Parenteral nutrition support for patients with pancreatic cancer. Results of a phase II study

A new label free spiral sensor using impedance spectroscopy to characterize hepatocellular carcinoma in tissue and serum samples

Hepatocellular carcinoma (HCC) stands as the most prevalent form of primary liver cancer, predominantly affecting patients with chronic liver diseases such as hepatitis B or C-induced cirrhosis. Diagnosis typically involves blood tests (assessing liver functions and HCC biomarkers), imaging procedures such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI), and liver biopsies requiring the removal of liver tissue for laboratory analysis. However, these diagnostic methods either entail lengthy lab processes, require expensive imaging equipment, or involve invasive techniques like liver biopsies. Hence, there exists a crucial need for rapid, cost-effective, and noninvasive techniques to characterize HCC, whether in serum or tissue samples. In this study, we developed a spiral sensor implemented on a printed circuit board (PCB) technology that utilizes impedance spectroscopy and applied it to 24 tissues and sera samples as proof of concept. This newly devised circuit has successfully characterized HCC and normal tissue and serum samples. Utilizing the distinct dielectric properties between HCC cells and serum samples versus the normal samples across a specific frequency range, the differentiation between normal and HCC samples is achieved. Moreover, the sensor effectively characterizes two HCC grades and distinguishes cirrhotic/non-cirrhotic samples from tissue specimens. In addition, the sensor distinguishes cirrhotic/non-cirrhotic samples from serum specimens. This pioneering study introduces Electrical Impedance Spectroscopy (EIS) spiral sensor for diagnosing HCC and liver cirrhosis in clinical serum-an innovative, low-cost, rapid (< 2 min), and precise PCB-based technology without elaborate sample preparation, offering a novel non-labeled screening approach for disease staging and liver conditions.

Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist

While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.

High-protein home parenteral nutrition in malnourished oncology patients: a systematic literature review

INTRODUCTION

Up to 83% of oncology patients are affected by cancer-related malnutrition, depending on tumour location and patient age. Parenteral nutrition can be used to manage malnutrition, but there is no clear consensus as to the optimal protein dosage. The objective of this systematic literature review (SLR) was to identify studies on malnourished oncology patients receiving home parenteral nutrition (HPN) where protein or amino acid delivery was reported in g/kg bodyweight/day, and to compare outcomes between patients receiving low (< 1 g/kg bodyweight/day), standard (1-1.5 g/kg/day), and high-protein doses (> 1.5 g/kg/day).

METHODS

Literature searches were performed on 5th October 2021 in Embase, MEDLINE, and five Cochrane Library and Centre for Reviews and Dissemination databases. Searches were complemented by hand-searching of conference proceedings, a clinical trial registry, and bibliographic reference lists of included studies and relevant SLRs/meta-analyses.

RESULTS

Nineteen publications were included; sixteen investigated standard protein, two reported low protein, and one included both, but none assessed high-protein doses. Only one randomised controlled trial (RCT) was identified; all other studies were observational studies. The only study to compare two protein doses reported significantly greater weight gain in patients receiving 1.15 g/kg/day than those receiving 0.77 g/kg/day.

CONCLUSION

At present, there is insufficient evidence to determine the optimal protein dosage for malnourished oncology patients receiving HPN. Data from non-HPN studies and critically ill patients indicate that high-protein interventions are associated with increased overall survival and quality of life; further studies are needed to establish whether the same applies in malnourished oncology patients.

Clinical applications of body composition and functional status tools for nutrition assessment of hospitalized adults: A systematic review

BACKGROUND

No global consensus exists on diagnostic criteria for malnutrition. Muscular deficits and functional impairments are major components of available malnutrition diagnostic frameworks because these facets of nutrition status significantly impact outcomes. The purpose of this review is to explore which body composition assessment (BCA) and functional status assessment (FSA) tools are being used for nutrition assessment (NA) and monitoring the response to nutrition interventions (RNIs) in adult inpatients.

METHODS

A literature search of Embase, Medline (Ovid), Web of Science, and Cochrane Central was performed to identify studies that used BCA and/or FSA tools for NA (along with an accepted NA diagnostic framework) and/or for monitoring RNI in adult inpatients.

RESULTS

The search yielded 3667 articles; 94 were included in the review. The number of studies using BCA and/or FSA tools for NA was 47 and also 47 for monitoring RNI. Seventy-nine percent of studies used bioimpedance for BCA, and 97% that included FSA utilized handgrip strength. When compared against sets of diagnostic criteria, many of the BCA and FSA tools showed promising associations with nutrition status.

CONCLUSION

Bioimpedance methods are the most widely used bedside BCA tools, and handgrip strength is the most widely used FSA tool; however, these methods are being used with a variety of protocols, algorithms, and interpretation practices in heterogeneous populations. To create a standardized nutrition status assessment process there is a need for validation studies on bedside methods and the development of globally standardized assessment protocols in clinical inpatient settings.

Effects of specialised nutritional interventions in patients with incurable cancer: a systematic review

Objective

To evaluate current evidence of the effect of specialised nutritional interventions on nutritional status, survival, quality of life and measures of functionality in patients with incurable cancer.

Methods

Systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed/MEDLINE, EMBASE, Scopus, LILACS and Cochrane Library databases. Clinical studies that evaluated different specialised nutritional interventions, such as nutritional counselling, oral nutritional supplementation (ONS), enteral nutrition (EN) and parenteral nutrition (PN), were eligible. Only studies classified as being of high methodological quality (ie, low or moderate risk of bias) were included.

Results

A total of 22 studies reporting on 2448 patients were deemed eligible. Five types of specialised nutrition were observed: mixed (multimodal nature, ie, dietary counseling, ONS, physical activity and/or drugs) (n=12), ONS (n=5), PN (n=3), EN (n=1) and multidisciplinary team counselling (n=1). Benefits of any kind from the interventions were reported in 14 (63.6%) studies, mainly resulting from mixed intervention. Nutritional status improved in 12 (60.0%) of 20 studies and quality of life improved in eight (50.0%) of 16 studies. Few studies have evaluated the influence of nutritional interventions on survival and measure of functionality, and have not shown improvement in these outcomes.

Conclusion

Despite the limited evidence, specialised nutritional interventions can yield positive effects for patients with incurable cancer, mainly in their nutritional status and quality of life.

Home Parenteral Nutrition in Patients with Advanced Cancer: Quality Outcomes from a Centralized Model of Care Delivery

Lack of expertise in home parenteral nutrition (HPN) management has been reported as a barrier to its initiation in patients with advanced cancer (AC), and there are limited data describing hospital readmissions and HPN-related complications. We aimed to assess a centralized approach for managing HPN in AC and evaluate associated outcomes, including hospital readmissions and HPN-related complications. This was a cohort study of adults with AC requiring palliative HPN between 2010–2018 at a tertiary intestinal failure (IF) center, primarily utilizing a centralized model of HPN oversight to discharge patients remotely from an oncology center to their homes over a wide geographic area. A total of 126 patients were included, with a median distance between the patient’s home and the IF center of 17.5 km (IQR 10.9–39.1; maximum 317.4 km). A total of 28 (22%) patients experienced at least one HPN-related complication, the most common being a central venous catheter (CVC) occlusion and electrolyte abnormalities. The catheter-related bloodstream infection (CRBSI) rate was 0.49/1000 catheter days. The CVC type, administration of concomitant chemotherapy via a distinct CVC lumen separate from PN, venting gastrostomy and distance between the patient’s home and the IF center were not associated with CRBSI or mechanical CVC complications. A total of 82 (65.1%) patients were readmitted while on HPN, but only 7 (8.5%) of these readmissions were HPN-related. A total of 44 (34.9%) patients died at home, 41 (32.5%) at a hospice and 41 (32.5%) in a hospital. In conclusion, this study demonstrates that a centralized approach to IF care can provide HPN to patients over a large geographical area while maintaining low HPN-related complications that are comparable to patients requiring HPN for benign conditions and low hospital readmission rates.

Clinical determinants and neural correlates of presbyphagia in community-dwelling older adults

Background

“Presbyphagia” refers to characteristic age-related changes in the complex neuromuscular swallowing mechanism. It has been hypothesized that cumulative impairments in multiple domains affect functional reserve of swallowing with age, but the multifactorial etiology and postulated compensatory strategies of the brain are incompletely understood. This study investigates presbyphagia and its neural correlates, focusing on the clinical determinants associated with adaptive neuroplasticity.

Materials and methods

64 subjects over 70 years of age free of typical diseases explaining dysphagia received comprehensive workup including flexible endoscopic evaluation of swallowing (FEES), magnetoencephalography (MEG) during swallowing and pharyngeal stimulation, volumetry of swallowing muscles, laboratory analyzes, and assessment of hand-grip-strength, nutritional status, frailty, olfaction, cognition and mental health. Neural MEG activation was compared between participants with and without presbyphagia in FEES, and associated clinical influencing factors were analyzed. Presbyphagia was defined as the presence of oropharyngeal swallowing alterations e.g., penetration, aspiration, pharyngeal residue pooling or premature bolus spillage into the piriform sinus and/or laryngeal vestibule.

Results

32 of 64 participants showed swallowing alterations, mainly characterized by pharyngeal residue, whereas the airway was rarely compromised. In the MEG analysis, participants with presbyphagia activated an increased cortical sensorimotor network during swallowing. As major clinical determinant, participants with swallowing alterations exhibited reduced pharyngeal sensation. Presbyphagia was an independent predictor of a reduced nutritional status in a linear regression model.

Conclusions

Swallowing alterations frequently occur in otherwise healthy older adults and are associated with decreased nutritional status. Increased sensorimotor cortical activation may constitute a compensation attempt to uphold swallowing function due to sensory decline. Further studies are needed to clarify whether the swallowing alterations observed can be considered physiological per se or whether the concept of presbyphagia may need to be extended to a theory with a continuous transition between presbyphagia and dysphagia.

Gastrointestinal Cancer Patient Nutritional Management: From Specific Needs to Novel Epigenetic Dietary Approaches

Nutritional habits impinge on the health of the gastrointestinal (GI) tract, contributing to GI disorder progression. GI cancer is a widespread and aggressive tumor sensitive to nutritional changes. Indeed, specific nutritional expedients can be adopted to prevent GI cancer onset and to slow down disease activity. Moreover, the patient’s nutritional status impacts prognosis, quality of life, and chemotherapy tolerance. These patients encounter the highest frequency of malnourishment risk, a condition that can progressively evolve into cachexia. Clinical studies dealing with this topic stressed the importance of nutritional counseling and put under the spotlight nutrient delivery, the type of nutrient supplementation, and timing for the start of nutritional management. A medical practitioner well-prepared on the topic of nutrition and cancer should operate in the clinical team dedicated to these oncological patients. This specific expertise needs to be implemented as soon as possible to adopt nutritional interventions and establish a proper patient-tailored dietary regimen. The nutritional gap closure should be prompt during anticancer treatment to stabilize weight loss, improve treatment tolerability, and ameliorate survival rate. Recently, novel nutritional approaches were investigated to target the bidirectional link between epigenetics and metabolism, whose alteration supports the onset, progression, and therapeutic response of GI cancer patients.

Nutritional status disorders and methods of their correction in patients with advanced pancreatic cancer

Despite of achieved progress in advanced pancreatic cancer treatment, the disease outcomes remain far from satisfying. The peculiarity of malnutrition treatment in these patients is the result of its causes complexity and progressively growing manifestations extent. The review represents mechanisms of malnutrition and approaches to their treatment.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer

Purpose

The pro vision of clinically assisted nutrition (CAN) in patients with advanced cancer is controversial, and there is a paucity of specific guidance, and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a Subgroup to develop evidence-based guidance on the use CAN in patients with advanced cancer.

Methods

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The outcomes of the review were categorised by the level of evidence, and a “category of guideline” based on the level of evidence (i.e. “recommendation”, “suggestion”, or “no guideline possible”).

Results

The Subgroup produced 11 suggestions, and 1 recommendation (due to the paucity of evidence). These outcomes relate to assessment of patients, indications for CAN, contraindications for CAN, procedures for initiating CAN, and re-assessment of patients.

Conclusions

This guidance provides a framework for the use of CAN in advanced cancer, although every patient needs individualised management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06613-y.

Relationship between body composition, exercise capacity and health-related quality of life in idiopathic pulmonary fibrosis

INTRODUCTION

Bioelectrical impedance analysis (BIA) can be used to estimate Fat-Free Mass Index (FFMI). However, the use of directly measured BIA variables, such as phase angle (PhA), has gained attention. The frequency of low FFMI and PhA and its associations with exercise capacity and health-related quality of life (HRQL) in patients with idiopathic pulmonary fibrosis (IPF) have been scarcely studied.

OBJECTIVES

To investigate the frequency of low FFMI and PhA and their associations with exercise capacity and HRQL in patients with IPF.

METHODS

Patients underwent assessment of lung function, body composition, exercise capacity by the 6 min walk distance (6MWD), and HRQL by the Medical Outcomes Study Short-Form 36-item Questionnaire (SF-36). Patients were classified as presenting normal or low PhA or FFMI, accordingly to the 10th percentiles of age-sex-body mass index (BMI)-specific reference values.

RESULTS

98 patients (84 males, age: 68±8 years, forced vital capacity: 64%±18%predicted) were included. 24 patients presented low PhA. They were characterised by worse lung function, exercise capacity and HRQL compared with patients with normal PhA. 10 patients presented low FFMI, but despite differences in body composition, no differences were found between these patients and patients with normal FFMI. In a single regression analysis, age, lung function and body composition variables (except FFMI) were related to 6MWD and SF-36 Physical Summary Score (R²=0.06-0.36, p<0.05). None of the variables were related to SF-36 Mental Summary Score.

CONCLUSION

One-fourth of the patients with IPF with normal to obese BMI present abnormally low PhA. Patients classified as low PhA presented worse lung function, exercise capacity and HRQL.

Safety and Feasibility of Fasting-Mimicking Diet and Effects on Nutritional Status and Circulating Metabolic and Inflammatory Factors in Cancer Patients Undergoing Active Treatment

Simple Summary

Our phase I/II clinical trial demonstrated that periodic cycles of a modified fasting regime (“fasting-mimicking diet” (FMD) by L-Nutra) were feasible and safe in cancer patients at low nutritional risk and that they did not negatively affect the patients’ body composition when combined with dietary and muscle training instructions to promote lean body mass re-gain in the periods between FMD cycles. While previously published studies of modified fasting in cancer patients exclusively enrolled patients receiving chemotherapy, in our trial, we also accrued patients treated with different types of therapies, including endocrine therapies (w/ or w/o CDK4/6 inhibitors), TKIs, proteasome inhibitors, immune check point inhibitors and radiotherapy. Eighteen different types of cancer are represented in our trial. Our study also shows that the FMD decreased fat mass and effectively lowered the circulating insulin, IGF1 and leptin. These are important elements of novelty of our study when compared to previously published trials.

Abstract

In preclinical studies, fasting was found to potentiate the effects of several anticancer treatments, and early clinical studies indicated that patients may benefit from regimes of modified fasting. However, concerns remain over possible negative impact on the patients’ nutritional status. We assessed the feasibility and safety of a 5-day “Fasting-Mimicking Diet” (FMD) as well as its effects on body composition and circulating growth factors, adipokines and cyto/chemokines in cancer patients. In this single-arm, phase I/II clinical trial, patients with solid or hematologic malignancy, low nutritional risk and undergoing active medical treatment received periodic FMD cycles. The body weight, handgrip strength and body composition were monitored throughout the study. Growth factors, adipokines and cyto/chemokines were assessed by ELISA. Ninety patients were enrolled, and FMD was administered every three weeks/once a month with an average of 6.3 FMD cycles/patient. FMD was largely safe with only mild side effects. The patients’ weight and handgrip remained stable, the phase angle and fat-free mass increased, while the fat mass decreased. FMD reduced the serum c-peptide, IGF1, IGFBP3 and leptin levels, while increasing IGFBP1, and these modifications persisted for weeks beyond the FMD period. Thus, periodic FMD cycles are feasible and can be safely combined with standard antineoplastic treatments in cancer patients at low nutritional risk. The FMD resulted in reduced fat mass, insulin production and circulating IGF1 and leptin. This trial was registered on Clinicaltrials.gov in July 2018 with the identifier NCT03595540.

The clinical and cost-effectiveness of supplemental parenteral nutrition in oncology

Background

Clinical guidelines recommend that parenteral nutrition (PN) is added to enteral nutrition (EN; supplemental parenteral nutrition (SPN)) in order to meet energy and protein needs in patients with cancer when EN alone is insufficient. However, although cancer-related malnutrition is common, there is poor awareness of the value of nutritional care, resulting in SPN being chronically underused.

Methods

We performed a targeted literature review and exploratory cost-utility analysis to gather evidence on the clinical effectiveness of SPN, and to estimate the potential cost-effectiveness of SPN versus EN alone in an example cancer setting.

Results

The literature review identified studies linking SPN with malnutrition markers, and studies linking malnutrition markers with clinical outcomes. SPN was linked to improvements in body mass index (BMI), fat-free mass, phase angle (PhA) and prealbumin. Of these markers, BMI and PhA were strong predictors of survival. By combining published data, we generated indirect estimates of the overall survival HR associated with SPN; these ranged from 0.80 to 0.99 (mode 0.87). In patients with Stage IV inoperable pancreatic cancer, the incremental cost-effectiveness ratio versus EN alone was estimated to be £41 350 or £91 501 depending on whether nursing and home delivery costs for EN and SPN were combined or provided separately.

Conclusion

Despite a lack of direct evidence, the results of the literature review demonstrate that SPN may provide important clinical and quality of life benefits to patients with cancer. The potential for any improvement in outcomes in the modelled patient population is very limited, so cost-effectiveness may be greater in patients with less severe disease and other types of cancer.

Diet and Exercise Interventions in Patients With Pancreatic Cancer: A Scoping Review

Diet and exercise interventions may help reverse malnutrition and muscle wasting common in pancreatic cancer. We performed a scoping review to identify the knowledge gaps surrounding diet and exercise interventions. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Embase, ProQuest Theses and Dissertations, and Google Scholar using the umbrella terms of "pancreatic cancer," "diet/nutrition," and "exercise." Included were articles reporting on ambulatory adults with diagnosed pancreatic cancer. Excluded were studies examining prevention and/or risk, animal, or cell lines. Of the 15,708 articles identified, only 62 met the final inclusion criteria. Almost half of the articles were randomized controlled studies (n = 27). Most studies were from the United States (n = 20). The majority examined dietary interventions (n = 41), with 20 assessing the use of omega-3 fatty acids. Exercise interventions were reported in 13 studies, with 8 examining a diet and exercise intervention. Most studies were small and varied greatly in terms of study design, intervention, and outcomes. We identified 7 research gaps that should be addressed in future studies. This scoping review highlights the limited research examining the effect of diet and exercise interventions in ambulatory patients with pancreatic cancer.

Home Parenteral Nutrition in Patients with Advanced Cancer: A Systematic Review and Meta-Analysis

The use of home parenteral nutrition (HPN) in patients with incurable cancer remains controversial with significant variation worldwide. We aimed to systematically evaluate the literature from 1960 to 2018 examining the use of HPN in advanced cancer patients for all intestinal failure indications and assess the potential benefits/burdens of HPN in this cohort of patients. The primary end point was survival and secondary end points were quality of life and nutritional/performance status. Meta-analysis was performed with a random effects model, where suitable. Of 493 studies retrieved, 22 met the quality inclusion criteria. Studies were mainly conducted in Western countries (Italy, USA, Canada, Germany), including a total of 3564 patients (mean age 57.8 years). Mean duration for HPN was 5.0 mo. Mean overall survival was 7.3 mo. Patients with improved performance status survived for longer on HPN. Quality of life was sparsely reported though there was no observed negative impact of PN. HPN-related complications were reported in eight studies only and were mainly catheter-related blood stream infections. In conclusion, HPN is used for several indications in advanced cancer, though there is significant heterogeneity of results. Disparities in geographical distribution of the studies may reflect variation in accessing HPN.

Monitoring Response to Home Parenteral Nutrition in Adult Cancer Patients

Current guidelines recommend home parenteral nutrition (HPN) for cancer patients with chronic deficiencies of dietary intake or absorption when enteral nutrition is not adequate or feasible in suitable patients. HPN has been shown to slow down progressive weight loss and improve nutritional status, but limited information is available on the monitoring practice of cancer patients on HPN. Clinical management of these patients based only on nutritional status is incomplete. Moreover, some commonly used clinical parameters to monitor patients (weight loss, body weight, body mass index, and oral food intake) do not accurately reflect patient’s body composition, while bioelectrical impedance analysis (BIA) is a validated tool to properly assess nutritional status on a regular basis. Therefore, patient’s monitoring should rely on other affordable indicators such as Karnofsky Performance Status (KPS) and modified Glasgow Prognostic Score (mGPS) to also assess patient’s functional status and prognosis. Finally, catheter-related complications and quality of life represent crucial issues to be monitored over time. The purpose of this narrative review is to describe the role and relevance of monitoring cancer patients on HPN, regardless of whether they are receiving anticancer treatments. These practical tips may be clinically useful to better guide healthcare providers in the nutritional care of these patients.

Early intravenous administration of nutritional support (IVANS) in metastatic gastric cancer patients at nutritional risk, undergoing first-line chemotherapy: study protocol of a pragmatic, randomized, multicenter, clinical trial

Background

Malnutrition is common in cancer patients, particularly in those affected by gastrointestinal malignancies, and negatively affects treatment tolerance, survival, functional status, and quality of life (QoL). Nutritional support, including supplemental parenteral nutrition (SPN), has been recommended at the earliest opportunity in malnourished cancer patients. The limited available evidence on the efficacy of SPN in gastrointestinal cancer patients is positive, particularly with regards to QoL, body composition, and energy intake, but the evidence on survival is still scanty. Furthermore, studies regarding the early administration of SPN in combination with nutritional counseling from the beginning of first-line chemotherapy (CT) are lacking. We hypothesize that early systematic SPN in combination with nutritional counseling (NC), compared with NC alone, can benefit patients with previously untreated metastatic gastric cancer at nutritional risk undergoing first-line CT.

Methods

The aim of this pragmatic, multicenter, randomized (1:1), parallel-group, open-label, controlled clinical trial is to evaluate the efficacy in terms of survival, weight maintenance, body composition, QoL and feasibility of cancer therapy of early systematic SNP. This is in combination with NC, compared with NC alone, in treatment-naïve metastatic gastric cancer patients at nutritional risk undergoing first-line CT.

Discussion

Malnutrition in oncology remains an overlooked problem. Although the importance of SPN in gastrointestinal cancer patients has been acknowledged, no studies have yet evaluated the efficacy of early SPN in metastatic gastric patients undergoing CT. The present study, which guarantees the early provision of nutritional assessment and support to all the enrolled patients in accordance with the recent guidelines and recommendations, could represent one of the first proofs of the clinical effectiveness of early intensive nutritional support in cancer patients undergoing CT. This study could stimulate further large randomized trials in different cancer types, potentially resulting in the improvement of supportive care quality.

Trial registration

This study is registered on ClinicalTrials.gov: NCT03949907.

Body composition assessment and sarcopenia in patients with pancreatic cancer: a systematic review and meta-analysis

BACKGROUND

Numerous studies have suggested an association between sarcopenia in pancreatic cancer and adverse outcomes. This systematic review examines the evidence for the impact of sarcopenia on post-operative complications and survival METHODS: A systematic literature search was conducted to identify randomised and non-randomised studies of sarcopenia in pancreatic cancer. Meta-analyses of intra- and post-operative outcomes were performed (operating time, all complications, major complications, pancreatic fistulae, peri-operative mortality, overall survival).

RESULTS

Forty-two studies reported the assessment of body composition in 7619 patients. Methods used to assess body composition in patients with pancreatic cancers were computerized tomography (n = 34), bioelectrical impedance analysis (n = 7), and dual-energy-X-ray-absorptiometry (n = 1). Only 10 studies reported the impact of pre-operative sarcopenia upon post-operative outcomes. Sarcopenia was associated with increased peri-operative mortality (OR: 2.40, CI_95%:1.19-4.85, p < 0.01) and decreased overall survival by univariable (HR: 1.95, CI_95%:1.35-2.81, p < 0.001) and multivariable analysis (HR: 1.78, CI_95%:1.54-2.05). Sarcopenia was not significantly associated with all complications (OR: 0.96, CI_95%:0.78-1.19) or pancreatic fistula (OR: 0.95, CI_95%: 0.59-1.54).

CONCLUSIONS

Assessment of sarcopenia in pancreatic cancer provides prognostic value but, more importantly, may provide a basis for therapeutic intervention. However, variation in the methods of assessing and reporting sarcopenia in this patient group limits the assessment of post-operative outcomes currently.

From guidelines to clinical practice: a roadmap for oncologists for nutrition therapy for cancer patients

Tackling malnutrition in cancer patients remains one of the most challenging tasks in clinical practice. Even though robust evidence exists stressing the role of nutritional status in relation to treatment outcome, its appropriate consideration in clinical practice is often lacking.

In this review, we discuss the significance of nutritional status and of malnutrition for the cancer patient. Drawn from experience and from current recommendations of the European Society for Clinical Nutrition and Metabolism (ESPEN), we propose concrete and manageable steps to routinely incorporate nutritional aspects in today’s oncological clinical practice.

[Nutritional Support for Patients with Pancreatic Cancer]

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.

Pancreatic Cancer Cachexia: The Role of Nutritional Interventions

Pancreatic cancer is a cancer with one of the highest mortality rates and many pancreatic cancer patients present with cachexia at diagnosis. The definition of cancer cachexia is not consistently applied in the clinic or across studies. In general, it is “defined as a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass with or without loss of fat mass that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.” Many regard cancer cachexia as being resistant to dietary interventions. Cachexia is associated with a negative impact on survival and quality of life. In this article, we outline some of the mechanisms of pancreatic cancer cachexia and discuss nutritional interventions to support the management of pancreatic cancer cachexia. Cachexia is driven by a combination of reduced appetite leading to reduced calorie intake, increased metabolism, and systemic inflammation driven by a combination of host cytokines and tumour derived factors. The ketogenic diet showed promising results, but these are yet to be confirmed in human clinical trials over the long-term. L-carnitine supplementation showed improved quality of life and an increase in lean body mass. As a first step towards preventing and managing pancreatic cancer cachexia, nutritional support should be provided through counselling and the provision of oral nutritional supplements to prevent and minimise loss of lean body mass.

Extracellular mass to body cell mass ratio as a potential index of wasting and fluid overload in hemodialysis patients. A case-control study

BACKGROUND & AIMS

Extracellular mass-to-body cell mass ratio (ECM/BCM ratio) which differentiates the proportion between intraextracellular compartments, could be a nutrition index of being wasted overloaded in hemodialysis (HD) patients. This study aimed to describe a cut-off point of the ECM/BCM ratio and, to find out the relationship between the nutritional-hydration status and this ratio in HD patients.

METHODS

A case-control study was carried out in 64 HD patients individually age-gender-matched to controls. Demographic, clinical and laboratory parameters were recorded. Bioelectrical impedance analysis was used to estimate ECM/BCM ratio as an indicator of the nutritional hydration status. Receiver operator characteristic (ROC) curve analysis was applied to determine the optimal cut-off point for identification of ECM/BCM ratio. An univariate and multivariate conditional logistic regression for the ECM/BCM ratio ≥1.20 was performed.

RESULTS

Median of ECM/BCM ratio was 1.50 (IQR:0.66) in HD patients, whereas 0.87 (IQR: 0.35) was found in controls (p < 0.001). HD-patients had lower body weight, serum albumin (s-albumin) and higher serum C-reactive protein (s-CRP) than controls. By ROC curve analysis, a cut-off point of 1.20 for the ECM/BCM ratio best discriminates to be wasted-overhydrated (sensitivity: 81.2%; specificity: 87.5%). Conditional logistic regression showed that for each 10%, ECM/BCM ratio increase the probability of developing fluid overload was increased 63% (OR: 1.63; 95% CI, 1.15-2.29), whereas an inverse association with s-albumin (OR: 0.15; 95% CI, 0.03-0.61) and other nutritional indicators were found.

CONCLUSIONS

The ECM/BCM ratio appears as a sensitive index that discriminates nutritional and/or hydration status in HD patients compared with age-gender-matched-controls. ECM/BCM ratios ≥1.20 are indicators of wasting and fluid overload in HD patients.

Pancreas Cancer-Associated Weight Loss

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.

Bioelectrical impedance analysis for monitoring cancer patients receiving chemotherapy and home parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) can improve survival, quality of life, nutritional and functional status in cancer patients. Bioelectrical impedance analysis (BIA) is a non-invasive, validated method to assess body composition. The objective of this prospective single-arm study was to investigate the impact of HPN in advanced cancer patients receiving chemotherapy assessed by BIA, clinical and laboratory measures.

METHODS

Adult malnourished cancer outpatients with solid tumors receiving anticancer treatments who were candidates for daily HPN were enrolled. Patients were assessed at baseline (T0), 60 (T1) and 90 days (T2) after HPN start. Assessments included anthropometric and clinical-oncological characteristics, performance status, inflammatory response and Patient-Generated Subjective Global Assessment (PG-SGA).

RESULTS

Sixty-five advanced cancer patients were enrolled. Median overall survival was 317 days. Body weight, BMI, oral calorie and protein intake increased over time (P < 0.01). At T2 the proportion of well-nourished patients, Karnofsky performance status and modified Glasgow prognostic score were improved (P < 0.01), total body water was reduced (P = 0.04), and fat mass increased (P = 0.04). Reactance, resistance and phase angle were significantly associated with survival at T0, T1, and T2, respectively. At T2, PG-SGA category A was a predictor of survival (P < 0.0001).

CONCLUSIONS

After 90 days of HPN, patients experienced significantly improved nutritional status, performance status, prognostic score and some BIA measures. HPN may be an important therapy in oncology patients receiving chemotherapy. Longitudinal use of BIA may help track the effects of HPN and disease progression, potentially contributing to optimal global patient management.

Optimization of Nutrition Therapy with the Use of Calorimetry to Determine and Control Energy Needs in Mechanically Ventilated Critically Ill Patients: The ONCA Study, a Randomized, Prospective Pilot Study

BACKGROUND

Adequate nutrition therapy in critically ill patients poses a challenge because of the variable energy and substrate needs. The objective was to investigate whether nutrition therapy involving indirect calorimetry (IC), instead of equations for assessment of energy needs, could improve the nutrition status of critically ill patients.

METHODS

Forty mechanically ventilated patients were randomized into a group in which energy needs were controlled by calorimetry (IC group) and a group treated with a formula-based approach reflecting standard care (SC group). The primary outcome was change in the phase angle (PhA), a bioelectrical impedance parameter related to nutrition status and prognosis.

RESULTS

The mean IC-based energy requirement was lower than the formula-based estimate (21.1 ± 6.4 versus [vs] 25 kcal/kg/d, P < .01). The IC group reached 98% ± 8% of the energy goal, whereas the SC group reached only 79% ± 29% (P < 0.05), although mean intake was similar in both groups. The protein intake goal was better met in the IC group (91% ± 24%) than the SC group (73% ± 33%). The PhA of the IC group did not change during treatment, whereas that of the SC group tended to decrease by 0.36° ± 0.86° (P = .077). A shorter length of stay in intensive care was observed in the IC than in the SC group (13 ± 8 vs 24 ± 20 days, P < .05).

CONCLUSION

Intensified individual nutrition therapy involving IC appears to be useful for improving nutrition status in critically ill patients.

Physical condition, nutritional status, fatigue, and quality of life in oncological out-patients

Objective:

Early detection of limited physical activity and nutritional deficiencies in cancer survivors could contribute to early treatment and preservation of quality of life. The aim of this study is to describe the association of physical condition and nutritional status with fatigue and quality of life in oncological out-patients.

Methods:

Data in this descriptive study was collected on bioelectrical impedance analysis, postural stability (stability index), body mass index, Karnofsky Index, quality of life (Short-Form 36-Item Health Survey) and fatigue (multidimensional fatigue inventory-20) in a consecutive sample of 203 oncological out-patients. Phase angle was calculated from bioelectrical impedance analysis. Values were intercorrelated and compared to appropriate standard values.

Results:

Phase angle and stability index outcomes were far below the values of a healthy population of similar age (p < 0.001). Quality of life was significantly lower than in the normal population (p < 0.001), and the level of fatigue was significantly higher (p < 0.001). Phase angle correlated with Karnofsky Index (p = 0.002) and Short-Form 36-Item Health Survey Summary physical function (p < 0.001). Furthermore, multidimensional fatigue inventory-20 scales ‘physical fatigue’ and ‘reduced activity’ were significantly associated with phase angle (p = 0.04, p = 0.005). Stability indices correlated with Short-Form 36-Item Health Survey physical function.

Conclusion:

The physical condition and the nutritional status are key components determining the individual quality of life of oncological out-patients. These variables also showed an association with the manifestation of fatigue. Results highlight the need for interdisciplinary cooperation to detect physical, nutritional and psychological deficiencies in oncological out-patients.

Longitudinal study of quality of life in advanced cancer patients on home parenteral nutrition

Since there is little knowledge regarding the quality of life (QoL) of cancer patients on home parenteral nutrition (HPN), we planned a prospective, longitudinal, double-center study to investigate the changes of QoL in these patients. One hundred and eleven adult cancer patients who were candidates for HPN following the indications of the European guidelines were consecutively enrolled. For QoL analysis, EORTC QLQ-C30 questionnaires were filled at the HPN start and after 1, 2, 3, and 4 months, and scores changes over time were analyzed according to the univariate mixed-effects linear model for repeated measures. Most patients had gastrointestinal cancers, were severely malnourished, and were in stage IV; two-thirds were still receiving oncologic treatments. Median weight loss over 3 months and body mass index were 11.7% and 20.7, respectively. Median survival was 4.7 (1-42) months; 67 and 34% of patients survived 3 and 6 months, respectively. Global QoL, physical functioning, role functioning, emotional functioning, appetite loss, and fatigue scores had a statistically significant trend over time (P < 0.001, P < 0.001, P = 0.007, P < 0.001, P = 0.004, P = 0.022, respectively). At the univariate analyses, the determinants significantly associated with changes in trend over time for physical, role, and emotional functioning were oncologic treatments (P < 0.001, P = 0.014, P = 0.040, respectively) and for appetite loss they were weight loss and Karnofsky performance status (P = 0.003, P = 0.023, respectively). Global QoL, physical, role, and emotional functioning improved during HPN even in advanced cancer patients on oncologic treatments.

Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection

Pancreatic cancer is an aggressive malignancy with a poor prognosis. The disease and its treatment can cause significant nutritional impairments that often adversely impact patient quality of life (QOL). The pancreas has both exocrine and endocrine functions and, in the setting of cancer, both systems may be affected. Pancreatic exocrine insufficiency (PEI) manifests as weight loss and steatorrhea, while endocrine insufficiency may result in diabetes mellitus. Surgical resection, a central component of pancreatic cancer treatment, may induce or exacerbate these dysfunctions. Nutritional and metabolic dysfunctions in patients with pancreatic cancer lack characterization, and few guidelines exist for nutritional support in patients after surgical resection. We reviewed publications from the past two decades (1995–2016) addressing the nutritional and metabolic status of patients with pancreatic cancer, grouping them into status at the time of diagnosis, status at the time of resection, and status of nutritional support throughout the diagnosis and treatment of pancreatic cancer. Here, we summarize the results of these investigations and evaluate the effectiveness of various types of nutritional support in patients after pancreatectomy for pancreatic adenocarcinoma (PDAC). We outline the following conservative perioperative strategies to optimize patient outcomes and guide the care of these patients: (1) patients with albumin < 2.5 mg/dL or weight loss > 10% should postpone surgery and begin aggressive nutrition supplementation; (2) patients with albumin < 3 mg/dL or weight loss between 5% and 10% should have nutrition supplementation prior to surgery; (3) enteral nutrition (EN) should be preferred as a nutritional intervention over total parenteral nutrition (TPN) postoperatively; and, (4) a multidisciplinary approach should be used to allow for early detection of symptoms of endocrine and exocrine pancreatic insufficiency alongside implementation of appropriate treatment to improve the patient’s quality of life.

Malnutrition Predicts Clinical Outcome in Patients with Neuroendocrine Neoplasia

Malnutrition is a common problem in oncological diseases, influencing treatment outcomes, treatment complications, quality of life and survival. The potential role of malnutrition has not yet been studied systematically in neuroendocrine neoplasms (NEN), which, due to their growing prevalence and additional therapeutic options, provide an increasing clinical challenge to diagnosis and management. The aim of this cross-sectional observational study, which included a long-term follow-up, was therefore to define the prevalence of malnutrition in 203 patients with NEN using various methodological approaches, and to analyse the short- and long-term outcome of malnourished patients. A detailed subgroup analysis was also performed to define risk factors for poorer outcome. When applying malnutrition screening scores, 21-25% of the NEN patients were at risk of or demonstrated manifest malnutrition. This was confirmed by anthropometric measurements, by determination of serum surrogate parameters such as albumin as well as by bioelectrical impedance analysis (BIA), particularly phase angle α. The length of hospital stay was significantly longer in malnourished NEN patients, while long-term overall survival was highly significantly reduced. Patients with high-grade (G3) neuroendocrine carcinomas, progressive disease and undergoing chemotherapy were at particular risk of malnutrition associated with a poorer outcome. Multivariate analysis confirmed the important and highly significant role of malnutrition as an independent prognostic factor for NEN besides proliferative capacity (G3 NEC). Malnutrition is therefore an underrecognized problem in NEN patients which should systematically be diagnosed by widely available standard methods such as Nutritional Risk Screening (NRS), serum albumin assessment and BIA, and treated to improve both short- and long-term outcomes.

Early Parenteral Nutrition in Patients with Biliopancreatic Mass Lesions, a Prospective, Randomized Intervention Trial

PURPOSE

Patients with biliopancreatic tumors frequently suffer from weight loss and cachexia. The in-hospital work-up to differentiate between benign and malignant biliopancreatic lesions requires repeated pre-interventional fasting periods that can aggravate this problem. We conducted a randomized intervention study to test whether routine in-hospital peripheral intravenous nutrition on fasting days (1000 ml/24 h, 700 kcal) has a beneficial effect on body weight and body composition.

MATERIAL AND METHODS

168 patients were screened and 100 enrolled in the trial, all undergoing in-hospital work-up for biliopancreatic mass lesions and randomized to either intravenous nutrition or control. Primary endpoint was weight loss at time of hospital discharge; secondary endpoints were parameters determined by bioelectric impedance analysis and quality of life recorded by the EORTC questionnaire.

RESULTS

Within three months prior to hospital admission patients had a median self-reported loss of 4.0 kg (25*th: -10.0 kg and 75*th* percentile: 0.0kg) of body weight. On a multivariate analysis nutritional intervention increased body weight by 1.7 kg (95% CI: 0.204; 3.210, p = 0.027), particularly in patients with malignant lesions (2.7 kg (95% CI: 0.71; 4.76, p < 0.01).

CONCLUSIONS

In a hospital setting, patients with suspected biliopancreatic mass lesions stabilized their body weight when receiving parenteral nutrition in fasting periods even when no total parenteral nutrition was required. Analysis showed that this effect was greatest in patients with malignant tumors. Further studies will be necessary to see whether patient outcome is affected as well.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02670265.

Nutrition in Pancreatic Cancer: A Review

BACKGROUND

Pancreatic cancer is the fourth leading cause of cancer-related mortality in both genders. More than 80% of patients suffer from significant weight loss at diagnosis and over time develop severe cachexia. Early nutritional support is therefore essential.

SUMMARY

This review evaluates the different nutritional therapies, such as enteral nutrition, parenteral nutrition and special nutritional supplements, on nutritional status, quality of life and survival.

KEY MESSAGE

Due to the high prevalence of malnutrition and the rapid development of anorexia-cachexia-syndrome, early nutritional intervention is crucial and supported by clinical data.

PRACTICAL IMPLICATIONS

Enteral nutrition should be preferred over parenteral nutrition. Omega-3 fatty acids and l-carnitine are promising substances for the prevention of severe cachexia, but further randomized controlled trials are needed to establish generally accepted guidelines on nutrition in pancreatic cancer.

The value of bioelectrical impedance analysis and phase angle in the evaluation of malnutrition and quality of life in cancer patients--a comprehensive review

Bioelectrical impedance analysis (BIA) and especially its derived parameter phase angle have been widely used in different populations. The variability of BIA measures has often been cited as a major limitation for its clinical use in evaluating nutritional status and overall health of patients. Cancer patients often present with malnourishment and cachexia, which complicate the course of treatment and affect outcomes. PubMed, CINAHL, EBSCO and Cochrane Library have been searched for relevant publications in English for BIA in cancer patients. Out of 197 total results, 27 original research articles related to BIA measures in cancer patients were included in this review. Studies indicate that the use of BIA and phase angle measures can benefit in the clinical management of cancer patients in multiple ways: in the prevention; diagnosis; prognosis; and outcomes related to treatments that affect nutritional and overall health status. Phase angle and fat-free mass measures were most commonly evaluated and correlated with nutritional status and survival rate. One limitation of BIA measures is the high interpatient variability which requires careful interpretation of results in the context of the individual patient rather than comparison with population data. The BIA and phase angle provide practitioners for the evaluation of nutritional and overall health status in cancer patients with a convenient and non-invasive technique and should be encouraged.

Phase angle and handgrip strength are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition

The assessment of nutritional intakes during hospitalization is crucial, as it is known that nutritional status tends to worsen during the hospital stay, and this can lead to the negative consequences of malnutrition. International guidelines recommend the use of parenteral nutrition (PN) in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. However, to date, there are no published data regarding either energy intake or objective measurements associated with it in this patient population. The aim of the present exploratory methodological study was to evaluate whether phase angle (PhA) and handgrip strength normalized for skeletal muscle mass (HG/SMM) are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. We evaluated 30 eligible patients, who were treated with personalized dietary modifications and supplemental PN for at least one week during hospitalization. In a liner regression model adjusted for age, gender, basal protein intake and the basal value of each variable, a trend toward improvement of PhA and preservation of HG/SMM was observed in patients satisfying the estimated calorie requirements (N = 20), while a significant deterioration of these parameters occurred in those who were not able to reach the target (N = 10). The mean adjusted difference and 95% CI were +1.4° (0.5-2.3) (p = 0.005) for PhA and +0.23 (0.20-0.43) (p = 0.033) for HG/SMM. A significant correlation between PhA and HG/SMM variations was also observed (r = 0.56 (95% CI, 0.23-0.77); p = 0.0023). PhA and HG/SMM were able to distinguish between hypophagic, non-surgical patients at nutritional risk who satisfied their estimated caloric requirements and those who did not after a one-week personalized nutritional support. Clinical studies are warranted, in order to verify these preliminary observations and to validate the role of PhA variations as early markers of anabolic/catabolic fluctuations.

Cachexia and pancreatic cancer: Are there treatment options?

Cachexia is frequently described in patients with pancreatic ductal adenocarcinoma (PDAC) and is associated with reduced survival and quality of life. Unfortunately, the therapeutic options of this multi-factorial and complex syndrome are limited. This is due to the fact that, despite extensive preclinical and clinical research, the underlying pathological mechanisms leading to PDAC-associated cachexia are still not fully understood. Furthermore, there is still a lack of consensus on the definition of cachexia, which complicates the standardization of diagnosis and treatment as well as the analysis of the current literature. In order to provide an efficient therapy for cachexia, an early and reliable diagnosis and consistent monitoring is required, which can be challenging especially in obese patients. Although many substances have been tested in clinical and preclinical settings, so far none of them have been proven to have a long-term effect in ameliorating cancer-associated cachexia. However, recent studies have demonstrated that multidimensional therapeutic modalities are able to alleviate pancreatic cancer-associated cachexia and ultimately improve patients’ outcome. In this current review, we propose a stepwise and pragmatic approach to facilitate and standardize the treatment of cachexia in pancreatic cancer patients. This strategy consists of nutritional, dietary, pharmacological, physical and psychological methods.

Pancreatic cancer cachexia: a review of mechanisms and therapeutics

Over the last decade, we have gained new insight into the pathophysiology of cachexia associated with pancreatic cancer. Unfortunately, its treatment is complex and remains a challenge. Pancreatic cancer cachexia is a multifactorial syndrome characterized by uncompensated adipose tissue and skeletal muscle loss in the setting of anorexia that leads to progressive functional impairment. This paper will review the current concepts of pancreatic cancer cachexia, its assessment and pathophysiology as well as current and future treatments. The successful management of pancreatic cancer cachexia will likely require a multimodal approach that includes nutritional support and combination pharmaceutical interventions.

Extracellular-to-body cell mass ratio and subjective global assessment in head-and-neck cancers

BACKGROUND

The ratio of extracellular mass to body cell mass (ecm/bcm), determined by bioelectrical impedance analysis, has been found to be a potentially useful indicator of nutrition status. Subjective global assessment (sga) is a subjective method of evaluating nutrition status in head-and-neck cancer. The present study was conducted to investigate the association between ecm/bcm and sga in head-and-neck cancer.

METHODS

Patients were classified as either well-nourished or malnourished by sga. Bioelectrical impedance analysis was conducted on a population of 75 patients with histologically confirmed head-and-neck cancer, and the ecm/bcm was calculated. Receiver operating characteristic curves were estimated using the nonparametric method to determine an optimal cut-off value of the ecm/bcm.

RESULTS

Compared with malnourished patients, those who were well-nourished had a statistically significantly lower ecm/bcm (1.11 vs. 1.28, p = 0.005). An ecm/bcm cut-off of 1.194 was 76% sensitive and 63% specific in detecting malnutrition.

CONCLUSIONS

The ecm/bcm can be an indicator that detects malnutrition in patients with head-and-neck cancer. Further observations are needed to validate the significance of the ecm/bcm and to monitor nutrition interventions.

Exocrine pancreatic insufficiency in adults: A shared position statement of the Italian association for the study of the pancreas

This is a medical position statement developed by the Exocrine Pancreatic Insufficiency collaborative group which is a part of the Italian Association for the Study of the Pancreas (AISP). We covered the main diseases associated with exocrine pancreatic insufficiency (EPI) which are of common interest to internists/gastroenterologists, oncologists and surgeons, fully aware that EPI may also occur together with many other diseases, but less frequently. A preliminary manuscript based on an extended literature search (Medline/PubMed, Cochrane Library and Google Scholar) of published reports was prepared, and key recommendations were proposed. The evidence was discussed at a dedicated meeting in Bologna during the National Meeting of the Association in October 2012. Each of the proposed recommendations and algorithms was discussed and an initial consensus was reached. The final draft of the manuscript was then sent to the AISP Council for approval and/or modification. All concerned parties approved the final version of the manuscript in June 2013.

Nutritional status and nutritional support before and after pancreatectomy for pancreatic cancer and chronic pancreatitis

Cachexia, malnutrition, significant weight loss, and reduction in food intake due to anorexia represent the most important pathophysiological consequences of pancreatic cancer. Pathophysiological consequences result also from pancreatectomy, the type and severity of which differ significantly and depend on the type of the operation performed. Nutritional intervention, either parenteral or enteral, needs to be seen as a method of support in pancreatic cancer patients aiming at the maintenance of the nutritional and functional status and the prevention or attenuation of cachexia. Oral nutrition could reduce complications while restoring quality of life. Enteral nutrition in the post-operative period could also reduce infective complications. The evidence for immune-enhanced feed in patients undergoing pancreaticoduodenectomy for pancreatic cancer is supported by the available clinical data. Nutritional support during the post-operative period on a cyclical basis is preferred because it is associated with low incidence of gastric stasis. Postoperative total parenteral nutrition is indicated only to those patients who are unable to be fed orally or enterally. Thus nutritional deficiency is a relatively widesoread and constant finding suggesting that we must optimise the nutritional status both before and after surgery.

L-Carnitine-supplementation in advanced pancreatic cancer (CARPAN)--a randomized multicentre trial

Background

Cachexia, a >10% loss of body-weight, is one factor determining the poor prognosis of pancreatic cancer. Deficiency of L-Carnitine has been proposed to cause cancer cachexia.

Findings

We screened 152 and enrolled 72 patients suffering from advanced pancreatic cancer in a prospective, multi-centre, placebo-controlled, randomized and double-blinded trial to receive oral L-Carnitine (4 g) or placebo for 12 weeks. At entry patients reported a mean weight loss of 12 ± 2,5 (SEM) kg. During treatment body-mass-index increased by 3,4 ± 1,4% under L-Carnitine and decreased (−1,5 ± 1,4%) in controls (p < 0,05). Moreover, nutritional status (body cell mass, body fat) and quality-of-life parameters improved under L-Carnitine. There was a trend towards an increased overall survival in the L-Carnitine group (median 519 ± 50 d versus 399 ± 43 d, not significant) and towards a reduced hospital-stay (36 ± 4d versus 41 ± 9d,n.s.).

Conclusion

While these data are preliminary and need confirmation they indicate that patients with pancreatic cancer may have a clinically relevant benefit from the inexpensive and well tolerated oral supplementation of L-Carnitine.