AFTER CHEMOTHERAPY

DAY 7 DAY 14
WBC DROP
Nausea vomitting
Fever

Mucositis
Candidiasis oral
enteritis
 RECOVERY FROM NEUTROPENIA REDUCES
MORTALITY DUE TO INFECTION

21%
1.0 Rise to
> 1.0
Neutrophil counts (10/l)

40%
Rise but
still< 1.0

NONE/FALL 59%
0.1
NONE 80%
AM
INITIAL CHANGE INFECTION MORTALITY
 1. Mucositis
Secondary to Cancer
Therapy
Dr. Wulyo Rajabto SpPD KHOM
Hematology-Medical Oncology
Internal Medicine
Dr. Cipto Mangunkusumo National Hospital
Faculty of Medicine University Indonesia
 Definition...
Mucositis is defined as inflammatory and/or
ulcerative lesions of the oral and/or
gastrointestinal tract.

Inflammation can go from mouth to anus.

Major cause: chemotherapy, radiotherapy.

 Oral Mucositis
Oral mucositis (OM) is known as the inflammation and ulceration of the oral
mucosa. 1
It is the side effect of cancer chemotherapy, radiotherapy (especially for head
and neck), hematopoietic stem cell transplantation. 1,2
Characteristics : Erythema, edema, mucosal shedding, ulceration and
pseudomembrane formation. 2
It is a potential source of life-threatening systemic infection.1

1. M.A. Stokman. F.K.L. Spijkervet. H.M. Boezen. J.P. Schouten. J.L.N. Roodenburg. E.G.E. de Vries. Preventive intervention possibilities in radiotherapy and chemotherapy-
induced oral mucositis: Results of meta-analyses. J Dent Res 85(8):690-700, 2006
2. Kishore Shetty. Charles F. Streckfus. Oral mucositis: Review of pathogenesis, diagnosis, prevention, and management. General Dentistry, July/August 2007. Pg. 335-344
3. Photos with permission from Dr Nadir Goksugur, Abant Izzet Baysal University Medical Faculty, Department of Dermatology, E-mail: nadirgo@yahoo.com
 Significance of Mucositis
Hinder nutrition
Use of parenteral nutrition for the patient

Painful
Severe pain requiring narcotics

With immunosuppression can lead to infection and sepsis

Especially in cases of transplantation
May lead to suboptimal cancer therapy

Can be very costly to the patient

 Pathogenesis
Initiation of tissue injury
Chemo and radiation induce cellular damage in
basal epithelial cells
Caused by free radicals

Upregulaton of inflammation via generation

of messenger signals
Free radicals cause upregulation of cytokines,
tissue injury and cell death
 Pathogenesis
Signalling and amplification
Activation of macrophages amplifies tissue injury
through molecular pathways

Ulceration and inflammation

Cell infiltrate, oral microflora, microtrauma and
secondary infection perpetuates inflammation

Healing
Reepithelization of ulcers
 Mucositis Assesment:
WHO scale for oral mucositis
 Cancer Therapies and Mucositis
Head and neck radiation
Grade 3-4 oral mucositis + 85% of patients

Hematopoietic stem cell transplantation

Grade 3-4 oral mucositis + 75% of patients
Related to immunosuppression

Chemotherapy
Not as severe
5-FU, capecitabine, irinotecan, tegafur can cause grade 3-4 diarrhea

Targeted therapy
Least severe
 Treatment for Mucositis
1. Rehydration and nutrition.

2. Pain control.

3. Mouthrinses and supportive medicines.

4. Antifungal/ antibiotics.
 Preventive Measures: Basic Oral Care Protocol

Maintenance of optimal nutritional support

Developing a daily oral hygiene routine: inspect teeth and

gums daily, brushing teeth and gums four times a day with a
soft brush and using mouth rinses

Proper denture care

Avoid painful stimuli: alcohol, smoking, hard and spicy foods

 Preventive Measures: Basic Oral Care Protocol

Maintenance of optimal nutritional support

Developing a daily oral hygiene routine: inspect teeth and

gums daily, brushing teeth and gums four times a day with a
soft brush and using mouth rinses

Proper denture care

Avoid painful stimuli: alcohol, smoking, hard and spicy foods

 Preventive Measures: Basic Oral Care Protocol

Maintenance of optimal nutritional support

Developing a daily oral hygiene routine: inspect teeth and

gums daily, brushing teeth and gums four times a day with a
soft brush and using mouth rinses

Proper denture care

Avoid painful stimuli: alcohol, smoking, hard and spicy foods

 Management of Mucositis
Pain control
Mouth rinses, ice chips, topical mouthrinses with 2%
lidocaine
Sucralfate gives no benefit
HSCT patients can use morphine

Nutritional support
Monitoring by dietician
Soft liquid diets
Gastrostomy tubes, total parenteral nutrition
 Management of Mucositis (2)
Oral decontamination
Especially important in HSTC
Standard oral care protocol: soft toothbrush and non-
medicated rinses

Palliation of dry mouth

Sip water as needed
Sugarless gums
Cholinergic agents as necessary

Bleeding
Topical hemostatic agents, transfusions
Specific Therapeutic interventions
Cryotherapy
Decrease delivery of chemotherapeutic agent to
mucosa
Only for short bolus infusions

Growth factors
IV recombinant human keratinocyte growth
factor-1 for prophylaxis
Specific Therapeutic interventions (2)
Anti-inflammatory agents
Benzydamine hydrochloride (NSAID) for prophylaxis

Antioxidants
Amifostine against reactive oxygen species

Antifungal infection

Low-level laser therapy

May reduce reactive oxygen species and pro-
inflammatory cytokines action
2015 ESMO Mucosal Injury Guidelines
 Conclusion
Mucositis caused by cancer therapy may cause severe
pain and diarrhea and can lead to decrease in nutrition
and infection

Primarily worst in patients with head and neck radiation

therapy and HSCT

Preventive measures: basic oral care protocol

Treatment:
Rehydration and nutritional support, pain control, oral
decontamination, supportive medicines, antifungal/
antibiotics.
2. Febrile neutropenia in cancer patient
Definition and assessment
 Empirical antibiotic treatment

Monotherapy:
1) Ceftazidime 3x1-2 g IV;
2) Meropenem 3x1 g IV atau Imipenem 4x500 mg
IV;
3) Cefepime 3x1-2 g IV;
4) Piperacillin-Tazobactam 3x4.5 g IV.

Combination: Monotherapy Amikasin/

Gentamicin/ Quinolon.