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Kato T, Mizumoto C, Inoue F, Watanabe T, Yamanaka S, Fukuhara S, Nakao K. Methotrexate‑related other iatrogenic immunodeficiency‑associated lymphoproliferative disorder in the CNS and medication‑related osteonecrosis of the jaw occurring simultaneously: A case report. Exp Ther Med 2024; 27:41. [PMID: 38125353 PMCID: PMC10731409 DOI: 10.3892/etm.2023.12329] [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: 05/18/2023] [Accepted: 10/11/2023] [Indexed: 12/23/2023] Open
Abstract
Methotrexate-related other iatrogenic immunodeficiency-associated lymphoproliferative disorder (MTX-OIIA-LPD) is prone to extranodal involvement but rarely involves the central nervous system (CNS). The present study reports a case of MTX-OIIA-LPD of the CNS discovered during medication-related osteonecrosis of the jaw (MRONJ) treatment in a 76-year-old woman with rheumatoid arthritis (RA). The chief complaint of the patient was bone exposure and pain in the right mandibular molar. The patient had been receiving MTX for RA and alendronate sodium hydrate for osteoporosis, followed by denosumab. Treatment was initiated based on a diagnosis of MRONJ. However, the patient experienced lightheadedness and floating dizziness afterwards. Examinations revealed scattered neoplastic lesions in the brain. The histopathological diagnosis was diffuse large B-cell lymphoma. A systemic search also revealed adrenal involvement. Since the patient was taking MTX, a diagnosis of MTX-OIIA-LPD was made and MTX was discontinued. Chemotherapeutic agents were administered since the central lesions became symptomatic. The MTX-OIIA-LPD lesions in the brain and adrenal glands completely resolved 8 months after onset. The physical condition of the patient improved, and the bone-exposed areas became epithelialized. Reports on MTX-LPD in the oral and maxillofacial region are few, which may delay its diagnosis. Therefore, biopsy of oral lesions in patients with MRONJ who are taking MTX and collaboration with related diagnostic departments, such as rheumatology and hematology, must be done to initiate the diagnosis and treatment of extraoral MTX-LPD.
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Affiliation(s)
- Tomoki Kato
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Fuminori Inoue
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Takuma Watanabe
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shigeki Yamanaka
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shizuko Fukuhara
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Kazumasa Nakao
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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Aragão Matos Carlos AC, Moreira Caetano Coelho L, Nóbrega Malta CE, Aragão Magalhães I, Fontes Borges MM, da Silva Júnior JE, Gonzaga Silva LF, de Barros Silva PG. Risk Factors for Bisphosphonate-Related Osteonecrosis of the Jaws in Bone Metastatic Breast and Prostate Cancer under Zoledronate Treatment: A Retrospective Analysis from 10 Years of Evaluation. Asian Pac J Cancer Prev 2023; 24:2681-2689. [PMID: 37642054 PMCID: PMC10685221 DOI: 10.31557/apjcp.2023.24.8.2681] [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: 03/12/2023] [Accepted: 08/09/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE This study aims to analyze the risk factors for BRONJ in patients taking zoledronic acid (ZA) for metastatic breast and prostate cancer. METHODS For this, a retrospective, quantitative, observational cohort study was conducted using data on adverse effects in the oral cavity in patients during chemotherapy for treatment of solid tumors available in the electronic patient record system of the Haroldo Juaçaba Hospital/Ceará Cancer Institute in the period from 2010, to 2019. Data were tabulated in Excel and exported to SPSS v20.0 software for statistical analysis, with 95% confidence. RESULTS Thus, it can be observed that the prevalence of BRONJ in patients under treatment for breast cancer and prostate cancer was <7%, with age <50 years of age (p=0.009), cytotoxic chemotherapy such as methotrexate (p=0.023), paclitaxel (p=0.005), capecitabine (p<0.001), gemcitabine (p=0.007) and bicalutamide (p=0.016), amount of ZA infusions (p<0.001) and hormone therapy (p=0.007), in addition, a slight reduction in survival and increased use of antidepressants (p=0.014) were observed. The reduced overall survival and increased use of antidepressants in patients who developed BRONJ, reinforcing the need for further research to study the mechanisms involved in the unconventional risk factors for BRONJ. CONCLUSION Thus, increasing the attention to these patients to prevent this condition from compromising the prognosis of these individuals.
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Affiliation(s)
- Anna Clara Aragão Matos Carlos
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceará, Fortaleza, Ceará, Brazil.
| | - Lívia Moreira Caetano Coelho
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceará, Fortaleza, Ceará, Brazil.
| | - Cássia Emanuella Nóbrega Malta
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceará, Fortaleza, Ceará, Brazil.
- Department of Dentistry, Unichristus, Fortaleza, Ceará, Brazil.
| | | | - Marcela Maria Fontes Borges
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceará, Fortaleza, Ceará, Brazil.
| | | | | | - Paulo Goberlânio de Barros Silva
- Department of Dental Clinic, Division of Oral Pathology, Faculty of Pharmacy, Dentistry and Nursing, Federal University of Ceará, Fortaleza, Ceará, Brazil.
- Department of Dentistry, Unichristus, Fortaleza, Ceará, Brazil.
- Ceará Oncology School, Ceará Cancer Institute, Hospital Haroldo Juaçaba, Fortaleza, Ceará, Brazil.
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Kuribayashi A, Kawashima S, Kayamori K, Sakamoto J, Tomisato H, Watanabe H, Kurabayashi T. Magnetic resonance imaging of methotrexate-related lymphoproliferative disorder with a chief complaint of oral symptoms. Oral Radiol 2023; 39:235-241. [PMID: 35689759 DOI: 10.1007/s11282-022-00626-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/10/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the magnetic resonance imaging (MRI) features of methotrexate-related lymphoproliferative disorder (MTX-LPD) in the oral cavity of a patient with a chief complaint of oral symptoms. METHODS We included six patients who visited our hospital between November 2014 and November 2019, histopathologically diagnosed with MTX-LPD. All images were examined using 3 T MRI and reviewed by two radiologists. RESULTS Masses were detected in five cases; all masses demonstrated signal hypointensity and homogeneous signal hyperintensity on T1- and T2-weighted images with fat suppression. Homogeneous enhancement with fat suppression was evident on post-contrast T1-weighted imaging. We performed dynamic contrast-enhanced MRI in three cases and observed early enhancement with a low washout ratio pattern in all cases. Four patients underwent diffusion-weighted MRI and revealed low mean apparent diffusion coefficient (ADC) of 0.57 (range 0.5-0.65) × 10-3 mm2/s. CONCLUSIONS We reported on the imaging characteristics of six rare cases of MTX-LPD in the oral cavity. Homogeneous hyperintensity on fat-suppressed T2-weighted images and low ADC values are possible features of MTX-LPD. Moreover, MTX-LPD can be differentiated from other carcinomas in the oral cavity.
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Affiliation(s)
- Ami Kuribayashi
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Sakurako Kawashima
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Kou Kayamori
- Department of Oral Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junichiro Sakamoto
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hiroshi Tomisato
- Department of Oral Radiology, Dental Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroshi Watanabe
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tohru Kurabayashi
- Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Flores-Hidalgo A, Thompson S, Paquette D. Long-standing ulcer in mandibular gingiva in a patient with polymyalgia rheumatica. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 135:169-174. [PMID: 36229368 DOI: 10.1016/j.oooo.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Andres Flores-Hidalgo
- Division of Oral and Maxillofacial Pathology, East Carolina University, Greenville, NC, USA; Department of Surgical Sciences, East Carolina University School of Dental Medicine, Greenville, NC, USA.
| | - Stevan Thompson
- Division of Oral and Maxillofacial Surgery, East Carolina University, Greenville, NC, USA; Department of Surgical Sciences, East Carolina University School of Dental Medicine, Greenville, NC, USA
| | - David Paquette
- Department of Surgical Sciences, East Carolina University School of Dental Medicine, Greenville, NC, USA
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Hussein H, Jogai S, Singh RP. Epstein-Barr virus associated mucocutaneous ulcer of the gingiva. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2023. [DOI: 10.1016/j.adoms.2023.100402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
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Milosavljević M, Jovanović M, Folić M, Živić M, Zdravković D, Veličković S, Janković S. Possible association of methotrexate use with osteonecrosis of the jaw: Systematic review. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e458-e463. [PMID: 35306206 DOI: 10.1016/j.jormas.2022.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/10/2022] [Accepted: 03/13/2022] [Indexed: 06/14/2023]
Abstract
The aim was to search systematically, evaluate, and then summarize scientific literature about possible methotrexate-associated osteonecrosis of the jaw (ONJ), its signs and symptoms, diagnosis, treatment, and prognosis in adults. After registration at PROSPERO this systematic review was conducted and reported according to the PRISMA checklist. The following databases were systematically searched: MEDLINE, EBSCO, The Cochrane Central Register of Controlled Trials (Central), SCIndex, Scopus, Google Scholar and Registry of clinical studies with human participants. In total 9 studies with 14 patients were included in the review. All cases of ONJ associated with methotrexate were described in patients suffering from Rheumatoid arthritis (RA), and only about 40% of them were taking other concomitant medication described to be associated with ONJ (bisphosphonates). Both sexes were equally affected, and the patients were rather old (over 60 years if age), already taking methotrexate for more than 12 years on average. Antibiotics were ineffective in the treatment of ONJ; after stopping methotrexate, all lesions healed after several months on average; however, half of the cases required covering of the exposed bone with mucosal flap. Recurrence of the methotrexate-associated ONJ was not observed for at least two years after the lesions were healed. Methotrexate-associated ONJ is serious clinical condition that may occur in patients with RA, but given the small number of cases we have found in the literature, direct involvement of methotrexate in the development of ONJ remains elusive.
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Affiliation(s)
- Marko Milosavljević
- University of Kragujevac, Faculty of Medical Sciences, Department of Dentistry, Serbia
| | - Milica Jovanović
- University of Kragujevac, Faculty of Medical Sciences, Department of Dentistry, Serbia.
| | - Marko Folić
- University of Kragujevac, Faculty of Medical Sciences, Department of Pharmacy, Serbia
| | - Miloš Živić
- University of Kragujevac, Faculty of Medical Sciences, Department of Dentistry, Serbia
| | - Dejan Zdravković
- University of Kragujevac, Faculty of Medical Sciences, Department of Dentistry, Serbia
| | - Stefan Veličković
- University of Kragujevac, Faculty of Medical Sciences, Department of Dentistry, Serbia
| | - Slobodan Janković
- University of Kragujevac, Faculty of Medical Sciences, Department of Pharmacy, Serbia
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Yassin Alsabbagh A, Higgs N, Moutasim K, Foria V, Webb R. Epstein - Barr virus positive Mucocutaenous ulcer presenting as medication related osteonecrosis of the jaw. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2021. [DOI: 10.1016/j.adoms.2021.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kawaharada M, Maruyama S, Abé T, Yamazaki M, Kurokawa A, Katagiri W, Takagi R, Hayashi T, Kobayashi T, Tanuma JI. Other iatrogenic immunodeficiency-associated lymphoproliferative disorders in the oral cavity: a clinicopathologic study of 4 cases and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:687-697. [PMID: 34511340 DOI: 10.1016/j.oooo.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/16/2021] [Accepted: 05/30/2021] [Indexed: 12/09/2022]
Abstract
OBJECTIVES Other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OI-LPD) have been reported as one of the adverse effects of immunosuppressive therapy. The aim of this study was to describe the clinicopathologic and immunohistochemical features of OI-LPD in the oral cavity. STUDY DESIGN Immunohistochemistry was performed to describe the immunohistochemical features in our 4 cases. The results were analyzed along with 62 cases of oral OI-LPD in the English and Japanese literature to define clinical and pathologic characteristic features. RESULTS In our immunohistochemical analysis, Epstein-Barr virus (EBV)-positive OI-LPD showed a higher percentage of mouse double minute 2-positive cells than EBV-negative samples. A literature survey revealed that OI-LPD (including the present cases) arises primarily in the gingiva, followed by the tongue, and usually occurs with a male-to-female ratio of 1:1.9. The rate of EBV positivity was 93.8%. Further, 31 of 66 patients had osteonecrosis of the jaw and 24 of 31 patients had taken multiple immunosuppressive drugs in combination. CONCLUSIONS We can therefore conclude that the overexpression of mouse double minute 2 in OI-LPD is associated with EBV infection, and the combination of multiple immunosuppressive drugs may be a risk factor for osteonecrosis of the jaw.
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Affiliation(s)
- Masami Kawaharada
- Division of Reconstructive Surgery for Oral and Maxillofacial Region, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan; Division of Oral Pathology, Faculty of Dentistry & Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Satoshi Maruyama
- Oral Pathology Section, Department of Surgical Pathology, Niigata University Hospital, Niigata, Japan
| | - Tatsuya Abé
- Division of Oral Pathology, Faculty of Dentistry & Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Manabu Yamazaki
- Division of Oral Pathology, Faculty of Dentistry & Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan
| | - Akira Kurokawa
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Wataru Katagiri
- Division of Reconstructive Surgery for Oral and Maxillofacial Region, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Ritsuo Takagi
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Takafumi Hayashi
- Division of Oral and Maxillofacial Radiology, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Tadaharu Kobayashi
- Division of Reconstructive Surgery for Oral and Maxillofacial Region, Faculty of Dentistry & Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Jun-Ichi Tanuma
- Division of Oral Pathology, Faculty of Dentistry & Graduate School of Medical and Dental Science, Niigata University, Niigata, Japan.
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Sacco R, Woolley J, Yates J, Calasans-Maia MD, Akintola O, Patel V. The role of antiresorptive drugs and medication-related osteonecrosis of the jaw in nononcologic immunosuppressed patients: A systematic review. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2021; 26:23. [PMID: 34221052 PMCID: PMC8240545 DOI: 10.4103/jrms.jrms_794_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/05/2020] [Accepted: 01/28/2021] [Indexed: 10/26/2022]
Abstract
Medication related osteonecrosis of the jaw (MRONJ) is a severe condition affecting the jaws of patients exposed to specific drugs, and is primarily described in patients receiving bisphosphonate (BP) therapy. However, more recently it has been observed in patients taking other medications, such as the RANK ligand inhibitor (denosumab) and antiangiogenic drugs. It has been proposed that the existence of other concomitant medical conditions may increase the incidence of MRONJ. The primary aim of this research was to analyze all available evidence and evaluate the reported outcomes of osteonecrosis of the jaws (ONJ) due to antiresorptive drugs in immunosuppressed patients. A multi-database (PubMed, MEDLINE, EMBASE and CINAHL) systematic search was performed. The search generated twenty-seven studies eligible for the analysis. The total number of patients included in the analysis was two hundred and six. All patients were deemed to have some form of immunosuppression, with some patients having more than one disorder contributing to their immunosuppression. Within this cohort the commonest trigger for MRONJ was a dental extraction (n=197). MRONJ complications and recurrence after treatment was sparsely reported in the literature, however a total of fourteen cases were observed. The data reviewed have confirmed that an invasive procedure is the commonest trigger of MRONJ with relatively high frequency of post-operative complications or recurrence following management. However, due to low-quality research available in the literature it is difficult to draw a definitive conclusion on the outcomes analysed in this systematic review.
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Affiliation(s)
- Roberto Sacco
- The University of Manchester, Division of Dentistry, School of Medical Sciences, Oral Surgery Department, Manchester, UK
| | - Julian Woolley
- King's College Dental Hospital, Oral Surgery Department, London, UK
| | - Julian Yates
- The University of Manchester, Division of Dentistry, School of Medical Sciences, Oral Surgery Department, Manchester, UK
| | | | - Oladapo Akintola
- King's College Dental Hospital, Oral Surgery Department, London, UK
| | - Vinod Patel
- Guy's Dental Hospital, Oral Surgery Department, London, UK
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Ramos-Baena JD, Jacinto-Alemán LF, Leyva-Huerta ER, Portilla-Robertson J. Epstein-Barr virus-positive ulcer in the oral cavity. J Oral Maxillofac Pathol 2021; 25:S46-S50. [PMID: 34083970 PMCID: PMC8123244 DOI: 10.4103/jomfp.jomfp_26_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 08/05/2019] [Accepted: 09/28/2020] [Indexed: 11/13/2022] Open
Abstract
Epstein–Barr virus-positive ulcer (EBV + U) is a recently reported B cell lymphoproliferative disorder in the oral cavity, oropharynx, gastrointestinal tract and skin, principally in immunosuppressed patients. A 53-year-old female patient with rheumatoid arthritis treated with methotrexate, presenting ulcers of unknown duration on the dorsum and the lateral left border of the tongue. Excisional biopsy, histopathological analysis and histochemical stains for syphilis (Warthin–Starry), mycotic diseases (Grocott silver methenamine), tuberculosis (Ziehl–Neelsen), immunohistochemistry tests for herpesvirus type 8 (CMV), EBV (LMP-1) and DNA extraction for polymerase chain reaction (PCR) assay to CMV, EBV and herpes simplex virus-1 were performed. Posterior to PCR assay, the final diagnosis was EBV + U in the oral cavity. Acyclovir® was prescribed, showing clinical improvement. A case of EBV + U with clinical characteristics similar to other lesions or conditions has been reported. Special assays are necessary for an accurate diagnosis and treatment.
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Affiliation(s)
- Jose David Ramos-Baena
- Oral and Maxilloficial Pathology Area, ENES-Leon, National Autonomous University of Mexico, Mexico City, Mexico
| | - Luis Fernando Jacinto-Alemán
- Department of Oral Medicine and Pathology, Postgraduate Division, Dental School, National Autonomous University of Mexico, Mexico City, Mexico
| | - Elba Rosa Leyva-Huerta
- Department of Oral Medicine and Pathology, Postgraduate Division, Dental School, National Autonomous University of Mexico, Mexico City, Mexico
| | - Javier Portilla-Robertson
- Department of Oral Medicine and Pathology, Postgraduate Division, Dental School, National Autonomous University of Mexico, Mexico City, Mexico
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Sandhu S, Sankar V. Osteonecrosis of the jaw secondary to haematopoietic stem cell transplantation. BMJ Case Rep 2021; 14:14/3/e241298. [PMID: 33664042 PMCID: PMC7934760 DOI: 10.1136/bcr-2020-241298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Osteonecrosis of the jaw (ONJ) is necrosis of mandibular or maxillary bone, which sometimes leads to bone exposure and sequestration. There is evidence that the microenvironment of the marrow stromal system is severely and irreversibly damaged after haematopoietic stem cell transplantation (HSCT) leading to a deficit in the quantity and quality of osteoblastic progenitors, compromising the ability to regenerate a normal osteogenic cell population and abnormality in bone remodelling/turnover. While osteonecrosis of the appendicular skeleton is a common complication after HSCT, there have been no reports of an association with ONJ. This is a report of the first case of ONJ secondary to HSCT in a 69-year-old woman who developed a unique pattern of osteonecrosis involving all four quadrants of the jaw 2 months after allogeneic stem cell transplantation.
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Affiliation(s)
- Shaiba Sandhu
- Department of Oral Medicine, Harvard School of Dental Medicine, Boston, Massachusetts, USA .,Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Vidya Sankar
- Tufts University School of Dental Medicine, Boston, Massachusetts, USA
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Teoh L, Moses G, Nguyen AP, McCullough MJ. Medication-related osteonecrosis of the jaw: Analysing the range of implicated drugs from the Australian database of adverse event notifications. Br J Clin Pharmacol 2020; 87:2767-2776. [PMID: 33245790 DOI: 10.1111/bcp.14681] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 01/14/2023] Open
Abstract
AIMS Medication-related osteonecrosis of the jaw (MRONJ) is an uncommon but potentially debilitating condition, characterised by nonhealing jawbone, with or without mucosal exposure, in the presence of certain drugs. Those already strongly associated with MRONJ include antiresorptives denosumab and bisphosphonates; however, a growing range of other non-antiresorptive drugs is implicated. The aim of this study was to analyse all case reports of MRONJ submitted to the publicly available Database of Adverse Event Notification from the Therapeutic Goods Administration in Australia. METHODS The Therapeutic Goods Administration was contacted on 6 January 2020 and asked for all reports containing the words "osteonecrosis of the jaw". This was provided in a spreadsheet of de-identified reports received from commencement of the database in 1971 until 1 October 2019. RESULTS The drugs implicated in the 419 cases were divided by established drugs with MRONJ and secondary drugs that possibly contribute to MRONJ development. While the majority of cases were associated with denosumab or bisphosphonates (n = 405), there were 14 reports where secondary agents that directly or indirectly affect bone turnover, were also implicated. Some of these secondary drugs, including adalimumab, etanercept, methotrexate and rituximab have previously been associated with MRONJ in published case reports. CONCLUSIONS This study contributes to the sparse but growing literature associating an increasing number of drugs with MRONJ, and underscores the importance of considering all possible drugs that elevate a patient's MRONJ risk.
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Minabe M, Suzuki T, Komatsu M, Hashimoto K, Nomura T. Intraoral localized methotrexate-associated lymphoproliferative disorders concurrent with antiresorptive agent-related osteonecrosis of the jaw: A case report and literature review. Clin Case Rep 2020; 8:2926-2935. [PMID: 33363853 PMCID: PMC7752373 DOI: 10.1002/ccr3.3192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/18/2020] [Accepted: 07/05/2020] [Indexed: 11/30/2022] Open
Abstract
Intraoral localized methotrexate-associated lymphoproliferative disorders can cause antiresorptive agent-related osteonecrosis of the jaw associated with infection due to its immunological abnormalities and ulcer formation.
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Affiliation(s)
- Masaki Minabe
- Department of Oral Medicine, Oral and Maxillofacial SurgeryTokyo Dental CollegeIchikawaJapan
| | - Taiki Suzuki
- Department of Oral Medicine, Oral and Maxillofacial SurgeryTokyo Dental CollegeIchikawaJapan
- Division of Oral and Maxillofacial SurgerySUBARU Health Insurance Society Ota Memorial HospitalOtaJapan
| | - Masumi Komatsu
- Department of Oral Medicine, Oral and Maxillofacial SurgeryTokyo Dental CollegeIchikawaJapan
| | - Kazuhiko Hashimoto
- Department of Pathology and Laboratory MedicineTokyo Dental CollegeIchikawa General HospitalIchikawaJapan
| | - Takeshi Nomura
- Department of Oral Medicine, Oral and Maxillofacial SurgeryTokyo Dental CollegeIchikawaJapan
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Taliaferro A, Samhouri Y, Rice J, Khan CM, Cillo JE. Rare Oral Presentation of a Mycophenolate Mofetil-Related Other Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorder (MMF-OIA-LPD) Lesion: A Case Report and Literature Review. J Oral Maxillofac Surg 2020; 79:398-403. [PMID: 32916134 DOI: 10.1016/j.joms.2020.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 01/26/2023]
Abstract
Oral manifestations of side effects of medications, such as methotrexate (MTX) for management of rheumatoid arthritis (RA) and mycophenolate mofetil (MMF) for solid organ transplant (SOT), are very rare. The known side effects include entities called other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD) due to immunosuppression caused by these medications. While there has been an increased incidence of oral cavity LPD reported in the literature associated with MTX, oral presentations that involve MMF are rare. This case report will detail a 74-year-old man with scleroderma treated with MMF who developed Epstein-Barr virus + polymorphic B-cell lymphoproliferative disorder in the right maxillary gingiva presenting as osteonecrosis of the jaw (ONJ). His oral presentation was successfully treated with a combination of surgery and MMF dosage reduction with an oral presentation free of disease at 6 months follow-up. This is the first known case report of an oral manifestation of MMF-related OIIA-LPD.
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Affiliation(s)
- Andrew Taliaferro
- Resident, Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh PA
| | - Yazan Samhouri
- Attending Physician, Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Allegheny General Hospital, Pittsburgh PA
| | - Jeremy Rice
- Resident, Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh PA
| | - Cyrus M Khan
- Attending Physician, Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Allegheny General Hospital, Pittsburgh PA
| | - Joseph E Cillo
- Division Chief, Residency Program Director, Director of Research, and Associate Professor, Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh PA.
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Eguia A, Bagán-Debón L, Cardona F. Review and update on drugs related to the development of osteonecrosis of the jaw. Med Oral Patol Oral Cir Bucal 2020; 25:e71-e83. [PMID: 31880288 PMCID: PMC6982985 DOI: 10.4317/medoral.23191] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/07/2019] [Indexed: 02/07/2023] Open
Abstract
Background Medication-related osteonecrosis of the jaw (MRONJ) is a rare, but serious adverse effect of certain drugs, of which bisphosphonates are the most widely known. This pathology is also associated with other medications such as the biologic antiresorptive agent, denosumab and some antiangiogenics such as sunitinib, bevacizumab or aflibercept. Very recently, new medications have also been associated with osteonecrosis of the jaw (ONJ). The objectives were to update the list of medications associated with ONJ, to analyze the fundamental aspects of this list and to describe the level of evidence available.
Material and Methods A narrative bibliographic review was made, using the PubMed-MedLine, DOAJ and SCIELO databases. Additional information was obtained through the online Medication Information Centre of the Spanish Agency of Medicines and Medical Devices (AEMPS – CIMA), the websites of the US Food & Drugs Administration (Drugs@FDA) and the European Medicines Agency (EMA).
Results The latest drugs identified as potential facilitators of this pathology include a number of anti-VEGF based antiangiogenic drugs and anti-TKI and different types of immunomodulators. Neither the level of evidence in this association nor the risk are equal for all these drugs. On the other hand, over the coming years, new drugs will be marketed with similar action mechanisms to those that are recognized as having this adverse effect.
Conclusions No effective therapy is currently known for the treatment of ONJ. Therefore, in order to prevent new cases of MRONJ, it is essential for all oral healthcare professionals to be fully up-to-date with the etiopathogenic aspects of this pathology and to be aware of those drugs considered to be a risk. Key words:Osteonecrosis of the jaw, MRONJ, bisphosphonates, antiresorptives, antiangiogenics.
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Affiliation(s)
- A Eguia
- Departamento de Inmunología, Microbiología y Parasitología Facultad de Medicina y Enfermería Universidad del País Vasco/Euskal Herriko Unibertsitatea UPV/EHU Apartado 699, 48080 Bilbao, Spain
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Tokuhira M, Tamaru JI, Kizaki M. Clinical management for other iatrogenic immunodeficiency-associated lymphoproliferative disorders. J Clin Exp Hematop 2019; 59:72-92. [PMID: 31257348 PMCID: PMC6661962 DOI: 10.3960/jslrt.19007] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD), a category of immunodeficiency-associated LPD according to the World Health Organization classification, is associated with immunosuppressive drugs (ISDs). Several factors, including autoimmune disease (AID) activity, Epstein-Barr virus (EBV) infection, ISD usage, and aging, influence the development of OIIA-LPD, resulting in complicated clinical courses and outcomes. Most OIIA-LPD develops in patients with rheumatoid arthritis using methotrexate (MTX-LPD). The management of MTX-LPD is based on the clinical course, i.e., with/without regression, with/without relapse/regrowth event (RRE), LPD subtype, and ISDs for AIDs after LPD development. There are three clinical courses after ISD withdrawal: regressive LPD without relapse/regrowth (R-G), regressive LPD with RRE (R/R-G), and persistent LPD (P-G). The majority of EBV+ diffuse large B-cell lymphomas are classified in R-G, whereas classic Hodgkin lymphoma is generally classified in R/R-G. Polymorphic LPD (P-LPD) in MTX-LPD develops with heterogeneous pathological features similar to monomorphic LPD. Chemotherapy for MTX-LPD is selected according to that for de novo LPD, although the strategy for aggressive P-LPD and non-specific LPD is not well established. The absolute lymphocyte count in the peripheral blood has been suggested as a candidate marker for MTX-LPD development and RRE. Several clinical issues, including correct diagnosis among overlapping clinicopathological features in MTX-LPD and clinical management of LPD by ISDs other than MTX, require further investigation.
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Jayashree S, Nirekshana K, Guha G, Bhakta-Guha D. Cancer chemotherapeutics in rheumatoid arthritis: A convoluted connection. Biomed Pharmacother 2018; 102:894-911. [PMID: 29710545 DOI: 10.1016/j.biopha.2018.03.123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/20/2018] [Accepted: 03/20/2018] [Indexed: 12/11/2022] Open
Abstract
Chemotherapy is one of the most popular therapeutic strategies to treat cancer. However, cancer chemotherapeutics have often been associated with impairment of the immune system, which might consequently lead to an augmented risk of autoimmune disorders, such as rheumatoid arthritis. Though the accurate mechanistic facets of rheumatoid arthritis induction have not been interpreted yet, a conglomeration of genetic and environmental factors might promote its etiology. What makes the scenario more challenging is that patients with rheumatoid arthritis are at a significantly elevated risk of developing various types of cancer. It is intriguing to note that diverse cancer chemotherapy drugs are also commonly used to treat symptoms of rheumatoid arthritis. However, a colossal multitude of such cancer therapeutics has demonstrated highly varied results in rheumatoid arthritis patients, including both beneficial and adverse effects. Herein, we attempt to present a holistic account of the variegated modalities of this complex tripartite cross-talk between cancer, rheumatoid arthritis and chemotherapy drugs in order to decode the sinuous correlation between these two appalling pathological conditions.
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Affiliation(s)
- S Jayashree
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India
| | - K Nirekshana
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India
| | - Gunjan Guha
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India.
| | - Dipita Bhakta-Guha
- Cellular Dyshomeostasis Laboratory (CDHL), Department of Biotechnology, School of Chemical and Bio Technology, SASTRA University, Thanjavur, 613 401, Tamil Nadu, India.
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