Nutritional status and general immune competence in patients with head and neck cancer

Anergy to 2,4-dinitrochlorobenzene (DNCB) has been reported as a highly significant adverse prognostic immunological factor in several studies of patients with squamous cell carcinomas involving the head and neck. Patients with these tumours often present with concurrent nutritional deficiencies. This paper reports the findings of a prospective study into both the nutritional status and general immune competence of 53 such patients.     

头颈部肿瘤患者营养指标与放疗急性毒性反应相关分析

目的探讨头颈部肿瘤患者各营养指标与放疗急性毒性不同反应之间的关系。方法前瞻性调查130名头颈部肿瘤患者在放疗第4周时的营养状况和急性放射毒性反应。采用典型相关分析法分析各营养指标与急性放射毒性不同反应之间的关系。结果患者营养状况的各项指标(血清前白蛋白、转铁蛋白、淋巴细胞、淋巴细胞百分比)与放疗急性毒性反应的各项指标(口干、咽/咽喉炎、疲劳、放射性皮炎)之间存在负相关关系,第一典型相关系数为0.653,有统计学意义。结论当血清前白蛋白、转铁蛋白、淋巴细胞、淋巴细胞百分比的检测值偏低时,及时给予营养支持,提高机体免疫力可以减轻口干、咽/咽喉炎等放射毒性反应发生的程度和数量。     

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

BACKGROUND: Malnourished head and neck cancer patients are at increased risk of postoperative complications. OBJECTIVE: We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery. DESIGN: Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding. RESULTS: Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died. CONCLUSIONS: Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.     

Outcomes of older and younger malnourished and well-nourished patients one year after hospitalization

The purpose of this study was to determine the relationship between malnutrition and later health status in old and young patients after hospitalization. Men were evaluated by nine criteria of malnutrition and classified as older (age 65 and older) and younger (younger than 65). About 32% of the younger and 45% of the older men were malnourished. At base-line, malnourished patients had more diagnoses (p less than 0.01) and depressed lymphocyte response to phytohemagglutinin (p less than 0.05). Older malnourished patients also had more depressed chemotaxis results (p less than 0.05). One year later, the malnourished patients still had more markers of malnutrition (p less than 0.001), more diagnostic problems (particularly infections) during the follow-up (p less than 0.01), and depressed lymphocyte response to phytohemagglutinin (p less than 0.05) and increased IgA levels (p less than 0.01). The only deaths (n = 4) occurred among the malnourished older men. Alcoholism in the malnourished young men may have contributed to their continued or recurrent status of protein energy malnutrition. The malnourished old patients could have had less recuperative powers and continued poorer diets. The study suggests malnourished hospitalized patients are at high risk for long-term health problems probably through continued or reoccurring episodes of malnutrition.     

头颈部肿瘤患者放射治疗期间营养状况综合评价

目的构建营养评价综合模型,评价头颈部肿瘤患者放疗期间营养状况。方法用SPSS 17.0软件,根据患者营养状况建立综合评价模型。经因子分析确定了4个公因子F1、F2、F3、F4。结果建立的综合评价模型为：F=0.485F1＋0.236F2＋0.164F3＋0.115F4。将患者综合评分按四分位数分为4类：正常、轻度、中度、重度营养不良。结论利用因子分析得到的营养综合评价模型,能更全面反映患者营养状况,有利于早期发现营养不良,及时给予营养干预。     

Perioperative enteral nutrition and quality of life of severely malnourished head and neck cancer patients: a randomized clinical trial

BACKGROUND AND AIMS: This study evaluated the use of perioperative nutritional support on Quality of Life (QOL) in malnourished head and neck cancer patients undergoing surgery. METHODS: 49 Malnourished (weight loss >10%) head and neck cancer patients who were included in a nutrition intervention trial were randomized to receive either no preoperative and standard postoperative tube-feeding (group I), standard preoperative and postoperative tube-feeding (group II) or arginine-supplemented preoperative and postoperative tube-feeding (group III). Of these patients, 31 completed a full QOL assessment on the first day of preoperative nutritional support, one day before surgery, and 6 months after surgery. Both a disease-specific (EORTC QLQ-C30) and a generic questionnaire (COOP-WONCA) were used. One way analysis of variance (ANOVA) and the Kruskal-Wallis test were applied for testing differences in scores between groups. RESULTS: Between baseline and the day before surgery, both preoperatively fed groups revealed a positive change for the dimensions physical and emotional functioning and dyspnea (with significance in group II, P=0.050,0.031,0.045 respectively). Group III showed a negative change in appetite (P=0.049). Between baseline and 6 months after surgery, there were no differences between group I and both pre-fed groups. There were no differences in favour of group III compared to group II. CONCLUSION: Enteral nutrition improves QOL of severely malnourished head and neck cancer patients in the period preceding surgery. No benefit of preoperative enteral feeding on QOL could be demonstrated 6 months after surgery.     

Associations between dietary patterns and head and neck cancer: the Carolina head and neck cancer epidemiology study

Few studies have examined the associations between dietary patterns and head and neck squamous cell carcinoma (SCC) or whether they differ by race. This was evaluated using data from a population-based case-control study (2002-2006) including 1,176 cases of head and neck SCC and 1,317 age-, race-, and gender-matched controls from central and eastern North Carolina whose diets had been assessed by food frequency questionnaire. Factor analysis identified 2 patterns of intake: 1) high consumption of fruits, vegetables, and lean protein and 2) high consumption of fried foods, high-fat and processed meats, and sweets. Associations were estimated using logistic regression, adjusting for matching factors and confounders. Heterogeneity by tumor site (oral/pharyngeal vs. laryngeal) and effect-measure modification were also evaluated. Reduced odds of head and neck SCC were found for the fruit, vegetable, and lean protein pattern (for highest quartile vs. lowest, odds ratio = 0.53, 95% confidence interval: 0.39, 0.71). The fried foods, high-fat and processed meats, and sweets pattern was positively associated only with laryngeal cancer (odds ratio = 2.12, 95% confidence interval: 1.21, 3.72). These findings underline the importance of a dietary pattern rich in fruits and vegetables and low in high-fat and processed meats and sweets for prevention of head and neck cancer.     

Zinc deficiency in head and neck cancer patients.

Although a great deal of attention has been given to protein and calorie malnutrition in patients with head and neck cancer, zinc status has not been assessed properly in such patients in the past.

In this study we characterized zinc status by cellular zinc criteria and assessed several measures of protein and calorie malnutrition in patients with head and neck cancer. We determined prognostic nutritional index (PNI) based on serum albumin, serum transferrin, triceps skin fold measures, and delayed hypersensitivity, as proposed by Buzby et al. In this study, the baseline zinc status and PNI of 60 head and neck cancer patients were correlated with the tumor size and overall stage of the disease.

Our results showed that the tumor size and overall stage correlated significantly to zinc status whereas no correlation was seen with PNI, alcohol intake, or smoking in our study subjects.

We conclude that zinc status is a better indicator of tumor burden and stage of the disease in head and neck cancer patients than the patients' overall nutritional status.     

Postsurgery enteral nutrition in head and neck cancer patients

OBJECTIVE: Patients with head and neck cancer undergoing surgery have a high incidence of postoperative complications. The aim of our study was to investigate whether postoperative nutrition of head and neck cancer patients, using an arginine-enriched diet, could improve nutritional variables as well as clinical outcomes. DESIGN: Randomized clinical trial. SETTING: Tertiary care. SUBJECTS: A population of 47 patients with oral and laryngeal cancer were enrolled. INTERVENTIONS: At surgery patients were randomly allocated to two groups: (a) patients receiving an enteral diet supplemented with arginine and fiber (group I); (b) patients receiving an isocaloric, isonitrogenous enteral formula (group II). RESULTS: No significant intergroup differences in the trend of the three plasma proteins and lymphocytes were detected. Gastrointestinal tolerance (diarrhea) of both formulas was good (17.4% group I and 8.3% group II; NS). During the 3 months after hospital discharge five patients died; no differences were detected between groups (13% group I and 8.3% group II; NS). The incidences postoperative infection complications were similar (nine patients) in both groups (21.7% group I and 16.7% group II; NS). Fistula were less frequent in enriched nutrition group (0% group I and 20.8% group II; P<0.05); wound infection was more frequent in group II, but without statistical difference (4.3% group I and 12.5% group II; NS). The length of postoperative stay was 22.8+/-11.8 days in the enriched group and 31.2+/-19.1 days in the control group (P=0.07). CONCLUSIONS: In conclusion, enriched formula improves local wound complications in postoperative head and neck cancer patients. Our results suggest that these patients could benefit from an immunonutrient-enhanced enteral formula.     

Postoperative enteral immunonutrition in head and neck cancer patients

AIMS: to determine if postoperative feeding of head and neck cancer patients, using an enteral diet supplemented with arginine, improves immunological and nutritional status, and clinical outcome, i.e., reduces postoperative infectious/wound complications and length of stay, when compared with an isocaloric, isonitrogenous control diet. METHODS: at operation 44 patients were randomized into two groups to receive: a) an enriched diet (n=23);b) an isocaloric, isonitrogenous control diet (n=21). Thirteen patients with a history of significant weight loss (> or = 10% over the last 6 months) were considered malnourished. Preoperatively and on postoperative days 1, 4 and 8 the following parameters were evaluated: albumin, prealbumin, transferrin, total number of lymphocytes, lymphocyte subsets (CD3, CD4, CD8 and CD4/CD8 ratio) and immunoglobulins. Postoperative complications and length of stay were recorded. RESULTS: 'visceral' serum proteins and immunological parameters decreased on postoperative day 1 in both groups. However, only the enriched group demonstrated a significant increase (P<0.05) in the total number of lymphocytes, CD4, CD4/CD8 on postoperative day 4, and total number of lymphocytes, CD3, CD4, CD4/CD8 on postoperative day 8. In the malnourished subgroup the administration of the enriched formula significantly reduced both postoperative infectious/wound complications and length of stay compared with the control group (P<0.05). CONCLUSIONS: enteral immunonutrition of head and neck cancer patients improves postoperative immunological response. Significant clinical advantages were observed in malnourished patients.     

Protein and carbohydrate absorptive efficiency of chronically malnourished and well-nourished patients during enteral feeding initiation

To investigate the efficiency of protein and carbohydrate absorption, we studied malnourished and well-nourished subjects during the first 72 hours of tube feeding. We furthermore investigated whether differences in absorptive efficiency existed between malnourished patients with and without nongastrointestinal malignancy. Twenty-one subjects starting tube feeding without edema or major organ failure and not on antibiotics (well-nourished controls = 7; malnourished = 7; malnourished with nongastrointestinal malignancy = 7) received 50 kcal/hr Osmolite continuously for 72 hours. Twelve of these subjects completed an additional 48 hours of study where they received 125 kcal/hr continuously. We performed hydrogen breath tests to assess carbohydrate absorption and determined stool nitrogen content to assess protein absorption. We also measured frequency of defecation, stool weight, and stool moisture content. The results of these tests failed to reveal statistically significant differences between the three groups in terms of protein and carbohydrate absorption, as well as failed to demonstrate the presence of diarrhea. We conclude that patients receiving an isoosmolar diet who are malnourished, or malnourished with nongastrointestinal malignancy, absorb carbohydrate and protein as well as well-nourished patients during enteral hyperalimentation.     

Protein and carbohydrate absorptive efficiency of chronically malnourished and well-nourished patients during enteral feeding initiation.

To investigate the efficiency of protein and carbohydrate absorption, we studied malnourished and well-nourished subjects during the first 72 hours of tube feeding. We furthermore investigated whether differences in absorptive efficiency existed between malnourished patients with and without nongastrointestinal malignancy. Twenty-one subjects starting tube feeding without edema or major organ failure and not on antibiotics (well-nourished controls = 7; malnourished = 7; malnourished with nongastrointestinal malignancy = 7) received 50 kcal/hr Osmolite continuously for 72 hours. Twelve of these subjects completed an additional 48 hours of study where they received 125 kcal/hr continuously. We performed hydrogen breath tests to assess carbohydrate absorption and determined stool nitrogen content to assess protein absorption. We also measured frequency of defecation, stool weight, and stool moisture content. The results of these tests failed to reveal statistically significant differences between the three groups in terms of protein and carbohydrate absorption, as well as failed to demonstrate the presence of diarrhea. We conclude that patients receiving an isoosmolar diet who are malnourished, or malnourished with nongastrointestinal malignancy, absorb carbohydrate and protein as well as well-nourished patients during enteral hyperalimentation.     

Selenium status of malnourished hospitalized patients

We evaluated selenium (Se) status of 44 hospitalized patients with protein-energy malnutrition. The patients were assigned to "normal" or "low" Se groups-1 and 2, respectively-based on whether the plasma Se level exceeded or was below the value of the mean-2SD of healthy Georgians'. Plasma and erythrocyte Se levels correlated significantly (r = .52, P less than .01). Erythrocyte glutathione peroxidase activity was highly correlated with plasma Se (r = .68) in group 2; there was no significant correlation between these parameters in group 1. In group 2 the mean plasma prealbumin level was significantly lower, and the mean corpuscular volume and serum glutamic oxaloacetic transaminase level were significantly higher compared to group 1. Other nutritional parameters did not correlate with Se status. Concomitant deficiencies of other nutrients were common in both patient groups. Se levels may relate to protein status, and abnormal hematologic and hepatic parameters may reflect low Se status and/or protein-energy malnutrition. Low Se status is common in malnourished patients from a low Se area, and Se supplementation should be included in their nutritional-repletion regimens.     

Gastrostomy tube placement in head and neck cancer patients undergoing radiotherapy

Background: In head and neck cancer (HNC) patients, the side effects of radiotherapy (RT) often lead to patients being unable to consume adequate nutrition and fluid (Chencharick and Mossman, 1983). Gastrostomy tube placement prior to RT can reduce incidence of severe weight loss and hospitalization during treatment (Beaver et al., 2001). However, gastrostomy tube usage is dependant upon HNC site and area of RT. The aims of the study were to identify the characteristics of those HNC patients who will require gastrostomy tube feeding during RT and utilize these data to target future patients for prophylactic tube placement prior to commencing RT and to write guidelines for the placement of feeding tubes. Method: Data were collected retrospectively regarding diagnosis, surgery and area of RT on all HNC patients who had had a prophylactic gastrostomy placed prior to RT between April 2000 and April 2002. Outcome measurements in terms of utilization of gastrostomy, body weight and nutrition related emergency admissions were recorded. Results: Thirty‐five patients had a prophylactic gastrostomy placed [26 male, nine female; mean age 62 (range 26–84) years]. Of these, 26 utilized their tube for feeding or fluids during RT. The sites of radiotherapy were: bilateral RT to the oro‐ or nasopharynx and neck (20 patients), bilateral RT to the neck (five) and RT to the left oropharynx and neck (one). The mean weight loss during RT in patients who utilized their prophylactic gastrostomy was 3.3 (range 0–11.5%) compared to 8 (5.5–12.0%) in patients who did not have a prophylactic gastrostomy. Only one of the patients with a prophylactic gastrostomy had a hospital admission (length of stay 11 days) compared to four patients who did not [mean length of stay 21 days (range 14–29)]. Six of the nine patients who did not utilize their gastrostomy for feeding and were able to maintain their nutrition orally, received bilateral RT to the neck only. Discussion: Most of the patients who received bilateral RT to the oro‐ or nasopharynx required gastrostomy feeding during RT, which is consistent with findings of Beaver et al. (2001) who reported the highest incidence of weight loss in patients receiving RT to the nasopharynx or base of the tongue. Conclusion: In view of the association between the site of RT and gastrostomy utilization, hospital admissions, length of stay and weight loss, HNC patients with planned bilateral RT to the oro‐ or nasopharynx or with existing dysphagia should be targeted for gastrostomy tube placement prior to starting treatment. References: Beaver, M.E., Matheny, K.E., Roberts, D.B. & Myers, J.N.(2001) Predictors of weight loss during radiation therapy. Otolaryngol. Head Neck Surg. 125 , 645–648. Chencharick, J.D. & Mossman, K.L. (1983) Nutritionalconsequences of the radiotherapy of head and neck cancer. Cancer 51 , 811–815.     

Enteral nutrition support of head and neck cancer patients.

Patients with head and neck cancer are at high risk for malnutrition due to dysphagia from the tumor and treatment. Despite difficulty with oral intake, these patients usually have a normal stomach and lower gastrointestinal tract. Enteral nutrition support via percutaneous endoscopic gastrostomy (PEG) administered in the home by the patient helps to prevent weight loss, dehydration, nutrient deficiencies, treatment interruptions, and hospitalizations. It also improves quality of life. Successful management of these patients requires orderly care and follow-up by a multidisciplinary nutrition team.     

Selenium status of malnourished hospitalized patients.

We evaluated selenium (Se) status of 44 hospitalized patients with protein-energy malnutrition. The patients were assigned to “normal” or “low” Se groups-1 and 2, respectively-based on whether the plasma Se level exceeded or was below the value of the mean-2SD of healthy Georgians'. Plasma and erythrocyte Se levels correlated significantly (r = .52, P less than .01). Erythrocyte glutathione peroxidase activity was highly correlated with plasma Se (r = .68) in group 2; there was no significant correlation between these parameters in group 1. In group 2 the mean plasma prealbumin level was significantly lower, and the mean corpuscular volume and serum glutamic oxaloacetic transaminase level were significantly higher compared to group 1. Other nutritional parameters did not correlate with Se status. Concomitant deficiencies of other nutrients were common in both patient groups. Se levels may relate to protein status, and abnormal hematologic and hepatic parameters may reflect low Se status and/or protein-energy malnutrition. Low Se status is common in malnourished patients from a low Se area, and Se supplementation should be included in their nutritional-repletion regimens.