G. Støre

Side effects and quality of life after inadvertent radiation overdosage in brachytherapy of head-and-neck cancer

PURPOSE By comparing our old (DP5, in use from 1978 to 1994) and new (Plato, Nucletron) dose planning system, we found that the old system underestimated doses by 20-25%. To study the possible consequences for the patients treated between 1978 and 1994, all who were still alive were invited to undergo an examination with respect to side effects and quality of life (QOL). MATERIALS AND METHODS The degree of overdosage was calculated by comparing the isodose distribution generated on the two dose planning systems. Eighty-four patients were then invited to undergo an examination with respect to side effects and QOL. The side effects were scored according to the LENT SOMA system and QOL according to European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30), and EORTC Quality of Life Questionnaire-Head & Neck 35 (QLQ-H&N35). RESULTS The mean overdosage of brachytherapy was 19.3%. No association was found between overdosage and side effects or QOL. For implants in the lateral border of the tongue, we found a statistically significant correlation between osteoradionecrosis and the following parameters: linear activity, total activity, dose rate, and extrapolated response dose. By multivariate analysis, only total implanted activity and the use of lead protection during brachytherapy were found to be of prognostic significance with respect to development of osteoradionecrosis. CONCLUSION The incidence of side effects after brachytherapy at the Norwegian Radium Hospital seems to have been somewhat higher in the period under investigation than at other institutions. There may be several explanations, including the use of external beam radiotherapy before brachytherapy and departure from the Paris system among others. However, the side effects were not associated with the overdosage that was the basis for the study. As opposed to the general consensus of opinion, long-term QOL was found to be worse after brachytherapy than after external beam radiotherapy. This calls for increased awareness and a systematic prospective registration of the long-term side effects of brachytherapy.

Osteoradionecrosis of the mandible : A microradiographic study of cortical bone

We undertook a microradiographic study in osteoradionecrotic mandibular bone to estimate the number of vascular channels in the compact bone, number of resorption areas, and number of regeneration areas. Normal mandibles had a similar number of vascular channels/vision field compared with compact bone in other parts of the body. Irradiation itself did not significantly alter this number. After osteoradionecrosis had developed in the mandible, the number of vascular channels increased (p = 0.02). Treatment with hyperbaric oxygen further increased the number of vascular channels/vision field (p < 0.003). The normal mandible had no resorptive or regenerative areas, either before or after radiotherapy. The osteoradionecrotic mandible, however, had an increased number of resorptive as well as regenerative areas/vision field. Fluorescence as an indication of incorporation of tetracycline was seen in the regenerative areas of all osteoradionecrotic specimens treated with doxycycline. The process started from the vascular channels, periosteum, and endosteum. We conclude that the compact bone of mandibular osteoradionecrosis has high metabolic activity with active resorption and regeneration of bone and the limitation of the blood supply through cortical vascular channels, seems to be only one of many important factors.

Mandibular osteotomies in patients with juvenile rheumatoid arthritic disease.

Objective: This retrospective study evaluates the results after orthognathic surgery in a group of patients with juvenile rheumatoid arthritis. Methods: The material comprised sixteen patients where genioplasty with or without bilateral sagittal split (BSSO) had been performed during a 10‐year period between 1991 and 2000. The patients were recalled for follow‐up examination and the clinical records and radiographs of the patients were analysed. Results: All patients reported an improved facial esthetics. Sixty‐two% reported altered neurosensory dysfunction in the inferior alveolar nerve, but no patients reported altered feelings to interfere with function. Two patients reported reduction in pain in the TMJ from a score 10 and 7 in the VAS‐scale preoperatively, to 0 after the orthognathic surgery. Eight of the patients reported this to be less uncomfortable compared to other surgical procedures because of their JRA. Ninety‐four% noted a positive social change after the operation. Conclusion: Orthognathic surgical treatment of the JRA patient improves the facial profile. The described procedures are safe and serious complications were not seen in our study.

Mandibular Access Osteotomies in Oral Cancer

Purpose: Mandibulotomy is a recognised surgical approach to tumours of the oral cavity and oropharynx. However, the nature and frequency of complications associated with this procedure varies in many studies. We report our experience with access osteotomies, with special reference to radionecrotic complications. Procedures: A retrospective study of 18 consecutive patients undergoing planned mandibular osteotomies as part of the ablative surgery was performed. Various flaps were used for tissue closure: myocutaneous flap (n = 8), nasolabial flap (n = 1) and radial forearm free vascular flap (n = 6). Primary closure using remaining mucosa was achieved in 3 patients. Results: Complete healing of the osteotomy was noted in 13 patients, and 5 patients (27%) developed major wound healing problems and osteoradionecrosis. Dental problems with resorption of the alveolar bone crest and loosening of the teeth adjacent to the osteotomy were seen in 7 patients (39%). Conclusions: Adequate soft-tissue closure is as important for a successful outcome as the type of osteotomy and fixation method applied. Extraction of the incisors is recommended for easier and safer tissue adaptation, especially when flaps are used for coverage and the osteotomy site will be included in the radiation field.

Osteoradionecrosis contains a wide variety of cultivable and non-cultivable bacteria

Abstract Background: Direct microscopy, 1 1The chief editor, Ingar Olsen, has had no part in the review and decision process of this paper.anaerobic culture and DNA–DNA hybridization have previously demonstrated an association between microorganisms and osteoradionecrosis (ORN). The purpose of our study was to use culture independent molecular techniques to detect bacteria in necrotic bone lesions of the mandible after radiation therapy. Design: Bacterial DNA was extracted from eight deep medullar specimens from resected mandibles (six cases), including one patient with relapse. 16S rRNA genes were PCR amplified, cloned, transformed into Escherichia coli and sequenced to determine species identity and closest relatives. Results: From the analysis of 438 clones, 59 predominant species were detected, 27% of which have not been cultivated. The predominant species detected from radionecrotic mandibles were Campylobacter gracilis, Streptococcus intermedius, Peptostreptococcus sp. oral clone FG014, uncultured bacterium clone RL178, Fusobacterium nucleatum, and Prevotella spp. The study demonstrated intersubject variability of the bacteria present in ORN. In contrast to the diverse bacterial profile detected in primary infection, only a few members of the oral indigenous flora were identified from the relapse case. Conclusions: Diverse bacterial profiles in specimens of ORN in marrow spaces of the mandible were detected by culture independent molecular techniques. To better understand the pathogenesis and to improve the therapy of the infection, detection of all members of the complex bacterial flora associated with ORN is necessary.

Colony morphologies, species, and biotypes of yeasts from thrush and denture stomatitis

Objective. To study the species and phenotypic characteristics of yeasts, i.e. colony morphology, biotypes, and biotype relatedness, and the oral distribution of yeasts, in thrush and denture stomatitis.Material and Methods. Yeast colony morphology was observed under a stereo-microscope and photographed with a digital camera. Genus, species, and biotypes of the yeast isolates were identified by using a commercial kit, ID 32C. Yeast biotype dendrograms were generated by Spotfire software and SPSS 15.0 for Windows. Results. Multiple colony morphologies were observed among the yeasts from both thrush and denture stomatitis. One genus, 6 species, and 21 biotypes were identified among the yeasts from thrush, while 2 genera, 7 species, and 20 biotypes were identified among the yeasts from denture stomatitis. Considerable similarities in predominant species, biotypes, and biotype clustering profiles were shown among the yeasts from thrush and denture stomatitis. However, Candida dubliniensis was identified exclusively in subgingival areas and biotype 7347340215 of C. albicans was identified more frequently in palate and sulci in thrush. Conclusions. A diversity of species and phenotypes was found among the yeasts in thrush and denture stomatitis. Candidal commensals were predominant in thrush and denture stomatitis, but the observation of divergent Candida species and biotypes, constituting 23% of all the yeast isolates, should not be ignored.