Advanced osteoradionecrosis of the maxilla: a 15-year, single-institution experience of surgical management

Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline

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.

Extra-mandibular Osteoradionecrosis after the Treatment of Head and Neck Cancer

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.

Osteoradionecrosis of the craniotomy flap: a rare complication of stereotactic radiosurgery

Osteoradionecrosis (ORN), ischemic necrosis of irradiated bone without evidence of persisting or recurrent tumor, is a known complication of radiation therapy. ORN of the skull has not been reported following stereotactic radiosurgery (SRS). We report two cases of ORN of the skull following SRS for recurrent meningiomas post-resection. Both patients developed ORN in their craniotomy flaps in areas that received high doses of radiation due to their proximity to the recurrent tumors. In each case, the ORN was asymptomatic and was detected on surveillance magnetic resonance imaging. Both patients were followed closely with imaging that ultimately revealed either stability or improvement in the ORN, confirming the diagnosis without the need for biopsy. The cases reveal a role for close imaging surveillance instead of immediate biopsy in patients with new enhancement involving bone in high-dose radiation treatment regions.

Prosthetic management of a midfacial defect

Surgical ablation of a large tumor creates a defect which is technically difficult to reconstruct. Radiated tissue bed poses a challenge to reconstruction and is complicated in presence of osteoradionecrosis. This report describes a case of a 62 year old gentleman with oral cancer who underwent surgery and radiotherapy twice. He developed an orocutaneous defect (OCD) following surgery and radiotherapy. Prosthetic rehabilitation of OCD was done. Full facial impression with irreversible hydrocolloid was made and wax sculpture made on the model obtained. Standard laboratory steps were followed for mould fabrication and maxillofacial silicone was used to fabricate the prosthesis. It was retained to the spectacle with silicone adhesives. The silicone facial prosthesis provided to the patient was easy to use, covered the defect and improved the quality of life of the patient.