Mucites radio-induites buccopharyngées : actualités sur la prise en charge

[Dental state in patients with head and neck cancers]

In France, in 2005, there were approximately 16,000 new cases of head and neck cancer. These cancers have an unfavourable prognosis: the survival rates at 3 and 10 years are 50% and 10% respectively. The consumption of alcohol and tobacco is the most important risk factor; in some countries HPV infection was identified as a risk factor of head and neck tumours. Furthermore, a poor oral hygiene seems to raise this risk. We found many decay and periodontium problems in patients with an upper aerodigestive tract cancer. An evaluation of dental state is necessary before any cancer treatment. Treatments by radiotherapy engender noxious effects: hypocellular, hypovascularization, hypoxie of the irradiated tissues, which lead to immediate and chronically oral complications such as mucositis, fibrosis, xerostomia, decay, or osteoradionecrosis. An oral follow-up of these patients can prevent these complications, or reduce the severity of oral complications, and promote a good oral state.

[Pain management in radiation oncology]

The goal of this article is to propose some practical means of pain management in radiation departments. Pain management in radiation oncology is difficult because of the high proportion of painful patients, underestimation by medical teams, and limited therapeutic options. Pain can cause mobilization difficulties, set-up errors, treatment interruption. According to procedure steps, a preventive attitude (for pre-radiation consultation) or an active attitude (for treatment) to quickly relieve the patient can be planned. This work is a brain storming about pain management. It is not a review about analgesic radiotherapy. The practical situations apply to patients to whom radiotherapy is indicated. Teamwork and anticipation are keywords to relieve patients. All proposed means are not always available for different reasons (time, finance, staff, training). The idea is to establish simple procedures that are appropriate to each center to fluidify acts, to optimize time for a successful irradiation.

Exploration of the protection of riboflavin laurate on oral mucositis induced by chemotherapy or radiotherapy at the cellular level: what is the leading contributor?

Oral or gastrointestinal mucositis is a frequent phenomenon in cancer patients receiving chemotherapy or radiotherapy. In addition, several clinical investigations have demonstrated in recent years that riboflavin laurate has the potential to protect the patients from the disease induced by chemotherapy or radiotherapy. In our studies, it is observed that riboflavin laurate can ameliorate either chemotherapy- or radiotherapy-induced toxicities on Helf cells, and the effect is greater than that of riboflavin. In addition, riboflavin laurate is able to transport through the Caco-2 cell monolayer as the prototype, indicating the protective effects may be produced by the prototype of riboflavin laurate, rather than simply by the released riboflavin.

Low-level laser therapy: a standard of supportive care for cancer therapy-induced oral mucositis in head and neck cancer patients?

BACKGROUND AND AIMS

Oral mucositis (OM) is still a common and severe acute side-effect of many oncologic treatments, especially in patients treated for head and neck cancer. It may affect quality of life, require supportive care and impact treatment planning and its efficacy. Low-level laser therapy (LLLT) seems to promote pain relief and reduces OM incidence and its severity. It has been recommended for these patients as a treatment option but without any consensus in the LLLT procedure. New recommendations and perspectives for clinical trials will be discussed. Materials (Subjects) and Methods: Step by step, the efficacy of soft laser in the management of iatrogenic oral mucositis has been evaluated during the last two decades. Its effectiveness and level of recommendation got stronger with time. We will report and discuss some major results and the latest recommendations published on this topic.

RESULTS

The major clinical results have been reported and analysed last year in a first meta-analysis (1)). 11 randomized placebo-controlled trials were selected with a total of 415 patients treated with chemotherapy and/or radiotherapy for head and neck cancer. The relative risk for developing OM was significantly reduced after LLLT but only for a dose between 1 to 6 Joules per point. Pain, severity and duration of OM grade ≥ 2 were also reduced without difference with placebo for possible side-effects. Nine years after the positive results published for patients treated by radiotherapy alone (2)), a new French randomized, multicentric, phase III trial for patients treated with new standard treatment, using LLLT in accordance to recent recommendations is ongoing. Seven centers are specifically established for this trial which should include a hundred patients.

CONCLUSIONS

The very encouraging results of LLLT in the prevention and treatment of OM in patients treated by chemotherapy or radiotherapy for advanced head and neck cancer could soon be proposed as a new standard of care, according to the multinational Association of Supportive care in Cancer (MASCC) criteria. Modern lasers are less time consuming and extraoral applicators for a possible use by trained paramedical staff could be helpful to complete clinician practice. A preventive dose of 2 J/cm(2) and a curative dose of 4 J/cm(2) if using a red wavelength lasers are now recommended.

[Esophageal toxicity of radiation therapy: clinical risk factors and management]

Acute radiation-induced esophagitis includes all clinical symptoms (odynophagia, dysphagia) occurring within 90 days after thoracic irradiation start. Its severity can be graded using RTOG and CTCAE scales. The clinical risk factors are: age, female gender, initial performance status, pre-therapeutic body mass index, pre-therapeutic dysphagia, tumoral and nodal stage, delivered dose, accelerated hyperfractionned radiotherapy, concomitant association of chemotherapy to radiotherapy and response to the treatment. The dosimetric parameters predictive of esophagitis are: mean dose, V(20Gy), V(30Gy), V(40Gy), V(45Gy) and V(50Gy). Amifostine is the only drug to have a proven radioprotective efficacy (evidence level C, ESMO recommendation grade III). The medical management of esophagitis associates a diet excluding irritant food, medication against gastroesophageal reflux, analgesic treatment according to the WHO scale and management of dehydration and denutrition by enteral feeding.