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OSTEONECROSIS OF THE MAXILLA RELATED TO BISPHOSPHONATES
Authored By: Keith Fischer and Collin Liu.
Patient: 78 year old female
History:

The patient is a 78-year-old woman with multiple myeloma, and breast cancer, taking Zometa.

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Findings:

Bone scan:

Radiopharmaceutical: 22.2 mCi Tc-99m MDP i.v.

There is markedly increased symetrical uptake in the maxilla. 
There are punctate foci of activity in a linear distribution spanning the right anterior third through sixth ribs, consistent with prior trauma and correlate with healing rib fractures on the concurrent CT.

Scattered foci of mildly increased uptake in the bilateral shoulders, thoracic spine, and lumbar spine are likely degenerative changes.

Maxillofacial CT:
There is fragmentation of the anterior maxilla with free-floating alveolar ridge. There is similar fragmentation of the right maxillary alveolar ridge (floor of maxillary sinus) in the area of the absent molars. Small pockets of air are seen tracking from the oral cavity upto this region of defect in the right maxillary sinus floor (not shown).

Irregularity, thickening, and sclerosis of the posterolateral wall of the right maxillary sinus may be secondary to osteonecrosis or chronic sinus disease. There is moderate to severe mucosal thickening of the maxillary sinuses.

DDx:

Sinusitis, metastatic disease

Diagnosis:

Osteonecrosis of the maxilla

 

General Discussion:

Full Patient History:
The patient is a 78-year-old woman with multiple myeloma and breast cancer, taking Zometa, who presented with clinical concern for osteonecrosis in the maxilla, after dental surgery.

General Discussion:
Bisphosphonate-related osteonecrosis of the jaw or maxilla is a condition found in patients who have received chronic intravenous or oral forms of bisphosphonate therapy for various bone-related conditions. It manifests as exposed, nonvital bone involving the maxillofacial structures. It be spontaneous or caused by trauma to dentoalveolar structures that have a limited capacity for bone healing due to the effects of bisphosphonate therapy(1).

Bisphosphonates are believed to bind to osteoclasts and interfere with bone remodeling. They interfere with the cholesterol biosynthesis pathway by inhibition of farnesyl diphosphate synthase. In time, the cytoskeleton of the osteoclast becomes dysfunctional and the ruffled border needed for bone resorption is unable to form(2). Aminobisphosphonates have also been shown to have antiangiogenic properties. The overall effect is a decrease in bone turnover and inhibition of the bone’s reparative ability. Injury to the bone in these patients via tooth extraction, dental surgery, or mechanical trauma is thought to initiate the disease.

Both CT and MRI are very useful in defining the extent of the lesions. 99Tcm-MDP three-phase bone scan is  the most sensitive for detecting osteonecrosis at an early stage.

In this case, there was dental surgery as well as maxillary sinusitis prior to the diagnosis of osteonecrosis, and CT and bone scan both confirmed the diagnosis.

 

References:

1. Bamias, A., E. Kastritis, C. Bamia, L. A. Moulopoulos, L. Melakopoulos, G. Bozas, V. Koutsoukou, D. Gika, A. Anagnostopoulos, C. Papadimitriou, E. Terpos, and M. A. Dimopoulos. 2005. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: Incidence and risk factors. Journal of Clinical Oncology 23:8580-8587.


2. Fisher, J. E., M. J. Rogers, J. M. Halasy, S. P. Luckman, D. E. Hughes, P. J. Masarachia, G. Wesolowski, R. G. G. Russell, G. A. Rodan, and A. A. Reszka. 1999. Alendronate mechanism of action: geranylgeraniol, an intermediate in the mevalonate pathway, prevents inhibition of osteoclast formation, bone resorption, and kinase activation in vitro. Proceedings of the National Academy of Sciences of the United States of America 96:133-138.


 

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Additional Details:

Case Number: 241459Owner(s): Keith Fischer and Collin LiuLast Updated: 02-07-2013
Anatomy: Skeletal System   Pathology: Iatrogenic
Modality: CT, Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: osteonecrosis, maxillary, sinus, bsnm

Case has been viewed 9 times.
Certified by Keith Fischer on 01-30-2013

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