Cone Beam Computed Tomography (CBCT) is Superior to Orthopantomogram (OPG) in Interpreting the Imaging Characteristics of Medication-Related Osteonecrosis of the Jaw (MRONJ and More Stage-Sensitive: A Prospective Assessment in 98 Cancer Patients

Objectives: To prospectively evaluate the imaging characteristics of Medication-Related Osteonecrosis of the Jaw (MRONJ), observed in the Orthopantomogram (OPG) and in Cone Beam Computed Tomography (CBCT), in patients with cancer. Materials and Methods: Cancer patients, who received Bone Targeting Agents (BTAs) and developed MRONJ, were prospectively included in the study. MRONJ was staged following the American Association of Oral and Maxillofacial Surgery (AAOMS) 2014 criteria. Four predefined radiological findings, osteolytic changes, sclerosis, periosteal reaction, and sequestration were assessed and were scored as “absent”, “localized”, “extensive” and “beyond the alveolar bone”. Results: Ninety-eight cancer patients were enrolled. Eighty patients (81.6%) received BTAs for over a year; 19 (19.4%) received BTAs between 13 to 24 months and 61 patients (62.2%) received BTAs for over 24 months. The majority of the patients (n=58, 59.2%) had stage 2 MRONJ and 35 (35.7%) were at MRONJ stage 3.Fifty-two (53.06%) patients were assessed with OPG and 89 (90.81%) with CBCT and CBCT was found more effective in detecting sclerosis and sequestration than OPG.Forty-three (43.87%) patients were assessed with both OPG and CBCT and were available for comparisons between OPG and CBCT. CBCT was significantly more accurate than OPG in interpreting the “beyond the alveolar bone” osteolytic changes, sclerosis, periosteal reaction and sequestration, in all MRONJ stages. P-value was 0.0002, <0.0001, 0.0027 and 0.0009 respectively.Furthermore, CBCT was significantly more accurate than OPG in interpreting the “extensive” and “beyond the alveolar bone” imaging characteristics, when comparisons included the patients with early stages of MRONJ, 1 and 2 and the patients with stage 3 of MRONJ. Conclusion: CBCT is superior and more stage-sensitive to OPG in interpreting and staging MRONJ and can be particularly useful to achieve an early diagnosis of MRONJ.

A Multidisciplinary Algorithm in the Non-Operative Management of Upper GI Complications – A Retrospective Cohort Study

Introduction: The non-operative management of UGI complications lacks consensus, despite being the subset that requires a concerted multidisciplinary approach. The aim of this study is to propose an algorithm of management, with early endoscopy and interventional radiology as adjuncts to surgical interventions.Methods: This retrospective cohort describes the management of 37 patients over a 5 year period with the evolution of a multidisciplinary team and an algorithm of management in a tertiary UGI centre. The cohort included 15 bariatric, 12 Cancer and 10 Oesophageal perforation patients. The primary outcome was the morbidity profile and mortality the secondary outcome.Results: The median number of stents used per patient across the groups was two. The leak resolution time was 34, 52.5 and 60.5 days among the cancer, bariatric and perforation groups, respectively. Radiological drains were required in about 36% of patients across the groups. Nutritional access was established with Naso-Jejunal tubes with overlapping TPN in the bariatric and perforation groups, while the cancer group had Feeding Jejunostomy tubes inserted during their resections. The mean duration of hospital stay was 29.5, 41.5 and 63 days respectively. Three (8%) patients developed major stent-related complications (Clavien-Dindo Grade 3b) requiring reoperation. There were no mortalities in the cohort.Conclusion: Though heterogeneous, UGI complications have common management principles. The non-operative management algorithm with endoscopy and adjuncts is still an aggressive, yet conservative approach with prompt control of sepsis and establishment of early nutrition. This multidisciplinary approach is an effective means of resolution with minimal morbidity and mortality.