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Regenerative Facial Reconstruction of Terminal Stage Osteoradionecrosis and Other Advanced Craniofacial Diseases With Adult Cultured Stem and Progenitor Cells
Regenerative Facial Reconstruction of Terminal Stage Osteoradionecrosis and Other Advanced Craniofacial Diseases With Adult Cultured Stem and Progenitor Cells
Regenerative Facial Reconstruction of Terminal Stage Osteoradionecrosis and Other Advanced Craniofacial Diseases with Adult Cultured Stem and Progenitor Cells
Foot
Background: Treatment options in cases of severe craniofacial disorders with bone loss and tissue damage are usually limited to vascularized and nonvascularized tissue transfers, allografts, mechanical devices and, more recently, facial transplantation. Despite the therapies available, the demand for new approaches is realized in cases where current therapies are unable to resume form and function. This study presents the feasibility of alternative treatments based on cultured bone marrow cells that yield mixed populations of mesenchymal, hematopoietic, and endothelial lineages at very early stages implemented as part of a novel regenerative procedure. Methods: One hundred milliliters of a bone marrow aspirate was inoculated into the automated single-pass perfusion technology system, AastromReplicell, for the development of the cellular product, tissue repair cells. After 12 days of incubation, cells were exposed to a specially designed osteogenic environment in an autogenous fibrin-rich and platelet-rich clot and membrane with a mineral base of -tricalcium phosphate and hydroxyapatite. Results: A case of maxillary and mandibular radionecrosis (stage IIIR) with pathologic fracture presented early osteogenesis, total recovery from alveolar nerve anesthesia, facial nerve reinnervation, and skin regeneration. Another case with nonhealed fracture, bone loss, and bilateral paresthesia demonstrated callus formation, bone regeneration, and nerve recovery. Finally, maxillary bone regenerated after massive deficiency. Oral functional restoration with implants and fixed prosthesis was accomplished in all cases. Conclusion: After nerve, bone, skin, and vessel formation in three patients with severe abnormality, bone marrow derived mixed cultured stem cell lineages could be considered a new paradigmatic approach to advanced disease. (Plast. Reconstr. Surg. 126: 1, 2010.)
reatment options in cases of severe facial bone and tissue loss are usually accomplished by autografts,1 allografts, cytokines, mechanical devices and, more recently, facial transplantation. Occasionally, the disease outweighs the balance between destruction and regeneration, mainly when tissues other than bone are involved.2,3 Many severe conditions remain challenging, without a clear curative solution, and patients are left with palliative or limited therapies. Autogenous grafts have been considered the
From the Head and Neck Surgery Unit, POLUSA Hospital. Received for publication January 22, 2010; accepted May 10, 2010. Copyright 2010 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181f24164
standard treatment in all osseous regenerative procedures. Bone substitutes, cytokines, and other substances are designed to enhance conventional grafting techniques or as an alternative to bone harvesting, potentially improving grafts or avoiding donor-site surgery and morbidity. The iliac crest has passed the test of time,1 proving to be the most prolific donor site of the body, with the greatest variety of bony structures and cell populations. The most remarkable quality is the relatively large populations of stem and progenitor cells in the
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
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Supplemental digital content is available for this article. Direct URL citations appear in the printed text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journals Web site (www.PRSJournal.com).
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used as another temporary scaffold. Three patients with severe disease were selected after meeting the following special criteria: 1. Severe facial tissue loss previously treated unsuccessfully. 2. Routine procedures for surgery. 3. Extensive informed consent, with a witness, obtained 15 days before surgery. 4. Hospital ethics committee approval. 5. Spanish ministry of health approval, European regulations for compassionate use of autologous stem cells. 6. All Conformite Europeenne/U.S. Food and Drug Administrationcertified materials. Exclusion of organic substances. 7. Extensive imaging diagnostics. 8. Exclusion criteria were as follows: Active or recent cancer, major health disorders. Smoking. Substance abuse. Metabolic bone or collagen disease. Poor oral hygiene. Pregnant or nursing women, women not using contraceptives. Inadequate medications, allergy to common drugs.
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CFU-F, colony forming unit, fibroblast; CFU-GM, colony forming unit, granulocyte, monocyte.
Thy-1, thymocyte differentiation antigen; CD, cluster of differentiation; CXCR4, chemokine receptor 4; VEGFR1, vascular endothelial growth factor receptor 1; lin, lineage.
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Fig. 1. Surgical site preparation and grafting of platelet-poor plasma plus mineral scaffold plus cells.
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Video 2. Supplemental Digital Content 3 demonstrates injecting cells, temporary scaffold, http://links.lww.com/PRS/A219.
9. Patient permission: screening for viruses and common tumor markers. 10. Consistently the same surgeons and anesthetist. 11. Healthy psychological background. 12. Agreement to publish outcomes in scientific journals regardless of poor or negative results. 13. Following the guidelines of the International Society for Stem Cell Research.
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RESULTS
Patient 1, a 63-year-old man with a history of radiation therapy for tonsillar cancer, reported pain in the right hemimandible. Computed tomographic scans (Fig. 3) disclosed a cystic lesion in the molar area. Diagnosed with limited mandibular and maxillary radionecrosis, the patient was treated elsewhere, returning 1 year later with a history of tooth extraction, pathologic fracture, life-threatening infection, prolonged hospitalization, and severe chronic pain with dysfunction. Several treatment strategies included surgical de bridement, 45 dives in hyperbaric oxygen, antibiotic therapy, and others. Despite these efforts, the disease worsened, and a new computed tomographic scan disclosed a severely fractured mandible (Fig. 3). (See Figure, Supplemental Digital Content 7, which demonstrates a new computed tomographic scan disclosing a severely fractured mandible, http://links.lww.com/PRS/A223.) Symptoms now included intraoral and extraoral suppuration from two fistulas, severe trismus, total lip anesthesia from alveolar nerve dam-
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Fig. 3. Three-dimensional computed tomographic scans show evolution of radionecrosis to pathologic fracture after dental extractions (stage IIIR).
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Fig. 4. Three-dimensional computed tomographic scans demonstrate critical state of necrosis and massive osteogenesis 4 months later. Necrotic and grafted areas are delimited by arrows and circles.
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Fig. 5. Preoperative and postoperative computed tomographic scans demonstrate significant bone formation.
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lography confirmed inexplicable reactivation of a radiotherapy-devastated parotid gland (Fig. 8). Patient 2 was a 56-year-old man with chronic pain, masticatory dysfunction and paresthesia of both lower lips, and a history of severe craniofacial trauma with maxillomandibular fractures 12 years previously. After several operations, the patient developed oral fistulas, chronic pain, functional limitations, and bilateral alveolar nerve impairment. Diagnostic imaging revealed poor consolidation, bone loss, and invasion of the mandibular canal with a screw. Cell application procedures were similar, except for bilateral nerve lateralization, sheath dissection, and cell injection (Fig. 2). Both sinuses were grafted, and the anterior maxilla was reconstructed with two poly(L-lactic acid) plates and grafts. Plates were exposed slightly 4 weeks later without infection but were not removed. Four months later, the same implants were inserted into both jaws, except in a small area of exposed plates where the bone was considered inappropriate. One year after surgery, the patient had resumed normal oral function with a fixed prosthesis. Both mental nerves recovered despite mild paresthesia at the screw-perforated site. Pain had subsided. Patient 3 was a 52-year-old man with masticatory dysfunction and joint pain resulting from the
absence of maxillary molars, with severe bone loss in the posterior maxilla, residual bone height areas of 1 mm, and perforations to the sinus. Lower limb and hip pathologic conditions contraindicated iliac harvesting. Calvarial harvesting was discarded because of unpredictable results with great volume defects, and allografts or xenografts alone were also rejected. Cell processing followed the same techniques described above; sinus lifts were grafted with platelet-poor plasma cells and platelet-rich plasma cells contralaterally. One implant was placed simultaneously, and the rest were placed at 4 months. A fixed prosthesis was inserted 2 months later. All patients led a normal life, with implantsupported fixed prostheses (Fig. 9). (See Figure, Supplemental Digital Content 15, which shows prosthetic rehabilitation in the area of previous radionecrosis, http://links.lww.com/PRS/A231.) All implants survived, and bone density and function continue to increase over time. More than 1 year later, a slight plate exposure remains the only complication to be reported.
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DISCUSSION
The therapeutic use of bone marrow derived stem and progenitor cells for human disease is not new. Native bone marrow, stimulation with gran-
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Fig. 6. Photomicrographs show changes in the histology of bone and skin. Osteocytes, osteoblasts, and osteoid formation are found at the time of implant insertion and 4 months after grafting (note unresorbed allograft on the right). Skin sample before and after surgery.
Fig. 7. Gadolinium-enhanced magnetic resonance imaging scan at 7 months demonstrates arteriogenesis of the facial and lingual vessels. Note the profuse angiogenesis at the level of the graft and the closed circuit with the maxillary artery.
Fig. 8. Sialographic image demonstrates parotid gland reactivation years after intense radiotherapy.
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ulocyte colony-stimulating factor, and blood apheresis and expanded bone marrow in autologous and homologous procedures have been used for years in hematopoietic replacement after iatrogenic destruction of blood-generative organs by radiotherapy, chemotherapy, or both. Hematopoietic stem cell therapy is not only a consolidated procedure but also a successful one. Adult stem cells have been the object of innumerable in vitro and animal experiments, demonstrating significant potential for the treatment of numerous diseases. Nevertheless, there is a paucity of reports in the literature on therapies in humans with other advanced conditions. In this article, we report the first use of a mixed population of autologous cultured bone marrow derived stem and progenitor cells in the treatment of severe craniofacial disorders, where an unexpected outcome demonstrated the regeneration of nervous, vascular, and dermal structures and bone. Osteoradionecrosis of the mandible develops over a period ranging from months to years after intense exposure to radiotherapy. Early stages are treated conservatively with routine dental care, oral hygiene, antibiotics, and extreme caution with extractions. Marx20 hypothesized the prophylactic and therapeutic use of hyperbaric oxygen, assuming revascularization and cell induction by high partial pressure of oxygen. Criticism and controversy20 followed, given the expensive and exclusive setup required and the uncertain results, mainly in advanced cases. The
mechanisms involved are controversial and are based not only on vascular deprivation but also on fibrous tissue formation and deficiencies in bone turnover. Furthermore, double-blind, placebo-controlled studies that found no benefit from hyperbaric oxygen for advanced osteoradionecrosis of the mandible21 have led to the emergence of new treatments. Restoration of the blood supply to the affected area continues to be critical. One of the first images of human angiogenesis and arteriogenesis after stem cell therapy in a case of radionecrosis is presented in this article (Fig. 7). (See Figures, Supplemental Digital Content 12, which shows a three-dimensional magnetic resonance imaging scan of angiogenesis, http://links.lww.com/PRS/A228; and Supplemental Digital Content 13, which shows high gadolinium uptake in the grafted area demonstrating vast angiogenesis, http://links.lww.com/PRS/A229.) Endothelial precursor cells and a wide variety and high levels of angiogenic cytokines (mainly vascular endothelial growth factor) may be responsible for the microvascular and macrovascular vessel development. It can be hypothesized that early vascular graft ingrowth is the basis of regeneration of all tissues, delivering oxygen, nutrients, chemical signaling, migrating cells, and immunity. Osteogenesis requires a copious blood supply but also an adequate cell pool. Other effects, such as marginal mandibular nerve function, the recovery of three completely inactive alveolar nerves, new skin formation
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ACKNOWLEDGMENTS
The authors thank Maria Jesus Lopez, neurophysiologist, and Paco Vidal, bioengineer, for enthusiastic and unselfish collaboration on this research.
REFERENCES
1. Sullivan WG, Szwajkun PR. Revascularization of cranial versus iliac crest bone grafts in the rat. Plast Reconstr Surg. 1991; 87:11051109. 2. Teng MS, Futran ND. Osteoradionecrosis of the mandible. Curr Opin Otolaryngol Head Neck Surg. 2005;13:217221. 3. Marx RE. Osteoradionecrosis: A new concept of its pathophysiology. J Oral Maxillofac Surg. 1983;41:283288.
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AQ1: AUTHORThere were two reference 5s on the ref list; they were renumbered as 5 and 6, and subsequent references 6 through 19 were renumbered as refs 7 through 20. (The original reference list did not have a ref. 20, so the original numbering resumed with ref. 21.) Correct as edited? If not, please revise reference citations and reference list as needed. AQ2: AUTHORGMP spelled out correctly? AQ3: AUTHORTable 1, column 3: Please confirm that the multiplication symbol (x) is correct in the column heading (x10(6)/ml) or revise as needed. AQ4: AUTHORTable 2, column 4: Please confirm that the multiplication symbol (x) is correct in the column heading (x10(6)/ml) or revise as needed. AQ5: AUTHORDescription of Supplemental Digital Content 12 correct as edited (threedimensional magnetic resonance imaging scan of angiogenesis)? If not, please revise as needed. AQ6: AUTHORRenumbered reference 20 is by Schwartz et al., not Marx. Please reconcile. AQ7: AUTHORRef. 14: Meeting information correct? If not, please revise as needed. 1