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Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a beneficial treatment option for patients with acute myeloid leukemia (AML). Prior to transplantation, patients require myeloablative conditioning (MAC) and although intensive conditioning decreases the risk of relapse, it induces high toxicity. Reduced intensity conditioning (RIC) as an alternative to MAC, helps to reduce toxicity but increases the risk of transplant rejection. Oral mucositis as a result of cytostatic, impaired immune system function and decreased salivation, is one of the most common oral complications of high-dose chemotherapy observed in early hematopoietic stem cell transplantation (HSCT). Oral erosions and ulcers that develop because of oral mucositis, serve as a portal of entry for viral, fungal, and bacterial antigens, and these infections, consequently, increase morbidity and mortality post-HSCT. However, as the use of allo-HSCT increases gradually in older adults and patients with comorbidities, there is a need to understand the occurrence of oral mucositis in patients with AML after allo-HSCT.
Wysocka-Słowik et al,1 recently published a study in Annals of Hematology, investigating the frequency and severity of oral mucositis depending on the type of conditioning regimen in patients with AML post-allo-HSCT.
A prospective cohort study in patients diagnosed with AML who had undergone allo-HSCT. Eligible patients (N = 80) were allocated to either MAC (n = 54) or RIC (n = 26) regimen based on age and comorbidities. Cytostatics included in the MAC group were fludarabine, busulfan, melphalan, and treosulfan, individually adjusted to each patient’s profile and applied in appropriate proportions as FluBu4, and the RIC group included fludarabine, busulfan, cytarabine, and total body irradiation (TBI), used as FluBu2 or Flu-CyTBI.
Table 1. Five-point scale*
Mucositis grade† |
WHO criteria |
---|---|
0 |
No signs |
1 |
Oral soreness +/− erythema, no erosions, oral discomfort |
2 |
Oral erythema, ulcers; solid diet tolerated |
3 |
Diffuse oral erythema, ulcers; liquid diet only |
4 |
Severe inflammation, diffuse inflammatory-necrotic lesions; alimentation not possible |
WHO, World Health Organization. |
Patients in the MAC group comprised 30 women and 24 men, with a mean age of 42±12 years, and 12 women and 14 men with a mean age of 56±13 years in the RIC group.
At preliminary examination, 84% of all patients demonstrated Grade 0 mucositis. However, at the first posttransplant examination this decreased to 34% of patients demonstrating Grade 0 mucositis, and a further decrease to 26% after the second posttransplant examination (Table 2), representing a statistically significant difference between first and second examination (p < 0.0001).
Table 2. Incidence of oral mucositis*
Mucositis grade† |
All patients (N = 80) |
||
---|---|---|---|
Preliminary examination |
First examination |
Second examination |
|
0 |
84 |
34 |
26 |
1 |
13 |
43 |
33 |
2 |
4 |
15 |
28 |
3 |
0 |
6 |
10 |
4 |
0 |
2 |
4 |
WHO, World Health Organization. |
Table 3. Incidence of oral mucositis based on type of conditioning*
Mucositis grade† |
MAC (n = 54) |
RIC (n = 26) |
||||
---|---|---|---|---|---|---|
Preliminary examin. |
First examin. |
Second examin. |
Preliminary examin. |
First examin. |
Second examin. |
|
0 |
85 |
26 |
17 |
84 |
50 |
46 |
1 |
13 |
46 |
31 |
12 |
35 |
35 |
2 |
2 |
19 |
33 |
4 |
8 |
15 |
3 |
0 |
7 |
15 |
0 |
4 |
0 |
4 |
0 |
2 |
4 |
0 |
4 |
4 |
examin., examination; MAC, myeloablative conditioning; RIC, reduced intensity conditioning; WHO, World Health Organization. |
Figure 1. Incidence of oral mucositis*
MAC, myeloablative conditioning; RIC, reduced intensity conditioning; WHO, World Health Organization.
*Adapted from Wysocka-Słowik et al.1
†Five-point scale recommended by the WHO.
The study demonstrated that oral mucositis occurred less frequently and with lower intensity in patients with RIC therapy compared to MAC therapy. Quality of life due to oral mucositis is greatly reduced in patients with AML leading to premature termination of treatment. With the continuous growth of allo-HSCT as a treatment option for patients with AML, it warrants further investigation of oral mucositis in these patients.
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