Neoadjuvant treatment: A window of opportunity for nutritional prehabilitation in patients with pancreatic ductal adenocarcinoma

Table 1 Prognostic role of nutritional status changes during neoadjuvant therapy in patients with pancreatic cancer

Ref.	Number of patients enrolled	Neoadjuvant treatment	Body composition changes (P value)	Body parameters and clinical outcomes (HR; P value)
Naumann et al[35], 2013, Retrospective	100	Gemcitabine-based chemoradiation	Weight decrease (P < 0.0001), BMI decrease (P < 0.0001), SAT decrease (P < 0.0001)	WL tended to negatively impact on OS (P > 0.05)
Cooper et al[36], 2015, Retrospective	89	Gemcitabine and Cisplatin followed by Gemcitabine-based chemoradiation	SKM area/height2 decrease (P = 0.01), VAT area/height2 decrease (P = 0.01), SAT/height2 decrease (P = 0.02)	Loss of SKM was related to a shorter DFS (HR 0.89, P = 0.04), loss of VAT was related to shorter PFS (HR 0.97, P = 0.01) and OS (HR 0.97, P = 0.001)
Cloyd et al[37], 2018, Retrospective	127	Gemcitabine, Capecitabine or 5-FU based chemoradiation	SKM stability (P > 0.05), VAT decrease (P < 0.001), SAT decrease (P = 0.02)	Body composition changes during were not associated with OS (P > 0.05)
Sandini et al[40], 2018, Retrospective	193	FOLFIRINOX-based chemoradiotherapy	TAT area decrease (P < 0.001), VAT area decrease (P < 0.0001), SKM area increase (P < 0.0001)	SKM area/height2 was higher in patients who underwent resection (P = 0.004)
Naumann et al[38], 2019, Retrospective	147	Gemcitabine-based chemoradiation	Weight decrease (P < 0.0001), SKM area decrease (P < 0.0001)	WL > 5% was associated with poor OS (HR 1.56, P = 0.028), SKM area loss > 5% was associated with poor OS (HR 1.50, P = 0.036)
Griffin et al[41], 2019, Retrospective	78	FOLFIRINOX and gemcitabine-based treatments	SKM area decrease (P < 0.0001), VAT decrease (P < 0.0001), SAT decrease (P < 0.0001)	Loss of lean mass was related to poor OS (HR 1.1, P = 0.003), loss of SKM was related to poor OS (HR 1.21, P = 0.001)
Naumann et al[39], 2019, Retrospective	141	Gemcitabine-based chemoradiation	Weight decrease (P < 0.001), BMI decrease (P < 0.0001), SAT, VAT and SKM areas decrease (P < 0.0001)	WL > 5% was associated with worse OS (HR 2.8, P = 0.009), SKM area loss > 5% was associated with poor OS (HR 5.54, P < 0.001)

BMI: Body mass index; DFS: Disease-free survival; HR: Hazard ratio; IMAT: Intramuscular adipose tissue; OS: Overall survival; PFS: Progression-free survival; SAT: Subcutaneous adipose tissue; SKM: Skeletal muscle; TAT: Total adipose tissue; VAT: Visceral adipose tissue; WL: Weight loss.

Table 2 Nutritional recommendation during neoadjuvant therapy in patients with pancreatic cancer

Nutritional recommendation during neoadjuvant therapy in patients with pancreatic cancer
Energy intake	Total energy expenditure should be measured; otherwise, 25 to 30 kcal/kg/d should be guaranteed
Protein intake	1.2-1.5 g/kg/d should be prescribed
Fish oil	Fish oil supplementation may improve the metabolic derangements
PERT	Tumor in the head: start PERT immediately
	Tumor in the body/tail: Perform PEI test before prescribing PERT
Immunonutrition	Immunonutrition-based supplements may improve clinical outcomes

PERT: Pancreatic enzymes replacement therapy; PEI: Pancreatic exocrine insufficiency.