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What Causes A Lesion In Lower And Inner Gums While Treating BRONJ?
Question: I am a stage 4 breast cancer survivor under the care of an oncologist. I have been on Zometa then X-Geva for 12 years. I was getting chronic laryngitis and was sent by my primary Dr to an ENT. The ENT saw some white spots in my mouth and larynx and decided to perform biopsies without consulting with my oncologist. He biopsied 8 locations, one on my mouth palate. I then developed BRONJ and was sent to an oral surgeon. After consulting with 3 oral surgeons, I found someone who would perform surgery to remove the palatial XXXXXXX as it was infected a majority of the time. The XXXXXXX is in the process of healing but I have now developed another lesion on my lower, inner gums and I have had two ear infections on that side (I have no idea if they are related). It is reasonable to assume that the ENT should have known of the risks of the biopsies and warned me of these risks? If he thought it was cancerous, should he have consulted with my oncologist before proceeding? Due to the problems I am having, I have had to take a temporary leave of absence at work and am taking pain killers (Tylenol) on a daily basis. Can more lesions continue to devlop? I fear for the future if this continues to be a problem.
Brief Answer:
This is a rare condition associated with your medications.
Detailed Answer:
Hi,
Thank you for your query.
1. Your medications are associated with BRONJ/ MRONJ. This is a rare condition and hence it is possible that your ENT was unaware about this condition. However, this condition may also develop spontaneously after so many years of use. Hence the minor trauma of the biopsies may be a coincidence. Dental extraction or palatal surgery is more likely to cause or worsen this condition.
2. The medication should be reviewed. Stopping the medications will allow the lesions to heal in 3 to 6 months. Rarely, surgical debridement or bone grafting may be required.
3. These lesions may persist or increase if medication is continued. The chronic laryngitis and ear infections will require further investigations to find out if these are also related. Imaging with CT/MRI, Tc99m, Ga67 bone scans will be of use here, including assessing the progress of this condition.
4. Transdermal pain patches may be helpful in your case.
I hope that I have answered your queries. If you have any further questions, I will be available to answer them.
Regards.
This is a rare condition associated with your medications.
Detailed Answer:
Hi,
Thank you for your query.
1. Your medications are associated with BRONJ/ MRONJ. This is a rare condition and hence it is possible that your ENT was unaware about this condition. However, this condition may also develop spontaneously after so many years of use. Hence the minor trauma of the biopsies may be a coincidence. Dental extraction or palatal surgery is more likely to cause or worsen this condition.
2. The medication should be reviewed. Stopping the medications will allow the lesions to heal in 3 to 6 months. Rarely, surgical debridement or bone grafting may be required.
3. These lesions may persist or increase if medication is continued. The chronic laryngitis and ear infections will require further investigations to find out if these are also related. Imaging with CT/MRI, Tc99m, Ga67 bone scans will be of use here, including assessing the progress of this condition.
4. Transdermal pain patches may be helpful in your case.
I hope that I have answered your queries. If you have any further questions, I will be available to answer them.
Regards.
Above answer was peer-reviewed by :
Dr. Arnab Banerjee
After I had the biopsy on my palate, the bone was left exposed- is this a contributor? Also, it appears that the side effects of X-Geva and Zometa are well documented. On all dental intake information, it asks if you have ever taken one of these drugs. How could an ENT not be aware of the risks and inform the patient? One cannot give informed consent if they are not told of the risks. Also, is it protocol to take so many biopsies of the same thing?
Brief Answer:
I do agree with you on most of the points raised.
Detailed Answer:
Hi,
Thank you for writing back.
1. Yes, exposed bone after a biopsy would contribute to the development of the osteonecrosis, as would trauma, dental extraction or oral surgery.
2. The side effects of these medications are well documented, including spontaneous development of such lesions. Since this condition is rare, the co-relation is not conclusively proven. The duration of your treatment is also very long.
3. What has happened cannot be undone. Your observations as to the informed consent by your ENT Specialist are true, but unfortunate. I think your Oncologist should also review the need for prolonged treatment.
4. Biopsies are usually limited if the lesions are similar and the practice of blind biopsies is less common. It is possible that multiple excision biopsies (diagnostic and therapeutic) were attempted in good faith.
5. I do agree with you on most of the points raised.
I hope that I have answered your queries. If you have any further questions, I will be available to answer them.
Regards.
I do agree with you on most of the points raised.
Detailed Answer:
Hi,
Thank you for writing back.
1. Yes, exposed bone after a biopsy would contribute to the development of the osteonecrosis, as would trauma, dental extraction or oral surgery.
2. The side effects of these medications are well documented, including spontaneous development of such lesions. Since this condition is rare, the co-relation is not conclusively proven. The duration of your treatment is also very long.
3. What has happened cannot be undone. Your observations as to the informed consent by your ENT Specialist are true, but unfortunate. I think your Oncologist should also review the need for prolonged treatment.
4. Biopsies are usually limited if the lesions are similar and the practice of blind biopsies is less common. It is possible that multiple excision biopsies (diagnostic and therapeutic) were attempted in good faith.
5. I do agree with you on most of the points raised.
I hope that I have answered your queries. If you have any further questions, I will be available to answer them.
Regards.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
As for the laryngitis according to the Drug Handbook it is the 3rd adverse side effect of taking Xgeva. Again shouldn't the ENT have this information as this book is in every medical facility? As well as required information for a nurse to know about this medication when treating a patient who takes it. So there should not be any concern about the laryngitis, which I have not had since the first time I went to this ENT. If you had a patient you knew was being treated for years for stage 4 breast cancer that has traveled to the bone and you observed these lesions; would you biopsy them yourself or refer the patient back to her oncologist with the your notes of the findings? Keeping in mind the laryngitis is no longer an issue or concern.
Brief Answer:
I would disagree on the laryngitis.
Detailed Answer:
Hi,
Thank you for writing back.
1. Laryngitis is a very common condition. These medications rarely cause laryngitis and though many medications cause laryngitis, even if suspected, only further investigation and treatment can rule out a connection. One episode in so many years of medication is not easy to co-relate. For example, your medications could have caused anaphylaxis. Though this is a known fact with most medications, there is no way of predicting whether this will happen to a patient or not.
2. It is agreed that BRONJ/ MRONJ is a known condition with your case history and the Oncologist should have been requested to review the medication. The fact that the biopsies can trigger this condition, while on the medications, should have been kept in mind.
3. HyperBaric Oxygen Therapy (HBOT) is another option to help heal the lesions and to try to prevent progression.
I hope that I have answered your queries. If you have any further questions, I will be available to answer them.
Regards.
I would disagree on the laryngitis.
Detailed Answer:
Hi,
Thank you for writing back.
1. Laryngitis is a very common condition. These medications rarely cause laryngitis and though many medications cause laryngitis, even if suspected, only further investigation and treatment can rule out a connection. One episode in so many years of medication is not easy to co-relate. For example, your medications could have caused anaphylaxis. Though this is a known fact with most medications, there is no way of predicting whether this will happen to a patient or not.
2. It is agreed that BRONJ/ MRONJ is a known condition with your case history and the Oncologist should have been requested to review the medication. The fact that the biopsies can trigger this condition, while on the medications, should have been kept in mind.
3. HyperBaric Oxygen Therapy (HBOT) is another option to help heal the lesions and to try to prevent progression.
I hope that I have answered your queries. If you have any further questions, I will be available to answer them.
Regards.
Note: Consult an experienced Otolaryngologist / ENT Specialist online for further follow up on ear, nose, and throat issues - Book a Call now.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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