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Reduced intensity conditioning and oral care measures prevent oral mucositis and reduces days of hospitalization in allogeneic stem cell transplantation recipients

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Abstract

Purpose

Oral mucositis (OM) is a side effect of intensive chemotherapy and radiation and has been reported to affect 75–100 % of hematopoietic stem cell transplantation (HSCT) recipients. The purpose of this study was to compare the incidence of OM in patients conditioned with myeloablative conditioning (MAC) to reduced-intensity conditioning (RIC) and to determine the effect of a new oral care protocol.

Methods

The study involved 171 HSCT recipients, with hematological malignancies transplanted between 2007 and 2011. Median age of the patients was 50 years (range 12–71). Ninety-nine (58 %) received RIC and 72 received MAC. Clinical features of OM were recorded from day −3 before to day +25 after HSCT using the World Health Organization (WHO) scoring system and the oral mucositis assessment score (OMAS).

Results

Overall, 87 % of the patients developed OM of any severity, which peaked on days 10–11. The mean WHO score was 1.7. In multivariate analysis, the severity of OM was associated with MAC (relative hazard (RH) 1.57, 95 % confidence interval (CI) 1.37–1.80, p < 0.001), all donor-recipient gender combinations except female-to-male (RH = 1.26, 95 % CI 1.10–1.4, p = 0.001), and early year of HSCT (RH = 0.84, 95%CI 0.7–0.96, p = 0.013). There was a correlation between long hospitalization and OM (day 15, r = 0.31, p < 0.001). There was a good correlation between the WHO and OMAS scoring systems for OM (r = 0.74, p < 0.001).

Conclusions

Oral mucositis was reduced in patients treated with RIC and in patients treated during recent years, when oral care was intensified. Increased scores of OM prolonged hospitalization.

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References

  1. Heimdahl A, Johnson G, Danielsson K et al (1985) Oral condition of patients with leukemia and severe aplastic anemia. Oral Surg Oral Med Oral Pathol 60:498–504

    Article  CAS  PubMed  Google Scholar 

  2. Barett AP (1986) Oral complications in bone marrow transplantation. Aust N Z J Med 16:239–40

    Article  Google Scholar 

  3. Blijlevens NMA, Donelly JP, De Pauw BE (2000) Mucosal barrier injury: biology, pathology, clinical counterparts and consequences of intensive treatment for heamatological malignancy: an overview. Bone Marrow Transplant 25:1269–1278

    Article  CAS  PubMed  Google Scholar 

  4. Schubert MM, Williams BE, Lloid ME, Donaldson G, Chapko MK (1992) Clinical assessment scale for the rating of oral mucosal changes associated with bone marrow transplantation. Development of an oral mucositis index. Cancer 69:2469–2477

    Article  CAS  PubMed  Google Scholar 

  5. Woo SB, Sonis ST, Monopoli MM, Sonis AL (1993) A longitudinal study of oral ulcerative mucositis in bone marrow transplant recipients. Cancer 72:1612–1617

    Article  CAS  PubMed  Google Scholar 

  6. Vagliano L, Feraut C, Gobetto G et al (2011) Incidence and severity of oral mucositis in patients undergoing haematopoietic SCT—results of a multicenter study. Bone Marrow Transplant 46:727–732

    Article  CAS  PubMed  Google Scholar 

  7. Mattsson T, Heimdahl A, Dahllöf G, Lönnqvist B, Nilsson B, Ringdén O (1991) Variables predicting oral mucosal lesions in allogeneic bone marrow recipients. Head Neck 13:224–229

    Article  CAS  PubMed  Google Scholar 

  8. Dahllöf G, Heimdahl A, Bolme P, Lönnqvist B, Ringdén O (1988) Oral condition in children treated with bone marrow transplantation. Bone Marrow Transplant 3:43–51

    PubMed  Google Scholar 

  9. Sonis ST (2009) Mucositis: the impact, biology and therapeutic opportunities of oral mucositis. Oral Oncol 45:1015–1020

    Article  CAS  PubMed  Google Scholar 

  10. Donelly JP, Muus P, Schattenberg A, De Witte T, Horrevorts A, DePauw BE (1992) A scheme for daily monitoring of oral mucositis in allogenic BMT recipients. Bone Marrow Transplant 9:409–413

    Google Scholar 

  11. Tabbara I, Zimmerman K, Morgan C, Naleh Z (2002) Allogenic hematopoietic stem cell transplantation. Complications and results. Arch Intern Med 162:1558–1566

    Article  PubMed  Google Scholar 

  12. Vera-Llonch M, Oster G, Ford CM, Lu J, Sonis S (2007) Oral mucositis and outcomes of allogeneic hematopoietic stem cell transplantation in patients with hematologic malignancies. Support Care Cancer 15:491–496

    Article  PubMed  Google Scholar 

  13. Ringdén O, Le Blanc K (2005) Allogeneic hematopoietic stem cell transplantation: state of the art and new perspectives. APMIS 113:813–30

    Article  PubMed  Google Scholar 

  14. Ringdén O, Labopin M, Ehninger G et al (2009) Reduced intensity conditioning compared with myeloablative conditioning using unrelated donor transplant in patients with acute myeloid leukemia. J Clin Oncol 27:4570–4577

    Article  PubMed  Google Scholar 

  15. Giralt S, Estey E, Albitar M et al (1997) Engraftment of allogeneic hematopoietic progenitor cells with purine analogue-containing chemotherapy: harnessing graft-versus-leukemia without myeloablative therapy. Blood 89:4531–4536

    CAS  PubMed  Google Scholar 

  16. McSweeney PA, Niederwieser D, Shizuru JA et al (2001) Hematopoietic cell transplantation in older patients with hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood 97:3390–3400

    Article  CAS  PubMed  Google Scholar 

  17. World Health Organization (1979) WHO handbook for reporting results for cancer treatment, vol 48. World Health Organization, Geneva, p 1

    Google Scholar 

  18. Sonis ST, Oster G, Fuchs H et al (2001) Oral mucositis and the clinical and economic outcomes of hematopoietic stem cell transplantation. J Clin Oncol 19:2201–2205

    CAS  PubMed  Google Scholar 

  19. Svahn BM, Remberger M, Myrbäck KE et al (2002) Home care during the pancytopenic phase after allogeneic hematopoietic stem cell transplantation is advantageous compared with hospital care. Blood 100:4317–4324

    Article  CAS  PubMed  Google Scholar 

  20. Schaffer M, Aldener-Cannavá A, Remberger M, Ringdén O, Olerup O (2003) Roles of HLA-B, HLA-C and HLA-DPA1 incompatibilities in the outcome of unrelated stem-cell transplantation. Tissue Antigens 62:243–250

    Article  CAS  PubMed  Google Scholar 

  21. Storb R, Deeg HJ, Fisher L et al (1988) Cyclosporine vs methotrexate for graft-v-host disease prevention in patients given marrow grafts for leukemia: long-term follow-up of three controlled trials. Blood 71:293–298

    CAS  PubMed  Google Scholar 

  22. Ringdén O, Remberger M, Persson U et al (1995) Similar incidence of graft-versus-host disease using HLA-A, -B and -DR identical unrelated bone marrow donors as with HLA-identical siblings. Bone Marrow Transplant 15:619–1625

    PubMed  Google Scholar 

  23. Ringdén O, Uzunel M, Rasmusson I et al (2006) Mesenchymal stem cells for treatment of therapy-resistant graft-versus-host disease. Transplantation 81:1390–1397

    Article  PubMed  Google Scholar 

  24. Lundgren G, Wilczek H, Lönnqvist B, Lindholm A, Wahren B, Ringdén O (1985) Acyclovir prophylaxis in bone marrow transplant recipients. Scand J Infect Dis 47:137–144

    CAS  Google Scholar 

  25. National Cancer Institute (2003) Common terminology criteria for adverse events (CTCAE). Version 3.0 ed. Cancer Therapy Evaluation Program, Bethesda

    Google Scholar 

  26. Sonis S, Edwards L, Lucey C (1999) The biological basis for the attenuation of mucositis: the example of interleukin-11. Leukemia 13:831–834

    Article  CAS  PubMed  Google Scholar 

  27. Lockhart PB, Sonis ST (1981) Alterations in the oral mucosa caused by chemotherapeutic agents: a histologic study. J Dermatol Surg Oncol 7:1019–1025

    Article  CAS  PubMed  Google Scholar 

  28. Dorr W, Spekl K, Martin M (2002) Radiation-induced oral mucositis in mice: strain differences. Cell Prolif 35:60–67

    Article  PubMed  Google Scholar 

  29. Ulrich CM, Yasui Y, Storb R et al (2001) Pharmacogenetics of methotrexate: toxicity among marrow transplantation patients varies with the methylenetetrahydrofolate reductase C677T polymorphism. Blood 98:231–234

    Article  CAS  PubMed  Google Scholar 

  30. Hassan MG, Oberg AN, Bekassy J et al (1991) Pharmacokinetics of high-dose busulphan in relation to age and chronopharmacology. Cancer Chemother Pharmacol 28:130–134

    Article  CAS  PubMed  Google Scholar 

  31. Garming Legert K, Remberger M, Ringdén O, Hassan M, Dahllöf G (2011) Long-term salivary function after conditioning with busulfan, fractionated or single dose TBI. Oral Dis 17:670–676. doi:10.1111/j.1601-0825.2011.01821.x

    Article  CAS  PubMed  Google Scholar 

  32. Keefe D, Schubert M, Elting L et al (2007) Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer 109:820–831

    Article  CAS  PubMed  Google Scholar 

  33. Bhatt V, Vendrell N, Nau K, Crumb D, Roy V (2010) Implementation of a standardized protocol for prevention and management of oral mucositis in patients undergoing hematopoietic cell transplantation. J Oncol Pharm Pract 16:195–204

    Article  CAS  PubMed  Google Scholar 

  34. Katrancı N, Ovayolu N, Ovayolu O, Sevinc A (2012) Evaluation of the effect of cryotherapy in preventing oral mucositis associated with chemotherapy—a randomized controlled trial. Eur J Oncol Nurs 16:339–344

    Article  PubMed  Google Scholar 

  35. Sonis ST, Elting LS, Keefe D et al (2004) Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients. Cancer 100:1995–2025

    Article  PubMed  Google Scholar 

  36. Barasch A, Peterson DE (2003) Risk factors for ulcerative oral mucositis in cancer patients: unanswered questions. Oral Oncol 39:91–100

    Article  PubMed  Google Scholar 

  37. Rapoport AP, Miller Watelet LF, Linder T et al (1999) Analysis of factors that correlate with mucositis in recipients of autologous and allogeneic stem-cell transplants. J Clin Oncol 17:2446–2453

    CAS  PubMed  Google Scholar 

  38. Dreizen S (1990) Description and incidence of oral complications. NCI Monogr 9:11–15

    PubMed  Google Scholar 

  39. Xiao C, Hanlon A, Zhang Q et al (2013) Symptom clusters in patients with head and neck cancer receiving concurrent chemoradiotherapy. Oral Oncol 49:360–366. doi:10.1016/j.oraloncology.2012.10.004. Epub 2012, PubMed PMID: 23168337

    Article  PubMed Central  PubMed  Google Scholar 

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Acknowledgments

This work was supported by grants from the Swedish Cancer Society (0070-B06-20XBC), the Children’s Cancer Foundation (06/094), the Swedish Dental Society, the Swedish Research Council, and Karolinska Institutet. The authors thank dental hygienist Britta Tjärnberg Halvarsson for the competent oral care and assistance with OM scoring. The authors also thank the staff at the Center for Allogeneic Stem Cell Transplantation for the compassionate and competent care of the patients.

Conflict of interest

The authors declare that there are no conflicts of interest. The authors have full control of all primary data and agree to allow the journal to review their data if requested.

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Authors and Affiliations

  1. Division of Oral Medicine and Pathology, Karolinska Institutet, Huddinge, Sweden

    Karin Garming Legert & Anders Heimdahl

  2. Division of Pediatric Dentistry, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden

    Karin Garming Legert & Göran Dahllöf

  3. Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Huddinge, Sweden

    Mats Remberger & Olle Ringdén

Authors
  1. Karin Garming Legert
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  2. Mats Remberger
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  3. Olle Ringdén
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  4. Anders Heimdahl
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  5. Göran Dahllöf
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Correspondence to Karin Garming Legert.

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Legert, K.G., Remberger, M., Ringdén, O. et al. Reduced intensity conditioning and oral care measures prevent oral mucositis and reduces days of hospitalization in allogeneic stem cell transplantation recipients. Support Care Cancer 22, 2133–2140 (2014). https://doi.org/10.1007/s00520-014-2190-7

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