胃癌辅助放化疗患者的营养状态与放化疗不良反应及治疗耐受性的关系

Association of nutrition with treatment compliance and toxicities in patients undergoing chemoradiation after gastrectomy

目的探讨胃癌术后辅助放化疗患者营养状况与放化疗不良反应及治疗耐受性之间的关系。方法采用前瞻及回顾性研究相结合的方法，连续纳入2010年12月至2012年5月间在复旦大学附属肿瘤医院放疗科住院行辅助放化疗的40例胃癌术后患者作为研究对象。采集的资料包括患者临床资料、手术前后体质量的改变、同步放化疗期间体质量、营养状态评估（营养风险筛查2002评分和患者主观整体评价量表）、血淋巴细胞计数、白蛋白的动态变化、放化疗不良反应及营养干预措施。记录患者同步放化疗及辅助化疗的完成情况。结果手术前至放疗开始前（T1～2）患者中位体质量下降百分比为10．0％，明显超过放化疗期间体质量下降百分比（4．3％，P〈0．05）。放化疗期间消化道不良反应发生率为95．0％（38／40），放疗期间（T3）体质量下降大于5％者出现Ⅱ°以上消化道不良反应者的比例[91.3％（21／23）比76．5％（13／17），P〈0．01]和出现3种以上消化道症状者的比例[82．4％（14／17）比39．1％（9／23），P〈0．05]均明显高于T3期间体质量下降小于或等于5％者。有14例（35．0％）患者未完成计划同步化疗，影响同步放化疗耐受性的因素有：手术前后（T1）体质量下降大于7％、T1～T2期间体质量下降大于10％、放疗前存在营养不良及放化疗期间需要营养支持（均P〈0．05）。1例（2．5％）患者失访，余下39例患者中9例（23．1％）中断了辅助化疗，影响辅助化疗依从性的因素有：T3期间体质量下降大于5％和T3期间需要营养支持及放疗结束时NRS2002评分大于或等于5（均P〈0．05）。结论胃癌术后患者在放疗前出现的明显营养不良会加剧放化疗期间不良反应，从而降低放化疗耐受性。放化疗期间的营养水平下降可能会影响辅助化疗依从性。对胃痛术后患者实行早期、持续的营养干预．是胃癌综合治疗的萤要绢成部分。

Objective To investigate the association of nutritional status with treatment compliance and toxicities in patients undergoing chemoradiation therapy （CRT） after gastrectomy. Methods From September 2010 to May 2012, 40 patients with gastric cancer received adjuvant CRT in the Department of Radiation, Shanghai Cancer Center. Data including clinical data, weight loss of perioperative period, dynamic changes of weight, NRS 2002 score, PG-SGA score, lymph cell count and serum albumin during CRT, toxic effects and nutritional interventions were collected. Treatment compliance of CRT and adjuvant chemotherapy was recorded. Associations among nutrition, toxicities and treatment compliance were statistically studied. Results Weight loss percentage from pre-operation to pre-CRT （T1-T2） was 10.0%, which was significantly higher than that of 4.3% during CRT （T3）（P〈 0.05）. Adverse reaction incidence of digestive tract during T3 was 95.0% （38/40）. Patients with weight loss〉5% during T3 had higher ratio of 〉 I1 degree digestive tract adverse reaction [91.3%（21/23） vs. 76.5% （13/17）, P〈0.01 ] and higher ratio of 〉3 symptoms of digestive tract [82.4% （14/17） vs. 39.1% （9/23）, P〈0.05] as compared to those with weight loss ≤5% during T3. Fourteen patients （35.0%） did not complete the synchronous CRT. Factors related to ineompletion of CRT were weight loss 〉7% after surgery （T1） or 〉10% during T1-T2, malnourishment before CRT, dependence on nutritional support during CRT. Factors related to incompletion of adjuvant chemotherapy were weight loss 〉5% during CRT （T3）, requirement for nutritional support and NRS 2002 score ≥5 at the end of radiation （all P〈0.05）. Conclusions Nutritional deterioration before CRT may aggravate the toxicities and reduce compliance of CRT in patients with radical resection of gastric cancer. Malnutrition during CRT may impair compliance to adjuvant chemotherapy. Therefore, early and persistent nutritional interventions are crucial considerations of strategies of muhidisciplinary treatment for patients with gastric cancer.