Relationship between Preoperative Nutritional Status and Clinical Outcomes in Patients with Head and Neck Cancer

The nutritional status in cancer patients is related to cancer survival and surgical outcome. The objective of this study was to examine the relationship between preoperative prognostic nutritional index (PNI) and post-operative clinical outcomes in head and neck cancer (HNC) patients. A total of 1282 head and neck cancer patients receiving surgical resection in Changhua Christian Hospital between 1 January 2010 and 30 August 2021 were recruited in the final analysis after undergoing propensity score matching analysis. The logistic regression model was used to assess the association of the PNI group with overall and various complications. The patients in the high PNI group had a significant lower incidence of overall complications, medical complications, and pulmonary complications; but not significant surgical complications. The high PNI group had lower mortality risk. The results in this study revealed that PNI score was a significant independent predictor of postoperative complications in HNC patients undergoing surgical resection. We recommend preoperative testing and evaluation of HNC patients to identify low PNI and high-risk groups for postoperative surveillance.     

Prognostic Nutritional Index Predicts Toxicity in Head and Neck Cancer Patients Treated with Definitive Radiotherapy in Association with Chemotherapy

Background: The Prognostic Nutritional Index (PNI) is a parameter of nutritional and inflammation status related to toxicity in cancer treatment. Since data for head and neck cancer are scanty, this study aims to investigate the association between PNI and acute and late toxicity for this malignancy. Methods: A retrospective cohort of 179 head and neck cancer patients treated with definitive radiotherapy with induction/concurrent chemotherapy was followed-up (median follow-up: 38 months) for toxicity and vital status between 2010 and 2017. PNI was calculated according to Onodera formula and low/high PNI levels were defined according to median value. Odds ratio (OR) for acute toxicity were calculated through logistic regression model; hazard ratios (HR) for late toxicity and survival were calculated through the Cox proportional hazards model. Results: median PNI was 50.0 (interquartile range: 45.5–53.5). Low PNI was associated with higher risk of weight loss > 10% during treatment (OR = 4.84, 95% CI: 1.73–13.53 for PNI < 50 versus PNI ≥ 50), which was in turn significantly associated with worse overall survival, and higher risk of late mucositis (HR = 1.84; 95% CI:1.09–3.12). PNI predicts acute weight loss >10% and late mucositis. Conclusions: PNI could help clinicians to identify patients undergoing radiotherapy who are at high risk of acute and late toxicity.     

Nutritional Support in Head and Neck Radiotherapy Patients Considering HPV Status

Malnutrition is a common problem in patients with head and neck cancer (HNC), including oropharyngeal cancer (OPC). It is caused by insufficient food intake due to dysphagia, odynophagia, and a lack of appetite caused by the tumor. It is also secondary to the oncological treatment of the basic disease, such as radiotherapy (RT) and chemoradiotherapy (CRT), as a consequence of mucositis with the dry mouth, loss of taste, and dysphagia. The severe dysphagia leads to a definitive total impossibility of eating through the mouth in 20–30% of patients. These patients usually require enteral nutritional support. Feeding tubes are a commonly used nutritional intervention during radiotherapy, most frequently percutaneous gastrostomy tube. Recently, a novel HPV-related type of OPC has been described. Patients with HPV-associated OPC are different from the HPV− ones. Typical HPV− OPC is associated with smoking and alcohol abuse. Patients with HPV+ OPC are younger and healthy (without comorbidities) at diagnosis compared to HPV− ones. Patients with OPC are at high nutritional risk, and therefore, they require nutritional support in order to improve the treatment results and quality of life. Some authors noted the high incidence of critical weight loss (CWL) in patients with HPV-related OPC. Other authors have observed the increased acute toxicities during oncological treatment in HPV+ OPC patients compared to HPV− ones. The aim of this paper is to review and discuss the indications for nutritional support and the kinds of nutrition, including immunonutrition (IN), in HNC, particularly OPC patients, undergoing RT/CRT, considering HPV status.     

GLIM-Defined Malnutrition in Patients with Head and Neck Cancer during the Qualification Visit for Home Enteral Nutrition

Patients with head and neck cancer (HNC) present multiple symptoms that increase the risk of malnutrition. Nutritional care, including enteral nutrition (EN), plays a crucial role in the management of this group of patients. The aim of the study was to determine the Global Leadership Initiative on Malnutrition (GLIM)-based stages of malnutrition and the relationship with selected biochemical parameters during the home enteral nutrition (HEN) qualification visit of patients with HNC. The retrospective analysis involved 224 patients with HNC referred for HEN. The following parameters were evaluated: body mass index (BMI), percent weight loss, and laboratory tests (serum albumin, total serum protein, C-reactive protein (CRP), and total lymphocyte count (TLC)). Malnutrition was defined using GLIM-based criteria. The prevalence of malnutrition based on GLIM criteria was 93.75% (15.18% moderately malnourished, 78.57% severely malnourished). There was a positive correlation between malnutrition based on GLIM criteria, serum albumin, and CRP. In the model assessing the odds of severe malnutrition according to the criteria of GLIM, TLC and CRP had a statistically significant effect on the chance in the probability of qualifying a patient to the severe malnutrition group, but the strength of the results was weak. The prevalence of malnutrition in HNC patients enrolled to HEN is high and most of them are severely malnourished. This suggests that it is important to identify more efficiently patients with risk of malnutrition at an earlier stage. GLIM criteria for malnutrition can be easily applied in this group of patients, but the definition of inflammation criteria should be clarified.     

Nutritional Interventions in Head and Neck Cancer Patients Undergoing Chemoradiotherapy: A Narrative Review

The present review aimed to define the role of nutritional interventions in the prevention and treatment of malnutrition in HNC patients undergoing CRT as well as their impact on CRT-related toxicity and survival. Head and neck cancer patients are frequently malnourished at the time of diagnosis and prior to the beginning of treatment. In addition, chemo-radiotherapy (CRT) causes or exacerbates symptoms, such as alteration or loss of taste, mucositis, xerostomia, fatigue, nausea and vomiting, with consequent worsening of malnutrition. Nutritional counseling (NC) and oral nutritional supplements (ONS) should be used to increase dietary intake and to prevent therapy-associated weight loss and interruption of radiation therapy. If obstructing cancer and/or mucositis interfere with swallowing, enteral nutrition should be delivered by tube. However, it seems that there is not sufficient evidence to determine the optimal method of enteral feeding. Prophylactic feeding through nasogastric tube or percutaneous gastrostomy to prevent weight loss, reduce dehydration and hospitalizations, and avoid treatment breaks has become relatively common. Compared to reactive feeding (patients are supported with oral nutritional supplements and when it is impossible to maintain nutritional requirements enteral feeding via a NGT or PEG is started), prophylactic feeding does not offer advantages in terms of nutritional outcomes, interruptions of radiotherapy and survival. Overall, it seems that further adequate prospective, randomized studies are needed to define the better nutritional intervention in head and neck cancer patients undergoing chemoradiotherapy.     

The Influence of Dysphagia on Nutritional and Frailty Status among Community-Dwelling Older Adults

Malnutrition is a core symptom of the frailty cycle in older adults. The purpose of this study was to investigate whether dysphagia influences nutrition or frailty status in community-dwelling older adults. The study participants were 320 Japanese community-dwelling older adults aged ≥65 years. All participants completed a questionnaire survey that included items on age, sex, family structure, self-rated health, nutritional and frailty status, and swallowing function. Nutritional status was categorized as malnourished, at risk of malnutrition, and well-nourished based on the Mini Nutrition Assessment-Short Form. The participants were then classified into a malnutrition (malnourished/at risk) or a well-nourished group (well-nourished). Frailty was assessed using the Cardiovascular Health Study criteria. The participants were then divided into a frailty (frail/pre-frail) or a non-frailty group (robust). Dysphagia was screened using the 10-item Eating Assessment Tool. Multiple logistic regression analysis was conducted to determine whether dysphagia was associated with nutritional or frailty status. The results revealed that dysphagia influenced both nutrition (odds ratio [OR]: 4.0; 95% confidence interval [CI]: 1.9–8.2) and frailty status (OR: 2.3; 95% CI: 1.0–5.2); therefore, the swallowing function would be an important factor for community-dwelling older adults on frailty prevention programs.     

The Association of Education,Employment and Living with a Partner with the Treatment among Patients with Head and Neck Cancer

The aim of this study was to explore possible associations between social and socioeconomic status and ongoing treatment among patients with head and neck cancer.Material and methodsData from 159 examined patients treated with head and neck cancer during the period from 2011 to 2012 were explored. A logistic regression analysis was used to assess association of social status (living with somebody vs. living alone), socioeconomic status (employed vs. unemployed) and education (primary/secondary/university) with treatment.ResultsThe results from logistic regression showed significant association of employment status and education with both interruption in radiochemotherapy and searching for additional help after surgery. Interruption of radiochemotherapy was almost 3 times more likely in a group of unemployed compared to the employed patients. Lack of searching for help after surgery was almost 4 times more likely in a group of unemployed compared to the employed and 5 times more likely in the group with the lowest education compared with the group with the highest education.ConclusionsThe study suggests that special attention needs to be paid, not only during but also after treatment, to the patients from low socioeconomic groups.     

Pretreatment Glasgow Prognostic Score Correlated with Serum Histidine Level and Three-Year Mortality of Patients with Locally Advanced Head and Neck Squamous Cell Carcinoma and Optimal Performance Status

Few prospective cohort trials have investigted the effect of pretreatment nutritional and inflammatory status on the clinical outcome of patients with cancer and optimal performance status and assessed the interplay between nutrition, inflammation, body composition, and circulating metabolites before treatment. Here, 50 patients with locally advanced head and neck squamous cell carcinoma (LAHNSCC) and Eastern Cooperative Oncology Group performance status (ECOG PS) ≤ 2 were prospectively recruited along with 43 healthy participants. Before concurrent chemoradiotherapy, compared with healthy controls, the cancer group showed lower levels of histidine, leucine, and phenylalanine and had low values in anthropometric and body composition measurements; however, the group displayed higher ornithine levels, more malnutrition, and severe inflammation. Pretreatment advanced Glasgow prognostic score (1 and 2) status was the sole prognostic factor for 3-year mortality rate and was associated with age and serum histidine levels in patients with cancer. Thus, even at the same tumor stage and ECOG PS, patients with LAHNSCC, poor nutrition, and high inflammation severity at baseline may have inferior survival outcomes than those with adequate nutrition and low inflammation severity. Assessment of pretreatment nutritional and inflammatory status should be included in the enrollment criteria in future studies.     

螺旋断层放射治疗技术在头颈部肿瘤中的应用

螺旋断层放射治疗技术是近年来逐渐发展起来的一种调强适形放疗技术,目前已经初步应用于口咽癌、鼻咽癌等多种头颈部肿瘤治疗中。与传统的调强放疗比,螺旋断层放射治疗技术具有剂量更准确、分布更均匀、更好保护重要器官以及降低放疗后不良反应发生率等优点。该文就国内外螺旋断层放射治疗技术在头颈部肿瘤中的应用予以综述。     

EPID在头颈部肿瘤放疗摆位中的应用

目的：确定电子射野影像系统（EPID）对头颈部放疗患者位置误差的修正效果。方法应用EPID对40例头颈部放疗患者的摆位误差进行测定分析。初次治疗前和以后每两周通过兆伏级EPID对患者治疗位置采集正交位射野验证影像,并与治疗计划中通过定位CT生成的数字重建射野（DRR）影像进行比对,医生认可比对结果后,记录下各方向摆位误差值。结果患者在x轴、y轴、z轴（x轴、y轴、z轴分别表示患者左右、前后和头脚方向）上的误差（系统误差±随机误差）分别为（0.7±1.33）mm,（0.28±1.74）mm,（0.13±1.29）mm;EPID验证结果和kV-CBCT验证结果在y轴、z轴方向无显著差异（P=0.859）,在x轴方向有显著差异（P=0.000）。结论在头颈部放疗时,EPID系统可以修正患者的位置误差。     

不同图像引导方式在头颈部肿瘤中成像剂量测量

目的测量不同图像引导方式在头模中的成像剂量。方法应用UNIDOS E型剂量仪（德国PTW公司）与30013型电离室,测量Varian Clinac iX直线加速器配置的EPID、OBI和CBCT图像引导功能在圆柱形模体的成像剂量。二维图像采用0o和270o两个正交野成像,三维图像采用CBCT成像。结果二维成像时,OBI系统（KV级X线）模体内各点平均吸收剂量0.74mGy,显著低于EPID系统（MV级X线）的90.93mGy,且图像清晰度优于后者;标准CBCT（KV级X线）各点平均吸收剂量4.77mGy,而低剂量CBCT模式仅为标准模式的50%,能够完成精确匹配。结论OBI系统比EPID系统成像剂量更低,图像质量更好。CBCT作为三维图像引导方式显著优于二维图像引导方式,进行日常的摆位验证也是安全的。因此,合理选择图像引导方式和设置图像采集参数,能够有效地减少患者的额外受照剂量。     

Comparison of Preoperative Nutritional Indexes for Outcomes after Primary Esophageal Surgery for Esophageal Squamous Cell Carcinoma

Background: This study aimed to compare the controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) for predicting postoperative outcomes in patients with esophageal squamous cell carcinoma undergoing esophagectomy. Methods: We retrospectively reviewed the data of 1265 consecutive patients who underwent elective esophageal surgery. The patients were classified into no risk, low-risk, moderate-risk, and high-risk groups based on nutritional scores. Results: The moderate-risk (hazard ratio [HR]: 1.55, 95% confidence interval [CI]: 1.24–1.92, p < 0.001 in CONUT; HR: 1.61, 95% CI: 1.22–2.12, p = 0.001 in GNRI; HR: 1.65, 95% CI: 1.20–2.26, p = 0.002 in PNI) and high-risk groups (HR: 1.91, 95% CI: 1.47–2.48, p < 0.001 in CONUT; HR: 2.54, 95% CI: 1.64–3.93, p < 0.001 in GNRI; HR: 2.32, 95% CI: 1.77–3.06, p < 0.001 in PNI) exhibited significantly worse 5-year overall survival (OS) compared with the no-risk group. As the nutritional status worsened, the trend in the OS rates decreased (p for trend in all indexes < 0.05). Conclusions: Malnutrition, evaluated by any of three nutritional indexes, was an independent prognostic factor for postoperative survival.     

Percutaneous Gastrostomy Tube Placement Using a Balloon Catheter in Patients With Head and Neck Cancer

Background: Patients with head and neck cancer frequently require gastrostomy feeding. The aim of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy with push‐type gastrostomy tubes using a rupture‐free balloon (RFB) catheter under computed tomography (CT) and fluoroscopic guidance in patients with head and neck cancer with swallowing disturbance or trismus. Methods: Percutaneous CT and fluoroscopic gastrostomy placement of push‐type gastrostomy tubes using a RFB catheter was performed in consecutive patients with head and neck cancer between April 2007 and July 2010. The technical success, procedure duration, and major or minor complications were evaluated. Results: Twenty‐one patients (14 men, 7 women; age range, 55–78 years; mean age, 69.3 years) underwent gastrostomy tube placement. The tumor location was the pharynx (n = 8), oral cavity (n = 7), and gingiva (n = 6). Gastrostomy was performed in 15 patients during treatment and 6 patients after treatment. Percutaneous radiologic gastrostomy was technically successful in all patients. The median procedure time was 35 ± 19 (interquartile range) minutes (range, 25–75). The average follow‐up time interval was 221 days (range, 10–920 days). No major complications related to the procedure were encountered. No tubes failed because of blockage, and neither tube dislodgement nor intraperitoneal leakage occurred during the follow‐up periods. Conclusion: Percutaneous CT and fluoroscopic‐guided gastrostomy with push‐type tubes using a RFB catheter is a relatively safe and effective means of gastric feeding, with high success and low complication rates in patients with head and neck cancer in whom endoscopy was not feasible.     

The Role of Pretreatment Percutaneous Endoscopic Gastrostomy in Facilitating Therapy of Head and Neck Cancer and Optimizing the Body Mass Index of the Obese Patient

Background: Chemoradiation of head and neck cancer induces severe dysphagia and malnutrition, which may lead to interruptions in therapy and reduction in its efficacy. Percutaneous endoscopic gastrostomy (PEG) feedings bypass the oropharynx, allowing administration of nutrients and medications into the stomach, thus preventing malnutrition, dehydration, and treatment interruption. Methods: Medical records of 161 patients treated for head and neck cancer who had PEGs placed prior to chemoradiation and 2 PEGs placed during chemoradiation were reviewed from the date of PEG placement throughout treatment and utilization. The objective was to determine the contribution of pretreatment PEGs to the therapy of patients with head and neck cancer and to optimize their body mass index. Results: Severe chemoradiation‐induced dysphagia developed in 160 patients (98%), necessitating PEG utilization for feeding and hydration. PEGs were used for a mean 251 ± 317 days. Significant complications related to PEG placement and utilization were infrequent. PEG feeding allowed chemoradiation to continue without interruption in 93% of patients. Individualized feeding regimens optimized body mass index in obese and overweight patients with a decline from 33.0 ± 3.4 to 28.4 ± 4.8 kg/m² (P < .001) and 27.3 ± 1.5 to 24.6 ± 2.7 kg/m² (P < .001), respectively. Radiation‐induced strictures developed in 12% of patients, requiring endoscopic dilatation. Conclusions: Enteral feeding through prechemoradiation‐placed PEGs is an effective and safe method for nutrition and hydration of patients with head and neck cancer undergoing chemoradiation. PEGs allowed chemoradiation to proceed with minimal interruptions despite severe dysphagia, which excluded oral intake for prolonged periods.     

Malnutrition Prevalence according to the GLIM Criteria in Head and Neck Cancer Patients Undergoing Cancer Treatment

Malnutrition is highly prevalent in people with head and neck cancer (HCN) and is associated with poorer outcomes. However, variation in malnutrition diagnostic criteria has made translation of the most effective interventions into practice challenging. This study aimed to determine the prevalence of malnutrition in a HNC population according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and assess inter-rater reliability and predictive validity. A secondary analysis of data available for 188 patients with HNC extracted from two cancer malnutrition point prevalence studies was conducted. A GLIM diagnosis of malnutrition was assigned when one phenotypic and one etiologic criterion were present. Phenotypic criteria were ≥5% unintentional loss of body weight, body mass index (BMI), and subjective evidence of muscle loss. Etiologic criteria were reduced food intake, and presence of metastatic disease as a proxy for inflammation. The prevalence of malnutrition was 22.6% (8.0% moderately malnourished; 13.3% severely malnourished). Inter-rater reliability was classified as excellent for the GLIM criteria overall, as well as for each individual criterion. A GLIM diagnosis of malnutrition was found to be significantly associated with BMI but was not predictive of 30 day hospital readmission. Further large, prospective cohort studies are required in this patient population to further validate the GLIM criteria.     

面罩固定技术在头颈部肿瘤放疗中的应用

本文介绍通过面罩固定技术使头颈部肿瘤患者摆位的精确度得到很大的提高,实践证明它是精确定位的一种行之有效的技术。     

Eliciting Preferences for Clinical Follow-Up in Patients with Head and Neck Cancer Using Best-Worst Scaling

Objectives

There are no commonly accepted standards for monitoring patients treated for head and neck cancer. The aim of this study was to assess patients’ preferences for different aspects of follow-up.

头颈肿瘤放射治疗后口干症的临床分析

目的：探讨放射治疗头颈肿瘤后产生口干症的影响因素。方法：对2005年8月～2006年1月收治的头颈肿瘤82例，在放疗期间每周末询问患者的口干情况，根据结果分析口干症的严重程度及影响。结果：当患者所接受放射剂量逐增时，口干症的发生率有非常显著的差异（x^2=26．24，P〈0．001）；年龄低于40岁组口干症的发生率与40岁以上组比较无明显差异（x^2=0.026，P〉0．05）。结论：头颈肿瘤放射治疗后可以发生口干症，与患者所受放射总剂量有关：而当患者接受高剂量照射时，患者年龄对口干症的发生率影响不大。放疗期间应尽可能降低或延迟口干症的发生．保证放疗质量。     

螺旋断层放疗系统自适应软件在评价腮腺剂量变化中的初步应用

介绍了研究螺旋断层放疗（Helical tomotherapy,HT）系统自适应软件系统在评价头颈部癌腮腺剂量学变化中的应用价值。该自适应软件以HT系统为平台,通过MVCT扫描得到的影像,计算感兴趣区域实际体积及照射剂量,并以此为基础决定是否进行重新改野以及改野的时机,为实现自适应放疗提供帮助。本研究以一例鼻咽癌为样本,评价双侧腮腺在整个放疗过程中的体积及剂量学变化。在每周及最后一次行MVCT扫描,共8次图像系列。随着治疗疗程的进行,腮腺体积逐渐缩小,接受剂量逐渐增加,腮腺体积变化和V1与D50呈负性相关（p均〈0.05）。     

Phase Angle,a Cornerstone of Outcome in Head and Neck Cancer

In patients with head and neck cancer, malnutrition is common. Most cases are treated by chemo-radiotherapy and surgery, with adverse effects on the aerodigestive area. Clinical and biochemical characteristics, health-related quality of life, survival, and risk of death were studied. The selected subjects were divided into normal- and low-phase-angle (PA) groups and followed up for at least two years. Mean ages were 67.2 and 59.3 years for low and normal PA, respectively. Patients with PA < 4.42° had significant differences in age, anthropometric and biochemical indicators of malnutrition, and inflammatory status compared to patients with PA > 4.42°. Statistical differences were found in the functional and symptom scales, with lower functional scores and higher symptom scores in patients with low PA. Median survival was 19.8 months for those with PA < 4.42° versus 34.4 months for those with PA > 4.42° (p < 0.001).The relative risk of death was related to low PA (2.6; p < 0.001). The percentage of living patients (41.7%) is almost the same as the percentage of deceased subjects (43.1%; p = 0.002), with high death rates in patients with PA < 4.42°. Phase angle was the most crucial predictor of survival and a risk factor for death in the studied cases.