Rehabilitation of pediatric retinoblastoma patients with ocular prostheses and their subsequent modifications: A 15-year retrospective study

PURPOSE

Enucleation is a common treatment modality performed for pediatric retinoblastoma patients, and the resultant defects are reconstructed using an ocular prosthesis. The prostheses are modified or replaced periodically, as the child develops due to orbital growth and patient-error. The purpose of this report is to evaluate the replacement frequency of prostheses in the pediatric oncologic population.

METHODS

A retrospective review was completed by the two senior research investigators, of patients that had ocular prostheses fabricated following enucleation of their retinoblastoma from 2005 to 2019 (n = 90). Data collected from the medical records of the patient included the pathology, date of surgery, date of prosthesis delivery, and the replacement schedule of the ocular prosthesis.

RESULTS

During the 15-year study period, 78 enucleated observations (ocular prosthesis fabricated) were included for analysis. The median age of the patients at the time of delivery of their first ocular prosthesis was calculated to be 2.6 years (range 0.3-18 years). The median time to the first modification of the prosthesis was calculated to be 6 months. The time to modification of the ocular prosthesis was further stratified by age.

CONCLUSION

Pediatric patients require modification of their ocular prostheses throughout their growth and development period. Ocular prostheses are reliable prostheses with predictable outcomes. This data is helpful to set an expectation among the patient, parent, and provider.

Comparison of the weight of conventionally heat-processed hollow and solid obturators and 3D printed hollow obturators

STATEMENT OF PROBLEM

The weight of larger obturators places increased stress on the supportive teeth and bearing tissue and allows gravity to act as a dislodging factor affecting the stability and retention of the prosthesis. However, whether conventionally processed and 3-dimensionally (3D) printed hollow obturators have similar reduced weights compared with solid obturators is unclear.

PURPOSE

The purpose of this in vitro study was to evaluate the weight difference between conventionally heat-processed complete denture obturators with and without hollowing and 3D printed obturators with a hollow bulb.

MATERIAL AND METHODS

Obturators were fabricated as conventionally heat-processed solid obturators, conventionally heat-processed with a hollow obturator bulb, and 3D printed with a hollow obturator bulb. Nine obturator prostheses were fabricated for each type of Aramany Class I, Class II, and Class III defect. The weights of each of the 27 obturator prostheses were measured, and a statistical analysis was performed with exact versions of the Kruskal-Wallis test or Wilcoxon Rank Sum test (α=.05).

RESULTS

Conventionally heat-processed solid obturators were significantly heavier than the conventionally heat-processed hollow (P<.001) or the 3D printed hollow obturators (P<.001). No significant difference (P=.222) was found between the conventionally heat-processed hollow and 3D printed hollow obturators. The decrease in weight was proportional to the size of the defect with the Aramany Class I defect having the largest differences in weight between the different fabrication methods, followed by Class II, and then Class III with a much smaller defect.

CONCLUSIONS

Additive manufacturing could be a suitable alternative to conventional techniques for the fabrication of a closed hollow obturator because of the comparable weights.

Osteonecrosis of the jaw associated with pembrolizumab

We report a case of osteonecrosis of the jaw (ONJ) with pembrolizumab, a rare yet possibly emerging complication. In this case, a temporal relationship between the development of ONJ and the patient's treatment regimen suggested an association between pembrolizumab/GVD therapy and the development of ONJ. Thrombocytosis and anatomic factors may also have played a role. The number of patients using pembrolizumab will likely continue to increase. We document this instance in order to better inform dental treatment around cancer patients undergoing pembrolizumab therapy.

Osteoradionecrosis of the Jaw Following Proton Radiation Therapy for Patients With Head and Neck Cancer

Importance

Proton radiation therapy (PRT) has reduced radiation-induced toxic effects, such as mucositis and xerostomia, over conventional photon radiation therapy, leading to significantly improved quality of life in patients with head and neck cancers. However, the prevalence of osteoradionecrosis (ORN) of the jaw following PRT in these patients is less clear.

Objective

To report the prevalence and clinical characteristics of ORN in patients with oral and oropharyngeal cancer (OOPC) treated with PRT.

Design, Setting, and Participants

This case series reports a single-institution experience (Memorial Sloan Kettering Cancer Center, New York, New York) between November 2013 and September 2019 and included 122 radiation therapy-naive patients with OOPC treated with PRT. Data were analyzed from 2013 to 2019.

Main Outcomes and Measures

Clinical parameters, including sex, age, comorbidities, tumor histology, concurrent chemotherapy, smoking, comorbidities, and preradiation dental evaluation, were obtained from the medical record. Patients with clinical or radiographic signs of ORN were identified and graded using the adopted modified Glanzmann and Grätz grading system. Characteristics of ORN, such as location, clinical presentation, initial stage at diagnosis, etiology, time to diagnosis, management, and clinical outcome at the last follow-up, were also collected.

Results

Of the 122 patients (mean [SD] age, 63 [13] years; 45 [36.9%] women and 77 [63.1%] men) included in this study, 13 (10.6%) developed ORN following PRT during a median (range) follow-up time of 40.6 (<1-101) months. All patients had spontaneous development of ORN. At the time of initial diagnosis, grade 0, grade 1, grade 2, and grade 3 ORN were seen in 2, 1, 9, and 1 patient, respectively. The posterior ipsilateral mandible within the radiation field that received the full planned PRT dose was the most involved ORN site. At a median (range) follow-up of 13.5 (0.2-58.0) months from the time of ORN diagnosis, complete resolution, stable condition, and progression of ORN were seen in 3, 6, and 4 patients, respectively. The 3-year rates of ORN and death in the total cohort were 5.2% and 21.5%, while the 5-year rates of ORN and death were 11.5% and 34.4%, respectively.

Conclusions and Relevance

In this case series, the prevalence of ORN following PRT was found to be 10.6%, indicating that ORN remains a clinical challenge even in the era of highly conformal PRT. Clinicians treating patients with OOPC with PRT should be mindful of this complication.

Osteoradionecrosis of the jaw: A mini review

Osteoradionecrosis (ORN) of the jaw is one of the most dreaded complications of head and neck radiation therapy. Despite the evolution of radiation treatment modalities, ORN continues to remain a therapeutic challenge and its etiopathogenesis still remains unclear. It is clinically characterized by exposed necrotic bone within the head and neck radiation field. Over the past years, several studies have reported on the definition, staging, incidence, etiology, and management of this oral complication. In this review, we summarize the literature on ORN and discuss our institutional experience and management strategies that aim to predict and mitigate risk for ORN.

Multiple myeloma masquerading as mandibular medication-related osteonecrosis of the jaw: a case report

This is a unique case report of a 67-year-old female diagnosed with multiple myeloma and extensive use of intravenous bisphosphonate, whose clinical and radiographic presentation of an oral lesion made it challenging to confirm its definitive diagnosis. This patient was referred to the dental service for a suspected medication-related osteonecrosis of the jaw (MRONJ). Clinically, the lesion was located underneath a fixed partial denture in the left posterior mandible. There was a purulent swelling on the lingual side of the fixed partial denture, and a hyperplastic exophytic lesion on the buccal side of the bridge. Panoramic radiograph showed a well circumscribed radiolucent lesion in the left mandible. A biopsy of the gingival lesion on the buccal aspect was inconclusive. As the positron emission tomography scan showed lytic lesions, oral manifestation of multiple myeloma could not be ruled out. A computed tomography-guided biopsy of the left mandible showed plasma cell neoplasm in the histological analysis. Upon confirmed diagnosis, the patient was treated with 20Gy to the left mandible and subsequent debridement of the loose necrotic bone. Following treatment, this gingival lesion resolved completely, and the tumour has remained stable till date.

Intraoral radiation stents-Primer for clinical use in head and neck cancer therapy

Intraoral radiation stents (IRS) are prosthetic devices that assist in the effective delivery of radiation to tumor tissues and aim to avoid unnecessary radiation to adjacent healthy tissues, thus limiting postradiotherapy toxicities. They are used to protect or displace vital structures, assist in positioning of the treatment beam for effective administration of radiotherapy, carry a radioactive material, shield healthy tissues of the oral cavity, and/or maintain the desired mouth opening during radiotherapy. With close collaboration between radiation oncologist and oral health care provider, several IRS can be fabricated by the latter for appropriate targeting and delivery of planned radiation dose and optimized treatment results. Modification of these IRS based on individual patient need is recommended to maximize prosthesis utility. The purpose of this review is to discuss the various types of IRS and highlight their clinical utility and benefits in patients receiving radiation therapy in the head and neck cancers.

Interim Implant-Supported Resection Prosthesis Following Fibula Free Flap Reconstruction of the Arch with Immediate Implants: A Novel Approach for the Oncologic Patient

Oral cancer treatment involving the maxilla and/or mandible often results in esthetic and functional deficits that can diminish the patient's quality of life. As a result, expeditious reconstruction of the defect and dental rehabilitation is desirable. Dental rehabilitation shortly after reconstruction with an osteocutaneous free flap and resection prosthesis is a persistent challenge for patients with oncologic defects where immediate dental rehabilitation is not a possibility. Additionally, conventional prosthesis fabrication techniques are impractical or impossible due to postoperative anatomical changes and limitations in clinical armamentarium. To address these limitations, a technique and a novel implant-supported prosthetic workflow for the oncologic patient were developed to provide interim dental rehabilitation for such clinical situations. This article describes the prosthesis fabrication technique, reports short-term outcomes, and evaluates patient-reported quality-of-life outcomes using the FACE-Q Head and Neck Cancer Module.

Maxillary Occlusal Splint Following Segmental Mandibulectomy and Osteocutaneous Free Flap Reconstruction - A Case Report

Postsurgical malocclusion is a possible sequela of care following segmental mandibulectomy and osteocutaneous free flap reconstruction. Patient-specific factors may make surgical correction an impossibility. In addition, conservative occlusal adjustments may be insufficient for correction of the occlusion. An alternative approach for the management of severe postoperative malocclusion is to fabricate a maxillary occlusal splint, which establishes interocclusal articulating surfaces and facilitates mastication. The purpose of this report is to demonstrate the technique and utility of a maxillary prosthesis to correct posttreatment malocclusion in the oncologic patient.

Dental intervention for the irradiated patient: time to re-evaluate dental treatment algorithms?

Modern radiotherapy delivery systems and treatment strategies are aimed at limiting the irradiation of healthy structures in the head and neck. This seeks to mitigate post-treatment toxicities and complications such as osteoradionecrosis of the jaw. Given the changes to radiotherapy, conventional workflows for the management of patients requiring dentoalveolar surgery may no longer be suitable. It may therefore be appropriate to revisit current treatment algorithms for the management of patients with radiotherapy to the jaws who require dentoalveolar surgery. At present, there are poor data on this. Development of a randomised trial may be warranted to establish the true relative risk for extraction of teeth in the setting of modern radiation therapy delivery systems.

Definitive maxillary obturator prosthesis: Timelines for fabrication and follow-up

INTRODUCTION

A definitive maxillary obturator prosthesis can be used to rehabilitate a maxillary defect with the aim of improving speech, deglutition, and elimination of oronasal regurgitation. The aims of this study were (1) to determine the time required to fabricate a definitive maxillary obturator prosthesis and (2) to compare the fabrication and follow-up times between a patient's first and second definitive maxillary obturator prosthesis.

MATERIALS AND METHODS

A retrospective review was completed of patients that had maxillary definitive obturators fabricated following head and neck surgery from 2002 to 2018 (n = 173). Demographics, clinical data, date of surgery, start date of fabrication, follow-up dates, and prosthesis follow-up data were collected.

RESULTS

The median time to delivery of the patient's first definitive maxillary obturator prosthesis from the date of surgery was 7.7 months for nonradiated patients and 9.6 months for radiated patients (P ≤ .05). Additionally, there was a significant difference in the median number of appointments to fabricate the 1st definitive maxillary obturator prosthesis as compared to the 2nd prosthesis (6 vs 5; P ≤ .05).

CONCLUSION

Fabrication timelines differed based on history of radiotherapy and patient experience. This data is helpful to set expectations for patients and practitioners regarding the process for prosthesis fabrication and follow-up.

Prosthetic rehabilitation of the geriatric oncologic rhinectomy patient utilizing a craniofacial implant-retained nasal prosthesis

This clinical report describes the expeditious treatment of a geriatric patient with squamous cell carcinoma of the nose treated with total rhinectomy, craniofacial implant placement, and a nasal prosthesis.

Primary Leiomyosarcoma of the Mandible: Posttreatment Malocclusion Treated with an Overpartial Mandibular Resection Prosthesis

Leiomyosarcoma is a rare malignant condition occurring in the maxillofacial region in which the mandible may be affected. Management of this tumor in the mandible may include segmental mandibulectomy, osteocutaneous fibula free-flap reconstruction, endosseous implants, and postoperative radiotherapy. Posttreatment malocclusion can be managed with an overpartial mandibular resection prosthesis. The purpose of this report is to describe the expeditious oral rehabilitation of an oncologic patient with posttreatment malocclusion, demonstrating the utility of an overpartial mandibular resection prosthesis.

Oral rehabilitation following fasciocutaneous free-flap reconstruction: A retrospective study

Aim:

The aim of this study is to retrospectively, observe a consecutive series of patients with segmental mandibulectomy defects reconstructed with fasciocutaneous free flaps and mandibular resection prostheses, and to review treatment concepts for the management of such patients.

Settings and Design:

Observational study done at Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Materials and Methods:

Records were reviewed of all patients who had fasciocutaneous free-flap reconstruction and fabrication of mandibular resection prostheses following segmental mandibulectomy between 2000 and 2017 at a tertiary cancer center. Mandibular resection prosthesis fabrication interval data, as well as follow-up interval data, were recorded.

Statistical Analysis Used:

Descriptive statistics.

Results:

Twenty-one consecutive patients had mandibular resection prostheses fabricated following segmental mandibulectomy and fasciocutaneous free-flap reconstruction during the study. The median time for mandibular resection prosthesis delivery following surgery was 9 months (range 4–41 months). There was a median of two-follow-up visits (range 0–4) within the first 90 days of mandibular resection prosthesis delivery.

Conclusions:

Oral rehabilitation with mandibular resection prosthesis following segmental mandibulectomy and fasciocutaneous free-flap reconstruction is an attainable treatment goal for the oncologic patient. Reviewing the proposed course of care is helpful for patient management.

Predicting radiation dosimetric distribution in different regions of the jaw in patients receiving radiotherapy for squamous cell carcinoma of the tonsil

BACKGROUND

Radiotherapy (RT), the main treatment for patients with head and neck cancer, can lead to dental complications.

METHODS

We identified 244 patients with squamous cell carcinoma of the tonsil treated with RT from 2004 to 2013. For each patient, we contoured the 10 tooth-bearing regions and calculated the radiation dose (gray, Gy) to each region. From this data set, we built two predictive models to determine the expected maximum radiation dose, one for the non-molar regions and another for the molar regions.

RESULTS

For the non-molars, the final model included location, T-classification, and overall stage, with a median absolute prediction error of 7.0 Gy. For the molars, the final model included location, T-classification, overall stage, and treatment year, with a median absolute error of 6.0 Gy.

CONCLUSIONS

Our current model offers a good estimation of the maximum radiation dose delivered to different regions of the jaw; future work will independently validate these models.

Intraoral Rehabilitation After Marginal Mandibulectomy

PURPOSE

To report the feasibility of oral rehabilitation in patients who had undergone marginal mandibulectomy and to describe the factors that impact the selection of a mandibular resection prosthesis.

MATERIALS AND METHODS

A retrospective review of patients who had undergone marginal mandibulectomy over a 14-year period at a tertiary care cancer center was undertaken. Measurements of the vertical height and width of the mandible and the distance between the alveolar crest and mandibular canal were measured after marginal mandibulectomy. The feasibility and success of tooth-borne or implant-supported resection prostheses were measured.

RESULTS

Following marginal mandibulectomy, the median heights between the alveolar crest and lower border of the mandible were 21.8 mm, 17.7 mm, and 14.3 mm in the anterior, premolar, and molar regions, respectively. However, the median distances between the alveolar crest and the mandibular canal in the premolar and molar regions were only 3.98 and 3.4 mm, respectively. These residual bone measurements are not satisfactory for implant-supported mandibular resection prostheses, which can be considered only in the anterior region of the mandible. Patients with marginal mandibulectomy in the premolar and molar regions can only be rehabilitated with removable dentures, provided they have remaining stable teeth to clasp and anchor the removable denture.

CONCLUSION

Implant-supported resection prostheses after marginal mandibulectomy are feasible only in the anterior segment of the mandible and are not possible in the premolar and molar regions.

Oncology Curricula in Postgraduate General Dentistry Programs: a Survey of Residency Program Directors

Management of patients undergoing treatment for cancer requires a multidisciplinary team including general dentistry providers; however, the relative knowledge and training of general dentists in the management of this patient population are relatively unknown. The purpose of this study was to assess the oncology curricula of postgraduate general dentistry training programs, from the perspective of the program directors, to better understand the opportunities for and/or barriers to dental care for cancer patients. A cross-sectional survey was sent to the 275 Commission on Dental Accreditation-accredited programs; 82 program directors responded (response rate, 30%). More than 50% of respondents indicated "none" or "little" curricular emphasis on cancer biology, bone marrow transplantation, immunotherapy, or prosthetics for use during head and/or neck surgery. Conversely, more than 50% of respondents indicated "moderate" or "substantial" emphasis on acute oral effects of cancer-related therapy, long-term oral effects of cancer-related therapy, antiresorptive medication pharmacology, radiotherapy techniques and biological effects, and osteonecrosis of the jaw. Residents had the most experience with radiotherapy patients and the least with bone marrow or transplantation patients. Overall, general dentistry program directors were enthusiastic to participate in the multidisciplinary team but reported challenges to including oncology curricula in residency training programs. Training for general dentistry providers in formalized postgraduate residency programs may be variable or limited-as a result, communication regarding patient management is critical. Opportunities exist to enhance the general dentistry curricula and, thereby, improve access to dental care for patients receiving treatment for cancer.

Oral rehabilitation for patients with marginal and segmental mandibulectomy: A retrospective review of 111 mandibular resection prostheses

STATEMENT OF PROBLEM

Treatment and timing considerations for patients seeking oral rehabilitation after marginal or segmental mandibulectomy (with osseous reconstruction) are not well understood.

PURPOSE

The purpose of this retrospective review study was to report the type and timing of oral rehabilitation for mandibular defects without discontinuity and to describe additional treatment considerations for rehabilitation.

MATERIAL AND METHODS

The records were reviewed of all patients who received a mandibular resection prosthesis after marginal mandibulectomy, marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and segmental mandibulectomy with fibula free-flap reconstruction between 2000 and 2017 in the tertiary cancer care institution. Patients not treated by the Dental Service in the institution were excluded. The specific type of rehabilitation was noted, as was the time interval between primary surgery and prosthesis delivery.

RESULTS

During the study period, 111 consecutive patients were treated by the Memorial Sloan Kettering Cancer Center Dental Service for mandibular rehabilitation. Forty-three patients underwent marginal mandibulectomy, 9 patients underwent marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and 59 patients underwent segmental mandibulectomy with fibula free-flap reconstruction. Most patients in all 3 groups received mandibular resection prostheses without the use of endosseous implants. Only 4 (8%) patients who had undergone marginal mandibulectomy underwent endosseous implant placement, all of which followed marginal mandibulectomy in anterior mandibular segments without free-flap reconstruction. Patients who underwent marginal mandibulectomy with fasciocutaneous free-flap reconstruction were only restored with removable mandibular resection prostheses, and none had endosseous implants. In patients who underwent segmental mandibulectomy, 13 (22%) were rehabilitated with endosseous implants. The majority in this cohort (>50%) received radiation therapy as part of their treatment. The median time to oral rehabilitation was 8 months after marginal mandibulectomy, 14 months after marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and 12 months after segmental mandibulectomy with fibula free-flap reconstruction.

CONCLUSIONS

Timing for oral rehabilitation may differ depending on the treatment modality followed for mandibular tumors in the patient with oral cancer. However, most patients in this cohort underwent rehabilitation with removable mandibular resection prostheses regardless of the timing of care. Endosseous implants were used infrequently, but research is needed to better understand their potential role and indication in the patient with oral cancer.

Endosseous (dental) implants in an oncologic population: a primer for treatment considerations

Successful intraoral rehabilitation for patients with head and neck cancer can be extremely challenging to both the patient and the physician due to anatomical, functional, and esthetic changes from the cancer and its treatment. The measures with optimal oral hygiene to prevent or minimize the sequelae of cancer treatments are fundamental to preservation of function and avoidance of complications of therapy. In patients with loss of teeth, endosseous (dental) implants offer an option to improve intraoral rehabilitation. This review presents the indications, problems, and relevant issues pertaining to the use of endosseous implants in a head and neck oncologic population. The problems associated with the traditional approaches for cancer treatment including surgery, radiotherapy, and chemotherapy, as well as those with antiresorptive medications are discussed as they relate to consideration for endosseous implants. This information can aid dental practitioners to select appropriate candidates for implant surgery, minimize postoperative complications, and maximize the successful oral rehabilitation of this patient population.

Three-dimensional printed definitive cast for a silicone obturator prosthesis: A clinical report

For patients with head and neck cancer requiring a maxillectomy, obturator prostheses help with quality of life. These patients routinely require adjuvant oncologic treatments with significant adverse effects. Treatment sequelae can leave patients with difficulty speaking and swallowing, reduced salivary function, reduction in maximal incisal opening, and at risk of osteoradionecrosis. A 55-year-old African-American woman presented with significant trismus and reduction in maximal incisal opening after treatment for squamous cell carcinoma of the left maxillary sinus. She had received a left total maxillectomy with adjuvant chemotherapy and radiation treatments. With her reduced opening, she was no longer able to insert her interim obturator prosthesis, which caused difficulty speaking and nasal regurgitation. A cone beam computed tomography scan was made of the patient's maxillectomy defect. From the Digital Imaging and Communications in Medicine file, a definitive cast was 3-dimensionally printed to fabricate a flexible silicone obturator prosthesis. This treatment has allowed the patient to return to a functional quality of life and could help other patients in similar situations.

The Role of Maxillofacial Prosthetics for the Surgically Treated Patient at National Cancer Institute-Designated Comprehensive Cancer Centers

OBJECTIVES/HYPOTHESIS

The current role of maxillofacial prosthetic care for head and neck cancer patients is not well understood. Additionally, perceived barriers for service provision are unknown. The purpose of this study was to evaluate the current role of maxillofacial prosthetic care at National Cancer Institute (NCI)-designated comprehensive cancer centers and to identify perceived barriers to care.

STUDY DESIGN

Multicenter, cross-sectional survey of head and neck division leaders at NCI-designated comprehensive cancer centers.

METHODS

Each head and neck division leader from the 47 NCI-designated comprehensive cancer centers was invited to participate. The main outcomes of this study were: 1) to evaluate the current role of maxillofacial prosthetics for the surgically treated head and neck cancer patient within NCI-designated comprehensive cancer centers and 2) to identify perceived barriers to care. Measured outcomes were obtained from an anonymous online survey and reported.

RESULTS

Twenty-eight of the 47 head and neck service chiefs responded (60% response rate). Respondents expressed preference for prosthetic rehabilitation for hard palate/upper gum, auricular, and nasal defects. Local flap or free tissue transfer was preferred for lower gum and soft palate defects. Cost-related factors were among the most reported perceived barriers to maxillofacial prosthetic care.

CONCLUSIONS

Maxillofacial prosthetics have an important role in the rehabilitation of the head and neck cancer patient. Perceived barriers for services exist, particularly as it relates to cost. Providers should be aware that these issues are likely to be more severe in regional or community centers.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:409-414, 2019.

Oral rehabilitation of the cancer patient: A formidable challenge

Rehabilitation of oral functions following surgery on the jaws is a goal that is often difficult to achieve. Removable dentures supported by remaining teeth or gum are often unstable and seldom satisfactory. On the other hand, endosseous (dental) implants offer a mechanism to provide stability to the dentures. This review, discusses factors related to the tumor, patient, treatment, and physicians which impact upon the feasibility and success of dental implants in patients with oral cancer.

Medication-related osteonecrosis of the jaw: An update on the memorial sloan kettering cancer center experience and the role of premedication dental evaluation in prevention

OBJECTIVE

The aim of this study was to investigate the relationship between type of antiresorptive medication and medication-related osteonecrosis of the jaw (MRONJ) onset and the role of premedication dental evaluation (PMDE) in the prevention of MRONJ.

STUDY DESIGN

Our database of patients with MRONJ was reviewed. The Kruskal-Wallis test was used to analyze the onset dose of the 3 frequent medication types associated with MRONJ. To evaluate the role of PMDE in the prevention of MRONJ, all patients on antiresorptive and/or antiangiogenic medications seen in the Dental Service of Memorial Sloan Kettering Cancer Center during a 10-year period were subclassified into 2 groups. Group I comprised patients seen for PMDE before the commencement of A/A and group II patients seen after prior exposure to antiresorptive and/or antiangiogenic medications. Fischer's exact test was used to compare the incidence of MRONJ in both groups.

RESULTS

Patients on denosumab developed MRONJ earlier compared with zoledronate and pamidronate (P = .003). Group I had a significantly reduced incidence of MRONJ (0.9%) compared with group II (10.5%) (P < .0001). Dentoalveolar trauma as a precipitating factor between groups I and II was not statistically significant.

CONCLUSIONS

Denosumab was associated with an earlier occurrence of MRONJ compared with zoledronate and pamidronate. The role of PMDE may be an effective preventive strategy in reducing the incidence of MRONJ.

Head and Neck Round Cell Sarcomas: A Comparative Clinicopathologic Analysis of 2 Molecular Subsets: Ewing and CIC-Rearranged Sarcomas

CIC-rearranged sarcoma (CRS) is a relatively new entity defined by its pathognomonic genetic signature and undifferentiated round cell phenotype, initially grouped together with the 'Ewing sarcoma-like tumors'. However, increasing data suggest that these tumors should be regarded as a stand-alone pathologic entity. We conducted a clinicopathologic analysis on molecularly conformed Ewing sarcoma (ES) and CRS arising in the head and neck (HN) and compared to a well characterized cohort of ES and CRS from other locations. A total of 41 HN round cell sarcoma patients were selected from our institutional and consultation files, including 25 ES (median 20 years) and 16 CRS (median 29 years). Clinical follow-up information was available for all ES patients, ranging from 4 to 436 months (median 70 months), while for CRS, follow-up information was available in 11 patients (69%), ranging from 1 to 269 months (median 27 months). The most common location for ES was the facial and jaw bones (56%), while CRS occurred exclusively in the soft tissue, commonly in the neck. CRS showed variable CD99 staining in 75% of cases and diffuse WT1 (6/6) reactivity, while all ES expressed diffuse membranous staining for CD99 but none for WT1 (0/6). The 2-year overall survival (OS) rate for HN-CRS patients was 78%, while for HN-ES it was 100%. The OS of ES and CRS showed a trend toward a favorable outcome for HN-round cell sarcomas compared to other sites. Our findings suggest that HN-CRS have different clinical presentation and pathologic features compared to ES and should be classified as a stand-alone pathologic entity.

A Clinicopathologic Study of Head and Neck Malignant Peripheral Nerve Sheath Tumors

Head and neck high grade malignant peripheral nerve sheath tumors (HN-MPNSTs) are rare highly aggressive soft tissue sarcomas that show overlapping morphologic and immunophenotypic features with melanoma and other high grade sarcomas, resulting in diagnostic challenges, particularly in sporadic settings. Recent discoveries have implicated loss of function mutations in the polycomb repressive complex 2 (PRC2) components, including EED or SUZ12 genes, as one of the leading pathogenetic mechanisms in high grade MPNST. MPNSTs with PRC2 loss are associated with complete loss of trimethylation at lysine 27 of histone H3 (H3K27me3), which emerged as a reliable immunohistochemical marker in the diagnosis of sporadic and radiation induced MPNST. As the diagnosis of MPNST in the HN is particularly challenging to distinguish from melanoma and other sarcoma types, we carried out a clinicopathologic analysis on HN-MPNST patients managed at our institution over a 20-year period (1997-2016), using the latest diagnostic criteria including H3K27me3 staining and other molecular investigations. The overall survival of HN-MPNST was compared with other HN soft tissue sarcomas. The diagnosis of HN-MPNST was confirmed in 13 patients (seven males and six females), with a mean age of 31 years; with 3 (23%) patients being of pediatric age. The most common site was the neck soft tissue (77%). Two-thirds of patients (n = 9) had stigmata of NF1, three had prior radiotherapy and only one developed a de novo MPNST. All except one tumor (86%) tested showed loss of H3K27me3 expression, including all non-NF1 patients. The 2 and 5-year DSS rates were 50 and 30%. The 2-year DFS rate was 21%. Adverse predictors on DSS included adult age (p = 0.011), prior-history of RT (p = 0.003) and recurrence (p = 0.003). Compared to other molecularly confirmed subsets of HN sarcomas (Ewing and Ewing-like sarcoma, rhabdomyosarcoma and synovial sarcoma), HN-MPNST had the worst overall survival (p < 0.0001). We conclude that HN-MPNSTs are highly aggressive sarcomas associated with an unfavorable outcome and the utility of H3K27me3 IHC stains in the evaluation of MPNST is a reliable ancillary diagnostic adjunct.

The role of parotid gland irradiation in the development of severe hyposalivation (xerostomia) after intensity-modulated radiation therapy for head and neck cancer: Temporal patterns, risk factors, and testing the QUANTEC guidelines

BACKGROUND

The aims of this study were to investigate temporal patterns and potential risk factors for severe hyposalivation (xerostomia) after intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC), and to test the two QUANTEC (Quantitative Analysis of Normal Tissue Effects in the Clinic) guidelines.

PATIENTS AND METHODS

Sixty-three patients treated at the Memorial Sloan Kettering Cancer Center between 2006 and 2015, who had a minimum of three stimulated whole mouth saliva flow measurements (WMSFM) at a median follow-up time of 11 (range: 3-24) months were included. Xerostomia was defined as WMSFM ≤25% compared to relative pre-radiotherapy. Patients were stratified into three follow-up groups: 1: <6 months; 2: 6-11 months; and 3: 12-24 months. Potential risk factors were investigated (Mann-Whitney U test), and relative risks (RRs) assessed for the two QUANTEC guidelines.

RESULTS

The incidence of xerostomia was 27%, 14% and 17% at follow-up time points 1, 2 and 3, respectively. At <6 months, the mean dose to the contralateral and the ipsilateral parotid glands (Dmean_contra, Dmean_ipsi) was higher among patients with xerostomia (Dmean_contra: 25 Gy vs. 15 Gy; Dmean_ipsi: 44 Gy vs. 25 Gy). Patients with xerostomia had higher pre-RT WMSFM (3.5 g vs. 2.4 g), and had been treated more frequently with additional chemotherapy (93% vs. 63%; all 4 variables: p < 0.05). At 6-11 months, Dmean_contra among patients with xerostomia was higher compared to patients without (26 Gy vs. 20 Gy). The RR as specified by the one- and two-gland QUANTEC guideline was 2.3 and 1.4 for patients with <6 months follow-up time, and 2.0 and 1.2 for patients with longer follow-up (6-11 + 6-24 months).

CONCLUSION

Xerostomia following IMRT peaks within six months post-radiotherapy and fades with time. Limiting the mean dose to both parotid glands (ipsilateral <25 Gy, contralateral <25 Gy) and reducing the use of chemotherapy will likely decrease the rate of xerostomia. Both QUANTEC guidelines are effective in preventing xerostomia.

A clinicopathologic study on SS18 fusion positive head and neck synovial sarcomas

OBJECTIVE

To determine clinicopathologic factors on survival in patients with head and neck synovial sarcoma.

PATIENTS AND METHODS

We retrospectively identified patients with molecularly confirmed synovial sarcomas of the head and neck (SS-HN), either by the presence of SS18-SSX fusion transcript by RT-PCR or SS18 gene rearrangement by FISH, who were managed at our institution over a 20-year period (1996-2015). Kaplan-Meier survival analysis and log-rank test were performed to evaluate variables related to disease specific survival (DSS). Fisher exact test was performed to evaluate variables related to local recurrence.

RESULTS

Thirty-four patients (20 males and 14 females, mean of 31years) with SS18-SSX fusion-positive SS-HN were identified. The parapharyngeal region of the neck was the most common site. The mean tumor size was 4.8cm (0.8-10cm). Two-thirds (n=23) of cases had a monophasic histology. The 2, 5 and 10-year DSS rates were 97%, 79% and 68%. The 5-year DSS rates for the adult/pediatric cohort were 74%/88%. Recurrence showed significant effect on DSS (p=0.021). There was no significant effect on DSS with age, therapy modality, tumor site, surgical margin, tumor size (⩽5cm vs. >5cm) and histopathologic subtype. Tumor site (i.e. skull base/paranasal sinus region) was associated with local recurrence (p=0.003).

CONCLUSION

In our cohort DSS rate was associated with recurrence. Tumors located in the skull base/paranasal sinus region were associated with a higher rate of local recurrence. Thus appropriate selection of high risk patients who can benefit from multimodality therapies might improve survival.

The prevalence and risk factors associated with osteoradionecrosis of the jaw in oral and oropharyngeal cancer patients treated with intensity-modulated radiation therapy (IMRT): The Memorial Sloan Kettering Cancer Center experience

OBJECTIVE

To determine the prevalence and correlation of various risk factors [radiation dose, periodontal status, alcohol and smoking] to the development of osteoradionecrosis (ORN).

PATIENTS AND METHODS

The records of 1023 patients treated with IMRT for oral cavity cancer (OCC) and oropharyngeal cancer (OPC) between 2004 and 2013 were retrospectively reviewed to identify patients who developed ORN. Fisher exact tests were used to analyze patient characteristics between ORN patients with OCC and OPC. Paired Wilcoxon tests were used to compare the dose volumes to the ORN and contralateral non-ORN sites. To evaluate an association between ORN and risk factors, a case-control comparison was performed. One to 2 ORN-free patients were selected to match each ORN patient by gender, tumor site and size. General estimation equations models were used to compare the risk factors in ORN cases and matched controls.

RESULTS

44 (4.3%) patients developed ORN during a median follow-up time of 52.5months. In 82% of patients, ORN occurred spontaneously. Patients with OPC are prone to develop ORN earlier compared to patients with OCC (P=0.03). OPC patients received a higher Dmax compared to OCC patients (P=0.01). In the matched case-control analysis the significant risk factors on univariate analysis were poor periodontal status, history of alcohol use and radiation dose (P=0.03, 0.002 and 0.009, respectively) and on multivariate analysis were alcohol use and radiation dose (P=0.004 and 0.026, respectively).

CONCLUSION

In our study, higher radiation dose, poor periodontal status and alcohol use are significantly related to the risk of developing ORN.

A clinicopathologic study of head and neck rhabdomyosarcomas showing FOXO1 fusion-positive alveolar and MYOD1-mutant sclerosing are associated with unfavorable outcome

BACKGROUND

Based on their distinctive histologic and genetic features, the latest WHO classification of soft tissue tumors includes four pathologic variants of rhabdomyosarcoma (RMS): embryonal (ERMS), alveolar (ARMS), spindle cell-sclerosing (SRMS-ScRMS) and pleomorphic RMS. The aim of this study focused on a detailed clinicopathologic and survival analysis of head and neck RMS (HNRMS) using the latest pathologic and molecular criteria reflecting this new subclassification in a large cohort.

PATIENTS AND METHODS

Patients managed for HNRMS in our institution (1996-2015) were analyzed. The presence of a FOXO1 fusion was required for the classification of ARMS. MYOD1 mutations in SRMS-ScRMS were tested when material available. Univariate and multivariate analyses were performed to evaluate variables related to overall survival (OS).

RESULTS

Ninety-nine HNRMS patients (52 males and 47 females, mean of 16years) were included in the study after pathologic re-review. The most common location was parameningeal (PM) (n=64), followed by non-orbital/non-PM (n=25) and orbital (n=10). There were 53 ERMS, 33 fusion-positive ARMS and 13 SRMS-ScRMS [SRMS (8); ScRMS (5)]. The 5-year OS rate for ERMS patients was significantly higher (82%) compared to ARMS (53%) and SRMS-ScRMS (50%) [SRMS (75%); ScRMS (30%)]. Univariate analysis showed that survival was dependent on histology (P=0.012), tumor size >5cm (P<0.001), regional lymph node involvement (P=0.002), metastasis at initial presentation (P<0.001), stage (P<0.001), and recurrence (P=0.002). Multivariate analysis confirmed histologic subtype to be significant (P=0.043).

CONCLUSION

Our findings reinforce that HNRMS is a heterogenous disease with ARMS and SRMS-ScRMS having an equally unfavorable outcome.

Long-term effect of chemotherapy-intensity-modulated radiation therapy (chemo-IMRT) on dentofacial development in head and neck rhabdomyosarcoma patients

Dentofacial developmental abnormalities have been reported in head and neck rhabdomyosarcoma (HNRMS) patients treated with conventional radiotherapy technique and chemotherapy. This current study investigates dentofacial long-term effects among HNRMS survivors managed with intensity-modulated radiotherapy (IMRT) and chemotherapy. In general, IMRT is a more effective 3D-conformal radiotherapy technique, which delivers high doses of radiation to the tumor target while minimizing doses received by the surrounding normal tissues. The medical records and radiographs of thirteen patients were reviewed to identify the following: 1. Facial asymmetry and jaw hypoplasia. 2. Effects on the dental tissue causing tooth agenesis/hypodontia, root agenesis/stunting/malformation, and/or enamel hypoplasia. 3. Trismus, hyposalivation/xerostomia. Seven patients presented with facial asymmetry and jaw hypoplasia, 9 patients presented with effects on the dental tissue [root agenesis/stunting/malformation (9), tooth agenesis/hypodontia (7) and enamel hypoplasia (3)] and 7 patients developed trismus and /or xerostomia. All patients with facial asymmetry and jaw hypoplasia also developed dental abnormalities. Patients with dentofacial developmental abnormalities were ≤7 years of age at treatment. Our study shows that dentofacial developmental abnormalities are still a burden in the era of IMRT and as prognosis of childhood malignancy improves and more patients survive, these late dentofacial sequelae among childhood cancer survivors will become more common. Dental oncologists should be integral members in the management of children with head and neck cancers.

Comparison of mean radiation dose and dosimetric distribution to tooth-bearing regions of the mandible associated with proton beam radiation therapy and intensity-modulated radiation therapy for ipsilateral head and neck tumor

OBJECTIVE

The purpose of this study was to compare the dosimetric distribution of ipsilateral proton beam radiation therapy (PBRT) with intensity-modulated radiation therapy (IMRT) in the tooth-bearing region of the mandible in patients with head and neck cancer (HNC).

STUDY DESIGN

The mandibular dosimetric distribution in patients with head and neck cancer treated with ≥60 Gy relative biologic equivalent PBRT was evaluated. The mean radiation doses were calculated in 5 regions: ipsilateral molar, ipsilateral premolar, anterior, contralateral premolar, and contralateral molar (CM) regions. CM was used as the reference region for comparative analysis. The mandibular dosimetric distribution in patients treated with PBRT was compared with that in IMRT patients with similar tumor sites and planning target volumes.

RESULTS

The mean radiation dose to the contralateral regions was lower in patients treated with PBRT compared with those treated with IMRT. The average mean radiation doses to the reference region (CM) in patients treated with PBRT (relative biologic equivalent) versus IMRT were oropharynx (2.2 Gy vs 23.2 Gy; P < .00002), parotid (0 Gy vs 11.8 Gy; P = .01), and oral cavity (0.4 Gy vs 15.6 Gy; P = .006).

CONCLUSIONS

This study revealed the effective tissue-sparing capability of PBRT compared with IMRT. Utilization of PBRT could translate to less radiation-related toxicity.

Objective assessment of trismus in oral and oropharyngeal cancer patients treated with intensity-modulated radiation therapy (IMRT)

PURPOSE

The aim of this study was to estimate the prevalence of trismus in oral and oropharyngeal cancer patients (OOPC) treated with intensity-modulated radiation therapy (IMRT) and to identify the role of risk factors in patients who developed trismus.

MATERIALS AND METHODS

A retrospective cohort study of OOPC treated with IMRT in our institution from 2009 to 2014 was performed. Patients eligible for this study had pre-RT and post-RT maximal inter-incisal opening (MIO) measurements at 6-48 months post-RT, treated with high-dose radiation (≥60 Gy) and pre-RT MIO ≥36 mm. A descriptive analysis to identify the incidence of trismus, with trismus stated as MIO ≤35 mm at or after 6 months post-RT measurement was performed. The role of risk factors such as age, gender, tumor site, tumor size (T), tumor stage, pre-RT MIO measurements and radiation dose to the tumor were assessed using Fisher exact test and the radiation doses to the ipsilateral muscles of mastication in patients who developed trismus were assessed by matching with control (non-trismus) patients using Wilcoxon Signed Rank test.

RESULTS

The study consisted of 54 patients with a median age of 55 years and 81% were males. The median follow-up time was 10 months. The prevalence of trismus was 14.8%. Patients with pre-RT MIO measurements ≤40 mm were at risk of developing trismus (P < 0.001). In trismus patients, the average mean radiation dose to the masseter and medial pterygoid muscles was numerically higher but not significantly different (P = 0.08; P = 0.22, respectively) to matched control patients. Age, gender, radiation dose to the tumor, tumor site, size (T) and stage were also found to be not significant.

CONCLUSION

Pre-RT MIO measurement was a significant risk factor for the development of trismus. However, this is a non-modifiable factor. Limiting radiation dose to the muscles of mastication could prevent this complication.

Metastatic solid tumors to the jaw and oral soft tissue: A retrospective clinical analysis of 44 patients from a single institution

PURPOSE

Metastatic solid tumors to the oral cavity are rare, frequently indicative of an end-stage disease process, and associated with poor survival rates. We performed a 20-year retrospective clinical analysis of our institution's cases of solid metastases to the oral cavity, and investigated these patients' clinical outcomes.

MATERIAL AND METHODS

A retrospective study of patients with metastatic solid tumors to the oral cavity over a 20-year period (October 1996 to September 2015) was conducted at Memorial Sloan Kettering Cancer Center. Patients were selected if they had a histopathologically confirmed diagnosis. Demographic, pathologic, and clinical information were reviewed to identify patient outcomes.

RESULTS

A total of 44 patients with metastatic non-melanocytic non-hematopoietic tumor to the oral cavity were identified: 24 males and 20 females (39 adults and 5 children) with a mean age of 54.3 years. In all, 24 cases involved the jaw and 20 cases involved the oral soft tissue. Eight patients (18.2%) had oral cavity metastases as the first indication of an occult malignancy. In adult patients, the common primary sites were the lungs (n = 9, 20%), kidney (n = 7, 16%), breast (n = 5, 11%), and colon (n = 4, 9%); and in pediatric patients the adrenal gland (3/5) was the most common site. Of the adult patients, 33 (84.6%) died of disease. From the time of metastasis diagnosis, patients with jaw metastases had a median and mean survival of 12 months and 27.7 months, respectively. In comparison, patients with oral soft tissue metastases had a median survival time of 5 months, and mean of 8 months. One pediatric patient (20%) died of disease 8 months after metastasis diagnosis.

CONCLUSION

Metastatic solid tumors to the oral cavity can be the first sign of a malignancy. Pediatric patients with oral cavity metastases have a better prognosis compared to adult patients. In this series, adults with oral soft tissue involvement had shorter survival times compared to patients with jaw involvement.

Osteonecrosis of the jaw in patients treated with denosumab for metastatic tumors to the bone: A series of thirteen patients

This case series describes the course of osteonecrosis of the jaw (ONJ) in thirteen patients with metastatic bone tumors treated solely with denosumab. Patients on denosumab may be more prone to developing ONJ even without a risk/precipitating factor and they may develop ONJ early in their denosumab therapy. The outcomes of ONJ in ten patients following a period of denosumab discontinuation after the onset of ONJ were: 3 had complete resolution of symptoms, 4 patients' ONJ progressed, 2 patients' ONJ was unchanged and in 1 patient there was partial ONJ resolution. The role of drug discontinuation prior to an invasive dental procedure or after the onset of ONJ still remains debatable.

Primary Ewing Family of Tumors of the Jaw Has a Better Prognosis Compared to Tumors of Extragnathic Sites

PURPOSE

Primary Ewing sarcoma of the jaw is rare. The aim of this study was to describe new cases of primary Ewing sarcoma of the jaw and investigate reported prognostic factors of Ewing sarcoma in this series and treatment outcome.

MATERIALS AND METHODS

Six patients with primary Ewing sarcoma of the jaw were treated at the Memorial Sloan Kettering Cancer Center (MSKCC) from 1992 through 2013. Clinical data, pathology reports, treatment prescribed, treatment regimens, outcome, and follow-up information were reviewed.

RESULTS

Five of 6 patients were female and 5 cases were in the mandible. No patient presented with metastatic disease at diagnosis. All cases were positive for CD99, and 3 patients with genetic confirmation were positive for EWS-FLI1 fusion or EWSR1 gene rearrangement. All patients received induction multiagent chemotherapy and surgical resection and 2 patients received adjuvant radiotherapy. Total (grade IV) or nearly total (grade III) tumor necrosis in 3 of 5 patients (60%) assessed for histologic response to chemotherapy indicated intense sensitivity. All patients were alive and free of disease, with no history of local recurrence, at a median follow-up period of 6.5 years.

CONCLUSION

Patients with primary Ewing sarcoma of the jaw have a good prognosis and metastasis is an uncommon occurrence at initial presentation.

Use of Orbital Conformer to Improve Speech in Patients with Confluent Maxillectomy and Orbital Defects

The basic objective in prosthetic restoration of confluent maxillary and orbital defects is to achieve a comfortable, cosmetically acceptable prosthesis that restores speech, deglutition, and mastication. It is a challenging task complicated by the size and shape of the defects. The maxillary obturator prosthesis often satisfies the objective of adequate deglutition; however, orbital defects that are not obturated in the medial, septal, or posterior walls allow air to escape, negatively impacting phonation. This article describes a technique to achieve favorable prosthetic rehabilitation in a patient with a maxillectomy and ipsilateral orbital exenteration. The prosthetic components include maxillary obturator, orbital conformer, and orbital prosthesis connected using rigid magnetic attachments.

Fabrication of a provisional nasal prosthesis

A technique for making a provisional nasal prosthesis for interim use after the ablation of a midface tumor is described. The technique is especially useful for the re-creation of a nasal form in an expedient and cost-effective manner. A preoperative definitive cast, or moulage, of the patient that includes a nasal form is used to fabricate a vacuum form of the midface. The vacuum form is evaluated on the patient, the extension is adjusted, and an external adhesive knit liner is applied to give the appearance of a contoured nasal bandage. The provisional nasal prosthesis is attached with medical adhesive tape and removed daily by the patient. The prosthesis is easily replaced during the course of treatment and has been found to be functional and esthetically acceptable to those patients receiving care from the Dental Service at Memorial Sloan Kettering Cancer Center.

Practical guidelines for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients with cancer

PURPOSE

This article discusses osteonecrosis of the jaw (ONJ) and offers health care professionals practical guidelines and recommendations for the prevention, diagnosis, and management of ONJ in cancer patients receiving bisphosphonate treatment.

METHODS

A panel of experts representing oral and maxillofacial surgery, oral medicine, endocrinology, and medical oncology was convened to review the literature and clinical evidence, identify risk factors for ONJ, and develop clinical guidelines for the prevention, early diagnosis, and multidisciplinary treatment of ONJ in patients with cancer. The guidelines are based on experience and have not been evaluated within the context of controlled clinical trials.

RESULTS

ONJ is a clinical entity with many possible etiologies; historically identified risk factors include corticosteroids, chemotherapy, radiotherapy, trauma, infection, and cancer. With emerging concern for potential development of ONJ in patients receiving bisphosphonates, the panel recommends a dental examination before patients begin therapy with intravenous bisphosphonates. Dental treatments and procedures that require bone healing should be completed before initiating intravenous bisphosphonate therapy. Patients should be instructed on the importance of maintaining good oral hygiene and having regular dental assessments. For patients currently receiving bisphosphonates who require dental procedures, there is no evidence to suggest that interrupting bisphosphonate therapy will prevent or lower the risk of ONJ. Frequent clinical assessments and conservative dental management are suggested for these patients. For treatment of patients who develop ONJ, a conservative, nonsurgical approach is strongly recommended.

CONCLUSION

An increased awareness of the potential risk of ONJ in patients receiving bisphosphonate therapy is needed. Close coordination between the treating physician and oral surgeon and/or a dental specialist is strongly recommended in making treatment decisions.

Intravenous bisphosphonate-related osteonecrosis of the jaw: long-term follow-up of 109 patients

OBJECTIVE

We report long-term follow-up of patients with intravenous bisphosphonate-related osteonecrosis of the jaw (BRONJ).

STUDY DESIGN

Medical and dental histories, including type and duration of bisphosphonate treatment and comorbidities, were analyzed and compared with clinical course of 109 patients with BRONJ at Memorial Sloan-Kettering Cancer Center Dental Service.

RESULTS

Median onset of BRONJ in months was 21 (zoledronic acid), 30 (pamidronate), and 36 (pamidronate plus zoledronic acid), with a significant difference between the pamidronate plus zoledronic acid and zoledronic acid groups (P = .01; Kruskal-Wallis). The median number of doses for BRONJ onset was significantly less with zoledronic acid (n = 18) than pamidronte plus zoledronic acid (n = 36; P = .001), but not pamidronate alone (n = 29). An association between diabetes (P = .05), decayed-missing-filled teeth (P = .02), and smoking (P = .03) and progression of BRONJ was identified through χ(2) test.

CONCLUSIONS

This long-term follow-up of BRONJ cases enhances the literature and contributes to the knowledge of BRONJ clinical course.

Oral tongue cancer gene expression profiling: Identification of novel potential prognosticators by oligonucleotide microarray analysis

Background

The present study is aimed at identifying potential candidate genes as prognostic markers in human oral tongue squamous cell carcinoma (SCC) by large scale gene expression profiling.

Methods

The gene expression profile of patients (n=37) with oral tongue SCC were analyzed using Affymetrix HG_U95Av2 high-density oligonucleotide arrays. Patients (n=20) from which there were available tumor and matched normal mucosa were grouped into stage (early vs. late) and nodal disease (node positive vs. node negative) subgroups and genes differentially expressed in tumor vs. normal and between the subgroups were identified. Three genes, GLUT3, HSAL2, and PACE4, were selected for their potential biological significance in a larger cohort of 49 patients via quantitative real-time RT-PCR.

Results

Hierarchical clustering analyses failed to show significant segregation of patients. In patients (n=20) with available tumor and matched normal mucosa, 77 genes were found to be differentially expressed (P< 0.05) in the tongue tumor samples compared to their matched normal controls. Among the 45 over-expressed genes, MMP-1 encoding interstitial collagenase showed the highest level of increase (average: 34.18 folds). Using the criterion of two-fold or greater as overexpression, 30.6%, 24.5% and 26.5% of patients showed high levels of GLUT3, HSAL2 and PACE4, respectively. Univariate analyses demonstrated that GLUT3 over-expression correlated with depth of invasion (P<0.0001), tumor size (P=0.024), pathological stage (P=0.009) and recurrence (P=0.038). HSAL2 was positively associated with depth of invasion (P=0.015) and advanced T stage (P=0.047). In survival studies, only GLUT3 showed a prognostic value with disease-free (P=0.049), relapse-free (P=0.002) and overall survival (P=0.003). PACE4 mRNA expression failed to show correlation with any of the relevant parameters.

Conclusion

The characterization of genes identified to be significant predictors of prognosis by oligonucleotide microarray and further validation by real-time RT-PCR offers a powerful strategy for identification of novel targets for prognostication and treatment of oral tongue carcinoma.

Osseointegrated craniofacial implants in the rehabilitation of orbital defects: an update of a retrospective experience in the United States

STATEMENT OF PROBLEM

Since their introduction, craniofacial implants have been used in prosthetic rehabilitation of facial defects. The literature, however, indicates marked variability in outcomes using implants for the retention of orbital prostheses.

PURPOSE

A multicenter report updating the experience in the United States with the use of craniofacial implants for prosthetic rehabilitation of orbital defects is presented.

MATERIAL AND METHODS

Surveys were sent to clinicians at 25 centers where maxillofacial prosthetic treatment is provided to obtain retrospective data regarding patients who completed implant-retained orbital prosthetic rehabilitation. Data on implant placement location, radiation treatment history, and use of hyperbaric oxygen therapy were collected and assessed in relationship to implant survival over time. The Kaplan-Meier life table and Wilcoxon analyses (alpha = .05) were used to assess the significance of the findings.

RESULTS

Ten centers responded, providing data suitable for statistical analysis on 153 implants placed to retain 44 orbital prostheses and followed for a mean period of 52.6 months. Forty-one implant integration failures occurred during this follow-up period, resulting in an overall integration survival rate of 73.2%. No significant relationship was found between radiation treatment history, hyperbaric oxygen therapy history, or implant placement location and implant survival. Individual responses revealed large variability between reporting centers in treatment outcomes.

CONCLUSION

Craniofacial implants may offer marked benefits in the prosthetic rehabilitation of orbital defects when compared to conventional adhesive retention designs. However, questions remain regarding long-term predictability and the impact specific factors may have on treatment outcomes. Insufficient data is currently available from which to draw statistically meaningful conclusions. The establishment of a national database designed to acquire adequate data to assess treatment outcomes is recommended.

Implant prosthodontic rehabilitation of fibula free-flap reconstructed mandibles: a Memorial Sloan-Kettering Cancer Center review of prognostic factors and implant outcomes

PURPOSE

This study aimed to estimate the cumulative survival rates (CSRs) of implants placed in reconstructed mandibles and to identify prognostic factors that may influence implant survival.

MATERIALS AND METHODS

The charts of 24 patients (10 male, 14 female) who had undergone mandibular resection and reconstruction with fibula free-flaps treated with implant-supported prostheses from April 1986 through December 2001 were reviewed. Information on demographics, surgical characteristics, treatment modalities, dentition, implant parameters, prostheses, and hyperbaric oxygen therapy (HBO) was gathered. Kaplan-Meier survival estimates were generated for the 100 implants that satisfied the inclusion criteria. Multivariate Cox proportional hazards regression models accounting for correlated implants within subjects were developed to identify prognostic factors for implant survival.

RESULTS

Ninteen implants had been placed in native mandible (3 in irradiated bone) and 81 in fibula bone flap. Six implants failed during the follow-up period (mean 51.7 months). The overall 5- and 10-year CSRs were 97.0% and 79.9%, respectively. In the univariate analysis, variables associated with implant survival were age, gender, chemotherapy, radiation therapy, HBO, irradiated bone, implant diameter, xerostomia, trismus, opposing dentition, and type of prosthesis. At 5 years, the CSR of implants in patients with HBO was 86.7%; HBO was statistically associated with an increased risk for implant failure (P = .005, hazard ratio = 19.79, 95% CI: 2.42 to 161.71).

DISCUSSION

The CSR was lower when implants were placed in a previously irradiated mandible. There is still a lack of reliable clinical evidence to support the effectiveness of HBO in these patients.

CONCLUSIONS

A high survival rate was demonstrated for implants placed in fibula free-flap reconstructed mandibles. The finding that HBO was a risk factor can probably be attributed to the small sample size; further study is needed in this patient population.

Prosthetic intervention in the era of microvascular reconstruction of the mandible--a retrospective analysis of functional outcome

PURPOSE

The purpose of this retrospective study was to compare the functional outcomes of patients who had mandibular resection and reconstruction with and without prosthetic intervention, and to identify predictive factors that may have an impact on functional outcomes.

MATERIALS AND METHODS

Two hundred twenty head and neck cancer patients who had undergone mandibular resection and reconstruction with at least 6 months of postoperative convalescence formed the basis of this retrospective review. Patients who did not receive prosthetic intervention formed group I (n = 142); those who received prosthetic intervention formed group II (n = 78). Functional outcomes were measured using four individual assessments (nutritional status, swallowing, masticatory performance, and speech) and one that combined the information from these assessments, the global measure of functional outcome (GMFO). Statistical analyses were used to compare the baseline characteristics and functional outcome between groups I and II and to analyze independent predictors for GMFO.

RESULTS

Of the 220 patients reviewed, 78 (35%) had prosthetic intervention; group II patients had better individual functional outcome measures and GMFO. Use of a prosthesis remained associated with GMFO after controlling for other significant predictors; other independent predictors were xerostomia, number of remaining mandibular teeth, number of tooth-to-tooth contacts, type of reconstruction, flap interference, and tongue defect. Patients who had fewer mandibular teeth and received a smaller prosthesis had better overall outcome than patients who received a larger prosthesis.

CONCLUSION

Patients who had prosthetic intervention after mandibular reconstruction had significantly better functional outcomes than patients who did not receive prosthetic intervention, even after adjusting for confounding variables.