Osteoradionecrosis of the jaw following proton radiation therapy for patients with head and neck cancer Journal Article


Authors: Singh, A.; Kitpanit, S.; Neal, B.; Yorke, E.; White, C.; Yom, S. K.; Randazzo, J. D.; Wong, R. J.; Huryn, J. M.; Tsai, C. J.; Zakeri, K.; Lee, N. Y.; Estilo, C. L.
Article Title: Osteoradionecrosis of the jaw following proton radiation therapy for patients with head and neck cancer
Abstract: Importance: Proton radiation therapy (PRT) has reduced radiation-induced toxic effects, such as mucositis and xerostomia, over conventional photon radiation therapy, leading to significantly improved quality of life in patients with head and neck cancers. However, the prevalence of osteoradionecrosis (ORN) of the jaw following PRT in these patients is less clear. Objective: To report the prevalence and clinical characteristics of ORN in patients with oral and oropharyngeal cancer (OOPC) treated with PRT. Design, Setting, and Participants: This case series reports a single-institution experience (Memorial Sloan Kettering Cancer Center, New York, New York) between November 2013 and September 2019 and included 122 radiation therapy-naive patients with OOPC treated with PRT. Data were analyzed from 2013 to 2019. Main Outcomes and Measures: Clinical parameters, including sex, age, comorbidities, tumor histology, concurrent chemotherapy, smoking, comorbidities, and preradiation dental evaluation, were obtained from the medical record. Patients with clinical or radiographic signs of ORN were identified and graded using the adopted modified Glanzmann and Grätz grading system. Characteristics of ORN, such as location, clinical presentation, initial stage at diagnosis, etiology, time to diagnosis, management, and clinical outcome at the last follow-up, were also collected. Results: Of the 122 patients (mean [SD] age, 63 [13] years; 45 [36.9%] women and 77 [63.1%] men) included in this study, 13 (10.6%) developed ORN following PRT during a median (range) follow-up time of 40.6 (<1-101) months. All patients had spontaneous development of ORN. At the time of initial diagnosis, grade 0, grade 1, grade 2, and grade 3 ORN were seen in 2, 1, 9, and 1 patient, respectively. The posterior ipsilateral mandible within the radiation field that received the full planned PRT dose was the most involved ORN site. At a median (range) follow-up of 13.5 (0.2-58.0) months from the time of ORN diagnosis, complete resolution, stable condition, and progression of ORN were seen in 3, 6, and 4 patients, respectively. The 3-year rates of ORN and death in the total cohort were 5.2% and 21.5%, while the 5-year rates of ORN and death were 11.5% and 34.4%, respectively. Conclusions and Relevance: In this case series, the prevalence of ORN following PRT was found to be 10.6%, indicating that ORN remains a clinical challenge even in the era of highly conformal PRT. Clinicians treating patients with OOPC with PRT should be mindful of this complication.. © 2022 American Medical Association. All rights reserved.
Keywords: adult; cancer chemotherapy; human tissue; aged; middle aged; debridement; retrospective studies; major clinical study; clinical feature; cancer radiotherapy; nuclear magnetic resonance imaging; follow up; antineoplastic agent; quality of life; pain; retrospective study; age; head and neck neoplasms; comorbidity; pentoxifylline; oropharynx cancer; protons; alpha tocopherol; chlorhexidine; gender; tongue cancer; radiation field; mouth neoplasms; osteoradionecrosis; bone necrosis; mouth cancer; fluorodeoxyglucose; head and neck tumor; periodontal disease; oropharyngeal neoplasms; mandible; proton; chlorhexidine gluconate; complication; jaw osteonecrosis; clinical outcome; oropharynx tumor; mouth tumor; proton therapy; amoxicillin plus clavulanic acid; hyperbaric oxygen therapy; tooth extraction; humans; human; male; female; article; positron emission tomography-computed tomography; oleyloxyethylphosphorylcholine; mandibular second molar; second premolar; tooth avulsion
Journal Title: JAMA Otolaryngology - Head and Neck Surgery
Volume: 149
Issue: 2
ISSN: 2168-6181
Publisher: American Medical Association  
Date Published: 2023-02-01
Start Page: 151
End Page: 159
Language: English
DOI: 10.1001/jamaoto.2022.4165
PUBMED: 36547968
PROVIDER: scopus
PMCID: PMC9912132
DOI/URL:
Notes: Article -- MSK Cancer Center Support Grant (P30 CA008748) acknowledged in PubMed and PDF -- MSK corresponding author is Cherry Estilo -- Export Date: 1 March 2023 -- Source: Scopus
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MSK Authors
  1. Joseph M Huryn
    108 Huryn
  2. Cherry Estilo
    93 Estilo
  3. Nancy Y. Lee
    876 Lee
  4. Richard J Wong
    415 Wong
  5. Ellen D Yorke
    450 Yorke
  6. SaeHee Kim Yom
    42 Yom
  7. Chiaojung Jillian   Tsai
    239 Tsai
  8. Kaveh Zakeri
    82 Zakeri
  9. Annu Singh
    22 Singh
  10. Charlie White
    41 White