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

Huoshan Dendrobium Zengye Jiedu Formula mitigates radiation-induced oral mucositis and improves oral immune microenvironment by targeting the EGFR/PI3K/AKT pathway: evidence from network pharmacology, molecular docking, and experimental validation

Introduction

Radiation-induced oral mucositis (RIOM) manifests as mucosal ulceration, pain, and dysphagia, disrupting treatment and quality of life. Its pathogenesis involves inflammatory imbalance and immune dysregulation, driven by microbial infiltration and cytokine storms. Current therapies remain inadequate, necessitating deeper exploration of immune-microbial interactions for effective interventions.

Methods

Bioactive components of Huoshan Dendrobium Zengye Jiedu Formula (HDZJF) and RIOM-related targets were retrieved from public databases. Core therapeutic targets and pathways were systematically analyzed via protein-protein interaction (PPI) networks, Gene Ontology (GO), and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment. Molecular docking evaluated interactions between HDZJF components and key targets. A rat RIOM model validated HDZJF efficacy by assessing mucositis severity, inflammatory cytokines, and EGFR/PI3K/AKT pathway protein expression.

Results

A total of 102 bioactive components and 379 potential targets for RIOM were identified. GO and KEGG enrichment analyses suggest that HDZJF exerts therapeutic effects on RIOM by modulating processes such as angiogenesis, inflammation, and apoptosis through pathways like PI3K-AKT. Molecular docking confirmed strong binding affinities between HDZJF components and key targets. In vivo, HDZJF reduced inflammation, promoted mucosal healing, improved body weight, and modulated protein expression related to EGFR/PI3K/AKT.

Discussion

The findings highlight HDZJF's capacity to alleviate RIOM by targeting the EGFR/PI3K/AKT pathway, thereby suppressing inflammatory responses and apoptotic processes. These results underscore HDZJF's translational potential for RIOM treatment and justify further clinical investigation into its therapeutic utility.

Analysis of factors related to radiation-induced oral mucositis in patients with head and neck tumors undergoing radiotherapy

OBJECTIVE

To explore the risk factors of radiation-induced oral mucositis (RIOM) in patients with head and neck tumors undergoing radiotherapy.

METHODS

A retrospective collection was conducted on patients with head and neck tumors who underwent radiotherapy and chemotherapy in our hospital from April 1, 2015 to April 1, 2019. They were divided into an incidence group (n = 48) and a non-incidence group (n = 76) based on whether RIOM occurred, and relevant data was collected for comparison.

RESULTS

There were statistically significant differences between the two groups of patients in terms of tumor type, smoking percentage, education level percentage, tumor stage, oral mucosal inflammation stage, radiotherapy dose, mucosal protectants, and oral hygiene condition(P < 0.05); The regression analysis results showed that smoking (OR=1.274, 95 % CI: 1.095-2.007), high-dose radiotherapy (OR=1.223, 95 % CI: 1.098-2.077), and poor oral hygiene (OR=1.367, 95 % CI: 1.024-2.890) were risk factors for RIOM.

CONCLUSION

Smoking, high-dose radiotherapy, and poor oral hygiene were risk factors for RIOM in head and neck patients after radiotherapy and chemotherapy.

Potentiality of Curcumin Against Radio-Chemotherapy Induced Oral Mucositis: A Review

In recent era, cancer is a major global health hazard and is mostly treated with either radio or chemotherapy. The above treatment procedure induces a secondary concern named as oral mucositis (OM). The disorder OM is specifically associated with oral mucosa and leads to bleeding, pain, difficulty in swallowing of solids, as well as fluids and speech difficulty. Curcumin is explored for prevention as well as treatment of OM. The article was organized via collection of enormous literatures by using the keywords like oral mucositis, chemotherapy, anti-inflammatory, curcumin, and clinical trials from search engines of different domains like Scopus, PubMed/MEDLINE, Science Direct, and Google Scholar with an increasing order of their year of publications. A numerous antineoplastic therapies resulted OM, as a devastating side effect. Moreover, the expanded pathogenesis of the disease permits a sound predictability over the patient's risk, thereby directing its adaptability and management protocols towards the achievement of novel therapeutics. An augmented interest towards curcumin as a potential therapeutic emerged because of its easy accessibility, antioxidant, anti-inflammatory, antiulcer, antimicrobial, and wound-healing abilities along with reduced side effects. Curcumin can potentially alter OM and OM-induced weight loss but showed a great heterogeneity.

Graphical Abstract

Effect of blood oxidative stress indicators on oral mucositis in patients undergoing radiotherapy for nasopharyngeal carcinoma

OBJECTIVES

To investigate the correlation of total antioxidant capacity (T-AOC), glutathione peroxidase (GSH-PX), and advanced oxidized protein product (AOPP) levels in the progression of oral mucositis (OM) during nasopharyngeal carcinoma (NPC) radiotherapy.

METHODS

This prospective study included 102 patients diagnosed with NPC and eligible for radiotherapy indications. T-AOC, GSH-PX, and AOPP were measured before treatment (T0) and during the second week (T1), fourth week (T2), and sixth week (T3) of the intensity-modulated radiation therapy (IMRT) period. Patients were categorized into severe OM (SOM) (n = 21) and Non-SOM (n = 81) groups at week 6. Serum T-AOC, GSH-PX, and AOPP levels were compared at different time periods. The trends of these markers in the two groups during the course of treatment were analyzed. Finally, stepwise logistic regression was conducted to analyze the risk factors for SOM in NPC patients undergoing IMRT.

RESULTS

At T1 and T2 of IMRT, T-AOC and GSH-PX were higher in the SOM group than in the Non-SOM group; At T3, T-AOC and GSH-PX were lower in the SOM group than in the Non-SOM group. T-AOC and GSH-PX had similar change trends in Non-SOM or SOM patients, i.e., T-AOC levels continued to increase at T2 and decreased at T3, and GSH-PX increased significantly at T2 and decreased at T3. Of interest was the fact that T-AOC and GSH-PX decreased significantly more in SOM patients than in Non-SOM patients at T3, and that AOPP levels were in a constant state of increase in SOM patients. Preoperative hypoproteinemia, the absence of oral mucosal protective agents, and the receipt of synchronous chemotherapy were independent risk factors for increasing the course of OM in patients with NPC.

CONCLUSIONS

NPC patients undergoing IMRT exhibit dynamic alterations in blood T-AOC, GSH-PX, and AOPP. Notably, the persistent elevation of these biomarkers, particularly AOPP, is significantly associated with the progression of SOM in these patients. These findings underscore the involvement of oxidative stress imbalance in the pathogenesis of oral mucositis following IMRT.

A longitudinal assessment of major mouthwashes used in alleviating pain and xerostomia among advanced nasopharyngeal carcinoma patients receiving chemoradiotherapy

OBJECTIVE

This longitudinal study aimed to evaluate the overall efficacy of mouthwashes in oral mucositis pain and mucositis xerostomia in advanced nasopharyngeal carcinoma (NPC) patients undergoing concurrent chemoradiotherapy (CCRT) at different phases throughout treatment.

METHODS

A longitudinal study enrolled 79 advanced NPC subjects receiving CCRT. The subjects were interviewed prospectively three times over 7 weeks for pain and xerostomia scores based on the various types of mouthwash used. The median pain score difference and median xerostomia score difference were utilised to determine mouthwash superiority.

RESULTS

Participants completed three interviews, during which 480 instances of mouthwash use were observed throughout different phases of the treatment period. The results showed that the median pain scores between mouthwashes differed significantly, H-Stat(3) = 30.0, 25.7 and 26.0, respectively, with p < 0.001 for all three interviews. The pain score reductions of lidocaine mouthwash (median = 2, interquartile range (IQR) = 3, 2 and 2.75 over the three interviews, respectively) were significantly higher than those of benzydamine and sodium bicarbonate mouthwashes. There were no significant differences between the studied mouthwashes in their xerostomia score reductions.

CONCLUSIONS

Lidocaine mouthwash was superior in managing oral mucositis pain at all phases throughout the entire chemoradiotherapy treatment for advanced NPC patients. There was insufficient evidence to determine the preferred mouthwash for treating oral mucositis xerostomia.

Rebamipide gargle and benzydamine gargle in prevention and management of chemo-radiotherapy and radiotherapy-induced oral mucositis in head and neck cancer patients (randomized clinical trial)

OBJECTIVES

This study aimed to evaluate the preventive and therapeutic effects of rebamipide gargle in comparison with benzydamine in head and neck cancer patients undergoing radiotherapy with or without chemotherapy.

MATERIALS AND METHODS

Phase III randomized clinical trial was conducted from January 2021 till August 2022 on one hundred patients with head and neck cancer receiving high doses of radiotherapy. These patients were equally allocated into either rebamipide group or benzydamine group, The measured outcomes were the incidence of oral mucositis ≥ grade1, according to the WHO mucositis scale, in addition to the duration, and the onset of oral mucositis.

RESULTS

There was no statistically significant difference between the two groups, regarding the incidence of a severe grade of oral mucositis (WHO grades 3), as well as the onset and duration of oral mucositis. Both gargles succeeded to prevent the development of WHO grade 4 oral mucositis. Side effects reported were mainly burning sensation in benzydamine group and nausea in rebamipide group.

CONCLUSION

Rebamipide mouthwash was as beneficial as benzydamine mouthwash in minimizing the incidence of severe oral mucositis induced by treatment of head and neck cancer. However, rebamipide gargle proved to be superior to benzydamine in terms of reduction in the severity of the radiation-induced oral mucositis.

TRIAL REGISTRATION

The trial was registered in the protocol Registration and Result system of Clinical Trials (Registration ID: NCT04685395)0.28-12-2020.