23 oktober 2017: Bron: Frontier Oncology 2017; 7: 89. Published online 2017 May 22.

Een enkele keer krijg ik de vraag wat te doen tegen de bijwerkingen van bestraling van de mond en keel bij mond- en keelkanker. Enkele maanden geleden verscheen een studierapport dat richtlijnen geeft hoe met name orale mucositus = slijmvliesbeschadiging te behandelen en eventueel te voorkomen is. Mijn aanpak van destijds staat er niet bij maar wil ik toch hier wel noemen want het heeft mij veel geholpen. En ook anderen die ik de tips heb gegeven. zie verderop in dit artikel.

Hier een schaal van opbouw van opbouw en ernst van orale mucositis van de WHO: (tekst gaat verder onder dit plaatje)

mucositis in de mond

Deze maand ben ik 20 jaar kankervrij na mijn laatste operatie oktober 1997. Naast alle herinneringen staat me nog altijd bij hoeveel last ik had van de bijwerkingen van de bestralingen. Ik kon op een bepaald moment niet meer praten, niet meer normaal eten (had sondevoeding via neussonde nodig), mijn hele hals vertoonde open wonden die ook nog eens veel pijn deden en mijn hele mond zat vol wondjes, wat ze dus orale mucositis noemen. De slijmvliezen worden bijna altijd beschadigd door de bestraling.

De uiterlijke wonden in de hals heb ik nog tijdens de bestralingsperiode dichtgekregen via levertraanzalf (Jewcovitol is bij elke apotheek en drogist verkrijgbaar) die ik drie keer per dag ververste en met een verband bedekte. Binnen 5 dagen waren de wonden aan de buitenkant dicht. De verpleegkundigen op de afdeling radiotherapie in het academisch ziekenhuis Utrecht hadden dit nog nooit gezien en een van hun heeft ons wel eens verteld dit ook aan andere patienten door te hebben gegeven. Ook voor andere vormen van kanker kan levertraanzalf denk ik voorkomen dat er ernstige huidbeschadigingen ontstaan. 

In de mond zelf heb ik de wondjes tijdens de bestralingsperiode niet weggekregen. Wel verminderde de pijn en na de bestraling kwam de speekselvorming zelfs weer grotendeels terug en mijn droge mond was na een jaar helemaal weg. Ik spoelde drie keer per dag met levertraan (Lovitran, verkrijgbaar in elke apotheek en drogist). Overigens worden door chemo ook vaak de slijmvliezen in de mond aangetast.

levertraanzalf jecovitollevertraan lovitran

In de klinische praktijk worden andere middelen gebruikt om orale mucositis te voorkomen en bestrijden. Veel patienten, (80 tot 100 procent hebben op een of andere manier last van de bestraling van mond- en keel) hebben last van orale mucositis veroorzaakt door de bestraling - radiotherapie. Pijn in de mond komt voor bij 69% van de patiënten, dysfagie bij 56% van de patiënten, pijnstillers worden gebruikt door 53% van de patiënten, gewichtsverlies van 3-7 kg, door sondevoeding en ziekenhuisopname (ICU toelating) bij 15% van de patiënten. En wijziging of onderbreking van de behandeling gebeurt bij 11%-16% van de patiënten. Alle reden dus om te zoeken naar preventieve middelen die al deze problemen kunnen verminderen of beter nog te voorkomen.

In deze studie: Radiation-Induced Oral Mucositis worden onderstaand genoemde aanpak in deze grafiek besproken en vertaal ik maar niet. Lees daarvoor het studierapport. Maar m.i. is levertraan en levertraanzalf een heel goed en goedkoop alternatief om huidbeschadigingen en orale mucositis te voorkomen of te behandelen als het al is ontstaan. (Voor alle duidelijkheid ik/wij heb geen enkel belang met de producenten van levertraanzalf of levertraan, ik ken ze niet eens. Lees ook onze disclaimer)

Over low dose laser als manier om orale mucositis aan te pakken staat ook een en ander op onze website en in de literatuurlijsten.

Table 9

Multinational Association for Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO) Clinical Practice Guidelines for oral mucositis (3).

Intervention/mode of administrationPurposeCancer treatmentLevel of evidence
Recommendations in favor of an intervention (strong evidence supports effectiveness in the treatment setting listed)
Oral cryotherapy for 30 min Prevention of OM Patients receiving bolus 5-fluorouracil chemotherapy Level II
Recombinant human keratinocyte growth factor-1 (palifermin) at a dose of 60 µg/kg per day for 3 days prior to conditioning treatment and for 3 days after transplant Prevention of OM Patients receiving high-dose chemotherapy and TBI, followed by autologous stem cell transplantation, for a hematological malignancy Level II
Low-level laser therapy (wavelength at 650 nm, power of 40 mW, and each square centimeter treated with the required time to a tissue energy dose of 2 J/cm2) Prevention of OM Patients receiving HSCT conditioned with high-dose chemotherapy, with or without TBI Level II
Patient-controlled analgesia with morphine Pain reduction Patients undergoing HSCT Level II
Benzydamine mouthwash Prevention of OM Patients with HNC receiving moderate dose radiation therapy (up to 50 Gy), without concomitant chemotherapy Level II
Suggestions in favor of an intervention (weaker evidence supports effectiveness in the treatment setting listed)
Oral care protocols Prevention of OM All age groups and across all cancer treatment modalities Level III
Oral cryotherapy Prevention of OM Patients receiving high-dose melphalan, with or without TBI, as conditioning for HSCT Level III
Low-level laser therapy (wavelength around 632.8 nm) Prevention of OM Patients undergoing radiotherapy, without concomitant chemotherapy, for HNC Level III
Transdermal fentanyl Pain reduction Patients receiving conventional or high-dose chemotherapy, with or without TBI Level III
2% morphine mouthwash Pain reduction Patients receiving chemoradiation for HNC Level III
0.5% doxepin mouthwash Pain reduction All patients with OM-induced pain Level IV
Systemic zinc supplements administered orally Prevention of OM HNC patients receiving radiation therapy or chemoradiation Level III
Recommendations against interventions (strong evidence indicates lack of effectiveness in the treatment setting listed)
PTA (polymyxin, tobramycin, amphotericin B) and BCoG (bacitracin, clotrimazole, gentamicin) Prevention of OM Patients receiving radiation therapy for HNC Level II
Iseganan antimicrobial mouthwash Prevention of OM Patients receiving high-dose chemotherapy, with or without TBI, for HSCT or in patients receiving radiation therapy or concomitant chemoradiation for HNC Level II
Iseganan antimicrobial mouthwash Prevention of OM Patients receiving high-dose chemotherapy, with or without TBI, for HSCT or in patients receiving radiation therapy or concomitant chemoradiation for HNC Level II
Sucralfate mouthwash Prevention of OM Patients receiving chemotherapy for cancer (I), or inpatients receiving radiation therapy (I) or concomitant chemoradiation (II) for HNC Level I, II
Sucralfate mouthwash Treatment of OM Patients receiving chemotherapy for cancer (I), or in patients receiving radiation therapy (II) for HNC Level I, II
Intravenous glutamine Prevention of OM Patients receiving high-dose chemotherapy, with or without TBI, for HSCT Level II
Suggestions against interventions (weaker evidence indicates lack of effectiveness in the treatment setting listed)
Chlorhexidine mouthwash Prevention of OM Patients receiving radiation therapy for HNC Level III
Granulocyte-macrophage colony-stimulating factor mouthwash Prevention of OM Patients receiving high-dose chemotherapy, for autologous or allogeneic HSCT Level II
Misoprostol mouthwash Prevention of OM Patients receiving radiation therapy for HNC Level III
Systemic pentoxifylline, administered orally Prevention of OM Patients undergoing HSCT Level III
Systemic pilocarpine, administered orally Prevention of OM Patients receiving radiation therapy for head and neck cancer (III), or patients receiving high-dose chemotherapy, with or without TBI, for HSCT (II) Level II and III

OM, oral mucositis; HSCT, hematopoietic stem cell transplantation; TBI, total body irradiation; HNC, head and neck cancer.

Criteria for each level of evidence (34).

Level I: evidence obtained from meta-analysis of multiple, well-designed, controlled studies; randomized trials with low false-positive and false-negative errors (high power).

Level II: evidence obtained from at least one well-designed experimental study; randomized trials with high false-positive and/or false-negative errors (low power).

Level III: evidence obtained from well-designed, quasi-experimental studies such as non-randomized, controlled single-group, pretest–posttest comparison, cohort, time, or matched case–control series.

Level IV: evidence obtained from well-designed, non-experimental studies, such as comparative and correlational descriptive and case studies.

Level V: evidence obtained from case reports and clinical examples.

Het volledige studierapport: Radiation-Induced Oral Mucositis is gratis in te zien.

Hier het abstract van de studie met referentielijst:

RIOM treatment focuses on palliative measures and symptoms relief; e.g., pain management, nutritional support, good oral hygiene, and reduced oral microbial load. Interestingly, mesenchymal stromal cells therapy for RIOM shows promise for potential therapeutic and clinically relevant benefits.

Front Oncol. 2017; 7: 89.
Published online 2017 May 22. doi:  10.3389/fonc.2017.00089
PMCID: PMC5439125

Radiation-Induced Oral Mucositis

Osama Muhammad Maria,1,2,3 Nicoletta Eliopoulos,3,4 and Thierry Muanza1,2,3,5,*
Author information ► Article notes ► Copyright and License information ►
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Abstract

Radiation-induced oral mucositis (RIOM) is a major dose-limiting toxicity in head and neck cancer patients. It is a normal tissue injury caused by radiation/radiotherapy (RT), which has marked adverse effects on patient quality of life and cancer therapy continuity. It is a challenge for radiation oncologists since it leads to cancer therapy interruption, poor local tumor control, and changes in dose fractionation. RIOM occurs in 100% of altered fractionation radiotherapy head and neck cancer patients. In the United Sates, its economic cost was estimated to reach 17,000.00 USD per patient with head and neck cancers. This review will discuss RIOM definition, epidemiology, impact and side effects, pathogenesis, scoring scales, diagnosis, differential diagnosis, prevention, and treatment.

Conclusion

Despite its high incidence, RIOM is a self-limited radiotherapy-induced normal tissue injury. It is a dose-limiting toxicity in most cases of head and neck cancer patients. However, in moderately to severely sick patients, it could be a lethal injury. Many preclinical and clinical studies have been conducted for the prevention and treatment of RIOM. Currently, there are numerous prevention and treatment strategies for RIOM. However, there is no single agent or management regimen that has been agreed upon between caregivers that significantly improves RIOM to a clinically relevant and satisfactory standard. Nevertheless, the current guidelines recommend good oral care, IMRT, radiation shields, palifermin, amifostine, and cryotherapy for RIOM prevention. RIOM treatment focuses on palliative measures and symptoms relief; e.g., pain management, nutritional support, good oral hygiene, and reduced oral microbial load. Interestingly, mesenchymal stromal cells therapy for RIOM shows promise for potential therapeutic and clinically relevant benefits. However, more studies are still needed to confirm such therapeutic potential.

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Author Contributions

OM: conception and design, collection and/or assembly of data, review writing, and final approval of the review. NE: conception, design, and final approval of the review. TM: conception and design, financial support, and final approval of the review.

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Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Footnotes

Funding. OM is an awardee of the Lady Davis Institute/Toronto-Dominion Bank studentship. This study was supported partially by Ride To Conquer Cancer (RTCC, Jewish General Hospital Foundation) and Fonds de Recherche du Quebec-Santé (FRQS) grants. English language editing was done by Jenny Warrington.

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mucositis, mond- en keelkanker, radiotherapie, bestraling, levertraanzalf, levertraan, preventie, low dosis laser, aften


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