Oral Mucositis due to Radiotherapy

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D.,

A 80-year-old CF with widespread multiple myeloma is admitted to the hospital with CC: jaw pain and not being able to eat.

Past medical history (PMH)

Myeloma, hypertension (HTN).

Physical examination

Painful left side of the jaw, limited mobility.

What is the most likely cause of symptoms?

- Lytic lesion of jaw bone due to myeloma
- Pathologic bone fracture of mandibula or maxilla

What would you do?

X-ray of mandibula and maxilla.
CT scan of the brain and facial bones.

What happened?

CT scan of the brain and facial bones showed a 2 x 2.8 x 2 cm expansile lucent area in the left body of the mandible consistent with multiple myeloma. Probable medial angulation displacement of a left-sided molar associated with the focal lytic lesion in the mandible.

What happened next?

Hem/Onc and radiation therapy consults were called and radiotherapy of mandible was recommended.

After 4 radiation treatments, patient started to complain of dry mouth and local pain. Physical examination showed mucositis. She is scheduled for a 10 treatments-course.

What is the treatment for mucositis due to radiation or chemotherapy?

Local treatment with Miracle Mouthwash" (see below).

Final diagnosis

Oral mucositis due to radiotherapy.

What did we learn from this case?

Radiation treatment interferes with the regeneration of oral epithelium resulting in mucositis. This process is painful and interferes with food intake. Chemotherapy can have a similar effect on the mucosa.

Mucositis develops in 60-70 % of patients receiving radiotherapy for head or neck malignancy.

Mucositis is treated symptomatically with oral hygiene and topical anesthetics which can be combined in a "cocktail," commonly called "Miracle Mouthwash" (lidocaine, diphenhydramine, and Maalox).

Single dose of palifermin prevents oral mucositis during chemotherapy in patients with cancer. Palifermin (trade name Kepivance, marketed by Biovitrum) is a human recombinant keratinocyte growth factor (KGF) produced in Escherichia coli. Palifermin costs approximately 5,000 Euros per treatment for a 70 kg patient.

References

Complications of radiotherapy for head and neck cancer - UpToDate (subscription required).

Palifermin Prevents Oral Mucositis During Chemotherapy in Patients With Cancer - Ann Intern Med, 2010 http://goo.gl/F7e1

Published: 06/12/2005
Updated: 09/20/2010

3 comments:

  1. I would modify the fractionation (myeloma is very radiosensitive) and the target volume (I don't know the technique, but it should be revised).

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  2. Access Pharmaceuticals, Inc. (OTC BB: ACCP), a biopharmaceutical company specializing in products for cancer and supportive care, announced it has received initial prescriptions for its recently launched product, MuGard – an FDA-approved, ready-to-use mucoadhesive oral wound rinse for the management of oral mucositis, a debilitating side effect of radiotherapy and/or chemotherapy. In addition, the Company has received reimbursement for the prescriptions from leading health care providers. MuGard has officially hit the U.S. market and will soon be in the hands of all that desperately need it.

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  3. "After 4 radiation treatments, patient started to complain of dry mouth and local pain. Physical examination showed mucositis."

    This is an inadequate description and demonstrates a lack of appreciation of radiation medicine. The fact that the patient has had 4 treatments means that without unusual addition factors, oral mucositis is highly unlikely, bordering on impossible.

    "Mucositis develops in 60-70 % of patients receiving radiotherapy for head or neck malignancy."

    Radiotherapy-induced mucositis follows a very well defined and near universal clinical course. At a rate of 8-10Gy per week or greater, mucositis will take 10 calendar days to manifest. Even in radiosensitive individuals the latent period for mucositis is not reduced (see Awwaad's text on mucosal toxicity), only the rapidity of production of sever side effects after this latent period. A 10 fraction course for myeloma is likely to be 30 Gray in 10 fractions given daily, and so the accumulated time is much too short for radiation induced mucositis. However in the week following this treatment, one would expect that 100% of the mucosal area which received the 30/10 dose would show the changes of mucositis with erythema and ulceration.

    If the patient were receiving concomitant mucositis-inducing chemotherapy, the timing of the oral mucositis would match that modality, but then when is 5FU used for myeloma?

    When it comes to managing oral mucositis, all these preparations are of little use over good oral hygiene and an alternate feeding route (like PEG). The biggest aid to the patient's mucositis would be a radiation plan that avoids the majority of the oral cavity. This is achieved by accurate anatomic voluming of the bone/soft tissue mass and mucosal tissues at risk, adequate immobilisation of the jaw in a treatment mask and a radiation plan using IMRT that minimises dose deposited in the oral cavity.

    I'll refrain from producing immunological cases, if you correct this one! Thank you.

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