MUCOSITE
• Frequenza
• Patogenesi
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)

MUCOSITE
• Frequenza
• Patogenesi
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)

Ulcerative mucositis and associated sequelae in patients receiving radiotherapy for head and neck cancer.
Da 34% a 43% con aggiunta cht
Russo G et al. The Oncologist 2008;13:886-898

MUCOSITE
• Frequenza
• Patogenesi
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)
• Tossicità tardiva

Historical belief of mucositis in cancer patients cytotoxic treatments kills rapidly dividing cells; cancerous and normal
Current belief of mucositis in cancer patients series of simultaneous events beginning in the epithelium
Working model of mucositis=5 phases
I.
Initiation
II. Upregulation
III. Signaling and Amplification
IV. Ulceration
V. Healing
Sonis et al., 2004

---Oral epithelium
---Basement membrane ---
----Lamina propia
------submucosa
Sonis, S. (2004). Oral mucositis in cancer therapy. The Journal of Supportive Oncology, 3 (3), 3-8.

MUCOSITE
• Frequenza
• Patogenesi
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)
• Tossicità tardiva

Prevention and treatment of oral mucositis in patients with head and neck cancer treated with (chemo) radiation: report of an Italian survey.
P. Bossi et al.
July 2014, Volume 22, Issue 7 , pp 1889-1896
Antimycotic prevention : preventive therapy with antibiotics or antimycotics is used by 47 % of the treating physicians; among these, antimycotic drugs are the most prescribed agents
• • 60 % of the patients with CRT for HNC develop oropharyngeal candidosis
• An Italian randomized trial showed a benefit with systemic fluconazole in comparison to placebo in preventing and delaying oropharyngeal candidosis
• no difference in OM severity between the two group
• concerns also regarding possible emergence of fluconazole-resistant fungal species

type of scale used to assess OM

Scala CTCAE 4.0
G0
G1
G2
WHO
None
RTOG
No change over baseline
Asymptomatic or mild symptoms; intervention not indicated
Moderate pain; not interfering with oral intake; modified diet indicated
Oral soreness, erythema
Oral erythema, ulcers, solid diet tolerated
Injection/ may experience mild pain not requiring analgesic
Patchy mucositis which may produce an inflammatory serosanguinitis discharge/ may experience moderate pain requiring analgesia
G3 Severe pain; interfering with oral intake
Oral ulcers, liquid diet only Confluent fibrinous mucositis/ may include severe pain requiring narcotic
G4 Life-threatening consequences; urgent intervention indicated
G5 Death
Oral alimentation impossible Ulceration, hemorrhage or necrosis

MUCOSITE
• Frequenza
• Patogenesi
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)
• Tossicità tardiva

Systematic review of the literature
De fi ning statement of consensus
Consensus rounds : voting
Threshold for Consensus > 75%, if not obtained come back to panel for modifications
Statements to external reviewers, final voting round

No suggestions is possible about the superiority of one scale over another identification/correction of clinical and therapeutic variables increasing the propensity to develop more severe mucositis (e.g. poor oral hygiene, periodontal disease, low body mass index, weight loss before therapy, immunosuppression, radiotherapy total dose and weekly dose rate on oral and oropharyngeal mucosa, recommended to assess regularly oral mucositis at least once-a-week, with recommendation to the patient to communicate any further worsening of symptoms. no superiority of one mouthwash over saline or bicarbonate rinses is demonstrated
Radiotherapy with the aim of maximal sparing of the mucosa outside any PTV.
When intensity Modulated RT (IMRT) is used, the total dose to the mucosa outside any PTV should be planned to be limited to 30 Gy in 6-7 weeks.

Cryotherapy (vasocostriction could impact on treatment efficacy).
Barrier agents such as sucralfate, GelClair® and Mucotrol® allopurinol gel application amifostine benzydamine mouthwashes (no direct comparison with bicarbonate)
Chlorexidine mouthwash
Glutamine

granulocyte macrophage colony-stimulating factor
Topical misoprostol (and Prostaglandin E2)
Antibiotic + antifungal pastilles
The prophylactic treatment with systemic fluconazole (except
Steroids (both topical and systemic use)
NSAIDS recombinant human KGF-1 (palifermin) in 2 randomized trials was shown to reduce the incidence of severe oral mucositis as assessed by physicians but the benefit was not paralleled by patient reported outcomes

Dolore
Xerostomia
Nausea
DISFAGIA malnutrizione sarcopenia/astenia
Depressione anoressia

DISFAGIA
• Frequenza
• Fisiopatologia
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)
• Tossicità tardiva

DISFAGIA
• Frequenza
• Fisiopatologia
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)
• Tossicità tardiva

Ulcerative mucositis and associated sequelae in patients receiving radiotherapy for head and neck cancer.
PERDITA DI PESO
SUPPORTO
Russo G et al. The Oncologist 2008;13:886-898

DISFAGIA
• Frequenza
• Fisiopatologia
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)
• Tossicità tardiva

I fase (volontaria): orobuccale. Lingua, palato, ugola
Masticazione
Saliva (amilasi, lipasi) faringea che stimolano il centro della deglutizione nel midollo allungato e ponte
Chiusura ugola, elevazione laringe, chiusura glottide, abbassamento epiglottide, apertura sfintere esofageo superiore, chiusura dopo transito del bolo

DISFAGIA
• Frequenza
• Fisiopatologia
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)
• Tossicità tardiva

Q8: Which are the main determinants that guide decision on gastrostomy placement before therapy (multiple choices allowed)?
Hanno risposto: 108 Hanno saltato la domanda: 3
Dose RT a muscoli costrittori a mucosa orofaringe
Perdita di peso pre-trattamento

DISFAGIA
• Frequenza
• Fisiopatologia
• Terapie di supporto cosa facciamo (survey)
• Terapie di supporto cosa è meglio fare (Consensus)
• Tossicità tardiva

Simulation Computerized Tomography (S-CT) - based delineation of
"Dysphagia Aspiration Related Structures” (DARS) and the collection of dosimetric parameters are suggested and encouraged, although not yet consolidated for routine use in clinical practice.
A multimetric model (more than one parameter: e.g. Dmean, different DVHs) should be considered in order to evaluate DARS dose constraints

PEG e SNG
Prospective study of percutaneous endoscopic gastrostomy tubes versus nasogastric tubes for enteral feeding in patients with head and neck cancer undergoing (chemo)radiation
J Corry et al.
PEG patients had : significantly less weight loss at 6 weeks post-treatment high insertion site infection rate (41%) longer median duration of use ( 146 vs 57 days , p < .001) and more grade 3 dysphagia in disease-free survivors at 6 months (25% vs 8%, p =
.07).
Patient self-assessed general physical condition and overall quality of life scores were similar in both groups. Overall costs were significantly higher for PEG patients.