What to Know About Osteoradionecrosis and Soft Tissue Radionecrosis Injuries After Radiation Treatment

Side effects from radiation therapy for cancer are common. Most acute side effects, like fatigue, nausea, and headaches, resolve quickly. But in rare cases, radiation therapy can cause delayed, serious complications, including injuries to your surrounding tissue.

Osteoradionecrosis (bone tissue death) and soft tissue radionecrosis (soft tissue death) are both rare complications of radiation therapy. They occur several months or sometimes even years after your radiation treatment.

Both osteoradionecrosis and soft tissue radionecrosis can cause serious symptoms. But with treatment, your condition can improve. Learn more about these conditions and available treatments at UPMC.

Delayed Complications from Radiation Therapy

Radiation therapy targets cells that rapidly turn over — like tumor cells, which rapidly divide. But some of your normal cells rapidly turn over, too. And when you get radiation therapy, some of those normal rapid turnover cells can also become infected.

“They try to focus the radiation as much as they can to the tumor specifically,” says Dr. Yolanda Michetti, MD, wound care specialist, UPMC in Central Pa. “Unfortunately, there still is good tissue within the way of that radiation. And so that surrounding good tissue, the healthy tissue, can get affected as well because that also can have some rapidly turning-over cells. And so, then, that can kind of lead to these radiation side effects.”

Those complications include osteoradionecrosis and soft tissue radionecrosis. Both are rare, happening in less than 10% of cases. You are more at risk with higher amounts of radiation, Dr. Michetti says.

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What Is Osteoradionecrosis?

Osteoradionecrosis is bone death as a result of radiation therapy. It happens most often after radiation for head and neck cancers. Bone death happens most often in the mandible, or lower jaw.

“With head and neck cancers, the mandible is oftentimes right there in the radiation field,” Dr. Michetti says. “And, unfortunately, head and neck cancers will sometimes require higher amounts of radiation. So, the mandible can get affected because of that.”

Osteoradionecrosis also can happen in the upper jaw, or maxilla. But the mandible is more susceptible.

What causes osteoradionecrosis?

Radiation kills small blood vessels within the bone, which are responsible for carrying oxygen and nutrients to the bone. This makes the bone less able to heal itself, which puts you at risk for infections and fractures.

Radiation therapy also can hit the salivary glands, Dr. Michetti says, which can cause patients to lose their salivary function. This can lead to a dry mouth, which can make it difficult to fight off bacteria in the mouth, leading to cavities and dental breakdown. When those patients then have teeth removed, their blood vessels can’t support the healing — which can lead to osteoradionecrosis.

Signs and symptoms of osteoradionecrosis

Common signs and symptoms of osteoradionecrosis include:

  • Pain.
  • Infections.
  • Fractures unrelated to trauma.
  • Dental fistulas (a pus-filled bump inside the mouth, a sign of infection).
  • Sores or ulcers of the jaw or mouth.
  • Disfiguration of the mouth or jaw.
  • Exposed bone inside the mouth or jaw.

Treatment for osteoradionecrosis

Treatment for osteoradionecrosis often involves a combination of hyperbaric oxygen therapy and surgery. Hyperbaric oxygen therapy involves the use of 100% oxygen, delivered at higher-than-normal pressure, to get more oxygen to the body tissues and promote new blood vessel growth.

UPMC Wound Healing works with other specialties — including dental, oral surgery, and Ear, Nose, and Throat (ENT) — to coordinate osteoradionecrosis care. Treatment often begins with 30 sessions of hyperbaric oxygen therapy (Monday to Friday). They will then undergo surgery.

“The hyperbaric oxygen therapy is done essentially to make the tissue healthier because we’re trying to improve that wound bed,” Dr. Michetti says. “We’re preparing the surgical site, and then once those patients are ready, they undergo their surgery.”

After surgery, a patient will get another 10 treatments of hyperbaric oxygen therapy to promote healing.

What Is Soft Tissue Radionecrosis?

Soft tissue radionecrosis is the death of soft tissue after radiation exposure. Like osteoradionecrosis, it happens when normal rapid-turnover cells are in the radiation field. The radiation affects blood flow to the soft tissue, depriving the tissue of oxygen and nutrients. This makes it difficult for the tissue to regenerate.

Unlike osteoradionecrosis, soft tissue radionecrosis can happen after radiation for a variety of cancers — breast, colorectal, cervical, head and neck, and more.

Soft tissue death happens over time — the injuries can take anywhere from six months to several years to appear.

“Unfortunately, this is a chronic process,” Dr. Michetti says. “It can lay dormant, and then, all of a sudden, get exacerbated — and you’re dealing with an issue years down the road.”

Signs and symptoms of soft tissue radionecrosis

The symptoms of soft tissue radionecrosis can vary depending on what tissue is affected. Common signs include pain, bleeding, and ulceration of the affected area. You are also more prone to infections.

The specific tissue that is affected can cause different symptoms. For example, soft tissue radionecrosis after radiation for colorectal cancers could lead to bleeding during bowel movements. Soft tissue radionecrosis from head and neck cancers could cause ulceration inside your mouth and the back of your throat, which can make swallowing difficult.

Treatment for soft tissue radionecrosis

Hyperbaric oxygen therapy is often the first-line treatment for soft tissue radionecrosis. The therapy often can heal patients’ wounds without the need for surgery, Dr. Michetti says.

“With soft tissue, you can let the body heal itself. That tissue will heal itself,” she says. “So, the majority of the time, we can treat with hyperbaric oxygen therapy and get good results.”

Some patients may need surgical debridement of the affected area.

For patients with soft tissue radionecrosis of the skin, a bio-engineered skin substitute may be a treatment option if other treatments are unsuccessful. These are engineered to look and function like normal human skin. They may be an option for chronic or non-healing wounds.

“The idea is that it provides a kind of scaffolding for healing,” Dr. Michetti says. “It can also provide stimulation of certain molecular pathways to improve the healing process.”

Why Choose UPMC Wound Healing Services?

At UPMC Wound Healing Services, we work to provide care for chronic or nonhealing wounds. Our multidisciplinary team works together to provide an individualized treatment plan for each patient. Treatments could include hyperbaric oxygen therapy, surgery, and more. We strive to provide comprehensive, compassionate care to every patient.

“We definitely provide an understanding of their disease or disease process because sometimes it can be very intimidating, not knowing what’s going on or why is this happening to me,” Dr. Michetti says. “It’s kind of giving them that support, the education, the awareness.”

To find a UPMC Wound Healing Services location near you, visit our website.

American Head and Neck Society, Osteoradionecrosis. Link

Jerome B. Buboltz, Stephen Hendriksen, and Jeffrey S. Cooper, StatPearls, Hyperbaric Soft Tissue Radionecrosis. Link

Canadian Cancer Society, Osteoradionecrosis. Link

Donald D. Davis, Mary E. Hanley, and Jeffrey S. Cooper, StatPearls, Osteoradionecrosis. Link

National Cancer Institute, Radiation Therapy Side Effects. Link

Oral Cancer Foundation, Complications, Osteoradionecrosis. Link

About UPMC

Headquartered in Pittsburgh, UPMC is a world-renowned health care provider and insurer. We operate 40 hospitals and 800 doctors’ offices and outpatient centers, with locations throughout Pennsylvania, Maryland, New York, West Virginia, and internationally. We employ 4,900 physicians, and we are leaders in clinical care, groundbreaking research, and treatment breakthroughs. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside as one of the nation’s best hospitals in many specialties and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals. We are dedicated to providing Life Changing Medicine to our communities.