Osteoradionecrosis

Author(s): 
Bahar Dasgeb, MD; Tania J. Phillips, MD, FRCPC

Department Editor
Tania J. Phillips, MD, FRCPC

Overall Learning Objective: The physician or podiatrist participant will develop a rational approach to the evaluation and treatment of a variety of uncommon wounds and will have an increased awareness of the differential diagnosis of cutaneous wounds and the systemic diseases associated with these wounds.

Submissions: To submit a case for consideration in Diagnostic Dilemmas, e-mail or write to Associate Editor, WOUNDS, 83 General Warren Blvd., Suite 100, Malvern, PA 19355, rolszewski@hmpcommunications.com.

Completion Time: The estimated time to completion for this activity is 1 hour.

Target Audience: This CME/CPME activity is intended for dermatologists, surgeons, podiatrists, internists, and other physicians who treat wounds.

At the conclusion of this activity, the participant should be able to:
1. Discuss the radiobiology and pathogenesis of irradiated skin injury and clinical features
2. List the factors that affect the severity of irradiation damage
3. Describe the treatment of osteoradionecrosis.

Disclosure: All faculty participating in Continuing Medical Education programs sponsored by The North American Center for Continuing Medical Education (NACCME) are expected to disclose to the meeting audience any real or apparent conflict(s) of interest related to the content of their presentation. Drs. Dasgeb and Phillips disclose that they have no financial conflicts relevant to the content of this activity.

Accreditation: This activity is sponsored by NACCME. NACCME is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.

Designation: NACCME designates this continuing medical education activity for 1 credit hour in Category 1 of the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours he/she spent in the educational activity. NACCME designates this continuing medical activity for .1 CEUs available to participating podiatrists.

Method of Participation: Participants must read the article and take, submit, and pass the post-test by September 15, 2005. Participants must completely fill out the answer and evaluation form, answer at least 70 percent of the questions correctly, and mail or fax the answer/evaluation forms to:
Trish Levy, CME Director, NACCME, HMP Communications
83 General Warren Blvd., Suite 100, Malvern, PA 19355
Fax (610) 560-0501

This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies.
Release date: September 15, 2004
Expiration date: September 15, 2005

Presentation

An 85-year-old Black woman was referred for consultation regarding a necrotic ulcer over her left chest. Her past medical history was significant for breast cancer treated by radical mastectomy and radiation therapy 28 years previously. Two years ago, she developed a spontaneous ulcer at the radiation therapy site. A biopsy in 2003 showed no evidence of malignancy. The ulcer continued to increase in size and depth. She reported the appearance of white fibrotic tissue in the center of the ulcer during the past year.
Past medical and surgical history were significant for hypertension, urinary incontinence, and syncope. Current medication include hydrochlorothiazide 12.5 mg by mouth every day and donepezil HCl 10 mg by mouth every day.

Physical Examination

Physical examination revealed a pleasant, underweight Black woman who was alert and oriented. In her left chest area, there was a 5cm x 3cm open wound with mildly inflamed borders (Figure 1). The bed of the ulcer was covered by hard, yellow, fibrinous material.

References: 

References

1. Spinazze RP. Osteoradionecrosis: Diagnosis: Prevention: Treatment. Available at http://www.uic.edu/ depts/doms/rounds-2.html. Accessed September 13, 2004.
2. Archambeau JO, Pezner R, Wasserman T. Pathophysiology of irradiated skin and breast. Int J Rdiat Oncol Biol Phys 1995 Mar 30;31(5):1171–85.
3. Malkinson FB. Radiobiology of the skin. In: Freedberg IM, Eisen AZ, Wolff K, et al. (eds). Fitzpatrick’s Dermatology in General Medicine, Fifth Edition. New York, NY: McGraw-Hill, 1999:1514–23.
4. Kvalheim G, Gundersen S, Hager B, Fodstat O. Intra-arterial infusion of mytomycin C in treatment of breast cancer: Occurrence of skin necrosis in irradiated patients. Radiother Oncol 1985;4(2):127–32.
5. McDonagh AJG, Right AL. Malignant melanoma at sites of therapeutic x-irradiation. Dermatologica 1990;181:8.
6. Shore RE. Overview of radiation-induced skin cancer in human. Int J Rdiat Biol 1990;57:809.
7. David LA, Sandor GK, Evans AW, et al. Hyperbaric oxygen therapy and mandibular osteoradionecrosis. J Can Den Assoc 2001;67(7):384.
8. Delanian S, Lefaix J. Complete healing of severe osteoradionecrosis with treatment combining pentoxyphylline, tocopherol, and clodronate. Br J Radiol 2002;75(467–469).
9. Sato M, Tanaka M, Wada L. Treatment of necrotic infection on the anterior chest wall secondary to mastectomy and postoperative radiotherapy by the application of omentum and mesh skin grafting. Surgery Today 2002;32(3):261–3.
10. Contant CM, van Geel AN, van der Holt B, Wiggers T. The pedicled omentoplasty and split skin graft (POSSG) for reconstruction of large chest wall defects. A validity study of 34 patients. Eur J Surg Oncol 1996;22(5):532–7.
11. Wojtanowski MH, Mandel MA. Osteoradionecrosis of the thoracic wall and its management. Am J Surg 1979;138(3):434–8.
12. Li YY, Liang M, Wang JL, et al. The complication of radiotherapy for the breast cancer and the treatment for radiation ulcer. Zhonghua Zheng Xing Wai Ke Za Zhi 2004;20(1):13–5.



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