Osteoradionecrosis following treatment for head and neck cancer and the effect of radiotherapy dosimetry: the Guy's and St Thomas' Head and Neck Cancer Unit experience

doi:10.1016/j.oooo.2016.01.007

Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Volume 122, Issue 1, July 2016, Pages 28-34

https://doi.org/10.1016/j.oooo.2016.01.007 Get rights and content

Objectives

To analyze clinical features, dosimetric parameters, and outcomes of osteoradionecrosis (ORN).

Study Design

Thirty-six patients with ORN who had been previously treated with radiotherapy (RT) were retrospectively identified between January 2009 and April 2014. ORN volumes were contoured on planning computed tomography (CT) scans. Near maximum dose (D2%), minimum dose (Dmin), mean dose (Dmean), and percentage of bone volume receiving 50 Gy (V50) were examined. Clinical and dosimetric variables were considered to compare ORN resolution versus ORN persistence.

Results

Median interval time from end of RT to development of ORN was 6 months. Of the ORN cases, 61% were located in the mandible. Dmean to affected bone was 57.6 Gy, and 44% had a D2% 65 Gy or greater. Smoking was associated with ORN persistence on univariate analysis, but no factors were found to impact ORN resolution or progression on logistic regression.

Conclusions

Prevention strategies for ORN development should be prioritized. Dose-volume parameters could have a role in preventing ORN.

Section snippets

Patient population

Data of patients with ORN treated for primary HNC between January 2009 and April 2014 were retrospectively reviewed. All cases were discussed in a meeting of a multidisciplinary team, including clinical oncologists, surgeons, dentists, radiologists, and pathologists. For all cases demographic data (including gender, age, smoking, alcohol, performance status), primary tumor parameters (i.e., localization, tumor stage, treatment modality, toxicity) and dental assessment documentation (time and

Baseline characteristics

Between January 2009 and April 2014, 653 consecutive patients with histologically proven HNC received radical RT. During this period, 36 patients were treated for ORN, with an overall incidence of 5.5%. Baseline patient and primary tumor characteristics are shown in Table II.

The vast majority of patients were male (n = 23; 64%) smokers (n = 27; 75%). At diagnosis, the primary tumor was mostly located in the oropharynx (n = 16; 44%), and the majority (n = 32; 89%) had locally advanced disease

Discussion

This is a single-institution retrospective analysis of patients diagnosed and treated for ORN following RT for HNC. The overall incidence of ORN in our patient population who received RT during this period was 5.5%. This relative low incidence might relate to the high proportion (89%) of patients treated with IMRT. Although limited data are available to assess the incidence in relation to RT technique and the influence of IMRT remains controversial, the prevalence of ORN in patients treated

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Dental considerations for head and neck cancer: A clinical review
2023, Saudi Dental Journal
Radiotherapy is one of the treatment modalities for the treatment of head and neck cancer (HNC). However, it leads to the development of chronic and acute side effects. These side effects impact negatively on the patient’s quality of life and oral functioning. This clinical review aims to provide basic information about HNC, understand the impact of radiotherapy on oral health, and explain the role of dental care providers for HNC patients during the pre-and post-radiotherapy time.
Electronic databases (i.e., PubMed, Scopus, and Google Scholar) were searched using defined keywords. The main inclusion criteria were any studies describing “dental management of patients with head and neck cancer” and “dental management of patients treated with radiotherapy.”
Thematic analysis was used to summaries the findings of the included studies (n = 102) into main headings and subheadings. All studies were published between 1970 and 2023.
The number of HNC patients is increasing. This necessitates the need for raising the awareness of dental care providers to the side-effects of HNC therapy which includes treatment with radiotherapy, chemotherapy, and/or surgery. Dental care providers should understand the common side-effects and their treatments besides their role in the pre- (i.e., dental extraction of teeth with poor prognosis and maintaining good oral hygiene) and post- (i.e., oral rehabilitation and post-HNC dental care) radiotherapy dental care.
Early detection of mandible osteoradionecrosis risk in a high comorbidity veteran population
2023, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Citation Excerpt :
Imaging studies conducted by the Joint Head and Neck Radiotherapy-MRI Development Cooperative at the University of Texas MD Anderson Cancer Center and collaborating institutions strongly support a hypothesis of radiation-altered bone vascularity as a critical contributor to ORN development [5–7]. Reported ORN rates range from 0 to 16 % [8–10]. This discrepancy in disease incidence may be partially explained by the evolution of radiation delivery from three dimensional conformal strategies to intensity-modulated radiation therapy (IMRT), which can deliver comparable doses to tumors with lower radiation delivery to surrounding tissues [11].
Osteoradionecrosis (ORN) of the mandible is a devastating complication of external beam radiation therapy (EBRT) for head and neck squamous cell carcinoma (HNSCC). We sought to ascertain ORN risk in a Veteran HNSCC population treatment with definitive or adjuvant EBRT and followed prospectively.
Retrospective analysis of prospective cohort.
Tertiary care Veterans Health Administration (VHA) medical center.
Patients with HNSCC who initiated treatment at the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) are prospectively tracked for quality of care purposes through the end of the cancer surveillance period (5 years post treatment completion). We retrospectively analyzed this patient cohort and extracted clinical and pathologic data for 164 patients with SCC of the oral cavity, oropharynx, larynx, and hypopharynx who received definitive or adjuvant EBRT (2016–2020).
Most patients were dentate and 80 % underwent dental extractions prior to EBRT of which 16 (16 %) had complications. The rate of ORN was 3.7 % for oral cavity SCC patients and 8.1 % for oropharyngeal SCC patients. Median time to ORN development was 156 days and the earliest case was detected at 127 days post EBRT completion. All ORN patients were dentate and underwent extraction prior to EBRT start.
ORN development can occur early following EBRT in a Veteran population with significant comorbid conditions but overall rates are in line with the general population. Prospective tracking of HNSCC patients throughout the post-treatment surveillance period is critical to early detection of this devastating EBRT complication.
Osteoradionecrosis rate in oropharynx cancer treated with dose volume histogram based constraints
2022, Radiotherapy and Oncology
Citation Excerpt :
Similar analyses have also found V50Gy to be significantly associated with ORN and suggest that a goal of minimizing V50Gy in plan optimization may reduce ORN incidence [10,22,23]. Volume of the mandible receiving 60 Gy has also shown potential utility as a constraint [10,18,24]. These approaches established the importance of intermediate-dose mandibular constraints, which led to the introduction of V44Gy and V58Gy as important dose thresholds.
Mandibular dose constraints are designed to limit high dose to small volumes to avoid osteoradionecrosis (ORN). Based upon a published experience, intermediate-dose constraints were introduced but have not been independently validated. We hypothesize that these constraints lower ORN rate without compromising other organs at risk (OAR).
Oropharyngeal cancer patients treated with standard fractionation adjuvant/definitive VMAT from 01/2014–08/2020 were included. In 09/2017, mandibular dose constraint was changed from historical constraint (HC) of D 0.1 cc < 70 Gy to modified constraints (MC) of V 44 Gy < 42%, V 58 Gy < 25%, D 0.5 cc < 70 Gy. OAR dosimetric changes and ORN development were evaluated. Regression modelling predicted long-term ORN cases in MC group.
There were 174 patients, 71 in MC group. Seven cases of ORN in HC group at a median follow up (FU) of 39 months and 1 case of ORN in MC group at a median FU of 11 months were observed. More patients in the MC group met V 44 Gy (87% vs 62%, p < 0.01) and V 58 Gy constraints (92% vs 73%, p < 0.01). Mean doses to OARs did not rise. Mandible V 44 Gy and V 58 Gy were significantly associated with ORN (p < 0.01 and p = 0.03, respectively) across all patients. In the HC group, V 44 Gy was independently associated with ORN (p = 0.01). To account for shorter FU in MC group, logistic regression of ORN based on V 44 Gy in HC patients was performed. This predicts 3.2 ORN cases in the MC group (95% CI: 0.00–6.4).
Achieving V 44 Gy and V 58 Gy was successful in 87% of cases without sacrificing target coverage or OARs and resulted in non-significant ORN decrease.
Is Dose Volume a Better Predictor of Osteoradionecrosis Risk Than Total Dose for Patients Who Have Received Head and Neck Radiation?
2022, Journal of Oral and Maxillofacial Surgery
Oral and maxillofacial surgeons frequently encounter patients who require extractions following exposure to head and neck radiation, and they must assess the risk of extraction and consider alternatives such as deliberate root retention. The purpose of this study was to determine whether dose volume would be a better predictor for osteoradionecrosis (ORN) than total dose.
This is a retrospective cohort study of patients diagnosed with ORN following head and neck radiation (administered between January 2006 and December 2018) and a comparison group selected based on site and dosage who did not develop ORN. The predictor variables were total radiation dose and mandibular dose volume, and the outcome variable was ORN occurrence. Covariates included age, sex, cancer stage and site, radiation therapy type, smoking status, alcohol use, adjuvant chemotherapy use, medical comorbidities, and concomitant tumor surgery. Logistic regression models were employed and area under receiver operating characteristic curve (AUROC) and model accuracy (Acc) were used to determine the better predictor.
A total of 56 patients were included in the study: 27 ORN positive (ORN+) and 29 matched controls who did not develop ORN (ORN-). Most patients were male (76.8%), considered smokers (78.6%), used alcohol (80.4%), were in stage IV (66.1%), received chemotherapy (75.0%), and received intensity modulated radiation therapy radiation (55.4%). The statistical models with V50 Gy (cc) and V65 Gy (cc) dosage variables exhibited greater predictability of ORN occurrence than total dose (AUROC: 0.90 vs 0.76 and model accuracy: 0.82 vs 0.75, respectively).
The results suggest that following head and neck radiation, dose volume may be a better predictor of ORN risk than total dose. This finding is significant, both for the oral and maxillofacial surgeon who is preoperatively assessing ORN risk following radiation exposure, and for the radiation oncologist striving to minimize the risk associated with their treatment.
Predictive factors for mandibular osteoradionecrosis after irradiation of head and neck cancers
2021, Cancer/Radiotherapie
L’identification des différents facteurs de risque d’ostéoradionécrose mandibulaire doit se faire en amont et au décours de la prise en charge des patients atteints d’un cancer des voies aérodigestives supérieures. Différents critères cliniques de cette complication sévère radio-induite sont liés au patient (radiosensibilité intrinsèque, malnutrition associée à une perte de poids, intoxication tabagique, atteinte des microcapillaires, état bucco-dentaire précaire, hyposalivation) et/ou liés à la maladie (cancer de la cavité buccale, taille tumorale avancée, envahissement mandibulaire tumoral). Des facteurs de risque thérapeutiques sont également associés à un risque plus élevé d’ostéoradionécrose (chirurgie tumorale première, chimiothérapie concomitante à l’irradiation, avulsion dentaire post-radiothérapique, inobservance préventive avec l’absence de suivi stomatologique et de mise en place quotidienne de gouttières fluorées et inobservance curative des traitements cicatrisants). Enfin, différentes études dosimétriques ont précisé les paramètres afin de cibler les valeurs de dose distribuée à la mandibule majorant le risque d’ostéoradionécrose. Une dose moyenne mandibulaire supérieure à 48–54 Gy et des pourcentages élevés de volume mandibulaire recevant 40 à 60 Gy semblent être discriminants dans le risque de développement d’une ostéoradionécrose.
The identification of the different risk factors for mandibular osteoradionecrosis (ORN) must be done before and after the management of patients with head and neck cancer. Various clinical criteria for this severe radiation-induced complication are related to the patient (intrinsic radiosensitivity, malnutrition associated with thin weight loss, active smoking intoxication, microcapillary involvement, precarious oral status, hyposalivation) and/or related to the disease (oral cavity, large tumor size, tumor mandibular invasion). Therapeutic risk factors are also associated with a higher risk of ORN (primary tumor surgery, concomitant radio-chemotherapy, post-irradiation dental avulsion, preventive non-observance with the absence of stomatological follow-up and daily installation of gutters fluoride and, non-observance curative healing treatments). Finally, various dosimetric studies have specified the parameters in order to target the dose values distributed in the mandible, which increases the risk of ORN. An mean mandibular dose greater than 48–54 Gy and high percentages of mandibular volume receiving 40 to 60 Gy appear to be discriminating in the risk of developing an ORN.
Osteoradionecrosis: Exposing the Evidence Not the Bone
2021, International Journal of Radiation Oncology Biology Physics
Osteoradionecrosis is a relatively rare but potentially morbid and costly complication of radiation therapy for head and neck cancer. Multidisciplinary diagnosis and treatment are essential. Despite evidence guiding individual aspects of care for osteoradionecrosis, there is a lack of broad consensus on the overall diagnosis and management of this condition. This study comprehensively reviews the literature, with a focus on the past 10 years, to guide evaluation and treatment.

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Oral and maxillofacial surgeryOsteoradionecrosis following treatment for head and neck cancer and the effect of radiotherapy dosimetry: the Guy's and St Thomas' Head and Neck Cancer Unit experience

Objectives

Study Design

Results

Conclusions

Section snippets

Patient population

Baseline characteristics

Discussion

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Oral Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Oral Surg Oral Med Pathol Oral Radiol Endod

Am J Otolaryngol

Radiother Oncol

Radiother Oncol

Radiother Oncol

Int J Oral Maxillofac Surg

Oral and maxillofacial surgery
Osteoradionecrosis following treatment for head and neck cancer and the effect of radiotherapy dosimetry: the Guy's and St Thomas' Head and Neck Cancer Unit experience