Reinert Christian Philipp, Pfannenberg Christina, Gatidis Sergios, la Fougère Christian, Nikolaou Konstantin, Hoefert Sebastian
Department of Radiology, Diagnostic and Interventional Radiology, University Hospital Tübingen, Tübingen, Germany.
Department of Radiology, Nuclear Medicine, University Hospital Tübingen, Tübingen, Germany.
Front Oncol. 2021 Jul 1;11:700397. doi: 10.3389/fonc.2021.700397. eCollection 2021.
Medication-related osteonecrosis of the jaw (MRONJ) is a serious side effect in antiresorptive treatment. Treatment of MRONJ is considered primarily conservative with oral mouth rinses and antibiotics but may demand surgery, depending on the complaints and general condition of the patient, the extent of the necrosis, and the overall prognosis with respect to the underlying disease. A 77 year old female patient with invasive ductal breast cancer and bone metastases was treated with intravenous bisphosphonate (BP) zoledronic acid. During therapy, she developed MRONJ in the mandible with severe pain. Clinical examination revealed confluent exposed bone of the lower left jaw and a fistula at the right molar region. The panoramic radiograph revealed a mandibular osseous involvement with diffuse radiopaque areas between radiolucent areas. For preoperative planning, F-fluoride positron emission tomography/computed tomography (PET/CT) of the jaw was performed, showing substantially increased F-fluoride uptake in regions 38 to 47 of the mandible with a focal gap in region 36 (area of clinically exposed bone). CT revealed medullary sclerosis and cortical thickening with confluent periosteal reaction and focal cortical erosion in the regions 37 to 42, whereas the regions 43 to 47 were only subtly sclerotic without cortical thickening. After systemic antibiotic therapy with sultamicillin following significant symptom and pain relief, F-fluoride PET/CT imaging was performed again after 5 months. No changes in either CT and PET were observed in regions 38 to 42, whereas the bony sclerosis was slightly increased in regions 43 to 47 with a slight reduction of F-fluoride uptake. F-fluoride PET/CT showed no significant changes assessing the extent of MRONJ prior and after systemic antibiotic therapy, providing no evidence that conservative treatment reduced the extent of the MRONJ-affected jawbone. The additional information of F-fluoride PET enables to identify the true extent of MRONJ which may be underestimated by CT imaging alone. Patients with MRONJ undergoing conservative treatment could benefit because additional imaging may be avoided as the pre-therapeutic F-fluoride PET/CT delivers all information needed for further treatment. Our findings support the recommendation of a surgical approach as long-term antibiotics cannot downsize the extent of MRONJ.
药物相关性颌骨坏死（MRONJ）是抗吸收治疗中的一种严重副作用。MRONJ的治疗主要被认为是采用口腔冲洗和抗生素进行保守治疗，但根据患者的主诉和总体状况、坏死范围以及基础疾病的总体预后，可能需要进行手术。一名77岁患有浸润性导管乳腺癌和骨转移的女性患者接受了静脉注射双膦酸盐（BP）唑来膦酸治疗。在治疗期间，她下颌骨发生了MRONJ并伴有剧痛。临床检查发现左下颌骨有融合的暴露骨，右侧磨牙区有瘘管。全景X线片显示下颌骨骨质受累，在透射区之间有弥漫性不透光区。为进行术前规划，对颌骨进行了F-氟化物正电子发射断层扫描/计算机断层扫描（PET/CT），显示下颌骨38至47区F-氟化物摄取显著增加，36区有一个局灶性间隙（临床暴露骨区域）。CT显示37至42区骨髓硬化、皮质增厚，伴有融合的骨膜反应和局灶性皮质侵蚀，而43至47区仅轻微硬化，无皮质增厚。在用舒他西林进行全身抗生素治疗且症状和疼痛明显缓解后，5个月后再次进行F-氟化物PET/CT成像。38至42区的CT和PET均未观察到变化，而43至47区的骨质硬化略有增加，F-氟化物摄取略有减少。F-氟化物PET/CT显示在全身抗生素治疗前后评估MRONJ范围无显著变化，没有证据表明保守治疗减少了受MRONJ影响的颌骨范围。F-氟化物PET的额外信息能够识别MRONJ的真实范围，而仅靠CT成像可能会低估该范围。接受保守治疗的MRONJ患者可能会受益，因为治疗前的F-氟化物PET/CT提供了进一步治疗所需的所有信息，从而可以避免额外的成像检查。我们的研究结果支持手术治疗的建议，因为长期使用抗生素并不能缩小MRONJ的范围。
