Intravenous Immunoglobulin as Prophylaxis of Chemotherapy-Induced Oral Mucositis

Extract

Oral mucositis is a distressing toxic effect of head and neck irradiation and systemic chemotherapy with many commonly utilized drugs in patients with cancer. Although various solutions, drugs, and physical modalities are used and studied as prophylactic measures ( 1 ), there has been little substantial improvement in the ability to prevent it.

Oral mucositis can occur as a result of therapy with high doses of methotrexate. The BFM-90 (Berlin—Frankfurt—Münster) protocol for treatment of childhood acute lymphoblastic leukemia includes four courses of high-dose methotrexate (5 g/m ² of body surface) given at 2-week intervals.

We report here on a 15-year-old male patient who developed severe grade 3 mucositis according to the North Central Cancer Treatment Group toxicity guidelines [i.e., intense erythema with edema or ecchymoses or deep ulceration, able to take soft foods and to maintain fluid intake ( 2 )] after the first three courses of high-dose methotrexate. After the fourth course of high-dose methotrexate, when 0.2 g of intravenous immunoglobulin per kilogram of body weight was administered, no oral mucositis (i.e., grade 0 toxicity) appeared. Intravenous immunoglobulin was applied 27 hours after the 24-hour methotrexate infusion. We simultaneously treated another male patient of the same age with the same drug regimen, but without intravenous immunoglobulin administration. This patient developed grade 3 mucositis after all four courses of high-dose methotrexate. An analogous situation was observed in a 5-year-old girl. She experienced oral grade 3 mucositis after the first two courses of high-dose methotrexate, but, after the other two courses, when intravenous immunoglobulin was administered concomitantly in the same schedule, no mucositis appeared.