Mucositis

Decision Making and Problem Solving

Mucositis in patients with hematologic malignancies: an overview
Pasquale Niscola, Claudio Romani, Luca Cupelli, Laura Scaramucci, Andrea Tendas, Teresa Dentamaro, Sergio Amadori, Paolo de Fabritiis

ABSTRACT
From the Haematology, Sant’ Eugenio Hospital and University “Tor Vergata”, Rome (PN, LC, LS, AT, TRD, SA, PdF); Department of Haematology, “ArmandoBusinco” Cancer Centre, Cagliari, Italy (CR). Acknowledgments: we are indebted to Dr. Giuliana Zanninelli and to Dr. Carla Fritz for their editorial assistance. Manuscript received May 1, 2006. Accepted November 20, 2006. Correspondence: Pasquale Niscola M. D., Haematology Division, Sant’Eugenio Hospital, Piazzale dell’Umanesimo 10, 00144 Rome. E-mail: pasquale.niscola@uniroma2.it

Mucosalbarrier injury (mucositis) is a common complication of many treatments used in hematologic malignancies, affecting most patients whose neoplasms are treated with intensive chemotherapy, and virtually all those receiving myeloablative conditioning regimens prior to hematopoietic stem cell transplantation. Mucositis has been identified as a critical risk factor for infections and is a major driver ofanalgesic and total parenteral nutrition use. Patients with this complication require careful analgesic therapy, additional nursing care and longer hospitalization. To date, the measures to prevent and treat this potentially devastating complication are inadequate and limited to the control of pain, infections, bleeding and nutrition. Nevertheless, in the last decade, a better insight into thepathogenesis of the mucosal damage has led to the development of novel therapeutic options which potentially could allow a targeted approach to mucositis. Key words: mucositis, pain, hematologic malignancies, graft-versus-host disease, hematopoietic stem cell transplantation. Haematologica 2007; 92:222-231 ©2007 Ferrata Storti Foundation

ucositis is a pathological process characterized by mucosaldamage, ranging from mild inflammation to deep ulcerations and affecting one or more parts of the alimentary tract, from the mouth to the anus, as a consequence of radiation therapy and/or chemotherapy.1 Indeed, for unknown reasons, other mucosae, apart from those lining the mouth and the intestine, generally escape toxicity, with the exception of bladder mucosa after alkylating agents and theconjunctiva after high doses of cytarabine. Although the mechanisms by which any mucosal injury occurs are likely to be similar, the unique properties of each part of the digestive tract may modify its response to a toxic challenge. The mucosal compartments of the alimentary tract share the same embryogenetic origin, but show different functional and anatomic features, so that two main syndromes may bedistinguished: oral mucositis (OM) and gastrointestinal mucositis (GIM).2 Treatment-induced mucositis is

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one of the most debilitating and troublesome side effects from the patient’s perspective and profoundly influences quality of life (QoL), being associated with a symptom burden including pain,3 bleeding, dysphagia, infections5 and food intake impairment, which can result in the needfor total parenteral nutrition (TPN).4 In addition, mucositis is associated with longer periods of hospitalization, significant health and financial costs and may interfere with the regular administration and dosing of programmed treatment plans and with a patient’s management.6,7 The most important complications associated with mucositis in oncohematologic patients receiving myelosuppressivechemotherapy are infections; indeed, in neutropenic patients mucositis is strongly associated with bacteremia and sepsis due to Gram-negative bacilli such as Escherichia coli and Pseudomonas aeruginosa, yeasts of the Candida species, and Gram-positive cocci, such as Streptococcus viridans, as probably happens in patients with

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