Nutrition therapy in esophageal cancer-Consensus statement of the Gastroenterological Society of Taiwan

A number of clinical guidelines on nutrition therapy in cancer patients have been published by national and international societies; however, most of the reviewed data focused on gastrointestinal cancer or non-cancerous abdominal surgery. To collate the corresponding data for esophageal cancer (EC), a consensus panel was convened to aid specialists from different disciplines, who are involved in the clinical nutrition care of EC patients. The literature was searched using MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the ISI Web of Knowledge. We searched for the best evidence pertaining to nutrition therapy in the case of EC. The panel summarized the findings in 3 sections of this consensus statement, based on which, after the diagnosis of EC, an initial distinction is made between the patients, as follows: (1) Assessment; (2) Therapy in patients with resectable disease; patients receiving chemotherapy or chemoradiotherapy prior to resection, and patients with unresectable disease, requiring chemoradiotherapy or palliative therapy; and (3) Formula. The resulting consensus statement reflects the opinions of a multidisciplinary group of experts, and a review of the current literature, and outlines the essential aspects of nutrition therapy in the case of EC. The statements are: Patients with EC are among one of the highest risk to have malnutrition. Patient generated suggestive global assessment is correlated with performance status and prognosis. Nutrition assessment for patients with EC at the diagnosis, prior to definitive therapy and change of treatment strategy are suggested and the timing interval can be two weeks during the treatment period, and one month while the patient is stable. Patients identified as high risk of malnutrition should be considered for preoperative nutritional support (tube feeding) for at least 7-10 days. Various routes for tube feedings are available after esophagectomy with similar nutrition support benefits. Limited intrathoracic anastomotic leakage postesophagectomy can be managed with intravenous antibiotics and self-expanding metal stent (SEMS) or jejunal tube. Enteral nutrition in patients receiving preoperative chemotherapy or chemoradiation provides benefits of maintaining weight, decreasing toxicity, and preventing treatment interruption. Tube feeding or SEMS can offer nutrition support in patients with unresectable esophageal cancer, but SEMS is not recommended for those with neoadjuvant chemoradiation before surgery. Enteral immunonutrition may preserve lean body mass and attenuates stress response after esophagectomy. Administration of glutamine may decrease the severity of chemotherapy induced mucositis. Enteral immunonutrition achieves greater nutrition status or maintains immune functions during concurrent chemoradiation.

Clinical application of total parenteral nutrition in patients with peritoneal carcinomatosis

Cancer patients with terminal stage peritoneal carcinomatosis are often unable to eat, rendering total parenteral nutrition (TPN) as the only option to avoid starvation. In this retrospective study, we reviewed the medical records of 46 patients with peritoneal carcinomatosis and compared them to the records of 51 patients who had gastrointestinal malignancy without evidence of peritoneal carcinomatosis. The factors evaluated include demographic data, cause of primary malignancy, ascites formation, anthropometric measurements, laboratory tests, and outcome measurements as well as factors associated with greater than 90-day survival. In-hospital mortality was observed in 31 of the 46 patients with peritoneal carcinomatosis, with a median survival time of 40 days (4-148 days) for all 46 patients. The median duration of TPN administration in the peritoneal carcinomatosis group was 24.1 ± 27.4 days (3-68 days). Severe infection related to TPN application was seen in 5/46 (10.7%) patients with peritoneal carcinomatosis and 6/51 (9.8%) patients without peritoneal carcinomatosis. The length of survival varied widely among terminal patients with peritoneal carcinomatosis. The average survival time in peritoneal carcinomatosis patients receiving TPN was short, indicating that the nutrition support of TPN was relatively suboptimal. Ascites was not a prognostic factor for peritoneal carcinomatosis, while body mass index was a predictor for 90-day survival.

Profiles of circulating endothelial cells and serum cytokines during adjuvant chemoradiation in rectal cancer patients

INTRODUCTION

This research aimed to demonstrate the correlation of circulating endothelial cells (CECs) count and serum cytokine levels with side effects and prognosis in rectal cancer patients receiving adjuvant chemoradiation.

METHODS

Eleven patients received proctectomy, chemoradiotherapy and follow-up for 4 years. Fifty-five blood samples were taken before radiation and during the course. The quantities of CECs were estimated by flow cytometry, and serological factors were measured by ELISA.

RESULTS

The CEC level in patients without tumor recurrence was significantly lower than in patients with tumor recurrence (p < 0.01). The IL-6 and TGF-β1 levels exhibited a similar profile (p < 0.01). For morbidity, the mean CEC level in patients with grade 3 diarrhea was significantly greater than patients with grades 1 (p < 0.001) and 2 diarrhea (p < 0.005).

CONCLUSIONS

Levels of CECs, serum IL-6, TGF-β1 and TNF-α during post-operative chemoradiation in rectal cancer patients might be candidate biomarkers for prognosis and morbidity (NCT00325871).

A randomised phase II study of pegylated arginine deiminase (ADI-PEG 20) in Asian advanced hepatocellular carcinoma patients

BACKGROUND

Human hepatocellular carcinoma (HCC) cells are largely deficient of argininosuccinate synthetase and thus auxotrophic for arginine. This study aims to investigate the efficacy and pharmacodynamics of pegylated arginine deiminase (ADI-PEG 20), a systemic arginine deprivation agent, in Asian HCC patients.

METHODS

Patients with advanced HCC who were not candidates for local therapy were eligible and randomly assigned to receive weekly intramuscular injections of ADI-PEG 20 at doses of 160 or 320 IU m(-2). The primary end point was disease-control rate (DCR).

RESULTS

Of the 71 accruals, 43.6% had failed previous systemic treatment. There were no objective responders. The DCR and the median overall survival (OS) of the intent-to-treat population were 31.0% (95% confidence interval (CI): 20.5-43.1) and 7.3 (95% CI: 4.7-9.9) months respectively. Both efficacy parameters were comparable between the two study arms. The median OS of patients with undetectable circulating arginine for more than or equal to and <4 weeks was 10.0 (95% CI: 2.1-17.9) and 5.8 (95% CI: 1.4-10.1) months respectively (P=0.251, log-rank test). The major treatment-related adverse events were grades 1-2 local and/or allergic reactions.

CONCLUSIONS

ADI-PEG 20 is safe and efficacious in stabilising the progression of heavily pretreated advanced HCC in an Asian population, and deserves further exploration.

Psoas abscess: a 10 year review

Psoas muscle abscesses are rarely encountered yet, and pose diagnostic and therapeutic challenges because of nonspecific clinical presentations. We retrospectively reviewed the medical records of adults with a psoas muscle abscess who were admitted to our hospital from January, 1988 to May, 1998. Over this ten year period, psoas abscesses were found in 11 cases. Six cases were primary and Staphylococcus spp. was the most commonly isolated. Five cases were a secondary psoas abscess while urological problems were the most common underlying condition. Fever, chills, lower back or flank pain and a palpable mass were the most common manifestations. Only one patient presented the classic triad of fever, flank pain, and limitation of hip movement (a typical psoas sign). Leukocytosis was the most common laboratory finding. Two of 11 cases presented septic shock. Two patients were admitted to the hospital with the initial diagnosis of psoas abscesses. Computerized tomographic (CT) scans accurately confirmed the clinical diagnosis in 9 of 11 patients. Diagnosis was then established one each by ultrasound (US) and magnetic resonance imaging (MRI), respectively. Four of 11 patients had negative findings initially by US. All patients were managed with drainage and antibiotics, nine were drained surgically, and two were managed with percutaneous drainage under CT guidance. Two patients died. Because of the lack of the classic symptoms and signs in most cases, a high degree of suspicion is important for early diagnosis of psoas abscess. CT scan is the standard technique of diagnosis. The prognosis is generally good with appropriate antibiotic treatment and complete drainage.

Hepatic actinomycosis: a case report

A 64-year-old man with hepatic actinomycosis presented with several months of weight loss and poor appetite. However, no fever was noted before admission. Findings on abdominal sonography and computed tomography scan were suggestive of hepatocellular carcinoma. A sono-guided percutaneous liver biopsy specimen demonstrated only chronic fibrosing inflammation. Therefore, laparotomy was performed and the diagnosis of hepatic actinomycosis was established after surgical resection. The patient was then successfully treated. The fact that hepatic actinomycosis may be very similar to hepatocellular carcinoma should be highly suspected. The hospital course of this patient concerning this condition and a brief review of the literature are presented to illustrate the diagnostic difficulties which may be encountered in such cases.

Malignant duodenocolic fistula: a case report

A 65 year-old female presented with diarrhea, body weight loss, malnutrition, elevated serum carcinoembryonic antigen (CEA) and electrolyte disturbances. A series of examinations showed colon cancer with a malignant duodenocolic fistula. Patient received extended right hemicolectomy with wide local excision of the duodenum (en bloc resection of the tumor). Recovery was smooth without local recurrence or metastasis after a six-month follow-up. Wide en bloc resection provides the only hope of cure in such cases. Treatment with extended right hemicolectomy with Whipple's procedure, or extended right hemicolectomy with extended local wide excision of duodenum, should be chosen, depending upon the extent of tumor invasion.