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136:Osteonecrosis Of The Jaw Associated With Ramucirumab[AAOM2021]
Poster Title: 136:Osteonecrosis Of The Jaw Associated With Ramucirumab[AAOM2021]
Submitted on 29 Mar 2021
Author(s): Andrew Marco Pischek, Dennis Shem, Annu Singh, Cherry Estilo, SaeHee Yom
Affiliations: Memorial Sloan Kettering Cancer Center, United States of America
This poster was presented at 2021 American Academy of Oral Medicine Virtual Conference
Poster Views: 349
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Poster Information
Abstract: Background: Spontaneous- or trauma-induced medication-related osteonecrosis of the jaw (MRONJ) has been well documented in anti-resorptive agents such as bisphosphate and denosumab, as well as angiogenic inhibitor medications, such as bevacizumab. Ramucirumab is also an angiogenic inhibitor (with mechanistic difference) used to treat non-small cell lung cancer and metastatic gastric or gastroesophageal (GE) junction cancer. This is the first reported case of spontaneous development of MRONJ in a patient treated with ramucirumab.

Case Summary: The patient is a 59-year-old male with a history of non-small cell lung cancer who was being treated with an angiogenesis inhibitor, ramucirumab. A total of five doses were administered 8 mg/kg every two weeks by intravenous infusion over 60 minutes over a three-month period. The patient was referred to the Dental Service at the Memorial Sloan Kettering Cancer Center (MSKCC) for evaluation of bilateral exposed mandibular alveolar bone initially identified by the patient’s local dental provider. The patient’s chief complaint was an inability to eat properly due to acute pain from presumed mucositis. There were no recent episodes of oral trauma reported by the patient. The bilateral areas of exposed bone were located in the posterior lingual mandible between the first and second molars. There was no associated soft tissue swelling, purulent discharge or fistula. The larger lesions measured 4x5mm with trailing smaller lesions on the right side and a 3x3mm lesion on the left side. Ulcerations were present on the ventral-lateral borders of the tongue, bilaterally, secondary to trauma from the sharp bone surfaces. The ulcerations measured 2x2 mm and 8x6 mm on the right and left side of the tongue, respectively. These areas of spontaneous exposure of mandibular alveolar bone likely represent MRONJ, possibly related to the patient’s history of ramucirumab. The patient was subsequently seen ten days following his initial evaluation for additional adjustment of rough exposed bone. These areas of bone exposure remained unchanged in size. Unfortunately, the patient succumbed to his disease 33 days following his initial visit.

Conclusion: Dental providers and medical oncologists should be mindful of the potential development of spontaneous MRONJ in patients being treated with ramucirumab.
Summary: This is a case of spontaneous exposure of bone associated with an angiogenesis inhibitor, ramucirumab, which showed characteristics similar to MRONJ.

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References: •Estilo, C. L. et al. “Osteonecrosis of the jaw related to
bevacizumab.” 2008.
•S. L. Ruggiero et al., “American Asso- ciation of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw–2014 update.” 2014.
•Iijima, Yosuke et al. “Delayed Healing of Tooth Extraction Sockets with Ramucirumab Use.” 2020.
•Pimolbutr K. et al. “Osteonecrosis of the jaw associated with antiangiogenics in Antiresorptive-Naïve patient: a comprehensive
review of the literature.” 2018.
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