Cytotoxic drugs, radiotherapy and oral candidiasis

Effects of Oral Cryotherapy on Anticipatory, and Acute Nausea and Vomiting in Patients With Breast Cancer Undergoing Adjuvant Chemotherapy: A Randomized Controlled Clinical Trial

PURPOSE

To determine the effects of oral cryotherapy (OC) on the anticipatory, and acute nausea and vomiting of patients with breast cancer who are receiving adjuvant chemotherapy.

PATIENTS AND METHODS

Seventy eligible patients with breast cancer were assigned to 2 groups by stratified randomization. This parallel grouped, randomized, clinical trial used the ice application protocol. OC application for an intervention group (IG, n = 35) was performed in 3 stages: i) instructions on by the investigator at the hospital; ii) the implementation accompanied by the investigator at the hospital; iii) the individual application of at home by patients. The IG had been doing the application for 12 weeks. The patients in the control group (CG, n = 35) received standard care. Additionally, Rhodes Index of Nausea Vomiting, and Retching, and EORTC QLQ-C30 Life Quality Index were conducted on the first (T1 = cycle 1 day 0), second (T2 = cycle 2 day 21), third (T3 = cycle 3 day 42), and fourth (T4 = cycle 4 day 63) cycles of adjuvant chemotherapy.

RESULTS

The anticipatory nausea scores in the T2 and T4, IG were significantly lower than the CG (P < .05). In the T3, all symptom sub-dimensions except symptom occurrence (t = -0,48; P = .63) of the IG were significantly lower than those of the CG (P < .05). In the T1, T2, T3, and T4, acute nausea, acute vomiting, acute retching, and anticipatory retching scores, were significantly lower than the CG (P < .05).

CONCLUSION

OC alone was effective and safe for the treatment of nausea and vomiting. The results of this study showed the clinical applicability of OC in the management of nausea and vomiting.

A preliminary study of suppression of candida infection by miconazole mucoadhesive tablets in oral or oropharyngeal cancer patients undergoing radiotherapy

Elevated numbers of candida in the oral cavity often lead to oral candidiasis development in patients undergoing radiotherapy for oral or oropharyngeal cancer. This study aimed to verify the effect of miconazole mucoadhesive tablets on suppression of oral candida infection during radiotherapy. For this preliminary interventional study, miconazole mucoadhesive tablets were attached to the oral mucosa for 14 days from when grade 2 oral mucositis appeared in patients with oral or oropharyngeal cancer receiving radiotherapy, and the incidence of oral candidiasis was investigated. Various clinical factors were examined; univariate and multivariate Cox regression analyses were performed to investigate and compare the efficacy of this drug in preventing oral candidiasis with results of our previous study as historical control. Miconazole mucoadhesive tablets were administered to 18 patients, and oral candidiasis was observed in one patient (5.6%) after treatment completion. Among 144 historical control patients, 43 (29.9%) developed oral candidiasis. Multivariate Cox regression showed that miconazole mucoadhesive tablets significantly reduced oral candidiasis development during radiotherapy (p = 0.049, Hazard ratio 0.136, 95% confidence interval 0.019–0.994). This preliminary study suggests the efficacy of miconazole mucoadhesive tablets in preventing oral candidiasis in oral or oropharyngeal cancer patients treated with radiotherapy.

Trial registration: Japan Registry of Clinical Trials (jRCT), jRCTs071190023. Registered 3 September, 2019.

Type 2 diabetes mellitus and oral Candida colonization: Analysis of risk factors in a Sri Lankan cohort

Aims: Oral candidiasis is a major oral manifestation of uncontrolled diabetes mellitus, and a number of cofactors are associated with the pathogenesis of this infection. Here, we describe the prevalence of oral Candida in a Sri Lankan cohort of type 2 diabetes mellitus and risk factors that predispose them to this common fungal infection. Methods: A case-control study was conducted in 250 diabetics with type 2 diabetes and 81 nondiabetic controls. Clinical and demographic data were collected using an interviewer administered questionnaire, and patient records. Oral rinse samples were collected to determine the candidal carriage, and the resultant yeast growth was quantified and speciated using multiplex-PCR and phenotypic analyses. Chi-square test (χ² test) and Fisher exact test were used for the determination of the significant relationships between risk factors and oral candidiasis. Results: The oral prevalence of Candida species among both groups was similar (81%) although a significantly higher proportion of diabetics (32.8%) yielded >2000 CFU/mL of yeasts compared with only 12.3% of the healthy controls (p < .05). Significant associations were noted between oral candidal carriage amongst diabetics, and (i) denture wearing, (ii) female gender and (iii) cigarette smoking (all, p < .05). Amongst both groups, C.albicans was the most common Candida species isolated followed by C. parapsilosis, C. tropicalis and C. glabrata. Conclusions: The oral infestation of Candida in our Sri Lankan cohort of diabetics is significantly higher than their healthy counterparts, and co-carriage of multiple yeast species is a common finding in the study population. As there are no previous such reports of the latter phenomenon particularly from the Asian region it is noteworthy, mainly in view of the recent data on the emergence of drug-resistant yeast species the world over.

Identification of uncommon oral yeasts from cancer patients by MALDI-TOF mass spectrometry

Background

Opportunistic infections due to Candida species occur frequently in cancer patients because of their inherent immunosuppression. The aim of the present study was to investigate the epidemiology of yeast species from the oral cavity of patients during treatment for oncological and haematological malignancies.

Methods

MALDI-TOF was performed to identify yeasts isolated from the oral cavity of 350 cancer patients. Moreover, antifungal susceptibility testing was performed in according to CLSI guidelines (M27-A3).

Results

Among 162 yeasts and yeast-like fungi isolated from the oral cavity of cancer patients, Candida albicans was the most common species (50.6%), followed by Candida glabrata (24.7%), Pichia kudriavzevii (Candida krusei (9.9%)), Candida tropicalis (4.3%), Candida dubliniensis (3.7%), Kluyveromyces marxianus (Candida kefyr (3.7%)) and Candida parapsilosis (1%). In addition, uncommon yeast species i.e., Saprochaete capitata, Saccharomyces cerevisiae, Clavispora lusitaniae (C. lusitaniae) and Pichia kluyveri (C. eremophila) were recovered from oral lesions. Oral colonization by C. albicans, non-albicans Candida species and uncommon yeasts were as follow; 55%, 44% and 1%, whereas oral infection due to C. albicans was 33.3%, non-albicans Candida species 60.6%, and uncommon yeasts 6.1%. Poor oral hygiene and xerostomia were identified as independent risk factors associated with oral yeast colonization. The overall resistance to fluconazole was 11.7% (19/162). Low MIC values were observed for anidulafungin for all Candida and uncommon yeast species.

Conclusions

This current study provides insight into the prevalence and susceptibility profiles of Candida species, including emerging Candida species and uncommon yeasts, isolated from the oral cavity of Iranian cancer patients. The incidence of oral candidiasis was higher amongst patients with hematological malignancies. The majority of oral infections were caused by non-albicans Candida species which were often more resistant to anti-fungal agents. Our findings suggest that anidulafungin should be used as antifungal of choice for prophylaxis in clinically high-risk patients with documented oral colonization or infection.

Candida infanticola and Candida spencermartinsiae yeasts: Possible emerging species in cancer patients

Opportunistic infections due to Candida species occur frequently in intensive care settings. We investigated the prevalence of Candida species among 65 clinical specimens obtained from 200 cancer patients by phenotypic and molecular (ITS sequencing and AFLP) methods. Among the 65 yeast isolates, Candida albicans was the most commonly isolated species (n = 34, 52.3%), whereas other Candida species comprised 47.7% (n = 31) and consisted of Candida glabrata (n = 14, 21.5%), Candida tropicalis (n = 5, 7.7%) and uncommon Candida species (n = 12, 18.5%) such as Candida pelliculosa (n = 3, 4.6%), Pichia kudriavzevii (= Candida krusei, n = 2, 3.1%), Candida orthopsilosis (n = 2, 3.1%), Candida parapsilosis (n = 1, 1.5%), Candida infanticola (n = 2, 3.1%), Candida spencermartinsiae (n = 1, 1.5%), and Kluyveromyces marxianus (=Candida kefyr, n = 1, 1.5%). Candida infanticola and Candida spencermartinsiae were recovered from oral lesions of cancer patients. Matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) easily confirmed these isolates as less common Candida isolates (4.6%). The in vitro antifungal susceptibilities of C. spencermartinsiae and the two strains of C. infanticola were determined according to CLSI guidelines (M27-A3). MIC results among these isolates showed they were susceptible to isavuconazole, posaconazole and voriconazole, however, fluconazole and caspofungin had high MIC values. These Candida species that may occur more commonly in infections remain unnoticed using commonly used phenotypical methods in routine microbiology laboratories. MALDI-TOF MS proved to be a more fast and robust diagnostic technique for identification of the yeasts isolated from different clinical specimens of cancer patients.

Denture Stomatitis: Causes, Cures and Prevention

Removable dentures are worn by 20% of the UK population and two thirds of these individuals have denture stomatitis. Poor oral hygiene is commonplace among this group, as is smoking and xerostomia, which also contribute to the development of denture stomatitis. A complex polymicrobial biofilm is able to proliferate on the surface of denture materials and matures to form visible denture plaque. This denture plaque biofilm stimulates a local inflammatory process that is detectable clinically as erythema, and hyperplasia. Systemically, denture plaque represents a potential risk factor for systemic disease, in particular aspiration pneumonia. Respiratory pathogens have been detected in the denture plaque and overnight denture wear has been linked to an increased risk of aspiration pneumonia. There is a general lack of evidence on the adequate management of denture stomatitis and we present a protocol for use in the primary care setting.

Liaison between micro-organisms and oral cancer

Oral cancer which is a subtype of head and neck, cancer is any neoplastic tissue growth in the oral cavity. It comprises an abnormal mass of cells that foists genetic mutation and impedes the normal cell cycle, resulting in its unrestrained growth. Various studies on the plausible link between oral microbial flora and cancer notwithstanding, our understanding of their link remains obscure and inadequate. The multitude of mechanisms by which the microflora initiate or spur Carcinogenesis are still under study and scrutiny. As is widely known, the oral cavity is an abode to a wide assortment of microbes, each present in contrasting amounts. It is observed that increased growth of the microflora is concomitant with known clinical risk factors for oral cancer. Manifold bacterial species have been found to interfere directly with eukaryotic cellular signaling, adopting a style typical of tumor promoters. Bacteria are also known to impede apoptosis thereby potentially promoting carcinogenesis. The viral role in carcinogenesis (by annulling of p53 tumor suppressor gene and other cellular proteins with subsequent alteration in host genome function) is well documented. Furthermore, the changes occurring in the commensal microflora in accompaniment with cancer development could possibly be used as a diagnostic indicator for early cancer detection. The intention of this review is to obtain a better understanding of the "role" that micro-organisms play in oral cancer etiology.

Management of oropharyngeal mycosis in head and neck cancer occurring during (chemo) radiotherapy: an Italian radio-oncologist survey

AIMS AND BACKGROUND

Oropharyngeal candidiasis is a common disorder in head and neck cancer patients (HNCPs) who underwent (chemo)-radiotherapy. An Italian survey was conducted in order to investigate radiation oncologists' behavior in regard to diagnosis, prevention, and treatment of oral candidiasis.

METHODS AND STUDY DESIGN

Between April and May 2013, a national online 18-question survey was sent to major Italian radiotherapy centers.

RESULTS

All Italian regions were represented and 86 radiation oncologists were involved. Eighty-three percent of responders estimated that oropharyngeal candidiasis occurred in 30%-40% of their HNCPs. The majority of responders were able to recognize oral mycosis when it occurred in a localized pseudomembranous form and all responders agreed with the fact that oral candidiasis was always associated with mucositis. A prophylactic therapy was prescribed occasionally by 35% and routinely by 20% of responders. Forty percent prescribed an antifungal drug in the case of suspected mycotic infection and 20% waited for symptomatic clinical evidence before prescribing a therapy. In the presence of candidiasis, mainly topical fluconazole (59%) and itraconazole (36%) were prescribed. Concomitant chemo-radiotherapy was first identified as a risk factor for mycosis occurrence and development. Ninety-nine percent of responders believed that oral mycosis was associated with increased toxicity and 44% of them interrupted treatment due to candidiasis.

CONCLUSIONS

A variety of approaches to oropharyngeal candidiasis emerges from this survey; further clinical trials are necessary to identify the best approach for oral mycosis prevention and treatment and to establish specific international guidelines for HNCPs.

Investigation of the oral infections and manifestations seen in patients with advanced cancer

Objective: A prospective, observational study was undertaken to investigate the epidemiology of oral infection among the patients with advanced malignancies, and to investigate the effects of therapy strategies and risk factors on the incidence of oral infection.

Methods: The patients with advanced malignancies were enrolled into the study. The incidence of oral infection with different malignant tumor groups or different treatment methods and the diagnoses of oral infection were confirmed. Demographic data on age, gender, bed rest time, nutritional status, smoking habit and the presence of oral prosthesis were also recorded.

Results: Oral infection was prevalent in 46% (391/850) of all cancer patients, with the highest rate in oral and maxillofacial cancer group (67%), followed by Hematological malignancy group (58.6%) and other groups (ranging from 43.3% to 35.3%). Oral candidiasis, oral herpes simplex, and oral mucositis were the popular infectious diseases in the patients. Chemotherapy and radiotherapy, especially combined radio- and chemotherapy, resulted in more oral infections compared with palliative care and surgery. Poor nutritional status and oral prosthesis were identified as independent risk factors associated with oral infection.

Conclusion: Oral infection is prevalent among advanced cancer patients and associated with therapy methods and risk factors. More oral health care should be carried out for the patients with advanced malignant tumor.

[Oropharyngeal candidiasis and radiotherapy]

The oropharyngeal candidiasis is a common condition in cancer patients treated by irradiation, during and after their treatment. For example, almost 70% of patients treated with chemoradiation for head and neck cancer are colonized, and 40% of symptomatic patients have an oropharyngeal candidiasis. Furthermore, we noticed an increase in non-albicans Candida strains, which are present in almost 50% of samples. Cancer treatments, especially radiation therapy, and comorbidities are risk factors of oropharyngeal candidiasis. Oropharyngeal candidiasis has substantial effects on quality of life, and may limit treatment. Epidemiologic data, physiopathology, clinical diagnosis criteria, consequences and treatment of oropharyngeal candidiasis will be discussed in this article.

Selection of orlistat as a potential inhibitor for lipase from Candida species

Infections caused by Candida species manifest in a number of diseases, including candidemia, vulvovaginal candidiasis, endocarditis, and peritonitis. Candida species have been reported to possess lipolytic activity due to the secretion of lipolytic enzymes such as esterases, lipases and phospholipases. Extra-cellular hydrolytic enzymes seem to play an important role in Candida overgrowth. Candidiasis is commonly treated with antimycotics such as clotrimazole and nystatin. The antimycotics bind to a major component of the fungal cell membrane (ergosterol), forming pores that lead to death of the fungus. However, the secondary effects caused during such treatment have aroused a need to develop a treatment based on lipase inhibition. Nonetheless, no such lipase inhibitors for candidiasis treatment are currently available. Thus, we have performed a docking study with the natural inhibitor, orlistat or tetrahydrolipstatin. Our results have shown ten possible binding inhibitors to Candida rugosa lipase (CRL), out of which one possibility was selected, based on the weakest interatomic distance of 2.7 Å. Therefore, we propose the selection and design of a potential inhibitor candidate, orlistat for the treatment of candidiasis infections. However, this study has to be supported with in vitro and in vivo experiments to demonstrate the effectiveness of orlistat in lipase inhibition.

Oropharyngeal candidiasis in head and neck cancer patients treated with radiation: update 2011

BACKGROUND

Oropharyngeal candidiasis (OPC) is a major cause of morbidity in patients with malignancies. It is a common complication of head and neck radiation therapy and can result in pain, dysgeusia (taste changes), anorexia, malnutrition, and esophageal or systemic dissemination. Clinicians should be aware of current epidemiology, elements of diagnosis, and therapeutic trials guiding the recent recommendations for prophylaxis and management of OPC, a disease often incorrectly perceived as benign.

METHODS

This review discusses OPC with focus in head and neck cancer patients receiving radiotherapy.

RESULTS

Local treatments are recommended as first-line therapy in milder forms of OPC. In the setting of local therapy, products that provide prolonged contact time and are not sucrose sweetened may result in successful prevention and management with low risk of oral/dental complications.

CONCLUSION

Diagnosis and management of OPC is required in head and neck cancer patients treated with radiation. Local therapy is suggested as first-line treatment for OPC, unless severe clinical infection or high risk immune suppression necessitate systemic therapy. The availability of effective locally delivered (topical) medications may provide potential for prophylaxis for carriers of Candida species in head and cancer patients during radiation therapy.

Epidemiology of oral yeast colonization and infection in patients with hematological malignancies, head neck and solid tumors

BACKGROUND

The aim of this study was to investigate the epidemiology of oral yeast colonization and infection amongst cancer patients.

METHODS

Patients with solid tumor, head-neck cancer or hematological malignancy were recruited into the study. Demographic data on age, gender, type of cancer, preceding treatment with antibiotics, anti-fungal agents, chemotherapy, radiation or surgery and presence of dentures were recorded on admission. Oral examination and microbial swabs were obtained and yeast culture, identification and antifungal susceptibility performed.

RESULTS

Oral yeast colonization was prevalent in 56.8% (227/400) of all cancer patients and 18.9% (43/227) of those had clinical and microbiological evidence of infection. The incidence of oral candidiasis in yeast colonized patients was highest in head neck cancer (29.2%) followed by hematological malignancies (20.5%) and solid tumor (17%) patients. Age and dentures were identified as independent risk factors associated with yeast carriage. Candida albicans was the dominant (74%) species (497.5 per 1000 cancer admissions) followed by C. glabrata (11.5%), C. tropicalis (2.6%), C. krusei (2.6%) and C. parapsilosis (1.9%). The overall resistance to azoles was 28.2% (75/266). Resistance to specific drugs was seen for fluconazole (4.5%), itraconazole (11.7%), ketoconazole (11.3%), voriconazole (0.75%) and caspofungin (41.1%) but none to amphotericin B or nystatin.

CONCLUSIONS

The highest incidence of oral candidiasis amongst cancer patients was seen in head neck cancers. The majority of infections were caused by C. albicans but almost one third of patients harbored non-C. albicans strains such as C. glabrata which were often more resistant to anti-fungal agents.

Treatment strategies for oropharyngeal candidiasis

BACKGROUND

Oropharyngeal candidiasis (OPC) is a common oral disease that may cause oral symptoms, lead to regional infection (e.g., esophageal candidiasis) and increase the risk of systemic fungal infection in the compromised host.

OBJECTIVE

Critical review of the literature of prevention and therapy.

METHODS

The literature was reviewed using PubMed, and specific keywords from the MeSH Database were used.

RESULTS/CONCLUSION

Management of OPC requires that the underlying risk factors of infection be diagnosed and managed whenever possible. Antimicrobials may be provided as topical or systemic therapy. Topical therapies may provide effective management for candidiasis in the non-compromised host and increase the control of colonization in the compromised host. Advances in prevention and management include new agents and improved mechanisms of topical drug delivery.

Management of oral infections in cancer patients

The myelosuppressive and mucosal-damaging consequences of cancer and cancer therapies place patients at high risk for developing infectious complications. Bacterial, fungal, and viral infections are all commonly encountered in the oral cavity, contributing to both morbidity and mortality in this patient population. Prevention, early and definitive diagnosis, and appropriate management are critical to ensure optimal treatment outcomes. With the majority of cancer patients treated as outpatients in the community setting, oral health care professionals play an important role in managing such infectious complications of cancer therapy.

Use of prophylactic antifungals in the immunocompromised host

Oral candidiasis is a significant infection in patients being treated with chemotherapy and radiotherapy for cancer, and in patients who are immunocompromised because of HIV infection and AIDS. Candida albicans is the most common fungal pathogen and has developed an extensive array of putative virulent mechanisms that allows successful colonization and infection of the host under suitable predisposing conditions. The purpose of this review of the literature was to assess the effectiveness of interventions for the prevention of oral candidiasis in immunocompromised patients and in patients treated for cancer with radiotherapy and/or chemotherapy. These patient categories were selected because they have been the topic of published randomized controlled clinical trials. The studies reviewed provide strong evidence that oral candidiasis is associated with greater morbidity and mortality in these populations, which substantiates the aggressive treatment and prophylaxis of this infection. The literature supports the recommendation that systemically applied antifungal drugs have the greatest efficacy for the treatment of oral candidiasis in cancer and immunocompromised patients; however, these therapies must be prescribed with a thorough assessment for the risk for developing drug-induced toxicities. Guidelines on the prevention of drug-resistant oral candidiasis in these patients are not available and require elucidation. Further studies are required to expand the knowledge base of evidence-based antifungal therapies in a wider variety of immunocompromised patients and conditions, such as Sjögren's syndrome, diabetes, and denture wearers. Additional exploration is needed to determine which antifungal drug formulation, dose, and method of delivery is preferable for the type of fungal infection and the underlying etiology.

Tulbaghia alliaceaphytotherapy: a potential anti-infective remedy for candidiasis

The reproductive health of individuals is severely compromised by HIV infection, with candidiasis being the most prevalent oral complication in patients. Although not usually associated with severe morbidity, oropharyngeal candidiasis can be clinically significant, as it can interfere with the administration of medications and adequate nutritional intake, and may spread to the esophagus. Azole antifungal agents are commonly prescribed for the treatment and prophylaxis of candidal infections, however, the emergence of drug resistant strains and dose limiting toxic effects has complicated the treatment of candidiasis. Consequently, safe and effective and affordable medicine is required to combat this fungus. Commercial garlic (Allium sativum) has been used since time immemorial as a natural antibiotic, however, very little is known about the antifungal properties of two indigenous South African species of garlic, namely Tulbaghia alliacea and Tulbaghia violacea, used as folk medicines for a variety of infections. This study compares the in vitro anticandidal activity of Tulbaghia alliacea, Tulbaghia violacea and Allium sativum extracts. It was found that the greatest concentrations of inhibitory components were extracted by chloroform or water. The IC50 concentrations of Tulbaghia alliacea were 0.007-0.038% (w/v). Assays using S. cerevisiae revealed that the T. alliacea extract was fungicidal, with a killing half-life of approximately 2 h. This inhibitory effect of the T. alliacea extracts was observed via TLC, and may be due to an active compound called marasmicin, that was identified using NMR. This investigation confirms that extracts of T. alliacea exhibit anti-infective activity against candida species in vitro.

The impact of cigarette/tobacco smoking on oral candidosis: an overview

Smoking is associated with a variety of changes in the oral cavity. Cigarette smoke has effects on saliva, oral commensal bacteria and fungi, mainly Candida, which causes oral candidosis, the most common opportunistic fungal infection in man. How cigarette smoke affects oral Candida is still controversial. This brief overview is an attempt to address the clinical findings on the relationship between smoking and oral candidosis and possible mechanisms of pathogenicity.