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