Osteonecrosis of the jaws in patient received bisphosphonates and sunitinib separately: A case report

Abstract

Recently published reports have suggested that antiangiogenic drugs such as sunitinib could potentiate the osteonecrosis of the jaw (ONJ) induced by bisphosphonates (BPs) and even induce this adverse effect per se. We reported a case of ONJ with renal cell carcinoma under sunitinib medication and history of BPs therapy. A 53-year-old man was referred to the oral surgery clinic complaining of painful exposed oral lesion and bone extraction from right lower jaw in the mouth. He underwent nephrectomy followed by 5 months treatment with cycles of 50 mg sunitinib (Sutent®) once a day for 4 weeks followed by 2 weeks drug free before lesion exposure in October 2016. However, the patient has encounter to intermittent mucositis and gingivitis in oral cavity several times. Our patient had a history of zoledronic acid (4 mg intravenously two times) administration due to primary cancer misdiagnosis. In our case, no dental procedure contributed to the occurrence of ONJ. The lesion was improved by sunitinib cessation and administration of antibiotics through 2 weeks. Mucosal injury induction as well as inhibition of angiogenic signaling pathways by sunitinib administration may have precipitated the occurrence of ONJ. In addition, a possible synergistic effect by previously BP treatment is another accused.

Osteonecrosis of the jaws produced by sunitinib: a systematic review

“…Following the criteria provided by the JBI (12) and Newcastle-Ottawa (13) quality assessment scales, the risk of bias in the studies was assessed. As shown in Table 2, the case reports provided by Ashrafi et al (14), Agrillo et al (15), Fleissig et al (7), Balmor et al (16), Bozas et al (17), Koch et al (18) y Brunello et al (19) have a low risk of bias.…”

“…Regarding ONJ location, 8 cases (13%) did not specify the location and in the remaining cases 34 occurred in the mandible (54%) and 21 in the maxilla (33%). Only in two cases was the stage specified at the time of diagnosis, being stage I (14,20).…”

“…Analyzing the improvement, it was only evaluated in four cases (8,14,17,19). In the first case, improvement was observed 2 weeks after the interruption of sunitinib, and in another case 3 weeks after the interruption of sunitinib.…”

“…In this paper, we have analyzed studies that have shown the presence of ONJ in patients treated with sunitinib, alone or combined with bisphosphonates. Most authors agree that the risk of ONJ is greater when antiangiogenic drugs are combined with bisphosphonates (3,8,14,16,21,23), others such as Ashrafi et al maintain that ONJ is more related to the use of sunitinib than to bisphosphonates, because the side effects improve with the disruption of sunitinib (14). On the other hand some authors argue that there is not enough evidence in the literature about the cause-effect relationship between sunitinib and ONJ (26).…”

Denosumab Related Osteonecrosis of Jaw: a Case Report

“…ONJ can be induced by BPs and other anticancer treatment. ONJ is potentiating by antiangiogenic drugs such as sunitinib, a medication approved for renal cell carcinoma [14]. A recently retrospective study [3] at the Cancer Institute of Lorraine (ICL), that inserted 141 patients using denosumab Xgeva ® , which 9 of them developed ONJ, concluded that this medication associated with invasive dental procedure can develop ONJ [3].…”