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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 257-261

A case of radiation-induced mucositis


Central Council for Research in Homoeopathy, Ministry of AYUSH, Government of , New Delhi, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Dr. R T Shaji Kumar
Central Council for Research in Homoeopathy, Ministry of AYUSH, Government of India, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_26_17

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  Abstract 


Oral mucositis is a common morbidity induced by radiation therapy and/or chemotherapy for head and neck malignancies. This often results in treatment delays, premature treatment cessation and increased cost. New treatments for oral mucositis are emerging but their success is variable. This is a case report of oral mucositis in Non-Hodgkin's Lymphoma (NHL) reported after 11th fraction of radiotherapy. Chief complaints were ulceration of mouth with painful swallowing. Clinical diagnosis as per the World Health Organization Grading Scale was Grade 3 oral mucositis. Phytolacca 30C was prescribed on the basis of acute totality of symptoms. Ulcers were reduced considerably within 4 days and radiotherapy was restarted and 22 fractions of radiation were completed. This case report suggests that homoeopathic intervention may be the treatment for mucositis in cancer patients undergoing radiation treatment.

Keywords: Cancer, Homoeopathy, Mucositis, Non-Hodgkin's Lymphoma, Radiotherapy


How to cite this article:
Shaji Kumar R T, Sachdeva J, Lamba CD. A case of radiation-induced mucositis. Indian J Res Homoeopathy 2017;11:257-61

How to cite this URL:
Shaji Kumar R T, Sachdeva J, Lamba CD. A case of radiation-induced mucositis. Indian J Res Homoeopathy [serial online] 2017 [cited 2019 Sep 18];11:257-61. Available from: http://www.ijrh.org/text.asp?2017/11/4/257/221956




  Introduction Top


Non-Hodgkin's Lymphoma (NHL) includes a heterogeneous group of lymphoproliferative disorders. The primary treatment for NHL includes chemotherapy, radiation, immunotherapy and stem cell transplant. The side effects from radiation therapy will depend on the area being treated. Patients can expect to have dry mouth, mouth sores, esophagitis and dysphagia if head and neck region is being irradiated.[1]

Oral mucositis is a common complication of cancer therapy and incidence ranges between 80% and 97%.[1],[2],[3] Incidence of Grade 3–4 mucositis may be up to 40%–55% depending upon type of radiotherapy and concomitant use of chemotherapy.[4],[5] The severity of oral mucositis is high in patients having primary tumours in the oral cavity, oropharynx or nasopharynx. Use of concurrent chemotherapy, total radiotherapy dose >50Gy, altered fractionation radiation schedules (e.g., more than one radiation treatment per day) are known to increase the incidence and severity of oral mucositis.[4],[6],[7]

Lesions of oral mucositis are often very painful and compromise nutrition and oral hygiene as well as increase the risk for local and systemic infection. Mucositis may limit the patient's ability to tolerate chemotherapy or radiation therapy and significantly affects patient's quality of life (QoL).[8] Severe oral toxicities can also compromise the delivery of optimal cancer therapy protocols, since treatment dose reduction or schedule modifications may be necessary to allow for resolution of oral lesions. In cases of severe oral morbidity, the patient may no longer be able to complete the recommended cancer therapy. These disruptions in cancer treatment due to oral complications can directly affect patient survivorship. Mucositis score is used to measure and convey the toxicity of a particular therapy which serves as a nursing management tool and is used to determine the efficacy of new treatments for the condition. The commonly used assessment tools are the World Health Organization (WHO) grading, Radiation Therapy Oncology Group grading, Oral Mucositis Assessment Scale and The National Cancer Institute Common Toxicity Criteria.[9],[10],[11]


  Case Report Top


History

A 55-year-old male (teacher by occupation), known case of NHL (high grade) was admitted to Delhi State Cancer Institute (DSCI) and Hospital on 4th May 2016 for the complaint of ulceration in oral cavity after 11th fraction of radiotherapy. Following allopathic medicines were prescribed for 8 days but there was no relief: tablet Ciprofloxacin 200mg/BD, injection Metrogyl 4mg/TDS, injection Forcan 100mg/OD, injection Tramedol 100mg/BD, injection Pantop OD, injection Emset BD, injection Lasix, Betadine mouth gargles, Zylee lotion LA, syrup Muccogel 2 tsp/OD. On 11th May 2016, the case was referred by a consultant to the homoeopathic unit with presenting complaints of ulceration in mouth with painful swallowing, pain radiating to ears on swallowing, feeling of roughness of throat with burning pain, feeling of heat in the throat with scanty stringy saliva since 4–5 days. Severe soreness and dryness of throat were present with aggravation in morning. The patient was thirsty with desire for cold water but was unable to drink, blood pressure was 160/100 mmHg, and pulse rate was 98 per/min.

Laboratory tests showed white blood cell count of 4.19μL, haemoglobin level of 5.44 g/dl, platelets of 343 × 109/L, differential leucocyte count –neutrophil - 69.7%, lymphocytes-11.4%, monocytes-10.8%, eosinophils-5.3%, basophils-0.6%. Biopsy (oropharynx) revealed diffuse large B cell NHL (high grade), BCL-2+ve and weak CD20+ve.

Examination

Oral mucosa was hyperaemic and congestion was seen on posterior aspect of hard, soft palate. Buccal mucosa having yellowish deposits with offensive smell. Tongue was reddish and dry. Small ulcerated patches were seen. On upper surface, there were dark bluish patches.

WHO grading was Grade 3.

Intervention

Homoeopathic medicine Phytolacca 30C procured from GMP certified manufacturer was dispensed in water doses every 2 hourly (6 doses) for 1 day on the basis of acute totality. The symptoms were graded as frequency intensity and duration [12] which comprised of ulcers on the tongue and throat with painful swallowing 3+; pain radiating to ears on swallowing 3+; feeling of roughness of throat with burning pain 3+; dark redness of oral cavity with congestion on posterior aspect of hard, soft palate and buccal mucosa 3+; tongue red with dark bluish patches on upper surface 2+.

Follow-up and outcomes

The follow up and outcomes after administration of homoeopathic medicine is given at [Table 1].
Table 1: Timeline of patient response and medicine prescribed with its dose

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  Discussion Top


Conventional management of oral mucositis has been largely palliative to date. In this case, homoeopathic medicine Phytolacca 30, prescribed on the basis of acute totality resolved the mucositis (WHO Grade 0) within 4 days, whereas usually Grade 3 mucositis takes 3–6 weeks to resolve.[13],[14],[15] Oral mucositis is a common, debilitating complication of cancer chemotherapy and radiotherapy. The development of Grade 3 mucositis warrants stoppage of radiotherapy as further injury to the mucosa causes its permanent damage.[16] It has been demonstrated that patients with oral mucositis are significantly more likely to have severe pain and a weight loss of ≥5%.[17] Justification of medicine Phytolacca includes Ulceration of mouth with pain radiating to ears on swallowing, feeling of roughness of throat with burning pain, dark redness or bluish redness of throat, tonguered tip, feeling rough and scalded. Bluish patches on the tongue were identified. Ulcerated sore throat cannot swallow even food and water.[18] Although Arsenic, Merc, Lach, Nat mur and Phosphorus were also closely indicated medicines for condition but not considered because Arsenic - absence of restlessness; Merc - thirst was not so marked; Lachesis - difficulty of swallowing present for both liquids and food; left-sided affection was not there and aggravation for touch and pressure was not there; Nat mur absence of mapped tongue; Phosphorus- bleeding from gums and ulcers, thirst for very cold water were not present.

Case was also assessed as per the Modified Naranjo Criteria, which suggest the causal relation between the intervention and outcome and the score was 8.[19] However, limitation of the case includes lack of objective evidences i.e., photographs and QoL scale.

This case shows the utility of Homoeopathy to treat radiation-induced mucositis. Homoeopathic medicines can help reduce the symptom burden, thereby improving QoL and compliance to radiation treatment. Homoeopathy can help reduce unscheduled radiation treatment breaks, which prolongs the total radiation treatment time, compromises on the efficacy of therapy and results in diminished treatment outcomes as well as reduced QoL. Economic burden is a major issue. The per patient incremental cost of Grade 1–2 oral mucositis can be as high as $1700 and that of Grade 3–4 oral mucositis can rise upto $6000.[20] Nonzee et al.'s analysis which was limited to severe oral mucositis (Grade 3–4) found the incremental cost per patient to be $17,000.[21] Reduction in days of hospitalization due to mucositis and costs can be effectively managed through homoeopathic treatment.


  Conclusion Top


Homoeopathy can play a key role in treatment of radiation-induced mucositis, thereby reducing radiation treatment breaks, days of hospitalization, improving adherence to radiation therapy. Further studies on appropriate sample are required to establish the efficacy of Homoeopathic intervention in radiation-induced mucositis patient.

Patient perspective

I was in ogonizing pain when I was under radiotherapy. I couldn't eat for days but after the homoeopathy treatment, I not only started eating, my ulcers were also cured completely.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

1.
Cheng KK, Leung SF, Thompson DR, Tai JW, Liang RH, Kan AS, et al. New measure of health-related quality of life for patients with oropharyngealmucositis: Development and preliminary psychometric evaluation. Cancer 2007;109:2590-9.  Back to cited text no. 1
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2.
Trotti A, Bellm LA, Epstein JB, Frame D, Fuchs HJ, Gwede CK, et al. Mucositis incidence, severity and associated outcomes in patients with head and neck cancer receiving radiotherapy with or without chemotherapy: A systematic literature review. RadiotherOncol 2003;66:253-62.  Back to cited text no. 2
    
3.
Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny AM, Littlewood A, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database of Systematic Reviews. 2011;2011:CD000978DOI: http://dx.doi.org/10.1002/14651858.CD000978.pub5.  Back to cited text no. 3
    
4.
Ps SK, Balan A, Sankar A, Bose T. Radiation induced oral mucositis. Indian J Palliat Care 2009;15:95-102.  Back to cited text no. 4
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5.
Vissink A, Jansma J, Spijkervet FK, Burlage FR, Coppes RP. Oral sequelae of head and neck radiotherapy. Crit Rev Oral Biol Med 2003;14:199-212.  Back to cited text no. 5
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Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in patients who have cancer. Dent Clin North Am 2008;52:61-77, viii.  Back to cited text no. 6
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7.
Krishnatry R, Nachankar AA, Gupta T, Agarwal JP. Oral radiation mucositis: A short review. Int J Head Neck Surgery 2011;2:37-43.  Back to cited text no. 7
    
8.
Naidu MU, Ramana GV, Rani PU, Mohan IK, Suman A, Roy P, et al. Chemotherapy-induced and/or radiation therapy-induced oral mucositis – Complicating the treatment of cancer. Neoplasia 2004;6:423-31.  Back to cited text no. 8
    
9.
Eilers J, Berger AM, Petersen MC. Development, testing, and application of the oral assessment guide. OncolNurs Forum 1988;15:325-30.  Back to cited text no. 9
    
10.
Sonis ST, Eilers JP, Epstein JB, LeVeque FG, Liggett WH Jr., Mulagha MT, et al. Validation of a new scoring system for the assessment of clinical trial research of oral mucositis induced by radiation or chemotherapy. Mucositis study group. Cancer 1999;85:2103-13.  Back to cited text no. 10
    
11.
Sonis, et al. Perspectives on cancer therapy-induced mucosal injury. Pathogenesis, measurement, epidemiology, and consequences for patients. Cancer 2004;100:1995-2025.  Back to cited text no. 11
    
12.
Vithoulkas G. The Science of Homeopathy. Grove Press Inc. New York; 1980. p. 182.  Back to cited text no. 12
    
13.
Nishimura N, Nakano K, Ueda K, Kodaira M, Yamada S, Mishima Y, et al. Prospective evaluation of incidence and severity of oral mucositis induced by conventional chemotherapy in solid tumors and malignant lymphomas. Support Care Cancer 2012;20:2053-9.  Back to cited text no. 13
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14.
Mosel DD, Bauer RL, Lynch DP, Hwang ST. Oral complications in the treatment of cancer patients. Oral Dis 2011;17:550-9.  Back to cited text no. 14
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15.
Epstein JB, Klasser GD. Emerging approaches for prophylaxis and management of oropharyngealmucositis in cancer therapy. Expert OpinEmerg Drugs 2006;11:353-73.  Back to cited text no. 15
    
16.
Mallick S, Benson R, Rath GK. Radiation induced oral mucositis: A review of current literature on prevention and management. Eur Arch Otorhinolaryngol 2016;273:2285-93.  Back to cited text no. 16
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17.
Elting LS, et al. Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies. Int J Radiat Oncol Biol Phys 2007;68:1110-20.  Back to cited text no. 17
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18.
Boericke W. Boericke's New Manual of Homoeopathic Materia Medica with Repertory. New Delhi, India: B. Jain Publishers (P) Ltd; 2007. p. 752.  Back to cited text no. 18
    
19.
Van Haselen RA. Homeopathic clinical case reports: Development of a supplement (HOM-CASE) to the CARE clinical case reporting guideline. Complementary Therapies in Medicine 2016;25:78-85.  Back to cited text no. 19
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20.
Elting LS, Cooksley CD, Chambers MS, Garden AS. Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies. Int J RadiatOncolBiolPhys 2007;68:1110-20.  Back to cited text no. 20
    
21.
Nonzee NJ, Dandade NA, Patel U, Markossian T, Agulnik M, Argiris A, et al. Evaluating the supportive care costs of severe radiochemotherapy-induced mucositis and pharyngitis: Results from a Northwestern University Costs of Cancer Program pilot study with head and neck and nonsmall cell lung cancer patients who received care at a county hospital, a Veterans Administration hospital, or a comprehensive cancer care center. Cancer 2008;113:1446-52.  Back to cited text no. 21
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