CASE REPORT Osteonecrosis of the mandible in a patient with lung adenocarcinoma undergoing anti-angiogenic therapy with bevacizumab F. Tzermpos 1 , A. Ismail 2 , M. Pavli 1 & K.I. Tosios 3 1 Department of Oral & Maxillofacial Surgery, Dental School of Athens, National and Kapodistrian University of Athens, Athens, Greece 2 Private Practice, Kiato, Greece 3 Department of Oral Pathology, Dental School of Athens, National and Kapodistrian University of Athens, Athens, Greece Key words: adenocarcinoma, bevacizumab, lung, ONJ, osteonecrosis Correspondence to: Mr Avraam Ismail Private practice 3 Sapfous Kiato 20 200 Greece Tel.:+00 3069 7913 7667 Fax: +00302742024032 email: avraam_is@hotmail.com Accepted: 21 December 2014 doi:10.1111/ors.12153 Abstract Bevacizumab is a recombinant monoclonal humanised antibody, designed to inhibit the binding ability of vascular endothelial growth factor to its receptor. Recently bevacizumab has been implemented in the treatment protocols against certain types of cancer. A 63-year-old Caucasian male patient with lung adenocarcinoma, presented in the OMFS clinic with a non-healing lesion of the mucosa at the region of tooth 17 including areas of exposed bone and presence of pus along with paraesthesia, distributed to the left side of the lower lip. The patient had undergone two chemotherapy cycles including IV bevacizumab which was administered once every 3 weeks in a dose of 15 mg/kg. The radiographic examination (Orthopantomogram, ConeBeamComputedTomography) revealed cortical erosion of the lingual plate on the posterior left mandibular region with involvement of the inferior alveolar nerve. A diagnosis of stage II osteonecrosis was established that was later confirmed by the histopathological evaluation and ruled out possible bone metastases. After 2 weeks of treatment with an empiric antibiotic regimen, the necrotic lesion was removed with surgical debridement and without complications. In the 6 months follow-up the diseased area was fully healed and the paraesthesia was improved. Clinical relevance Osteonecrosis of the jaw is a rare implication of angiogenic therapy with bevacizumab and only a few case reports have been published on the matter. The data from the present report further contributes to the understanding of the disease’s pathophysiology and to the foreground for the publication of official guidelines regarding the management of patients receiving antiangiogenic treatment. Introduction Bevacizumab is a recombinant humanised monoclo- nal antibody that targets the vascular endothelial growth factor A (VEGF-A) and inhibits the ability of VEGF to bind on its receptor 1 . The FDA has approved the use of bevacizumab for the treatment of metastatic colorectal cancer, advanced non-squamous non-small cell lung cancer, metastatic renal cell carcinoma and glioblastoma. A series of case reports have been published recently, relating the use of this monoclonal antibody with osteonecrosis of the jaw (Table 1), while a strong asso- ciation between bisphosphonates and the disease has already been established 11 . Medication related ONJ, is the pathological clinical entity, that is recorded in patients who have not been radiated for therapeutic purposes and exposed bone has been revealed in the maxillofacial region or can be probed through fistula(e), persisting at least for 8 weeks, after current or previous use of antiresorptive or antiangiogenic agents 11 . In 2008 it was first reported by Estilo et al., that a 51- and a 33-year-old female patients, who were Oral Surgery 9 (2016) 40--46. © 2015 The British Association of Oral Surgeons and John Wiley & Sons Ltd 40 Oral Surgery ISSN 1752-2471