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Recommendations Summary

ONC: Head and Neck Cancer: Surgery and Use of Arginine-Enhanced Medical Food Supplement or EN 2007

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

• Recommendation(s)

  ONC: Head and neck cancer: Post-operative use of arginine

  Post-operative use of arginine-enhanced medical food supplements (MFS) or enteral nutrition (EN) to improve outcomes for patients with head and neck cancer is not recommended. Arginine-enhanced versus non-arginine-enhanced MFS and EN did not produce significant changes in weight and body composition in either well-nourished or malnourished subjects. Most evidence shows there is no impact of arginine-enhanced MFS or EN on immune function. Limited research reported that arginine-enhanced EN can improve post-operative complications and LOS in malnourished patients.

  Rating: Fair
  Imperative

  ONC: Head and neck cancer: Pre-operative use of arginine

  Pre-operative use of arginine-enhanced EN to improve outcomes for patients with head and neck cancer is not recommended. No significant improvement in clinical outcomes, nutritional status, or surgery-induced immune suppression was observed among malnourished compared to patients receiving a non-enhanced EN, or those who did not receive EN.

  Rating: Fair
  Imperative

  • Risks/Harms of Implementing This Recommendation

    No potential risks or harms are associated with these recommendations.

  • Conditions of Application

     No conditions of application limit the application of these recommendations.

  • Potential Costs Associated with Application

    No obvious costs are associated with the application of these recommendations.

  • Recommendation Narrative

    • Two positive quality and one neutral quality RCT suggested that the catabolic process that occurs in post-surgical head and neck cancer patients is not altered by arginine.
      • deLuis, Izaola et al, 2004 (positive quality) and deLuis et al,  2002 (neutral quality) provided a supplement enriched with arginine (.625g per 100ml) to head and neck cancer patients for an average of 21 and 22 days. Changes in weight from baseline were not significant in either or the arginine and control groups.
      • deLuis, Izaola et al,  2005 (positive quality) provided 1.2g arginine per 100 ml for 90 days to head and neck cancer patients. Changes in weight, FFM, FM, TSF, and AC were not significant.
    • One positive quality RCT (de Luis, Izaola et al, 2005) compared the use of an oral supplement enhanced with arginine vs. an omega-3 enhanced formula with head and neck cancer patients. Both groups experienced a significant improvement in plasma protein levels while only the omega-3 group experienced weight gain. There was no significant difference in fat-free mass between the two groups. There was no significant benefit of arginine over omega-3 fatty acid supplementation in this group of patients.
    • Two positive quality RCTs (de Luis, Izaola et al, 2004; de Luis, Arranz et al, 2005) found no significant differences in plasma proteins and immune parameters between head and neck cancer patients receiving arginine-enhanced vs. standard enteral formulas.
    • One neutral quality study (de Luis, Aller et al, 2002) found that fistula development was significantly less common among head and neck cancer patients receiving arginine-enhanced enteral feedings, otherwise no statistically significant differences were observed between those receiving arginine-enhanced vs. standard enteral formulas.
    • One positive quality RCT (Riso et al, 2000) compared the use of an arginine-enhanced enteral formula to a control isocaloric, isonitrogenous enteral formula in post-operative patients with head and neck cancer to measure immunologic and clinical outcomes. The study group receiving the arginine-enhanced formula experienced an improved post-operative immunological response, most notably in patients who were classified as malnourished prior to the start of the study. The malnourished group also experienced a decrease in both post-operative complications and LOS compared to the control group.
    • One positive quality RCT (Van Bokhorst-de van der Schueren et al, 2001) compared the use of an arginine-enhanced enteral formula to a standard enteral formula or no enteral feedings. No significant differences in clinical outcomes, nutritional status, or surgery-induced immune suppression were observed between the three groups.

  • Recommendation Strength Rationale

    • Based on five positive quality and one neutral quality RCTs,  conclusion statements are grade II and III.

• Supporting Evidence

  The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

  Can the catabolic process that occurs in head and neck cancer patients be altered by amino acids?
  
  Is there a relationship between use of an arginine-enhanced enteral nutrition and plasma protein levels and immune function with postoperative patients with head and neck cancer?
  
  Is there a relationship between use of an arginine-enhanced medical food supplement and post-operative complications in patients with oral or laryngeal cancer?
  
  Is there a relationship between use of a preoperative arginine-enhanced enteral nutrition formula and reduction in post-operative complications by patients with oral or laryngeal cancer?
  
  Is there a relationship between post-operative arginine-enhanced enteral nutrition and post-operative wound complication rates by patients with oral or laryngeal cancer?
  
  Is there a relationship between the use of postoperative arginine-enhanced enteral nutrition and treatment-related diarrhea by patients with oral or laryngeal cancer?
  
  Does the intake of an arginine-enhanced medical food supplement improve plasma protein levels in post-surgical patients with head and neck cancer?

  • References

    de Luis, D.A., Izaola, O., Cuellar, L., Terroba, M.C., Aller, R. Randomized clinical trial with an enteral arginine-enhanced formula in early postsurgical head and neck cancer patients. Eur J Clin Nutr. 2004 Nov;58(11):1505-8.
    
    de Luis, D.A., Aller, R., Izaola, O., Cuellar, L., Terroba, M.C. Postsurgery enteral nutrition in head and neck cancer patients. 2002, European Journal of Clinical Nutrition 56:1126-1129.
    
    de Luis DA, Izaola O, Aller R, Cuellar L, Terroba MC. A randomized clinical trial with oral Immunonutrition (omega3-enhanced formula vs. arginine-enhanced formula) in ambulatory head and neck cancer patients. Ann Nutr Metab. 2005 Mar-Apr;49(2):95-9.
    
    de Luis, D.A., Arranz, M., Aller, R., Izaola, O., Cuellar, L., Terroba, MC. Immunoenhanced enteral nutrition, effect on inflammatory markers in head and neck cancer patients. Eur J Clin Nutr. 2005, 59 ; 145-147.
    
    Riso, S., Aluffi, P., Brugnanai, M., Farinetti, F., Pia, F., D’andrea, F. Postoperative enteral immunonutrition in head and neck cancer patients Clin Nutr. 2000 Dec;19(6):407-12.
    
    van Borkhurst-de van der Schueren, M.A.E., Quak, J., von Blomberg-van der Flier, B.M.E., Kuik, D.J., Langendoen, S.I., Snow, G.B., Green, C.J., van Leeuwen, P.A.M. Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients. Am J Clin Nutri 2001; 73: 323-32.