Does Fluorodeoxyglucose Positron Emission Tomography With Computed Tomography Facilitate Treatment of Medication-Related Osteonecrosis of the Jaw?

A Comparison of 18 F-FDG PET/CT and 68 Ga-PSMA PET/CT in Detecting Osteonecrosis of the Jaw in a Patient With Prostate Cancer

ABSTRACT

Medication-related osteonecrosis of the jaw (ONJ) is rare adverse effect of zoledronic acid. We present ONJ detected in a 65-year-old man with prostate cancer who underwent 18 F-FDG PET/CT for metabolic characterization and to exclude a second primary malignancy of the liver lesion observed in 68 Ga-PSMA PET/CT. ONJ has high metabolic activity on 18 F-FDG PET/CT and no PSMA receptor activation on the 68 Ga-PSMA PET/CT. In this case, we wanted to underline the importance of 18 F-FDG PET/CT imaging of medication-related ONJ in patients receiving zoledronic acid therapy and to emphasize that rapid and appropriate treatment can be provided.

Sixty-Month Follow Up of Clinical MRONJ Cases Treated with CGF and Piezosurgery

AIMS

Medication-related osteonecrosis of the jaw (MRONJ) is a drug-related adverse reaction characterized by bone destruction and necrosis in the jaw. This case series aims to evaluate the treatment approaches and outcomes in MRONJ patients.

MATERIALS AND METHODS

The retrospective study was conducted at the Dental Unit of the University of Bari, Italy. Patients with MRONJ were treated and followed up for 60 months. The treatment approach involved piezosurgery and concentrated growth factor (CGF). Six clinical cases from this group are described in detail.

RESULTS

None of the patients showed recurrence of necrotic MRONJ lesions during the follow-up period. The surgical interventions, including bone resections and the application of CGF, resulted in successful mucosal healing and the prevention of disease progression.

CONCLUSIONS

This study highlights the complexity of managing MRONJ and the importance of a multidisciplinary approach. Conservative treatment options and minimally invasive surgery have shown efficacy in controlling symptoms and improving patients' quality of life. However, the optimal treatment approach remains a challenge, and further studies are needed to evaluate alternative therapies and resective surgery. A comprehensive preoperative evaluation and collaboration among dental, endocrinology, and oncology specialists are crucial for personalized and multidisciplinary management. Ongoing research efforts are necessary to explore new therapeutic modalities and improve our understanding of MRONJ management, providing better support to patients dealing with this complex condition.

Reporting Criteria for Clinical Trials on Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review and Recommendations

Medication-related osteonecrosis of the jaw (MRONJ) is a complication caused by anti-resorptive agents and anti-angiogenesis drugs. Since we wanted to write a protocol for a randomized clinical trial (RCT), we reviewed the literature for the essential information needed to estimate the size of the active patient population and measure the effects of therapeutics. At the same time, we designed a questionnaire intended for clinicians to collect detailed information about their practices. Twelve essential criteria and seven additional items were identified and compiled from 43 selected articles. Some of these criteria were incorporated in the questionnaire coupled with data on clinical practices. Our review found extensive missing data and a lack of consensus. For example, the success rate often combined MRONJ stages, diseases, and drug treatments. The occurrence date and evaluation methods were not harmonized or quantitative enough. The primary and secondary endpoints, failure definition, and date coupled to bone measurements were not well established. This information is critical for writing a RCT protocol. With this review article, we aim to encourage authors to contribute all their findings in the field to bridge the current knowledge gap and provide a stronger database for the coming years.

18F-FDG PET/CT for early response assessment of jaw osteoradionecrosis after the PENTOCLO protocol: A promising imaging modality

INTRODUCTION

The Pentoxifylline, Tocopherol and Clodronate protocol (PENTOCLO) showed promising results for jaw osteoradionecrosis (ORN) management. However, the clinical and radiological improvements are often delayed, leading to unwanted long-term treatment, with potential loss of opportunity for more radical surgical treatments. Our objective was to assess the diagnosis performance of ¹⁸F-FDG PET/CT to early predict ORN response to the PENTOCLO protocol.

MATERIALS AND METHODS

All patients from our center who were treated with the PENTOCLO protocol and with a ¹⁸F-FDG PET/CT performed at diagnosis and three months after the end of antibiotherapy were retrospectively included. The PENTOCLO protocol was always combined with prior appropriate antibiotherapy for six weeks. The healing endpoint was divided into healing, stability or worsening, according to the combination of clinical and radiological assessments at the date of last follow-up. For each patient, the difference between the maximal standardized uptake value (ΔSUVmax) of the ORN lesion at three months and baseline were computed. Diagnostic performance of ¹⁸F-FDG PET/CT was evaluated by sensitivity, specificity and the area under the receiver operating characteristic curve (ROC-AUC) of ΔSUVmax.

RESULTS

24 patients were included with an average follow-up of 29.3 months. The healing, stability and worsening rate were 25%, 62.5% and 12.5% respectively. The AUC for discriminating worsening vs stability or healing was 0.92 (IC95 [0.81-1.00]). A ΔSUVmax greater than or equal to 0 was predictive of a worsening with a sensitivity and specificity of 84 and 66% respectively.

CONCLUSION

¹⁸F-FDG PET/CT imaging could be useful for early prediction of PENTOCLO treatment resistance with appropriate antibiotherapy.

Tips and Tricks and Clinical Outcome of Cryopreserved Human Amniotic Membrane Application for the Management of Medication-Related Osteonecrosis of the Jaw (MRONJ): A Pilot Study

Medication-related osteonecrosis of the jaw (MRONJ) is a complication of certain pharmacological treatments such as bisphosphonates, denosumab, and angiogenesis inhibitors. There are currently no guidelines on its management, particularly in advanced stages. The human amniotic membrane (hAM) has low immunogenicity and exerts anti-inflammatory, antifibrotic, antimicrobial, antiviral, and analgesic effects. It is a source of stem cells and growth factors promoting tissue regeneration. hAM acts as an anatomical barrier with suitable mechanical properties (permeability, stability, elasticity, flexibility, and resorbability) to prevent the proliferation of fibrous tissue and promote early neovascularization at the surgical site. In oral surgery, hAM stimulates healing and facilitates the proliferation and differentiation of epithelial cells in the oral mucosa and therefore its regeneration. We proposed using cryopreserved hAM to eight patients suffering from cancer (11 lesions) with stage 2–3 MRONJ on a compassionate use basis. A collagen sponge was added in some cases to facilitate hAM grafting. One or three hAMs were applied and one patient had a reapplication. Three patients had complete closure of the surgical site with proper epithelialization at 2 weeks, and two of them maintained it until the last follow-up. At 1 week after surgery, three patients had partial wound dehiscence with partial healing 3 months later and two patients had complete wound dehiscence. hAM reapplication led to complete healing. All patients remained asymptomatic with excellent immediate significant pain relief, no infections, and a truly positive impact on the patients’ quality of life. No adverse events occurred. At 6 months of follow-up, 80% of lesions had complete or partial wound healing (30 and 50%, respectively), while 62.5% of patients were in stage 3. Radiological evaluations found that 85.7% of patients had stable bone lesions (n = 5) or new bone formation (n = 1). One patient had a worsening MRONJ but remained asymptomatic. One patient did not attend his follow-up radiological examination. For the first time, this prospective pilot study extensively illustrates both the handling and surgical application of hAM in MRONJ, its possible association with a collagen sponge scaffold, its outcome at the site, the application of multiple hAM patches at the same time, and its reapplication.

Predictive factors for refractory stage I and II anti-resorptive agent-related osteonecrosis of the jaw

OBJECTIVES

We aimed to predict the possibility of patients with stage I and II anti-resorptive agent-related osteonecrosis of the jaw (ARONJ) developing resistance to our treatment protocol by evaluating their clinical and imaging factors.

MATERIALS AND METHODS

We enrolled 58 patients with ARONJ who underwent imaging modality. As objective variables, we considered the healing, stage-down, and stable stages as successful outcomes, and the stage-up stage as resistant-to-treatment. As explanatory variables, we investigated the clinical and imaging factors. Furthermore, we examined stage-down as an improvement outcome to compare with the stable and stage-up stages, which were considered as no-improvement outcomes. We conducted unpaired between-group comparisons on all explanatory variables using χ² tests for independence.

RESULTS

Among 58 patients, the treatment was successful in 53 (91.4%); however, the disease was resistant in five (8.6%). Among the clinical factors, the resistant patients had a longer duration of administration of bone-modifying agents (BMAs) (cut-off: 1251 days, p = 0.032, odds ratio = 11.2, 95% confidence interval 1.115-122.518). In addition, the target disease that was being treated bone metastasis of malignant tumor was the only significant refractory factor (p = 0.024, OR: 3.667 95% CI 1.159-11.603) CONCLUSIONS: A combination of metabolic and morphological imaging modalities may be useful for oral surgeons to evaluate the disease activity and predict course of refractory ARONJ.

Usefulness of Quantitative Bone SPECT/CT for Evaluating Treatment Response in a Patient with Mandibular Osteomyelitis

We report here a case of mandibular osteomyelitis in a 63-year-old female in which quantitative values determined using bone SPECT/CT were useful to evaluate response to antibiotic therapy, hyperbaric oxygen therapy, and sequestomy. After finishing therapy, the chief complaints were well relieved, and posttreatment Tc-99m HMDP bone SPECT/CT examination showed decreased uptake. The maximum standardized uptake value (SUV), peak SUV, mean SUV, metabolic bone volume, and total bone uptake of the untreated lesion were 6.26, 5.16, 3.97, and 11.86 mL and 42.21, respectively, which were decreased to 4.65, 3.90, 2.77, and 9.67 mL and 26.80, respectively, following hyperbaric oxygen therapy and antibiotic administration, and were moreover decreased to 4.28, 3.67, 2.75, and 6.24 mL and 17.19, respectively, after sequestomy. In comparison with pretreatment situation, those parameters were decreased by −25.7, −24.4, −30.2, −18.5, and −36.5%, respectively, following hyperbaric oxygen therapy and antibiotic administration, and moreover by −31.6, −28.9, −30.7, −47.4, and −59.3, respectively, after sequestomy, likely reflecting treatment response. Quantitative bone SPECT/CT may be useful to evaluate bone inflammatory activity and treatment response in a patient with mandibular osteomyelitis.

Bisphosphonate application and volumetric effects on MRONJ lesions

The purpose of this investigation was to analyze the volume of medication-related osteonecrosis of the jaw (MRONJ) lesions by semi-automatic segmentation of cone-beam computed tomography images, and correlate the results with the underlying diseases and applied medication. MRONJ lesions detected in cone-beam computed tomography images were assessed. The open-source software ITK-Snap enabled volumetric measurements of MRONJ lesions based on semi-automatic segmentation. Results were analyzed according to necrosis volume, localization, and gender. In addition, the underlying disease and the type of application of antiresorptive medication were investigated. Cone-beam computed tomography images of 66 patients were studied. 34 male and 32 female patients were included, with ages ranging from 50 to 93 years at the time of diagnosis. The mean volume was 993.24 ± 620.94 mm³: 484.73 ± 230.97 mm³ for the upper jaw and 1084.04 ± 625.74 mm³ for the lower jaw. The results indicated statistically significant differences between lesions of the upper and lower jaw, regardless of gender (p = 0.003). The analysis of differences between males and females did not show any significant results (p = 0.464), although males presented slightly larger lesions than females. With regard to the underlying disease, patients with osteoporosis presented larger volumes, whereas patients with malignant tumors presented smaller volumes. Nevertheless, no statistically significant differences according to the underlying disease (p = 0.313) were detected. However, patients with intravenous (iv) application showed statistically significantly larger lesions than patients who underwent oral or subcutaneous (s.c.) applications (p = 0.004). It seems that the osteonecrosis volume correlates with the applied antiresorptive agents. Larger MRONJ lesions should be expected in patients who receive intravenous antiresorptive therapy.

Therapy-Related Imaging Findings in Patients with Sarcoma

Knowledge of imaging findings related to therapy administered to patients with sarcoma is pivotal in selecting appropriate care for these patients. Imaging studies are performed as surveillance in asymptomatic patients or because symptoms, including anxiety, develop. In addition to detection of recurrent disease and assessment of response to therapy, diagnosis of conditions related to therapy that may or may not need treatment has a marked positive impact on quality of life. The purpose of this review is to assist radiologists, nuclear physicians, and others clinicians involved in the diagnosis and treatment of these patients in recognizing imaging findings related to therapy and not to activity of the previously treated sarcoma. Imaging findings are time dependent and often specific in relation to therapy given.

Adjuvant therapies for MRONJ: A systematic review

OBJECTIVE

Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction caused by the use of antiresorptive antiangiogenic medication. Treating MRONJ is difficult and besides standard treatments, which are conservative medical and surgical approaches, there are some adjuvant therapies that might further stimulate healing. The aim of this systematic review is to compare outcome and effectiveness of currently available adjuvant therapies for MRONJ.

METHODS

This systematic review was conducted following the PRISMA guidelines. Articles focusing on mucosal healing in patients treated with an adjuvant therapy for MRONJ were selected and analysed. Inclusion was not limited to randomized controlled trials to present a complete review of the current literature.

RESULTS

A search was performed in Pubmed, Embase, Web of Science and Cochrane Central Register of Controlled Trials. Thirty articles out of 3297 were included. Laser ablation had a success of 60-95% for complete healing. The controlled trials of leukocyte- and platelet-rich-fibrine (LPRF) showed 60-100% success for the same outcome. Fluorescence guided surgery had a complete healing percentage of 85-90%.

CONCLUSIONS

The results suggest that laser ablation, LPRF and fluorescence guided surgery might have a potential in improving the healing process. Interpreting the results should however be done with great care and a critical point of view, as most articles had a medium to high risk of bias. More randomized controlled trials are necessary to define the most beneficial therapy protocols.

CLINICAL RELEVANCE

It seems that adjuvant surgical therapies for treating MRONJ are beneficial for mucosal healing, but there is only low scientific evidence.

Quantitative evaluation of anti-resorptive agent-related osteonecrosis of the jaw using bone single photon emission computed tomography in clinical settings: relationship between clinical stage and imaging

OBJECTIVE

This study aimed to use quantitative values, calculated from bone single photon emission computed tomography (SPECT) imaging, to estimate the reliability of progression evaluation for anti-resorptive agent-related osteonecrosis of the jaw (ARONJ).

METHODS

The study population consisted of 21 patients (23 lesions), clinically diagnosed with mandibular ARONJ, who underwent SPECT/CT scanning. Diagnosis and staging of ARONJ were performed according to the American Association of Oral and Maxillofacial Surgeons (AAOMS) definition and the recommendations of the International Task Force on ONJ. Hybrid SPECT/CT imaging quantitative analyses were performed on a workstation. Each volume of interest (VOI) was semi-automatically placed over a lesion with areas of high tracer accumulation, using the GI-BONE^® software default threshold method settings. Additionally, control VOI was manually set over an unaffected area. Measured parameters included standardized uptake values (SUV)-maximum (SUV_max) and mean (SUV_mean), metabolic bone volume (MBV)-the total volume above the threshold, and total bone uptake (TBU) as calculated by MBV × SUV_mean. We also calculated the SUV ratio (rSUV) between the lesion and control area, factoring for differences in individual bone metabolism; the ratios were termed rSUV_max and rSUV_mean, accordingly. The product of multiplying the rSUV_mean by MBV of a lesion was defined as the ratio of TBU (rTBU). Quantitative values were compared between clinical stages by the Kruskal-Wallis test and subsequent post hoc analysis.

RESULTS

MBVs (cm³) were: median, [IQR] Stage 1, 8.28 [5.62-9.49]; Stage 2, 15.28 [10.64-24.78]; and Stage 3, 34.61 [29.50-40.78]. MBV tended to increase with stage increase. Furthermore, only MBV showed a significant difference between clinical stages (p < 0.01). Subsequent post hoc analysis showed no significant difference between stages 1 and 2 (p = 0.12) but a significant difference between stages 2 and 3 (p = 0.048). rSUVmax and rTBU tended to increase with stage increase, but the differences between the stages were not significant (p = 0.10 and p = 0.055, respectively).

CONCLUSION

MBV, which includes the concept of volume, showed significant differences between clinical stages and tended to increase with the stage increase. As an objective and reliable indicator, MBV might be an adjunct diagnostic method for staging ARONJ.

Volumetric analysis of MRONJ lesions by semiautomatic segmentation of CBCT images

PURPOSE

The purpose of this study was to evaluate potential differences in volumes of areas of osteolysis caused by medication-related osteonecrosis of the jaw (MRONJ) between the upper and lower jaw. We aim to analyze the clinical relevance of volumetric measurement of osteolytic lesions for surgical planning of MRONJ patients.

METHODS

Sixty-seven patients who were clinically and histopathologically diagnosed with MRONJ were retrospectively included in this study. Cone beam computed tomography (CBCT) images were evaluated according to localization, affected anatomical structures, and volumetric measurement of osteolytic lesions caused by MRONJ in appliance of CBCT datasets by using ITK-SNAP.

RESULTS

The most frequently affected localization is the mandible, whereas female patients show significantly more often lesions of the maxilla. The cortical bone was predominantly affected. Furthermore, the affection of teeth, sinus floor, inferior alveolar nerve canal, or even a pathological fracture of the mandible are infrequently existing. The volumetric measurements revealed a statistically significant greater absolute osteolysis volume in males.

CONCLUSIONS

Image analysis and volumetric measurements of osteolytic lesions of MRONJ patients is a helpful tool to further understand the clinical appearance and identify compromised anatomic landmarks. Volumetric analysis aids in pre-surgical planning and visualizes the individual extent of the disease for each patient.

Comparative evaluation of SPECT/CT and CBCT in patients with mandibular osteomyelitis and osteonecrosis

OBJECTIVES

Therapy of osteomyelitis and osteonecrosis very often requires surgery. Proper preoperative radiological evaluation of a lesion's localization and extent is a key in planning surgical bone resection. This study aims to assess the differences between single-photon emission computed tomography and cone beam computed tomography when detecting an osteomyelitis/osteonecrosis lesion as well as the lesion's qualitative parameters, extent, and localization.

MATERIAL AND METHODS

Identification of candidates was performed retrospectively following a search for patients with histologically or clinically confirmed osteomyelitis or osteonecrosis. They were matched with a list of patients whose disease extent and localization had been evaluated using single-photon emission computed tomography and cone beam computed tomography in the context of clinical investigations. Subsequently, two experienced examiners for each imaging technique separately performed de novo readings. Detection rate, localization, extent, and qualitative parameters of a lesion were then compared.

RESULTS

Twenty-one patients with mandibular osteomyelitis and osteonecrotic lesions were included. Cone beam computed tomography detected more lesions than single-photon emission computed tomography (25 vs. 23; 100% vs. 92%). Cone beam computed tomography showed significantly greater depth, area, and volume, whereas length and width did not differ statistically between the two groups.

CONCLUSION

Both single-photon emission computed tomography and cone beam computed tomography could sensitively detect osteomyelitis/osteonecrosis lesions. Only single-photon emission computed tomography showed metabolic changes, whereas cone beam computed tomography seemed to display anatomic morphological reactions more accurately. The selection of the most adequate three-dimensional imaging and the correct interpretation of preoperative imaging remains challenging for clinicians.

CLINICAL RELEVANCE

In daily clinical practice, three-dimensional imaging is an important tool for evaluation of osteomyelitis/osteonecrosis lesions. In this context, clinicians should be aware of differences between single-photon emission computed tomography and cone beam computed tomography when detecting and assessing an osteomyelitis/osteonecrosis lesion, especially if a surgical bone resection is planned.

Symposium: Imaging modalities for drug-related osteonecrosis of the jaw (1), role of imaging in drug-related osteonecrosis of the jaw: An up-to-date review (secondary publication)

MRONJ/ARONJ is a serious adverse effect of medication, although the incidence of the disease is rare, and there are still controversial issues regarding the pathogenesis of MRONJ/ARONJ. Medications that can lead to MRONJ/ARONJ are commonly used to treat osteoporosis and to prevent bone fractures caused by bone metastasis of malignancies. The long-standing disease state of ONJ deteriorates the quality of life of affected patients. Early detection and prevention of the disease are key to alleviating pain and discomfort. To date, several imaging modalities have been introduced to depict the lesions. Imaging modalities, radiography, CT, MRI and nuclear medicine provide important information for managing this challenging disease.

A literature review of perioperative antibiotic administration in surgery for medication-related osteonecrosis of the jaw

PURPOSE

Few studies exist that focus on the details of perioperative antibiotic administration for surgery to treat medication-related osteonecrosis of the jaw (MRONJ). The regime and duration of perioperative antibiotics applied in published studies were reviewed to clarify appropriate perioperative antibiotic use in MRONJ surgery.

METHODS

A literature search was conducted using the MEDLINE database via PubMed.

RESULTS

The search resulted in 453 hits on PubMed. After reading the downloaded full-text articles, 17 articles met the inclusion and exclusion criteria. The most common perioperative antibiotic used for MRONJ surgery was a combination of penicillin-based antibiotics and β-lactamase inhibitor (52.9%), and the second most common regime was penicillin-based antibiotics with metronidazole (17.6%). The duration of administration was 2 weeks postoperatively in nine studies, whereas four studies applied long-term administration (2-6 weeks postoperatively).

CONCLUSIONS

Oral and maxillofacial surgeons mostly prefer penicillin-based antibiotics plus β-lactamase inhibitor or metronidazole for MRONJ surgery. The duration of administration of these medications may be based on empirical experience.

Potential role of post-treatment follow-up FDG-PET CT to detect mandibular osteoradionecrosis: A case report

It was hypothesized that fluorodeoxyglucose (FDG) uptake on post-treatment follow-up positron emission tomography with computed tomography (PET CT; using PET CT to monitor and rule out recurrence and metastasis of head and neck carcinoma) would be useful for detecting and understanding the disease state of osteoradionecrosis (ORN) of the jaw. The present study included 14 patients who developed mandibular ORN following radiation therapy (RT) for head and neck cancer and underwent follow-up PET CT several times following RT. Areas exhibiting FDG uptake were retrospectively assessed on post-treatment follow-up PET CT images and were classified into three types: Spot type: Only spot accumulation of FDG; localized type: Accumulation of FDG restricted to within the bone resorption area; extensive type: Accumulation of FDG extending into surrounding soft tissue. PET classification at the time of clinical diagnosis of mandibular ORN in the 14 patients demonstrated the extensive type in 43%, localized type in 36% and spot type in 21%. An increased area of FDG uptake around the ORN was revealed retrospectively on post-treatment follow-up FDG PET-CT images in 50% of patients. Alterations in PET classification included spot type to localized type in 36% and localized type to extensive type in 14%. A significantly increased number of patients with extensive-type ORN (P=0.026) required surgery. Post-treatment follow-up FDG-PET CT may be useful for early detection and better understanding of ORN.

Antiresorptive treatment-associated ONJ

Osteonecrosis of the jaw (ONJ) is a severe complication of therapy with antiresorptive agents (e.g. bisphosphonates and denosumab), which are used to manage bone metastases from cancer, to reduce the incidence of skeletal-related events. Available data indicate that 0-27, 5% of patients exposed to antiresorptive agents may develop ONJ, depending on the number of infusions and the duration of therapy. Besides antiresorptive therapy, a number of risk factors for osteonecrosis have been identified. Oral surgical procedures, tooth extractions and infection to the jawbones are considered the main risk factors for developing ONJ, when receiving antiresorptive therapy. However, a growing number of patients develop ONJ without apparent risk factors, raising concern for other predisposing factors. Jaw bone necrosis may be irreversible, resulting in a chronic disease with negative impact on the quality of patients' lives. The role of risk reduction strategies like meticulous dental screening and optimal oral hygiene is fundamental for preventing development of ONJ. ONJ is usually treated conservatively to relieve the symptoms and manage jaw bone necrosis. In certain cases, surgical intervention is required. Future research should emphasize individual predisposition to ONJ, more effective preventive measures and more efficient therapeutic procedures.