Oral mucositis in head and neck cancer: Evidence-based management and review of clinical trial data

Efficacy of turmeric in the treatment of oral mucositis in patients with head and neck cancer after radiotherapy or chemoradiotherapy: a systematic review and meta-analysis

Background

Oral mucositis is a major complication for head and neck cancer (HNC) patients after radiotherapy or chemotherapy. A meta-analysis was performed to assess the efficacy of turmeric in the treatment of oral mucositis in HNC patients.

Methods

Randomized controlled trials investigating our topic were included in the meta-analysis. The clinical outcomes considered were the severity of oral mucositis, pain level, and weight loss.

Results

A total of eight articles that met our inclusion criteria were included in our meta-analysis. At the 3-week follow-up visit, the turmeric group showed significantly lower grades of oral mucositis compared to the control group (p = 0.03). When compared to the placebo group, a significant difference in the degree of oral mucositis was observed at the 4-(p = 0.03) and 6-week (p < 0.00001) follow-up visits. No significant difference in pain levels was observed between the turmeric and control groups at any of the follow-up visits. However, a significant improvement in pain levels for the turmeric group when compared with the placebo group was observed only at the 6-week follow-up visit (p = 0.006). Interestingly, a significant improvement in pain levels was observed for the turmeric group at the 2-, 4-, 5-, and 6-week follow-up visits (p < 0.05) when compared to the non-placebo group. The turmeric group showed less weight loss than the control group at the final follow-up visit (p = 0.03).

conclusion

Our meta-analysis showed that using turmeric may be effective in improving both the severity of oral mucositis and pain levels in HNC patients who have received radiotherapy or radiochemotherapy. In addition, the turmeric group experienced less weight loss.

The Trajectory of Oral Mucositis in Head and Neck Cancer Patients Undergoing Radiotherapy and its Influencing Factors

BACKGROUND

Oral mucositis (OM) is a common and severe side effect of radiotherapy in head and neck cancer (HNC). The study aimed to investigate the longitudinal changes in OM and its influencing factors in patients with HNC during radiotherapy.

METHODS

This was a retrospective longitudinal observational study. From July 2022 to March 2023, patients with HNC undergoing radiation therapy were enrolled. OM, oral hygiene, oral infections, oral pain, feeding route, and laboratory indicators were measured at 7 times. The influencing factors of OM were analyzed using generalized estimation equations (GEEs).

RESULTS

A total of 160 patients were included in this study. The prevalence of severe OM at T0, T1, T2, T3, T4, T5, and T6 was 0, 0, 2.5%, 9.4%, 26.9%, 24.4%, and 26.9%, respectively. The prevalence of grade 1-2 OM at T0, T1, T2, T3, T4, T5, and T6 was 0, 16.3%, 53.1%, 65.1%, 61.9%, 70.7%, and 71.3%, respectively. Duration of diagnosis, clinical stage, N stage, M stage, surgery, diabetes, radiotherapy dose, oral hygiene, oral infection, oral pain, feeding route, and lymphocyte impacted OM significantly in the GEEs multivariate model.

CONCLUSIONS

OM occurs in almost all patients with HNC who undergo radiotherapy. Changes in the severity of OM are a dynamic process, with the severity increasing with the cumulative radiotherapy dose. Specialist oral evaluation and oral care are needed to alleviate the severity of OM in HNC patients.

Effectiveness of gold nanoparticles in prevention and treatment of oral mucositis in animal models: a systematic review

BACKGROUND

Oral mucositis remains a significant complication during cancer therapy with no effective treatment. Gold nanoparticles offer anti-inflammatory, antioxidant properties with low toxicity. This study systematically reviews the literature assessing gold nanoparticles in the management of oral mucositis in animal models.

METHODS

A literature search was undertaken using MEDLINE, Embase, PubMed, and Web of Science databases, using the format for Systematic Review Centre for Laboratory Animal Experimentation. Prior to the review, the protocol was registered in the systematic review register, PROSPERO (registration no. CRD42021272169). Outcome measures included ulceration, histopathological scores, inflammatory mediators, microbial growth, and pain. Study quality was analysed by SYRCLE risk-of-bias tool.

RESULTS

Only one study met the inclusion criteria, documenting reduction in ulceration, inflammatory, and oxidative biomarkers. Exposure to AuNPs prevented inflammatory response induced by 5-fluorouracil in oral mucosa of hamsters. However, a high risk of bias necessitates further research.

CONCLUSION

This review identifies a potential therapeutic strategy for prevention and management of oral mucositis. It also provides future direction for gold nanoparticle research in oral mucositis; however, there is lack of sufficient evidence to derive any conclusion. Research with standardized parameters including nanoparticle size, capping agent, surface charge, and appropriate oral mucositis animal models will establish risk-benefit balance and margin of safety for therapeutic use of gold nanoparticles for oral mucositis.

Hematopoietic colony-stimulating factors in head and neck cancers: Recent advances and therapeutic challenges

Colony-stimulating factors (CSFs) are key cytokines responsible for the production, maturation, and mobilization of the granulocytic and macrophage lineages from the bone marrow, which have been gaining attention for playing pro- and/or anti-tumorigenic roles in cancer. Head and neck cancers (HNCs) represent a group of heterogeneous neoplasms with high morbidity and mortality worldwide. Treatment for HNCs is still limited even with the advancements in cancer immunotherapy. Novel treatments for patients with recurrent and metastatic HNCs are urgently needed. This article provides an in-depth review of the role of hematopoietic cytokines such as granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), macrophage colony-stimulating factor (M-CSF), and interleukin-3 (IL-3; also known as multi-CSF) in the HNCs tumor microenvironment. We have reviewed current results from clinical trials using CSFs as adjuvant therapy to treat HNCs patients, and also clinical findings reported to date on the therapeutic application of CSFs toxicities arising from chemoradiotherapy.

Effectiveness of fluconazole as antifungal prophylaxis in cancer patients undergoing chemotherapy, radiotherapy, or immunotherapy: systematic review and meta-analysis

This review assessed the effectiveness of fluconazole as antifungal prophylaxis on the incidence of oral fungal diseases in patients undergoing cancer treatment. The secondary outcomes evaluated were the adverse effects, discontinuation of cancer therapy due to oral fungal infection, mortality by a fungal infection, and the mean duration of antifungal prophylaxis. Twelve databases and records were searched. The RoB 2 and ROBINS I tools were used to assess the risk of bias. The relative risk (RR), risk difference, and standard mean difference (SMD) were applied with 95% confidence intervals (CI). The certainty of the evidence was determined by GRADE. Twenty-four studies were included in this systematic review. In randomized controlled trials pooling, fluconazole was a protective factor for the primary outcome (RR = 0.30; CI: 0.16, 0.55; p < 0.01, vs placebo). Compared to other antifungals, fluconazole was only more effective than the subgroup of amphotericin B and nystatin (alone or in combination) (RR = 0.19; CI: 0.09, 0.43; p < 0.01). Fluconazole was also a protective factor in non-randomized trials pooling (RR = 0.19; CI: 0.05, 0.78; p = 0.02, vs untreated). The results showed no significant differences for the secondary outcomes. The certainty of the evidence was low and very low. In conclusion, prophylactic antifungals are necessary during cancer treatment, and fluconazole was shown to be more effective in reducing oral fungal diseases only compared with the subgroup assessing amphotericin B and nystatin, administered alone or in combination.

Severe Oral Mucositis After Intensity-Modulated Radiation Therapy for Head and Neck Cancer

Importance

Oral mucositis (OM) is a common and debilitating adverse effect observed in patients with head and neck cancer (HNC) receiving radiation therapy (RT). Previous studies examining associations between OM and clinical outcomes were performed in the era of 3-dimensional conformal RT planning with low rates of concurrent chemotherapy, and thus may not reflect current practice.

Objective

To prospectively assess patient-reported OM and identify its associations with clinical outcomes and quality of life.

Design, Setting, and Participants

This cohort study performed at a single institution included 702 consecutive patients who underwent definitive or adjuvant intensity-modulated RT (IMRT) for primary HNC from February 9, 2015, to May 27, 2022. Data were analyzed from November 28, 2022, to August 18, 2023.

Main Outcomes and Measures

Severity of OM was assessed based on highest reported mouth and throat soreness (MTS) score during radiotherapy according to the Oral Mucositis Weekly Questionnaire-Head and Neck Cancer survey, which was administered weekly during IMRT. Linear mixed models were used to compare mean MTS scores grouped by disease site and chemotherapy regimen. Fisher exact tests and 1-way analysis of variance tests were performed to identify associations between severity of OM and clinical outcomes.

Results

Among 576 eligible patients, the median age was 62.5 (IQR, 56.3-69.1) years, and 451 patients (78.3%) were men. In terms of race and ethnicity, 6 patients (1.0%) were American Indian or Alaska Native; 2 (0.3%), Asian; 31 (5.4%), Black; 8 (1.4%), Hispanic or Latino; 509 (88.4%), White; and 28 (4.9%), unknown. The most common treatment site was oropharynx (268 [46.5%]), and most patients received concurrent chemotherapy (464 [80.6%]). By the end of treatment, 360 patients (62.5%) developed severe OM and 568 (98.6%) developed some degree of OM. Linear mixed models found no significant differences in OM between HNC disease sites. Groups with greater highest severity of OM reported had higher rates of measured outcomes (listed respectively by MTS score 0, 1, 2, 3, and 4): feeding tube placement (0%, 3.6% [2 of 56], 6.6% [10 of 152], 14.7% [40 of 272], and 21.6% [19 of 88]; P = .001), hospitalization (12.5% [1 of 8], 10.7% [6 of 56], 15.1% [23 of 152], 23.9% [65 of 272], and 28.4% [25 of 88]; P = .02), opiate use (0%, 19.6% [11 of 56], 42.8%[65 of 152], 61.4% [167 of 272], and 64.8% [57 of 88]; P < .001) and experienced greater weight loss (median, -0.7 [IQR, -1.7 to -0.4] kg; median, 3.9 [IQR, 1.1 to 6.1] kg; median, 5.0 [IQR, 2.2 to 7.7] kg; median, 4.7 [IQR, 2.1 to 7.7] kg; and median, 7.7 [IQR, 2.8 to 10.6] kg; P < .001).

Conclusions and Relevance

In this cohort study of patients with HNC, 62.5% developed severe OM. Higher severity of OM was associated with feeding tube placement, hospitalization, opiate use, and weight loss. Improvements in OM prevention and management are needed.

Comparative evaluation of oral mucositis in oral cancer patients undergoing 3-dimensional conformal radiation therapy and intensity modulated radiation therapy with or without chemotherapy

Context

Oral cancer is a significant cause of death across the world. A combined multimodal approach integrating surgery and radiation therapy (RT) with or without chemotherapy (CT) is commonly employed in advanced oral cancer to prevent recurrences and locoregional spread. Oral mucositis is a common acute toxicity reported in patients undergoing RT and CT. The delivery of optimal cancer therapy protocols is compromised due to morbidity caused by oral mucositis.

Aims

To compare the severity of oral mucositis in oral cancer patients undergoing 3-Dimensional Conformal Radiation Therapy (3DCRT) and Intensity Modulated Radiation Therapy (IMRT) with or without concomitant CT.

Settings and Design

This was a prospective, unicentric and longitudinal study conducted in a cancer centre.

Methods and Material

One hundred four patients with locally advanced oral cancer were enrolled in this study. Fifty-two patients were treated with IMRT and 52 patients with 3DCRT to a dose of >60 Gy, along with concurrent cisplatin weekly CT. Mucositis was recorded before the start, in the end, 1 month, and 3 months post-chemoradiotherapy treatment.

Statistical Analysis Used

Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) software (v. 21.0, Chicago. 2012). Descriptive and frequency statistics were performed for different parameters assessed in 3DCRT and IMRT group.

Results

Grade 3 mucositis was the most predominant grade observed in both groups at the end of treatment. Thirty-six patients (69.3%) versus 24 patients (46.1%) developed grade 3 mucositis in 3DCRT and IMRT group, respectively (P = 0.013). Healing was better with IMRT group when compared to 3DCRT group 1 month and 3 months post-RT. Mucositis was severe in patients undergoing concomitant CT.

Conclusions

IMRT reduced the incidence of severe mucositis and also improved the treatment-compliance compared to 3DCRT in locally advanced head neck cancer patients treated by chemoradiotherapy.

A Prospective Study of Nurse-Led Oral Mucositis Management: Impact on Health Outcomes of Patients Receiving Radiotherapy for Head and Neck Cancer and Lung Cancer

OBJECTIVES

The study aimed to evaluate the impact of nurse-led mucositis management on the health outcomes of patients receiving radiotherapy for head and neck cancer and lung cancer. The study adopted a holistic approach that involved the patient in the care process by screening, providing education and counseling about mucositis management and integrating it into daily life by the radiotherapy nurse.

DATA SOURCES

In this prospective, longitudinal cohort study, 27 patients were assessed and monitored through use of the WHO Oral Toxicity Scale and Oral Mucositis Follow-up Form and educated on mucositis during their radiotherapy through use of the Mucositis Prevention and Care Guide. At the end of radiotherapy, an evaluation of the radiotherapy process was performed. In this study, each patient was followed for 6 weeks from the start of radiotherapy.

CONCLUSION

The worst clinical data for oral mucositis and its variables emerged at week 6 of treatment. While the Nutrition Risk Screening score increased over time, weight decreased was observed to decrease. The mean stress level was 4.74 ± 0.33 in the first week and 5.77 ± 0.35 in the last week. It was observed that 88.9% of the patients showed good compliance with the treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nurse-led mucositis management contributes to better patient outcomes during the radiotherapy process. Such an approach improves oral care management in patients receiving radiotherapy for head and neck and lung cancer, demonstrating its positive impact on additional patient-focused outcomes.

Scales to graduate oral mucositis: What are the limitations?

Oral mucositis is a common acute complication of a head and neck squamous cell carcinoma treatment. Multiple scales can be used to diagnose and grade this lesion, but they all have some limitation regarding this group of patients. Most of these issues are associated with the hardness to differentiate signs and symptoms from oral mucositis vs. the inherent neoplasm. This study highlights the importance of a specifically developed scale for patients with head and neck squamous cell carcinoma.

Towards unravelling biological mechanisms behind radiation-induced oral mucositis via mass spectrometry-based proteomics

Objective

Head and neck cancer (HNC) accounts for almost 890,000 new cases per year. Radiotherapy (RT) is used to treat the majority of these patients. A common side-effect of RT is the onset of oral mucositis, which decreases the quality of life and represents the major dose-limiting factor in RT. To understand the origin of oral mucositis, the biological mechanisms post-ionizing radiation (IR) need to be clarified. Such knowledge is valuable to develop new treatment targets for oral mucositis and markers for the early identification of "at-risk" patients.

Methods

Primary keratinocytes from healthy volunteers were biopsied, irradiated in vitro (0 and 6 Gy), and subjected to mass spectrometry-based analyses 96 h after irradiation. Web-based tools were used to predict triggered biological pathways. The results were validated in the OKF6 cell culture model. Immunoblotting and mRNA validation was performed and cytokines present in cell culture media post-IR were quantified.

Results

Mass spectrometry-based proteomics identified 5879 proteins in primary keratinocytes and 4597 proteins in OKF6 cells. Amongst them, 212 proteins in primary keratinocytes and 169 proteins in OKF6 cells were differentially abundant 96 h after 6 Gy irradiation compared to sham-irradiated controls. In silico pathway enrichment analysis predicted interferon (IFN) response and DNA strand elongation pathways as mostly affected pathways in both cell systems. Immunoblot validations showed a decrease in minichromosome maintenance (MCM) complex proteins 2-7 and an increase in IFN-associated proteins STAT1 and ISG15. In line with affected IFN signalling, mRNA levels of IFNβ and interleukin 6 (IL-6) increased significantly following irradiation and also levels of secreted IL-1β, IL-6, IP-10, and ISG15 were elevated.

Conclusion

This study has investigated biological mechanisms in keratinocytes post-in vitro ionizing radiation. A common radiation signature in keratinocytes was identified. The role of IFN response in keratinocytes along with increased levels of pro-inflammatory cytokines and proteins could hint towards a possible mechanism for oral mucositis.

Nano shield: a new tetrahedral framework nucleic acids-based solution to radiation-induced mucositis

Radiation-induced oral mucositis (RIOM) is considered to be one of the most important public health problems today, affecting the overall well-being of millions of patients who have received radiotherapy. Nevertheless, the field of preventing and treating RIOM is still widely unexplored. Curcumin (Cur) with its promising anti-inflammatory and antioxidant properties is accompanied with obstacles in application, including poor dissolubility, instability and low bioavailability. In this study, a tetrahedral framework nucleic acid drug delivery system (TFNAS) was synthesized and established using a novel method to carry Cur (Cur-TFNAS) for efficient drug delivery. The results showed that Cur-TFNAS enhanced the antioxidant capacity of human oral mucosal keratin-forming cells (HOKs) compared to free Cur and TFNAS. Meanwhile, Cur-TFNAS reduced DNA damage and shielded the cells from inflammatory factors. A similar result was also well documented in vivo. Herein, we consider that Cur-TFNAS acts as a nano-shield for preventing radiation oral mucositis and shows important clinical value in the future.

Benzydamine-An Affordable Over-the-Counter Drug with Psychoactive Properties-From Chemical Structure to Possible Pharmacological Properties

Benzydamine is a non-steroidal anti-inflammatory drug with distinct pharmacological properties from other compounds in the same therapeutic class. The differences are structural and pharmacological in nature; the anti-inflammatory mechanism is not strictly explained by the ability to interfere with the synthesis of prostaglandins. The compound is used strictly in local inflammatory diseases (inflammation in the oral and vaginal mucosa). In addition to the therapeutic indications found in the summary of product characteristics (SPC), the compound is used, in high doses, as a psychotropic substance for oral administration, having similar properties to lysergic acid diethylamide (LSD). As an over-the-counter (OTC) compound, it is easy to obtain, and the consequences of using it for purposes other than those assumed by the manufacturer raise various concerns. The reasons are related to the pharmacodynamic and pharmaco-toxicological properties, since neither the mechanism of action nor the possible side effects that would result from systemic consumption, in high doses, even occasionally, have been fully elucidated. The present review aims to analyze the pharmacodynamic properties of benzydamine, starting from the chemical structure, by comparison with structurally similar compounds registered in therapy (as an anti-inflammatory or analgesic) or used for recreational purposes.

Antimicrobial photodynamic therapy for the treatment of oral mucositis - a comparative study

OBJECTIVES

The aim was to evaluate the effectiveness of the photobiomodulation associated to antimicrobial photodynamic therapy in the treatment of oral mucositis.

BACKGROUND

Oral Mucositis is a frequent complication of oral cavity and oropharynx cancer. Considering the OM aggravation by microorganisms contamination, disinfection provide by antimicrobial photodynamic therapy could be an effective approach.

MATERIAL AND METHODS

This comparative study included fourteen patients undergoing radiochemotherapy for oral cavity and oropharynx cancer treatment, who developed oral mucositis.

CONTROL GROUP

photobiomodulation. Intervention group: photobiomodulation and antimicrobial photodynamic therapy. The lesion size, duration, pain, and identification of microorganisms were evaluated.

RESULTS

The mean reduction in oral mucositis size in the intervention group was 0.70 cm² (±0.35) and 0.30 cm² (±1.10) for the control group. The mean duration of oral mucositis was 18.37 days (±12.12) for the intervention group and 23 days (±14.78) for the control group. The intervention group had a mean reduction of 3.40 points on the pain scale (±2.44), while the control group had 0.17 (±2.28). In the intervention group, the predominant isolated microbiota was featured as mixed culture (n=4/ 50%), followed of Gram Positive (n=3/ 37.50%), and Gram Negative (n=1/ 12.55%). In the control group, mixed culture was also more frequent (n=4 / 66%), followed by Gram Positive (n=2 /34%). Gram Negative was not predominantly isolated in the control group.

CONCLUSION

No statistical significance was found between PBM-T alone and PBM-T + PDT. However, the better outcomes reached by PBM-T + PDT group would suggest there could be a role for combined treatment in the management of OM lesions.

The relationship of serum gastrin-17 and oral mucositis in head and neck carcinoma patients receiving radiotherapy

OBJECTIVE

The aim of this study was to analyze the relationship of serum gastrin-17 (G-17) and oral mucositis in head and neck carcinoma (HNC) patients receiving radiotherapy.

METHODS

Serum G-17 were detected in patients before and after radiotherapy. Patients were divided into high G-17 group (baseline serum G-17 ≥ 5pmol/L) and low G-17 group (baseline serum G-17 < 5pmol/L). The severity of oral mucositis was analyzed between the two groups. Other complications such as dysphagia, salivary gland, mandible, thyroid function, larynx, pain, and weight loss were also investigated.

RESULTS

Forty-two patients were analyzed in this study. The level of serum G-17 had a significant decrease after radiotherapy (7.29 ± 5.70pmol/L versus 4.93 ± 4.46pmol/L, P = 0.038). In low serum G-17 group, the incidences of grade 0, 1-2 and 3-4 of oral mucositis were 0%, 30.4%, and 69.6%, respectively. In high serum G-17 group, the incidences of grade 0, 1-2 and 3-4 of oral mucositis were 0%, 63.2%, and 36.8%, respectively. Pearson correlation analysis showed that serum G-17 was negatively correlated with oral mucositis (r=-0.595, P < 0.01). Weight loss of low G-17 group was more serious than that of high G-17 group.

CONCLUSION

Serum G-17 has a close relationship with oral mucositis. Baseline serum G-17 may be a potential predictor for the severity of oral mucositis in HNC patients receiving radiotherapy.

Antimicrobial Peptides-Mechanisms of Action, Antimicrobial Effects and Clinical Applications

The growing emergence of antimicrobial resistance represents a global problem that not only influences healthcare systems but also has grave implications for political and economic processes. As the discovery of novel antimicrobial agents is lagging, one of the solutions is innovative therapeutic options that would expand our armamentarium against this hazard. Compounds of interest in many such studies are antimicrobial peptides (AMPs), which actually represent the host's first line of defense against pathogens and are involved in innate immunity. They have a broad range of antimicrobial activity against Gram-negative and Gram-positive bacteria, fungi, and viruses, with specific mechanisms of action utilized by different AMPs. Coupled with a lower propensity for resistance development, it is becoming clear that AMPs can be seen as emerging and very promising candidates for more pervasive usage in the treatment of infectious diseases. However, their use in quotidian clinical practice is not without challenges. In this review, we aimed to summarize state-of-the-art evidence on the structure and mechanisms of action of AMPs, as well as to provide detailed information on their antimicrobial activity. We also aimed to present contemporary evidence of clinical trials and application of AMPs and highlight their use beyond infectious diseases and potential challenges that may arise with their increasing availability.

Effect of chewing gum on the management of chemotherapy-induced oral mucositis in children: Systematic review of experimental studies

OBJECTIVE

It was aimed to systematically synthesise the available literature on examining the effect of chewing gum in the management/reduction of chemotherapy-induced oral mucositis in children.

METHODS

The PRISMA was followed for the systematic review. All published studies obtained from the relevant databases were examined while the research question and inclusion and exclusion criteria were considered. The Joanna Briggs Institute (JBI) critical appraisal tools were used to evaluate the quality of the studies.

RESULTS

A total of five studies met the inclusion criteria: three randomised controlled trials (RCT) and two quasi-experimental studies with a total of 461 paediatric oncology patients were included. Heterogeneity was found across all studies regarding the application of gum chewing and regarding the effectiveness of gum chewing. Two RTCs and one quasi-experimental study reported that gum chewing is not effective to reduce severe oral mucositis, but effective to reduce moderate and mild oral mucositis, and one RTC reported that gum chewing is not effective to reduce oral mucositis.

CONCLUSION

Experimental studies particularly randomised controlled trials using rigorous designs, consistent outcome measures, and larger sample sizes are required to determine the efficacy of chewing gum in reducing chemotherapy-induced oral mucositis in paediatric oncology patients. Study was registered in PROSPERO and number was CRD42022328916.

Noninvasive Systemic Modalities for Prevention of Head and Neck Radiation-Associated Soft Tissue Injury: A Narrative Review

BACKGROUND

 Radiation-associated soft tissue injury is a potentially devastating complication for head and neck cancer patients. The damage can range from minor sequelae such as xerostomia, which requires frequent daily maintenance, to destructive degenerative processes such as osteoradionecrosis, which can contribute to flap failure and delay or reverse oral rehabilitation. Despite the need for effective radioprotectants, the literature remains sparse, primarily focused on interventions beyond the surgeon's control, such as maintenance of good oral hygiene or modulation of radiation dose.

METHODS

 This narrative review aggregates and explores noninvasive, systemic treatment modalities for prevention or amelioration of radiation-associated soft tissue injury.

RESULTS

 We highlighted nine modalities with the most clinical potential, which include amifostine, melatonin, palifermin, hyperbaric oxygen therapy, photobiomodulation, pentoxifylline-tocopherol-clodronate, pravastatin, transforming growth factor-β modulators, and deferoxamine, and reviewed the benefits and limitations of each modality. Unfortunately, none of these modalities are supported by strong evidence for prophylaxis against radiation-associated soft tissue injury.

CONCLUSION

 While we cannot endorse any of these nine modalities for immediate clinical use, they may prove fruitful areas for further investigation.

In pursuit of next-generation therapeutics: Antimicrobial peptides against superbugs, their sources, mechanism of action, nanotechnology-based delivery, and clinical applications

Antimicrobial peptides (AMPs) attracted attention as potential source of novel antimicrobials. Multi-drug resistant (MDR) infections have emerged as a global threat to public health in recent years. Furthermore, due to rapid emergence of new diseases, there is pressing need for development of efficient antimicrobials. AMPs are essential part of the innate immunity in most living organisms, acting as the primary line of defense against foreign invasions. AMPs kill a wide range of microorganisms by primarily targeting cell membranes or intracellular components through a variety of ways. AMPs can be broadly categorized based on their physico-chemical properties, structure, function, target and source of origin. The synthetic analogues produced either with suitable chemical modifications or with the use of suitable delivery systems are projected to eliminate the constraints of toxicity and poor stability commonly linked with natural AMPs. The concept of peptidomimetics is gaining ground around the world nowadays. Among the delivery systems, nanoparticles are emerging as potential delivery tools for AMPs, amplifying their utility against a variety of pathogens. In the present review, the broad classification of various AMPs, their mechanism of action (MOA), challenges associated with AMPs, current applications, and novel strategies to overcome the limitations have been discussed.

Inflammation-targeted cannabidiol-loaded nanomicelles for enhanced oral mucositis treatment

One of the most common complications of cancer chemotherapy is oral mucositis (OM), a serious kind of oral ulceration, but its effective treatment remains a serious challenge. In this study, we used deoxycholic acid and fucoidan to prepare inflammation-targeting nanomicelles (FD), because fucoidan can target inflammation due to its high binding affinity for P-selectin. The hydrophobic anti-inflammatory drug cannabidiol (CBD) was then loaded into the hydrophobic core of FD. The resulting CBD-loaded FD micelles (CBD/FD) had uniform particle size and morphology, as well as favorable serum stability. Moreover, administration of the FD micelles via intravenous injection or in situ dripping in an OM mouse model enhanced the accumulation and retention of CBD. CBD/FD also showed a better anti-inflammatory effect compared to free CBD after local or systemic administration in vivo, while they accelerated OM healing and inhibited Ly6G inflammatory cell infiltration and NF-κB nuclear transcription. Our results show that CBD/FD nanomicelles are a promising agent for OM treatment.

Possible cytoprotective mechanisms of oxytocin against 5-fluorouracil-induced gastrointestinal mucositis

Gastrointestinal mucositis is a common and dose-limiting side effect characterized by ulcerative lesions in the mucosa of the digestive tract in patients receiving anticancer drugs such as 5-fluorouracil (5-FU), a potent antineoplastic drug. Several protocols have reported the efficacy of therapeutic interventions to prevent this side effect, although complete success has not yet been achieved and mucositis remains one of the most serious complications associated with 5-FU therapy. Oxytocin, a well-known antistress agent, has been reported to have comparable effects to ranitidine. Previous studies have shown that oxytocin inhibits gastric acid secretion and the expression of proinflammatory cytokines in rats. If oxytocin can reduce stress-induced ulcers via antioxidant, antiapoptotic, and anti-inflammatory pathways, then it may have a dose-dependent effect on gastrointestinal mucositis caused by 5-FU.

Efficacy of GMI, a fungal immunomodulatory protein, for head and neck cancer patients with chemotherapy-related oral mucositis: An open-labeled prospective single-arm study

BACKGROUND

Cancer patients usually suffer from intensive chemotherapy-related oral mucositis (OM), yet limited effective treatment can rapidly alleviate OM severity.

METHODS

This prospective study examined the efficacy of Reishimmune-S containing one fungal immunomodulatory protein, GMI on OM in patients with head and neck cancer. Patients with head and neck cancer and the diagnosis of chemotherapy-related OM were enrolled randomizedly to receive standard supportive care with/without Reishimmune-S 500 mg/day orally for consecutive 14 days. Due to intolerance to standard supportive care alone in the control arm, only the experimental arm with Reishimmune-S supplementation was analyzed in our trial. OM grading was evaluated as the primary outcome on day 1, 8, and 15. Secondary outcomes were absolute neutrophil counts and quality of life assessed by the EORTC-QLQ-H&N 35 questionnaire on day 1, 8, and 15.

RESULTS

Reishimmune-S supplement significantly reduced OM grading both at day 8 and 15. Trouble with social contact and weight loss conditions were also improved by Reishimmune-S. Reishimmune-S did not significantly affect absolute neutrophil counts during the 15-day follow-up.

CONCLUSION

Reishimmune-S supplement potentially alleviates the severity of chemotherapy-mediated OM.

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.

Phytochemical-rich vegetable and fruit juice alleviates oral mucositis during concurrent chemoradiotherapy in patients with locally advanced head and neck cancer

Background

Objective

Methods

Results

Conclusion

Section

Taxonomy

•

The blended vegetable and fruit juice (VFJ) was rich in total polyphenols and carotenoids.

•

In head and neck cancer patients, the VFJ was significantly associated with a lower risk of chemoradiotherapy-induced ulcerative oral mucositis.

•

VFJ is healthy, safe, and effective dietary strategy against oral mucositis.

Oral Administration of Probiotics Reduces Chemotherapy-Induced Diarrhea and Oral Mucositis: A Systematic Review and Meta-Analysis

Background

Chemotherapy generally causes serious diarrhea and oral mucositis in cancer patients, and subsequently affects treatment. Oral administration of probiotics provides a therapeutic choice to address these limitations. This study aims to conduct a systematic review and meta-analysis on the efficacy of oral probiotic use in the management of the chemotherapy-induced adverse reactions, and to summarize the mechanisms underlying the action.

Methods

We searched PubMed, Embase, ClinicalTrials.gov, and Web of Science from the start of the study to its completion on Dec. 31, 2021. Risk of bias was assessed using Cochrane Collaboration's Tool. Statistical analysis of the acquired data was performed via the RevMan and the Stata Statistical Software. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42020220650).

Results

Twelve randomized controlled trials including 1,013 patients were recruited and analyzed via the standard procedure of meta-analysis. In contrast to the control group, orally taking probiotics significantly decreased the risk of chemotherapy-induced diarrhea (≥ 1 grade) (RR = 0.70; 95% Cl: 0.56, 0.88; P = 0.002) and oral mucositis (≥ 1 grade) (RR: 0.84; 95% Cl: 0.78, 0.91; P < 0.00001) at all grades. Further analysis found that severe diarrhea (≥ 2 grades) (RR: 0.50; 95% Cl: 0.32, 0.78; P = 0.002) and severe oral mucositis also significantly declined (≥ 3 grades) (RR: 0.66; 95% Cl: 0.55, 0.79; P < 0.00001) after oral probiotic use. Interestingly, the beneficial effects of probiotics displayed statistically significant only in Asian patients. Importantly, the more species of bacteria they took, the lower the incidences of the adverse reactions occurred. We used Egger's test P value to confirm that there is no publication bias.

Conclusions

This meta-analysis demonstrated that orally administrated probiotics has a potential to decrease chemotherapy-induced diarrhea and oral mucositis incidences. However, the efficacy of oral probiotic use against the adverse reactions needs to be further verified through more clinical trials, and the species and number of probiotics have to be optimized and standardized prior to clinical applications.

Systematic Review Registration

https://www.crd.york.ac.uk, identifier: 220650.

Diclofenac versus tramadol for mucositis related pain in head and neck cancer patients undergoing concurrent chemoradiation-a phase 3 study

Background

Oral mucositis related pain during CTRT in head and neck cancers is a common problem. Unfortunately, in spite of it being common, there is limited evidence for selection of systemic analgesic in this situation. Hence, this study was designed to compare the analgesic effect of a non-steroidal anti-inflammatory drug (diclofenac) versus a weak opioid (tramadol).

Patients and methods

This was an open-label, parallel design, superiority randomised controlled study. In this study, head and neck cancer patients undergoing radical or adjuvant chemoradiation, who had grade 1 or above mucositis (in accordance with Common Terminology Criteria for Adverse Events version 4.03) and had pain related to it were randomly assigned to either diclofenac or tramadol for mucositis related pain control. The primary endpoint was analgesia after the first dose. The secondary endpoints were the rate of change in analgesic within 1 week, adverse events and quality of life.

Results

One hundred and twenty-eight patients were randomised, 66 in diclofenac and 62 in tramadol arm. The median area under the curve for graph of pain across time after first dose of pain medication for the diclofenac arm and the tramadol arm was 348.936 units (range: 113.64–1,969.23) and 420.87 (101.97–1,465.96), respectively, (p = 0.05619). Five patients (8.1%) in the tramadol arm and 11 patients (16.7%) in the diclofenac arm required a change in analgesic within 1 week of starting the analgesic (p = 0.184). There was no statistically significant difference in any adverse events between the two arms. However, the rate of any grade of renal dysfunction was numerically higher in the diclofenac arm (10.6% versus 4.8%, p = 0.326).

Conclusion

In this phase 3 study, evaluating diclofenac and tramadol for chemoradiation induced mucositis pain, there was no statistical difference in analgesic activity of these two drugs.

Head and neck radiotherapy leading to extensive late oral soft-tissue necrosis

Radiotherapy is generally used as an adjuvant treatment in malignant head and neck tumors, which can cause a series of toxicities to tissues involved in the radiation field. Hard tissue necrosis surrounding the tumor is widely debated and recognized; however, oral mucosa necrosis as a late effect of head and neck radiotherapy is a toxicity that has been little explored and understood in the literature. The present report describes a 53-year-old Caucasian, diabetic man with a painful yellowish mass in the buccal mucosa, remaining oral mucositis with history of radiotherapy completed 90 days ago as adjuvant treatment for a polymorphic adenocarcinoma in the palate. Photobiomodulation was used as therapy for tissue necrosis with good therapeutic response despite discontinuation of treatment by the patient. Since there are few descriptions and illustrations of radiotherapy-related soft tissue necrosis, the current case may bring some new experience with this important topic, which directly impacts on the patient's quality of life.

[Low-level laser therapy in oncology - what's new? Analysis of 2018-2021 publications]

Low-level laser therapy (LLLT) is included in the Federal project «Fight against oncological diseases», which provides for equipping all specialized medical institutions in Russia with the appropriate devices until 2026.

PURPOSE OF THE STUDY

Publications analysis on the use of LLLT in oncology.

MATERIAL AND METHODS

To search for publications, databases and libraries were used: PubMed, Scopus, ResearchGate, Google Scholar, J-STAGE, eLibrary.ru for the period 2018-2021. For analysis, publications were selected that are of interest from the point of view of improving the methodology of LLLT, the prospects for the development of this method in the prevention, treatment and rehabilitation of patients. A total of 223 publications were found, including 39 reviews and meta-analyses, mostly in English (165) and Portuguese (41).

RESULTS AND DISCUSSION

The inclusion of LLLT in the ISOO/MASCC/ASCO recommendations for the treatment of complications such as mucositis, salivary gland hypofunction and xerostomia caused by non-surgical methods of treating cancer patients should be considered as a promising trend. An extremely low level of quality of LLLT techniques was noted, most often the replacement with meaningless «doses», «fluences» instead of the necessary parameters: wavelength, operating mode, power, frequency, exposure, etc. The use of only local illumination instead of systemic methods of LLLT does not allow obtaining the best results of treatment and prevention. Eliminating the shortcomings of treatment protocols with a focus on Russian experience, when laser blood illumination (intravenously or externally) and laser acupuncture are also necessarily carried out with local illumination of the lesion, will bring the effectiveness of LLLT to a qualitatively new, higher level.

Morbidity in Patients with Nasopharyngeal Carcinoma and Radiation-Induced Skin Lesions: Cause, Risk Factors, and Dermatitis Evolution and Severity

OBJECTIVE

Radiation-induced skin injuries such as lesions (RSLs) and dermatitis are the most common complication during radiotherapy (RT) for nasopharyngeal carcinoma, but little is known about risk factors unique to oncology. This study sought a greater understanding of these risk factors to stratify patients based on risk and guide clinical decision-making.

METHODS

Investigators analyzed the data of 864 consecutive patients referred to the RT center of the Southern Theater General Hospital for a new RSL from 2013 to 2019. These patients were followed up for an average of approximately 16 months until their death or March 30, 2020, whichever came first. Multivariate logistic regression analysis and Cox proportional hazards model were used to identify predictors of grade 3 or 4 dermatitis.

RESULTS

The main causes of treatment interruption included dermatitis and oral mucositis. Significant patient-specific risk factors for RSLs included current smoking, current drinking, and lower Karnofsky Performance Scale score and significant procedure-specific risk factors included receiving intensity-modulated radiation therapy (IMRT), hyperfractionated RT, induction chemotherapy, multicycle chemotherapy, and taxol- and cisplatin-based drugs. The three factors that independently predicted risk of RSL were IMRT, lower Karnofsky Performance Scale score, and multicycle chemotherapy. Comparing predictive factors among patients with severe RSL revealed that patients who received IMRT were more likely to develop grade 3 or 4 dermatitis.

CONCLUSIONS

Oncology providers should note that IMRT is an aggressive technique with a trend toward increased RSL. Providers should pay special attention to adverse effects to skin in patients with nasopharyngeal carcinoma.

The effects of herbal medicines on cancer therapy-induced oral mucositis: A literature review

Cancer therapy-induced oral mucositis (OM) is one of the most troublesome morbidities after radio-chemotherapy. Age, nutritional status, tumor type, oral hygiene, and treatment method are the determinants for OM incidence. In addition, oxygen-free radicals can act as a trigger for an inflammatory milieu that causes OM. Based on the debilitating nature of OM, finding a safe and inexpensive agent with anti-inflammatory, anti-microbial, and antioxidative properties can be valuable for this situation. Considering the harmful effects of some chemical agents, herbal medicine has been suggested as a potential alternative owing to unique properties such as safety, availability and low cost. Many studies have illustrated several pharmacological properties of herbal medicines in recent years, such as anti-inflammatory, anti-microbial, and antioxidative activities, which are essential factors in the palliation of cancer therapy-induced OM. This review aimed to evaluate herbal medicines' effects on cancer therapy-induced OM. According to this comprehensive review, it is concluded that medicinal plants and phytochemicals can be used as practical agents in the palliation of cancer therapy-induced OM without any serious side effects.

Biomedical Relevance of Novel Anticancer Peptides in the Sensitive Treatment of Cancer

The global increase in cancer mortality and economic losses necessitates the cautious quest for therapeutic agents with compensatory advantages over conventional therapies. Anticancer peptides (ACPs) are a subset of host defense peptides, also known as antimicrobial peptides, which have emerged as therapeutic and diagnostic candidates due to several compensatory advantages over the non-specificity of the current treatment regimens. This review aimed to highlight the ravaging incidence of cancer, the use of ACPs in cancer treatment with their mechanisms, ACP discovery and delivery methods, and the limitations for their use. This would create awareness for identifying more ACPs with better specificity, accuracy and sensitivity towards the disease. It would also promote their efficacious utilization in biotechnology, medical sciences and molecular biology to ease the severity of the disease and enable the patients living with these conditions to develop an accommodating lifestyle.

Oral mucositis. Is it present in the immunotherapy of the immune checkpoint pd1/pd-l1 against oral cancer? A systematic review

BACKGROUND

Oral mucositis (OM) is a painful lesion that takes place in the mucosa of the oral cavity, usually its etiology is associated with drug therapies in cancer patients. It is presented as well-defined ulcers whose painful symptomatology sometimes implies the suspension of oncological treatment or parenteral feeding, being therefore an important adverse effect, marking the evolution of these types of therapies against cancer. The present work aim is to know the prevalence of oral mucositis in oral cancer immunotherapy compared to its prevalence in standard therapy.

MATERIAL AND METHODS

A protocol was developed for a systematic review following PRISMA® guidelines and a focused question (PICO) was constructed. A comprehensive literature search was conducted on electronic databases including PubMed, the SCOPUS database, the Cochrane library and the Web of Science (WOS).

RESULTS

Six clinical trials were included that met the different inclusion criteria. In these articles, a discrepancy between the prevalence of OM in patients treated with chemotherapy and patients treated with immunotherapy related to the immune checkpoint PD-1/PD-L1 (Nivolumab and Pembrolizumab) was observed.

CONCLUSIONS

The prevalence of oral mucositis is lower in new immunotherapy with monoclonal antibodies against oral cancer than drugs used so far (chemotherapy drugs [methotrexate, cisplatin] as well as cetuximab). However, more studies should be carried out to confirm these data.

Genes Relevant to Tissue Response to Cancer Therapy Display Diurnal Variation in mRNA Expression in Human Oral Mucosa

Background:

To address a critical gap for application of cancer chronotherapy of when would be the best time(s) for treating an individual cancer patient, we conducted a pilot study to characterize diurnal variations of gene expression in oral mucosal tissue, which is vulnerable to damage from cancer therapies.

Methods:

We conducted RNA-seq assay on individual oral mucosal samples collected from 11 healthy volunteers every 4 hours (6 time points). Using a cosine-based method, we estimated the individual and average values of peak-time and amplitude for each gene. Correlations between gene expression peak-times and age was examined, adjusting for individual’s sleep timing.

Results:

Among candidate gene pathways that are relevant to treatment response, 7 of 16 genes (PER3, CIART, TEF, PER1, PER2, CRY2, ARNTL) involved in circadian regulation and 1 of 118 genes (WEE1) involved in cell cycle regulation achieved p-value ≤ 0.1 and relative amplitude>0.1. The average peak times were approximately 10:15 for PER3, CIART and TEF, 10:45 for PER1, 13:00 for WEE1, PER2 and CRY2, and 19:30 for ARNTL. Ranges in peak times across individuals differed by gene (e.g., 8 hours for PER1; 16.7 hours for WEE1). Older people had later peak times for PER1 (r = 0.77, p = 0.03) and PER3 (r = 0.69, p-value = 0.06).

Conclusion:

In oral mucosa, expression of some genes relevant to treatment response displayed diurnal variation. These genes may be candidates for development of biomarkers for optimizing individual timing of cancer therapy using non-invasively collected oral mucosa.

Radiation-induced acute injury of intensity-modulated radiotherapy versus three-dimensional conformal radiotherapy in induction chemotherapy followed by concurrent chemoradiotherapy for locoregionally advanced nasopharyngeal carcinoma: a prospective cohort study

To address whether the addition of intensity-modulated radiotherapy (IMRT) compared to three-dimensional conformal radiotherapy (3D-CRT) aggravate radiation-induced acute injury of locoregionally advanced nasopharyngeal carcinoma (LANPC) patients with induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CCRT). We conducted a prospective study of 182 patients in the stage III to IVb with biopsy-proven nonmetastatic LANPC who newly underwent radiotherapy and sequentially received IC, followed by CCRT at our institution. Occurring time of radiation-induced toxicities were estimated and compared using the Kaplan–Meier method and Log-rank test. The most severe acute toxicities included oral mucositis in 97.25% and dermatitis in 90.11%. Subset analysis revealed that Grade 3–4 acute dermatitis were significantly higher in the IMRT than 3D-CRT. Oral mucositis and dermatitis were the earliest occurrence of acute injuries (2 years: 60.44% and 17.58%). Patients in IMRT group achieved significantly lower risk of bone marrow toxicity, but higher risk of leukopenia and gastrointestinal injury. Multivariate analyses also demonstrated that IMRT, female gender and hepatitis were the independent prognostic factors for bone marrow toxicity. In a combined regimen of IC followed by CCRT for the treatment of LANPC, IMRT seems to be an aggressive technique with a trend towards increased gastrointestinal and hematological toxicities, but decreased bone marrow toxicity than those treated with 3D-CRT. This study provides a comprehensive summary of prospective evidence reporting the side effects in the management of LANPC patients. We quantify the occurrence risks of chemoradiotherapy-induced acute injuries through analysis of time-to-event.

Role of Glutamine in the Management of Oral Mucositis in Patients with Cancer: A Meta-Analysis of Randomized Controlled Trials

As the effectiveness of glutamine supplementation for oral mucositis (OM) in patients with cancer remains controversial, a comprehensive summary and analysis of available evidence is necessary. The aim of the present meta-analysis was to evaluate the benefits of glutamine supplementation on OM and OM-related adverse reactions in patients with cancer receiving chemotherapy (CT) and/or radiotherapy (RT), using data from randomized controlled trials (RCTs). The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for RCTs on the use of glutamine for treating OM, published until September 11, 2020. Risk ratios (RRs) or standardized mean differences (SMDs) and 95% confidence intervals (CI) were calculated using RevMan 5.3. Fifteen studies with 988 participants were included. Glutamine did not reduce the incidence of OM (RR 0.94), but it reduced the severity of OM (SMD -0.73) and incidence of severe OM (RR 0.41). Additionally, glutamine reduced the incidence of opioid analgesic use (RR 0.84), feeding tube use (RR 0.46), hospitalization (RR 0.39), and treatment interruption (RR 0.49) caused by OM. Glutamine effectively improved OM and reduced OM-related adverse reactions in patients with cancer receiving CT and/or RT.

Effect of Dexamethasone-Loaded PLGA Nanoparticles on Oral Mucositis Induced by 5-Fluorouracil

Oral mucositis (OM) is characterized by the presence of severe ulcers in the oral region that affects patients treated with chemotherapy. It occurs in almost all patients who receive radiotherapy of the head and neck, as well as patients who undergo hematopoietic cell transplantation. The pathophysiology of OM is complex, and there is no effective therapy. The aim of this study was to evaluate the effect of dexamethasone-loaded poly(d,l-Lactic-co-glycolic) nanoparticles (PLGA-DEX NPs) on an OM model induced in hamsters. The NPs were synthesized using the emulsification-solvent evaporation method and were characterized by the size, zeta potential, encapsulation efficiency, atomic force microscopy, physicochemical stability, and the in vitro release. The OM was induced by the administration of 5-FU on the first and second days and mechanical trauma on the 4th day of the experiment. PLGA-DEX NPs were administered to treat OM. The animals were euthanized on the 10th day. Macroscopic and histopathological analyses were performed, measurement of malonaldehyde (MDA) and ELISA was used to determine the levels of IL-1β and TNF-α. Immunoexpressions of NF-κB, COX-2, and TGF-β were determined by immunohistochemistry, and qRT-PCR was used to quantify the gene expression of the GILZ, MKP1, and NF-κB p65. The PLGA-DEX NPs (0.1 mg/kg) significantly reduced macroscopic and histopathological scores, decreased MDA, TNF-α and IL-1β levels, immunostaining for NF-κB, COX-2, TGF-β, and suppressed NF-κB p65 mRNA expression, but increased GILZ and MKP1 expression.

Oral mucositis: the hidden side of cancer therapy

Inflammation response of epithelial mucosa to chemo- radiotherapy cytotoxic effects leads to mucositis, a painful side effect of antineoplastic treatments. About 40% of the patients treated with chemotherapy develop mucositis; this percentage rises to about 90% for head and neck cancer patients (HNC) treated with both chemo- and radiotherapy. 19% of the latter will be hospitalized and will experience a delay in antineoplastic treatment for high-grade mucositis management, resulting in a reduction of the quality of life, a worse prognosis and an increase in patient management costs. Currently, several interventions and prevention guidelines are available, but their effectiveness is uncertain. This review comprehensively describes mucositis, debating the impact of standard chemo-radiotherapy and targeted therapy on mucositis development and pointing out the limits and the benefits of current mucositis treatment strategies and assessment guidelines. Moreover, the review critically examines the feasibility of the existing biomarkers to predict patient risk of developing oral mucositis and their role in early diagnosis. Despite the expression levels of some proteins involved in the inflammation response, such as TNF-α or IL-1β, partially correlate with mucositis process, their presence does not exclude others mucositis-independent inflammation events. This strongly suggests the need to discover biomarkers that specifically feature mucositis process development. Non-coding RNAs might hold this potential.

Antimicrobial peptides: a promising strategy for lung cancer drug discovery?

INTRODUCTION

Antimicrobial peptides (AMPs), also called host defense peptides (HDPs), are identified in almost any form of life, which play an important role in innate immune systems. They have a broad spectrum of antifungal, antiviral, antibacterial, and anticancer activities. Lung cancer remains the leading cause of global cancer-related death. Unfortunately, lung cancer chemotherapy is accompanied by serious side effects, nonspecific toxicity, and multidrug resistance. Hence, to overcome these drawbacks, anticancer peptides (ACPs) derived from AMPs may represent a potential promising synergistic treatment strategy for lung cancer.

AREAS COVERED

In this review, the authors provide the recent advancements in the use of AMPs for the treatment of lung cancer. Furthermore, the anti-lung cancer modes of action of these peptides have been fully reviewed. Importantly, various strategies for increasing the efficiency and safety of AMPs have been discussed.

EXPERT OPINION

The combination of AMPs and other cancer treatment approaches such as chemotherapy, nanoparticle-based delivery systems, and photodynamic therapy can be used as a promising revolutionary strategy for the treatment of lung cancer. The most significant limitations of this strategy that need to be focused on are low efficiency and off-target events.

Role for Lipids Secreted by Irradiated Peripheral Blood Mononuclear Cells in Inflammatory Resolution in Vitro

Periodontal inflammation is associated with dying cells that potentially release metabolites helping to promote inflammatory resolution. We had shown earlier that the secretome of irradiated, dying peripheral blood mononuclear cells support in vitro angiogenesis. However, the ability of the secretome to promote inflammatory resolution remains unknown. Here, we determined the expression changes of inflammatory cytokines in murine bone marrow macrophages, RAW264.7 cells, and gingival fibroblasts exposed to the secretome obtained from γ-irradiated peripheral blood mononuclear cells in vitro by RT-PCR and immunoassays. Nuclear translocation of p65 was detected by immunofluorescence staining. Phosphorylation of p65 and degradation of IκB was determined by Western blot. The secretome of irradiated peripheral blood mononuclear cells significantly decreased the expression of IL1 and IL6 in primary macrophages and RAW264.7 cells when exposed to LPS or saliva, and of IL1, IL6, and IL8 in gingival fibroblasts when exposed to IL-1β and TNFα. These changes were associated with decreased phosphorylation and nuclear translocation of p65 but not degradation of IκB in macrophages. We also show that the lipid fraction of the secretome lowered the inflammatory response of macrophages exposed to the inflammatory cues. These results demonstrate that the secretome of irradiated peripheral blood mononuclear cells can lower an in vitro simulated inflammatory response, supporting the overall concept that the secretome of dying cells promotes inflammatory resolution.

Prophylactic and Therapeutic Effects of Curcumin on Treatment-Induced Oral Mucositis in Patients with Head and Neck Cancer: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Clinical trials have explored the role of curcumin in the prevention and treatment of oral mucositis (OM) in head and neck cancer patients. To provide evidence for curcumin management of OM for clinicians, a comprehensive meta-analysis of these findings is necessary. This meta-analysis aimed to evaluate the efficacy and safety of curcumin for OM caused by radiotherapy (RT) and/or chemotherapy (CT) for head and neck cancer.

METHODS

Randomized controlled trials were identified from the PubMed, Embase, Web of Science, Cochrane Library, Medline, and Google Scholar databases. RevMan 5.3 was used for statistical analysis to calculate the combined risk ratios (RRs).

RESULTS

Six studies involving 266 patients were included. Curcumin considerably reduced weight loss (mean difference [MD] - 0.78) in both the prophylactic and therapeutic phases. When used as a preventative treatment, curcumin did not reduce the incidence of OM (RR 0.99), but it did reduce the incidence of severe OM (RR 0.44) and the mean severity of OM (SMD -1.44). Curcumin also reduced the severity of OM (MD 0.82) compared to chlorhexidine.

CONCLUSION

Curcumin is a safe, natural bioactive substance that can effectively prevent and treat OM in patients receiving RT and/or CT, as well as reduce weight loss.

Oral Mucositis: An Update on Innate Immunity and New Interventional Targets

Oral mucositis (OM), a common debilitating toxicity associated with chemo- and radiation therapies, is a significant unmet clinical need for head and neck cancer patients. The biological complexities of chemoradiotherapy-induced OM involve interactions among disrupted tissue structures, inflammatory infiltrations, and oral microbiome, whereby several master inflammatory pathways constitute the complicated regulatory networks. Oral mucosal damages triggered by chemoradiotherapy-induced cell apoptosis were further exacerbated by the amplified inflammatory cascades dominantly governed by the innate immune responses. The coexistence of microbiome and innate immune components in oral mucosal barriers indicates that a signaling hub coordinates the interaction between environmental cues and host cells during tissue and immune homeostasis. Dysbiotic shifts in oral microbiota caused by cytotoxic cancer therapies may also contribute to the progression and severity of chemoradiotherapy-induced OM. In this review, we have updated the mechanisms involving innate immunity-governed inflammatory cascades in the pathobiology of chemoradiotherapy-induced OM and the development of new interventional targets for the management of this severe morbidity in head and neck cancer patients.

Comparative prevention potential of 10 mouthwashes on intolerable oral mucositis in cancer patients: A Bayesian network analysis

BACKGROUND

There is a wide variety of mouthwashes currently available for the prevention of intolerable oral mucositis (OM) onset. Because of a lack of evidence from head-to-head randomized controlled trials (RCTs), the relative effects of these mouthwashes in intolerable OM patients remain unclear. This study compared the preventive effect of ten mouthwashes in intolerable OM.

METHODS

A literature search was performed of the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and MEDLINE (PubMed) databases. Reports published from 1990 to 2019 focusing on mouthwashes for preventing OM were identified. Authors assessed the studies' risk of bias in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and followed the PRISMA for Network Meta-Analyses Statement. Authors estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis with random effects.

RESULTS

Thirty-six RCTs, with a total of 2594 patients, were included in the present study. Bayesian network analysis showed that honey (Odd Ratio [OR] 0.17, 95%CI 0.09 to 0.30), chamomile (OR 0.09, 95% CI 0.01 to 0.52), curcumin (OR 0.23, 95% CI 0.08 to 0.67) and benzydamine (OR 0.26, 95% CI 0.12 to 0.54) mouthwashes were superior to placebo. Honey mouthwashes were more efficacious than chlorhexidine (OR 0.34, 95% CI 0.12 to 0.92), sucralfate (OR 0.26, 95% CI 0.06 to 0.96) and povidone-iodine (OR 0.30, 95% CI 0.11 to 0.82) mouthwashes. Other mouthwashes showed no significant differences.

CONCLUSIONS

According to the analysis of rank probabilities, chamomile, honey, curcumin and benzydamine mouthwashes may be the most advantageous in terms of the prevention of intolerable OM.

Diclofenac Mouthwash as a potential therapy for reducing pain and discomfort in chemo-radiotherapy-induced oral mucositis

AIMS

Oral and/or oropharyngeal acute mucositis during and after chemo-radiotherapy (chemo-RT) for head and neck squamous cell carcinoma (HNSCC) can be extremely painful, sometimes requiring nasogastric feeding to enable adequate nutrition. The MASCC/ISOO evidence-based guidelines recommend benzydamine mouthwash for mucositis prevention in RT (recently updated to include chemo-RT), and a Cochrane systematic review found other agents to be effective in prophylaxis. Diclofenac mouthwash is licensed for painful oral mucosal inflammatory conditions but to our knowledge has not been assessed in chemo-RT-associated oral mucositis.

METHOD

A clinical observation and service evaluation study in 10 patients undergoing chemo-RT for HNSCC to assess the potential value of diclofenac mouthwash (0.74 mg/mL) in reducing symptoms. Patients used 20ml of mouthwash up to 4 times a day starting in week 3 (of a 6-week course of treatment), recording pain and discomfort scores using a visual analogue scale on days 0, 1,7 and 14 (until the end of week 4). As per our current clinical practice, oral mucositis was not clinically scored as an outcome. Statistical analysis was performed using a one-way ANOVA.

RESULTS

Using diclofenac mouthwash, 9/10 patients experienced pain score reduction from day 0 (mean score 6.75 ± SD 1.83) to day 2 (5.05 ± SD 1.62) and day 14 (4.09 ± SD 1.96).

CONCLUSIONS

Diclofenac mouthwash may be beneficial for managing chemo-RT-induced oral mucositis. While a prospective randomised clinical trial is needed, it can be prescribed for this condition within its current licence.