A Review of Clinical Radioprotection and Chemoprotection for Oral Mucositis

Development and psychometric testing of a self-management scale for cancer survivors with radiotherapy/chemotherapy-induced oral mucositis in China

Objective

This study aims to develop and validate a self-management scale for radiotherapy/chemotherapy-induced oral mucositis (SMS-RIOM/CIOM) in cancer survivors, addressing the need for a comprehensive tool to assess self-management capabilities.

Methods

This study employed a two-phase process: (1) initial scale development through literature review, semi-structured interviews, and expert consultations, and (2) psychometric testing with 420 cancer survivors from five wards of Zibo Hospital. The psychometric evaluation included item analysis, content validity testing, reliability assessments, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA).

Results

The finalized SMS-RIOM/CIOM consists of 15 items across four dimensions: medication management, oral pain management, disease monitoring, and daily life management. EFA explained 77.322% of the total variance, while CFA demonstrated an excellent model fit (χ²/df=1.909, RMSEA=0.064, RMR=0.052, GFI=0.911, CFI=0.964, NFI=0.928, TLI=0.955, IFI=0.964). Reliability metrics were robust, including Cronbach's alpha of 0.902, split-half reliability of 0.849, test-retest reliability of 0.862, and a scale content validity index of 0.910.

Conclusions

The SMS-RIOM/CIOM is a reliable and valid tool for assessing self-management in cancer survivors with RIOM/CIOM. It provides valuable insights for clinical practice, enabling targeted interventions to improve self-management and enhance the quality of life for cancer survivors. Further research is recommended to validate its application across diverse populations and healthcare settings.

Managing strategies of chemotherapy and radiotherapy-induced oral mucositis

Radiotherapy and chemotherapy are widely employed as primary non-surgical cancer treatments; however, their non-selective cytotoxicity often leads to adverse events such as oral mucositis (OM), particularly in head and neck cancer therapies. International guidelines provide recommendations for managing chemoradiotherapy-induced OM in various clinical contexts. Subsequently, emerging researches have introduced evidence supporting novel approaches or existing regimens for OM prevention and treatment. The repurposing of established drugs has garnered significant interest due to its shorter development timeline, improved safety profiles, and lower costs compared to new drug development. For example, clinical trials assessing established drugs such as melatonin, clonidine, and pentoxifylline indicate promising potential for managing OM. Additionally, several emerging pharmacological interventions have demonstrated considerable efficacy; SAMITAL and rhIL-11 are supported by phase II clinical trials and prospective studies, while probiotics like Streptococcus salivarius K12 and curcumin have shown effectiveness in randomized clinical trials. Furthermore, recent high-level studies have reinforced the efficacy of non-pharmacological interventions, such as photobiomodulation (PBM) and cryotherapy, over the past two years. In all, given the evidence supporting different strategies, PBM and oral cryotherapy are highly recommended for managing OM when feasible. Topical clonidine, melatonin, oral pentoxifylline, topical SAMITAL or rhIL-11, oral SsK12, and curcumin may also be utilized but would benefit from validation in larger trials. Besides, Verbascoside, Palifermin, Amifostine, and Avasopasem manganese can be suggested for OM management, while the side effects should be monitored. The accessibility and cost/effectiveness of specific managing strategies of OM should be considered when selecting appropriate options.

The Effectiveness of Curcumin in Treating Oral Mucositis Related to Radiation and Chemotherapy: A Systematic Review

Chemotherapy (CT) and radiation therapy (RT), while effective against cancer, often cause severe side effects, such as oral mucositis and other oral diseases. Oral mucositis, characterized by inflammation and ulceration of the oral mucosa, is one of the most painful side effects that can reduce quality of life and limit cancer treatment. Curcumin, a polyphenol from Curcuma longa, has garnered attention for its anti-inflammatory, antioxidant, and anti-carcinogenic properties, which protect the oral mucosa by reducing oxidative stress and modulating inflammation. This study reviews the therapeutic potential of curcumin in preventing and managing oral mucositis caused by CT and RT. Clinical trials show curcumin's effectiveness in reducing the incidence and severity of oral mucositis. Although curcumin supplementation appears to be a promising and cost-effective approach for mitigating oral complications in cancer patients, further clinical trials are needed to confirm its efficacy and optimize dosing strategies.

Application of In Situ Mucoadhesive Hydrogel with Anti-Inflammatory and Pro-Repairing Dual Properties for the Treatment of Chemotherapy-Induced Oral Mucositis

Chemotherapy-induced oral mucositis (CIOM) is a prevalent complication of chemotherapy and significantly affects the treatment process. However, effective treatment for CIOM is lacking due to the unique environment of the oral cavity and the single effect of current drug delivery systems. In this present study, we propose an innovative approach by combining a methacrylate-modified human recombinant collagen III (rhCol3MA) hydrogel system with hyaluronic acid-epigallocatechin gallate (HA-E) and dopamine-modified methacrylate-alginate (AlgDA-MA). HA-E is used as an antioxidant and anti-inflammatory agent and synergizes with AlgDA-MA to improve the wet adhesion of hydrogel. The results of rhCol3MA/HA-E/AlgDA-MA (Col/HA-E/Alg) hydrogel demonstrate suitable physicochemical properties, excellent wet adhesive capacity, and biocompatibility. Notably, the hydrogel could promote macrophage polarization from M1 to M2 and redress human oral keratinocyte (HOK) inflammation by inhibiting NF-κB activation. Wound healing evaluations in vivo demonstrate that the Col/HA-E/Alg hydrogel exhibits a pro-repair effect by mitigating inflammatory imbalances, fostering early angiogenesis, and facilitating collagen repair. In summary, the Col/HA-E/Alg hydrogel could serve as a promising multifunctional dressing for the treatment of CIOM.

In vitro cytoprotective and in vivo anti-oral mucositis effects of melatonin and its derivatives

According to our preliminary study, melatonin and its N-amide derivatives (N-(2-(1-4-bromobenzoyl-5-methoxy-1H-indol-3-yl)ethyl)acetamide (BBM) and 4-bromo-N-(2-(5-methoxy-1H-indol-3-yl)ethyl)benzamide (EBM)) inhibited the marker of acute inflammation in tests in vitro and in vivo. The anti-inflammatory agent is intended for the prevention and treatment of chemotherapy-induced toxicity. In this study aimed to evaluate the effect of melatonin and its derivatives on mechanisms related to chemotherapy-induced oral mucositis by in vitro ROS and 5-FU-induced human keratinocyte cells as well as in vivo oral mucositis model. In in vitro H2O2-induced HaCaT cells, BBM had the highest level of protection (34.57%) at a concentration 50 µM, followed by EBM (26.41%), and melatonin (7.9%). BBM also protected cells against 5-FU-induced to 37.69-27.25% at 12.5-100 µM while EBM was 36.93-29.33% and melatonin was 22.5-11.39%. In in vivo 5-FU-induced oral mucositis in mice, melatonin, BBM, and EBM gel formulations protected tissue damage from 5-FU similar to the standard compound, benzydamine. Moreover, the weight of mice and food consumption recovered more quickly in the BBM group. These findings suggested that it was possible to develop BBM and EBM as new therapeutic agents for the treatment of oral mucositis.

Oral Mucositis Management in Children under Cancer Treatment: A Systematic Review

Children undergoing antineoplastic treatment often present severe side effects due to the dosage and duration of treatments, with oral mucositis emerging as one of the most prevalent and painful inflammatory conditions. There is a growing body of evidence on therapeutic interventions such as cryotherapy, low-level laser therapy, and natural compounds for this condition. The aim of this systematic review was to identify and compare therapies for the management of cancer treatment-induced oral mucositis in pediatric patients. From 2655 articles obtained in initial searches, 39 articles were considered in this systematic review, after applying inclusion/exclusion criteria. Low-level laser therapy, palifermin, honey, and zinc demonstrated reductions in oral mucositis incidence, duration, severity, and pain reported by the patient. Although there are several therapies in place for the prevention and treatment of oral mucositis in children, evidence of their efficacy is still inconclusive to establish accurate clinical protocols.

Plant-Derived Polyphenols to Prevent and Treat Oral Mucositis Induced by Chemo- and Radiotherapy in Head and Neck Cancers Management

Oral Mucositis (OM) is the most common side effect due to chemotherapy and radiotherapy, which are the conventional treatment options for head and neck cancers. OM is a severe inflammatory condition characterized by multifactorial etiopathogenesis. It further negatively affects patients' quality of life by severe impairment of normal oral functions. Consequently, it is mandatory to identify new effective therapeutic approaches to both prevent and treat OM while also avoiding any recurrence. Polyphenols recently attracted the interest of the scientific community due to their low toxicity and wide range of biological activities making them ideal candidates for several applications in the odontostomatological field, particularly against OM. This review collects the in vivo studies and the clinical trials conducted over the past 13 years evaluating the preventive and curative effects of several polyphenolic compounds towards chemo- and radiotherapy-induced OM, both when administered alone or as a plant-extracted phytocomplex. The literature fully confirms the usefulness of these molecules, thus opening the possibility of their clinical application. However, polyphenol limitations (e.g., unfavourable physicochemical properties and susceptibility to degradation) have emerged. Consequently, the interest of the scientific community should be focused on developing innovative delivery systems able to stabilize polyphenols, thus facilitating topical administration and maximizing their efficacy.

Repurposing of FDA approved kinase inhibitor bosutinib for mitigation of radiation induced damage via inhibition of JNK pathway

Radiotherapy is a common modality for cancer treatment. However, it is often associated with normal tissue toxicity in 20-80% of the patients. Radioprotectors can improve the outcome of radiotherapy by selectively protecting normal cells against radiation toxicity. In the present study, compound libraries containing 54 kinase inhibitors and 80 FDA-approved drugs were screened for radioprotection of lymphocytes using high throughput cell analysis. A second-generation FDA-approved kinase inhibitor, bosutinib, was identified as a potential radioprotector for normal cells. The radioprotective efficacy of bosutinib was evinced from a reduction in radiation induced DNA damage, caspase-3 activation, DNA fragmentation and apoptosis. Oral administration of bosutinib protected mice against whole body irradiation (WBI) induced morbidity and mortality. Bosutinib also reduced radiation induced bone-marrow aplasia and hematopoietic damage in mice exposed to 4 Gy and 6 Gy dose of WBI. Mechanistic studies revealed that the radioprotective action of bosutinib involved interaction with cellular thiols and modulation of JNK pathway. The addition of glutathione and N-acetyl cysteine significantly reduced the radioprotective efficacy of bosutinib. Moreover, bosutinib did not protect cancer cells against radiation induced toxicity. On the contrary, bosutinib per se exhibited anticancer activity against human cancer cell lines. The results highlight possible use of bosutinib as a repurposable radioprotective agent for mitigation of radiation toxicity in cancer patients undergoing radiotherapy.

Prophylaxis of Oral Mucositis with Iodine Solution during Concurrent Chemoradiation of Head and Neck Cancer: Preliminary Results of a Double-Blind, Randomized Controlled Trial

OBJECTIVE

This study aims to evaluate the clinical efficacy of an in-house iodine solution (IS) mouthwash for the prophylaxis of concurrent chemoradiation (CCRT) induced oral mucositis (OM) in head & neck cancer (HNC) patients.

METHODS

This prospective, double-blind, randomized controlled trial was conducted on 20 HNC patients, being treated with definite or postoperative CCRT, at the Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. The patients were randomly assigned (1:1) to the treatment group or the control group. Patients in the treatment group gargled IS three times daily after meals, while patients in the control group gargled normal saline solutions (NSS). Assessment of OM was performed before starting CCRT, once a week during CCRT, and 4 weeks after CCRT was completed. The primary outcome was Oral Mucositis Assessment Scale (OMAS).

RESULTS

The mean weekly OMAS, pain score, and impact on swallowing score were not statistically significant in patients who rinsed with IS mouthwash compared to those who received NSS (p > 0.999 in every week). There was no difference in the mean onset to OM (all grades) (p = 0.704), and the mean duration of OM (all grades) (p = 0.365). Severe OM (WHO grade 3-4) occurred in three patients [IS=2, NSS=1] with the median onset of 45.50 & 33.00 days (p = NA), and the duration of 8.00 & 57.00 days (p = NA) in the IS and NSS groups, respectively. Oral candidiasis occurred in one patient from the NSS group while no secondary infection of oral mucosa was observed in the patients receiving IS mouthwash.

CONCLUSION

The study could not reach statistically significance to show that IS mouthwash was effective in of prevention CCRT-induced OM. Further study with a larger number of participants is encouraged.

Holistic Approach of a Leukemic Child Suffering from Oral Mucositis with Coinfections: A Case Report

Oral mucositis (OM) is a life-threatening side effect of chemo-radiotherapy. OM can provide a portal of entry for many microorganisms as coinfections which potentially generate other oral lesions. This case report describes a holistic approach to obtaining the successful treatment of OM with necrotizing ulcerative stomatitis (NUS) and oral candidiasis as coinfections in pediatric acute lymphoblastic leukemia (ALL). A 2-year-8-month-old boy was referred from the Pediatrics Department at Dr. Hasan Sadikin General Hospital with the chief complaint of canker sore and eating difficulty for the past two weeks. He had undergone the twelfth cycle of the last chemotherapy using methotrexate regimen. Extraoral examination revealed anemic conjunctiva, icteric sclera, and dry lips. Well-defined irregular multiple ulcers covered by yellowish to grayish pseudomembranous were found on the upper and lower labial mucosa, right and left buccal mucosa, tongue, palate, and gingiva. Potassium hydroxide (KOH) examination showed fungi in the oral lesions smear. The established diagnosis was OM with NUS and oral candidiasis as coinfections. Debridement was done using chlorine dioxide-zinc and 0.2% chlorhexidine gluconate. We collaborated with the pediatrician who prescribed ceftazidime, meropenem, and fluconazole, and also with parents. The holistic approach is beneficial and important in improving quality of life and supporting the successful treatment of OM with coinfections.

Ascidian-Inspired Temperature-Switchable Hydrogels with Antioxidant Fullerenols for Protecting Radiation-Induced Oral Mucositis and Maintaining the Homeostasis of Oral Microbiota

A key characteristic of radiation-induced oral mucositis (RIOM) is oxidative stress mediated by the "reactive oxygen species (ROS) storm" generated from water radiolysis, resulting in severe pathological lesions, accompanied by a disturbance of oral microbiota. Therefore, a sprayable in situ hydrogel loaded with "free radical sponge" fullerenols (FOH) is developed as antioxidant agent for RIOM radioprotection. Inspired by marine organisms, 3,4,5-trihydroxyphenylalanine (TOPA) which is enriched in ascidians is grafted to clinically approved temperature-switchable Pluronic F127 to produce gallic acid (containing the TOPA fragment)-modified Pluronic F127 (MGA) hydrogels to resist the fast loss of FOH via biomimetic adhesion during oral movement and saliva erosion. Based on this, progressive RIOM found in mice is alleviated by treatment of FOH-loaded MGA hydrogels whether pre-irradiation prophylactic administration or post-irradiation therapeutic administration, which contributes to maintaining the homeostasis of oral microbiota. Mechanistically, FOH inhibits cell apoptosis by scavenging radiation-induced excess ROS and up-regulates the inherent enzymatic antioxidants, thereby protecting the proliferation and migration of mucosal epithelial cells. In conclusion, this work not only provides proof-of-principle evidence for the oral radioprotection of FOH by blocking the "ROS storm", but also provides an effective and easy-to-use hydrogel system for mucosal in situ administration.

Radiotherapy-induced severe oral mucositis: pharmacotherapies in recent and current clinical trials

INTRODUCTION

Oral mucositis (OM) is among the most common, damaging side effects of head and neck radiation therapy and may interfere with patients' ability to comply with optimal treatment.

AREAS COVERED

The increasing unmet clinical need, recent clinical trial successes, and the commercial potential have catalyzed interest in the development of effective intervention for OM. A range of small molecules are under development - some still in the preclinical stage, but others close to NDA submission. This review will focus on those drugs which have recently been assessed in a clinical trial and those which are still under clinical study as a prevention or treatment for radiation-associated OM.

EXPERT OPINION

In response to the unmet clinical need, both the biotechnology and pharmacological industries have been actively pursuing an agent to prevent/treat radiation-associated OM. This effort has been catalyzed by the identification of multiple drug targets which contribute to OM's pathogenesis. The lessons learned from the many trials which have previously stumbled have led to standardization of clinical trial design, endpoint efficacy definitions, rater assessment, and data interpretation over the past decade. Consequently, results of recently completed clinical trials provide optimism that effective treatment options should be available in the not-too-distant future.

A Review of RRx-001: A Late-Stage Multi-Indication Inhibitor of NLRP3 Activation and Chronic Inflammation

Chronic unresolving inflammation is emerging as a key underlying pathological feature of many if not most diseases ranging from autoimmune conditions to cardiometabolic and neurological disorders. Dysregulated immune and inflammasome activation is thought to be the central driver of unresolving inflammation, which in some ways provides a unified theory of disease pathology and progression. Inflammasomes are a group of large cytosolic protein complexes that, in response to infection- or stress-associated stimuli, oligomerize and assemble to generate a platform for driving inflammation. This occurs through proteolytic activation of caspase-1-mediated inflammatory responses, including cleavage and secretion of the proinflammatory cytokines interleukin (IL)-1β and IL-18, and initiation of pyroptosis, an inflammatory form of cell death. Several inflammasomes have been characterized. The most well-studied is the nucleotide-binding domain (NOD)-like receptor protein 3 (NLRP3) inflammasome, so named because the NLRP3 protein in the complex, which is primarily present in immune and inflammatory cells following activation by inflammatory stimuli, belongs to the family of nucleotide-binding and oligomerization domain (Nod) receptor proteins. Several NLRP3 inflammasome inhibitors are in development, all with multi-indication activity. This review discusses the current status, known mechanisms of action, and disease-modifying therapeutic potential of RRx-001, a direct NLRP3 inflammasome inhibitor under investigation in several late-stage anticancer clinical trials, including a phase 3 trial for the treatment of third-line and beyond small cell lung cancer (SCLC), an indication with no treatment, in which RRx-001 is combined with reintroduced chemotherapy from the first line, carboplatin/cisplatin and etoposide (ClinicalTrials.gov Identifier: NCT03699956). Studies from multiple independent groups have now confirmed that RRx-001 is safe and well tolerated in humans. Additionally, emerging evidence in preclinical animal models suggests that RRx-001 could be effective in a wide range of diseases where immune and inflammasome activation drives disease pathology.

Apigenin in cancer therapy: Prevention of genomic instability and anticancer mechanisms

The incidence of cancer has been growing worldwide. Better survival rates following the administration of novel drugs and new combination therapies may concomitantly cause concern regarding the long-term adverse effects of cancer therapy, for example, second primary malignancies. Moreover, overcoming tumour resistance to anticancer agents has been long considered as a critical challenge in cancer research. Some low toxic adjuvants such as herb-derived molecules may be of interest for chemoprevention and overcoming the resistance of malignancies to cancer therapy. Apigenin is a plant-derived molecule with attractive properties for chemoprevention, for instance, promising anti-tumour effects, which may make it a desirable adjuvant to reduce genomic instability and the risks of second malignancies among normal tissues. Moreover, it may improve the efficiency of anticancer modalities. This paper aims to review various effects of apigenin in both normal tissues and malignancies. In addition, we explain how apigenin may have the ability to protect usual cells against the genotoxic repercussions following radiotherapy and chemotherapy. Furthermore, the inhibitory effects of apigenin on tumours will be discussed.

Effects of various treatments for preventing oral mucositis in cancer patients: A network meta-analysis

BACKGROUND

Oral mucositis (OM) is a common side effect of chemotherapy and radiotherapy in patients with cancers. The prevention or treatment of OM in cancer patients is crucial in the treatment of cancer.

METHODS

We searched PubMed, Embase, and Cochrane Library for the randomized control trials (RCTs) of interventions for preventing and treating OM. Network meta-analysis (NMA) was performed to estimate odds ratios (ORs) and 95% confidence intervals (CI) from both direct and indirect evidence. The prespecified primary efficacy outcome was the treatment effect of moderate to severe oral mucositis with 12 interventions. The outcome was moderate to a severe grade of OM.

RESULTS

This study included 55 RCTs with 3,552 participants. The results showed that honey significantly lowered the risk of chemo/radiotherapy-induced moderate to severe oral mucositis than placebo (OR: 0.01, 95%CI 0.00 to 0.45), followed by lignocaine (OR: 0.07, 95%CI 0.00 to 0.95). The surface under cumulative ranking curve (SUCRA) values for honey were 0.95, followed by lignocaine (SUCRA, 0.81) and benzydamine (SUCRA, 0.78).

CONCLUSIONS

The honey is effective for patients with cancer undergoing chemotherapy or radiotherapy-induced oral mucositis.

RRx-001 and the "Right stuff": Protection and treatment in outer space

From antibiotics to aspirin to antimalarials and to anticancer agents, about half of the world's best-selling drugs are derived from nature. However, accelerating climatic disruption, habitat destruction, pollution, and biodiversity loss all negatively impact the potential of natural sources to continue to serve as repositories of novel pharmaceuticals. On that basis, the final frontier for drug development is perhaps not the rainforests, coral reefs, and other natural habitats but rather the aerospace industry with its virtually unlimited and inexhaustible man-made 'library' of potentially bioactive compounds. The first aerospace-sourced therapeutic to reach the clinic is RRx-001, an inhibitor of the NOD-like receptor - Nucleotide-binding oligomerization domain with Leucine rich Repeat and Pyrin domain (NLRP3) inflammasome in a Phase 3 trial for the treatment of small cell lung cancer (SCLC) and in a soon-to-start Phase 3 trial for protection against chemoradiotherapy-induced severe oral mucositis in first line head and neck cancer. As manned missions to the Moon, Mars, and asteroids as well as space tourism beckon, it is perhaps fitting that a compound like RRx-001, which is derived from 1,3,3-Trinitroazetidine (TNAZ), an explosive propellant for rockets, is a potential "all purpose" option to mitigate the major biomedical effects of space radiation exposures including cancer development and other tissue degenerations both within mission and after mission. This article highlights the promise of RRx-001 to attenuate the acute and late effects of radiation exposure on astronauts including the development of cancer.

Sildenafil improves radiation-induced oral mucositis by attenuating oxidative stress, NF-κB, ERK and JNK signalling pathways

Radiation-induced oral mucositis is a common and dose-limiting complication of head and neck radiotherapy with no effective treatment. Previous studies revealed that sildenafil, a phosphodiesterase 5 inhibitor, has anti-inflammatory and anti-cancer effects. In this study, we investigated the effect of sildenafil on radiation-induced mucositis in rats. Two doses of radiation (8 and 26 Gy X-ray) were used to induce low-grade and high-grade oral mucositis, separately. A control group and three groups of sildenafil citrate-treated rats (5, 10, and 40 mg/kg/day) were used for each dose of radiation. Radiation increased MDA and activated NF-κB, ERK and JNK signalling pathways. Sildenafil significantly decreased MDA level, nitric oxide (NO) level, IL1β, IL6 and TNF-α. The most effective dose of sildenafil was 40 mg/kg/day in this study. Sildenafil also significantly inhibited NF-κB, ERK and JNK signalling pathways and increased bcl2/bax ratio. In addition, high-dose radiation severely destructed the mucosal layer in histopathology and led to mucosal cell apoptosis in the TUNEL assay. Sildenafil significantly improved mucosal structure and decreased inflammatory cell infiltration after exposure to high-dose radiation and reduced apoptosis in the TUNEL assay. These findings show that sildenafil can improve radiation-induced oral mucositis and decrease the apoptosis of mucosal cells via attenuation of inflammation and oxidative stress.

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.

The small molecule NLRP3 inhibitor RRx-001 potentiates regorafenib activity and attenuates regorafenib-induced toxicity in mice bearing human colorectal cancer xenografts

The multi-kinase inhibitor Regorafenib, approved for the treatment of metastatic colorectal cancer, is poorly tolerated with a Grade 3/4 drug related adverse event rate of 54% resulting in frequent dose reductions and discontinuations. RRx-001 is a minimally toxic NLRP3 inhibitor small molecule with macrophage-repolarizing properties in Phase 3 clinical trials. Studies have demonstrated the inhibitory impact of M2 macrophages on the activity of tyrosine kinases, suggesting that the repolarization of macrophages by RRx-001 may enhance the activity of TKIs. The purpose of these experiments was to determine whether RRx-001 demonstrated in vitro and in vivo synergy with regorafenib in colorectal cancer and whether RRx-001 attenuated the toxicity of regorafenib. Tumor-bearing mice were randomized into four cohorts: RRx-001 alone, regorafenib alone, RRx-001 + regorafenib and control. RRx-001 demonstrated in vitro and in vivo synergy with regorafenib with attenuation of toxicity in colorectal cancer cell lines. These results provide a rationale to treat colorectal cancer with RRx-001 plus another tyrosine kinase inhibitor like regorafenib.

Oral-Gut Microbiome Axis in the Pathogenesis of Cancer Treatment-Induced Oral Mucositis

Oral mucositis (OM) is one of the most common and debilitating oral complications of cancer treatments including chemotherapy, radiotherapy, and hematopoietic stem cell transplantation. It is associated with severe pain and difficulties in chewing, swallowing, and speech. This leads to impairment of basic oral functions and could result in unplanned treatment interruption or modification. As such, OM negatively impacts both patients' quality of life as well as tumor prognostic outcomes. Understanding pathways underlying OM pathogenesis help identify new targets for intervention or prevention. The pathophysiology of OM has been widely studied over past decades with several pathways related to oxidative stress, inflammation, and molecular and cellular signaling being implicated. In this mini-review, we will discuss the emerging role of the oral-gut microbiome axis in the development of OM. Particularly, we will elaborate on how the alterations in the oral and gut microbiota as well as intestinal dysfunction caused by cancer treatments could contribute to the pathogenesis of OM. Further, we will briefly discuss the potential methods for targeting the oral-gut microbiome axis to improve OM outcomes.

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.

Neutrophil-to-Lymphocyte Ratio as a Factor Predicting Radiotherapy Induced Oral Mucositis in Head Neck Cancer Patients Treated with Radiotherapy

BACKGROUND

The objective of this research conducted in head and neck cancer (HNC) patients was the assessment of the relationship between neutrophil-to-lymphocyte ratio (NLR) and the incidence of severe radiotherapy (RT) induced oral mucositis (OM), as well as overall survival (OS).

METHODS

The study involved 207 patients in advanced stages (III-IV) of HNC. RTOG/EORTC scale was used to assess OM. The pre-treatment NLR was specified as the absolute neutrophil count divided by the absolute lymphocyte count.

RESULTS

Starting from second to seventh week of RT, we observed a significant, positive correlation between NLR values and OM grade. From the second to seventh week of RT, higher NLR values were related with significant increases (from 2- to over 24-fold) in the risk of occurrence of more severe OM (multivariate analysis confirmed its independent influence). Moreover, multivariate analysis for survival revealed that both higher TNM stage (HR = 1.84; p = 0.0043) and higher NLR values (HR = 1.48; p = 0.0395) were independent prognostic factors.

CONCLUSION

NLR is a simple and accurate parameter that is useful in the evaluation of the risk of more severe OM, as well as an independent prognostic factor of OS in patients subjected to RT due to HNC.

A hypothesis for the pathogenesis of radiation-induced oral mucositis: when biological challenges exceed physiologic protective mechanisms. Implications for pharmacological prevention and treatment

Oral mucositis (OM) remains a significant unmet need for patients being treated with standard concomitant chemoradiation (CRT) regimens for head and neck cancers (HNC). OM's pathogenesis is complex and includes both direct and indirect damage pathways. In this paper, the field is reviewed with emphasis on the initiating and sustaining role of oxidative stress on OM's pathobiology. A hypothesis is presented which suggests that based on OM's clinical and biological trajectory, mucosal damage is largely the consequence of cumulative CRT-induced biological changes overwhelming physiologic self-protective mechanisms. Furthermore, an individual's ability to mount and maintain a protective response is dependent on interacting pathways which are primarily determined by a multiplex consisting of genomics, epigenomics, and microbiomics. Effective biologic or pharmacologic OM interventions are likely to supplement or stimulate existing physiologic damage-control mechanisms.

A "Failed" Assay Development for the Discovery of Rescuing Small Molecules from the Radiation Damage

With improving survival rates for cancer patients, the side effects of radiation therapy, especially for pediatric or more sensitive adult patients, have raised interest in preventive or rescue treatment to overcome the detrimental effects of efficient radiation therapies. For the discovery of rescuing small molecules for radiation damage to the endothelium, we have been developing a 96-well microplate-based in vitro assay for high-throughput compatible measurement of radiation-induced cell damage and its rescue by phenotypic high-content imaging. In contrast to traditional radiation assays with detached cells for clonogenic formation, we observed cells with live-cell imaging in two different kinds of endothelial cells, up to three different cell densities, two gamma-infrared radiation dose rates, more than four different radiation doses, and acute (within 24 h with one to two h intervals) and chronic (up to 7 days) responses by phenotypic changes (digital phase contrast) and functional assays (nuclear, live-cell, and dead-cell staining) at the end of the assay. Multiple potential small molecules, which have been reported for rescuing radiation damage, have been tested as assay controls with dose responses. At the end, we did not move ahead with the pilot screening. The lessons learned from this "failed" assay development are shared.

Discovery of RRx-001, a Myc and CD47 Downregulating Small Molecule with Tumor Targeted Cytotoxicity and Healthy Tissue Cytoprotective Properties in Clinical Development

After extensive screening of aerospace compounds in an effort to source a novel anticancer agent, RRx-001, a first-in-class dinitroazetidine small molecule, was selected for advancement into preclinical and clinical development. RRx-001 is a minimally toxic small molecule with a distinct chemical structure and mechanism of action. The paradox of RRx-001 is that it mediates both antitumor cytotoxicity and normal tissue protection. The question of exactly how RRx-001 does this, and by means of what mechanism(s), depending on the route of delivery, intravenous or intratumoral, are explored. RRx-001 is currently in phase 2 and 3 clinical trials for the treatment of multiple solid tumor malignancies and as a supportive care drug.

Direct costs associated with the management of mucositis: A systematic review

Mucositis is one of the more frequent and costly adverse events following cancer treatment. To evaluate and report the direct economic outcomes associated with the management of mucositis across several cancer treatments we conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Scopus, MEDLINE/PubMed, and Embase were searched electronically and a total of 37 relevant studies were included. The costs attributable to mucositis in the hematopoietic stem cell transplantation setting ranged from 1124,47 US dollars (USD) to 299 214,14 USD per patient. The radiotherapy/chemoradiotherapy/radiotherapy plus molecular targeted therapy accounted for mucositis costs that ranged from 51,23 USD to 33 560,58 USD per patient. Costs for mucositis in the chemotherapy setting ranged from 4,18 USD to 31 963,64 USD per patient. When the cancer treatment was not specified, costs of mucositis ranged from 565,85 USD to as high as 20 279, 12 USD per patient. Mucositis costs from multimodal therapy ranged from 12,42 USD to 5670,46 USD per patient. The molecular targeted therapy setting included only one study and depending on the healthcare providers' perspective of each country evaluated, mucositis' costs ranged from 45,78 USD to 3484,91 USD per patient. Mucositis is associated with increased resource use, consultations, hospitalizations and extended hospitalizations, leading to a substantial incremental cost that exacerbates the economic burden on the patient, health plan and health system across several cancer treatments and diagnosis. More studies with a prospective evaluation of the economic costs associated with mucositis management are needed.

The Efficacy of Heat-Clearing (Qingre) and Detoxifying (Jiedu) Traditional Chinese Medicine Gargle for Chemotherapy-Induced Oral Mucositis: A Systematic Review and Meta-Analysis

Objective: Chemotherapy-induced oral mucositis (CIOM) is an extremely serious complication of cancer. In China, the heat-clearing (Qingre) and detoxifying (Jiedu) traditional Chinese medicine QRJD-TCM gargle has been widely used to treat CIOM. To date, no systematic evaluation has been conducted on the clinical efficacy of QRJD-TCM gargle in treating CIOM. The objective of this systematic review and meta-analysis was to evaluate the efficacy of QRJD-TCM gargle in the treatment of CIOM. Methods: Relevant randomized controlled trials (RCTs) comparing QRJD-TCM gargle with conventional Western medicine mouthwash (CWMM) for CIOM were confirmed by systematically searching PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journal Database, Wanfang Database, and Sinomed until October 20, 2020. Two researchers independently assessed the risk of bias according to the Cochrane risk-of-bias criteria. Excel 2010 was used in setting up a database of extracted information, and RevMan 5.3.0 was used in analyzing included trial data. The composition of the QRJD-TCM gargle was evaluated. Results: A total of 25 articles were included in this meta-analysis. Results showed that compared with CWMM, QRJD-TCM gargle can reduce the incidence of CIOM (OR = 0.23, 95% CI [0.18, 0.29], p < 0.00001) and severity of CIOM (grade I-II: OR = 0.36, 95%CI [0.28, 0.46], p < 0.00001; grade III-IV: OR = 0.15, 95%CI [0.09, 0.28], p < 0.00001). In addition, QRJD-TCM gargle improved the effective rate of CIOM (OR = 15.91, 95% CI [7.93, 31.89], p < 0.00001). Conclusion: QRJD-TCM gargle is effective in preventing and treating CIOM. However, more standard, double-blind, and multicenter randomized controlled studies are needed to further confirm the efficacy of QRJD-TCM gargle in the prevention and treatment of CIOM.

Early side effects of radiation treatment for head and neck cancer

Purpose of this review of medical literature is to present the immediate side effects of radiation therapy for head and neck cancer and their treatment. The likelihood and severity of these immediate side effects depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation. Early side effects include: inflammation of the oropharyngeal mucosa (mucositis), painful swallowing (odynophagia), difficulty swallowing (dysphagia), hoarseness, lack of saliva (xerostomia), orofacial pain, laryngeal radionecrosis, dermatitis, hair loss, nausea, vomiting, inadequate nutrition and hydration, and weight loss. These complications can interfere with, and delay treatment. Most of these side effects generally dissipate over time. In conclusion, radiation treatment for the head and neck cancer causes significant early side effects. Many of these side effects present difficult challenges to the patients. Their recognition and treatment can significantly improve the patients' health, long-term survival and quality of life. The review provides information that can assist head and cancer survivors deal with radiation side effects.

Usefulness of Honey as an Adjunct in the Radiation Treatment for Head and Neck Cancer: Emphasis on Pharmacological and Mechanism/s of Actions

BACKGROUND

In the treatment of head and neck cancer (HNC), ionizing radiation is an important modality in achieving curative objectives. However, the effective use of radiation is compromised by the side effects resulting from the damage to the adjacent normal tissue. Preclinical studies carried out in the recent past have shown that the age old dietary agent honey, which also possess myriad medicinal use is beneficial in mitigating diverse radiation-induced side effects like mucositis, xerostomia, fatigue, weight loss and to promote healing of refractory wounds.

OBJECTIVE

The objective of this memoir is to review the beneficial effects of honey in mitigating radiation-induced side effects in HNC and to emphasize on the underlying mechanism of action for the beneficial effects Methods: Two authors searched Google Scholar, PubMed, Embase, and the Cochrane Library for publications up to December 2019 to assess the ability of honey in reducing the severity of radiation-induced ill effects in the treatment of HNC. Subsequently, the adjunct pharmacological effects and mechanism/s responsible were also searched for and appropriately used to substantiate the underlying mechanism/s of action for the beneficial effects.

RESULTS

The existing data is suggestive that honey is beneficial in mitigating the radiation-induced mucositis, xerostomia, healing of recalcitrant wounds in radiation exposed regions and multiple pathways mediate the beneficial effects especially, free radical scavenging, antioxidant, wound healing, anticancer, analgesic, anti-inflammatory, anabolic, anti-fatigue and anti-anaemic effects that add additional value to the use of honey as an adjunct in cancer therapy.

CONCLUSION

For the first time this review addresses the underlying pharmacological effects related to the beneficial effects of honey in radiation-induced damage, and attempts at emphasizes the lacunae that need further studies for optimizing the use of honey as an adjunct in radiotherapy of HNC. The authors suggest that future studies should be directed at understanding the detail molecular mechanisms responsible for the beneficial effects using validated cell culture and animal models of study. Large multi centric clinical trials with standardised honey is also needed to understand the clinical use of honey.

Molecular effects of photon irradiation and subsequent aftercare treatment with dexpanthenol-containing ointment or liquid in 3D models of human skin and non-keratinized oral mucosa

This study aimed to investigate the molecular effects of radiation and subsequent aftercare treatment with dexpanthenol-containing ointment and liquid on established full-thickness 3D skin models depicting acute radiodermatitis and mucositis. To mimic radiomucositis and radiodermatitis, non-keratinized mucous membrane and normal human skin models were irradiated with 5 Gray. Afterwards, models were treated topically every second day with dexpanthenol-containing ointment or liquid in comparison with placebo and untreated controls. On day 7 after irradiation, histological examination showed impairments in irradiated models. In contrast, models treated with dexpanthenol-containing ointment or liquid showed a completely restored epidermal part. While gene expression profiling revealed an induction of genes related to a pro-inflammatory milieu, oxidative stress and an impaired epidermal differentiation after irradiation of the models, aftercare treatment with dexpanthenol-containing ointment or liquid revealed anti-oxidative and anti-inflammatory effects and had a positive effect on epidermal differentiation and structures important for physical and antimicrobial barrier function. Our findings confirm the potential of our established models as in vitro tools for the replacement of pharmacological in vivo studies regarding radiation-induced skin injuries and give indications of the positive effects of dexpanthenol-containing externals after radiation treatments as part of supportive tumor treatment.

Ocoxin as a complement to first line treatments in cancer

Chemotherapy and radiotherapy are the most frequent treatment for patients suffering from malignant progression of cancer. Even though new treatments are now being implemented, administration of these chemotherapeutic agents remains as the first line option in many tumor types. However, the secondary effects of these compounds represent one of the main reasons cancer patients lose life quality during disease progression. Recent data suggests that Ocoxin, a plant extract and natural compound based nutritional complement rich in antioxidants and anti-inflammatory mediators exerts a positive effect in patients receiving chemotherapy and radiotherapy. This mixture attenuates the chemotherapy and radiotherapy-related side effects such as radiation-induced skin burns and mucositis, chemotherapy-related diarrhea, hepatic toxicity and blood-infection. Moreover, it has been proven to be effective as anticancer agent in different tumor models both in vitro and in vivo, potentiating the cytotoxic effect of several chemotherapy compounds such as Lapatinib, Gemcitabine, Paclitaxel, Sorafenib and Irinotecan. The aim of this review is to put some light on the potential of this nutritional mixture as an anticancer agent and complement for the standard chemotherapy routine.

Pehuén (Araucaria araucana) seed residues are a valuable source of natural antioxidants with nutraceutical, chemoprotective and metal corrosion-inhibiting properties

In the last decade, green chemistry has been attracting great interest in many contexts, including, among others, natural antioxidants. However, only a few works deal with natural residue extracts and biowaste, which could be an efficient, economical and environmentally friendly source for the production of useful compounds. In this study, we look for antioxidant activity in Araucaria araucana seeds, an iconic pine species of the Argentine and Chilean Patagonia commonly known as "pehuén". Piñones are the edible pehuén seeds, and it is estimated that approximately 40 tons of piñones are harvested annually in Argentina and Chile. The chemical composition, antioxidants, metal corrosion-inhibiting properties and biological activity of edible and discarded piñón tissues were determined. Acute toxicity was discarded by in vitro testing and double fluorescent staining. Biological activity was evaluated in vivo by determining redox markers in salivary glands from rats treated with Cyclophosphamide (an oncological drug). All piñón tissues had antioxidants and antioxidant activity, with the coats showing the highest levels (up to 404 µg ascorbic acid equivalent per mg). The coats, in particular, had high gallic acid, catechin, quercetin and tannin contents, and more antioxidant activity, polyphenols and flavonoids than berries from the region. Results by X-ray fluorescence spectrometry showed that Na, Mg, P, S, Cl, K, and Ca were majority elements in the coat, embryo and endosperm. Furthermore, coat extract also showed significant anti-corrosion activity and in vivo protection against oxidative damage. The results indicate that piñón biowaste is a low-cost attractive source of natural antioxidants with potential nutraceutical, medical and metal corrosion protection applications.

Oral mucositis

Oral mucositis is one of the most common complications of cancer therapy. It is a nonhematologic complication of cytotoxic chemotherapy and radiotherapy and reduces the quality of life. It is estimated that 40% the cases on standard chemotherapy may develop oral mucositis. Patients receiving radiation, especially in the cases of head and neck cancer, have 30%-60% chances of developing mucositis. Chemotherapy and radiotherapy interfere with the normal turnover of epithelial cells, leading to mucosal injuries. These injuries can also occur due to indirect invasion of Gram negative bacteria and fungi as most of the chemo-therapeutic agents will cause neutropenia and will give a favorable environment for the development of mucositis. The patient-related factors are also responsible for developing mucositis in chemo-induced and radiation-induced mucositis. Poor oral hygiene may also be responsible for bacterial super infection followed by chemotherapy. Mucositis is of two kinds: direct and indirect mucositis. Direct mucositis - The epithelial cells of the oral mucosa undergo rapid turnover in usually 7-14 days due to which these cells are more susceptible to the effect of the cytotoxic therapy which results in oral mucositis. Indirect mucositis - it can develop due to the infection caused by Gram-negative bacteria and fungal infection. There will be a greater risk for oral infection due to neutropenia. The onset of mucositis secondary to mylo-suppression varies depending upon the timing of the neutrophil count associated with chemotherapy agents but they typically develop around 10-21 days after chemotherapy administration.

Metformin: (future) best friend of the radiation oncologist?

Several molecules are being investigated for their ability to enhance the anti-tumor effect of radiotherapy. The widely prescribed antidiabetic drug metformin has been suggested to possess anti-cancer activity; data indicate that metformin could also enhance radiation sensitivity. The purpose of this review is to summarize current knowledge on the specific effect of metformin in the field of RT, while also discussing the many unknowns that persist. Preclinical models point to multiple mechanisms involved in the radiosensitizing effects of metformin that are mainly linked to mitochondrial complex I inhibition and AMP-activated protein kinase. Transposition of results from bench to bedside will be discussed through the lens of the drug concentration, its potential limits in human settings, and possible alternatives. Clinical data suggest metformin improves progression-free and overall survival in patients for many different cancers treated with RT; nevertheless, the results are not always consistent. The main limitations of the reviewed literature are the retrospective nature of studies, and most of the time, a lack of information on MTF treatment duration and the administered dosages. Despite these limitations, the possible mechanisms of the role of metformin and its utility in enhancing radiotherapy treatments are analyzed. Ongoing clinical trials are also discussed.

Polymorphism of TNFRSF1 A may act as a predictor of severe radiation-induced oral mucositis and a prognosis factor in patients with head and neck cancer

OBJECTIVE

The aim of this study was to evaluate the relationship between single nucleotide polymorphism (SNP) (-135 T>C) of TNFRSF1 A and the frequency of occurrence and severity of oral mucositis (OM) in patients with head and neck cancer (HNC) treated with radiotherapy (RT).

STUDY DESIGN

This retrospective, cohort study included 60 patients with HNC treated with intensity-modulated radiation therapy (IMRT). TNFRSF1 A SNP analysis (-135 T>C) was performed by using molecular probes (TaqMan, ThermoFisher Scientific, Waltham, MA) in DNA isolated from peripheral blood (QIAamp DNA MiniKit; Qiagen, Germantown, MD).

RESULTS

CC genotype was related to 4.5-fold higher risk of grade 2 OM after the second week of RT. Similarly, CC carriers had a significantly higher risk of severe (grade 3) OM after the fourth (6-fold) and fifth (7.5-fold) weeks of RT. The CC genotype of the TNFRSF1 A gene was significantly correlated with a higher risk of shorter overall survival (OS) (> 37 months follow-up period; hazard ratio [HR] = 2.78).

CONCLUSIONS

SNP (-135 T>C) of the TNFRSF1 A gene may act as a predictor of OM occurrence in patients with HNC treated with IMRT. The studied SNP may also serve as a prognostic factor in such cases.

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.

Pathogenesis and Treatment of Pancreatic Cancer Related Pain

Pancreatic cancer is often diagnosed due to the patient seeking medical attention for abdominal pain. It is among the most painful cancers, with pain severity strongly correlating with prognosis. Perineural invasion is a prominent feature of pancreatic cancer and often the first route of metastasis resulting in neuropathic pain. While surgical pain is present, it is generally short-lived; chemo- and radio-therapy associated side effect pain is often longer lasting and more difficult to manage. Treatment-induced mucositis in response to chemotherapy occurs throughout the GI tract resulting in infection-prone ulcers on the lip, buccal mucosa, palate or tongue. Cisplatin treatment is associated with axonal neuropathy in the dorsal root ganglion, although other large sensory fibers can be affected. Opioid-induced hyperalgesia can also emerge in patients. Along with traditional means to address pain, neurolytic celiac plexus block of afferent nociceptive fibers has been reported to be effective in 74% of patients. Moreover, as cancer treatments become more effective and result in improved survival, treatment-related side effects become more prevalent. Here, pancreatic cancer and treatment associated pain are reviewed along with current treatment strategies. Potential future therapeutic strategies to target the pathophysiology underlying pancreatic cancer and pain induction are also presented.

Effects of 9 oral care solutions on the prevention of oral mucositis: a network meta-analysis of randomized controlled trials

BACKGROUND

Oral mucositis (OM) is a common, disabling, and severe early effect of chemotherapy and radiotherapy that limits the effectiveness of anticancer therapy. The prevention and treatment of OM in patients with malignant tumors is an urgent problem in the field of anticancer therapy.

METHODS

Databases including PubMed, Embase, Scopus, The Cochrane Library, and Google Scholar were searched to collect published randomized control trials (RCTs) about the effects of different oral care solutions on the prevention of OM from inception to January 2019. We used the Cochrane Handbook to assess the methodological quality of the RCTs. Two of the authors independently extracted the articles and predefined data. Network meta-analysis was then performed using Stata 15.0 software.

RESULTS

A total of 28 RCTs involving 1861 patients were included. The results of network meta-analysis showed that chlorhexidine, benzydamine, honey, and curcumin were more effective than placebo (P < .05) and that honey and curcumin were more effective than povidone-iodine (P < .05). Probability ranking according to the Surface Under the Cumulative Ranking curve showed the following treatments: curcumin, honey, benzydamine, chlorhexidine, allopurinol, sucralfate, granulocyte-macrophage colony-stimulating factor, povidone-iodine, and aloe.

CONCLUSION

Our preliminary results indicate that curcumin and honey may serve as the preferred options for patients to prevent OM. The findings may offer an important theoretical basis for clinical prevention and treatment. However, this conclusion still requires an RCT with a larger sample size for further verification.

Differences between the oral changes presented by patients with solid and hematologic tumors during the chemotherapeutic treatment

Objective:

This study sought to identify the differences between the oral changes presented by patients with solid and hematologic tumors during chemotherapeutic treatment.

Methodology:

This is an observational, prospective and quantitative study using direct documentation by follow-up of 105 patients from 0 to 18 years using the modified Oral Assessment Guide (OAG). Of the 105 patients analyzed, 57 (54.3%) were boys with 7.3 years (±5.2) mean age. Hematologic neoplasms accounted for 51.4% of all cases.

Results:

Voice, lips, tongue, and saliva changes were not significantly different (p>0.05) between patients with solid or hematologic tumors and during the follow-up. From the 6^th until the 10^th week of chemotherapeutic treatment alterations in swallowing function, in the mucous membrane (buccal mucosa and palate), in the labial mucosa, and in the gingiva occurred and were distributed differently between the two tumors groups (p<0.05). The main alterations were observed in patients with hematologic tumors.

Conclusion:

It was concluded that the oral changes during the chemotherapeutic treatment occurred especially in swallowing function, in the mucous membrane, in the labial mucosa and in the gingiva, and these alterations were found mainly in patients with hematologic tumors.

Metabolomic studies in tissues of mice treated with amifostine and exposed to gamma-radiation

Although multiple radioprotectors are currently being investigated preclinically for efficacy and safety, few studies have investigated concomitant metabolic changes. This study examines the effects of amifostine on the metabolic profiles in tissues of mice exposed to cobalt-60 total-body gamma-radiation. Global metabolomic and lipidomic changes were analyzed using ultra-performance liquid chromatography (UPLC) quadrupole time-of-flight mass spectrometry (QTOF-MS) in bone marrow, jejunum, and lung samples of amifostine-treated and saline-treated control mice. Results demonstrate that radiation exposure leads to tissue specific metabolic responses that were corrected in part by treatment with amifostine in a drug-dose dependent manner. Bone marrow exhibited robust responses to radiation and was also highly responsive to protective effects of amifostine, while jejunum and lung showed only modest changes. Treatment with amifostine at 200 mg/kg prior to irradiation seemed to impart maximum survival benefit, while the lower dose of 50 mg/kg offered only limited survival benefit. These findings show that the administration of amifostine causes metabolic shifts that would provide an overall benefit to radiation injury and underscore the utility of metabolomics and lipidomics to determine the underlying physiological mechanisms involved in the radioprotective efficacy of amifostine. This approach may be helpful in identifying biomarkers for radioprotective efficacy of amifostine and other countermeasures under development.

Milk modulates macrophage polarization in vitro

Objective

Milk holds an anti-inflammatory response that is particularly important to protecting infants against necrotizing enterocolitis. Milk might also exert anti-inflammatory effects in adulthood, including the oral cavity where macrophages of the oral mucosal control innate immunity defense. It remains unknown, however, whether milk can modulate the local inflammatory response by affecting the polarization of macrophages.

Material and Methods

To determine whether pasteurized human milk and pasteurized cow milk can provoke macrophage polarization, murine bone marrow macrophages and RAW264.7 cells were exposed to human saliva or the inflammatory cytokines IL1β and TNFα. Activation of pro-(M1) inflammatory response is indicated by the expression of IL1 and IL8. To determine polarization towards a M2 phenotype, the expression of arginase 1 (ARG1) and chitinase-like 3 (Chil3) was determined by reverse transcriptase PCR and immunoassay. Western blot was done on phosphorylated p38 and JNK.

Results

Aqueous fractions of human milk and cow milk from different donors, respectively, significantly decreased the inflammatory response of primary macrophages and RAW264.7 cells when exposed to saliva or IL1 and TNFα. Similar to IL4, human milk and cow milk caused a robust expression of ARG1 and Chil3 in primary macrophages. The polarization of macrophages by pasteurized milk occurred independent of the phosphorylation of p38 and JNK.

Conclusion

These data suggest that pasteurized milk, independent of the origin, can cause the polarization of macrophages from a pro-inflammatory M1 towards a pro-resolving M2 phenotype. Thus, milk might have a protective role for the oral cavity by modulation of the macrophage-based innate immune system.

Swellable polymeric particles for the local delivery of budesonide in oral mucositis

Topical drug delivery in the oral mucosa has its set of challenges due to the unique anatomical and physiological features of the oral cavity. As such, the outcomes of local pharmacological treatments in oral disorders can fail due to unsuccessfully drug delivery. Oral mucositis, a severe inflammatory and ulcerative side effect of oncological treatments, is one of such diseases. Although the damaged tissue is within reach, no approved topical drug treatment is available. Several strategies based on its physiopathology have been implemented and clinically used. Even so, results tend to lack or be insufficient to improve patient's quality of life. The use of corticosteroids has been employed in such strategies due to their strong anti-inflammatory action. Typically, these are administrated in simple liquid formulations, where the drug is dispersed or solubilized, lacking the ability to maintain local concentration. In this work, we propose the development of a biocompatible delivery system with boosted abilities of retention and control release of budesonide, a corticosteroid with an elevated ratio of topical anti-inflammatory to systemic action. Through spray-drying, polymeric particles of Chitosan and Eudragit® E PO were produced and characterized for the vectorization of this drug.