Theresa M. Hofstede

Osteoradionecrosis and Radiation Dose to the Mandible in Patients With Oropharyngeal Cancer

PURPOSE To determine the association between radiation doses delivered to the mandible and the occurrence of osteoradionecrosis (ORN). METHODS AND MATERIALS We reviewed the records of 402 oropharyngeal cancer patients with stage T1 or T2 disease treated with definitive radiation between January 2000 and October 2008 for the occurrence of ORN. Demographic and treatment variables were compared between patients with ORN and those without. To examine the dosimetric relationship further, a nested case-control comparison was performed. One to 2 ORN-free patients were selected to match each ORN patient by age, sex, radiation type, treatment year, and cancer subsite. Detailed radiation treatment plans for the ORN cases and matched controls were reviewed. Mann-Whitney test and conditional logistic regression were used to compare relative volumes of the mandible exposed to doses ranging from 10 Gy-60 Gy in 10-Gy increments. RESULTS In 30 patients (7.5%), ORN developed during a median follow-up time of 31 months, including 6 patients with grade 4 ORN that required major surgery. The median time to develop ORN was 8 months (range, 0-71 months). Detailed radiation treatment plans were available for 25 of the 30 ORN patients and 40 matched ORN-free patients. In the matched case-control analysis, there was a statistically significant difference between the volumes of mandible in the 2 groups receiving doses between 50 Gy (V50) and 60 Gy (V60). The most notable difference was seen at V50, with a P value of .02 in the multivariate model after adjustment for the matching variables and dental status (dentate or with extraction). CONCLUSIONS V50 and V60 saw the most significant differences between the ORN group and the comparison group. Minimizing the percent mandibular volume exposed to 50 Gy may reduce ORN risk.

Osseointegrated implant-based dental rehabilitation in head and neck reconstruction patients

Dental restoration is an integral part of head and neck cancer reconstruction.

Dynamic contrast-enhanced MRI detects acute radiotherapy-induced alterations in mandibular microvasculature: Prospective assessment of imaging biomarkers of normal tissue injury

Normal tissue toxicity is an important consideration in the continued development of more effective external beam radiotherapy (EBRT) regimens for head and neck tumors. The ability to detect EBRT-induced changes in mandibular bone vascularity represents a crucial step in decreasing potential toxicity. To date, no imaging modality has been shown to detect changes in bone vascularity in real time during treatment. Based on our institutional experience with multi-parametric MRI, we hypothesized that DCE-MRI can provide in-treatment information regarding EBRT-induced changes in mandibular vascularity. Thirty-two patients undergoing EBRT treatment for head and neck cancer were prospectively imaged prior to, mid-course, and following treatment. DCE-MRI scans were co-registered to dosimetric maps to correlate EBRT dose and change in mandibular bone vascularity as measured by Ktrans and Ve. DCE-MRI was able to detect dose-dependent changes in both Ktrans and Ve in a subset of patients. One patient who developed ORN during the study period demonstrated decreases in Ktrans and Ve following treatment completion. We demonstrate, in a prospective imaging trial, that DCE-MRI can detect dose-dependent alterations in mandibular bone vascularity during chemoradiotherapy, providing biomarkers that are physiological correlates of acute of acute mandibular vascular injury and recovery temporal kinetics.

Diagnostic considerations and prosthetic rehabilitation of a cocaine-induced midline destructive lesion: A clinical report.

The intranasal inhalation of cocaine has numerous complications. In addition to its systemic effects, cocaine can cause extensive destruction of the osteocartilaginous midline structures of the palate, nose, and sinuses. Without an accurate social and clinical history, a cocaine-induced midline destructive lesion can cause diagnostic difficulties, because its clinical presentation closely mimics other diseases. This clinical report describes an oronasal defect caused by cocaine use, the diagnostic considerations of these lesions, and prosthetic management of the defect.

Maxillofacial rehabilitation of a 7-year-old boy with osteosarcoma of the mandible using a free fibula flap and implant-supported prosthesis: a clinical report.

This clinical report describes the multidisciplinary approach in the maxillofacial rehabilitation of a 7-year-old boy diagnosed with osteosarcoma of the mandible. Following surgical resection of the left half of the mandible from the angle to the parasymphyseal region, a free osseocutaneous flap from the fibula was used to successfully reconstruct the mandible. Dental implants were subsequently placed, and an implant-supported, removable mandibular resection prosthesis was fabricated. Prosthodontic planning and treatment considerations in a growing child with a reconstructed mandible are discussed.

The multiple oral presentations of multiple myeloma

PurposeThe purpose of this case series is to show the varied oral presentations of multiple myeloma, illustrating the importance of carefully surveying the oral cavity for suspicious lesions that could be indicative of palpable disease and/or recurrence. The diagnostic criteria and prognostic features for multiple myeloma were also reviewed.Case series summaryThis report focuses on five patients with myeloma manifestations involving the oral cavity, in which the oral presentation of multiple myeloma was an early indication of disease relapse. Although the clinical presentation may be variable, the majority of patients will develop lytic bone lesions and less commonly, extramedullary involvement during the course of their disease.DiscussionThe presentation of myeloma can be varied and the oral presentation, although rare, may be the sole manifestation or part of a group of signs of disease progression. Clinical presentations of patients with myelomatous lesions can mimic common dental pathologies, which then, in turn, can lead to delays in diagnosis and treatment.ConclusionAs members of an interdisciplinary oncology team, it is essential to be familiar with oral manifestations of multiple myeloma and proper diagnostic/biopsy techniques in order to avoid misdiagnosis and treatment delays.

Symptom burden and dysphagia associated with osteoradionecrosis in long-term oropharynx cancer survivors: A cohort analysis

OBJECTIVE The purpose is to examine the relationship between mandibular osteoradionecrosis (ORN) and chronic dysphagia in long-term oropharynx cancer (OPC) survivors, and to determine the perceived symptom burden associated with ORN. MATERIALS AND METHODS Medical records of 349 OPC patients treated with bilateral IMRT and systemic therapy were reviewed. ORN was graded using a published 4-point classification schema. Patients were considered to have chronic dysphagia if they had aspiration pneumonia, stricture or aspiration detected by fluoroscopy or endoscopy, and/or feeding tube dependence in long-term follow-up ⩾1year following radiotherapy. MD Anderson Symptom Inventory - Head and Neck Module (MDASI-HN) scores were analyzed in a nested cross-sectional survey sample of 118 patients. RESULTS 34 (9.7%, 95% CI: 6.8-13.3%) patients developed ORN and 45 (12.9%, 95% CI: 9.6-16.9%) patients developed chronic dysphagia. Prevalence of chronic dysphagia was significantly higher in ORN cases (12/34, 35%) compared to those who did not develop ORN (33/315, 11%, p<0.001). ORN grade was also significantly associated with prevalence of dysphagia (p<0.001); the majority of patients with grade 4 ORN requiring major surgery (6 patients, 75%) were found to have chronic dysphagia. Summary MDASI-HN symptom scores did not significantly differ by ORN grade. Significantly higher symptom burden was reported, however, among ORN cases compared to those without ORN for MDASI-HN swallowing (p=0.033), problems with teeth and/or gums (p=0.016) and change in activity (p=0.015) item scores. CONCLUSIONS ORN is associated with excess burden of chronic dysphagia and higher symptom severity related to swallowing, dentition and activity limitations.

Osteoradionecrosis in patients with salivary gland malignancies.

PURPOSE The present study was undertaken to evaluate osteoradionecrosis (ORN) in patients with salivary gland malignancies (SGM) after treatment with radiation therapy. MATERIALS AND METHODS The medical records of 172 patients treated with radiation therapy for SGM during a 12-year period (August 2001 to November 2013) were reviewed. Incidence, time to event, staging and management of ORN were analyzed. RESULTS Of the 172 patients, 7 patients (4%) developed ORN (median latency: 19months, range: 4-72months). Of those 7 patients, 4 required major surgery, 1 required hyperbaric oxygen therapy (HBO), one required minor debridement, and one required conservative management. Total prescribed radiation dose varied from 50Gy (1 case) to 70Gy (1 case) among those patients who developed ORN, and radiotherapy was delivered postoperatively after osseous resection in 4 of 7 cases. Three of the 7 cases of ORN occurred after traumatic injury to the bone. Of the 7 patients who developed ORN, 3 had SGM of the major glands, 3 had other sites of the oral cavity, and 1 had a sinonasal location. CONCLUSION While the rate of ORN after radiotherapy for SGM was somewhat lower (4%) than previously published data on patients with squamous cell carcinomas of the head and neck treated with radiation therapy (8-14%), ORN necessitating major surgery remains a clinically significant, possible late effect of radiotherapy in SGM survivors. Location of SGM is very important, with cases that developed ORN disproportionally having primary disease arising in the oral cavity.

Dose-volume correlates of mandibular osteoradionecrosis in Oropharynx cancer patients receiving intensity-modulated radiotherapy: Results from a case-matched comparison

PURPOSE To determine dosimetric parameters associated with osteoradionecrosis (ORN) in oropharyngeal cancer (OPC) patients in the IMRT era. MATERIAL AND METHODS Subsequent to institutional review board approval, we identified ORN in OPC patients treated with IMRT from 2002 to 2013. 1:2 case-control matching was implemented. Mandibular dose-volume histograms (DVH) were extracted. Dosimetric parameters were compared using non-parametric stats. Recursive partitioning analysis (RPA) was done to identify DVH correlates of ORN. RESULTS 68 ORN cases and 131 controls were matched. Median follow-up was 41months and median time to development of ORN was 16months. Mandibular mean dose was significantly higher in the ORN cohort (48.1 vs 43.6Gy, p<0.0001). However, the maximum dose was not statistically different. DVH bins from V35 to V73 were all significantly higher in the ORN cohort compared with controls (p<0.0006). Two DVH parameters were identified in RPA analysis, V43 and V58. The majority (81%) of ORN cases were observed with both V44≥42% and V58≥25%. CONCLUSIONS Our data demonstrate that a wide range of DVH parameters in the intermediate and high beam path were all significantly higher in ORN patients. Mandibular V44<42% and V58<25% represent reasonable DVH constraints for IMRT plan acceptability, when tumor coverage is not compromised.

Auricular Prosthetic Rehabilitation

The complete or partial loss of an ear can have a negative impact on self-esteem, and physical disfigurement can impair social integration. An auricular prosthesis can replace the absent or partially absent ear resulting from tumor ablation, infection, congenital defect, or trauma. This chapter briefly describes considerations in fabricating an auricular prosthesis as well as case presentations to support the benefit of a prosthetic ear compared to soft tissue reconstruction.