Osteonecrosi della mandibola, ulcera radionecrotica e proctite post-attinica

Definizione

Dopo terapia radiante una modesta percentuale di pazienti (fino al 5-15% per l’osteoradionecrosi della mandibola per particolari trattamenti nei tumori del testa-collo) manifesta una patologia a carico dei tessuti molli o delle ossa.

I quadri clinici più frequenti sono osteoradionecrosi della mandibola, l’ulcera cutanea a tendenza necrotizzante senza tendenza alla guarigione (ulcera torpida radionecrotica) e delle mucose (proctite post attinica) 

Bibliografia utilizzabile ai fini dell’individuazione delle prove di efficacia

The Cochrane Collaboration
Hyperbaric oxigen therapy for late radiation tissue injury” (Review) Bennett M., Feldmeier J., Hampson N., Smee R., Milross C.Maggio 2012

 

These small trials suggest that for people with LRTI affecting tissues of the head, neck, anus and rectum, HBOT is associated with improved outcome. HBOT also appears to reduce the chance of ORN following tooth extraction in an irradiated field. There was no such evidence of any important clinical effect on neurological tissues. The application of HBOT to selected patients and tissues may be justified.
Altre Revisioni Sistematiche
Hanson B, MacDonald R, Shaukat A. Endoscopic and medical therapy for chronic radiation proctopathy: a systematic review. Diseases of the Colon and Rectum 2012; 55(10): 1081-1095 There is… a low-level evidence for use of… hyperbaric oxygen
  • No Clinical evidence
UpToDate
Aggiornamento a Set 2013 Thus, at the present time, it is not a practical means of treating chronic radiation enteritis outside of centers specializing in this approach, particularly since its effectiveness has not been well-studied.the benefit of HBO to prevent or treat established osteoradionecrosis of the jaw in irradiated patients with head and neck cancer is uncertain

 1 Rapporto di Technology Assessment AHRQ Gowrl Raman, Bruce Kupelnick, Priscilla Chew, Joseph Lau “A Horizon Scan: Uses of Hyperbaric Oxigen Therapy” ottobre 2006

riporta la revisione sistematica di Pasquier D., Hoelscher T., Schmutz J. “Hyperbaric oxigen therapy in the treatment of radio-induced lesions in normal tissues: a literature review” Radiotherapy and Oncology 72(1):1-13, 2004. Gli autori identificano un RCT che dimostra che l’OTI riduce l’osteoradionecrosi nei tessuti sottoposti a terapia radiante dopo estrazione dentaria.

Criteri diagnostici di ammissione

  • Pazienti con osteoradionecrosi della mandibola sottoposta a radioterapia con almeno 6000 cGy da almeno 6 mesi e non più di 15 anni
  • Pazienti con ulcera torpida radionecrotica della testa e del collo dopo radioterapia con almeno 6000 cGy da almeno 6 mesi e non più di 15 anni che non risponde ad altri trattamenti
  • Proctite post attinica che non risponde ad altri trattamenti
  • Profilassi dell’osteoradionecrosi nell’estrazione dentaria in mandibola irradiata con dosi superiori a 6000 cGy in un periodo compreso tra i 6 mesi e i 15 anni precedenti.
  • Cistite emorragica resistente alla terapia convenzionale

Valutazione clinico-anamnetica all’ammissione 

  • TAC con controllo emato-morfologico
  • Caratteristiche generali del pz, con particolare riguardo a comorbidità (diabete, ipertensione, aterosclerosi, anemia, collagenopatie) e stili di vita
  • Caratteristiche tecnico-dosimetriche del trattamento eseguito e della eventuale associazione con farmaci antiblastici
  • Storia della radionecrosi (fattori, segni e precedenti trattamenti) con valutazione di Grado secondo Scale precodificate, quali LENT-SOMA, scala EORTC/RTOG di tossicità o gli stadi sec. la classificazione di Marx e con valutazione dei sintomi presenti (in particolare per la sintomatologia algica-VAS)
  • Documentazione fotografica
  • Valutazione sulla necessità “a priori” di intervento chirurgico
  • Tampone microbiologico all’ingresso (se lesione aperta) 

SOMA scales:

Grade 1 Represents the most minor symptoms that require no treatment
Grade 2 Represents moderate symptoms, requiring only conservative treatment
Grade 3 Represents severe symptoms, which have a significant negative impact on daily activities, and which require more aggressive treatment
Grade 4 Represents irreversible functional damage, necessitating major therapeutic intervention
Grade 5 Represents death or loss of the organ

Scala EORTC/RTOG di

Classificazione di MARX:

Stage I

Presenza di esposizione ossea, in pz. ancora non sottoposto a pulizia chirurgica (sequestrectomia)

“All patients who meet the definition of osteoradionecrosis except those with cutaneous fistulae, pathologic fracture, or radiographic evidence of bone resorption. (These three subsets of patients are classified as Stage III.) Stage I patients receive 30 HBOT treatments. Wounds are maintained with irrigation only or with saline rinses. No bone is surgically removed. If, after 30 treatments, the wound shows improvement, as evidenced by decrease in amount of exposed bone; less resporption or spontaneous sequestration of exposed bone; or decreased softening of exposed bone; the patient completes another 10 treatments. The total 40 HBOT treatments are meant to achieve full mucosal cover. If there is no clinical improvement after 30 HBOT treatments or complete resolution, such as extended or continued exposure of bone, absence of mucosal proliferation, or presence of inflammation, the patient is advanced further to Stage II. (See Technical Treatment Protocol for suggestions on pressure levels and duration of individual treatments)”.

Stage II

Pz. sottoposto a chirurgia (sequestrectomia) dell’osso necrotico e a tentativo ricostruttivo con lembo muco-periostale

“Surgeons attempt a local surgical debridement to identify those patients with only superficial or cortical bone involvement, and who can be resolved without jaw resection. A transoral alveolar sequestrectomy is performed with fine saline-cooled, air-driven saws. Minimal periosteal manipulation is done for labial access to the mandible. The lingual periosteum is allowed to remain completely attached until the specimen is delivered, and then only that which is attached to the specimen is reflected from bone. The resultant mucoperiosteal flaps are closed in three layers over a base of bleeding bone. If healing progresses without complication, HBOT is continued with 10 additional sessions. If the wound dehisces, leaving exposed non-healing bone, the patient is advanced to Stage III. In those patients who initially present with orocutaneous fistulae, with pathologic fracture, or with radiographic osteolysis to the inferior border, the initial 30 HBOT treatments are given, and the patient enters Stage III directly”.

Stage III

Presenza di fistole cutanee, fratture patologiche, osteolisi del bordo inferiore della mandibola. Deiscenza di precedente intervento di copertura con lembo muco-periostale.

“After 30 HBOT treatments, the patient undergoes a transoral partial jaw resection, the margins of which are determined at the time of surgery by the presence of bleeding bone. The segments of the mandible are stabilized either with extraskeletal pin fixation or with maxillo mandibular fixation. If there was an orocutaneous fistula, or large soft tissue loss, primary closure or soft-tissue reconstruction is accomplished during this surgery. HBOT is continued for another 10 treatments, and the patient is advanced to Stage III-R”.

Stage III-R

Paziente sottoposto a intervento di resezione della mandibola e di ricostruzione dei tessuti molli

These patients present the most difficult cases. Early reconstruction and rehabilitation produces the best results. Ten weeks after resection, the soft tissues are healing, and the potential graft bed is free from contamination and infection. Bony reconstruction is undertaken from a strictly transutaneous approach without oral flora contamination. Ten post-reconstructive HBOT treatments are given, and the jaw fixation is maintained for eight weeks. If no further surgery is required, the patient begins appointments with a maxillofacial prosthodontist for full prosthetic rehabilitation one month after release of his fixation. If additional surgery is required, such as a tongue release, vestibuloplasty, or excision of redundant tissue, surgeons schedule procedures one month after fixation is released. After surgery, the patient is referred to a maxillofacial prosthodontist”. 

VAS

NRS (Scala Numerica di Valutazione del Dolore)
Istruzioni: Considerando una scala da 0 a 10 in cui a 0 corrisponde l’assenza di dolore e a 10 il massimo di dolore immaginabile, quanto valuta l’intensità del suo dolore? (esempio di scala numerica a intervalli).

LIMITAZIONI AL TRATTAMENTO

Il trattamento è controindicato nei pazienti con neoplasie non trattate (chemio e radioterapie)

BENEFICIO ATTESO E INDICATORI DI EFFICACIA

Il beneficio è incerto.

Possibili indicatori:

  • tempo per la risoluzione di sintomatologia algica (su scala VAS)
  • modificazione di un eventuale programma chirurgico
  • riduzione della frequenza di provvedimenti topici in precedenza eseguiti
  • % di guarigioni ad un anno

Schema di trattamento

DIAGNOSI N. max trattamenti Osservazioni
Osteoradionecrosi della mandibola 50  
Ulcera radionecrotica e procrite post-attinica 30
Profilassi estrazione dentaria 20 +10 (prima e dopo, con penicillina perioperatoria)

Altra bibliografia raccolta sull’argomento 

  1. Annane D., Depondt J., Aubert P., Villart M., “Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind trial” from the ORN96 study group. Journal of Clinical Oncology: official journal of the American Society of Clinical Oncology 2004; Vol 22; Issue 24; pages 4893-900 che giunge alla conclusione che l’OTI non è di beneficio nei pz con radionecrosi della mandibola.
  2. Feldmeier JJ, Heimbach RD, Davolt DA, Court WS, Stegmann BJ, Sheffield PJ. Hyperbaric oxygen as an adjunctive treatment for delayed radiation injury of the chest wall: a retrospective review of twenty-three cases. Undersea Hyperb Med 1995; 22:383-93
  3. Feldmeier JJ, Heimbach RD, Davolt DA, Court WS, Stegmann BJ, Sheffield PJ. Hyperbaric oxygen an adjunctive treatment for delayed radiation injuries of the abdomen and pelvis. Undersea Hyperb Med 1996; 23:205-13
  4. Feldmeier JJ. Hyperbaric oxygen for delayed radiation injuries. Undersea Hyperb Med 2004; 31:133-45
  5. Mayer R, Klemen H, Quehenberger F, et al. Hyperbaric oxygen–an effective tool to treat radiation morbidity in prostate cancer. Radiother Oncol 2001; 61:151-6

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