MRI evaluation of bisphosphonate-related osteonecrosis of the jaw

Transcription

1 MRI evaluation of bisphosphonate-related osteonecrosis of the jaw Poster No.: C-1949 Congress: ECR 2012 Type: Authors: Keywords: DOI: Scientific Paper G. Filonzi, A. Bazzocchi, P. Spinnato, E. Salzzoni; Bologna/IT Head and neck, Bones, MR, Experimental investigations, Comparative studies, Osteoporosis, Neoplasia, Hematologic diseases /ecr2012/C-1949 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 9

2 Purpose Bisphosphonates are a group of drugs used in the treatment of many common diseases, such osteoporosis, bone metastasis, myeloma. Their role is to inhibit osteoclast function, leading to lower bone resorption. Since 2003 an increasing number of bisphosphonate-related osteonecrosis of the jaw (BRONJ) were reported. BRONJ is a severe, challenging condition, characterized by exposure, pain, infection of necrotic bone, with masticatory and speech problems. Fig. 1 on page 2 Swelling, ulcerations and fistulas are the most common complications involving the soft tissues. Fig. 2 on page 3 Treatment of BRONJ remains controversial; surgery is often the only possible definitive treatment, although relapse is unfortunately common. A correct radiologic approach to BRONJ is important to reach an early diagnosis, to define the extension and the margin of lesions for the surgical treatment and in the follow-up of patients. CT and MRI are both used for the evaluation of BRONJ, but some comparative studies have underlined that signal intensity changes on MRI, especially after contrast infusion, may appear more extensive than CT alterations. This could be important for the surgical planning, in order to eradicate all necrotic tissue and to avoid relapses. The aim of this study is to evaluate the role of MRI in the assessment of BRONJ lesions, and to evaluate the possible impact in the clinical and surgical management of BRONJ patients. Images for this section: Page 2 of 9

3 Fig. 1: Typical presentation of BRONJ, with exposure of necrotic bone tissue of the left mandibular branch and swelling of soft tissues near the lesion. Page 3 of 9

4 Fig. 2: Cutaneous ulceration in the left submandibular area caused by a necrotic bone lesion in the mandular branch, with a fistula involving the soft tissues. Page 4 of 9

5 Methods and Materials Twenty-three patients (9 males, 14 females), mean age 64.8 (range 49-72) with suspected BRONJ have been evaluated with clinical examination and MRI (Signa Excite- HDX, General Electric Medical Systems, Milwaukee, Wis - head array). Eleven patients (47.8%) had been treated for myeloma, 7 (30.4%) for bone metastasis and 5 (21.7%) for osteoporosis. 12 patients (52.2%) had been treated with I.V. infusion of Zoledronate 5 patients (21.7%) with I.V. infusion of Zoledronate and Pamidronate (I.V. infusions), 3 (13%) with I.M. infusion of Alendronate, and 3 (13%) with Clodronic Acid per os. The trigger factor was an extraction of one or more teeth in 9 patients (39.1%), a spontaneous avulsion in 6 (26.1%), a prosthesis implant in 3 (13%) and was unknown in 5 (21.7%). Our MRI protocol included 3D-FSPGR-T1w scans before and after contrast infusion (gd- DTPA). Scanning duration for each patient was recorded and mean time calculated. Results Nineteen patients was found to have BRONJ, and 24 total lesions were detected and confirmed by histological examination. Among those, 20 lesions (83.3%) developed on the lower jaw, and 4 (16.6%) on the upper jaw. MRI identified 22 (91.7%) lesions, while clinical examination 14 (58.3%). MRI identified all the lesions detected also by clinical examination, except in one case (4.2%), due to the presence of artifacts. On the other hand, 9 lesions (37.5%) have been detected only by MRI. It is important to underline that in most cases lesions appeared at MRI evaluation larger than suspected with clinical examination. MRI also showed swelling of the soft tissues in 7 patients (30.4%), while in 3 (13%) patient fistulous tracts between the necrotic bone and the soft tissues have been detected. Fig. 5 on page 7 Page 5 of 9

6 BRONJ lesions appeared as an area of iso- or hypo-intensity on T1-weighted sequences, with variable enhancement after contrast infusion. Fig. 3 on page 6, Fig. 4 on page 6 This findings agree with previous studies, where also STIR sequences were performed, with more ambiguous findings. We didn't perform STIR scans, as we wanted to shorten the scanning time. Effectively, mean scanning time in our study was 26.4 ± 11.4 minutes, significantly shorter than other studies, while sensitivity resulted comparable. Images for this section: Fig. 3: Typical behaviour of a BRONJ lesion on a T1 weighted axial sequence before (left) and after (right) contrast enhancement, showing a large osteonecrotic lesion of the right mandibular branch. Page 6 of 9

7 Fig. 4: Image shows a BRONJ lesion of the left maxilla. It appears hypointense on T1-w axial (left) and sagittal sequences (right) with a ring hyperintensity after contrast enhancement (center). Fig. 5: T1-w sagittal sequence with contrast enhancement showing an osteonecrotic lesion of the left mandibular branch (left); on the vestibular side, in the soft tissues, is identifiable a necrotic collection (center), in communication with submabibular space with a fistula (right). Page 7 of 9

8 Conclusion Our study confirmed that MRI have high sensibility in the detection of BRONJ lesions, even when not suspected by clinical examination, and is able to evaluate the extension of the disease and the involvement of the soft tissues as well. This could lead to an earlier diagnosis, to an improvement of surgery outcome and could reduce the number of relapses and post-surgery complications. Even if in limited number of cases, our study, performed only with 3D-FSPGR sequences, showed similar sensitivity than others performed with more sequences (STIR), with a significant lower time consumption. References 1) Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J. Oral Maxillofac Surg 2003; 61: ) Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonate induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 2005;63: ) Woo SB, Hellstein JW, Kalmar JR. Narrative review: bisphosphonates and osteonecrosis of the jaws. Ann Int Med 2006 May 16;144(10): ) Durie BG, Katz M, Crowley J. Osteonecrosis of the jaw and bisphosphonates. N Engl J Med 2005; 353: ) Phal PM, Myall RW, Assael LA, Weissman JL. Imaging findings of bisphosphonateassociated osteonecrosis of the jaws. Am J Neuroradiol Jun-Jul;28(6): ) Bisdas S, Chambron Pinho N, Smolarz A, Sader R. Vogl TJ, Mack MG. Biphosphonate-induced osteonecrosis of the jaws: CT and MRI spectrum of findings in 32 patients. Clin. Radiol Jan 63(1): 78/9 Page 8 of 9

9 7) Bedogni A, Blandamura S, Lokmic Z, Palumbo C., Bisphosphonate-associated jawbone osteonecrosis: a correlation between imaging techniques and histopathology. Oral Radiol Endod 2008 Mar 105(3): ) Bedogni A, Saia G, Bettini G, Tronchet A, Totola A, Bedogni G, Ferronato G, Nocini PF, Blandamura S. Long-term outcomes of surgical resection of the jaws in cancer patients with bisphosphonate-related osteonecrosis. Oral Oncol May;47(5): Epub 2011 Mar 24. 8) Chiandussi S, Biasotto M, Dore F, Cavalli F, Cova M, Clinical and diagnostic imaging of bisphosphonate-associated osteonecrosis of the jaws. Dentomaxllofacial Radiology 2006 Jul 35 (4) 263/43. 9) Morag Y, Morag-Hezroni M, Jamadar DA, Ward BB, Jacobson JA, Zwetchkenbaum SR, Helman J. Bisphosphonate-related osteonecrosis of the jaw: a pictorial review. Radiographics 2009 Nov;29(7): ) García-Ferrer L, Bagán JV, Martínez-Sanjuan V, Hernandez-Bazan S, García R, Jiménez-Soriano Y, Hervas V. MRI of mandibular osteonecrosis secondary to bisphospohonates. AJR Am J Roentgenol Apr;190(4): Personal Information Page 9 of 9