Retinol (vitamin A) and retinol-binding protein serum levels in children with cancer at onset

APPLIED

NUTRITIONAL

INVESTIGATION

Nut&ion

Vol. 13, No. I, 1997

Retinol (Vitamin A) and Retinol-Binding Protein Serum Levels in Children with Cancer at Onset CARLO

PAOLO FIORE, MD,* ELI0 CASTAGNOLA, MD,? NORA MARCHESE, PHD,$ DUFOUR, MD,5 ALBERT0 GARAVENTA,§ MD, SALVATORE MANGRAVITI, AND PAOLO CORNAGLIA-FERRARIS, MD5

MD,$

From the *Department of Dietetics, t Department of Infectious Diseases, $L.uboratory of Clinical Chemistry, and the 9 Department of Hematology-Oncology, Giannina Gaslini Institute, Genova, Italy Date accepted: 10 May 1996

ABSTRACT The aim

neoplasia (NDN) admitted to the Department of Hematology-Oncology of G. Gaslini Institute. Vit A levels, retinol-binding protein (RBP), and nutritional status were evaluated in 54 children with NDN (22 solid tumors other than neuroblastoma, 16 neuroblastomas, 9 lymphomas, 7 acute lymphoblastic leukemia). Biochemical test results were also compared with those of 47 healthy controls (HC) comparable for sex and age. In children with NDN, mean Vit A plasma level results were 350 pg/L (95% CI 288412); in HC they were 517 pg/L (95% CI 471-563), P < 0.001. Mean RBP value results were 3.2 mg/dL (95% CI 2.6-3.9) in NDN and 4.9 mg/dL in HC (95% CI 4.5-5.3), P < 0.001. Fifteen (28%) out of 54 children with NDN were classified as well-nourished, 27/54 (50%) were considered at risk of malnutrition, and 12 (22%) were malnourished. Children with NDN presented reduced Vit A and RBP mean values compared with those of HC. Further studies are needed to better evaluate Vit A metabolism in children with cancer at onset. OEZsevier Science Inc. 1997. Nutrition 1997:13:17-20 Key words:

of the study was to evaluate vitamin A (Vit A) plasma levels in children with newly diagnosed

vitamin A, retinol-binding

protein, cancer at onset, nutritional status, pediatric

INTRODUCTION

One of the most important roles of retinol (Vitamin A, Vit A) is the promotion of differentiation and growth of a wide range of cells and tissues in the perinatal period and infancy. Vit A is a key factor in controlling neuroectodermal cell development and function. Recently it has been suggested that pcarotene, the natural precursor of Vit A, and several other nutrients including tocopherol, vitamin C, and selenium reduce the risk of cancer in humans. This hypothesis has been supported by prospective and retrospective studies of dietary intake of /3carotene and cancer, and prospective studies of P-carotene and/ or retinol serum levels in cancer patients.‘-* Retinoic acid induces the differentiation of neuroblastoma in vitro, teratocarcileukemia cell lines noma in vitro,‘.” and human promyelocytic such as HL60,” and its administration has been demonstrated to be effective in the case of acute promyelocytic leukemia, as

Correspondence to: Paolo Fiore, MD, Department

Nutrition 13:17-20, 1997 OElsevier Science Inc. 1997 Printed in the USA. All rights reserved.

of Dietetics,

Giannina

complete clinical remission was achieved following treatment with tretinoin in two independent studies.‘2.‘7 Clinical trials utilizing different retinoids in several other neoplastic disorders are still in progress. As far as the role of Vit A or other dietary factors in inducing and/or favoring cancer remission in children is concerned, no evidence has been provided. Therefore, we evaluated Vit A plasma levels in patients with newly diagnosed neoplasia (NDN) admitted to the Department of Hematology-Oncology of G. Gaslini Institute during the period January-December 1994. CLINICAL MATERIALS

AND METHODS

Vit A levels were evaluated in children admitted to the Department of Hematology-Oncology of G. Gaslini Institute with NDN during the period January-December 1994. Other parameters, strictly related to Vit A metabolism, were

Gaslini

ELSEVIER

Children’s

Hospital,

Largo G. Gaslini,

5, 16148 Geneva-Italy

0899-9007/97/$17.00 PII: SO899-9007(96)003 17-6

VITAMIN also evaluated. In particular we evaluated levels of retinolbinding protein (RBP) because it is the carrier-protein for transport of Vit A to its target cells; and Zn because adequate serum levels of this micronutrient are needed for normal hepatic production of Apo-RBP.14 Malnutrition is common on diagnosis of malignancy in pediatric patients.‘6-‘9 Since abnormalities of the nutritional status (NS) could affect the turnover of RBP and other proteins, ” we also evaluated NS by means of biochemical parameters, specifically prealbumin (TBPA) and albumin ( Alb) levels and anthropometric measures (weight and height). Finally, since Vit A levels can be directly or indirectly influenced by food intake, we also evaluated dietary intake. Vit A levels can be directly and/or indirectly influenced by concomitant infectious diseases with fever >38”C, renal failure, liver disease, malabsorption, or cystic fibrosis, “~20 therefore patients with these conditions at the time of diagnosis of neoplasia were not included in the study. Laboratory

Methods

Alb, TBPA, and RBP serum concentrations were all quantified with a laser nephelometer (Behring Diagnostics, Marburg, Germany); monospecific antisera, diluents, standards, and controls were all from Behring Diagnostics. Sample predilution was 1:400 for Alb and 1: 10 for both RBP and TBPA. The ratio of sample to antibody was lOO/ 130 mL for Albiantisemm, while for both TBPA and RBP it was 80/80 mL. Zn concentrations were performed by flame atomic absorption spectrophotometry using AAS 560 (Perkin-Elmer, Norwalk, CT, USA). For retinol assessment, sera collected from each patient at onset were never exposed to natural illumination and stored at -70°C. Retinol (Vit A) concentration was evaluated by high performance liquid chromatography (pump model 2OOLC, PerkinElmer), with spectrophotometric detection at 280 nm. Briefly, a 5-mm C-18 analytical column connected with a C-18 guard column was used. The mobile phase was water in methanol (2/98 by volume) and the flow rate was 1 mL/min. Injected volume was 50 pL. Standard curve was obtained by using as internal standard retinyl acetate for retinol. The peak/area ratio was linear up to at least 36.8 pmol/L for retinol. Samples for serum proteins, Zn, and Vit A evaluation were taken before administration of antineoplastic chemotherapy and relevant diagnostic procedures, including biopsies. Anthropometric

Assessment

and Dietary Evaluation

Weight (W) and height or length (H) were measured by standard procedures.*’ Percentiles for age and related indices of weight-for-height (W/H), weight-for-age (W/A), and heightfor-age (H/A) percentiles were calculated for each child by the Anthro 1 .O1 software anthropometric program (Division of Nutrition, Centers for Disease Control [ CDC] , Atlanta, GA, USA), based on CDC/World Health Organization (WHO) growth reference values. The CDC/WHO International Growth Reference permits calculation of W/H indices for male children until 138 mo of age and smaller than 145 cm, and female children through 120 mo of age and smaller than 137 cm, due to the variable timing of the pubertal growth spurt. For those children who fell outside these parameters, body mass index was calculated and we considered the 3rd percentile as cut-off for definition of malnutritionz2 Energy and nutrient evaluation of each child was based on parental recall of the food eaten by the child in the 48 h preceding admission (48-h dietary recall method). Dietary histories were obtained by a dietitian with standardized interview and nutritional data were compiled by a nutritional software program (Ped-Diet ver. 1.0, Department of Dietetics, G. Gaslini

A SERUM

LEVELS

IN CHILDREN

WITH

CANCER

Children’s Hospital Data Center, Genova, Italy). Results were expressed as a percentage of the age- and sex-specific Italian recommended daily allowances (RDA) (LARN, Istituto Nazionale Nutrizione, Roma, Italy) .23 Patients were classified as: at risk of malnutrition (subclinical malnourished) in the presence of TBPA and/or Alb values ~15 mg/dL and 3.5 g/dL, respectively; acutely malnourished in the presence of W loss >5% in the last month and/or W/H <5th percentile when H was 25th percentile for age; or chronically malnourished when both W/A and H/A were ~5th percentile. ‘6.2’,B Patients consuming <80% RDA were considered as eating less than normal and at risk for nutritional depletion. Control Group Vit A, RBP, TBPA, and Alb were also evaluated in a control group of healthy children (HC) attending medical or surgical outpatient clinics without significant acute or chronic illness, and with normal growth (no children with W/A, H/A, or WI H index <5th percentile NCHS). Zn values were not evaluated in this group of patients; therefore, normal values of Zn were considered those reported in literature.” STATISTICAL

ANALYSIS

Statistical analysis was performed by means of t test for independent data for continuous variables. Chi-square or Fisher’s exact test, when appropriate, was used for comparison of categorical variables. The standard value of P = 0.05 was considered. In cases of multiple comparisons, the Bonferroni’s rule was used, dividing the standard P value (0.05) by the number of comparisons performed (NDN low Vit A versus other neoplastic diseases; NDN low Vit A versus normal controls; other neoplastic diseases versus normal controls) to obtain the new value of P = 0.015 as threshold limit of significance. All tests were two-tailed. RESULTS

The study was performed on 54 children, 24 males and 30 females, ages 8 mo to 16.5 y (mean 5.6 y). Newly diagnosed neoplasias included the following: 22 solid tumors other than neuroblastoma, 16 neuroblastomas, 9 lymphomas, and 7 acute lymphoblastic leukemia. The control group was represented by 47 healthy children, 21 males and 26 females, ages 8 mo to 15.5 y (mean 5.9 y) comparable for sex and age. Biochemical

Analyses

Table I reports mean values of Vit A, RBP, TBPA, and Alb both in patients with NDN and in HC. There is a statistically significant difference between Vit A, RBP, TBPA, and Alb mean values observed in NDN and HC groups (P < 0.001). In patients with NDN mean Zn levels were 63 mg/dL (95% CI 60-65), which is within the lower normal range.25 Nutritional

Status

Fifteen (28%) out of 54 children with NDN were classified as well-nourished and 39 were classified to be at risk of malnutrition or malnourished. Isolated abnormalities of biochemical nutritional parameters (Alb and TBPA) determined a diagnosis of patient at risk for malnutrition in 27/54 (50%). Another 11(20%) were classified as acutely malnourished because of W/H <5th percentile and/or body weight loss >5% in the last month. only one (2%) of the NDN children was classified as chronically malnourished. Dietary assessment determined that, at diagnosis, 18 children (33%) were consuming less than RDA for their age and their own previous intake. Nine of them were malnourished at diagnosis of cancer. Moreover, we observed that 14 patients had

VITAMIN

A SERUM LEVELS IN CHILDREN WITH CANCER TABLE I.

LEVELS OF VITAMIN A, RBP, AND OTHER SERUM PROTEINS IN CHILDREN WITH NEWLY DIAGNOSED NEOPLASIA (NDN) AND IN A GROUP OF HEALTHY CONTROLS Children with NDN (n = 54) MEAN VITAMIN A (&L) (95% CI) MEAN RBP (mg/dL) (95% CI) MEAN TBPA (mg/dL) (95% CI) MEAN ALBUMIN (mg/dL) (95% Cl)

350* (288-412) 3.2* (2.6-3.9) 18.8L (16.6-21) 3741* (3580-3902)

Healthy controls (n = 47) 517 (471-563) 4.9 (4.5-5.3) 27.3 (25.5-29) 5838 (5665-6010)

* These values are significantly different from those observed in healthy controls (P < 0.001; r test for independent data). RBP, retinal-binding protein; TBPA, prealbumin.

low levels of Vit A and RBP. However, no difference in sex, age, underlying disease, or NS was found when comparing these children with other NDN patients (data not shown).

extremely

DISCUSSION

In our study we have demonstrated that children with NDN have mean Vit A and RBP plasma levels significantly lower than those observed in matched HC. Vit A and RBP levels can be influenced by many factors, which can be concomitant in a single patient: malnutrition and/or inadequate dietary intake, infectious diseases with fever >38”C, renal failure, liver disease, malabsorption, and cystic fibrosis. Many of these conditions were absent at the time of NDN in our patients. Clinically relevant malnutrition was present in 12 (22%) patients, risk of development of malnutrition was present in another 27 (50%) of patients, while 15 (28%) were well-nourished patients. Therefore 72% of patients were somewhat malnourished. However, low RBP values depended on a low release of RBP (as APO-RBP) by hepatocytes in the presence of low hepatic Vit A storage26 due to inadequate intake or low levels of Zn.14 This fact is unlikely in our population since inadequate food intake was present in only 18/54 (33%) of our patients and Zn levels were within the normal range. Therefore, in our study population, low Vit A semm levels seem to be related to nutritional abnormalities secondary to cancer, which were present in 72% of children, more than an inadequate food intake. This hypothesis is further supported by the observations that children with NDN show TBPA and Alb plasma levels statistically lower than those observed in healthy matched controls. Therefore, since Vit A deficiency does not affect TBPA homeostasis,‘5 the low

19

Vit A levels we observed in our patients could not have caused the presence of low TBPA. An increase of metabolic rate and energy consumption in cancer patients is well documented in various studies.27-29Reduced synthesis of visceral proteins in these patients might be due to abnormalities of nitrogen metabolism that occur prior to any decline of nitrogen (food) intake and therefore the initial subclinical malnutrition could not be entirely due to the reduction of food intake, but might also entail a tumor-specific metabolic abnormality.30The presence of PEM (also in subclinical degree) may consequently decrease RBP production because of a limited supply of energy and/or protein substrate; hepatic release of Vit A may then be impaired, resulting in decreased serum retinol levels. Moreover, because of the many variables conditioning absorption, transport, and the complex metabolism of p-carotene and retinol,“.32 it is very difficult to speculate on the supposed direct relationship between malnutrition and abnormalities of these micronutrients, especially in cancer patients who present many abnormalities in metabolic pathways.27-29 In conclusion, low levels of Vit A and RBP, associated with abnormalities of nutritional parameters (mote frequently TBPA serum concentrations) were seen in children with NDN when compared with matched HC. This difference has probably a multifactorial origin possibly related to major cancer-associated metabolic changes. In the wake of our actual findings we cannot adequately explain the relationship between the interactions of Vit A status and neoplastic disease. In the design of future studies, more consideration should be given to the correlations between serum Vit A levels and clinical parameters such as prognosis, stage, and type of cancer (e.g., solid tumors versus leukemias; neuroblastomas versus solid tumors other than neuroblastomas) . However, the role of Vit A in maintaining the integrity of epithelial and mucosal surfaces and in cell-mediated and humoral immunity requires further study to better evaluate Vit A metabolism in children with cancer at onset and during treatment. However, this cannot be accomplished by singly measuring Vit A serum concentration. Relative dose response, modified relative dose response, and/or the conjunctival impression cytology may be useful tests in estimating Vit A liver stores and in detecting early physiologic changes that occur in Vit A deficiency.27,28Moreover, these tests may help to better clarify the relationship between Vit A status and cancer. SUMMARY

In our study Vit A and RBP plasma levels in children with NDN were significantly lower than those observed in controls. A subgroup of these patients presented very low levels of Vit A and RBP. Further studies are needed to better evaluate Vit A metabolism and the relationship with cancer in children. ACKNOWLEDGMENTS We thank Mrs. Skye Dixon for her help in the preparation of this manuscript.

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A SERUM LEVELS IN CHILDREN WITH CANCER

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