Abstract

Objective: The prognostic nutritional index (PNI) reflects the immunological response and nutritional status. We evaluated the effect of immunonutrition on PNI in patients with brain tumors receiving chemoradiotherapy and immunonutritional support.

Methods: Demographic, laboratory and clinical data were collected retrospectively from 30 consecutive brain tumor patients who received brain chemoradiotherapy between 2019 and 2022 in our clinic and who were given immunonutrition support during their treatment. The cut-off PNI value before adjuvant therapy was calculated in patients who received immunonutrition support in the postoperative period and compared with the PNI values after adjuvant therapy.

Results: While glioblastoma patients constitute the majority (60%) of all patients diagnosed as pathological, different histopathological brain tumors were also included in the study (meningioma, oligodendroglioma). The mean albümin value before adjuvant treatment was 4.04 g/dL, while the mean albümin value after adjuvant treatment increased to 4.16 g/dL (p=0,057). The optimal cut-off value for PNI was found to be 45.5 by ROC analysis. PNI was calculated as 49.38 ± 6.03 SD before adjuvant treatment and 49.40 ± 6.12 SD after adjuvant treatment (p>0.05).

Retrospective analysis was conducted on over 30 HGG patients who did not receive immunonutritional supplementation containing Arg/gln/HMB (Arginine/glutamine/Beta-Hydroxy Beta-Methylbutyrate). Interestingly, the analysis revealed that the average PNI was 45.15 before adjuvant therapy and decreased to 42.26 after adjuvant therapy, indicating a statistically significant decline in PNI among those without immunonutritional supplementation. This finding suggests a potential beneficial impact of immunonutritional supplementation on PNI.

Conclusions: Immunonutrition support has positive effects on PNI and albumin levels in brain tumor patients who will undergo postoperative radiotherapy/chemoradiotherapy. It can be thought that low PNI, which may be an indicator of hematological and nutritional toxicity predicted by brain chemoradiotherapy, can be prevented by immunonutrition support.

Keywords: prognostic nutritional index, immunonutrition, brain tumors, chemoradiotherapy

Copyright and license

Copyright © 2024 The author(s). This is an open-access article under the terms of the Creative Commons Attribution License (CC BY) which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited.

How to cite

1.
Akmansu M, Korucu Y, Dabak Gönülal S. The effect of immunonutrition support on the prognostic nutritional index in the postoperative period in brain tumors. Clin Sci Nutr. 2024;6(3):123-136. doi:10.62210/ClinSciNutr.2024.95

References

  1. Ostrom QT, Gittleman H, Fulop J, et al. CBTRUS Statistical Report: Primary Brain and Central Nervous System Tumors Diagnosed in the United States in 2008-2012. Neuro Oncol. 2015;17(Suppl 4):iv1-iv62. https://doi.org/10.1093/neuonc/nov189
  2. Stupp R, Hegi ME, Mason WP, et al. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol. 2009;10:459-466. https://doi.org/10.1016/S1470-2045(09)70025-7
  3. Stupp R, Mason WP, van den Bent MJ, et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005;352:987-996. https://doi.org/10.1056/NEJMoa043330
  4. Binabaj MM, Bahrami A, ShahidSales S, et al. The prognostic value of MGMT promoter methylation in glioblastoma: A meta-analysis of clinical trials. J Cell Physiol. 2018;233:378-386. https://doi.org/10.1002/jcp.25896
  5. SongTao Q, Lei Y, Si G, et al. IDH mutations predict longer survival and response to temozolomide in secondary glioblastoma. Cancer Sci. 2012;103:269-273. https://doi.org/10.1111/j.1349-7006.2011.02134.x
  6. Gorlia T, van den Bent MJ, Hegi ME, et al. Nomograms for predicting survival of patients with newly diagnosed glioblastoma: prognostic factor analysis of EORTC and NCIC trial 26981-22981/CE.3. Lancet Oncol. 2008;9:29-38. https://doi.org/10.1016/S1470-2045(07)70384-4
  7. Helseth R, Helseth E, Johannesen TB, et al. Overall survival, prognostic factors, and repeated surgery in a consecutive series of 516 patients with glioblastoma multiforme. Acta Neurol Scand. 2010;122:159-167. https://doi.org/10.1111/j.1600-0404.2010.01350.x
  8. Kim YS, Kim SH, Cho J, et al. MGMT gene promoter methylation as a potent prognostic factor in glioblastoma treated with temozolomide-based chemoradiotherapy: a single-institution study. Int J Radiat Oncol Biol Phys. 2012;84:661-667. https://doi.org/10.1016/j.ijrobp.2011.12.086
  9. Green CJ. Existence, causes and consequences of disease-related malnutrition in the hospital and the community, and clinical and financial benefits of nutritional intervention. Clinical Nutrition. 1999;18(Suppl 2):3-28.
  10. Martin L, Senesse P, Gioulbasanis I, et al. Diagnostic criteria for the classification of cancer-associated weight loss. J Clin Oncol. 2015;33:90-99. https://doi.org/10.1200/JCO.2014.56.1894
  11. Dewys WD, Begg C, Lavin PT, et al. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med. 1980;69:491-497. https://doi.org/10.1016/s0149-2918(05)80001-3
  12. Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF. Prognostic nutritional index in gastrointestinal surgery. Am J Surg. 1980;139:160-167. https://doi.org/10.1016/0002-9610(80)90246-9
  13. Wang Z, Wang Y, Zhang X, Zhang T. Pretreatment prognostic nutritional index as a prognostic factor in lung cancer: Review and meta-analysis. Clin Chim Acta. 2018;486:303-310. https://doi.org/10.1016/j.cca.2018.08.030
  14. Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients. Nihon Geka Gakkai Zasshi. 1984;85:1001-1005.
  15. Man Z, Pang Q, Zhou L, et al. Prognostic significance of preoperative prognostic nutritional index in hepatocellular carcinoma: a meta-analysis. HPB (Oxford). 2018;20:888-895. https://doi.org/10.1016/j.hpb.2018.03.019
  16. Dai Y, Liu M, Lei L, Lu S. Prognostic significance of preoperative prognostic nutritional index in ovarian cancer: A systematic review and meta-analysis. Medicine (Baltimore). 2020;99:e21840. https://doi.org/10.1097/MD.0000000000021840
  17. Sun G, Li Y, Peng Y, et al. Impact of the preoperative prognostic nutritional index on postoperative and survival outcomes in colorectal cancer patients who underwent primary tumor resection: a systematic review and meta-analysis. Int J Colorectal Dis. 2019;34:681-689. https://doi.org/10.1007/s00384-019-03241-1
  18. Jeon HG, Choi DK, Sung HH, et al. Preoperative Prognostic Nutritional Index is a Significant Predictor of Survival in Renal Cell Carcinoma Patients Undergoing Nephrectomy. Ann Surg Oncol. 2016;23:321-327. https://doi.org/10.1245/s10434-015-4614-0
  19. Qi Q, Song Q, Cheng Y, Wang N. Prognostic Significance of Preoperative Prognostic Nutritional Index for Overall Survival and Postoperative Complications in Esophageal Cancer Patients. Cancer Manag Res. 2021;13:8585-8597. https://doi.org/10.2147/CMAR.S333190
  20. Hirahara N, Tajima Y, Fujii Y, et al. Preoperative Prognostic Nutritional Index Predicts Long-Term Surgical Outcomes in Patients with Esophageal Squamous Cell Carcinoma. World J Surg. 2018;42:2199-2208. https://doi.org/10.1007/s00268-017-4437-1
  21. Sasahara M, Kanda M, Ito S, et al. The Preoperative Prognostic Nutritional Index Predicts Short-Term and Long-Term Outcomes of Patients with Stage II/III Gastric Cancer: Analysis of a Multi-Institution Dataset. Dig Surg. 2020;37:135-144. https://doi.org/10.1159/000497454
  22. Hofbauer SL, Pantuck AJ, de Martino M, et al. The preoperative prognostic nutritional index is an independent predictor of survival in patients with renal cell carcinoma. Urol Oncol. 2015;33:68.e1-7. https://doi.org/10.1016/j.urolonc.2014.08.005
  23. Liu J, Jiang S, Yang X, Li X, Wang N. The Significant Value of Preoperative Prognostic Nutritional Index for Survival in Pancreatic Cancers: A Meta-analysis. Pancreas. 2018;47:793-799. https://doi.org/10.1097/MPA.0000000000001089
  24. Yang Y, Gao P, Song Y, et al. The prognostic nutritional index is a predictive indicator of prognosis and postoperative complications in gastric cancer: A meta-analysis. Eur J Surg Oncol. 2016;42:1176-1182. https://doi.org/10.1016/j.ejso.2016.05.029
  25. Mohri Y, Inoue Y, Tanaka K, Hiro J, Uchida K, Kusunoki M. Prognostic nutritional index predicts postoperative outcome in colorectal cancer. World J Surg. 2013;37:2688-2692. https://doi.org/10.1007/s00268-013-2156-9
  26. Sun K, Chen S, Xu J, Li G, He Y. The prognostic significance of the prognostic nutritional index in cancer: a systematic review and meta-analysis. J Cancer Res Clin Oncol. 2014;140:1537-1549. https://doi.org/10.1007/s00432-014-1714-3
  27. Shibutani M, Maeda K, Nagahara H, et al. The prognostic significance of the postoperative prognostic nutritional index in patients with colorectal cancer. BMC Cancer. 2015;15:521. https://doi.org/10.1186/s12885-015-1537-x
  28. Hayasaka K, Shiono S, Suzuki K, Endoh M, Okada Y. Postoperative prognostic nutritional index as a prognostic factor after non-small cell lung cancer surgery. Gen Thorac Cardiovasc Surg. 2020;68:1163-1171. https://doi.org/10.1007/s11748-020-01366-7
  29. Park S, Ahn HJ, Yang M, Kim JA, Kim JK, Park SJ. The prognostic nutritional index and postoperative complications after curative lung cancer resection: A retrospective cohort study. J Thorac Cardiovasc Surg. 2020;160:276-285.e1. https://doi.org/10.1016/j.jtcvs.2019.10.105
  30. Tsukagoshi M, Araki K, Igarashi T, et al. Lower Geriatric Nutritional Risk Index and Prognostic Nutritional Index Predict Postoperative Prognosis in Patients with Hepatocellular Carcinoma. Nutrients. 2024;16:940. https://doi.org/10.3390/nu16070940
  31. Xu WZ, Li F, Xu ZK, et al. Preoperative albumin-to-globulin ratio and prognostic nutrition index predict prognosis for glioblastoma. Onco Targets Ther. 2017;10:725-733. https://doi.org/10.2147/OTT.S127441
  32. Zhou XW, Dong H, Yang Y, et al. Significance of the prognostic nutritional index in patients with glioblastoma: A retrospective study. Clin Neurol Neurosurg. 2016;151:86-91. https://doi.org/10.1016/j.clineuro.2016.10.014
  33. Liu M, Wang L. Prognostic significance of preoperative serum albumin, albumin-to-globulin ratio, and prognostic nutritional index for patients with glioma: A meta-analysis. Medicine (Baltimore). 2020;99:e20927. https://doi.org/10.1097/MD.0000000000020927
  34. Rigamonti A, Imbesi F, Silvani A, et al. Prognostic nutritional index as a prognostic marker in glioblastoma: Data from a cohort of 282 Italian patients. J Neurol Sci. 2019;400:175-179. https://doi.org/10.1016/j.jns.2019.04.002
  35. He Q, Zhao W, Ren Q. The Prognostic Value of the Prognostic Nutritional Index in Operable High-Grade Glioma Patients and the Establishment of a Nomogram. Front Oncol. 2022;11:724769. https://doi.org/10.3389/fonc.2021.724769
  36. Oyman A, Işık S, Eröz S, et al. The effect of preoperative prognostic nutritional index on outcome in glioblastoma multiforme patients. J Surg Med. 2022;6:177-180. https://doi.org/10.28982/josam.1049310
  37. Kim YJ, Oh H, Lee SJ, et al. Prognostic significance of the postoperative prognostic nutritional index in patients with glioblastoma: a retrospective study. BMC Cancer. 2021;21:942. https://doi.org/10.1186/s12885-021-08686-8
  38. Garrett C, Becker TM, Lynch D, et al. Comparison of neutrophil to lymphocyte ratio and prognostic nutritional index with other clinical and molecular biomarkers for prediction of glioblastoma multiforme outcome. PLoS One. 2021;16:e0252614. https://doi.org/10.1371/journal.pone.0252614
  39. Huq S, Khalafallah AM, Botros D, et al. The Prognostic Impact of Nutritional Status on Postoperative Outcomes in Glioblastoma. World Neurosurg. 2021;146:e865-e875. https://doi.org/10.1016/j.wneu.2020.11.033
  40. Kaźmierczak-Siedlecka K, Daca A, Folwarski M, Makarewicz W, Lebiedzińska A. Immunonutritional support as an important part of multidisciplinary anti-cancer therapy. Cent Eur J Immunol. 2020;45:454-460. https://doi.org/10.5114/ceji.2020.103339
  41. Çoker A. Immunonutrition. Turk J Intensive Care. 2006;4:40-44.
  42. Caburet C, Farigon N, Mulliez A, et al. Impact of nutritional status at the outset of assessment on postoperative complications in head and neck cancer. Eur Ann Otorhinolaryngol Head Neck Dis. 2020;137:393-398. https://doi.org/10.1016/j.anorl.2019.12.005
  43. Yeh HH, Lai WW, Chen HHW, Liu HS, Su WC. Autocrine IL-6-induced Stat3 activation contributes to the pathogenesis of lung adenocarcinoma and malignant pleural effusion. Oncogene. 2006;25:4300-4309. https://doi.org/10.1038/sj.onc.1209464
  44. Turnquist C, Ryan BM, Horikawa I, Harris BT, Harris CC. Cytokine Storms in Cancer and COVID-19. Cancer Cell. 2020;38:598-601. https://doi.org/10.1016/j.ccell.2020.09.019
  45. Akmansu M, Unsal D, Bora H, Elbeg S. Influence of locoregional radiation treatment on tumor necrosis factor-alpha and interleukin-6 in the serum of patients with head and neck cancer. Cytokine. 2005;31:41-45. https://doi.org/10.1016/j.cyto.2005.02.009
  46. Arslan K, Baş S. The relationship between the prognostic nutritional index and the clinical course of COVID-19: a single-center experience. Journal of Medicine and Palliative Care. 2022;3:92-97. https://doi.org/10.47582/jompac.1110431
  47. He ZQ, Ke C, Al-Nahari F, et al. Low preoperative prognostic nutritional index predicts poor survival in patients with newly diagnosed high-grade gliomas. J Neurooncol. 2017;132:239-247. https://doi.org/10.1007/s11060-016-2361-0
  48. Ding JD, Yao K, Wang PF, Yan CX. Clinical significance of prognostic nutritional index in patients with glioblastomas. Medicine (Baltimore). 2018;97:e13218. https://doi.org/10.1097/MD.0000000000013218
  49. Borg N, Guilfoyle MR, Greenberg DC, Watts C, Thomson S. Serum albumin and survival in glioblastoma multiforme. J Neurooncol. 2011;105:77-81. https://doi.org/10.1007/s11060-011-0562-0
  50. Liu W, Qdaisat A, Yeung J, et al. The Association Between Common Clinical Characteristics and Postoperative Morbidity and Overall Survival in Patients with Glioblastoma. Oncologist. 2019;24:529-536. https://doi.org/10.1634/theoncologist.2018-0056
  51. Brooks WH, Netsky MG, Normansell DE, Horwitz DA. Depressed cell-mediated immunity in patients with primary intracranial tumors. Characterization of a humoral immunosuppressive factor. J Exp Med. 1972;136:1631-1647. https://doi.org/10.1084/jem.136.6.1631
  52. Kikuchi K, Neuwelt EA. Presence of immunosuppressive factors in brain-tumor cyst fluid. J Neurosurg. 1983;59:790-799. https://doi.org/10.3171/jns.1983.59.5.0790
  53. Mendez JS, Govindan A, Leong J, Gao F, Huang J, Campian JL. Association between treatment-related lymphopenia and overall survival in elderly patients with newly diagnosed glioblastoma. J Neurooncol. 2016;127:329-335. https://doi.org/10.1007/s11060-015-2037-1
  54. Wick W, Meisner C, Hentschel B, et al. Prognostic or predictive value of MGMT promoter methylation in gliomas depends on IDH1 mutation. Neurology. 2013;81:1515-1522. https://doi.org/10.1212/WNL.0b013e3182a95680
  55. Eckel-Passow JE, Lachance DH, Molinaro AM, et al. Glioma Groups Based on 1p/19q, IDH, and TERT Promoter Mutations in Tumors. N Engl J Med. 2015;372:2499-2508. https://doi.org/10.1056/NEJMoa1407279