Zoledronic acid for the prevention of bone loss in patients with previously untreated lymphoma undergoing chemotherapy

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Background: Treatment of lymphoma with alkylating agents and steroids causes bone loss and increased fracture risk. In addition, over half of all untreated lymphoma patients are osteopenic or osteoporotic at diagnosis. Pamidronate reduces bone loss and risk of vertebral fractures in lymphoma patients undergoing chemotherapy (CT). However, the effects of the more potent bisphosphonate (BP) zoledronic acid (ZA) in this setting are unknown. Therefore, we report on a phase III trial evaluating the effect of ZA on bone mineral density (B) in patients with newly-diagnosed lymphoma undergoing CT. Methods: In total, 72 patients will be randomized to either the control arm [calcium carbonate (1,200 mg orally/day) plus vitamin D (400 IU orally/day)], or the BP arm [calcium carbonate and vitamin D as in the control arm plus ZA (4 mg IV at baseline and at 6 months)]. The primary endpoint is the absolute change in B of the lumbar spine (LS) and femoral neck (FN) at baseline and 12 months. Results: Thus far, 112 patients have been screened for enrollment. Twenty-seven patients (24.1%) failed screening due to periodontal disease, a predetermined exclusion criterion of the study. To date, 14 patients in the control arm and 9 patients in the BP arm have completed the one-year follow up period including baseline and one-year B evaluations. Comparing patients in the control arm to those in the BP arm, the average absolute change in B at the LS was -0.048 g/cm2 vs. 0.0093 g/cm2 (p=0.005), at the left FN was -0.039 g/cm2 vs. 0.0074 g/cm2 (p=0.01), and at the right FN was -0.043 g/cm2 vs. 0.0211 g/cm2 (p<0.001), respectively. There have been no therapy-related serious adverse events or skeletal fractures in either arm. Conclusions: ZA in combination with calcium carbonate and vitamin D improves the B of patients with lymphoma undergoing CT. Given the incidence of below-average pre-treatment B and the known deleterious effects of lymphoma therapy on bone density, baseline B evaluation is warranted in all lymphoma patients. The high rate of periodontal disease in this patient population emphasizes the need for careful dental evaluation prior to BP therapy given the well-described, albeit rare, risk of osteonecrosis of the jaw from ZA.

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Osteonecrosis of the jaw: Long-term follow-up shows variable rate of healing

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Background: Osteonecrosis of the jaw (ONJ) is a rare but clinically significant disorder recently reviewed in a large retrospective study (Hoff et al, 42nd ASCO Annual Meeting 2006, Abstract #8528). A subset of the ONJ patients from that study with breast cancer or multiple myeloma (MM) was followed at the University of Texas M.D. Anderson Cancer Center (UTMDACC) dental clinic. This analysis describes the natural history of ONJ in this subset. Methods: Thirteen of 29 ONJ patients treated with intravenous bisphosphonates (IVBP) at UTMDACC and 1 treated elsewhere were evaluated in the dental clinic for > 6 months (MM, n=7; breast cancer, n=7). The maximum length of exposed bone was measured at each visit. Patients received a standard regimen of conservative dental care with debridement when indicated. Results: All 14 patients received zoledronic acid (median cumulative dose 72 mg; range 24–152) and 10 also received pamidronate (median cumulative dose 1,710 mg; range 90–2,700). They were followed for a median duration of 17.1 months (range: 7.1–67.3). The mean length of exposed bone at initial evaluation was 11 mm (SD: 8.4). Each patient demonstrated fluctuating clinical courses. The lesion from baseline to the last visit progressed in 7 patients (median increase of 13 mm), remained stable in 2, regressed in 2 and resolved in 3. Persistent ONJ was seen if IVBP was stopped (n=8), decreased in frequency (n=1) or continued at the same dose/frequency (n=2). Complete resolution occurred in 3 MM patients, where IVBP was discontinued, decreased in frequency or replaced by weekly oral alendronate. Conclusions: Our experience shows that ONJ resolved in 21% but persisted in the majority of patients with a duration of up to 5 years with conservative dental care. Further studies are needed to evaluate the pathogenesis and healing process of ONJ.

No significant financial relationships to disclose.

Osteopenia and osteoporosis in untreated non-Hodgkin's lymphoma patients: An important and potentially treatable survivorship issue in lymphoma

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Background: Alkylating agents and steroids can cause premature osteoporosis, increasing the risk of vertebral and hip fracture. The bisphosphonate pamidronate every 3 months can reduce bone loss and the risk of new vertebral fractures in lymphoma patients receiving chemotherapy.(Kim et al., 2004 Am J Med) We are conducting a randomized study of the more potent bisphosphonate zoledronic acid in untreated non-Hodgkin's lymphoma (NHL) patients to study chemotherapy induced bone loss. Methods: During the accrual period, we report the baseline bone mineral density (BMD) characteristics for screened untreated NHL patients. Exclusion criteria included bone fractures, BMD T-scores worse than -2.0, CrCl < 60 mL/min, dental problems, prior bisphosphonate or significant steroid use. Patients accrued to the study were randomized to receive either: 1) oral calcium and vitamin D (Ca+D) or 2) Ca+D and 4 mg zoledronic acid IV at baseline and at 6 months. Results: Patient characteristics: 59 males and 55 females with median age 63 (range: 18–87). Lymphoma types: B-cell n=111, T-cell 3; follicular (FL) 56, diffuse large B-cell (DLBCL) 33, mantle cell 8, and others, totaling 114 patients. Of untreated NHL individuals screened for baseline BMD to date 11/114 (10%) had osteoporosis and 62/114 (54%) had osteopenia or osteoporosis. The lowest BMD was a T-score of -4.4. Other bone, dental, and endocrine abnormalities excluded some patients from treatment randomization. Patients with T scores < -2.0 were considered for off-study treatment with bisphosphonates. Osteopenia and osteoporosis were common across lymphoma subtypes: FL 25/56 (45%), DLBCL 20/33 (61%), mantle cell 6/8 (75%), and marginal zone 5/6 (83%). The low rate of osteopenia/osteoporosis of 25% for Burkitt/Burkitt-like lymphoma may reflect fast lymphoma kinetics without associated increase in bone loss. Conclusions: Baseline testing of BMD revealed osteopenia or osteoporosis in the majority of untreated NHL patients. This widely available and non-invasive test should be considered in untreated NHL patients. Our ongoing clinical trial will address the potential role of zoledronic acid in preserving bone density for survivors of NHL. ClinicalTrials.gov Identifier: NCT00352846

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Osteonecrosis of the jaw in patients receiving intravenous bisphosphonate therapy

8528

There have been reports of osteonecrosis of the jaw (ONJ) in patients (pts) with metastatic bone disease (MBD) treated with IV bisphosphonates (IVBP). To estimate the frequency and identify risk factors for ONJ we performed a retrospective analysis of pts treated with IVBP. The cohort included 4019 patients identified through the MDACC pharmacy database (PD) treated with IVBP from 9/1996 to 2/2004, and 6 patients diagnosed with ONJ at the MDACC Dental Clinic. ONJ was defined as exposed non-healing bone of at least 3 months duration. Preliminary statistical analysis included 4000 patients. The most common diagnoses were breast cancer [BRCA] (1340), MM (550) and lung cancer (380).The indications for IVBP therapy included MBD (60%), hypercalcemia (25%), MM (14%) and osteoporosis (7%). We identified 34 patients with ONJ: 18 BRCA, 14 MM, 1 prostate cancer and 1 thyroid cancer. The frequency of ONJ was calculated by including patients from the PD only: 16/1338 (1.2 %) in BRCA and 14/448 (3.1%) in MM. Patients with ONJ received pamidronate [P] (6), zoledronate [Z] (10), combination of P and Z (15). The mean cumulative dose (MCD) of P was 2182 mg (720–4410) in MM and 2745mg (1980–3510) in BRCA. MCD of Z was 61 mg (24–152) in MM and 62 mg (28–110) in BRCA. The total doses of P and Z were significantly higher in the ONJ group VS NON-ONJ group (P<0.0001). Pts with ONJ had longer duration of disease and longer follow-up than NON-ONJ cases (P<0.0001). Univariate and multivariate logistic regression analyses (MLRA) revealed dental extractions (DE), ER positive tumors, and treatments with P and Z as significant factors associated with ONJ in BRCA pts. In MM, DE, periodontal disease and osteoporosis were significant factors. Further statistical analysis, including Cox regression analysis, is under way. ONJ pts were treated with aggressive oral hygiene, oral rinses, debridement of necrotic bone and antibiotics. 15 pts were followed at the dental clinic longer than 6 months. ONJ healed in 1, improved in 1, stable in 4 and progressed in 9 pts. In conclusion, ONJ is a significant but uncommon event. Higher doses of IVBP, longer treatment duration, DE, and periodontal disease are associated with a greater risk to develop ONJ. Good dental care and avoidance of dental interventions should be recommended to all patients treated with IVBP.

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Minimizing oral complications of cancer treatment

Aggressive cancer therapy places patients at greater risk for oral complications and treatment-related consequences. Unfortunately, prevention and/or treatment of such oral sequelae have become often overlooked priorities of the treatment team. We describe a philosophy of management of the cancer patient that specifically emphasizes the prevention and treatment of oral complications associated with cancer therapy. These concepts and principles are based on treatment protocols and ongoing clinical practices at The University of Texas M. D. Anderson Cancer Center in Houston, Texas.

Oral complications associated with aspergillosis in patients with a hematologic malignancy. Presentation and treatment

Opportunistic mycotic infections, such as aspergillosis, can produce morbid consequences with or without aggressive therapy in an immunocompromised patient. Treatment including amphotericin B and resection of the infected tissue must be considered early in the overall management of the patient. We describe two patients with acute myelogenous leukemia who underwent intense cytoreductive therapy with bone marrow transplantation and an associated fungal infection treated with an investigational form of amphotericin B.

Oral and dental management of the cancer patient: prevention and treatment of complications

Aggressive cancer therapy places patients at greater risk for oral complications and treatment-related consequences. Unfortunately, prevention and/or treatment of such oral sequelae has become an often overlooked priority of the treatment team. We describe a philosophy of management of the cancer patient that specifically emphasizes the prevention and treatment of oral complications associated with cancer therapy. These concepts and principles are based on treatment protocols and ongoing clinical research at the University of Texas M.D. Anderson Cancer Center in Houston, Texas.

Prosthodontic and surgical considerations for pediatric patients requiring maxillectomy

The quality of treatment and rehabilitation for the head and neck cancer patient, especially the pediatric patient, has progressed markedly over the years due to the cooperation of specialists involved in the total care of the patient. Defects of the oral cavity caused by trauma or removal of malignant or benign tissue require special treatment considerations with the pediatric patient. Aside from radiation and chemotherapy, other forms of adjuvant therapy, such as physical therapy, and patient and family counseling, are needed for proper rehabilitation. In addition, oral hygiene is essential in the overall rehabilitative process. Pediatric dental, orthodontic, prosthodontic, and oral and maxillofacial surgery specialties become integrated in treating the pediatric patient. The concentrated multidisciplinary treatment reduces post-treatment morbidity by shortening recovery and immediate rehabilitation time and by providing long-term care during the critical growth period.

Micronuclei, a biomarker for chemoprevention trials: results of a randomized study in oral pre-malignancy

Biomarkers are being sought that could serve as surrogate end points for chemoprevention trials. Micronuclei, cytoplasmic fragments of DNA, have been proposed as a biomarker and studied in oral pre-malignancy. This study evaluated micronuclei frequency in a randomized chemoprevention trial of oral pre-malignancy. A recent clinical trial evaluated the responses of pre-malignant oral lesions to 3 months of therapy with isotretinoin followed by 9 months of either low-dose isotretinoin or beta-carotene. For 57 study participants, micronuclei were counted in mucosal scrapings of the lesion and in normal-appearing mucosa at baseline and following 3 months and 12 months of therapy. Micronuclei counts were higher in scrapings from the lesion than in the normal-appearing mucosa. Following 3 months of isotretinoin, the micronuclei counts in scrapings of the lesion were significantly reduced. With treatment, the mean micronuclei count declined at 3 months. In a randomized comparison, both isotretinoin and beta-carotene maintained the suppression of micronuclei. The change in micronuclei count was not associated with the clinical or histological response to treatment. Chemoprevention treatment with isotretinoin led to a reduction in frequency of micronuclei, a marker of recent DNA injury, which was then maintained by both isotretinoin and beta-carotene.

Cariogenic microflora in patients with Hodgkin's disease before and after mantle field radiotherapy

Because mantle field radiotherapy is associated with partial xerostomia in patients with Hodgkin's disease, the purpose of this study was to evaluate their cariogenic microflora before and after completion of radiotherapy. We obtained samples of oral saline solution rinse from 40 patients with Hodgkin's disease before radiotherapy and from 31 patients with Hodgkin's disease who had survived 1 to 24 years after radiotherapy. We also evaluated caries experience and history of fluoride gel use for caries prevention in these patients. Mutans streptococci and lactobacilli levels were significantly higher in the postradiotherapy patients with carious teeth, particularly in those with limited home use of fluoride gels. In the postradiotherapy group, caries parameters were significantly higher (p < 0.05) than in the preradiotherapy group. Within the postradiotherapy group, both caries and microbial parameters tended to be higher in patients who were less compliant about using the recommended 0.4% stannous fluoride "brush-in" technique than in those who used the gel regularly at home. This study indicates that for patients with Hodgkin's disease who receive mantle field irradiation during the management of their disease, a sustained brush-in program with stannous fluoride gel can be of benefit for caries prevention and for limitation of oral levels of cariogenic mutans streptococci.

Chemoprevention as a form of cancer control

Once considered a futuristic concept, chemoprevention for pre-malignant oral leukoplakia lesions is now a reality. Oral leukoplakia can proceed to invasive disease and expose the upper aerodigestive tract to carcinoma. Risk factors, diagnosis and research in chemoprevention are discussed.

Effect of radioactive iodine therapy on salivary flow rates and oral Streptococcus mutans prevalence in patients with thyroid cancer

Unstimulated and stimulated salivary flow rates, Streptococcus mutans samples, and dental caries data were obtained from 50 patients with thyroid cancer who had received radioactive iodine, I131, from 0.3 to 20 years earlier. The salivary flow rates were compared with a healthy control group, and the S. mutans counts were compared to a group of patients with head and neck cancer who were sampled before radiotherapy. Flow rates were found to be significantly lower in the patients with thyroid cancer, and S. mutans levels were slightly but not significantly higher than the controls. Longitudinal flow rate data taken on four patients, who served as their own controls before and after I131 therapy, indicated a trend in saliva reduction.

Evaluation of a rapid enzyme-linked immunoassay for the diagnosis of herpes simplex virus in cancer patients with oral lesions

Oral herpes simplex virus infection in immunocompromised cancer patients can have a variety of different clinical appearances, which makes diagnosis difficult, and it can be associated with significant morbidity. Prompt diagnosis is important so that therapy can be started as soon as possible. The standard by which the diagnosis of herpes simplex virus is made is a culture that can take up to 10 days to produce results. In an effort to test a possibly better method, we evaluated a 12-minute, enzyme-linked immunoassay and found the sensitivity, specificity, positive predictive value, and negative predictive value to be 75.9%, 90.0%, 84.6%, and 83.7%, respectively. This test is easy, inexpensive, and can be done in a clinical setting, thus providing a prompt, accurate result so that treatment can be started without delay. This promptness is especially important in the immunocompromised cancer patient.

Clinical correlation of oral-dental findings with radiographs and with total body bone scans

Bone scans are frequently used to detect osteoblastic areas in bone, including bony metastases in patients with existing tumors. Various dental conditions have been found to cause areas in the jaws to have increased uptake of radiopharmaceuticals. We studied 30 patients with an existing cancer or previous history of cancer with the use of total body bone scans, panoramic radiographs, and dental examinations, and we found no correlation between the intensity of radionuclide uptake in the jaws on the bone scans and the number of teeth in each jaw, the age of the patient, the degree of periodontal disease, or the number of dental pathoses per jaw. The frequency and intensity of positive scan results were related to the presence or absence of intrabony lesions in the jaws. Dental disease therefore does not appear to mask metastatic disease in the jaws; however, when metastasis is suspected, a dental examination with radiographs is recommended.

Comparison of low-dose isotretinoin with beta carotene to prevent oral carcinogenesis

BACKGROUND

High-dose isotretinoin therapy has been determined to be an effective treatment for leukoplakia. However, a high rate of relapses and toxic reactions led us to conduct a trial of a much lower dose of isotretinoin in the hope of maintaining a response and limiting toxicity.

METHODS

In the first phase of the study, 70 patients with leukoplakia underwent induction therapy with a high dose of isotretinoin (1.5 mg per kilogram of body weight per day) for three months; in the second phase, patients with responses or stable lesions were randomly assigned to maintenance therapy with either beta carotene (30 mg per day) or a low dose of isotretinoin (0.5 mg per kilogram per day) for nine months.

RESULTS

In the first phase, the rate of response to high-dose induction therapy in the 66 patients who could be evaluated was 55 percent (36 patients). The lesions of seven patients progressed, and therefore they did not participate in the second phase of the trial. Of the 59 patients included in the second phase, 33 were assigned to beta carotene therapy and 26 to low-dose isotretinoin therapy; these two groups did not differ significantly in prognostic factors. Of the 53 patients who could be evaluated, 22 in the low-dose isotretinoin group and 13 in the beta carotene group responded to maintenance therapy or continued to have stable lesions (92 percent vs. 45 percent, P < 0.001). In situ carcinoma developed in one patient in each group, and invasive squamous-cell carcinoma in five patients in the beta carotene group. Toxicity was generally mild, though greater in the group given low-dose isotretinoin therapy.

CONCLUSIONS

When preceded by high-dose induction therapy, low-dose isotretinoin therapy was significantly more active against leukoplakia than beta carotene and was easily tolerated.

Effects of total body irradiation on salivary gland function and caries-associated oral microflora in bone marrow transplant patients

Forty-one cancer patients who received chemoradiotherapy conditioning with bone marrow transplantation were examined for changes in salivary gland function and caries-associated oral microflora. Salivary flow rates (stimulated and unstimulated) and Streptococcus mutans levels decreased after pretransplant cytoreductive therapy and posttransplant prophylactic antibiotic therapy. Normal levels returned with time after the patients left the protected environment. Lactobacillus counts were not affected. Chronic graft-versus-host disease did not significantly influence saliva production. Results indicate that irradiation is probably the major factor responsible for the transient xerostomia.

Dental implants and chemotherapy complications

The cancer patient receiving chemotherapy often suffers severe oral complications related to the administration of antineoplastic drugs. Cancer patients who also have transmucosal or endosseous dental implants pose special problems for medical oncologists and dentists, both when planning for chemotherapy and when providing supportive care during the course of treatment. The relationship between dental implants and cancer chemotherapy is described and complications experienced by implant patients treated with chemotherapy at The University of Texas M.D. Anderson Cancer Center are reviewed. Recommendations on various aspects of management involving implant evaluation and the removal or retention of dental implants are discussed.

Salivary flow rates in patients with head and neck cancer 0.5 to 25 years after radiotherapy

In this clinical study at the University of Texas M. D. Anderson Cancer Center, unstimulated and stimulated salivary flow rates were obtained from 47 patients with head and neck cancer who had received mantle, unilateral facial, or bilateral facial field radiotherapy from 0.5 to 25 years earlier. The magnitude of salivary flow rate reduction compared with a healthy control group was primarily related to the radiation dosage and the amount of salivary gland tissue included in the irradiated fields. Flow rates were lower for women in all groups, but these differences were not statistically significant.

Oral complications associated with cancer therapy. An M. D. Anderson Cancer Center experience

Oral complications associated with cancer therapy may not be inevitable. The intensity and duration can be prevented or alleviated by correcting existing oral-dental pathology and maintaining meticulous oral care. Microbial (bacterial, fungal and viral) assessment not only allows appropriate documentation of mucositis versus mucosal infection but directs therapeutic treatment.

Clinically isolated mandibular relapse in childhood acute leukemia

With improved methods for preventing extramedullary relapse in the leptomeninges and gonads, the problem of clinically isolated relapse at other sites has become more significant. The authors report here two children with acute leukemia who developed mandibular relapse while in complete hematologic remission. One had been off chemotherapy for acute lymphoid leukemia for 2.5 years. The other child is apparently the first patient with promyeloid morphologic features to experience relapse at this site. Both children are in second complete remission and off treatment after local radiation therapy and second courses of chemotherapy. Review of these two and five previously reported isolated mandibular relapses in childhood leukemia indicate that they are usually delayed until after cessation of therapy. Treatment with radiation and combination chemotherapy can result in long remission and possibly cure.

Dental and maxillofacial abnormalities in long-term survivors of childhood cancer: effects of treatment with chemotherapy and radiation to the head and neck

Sixty-eight long-term survivors of childhood cancer were evaluated for dental and maxillofacial abnormalities. Forty-five patients had received maxillofacial radiation for lymphoma, leukemia, rhabdomyosarcoma, and miscellaneous tumors. Forty-three of the 45 patients and the remaining 23 who had not received maxillofacial radiation also received chemotherapy. Dental and maxillofacial abnormalities were detected in 37 of the 45 (82%) radiated patients. Dental abnormalities comprised foreshortening and blunting of roots, incomplete calcification, premature closure of apices, delayed or arrested tooth development, and caries. Maxillofacial abnormalities comprised trismus, abnormal occlusal relationships, and facial deformities. The abnormalities were more severe in those patients who received radiation at an earlier age and at higher dosages. Possible chemotherapeutic effects in five of 23 patients who received treatment for tumors located outside the head and neck region comprised acquired amelogenesis imperfecta, microdontia of bicuspid teeth, and a tendency toward thinning of roots with an enlarged pulp chamber. Dental and maxillofacial abnormalities should be recognized as a major consequence of maxillofacial radiation in long-term survivors of childhood cancer, and attempts to minimize or eliminate such sequelae should involve an effective interaction between radiation therapists, and medical and dental oncologists.

Oral histoplasmosis: diagnostic complication and treatment

Intraoral histoplasmosis is difficult to diagnose, both because the clinician fails to be aware of it and because the lesion has clinical similarities to other disease entities, creating a misleading clinical impression. Effective communication between clinician and pathologist is essential, if one is to arrive at an accurate diagnosis and provide the best treatment. A new antimycotic agent, ketoconazole, is now available for oral administration. Studies indicate that it has major therapeutic advantages and significantly lower toxicity than comparable antimycotic agents.

Angiosarcoma metastatic to the maxillary tuberosity gingiva

A case of angiosarcoma metastatic to the maxillary gingiva is presented. A review of the literature and an epidemiologic survey of angiosarcoma cases since 1944 at the M. D. Anderson Hospital and Tumor Institute prove this to be an extremely rare occurrence. Generally, metastasis to the oral/perioral tissues occurs as a late sequela secondary to diffuse metastatic disease. In this case, however, two extensive metastatic tumor surveys determined that the only metastasis was to the oral site. The lesion clinically mimicked an inflammatory process. It is hoped that this presentation will reinforce aggressive pursuit of innocuous-appearing oral lesions when the patient has a history of malignant disease and will further encourage dental involvement in the oral/dental assessment and are of the cancer patient.

Central adenocarcinoma of the mandible

A seemingly straightforward clinical diagnosis of ameloblastoma was made of a large radiolucent, multicystic lesion in the mandible. Biopsy and metastatic tumor work-up revealed the tumor to be primary in the mandible. A histopathologic diagnosis of papillary adenocarcinoma of salivary gland origin was made. This article reports a well-documented primary mandibular salivary gland tumor. A review of the literature and light and electron microscopic interpretation of this tumor are presented.