Tumor-agnostic plasma assay for circulating tumor DNA detects minimal residual disease and predicts outcome in locally advanced squamous cell carcinoma of the head and neck

BACKGROUND

Forty to fifty percent of patients with locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) relapse despite multimodal treatment. Circulating tumor DNA (ctDNA) has the potential to detect minimal residual disease (MRD) after curative-intent therapy and to identify earlier which patients will progress. We developed a tumor-agnostic plasma ctDNA assay to detect MRD in unselected LA SCCHN with the aim of predicting progression-free survival (PFS) and overall survival without the need for tumor sequencing.

PATIENTS AND METHODS

A 26-gene next-generation sequencing panel was constructed that included the most frequently mutated genes in SCCHN and two HPV-16 genes. MRD was assessed in each patient through an in-house informatic workflow informed by somatic mutations identified in the corresponding pre-treatment plasma sample. The presence of MRD was defined as the detection of ctDNA in one plasma sample collected within 1-12 weeks of the end of curative treatment. The primary endpoint was the PFS rate at 2 years. At least 32 patients were planned for inclusion with the hypothesis that PFS at 2 years was >80% in MRD-negative patients and <30% in MRD-positive patients (α = 0.05, β = 0.9).

RESULTS

We sequenced DNA from 116 plasma samples derived from 53 LA SCCHN patients who underwent curative-intent treatment. ctDNA was detected in 41/53 (77%) patients in the pre-treatment samples. Out of these 41 patients, 17 (41%) were MRD positive after treatment. The 2-year PFS rate was 23.53% (9.9% to 55.4%) and 86.6% (73.4% to 100%) in MRD-positive and MRD-negative patients, respectively (P < 0.05). Median survival was 28.37 months (14.30 months-not estimable) for MRD-positive patients and was not reached for the MRD-negative cohort (P = 0.011).

CONCLUSIONS

Our ctDNA assay detects MRD in LA SCCHN and predicts disease progression and survival without the need for tumor sequencing, making this approach easily applicable in daily practice.

Comparable Accuracy of Quantitative and Visual Analyses of [18F]FDG PET/CT for the Detection of Lymph Node Metastases from Head and Neck Squamous Cell Carcinoma

BACKGROUND

In head and neck squamous cell carcinoma (HNSCC), [18F]FDG PET/CT is recommended for detecting recurrent disease and in the initial staging for evaluating distant metastases, but its use in detecting cervical lymph metastases remains unclear. The aim of this study is to evaluate and compare the diagnostic accuracy of [8F]FDG-PET/CT using visual and semi-quantitative analyses for detecting the nodal involvement in HNSCC.

METHODS

We analyzed consecutive patients who underwent a preoperative [18F]FDG-PET/CT and neck dissection for HNSCC at our tertiary hospital. A blinded evaluation of the [18F]FDG uptake in each neck level was performed using a semi-quantitative approach (SUVmax and SUVR) and a visual grading system (uptake superior to the internal jugular vein for grade 1 and superior to the liver for grade 2). Analyses were compared to the histological results.

RESULTS

In our 211 patients, analyses demonstrated similar diagnostic accuracy using a semi-quantitative approach or a visual grading system. Regarding the visual grading system, [18F]FDG-PET/CT detected nodal metastases with a specificity of 83% for lymph nodes classified as grade 1 and 98% for those classified as grade 2. The sensitivity was moderate, ranging from 60 to 63%.

CONCLUSIONS

[18F]FDG PET/CT has a high specificity for detecting lymph node metastases in HNSCC and therefore must be considered in the nodal clinical staging.

Medication-related osteonecrosis of the jaw, a risk to reassess in osteoporotic patients

INTRODUCTION

The use of antiresorptive drugs concerns many medical specialties either in relation to their prescription for osteoporosis or cancer, or in relation to the treatment of their side effects. In the literature, less than 10% of medication-related osteonecrosis of the jaw are related to patients treated for osteoporosis, while 90% are found in patients treated for cancer. Despite the increasing number of osteoporotic patients taking high doses of antiresorptive drugs, only few studies describe this topic. The main aim of this study was to highlight the occurrence of medication-related osteonecrosis of the jaw in osteoporotic patients compared to cancer patients. The second aim was to highlight risk factors in the two groups, to try to understand the high number of osteoporotic patients in our population.

MATERIALS AND METHODS

A retrospective study was conducted between December 2004 and March 2021 to identify all cases of medication-related osteonecrosis of the jaw in our department with emphasis on the osteoporotic population. Demographic, systemic and local risk factors were collected as well as the type, dose and duration of the anti-resorptive drugs treatment. Evolution and follow-up were also recorded.

RESULTS

One hundred sixty five patients presented with medication-related osteonecrosis of the jaw, of whom 67 (40,6%) were osteoporotic. Seventeen (25,4%) patients were males and 50 females (74,6%). Risk factors were tobacco consumption (28,4%), anemia (20,9%), alcohol consumption (19,4%). Use of corticoids or anticoagulant/antithrombotic therapy was related in 20,9% and 16,4%, respectively. The mean age at MRONJ diagnosis was 74,4 (50-98). The mean follow up time was 23,7 months (1-110).

CONCLUSION

Unlike the literature where medication-related osteonecrosis of the jaw in osteoporotic patients represents less than 10%, the rate in our series was much higher and represents 40% of the patients. This highlights the importance of a complete dental examination before and during antiresorptive drugs treatment, even in the case of osteoporotic patients.

Can L-PRF be helpful for delayed deep wound healing after a tracheotomy or lymph node dissection in a pN0 status?: A case report

INTRODUCTION AND IMPORTANCE

Leukocyte platelet-rich fibrin (L-PRF) is used for its ability to deliver high concentrations of autologous growth factors to host tissues, to promote tissue repair.

CASE PRESENTATION

This report describes the case of a 48-year-old woman with tongue cancer treated surgically (pT3pN0), who experienced a delay of five weeks in the process of deep wound healing after a tracheotomy and cervical lymph node dissection that was treated with L-PRF. The patient had no risk factors for delayed wound healing, except for active preoperative smoking. Several attempts were made to stimulate bleeding and edge-to-edge closure, without conclusive results. However, five days after L-PRF placement, the subcutaneous tissues were adhering to the deep planes in both wounds. Fifteen days after L-PRF treatment, a complete wound healing was observed which allowed initiation of postoperative radiotherapy.

CLINICAL DISCUSSION

This case report questions the potential of L-PRF for patients with a pN0 status, not only in superficial wounds, but also in deep wound healing. However, the use of L-PRF for patients with a pN1 status is not recommended, given the possible presence of tumour cells in the tissues, and the activation of these tumour cells by the growth factors present in L-PRF.

CONCLUSION

This report supports the idea that L-PRF can contribute to deep soft tissue healing for patients with a pN0 status due to its positive clinical healing effects.

Is medication related osteonecrosis of the jaw around implants a rare entity? A case series with a focus on etiopathophysiology

OBJECTIVES

Medication Related Osteonecrosis of the Jaw (MRONJ) around dental implants is a rare complication of antiresorptive drug (ARD) treatment. MRONJ has been described in patients with implants placed before, during or after ARD treatment. The aim of this study was to review our cases and to discuss a preventive approach to avoid the risk of MRONJ around implants.

MATERIALS AND METHODS

In a retrospective analysis of the 168 MRONJ seen in our department from 2005 to 2021, we searched for cases of patients with MRONJ around dental implants.

RESULTS

Six patients (4 females, 2 males) presented with MRONJ around 17 implants. Median age was 64 (50-83) years. Four patients received ARD treatment for osteoporosis and 2 for cancer. The maxilla was more affected than the mandible. Six implants were placed after the initiation of ARD treatment and eleven were placed before initiation of ARD treatments. Eight implants were managed surgically while 9 implants were managed conservatively.

CONCLUSION

In this series, implants were placed before or after starting ARD treatment. Despite initial successful osseointegration, MRONJ occurred months or years after initiation of ARD treatment. The role of periimplantitis should be discussed as well as the role of microcracks in the bone following implant loading. Less is known over the effect of ARD treatment after implant osseointegration. Implants could be a risk factor for MRONJ and must be checked regularly (every 3 months). It is important to check the healthy and biomechanical harmony of the implant system during the pre-treatment assessment.

Dental prevention of maxillo-mandibular osteoradionecrosis: A ten-year retrospective study

INTRODUCTION

Osteoradionecrosis (ORN) remains a frequent complication of radiotherapy in head and neck cancer. As ORN management is often complex, it is essential to focus on its prevention, mainly by dental prophylaxis. The objectives of this study were to evaluate a dental preventive approach based on ORN data and to highlight individual risk factors statistically associated with time-to-ORN.

MATERIALS AND METHODS

A retrospective study (January 2004-December 2013) included 415 patients with head and neck cancer who received radiotherapy in their treatment with at least 50 Grays on maxillo-mandibular bones. Pre-radiotherapy dental assessment (clinical and radiological) and prevention (with standardised extraction protocol) were performed.

RESULTS

The ORN rate was 7.5%, with a dental origin in 35.5% of cases, mainly represented by dental infection in exclusive mandibular locations. More than 90% of patients were partially or completely dentate, and more than 70% had poor oral hygiene. Dental extractions were performed in 67.9% of patients before radiotherapy and in 42.9% after radiotherapy. Statistically significant risk factors associated with time-to-ORN were addictions (tobacco and alcohol), diabetes, oropharyngeal tumour location, combination of surgery followed by radiotherapy and post-radiotherapy dental extractions.

DISCUSSION AND CONCLUSION

Considering that ORN implies severe disabilities and complex management, the rate of 7.5% is unacceptable. A better dental prevention could reduce this rate by one-third. Dental extractions could be systematic in high-dose irradiation mandibular areas in patients presenting with poor oral hygiene and/or statistically significant risk factors for the occurrence of ORN. Moreover, favourable oral condition after radiotherapy should be maintained.

Medication-related osteonecrosis of the jaw related to epacadostat and pembrolizumab

MRONJ is a well-known side effect of various medications, such as antiresorptive drugs, anti-angiogenic agents, immunomodulators and immunosuppressants. MRONJ related to immunotherapy is rarely described, with only one case related to ipilimumab. The interaction between the immune system and osteoclast lineage cells is well known. T cells release factors and cytokines that control osteoclastogenesis, and osteoclasts produce factors with an action on T cells. We attempted to explain how immunotherapy could cause MRONJ through the case report of a young patient with metastatic melanoma who developed maxilla MRONJ after pembrolizumab and epacadostat treatment.

Axillary lymph node metastasis in second oropharyngeal cancer

BACKGROUND

The risk of metastasizing in axillary lymph node is occasional in the head and neck cancers. This pattern of spread is difficult to explain and totally unpredictable even for these lymphophilic cancers.

OBSERVATION

A 72-year-old patient benefited, 11 years ago, of surgical oncology care associated with adjuvant radiotherapy for squamous cell carcinoma of the left floor of the mouth (pT4 pN2b M0). He presented a second primary malignancy at the right oropharyngeal level. Pet CT revealed a right infraclinic axillary metastasis. The metastatic origin was confirmed by pathological analysis.

DISCUSSION

The current management of head and neck cancers is based on the histological pattern of infiltration, the size of the primary tumor and the pattern of metastasizing lymph nodes and potential distant spreading. Current tests allow us to diagnose most distant metastases even outside the usual area of lymphatic drainage. Involvement of axillary lymph node, probably through retrograde lymphatic spreading is not so rare in recurrences of oropharyngeal cancer (T3-T4, N2…) as we have observed in the literature. In this review, we raise some degree of similarity between such oncological progression and factors related to this aberrant spreading.

Successful treatment of grade III osteoradionecrosis with mandibular fracture with pentoxifylline, tocopherol and clodronate

Osteoradionecrosis (ORN) is one of the most severe complications after head and neck radiotherapy. Once established, ORN is difficult to manage and is traditionally considered to be irreversible. Since the recent understanding of the pathophysiology of ORN is based on the concept of radiation-induced fibrosis, a new therapeutic medical regimen has been proposed comprising the combination of pentoxifylline, tocopherol and clodronate (PENTOCLO). A 55-year-old woman presented with grade III ORN with large intraoral bone exposure, a fracture of the left posterior horizontal branch and an orocutaneous fistula. Because she refused surgery, medical treatment with PENTOCLO was proposed. After 55months of treatment, there was complete mucosal coverage and complete consolidation of the fracture site around the orocutaneous fistula. PENTOCLO treatment can help some patients with grade III disease, as in this case. Further prospective randomized controlled trials are needed to confirm this result.

Buccal paraneoplastic pemphigus multi-resistant: Case report and review of diagnostic and therapeutic strategies

Paraneoplastic pemphigus is a rare autoimmune blistering disease generally associated with malignancy. The clinical presentation consists typically of painful and diffuse erosive stomatitis that may be accompanied by polymorphic skin lesions and systemic involvement. Diagnosis is based on clinical manifestations and confirmed by histology and immunological testing. The current first-line treatment is systemic corticosteroids and adjuvant therapies, including immunosuppressive agents. We report a case of buccal paraneoplastic pemphigus resistant to ibrutinib and rituximab successfully treated with azathioprine and polyclonal immunoglobulins.

Dramatic osteonecrosis of the jaw associated with oral bisphosphonates, periodontitis, and dental implant removal

INTRODUCTION

Osteoporosis affects millions of elderly patients, and anti-resorptive drugs (ARD) such as bisphosphonates (BP) represent the first-line therapy. Despite the benefits related to the use of these medications, osteonecrosis of the jaw is a significant complication in a subset of patients receiving these drugs.

CASE PRESENTATION

This report documents a case of dramatic bisphosphonate-related osteonecrosis associated with periodontitis and dental implant removal in an osteoporotic patient treated with per os bisphosphonates for an uninterrupted period of 15 years.

CONCLUSION

The aim of this report was to discuss the administration period of BP in the treatment of osteoporosis, the decision-making and clinical management of severe MRONJ and the indications for dental implant placement in these specific patients.

[Etiologic diagnosis of jaw osteonecrosis, other than bisphosphonate and radiotherapy related osteitis]

Our purpose was to highlight the various etiologies of maxillo-mandibular osteonecrosis, other than radiotherapy and biphosphonate related osteitis that have been abundantly reported. We performed a PubMed search from August 1, 1972 to August 1, 2012 using the following MeSH terms: "osteonecrosis", "bone", "necrosis", "jaw", "maxilla", "mandible", "palate", "oral", "avascular necrosis", NOT "bisphosphonate" NOT "osteoradionecrosis". Most cases of osteonecrosis were iatrogenic. Viral, mycotic, or bacterial infections were less frequent causes. Cocaine abuse, Wegener's granulomatosis, and N/K lymphoma were other etiologies. It is important to identify the various etiologies rapidly to manage this sometimes very mutilating condition adequately.

Etiologic diagnosis of jaw osteonecrosis, other than bisphosphonate and radiotherapy related osteonecrosis

Our purpose was to highlight the various etiologies of maxillo-mandibular osteonecrosis, other than radiotherapy and biphosphonate related osteitis that have been abundantly reported. We performed a PubMed search from August 1, 1972 to August 1, 2012 using the following MeSH terms: "osteonecrosis", "bone", "necrosis", "jaw", "maxilla", "mandible", "palate", "oral", "avascular necrosis", NOT "bisphosphonate" NOT "osteoradionecrosis". Most cases of osteonecrosis were iatrogenic. Viral, mycotic, or bacterial infections were less frequent causes. Cocaine abuse, Wegener's granulomatosis, and N/K lymphoma were other etiologies. It is important to identify the various etiologies rapidly to manage this sometimes very mutilating condition adequately.

Pentoxifylline and tocopherol in the treatment of yearly zoledronic acid-related osteonecrosis of the jaw in a corticosteroid-induced osteoporosis

Osteonecrosis of the jaw (ONJ) is a well-known side effect of bisphosphonate (BP) therapy. ONJ is specifically related to the intravenous form of BPs and is usually seen in combination with other risk factors, such as dental surgery, concurrent corticosteroids, chemotherapy, and tobacco use. The risk of developing ONJ in patients treated with oral BPs for osteoporosis is lower than that in patients with cancer but is still significant. Zoledronic acid is a third-generation nitrogen-containing BP. It was first used in the treatment of malignancy as a monthly infusion and then approved for the treatment of osteoporosis as a yearly infusion and is an attractive option that is more reliable than the oral form. ONJ related to the use of yearly zoledronic acid is rarely reported in the literature and is most likely underestimated. Pentoxifylline and tocopherol have been used in the treatment of osteoradionecrosis for many years, with observed lesion improvement. The authors present a case of ONJ development after 3 yearly zoledronic acid infusions for corticosteroid-induced osteoporosis. The patient was successfully managed using conservative treatment with pentoxifylline and tocopherol.

Tumour response and safety of cetuximab in a window pre-operative study in patients with squamous cell carcinoma of the head and neck

BACKGROUND

To investigate the safety and activity of cetuximab in the pre-operative treatment of squamous cell carcinoma of the head and neck (SCCHN).

PATIENTS AND METHODS

Cetuximab was administered for 2 weeks before surgery to 33 treatment-naïve patients selected for primary surgical treatment. Tumour biopsies, 2-[fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography ((18)FDG-PET) and imaging were carried out at baseline and before surgery. The primary aim of the study was safety and the secondary aims included metabolical, radiological and pathological tumour response. Five untreated patients were included as controls.

RESULTS

Cetuximab given 24 h before surgery was safe. Ninety percent of patients had (18)FDG-PET partial response (EORTC guideline) in the cetuximab group versus 0% in the control group. Delta maximal standardized uptake values (ΔSUVmax) were correlated with tumour cellularity on the surgical specimens (P < 0.0001). For patients with ΔSUVmax less than -25% or less than -50%, Ki67 was significantly decreased by cetuximab (P = 0.01 and 0.003). Cetuximab induced down-regulation of pEGFR (P = 0.0004) and pERK (P = 0.003).

CONCLUSIONS

Short-course pre-operative administration of cetuximab is safe and shows a high rate of (18)FDG-PET response. (18)FDG-PET response was correlated with residual tumour cellularity suggesting that (18)FDG-PET deserves further investigation as a potential early marker of cetuximab activity in SCCHN.

¹⁸F-FDG PET/CT and MRI in the follow-up of head and neck squamous cell carcinoma

We evaluated the diagnostic performance of (18)F-FDG PET/CT and MRI for the assessment of head and neck squamous cell carcinoma (HNSCC) relapse. Since early treatment might prevent inoperable relapse, we also evaluated THE performance of early unenhanced (18)F-FDG PET/CT in residual tumor detection. The study was prospectively performed on 32 patients who underwent (18)F-FDG PET/CT and MRI before treatment and at 4 and 12 months after treatment. (18)F-FDG PET/CT was also performed 2 weeks after the end of radiotherapy. Histopathology or a minimum of 18 months follow-up were used as gold standard. Before treatment (18)F-FDG PET/CT and MRI detected all primary tumors except for two limited vocal fold lesions (sensitivity 94%). MRI was more sensitive than (18)F-FDG PET/CT for the detection of local extension sites (sensitivity 75 vs 58%), but at the cost of a higher rate of false positive results (positive predictive value 74 vs 86%). For relapse detection at 4 months, sensitivity was significantly higher for (18)F-FDG PET/CT (92%) than for MRI (70%), but the diagnostic performances were not significantly different at 12 months. For the detection of residual malignant tissue 2 weeks post-radiotherapy, sensitivity and specificity of (18)F-FDG PET/CT were respectively 86 and 85% (SUV cut-off value 5.8). (18)F-FDG PET/CT is effective in the differentiation between residual tumor and radiation-induced changes, as early as 2 weeks after treatment of a primary HNSCC. For follow-up, performance of (18)F-FDG PET/CT and MRI are similar except for a higher sensitivity of (18)F-FDG PET/CT at 4 months.

[Current therapeutic approach of the white sponge naevus of the oral cavity]

We report a case of White Sponge Naevus of the tongue in a 50 years-old man. White Sponge Naevus of the oral cavity is a rare, benign and dominant autosomic inherited disorder, which presents in the form of a white, hyperplasic and verrucous or spongious lesion of the oral mucosa. Differential diagnosis is clinically difficult with more common white lesions of the oral cavity. Various therapeutic approaches have been proposed. Systemic antibiotics or local applications of retinoic acid provide limited benefits but are poorly effective. To our knowledge, CO2 Laser has never been tried to treat a White Sponge Naevus of the oral cavity. We performed a complete removal of the lesion with CO2 Laser, but complete recurrence occurred. Finally, a surgical resection was realized, which proved to be effective. Two years later, the patient is free of recurrence. This article proposes a review of the literature on what is known on White Sponge Naevus of the oral mucosa. We stress the importance of confrontation between anamnesis, clinical examination and pathologic findings to lead to the proper diagnosis of this rare disease.

[Recurrent maxillo-mandibular odontogenic keratocysts: prevention and treatment]

Keratocyst is an odontogenic cyst with an aggressive clinical behavior and a high recurrence rate. Our work describes a 62 year-old patient with Gorlin's syndrome presenting advanced recurrent maxillo-mandibular keratocysts. He already had multiple resections of these lesions. Early diagnosis and treatment of keratocysts is crucial to reduce the extension of the cysts and minimize their malignant transformation especially when they are part of a Gorlin's syndrome.

Bisphosphonate-related osteonecrosis of the jaw and its associated risk factors: a Belgian case series

OBJECTIVES

Bisphosphonate-related osteonecrosis of the jaw (BROJ) is a serious oral complication of bisphosphonate (BP) treatment involving the exposure of necrotic maxillary or mandibular bone. Our purpose is to describe the clinical presentation of 34 cases of BROJ and to identify potential risk factors.

STUDY DESIGN

A retrospective study was performed in four Belgian institutions.

METHODS

Complete medical histories were recorded and analyzed. These data include age, gender, initial disease requiring BP, type and duration of BP treatment, symptomatology and location of BROJ, prior dental procedures, treatment of the BROJ and treatment outcome, and radiographic, histological, and microbiological data.

RESULTS

Bisphosphonates (BP) were used in the management of disseminated cancers in 30 patients (88.5% of total studied), while four patients received BP due to osteoporosis (11.5%). The most frequently used BP was zoledronic acid in 29 patients (83%). Microbiological data obtained in 25 patients demonstrated that 72% of these patients were infected or colonized by an actinomyces. Eight of the 14 patients (57%) who received only medical treatment were cured. Of the 20 patients who underwent surgical treatments, only four were completely cured (20%). BROJ lesions smaller than 1 cm are associated with better prognosis in terms of treatment outcomes (P = .0009). Local treatments combined with long-term antibiotics are also correlated with better prognosis (P = .02).

CONCLUSIONS

Lesions smaller than 1 cm and lesions that were subject to medical treatments are associated with a better outcome. Surgical treatments appear to be non-beneficial for BROJ.

[Osteoporosis, bisphosphonates and jaws osteochemonecrosis]

Bisphosphonates are widely used in the treatment of nonmalignant bone disease like osteoporosis, Paget's disease and malignant disease like malignant hypercalcemia, osteolytic metastasis from breast and prostate cancer and multiple myeloma. Jaws osteonecrosis is described since 2003 and is more often associated with the intraveinous use than oral use. Higher risk of osteonecrosis is noted after 3 years of osteoporosis treatment. The precipitating event is often a tooth extraction or other invasive procedure. There is no effective treatment for this pathology. Careful oral examination is necessary before prescribing bisphosphonates and dental treatment must be achieved before the initiation of treatment.

[Melanoma of the oral mucosa]

INTRODUCTION

The oral melanoma (OM) account for 1% of all melanomas. The prognosis is poor despite an adequate locoregional control of the disease.

CLINICAL CASE

A 45-year-old woman presented with submandibular lymph nodes, having metastised from a melanoma. Oral cavity examination revealed a pigmented lesion of the gingiva in front of tooth 12, with satellite spots. Surgical treatment, radiotherapy, chemotherapy, and immunotherapy failed and the patient died 16 months after diagnosis.

DISCUSSION

Oral melanomas have a poor prognosis probably because they are generally detected late. The most common sites for oral melanomas are the palate and maxillary gingiva. About 30% of OM is preceded by areas of oral pigmentation for several months or years. The prognosis is poor with a 5% to 20% five-year survival rate.

[Avascular mandibular necrosis]

INTRODUCTION

Jaw osteonecrosis is, in most cases, caused by external irradiation. It is otherwise a rare occurrence.

OBSERVATION

A 52-year-old patient was referred to this hospital for several tooth extractions. In the procedure follow-up, the external aspect of the mandible was more and more exposed. This led to the spontaneous loss of a voluminous bone fragment. The patient had never undergone radiotherapy or a course of bisphosphonates but had a long-term cardio-vascular history. He had undergone endarterectomy of both carotids, an ilio-femoral by-pass, and a coronary dilatation. The diagnosis of bone infarction on a chronic osteomyelitis was made.

DISCUSSION

Blood coagulation disorders are responsible for most cases of bone infarction. Other risk factors include local trauma, chemotherapy, corticoids, and bisphosphonates. Necrosis of the jawbones is rare even though these are prone to trauma and infections. Symptoms are not specific and imaging is contributive late in the evolution. The results of medical treatment (antibiotherapy, vasodilators, and hyperbaric oxygenotherapy) and surgical debridement are very inconsistent.

[Osteochemonecrosis of the jaws and bisphosphonates: a case report and literature review]

Jaws osteonecrosis were, in most cases, caused by external irradiation. It was otherwise a rare occurrence. However, bisphosphonates have recently been associated with osteonecrosis of the mandible or the maxilla. Bisphosphonates are widely used in the treatment of osteoporosis, multiple myeloma and osteolytic bone metastases. They inhibit bone resorption by osteoclasts and disrupt the bone turnover. The so-caused bone expositions are painful and prone to surinfection. Even after cessation of the bisphosphonates, the results of medical and surgical treatment are very inconsistent. A thorough dental check-up is recommended before initiating a course of bisphosphonates.

Bisphosphonates et ostéo(chimio)nécrose maxillo-mandibulaire

INTRODUCTION

Maxillo-mandibular osteonecrosis is exceptional outside a context of cervico-facial radiotherapy. Bisphosphonates are non-metabolized pyrophosphate analogues which inhibit osteoclastic activity. Bisphosphonates are prescribed for the treatment of malignant hypercalcemia, osteolysis associated with metastatic bone disease, Paget's disease and osteoporosis. Maxillomandibular osteonecrosis with bisphosphonates can be observed in 1/10000 patients, but is probably underestimated due to lack of dental examination.

MATERIAL AND METHODS

We describe six cases of mandibular necrosis associated with bisphosphonates: five of them as part of their treatment regimen for a neoplastic condition and one for osteoporosis.

RESULTS

Two patients developed spontaneous bone necrosis. In two others, tooth extraction preceded the onset of osteonecrosis. In the last two patients, we noted a preexisting dental infection. All the histopathological examinations showed necrotic bone colonized by Actinomyces.

DISCUSSION

Bisphosphonate-induced osteonecrosis is only found in the maxillomandibular area because the jaws are the only bone in the skeleton exposed to the external environment. The mandible is rendered particularly prone to necrosis even after minor trauma because of its terminal vascularization. Careful oral examination is recommended before prescribing bisphosphonate therapy.

[Oral verrucous carcinoma]

Verrucous carcinoma is a rare, low-grade, well-differentiated form of squamous cell carcinoma seen on skin and mucosa. It is a slow-growing and locally aggressive tumor whose standard treatment is surgery. A case of strongly invasive oral verrucous carcinoma is presented with the medical history. The differential diagnosis of this neoplasm is difficult and requires clinic and pathologic data confrontation. In this paper, the importance of knowing the malignant potential of this lesion is stressed. Indeed, in 20% of verrucous carcinoma, foci of squamous cell carcinoma can be found. A review of literature and a differential diagnosis of verrucous carcinoma are presented.

[Central reparative giant cell granuloma of the maxilla. Apropos of a case]

Central giant cell granulomas are uncommon, locally aggressive and benign tumors of the maxillofacial skeleton. The authors report a case of tumor arising from the maxilla and present a review of essential characteristics of the lesion.

[Facial pain]

Whether acute, chronic or recurrent, facial pain remains an therapeutic challenge. Neurological tests, otorhinolaryngologic, dental or psychiatric examinations do not always provide a precise diagnosis. We propose a review of painful diseases most often found in the head and neck region. A differential diagnosis between psychiatric and functional diseases is proposed although the subjective component is always present. Neuralgias, migraine, cluster headache, tension-type headache, atypical facial pain and cancer pain are reviewed.