
- Institute for Health Policy, Management and Evaluation, University of Toronto
| | - John N Waldon
- Department of Radiation Oncology, Princess Margaret Cancer Centre; University of Toronto
| | - Clifton David Fuller
- The University of Texas MD Anderson Cancer Center, Department of Radiaion Oncology
| | - Andrew J Hope
- Department of Radiation Oncology, Princess Margaret Cancer Centre; University of Toronto
| | - Salvatore L Ruggiero
- Department of Oral and Maxillofacial Surgery, Stony Brook University
- Hofstra North Shore-LIJ School of Medicine
| | | | - Ali A Hosni
- Department of Radiation Oncology, Princess Margaret Cancer Centre; University of Toronto
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31
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Li CX, Sun JL, Gong ZC, Liu H, Ding MC, Zhao HR. An umbrella review exploring the effect of radiotherapy for head and neck cancer patients on the frequency of jaws osteoradionecrosis. Cancer Radiother 2023; 27:434-446. [PMID: 37268457 DOI: 10.1016/j.canrad.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Efforts have been made to reduce epidemiological indicators of osteoradionecrosis in patients with head and neck cancer over recent years. This umbrella review aims to synthesize the information of the systematic reviews/meta-analyses investigating the effect of radiotherapy in patients with head and neck cancer on the frequency of osteoradionecrosis and to identify and analyze the gaps in current scientific literature. MATERIAL AND METHODS A systematic review of systematic reviews with and without meta-analysis of intervention studies was conducted. Qualitative analysis of the reviews and their quality evaluation were performed. RESULTS A total of 152 articles were obtained, and ten of them were selected for the final analysis, where six were systematic reviews and four were meta-analysis. According to the guide Assessing the Methodological Quality of Systematic Reviews (Amstar), eight articles included were of high quality and two of medium quality. These descriptive systematic reviews/meta-analyses included a total of 25 randomized clinical trials, showing that radiotherapy has positive effects on the frequency of osteoradionecrosis. Even though a reduction in the incidence of osteoradionecrosis was observed back in the history, in systematic reviews with meta-analysis, overall effect estimators were not significant. CONCLUSIONS Differential findings are not enough to demonstrate that there is a significant reduction in the frequency of osteoradionecrosis in patients with head and neck cancer treated by radiation. Possible explanations are related to factors such as the type of studies analyzed, indicator of irradiated complication considered, and specific variables included in the analysis. Many systematic reviews did not address publication bias and did identify gaps in knowledge that require further clarification.
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Affiliation(s)
- C X Li
- Department of Oral and Maxillofacial Oncology & Surgery, Xinjiang Medical University Affiliated First Hospital, Urumqi 830054, China; School/Hospital of Stomatology, Xinjiang Medical University, Urumqi 830011, China; Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi 830054, China.
| | - J-L Sun
- Department of Preventive Medicine, School of Medicine, Shihezi University, Shihezi 832003, China
| | - Z-C Gong
- Department of Oral and Maxillofacial Oncology & Surgery, Xinjiang Medical University Affiliated First Hospital, Urumqi 830054, China; School/Hospital of Stomatology, Xinjiang Medical University, Urumqi 830011, China; Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi 830054, China.
| | - H Liu
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai 200003, China; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai 200433, China
| | - M-C Ding
- State Key Laboratory of Military Stomatology, National Clinical Research Center for Oral Diseases, Shaanxi Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, School of Stomatology, The Fourth Military Medical University, Xi'an 710032, China
| | - H-R Zhao
- The First Ward of Oncological Department, Cancer Center, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China.
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32
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Somay E, Topkan E. In Regard to Nath et al. (2022) (doi: 10.1007/s12070-021-02941-x). Indian J Otolaryngol Head Neck Surg 2023; 75:2735-2736. [PMID: 37636770 PMCID: PMC10447657 DOI: 10.1007/s12070-023-03639-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/23/2023] [Indexed: 08/29/2023] Open
Affiliation(s)
- Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, 82. Street No: 26 Bahcelievler, Ankara, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
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Kovarik PDE, Patil R, Cvek J, Kelly C, Jackson M, Mackenzie L, West N, Willis N, Kovarik JP, Banks R, Kennedy M, Adams J, Iqbal MS. Extra-mandibular Osteoradionecrosis after the Treatment of Head and Neck Cancer. Clin Oncol (R Coll Radiol) 2023; 35:e498-e505. [PMID: 37433701 DOI: 10.1016/j.clon.2023.06.013] [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: 02/07/2023] [Revised: 06/09/2023] [Accepted: 06/23/2023] [Indexed: 07/13/2023]
Abstract
AIMS Osteoradionecrosis (ORN) is a serious toxicity of head and neck radiotherapy. It predominantly affects the mandible. Extra-mandibular ORN is rare. The aim of this study was to report the incidence and outcomes of extra-mandibular ORNs from a large institutional database. MATERIALS AND METHODS In total, 2303 head and neck cancer patients were treated with radical or adjuvant radiotherapy. Of these, extra-mandibular ORN developed in 13 patients (0.5%). RESULTS Maxillary ORNs (n = 8) were a consequence of the treatment of various primaries (oropharynx = 3, sinonasal = 2, maxilla = 2, parotid = 1). The median interval from the end of radiotherapy to the development of ORN was 7.5 months (range 3-42 months). The median radiotherapy dose in the centre of the ORN was 48.5 Gy (range 22-66.5 Gy). Four patients (50%) healed in 7, 14, 20 and 41 months. All temporal bone ORNs (n = 5) developed after treatment to the parotid gland (of a total of 115 patients who received radiotherapy for parotid gland malignancy). The median interval from the end of radiotherapy to the development of ORN was 41 months (range 20-68 months). The median total dose in the centre of the ORN was 63.5 Gy (range 60.2-65.3 Gy). ORN healed in only one patient after 32 months of treatment with repeated debridement and topical betamethasone cream. CONCLUSION Extra-mandibular ORN is a rare late toxicity and this current study provides useful information on its incidence and outcome. The risk of temporal bone ORN should be considered in the treatment of parotid malignancies and patients should be counselled. More research is required to determine the optimal management of extra-mandibular ORN, particularly on the role of the PENTOCLO regimen.
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Affiliation(s)
- P D E Kovarik
- Department of Oncology, University of Ostrava, Ostrava, Czech Republic; Northumbria Healthcare NHS Trust, Newcastle upon Tyne, UK
| | - R Patil
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - J Cvek
- Department of Oncology, University of Ostrava, Ostrava, Czech Republic
| | - C Kelly
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M Jackson
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - L Mackenzie
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - N West
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - N Willis
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - J P Kovarik
- Institute of Dentistry and Oral Sciences, Palacky University Olomouc, Olomouc, Czech Republic
| | - R Banks
- Department of Oral and Maxillofacial Surgery, Royal Sunderland Hospital, Sunderland, UK
| | - M Kennedy
- Department of Oral and Maxillofacial Surgery, Freeman Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - J Adams
- Department of Oral and Maxillofacial Surgery, Freeman Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M S Iqbal
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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Sijtsema ND, Verduijn GM, Nasserinejad K, van Norden Y, Mast H, van der Lugt A, Hoogeman MS, Petit SF. Development of a local dose-response relationship for osteoradionecrosis within the mandible. Radiother Oncol 2023; 186:109736. [PMID: 37315578 DOI: 10.1016/j.radonc.2023.109736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE Osteoradionecrosis (ORN) of the mandible is a severe complication following radiotherapy of the head and neck, but not all regions of the mandible may be equally at risk. Therefore our goal was to explore a local dose response relationship for subregions of the mandible. MATERIALS AND METHODS All oropharyngeal cancer patients treated at our hospital between 2009 and 2016 were reviewed. Follow-up was cut-off at 3 years. For patients that developed ORN, the ORN volume was delineated on the planning CT. Each mandible was divided into 16 volumes of interest (VOIs) based on the location of the dental elements and the presence of ORN in each was scored. Generalized estimating equations were used to build a model for the probability of developing ORN in an element VOI. RESULTS Of the 219 included patients, 22 developed ORN in 89 element VOIs. Mean dose to the element VOI (odds ratio (OR) = 1.05 per Gy, 95% confidence interval (CI): (1.04,1.07)), pre-radiotherapy extractions of an element ipsilateral to element of interest (OR = 2.81, 95% CI: (1.12,7.05)), and smoking at start of radiotherapy (OR = 3.37, 95% CI: (1.29,8.78)) were significantly associated with an increased probability of ORN in the VOI. CONCLUSION The developed dose-response model indicates that the probability of ORN varies within the mandible and strongly depends on the local dose, the location of extractions, and smoking.
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Affiliation(s)
- Nienke D Sijtsema
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Gerda M Verduijn
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Kazem Nasserinejad
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Innovative Statistical Consulting, Therapeutics Development Team, Cytel Inc., Cambridge, MA, USA
| | - Yvette van Norden
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hetty Mast
- Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mischa S Hoogeman
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Physics and Informatics, HollandPTC, Delft, The Netherlands
| | - Steven F Petit
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Somay E, Topkan E, Pehlivan B, Selek U. In reply to Cheng et al. (DOI: 10.1186/s13550-023-00965-8). EJNMMI Res 2023; 13:76. [PMID: 37589948 PMCID: PMC10435427 DOI: 10.1186/s13550-023-01018-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/02/2023] [Indexed: 08/18/2023] Open
Affiliation(s)
- Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, 82. Street No: 26, Bahcelievler, Ankara Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, Faculty of Medicine, Koc University, Istanbul, Turkey
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Topkan E, Somay E, Yilmaz B, Pehlivan B, Selek U. Valero's host index is useful in predicting radiation-induced trismus and osteoradionecrosis of the jaw risks in locally advanced nasopharyngeal carcinoma patients. BMC Cancer 2023; 23:651. [PMID: 37438683 DOI: 10.1186/s12885-023-11155-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND In the absence of previous research, we sought to assess the H-Index's predictive significance for radiation-induced trismus (RIT) and osteoradionecrosis of the jaw (ORNJ) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) receiving concurrent chemoradiotherapy (C-CRT). PATIENTS AND METHODS The research comprised 295 LA-NPC patients who had C-CRT and pre- and post-C-CRT oral exams between June 2010 and December 2021. The H-Index was calculated using neutrophils, monocytes, lymphocytes, hemoglobin, and albumin measurements obtained on the first day of C-CRT. Patients were divided into three and two H-index groups, respectively, based on previously established cutoff values (1.5 and 3.5) and the cutoff value determined by our receiver operating characteristic (ROC) curve analysis. The primary objective was the presence of any significant connections between pretreatment H-Index groups and post-C-CRT RIT and ORNJ rates. RESULTS RIT and ORNJ was diagnosed in 46 (15.6%) and 13 (7.8%) patients, respectively. The original H-Index grouping could only categorize RIT and ORNJ risks at a cutoff value of 3.5, with no significant differences in RIT and ORNJ rates between groups with H-Index 1.5 and 1.5 to 3.5 (P < 0.05 for each). The ideal H-Index cutoff for both RIT and ORNJ rates was found to be 5.5 in ROC curve analysis, which divided the entire research population into two groups: H-Index ≤ 5.5 (N = 195) and H-Index > 5.5 (N = 110). Intergroup comparisons revealed that patients in the H-Index > 5.5 group had significantly higher rates of either RIT (31.8% vs. 5.9%; P < 0.001) or ORNJ (17.3% vs. 2.2%; P < 0.001) than their H-Index ≤ 5.5 counterparts. The results of the multivariate analysis showed that H-Index > 5.5 was independently linked to significantly higher RIT (P < 0.001) and ORNJ (P < 0.001) rates. CONCLUSION Pre-C-CRT H-Index > 5.5 is associated with significantly increased RIT and ORNJ rates in LA-NPC patients receiving definitive C-CRT.
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Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Medical Faculty, Baskent University, Adana, Turkey.
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Busra Yilmaz
- Department of Oral and Maxillofacial Radiology, School of Dental Medicine, Bahcesehir University, Istanbul, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey
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Somay E, Topkan E, Kucuk A, Selek U. Comment on "Osteoradionecrosis versus Cancer Recurrence: An Unresolved Clinical Dilemma" (DOI: 10.1159/000527261). ORL J Otorhinolaryngol Relat Spec 2023; 85:243-244. [PMID: 37423207 DOI: 10.1159/000531453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/17/2023] [Indexed: 07/11/2023]
Affiliation(s)
- Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Ahmet Kucuk
- Department of Radiation Oncology, Mersin Education and Research Hospital, Mersin, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, Faculty of Medicine, Koc University, Istanbul, Turkey
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Reber B, Van Dijk L, Anderson B, Mohamed ASR, Fuller C, Lai S, Brock K. Comparison of Machine-Learning and Deep-Learning Methods for the Prediction of Osteoradionecrosis Resulting From Head and Neck Cancer Radiation Therapy. Adv Radiat Oncol 2023; 8:101163. [PMID: 36798732 PMCID: PMC9926206 DOI: 10.1016/j.adro.2022.101163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
Purpose Deep-learning (DL) techniques have been successful in disease-prediction tasks and could improve the prediction of mandible osteoradionecrosis (ORN) resulting from head and neck cancer (HNC) radiation therapy. In this study, we retrospectively compared the performance of DL algorithms and traditional machine-learning (ML) techniques to predict mandible ORN binary outcome in an extensive cohort of patients with HNC. Methods and Materials Patients who received HNC radiation therapy at the University of Texas MD Anderson Cancer Center from 2005 to 2015 were identified for the ML (n = 1259) and DL (n = 1236) studies. The subjects were followed for ORN development for at least 12 months, with 173 developing ORN and 1086 having no evidence of ORN. The ML models used dose-volume histogram parameters to predict ORN development. These models included logistic regression, random forest, support vector machine, and a random classifier reference. The DL models were based on ResNet, DenseNet, and autoencoder-based architectures. The DL models used each participant's dose cropped to the mandible. The effect of increasing the amount of available training data on the DL models' prediction performance was evaluated by training the DL models using increasing ratios of the original training data. Results The F1 score for the logistic regression model, the best-performing ML model, was 0.3. The best-performing ResNet, DenseNet, and autoencoder-based models had F1 scores of 0.07, 0.14, and 0.23, respectively, whereas the random classifier's F1 score was 0.17. No performance increase was apparent when we increased the amount of training data available for DL model training. Conclusions The ML models had superior performance to their DL counterparts. The lack of improvement in DL performance with increased training data suggests that either more data are needed for appropriate DL model construction or that the image features used in DL models are not suitable for this task.
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Affiliation(s)
- Brandon Reber
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lisanne Van Dijk
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
- University of Groningen, Groningen, Netherlands
| | - Brian Anderson
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
- University of California, San Diego, San Diego, California
| | | | - Clifton Fuller
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Lai
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy Brock
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Owosho AA, DeColibus K, Hedgepeth B, Wood BC, Sansoni RE, Gleysteen JP, Schwartz DL. The Role of Dental Practitioners in the Management of Oncology Patients: The Head and Neck Radiation Oncology Patient and the Medical Oncology Patient. Dent J (Basel) 2023; 11:dj11050136. [PMID: 37232787 DOI: 10.3390/dj11050136] [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: 02/08/2023] [Revised: 04/12/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023] Open
Abstract
This narrative review addresses the role of a dentist in the management of oncology patients, highlighting the oral complications that arise in head and neck radiation oncology patients and medical oncology patients. The prevention and management of these complications are discussed.
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Affiliation(s)
- Adepitan A Owosho
- Department of Diagnostic Sciences, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Katherine DeColibus
- Division of Oral Diagnosis, Department of Diagnostic Sciences, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Beverly Hedgepeth
- Division of Oral Diagnosis, Department of Diagnostic Sciences, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Burton C Wood
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Ritter E Sansoni
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - John P Gleysteen
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
- Division of Head and Neck Surgical Oncology, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - David L Schwartz
- Department of Radiation Oncology, College of Medicine, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
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Topkan E, Kucuk A, Somay E, Yilmaz B, Pehlivan B, Selek U. Review of Osteoradionecrosis of the Jaw: Radiotherapy Modality, Technique, and Dose as Risk Factors. J Clin Med 2023; 12:3025. [PMID: 37109361 PMCID: PMC10143049 DOI: 10.3390/jcm12083025] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
Radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) is the cornerstone of organ-sparing or adjuvant therapy for nearly all head and neck cancers. Unfortunately, aggressive RT or CCRT can result in severe late toxicities, such as osteoradionecrosis of the jaws (ORNJ). The incidence of ORNJ is currently less than 5-6% due to advances in dental preventive care programs, RT planning systems, and RT techniques. Although numerous patient-, tumor-, and treatment-related factors may influence the incidence rates of ORNJ, RT modality (equipment), technique, and dose-volume-related factors are three of the most influential factors. This is mainly because different RT equipment and techniques have different levels of success at delivering the prescribed dose to the focal volume of the treatment while keeping the "organ at risk" safe. ORNJ risk is ultimately determined by mandibular dose, despite the RT technique and method being known predictors. Regardless of the photon delivery method, the radiobiological effects will be identical if the total dose, dose per fraction, and dose distribution within the tissue remain constant. Therefore, contemporary RT procedures mitigate this risk by reducing mandibular dosages rather than altering the ionizing radiation behavior in irradiated tissues. In light of the paucity of studies that have examined the impact of RT modality, technique, and dose-volume-related parameters, as well as their radiobiological bases, the present review aims to provide a comprehensive overview of the published literature on these specific issues to establish a common language among related disciplines and provide a more reliable comparison of research results.
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Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Medical Faculty, Baskent University, Adana 01120, Turkey
| | - Ahmet Kucuk
- Clinics of Radiation Oncology, Mersin City Education and Research Hospital, Mersin 33160, Turkey
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara 06490, Turkey
| | - Busra Yilmaz
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Baskent University, Ankara 06490, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul 34349, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, School of Medicine, Koc University, Istanbul 34450, Turkey
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, TX 77030, USA
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Zhao F, Yang D, Li X. Effect of radiotherapy interruption on nasopharyngeal cancer. Front Oncol 2023; 13:1114652. [PMID: 37091186 PMCID: PMC10116059 DOI: 10.3389/fonc.2023.1114652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/27/2023] [Indexed: 04/25/2023] Open
Abstract
Nasopharyngeal carcinoma (NPC) is a malignant tumor originating from the epithelial cells of the nasopharynx with a unique geographic distribution, and is particularly prevalent in East and Southeast Asia. Due to its anatomical location, the surgery is difficult to access and the high sensitivity of nasopharyngeal cancer to radiotherapy (RT) makes it the main treatment modality. Radical radiotherapy is the first-line treatment for early-stage nasopharyngeal carcinoma and the cornerstone of multidisciplinary treatment for patients with locally advanced nasopharyngeal carcinoma. Nevertheless, radiotherapy interruption is inevitable as a consequence of unavoidable factors such as public holidays, machine malfunction, patient compliance, and adverse response to treatment, which in turn leads to a reduction in bioactivity and causes sublethal loss of tumor cells to repair. Unirradiated tumor cells are more likely to repopulate at or near their original fastest growth rate during this interval. If no measures are taken after the radiotherapy interruption, such as increasing the dose of radiotherapy and systemic therapy, the tumor is most likely to go uncontrolled and then progress. This review describes the effects of radiotherapy interruption on nasopharyngeal carcinoma, the mechanism of the effect, and explores the measures that can be taken in response to such interruption.
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Affiliation(s)
- Fangrui Zhao
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Dashuai Yang
- Department of Hepatobiliary Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiangpan Li
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
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Wu SS, Hong H, Fritz M, Ku J, Prendes B, Silver N, Genther DJ, Ciolek P, Byrne P, Brauer P, Reddy CA, Woody N, Campbell S, Koyfman SA, Lamarre ED. Rates of osteoradionecrosis in resected oral cavity cancer reconstructed with free tissue transfer in the intensity-modulated radiotherapy era. Head Neck 2023; 45:890-899. [PMID: 36808674 DOI: 10.1002/hed.27310] [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: 07/23/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Resected oral cavity carcinoma defects are often reconstructed with osteocutaneous or soft-tissue free flaps, but risk of osteoradionecrosis (ORN) is unknown. METHODS This retrospective study included oral cavity carcinoma treated with free-tissue reconstruction and postoperative IMRT between 2000 and 2019. Risk-regression assessed risk factors for grade ≥2 ORN. RESULTS One hundred fifty-five patients (51% male, 28% current smokers, mean age 62 ± 11 years) were included. Median follow-up was 32.6 months (range, 1.0-190.6). Thirty-eight (25%) patients had fibular free flap for mandibular reconstruction, whereas 117 (76%) had soft-tissue reconstruction. Grade ≥2 ORN occurred in 14 (9.0%) patients, at a median 9.8 months (range, 2.4-61.5) after IMRT. Post-radiation teeth extraction was significantly associated with ORN. One-year and 10-year ORN rates were 5.2% and 10%, respectively. CONCLUSIONS ORN risk was comparable between osteocutaneous and soft-tissue reconstruction for resected oral cavity carcinoma. Osteocutaneous flaps can be safely performed with no excess concern for mandibular ORN.
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Affiliation(s)
- Shannon S Wu
- Cleveland Clinic Lerner, College of Medicine, Cleveland, Ohio, USA
| | - Hanna Hong
- Cleveland Clinic Lerner, College of Medicine, Cleveland, Ohio, USA
| | - Michael Fritz
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Jamie Ku
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Brandon Prendes
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Natalie Silver
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Dane J Genther
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Peter Ciolek
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Patrick Byrne
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
| | - Philip Brauer
- Case Western Reserve, University School of Medicine, Cleveland, Ohio, USA
| | - Chandana A Reddy
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Neil Woody
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Shauna Campbell
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Shlomo A Koyfman
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Eric D Lamarre
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
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Trotter J, Lin A. Advances in Proton Therapy for the Management of Head and Neck Tumors. Surg Oncol Clin N Am 2023; 32:587-598. [PMID: 37182994 DOI: 10.1016/j.soc.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Proton therapy (PBRT) is a form of external beam radiotherapy with several dosimetric advantages compared with conventional photon (x-ray) radiotherapy. Unlike x-rays, protons deposit most of their dose over a finite range, with no exit dose, in a pattern known as the Bragg peak. Clinically, this can be exploited to optimize dose to tumors while delivering a lower integral dose to normal tissues. However, the optimal role of PBRT is not as well-defined as advanced x-ray-based techniques such as intensity-modulated radiotherapy.
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Hosseinian S, Hemmati M, Dede C, Salzillo TC, van Dijk LV, Mohamed ASR, Lai SY, Schaefer AJ, Fuller CD. Cluster-Based Toxicity Estimation of Osteoradionecrosis via Unsupervised Machine Learning: Moving Beyond Single Dose-Parameter Normal Tissue Complication Probability by Using Whole Dose-Volume Histograms for Cohort Risk Stratification. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.24.23287710. [PMID: 37034700 PMCID: PMC10081413 DOI: 10.1101/2023.03.24.23287710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Purpose Given the limitations of extant models for normal tissue complication probability estimation for osteoradionecrosis (ORN) of the mandible, the purpose of this study was to enrich statistical inference by exploiting structural properties of data and provide a clinically reliable model for ORN risk evaluation through an unsupervised-learning analysis. Materials and Methods The analysis was conducted on retrospective data of 1,259 head and neck cancer (HNC) patients treated at the University of Texas MD Anderson Cancer Center between 2005 and 2015. The (structural) clusters of mandibular dose-volume histograms (DVHs) were identified through the K-means clustering method. A soft-margin support vector machine (SVM) was used to determine the cluster borders and partition the dose-volume space. The risk of ORN for each dose-volume region was calculated based on the clinical risk factors and incidence rates. Results The K-means clustering method identified six clusters among the DVHs. Based on the first five clusters, the dose-volume space was partitioned almost perfectly by the soft-margin SVM into distinct regions with different risk indices. The sixth cluster overlapped the others entirely; the region of this cluster was determined by its envelops. These regions and the associated risk indices provide a range of constraints for dose optimization under different risk levels. Conclusion This study presents an unsupervised-learning analysis of a large-scale data set to evaluate the risk of mandibular ORN among HNC patients. The results provide a visual risk-assessment tool (based on the whole DVH) and a spectrum of dose constraints for radiation planning.
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Affiliation(s)
| | - Mehdi Hemmati
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cem Dede
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Travis C. Salzillo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lisanne V. van Dijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Abdallah S. R. Mohamed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Y. Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Andrew J. Schaefer
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Clifton D. Fuller
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Liao PH, Lin C, Huang JY, Lin HM, Kuo TJ. Association between tooth extraction during radiotherapy and the risk of osteoradionecrosis in patients with head and neck cancers. Eur Arch Otorhinolaryngol 2023; 280:2945-2952. [PMID: 36892614 DOI: 10.1007/s00405-023-07885-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/14/2023] [Indexed: 03/10/2023]
Abstract
PURPOSE It is commonly recommended that tooth extraction should be performed prior to radiotherapy (RT) in patients with head neck cancer to prevent osteoradionecrosis (ORN). However, doctors still occasionally encounter patients who require tooth extraction during RT. This study aimed to determine the risk of ORN in patients who undergo tooth extraction during RT. METHODS Data were collected from Taiwan's National Health Insurance Research Database. We retrospectively enrolled 24,412 patients with head and neck cancer treated with radiotherapy between 2011 and 2017. The associations between ORN and demographic characteristics, timing of tooth extraction, and treatments were examined using univariate and multivariable Cox proportional hazards regression models. RESULTS A total of 24,412 head and neck cancer patients were enrolled; 133 patients underwent tooth extraction during RT and 24,279 patients did not undergo tooth extraction during RT. Tooth extraction during RT was not associated with a significantly higher risk of ORN (hazard ratio [HR] = 1.303, P = 0.4862). Tumor site, RT dose ≥ 60 Gy, age < 55 y/o, mandibulectomy, chronic periodontitis, and chemotherapy were significantly associated with a higher risk of ORN. CONCLUSION The risk of ORN in head and neck cancer is not significantly different between patients who undergo tooth extraction during RT and patients who do not undergo tooth extraction during RT.
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Affiliation(s)
- Pei-Hsun Liao
- Department of Otolaryngology, Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Che Lin
- Department of Orthopaedic, Shuang Ho Hospital, New Taipei City, Taiwan
| | - Jing-Yang Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Hsin-Mei Lin
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tsu-Jen Kuo
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung, Taiwan.
- School of Dentistry, Chung Shan Medical University, 110, Sec. 1, Chien-Kuo N. Rd., Taichung, Taiwan.
- Department of Marine Biotechnology and Resources, National Sun Yat-Sen University, Kaohsiung, Taiwan.
- Eternal Dental Clinic, Taichung, Taiwan.
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Delpon G, Renouf M, Langé M, Blery P, Dupas C, Longis J, Thariat J, Doré M. Systematic dosimetric evaluation of risk of osteoradionecrosis (DERO): First results of dose reporting for preventing teeth osteoradionecrosis after head and neck irradiation. Cancer Radiother 2023; 27:103-108. [PMID: 36739196 DOI: 10.1016/j.canrad.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/11/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE OsteoRadioNecrosis (ORN) is a late complication of radiation for head and neck cancer. Predicting ORN is a major challenge. We developed DERO (Dosimetric Evaluation of Risk of ORN), a semi-automatic tool which reports doses delivered to tooth-bearing sectors, to guide post-therapeutic dental care. We present the method and the first results of a 125-patient prospective cohort. MATERIAL AND METHODS Dosimetric data of patients treated with IMRT for head and neck cancer were prospectively segmented to the DERO algorithm. Four arches corresponding to 8-tooth sectors were semi-automatically generated. Thirty-two cylindrical Regions Of Interest (ROI) corresponding to each tooth and surrounding periodontium were created by linear interpolation. Mean doses (Dmean) of ROI were extracted and included in a database, along with data about primary tumor site, laterality and dose values from organs at risk. Dmean to tooth sectors were computed for molar sectors, (teeth X5 to X8) and anterior sectors (teeth X1 to X4). An individual dose map was generated and delivered to patients and dentists. RESULTS Dosimetric data from 125 patients treated with Tomotherapy® were prospectively collected and analyzed: 9 parotid tumors (PA), 41 Sub-Hyoid tumors (larynx, hypopharynx) (SH), 43 Oropharynx tumors (OR), 32 Oral Cavity tumors (OC). Irradiation was unilateral for 100% of PA tumors (9), 12% of OR tumors (5) and 47% of OC tumors (15). For unilateral cervical irradiation, Dmean in ipsilateral molar sectors was 54Gy for OC tumors, 45Gy for OR tumors, 20Gy for PA tumors. For Oral Cavity bilateral irradiation, Dmean was high in all tooth sectors, 49 to 55Gy. For SH tumors, Dmean in molar sectors was 27Gy. A dose gradient of 10 to 20Gy was observed between molar and anterior sectors whether radiation was uni or bilateral. CONCLUSION Mandibular molar sectors of Oropharynx and Oral Cavity tumors were exposed to high Dmean of 40 to 50Gy. On the other hand, tooth sectors received lower doses for SH radiation. The DERO tool guide post-radiation dental care with a personalized dosimetric cartography to patient. With data update and patient follow-up, we will be able to determine ORN risk after head and neck radiation.
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Affiliation(s)
- G Delpon
- Medical physics department, institut de cancérologie de l'Ouest, Saint-Herblain, France; IMT atlantique, Nantes université, CNRS/IN2P3, Subatech, Nantes, France
| | - M Renouf
- Radiation oncology department, institut de cancérologie de l'Ouest, Saint-Herblain, France
| | - M Langé
- Radiation oncology department, institut de cancérologie de l'Ouest, Saint-Herblain, France
| | - P Blery
- Nantes université, Oniris, Inserm, regenerative medicine and skeleton, RMeS, UMR 1229, Nantes, France; Odontology department, centre hospitalo-universitaire, Nantes, France
| | - C Dupas
- Odontology department, centre hospitalo-universitaire, Nantes, France
| | - J Longis
- Maxillofacial surgery department, centre hospitalo-universitaire, Nantes, France
| | - J Thariat
- Radiation oncology department, Centre François-Baclesse, Caen, France; Laboratoire de physique corpusculaire, IN2P3/ENISAEN-CNRS, Caen, France; Normandie université, Caen, France
| | - M Doré
- Radiation oncology department, institut de cancérologie de l'Ouest, Saint-Herblain, France.
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Singh A, Kitpanit S, Neal B, Yorke E, White C, Yom SK, Randazzo JD, Wong RJ, Huryn JM, Tsai CJ, Zakeri K, Lee NY, Estilo CL. Osteoradionecrosis of the Jaw Following Proton Radiation Therapy for Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2023; 149:151-159. [PMID: 36547968 PMCID: PMC9912132 DOI: 10.1001/jamaoto.2022.4165] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
Importance Proton radiation therapy (PRT) has reduced radiation-induced toxic effects, such as mucositis and xerostomia, over conventional photon radiation therapy, leading to significantly improved quality of life in patients with head and neck cancers. However, the prevalence of osteoradionecrosis (ORN) of the jaw following PRT in these patients is less clear. Objective To report the prevalence and clinical characteristics of ORN in patients with oral and oropharyngeal cancer (OOPC) treated with PRT. Design, Setting, and Participants This case series reports a single-institution experience (Memorial Sloan Kettering Cancer Center, New York, New York) between November 2013 and September 2019 and included 122 radiation therapy-naive patients with OOPC treated with PRT. Data were analyzed from 2013 to 2019. Main Outcomes and Measures Clinical parameters, including sex, age, comorbidities, tumor histology, concurrent chemotherapy, smoking, comorbidities, and preradiation dental evaluation, were obtained from the medical record. Patients with clinical or radiographic signs of ORN were identified and graded using the adopted modified Glanzmann and Grätz grading system. Characteristics of ORN, such as location, clinical presentation, initial stage at diagnosis, etiology, time to diagnosis, management, and clinical outcome at the last follow-up, were also collected. Results Of the 122 patients (mean [SD] age, 63 [13] years; 45 [36.9%] women and 77 [63.1%] men) included in this study, 13 (10.6%) developed ORN following PRT during a median (range) follow-up time of 40.6 (<1-101) months. All patients had spontaneous development of ORN. At the time of initial diagnosis, grade 0, grade 1, grade 2, and grade 3 ORN were seen in 2, 1, 9, and 1 patient, respectively. The posterior ipsilateral mandible within the radiation field that received the full planned PRT dose was the most involved ORN site. At a median (range) follow-up of 13.5 (0.2-58.0) months from the time of ORN diagnosis, complete resolution, stable condition, and progression of ORN were seen in 3, 6, and 4 patients, respectively. The 3-year rates of ORN and death in the total cohort were 5.2% and 21.5%, while the 5-year rates of ORN and death were 11.5% and 34.4%, respectively. Conclusions and Relevance In this case series, the prevalence of ORN following PRT was found to be 10.6%, indicating that ORN remains a clinical challenge even in the era of highly conformal PRT. Clinicians treating patients with OOPC with PRT should be mindful of this complication.
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Affiliation(s)
- Annu Singh
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarin Kitpanit
- Department of Radiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Pathumwan, Bangkok
| | - Brian Neal
- ProCure Proton Therapy Center, Somerset, New Jersey
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charlie White
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - SaeHee K. Yom
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph D. Randazzo
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J. Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph M. Huryn
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Dental Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kaveh Zakeri
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y. Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cherry L. Estilo
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Tufano-Sugarman AM, Wang KY, Kohn N, Ghaly M, Parashar B, Frank D, Kamdar D, Pereira L, Fantasia J, Seetharamu N. Osteoradionecrosis versus Cancer Recurrence: An Unresolved Clinical Dilemma. ORL J Otorhinolaryngol Relat Spec 2022; 85:28-35. [PMID: 36455537 DOI: 10.1159/000527261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 08/05/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Osteoradionecrosis is a rare and debilitating risk of definitive chemoradiotherapy for head and neck squamous cell carcinoma. It is difficult to distinguish between osteoradionecrosis and recurrent or progressive disease, as clinical and radiologic features may be similar. Our aim was to compare the clinical presentation and radiologic features of osteonecrosis with those of recurrent or progressive cancer. METHODS We conducted a single-center case series of 19 patients with head and neck squamous cell carcinoma diagnosed between 2011 and 2019 who subsequently developed clinical and/or radiological suspicion of osteoradionecrosis. The population was a referred sample from head and neck cancer physicians at Northwell Health Cancer Institute. Clinician notes and imaging reports were reviewed to assign a final diagnosis of either cancer, osteonecrosis, or indeterminate. RESULTS No differences were found in the clinical presentation or radiologic features between groups. Median time between treatment and development of symptoms was longer in patients with a final diagnosis of osteoradionecrosis than recurrent or progressive disease (5 vs. 3 months), but this difference was not statistically significant. Radiation dose and type were not associated with diagnosis. Mean standard uptake value maximums on positron emission tomography/computed tomography were significantly higher in the cancer group (median 14.8 vs. 9.1, p < 0.0152). At 1 year after first suspicion of osteoradionecrosis, 100% of osteoradionecrosis patients were alive, versus 28.6% of cancer patients. DISCUSSION/CONCLUSION There is significant overlap in clinical and radiologic features of osteoradionecrosis and cancer. Standard uptake maximums may be helpful in predicting diagnosis. Occurrence of symptoms within 6 months of completing chemoradiotherapy should raise the concern for malignancy.
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Affiliation(s)
- Andrea M Tufano-Sugarman
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Kevin Y Wang
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Nina Kohn
- Biostatistics Department, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Maged Ghaly
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Bhupesh Parashar
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Douglas Frank
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Dev Kamdar
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Lucio Pereira
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - John Fantasia
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Nagashree Seetharamu
- Department of Hematology Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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Recent advances in the oncological management of head and neck cancer and implications for oral toxicity. Br Dent J 2022; 233:737-743. [DOI: 10.1038/s41415-022-5195-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022]
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50
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Lee CT, Litwin S, Yao CMKL, Liu JC, Ridge JA, Galloway TJ. Osteoradionecrosis rate in oropharynx cancer treated with dose volume histogram based constraints. Radiother Oncol 2022; 176:215-221. [PMID: 36252636 DOI: 10.1016/j.radonc.2022.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Mandibular dose constraints are designed to limit high dose to small volumes to avoid osteoradionecrosis (ORN). Based upon a published experience, intermediate-dose constraints were introduced but have not been independently validated. We hypothesize that these constraints lower ORN rate without compromising other organs at risk (OAR). METHODS Oropharyngeal cancer patients treated with standard fractionation adjuvant/definitive VMAT from 01/2014-08/2020 were included. In 09/2017, mandibular dose constraint was changed from historical constraint (HC) of D 0.1 cc < 70 Gy to modified constraints (MC) of V 44 Gy < 42%, V 58 Gy < 25%, D 0.5 cc < 70 Gy. OAR dosimetric changes and ORN development were evaluated. Regression modelling predicted long-term ORN cases in MC group. RESULTS There were 174 patients, 71 in MC group. Seven cases of ORN in HC group at a median follow up (FU) of 39 months and 1 case of ORN in MC group at a median FU of 11 months were observed. More patients in the MC group met V 44 Gy (87% vs 62%, p < 0.01) and V 58 Gy constraints (92% vs 73%, p < 0.01). Mean doses to OARs did not rise. Mandible V 44 Gy and V 58 Gy were significantly associated with ORN (p < 0.01 and p = 0.03, respectively) across all patients. In the HC group, V 44 Gy was independently associated with ORN (p = 0.01). To account for shorter FU in MC group, logistic regression of ORN based on V 44 Gy in HC patients was performed. This predicts 3.2 ORN cases in the MC group (95% CI: 0.00-6.4). CONCLUSION Achieving V 44 Gy and V 58 Gy was successful in 87% of cases without sacrificing target coverage or OARs and resulted in non-significant ORN decrease.
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Affiliation(s)
- Charles T Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA United States.
| | - Samuel Litwin
- Department of Biostatistics and Bioinformatics, Fox Chase Cancer Center, Philadelphia, PA United States.
| | - Christopher M K L Yao
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - Jeffrey C Liu
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States; Department of Otolaryngology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States.
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States.
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA United States.
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