A 60-year-old man was visited at the Alessandria Hospital Oncology Unit on August 2011 for a routine visit before a chemotherapy administration (FOLFOX scheme and bevacizumab), complaining of left mandible pain (VAS: visual analogue scale, score 6) and an oral mucosal break; the oral examination revealed a lingual-side bone exposure, 1 cm in diameter (no photo available). Four weeks before, he had started treatment with chemotherapy associated with bevacizumab for the second time.\nHis cancer history had begun on February 2010 with the diagnosis of rectal cancer and lung metastases. He underwent treatment with pelvic radiotherapy and simultaneous chemotherapy (oxaliplatin and fluorouracil in a continuous infusion) and then rectal surgery (on July 2010); additional chemotherapy (FOLFIRI) was administered in August 2010. Some pulmonary metastases were surgically removed on November 2010 but residual disease was still present in a chest postoperative CT scan.\nHe received chemotherapy (FOLFIRI scheme) and bevacizumab (5 mg/kg day 1 every 14 days) between December 2010 and March 2011 (eight cycles over four months). Due to pulmonary progression of the disease, he underwent a short treatment with an experimental agent in another cancer center, suspended on July 2011 due to the diagnosis of brain metastases, treated with radiotherapy. He then started new chemotherapy (FOLFOX scheme) with bevacizumab again.\nHis dental history revealed that he had been submitted for left mandible third molar (3.8) extraction at a private dental office on January 2011 (during the first bevacizumab treatment) without notifying the treating oncologist; the patient complained about incomplete and delayed socket closure after extraction.\nOn August 2011, at an oncology unit visit shortly after the start of the second course of bevacizumab therapy (two administrations), a painful mandible bone exposure was noted and the patient was referred to the Alessandria Hospital ONJ multidisciplinary team; antibiotics (amoxicilline plus clavulanic acid 1 g every 8–12 h and metronidazole 500 mg every 12 h) in combination with a chlorhexidine 0.12% oral rinse were prescribed, with immediate pain reduction. Rx ortopantomography showed no signs of osteolysis but just the profile of the residual socket at the extraction site (). A CT scan without contrast showed a mandible bone cortical lesion in the previous tooth extraction site, 7 mm × 4 mm in size (a–c). Spontaneous expulsion of a bone fragment was referred by the patient two weeks later. The patient was not further visited by the ONJ multidisciplinary team due to death shortly after an episode of pulmonary embolism on October 2011.
Patient C is a 68-year-old white man who was diagnosed with metastatic RCC, clear cell type in July 2008 discovered as part of an evaluation for new onset atrial fibrillation. He had a 7.1 × 9.7 cm left renal mass, enlarged retroperitoneal and mediastinal lymph nodes and multiple lung nodules. Mediastinal lymph node was positive for metastatic RCC on biopsy. He underwent debulking nephrectomy in August 2008 and then had a trial of high-dose IL-2 (600,000 IU/kg) which failed with progressive disease. He began sunitinib 50 mg daily for 4 weeks of a 6 week cycle, and had initially stable disease, but progressed after 36 weeks. He then began everolimus 10 mg daily but developed symptomatic mTOR-inhibitor-associated pneumonitis which resolved with steroids and discontinuation of everolimus. He then began bevacizumab 10 mg/m2 given every 2 weeks and had an initial minor response then prolonged stable disease. He remains on therapy at 24 weeks to date. He continues to be very active, golfing regularly and traveling.