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World J Gastrointest Oncol. Oct 15, 2021; 13(10): 1440-1452
Published online Oct 15, 2021. doi: 10.4251/wjgo.v13.i10.1440
Nutritional therapy for hepatocellular carcinoma
Astrid Ruiz-Margáin, Berenice M Román-Calleja, Paulina Moreno-Guillén, José A González-Regueiro, Deyanira Kúsulas-Delint, Alejandro Campos-Murguía, Nayelli C Flores-García, Ricardo Ulises Macías-Rodríguez
Astrid Ruiz-Margáin, Berenice M Román-Calleja, Paulina Moreno-Guillén, Liver Nutrition Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
Astrid Ruiz-Margáin, Ricardo Ulises Macías-Rodríguez, Liver Fibrosis and Nutrition Lab, MICTLÁN-Network (Mechanisms of Liver Injury, Cell Death and Translational Nutrition in Liver Diseases- Research Network), Mexico City 14080, Mexico
José A González-Regueiro, Deyanira Kúsulas-Delint, Alejandro Campos-Murguía, Nayelli C Flores-García, Ricardo Ulises Macías-Rodríguez, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
Author contributions: Ruiz-Margáin A and Macías-Rodríguez RU contributed to study conception and design; All authors contributed to acquisition of data, analysis of data, interpretation of data, drafting the article, making critical revisions for the content of the manuscript and writing and approving the final version of the article to be published.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Astrid Ruiz-Margáin, BSc, MSc, PhD, Assistant Professor, Liver Nutrition Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Col. Belisario Dominguez Seccion XVI, Mexico City 14080, Mexico. astrid.ruizm@incmnsz.mx
Received: February 22, 2021
Peer-review started: February 22, 2021
First decision: May 8, 2021
Revised: May 23, 2021
Accepted: August 9, 2021
Article in press: August 9, 2021
Published online: October 15, 2021
Processing time: 233 Days and 5.9 Hours
Abstract

Hepatocellular carcinoma (HCC) is the most frequent primary liver cancer and presents together with cirrhosis in most cases. In addition to commonly recognized risk factors for HCC development, such as hepatitis B virus/hepatitis C virus infection, age and alcohol/tobacco consumption, there are nutritional risk factors also related to HCC development including high intake of saturated fats derived from red meat, type of cooking (generation of heterocyclic amines) and contamination of foods with aflatoxins. On the contrary, protective nutritional factors include diets rich in fiber, fruits and vegetables, n-3 polyunsaturated fatty acids and coffee. While the patient is being evaluated for staging and treatment of HCC, special attention should be paid to nutritional support, including proper nutritional assessment and therapy by a multidisciplinary team. It must be considered that these patients usually develop HCC on top of long-lasting cirrhosis, and therefore they could present with severe malnutrition. Cirrhosis-related complications should be properly addressed and considered for nutritional care. In addition to traditional methods, functional testing, phase angle and computed tomography scan derived skeletal muscle index-L3 are among the most useful tools for nutritional assessment. Nutritional therapy should be centered on providing enough energy and protein to manage the increased requirements of both cirrhosis and cancer. Supplementation with branched-chain amino acids is also recommended as it improves response to treatment, nutritional status and survival, and finally physical exercise must be encouraged and adapted to individual needs.

Keywords: Sarcopenia; Liver; Cancer; Diet; Branched-chain amino acids; Nutrition

Core Tip: Hepatocellular carcinoma is often found in patients with cirrhosis; nutritional management for both conditions can be challenging due to increased energy requirements and increased liver-related complications. Nutritional support must include sufficient energy and proteins to overcome the highly catabolic state derived from the two conditions. Branched-chain amino acids are recommended in both cirrhosis and hepatocellular carcinoma as they can improve muscle mass, body protein, response to treatment and quality of life. Finally, an adequate and feasible exercise program should be provided as a part of the nutritional plan, aiming to improve the overall status.