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Background Bisphosphonates, such as zoledronic acid, are commonly used to treat bone metastasis from malignant conditions, such as multiple myeloma, or from solid tumors, such as breast or prostate cancer. Medication-related osteonecrosis of the jaw (MRONJ) is one of the complications of bisphosphonate treatment. The reported incidence of MRONJ among patients with cancers and bone metastases treated with zoledronic acid is 1.3%. MRONJ has been reported to have an incidence rate of up to 18.5%. The clinical and radiographic presentations of MRONJ are very similar to those of bone metastases, making early diagnosis and timely treatment challenging. This is a case report of a patient with multiple myeloma with a history of treatment with zoledronic acid and whose initial presentation of an intraoral lesion made it challenging to distinguish between bone metastasis and MRONJ. Case Summary This is a case report of a 67-year-old female with multiple myeloma, with a history of zoledronic acid, 28 doses taken from 2013 to 2016 and the disease in remission. The patient initially presented with a 1-week history of firm gingival swelling buccal and lingual to a fixed partial denture (FPD) in the left mandible. Panoramic radiography showed a well-defined radiolucent lesion. Considering her history of antiresorptive treatment, MRONJ was considered as one of the diagnoses. However, because of the unusual hyperkeratotic nature of the buccal gingiva, relapsed disease was included in the differential diagnosis. Because of the unconventional clinical manifestation and concerns about relapsed disease, computed tomography guided bone biopsy was performed, and it revealed plasma cell neoplasm and necrotic bone. The patient was treated with palliative radiation therapy and antibiotics, which resulted in a significant decrease in her symptoms. Eventually, a portion of the FPD was removed, and an exposed bony site with a mobile bony sequestrum was revealed. Removal of the sequestrum led to complete gingival healing of the exposed site. Conclusions Maxillofacial manifestation of bone metastasis is common but is often overlooked. Therefore, it should be considered in the differential diagnosis when a patient with a history of antiresorptive medications presents with a gingival mass and/or exophytic bone. Good clinical judgment and well-timed bone biopsy and diagnostic imaging can lead to the correct diagnosis and optimal treatment.

Modern radiotherapy delivery systems and treatment strategies are aimed at limiting the irradiation of healthy structures in the head and neck. This seeks to mitigate post-treatment toxicities and complications such as osteoradionecrosis of the jaw. Given the changes to radiotherapy, conventional workflows for the management of patients requiring dentoalveolar surgery may no longer be suitable. It may therefore be appropriate to revisit current treatment algorithms for the management of patients with radiotherapy to the jaws who require dentoalveolar surgery. At present, there are poor data on this. Development of a randomised trial may be warranted to establish the true relative risk for extraction of teeth in the setting of modern radiation therapy delivery systems.

Objective The purpose of this study was to compare the dosimetric distribution of ipsilateral proton beam radiation therapy (PBRT) with intensity-modulated radiation therapy (IMRT) in the tooth-bearing region of the mandible in patients with head and neck cancer (HNC). Study Design The mandibular dosimetric distribution in patients with head and neck cancer treated with ≥60 Gy relative biologic equivalent PBRT was evaluated. The mean radiation doses were calculated in 5 regions: ipsilateral molar, ipsilateral premolar, anterior, contralateral premolar, and contralateral molar (CM) regions. CM was used as the reference region for comparative analysis. The mandibular dosimetric distribution in patients treated with PBRT was compared with that in IMRT patients with similar tumor sites and planning target volumes. Results The mean radiation dose to the contralateral regions was lower in patients treated with PBRT compared with those treated with IMRT. The average mean radiation doses to the reference region (CM) in patients treated with PBRT (relative biologic equivalent) versus IMRT were oropharynx (2.2 Gy vs 23.2 Gy; P P = .01), and oral cavity (0.4 Gy vs 15.6 Gy; P = .006). Conclusions This study revealed the effective tissue-sparing capability of PBRT compared with IMRT. Utilization of PBRT could translate to less radiation-related toxicity.

Based on their distinctive histologic and genetic features, the latest WHO classification of soft tissue tumors includes four pathologic variants of rhabdomyosarcoma (RMS): embryonal (ERMS), alveolar (ARMS), spindle cell-sclerosing (SRMS-ScRMS) and pleomorphic RMS. The aim of this study focused on a detailed clinicopathologic and survival analysis of head and neck RMS (HNRMS) using the latest pathologic and molecular criteria reflecting this new subclassification in a large cohort.Patients managed for HNRMS in our institution (1996-2015) were analyzed. The presence of a FOXO1 fusion was required for the classification of ARMS. MYOD1 mutations in SRMS-ScRMS were tested when material available. Univariate and multivariate analyses were performed to evaluate variables related to overall survival (OS).Ninety-nine HNRMS patients (52 males and 47 females, mean of 16years) were included in the study after pathologic re-review. The most common location was parameningeal (PM) (n=64), followed by non-orbital/non-PM (n=25) and orbital (n=10). There were 53 ERMS, 33 fusion-positive ARMS and 13 SRMS-ScRMS [SRMS (8); ScRMS (5)]. The 5-year OS rate for ERMS patients was significantly higher (82%) compared to ARMS (53%) and SRMS-ScRMS (50%) [SRMS (75%); ScRMS (30%)]. Univariate analysis showed that survival was dependent on histology (P=0.012), tumor size5cm (P0.001), regional lymph node involvement (P=0.002), metastasis at initial presentation (P0.001), stage (P0.001), and recurrence (P=0.002). Multivariate analysis confirmed histologic subtype to be significant (P=0.043).Our findings reinforce that HNRMS is a heterogenous disease with ARMS and SRMS-ScRMS having an equally unfavorable outcome.

PurposeMetastatic solid tumors to the oral cavity are rare, frequently indicative of an end-stage disease process, and associated with poor survival rates. We performed a 20-year retrospective clinical analysis of our institution's cases of solid metastases to the oral cavity, and investigated these patients' clinical outcomes.Material and methodsA retrospective study of patients with metastatic solid tumors to the oral cavity over a 20-year period (October 1996 to September 2015) was conducted at Memorial Sloan Kettering Cancer Center. Patients were selected if they had a histopathologically confirmed diagnosis. Demographic, pathologic, and clinical information were reviewed to identify patient outcomes.ResultsA total of 44 patients with metastatic non-melanocytic non-hematopoietic tumor to the oral cavity were identified: 24 males and 20 females (39 adults and 5 children) with a mean age of 54.3 years. In all, 24 cases involved the jaw and 20 cases involved the oral soft tissue. Eight patients (18.2%) had oral cavity metastases as the first indication of an occult malignancy. In adult patients, the common primary sites were the lungs (n=9, 20%), kidney (n=7, 16%), breast (n=5, 11%), and colon (n=4, 9%); and in pediatric patients the adrenal gland (3/5) was the most common site. Of the adult patients, 33 (84.6%) died of disease. From the time of metastasis diagnosis, patients with jaw metastases had a median and mean survival of 12 months and 27.7 months, respectively. In comparison, patients with oral soft tissue metastases had a median survival time of 5 months, and mean of 8 months. One pediatric patient (20%) died of disease 8 months after metastasis diagnosis.ConclusionMetastatic solid tumors to the oral cavity can be the first sign of a malignancy. Pediatric patients with oral cavity metastases have a better prognosis compared to adult patients. In this series, adults with oral soft tissue involvement had shorter survival times compared to patients with jaw involvement.

Osteoradionecrosis (ORN) remains an unintended debilitating complication of radiation therapy despite the advent of intensity-modulated radiation therapy (IMRT) which aims to deliver doses of radiation to the tumor site while minimizing doses to healthy tissues [[1], [2], [3], [4]. The etiopathogenesis of ORN has been attributed to the avascular effect of radiation to the bone resulting in hypoxia, hypovascularity, and hypocellularity [5], [6]. Radiation-induced fibrosis has also been implicated in the pathophysiology of ORN [7. Recent studies have placed reported incidences of ORN at 1–30% [2], [8], [9], [10], [11]. ORN of the jaw was defined as an area of exposed necrotic bone greater than 1 cm in an area of previous irradiation that failed to heal after 6 months [5]. This definition of ORN has been used for years and still remains the most widely used clinical criterion for the diagnosis of ORN though it fails to incorporate cases with radiologic evidence of necrosis with intact mucosa [5], [12], [13], [14], [15]. Although a report by Van Merkesteyn et al. described a case of ORN of the jaw with intact mucosa [16], subsequently only two series have likewise reported this condition. In 2000, Store and Boysen reported 17 patients with radiographic osteoradionecrosis of the jaw (rORN) with intact mucosa at initial diagnosis as did He et al. in a recent article where they described 16 patients presenting with rORN with intact mucosa [17], [18]Thus, it appears that rORN with intact mucosa is underdiagnosed. The objectives of this article are to: 1. Describe new cases of rORN with intact mucosa. 2. Correlate the dosimetric analyses of the involved area with the radiographic presentation and to determine the best predictor of rORN with intact mucosa. 3. Propose modification of Store and Boysen’s staging system of ORN. 4. Propose clinical guidelines for early identification of rORN with intact mucosa.

Objectives Osteoradionecrosis (ORN) is a complication of head and neck radiation therapy (RT) and is associated with significant morbidity. The incidence of ORN is variable, and it has been speculated to be lower with advanced RT techniques. Risk factors that have been associated with the development of ORN mainly include trauma and a radiation dose to the head and neck region greater than 60 Gy. However, in a study conducted by our group, ORN developed spontaneously (without any known history of trauma or dentoalveolar procedure) in 82% of the ORN cohort following intensity-modulated radiation therapy (IMRT).The purpose of this study was to characterize spontaneous ORN and to compare spontaneous ORN with nonspontaneous ORN (e.g., related to trauma or dentoalveolar procedures). Study Design Following approval by the Institutional Review Board of the Memorial Sloan Kettering Cancer Center (MSKCC), the treatment records of 44 patients with spontaneous ORN (group A) and 24 patients with nonspontaneous ORN (group B) treated with IMRT at the MSKCC for head and neck cancer (HNCa) were identified and retrospectively reviewed. Average prescribed mean and maximum radiation doses for the region of ORN were calculated by using MSKCC's proprietary radiation treatment planning software. Furthermore, Fischer's exact test was used to compare patient characteristics, such as primary site, tumor stage, smoking status, and other comorbidities, between the spontaneous ORN group and the nonspontaneous ORN group. Results According to preliminary data from 12 patients in group A and 6 patients from group B, the patients in group A appeared to have been exposed to higher radiation doses (Dmax; greater than 70 Gy) compared with group B. Furthermore, no statistical significance was noted between the 2 groups with regard to primary tumor, tumor stage, smoking status, and comorbidities, such as cardiovascular disease and hypertension (P > .05). However, statistical significance was evident for diabetes in group B (P Conclusions Collection of data on the expanded cohort of patients from each group, as well as other variables, such as radiation therapy fractionation, is ongoing. Our initial data indicates that increased radiation dose greater than 70 Gy may be associated with the development of spontaneous ORN.

ObjectiveThe aim of this study was to investigate the relationship between type of antiresorptive medication and medication-related osteonecrosis of the jaw (MRONJ) onset and the role of premedication dental evaluation (PMDE) in the prevention of MRONJ.Study designOur database of patients with MRONJ was reviewed. The Kruskal-Wallis test was used to analyze the onset dose of the 3 frequent medication types associated with MRONJ. To evaluate the role of PMDE in the prevention of MRONJ, all patients on antiresorptive and/or antiangiogenic medications seen in the Dental Service of Memorial Sloan Kettering Cancer Center during a 10-year period were subclassified into 2 groups. Group I comprised patients seen for PMDE before the commencement of A/A and group II patients seen after prior exposure to antiresorptive and/or antiangiogenic medications. Fischer's exact test was used to compare the incidence of MRONJ in both groups.ResultsPatients on denosumab developed MRONJ earlier compared with zoledronate and pamidronate (P = .003). Group I had a significantly reduced incidence of MRONJ (0.9%) compared with group II (10.5%) (P

Objective To determine the prevalence and correlation of various risk factors [radiation dose, periodontal status, alcohol and smoking] to the development of osteoradionecrosis (ORN). Patients and methods The records of 1023 patients treated with IMRT for oral cavity cancer (OCC) and oropharyngeal cancer (OPC) between 2004 and 2013 were retrospectively reviewed to identify patients who developed ORN. Fisher exact tests were used to analyze patient characteristics between ORN patients with OCC and OPC. Paired Wilcoxon tests were used to compare the dose volumes to the ORN and contralateral non-ORN sites. To evaluate an association between ORN and risk factors, a case-control comparison was performed. One to 2 ORN-free patients were selected to match each ORN patient by gender, tumor site and size. General estimation equations models were used to compare the risk factors in ORN cases and matched controls. Results 44 (4.3%) patients developed ORN during a median follow-up time of 52.5 months. In 82% of patients, ORN occurred spontaneously. Patients with OPC are prone to develop ORN earlier compared to patients with OCC (P = 0.03). OPC patients received a higher Dmax compared to OCC patients (P = 0.01). In the matched case-control analysis the significant risk factors on univariate analysis were poor periodontal status, history of alcohol use and radiation dose (P = 0.03, 0.002 and 0.009, respectively) and on multivariate analysis were alcohol use and radiation dose (P = 0.004 and 0.026, respectively). Conclusion In our study, higher radiation dose, poor periodontal status and alcohol use are significantly related to the risk of developing ORN.

CASE PRESENTATION In October 2012, a 70-year-old black woman presented to her ophthalmologist, who noted that she had a left parotid mass. She was subsequently referred to a hospital to have the mass evaluated. It was unclear how long the mass was present, but there were no symptoms. The patient reported no family history of malignancy, and her health was significant for type 2 diabetes mellitus, non-insulin-dependent. The patient had smoked 2 packs a day for 22 years, but she stated that she had quit 40 years ago. She stated she drank 1 to 2 alcoholic beverages per month. At an outside hospital, ultrasonography found a heterogeneously hypoechoic mass with irregular margins containing focal necrosis with possible deep extracapsular extension measuring 1.96 2.49 cm. No increased flow signal was seen on Doppler mode. A fine-needle aspiration (FNA) of the parotid mass was suspicious for acinic cell carcinoma. Within the same month, the patient was sent to Memorial Sloan Kettering Cancer Center. A computed tomography (CT) scan of the neck found an ill-defined, enhancing soft tissue mass in the left parotid tail with no deep parotid involvement, measuring 2.3 1.9 2.0 cm (Figure 1). No abnormal lymphadenopathy was noted in the neck. A second FNA taken of the left parotid found a salivary gland neoplasm with a cylindromatous pattern, which favored pleomorphic adenoma (Figure 2). The FNA slides from the previous hospital were also reviewed, and ultimately the diagnoses encompassed a differential diagnosis that included both acinic cell carcinoma and pleomorphic adenoma. A positron emission tomographyecomputed tomography scan found a 1.3 1.5-cm left parotid nodule with a maximum standardized uptake value of 2.7 (Figure 3). No hypermetabolic lymphadenopathy was noted in the neck.

Purpose Oversuppression of bone turnover can be a critical factor in the pathogenesis of osteonecrosis of the jaw (ONJ). We investigated N-telopeptide of type I collagen (NTX) and bone-specific alkaline phosphatase (BAP) as potential predictors of ONJ onset. Patients and Methods Patients with ONJ and available stored serum were identified retrospectively from the institutional databases. Four approximate points were examined: point of ONJ diagnosis and 12, 6, and 1 month before the diagnosis. NTX and BAP were measured using enzyme-linked immunosorbent assays and examined as possible predictors of ONJ. Results From March 1998 to September 2009, we identified 122 patients with ONJ. Of these, 56 (46%) had one or more serum samples available. Overall, 55 patients (98%) received bisphosphonates. Using the exact dates, no obvious patterns in either NTX or BAP were noted. Similarly, using the ordinal points, no evidence of suppression of NTX or BAP over time was seen. The consecutive median values were as follows: The median NTX values were 8.0 nmol/L (range 3.8 to 32.9) at 12 months before ONJ; 9.5 nmol/L (range 4.7 to 42.7) at 6 months; 9.5 nmol/L (range 4.5 to 24.6) at 1 month, and 10.4 nmol/L (range 4.4 to 32.5) at the ONJ diagnosis. The median BAP values were BAP 18.0 U/L (range 7.0 to 74) at 12 months before ONJ; 18.0 U/L (range 4.0 to 134) at 6 months; 14.0 U/L (range 4.0 to 132) at 1 month, and 18.0 U/L (range 0.7 to 375) at the ONJ diagnosis. Only 2 patients (4%) had NTX and 17 (30%) had BAP below the normal range at the ONJ diagnosis. Conclusions In the present large retrospective study, no trends were seen in the NTX and BAP levels before the ONJ diagnosis.

ObjectiveTo determine clinicopathologic factors on survival in patients with head and neck synovial sarcoma.Patients and methodsWe retrospectively identified patients with molecularly confirmed synovial sarcomas of the head and neck (SS-HN), either by the presence of SS18-SSX fusion transcript by RT-PCR or SS18 gene rearrangement by FISH, who were managed at our institution over a 20-year period (1996-2015). Kaplan-Meier survival analysis and log-rank test were performed to evaluate variables related to disease specific survival (DSS). Fisher exact test was performed to evaluate variables related to local recurrence.ResultsThirty-four patients (20 males and 14 females, mean of 31years) with SS18-SSX fusion-positive SS-HN were identified. The parapharyngeal region of the neck was the most common site. The mean tumor size was 4.8cm (0.8-10cm). Two-thirds (n=23) of cases had a monophasic histology. The 2, 5 and 10-year DSS rates were 97%, 79% and 68%. The 5-year DSS rates for the adult/pediatric cohort were 74%/88%. Recurrence showed significant effect on DSS (p=0.021). There was no significant effect on DSS with age, therapy modality, tumor site, surgical margin, tumor size (⩽5cm vs. >5cm) and histopathologic subtype. Tumor site (i.e. skull base/paranasal sinus region) was associated with local recurrence (p=0.003).ConclusionIn our cohort DSS rate was associated with recurrence. Tumors located in the skull base/paranasal sinus region were associated with a higher rate of local recurrence. Thus appropriate selection of high risk patients who can benefit from multimodality therapies might improve survival.

PurposeThe aim of this study was to estimate the prevalence of trismus in oral and oropharyngeal cancer patients (OOPC) treated with intensity-modulated radiation therapy (IMRT) and to identify the role of risk factors in patients who developed trismus.Materials and methodsA retrospective cohort study of OOPC treated with IMRT in our institution from 2009 to 2014 was performed. Patients eligible for this study had pre-RT and post-RT maximal inter-incisal opening (MIO) measurements at 6-48 months post-RT, treated with high-dose radiation (≥60Gy) and pre-RT MIO ≥36mm. A descriptive analysis to identify the incidence of trismus, with trismus stated as MIO ≤35mm at or after 6 months post-RT measurement was performed. The role of risk factors such as age, gender, tumor site, tumor size (T), tumor stage, pre-RT MIO measurements and radiation dose to the tumor were assessed using Fisher exact test and the radiation doses to the ipsilateral muscles of mastication in patients who developed trismus were assessed by matching with control (non-trismus) patients using Wilcoxon Signed Rank test.ResultsThe study consisted of 54 patients with a median age of 55 years and 81% were males. The median follow-up time was 10 months. The prevalence of trismus was 14.8%. Patients with pre-RT MIO measurements ≤40mm were at risk of developing trismus (P&nbsp

BackgroundThe aims of this study were to investigate temporal patterns and potential risk factors for severe hyposalivation (xerostomia) after intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC), and to test the two QUANTEC (Quantitative Analysis of Normal Tissue Effects in the Clinic) guidelines.Patients and methodsSixty-three patients treated at the Memorial Sloan Kettering Cancer Center between 2006 and 2015, who had a minimum of three stimulated whole mouth saliva flow measurements (WMSFM) at a median follow-up time of 11 (range: 3-24) months were included. Xerostomia was defined as WMSFM ≤25% compared to relative pre-radiotherapy. Patients were stratified into three follow-up groups: 1

Objective Very few studies have evaluated the efficacy of pentoxifylline and tocopherol (PENT-E) in the management of medication-related osteonecrosis of the jaw (MRONJ), although some studies have shown the therapeutic and prophylactic benefit of PENT-E in the management of osteoradionecrosis. We report the outcomes of MRONJ managed with PENT-E in patients with metastatic bone disease or multiple myeloma. Study Design Seven patients diagnosed with established cases of refractory MRONJ caused by antiresorptive medications for the management of metastatic bone tumors or multiple myeloma were administered PENT-E for a mean period of 16.8 months (range 3-48 months). Results At the latest follow-up visit, all patients demonstrated relief of symptoms. There was radiographic evidence of new bone fill of prior radiolucent defect in all patients. Two patients had resolution of exposed bone, two patients had partial resolution, one patient had no change in exposed bone, and one patient with three sites of exposed bone before starting PENT-E had resolution in one site, partial resolution in another site, and no change in the third site. PENT-E was well tolerated in all patients. Conclusions Our case series demonstrated that PENT-E was well tolerated and may be an effective adjunct in the management of MRONJ.

Purpose Primary Ewing sarcoma of the jaw is rare. The aim of this study was to describe new cases of primary Ewing sarcoma of the jaw and investigate reported prognostic factors of Ewing sarcoma in this series and treatment outcome. Materials and Methods Six patients with primary Ewing sarcoma of the jaw were treated at the Memorial Sloan Kettering Cancer Center (MSKCC) from 1992 through 2013. Clinical data, pathology reports, treatment prescribed, treatment regimens, outcome, and follow-up information were reviewed. Results Five of 6 patients were female and 5 cases were in the mandible. No patient presented with metastatic disease at diagnosis. All cases were positive for CD99, and 3 patients with genetic confirmation were positive for EWS-FLI1 fusion or EWSR1 gene rearrangement. All patients received induction multiagent chemotherapy and surgical resection and 2 patients received adjuvant radiotherapy. Total (grade IV) or nearly total (grade III) tumor necrosis in 3 of 5 patients (60%) assessed for histologic response to chemotherapy indicated intense sensitivity. All patients were alive and free of disease, with no history of local recurrence, at a median follow-up period of 6.5 years. Conclusion Patients with primary Ewing sarcoma of the jaw have a good prognosis and metastasis is an uncommon occurrence at initial presentation.

A 52-year-old male with history of metastatic melanoma of unknown primary, stage IV with metastases to the left iliac region as well as pancreatic head was diagnosed in early 2014. The metastatic melanoma to the iliac bone presented as a large painful lesion and radiologically as a large lytic lesion. He was treated with palliative radiotherapy, 27 Gy in 3 fractions completed in March 2014 and at about the same time started on Ipilimumab at 3 mg/kg intravenous (230 mg) every 3 weeks for a total of 4 doses, the last one in May 2014. Six days following the second dose of Ipilimumab, the patient presented with a gingival swelling on the lingual aspect of the right mandible. On examination, there was a swelling of the lingual gingiva adjacent to the right mandibular molars, localized bleeding on probing, mild discomfort, and a small amount of purulent discharge was expressed from the gingival sulcus on palpation (Fig. 1A). Panoramic and periapical radiographs showed no obvious radiopaque or radiolucent lesions. The area was irrigated with 0.12% chlorhexidine. He was advised to irrigate the area 3 times per day with chlorhexidine. One week later, he presented for a follow-up, at which time he said “it doesn't feel better”. On examination, the swelling had progressed, a fistula was noted from the lingual area of the right mandibular second molar to the mylohyoid space, and on palpation purulence was expressed from the fistula with slight discomfort. Nevertheless, the patient had excellent oral hygiene. He was prescribed Augmentin 875 mg bid for 7 days. A month later, he presented with a complaint of “my other doctor thought he saw some exposed bone in the area that we have been watching”. He stated that it was asymptomatic; however his tongue noticed something rough. On examination, there was a 2 × 2 mm exposed necrotic-appearing bone on the lingual aspect of the right mandibular second molar (Fig. 1B), there was slight purulence on palpation and the bone was mobile but no tenderness or sensitivity on manipulation. The patient was instructed to continue with the chlorhexidine rinse. In 3 weeks, he returned with the complaint of “the bone is moving around now and bothering my tongue”. There was no history of pain from that area. On examination, an area of exposed necrotic bone measuring 10 × 5 mm was present (Fig. 1C); the bone was very mobile and easily removed with cotton forceps with no associated pain or bleeding on removal. The patient was advised to continue the chlorhexidine rinse. The specimen was submitted for histopathologic evaluation (Fig. 1D), which was reported as a non-vital bone (sequestrum) with bacterial colonies consistent with actinomyces species associated with acute inflammatory cells (Fig. 1E). At his 2 month follow-up examination, the area had fully resolved and healed with no purulent discharge or pain on palpation (Fig. 1F). Fig. 1 Clinical picture at initial presentation showing a gingival swelling (A), clinical picture a month later showing a 2 × 2 mm area of exposed bone (B), clinical picture 3 weeks later showing a 10 × 5 mm area of exposed necrotic bone (C), ... The clinical findings of bone exposure of the jaw with histopathologic diagnosis of sequestrum with actinomyces and neutrophils are similar to osteonecrosis of the jaw (ONJ) in patients treated with anti-resorptive or antiangiogenic agents. With no history of radiation therapy to the jaw or metastasis of the tumor to the jaw, this can be termed medication related osteonecrosis of the jaw (MRONJ) [1]. Since 2003, there has been an increase in ONJ cases related to anti-resorptive medications such as Alendronate (oral bisphosphonate), Pamidronate and Zolendronate (intravenous bisphosphonate), Denosumab (humanized monoclonal antibody) and anti-angiogenic medications such as Sunitinib (tyrosine kinase inhibitor) and Bevacizumab (humanized monoclonal antibody), which targets the vascular endothelial growth factor pathway [[2], [3], [4], [5], [6], [7]]. This patient had not used any of the aforementioned class of medications. Ipilimumab was approved by the US Food and Drug Administration in March 2011 as an immunotherapy for the management of advanced (unresectable or metastatic) melanoma both in naive or post-chemotherapy treated patients. Ipilimumab is a humanized monoclonal antibody against cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4). CTLA-4 is expressed in activated T-cells and in suppressor T-regulatory cells which bind to antigen presenting cells thereby lessening T-cell responses. Blocking the CTLA-4 increases the antitumor responses by activated T-cells. Ipilimumab has demonstrated clinical benefits in the management of melanoma [[8], [9]]. The adverse toxicities of Ipilimumab have been attributed to increased immune-reactivity against normal tissues causing pruritus, diarrhea, vitiligo, hepatitis, and endocrinopathies [10]. Bone necrosis was not reported. We suggest that Ipilimumab may have been involved in the process of bone necrosis in this patient. Ipilimumab increases systemic activated T-cells presence. CTLA4 deficient activated T-cells have been shown to be associated with osteonecrosis, as activated T-cells may elicit osteoclastogenesis via osteoprotegerin ligand resulting in bone loss [11]. Trauma from regular oral activity (chewing or tooth brushing) could increase the demand on this vulnerable bone to mend itself, resulting in localized bone necrosis. To our knowledge, this is the first report of ONJ in a patient treated with Ipilimumab. Thousands of patients have been treated with Ipilimumab. If osteonecrosis is an associated complication, it is probably rare and maybe because patients are treated for a short time. As this is a relatively new medication with great promise for management of melanoma and other advanced-stage malignancy clinicians involved in the care of patients managed with Ipilimumab should be aware of this complication.

Angiosarcomas are rare, malignant neoplasms of vascular origin that account for less than 1% of all soft tissue tumors. Angiosarcomas of the oral cavity are especially rare, and brachytherapy may be prescribed as a localized treatment to manage these malignancies. Intraoral brachytherapy requires collaboration between the radiation oncologist and a dental professional for the fabrication of the brachytherapy delivery prosthesis. The present clinical report describes an intraoral angiosarcoma and the fabrication of an intraoral brachytherapy prosthesis to manage this malignancy.

Objective We report long-term follow-up of patients with intravenous bisphosphonate–related osteonecrosis of the jaw (BRONJ). Study Design Medical and dental histories, including type and duration of bisphosphonate treatment and comorbidities, were analyzed and compared with clinical course of 109 patients with BRONJ at Memorial Sloan-Kettering Cancer Center Dental Service. Results Median onset of BRONJ in months was 21 (zoledronic acid), 30 (pamidronate), and 36 (pamidronate plus zoledronic acid), with a significant difference between the pamidronate plus zoledronic acid and zoledronic acid groups (P = .01; Kruskal-Wallis). The median number of doses for BRONJ onset was significantly less with zoledronic acid (n = 18) than pamidronte plus zoledronic acid (n = 36; P = .001), but not pamidronate alone (n = 29). An association between diabetes (P = .05), decayed-missing-filled teeth (P = .02), and smoking (P = .03) and progression of BRONJ was identified through χ2 test. Conclusions This long-term follow-up of BRONJ cases enhances the literature and contributes to the knowledge of BRONJ clinical course.

Objectives Osteoradionecrosis is a significant complication following head and neck radiotherapy. The purpose of this study was to determine the intensity-modulated radiation therapy (IMRT) dosages delivered to the tooth-bearing regions of the mandible. Study Design A total of 28 patients with base of tongue cancer with the following stages: T1-2/N2-3 (n = 10), T3-4/N2-3 (n = 10), and T1-4/N0 (n = 8), treated with IMRT, were included. Average mean and maximum doses were calculated for the anterior, premolar, and molar regions. Results Lower doses were seen in anterior bone with smaller tumors. Large tumors, regardless of laterality, resulted in high doses to the entire mandible, with anterior bone receiving more than 6000 cGy. Conclusions Tumor size is important in preradiation dental treatment planning. This information is important in planning pre- and postradiation dental extractions. Dosimetric analyses correlating mean and maximum point dose with clinical presentation and outcomes are needed to determine the best predictor of osteoradionecrosis risk.