Role of Oral Glutamine in Prevention and Treatment of Oral Mucositis in Head and Neck Cancer Patients Receiving Chemoradiation

• Hashmath Khanum

  Radiation Oncology, Kidwai Cancer Institute, Bengaluru, India

• Iqbal Ahmed

  Radiation Oncology, Bangalore Medical College & Research Institute, Bengaluru, India

• V. Chendil

  Radiation Oncology, Bangalore Medical College & Research Institute, Bengaluru, India

• Rajesh Javarappa

  Radiation Oncology, Bangalore Medical College & Research Institute, Bengaluru, India

• Amrut Kadam

  Radiation Oncology, Bangalore Medical College & Research Institute, Bengaluru, India

Purpose: To evaluate the efficiency of glutamine in the prevention & treatment of mucositis in head and neck cancer patients undergoing chemoradiation.

Material and Methods: Forty patients of histologically proven head and neck carcinomas undergoing chemoradiation with Conventional Radiation on telecobalt and concurrent Cisplatin were randomised into 2 groups. The study group received oral glutamine solution 2 hours prior to undergoing radiotherapy on all days of treatment. The severity and duration of mucositis were recorded once every week using WHO and RTOG grading system for all patients undergoing treatment.

Results: Glutamine lead to a delay in the onset of mucositis. The overall incidence of grade  mucositis was significantly low in glutamine arm (22% vs 55%, p= 0.006). On weekly assessments, the incidence of grade mucositis in study arm compared to the control was 0 vs 30%, p=0.02 at 4 weeks, 15.8 vs 45%, p= 0.038 at 5 weeks and 22 vs 70%, p=0.001 at 6 weeks. However, there was no statistically significant difference in the incidence of grade 1 and 2 mucositis in both arms.

Conclusion: Use of oral glutamine reduces the incidence and duration of oral mucositis and hence helpful in the prevention and treatment of oral mucositis with good compliance and further result in good locoregional control of the disease.

Takiar R, Nadayil D, Nandakumar A. Projections of Number of Cancer Cases in India (2010-2020) by Cancer Groups. Asian Pacific J Cancer Prev 11: 1045-1049.

Zlotolow IM. General consideration in prevention and treatment of oral manifestation of cancer therapies. In: Berget AP, Weissman DE, editors. Principles and practice of surgical oncology. Philadelphia, PA: Lippincott raven; 1998; p. 237.

Vissink A, Jansma J, Sp jkervet FK, Burlage FR, Coppes RP. Oral sequelae of head and neck radiotherapy. Crit Rev Oral Biol Med 2003; 14:199-212. https://doi.org/10.1177/154411130301400305

Trotti A, Bellm LA, Epstein JB, 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, Radiother Oncol 2003; 66: 253-262. https://doi.org/10.1016/S0167-8140(02)00404-8

Mead GM. Management of oral mucositis associated with cancer chemotherapy. Lancet 2002; 359: 815-6. https://doi.org/10.1016/S0140-6736(02)07960-6

Krebs H. Glutamine metabolism in animal body. In: Mora J, Palacios R, editors. Glutamine: Metabolism, enzymology and regulation. New York: Academic press; 1980; pp. 319-25. https://doi.org/10.1016/B978-0-12-506040-0.50023-6

Savarese DM, Savy G, Vahdat L, Wischmeyer PE, Corey B. Prevention of chemotherapy and radiation toxicity with glutamine. Cancer Treat Rev 2003; 29: 501-13. https://doi.org/10.1016/S0305-7372(03)00133-6

Klimberg VS, Souba WW, Dolson DJ, Salloum RM, Hautamaki RD, Plumley DA, et al. Prophylactic glutamine protects the intestinal mucosa from radiation injury. Cancer 1990; 66: 62-8. https://doi.org/10.1002/1097-0142(19900701)66:1<62::AID-CNCR2820660113>3.0.CO;2-E

Vokes EE, Weichselbaum RR. Measurable impact: multimodality therapy of Head and neck cancer. Int J Radiat Oncol Biol Phys 1993; 27: 481-482. https://doi.org/10.1016/0360-3016(93)90263-U

Forastiere AA, et al. Concurrent chemotherapy and Radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003; 349: 2091-2098. https://doi.org/10.1056/NEJMoa031317

Jean-Pierre Pignon, Aurelie le Maitre a, Emilie Maillard, Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17346 patients. Radiotherapy and Oncology 2009; 92: 4-14. https://doi.org/10.1016/j.radonc.2009.04.014

Blanchard P, Baujat B, Holostenco V. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): A comprehensive analysis by tumour site. Radiotherapy and Oncology 2011; 100: 33-40. https://doi.org/10.1016/j.radonc.2011.05.036

Principles and Practice of Radiation Oncology; 5th Edition: Carlos Perez, Luther Brady.

Lacey, JM; Wilmore, DW. "Is glutamine a conditionally essential amino acid?" Nutrition Reviews 1990; 48(8): 297-309. https://doi.org/10.1111/j.1753-4887.1990.tb02967.x

Yamamoto T, Shimoyama T, Kuriyama M (8 December). "Dietary and enteral interventions for Crohn's disease. Current Opinion in Biotechnology 2016; 44: 69-73. https://doi.org/10.1016/j.copbio.2016.11.011

Huang EY, Leung SW, Wang CJ, Chen HC, Sun LM, Fang FM, et al. Oral glutamine to alleviate radiation induced oral mucositis: A pilot randomized trial. Int J Radiat Oncol Biol Phy 2000; 46: 535-9. https://doi.org/10.1016/S0360-3016(99)00402-2

Chattopadhyay S, et al. Role of oral glutamine in alleviation and prevention of radiation induced oral mucositis: A prospective randomized study. South Asian Journal of Cancer 2014; 3(1): 8-12. https://doi.org/10.4103/2278-330X.126501

Vidal-Casariego A, et al. Efficacy of glutamine in prevention of oral mucositis and radiation induced esophagitis: retrospective study. Nutrition and Cancer 2013; 65(3): 424-429. https://doi.org/10.1080/01635581.2013.765017

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