General characteristics and clinical evolution
The diagnoses found were cervical cancer (14), endometrial cancer (3), uterine rhabdomyosarcoma (1) and invasive squamous cell carcinoma of the vaginal dome (1). There was previous resective surgery in 6 cases. Upon admission, some nonspecific gastrointestinal symptoms were recorded. During PR, symptoms appeared such as: diarrhea (74%), abdominal discomfort (47%), nausea (32%) and intestinal cramps (16%), among others. 12 patients (63%) reported urological symptoms secondary to RP. The diarrhea episodes were intermittent and mild in intensity (short duration, without dehydration, without alterations in daily work or nighttime sleep).
Laboratory exams
Within normal limits in most patients. However, before treatment five patients had anemia, and seven afterwards. After PR, leukocytes (p=0.006) and lymphocyte count (p=0.000) severely decreased. The other exams did not vary significantly.
Nutritional condition
Before RP, the EGS classified 74% of the patients as Well-Nourished and 26% as Moderate Malnutrition or Risk. According to the BMI, eutrophicism was found in 43% of the cases and overweight in the rest. At the end of the RP, the EGS showed an increase in patients with moderate or risk DNT (42%). According to BMI, malnutrition appeared in 5% and overweight was reduced (21%). (Table 1)
Anthropometry
At the end of the treatment period, significant decreases were detected in: body weight of 0.6 ± 1.5 kg, biceps fold thickness of 1.5 ± 2.4 mm and body fat percentage of 0. 8 ± 1.3%. (Table 2) The other changes were not significant; but they all decreased.
Dual Radiological Energy Absorptiometry (DEXA)
After RP, significant wear was found in the total mass of 0.7 ± 1.2 Kg, and in the FFM of 0.9 + 1.4 Kg. (Table 3) The decrease in the FFM was greater in patients with diarrhea (deltas = -1.1 vs -0.1 Kg), without reaching statistical significance. There was no significant difference in the rest of the parameters.
Food intake
During PR, appetite was reduced (in 15% of patients) and caloric intake (in 73% of them). Fiber consumption significantly decreased by 1.9 ± 3.9 g/day due to medical indication, and tocopherol consumption by 0.4 ± 0.8 tocopherol equivalents/day. (Table 4) Upon admission, intake was below the RDA in calcium, tocopherol and pyridoxine and at the end of PR, in these same nutrients and also in potassium and niacin.
Energy expenditure
At the end of the RP period, the GER did not change significantly, nor did it change when corrected by GLM. A significant reduction of 124.1 ± 278.8 Kcal/day was observed in GET. (Table 5) Physical activity decreased after treatment. Changes in nutritional variables and changes in Energy Expenditure did not correlate. When comparing energy expenditure in patients with and without diarrhea, and patients with and without previous surgery, no significant differences were found.
Intestinal permeability
Upon completion of PR, the lactulose/mannitol ratio (L/M) increased significantly by 0.034 ± 0.062%, at the expense of a 0.29% increase in urinary lactulose excretion. (Table 6). In five cases the L/M ratio was reduced; These patients did not behave differently from the rest of the group in nutritional and histological parameters. Intestinal permeability was not correlated with nutritional variables and increased similarly in patients with and without diarrhea.
Intestinal Transit Time (ITT)
A significant reduction in TTI of 35.6 ± 53.6 minutes (p=0.009) was found after PR in 75% of subjects. This change was not correlated with intestinal permeability (r = 0.16). The TTI found by INTA, with the same method, in healthy volunteers was 87 ± 11.8 minutes.(19) In this study, no patient had factors that altered the TTI, and each patient was compared with herself; Therefore, a control group was not considered.
Small intestine biopsy
Morphology and morphometry: in the first evaluation, the architecture of the intestinal mucosa was preserved (1 to 2 on the scale) with regular villi and a normal crypt/villus (C/V) ratio. The epithelium was regular with an average of 24.4 ± 8.2% LEL. The fluted edging was preserved. The cellularity of the lamina propria was normal. After RP, the villi showed a normal appearance, but some were longer than usual, giving a disorganized appearance, some of them were bifurcated and others fused to form bridges. In the crypts, disorder was also observed, consisting of the opening of several crypts into a single villus and the fusion of some of them. Given the demands of the technique; no change in villus length was demonstrated. These turned out to be systematically shorter; However, qualitatively some were similar in length to those from the first biopsy or even longer and it was not possible to measure them due to their poor orientation. In the crypts, a significant increase in depth was found (12.72 ± 22.26 microns. (Table 7) In the biopsies before RP, 27.3% had a C/V ratio less than 1/3, while that after radiotherapy, these cases represented 63.6% (non-significant change, according to Mac Nemar test). The cellularity of the lamina propria remained similar to that of the first biopsy. The LIE number did not vary significantly after radiotherapy. RP. Morphometric changes were not correlated with nutritional variables, nor with intestinal permeability. Morphometry was not different in patients with diarrhea or in those who had previous surgery.
Immunofluorescence (CD25): at both evaluation times, there was a minimal number of positive cells; before RP there were 2.0 ± 0.8 and after 3.3 ± 1.2.
Immunohistochemistry (Metallothionein). The results were expressed with the established scale, in the three compartments (crypt, lamina propria and epithelium). As this is a comparative study between the pre and post RP situation, a control group was not included. However, as there are no publications on the normal amount of MT in the human intestine, to have a reference point, 10 small intestine biopsies were studied whose histological report defined these tissues as normal. In these it was observed: the epithelium with little marking (0 to 1); lamina propria, mild to moderate (between 1 and 2), staining always tended to be in the distal third of the villus; and in the crypts and was moderate to intense (1 to 3). The result of the biopsies before RP was similar to that of the normal biopsy group. In the post-RP biopsies, a clear increase in staining was found in 55% of the samples, especially in the lamina propria (p = 0.066 Wicolxon test), while in the rest it decreased or remained the same. Of the six patients in whom the TM score increased, five had diarrhea. The L/M ratio was not different from that of the group with decreased MT. Patients with increased MT post-RP had a lower increase in crypt depth (p = 0.04) but a greater number of IELs (p = 0.003).