Radiation-Induced Oral Mucositis

Efficacy of natural products in preventing oral mucositis resulting from cancer therapies: A network meta-analysis of randomized controlled trials

BACKGROUND

Oral mucositis significantly compromises the quality of life for patients undergoing cancer therapies. This study aimed to evaluate the effectiveness of natural products in either preventing or alleviating oral mucositis resulting from cancer treatments.

METHODS

A systematic review and network meta-analysis were conducted, sourcing data from the Cochrane Library, PubMed, Embase, Airiti Library, and Wan Fang Data Knowledge Service Platform until August 2023. The study was registered in PROSPERO (CRD42021285433). Confidence in Network Meta-Analysis (CINeMA) and R software 4.1.3 were used for analysis.

RESULTS

From 1556 identified articles, 36 randomized controlled trials (RCTs) were analyzed, involving 2083 patients. Honey, notably, was found to significantly reduce the overall incidence of oral mucositis compared to standard care, with a relative risk (RR) of 0.80 (95% CI: 0.67-0.96). It was particularly effective against moderate-to-severe oral mucositis (grade ≥ 2), reducing incidence with RR of 0.48 (95% CI: 0.30-0.75) versus placebo and 0.56 (95% CI: 0.34-0.93) against standard care. Other natural products, including propolis, chamomile, and P. major L., also demonstrated significant efficacy in reducing the incidence of oral mucositis. Regarding pain relief, honey, and P. major L. emerged as effective, significantly reducing pain severity with a mean difference (MD) of -2.96 (95% CI: -3.80 to -1.94) compared to placebo.

CONCUSSION

This network meta-analysis supports the use of honey, propolis, chamomile, and P. major L. as effective natural products in the prevention and treatment of oral mucositis among cancer patients. Specifically, honey is highlighted for its significant impact on reducing both the overall incidence and the severity of moderate-to-severe oral mucositis. By leveraging their anti-inflammatory and antioxidant properties, integrating these natural products into the standard care regimen could markedly improve the well-being of individuals undergoing cancer therapy.

Marine algae-derived characterized bioactive compounds as therapy for cancer: A review on their classification, mechanism of action, and future perspectives

In 2022, there were around 20 million new cases and over 9.7 million cancer-related deaths worldwide. An increasing number of metabolites with anticancer activity in algae had been isolated and identified, which were promising candidates for cancer therapy. Red algae are well-known for the production of brominated metabolites, including terpenoids and phenols, which have the capacity to induce cell toxicity. Some non-toxic biological macromolecules, including polysaccharides, are distinct secondary metabolites found in many algae, particularly green algae. They possess anticancer activities by inhibiting tumor angiogenesis, stimulating the immune response, and inducing apoptosis. However, the structure-activity relationship between these components and antitumor activity, as well as certain taxa within the algae, remains relatively unstudied. This work is based on the reports published from 2003 to 2024 in PubMed and ISI Web of Science databases. A comprehensive review of the characterized algal anticancer active compounds, together with their structure and mechanism of action was performed. Also, their structure-activity relationship was preliminarily summarized to better assess their potential properties as a natural, safe bioactive product to be used as an alternative for the treatment of cancers, leading to new opportunities for drug discovery.

Proton FLASH Radiotherapy Ameliorates Radiation-induced Salivary Gland Dysfunction and Oral Mucositis and Increases Survival in a Mouse Model of Head and Neck Cancer

Head and neck cancer radiotherapy often damages salivary glands and oral mucosa, severely negatively impacting patients' quality of life. The ability of FLASH proton radiotherapy (F-PRT) to decrease normal tissue toxicity while maintaining tumor control compared with standard proton radiotherapy (S-PRT) has been previously demonstrated for several tissues. However, its potential in ameliorating radiation-induced salivary gland dysfunction and oral mucositis and controlling orthotopic head and neck tumor growth has not been reported. The head and neck area of C57BL/6 mice was irradiated with a single dose of radiotherapy (ranging from 14-18 Gy) or a fractionated dose of 8 Gy × 3 of F-PRT (128 Gy/second) or S-PRT (0.95 Gy/second). Following irradiation, the mice were studied for radiation-induced xerostomia by measuring their salivary flow. Oral mucositis was analyzed by histopathologic examination. To determine the ability of F-PRT to control orthotopic head and neck tumors, tongue tumors were generated in the mice and then irradiated with either F-PRT or S-PRT. Mice treated with either a single dose or fractionated dose of F-PRT showed significantly improved survival than those irradiated with S-PRT. F-PRT-treated mice showed improvement in their salivary flow. S-PRT-irradiated mice demonstrated increased fibrosis in their tongue epithelium. F-PRT significantly increased the overall survival of the mice with orthotopic tumors compared with the S-PRT-treated mice. The demonstration that F-PRT decreases radiation-induced normal tissue toxicity without compromising tumor control, suggests that this modality could be useful for the clinical management of patients with head and neck cancer.

Clinical and biochemical assessment of the effect of glutamine in management of radiation induced oral mucositis in patients with head and neck cancer: Randomized controlled clinical trial

BACKGROUND

This study aimed to evaluate the effect of oral glutamine suspension on salivary levels of transforming growth factor beta 1 (TGF-β1), a cytokine involved in inflammation and Tumor progression, and the severity of radiation-induced oral mucositis (RIOM) in head and neck cancer patients. This is the first study to investigate the impact of glutamine on TGF-β1 levels in head and neck cancer patients with radiation induced oral mucositis (RIOM).

METHODS

In this randomized controlled clinical trial, 50 HNC patients were enrolled and received either glutamine oral suspension or maltodextrin as a placebo from the baseline of RIOM to the end of radiotherapy. Salivary TGF-β1 levels were measured at baseline and after treatment. Also, RIOM was assessed using the World Health Organization (WHO) Oral Toxicity Scale, the Oral Mucositis Assessment Scale (OMAS), the Pain Visual Analog Scale (Pain-VAS), the incidence of opioid use, and body mass index (BMI).

RESULTS

Glutamine significantly reduced salivary TGF-β1 levels and improved RIOM symptoms, such as pain, opioid use, and weight loss. The reduction of TGF-β1 levels was associated with the improvement of RIOM severity.

CONCLUSION

Glutamine may modulate the inflammatory response and enhance wound healing in RIOM by decreasing salivary TGF-β1 levels. These findings support the use of glutamine as a potential intervention for RIOM and nutritional support for improving radiation sensitivity.

TRIAL REGISTRATION

This study was registered on clinicalTrials.gov with identifier no. NCT05856188.

Recombinant Human Keratinocyte Growth Factor Ameliorates Cancer Treatment-Induced Oral Mucositis on a Chip

Oral mucositis (OM) is a severe complication of cancer therapies caused by off-target cytotoxicity. Palifermin, which is recombinant human keratinocyte growth factor (KGF), is currently the only mitigating treatment available to a subset of OM patients. This study used a previously established model of oral mucositis on a chip (OM-OC) comprised of a confluent human gingival keratinocytes (GIE) layer attached to a basement membrane-lined subepithelial layer consisting of human gingival fibroblasts (HGF) and human dermal microvascular endothelial cells (HMEC) on a stable collagen I gel. Cisplatin, radiation, and combined treatments are followed by a recovery period in the OM-OC to determine possible cellular and molecular mechanisms of OM under effects of KGF. Cancer treatments affected the keratinocyte layer, causing death and epithelial barrier loss. Both keratinocytes and subepithelial cells died rapidly, as evidenced by propidium iodide staining. In response to radiation exposure, cell death occurred in the apical epithelial layer, predominantly, within 24h. Cisplatin exposure predominantly promoted death of basal epithelial cells within 32-36h. Presence of KGF in OM-OC protected tissues from damage caused by cancer treatments in a dose-dependent manner, being more effective at 10 ng/mL. As verified by F-actin staining and the Alamar Blue assay, KGF contributed to epithelial survival and induced proliferation of GIE and HGF as well as HMEC within 120h. When the expression of eighty inflammatory cytokines is evaluated at OM induction (Day 12) and resolution (Day 18) stages in OM-OC, some cytokines are identified as potential novel therapeutic targets. In comparison with chemoradiation exposure, KGF treatment showed a trend to decrease IL-8 and TNF-a expression at Day 12 and 18, and TGF-β1 at Day 18 in OM-OC. Taken together, these findings support the utility of OM-OC as a platform to model epithelial damage and evaluate molecular mechanisms following OM treatment.

Efficacy of nonpharmacological interventions for severe radiation-induced oral mucositis among head and neck cancer patients: A network meta-analysis of randomised controlled trials

AIMS AND OBJECTIVES

To assess the effectiveness of different nonpharmacological treatments for severe radiation-induced oral mucositis in patients with head and neck cancer.

BACKGROUND

Radiation-induced oral mucositis is highly prevalent in patients with head and neck cancer. Current medications for radiation-induced oral mucositis are limited in effectiveness and susceptible to side effects, and while there is an increasing adoption of nonpharmacological interventions, the optimal one remains unclear.

DESIGN

Systematic review and network meta-analysis based on the PRISMA-NMA guidelines.

METHODS

Six databases were searched. Two authors independently performed the literature screening, data extraction and methodological quality assessment of the included studies. Traditional pairwise meta-analysis was performed by R Studio. A network meta-analysis was then conducted to assess the effects of nonpharmacological interventions for severe radiation-induced oral mucositis in patients with head and neck cancer.

RESULTS

Fifty-two studies involving seven types of nonpharmacological interventions were enrolled. The network meta-analysis indicated that natural plant-based therapies might be the most effective, health education interventions might be the second most effective, and honey might be the third most effective interventions for reducing the incidence of severe radiation-induced oral mucositis. For reducing the incidence of severe oral mucositis-related pain, the pairwise meta-analysis showed that only natural plant-based therapies and health education interventions were effective.

CONCLUSIONS

Nonpharmacological interventions are effective in the management of severe radiation-induced oral mucositis among patients with head and neck cancer.

RELEVANCE TO CLINICAL PRACTICE

Nonpharmacological interventions are a category of safe and effective adjunctive therapies that should be encouraged in clinical practice.

TRIAL REGISTRATION DETAILS

CRD42023400745.

Analysis of the association between salivary proteins and oral mucositis in patients with head and neck cancer undergoing IMRT: a longitudinal study

INTRODUCTION

This longitudinal study assessed the association between salivary protein composition and the clinical onset/severity of oral mucositis (OM) in patients with head and neck tumours treated with intensity-modulated-radiotherapy (IMRT).

METHODS

Saliva samples/clinical data were obtained from 40 head and neck cancer patients treated at Guy's Hospital before -IMRT(T0) and after-IMRT (T1 = 6 m, T2 = 12 m) (ethics approval/consent). Salivary flow rate, total protein concentration, and secretion rate were determined from saliva samples and compared with pre-treatment values. OM was assessed, total/specific salivary proteins, including mucin 5B and 7, IgA, cystatin-S, albumin, and α-amylase, were quantified.

RESULTS

95% patients experienced OM during IMRT, with 33 subjects reaching grade 2&3. At T1, there was a significant reduction in salivary flow rate, total protein secretion rate, α-amylase and cystatin-S compared to baseline. Remarkably IMRT did not significantly alter mucin 5B and 7, or the IgA secretion rate at any time point. At T1, all the analyzed proteins were associated with the OM outcomes. In addition, there was a significant inverse correlation between IgA concentration at T0 and the severity of OM during IMRT.

CONCLUSION

This study revealed significant associations between several salivary proteins and OM in patients with head and neck cancer undergoing IMRT. Further longitudinal studies are needed to confirm these results.

CLINICAL SIGNIFICANCE

The study contributes to the understanding of certain salivary proteins association with OM. This could be the first step towards identifying potential salivary markers that could offer perspectives for personalized medicine approaches to improve their quality of life (QoL).

RESEARCH QUESTION

What is the association between salivary proteins and the occurrence and severity of OM in head and neck cancer patients?

AIM

To assess the association between salivary protein composition with the clinical onset/severity of oral mucositis (OM) in head and neck cancer patients treated with intensity modulated radiotherapy.

NULL HYPOTHESIS

There is no association between salivary proteins and onset/severity of OM in HNC patients.

Systemic Anti-Inflammatory Agents in the Prevention of Chemoradiation-Induced Mucositis: A Review of Randomised Controlled Trials

Mucositis is a pathological condition characterised by inflammation and ulceration of the mucous membranes lining the alimentary canal, particularly in the mouth (oral mucositis) and the gastrointestinal tract. It is a common side effect of cancer treatments, including chemotherapy and radiotherapy, and it is sometimes responsible for treatment interruptions. Preventing mucositis throughout the alimentary tract is therefore crucial. However, current interventions mainly target either oral or gastrointestinal side effects. This review aimed to investigate the use of systemically administered anti-inflammatory agents to prevent mucositis in cancer patients undergoing cancer treatment. PubMed, Ovid, Scopus, Web of Science, WHO ICTRP and ClinicalTrials.gov were screened to identify eligible randomised controlled trials (RCTs). The published literature on anti-inflammatory agents provides mixed evidence regarding the degree of efficacy in preventing/reducing the severity of mucositis in most anticancer treatments; however, sample size continued to be a significant limitation, alongside others discussed. Our review yielded a list of several anti-inflammatory agents that exhibit potential mucositis-preventive effects in cancer patients undergoing cancer treatment, which can be used to inform clinical practice.

Prediction of severe radiation-induced oral mucositis in locally advanced nasopharyngeal carcinoma using the combined systemic immune-inflammatory index and prognostic nutritional index

OBJECTIVE

Severe radiation-induced oral mucositis (sRIOM) can seriously affect patients' quality of life and treatment compliance. This study was to investigate the utility of the systemic immune-inflammatory index (SII) and prognostic nutritional index (PNI) in predicting sRIOM in patients with locally advanced nasopharyngeal carcinoma (LANPC).

METHODS

295 patients with LANPC were retrospectively screened. The pre-radiotherapy SII and PNI were calculated based on peripheral blood samples. A receiver operating characteristic (ROC) curve was used to determine the cut-off value. Logistic regression was used for univariate and multivariate analyses. Patients were classified into three groups based on the SII-PNI score: score of 2, high SII (> cut-off value) and low PNI (≤ cut-off value); score of 1, either high SII or low PNI; score of 0, neither high SII nor low PNI.

RESULTS

The SII-PNI demonstrated significant predictive ability for sRIOM occurrence, as evidenced by an area under the curve (AUC) of 0.738. The incidence rates of sRIOM with SII-PNI score of 2, 1, and 0 were 73.86%, 44.35%, and 18.07%, respectively. Multivariate analysis confirmed that the SII-PNI score was an independent risk factor for sRIOM.

CONCLUSION

The SII-PNI score is a reliable and convenient indicator for predicting sRIOM in patients with LANPC.

Cell type-specific transforming growth factor-β (TGF-β) signaling in the regulation of salivary gland fibrosis and regeneration

Salivary gland damage and hypofunction result from various disorders, including autoimmune Sjögren's disease (SjD) and IgG4-related disease (IgG4-RD), as well as a side effect of radiotherapy for treating head and neck cancers. There are no therapeutic strategies to prevent the loss of salivary gland function in these disorders nor facilitate functional salivary gland regeneration. However, ongoing aquaporin-1 gene therapy trials to restore saliva flow show promise. To identify and develop novel therapeutic targets, we must better understand the cell-specific signaling processes involved in salivary gland regeneration. Transforming growth factor-β (TGF-β) signaling is essential to tissue fibrosis, a major endpoint in salivary gland degeneration, which develops in the salivary glands of patients with SjD, IgG4-RD, and radiation-induced damage. Though the deposition and remodeling of extracellular matrix proteins are essential to repair salivary gland damage, pathological fibrosis results in tissue hardening and chronic salivary gland dysfunction orchestrated by multiple cell types, including fibroblasts, myofibroblasts, endothelial cells, stromal cells, and lymphocytes, macrophages, and other immune cell populations. This review is focused on the role of TGF-β signaling in the development of salivary gland fibrosis and the potential for targeting TGF-β as a novel therapeutic approach to regenerate functional salivary glands. The studies presented highlight the divergent roles of TGF-β signaling in salivary gland development and dysfunction and illuminate specific cell populations in damaged or diseased salivary glands that mediate the effects of TGF-β. Overall, these studies strongly support the premise that blocking TGF-β signaling holds promise for the regeneration of functional salivary glands.

Streptococcus salivarius K12 Alleviates Oral Mucositis in Patients Undergoing Radiotherapy for Malignant Head and Neck Tumors: A Randomized Controlled Trial

PURPOSE

Oral mucositis (OM) is a common debilitating toxicity associated with radiotherapy (RT) for malignant head and neck tumors. This prospective, randomized, double-blind, placebo-controlled trial aimed to evaluate the efficacy and safety of Streptococcus salivarius K12 (SsK12) in reducing the incidence, duration, and severity of severe OM (SOM).

METHODS

A total of 160 patients with malignant head and neck tumors undergoing definitive or postoperative adjuvant RT were randomly assigned (1:1) to receive SsK12 probiotic (n = 80) or placebo (n = 80) at West China Hospital, Sichuan University, Chengdu, China. Patients were instructed to suck SsK12 or placebo lozenges thrice daily from the initiation to the end of RT. OM was evaluated twice a week during RT and once a week thereafter for up to 8 weeks. The primary end point was the incidence of SOM. Adverse events were assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0.

RESULTS

Baseline patient characteristics were similar in the SsK12 and placebo groups. The incidence of SOM was significantly lower in the SsK12 group as compared with the placebo group (36.6% v 54.2%; P = .0351). The duration (median, 0.0 days v 7.0 days; mean, 8.9 days v 18.3 days; P = .0084) and time to develop SOM (median, not estimable v 42.0 days; hazard ratio, 0.55 [95% CI, 0.34 to 0.89]; log-rank test: P = .0123) were also improved in the case of the SsK12 group. Adverse events were similar between the groups, and mild or moderate gastrointestinal reactions (flatulence or dyspepsia) associated with the lozenges were observed in two patients in the SsK12 group. High-throughput sequencing results indicated that SsK12 inhibited opportunistic pathogens and enriched oral commensals during RT.

CONCLUSION

In this prospective, randomized clinical trial, SsK12 probiotic significantly reduced the incidence, onset, and duration of SOM with a good safety profile.

Efficacy of photobiomodulation therapy in the management of oral mucositis in patients with head and neck cancer: A systematic review and meta-analysis of randomized controlled trials

Numerous studies have examined the effectiveness of photobiomodulation therapy (PBMT) in reducing chemoradiotherapy (CRT)-induced oral mucositis (OM) in patients with head and neck cancer (HNC). Despite this, there is an urgent need to update the meta-analyses on this topic. This meta-analysis aims to explore the impact of PBMT on CRT-induced OM in these patients. We conducted a systematic search in PubMed, Embase, Cochrane, LILACS, and Web of Science from January 2000 to October 2023. This search focused on randomized controlled trials (RCTs) that assessed the effects of PBMT on CRT-induced OM. The study included a total of 14 RCTs encompassing 869 patients with HNC. The incidence of OM in the PBMT group was significantly lower from the second week onwards compared to the control group (RR = 0.49, CI = 0.25-0.97, I2  = 71%, p = 0.04), and this was present until the seventh week (RR = 0.77, CI = 0.61-0.99, I2  = 89%, p = 0.04). Furthermore, the occurrence of severe mucositis in the PBMT group decreased from the third week (RR = 0.51, CI = 0.29-0.90, I2  = 12%, p = 0.02) until the conclusion of the intervention (RR = 0.45, CI = 0.24-0.85, I2  = 80%, p = 0.01). Additionally, PBMT showed beneficial effects in alleviating OM-related pain (WMD = -1.09, 95% CI = -1.38 to -0.880, I2  = 13%, p < 0.00001). The use of He-Ne or InGaAlP lasers with a power range of 10-25 mW demonstrated the most favorable outcomes in preventing and treating OM. PBMT has shown considerable efficacy in reducing the incidence, severity, and pain associated with OM in patients with HNC. Future studies are encouraged to further investigate the most effective parameters for PBMT in the management of OM.

Evidence summary on managing radiotherapy-induced oral mucositis in patients with head and neck cancer

Objective

To summarize the best evidence for managing radiotherapy-induced oral mucositis in patients with head and neck cancer, and improve the quality of care.

Methods

According to the "6S" evidence pyramid model, we searched local and other part of world published clinical guidelines, expert consensus, evidence summary, and systematic review. The literature quality assessment followed the Appraisal of Guidelines for Research and Evaluation (AGREE II). for guidelines, AMSTAR-2 for systematic reviews, and Joanna Briggs Institute (JBI) Evidence-Based Health Care Center's quality evaluation tool for expert opinions and expert consensus articles. The quality of other literature was evaluated according to the type of original literature. If there were any conflicts about the conclusions drawn from different sources of evidence, this study followed the principle of high-quality evidence priority and the latest published authoritative literature priority. The "JBI Evidence Pre-grading and Evidence Recommendation Level System 2014" was adopted for the evidence lacking a grading system. Quality evaluation, evidence extraction, and summary were performed by 2 or more researchers, combined with the advice of the head and neck cancer radiotherapy professionals.

Results

Finally, a total of ten pieces of literature were included. Twenty-two best evidence items for radiotherapy-induced oral mucositis management were summarized from six aspects, including multidisciplinary management, oral assessment, basic oral care, pain management, nutritional support, and application of honey or propolis.

Conclusions

This study provides clinical caregivers with the evidence-based measures on managing radiotherapy-induced oral mucositis. Clinical backgrounds, patients' condition, willingness, economy, and cost-effectiveness should be fully considered when promoting evidence transformation. Applying evidence-based approaches with high feasibility, strong appropriateness, clinical significance and high effectiveness could reduce the incidence of severe radiotherapy-induced oral mucositis in patients with head and neck cancer.

Systematic review registration

This study has been registered on the Fudan University Centre for Evidence-based Nursing. Registration No. is ES20232732.

INFRARED THERMAL IMAGING CONTROL OF RADIATION DERMATITIS DYNAMICS

BACKGROUND

Radiation-induced dermatitis impairs the quality of life of cancer patients and may lead to the need of interrupting radiotherapy. The grade of dermatitis is subjectively assessed by the visual examination. There is an urgent need for both objective and quantitative methods for assessing the current grade of dermatitis and predicting its severity at an early stage of radiotherapy.

AIM

The aim of the study was to evaluate the advantages and limitations of infrared thermography for monitoring the current level of radiation-induced dermatitis and predicting its severity by quantitative analysis of the thermal field dynamics in the irradiated zone.

MATERIALS AND METHODS

30 adult patients were examined by infrared thermography during the course of 2D conventional radiotherapy for malignant tumors of various types and localizations. Our approach for quantifying the thermal field caused by dermatitis alone was applied. A statistical (correlation and ROC) analysis was performed.

RESULTS

Dermatitis of varying severity was observed in 100% of the patients studied. The dynamics in the intensity of the anomalous thermal fields in the irradiated zone correlated with the dynamics of dermatitis grades, excluding the case of a radiosensitive tumor (correlation coefficient 0.74÷0.84). It was found that the maximum toxicity (dermatitis grade ≥ 3) develops in patients who how significant hyperthermia in the area of interest (≥ 0.7 °C) at an early stage of radiotherapy. The ROC analysis demonstrated the "good quality" of the prognosis method (AUC = 0.871).

CONCLUSIONS

The non-invasive and cheap infrared thermography is a suitable tool for objective quantitative monitoring the current dermatitis grade during radiotherapy as well as predicting its severity for any tumor location.

Unveiling the Multifaceted Management of Oral Mucositis in Cancer Patients: A Narrative Review

Oral mucositis (OM) is a major and common adverse reaction to cancer treatment, occurring in all patients who undergo radiation therapy or chemotherapy that includes the mucosal areas of the oral and oropharyngeal region. The pathophysiology of OM remains incompletely understood, and there are many unanswered questions about the risk factors for developing OM. Multidisciplinary clinicians and researchers must collaborate to better understand and expand treatment strategies for OM and other inflammatory conditions in oncology. This will lead to the development of more effective treatments and reduce the burden of OM in cancer patients. This article comprehensively reviews the risk factors and patient factors associated with OM, its pathogenesis, clinical presentation, grading, and management.

Predictive Factors for Critical Weight Loss in Saudi Head and Neck Cancer Patients Undergoing (Chemo)Radiotherapy

Weight loss is a significant health problem among patients with head and neck cancer (HNC) that is attributable primarily to the tumor or tumor therapy. Critical weight loss (CWL) is defined as the unintentional loss of ≥5% of weight. Therefore, this study's goal was to investigate and determine the possible factors influencing CWL among patients with HNC who have received radiotherapy or concurrent chemoradiotherapy (CCRT). We conducted a retrospective analysis of 175 patients who received radiotherapy or CCRT as either their primary, adjuvant, or combined treatment at the Oncology Center in King Abdullah Medical City. All patients were ≥18 years of age and diagnosed with HNC with no metastasis. The study results showed that 107 patients (61%) had CWL, while 68 (39%) did not. The following factors were significantly predictive of CWL with a multivariate regression analysis: pretreatment BMI (AOR = 1.1, 95% CI = 1.02-1.17), oral cavity cancer (AOR = 10.36, 95% CI = 1.13-94.55), and male sex (AOR = 3.15, 95% CI = 1.39-7.11). In conclusion, weight loss is highly prevalent among HNC patients during treatment. Accordingly, pretreatment BMI, cancer in the oral cavity, and being male can be considered predictive factors for CWL.

Nutritional Status and Incidence of Radiation-Induced Oral Mucositis in Nasopharyngeal Carcinoma Patients Treated with Chemoradiotherapy

Malnutrition is prevalent among patients with nasopharyngeal carcinoma undergoing radiotherapy. This study examined the nutritional status and incidence of radiation-induced oral mucositis (RIOM) in patients with nasopharyngeal carcinoma. A retrospective analysis was conducted to compare the incidence of RIOM, Nutritional Risk Screening (NRS) 2002 score, weight, body mass index (BMI), and hemoglobin levels in 338 patients treated with induction chemotherapy (IC) plus concurrent chemoradiotherapy (CCRT) or treated with CCRT alone. The IC + CCRT group exhibited an increase in weight and BMI but a decrease in hemoglobin levels after IC compared with baseline (p < 0.001). Both groups showed differences in weight at Week 0 and BMI at Weeks 0-2 of radiotherapy (p < 0.05). The IC + CCRT group experienced an increase in NRS 2002 scores from Week 2 to Week 6 (p < 0.05). The hemoglobin levels of the IC + CCRT group were consistently lower throughout radiotherapy (p < 0.001). However, no significant difference was observed in the incidence of RIOM between the two groups (p = 0.246). Patients treated with IC + CCRT exhibited a higher nutritional risk during radiotherapy. Although the incidence of Grade III RIOM was high, no significant difference was found between the groups.

Cryotherapy for oral mucositis in cancer: review of systematic reviews and meta-analysis

BACKGROUND

One of the most common side effects of cancer treatment is oral mucositis. Although studies have shown that oral cryotherapy has a favourable effect on oral mucositis, the reliability of the results is questionable.

OBJECTIVE

The goal of this umbrella review was to provide insight into the effects of oral cryotherapy against oral mucositis in patients with cancer, as well as to assess the certainty of this evidence.

METHOD

Studies were searched for through PubMed, Scopus and Web of Science, with no restrictions until August 2021. The risk ratio (RR) and 95% CI for each meta-analysis were recalculated using a random-effects model, and the certainty of the evidence was judged using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Ten meta-analyses including 25 original RCTs that fit our inclusion criteria were included. The use of oral cryotherapy markedly reduced the occurrence of overall (RR 0.72, 95% CI 0.64 to 0.83, n=20 trials), moderate to severe (RR 0.60, 95% CI 0.45 to 0.80, n=16 trials) and severe oral mucositis (RR 0.48, 95% CI 0.34 to 0.67, n=16 trials), as well as average severity score of oral mucositis (standardised mean difference=-0.94, 95% CI -1.28 to -0.59, n=4 trials) in comparison to a control group; however, the certainty of evidence for all outcomes was rated very low.

CONCLUSION

In patients with cancer, oral cryotherapy appears to greatly lower the severity and occurrence of oral mucositis, but, with very low certainty of evidence.

Management of radiation-induced oral mucositis in head and neck cancer patients: a real-life survey among 25 Italian radiation oncology centers

AIM

Radiation-induced oral mucositis (RIOM) is the most frequent side effect in head and neck cancer (HNC) patients treated with curative radiotherapy (RT). A standardized strategy for preventing and treating RIOM has not been defined. Aim of this study was to perform a real-life survey on RIOM management among Italian RT centers.

METHODS

A 40-question survey was administered to 25 radiation oncologists working in 25 different RT centers across Italy.

RESULTS

A total of 1554 HNC patients have been treated in the participating centers in 2021, the majority (median across the centers 91%) with curative intent. Median treatment time was 41 days, with a mean percentage of interruption due to toxicity of 14.5%. Eighty percent of responders provide written oral cavity hygiene recommendations. Regarding RIOM prevention, sodium bicarbonate mouthwashes, oral mucosa barrier agents, and hyaluronic acid-based mouthwashes were the most frequent topic agents used. Regarding RIOM treatment, 14 (56%) centers relied on literature evidence, while internal guidelines were available in 13 centers (44%). Grade (G)1 mucositis is mostly treated with sodium bicarbonate mouthwashes, oral mucosa barrier agents, and steroids, while hyaluronic acid-based agents, local anesthetics, and benzydamine were the most used in mucositis G2/G3. Steroids, painkillers, and anti-inflammatory drugs were the most frequent systemic agents used independently from the RIOM severity.

CONCLUSION

Great variety of strategies exist among Italian centers in RIOM management for HNC patients. Whether different strategies could impact patients' compliance and overall treatment time of the radiation course is still unclear and needs further investigation.

Wearing individualized 3D printed oral stent to protect normal tissues in patients with nasopharyngeal carcinoma during radiotherapy

PURPOSE

To demonstrate a new individualized 3D printed oral stent in radiotherapy of nasopharyngeal carcinoma (NPC) patients and carry out a comparative analysis combining with clinical case.

MATERIAL AND METHODS

Thirty NPC patients treated in our institution from September 2021 to October 2022 were prospectively enrolled. An individualized 3D printed oral stent was designed for each patient, and one set of computed tomography (CT) slices were obtained with /without wearing the oral stent, respectively. After delineation of target volumes and organs at risk (OARs) on the two CT slices, we finished two treatment plans by using the same target objectives, critical constraints and plan setup for each patient. Finally, the dose distribution and other dosimetric parameters of target volumes and OARs between the two plans were compared.

RESULTS

Tongue volume and tongue length outside of mouth was 10.4 ± 2.5 cm3 and 2.8 ± 0.6 cm, respectively, distance between dorsal surface of oral tongue and plate increased from 0.3 ± 0.3 cm to 2.2 ± 0.5 cm by wearing the oral stent. For the target volume, there was no significant difference. However, Dmax of tongue, tongue tip and periglottis decreased significantly from 6352.6 ± 259.9 cGy to 5994.9 ± 478.9 cGy, 3499.8 ± 250.6 cGy to 3357.7 ± 158.0 cGy and 6345.5 ± 171.0 cGy to 6133.4 ± 263.3 cGy, respectively (p = 0.000); Dmean of tongue, tongue tip and periglottis decreased significantly from 3714.7 ± 204.2 cGy to 3169.7 ± 200.9 cGy, 3060.8 ± 216.2 cGy to 2509.6 ± 196.7 cGy and 3853.3 ± 224.9 cGy to 3079.3 ± 222.0 cGy, respectively (p = 0.000).

CONCLUSION

The individualized 3D printed oral stent can reduce the dose of oral tissues and organs, so as to reduce the oral adverse reactions and improve the compliance of patients and the quality of their life. The technique can be used in radiotherapy of NPC patients.

Efficacy and safety of NAHAO® hydrogel in amelioration of chemoradiotherapy-induced oral mucositis: An preliminary clinical study (ChiCTR2200064766)

OBJECTIVE

To evaluate the efficacy of NAHAO® oral mucosal antibacterial care solution (NAHAO® spray) on attenuating oral mucositis (OM) symptoms and related mechanisms investigation.

MATERIAL AND METHODS

Experimental OM models were established by acetic acid and 5-fluorouracil combined with mechanical trauma. We investigated spontaneous pain of conscious OM rats after using NAHAO®. The expression of NF-κB in affected trigeminal ganglion was measured by western blot. In clinical study, 60 patients who developed post-treatment OM of grade 2 or above or persistent mucosal pain with a score equal to or greater than 4 points were selected. All patients were required to receive NAHAO® spray 8 times a day and were examined for OM degrees and oral mucosal pain scores before and after application.

RESULTS

Experimental data from experimental model suggested that clinical efficacy of NAHAO® spray was involved in inflammation inhibition via NF-κB pathway. The results of clinical study showed that NAHAO® spray improved the symptoms of OM, there is statistically significant difference in oral mucosal pain scores after treated with NAHAO, and the dietary restrictions were also improved.

CONCLUSION

NAHAO® spray alleviates pain and improves the diet situation in OM patients, which is partly mediated through the inhibition of NF-κB pathway.

Attempts to Understand Oral Mucositis in Head and Neck Cancer Patients through Omics Studies: A Narrative Review

Oral mucositis (OM) is a common and clinically impactful side effect of cytotoxic cancer treatment, particularly in patients with head and neck squamous cell carcinoma (HNSCC) who undergo radiotherapy with or without concomitant chemotherapy. The etiology and pathogenic mechanisms of OM are complex, multifaceted and elicit both direct and indirect damage to the mucosa. In this narrative review, we describe studies that use various omics methodologies (genomics, transcriptomics, microbiomics and metabolomics) in attempts to elucidate the biological pathways associated with the development or severity of OM. Integrating different omics into multi-omics approaches carries the potential to discover links among host factors (genomics), host responses (transcriptomics, metabolomics), and the local environment (microbiomics).

Facial pain, health-related quality of life and trismus-related symptoms up to 5 years post-radiotherapy for head and neck cancer

PURPOSE

Pain is a frequent symptom of head and neck cancer (HNC) but longitudinal studies investigating facial pain are scarce. We aimed to investigate prevalence of facial pain, its effect on health-related quality of life (HRQL) and trismus-related symptoms in a HNC cohort.

METHODS

Patients (n = 194) were prospectively followed post completion of radiotherapy (RT). Outcome measures included facial pain, HRQL, trismus-specific symptoms, and maximal interincisal opening (MIO).

RESULTS

Facial pain was reported by 50% at baseline. Corresponding figures for 3-, 12-, and 60 months post-RT were 70%, 54% and 41%. Moderate to severe pain was reported in 29-44% of patients reporting pain during the study period. Patients reporting pain scored significantly worse on more HRQL variables and trismus symptoms, as well as had significantly smaller MIO at all follow-up time points.

CONCLUSIONS

Facial pain was common in HNC patients pre- and post-RT and remained prevalent up to 5 years after completion of RT. Reductions in MIO were associated with more facial pain. Pain was also associated with worse HRQL.

Secondary lesions of the mucous membrane of the oral cavity as a side effect of complex anticancer treatment: a literature review

Today, both Ukraine and the world at large are faced with a significant number of oncological diseases with various localizations. The current state of diagnosis, prevention, early detection, and access to treatment leads to a substantial number of people in each country's healthcare system who require comprehensive cancer treatments. Modern medical and diagnosis protocols in oncology involve the usage of ionizing radiation and aggressive toxic chemotherapeutic agents which can significantly disrupt the physiology of the mucous membrane of the digestive tract during treatment, especially of the oral cavity. The most common complication of complex anticancer therapy is the development of various lesions of the oral cavity, including mucositis, which harms the patient's quality of life, limits the doses of chemotherapy and radiation therapy the patient can receive, and also negatively affects the effectiveness of complex therapy treatment. Acute oral mucositis is observed among almost 100% of treatment cases. This is a significant problem for clinical oncology as it may also reduce patient compliance with comprehensive anticancer treatment. The results indicate the presence of oral problems in 100% of patients receiving specialized antitumor chemotherapy and radiotherapy, as well as the presence of a high need for specialized dental treatment.

Nurses' knowledge on assessment and management of cancer therapy-associated oral mucositis

AIM

This study aimed to explore baseline nursing knowledge on assessment and management of patients at risk for developing cancer therapy-associated oral mucositis (OM) at a tertiary hospital in Ghana.

DESIGN

A descriptive generic qualitative study design was conducted. The study population were nurses who cared for patients diagnosed with cancer.

METHODS

Participants were recruited using a purposive non-probability sampling technique. Data were obtained through face-to-face interviews using semi-structured interview guide. Data collection and analysis were done concurrently.

RESULTS

The study found that nurses had knowledge on the pre-treatment assessment of clients undergoing cancer treatment; however, they had insufficient knowledge on the standardized tool for the assessment of OM. They also lack a definitive approach to prevent and treat OM. Nurses provided general education on cancer treatment but paid little attention to the education on the possible side effect that includes OM. Additionally, insufficient knowledge level of nurses on cancer treatment-associated mucositis and lack of structured protocol for OM coupled with unavailable tools for assessing the oral mucosa were also identified as militating against the management of OM. Findings from this study will guide policy that will improve the care that clients who are at risk of oral mucositis receive.

Management of Cancer Therapy-Induced Oral Mucositis Using Photobiomodulation Therapy: An Overview of Systematic Reviews

Objective: To systematically summarize the evidence for photobiomodulation therapy (PBMT) in the prevention and treatment of oral mucositis (OM) in patients undergoing cancer treatment. An electronic search was conducted in 8 databases and grey literature. Background: PBMT is recommended for the management of OM resulting from cancer treatment, with several systematic reviews (SRs) being published in recent years on this topic. Methods: Only SRs with outcomes from clinical trials were included, with no language or year restriction. The AMSTAR 2 tool was used to assess the methodological quality of the SRs. Results: Five thousand eight hundred fifty-six references were found, and 16 were selected for this review. OM prevention and treatment were favorable for PBMT in most studies, with a significant reduction in OM severity. Most studies obtained moderate confidence. Conclusions: PBMT represents an effective strategy in the management of OM, and this evidence is supported by studies with acceptable methodological quality.

Management of oral mucositis: a systematic review

INTRODUCTION

Oral mucositis is one of the most common complications following chemotherapy and/or head and neck radiotherapy. Various treatments for oral mucositis have been proposed. However, there has still been no review of the most frequent and most effective type of therapy to treat oral mucositis. This systematic review aims to determine the most frequent and effective types of therapy to treat and reduce the severity of oral mucositis.

EVIDENCE ACQUISITION

The literature search was carried out using PRISMA guidelines. Publications included from 2010 to June 2021 with a clinical trial, prospective, and retrospective observational research design. The following databases were used: PubMed, Cochrane Library, and Wiley Online Library. The search was for limited articles published in English, which were screened and analyzed by three authors. The risk of bias of each study was also assessed by three authors simultaneously, using different types of instruments depending on its study design.

EVIDENCE SYNTHESIS

Forty-seven of 1274 journals were included. From 3577 subjects, oral mucositis was more common in males than females (2.12: 1), with a mean age of 56.39 (18-90 years). The most commonly used types of therapy are low-level laser therapy (396 subjects) and lysozyme-based compounds (314 subjects). Meanwhile, the most effective type of therapy is low-level laser therapy.

CONCLUSIONS

Low-level laser therapy is the most commonly used oral mucositis therapy and is also the most effective in reducing the degree of oral mucositis and associated pain.

Randomised controlled trial of Jiandu granule in preventing chemoradiotherapy-induced oral mucositis

OBJECTIVE

This clinical trial aimed to evaluate the efficacy and safety of Jiandu granule, a Chinese herbal medicine formula, for preventing oral mucositis in patients with nasopharyngeal carcinoma undergoing concurrent chemoradiotherapy.

MATERIALS AND METHODS

A single-centre, open-label, randomised controlled trial was conducted, enrolling 138 patients with locally advanced nasopharyngeal carcinoma. Patients were randomly allocated to either the experimental group (n = 69) or the control group (n = 69). Both groups received concurrent chemoradiotherapy and standard care for oral mucositis, with the experimental group additionally receiving Jiandu granule intervention. The primary outcome was the incidence of severe oral mucositis (grade III to IV).

RESULTS

In the full-analysis set, severe oral mucositis occurred in 14 of 69 (20.3%) patients in the experimental group and 31 of 69 (44.9%) patients in the control group (absolute risk reduction: 24.6%; relative risk reduction: 54.8%; p = 0.002; number needed to treat: 4). Jiandu granule was associated with mild/moderate gastrointestinal reactions, with an overall incidence of 5.9%.

CONCLUSION

Jiandu granule reduced the incidence of severe oral mucositis in nasopharyngeal carcinoma patients during concurrent chemoradiotherapy and had an acceptable safety profile.

Routine Prophylactic Percutaneous Endoscopic Gastrostomy in Head and Neck Cancers with Bilateral Neck Irradiation: A Regional Cancer Experience in New Zealand

INTRODUCTION

Patients with head and neck cancer (HNC) are particularly susceptible to dysphagia and malnutrition. Prophylactic percutaneous endoscopic gastrostomy (PEG) placement is a method used to manage these issues, but practices vary among institutions. At Midcentral District Health Board, patients receiving radiotherapy to the primary and bilateral neck regions routinely undergo prophylactic PEG placement. This study aimed to review the nutritional and PEG-related outcomes of these patients.

METHODS

Records of 49 patients were retrospectively reviewed. Their demographics, tumour and treatment characteristics were recorded. We evaluated patient weight loss, non-elective hospitalisation, treatment interruption rates, PEG-related complications, usage, dependency rates and late dysphagia rates.

RESULTS

Oropharyngeal cancers were the most common primary site (61.2%), and 83.7% of patients received primary chemoradiotherapy. Mean weight loss at treatment completion was 5.6% ± 4.3 (4.6 kg ± 3.9). The rate of non-elective hospitalisations was 26.5%, and only 2% of patients had treatment interruptions. Peristomal infection was the most frequent PEG complication (20.4%). No PEG-related mortality was reported. Median duration of PEG dependency was 97 days (14-388 days). Two patients remained permanently dependent at 3 years due to grade 3 dysphagia, and six patients experienced grade ≥2 late dysphagia.

CONCLUSION

Our study showed that prophylactic PEG tube placement was relatively safe, with a high utilisation rate and low long-term dependence on PEG tubes after treatment completion. However, complications related to their use should be addressed through a multidisciplinary approach, with careful assessment by clinicians. The weight loss and hospitalisation rates observed were consistent with earlier studies that utilised prophylactic PEG tubes.

Effectiveness of Cryotherapy on Cancer Therapy-Induced Oral Mucositis: An Umbrella Review

BACKGROUND

Oral mucositis (OM) considerably affects the experience of patients with cancer during treatment. This study investigated the effects of cryotherapy on cancer therapy-induced OM.

OBJECTIVE

This study aimed to systematically appraise evidence on whether cryotherapy can reduce the incidence and severity of OM.

METHODS

We conducted an umbrella review to examine the effect of cryotherapy on cancer-related OM. The primary outcome was the incidence and severity of OM. We performed a subgroup analysis including solid cancers and hematological malignancies.

RESULTS

Five meta-analyses were included. Cryotherapy could more effectively reduce the incidence of severe OM (risk ratio [RR], 0.37; 95% prediction interval [PI], 0.22-0.64). In the subgroup analyses of solid cancers or hematological malignancies, cryotherapy significantly reduced the incidence of grades 2 to 4 OM in patients with solid cancers (RR, 0.51; 95% PI, 0.34-0.78 and RR, 0.52; 95% PI, 0.36-0.74). However, no significant difference was observed in the incidence of OM in patients with hematological malignancies regarding any grade or grade 3 or 4 OM. Moreover, cryotherapy did not significantly reduce the OM duration (mean difference, -0.13; 95% PI, -20.89 to 20.63; mean difference, -2.99, 95% PI, -8.10 to 2.12).

CONCLUSION

Cryotherapy can reduce the incidence of severe OM induced by chemotherapy or radiotherapy.

IMPLICATION FOR PRACTICE

We recommend the inclusion of this safe, simple, and convenient intervention in chemotherapy or radiotherapy plans. Additional clinical trials are warranted to extend the limited evidence on the effectiveness of cryotherapy in reducing the severity and duration of OM.

Ayurvedic Drug Triphala in Combination with Providone Iodine Mitigates Radiation-Induced Mucositis in Head and Neck Cancer Patients without Affecting the Tumor Response

Radiation-induced mucositis is a dose-limiting concern in the treatment of head and neck cancers (HNC). This study was conducted to determine the effectiveness of the Ayurvedic drug Triphala in reducing radiation-induced mucositis and influencing tumour control when combined with providone iodine. Data from patient files of HNC patients who received Triphala in conjunction with iodine or iodine alone over the course of curative radiotherapy (> 60 Gy) from May 2013 to February 2015 were extracted for this retrospective chart based study. Data was subjected to statistical analysis, X2 and unpaired t test using the Statistical Package for Social Sciences (SPSS), version 17 (IBM, Chicago, USA). When compared to iodine alone, the group that utilised Triphala gargling was very efficient in delaying mucositis, the extent of weight loss (p = 0.038), the incidence (p = 0.03), and the number (p = 0.02) of treatment breaks. However, it had no influence on the radiation-induced tumour response. According to the observations, Triphala coupled with iodine was more successful in preventing radiation mucositis, and without affecting the killing of tumour cells than iodine gargle alone. According to the authors, this is the first observation to demonstrate the value of combining providone iodine with Triphala in preventing radiation-induced oral mucositis.

Omega-3 nanoemulgel in prevention of radiation-induced oral mucositis and its associated effect on microbiome: a randomized clinical trial

BACKGROUND

Oral mucositis (OM) is recognized as one of the most frequent debilitating sequelae encountered by head and neck cancer (HNC) patients treated by radiotherapy. This results in severe mucosal tissue inflammation and oral ulcerations that interfere with patient's nutrition, quality of life (QoL) and survival. Omega-3 (ω-3) polyunsaturated fatty acids (PUFAs) have recently gained special interest in dealing with oral diseases owing to its anti-inflammatory, anti-oxidant and wound healing properties. Thus, this study aims to assess topical Omega-3 nanoemulgel efficacy in prevention of radiation-induced oral mucositis and regulation of oral microbial dysbiosis.

MATERIALS AND METHODS

Thirty-four head and neck cancer patients planned to receive radiotherapy were randomly allocated into two groups: Group I: conventional preventive treatment and Group II: topical Omega-3 nanoemulgel. Patients were evaluated at baseline, three and six weeks after treatment using the World Health Organization (WHO) grading system for oral mucositis severity, Visual Analogue Scale (VAS) for perceived pain severity, and MD-Anderson Symptom Inventory for Head and Neck cancer (MDASI-HN) for QoL. Oral swabs were collected to assess oral microbiome changes.

RESULTS

VAS scores and WHO mucositis grades were significantly lower after six weeks of treatment with topical Omega-3 nanoemulgel when compared to the conventional treatment. The total MDASI score was significantly higher in the control group after three weeks of treatment, and the head and neck subscale differed significantly at both three and six weeks. A significant reduction in Firmicutes/Bacteroidetes ratio was observed after six weeks in the test group indicating less microbial dysbiosis.

CONCLUSIONS

Topical Omega-3 nanoemulgel demonstrated a beneficial effect in prevention of radiation-induced oral mucositis with a possibility of regulating oral microbial dysbiosis.

Sex-dependent differences in the genomic profile of lingual sensory neurons in naïve and tongue-tumor bearing mice

Mechanisms of sex-dependent orofacial pain are widely understudied. A significant gap in knowledge exists about comprehensive regulation of tissue-specific trigeminal sensory neurons in diseased state of both sexes. Using RNA sequencing of FACS sorted retro-labeled sensory neurons innervating tongue tissue, we determined changes in transcriptomic profiles in males and female mice under naïve as well as tongue-tumor bearing conditions Our data revealed the following interesting findings: (1) FACS sorting obtained higher number of neurons from female trigeminal ganglia (TG) compared to males; (2) Naïve female neurons innervating the tongue expressed immune cell markers such as Csf1R, C1qa and others, that weren't expressed in males. This was validated by Immunohistochemistry. (3) Accordingly, immune cell markers such as Csf1 exclusively sensitized TRPV1 responses in female TG neurons. (4) Male neurons were more tightly regulated than female neurons upon tumor growth and very few differentially expressed genes (DEGs) overlapped between the sexes, (5) Male DEGs contained higher number of transcription factors whereas female DEGs contained higher number of enzymes, cytokines and chemokines. Collectively, this is the first study to characterize the effect of sex as well as of tongue-tumor on global gene expression, pathways and molecular function of tongue-innervating sensory neurons.

Methylene Blue for the Treatment of Radiation-Induced Oral Mucositis during Head and Neck Cancer Treatment: An Uncontrolled Cohort

Pain from radiation-therapy-induced oral mucositis during head-neck cancer treatment is aggravated by concurrent chemotherapy and commonly fails traditional treatments. To explore safe and sustainable alternatives, we investigated methylene blue oral rinse to reduce radiation-therapy-related oral mucositis pain. For this, we conducted a retrospective observational cohort study in a tertiary-care academic care cancer center including 85 patients with refractory oral mucositis pain during radiation therapy for head-neck cancer. Changes in pain (scale 0-10), oral function burden (scale 0-6) and requirement for percutaneous endoscopic gastrostomy tube placement were measured. Among 58 patients, 60% received radiation therapy alone and 40% received concurrent chemotherapy-radiation therapy. Methylene blue oral rinse (MBOR) significantly decreased oral mucositis pain for at least 6.2 h (median + SD 8 ± 1.68 before vs. 2 ± 2.20 after; p < 0.0001) and oral function burden (3.5 ± 1.33 before vs. 0 ± 0.86 after; p < 0.0001). Eleven patients (19%) had percutaneous endoscopic gastrostomy tubes placed before using methylene blue oral rinse; subsequently, four (36%) resumed oral alimentation after methylene blue oral rinse. Two patients (3%) required percutaneous endoscopic gastrostomy tubes despite methylene blue oral rinse. Minimal adverse events were reported (n = 9, 15%). Our study showed that methylene blue oral rinse was an effective and safe topical treatment for opioid-refractory oral pain from oral mucositis associated with radiation therapy for head-neck cancer.

Network Pharmacology and Molecular Docking Reveal the Mechanism of Corydalis saxicola Bunting Total Alkaloids in Treating Radiation-Induced Oral Mucositis

The study aims to explore the effect and mechanism of total alkaloids of Corydalis saxicola Bunting (CSBTA) in the treatment of radiation induced oral mucositis (RIOM) through network pharmacology and molecular docking. The components and corresponding targets of Corydalis saxicola Bunting were screened by literature review. RIOM related targets were obtained in GeneCards. Cytoscape software was used to construct the component-target-pathway network. Protein-Protein Interaction (PPI) networks was constructed by String database. GO and KEGG enrichment analyses were performed by Metascape. AutoDock Vina 4.2 software was used for molecular docking. There were 26 components of CSBTA targeting 61 genes related to RIOM. Through Cytoscape and PPI analysis, 15 core target genes of CSBTA for treating RIOM were identified. GO functional analysis indicated that CSBTA might play a role through kinase binding and protein kinase activation. KEGG pathway analysis showed that the core targets of CSBTA were mainly focused on cancer and reactive oxygen species (ROS) pathway. The results of molecular docking showed that CSBTA had strong binding energy with target protein including SRC, AKT and EGFR. The study demonstrates that CSBTA may treat RIOM by affecting SRC, AKT and EGFR through ROS pathway.

Proton therapy and oral mucositis in oral & oropharyngeal cancers: outcomes, dosimetric and NTCP benefit

INTRODUCTION

Radiation-induced oral mucositis (RIOM), is a common, debilitating, acute side effect of radiotherapy for oral cavity (OC) and oropharyngeal (OPx) cancers; technical innovations for reducing it are seldom discussed. Intensity-modulated-proton-therapy (IMPT) has been reported extensively for treating OPx cancers, and less frequently for OC cancers. We aim to quantify the reduction in the likelihood of RIOM in treating these 2 subsites with IMPT compared to Helical Tomotherapy.

MATERIAL AND METHODS

We report acute toxicities and early outcomes of 22 consecutive patients with OC and OPx cancers treated with IMPT, and compare the dosimetry and normal tissue complication probability (NTCP) of ≥ grade 3 mucositis for IMPT and HT.

RESULTS

Twenty two patients, 77% males, 41% elderly and 73% OC subsite, were reviewed. With comparable target coverage, IMPT significantly reduced the mean dose and D32, D39, D45, and D50, for both the oral mucosa (OM) and spared oral mucosa (sOM). With IMPT, there was a 7% absolute and 16.5% relative reduction in NTCP for grade 3 mucositis for OM, compared to HT. IMPT further reduced NTCP for sOM, and the benefit was maintained in OC, OPx subsites and elderly subgroup. Acute toxicities, grade III dermatitis and mucositis, were noted in 50% and 45.5% patients, respectively, while 22.7% patients had grade 3 dysphagia. Compared with published data, the hospital admission rate, median weight loss, feeding tube insertion, unplanned treatment gaps were lower with IMPT. At a median follow-up of 15 months, 81.8% were alive; 72.7%, alive without disease and 9%, alive with disease.

CONCLUSION

The dosimetric benefit of IMPT translates into NTCP reduction for grade 3 mucositis compared to Helical Tomotherapy for OPx and OC cancers and encourages the use of IMPT in their management.

Expression of Salivary Ceramide Synthase 1 (CERS1) in Recurrent Aphthous Stomatitis (RAS): A Cross-Sectional Institutional Study

Background The increased rate of apoptosis is one of the major causes of ulcer formation. A variety of factors can influence the rate of apoptosis. Ceramide (CER) is one such factor that has been proposed to play a role in signaling apoptosis induced by extracellular agents. Recurrent aphthous stomatitis (RAS) is a common condition that initially presents in children or adolescents. Multiple recurrent small, round, or ovoid ulcers with erythematous haloes and circumscribed margins are its characteristic features. Its pathogenesis is still a mystery. Ceramide synthase 1 (CERS1) aids in the production of C18 CER. Although the role of CERS1 in aphthous is well understood, its possible intricate role in pathogenesis remains unknown. Aim To evaluate the expression of salivary CERS1 in patients with RAS and healthy individuals. Materials and methods 30 patients were included in the present study. Ethical clearance for this study was obtained, and there were no gender or age limits for enrollment. After obtaining informed consent, 30 salivary samples were collected from patients with RAS (n=15) and from healthy individuals (n=15). Enzyme-linked immunosorbent assay (ELISA) was performed using the CERS1 kit by MyBioSource Inc (San Diego, USA) and the results were recorded. The Chi-square test and Independent t-test were used for statistical analysis with SPSS v23.0 (IBM, Chicago, USA) with a significant p-value of <0.05. Results CERS1 expression was identified in the saliva of all participants. There was a decrease in the salivary CERS1 level in RAS patients (7.6 +/- 2.0 pg/ml) when compared to healthy individuals (8.3 +/- 1.8 pg/ml) but it did not achieve statistical significance. Conclusion We found that salivary CERS1 levels decreased in RAS patients. More research is required to understand CERS1's pathogenetic role.

Towards unravelling biological mechanisms behind radiation-induced oral mucositis via mass spectrometry-based proteomics

Objective

Head and neck cancer (HNC) accounts for almost 890,000 new cases per year. Radiotherapy (RT) is used to treat the majority of these patients. A common side-effect of RT is the onset of oral mucositis, which decreases the quality of life and represents the major dose-limiting factor in RT. To understand the origin of oral mucositis, the biological mechanisms post-ionizing radiation (IR) need to be clarified. Such knowledge is valuable to develop new treatment targets for oral mucositis and markers for the early identification of "at-risk" patients.

Methods

Primary keratinocytes from healthy volunteers were biopsied, irradiated in vitro (0 and 6 Gy), and subjected to mass spectrometry-based analyses 96 h after irradiation. Web-based tools were used to predict triggered biological pathways. The results were validated in the OKF6 cell culture model. Immunoblotting and mRNA validation was performed and cytokines present in cell culture media post-IR were quantified.

Results

Mass spectrometry-based proteomics identified 5879 proteins in primary keratinocytes and 4597 proteins in OKF6 cells. Amongst them, 212 proteins in primary keratinocytes and 169 proteins in OKF6 cells were differentially abundant 96 h after 6 Gy irradiation compared to sham-irradiated controls. In silico pathway enrichment analysis predicted interferon (IFN) response and DNA strand elongation pathways as mostly affected pathways in both cell systems. Immunoblot validations showed a decrease in minichromosome maintenance (MCM) complex proteins 2-7 and an increase in IFN-associated proteins STAT1 and ISG15. In line with affected IFN signalling, mRNA levels of IFNβ and interleukin 6 (IL-6) increased significantly following irradiation and also levels of secreted IL-1β, IL-6, IP-10, and ISG15 were elevated.

Conclusion

This study has investigated biological mechanisms in keratinocytes post-in vitro ionizing radiation. A common radiation signature in keratinocytes was identified. The role of IFN response in keratinocytes along with increased levels of pro-inflammatory cytokines and proteins could hint towards a possible mechanism for oral mucositis.

Treatment of Oral Mucositis Using Platelet-Rich-Fibrin: A Retrospective Study on Oncological Patients

Oral mucositis is an inflammatory mucosal demolition frequently observed during treatments for neoplastic diseases such as chemotherapy or radiation therapy. The side effects of these treatments often drastically reduce patients' quality of life. Oral mucositis is the result of the systemic consequences of chemotherapy and radiotherapy, which due to their cytotoxic and local effects, lead to pain and severe ulceration with a consequent decrease in the quality of life of affected subjects. Plasma rich in fibrin is often used to enhance soft tissue wound healing and fight bacterial sepsis through the presence of leukocytes within it. The retrospective study aimed to evaluate the efficacy and safety of the topic use of platelet gel in the clinical management of oral mucositis to improve the life quality of patients. The results of the study were promising even though the topical application of platelet-rich-fibrin is like a skin-care treatment. Future studies with a larger sample of patients will be needed to understand the real benefits of platelet-rich-fibrin.

Evaluation of recurrence, mortality and treatment complications of oral squamous cell carcinoma in public health centers in Shiraz during 2010 to 2020

INTRODUCTION

Oral Squamous cell Carcinoma (OSCC) is the most common oral cancer and is treated with surgery, radiotherapy and chemotherapy. Various complications of treatment include xerostomia, mucositis, and trismus, which affect patients' quality of life. The aim of this study is to evaluate the mortality, recurrence rate and prevalence of oral complications in treated patients.

METHOD AND MATERIALS

This cross-sectional study reviewed 326 cases of patients with OSCC who were referred to public health centers in Shiraz (Khalili Hospital and Dental School) from 2010 to 2020. All patients were contacted, and the survivors were called and examined by an oral physician. A medical record was created for them, including demographic information, location of the lesion, type of treatment, history of recurrence, metastasis and oral complications.

RESULTS

53.5% of patients were male and 46.5% were female. The mean age of patients was 58.68 years. Mortality and recurrence rate was respectively 49.8% and 17.8%. The most common location of the lesion was tongue (64%). Surgery was done for all patients. 97.4% of patients complained of xerostomia, 46.2% of mucositis and 44.3% of trismus.

CONCLUSION

The most common complications of treatment are xerostomia, mucositis, and trismus, respectively. Frequent and regular follow-ups and supportive therapies reduce these complications and improve patients' quality of life.

Sex-dependent Differences in the Genomic Profile of Lingual Sensory Neurons in Naïve and Tongue-Tumor Bearing Mice

Mechanisms of sex-dependent orofacial pain are widely understudied. A significant gap in knowledge exists about comprehensive regulation of tissue-specific trigeminal sensory neurons in diseased state of both sexes. Using RNA sequencing of FACS sorted retro-labeled sensory neurons innervating tongue tissue, we determined changes in transcriptomic profiles in males and female mice under naïve as well as tongue-tumor bearing conditions Our data revealed the following interesting findings: 1) Tongue tissue of female mice was innervated with higher number of trigeminal neurons compared to males; 2) Naïve female neurons innervating the tongue exclusively expressed immune cell markers such as Csf1R, C1qa and others, that weren't expressed in males. This was validated by Immunohistochemistry. 4) Accordingly, immune cell markers such as Csf1 exclusively sensitized TRPV1 responses in female TG neurons. 3) Male neurons were more tightly regulated than female neurons upon tumor growth and very few differentially expressed genes (DEGs) overlapped between the sexes, 5) Male DEGs contained higher number of transcription factors whereas female DEGs contained higher number of enzymes, cytokines and chemokines. Collectively, this is the first study to characterize the effect of sex as well as of tongue-tumor on global gene expression, pathways and molecular function of tongue-innervating sensory neurons.

The application of the PDCA cycle in the nutritional management of patients with nasopharyngeal carcinoma

OBJECTIVE

This study is to explore the effect of the Plan-Do-Check-Act (PDCA) cycle on the nutritional management of patients with nasopharyngeal carcinoma (NPC).

METHODS

A total of 100 NPC patients were randomly divided into a control group and a PDCA group, with 50 patients in each group. The control group adopted a routine nutritional management strategy, and the PDCA group adopted a PDCA cycle management strategy. The body weight, body mass index (BMI), hemoglobin, serum prealbumin, serum albumin, the Patient-Generated Subjective Global Assessment (PG-SGA) score, the Nutrition Risk Screening 2002 (NRS-2002) score, the incidence rate of nutritional risk, the grade of malnutrition, and the grade of oral mucositis were compared between the two groups.

RESULTS

The body weight, BMI, and serum prealbumin in the PDCA group were higher than those in the control group, and the difference was statistically significant (p < 0.05). The NRS2002 score and PG-SGA score in the PDCA group were lower than those in the control group, and the differences were statistically significant (p < 0.05). The incidence of nutritional risk, the grade of malnutrition, and the grade of oral mucositis were less in the PDCA group than those in the control group (p < 0.05). There was no significant difference in hemoglobin and serum albumin between the two groups (p > 0.05).

CONCLUSION

The PDCA cycle can improve body weight, BMI, and serum prealbumin in NPC patients. It can reduce the NRS2002 score, the PG-SGA score, the incidence of nutritional risk, the severity of malnutrition, and the severity of oral mucositis in NPC patients.

Ascidian-Inspired Temperature-Switchable Hydrogels with Antioxidant Fullerenols for Protecting Radiation-Induced Oral Mucositis and Maintaining the Homeostasis of Oral Microbiota

A key characteristic of radiation-induced oral mucositis (RIOM) is oxidative stress mediated by the "reactive oxygen species (ROS) storm" generated from water radiolysis, resulting in severe pathological lesions, accompanied by a disturbance of oral microbiota. Therefore, a sprayable in situ hydrogel loaded with "free radical sponge" fullerenols (FOH) is developed as antioxidant agent for RIOM radioprotection. Inspired by marine organisms, 3,4,5-trihydroxyphenylalanine (TOPA) which is enriched in ascidians is grafted to clinically approved temperature-switchable Pluronic F127 to produce gallic acid (containing the TOPA fragment)-modified Pluronic F127 (MGA) hydrogels to resist the fast loss of FOH via biomimetic adhesion during oral movement and saliva erosion. Based on this, progressive RIOM found in mice is alleviated by treatment of FOH-loaded MGA hydrogels whether pre-irradiation prophylactic administration or post-irradiation therapeutic administration, which contributes to maintaining the homeostasis of oral microbiota. Mechanistically, FOH inhibits cell apoptosis by scavenging radiation-induced excess ROS and up-regulates the inherent enzymatic antioxidants, thereby protecting the proliferation and migration of mucosal epithelial cells. In conclusion, this work not only provides proof-of-principle evidence for the oral radioprotection of FOH by blocking the "ROS storm", but also provides an effective and easy-to-use hydrogel system for mucosal in situ administration.

Correlations between the severity of radiation-induced oral mucositis and salivary epidermal growth factor as well as inflammatory cytokines in patients with head and neck cancer

BACKGROUND

This study aimed to investigate correlations of the severity of radiation-induced oral mucositis (RIOM) with epidermal growth factor (EGF) and inflammatory cytokines in patients with head and neck cancer (HNC).

METHODS

Levels of inflammatory cytokines and EGF in saliva of HNC patients were measured. Correlations of inflammatory cytokines and EGF levels with RIOM severity and pain degree, and their diagnostic values on RIOM severity were determined.

RESULTS

Elevated IFN-γ, TNF-α, IL-2, and IL-6 levels, and reduced IL-4, IL-10, and EGF levels were found in patients with severe RIOM. IFN-γ, TNF-α, IL-2, and IL-6 were positively correlated with RIOM severity, while IL-10, IL-4, and EGF were negatively correlated with it. All factors were effective in predicting the severity of RIOM.

CONCLUSION

IFN-γ, TNF-α, IL-2, and IL-6 in saliva of patients with HNC are positively correlated with the severity of RIOM, and IL-4, IL-10, and EGF were negatively correlated with it.

Prevention of radiotherapy-related oral mucositis with zinc and polyherbal mouthwash: a double-blind, randomized clinical trial

BACKGROUND

A significant percentage of head and neck cancer (HNCs) patients receiving RT experience oral mucositis (OM). This study aimed to evaluate the effect of the polyherbal (containing chamomile, peppermint oil, Aloe vera, and honey) and zinc mouthwashes in comparison to the control (chlorhexidine) and placebo groups for prevention of radiation-induced OM.

METHODS

This study was a double-blinded randomized clinical trial, conducted on 67 patients with HNCs undergoing radiotherapy. The eligible participants were randomized to receive either one of the following; zinc sulfate, polyherbal, chlorhexidine (Vi-one 0.2% CHX), or placebo mouthwash for 6 weeks. Follow-up evaluation of oral hygiene and the checklists of OM and the intensity of pain were filled out according to WHO assessment tool, Oral Mucositis Assessment Scale (OMAS), and Visual Analog Scale (VAS) in all the participants weekly for seven consecutive weeks.

RESULTS

The results of present clinical trial demonstrated that the use of either zinc sulfate or polyherbal mouthwash significantly reduced the scores of OM and the severity of pain during weeks 2 to 7 after consumption compared with the CHX or placebo mouthwashes (P < 0.05). According to the post hoc analysis and compared with the placebo, a significantly better result was reported for zinc sulfate and polyherbal mouthwashes at weeks 2 to 7, but not for the CHX mouthwash.

CONCLUSION

This study showed that the use of zinc sulfate or polyherbal mouthwashes is effective in prevention of both OM severity scores and pain related to OM intensity at weeks 2 to 7 following consumption in HNCs patients. Trial registration IRCT20190123042475N1 and IRCT20190123042475N2. Registration date: 2019-06-09, 2019-07-26.

Dose-volume constraints for head-and-neck cancer in carbon ion radiotherapy: A literature review

BACKGROUND

Carbon ion radiotherapy (CIRT) has been applied in cancer treatment for over 25 years. However, guidelines for dose-volume constraints have not been established yet. The aim of this review is to summarize the dose-volume constraints in CIRT for head-and-neck (HN) cancer that were determined through previous clinical studies based on the Japanese models for relative biological effectiveness (RBE).

METHODS

A literature review was conducted to identify all constraints determined for HN cancer CIRT that are based on the Japanese RBE models.

RESULTS

Dose-volume constraints are reported for 17 organs at risk (OARs), including the brainstem, ocular structures, masticatory muscles, and skin. Various treatment planning strategies are also presented for reducing the dose delivered to OARs.

CONCLUSIONS

The reported constraints will provide assistance during treatment planning to ensure that radiation to OARs is minimized, and thus adverse effects are reduced. Although the constraints are given based on the Japanese RBE models, applying the necessary conversion factors will potentially enable their application by institutions worldwide that use the local effect model for RBE.

Did you choose appropriate mouthwash for managing chemoradiotherapy-induced oral mucositis? The therapeutic effect compared by a Bayesian network meta-analysis

Background

Oral mucositis (OM) is one of the most common adverse effects of radiotherapy and chemotherapy. It greatly affects the patients' quality of life and hinders cancer treatment implementation. Treating OM with mouthwash is a widely used strategy that can effectively relieve symptoms and promote healing. However, the wide mouthwash selection confuses clinicians. This Bayesian network meta-analysis aimed to compare the effects of various mouthwash types used to treat OM and provide high-level evidence-based recommendations for OM treatment.

Methods

Database search included PubMed, Embase, Cochrane Library, and Web of Science from inception to April 21, 2022. The primary outcome was OM score improvement following the World Health Organization grades. The randomized controlled trial (RCT) bias risk assessment tool provided in the Cochrane Handbook assessed the studies' risk of bias. We performed pairwise and Bayesian network meta-analysis with random effects following the PRISMA guideline.

Results

The study included 13 RCTs with 570 patients. Pairwise comparisons showed that povidone-iodine was more effective than chlorhexidine (weighted mean difference [WMD], -2.64; 95% confidence interval [CI], -2.72 to -2.56) but inferior to granulocyte-macrophage colony-stimulating factor (GM-CSF; WMD, 0.20; 95% CI, 0.06-0.34) after one week of mouthwash treatment. Vitamin E (WMD, -0.94; 95% CI, -1.03 to -0.85), natural drugs (WMD, -0.93; 95% CI, -1.46 to -0.40), and phenytoin (WMD, -0.38; 95% CI, -0.59 to -0.17) exhibited better therapeutic effects than a placebo after three weeks of treatment. Bayesian network meta-analysis showed that povidone-iodine was superior to chlorhexidine in treating OM (WMD, 2.63; 95% CI, 0.20-5.01). Other mouthwashes showed no significant differences. Rank probability indicated that the best OM therapeutic mouthwashes were GM-CSF (54%), vitamin E (24%), and natural drugs (43%) after one, two, and three weeks of treatment, respectively.

Conclusion

GM-CSF was the most effective mouthwash type for OM treatment. When considering the cost and effectiveness, povidone-iodine and sodium bicarbonate might be the most advantageous. Furthermore, natural drugs have the same potential in treating OM. Safety and acceptability are their most outstanding characteristic.

Baseline gut microbiota composition is associated with oral mucositis and tumour recurrence in patients with head and neck cancer: a pilot study

PURPOSE

Mounting evidence suggests that the gut microbiome influences radiotherapy efficacy and toxicity by modulating immune signalling. However, its contribution to radiotherapy outcomes in head and neck cancer (HNC) is yet to be investigated. This study, therefore, aimed to uncover associations between an individual's pre-therapy gut microbiota and (i) severity of radiotherapy-induced oral mucositis (OM), and (ii) recurrence risk in patients with HNC.

METHODS

In this prospective pilot study, 20 patients with HNC scheduled to receive radiotherapy or chemoradiotherapy were recruited. Stool samples were collected before treatment and microbial composition was analysed using 16S rRNA gene sequencing. OM severity was assessed using the NCI-CTCAE scoring system. Patients were also followed for 12 months of treatment completion to assess tumour recurrence.

RESULTS

Overall, 80% of the patients were male with a median age of 65.5 years. Fifty-three percent experienced mild/moderate OM while 47% developed severe OM. Furthermore, 18% experienced tumour relapse within 1 year of treatment completion. A pre-treatment microbiota enriched of Eubacterium, Victivallis, and Ruminococcus was associated with severe OM. Conversely, a higher relative abundance of immunomodulatory microbes Faecalibacterium, Prevotella, and Phascolarctobacterium was associated with a lower risk of tumour recurrence.

CONCLUSION

Our results indicate that a patient's gut microbiota composition at the start of treatment is linked to OM severity and recurrence risk. We now seek to validate these findings to determine their ability to predict treatment outcomes in HNC, with the goal of using this data to inform second-generation microbial therapeutics to optimise treatment outcomes for patients with HNC.