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Roeland EJ, Bohlke K, Baracos VE, Bruera E, del Fabbro E, Dixon S, Fallon M, Herrstedt J, Lau H, Platek M, Rugo HS, Schnipper HH, Smith TJ, Tan W, Loprinzi CL. Management of Cancer Cachexia: ASCO Guideline. J Clin Oncol 2020; 38:2438-2453. [DOI: 10.1200/jco.20.00611] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To provide evidence-based guidance on the clinical management of cancer cachexia in adult patients with advanced cancer. METHODS A systematic review of the literature collected evidence regarding nutritional, pharmacologic, and other interventions, such as exercise, for cancer cachexia. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and systematic reviews of RCTs published from 1966 through October 17, 2019. ASCO convened an Expert Panel to review the evidence and formulate recommendations. RESULTS The review included 20 systematic reviews and 13 additional RCTs. Dietary counseling, with or without oral nutritional supplements, was reported to increase body weight in some trials, but evidence remains limited. Pharmacologic interventions associated with improvements in appetite and/or body weight include progesterone analogs and corticosteroids. The other evaluated interventions either had no benefit or insufficient evidence of benefit to draw conclusions on efficacy. Limitations of the evidence include high drop-out rates, consistent with advanced cancer, as well as variability across studies in outcomes of interest and methods for outcome assessment. RECOMMENDATIONS Dietary counseling may be offered with the goals of providing patients and caregivers with advice for the management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely. In the absence of more robust evidence, no specific pharmacological intervention can be recommended as the standard of care; therefore, clinicians may choose not to prescribe medications specifically for the treatment of cancer cachexia. Nonetheless, when it is decided to trial a drug to improve appetite and/or improve weight gain, currently available pharmacologic interventions that may be used include progesterone analogs and short-term (weeks) corticosteroids.
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | | | - Marie Fallon
- Edinburgh Oncology Centre, University of Edinburgh, UK
| | - Jørn Herrstedt
- Zealand University Hospital Roskilde and University of Copenhagen, Denmark
| | - Harold Lau
- University of Calgary, Calgary, Alberta, Canada
| | - Mary Platek
- Roswell Park Comprehensive Cancer Center and D’Youville College, Buffalo, NY
| | - Hope S. Rugo
- University of California San Francisco, San Francisco, CA
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102
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Roeland EJ, Bohlke K, Baracos VE, Bruera E, del Fabbro E, Dixon S, Fallon M, Herrstedt J, Lau H, Platek M, Rugo HS, Schnipper HH, Smith TJ, Tan W, Loprinzi CL. Management of Cancer Cachexia: ASCO Guideline. J Clin Oncol 2020. [DOI: 10.1200/jco.20.00611 10.1200/jco.20.00611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To provide evidence-based guidance on the clinical management of cancer cachexia in adult patients with advanced cancer. METHODS A systematic review of the literature collected evidence regarding nutritional, pharmacologic, and other interventions, such as exercise, for cancer cachexia. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and systematic reviews of RCTs published from 1966 through October 17, 2019. ASCO convened an Expert Panel to review the evidence and formulate recommendations. RESULTS The review included 20 systematic reviews and 13 additional RCTs. Dietary counseling, with or without oral nutritional supplements, was reported to increase body weight in some trials, but evidence remains limited. Pharmacologic interventions associated with improvements in appetite and/or body weight include progesterone analogs and corticosteroids. The other evaluated interventions either had no benefit or insufficient evidence of benefit to draw conclusions on efficacy. Limitations of the evidence include high drop-out rates, consistent with advanced cancer, as well as variability across studies in outcomes of interest and methods for outcome assessment. RECOMMENDATIONS Dietary counseling may be offered with the goals of providing patients and caregivers with advice for the management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely. In the absence of more robust evidence, no specific pharmacological intervention can be recommended as the standard of care; therefore, clinicians may choose not to prescribe medications specifically for the treatment of cancer cachexia. Nonetheless, when it is decided to trial a drug to improve appetite and/or improve weight gain, currently available pharmacologic interventions that may be used include progesterone analogs and short-term (weeks) corticosteroids.
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | | | - Marie Fallon
- Edinburgh Oncology Centre, University of Edinburgh, UK
| | - Jørn Herrstedt
- Zealand University Hospital Roskilde and University of Copenhagen, Denmark
| | - Harold Lau
- University of Calgary, Calgary, Alberta, Canada
| | - Mary Platek
- Roswell Park Comprehensive Cancer Center and D’Youville College, Buffalo, NY
| | - Hope S. Rugo
- University of California San Francisco, San Francisco, CA
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van der Kroft G, van Dijk DPJ, Rensen SS, Van Tiel FH, de Greef B, West M, Ostridge K, Dejong CHC, Neumann UP, Olde Damink SWM. Low thoracic muscle radiation attenuation is associated with postoperative pneumonia following partial hepatectomy for colorectal metastasis. HPB (Oxford) 2020; 22:1011-1019. [PMID: 31735648 DOI: 10.1016/j.hpb.2019.10.1532] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/11/2019] [Accepted: 10/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low skeletal muscle radiation attenuation (SM-RA) is indicative of myosteatosis and diminished muscle function. It is predictive of poor outcome following oncological surgery in several cancer types. Postoperative pneumonia is a known risk factor for increased postoperative mortality. We hypothesized that low SM-RA of the respiratory muscles at the 4th thoracic-vertebra (T4) is associated with postoperative pneumonia following liver surgery. METHODS Postoperative pneumonia was identified using prospective infection control data. Computed tomography body composition analysis was performed at the L3-and T4 level to determine SM-RA. Body composition variables were corrected for confounders and related to postoperative pneumonia and admission time by multivariable logistic regression. RESULTS Body composition analysis of 180 patients was performed. Twenty-one patients developed postoperative pneumonia (11.6%). Multivariable analysis showed that low T4 SM-RA as well as low L3 SM-RA were significantly associated with postoperative pneumonia (OR 3.65, 95% CI 1.41-9.49, p < 0.01) and (OR 3.22, 95% CI 1.20-8.61, p = 0.02, respectively). CONCLUSION Low SM-RA at either the L3-or T4-level is associated with a higher risk of postoperative pneumonia following CLRM resection.
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Affiliation(s)
- Gregory van der Kroft
- Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, Uniklinikum RWTH-Aachen, European Surgical Center Aachen Maastricht (ESCAM), Aachen, Germany.
| | - David P J van Dijk
- Department of Surgery, Maastricht University Medical Center, Department of Surgery, European Surgical Center Aachen Maastricht (ESCAM), Maastricht, the Netherlands
| | - Sander S Rensen
- Department of Surgery, Maastricht University Medical Center, Department of Surgery, European Surgical Center Aachen Maastricht (ESCAM), Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Frank H Van Tiel
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Bianca de Greef
- Department of Clinical Epidemiology & Medical Technology Assessment, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Malcolm West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Kris Ostridge
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Cornelis H C Dejong
- Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, Uniklinikum RWTH-Aachen, European Surgical Center Aachen Maastricht (ESCAM), Aachen, Germany; Department of Surgery, Maastricht University Medical Center, Department of Surgery, European Surgical Center Aachen Maastricht (ESCAM), Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Ulf P Neumann
- Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, Uniklinikum RWTH-Aachen, European Surgical Center Aachen Maastricht (ESCAM), Aachen, Germany; Department of Surgery, Maastricht University Medical Center, Department of Surgery, European Surgical Center Aachen Maastricht (ESCAM), Maastricht, the Netherlands
| | - Steven W M Olde Damink
- Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, Uniklinikum RWTH-Aachen, European Surgical Center Aachen Maastricht (ESCAM), Aachen, Germany; Department of Surgery, Maastricht University Medical Center, Department of Surgery, European Surgical Center Aachen Maastricht (ESCAM), Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
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104
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Burfeind KG, Zhu X, Norgard MA, Levasseur PR, Huisman C, Michaelis KA, Olson B, Marks DL. Microglia in the hypothalamus respond to tumor-derived factors and are protective against cachexia during pancreatic cancer. Glia 2020; 68:1479-1494. [PMID: 32039522 PMCID: PMC7205589 DOI: 10.1002/glia.23796] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 12/14/2022]
Abstract
Microglia in the mediobasal hypothalamus (MBH) respond to inflammatory stimuli and metabolic perturbations to mediate body composition. This concept is well studied in the context of high fat diet induced obesity (HFDO), yet has not been investigated in the context of cachexia, a devastating metabolic syndrome characterized by anorexia, fatigue, and muscle catabolism. We show that microglia accumulate specifically in the MBH early in pancreatic ductal adenocarcinoma (PDAC)-associated cachexia and assume an activated morphology. Furthermore, we observe astrogliosis in the MBH and hippocampus concurrent with cachexia initiation. We next show that circulating immune cells resembling macrophages infiltrate the MBH. PDAC-derived factors induced microglia to express a transcriptional profile in vitro that was distinct from that induced by lipopolysaccharide (LPS). Microglia depletion through CSF1-R antagonism resulted in accelerated cachexia onset and increased anorexia, fatigue, and muscle catabolism during PDAC. This corresponded with increased hypothalamic-pituitary-adrenal (HPA) axis activation. CSF1-R antagonism had little effect on inflammatory response in the circulation, liver, or tumor. These findings demonstrate that microglia are protective against PDAC cachexia and provide mechanistic insight into this function.
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Affiliation(s)
- Kevin G. Burfeind
- Papé Family Pediatric Research InstituteOregon Health & Science UniversityPortlandOregon
- Medical Scientist Training Program, Oregon Health & Science UniversityPortlandOregon
| | - Xinxia Zhu
- Papé Family Pediatric Research InstituteOregon Health & Science UniversityPortlandOregon
| | - Mason A. Norgard
- Papé Family Pediatric Research InstituteOregon Health & Science UniversityPortlandOregon
| | - Peter R. Levasseur
- Papé Family Pediatric Research InstituteOregon Health & Science UniversityPortlandOregon
| | - Christian Huisman
- Papé Family Pediatric Research InstituteOregon Health & Science UniversityPortlandOregon
| | - Katherine A. Michaelis
- Papé Family Pediatric Research InstituteOregon Health & Science UniversityPortlandOregon
- Medical Scientist Training Program, Oregon Health & Science UniversityPortlandOregon
| | - Brennan Olson
- Papé Family Pediatric Research InstituteOregon Health & Science UniversityPortlandOregon
- Medical Scientist Training Program, Oregon Health & Science UniversityPortlandOregon
| | - Daniel L. Marks
- Papé Family Pediatric Research InstituteOregon Health & Science UniversityPortlandOregon
- Knight Cancer InstituteOregon Health & Science UniversityPortlandOregon
- Brenden‐Colson Center for Pancreatic CareOregon Health and & Science UniversityPortlandOregon
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105
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Razzaque MS, Atfi A. Regulatory Role of the Transcription Factor Twist1 in Cancer-Associated Muscle Cachexia. Front Physiol 2020; 11:662. [PMID: 32655411 PMCID: PMC7324683 DOI: 10.3389/fphys.2020.00662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/25/2020] [Indexed: 12/19/2022] Open
Abstract
Muscle cachexia is a catabolic response, usually takes place in various fatal diseases, such as sepsis, burn injury, and chronic kidney disease. Muscle cachexia is also a common co-morbidity seen in the vast majority of advanced cancer patients, often associated with low quality of life and death due to general organ dysfunction. The triggering events and underlying molecular mechanisms of muscle wasting are not yet clearly defined. Our recent study has shown that the ectopic expression of Twist1 in muscle progenitor cells is sufficient to drive muscle structural protein breakdown and attendant muscle atrophy, reminiscent of muscle cachexia. Intriguingly, muscle Twist1 expression is highly induced in cachectic muscles from several mouse models of pancreatic ductal adenocarcinoma (PDAC), raising the interesting possibility that Twist1 may mediate PDAC-driven muscle cachexia. Along these lines, both genetic and pharmacological inactivation of Twist1 function was highly significant at protecting against cancer cachexia, which translated into a significant survival benefit in the experimental PDAC animals. From a translational perspective, elevated expression of Twist1 is also detected in cancer patients with severe muscle wasting, implicating a role of Twist1 in cancer cachexia, and further providing a possible target for therapeutic attenuation of cachexia to improve cancer patient survival. In this article, we will briefly summarize how Twist1 acts as a master regulator of tumor-induced cachexia, and discuss the relevance of our findings to muscle wasting diseases in general. The mechanism of decreased muscle mass in various catabolic conditions is thought to rely on similar pathways, and, therefore, Twist1-induced cancer cachexia may benefit diverse groups of patients with clinical complications associated with loss of muscle mass and functions, beyond the expected benefits for cancer patients.
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Affiliation(s)
- Mohammed S Razzaque
- Department of Pathology, Lake Erie College of Osteopathic Medicine, Erie, PA, United States
| | - Azeddine Atfi
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, United States
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106
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Nosacka RL, Delitto AE, Delitto D, Patel R, Judge SM, Trevino JG, Judge AR. Distinct cachexia profiles in response to human pancreatic tumours in mouse limb and respiratory muscle. J Cachexia Sarcopenia Muscle 2020; 11:820-837. [PMID: 32039571 PMCID: PMC7296265 DOI: 10.1002/jcsm.12550] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/20/2019] [Accepted: 01/07/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cancer cachexia is a life-threatening metabolic syndrome that causes significant loss of skeletal muscle mass and significantly increases mortality in cancer patients. Currently, there is an urgent need for better understanding of the molecular pathophysiology of this disease so that effective therapies can be developed. The majority of pre-clinical studies evaluating skeletal muscle's response to cancer have focused on one or two pre-clinical models, and almost all have focused specifically on limb muscles. In the current study, we reveal key differences in the histology and transcriptomic signatures of a limb muscle and a respiratory muscle in orthotopic pancreatic cancer patient-derived xenograft (PDX) mice. METHODS To create four cohorts of PDX mice evaluated in this study, tumours resected from four pancreatic ductal adenocarcinoma patients were portioned and attached to the pancreas of immunodeficient NSG mice. RESULTS Body weight, muscle mass, and fat mass were significantly decreased in each PDX line. Histological assessment of cryosections taken from the tibialis anterior (TA) and diaphragm (DIA) revealed differential effects of tumour burden on their morphology. Subsequent genome-wide microarray analysis on TA and DIA also revealed key differences between their transcriptomes in response to cancer. Genes up-regulated in the DIA were enriched for extracellular matrix protein-encoding genes and genes related to the inflammatory response, while down-regulated genes were enriched for mitochondria related protein-encoding genes. Conversely, the TA showed up-regulation of canonical atrophy-associated pathways such as ubiquitin-mediated protein degradation and apoptosis, and down-regulation of genes encoding extracellular matrix proteins. CONCLUSIONS These data suggest that distinct biological processes may account for wasting in different skeletal muscles in response to the same tumour burden. Further investigation into these differences will be critical for the future development of effective clinical strategies to counter cancer cachexia.
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Affiliation(s)
- Rachel L Nosacka
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, USA
| | - Andrea E Delitto
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, USA
| | - Dan Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, USA
| | - Rohan Patel
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, USA
| | - Sarah M Judge
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, USA
| | - Jose G Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, USA
| | - Andrew R Judge
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, USA
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107
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Weight loss in pancreatic cancer: A missing criterion of resecability. Pancreatology 2020; 20:787. [PMID: 32409280 DOI: 10.1016/j.pan.2020.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 12/11/2022]
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108
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Trestini I, Paiella S, Sandini M, Sperduti I, Elio G, Pollini T, Melisi D, Auriemma A, Soldà C, Bonaiuto C, Tregnago D, Avancini A, Secchettin E, Bonamini D, Lanza M, Pilotto S, Malleo G, Salvia R, Bovo C, Gianotti L, Bassi C, Milella M. Prognostic Impact of Preoperative Nutritional Risk in Patients Who Undergo Surgery for Pancreatic Adenocarcinoma. Ann Surg Oncol 2020; 27:5325-5334. [PMID: 32388740 DOI: 10.1245/s10434-020-08515-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Nutritional derangements are common hallmarks of pancreatic cancer (PC). Their early detection and management are usually overlooked in routine practice. This study aimed to explore preoperative nutritional status and its prognostic value in patients undergoing surgery for PC. METHODS Data from 73 patients who underwent surgery for PC from November 2015 to January 2018 at the General and Pancreatic Surgery Unit, The Pancreas Institute, University Hospital of Verona Hospital, Verona, Italy, were retrospectively evaluated. The Nutritional Risk Screening (NRS)-2002 was used to evaluate the preoperative nutritional risk. Body composition was assessed using bioimpedance vectorial analysis (BIVA) on the day prior to surgery. The effect of clinical, pathological, and nutritional characteristics on overall survival (OS) was investigated using a Cox and logistic regression model. Kaplan-Meier curves were compared using the log-rank test. RESULTS Most patients (80.8%) were at preoperative risk of malnutrition (NRS-2002 ≥ 3) despite a mean BMI of 24.1 kg/m2(± 4.3). Twenty-four patients (32.9%) received neoadjuvant therapy prior to surgery. Preoperative NRS-2002 was significantly higher in this subset of patients (p = 0.026), with a significant difference by chemotherapy regimens (in favor of FOLFIRINOX, p = 0.035). In a multivariate analysis, the only independent prognostic factor for OS was the NRS-2002 score (HR 5.24, p = 0.013). Particularly, the likelihood of 2-year survival was higher in NRS < 3 (p = 0.009). CONCLUSIONS Our analysis confirms that preoperative malnutrition has a detrimental impact on OS in PC patients undergoing radical surgery for PC. Careful preoperative nutritional evaluation of PC patients should be mandatory, especially in those who are candidates for neoadjuvant therapy.
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Affiliation(s)
- Ilaria Trestini
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Marta Sandini
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Isabella Sperduti
- Biostatistical Unit - Clinical Trials Center, Bio-Statistics Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Giovanni Elio
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Pollini
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Davide Melisi
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Auriemma
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Caterina Soldà
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Clelia Bonaiuto
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Daniela Tregnago
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alice Avancini
- Biomedical Sciences, Department of Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Deborah Bonamini
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Massimo Lanza
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Pilotto
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Chiara Bovo
- Healthcare Department Administrator, Azienda Ospedaliera Universitaria Integrata (AOUI), Verona, Italy
| | - Luca Gianotti
- Department of Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Michele Milella
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Shukla SK, Markov SD, Attri KS, Vernucci E, King RJ, Dasgupta A, Grandgenett PM, Hollingsworth MA, Singh PK, Yu F, Mehla K. Macrophages potentiate STAT3 signaling in skeletal muscles and regulate pancreatic cancer cachexia. Cancer Lett 2020; 484:29-39. [PMID: 32344015 DOI: 10.1016/j.canlet.2020.04.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/06/2020] [Accepted: 04/20/2020] [Indexed: 12/25/2022]
Abstract
Incidence of cachexia is highly prevalent in pancreatic ductal adenocarcinoma (PDAC); advanced disease stage directly correlates with decreased muscle and fat mass in PDAC patients. The pancreatic tumor microenvironment is central to the release of systemic factors that govern lipolysis, proteolysis, and muscle and fat degeneration leading to the cachectic phenotype in cancer patients. The current study explores the role of macrophages, a key immunosuppressive player in the pancreatic tumor microenvironment, in regulating cancer cachexia. We observed a negative correlation between CD163-positive macrophage infiltration and muscle-fiber cross sectional area in human PDAC patients. To investigate the role of macrophages in myodegeneration, we utilized conditioned media transplant assays and orthotopic models of PDAC-induced cachexia in immune-competent mice with and without macrophage depletion. We observed that macrophage-derived conditioned medium, in combination with tumor cell-conditioned medium, promoted muscle atrophy through STAT3 signaling. Furthermore, macrophage depletion attenuated systemic inflammation and muscle wasting in pancreatic tumor-bearing mice. Targeting macrophage-mediated STAT3 activation or macrophage-derived interleukin-1 alpha or interleukin-6 diminished myofiber atrophy. Taken together, the current study identified the critical association between macrophages and cachexia phenotype in pancreatic cancer.
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Affiliation(s)
- Surendra K Shukla
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Spas D Markov
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kuldeep S Attri
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Enza Vernucci
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ryan J King
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aneesha Dasgupta
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Paul M Grandgenett
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Michael A Hollingsworth
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Pankaj K Singh
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Fang Yu
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kamiya Mehla
- The Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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Daly LE, Dolan RD, Power DG, Ní Bhuachalla É, Sim W, Cushen SJ, Fallon M, Simmons C, McMillan DC, Laird BJ, Ryan AM. Determinants of quality of life in patients with incurable cancer. Cancer 2020; 126:2872-2882. [DOI: 10.1002/cncr.32824] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/19/2019] [Accepted: 01/24/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Louise E. Daly
- School of Food and Nutritional Sciences College of Science, Engineering and Food Science University College Cork Cork Ireland
| | - Ross D. Dolan
- Academic Unit of Surgery University of Glasgow Glasgow United Kingdom
| | - Derek G. Power
- Department of Medical Oncology Mercy and Cork University Hospital Cork Ireland
| | - Éadaoin Ní Bhuachalla
- School of Food and Nutritional Sciences College of Science, Engineering and Food Science University College Cork Cork Ireland
| | - Wei Sim
- Academic Unit of Surgery University of Glasgow Glasgow United Kingdom
| | - Samantha J. Cushen
- School of Food and Nutritional Sciences College of Science, Engineering and Food Science University College Cork Cork Ireland
| | - Marie Fallon
- Edinburgh Cancer Research Centre Institute of Genetics and Molecular Medicine University of Edinburgh Edinburgh United Kingdom
| | - Claribel Simmons
- Edinburgh Cancer Research Centre Institute of Genetics and Molecular Medicine University of Edinburgh Edinburgh United Kingdom
| | | | - Barry J. Laird
- Edinburgh Cancer Research Centre Institute of Genetics and Molecular Medicine University of Edinburgh Edinburgh United Kingdom
| | - Aoife M. Ryan
- School of Food and Nutritional Sciences College of Science, Engineering and Food Science University College Cork Cork Ireland
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Abstract
PURPOSE OF REVIEW Cancer cachexia is a complex condition that occurs in approximately 50% of cancer patients and in 80% of those with advanced cancer. It is characterized by lean body mass loss, adipose tissue loss, altered metabolism, increased inflammation, and a decrease in quality of life. Cancer cachexia is a frustrating condition to manage and treatment requires an innovative approach. The purpose of this article is to review the current treatments for cancer cachexia and how they could be used in a multimodal approach. RECENT FINDINGS Cancer cachexia has many causes, but is primarily a result of reduced energy-protein intake and altered metabolism augmented by a proinflammatory state. There is not a formal consensus on diagnosing cancer cachexia, but proactive screening and assessments for malnutrition are an effective first step toward identifying high-risk patients. Treatment of cancer cachexia includes optimizing nutrition care, using appropriate pharmacological agents, preserving lean body mass, and the cooperation of the healthcare team. SUMMARY Cancer cachexia is a complex multifactorial condition that can only be successfully managed and treated with a multimodal approach that involves a multidisciplinary team that includes an oncology registered dietitian nutritionist and exercise physiologist that target early detection and management of cancer cachexia.
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112
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Daly L, Dolan R, Power D, Ní Bhuachalla É, Sim W, Fallon M, Cushen S, Simmons C, McMillan DC, Laird BJ, Ryan A. The relationship between the BMI-adjusted weight loss grading system and quality of life in patients with incurable cancer. J Cachexia Sarcopenia Muscle 2020; 11:160-168. [PMID: 31692296 PMCID: PMC7015235 DOI: 10.1002/jcsm.12499] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/04/2019] [Accepted: 08/12/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Weight loss (WL) has long been recognized as an important factor associated with reduced quality of life (QoL) and reduced survival in patients with cancer. The body mass index (BMI)-adjusted weight loss grading system (WLGS) has been shown to be associated with reduced survival. However, its impact on QoL has not been established. The aim of this study was to assess the relationship between this WLGS and QoL in patients with advanced cancer. METHODS A biobank analysis was undertaken of adult patients with advanced cancer. Data collected included patient demographics, Eastern Cooperative Oncology Group performance status, and anthropometric parameters (BMI and %WL). Patients were categorized according to the BMI-adjusted WLGS into one of five distinct WL grades (grades 0-4). QoL was collected using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30. The Kruskal-Wallis test and multivariate logistic regression analyses were used to assess the relationship between the WLGS and QoL scores. Overall survival was assessed using Kaplan-Meier curve and Cox proportional hazard models. RESULTS A total of 1027 patients were assessed (51% male, median age: 66 years). Gastrointestinal cancer was most prevalent (40%), and 87% of patients had metastatic disease. Half (58%) of patients had a WL grade of 0-1, while 12%, 20%, and 10% had WL grades of 2, 3, and 4, respectively. Increasing WL grades were significantly associated with poorer QoL functioning and symptoms scales (all P < 0.05). Physical, role, and emotional functioning decreased by a median of >20 points between WL grade 0 and WL grade 4, while appetite loss, pain, dyspnoea, and fatigue increased by a median score >20 points, indicative of a large clinical significant difference. Increasing WL grades were associated with deteriorating QoL summary score. WL grades 2, 3, and 4 were independently associated with a QoL summary score below the median (<77.7) [odds ratio (OR) 1.69, P = 0.034; OR 2.06, P = 0.001; OR 4.29, P < 0.001, respectively]. WL grades 3 and 4 were independently associated with reduced overall survival [hazard ratio 1.54 (95% confidence interval: 1.22-1.93), P < 0.001 and hazard ratio 1.87 (95% confidence interval: 1.42-2.45), P < 0.001, respectively]. CONCLUSIONS Our findings support that the WLGS is useful in identifying patients at risk of poor QoL that deteriorates with increasing WL grades. WL grade 4 is independently associated with a particularly worse prognosis and increased symptom burden. Identification and early referral to palliative care services may benefit these patients.
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Affiliation(s)
- Louise Daly
- School of Food and Nutritional Sciences, College of Science, Engineering and Food Science, University College Cork, Cork, Ireland
| | - Ross Dolan
- Academic Unit of Surgery, University of Glasgow, Glasgow, UK
| | - Derek Power
- Department of Medical Oncology, Mercy and Cork University Hospital, Cork, Ireland
| | - Éadaoin Ní Bhuachalla
- School of Food and Nutritional Sciences, College of Science, Engineering and Food Science, University College Cork, Cork, Ireland.,Cork Cancer Research Centre, University College Cork, Cork, Ireland
| | - Wei Sim
- Academic Unit of Surgery, University of Glasgow, Glasgow, UK
| | - Marie Fallon
- Edinburgh Cancer Research Centre, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Samantha Cushen
- School of Food and Nutritional Sciences, College of Science, Engineering and Food Science, University College Cork, Cork, Ireland
| | - Claribel Simmons
- Edinburgh Cancer Research Centre, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Barry J Laird
- Edinburgh Cancer Research Centre, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Aoife Ryan
- School of Food and Nutritional Sciences, College of Science, Engineering and Food Science, University College Cork, Cork, Ireland.,Cork Cancer Research Centre, University College Cork, Cork, Ireland
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113
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Pancreatic Enzyme Replacement Therapy in Pancreatic Cancer. Cancers (Basel) 2020; 12:cancers12020275. [PMID: 31979186 PMCID: PMC7073203 DOI: 10.3390/cancers12020275] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/14/2020] [Accepted: 01/20/2020] [Indexed: 12/19/2022] Open
Abstract
Pancreatic cancer is an aggressive malignancy and the seventh leading cause of global cancer deaths in industrialised countries. More than 80% of patients suffer from significant weight loss at diagnosis and over time tend to develop severe cachexia. A major cause of weight loss is malnutrition. Patients may experience pancreatic exocrine insufficiency (PEI) before diagnosis, during nonsurgical treatment, and/or following surgery. PEI is difficult to diagnose because testing is cumbersome. Consequently, PEI is often detected clinically, especially in non-specialised centres, and treated empirically. In this position paper, we review the current literature on nutritional support and pancreatic enzyme replacement therapy (PERT) in patients with operable and non-operable pancreatic cancer. To increase awareness on the importance of PERT in pancreatic patients, we provide recommendations based on literature evidence, and when data were lacking, based on our own clinical experience.
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114
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McLaughlin M, Christie A, Campbell A. Case Report of Exercise to Attenuate Side Effects of Treatment for Pancreatic Cancer. Case Rep Oncol 2019; 12:845-854. [PMID: 31762759 PMCID: PMC6873030 DOI: 10.1159/000503815] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 12/31/2022] Open
Abstract
Treatments for pancreatic cancer can have debilitating side effects including fatigue, weight loss, and cardiac toxicity, resulting in functional loss and psychological distress. Exercise has been proposed as a therapy to counteract physical and psychological detriments. The case: A 47-year-old male undergoing chemotherapy for stage 3 locally advanced pancreatic cancer. He was cycling during hospital chemotherapy infusions (6 fortnightly cycles of FOLFIRINOX: 5-FU 2, 400 mg/m2, over 48 h: irinotecan 180 mg/m2, oxaliplatin 85 mg/m2, no 5-FU bolus) plus 12 weeks of twice weekly aerobic and resistance exercise. Over 12 weeks, body composition was maintained, and physical function improved, with specific increases in muscular strength of up to 50% and aerobic capacity improving by 9%. Moreover, quality of life, fatigue, psychological distress, and sleep quality improved by 38, 113, 50, and 9%, respectively. Additionally, the participant experienced more severe side effects in week 6, when he did not cycle to a high intensity during hospital infusion and had less total weekly exercise. After cycle 6 (week 11), chemotherapy was halted, and a Whipple resection procedure was successfully performed. It can be concluded that regular aerobic and resistance exercise plus exercise during infusion can attenuate expected decline in physical and mental health with pancreatic cancer treatment and may reduce treatment side effects and have favourable effects on prognosis.
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Affiliation(s)
| | - Alan Christie
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, United Kingdom
| | - Anna Campbell
- Edinburgh Napier University, Edinburgh, United Kingdom
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115
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Dev R, Bruera E, Dalal S. Insulin resistance and body composition in cancer patients. Ann Oncol 2019; 29 Suppl 2:ii18-ii26. [PMID: 29506229 DOI: 10.1093/annonc/mdx815] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Cancer cachexia, weight loss with altered body composition, is a multifactorial syndrome propagated by symptoms that impair caloric intake, tumor byproducts, chronic inflammation, altered metabolism, and hormonal abnormalities. Cachexia is associated with reduced performance status, decreased tolerance to chemotherapy, and increased mortality in cancer patients. Insulin resistance as a consequence of tumor byproducts, chronic inflammation, and endocrine dysfunction has been associated with weight loss in cancer patients. Insulin resistance in cancer patients is characterized by increased hepatic glucose production and gluconeogenesis, and unlike type 2 diabetes, normal fasting glucose with high, normal or low levels of insulin. Cancer cachexia results in altered body composition with the loss of lean muscle mass with or without the loss of adipose tissue. Alteration in visceral adiposity, accumulation of intramuscular adipose tissue, and secretion of adipocytokines from adipose cells may play a role in promoting the metabolic derangements associated with cachexia including a proinflammatory environment and insulin resistance. Increased production of ghrelin, testosterone deficiency, and low vitamin D levels may also contribute to altered metabolism of glucose. Cancer cachexia cannot be easily reversed by standard nutritional interventions and identifying and treating cachexia at the earliest stage of development is advocated. Experts advocate for multimodal therapy to address symptoms that impact caloric intake, reduce chronic inflammation, and treat metabolic and endocrine derangements, which propagate the loss of weight. Treatment of insulin resistance may be a critical component of multimodal therapy for cancer cachexia and more research is needed.
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Affiliation(s)
- R Dev
- Department of Symptom Control & Palliative Medicine, University of Texas MD Anderson Cancer Center, Houston, USA
| | - E Bruera
- Department of Symptom Control & Palliative Medicine, University of Texas MD Anderson Cancer Center, Houston, USA
| | - S Dalal
- Department of Symptom Control & Palliative Medicine, University of Texas MD Anderson Cancer Center, Houston, USA
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116
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Defining a new model of interdisciplinary cancer cachexia care in regional Victoria, Australia. Support Care Cancer 2019; 28:3041-3049. [DOI: 10.1007/s00520-019-05072-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 09/05/2019] [Indexed: 12/24/2022]
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117
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Cardial Tobias G, Lucas Penteado Gomes J, Paula Renó Soci U, Fernandes T, Menezes de Oliveira E. A Landscape of Epigenetic Regulation by MicroRNAs to the Hallmarks of Cancer and Cachexia: Implications of Physical Activity to Tumor Regression. Epigenetics 2019. [DOI: 10.5772/intechopen.84847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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118
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Griffin OM, Duggan SN, Ryan R, McDermott R, Geoghegan J, Conlon KC. Characterising the impact of body composition change during neoadjuvant chemotherapy for pancreatic cancer. Pancreatology 2019; 19:850-857. [PMID: 31362865 DOI: 10.1016/j.pan.2019.07.039] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/07/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic Cancer remains a lethal disease for the majority of patients. New chemotherapy agents such as Folfirinox offer therapeutic potential for patients who present with Borderline Resectable disease (BRPC). However, results to date are inconsistent, with factors such as malnutrition limiting successful drug delivery. We sought to determine the prevalence of sarcopenia in BRPC patients at diagnosis, and to quantify body composition change during chemotherapy. METHODS The diagnostic/restaging CT scans of BRPC patients were analysed. Body composition was measured at L3 using Tomovision Slice-O-Matic™. Total muscle and adipose tissue mass were estimated using validated regression equations. Sarcopenia was defined as per gender- and body mass index (BMI)-specific lumbar skeletal muscle index (LSMI) and muscle attenuation reference values. RESULTS Seventy-eight patients received neo-adjuvant chemotherapy, and 67 patients underwent restaging CT, at which point a third were deemed resectable. Half were sarcopenic at diagnosis, and sarcopenia was equally prevalent across all BMI categories.. Skeletal muscle and adipose tissue (intra-muscular, visceral and sub-cutaneous) area decreased during chemotherapy (p < 0.0001). Low muscle attenuation was observed in half of patients at diagnosis, and was associated with increased mortality risk. Loss of lean tissue parameters during chemotherapy was associated with an increased mortality risk; specifically fat-free mass, HR 1.1 (95% CI 1.03-1.17, p = 0.003) and skeletal muscle mass, HR 1.21 (95%CI 1.08-1.35, p = 0.001). CONCLUSIONS Sarcopenia was prevalent in half of patients at the time of diagnosis with BRPC. Low muscle attenuation at diagnosis, coupled with lean tissue loss during chemotherapy, independently increased mortality risk.
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Affiliation(s)
- Oonagh M Griffin
- Professorial Surgical Unit, Trinity College Dublin, Trinity Centre for Health Science, Tallaght, Dublin 24, Ireland; National Surgical Centre for Pancreatic Cancer, St Vincent's University Hospital, Dublin 24, Ireland.
| | - Sinead N Duggan
- Professorial Surgical Unit, Trinity College Dublin, Trinity Centre for Health Science, Tallaght, Dublin 24, Ireland
| | - Ronan Ryan
- Department of Radiology, St Vincent's University Hospital, Dublin 24, Ireland
| | - Raymond McDermott
- Department of Medical Oncology, St Vincent's University Hospital, Dublin 24, Ireland
| | - Justin Geoghegan
- National Surgical Centre for Pancreatic Cancer, St Vincent's University Hospital, Dublin 24, Ireland
| | - Kevin C Conlon
- Professorial Surgical Unit, Trinity College Dublin, Trinity Centre for Health Science, Tallaght, Dublin 24, Ireland; National Surgical Centre for Pancreatic Cancer, St Vincent's University Hospital, Dublin 24, Ireland
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119
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Jung MK. [Nutritional Support for Patients with Pancreatic Cancer]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 74:87-94. [PMID: 31438660 DOI: 10.4166/kjg.2019.74.2.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 07/29/2019] [Accepted: 08/01/2019] [Indexed: 02/04/2023]
Abstract
Pancreatic cancer is the ninth common malignancy in South Korea. It has a dismal prognosis with a 5-year overall survival rate of less than 10%, and pancreatic cancer is associated with cancer cachexia, which is defined as the loss of muscle mass that is not reversible by conventional nutritional support. Cachexia is noted in over 85% of all pancreatic cancer patients and it is strongly related with the disease's mortality. Nearly 30% of pancreatic cancer deaths are due to cachexia rather than being due to the tumor burden. Therefore, it is crucial to discover the mechanisms behind the development of muscle wasting in pancreatic cancer patients and find novel therapeutics for targeting cachexia. This review deals with the current understanding about the development of cachexia and nutritional support in those patients suffering with pancreatic cancer.
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Affiliation(s)
- Min Kyu Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
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120
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Talbert EE, Cuitiño MC, Ladner KJ, Rajasekerea PV, Siebert M, Shakya R, Leone GW, Ostrowski MC, Paleo B, Weisleder N, Reiser PJ, Webb A, Timmers CD, Eiferman DS, Evans DC, Dillhoff ME, Schmidt CR, Guttridge DC. Modeling Human Cancer-induced Cachexia. Cell Rep 2019; 28:1612-1622.e4. [PMID: 31390573 PMCID: PMC6733019 DOI: 10.1016/j.celrep.2019.07.016] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/24/2019] [Accepted: 07/03/2019] [Indexed: 01/03/2023] Open
Abstract
Cachexia is a wasting syndrome characterized by pronounced skeletal muscle loss. In cancer, cachexia is associated with increased morbidity and mortality and decreased treatment tolerance. Although advances have been made in understanding the mechanisms of cachexia, translating these advances to the clinic has been challenging. One reason for this shortcoming may be the current animal models, which fail to fully recapitulate the etiology of human cancer-induced tissue wasting. Because pancreatic ductal adenocarcinoma (PDA) presents with a high incidence of cachexia, we engineered a mouse model of PDA that we named KPP. KPP mice, similar to PDA patients, progressively lose skeletal and adipose mass as a consequence of their tumors. In addition, KPP muscles exhibit a similar gene ontology as cachectic patients. We envision that the KPP model will be a useful resource for advancing our mechanistic understanding and ability to treat cancer cachexia.
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Affiliation(s)
- Erin E Talbert
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA; Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Maria C Cuitiño
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 29425, USA; Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Katherine J Ladner
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA
| | - Priyani V Rajasekerea
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA
| | - Melissa Siebert
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA
| | - Reena Shakya
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA
| | - Gustavo W Leone
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 29425, USA; Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Michael C Ostrowski
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 29425, USA; Department of Biochemistry and Molecular Biology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Brian Paleo
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH 43210, USA
| | - Noah Weisleder
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH 43210, USA
| | - Peter J Reiser
- Division of Biosciences, The Ohio State University, Columbus, OH 43210, USA
| | - Amy Webb
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA
| | - Cynthia D Timmers
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 29425, USA; Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Daniel S Eiferman
- Division of Trauma, Critical Care, and Burn, The Ohio State University, Columbus, OH 43210, USA
| | - David C Evans
- Division of Trauma, Critical Care, and Burn, The Ohio State University, Columbus, OH 43210, USA
| | - Mary E Dillhoff
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA; Division of Surgical Oncology, The Ohio State University, Columbus, OH 43210, USA
| | - Carl R Schmidt
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA; Division of Surgical Oncology, The Ohio State University, Columbus, OH 43210, USA
| | - Denis C Guttridge
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University, Columbus, OH 43210, USA; Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 29425, USA.
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121
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Adiamah A, Ranat R, Gomez D. Enteral versus parenteral nutrition following pancreaticoduodenectomy: a systematic review and meta-analysis. HPB (Oxford) 2019; 21:793-801. [PMID: 30773452 DOI: 10.1016/j.hpb.2019.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The need for nutritional support following pancreaticoduodenectomy is well recognised due to the high prevalence of malnutrition, but the optimal delivery route is still debated. This meta-analysis evaluated postoperative outcomes in patients receiving enteral or parenteral nutrition. METHODS EMBASE, MEDLINE and Cochrane databases were searched to identify randomised controlled trials comparing enteral and parenteral nutrition in patients undergoing pancreaticoduodenectomy. The primary outcome measure was delayed gastric emptying (DGE). Secondary outcome measures included length of hospital stay (LOS); postoperative pancreatic fistula (POPF); post-pancreaticoduodenectomy haemorrhage (PPH); and infective complications (IC). RESULTS Five randomised controlled trials met inclusion criteria and reported on 690 patients (enteral nutrition n = 383; and parenteral nutrition n = 307). Median age was 61.5 years (interquartile range 60.1-63.6). The pooled relative risk (RR) of the primary outcome, DGE, was 0.97 (95% confidence interval (CI) 0.52-1.81, p = 0.93). There were no statistically significant difference in the secondary outcome measures of POPF (RR 1.07, 95% CI 0.42-2.76, p = 0.88); PPH (RR 0.67, 95% CI 0.31-1.48, p = 0.33) and infectious complications (RR 0.76, 95% CI 0.50-1.17, p = 0.22). However, LOS favoured enteral nutrition, weighted mean difference -1.63 days (95% CI -2.80, -0.46, p = 0.006). CONCLUSIONS EN is associated with a significantly shorter LOS compared to PN in patients undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Alfred Adiamah
- Department of Hepatobiliary Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom
| | - Reesha Ranat
- Department of Hepatobiliary Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom
| | - Dhanwant Gomez
- Department of Hepatobiliary Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom.
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122
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Ryan AM, Prado CM, Sullivan ES, Power DG, Daly LE. Effects of weight loss and sarcopenia on response to chemotherapy, quality of life, and survival. Nutrition 2019; 67-68:110539. [PMID: 31522087 DOI: 10.1016/j.nut.2019.06.020] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/20/2019] [Indexed: 02/07/2023]
Abstract
It has frequently been shown that patients with cancer are one of the largest hospital patient groups with a prevalence for malnutrition. Weight loss is a frequent manifestation of malnutrition in patients with cancer. Several large-scale studies over the past 35 y have reported that involuntary weight loss affects 50% to 80% of these patients with the degree of weight loss dependent on tumor site and type and stage of disease. The aim of this review was to determine the consequences of malnutrition, weight loss, and muscle wasting in relation to chemotherapy tolerance, postoperative complications, quality of life, and survival in patients with cancer. The prognostic impact of weight loss on overall survival has long been recognised with recent data suggesting losses as little as 2.4% predicts survival independent of disease, site, stage or performance score. Recently the use of gold-standard methods of body composition assessment, including computed tomography, have led to an increased understanding of the importance of muscle abnormalities, such as low muscle mass (sarcopenia), and more recently low muscle attenuation, as important prognostic indicators of unfavourable outcomes in patients with cancer. Muscle abnormalities are highly prevalent (ranging from 10-90%, depending on cancer site and the diagnostic criteria used). Both low muscle mass and low muscle attenuation have been associated with poorer tolerance to chemotherapy; increased risk of postoperative complications; significant deterioration in a patients' performance status, and poorer psychological well-being, overall quality of life, and survival.
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Affiliation(s)
- Aoife M Ryan
- School of Food and Nutritional Sciences, College of Science, Engineering and Food Science, University College Cork, Ireland; Cork Cancer Research Centre, University College Cork, Cork, Ireland.
| | - Carla M Prado
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Erin S Sullivan
- School of Food and Nutritional Sciences, College of Science, Engineering and Food Science, University College Cork, Ireland; Cork Cancer Research Centre, University College Cork, Cork, Ireland
| | - Derek G Power
- Department of Medical Oncology, Mercy and Cork University Hospitals, Cork, Ireland
| | - Louise E Daly
- School of Food and Nutritional Sciences, College of Science, Engineering and Food Science, University College Cork, Ireland; Cork Cancer Research Centre, University College Cork, Cork, Ireland
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123
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Walker WH, Borniger JC. Molecular Mechanisms of Cancer-Induced Sleep Disruption. Int J Mol Sci 2019; 20:E2780. [PMID: 31174326 PMCID: PMC6600154 DOI: 10.3390/ijms20112780] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 02/07/2023] Open
Abstract
Sleep is essential for health. Indeed, poor sleep is consistently linked to the development of systemic disease, including depression, metabolic syndrome, and cognitive impairments. Further evidence has accumulated suggesting the role of sleep in cancer initiation and progression (primarily breast cancer). Indeed, patients with cancer and cancer survivors frequently experience poor sleep, manifesting as insomnia, circadian misalignment, hypersomnia, somnolence syndrome, hot flushes, and nightmares. These problems are associated with a reduction in the patients' quality of life and increased mortality. Due to the heterogeneity among cancers, treatment regimens, patient populations and lifestyle factors, the etiology of cancer-induced sleep disruption is largely unknown. Here, we discuss recent advances in understanding the pathways linking cancer and the brain and how this leads to altered sleep patterns. We describe a conceptual framework where tumors disrupt normal homeostatic processes, resulting in aberrant changes in physiology and behavior that are detrimental to health. Finally, we discuss how this knowledge can be leveraged to develop novel therapeutic approaches for cancer-associated sleep disruption, with special emphasis on host-tumor interactions.
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Affiliation(s)
- William H Walker
- Department of Neuroscience, West Virginia University, Morgantown, WV 26506, USA.
| | - Jeremy C Borniger
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA.
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124
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Nakayama H, Suzuki M, Kato T, Echizen H. Vancomycin Pharmacokinetics in Patients with Advanced Cancer Near End of Life. Eur J Drug Metab Pharmacokinet 2019; 44:837-843. [PMID: 31154618 DOI: 10.1007/s13318-019-00564-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVE The effect of cancer cachexia on the pharmacokinetics of vancomycin remains unclear. We investigated whether the pharmacokinetics of vancomycin and the risk of kidney injury are altered with the development of cancer cachexia. METHODS A retrospective analysis was conducted using therapeutic drug monitoring data obtained from 86 cancer patients who received vancomycin intravenously for infection. The patients were classified into four groups according to the stage of cachexia defined by international consensus-non-cachexia (n = 26), pre-cachexia (n = 10), cachexia (n = 21) and refractory cachexia (n = 29). Vancomycin pharmacokinetics were analyzed by a traditional one-compartment model and Bayesian method using plasma concentrations measured in these patients. Renal function and pharmacokinetic parameters were compared between the non-cachexia patients (n = 26) and total cancer cachexia patients (n = 60). RESULT No significant difference in estimated glomerular filtration rate was observed between the non-cachexia and the total cancer cachexia patients. In contrast, systemic clearance of vancomycin was significantly lower in the total cancer cachexia patients compared with the non-cachexia patients when analyzed by the traditional one-compartment model [median (range)-49.7 (9.8‒98.7) vs 70.2 (12.5‒211.8) mL/min, p < 0.01] and by the Bayesian method [45.6 (12.5-84.7) vs 63.3 (12.2-102.5) mL/min, p < 0.05]. None of the non-cachexia patients developed kidney injury, whereas 15% (9 of 60 patients) of the total cancer cachexia patients developed kidney injuries (p = 0.052). CONCLUSIONS The present study revealed that cancer patients with cachexia may have reduced vancomycin clearance compared with those without cachexia. Cancer cachexia may be a risk factor of vancomycin-associated kidney injury, independent of renal function.
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Affiliation(s)
- Hirokazu Nakayama
- Department of Pharmacy, NTT Medical Center Tokyo, 5-9-22 Higashi-gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan.
| | - Masahiro Suzuki
- Department of Palliative Care, NTT Medical Center Tokyo, 5-9-22 Higashi-gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Toshiaki Kato
- Department of Pharmacy, NTT Medical Center Tokyo, 5-9-22 Higashi-gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Hirotoshi Echizen
- Department of Pharmacotherapy, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan
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Muscaritoli M, Molfino A, Scala F, Christoforidi K, Manneh-Vangramberen I, De Lorenzo F. Nutritional and metabolic derangements in Mediterranean cancer patients and survivors: the ECPC 2016 survey. J Cachexia Sarcopenia Muscle 2019; 10:517-525. [PMID: 30953399 PMCID: PMC6596398 DOI: 10.1002/jcsm.12420] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 02/04/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The prevalence of nutritional derangements in patients with cancer is high. This survey assessed patients' awareness of cancer-related nutritional issues and evaluated how important they perceive the impact of nutrition on cancer and treatment to be. METHODS A structured questionnaire was developed to determine: presence of feeding problems, perception of nutrition importance, and perception of physicians' approach to nutrition. The European Cancer Patient Coalition disseminated the questionnaire to its members in 10 countries. The Mediterranean cluster (Italy, Spain, and Greece) was analysed separately to further determine specific patterns in answers. RESULTS In total, 907 respondents completed the questionnaire (68.8% female participants; 51.7% with cancer; 48.3% cancer survivors; 59.3% diagnosed with cancer ≤3 years ago; 46.2% receiving treatment for <1 year). Feeding problems during illness/therapy were experienced by 72.5% (628/867) of all respondents (Italian: 90.0%, 117/130), although up to 53.9% (467/867) reported that physicians did not check their feeding status. Overall, 69.6% (586/842) of respondents reported weight loss after cancer diagnosis (moderate to severe: 36.7%, 309/842). For Italian respondents, the percentages of overall weight loss and moderate-to-severe weight loss were 85.1% (109/128) and 70.3% (90/128), respectively. Only 35.0% (295/842) of all respondents reported having their weight measured regularly during treatment; 45.7% (385/842) believed their physician considered cancer-related weight loss unimportant. Respondents [all: 56.9% (472/830); Italian: 73.0% (92/126); Spanish: 68.9% (42/61); Greek: 79.7% (47/59)] were unaware of supplements' negative effects during therapy or the need to inform their physician about these supplements [all: 43.6% (362/830); Italian: 55.6% (70/126); Spanish: 47.5% (29/61); Greek: 49.2% (29/59)]. The term 'cachexia' was generally unknown to respondents [all: 72.9% (603/827); Italian: 64.3% (81/126); Spanish: 68.9% (42/61); Greek: 47.5% (28/59)] and most respondents [all: 92.4% (764/827); Italian: 91.3% (115/126); Spanish: 91.8% (56/61); Greek: 86.4% (51/59)] received no cachexia-related information. CONCLUSIONS Patients reported differences in perspective between them and physicians on cancer-related nutritional issues and the specific nutritional approaches available for cancer treatment. Increasing physician focus on nutrition during treatment, particularly among Italian physicians, and providing information on optimizing nutrition to patients are essential factors to improving patients' quality of life.
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Affiliation(s)
- Maurizio Muscaritoli
- Department of Translational and Precision Medicine (formerly Department of Clinical Medicine), Sapienza University of Rome, Rome, Italy
| | - Alessio Molfino
- Department of Translational and Precision Medicine (formerly Department of Clinical Medicine), Sapienza University of Rome, Rome, Italy
| | - Ferdinando Scala
- Healthware International c/o Palazzo Innovazione, Salerno, Italy
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126
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Yoon SL, Kim JA, Kelly DL, Lyon D, George TJ. Predicting unintentional weight loss in patients with gastrointestinal cancer. J Cachexia Sarcopenia Muscle 2019; 10:526-535. [PMID: 30834673 PMCID: PMC6596456 DOI: 10.1002/jcsm.12398] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 11/21/2018] [Accepted: 01/01/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Unintentional weight loss is a major problem for patients with gastrointestinal (GI) cancers because it affects treatment, survival outcomes, and quality of life. To date, little is known about the trajectory of weight loss and the relationship between baseline body mass index (BMI), location of the cancer, and outcomes. The aims of this study were to investigate patterns of weight loss over time in patients with GI cancer according to BMI groups (low, normal, and high) and location of cancer. METHODS We examined de-identified electronic medical record data of 801 adults (>21 years) with GI cancer using ICD-9 codes (150-159). Descriptive statistics and linear mixed models were used to examine unintentional weight loss over time by BMI group (low, normal, and high) and to determine the effect of primary cancer site and patient characteristics on weight loss. RESULTS The mean age of patients was 66.5 ± 11.9 years (21-95 years), with 58% male and 86% White. Mean weight loss over 3 years was 21.39 kg. At the first observation point, 7.8% were in the low BMI group, 30.1% were in the normal, and 62% were in the high group. At the end of observation, a majority of deaths (35.5%) occurred in the low BMI group (BMI < 20 kg/m2 ). Significant weight loss was observed in patients with gastric (t = -5.11, P < 0.001), oesophageal (t = -4.18, P < 0.001), and pancreatic (35.8%, t = -3.58, P < 0.001) cancers. Predictors of weight change were gender (F = 64.93, P < 0.001), cancer stage (F = 7.28, P < 0.001), and site by days (F = 8.24, P < 0.001). Weight loss rates were similar among the three BMI groups, but patterns were different based on primary cancer type as a function of days within each group. CONCLUSIONS Weight loss in patients with GI cancers has implications for survival. Patients with upper GI cancers experienced more weight loss and decreased survival rates compared with patients with lower GI cancers. Patients with a combination of upper GI cancer (oesophagogastric or pancreatic) and low baseline BMI had the fewest survival days and worst patient outcomes. Early intervention for weight management plays a critical role for improving the health outcomes and fatality rates of these patients.
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Affiliation(s)
- Saunjoo L Yoon
- College of Nursing, University of Florida, HPNP Complex, P.O. Box 100187, Gainesville, FL, USA
| | - Jung A Kim
- School of Nursing, Hanyang University, Seoul, South Korea
| | - Debra Lynch Kelly
- College of Nursing, University of Florida, HPNP Complex, P.O. Box 100187, Gainesville, FL, USA
| | - Debra Lyon
- College of Nursing, University of Florida, HPNP Complex, P.O. Box 100187, Gainesville, FL, USA
| | - Thomas J George
- College of Medicine, Division of Hematology and Oncology, University of Florida, Gainesville, FL, USA
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127
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Gruber ES, Jomrich G, Tamandl D, Gnant M, Schindl M, Sahora K. Sarcopenia and sarcopenic obesity are independent adverse prognostic factors in resectable pancreatic ductal adenocarcinoma. PLoS One 2019; 14:e0215915. [PMID: 31059520 PMCID: PMC6502449 DOI: 10.1371/journal.pone.0215915] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/10/2019] [Indexed: 02/07/2023] Open
Abstract
Background Incidence and mortality of pancreatic ductal adenocarcinoma (PDAC) are on the rise. Sarcopenia and sarcopenic obesity have proven to be prognostic factors in different types of cancers. In the context of previous findings, we evaluated the impact of body composition in patients undergoing surgery in a national pancreatic center. Methods Patient’s body composition (n = 133) was analyzed on diagnostic CT scans and defined as follows: Skeletal muscle index ≤38.5 cm2/m2 (women), ≤52.4 cm2/m2 (men); obesity was classified as BMI ≥25kg/m2. Results Sarcopenia showed a negative impact on overall survival (OS; 14 vs. 20 months, p = 0.016). Sarcopenic patients suffering from obesity showed poorer OS compared to non-sarcopenic obese patients (14 vs. 23 months, p = 0.007). Both sarcopenia and sarcopenic obesity were associated with sex (p<0.001 and p = 0.006; males vs. females 20% vs. 38% and 12% vs. 38%, respectively); sarcopenia was further associated with neoadjuvant treatment (p = 0.025), tumor grade (p = 0.023), weight loss (p = 0.02) and nutritional depletion (albumin, p = 0.011) as well as low BMI (<25 kg/m2, p = 0.038). Sarcopenic obese patients showed higher incidence of major postoperative complications (p<0.001). In addition, sarcopenia proved as an independent prognostic factor for OS (p = 0.031) in the multivariable Cox Regression model. Conclusion Patients with sarcopenia and sarcopenic obesity undergoing resection for PDAC have a significantly shorter overall survival and a higher complication rate. The assessment of body composition in these patients may provide a broader understanding of patients’ individual condition and guide specific supportive strategies in patients at risk.
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Affiliation(s)
- Elisabeth S. Gruber
- Division of General Surgery, Department of Surgery, Pancreatic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- * E-mail: (ESG); (KS)
| | - Gerd Jomrich
- Division of General Surgery, Department of Surgery, Pancreatic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Dietmar Tamandl
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Gnant
- Division of General Surgery, Department of Surgery, Pancreatic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Martin Schindl
- Division of General Surgery, Department of Surgery, Pancreatic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Klaus Sahora
- Division of General Surgery, Department of Surgery, Pancreatic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- * E-mail: (ESG); (KS)
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128
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Hendifar AE, Petzel MQB, Zimmers TA, Denlinger CS, Matrisian LM, Picozzi VJ, Rahib L. Pancreas Cancer-Associated Weight Loss. Oncologist 2019; 24:691-701. [PMID: 30591550 PMCID: PMC6516128 DOI: 10.1634/theoncologist.2018-0266] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/18/2018] [Indexed: 12/17/2022] Open
Abstract
Unintentional weight loss in patients with pancreatic cancer is highly prevalent and contributes to low therapeutic tolerance, reduced quality of life, and overall mortality. Weight loss in pancreatic cancer can be due to anorexia, malabsorption, and/or cachexia. Proper supportive care can stabilize or reverse weight loss in patients and improve outcomes. We review the literature on supportive care relevant to pancreatic cancer patients, and offer evidence-based recommendations that include expert nutritional assessment, counseling, supportive measures to ensure adequate caloric intake, pancreatic enzyme supplementation, nutritional supplement replacement, orexigenic agents, and exercise. Pancreatic Cancer Action Network-supported initiatives will spearhead the dissemination and adoption of these best supportive care practices. IMPLICATIONS FOR PRACTICE: Weight loss in pancreatic cancer patients is endemic, as 85% of pancreatic cancer patients meet the classic definition of cancer cachexia. Despite its significant prevalence and associated morbidity, there is no established approach to this disease entity. It is believed that this is due to an important knowledge gap in understanding the underlying biology and lack of optimal treatment approaches. This article reviews the literature regarding pancreas cancer-associated weight loss and establishes a new framework from which to view this complex clinical problem. An improved approach and understanding will help educate clinicians, improve clinical care, and provide more clarity for future clinical investigation.
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Affiliation(s)
| | | | - Teresa A Zimmers
- Indiana University, Simon Cancer Center, Indianapolis, Indiana, USA
| | | | - Lynn M Matrisian
- Pancreatic Cancer Action Network, Manhattan Beach, California, USA
| | | | - Lola Rahib
- Pancreatic Cancer Action Network, Manhattan Beach, California, USA
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129
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Colloca G, Di Capua B, Bellieni A, Cesari M, Marzetti E, Valentini V, Calvani R. Muscoloskeletal aging, sarcopenia and cancer. J Geriatr Oncol 2019; 10:504-509. [DOI: 10.1016/j.jgo.2018.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 08/26/2018] [Accepted: 11/20/2018] [Indexed: 12/16/2022]
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130
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Chen XY, Zhang XZ, Ma BW, Li B, Zhou DL, Liu ZC, Chen XL, Shen X, Yu Z, Zhuang CL. A comparison of four common malnutrition risk screening tools for detecting cachexia in patients with curable gastric cancer. Nutrition 2019; 70:110498. [PMID: 31655470 DOI: 10.1016/j.nut.2019.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/25/2019] [Accepted: 04/01/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Although there is international consensus regarding the importance of cachexia, no tools exist, to our knowledge, for cachexia screening among patients with cancer. The aim of this study was to evaluate whether patients with cancer and cachexia could be identified using the four most commonly used nutritional screening tools: the Malnutrition Universal Screening Tool (MUST), the Nutritional Risk Screening (NRS)-2002, the Malnutrition Screening Tool (MST), and the Short Nutritional Assessment Questionnaire (SNAQ). METHODS Clinical data were prospectively collected for patients who underwent elective radical gastrectomy for gastric cancer in two large centers between August 2014 and February 2018. Patients were also screened using the MUST, NRS-2002, MST, and SNAQ tools. The screening results were subsequently compared with the international consensus diagnostic criteria for cancer cachexia. RESULTS A total of 1001 patients were evaluated, including 363 patients (36.3%) with cancer cachexia. Among the patients "at nutritional risk" based on each tool, the proportions of cachexia were 87.3% for the MUST tool, 84.3% for the MST tool, 76.6% for the NRS-2002 tool, and 54.3% for the SNAQ tool. The MST tool provided the largest area under the curve for identifying cancer cachexia (0.914; P < 0.001). CONCLUSION Among the tools examined, the MST had the greatest ability to detect cancer cachexia among patients with gastric cancer.
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Affiliation(s)
- Xi-Yi Chen
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to TongJi University, Shanghai, China; Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xian-Zhong Zhang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to TongJi University, Shanghai, China
| | - Bing-Wei Ma
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to TongJi University, Shanghai, China
| | - Bo Li
- Department of Endocrinology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong-Lei Zhou
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to TongJi University, Shanghai, China
| | - Zhong-Chen Liu
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to TongJi University, Shanghai, China
| | - Xiao-Lei Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xian Shen
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhen Yu
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to TongJi University, Shanghai, China.
| | - Cheng-Le Zhuang
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital Affiliated to TongJi University, Shanghai, China.
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131
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Zhu X, Burfeind KG, Michaelis KA, Braun TP, Olson B, Pelz KR, Morgan TK, Marks DL. MyD88 signalling is critical in the development of pancreatic cancer cachexia. J Cachexia Sarcopenia Muscle 2019; 10:378-390. [PMID: 30666818 PMCID: PMC6463469 DOI: 10.1002/jcsm.12377] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/08/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Up to 80% of pancreatic cancer patients suffer from cachexia, a devastating condition that exacerbates underlying disease, reduces quality of life, and increases treatment complications and mortality. Tumour-induced inflammation is linked to this multifactorial wasting syndrome, but mechanisms and effective treatments remain elusive. Myeloid differentiation factor (MyD88), a key component of the innate immune system, plays a pivotal role in directing the inflammatory response to various insults. In this study, we tested whether MyD88 signalling is essential in the development of pancreatic cancer cachexia using a robust mouse tumour model. METHODS Sex, age, and body weight-matched wide type (WT) and MyD88 knockout (MyD88 KO) mice were orthotopically or intraperitoneally implanted with a pancreatic tumour cell line from a syngeneic C57BL/6 KRASG12D/+ P53R172H/+ Pdx-Cre (KPC) mouse. We observed the effects of MyD88 signalling during pancreatic ductal adenocarcinoma progression and the cachexia development through behavioural, histological, molecular, and survival aspects. RESULTS Blocking MyD88 signalling greatly ameliorated pancreatic ductal adenocarcinoma-associated anorexia and fatigue, attenuated lean mass loss, reduced muscle catabolism and atrophy, diminished systemic and central nervous system inflammation, and ultimately improved survival. Our data demonstrate that MyD88 signalling plays a critical role in mediating pancreatic cancer-induced inflammation that triggers cachexia development and therefore represents a promising therapeutic target. CONCLUSIONS MyD88-dependent inflammation is crucial in the pathophysiology of pancreatic cancer progression and contributes to high mortality. Our findings implicate the importance of innate immune signalling pathways in pancreatic cancer cachexia and a novel therapeutic target.
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Affiliation(s)
- Xinxia Zhu
- Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Kevin G Burfeind
- Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR, 97239, USA.,Medical Scientist Training Program, Oregon Health & Science University, Portland, USA
| | - Katherine A Michaelis
- Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR, 97239, USA.,Medical Scientist Training Program, Oregon Health & Science University, Portland, USA
| | - Theodore P Braun
- Knight Cancer Institute, Oregon Health & Science University, Portland, USA
| | - Brennan Olson
- Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR, 97239, USA.,Medical Scientist Training Program, Oregon Health & Science University, Portland, USA
| | - Katherine R Pelz
- Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Terry K Morgan
- Department of Pathology, Oregon Health & Science University, Portland, USA
| | - Daniel L Marks
- Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR, 97239, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, USA
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132
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Abstract
Cancer is a systemic disease. In order to fully understand it, we must take a holistic view on how cancer interacts with its host. The brain monitors and responds to natural and aberrant signals arriving from the periphery, particularly those of metabolic or immune origin. As has been well described, a hallmark of cancer is marked disruption of metabolic and inflammatory processes. Depending on the salience and timing of these inputs, the brain responds via neural and humoral routes to alter whole-body physiology. These responses have consequences for tumor growth and metastasis, directly influencing patient quality of life and subsequent mortality. Additionally, environmental inputs such as light, diet, and stress, can promote inappropriate neural activity that benefits cancer. Here, I discuss evidence for brain-tumor interactions, with special emphasis on subcortical neuromodulator neural populations, and potential ways of harnessing this cross-talk as a novel approach for cancer treatment.
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Affiliation(s)
- Jeremy C Borniger
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, P154 MSLS Building, 1201 Welch Rd., Stanford, CA 94305, USA
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133
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Park JS, Kim HM, Jeung HC, Kang SA. Association between early nutritional risk and overall survival in patients with advanced pancreatic cancer: A single-center retrospective study. Clin Nutr ESPEN 2019; 30:94-99. [PMID: 30904235 DOI: 10.1016/j.clnesp.2019.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 11/14/2018] [Accepted: 01/31/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS We investigated the predictors of overall survival (OS) among Korean patients with advanced pancreatic cancer (PC) according to their baseline nutritional status. METHODS We retrospectively reviewed the data of 412 inpatients with PC between January 2007 and February 2015 at the Department of Oncology of the Gangnam Severance Hospital, Korea. Data on demographic and clinical parameters were collected from electronic medical records, and OS was estimated using the Kaplan-Meier method. Stepwise Cox regression analysis was used to determine the factors associated with survival. Patients with a Nutritional Risk Screening (NRS) 2002 score <3 were classified as "no-risk; " those with a score of 3 were classified as "moderate-risk; " and those with a score of ≥4 were classified as "high-risk." RESULTS Following nutritional screening at baseline, 194 patients (47.1%, mean age 61.8 ± 9.9 years) were classified as the "no risk" group; 81 patients (19.7%, mean age 65.4 ± 10.8 years), as the "moderate risk" group; and 137 patients (33.3%, mean age 67.8 ± 12.0 years), as the "high risk" group. Predictors of survival were NRS 2002 score (hazard ratio [HR] = 1.238; 95% confidence interval [CI] = 1.143-1.341), percentage of lymphocytes (HR = 0.973; 95% CI = 0.962-0.984), C-reactive protein level (HR = 1.003; 95% CI = 1.001-1.006), carcinoembryonic antigen level (HR = 1.000; 95% CI = 1.000-1.000), and carbohydrate antigen 19-9 level (HR = 1.000; 95% CI = 1.000-1.000). Kaplan-Meier survival analysis showed significant differences in the median OS among the NRS 2002 groups: "no risk" group: 12.3 ± 0.4 months (95% CI: 11.47-13.13 months); "moderate risk" group: 6.5 ± 0.9 months (95% CI: 4.78-8.17 months); and "high risk" group: 5.5 ± 0.6 months (95% CI: 4.31-6.69 months). CONCLUSIONS A good baseline nutritional status was associated with OS among Korean patients with advanced PC. An improvement in the nutritional status of patients with advanced PC through baseline nutritional interventions is therefore necessary to prolong OS.
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Affiliation(s)
- Joung Soon Park
- Department of Clinical Nutrition, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hyung-Mi Kim
- Department of Clinical Nutrition, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hei-Cheul Jeung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Soon Ah Kang
- Department of Converting Technology, Graduated of Venture, Hoseo University, Seoul, Republic of Korea.
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134
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Abstract
Purpose of Review Over the past two decades, advances have been made in understanding the pathophysiology of cancer-associated weight loss, termed “cachexia.” To date, there is no proven effective intervention to completely reverse cachexia and there are no approved drug therapies to treat it. This paper will review relevant literature in relation to communicating with adolescents and young adults about cancer-associated weight loss. Recent Findings Adolescents and young adults (AYAs) who have cancer are a unique group of patients due to their stage of development and maturity. Summary This article outlines issues specific to this patient cohort that need to be considered to better understand the impact of cachexia and explore pertinent matters when communicating with AYAs in relation to cachexia.
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135
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Yang J, Zhang Z, Zhang Y, Ni X, Zhang G, Cui X, Liu M, Xu C, Zhang Q, Zhu H, Yan J, Zhu VF, Luo Y, Hagan JP, Li Z, Fang J, Jatoi A, Fernandez-Zapico ME, Zheng L, Edil BH, Bronze MS, Houchen CW, Li YP, Li M. ZIP4 Promotes Muscle Wasting and Cachexia in Mice With Orthotopic Pancreatic Tumors by Stimulating RAB27B-Regulated Release of Extracellular Vesicles From Cancer Cells. Gastroenterology 2019; 156:722-734.e6. [PMID: 30342032 PMCID: PMC6878980 DOI: 10.1053/j.gastro.2018.10.026] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 09/13/2018] [Accepted: 10/09/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Cachexia, which includes muscle wasting, is a frequent complication of pancreatic cancer. There are no therapies that reduce cachexia and increase patient survival, so it is important to learn more about its mechanisms. The zinc transporter ZIP4 promotes growth and metastasis of pancreatic tumors. We investigated its effects on muscle catabolism via extracellular vesicle (EV)-mediated stimulation of mitogen-activated protein kinase 14 (p38 MAPK). METHODS We studied nude mice with orthotopic tumors grown from human pancreatic cancer cell lines (AsPC-1 and BxPC-3); tumors were removed 8 days after cell injection and analyzed by histology. Mouse survival was analyzed by Kaplan-Meier curves. ZIP4 was knocked down in AsPC-1 and BxPC-3 cells with small hairpin RNAs; cells with empty vectors were used as controls. Muscle tissues were collected from mice and analyzed by histology and immunohistochemistry. Conditioned media from cell lines and 3-dimensional spheroid/organoid cultures of cancer cells were applied to C2C12 myotubes. The myotubes and the media were analyzed by immunoblots, enzyme-linked immunosorbent assays, and immunofluorescence microscopy. EVs were isolated from conditioned media and analyzed by immunoblots. RESULTS Mice with orthotopic tumors grown from pancreatic cancer cells with knockdown of ZIP4 survived longer and lost less body weight and muscle mass than mice with control tumors. Conditioned media from cancer cells activated p38 MAPK, induced expression of F-box protein 32 and UBR2 in C2C12 myotubes, and also led to loss of myofibrillar protein myosin heavy chain and myotube thinning. Knockdown of ZIP4 in cancer cells reduced these effects. ZIP4 knockdown also reduced pancreatic cancer cell release of heat shock protein (HSP) 70 and HSP90, which are associated with EVs, by decreasing CREB-regulated expression of RAB27B. CONCLUSIONS ZIP4 promotes growth of orthotopic pancreatic tumors in mice and loss of muscle mass by activating CREB-regulated expression of RAB27B, required for release of EVs from pancreatic cancer cells. These EVs activate p38 MAPK and induce expression of F-box protein 32 and UBR2 in myotubes, leading to loss of myofibrillar myosin heavy chain and myotube thinning. Strategies to disrupt these pathways might be developed to reduce pancreatic cancer progression and accompanying cachexia.
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Affiliation(s)
- Jingxuan Yang
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - Zicheng Zhang
- Department of Integrative Biology & Pharmacology, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - Yuqing Zhang
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Xiaoling Ni
- The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA,Department of General Surgery, Zhongshan Hospital, Shanghai Medical College, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Guohua Zhang
- Department of Integrative Biology & Pharmacology, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - Xiaobo Cui
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - Mingyang Liu
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Can Xu
- The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA,Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Qiang Zhang
- The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - Huiyun Zhu
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Jie Yan
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA,Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Vivian F. Zhu
- The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - Yusheng Luo
- The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - John P. Hagan
- The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Jing Fang
- The Key Lab of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai 200031, China,Cancer Institute, The Affiliated Hospital of Qingdao University, Qingdao, 266061, China
| | - Aminah Jatoi
- Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Lei Zheng
- The Sidney Kimmel Comprehensive Cancer Center and Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Barish H. Edil
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Michael S. Bronze
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Courtney W. Houchen
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Yi-Ping Li
- Department of Integrative Biology and Pharmacology, the University of Texas Health Science Center at Houston, Houston, Texas.
| | - Min Li
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; The Vivian L. Smith Department of Neurosurgery, the University of Texas Health Science Center at Houston, Houston, Texas; Department of Integrative Biology and Pharmacology, the University of Texas Health Science Center at Houston, Houston, Texas.
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Progressive Resistance Training to Impact Physical Fitness and Body Weight in Pancreatic Cancer Patients: A Randomized Controlled Trial. Pancreas 2019; 48:257-266. [PMID: 30589829 DOI: 10.1097/mpa.0000000000001221] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Maintaining or improving muscle mass and muscle strength is an important treatment goal in pancreatic cancer (PC) patients because of high risk of cachexia. Therefore, we assessed feasibility and effectivity of a 6-month progressive resistance training (RT) in PC patients within a randomized controlled trial. METHODS Sixty-five PC patients were randomly assigned to either supervised progressive RT (RT1), home-based RT (RT2), or usual care control group (CON). Both exercise groups performed training 2 times per week for 6 months. Muscle strength for knee, elbow, and hip extensors and flexors and cardiorespiratory fitness and body weight were assessed before and after the intervention period. RESULTS Of 65 patients, 43 patients were analyzed. Adherence rates were 64.1% (RT1) and 78.4% (RT2) of the prescribed training sessions. RT1 showed significant improvements in elbow flexor/extensor muscle strength and in maximal work load versus CON and RT2 (P < 0.05). Further, knee extensors were significantly improved for RT1 versus CON (P < 0.05). Body weight revealed no significant group differences over time. CONCLUSIONS Progressive RT was feasible in PC patients and improved muscle strength with significant results for some muscle groups. Supervised RT seemed to be more effective than home-based RT.
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Cancer related fatigue and cancer cachexia are the consequence of endocrine failure caused by persistent stress. Med Hypotheses 2019; 123:60-62. [DOI: 10.1016/j.mehy.2018.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/01/2018] [Accepted: 12/22/2018] [Indexed: 01/13/2023]
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Anker MS, Holcomb R, Muscaritoli M, von Haehling S, Haverkamp W, Jatoi A, Morley JE, Strasser F, Landmesser U, Coats AJS, Anker SD. Orphan disease status of cancer cachexia in the USA and in the European Union: a systematic review. J Cachexia Sarcopenia Muscle 2019; 10:22-34. [PMID: 30920776 PMCID: PMC6438416 DOI: 10.1002/jcsm.12402] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/09/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Cachexia has significant impact on the patients' quality of life and prognosis. It is frequently observed in patients with cancer, especially in advanced stages, but prevalence data for the overall population are lacking. Good quality estimates of cancer cachexia in general and for each of the major cancer types would be highly relevant for potential treatment development efforts in this field. Both the USA and European Union (EU) have implemented special clinical development rules for such rare disorders what are called 'orphan diseases'. The cut-off level for a disease to be considered an orphan disease in the USA is 200 000 people (0.06% of the population) and EU is 5 per 10 000 people (0.05% of the population). METHODS For this systematic review, we searched at PubMed (from inception to 31 January 2018) to identify clinical studies that assessed the prevalence of cachexia in cancer patients at risk. Studies reporting the prevalence of either cancer cachexia or wasting disease in the top-10 cancer types and 4 other selected cancer types known to be particularly commonly complicated by cachexia were included in this analysis (i.e. prostate cancer, breast cancer, colorectal cancer, melanoma, endometrial cancer, thyroid cancer, urinary bladder cancer, non-hodgkin lymphoma, lung cancer, kidney and renal pelvis cancer, head and neck cancer, gastric cancer, liver cancer, and pancreatic cancer). We calculated the current burden of cancer cachexia, disease by disease, in the USA and in the EU and compared them to the current guidelines for the definition of orphan disease status. RESULTS We estimate that in 2014 in the USA, a total of 527 100 patients (16.5 subjects per 10 000 people of the total population), and in 2013 in the EU, a total of 800 300 patients (15.8 subjects per 10 000 people of the total population) suffered from cancer cachexia (of any kind). In the 14 separately analysed cancer types, the prevalence of cancer cachexia in the USA ranged between 11 300 (0.4/10 000, gastric cancer) and 92 000 patients (2.9/10 000, lung cancer) and in the EU between 14 300 (0.3/10 000, melanoma of the skin) and 150 100 (3.0/10 000, colorectal cancer). CONCLUSIONS The absolute number of patients affected by cancer cachexia in each cancer group is lower than the defined thresholds for orphan diseases in the USA and EU. Cancer cachexia in each subgroup separately should be considered an orphan disease.
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Affiliation(s)
- Markus S Anker
- Division of Cardiology and Metabolism, Department of Cardiology & Berlin-Brandenburg Center for Regenerative Therapies (BCRT), DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Charité-Universitätsmedizin Berlin (CVK), Berlin, Germany.,Department of Cardiology, Charité Campus Benjamin Franklin, Berlin, Germany
| | | | | | - Stephan von Haehling
- Department of Cardiology and Pneumology, DZHK (German Center for Cardiovascular Research), University of Göttingen Medical Center (UMG), Göttingen, Germany
| | - Wilhelm Haverkamp
- Department of Internal Medicine and Cardiology, Charité University Medicine, Berlin, Germany
| | | | - John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, Saint Louis, MO, 63104, USA
| | - Florian Strasser
- Oncological Palliative Medicine, Clinic Medical Oncology and Haematology, Department of Internal Medicine, Cantonal Hospital, St Gallen and Integrated Cancer Rehabilitation, Klinik Gais, Switzerland
| | - Ulf Landmesser
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin Institute of Health (BIH), Berlin, Germany.,Department of Cardiology Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology & Berlin-Brandenburg Center for Regenerative Therapies (BCRT), DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Charité-Universitätsmedizin Berlin (CVK), Berlin, Germany
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Rungsakulkij N, Tangtawee P, Suragul W, Muangkaew P, Mingphruedhi S, Aeesoa S. Correlation of serum albumin and prognostic nutritional index with outcomes following pancreaticoduodenectomy. World J Clin Cases 2019; 7:28-38. [PMID: 30637250 PMCID: PMC6327128 DOI: 10.12998/wjcc.v7.i1.28] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/26/2018] [Accepted: 12/21/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a complex surgical procedure with a high morbidity rate. The serious complications are major risk factors for poor long-term surgical outcome. Studies have reported an association between early postoperative prognostic nutritional index (PNI) and prediction of severe complications after abdominal surgery. However, there have been no studies on the use of early postoperative PNI for predicting serious complications following PD.
AIM To analyze the risk factors and early postoperative PNI for predicting severe complications following PD.
METHODS We retrospectively analyzed 238 patients who underwent PD at our hospital between January 2007 and December 2017. The postoperative complications were classified according to the Dindo-Clavien classification. Grade III-V postoperative complications were classified as serious. The risk factors for serious complications were analyzed by univariate analysis and multivariate logistic regression analysis.
RESULTS Overall complications were detected in 157 of 238 patients (65.9%) who underwent PD. The grade III-V complication rate was 26.47% (63/238 patients). The mortality rate was 3.7% (9/238 patients). Multivariate logistic regression analysis revealed that preoperative serum albumin [odds ratio (OR): 0.883, 95% confidence interval (CI): 0.80-0.96; P < 0.01] and PNI on postoperative day 3 < 40.5 (OR: 2.77, 95%CI: 1.21-6.38, P < 0.05) were independent factors associated with grade III-V postoperative complications.
CONCLUSION Perioperative albumin is an important factor associated with serious complications following PD. Low early postoperative PNI (< 40.5) is a predictor for serious complications.
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Affiliation(s)
- Narongsak Rungsakulkij
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Pongsatorn Tangtawee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Wikran Suragul
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Paramin Muangkaew
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Somkit Mingphruedhi
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Suraida Aeesoa
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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140
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Yakovenko A, Cameron M, Trevino JG. Molecular therapeutic strategies targeting pancreatic cancer induced cachexia. World J Gastrointest Surg 2018; 10:95-106. [PMID: 30622678 PMCID: PMC6314860 DOI: 10.4240/wjgs.v10.i9.95] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 11/01/2018] [Accepted: 11/27/2018] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PC) induced cachexia is a complex metabolic syndrome associated with significantly increased morbidity and mortality and reduced quality of life. The pathophysiology of cachexia is complex and poorly understood. Many molecular signaling pathways are involved in PC and cachexia. Though our understanding of cancer cachexia is growing, therapeutic options remain limited. Thus, further discovery and investigation of the molecular signaling pathways involved in the pathophysiology of cachexia can be applied to development of targeted therapies. This review focuses on three main pathophysiologic processes implicated in the development and progression of cachexia in PC, as well as their utility in the discovery of novel targeted therapies.
Skeletal muscle wasting is the most prominent pathophysiologic anomaly in cachectic patients and driven by multiple regulatory pathways. Several known molecular pathways that mediate muscle wasting and cachexia include transforming growth factor-beta (TGF-β), myostatin and activin, IGF-1/PI3K/AKT, and JAK-STAT signaling. TGF-β antagonism in cachectic mice reduces skeletal muscle catabolism and weight loss, while improving overall survival. Myostatin/activin inhibition has a great therapeutic potential since it plays an essential role in skeletal muscle regulation. Overexpression of insulin-like growth factor binding protein-3 (IGFBP-3) leads to increased ubiquitination associated proteolysis, inhibition of myogenesis, and decreased muscle mass in PC induced cachexia. IGFBP-3 antagonism alleviates muscle cell wasting.
Another component of cachexia is profound systemic inflammation driven by pro-cachectic cytokines such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and interferon gamma (INF-γ). IL-6 antagonism has been shown to reduce inflammation, reduce skeletal muscle loss, and ameliorate cachexia. While TNF-α inhibitors are clinically available, blocking TNF-α signaling is not effective in the treatment of cancer cachexia. Blocking the synthesis or action of acute phase reactants and cytokines is a feasible therapeutic strategy, but no anti-cytokine therapies are currently approved for use in PC. Metabolic alterations such as increased energy expenditure and gluconeogenesis, insulin resistance, fat tissue browning, excessive oxidative stress, and proteolysis with amino acid mobilization support tumor growth and the development of cachexia. Current innovative nutritional strategies for cachexia management include ketogenic diet, utilization of natural compounds such as silibinin, and supplementation with ω3-polyunsaturated fatty acids. Elevated ketone bodies exhibit an anticancer and anticachectic effect. Silibinin has been shown to inhibit growth of PC cells, induce metabolic alterations, and reduce myofiber degradation. Consumption of ω3-polyunsaturated fatty acids has been shown to significantly decrease resting energy expenditure and regulate metabolic dysfunction.
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Affiliation(s)
- Anastasiya Yakovenko
- University of Florida College of Medicine, Gainesville, Florida 32610, United States
| | - Miles Cameron
- University of Florida College of Medicine, Gainesville, Florida 32610, United States
| | - Jose Gilberto Trevino
- Department of Surgery, University of Florida Health Sciences Center, Gainesville, Florida 32610, United States
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TRIF is a key inflammatory mediator of acute sickness behavior and cancer cachexia. Brain Behav Immun 2018; 73:364-374. [PMID: 29852290 PMCID: PMC6129432 DOI: 10.1016/j.bbi.2018.05.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/21/2018] [Accepted: 05/27/2018] [Indexed: 12/11/2022] Open
Abstract
Hypothalamic inflammation is a key component of acute sickness behavior and cachexia, yet mechanisms of inflammatory signaling in the central nervous system remain unclear. Previous work from our lab and others showed that while MyD88 is an important inflammatory signaling pathway for sickness behavior, MyD88 knockout (MyD88KO) mice still experience sickness behavior after inflammatory stimuli challenge. We found that after systemic lipopolysaccharide (LPS) challenge, MyD88KO mice showed elevated expression of several cytokine and chemokine genes in the hypothalamus. We therefore assessed the role of an additional inflammatory signaling pathway, TRIF, in acute inflammation (LPS challenge) and in a chronic inflammatory state (cancer cachexia). TRIFKO mice resisted anorexia and weight loss after peripheral (intraperitoneal, IP) or central (intracerebroventricular, ICV) LPS challenge and in a model of pancreatic cancer cachexia. Compared to WT mice, TRIFKO mice showed attenuated upregulation of Il6, Ccl2, Ccl5, Cxcl1, Cxcl2, and Cxcl10 in the hypothalamus after IP LPS treatment, as well as attenuated microglial activation and neutrophil infiltration into the brain after ICV LPS treatment. Lastly, we found that TRIF was required for Ccl2 upregulation in the hypothalamus and induction of the catabolic genes, Mafbx, Murf1, and Foxo1 in gastrocnemius during pancreatic cancer. In summary, our results show that TRIF is an important inflammatory signaling mediator of sickness behavior and cachexia and presents a novel therapeutic target for these conditions.
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142
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Mikkelsen MK, Lund CM, Vinther A, Tolver A, Ragle AM, Johansen JS, Chen I, Engell-Noerregaard L, Larsen FO, Zerahn B, Nielsen DL, Jarden M. Engaging the older cancer patient; Patient Activation through Counseling, Exercise and Mobilization - Pancreatic, Biliary tract and Lung cancer (PACE-Mobil-PBL) - study protocol of a randomized controlled trial. BMC Cancer 2018; 18:934. [PMID: 30261853 PMCID: PMC6161425 DOI: 10.1186/s12885-018-4835-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/18/2018] [Indexed: 01/06/2023] Open
Abstract
Background Several intervention studies have demonstrated that exercise training has beneficial effects among cancer patients. However, older cancer patients are underrepresented in clinical trials, and only few exercise-based studies have focused specifically on older patients with cancer. In particular, research investigating the effects of exercise training among older patients with advanced cancer is lacking. The purpose of the current study is to investigate the effect of a 12-week multimodal and exercise-based intervention among older patients (≥65 years) with advanced pancreatic, biliary tract or lung cancer, who are treated with first-line palliative chemotherapy, immunotherapy or targeted therapy. Methods PACE-Mobil-PBL is a two-armed randomized controlled trial. Participants will be randomized 1:1 to an intervention group (N = 50) or a control group (N = 50). Participants in the intervention group will receive standard oncological treatment and a 12-week multimodal intervention, comprised of: (I) supervised exercise training, twice weekly in the hospital setting, (II) home-based walking with step counts and goal-setting, (III) supportive and motivational nurse-led counseling, and (IV) protein supplement after each supervised training session. Participants in the control group will receive standard oncological treatment. The primary outcome is physical function measured by the 30-s chair stand test. Secondary outcomes include measures of feasibility, activity level, physical capacity and strength, symptom burden, quality of life, toxicity to treatment, dose reductions, inflammatory biomarkers, body weight and composition, hospitalizations and survival. Assessments will be conducted at baseline, and after 6, 12 and 16 weeks. Discussion The current study is one of the first to investigate the effect of an exercise-based intervention specifically targeting older patients with advanced cancer. PACE-Mobil-PBL supports the development of health promoting guidelines for older patients with cancer, and the study results will provide new and valuable knowledge in this understudied field. Trial registration The study was prospectively registered at ClinicalTrials.gov on January 26, 2018 (ID: NCT03411200). Electronic supplementary material The online version of this article (10.1186/s12885-018-4835-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marta Kramer Mikkelsen
- Department of Oncology and Hematology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark. .,Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Cecilia Margareta Lund
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.,Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, Herlev, 2730, Denmark
| | - Anders Vinther
- Department of Rehabilitation, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.,QD-Research Unit, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Anders Tolver
- Data Science Laboratory, Department of Mathematical Sciences, University of Copenhagen, 2100 Copenhagen Ø, Denmark
| | - Anne-Mette Ragle
- Department of Rehabilitation, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Julia Sidenius Johansen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark.,Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, Herlev, 2730, Denmark
| | - Inna Chen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Lotte Engell-Noerregaard
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Finn Ole Larsen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Dorte Lisbet Nielsen
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark
| | - Mary Jarden
- Department of Oncology and Hematology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, 1014 Copenhagen K, Denmark
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143
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van der Werf A, van Bokhorst QNE, de van der Schueren MAE, Verheul HMW, Langius JAE. Cancer Cachexia: Identification by Clinical Assessment versus International Consensus Criteria in Patients with Metastatic Colorectal Cancer. Nutr Cancer 2018; 70:1322-1329. [PMID: 30235002 DOI: 10.1080/01635581.2018.1504092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cancer cachexia is associated with poorer outcomes and is often diagnosed by the Fearon criteria. Oncologists clinically identify cachexia based on a patient's presentation. In this study agreement between these identification methods was evaluated and associations with outcomes were studied in patients with metastatic colorectal cancer. METHODS Fearon criteria comprised weight loss >5% OR weight loss >2% with either BMI <20 kg/m2 or sarcopenia (determined by CT-imaging). Clinical assessment by the oncologist was based on the patient's clinical presentation. Agreement was tested with Kappa. Associations with treatment tolerance and progression free survival (PFS) were tested with logistic regressions and Cox proportional hazards, respectively. RESULTS Of 69 patients, 52% was identified as cachectic according to Fearon criteria and 9% according to clinical assessment. Agreement between both methods was slight (Kappa 0.049, P = 0.457). Clinically cachectic patients had a shorter PFS than clinically non-cachectic patients (HR 3.310, P = 0.016). No other differences in outcomes were found between cachectic vs. non-cachectic patients using both methods. CONCLUSIONS The agreement between cancer cachexia identification by clinical assessment vs. Fearon criteria was slight. Further improvement of cachexia criteria is necessary to identify cachectic patients at risk of poorer outcomes, who may benefit from targeted cachexia interventions.
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Affiliation(s)
- Anne van der Werf
- a Department of Medical Oncology, Internal Medicine , VU University Medical Center , Amsterdam , The Netherlands.,b Department of Nutrition and Dietetics, Internal Medicine , VU University Medical Center , Amsterdam , The Netherlands
| | - Querijn N E van Bokhorst
- b Department of Nutrition and Dietetics, Internal Medicine , VU University Medical Center , Amsterdam , The Netherlands
| | - Marian A E de van der Schueren
- b Department of Nutrition and Dietetics, Internal Medicine , VU University Medical Center , Amsterdam , The Netherlands.,c Faculty of Health and Social Studies, Department of Nutrition, Sports and Health , HAN University of Applied Sciences , Nijmegen , The Netherlands
| | - Henk M W Verheul
- a Department of Medical Oncology, Internal Medicine , VU University Medical Center , Amsterdam , The Netherlands
| | - Jacqueline A E Langius
- a Department of Medical Oncology, Internal Medicine , VU University Medical Center , Amsterdam , The Netherlands.,d Faculty of Health, Nutrition and Sport, Department of Nutrition and Dietetics , The Hague University of Applied Sciences , The Hague , The Netherlands
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Barreto SG. Pancreatic cancer: let us focus on cachexia, not just sarcopenia! Future Oncol 2018; 14:2791-2794. [PMID: 30192167 DOI: 10.2217/fon-2018-0369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Savio George Barreto
- Division of Surgery & Perioperative Medicine Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia.,College of Medicine & Public Health, Flinders University, South Australia, Australia
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145
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El Amrani M, Vermersch M, Fulbert M, Prodeau M, Lecolle K, Hebbar M, Ernst O, Pruvot FR, Truant S. Impact of sarcopenia on outcomes of patients undergoing pancreatectomy: A retrospective analysis of 107 patients. Medicine (Baltimore) 2018; 97:e12076. [PMID: 30278487 PMCID: PMC6181530 DOI: 10.1097/md.0000000000012076] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
To evaluate the prevalence of sarcopenia in patients undergoing pancreatic surgery and to examine its impact on the surgical outcomes and survival of patients.Skeletal muscle index (SMI) was measured on preoperative CT. A patient was considered sarcopenic if SMI was <38.5 cm/m for a female or <52.4 cm/m for a male. Postoperative pancreatic fistula (POPF) and severe morbidity (Clavien≥3) were analyzed. Survival of patients with cancer was calculated using the Kaplan-Meier method.In total, 107 consecutive patients were included. Among them, 50 (47%) patients were sarcopenic and 65 (60%) were undernourished. The rates of severe morbidity and mortality were comparable between sarcopenic and nonsarcopenic groups. However, all POPF grade B or C and deaths occurred in the sarcopenic or nonsarcopenic overweight group (BMI > 25) with significantly lengthened hospital stays (P = .003). After pancreatectomy for cancer, 31 (40.2%) patients showed postoperative recurrence and 23 (29.9%) died after a median follow-up of 15 ± 13.5 months. Despite comparable histological types and stages, the median overall and disease-free survivals were lower in sarcopenic patients (16 months vs not reached, P = .02 and 11.1 months vs 22.5 months; P = .04, respectively). The multivariate analysis revealed that, sarcopenia trended to increase the risk of death (HR = 2.04, P = .07).Sarcopenia negatively impacted short- and long-term outcomes in patients undergoing pancreatectomy.
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Affiliation(s)
| | | | | | | | | | | | - Olivier Ernst
- Department of Digestive and Interventional Radiology
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146
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Cresta Morgado P, Daud M, Carballido M, Méndez G, Iseas S, Lobbe V, De Simone G, Navigante A. Relationship between skeletal muscle function, body composition, and weight loss in patients with advanced pancreatic and gastrointestinal cancers. Support Care Cancer 2018; 27:1181-1186. [PMID: 30121788 DOI: 10.1007/s00520-018-4421-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 08/12/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Muscle function and its correlation with body composition and weight loss have not been studied deeply in pancreas and gastrointestinal cancers. This research aims to determine the skeletal muscle function and its relationship with body compartments, significant weight loss, and performance status (ECOG) 0-2 in a population with advanced digestive cancers. METHODS A cross-sectional study was designed to determine the relationship between muscular function, weight loss, and body composition. Patients with advanced digestive adenocarcinomas were evaluated. Muscle strength was examined by hand grip technique and body composition by bioimpedance analysis. Values of hemoglobin and albumin were measured in plasma. RESULTS A sample of 81 patients was included. They had adenocarcinoma of stomach (n = 9), pancreas (n = 28), or colorectum (n = 44). With regard to skeletal muscle function, sub-maximal strength increased when percentage of weight loss decreased (p = 0.002) or when any of the following variables increased: skeletal muscle (p < 0.001), waist-hip ratio (p < 0.001), body surface area (p < 0.001), and body mass index (p = 0.001). According to multivariate analysis of these variables, only percentage of weight loss and skeletal muscle remained statistically significant. Endurance had no correlation with any of the variables. Higher weight loss was found in tumors of the upper tract (stomach and pancreas) in comparison with those of the lower tract (colorectal) (p = 0.005). CONCLUSIONS In advanced digestive cancer, sub-maximal strength correlated inversely with weight loss and directly with skeletal muscle such as in lung and head and neck cancers. On the other hand, endurance had no correlation with any of the variables considered.
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Affiliation(s)
- P Cresta Morgado
- Translational Research Unit, Instituto de Oncología Ángel H. Roffo, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - M Daud
- Pallium Latinoamerica, Buenos Aires, Argentina
| | - M Carballido
- Section of Clinical Oncology, Hospital de Gastroenterología Bonorino Udaondo, Buenos Aires, Argentina
| | - G Méndez
- Section of Clinical Oncology, Hospital de Gastroenterología Bonorino Udaondo, Buenos Aires, Argentina
| | - S Iseas
- Section of Clinical Oncology, Hospital de Gastroenterología Bonorino Udaondo, Buenos Aires, Argentina
| | - V Lobbe
- Nutrition Unit, Hospital de Gastroenterología Bonorino Udaondo, Buenos Aires, Argentina
| | - G De Simone
- Pallium Latinoamerica, Buenos Aires, Argentina.,Section of Palliative Care Medicine, Hospital de Gastroenterología Bonorino Udaondo, Buenos Aires, Argentina
| | - A Navigante
- Translational Research Unit, Instituto de Oncología Ángel H. Roffo, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina. .,Pallium Latinoamerica, Buenos Aires, Argentina. .,Hospital Bonorino Udaondo, Caseros 2061 (C1264AAA), 1er Piso Pabellón C, Buenos Aires, Argentina.
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147
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Judge SM, Nosacka RL, Delitto D, Gerber MH, Cameron ME, Trevino JG, Judge AR. Skeletal Muscle Fibrosis in Pancreatic Cancer Patients with Respect to Survival. JNCI Cancer Spectr 2018; 2:pky043. [PMID: 30637373 PMCID: PMC6322478 DOI: 10.1093/jncics/pky043] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/20/2018] [Accepted: 07/25/2018] [Indexed: 12/18/2022] Open
Abstract
Background Cancer cachexia is a catabolic condition characterized by skeletal muscle wasting, consequent to tumor burden, which negatively impacts tolerance to cancer therapies and contributes to increased mortality. Partly because of the limited knowledge of the underlying mechanisms of cancer cachexia derived from human studies, however, the ability to therapeutically intervene remains elusive. The purpose of the current study was therefore to better define the phenotype of skeletal muscle obtained from patients with pancreatic ductal adenocarcinoma (PDAC), which has one of the highest rates of cachexia. Methods Morphological analyses were performed on rectus abdominis muscle biopsies obtained from resectable PDAC patients undergoing tumor resection surgery (N = 20) and from weight-stable non-cancer control subjects undergoing benign abdominal surgery (N = 16). PDAC patients with a body weight loss of greater than 5% during the previous 6 months were considered cachectic (N = 15). Statistical tests were two sided. Results Skeletal muscle from cachectic PDAC patients had increased collagen content compared with non-cancer control subjects (1.43% vs 9.66%, P = .0004, Dunn test). Across all PDAC patients, collagen content positively correlated with body weight loss (P = .0016, r = 0.672), was increased in patients with lymph node metastasis (P = .007, Mann-Whitney U test), and was associated with survival on univariate (HR = 1.08, 95% confidence interval [CI] = 1.02 to 1.04, P = .008) and multivariable analyses (HR = 1.08, 95% CI = 1.00 to 1.17, P = .038). Cachectic PDAC patients also displayed increased lipid deposition (2.63% vs 5.72%, P = .042), infiltration of CD68+ macrophages (63.6 cells/mm2 vs 233.8 cells/mm2, P = .0238), calcium deposition (0.21% vs 2.51%, P = .030), and evidence of deficient cellular quality control mechanisms (Mann-Whitney U test). Transcriptional profiling of all patients supported these findings by identifying gene clusters related to wounding, inflammation, and cellular response to TGF-β upregulated in cachectic PDAC patients compared with non-cancer control subjects. Conclusions To our knowledge, this work is the first to demonstrate increased collagen content in cachectic PDAC patients that is associated with poor survival.
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Affiliation(s)
- Sarah M Judge
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, FL
| | - Rachel L Nosacka
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, FL
| | - Daniel Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Michael H Gerber
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Miles E Cameron
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Jose G Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, Gainesville, FL
| | - Andrew R Judge
- Department of Physical Therapy, University of Florida Health Science Center, Gainesville, FL
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148
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Kato Y, Yamada S, Suenaga M, Takami H, Niwa Y, Hayashi M, Iwata N, Kanda M, Tanaka C, Nakayama G, Koike M, Fujiwara M, Kodera Y. Impact of the Controlling Nutritional Status Score on the Prognosis After Curative Resection of Pancreatic Ductal Adenocarcinoma. Pancreas 2018; 47:823-829. [PMID: 29975352 DOI: 10.1097/mpa.0000000000001105] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The controlling nutritional status (CONUT) score is a useful tool to evaluate immune-nutritional status. This study aimed to investigate the impact of the CONUT score on short- and long-term outcomes after curative resection of pancreatic ductal adenocarcinoma (PDAC). METHODS Consecutive 344 PDAC patients receiving pancreatectomy without neoadjuvant therapy were examined retrospectively. After the best predictive value of the CONUT score for survival was identified, association between the CONUT score and long-term outcomes was evaluated using log-rank tests and a Cox regression model. Then correlations between the CONUT score and postoperative complications were analyzed. RESULTS The optimal cutoff value of the CONUT score was 4. The high CONUT score group showed significantly lower overall survival than the low CONUT score group (P = 0.002). In contrast, no significant difference in recurrence-free survival was found (P = 0.43). A multivariate analysis demonstrated that high CONUT score had an independent association with overall survival (hazard ratio, 1.64; P = 0.003). The CONUT score showed no association with postoperative pancreatic fistula, Clavien-Dindo grade, or postoperative hospital stay. CONCLUSION The CONUT score had an independent association with survival in patients with PDAC after pancreatectomy and was not associated with recurrence or postoperative complications.
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Affiliation(s)
- Yoshiyasu Kato
- From the Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
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149
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Takeyama T, Hirooka Y, Kawashima H, Ohno E, Ishikawa T, Yamamura T, Furukawa K, Funasaka K, Nakamura M, Miyahara R, ishigami M, Goto H. Objective evaluation of blood flow in the small-intestinal villous: quantification of findings from dynamic endoscopy with concomitant narrow-band imaging. Endosc Int Open 2018; 6:E941-E949. [PMID: 30083582 PMCID: PMC6070375 DOI: 10.1055/a-0619-4965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/09/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND AIMS We have previously shown that the increase in blood flow volume in jejunum villi after spraying of 10 % dextrose solution correlates with pancreatic exocrine function (PEF). The aim of this study was to establish an objective method to evaluate the amount of jejunum villous blood flow using a novel image analysis system. PATIENTS AND METHODS The subjects were 26 patients who underwent upper gastrointestinal endoscopy with a newly developed small intestine endoscope (SIF-Y0007, Olympus, Tokyo, Japan). By defining the ratio of capillary occupancy in each villus at levels from 1 to 5, villous blood flow was evaluated subjectively on the villous blood flow scale (VBFS). Objective evaluation was performed based on luminance analysis. The morphological opening process was used to make images with leveled brightness. A histogram was prepared from the luminance information and the standard deviation was determined and defined as SDOV (Standard Deviation calculated from a histogram made by luminance analysis Of Villi). PEF was evaluated by measuring the BT-PABA (N-benzoyl-L-tyrosyl-p-aminobenzoic acid) excretion rate. RESULTS There was a significant positive correlation between VBFS and SDOV ( P < 0.0001, ρ = 0.5882). SDOV was also positively correlated with PEF ( P = 0.0004, ρ = 0.6421). CONCLUSIONS SDOV is a new objective index for evaluation of blood flow volume in jejunum villi. SDOV may be useful in clinical practice to estimate PEF and for clarification of the mechanisms underlying the functional correlation between the pancreas and small intestine.
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Affiliation(s)
- Tomoaki Takeyama
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoshiki Hirooka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan,Corresponding author Yoshiki Hirooka Department of EndoscopyNagoya University Hospital65, Tsuruma-ChoShowa-KuNagoyaAichi 466-8550Japan+81-52-7358806
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kohei Funasaka
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Masanao Nakamura
- Department of Internal Medicine, Division of Therapeutic Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masatoshi ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hidemi Goto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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150
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Erstad DJ, Sojoodi M, Taylor MS, Ghoshal S, Razavi AA, Graham-O'Regan KA, Bardeesy N, Ferrone CR, Lanuti M, Caravan P, Tanabe KK, Fuchs BC. Orthotopic and heterotopic murine models of pancreatic cancer and their different responses to FOLFIRINOX chemotherapy. Dis Model Mech 2018; 11:dmm.034793. [PMID: 29903803 PMCID: PMC6078400 DOI: 10.1242/dmm.034793] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/11/2018] [Indexed: 12/16/2022] Open
Abstract
Syngeneic, immunocompetent allograft tumor models recapitulate important aspects of the tumor microenvironment and have short tumor latency with predictable growth kinetics, making them useful for trialing novel therapeutics. Here, we describe surgical techniques for orthotopic and heterotopic pancreatic ductal adenocarcinoma (PDAC) tumor implantation and characterize phenotypes based on implantation site.Mice (n=8 per group) were implanted with 104 cells in the pancreas or flank. Hy15549 and Han4.13 cell lines were derived from primary murine PDAC (Ptf1-Cre; LSL-KRAS-G12D; Trp53 Lox/+) on C57BL/6 and FVB strains, respectively. Single-cell suspension and solid tumor implants were compared. Tumors were treated with two intravenous doses of FOLFIRINOX and responses evaluated.All mice developed pancreatic tumors within 7 days. Orthotopic tumors grew faster and larger than heterotopic tumors. By 3 weeks, orthotopic mice began losing weight, and showed declines in body condition requiring euthanasia starting at 4 weeks. Single-cell injection into the pancreas had near 100% engraftment, but solid tumor implant engraftment was ∼50% and was associated with growth restriction. Orthotopic tumors were significantly more responsive to intravenous FOLFIRINOX compared with heterotopic tumors, with greater reductions in size and increased apoptosis. Heterotopic tumors were more desmoplastic and hypovascular. However, drug uptake into tumor tissue was equivalent regardless of tumor location or degree of fibrosis, indicating that microenvironment differences between heterotopic and orthotopic tumors influenced response to therapy.Our results show that orthotopic and heterotopic allograft locations confer unique microenvironments that influence growth kinetics, desmoplastic response and angiogenesis. Tumor location influences chemosensitivity to FOLFIRINOX and should inform future preclinical trials.This article has an associated First Person interview with the first author of the paper.
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Affiliation(s)
- Derek J Erstad
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Mozhdeh Sojoodi
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Martin S Taylor
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Sarani Ghoshal
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Allen A Razavi
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Katherine A Graham-O'Regan
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, United States
| | - Nabeel Bardeesy
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Michael Lanuti
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Peter Caravan
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, United States.,Institute for Innovation in Imaging, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Bryan C Fuchs
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
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