从肿瘤科医师角度谈药物相关性颌骨坏死的诊疗进展

Diagnosis and treatment of medication-related osteonecrosis of the jaws from an oncologist's perspectives

随着晚期肿瘤治疗效果的提高和骨改良药物的使用增加,药物相关性颌骨坏死(medication-related osteonecrosis of the jaw,MRONJ)越来越常见,严重影响患者的生命质量,同时干扰肿瘤的正常治疗。以往MRONJ长期处于肿瘤科和口腔科之间的边缘地带,科室间衔接不畅,漏诊、误诊常见,缺乏规范的协作管理,诊治效果不尽如人意。作为首诊者和骨改良药物的处方者,肿瘤科医师对MRONJ的认知和诊疗技能亟需提高,与口腔科之间的衔接和协作亟待加强。笔者通过分析2019年多国癌症支持治疗协会/国际口腔肿瘤学会/美国临床肿瘤学会联合发布的MRONJ临床实践指南,并结合近年相关学术进展以及临床诊疗经验,从一名肿瘤科医师的视角总结肿瘤科医师如何在癌症诊断时、开始药物治疗前、药物治疗期间、MRONJ发生后等关键时间点发挥作用,以期为多学科协作组提供切实可行的优化建议,做到对MRONJ早知晓、早预防、早识别以及正确治疗,提高患者生命质量,改善临床结局。

Along with the improvement of cancer treatment and the increasing use of bone-modifying agents,medication-related osteonecrosis of the jaw(MRONJ)has become more and more common,which may lead to reduce quality of life for patients and interrupt their regular tumor treatments.Being an oral condition in the maxillofacial region of patients associated with adverse side effect of certain bone-modifying agent related cancer therapies,MRONJ falls in a gray area between oncology and stomatology and can be challenging to treat and manage if standard clinical practice and care management guideline is not well established.Missed diagnosis and misdiagnosis of MRONJ become common when there is lack of elucidated diagnostic criteria and coordination in treatment planning between patient′s oncologist and dentist.Patient′s primary attending oncologist who initiates therapy with bone-modifying agent should be aware of MRONJ and well knowledgeable in best practices for preventing and managing MRONJ.With the focus on coordination of care in mind,an oral health assessment of the patient should be undertaken before initiating therapy and a dental treatment plan should be developed and implemented in coordination with the patient′s dentist.Based on the systematic review of the 2019"Medication-Related Osteonecrosis of the Jaw MASCC/ISOO/ASCO(Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology/American Society of Clinical Oncology)Clinical Practice Guideline",combined with clinical experience and academic research progress of related subject in recent years,from the perspective of an oncologist,the author summarizes how oncologists play a pivotal role in every step of the way from the initial cancer diagnosis,pre-cancer treatment assessment,care management during bone-modifying agent therapy,to the diagnosis,treatment,and management of MRONJ.The primary focus of the present article is to formulate optimized recommendations and provide guidance for multidisciplinary teams regarding best practices in the prevention and management of MRONJ in patients with cancer,in terms of early awareness,prevention,detection as well as implementation of effective treatment plan to improve clinical outcome and increase quality of life for the patients.