Case Descriptions A 73-year-old woman presented to The University of Texas MD Anderson Cancer Center oral oncology clinic for evaluation of a large hard palate defect communicating into the nasal cavity and exposed bone on the left mandible. The patient had been diagnosed with metastatic renal cell carcinoma (RCC) and had been treated with sunitinib for the previous 2 years. The patient received sunitinib (37.5 mg) on a daily basis for 4 weeks before surgery to remove the RCC and did not receive sunitinib for 2 weeks after the surgery. After this 2-week period, the patient was treated with a maintenance dose of sunitinib (37.5 mg, 3 days a week). The patient also had zoledronic acid (4mg) IV infusions every 4 weeks for 3 months (Total of 3 infusions) owing to a left iliac osteolytic bone lesion. Six months before presenting at our clinic, the patient saw her local dentist for a routine check-up. She developed a small laceration on her hard palate caused by the edge of the film used when the dentist performed routine radiography. The laceration progressed to a large nonhealing wound. The bony hard palate became involved with deterioration, leading to sequestration of bone and tissue from the mouth. Intraoral examination revealed a large, 3-cm defect on the midline of the hard palate, communicating into the nasal cavity but not extending into the soft palate (Fig 1). The left posterior lingual mandibular area had 1.5 cm bone exposure under the 3-unit fixed dental prosthesis #18-20 (Figs 2,3). An obturator prosthesis was fabricated to close the oral-nasal communication. The exposed left lingual mandibular necrotic bone eventually progressed to the midline and extended inferiorly 50 Kidney Cancer Journal to the floor of mouth. A new site of exposed bone was identified on the right mandible measuring 1cm. Due to inability to control progression necrosis and pain of the jaw, the patient underwent a subtotal mandibulectomy and immediate fibula free flap reconstruction and placement of a reinforcing and stabilizing titanium reconstruction plate (Synthes TruMatch Proplan). (Fig 4, 5) Following 6 months healing phase, removable mandibular resection prosthesis was fabricated. (Fig 6) This prosthesis will help with oral functional difficulties including poor lip support, drooling of saliva, poor bolus control and speech disturbance. The patient requires a mandibular resection prosthesis, which will help maintain functional positioning of the jaws, improve speech, mastication and deglutition. Discussion The case report describes a patient who developed extensive stage III medication-related ONJ on the hard palate and mandible, in which she underwent subtotal mandibulectomy with immediate fibula free flap reconstruction. Patients with advanced RCC with bone metastases are typically treated with a combination of TKIs, such as sunitinib, and zoledronic acid. This combination improves median overall survival and has better treatment efficacy than other regimens.4 However, several studies showed that the combination of sunitinib and zoledronic acid increases the incidence of ONJ in patients with metastatic renal cell carcinoma.4-7 Fusco et al7 conducted a multicenter study of metastatic renal cell cancer treated with bisphosphonates and targeted agents. They concluded that ONJ is not a rare occurrence and attributed its icrease Figure 2. Figure 3. Figure 4. Figure 5.
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