Τοξικές Επιδράσεις στη Στοματική Κοιλότητα μετά από Μεταμόσχευση Αιμοποιητικών Προγονικών Κυττάρων
Σιούτου -Σκανδάλη Α.1, Δαμιανάκου Χ.2, Σκλαβούνου Α.3
Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών, Οδοντιατρική Σχολή και τμήμα Κλινικής Αιματολογίας και Μονάδας Μεταμόσχευσης Μυελού,
ΓΝΑ «Γ. Γεννηματάς».
1. Αιματολόγος, Αναπληρώτρια Διευθύντρια, Τμήμα Κλινικής Αιματολογίας
και Μονάδας Μεταμόσχευσης Μυελού, ΓΝΑ «Γ.
ΓΕΝΝΗΜΑΤΑΣ».
2. Επίκ. Καθηγήτρια Ακίνητης Προσθετικής, Τομέας Προσθετολο-
γίας Οδοντιατρικής Σχολής Πανεπιστημίου Αθηνών.
3. Αναπλ. Καθηγήτρια Στοματολογίας, Τομέας Παθολογίας και
Χειρουργικής Στόματος Οδοντιατρικής Σχολής Πανεπιστημίου
Αθηνών.
Αρχεία Ελληνικής Στοματικής και Γναθοπροσωπικής Χειρουργικής 5(2): 94 - 109, 2004.
ΠΕΡΙΛΗΨΗ
Η μεταμόσχευση αιμοποιητικών κυττάρων (ΜΑΚ) αποτελεί θεραπεία ίασης για ορισμένες αιματολογικές
κακοήθειες και σύνδρομα μη αναστρέψιμης μυελικής ανεπάρκειας.
Η στοματική κοιλότητα είναι ιδιαίτερα ευαίσθητη στις άμεσες και έμμεσες τοξικές δράσεις της χημειο-ακτι-
νοθεραπείας που χρησιμοποιείται στα πρωτόκολλα μεταμόσχευσης αιμοποιητικών προγονικών κυττάρων. Η
εκτίμηση της κατάστασης του στόματος και η αποκατάσταση της οδοντοστοματολογικής νόσου πριν τη μεταμόσχευση
αποτελεί ουσιαστικό στοιχείο της συνολικής φροντίδας του ασθενούς η οποία αφορά τόσο στην
πρόληψη όσο και στη θεραπεία με στόχο την ελαχιστοποίηση των κινδύνων για την εμφάνιση στοματικών
και επακόλουθων συστηματικών επιπλοκών.
Η νόσος του μοσχεύματος κατά του ξενιστή (GVHD-graft versus host disease) αποτελεί τη συχνότερη και
σοβαρότερη επιπλοκή της αλλογενούς μεταμόσχευσης αιμοποιητικών κυττάρων και ο στοματικός βλεννογόνος
το όργανο-στόχο τόσο της οξείας όσο και της χρόνιας νόσου. Οι στοματικές επιπλοκές της χρόνιας
κυρίως GVHD είναι επώδυνες, επίμονες και δυσίατες και απαιτούν τη στενή συνεργασία ομάδας ειδικών και
συνδυασμένες θεραπευτικές παρεμβάσεις.
Εφόσον όλο και περισσότεροι ασθενείς επιβιώνουν χωρίς νόσο για πολλά χρόνια, ο κίνδυνος για την
ανάπτυξη δευτερογενών κακοηθειών στο στόμα καθίσταται όλο και περισσότερο προφανής. Η συνεχής
παρακολούθηση και φροντίδα των ασθενών αυτών αποτελεί πρωταρχική υποχρέωση της ιατρικής κοινότητας
με στόχο τη διασφάλιση της ποιότητας ζωής τους.
Λέξεις κλειδιά: Μεταμόσχευση αιμοποιητικών κυττάρων, φάσεις μεταμόσχευσης, βλάβη βλεννογόνιου φραγμού, στοματική GVHD.
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Ιατρικές εκδόσεις Λίτσας. Αθήνα 2000.
Antin J A: Acute graft-versus-host diease: inflammation run amok?
J Clin Invest 107: 1497-1498, 2001.
Armstrong TS: Stomatitis in the bone marrow transplant patient.
An overview and proposed oral care protocol. Cancer Nurs
1994; 17: 403-10.
Atkinson K: Reconstruction of the hematopoietic and immune
systems after marrow transplantation. Bone Marrow
Transplant 5: 209-226, 1990.
Bearman S, Appelbaum F, Buckner C, et al: Regimen-related
toxicity in patients undergoing bone marrow transplantation. J
Clin Oncol 1988; 6: 1562-1568.
Berman SI: The syndrome of hepatic veno-occlusive disease after
morrow transplantation. Blood 1995; 85: 3005-3020.
Blijlevens NMA, Donnelly JP, De Pauw BE: Mucosal barrier
injury: biology, pathologym, clinical counterparts and
consequences of intensive treatment for hematological
malignancy: an overview. Bone Marrow Transplantation
2000; 25: 1269-1278.
Blijlevens NMA: Mucosal damage: a major risk factor for severe
complications after cytotoxic therapy? In: Hematology 2003:
American Society of Hematology Educational Program Book
2003; pp 438-445.
Centers for Disease Control and Prevention. Guidelines for
preventing opportunistic infections among hematopoietic stem
cell transplant recipients. Recommendations of CDC, the
Infectious Diseases Society of America, and the American
Society of Blood and Marrow Transplantation. Biol Blood
Marrow Transplant 2000; 6: 665-670.
Cheng KK, Mollassiotis A, Chang AM, Cheung SS: Evaluation of
an oral care protocol intervention in the prevention of
chemotherapy-induced oral mucositis in paediatric cancer
patients. Eur J Cancer 2001; 37: 2056-2063.
Child FJ, Ratnaval R, Walkins Ρ et al: Extracorporeal
photopheresis (ECP) in the treatment of chronic graft-versushost
disease (GVHD). Bone Marrow Transplant 1991; 23:
881-7.
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Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών, Οδοντιατρική Σχολή και τμήμα Κλινικής Αιματολογίας και Μονάδας Μεταμόσχευσης Μυελού,
ΓΝΑ «Γ. Γεννηματάς».
1. Αιματολόγος, Αναπληρώτρια Διευθύντρια, Τμήμα Κλινικής Αιματολογίας
και Μονάδας Μεταμόσχευσης Μυελού, ΓΝΑ «Γ.
ΓΕΝΝΗΜΑΤΑΣ».
2. Επίκ. Καθηγήτρια Ακίνητης Προσθετικής, Τομέας Προσθετολο-
γίας Οδοντιατρικής Σχολής Πανεπιστημίου Αθηνών.
3. Αναπλ. Καθηγήτρια Στοματολογίας, Τομέας Παθολογίας και
Χειρουργικής Στόματος Οδοντιατρικής Σχολής Πανεπιστημίου
Αθηνών.
Αρχεία Ελληνικής Στοματικής και Γναθοπροσωπικής Χειρουργικής 5(2): 94 - 109, 2004.
ΠΕΡΙΛΗΨΗ
Η μεταμόσχευση αιμοποιητικών κυττάρων (ΜΑΚ) αποτελεί θεραπεία ίασης για ορισμένες αιματολογικές
κακοήθειες και σύνδρομα μη αναστρέψιμης μυελικής ανεπάρκειας.
Η στοματική κοιλότητα είναι ιδιαίτερα ευαίσθητη στις άμεσες και έμμεσες τοξικές δράσεις της χημειο-ακτι-
νοθεραπείας που χρησιμοποιείται στα πρωτόκολλα μεταμόσχευσης αιμοποιητικών προγονικών κυττάρων. Η
εκτίμηση της κατάστασης του στόματος και η αποκατάσταση της οδοντοστοματολογικής νόσου πριν τη μεταμόσχευση
αποτελεί ουσιαστικό στοιχείο της συνολικής φροντίδας του ασθενούς η οποία αφορά τόσο στην
πρόληψη όσο και στη θεραπεία με στόχο την ελαχιστοποίηση των κινδύνων για την εμφάνιση στοματικών
και επακόλουθων συστηματικών επιπλοκών.
Η νόσος του μοσχεύματος κατά του ξενιστή (GVHD-graft versus host disease) αποτελεί τη συχνότερη και
σοβαρότερη επιπλοκή της αλλογενούς μεταμόσχευσης αιμοποιητικών κυττάρων και ο στοματικός βλεννογόνος
το όργανο-στόχο τόσο της οξείας όσο και της χρόνιας νόσου. Οι στοματικές επιπλοκές της χρόνιας
κυρίως GVHD είναι επώδυνες, επίμονες και δυσίατες και απαιτούν τη στενή συνεργασία ομάδας ειδικών και
συνδυασμένες θεραπευτικές παρεμβάσεις.
Εφόσον όλο και περισσότεροι ασθενείς επιβιώνουν χωρίς νόσο για πολλά χρόνια, ο κίνδυνος για την
ανάπτυξη δευτερογενών κακοηθειών στο στόμα καθίσταται όλο και περισσότερο προφανής. Η συνεχής
παρακολούθηση και φροντίδα των ασθενών αυτών αποτελεί πρωταρχική υποχρέωση της ιατρικής κοινότητας
με στόχο τη διασφάλιση της ποιότητας ζωής τους.
Λέξεις κλειδιά: Μεταμόσχευση αιμοποιητικών κυττάρων, φάσεις μεταμόσχευσης, βλάβη βλεννογόνιου φραγμού, στοματική GVHD.
REFERENCES
Αγγελόπουλος ΑΠ, Παπανικολάου Σ, Αγγελοπούλου Ε: Σύχρονη
Στοματική και Γναθοπροσωπική Παθολογία. 3η έκδοση.
Ιατρικές εκδόσεις Λίτσας. Αθήνα 2000.
Antin J A: Acute graft-versus-host diease: inflammation run amok?
J Clin Invest 107: 1497-1498, 2001.
Armstrong TS: Stomatitis in the bone marrow transplant patient.
An overview and proposed oral care protocol. Cancer Nurs
1994; 17: 403-10.
Atkinson K: Reconstruction of the hematopoietic and immune
systems after marrow transplantation. Bone Marrow
Transplant 5: 209-226, 1990.
Bearman S, Appelbaum F, Buckner C, et al: Regimen-related
toxicity in patients undergoing bone marrow transplantation. J
Clin Oncol 1988; 6: 1562-1568.
Berman SI: The syndrome of hepatic veno-occlusive disease after
morrow transplantation. Blood 1995; 85: 3005-3020.
Blijlevens NMA, Donnelly JP, De Pauw BE: Mucosal barrier
injury: biology, pathologym, clinical counterparts and
consequences of intensive treatment for hematological
malignancy: an overview. Bone Marrow Transplantation
2000; 25: 1269-1278.
Blijlevens NMA: Mucosal damage: a major risk factor for severe
complications after cytotoxic therapy? In: Hematology 2003:
American Society of Hematology Educational Program Book
2003; pp 438-445.
Centers for Disease Control and Prevention. Guidelines for
preventing opportunistic infections among hematopoietic stem
cell transplant recipients. Recommendations of CDC, the
Infectious Diseases Society of America, and the American
Society of Blood and Marrow Transplantation. Biol Blood
Marrow Transplant 2000; 6: 665-670.
Cheng KK, Mollassiotis A, Chang AM, Cheung SS: Evaluation of
an oral care protocol intervention in the prevention of
chemotherapy-induced oral mucositis in paediatric cancer
patients. Eur J Cancer 2001; 37: 2056-2063.
Child FJ, Ratnaval R, Walkins Ρ et al: Extracorporeal
photopheresis (ECP) in the treatment of chronic graft-versushost
disease (GVHD). Bone Marrow Transplant 1991; 23:
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