Andrew Salama

Osteonecrosis of the Jaw in Multiple Myeloma Patients: Clinical Features and Risk Factors

PURPOSEnTo describe the clinical, radiologic, and pathologic features and risk factors for osteonecrosis of the jaw (ONJ) in multiple myeloma (MM) patients.nnnPATIENTS AND METHODSnA retrospective review of 90 MM patients who had dental assessments, including 22 patients with ONJ. There were 62 men; the median age was 61 years in ONJ patients and 58 years among the rest. Prior MM therapy included thalidomide (n = 67) and stem-cell transplantation (n = 72). Bisphosphonate therapy included zoledronate (n = 34) or pamidronate (n = 17) and pamidronate followed by zoledronate (n = 33). Twenty-seven patients had recent dental extraction, including 12 patients in the ONJ group. Median time from MM diagnosis to ONJ was 8.4 years for the whole group.nnnRESULTSnPatients usually presented with pain. ONJ occurred posterior to the cuspids (n = 20) mostly in the mandible. Debridement and sequestrectomy with primary closure were performed in 14 patients; of these, four patients had major infections and four patients had recurrent ONJ. Bone histology revealed necrosis and osteomyelitis. Microbiology showed actinomycetes (n = 7) and mixed bacteria (n = 9). More than a third of ONJ patients also suffered from long bone fractures (n = 4) and/or avascular necrosis of the hip (n = 4). The variables predictive of developing ONJ were dental extraction (P = .009), treatment with pamidronate/zoledronate (P = .009), longer follow-up time (P = .03), and older age at diagnosis of MM (P = .006).nnnCONCLUSIONnONJ appears to be time-dependent with higher risk after long-term use of bisphosphonates in older MM patients often after dental extractions. No satisfactory therapy is currently available. Trials addressing the benefits/risks of continuing bisphosphonate therapy are needed.

Gingival carcinoma: retrospective analysis of 72 patients and indications for elective neck dissection.

Gingival squamous cell carcinoma (SCC) is relatively uncommon, and little is known about its metastatic pattern. We retrospectively reviewed 864 consecutive patients with oral SCC who were seen at the University of Maryland Department of Oral and Maxillofacial Surgery (1991-2005), and identified 111 cases of gingival SCC. Inclusion criteria were fulfilled in 72 patients (mean duration of follow up 49 (1-153) months). Mean (range) age was 72 (45-93) years; 41 patients were women and 31 men. Distribution was almost equal: mandible 35 and maxilla 37. Forty (56%) were in the early stages (pI/II) and 32 (44%) in the later stages (pIII/IV). Twenty-nine patients had primary neck dissections, of whom 7/21 had clear, and 6/8 invaded, cervical nodes. The total number of occult nodal metastases was 9/29 (31%) in the mandible and 14/35 in the maxilla (one patient with initially clear nodes had both invaded nodes at neck dissection and a recurrence in the neck). The number of early compared with late stage occult metastases was 4 of 20 patients (20% T1/T2) and 5 of 9 patients (55% T3/T4) in the mandible and 2 of 22 patients (9% T1/T2) and 2 of 13 patients (15% T3/T4) in the maxilla. Two of 9 patients developed occult nodes within T2 maxillary gingival SCC. Bony invasion was identified in 17 patients (24%) occurring in 8 of 19 patients (42%) with invaded nodes compared with 9 of 53 patients (17%) with clear nodes. Overall survival at 2 and 5 years was 53 of 72 patients (74%) and 27 of 72 patients (38%) respectively. Elective neck dissection is indicated for all stages of mandibular gingival tumours and T3/T4 carcinomas of the maxillary gingiva. T2 maxillary SCC should be considered for elective neck dissection. Overall disease-free survival was worse among those with cervical metastases (p=0.004) and those who had had marginal resections (p=0.04).

Malignant peripheral primitive neuroectodermal tumor‐peripheral neuroepithelioma of the head and neck: A clinicopathologic study of five cases and review of the literature

The term primitive neuroectodermal tumor (PNET) encompasses a number of neoplasms of common neuroectodermal origin, but of variable clinical, histopathologic, ultrastructural, and molecular characteristics. Here, we focus on one particular member of the PNET family, the malignant peripheral PNET (pPNET) or peripheral neuroepithelioma of head and neck.

A novel bioassay model to determine clinically significant bisphosphonate levels

PurposeBisphosphonate-associated osteonecrosis (BON) is a recently recognized oral complication of bisphosphonate (BP) therapy. Currently, research into the pathogenesis of BON has been hampered by being deficient in studies capable of measuring the level of BP in saliva or at the bone–soft tissue interface. The objective of this current study was to develop a novel bioassay model representative of the oral levels of BPs in patients presenting with or at risk for BON.MethodsZoledronic acid (ZA) injectable was used to develop standardized MTS cell proliferation assay curves at concentrations of 0–10xa0μM, which were used either in a dilution in normal media, mimicking BP freed from bone or used to “spike” saliva individuals not taking BPs and mimicking BP levels being excreted. This bioassay was then used to estimate BP levels from samples of saliva and bone ex vivo from patients with and without BON.ResultsSaliva and bone from patients with existing BON showed levels of BP ranging from 0.4 to 4.6xa0μM, while patients receiving IV infusion of BP and naïve to BON showed levels in saliva ranging from 0.4 to 5xa0μM. All control specimens and patients naïve to BP showed levels at 0xa0μM.ConclusionsGiven the fact that BPs are poor candidates for detection using standard methods (HPLC), this bioassay provides us with the ability to estimate clinically relevant concentrations of BP capable of producing apoptosis and the inhibition cell proliferation of oral mucosal cells based on previous studies. Subsequently, apoptosis and the inhibition of proliferation could lead to BON, secondary to the exposure of the bone in the unique microenvironment of the oral cavity.

Maxillofacial metastases: a retrospective review of one institution's 15-year experience.

PURPOSEnMetastasis to the maxillofacial region is a rare occurrence. In our retrospective study of patients with metastasis to the maxillofacial region, the subjects were evaluated to define the clinical behavior patterns in response to the treatment given.nnnMATERIALS AND METHODSnA retrospective record review during a 15-year period (1990 to 2005) was conducted. The patients were selected for inclusion in the present study if they had histologically confirmed maxillofacial metastases.nnnRESULTSnIn our retrospective study, during the 15-year period, 1,221 new patients with maxillofacial/oral cancer were seen and evaluated. Of these 1,221 patients, 26 (16 men and 10 women) were identified as having a histologically confirmed metastasis to the maxillofacial region, for an incidence of 2.1%.nnnCONCLUSIONSnPatients with metastasis to the maxillofacial region are often deemed to not be surgical candidates because of the extensive nature of the metastatic disease. We believe that surgical intervention plays a beneficial role in improving quality of life in a properly selected group of patients with metastasis to the maxillofacial region. In our case series, surgery was performed in about 50% of the patients, and palliation and radiotherapy were the most commonly used modalities.

Free-flap failures and complications in an American oral and maxillofacial surgery unit

Free tissue transfer is a reliable surgical technique that enables primary reconstruction following ablative surgery. Widely practised in many European units, acceptance into mainstream oral and maxillofacial surgery in the USA has been slow. The authors reviewed free flap practice patterns and outcomes in a US oral and maxillofacial surgery training program with specific emphasis on failures and complications to illustrate obstacles encountered during the initial phase of practice implementation. The demographic and clinical data of 71 consecutive patients who underwent microvascular reconstruction over 3 years (2002-2005) were reviewed. The study group included 48 males and 23 females who underwent 72 free tissue transfer procedures. Fourteen patients required operative exploration in the perioperative period. Six patients were explored for clinically compromised flaps. Thrombotic events occurred in 4 patients; 1 flap was successfully salvaged. There were 4 flap failures and 9 complications related to the donor site. Two perioperative deaths occurred from non-flap-related complications. Prolonged hospital stay and ICU utilization was observed in patients with surgical complications. Complications in this study did not affect the overall success rates of free-flaps. Salvage rates from thrombotic events were unaffected despite rigid flap monitoring protocols.

Treatment of cT1N0M0 tongue cancer: outcome and prognostic parameters.

PURPOSEnThe objective of the present study was to summarize the treatment and outcomes of cT1N0M0 tongue cancer for which the management is less defined.nnnMATERIALS AND METHODSnA total of 65 consecutive cases of cT1 tongue cancer were retrospectively reviewed. The Fisher exact, χ(2), and Wilcoxon tests were used to statistically analyze the data.nnnRESULTSnThe tumor depth had a significant relation to the presence of neck metastasis (P < .05). A 3-mm cutoff point provided better predictive value, with a sensitivity of 92.9% and specificity of 43.1%. The biopsy depth combined with palpation was accurate in determining the tumor depth preoperatively in 87.7%. On multivariate analysis, only the tumor site (ventral tongue) and the presence of erythroleukoplakia had any significant relation to disease-free survival (P = .010).nnnCONCLUSIONSnElective neck dissection should be considered for patients with cT1N0 oral tongue squamous carcinoma with a biopsy depth of 3 mm or greater. The biopsy depth, combined with the clinical examination findings, is a useful method to help determine the tumor depth preoperatively.

Metastatic neuroendocrine carcinomas to the head and neck: report of 4 cases and review of the literature

Neuroendocrine carcinoma (NEC) is a cancer arising from neuroendocrine cells, most commonly in the lungs. Rarely, NEC may metastasize to the head and neck. Here, we present 4 cases of metastatic NEC to the jaws and major salivary glands. Patients were 3 females and 1 male, ages ranging from 48 to 82 (mean 59). Three primaries were located in the lung and one in the breast. The parotid was the site of metastasis in 2 patients, with the jaws being involved in the other 2. Histologic and immunohistochemical examination revealed 2 well-differentiated NEC and 2 poorly differentiated NEC. Treatment included surgery, radiation, and chemotherapy. Our series shows these lesions can present in the oral and maxillofacial region as frank malignancies or mimic benign processes. Although rare, these tumors should be included in the differential diagnosis of head and neck lesions, particularly when the patient presents with a history of a previous NEC.

Is it necessary to resect bone for low-grade mucoepidermoid carcinoma of the palate?

Minor intraoral tumours of the salivary glands are relatively uncommon. Most are histologically low grade and display no aggressive clinical features such as bony invasion or regional metastases. The aim of this study was to investigate retrospectively a bone-sparing approach to resection of low grade mucoepidermoid carcinoma of the hard palate in 18 patients. Only one had radiographic evidence of bony invasion and was treated by composite resection of the hard palate. Sixteen patients were treated by wide local excision with 1cm margins of soft tissue using the periosteum of the hard palate as the deep margin. The mean (SD) follow-up time was 44 months, (range 2-140). Among patients who had only soft tissue resection the histological margins were clear in 11 patients, and 5 had close or invaded margins that were all localised to the deep margin. There were no local recurrences during the follow-up period. We suggest that a bone-sparing approach to such tumours gives adequate local control, and composite resections should be reserved for tumours that have obviously invaded the hard palate.

Comparative clinicoanatomical study of ilium and fibula as two commonly used bony donor sites for maxillofacial reconstruction

We assessed the morphological characteristics and dimensions of the ilium and fibula to evaluate the suitability of particular areas of bone for use as donor sites for dental reconstructions that carry implants. We measured the dimensions of 130 bilaterally harvested ilium and fibula bones from 65 adult cadavers using osteometric methods, and analysed the effects of age, sex, and side. Dimensions at measuring points, overall suitability for implantation, and relations among age, sex, and side, were evaluated statistically. We report observations of bone morphology involving cross-sections, and clinical relevance. Although the mean dimensions of the fibula and iliac crest were adequate, some segments would not support an implant 10 mm long and 3.5 mm wide. The overall suitability of parts of the iliac block fell to 30%. Fibular morphology is characterised by constant height and width, and relation of cortical and cancellous bone. Bony dimensions on the iliac fossa and fibula were significantly greater in men than in women. Age had a negative impact in one area of the iliac fossa, but nowhere on the iliac crest. Side was not significant. We found differences in dimensions and morphology between measuring points on the same bone. Precise knowledge about which areas of the donor sites can reliably provide sufficient bone to carry implants after reconstructions will allow greater flexibility and safety when reconstructions are designed.