Total parenteral nutrition and chemotherapy in cancer patients

A common problem in cancer patients is a significant degree of malnutrition which disturbs and the accomplishment of surgery, chemotherapy and radiotherapy. Most patients with advanced cancer who should be treated with intensive chemotherapy are unable to ingest, digest or absorb sufficiently quantities of food and many antineoplastic agents affect the function of the alimentary tract. Therefore, total parenteral nutrition is a suitable method of nutritional support in these patients. The intravenous administration of nutrients can improve and maintain not only the nutritional status, but also the cell-mediated immunity of patients, and an effective or large doses of agents can be given as a result of increased tolerance. These effects are expected to enhance the potential of tumor response to chemotherapy. At the present time, only a few trials such as pulse TPN and amino acid imbalance therapy have been tried, but a specific nutritional regimen based on the altered metabolism in tumor and host should be developed in future.     

头颈部肿瘤放疗者营养与支持治疗专家共识

放疗是头颈部肿瘤最常用的治疗手段。恶性肿瘤本身代谢异常及治疗过程中伴随的急性和晚期毒性等极易导致患者发生营养不良,其发生率高达44%~88%,其中重度营养不良的发生率为20%~40%。患者一旦发生营养不良,其治疗耐受性和敏感性会降低,治疗并发症会进一步增高,从而延长住院时间增加治疗费用,最终影响患者疗效。因此,营养与支持治疗是头颈肿瘤患者治疗的重要组成部分。为了使这部分患者得到合理、有效的营养与支持治疗,根据我国目前的肿瘤放疗和肿瘤营养治疗现状,参考国内外相关指南,制定适合我国情况的头颈部肿瘤放疗患者营养与支持治疗专家共识非常必要。     

肠内外营养支持对老年结直肠癌患者腹腔镜术后疗效的影响

目的观察肠内营养(EN)和肠外营养(PN)对老年结直肠癌患者术后疗效的影响。方法选取134例老年结直肠癌术后患者,采用随机数字表法分为EN-PN组(n=79)和PN组(n=55),EN-PN组患者采用EN和PN联合应用,PN组患者采用单纯PN。观察两组患者的耐受情况、术后不良反应及并发症、胃肠功能恢复时间和住院时间,并比较两组患者手术前后血清总蛋白(TP)、白蛋白(ALB)、前清蛋白(PA)、转铁蛋白(TF)、总淋巴细胞数(TLC)和小野寺预后营养指数(OPNI)。结果 EN-PN组患者耐受性较好,与PN组相比,不良反应及并发症无显著增加,差异无统计学意义(P>0.05),胃肠功能恢复时间和住院时间较PN组显著减少,差异有统计学意义(P<0.05);EN-PN组患者术后第8天血清TP、ALB、PA、TF、TLC和OPNI较PN组均显著升高,差异有统计学意义(P<0.05)。PN组患者的TF、TLC和OPNI显著升高,差异有统计学意义(P<0.05)。结论对于老年结直肠癌患者,EN-PN联合应用能有效改善患者的术后营养和免疫状态,有利于患者术后恢复,且安全性较高。     

肠内营养联合肠外营养治疗老年胃癌患者的临床研究

目的探讨肠内营养结合肠外营养治疗老年胃癌患者的临床效果。方法选取2014年6月至2016年5月间上海市普陀区人民医院收治的80例胃癌手术患者,采用抽签法分为治疗组与对照组,每组40例。对照组患者采用全肠外营养治疗,治疗组患者在肠内营养基础上结合肠外营养治疗。比较两组患者手术前后的营养指标、术后并发症发生率及术后恢复情况。结果治疗组患者术后并发症发生率为7.5%,低于对照组的25.0%,两组比较,差异有统计学意义(P<0.05)。治疗组患者血红蛋白(HGB)、总蛋白(TP)和白蛋白(ALB)数值均优于对照组,差异均有统计学意义(均P<0.05);两组患者白细胞(WBC)和前白蛋白(PA)比较,差异无统计学意义(P>0.05)。治疗组患者通气时间为(3.12±1.05)d,显著短于对照组的(4.45±1.26)d,差异有统计学意义(P<0.05);两组患者住院时间、进流质时间和住院费用比较,差异均无统计学意义(均P>0.05)。结论肠内营养结合肠外营养治疗老年胃癌手术患者,临床疗效显著,可有效改善营养代谢,安全性高,值得临床推广应用。     

早期肠内营养和肠外营养支持对早期胃癌切除术后患者的影响

目的探讨早期肠内营养和肠外营养支持对早期胃癌切除术后患者的影响。方法选取早期胃癌切除术后患者120例,按照随机数字表法将患者随机分为治疗组和对照组,每组各60例。治疗组患者给予肠内营养支持,对照组患者给予肠外营养支持,干预周期为7 d。结果与治疗组患者比较,营养支持后对照组患者血清总胆红素、丙氨酸氨基转移酶和门冬氨酸氨基转移酶值明显升高,差异有统计学意义(P<0.05)。营养支持后,两组患者血清前白蛋白、血清血蛋白、CD+3和CD+4值明显升高,差异均有统计学意义(均P<0.05)。随访3个月,治疗组患者的切口感染、心胸腔积液、肺部感染、吻合口漏等并发症的总发生率明显小于对照组患者,差异有统计学意义(P<0.05)。结论肠内营养支持能促进早期胃癌切除术后患者免疫功能和机体营养状况的恢复,对患者的肝功能损害小,安全性更好,值得临床推广应用。     

贲门腺癌化疗加静脉营养支持的细胞动力学研究

目的应用细胞动力学方法,探讨短期静脉营养支持对晚期贲门腺癌化疗效果的影响.方法1997年1月～1999年10月,选择无法根治切除的晚期贲门腺癌患者38例中男22例、女16例,中位年龄54岁.Ⅲ期25例,Ⅳ期6例.将患者随机分为①营养组(12例)、②化疗组(12例)和③营养+化疗组(14例).营养配方氮0.15*kg-1*d-1,非蛋白质热量20Kcal*kg-1*d-1,肠外营养支持平均7天.联合化疗方案为5-氟尿嘧啶、四氢叶酸钙、丝裂霉素和表阿霉素,28天为一周期,完成至少2个周期.在治疗前后均进行胃镜检查,对肿瘤及正常胃粘膜的不同部位进行采样,经流式细胞仪测定,对照分析三组的癌细胞和正常细胞DNA含量、倍体类型及细胞周期各时相比例,比较组间的化疗有效率.结果治疗后肿瘤细胞S期和S+G2+M期的百分数在营养组明显增高(P分别＜0.01和＜0.05),营养+化疗组显著下降(P均＜0.001),化疗组无变化(P＞0.05),各组正常胃粘膜在治疗前后无变化(P＞0.05).营养+化疗组的化疗有效率明显高于化疗组(P＜0.05).结论短期静脉营养支持能提高患者的生活质量,刺激贲门腺癌细胞增殖的同时能增强贲门腺癌的化疗效果.     

Nutritional support for cancer bearing patients]

A care system for cancer bearing patients at a highly advanced stage should be informed by a better quality of life based on a life style of the patients and their families. These patients are suffering from various types of trouble including pain, loss of appetite and nausea, which preclude oral intake. Radiotherapy or chemotherapy can be another factor aggravating their nutritional state. In terms of nutritional management, intravenous or enteral alimentation is indispensable, but these conventional alimentary supports generally lead to prolonged hospitalization and re-admission. If parenteral nutritional care can be given to patients at home and not in the hospital, it is leading to the improved quality of life would result. We focus on the issue of home alimentary care, especially intravenous alimentation, for cancer patients at the terminal stage from the nursing standpoint.     

Enteral and parenteral nutrition in anorectic patients with advanced gastrointestinal cancer

Seventeen patients with advanced, noncurable gastrointestinal cancer with symptoms of anorexia and malnutrition were treated with controlled enteral or total parenteral nutrition over a 3-week period. Eleven patients received enteral and six parenteral nutrition. The nutrition was given with 30-40 kcal/kg b.w. daily. No anticancer treatment was given. Before and after the treatment period, the patients were assessed regarding their nutritional, immunological, and performance status. None of the studied nutritional parameters changed significantly over the 3-week period and there was no clear indication of an improved lymphocyte reactivity. There was a tendency toward improvement in performance status for the patients on enteral nutrition, while the reverse seemed to be true for the parenteral group. It is concluded that nutritional support may halt the progressive malnutrition often seen in patients with cancer and serve as a palliative treatment in selected patients.     

Total parenteral nutrition for home therapy in cancer patients]

Home parenteral nutrition (HPN) was used in 14 cancer patients within a 4-yr and 4-month period. Indications included severe malabsorption, short bowel syndrome, radiation enteritis, and malignancies. The mean duration of HPN was 184 days (range: 21-706 days). HPN duration for patients with benign causes (BP) was longer [427 days (range: 176-706 days)] than for cancer-related patients (CP) [49 days (range: 21-121 days)]. The mean catheter life spans to date for BP and CP have been 596 days (range: 187-1173 days) and 127 days (range: 73-278 days), respectively. Serious catheter problems occurred 4 times in BP with the external catheter. Metabolic complications with clinical symptoms occurred in one BP who had short bowel syndrome. We followed with an evaluation of the quality of life of HPN patients. Three in 14 cases returned to work, two of them part time, and two others did most of the housekeeping, but 9 remained at home receiving only outpatient treatment. Some physical distress was recorded in all but one case. We concluded that HPN for cancer patients is a relatively safe, effective means of improving and maintaining the nutritional status, and it can reduce the length of hospitalization. We attempted to evaluate whether these patients were able to achieve a meaningful and satisfactory social and familial life. Our study was not sufficient to assess the psychological and social problems. We should establish criteria for quality of life to evaluate overall satisfaction with conditions of life under HPN.     

Metabolic response to total parenteral nutrition in cancer patients.

In order to evaluate the metabolic response of nutritionally deprived cancer patients to parenteral nutrition, metabolic parameters including glucose turnover, oxidation, and Cori cycle activity were measured in eight patients before and during short-term (5 to 10 days) i.v. nutrition, with solutions containing amino acids and hypertonic glucose. Before parenteral nutrition, five patients had essentially normal glucose turnover, oxidation, and Cori cycle activity, whereas three patients had moderately increased glucose turnover and markedly increased Cori cycle activity. In response to parenteral nutrition, plasma glucose, insulin, and venous lactate concentration increased and free fatty acid decreased. The percentage of respiratory CO2 from glucose oxidation and the rate of oxidation increased. CO2 production increased, whereas O2 consumption was essentially unchanged. Respiratory quotient rose to greater than 1.0. Endogenous glucose production and high basal Cori cycle activity were decreased. Total parenteral nutrition was judged clinically beneficial in five patients, whereas one patient was unchanged. Deleterious responses, including moderate lactic acidemia, occurred in two of three patients with elevated basal Cori cycle activity.     

恶性肿瘤放疗患者营养治疗专家共识

营养不良在恶性肿瘤放疗患者中发生率高,降低治疗疗效,增加治疗副反应,因此应该对放疗患者常规进行营养风险筛查（推荐采用NRS 2002 量表）和营养评估（推荐采用PG-SGA 量表）。恶性肿瘤放疗患者在“围放疗期”需要进行全程营养管理。放疗前需根据PG-SGA 评分,放疗中需根据PG-SGA 评分和RTOG 急性放射损伤分级,放疗后需根据 PG-SGA 评分和RTOG 晚期放射损伤分级,规范化、个体化选择营养治疗方式。营养治疗方式遵循“五阶梯模式”。肠内 营养途径选择遵循“四阶梯模式”。当患者无法通过肠内营养获得足够的营养需要或出现严重放射性黏膜炎、放射性肠炎 或肠功能衰竭时,推荐及时联合部分或全肠外营养。恶性肿瘤放疗患者能量目标量推荐为25~30kcal/(kg·d)。在放疗过程中, 患者能量需求受到肿瘤负荷、应激状态和急性放射损伤的影响而变化,因此需要个体化给予并进行动态调整。恶性肿瘤放 疗患者推荐提高蛋白质摄入量,对于一般患者推荐 1.2~1.5g/(kg·d),对于严重营养不良患者,推荐 1.5~2.0g/(kg·d),对于并 发恶液质的患者可提高到 2.0g/(kg·d)。     

全肠外营养在晚期肿瘤中应用价值探讨

目的探讨晚期肿瘤患者全肠外营养支持的临床价值。方法通过多项指标评价38例晚期肿瘤患者的营养状况和免疫功能,38例患者均存在营养不良和免疫功能低下,将病人分为二组,治疗组22例,行颈内静脉置管给予全肠外营养;对照组16例则行口服饮食和(或)常规外周静脉营养。3周后再测定各项指标并行统计学处理。结果治疗组治疗前和治疗组治疗后与对照组治疗后的营养指标、免疫功能指标均明显改善(均P<0.05),治疗组生存期明显延长(P<0.01)。结论全肠外营养可以改善晚期肿瘤患者的营养状况,提高免疫力,改善生活质量,延长生存期。     

Nutritional support of bone marrow transplant recipients: a prospective, randomized clinical trial comparing total parenteral nutrition to an enteral feeding program

Although standard supportive care for bone marrow transplant (BMT) recipients includes total parenteral nutrition (TPN), it has not been shown that this is the most appropriate method of nutritional support. To determine whether current BMT recipients require TPN during the early recovery period, we conducted a prospective, randomized clinical trial comparing TPN and an individualized enteral feeding program (counseling, high protein snacks and/or tube feeding). Nutritional assessment included measurement of serum proteins, anthropometry, and body composition analysis. For the latter, total body water and extracellular fluid were measured by standard radioisotope dilution techniques and used to quantitate body cell mass and body fat plus extracellular solids (FAT + ECS). In 27 TPN patients, body composition 28 days after BMT, expressed as a percentage of baseline, was body cell mass, 100%, extracellular fluid, 108%, FAT + ECS, 108%, and in 30 enteral feeding program patients, was body cell mass, 93%, extracellular fluid, 104%, and FAT + ECS, 94%. Only the difference in FAT + ECS was statistically significant (p less than 0.01). Compared to the enteral feeding program, TPN was associated with more days of diuretic use, more frequent hyperglycemia, and more frequent catheter removal (prompted by catheter-related complications), but less frequent hypomagnesemia. There were no significant differences in the rate of hematopoietic recovery, length of hospitalization, or survival, but nutrition-related costs were 2.3 times greater in the TPN group. We conclude that TPN is not clearly superior to individualized enteral feeding and recommend that TPN be reserved for BMT patients who demonstrate intolerance to enteral feeding.     

New strategies and designs in pancreatic cancer research: consensus guidelines report from a European expert panel

Although the treatment of pancreatic ductal adenocarcinoma (PDAC) remains a huge challenge, it is entering a new era with the development of new strategies and trial designs. Because there is an increasing number of novel therapeutic agents and potential combinations available to test in patients with PDAC, the identification of robust prognostic and predictive markers and of new targets and relevant pathways is a top priority as well as the design of adequate trials incorporating molecular-driven hypothesis. We presently report a consensus strategy for research in pancreatic cancer that was developed by a multidisciplinary panel of experts from different European institutions and collaborative groups involved in pancreatic cancer. The expert panel embraces the concept of exploratory early proof of concept studies, based on the prediction of response to novel agents and combinations, and randomised phase II studies permitting the selection of the best therapeutic approach to go forward into phase III, where the recommended primary end point remains overall survival. Trials should contain as many translational components as possible, relying on standardised tissue and blood processing and robust biobanking, and including dynamic imaging. Attention should not only be paid to the pancreatic cancer cells but also to microenvironmental factors and stem/stellate cells.     

Nutritional support and prognosis in patients with head and neck cancer

We retrospectively studied the relationship between nutritional status as indicated by the presence or absence of the cutaneous delayed hypersensitivity response and treatment-related morbidity, disease recurrence, and survival at 2 years in 67 consecutive patients with head and neck carcinoma. Serial nutritional assessments were conducted throughout the course of combined initial antineoplastic treatment and nutritional support. The presence of cell-mediated immunity at the end of treatment was associated with a 2-year survival rate of 100%, whereas patients who were anergic at the end of treatment had a 2-year survival rate of 48% (P < 0.01). Morbidity due to surgical therapy and tumor recurrence rates were also higher in the anergic group (P < 0.01). Prognosis in head and neck cancer is based on many factors, but vigorous nutritional support during initial treatment may have some effect on morbidity, tumor recurrence, and survival time. © Wiley-Liss, Inc.     

Nutritional support in cancer treatment

The role of artificial nutritional support, ie, both intravenous and enteral nutrition by infusion of chemically defined nutrients, is considered adjunct to cancer treatment. Despite a vast body of literature reflecting numerous attempts to demonstrate a supportive role for nutrition, little benefit has actually been confirmed in controlled investigations regarding outcome and objective remission in progressive cachexia. However, the impact of nutritional support on quality of life has only been considered in a few preliminary attempts in cancer patients. We suggest that the lack of evidence in cancer treatment for a significant role of nutritional support in a general sense is probably explained both by inappropriately designed investigations and by the unrecognized fact that standard clinical nutrition is hampered by nutrition-related inefficiencies that have not been well described before. Improved understanding of such deficiencies and the development of more sophisticated regimens in line with "nutrition pharmacology" instead of plain feeding with calories and protein may change this fallacy in the near future.     

Total parenteral nutrition and cancer clinical trials

Twenty-eight prospective randomized controlled clinical trials evaluating the use of total parenteral nutrition (TPN) in cancer patients were identified through a search of major indexing sources. The data were pooled across studies to increase the ability to detect therapeutic effects. The impact of publication bias and the quality of reporting each trial were used to critically assess the conclusions drawn from the pooled analysis. The authors conclude that TPN may be useful when used preoperatively in patients with gastrointestinal tract cancer. It appears to be beneficial in reducing major surgical complications (pooled P = 0.01) and operative mortality (pooled P = 0.02). No statistically significant benefit from TPN could be demonstrated in survival, treatment tolerance, treatment toxicity, or tumor response in patients receiving chemotherapy or radiotherapy. An increase in the risk of developing an infection in chemotherapy patients given TPN (pooled P less than 0.0001) underscores the importance of demonstrating significant benefits in randomized trials before TPN is used routinely in these patients.