Efficacy of Episil® in patients with hematologic malignancies: a comparative study

BACKGROUND

Episil® is a nonabsorbable liquid medical material used to coat and protect the mucosa in patients with oral mucositis. A few studies have reported its efficacy in patients with head and neck cancer. However, reports on its use in patients with hematologic malignancies are scarce. Thus, we aimed to evaluate the efficacy of Episil for the treatment of oral mucositis in patients with acute myelogenous leukemia, malignant lymphoma, acute lymphocytic leukemia, multiple myeloma, and myelodysplastic syndrome.

METHODS

Between May 2018 and March 2019, a total of thirty-seven patients with acute myelogenous leukemia, malignant lymphoma, acute lymphocytic leukemia, multiple myeloma, and myelodysplastic syndrome who received Episil® for the treatment of oral mucositis were included in this study. All patients were treated at the Hiroshima Red Cross and Atomic-bomb Surgery Hospital. To determine the severity of oral mucositis, 22 out of the 37 patients were interviewed and compared objectively using the Common Terminology Criteria for Adverse Events, version 3.0. In addition, subjective measures of the effects of oral mucositis were assessed using an original evaluation protocol (a unique evaluation chart specific to the Department of Oral Surgery, Hiroshima Red Cross & Atomic-bomb Survivors Hospital).

RESULTS

Out of 37 participants recruited in the study, 31 (84%) described the sensation of Episil® as very good or good. Moreover, the severity of mucositis was found to decrease after the use of Episil® in seven patients out of 22 (19%), particularly in those with mucositis at multiple sites. Participants' evaluations revealed pain relief and improvement in speech and feeding functions. Participants with grade 3 mucositis reported a greater improvement in pain relief, speech, and feeding functions than those with grade 2 mucositis.

CONCLUSIONS

This study suggests the efficacy of Episil® in treating oral mucositis in patients with hematologic malignancies, particularly in those with oral mucositis at multiple sites. In addition to pain relief, Episil® may improve speech and feeding functions.

Effects of an elemental diet to reduce adverse events in patients with esophageal cancer receiving docetaxel/cisplatin/5-fluorouracil: a phase III randomized controlled trial-EPOC 2 (JFMC49-1601-C5)

Background

Oral mucositis (OM) is an unpleasant adverse event in patients receiving chemotherapy. A prospective feasibility study showed that elemental diet (ED), an oral supplement that does not require digestion, may prevent OM. Based on this, we established a central review system for oral cavity assessment by dental oncology specialists blinded to background data. We used this system to elucidate the preventive effect of an ED against OM in patients with esophageal cancer receiving docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy.

Patients and methods

In this phase III, multicenter, parallel-group, controlled trial, patients consuming a normal diet orally were randomly assigned (1 : 1) to receive two cycles of DCF with (group A) or without (group B) an ED (Elental® 160 g/day). We assessed the incidence of grade ≥2 OM evaluated by two reviewers, changes in body weight, prealbumin, C-reactive protein, and DCF completion rate based on ED compliance.

Results

Of the 117 patients randomly assigned to treatment, four failed to start treatment and were excluded from the primary analysis; thus, groups A and B comprised 55 and 58 patients, respectively. There were no significant differences in background characteristics. Grade ≥2 OM was observed in eight (15%) and 20 (34%) patients in groups A and B, respectively (P = 0.0141). Changes in body weight and prealbumin during the two DCF cycles were significantly higher in group A than B (P = 0.0022 and 0.0203, respectively). During the first cycle, changes in C-reactive protein were significantly lower in group A than B (P = 0.0338). In group A (receiving ED), the DCF completion rate was 100% in patients with 100% ED compliance and 70% in patients failing ED completion (P = 0.0046).

Conclusions

The study findings demonstrate that an ED can prevent OM in patients with esophageal cancer receiving chemotherapy.

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Patients receiving docetaxel, cisplatin, and 5-fluorouracil (DCF) chemotherapy commonly develop oral mucositis (OM).

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An elemental diet (ED) was able to prevent OM in patients with esophageal cancer receiving DCF.

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Grade ≥2 OM was observed in 15% of patients receiving the ED versus 34% of those not receiving the ED (P = 0.0141).

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Body weight was maintained in the ED group, and hematologic toxicities were lower, compared with the non-ED group.

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The DCF completion rate significantly correlated with ED compliance (P = 0.0046).

Understanding oral mucositis and the principles of effective mouth care

Mucositis involves an inflammation of the oral or gastrointestinal mucosa and is a common complication of cancer treatment. Mucositis is usually associated with high-dose chemotherapy, radiotherapy and, more recently, molecular targeted therapy. Oral mucositis refers specifically to inflammation and ulceration that occurs in the mouth. If not treated promptly, it can potentially lead to life-threatening infection requiring hospitalisation and intravenous antibiotics. This article discusses the causes and nursing management of oral mucositis, with an emphasis on self-care and optimal oral hygiene, as well as pharmacological interventions.

Oral stomatitis and mTOR inhibitors: A review of current evidence in 20,915 patients

BACKGROUND

Traditional treatment of malignancies with chemotherapeutic agents is often affected by the damage inflicted on non-cancerous cells. Toxicities of the oral cavity, such as mucositis and stomatitis, are some of the most significant and unavoidable toxicities associated with anti-cancer therapies. For such reason, in the last decades, newer targeted agents have been developed aiming to decrease the rates of side effects on healthy cells. Unfortunately, targeted anti-cancer therapies also showed significant rate of toxicity on healthy tissues. mTOR inhibitors showed some adverse events, such as hyperglycemia, hyperlipidemia, hypophosphatemia, hematologic toxicities, and mucocutaneous eruption, but the most important are still stomatitis and skin rash, often reported as dose-limiting side effects.

PATIENTS AND METHODS

A search of the literature was performed by authors on the PubMed online database using the following key words: "sirolimus" OR "everolimus" OR "temsirolimus" OR "deforolimus" OR "ridaforolimus" combined with the Boolean operator AND with the terms: "stomatitis" OR "mucositis" OR "oral pain." Titles and abstracts of 382 potentially relevant studies were screened; of these, 114 studies were excluded because they did not report the inclusion criteria. In the second round, 268 studies were read full-text, but only 135 reported the inclusion criteria and were included for data extraction. Of the included studies, 95 referred to everolimus use, 16 to ridaforolimus, and 26 to temsirolimus (two studies referred to both everolimus and temsirolimus).

RESULTS

The incidence rate of stomatitis according to the agent used was 25.07% (3,959/15,787) for everolimus, 27.02% (724/2,679) for temsirolimus, and 54.76% (598/1,092) for ridaforolimus. All the three agents analyzed showed high rates of low-grade stomatitis (G1-G2), while the onset of severe stomatitis (G3-G4) was rare.

CONCLUSIONS

Analysis of the reports with patients treated with everolimus, temsirolimus, and ridaforolimus showed a clear prevalence of stomatitis grade 1 or 2. These data differ from that of patients treated with conventional chemotherapy in which mucositis is predominantly of grade 3 or 4.

The Effect of Honey on Radiation-induced Oral Mucositis in Head and Neck Cancer Patients

Aim:

The aim of this study is to evaluate the effect of honey on clinically scoring grades of oral mucositis.

Materials and Methods:

This interventional study was carried out in Radiation Oncology Department of Mayo Hospital, Lahore. In this study, 82 patients of both genders, of head and neck cancer, planned for radiotherapy, were divided into two groups by random sampling numbers. Patients in both groups were treated with a total dose of 60–78 Grays in 4–6 weeks. In treatment group, patients were instructed to take 20 mL of honey. In control group, they were advised to rinse with 0.9% of saline. Patients were evaluated every week to assess the grades of oral mucositis up to 6 weeks. The assessment tool was Radiation Therapy Oncology Group Grading System. The statistical analysis was done by Chi-square test.

Results:

In honey-treated group, the proportion of mucositis (Grades 3 and 4) was lower and statistically significant as compared to control group at the end of 6 weeks of radiation.

Conclusion:

This study showed that oral intake of honey during radiotherapy is valuable in the reduction of severity of oral mucositis.

Mechanism-based management for mucositis: option for treating side effects without compromising the efficacy of cancer therapy

Mucositis is a major side effect induced by chemotherapy and radiotherapy. Although mucositis is a leading cause of morbidity and mortality in cancer patients, management is largely limited to controlling symptoms, and few therapeutic agents are available for treatment. Since mucositis could be inhibited by the modulation of radiotherapy- or chemotherapy-induced pathways independently of cancer treatment, there is an opportunity for the development of more targeted therapies and interventions. This article examined potential therapeutic agents that have been investigated for the prevention and/or inhibition of mucositis induced by conventional chemotherapy and radiotherapy. They can be classified according to their mechanisms of action: scavenging reactive oxygen species, inhibition of specific cytokine production or inflammation, and inhibition of apoptosis. These early events may be good target pathways for preventing the pathogenesis of mucositis. Considering that both cancer therapy and therapeutic agents for mucositis act on both normal and cancer cells, agents that inhibit mucositis should act through mechanisms that selectively protect normal cells without compromising cancer treatment. Therefore, mechanism-based guidance for the treatment of mucositis is critical to prevent risky treatments for cancer patients and to relieve detrimental side effects effectively from cancer therapy.

Fibroblast growth factors, old kids on the new block

The fibroblast growth factors (FGFs) are a family of cell intrinsic regulatory peptides that control a broad spectrum of cellular activities. The family includes canonic FGFs that elicit their activities by activating the FGF receptor (FGFR) tyrosine kinase and non-canonic members that elicit their activities intracellularly and via FGFR-independent mechanisms. The FGF signaling axis is highly complex due to the existence of multiple isoforms of both ligands and receptors, as well as cofactors that include the chemically heterogeneous heparan sulfate (HS) cofactors, and in the case of endocrine FGFs, the Klotho coreceptors. Resident FGF signaling controls embryonic development, maintains tissue homeostasis, promotes wound healing and tissue regeneration, and regulates functions of multiple organs. However, ectopic or aberrant FGF signaling is a culprit for various diseases, including congenital birth defects, metabolic disorder, and cancer. The molecular mechanisms by which the specificity of FGF signaling is achieved remain incompletely understood. Since its application as a druggable target has been gradually recognized by pharmaceutical companies and translational researchers, understanding the determinants of FGF signaling specificity has become even more important in order to get into the position to selectively suppress a particular pathway without affecting others to minimize side effects.

Topical application of Aloe vera and vitamin E on induced ulcers on the tongue of rats subjected to radiation: clinical and histological evaluation

OBJECTIVE

The aim of this study is to assess the effect of two types of antioxidants, vitamin E (VE) and Aloe vera (AV), on healing of induced oral lesions after radiation in a murine model by clinical and histological analysis.

METHODS

The animals were randomly divided into three groups of 12 animals each (400 mg VE, 70 % AV and control) and two time periods (5 and 7 days). They were irradiated with a single dose of 30 Gy, and after 24 h, a lesion was produced on the ventral tongue of each animal. The products were applied daily in their respective group until euthanasia.

RESULTS

On clinical analysis, there was a higher frequency of lesions in the animals of the control group at both periods. The area of the lesions was also greater in the control group compared with the groups AV and VE (5 days p = 0.006; 7 days p = 0.002). On microscopic analysis, the degree of inflammation differed between the study groups and experimental periods. At 5 days, the statistical difference was not significant among the groups evaluated, but at 7 days, animals in the control group showed intense inflammation, while those in groups VE and AV exhibited mild to moderate inflammation (p = 0.002).

CONCLUSION

The results suggest that VE and AV contributed to the decrease in inflammatory response and healing of the lesions induced on the tongue of rats subjected to radiation.

The weaned pig as a model for Doxorubicin-induced mucositis

BACKGROUND

Chemotherapy-induced mucositis (CIM) complicates cancer therapy and limits maximum tolerated doses and efficacy. Rodent models do not reproducibly mimic clinical CIM, so alternative models are needed.

METHODS

CIM severity was assessed after weaned pigs were treated with doxorubicin (5 and 3.75 mg/kg) using clinical observations, laboratory parameters and gastrointestinal structure and functions. Bovine colostrum was provided as an experimental intervention to the pigs treated receiving the 3.75 mg/kg dose.

RESULTS

Doxorubin at 3.75 mg/kg decreased food intake and weight gain (p < 0.05) and caused diarrhea and vomiting that coincided with damage to the small intestine mucosa based on histological scoring (p < 0.05). It resulted in higher serum TNF-α concentrations, increased chloride secretion and reduced brush border membrane disaccharidase activities and carrier-mediated glucose uptake (all p < 0.05). The gastrointestinal damage and dysfunction resemble the clinical and laboratory features of CIM in humans; these can be partially prevented by providing cow colostrum.

CONCLUSION

The weaned pig is a relevant large animal for studying CIM and evaluating existing and experimental interventions for mucositis.

Oral mucositis in cancer treatment: Natural history, prevention and treatment

Oral mucositis is a condition that is characterized by ulcerative lesions in the mucosa of patients undergoing radiotherapy or chemotherapy. Oral mucositis is currently considered to be the most severe complication of anticancer therapy, affecting 40-80% of patients undergoing chemotherapy and almost all those undergoing radiotherapy of the head and neck. Although they do not prevent lesions from appearing, drugs for the treatment of oral mucositis are required to minimize its clinical aggressiveness and improve the nutritional status, hydration and quality of life of the affected patients. Furthermore, the prevention and control of oral ulcers is crucial for cancer prognosis, since the establishment of severe lesions may lead to temporary or permanent treatment discontinuation and compromise cancer control. The objective of this study was to present a review on this condition, its causes and its treatment to professional clinical dentists, in order to help minimize patient suffering. A search was conducted through PubMed, Lilacs and MedLine, to retrieve related articles published between 1994 and 2013.

Mammalian target of rapamycin inhibitor-associated stomatitis

With the recent introduction of inhibitors of mammalian target of rapamycin (mTOR) in oncology, distinct cutaneous and oral adverse events have been identified. In fact, stomatitis and rash are documented as the most frequent and potentially dose-limiting side effects. Clinically, mTOR inhibitor-associated stomatitis (mIAS) more closely resembles aphthous stomatitis than oral mucositis due to conventional anticancer therapies. While most cases of mIAS are mild to moderate and self-limiting, more severe and persistent mIAS can become a dose-limiting toxicity. Small ulcerations may cause significant pain and mucosal sensitivity may occur in the absence of clinical changes. Use of clinical assessment tools that are primarily driven by ulceration size may underestimate mIAS, and assessment should include patient-reported outcomes. This article provides an up-to-date review of the clinical presentation, terminology, pathogenesis, assessment and management of mIAS and other mTOR inhibitor-associated oral adverse events. In addition, areas of future research are considered.

Adherence Issues for Oral Antineoplastics

Nonadherence to antineoplastics is a growing concern because of the increasing number of novel oral targeted anticancer therapies. Many of these agents are administered on a chronic continuous schedule for an indefinite period of time where adherence is crucial to achieve optimal disease control and prolong survival. Many factors are known to contribute to medication nonadherence. Prevention, early detection, and management of adverse drug reactions associated with oral targeted therapies require close vigilance. Knowing how to prevent and manage adverse drug reactions will help clinicians develop strategies to promote patient adherence to oral anticancer treatment regimens. Optimal adherence requires a dynamic patient-provider alliance through education, communication, ongoing monitoring, and follow-up.