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Renouf M, Auger S, Campion L, Delpon G, Longis J, Dupas C, Blery P, Thariat J, Doré M. Prognostic Factors of Mandibular Osteoradionecrosis Including Accurate Colocalization of Avulsions and Dosimetric Dental Mapping Software, a Case-control Study. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00518-2. [PMID: 38685504 DOI: 10.1016/j.ijrobp.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Osteoradionecrosis (ORN) of the mandible remains a significant complication in the intensity modulated radiation therapy (IMRT) era. Dental dose cannot be predicted from heterogeneous IMRT dose distributions; mandibular dose metrics cannot guide dentist avulsion decisions in high-risk ORN situations. Using a mapping tool to report dental root dose, avulsions, and ORN sites, we re-examined ORN risk factors in a case-control study. METHODS AND MATERIALS From 2008 to 2019, 897 consecutive patients with oral cavity/oropharynx or unknown primary cancer undergoing IMRT were analyzed to identify ORN cases. These were matched (1 ORN/2 controls) retrospectively for tumor location, surgery, and tobacco consumption in a monocentric case-control study. Univariate and multivariate analyses integrated ORN factors and accurate dental dose data (grouped into 4 mandibular sectors). Generalizability was investigated in a simulated population database. RESULTS A total of 171 patients were included. The median follow-up was 5.2 and 4.5 years in the ORN and control groups, respectively. The median time to ORN was 12 months. In univariate analysis, post-IMRT avulsions at the ORN site (hazard ratio [HR] = 3.6; 95% confidence interval [CI] = 1.5-8.9; P = .005), tumor laterality (HR, 4.4; 95% CI, = 1.4-14, P = .01), mean mandibular dose (HR, 1.1; 95% CI, = 1.01-1.1; P = .018) and mean dose to the ORN site (HR, 1.1; 95% CI, = 1.1-1.2; P < .001) correlated with higher ORN risk. In multivariate analysis, mean dose to the ORN site (HR, 1.1; 95% CI, = 1.1-1.2; P < .001) and post-IMRT avulsions at the ORN site (HR, 4.6; 95% CI, = 1.5-14.7; P = .009) were associated with ORN. For each increase in gray in dental dose, the ORN risk increased by 12%. Simulations confirmed study observations. CONCLUSIONS Dental dose and avulsions are associated with ORN, with a 12% increase in risk with each additional gray. Accurate dose information can help dentists in their decisions after IMRT.
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Affiliation(s)
- Marion Renouf
- Institut de Cancérologie de l'Ouest, Nantes, France; Centre Hospitalier Départemental Vendée, La Roche Sur Yon, France.
| | - Simon Auger
- Centre Hospitalier Universitaire, Nantes, France
| | - Loïc Campion
- Institut de Cancérologie de l'Ouest, Nantes, France; Nantes Université, INSERM 1307, CNRS 6075, Université d'Angers, CRCI2NA, Nantes, France
| | - Grégory Delpon
- Institut de Cancérologie de l'Ouest, Nantes, France; Laboratoire SUBATECH, UMR 6457 CNRS-IN2P3, IMT Atlantique, Nantes, France
| | - Julie Longis
- Maxillofacial Surgery Department, Centre Hospitalier Universitaire, Nantes, France
| | - Cécile Dupas
- Centre Hospitalier Universitaire, Nantes, France
| | - Pauline Blery
- Centre Hospitalier Universitaire, Nantes, France; INSERM UMRS 1229, France
| | - Juliette Thariat
- Centre François Baclesse, Caen, France; Laboratoire de Physique Corpusculaire IN2P3/ENSICAEN/CNRS UMR 6534, Normandie Université, Caen, France
| | - Mélanie Doré
- Institut de Cancérologie de l'Ouest, Nantes, France
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Buurman DJM, Speksnijder CM, Granzier ME, Timmer VCML, Hoebers FJP, Kessler P. The extent of unnecessary tooth loss due to extractions prior to radiotherapy based on radiation field and dose in patients with head and neck cancer. Radiother Oncol 2023; 187:109847. [PMID: 37543058 DOI: 10.1016/j.radonc.2023.109847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/01/2023] [Accepted: 07/31/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND AND PURPOSE Prior to radiotherapy (RT), teeth with poor prognosis that pose a risk for post-RT osteoradionecrosis (ORN) are removed. To allow enough time for adequate wound healing prior to RT, decisions are made based on the estimated radiation dose. This study aimed to gain insight into (1) the overall number of teeth extracted and (2) the patient and tumor characteristics associated with the number of redundantly extracted teeth. MATERIALS AND METHODS Patients with head and neck cancer (HNC), treated with RT between 2015 and 2019, were included in this cross-sectional study. For each extracted tooth the radiation dose was calculated retrospectively. The cut-off point for valid extraction was set at ≥ 40 Gy in accordance with the national protocol. Potential factors for doses ≥ 40 Gy were identified, including age, sex, tumor location, tumor (T) and nodal stage (N), overall tumor stage and number of teeth extracted. RESULTS A total of 1759 teeth were removed from 358 patients. Of these 1759 teeth, 1274 (74%) appeared to have been removed redundantly, based on the mean dose (Dmean) of < 40 Gy. Using the maximum dose (Dmax) of < 40 Gy, 1080 teeth (61%) appeared to have been removed redundantly. Tumor location and N-classification emerged as the most important associative variables in the multivariable regression analysis. CONCLUSION To our knowledge this is the first study to provide insight into the amount of teeth redundantly extracted prior to RT and represents a step forward in de-escalating the damage to the masticatory system prior to RT.
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Affiliation(s)
- Doke J M Buurman
- Maastricht University Medical Center, Department of Cranio-Maxillofacial Surgery, P.O. Box 5800 6202 AZ, Maastricht, the Netherlands; Maastricht University Medical Center, GROW School for Oncology and Reproduction, P.O. Box 616 6200 MD, Maastricht, the Netherlands.
| | - Caroline M Speksnijder
- Maastricht University Medical Center, Department of Cranio-Maxillofacial Surgery, P.O. Box 5800 6202 AZ, Maastricht, the Netherlands; University Medical Center Utrecht Cancer Center, Department of Head and Neck Surgical Oncology, Utrecht University, P.O. Box 85500 3508 GA, Utrecht, the Netherlands; University Medical Center Utrecht, Department of Oral and Maxillofacial Surgery and Special Dental Care, Utrecht University, P.O. Box 85500 3508 GA, Utrecht, the Netherlands
| | - Marlies E Granzier
- MAASTRO, Department of Radiation Oncology, Doctor Tanslaan 12 6229 ET, Maastricht, the Netherlands
| | - Veronique C M L Timmer
- Maastricht University Medical Center, Department of Cranio-Maxillofacial Surgery, P.O. Box 5800 6202 AZ, Maastricht, the Netherlands; Maastricht University Medical Center, GROW School for Oncology and Reproduction, P.O. Box 616 6200 MD, Maastricht, the Netherlands
| | - Frank J P Hoebers
- Maastricht University Medical Center, GROW School for Oncology and Reproduction, P.O. Box 616 6200 MD, Maastricht, the Netherlands; MAASTRO, Department of Radiation Oncology, Doctor Tanslaan 12 6229 ET, Maastricht, the Netherlands
| | - Peter Kessler
- Maastricht University Medical Center, Department of Cranio-Maxillofacial Surgery, P.O. Box 5800 6202 AZ, Maastricht, the Netherlands; Maastricht University Medical Center, GROW School for Oncology and Reproduction, P.O. Box 616 6200 MD, Maastricht, the Netherlands
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Duan J, Bernard ME, Castle JR, Feng X, Wang C, Kenamond MC, Chen Q. Contouring quality assurance methodology based on multiple geometric features against deep learning auto-segmentation. Med Phys 2023; 50:2715-2732. [PMID: 36788735 PMCID: PMC10175153 DOI: 10.1002/mp.16299] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 01/06/2023] [Accepted: 01/26/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Contouring error is one of the top failure modes in radiation treatment. Multiple efforts have been made to develop tools to automatically detect segmentation errors. Deep learning-based auto-segmentation (DLAS) has been used as a baseline for flagging manual segmentation errors, but those efforts are limited to using only one or two contour comparison metrics. PURPOSE The purpose of this research is to develop an improved contouring quality assurance system to identify and flag manual contouring errors. METHODS AND MATERIALS DLAS contours were used as a reference to compare with manually segmented contours. A total of 27 geometric agreement metrics were determined from the comparisons between the two segmentation approaches. Feature selection was performed to optimize the training of a machine learning classification model to identify potential contouring errors. A public dataset with 339 cases was used to train and test the classifier. Four independent classifiers were trained using five-fold cross validation, and the predictions from each classifier were ensembled using soft voting. The trained model was validated on a held-out testing dataset. An additional independent clinical dataset with 60 cases was used to test the generalizability of the model. Model predictions were reviewed by an expert to confirm or reject the findings. RESULTS The proposed machine learning multiple features (ML-MF) approach outperformed traditional nonmachine-learning-based approaches that are based on only one or two geometric agreement metrics. The machine learning model achieved recall (precision) values of 0.842 (0.899), 0.762 (0.762), 0.727 (0.842), and 0.773 (0.773) for Brainstem, Parotid_L, Parotid_R, and mandible contours, respectively compared to 0.526 (0.909), 0.619 (0.765), 0.682 (0.882), 0.773 (0.568) for an approach based solely on Dice similarity coefficient values. In the external validation dataset, 66.7, 93.3, 94.1, and 58.8% of flagged cases were confirmed to have contouring errors by an expert for Brainstem, Parotid_L, Parotid_R, and mandible contours, respectively. CONCLUSIONS The proposed ML-MF approach, which includes multiple geometric agreement metrics to flag manual contouring errors, demonstrated superior performance in comparison to traditional methods. This method is easy to implement in clinical practice and can help to reduce the significant time and labor costs associated with manual segmentation and review.
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Affiliation(s)
- Jingwei Duan
- Department of Radiation Medicine, University of Kentucky, Lexington, KY 40506
| | - Mark E. Bernard
- Department of Radiation Medicine, University of Kentucky, Lexington, KY 40506
| | - James R. Castle
- Carina Medical LLC, 145 Graham Ave, A168, Lexington, KY 40506
| | - Xue Feng
- Carina Medical LLC, 145 Graham Ave, A168, Lexington, KY 40506
| | - Chi Wang
- Department of Internal Medicine, University of Kentucky, Lexington, KY 40506
| | - Mark C. Kenamond
- Department of Radiation Medicine, University of Kentucky, Lexington, KY 40506
| | - Quan Chen
- Department of Radiation Medicine, University of Kentucky, Lexington, KY 40506
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Liao PH, Lin C, Huang JY, Lin HM, Kuo TJ. Association between tooth extraction during radiotherapy and the risk of osteoradionecrosis in patients with head and neck cancers. Eur Arch Otorhinolaryngol 2023; 280:2945-2952. [PMID: 36892614 DOI: 10.1007/s00405-023-07885-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/14/2023] [Indexed: 03/10/2023]
Abstract
PURPOSE It is commonly recommended that tooth extraction should be performed prior to radiotherapy (RT) in patients with head neck cancer to prevent osteoradionecrosis (ORN). However, doctors still occasionally encounter patients who require tooth extraction during RT. This study aimed to determine the risk of ORN in patients who undergo tooth extraction during RT. METHODS Data were collected from Taiwan's National Health Insurance Research Database. We retrospectively enrolled 24,412 patients with head and neck cancer treated with radiotherapy between 2011 and 2017. The associations between ORN and demographic characteristics, timing of tooth extraction, and treatments were examined using univariate and multivariable Cox proportional hazards regression models. RESULTS A total of 24,412 head and neck cancer patients were enrolled; 133 patients underwent tooth extraction during RT and 24,279 patients did not undergo tooth extraction during RT. Tooth extraction during RT was not associated with a significantly higher risk of ORN (hazard ratio [HR] = 1.303, P = 0.4862). Tumor site, RT dose ≥ 60 Gy, age < 55 y/o, mandibulectomy, chronic periodontitis, and chemotherapy were significantly associated with a higher risk of ORN. CONCLUSION The risk of ORN in head and neck cancer is not significantly different between patients who undergo tooth extraction during RT and patients who do not undergo tooth extraction during RT.
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Affiliation(s)
- Pei-Hsun Liao
- Department of Otolaryngology, Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Che Lin
- Department of Orthopaedic, Shuang Ho Hospital, New Taipei City, Taiwan
| | - Jing-Yang Huang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Hsin-Mei Lin
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tsu-Jen Kuo
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung, Taiwan.
- School of Dentistry, Chung Shan Medical University, 110, Sec. 1, Chien-Kuo N. Rd., Taichung, Taiwan.
- Department of Marine Biotechnology and Resources, National Sun Yat-Sen University, Kaohsiung, Taiwan.
- Eternal Dental Clinic, Taichung, Taiwan.
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Chua GWY, Vig PS. Overview of radiotherapy-induced chronic pain in childhood cancer survivors: A narrative review. PAEDIATRIC & NEONATAL PAIN 2023; 5:1-9. [PMID: 36911786 PMCID: PMC9997122 DOI: 10.1002/pne2.12094] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 12/15/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
Radiotherapy is an important aspect of oncological treatment in several childhood cancers. However, radiotherapy is known to have numerous side effects, including detrimental effects on growth, neurocognitive impairment, and the development of secondary malignancies. One less studied long-term side effect of pediatric radiotherapy treatment is chronic pain. While the short-term toxicities of radiotherapy resolve over a few weeks to months, the chronic pain caused by radiotherapy-induced tissue damage can significantly affect children's quality of life. As long-term childhood cancer survivors age into adulthood, they are typically followed up by a wide variety of doctors, not all of whom may be familiar with radiotherapy-induced chronic pain and its management. The aim of this review is to discuss the various common manifestations of radiotherapy-related pain in children, as well as ways to identify and manage these. Common radiotherapy-related side effects leading to chronic pain symptoms include radiation fibrosis, enteritis, dermatitis, lymphedema, neuropathic pain, and effects on bone development. The pathophysiology, evaluation and management of these are briefly summarized in this review. This is followed by an overview of radiotherapy techniques that allow greater sparing of normal tissue, minimizing future painful side effects. Finally, the assessment of pain in children is described, as well as strategies for management, and red flag symptoms that should prompt urgent specialist referral. In conclusion, a good understanding of the long-term side effects of radiotherapy treatment in children is essential for the various medical professionals that follow-up the child in the years after treatment. For young children, the evaluation of pain is in itself a challenge, and effects on growth, development, and learning are crucial. For older children, social and psychological factors become increasingly important. As radiation therapy techniques continue to advance, the spectrum and incidence of chronic pain syndromes may change over time.
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Affiliation(s)
- Gail Wan Ying Chua
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | - Prachi Simran Vig
- Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
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Ansinelli H, Gay C, Nguyen S, Morrison CM, Robbins JR. Personalized precision radiotherapy and its evolving role for human papillomavirus-positive oropharyngeal cancer. JOURNAL OF THE NATIONAL CANCER CENTER 2023; 3:72-82. [PMID: 39036313 PMCID: PMC11256722 DOI: 10.1016/j.jncc.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/19/2022] [Accepted: 11/30/2022] [Indexed: 12/31/2022] Open
Abstract
Human papilloma virus (HPV)-associated oropharyngeal cancer (OPC) is a unique entity with increased responsiveness to treatment and excellent oncologic outcomes. The purpose of this narrative review is to highlight how an improved prognosis for HPV (+) tumors and an ever-increasing understanding of the risk factors, risk stratification, and areas of potential spread are shaping management options. Additionally, we aim to detail how advances in treatment technology on both the surgical and radiation fronts are facilitating the delivery of increasingly personalized and precise treatments. This review will describe key aspects of recent and currently-ongoing trials investigating the de-escalation and individualization of treatment in this patient cohort, and how they are building a foundation for distinct treatment paradigms for HPV (+) tumors. Further studies into the integration of biomarker-guided treatments combined with clinical trial enrollment will help ensure a future of personalized treatments and improved outcomes, both in terms of oncologic outcomes and toxicity, for patients with HPV (+) OPC.
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Affiliation(s)
- Hayden Ansinelli
- University of Arizona College of Medicine, Department of Radiation Oncology, Tucson, United States
| | - Chris Gay
- University of Arizona College of Medicine, Department of Radiation Oncology, Tucson, United States
| | - Steven Nguyen
- University of Arizona College of Medicine, Department of Radiation Oncology, Tucson, United States
| | - Christopher M. Morrison
- University of Arizona College of Medicine, Department of Radiation Oncology, Tucson, United States
| | - Jared R. Robbins
- University of Arizona College of Medicine, Department of Radiation Oncology, Tucson, United States
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Lee CT, Litwin S, Yao CMKL, Liu JC, Ridge JA, Galloway TJ. Osteoradionecrosis rate in oropharynx cancer treated with dose volume histogram based constraints. Radiother Oncol 2022; 176:215-221. [PMID: 36252636 DOI: 10.1016/j.radonc.2022.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Mandibular dose constraints are designed to limit high dose to small volumes to avoid osteoradionecrosis (ORN). Based upon a published experience, intermediate-dose constraints were introduced but have not been independently validated. We hypothesize that these constraints lower ORN rate without compromising other organs at risk (OAR). METHODS Oropharyngeal cancer patients treated with standard fractionation adjuvant/definitive VMAT from 01/2014-08/2020 were included. In 09/2017, mandibular dose constraint was changed from historical constraint (HC) of D 0.1 cc < 70 Gy to modified constraints (MC) of V 44 Gy < 42%, V 58 Gy < 25%, D 0.5 cc < 70 Gy. OAR dosimetric changes and ORN development were evaluated. Regression modelling predicted long-term ORN cases in MC group. RESULTS There were 174 patients, 71 in MC group. Seven cases of ORN in HC group at a median follow up (FU) of 39 months and 1 case of ORN in MC group at a median FU of 11 months were observed. More patients in the MC group met V 44 Gy (87% vs 62%, p < 0.01) and V 58 Gy constraints (92% vs 73%, p < 0.01). Mean doses to OARs did not rise. Mandible V 44 Gy and V 58 Gy were significantly associated with ORN (p < 0.01 and p = 0.03, respectively) across all patients. In the HC group, V 44 Gy was independently associated with ORN (p = 0.01). To account for shorter FU in MC group, logistic regression of ORN based on V 44 Gy in HC patients was performed. This predicts 3.2 ORN cases in the MC group (95% CI: 0.00-6.4). CONCLUSION Achieving V 44 Gy and V 58 Gy was successful in 87% of cases without sacrificing target coverage or OARs and resulted in non-significant ORN decrease.
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Affiliation(s)
- Charles T Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA United States.
| | - Samuel Litwin
- Department of Biostatistics and Bioinformatics, Fox Chase Cancer Center, Philadelphia, PA United States.
| | - Christopher M K L Yao
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - Jeffrey C Liu
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States; Department of Otolaryngology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States.
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States.
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA United States.
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Tadokoro Y, Hasegawa T, Takeda D, Murakami A, Yatagai N, Iwata E, Saito I, Kusumoto J, Akashi M. Factors Associated with Treatment Outcomes and Pathological Features in Patients with Osteoradionecrosis: A Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116565. [PMID: 35682149 PMCID: PMC9180928 DOI: 10.3390/ijerph19116565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/19/2022] [Accepted: 05/26/2022] [Indexed: 12/10/2022]
Abstract
A standard treatment for osteoradionecrosis (ORN) has not yet been established because of the diversity. Therefore, identifying the risk factors for a poor prognosis is essential. This study retrospectively investigated the factors associated with the prognosis of ORN in 68 patients. Relevant clinical data of all patients were obtained. Of the patients, 16 who underwent extensive surgery underwent histopathological analysis. The necrotic changes of the anterior and posterior margins in the cortical and cancellous bones were investigated. Multivariate analyses showed statistically significant associations between poor prognosis in patients with ORN and high radiation dose (hazard ratio [HR] 1.15), orocutaneous fistula (HR 2.93), and absence of sequestration (HR 2.49). Histopathological analysis showed a viable anterior margin of the middle portion of the cortical bone for all recovered cases; in contrast, most cases (75%) with a poor prognosis showed necrotic changes. The anterior margin of the cancellous bone was viable and resilient to high irradiation, regardless of the prognosis. These results suggest that patients with orocutaneous fistula should receive early surgical intervention, even if the affected area is limited or asymptomatic. In extensive surgery, a sufficient safety margin of necrotic bone, particularly in the anterior region, is required to improve the prognosis.
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Glas HH, Kraeima J, Tribius S, Leusink FKJ, Rendenbach C, Heiland M, Stromberger C, Rashad A, Fuller CD, Mohamed ASR, Lai SY, Witjes MJH. Three-Dimensional Evaluation of Isodose Radiation Volumes in Cases of Severe Mandibular Osteoradionecrosis for the Prediction of Recurrence after Segmental Resection. J Pers Med 2022; 12:jpm12050834. [PMID: 35629256 PMCID: PMC9143211 DOI: 10.3390/jpm12050834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Pre-operative margin planning for the segmental resection of affected bone in mandibular osteoradionecrosis (ORN) is difficult. The aim of this study was to identify a possible relation between the received RT dose, exposed bone volume and the progression of ORN after segmental mandibular resection. Method: Patients diagnosed with grade 3-4 ORN for which a segmental resection was performed were included in the study. Three-dimensional reconstructions of RT isodose volumes were fused with postoperative imaging. The primary outcome was the recurrence of ORN after segmental resection. Subsequently, RT exposed mandibular bone volumes were calculated and the location of the bone cuts relative to the isodose volumes were assessed. Results: Five out of thirty-three patients developed recurrent ORN after segmental mandibular resection. All cases with recurrent ORN were resected inside an isodose volume of ≥56 Gy. The absolute mandibular volume radiated with 56 Gy was significantly smaller in the recurrent group (10.9 mL vs. 30.7 mL, p = 0.006), as was the proportion of the mandible radiated with 56 Gy (23% vs. 45%, p = 0.013). Conclusion: The volume of radiated bone was not predictive for risk of progression. The finding that recurrent ORN occurred with bone resection margins within the 56 Gy isodose volume suggests that this could serve as a starting point for the pre-operative planning of reducing the risk of ORN recurrence.
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Affiliation(s)
- Haye H. Glas
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9713GZ Groningen, The Netherlands; (J.K.); (M.J.H.W.)
- Correspondence: ; Tel.: +31-(0)50-361-25-61
| | - Joep Kraeima
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9713GZ Groningen, The Netherlands; (J.K.); (M.J.H.W.)
| | - Silke Tribius
- Hermann-Holthusen-Institute for Radiation Oncology, Asklepios Hospital St. Georg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Frank K. J. Leusink
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Center, 1100DD Amsterdam, The Netherlands;
| | - Carsten Rendenbach
- Department of Oral and Maxillofacial Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 12203 Berlin, Germany; (C.R.); (M.H.)
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 12203 Berlin, Germany; (C.R.); (M.H.)
| | - Carmen Stromberger
- Department of Radiation Oncology and Radiation Therapy, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 12203 Berlin, Germany;
| | - Ashkan Rashad
- Department of Oral, Maxillofacial and Facial Plastic Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany;
| | - Clifton D. Fuller
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.D.F.); (A.S.R.M.); (S.Y.L.)
| | - Abdallah S. R. Mohamed
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.D.F.); (A.S.R.M.); (S.Y.L.)
| | - Stephen Y. Lai
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (C.D.F.); (A.S.R.M.); (S.Y.L.)
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Max J. H. Witjes
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, 9713GZ Groningen, The Netherlands; (J.K.); (M.J.H.W.)
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Hyperbaric oxygen treatment of mandibular osteoradionecrosis: Combined data from the two randomized clinical trials DAHANCA-21 and NWHHT2009-1. Radiother Oncol 2021; 166:137-144. [PMID: 34843843 DOI: 10.1016/j.radonc.2021.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/22/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE Osteoradionecrosis (ORN) of the mandible is a serious complication of head and neck radiotherapy. This study aims to investigate the effect of hyperbaric oxygen (HBO) treatment on ORN in two randomized, controlled multicentre trials. METHODS AND MATERIALS Patients with ORN with indication for surgical treatment were randomised to either group 1: surgical removal of necrotic mandibular bone supplemented by 30 pre- and 10 postoperative HBO exposures at 243 kPa for 90 min each, or group 2: surgical removal of necrotic bone only. Primary outcome was healing of ORN one year after surgery evaluated by a clinically adjusted version of the Common Toxicity Criteria of Adverse Events (CTCAE) v 3.0. Secondary outcomes included xerostomia, unstimulated and stimulated whole salivation rates, trismus, dysphagia, pain, Activities of Daily Living (ADL) and quality of life according to EORTC. Data were combined from two separate trials. Ninety-seven were enrolled and 65 were eligible for the intent-to-treat analysis. The 33% drop-out was equally distributed between groups. RESULTS In group 1, 70% (21/30) healed compared to 51% (18/35) in group 2. HBO was associated with an increased chance of healing independent of baseline ORN grade or smoking status as well as improved xerostomia, unstimulated whole salivary flow rate, and dysphagia. Due to insufficient recruitment, none of the endpoints reached a statistically significant difference between groups. ADL data could only be obtained from 50 patients. CONCLUSION Hyperbaric oxygen did not significantly improve the healing outcome of osteoradionecrosis after surgical removal of necrotic bone as compared to standard care (70% vs. 51%). This effect is not statistically significant due to the fact that the study was underpowered and is therefore prone to type II error.
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11
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Blažek T, Zděblová Čermáková Z, Knybel L, Hurník P, Štembírek J, Resová K, Paračková T, Formánek M, Cvek J, Soumarová R. Dose escalation in advanced floor of the mouth cancer: a pilot study using a combination of IMRT and stereotactic boost. Radiat Oncol 2021; 16:122. [PMID: 34187494 PMCID: PMC8243893 DOI: 10.1186/s13014-021-01842-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE We evaluated the efficiency and toxicity of stereotactic hypofractionated boost in combination with conventionally fractionated radiotherapy in the treatment of advanced floor of the mouth cancer. METHODS Thirty-seven patients with advanced stage of the floor of the mouth cancer, histologically confirmed squamous cell carcinoma (p16 negative) ineligible for surgical treatment, were indicated for radiochemotherapy or hyperfractionated accelerated radiotherapy (HART). The radiotherapy protocol combined external beam radiotherapy (EBRT) and a stereotactic hypofractionated boost to the primary tumor. The dose delivered from EBRT was 70-72.5 Gy in 35/50 fractions. The hypofractionated boost followed with 10 Gy in two fractions. For the variables-tumor volume, stage and grade a multivariate analysis was performed to find the relationship between overall survival, local progression and metastasis. Toxicity was evaluated according to CTCAE scale version 4. RESULTS After a median follow-up of 16 months, 23 patients (62%) achieved complete remission. The median time to local progression and metastasis was 7 months. Local control (LC) at 2 and 5-years was 70% and 62%, respectively. Progression-free survival (PFS) and overall survival (OS) were 57% and 49% at 2 years and 41% and 27% at 5 years, respectively. Statistical analysis revealed that larger tumors had worse overall survival and a greater chance of metastasis. Log-Rank GTV > 44 ccm (HR = 1.96; [95% CI (0.87; 4.38)]; p = 0.11). No boost-related severe acute toxicity was observed. Late osteonecrosis was observed in 3 patients (8%). CONCLUSION The combination of EBRT and stereotactic hypofractionated boost is safe and seems to be an effective option for dose escalation in patients with advanced floor of the mouth tumors who are ineligible for surgical treatment and require a non-invasive approach.
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Affiliation(s)
- Tomáš Blažek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,3Rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Zuzana Zděblová Čermáková
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic. .,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.
| | - Lukáš Knybel
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Pavel Hurník
- Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Pathology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jan Štembírek
- Department of Oral and Maxillofacial Surgery, University Hospital Ostrava, Ostrava, Czech Republic.,Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Brno, Czech Republic
| | - Kamila Resová
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, Palacký University Olomouc, Olomouc, Czech Republic
| | - Tereza Paračková
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, Palacký University Olomouc, Olomouc, Czech Republic
| | - Martin Formánek
- Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Otorhinolaryngology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Renata Soumarová
- 3Rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic.,Department of Oncology, University Hospital Královské Vinohrady Prague, Prague, Czech Republic
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12
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Platelet-rich fibrin as a treatment option for osteoradionecrosis: A literature review. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2021; 123:e20-e27. [PMID: 34171527 DOI: 10.1016/j.jormas.2021.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/11/2021] [Accepted: 06/07/2021] [Indexed: 11/20/2022]
Abstract
The aim of this review is to establish the usefulness and effectiveness of using platelet-rich fibrin (PRF) in the treatment of osteoradionecrosis (ORN) lesions. A review of the literature was performed using keywords through the PubMed-Medline and Cochrane Library search engine. Inclusion criteria were: (1) original publication in either the French or the English language, (2) studies conducted in humans, (3) presence of ORN lesions following head and neck radiotherapy (RT), (4) use of PRF or derivates in the treatment of ORN lesions, (5) clinical variables and outcomes mentioned in the study. Overall, four case reports were retained. Two publications were removed from the initial seven results after application of the inclusion criteria. A recent randomised clinical trial was not considered since the group analysed the effectiveness of leukocyte-enriched Plasmas-Rich-Fibrin (LPRF) in preventing ORN, but not in treating it. Therefore, four publications were retained for analysis. Results suggest that using PRF as an adjunct to surgical therapy is beneficial in treating ORN lesions although no controlled studies were found. Therefore, additional controlled clinical studies are warranted to better define the effectiveness and recommendation of this approach.
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13
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Saito I, Hasegawa T, Kawashita Y, Kato S, Yamada SI, Kojima Y, Ueda N, Umeda M, Shibuya Y, Kurita H, Kirita T, Akashi M. Association between dental extraction after radiotherapy and osteoradionecrosis: A multi-centre retrospective study. Oral Dis 2021; 28:1181-1187. [PMID: 33650256 DOI: 10.1111/odi.13826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Radiotherapy (RT) carries a substantial risk for the development of osteoradionecrosis (ORN) of the jaw. This study was performed to investigate the relationship between dental extractions after RT and the development of ORN. MATERIAL AND METHODS Thirty-two patients with head and neck cancer who underwent tooth extraction after RT were investigated for correlations between the development of ORN and various factors. RESULTS Postextraction ORN was diagnosed in 12 (12.1%) teeth of 9 patients. The RT dose against the site of tooth extraction was 62.0 and 37.4 Gy in the ORN and Non-ORN groups, respectively (p < .001). The duration from RT to tooth extraction was 41.2 and 28.2 months in the ORN and Non-ORN groups, respectively (p = .025). Tooth extraction was significantly associated with ORN in patients with a high RT dose against the site (odds ratio = 1.231) and a longer duration of time from RT (odds ratio = 1.084). CONCLUSIONS Extraction of non-restorable teeth and those with a poor prognosis should not necessarily be postponed even when patients are undergoing RT. However, clinicians should pay special attention to postoperative management after tooth extraction in patients with a high RT dose and longer time from RT.
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Affiliation(s)
- Izumi Saito
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takumi Hasegawa
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yumiko Kawashita
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Shinichiro Kato
- Department of Oral and Maxillofacial Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shin-Ichi Yamada
- Department of Dentistry and Oral Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuka Kojima
- Department of Dentistry and Oral Surgery, Kansai Medical University, Hirakata, Japan
| | - Nobuhiro Ueda
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Kashihara, Japan
| | - Masahiro Umeda
- Department of Clinical Oral Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Yasuyuki Shibuya
- Department of Oral and Maxillofacial Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroshi Kurita
- Department of Dentistry and Oral Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tadaaki Kirita
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Kashihara, Japan
| | - Masaya Akashi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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14
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Liao PH, Chu CH, Hung YM, Tang PL, Kuo TJ. Tumor subsites and risk of osteoradionecrosis of the jaw in patients with oral cavity cancer: a national-based cohort study. Eur Arch Otorhinolaryngol 2021; 278:3425-3433. [PMID: 33389009 DOI: 10.1007/s00405-020-06529-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 11/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The association between the tumor subsites of the oral cavity and the risk of osteoradionecrosis of the jaw (ORNJ) remains unclear. We study the correlation between oral cavity tumor subsites and the risk of ORNJ in a nationwide population-based database. METHODS We enrolled 16,701 adult patients with oral cavity cancers who were treated with radiotherapy between 2000 and 2013. The subsites of the oral tumor, treatments of oral cavity cancers, and the timing of tooth extraction were examined for their association with ORNJ in oral cancer patients. RESULTS 903 patients (5.40%) developed ORNJ. Of the relevant variables, pre-RT mandible surgery, tooth extraction either before or after RT, and tumor sites were associated with the risk of ORNJ. The adjusted HRs for ORNJ in the mouth floor, gums, retromolar, and buccal cancer were 2.056 (1.490-2.837), 1.909 (1.552-2.349), 1.683 (1.105-2.562), and 1.303 (1.111-1.528), respectively, compared with the risk of tongue cancer. There was no significant difference in the risk of ORNJ between the pre-RT extraction group, the during-RT extraction group, and the post-RT extraction (less than 6 months) group; the post-RT extraction (more than 6 months) group had a significantly higher risk of ORNJ. CONCLUSIONS This study demonstrated that oral cavity tumor subsite is an independent risk factor of ORNJ after RT. Post-RT extraction (less than 6 months) group did not carry a significantly higher risk of ORNJ compared with pre-RT extraction group or during RT extraction group.
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Affiliation(s)
- Pei-Hsun Liao
- Department of Otolaryngology, Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chu
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Yao-Min Hung
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Yang Ming University, Taipei, Taiwan.,Yuhing Junior College of Health Care and Management, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal United Hospital, Kaohsiung, Taiwan
| | - Pei-Ling Tang
- Research Center of Medical Informatics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Nursing, Meiho University, Pingtung, Taiwan.,College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsu-Jen Kuo
- School of Dentistry, Chung Shan Medical University, 110, Sec. 1, Chien-Kuo N. Rd., 40201, Taichung, Taiwan. .,Department of Dentistry, Chung Shan Medical University Hospital, Taichung, Taiwan. .,Department of Marine Biotechnology and Resources, National Sun Yat-Sen University, Kaohsiung, Taiwan. .,Department of Stomatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
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15
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Patel D, Haria S, Patel V. Oropharyngeal cancer and osteoradionecrosis in a novel radiation era: a single institution analysis. ACTA ACUST UNITED AC 2020. [DOI: 10.1111/ors.12546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- D. Patel
- Department of Oral Surgery Stoke Mandeville Hospital Aylesbury UK
| | - S. Haria
- Fl 23 Oral Surgery Department Guy's & St Thomas' NHS Foundation Trust London UK
| | - V. Patel
- Fl 23 Oral Surgery Department Guy's & St Thomas' NHS Foundation Trust London UK
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16
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Assessment of risk factors associated with development of oronasal fistula as a late complication after carbon-ion radiotherapy for head and neck cancer. Radiother Oncol 2019; 144:53-58. [PMID: 31733488 DOI: 10.1016/j.radonc.2019.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/21/2019] [Accepted: 10/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Oronasal fistulae (ONF) are one of the rare but serious complications of conventional photon radiotherapy. This study aimed to identify the risk factors for the development of ONF after carbon-ion radiotherapy (C-ion RT). MATERIALS AND METHODS The data of 62 cases of sinonasal and oral cavity cancers treated with C-ion RT and followed-up in excess of 5 years were retrospectively reviewed. The correlation between the clinical and dosimetric parameters and the development of ONF was analysed. RESULTS A total of 80.6% cases had sinonasal malignancies, and most tumours had advanced T stages (96.8%). Maxillary invasion was observed in 16 cases (25.8%), and malignant melanoma was the most common histology (46.8 %). All the cases received a dose of between 57.6 Gy (RBE) and 64 Gy (RBE) in 16 fractions over 4 weeks. At a median follow up of 88.8 months, 23 cases (37.1%) developed small localised ONF; however, none were of grade III severity. On separate multivariate analyses of clinical parameters in the entire cohort and in cases without maxillary invasion, the number of teeth irradiated with more than 50 Gy (RBE) was found to be the common significant independent risk factor for development of ONF. CONCLUSION The number of teeth irradiated with more than 50 Gy (RBE) is a significant independent risk factor for the development of ONF, which is a late complication of C-ion RT delivered in 16 fractions.
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17
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Renda L, Tsai TY, Huang JJ, Ito R, Hsieh WC, Kao HK, Hung SY, Huang Y, Huang YC, Chang YL, Cheng MH, Chang KP. A nomogram to predict osteoradionecrosis in oral cancer after marginal mandibulectomy and radiotherapy. Laryngoscope 2019; 130:101-107. [PMID: 30786034 DOI: 10.1002/lary.27870] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/15/2019] [Accepted: 01/25/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE There is no useful tool to clinically predict the occurrence of osteoradionecrosis (ORN) of the mandible quantitatively. The aim was to investigate the risk factors, including different modalities of radiotherapy, for developing mandibular ORN in patients undergoing marginal mandibulectomy and postoperative radiotherapy. METHODS Between January 2006 and December 2012, 167 subjects who underwent marginal mandibulectomy and postoperative radiotherapy with different modalities were enrolled. The association of ORN with mandibular bone measurements and patient variables was analyzed, and a nomogram was established. RESULTS Fifteen (8.98%) of the 167 patients developed ORN during the follow-up period, and ORN was significantly associated with diabetes mellitus (DM), body mass index (BMI), remaining bone height, remaining bone height to original bone height ratio, resected bone height to original bone height ratio, and mandibular dose (P: < 0.001, 0.004, 0.042, 0.018, 0.010, 0.020, respectively). Interestingly, the risk of ORN had no significant difference between conformal and intensity modulation radiation therapy (P = 0.407). Multivariate analysis revealed that DM and resected bone height to original bone height ratio ≥ 50% were independent risk factors for postoperative ORN. A nomogram consisting of BMI, DM, resected bone height to original bone height ratio, mandibulotomy, and mandibular dose for predicting the ORN-free probability was established; and the c-index of the nomogram for ORN status was 0.803. CONCLUSION A nomogram based on the risk factors was plotted to strengthen the prediction of ORN quantitatively. Surgeons should be more discrete regarding the treatment plan for patients with higher probability of ORN. LEVEL OF EVIDENCE 3b Laryngoscope, 130:101-107, 2020.
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Affiliation(s)
- Levent Renda
- Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Antalya Research and Education Hospital, Antalya, Turkey
| | - Tsung-You Tsai
- Department of Pathology, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan
| | - Jung-Ju Huang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ran Ito
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan
| | - Wei-Chuan Hsieh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan
| | - Huang-Kai Kao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Yu Hung
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan
| | - Yenlin Huang
- Department of Pathology, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan
| | - Yu-Chen Huang
- Department of Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan
| | - Yu-Liang Chang
- Department of Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan
| | - Ming-Huei Cheng
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kai-Ping Chang
- Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Kwei-Shan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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von der Grün J, Köhn J, Loutfi-Krauss B, Blanck O, Rödel C, Balermpas P. Second infield re-irradiation with a resulting cumulative equivalent dose (EQD2 max ) of >180 Gy for patients with recurrent head and neck cancer. Head Neck 2018; 41:E48-E54. [PMID: 30521102 DOI: 10.1002/hed.25428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/23/2018] [Accepted: 09/21/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND For locally recurrent head and neck cancer, re-irradiation with modern techniques like stereotactic body radiotherapy is a promising, possibly curative alternative to palliative systemic therapy. METHODS We report on 1 patient with nasopharyngeal carcinoma (NPC) and 1 patient with cutaneous squamous cell carcinoma (SCC). Both patients received full dose primary treatment (>66 Gy, EQD2), full dose re-irradiation (>50 Gy, EQD2), and a second course of re-irradiation via robotic radiosurgery (CyberKnife) for a second local recurrence. RESULTS Both treatments resulted in adequate tumor response. No grade III-IV acute or late toxicities occurred. Follow-up at 6 months after third irradiation showed partial remission for the patient with NPC. In the second case (SCC), no toxicities occurred and the tumor was in remission 18 months after last treatment. CONCLUSION These cases show that a second course of re-irradiation utilizing modern techniques like robotic radiosurgery might be feasible for carefully selected patients with head and neck cancer.
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Affiliation(s)
- Jens von der Grün
- Department of Radiation Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Janett Köhn
- Department of Radiation Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Britta Loutfi-Krauss
- Department of Radiation Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany.,Saphir Radiosurgery Center, Frankfurt, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Frankfurt, Germany.,Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Claus Rödel
- Department of Radiation Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK) Partner Site Frankfurt am Main, Germany
| | - Panagiotis Balermpas
- Department of Radiation Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany.,Saphir Radiosurgery Center, Frankfurt, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK) Partner Site Frankfurt am Main, Germany
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Irie MS, Mendes EM, Borges JS, Osuna LGG, Rabelo GD, Soares PBF. Periodontal therapy for patients before and after radiotherapy: A review of the literature and topics of interest for clinicians. Med Oral Patol Oral Cir Bucal 2018; 23:e524-e530. [PMID: 30148466 PMCID: PMC6167093 DOI: 10.4317/medoral.22474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/22/2018] [Indexed: 11/22/2022] Open
Abstract
Background To review and discuss important topics regarding periodontal treatment pre- and post-radiotherapy for head and neck cancer in human patients; to discuss the references for adequate techniques, the appropriate moment for tooth extractions and periodontal management; and to discuss the prevention of osteoradionecrosis. Material and Methods Thirty-nine studies including original studies, randomized clinical trials (RCTs) and reviews were searched in online databases MEDLINE (PubMed) and the Cochrane library. No year of publication restriction was applied. Results Language was restricted to English, and the following Medical Subject Heading terms were used: radiotherapy, radiation therapy and periodontal treatment. Studies regarding periodontal treatment and tooth extraction that involved clinical management of irradiated patients were selected. Conclusions The treatment of periodontal diseases before radiotherapy is mainly required to avoid future dental extraction and to reduce the development of osteoradionecrosis. Periodontal treatment in irradiated patients mostly includes scaling and root planing, extraction of condemned teeth and topical and systemic antimicrobial therapy. Tooth removal should be planned at least 14 days before the first day of radiation treatment. Particular care and mouthwashes should be taken during and after radiation. Clinical Significance The management of irradiated patients represents a challenge for health professionals, including dentists. It is important to establish recommendations for clinicians concerning dental and periodontal management in irradiated patients before, during and after treatment. Key words:Head and neck cancer, radiotherapy, periodontal treatment, periodontitis.
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Affiliation(s)
- M-S Irie
- Universidade Federal de Uberlândia, Faculdade de Odontologia, Av. Pará, 1720, Bloco 4L, Anexo A, Campos Umuarama, CEP: 38400-902, Uberlândia, Minas Gerais, Brazil,
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20
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Jumeau R, Nguyen-Tan PF, Bahig H, Liem X, Lambert L, Schmittbuhl M, Simard D, Filion E. Pre-irradiation dental care: Ready-to-use templates for oropharyngeal cancers. Rep Pract Oncol Radiother 2018; 23:270-275. [PMID: 30090026 DOI: 10.1016/j.rpor.2018.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/02/2018] [Accepted: 06/23/2018] [Indexed: 11/30/2022] Open
Abstract
Aim To develop a tool in order to guide pre-irradiation dental care (PIDC) for patients with oropharyngeal cancers. Background Osteoradionecrosis of the jaws is a potential complication of radiotherapy (RT) for head and neck cancers. To prevent this complication, PIDC can involve multiple dental extractions as a preventative measure to avoid post-RT complications. However, there is no standardized tool to guide PIDC. Materials and methods From January 2005 to October 2015, 120 head and neck cancer patients were prospectively included in a study investigating dysgeusia after RT. From this cohort, patients were enrolled according to the following inclusion criteria: histopathological confirmation of oropharyngeal squamous cell carcinoma; stage T1-4 N1-3 M0; ≤10 missing teeth. Individual teeth were retrospectively delineated on planning computed tomography and doses to dentition were assessed to generate templates. Results Thirty-three patients were included. Molars received highest doses with a mean dose of 50 Gy (range; 19-75 Gy). Ipsi-lateral and contralateral wisdom teeth received RT dose superior to 50 Gy in 92% and 56% of cases, respectively. Patients with advanced disease (T4 or N2c-3) received higher mean doses on inferior and ipsi-lateral dental arches compared to other patients (T1-3 N0-2b): 42 Gy vs. 39 Gy and 44 Gy vs. 39 Gy (p < 0.05), respectively. Conclusion Pre-RT dose distribution templates are an objective way to prepare PIDC. Further studies with a larger cohort are needed to validate these templates.
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Affiliation(s)
- Raphaël Jumeau
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Phuc Félix Nguyen-Tan
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Houda Bahig
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Xavier Liem
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Louise Lambert
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Matthieu Schmittbuhl
- Faculty of Dentistry, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Dany Simard
- Department of Radiation Physics, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Edith Filion
- Department of Radiation Oncology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
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Tursun R, Green JM, Winokur D, Ledoux A. Synchronous Reconstruction of a Total Mandibulectomy Defect With a Single Fibula Osteocutaneous Free Flap. J Oral Maxillofac Surg 2017; 76:230.e1-230.e8. [PMID: 28961429 DOI: 10.1016/j.joms.2017.08.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/24/2017] [Accepted: 08/25/2017] [Indexed: 10/18/2022]
Abstract
Osteoradionecrosis (ORN) is a well-known and usually late complication of radiation therapy in the treatment of head and neck cancer. Although the therapy can be life extending, it also produces tissue toxicity in ipsilateral and contralateral tissues in an acute and chronic fashion. In the most severe cases of ORN, such as the one presented in this report, bilateral disease results in the need for total mandibulectomy and creates a tremendous reconstructive challenge. The advent of microvascular surgery and free tissue transfer has caused an evolution of the management protocol for severe ORN cases. This report describes a unique case of total mandibulectomy with synchronous reconstruction using a single vascularized fibula osteocutaneous flap with subsequent dental implant reconstruction and prosthetic rehabilitation.
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Affiliation(s)
- Ramzey Tursun
- Assistant Professor of Clinical Surgery and Director, Head and Neck Oncologic and Microvascular Reconstructive Surgery, Division of Oral and Maxillofacial Surgery, University of Miami-Miller School of Medicine/Jackson Health System, Miami, FL.
| | - J Marshall Green
- Associate Program Director, Facial Plastic and Reconstructive Surgery, Oral-Head and Neck Oncology, Division of Oral and Maxillofacial Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; Assistant Professor of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD; Adjunct Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, University of Miami-Miller School of Medicine, Miami, FL
| | - Daniel Winokur
- Chief Resident, Division of Oral and Maxillofacial Surgery, University of Miami-Miller School of Medicine/Jackson Health System, Miami, FL
| | - Andre Ledoux
- Fellow, Head and Neck Oncologic and Microvascular Reconstructive Surgery, Division of Oral and Maxillofacial Surgery, University of Miami-Miller School of Medicine/Jackson Health System, Miami, FL
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22
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Singh AK, Mimikos C, Groman A, Dibaj S, Platek AJ, Cohan DM, Hicks WL, Gupta V, Arshad H, Kuriakose MA, Warren GW, Platek ME. Combined surgery and radiation improves survival of tonsil squamous cell cancers. Oncotarget 2017; 8:112442-112450. [PMID: 29348837 PMCID: PMC5762522 DOI: 10.18632/oncotarget.20122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 07/31/2017] [Indexed: 01/07/2023] Open
Abstract
Objective The study evaluated the addition of surgery (S) to radiation (RT) on survival of squamous cell carcinomas (SCC) of tonsillar-fossa (TF) in a modern cohort with similar epidemiology and treatment as current patients. Study Design Retrospective analysis utilizing Surveillance, Epidemiology, and End Results (SEER) Program data. Results For all stages combined TF patients who received S+RT had superior OS (p < 0.01) and DSS (p < 0.01). For each stage OS and DSS was superior for S+RT (p < 0.05). In multivariate analysis, HRs for OS were statistically significantly higher for TF patients (stage 2, 3, and 4) receiving RT alone (p < 0.001). Materials and Methods TF SCC patients treated with either S+RT or RT alone between 2004 and 2011 were examined (n = 6,476). Primary outcome measures included overall survival (OS) and disease specific survival (DSS). Cox proportional hazard ratios (HR) were estimated for patients treated with S+RT compared to RT alone. Conclusions OS and DSS were superior for all stages combined and for stages 2, 3, and 4 in TF patients who received S+RT compared to RT alone.
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Affiliation(s)
- Anurag K Singh
- Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Christina Mimikos
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Adrienne Groman
- Department of Biostatistics, Roswell Park Cancer Institute, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Shiva Dibaj
- Department of Biostatistics, Roswell Park Cancer Institute, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Alexis J Platek
- Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - David M Cohan
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Wesley L Hicks
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Vishal Gupta
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Hassan Arshad
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Moni A Kuriakose
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Graham W Warren
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA.,Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston, SC, USA
| | - Mary E Platek
- Department of Head and Neck/Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA.,Department of Health, Nutrition and Dietetics, Buffalo State College (SUNY), Buffalo, NY, USA
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Dose-volume correlates of mandibular osteoradionecrosis in Oropharynx cancer patients receiving intensity-modulated radiotherapy: Results from a case-matched comparison. Radiother Oncol 2017; 124:232-239. [PMID: 28733053 PMCID: PMC5572506 DOI: 10.1016/j.radonc.2017.06.026] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 06/22/2017] [Accepted: 06/25/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine dosimetric parameters associated with osteoradionecrosis (ORN) in oropharyngeal cancer (OPC) patients in the IMRT era. MATERIAL AND METHODS Subsequent to institutional review board approval, we identified ORN in OPC patients treated with IMRT from 2002 to 2013. 1:2 case-control matching was implemented. Mandibular dose-volume histograms (DVH) were extracted. Dosimetric parameters were compared using non-parametric stats. Recursive partitioning analysis (RPA) was done to identify DVH correlates of ORN. RESULTS 68 ORN cases and 131 controls were matched. Median follow-up was 41months and median time to development of ORN was 16months. Mandibular mean dose was significantly higher in the ORN cohort (48.1 vs 43.6Gy, p<0.0001). However, the maximum dose was not statistically different. DVH bins from V35 to V73 were all significantly higher in the ORN cohort compared with controls (p<0.0006). Two DVH parameters were identified in RPA analysis, V43 and V58. The majority (81%) of ORN cases were observed with both V44≥42% and V58≥25%. CONCLUSIONS Our data demonstrate that a wide range of DVH parameters in the intermediate and high beam path were all significantly higher in ORN patients. Mandibular V44<42% and V58<25% represent reasonable DVH constraints for IMRT plan acceptability, when tumor coverage is not compromised.
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24
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Lai TY, Wang TH, Liu CJ, Chao TF, Chen TJ, Hu YW. Risk factors for osteonecrosis of the jaw in oral cancer patients after surgery and eventual adjuvant treatment: The potential role of chemotherapy. Radiother Oncol 2017; 123:406-411. [PMID: 28532609 DOI: 10.1016/j.radonc.2017.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/13/2017] [Accepted: 05/04/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE To identify the risk factors for osteonecrosis of the jaw (ONJ) in oral cancer patients after surgery with and without adjuvant therapy in a nationwide, population-based study. MATERIAL AND METHODS Using the Taiwan National Health Insurance Research Dataset, we recruited patients with newly diagnosed oral cancer between 1997 and 2011. All of them underwent primary surgery. Data regarding demographic characteristics; tooth extractions; medications; and cancer treatments, including types of mandibular surgery, radiotherapy and platinum-based chemotherapy, were collected for analysis. RESULTS We identified 25,858 patients who suffered 2802 ONJ events. The ONJ incidence rate was 3.45 per 100 person-years. Lip cancer was associated with the highest risk of ONJ, followed by buccal mucosa, gum, mouth floor and tongue cancer. Using a time-dependent Cox regression model, multivariable analysis demonstrated that mandibulotomy (hazard ratio (HR), 1.25; 95% confidence interval (CI), 1.01-1.55; p<0.001), radiotherapy (HR, 1.39; 95% CI, 1.26-1.54; p<0.001) and platinum-based chemotherapy (HR, 1.94; 95% CI, 1.56-2.41; p<0.001) were significant risk factors for ONJ. In the subgroup analysis of patients receiving radiotherapy and patients not receiving radiotherapy, platinum-based chemotherapy remained a risk factor for ONJ. CONCLUSIONS Mandibulotomy, radiotherapy and platinum-based chemotherapy were associated with an increased ONJ risk. Chemotherapy was a risk factor regardless of whether radiotherapy was administered.
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Affiliation(s)
- Tzu-Yu Lai
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taiwan
| | - Ti-Hao Wang
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taiwan; Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Jen Liu
- Division of Hematology and Oncology, Department of Internal Medicine, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Wen Hu
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.
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25
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Oertel M, Reinartz G, Scobioala S, Eich HT. Successful treatment of a rare case of ameloblastic fibrosarcoma with radiation therapy. Strahlenther Onkol 2017; 193:666-672. [DOI: 10.1007/s00066-017-1136-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 04/01/2017] [Indexed: 11/30/2022]
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26
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Dieleman F, Phan T, van den Hoogen F, Kaanders J, Merkx M. The efficacy of hyperbaric oxygen therapy related to the clinical stage of osteoradionecrosis of the mandible. Int J Oral Maxillofac Surg 2017; 46:428-433. [DOI: 10.1016/j.ijom.2016.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 11/26/2016] [Accepted: 12/09/2016] [Indexed: 10/20/2022]
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27
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Razfar A, Mundi J, Grogan T, Lee S, Elashoff D, Abemayor E, St John M. IMRT for head and neck cancer: Cost implications. Am J Otolaryngol 2016; 37:479-483. [PMID: 27968955 DOI: 10.1016/j.amjoto.2015.02.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 02/07/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Intensity-modulated radiotherapy (IMRT) is a dose-delivery technology allowing for a reduction in radiotherapy side effects. It has been rapidly adopted despite the lack of prospective studies showing improved outcomes. We sought to compare the cost through Medicare reimbursement patterns of surgery, IMRT, and conventional XRT in treating head and neck cancer. We then identified factors that correlate with these differences. METHODS Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data were examined to determine treatment patterns for 47,237 patients with head and neck carcinoma from 2000 to 2007. We identified 14,748 patients that met our inclusion criteria. We then compared cost related to head and neck cancer treatments on the basis of Medicare payments. RESULTS From 2000 to 2007, the usage of IMRT increased from 1.5% to 48.6% while the usage of conventional XRT decreased from 98.5% to 51.4% (p<0.0001). During this time, patients undergoing IMRT had a mean cost of $101,099 compared to $42,843 for XRT. For patients with early stage tumors, surgery alone cost $18,140, traditional XRT $32,296 while IMRT cost $95,047 (p<0.0001). When removing patients who underwent concomitant chemotherapy, patients treated with IMRT cost $67,576 compared to $24,955 for non-IMRT patients (p<0.0001). CONCLUSIONS IMRT has become widely adopted as a primary treatment modality in head and neck cancer. We demonstrated that IMRT is significantly more costly than traditional treatment for head and neck cancers. Prospective studies investigating the comparative efficacy of IMRT will be needed in order to determine if this increased cost correlates with patient outcomes. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Ali Razfar
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jagmeet Mundi
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Tristan Grogan
- Department of Biostatistics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Steve Lee
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David Elashoff
- Department of Biostatistics, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Elliot Abemayor
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; UCLA Head and Neck Cancer Program, Los Angeles, CA
| | - Maie St John
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; UCLA Head and Neck Cancer Program, Los Angeles, CA.
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28
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De Felice F, Musio D, Tombolini V. Osteoradionecrosis and intensity modulated radiation therapy: An overview. Crit Rev Oncol Hematol 2016; 107:39-43. [PMID: 27823650 DOI: 10.1016/j.critrevonc.2016.08.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 07/12/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022] Open
Abstract
Osteoradionecrosis (ORN) is an ongoing topic, especially about its definition, pathogenesis, staging system and management algorithm. But what about its real incidence in intensity modulated radiotherapy (IMRT) era? This paper discusses the mandible in radiation therapy planning as organ at risk and reviews the literature for evidence of radiation damage, discussing likely dose constraints and the use of IMRT to reduce radiation dose to this structure. PubMed search was performed.
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Affiliation(s)
- Francesca De Felice
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Viale Regina Elena 326, 00161 Rome, Italy.
| | - Daniela Musio
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Viale Regina Elena 326, 00161 Rome, Italy
| | - Vincenzo Tombolini
- Department of Radiotherapy, Policlinico Umberto I "Sapienza" University of Rome, Viale Regina Elena 326, 00161 Rome, Italy; Spencer-Lorillard Foundation, Viale Regina Elena 262, Rome, Italy
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29
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Dynamic contrast-enhanced MRI detects acute radiotherapy-induced alterations in mandibular microvasculature: prospective assessment of imaging biomarkers of normal tissue injury. Sci Rep 2016; 6:29864. [PMID: 27499209 PMCID: PMC4976364 DOI: 10.1038/srep29864] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 06/27/2016] [Indexed: 11/28/2022] Open
Abstract
Normal tissue toxicity is an important consideration in the continued development of more effective external beam radiotherapy (EBRT) regimens for head and neck tumors. The ability to detect EBRT-induced changes in mandibular bone vascularity represents a crucial step in decreasing potential toxicity. To date, no imaging modality has been shown to detect changes in bone vascularity in real time during treatment. Based on our institutional experience with multi-parametric MRI, we hypothesized that DCE-MRI can provide in-treatment information regarding EBRT-induced changes in mandibular vascularity. Thirty-two patients undergoing EBRT treatment for head and neck cancer were prospectively imaged prior to, mid-course, and following treatment. DCE-MRI scans were co-registered to dosimetric maps to correlate EBRT dose and change in mandibular bone vascularity as measured by Ktrans and Ve. DCE-MRI was able to detect dose-dependent changes in both Ktrans and Ve in a subset of patients. One patient who developed ORN during the study period demonstrated decreases in Ktrans and Ve following treatment completion. We demonstrate, in a prospective imaging trial, that DCE-MRI can detect dose-dependent alterations in mandibular bone vascularity during chemoradiotherapy, providing biomarkers that are physiological correlates of acute of acute mandibular vascular injury and recovery temporal kinetics.
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30
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Kuhnt T, Stang A, Wienke A, Vordermark D, Schweyen R, Hey J. Potential risk factors for jaw osteoradionecrosis after radiotherapy for head and neck cancer. Radiat Oncol 2016; 11:101. [PMID: 27473433 PMCID: PMC4967325 DOI: 10.1186/s13014-016-0679-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 07/23/2016] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION To identify potential risk factors for the development of jaw osteoradionecrosis (ORN) after 3D-conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) among patients with newly diagnosed head and neck cancer. MATERIAL AND METHODS This study included 776 patients who underwent 3D-CRT or IMRT for head and neck cancer at the Department of Radiotherapy at the University Hospital Halle-Wittenberg between 2003 and 2013. Sex, dental status prior to radiotherapy, tumor site, bone surgery during tumor resection, concomitant chemotherapy, and the development of advanced ORN were documented for each patient. ORN was classified as grade 3, 4, or 5 according to the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer classification or grade 3 or 4 according to the late effects in normal tissues/subjective, objective, management, and analytic scale. The cumulative incidence of ORN was estimated. Cox regression analysis was used to identify prognostic risk factors for the development of ORN. RESULTS Fifty-one patients developed advanced ORN (relative frequency 6.6 %, cumulative incidence 12.4 %). The highest risk was found in patients who had undergone primary bone surgery during tumor resection (hazard ratio [HR] = 5.87; 95 % confidence interval [CI]: 3.09-11.19) and in patients with tumors located in the oral cavity (HR = 4.69; 95 % CI: 1.33-16.52). Sex, dentition (dentulous vs. edentulous), and chemotherapy had no clinically relevant influence. DISCUSSION AND CONCLUSION In contrast to most previous studies, we noted a low cumulative incidence of advanced ORN. Patients with tumors located in the oral cavity and those who undergo bone surgery during tumor resection prior to RT may be considered a high-risk group for the development of ORN.
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Affiliation(s)
- Thomas Kuhnt
- Department of Diagnostic Imaging and Radiation Medicine, University Clinic, University Leipzig, Leipzig, Germany
| | - Andreas Stang
- Department of Medical Informatics, Biometry and Epidemiology, University Clinic Essen, Essen, Germany
| | - Andreas Wienke
- Department of Medical Epidemiology, Biometry and Computer Science Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Dirk Vordermark
- Department of Radiotherapy, University Clinic, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Ramona Schweyen
- Department of Prosthetic Dentistry, University School of Dental Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Jeremias Hey
- Department of Prosthetic Dentistry, University School of Dental Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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31
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Dhanda J, Pasquier D, Newman L, Shaw R. Current Concepts in Osteoradionecrosis after Head and Neck Radiotherapy. Clin Oncol (R Coll Radiol) 2016; 28:459-66. [PMID: 27038708 DOI: 10.1016/j.clon.2016.03.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/01/2016] [Accepted: 03/10/2016] [Indexed: 11/17/2022]
Abstract
Osteoradionecrosis (ORN) of the jaws is a feared complication of head and neck radiotherapy. ORN causes significant morbidity for patients and controversy among clinicians. This overview considers the variations in definition and classification of the condition that affect estimates of incidence and also the interpretation of evidence. The influence of newer radiotherapy techniques in reducing ORN through reduced dose and xerostomia is balanced against a probable increase in a vulnerable population through a rising head and neck cancer incidence. Theories of pathophysiology of ORN include radiation-induced osteomyelitis, hypoxic and hypovascular theory and fibroatrophic theory. Prevention strategies include restorative dentistry and radiation planning techniques. Treatments range from conservative 'watch and wait' through to more radical surgical strategies. Newer medical management strategies are available with a limited evidence base. The use of hyperbaric oxygen therapy remains controversial and the background and need for newer hyperbaric oxygen trials is discussed.
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Affiliation(s)
- J Dhanda
- Department of Maxillofacial Surgery, Queen Victoria Hospital, East Grinstead, UK.
| | - D Pasquier
- Academic Department of Radiation Oncology, Centre O. Lambret, Lille, CRIStAL UMR CNRS 9189, France
| | - L Newman
- Department of Maxillofacial Surgery, Queen Victoria Hospital, East Grinstead, UK
| | - R Shaw
- Department of Molecular and Clinical Cancer Medicine, North West Cancer Research Centre, The University of Liverpool Cancer Research Centre, Liverpool, UK
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32
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Osteoradionecrosis following treatment for head and neck cancer and the effect of radiotherapy dosimetry: the Guy's and St Thomas' Head and Neck Cancer Unit experience. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 122:28-34. [DOI: 10.1016/j.oooo.2016.01.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/05/2016] [Accepted: 01/09/2016] [Indexed: 11/23/2022]
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33
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Maesschalck TD, Dulguerov N, Caparrotti F, Scolozzi P, Picardi C, Mach N, Koutsouvelis N, Dulguerov P. Comparison of the incidence of osteoradionecrosis with conventional radiotherapy and intensity-modulated radiotherapy. Head Neck 2016; 38:1695-1702. [PMID: 27240700 DOI: 10.1002/hed.24505] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Modern techniques of radiotherapy are supposed to decrease the incidence of osteoradionecrosis of the mandible (ORNM). The purpose of this study was to compare the incidence of ORNM after intensity-modulated radiotherapy (IMRT) in comparison to conventional 3D conformal radiotherapy techniques (conventional RT). METHODS We conducted a retrospective study of consecutive unselected patients treated in a single institution between 2002 and 2012. To minimize confounding effects, only patients with oropharyngeal carcinoma without surgery of the primary site were included. RESULTS The cohorts included 145 patients in the conventional RT group and 89 patients in the IMRT group. Total incidence rate of ORNM was similar for both groups with rates of 11% versus 10% (n = 16 for conventional RT and n = 9 for IMRT; p = 1.0). Subanalysis revealed more ORNM in T4 classified lesions with IMRT (p = .007). Analysis of different risk factors showed no statistically significant difference between ORNM and no-ORNM patients. CONCLUSION We found no reduction in ORNM with IMRT. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.
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Affiliation(s)
- Thibault De Maesschalck
- Department of Oto-Rhino-Laryngology - Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Nicolas Dulguerov
- Department of Oto-Rhino-Laryngology - Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Francesca Caparrotti
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Paolo Scolozzi
- Department of Maxillo-Facial Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Cristina Picardi
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Nicolas Mach
- Department of Medical Oncology, Geneva University Hospital, Geneva, Switzerland
| | | | - Pavel Dulguerov
- Department of Oto-Rhino-Laryngology - Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland.
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Kuo TJ, Leung CM, Chang HS, Wu CN, Chen WL, Chen GJ, Lai YC, Huang WC. Jaw osteoradionecrosis and dental extraction after head and neck radiotherapy: A nationwide population-based retrospective study in Taiwan. Oral Oncol 2016; 56:71-7. [PMID: 27086489 DOI: 10.1016/j.oraloncology.2016.03.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/04/2016] [Accepted: 03/07/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Osteoradionecrosis of the jaws (ORNJ) is painful for patients and relatively difficult to treat clinically. The high risk of ORNJ for post radiotherapy R/T dental extraction is known; however, many patients still have to have teeth extracted after head and neck R/T. The objective of the present study is to review post R/T dental extraction and determine the ORNJ risk. MATERIALS AND METHODS We preformed a retrospective cohort study of 1759 patients with head and neck cancer s/p R/T from a random sample of 1,000,000 insurants in the National Health Insurance Research Database during 2000-2013 in Taiwan. Statistical methods included two-proportion Z-test. RESULTS We evaluated two cohorts: 522 patients with post R/T dental extraction and 1237 patients without post R/T extraction. Overall moderate-to-severe ORNJ after R/T was 2.22% (39/1759), and a total of 39 ORNJ cases were noted during an average of 3.02years (range: 0.62-8.89years, ±2.07). ORNJ prevalence in the overall post R/T extraction-exposed cohort (5.17%, 27/522) was significantly greater than that in the unexposed cohort (0.97%, 12/1237). In a group of patients with ⩽5 post R/T dental extractions (n=373), the ORNJ risk was 2.4% (ORNJ case n=9); in a group of patients with >5 dental extractions (n=149), the ORNJ risk was 12.1% (ORNJ case n=18) (Z-score=4.5062; p-value<0.0001). In the extraction-exposed cohort, the ORNJ risk is higher if the index day to first extraction day was ⩽0.5year (n=103) compared with the group with the index day to first extraction day >0.5year (n=419) (Z-score=-2.1506; p-value=0.0315). CONCLUSION A tooth extraction time less than half a year after R/T or during the head and neck R/T period, and extraction tooth number ⩽5 would significant lower the ORNJ prevalence.
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Affiliation(s)
- Tsu-Jen Kuo
- Department of Stomatology, Kaohsiung Veterans General Hospital, Taiwan, ROC
| | - Chung-Man Leung
- Department of Radiation Oncology, Kaohsiung Veterans General Hospital, Taiwan, ROC
| | - Hao-Sheng Chang
- Department of Stomatology, Kaohsiung Veterans General Hospital, Taiwan, ROC
| | - Chao-Nan Wu
- Department of Dentistry, Kaohsiung Veterans General Hospital, Taiwan, ROC.
| | - Wei-Li Chen
- Department of Stomatology, Kaohsiung Veterans General Hospital, Taiwan, ROC
| | - Guang-Jhong Chen
- Department of Stomatology, Kaohsiung Veterans General Hospital, Taiwan, ROC
| | - Yu-Cheng Lai
- Department of Orthopedics, Kaohsiung Veterans General Hospital, Taiwan, ROC
| | - Wei-Chun Huang
- Section of Critical Care Medicine, Kaohsiung Veterans General Hospital, Taiwan, ROC
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Raguse JD, Hossamo J, Tinhofer I, Hoffmeister B, Budach V, Jamil B, Jöhrens K, Thieme N, Doll C, Nahles S, Hartwig ST, Stromberger C. Patient and treatment-related risk factors for osteoradionecrosis of the jaw in patients with head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 121:215-21.e1. [DOI: 10.1016/j.oooo.2015.10.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/23/2015] [Accepted: 10/07/2015] [Indexed: 10/22/2022]
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Abstract
Radiation therapy plays a central and continuously evolving role in the treatment of head and neck cancer. In this review, some basic principles of radiation oncology are explained and common clinical scenarios are addressed in which radiation therapy forms part of the treatment course, with a focus on issues most pertinent to the interaction of radiation oncology with surgical treatment. These issues include refinement of the indications guiding the choice of adjuvant radiation therapy or chemoradiotherapy, sequencing and timing of therapies before or after definitive surgical management, and scientific and technical advances with the potential to reduce radiation-related toxicity.
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Affiliation(s)
- Sue S Yom
- Department of Radiation Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, Box 1708, 1600 Divisadero Street, MZ Building R H1031, San Francisco, CA 94143-1708, USA.
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Brożyna B, Szymańska H, Ptaszyński K, Woszczyński M, Lechowska-Piskorowska J, Gajewska M, Rostkowska J, Chełmiński K, Bulski W, Krajewski R. Tissue response after implantation of pure titanium and bioresorbable screws in scapula with postoperative irradiation: an experimental study on rats. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 120:443-52. [PMID: 26346909 DOI: 10.1016/j.oooo.2015.06.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/25/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The study focuses on the comparison of tissue reaction to titanium and bioresorbable implants with and without postoperative irradiation on an animal model. MATERIALS AND METHODS Thirty-nine LEW/W rats were randomly assigned to experimental or control groups. One titanium and one bioresorbable screw (poly-L-lactide [PLLA] and L- and D-lactide poly-L/D-lactide [PDLLA]) were implanted into the left scapulas of 24 rats. Half of them received 30 Gy to the operation site and the other half received 42 Gy. In the control groups, 3 rats received 30 Gy, and 6 rats received 42 Gy to the scapula area without operation; and 6 rats had implants inserted as in the experimental group, but received no postoperative irradiation. The scapulas were removed 14 or 30 days after irradiation and a histologic analysis was performed. RESULTS The host tissue reaction to titanium and PLLA-PDLLA screws without postoperative irradiation was of similar intensity. In irradiated animals, the inflammatory tissue reaction was more evident around the titanium screws than around the bioresorbable screws, irrespective of the radiation dose and of the time that elapsed from the irradiation. The reaction was more evident on the 14th day than on the 30th day after the last radiation dose (70 and 86 days after surgery, respectively). The intensity of the inflammatory tissue reaction, irrespective of the implant type, was more intense in the group irradiated with 42 Gy. CONCLUSIONS PLLA-PDLLA implants appear to cause less tissue reaction after irradiation and could be safer reconstructive devices than titanium implants for patients undergoing surgery and adjuvant radiotherapy for cancer.
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Affiliation(s)
- Bogusław Brożyna
- Department of Head and Neck Cancer, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland
| | - Hanna Szymańska
- Department of Genetics, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland
| | - Konrad Ptaszyński
- Department of Pathology, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland
| | - Marek Woszczyński
- Department of Genetics, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland
| | - Joanna Lechowska-Piskorowska
- Department of Genetics, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland
| | - Marta Gajewska
- Department of Genetics, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland.
| | - Joanna Rostkowska
- Department of Medical Physics, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland
| | - Krzysztof Chełmiński
- Department of Medical Physics, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland.
| | - Wojciech Bulski
- Department of Medical Physics, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland
| | - Romuald Krajewski
- Department of Head and Neck Cancer, The Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgen Str. 5, 02781 Warsaw, Poland
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Risk profile for osteoradionecrosis of the mandible in the IMRT era. Strahlenther Onkol 2015; 192:32-9. [PMID: 26265308 PMCID: PMC4705130 DOI: 10.1007/s00066-015-0875-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/02/2015] [Indexed: 11/10/2022]
Abstract
Background The risk for osteoradionecrosis (ORN) of the mandible is positively related to bone volume exposed to > ~ 60 Gy. We hypothesized that in combined treatment, surgery may also be a risk factor. Patients and methods The impact of mandibular surgery on ORN in locally disease-free IMRT cohorts was retrospectively analyzed. Results Between October 2002 and October 2013, 531 of 715 patients with oral cavity cancer (OCC), mesopharyngeal cancer (MC), or salivary gland tumor were treated with the mandible bone exposed to ~ > 60 Gy (mean follow-up, 38 months; 7–143 months). Of the 531 patients, 36 developed ORN (7 %; 1.5 % with grade 3–4). The ORN rate in definitive IMRT MC (16/227) and in postoperative IMRT OCC patients with no mandibular surgery (3/46) was 7 % each; in OCC patients with mandibular surgery the rate was 29 % (15/60, p = 0.002). Marginal or periosteal bone resection was found to be a high risk factor (39 %, vs. 7 % followed by segmental or no resection, p < 0.0001). Conclusion Marginal or periosteal bone resection of the mandible was identified as the highest ORN risk factor in our IMRT cohort.
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Osteoradionecrosis: an old toxicity in the IMRT era? Oral Oncol 2015; 51:e60-1. [PMID: 25812433 DOI: 10.1016/j.oraloncology.2015.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/04/2015] [Accepted: 03/07/2015] [Indexed: 11/23/2022]
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Robard L, Louis MY, Blanchard D, Babin E, Delanian S. Medical treatment of osteoradionecrosis of the mandible by PENTOCLO: Preliminary results. Eur Ann Otorhinolaryngol Head Neck Dis 2014; 131:333-338. [DOI: 10.1016/j.anorl.2013.11.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 08/26/2013] [Accepted: 11/04/2013] [Indexed: 11/30/2022]
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Brożyna B, Chełmiński K, Bulski W, Giżyńska M, Grochowska P, Walewska A, Zalewska M, Kawecki A, Krajewski R. Dosimetry of dose distributions in radiotherapy of patients with surgical implants. Radiat Phys Chem Oxf Engl 1993 2014. [DOI: 10.1016/j.radphyschem.2014.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Fan H, Kim SM, Cho YJ, Eo MY, Lee SK, Woo KM. New approach for the treatment of osteoradionecrosis with pentoxifylline and tocopherol. Biomater Res 2014; 18:13. [PMID: 26331064 PMCID: PMC4552457 DOI: 10.1186/2055-7124-18-13] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 09/12/2014] [Indexed: 12/26/2022] Open
Abstract
Osteoradionecrosis (ORN) of the jaw is a significant complication of radiotherapy for oral cavity cancer. In addition to antibiotic medication, treatment options such as hyperbaric oxygen therapy, surgical approaches, and combined therapy with pentoxifylline and tocopherol have been recently introduced. In this review article, we will discuss the definition and classifications of osteoradionecrosis, its etiology and pathophysiology, previous treatment options, oral and maxillofacial complications of radiotherapy, basic information on pentoxifylline and tocopherol, recent reports of pentoxifylline and tocopherol combined therapy, and, finally, ORN-induced animal models and future approaches.
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Affiliation(s)
- Huan Fan
- />Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 62-1 Changgyeonggungno, Jongno-gu, Seoul, 110-768 South Korea
| | - Soung Min Kim
- />Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 62-1 Changgyeonggungno, Jongno-gu, Seoul, 110-768 South Korea
| | - Yun Ju Cho
- />Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 62-1 Changgyeonggungno, Jongno-gu, Seoul, 110-768 South Korea
| | - Mi Young Eo
- />Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, 62-1 Changgyeonggungno, Jongno-gu, Seoul, 110-768 South Korea
| | - Suk Keun Lee
- />Department of Oral Pathology, College of Dentistry, Gangneung-Wonju National University, Gangneung, South Korea
| | - Kyung Mi Woo
- />Department of Dental Pharmacology & Therapeutics, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, South Korea
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Jiang YM, Zhu XD, Qu S. Incidence of osteoradionecrosis in patients who have undergone dental extraction prior to radiotherapy: A systematic review and meta-analysis. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2014. [DOI: 10.1016/j.ajoms.2014.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Demian NM, Shum JW, Kessel IL, Eid A. Oral surgery in patients undergoing chemoradiation therapy. Oral Maxillofac Surg Clin North Am 2014; 26:193-207. [PMID: 24794266 DOI: 10.1016/j.coms.2014.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Oral health care in patients undergoing chemotherapy and/or radiation therapy can be complex. Care delivered by a multidisciplinary approach is timely and streamlines the allocation of resources to provide prompt care and to attain favorable outcomes. A hospital dentist, oral and maxillofacial surgeon, and a maxillofacial prosthodontist must be involved early to prevent avoidable oral complications. Prevention and thorough preparation are vital before the start of chemotherapy and radiation therapy. Oral complications must be addressed immediately and, even with the best management, can cause delays and interruption in treatment, with serious consequences for the outcome and prognosis.
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Affiliation(s)
- Nagi M Demian
- Oral & Maxillofacial Surgery Department, The University of Texas School of Dentistry, Lyndon B. Johnson Hospital, UT Annex 112 B, 5656 Kelly, Houston, TX 77026, USA; The Externship Program, Dental Branch at UTHSC, UT Annex 112 B, 5656 Kelly, Houston, TX 77026, USA.
| | - Jonathan W Shum
- Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center at Houston, 7500 Cambridge Street, Suite 6510, Houston, TX 77054, USA
| | - Ivan L Kessel
- Department of Radiation Oncology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Ahmed Eid
- General Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 0462, Houston, TX 77030, USA
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Sasahara G, Koto M, Ikawa H, Hasegawa A, Takagi R, Okamoto Y, Kamada T. Effects of the dose-volume relationship on and risk factors for maxillary osteoradionecrosis after carbon ion radiotherapy. Radiat Oncol 2014; 9:92. [PMID: 24708583 PMCID: PMC3992144 DOI: 10.1186/1748-717x-9-92] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 03/29/2014] [Indexed: 11/26/2022] Open
Abstract
Background Osteoradionecrosis (ORN) is a critical complication after carbon ion (C-ion) or photon radiotherapy (RT) for head and neck tumors. However, the risk factors for ORN after C-ion RT remain unclear. Therefore, the present study aimed to investigate the effects of the dose-volume relationship on and risk factors for ORN development after C-ion RT. We, however, focused on the maxillary bone because most tumors treated with C-ion RT were primarily located in the sinonasal cavity. Methods The patients enrolled in this study received more than 10% of the prescribed total dose of 57.6 Gy equivalent (GyE) in 16 fractions to their maxilla. All patients were followed up for more than 2 years after C-ion RT. Those with tumor invasion to the maxilla before C-ion RT or local recurrence after the treatment were excluded from the study to accurately evaluate the effects of irradiation on the bone. Sixty-three patients were finally selected. The severity of ORN was assessed according to the Common Terminology Criteria for Adverse Events version 4.0. The correlation between clinical and dosimetric parameters and ORN incidence was retrospectively analyzed. Results The median follow-up period was 79 months. Of the 63 enrolled patients, 26 developed ORN of grade ≥1. Multivariate analysis revealed that the maxilla volume receiving more than 50 GyE (V50) and the presence of teeth within the planning target volume were significant risk factors for ORN. Dose-volume histogram analysis revealed that V10 to V50 parameters were significantly higher in patients with ORN than in those without ORN. Conclusions V50 and the presence of teeth within the planning target volume were independent risk factors for the development of ORN after C-ion RT using a 16-fraction protocol.
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Affiliation(s)
| | - Masashi Koto
- Research Center for Charged Particle Therapy Hospital, National Institute of Radiological Sciences, Chiba, Japan.
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Nolen D, Cannady SB, Wax MK, Scharpf J, Puscas L, Esclamado RM, Fritz M, Freiberger J, Lee WT. Comparison of complications in free flap reconstruction for osteoradionecrosis in patients with or without hyperbaric oxygen therapy. Head Neck 2014; 36:1701-4. [DOI: 10.1002/hed.23520] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2013] [Indexed: 11/12/2022] Open
Affiliation(s)
- David Nolen
- Division of Otolaryngology-Head and Neck Surgery; Duke University Medical Center Department of Surgery; Durham North Carolina
| | - Steven B. Cannady
- Division of Head and Neck Surgery, Department of Otolaryngology; SUNY Downstate Medical Center (formerly at Rochester Head and Neck Center); New York New York
| | - Mark K. Wax
- Department of Otolaryngology; Oregon Health and Science University; Portland Oregon
| | - Joseph Scharpf
- Head and Neck Institute; Cleveland Clinic; Cleveland Ohio
| | - Liana Puscas
- Division of Otolaryngology-Head and Neck Surgery; Duke University Medical Center Department of Surgery; Durham North Carolina
- Section of Otolaryngology-Head and Neck Surgery; Durham Veterans Affairs Medical Center; Durham North Carolina
| | - Ramon M. Esclamado
- Division of Otolaryngology-Head and Neck Surgery; Duke University Medical Center Department of Surgery; Durham North Carolina
| | - Michael Fritz
- Head and Neck Institute; Cleveland Clinic; Cleveland Ohio
| | - John Freiberger
- Department of Anesthesia Division of Hyperbaric Medicine; Duke University Medical Center Department of Surgery; Durham North Carolina
| | - Walter T Lee
- Division of Otolaryngology-Head and Neck Surgery; Duke University Medical Center Department of Surgery; Durham North Carolina
- Section of Otolaryngology-Head and Neck Surgery; Durham Veterans Affairs Medical Center; Durham North Carolina
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Abstract
Patients with a history of head and neck cancer resection require extensive prosthodontic rehabilitation following cancer treatment. The oral anatomy drastically changes from ablative therapy, and the oral tissue response becomes altered as a consequence of radiation and chemotherapy. Successful restoration of oral function in this specific patient population was increasingly difficult before the widespread use of dental implants. Implant-borne prosthetics are now often used. However, surgical guidelines remain unclear with regard to oncology-related parameters. In this article, guidelines are introduced for implant therapy in the cancer patients according to radiation dosage and timing. Indications for hyperbaric oxygen treatment are highlighted along with risk assessment associated with implant placement. These guidelines are intended to augment knowledge obtained through oncology consultation; moreover, provide a rationale for implant therapy within the course of cancer treatment.
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48
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Late term tolerance in head neck cancer patients irradiated in the IMRT era. Radiat Oncol 2013; 8:259. [PMID: 24192223 PMCID: PMC4229314 DOI: 10.1186/1748-717x-8-259] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/23/2013] [Indexed: 11/10/2022] Open
Abstract
Background The aim was to quantify severe transient and persisting late term effects in our single institution head neck cancer (HNC) cohort treated with curatively intended intensity modulated radiation therapy (IMRT). Hypothesis was if a 2-year follow up (FU) is sufficient to estimate the long term tolerance in HNC irradiated in the IMRT era. Methods Between 01/2002-8/2012, 707/1211 (58%) consecutively treated IMRT patients met the inclusion criteria of a FU time >12 months and loco-regional disease control (LRC). 45% presented with loco-regionally advanced disease; 55% were referred for curative definitive IMRT (66 Gy-72 Gy in 30–35 fractions), 45% underwent postoperative IMRT (60-66 Gy in 30–33 fractions). Systemic concomitant therapy was administered in 85%. Highly consistent treatment procedures were performed with respect to contouring processes, dose constraints, radiation schedules, and the use of systemic therapy. Grade 3/4 late term effects were prospectively assessed and analyzed with respect to subgroups at particular risk for specific late effects. Results Mean/median FU of the cohort was 41/35 months (15–124). 13% of the patients (92/707) experienced any grade 3/4 late effects (101 events in 92/707 patients), 81% in the first 12 months after radiation. 4% of all developed persisting late grade 3/4 effects (25 events in 25/707 patients). Conclusions IMRT led to a high late term tolerance in loco-regionally disease free HNC patients. The onset of any G3/4 effects showed a plateau at 2 years. The question of the cervical vessel tolerance in disease free long time survivors is still open and currently under evaluation at our institution.
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DUMA MARCIANANONA, GEINITZ HANS, KAMPFER SEVERIN, KESTING MARCOR. A novel setup approach for helical tomotherapy in head and neck cancer: A case report. Oncol Lett 2013; 6:1470-1474. [PMID: 24179543 PMCID: PMC3813675 DOI: 10.3892/ol.2013.1558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 07/26/2013] [Indexed: 11/06/2022] Open
Abstract
Head and neck cancers that are associated with high-risk factors have a poor prognosis. In such patients, post-operative radiochemotherapy is mandatory. The present study describes the case of a 71-year-old high-risk head and neck cancer patient who was not able to tolerate the supine position for the radiotherapy setup. A lateral immobilization with a head mask and a vacuum cushion was performed. The patient underwent daily computed tomography (CT)-guided radiation therapy [image-guided radiation therapy (IGRT)]. At nine months post-radiotherapy, the patient had no xerostomia and no swallowing dysfunction. However, the patient suffered a local recurrence and succumbed due to bleeding of the tumor a number of weeks after the recurrence. A recalculation of the actual delivered dose, taking the daily delivered dose into account, was performed. The recurrence occurred within the high-dose region. In selected cases of patients with head and neck cancers who are unable to tolerate the supine position, lateral positioning and high precision treatment is possible using daily IGRT.
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Affiliation(s)
- MARCIANA NONA DUMA
- Department of Radiation Oncology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany,Correspondence to: Dr Marciana Nona Duma, Department of Radiation Oncology, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstr 22, Munich, Bayern 81675, Germany, E-mail:
| | - HANS GEINITZ
- Department of Radiation Oncology, Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria
| | - SEVERIN KAMPFER
- Department of Radiation Oncology, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - MARCO R. KESTING
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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Beadle BM, Liao KP, Chambers MS, Elting LS, Buchholz TA, Kian Ang K, Garden AS, Guadagnolo BA. Evaluating the impact of patient, tumor, and treatment characteristics on the development of jaw complications in patients treated for oral cancers: a SEER-Medicare analysis. Head Neck 2013; 35:1599-605. [PMID: 23150453 DOI: 10.1002/hed.23205] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2012] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Jaw complications, including osteoradionecrosis, are significant sequelae of radiation therapy (RT) for oral cancers. This study identifies the impact of patient, tumor, and treatment characteristics on the development of jaw complications in patients treated with RT. METHODS The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients treated with RT for oral cancers from 1999 to 2007. Jaw complications were identified by International Classification of Diseases 9th revision (ICD-9) diagnosis codes and/or related procedures using Current Procedural Terminology (CPT) and ICD-9 codes. RESULTS A total of 1848 patients were identified. With a median follow-up of 2.5 years, 297 patients (16.1%) developed jaw complications: 226 patients had a diagnosis, 41 patients had a procedure, and 30 patients had both. On multivariate analysis, female sex, lack of chemotherapy use, and fewer comorbidities were associated with a statistically significant increase in jaw complications. CONCLUSIONS Even with modern techniques, jaw complications are a notable and potentially devastating side effect of RT for oral cancers.
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Affiliation(s)
- Beth M Beadle
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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