Rapid resolution of refractory chemotherapy-induced oral mucositis with platelet gel-released supernatant in a pediatric cancer patient: a case report

Intravenous opioids for chemotherapy-induced severe mucositis pain in children: Systematic review and single-center case series of management with patient- or nurse-controlled analgesia (PCA/NCA)

BACKGROUND

Chemotherapy-induced oral mucositis can result in severe pain. Intravenous (IV) opioids are recommended, but management protocols vary. We systematically reviewed studies reporting IV opioid use for pain related to chemotherapy-induced severe oral mucositis in children and conducted a large single-center case series.

METHODS

Ovid MEDLINE, PubMed, and Cochrane databases were searched for studies reporting IV opioid duration and/or dose requirements for severe mucositis. Secondly, our pain service database was interrogated to describe episodes of opioid administration by patient- or nurse-controlled analgesia (PCA/NCA) for children with mucositis and cancer treatment-related pain.

RESULTS

Seventeen studies (six randomized trials, two prospective observational, three retrospective cohort, six retrospective case series) included IV opioid in 618 patients (age 0.3-22.3 years), but reported parameters varied. Mucositis severity and chemotherapy indication influenced IV opioid requirements, with duration ranging from 3 to 68 days and variable dose trajectories (hourly morphine or equivalent 0-97 mcg/kg/h). Our 7-year series included PCA/NCA for 364 episodes of severe mucositis (302 patients; age 0.12-17.2 years). Duration ranged from 1 to 107 days and dose requirements in the first 3 days from 1 to 110 mcg/kg/h morphine. Longer PCA/NCA duration was associated with: higher initial morphine requirements (ρ = 0.46 [95% CI 0.35, 0.57]); subsequent increased pain and need for ketamine co-analgesia (118/364 episodes with opioid/ketamine 13.9 [9.8-22.2] days vs opioid alone 6.0 [3.9-10.8] days; median [IQR]); but not with age or sex.

CONCLUSIONS

Management of severe mucositis pain can require prolonged IV opioid therapy. Individual and treatment-related variability in analgesic requirements highlight the need for regular review, titration, and management by specialist services.

Efficacy of Platelet Gel in Children with Stomatitis during Chemotherapy

Introduction. Stomatitis (oral mucositis) is a very serious adverse effect of anticancer therapy, and it may exacerbate treatment outcomes as well as prognoses. Stomatitis is associated with pain during chewing and swallowing, causing discomfort and interfering with eating. It can also lead to weight loss and a delay in child growth and development. None of the numerous therapies used for stomatitis management can be considered universal or sufficiently effective. Allogeneic platelet gel, a formulation that adheres closely to mucosal lesions and is rich in growth factors, may be an effective treatment for accelerating the erosion-healing process. Methods. A prospective, open-label study on the efficacy of platelet gel used for the treatment of stomatitis in children during chemotherapy. Platelet gel was applied to oral mucosal lesions four times a day. Results. 28 patients with Grade II and Grade III stomatitis were enrolled in the study. The first day after applying platelet gel, 93% of patients reported relief from pain. Within 4 to 5 days, one degree of mucosal lesion regression was reported in 89% of patients, indicating a 3 to 5 day reduction in therapy compared to our previous experience. In only two patients did we observe mild adverse events in the form of a burning sensation. Conclusion. Platelet gel contributed to both pain reduction and acceleration of the oral mucosa healing process. It is a safe and effective therapy for children with stomatitis induced by chemotherapy.

Current applications of platelet gels in wound healing-A review

Human platelets play important roles in several physiologic and pathologic processes. Platelet concentrates are activated with thrombin or calcium, resulting in a viscous coagulum (platelet gel [PG]), composed of 95% platelets at least. PG is increasingly used for the treatment of a variety of soft and hard tissue defects, most notably in the management of chronic non-healing wounds. During wound healing, platelets not only play a critical role in primary hemostasis and thrombosis, but also release growth factors and cytokines to promote tissue regeneration, enhance collagen synthesis, and trigger an immune response. This review addresses a variety of aspects relevant to the functions of well-known platelet growth factors, animal and clinical studies of PG in the last decade, and different sources of platelets for PG. PG is used for non-healing chronic wounds, such as oral ulcerations related to epidermolysis bullosa and chronic graft-versus-host disease, for those, the traditional treatment effect is poor. PG maybe provide a new therapeutic direction for these diseases. Nevertheless, some uncertainty is present, the number of clinical studies is not enough. Hence, randomized controlled trials are still required to study the potential of the use of PG in the near future.

Impressive tissue regeneration of severe oral mucositis post stem cell transplantation using cord blood platelet gel

BACKGROUND

Platelet gel from cord blood (CBPG) is a recently developed blood component for topical use. We report a case of life-threatening mucositis after high-dose chemotherapy with fotemustine and cytarabine that was successfully treated with CBPG.

CASE REPORT

A patient with non-Hodgkin lymphoma who was undergoing autologous hematopoietic stem cell transplantation developed severe oral and esophageal mucositis with severe bacterial sepsis and cytomegalovirus infection, causing prolonged neutropenia. CBPG was topically administered daily to the oral cavity. The CBPG was partially reabsorbed and partially swallowed.

RESULTS

After 8 consecutive days of administration, the patient's oral mucosa markedly improved, showing restitutio ad integrum, and the patient's clinical status progressively improved. No side effects were seen after CBPG application.

CONCLUSION

This case supports the need to conduct controlled studies comparing the efficacy of autologous and allogeneic platelet gel from adult and umbilical cord blood for the topical treatment of severe oral mucositis occurring after high-dose chemotherapy.