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头颈肿瘤是包含源自上呼吸道和上消化道被覆上皮、头颈部皮肤等多种不同类型肿瘤的总称,是发病率和病死率均较高的一种恶性肿瘤[1]。放疗是根治或姑息治疗头颈肿瘤的重要手段,60%~80%的患者需要接受放疗[2]。射线对肿瘤细胞和正常细胞均有毒性作用,其在破坏肿瘤细胞的同时,也会破坏正常细胞,特别是快速分裂的组织细胞。由于头颈部位生理构造的特殊性且有大面积的黏膜组织,尽管目前可以选择调强放疗,但也无法完全避免放射野内口腔黏膜的损伤,进而出现吞咽困难、口腔干燥、食欲下降和味觉丧失等症状,导致营养不良。营养不良能够降低肿瘤细胞的放射敏感性、影响放疗摆位的精确性、增加放疗的不良反应、降低放疗耐受性、增加感染风险、延长住院时长,从而降低放疗疗效和患者的生活质量[3]。Zahn等[4]曾对头颈肿瘤放疗患者蛋白质摄入量与口腔黏膜炎程度之间的关系进行研究,结果显示,在头颈肿瘤放疗期间,蛋白质摄入量与患者口腔黏膜炎反应程度相关。放射性黏膜损伤除了进行相关护理及对症处理(如缓解疼痛、预防感染和避免出血等)措施外,探究科学的营养方案对促使其快速修复意义重大。本研究对头颈肿瘤患者在根治性放化疗期间蛋白质摄入量对黏膜损伤和营养状态的影响进行前瞻性研究。
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2组患者在年龄、身高、血压、心率(t=−1.59~1.26,均P>0.05)、性别、学历和病种(鼻咽癌与其他疾病)(χ2=0.01~0.45,均P>0.05)方面的差异均无统计学意义。
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干预组口腔黏膜损伤程度为1级+2级的病例数占比[27/32(84%)]高于对照组[18/29(62%)],而3级+4级的病例数占比[5/32(16%)]少于对照组[11/29(38%)],且差异有统计学意义(χ2=3.913,P=0.04)。
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由表1可知,在根治性放化疗期间,在体重、体重指数、握力和血清白蛋白的差值(研究结束时得到的数据与研究开始时的数据之差)指标,干预组优于对照组,且差异均有统计学意义(均P<0.05);而2组在骨骼肌、体脂肪和血红蛋白的差值指标的差异均无统计学意义(均P>0.05)。
项目 干预组(n=32) 对照组(n=29) t值 P值 体重(kg) 基线值 68.92±11.38 65.02±9.75 1.43 0.16 差值 −2.80±2.66 −4.85±2.35 3.18 0.00 体重指数(kg/m2) 基线值 24.84±3.63 24.14±3.10 0.80 0.43 差值 −1.00±0.95 −1.81±0.89 3.38 0.00 骨骼肌(kg) 基线值 27.24±4.84 25.22±4.41 1.70 0.09 差值 −1.03±1.38 −1.87±2.82 1.51 0.14 体脂肪(kg) 基线值 19.50±6.37 19.13±6.61 0.22 0.83 差值 −0.99±1.73 −1.76±2.51 1.41 0.17 握力(kg) 基线值 27.50±5.18 29.24±7.59 −1.06 0.30 差值 5.59±4.20 2.59±5.32 2.46 0.02 血红蛋白(g/L) 基线值 136.28±15.67 133.14±18.83 0.71 0.48 差值 −5.97±10.45 −9.83±12.37 1.32 0.19 血清白蛋白(g/L) 基线值 42.78±3.09 41.99±2.93 1.03 0.31 差值 −1.40±3.37 −3.07±2.92 2.06 0.04 注:基线值为研究刚开始时收集的数据;差值为研究结束时得到的数据与基线值之差。对照组为接受在院常规膳食方案[蛋白质摄入量为1.0~1.2 g/(kg·d)];干预组为在常规膳食基础上,接受在院蛋白质口服补充方案[补充乳清蛋白粉50 g/d,使总蛋白质摄入量达1.5~2.0 g/(kg·d)] 表 1 2组头颈部肿瘤患者在根治性放化疗期间营养指标变 化的比较(
±s)$\bar x $ Table 1. Comparison of nutritional indexes between two groups of patients with head and neck cancer during radical radiotherapy and chemotherapy (
±s)$\bar x $ -
由表2可知,2组头颈部肿瘤患者在疗效评价、腹泻、便秘及发热指标上的差异均无统计学意义(均P>0.05)。
组别 部分缓解 完全缓解 腹泻 便秘 发热 干预组(n=32) 31 13 3 5 3 对照组(n=29) 27 10 1 8 4 χ2值 0.46 0.24 0.87 1.30 0.29 P值 0.60 0.80 0.61 0.35 0.69 注:对照组为接受在院常规膳食方案[蛋白质摄入量为1.0~1.2 g/(kg·d)];干预组为在常规膳食基础上,接受在院蛋白质口服补充方案[补充乳清蛋白粉50 g/d,使总蛋白质摄入量达1.5~2.0 g/(kg·d)] 表 2 2组头颈部肿瘤患者的疗效评价及并发症的比较(例)
Table 2. Comparison of curative effect and complications between two groups of patients with head and neck tumor (case)
蛋白质摄入水平在头颈肿瘤放化疗中的应用研究
Application study of protein intake in head and neck cancer patients undergoing radiotherapy
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摘要:
目的 探讨蛋白质摄入量对头颈肿瘤患者根治性放化疗期间黏膜损伤和营养状况的影响。 方法 选取2018年7月至2019年12月南京大学医学院附属鼓楼医院收治的72例头颈肿瘤患者的临床资料进行前瞻性研究。采用数字随机表法将患者分为2组,根据剔除标准,最终干预组纳入患者32例[男性27例、女性5例,年龄(51.67±12.92)岁]、对照组29例[男性23例、女性6例,年龄(56.03±8.26)岁]。干预组在常规膳食基础上接受在院蛋白质补充方案[补充乳清蛋白粉50 g/d,使总蛋白质摄入量达1.5~2.0 g/(kg·d)];对照组采用在院常规膳食方案[蛋白质摄入量为1.0~1.2 g/(kg·d)]。所有患者均采用根治性同步放化疗方案。比较治疗前后2组患者的黏膜损伤程度、营养指标变化、治疗疗效和相关并发症。计数资料的比较采用四格表χ2检验;两样本均数的比较采用成组t检验。 结果 2组患者在年龄、身高、血压、心率(t=−1.59~1.26)、性别、学历和病种(鼻咽癌与其他疾病)(χ2=0.01~0.45)方面的差异均无统计学意义(均P>0.05)。在口腔黏膜损伤方面,干预组患者的损伤程度低于对照组[16%(5/32)对38%(11/29)],且差异有统计学意义(χ2=3.913,P=0.04);在营养指标方面,干预组与对照组比较,除了骨骼肌、体脂肪和血红蛋白外,干预组在体重[(−2.80±2.66) kg对(−4.85±2.35) kg,t=3.18,P<0.01]、体重指数[(−1.00±0.95) kg/m2对(−1.81±0.89) kg/m2,t=3.38,P<0.01]、握力[(5.59±4.20) kg对(2.59±5.32) kg,t=2.46,P=0.02]和血清白蛋白[(−1.40±3.37)g/L对(−3.07±2.92) g/L,t=2.06,P=0.04]指标的维持上均优于对照组。2组在疗效评价、腹泻、便秘和发热指标上的差异均无统计学意义(χ2=0.24~1.30,均P>0.05)。 结论 在头颈肿瘤根治性放化疗中,补充蛋白质有缓解患者放射性黏膜损伤程度的作用,在保持患者营养指标上也具有优势。 Abstract:Objective To explore the effects of strengthening protein on mucosal injury and nutritional status in patients with head and neck cancer undergoing radiotherapy. Methods A total of 72 patients with head and neck cancer admitted to Nanjing Drum Tower Hospital Cancer Center from July 2018 to December 2019 were involved in this prospective study. All patients were randomly divided into two groups according to the random number table. Eventually, 32 cases (5 females, 27 males, 51.67±12.92 years old ) were included in the intervention group, which accepted additional protein intake based on a conventional diet (50 g/d supplementary whey protein powder to reach the total protein of 1.5–2.0 g/(kg·d)), and 29 cases were included in the control group (6 females, 23 males, 56.03±8.26 years old), which treated with a conventional diet (the total protein of 1.0–1.2 g/(kg·d)) according to the elimination criteria. All the patients were treated with radical concurrent chemoradiotherapy. The degree of mucosal damage, the change of nutritional indexes, therapeutic effect and related complications between the two groups were compared before and after treatment. The fourfold table χ2 test was used in the comparison of enumeration data and group t test was used to compare the means of two samples. Results There were no statistically significant differences in age, height, blood pressure, heart rate (t=−1.59–1.26, all P>0.05), sex, education background and disease types (nasopharyngeal carcinoma and other diseases) (χ2=0.01–0.45, all P>0.05) between the two groups. In terms of oral mucosal injury, the degree of injury in the intervention group was lower than that in the control group (16%(5/32) vs. 38%(11/29), χ2=3.913, P=0.04). In nutritional indicators, intervention group was better than the control group in maintaining weight [(−2.80±2.66) kg vs. (−4.85±2.35) kg, t=3.18, P<0.01], body mass index [(−1.00±0.95) kg/m2 vs. (−1.81±0.89) kg/m2, t=3.38, P<0.01], grip strength [(5.59±4.20) kg vs. (2.59±5.32) kg, t=2.46, P=0.02], serum albumin [(−1.40±3.37) g/L vs. (−3.07±2.92) g/L, t=2.06, P=0.04] except the skeletal muscle, body fat, hemoglobin. There was no significant difference between the two groups in efficacy evaluation, diarrhea, constipation, and fever (χ2=0.24−1.30, all P>0.05). Conclusion Strengthening protein supplement can help effectively reduce the degree of mucosal injury and have advantages in maintaining the indexes of the nutritional status of head and neck cancer patients. -
Key words:
- Head and neck neoplasms /
- Radiotherapy /
- Mucosal injury /
- Protein /
- Malnutrition
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表 1 2组头颈部肿瘤患者在根治性放化疗期间营养指标变 化的比较(
±s)$\bar x $ Table 1. Comparison of nutritional indexes between two groups of patients with head and neck cancer during radical radiotherapy and chemotherapy (
±s)$\bar x $ 项目 干预组(n=32) 对照组(n=29) t值 P值 体重(kg) 基线值 68.92±11.38 65.02±9.75 1.43 0.16 差值 −2.80±2.66 −4.85±2.35 3.18 0.00 体重指数(kg/m2) 基线值 24.84±3.63 24.14±3.10 0.80 0.43 差值 −1.00±0.95 −1.81±0.89 3.38 0.00 骨骼肌(kg) 基线值 27.24±4.84 25.22±4.41 1.70 0.09 差值 −1.03±1.38 −1.87±2.82 1.51 0.14 体脂肪(kg) 基线值 19.50±6.37 19.13±6.61 0.22 0.83 差值 −0.99±1.73 −1.76±2.51 1.41 0.17 握力(kg) 基线值 27.50±5.18 29.24±7.59 −1.06 0.30 差值 5.59±4.20 2.59±5.32 2.46 0.02 血红蛋白(g/L) 基线值 136.28±15.67 133.14±18.83 0.71 0.48 差值 −5.97±10.45 −9.83±12.37 1.32 0.19 血清白蛋白(g/L) 基线值 42.78±3.09 41.99±2.93 1.03 0.31 差值 −1.40±3.37 −3.07±2.92 2.06 0.04 注:基线值为研究刚开始时收集的数据;差值为研究结束时得到的数据与基线值之差。对照组为接受在院常规膳食方案[蛋白质摄入量为1.0~1.2 g/(kg·d)];干预组为在常规膳食基础上,接受在院蛋白质口服补充方案[补充乳清蛋白粉50 g/d,使总蛋白质摄入量达1.5~2.0 g/(kg·d)] 表 2 2组头颈部肿瘤患者的疗效评价及并发症的比较(例)
Table 2. Comparison of curative effect and complications between two groups of patients with head and neck tumor (case)
组别 部分缓解 完全缓解 腹泻 便秘 发热 干预组(n=32) 31 13 3 5 3 对照组(n=29) 27 10 1 8 4 χ2值 0.46 0.24 0.87 1.30 0.29 P值 0.60 0.80 0.61 0.35 0.69 注:对照组为接受在院常规膳食方案[蛋白质摄入量为1.0~1.2 g/(kg·d)];干预组为在常规膳食基础上,接受在院蛋白质口服补充方案[补充乳清蛋白粉50 g/d,使总蛋白质摄入量达1.5~2.0 g/(kg·d)] -
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