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Peterson DE, Koyfman SA, Yarom N, Lynggaard CD, Ismaila N, Forner LE, Fuller CD, Mowery YM, Murphy BA, Watson E, Yang DH, Alajbeg I, Bossi P, Fritz M, Futran ND, Gelblum DY, King E, Ruggiero S, Smith DK, Villa A, Wu JS, Saunders D. Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline. J Clin Oncol 2024; 42:1975-1996. [PMID: 38691821 DOI: 10.1200/jco.23.02750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/22/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer. METHODS The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008. RESULTS A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation. RECOMMENDATIONS Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.
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Affiliation(s)
| | | | - Noam Yarom
- Sheba Medical Center, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Charlotte Duch Lynggaard
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Lone E Forner
- Department of Oral and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark
| | | | - Yvonne M Mowery
- UPMC Hillman Cancer Center, Pittsburgh, PA
- University of Pittsburgh, Pittsburgh, PA
| | | | - Erin Watson
- Department of Dental Oncology, Princess Margaret Cancer Center/Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - David H Yang
- BC Cancer/University of British Columbia, Vancouver, Canada
| | - Ivan Alajbeg
- University of Zagreb School of Dental Medicine, Zagreb, Croatia
| | - Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Neal D Futran
- University of Washington School of Medicine, Seattle, WA
| | | | - Edward King
- Northern Colorado Head and Neck Cancer Support Group, Windsor, CO
| | - Salvatore Ruggiero
- New York Center for Orthognathic and Maxillofacial Surgery, New York, NY
| | | | | | - Jonn S Wu
- BC Cancer/University of British Columbia, Vancouver, Canada
| | - Deborah Saunders
- Health Sciences North Research Institute, Northern Ontario School of Medicine, Health Sciences North, Sudbury, Ontario, Canada
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Kostares E, Kostares M, Kostare G, Tsakris A, Kantzanou M. Prevalence of free flap failure in mandibular osteoradionecrosis reconstruction: a systematic review and meta-analysis. Sci Rep 2024; 14:11087. [PMID: 38750124 PMCID: PMC11096303 DOI: 10.1038/s41598-024-61862-1] [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: 10/23/2023] [Accepted: 05/10/2024] [Indexed: 05/18/2024] Open
Abstract
Our study aimed to estimate the prevalence of total free flap failure following free flap reconstruction for mandibular osteoradionecrosis (mORN) and assess the impact of potential moderators on this outcome. A comprehensive systematic literature search was independently conducted by two reviewers using the Medline, Scopus, Web of Science and Cochrane Library databases. Quality assessment of the selected studies was performed, and prevalence estimates with 95% confidence intervals (CI) were calculated. Outlier and influential analyses were conducted, and meta-regression analyses was employed to investigate the effects of continuous variables on the estimated prevalence. Ultimately, forty-six eligible studies (involving 1292 participants and 1344 free flaps) were included in our meta-analysis. The findings of our study revealed a prevalence of 3.1% (95% CI 1.3-5.4%) for total free flap failure after reconstruction for mORN. No study was identified as critically influential, and meta-regression analysis did not pinpoint any potential sources of heterogeneity. These findings provide valuable insights for researchers and serve as a foundation for future investigations into the management of mandibular osteoradionecrosis and the prevention of free flap failure in this context.
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Affiliation(s)
- Evangelos Kostares
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece.
| | - Michael Kostares
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Georgia Kostare
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Maria Kantzanou
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
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Immune microenvironment: novel perspectives on bone regeneration disorder in osteoradionecrosis of the jaws. Cell Tissue Res 2023; 392:413-430. [PMID: 36737519 DOI: 10.1007/s00441-023-03743-z] [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: 06/23/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
Osteoradionecrosis of the jaws (ORNJ) is a severe complication that occurs after radiotherapy of head and neck malignancies. Clinically, conservative treatments and surgeries for ORNJ exhibited certain therapeutic effects, whereas the regenerative disorder of the post-radiation jaw remains a pending problem to be solved. In recent years, the recognition of the role of the immune microenvironment has led to a shift from an osteoblasts (OBs) or bone marrow mesenchymal stromal cells (BMSCs)-centered view of bone regeneration to the concept of a complicated microecosystem that supports bone regeneration. Current advances in osteoimmunology have uncovered novel targets within the immune microenvironment to help improve various regeneration therapies, notably therapies potentiating the interaction between BMSCs and immune cells. However, these researches lack a thorough understanding of the immune microenvironment and the interaction network of immune cells in the course of bone regeneration, especially for the post-operative defect of ORNJ. This review summarized the composition of the immune microenvironment during bone regeneration, how the immune microenvironment interacts with the skeletal system, and discussed existing and potential strategies aimed at targeting cellular and molecular immune microenvironment components.
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Osteoradionecrosis of the Jaw-Comparison between Bone and Soft Tissue Injury and Their Influence on Surgical Outcomes-A Retrospective Cohort Study. Diagnostics (Basel) 2023; 13:diagnostics13030366. [PMID: 36766471 PMCID: PMC9914009 DOI: 10.3390/diagnostics13030366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/20/2022] [Accepted: 01/14/2023] [Indexed: 01/21/2023] Open
Abstract
Surgical therapy of osteoradionecrosis of the jaw (ORN) is challenging and requires treatment of the affected hard and soft tissue. To understand how tissue injury after irradiation influences surgical outcomes, the objective of this study was to find out whether (a) bone-related, (b) soft tissue-related, and (c) treatment-related parameters influence the surgical success of patients with ORN. A total of 175 patients (324 lesions) were included in this retrospective, single-center study. All patients were diagnosed with ORN and underwent surgical therapy. The primary outcome was complete soft tissue recovery (mucosa/skin) and the absence of symptoms 3 months after surgery. At the time of follow-up, 58% of patients (189 of 324 lesions) had intact intraoral or extraoral soft tissue. The extent of bone destruction had no effect on treatment success, whereas soft tissue injury due to fibrosis (OR: 0.344; CI 0.142-0.834; p = 0.01818) and xerostomia (OR: 0.163; CI 0.064-0.419; p = 0.00016) increased the probability of treatment failure. Soft tissue reconstruction with a microvascular graft improved therapeutic success compared to local wound closure (OR: 2.998; CI 1.371-6.555; p = 0.006). Thus, for the treatment of ORN, it is extremely important to pay attention not only to the extent of bone destruction but especially to soft tissue defects. Because the extent of soft tissue injury is a predictor for therapeutic success, it should influence the choice of surgical treatment.
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Jenkins GW, Iqbal MS, West N, Davidson Z, Kennedy MP, Adams JR. Retrospective review of Osteoradionecrosis cases treated with virtual surgical planning following review of received irradiation dose to the mandible. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2022. [DOI: 10.1016/j.adoms.2022.100342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Contrera KJ, Chinn SB, Weber RS, Roberts D, Myers JN, Lai SY, Lewis CM, Hessel AC, Gillenwater AM, Mulcahy CF, Yu P, Hanasono MM, Fuller CD, Chambers MS, Zafereo ME. Outcomes after definitive surgery for mandibular osteoradionecrosis. Head Neck 2022; 44:1313-1323. [PMID: 35238096 PMCID: PMC9081223 DOI: 10.1002/hed.27024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To analyze charges, complications, survival, and functional outcomes for definitive surgery of mandibular osteoradionecrosis (ORN). MATERIALS AND METHODS Retrospective analysis of 76 patients who underwent segmental mandibulectomy with reconstruction from 2000 to 2009. RESULTS Complications occurred in 49 (65%) patients and were associated with preoperative drainage (odds ratio [OR] 4.40, 95% confidence interval [CI] 1.01-19.27). The adjusted median charge was $343 000, and higher charges were associated with double flap reconstruction (OR 8.15, 95% CI 2.19-30.29) and smoking (OR 5.91, 95% CI 1.69-20.72). Improved swallow was associated with age <67 years (OR 3.76, 95% CI 1.16-12.17) and preoperative swallow (OR 3.42, 95% CI 1.23-9.51). Five-year ORN-recurrence-free survival was 93% while overall survival was 63% and associated with pulmonary disease (HR [hazard ratio] 3.57, 95% CI 1.43-8.94). CONCLUSIONS Although recurrence of ORN is rare, surgical complications are common and charges are high. Poorer outcomes and higher charges are associated with preoperative factors.
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Affiliation(s)
- Kevin J. Contrera
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
- Department of Plastic and Reconstructive Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Steven B. Chinn
- Department of Otolaryngology – Head and Neck Surgery, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan, USA
| | - Randal S. Weber
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Dianna Roberts
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffery N. Myers
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Y. Lai
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Carol M. Lewis
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Amy C. Hessel
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann M. Gillenwater
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Collin F. Mulcahy
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Peirong Yu
- Department of Plastic and Reconstructive Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M. Hanasono
- Department of Plastic and Reconstructive Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark S. Chambers
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark E. Zafereo
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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Aljohani S, Fliefel R, Brunner TF, Chronopoulos A, Binmadi N, Otto S. Fluorescence-guided surgery for osteoradionecrosis of the jaw: a retrospective study. J Int Med Res 2022; 50:3000605221104186. [PMID: 35698727 PMCID: PMC9201330 DOI: 10.1177/03000605221104186] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Osteoradionecrosis of the jaw (ORNJ) is one of the most severe head and neck complications in patients treated with radiotherapy. The goal of treatment is to suppress ORNJ progression. Currently, surgical removal of necrotic bone is an effective management approach for advanced stages. In this study, we present our experience in managing ORNJ using fluorescence-guided surgery. METHODS Nineteen ORNJ lesions in 15 hospitalized patients were treated with fluorescence-guided surgery. We retrospectively reviewed patients' demographic data, comorbidities, local preceding event, location, ORNJ stage, and treatment outcomes with a median follow-up of 12 months. RESULTS Twelve lesions (63%) were treated surgically under tetracycline fluorescence, and seven lesions (37%) were surgically treated under auto-fluorescence. Overall, four lesions (21%) achieved complete mucosal healing, eight lesions (42%) showed partial mucosal healing with bone exposure and no signs or symptoms of inflammation, and seven lesions (37%) were progressive. The results showed that either healing or ORNJ stabilization was achieved in 63% of lesions (n = 12). CONCLUSION Fluorescence-guided surgery can be beneficial in curing or stabilizing ORNJ. However, randomized clinical trials are needed to confirm these findings.
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Affiliation(s)
- Suad Aljohani
- Department of Oral Diagnostic Sciences, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, Munich, Germany
| | - Riham Fliefel
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, Munich, Germany.,Experimental Surgery and Regenerative Medicine (ExperiMed), Department of Surgery, Ludwig Maximilians University, Munich, Germany.,Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Teresa Franziska Brunner
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, Munich, Germany
| | - Aristeidis Chronopoulos
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, Munich, Germany
| | - Nada Binmadi
- Department of Oral Diagnostic Sciences, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig Maximilians University, Munich, Germany
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Johnston DT, Phero JA, Hechler BL. The Necessity of Antibiotics in the Management of Surgically Treated Mandibular Osteomyelitis: A Systematic Review. Oral Surg Oral Med Oral Pathol Oral Radiol 2022; 135:11-23. [PMID: 35863960 DOI: 10.1016/j.oooo.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/01/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Mandibular osteomyelitis remains an incompletely understood entity, and treatment of its various presentations remains diverse. The purpose of this study was to review the necessity of antibiotic therapy after surgical treatment of mandibular osteomyelitis. STUDY DESIGN A systematic review of published articles on surgical management of mandibular osteomyelitis with or without postoperative antibiotic therapy was performed to answer the question, "Does the use of postoperative antibiotics compared with surgery alone alter the success rate in treating mandibular osteomyelitis?" The most recent evidence was sought by searching PubMed, Embase, and Scopus databases. Article appraisal was performed by 2 reviewers. RESULTS Forty-five articles were found that met the inclusion criteria, with all studies being retrospective cohort or case series designs. Only 13 articles used Zurich classification designations of acute osteomyelitis, secondary chronic osteomyelitis, or primary chronic osteomyelitis, and the general heterogeneity of these articles made comparison difficult. No study made an intentional statistical assessment of various antibiotic protocols. CONCLUSIONS Limited evidence suggested that resection may have better success rates than other forms of surgical intervention, regardless of antibiotic therapy. This systematic review questions the perceived necessity of intermediate- or long-term antibiotic therapy in the management of mandibular osteomyelitis after surgical resection.
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Utilising radiotherapy dose to guide 3D surgical reconstructions for mandibular osteoradionecrosis. JOURNAL OF RADIOTHERAPY IN PRACTICE 2022. [DOI: 10.1017/s1460396922000115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Introduction:
Following radiotherapy for head and neck cancer, a proportion of patients present with mandibular osteoradionecrosis (ORN). Reported incidence and presentation of ORN vary widely, although often initiated by trauma with radiotherapy being the biggest risk factor. Evolved disease requires surgery, mandibular resection and reconstruction. As ORN is a progressive disease, it can manifest beyond resected volumes, compromising surgery. To minimise surgical failures, we present incorporating radiotherapy dose into the surgical design and decision processes—dose guided surgery (DGS).
Method:
Five mandibular ORN patients, referred for resection and reconstruction, underwent DGS—mandible visualised on diagnostic CT, propagated to radiotherapy planning CT, radiotherapy dose displayed on the mandible, high-risk mandible converted to stl files and incorporated in the surgical design.
Results:
DGS ensures high-dose, high-risk ORN mandible is resected, and fixation devices are located in low-dose, low-risk areas.
Conclusions:
DGS represents a potential new standard of care for patients presenting with mandibular ORN post-radiotherapy. Formal follow-up of this small cohort is ongoing although DSG is anticipated to increase the success rate of this high cost, high burden procedure compared to surgery designed on clinical and radiological assessments alone.
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Gigliotti MJ, Patel N, McLaughlin C, Rothermel A, Henry C, Rizk E. Osteoradionecrosis and microvascular free flap failure managed with negative pressure wound therapy: A case report. Br J Neurosurg 2021; 37:1-6. [PMID: 34148435 DOI: 10.1080/02688697.2021.1940845] [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: 10/09/2020] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
A 56-year-old female with a history of meningioma status post subtotal resection (Simpson grade IV) and extensive radiation therapy presented with osteoradionecrosis (O.R.N.) managed previously with a microvascular free flap (MVFF). The evaluation revealed worsening O.R.N. and a scalp defect of 15 × 10 cm. The patient underwent MVFF reconstruction utilizing a free latissimus muscle flap covered by meshed split-thickness skin graft (STSG). Her surgery was complicated by delayed free flap failure and Serratia marcescens growth, which occurred sometime after discharge from the hospital. This was managed with removal of the free muscle flap and skin graft, serial debridement's, antibiotics, and replacements of a synthetic dural matrix and negative pressure wound therapy (NPWT). Once a clean wound bed was again obtained, the patient underwent fasciocutaneous anterolateral thigh (A.L.T.) MVFF reconstruction, which was complicated by left hypoglossal nerve injury, dehiscence of the flap inset, and dehiscence of the neck access incision requiring revision surgery. On the last follow-up 2 weeks after her surgery, the patient had 100% flap viability and a 2 × 1.5 cm on the left parietal aspect of the flap healing be secondary intent. We demonstrate that NPWT is successful in managing open calvarial wounds due to O.R.N.
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Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, USA
| | - Neel Patel
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, USA
| | - Caroline McLaughlin
- Department of Plastic Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, USA
| | - Alexis Rothermel
- Department of Plastic Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, USA
| | - Cathy Henry
- Department of Plastic Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, USA
| | - Elias Rizk
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, USA
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Hato H, Sakata KI, Sato J, Satoh A, Hayashi T, Kitagawa Y. Clinical study of treatment methods and associated factors in mandibular osteoradionecrosis. J Oral Sci 2021; 63:289-291. [PMID: 34092776 DOI: 10.2334/josnusd.21-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This study aimed to determine the appropriate treatment methods and evaluate associated factors by comparing nonoperative treatment alone with a combination of both nonoperative and surgical treatment in 34 patients with mandibular osteoradionecrosis (mORN). The associated cure factors were analyzed by Cox regression. Propensity scores were calculated from factors that were not significant in the univariate analysis and used as covariates in the multivariate analysis. The cure rate among patients who received nonoperative and surgical treatment was higher than that observed with nonoperative treatment alone. Only the treatment method was associated with cure in both univariate and multivariate analyses.
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Affiliation(s)
- Hiroyuki Hato
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
| | - Ken-Ichiro Sakata
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
| | - Jun Sato
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
| | - Akira Satoh
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
| | - Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery, Asahikawa Medical University
| | - Yoshimasa Kitagawa
- Department of Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University
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Ma C, Gao W, Liu Z, Zhu D, Zhu F, Li X, He Y. Radiation-Induced Soft Tissue Injuries in Patients With Advanced Mandibular Osteoradionecrosis: A Preliminary Evaluation and Management of Various Soft Tissue Problems Around Radiation-Induced Osteonecrosis Lesions. Front Oncol 2021; 11:641061. [PMID: 33996554 PMCID: PMC8113699 DOI: 10.3389/fonc.2021.641061] [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: 12/13/2020] [Accepted: 03/29/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Radiation-induced soft-tissue injuries (STIs) in mandibular osteoradionecrosis (ORN) are not well studied regarding their correlations with nearby bone lesions. The aim of this study is to investigate the severity of radiation-induced STIs in advanced mandibular ORN and its relationship with hard-tissue damage and postoperative outcomes. Methods A retrospective study was performed in our institution from January 2017 to December 2019. Aside from demographic factors, the associations between the triad ORN variables (irradiation doses, ORN stages, ORN sizes) and radiation-related STI factors, vascular characteristics, and postoperative functional recovery were assessed. In addition, the severity of STI was also compared with treatment outcomes. Such correlations were established via both univariate and multivariable analyses. Results A total number of 47 patients were included. The median follow-up reached 27 months. Nasopharyngeal cancer was the histology type among most patients (n = 21, 44.7%). The median irradiation doses reached 62 Gy (range, 40–110 Gy). For STI, the symptom scoring equaled an average of 5.4 (range from 1 to 12), indicative of the severity of STI problems. During preoperative MRI examinations, signs of hypertrophy or edema (n = 41, 87.2%) were frequently discerned. Most patients (n = 23, 48.9%) also had extensive muscular fibrosis and infection, which required further debridement and scar release. Surprisingly, most STI factors, except cervical fibrosis (p = 0.02), were not in parallel with the ORN levels. Even the intraoperative soft-tissue defect changes could not be extrapolated by the extent of ORN damage (p = 0.096). Regarding the outcomes, a low recurrence rate (n = 3, 6.9%) was reported. In terms of soft tissue-related factors, we found a strong correlation (p = 0.004) between symptom scores and recurrence. In addition, when taking trismus into consideration, both improvements in mouth-opening distance (p < 0.001) and facial contour changes (p = 0.004) were adversely affected. Correlations were also observed between the intraoperative soft-tissue defect changes and complications (p = 0.024), indicative of the importance of STI evaluation and management. Conclusions The coexistence of hard- and soft-tissue damage in radiation-induced advanced mandibular ORN patients reminds surgeons of the significance in assessing both aspects. It is necessary to take the same active measures to evaluate and repair both severe STIs and ORN bone lesions.
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Affiliation(s)
- Chunyue Ma
- Department of Oral Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weijin Gao
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhonglong Liu
- Department of Oral Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dan Zhu
- Department of Radiology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fengshuo Zhu
- Department of Oral Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoguang Li
- Department of Oral Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yue He
- Department of Oral Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Yamashita J, Akashi M, Takeda D, Kusumoto J, Hasegawa T, Hashikawa K. Occurrence and Treatment Outcome of Late Complications After Free Fibula Flap Reconstruction for Mandibular Osteoradionecrosis. Cureus 2021; 13:e13833. [PMID: 33859894 PMCID: PMC8038921 DOI: 10.7759/cureus.13833] [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] [Indexed: 11/05/2022] Open
Abstract
PURPOSE This study aimed to evaluate the occurrence and treatment outcome of late complications after free fibula osteocutaneous flap reconstruction for mandibular osteoradionecrosis (ORN). METHODS We enrolled 15 consecutive patients (14 men, one woman; median age 65 years, range 57-80 years) who underwent free fibula reconstruction for advanced mandibular ORN during 2013-2017 with two or more years of follow-up. Late complications included infection, plate exposure, and recurrence at the resection margin. The effect of perioperative antibiotic administration on late complications was also assessed. RESULTS Late complications occurred in 33.3% (5/15) of patients, including two infections (local and distant), two plate exposures, and two recurrences (plate exposure and recurrence occurred in one patient). Perioperative antibiotic administration duration did not significantly affect the occurrence of postoperative late complications. All late complications were treated without problems. CONCLUSIONS Late complications after ORN reconstructive surgery are not uncommon, but can be treated properly.
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Affiliation(s)
- Junya Yamashita
- Oral and Maxillofacial Surgery, Kobe University Hospital, Kobe, JPN
| | - Masaya Akashi
- Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, JPN
| | - Daisuke Takeda
- Oral and Maxillofacial Surgery, Kobe University Hospital, Kobe, JPN
| | - Junya Kusumoto
- Oral and Maxillofacial Surgery, Kobe University Hospital, Kobe, JPN
| | - Takumi Hasegawa
- Oral and Maxillofacial Surgery, Kobe University Hospital, Kobe, JPN
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14
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Dosimetry-guided virtual surgical planning in the reconstruction of mandibular osteoradionecrosis. Br J Oral Maxillofac Surg 2021; 59:947-951. [PMID: 34256959 DOI: 10.1016/j.bjoms.2021.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/18/2021] [Indexed: 01/08/2023]
Abstract
Patients with osteoradionecrosis (ORN) of the mandible pose additional challenges to the attending clinician when it comes to major reconstructive head and neck surgery. We present a novel technique to assist in the virtual surgical planning of mandibular ORN, which involves deforming previously delivered radiation dosimetry data on to the virtual mandible to aid in the assessment of surgical resection margins. This is a retrospective case series of patients whose treatment involved a traditional virtual surgical planning approach or dosimetry-guided virtual surgical planning. All the patients whose treatment involved dosimetry-guided virtual surgical planning had evidence of bony consolidation between the native mandible and fibular free flap. In comparison, only three of the nine patients in the traditional virtual surgical planning group demonstrated bony healing on subsequent imaging. In this known cohort of difficult-to-manage patients, any technique that helps to improve outcomes is a welcome addition to the armamentarium of the surgeon.
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15
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Fasciocutaneous Flaps for Refractory Intermediate Stage Osteoradionecrosis of the Mandible-Is It Time for a Shift in Management? J Oral Maxillofac Surg 2020; 79:1156-1167. [PMID: 33359101 DOI: 10.1016/j.joms.2020.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/14/2020] [Accepted: 11/20/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Historically, free tissue transfer has been reserved for advanced stage osteoradionecrosis (ORN) of the jaw with pathologic fracture or cutaneous fistula. The purpose of this study was to evaluate if in patients with recalcitrant intermediate stage ORN, would mandibular debridement in combination with vascularized soft tissue coverage result in durable symptom and disease resolution. PATIENTS AND METHODS A retrospective cohort study of patients with mandibular ORN was performed comparing a mandibular preserving approach with a fasciocutaneous forearm flap for progressive treatment-resistant intermediate stage ORN to mandibulectomy and vascularized bone flap (VBF) reconstruction for advanced stage ORN. The primary outcome was ORN resolution. RESULTS The sample was composed of 35 patients. One-hundred percent of patients undergoing a mandibular preserving approach experienced ORN resolution compared with 83.3% in the segmental mandibulectomy and VBF reconstruction group (P = .28). Patients in the mandibular preservation group experienced a shorter hospitalization (6 vs 9 days; P = .07), decreased length of surgery (384.9 vs 406.3 minutes; P = .01), and less delayed healing requiring local wound care (9.1 vs 45.8% of patients; P = .06). CONCLUSIONS A mandibular preserving approach is successful at arresting intermediate stage ORN and is associated with a decreased operative time, a shorter hospitalization, and less need for prolonged wound care when compared with VBF reconstruction for advanced stage ORN.
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16
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Novel Technique with Double Free Flap Design for Advanced Mandibular Osteoradionecrosis: A Case Series. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3149. [PMID: 33133983 PMCID: PMC7544289 DOI: 10.1097/gox.0000000000003149] [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: 07/20/2020] [Accepted: 08/04/2020] [Indexed: 11/26/2022]
Abstract
Advanced mandibular osteoradionecrosis is arguably among the most challenging cases for reconstructive head and neck surgeons. Several reconstructive methods for complex mandibular defects have been reported; however, for advanced mandibular osteoradionecrosis, a safe option that minimizes the risk of renewed fistulation and infections is needed. For this purpose, we present a new technique using a fascia-sparing vertical rectus abdominis musculocutaneous flap as protection for a vascularized free fibula graft (FFG). This technique also optimizes recipient site healing and functionality while minimizing donor site morbidity. Our initial experiences from a 4 patient case series are included. Mean operative time was 551 minutes (SD: 81 minutes). All donor sites were closed primarily. Mean time to discharge was 13 days (SD: 7 days), and mean time to full mobilization was 2 days (SD: 1 days). This double free flap technique completely envelops the FFG and plate with nonirradiated muscle. It allows for the transfer of an FFG without a skin island, thus avoiding the need for split skin graft closure. This results in faster healing and minimizes the risk of fibula donor site morbidity. The skin island of the vertical rectus abdominis musculocutaneous flap has the added benefit of providing intraoral lining, which minimizes contractures and trismus. Although prospective long-term studies comparing this approach to other double flap procedures are needed, we argue that this technique is an optimal approach to safeguard the mandibular FFG reconstruction against the inherent risks of renewed complications in irradiated unhealthy tissue.
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Gallego L, Junquera L, García-Consuegra L, Martinez A, Meana Á. Regeneration of mandibular osteoradionecrosis with autologous cross-linked serum albumin scaffold. Regen Med 2020; 15:1841-1849. [PMID: 32815773 DOI: 10.2217/rme-2020-0042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Osteoradionecrosis is one of the most severe complications of radiotherapy administered for head and neck tumors. We present the first two cases of advanced and refractory mandibular osteoradionecrosis treated by application of a novel autologous cross-linked 3D serum matrix. Patients were followed clinically and radiographically up to 24 months. Complete wound healing and intact mucosal cover were achieved in both cases. At 12 months, the radiographic values showed an almost complete regeneration of the bone defect, which continued a favourable progression increased to the maximum by 24 months after surgery. The use of an autologous serum-derived scaffold proved to be a quick, predictable, cost-effective and safe adjunct to the conservative surgical treatment of this pathology.
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Affiliation(s)
- Lorena Gallego
- Department of Oral & Maxillofacial Surgery. Cabueñes University Hospital, 33394 Gijón, Spain.,Department of Surgery and Medical-Surgical Specialties, University of Oviedo, 33006 Oviedo, Spain
| | - Luis Junquera
- Department of Surgery and Medical-Surgical Specialties, University of Oviedo, 33006 Oviedo, Spain.,Department of Oral & Maxillofacial Surgery, Central University Hospital, 33006 Oviedo, Spain
| | - Luis García-Consuegra
- Department of Surgery and Medical-Surgical Specialties, University of Oviedo, 33006 Oviedo, Spain.,Department of Oral & Maxillofacial Surgery, Central University Hospital, 33006 Oviedo, Spain
| | - Antonio Martinez
- Department of Radiology, Cabueñes University Hospital, 33394 Gijón, Spain
| | - Álvaro Meana
- Community Blood & Tissue Center of Asturias, 33006 Oviedo, Spain.,Ophthalmologic Research Foundation, U714, CIBER Rare Diseases (CIBERER), Oviedo, Spain
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