Prognostic value of sarcopenia in adults with solid tumours: A meta-analysis and systematic review

Preoperative computed tomography-determined sarcopenia is a reliable prognostic factor in patients with gastric cancer after radical gastrectomy: A sex-specific analysis

Background

The predictive role of sarcopenia in cancer prognosis is an area of increasing concern. However, the influence of sex difference on the predictive role of sarcopenia in cancer prognosis has not been clearly defined. This retrospective cohort study investigated the effect of preoperative sarcopenia on the long-term outcomes of patients with gastric cancer (GC) based on sexual dimorphism.

Methods

Preoperative abdominal computed tomography (CT) scans from 379 GC patients who underwent radical gastrectomy were carefully analyzed. The patients were categorized into sarcopenia and non-sarcopenia groups according to the L3 skeletal muscle index (L3 SMI) measured on CT scans. Moreover, other indexes which can be used to evaluate the muscle area or the muscle quality, including skeletal muscle area (SMA), visceral fat area (VFA), subcutaneous fat area (SFA), skeletal muscle radiation attenuation (SM-RA), visceral fat index (VFI), subcutaneous fat index (SFI), and subcutaneous and visceral ratio (SV), were obtained from CT scans.

Results

There were 254 men and 125 women included in our study. After calculation, we defined sex-specific SMI-related mortality cutoff as 39.73 and 32.97 cm²/m² for men and women. Univariable analysis showed that pathological tumor-node-metastasis (pTNM), depth of invasion, lymph node metastasis, differentiation degree, preoperative sarcopenia (for men), SMA (for men), L3 SMI, SFA (for women), SFI (for women), SV (for women), and SM-RA (especially for men) were significant independent predictors of overall survival (OS). Multivariable analysis showed that pTNM, depth of invasion, poor differentiation, and SM-RA were significantly associated with 5-year OS in GC patients. However, CT-determined sarcopenia was associated with significantly worse OS only in men, and SFA was significantly associated with 5-year OS only in women.

Conclusion

SM-RA is a reliable prognostic factor in patients with GC after radical gastrectomy. The impact of indexes mentioned above on survival outcomes is dependent on sex. CT-determined preoperative sarcopenia, a muscle-related indicator, was associated with outcomes in men. Adipose-related indicator (SFA), instead, was associated with outcomes in women.

The relationship between objective measures of physical function and serum lactate dehydrogenase in older adults with cancer prior to treatment

BACKGROUND

Lactate dehydrogenase (LDH) reflects tumor burden and is a prognosticator of all-cause mortality in patients with cancer. Objective measures of physical function are associated with clinically relevant outcomes in older adults with cancer. However, whether physical function is associated with LDH in geriatric oncology is unknown. The objective of this study was to assess the relationship between objective measures of physical function and serum LDH in older adults with cancer prior to treatment.

METHODS

Data from older adults with cancer prior to treatment were retrieved from an institutional database and medical records within a tertiary cancer centre. Physical function measures involved muscle strength and physical performance. Muscle strength and physical performance were assessed through grip strength and the Short Physical Performance Battery (SPPB), respectively. LDH was log transformed using the natural logarithm. Multivariable logistic regression was used to examine the relationship between objective measures of physical function and LDH prior to treatment in all participants. Stratified analyses were performed for participants with solid and hematological cancers.

RESULTS

A total of 257 participants (mean age: 80.2y) were included in the analysis. Most participants were females (50.6%) and were diagnosed with locally advanced (26.8%), gastrointestinal disease (35.0%). The multivariable analysis indicated that SPPB was inversely associated with LDH in all participants (B = -0.019, 95%CI = -0.036 to -0.002, p = 0.028). Notably, the inverse relationship between SPPB and LDH persisted only in patients with hematological malignancies in the multivariable model of the stratified analysis (B = -0.049, 95%CI = -0.087 to -0.011, p = 0.013). Neither grip strength alone nor the combination of low grip strength and/or SPPB were associated with LDH. Compared to participants with metastatic disease, those with localized or locally advanced disease had lower serum LDH.

CONCLUSION

Physical performance is inversely associated with serum LDH in older adults with hematological cancers prior to treatment.

Absence of association between CT-assessed skeletal muscle mass and long-term oncological outcomes after curative therapy for colorectal liver metastasis

BACKGROUND

Sarcopenia is associated with impaired short- and long-term outcomes in gastrointestinal cancers. Whether sarcopenia is associated with impaired survival after local therapy of Colorectal Cancer Liver Metastases (CRLM) remains controversial. This study aimed to determine the influence of sarcopenia on long-term outcomes after curative-intent therapy for CRLM.

METHODS

Patients undergoing local therapy for CRLM between 2003 and 2019 were retrospectively analyzed using the skeletal muscle index at the level of the third lumbar vertebra as an indicator of sarcopenia. Factors associated with overall (OS) and disease-free (DFS) survival were analyzed using univariable and multivariable cox regression.

RESULTS

In total 213/465 patients (46%) were considered sarcopenic. Sarcopenic patients had no impaired 5-year OS or DFS compared to non-sarcopenic patients, 38% vs 44% (p = 0.153) and 19 vs 23% (p = 0.339) respectively. Sarcopenia was not associated with impaired OS (HR = 1.11, 95%CI = 0.85-1.46, p = 0.43) or DFS (HR = 0.99, 95%CI = 0.77-1.28, p = 0.96) in multivariable analysis. There were no significant differences in postoperative complications (p = 0.47), the incidence (p = 0.65) and treatment (p = 0.37) of recurrent metastases. Five-year OS after resection for recurrences was 14% (sarcopenic) and 22% (non-sarcopenic) p 0.716.

CONCLUSION

Sarcopenia assessed by computed tomography was not associated with impaired survival outcomes in the group of CRLM patients overall.

Biomarkers extracted by fully automated body composition analysis from chest CT correlate with SARS-CoV-2 outcome severity

The complex process of manual biomarker extraction from body composition analysis (BCA) has far restricted the analysis of SARS-CoV-2 outcomes to small patient cohorts and a limited number of tissue types. We investigate the association of two BCA-based biomarkers with the development of severe SARS-CoV-2 infections for 918 patients (354 female, 564 male) regarding disease severity and mortality (186 deceased). Multiple tissues, such as muscle, bone, or adipose tissue are used and acquired with a deep-learning-based, fully-automated BCA from computed tomography images of the chest. The BCA features and markers were univariately analyzed with a Shapiro–Wilk and two-sided Mann–Whitney-U test. In a multivariate approach, obtained markers were adjusted by a defined set of laboratory parameters promoted by other studies. Subsequently, the relationship between the markers and two endpoints, namely severity and mortality, was investigated with regard to statistical significance. The univariate approach showed that the muscle volume was significant for female (p_severity ≤ 0.001, p_mortality ≤ 0.0001) and male patients (p_severity = 0.018, p_mortality ≤ 0.0001) regarding the severity and mortality endpoints. For male patients, the intra- and intermuscular adipose tissue (IMAT) (p ≤ 0.0001), epicardial adipose tissue (EAT) (p ≤ 0.001) and pericardial adipose tissue (PAT) (p ≤ 0.0001) were significant regarding the severity outcome. With the mortality outcome, muscle (p ≤ 0.0001), IMAT (p ≤ 0.001), EAT (p = 0.011) and PAT (p = 0.003) remained significant. For female patients, bone (p ≤ 0.001), IMAT (p = 0.032) and PAT (p = 0.047) were significant in univariate analyses regarding the severity and bone (p = 0.005) regarding the mortality. Furthermore, the defined sarcopenia marker (p ≤ 0.0001, for female and male) was significant for both endpoints. The cardiac marker was significant for severity (p_female = 0.014, p_male ≤ 0.0001) and for mortality (p_female ≤ 0.0001, p_male ≤ 0.0001) endpoint for both genders. The multivariate logistic regression showed that the sarcopenia marker was significant (p_severity = 0.006, p_mortality = 0.002) for both endpoints (OR_severity = 0.42, 95% CI_severity: 0.23–0.78, OR_mortality = 0.34, 95% CI_mortality: 0.17–0.67). The cardiac marker showed significance (p = 0.018) only for the severity endpoint (OR = 1.42, 95% CI 1.06–1.90). The association between BCA-based sarcopenia and cardiac biomarkers and disease severity and mortality suggests that these biomarkers can contribute to the risk stratification of SARS-CoV-2 patients. Patients with a higher cardiac marker and a lower sarcopenia marker are at risk for a severe course or death. Whether those biomarkers hold similar importance for other pneumonia-related diseases requires further investigation.

Effect of Pre-Existent Sarcopenia on Oncological Outcome of Advanced Thyroid Cancer Patients Treated with Tyrosine Kinase Inhibitors

(1) Background: Sarcopenia is associated with poor survival and treatment outcomes in several human cancers. The aim of the study was to investigate the prevalence of sarcopenia in a cohort of 58 Caucasian patients with advanced thyroid cancer before and during TKI treatment. The impact of this condition on the outcome of patients was also evaluated. (2) Methods: Sarcopenia was evaluated using the Skeletal Muscle Index (SMI). (3) Results: Pre-treatment sarcopenia was found in 20.7% of patients and this condition significantly affected treatment outcome, emerging as the parameter that has the greatest impact on Progression Free Survival (PFS) (HR 4.29; 95% CI, 1.21−15.11, p = 0.02). A significant reduction in SMI values was observed 3 (p = 0.002) and 12 months (p < 0.0001) after TKI treatment. At a 12-month follow-up, sarcopenia prevalence increased up to 38.5%. Here, 12-month sarcopenia was predicted by a lower SMI (p = 0.029), BMI (p = 0.02) and weight (p = 0.04) and by the presence of bone metastases (p = 0.02). (4) Conclusions: This is the first study that evaluated sarcopenia prevalence and its change over time in Caucasian patients with advanced thyroid cancer under TKI therapy. Sarcopenia seems to be a prognostic factor of TKI treatment outcome, suggesting the importance of the assessment of the nutritional status and body composition in advanced thyroid cancer patients.

Association between Energy Balance-Related Factors and Clinical Outcomes in Patients with Ovarian Cancer: A Systematic Review and Meta-Analysis

Background: This systematic review and meta-analysis synthesized evidence in patients with ovarian cancer at diagnosis and/or during first-line treatment on; (i) the association of body weight, body composition, diet, exercise, sedentary behavior, or physical fitness with clinical outcomes; and (ii) the effect of exercise and/or dietary interventions. Methods: Risk of bias assessments and best-evidence syntheses were completed. Meta-analyses were performed when ≥3 papers presented point estimates and variability measures of associations or effects. Results: Body mass index (BMI) at diagnosis was not significantly associated with survival. Although the following trends were not supported by the best-evidence syntheses, the meta-analyses revealed that a higher BMI was associated with a higher risk of post-surgical complications (n = 5, HR: 1.63, 95% CI: 1.06−2.51, p = 0.030), a higher muscle mass was associated with a better progression-free survival (n = 3, HR: 1.41, 95% CI: 1.04−1.91, p = 0.030) and a higher muscle density was associated with a better overall survival (n = 3, HR: 2.12, 95% CI: 1.62−2.79, p < 0.001). Muscle measures were not significantly associated with surgical or chemotherapy-related outcomes. Conclusions: The prognostic value of baseline BMI for clinical outcomes is limited, but muscle mass and density may have more prognostic potential. High-quality studies with comprehensive reporting of results are required to improve our understanding of the prognostic value of body composition measures for clinical outcomes. Systematic review registration number: PROSPERO identifier CRD42020163058.

Body Composition as a Predictor of the Survival in Anal Cancer

Background and aim: Sarcopenia and body composition parameters such as visceral and subcutaneous adipose tissue and visceral-to-subcutaneous adipose tissue ratio have been shown to be relevant biomarkers for prognosis in patients with different types of cancer. However, these findings have not been well studied in anal cancer to date. Therefore, the aim of this study was to evaluate the prognostic value of different body composition parameters in patients undergoing radiation therapy for the treatment of anal cancer with curative intent. Material and Methods: After approval by the institutional ethical committee, we retrospectively identified 81 patients in our local registry, who received radical intensity-modulated radiotherapy for the management of anal squamous cell cancer (ASCC). Clinical information, including body mass index (BMI), survival, and toxicities outcome, were retrieved from the local hospital registry. Based on the pre-therapeutic computer tomography (CT), we measured the total psoas muscle area, visceral adipose tissue area (VAT), subcutaneous adipose tissue area (SAT), and visceral-to-subcutaneous adipose tissue area ratio (VSR). In addition to the classical prognostic factors as T-stage, N-stage, gender, and treatment duration, we analyzed the impact of body composition on the prognosis in univariate and multivariate analyses. Results: Sarcopenia was not associated with increased mortality in anal cancer patients, whereas increased BMI (≥27 kg/m2) and VSR (≥0.45) were significantly associated with worsened overall survival and cancer-specific survival in both univariate and multivariate analyses. VSR-not BMI-was statistically higher in males. Sarcopenia and VSR ≥ 0.45 were associated with advanced T-stages. None of the body composition parameters resulted in a significant increase in treatment-related toxicities. Conclusion: BMI and visceral adiposity are independent prognostic factors for the survival of patients with anal cancer. Measurements to treat adiposity at the time of diagnosis may be needed to improve the survival outcomes for the affected patients.

The impact of sarcopenia on adverse events associated with gastric endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) is one of the main methods of treatments for early gastric cancer. Sarcopenia is a known risk factor for postoperative adverse events; however, the effect of sarcopenia on gastric ESD is unclear. We investigated the impact of sarcopenia on short-term prognosis after gastric ESD.

METHODS

This was a retrospective cohort study. We reviewed 832 patients who underwent gastric ESD between January 2015 and December 2019 and classified them into two groups: sarcopenia and non-sarcopenia groups. The curative resection rate, adverse events, and lengths of hospital stay were evaluated. We also evaluated risk factors associated with adverse events.

RESULTS

700 patients were analyzed (239 in the sarcopenia group and 461 in the non-sarcopenia group). The curative resection rates were similar in both groups. Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 2 (17% vs. 10%) were significantly more common, and the length of hospital stay was longer (8 vs. 7 days) in the sarcopenia group. Univariate analysis identified age ≥ 75 years, antithrombotic medication, history of gastric surgery, submucosal (SM) invasion, and sarcopenia as risk factors for CTCAE grade ≥ 2. Multivariate analysis showed that sarcopenia [odds ratio (OR) 1.79, 95% confidence interval (CI) 1.11-2.89, p = 0.016], history of gastric surgery (OR 9.32, 95% CI 1.97-44.05, p = 0.005), and SM invasion (OR 2.14, 95% CI 1.24-3.70, p = 0.006) were significant independent risk factors.

CONCLUSIONS

Sarcopenia significantly affected short-term prognosis and is a novel risk factor for gastric ESD.

Predictive significance of body composition indices in patients with head and neck squamous cell carcinoma treated with nivolumab: A multicenter retrospective study

BACKGROUND

The identification of predictive factors is imperative for identifying patients with optimal responses to nivolumab. We aimed to determine whether body composition parameters can predict treatment outcomes in patients with head and neck squamous cell carcinoma (HNSCC) treated with nivolumab.

METHOD

We performed a multicenter retrospective chart review of patients with recurrent and/or metastatic HNSCC treated with nivolumab between 2017 and 2020. Computed tomography images and anthropometric measures were used to determine the skeletal muscle index (SMI), subcutaneous adipose index, visceral adipose index (VAI), and body mass index. Objective response, overall survival (OS), progression-free survival (PFS), and severe immune-related adverse events (irAEs) were the main outcomes. Odds ratios (ORs) and hazard ratios (HRs) for low-index groups compared with high-index groups were calculated for these outcomes.

RESULTS

Our study comprised 114 patients with a median follow-up period of 23.1 months. Low SMI and low VAI were significantly associated with poor disease control [OR: 0.39, 95% confidence interval (CI): 0.15-0.97] and poor response (OR: 0.38, 95% CI: 0.15-0.94), respectively. Low SMI independently predicted poor OS (HR: 2.06, 95% CI: 1.16-3.67), poor PFS (HR: 1.74, 95% CI: 1.04-2.92), and increased incidence of irAEs (OR: 6.00, 95% CI: 1.04-34.61). Low VAI independently predicted poor PFS (HR 2.07, 95% CI: 1.15-3.73).

CONCLUSION

The SMI and VAI are predictive factors of nivolumab therapy in patients with HNSCC. Body composition indices should be assessed before nivolumab treatment for achieving optimal responses to nivolumab.

Automated versus manual analysis of body composition measures on computed tomography in patients with bladder cancer

PURPOSE

Manual measurement of body composition on computed tomography (CT) is time-consuming, limiting its clinical use. We validate a software program, Automatic Body composition Analyzer using Computed tomography image Segmentation (ABACS), for the automated measurement of body composition by comparing its performance to manual segmentation in a cohort of patients with bladder cancer.

METHOD

We performed a retrospective analysis of 285 patients treated for bladder cancer at the Duke University Health System from 1996 to 2017. Abdominal CT images were manually segmented at L3 using Slice-O-Matic. Automated segmentation was performed with ABACS on the same L3-level images. Measures of interest were skeletal muscle (SM) area, subcutaneous adipose tissue (SAT) area, and visceral adipose tissue (VAT) area. SM index, SAT index, and VAT index were calculated by dividing component areas by patient height2 (m2). Patients were dichotomized as sarcopenic, having excessive subcutaneous fat, or having excessive visceral fat using published cut-off values. Agreement between manual and automated segmentation was assessed using the Pearson product-moment correlation coefficient (PPMCC), the interclass correlation coefficient (ICC3), and the kappa statistic (κ).

RESULTS

There was strong agreement between manual and automatic segmentation, with PPMCCs > 0.90 and ICC3s > 0.90 for SM, SAT, and VAT areas. Categorization of patients as sarcopenic (κ = 0.73), having excessive subcutaneous fat (κ = 0.88), or having excessive visceral fat (κ = 0.90) displayed high agreement between methods.

CONCLUSIONS

Automated segmentation of body composition measures on CT using ABACS performs similarly to manual analysis and may expedite data collection in body composition research.

Body composition change during neoadjuvant chemotherapy for breast cancer

Background

Sarcopenia is receiving attention in oncology as a predictor of increased chemotherapy toxicities. Research into body composition change during neoadjuvant chemotherapy for breast cancer is both urgently needed and generally lacking. This study assessed sarcopenia prevalence before and after neoadjuvant chemotherapy using CT imaging, evaluated body composition changes during neoadjuvant chemotherapy, and determined predictors of sarcopenia status after neoadjuvant chemotherapy for breast cancer.

Materials and Methods

In this retrospective, descriptive study, we used data collected from 2017 to 2020 to measure body composition parameters on cross-sectional CT slices for 317 Korean women with breast cancer patients before and at completion of neoadjuvant chemotherapy. Changes in skeletal muscle index, visceral fat index, subcutaneous fat index, and sarcopenia were assessed and correlated, and multivariate logistic regression was conducted to identify predictive factors associated with sarcopenia status at completion of neoadjuvant chemotherapy.

Results

Of the 80 breast cancer patients (25.2%) who had sarcopenia before beginning neoadjuvant chemotherapy, 64 (80.0%) retained their sarcopenia status after chemotherapy. Weight, body mass index, body surface area, and visceral fat index showed significant increases after neoadjuvant chemotherapy; notably, only skeletal muscle index significantly decreased, showing a reduction of 0.44 cm2/m2 (t (316) = 2.15, p &lt;.5). Lower skeletal muscle index at baseline was associated with greater loss of muscle mass during neoadjuvant chemotherapy (r = −.24, p &lt;.001). Multivariate logistic regression showed that baseline sarcopenia status was the only significant predictor of sarcopenia status after neoadjuvant chemotherapy (p &lt;.001). Specifically, the log odds of sarcopenia after neoadjuvant chemotherapy were 3.357 higher in the baseline sarcopenia group than in the group without baseline sarcopenia (β = 3.357, p &lt;.001).

Conclusion

Sarcopenia during neoadjuvant chemotherapy can be obscured by an increasing proportion of fat in body composition if clinical assessment focuses on only body mass index or body surface area rather than muscle mass. For breast cancer patients who have sarcopenia when they begin neoadjuvant chemotherapy, the risk of muscle mass loss during treatment is alarmingly high. To reduce masking of muscle mass loss during treatment, comprehensive evaluation of body composition, beyond body surface area assessment, is clearly needed.

Management of Sarcopenia in Patients with Rheumatoid Arthritis

This review summarizes the evidence for the management of sarcopenia in patients with rheumatoid arthritis (RA) in terms of drugs, exercise, and nutrition. Sarcopenia is a decrease in skeletal muscle mass and muscle strength or physical function. The prevalence of sarcopenia in patients with RA is higher than that in the general population. The treatment and management of sarcopenia in patients with RA are clinically important for long-term prognosis. One of the mechanisms of muscle metabolism is the pro-inflammatory cytokine pathway, which involves tumour necrosis factor α (TNF-α) and interleukin 6 (IL-6), and is a common pathway in the pathogenesis of RA. Thus, TNF-α and IL-6 inhibitors may play a potential role in controlling sarcopenia. In exercise therapy, a combination of moderate resistance and aerobic exercise may be effective in improving muscle strength, muscle mass, and physical function; however, intense exercise may exacerbate the inflammatory response in RA. Regarding nutrition, protein intake is generally considered beneficial, but other nutrients such as vitamin D and carotenoids have also been studied. Overall, there remains a lack of concrete evidence on sarcopenia treatment and management in patients with RA from any perspective; more longitudinal and intervention studies are needed in the future.

Hybrid Exercise Program for Sarcopenia in Older Adults: The Effectiveness of Explainable Artificial Intelligence-Based Clinical Assistance in Assessing Skeletal Muscle Area

Background: Sarcopenia is a geriatric syndrome characterized by decreased skeletal muscle mass and function with age. It is well-established that resistance exercise and Yi Jin Jing improve the skeletal muscle mass of older adults with sarcopenia. Accordingly, we designed an exercise program incorporating resistance exercise and Yi Jin Jing to increase skeletal muscle mass and reverse sarcopenia in older adults. Additionally, machine learning simulations were used to predict the sarcopenia status after the intervention. Method: This randomized controlled trial assessed the effects of sarcopenia in older adults. For 24 weeks, 90 older adults with sarcopenia were divided into intervention groups, including the Yi Jin Jing and resistance training group (YR, n = 30), the resistance training group (RT, n = 30), and the control group (CG, n = 30). Computed tomography (CT) scans of the abdomen were used to quantify the skeletal muscle cross-sectional area at the third lumbar vertebra (L3 SMA). Participants’ age, body mass, stature, and BMI characteristics were analyzed by one-way ANOVA and the chi-squared test for categorical data. This study explored the improvement effect of three interventions on participants’ L3 SMA, skeletal muscle density at the third lumbar vertebra (L3 SMD), skeletal muscle interstitial fat area at the third lumbar vertebra region of interest (L3 SMFA), skeletal muscle interstitial fat density at the third lumbar vertebra (L3 SMFD), relative skeletal muscle mass index (RSMI), muscle fat infiltration (MFI), and handgrip strength. Experimental data were analyzed using two-way repeated-measures ANOVA. Eleven machine learning models were trained and tested 100 times to assess the model’s performance in predicting whether sarcopenia could be reversed following the intervention. Results: There was a significant interaction in L3 SMA (p < 0.05), RSMI (p < 0.05), MFI (p < 0.05), and handgrip strength (p < 0.05). After the intervention, participants in the YR and RT groups showed significant improvements in L3 SMA, RSMI, and handgrip strength. Post hoc tests showed that the YR group (p < 0.05) yielded significantly better L3 SMA and RSMI than the RT group (p < 0.05) and CG group (p < 0.05) after the intervention. Compared with other models, the stacking model exhibits the best performance in terms of accuracy (85.7%) and F1 (75.3%). Conclusion: One hybrid exercise program with Yi Jin Jing and resistance exercise training can improve skeletal muscle area among older adults with sarcopenia. Accordingly, it is possible to predict whether sarcopenia can be reversed in older adults based on our stacking model.

Sex-Specific Cut-Off Values for Low Skeletal Muscle Mass to Identify Patients at Risk for Treatment-Related Adverse Events in Head and Neck Cancer

A low skeletal muscle index (SMI), defined with cut-off values, is a promising predictor for adverse events (AEs) in head and neck squamous cell cancer (HNSCC) patients. The aim was to generate sex-specific SMI cut-off values based on AE to diagnose low SMI and to analyse the relationship between low SMI and AEs in HNSCC patients. In this present study, HNSCC patients were prospectively included in a large oncological data-biobank and SMI was retrospectively measured using baseline neck scans. In total, 193 patients were included and were stratified according to treatment modality: (chemo-)radiotherapy ((C)RT) (n = 135) and surgery (n = 61). AE endpoints were based on the occurrence of clinically relevant toxicities (Common Terminology Criteria for Adverse Events grade ≥ III) and postoperative complications (Clavien–Dindo Classification grade ≥ II). Sex-specific SMI cut-off values were generated with receiver operating characteristic curves, based on the AE endpoints. The relationship of the baseline characteristics and AEs was analysed with logistic regression analysis, with AEs as the endpoint. Multivariable logistic analysis showed that low SMI (OR 3.33, 95%CI 1.41–7.85) and tumour stage (OR 3.45, 95%CI 1.28–9.29) were significantly and independently associated to (C)RT toxicity. Low SMI was not related to postoperative complications. To conclude, sex-specific SMI cut-off values, were generated based on the occurrence of AEs. Low SMI and tumour stage were independently related to (C)RT toxicity in HNSCC patients.

n-3 PUFA dietary lipid replacement normalizes muscle mitochondrial function and oxidative stress through enhanced tissue mitophagy and protects from muscle wasting in experimental kidney disease

INTRODUCTION AND METHODS

Skeletal muscle mitochondrial dysfunction may cause tissue oxidative stress and consequent catabolism in chronic kidney disease (CKD), contributing to patient mortality. We investigated in 5/6-nephrectomized (Nx) rats the impact of n3-polyunsaturated fatty-acids (n3-PUFA) isocaloric partial dietary replacement on gastrocnemius muscle (Gm) mitochondrial master-regulators, ATP production, ROS generation and related muscle-catabolic derangements.

RESULTS

Nx had low Gm mitochondrial nuclear respiratory factor-2 and peroxisome proliferator-activated receptor gamma coactivator-1alpha, low ATP production and higher mitochondrial fission-fusion protein ratio with ROS overproduction. n3-PUFA normalized all mitochondrial derangements and pro-oxidative tissue redox state (oxydized to total glutathione ratio). n3-PUFA also normalized Nx-induced muscle-catabolic proinflammatory cytokines, insulin resistance and low muscle weight. Human uremic serum reproduced mitochondrial derangements in C2C12 myotubes, while n3-PUFA coincubation prevented all effects. n3-PUFA also enhanced muscle mitophagy in-vivo and siRNA-mediated autophagy inhibition selectively blocked n3-PUFA-induced normalization of C2C12 mitochondrial ROS production.

CONCLUSIONS

In conclusion, dietary n3-PUFA normalize mitochondrial master-regulators, ATP production and dynamics in experimental CKD. These effects occur directly in muscle cells and they normalize ROS production through enhanced mitophagy. Dietary n3-PUFA mitochondrial effects result in normalized catabolic derangements and protection from muscle wasting, with potential positive impact on patient survival.

Sarcopenia as a Predictor of Short- and Long-Term Outcomes in Patients Surgically Treated for Malignant Pleural Mesothelioma

Simple Summary

Malignant pleural mesothelioma (MPM) is an aggressive asbestos-related tumor with a poor prognosis. Surgery, often considered in the context of multimodality treatment, may be burdened by high morbidity, and for this reason, it should be reserved for patients who have a good pre-operative performance status. Sarcopenia, a well-established predictor of negative outcomes in several clinical settings, is still underinvestigated in MPM. The aim of the study is to elucidate the prognostic impact of muscular loss on surgical outcomes in patients with MPM. We demonstrated that, respectively, pre- and post-operative sarcopenia strongly affects the risk of post-operative complications and long-term survival after surgery for MPM. This finding will help clinicians to perform a better selection of patients, taking into consideration the enrollment in dedicated rehabilitation programs before surgery.

Abstract

Surgery for malignant pleural mesothelioma (MPM) should be reserved only for patients who have a good performance status. Sarcopenia, a well-known predictor of poor outcomes after surgery, is still underinvestigated in MPM. The aim of this study is to evaluate the role of sarcopenia as a predictor of short-and long-term outcomes in patients surgically treated for MPM. In our analysis, we included patients treated with a cytoreductive intent in a multimodality setting, with both pre- and post-operative CT scans without contrast available. We excluded those in whom a complete macroscopic resection was not achieved. Overall, 86 patients were enrolled. Sarcopenia was assessed by measuring the mean muscular density of the bilateral paravertebral muscles (T12 level) on pre-and post-operative CTs; a threshold value of 30 Hounsfield Units (HU) was identified. Sarcopenia was found pre-operatively in 57 (66%) patients and post-operatively in 61 (74%). Post-operative sarcopenic patients had a lower 3-year overall survival (OS) than those who were non-sarcopenic (34.9% vs. 57.6% p = 0.03). Pre-operative sarcopenia was significantly associated with a higher frequency of post-operative complications (65% vs. 41%, p = 0.04). The evaluation of sarcopenia, through a non-invasive method, would help to better select patients submitted to surgery for MPM in a multimodality setting.

Body mass index and serum markers associated with progression-free survival in lung cancer patients treated with immune checkpoint inhibitors

BACKGROUND

ICIs have remarkably affected the treatment strategies for numerous malignancies, including lung cancer. However, only a fraction of patients experience durable responses to ICIs; thus, there is an urgent need to identify the parameters related to ICI therapeutic effects. In this study, we investigated nutritional status surrogates and several serum markers to estimate the efficacy of ICIs.

MATERIALS AND METHODS

The records of 66 patients with stage III/IV lung cancer who received ICIs were retrospectively analyzed. Features of patients' clinical pathology, including age, sex, histology, line of treatment, BMI, serum albumin, serum creatinine, and serum inflammatory markers such as LMR and PLR, were examined. Progression-free survival was the primary endpoint. Relationships among categorical variables were assessed by the chi-squared test. Survival analysis was performed using the Kaplan-Meier method followed by the log-rank test. Cox multivariate analysis was performed to analyze the association between each variable and the survival time of patients.

RESULTS

The patients with BMI ≥ 25 (kg/m2), serum ALB≥37 (g/dL), serum creatinine ≥61.8 (μmol/L), LMR ≥ 2.12 had a significantly prolonged PFS in comparison with BMI<25 (kg/m2), ALB<37 (g/dL), creatinine<61.8 (μmol/L), LMR<2.12 (p < 0.05). No statistically significant difference was detected between patients with PLR < 135 and PLR ≥ 135 (p = 0.612). Multivariate analysis revealed that ALB≥37 (g/dL) and creatinine ≥ 61.8 (μmol/L) were associated with prolonged PFS, while statistical significance was not achieved in the BMI groups.

CONCLUSIONS

The current results indicated that high BMI is related to longer PFS in lung cancer patients treated with ICIs, which may be correlated with high levels of serum albumin and creatinine.

The Association between Muscle Quantity and Overall Survival Depends on Muscle Radiodensity: A Cohort Study in Non-Small-Cell Lung Cancer Patients

The prognostic value of CT-derived muscle quantity for overall survival (OS) in patients with non-small-cell lung cancer (NSCLC) is uncertain due to conflicting evidence. We hypothesize that increased muscle quantity is associated with better OS in patients with normal muscle radiodensity but not in patients with fatty degeneration of muscle tissue and low muscle radiodensity. We performed an observational cohort study in NSCLC patients treated with radiotherapy. A deep learning algorithm was used to measure muscle quantity as psoas muscle index (PMI) and psoas muscle radiodensity (PMD) on computed tomography. The potential interaction between PMI and PMD for OS was investigated using Cox proportional-hazards regression. Baseline adjustment variables were age, sex, histology, performance score and body mass index. We investigated non-linear effects of continuous variables and imputed missing values using multiple imputation. We included 2840 patients and observed 1975 deaths in 5903 patient years. The average age was 68.9 years (standard deviation 10.4, range 32 to 96) and 1692 patients (59.6%) were male. PMI was more positively associated with OS for higher values of PMD (hazard ratio for interaction 0.915; 95% confidence interval 0.861-0.972; p-value 0.004). We found evidence that high muscle quantity is associated with better OS when muscle radiodensity is higher, in a large cohort of NSCLC patients treated with radiotherapy. Future studies on the association between muscle status and OS should accommodate this interaction in their analysis for more accurate and more generalizable results.

Nutritional Factors during and after Cancer: Impacts on Survival and Quality of Life

The French National Cancer Institute conducted a collective expertise study with researchers and clinical experts from the French Network for Nutrition And Cancer Research (NACRe Network). The objective was to update the state of knowledge on the impacts of nutritional factors on clinical endpoints during or after cancer. Data from 150 meta-analyses, pooled analyses or intervention trials and 93 cohort studies were examined; they concerned 8 nutritional factors, 6 clinical events and 20 cancer locations. This report shows that some nutritional factors have impacts on mortality and on the risks of recurrence or second primary cancer in cancer patients. Therefore, high-risk nutritional conditions can be encountered for certain cancer sites: from the diagnosis and throughout the health care pathways, weight loss (lung and esophageal cancers), malnutrition (lung, esophageal, colorectal, pancreatic, gastric and liver cancers), weight gain (colorectal, breast and kidney cancers) and alcohol consumption (upper aerodigestive cancers) should be monitored; and after cancer treatments, excess weight should be detected (colorectal, breast and kidney cancers). These situations require nutritional assessments, and even support or management by health care professionals, in the context of tertiary prevention. This report also highlights some limitations regarding the existing literature and some needs for future research.

Association between high preoperative body mass index and mortality after cancer surgery

Despite an association between obesity and increased mortality in the general population, obesity has been paradoxically reported with improved mortality of surgery and some types of cancer. However, this has not been fully investigated in patients undergoing cancer surgery. Using a cohort consisting of mostly Asian population, we enrolled 87,567 adult patients who underwent cancer surgery from March 2010 to December 2019. They were divided into three groups according to body mass index (BMI): 53,980 (61.6%) in the normal (18.5–25 kg/m2), 2,787 (3.2%) in the low BMI (<18.5 kg/m2), and 30,800 (35.2%) in the high BMI (≥25 kg/m2) groups. The high BMI group was further stratified into overweight (25–30 kg/m2) and obese (≥30 kg/m2) groups. The primary outcome was mortality during three years after surgery. Following adjustment by inverse probability weighting, mortality during three years after surgery was significantly lower in the high BMI group than the normal (4.8% vs. 7.0%; hazard ratio [HR], 0.69; confidence interval [CI], 0.64–0.77; p < 0.001) and low BMI (4.8% vs. 13.0%; HR: 0.38; CI: 0.35–0.42; p < 0.001) groups. The mortalities of the overweight and obese groups were lower than that of the normal group (7.0% vs. 5.0%; HR: 0.72; CI: 0.67–0.77; p < 0.001 and 7.0% vs. 3.3%; HR: 0.57; CI: 0.50–0.65; p < 0.001, respectively). This association was not observed in female patients and those undergoing surgery for breast and gynecological cancers. High BMI may be associated with decreased mortality after cancer surgery. Further investigations are needed for clinical application of our finding.

Association between sarcopenia based on psoas muscle index and the response to nivolumab in metastatic renal cell carcinoma: A retrospective study

Purpose

Two methods are used to identify sarcopenia by calculating skeletal muscle area on computed tomography: the skeletal muscle index (SMI) and the psoas muscle index (PMI). Programmed death (PD)-1 inhibitors are helpful in treating metastatic renal cell carcinoma (mRCC). However, there remains insufficient information regarding a clear and easy-to-use biomarker for predicting the response to PD-1 inhibitors in patients with mRCC. Therefore, we investigated the influence of sarcopenia on clinical outcomes in patients with mRCC undergoing treatment with nivolumab.

Materials and Methods

This study evaluated 96 patients with RCC who received nivolumab. The SMI and PMI were calculated for each patient and normalized for stature by use of the following formulas: SMI (cm²/m²)=([skeletal muscle cross-sectional area at the level of L3]/[height]²) and PMI (cm²/m²) = ([left-right sum of the psoas muscle areas at the level of L3]/[height]²). The relationship of the clinical variables with progression-free survival and overall survival (OS) was examined using a Cox proportional hazards model.

Results

According to the SMI-based definition of sarcopenia, 74.0% of patients had sarcopenia. However, according to the PMI-based definition of sarcopenia, only 34.3% of patients were diagnosed with sarcopenia. Multivariate analysis identified sarcopenia based on PMI (hazard ratio [HR], 3.85; 95% confidence interval [CI], 2.04–7.26; p<0.001) and International Metastatic RCC Database Consortium poor risk status (HR, 1.90; 95% CI, 1.03–3.50; p=0.041) as significant and independent prognostic factors of OS.

Conclusions

PMI-based sarcopenia is a significant prognostic factor for OS in patients with RCC who receive nivolumab therapy.

Effect of Pre-Existing Sarcopenia on Oncological Outcomes for Oral Cavity Squamous Cell Carcinoma Undergoing Curative Surgery: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study

Purpose: The effect of pre-existing sarcopenia on patients with oral cavity squamous cell carcinoma (OCSCC) remains unknown. Therefore, we designed a propensity score-matched population-based cohort study to compare the oncological outcomes of patients with OCSCC undergoing curative surgery with and without sarcopenia. Patients and Methods: We included patients with OCSCC undergoing curative surgery and categorized them into two groups according to the presence or absence of pre-existing sarcopenia. Patients in both the groups were matched at a ratio of 2:1. Results: The matching process yielded 16,294 patients (10,855 and 5439 without and with pre-existing sarcopenia, respectively). In multivariate Cox regression analyses, the adjusted hazard ratio (aHR, 95% confidence interval [CI]) of all-cause mortality for OCSCC with and without pre-existing sarcopenia was 1.15 (1.11−1.21, p < 0.0001). Furthermore, the aHRs (95% CIs) of locoregional recurrence and distant metastasis for OCSCC with and without pre-existing sarcopenia were 1.07 (1.03−1.18, p = 0.0020) and 1.07 (1.03−1.20, p = 0.0148), respectively. Conclusions: Pre-existing sarcopenia might be a significant poor prognostic factor for overall survival, locoregional recurrence, and distant metastasis for patients with OCSCC undergoing curative surgery. In susceptible patients at a risk of OCSCC, sarcopenia prevention measures should be encouraged, such as exercise and early nutrition intervention.

The impact of pre-treatment muscle strength and physical performance on treatment modification in older adults with cancer following comprehensive geriatric assessment

BACKGROUND

Grip strength (GS) and the short physical performance battery (SPPB) have been shown to predict clinical outcomes in older adults with cancer. However, whether pre-treatment GS and SPPB impact treatment decisions following comprehensive geriatric assessment (CGA) is poorly understood. Our objective was to assess the impact of low GS and/or SPPB on treatment modification to initially proposed treatment plans in older adults with cancer following CGA.

METHODS

This was a retrospective cohort study of older adults who had undergone CGA before receiving cancer treatment. Data were retrieved from a prospective database in an academic cancer centre and medical records. Treatment modification following CGA was defined as reduced treatment intensity or transition from active treatment to supportive care. Multivariable logistic regression assessed the impact of pre-treatment GS and SPPB on treatment modification following CGA.

RESULTS

In total, 515 older adults (mean age: 80.7y) who had undergone CGA prior to cancer treatment were included. Low muscle strength and/or physical performance was observed in 66.4% of participants. Treatment was modified in 49.5% of the cohort following CGA. Low GS and/or SPPB combined was predictive of treatment modification (OR = 1.77, 95%CI = 1.07-2.90, P = 0.025) in multivariable analysis. Additional predictors of treatment modification included palliative treatment intent, comorbidities and malnutrition.

CONCLUSIONS

Low GS and/or SPPB combined prior to cancer treatment predicts treatment modification in older adults with cancer and may be useful in treatment decision-making. Management of poor muscle strength and physical performance should be offered to optimize patient care and potentially improve treatment outcomes.

Which anthropometric measurement is better for predicting survival of patients with cancer cachexia?

No relevant studies have yet been conducted to explore which measurement can best predict the survival time of patients with cancer cachexia. This study aimed to identify an anthropometric measurement that could predict the 1-year survival of patients with cancer cachexia. We conducted a nested case-control study using data from a multicentre clinical investigation of cancer from 2013 to 2020. Cachexia was defined using the Fearon criteria. A total of 262 patients who survived less than 1 year and 262 patients who survived more than 1 year were included in this study. Six candidate variables were selected based on clinical experience and previous studies. Five variables, BMI, mid-arm circumference, mid-arm muscle circumference, calf circumference and triceps skin fold (TSF), were selected for inclusion in the multivariable model. In the conditional logistic regression analysis, TSF (P = 0·014) was identified as a significant independent protective factor. A similar result was observed in all patients with cancer cachexia (n 3084). In addition, a significantly stronger positive association between TSF and the 1-year survival of patients with cancer cachexia was observed in participants aged > 65 years (OR: 0·94; 95 % CI 0·89, 0·99) than in those aged ≤ 65 years (OR: 0·96; 95 % CI 0·93, 0·99; P_interaction = 0·013) and in participants with no chronic disease (OR: 0·92; 95 % CI 0·87, 0·97) than in those with chronic disease (OR: 0·97; 95 % CI 0·94, 1·00; P_interaction = 0·049). According to this study, TSF might be a good anthropometric measurement for predicting 1-year survival in patients with cancer cachexia.

The Differential Clinical Impacts of Cachexia and Sarcopenia on the Prognosis of Advanced Pancreatic Cancer

Simple Summary

Pancreatic cancer (PC) is one of the most lethal malignancies across the world. More than 80% patients are diagnosed at an advanced stage with limited treatment options. PC has the highest frequency of developing cancer cachexia (CC)–sarcopenia (SC) syndrome, but there is no optimal efficient intervention for CC or SC targeting their complicated biological and irreversible processes. As a result, identifying the clinicopathological features and patient characteristics in each advanced PC patient with CC and/or SC is urgently needed to distinguish different wasting phenotypes or body composition and thus support precision medicine and achieve optimal outcomes. We performed a retrospective cohort study of 232 advanced PC patients to determine the differential clinical characteristics of CC and SC and the overlap of CC- or SC-related factors in each patient. The impacts of CC, SC, and their relevant factors on the outcomes of PC patients were also evaluated.

Abstract

Pancreatic cancer (PC) has the highest frequency of developing cancer cachexia (CC)–sarcopenia (SC) syndrome, which negatively influences patients’ outcome, quality of life, and tolerance/response to treatments. However, the clinical impacts of CC, SC, and their associated factors on outcomes for advanced PC has yet to be fully investigated. A total of 232 patients were enrolled in this study for the retrospective review of their clinical information and the measurement of skeletal muscle areas at the third lumber vertebra by computed tomography scan to identify CC or SC. The association and concurrent occurrence of clinicopathological features in each patient, prevalence rates, and prognosis with the CC or SC were calculated. CC and SC were observed in 83.6% (n = 194) and 49.1% (n = 114) of PC patients, respectively. Low hemoglobin levels more often occurred in CC patients than in non-CC patients (p = 0.014). Older age (p = 0.000), female gender (p = 0.024), low body mass index (BMI) values (p = 0.004), low hemoglobin levels (p = 0.036), and low albumin levels (p = 0.001) were more often found in SC patients than in non-SC patients. Univariate and multivariate analyses showed that CC was an independent poor prognostic factor of overall survival (OS) and progression-free survival for all patients, the chemotherapy (C/T) subgroup, and the high BMI subgroup. Meanwhile, SC was an independent predictor of poor OS for the subgroups of C/T or high BMI but not for all patients. These findings reveal the clinical differences for CC and SC and provide useful information for predicting the prognosis of advanced PC patients and conducting personalized medicine.

GNRI And Conut Scores: Simple Predictors of Sarcopenia in Metastatic Colorectal Cancer Patients

OBJECTIVE

To evaluate the correlation between sarcopenia and inflammation- and nutrition-based markers in metastatic colorectal cancer (mCRC) patients.

MATERIALS AND METHODS

Age, body mass index (BMI), neutrophil/lymphocyte ratio (NLR), modified Glasgow prognostic score (mGPS), prognostic nutrition index (PNI), cachexia index (CIn), skeletal muscle index (SMI), controlling nutritional status (CONUT) score, and geriatric nutritional risk index (GNRI) were evaluated in 185 patients. Ideal cut-off values for the GNRI score were determined with the ROC curve analysis, and the patients were divided into two groups as low and high GNRI. Sarcopenia was diagnosed using CT scanning, the gold standard method. Univariate and multivariate Cox proportional hazard analyses were done based on the above-listed parameters to assess the correlation between sarcopenia and changes in immuno-nutrition and inflammatory response. Kaplan-Meier analysis was also done to evaluate survival.

RESULTS

Univariate analysis of the 185 patients based on the EGWSOP 2018 threshold values showed correlation between the presence of sarcopenia and male gender, diagnosed colon cancer, history of metastasectomy, BMI < 24, high mGPS score, PNI score ≥ 45, high CONUT score, and low GNRI score (p < 0.05). In multivariate analysis, low GNRI (HR: 2.40; 95% CI: 1.03-5.544; p = 0.040), and high-CONUT scores (HR: 2.01; 95% CI: 1.06-3.73; p = 0.029) were identified as independent prognostic factors for the presence of sarcopenia.

CONCLUSION

GNRI and CONUT scores are elementary and practical predictors for sarcopenia, a condition which is associated with poor outcomes in mCRC patients.

Cancer Cachexia and Antitumor Immunity: Common Mediators and Potential Targets for New Therapies

Cancer cachexia syndrome (CCS) is a multifactorial metabolic syndrome affecting a significant proportion of patients. CCS is characterized by progressive weight loss, alterations of body composition and a systemic inflammatory status, which exerts a major impact on the host’s innate and adaptive immunity. Over the last few years, the development of immune checkpoint inhibitors (ICIs) transformed the treatment landscape for a wide spectrum of malignancies, creating an unprecedented opportunity for long term remissions in a significant subset of patients. Early clinical data indicate that CCS adversely impairs treatment outcomes of patients receiving ICIs. We herein reviewed existing evidence on the potential links between the mechanisms that promote the catabolic state in CCS and those that impair the antitumor immune response. We show that the biological mediators and processes leading to the development of CCS may also participate in the modulation and the sustainment of an immune suppressive tumor microenvironment and impaired anti-tumor immunity. Moreover, we demonstrate that the deregulation of the host’s metabolic homeostasis in cancer cachexia is associated with resistance to ICIs. Further research on the interrelation between cancer cachexia and anti-tumor immunity is required for the effective management of resistance to immunotherapy in this specific but large subgroup of ICI treated individuals.

Quality is more important than quantity: pre-operative sarcopenia is associated with poor survival in advanced ovarian cancer

BACKGROUND

Sarcopenia is prevalent among older patients with cancer and is associated with poor outcomes.

OBJECTIVE

To explore the relationship between muscle mass, quality, and patient age with overall survival after surgery for advanced ovarian cancer.

METHODS

Patients with advanced stage (IIIC/IV) ovarian cancer who underwent primary cytoreductive surgery between January 2006 and July 2016 were included. Body composition measures were calculated from pre-operative CT imaging: skeletal muscle index (skeletal muscle index=skeletal muscle area normalized for height), skeletal muscle density, and skeletal muscle gauge (product of skeletal muscle index and skeletal muscle density). Each measure was transformed to a z-score and evaluated for association with risk of death using Cox proportional hazards models. Recursive partitioning was used to classify patients into homogeneous subgroups considering age and skeletal muscle gauge as predictors of overall survival.

RESULTS

The study included 429 patients (mean age 64.2 years). Increased age moderately correlated with decreased skeletal muscle gauge (r=-0.45). Decreasing skeletal muscle density and skeletal muscle gauge were significantly associated with increased risk of death; HR (95% CI) per 1-unit decrease in z-score of 1.24 (1.10 to 1.39) for skeletal muscle density and 1.27 (1.12 to 1.44) for skeletal muscle gauge. Associations were diluted after adjusting for age (1.13 (1.00 to 1.29) skeletal muscle density and 1.14 (0.99 to 1.30) skeletal muscle gauge). Recursive partitioning identified three subgroups: <60 years old, ≥60 years old with skeletal muscle gauge ≥937.3, and ≥60 years old with skeletal muscle gauge <937.3; median overall survival was 5.8, 3.3, and 2.3 years, respectively (p<0.001).

CONCLUSIONS

Skeletal muscle gauge, a novel sarcopenia measure incorporating quantity and quality, was associated with poorer survival in patients with advanced ovarian cancer, particularly among patients older than 60. Expanding our knowledge of how sarcopenia relates to solid tumor outcomes among high-risk patients can modify our treatment approach.

Comparison of the prognostic effect of sarcopenia on atezolizumab plus bevacizumab and lenvatinib therapy in hepatocellular carcinoma patients

Background and Aim

Sarcopenia has received much attention as a poor prognostic factor in various fields, and has also been reported to worsen prognosis in patients with hepatocellular carcinoma (HCC) treated with sorafenib or lenvatinib (LEN). Atezolizumab/bevacizumab (ATZ/BEV) is recommended as first‐line drug therapy for unresectable‐HCC, but the effect of sarcopenia on patients treated with ATZ/BEV is unknown.

Methods

We enrolled 98 patients treated with ATZ/BEV or LEN. Computed tomography performed before the initiation of drug therapy was used to diagnose sarcopenia in accordance with the criteria proposed by the Japanese Society of Hepatology. Patients were divided into two groups based on the presence or absence of sarcopenia in each regimen, and patient characteristics, adverse events, and prognosis were compared.

Results

In ATZ/BEV therapy, 57.1% of patients had sarcopenia. The sarcopenia group had significantly more women (P = 0.0125) and more macroscopic vascular invasion (P = 0.0270). Sarcopenia had no significant effect on progression‐free survival (PFS) and overall survival (OS). In LEN therapy, 63.4% of patients had sarcopenia. The sarcopenia group was significantly older (P = 0.0064) and had a higher number of women (P = 0.0003), a higher neutrophil–lymphocyte ratio (P = 0.0222), worse albumin–bilirubin grade (P = 0.0087), and worse best response (P = 0.0255). PFS (P = 0.0091) and OS (P = 0.0006) were worse in the sarcopenia group. In multivariate analysis, age (P = 0.0362), lymphocyte–monocyte ratio (P = 0.0365), and sarcopenia (P = 0.0268) were independent prognostic factors for OS.

Conclusion

In ATZ/BEV therapy, sarcopenia does not determine prognosis, and therapeutic efficacy can be expected even in cases of sarcopenia.

Low preoperative psoas muscle mass index is a risk factor for distal cholangiocarcinoma recurrence after pancreatoduodenectomy: a retrospective analysis

BACKGROUND

This study aimed to investigate whether preoperative muscle mass is associated with the recurrence of distal cholangiocarcinoma after pancreatoduodenectomy (PD).

METHODS

We retrospectively examined 88 patients who had undergone PD for distal cholangiocarcinoma. The preoperative psoas muscle mass index (PMI) was measured using computed tomography as an index of muscle mass. We performed multivariate analysis of factors influencing early recurrence and developed a prognostic survival model using independent risk factors for recurrence.

RESULTS

The cut-off PMI values for recurrence within 1 year of surgery, determined from the receiver operating characteristic curve, were 5.90 cm²/m² in males and 3.98 cm²/m² in females. Multivariate analysis of effects associated with early recurrence within 1 year indicated that low PMI (odds ratio [OR] 9.322; 95% confidence interval [CI] 2.832 - 30.678; p = 0.0002) and lymph node metastasis (OR 5.474; 95% CI 1.620 - 18.497; p = 0.0062) were independent risk factors, and the median recurrence-free survival (RFS) of the low and high PMI groups were 21.6 and 81.0 months, respectively (p = 0.0214). The median RFS for zero, one, and two risk factors of low PMI and lymph node metastasis were as follows: zero variables, median not reached; one variable, 15.3 months; two variables: 6 months.

CONCLUSIONS

Low preoperative PMI may be a risk factor for distal cholangiocarcinoma recurrence after PD.

TRIAL REGISTRATION

The Institutional Review Board of St. Marianna University School of Medicine approved this study prior to commencement of data collection and analysis on October 9, 2020 (IRB no. 5006) and waived the informed consent requirement.

Cut-off values for low skeletal muscle mass at the level of the third cervical vertebra (C3) in patients with head and neck cancer

BACKGROUND

Low skeletal muscle mass is associated with adverse outcomes in patients with cancer. For patients with head and neck cancer (HNC), skeletal muscle mass is often assessed at the third cervical vertebra on head and neck imaging. Due to the unavailability of standardized cut-off values for low skeletal muscle mass in patients with head and cancer, there is heterogeneousness of cut-off values for low skeletal muscle mass described in literature. Therefore, we aim to provide standardized cut-off values for low skeletal muscle mass in HNC patients.

METHODS

A retrospective cohort study was performed. Between 2008 and 2018, HNC patients with head and neck imaging were included. Skeletal muscle area (SMA) was manually delineated at the level of the third cervical vertebra and corrected for patients squared height to obtain the cervical skeletal muscle mass index. Gender and body-mass index specific cut-off values for low skeletal muscle mass were calculated based on mean cervical skeletal muscle mass index minus 2 standard deviations as suggested in literature.

RESULTS

Of the 1,415 included patients, the majority was male (69.8%) and had a body mass index below 25 kg/m2 (59.2%). A primary tumor localization in the oropharynx (35.3%) and a tumor, node, metastasis stage IV tumor (60.5%) were most frequently observed. Cervical skeletal muscle mass index was significantly correlated with gender (r2=0.4, P<0.01) and body mass index (r2=0.4, P<0.01). For male patients with a body mass index <25 and ≥25 kg/m2, a cervical skeletal muscle mass index of respectively ≤6.8 and ≤8.5 cm2/m2 was defined for low skeletal muscle mass. For female patients with a body mass index <25 and ≥25 kg/m2, a cervical skeletal muscle mass index of respectively ≤5.3 and ≤6.4 cm2/m2 was defined for low skeletal muscle mass.

CONCLUSIONS

This study is the first to provide standardized cut-off values for low skeletal muscle mass at the level of the third cervical vertebra in patients with HNC. This information may aid in the uniformity of low skeletal muscle mass definition in research.

Clinical impact of body composition on postoperative outcomes during neoadjuvant chemoradiation therapy for distal bile duct cancer

Body composition changes during neoadjuvant therapy and their clinical significance have not been clarified. The present study aimed to investigate body composition changes during neoadjuvant chemoradiation therapy (NACRT) in patients with distal bile duct cancer and the clinical impact on postoperative complications and the prognosis. A total of 16 patients with distal bile duct cancer who underwent curative resection after NACRT were retrospectively evaluated. The area of skeletal muscle, visceral fat and subcutaneous fat on computed tomography and immunological and nutritional indices were assessed before and after NACRT. All 16 patients completed NACRT followed by pancreaticoduodenectomy without mortality. There was no significant change in the skeletal muscle mass index (SMI) during NACRT. Of the 16 patients, nine (56%) were defined as sarcopenic before NACRT, and eight (50%) met the criteria for sarcopenic after NACRT. The SMI and total fat area were significantly associated with postoperative pancreatic fistula (POPF) (P=0.019 and P=0.007, respectively). The patients with sarcopenia had a shorter disease-free survival time and overall survival time in comparison to patients without sarcopenia (P=0.025 and P=0.115, respectively). In conclusion, NACRT for distal bile duct cancer did not significantly affect the body composition, or the immunological or nutritional indices. Sarcopenia after NACRT was significantly associated with early recurrence in patients with distal bile duct cancer who received NACRT.

The prognostic impact of preoperative body composition in perihilar and intrahepatic cholangiocarcinoma

Cholangiocarcinoma (CCA) is a rare but highly aggressive malignancy of the biliary system. Although it is amenable to surgical resection in early disease, outcomes are frequently dismal. Here, we investigated the prevalence of body composition (BC) alterations and their prognostic role for surgical patients with intrahepatic (iCCA) and perihilar (pCCA) disease. Patients undergoing curative‐intent surgery for iCCA or pCCA between 2010 and 2019 at University Hospital Aachen were included. Axial computed tomography images were retrospectively assessed with a segmentation tool (3D Slicer) at the level of the third lumbar vertebra to determine lumbar skeletal muscle (SM) index, mean SM radiation attenuation, and visceral fat area. The related BC pathologies sarcopenia, myosteatosis, visceral obesity, and sarcopenic obesity were determined using previously described cutoffs. A total of 189 patients (86 with iCCA, 103 with pCCA) were included. Alterations of BC were highly prevalent in iCCA and pCCA, respectively: sarcopenia, 33% (28/86) and 39% (40/103); myosteatosis, 66% (57/86) and 66% (68/103); visceral obesity, 56% (48/86) and 67% (69/103); sarcopenic obesity, 11% (9/86) and 17% (17/103). Sarcopenia and myosteatosis did not have a significant prognostic role for disease‐free survival (DFS) and overall survival (OS). Patients with iCCA with sarcopenic obesity (n = 9) had significantly shorter OS than patients without sarcopenic obesity (n = 7; log‐rank p = 0.002; median OS, 11 months and 31 months; 1‐year mortality, 55.6% [5/9] and 22% [17/77]; 5‐year mortality, 88.9% [8/9] and 61% [47/77], respectively). In multivariable analysis, only tumor‐related risk factors remained prognostic for DFS and OS. Sarcopenic obesity may affect clinical outcomes after curative‐intent surgery for iCCA, indicating that imaging‐based analysis of BC may hold prognostic value for long‐term survival and could aid preoperative patient selection.

The effect of sarcopenic obesity and muscle quality on complications after DIEP-flap breast reconstruction

Introduction

The aim of this study was to evaluate whether sarcopenic obesity and muscle quality as expressed by skeletal muscle radiodensity (SMD) are associated to postoperative complications in women undergoing DIEP-flap breast reconstruction (BR).

Methods

All patients who underwent DIEP-flap BR at our tertiary center between 2010 and 2018 were asked to sign informed consent for the use of their electronic medical records and images. By outlining anatomical skeletal muscle contours on the preoperative abdominal CT-scan at lumbar level L3, SMD and skeletal muscle indices (SMI) were measured by two observers independently. Using logistic regression analyses, the association between sarcopenic obesity (BMI >25 & SMI <39), low SMD (<40HU), and Clavien-Dindo (CD) grade ≥ II complications was evaluated. In this way odds ratios (OR) and adjusted odds ratios (OR_adjusted) were provided.

Results

Out of the 103 patients included in this study, 36% had CD grade ≥ II complications within 30 days of surgery. Twenty patients (19%) suffered from sarcopenic obesity of whom eleven patients (55%) had CD grade ≥ II complications (OR = 2.7, p = 0.05). In a multivariate analysis, sarcopenic obesity was not significantly related to a higher complication rate (OR_adjusted = 2.2, p = 0.14) but women with SMD below average and those with prior radiotherapy had a higher risk for grade ≥ II complications (OR_adjusted = 2.9, p = 0.02 and OR_adjusted = 2.7, p = 0.02 respectively).

Conclusion

Below average SMD (<40HU) was found to be associated with the development of postoperative CD grade ≥ II complications in women undergoing DIEP-flap BR. Future research should evaluate whether improving SMD reduces the complication incidence in this patient group.

Relationship between BMI, CT-derived body composition and colorectal neoplasia in a bowel screening population

Introduction

Obesity is associated with an increased risk of colorectal cancer (CRC). Unlike the indirect measures such as BMI, CT-Body composition (CT-BC) allows for the assessment of both volume and distribution of adipose tissue. Therefore, the aim of this study was to examine the relationship between host characteristics, BMI, CT-BC measurements and the incidence of colorectal neoplasia.

Methods

Patients undergoing CT Colonography (CTC) as part of the Scottish Bowel Screening Programme, between July 2009 and February 2016, were eligible for inclusion. Data were collected including demographic data, clinicopathological variables and CT-BC measurements including skeletal muscle index (SMI), subcutaneous fat index (SFI) and visceral fat area (VFA). CTC, colonoscopy, and pathology reports were used to identify CRC incidence. Associations between demographic data, clinicopathological variables, CT-BC measurements, colorectal neoplasia and advanced colorectal neoplasia were analysed using univariate and multivariate binary logistics regression.

Results

286 patients met the inclusion criteria. Neoplasia was detected in 105 (37%) of the patients with advanced neoplasia being detected in 72 (69%) of patients. On multivariate analysis sex (p < 0.05) and high VFA (p < 0.001) remained independently associated with colorectal neoplasia. On multivariate analysis a high SFI (p < 0.01) remained independently associated with advanced colorectal neoplasia. BMI was not associated with either colorectal neoplasia or advanced colorectal neoplasia.

Conclusion

When directly compared to BMI, CT derived fat measurements were more closely associated with the degree of neoplasia in patients undergoing colorectal cancer screening. In patients investigated with CT colonography, CT adipose measures may stratify the risk and grade of neoplasia.

Impact of Baseline Muscle Mass and Myosteatosis on the Development of Early Toxicity During First-Line Chemotherapy in Patients With Initially Metastatic Pancreatic Cancer

Objectives

Although chemotherapy is the only treatment option for metastatic pancreatic cancer (PDAC), patients frequently encounter adverse events during chemotherapy leading deterioration of patients' quality of life and treatment interruption. We evaluated the role of baseline CT-assessed body composition in predicting early toxicity during first cycle of the first-line chemotherapy in patients with metastatic PDAC.

Methods

This retrospective study included 636 patients with initially metastatic PDAC who underwent first-line chemotherapy from January 2009 to December 2019. Chemotherapy regimen, baseline laboratory data, and body composition parameters acquired from baseline CT were obtained. The skeletal muscle index (SMI) was used to identify patients with a low muscle mass (SMI < 41 cm2/m2 for women, and < 43 cm2/m2 [body mass index < 25 cm/kg2] or < 53 cm2/m2 [body mass index ≥ 25 cm/kg2] for men), and myosteatosis was defined as low-attenuated muscle area divided by skeletal muscle area (LAMA/SMA index) ≥ 20%. Univariate and multivariable binary logistic regression analyses were performed using bootstrapping with 500 interactions to identify predictors of grade 3-4 toxicity and any treatment-modifying toxicity which led to a dose reduction, delayed administration, drug skip or discontinuation.

Results

During the first cycle of the first-line chemotherapy, grade 3-4 toxicity and treatment-modifying toxicity occurred in 160 patients (25.2%) and in 247 patients (38.8%), respectively. The presence of both low muscle mass and myosteatosis was significantly associated with the occurrence of both grade 3-4 toxicity (odd ratio [OR], 1.73; 95% confidence interval [CI], 1.14-2.63) and treatment-modifying toxicity (OR, 1.83; 95% CI, 1.26-2.66) whereas low muscle mass alone did not.

Conclusions

The presence of both low muscle mass and myosteatosis assessed on baseline CT may be used to predict early chemotherapy-related toxicity in patients with metastatic PDAC.

Low skeletal muscle mass and post-operative complications after surgery for liver malignancies: a meta-analysis

Purpose

To assess the influence of low skeletal muscle mass (LSMM) on post-operative complications in patients with hepatic malignancies grade (Clavien Dindo ≥ 3) undergoing resection.

Methods

MEDLINE, Cochrane, and SCOPUS databases were screened for associations between sarcopenia and major post-operative complications (≥ grade 3 according to Clavien-Dindo classification) after resection of different malignant liver tumors. RevMan 5.3 software was used to perform the meta-analysis. The methodological quality of the included studies was assessed according to the QUIPS instrument.

Results

The analysis included 17 studies comprising 3157 patients. Subgroup analyses were performed for cholangiocarcinoma (CCC), colorectal cancer (CRC) liver metastases, and hepatocellular carcinoma (HCC). LSMM as identified on CT was present in 1260 patients (39.9%). Analysis of the overall sample showed that LSMM was associated with higher post-operative complications grade Clavien Dindo ≥ 3 (OR 1.56, 95% CI 1.25–1.95, p < 0.001). In the subgroup analysis, LSMM was associated with post-operative complications in CRC metastases (OR 1.60, 95% CI 1.11–2.32, p = 0.01). In HCC and CCC sub-analyses, LSMM was not associated with post-operative complications in simple regression analysis.

Conclusion

LSMM is associated with major post-operative complications in patients undergoing surgery for hepatic metastases and it does not influence major post-operative complications in patients with HCC and CCC.

Development and validation of a grading system for assessing muscle mass phenotype using mid-upper arm muscle area and handgrip strength in patients with incurable cancer

BACKGROUND

This study aimed to develop and validate a distinct method to evaluate muscle mass phenotype in patients with incurable cancer based on a combination of mid-upper arm muscle area (MUAMA) and handgrip strength (HGS).

METHODS

This prospective cohort study was conducted with patients with incurable cancer who were enrolled at the palliative care unit of a cancer institute. The 1,660 patients were randomized into two data sets: training (70%; n = 1162), used to determine the muscle mass phenotype groups, derived from a combination of MUAMA and HGS cutoff points related to 180-days mortality; and validation (30%; n = 498), used to evaluate the relationship of the proposed muscle phenotype grading system with performance status, body composition, nutrition status, and mortality.

RESULTS

The training data set resulted in three distinct groups formed by combining the cutoff points of MUAMA and HGS, with the best muscle mass phenotype being group 1, the group with any impairment of muscle mass being the 2, and the worst muscle mass phenotype being group 3. In the validation data set, lower performance status (both sexes p < 0.001), worse skeletal muscle index (both sexes p < 0.001), muscle radiodensity (men, p = 0.001; women, p = 0.008), and nutritional status (men, p = 0.003; women, p < 0.001) were observed as MUAMA and HGS values diminished. Patients in group 3 presented significantly higher risk of 180-day mortality (both sexes p < 0.001).

CONCLUSION

The muscle mass phenotype grading system proved to be able to identify patients with lower performance status, worse body composition measurements and nutritional status, and higher risk of death in 180 days.

Clinical Relevance of Myopenia and Myosteatosis in Colorectal Cancer

Sarcopenia was initially described as a decrease in muscle mass associated with aging and subsequently also as a consequence of underlying disease, including advanced malignancy. Accumulating evidence shows that sarcopenia has clinically significant effects in patients with malignancy, including an increased risk of adverse events associated with medical treatment, postoperative complications, and a poor survival outcome. Colorectal cancer (CRC) is one of the most common cancers worldwide, and several lines of evidence suggest that preoperative sarcopenia negatively impacts various outcomes in patients with CRC. In this review, we summarize the current evidence in this field and the clinical relevance of sarcopenia in patients with CRC from three standpoints, namely, the adverse effects of medical treatment, postoperative infectious complications, and oncological outcomes.

Sarcopenia as an Independent Risk Factor for Specific Cancers: A Propensity Score-Matched Asian Population-Based Cohort Study

Purpose: Whether preexisting sarcopenia is an independent risk factor for cancer incidence remains unclear. Therefore, we performed this propensity score (PS)-matched (PSM) population-based cohort study to compare the incidence rate ratios (IRRs) of specific cancers between patients with and without sarcopenia. Patients and Methods: The patients were categorized into two groups according to the presence or absence of sarcopenia, matched at a 4:1 ratio. Results: PS matching yielded a final cohort of 77,608 patients (15,527 in the sarcopenia and 62,081 nonsarcopenia groups) eligible for further analysis. In our multivariate Cox regression analysis, compared with the nonsarcopenia group, the adjusted hazard ratio (aHR; 95% confidence interval (CI)) for cancer risk in the sarcopenia group was 1.277 (1.10 to 1.36; p < 0.001). Furthermore, the adjusted IRRs (95% CIs) for sarcopenia patients were pancreatic cancer 3.77 (1.79 to 4.01), esophageal cancer 3.38 (1.87 to 4.11), lung cancer 2.66 (1.15 to 2.90), gastric cancer 2.25 (1.54 to 3.23), head and neck cancer 2.15 (1.44 to 2.53), colorectal cancer 2.04 (1.77 to 2.30), hepatocellular carcinoma 1.84 (1.30 to 2.36), breast cancer 1.56 (1.12 to 1.95), and ovarian cancer 1.43 (1.10 to 2.29), respectively. Conclusions: Sarcopenia might be a significant cancer risk factor for lung, colorectal, breast, head and neck, pancreas, gastric, esophageal, and ovarian cancer, as well as hepatocellular carcinoma.

Prognostic Impact of Postoperative Loss of Skeletal Muscle Mass in Patients Aged 70 Years or Older with Esophageal Cancer

BACKGROUND

The number of patients with esophageal cancer aged ≥ 70 years with a poor prognosis is increasing. In general patients with esophageal cancer, postoperative loss of skeletal muscle mass (SMM) is a prognostic factor. This study was designed to investigate the prognostic impact of postoperative loss of SMM in patients aged ≥ 70 years with esophageal cancer.

METHODS

This study was a single-center, retrospective cohort study. Patients with esophageal cancer who underwent R0 esophagectomy between 2016 and 2020 were included. The percentage postoperative loss of skeletal muscle mass index (SMI%) was calculated using computed tomography images before and at 4 ± 2 months after surgery.

RESULTS

The number of subjects in the ≥ 70-year and < 70-year age groups was 166 and 218, respectively. The median SMI% was 5% in all patients; thus, 5% was defined as the cutoff point to define major loss of SMI. Major loss of SMI impacted 3-year overall survival (OS) in the ≥ 70-year age group, independent of age, sex, clinical stage, pathological T and N factors, Charlson comorbidity index, and length of hospital stay (adjusted hazard ratio [HR]: 4.400; 95% confidence interval: 1.202-16.105; P = 0.025). The adjusted HR of major loss of SMI in the ≥ 70-year age group was higher than in the < 70-year age group (adjusted HR: 4.400 vs. 2.388, respectively).

CONCLUSIONS

Postoperative loss of SMI in patients with esophageal cancer aged ≥ 70 years more strongly impacted 3-year OS than in patients aged < 70 years.

Sarcopenia in Patients With Spinal Metastasis: A Systematic Review and Meta-Analysis of Retrospective Cohort Studies

Background

As a metastasis cancer that happens up to 70% of the cancer patients, spinal metastasis is drawing attention for its significant impairment to health. There exist several predictive models designed to estimate mortality in spinal metastasis patients but they are reported with limited accuracy. In recent years, some retrospective cohort studies have been carried out to associate sarcopenia with mortality in spinal metastasis.

Introduction

As a risk factor leading to adverse events in many diseases, sarcopenia was considered to significantly impact on patients with spinal metastasis in mortality by some scientists. We aimed to look through the current evidence and use statistic measures to value the role of sarcopenia in spinal metastasis. In this study, we are going to perform a systematic review and meta-analysis of available retrospective cohort studies where sarcopenia is assessed for outcomes in spinal metastasis patients.

Methods

On October 7, 2021, we performed a search in PubMed, Embase, and the Cochrane Library. We set no restrictions on language, date or areas. Results were expressed as hazard ratio (HR) or odds ratio (OR) with 95% CI by random effects model. Sensitivity analyses were performed to explore sources of heterogeneity and stability of results.

Results

Of the 4,196 papers screened, 10 retrospective cohort studies were included, with a total of 1,674 patients. Results showed that sarcopenia was associated with higher overall mortality (OR, 1.60; 95% CI 1.35–1.90) and lower overall survival (HR, 2.08; 95% CI 1.55–2.80). The sensitivity analysis proved the stability of results in terms of publication years, region, time of diagnosis, sample size, female rate, measurement and follow up period.

Conclusions

Sarcopenia is a robust indicator of mortality in spinal metastasis patients and it might be applied to decision-making tools to assess survival probability and adjust the extent of treatment, while a lack of higher level of evidence is existing.

Systematic Review Registration

PROSPERO CRD42021283348.

Sarcopenia Prevalence and Risk Factors among Residents in Aged Care

The aim of this study was to investigate the prevalence of sarcopenia and associated risk factors among older adults living in three residential aged care (RAC) facilities within Auckland, New Zealand. A total of 91 older adults (63% women, mean age ± SD; 86.0 ± 8.3 years) were recruited. Using the European Working Group on Sarcopenia in Older People criteria, sarcopenia was diagnosed from the assessment of: appendicular skeletal muscle mass/height², using an InBody S10 body composition analyser and a SECA portable stadiometer or ulna length to estimate standing height; grip strength using a JAMAR handheld dynamometer; and physical performance with a 2.4-m gait speed test. Malnutrition risk was assessed using the Mini Nutrition Assessment–Short Form (MNA-SF). Most (83%) of residents were malnourished or at risk of malnutrition, and 41% were sarcopenic. Multivariate regression analysis showed lower body mass index (Odds Ratio (OR) = 1.4, 95% CI: 1.1, 1.7, p = 0.003) and lower MNA-SF score (OR = 1.6, 95% CI: 1.0, 2.4, p = 0.047) were predictive of sarcopenia after controlling for age, level of care, depression, and number of medications. Findings highlight the need for regular malnutrition screening in RAC to prevent the development of sarcopenia, where low weight or unintentional weight loss should prompt sarcopenia screening and assessment.