New Insights into Relationship between Nutritional Status and Chemotherapy Tolerance in an Obese Patient

Case Report

Austin J Clin Case Rep. 2019; 6(3): 1151.

New Insights into Relationship between Nutritional Status and Chemotherapy Tolerance in an Obese Patient

Zheng H1, Pan Q1, You L1, Lou F1, Dong Y1, Niu Z2, Li H1, Wang W1, Sun J1 and Pan H1*

¹Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China

²Department of Radiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China

*Corresponding author: Hongming Pan, Department of Medical Oncology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, 3#East Qinchun Road, Hangzhou, Zhejiang, China

Received: June 04, 2019; Accepted: July 04, 2019;Published: July 11, 2019


We hereby report a case of a 52-year-old Chinese obese male, diagnosed with nasopharyngeal carcinoma. During the first cycle of induction chemotherapy with full weight-based dosing, he developed complication of severe diarrhea, grade III myelosuppression, septic shock, hypovolemic shock and acute kidney injury. He was then transferred to intensive care unit. For this young and treatment-naive patient, in addition to several comorbidities, body composition analysis revealed an abnormality: The patient had normal amount of skeletal muscle mass but excess amount of adipose tissue in viscera and subcutaneous tissue. The patient’s visceral adipose tissue/ subcutaneous adipose tissue ratio was up to 1.10 and was above the mean of average person. As Asians may be fatter than Caucasian in the same BMI, we readdress that the disturbance of fat distribution and fat quantity may also affect the tolerance of chemotherapy drugs and propose new directions that are worth exploring.

Keywords: Chemotherapy toxicity; Obesity; Body composition; Nasopharyngeal carcinoma


A number of literatures suggest to incorporate body composition evaluation into chemotherapy dose determination. A large number of these literatures show that low lean body mass or sarcopenia is a significant predictor of toxicity, such as 5-fluorouracil, capecitabine, anthracycline and taxane [1-3]. These studies were mostly finished in Caucasian and few studies have been done in Asian patients. Although Asians may have lower BMI, they have paradoxically higher proportions of body fat compared to Caucasians [4,5]. Wider variations in volumes of visceral adipose tissue than in volumes of skeletal muscle were observed within a cohort of Asian breast cancer patients [6]. This study in Asian breast demonstrates that body fat composition is predictive of doxorubicin-related hematologic toxicities, whereas BSA-based dosing and muscle volume are not. Wejie Gu et al. also reported that radiologic measurement of visceral adipose tissue is an independent prognostic factor for Asian patients treated with targeted therapy for advanced renal cell carcinoma, whereas skeletal muscle is not, which is inconsistent with counterparts in Caucasians [7].

Case Presentation

A 52-year-old Chinese male presented in July 2018 with a painless mass on the left side of the neck, about the size of a pigeon egg. The patient was diagnosed with low/undifferentiated carcinoma of nasopharyngeal stage T3N1M0. In his past history, chronic viral hepatitis B infection was found 20 years ago and treated with entecavir 1# once a day. Hypertension was found over 10 years ago, the highest blood pressure was 180-190/100-110mmHg, and 75mg of irbesartan was taken once a day for hypertension control. Gout was found 3 years ago. Colchicine was taken as needed.

Induction chemotherapy was initiated. The TPF regime (docetaxel + cisplatin + 5-fluorouracil) was adopted in Aug. 8th 2018. Details are shown below: cisplatin 70mg intravenous drip d1, d2+docetaxel 140mg intravenous drip d1+ fluorouracil 3g intravenous injection (pump) 96h. On the day 6, the patient became critically ill. He developed abdominal pain and diarrhea the night before and complained of dry mouth. After 7 or 8 episodes of diarrhea, for watery stool, he became weak and sweaty. The blood pressure measurement was about 80/40mmHg, and the oxygen saturation was reduced to 80%. Laboratory investigations revealed that white cell count, the absolute number of neutrophils and blood platelet count were reduced to 1.5x109/L, 0.87x109/L and 96x109/L respectively. Other abnormal results were: C-reactive protein (CRP) 149.7mg/L, procalcitonin (PCT) 43.73ng/ml. He was treated with recombinant human granulocyte colony stimulating factor 300ug as well as dopamine and fluid infusion. Imipenem/Cilastatin 0.5g intravenous drip q8h was initially applied for the purpose of fighting infection.

At the night of day 6, the patient was in irritable state and sweating profusely and his limbs were wet and cold. The pulse was fast. His vital signs were shown as below: Temperature 38oC, Heartrate 135- 150bpm, Respiration rate 45bpm, Blood pressure 100/60mmHg. He was transferred into intensive care unit (ICU). In ICU, the patient still had watery stools, companying nausea and vomiting. CRP and PCT elevated to 513.4mg/L and >100ng/mL respectively. The patient was diagnosed with septic shock, myelosuppression (blood platelet count dropped to 42x109/L) and acute kidney injury (serum creatinine levels 142μmol/L, BUN 11.47mmol/L). In the day 7, no positive bacteria were detected in fecal culture and PICC catheter culture showed no anaerobic and aerobic bacteria from left and right, Empirical antiinfection treatment was adjusted to: meropenem 1g intravenous drip q8h, teicoplanin 400mg intravenous drip q12h, rifaximin 0.2g oral q6h and metronidazole 400mg oral q8h.On day 11, inflammation markers and blood cell count began to come back to normal and the patient had no complaint of special discomfort, so the patient was transferred back to the general oncology ward.

Second cycle was not initiated until day 35. Drug dose was reduced to 75% in the second cycle: cisplatin 50mg intravenous drip d1, d2+docetaxel 100mg intravenous drip d1+ fluorouracil 2.25g intravenous injection (pump) 96h. After three cycles of induction chemotherapy, therapeutic evaluation was evaluated as complete response (Figure 1).

Citation: Zheng H, Pan Q, You L, Lou F, Dong Y, Niu Z, et al. New Insights into Relationship between Nutritional Status and Chemotherapy Tolerance in an Obese Patient. Austin J Clin Case Rep. 2019; 6(3): 1151.