Page 33 - GP Fall Final 2017

Treatment for Melanoma and MRONJ
A Case Study with an Introduction to Tafinlar, Mekinist, and Xgeva
®
A Review of Melanoma and MRONJ

By James R. Keenan, DDS, MS, MAGD and Analia Veitz-Keenan, DDS
A 59-year-old Caucasian female patient her neck below her right ear (Figures 2,3). ity of the crestal bone in the corresponding
presented to our office stating, “My doctor She reported that it has been present for a area and a broad radiolucent area beneath
wanted you to examine my gum.” The pa- considerable amount of time and that her the right maxillary sinus. While there was
tient had a history of melanoma on her left dermatologist provided reassurance that it no history of recent surgical intervention or
leg which had undergone surgical resection didn’t pose any issue and would be moni- any trauma in the upper right quadrant, os-
along with a sentinel lymph node biopsy tored. Intraoral exam revealed partial eden- teonecrosis was suspected based upon the
four years ago. There was a recurrence of tulism in the maxilla and mandible. There patient’s use of Xgeva (denosumab). The
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the melanoma on the left leg two years ago. was poor oral hygiene with heavy localized patient was referred to an oral maxillofa-
Again, the patient had undergone surgical calculus on the mandibular anteriors. The cial surgeon for further evaluation. Regular
resection. She reported that she had Gam- upper left first molar, #14, had a retained monitoring of the patient’s oral cavity was
ma Knife surgery. The patient also report- root. The maxillary dentition had a canted recommended to evaluate the resolution of
®
ed that she recently had her right maxillary display (Figure 4). Erythema migrans (geo- the existing exposed area and to determine
sinus drained under general anesthesia. graphic tongue) was visible on the dorsal if any new sites have appeared. Additional-
The patient reported that she has been on a surface of the tongue (Figure 5) and there ly, strict adherence to oral hygiene recom-
Tafinlar and Mekinist combination targeted was a fibroma measuring about 10 mm in mendations to maintain optimal oral health
therapy and Xgeva (denosumab) for the diameter on the left buccal mucosa (Figure was strongly encouraged.
®
past 15 months. She could not recall her 6). There were no sharp edges detectable
last dental visit but she confirmed that it on any of the teeth in the upper or lower left Tafinlar and Mekinist
had been more than 10 years ago. quadrants. Upon examination of the upper Tafinlar (dabrafenib) (Novartis Pharma-
right quadrant an area of exposed bone was ceutical Corp.) and Mekinist (trametinib)
Immediately apparent as the patient sat in noted in the area where the 1 and 2 pre- (Novartis Pharmaceutical Corp.) are used
st
nd
the dental chair was the considerable swell- molars would be located. The color of the in combination as a targeted therapy for
ing on the ankle and instep of her left foot soft tissue was within normal limits and the treatment of advanced or metastatic
(lymphedema) (Figure 1) for which she there was no observable ulceration. Intra melanoma. The goal of the combination
was wearing a compression stocking on oral periapical films and a panoramic image treatment focuses on prolonging surviv-
her left leg. The patient was fair skinned were taken (Figures 7,8). There was confir- al, eliminating cancer, shrinking or stop-
with blonde hair. She reported to be as- mation that there was no residual presence ping the growth of known metastases, and
ymptomatic within her oral cavity. A head of tooth #2,3,4 or 5. However, the periapi- providing comfort to the patient. At least
1
and neck exam revealed a growth along cal film did display a break in the continu- 50% of patients with advanced melanoma

Figure 1. Leukoedema observed in left ankle Figure 2. Growth observed along right side of Figure 3. Growth observed along right side of
and foot. neck, extended view. neck, close-up view.

Figure 4. Intraoral facial view. Figure 5. Geographic tongue (erythema Figure 6. Fibroma on left buccal mucosa.
migrans).
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