Osteonecrosis of the jaw in a metastatic lung cancer patient with bone metastases undergoing pembrolizumab + denosumab combination therapy: Case report and literature review

Abstract The rare adverse drug reaction MRONJ (medication-related osteonecrosis of the jaw) can be induced by treatment with antiresorptive, antiangiogenic, or immunomodulating agents. Immune checkpoint inhibitors (ICIs; e.g., pembrolizumab) are the standard care for advanced or metastatic cancer patients. Denosumab directed against receptor activator of NF-kB ligand (RANKL) is approved for preventing skeletal-related events (SREs) in cancer patients with bone metastases. The combination therapy of ICIs + denosumab has shown promising efficacy and no unexpected safety issues in metastatic melanoma and lung cancer patients with bone metastases. We present a rare case of advanced mandibular osteonecrosis in an adult female with metastatic lung cancer and bone metastases who received concomitant pembrolizumab + denosumab.