The Status And Clinical Significance Of Nutrition During Concurrent Chemoradiotherapy For Nasopharyngeal Carcinoma Patients

PART 1THE CHANGES OF NUTRITIONAL STATUS AND HEMATOLOGICAL PARAMETERS DURING CONCURRENT CHEMORADIOTHERAPY FOR NASOPHARYNGEAL CARCINOMAObjective: Exploring the impact of chemoradiotherapy on the nutritional status of patients with nasopharyngeal carcinoma through the analysis of change of nutritional status and related hematological parameters in the process of concurrent chemoradiotherapy to discuss the reliable monitoring factors of malnutrition.Methods: 134 untreated patients with nasopharyngeal carcinoma from August2011 to December 2012 in Affiliated Cancer Hospital of Guangxi Medical University,and met the following conditions: 18 years of age;pathological diagnosis of non keratinizing nasopharyngeal carcinoma;treated with IMRT(intensity-modulated radiotherapy),excludes distant metastasis and other malignant tumor history.The relevant data,the nutritional status and hematological parameters included: age,gender,disease history,smoking,drinking,nutritional support,height,KPS score,concurrent chemotherapy,BMI(Body mass index),TNM stage,pathological type,and Nutritional risk screening(NRS),Patient-generated subjective global assessment(PG-SGA),and related blood indexes such as Total Protein(TP),albumin(ALB),Globulin(GLOB),Transferrin(TRF),Creatinine(Cre),Blood urea,nitrogen(BUN),Blood platelet(PLT),White blood cell(WBC),Neutrophil count(NC),Lymphocyte count(LC),Red blood corpuscle(RBC),Hemoglobin(Hb)level.The changes of nutritional status and related hematological indexes were recorded before,in the middle of radiotherapy(40Gy)and at the end of radiotherapy.The analysis of variance was used to analyze the change of continuous variables,the difference was statistically significant(<0.05).Results: 1.Before chemoradiotherapy,the patients of BMI<18.5 were 5.97%(8/134),and patients lost the weight>5% in the last 3 months were27.61%(37/134).The patients with NRS scores ? 3.0,namely the risk of malnutrition and nutrition support treatment,were 30.6%(41/134).3.73%(5/134)patients were grade C of PG-SGA score,43.28%(58/134)were grade B.2.In the middle of chemoradiotherapy,the range of weight loss was-5.45% to11.32%,with an average value of 2.4%.There were about 82.09%(110/134)lost weight,accounted for 21.64%(29/134)lost more than 5% of weight,7.46%(10/134)loss more than 10%.The patients with NRS scores ?3.0 were 75.37%(101/134).20.9%(28/134)patients were grade C,55.9%(75/134)were grade B of PG-SGA score.3 At the end of radiotherapy,the proportion of weight loss ranged from-3.64%to 19.51%,with an average of 6.27%.Patients with BMI<18.5 were 18.66%(25/134).Among them,89.55%(120/134)lost their weight,accounted for32.09%(43/134)lost more than 5% of weight,28.36%(38/134)loss more than10%.Patients with NRS scores?3.0 were 85.82%(115/134),32.09%(43/134)of patients were grade C,58.96%(79/134)were grade B of PG-SGA score.4 Compared with before treatment,the nutritional status: BMI,NRS and PG-SGA of patients in the middle and at the end of radiotherapy were significantly worse(P <0.001),Correspondingly,the hematological indexes,except creatinine,total protein,serum albumin,globulin,urea nitrogen,white blood cell,neutral granulocyte count,lymphocyte count,red blood cell,hemoglobin levels continued to decline,and the ferritin increased,the difference was statistically significant(P <0.001).Compared with before treatment,platelets decreased significantly in the middle of treatment,but there was no significant difference between the end and the middle of treatment.5 There was a negative correlation between albumin and NRS2002 score,erythrocyte and hemoglobin with NRS2002 score and PG-SGA score before treatment(P <0.001).4 weeks after treatment,total protein,There was a negative correlation between albumin and hemoglobin with PG-SGA at 4 weeks(P <0.001).At the end of treatment,There was a negative correlation between WBC,neutrophil count,lymphocyte count,red blood cell and hemoglobin and NRS2002 score.Moreover,there was a high negative correlation between the total protein,albumin,white blood cells,neutrophils,lymphocytes and red blood cells and red blood protein and PG-SGA score(P <0.001).Conclusion: Patients with nasopharyngeal carcinoma have a high risk of malnutrition before treatment,and in the course of concurrent chemoradiotherapy,the corresponding nutritional status and hematological parameters were shown to be persistent deterioration.Albumin,red blood cell and hemoglobin have some correlation with the nutritional status score,so they could be used as the monitoring factors of nutritional status.PART 2THE INFLUENCING FACTORS ON MALNUTRITION IN PATIENTS WITH NASOPHARYNGEAL CARCINOMA DURING CONCURRENT CHEMORADIOTHERAPYObjective: To study the influencing factors on malnutrition in patients with nasopharyngeal carcinoma during concurrent chemoradiotherapyMethods: 134 untreated patients with nasopharyngeal carcinoma from August2011 to December 2012 in Affiliated Cancer Hospital of Guangxi Medical University.The tumor were measured by two radiation oncologists and one radiologist in MR images before treatment,and then tumor volume(Gross tumor volume,GTV)was calculated depending on the tumor size of each layer which is from the delineation of tumor boundaries of the extent of tumor invasion in MRI.The MR images of the nasopharynx and the neck were used to record the anatomical location of tumor invasion: the parapharyngeal space,the palatal /anterior muscle,the nasal cavity,the oropharynx,the hypopharynx,the skull base bone,the pterygopalatine fossa,the paranasal sinus,the medial pterygoid muscle,the lateral pterygoid muscle,intracranial.According to the WHO histopathological classification of nasopharyngeal carcinoma in 1991,WHO-II and type III were selected and divided into two groups: differentiated group and undifferentiated group.The general characteristics of the patients(gender,age,chemotherapy,the body weight loss before radiotherapy,BMI,accompanying disease,smoking history,drinking history and nutritional support)and tumor(TNM staging,differentiation degree,tumor size and location of invasion),were used to assess the haematological index and nutritional status before,middle and after chemoradiotherapy and to explore the Influencing factors on malnutrition in patients with nasopharyngeal carcinoma during concurrent chemoradiotherapy.Results: 1 Age and chemotherapy were weakly and highly correlated with PG-SGA score before radiotherapy,respectively(CC=0.212 and 0.751,P=0.014 and P<0.001);gender,smoking,alcohol consumption,and individual disease had no correlation with PG-SGA score before radiotherapy.No correlation was found between age,gender,history of personal disease,smoking,alcohol consumption and nutrition treatment(P >0.05)with PG-SGA after radiotherapy.2.There were moderate correlation between T staging with albumin,hemoglobin and body weight after chemoradiotherapy(CC=-0.441,-0.395 and0.493,respectively,P < 0.001),high correlation with PG-SGA score(CC=0.781,<0.001).3.N staging was weak correlated with albumin,hemoglobin and PG-SGA(CC=-0.190,-0.203 and 0.235,respectively,p=0.028,0.018 and 0.006).4.Invasion of palatal muscle/prevertebral muscle,oropharynx,skull base,masticator space,paranasal sinus,intracranial invasion were moderate correlated with PG-SGA quantitative score(CC=-0.507,-0.469,0.618,0.467,0.527 and0.548 respectively,P <0.001).5 Tumor volume before treatment was negatively correlated with albumin and hemoglobin after treatment,and positively correlated with and PG-SGA quantitative score and weight loss after treatment(CC=-0.423,-0.24,0.786 and 0.502,respectively,P < 0.001 0.005 <0.001,< 0.001).there were significant differences between large tumor volume(? 24.7cm3)with small tumor volume(<24.7cm3)about PG-SGA quantitative score before and after chemoradiotherapy(P <0.001).6.It could not be considered that there was a correlation between pathological types with albumin,hemoglobin,the third weight loss and PG-SGA quantitative score(CC=-0.004,-0.045,0.004,0.049,respectively,P >0.05).Conclusion: 1.Chemotherapy,Tumor volume,T stage,invasion in palatal muscle/anterior muscle,oropharynx,skull base bone,masticatory muscle space,paranasal sinus,intracranial are the main influencing factors related to malnutrition in patients with chemoradiotherapy.2.Age,female,concurrent chemotherapy,smoking,adrinking,N stage and differentiation were weakly or not correlated with malnutrition in nasopharyngeal carcinoma patients after chemoradiotherapy.PART 3THE PROGNOSTIC SIGNIFICANCE OF MALNUTRITION IN PATIENTS WITH NASOPHARYNGEAL CARCINOMA DURING CHEMORADIOTHERAPYObjective: Analyzing the general characteristics of nasopharyngeal carcinoma(NPC)patients before and after chemoradiotherapy to evaluate the prognostic value of malnutrition in patients with nasopharyngeal carcinoma.Methods: 134 untreated patients with nasopharyngeal carcinoma from August2011 to December 2012 in Affiliated Cancer Hospital of Guangxi Medical University.To evaluate the effect of general characteristics of the patients (gender,age,concomitant disease,smoking,drinking and nutritional support),nasopharyngeal carcinoma radiotherapy and chemotherapy before and after blood indexes(albumin,erythrocyte,hemoglobin)and nutritional score(NR2002 score and PG-SGA score)on prognosis.Exploring the effects of general conditions,hematological parameters,nutritional status score and clinical T staging on 5 year cumulative survival(OS),local recurrence free survival(LRFS),and distant metastasis free survival(DMFS).Cox proportional hazards regression model was used to analyze the prognostic factors of nasopharyngeal carcinoma.Results: The 5 years OS of T1-T4 were 89.7%,87.5%,78.4% and 63.9%(p=0.04),but the P values of T1 and T2,T2 and T3,T3 and T4,were >0.05.The5 years LRFS of T1-T4 were 89.7%,90.6%,81.1% and 88.9%(p=0.573),respectively,the 5 years of DMFS were 89.7%,90.6%,81.1%,and 66.7%,respectively(p=0.029).The independent prognostic factors of 5 years OS were PG-SGA quantitative score(HR 1.264,95%CI 1.071-1.491,P=0.006)and NRS2002(HR 3.903,95%CI 1.302-11.701,P=0.015)before treatment;PG-SGA score and hemoglobin during treatment,PG-SGA score(HR0.77,95%CI0.687-0.863,p=0)and hemoglobin after treatment.The independent prognostic factors for 5 years LRFS were red blood cells,hemoglobin before treatment and with red blood cells after treatment.Independent prognostic factors for 5 years DMFS were PG-SGA score before treatment(HR1.369,95%CI 1.169-1.604,p=0.000),PG-SGA score during treatment(HR1.202,95%CI1.091-1.323,p=0.000)and PG-SGA score(HR0.869,95%CI0.762-0.99,p=0.035)and red blood cell after treatment.Conclusion: 1 T staging is no longer an independent prognostic factor,and the subgroup of T staging is lack of ability to predict prognosis.2 PG-SGA quantitative score showed better predictive ability in the 5 years OS and DMFS.But for LRFS,no independent factors were found.