Phenylbutyrate Mouthwash Mitigates Oral Mucositis During Radiotherapy or Chemoradiotherapy in Patients With Head-and-Neck Cancer

Impact of Early Diagnosis of Maxillofacial Metastases on Treatment and Patient Outcomes - A Retrospective Study

Introduction

Maxillofacial metastases from distant primary sites account for less than 1% of cancer in the head-and-neck region and are often misdiagnosed as benign or inflammatory conditions. The purpose of this study was to describe the clinical characteristics of patients with maxillofacial metastases, treatment and outcomes.

Materials and Methods

Subjects with head-and-neck cancer were identified from the institutional database. Descriptive statistics were employed.

Results

Of 532 patients with head-and-neck cancer between 2008 and 2020, 15 (2.8%) had histologically verified metastatic lesions, of which 53.33% males with a mean age of 69 years. The median time from symptom onset to diagnosis was 17 days (range: 7-60). The mandible was the most common location (40%), followed by the parotid gland (33.33%) and maxilla (13.33%). Adenocarcinoma was the most frequent histology (60%), and half of the patients had extraoral manifestations. Tumour origin was gastrointestinal, lung (33.33% each), prostate (20%) and breast (13.3%). No predilection for tumour type or histology and location were seen. Radiographic features were non-specific, with computed tomography (CT) demonstrating periosteal reaction, bone expansion and lytic lesions and high variability in Positron Emission Tomography (PET) standardised uptake value (minimum: 2.0, maximum: 10.93 and mean: 4.14). Diagnosis led to altered treatment in 60%, more in extraoral than intraoral manifestations (71% vs. 37.5%); 40% received radiotherapy, 20% systemic treatment and none underwent surgery. Over half of the patients passed away within 6 months, median survival was 5 months, shorter in patients with intraoral than extraoral disease (3 vs. 13.2 months, P < 0.05).

Discussion

Maxillofacial metastases have elusive manifestations and often warrant specific treatment. Prospective data should evaluate associations between timely diagnosis and symptomatic improvement and survival.

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.

Natural Products for the Prevention and Treatment of Oral Mucositis-A Review

Cancer, a major world public health problem, is associated with chemotherapy treatments whose administration leads to secondary concerns, such as oral mucositis (OM). The OM disorder is characterized by the presence of ulcers in the oral mucosa that cause pain, bleeding, and difficulty in ingesting fluids and solids, or speaking. Bioactive compounds from natural sources have arisen as an effective approach for OM. This review aims to summarize the new potential application of different natural products in the prevention and treatment of OM in comparison to conventional ones, also providing a deep insight into the most recent clinical studies. Natural products, such as Aloe vera, Glycyrrhiza glabra, Camellia sinensis, Calendula officinalis, or honeybee crops, constitute examples of sources of bioactive compounds with pharmacological interest due to their well-reported activities (e.g., antimicrobial, antiviral, anti-inflammatory, analgesic, or wound healing). These activities are associated with the bioactive compounds present in their matrix (such as flavonoids), which are associated with in vivo biological activities and minimal or absent toxicity. Finally, encapsulation has arisen as a future opportunity to preserve the chemical stability and the drug bioa vailability of bioactive compounds and, most importantly, to improve the buccal retention period and the therapeutic effects.

Efficacy and safety of thalidomide in preventing oral mucositis in patients with nasopharyngeal carcinoma undergoing concurrent chemoradiotherapy: A multicenter, open-label, randomized controlled trial

BACKGROUND

This multicenter clinical trial was designed to evaluate the efficacy and safety of thalidomide (THD) in preventing oral mucositis (OM) in patients with nasopharyngeal carcinoma (NPC) undergoing concurrent chemoradiotherapy (CCRT).

METHODS

Patients with locally advanced NPC were randomly assigned to either a THD group or a control group. All 160 patients received radical intensity-modulated radiotherapy plus cisplatin-based concurrent chemotherapy and basic oral hygiene guidance. Patients in the THD group received additional THD at the beginning of CCRT. The primary end points were the latency period and the incidence of OM. The secondary end points were mouth and throat soreness (MTS), weight loss, short-term efficacy, and adverse events.

RESULTS

The median latency period of OM was 30 and 14 days in the THD and control groups, respectively (hazard ratio, 0.32; 95% confidence interval, 0.23-0.35; P < .0001). The incidence of OM and severe OM (World Health Organization grade 3 or higher) was significantly lower in the THD group than the control group (87.5% vs 97.5% [P = .016] and 27.5% vs 46.3% [P = .014], respectively). THD treatment also remarkably reduced the intensity of MTS and the degree of weight loss. In comparison with the control group, the incidence of nausea, vomiting, and insomnia was significantly decreased, whereas the incidence of dizziness and constipation was obviously increased in the THD group. The objective response rates 3 months after CCRT were similar between the groups.

CONCLUSIONS

THD prolonged the latency period, reduced the incidence of OM, and did not affect the short-term efficacy of CCRT in patients with NPC.

LAY SUMMARY

Oral mucositis is the most common complication of nasopharyngeal carcinoma during chemoradiotherapy; it decreases the patient's quality of life, and ideal mucosal protective agents are lacking. A few basic research and preclinical studies have shown that thalidomide may be an approach to ameliorating oral mucositis. The results of the current study confirm that thalidomide has a protective effect against oral mucositis in patients who have received chemoradiotherapy for nasopharyngeal carcinoma.

The survival outcome of nasopharyngeal cancer patients with traditional Chinese medicine external use: A hospital-based study

ETHNOPHARMACOLOGICAL RELEVANCE

External-use traditional Chinese medicine (TCM) agents are widely used to relieve the adverse effects of radiation therapy in nasopharyngeal cancer patients.

AIM OF THE STUDY

Our study aimed to evaluate the influence of external-use TCM agents to relieve radiotherapy-related adverse effects on the efficacy of radiation therapy and the prognosis of nasopharyngeal cancer patients.

MATERIALS AND METHODS

By using the Chang Gung Research Database (CGRD), we analyzed 1823 newly diagnosed nasopharyngeal cancer patients with radiotherapy-related adverse effects between 2001/01 and 2015/12. We used Kaplan-Meier analysis and a Cox regression model to estimate the differences in effects on survival outcomes between two groups, TCM external users and non-TCM external users.

RESULTS

We found that TCM external users had significantly better 3-year and 5-year overall survival rates (log-rank test, p = 0.0377 and p = 0.034, respectively) than non-TCM external users. The 3-year and 5-year disease-free survival rates were not statistically significantly different between the groups. We also found a trend of improved 3-year and 5-year overall survival rates in TCM external users with advanced-stage disease, without statistical significance (log-rank test, p = 0.10 and p = 0.089, respectively). The subgroup analysis revealed lower risks of mortality in TCM external users among the nonhypertension, nonhyperlipidemia, nonischemic heart disease, noncirrhosis, and nonchronic kidney disease groups.

CONCLUSIONS

Our study showed that TCM agents external use could significantly improve 3-year and 5-year overall survival rates in nasopharyngeal cancer patients with radiotherapy-related adverse effects.

A randomized, controlled phase II trial of maxillofacial and oral massage in attenuating severe radiotherapy-induced oral mucositis and lipid metabolite changes in nasopharyngeal carcinoma

PURPOSE

This randomized controlled phase II study investigated the efficacy, safety and underlying mechanism of maxillofacial and oral massage (MOM) in nasopharyngeal carcinoma (NPC) patients receiving intensity-modulated radiotherapy.

METHODS

A total of 158 NPC patients were randomly assigned 1:1 to routine oral care and medication (the control group) or that with additional MOM (the treatment group). The primary endpoint was the incidence of severe radiotherapy-induced oral mucositis (SRTOM). In addition, the time of initiation and duration of RTOM and SRTOM, adverse events, dynamic changes of lipid metabolites in peripheral blood were analyzed.

RESULTS

Seventy-six patients in the treatment group and seventy-nine in the control group completed the trial. The incidence of SRTOM in the treatment group was lower than the control (26.3% vs. 46.8%, P = 0.008). The median initiation time to RTOM and SRTOM was significantly longer in the treatment group than the control (RTOM:12 vs 10 days, hazard ratio [HR] 0.52, P < 0.001; SRTOM: 28.5 vs 19 days, HR 0.5579, P = 0.002). While the median duration time of RTOM and SRTOM in the treatment group was shorter (RTOM: 20.7 vs 24.7 days, P = 0.001; SRTOM: 8.05 vs 13.08 days, P < 0.001). Only 1.3% of patients obtained grade 3 or higher adverse events during MOM. The anti-inflammatory lipids increased significantly after MOM, especially with 10.6 Gy or higher.

CONCLUSION

MOM significantly attenuated the incidence of SRTOM in NPC patients. The adverse events of MOM were slight and tolerant. MOM enhanced anti-inflammatory lipid metabolites, which might be an underlying mechanism.

Topical Treatment of Oral Mucositis in Cancer Patients: A Systematic Review of Randomized Clinical Trials

BACKGROUND AND PURPOSE

Evidence-based protocols of topical therapy for oral mucositis (OM) induced by chemoradiotherapy (CRT) are continuously established and updated. Thus, the present systematic review aims to evaluate the scientific literature in terms of effectiveness of topical treatment of OM in cancer patients undergoing CRT.  Materials and Methods: This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist. Randomized clinical trials were identified through electronic database searches on CINAHL, Cochrane Library, LILACS, Livivo, PubMed, SCOPUS, and Web of Science. Grey literature was also assessed on Google Scholar, Open Grey, and ProQuest. The risk of bias in the included studies was assessed by the Cochrane Collaboration Risk of Bias Tool.

RESULTS

Twenty-three randomized clinical trials (n=1169 patients) met the inclusion criteria. Twenty-three different topical agents were examined and categorized into five groups: analgesics (30.4%), natural agents (21.7%), other topical agents (21.7%), antimicrobial agents (17.4%), and growth factors (8.8%). Of the included studies, 50% presented a resolution of OM within 14 days. Topical natural agents yielded good results with average resolution time of 3-7 days. The included studies generally demonstrated that patients treated with mouthwashes presented superior benefits compared to the control, depending on OM severity.

CONCLUSION

Topical agents effectively reduced the severity of OM lesions and pain intensity in patients receiving chemoradiotherapy, although the effects varied by agent type. However, the heterogeneity in the results of these topical intervention studies underscores the need for standardized clinical trial methodologies.

CLINICAL RELEVANCE

Topical agents were effective in patients with severe OM lesions receiving chemoradiotherapy and are a good alternative of home care in relation to pain control, reduction of inflammation and consequent improvement in quality of life.<br />.

Systematic review of natural and miscellaneous agents, for the management of oral mucositis in cancer patients and clinical practice guidelines - part 2: honey, herbal compounds, saliva stimulants, probiotics, and miscellaneous agents

OBJECTIVE

To update the clinical practice guidelines for the management of oral mucositis (OM) that were developed by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). This part focuses on honey, herbal compounds, saliva stimulants, probiotics, and miscellaneous agents.

METHODS

A systematic review was conducted by the Mucositis Study Group of MASCC/ISOO. The body of evidence for each intervention, in each clinical setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, one of the following guidelines were determined: Recommendation, Suggestion, No Guideline Possible.

RESULTS

A total of 78 papers were identified within the scope of this section, of which 49 were included in this review and merged with nine publications that were reported in the previous guidelines update. A new Suggestion was made for honey (combined topical and systemic delivery) for the prevention of OM in head and neck cancer patients receiving radiotherapy with or without chemotherapy. A new Suggestion clarified that chewing gum is not effective for the prevention of OM in pediatric patients with hematological or solid cancer treated with chemotherapy. No guideline was possible for other interventions.

CONCLUSIONS

Numerous natural products and herbal remedies were studied for the management of OM. Of the agents reviewed in this systematic review, a guideline in favor was made for honey (combined topical and systemic), while a guideline against was made for chewing gum. Additional research is warranted to clarify the potential of other interventions.

Efficacy of controlled-release oxycodone for reducing pain due to oral mucositis in nasopharyngeal carcinoma patients treated with concurrent chemoradiotherapy: a prospective clinical trial

BACKGROUND

Pain due to oral mucositis (OM) is a major problem during concurrent chemoradiotherapy (CCRT) in nasopharyngeal carcinoma (NPC) patients.

METHODS

We enrolled 56 NPC patients receiving CCRT and allocated them into two groups: moderate pain group (n = 27) and a severe pain group (n = 29) according to the degree of pain reported (moderate = numerical rating scale (NRS) score 4-6 or severe = NRS score 7-10) at initiation of controlled-release oxycodone (CRO) treatment.

RESULTS

Total dose of CRO was significantly higher in severe pain patients than in moderate pain patients (791.60 ± 332.449 mg vs. 587.27 ± 194.940 mg; P = 0.015). Moderate pain patients had significantly better quality of life (P = 0.037), lower weight loss (P = 0.030) and more active CCRT response (90.9% vs. 64.0%; P = 0.041). Although 24-h pain control rate was comparable in the two groups (85.2% vs. 86.2%; P = 0.508), the moderate pain group score eventually stabilized at ~ 2 vs. 3 in the severe pain group (P < 0.001); the titration time to reach bearable pain (NRS ≤ 3) was also significantly shorter in moderate pain patients (2.45 ± 0.60 days vs. 3.60 ± 1.98 days; P = 0.012). Incidence of adverse events was comparable in both groups.

CONCLUSIONS

The study findings suggest that early introduction of low-dose CRO at the moderate pain stage could help reduce the total dose required, provide better pain control, improve quality of life, and enhance CCRT response.

A novel formulation for radiotherapy-induced oral mucositis: Triamcinolone acetonide mucoadhesive film

Background

The main purpose of this study was to evaluate the effectiveness of triamcinolone acetonide (TA) mucoadhesive films versus placebo as a preventive and therapeutic intervention of oral mucositis (OM) induced by radiotherapy for head-and-neck cancer (HNC) patients.

Materials and Methods

In this double-blind, randomized case-controlled clinical trial, 60 HNC patients were randomized to receive TA mucoadhesive films (n = 30) or placebo mucoadhesive films (n = 30) taken four times daily. Mucositis severity was assessed during the course of radiation therapy using the World Health Organization scales, and pain scores were assessed using visual analog scale. Repeated measures ANOVA was used for data analysis.

Results

Mean ± standard deviation age of the TA group was 58.53 ± 8.89 years and 60% were male, whereas in the placebo group, it was 56.46 ± 9.36 years and 56.7% were male (P > 0.05). The mean value of pain score was significantly reduced in the TA group (5.36 ± 1.29 vs. 2.20 ± 2.02) compared with the placebo group (5.34 ± 0.78 vs. 4.69 ± 0.77) during 4 weeks (P < 0.001); repeated measures ANOVA analysis showed that the mean value of grade mucositis was significantly reduced in the TA group (2.40 ± 0.49 vs. 0.96 ± 0.81) compared with the placebo group (2.36 ± 0.80 vs. 1.86 ± 0.93) during 4 weeks (P < 0.001).

Conclusion

TA film could be considered as an effective approach for reducing the mucositis grading and pain score in the patients with OM.

Efficacy of Azatyrosine-Phenylbutyric Hydroxamides, a Histone Deacetylase Inhibitor, on Chemotherapy-Induced Gastrointestinal Mucositis

Gastrointestinal mucositis is a serious side effect of chemotherapy. Currently, no effective treatment exists for chemotherapy-induced mucositis, prompting the need to develop an anti-mucositis agent for use in clinics. The present study investigated whether azatyrosine-PBHA (AzP), a histone deacetylase inhibitor, has a therapeutic effect on intestinal mucosa. The results indicated that AzP did not affect the proliferation and viability of cancer cells, outcomes that are achieved by suberoylanilide hydroxamic acid (SAHA). However, AzP could decrease production of the inflammatory mediators interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and tumor-necrosis factor-α (TNF-α). In vivo histopathological assessment showed that AzP reduced cisplatin-induced injury to the jejunum villi and triggered weight loss in the C57BL/6 mice. Immunohistochemistry (IHC) results demonstrated that mice treated with AzP also recovered from cisplatin-induced injury to the intestinal mucosa. Mechanistic in vitro study using DAVID/KEGG enrichment analysis of microarray data and confirmation by a Western blot indicated the influence of AzP on the MEK/ERK and AKT-dependent pathway. In conclusion, the study demonstrated that AzP might regulate the MEK/ERK MAPK signaling pathway to attenuate MCP-1, TNF-α, and IL-6 production and provide opportunities for the development of new anti-inflammatory drugs targeting mucositis.

Randomized, Double-Blind, Placebo-Controlled Trial of Shuanghua Baihe Tablets to Prevent Oral Mucositis in Patients With Nasopharyngeal Cancer Undergoing Chemoradiation Therapy

PURPOSE

Oral mucositis is a common unpreventable complication associated with chemoradiation therapy. Shuanghua Baihe tablets have been approved by the Chinese Food and Drug Administration for treating recurrent oral mucosa ulceration. This study assessed whether Shuanghua Baihe tablets could prevent oral mucositis during chemoradiation therapy for locally advanced nasopharyngeal carcinoma.

METHODS AND MATERIALS

This multicenter, randomized, double-blind, placebo-controlled trial was conducted at 11 hospitals in China between January 22, 2014, and September 21, 2015. Eligible patients (N=240, 18-70 years old) with pathologically diagnosed locally advanced nasopharyngeal carcinoma were randomly assigned (computer-block randomization; 1:1) to receive Shuanghua Baihe tablets or a placebo (4 tablets, 3 times a day, for 7 weeks) at the initiation of chemoradiation therapy. Administration of Shuanghua Baihe tablets could be ended if grade 3 or higher oral mucositis developed and patients were unwilling to continue taking the drug. The primary endpoints were oral mucositis incidence and latency.

RESULTS

The incidence of oral mucositis during this study was significantly lower in the Shuanghua Baihe group (85.0%; 95% confidence interval [CI], 78.6%-91.4%) than in the placebo group (96.6%; 95% CI, 93.4%-99.9%; P=.0028). The median latency period was 28 days in the Shuanghua Baihe group and 14 days in the placebo group (hazard ratio, 0.17; 95% CI, 0.12-0.23; P<.0001). Compared with placebo, Shuanghua Baihe tablets significantly reduced the oral mucositis severity scores recorded by the investigators (Oral Mucositis Score, 24.0 [range, 0.0-67.8] vs 57.5 [range, 0.0-98.0]; P<.0001), full-time nurses (Oral Assessment Guide score, 462.0 [range, 392.0-664.7] vs 520.4 [range, 392.0-714.0]; P<.0001), and patients (score for soreness of mouth and throat, 4.0 [range, 0-10] vs 6.0 [range, 0-10]; P<.0001). No serious adverse events were observed, and the incidence of mild or moderate gastrointestinal adverse events associated with Shuanghua Baihe tablets was 3.3%. The short-term response rate was similar in patients receiving Shuanghua Baihe tablets and those receiving placebo during chemoradiation therapy during this study.

CONCLUSIONS

Shuanghua Baihe tablets reduced the occurrence, latency, and severity of oral mucositis in patients with nasopharyngeal cancer during chemoradiation therapy treatment.

Effectiveness of Black Mulberry Molasses in Prevention of Radiotherapy-Induced Oral Mucositis: A Randomized Controlled Study in Head and Neck Cancer Patients

OBJECTIVES

Radiation-induced oral mucositis is one of the problems experienced by 70%-80% of patients receiving radiation therapy (RT). This randomized controlled trial assessed the effectiveness of black mulberry molasses in the prevention of oral mucositis in head and neck cancer patients receiving RT.

INTERVENTIONS AND OUTCOME MEASURES

Eighty head and neck cancer patients scheduled to undergo RT to the oropharyngeal mucosa were randomly assigned to receive RT (42) or RT plus mulberry molasses (38). The research data were collected with a Patient Description Form, Common Terminology Criteria for Adverse Events, version 4.0, an Oral Assessment Guide, and the University of Washington Quality of Life Assessment Questionnaire.

RESULTS

The incidence and severity of oral mucositis were lower in the black mulberry molasses group. However, black mulberry molasses usage was an only independent and significant factor in prevention of mucositis [HR 0.63 (%95 GI 0.40-0.98)]. There were no differences between the quality of life scores of experimental and control groups.

CONCLUSIONS

This randomized controlled study showed that black mulberry molasses usage is an effective intervention in the prevention of the radiation-induced mucositis of head and neck cancer patients. However, to confirm these results, further studies are needed.

A review of radiation countermeasures focusing on injury-specific medicinals and regulatory approval status: part III. Countermeasures under early stages of development along with 'standard of care' medicinal and procedures not requiring regulatory approval for use

PURPOSE

Terrorist attacks, with their intent to maximize psychological and economic damage as well as inflicting sickness and death on given targeted populations, are an ever-growing worldwide concern in government and public sectors as they become more frequent, violent, and sensational. If given the chance, it is likely that terrorists will use radiological or nuclear weapons. To thwart these sinister efforts, both physical and medical countermeasures against these weapons are currently being researched and developed so that they can be utilized by the first responders, military, and medical providers alike. This is the third article of a three-part series in which we have reviewed additional radiation countermeasures that are currently under early preclinical phases of development using largely animal models and have listed and discussed clinical support measures, including agents used for radiation-induced emesis, as well as countermeasures not requiring Food and Drug Administration approval.

CONCLUSIONS

Despite the significant progress that has been made in this area during the last several years, additional effort is needed in order to push promising new agents, currently under development, through the regulatory pipeline. This pipeline for new promising drugs appears to be unreasonably slow and cumbersome; possible reasons for this inefficiency are briefly discussed. Significant and continued effort needs to be afforded to this research and development area, as to date, there is no approved radioprotector that can be administered prior to high dose radiation exposure. This represents a very significant, unmet medical need and a significant security issue. A large number of agents with potential to interact with different biological targets are under development. In the next few years, several additional radiation countermeasures will likely receive Food and Drug Administration approval, increasing treatment options for victims exposed to unwanted ionizing irradiation.

Management of afatinib-induced stomatitis

Severe stomatitis may lead to the need to interrupt or discontinue cancer therapy and, thus, may affect control of the primary disease. Stomatitis may also increase the risk of local and systemic infection and significantly affects the quality of life and the cost of care. The present study was conducted to evaluate the efficacy of two traditional herbal medicines in controlling treatment-induced stomatitis in a small cohort of lung cancer patients treated with afatinib. All patients who were treated with afatinib for epidermal growth factor receptor (EGFR) mutated nonsmallcell lung cancer (NSCLC) between January, 2015 and March, 2016, were included in this study. During the study period, a total of 14 NSCLC patients were treated with afatinib, an EGFR-tyrosine kinase inhibitor (TKI). Two patients already had stomatitis at the time of initiation of afatinib therapy; among the remaining 12 NSCLC patients, 2 (16.7%) developed stomatitis. All the lesions in the 4 patients who developed stomatitis were completely alleviated after 2 weeks of therapy with Aznol mouthwash, a chamomile extract with anti-inflammatory effects, and Hangeshashinto, a traditional herbal (Kampo) medicine. Afatinib therapy was re-initiated, but none of the patients developed stomatitis thereafter. To the best of our knowledge, this is the first report evaluating oral care and management of stomatitis. This type of care and treatment may reduce the incidence of complications associated with EGFR-TKI therapy.

CT-guided 125I brachytherapy in the treatment of distant metastases in the oral cavity and maxillofacial region

PURPOSE

We aimed to evaluate the feasibility and clinical effectiveness of CT-guided ¹²⁵I brachytherapy for distant oral and maxillofacial metastases.

MATERIALS AND METHODS

We retrospectively analyzed 65 patients with 84 distant oral and maxillofacial metastases. Thirty-one patients with 38 lesions received ¹²⁵I brachytherapy (group A) and 34 with 46 lesions received external beam radiotherapy (EBRT; group B).

RESULTS

Median follow-up time was 16 months. The 3-, 6-, 12-, 18-, and 24-month local control rates for group A were 83.9%, 75.9%, 66.7%, 38.4%, and 25.0%, respectively; for group B they were 76.5%, 62.5%, 43.8%, 25.0%, and 0.0%, respectively (P<.05); the median local tumor progression-free survival times were 14 and 9 months, respectively. Group A had a better local tumor progression-free survival (LTPFS) relative to group B (P<.001; HR, 6.961 [95%CI, 2.109, 9.356]). Cox proportional hazards regression analysis indicated that ¹²⁵I brachytherapy, tumor size, and primary pathological type were the independent factors affecting LTPFS. Additionally, ¹²⁵I brachytherapy showed better performance in relieving patient clinical symptoms relative to EBRT (P<.05). Group A also had fewer complications than group B, especially regarding grade 3/4 complications according to Radiation Therapy Oncology Group grading criteria. Mean overall survival times in groups A and B were 17.1 and 14.8 months, respectively.

CONCLUSION

CT-guided ¹²⁵I brachytherapy is feasible and safe for distant oral and maxillofacial metastases; it achieved a better local control rate, longer LTPFS and fewer complications without compromising overall survival compared with EBRT.

Dynamics of wound healing signaling as a potential therapeutic target for radiation-induced tissue damage

We hypothesized the histone deacetylase inhibitor phenylbutyrate (PB) has beneficial effects on radiation-induced injury by modulating the expression of DNA repair and wound healing genes. Hamsters received a radiosurgical dose of radiation (40 Gy) to the cheek and were treated with varying PB dosing regimens. Gross alteration of the irradiated cheeks, eating function, histological changes, and gene expression during the course of wound healing were compared between treatment groups. Pathological analysis showed decreased radiation-induced mucositis, facilitated epithelial cell growth, and preventing ulcerative wound formation, after short-term PB treatment, but not after vehicle or sustained PB. The radiation-induced wound healing gene expression profile exhibited a sequential transition from the inflammatory and DNA repair phases to the tissue remodeling phase in the vehicle group. Sustained PB treatment resulted in a prolonged wound healing gene expression profile and delayed the wound healing process. Short-term PB shortened the duration of inflammatory cytokine expression, triggered repeated pulsed expression of cell cycle and DNA repair-regulating genes, and promoted earlier oscillatory expression of tissue remodeling genes. Distinct gene expression patterns between sustained and short-term treatment suggest dynamic profiling of wound healing gene expression can be an important part of a biological therapeutic strategy to mitigate radiation-related tissue injury.

The efficacy of erythropoietin mouthwash in prevention of oral mucositis in patients undergoing autologous hematopoietic SCT: a double-blind, randomized, placebo-controlled trial

Oral mucositis (OM) as a complication of high-dose chemotherapy is frequently occurred in hematopoietic stem cell transplantation (HSCT) settings. Erythropoietin (EPO) has anti-inflammatory, antioxidant and wound-healing properties and therefore could have an important role in the prevention of OM. We conducted a double-blind, randomized, placebo-controlled trial to evaluate the EPO mouthwash effect on OM incidence and severity in 80 patients with non-Hodgkin's lymphoma, Hodgkin disease (HD) or multiple myeloma, undergoing autologous hematopoietic stem cell transplantation. Patients received either EPO mouthwash (50 IU/ml, 15 ml four times a day) (n = 40) or placebo (n = 40) from the starting day of high-dose chemotherapy until day +14 after transplantation or until the day of discharge from the hospital, whichever occurred first. OM was evaluated daily for 21 days after transplantation or until resolution of OM according to World Health Organization oral toxicity scale. The incidence of OM (grades 1-4) in the EPO mouthwash group and control group was significantly different (27.5% vs 77.5%, p < 0.001). The mean ± SD of two other parameters of OM including maximum intensity OM score (0.60 ± 1.06 vs 1.67 ± 1.27) and average intensity OM score (0.47 ± 0.80 vs 1.28 ± 0.86) was significantly lower in the intervention group (p < 0.001). Moreover, the mean ± SD duration of OM was also significantly shorter among the EPO mouthwash recipients (1.92 ± 3.42 days vs 5.42 ± 3.86 days, P < 0.001). Also, the duration of neutropenic fever was significantly shorter in the intervention group (2.12 ± 2.42 days vs 3.95 ± 4.01 days, p = 0.016). It is concluded that EPO mouthwash can reduce the incidence and duration of OM. Copyright © 2015 John Wiley & Sons, Ltd.