Efficacy of elemental diet on prevention for chemoradiotherapy-induced oral mucositis in patients with oral squamous cell carcinoma

Stomatitis Healing via Hydrogels Comprising Proline, Carboxyvinyl Polymer, and Water

Chemotherapy using anticancer agents and radiotherapy of cancers frequently induce the development of stomatitis as a side effect. In the present study, hydrogels for effective stomatitis healing under anticancer drug administration were developed using three components, namely proline, carboxyvinyl polymer, and water (denoted proline gels). Characterization including tilting, Fourier transform infrared spectra, and viscoelasticity measurements indicated that proline gels with proline concentrations over 300 μmol/g could retain water on the tongue of mice. The degradation and release behavior of proline gels in serological environments were evaluated, revealing that proline gels were degraded by serological salt concentrations, and the cumulative amount of proline released from proline gels depended on the concentration of proline in the gel. Proline gels were applied to the stomatitis area on the tongue of mice under anticancer drug administration, with subsequent reduction in the stomatitis area and regeneration of the mucosal epithelium layer, demonstrating effective stomatitis healing by proline gels with proline concentrations over 500 μmol/g. Other control samples including the carboxyvinyl polymer or proline alone did not reduce the stomatitis area in model mice. These results suggested that the proline gel is promising for the mucosa regeneration of anticancer drug-induced stomatitis.

Impact of a glutamine-enriched peptide formula on gastrointestinal toxicity and on the interruption of oncologic treatment in patients with adenocarcinoma of the rectum

Background

Patients with rectal cancer may develop gastrointestinal toxicity associated with chemo-radiotherapeutic treatment that conditions their clinical, functional, and nutritional evolution. The aim of the study was to evaluate the efficacy of nutritional supplementation with a glutamine-enriched peptide diet (PD) compared to exclusive dietary advice (DA) on gastrointestinal toxicity, interruption of oncologic treatment, and nutritional evolution in patients with rectal cancer undergoing neoadjuvant treatment.

Methods

Prospective cohort study with two groups. Patients with rectal cancer in treatment with neoadjuvant chemo-radiotherapy were recruited. One group of patients received nutritional supplementation with PD, and another group received DA exclusively, from the beginning of radiotherapy until the time of surgery. Intestinal toxicity was evaluated with the CTCAE 5.0 scale, functionality with the ECOG scale and nutritional status with GLIM criteria.

Results

Fifty-four patients were initially selected, although 51 were finally enrolled: 25 in the PD group and 26 in the DA group. There was a reduction in the risk of diarrhea in the PD group midway through radiotherapy treatment [RR of 0.218 (95% CI = 0.052-0.923)] and at the end of treatment [RR of 0.103 (95% CI = 0.020-0.537)], as well as a reduction in the risk of developing mucositis at the end of treatment [RR of 0.405 (95% CI = 0.280-0.584)]. The use of a PD also decreased treatment interruptions with radiotherapy in stage III patients (0 vs. 15.8%, p = 0.049) and in malnourished patients (0 vs. 18.2%, p = 0.040).

Conclusion

The glutamine-enriched peptide diet had a protective effect on the development of diarrhea and mucositis associated with chemo-radiotherapeutic treatment in patients with colorectal cancer under neoadjuvant treatment, as well as the interruption of radiotherapeutic treatment.

Clinical, Functional, and Nutritional Efficacy of a Glutamine-Enriched Oligomeric Diet in Patients with Rectal Cancer

AIMS

This work aims to evaluate the efficacy of nutritional supplementation with a glutamine-enriched oligomeric diet (GEOD) compared to a standard polymeric diet (SPD) in terms of oncology treatment-related diarrhea (OTRD) (frequency and consistency of stools), gastrointestinal toxicity, and functional and nutritional progress.

METHODS

This prospective cohort study compared two groups of patients with rectal cancer in treatment with neoadjuvant chemotherapy and radiotherapy who were at risk of malnutrition. Patients were randomized to receive either 400 ml of GEOD or of SPD from the start of radiotherapy to 30 days after its completion.

RESULTS

Eighty patients were recruited, 40 per arm. The GEOD arm had improved stool consistency and a greater reduction in the number of stools compared to the SPD arm (p < 0.001). The relative risk (RR) of developing diarrhea in the GEOD arm was 0.059 (95% CI 0.015-0.229). There was a reduced risk of developing intestinal mucositis in the GEOD arm compared to the SPD arm [RR 0.202 (95% CI 0.102 - 0.399)]. The GEOD arm had greater improvements in functional and nutritional status (p < 0.001).

CONCLUSIONS

GEOD had a protective effect in terms of the development of gastrointestinal toxicity associated with chemotherapy and radiotherapy treatment in patients with rectal cancer.

Cationic antimicrobial peptide NRC-03 induces oral squamous cell carcinoma cell apoptosis via CypD-mPTP axis-mediated mitochondrial oxidative stress

Pleurocidin-family cationic antimicrobial peptide NRC-03 exhibits potent and selective cytotoxicity towards cancer cells. However, the anticancer effect of NRC-03 in oral squamous cell carcinoma (OSCC) and the molecular mechanism of NRC-03 induced cancer cell death is still unclear. This study focused to investigate mitochondrial oxidative stress-mediated altered mitochondrial function involved in NRC-03-induced apoptosis of OSCC cells. NRC-03 entered the OSCC cells more easily than that of normal cells and bound to mitochondria as well as the nucleus, causing cell membrane blebbing, mitochondria swelling, and DNA fragmentation. NRC-03 induced high oxygen consumption, reactive oxygen species (ROS) release, mitochondrial dysfunction, and apoptosis in OSCC cells. Non-specific antioxidant N-acetyl-l-cysteine (NAC), or mitochondria-specific antioxidant mitoquinone (MitoQ) alleviated NRC-03-induced apoptosis and mitochondrial dysfunction indicated that NRC-03 exerts a cytotoxic effect in cancer cells via inducing cellular and mitochondrial oxidative stress. Moreover, the expression of cyclophilin D (CypD), the key component of mitochondrial permeability transition pore (mPTP), was upregulated in NRC-03-treated cancer cells. Blockade of CypD by siRNA-mediated depletion or pharmacological inhibitor cyclosporine A (CsA) significantly suppressed NRC-03-induced mitochondrial oxidative stress, mitochondrial dysfunction, and apoptosis. NRC-03 also activated MAPK/ERK and NF-κB pathways. Importantly, intratumoral administration of NRC-03 inhibited the growth of CAL-27 cells-derived tumors on xenografted animal models. Taken together, our study indicates that NRC-03 induces apoptosis in OSCC cells via the CypD-mPTP axis mediated mitochondrial oxidative stress.

Effectiveness of elemental diets to prevent oral mucositis associated with cancer therapy: A meta-analysis

BACKGROUND & AIMS

During chemo- or radiotherapy, oral mucositis is associated with severely affected nutrition, prolonged hospital stays, increased risk of infections, death, hindered cancer treatment, and compromised patient prognosis. Although oral mucositis management is critical, no preventive methods have been firmly established. Nutritional therapy with the oral amino acid-rich elemental diet (ED) Elental® may prevent body composition changes and oral mucositis as dose-limiting toxicities of cancer therapy. This meta-analysis evaluated the effectiveness of ED for the prevention of grade ≥2 oral mucositis in patients with cancer undergoing chemotherapy or radiotherapy.

METHODS

A PubMed literature search for randomized clinical trials and/or observational studies in English was conducted. Odds ratios and their confidence intervals were calculated, and fixed- or random-effects models applied.

RESULTS

Of 24 relevant studies, nine conducted in Japan (including 445 patients) were subjected to a meta-analysis. Heterogeneity was 56%. Using a random-effects model, the resulting odds ratio (95% confidence interval) was 0.25 (0.10, 0.61). Funnel plot analysis showed no publication bias. There was no heterogeneity by study design, but esophageal cancer exhibited heterogeneity. The respective odds ratios (fixed-effects model) were 0.10 (0.03, 0.30) for observational studies and 0.48 (0.28, 0.82) for randomized control trials. The odds ratio (confidence interval) using a random-effects model was 0.35 (0.12, 0.99) for esophageal cancer; using a fixed-effects model, odds ratios were 0.07 (0.02, 0.29) for gastroenterological cancer and 0.26 (0.04, 1.60) for oral cancers.

CONCLUSIONS

The ED reduced the risk of developing oral mucositis, regardless of study design. The effectiveness was more marked in patients with gastroenterological cancer followed by esophageal cancer; ED was not effective in patients with oral cancer.

An elemental diet protects mouse salivary glands from 5‑fluorouracil‑induced atrophy

An elemental diet (ED) reduces adverse effects of chemotherapy, including oral mucositis, in patients with cancer. However, the detailed mechanism(s) of the healing effects of an ED remains unclear. In the present study, the protective effects of the ED, Elental^®, were examined against 5-fluorouracil (5-FU)-induced oral mucositis and salivary gland atrophy in mice. Mucositis was induced in female ICR mice by injection of 5-FU. The mice were orally administered Elental^® (ED group) or saline (control group). After treatment, the mice body weight, salivary gland weight and the histological changes in the salivary gland granular duct area were monitored. The mice body weight remained stable in the ED group, but was significantly decreased in the control group. Moreover, the salivary gland weight was higher in the ED group compared with the control group. In addition, the salivary gland granular duct area cells were larger in the ED group compared with the control group. Whole transcriptome analysis and network analysis were conducted to understand the mechanisms of action of Elental^® against oral mucositis. Whole transcriptome analysis and Ingenuity Pathways Analysis data suggested that Elental^® contributed to the recovery of mitochondrial function in 5-FU-damaged salivary glands. Immunohistochemical analysis of salivary gland tissue demonstrated that the expression of cytochrome c oxidase subunit 4 and epidermal growth factor were higher in the ED group compared with the control group. Next, the rate of apoptosis in the salivary glands was examined using terminal deoxynucleotidyl transferase-mediated nick end labeling (TUNEL) assays. The number of TUNEL-positive cells in the salivary glands was lower in the ED group compared with the control group. These findings suggested that Elental^® may protect mouse salivary glands from 5-FU-induced atrophic changes, which suggests that ED treatment may improve xerostomia and alleviate oral mucositis in patients with cancer receiving 5-FU-based chemotherapy.

Head and neck radiotherapy effects on the dental pulp vitality and response to sensitivity tests. A systematic review with meta-analysis

BACKGROUND

There is no consensus whether radiotherapy for head and neck cancer (HNC) could induce pulp necrosis. Therefore, a systematic review of clinical studies is necessary.

OBJECTIVES

To evaluate the evidences on radiotherapy for HNC and pulp status.

METHODS

A systematic search of articles published until November 2021 was performed in the MEDLINE/PubMed, Cochrane Library, Web of Science (All Databases), Scopus, EMBASE and Open Grey databases. The eligibility criteria were based on the PICOS strategy, as follows: (P) vital teeth of adult patients with intraoral and/or oropharyngeal cancer; (I) radiotherapy; (C) control group or values of the same tooth before radiotherapy (basal values); (O) pulpal status after radiotherapy; (S) clinical studies. The Cochrane Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool was used to assess the quality of the included studies. Meta-analyses were performed using fixed and random effects. The overall quality of evidence was assessed through the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Six studies were included for qualitative analysis. Five were classified as serious risk of bias and one as moderate risk of bias. Four studies reported altered pulp responses to cold thermal test after radiotherapy initiation. Meta-analyses were performed using three included studies. From these, all were included in the meta-analysis for pulp response values to cold sensitivity test immediately after radiotherapy initiation (risk ratio: 0.00[CI:0.00, 0.02], P < 0.00001; I² = 0%); and two in the meta-analysis for pulp response values to cold sensitivity test after 4-5 months of radiotherapy (risk ratio: 0.01[CI: 0.00. 0.06], P < 0.00001; I² = 0%). Two reported progressively higher readings to pulp response in the electrical test after radiotherapy initiation (mean difference: -11.46[-13.09, -9.84], P < 0.00001; I² = 68%) and at all periods evaluated. Two studies demonstrated a pulp oxygen saturation (SpO₂ ) decrease at the end of radiotherapy; and increase after 4-6 months of radiotherapy beginning. And other demonstrated normal dental pulp SpO₂ 4 to 6 years after treatment. GRADE analysis presented a moderate certainty of evidence.

DISCUSSION

This review verified that radiotherapy for HNC causes significant alterations on the dental pulp responses, but does not seem to induce pulp necrosis. Significant limitations regarding controlling for confounding factors, classification of interventions and measurement of outcomes were verified, evidencing the need for well-designed studies.

CONCLUSIONS

This systematic review demonstrated that radiotherapy for HNC induced significant changes in the pulp response with moderate quality of evidence. Such altered responses cannot determine pulp status accurately.

Amino Acids May Have Protective Effects on Salivary Glands of 5-FU-administered Mice

BACKGROUND/AIM

This study aimed to identify the most useful components of Elental^® in the treatment of 5-fluorouracil (FU)-induced mucositis and salivary gland atrophy in mice.

MATERIALS AND METHODS

Mice (except the control group) were intraperitoneally injected with 5-FU. The mice received saline (control group and 5-FU group), dextrin (Dextrin group), amino acids (17AA group), or Elental^® (Elental^® group).

RESULTS

The volume and weight of salivary glands was higher in 17AA and Elental^® groups compared to 5-FU group. The number of mucous glands was higher, whereas the number of damaged granular ductal epithelial cells was lower in the salivary glands of all groups except the 5-FU group. Salivation was also decreased in the 5-FU group compared to the other groups.

CONCLUSION

Amino acids could be the most effective components of Elental^® for protecting mouse salivary glands from 5-FU-induced atrophic changes, and might be useful in the treatment of oral mucositis in cancer patients.

Efficacy of the pretreatment geriatric nutritional risk index for predicting severe adverse events in patients with head and neck cancer treated with chemoradiotherapy: Efficacy of the pretreatment Geriatric Nutritional Risk Index for predicting severe adverse events

OBJECTIVE

The Geriatric Nutritional Risk Index (GNRI) is a simple and well-established nutritional assessment tool. Although concurrent chemoradiotherapy (CCRT), particularly cisplatin-based CCRT, is a standard treatment for locoregional advanced head and neck squamous cell carcinoma (HNSCC), the predictive factors of adverse events related to CCRT remain to be elucidated. The present study aimed to determine the association between GNRI and CCRT-related adverse events in patients of all ages with head and neck cancer (HNC) who underwent CCRT.

METHODS

We retrospectively analyzed and compared the clinical characteristics and adverse events of 82 patients with HNC treated with CCRT according to their GNRI at the Department of Otolaryngology, Head and Neck Surgery, University of Tsukuba Hospital, between May 2014 and November 2019. The GNRI was calculated according to the equation: 1.489 × serum albumin (g/L) + 41.7 × (body weight/ideal body weight). We compared two groups: low GNRI (GNRI < 98) and normal GNRI (GNRI ≥ 98) groups.

RESULTS

Eighty-two patients were enrolled in this study. There were 61 (76%) and 21 (26%) patients in the normal GNRI group and low GNRI group, respectively. There were significant differences in the incidence of grade ≥ 3 radiation mucositis, radiation dermatitis, and leukopenia between the low GNRI group and the normal GNRI groups.

CONCLUSIONS

Patients with low GNRI scores were more likely to have severe adverse events. Pretreatment GNRI predicted severe CCRT-related adverse events in patients of all ages with HNC undergoing CCRT.

Clinical Outcome in Children with Chemotherapy-Induced Mucositis

OBJECTIVES

This study was conducted to assess the impact of oral mucositis on nutrition and performance status in pediatric cancer patients treated by chemotherapy.

DATA SOURCES

A total of 46 children were followed for mucositis episode, and their mean Oral Assessment Guide score was 20.2. Main concomitant disorders were hematological changes (86.9%), loss of appetite (60.7%), vomiting (28.3%), and diarrhea (10.9%).

CONCLUSION

Anthropometric changes were highlighted by a decrease in body mass index (P = .03) and a decrease of Waterlow score (P = .007). Most patients had a low Lansky Play Performance Scale (LPPS) ≤40 (86.9%). High mucositis grades (P = .007) and long hospital stay (P = .005) were associated with a significant reduction in Lansky Play Performance Scale. Patient's follow-up showed need for hospitalization (84.8%), delay in chemotherapy treatment (71.7%), use of opioides (34.8%), and use of parenteral nutrition (26.1%). Death occurred in 10.9% of the cases.

IMPLICATIONS FOR NURSING PRACTICE

These findings illustrate the impact of mucositis on nutrition and performance status in children undergoing chemotherapy, which considerable affected their outcome.

Assessment and prevalence of concomitant chemo-radiotherapy-induced oral mucositis in patients with oral squamous cell carcinoma

BACKGROUND/AIM

Quantification of oral mucositis that progresses during concomitant chemo-radiotherapy (CCRT) is essential for its management. It is important to determine the methods that are simple, reliable and beneficial in foreseeing mucositis at earlier stages of treatment.

MATERIALS AND METHODS

A prospective study was conducted on 100 oral cancer patients receiving CCRT following the inclusion criteria. Patients were evaluated for mucositis i.e. erythema and ulcers by using the World Health Organization (WHO) scale and the oral mucositis assessment scale (OMAS), whereas mature and immature cells were identified by exfoliative cytology. Clinical examination and procedure of oral cavity were performed before, on days 5, 17, and at the end of treatment.

RESULTS

Oral mucositis was observed in all oral squamous cell carcinoma (OSCC) patients receiving CCRT on different days with noteworthy increase from day 5 of CCRT to the end of treatment. For OMAS grading related to ulceration and erythema, Grade 1 (7.2%; 34%) was most commonly seen on the 5th day of CCRT, Grade 2 (29%; 19%) and Grade 3 (19%) were most frequently seen at the 17th day and end of CCRT, accordingly. With respect to WHO scale grades 1 and 2 (18.3%; 21.5%) was most frequently observed at the 17th day of CCRT, whereas grades 3 and 4 (12.5%; 2%) was noted at the end of CCRT. There was statistically significant increase in the percentage of immature cells at the end of CCRT (99%). A significant association (P < 0.0000) was observed among the days of smear and maturation stages of epithelial cells as well as among WHO mucositis grading, OMAS and types of epithelial cells, respectively.

CONCLUSION

According to the findings of the study, oral mucositis grade is directly proportional to the progressing days of CCRT. Oral mucositis is frequently related to adverse clinical outcomes, affecting the patient’s quality of life. It is essential to develop methods that can be employed for the assessment of CCRT associated oral mucositis.

Randomized study of prevention of gastrointestinal toxicities by nutritional support using an amino acid-rich elemental diet during chemotherapy in patients with esophageal cancer (KDOG 1101)

BACKGROUND

This randomized study was designed to evaluate the clinical effect of an elemental diet during chemotherapy in patients with esophageal cancer.

METHODS

The inclusion criteria were as follows: (1) esophageal squamous cell carcinoma, (2) stage IB-IV, (3) schedule to receive docetaxel, cisplatin, and 5-fluorouracil (DCF chemotherapy), (4) 20-80 years old, (5) performance status of 0-2, (6) oral intake ability, and (7) written informed consent. Patients were divided into two groups: the elemental supplementary group and the non-supplementary group. Patients received ELENTAL^® (160 g/day) orally 9 weeks after the start of chemotherapy. Primary endpoint was the incidence of grade 2 or higher gastrointestinal toxicity according to the Common Terminology Criteria for Adverse Events, version 4.0. Secondary endpoints were the incidence of all adverse events and the evaluation of nutritional status.

RESULTS

Thirty-six patients in the elemental supplementary group and 35 patients in the non-supplementary group were included in the analysis. The incidence of grade 2 or higher gastrointestinal toxicity and all grade 3 or 4 adverse events did not differ significantly between the groups. In the elemental supplementary group, the body weight (p = 0.057), muscle mass (p = 0.056), and blood levels of transferrin (p = 0.009), total amino acids (p = 0.019), and essential amino acids (p = 0.006) tended to be maintained after chemotherapy.

CONCLUSION

Nutritional support provided by an amino acid-rich elemental diet was ineffective for reducing the incidence of adverse events caused by DCF chemotherapy in patients with esophageal cancer.

Radiation-Induced Oral Mucositis in Head and Neck Cancer Patients. Five Years Literature Review

Backround: Radiation-induced oral mucositis consists of a series of relatively frequent side effects after head and neck cancer radiotherapy and has an adverse impact on both regular treatment process and the quality of life of patients.

OBJECTIVE

The purpose of the present review is to optimize the current management of radiation-induced oral mucositis in head and neck cancer patients.

METHODS

PubMed database research was performed on articles published since 2015 that demonstrated efficacy in the management of radiation-induced oral mucositis in head and neck cancer patients. The study selection included observational, prospective, comparative, randomized, double- blind, placebo-controlled or uncontrolled, and retrospective studies, as well as systematic reviews and metanalyses.

RESULTS

From the 931 citations obtained from the search, only 94 articles met the inclusion criteria, including mucosal protectants, anti-inflammatory agents, growth factors, and various miscellaneous and natural agents. Several methods, including both pharmacological and natural agents, have been proposed for the management of oral mucositis. In addition to the already known interventions with strong evidence, according to the Multinational Association of Supportive Care in Cancer and he International Society of Oral Oncology guidelines, further agents have been used. However, a great number of them lack clear evidence, which surely requires the design of more controlled clinical trials for a better assessment of the ideal methods.

CONCLUSION

The management of oral mucositis constitutes an active area of research. In light of these results, it is aimed to illustrate those treatment strategies that are most effective regarding the treatment approach of oral mucositis.

Elemental diet directly affects chemotherapy-induced dermatitis and raw wound areas

Elental^® is an L-glutamine-rich elemental diet (ED) that has been widely used in Japan as a nutritional supplement for malnourished patients. In addition, Elental^® has been successfully used in the management of chemotherapy-induced mucositis in cancer patients. Recently, it was also reported that Elental^® can effectively reduce chemotherapy-induced oral mucositis in patients with oral squamous cell carcinoma, and can also reduce mucositis and dermatitis in animal models. However, it is unclear whether oral intake or topical application of Elental^® can act directly on chemotherapy-induced oral mucositis or dermatitis. The aim of the present study was to investigate the possible direct healing effect of Elental^® on chemotherapy-induced dermatitis and raw wound areas in a mouse model. Dermatitis and raw wounds were induced in nude mice by administration of 5-fluorouracil (5-FU) (via gastric tube) and mechanical injury (using a metal brush or a surgical knife). We then compared the outcome following oral or topical application of Elental^® in these mice. The effect of Elental^® on the growth and migration ability of the human oral keratinocyte cell line, HOK, was also examined using MTT and migration assays, respectively. In the mouse model, both oral administration and topical application of Elental^® reduced 5-FU-induced dermatitis and healed raw wound areas more effectively compared with the topical application of saline. The MTT assay revealed that Elental^® exerted a growth-promoting effect on HOKs. In addition, Elental^® enhanced the ability of HOKs to migrate, as demonstrated by the migration assay. These findings demonstrated that the topical application as well as the oral intake of Elental^® exerted a direct healing effect on chemotherapy-induced dermatitis or raw wound areas. The data also indicated that oral intake of an ED may exert a direct healing effect on chemotherapy-induced oral mucositis.

Clinical and Nutritional Effectiveness of a Nutritional Protocol with Oligomeric Enteral Nutrition in Patients with Oncology Treatment-Related Diarrhea

(1) Background: Poor nutritional status and diarrhea are common complications in cancer patients. (2) Methods: This multicenter, observational, prospective study evaluated the effectiveness of an oligomeric enteral nutrition (OEN) protocol in the improvement of nutritional status and reduction of diarrhea symptoms. Nutritional status was assessed with the Subjective Global Assessment (SGA), Body Mass Index (BMI) and albumin levels. Diarrhea was evaluated by the frequency and consistency of stools (Bristol Stool form scale). (3) Results: After 8 weeks of OEN protocol, the nutritional status improved in 48.3% of patients, with an increased proportion of patients at risk of malnourishment (+27.3%) at the expense of a decrease of moderately (−19.9%) and severely (−7.3%) malnourished patients (p < 0.001). Serum albumin and BMI significantly increased after 8 weeks of OEN treatment (p < 0.005). OEN showed a 71.1% effectiveness in the improvement of stool consistency. The mean number of stools per day significantly decreased from baseline (4.17 stools/day) to week 8 (1.42 stools/day; p = 0.0041). The nutritional status significantly improved even in those patients with persistent diarrhea. (4) Conclusion: The proposed OEN protocol seemed to be effective in improving the nutritional status, frequency and consistency of stools in patients with oncology treatment-related diarrhea even in persistent cases.

Risk factors for aspiration pneumonia during concurrent chemoradiotherapy or bio-radiotherapy for head and neck cancer

Background

Aspiration pneumonia is one of the most important side effects of chemoradiotherapy (CRT) and bio-radiotherapy (BRT) in patients with head and neck cancer (HNC). Aspiration pneumonia can lead to cancer-related mortality in HNC patients. However, the relationship between aspiration pneumonia occurring during CRT or BRT for HNC and treatment outcomes in HNC patients is not well characterized. In this study, we assessed the influence of aspiration pneumonia on treatment outcomes and sought to identify the clinical risk factors for aspiration pneumonia during definitive CRT and BRT in HNC patients.

Methods

We retrospectively assessed the data pertaining to patients with locally advanced HNC who received definitive CRT or BRT at the Shizuoka Cancer Center between August 2006 and December 2016.

Results

Among the 374 HNC patients who received CRT or BRT, 95 (25.4%) developed aspiration pneumonia during treatment. Aspiration pneumonia was significantly associated with therapeutic response to CRT or BRT (multivariate adjusted odds ratio for complete response, 0.52, p = 0.020) and poor overall survival (multivariate adjusted hazard ratio for overall survival, 1.58, p = 0.024). The multivariate analyses identified four independent factors for aspiration pneumonia: poor oral hygiene, high N-classification, hypoalbuminemia before treatment, and inpatient treatment.

Conclusions

Aspiration pneumonia occurring during CRT or BRT has a detrimental effect on the therapeutic response and survival of HNC patients. Careful attention should be paid to these risk factors for aspiration pneumonia in HNC patients undergoing CRT or BRT.

Oligomeric Enteral Nutrition in Undernutrition, due to Oncology Treatment-Related Diarrhea. Systematic Review and Proposal of An Algorithm of Action

Oncology treatment-related diarrhea and malnutrition appear together in oncological patients because of the disease itself, or the treatments that are administered for it. Therefore it is essential to carry out a nutritional treatment. Enteral nutrition formulas, containing peptides and medium chain triglycerides, can facilitate absorption in cases of malabsorption. There are few references to the use of enteral nutrition in the clinical society guidelines of patient management with oncology treatment-related diarrhea (OTRD). A bibliographic review of the studies with oligomeric enteral nutrition in OTRD found only nine studies with chemotherapy (all with the same oligomeric formula in which oral mucositis improves, while the rest of the outcomes show different results), and eight studies with radiotherapy (with different products and very heterogeneous results). We hereby present our action algorithm to supplement the diet of OTRD patients with an oligomeric enteral nutrition formula. The first step is the nutritional assessment, followed by the assessment of the functional capacity of the patient’s intestine. With these two aspects evaluated, the therapeutic possibilities available vary in degrees of complexity: These will range from the usual dietary recommendations, to supplementation with oral oligomeric enteral nutrition, along with complete enteral nutrition with oligomeric formula, and up to potentially total parenteral nutrition.

Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements

PURPOSE

To update the clinical practice guidelines for the use of natural and miscellaneous agents for the prevention and/or treatment of oral mucositis (OM).

METHODS

A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer / International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible.

RESULTS

A total of 78 papers were identified within the scope of this section, out of which 29 were included in this part, and were analyzed with 27 previously reviewed studies. A new Suggestion was made for oral glutamine for the prevention of OM in head and neck (H&N) cancer patients receiving radiotherapy with concomitant chemotherapy. The previous Recommendation against the use of parenteral glutamine for the prevention of OM in hematopoietic stem cell transplantation (HSCT) patients was re-established. A previous Suggestion for zinc to prevent OM in H&N cancer patients treated with radiotherapy or chemo-radiotherapy was reversed to No Guideline Possible. No guideline was possible for other interventions.

CONCLUSIONS

Of the vitamins, minerals, and nutritional supplements studied for the management of OM, the evidence supports a Recommendation against parenteral glutamine in HSCT patients and a Suggestion in favor of oral glutamine in H&N cancer patients for the management of OM.

Effect of Early Nutrition Intervention on Advanced Nasopharyngeal Carcinoma Patients Receiving Chemoradiotherapy

Background: Patients with nasopharyngeal carcinoma (NPC) frequently developed the problem of malnutrition at the time of diagnosis. Chemoradiotherapy (CRT) can even worsen the situation. Therefore, nutritional intervention should be applied to prevent CRT-associated weight loss and interruption of CRT. However, it is still controversial if early nutritional intervention is beneficial to NPC patients with CRT. This study is to investigate the influence of early nutritional intervention on advanced NPC patients with CRT by evaluating the nutritional status and CRT treatment tolerance. Methods: A cohort of 78 stage III-IV nasopharyngeal carcinoma patients was divided into early (n=46) and late (n=32) nutrition intervention groups. The early group of patients received nutritional support at the beginning of CRT, whereas the late group received such a support until development of the side effects, like 50% required oral dietary intake or >10% weight loss. The data were collected and statistically analyzed. Results: There was no significant difference in baseline clinical characteristics between these two groups, suggesting that no selection bias occurred. Both groups of patients had weight loss at the end of CRT and 3 months thereafter. However, at the later time point, the early group started to regain their weight, while the late group continued to lose weight. At both time points, the early group had a lower percentage of weight loss than the late group. Similar results were also obtained for BMI, albumin, and pre-albumin levels (All p<0.05). Besides, the early group showed a lower rate of advanced mucositis, a lower percentage of patients with more than 3 days RT breaks, fewer days of RT delayed for toxicity, and a lower percentage of patients with unplanned hospitalizations (All p<0.05). A linear correlation was also found between the percentage of weight loss and the number of days of RT delayed. Conclusion: Early nutritional intervention provides beneficial outcomes to NPC patients by maintaining their nutritional status and enhancing CRT treatment tolerance. Our results also indicated early nutrition intervention may reduce the hospital cost and improve patients' life quality.

Radiation-induced Oral Mucositis in Brazilian Patients: Prevalence and Associated Factors

Aim: To determine the prevalence of radiation-induced oral mucositis (OM) and associated factors.

PATIENTS AND METHODS

A cross-sectional retrospective study was performed at a reference dental care center. The medical records of patients submitted to radiotherapy for the treatment of head and neck cancer were used to collect clinical and demographic variables. The data were submitted to descriptive analysis and multivariate Poisson regression with robust variance [p<0.05; 95% confidence intervaI (CI)].

RESULTS

Four hundred and thirteen patients were analyzed. The mean age was 55±14 years. The prevalence of OM in the overall sample was 41.9% and was higher among males (78.2%). The following variables were significantly associated with the outcome: radiation dose [prevalence ratio (PR)= 1.04; 95% CI=1.02-1.06]; concomitant chemotherapy (PR=1.48, 95% CI=1.05-2.08); oral candidiasis (PR=1.97, 95% CI=1.44-2.68); and osteoradionecrosis (PR=1.51, 95% CI=1.10-2.06).

CONCLUSION

Radiation-induced OM was associated with radiation dose, concomitant chemotherapy, oral candidiasis and osteoradionecrosis. The rate of OM underscores the importance of adequate oral care prior to treatment for head and neck cancer.

The Elental® elemental diet for chemoradiotherapy-induced oral mucositis: A prospective study in patients with oral squamous cell carcinoma

Oral mucositis is a common adverse effect of cancer treatment that can increase the risk for local and systemic infection. This prospective study was designed to evaluate the preventive effects of an amino-acid-rich elemental diet (ED), Elental^®, on radiotherapy- or chemoradiotherapy-induced mucositis in oral squamous cell carcinoma (OSCC) patients. Fifty patients were enrolled in this prospective study, who had received radiation (60-70 Gy) with/without chemotherapy [S-1, UFT, cisplatin (CDDP), docetaxel (DOC) plus CDDP, or Cetuximab]. The Elental^® group (25 patients) had received Elental^® during treatment, and the control group (25 patients) had not. Multivariate logistic regression analysis was used to identify the factors related to abatement of oral mucositis. A comparison of the rates of completion of chemoradiation treatments as well as the nutritional or inflammatory status between Elental^® and control groups was performed. Multivariate analysis indicated that most of the patients who received Elental^® suffered from a lower degree of mucositis and showed significantly improved rate of completion of chemoradiation (no interruption) compared to the control group. There was a significant difference between the Elental^® group and the control group in terms of the mean change of C-reactive protein (CRP) levels in blood serum; however, there was no significant difference in terms of a mean change of body weight and total protein level in blood serum before and after chemoradiation. Our study shows that the Elental^® elemental diet could be useful for the treatment of oral mucositis induced by chemoradiation. Elental^® might also promote improved completion rates of chemoradiotherapy in OSCC patients.

Effectiveness of a comprehensive oral management protocol for the prevention of severe oral mucositis in patients receiving radiotherapy with or without chemotherapy for oral cancer: a multicentre, phase II, randomized controlled trial

The aim of this phase II, multicentre, randomized controlled trial was to evaluate the effectiveness of a comprehensive oral management protocol for the prevention of severe oral mucositis in patients with oral cancer receiving radiotherapy alone or chemoradiotherapy. In total, 124 patients with oral cancer were enrolled from five institutions. Of these, 37 patients undergoing radiotherapy were randomly divided into an intervention group (n=18) and a control group (n=19). The remaining 87 patients, who were undergoing chemoradiotherapy, were also randomized into an intervention group (n=42) and a control group (n=45). During radiotherapy, patients in the control group received only oral care, while those in the intervention group additionally received spacers to cover the entire dentition, pilocarpine hydrochloride, and topical dexamethasone ointment for oral mucositis. The primary endpoint was the incidence of severe oral mucositis. The intervention was significantly associated with a decreased incidence of severe oral mucositis in patients receiving radiotherapy alone (P=0.046), but not in those receiving chemoradiotherapy (P=0.815). These findings suggest that an oral management protocol can prevent severe oral mucositis in patients with oral cancer undergoing radiotherapy without concurrent chemotherapy.

Adjunctive Treatments for the Prevention of Chemotherapy- and Radiotherapy-Induced Mucositis

Background: Chemoradiotherapy-associated mucositis can manifest as pain, inflammation, dysphagia, diarrhea, weight loss, rectal bleeding, and infection. Mucositis is a major dose-limiting side effect of chemotherapy, affecting nutritional intake and oral and intestinal function. Despite several interventions being available, there is a need for safe and effective preventative and treatment options for treatment-induced mucositis. The goals of this review are to discuss interventions based on foods and natural products and present the research to date. Methods: A narrative literature review identified 60 clinical studies examining various nutritional compounds and 20 examining probiotics. 9 studies on probiotics for the prevention of diarrhea were also assessed on methodological quality and limitations identified. Results: Several compounds have been posited as useful adjuvants for cancer treatment–related mucositis. Probiotics demonstrate efficacy for the prevention and treatment of chemoradiotherapy-induced gastrointestinal toxicity without significant side effects. Glutamine and activated charcoal were reported to reduce chemotherapy-induced diarrhea but not radiation-induced intestinal mucositis. Honey has been reported to decrease treatment interruptions, weight loss, and delays the onset of oral mucositis. Zinc, glutamine, and topical vitamin E were demonstrated efficacy for oral mucositis. Conclusion: There is plausible clinical evidence for the administration of several adjunctive treatments for the prevention and treatment of mucositis. Probiotics were reported to reduce the burden of intestinal mucositis and treatment-induced diarrhea. Activated charcoal and glutamine are beneficial for chemotherapy-induced diarrhea, whereas the administration of honey, zinc, and glutamine reduce the risk of developing oral mucositis during chemotherapy or radiotherapy.

Peroxisome proliferator activated receptor-gamma stimulation for prevention of 5-fluorouracil-induced oral mucositis in mice

BACKGROUND

Oral mucositis is a side effect of treatment regimens containing 5-fluorouracil (5-FU). The purpose of this study was to present our evaluation to see if rosiglitazone (RGZ) protected normal tissues from chemotherapy-induced oral mucositis.

METHODS

C57BL/6J mice were treated with 5-FU for 5 days, with or without RGZ. Mice were euthanized after 5, 8, 11, or 15 days, and mucosal segments were collected.

RESULTS

The RGZ did not affect the 5-FU-induced decrease in mouse body weight. The 5-FU caused loss of epithelial architecture, collagen fiber impairment, and inflammatory infiltration. The RGZ reduced leukocyte infiltration, preserved tissue structure, and dampened the 5-FU-induced expression of p53 and matrix metalloproteinase (Mmp)-2 after 5 days, and of Mmp-2 and interleukin (Il-1β after 15 days. The RGZ inhibited the 5-FU-induced increase of transforming growth factor-beta (TGF-β) and nuclear factor-kappa B (NF-κB) proteins and restored collagen protein levels.

CONCLUSION

The RGZ had a protective effect on oral mucosa damaged by chemotherapy. These data encourage the further study of RGZ for the prevention of 5-FU-induced mucositis in patients with cancer.

Elemental Diet Accelerates the Recovery From Oral Mucositis and Dermatitis Induced by 5-Fluorouracil Through the Induction of Fibroblast Growth Factor 2

Mucositis and dermatitis induced by anticancer agents are common complications of anticancer therapies. In this study, we evaluated the efficacy of Elental (Ajinomoto Pharmaceutical Ltd, Tokyo, Japan), an elemental diet with glutamine in the treatment of 5-fluorouracil (5-FU)-induced oral mucositis and dermatitis in vivo and tried to clarify the underlying mechanisms of its action. Oral mucositis and dermatitis was induced through a combination of 5-FU treatment and mild abrasion of the cheek pouch in hamsters and the dorsal skin in nude mice respectively. These animals received saline, dextrin or Elental suspension (18 kcal/100 g) by a gastric tube daily until sacrifice. Elental reduced oral mucositis and dermatitis more effectively than dextrin in the animal model. Moreover, growth facilitating effects of Elental on HaCaT cells were examined in vitro. MTT assay, wound healing assay, and migration assay revealed that Elental could enhance the growth, invasion, and migration ability of HaCaT. ELISA and Western blotting showed upregulated FGF2 in Elental-treated HaCaT. These findings suggest that Elental is effective for the treatment of mucositis and dermatitis, and may accelerate mucosal and skin recovery through FGF2 induction and reepithelization.

Double-blind randomized study of oral glutamine on the management of radio/chemotherapy-induced mucositis and dermatitis in head and neck cancer

This randomized clinical trial was designed to determine whether glutamine administration was effective in reducing the incidence and severity of mucositis and dermatitis induced by radiotherapy (RT) or chemoradiotherapy (CHRT) in patients with head and neck cancer (HNC). Fifty patients were randomized to receive orally either L-Glutamine or placebo (25 patients in each arm). In the glutamine-treated group, 10 g of oral glutamine was administered three times daily. The primary endpoint was to compare the appearance of clinical mucositis between groups at the 6th week, according to the Common Terminology Criteria for Adverse Events. Secondary endpoints were: Functional mucositis, mucositis onset, cervicofacial dermatitis, pain, weight loss and assessment of quality of life (according to the M.D. Anderson Symptom Inventory-Head and Neck). In total, 76 and 87.5% developed clinical mucositis in the glutamine and placebo group, respectively. The incidence and severity grade of mucositis at the 6th week did not exhibit statistically significantly differences between the two groups, although it had a higher value in the placebo group. Significant reduction of dermatitis incidence (P=0.038) and severity (P=0.032) was found in the glutamine group. There were no differences in other outcomes such as pain, weight loss and mucositis onset, in treatment parameters including concomitant chemotherapy, radiation dose and previous surgery, or in quality of life. The present study revealed that glutamine provided slight clinical effects compared with placebo in terms of reducing oral mucositis induced by RT or CHRT in patients with HNC at the 6th week; however, the results were not statistically significant. Although the findings suggested a significant benefit in reducing the incidence and severity of dermatitis, further confirmatory studies are required.

A PPAR gamma agonist protects against oral mucositis induced by irradiation in a murine model

BACKGROUND

Due to its anti-inflammatory, antifibrotic and antineoplastic properties, the PPAR gamma agonist rosiglitazone is of interest in prevention and therapy of radiation-induced toxicities. We aimed to evaluate the radioprotective effect of rosiglitazone in a mouse model of radiation-induced oral mucositis.

MATERIAL AND METHODS

Oral mucositis was obtained by irradiation of the oral region of C57BL/6J mice, pretreated or not with rosiglitazone. Mucositis was assessed by macroscopic scoring, histology and molecular analysis. Tumor xenograft was obtained by s.c. injection of Hep-2 cells in CD1 mice. Tumor volume was measured twice a week to evaluate effect of rosiglitazone alone and combined with radiotherapy.

RESULTS

Irradiated mice showed typical features of oral mucositis, such as oedema and reddening, reaching the peak of damage after 12-15days. Rosiglitazone markedly reduced visible signs of mucositis and significantly reduced the peak. Histological analysis showed the presence of an inflammatory cell infiltrate after irradiation; the association with rosiglitazone noticeably reduced infiltration. Rosiglitazone significantly inhibited radiation-induced tnfα, Il-6 and Il-1β gene expression. Rosiglitazone controlled the increase of TGF-β and NF-kB p65 subunit proteins induced by irradiation, and enhanced the expression of catalase. Irradiation and rosiglitazone significantly reduced tumor volume as compared to control. Rosiglitazone did not protect tumor from the therapeutic effect of radiation.

CONCLUSION

Rosiglitazone exerted a protective action on normal tissues in radiation-induced mucositis. Moreover, it showed antineoplastic properties on head-neck carcinoma xenograft model and selective protection of normal tissues. Thus, PPAR gamma agonists should be further investigated as radioprotective agents in head and neck cancer.