Secondary Oral Cancer after Systemic Treatment of Hematological Malignancies and Oral GVHD: A Systematic Review

Comparison of oral chronic graft-versus-host disease characteristics between patients with malignant and non-malignant hematopoietic disorders

OBJECTIVES

To characterize and compare the clinical manifestations of oral chronic graft-versus-host disease (cGVHD) in patients with malignant hematopoietic disorders versus those with non-malignant hematopoietic disorders, and to analyze associated risk factors.

MATERIALS AND METHODS

Detailed examinations of the oral cavity were conducted in patients with malignant hematopoietic disorders (n = 52) and non-malignant hematopoietic disorders (n = 56) who developed oral cGVHD following allogeneic hematopoietic stem cell transplantation (allo-HSCT). The severity of oral cGVHD was scored, and logistic regression analysis was employed to identify risk factors for oral cGVHD (n = 261).

RESULTS

The incidence of oral cGVHD in patients with malignant hematopoietic disorders was significantly higher compared to those with non-malignant hematopoietic disorders (51.49% vs 35.00%, P = 0.01). Additionally, a significantly greater proportion of patients with malignant hematopoietic disorders had an oral lesion score exceeding 5 compared to patients with non-malignant hematopoietic disorders (17/52 vs 7/56, P < 0.0001). The median time from transplantation to the onset of oral cGVHD was earlier in patients with malignant hematopoietic disorders than in patients with non-malignant hematopoietic disorders (6 months vs 7 months, P = 0.001). Furthermore, female donors to male recipients [OR = 1.926, 95% CI (1.07, 3.442), P = 0.027] emerged as an independent risk factor for oral cGVHD.

CONCLUSION

Compared to patients with non-malignant hematopoietic disorders, those with malignant hematopoietic disorders exhibit a higher incidence of complications following allo-HSCT. Additionally, patients with malignant hematopoietic disorders experience a more rapid disease onset and are at a greater risk of developing severe oral cGVHD. Furthermore, female donors to male recipients represents a significant risk factor for oral cGVHD but not associated with diagnoses with benign and malignant blood disorders.

CLINICAL RELEVANCE

This study elucidates the distinct characteristics of oral cGVHD in patients with malignant hematopoietic disorders and non-malignant hematopoietic disorders, providing valuable insights for developing more precise and personalized clinical treatment strategies for these patients.

Oral Chronic Graft-Versus-Host Disease: Pathogenesis, Diagnosis, Current Treatment, and Emerging Therapies

Chronic graft-versus-host disease (cGvHD) is a multisystem disorder that occurs in recipients of allogeneic hematopoietic (alloHCT) stem cell transplants and is characterized by both inflammatory and fibrotic manifestations. It begins with the recognition of host tissues by the non-self (allogeneic) graft and progresses to tissue inflammation, organ dysfunction and fibrosis throughout the body. Oral cavity manifestations of cGVHD include mucosal features, salivary gland dysfunction and fibrosis. This review synthesizes current knowledge on the pathogenesis, diagnosis and management of oral cGVHD, with a focus on emerging trends and novel therapeutics. Data from various clinical studies and expert consensus are integrated to provide a comprehensive overview.

Self-perceived oral health in hemato-oncological patients and the relation to quality of life

PURPOSE

To assess the self-reported oral health and oral health-related quality of life of patients diagnosed with hemato-oncological disease.

PATIENTS AND METHODS

Data was collected through a digital questionnaire in collaboration with the Dutch patient organization Hematon. The questionnaires EORTC-QLQ-C30, EORTC-QLQ-OH15, shortened Xerostomia Inventory (XI), and the OHIP-14 were used.

RESULTS

Seven hundred five patients were included (52.5% female, mean age 63.2 ± 10.1). The majority was diagnosed more than 2 years ago (86%) and had received treatment (81%) for their disease. Lymphoma, leukemia, and multiple myeloma were the most frequent malignancies. Chemotherapy alone, chemotherapy in combination with targeted therapy or immunotherapy, and myeloablative chemotherapy followed by autologous stem cell transplantation were the most common treatment modalities. The XI identified that 40.5% met the criteria for xerostomia. Other complaints included mouth soreness and sensitivity, gingival pain and bleeding, problems with teeth or with an ill-fitting denture. Despite reporting oral complaints, most patients experienced a rather good OH-QoL. A high xerostomia score led to a significantly lower OH-QoL. Female gender, history of stem cell transplantation, radiation to head and neck, and multiple daily medication use were significant predictors of xerostomia.

CONCLUSION

Patients with hematologic malignancies frequently reported a dry mouth and other oral complaints including mouth soreness and sensitivity, gingival pain and bleeding, and problems with teeth. Despite these oral complaints, most patients experienced a relatively good OH-QoL. Future longitudinal studies are needed, and health professionals should have an active role in providing oral supportive care based on patients' individual needs.

Multiple Oral Manifestations in a Patient With Chronic Graft Versus Host Disease: A Case Report

Hematopoietic stem cell transplantation (HSCT) is the standard treatment for hematopoietic malignancies and certain solid tumors; however, graft-versus-host disease (GVHD) remains a significant complication. Chronic GVHD (cGVHD), which occurs more than 100 days post-transplant, can lead to various oral manifestations that necessitate multidisciplinary management to prevent disease progression and enhance the quality of life. We present the case of a 60-year-old woman who developed dry mouth, oral pain, a brown-yellow tongue, and dental caries seven years after receiving HLA-matched unrelated donor HSCT. Examination revealed a brown-yellow hairy tongue, extensive tooth decay, reduced saliva production, and oral leukoplakia with mild epithelial hyperplasia, along with dysfunction of the salivary and lacrimal glands. Following appropriate treatment, the patient's symptoms resolved without recurrence at the six-month follow-up. This case highlights the importance of professional diagnosis, timely interventions, and regular monitoring in managing oral cGVHD to achieve a favorable prognosis.

Prevalence of platinum-induced ototoxicity among patients suffering from hematological malignancies - a systematic review

Platinum-based compounds used for treating hematologic malignancies can lead to various side effects. One such side effect is ototoxicity, which is characterized by permanent bilateral sensorineural hearing loss or tinnitus. Initially, it mainly affects high frequencies, but as the condition progresses, it may also affect low frequencies. Occurrence of ototoxicity has been reported in up to 80% of patients. However, the precise incidence among hematology patients remains unknown. Following Preferred Reporting Items for Systematic Reviews and meta- analyses guidelines, a systematic review was conducted to assess the incidence of ototoxicity among hematology patients undergoing platinum compound-based chemotherapy. Four databases - PubMed, Scopus, Embase, and Web of Science - were searched to identify relevant articles published in the period 2000-2023. Initially, 538 articles were screened, with only 5 meeting the criteria for inclusion in the analysis. The systematic review included a total of 77 patients, the majority of whom had Hodgkin's lymphoma (65 patients, 84.4%). Only one patient had leukemia. Of all patients, 16 (20.8%) developed ototoxicity. It is crucial for hematologic patients to undergo regular monitoring and audiometric tests even up to 10 years after treatment. Conducting prospective studies to evaluate hearing before, during, and after treatment is necessary to enhance the management of hematological patients.

MASCC/ISOO Clinical Practice Statement: The risk of secondary oral cancer following hematopoietic cell transplantation

PURPOSE

A MASCC/ISOO Clinical Practice Statement (CPS) is aimed at generating a concise tool for clinicians that concentrates practical information needed for the management of oral complications of cancer patients. This CPS is focused on the risk of secondary oral cancer following hematopoietic cell transplantation (HCT).

METHODS

This CPS was developed based on critical evaluation of the literature followed by a structured discussion of a group of leading experts, members of the Oral Care Study Group of MASCC/ISOO. The information is presented in the form of succinct bullets to generate a short manual about the best standard of care.

RESULTS

Studies described a 7-16-fold higher risk of secondary oral cancer (mainly squamous cell carcinoma) in allogeneic HCT (alloHCT) recipients, particularly in those who developed chronic graft versus host disease (cGVHD). Risk increases over time and is influenced by several risk factors. In autologous HCT, oral cancer risk seemed only slightly elevated.

CONCLUSION

Clinicians should be aware of the higher oral cancer risk in alloHCT survivors, and emphasize the importance of lifelong oral cancer surveillance (at least every 6-12 months) and avoiding cancer promoting lifestyle factors in an empathic way, particularly of those with (a history of) cGVHD. Post-HCT for Fanconi anemia or dyskeratosis congenita, education and rigorous follow-up is even more crucial. In case of suspected oral lesions in the presence of oral mucosal cGVHD, a GVHD intervention may facilitate diagnosis. Suspected lesions should be biopsied. More research is needed on the role of HPV in oral cancer post-HCT.

Oral cancer and oral potentially malignant disorders in patients with Fanconi anemia - A systematic review

The purpose of the present study was to perform a systematic review focusing on oral squamous cell carcinoma (OSCC) and oral potentially malignant disorders (OPMD) in Fanconi anemia (FA) individuals. Electronic searches were undertaken in five databases supplemented by manual scrutiny and gray literature. Case reports and/or cases series were included. The searches yielded 55 studies describing 112 cases of OSCC (n = 107) and/or OPMD (n = 5) in FA individuals. The mean age at diagnosis of OSCC/OPMD was 27.1 (±9.6) years, and females (51.8 %) were slightly more affected. Ulcer (n = 37) or mass (n = 25) were described as clinical presentations for OSCC and OPMD. White lesions (n = 4) were the most common manifestation in OPMD. Tongue (47.2 %) was the most frequent location. Sixty-one (54.5 %) individuals underwent HSCT. Surgical resection (n = 75) was the main treatment adopted. The estimated rate of OPMD malignant transformation was 1.8 % and recurrences following OSCC excision occurred in 26.8 % of individuals. Overall, at 60 months of follow-up, the probability of survival fell to 25.5 % and at 64 months the probability of recurrence increased to 63.2 %. The present data support the need for strict surveillance of patients with FA, even in the absence of OPMD, for early OSCC detection and reduction of mortality.

[Secondary cancers following allogeneic hematopoietic stem cell transplantation: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]

The Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) held the 13th edition of the Clinical Practices Harmonization Workshops. Our workgroup reviewed the current data on the incidence, screening methods and international guidelines for the prevention of secondary solid cancers following allogeneic hematopoietic stem cell transplantation. The purpose of this workshop was to provide recommendations for the screening and prevention of secondary malignancies to Francophone transplantation centers.

Oral Manifestations of Graft vs. Host Disease: A Comprehensive Review for Best Practice in Dentistry

Graft-versus-host disease (GVHD) is a complication of hematopoietic stem cell transplantation (HSCT). GVHD may also develop following solid transplants or blood transfusions if white blood cells are transferred. GVHD affects multiple organs, including the oral tissues. This pictorial review provides a background of GVHD to dental practitioners, describes the most common oral manifestations of GVHD, and highlights the main treatment modifications needed to deliver dental care to patients with GVHD. A narrative review enriched with clinical data was performed by searching the scientific literature for all articles regarding GVHD and oral manifestations/therapies. All articles without exclusion criteria, except animal tests, were included in the above review. Acute GVHD may manifest in the oral mucosa; however, it often develops immediately following HSCT when routine dental treatment is postponed. Chronic GVHD may manifest in the oral mucosa, the salivary glands, and the musculoskeletal compartment. It may indirectly affect the teeth and the oral flora, putting the patient at risk for infections. Importantly, GVHD poses an increased risk for oral cancer. GVHD has a wide range of oral manifestations, some of which may affect dental treatment.

Systemic Inflammatory Disorders, Immunosuppressive Treatment and Increase Risk of Head and Neck Cancers-A Narrative Review of Potential Physiopathological and Biological Mechanisms

Head and neck cancers (HNCs) are known to present multiple factors likely to influence their development. This review aims to provide a comprehensive overview of the current scientific literature on the interplay between systemic inflammatory disorders, immunosuppressive treatments and their synergistic effect on HNC risk. Both cell-mediated and humoral-mediated systemic inflammatory disorders involve dysregulated immune responses and chronic inflammation and these inflammatory conditions have been associated with an increased risk of HNC development, primarily in the head and neck region. Likewise, the interaction between systemic inflammatory disorders and immunosuppressive treatments appears to amplify the risk of HNC development, as chronic inflammation fosters a tumor-promoting microenvironment, while immunosuppressive therapies further compromise immune surveillance and anti-tumor immune responses. Understanding the molecular and cellular mechanisms underlying this interaction is crucial for developing targeted prevention strategies and therapeutic interventions. Additionally, the emerging field of immunotherapy provides potential avenues for managing HNCs associated with systemic inflammatory disorders, but further research is needed to determine its efficacy and safety in this specific context. Future studies are warranted to elucidate the underlying mechanisms and optimize preventive strategies and therapeutic interventions.

Perspectives on oral chronic graft-versus-host disease from immunobiology to morbid diagnoses

Chronic Graft-versus-Host Disease (cGVHD) is a major long-term complication, associated with morbidity and mortality in patients following allogenic hematopoietic cell transplantation (HCT) for immune hematopoietic disorders. The mouth is one of the most frequently affected organs after HCT (45-83%) and oral cGVHD, which may appear as the first visible sign. Manifestations present with mucosal lichenoid lesions, salivary gland dysfunction and limited oral aperture. Diagnosis of oral cGVHD severity is based on mucosal lesions with symptoms of sensitivity and pain and reduced oral intake. However, diagnostic difficulties arise due to subjective definitions and low specificity to cover the spectrum of oral cGVHD. In recent years there have been significant improvements in our understanding of the underlying oral cGVHD disease mechanisms. Drawing upon the current knowledge on the pathophysiology and biological phases of oral cGVHD, we address oral mucosa lichenoid and Sjogren's Syndrome-like sicca syndromes. We consider the response of alloreactive T-cells and macrophages to recipient tissues to drive the pathophysiological reactions and biological phases of acute inflammation (phase 1), chronic inflammation and dysregulated immunity (phase 2), and subsequent aberrant fibrotic healing (phase 3), which in time may be associated with an increased malignant transformation rate. When formulating treatment strategies, the pathophysiological spectrum of cGVHD is patient dependent and not every patient may progress chronologically through the biological stages. As such there remains a need to address and clarify personalized diagnostics and management to improve treatment descriptions. Within this review, we highlight the current state of the art knowledge on oral cGVHD pathophysiology and biological phases. We address knowledge gaps of oral cGVHD, with a view to facilitate clinical management and improve research quality on lichenoid biology and morbid forms of oral cGVHD.

Immunopathological insights into villitis of unknown etiology on the basis of transplant immunology

Villitis of unknown etiology (VUE) is an inflammatory disease characterized by the infiltration of maternal CD8 +T cells into the placental villi. Although the pathogenesis of VUE is still debated, dysregulation of the immune system appears to be an important factor in the development of the disease. Interaction of maternal T cells with the fetal antigens seems to be the trigger for the VUE onset. In this context, graft vs host disease (GVHD) and allographic rejection seem to share similarities in the VUE immunopathological mechanism, especially those related to immunoregulation. In this review, we compared the immunological characteristics of VUE with allograft rejection, and GVHD favoring a better knowledge of VUE pathogenesis that may contribute to VUE therapeutics strategies in the future.

Oral Cancer in HSCT Pediatric Patients Arising on GVHD: A Comprehensive Review

After haematopoietic stem cell transplantation and a history of GVHD, the risk of developing secondary malignancies, including oral cancer, is higher. This risk increases with time post-transplantation; therefore, pediatric patients undergoing HSCT, who have long-term survival chances, are in a high-risk category. The aim of this review is to provide data on HSCT, GVHD, clinical manifestations, histological features and treatment of oral cancer, and outcomes in HSCT pediatric patients, affected by oral GVHD, who have been developed OSCC. Descriptive statistics were used to validate data. Fifteen studies on a total of 33 patients were selected. Data on oral cancer showed that the tongue was the most frequently involved site (13 pts; 39.39%), followed by the floor of the mouth (4 pts; 12.12%), and buccal mucosa (4 pts; 12.12%). Oral squamous cell carcinoma was the histological feature reported. There were 19 (57.58%) deaths occurring between 2 and 46.5 months after OC diagnosis. Eleven patients survived with a median follow-up of 34 months. Considering the high risk of developing oral cancer, a conventional oral examination every 6 months is recommended for HSCT pediatric patients who have developed GVHD.