Acta Oncologica
ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: http://www.tandfonline.com/loi/ionc20
The Effect of Postoperative Radiotherapy on Leukocyte Zinc, Serum Trace Elements and Nutritional Status of Breast Cancer Patients Heikki M. J. Antila, Matti S. Salo, Veikko Näntö, Vainamo Nikkanen & Olli Kirvelä To cite this article: Heikki M. J. Antila, Matti S. Salo, Veikko Näntö, Vainamo Nikkanen & Olli Kirvelä (1992) The Effect of Postoperative Radiotherapy on Leukocyte Zinc, Serum Trace Elements and Nutritional Status of Breast Cancer Patients, Acta Oncologica, 31:5, 569-572, DOI: 10.3109/02841869209088308 To link to this article: https://doi.org/10.3109/02841869209088308
Published online: 08 Jul 2009.
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Acta Oncologica Vol. 31, No. 5, pp. 569-512, 1992
THE EFFECT O F POSTOPERATIVE RADIOTHERAPY ON LEUKOCYTE ZINC, SERUM TRACE ELEMENTS AND NUTRITIONAL STATUS O F BREAST CANCER PATIENTS HEIKKIM. J. ANTILA,MATTI S. SALO,VEIKKONANTO, VAINAMONIKKANEN and OLLIKIRVELA
Mononuclear (MNC) and polymorphonuclear cell (PMNC) zinc content was determined together with serum zinc, copper, selenium and iron concentrations in 24 operable breast cancer patients during and after postoperative radiotherapy. Anthropometric and biochemical indices of nutritional status were measured as background data. The measurements were carried out in the years 1987-1988. Nine patients used unconventional multivitamin or trace element preparations. A steady but statistically insignificant decrease in PMNC zinc was seen during treatment. No changes occurred in MNC zinc. Serum copper levels increased in five patients possibly due to tamoxifen treatment, but no other alterations occurred in serum trace element levels. Appetite was well maintained and nutritional status remained unaltered. Postoperative radiotherapy for breast carcinoma had thus no effect on either trace element or nutritional status. Patient-initiated alternative treatments did not significantly affect their trace element levels. This was probably due to small supplementation doses or irregular use of the preparations.
Both elevated (1) and decreased (2) serum zinc concentrations have been reported in patients with breast cancer. Alterations in serum copper ( 1, 3) and selenium (4,5) levels also occur in patients with gynecological and breast cancer. Disturbed zinc metabolism manifested by low serum zinc concentrations ( 6 ) and increased whole-body retention of "Zn (7), may persist for months after major surgery. Although the effect of postoperative radiotherapy (RT) on the nutritional status of breast cancer patients is usually slight, the combined effect of mastectomy and
Received 26 September 1991. Accepted 15 March 1992. From the Department of Anaesthesiology ( H . Antila, M. Salo, 0. Kirvell) Clinical Chemistry (V. Nanto) and Oncology (V. Nikkanen), University of Turku, and Joint Clinical Chemistry Laboratory of the University of Turku, Turku University Central Hospital and Wallac Inc. (V. Nanto), Turku, Finland. Correspondence to: Dr Heikki Antila, Department of Anaesthesiology. Turku University Central Hospital, Kiinamyllynk. 4-8, SF-20250 Turku, Finland.
irradiation may predispose to subclinical trace element deficiencies. Normal immunological functions (8) and healing process (9) require zinc. These factors are important for cancer patients in resisting tumor growth and for normal postoperative recovery. Therefore, it is important to detect possible deficiency states also in patients receiving relatively mildly stressing therapy. The aim of this study was to investigate whether subclinical zinc deficiency develops during and after radiotherapy of breast cancer. Zinc determinations were made on mononuclear cells (MNC), polymorphonuclear cells (PMNC) and serum. Serum concentrations of copper, selenium and iron, all with possible importance to cancer patients, were measured simultaneously. The nutritional status of the patients was assessed using anthropometric and biochemical indices. As this study was designed on a clinical basis, the alternative trace element supplementation started by the patients was not restricted. Instead, patients with supplementation were analyzed separately in an attempt to find possible effects on the trace element parameters measured. 569
570
H. M. ANTILA ET AL.
Material and Methods Twenty-four consecutive female patients with operable breast cancer were included in the study. All patients were admitted to the Department of Oncology of Turku University Central Hospital for postoperative radiotherapy. The study was carried out between September 1987 and August 1988. The study protocol was approved by the Ethics Committee of the University of Turku and Turku University Central Hospital. Informed consent was obtained from each patient. The mean age of the patients was 57 (SD 7) years, height 163 (SD 6 ) cm and weight 70 (SD 12) kg. Seven patients had concominant disease including diabetes, essential hypertension, coronary heart disease, cardiac dysrhytmia, chronic urinary tract infection and carcinoma of the contralateral breast treated two years earlier. Five patients were receiving adjuvant tamoxifen 40 mg/day. Nine patients had started unconventional trace element supplementation. Their trace element doses were estimated by means of a questionnaire. The estimated daily doses of selenium were between 30-200pglday (9 patients), of zinc between 1-30 mg/day ( 8 patients), of copper between 1-3 mg/day (6 patients) and of iron between 15-20 mg/day ( 2 patients). Thirteen patients undergoing mastectomy with axillary node evacuation were receiving postoperative RT 45 Gy with high energy photons to the axillary, supraclavicular and parasternal regions and 49 Gy with 6-12 MeV electrons to the chest wall over a period of approximately five weeks. Eleven patients were treated with segmental resection and axillary evacuation and received RT 50Gy with photons to the intact breast and a 10Gy boost with 6- 12 MeV electrons over about 6 weeks. The operations were performed 42 (SD 8) days before the patients entered the study (range 31-56 days). Blood samples were collected and anthropometric measurements made at the beginning, in the middle, and at the end of the RT as well as two weeks and two months after therapy. All blood samples for trace element and protein determinations were taken between 7 and 9.30 a.m from a large antecubital vein after an overnight fast. Other diseases, previous malignancies, Karnofsky performance status (lo), appetite, eating habits, smoking, alcohol consumption and medication were evaluated with a questionnaire before and after RT. Trace element determinations (Zn, Cu, Fe, Br) were made with the multielemental particle induced x-ray emission (PIXE) technique at the Accelerator Laboratory of Wbo Akademi in Turku. The methods of sample preparation and analysis have been described elsewhere ( 11). Serum selenium concentrations were measured with an electrothermal atomic absorption spectrophotometer (PE 3030 Zeeman, Perkin Elmer, fjberlingen, Germany). Serum albumin, prealbumin, transferrin and ceruloplasmin concentrations were measured immunochemically by nephelometry (Nephelometer-Analyzer, Behring-Werke, Mar-
burg, FRG; antisera for transferrin determinations were supplied by Behring and those for albumin, prealbumin and ceruloplasmin by Dacopatts Ltd., Copenhagen, Denmark). Reference preparations for calibration of transferrin and prealbumin determinations were supplied by Behring and those for albumin and ceruloplasmin by the College of American Pathologists. Serum total protein was measured by a Hitachi 705 Automatic Analyzer using a modification of the biuret reaction (Boehringer Mannheim GmbH, Germany). All anthropometric measurements were made by a nurse previously instructed by the first author in the procedure. The details of methods used have been described elsewhere (12). The patients were undressed and their body weight was measured using a beam scale (Seca, Vogel & Halke, Hamburg, Germany, accuracy 100 9). Mid-upper arm circumference (MAC) was measured from the midpoint of the acromion and the end of the humerus. Measurement of triceps skinfold (TSF) and subscapular skinfold (SSF) were made with skinfold caliper (John Bull. British Indicators Ltd., UK). A reading was obtained after 3 s, and the mean of three readings was recorded. Measurements were made from the intact side. Statistical analyses were carried out by the analysis of variance with unbalanced repeated measurements ( 13). Comparison of Karnofsky performance status before and after radiotherapy was made with the paired t-test. Results No statistically significant changes could be seen either in MNC or PMNC zinc content. However, a steady decreasing tendency in PMNC zinc values occurred during radiotherapy with a return to baseline values by the end of the follow-up period. The mean cell and serum values were all well within reference intervals (Table). Serum zinc and iron levels remained more or less unchanged during the follow-up period. A significant change was seen in serum copper values during the follow-up period (p = 0.006). However, this change appeared to be related to tamoxifen treatment, since serum copper concentrations were stable and lower in patients without tamoxifen. The mean serum selenium concentrations were slightly above the current Finnish reference values (Table). This was due to the high serum selenium levels ( >2.0 pmol/l, maximum 2.71 pmol/l) seen in three patients using unconventional supplementation. However, we could not demonstrate any statistically significant difference in serum or intracellular trace element levels between patients with or without unconventional supplementation. No statistically significant differences in PMNC and MNC zinc or serum trace element concentrations could be seen between the two methods of radiotherapy. The nutritional status of the patients did not undergo any changes either as assessed with anthropometric measure-
57 1
TRACE ELEMENTS A N D RADIOTHERAPY
Table Intracelluhr and serum trace element values in breast cancer patients during and after radiotherapy ________
_____~
~
~
~
MNC-zinc (pg/IO"' cells) Reference interval 24.4- 127.9
~
~
~
~
~
PMNC-zinc (pg/lO'" cells) Reference inteval 17.0-82.2
_
_
_
_
_
_
Time*
Mean
SD
Range
n
Mean
SD
Range
n
Mean
SD
Range
n
0 Half End 2 weeks 2 months
77.0 84.3 86.3 86.9 109.2
32.1 61.1 58.6 47.2 37.7
28.9- 141.3 2.1-224.1 8.7-243.0 29.3- 183.0 46.9- 174.4
16 20 21 20 18
56.5 53.1 48.8 46.7 56.2
35.5 12.0 12.7 12.6 19.3
37.7-196.5 36.1-87.5 17.3-73.0 7.1-61.3 38.0-96.7
19 19 22
11.9 11.7 12.0 11.2 12.0
1.7 1.4 1.6 2.1 2.7
8.6-15.1 8.7-14.8 9.0-14.6 8.0-16.8 9.1-22.1
24 21 24 23 20
S-iron (pmol/l) Reference interval 7.2-43.4 Time
Mean
SD
Range
n
19
20
S-copper ( p mol/ 1 ) Reference interval 1 I .6-22.7 Mean
SD
Range
S-selenium (pmol/l) Reference values 1.41 (SD 0.14)**
n
Mean
SD
Range ~
0
Half End 2 weeks 2 months
12.4 13.1 13.5 10.7 14.9
6.3 5.2 5.3 3.4 6.9
4.3-22.7 7.0-26.3 6.2-16.1 4.3-36.8 4.8-36.8
24 21 24 23 20
20.3 19.2 20.1 22.1 21.6
3.5 3.7 4.8 5.9 4.3
12.9-28.8 11.3-32.4 13.3-34.9 13.8-34.9 15.6-31.0
_
S-zinc (pmol/l) Reference interval 9.3- 19.1
24 21 24 23 20
1.66 1.58 1.63 1.61 1.54
0.28 0.32 0.31 0.26 0.17
1.26-2.59 1.01-2.71 1.32-2.67 1.18-2.32 1.24-1.93
n ~
24 23 24 24 21
* 0 = before radiotherapy, Half = in the middle of RT. End = at the end of RT, 2 weeks = 2 weeks after the end of RT, 2 months = 2 months after the end of RT.
** Reference values for healthy south-westem Finnish
population in June 1988 (14).
ments (weight, triceps skinfold, mid-upper arm circumference, subscapular skinfold) or biochemical parameters (serum albumin, prealbumin, transferrin). In 19 patients no changes in appetite could be noted as estimated by a questionnaire at the end of therapy. Only three patients reported slightly decreased appetite, whereas two patients reported increased appetite. Karnofsky performance status increased from 87 (SD 6, the onset of RT) to 94 (SD 5, the end of RT) ( p = 0.0006).
Discussion
Totdl leukocyte zinc content has been used successfully in the estimation of zinc status (15). As different leukocyte populations contain different amounts of zinc, recent studies suggest that PMNC and MNC zinc are more suitable for this purpose ( 16, 17). PMNC zinc is known to decrease during experimental zinc deficiency, with only slight changes in MNC zinc (17). PMNC zinc also correlates with the zinc content of muscle, where 50-60% of total body zinc is found (18). Furthermore, PMNC zinc is unaffected by leukocytosis, inflammation and stress and may therefore provide more reliable information about zinc status (19). In the present study, a steady, although statistically non-significant decrease occurred in PMNC zinc content. No changes were seen in MNC zinc content. Furthermore, interindividual variation in MNC zinc was much greater than in PMNC zinc. The unexpected peak in MNC zinc content at the end of follow-up period would rather reflect
this great variation than any genuine change in the zinc status of the patients. A decrease occurred in PMNC zinc, while serum and MNC zinc remained unaltered, may indicate that PMNC zinc is a more sensitive index of zinc status than MNC and serum zinc. Finnish breast cancer patients appear to be eager to start unconventional self-medications. In the present study, 9 patients of 24 used trace element supplementation. However, in our patients these alternative treatments did not seem to have any significant effect on serum or intracellular trace element levels during radiotherapy, except for the three patients who had high serum selenium concentrations. The quantitation of trace element supplementation was based on the patients' reports and was thus liable to inaccuracies. However, the doses that were used appeared to be relatively small. In only one patient the reported additional daily doses of zinc and selenium were high (more than twice the recommended dietary allowances). It is also possible that the patients did not take the preparations every day, which leads to overestimation of the daily intake. Finnish reference values for serum selenium concentrations have steadily increased since 1985, when enrichment of fertilizers with sodium selenate started in Finland with the aim of compensating for the low selenium content of the soil (14, 20). The slightly elevated mean serum selenium levels of our patients were probably explained by the high values of three patients who were using additional supplementation. When these patients were omitted from the analyses, the mean serum selenium concentration at
_
~
512
H.
M. ANTILA ET AL
entry t o the study was 1.42 (SD 0.37), which is almost the reference value of spring 1988 (1.41, SD 0.14), as reported by Makela et al. (14). The changes in trace element parameters and nutritional status of our patients were slight. This is understandable, since irradiation therapy for breast cancer is directed t o a limited area and does not impair food intake. The interval between mastectomy and the onset of RT was more than one month in all patients, allowing the patients t o recover from operation. This was also seen in the increasing Karnofsky status values during treatment. In conclusion, as the mean values of all indices of zinc status safely remained between the reference interval, the development of even subclinical zinc deficiency is unlikely in this patient group. High serum selenium levels were seen in three patients with unconventional supplementation. However, no statistically significant effect of unconventional trace element supplementation was demonstrated. Consequently, in most patients the supplementation was without clinical importance. Nutritional status and appetite were well maintained in the patients during radiotherapy.
ACKNOWLEDGEMENTS Miss Leena-Maija Salusvuori, Mrs. Tarja Lehto and Mrs. Anu Kupiainen provided excellent technical assistance. PIXE determinations were made by Mr. Fredrik Hernberg, B.A. The statistical analyses were carried out by Mrs. Arja Virtanen, B.A. Sources of support: Medipolar, the Research and Science Foundation of Farmos, the Cancer Foundation of Finland, the University Foundation of Turku and the City of Turku.
REFERENCES I. Cavallo F, Gerber M, Marubini E, et al. Zinc and copper in breast cancer. A joint study in northern Italy and southern France. Cancer 1991: 67: 738-45. -.7 Holtkamp W, Thiery J, Rausschecker H, Nagel GA, Reis HE. Erniedrigte Plasmazinkspiegel beim metastasierten Mammakarzinom. Onkologie 1990; 13: 207-9. 3. Pizzolo G, Savarin T, M o h o AM, Ambrosetti A, Todeschini G, Vettore L. The diagnostic value of serum copper levels and other hematochemical parameters in malignancies. Tumori 1978; 64: 55-61. 4. Krsnjavi H, Beker D. Selenium in serum as a possible parameter for assessment of breast disease. Breast Cancer Res Treat 1990; 16: 57-61. 5. Sundstrom H. Selenium and gynecological cancer (dissertation). Oulu: University of Oulu, 1986.
6. Antila H, Salo M, Nanto V, Irjala K, Brenner R, Vapaavuori M. Serum iron, zinc, copper, selenium and bromide concentrations after coronary bypass operation. JPEN 1990; 14: 85-9. 7. Cornelisse C, Van Der Sluys Veer J, Binsma JJM, Van Den Hamen CJA. Investigation of the zinc status of surgical patients-11. Influence of vascular reconstruction on the zinc status. Nucl Med Biol 1986; 13: 557-63. 8. Castillo-Duran C, Heresi G , Fisberg M, Uauy R. Controlled trial of zinc supplementation during recovery from malnutrition: effects of growth and immune function. Am J Clin Nutr 1987; 45: 602-8. 9. Shenkin A, Fell GS. Micronutrients. In: Woolfson AMJ, ed. Biochemistry of hospital nutrition. Edinburgh: Churchill Livingstone, 1986: 83- 122. 10. Karnofsky DA, Burchenall JH. The clinical evaluation of chemotherapeutic agents in cancer. In: Macleod MC. ed. Evaluation of chemotherapeutic agents. New York: Columbia University Press, 1949: 1999-2005. I I . Antila HMJ, Salo MS, Nanto V, Brenner R, Kirvela 0, van Riemsdijk J. Mononuclear and polymorphonuclear cell zinc and serum trace element concentrations in healthy adults. Trace elements in medicine. 1992 (In press.) 12. Bishop CH, Bowen PE, Ritchey SJ. Norms for nutritional assessment of American adults by upper arm anthropometry. Am J Clin Nutr 1981; 34: 2530-9. 13. Schluchter MD. Unbalanced repeated measures models with structured covariance matrix. In: Dixon WJ. ed. BMDP statistical software manual. Berkeley: University of California Press, 1990: I207 -44. 14. Makela A-L, Nanto V, Make12 P. The effect of selenium enrichment of fertilizers on selenium status of healthy Finnish medical students. In: Chromium- trace elements in endocrinology. Proc Third Int Congr Trace Elements in Medicine and Biology; 1991 Jan 15-18. Les Deux Alpes, France. 15. Patrick J, Dervish C. Leukocyte zinc in the assessment of zinc status. CRC Crit Rev Clin Lab Sci 1985; 20: 95- 114. 16. Purcell SK, Hambidge M, Jacobs MA. Zinc concentrations in mononuclear and polymorphonuclear leukocytes. Clin Chim Acta 1986; 155: 179-84. 17. Goode HF. The assessment of zinc in various blood components with relevance to body zinc status (dissertation). Leeds: University of Leeds, 1989. 18. Goode HF, Kelleher J, Walker BE, Hall RI, Guillou PJ. Cellular and muscle zinc in surgical patients with and without gastrointestinal cancer. Clin Sci 1990; 79: 247-52. 19. Goode HF, Kelleher J, Walker BE. The effects of acute infection on indices of zinc status. Clin Nutr 1991; 10: 55 9. 20. Alfthan G. Human selenium status, dietary intake and bioavailability in Finland as assessed by selenium and glutathione peroxidase determinations (dissertation). Helsinki: National Public Health Institute, 1990.
ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: http://www.tandfonline.com/loi/ionc20
The Effect of Postoperative Radiotherapy on Leukocyte Zinc, Serum Trace Elements and Nutritional Status of Breast Cancer Patients Heikki M. J. Antila, Matti S. Salo, Veikko Näntö, Vainamo Nikkanen & Olli Kirvelä To cite this article: Heikki M. J. Antila, Matti S. Salo, Veikko Näntö, Vainamo Nikkanen & Olli Kirvelä (1992) The Effect of Postoperative Radiotherapy on Leukocyte Zinc, Serum Trace Elements and Nutritional Status of Breast Cancer Patients, Acta Oncologica, 31:5, 569-572, DOI: 10.3109/02841869209088308 To link to this article: https://doi.org/10.3109/02841869209088308
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 86
View related articles
Citing articles: 5 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ionc20
Acta Oncologica Vol. 31, No. 5, pp. 569-512, 1992
THE EFFECT O F POSTOPERATIVE RADIOTHERAPY ON LEUKOCYTE ZINC, SERUM TRACE ELEMENTS AND NUTRITIONAL STATUS O F BREAST CANCER PATIENTS HEIKKIM. J. ANTILA,MATTI S. SALO,VEIKKONANTO, VAINAMONIKKANEN and OLLIKIRVELA
Mononuclear (MNC) and polymorphonuclear cell (PMNC) zinc content was determined together with serum zinc, copper, selenium and iron concentrations in 24 operable breast cancer patients during and after postoperative radiotherapy. Anthropometric and biochemical indices of nutritional status were measured as background data. The measurements were carried out in the years 1987-1988. Nine patients used unconventional multivitamin or trace element preparations. A steady but statistically insignificant decrease in PMNC zinc was seen during treatment. No changes occurred in MNC zinc. Serum copper levels increased in five patients possibly due to tamoxifen treatment, but no other alterations occurred in serum trace element levels. Appetite was well maintained and nutritional status remained unaltered. Postoperative radiotherapy for breast carcinoma had thus no effect on either trace element or nutritional status. Patient-initiated alternative treatments did not significantly affect their trace element levels. This was probably due to small supplementation doses or irregular use of the preparations.
Both elevated (1) and decreased (2) serum zinc concentrations have been reported in patients with breast cancer. Alterations in serum copper ( 1, 3) and selenium (4,5) levels also occur in patients with gynecological and breast cancer. Disturbed zinc metabolism manifested by low serum zinc concentrations ( 6 ) and increased whole-body retention of "Zn (7), may persist for months after major surgery. Although the effect of postoperative radiotherapy (RT) on the nutritional status of breast cancer patients is usually slight, the combined effect of mastectomy and
Received 26 September 1991. Accepted 15 March 1992. From the Department of Anaesthesiology ( H . Antila, M. Salo, 0. Kirvell) Clinical Chemistry (V. Nanto) and Oncology (V. Nikkanen), University of Turku, and Joint Clinical Chemistry Laboratory of the University of Turku, Turku University Central Hospital and Wallac Inc. (V. Nanto), Turku, Finland. Correspondence to: Dr Heikki Antila, Department of Anaesthesiology. Turku University Central Hospital, Kiinamyllynk. 4-8, SF-20250 Turku, Finland.
irradiation may predispose to subclinical trace element deficiencies. Normal immunological functions (8) and healing process (9) require zinc. These factors are important for cancer patients in resisting tumor growth and for normal postoperative recovery. Therefore, it is important to detect possible deficiency states also in patients receiving relatively mildly stressing therapy. The aim of this study was to investigate whether subclinical zinc deficiency develops during and after radiotherapy of breast cancer. Zinc determinations were made on mononuclear cells (MNC), polymorphonuclear cells (PMNC) and serum. Serum concentrations of copper, selenium and iron, all with possible importance to cancer patients, were measured simultaneously. The nutritional status of the patients was assessed using anthropometric and biochemical indices. As this study was designed on a clinical basis, the alternative trace element supplementation started by the patients was not restricted. Instead, patients with supplementation were analyzed separately in an attempt to find possible effects on the trace element parameters measured. 569
570
H. M. ANTILA ET AL.
Material and Methods Twenty-four consecutive female patients with operable breast cancer were included in the study. All patients were admitted to the Department of Oncology of Turku University Central Hospital for postoperative radiotherapy. The study was carried out between September 1987 and August 1988. The study protocol was approved by the Ethics Committee of the University of Turku and Turku University Central Hospital. Informed consent was obtained from each patient. The mean age of the patients was 57 (SD 7) years, height 163 (SD 6 ) cm and weight 70 (SD 12) kg. Seven patients had concominant disease including diabetes, essential hypertension, coronary heart disease, cardiac dysrhytmia, chronic urinary tract infection and carcinoma of the contralateral breast treated two years earlier. Five patients were receiving adjuvant tamoxifen 40 mg/day. Nine patients had started unconventional trace element supplementation. Their trace element doses were estimated by means of a questionnaire. The estimated daily doses of selenium were between 30-200pglday (9 patients), of zinc between 1-30 mg/day ( 8 patients), of copper between 1-3 mg/day (6 patients) and of iron between 15-20 mg/day ( 2 patients). Thirteen patients undergoing mastectomy with axillary node evacuation were receiving postoperative RT 45 Gy with high energy photons to the axillary, supraclavicular and parasternal regions and 49 Gy with 6-12 MeV electrons to the chest wall over a period of approximately five weeks. Eleven patients were treated with segmental resection and axillary evacuation and received RT 50Gy with photons to the intact breast and a 10Gy boost with 6- 12 MeV electrons over about 6 weeks. The operations were performed 42 (SD 8) days before the patients entered the study (range 31-56 days). Blood samples were collected and anthropometric measurements made at the beginning, in the middle, and at the end of the RT as well as two weeks and two months after therapy. All blood samples for trace element and protein determinations were taken between 7 and 9.30 a.m from a large antecubital vein after an overnight fast. Other diseases, previous malignancies, Karnofsky performance status (lo), appetite, eating habits, smoking, alcohol consumption and medication were evaluated with a questionnaire before and after RT. Trace element determinations (Zn, Cu, Fe, Br) were made with the multielemental particle induced x-ray emission (PIXE) technique at the Accelerator Laboratory of Wbo Akademi in Turku. The methods of sample preparation and analysis have been described elsewhere ( 11). Serum selenium concentrations were measured with an electrothermal atomic absorption spectrophotometer (PE 3030 Zeeman, Perkin Elmer, fjberlingen, Germany). Serum albumin, prealbumin, transferrin and ceruloplasmin concentrations were measured immunochemically by nephelometry (Nephelometer-Analyzer, Behring-Werke, Mar-
burg, FRG; antisera for transferrin determinations were supplied by Behring and those for albumin, prealbumin and ceruloplasmin by Dacopatts Ltd., Copenhagen, Denmark). Reference preparations for calibration of transferrin and prealbumin determinations were supplied by Behring and those for albumin and ceruloplasmin by the College of American Pathologists. Serum total protein was measured by a Hitachi 705 Automatic Analyzer using a modification of the biuret reaction (Boehringer Mannheim GmbH, Germany). All anthropometric measurements were made by a nurse previously instructed by the first author in the procedure. The details of methods used have been described elsewhere (12). The patients were undressed and their body weight was measured using a beam scale (Seca, Vogel & Halke, Hamburg, Germany, accuracy 100 9). Mid-upper arm circumference (MAC) was measured from the midpoint of the acromion and the end of the humerus. Measurement of triceps skinfold (TSF) and subscapular skinfold (SSF) were made with skinfold caliper (John Bull. British Indicators Ltd., UK). A reading was obtained after 3 s, and the mean of three readings was recorded. Measurements were made from the intact side. Statistical analyses were carried out by the analysis of variance with unbalanced repeated measurements ( 13). Comparison of Karnofsky performance status before and after radiotherapy was made with the paired t-test. Results No statistically significant changes could be seen either in MNC or PMNC zinc content. However, a steady decreasing tendency in PMNC zinc values occurred during radiotherapy with a return to baseline values by the end of the follow-up period. The mean cell and serum values were all well within reference intervals (Table). Serum zinc and iron levels remained more or less unchanged during the follow-up period. A significant change was seen in serum copper values during the follow-up period (p = 0.006). However, this change appeared to be related to tamoxifen treatment, since serum copper concentrations were stable and lower in patients without tamoxifen. The mean serum selenium concentrations were slightly above the current Finnish reference values (Table). This was due to the high serum selenium levels ( >2.0 pmol/l, maximum 2.71 pmol/l) seen in three patients using unconventional supplementation. However, we could not demonstrate any statistically significant difference in serum or intracellular trace element levels between patients with or without unconventional supplementation. No statistically significant differences in PMNC and MNC zinc or serum trace element concentrations could be seen between the two methods of radiotherapy. The nutritional status of the patients did not undergo any changes either as assessed with anthropometric measure-
57 1
TRACE ELEMENTS A N D RADIOTHERAPY
Table Intracelluhr and serum trace element values in breast cancer patients during and after radiotherapy ________
_____~
~
~
~
MNC-zinc (pg/IO"' cells) Reference interval 24.4- 127.9
~
~
~
~
~
PMNC-zinc (pg/lO'" cells) Reference inteval 17.0-82.2
_
_
_
_
_
_
Time*
Mean
SD
Range
n
Mean
SD
Range
n
Mean
SD
Range
n
0 Half End 2 weeks 2 months
77.0 84.3 86.3 86.9 109.2
32.1 61.1 58.6 47.2 37.7
28.9- 141.3 2.1-224.1 8.7-243.0 29.3- 183.0 46.9- 174.4
16 20 21 20 18
56.5 53.1 48.8 46.7 56.2
35.5 12.0 12.7 12.6 19.3
37.7-196.5 36.1-87.5 17.3-73.0 7.1-61.3 38.0-96.7
19 19 22
11.9 11.7 12.0 11.2 12.0
1.7 1.4 1.6 2.1 2.7
8.6-15.1 8.7-14.8 9.0-14.6 8.0-16.8 9.1-22.1
24 21 24 23 20
S-iron (pmol/l) Reference interval 7.2-43.4 Time
Mean
SD
Range
n
19
20
S-copper ( p mol/ 1 ) Reference interval 1 I .6-22.7 Mean
SD
Range
S-selenium (pmol/l) Reference values 1.41 (SD 0.14)**
n
Mean
SD
Range ~
0
Half End 2 weeks 2 months
12.4 13.1 13.5 10.7 14.9
6.3 5.2 5.3 3.4 6.9
4.3-22.7 7.0-26.3 6.2-16.1 4.3-36.8 4.8-36.8
24 21 24 23 20
20.3 19.2 20.1 22.1 21.6
3.5 3.7 4.8 5.9 4.3
12.9-28.8 11.3-32.4 13.3-34.9 13.8-34.9 15.6-31.0
_
S-zinc (pmol/l) Reference interval 9.3- 19.1
24 21 24 23 20
1.66 1.58 1.63 1.61 1.54
0.28 0.32 0.31 0.26 0.17
1.26-2.59 1.01-2.71 1.32-2.67 1.18-2.32 1.24-1.93
n ~
24 23 24 24 21
* 0 = before radiotherapy, Half = in the middle of RT. End = at the end of RT, 2 weeks = 2 weeks after the end of RT, 2 months = 2 months after the end of RT.
** Reference values for healthy south-westem Finnish
population in June 1988 (14).
ments (weight, triceps skinfold, mid-upper arm circumference, subscapular skinfold) or biochemical parameters (serum albumin, prealbumin, transferrin). In 19 patients no changes in appetite could be noted as estimated by a questionnaire at the end of therapy. Only three patients reported slightly decreased appetite, whereas two patients reported increased appetite. Karnofsky performance status increased from 87 (SD 6, the onset of RT) to 94 (SD 5, the end of RT) ( p = 0.0006).
Discussion
Totdl leukocyte zinc content has been used successfully in the estimation of zinc status (15). As different leukocyte populations contain different amounts of zinc, recent studies suggest that PMNC and MNC zinc are more suitable for this purpose ( 16, 17). PMNC zinc is known to decrease during experimental zinc deficiency, with only slight changes in MNC zinc (17). PMNC zinc also correlates with the zinc content of muscle, where 50-60% of total body zinc is found (18). Furthermore, PMNC zinc is unaffected by leukocytosis, inflammation and stress and may therefore provide more reliable information about zinc status (19). In the present study, a steady, although statistically non-significant decrease occurred in PMNC zinc content. No changes were seen in MNC zinc content. Furthermore, interindividual variation in MNC zinc was much greater than in PMNC zinc. The unexpected peak in MNC zinc content at the end of follow-up period would rather reflect
this great variation than any genuine change in the zinc status of the patients. A decrease occurred in PMNC zinc, while serum and MNC zinc remained unaltered, may indicate that PMNC zinc is a more sensitive index of zinc status than MNC and serum zinc. Finnish breast cancer patients appear to be eager to start unconventional self-medications. In the present study, 9 patients of 24 used trace element supplementation. However, in our patients these alternative treatments did not seem to have any significant effect on serum or intracellular trace element levels during radiotherapy, except for the three patients who had high serum selenium concentrations. The quantitation of trace element supplementation was based on the patients' reports and was thus liable to inaccuracies. However, the doses that were used appeared to be relatively small. In only one patient the reported additional daily doses of zinc and selenium were high (more than twice the recommended dietary allowances). It is also possible that the patients did not take the preparations every day, which leads to overestimation of the daily intake. Finnish reference values for serum selenium concentrations have steadily increased since 1985, when enrichment of fertilizers with sodium selenate started in Finland with the aim of compensating for the low selenium content of the soil (14, 20). The slightly elevated mean serum selenium levels of our patients were probably explained by the high values of three patients who were using additional supplementation. When these patients were omitted from the analyses, the mean serum selenium concentration at
_
~
512
H.
M. ANTILA ET AL
entry t o the study was 1.42 (SD 0.37), which is almost the reference value of spring 1988 (1.41, SD 0.14), as reported by Makela et al. (14). The changes in trace element parameters and nutritional status of our patients were slight. This is understandable, since irradiation therapy for breast cancer is directed t o a limited area and does not impair food intake. The interval between mastectomy and the onset of RT was more than one month in all patients, allowing the patients t o recover from operation. This was also seen in the increasing Karnofsky status values during treatment. In conclusion, as the mean values of all indices of zinc status safely remained between the reference interval, the development of even subclinical zinc deficiency is unlikely in this patient group. High serum selenium levels were seen in three patients with unconventional supplementation. However, no statistically significant effect of unconventional trace element supplementation was demonstrated. Consequently, in most patients the supplementation was without clinical importance. Nutritional status and appetite were well maintained in the patients during radiotherapy.
ACKNOWLEDGEMENTS Miss Leena-Maija Salusvuori, Mrs. Tarja Lehto and Mrs. Anu Kupiainen provided excellent technical assistance. PIXE determinations were made by Mr. Fredrik Hernberg, B.A. The statistical analyses were carried out by Mrs. Arja Virtanen, B.A. Sources of support: Medipolar, the Research and Science Foundation of Farmos, the Cancer Foundation of Finland, the University Foundation of Turku and the City of Turku.
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6. Antila H, Salo M, Nanto V, Irjala K, Brenner R, Vapaavuori M. Serum iron, zinc, copper, selenium and bromide concentrations after coronary bypass operation. JPEN 1990; 14: 85-9. 7. Cornelisse C, Van Der Sluys Veer J, Binsma JJM, Van Den Hamen CJA. Investigation of the zinc status of surgical patients-11. Influence of vascular reconstruction on the zinc status. Nucl Med Biol 1986; 13: 557-63. 8. Castillo-Duran C, Heresi G , Fisberg M, Uauy R. Controlled trial of zinc supplementation during recovery from malnutrition: effects of growth and immune function. Am J Clin Nutr 1987; 45: 602-8. 9. Shenkin A, Fell GS. Micronutrients. In: Woolfson AMJ, ed. Biochemistry of hospital nutrition. Edinburgh: Churchill Livingstone, 1986: 83- 122. 10. Karnofsky DA, Burchenall JH. The clinical evaluation of chemotherapeutic agents in cancer. In: Macleod MC. ed. Evaluation of chemotherapeutic agents. New York: Columbia University Press, 1949: 1999-2005. I I . Antila HMJ, Salo MS, Nanto V, Brenner R, Kirvela 0, van Riemsdijk J. Mononuclear and polymorphonuclear cell zinc and serum trace element concentrations in healthy adults. Trace elements in medicine. 1992 (In press.) 12. Bishop CH, Bowen PE, Ritchey SJ. Norms for nutritional assessment of American adults by upper arm anthropometry. Am J Clin Nutr 1981; 34: 2530-9. 13. Schluchter MD. Unbalanced repeated measures models with structured covariance matrix. In: Dixon WJ. ed. BMDP statistical software manual. Berkeley: University of California Press, 1990: I207 -44. 14. Makela A-L, Nanto V, Make12 P. The effect of selenium enrichment of fertilizers on selenium status of healthy Finnish medical students. In: Chromium- trace elements in endocrinology. Proc Third Int Congr Trace Elements in Medicine and Biology; 1991 Jan 15-18. Les Deux Alpes, France. 15. Patrick J, Dervish C. Leukocyte zinc in the assessment of zinc status. CRC Crit Rev Clin Lab Sci 1985; 20: 95- 114. 16. Purcell SK, Hambidge M, Jacobs MA. Zinc concentrations in mononuclear and polymorphonuclear leukocytes. Clin Chim Acta 1986; 155: 179-84. 17. Goode HF. The assessment of zinc in various blood components with relevance to body zinc status (dissertation). Leeds: University of Leeds, 1989. 18. Goode HF, Kelleher J, Walker BE, Hall RI, Guillou PJ. Cellular and muscle zinc in surgical patients with and without gastrointestinal cancer. Clin Sci 1990; 79: 247-52. 19. Goode HF, Kelleher J, Walker BE. The effects of acute infection on indices of zinc status. Clin Nutr 1991; 10: 55 9. 20. Alfthan G. Human selenium status, dietary intake and bioavailability in Finland as assessed by selenium and glutathione peroxidase determinations (dissertation). Helsinki: National Public Health Institute, 1990.
