Nutritional support in patients with oesophageal cancer

Efficacy and safety of concurrent programmed cell death protein 1 inhibitor and definitive radiotherapy with immunonutrition support in esophageal squamous cell cancer: a phase II multicenter clinical trial

BACKGROUND

Esophageal cancer is one of the most common malignant tumors, with China accounting for 50% of the world's total incidence. Concurrent chemoradiotherapy (cCRT) with platin-based dual-drug regimen is the standard treatment for inoperable, locally advanced esophageal cancer in patients with a good performance status. However, certain patients possess risk factors that heighten toxicity and reduce their tolerance to cCRT, thereby challenging the feasibility of standard treatment. This study evaluates an alternative therapeutic approach combining programmed cell death protein 1 inhibitor (PD-1 inhibitor), definitive radiotherapy, and immunonutrition support for patients with unresectable non-metastatic esophageal cancer expressing PD-L1 who are intolerant to cCRT.

METHODS

This is a phase II, single-arm, multicenter clinical trial involving patients with histologically confirmed unresectable esophageal squamous cell carcinoma (ESCC), who exhibit positive PD-L1 and are unsuitable for cCRT. Participants will receive a total radiotherapy dose of 50-60 Gy in 25-30 fractions, sintilimab (200 mg every three weeks), alongside, supplemented by enteral nutritional emulsion (600-1600 ml/day). The primary endpoint is the 1-year progression-free survival rate, with secondary endpoints including objective response rate, overall survival and incidence of adverse events.

CONCLUSION

This research has the potential to redefine treatment for inoperable ESCC patients who cannot tolerate conventional therapies. By evaluating a less toxic regimen that combines immunotherapy, radiotherapy, and nutritional support, we aim to determine if this approach can improve both survival rates and quality of life. The synergistic effects of immunonutrition support and PD-1 inhibitor will also be explored.

TRIAL REGISTRATION

NCT06342167.

Intensified outpatient nutrition management improves body weight and skeletal muscle loss after esophageal cancer surgery: a single-center, retrospective, single-arm clinical study

BACKGROUND

The progression of malnutrition and sarcopenia after esophagectomy for esophageal cancer negatively influences long-term prognosis. To improve nutritional status after esophagectomy, we introduced an intensified nutrition management (iNM) protocol, in which nutritional counselling by dietitians was provided more frequently. The aim of this study was to evaluate the efficacy of iNM compared with the conventional NM (cNM).

METHODS

We included 126 patients who underwent esophagectomy before and after NM revision, and compared nutritional status and changes in body composition after esophagectomy between the cNM and iNM groups. Nutritional parameters were assessed, and we also calculated skeletal muscle index (SMI), skeletal muscle density (SMD), and visceral fat area (VFA) using computed tomography volumetry.

RESULTS

There were no significant differences in baseline characteristics or surgical outcomes between the groups. Compared with the cNM group, nutritional counselling was provided more frequently (P < 0.001) in the iNM group, and compliance rate increased from 56.3 to 91.9% (P < 0.001). Body weight loss at 4 and 6 months and SMI reduction at 6 months were significantly improved in the iNM group compared with the cNM group (P < 0.001, P = 0.032, and P = 0.023, respectively). There were no significant differences in the changes in SMD, VFA, serum albumin level, and prealbumin level between the two groups.

CONCLUSIONS

Outpatient iNM significantly mitigated the reduction in body weight and SMI 3-6 months after esophagectomy.

The Impact of Preoperative and Postoperative Nutritional Interventions on Treatment Outcomes and Quality of Life in Colorectal Cancer Patients-A Comprehensive Review

Colorectal cancer (CRC) is one of the most prevalent cancers worldwide, with high morbidity and mortality rates. Nutritional status has emerged as a significant factor influencing the prognosis and survival of CRC patients. This comprehensive literature review examines the role of nutritional support in improving treatment outcomes, including the efficacy of interventions, patient quality of life (QoL), and the modulation of inflammatory responses. The findings suggest that tailored nutritional interventions improve clinical outcomes, enhance QoL, and reduce treatment-related complications, particularly by attenuating inflammation. Furthermore, the review highlights the cost-effectiveness of nutritional strategies and identifies key methods to enhance patient compliance with dietary recommendations. In conclusion, integrating nutritional support into CRC treatment plans is crucial for optimizing clinical management and improving patient well-being.

Comparison of nasojejunal nutrition and intravenous nutrition supplementation in patients with upper gastrointestinal tract strictures and analysis of risk factors for malnutrition

This study examines the effectiveness of nasojejunal and intravenous nutrition in supplementing nutrition for patients with upper gastrointestinal (GI) strictures and analyzes the risk factors associated with malnutrition to provide references for clinical nutrition strategies. A retrospective analysis was conducted on 71 patients with upper GI strictures caused by esophageal and gastric cancers, who received nutritional support from January 2015 to January 2023. Out of these, 53 patients had complete baseline and follow-up data. We collected general clinical and perioperative data for comparison of the efficacy between nasojejunal nutrition and intravenous nutrition. Risk factors for malnutrition were analyzed using univariate and multivariate logistic regression. Malnutrition occurred in 24.53% (13/53) of the patients with upper GI strictures. The incidence of malnutrition was 6.06% (2/33) in the nasojejunal nutrition group compared to 55.00% (11/20) in the intravenous nutrition group, with a statistically significant difference (P < .001). Univariate and multivariate regression analyses identified diabetes (P < .001), initial blood K (P = .011), pathological staging (P < .001), and pathological grading (P < .001) as risk factors for malnutrition in patients with upper GI strictures. Diabetes (P = .028), initial blood K (P = .018), and pathological staging (P = .011) were found to be independent risk factors. Nasojejunal nutrition results in a lower incidence of malnutrition compared to intravenous nutrition in patients with upper GI strictures. Diabetes, initial blood K, pathological staging, and pathological grading are risk factors for malnutrition, with diabetes, initial blood K, and pathological staging serving as independent risk factors.

Effects of parenteral nutrition + best supportive nutritional care vs. best supportive nutritional care alone on quality of life in patients with pancreatic cancer-a secondary analysis of PANUSCO

PURPOSE

Parenteral nutrition (PN) can be an effective treatment to improve the nutritional status of patients with pancreatic cancer, but the effects of PN on quality of life (QoL) are still understudied. Therefore, we aimed at investigating whether the best supportive nutritional care (BSNC) in combination with PN at home compared to BSNC alone changed QoL in patients with advanced pancreatic cancer undergoing chemotherapy over a period of 7 weeks.

METHODS

n = 12 patients in the PANUSCO study received nutritional counseling only (control group (CG)) and n = 9 patients were also given supportive PN (intervention group (IG)). The primary endpoint was the change of QoL (EORTC-QLQ-C30 and QLQ-PAN26) over 7 weeks between the groups.

RESULTS

There was a significant worsening in social functioning in IG (p = 0.031) and a significant difference between groups in change of social functioning (p = 0.020). In all other domains of QoL, there was no significant difference between groups. Within groups, there was a significant improvement in the domain weight loss in IG (p = 0.031), showing that patients were less worried about their weight being too low. Furthermore, there was a significant difference in the change of BW over time between groups (p < 0.001) with IG showing an increase (p = 0.004) and CG showing no change (p = 0.578).

CONCLUSION

The administration of PN had in one of five domains negative consequences on QoL. The decision to administer PN should always be made individually and together with the patient, and the impact on QoL should be included in the decision to administer PN.

Synergistic effects of Ω-3 polyunsaturated fatty acid supplementation and programmed cell death protein 1 blockade on tumor growth and immune modulation in a xenograft model of esophageal cancer

BACKGROUND

Esophageal cancer, especially esophageal squamous cell carcinoma (ESCC), remains a significant global health challenge with limited survival rates. This study aimed to elucidate the combined effects of immune-modulating nutrition (IMN) with Ω-3 polyunsaturated fatty acid (PUFA) supplementation and anti-programmed cell death protein 1 (PD-1) treatment on tumor growth and immune responses in a xenograft model of ESCC.

METHODS

A total of 36 C57BL/6 mice were used to construct a xenograft model using the mouse esophageal cancer cell line AKR. Mice were subjected to treatment with anti- PD-1 antibody combined with either Ω-3 PUFA-rich or Ω-3 PUFA-deficient nutrition. Tumor growth, immune markers, cytokine profiles, and metabolic changes were evaluated.

RESULTS

The combination of anti-PD-1 and Ω-3 PUFA supplementation significantly inhibited tumor growth more effectively than anti-PD-1 treatment alone. Enhanced expression of immune markers PD-L1 and CD3 was observed in Ω-3 PUFA-fed mice. Additionally, compared with anti-PD-1 therapy and anti-PD-1 plus Ω-3 PUFA-deficient nutrition, Ω-3 PUFAs intensified alterations in key chemokines and cytokines, including elevated IL-12, IFN-γ, and GM-CSF levels, and reduced CXCL12 levels. However, Ω-3 PUFAs did not significantly alter the glycolysis and tryptophan metabolic program induced by anti-PD-1.

CONCLUSION

Our findings indicated the potential synergetic therapeutic benefits of combining anti-PD-1 treatment with Ω-3 PUFA supplementation in ESCC, which offered promising avenue for further research.

Can Chinese herbal medicine offer feasible solutions for newly diagnosed esophageal cancer patients with malnutrition? a multi-institutional real-world study

Background

Esophageal cancer (EC) is a major cause of cancer-related mortality in Taiwan and globally. Patients with EC are highly prone to malnutrition, which adversely affects their prognosis. While Chinese herbal medicine (CHM) is commonly used alongside conventional anti-cancer treatments, its long-term impact on EC patients with malnutrition remains unclear.

Methods

This study utilized a multi-center cohort from the Chang Gung Research Database, focusing on the long-term outcomes of CHM in EC patients with malnutrition between 1 January 2001, and 31 December 2018. Patients were monitored for up to 5 years or until death. Overall survival (OS) rates were calculated using the Kaplan-Meier method. Overlap weighting and landmark analysis were employed to address confounding and immortal time biases. Additionally, the study analyzed prescription data using a CHM network to identify key CHMs for EC with malnutrition, and potential molecular pathways were investigated using the Reactome database.

Results

EC patients with malnutrition who used CHM had a higher 5-year OS compared with nonusers (22.5% vs. 9% without overlap weighting; 24.3% vs. 13.3% with overlap weighting; log-rank test: p = 0.006 and 0.016, respectively). The median OS of CHM users was significantly longer than that of nonusers (19.8 vs. 12.9 months, respectively). Hazard ratio (HR) analysis showed a 31% reduction in all-cause mortality risk for CHM users compared with nonusers (HR: 0.69, 95% confidence interval: 0.50-0.94, p = 0.019). We also examined 665 prescriptions involving 306 CHM, with Hedyotis diffusa Willd. exhibiting the highest frequency of use. A CHM network was created to determine the primary CHMs and their combinations. The identified CHMs were associated with the regulation of immune and metabolic pathways, particularly in areas related to immune modulation, anti-cancer cachexia, promotion of digestion, and anti-tumor activity.

Conclusion

The results of this study suggest a correlation between CHM use and improved clinical outcomes in EC patients with malnutrition. The analysis identified core CHMs and combinations of formulations that play a crucial role in immunomodulation and metabolic regulation. These findings lay the groundwork for more extensive research on the use of CHM for the management of malnutrition in patients with EC.

Enhancing Nutrition Support for Esophageal Cancer Patients: Understanding Factors Influencing Feeding Tube Utilization

Objective: We sought to identify factors that can predict esophageal cancer (EC) patients at high risk of requiring feeding tube insertion. Methods: A retrospective cohort review was conducted, including all patients diagnosed with EC at our cancer center from 2013 to 2018. Multivariate logistic regression was performed comparing the group that required a reactive feeding tube insertion to those who did not require any feeding tube insertion to identify risk factors. Results: A total of 350 patients were included in the study, and 132/350 (38%) patients received a feeding tube. 50 out of 132 (38%) patients had feeding tube inserted reactively. Severe dysphagia (OR 19.9, p < 0.001) at diagnosis and decision to undergo chemotherapy (OR 2.8, p = 0.008) appeared to be predictors for reactive feeding tube insertion. The reactive insertion group had a 7% higher rate of complications relating to feeding tube. Conclusion: Severe dysphagia at diagnosis and undergoing chemotherapy were identified as risk factors for requiring a feeding tube. Ultimately, the aim is to create a predictive tool that utilizes these risks factors to accurate identify high-risk patients who may benefit from prophylactic feeding tube insertion.

[Nutritional supportive care in the course of patients with esophagogastric cancers]

Supportive care plays a central role in the management of patients with esophagogastric cancers, at all disease stages. Malnutrition has a high prevalence in this population, reaching up to 60 % of the patients. Sarcopenia and cachexia are also common. These complications have negative impact on functional abilities, quality of life and overall survival. They impair anti-tumor treatments effectiveness and increase their toxicity. Early detection and management are needed, before reaching advanced stages, which are refractory to therapeutic interventions. Specific nutritional support is recommended, relying on different nutritional support tools (dietetic counseling, oral supplements, artificial nutrition), depending on the clinical situation. When artificial nutrition is recommended, enteral nutrition (nasogastric tube, gastrostomy or jejunostomy) should be preferred. When enteral nutrition is impossible or insufficient, parenteral nutrition could be necessary. For patients with advanced esophagogastric cancers, digestive prostheses and decompressive radiation therapy may have a symptomatic benefit on dysphagia. Adapted physical activity is also recommended at all stages of cancer care and ongoing clinical trials will help to specify its modalities and to optimize its place in the therapeutic strategy. Finally, psychosocial support could be useful. A combined approach of these different interventions on the nutritional, physical and psychological aspects is beneficial for patients with esophagogastric cancers. This multimodal and multidisciplinary approach applies to both the early stages of the disease, with prehabilitation and/or rehabilitation to reduce perioperative morbidity and mortality and the advanced stages, with a benefit on survival and quality of life, in parallel with anti-tumor treatments.

The association between mortality and use of Chinese herbal medicine among incident stage IV esophageal cancer patients: A retrospective cohort study with core herbs exploration

Esophageal cancer (EC) remains a leading cause of death worldwide and in Taiwan. The prognosis of advanced-stage EC is notably poor, and the treatment options are limited. Chinese herbal medicine (CHM) has been widely used as a complementary treatment for cancer, yet the long-term effect of CHM in stage IV EC remains unclear. The multi-institutional cohort obtained from the Chang Gung research database (CGRD) was used to study the long-term outcome of CHM use among incident stage IV EC patients from 1 January 2002, to 31 December 2018. All patients were followed up to 5 years or the occurrence of death. The overall survival (OS) and disease-specific survival rates were conducted using Kaplan-Meier estimation. Overlap weighing and landmark analysis were used to eliminate confounding and immortal time biases. Furthermore, we demonstrated the core CHMs for stage IV EC by using the Chinese herbal medicine network (CMN) analysis on prescriptions. Nine hundred eighty-five stage IV EC patients were analyzed, including 74 CHM users and 911 non-CHM users. We found the use of CHM was associated with a higher 5-year overall survival rate than CHM nonusers (the cumulative probability: 19.52% versus 6.04%, log-rank test: p < 0.001, and the p < 0.001 with overlap weighting). In addition, the overall median survival time was about 7 months longer among CHM users. Moreover, the lower 1-, 3-, 5-year disease-specific survival rates were higher among CHM users. Additionally, the risk of all-cause mortality was lower among CHM users when considering accessible demographic covariates (adjusted hazard ratio: 0.59, 95%CI: 0.39, 0.89, p = 0.011). Furthermore, the CMN analysis revealed that CHMs improved health while relieving tumor burden. For example, Hedyotis diffusa Willd . was the core CHM with an anti-cancer effect, while Fritillaria thunbergii Miq and Sevilla maindronide Rochebrune were used together to relieve cancer-related gastrointestinal discomfort. The use of CHM seems safe and possibly beneficial among stage IV EC patients with a higher 5-year OS. Further clinical trials on CHM were guaranteed to explore the role of CHM in managing stage IV EC patients.

Minimally invasive surgical techniques for oesophageal cancer and nutritional recovery: a prospective population-based cohort study

OBJECTIVES

To explore whether the minimally invasive oesophagectomy (MIE) or hybrid minimally invasive oesophagectomy (HMIE) are associated with better nutritional status and less weight loss 1 year after surgery, compared with open oesophagectomy (OE).

DESIGN

Prospective cohort study.

SETTING

All patients undergoing oesophagectomy for cancer in Sweden during 2013-2018.

PARTICIPANTS

A total of 424 patients alive at 1 year after surgery were eligible, and 281 completed the 1-year assessment. Of these, 239 had complete clinical data and were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was nutritional status at 1 year after surgery, assessed using the abbreviated Patient-Generated Subjective Global Assessment questionnaire. The secondary outcomes included postoperative weight loss at 6 months and 1 year after surgery.

RESULTS

Of the included patients, 78 underwent MIE, 74 HMIE while 87 patients underwent OE. The MIE group had the highest prevalence of malnutrition (42% vs 22% after HMIE vs 25% after OE), reduced food intake (63% vs 45% after HMIE vs 39% after OE), symptoms reducing food intake (60% vs 45% after HMIE vs 60% after OE) and abnormal activities/function (45% vs 32% after HMIE vs 43% after OE). After adjustment for confounders, MIE was associated with a statistically significant increased risk of reduced food intake 1 year after surgery (OR 2.87, 95% CI 1.47 to 5.61), compared with OE. Other outcomes were not statistically significantly different between the groups. No statistically significant associations were observed between surgical techniques and weight loss up to 1 year after surgery.

CONCLUSIONS

MIE was statistically significantly associated with reduced food intake 1 year after surgery. However, no differences were observed in weight loss between the surgical techniques. Further studies on nutritional impact of surgical techniques in oesophageal cancer are needed.

Nutritional Support in Older Patients with Esophageal Cancer Undergoing Chemoradiotherapy

Esophageal cancer (EC) is the eighth most prevalent malignancy and the sixth leading cause of cancer-related death worldwide. The proportion of older adults with EC has increased dramatically in recent decades due to increased life expectancy. Older patients with EC are at a highest risk of malnutrition and this predicts early death. In older patients with EC, dysphagia is a common symptom; additionally, comorbidities, polypharmacy, and physiological changes of aging such as decreased muscle mass and geriatric issues including altered cognition, mobility, and mood contribute to malnutrition. Chemoradiotherapy (CRT) is the primary treatment for unresectable locally advanced EC patients, as it successfully reduces local recurrence and distant metastases while also extending survival. In older patients with EC, nutrition is an interventional condition, unlike many other geriatric risk factors. Optimizing nutritional support may reduce treatment toxicity and facilitate the completion of definitive or neoadjuvant CRT. The relevance of nutritional status and food intake is becoming more widely acknowledged, and it now encompasses the entire spectrum of EC treatment in older patients, from diagnosis to perioperative care to long-term care. This review aims to discuss the current research on nutritional support in older patients with esophageal cancer undergoing CRT.

Outcomes following interventions to sustain body weight in esophageal cancer patients starting preoperative therapy: a retrospective cohort study

Background

To improve nutritional status and dysphagia, esophageal cancer patients starting neoadjuvant therapy in advance of curative-intent surgery may receive a jejunostomy tube (J-tube) or esophageal stent, or they may be managed without a feeding modality. We examined percent total weight loss (%TWL), reinterventions, and progression to surgery in relation to these options.

Methods

The retrospective cohort study included stage II–III esophageal cancer patients diagnosed during 2010–2017 who received J-tube, stent, or nutritional counseling only, without a procedure, when starting chemotherapy or combined modality chemoradiation. Data were obtained from the electronic medical record and chart review. We compared median %TWL between intervention groups and reinterventions using Chi-square and Kruskal-Wallis tests.

Results

Among the 366 patients, median %TWL reached a nadir at 120 days, when it was 7% for patients with no procedure (N=307), 4% for J-tube (N=39), and 16% for stent (N=20) (P=0.01). Individual case analysis revealed 72–80% of the patients in the three groups started chemotherapy or chemoradiation as neoadjuvant curative-intent therapy (P difference =0.79). In J-tube patients, the reasons for intervention was anticipation of weight loss in 49% and mitigation of actual weight loss in 15%, whereas 95% of stent patients received the stent for dysphagia (P<0.001). A complication of the procedure was recorded in 85% of stent patients and 74% of J-tube patients (P<0.001). Among those who received no procedure initially, 25% received one later, compared with 15% of J-tube patients and 70% of stent patients who received a second procedure (P<0.001). Progression to surgery was observed in 65% of patients with no procedure, 51% of patients with J-tube, and 40% of stent patients, P=0.28).

Conclusions

For stage II–III esophageal cancer patients starting chemotherapy, this study gives evidence that stents were associated with significant %TWL and risk of reintervention. Although J-tube patients returned to baseline weight sooner than those with no procedure, they experienced complications from their J-tubes. For esophageal cancer patients undergoing curative-intent treatment and with acceptable levels of weight loss, no procedure at all may be superior to placing a J-tube in terms of complications, weight loss, and progression to curative-intent surgery.

Oesophageal cancer: The effect of early nutrition support on clinical outcomes

BACKGROUND AND AIMS

Malnutrition is prevalent in oesophageal cancer. Evidence for the use of nutrition support and prehabilitation in this cohort is variable. The aim of this study was to examine the effect of early nutrition support and functional measures of nutritional status on post-operative outcomes in adult patients with oesophageal cancer.

METHODS

Retrospective review of adults with oesophageal cancer undergoing oesophagectomy (n = 151). Early nutrition support was defined as: oral or enteral nutrition supplementation during neoadjuvant treatment. Late nutrition support defined as: oral or enteral nutrition supplementation prescribed post-operatively. Nutrition outcome measures were; percentage weight loss from 3 to 6 months prior to diagnosis, peri- and post-operatively, and pre-operative assessment of handgrip-strength (HGS).

RESULTS

Pre-operative weight loss ≥10% was a significant predictor of mortality at 1 year (OR 2.84, 95%CI 1.03-7.83, p = 0.04) independent of tumour stage, adjuvant treatment, age and gender. Adults prescribed early nutrition support during neoadjuvant treatment experienced less weight loss at 12-months post-oesophagectomy compared to adults prescribed late oral nutrition support (p=<0.05). Pre-operative HGS measurements were not a useful predictor of postoperative complications (p = 0.2), length of stay (p = 0.9) or 90-day mortality (p = 0.6).

CONCLUSIONS

Pre-operative weight loss ≥10% was associated with mortality. Early nutrition support was associated with less weight loss at 12-months post-operatively. Pre-operative HGS measures did not have prognostic value as a stand-alone measure. Future work should investigate the efficacy of early nutrition support in reducing both pre- and post-operative weight loss to improve nutritional status and surgical outcomes as part of a multimodal prehabilitation programme in adults with oesophageal cancer.

Cachexia and Dietetic Interventions in Patients With Esophagogastric Cancer: A Multicenter Cohort Study

BACKGROUND

Cachexia is common in patients with esophagogastric cancer and is associated with increased mortality. Nutritional screening and dietetic interventions can be helpful in preventing evolvement of cachexia. Our aim was to study the real-world prevalence and prognostic value of pretreatment cachexia on overall survival (OS) using patient-reported weight loss, and to explore dietetic interventions in esophagogastric cancer.

MATERIALS AND METHODS

Patients with esophagogastric cancer (2015-2018), regardless of disease stage, who participated in the Prospective Observational Cohort Study of Esophageal-Gastric Cancer Patients (POCOP) and completed patient-reported outcome measures were included. Data on weight loss and dietetic interventions were retrieved from questionnaires before start of treatment (baseline) and 3 months thereafter. Additional patient data were obtained from the Netherlands Cancer Registry. Cachexia was defined as self-reported >5% half-year body weight loss at baseline or >2% in patients with a body mass index (BMI) <20 kg/m2 according to the Fearon criteria. The association between cachexia and OS was analyzed using multivariable Cox proportional hazard analyses adjusted for sex, age, performance status, comorbidities, primary tumor location, disease stage, histology, and treatment strategy.

RESULTS

Of 406 included patients, 48% had pretreatment cachexia, of whom 65% were referred for dietetic consultation at baseline. The proportion of patients with cachexia was the highest among those who received palliative chemotherapy (59%) or best supportive care (67%). Cachexia was associated with decreased OS (hazard ratio, 1.52; 95% CI, 1.11-2.09). Median weight loss after 3-month follow-up was lower in patients with cachexia who were referred to a dietician at baseline compared with those who were not (0% vs 2%; P=.047).

CONCLUSIONS

Nearly half of patients with esophagogastric cancer have pretreatment cachexia. Dietetic consultation at baseline was not reported in more than one-third of the patients with cachexia. Because cachexia was independently associated with decreased survival, improving nutritional screening and referral for dietetic consultation are warranted to prevent further deterioration of malnutrition and mortality.

Possible clinical outcomes using early enteral nutrition in individuals with allogeneic hematopoietic stem cell transplantation: A single-center retrospective study

OBJECTIVES

Intensive nutritional support during allogeneic hematopoietic stem cell transplantation (allo-HSCT) yields improved clinical outcomes. However, the clinical implications of early enteral nutrition (EN) in allo-HSCT remain unclear. This retrospective study was conducted to determine the significance of early EN in individuals who underwent allo-HSCT, and the association between early nutritional intervention and clinical outcomes, including the status of the intestinal microbiome.

METHODS

Thirty-one participants received EN before conditioning. The intestinal microbiota was examined by meta 16S rRNA gene sequencing of fecal samples.

RESULTS

The median body mass variation was only -0.35 kg on day 60. The probability of 2-y overall survival was 61.1%. The cumulative incidence of treatment-related mortality was 17.4%, and those of acute graft-versus-host disease were 32.3% (grades II-IV) and 3.2% (grades III-IV). Chronic graft-versus-host disease was observed in four participants. Dysbiosis of the intestines and acute graft-versus-host disease occurred simultaneously, and Enterococcus species were abundant.

CONCLUSIONS

Our results suggest that early nutritional support can improve the outcomes for individuals who have undergone allo-HSCT and can maintain homeostasis of their intestinal microbiome. Future prospective clinical trials are required to elucidate the role of EN in allo-HSCT and the association between the intestinal microbiome and EN.

Nutrition and gastroenterological support in end of life care

Malnutrition and the broad spectrum of cancer cachexia frequently occur in patients with malignant disease of all tumour stages and impact on survival and quality of life of patients. Structured screening for the risk of malnutrition with validated tools and nutritional assessment are the prerequisite for adequate nutritional support in cancer patients. In patients receiving tumour directed therapy, the patients diet should meet the requirements to give optimal support, while later on comfort feeding is part of symptom focused palliation. The basis of nutritional support in a malnourished patient is nutritional counselling, and nutritional support can be offered within a step-up approach meeting the patient's needs. A combination of nutritional support with interventions targeting metabolic changes and physical exercise is suggested to treat cancer cachexia.

Nutritional management of patients with oesophageal cancer throughout the treatment trajectory: benchmarking against best practice

PURPOSE

Oesophageal cancer (OC) impacts nutritional status and outcomes. This study aims to benchmark the current nutrition management of patients with OC against best practice recommendations, identify critical points in the treatment trajectory where nutritional status is compromised, service gaps and opportunities for improvement.

METHODS

A retrospective audit collected demographic, medical and nutritional data from medical records of patients who received curative treatment for OC at a tertiary referral hospital in Sydney, Australia.

RESULTS

Thirty-seven patient records were audited over the time period. Twenty-nine patients underwent nutrition screening on admission to the service. Eighteen out of 25 patients receiving neoadjuvant radiation therapy, all patients during surgical admission, and only 19 patients at postsurgical discharge were seen by a dietitian. All patients received tube feeding post-operatively; however, initiation within 24 h only occurred for 14 patients. Weight significantly declined over the course of treatment (p < 0.001), whilst malnutrition during surgical admission (p = 0.004) and postsurgical discharge (p = 0.038) were both associated with significantly higher unplanned readmissions.

CONCLUSIONS

Best practice recommendations were met for aspects of the immediate post-operative period; however, service gaps remain during pre-operative and post-discharge care. Findings from this study indicate that nutritional care is inconsistent across different treatment stages, and malnutrition impacts negatively on unplanned readmission. Research is needed to address evidence-practice gaps, assess appropriateness of recommendations and provide evidence for models of care during multimodality treatments and across different services.

Comparison of enteral nutrition with total parenteral nutrition for patients with locally advanced unresectable esophageal cancer harboring dysphagia in definitive chemoradiotherapy

BACKGROUND

The nutritional status of patients with esophageal squamous cell carcinoma (ESCC) harboring dysphagia is often poor. The efficacy and safety of enteral nutrition (EN) versus total parenteral nutrition (TPN) have not been addressed in patients with ESCC requiring nutritional support during definitive chemoradiotherapy (dCRT).

METHODS

We performed a retrospective analysis of 51 locally advanced unresectable ESCC patients with dysphagia receiving EN (n = 28) or TPN (n = 23) during dCRT between 2009 and 2016.

RESULTS

Patient characteristics in EN vs. TPN were as follows: median age (range), 67 (34 to 82) vs. 66 (57 to 83); ECOG performance status 0/1/2, 11/15/2 vs. 7/14/2; dysphagia score 2/3/4, 11/15/2 vs. 14/8/1; and primary tumor location Ce/Ut/Mt/Lt/Ae, 4/6/14/3/1 vs. 2/2/16/1/2. Median changes in serum albumin level one month after dCRT were +8.8% (-36 to 40) in EN and -12% (-64 to 29) in TPN (P = 0.00377). Weight, body mass index, and skeletal muscle area were not significantly different between the groups. Median durations of hospitalization were 50 days (18 to 72) in EN and 63 days (36 to 164) in TPN (P = 0.00302). Adverse events during dCRT in EN vs. TPN were as follows: catheter-related infection, 0 vs. 6 (27%); aspiration pneumonia, 3 (11%) vs. 2 (9%); mediastinitis, 3 (11%) vs. 1 (5%); grade ≥3 neutropenia, 6 (21%) vs. 14 (64%) (P = 0.00287); and febrile neutropenia, 0 vs. 6 (27%) (P = 0.00561).

CONCLUSIONS

EN may be advantageous for improving serum albumin level, and reducing hematological toxicity and duration of hospitalization compared with TPN during dCRT in ESCC patients.

Systemic prognostic score and nomogram based on inflammatory, nutritional and tumor markers predict cancer-specific survival in stage II-III gastric cancer patients with adjuvant chemotherapy

BACKGROUND

To investigate the clinical utility of several established inflammatory, nutritional and tumor markers, and to construct a new scoring system based on preoperative prognostic markers to predict outcomes in gastric cancer (GC).

METHODS

We retrospectively assessed 688 consecutive patients who underwent curative resection followed by adjuvant chemotherapy for stage II-III GC from 2000 to 2012.

RESULTS

On multivariate analysis, C-reactive protein/albumin (CRP/Alb) ratio (>0.2), prognostic nutritional index (PNI) (score 1), preoperative body weight loss (>6%) and carbohydrate antigen 19-9 (CA 19-9) (>27 U/mL) independently predicted unfavorable cancer-specific survival (CSS). These 4 preoperative prognostic markers were allocated 1 point each. Then, a new systemic prognostic score (SPS) was constructed based on the total score. Multivariate analysis revealed that SPS was an independent predictor of CSS (P < 0.001). Patients with a SPS of 0, 1, 2, or 3/4 had a 5-year CSS rates of 67.2%, 45.3%, 29.0%, and 10.6%, respectively (0 vs. 1 [P < 0.001], 1 vs. 2 [P = 0.031] and 2 vs. 3/4 [P = 0.004]). The median survival times for SPS 0, SPS 1, SPS 2 and SPS 3/4 were 68.7, 47.1, 28.3 and 16.3 months, respectively. The area under the receiver operating characteristics (ROC) curve for SPS was higher than other markers (P < 0.001). Furthermore, a nomogram that integrated TNM stage, tumor location and SPS exhibited superior discrimination power compared with the TNM stage alone (C-index, 0.714 vs. 0.630, respectively; P < 0.001).

CONCLUSION

The preoperative SPS combining inflammatory, nutritional and tumor markers independently predicted postoperative survival in stage II-III GC patients treated with adjuvant chemotherapy.

Long-term weight development after esophagectomy for cancer-comparison between open Ivor-Lewis and minimally invasive surgical approaches

Esophagectomy is an extensive procedure with severe postoperative effects. It can be assumed that the greater the trauma, the longer the nutritional recovery. This retrospective observational single-center cohort study compared weight development after esophagectomy with open and minimally invasive techniques. Three groups were compared in this study, one representing the first 41 patients who underwent the minimally invasive McKeown esophagectomy (MIMK). The second group included the first 84 consecutive patients operated with the minimally invasive Ivor-Lewis esophagectomy (MIIL). The third group comprised 100 consecutive patients operated with open thoracoabdominal Ivor-Lewis esophagectomy (IL). Virtually all patients submitted to a minimally invasive esophagectomy (MIE) and the majority with an IL had a jejunal catheter inserted during operation for postoperative enteral feeding. All together 225 patients were included in this study. The mean weight loss during the first year was 13.1% (±4.1), 11.2% (±6.1), and 9.6% (±7.5) in the IL, MIIL, and MIMK group, respectively (P = 0.85 and P = 0.95, respectively). The median duration of postoperative enteral nutrition support varied substantially within the groups and was 23.5 days in the IL group (range: 0-2033 days), 54.5 days in those having an MIIL (range: 0-308 days; P ≤ 0.001) and 57.0 days among patients in the MIMK group (range: 0-538 days; P ≤ 0.022). There was no difference in the risk of losing at least 10% of the preoperative weight at 3 or 6 months postoperatively between the groups. However, in patients who suffered severe complications (Clavien-Dindo score ≥ IIIb) after MIIL, there was a nonsignificant trend toward a lower risk of a 10% or greater weight loss, 3 months postoperatively. In conclusion, the greater surgical trauma associated with the traditional open esophagectomy was not followed by more severe weight loss, or other signs of poorer nutritional recovery, when compared to minimal invasive surgical techniques.

Treatment for unresectable or metastatic oesophageal cancer: current evidence and trends

Approximately half of the patients diagnosed with oesophageal cancer present with unresectable or metastatic disease. Treatment for these patients aims to control dysphagia and other cancer-related symptoms, improve quality of life and prolong survival. In the past 25 years, modestly improved outcomes have been achieved in the treatment of patients with inoperable non-metastatic cancer who are medically not fit for surgery or have unresectable, locally advanced disease. Concurrent chemoradiotherapy offers the best outcomes in these patients. In distant metastatic oesophageal cancer, several double-agent or triple-agent chemotherapy regimens have been established as first-line treatment options. In addition, long-term results of multiple large randomized phase III trials using additional targeted therapies have been published in the past few years, affecting contemporary clinical practice and future research directions. For the local treatment of malignant dysphagia, various treatment options have emerged, and self-expandable metal stent (SEMS) placement is currently the most widely applied method. Besides the continuous search for improved SEMS designs to minimize the risk of associated complications, efforts have been made to develop and evaluate the efficacy of antireflux stents and irradiation stents. This Review outlines the current evidence and ongoing trends in the different modern-day, multidisciplinary interventions for patients with unresectable or metastatic oesophageal cancer with an emphasis on key randomized trials.

Nutritional management of older adults with gastrointestinal cancers: An International Society of Geriatric Oncology (SIOG) review paper

Malnutrition is one of the most common physical manifestations of gastrointestinal (GI) cancers and is often under-diagnosed and under-treated. Like cancers, malnutrition occurs more commonly in older adults, with potential negative consequences to quality of life, functional status, tolerance to treatment, and prognosis. Nutritional assessment and management require a proactive and systematic, multi-disciplinary approach. Early assessment, detection, and prompt intervention of cancer-associated malnutrition and cachexia are equally essential to achieve better quality nutritional care for older oncology patients. This article aims to provide an overview of the evidence associated with poor nutrition and outcomes in older adults with GI cancers, and recommends a management approach from a geriatric oncologist's perspective.

Handgrip Strength Is Associated With Treatment Modifications During Neoadjuvant Chemoradiation in Patients With Esophageal Cancer

RATIONALE

It has been shown that early nutrition intervention improves nutrition status (NS) and treatment tolerance in patients with esophageal cancer. However, it remains unknown whether pretreatment parameters of NS are associated with treatment modifications (TMs) during neoadjuvant chemoradiation (CR) in patients who are intensively nutritionally supervised during treatment.

METHODS

All outpatients with esophageal cancer who were scheduled for CR in the VU medical center from 2006-2015 were included. NS was assessed by body mass index (BMI), weight loss in the past 6 months (WL), fat mass index (FMI) and fat-free mass index (FFMI), handgrip strength (HGS), and energy/protein intake. Logistic regression analyses, adjusted for age, sex, previous tumor, tumor stage, and physical status, were applied. TMs were defined as delay, dose reduction or discontinuation of chemotherapy and/or radiotherapy, hospitalization, or mortality (yes/no).

RESULTS

In total, 162 patients were included (73% male; mean age 65 ± 9 years). Mean BMI was 25.1 ± 4.5 kg/m2, and WL was 4.8 ± 5.1 kg. HGS and FFMI were below the 10th percentile of reference values in 21 and 37 patients, respectively. Thirty-five (22%) patients experienced at least 1 TM during CR; unplanned hospitalization (n = 18, 11%) was the most prevalent. After adjustments for confounders, only HGS was statistically significantly associated with TMs (odds ratio, 0.93; 95% confidence interval, 0.88-1.00).

CONCLUSION

In this group of intensively supervised patients with esophageal cancer, pretreatment parameters of NS had little influence on TMs during CR. Only a lower HGS was associated with TMs.

Oesophageal Adenocarcinoma: A Patient and Physician's Perspective

This article is co-authored by a patient with oesophageal adenocarcinoma and his physician, who performed oesophagectomy. The patient relates his pre-operative preparation and post-operative experience. The physician comments on the alarming increase in the incidence of this cancer, risk factors, and treatment. As illustrated by the patient's report, the physician also discusses the importance of maintaining adequate nutrition, cardiorespiratory fitness, and a positive psychological attitude.

Risks and Benefits of Multimodal Esophageal Cancer Treatments: A Meta-Analysis

BACKGROUND Esophageal cancer has traditionally been associated with very poor outcomes. A number of therapies are available for the treatment and palliation of esophageal cancer, but little systematic evidence compares the efficacy of different treatment strategies. This meta-analysis aimed to investigate whether treatments in addition to radiotherapy could provide better efficacy and safety. MATERIAL AND METHODS We identified a total of 12 eligible studies with 18 study arms by searching PubMed, the Cochrane Library, EMBASE, and Clinical Trials.gov without time or language restrictions. The final search was conducted on 17 August 2016. We calculated mean differences (MD) and risk ratios (RR) with 95% confidence intervals (CI) for continuous and dichotomous data, respectively. Heterogeneity was calculated and reported using Tau², Chi², and I² analyses. RESULTS Twelve studies with 18 study arms were included in the analysis. Addition of surgery to chemo-radiotherapy resulted in improved median survival time (p=0.009) compared with chemo-radiotherapy alone, but all other outcomes were unaffected. Strikingly, and in contrast with patients with squamous cell carcinomas, the subset of patients with adenocarcinoma who received therapies in addition to radiotherapy showed a significant improvement in median survival time (p<0.0001), disease-free survival (p=0.007), 2-year survival rates (p=0.002), and 3-year survival rates (p=0.01). The incidence of adverse effects increased substantially with additional therapies. CONCLUSIONS This meta-analysis reveals stark differences in outcomes in patients depending on the type of carcinoma. Patients with squamous cell carcinoma should be educated about the risks and benefits of undergoing multiple therapies.

The physiotherapist and the esophageal cancer patient: from prehabilitation to rehabilitation

Esophageal cancer is a serious malignancy often treated with multimodal interventions and complex surgical resection. As treatment moves to centers of excellence with emphasis on enhanced recovery approaches, the role of the physiotherapist has expanded. The aim of this review is to discuss the rationale behind both the evolving prehabilitative role of the physiotherapist and more established postoperative interventions for patients with esophageal cancer. While a weak association between preoperative cardiopulmonary fitness and post-esophagectomy outcome is reported, cardiotoxicity during neoadjuvant chemotherapy and/or radiotherapy may heighten postoperative risk. Preliminary studies suggest that prehabilitative inspiratory muscle training may improve postoperative outcome. Weight and muscle loss are a recognized sequelae of esophageal cancer and the functional consequences of this should be assessed. Postoperative physiotherapy priorities include effective airway clearance and early mobilization. The benefits of respiratory physiotherapy post-esophagectomy are described by a small number of studies, however, practice increasingly recognizes the importance of early mobilization as a key component of postoperative recovery. The benefits of exercise training in patients with contraindications to mobilization remain to be explored. While there is a strong basis for tailored physiotherapy interventions in the management of patients with esophageal cancer, this review highlights the need for studies to inform prehabilitative and postoperative interventions.

Nutritional status, management and clinical outcomes in patients with esophageal and gastro-oesophageal cancers: A descriptive study

AIM

The aims of this study were to investigate the nutritional management practice and nutritional status of patients with oesophageal and gastro-oesophageal cancers, and to propose strategies for improving their nutritional and clinical outcomes.

METHODS

All patients diagnosed with oesophageal and gastro-oesophageal cancers and treated with chemotherapy and/or radiotherapy at the Liverpool Cancer Therapy Centre (between August 2010 and February 2014) were included in this retrospective study. Patient and tumour characteristics, nutritional status and management were compared to clinical outcomes.

RESULTS

A total of 69 patients met the inclusion criteria. The median weight loss prior to treatment commencement was 10.5% (Interquartile Range (IQR) = 6.6-15.4). A decline in nutritional status continued throughout the treatment course. The median percentage of weight loss during treatment was 3.53% (IQR = 0.00-6.84). Seven and 19 patients required nutrition intervention using a feeding tube or stent insertion to manage dysphagia, respectively. In patients treated with a curative intent, radiotherapy was completed in 100% of those with a nasogastric tube insertion as compared to 80% who had a stent insertion. There was a higher percentage of patients from culturally and linguistically diverse (CALD) background, experiencing significant weight loss when compared with their non-CALD counterparts (P = 0.04).

CONCLUSIONS

Patients with oesophageal and gastro-oesophageal cancers commonly present with significant weight loss and this continues during the course of their anti-cancer treatment. A standardised protocol of nutrition management for these cancer patients is recommended, focusing on assisting patients from CALD backgrounds.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Nutrition in Patients with Gastric Cancer: An Update

BACKGROUND

Nutritional management of patients with gastric cancer (GC) represents a challenge.

SUMMARY

This review provides an overview of the present evidence on nutritional support in patients with GC undergoing surgery as well as in those with advanced disease.

KEY MESSAGE

For patients undergoing surgery, the preoperative nutritional condition directly affects postoperative prognosis, overall survival and disease-specific survival. Perioperative nutritional support enriched with immune-stimulating nutrients reduces overall complications and hospital stay but not mortality after major elective gastrointestinal surgery. Early enteral nutrition after surgery improves early and long-term postoperative nutritional status and reduces the length of hospitalization as well. Vitamin B12 and iron deficiency are common metabolic sequelae after gastrectomy and warrant appropriate replacement. In malnourished patients with advanced GC, short-term home complementary parenteral nutrition improves the quality of life, nutritional status and functional status. Total home parenteral nutrition represents the only modality of caloric intake for patients with advanced GC who are unable to take oral or enteral nutrition.

PRACTICAL IMPLICATIONS

Early evaluations of nutritional status and nutritional support represent key aspects in the management of GC patients with both operable and advanced disease.

The impact of chemosensory and food-related changes in patients with advanced oesophagogastric cancer treated with capecitabine and oxaliplatin: a qualitative study

Purpose

Chemosensory changes are frequently observed side effects of cytotoxic treatment and have an impact on daily life by altering food-related behaviour and daily practices. For oesophagogastric cancer patients, these changes can be particularly important as they may have specific needs with regard to eating, due to obstruction of the upper intestinal tract. The purpose of this study was to gain insight into the impact of chemosensory and food-related changes in oesophagogastric cancer patients undergoing chemotherapy and how this may influence the practical and social aspects of food-related behaviour of patients and their relatives.

Methods

We used a qualitative interview approach with a cross-sectional design using semi-structured interviews. Template analysis was used to analyse patients’ experiences with and the impact of chemosensory changes on daily life. Thirteen advanced oesophagogastric cancer patients treated with capecitabine and oxaliplatin were included by convenience sampling, recruited from one academic hospital, and interviewed at home or in the hospital.

Results

There was a large variation in the impact of chemosensory changes in oesophagogastric cancer (OGC) patients, though daily life was impacted substantially when chemosensory and/or food-related changes were experienced. Three main themes emerged from the interviews: altered food preferences, practical constraints in daily life, and impact on social functioning.

Conclusion

Chemosensory and food-related changes significantly influenced food preferences and had practical and social consequences in daily life of patients and their relatives. Specific nutritional care for these patients should be directed towards enhancing food enjoyment and should take the specific needs, related to the location of the tumour, into account.

Feeding Challenges in Patients with Esophageal and Gastroesophageal Cancers

BACKGROUND

Patients undergoing treatment for esophagogastric or esophageal cancer are exposed to a considerably high risk of malnutrition due to early obstruction of the gastrointestinal passage. Presently most of the patients undergo modern multimodal therapies which require chemoradiation or chemotherapy ahead of surgery. Therefore reconstruction of the obstructed gastrointestinal passage is considerably delayed. Surgery as the only curative option after neoadjuvant treatment is the mainstay of therapy in this setting. However, many patients are at risk for the development of postoperative complications associated with the complexity of the surgical procedure. Therefore enteral feeding as a prerequisite to avoid malnutrition represents a special therapeutic challenge.

SUMMARY

This review describes the recent literature on the incidence and influence of perioperative malnutrition on oncologic outcome, measures to determine patients at risk, possible strategies to reduce or avoid malnutrition by supportive enteral/parenteral nutrition, implementation of the enhanced recovery after surgery programs and feeding routes, but also surgical and adjuvant procedures in the curative and palliative setting for patients undergoing treatment for gastroesophageal cancers.

KEY MESSAGES

Appropriate identification of patients at risk is crucial to avoid malnutrition. Early nutritional interventions during multimodal/neoadjuvant treatment may be beneficial for weight loss reduction although the evidence is not conclusive. Pouch reconstructions during surgery should be applied in order to increase quality of life and eating capacity. Reduction of postoperative complications could provide potential benefits. In palliative patients, insertion of self-expanding metal stents can reduce dysphagia and improve quality of life, but does not prolong overall survival. Further evidence is required to determine the value of the procedures and measures described in this review.

PRACTICAL IMPLICATIONS

Nutritional risk scoring should be performed for every gastroesophageal cancer patient. Sophisticated reconstruction methods and early recovery programs should be enforced to reduce perioperative starvation periods. Self-expanding metal stents should be used for palliative patients.

Palliative enteral feeding for patients with malignant esophageal obstruction: a retrospective study

BACKGROUND

Malignant esophageal obstruction leads to dysphagia, deterioration in quality of life, and malnutrition. Traditional bedside nasogastric (NG) tube placement is very difficult under these circumstances. However, endoscopically assisted NG tube placement under fluoroscopic guidance could be an alternative option for establishing palliative enteral nutrition. This study aimed to compare the clinical outcomes of enteral tube feeding and esophageal stenting for patients with malignant esophageal obstruction and a short life expectancy.

METHODS

Thirty-one patients were divided into 3 groups according to their treatment modality: NG tube (n = 12), esophageal stent group (n = 10), and supportive care with nil per os (NPO) (n = 9). Enteral nutrition, clinical outcomes, length of hospital stay, and median survival were evaluated.

RESULTS

There were no significant baseline differences among the groups, except in age. The tube and stent groups had significantly higher enteral calorie intake (p = 0.01), higher serum albumin (p < 0.01), shorter hospital stay (p = 0.01), and longer median survival (p < 0.01) than the NPO group. The incidence of dislodgement in the tube group was significantly higher than in the stent group (58% vs. 20%, respectively; p = 0.01). However, stenting costs more than NG tube placement.

CONCLUSIONS

Palliative enteral feeding by NG tube is safe, inexpensive, and has a low complication rate. Endoscopically assisted NG tube placement under fluoroscopic guidance could be a feasible palliative option for malignant esophageal obstruction for patients who have a short life expectancy.

Oral cancer malnutrition impacts weight and quality of life

Diet is important for both quality of life (QoL) and survival of patients with oral cancer. Their intake of food is impeded by functional restrictions in chewing and swallowing. In the DÖSAK REHAB STUDY 1652 patients from 38 hospitals within the German-language area of Germany; Austria and Switzerland were examined with regard to functional and psychological variables having an impact on diet. Chewing and swallowing are correlated with mobility of the tongue and the mandible as well as opening of the mouth. Thirty five percent of the patients lost weight; 41% maintained their weight and 24% gained weight. The QoL of patients who were able to maintain their weight and of those who gained weight was significantly better than that of patients who lost weight. A normal diet was important for maintaining weight. Mashed food; liquid food and loss of appetite were closely associated with loss of weight; although it was possible for nutritional counseling and dietary support to be implemented particularly favorably in this respect. Due to problems with eating patients' strength deteriorated; thus restricting activity. Radiotherapy had a negative impact on diet and weight. It influenced sense of taste; dryness of the mouth; swelling and discomfort when ingesting food. Pain and scars in the region of the operation also cause patients to dislike hard; spicy and sour food. Support from a nutritional counselor in implementing a calorie-rich diet remedied this and such support needs to be integrated into patient management. The fact that a poor nutritional status is of such great importance is well-known; but what is often lacking is the systematic implementation of continued professional nutritional counseling over a long period of time; weight control and psycho-social support of the operated patients; particularly those who also have had radiotherapy.

Does prior percutaneous endoscopic gastrostomy alter post-operative outcome after esophagectomy

BACKGROUND

With the introduction of neoadjuvant chemoradiotherapy in patients with esophageal carcinoma, nutritional access has become essential to counter deleterious effects of dysphagia. Current NCCN guidelines do not recommend PEG prior to esophagectomy in these patients, but there is little evidence for this recommendation. The objective of this study was to compare outcomes in patients who underwent esophagectomy with or without prior PEG placement.

METHODS

We retrospectively reviewed 96 patients who underwent esophagectomy between 2005 and 2012 for esophageal carcinoma. Patients were divided into two groups; Group I (PEG +ve) and Group II (PEG -ve). Patient characteristics, operative variables, and post-operative complications were compared. χ (2) and Fisher's test were used for categorical, while t test was used for interval variables.

RESULTS

Median age was 51(18-70) years. Lower thoracic tumors were more common in Group I (69 vs. 63 %) (P = 0.04) and more patients underwent minimally invasive surgery in this group (50 vs. 2.6 %) (P < 0.0001). Mean blood loss (326 vs. 465 ml) (P = 0.02) and ICU stay (1.6 vs. 4.3 days) (P = 0.01) were significantly lower in Group I. There was no 30-day mortality in Group I versus 10.5 % in Group II (P = 0.01). No significant difference in anastomotic leak and stricture rate was observed. Gastric conduit was used in all patients for reconstruction. One patient had malignancy in PEG site biopsy.

CONCLUSION

Percutaneous endoscopic gastrostomy before esophagectomy is safe and does not adversely impact post-operative outcomes.

Pilot genome-wide study of tandem 3' UTRs in esophageal cancer using high-throughput sequencing

Regulatory regions within the 3' untranslated region (UTR) influence polyadenylation (polyA), translation efficiency, localization and stability of mRNA. Alternative polyA (APA) has been considered to have a key role in gene regulation since 2008. Esophageal carcinoma is the eighth most common type of cancer worldwide. The association between polyA and disease highlights the requirement for comprehensive characterization of genome-wide polyA profiles. In the present study, global polyA profiles were established using the sequencing APA sites (SAPAS) method in order to elucidate the interrelation between 3' UTR length and the development of esophageal cancer. PolyA profiles were analyzed in squamous cell carcinoma, with ~903 genes identified to have shortened 3' UTRs and 917 genes identified to use distal polyA sites. The genes with shortened 3' UTRs were primarily associated with adherens junctions and the cell cycle. Four differentially expressed genes were also found, among which three genes were observed to be upregulated in cancerous tissue and involved in the positive regulation of cell motion, migration and locomotion. One gene was found to be downregulated in cancerous tissue, and associated with oxidative phosphorylation. These findings suggest that esophagitis may have a key role in the development of esophageal carcinoma. Furthermore, the genes with tandem 3' UTRs and differential expression identified in the present study may have the potential to be used as biomarkers for the diagnosis and prognosis of esophageal cancer.