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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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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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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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Otto S, Shreeja S, Kakoschke SC, Albittar MM, Widenhorn A, Kakoschke TK. Pre- and Post-Operative Quality of Life in Patients with Osteoradionecrosis of the Jaw. Cancers (Basel) 2024; 16:2256. [PMID: 38927961 PMCID: PMC11201672 DOI: 10.3390/cancers16122256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/02/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Osteoradionecrosis of the jaw (ORNJ) is a feared complication following radiation therapy performed for oncological treatment of head and neck cancers (HNC). To date, there is no clear evidence regarding the impact of surgical treatment of ORNJ on the quality of life (QoL) of affected patients. However, understanding the significance of the surgical treatment approach and its effects on QoL is an essential factor in the decision-making process for optimal, individualized therapy. In this prospective clinical study, QoL was assessed in relation to health related QoL (HRQoL) and oral health related QoL (OHQoL) before and after surgical treatment of ORNJ using standardized questionnaires (EORTC QLQ-C30, QLQ-HN35, OHIP-14). The overall QoL scores as well as individual domains of the collected scales regarding functional and symptom-related complaints were statistically analyzed. Subgroups concerning age, gender, different risk factors and type of ORNJ therapy were compared using Kruskal Wallis test. In addition, clinical and demographic patient data were collected and analyzed. QoL improvement correlated with the type of surgical ORNJ and the length of hospitalization. Better QoL scores were achieved post-operatively regarding different symptoms like pain, swallowing and mouth opening. Long-term effects of radiation therapy remained visibly restrictive to QoL and worsen over time.
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Affiliation(s)
- Sven Otto
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, Lindwurmstrasse 2a, 80337 Munich, Germany; (S.O.)
| | - Shreeja Shreeja
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, Lindwurmstrasse 2a, 80337 Munich, Germany; (S.O.)
- Deggendorf Institute of Technology, European Campus Rottal-Inn, Max-Breiherr-Strasse 32, 84347 Pfarrkirchen, Germany;
| | - Sara Carina Kakoschke
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, Lindwurmstrasse 2a, 80337 Munich, Germany; (S.O.)
- Department of General, Visceral, and Transplant Surgery, University Hospital, LMU Munich, Marchioninistrasse 15, 81337 Munich, Germany
| | - Mohammed Michael Albittar
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, Lindwurmstrasse 2a, 80337 Munich, Germany; (S.O.)
| | - Andreas Widenhorn
- Deggendorf Institute of Technology, European Campus Rottal-Inn, Max-Breiherr-Strasse 32, 84347 Pfarrkirchen, Germany;
- Economics and Quantitative Methods Department, International School of Management, Karlstrasse 35, 80333 Munich, Germany
| | - Tamara Katharina Kakoschke
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, University Hospital, LMU Munich, Lindwurmstrasse 2a, 80337 Munich, Germany; (S.O.)
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Kostares E, Kostares M, Kostare G, Tsakris A, Kantzanou M. Prevalence of free flap failure in mandibular osteoradionecrosis reconstruction: a systematic review and meta-analysis. Sci Rep 2024; 14:11087. [PMID: 38750124 PMCID: PMC11096303 DOI: 10.1038/s41598-024-61862-1] [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: 10/23/2023] [Accepted: 05/10/2024] [Indexed: 05/18/2024] Open
Abstract
Our study aimed to estimate the prevalence of total free flap failure following free flap reconstruction for mandibular osteoradionecrosis (mORN) and assess the impact of potential moderators on this outcome. A comprehensive systematic literature search was independently conducted by two reviewers using the Medline, Scopus, Web of Science and Cochrane Library databases. Quality assessment of the selected studies was performed, and prevalence estimates with 95% confidence intervals (CI) were calculated. Outlier and influential analyses were conducted, and meta-regression analyses was employed to investigate the effects of continuous variables on the estimated prevalence. Ultimately, forty-six eligible studies (involving 1292 participants and 1344 free flaps) were included in our meta-analysis. The findings of our study revealed a prevalence of 3.1% (95% CI 1.3-5.4%) for total free flap failure after reconstruction for mORN. No study was identified as critically influential, and meta-regression analysis did not pinpoint any potential sources of heterogeneity. These findings provide valuable insights for researchers and serve as a foundation for future investigations into the management of mandibular osteoradionecrosis and the prevention of free flap failure in this context.
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Affiliation(s)
- Evangelos Kostares
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece.
| | - Michael Kostares
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Georgia Kostare
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Maria Kantzanou
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
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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 DOI: 10.2340/1651-226x.2024.35222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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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Cui H, Wang Y, Ma J, Zhou L, Li G, Li Y, Sun Y, Shen J, Ma T, Wang Q, Feng X, Dong B, Yang P, Li Y, Ma X. Advances in exosome modulation of ferroptosis for the treatment of orthopedic diseases. Pathol Res Pract 2024; 257:155312. [PMID: 38663177 DOI: 10.1016/j.prp.2024.155312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 05/12/2024]
Abstract
Current treatments for orthopaedic illnesses frequently result in poor prognosis, treatment failure, numerous relapses, and other unpleasant outcomes that have a significant impact on patients' quality of life. Cell-free therapy has emerged as one of the most promising options in recent decades for improving the status quo. As a result, using exosomes produced from various cells to modulate ferroptosis has been proposed as a therapeutic method for the condition. Exosomes are extracellular vesicles that secrete various bioactive chemicals that influence disease treatment and play a role in the genesis and progression of orthopaedic illnesses. Ferroptosis is a recently defined kind of controlled cell death typified by large iron ion buildup and lipid peroxidation. An increasing number of studies indicate that ferroptosis plays a significant role in orthopaedic illnesses. Exosomes, as intercellular information transfer channels, have been found to play a significant role in the regulation of ferroptosis processes. Furthermore, accumulating research suggests that exosomes can influence the course of many diseases by regulating ferroptosis in injured cells. In order to better understand the processes by which exosomes govern ferroptosis in the therapy of orthopaedic illnesses. This review discusses the biogenesis, secretion, and uptake of exosomes, as well as the mechanisms of ferroptosis and exosomes in the therapy of orthopaedic illnesses. It focuses on recent research advances and exosome mechanisms in regulating iron death for the therapy of orthopaedic illnesses. The present state of review conducted both domestically and internationally is elucidated and anticipated as a viable avenue for future therapy in the field of orthopaedics.
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Affiliation(s)
- Hongwei Cui
- Tianjin Medical University Orthopedic Clinical College, Tianjin 300050, China; Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Yan Wang
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Jianxiong Ma
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China.
| | - Liyun Zhou
- Tianjin Medical University Orthopedic Clinical College, Tianjin 300050, China; Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Guang Li
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Yiyang Li
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Yadi Sun
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Jiahui Shen
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Tiancheng Ma
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Qiyu Wang
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Xiaotian Feng
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Benchao Dong
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Peichuan Yang
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Yan Li
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
| | - Xinlong Ma
- Tianjin Hospital of Tianjin University (Tianjin Hospital), Tianjin 300211, China; Tianjin Orthopedic Institute, Tianjin 300050, China; Tianjin Key Laboratory of Orthopedic Biomechanics and Medical Engineering, Tianjin 300050, China
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Schroter GT, Stopiglia RMM, Carvalho GL, Morimoto S, Mota ME, Alves FA, Jaguar GC, Moreira MS. Osteoradionecrosis treatment in head and neck cancer patients: An overview of systematic reviews. SPECIAL CARE IN DENTISTRY 2024; 44:621-635. [PMID: 37534945 DOI: 10.1111/scd.12910] [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: 04/13/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/04/2023]
Abstract
AIMS Evaluate the existing evidence of osteoradionecrosis (ORN) treatment in adults with head and neck cancer, the methodological quality and the evidence grade within systematic reviews (SRs). METHODS An extensive systematic literature search of SRs that addressed ORN in head and neck cancer patients was conducted with screening of eligible studies, data extraction, methodological (AMSTAR 2) and evidence quality assessment (GRADE) of the SRs by independent and calibrated authors. RESULTS A total of six SRs were enrolled. Based primarily on studies from the 1990s, there is critically low- or moderate-quality evidence that hyperbaric oxygen therapy (HBO) improves ORN healing. From 2005 onward, evidence has been discovered in relation to treatment with pentoxifylline and tocopherol (PENTO). The SRs indicate that the management of ORN with PENTO appears to be promising. The greatest rates of healing are seen in mild and moderate stages of ORN. However, the quality of evidence regarding PENTO, surgery and other treatments remains critically low. CONCLUSION There is no standardized protocol to treat ORN. PENTO appears to be the most promising conservative treatment; however, the current level of evidence regarding PENTO is still critically low. More robust clinical studies are needed to establish the best treatment for ORN.
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Affiliation(s)
| | | | | | - Susana Morimoto
- Postgraduate Program in Dentistry, Ibirapuera University, São Paulo, Brazil
| | - Maria Emília Mota
- Department of Stomatology, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil
| | - Fábio Abreu Alves
- Department of Stomatology, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil
- Department of Stomatology, AC Camargo Cancer Center, São Paulo, Brazil
| | | | - Maria Stella Moreira
- Department of Stomatology, School of Dentistry, University of São Paulo (USP), São Paulo, Brazil
- Department of Stomatology, AC Camargo Cancer Center, São Paulo, Brazil
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Grasl S, Wassipaul C, Fischer G, Arnoldner C, Janik S. An Unknown Foreign laryngeal Object: an exotic complication of skull base osteoradionecrosis. Eur Arch Otorhinolaryngol 2024; 281:2755-2759. [PMID: 38381152 PMCID: PMC11023982 DOI: 10.1007/s00405-024-08507-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Osteoradionecrosis (ORN) of the skull base is a rare complication after head and neck radiation with a broad variety of subsequent complications. METHODS A 68-year-old woman with a complex oncological history (right-sided sphenoid meningioma; left-sided neck metastasis of a Cancer of Unknown Primary-CUP) was admitted with a right-sided epi-/ oropharyngeal mass and severe pain exacerbations for further evaluation. CT scan revealed an advanced ORN of the skull base with subsequent abruption of the ventral part of the clivus. This dislocated part of the clivus wedged in the oropharynx for 48 h and then moved towards the larynx, resulting in dyspnea and almost complete airway obstruction. RESULTS Due to the dangerous airway situation, an urgent exploration and removal of the dislocated clivus was necessary. After a potential cervical spine instability was ruled out, the patient's airway was initially secured with an awake tracheotomy and the clivus was removed transorally. The tracheostomy tube was removed during the ongoing inpatient stay, and the patient was discharged with significant pain relief. CONCLUSIONS The present case illustrates an orphan complication of skull base ORN resulting in a major airway emergency situation.
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Affiliation(s)
- Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Wassipaul
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Gregor Fischer
- Department of Otolaryngology, Karl Landsteiner University Hospital, Krems, Austria
| | - Christoph Arnoldner
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria.
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Owosho AA, DeColibus KA, Okhuaihesuyi O, Levy LC. Prophylactic Use of Pentoxifylline and Tocopherol for Prevention of Osteoradionecrosis of the Jaw after Dental Extraction in Post-Radiated Oral and Oropharyngeal Cancer Patients: An Initial Case Series. Dent J (Basel) 2024; 12:83. [PMID: 38667995 PMCID: PMC11049290 DOI: 10.3390/dj12040083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Osteoradionecrosis of the jaw is a morbid complication of radiotherapy in patients with oral and oropharyngeal cancers that may be precipitated by dental extractions. Pentoxifylline and tocopherol (PENTO) has been utilized in the management of osteoradionecrosis and as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. This observational study aims to report the outcome of the prophylactic use of PENTO in the prevention of osteoradionecrosis of the jaw after dental extractions in post-radiated oral and oropharyngeal cancer patients and to review the current literature on this topic. Four post-radiated oral and oropharyngeal oncology patients were referred to the dental oncology clinic of the University Dental Practice, University of Tennessee Health Sciences Center for dental extractions. All four patients were prescribed pentoxifylline 400 mg BID (twice a day) and tocopherol 400 IU BID (oral tablets) for 2 weeks before extraction(s) and for 6 weeks after extraction(s). All patients were followed up every week after the second week post-extraction if feasible until the extraction site(s) healed (covered by mucosa). The assessment endpoint was defined as 6 weeks post-extraction with the outcomes assessed as using four categories determined by the area of exposed bone: complete healing (complete mucosal coverage of extraction site); partial healing (reduction in size of extraction site); no change; and progression (increase in size of the extraction site). At the assessment endpoint, all patients had complete healing of all extraction sites. The ORN rate at the patient level (0/4) and individual tooth level (0/8) was 0%. All patients tolerated the PENTO medications and no adverse effects from the use of these medications were reported. This limited study in addition to the other reviewed studies estimates the rate of ORN at the patient level as 3.2% (14/436) for post-radiated head and neck oncology patients after dental extractions/invasive oral procedures. In conclusion, this PENTO regimen can reduce/prevent the incidence of ORN in post-radiated head and neck oncology patients. This safe and cost-effective protocol (PENTO regimen) should be further evaluated as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. We recommend large prospective studies to be carried out to further validate these findings.
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Affiliation(s)
- Adepitan A. Owosho
- Department of Diagnostic Sciences, College of Dentistry/Department of Otolaryngology—Head & Neck Surgery, College of Medicine, The University of Tennessee Health Sciences Center, 875 Union Avenue, Memphis, TN 38163, USA
| | - Katherine A. DeColibus
- Department of Diagnostic Sciences, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
| | - Osariemen Okhuaihesuyi
- Missouri School of Dentistry and Oral Health, A.T. Still University, Kirksville, MO 63501, USA
| | - Layne C. Levy
- Advanced Education in General Dentistry, College of Dentistry, The University of Tennessee Health Sciences Center, Memphis, TN 38163, USA
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11
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Shih YJ, Huang JY, Lai YC, Lin HM, Kuo TJ. Tooth extraction within 2 weeks before radiotherapy and osteoradionecrosis: A nationwide cohort study. Oral Dis 2024; 30:575-585. [PMID: 35951468 DOI: 10.1111/odi.14349] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 07/05/2022] [Accepted: 08/08/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The theory of at least 2-week waiting period between tooth extraction and head and neck radiotherapy could reduce osteoradionecrosis remains controversial. Thus, this study examined the theory and associated factors. MATERIALS AND METHODS Data were retrieved from the National Health Insurance Research Database, Taiwan Cancer Registry Database, and Cause of Death Statistics. We included 24,353 patients with head and neck cancer who received radiotherapy from 2011 to 2017 and were followed up until 2019. The patients were divided into three groups: those undergoing tooth removal 2-8 weeks before radiotherapy, those undergoing tooth removal within 2 weeks before radiotherapy, and others. Confounding factors were clinical information, physical conditions, and risky habits. We used the Cox regression model to assess osteoradionecrosis risk. RESULTS No significant difference in osteoradionecrosis risk was observed between those undergoing tooth extraction within 2 weeks before radiotherapy and the other groups. An irradiation dose of ≥60 Gy, chemotherapy, tumor excision, post-radiotherapy tooth extraction, mandibulectomy, hyperlipidemia, and oral cavity as the tumor subsite were significantly positively associated with osteoradionecrosis risk. CONCLUSION A waiting period of ≥2 weeks between tooth extraction and radiotherapy did not significantly reduce osteoradionecrosis risk.
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Affiliation(s)
- Yin-Ju Shih
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung, Taiwan
- Department of Oral and Maxillofacial Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Jing-Yang Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yu-Cheng Lai
- Department of Orthopedics, Asia University Hospital, Taichung, Taiwan
- Department of Marine Biotechnology and Resources, National Sun Yat-Sen University, Kaohsiung, 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
- Department of Marine Biotechnology and Resources, National Sun Yat-Sen University, Kaohsiung, Taiwan
- School of Dentistry, Chung Shan Medical University, Taichung, Taiwan
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12
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Straub A, Stapf M, Brands RC, Kübler AC, Lâm TT, Vollmer A, Gubik S, Scherf-Clavel O, Hartmann S. Investigation of clindamycin concentrations in human plasma and jawbone tissue in patients with osteonecrosis of the jaw: A prospective trial. J Craniomaxillofac Surg 2024; 52:355-362. [PMID: 38368214 DOI: 10.1016/j.jcms.2024.01.014] [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: 08/10/2023] [Revised: 10/18/2023] [Accepted: 01/16/2024] [Indexed: 02/19/2024] Open
Abstract
The aim of this study was to investigate the jawbone concentration of clindamycin (CLI) in patients with an osteonecrosis of the jaw (ONJ). Patients with medication-related ONJ (MRONJ) and osteoradionecrosis (ORN) with an antibiotic treatment with CLI were included. Plasma, vital and necrotic bone samples were collected. Plasma and jawbone samples were analyzed by liquid chromatography-tandem mass spectrometry. Patients with MRONJ exhibited a mean plasma CLI concentration of 9.6 μg/mL (SD ± 3.6 μg/mL) and mean concentrations of 2.3 μg/g CLI (SD ± 1.4 μg/g) and 2.1 μg/g CLI (SD ± 2.4 μg/g) in vital and necrotic bone samples, without statistical significance (p = 0.79). In patients with ORN, mean concentration in plasma was 12.0 μg/mL (SD ± 2.6 μg/mL), in vital bone 2.1 μg/g (SD ± 1.5 μg/g), and in necrotic bone 1.7 μg/g (SD ± 1.2 μg/g). Vital and necrotic bone concentrations did not differ significantly (p = 0.88). The results demonstrate that CLI concentrations are considerably lower than in plasma, but sufficient for most bacteria present in ONJ. Within the limitations of the study, it seems that CLI is a relevant alternative to other antibiotics in the treatment of ONJ because it reaches adequate concentrations in jawbone.
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Affiliation(s)
- Anton Straub
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany.
| | - Maximilian Stapf
- Institute for Pharmacy and Food Chemistry, University of Würzburg, Am Hubland, 97074, Würzburg, Germany
| | - Roman C Brands
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
| | - Alexander C Kübler
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
| | - Thiên-Trí Lâm
- Institute for Hygiene and Microbiology, University of Würzburg, Josef-Schneider-Str. 2/E1, 97080, Würzburg, Germany
| | - Andreas Vollmer
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
| | - Sebastian Gubik
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
| | - Oliver Scherf-Clavel
- Institute for Pharmacy and Food Chemistry, University of Würzburg, Am Hubland, 97074, Würzburg, Germany; Aalen University, Faculty of Chemistry, Beethovenstraße 1, 73430, Aalen, Germany
| | - Stefan Hartmann
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
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Florimond M, Duong LT, Lours E, Brau JJ, Ferré FC, Fouilloux I, Boukpessi T. Oral Health in Patients with History of Head and Neck Cancer: Complexity and Benefits of a Targeted Oral Healthcare Pathway. Curr Oncol Rep 2024; 26:258-271. [PMID: 38376626 PMCID: PMC10920472 DOI: 10.1007/s11912-024-01507-8] [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] [Accepted: 02/07/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE OF REVIEW This work consists in a literature review on the current state of knowledge regarding the oral management of patients with a history of head and neck cancer (HNC), corroborated by clinical cases and illustrated by clear infographic summaries. It aims to provide healthcare professionals with a comprehensive overview of the oral health status of HCN patients. RECENT FINDINGS Head and neck cancers (HNCs) represent the seventh most common type of cancer worldwide, with over 660,000 annual new cases. Despite the significant negative impact of HNCs on oral health, patients often receive no or inappropriate oral care while the significant impact of oral pathologies on cancer prognosis is commonly underestimated. This work (i) describes the oral cavity during and after HNC through the prism of care complexity and (ii) highlights several potential key factors that could worsen long-time patients' prognosis and quality of life. By investigating the biological, microbiological, functional, and psychological dimensions of the interrelationships between HNCs and oral health, the authors explored the barriers and benefits of a targeted oral healthcare pathway. This article emphasizes the importance of multidisciplinary care and highlights the need for further research elucidating the intricate relationships between oral health and HNCs, particularly through the microbiota.
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Affiliation(s)
- Marion Florimond
- URP 2496 BRIO, Biomedical Research in Odontology, Université Paris Cité, 1 Rue Maurice Arnoux, 92120, Montrouge, France.
- Dental Faculty, Department of Oral Biology, Université Paris Cité, Paris, France.
- Dental Department, Charles Foix Hospital, AP-HP, 94200, Ivry Sur Seine, France.
| | - Lucas T Duong
- Dental Department, Charles Foix Hospital, AP-HP, 94200, Ivry Sur Seine, France
- Centre de Recherche Des Cordeliers, UMRS 1138, Molecular Oral Pathophysiology, Université Paris Cité, INSERM, Sorbonne Université, Paris, France
- Dental Faculty, Department of Oral Surgery, Université Paris Cité, Paris, France
- Department of Head and Neck Surgical Oncology, Institut Gustave Roussy, Villejuif, France
| | - Elodie Lours
- Dental Department, Charles Foix Hospital, AP-HP, 94200, Ivry Sur Seine, France
| | - Jean-Jacques Brau
- Department of Head and Neck Surgical Oncology, Institut Gustave Roussy, Villejuif, France
| | - François C Ferré
- Dental Department, Charles Foix Hospital, AP-HP, 94200, Ivry Sur Seine, France
- Centre de Recherche Des Cordeliers, UMRS 1138, Molecular Oral Pathophysiology, Université Paris Cité, INSERM, Sorbonne Université, Paris, France
- Dental Faculty, Department of Oral Surgery, Université Paris Cité, Paris, France
| | - Isabelle Fouilloux
- Dental Department, Charles Foix Hospital, AP-HP, 94200, Ivry Sur Seine, France
- Dental Faculty, Department of Prosthetics, Université Paris Cité, Paris, France
| | - Tchilalo Boukpessi
- URP 2496 BRIO, Biomedical Research in Odontology, Université Paris Cité, 1 Rue Maurice Arnoux, 92120, Montrouge, France
- Dental Department, Pitié Salpêtrière Hospital, AP-HP, 75013, Paris, France
- Dental Faculty, Department of Restorative Dentistry and Endodontics, Université Paris Cité, Paris, France
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14
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Quah B, Yong CW, Lai CWM, Islam I. Efficacy of adjunctive modalities during tooth extraction for the prevention of osteoradionecrosis: A systematic review and meta-analysis. Oral Dis 2024. [PMID: 38396363 DOI: 10.1111/odi.14902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/18/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Jaw osteoradionecrosis (ORN) is a complication in patients with previous head and neck radiotherapy. Its incidence increases with dental extractions. Hence, this review aimed to evaluate the efficacy of adjunctive treatment modalities undertaken at the time of extraction in previous head and neck radiotherapy patients in preventing ORN. METHODS A systematic review was conducted, where studies with data on ORN incidence after extraction with or without adjunctive interventions were included. Meta-analyses were conducted to estimate the pooled prevalence of ORN per intervention and the pooled odds ratio for incidence of ORN between interventions. RESULTS In total, 1520 patients in 29 studies were included. Interventions identified were hyperbaric oxygen (HBO), pentoxifylline-tocopherol (PENTO), antibiotics (ABX), platelet-rich fibrin and photobiomodulation. The pooled prevalence of ORN for HBO (4.6%), PENTO (3.4%) and ABX (3.8%) was significantly lower than the Control (17.6%). For studies with direct comparisons between groups, HBO had lower but not significant odds of developing ORN than the Control (OR 0.27) and ABX (OR 0.57). CONCLUSIONS HBO, PENTO and ABX may reduce the incidence of ORN compared to no intervention. Given that all three have similar incidences of ORN, ABX may be the most cost-effective and accessible adjunctive modality.
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Affiliation(s)
- Bernadette Quah
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
| | - Chee Weng Yong
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
| | - Clement Wei Ming Lai
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
| | - Intekhab Islam
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
- Department of Oral and Maxillofacial Surgery, Discipline of Oral and Maxillofacial Surgery, National University Centre for Oral Health, Singapore, Singapore
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Chiu KW, Yu TP, Kao YS. A systematic review and meta-analysis of osteoradionecrosis following proton therapy in patients with head and neck cancer. Oral Oncol 2024; 148:106649. [PMID: 38035508 DOI: 10.1016/j.oraloncology.2023.106649] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/24/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Head and neck cancer ranks as the seventh most common cancer worldwide. Proton therapy is widely used in head and neck cancer. Osteoradionecrosis(ORN) is currently a commonly investigated side effect of proton therapy. A meta-analysis is needed to investigate this topic. MATERIAL/METHODS Two authors searched three databases, including PubMed, Embase, and Cochrane Library; the search period was from inception to June 2023. The search keyword was set to be ((("osteoradionecrosis") OR ("osteonecrosis")) AND ("proton")). RESULTS We initially collected 410 articles, and after article selections, 22 articles remained in our systematic reviews. Due to the overlapping of patient populations, 17 studies were finally included in our meta-analysis. The pooled grade 3 or more ORN rate is 0.01(95 % CI = 0.01-0.03). Subgroup analysis showed that IMPT didn't reduce grade 3 or more ORN compared with 3DCPT (p = 0.15). CONCLUSIONS Our meta-analysis showed that severe ORN rarely occurred in proton therapy for head and neck cancer patients.
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Affiliation(s)
- Kun-Wei Chiu
- Department of Otorhinolaryngology, Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Tzu-Ping Yu
- Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Yung-Shuo Kao
- Department of Radiation Oncology, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan, ROC.
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16
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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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Palmier NR, Prado-Ribeiro AC, Mariz BALA, Rodrigues-Oliveira L, Paglioni MDP, Napimoga JTC, Pedroso CM, Morais-Faria K, Oliveira MCQD, Vechiato-Filho AJ, Brandão TB, Santos-Silva AR. The impact of radiation caries on morbidity and mortality outcomes of head and neck squamous cell carcinoma patients. SPECIAL CARE IN DENTISTRY 2024; 44:184-195. [PMID: 36872650 DOI: 10.1111/scd.12843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 03/07/2023]
Abstract
AIMS Radiation caries (RC) is a highly prevalent and chronic complication of head and neck radiotherapy (HNRT) and presents a challenge for clinicians and patients. The present study aimed to assess the impact of RC on the morbidity and mortality outcomes of head and neck squamous cell carcinoma (HNSCC) patients. METHODS AND RESULTS Patients were divided into three groups: (1) RC (n = 20), (2) control (n = 20), and (3) edentulous (n = 20). Information regarding the number of appointments, dental procedures, osteoradionecrosis (ORN), prescriptions, and hospital admissions were collected. Mortality outcomes were assessed through disease-free survival (DFS) and overall survival (OS) rates. RC patients required more dental appointments (p < .001), restorations (p < .001), extractions (p = .001), and antibiotic and analgesic prescriptions (p < .001). Kaplan-Meier subgroup analyses showed a significantly increased risk of ORN in RC compared to edentulous patients (p = .015). RC patients presented lower DFS rates (43.2 months) than the control and edentulous groups (55.4 and 56.1 months, respectively). CONCLUSIONS RC impacts morbidity outcomes among cancer survivors due to increased demand for medication prescriptions, multiple specialized dental appointments, invasive surgical treatments, increased risk of ORN, and increased need for hospital admissions.
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Affiliation(s)
- Natália Rangel Palmier
- Dental Oncology Service, Instituto do Câncer do Estado de São Paulo, ICESP-FMUSP, São Paulo, Brazil
| | | | | | - Letícia Rodrigues-Oliveira
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Mariana de Pauli Paglioni
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Juliana Trindade Clemente Napimoga
- São Leopoldo Mandic Institute and Research Center, Laboratory of Neuroimmune Interface of Pain Research, Faculdade São Leopoldo Mandic, Campinas, Sao Paulo, Brazil
| | - Caique Mariano Pedroso
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Karina Morais-Faria
- Dental Oncology Service, Instituto do Câncer do Estado de São Paulo, ICESP-FMUSP, São Paulo, Brazil
| | | | | | - Thaís Bianca Brandão
- Dental Oncology Service, Instituto do Câncer do Estado de São Paulo, ICESP-FMUSP, São Paulo, Brazil
| | - Alan Roger Santos-Silva
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
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Sharma S, Shankar R, Ravi Kiran BS, Breh R, Sarangi S, Kumar Upadhyay A. A Narrative Review of Osteonecrosis of the Jaw: What a Clinician Should Know. Cureus 2023; 15:e51183. [PMID: 38283469 PMCID: PMC10817767 DOI: 10.7759/cureus.51183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is an uncommon complication of antiresorptive therapy (ART) in patients receiving higher and more frequent doses of osteoclast inhibitors. The jaws are the most common site, as they have high bone turnover. The oral structures are exposed to various types of stresses, like mastication and dental diseases, which lead to microtrauma and increased bone remodeling. The hallmark feature of MRONJ is the area of exposed, necrotic, nonhealing, asymptomatic bone for more than eight weeks. Objective signs are pain in the jaw and oral cavity, loose teeth, gingival swelling, ulceration, soft tissue infection, and paresthesia in the trigeminal nerve branches' territory. Clinically, the MRONJ has been defined in four stages, from stage 0 to stage 3. Close coordination between the dentist and oncologist is critical for optimal treatment. Conservative management should be preferred over surgical management. There is significant underreporting and misdiagnosis of MRONJ cases in regular clinical practice. There needs to be more awareness among treating physicians about this sporadic complication of bisphosphonate therapy. This narrative review has given a detailed insight into the subject, starting with etiology, pathogenesis, incidence, clinical presentation, workup, staging, and various management strategies. The review article focuses mainly on practical aspects of MRONJ, which every clinician dealing with the disease must know. With a better awareness of this potential complication, healthcare practitioners dealing with at-risk patients can better diagnose, prevent, address, and provide necessary care.
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Affiliation(s)
- Swati Sharma
- Prosthodontics, Tata Main Hospital, Jamshedpur, IND
| | - Rama Shankar
- Oral and Maxillofacial Surgery, Tata Main Hospital, Jamshedpur, IND
| | | | - Rohit Breh
- Orthodontics, Tata Main Hospital, Jamshedpur, IND
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de Freitas LC, Kawamoto EL, Souza AMA, Kawakami PY, Gonçalves AS, Azevedo LH. Use of Phototherapy and Er-YAG Laser in the Management of Mandible Osteoradionecrosis: A Case Report. J Lasers Med Sci 2023; 14:e58. [PMID: 38144942 PMCID: PMC10746881 DOI: 10.34172/jlms.2023.58] [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: 03/16/2023] [Accepted: 10/07/2023] [Indexed: 12/26/2023]
Abstract
Introduction: Osteoradionecrosis (ORN) is a secondary complication from radiotherapy, which is difficult to manage and significantly reduces the life quality of the affected patients. Case Report: A 59-year-old female patient, diagnosed with infiltration by squamous cell carcinoma in the left cervical region, underwent adjuvant cervical-facial radiotherapy with a total dose of 66.6 Gy of radiation. Eight years after the diagnosis, the patient underwent multiple extractions and, subsequently, the installation of osseointegrated implants, evolving to extensive intraoral bone exposure associated with oral cutaneous fistula. The patient was initially exposed to photobiomodulation therapy (PBMT), with a low-power laser at wavelengths of 660 nm and 808 nm, and thereafter to antimicrobial photodynamic therapy (aPDT). After an improvement in the clinical condition and resolution of the oral cutaneous fistula, a surgical procedure with the Er: YAG laser was performed to remove the remaining necrotic bone. Once the ORN condition was completely treated, the patient's oral rehabilitation was implemented by the installation of an upper mucous-supported total prosthesis and a lower implant-supported prosthesis. Conclusion: The patient is in a clinical follow-up and has no signs of bone necrosis recurrence, suggesting that low and high-power laser treatment can be an effective therapeutic alternative to resolve this condition.
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Affiliation(s)
| | | | - Ana Maria Aparecida Souza
- Master’s Professional Program on Lasers in Dentistry, University of São Paulo, São Paulo, São Paulo, Brazil
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20
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Çolak S, Erdil A, Gevrek F. Effects of systemic Anatolian propolis administration on a rat-irradiated osteoradionecrosis model. J Appl Oral Sci 2023; 31:e20230231. [PMID: 37909529 PMCID: PMC10609641 DOI: 10.1590/1678-7757-2023-0231] [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: 07/07/2023] [Revised: 08/07/2023] [Accepted: 09/12/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVE Radiotherapy after head and neck cancer is associated with the risk of osteonecrosis development. This study aims to investigate the effectiveness of systemic propolis application to prevent the disease as it has no definite treatment protocol despite the proposed treatment methods and significantly decreases individuals' quality of life. METHODOLOGY In total, 29 male Wistar-Albino rats were divided into control, 35 Gy irradiation (Group 1), 35 Gy irradiation+100 mg/kg/ml propolis administration (Group 2), and 35 Gy irradiation+200 mg/kg/ml propolis administration groups (Group 3). Propolis was first applied on the day after radiotherapy, except for the control group. Right first and second molars were extracted from all rats three weeks following radiotherapy. Samples were collected seven weeks after radiotherapy. Osteoblast and osteoclast counts were calculated by histomorphometric analysis. Immunohistochemical analysis determined bone morphogenic protein-2 (BMP-2) and transforming growth factor beta-3 (TGFβ-3). RESULTS Group comparison found non-significant differences regarding osteoblast (p=0.130) and osteoclast (p=0.063) counts. However, Group 1 showed the lowest mean osteoblast (OBL: 82.63 [±13.10]) and highest mean osteoclast counts (OCL: 12.63 [±5.55]). OBL/OCL ratio showed significant differences between groups (p=0.011). Despite the significant difference between the Control and Groups 1 (p=0.006) and 2 (p=0.029), Group 3 showed a non-significant difference (p=0.091). For BMP-2 and TGFB3, the control group showed significant differences with the other two groups (p<0.001), except for Group 3. CONCLUSION Anatolian propolis showed beneficial effects in a radiotherapy-mediated osteonecrosis model, highlighting its potential as a promising intervention.
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Affiliation(s)
- Sefa Çolak
- Tokat Gaziosmanpaşa University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Tokat, Turkey
| | - Aras Erdil
- Uşak University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Uşak, Turkey
| | - Fikret Gevrek
- Tokat Gaziosmanpaşa University, Faculty of Medicine, Department of Histology and Embryology, Tokat, Turkey
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Sankar V, Xu Y. Oral Complications from Oropharyngeal Cancer Therapy. Cancers (Basel) 2023; 15:4548. [PMID: 37760517 PMCID: PMC10526346 DOI: 10.3390/cancers15184548] [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: 08/15/2023] [Revised: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Post-oropharyngeal cancer treatment complications include a multitude of oral side effects that impact overall survival and quality of life. These include acute and chronic conditions affecting the oral cavity and head and neck, such as mucositis, infection, xerostomia, dysgeusia, radiation caries, osteonecrosis, and trismus. This review will summarize the most common oral complications from oropharyngeal cancer therapy. The authors would like to point out that the literature cited frequently combines oropharyngeal and head and neck cancer results. If recommendations are made strictly related to oropharyngeal cancers, this will be highlighted.
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Affiliation(s)
- Vidya Sankar
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA 02111, USA;
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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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Paiva GLA, de Campos WG, Rocha AC, Júnior CAL, Migliorati CA, Dos Santos Silva AR. Can the prophylactic use of pentoxifylline and tocopherol before dental extractions prevent osteoradionecrosis? A systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 136:33-41. [PMID: 36882364 DOI: 10.1016/j.oooo.2023.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/04/2023] [Accepted: 01/12/2023] [Indexed: 01/21/2023]
Abstract
PURPOSE This systematic review aimed to determine whether the pentoxifylline and tocopherol (PENTO) protocol effectively reduce the risk of osteoradionecrosis (ORN) in patients undergoing tooth extraction after head and neck radiotherapy. METHODS We searched PubMed, SCOPUS, LILACS, EMBASE, Web of Science, and Cochrane databases up to August 2022. We considered only studies that included patients diagnosed with head and neck cancer undergoing tooth extraction with PENTO prophylaxis after radiotherapy. RESULTS Of the 642 studies identified, 4 were included. Across the included studies, 387 patients had 1871 teeth extracted while on PENTO prophylaxis. The interval of the PENTO protocol differed among the studies included. Overall, a total of 12 (3.1%) patients had ORN, whereas at the individual tooth level analysis the ORN rate was 0.9%. CONCLUSIONS Insufficient evidence exists to promote using the PENTO protocol before dental extractions to prevent ORN.
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Affiliation(s)
| | | | - André Caroli Rocha
- Department of Oral and Maxillofacial Surgery, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | | | - Cesar Augusto Migliorati
- Department of Oral & Maxillofacial Diagnostic Sciences, College of Dentistry, University of Florida, Gainesville, FL, USA
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Arianpour K, Meleca JB, Liu SW, Prendes BL, Ciolek PJ, Genther DJ, Mangie C, Khanna S, Fritz MA. Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis. JAMA Otolaryngol Head Neck Surg 2023; 149:621-627. [PMID: 37261824 PMCID: PMC10236321 DOI: 10.1001/jamaoto.2023.1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/06/2023] [Indexed: 06/02/2023]
Abstract
Importance Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed. Objective To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN. Design, Settings, and Participants This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023. Main Outcomes and Measures Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals. Results The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months. Conclusions and Relevance The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.
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Affiliation(s)
| | - Joseph B. Meleca
- Otolaryngology–Head & Neck Surgery, University of Chicago, Chicago, Illinois
| | - Sara W. Liu
- Facial Plastic and Microvascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Brandon L. Prendes
- Facial Plastic and Microvascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Peter J. Ciolek
- Facial Plastic and Microvascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Dane J. Genther
- Facial Plastic and Microvascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Craig Mangie
- Oral Maxillofacial Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sagar Khanna
- Oral Maxillofacial Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A. Fritz
- Facial Plastic and Microvascular Surgery, Cleveland Clinic, Cleveland, Ohio
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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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Li Z, Fu R, Huang X, Wen X, Zhang L. Oral microbiota may affect osteoradionecrosis following radiotherapy for head and neck cancer. J Transl Med 2023; 21:391. [PMID: 37328857 PMCID: PMC10276415 DOI: 10.1186/s12967-023-04219-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 05/21/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Osteoradionecrosis (ORN) is a serious complication of radiotherapy for head and neck cancer (HNC). However, its etiology and pathogenesis have not been completely elucidated. Recent studies suggest the involvement of the oral microbiota in the development of ORN. The aim of this study was to assess the correlation between oral microbiota and the extent of bone resorption in ORN patients. MATERIALS AND METHODS Thirty patients who received high-dose radiotherapy for HNC were enrolled. Tissue specimens were collected from the unaffected and affected sides. The diversity, species differences and marker species of the oral microbial community were determined by 16 S rRNA sequencing and bioinformatics analysis. RESULTS The ORN group had greater microbial abundance and species diversity. The relative abundance of f_Prevotellaceaeand, f_Fusobacteriaceae, f_Porphyromonadaceae, f_Actinomycetaceae, f_Staphylococcaceae, g_Prevotella, g_Staphylococcus, s_Endodontalis and s_Intermedia were particular;y increased in ORN, suggesting a potential association between the oral microbiota and ORN. Furthermore, g_Prevotella, g_Streptococcus, s_parvula and s_mucilaginosa were identified as potential diagnostic and prognostic biomarkers of ORN. Association network analysis also suggested an overall imbalance in species diversity and ecological diversity in the oral microbiota of ORN patients. In addition, pathway analysis indicated that the dominant microbiota in ORN may disrupt bone regeneration by regulating specific metabolic pathways that increase osteoclastic activity. CONCLUSION Radiation-induced ORN is associated with significant changes in the oral microbiota, and the latter may play a potential role in the etiopathology of post-radiation ORN. The exact mechanisms through which the oral microbiota influence osteogenesis and osteoclastogenesis remain to be elucidated.
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Affiliation(s)
- Zhengrui Li
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai, China
- National Center for Stomatology, Shanghai, China
- National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Shanghai, China
- Shanghai Research Institute of Stomatology, Shanghai, China
- Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Rao Fu
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai, China
- National Center for Stomatology, Shanghai, China
- National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Shanghai, China
- Shanghai Research Institute of Stomatology, Shanghai, China
- Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Xufeng Huang
- Faculty of Dentistry, University of Debrecen, Debrecen, 4032, Hungary
| | - Xutao Wen
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai, China
- National Center for Stomatology, Shanghai, China
- National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology, Shanghai, China
- Shanghai Research Institute of Stomatology, Shanghai, China
- Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China
| | - Ling Zhang
- Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- College of Stomatology, Shanghai Jiao Tong University, Shanghai, China.
- National Center for Stomatology, Shanghai, China.
- National Clinical Research Center for Oral Diseases, Shanghai, China.
- Shanghai Key Laboratory of Stomatology, Shanghai, China.
- Shanghai Research Institute of Stomatology, Shanghai, China.
- Shanghai Center of Head and Neck Oncology Clinical and Translational Science, Shanghai, China.
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27
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Lalla RV, Hodges JS, Treister NS, Sollecito TP, Schmidt BL, Patton LL, Lin A, Brennan MT. Tooth-level predictors of tooth loss and exposed bone after radiation therapy for head and neck cancer. J Am Dent Assoc 2023; 154:519-528.e4. [PMID: 37236706 PMCID: PMC10664022 DOI: 10.1016/j.adaj.2023.03.009] [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: 12/09/2022] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The objective of this study was to identify tooth-level risk factors for use during preradiation dental care management to predict risk of tooth failure (tooth lost or declared hopeless) and exposed bone after radiation therapy (RT) for head and neck cancer (HNC). METHODS The authors conducted a prospective observational multicenter cohort study of 572 patients receiving RT for HNC. Participants were examined by calibrated examiners before RT and then every 6 months until 2 years after RT. Analyses considered time to tooth failure and chance of exposed bone at a tooth location. RESULTS The following pre-RT characteristics predicted tooth failure within 2 years after RT: hopeless teeth not extracted pre-RT (hazard ratio [HR], 17.1; P < .0001), untreated caries (HR, 5.0; P < .0001), periodontal pocket 6 mm or greater (HR, 3.4; P = .001) or equaling 5 mm (HR, 2.2; P = .006), recession over 2 mm (HR, 2.8; P = .002), furcation score of 2 (HR, 3.3; P = .003), and any mobility (HR, 2.2; P = .008). The following pre-RT characteristics predicted occurrence of exposed bone at a tooth location: hopeless teeth not extracted before RT (risk ratio [RR], 18.7; P = .0002) and pocket depth 6 mm or greater (RR, 5.4; P = .003) or equaling 5 mm (RR, 4.7; P = .016). Participants with exposed bone at the site of a pre-RT dental extraction averaged 19.6 days between extraction and start of RT compared with 26.2 days for participants without exposed bone (P = .21). CONCLUSIONS Individual teeth with the risk factors identified in this study should be considered for extraction before RT for HNC, with adequate healing time before start of RT. PRACTICAL IMPLICATIONS The findings of this trial will facilitate evidence-based dental management of the care of patients receiving RT for HNC. This clinical trial was registered at Clinicaltrials.gov. The registration number is NCT02057510.
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Kalita F, Gupta DS, Gehlot N, Mitra S, Singh S, Pillai SS. Osteonecrosis of the Jaws: An Update and Review of Literature. J Maxillofac Oral Surg 2023; 22:344-351. [PMID: 37122785 PMCID: PMC10130280 DOI: 10.1007/s12663-023-01876-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/20/2023] [Indexed: 03/07/2023] Open
Abstract
Aim To provide a concise review on risk factors, stages, pathophysiology, prevention and possible treatment options for both MRONJ and ORN individually. Methods The review was conducted according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' (PRISMA) guidelines. A comprehensive search of the PUBMED, Ebsco, SCOPUS, WEB OF SCIENCE and NDH for articles published up until 2021 was performed. After screening and full text analyses, 44 studies were included in this review. Definition, risk factors, etiology, symptoms, stages, pathophysiology, prevention and possible management options were explored and highlighted in this article. Results Three studies described osteonecrosis of jaw (ONJ) in general, 15 studies described ONJ associated with radiotherapy and 26 studies described ONJ associated with medications. Both the two conditions (ORN) and (MRONJ) have relatively similar clinical presentations clearing the fact that a resemblance in clinical presentations does not necessarily denote a similar pathophysiology. Conclusion However, various advancements have been made in the control and management of ONJ, but until and unless need for high tumoricidal doses exists, ONJ will certainly continue to remain as a clinical challenge demanding satisfactory treatment to improve the quality of life of the patient.
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Affiliation(s)
- Flora Kalita
- Department of Oral and Maxillofacial Surgery, Teerthanker Mahaveer Dental College, and Research Centre, Teerthanker Mahaveer Universitry, Uttar Pradesh, Delhi Road, NH-24, Bagadpur, Moradabad, 244001 India
| | - Durga Shanker Gupta
- Department of Oral and Maxillofacial Surgery, Teerthanker Mahaveer Dental College, and Research Centre, Teerthanker Mahaveer Universitry, Uttar Pradesh, Delhi Road, NH-24, Bagadpur, Moradabad, 244001 India
| | - Neelima Gehlot
- Department of Oral and Maxillofacial Surgery, Teerthanker Mahaveer Dental College, and Research Centre, Teerthanker Mahaveer Universitry, Uttar Pradesh, Delhi Road, NH-24, Bagadpur, Moradabad, 244001 India
| | - Subhajit Mitra
- Department of Oral and Maxillofacial Surgery, Teerthanker Mahaveer Dental College, and Research Centre, Teerthanker Mahaveer Universitry, Uttar Pradesh, Delhi Road, NH-24, Bagadpur, Moradabad, 244001 India
| | - Snigdha Singh
- Department of Oral and Maxillofacial Surgery, Teerthanker Mahaveer Dental College, and Research Centre, Teerthanker Mahaveer Universitry, Uttar Pradesh, Delhi Road, NH-24, Bagadpur, Moradabad, 244001 India
| | - Sooraj S. Pillai
- Department of Oral and Maxillofacial Surgery, Teerthanker Mahaveer Dental College, and Research Centre, Teerthanker Mahaveer Universitry, Uttar Pradesh, Delhi Road, NH-24, Bagadpur, Moradabad, 244001 India
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Goh EZ, Beech N, Johnson NR, Batstone M. The dental management of patients irradiated for head and neck cancer. Br Dent J 2023; 234:800-804. [PMID: 37291302 PMCID: PMC10250190 DOI: 10.1038/s41415-023-5864-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/10/2023] [Accepted: 03/03/2023] [Indexed: 06/10/2023]
Abstract
Patients undergoing radiotherapy for head and neck cancers are prone to a range of dental complications, including mucositis, trismus, xerostomia, radiation caries and osteoradionecrosis. Specific considerations include the preventive, restorative and rehabilitative management of such patients, and the prevention and treatment of complications. This article aims to highlight the current understanding and management of dental needs for patients who have had or will undergo radiotherapy.
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Affiliation(s)
- Elizabeth Z Goh
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
| | - Nicholas Beech
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nigel R Johnson
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; School of Dentistry, University of Queensland, Brisbane, Queensland, Australia; Oral and Maxillofacial Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Martin Batstone
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Oral and Maxillofacial Department, Royal Brisbane and Women´s Hospital, Brisbane, Queensland, Australia
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30
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Tee R, Schweizer R, Gomez-Martinez-de-Lecea C, Vejbrink Kildal V, Thor A, Rodriguez-Lorenzo A. Early Second Free Flap is Required in Osteoradionecrosis-related Nonunion after Primary Mandible Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5024. [PMID: 37334393 PMCID: PMC10270492 DOI: 10.1097/gox.0000000000005024] [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: 01/01/2023] [Accepted: 03/21/2023] [Indexed: 06/20/2023]
Abstract
Osteoradionecrosis (ORN) manifested as symptomatic nonunion between primary free flap and native mandible after primary bony reconstruction of the mandible is an entity not included in current conventional ORN staging guidelines. This article reports on and proposes early management of this debilitating condition using a chimeric scapular tip free flap (STFF). Methods A retrospective review was performed examining cases with bony nonunion at the junction of primary free fibula flap (FFF) and native mandible at a single center over a 10-year duration, which required a second free bone flap. Details of each case (patient demographics, oncological details, primary surgery, presentation, and secondary surgery) were documented and analyzed. Outcomes of the treatment were assessed. Results Four patients (two men and two women; age range, 42-73 years) out of a total of 46 primary FFF were identified. All patients presented with symptoms of low-grade ORN and radiological signs of nonunion. All cases were reconstructed with chimeric STFF. The duration of follow-up ranged from 5 to 20 months. All patients reported resolution of symptoms and radiological evidence of union. Two of four patients subsequently received osseointegrated dental implants. Conclusions Institutional rate of nonunion after primary FFF requiring a second free bone flap is 8.7%. All the patients of this cohort presented with a similar clinical entity easily discounted as an infected nonunion postosseous flap reconstruction. There is no ORN grading system that currently guides the management of this cohort. Good outcomes are possible with early surgical intervention with a chimeric STFF.
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Affiliation(s)
- Richard Tee
- From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Riccardo Schweizer
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), University of Zurich, Zurich, Switzerland
| | | | - Villiam Vejbrink Kildal
- From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Andreas Thor
- From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Andres Rodriguez-Lorenzo
- From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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31
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Lu YJ, Chen CC, Chen SH, Lin CH, Lin YT, Lin CH, Hsu CC. Incidence and Risk Factors for Extremity Osteoradionecrosis after Limb-Sparing Surgery and Adjuvant Radiotherapy. Cancers (Basel) 2023; 15:cancers15082339. [PMID: 37190268 DOI: 10.3390/cancers15082339] [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: 03/05/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Osteoradionecrosis (ORN) is a major complication after radiotherapy. Most studies on ORN have focused on patients with mandibular lesions, with few studies including patients with extremity soft tissue sarcoma (STS). We included 198 patients with extremity STS who underwent limb-sparing surgery and adjuvant radiotherapy between 2004 and 2017. The incidence rate of extremity ORN was 3.5% (7/198), with most lesions (6/7) located in the lower extremities. The mean follow-up time was 62 months. Clinical presentations included chronic ulcers, soft tissue necrosis, sinus discharge, bone nonunion, and pathological fractures. Compared with the non-ORN group, the ORN group had a significantly higher total radiation dose (68 Gy vs. 64 Gy, p = 0.048) and greater use of intraoperative periosteal stripping (p = 0.008). Repeat surgeries and subsequent soft tissue reconstruction or limb amputation were performed as treatments. The risk and management of ORN in patients with extremity STS was ignored previously. Because the disease is complex and affects both clinicians and patients, careful surveillance should be undertaken.
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Affiliation(s)
- Yun-Jui Lu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chun-Chieh Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yu-Te Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
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Li Y, Liu H, Ding Y, Li W, Zhang Y, Luo S, Xiang Q. The Use of Hydrogel-Based Materials for Radioprotection. Gels 2023; 9:gels9040301. [PMID: 37102914 PMCID: PMC10137482 DOI: 10.3390/gels9040301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Major causes of the radiation-induced disease include nuclear accidents, war-related nuclear explosions, and clinical radiotherapy. While certain radioprotective drug or bioactive compounds have been utilized to protect against radiation-induced damage in preclinical and clinical settings, these strategies are hampered by poor efficacy and limited utilization. Hydrogel-based materials are effective carriers capable of enhancing the bioavailability of compounds loaded therein. As they exhibit tunable performance and excellent biocompatibility, hydrogels represent promising tools for the design of novel radioprotective therapeutic strategies. This review provides an overview of common approaches to radioprotective hydrogel preparation, followed by a discussion of the pathogenesis of radiation-induced disease and the current states of research focused on using hydrogels to protect against these diseases. These findings ultimately provide a foundation for discussions of the challenges and future prospects associated with the use of radioprotective hydrogels.
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Affiliation(s)
- Yang Li
- Center of Emergency, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
- Institute of Combined Injury, State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Chongqing 400038, China
| | - Han Liu
- Center of Emergency, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yaqun Ding
- Center of Emergency, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Wanyu Li
- Institute of Combined Injury, State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Chongqing 400038, China
| | - Yuansong Zhang
- Center of Emergency, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Shenglin Luo
- Institute of Combined Injury, State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Chongqing 400038, China
| | - Qiang Xiang
- Center of Emergency, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
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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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Wilde DC, Kansara S, Banner L, Morlen R, Hernandez D, Huang AT, Mai W, Fuller CD, Lai S, Sandulache VC. Early detection of mandible osteoradionecrosis risk in a high comorbidity veteran population. Am J Otolaryngol 2023; 44:103781. [PMID: 36640532 DOI: 10.1016/j.amjoto.2022.103781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Osteoradionecrosis (ORN) of the mandible is a devastating complication of external beam radiation therapy (EBRT) for head and neck squamous cell carcinoma (HNSCC). We sought to ascertain ORN risk in a Veteran HNSCC population treatment with definitive or adjuvant EBRT and followed prospectively. STUDY DESIGN Retrospective analysis of prospective cohort. SETTING Tertiary care Veterans Health Administration (VHA) medical center. METHODS Patients with HNSCC who initiated treatment at the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) are prospectively tracked for quality of care purposes through the end of the cancer surveillance period (5 years post treatment completion). We retrospectively analyzed this patient cohort and extracted clinical and pathologic data for 164 patients with SCC of the oral cavity, oropharynx, larynx, and hypopharynx who received definitive or adjuvant EBRT (2016-2020). RESULTS Most patients were dentate and 80 % underwent dental extractions prior to EBRT of which 16 (16 %) had complications. The rate of ORN was 3.7 % for oral cavity SCC patients and 8.1 % for oropharyngeal SCC patients. Median time to ORN development was 156 days and the earliest case was detected at 127 days post EBRT completion. All ORN patients were dentate and underwent extraction prior to EBRT start. CONCLUSION ORN development can occur early following EBRT in a Veteran population with significant comorbid conditions but overall rates are in line with the general population. Prospective tracking of HNSCC patients throughout the post-treatment surveillance period is critical to early detection of this devastating EBRT complication.
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Affiliation(s)
- David Chamberlayne Wilde
- Bobby R. Alford Department of Otolaryngology- Head and Neck Surgery, Baylor College of Medicine - 1977 Butler Blvd Suite E5.200, Houston, TX 77030, United States of America
| | - Sagar Kansara
- Bobby R. Alford Department of Otolaryngology- Head and Neck Surgery, Baylor College of Medicine - 1977 Butler Blvd Suite E5.200, Houston, TX 77030, United States of America
| | - Logan Banner
- Oral and Maxillofacial Section, Dental Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center - 2002 Holcombe Blvd, Houston, TX 77030, United States of America
| | - Rickey Morlen
- Oral and Maxillofacial Section, Dental Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center - 2002 Holcombe Blvd, Houston, TX 77030, United States of America
| | - David Hernandez
- Bobby R. Alford Department of Otolaryngology- Head and Neck Surgery, Baylor College of Medicine - 1977 Butler Blvd Suite E5.200, Houston, TX 77030, United States of America; ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center - 2002 Holcombe Blvd, Houston, TX 77030, United States of America
| | - Andrew Tsao Huang
- Bobby R. Alford Department of Otolaryngology- Head and Neck Surgery, Baylor College of Medicine - 1977 Butler Blvd Suite E5.200, Houston, TX 77030, United States of America; ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center - 2002 Holcombe Blvd, Houston, TX 77030, United States of America
| | - Weiyuan Mai
- Radiation Oncology Section, Radiology Care Line, Michael E. DeBakey Veterans Affairs Medical Center - 2002 Holcombe Blvd, Houston, TX 77030, United States of America
| | - Clifton David Fuller
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center - 1515 Holcombe Blvd, Houston, TX 77030, United States of America
| | - Stephen Lai
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center - 1515 Holcombe Blvd, Houston, TX 77030, United States of America
| | - Vlad Constantin Sandulache
- Bobby R. Alford Department of Otolaryngology- Head and Neck Surgery, Baylor College of Medicine - 1977 Butler Blvd Suite E5.200, Houston, TX 77030, United States of America; ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center - 2002 Holcombe Blvd, Houston, TX 77030, United States of America; Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey Veterans Affairs Medical Center - 2002 Holcombe Blvd, Houston, TX 77030, United States of America.
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Merits of the free periosteal femoral condyle flap in the management of advanced mandibular osteoradionecrosis. Int J Oral Maxillofac Surg 2023; 52:175-180. [PMID: 35717279 DOI: 10.1016/j.ijom.2022.05.006] [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: 01/15/2022] [Revised: 04/12/2022] [Accepted: 05/19/2022] [Indexed: 01/11/2023]
Abstract
The management of advanced mandibular osteoradionecrosis (ORN) is poorly codified and requires repeated time-consuming, morbid surgical procedures. The free periosteal medial femoral condyle flap could be used for the management of extensive mandibular ORN with fracture, to avoid non-conservative surgery such as mandibulectomy. The purpose of this study was to report the authors' experience using periosteal flaps for advanced ORN and to assess the therapeutic effectiveness of these flaps in this context. A series of 10 patients who underwent bone revascularization with a free periosteal femoral flap for the management of advanced ORN (Notani class III) is reported. The onset of bone consolidation, length of hospital stay, duration of surgery, donor site morbidity, and the option of dental rehabilitation in the event of a successful outcome were assessed. Osteogenesis was observed in 70% of cases. Thirty percent of patients benefited from dental implant rehabilitation. The mean follow-up was 73.1 months. No patient experienced any sequelae at the flap harvest site. In the authors' opinion, the free periosteal medial femoral condyle flap appears to offer a therapeutic solution for patients with advanced stages of ORN.
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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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Osteoradionecrosis of the Jaw-Comparison between Bone and Soft Tissue Injury and Their Influence on Surgical Outcomes-A Retrospective Cohort Study. Diagnostics (Basel) 2023; 13:diagnostics13030366. [PMID: 36766471 PMCID: PMC9914009 DOI: 10.3390/diagnostics13030366] [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: 11/29/2022] [Revised: 12/20/2022] [Accepted: 01/14/2023] [Indexed: 01/21/2023] Open
Abstract
Surgical therapy of osteoradionecrosis of the jaw (ORN) is challenging and requires treatment of the affected hard and soft tissue. To understand how tissue injury after irradiation influences surgical outcomes, the objective of this study was to find out whether (a) bone-related, (b) soft tissue-related, and (c) treatment-related parameters influence the surgical success of patients with ORN. A total of 175 patients (324 lesions) were included in this retrospective, single-center study. All patients were diagnosed with ORN and underwent surgical therapy. The primary outcome was complete soft tissue recovery (mucosa/skin) and the absence of symptoms 3 months after surgery. At the time of follow-up, 58% of patients (189 of 324 lesions) had intact intraoral or extraoral soft tissue. The extent of bone destruction had no effect on treatment success, whereas soft tissue injury due to fibrosis (OR: 0.344; CI 0.142-0.834; p = 0.01818) and xerostomia (OR: 0.163; CI 0.064-0.419; p = 0.00016) increased the probability of treatment failure. Soft tissue reconstruction with a microvascular graft improved therapeutic success compared to local wound closure (OR: 2.998; CI 1.371-6.555; p = 0.006). Thus, for the treatment of ORN, it is extremely important to pay attention not only to the extent of bone destruction but especially to soft tissue defects. Because the extent of soft tissue injury is a predictor for therapeutic success, it should influence the choice of surgical treatment.
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Osteonecrosis of the Jaw. Dent J (Basel) 2023; 11:dj11010023. [PMID: 36661560 PMCID: PMC9858620 DOI: 10.3390/dj11010023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
Osteonecrosis of the jaw is a condition in which bone cells die due to various causes. It is classified as drug-induced jaw osteonecrosis, osteoradionecrosis, traumatic, non-traumatic, and spontaneous osteonecrosis. Antiresorptive or antiangiogenic drugs cause drug-induced osteonecrosis. The combination of medications, microbial contamination, and local trauma induces this condition. Osteoradionecrosis is a severe radiation therapy side effect that can affect people with head and neck cancer. It is described as an exposed bone area that does not heal for longer than three months after the end of radiation treatment with the absence of any indications of an original tumor, recurrence, or metastasis. Trauma (tooth extraction), tumor site, radiation dose that the patient receives, the area of the bone which is irradiated, oral hygiene, and other factors are risk factors for the development of osteonecrosis. Less frequently, osteonecrosis can also be induced by non-traumatic and traumatic causes. Non-traumatic osteonecrosis is brought on by infections, acquired and congenital disorders, as well as the impact of chemicals. Traumatic osteonecrosis is brought on by thermal, mechanical, or chemical damage. The treatment of osteonecrosis can be conservative, which aims to be beneficial for the patient's quality of life, and surgical, which involves debridement of the necrotic bone.
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Zamora C, Castillo M, Puac-Polanco P, Torres C. Oncologic Emergencies in the Head and Neck. Radiol Clin North Am 2023; 61:71-90. [DOI: 10.1016/j.rcl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Danielsson D, Hagel E, Dybeck-Udd S, Sjöström M, Kjeller G, Bengtsson M, Abtahi J, von Beckerath M, Thor A, Halle M, Friesland S, Mercke C, Westermark A, Högmo A, Munck-Wikland E. Brachytherapy and osteoradionecrosis in patients with base of tongue cancer. Acta Otolaryngol 2023; 143:77-84. [PMID: 36595465 DOI: 10.1080/00016489.2022.2161627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Base of tongue cancer incidence and patient survival is increasing why treatment sequelae becomes exceedingly important. Osteoradionecrosis (ORN) is a late adverse effect of radiotherapy and brachytherapy (BT) could be a risk factor. Brachytherapy is used in three out of six health care regions in Sweden. AIMS Investigate if patients treated in regions using BT show an increased risk for ORN and whether brachytherapy has any impact on overall survival. MATERIAL AND METHODS We used data from the Swedish Head and Neck Cancer Register between 2008-2014. Due to the nonrandomized nature of the study and possible selection bias we compared the risk for ORN in brachy vs non-brachy regions. RESULTS Fifty out of 505 patients (9.9%) developed ORN; eight of these were treated in nonbrachy regions (16%), while 42 (84%) were treated in brachy regions. Neither age, sex, TNM-classification/stage, p16, smoking, neck dissection, or chemotherapy differed between ORN and no-ORN patients. The risk for ORN was significantly higher for patients treated in brachy regions compared to non-brachy regions (HR = 2,63, p = .012), whereas overall survival did not differ (HR = 0.95, p = .782). CONCLUSIONS AND SIGNIFICANCE Brachytherapy ought to be used cautiously for selected patients or within prospective randomized studies.
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Affiliation(s)
- Daniel Danielsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Eva Hagel
- Learning, Informatics, Management, and Ethics, Medical Statistics Unit, Karolinska Institutet, Stockholm, Sweden
| | - Sebastian Dybeck-Udd
- Department of Oral and Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Sjöström
- Department of Odontology, Umeå University, Sweden.,Oral and Maxillofacial Surgery, Umeå University Hospital, Umeå, Sweden
| | - Göran Kjeller
- Department of Oral and Maxillofacial Surgery, Institute of Odontology, The Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Martin Bengtsson
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Oral and Maxillofacial Surgery, Skåne University Hospital, Lund, Sweden
| | - Jahan Abtahi
- Department of Oral and Maxillofacial Surgery, Linköping University Hospital, Linköping, Sweden
| | - Mathias von Beckerath
- Department of Medical Sciences, Örebro University, Örebro, Sweden.,Medical Unit Head and Neck, Lung and Skin Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Thor
- Institute for Surgical Sciences, Oral and Maxillofacial Surgery, Uppsala University, Sweden
| | - Martin Halle
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Signe Friesland
- Medical Unit Head and Neck, Lung and Skin Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Claes Mercke
- Medical Unit Head and Neck, Lung and Skin Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Anders Högmo
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Eva Munck-Wikland
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Medical Unit Head and Neck, Lung and Skin Cancer, Karolinska University Hospital, Stockholm, Sweden
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Kanakaraj M, Chinnannan M, Nagarathinam AE, Rangarajan RV, Devadas AG, Jeyaraman M. Osseous Tissue Engineering in the Management of Mandibular Osteoradionecrosis - An Evaluative Study. Ann Maxillofac Surg 2023; 13:19-25. [PMID: 37711534 PMCID: PMC10499288 DOI: 10.4103/ams.ams_164_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 02/02/2023] [Accepted: 02/07/2023] [Indexed: 09/16/2023] Open
Abstract
Introduction Osteoradionecrosis (ORN), a non-infectious, necrotic condition of the bone, occurs as a major complication of radiotherapy to the irradiated site. Simple irrigation of the involved bone to partial or complete resection of the involved bones is being employed in its conventional management. Osseous tissue engineering (OTE) provides a new strategy by regenerating bone cells along with biocompatible scaffolds and micromolecules to produce an engineered osseous tissue. Materials and Methods In this study, mandibular ORN following radiation secondary to oropharyngeal squamous cell carcinoma was included. OTE with composite engineered tissue containing a mixture of autologous culture expanded dental pulp stem cells (DPSCs), autologous uncultured bone marrow aspiration concentrate (BMAC) and autologous platelet-rich plasma (PRP) loaded in β-tricalcium phosphate (β-TCP) or hydroxyapatite (HA) sponge scaffold was used in the mandibular defect and the surrounding tissues. An assessment of clinical, radiological and functional attributes was done. Results A total of six cases with a mean age of 58.6 years were included in the study. We noted significant improvement in the mean post-operative score for pain and mouth opening; functional improvement in eating solid/liquid food, tongue movement, speech and deglutition were observed. The aesthetics was measured with Vancouver score and revealed a significance at P < 0.05; also lip competency and occlusion were noted in all the patients. No major complications were noticed until a mean follow-up of 28 months. Discussion Tissue engineering with a regenerative cocktail of autologous culture expanded DPSCs, autologous uncultured BMAC and autologous PRP loaded in HA or β-TCP utilised in the surgical reconstruction of the mandible is an effective treatment modality in the management of mandibular ORN following irradiation.
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Affiliation(s)
- Manimaran Kanakaraj
- Department of Oral and Maxillofacial Surgery, KSR Institute of Dental Sciences and Research, Tiruchengode, India
| | - Marudhamani Chinnannan
- Department of Oral and Maxillofacial Surgery, KSR Institute of Dental Sciences and Research, Tiruchengode, India
| | | | | | | | - Madhan Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Chennai, Tamil Nadu, India
- Department of Biotechnology, School of Engineering and Technology, Sharda University, Greater Noida, Uttar Pradesh, India
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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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Kalsi H, McCaul LK, Rodriguez JM. The role of primary dental care practitioners in the long-term management of patients treated for head and neck cancer. Br Dent J 2022; 233:765-768. [DOI: 10.1038/s41415-022-5148-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/07/2022] [Indexed: 11/13/2022]
Abstract
AbstractPatients treated for head and neck cancer may be susceptible to a higher incidence of dental disease due to long-term sequelae of treatment for head and neck cancer. Most patients with head and neck cancer are discharged from a hospital environment and responsibility for long-term dental care is transferred back from the restorative dentistry team to the dentist and dental care professionals in primary care. Treatment of these patients should be undertaken in a supportive environment, taking into account the physical and psychological repercussions of previous treatment. With the exception of some surgical procedures, routine dental care is not contraindicated in patients after head and neck cancer treatment and it is expected that the dentist and dental care professionals will be responsible for long-term routine dental treatment. Primary dental care practitioners should be aware of the process to refer patients back to the head and neck cancer multidisciplinary team if they note a suspicious change during their routine clinical examinations. Referral to a restorative dentistry consultant for planning and carrying out complex items of care may sometimes be necessary, but patients should always remain under the long-term care of their primary dental care practitioner.
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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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Normando AGC, Pérez-de-Oliveira ME, Guerra ENS, Lopes MA, Rocha AC, Brandão TB, Prado-Ribeiro AC, Gueiros LAM, Epstein JB, Migliorati CA, Santos-Silva AR. To extract or not extract teeth prior to head and neck radiotherapy? A systematic review and meta-analysis. Support Care Cancer 2022; 30:8745-8759. [PMID: 35713725 DOI: 10.1007/s00520-022-07215-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/09/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Teeth with poor prognosis are generally recommended to be extracted prior to head and neck radiotherapy (RT) to reduce the risk of developing osteoradionecrosis (ORN), although controversies have been reported. The present systematic review aimed to determine whether tooth extraction prior to head and neck RT may be associated with a reduced risk of developing ORN compared to dental extraction during or after RT. METHODS The review protocol was registered in PROSPERO (CRD42021241631). The review was reported according to the PRISMA checklist and involved a comprehensive search of PubMed, Scopus, Embase, Cochrane Library, LILACS, and Web of Science, in addition to the gray literature. The selection of studies was performed in two phases by two reviewers independently. The risk of bias of individual studies was analyzed using the Joanna Briggs Institute checklist for cross-sectional studies, and the certainty of evidence was assessed using the GRADE tool. RESULTS Twenty-eight observational studies were included in the qualitative synthesis, which showed substantial heterogeneity regarding the association between the timing of tooth extraction and ORN development. Twenty-seven of 28 studies were pooled in a meta-analysis that demonstrated a significant association between an increased risk of ORN and post-RT tooth extraction (odds ratio: 1.98; 95% CI: 1.17-3.35; p = 0.01). CONCLUSION It was confirmed with moderate certainty that dental extractions should be performed prior to the start of head and neck RT to reduce the risk of ORN.
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Affiliation(s)
- Ana Gabriela Costa Normando
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, SP, Brazil
| | | | - Eliete Neves Silva Guerra
- Laboratory of Oral Histopathology, Health Sciences Faculty, University of Brasilia, Brasilia, DF, Brazil
| | - Márcio Ajudarte Lopes
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, SP, Brazil
| | - André Caroli Rocha
- Oral Medicine Department, AC Camargo Cancer Center, São Paulo, SP, Brazil.,Clinics Hospital of the Medical School of the University of São Paulo, São Paulo, Brazil
| | - Thaís Bianca Brandão
- Dental Oncology Service, Instituto Do Câncer Do Estado de São Paulo (ICESP-FMUSP), São Paulo, Brazil
| | - Ana Carolina Prado-Ribeiro
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, SP, Brazil.,Dental Oncology Service, Instituto Do Câncer Do Estado de São Paulo (ICESP-FMUSP), São Paulo, Brazil
| | - Luiz Alcino Monteiro Gueiros
- Departamento de Clínica E Odontologia Preventiva, Oral Medicine Unit, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Joel B Epstein
- Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, USA.,City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | | | - Alan Roger Santos-Silva
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, SP, Brazil.
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Vorakulpipat P, Suphangul S, Fuangtharnthip P, Ghanaati S, Vorakulpipat C. Combination of Advanced Platelet-Rich Fibrin and Pentoxifylline/Tocopherol as a Novel Preventive Option in Osteoradionecrosis: A Case Report. Eur J Dent 2022; 17:250-254. [PMID: 36195210 PMCID: PMC9949969 DOI: 10.1055/s-0042-1750777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Osteoradionecrosis (ORN) of the jaws is an uncommon complication of radiation therapy that seriously affects the oral and maxillofacial region. Management of ORN is intrinsically difficult and treatment effects are unpredictable. ORN can be treated with pentoxifylline/tocopherol and autologous platelet concentrates to promote wound healing. Furthermore, the low speed of relative centrifugal forces platelet-rich fibrin (PRF + ) has been shown high efficacy for ORN. A 72-year-old male patient with history of radiation treatment for squamous cell carcinoma in the left side of the tongue. Six years after the treatment, his upper right first molar tooth (no. 16) was surgically extracted due to persistent pain. A few months following the extraction, intraoral examination showed gingival inflammation, and pain when palpation around the edentulous area of tooth no. 16. Radiological examination revealed retained root of 16 with radiolucent area and horizontal bone loss around upper right second molar tooth (no. 17). Pentoxifylline and tocopherol were given for a week before the surgical operation and were continued for 8 weeks after the operation. Retained roots of teeth no. 16 and 17 were removed and the sockets were debrided, the advanced PRF+ (A-PRF + ) membranes were placed followed by primary wound closure. Following 2 weeks of treatment, the mucosa healed and progressed to complete mucosal coverage at 2 months with no pathological findings or ORN progression. At 6-month follow-up, clinical and cone-beam computed tomography (CBCT) revealed no pathology. Our case demonstrates that the combination of pentoxifylline/tocopherol and the A-PRF+ surgical approach can be useful for wound healing and prevention of ORN.
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Affiliation(s)
- Pasinee Vorakulpipat
- Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand,FORM-Lab, Frankfurt Orofacial Regenerative Medicine, Department for Oral, Cranio-Maxillofacial and Facial Plastic Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Suphachai Suphangul
- Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Pornpoj Fuangtharnthip
- Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Shahram Ghanaati
- Department for Oral, Cranio-Maxillofacial and Facial Plastic Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany,FORM-Lab, Frankfurt Orofacial Regenerative Medicine, Department for Oral, Cranio-Maxillofacial and Facial Plastic Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Chakorn Vorakulpipat
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok, Thailand,FORM-Lab, Frankfurt Orofacial Regenerative Medicine, Department for Oral, Cranio-Maxillofacial and Facial Plastic Surgery, Johann Wolfgang Goethe University, Frankfurt, Germany,Address for correspondence Chakorn Vorakulpipat, DDS, MD, Dr Med Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol UniversityNo. 6 Yothi Road, Ratchathewi District, Bangkok 10400Thailand
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Urquhart O, DeLong HR, Ziegler KM, Pilcher L, Pahlke S, Tampi MP, O'Brien KK, Patton LL, Agrawal N, Hofstede TM, Kademani D, Lingen MW, Treister NS, Tsai CJ, Carrasco-Labra A, Lipman RD. Effect of preradiation dental intervention on incidence of osteoradionecrosis in patients with head and neck cancer: A systematic review and meta-analysis. J Am Dent Assoc 2022; 153:931-942.e32. [PMID: 35985883 DOI: 10.1016/j.adaj.2022.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/23/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this systematic review was to examine whether dental intervention involving bone or soft-tissue manipulation preradiotherapy (pre-RT) is associated with lower rates of osteoradionecrosis of the jaw (ORNJ) in patients with head and neck cancer (HNC). TYPES OF STUDIES REVIEWED The authors included relevant studies from MEDLINE, Embase, and Cochrane Library, including observational studies published from 2007 through 2021 and involving adults who underwent dental intervention pre-RT for HNC. Authors assessed evidence certainty by using the Grading of Recommendations Assessment, Development, and Evaluation approach. Random-effects models were used to calculate pooled relative risk estimates and hazard ratios. When meta-analysis was not possible, study-level measures of association and narrative summaries of the evidence were reported. RESULTS Twenty-two studies were included. From the pooled, unadjusted analysis, patients undergoing pre-RT extractions may have a 55% increased risk of experiencing ORNJ (relative risk, 1.55; 95% CI, 0.85 to 2.86; very low certainty); the unadjusted pooled hazard ratio was 3.19 (95% CI, 0.99 to 10.31; very low certainty), corresponding to a possible increased hazard of developing ORNJ (very low certainty). Findings for other pre-RT procedures manipulating bone or tissue relied on limited, observational studies with low or very low certainty evidence. CONCLUSIONS Mostly very low certainty evidence suggests that patients with HNC who need pre-RT dental intervention may have an increased risk of developing ORNJ compared with those who do not. PRACTICAL IMPLICATIONS Maintaining optimal oral health may help reduce the need for urgent pre-RT dental treatment, potentially reducing ORNJ risk and minimizing delay of oncologic treatment in patients with HNC.
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48
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Raj R, Nair AH, Krishnan NA, Balasubramanian D, Iyer S, Thankappan K. Advances and Controversies in the Management of Osteoradionecrosis After Head and Neck Cancer Treatment: A Narrative Review. J Maxillofac Oral Surg 2022; 21:836-844. [PMID: 36274865 PMCID: PMC9475005 DOI: 10.1007/s12663-021-01680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 12/08/2021] [Indexed: 01/09/2023] Open
Abstract
Osteoradionecrosis (ORN) is a painful and debilitating serious late complication following treatment for head and neck cancer (HNC) often requiring surgical resection of the jaw and complex multidisciplinary management. An important aggravating factor for mandibular ORN is surgical trauma, commonly dental extractions or implant placement following head and neck radiotherapy. The evidence on the treatment protocols ranges from conservative management to more radical surgical strategies including the use of hyperbaric oxygen therapy. The available evidence on the preventive approaches for ORN includes prophylactic dental care prior to radiotherapy, the use of hyperbaric oxygen (HBO) treatment and prophylactic antibiotics for post-radiotherapy extractions. However, the efficacy of hyperbaric oxygen therapy has been questioned recently signifying poor understanding of the pathophysiology of the condition and therapies targeting the fibroatrophic process have become a focus of ORN treatment. Implementing recent IMRT radiation techniques has also shown evidence to reduce the incidence of ORN. This review provides an insight into the variations in definition and classification of the ORN, the controversies in its pathophysiology and the advances in the prevention and management.
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Affiliation(s)
- Radhu Raj
- Department of Prosthodontics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Aarya Haridasan Nair
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
| | - Nitin Anand Krishnan
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
| | - Deepak Balasubramanian
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
| | - Subramania Iyer
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
| | - Krishnakumar Thankappan
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041 Kerala India
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Gaio-Lima C, Castedo J, Cruz M, Candeias M, Camacho Ó. The role of hyperbaric oxygen therapy in the treatment of radiation lesions. CLINICAL & TRANSLATIONAL ONCOLOGY : OFFICIAL PUBLICATION OF THE FEDERATION OF SPANISH ONCOLOGY SOCIETIES AND OF THE NATIONAL CANCER INSTITUTE OF MEXICO 2022; 24:2466-2474. [PMID: 35976581 DOI: 10.1007/s12094-022-02892-x] [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: 04/04/2022] [Accepted: 07/14/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Cancer remains one of the leading causes of death worldwide, with 50-60% of patients requiring radiotherapy during the course of treatment. Patients' survival rate has increased significantly, with an inevitable increase in the number of patients experiencing side effects from cancer therapy. One such effect is late radiation injuries in which hyperbaric oxygen therapy appears as complementary treatment. With this work we intend to divulge the results of applying hyperbaric oxygen therapy among patients presenting radiation lesions in our Hyperbaric Medicine Unit. MATERIALS AND METHODS Retrospective analysis of clinical records of patients with radiation lesions treated at the Hyperbaric Medicine Unit assessed by the scale Late Effects of Normal Tissues-Subjective, Objective, Management, Analytical (LENT-SOMA) before and after treatment, between October 2014 and September 2019 were included. Demographic characteristics, primary tumor site, subjective assessment of the LENT-SOMA scale before and after treatment were collected and a comparative analysis (Students t test) was done. RESULTS 88 patients included: 33 with radiation cystitis, 20 with radiation proctitis, 13 with osteoradionecrosis of the mandible and 22 with radiation enteritis. In all groups, there was a significant decrease (p < 0.005) in the subjective parameter of the LENT-SOMA scale. DISCUSSION Late radiation lesions have a major influence on patients' quality of life. In our study hyperbaric oxygen therapy presents as an effective therapy after the failure of conventional treatments. CONCLUSION Hyperbaric oxygen therapy is an effective complementary therapy in the treatment of refractory radiation lesions.
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Affiliation(s)
- Clara Gaio-Lima
- Serviço de Anestesiologia, ULSM (Unidade Local de Saúde de Matosinhos), Matosinhos, Portugal.
- ULSM (Unidade Local de Saúde de Matosinhos), Unidade de Medicina Hiperbárica, Matosinhos, Portugal.
| | - João Castedo
- Serviço de Anestesiologia, ULSM (Unidade Local de Saúde de Matosinhos), Matosinhos, Portugal
| | - Mafalda Cruz
- Serviço de Radioterapia, IPO Porto (Instituto Português de Oncologia do Porto Francisco Gentil), Porto, Portugal
| | | | - Óscar Camacho
- Serviço de Anestesiologia, ULSM (Unidade Local de Saúde de Matosinhos), Matosinhos, Portugal
- ULSM (Unidade Local de Saúde de Matosinhos), Unidade de Medicina Hiperbárica, Matosinhos, Portugal
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50
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Mohta V, Chaubey P, Iqbal MA, Singh K, Wagh A, Sapre S. Leuconostoc, a masquerading pathogen in oral cancer patient: A rare case report. Indian J Med Microbiol 2022; 40:599-601. [PMID: 35970626 DOI: 10.1016/j.ijmmb.2022.07.011] [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: 02/26/2022] [Revised: 07/11/2022] [Accepted: 07/17/2022] [Indexed: 11/27/2022]
Abstract
Osteoradionecrosis is the most common cause of mandibular osteomyelitis. Here we are reporting a case of osteomyelitis of the mandible caused by Leuconostoc mesenteroides spp cremoris. The frequency of Leuconostoc infections are under reported mainly due to its difficult identification. Non pathogenic organism like leuconostoc can cause infection in the immunocompromised and should warrant proper microbial identification and adequate targeted treatment to manage the patients.
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Affiliation(s)
- Vandana Mohta
- Dept of Head Neck Oncology, Rastrasant Tukdoji Cancer Hospital and Research Centre, India.
| | - Priyanka Chaubey
- Dept of Microbiology, Rastrasant Tukdoji Cancer Hospital and Research Centre, India.
| | - Mohd Athar Iqbal
- Dept of Oral Maxillofacial Surgery, Rastrasant Tukdoji Cancer Hospital and Research Centre, India.
| | - Kartar Singh
- Dept of Radiotherapy, Rastrasant Tukdoji Cancer Hospital and Research Centre, India.
| | - Aniruddha Wagh
- Dept of Head Neck Oncology, Rastrasant Tukdoji Cancer Hospital and Research Centre, India.
| | - Satsheel Sapre
- Dept of Head Neck Oncology, Rastrasant Tukdoji Cancer Hospital and Research Centre, India.
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