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Double-blind placebo-controlled multicenter phase II trial to evaluate D-methionine in preventing/reducing oral mucositis induced by radiation and chemotherapy for head and neck cancer.
Hamstra, DA, Lee, KC, Eisbruch, A, Sunkara, P, Borgonha, S, Phillip, B, Campbell, KCM, Ross, BD, Rehemtulla, A
Head & neck. 2018;(7):1375-1388
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Abstract
BACKGROUND The purpose of this study was to test if oral D-methionine (D-met) reduced mucositis during chemoradiotherapy. METHODS We conducted a placebo-controlled double-blind randomized phase II trial of D-met (100 mg/kg p.o. b.i.d.) testing the rate of severe (grades 3-4) mucositis. RESULTS Sixty patients were randomized. Grade 2 + oral pain was higher with placebo (79% vs 45%; P = .0165), whereas grade 2 + body odor was greater with D-met (3% vs 41%; P = .0015). Mucositis was decreased with D-met by the physician (World Health Organization [WHO], P = .007; Radiation Therapy Oncology Group [RTOG], P = .009) and patient functional scales (RTOG, P = .0023). The primary end point of grades 3 to 4 mucositis on the composite scale demonstrated a decrease with D-met (48% vs 24%; P = .058), which was borderline in significance. A planned secondary analysis of a semiquantitative scoring system noted decreased oral ulceration (2.2 vs 1.5; P = .023) and erythema (1.6 vs 1.1; P = .048) with D-met. CONCLUSION Although not meeting the primary end point, results of multiple assessments suggest that D-met decreased mucositis.
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Nutrition and Perioperative Care for the Patient with Head and Neck Cancer.
Gill, A, Farwell, DG, Moore, MG
Oral and maxillofacial surgery clinics of North America. 2018;(4):411-420
Abstract
Recovery after major head and neck cancer surgery is a complex process. In addition to perioperative sequelae such as pain, wound infections, venous thromboembolism (VTE), and pneumonia, these patients frequently suffer from malnutrition. We provide a contemporary evidence-based approach to common aspects of perioperative care to guide the clinician in the optimal management of patients. Particular emphasis is placed on the preoperative education of patients and the identification and management of malnutrition around the time of surgery. This article discusses recommendations for perioperative antibiotics, pain management, and prophylaxis against VTE and pneumonia in this patient population.
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Head and Neck Cancer Tumor Seeding at the Percutaneous Endoscopic Gastrostomy Site.
Greaves, JR
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2018;(1):73-80
Abstract
The National Institutes of Health National Cancer Institute estimates that over 13,000 new cases of head and neck cancer (HNC) will be diagnosed in 2017. Patients with HNC often require enteral nutrition (EN) via gastrostomy tube to provide nutrition support and hydration because of tumor obstruction of the oropharynx and/or cumulative effects of chemoradiation therapy. The percutaneous endoscopic gastrostomy (PEG) tube has become the preferred technique for EN access because placement is considered a minimally invasive procedure. There are 3 methods of PEG placement: Gauderer-Ponsky "pull," Sachs-Vine "push," and Russell "push" method. The Gauderer-Ponsky "pull" method has become the preferred method of PEG placement. It has been previously reported that the rate of stomal metastasis can be 0.5%-1% of those undergone the Gauderer-Ponsky "pull" method that is consistent with HNC morphology. Other researchers believe the rate may be as high as 0.5%-3%. This article reviews the 3 methods of PEG placement, as well as all potential complications, including metastatic seeding at the PEG site. In addition, 1 additional case of tumor seeding at the PEG site will be reviewed. Consideration for avoidance of the Gauderer-Ponsky pull method of PEG placement or other methods of feeding tube placement where the gastrostomy tube has to pass through the oral cavity before exiting the abdominal wall in patients with squamous cell carcinoma of the head and neck should be considered.
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Photodynamic treatment outcomes of potentially-malignant lesions and malignancies of the head and neck region: A systematic review.
Gondivkar, SM, Gadbail, AR, Choudhary, MG, Vedpathak, PR, Likhitkar, MS
Journal of investigative and clinical dentistry. 2018;(1)
Abstract
AIM: The aim of the present study was to systematically review the efficacy of photodynamic therapy (PDT) in the management of oral potentially-malignant disorders (PMDS) and head and neck squamous cell carcinoma (HNSCC). METHODS From 1985 to 2015, PubMed/Medline, Google Scholar, EMBASE, and ISI Web of Knowledge were searched using different combinations of the following key words: PDT, oral precancer, leukoplakia, erythroplakia, erythroleukoplakia, verrucous hyperplasia, oral submucous fibrosis, and HNSCC. Review articles, experimental studies, case reports, commentaries, letters to the editor, unpublished articles, and articles published in languages other than English were excluded. RESULTS Twenty-six studies were included in the present study. The number of patients ranged from 2 to 147, with a mean age of 50-67 years. The reported numbers of PMDS and HNSCC ranged between 5 and 225. Photosensitizers used were aminolevulinic acid, meta-tetrahydroxyphenylchlorin, Foscan, hematoporphyrin derivatives, Photofrin, Photosan, and chlorine-e6. Laser wavelength, power density, irradiation duration were 585-652 nm, 50-500 mW/cm2 , and 1-143 minutes, respectively. Complete, partial, and no response to PDT was found in 22.58%-100%, 4%-66%, and 0%-38.70% of PMDS, respectively, and 16%-100% of complete response in HNSCC patients. CONCLUSION PDT is effective in the management of PMDS and HNSCC.
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Prophylactic versus reactive gastrostomy tube placement in advanced head and neck cancer treated with definitive chemoradiotherapy: A systematic review.
McClelland, S, Andrews, JZ, Chaudhry, H, Teckie, S, Goenka, A
Oral oncology. 2018;:77-81
Abstract
Although chemoradiotherapy (CRT) has improved disease outcomes in advanced head and neck cancer (aHNC), toxicity remains a major concern. Treatment interruptions and decreased quality of life (QOL) can occur due to malnutrition, secondary to mucositis, dysphagia and odynophagia. Gastrostomy tubes are used in many patients to improve nutrition during CRT. The optimal timing of PEG placement in patients with aHNC undergoing CRT remains controversial. Using the PubMed database, we performed a systematic review of published CRT series in aHNC to guide decision-making regarding optimal timing of percutaneous endoscopic gastrostomy (PEG) placement. We aimed to compare outcomes when patients are treated with prophylactic PEG (pPEG) versus reactive PEG (rPEG). Twenty-two studies examining the role of PEG placement in CRT for aHNC were reviewed. pPEG reduces the number of malnourished patients (defined as >10% of body weight), but average weight loss at various time points following treatment appears similar to patients with rPEG. pPEG is also associated with improved QOL at 6 months, and greater long term PEG dependence. Clinical and dosimetric parameters that correlate with malnutrition in patients without pPEG include advanced age, percent weight loss preceding treatment, and radiation dose to the pharyngeal constrictor muscles. Based on this evidence, our institutional strategy is to encourage pPEG in those patients deemed at greatest risk of becoming malnourished during the course of treatment, and to approach the remainder of patients with rPEG.
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Free Flap Head and Neck Reconstruction with an Emphasis on Postoperative Care.
van Gijn, DR, D'Souza, J, King, W, Bater, M
Facial plastic surgery : FPS. 2018;(6):597-604
Abstract
Microsurgical free tissue transfer represents the mainstay of care in both ablative locoregional management and the simultaneous reconstruction of a defect. Advances in microsurgical techniques have helped balance the restoration of both form and function-decreasing the significant morbidity once associated with large ablative, traumatic, or congenital defects-while providing immediate reconstruction enabling early aesthetic and functional rehabilitation. There are a multitude of perioperative measures and considerations that aim to maximize the success of free tissue transfer. These include nutritional support, tight glycemic control, acknowledgment of psychological and psychiatric factors, intraoperative surgical technique, and close postoperative monitoring of the patients' hemodynamic physiology. While the success rates of free tissue transfer in experienced hands are comparable to alternative options, the consequences of flap failure are catastrophic-with the potential for significant patient morbidity, prolonged hospital stay (and associated increased financial implications), and increasingly limited options for further reconstruction. Success is entirely dependent on a continuous arterial inflow and venous outflow until neovascularization occurs. Flap failure is multifactorial and represents a dynamic process from the potentially reversible failing flap to the necrotic irreversibly failed flap-necessitating debridement, prolonged wound care, and ultimately decisions concerned with future reconstruction. The overriding goal of free flap monitoring is therefore the detection of microvascular complications prior to permanent injury occurring-identifying and intervening within that critical period between the failing flap and the failed flap-maximizing the potential for salvage. With continued technique refinement, microvascular free flap reconstruction offers patients the chance for both reliable functional and aesthetic restoration in the face of significant ablative defects. The caveat to this optimism is the requirement for considered perioperative care and the optimization of those factors that may offer the difference between success and failure.
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Maxillofacial Prosthetics.
Phasuk, K, Haug, SP
Oral and maxillofacial surgery clinics of North America. 2018;(4):487-497
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Abstract
The treatment of head and neck cancers requires a team approach. Maxillofacial prosthetics and oncologic dentistry are involved in many phases of the treatment. After the cancer ablation surgery, if surgical reconstruction cannot not completely restore the surgical defect site, maxillofacial prostheses plays an important role to rehabilitate the patient's mastication, swallowing, and speech. For patients undergoing chemoradiation therapy, the outcome is enhanced by jaw positioning stent and fluoride carrier mouthpiece. This perioperative care by maxillofacial prosthetics improves the posttreatment outcomes and the patient's quality of life.
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Pre-Radiation dental considerations and management for head and neck cancer patients.
Kufta, K, Forman, M, Swisher-McClure, S, Sollecito, TP, Panchal, N
Oral oncology. 2018;:42-51
Abstract
Treatment of head and neck cancer (HNC) is accompanied by a high rate of morbidity, and complications can have a lifelong, profound impact on both patients and caregivers. Radiation-related injury to the hard and soft tissue of the head and neck can significantly decrease patients' quality of life. The purpose of this study is to provide patent-specific guidelines for managing the oral health and related side effects of HNC patients treated with radiation therapy. Based on reviewed articles retrieved on the PubMed database, guidelines for management of the oral health of this patient population were organized into three separate categories: cancer, patient, and dentition. The location, type, and staging of the cancer, along with the radiation used to treat the cancer significantly impact dental treatment. Several unique patient characteristics such as motivation, presence of support system, socioeconomic status, nutrition, and race have all been found to affect outcomes. Dental disease and available supportive dental management was found to significantly impact treatment and quality of life in this patient population. By comprehensively assessing unique cancer, patient, and dental-related factors, this review provides individualized evidence-based guidelines on the proper management of this complex and vulnerable patient population.
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The effect of the use of thyme honey in minimizing radiation - induced oral mucositis in head and neck cancer patients: A randomized controlled trial.
Charalambous, M, Raftopoulos, V, Paikousis, L, Katodritis, N, Lambrinou, E, Vomvas, D, Georgiou, M, Charalambous, A
European journal of oncology nursing : the official journal of European Oncology Nursing Society. 2018;:89-97
Abstract
PURPOSE Radiation-induced oral mucositis is one of the main side effects during and after the treatment of head and neck cancer patients. The study was designed to provide evidence on the effectiveness of thyme honey on oral mucositis management. METHODS This was a randomised controlled trial (RCT) with 72 head and neck cancer patients who were divided either to the intervention group (thyme honey rinses) or to the control group (saline rinses). Oral mucositis was assessed according to the Radiation Therapy Oncology Group (RTOC criteria), and assessments were performed weekly starting at the 4th week of the radiotherapy for seven weeks and repeated once 6 months later. Additionally, the Oral Mucositis Weekly Questionnaire (OMWQ) was given at 4th week of radiotherapy, 1 month after the completion of radiotherapy and 6 months later. The ClinicalTrials.gov Identifier for this study is NCT01465308. This paper reports on the findings regarding thyme honey's effectiveness on oral mucositis. RESULTS Generalized estimating equations revealed that patients in the intervention group were graded lower in the objective assessment of oral mucositis (p < 0,001), maintained their body weight (p < 0,001) and showed an improvement in their global health (p = 0.001) compared to the control group. Quality of life of the patients in the same group was also statistically significantly higher than that of the patients of the control group (p < 0,001). CONCLUSION The study provided evidence on the positive effect of thyme honey on the management of radiation-induced oral mucositis and quality of life in head and neck cancer patients.
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Pentoxifylline, tocopherol, and clodronate for the treatment of mandibular osteoradionecrosis: a systematic review.
Martos-Fernández, M, Saez-Barba, M, López-López, J, Estrugo-Devesa, A, Balibrea-Del-Castillo, JM, Bescós-Atín, C
Oral surgery, oral medicine, oral pathology and oral radiology. 2018;(5):431-439
Abstract
OBJECTIVE The purpose of this study was to evaluate the healing benefit provided by the antioxidant and antifibrotic properties of pentoxifylline-tocopherol or pentoxifylline-tocopherol-clodronate in combination therapy for osteoradionecrosis. STUDY DESIGN We searched for relevant reports in PubMed by using a combination of "osteoradionecrosis" and the following keywords: "pentoxifillyne," "tocopherol," "vitamin E," or "clodronate." We considered articles in English or Spanish, with no limitations on the publication date. RESULTS The combination of pentoxifylline plus tocopherol with or without clodronate was found to be effective for the treatment of mandibular osteoradionecrosis, although data were generally scarce and mostly came from retrospective case series. CONCLUSIONS This drug therapy is well tolerated and could be promising for the treatment of mandibular osteoradionecrosis, but prospective randomized controlled clinical trials are needed for further clarification.