Cancer cachexia update in head and neck cancer: Pathophysiology and treatment

Prophylactic Versus Reactive Megestrol Acetate Use for Critical Body Weight Loss in Patients with Pharyngeal and Laryngeal Squamous Cell Carcinoma Undergoing Concurrent Chemoradiotherapy

This study compared the effects of megestrol acetate (MA) prophylactic (p-MA) versus reactive (r-MA) use for critical body-weight loss (>5% from baseline) during concurrent chemoradiotherapy (CCRT) in patients with advanced pharyngolaryngeal squamous cell carcinoma (PLSCC).

Patients receiving CCRT alone in two phase-II trials were included for analyses. Both the p-MA and r-MA cohorts received the same treatment protocol at the same institution, and the critical body-weight loss, survival, and adverse event profiles were compared.

The mean (SD) weight loss was 5.1% (4.7%) in the p-MA cohort (n = 54) vs. 8.1% (4.6%) in the r-MA cohort (n = 50) (p = .001). The percentage of subjects with body-weight loss >5% was 42.6% in the p-MA cohort vs. 68.0% in the r-MA cohort (p = .011). Tube feeding was needed in 22.2% of p-MA vs. 62.0% of r-MA patients (p < .001). Less neutropenia (26.0% vs. 70.0% [p < .001]) and a shorter duration of grade 3-4 mucositis (2.4 ± 1.4 vs. 3.6 ± 2.0 wk [p = .009]) were observed with p-MA treatment. Disease-specific survival, locoregional control, or distant metastasis-free survival did not differ. Less competing mortality from secondary primary cancer resulted in a better overall survival trend in the p-MA cohort.

p-MA may reduce body-weight loss and improve adverse event profiles during CCRT for patients with PLSCC.

Cachexia and head and neck squamous cell carcinoma: A scoping review

OBJECTIVE

The objective of this paper was to provide an understanding of cachexia in relation to oral squamous cell carcinoma relevant to oral health care. The paper is a scoping review of aspects of the clinical presentation, aetiology and management of cachexia in relation to oral health and oral health care.

METHODS

A combined search of MEDLINE and EMBASE databases (via OVID) was conducted using the terms ([Head and Neck] OR [Oral Squamous Cell Carcinoma]) AND (Cachexia). Duplicates were removed and results were subsequently limited to studies published between 2000 and 2023, humans and English language. After screening and full-text assessment a total number of 87 studies were included in the review.

RESULTS

It is evident that cachexia is a not uncommon feature of patients with advanced malignancy of the head and neck driven by a multitude of mechanisms, induced by the tumour itself, that lead to reduced nutritional intake, increased metabolism and loss of adipose and skeletal tissue.

CONCLUSION

While a variety of nutritional, physical, psychological and pharmacological interventions may improve quality and duration of life, ultimately the diagnosis of cachexia in relation to head and neck cancer remains an indicator of poor life expectancy.

Transcriptome-based deep learning analysis identifies drug candidates targeting protein synthesis and autophagy for the treatment of muscle wasting disorder

Sarcopenia, the progressive decline in skeletal muscle mass and function, is observed in various conditions, including cancer and aging. The complex molecular biology of sarcopenia has posed challenges for the development of FDA-approved medications, which have mainly focused on dietary supplementation. Targeting a single gene may not be sufficient to address the broad range of processes involved in muscle loss. This study analyzed the gene expression signatures associated with cancer formation and 5-FU chemotherapy-induced muscle wasting. Our findings suggest that dimenhydrinate, a combination of 8-chlorotheophylline and diphenhydramine, is a potential therapeutic for sarcopenia. In vitro experiments demonstrated that dimenhydrinate promotes muscle progenitor cell proliferation through the phosphorylation of Nrf2 by 8-chlorotheophylline and promotes myotube formation through diphenhydramine-induced autophagy. Furthermore, in various in vivo sarcopenia models, dimenhydrinate induced rapid muscle tissue regeneration. It improved muscle regeneration in animals with Duchenne muscular dystrophy (DMD) and facilitated muscle and fat recovery in animals with chemotherapy-induced sarcopenia. As an FDA-approved drug, dimenhydrinate could be applied for sarcopenia treatment after a relatively short development period, providing hope for individuals suffering from this debilitating condition.

Molecular Mechanisms of Cachexia: A Review

Cachexia is a condition characterized by substantial loss of body weight resulting from the depletion of skeletal muscle and adipose tissue. A considerable fraction of patients with advanced cancer, particularly those who have been diagnosed with pancreatic or gastric cancer, lung cancer, prostate cancer, colon cancer, breast cancer, or leukemias, are impacted by this condition. This syndrome manifests at all stages of cancer and is associated with an unfavorable prognosis. It heightens the susceptibility to surgical complications, chemotherapy toxicity, functional impairments, breathing difficulties, and fatigue. The early detection of patients with cancer cachexia has the potential to enhance both their quality of life and overall survival rates. Regarding this matter, blood biomarkers, although helpful, possess certain limitations and do not exhibit universal application. Additionally, the available treatment options for cachexia are currently limited, and there is a lack of comprehensive understanding of the underlying molecular pathways associated with this condition. Thus, this review aims to provide an overview of molecular mechanisms associated with cachexia and potential therapeutic targets for the development of effective treatments for this devastating condition.

A Multi-Site, International Audit of Malnutrition Risk and Energy and Protein Intakes in Patients Undergoing Treatment for Head Neck and Esophageal Cancer: Results from INFORM

Patients with foregut tumors are at high risk of malnutrition. Nutrition care focuses on identifying individuals at risk of malnutrition and optimizing nutrient intake to promote the maintenance of body weight and lean body mass. This multi-center prospective, longitudinal study audited nutrition care practices related to screening for risk of malnutrition (Patient-Generated Subjective Global Assessment Short Form; PG-SGA SF), and nutrition interventions prescribed (route; adequacy of energy and protein intakes). Audits occurred at four time periods: baseline (before treatment) and at 2, 4, and 6 months after starting cancer treatment; 170 patients (esophageal (ESO; n = 51); head and neck (HN; n = 119)) were enrolled. Nutrition risk (PG-SGA SF score ≥ 4) was prevalent at every time period: HN (baseline: 60%; 6 months 66%) and ESO (77%; 72%). Both groups had significant (p < 0.001) weight losses over the 6 month audit period (HN = 13.2% ESO = 11.4%). Enteral nutrition (EN) was most likely to be prescribed at 2 months for HN and at 4 and 6 months for ESO. Target prescribed energy and protein intakes were not met with any nutrition intervention; although adequacy was highest for those receiving EN. Nutrition care practices differed for HN and ESO cancers and there may be time points when additional nutrition support is needed.

Does Human Papillomavirus Infection Influence the Frequency and Severity of Nutritional Disorders in Head and Neck Cancer?

BACKGROUND

About 87% of head and neck cancer (HNC) patients (mostly oropharyngeal cancer-OPC) are infected with human papillomavirus (HPV). Recent studies have demonstrated a significant correlation between HPV infection and nutritional disorders in HNC patients. Therefore, we formed a hypothesis that nutritional disorders or their severity in HNC patients may be associated with the occurrence of HPV infection due to known molecular differences in involved tissue. This literature review aimed to evaluate the influence of HPV infection on the occurrence and severity of nutritional disorders in HNC patients.

MATERIALS AND METHODS

The PubMed database was used to search papers with the keywords "HPV", "HNC", and "nutritional disorders" in different variants and combinations.

CONCLUSIONS

The data available in the discussed papers indicate, among other things, that HPV-positive patients may be at higher risk of malnutrition, critical weight loss, and necessity for gastrostomy after radiotherapy or chemoradiotherapy (C-RT). It should be highlighted that despite some studies demonstrating positive results, currently available data regarding the influence of HPV infection on the occurrence and severity of nutritional disorders in HNC remain limited and inconclusive, and thus further research on this issue is warranted.

Pretreatment Glasgow Prognostic Score Correlated with Serum Histidine Level and Three-Year Mortality of Patients with Locally Advanced Head and Neck Squamous Cell Carcinoma and Optimal Performance Status

Few prospective cohort trials have investigted the effect of pretreatment nutritional and inflammatory status on the clinical outcome of patients with cancer and optimal performance status and assessed the interplay between nutrition, inflammation, body composition, and circulating metabolites before treatment. Here, 50 patients with locally advanced head and neck squamous cell carcinoma (LAHNSCC) and Eastern Cooperative Oncology Group performance status (ECOG PS) ≤ 2 were prospectively recruited along with 43 healthy participants. Before concurrent chemoradiotherapy, compared with healthy controls, the cancer group showed lower levels of histidine, leucine, and phenylalanine and had low values in anthropometric and body composition measurements; however, the group displayed higher ornithine levels, more malnutrition, and severe inflammation. Pretreatment advanced Glasgow prognostic score (1 and 2) status was the sole prognostic factor for 3-year mortality rate and was associated with age and serum histidine levels in patients with cancer. Thus, even at the same tumor stage and ECOG PS, patients with LAHNSCC, poor nutrition, and high inflammation severity at baseline may have inferior survival outcomes than those with adequate nutrition and low inflammation severity. Assessment of pretreatment nutritional and inflammatory status should be included in the enrollment criteria in future studies.

Postoperative consequences of cancer cachexia after head and neck free flap reconstruction

BACKGROUND

Cachexia is detrimental for patients with head and neck cancer (HNC). However, postoperative consequences of HNC cachexia remain unknown.

METHODS

A 2014-2019 retrospective review was performed of adults undergoing aerodigestive HNC resection with free tissue reconstruction. Propensity score matching using inverse probability of treatment weighting (IPTW) of cachectic and control groups was employed to adjust for covariate imbalances followed by binary logistic regression on postoperative outcomes.

RESULTS

Out of 252 total patients, 135 (53.6%) had cancer cachexia. The cohort was predominantly white (94.4%) males (65.1%) aged 61.5 ± 11.5 years with stage III-IV (84.1%) malignancy of the oral cavity (66.3%). After matching cohort pre- and intra-operative covariates using IPTW, cancer cachexia remained a strong, significant predictor of serious National Surgical Quality Improvement Program (NSQIP) complications (OR [95%CI] = 3.84 [1.80-8.21]) and major Clavien-Dindo complications (OR [95%CI] = 3.00 [1.18-7.60]).

CONCLUSIONS

Cancer cachexia is associated with worse HNC free flap reconstruction outcomes.

Managing Cachexia in Head and Neck Cancer: a Systematic Scoping Review

Introduction

Patients with head and neck cancer (HNC) are usually confronted with functional changes due to the malignancy itself or its treatment. These factors typically affect important structures involved in speech, breathing, chewing, swallowing, and saliva production. Consequently, the intake of food will be limited, which further contributes to loss of body weight and muscle mass, anorexia, malnutrition, fatigue, and anemia. This multifactorial condition can ultimately lead to cancer cachexia syndrome. This study aims to examine the treatment of cachexia in HNC patients.

Methods

We systematically searched OvidMedline, PubMed, Scopus, and Web of Science for articles examining the treatment of cachexia in HNC.

Results

A total of nine studies were found, and these suggested interventions including nutritional, pharmacologic, therapeutic exercise, and multimodal approaches. The nutritional intervention includes essential components such as dietary counseling, oral nutritional supplements, and medical nutritional support. Individualized nutritional interventions include oral, enteral (feeding tubes i.e., percutaneous endoscopic gastrostomy [PEG], nasogastric tube [NGT]) and parenteral nutrition. The pharmacologic interventions aim at increasing the appetite and weight of cachectic patients. Therapeutic exercise and increased physical activity can help to enhance the synthesis of muscle protein, reducing inflammation and the catabolic effects of cachexia syndrome.

Conclusion

Owing to the multifactorial nature of this syndrome, it is expected that the management approach should be multi-interventional. Early implementation of these interventions may help to improve survival and quality of health and life of cachectic HNC patients.

A Single Axial Slice of the Sternocleidomastoids and Paravertebral Muscles Associated with Worse Local Progression-Free Survival and Severe Toxicity in Sarcopenic Head and Neck Cancer Patients Undergoing Radiotherapy

Objective

The objective of this study is to contrast the predictive ability of targeted muscle groups as radiographic proxies of sarcopenia on computerized tomography (CT) with body mass index (BMI) in head and neck cancer patients (H&NCP) undergoing radiation at a safety net hospital, and to evaluate sarcopenia with survival, local progression, toxicities and treatment delays.

Methods

A retrospective review included 52 H&NCP treated between 2017-2019. The posterior neck muscles (PN), sternocleidomastoids (SCM), and their summed volume (AM) were contoured at C3 on patients’ pre-treatment CT scans, then normalized to obtain skeletal muscle index (MI) values. Pre-treatment BMI was also evaluated. Cutoffs for sarcopenia were determined by receiver operating characteristic curves. Overall survival and local recurrence-free survival were evaluated by Kaplan-Meier. Acute grade 3 or higher toxicities were evaluated by binomial logistic regression.

Results

Using all neck muscles (AM-MI) produced the best model for predicting outcomes, outperforming individual muscle groups and BMI. Local progression-free survival was worse in sarcopenic patients at 25.81 months versus 35.40 months (p=0.026). Acute grade 3 or higher toxicities were associated with sarcopenia (p=0.005).

Conclusions

In this small, retrospective single-institution experience at a safety net hospital, a single axial slice of the combined sternocleidomastoids and paravertebral muscles at C3 performed better than either muscle group alone or pre-treatment BMI at predicting oncologic outcomes.

Inflammation Status and Body Composition Predict Two-Year Mortality of Patients with Locally Advanced Head and Neck Squamous Cell Carcinoma under Provision of Recommended Energy Intake during Concurrent Chemoradiotherapy

Only few prospective cohort trials have evaluated the risk factors for the 2-year mortality rate between two patient subgroups with locally advanced head and neck squamous cell carcinoma (LAHNSCC): oral cavity cancer with adjuvant concurrent chemoradiotherapy (CCRT) (OCC) and non-oral cavity cancer with primary CCRT (NOCC), under the recommended calorie intake and investigated the interplay among calorie supply, nutrition–inflammation biomarkers (NIBs), and total body composition change (TBC), as assessed using dual-energy X-ray absorptiometry (DXA). Patients with LAHNSCC who consumed at least 25 kcal/kg/day during CCRT were prospectively recruited. Clinicopathological variables, blood NIBs, CCRT-related factors, and TBC data before and after treatment were collected. Factor analysis was performed to reduce the number of anthropometric and DXA-derived measurements. Cox proportional hazards models were used for analysis. We enrolled 123 patients with LAHNSCC (69 with OCC and 54 with NOCC). The mean daily calorie intake correlated with the treatment interval changes in total body muscle and fat. Patients consuming ≥30 kcal/kg/day had lower pretreatment levels but exhibited fewer treatment interval changes in anthropometric and DXA measurements than patients consuming <30 kcal/kg/day. In the multivariate analysis of the 2-year mortality rate, the prognostic influence of the recommended calorie intake could not be confirmed, but different risk factors (performance status, pretreatment platelet-to-lymphocyte ratio, and treatment interval body muscle changes in patients with OCC; age, pretreatment neutrophil-to-lymphocyte ratio, and body fat storage in patients with NOCC) showed independent effects. Therefore, the inflammation status and body composition, but not the recommended calorie supply, contribute to the 2-year mortality rate for patients with LAHNSCC receiving CCRT.

Concurrent Chemoradiotherapy Induces Body Composition Changes in Locally Advanced Head and Neck Squamous Cell Carcinoma: Comparison between Oral Cavity and Non-Oral Cavity Cancer

Few prospective cohort trials have evaluated the difference in treatment-interval total body composition (TBC) changes assessed by dual-energy X-ray absorptiometry (DXA) between two patient subgroups with locally advanced head and neck squamous cell carcinoma (LAHNSCC) receiving concurrent chemoradiotherapy (CCRT): oral cavity cancer with adjuvant CCRT (OCC) and non-oral cavity with primary CCRT (NOCC). This study prospectively recruited patients with LAHNSCC. Clinicopathological variables, blood nutritional/inflammatory markers, CCRT-related factors, and TBC data assessed by DXA before and after treatment were collected. Multivariate linear regression analysis identified the factors associated with treatment-interval changes in body composition parameters, including lean body mass (LBM), total fat mass (TFM), and bone mineral content (BMC). A total of 127 patients (OCC (n = 69) and NOCC (n = 58)) were eligible. Body composition parameters were progressively lost during CCRT in both subgroups. Extremities lost more muscle mass than the trunk for LBM, whereas the trunk lost more fat mass than the extremities for TFM. BMC loss preferentially occurred in the trunk region. Different factors were independently correlated with the interval changes of each body composition parameter for both OCC and NOCC subgroups, particularly mean daily calorie intake for LBM and TFM loss, and total lymphocyte count for BMC loss. In conclusion, treatment-interval TBC changes and related contributing factors differ between the OCC and NOCC subgroups.

Poor dental condition is a factor of imbalance of the nutritional status at the outset of management of head and neck cancer

OBJECTIVES

To determine whether deterioration of dental condition at the outset of management of head and neck cancer (HNC) is a nutritional risk and whether social deprivation is a cause of the poor dental condition observed in HNC patients.

MATERIAL AND METHODS

A nutritional assessment form (NAF) and the Nutrition Risk Index (NRI) were used to standardize the nutritional status of 108 patients at the outset of management of HNC (2017-2019). The NAF includes assessment of weight loss over the past 3 months, the amount and difficulty of food intake, and the presence of digestive disorders. Dental condition was assessed by the decayed, filled, and missing teeth acopre (DFM) index and the masticatory coefficient (MC). Dental status and social deprivation were correlated with the EPICES score.

RESULTS

A correlation was found between the extent of weight loss and dental condition. The MC was higher in absence of weight loss (46% vs. 27%, p = 0.03) and the DMF lower when weight loss was less than 5% (22.3 vs. 26.9 if > 5% loss of weight, p = 0.005). No correlation was found between dental status and nutritional status. Social deprivation was associated with a lower MC (26% vs. 50%, p < 0.001).

CONCLUSION

Dental condition is a risk factor for weight loss at the outset of management of HNC but is not a determinant of nutritional status. Clinical relevance Dental condition is no longer considered simply as a source of potential complications after radiotherapy but also as an important factor for nutritional status.

Association Between Interleukin-6 and Head and Neck Squamous Cell Carcinoma: A Systematic Review

Interleukin-6 (IL-6) is a proinflammatory cytokine which plays an important role in several regulatory mechanisms of cancer. Moreover, experimental and clinical studies have reported that IL-6 targeted therapies might provide significant benefits for cancer treatment. The purpose of this systematic review is to evaluate IL-6 activity in patients with head and neck squamous cell carcinoma (HNSCC). A systematic review of the association between serum, saliva and tumor IL-6 and HNSCC was developed on PubMed/Medline in the publication range from January 1995 to January 2019. Our literature analysis demonstrated that overexpression and elevated serum and/or saliva IL-6 concentrations in patients with HNSCC are related to poor survival and oncological outcomes. Although there is a correlation between IL-6 concentrations and tumorigenicity, it is noteworthy that IL-6 targeted therapies are generally performed in vitro and in experimental studies. Therefore, prospective, randomized clinical trials are required that focus on IL-6 targeted therapies for the treatment of HNSCC.

Radiologically Defined Sarcopenia Affects Survival in Head and Neck Cancer: A Meta-Analysis

OBJECTIVE

To determine whether radiologically defined sarcopenia at the C3 or L3 level as measured by computed tomography or magnetic resonance imaging is prognostic of overall survival (OS) in head and neck cancers (HNCs).

METHODS

Literature searches of PubMed, Embase, and Scopus were conducted on July 12, 2019, to include articles written in the English language with no constraints on publication date. To be included in the analysis, articles had to report the prognostic impact of skeletal muscle mass measured radiologically at the C3 or L3 vertebral level in HNC patients; hazard ratios (HRs) for OS; 95% confidence intervals (CIs); be from a clinical trial, cohort, or case-control study; and have English full-text availability. Articles were reviewed in consensus by two reviewers, with disagreements reviewed by a third reviewer. Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis Of Observational Studies in Epidemiology Checklist guidelines were used for reporting. Study quality assessment was performed using Quality In Prognosis Studies tool. The random-effects DerSimonian and Laird method was used for meta-analysis.

RESULTS

Ten articles, nine retrospective and one prospective, were included in this meta-analysis (n = 2,181 patients). Significant differences were found in OS for HNC patients with sarcopenia (HR = 1.98; 95% CI: 1.64-2.39; P < .00001). No heterogeneity was detected in either the overall or subgroup analyses.

CONCLUSIONS

Radiologically defined sarcopenia is a negative predictor of OS in patients with HNC. Early detection of sarcopenia in cancer patients may help guide nutritional and adjuvant support to improve treatment outcomes.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:333-341, 2021.

Determining Malnutrition Assessment Criteria to Predict One-Year Mortality for Locally Advanced Head and Neck Cancer Patients Undergoing Concurrent Chemoradiotherapy

Study on the impact of pretreatment malnutrition on treatment outcomes in locally advanced head and neck cancer (LAHNC) patients is still lacking. We prospectively collected various malnutrition assessment methods including nutrition indexes, inflammatory biomarkers, and lean body mass index (LBMI) data before treatments. The one year mortality rate was assessed, and the factors associated with this outcome were investigated. Furthermore, the association between malnutrition assessment methods was examined. A total of 113 patients were enrolled. By prognostic stratification based on the prognostic nutritional index (PNI) and platelet-to-lymphocyte ratio (PLR) combination, the low PNI/high PLR group had highest and the high PNI/low PLR group had the lowest mortality rate. Furthermore, the PNI was positively correlated with the LBMI, and the PLR was inversely correlated with the LBMI. PNI and PLR were found to be independent prognostic factors of one year mortality and also associated with the loss of muscle.

Combined analysis of miRNA-181a with phase angle derived from bioelectrical impedance predicts radiotherapy-induced changes in body composition and survival of male patients with head and neck cancer

BACKGROUND

Nutritional deficits developing as an effect of applied radiotherapy (RTH) negatively affect patients' quality of life, survival, and therapy outcomes. We demonstrated novel approach to prediction of RTH-induced changes in body composition of patients with head and neck cancer using phase angle (PA) derived from bioelectrical impedance in combination with miRNA-181a expression.

RESULTS

Patients with simultaneous presence of low PA and high miRNA expression were at a significantly higher risk of decreasing the fat-free mass index (FFMI) <14.9 kg/m² (odds ratio [OR] = 5.14; P = .02), FFM < 44.7 kg (OR = 6.20; P = .04), and lean mass (OR = 10.0; P = .04) during the therapy period. Receiver operating curve analysis allowed to predict changes in FFMI, lean mass, and FFM with area under the curve calculation over 0.700. The simultaneous presence of high miRNA and low PA negatively affected patients' survival (OR = 5.12; P = .02).

CONCLUSION

Evaluation of PA in combination with miRNA demonstrates higher diagnostic accuracy and predictive value for detecting RTH-induced changes in body composition of patients with cancer.

Association between pretreatment obesity, sarcopenia, and survival in patients with head and neck cancer

BACKGROUND

Body mass index (BMI), sarcopenia, and obesity-related comorbidities have been associated with head and neck squamous cell carcinoma (HNSCC) progression.

METHODS

We conducted a retrospective analysis of 441 normal-weight, overweight, and obese HNSCC patients treated at Montefiore Medical Center (New York). Patients were grouped by BMI prior to treatment and assessed for differences in survival adjusting for comorbid conditions (cardiovascular disease and diabetes). Evidence of sarcopenia was also assessed using pretreatment abdominal CT scans in a subset of 113 patients.

RESULTS

Prior to treatment, 55% of HNSCC patients were overweight or obese. Overweight/obese patients had significantly better overall survival (hazard ratio [HR] = 0.4, 95% CI: 0.3-0.6) compared to normal-weight patients, independent of comorbid conditions. Patients with sarcopenia had significantly poorer survival (HR = 2.1, 95% CI: 1.1-3.9) compared to non-sarcopenic patients, with the strongest association seen among overweight/obese patients.

CONCLUSION

Our data support the importance of sarcopenia assessment, in addition to BMI, among patients with HNSCC.

Understanding the Role of Exercise in Cancer Cachexia Therapy

Cachexia, the unintentional loss of body weight, is prevalent in many cancer types, and the associated skeletal muscle mass depletion increases patient morbidity and mortality. While anorexia can be present, cachexia is not reversible with nutritional therapies alone. Pharmacological agents have been proposed to treat this condition, but there are currently no approved treatments. Nonetheless, the hallmark characteristics associated with cancer cachexia remain viable foundations for future therapies. Regular physical activity holds a promising future as a nonpharmacological alternative to improve patient survival through cachexia prevention. Evidence suggests exercise training is beneficial during cancer treatment and survival. However, the mechanistic examination of cachectic skeletal muscle's response to exercise is both needed and justified. The primary objective of this review is to discuss the role of exercise for the prevention and treatment of cancer-associated muscle wasting. Initially, we provide an overview of systemic alterations induced by cancer and their role in the regulation of wasting processes during cachexia progression. We then discuss how exercise could alter disrupted regulatory pathways related to growth and metabolism during cancer-induced muscle atrophy. Last, we outline current exercise prescription guidelines and how exercise could be a potential behavioral therapy to curtail cachexia development in cancer patients.

The TLR7/8/9 Antagonist IMO-8503 Inhibits Cancer-Induced Cachexia

: Muscle wasting is a feature of the cachexia syndrome, which contributes significantly to the mortality of patients with cancer. We have previously demonstrated that miR-21 is secreted through extracellular vesicles (EV) by lung and pancreatic cancer cells and promotes JNK-dependent cell death through its binding to the TLR7 receptor in murine myoblasts. Here, we evaluate the ability of IMO-8503, a TLR7, 8, and 9 antagonist, to inhibit cancer-induced cachexia. Using EVs isolated from lung and pancreatic cancer cells and from patient plasma samples, we demonstrate that IMO-8503 inhibits cell death induced by circulating miRNAs with no significant toxicity. Intraperitoneal administration of the antagonist in a murine model for Lewis lung carcinoma (LLC-induced cachexia) strongly impaired several cachexia-related features, such as the expression of Pax7 as well as caspase-3 and PARP cleavage in skeletal muscles, and significantly prevented the loss of lean mass in tumor-bearing mice. IMO-8503 also impaired circulating miRNA-induced cell death in human primary myoblasts. Taken together, our findings strongly indicate that IMO-8503 serves as a potential therapy for the treatment of cancer cachexia. SIGNIFICANCE: Cancer-associated cachexia is a significant problem for patients with cancer that remain poorly understood, understudied, and inadequately treated; these findings report a potential new therapeutic for the treatment of TLR7-mediated cancer cachexia.

An analysis of the types of recently published research in the field of cachexia

Introduction Cachexia is a common complication of many and varied chronic disease processes, yet it has received very little attention as an area of clinical research effort until recently. We sought to survey the contemporary literature on published research into cachexia to define where it is being published and the proportion of output classified into the main types of research output. Methods I searched the PubMed listings under the topic research term "cachexia" and related terms for articles published in the calendar years of 2015 and 2016, regardless of language. Searches were conducted and relevant papers extracted by two observers, and disagreements were resolved by consensus. Results There were 954 publications, 370 of which were review articles or commentaries, 254 clinical observations or non-randomised trials, 246 original basic science reports and only 26 were randomised controlled trials. These articles were published in 478 separate journals but with 36% of them being published in a core set of 23 journals. The H-index of these papers was 25 and there were 147 papers with 10 or more citations. Of the top 100 cited papers, 25% were published in five journals. Of the top cited papers, 48% were review articles, 18% were original basic science, and 7% were randomised clinical trials. Discussion This analysis shows a steady but modest increase in publications concerning cachexia with a strong pipeline of basic science research but still a relative lack of randomised clinical trials, with none exceeding 1000 patients. Research in cachexia is still in its infancy, but the solid basic science effort offers hope that translation into randomised controlled clinical trials may eventually lead to effective therapies for this troubling and complex clinical disease process.

A review of weight loss and sarcopenia in patients with head and neck cancer treated with chemoradiation

Background

Concurrent chemotherapy and radiation (CTRT) improves disease-free survival in locally advanced head and neck cancer but is associated with numerous acute and chronic toxicities resulting in substantial alterations in body mass and composition. We aim to summarize the current evidence on body composition changes experienced by patients undergoing CTRT, examine the impact of these changes on clinical outcomes and address potential interventions aimed at mitigating the loss.

Main Body

Loss of 20 % of pre-CTRT weight predicts poorer treatment tolerance and 30-day mortality. While clinical practice focuses on body weight, emerging data indicates that CTRT causes profound adverse changes in lean body mass (sarcopenia). Higher prevalence of sarcopenia predicts poorer disease-free survival as well as overall survival, lower quality of life and functional performance. The magnitude of CTRT-induced sarcopenia is the equivalent to that observed in a decade of aging in a healthy adult. Alterations in body composition are only explained, in part, by decreased caloric intake; other significant predictors include body mass index, stage, and dysphagia. Lifestyle interventions aimed at preventing loss of whole-body and especially lean mass include nutritional counseling, nutritional supplements, dietary supplements and exercise training. Personalized nutritional counseling has been associated with improvement in quality of life, while the benefits of feeding tube placement are inconsistent. There are inconsistently reported benefits of resistance training in this population.

Conclusion

Patients with head and neck cancer undergoing CTRT therapy experience dramatic shifts in body composition, including sarcopenia, which can negatively impact clinical outcomes. Efforts to understand the magnitude, clinical importance and mechanisms of sarcopenia are needed to inform a more personalized approach to mitigating the body composition changes associated with CTRT.

Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy

AIM

To highlight the problems associated with nutrition that occur in patients with squamous cell carcinoma of the head and neck (SCCHN).

BACKGROUND

SCCHN is associated with weight loss before, during and after radiotherapy or concurrent chemoradiotherapy. Because of serious consequences of malnutrition and cachexia on treatment outcome, mortality, morbidity, and quality of life, it is important to identify SCCHN patients with increased risk for the development of malnutrition and cachexia.

MATERIALS AND METHODS

Critical review of the literature.

RESULTS

This review describes pathogenesis, diagnosis and treatment of malnutrition and cancer cachexia. Treatment of malnutrition and cancer cachexia includes nutritional interventions and pharmacological therapy. Advantages and disadvantages of different nutritional interventions and their effect on the nutritional status, quality of life and specific oncological treatment are presented.

CONCLUSIONS

Nutritional management is an essential part of care of these patients, including early screening, assessment of nutritional status and appropriate intervention.