Parenteral hyperalimentation in gynecologic oncology patients

Parenteral Hyperalimentation in Patients with Advanced Neoplastic Disease

Two groups of patients suffering from advanced neoplastic disease were fed parenterally for a period ranging from 1 to 16 weeks. The parameters considered were: weight change, serum albumin level, lymphocyte transformation test and serum immunoglobulin level. There were 23 patients in one group and 21 patients in the other. Regimens included for group I: saline solution (1000–1500 ml), glucose (100–150 g) and amino acids (15–30 g) per day; for group 2: 40–50 Cal/kg per day (dextrose about 15 g/kg per day), about 2 g of amino acids/kg/day and about 40–50 ml water/kg/day. In addition, 13 patients underwent both treatments sequentially. All the Group I patients lost weight (1.3 kg/week); while out of 23 patients in Group 2, 15 gained weight, 2 remained unchanged and 6 continued to lose weight, but to a lesser rate than before hyperalimentation (the average weight gain was 1.1 kg/week). Serum albumin levels decreased in 19 out of 25 patients in Group I and increased in 14 out of 26 patients of Group 2. Initial values of the lymphocyte blast transformation test were very low in both groups of patients, and an increase was observed only in patients treated by hyperalimentation. The increase was more evident in patients who were not under antiblastic treatment. Changes in serum immunoglobulin levels were not significant. The authors conclude that malnutrition plays a very important role in neoplastic cachexia and can be improved by parenteral hyperalimentation. Although it is possible that in the near future hyperalimentation and conventional neoplastic therapies will play complementary roles in treatment of advanced neoplastic disease, malnutrition is still the specific indication for intravenous hyperalimentation.

Effect of methionine-deprived nutrition on cell growth and cell kinetics in cell cultures and experimental tumors

The effect of methionine-deprived nutrition on cell growth and cell kinetics was investigated in cell cultures and in tumor-bearing rats using the total parenteral nutrition (TPN) technique. A simultaneous flow cytometric measurement of the cellular DNA content and the amount of 5-bromodeoxyuridine incorporated into cellular DNA was performed for analysis of cell kinetics. The methionine-free medium demonstrated a cytocidal effect on the growth of SLC cells after 6 hours of culturing. It decreased viability from 80% in the control medium to 23%, and it decreased the S phase and increased the G0/G1 phase of the cell cycles. The methionine-deprived medium showed a concentration-dependent inhibition in cellular growth. Methionine-deprived TPN was seen to inhibit AH109A and SLC tumor growth compared with conventional TPN and decreased the S phase and increased the G0/G1 phase of cell cycles. These results confirm that methionine deprivation blocks cells from processing into the G1 phase and recycling, and that it is effective in inhibiting tumor growth in cultures and in vivo.

Effect of energy substrate manipulation on tumour cell proliferation in parenterally fed cancer patients

The effects of isocaloric carbohydrate-based vs. fat-based total parenteral nutrition (TPN) regimens on cancer cell proliferation and host nutritional status were evaluated in 27 patients with tumours of the gastro intestinal tract consecutively assigned to receive for 14 days: a glucose-based (A) or a lipid-based (B) TPN formula, or an oral diet (C) isocaloric and isonitrogenous to A and B. Cancer cell replication rate was evaluated by thymidine labelling index (LI) on tumour samples before and at the end of each nutritional regimen. The number of replicating cells increased by 32.2% in patients receiving regimen A. LI decreased by 24.3% in patients given regimen B. LI values were slightly increased (+15%) in patients maintained on regimen C. Nutritional status remained within normal limits. None of the LI changes observed between and within the three arms of the trial were found to be statistically significant. Thus we failed to prove that glucose consistently stimulates or lipids inhibit tumour proliferation despite a trend in this sense.

Total parenteral nutrition in poor prognosis gestational trophoblastic disease

From 1978 through 1984, 35 women received therapy for poor prognosis gestational trophoblastic disease (GTD) at Duke University Medical Center. Total parenteral nutrition (TPN) was utilized in nine patients (26%) for reasons including inadequate oral intake, nutritional depletion, and/or bone marrow suppression. Overall survival with follow-up ranging from 12 to 78 months was 88% for the TPN group and 70% for the non-TPN group (P = 0.38). Median duration of TPN therapy was 4 weeks (2-46 weeks). Intensity of therapy was comparable between the groups. Median weight gain of 0.15 kg/week for the TPN group was significantly greater than the 0.18/kg/week weight loss in the non-TPN group (P less than 0.001). Severe nutritional depletion represented by both low serum albumin (less than or equal to 2.5 gm/dl) and weight loss greater than or equal to 10% had a higher mortality rate than when only one of these factors existed (P = 0.006). Future studies need to further define the proper role of TPN in patients with poor prognosis GTD especially in those with severe nutritional deficits.

Critical evaluation of the role of nutritional support for radiation therapy patients

Nutritional intake or absorption may be compromised by radiation therapy (RT) when large portions of the gastrointestinal tract are treated. Dietary counseling, oral supplements, tube feedings and intravenous hyperalimentation (IVH) have been employed to limit weight loss and lessen intestinal RT side effects. Unfortunately, no prospective study reviewed has shown improved tumor control or patient survival. Special diets and IVH have also been employed in select patients to relieve chronic malabsorption from severe radiation enteritis.

Does total parenteral nutrition (TPN) really promote tumor growth? A morphometric study

An experimental study was undertaken to evaluate the effects of total parenteral nutrition (TPN) on tumor growth in rats. Sato lung cancer was transplanted subcutaneously in male Donryu rats. Two weeks after inoculation, experimental animals were divided into three groups: Group I (5% G); Group II (21% G, 4% A.A; TPN) received intravenous infusion through cervical vein; Group III rats were maintained on a regular diet. All of the animals were killed on the eighth day. There was a significant increase in tumor volume and tumor weight in both G-II (7.3 +/- 3.9 cm3, 8.7 +/- 6.3 g) and G-III (7.4 +/- 4.6 cm3, 9.7 +/- 5.4 g), as compared with G-I (3.3 +/- 1.4 cm3, 3.7 +/- 1.9 g). In morphometric studies, an average area of tumor cell in G-II was 267 +/- 172 microns2, being significantly larger than in G-I (195 +/- 95 microns2) or G-III (185 +/- 93 microns2). The nuclear diameter of tumor cell was 9.9 +/- 2.2 microns in G-II, 9.2 +/- 1.9 micron in G-III, and 8.5 +/- 1.5 micron in G-I, respectively. Total water balance throughout the experimental period was +84.0 +/- 14.5 ml/100 g BW in G-II, +86.3 +/- 8.2 ml/100 g BW in G-III, and +44.8 +/- 22.5 ml/100 g body weight in G-I, respectively. Increased tumor volume and tumor weight found in G-II may not be due to hyperplasia of each tumor cell, but rather due possibly to water retention in tumor tissue.

Nutritional support as an adjunct to radiation therapy

Patients with malignancies which are treated with therapeutic radiation are at risk for nutritional problems, both from their underlying malignancy as well as from their treatment. These effects may be acute or chronic and relate to the site of the tumor and regions irradiated. There is a large experience with nutritional intervention in irradiated patients, including oral feedings and enteral and parenteral nutritional support. The indications for the specific administration of nutritional support during radiotherapy depend on the nutritional status of the patient and the area irradiated, as well as the individual prognosis. Patients who are malnourished at the time of treatment are most likely to profit from nutritional intervention. To date, prospective randomized trials of nutritional support in patients undergoing radiotherapy fail to show a benefit of routine adjuvant nutritional intervention in terms of improved response and tolerance to treatment, improved local control or survival rates, or reduction of complications from therapy.

Whole-body protein metabolism in cancer-bearing patients. Effect of total parenteral nutrition and associated serum insulin response

Aggressive nutritional support of the cancer patient undergoing treatment has become widespread standard practice. In order to evaluate the effect of total parenteral nutrition (TPN) on protein metabolism, 11 patients with localized squamous cell carcinoma of the distal esophagus were studied in the postabsorptive state and again after 2 weeks of TPN. After two weeks of TPN, these cancer patients demonstrated a significant increase in body weight associated with positive nitrogen balance and an insignificant increase in total body potassium (determined by whole body 40K scanning), a measure of lean body mass. Serum transferrin, ceruloplasmin, and total protein did not change significantly, whereas serum albumin decreased significantly (3.5 +/- 0.1 to 3.1 +/- 0.1 g dl-1). Evaluation of whole-body protein kinetics by constant infusion of 15N-glycine demonstrated a significant increase in protein flux (2.79 +/- 0.20 to 4.02 +/- 0.33 g protein kg-1 day-1). In the group as a whole, protein synthesis increased and catabolism decreased, but not significantly. Skeletal muscle protein catabolism, as measured by the rate of excretion of urinary 3-methylhistidine (mumol kg-1 day-1) decreased significantly after 2 weeks of TPN (2.5 +/- 0.1 to 1.9 +/- 0.2). A change from basal to stimulated (TPN) serum insulin level of 40 to 120 microU/ml was found to be associated with optimal changes in protein synthesis and skeletal muscle catabolism. Five patients fell within this optimal range of serum insulin, and demonstrated a significant increase in the rate of wholebody protein synthesis (2.13 +/- 0.35 to 3.56 +/- 0.45 g protein kg-1 day-1) with an insignificant increase in whole-body protein catabolism (2.74 +/- 0.42 to 3.16 +/- 0.43), and a significant decrease in urinary 3-methylhistidine excretion (2.50 +/- 0.35 to 1.53 +/- 0.24) after 2 weeks of TPN. It is concluded that optimum nutritional support with TPN is beneficial to the cancer patients' protein economy by stimulating whole body protein synthesis while decreasing skeletal muscle protein catabolism. It is also concluded that there exists a range of serum insulin in which whole-body protein synthesis and catabolism are optimized.

The efficacy of nutritional assessment and support in cancer surgery

Malnutrition is common in cancer patients and may be an important determinant of operative morbidity and mortality. To determine whether preoperative nutritional assessment can be used to identify a group of high-risk patients, and whether preoperative TPN decreases morbidity and mortality in this group, retrospective, nonrandomized review of 159 patients who were subjected to major cancer surgery was performed. All patients underwent preoperative multiparameter assessment. A previously developed and validated nutritional assessment model (Prognostic Nutritional Index) was used to evaluate the probability of operative complications. Based on predicted outcome (PNI), patients were assigned to either a high-risk or low-risk group for statistical comparison with actual outcome. The effect of preoperative TPN was then analyzed in both risk groups for determination of efficacy of preoperative nutritional support. Substantial malnutrition was found to exist among patients undergoing major cancer surgery and was closely correlated with subsequent morbidity and mortality. This predictive nutritional assessment model accurately identifies a subset of cancer surgery patients at increased risk of operative morbidity and mortality. In this high risk group (PNI greater than or equal to 40%), preoperative nutritional support significantly reduces operative morbidity.

Reduction of operative morbidity and mortality by combined preoperative and postoperative nutritional support

A previously developed and validated predictive nutritional assessment model (Prognostic Nutritional Index) was applied to a heterogenous surgical population. Without knowledge of the then undeveloped PNI, adequate preoperative nutritional repletion (TPN) was provided on clinical indications alone to 50 of 145 patients with the remaining 95 patients receiving no preoperative total parenteral nutrition. Analysis of the two groups found no baseline differences in nutritional status, type and severity of disease and/or operative therapy, and other potentially important variables. In the high-risk stratified group as defined by admission nutritional assessment and calculated PNI (greater than or equal to 50%), adequate preoperative TPN reduced postoperative complications 2.5-fold (p < 0.01), postoperative major sepsis six-fold (p < 0.005) and mortality five-fold (p < 0.01). Clinical "eyeball" evaluation of nutritional status cannot identify high-risk individuals. This nutritional assessment predictive model (PNI) identifies the subset of operative candidates in whom adequate preoperative nutritional support significantly reduces operative morbidity and/or mortality.

Host-tumor interaction and nutrient supply

Adequate parenteral nutritional support improves nutritional status in cancer patients, but its effect on tumor growth remains controversial. Using a transplantable mammary adenocarcinoma in a rat-TPN model, the relative effect of different exogenous intravenous nutrients on tumor growth and host maintenance was studied. Relative to chow controls, starvation increased host depletion without reducing tumor growth. Adequate carbohydrate calories alone neither improved host maintenance nor stimulated tumor growth, yet adequate amino acids alone did improve host maintenance but also stimulated tumor growth. Adequate amino acids and carbohydrates given simultaneously maximized both host maintenance and tumor growth. In contrast, an isocaloric, isonitrogenous, intravenous diet providing non-nitrogenous calories as fat promoted host maintenance equivalent to carbohydrate-based TPN with no tumor stimulation. This apparent differential utilization of fat calories by normal and malignant cells may permit manipulation of the relative benefit of parenteral nutrition to host or to tumor, permitting host repletion without tumor stimulation or alternatively tumor stimulation at appropriate times to increase sensitivity to phase-specific antineoplastic therapy.

Parenteral feeding in the management of children with cancer

Total parenteral nutrition TPN has been used to treat or prevent malnutrition in 65 children with a variety of solid tumors and leukemia in the past 7 years. TPN was used in 58 patients with gastrointestinal complications of surgery, chemotherapy, or radiation; in 2 patients for preoperative correction of malnutrition; and in 8 who were entered into a prospective study. During TPN, general nutrition and appearance improved in all patients. Weight gain was noted in most. Despite gastrointestinal complications, which usually require the interruption of chemotherapy and radiation, treatment could be continued at full dose in 31 children with nutritional support by TPN. TPN was discontinued in 6 patients when blood cultures became positive. Sepsis was treated successfully by removal of the central venous catheter in all 6 and administration of antibiotics in 3. TPN appears to be safe and effective means of combating malnutrition which may occur with cancer and its therapy.

Parenteral nutritional support in children with cancer

Acute and chronic starvation is often associated with childhood cancer. Total parenteral nutrition (TPN) with 20% glucose and 3.0% amino acids, and minerals and vitamins was instituted to treat or prevent malnutrition in 41 children with cancer, ages three months to 18 years. TPN was required for anorexia, vomiting and diarrhea associated with anti-cancer therapy in 33 patients for intestinal complications or surgery in nine, and for preoperative correction of malnutrition in two. During TPN, general nutrition and appearance improved in all patients. Weight gain was noted in most. Despite gastrointestinal complications which usually require the interruption of chemotherapy and irradiation, in 21 children treatment could be continued at full dose with nutritional support by TPN. TPN was discontinued in six patients when blood cultures became positive. Sepsis was treated successfully by removal of the central venous catheter in all six and administration of antibiotics in three. No metabolic complications were noted. TPN appears to be a safe and effective means of combating the malnutrition which may occur with cancer and its therapy.