Clinical characteristics and diagnostic process of concurrent malignancies patients with osteoradionecrosis of the jaw as the initial manifestation: a single center case series study

Osteoradionecrosis of the jaw (ORNJ) is a severe and refractory late complication of radiotherapy (RT) for head and neck malignancies. Prior case reports have established that ORNJ can coexist with malignant tumors, exhibiting significant similarities in clinical and radiological features. This study aims to summarize the clinical and imaging features of patients who initially presented with ORNJ after radiotherapy but finally diagnosed with concurrent malignancies, providing recommendations for clinical diagnosis workflow, and thereby minimizing clinical misdiagnosis and missed diagnosis. A total of 106 patients were clinical diagnosed with ORNJ who underwent surgical treatment at the Hospital of Stomatology, Sun Yat-sen University, between January 2019 and December 2023, were retrospectively included. Demographic data, clinical characteristics, radiological manifestations, and pathological features were comprehensively collected. Statistical analyses and typical photographs comparison were performed to evaluate differences between ORNJ patients with and without malignancies. Among the 106 ORNJ patients, the average age was 52.97 ± 11.48 years, with 68.87% being male and 72.64% involved mandible. Histopathological evaluation revealed that, five patients (4.72%) presented with concurrent jaw malignancies. These five jaw malignancies consisted of three squamous cell carcinoma (SCCs), one osteosarcoma, and one fibrosarcoma. In our cohort, the incidence of post-radiation SCC was 3/106 for ORNJ patients, indicating an elevated risk of malignancy among patients with ORNJ. Given the considerable overlap in radiographic and initial clinical features between ORNJ with and without malignancy, histopathological examination constitutes the sole definitive means of differentiation. For patients who are initially diagnosed with ORNJ, it is necessary to be vigilant about the possibility of concurrent malignancies. Atypical soft tissue hyperplasia within the lesion should raise strong suspicion. Therefore, preoperative biopsy and intraoperative frozen‑section examination are strongly recommended. Moreover, we have developed a standardized clinical workflow that can be directly implemented to reduce the risk of missed malignancy in patients with a clinical diagnosis of ORNJ.