MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy

Background

Mucositis is a significant toxicity of cancer therapy with numerous systemic sequelae. The goal of this systematic review was to update the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO) Clinical Practice Guidelines for the management of mucositis.

Methods

The literature was reviewed systematically to identify interventions for mucositis. Studies were rated according to the presence of major and minor flaws according to previously published criteria. The body of evidence for each intervention and in each treatment setting was assigned a level of evidence based on previously published criteria. Guidelines were developed based on the level of evidence, with 3 possible guideline determinations: recommendation, suggestion, or no guideline possible.

Results

The guideline covers evidence from 1197 publications related to oral or gastrointestinal mucositis. Thirteen new guidelines were developed for or against the use of various interventions in specific treatment settings, and 11 previous guidelines were confirmed after aa review of new evidence. Thirteen previously established guidelines were carried over because there was no new evidence for these interventions.

Conclusions

The updated MASCC/ISOO Clinical Practice Guidelines for mucositis provide professional health caregivers with a clinical setting‐specific, evidence‐based tool to help with the management of mucositis in patients who have cancer.

The Multinational Association of Supportive Care in Cancer and the International Society of Oral Oncology developed clinical practice guidelines for the management of mucositis, with the first edition published in 2004 and periodically updated. This summary presents the 2019/2020 guidelines update, which is based on a systematic review, and generates a tool that will help clinicians to select evidence‐based interventions.

Oral chronic GVHD outcomes and resource utilization: a subanalysis from the chronic GVHD consortium

OBJECTIVES

This study evaluated the extent to which oral chronic graft-versus-host disease (cGVHD) consensus assessments are predictive of management across institutions with and without oral medicine (OM) centers, and whether ancillary care guidelines are followed within clinical practice.

METHODS

Longitudinal oral cGVHD data were abstracted from the cGVHD Consortium, and additional mouth-specific management data were analyzed across five transplant centers.

RESULTS

Seventy-nine patients with 656 visits were observed for a median of 7.1 months with one visit per follow-up month. Ancillary therapies for oral cGVHD were prescribed for 67% of patients for a median of 0.46 months (per follow-up month) at OM centers and 0.78 months at non-OM centers. Patients treated with ancillary therapy were more likely to have an National Institutes of Health (NIH) mouth score of ≥1 (P < 0.001, odds ratio: 5.1) and mouth pain (P = 0.01, odds ratio: 2.6). The odds ratios of receiving ancillary therapy from OM experts were higher than transplant physicians (53%; P = 0.03).

CONCLUSIONS

Oral cGVHD consensus assessments corresponding with ancillary therapy use were mouth pain and NIH mouth score, with higher odds ratios of receiving therapy from OM experts. Ancillary care guidelines for oral cGVHD are reflected in academic clinical practice with respect to utilization of recommended prescriptions.

Oral epithelial dysplasia and squamous cell carcinoma following allogeneic hematopoietic stem cell transplantation: clinical presentation and treatment outcomes

Background

Late complications of allogeneic hematopoietic stem cell transplantation (HSCT) include a risk of secondary malignancies, including oral cancers. Optimization of best clinical practices for early diagnosis and treatment of oral premalignant or malignant lesions requires an assessment of potential predisposing risk factors as well as treatment outcomes.

Methods

The medical records of patients who developed oral epithelial dysplasia (OED) and oral squamous cell carcinoma (OSCC) following allogeneic HSCT were reviewed. Data on demographics, HSCT course, chronic graft-versus-host disease (cGVHD), smoking and alcohol consumption, oral lesion characteristics, mode of therapy and clinical outcome were recorded; landmark survival was calculated.

Results

Twenty-six patients with OED (n = 8) and OSCC (n = 18) were identified with a median follow-up of 26.5 and 21.5 months, respectively. Premalignant and malignant oral lesions were diagnosed at a median time of 2.5 and 8 years after HSCT, respectively. Chronic GVHD was present in 96% of patients and of these, 96% had oral involvement. Multifocal oral cancer was found in 28% of cases, and localized recurrence was observed in 44% of cases. Five-year overall survival was 75% and 70% for OED and OSCC, respectively.

Conclusions

These results suggest that oral cGVHD may be considered a potential risk factor for the development of OSCC following allogeneic HSCT. The observation that oral cancers were frequently multifocal and recurred locally supports the concept of field cancerization and suggests that these cancers may be more aggressive compared with the non-HSCT population. Vigilant follow-up and coordination of care between hematologists and oral health specialists are critical to minimize morbidity and mortality.

Paediatric intraoral mucoepidermoid carcinoma mimicking a bone lesion

BACKGROUND

Mucoepidermoid carcinoma of the salivary glands occurs most frequently in adults during the fifth and sixth decades of life. Although uncommon, it is the main malignant salivary gland tumour in children, particularly adolescents.

CASE REPORT

A 14-year-old girl presented with a mass in her palate that had had a duration of one year. On panoramic X-ray, a well-delimited radiolucent area was observed on the left maxillary sinus region. The initial clinical diagnostic hypothesis was that this was a central giant cell granuloma. An incisional biopsy was performed and the final microscopic diagnosis was mucoepidermoid carcinoma. The tumour was removed by a wide transoral resection and the patient has been asymptomatic for 4 years.

CONCLUSION

Mucoepidermoid carcinoma in paediatric patients is uncommon, but it must be considered in differential diagnoses of intraoral submucosal mass/nodules in children, particularly in the palate.

A randomised, prospective comparison of allogeneic bone marrow and peripheral blood progenitor cell transplantation in the treatment of haematological malignancies

We present the results of a prospective, randomised study comparing PBPC and BM focusing on engraftment, acute and chronic GVHD and survival. Forty patients with haematological malignancies received HLA-identical sibling BM (group A) or PBPC (group B). Evaluable patients were 19 (A) and 18 (B). Median age was 35 (17-56) in A and 29.5 (9-51) in B. Conditioning was mainly Bu-Cy2; GVHD prophylaxis was CSA-MTX. PBPC were harvested after 5 days of G-CSF 10 microg/kg/day. Median days for an ANC >0.5 x 10(9)/l was 18 (13-30) in A and 16 (11-25) in B (P = 0.10). Platelets >20 x 10(9)/l occurred at +17 (10-40) in A and +12 (9-36) in B (P = 0.01). The probability of > or =2 grade a-GVHD was 19% (A) and 27% (B) (P = 0.53). The probability of all grade c-GVHD was 70% with BM. In spite of the small number of patients in group B (PBPC), our data suggest the great majority of them will have c-GVHD (P = 0.08); extensive disease was present in 50 and 100%, respectively (P = 0.05). The estimates of overall survival for A and B at 1000 days are 51 and 47%, respectively (P = 0.67); DFS at 1000 days are 52 and 58%, respectively (P = 0.50). PBPC resulted in faster platelet engraftment. The incidence of acute and chronic GVHD was similar in both groups, but the severity of c-GVHD was higher with PBPC. No differences in survival and DFS have been observed to date.

Ultrastructure of hepatocyte abnormalities in perimetastatic areas

The ultrastructural pathology of non-invaded hepatocytes located in close proximity to metastases from diverse gastrointestinal carcinomas was studied. Observed abnormalities included swelling of rough and smooth endoplasmic reticulum, proliferation of lysosomes, and mitochondrial alterations as presence of granules and paracrystalline inclusions, marked pleomorphism, and lack of cristae. These results show that, contrary to the classical conception, the non-invaded cells surrounding primary tumours or their metastases could be abnormal.

Dimensions of experiential learning at group relations conferences

Four hundred and seventy-seven professionals attended thirteen group relations conferences. Conferences varied across three dimensions: context, including sponsorship and history: design, involving duration, intensity (residential setting) and complexity; and linkages, the social and authority ties between members and staff. Three month follow-up questionnaires were collected from sixty percent of participants. Significantly more self-assessed learning was reported by those who attended the residential than the non-residential conferences. The results, from a large diversified sample, suggest that a combination of training in a residential setting, strong institutional sponsorship and pre-existing authority and social linkages between members and staff resulted in the most reported learning. Group relations conferences provide unique learning opportunities for mental health professionals, (Correa et al. 1981) and have been increasingly used in the United States and Europe during the last twenty years. Despite this, there is little research evaluating the outcomes of such training in terms of member learning or the differential effectiveness of the alternative forms of conferences currently available. Conferences vary along three major dimensions: a) context, including the institutional sponsorship as well as the history of previous conferences held at the same site, b) design, including the duration, intensity and number of events which make up the conference, and c) linkages, the social and authority relations among members and staff. A review of the first decade of group relations work in the United States concluded that the characteristics of a conference, including the setting have an important impact on member learning, (Klein 1978).(ABSTRACT TRUNCATED AT 250 WORDS)

[Vascular conductance and critical closing pressure in the isolated canine lung in situ. Its natural history]

The vascular pressure-flow relationship (P-QL) in West's zone II condition were studied in isolated, in situ, canine, left lower lobe (ISLL) in order to characterize the total resistance in the pulmonary vascular bed (Rp), the normal values for pulmonary vascular conductance (Cv) and for critical closing pressure (PLc). After the basal parameters were obtained, measurements of Cv and PLc were done every 30' in order to know the natural history (NH) of this canine ISLL preparation. The P-QL relationship of the pulmonary vasculature of the ISLL preparation, perfused under classical zone II conditions, can be characterized by a rectilinear segment at high flow, a curvilinear segment at low flow and a pulmonary arterial pressure that exceeds alveolar (PA) pressure at zero flow. This demonstrates the existence of critical closing pressure (PLc) in the pulmonary vascular bed. The mean control Cv and PLc were 38.5 +/- 14 (ml. min)/mmHg and 7.9 +/- 2.2 mmHg respectively; those parameters did not change through the observation of the experiment. PLc was found to be independent of bronchial flow and it was not related to PA when the values for this pressure were less than 5 cm H20. On the contrary, higher levels of PA pressure were significantly related to PLc (r = 0.94, p less than 0.05). We conclude that in this model of ISLL in West's zone II condition it is possible to study the two components of Rp, one given by vessels that determine changes in flow resistance and for the other vessels disclosing critical closure. The values of these components remained stable over 180' of observation.