Denosumab-related osteonecrosis of the jaw after tooth extraction and the effects of a short drug holiday in cancer patients: a multicenter retrospective study

Pre-existing inflammation, corticosteroid therapy, periapical periodontitis, longer duration of denosumab therapy, and female sex were significantly associated with an increased risk of denosumab-related osteonecrosis of the jaw after tooth extraction in patients with cancer on oncologic doses of denosumab. A short drug holiday did not protect against this complication.

INTRODUCTION

This study retrospectively investigated the relationship between various risk factors, including brief discontinuation of denosumab, and development of denosumab-related osteonecrosis of the jaw (DRONJ) after tooth extraction in patients with cancer who were receiving oncologic doses of this agent.

METHODS

Data were collected on demographic characteristics, duration of denosumab therapy, whether or not denosumab was discontinued before tooth extraction (drug holiday), duration of discontinuation, presence of pre-existing inflammation, and whether or not additional surgical procedures were performed. Risk factors for DRONJ after tooth extraction were evaluated by univariate and multivariate analyses.

RESULTS

A total of 136 dental extractions were performed in 72 patients (31 men, 41 women) with cancer who were receiving oncologic doses of denosumab. Post-extraction DRONJ was diagnosed in 39 teeth (28.7%) in 25 patients. Tooth extraction was significantly associated with development of DRONJ only in patients with pre-existing inflammation (odds ratio [OR] 243.77), those on corticosteroid therapy (OR 73.50), those with periapical periodontitis (OR 14.13), those who had been taking oncologic doses of denosumab for a longer period (OR 4.69), and in women (OR 1.04). There was no significant difference in the occurrence of DRONJ between patients who had a drug holiday before tooth extraction and those who did not.

CONCLUSIONS

These findings suggest that inflamed teeth should be extracted immediately in patients with cancer who are receiving oncologic doses of denosumab. Drug holidays have no significant impact on the risk of DRONJ.

Preoperative underweight is associated with adverse postoperative events in patients undergoing microvascular reconstruction surgery for oral and maxillofacial cancer

We aimed to describe the prevalence of postoperative complications and evaluate its relationship with underweight, obesity, preoperative nutritional status, and systemic inflammation status in patients undergoing microvascular reconstruction for oral and maxillofacial cancer. Patients who were ≥20 years old and underwent microvascular reconstruction surgery between January 2009 to June 2019 were investigated. Patient demographics including body mass index, prognostic nutritional status, and neutrophil-lymphocyte ratio were collected. Logistic regression analysis was applied to evaluate these impacts on postoperative complications. A postoperative complication was defined as a Clavien-Dindo classification more than or equal to II. Of the 145 patients included in the analysis, 83 patients (57.2%) experienced postoperative complications, belonging to a Clavien-Dindo classification Ⅱ (n=71), Ⅲb (n=11), and Ⅳa (n=1). Multiple logistic regression revealed that a body mass index less than 18.5 kg/m² (odds ratio 6.19, 95% confidential interval 1.34-28.6, P=0.02) was related to postoperative complications. Another multiple logistic regression model including all explanatory factors found that underweight (P=0.03) was related to postoperative complications. This retrospective study showed that preoperative underweight was associated with postoperative complications as evaluated by the Clavien-Dindo classification.

Medication-related osteonecrosis of the jaw after tooth extraction in cancer patients: a multicenter retrospective study

Root amputation, immunosuppressive therapy, mandibular tooth extraction, pre-existing inflammation, and longer duration of treatment with bone-modifying agents were significantly associated with an increased risk of medication-related osteonecrosis of the jaw. Hopeless teeth should be extracted without drug holiday before the development of inflammation in cancer patients receiving high-dose bone-modifying agents.

INTRODUCTION

No studies have comprehensively analyzed the influence of pre-existing inflammation, surgical procedure-related factors such as primary wound closure, demographic factors, and drug holiday on the incidence of medication-related osteonecrosis of the jaw (MRONJ). The purpose of this study was to retrospectively investigate the relationships between these various factors and the development of MRONJ after tooth extraction in cancer patients receiving high-dose bone-modifying agents (BMAs) such as bisphosphonates or denosumab.

METHODS

Risk factors for MRONJ after tooth extraction were evaluated with univariate and multivariate analyses. The following parameters were investigated in all patients: demographics, type and duration of BMA use, whether BMA use was discontinued before tooth extraction (drug holiday), the duration of such discontinuation, the presence of pre-existing inflammation, and whether additional surgical procedures (e.g., incision, removal of bone edges, root amputation) were performed.

RESULTS

We found that root amputation (OR = 22.62), immunosuppressive therapy (OR = 16.61), extraction of mandibular teeth (OR = 12.14), extraction of teeth with pre-existing inflammation, and longer duration (≥ 8 months) of high-dose BMA (OR = 7.85) were all significantly associated with MRONJ.

CONCLUSIONS

Tooth extraction should not necessarily be postponed in cancer patients receiving high-dose BMA. The effectiveness of a short-term drug holiday was not confirmed, as drug holidays had no significant impact on MRONJ incidence. Tooth extraction may be acceptable during high-dose BMA therapy until 8 months after initiation.

Effects of deep sedation under mechanical ventilation on cognitive outcome in patients undergoing surgery for oral and maxillofacial cancer and microvascular reconstruction

OBJECTIVE

Cognitive impairment after intensive care unit (ICU) admission is becoming increasingly recognized. High-dose deep sedation has been suggested to play an important role in the development of cognitive impairment. However, the impact of heavy sedation as a single cause in the development of cognitive impairment in ICU patients remains unclear. In this study we investigated whether a three-day deep sedation protocol could reduce cognitive function in mechanically ventilated non-critical patients.

DESIGN

A prospective observational study was carried out.

PATIENTS

A total of 17 surgical patients were studied.

INTERVENTION

None.

VARIABLES OF INTEREST

Cognitive function before and after ICU admission.

RESULTS

Thirty-one patients requiring three days of sedation after microvascular reconstruction were initially enrolled in the study. Sedation in the ICU was maintained with propofol and dexmedetomidine combined with fentanyl. Cognitive function was assessed using a battery of 6 neuropsychological tests two days before surgery and three weeks after surgery. Finally, a total of 17 patients were included in the analysis. Cognitive impairment (defined as a decline of >20% from the pre-admission cognitive evaluation scores in at least two of 6 tests) was observed in 5 of the 17 patients (29%). However, there were no significant differences between the pre- and post-admission cognitive evaluations in 6 tests.

CONCLUSIONS

Middle-term cognitive function can be impaired in some patients subjected to deep sedation during several days following maxillary-mandibular oral surgery with microvascular reconstruction.

A multicenter retrospective study of the risk factors associated with medication-related osteonecrosis of the jaw after tooth extraction in patients receiving oral bisphosphonate therapy: can primary wound closure and a drug holiday really prevent MRONJ?

Root amputation, extraction of a single tooth, bone loss or severe tooth mobility, and an unclosed wound were significantly associated with increased risk of developing medication-related osteonecrosis of the jaw (MRONJ). We recommend a minimally traumatic extraction technique, removal of any bone edges, and mucosal wound closure as standard procedures in patients receiving bisphosphonates.

INTRODUCTION

Osteonecrosis of the jaws can occur following tooth extraction in patients receiving bisphosphonate drugs. Various strategies for minimizing the risk of MRONJ have been advanced, but no studies have comprehensively analyzed the efficacy of factors such as primary wound closure, demographics, and drug holidays in reducing its incidence. The purpose of this study was to retrospectively investigate the relationships between these various risk factors after tooth extraction in patients receiving oral bisphosphonate therapy.

METHODS

Risk factors for MRONJ after tooth extraction were evaluated using univariate and multivariate analysis. All patients were investigated with regard to demographics; type and duration of oral bisphosphonate use; whether they underwent a discontinuation of oral bisphosphonates before tooth extraction (drug holiday), and the duration of such discontinuation; and whether any additional surgical procedures (e.g., incision, removal of bone edges, root amputation) were performed.

RESULTS

We found that root amputation (OR = 6.64), extraction of a single tooth (OR = 3.70), bone loss or severe tooth mobility (OR = 3.60), and an unclosed wound (OR = 2.51) were significantly associated with increased risk of developing MRONJ.

CONCLUSIONS

We recommend a minimally traumatic extraction technique, removal of any bone edges, and mucosal wound closure as standard procedures in patients receiving bisphosphonates. We find no evidence supporting the efficacy of a pre-extraction short-term drug holiday from oral bisphosphonates in reducing the risk of MRONJ.

A Ferromagnetic Foreign Body at the Lateral Aspect of the Mandibular Ramus in a Medically Compromised Patient

A case of a ferromagnetic foreign body in a medically compromised patient was reported. The patient was a 45-year-old male who consulted our department complaining of a foreign body accidentally impacted in the right cheek. X-ray examination revealed a foreign body at the lateral aspect of the right mandibular ramus. The removal of the foreign body was scheduled, but the patient did not return for the procedure. After 8 years he revisited our department for the removal of the foreign body, because it had been found to be ferromagnetic and a barrier to MRI examination. X-ray examination confirmed the foreign body was located at the same site as 8 years prior. Although the patient was suffering from liver cirrhosis with thrombocytopenia and leukopenia, the foreign body was successfully removed under general anesthesia. The foreign body was 12 × 5 × 1 mm, weighed 0.48 g, and was ferromagnetic. The patient’s postoperative course was uneventful. X-ray examination confirmed the removal of the foreign body. Since the surgery, the patient has been in generally stable condition with no complications. This case was a rare example of a foreign body that needed to be removed for medical examination.

Protumoral roles of melanoma inhibitory activity 2 in oral squamous cell carcinoma

BACKGROUND

The role of melanoma inhibitory activity 2 (MIA2) was examined in human oral squamous cell carcinoma (OSCC).

METHODS

MIA2 role was examined by immunohistochemistry of human OSCCs and knockdown studies using human 3 OSCC cell lines with MIA2 expression.

RESULTS

MIA2 expression was observed in 62 (66.7%) of 93 OSCCs and was associated with tumour expansion and nodal metastasis. Melanoma inhibitory activity 2 expression was inversely correlated with intratumoral infiltration of lymphocytes. Invasion and anti-apoptotic survival were reduced by MIA2 knockdown in HSC3 cells. MOLT-3 lymphocytes infiltrating the HSC3 cell layer was enhanced by MIA2 knockdown or MIA2 depletion with the antibody. In HSC3 cells, MIA2 knockdown decreased the expressions of vascular endothelial growth factor (VEGF), VEGF-C, and VEGF-D. The downregulation of VEGF-C and -D was caused by inhibition of p38 and extracellular signal-regulated kinase (ERK)1/2, respectively. Melanoma inhibitory activity 2 was co-precipitated with integrin α4 andα5 in HSC3 cells. Integrin α4 knockdown decreased p38 phosphorylation and increased apoptosis, whereas integrin α5 knockdown decreased c-Jun N-terminal kinase (JNK) phosphorylation and apoptosis. Inhibition of JNK decreased apoptosis in the HSC3 cells.

CONCLUSION

These findings suggest that the roles of MIA2 might be based on the variety of the integrins and the subtypes of mitogen-activated protein kinase.

Preoperative concurrent chemoradiotherapy for stages II-IV oral squamous cell carcinoma: a retrospective analysis and the future possibility of this treatment strategy

This study evaluated survival in 154 patients with stages II-IV oral squamous cell carcinoma (OSCC) treated with preoperative concurrent chemoradiotherapy and assessed the future use of this treatment strategy. 14 patients exhibited advanced stage II, 73 exhibited stage III and 67 exhibited stage IV. All patients received 40Gy irradiation and concurrent cisplatin-based chemotherapy in two courses. Radical surgery was undertaken after 2-6 weeks. The clinical tumour response, histopathologic regression grade, residual tumour grade (RGrade) in the primary tumour and the level of residual pN+ were associated with prognosis. 90% of patients with complete response and 73% of patients with good partial response in the primary tumour were RGrade 0 (no residual tumour cells) or RGrade 1 (viable tumour cells remained within central superficial portion). In patients with complete response in the neck, residual pN+ was only seen in levels IB (8%) and IIA (8%); the higher the level of residual pN+, the lower the survival rate (p<0.0001). This treatment strategy was excellent for stages II-IV OSCC. It may be possible to perform minimally invasive surgery in which the extent of resection in primary tumour and neck is reduced in patients who achieve good response following preoperative chemoradiotherapy.

Reg IV expression is associated with cell growth and prognosis of adenoid cystic carcinoma in the salivary gland

AIMS

Regenerating islet-derived family, member 4 (Reg IV) is associated with the progression of various cancers. The aim was to examine Reg IV expression in adenoid cystic carcinomas (ACCs) in salivary glands.

METHODS AND RESULTS

Reg IV expression was detected by immunohistochemistry and compared with clinicopathological parameters. Expression of phosphorylated epidermal growth factor receptor (pEGFR), phosphorylated AKT (pAKT) and MUC2 was examined by immunohistochemistry. Reg IV function was assessed with Reg IV antisense S-oligodeoxynucleotides (AS) in ACC3 human ACC cells. Reg IV was expressed by salivary duct epithelia and acinus myoepithelia, but not in squamous epithelia. Reg IV expression was found in 41% (17/41) of ACCs, but in none of 40 oral squamous cell carcinomas (OSCCs) and was associated with nodal metastasis (P = 0.047) and poor prognosis (P = 0.012) in ACCs. Reg IV expression was associated with pEGFR (14/17, 82%) in Reg IV+ ACCs, but had no relationship with pAKT or MUC2 expression in ACCs. Cell growth was inhibited by AS treatment in Reg IV+ ACC3 cells, but not in HSC-4 OSCC cells, whereas in vitro invasion of neither cell types was affected by AS treatment.

CONCLUSIONS

These results suggest that Reg IV might accelerate cell growth and disease progression of ACCs.

The effects of the sympathetic nerves on lumbar radicular pain

A rat model of lumbar root constriction with an additional sympathectomy in some animals was used to assess whether the sympathetic nerves influenced radicular pain. Behavioural tests were undertaken before and after the operation.

On the 28th post-operative day, both dorsal root ganglia and the spinal roots of L4 and L5 were removed, frozen and sectioned on a cryostat (8 μm to 10 μm). Immunostaining was then performed with antibodies to tyrosine hydroxylase (TH) according to the Avidin Biotin Complex method. In order to quantify the presence of sympathetic nerve fibres, we counted TH-immunoreactive fibres in the dorsal root ganglia using a light microscope equipped with a micrometer graticule (10 x 10 squares, 500 mm x 500 mm). We counted the squares of the graticule which contained TH-immunoreactive fibres for each of five randomly-selected sections of the dorsal root ganglia.

The root constriction group showed mechanical allodynia and thermal hyperalgesia. In this group, TH-immunoreactive fibres were abundant in the ipsilateral dorsal root ganglia at L5 and L4 compared with the opposite side. In the sympathectomy group, mechanical hypersensitivity was attenuated significantly.

We consider that the sympathetic nervous system plays an important role in the generation of radicular pain.

Receptor for advanced glycation end products (RAGE) is important in the prediction of recurrence in human oral squamous cell carcinoma

AIMS

Receptor for advanced glycation end products (RAGE) has recently been recognized as a cancer-associated protein responsible for cancer progression and metastasis in gastrointestinal cancers. The aim was to examine the role of RAGE in oral squamous cell carcinoma (OSCC).

METHODS AND RESULTS

RAGE expression was examined by immunohistochemistry in 74 OSCC patients and evaluated with a grading based on Allred's score. RAGE expression was compared with clinicopathological parameters including clinical stage, invasive depth, nodal metastasis, disease recurrence and disease-free survival. High-grade expression of RAGE (RAGE-H) was observed in 30 (40.5%) of 74 OSCCs. RAGE-H was associated with depth of invasion (P < 0.0001) and local recurrence (P < 0.0001), but not with histological differentiation, clinical stage or nodal metastasis. Disease-free survival in patients with RAGE-H was significantly worse than in those with low-level RAGE expression. Multivariate analysis showed RAGE-H to be an independent prognostic factor for disease-free survival in OSCC patients (P = 0.0022).

CONCLUSION

RAGE is a relevant factor in predicting disease recurrence and patients' prognosis in OSCC.

Morphological differences in the temporomandibular joints in asymmetrical prognathism patients

OBJECTIVE

To investigate the morphology of the temporomandibular joints (TMJ) in skeletal asymmetry with prognathism.

DESIGN

Three-group observational clinical study.

SETTING AND SAMPLE POPULATION

University setting. Thirty-five patients undergoing orthognathic surgery without signs and symptoms of TMJ disorder were assigned to three groups (right deviation, n = 11; left deviation, n = 14; and non-deviation; n = 10) based on anteroposterior cephalometric analysis.

OUTCOME MEASURE

Positional and morphological differences of the TMJs were evaluated using a total of 70 bilateral sagittal TMJ magnetic resonance images.

RESULTS

In both the right and left deviation groups, the TMJ on the deviated side showed a significantly steeper eminence than that on the non-deviated side (p < 0.05). The anterior joint space was narrower on the deviated side than on the non-deviated side whereas the posterior joint space did not differ markedly, indicating an anterior position of the condyle in the glenoid fossa of the TMJ on the deviated side. Disk displacement comparisons revealed no significant differences between left and right sides in the symmetry or asymmetry group.

CONCLUSION

Asymmetrical prognathism patients exhibit significant morphological differences between the right and left TMJs concerning the slope of the articular eminence, which correspond to facial asymmetry.

Haemostatic management of intraoral bleeding in patients with von Willebrand disease

OBJECTIVES

To develop plans for the haemostatic management of intraoral bleeding in patients with von Willebrand disease (VWD).

SUBJECTS AND METHODS

Thirty-seven episodes of haemostatic management of intraoral bleeding in 19 VWD patients were analysed retrospectively based on the medical records.

RESULTS AND CONCLUSIONS

When performing tooth extractions in patients with type 1 or 2A VWD [responsive to 1-deamino-8-D-arginine-vasopressin (DDAVP)], 0.35-0.4 microg kg(-1) of DDAVP should be administered intravenously at three times. In patients with type 2A VWD (unresponsive to DDAVP) or patients with type 2B or 2N VWD, 50-90 U [as ristocetin cofactor (VWF:RCof)] kg(-1) of a factor VIII concentrate containing von Willebrand factor (FVIII/VWF concentrate) should be administered twice in routine extractions, and four to six times in surgical extractions. Gingival bleeding related to primary teeth can be mostly managed by pressure haemostasis alone. However, when treating gingival bleeding caused by marginal periodontitis, it is often necessary to administer 0.4 microg kg(-1) of DDAVP or 40-70 U (as VWF:RCof) kg(-1) of a FVIII/VWF concentrate. As local haemostasis is difficult to achieve in bleeding from the tongue or labial or mandibular haematoma, it is necessary to administer 0.4 microg kg(-1) of DDAVP or 60-80 U (as VWF:RCof) kg(-1) of a FVIII/VWF concentrate. In addition, oral administration of 20 mg kg(-1) day(-1) of tranexamic acid should be combined with the regimens described above.

A patient with untreated tongue carcinoma surviving for 15 years

A rare case of untreated tongue carcinoma survived for 15 years is presented. A 43-year-old Japanese woman was referred to our department with a 1.8 cm x 1.0 cm white and red non-indurated lesion of the left border of the tongue. The histological examination showed a diagnosis of well-differentiated squamous cell carcinoma. We informed the patient and her family that she had a Stage I tongue carcinoma and needed to receive treatment immediately. However, they refused treatment. Fifteen years later, the patient presented again, complaining of a 55 mm x 40 mm painful gradual-growth swelling of the same site as before, and the clinical stage was T3N2aM0 (Stage IV). The patient agreed to receive radical surgery following preoperative chemoradiotherapy this time. Currently the patient has been free of recurrence for 4 years. Clinical and immunohistochemical features of this rare case are presented and discussed.

Suppressive effects of a selective cyclooxygenase-2 inhibitor, etodolac, on 4-nitroquinoline 1-oxide-induced rat tongue carcinogenesis

The present study was conducted to examine effects of a clinically available selective cyclooxygenase (COX)-2 inhibitor, etodolac, on the development of rat tongue squamous cell carcinomas (SCCs) induced by 4-nitroquinoline 1-oxide (4-NQO), and on the immunohistochemically demonstrable expression of COX-2. Fischer 344 rats, 6 weeks old at the commencement, were administered 4-NQO at the doses of 20-30 ppm in their drinking water for 12 weeks. Then, etodolac was supplemented into the diet at doses of 150 and 300ppm for 16 weeks. Rats were sacrificed at 28 weeks and tongue lesions were histologically examined. The incidence and the multiplicity of SCCs induced by 4-NQO were dose-dependently reduced by etodolac, with significance at the highest dose of 300 ppm. Etodolac did not significantly affect the immunohistochemical expression of COX-2 in the lesions which did develop. These results indicate that etodolac can inhibit the development of rat tongue SCCs, probably by inhibiting COX-2 activity rather than its expression. Thus, etodolac may be a promising candidate chemopreventive agent for individuals at high risk of oral cancer.

Haemostatic management of intraoral bleeding in patients with congenital deficiency of alpha2-plasmin inhibitor or plasminogen activator inhibitor-1

Haemostatic management of intraoral bleeding was investigated in patients with congenital alpha2-plasmin inhibitor (alpha2-PI) deficiency or congenital plasminogen activator inhibitor- 1 (PAI-1) deficiency. When extracting teeth from patients with congenital alpha2-PI deficiency, we advocate that 7.5-10 mg kg(-1) of tranexamic acid be administered orally every 6 h, starting 3 h before surgery and continuing for about 7 days. For the treatment of continuous bleeding, such as post-extraction bleeding, 20 mg kg(-1) of tranexamic acid should be administered intravenously, and after achieving local haemostasis 7.5 mg kg(-1) of tranexamic acid should be administered orally every 6 h for several days. In addition, when treating haematoma caused by labial or gingival laceration or buccal or mandibular contusion, haemostasis should be achieved by administering 7.5-10 mg kg(-1) of tranexamic acid every 6 h. Tranexamic acid can also be used for haemostatic management of intraoral bleeding in patients with congenital PAI-1 deficiency, but is less effective when compared with use in patients with congenital alpha2-PI deficiency. Continuous infusion of 1.5 mg kg(-1) h(-1) of tranexamic acid is necessary for impacted tooth extraction requiring gingival incision or removal of local bone.

Herbal medicine induced Stevens-Johnson syndrome: a case report

A severe form of Erythema multiforme (EM), diagnosed as Stevens-Johnson syndrome (SJS) was detected in a 10-year-old Indian male child who took herbal medication of plant origin prescribed by a traditional healer for remission of his fever. The child developed a severe and florid form of mucocutaneous oral ulceration, severe ocular manifestations, along with marked constitutional disturbances and dehydration. An extensive literature search revealed few previous reports of herbal drug induced EM and SJS. In India, traditional therapy with herbal preparation (Ayurvedic medicine) is not uncommon.

Primary tumour resection of tongue carcinoma based on response to preoperative therapy

The purpose of this study was to investigate the selection of resection techniques for primary lesions of advanced tongue carcinoma based on the effectiveness of our current preoperative therapy. Forty-three patients with advanced but potentially resectable squamous cell carcinoma of the tongue were included in this study. All patients were treated with preoperative concurrent chemoradiotherapy followed by conventional surgical resection. Semiserial sections of whole surgical specimen of primary lesion were evaluated histopathologically. In patients who achieved 85% and above regression, the extent of residual tumours two-dimensionally and in the deep layers was lesser, and the rate of tumour cell survival was lower, than in other patients. Furthermore, residual tumours tended to be localized to the superficial layers in the centre. These findings suggest that even in advanced tongue carcinomas it is possible to avoid extended resection and perform a less invasive surgery in which the extent of resection is reduced to preserve morphology and function in patients who achieved 65% and above regression following preoperative chemoradiotherapy.

Mandibular reconstruction using a vascularised fibula osteocutaneous flap in a patient with pyknodysostosis

We present the first successful report of mandibular reconstruction using a free fibula osteocutaneous flap in a patient with pyknodysostosis. The patient had recurrent refractory osteomyelitis of the mandible, which was initially treated with resection and reconstruction using an AO plate. Recurrent fistula formation with loosening of the plate was treated by radical re-excision and reconstruction with a free fibula flap. The postoperative course was uneventful; at 14 months the bony union was almost complete, without resorption or atrophy of the grafted fibula on radiography.

Clinical study of disseminated intravascular coagulation in oral and maxillofacial regions--predictors of onset and prognosis

OBJECTIVES

To examine disseminated intravascular coagulation (DIC) cases in detail to identify the predictors of onset and prognosis.

STUDY DESIGN

The clinical records of eight patients with DIC were examined with regard to the patient's background, underlying disease, direct inducers, duration, contents of treatments and outcome. The factors which controlled the onset and prognosis of DIC were examined in cases receiving surgery for malignant neoplasm compared with non-DIC cases. Wilcoxon test was used for statistical analysis.

RESULTS

There were seven males and one female, age range from 25 to 93 years. The underlying diseases were six malignant neoplasms, one severe infection, and one case of multiple injuries of the mandible. Seven patients had pretherapeutic complications, and six patients recovered. Reduction in platelet counts immediately after the operation revealed high values up to 36%, and patients with more than two pretherapeutic complications were more susceptible to DIC when major postoperative complications occurred. The operation time and blood loss may also have affected the outcome.

CONCLUSION

Change of platelet counts, number of pretherapeutic complications, operation time and blood loss are important for predicting the onset and prognosis of DIC in the oral and maxillofacial regions.

A new strategy for cancer therapy based on a predictive indicator

Tumor-associated genes have been analyzed at the molecular level in recent years, and using the analyses of these genes as a predictive indicator for cancer therapy has attracted attention. Among such genes, the actions of a tumor suppressor gene p53 are focused on the cancer therapy, and it is suggested that p53 genotypes can be used as a predictive indicator for radiotherapy, thermotherapy and chemotherapy. Transfection of wtp53 to p53-null cells increased radiation- or thermo-sensitivity and stimulated apoptosis induced by these therapies. Although therapy-induced apoptosis is suppressed in mp53 cells, apoptosis can be stimulated by glycerol treatment as a chemical chaperone. Therefore, a new strategy of combining p53-targeted gene therapy or chemical chaperone therapies is expected to improve the outcome and efficiency of cancer therapy in the future.

Prognostic value of response to preoperative chemoradiotherapy and residual tumor grades in tongue carcinoma

OBJECTIVE

The purposes of the present study were to analyze our experience with preoperative chemoradiotherapy followed by surgery for advanced tongue carcinoma and to assess the prognostic value of response to preoperative therapy in these tumors.

STUDY DESIGN

Between May 1988 and December 1999, a total of 43 patients with advanced but potentially resectable squamous cell carcinoma of the tongue were candidates for this study. A minimum tumor size of 3 cm was required. The mean age was 59.8 years (range, 26-85 years); 13 cases were advanced stage II, 23 cases were stage III, and 7 cases were stage IV. All patients were treated preoperatively with cisplatin- or carboplatin-based chemotherapy in combination with simultaneous irradiation to a target volume of 40 Gy; 2-6 weeks later, they underwent curative surgery. Tumor regression rate, residual tumor grade, and histologic regression grade to the preoperative therapy were analyzed to determine their influence on the prognosis.

RESULTS

With a median follow-up of 60.5 months, overall survival rates were 86.0% for all cases, 92.3% for stage II cases, 77.3% for stage III cases, and 100% for stage IV cases. The progression-free survival rates according to tumor regression rate were 33.3% for group 1 (< 50% tumor regression), 66.7% for group 2 (> or = 50% and < 75% regression), 100% for group 3 (> or = 75% and < 100% regression), and 96.0% for group 4 (complete regression). The higher the tumor regression rates, the higher the survival rates. When patients who achieved a regression rate of 75% or higher were compared with those who did not, there was a significant difference in survival (P < .0001). The factors of residual tumor grade and histologic regression grade also had good correlations with the prognosis (residual tumor grade, P =.0324; histologic regression grade, P < .0001).

CONCLUSIONS

The findings of the present study suggest that response to preoperative chemoradiotherapy, such as tumor regression rate, residual tumor grade, and histologic regression grade, could be of prognostic value in patients with tongue carcinoma.

Insufficiency fracture of the spine: a prospective analysis based on radiographic and scintigraphic diagnosis

To investigate the clinical characteristics of insufficiency fracture of the spine, patients aged 65 years or older, who had been hospitalized for acute low back pain without either an acute traumatic event or a previous history of malignant disease, were examined by plain radiographs and technetium-99m methylene disphosphonate bone scanning. Fifteen patients were diagnosed as having a vertebral insufficiency fracture on the basis of: (a) radiographic oseteopenia of the vertebra; (b) positive bone scan images; and (c) no episode of newly identified malignant disease in a subsequent 1 year follow up. These patients were analysed with respect to age, gender, bone mineral density, the number and distribution of the affected vertebrae, the extent of vertebral deformity, and consistency between radiographic and bone scan findings. Vertebral insufficiency fractures exhibited: (a) strict female predominance; (b) concave deformity of the affected vertebra; (c) a wide range of the vertebral height ratios and fracture distribution; and (d) low consistency between the vertebral deformity assessed by the lateral radiograph and positive activity on bone scanning. These findings represent a unique clinical feature of vertebral insufficiency fracture, and also emphasize the difficulty of radiographic diagnosis, as well as the importance of a comprehensive diagnostic approach.

Primary non-Hodgkin's lymphoma of the mandible treated with radiotherapy, chemotherapy, and autologous peripheral blood stem cell transplantation

Extranodal presentation in non-Hodgkin's lymphoma (NHL) is uncommon, and the mandible is very rarely involved. Primary NHL of the mandible, for the most part, has intermediate or high malignancy and has a much greater incidence of local recurrence compared with other sites of involvement. A 48-year-old Japanese man with NHL of the mandible received radiotherapy, followed by high-dose chemotherapy supported with peripheral blood stem cell transplantation (PBSCT). High-dose cyclophosphamide, Adriamycin, and vincristine were used for pretransplant conditioning. He achieved complete remission and has survived in continuous complete remission for more than 72 months to date. Marrow-ablative chemotherapy facilitated by PBSCT is thought to be useful as part of the primary therapy for patients with NHL who have poorer prognoses.

Epigenetic alterations in methylation in oral squamous cell carcinoma cell lines detected by two-dimensional gel electrophoresis

It has been described that DNA alterations in human oral squamous cell carcinomas were successfully demonstrated as 6 spots being commonly reduced in more than 50% of 10 lesions using the restriction landmark genomic scanning (RLGS) method. In the present study, the question of whether the DNA alterations involve not only genetic but also epigenetic change was examined with the use of cell lines Ca9-22, HO-1-u-1, HSC-2 and KB and treatment with a demethylating agent 5-aza-2'-deoxycytidine (5-AzaCDR). Intensities of two of the reduced spots were amplified in the cell lines by the 5-AzaCDR treatment, showing that they were due to altered DNA methylation. Our study provides clear evidence that epigenetic changes, like the methylation are related to carcinogenesis in human oral squamous cell epithelium.

Oral clonidine reduces the requirement of prostaglandin E1 for induced hypotension

PURPOSE

To determine the effects of preanesthetic oral clonidine on the dose of prostaglandin EI (PGEI) required to produce hypotension during anesthesia.

METHOD

Oral placebo, 75 microg or 150 microg clonidine were administered 60 min prior to induction of anesthesia. Anesthesia was maintained with O2:N2O (30:70) and isoflurane 1.0%. After hemodynamic stabilization, an infusion of prostaglandin EI was started (0.05 microg x kg(-1) x min(-1)) and the rate of infusion was adjusted to maintain mean arterial pressure (MAP) between 60-70 mm Hg during operation.

RESULTS

Duration of hypotension in placebo, 75 microg and 150 microg preanesthetic oral clonidine treated groups were 132+/-46, 117+/-37 and 129+/-56 min, respectively. The PGEI requirement in each group were 1563+/-180 (28.6+/-3.2), 594+/-197 (10.8+/-3.6) and 283+/-30 (5.5+/-3.6) microg (microg x kg(-1)), respectively. In addition, blood loss in each group were 1461+/-389, 805+/-240 and 931+/-40 ml, respectively.

CONCLUSION

Preanesthetic oral clonidine decreased the dose of PGEI required to produce hypotension, and decreased the blood loss during operation.

Eruption speed and rate of angulation change of a cyst-associated mandibular second premolar after marsupialization of a dentigerous cyst

The purpose of this study was to investigate the eruption speed and rate of angulation change of a cyst-associated mandibular second premolar after marsupialization of a dentigerous cyst in preadolescents. Premolars on the cyst and noncyst sides and size of the cyst were retrospectively examined with a total of 42 pairs of normalized panoramic radiographs in 20 patients who underwent neither extraction nor orthodontic traction of the cyst-associated mandibular second premolar after marsupialization. Sixteen premolars at the intraosseous eruption stage in a total of 9 preadolescents without cysts were also examined. The eruption speed and rate of angulation change of the cyst-associated mandibular second premolar were significantly faster than those of the premolars without cysts, and significantly correlated with the diminishing rate of the cyst size, which rapidly decreased for the first 3 months after marsupialization. In addition, the eruption speed of the cyst-associated mandibular second premolar correlated with that of the premolar on the noncyst side, and the rate of angulation change inversely correlated with the level of root formation. The results suggest that a cyst-associated permanent tooth erupts more rapidly regardless of the level of root formation and size and type of the cyst, and the abnormally tilted tooth axis improves more rapidly for the first three months after marsupialization of a dentigerous cyst in preadolescents.