Although the incidence of glioma is gradually increasing, more people can live longer.8 In addition to technology and drugs, such as immunotherapy, the concept of multidisciplinary collaboration (MDT) is also indispensable. It is no longer a simple task that could be fulfilled by a single discipline such as neurosurgery, chemotherapy, or neuro-oncology, but requires multidisciplinary cooperation9. Appropriate and continuous care is also crucial for the prognosis of patients10. DIPG, as a common glioma in children, has its uniqueness compared to adult gliomas. This disease cannot be treated surgically, and the currently considered effective method is only radiotherapy, with a short survival period11. Because of the special location of DIPG, patients often have symptoms in the early stage of the disease and progress rapidly6. Due to the difficulty of swallowing and decreased appetite caused by tumor compression, patients often face the problem of insufficient nutritional intake in the early stage. In addition to the decrease in oral intake, tumor-related cachexia, decreased digestive ability, decreased gastrointestinal function, increased catabolism, and side effects of radiotherapy and chemotherapy all exacerbate the decline in the patient’s nutritional status12,13.
In this article, we used the PNI index to assess the nutritional status of patients at the time of onset, after radiotherapy, and in the late stage of the disease. The PNI, compared to previous single nutritional indicators, uses serum protein levels and has greater prognostic value for patients with glioma, which has been verified by several studies14. In the late stage of the disease, the overall PNI of patients is the lowest among the three time periods, and it is linearly related to the PNI after radiotherapy. At the same time, this article confirms that the PNIs is significantly correlated with the prognosis of DIPG patients. Therefore, this suggests that for patients with DIPG, it is important to maintain a good nutritional status during the course of the disease. However, due to the special nature of the pediatric population, there are inherent difficulties in nutritional support for this population. Combined with the difficulty of swallowing, respiratory difficulty, early loss of appetite in DIPG patients, and the resistance of guardians to invasive nutritional support measures (e.g. gastrointestinal tube), this difficulty in nutritional support will be further exacerbated. In addition, most families have a serious lack of long-term care and nutritional support experience for DIPG patients, which further reminds us that it is very important to continuously give patients’ families enough care suggestions in subsequent treatments. As a tumor with H3K27M mutation, DIPG is sensitive to radiation, and the symptoms of patients can often be significantly relieved, and some patients may even survive for a long time because of this. However, at present, palliative radiotherapy for DIPG can only promote the median survival time of patients to around 1 year15. For most patients, progression after radiotherapy is inevitable, and our results suggest that the time of progression also has a predictive effect on the prognosis of patients. The PNI will reach a peak after radiotherapy, and it is positively correlated with the time of tumor re-progression. Therefore, this suggests that it is a very suitable time for nutritional intervention. But whether this intervention is effective still needs to be verified by clinical trials.
Patients with DIPG often have limb muscle disorders leading to bed rest in the early stage, and the compression on the medulla oblongata respiratory center caused by posterior cranial fossa lesions, resulting difficulty in expectoration, so bed-related complications often appear early, such as venous thrombosis, pneumonia, etc. In this study, 10 patients had pneumonia infections, and 7 patients underwent tracheostomy due to repeated pneumonia during the course of the disease. At the same time, 11 patients had venous thrombosis, and 1 patient had pulmonary embolism during the course of the disease. According to multivariate COX survival analysis, it was found that these common complications all affected the 12-month survival rate and total survival time of patients, so these complications need to be actively prevented and treated.
This article has several shortcomings. First, it has not been able to adopt a prospective cohort study for nutritional intervention measures, so its effectiveness needs to be further verified. Secondly, DIPG itself has a low incidence rate, and follow-up is very difficult. The sample of this research is small, and the bias of the sample size exists. In addition, there are differences in prognosis caused by direct treatment interventions for patients. Each patient receives different doses of radiotherapy, and some patients also receive other treatments, including chemotherapy and traditional medicine.