Impact of preoperative skeletal muscle mass and physical performance on short-term and long-term postoperative outcomes in patients with esophageal cancer after esophagectomy

Prognostic value of sarcopenia and myosteatosis alterations on survival outcomes for esophageal squamous cell carcinoma before and after radiotherapy

OBJECTIVE

We assessed the impact and prognostic significance of alterations in muscle quality and quantity (myosteatosis and sarcopenia, respectively) in patients with esophageal cancer treated with radiotherapy (RT).

METHODS

We retrospectively pooled 258 patients with esophageal squamous cell cancer who underwent RT. Myosteatosis and sarcopenia were determined based on the skeletal muscle index derived from the muscle area and attenuation at the L3 level from computed tomography images. Subgroups were formed as 2 subgroups of non-sarcopenia/myosteatosis and sarcopenia/myosteatosis (with or without other muscle status) at either timepoint of RT, 3 subgroups of only-sarcopenia, only myosteatosis (without other muscle status), and the co-presence of sarcopenia and myosteatosis at either timepoint of RT, as well as 4 subgroups of continuous sarcopenia/myosteatosis, developed sarcopenia/myosteatosis, reduced sarcopenia/myosteatosis and non-sarcopenia/myosteatosis according to alterations of muscle status at both timepoints of RT. Overall survival (OS) was compared. Univariate and multivariate analyses based on Cox regression identified independent risk factors for prognosis.

RESULTS

Either pre- or post-RT, patients with sarcopenia and myosteatosis (with or without other muscle status) had poor OS. Patients with only myosteatosis (without other muscle status) showed the best OS (1352 days pre-RT vs. 1648 days post-RT), while patients with concurrent myosteatosis and sarcopenia had the worst OS (907 days pre-RT vs. 706 days post-RT). The ascending order of OS for sarcopenia alterations was as follows: continuous sarcopenia (1093 days), non-sarcopenia (1740 days), developed sarcopenia (2187 days), and reduced sarcopenia (2208 days) (P = 0.002). The ascending order of OS for myosteatosis alterations was ranked as follows: continuous myosteatosis (1165 days), reduced myosteatosis (1275 days), developed myosteatosis (1783 days), and non-myosteatosis (1942 days) (P = 0.061). Univariate and multivariate Cox regression analyses revealed that increased age, longer tumor length, developed myosteatosis, and continuous myosteatosis were independent prognostic factors for OS.

CONCLUSIONS

Muscle mass status at presentation and alterations in patients with esophageal cancer before and after RT should be considered prognostic indicators.

Essential updates 2022/2023: Recent advances in perioperative management of esophagectomy to improve operative outcomes

In the era of minimally invasive surgery, esophagectomy remains a highly invasive procedure with a high rate of postoperative complications. Preoperative risk assessment is essential for planning esophagectomy in patients with esophageal cancer, and it is crucial to implement evidence-based perioperative management to mitigate these risks. Perioperative support from multidisciplinary teams has recently been reported to improve the perioperative nutritional status and long-term survival of patients undergoing esophagectomy. Intraoperative management of anesthesia and fluid therapy also significantly affects short-term outcomes after esophagectomy. In this narrative review, we outline the recent updates in the perioperative management of esophagectomy, focusing on preoperative risk assessment, intraoperative management, and perioperative support by multidisciplinary teams to improve operative outcomes.

Global Leadership Initiative in Sarcopenia (GLIS)-defined sarcopenia increases the mortality of esophageal cancer patients after esophagectomy: A Chinese real-world cohort study

OBJECTIVES

To assess the impact of the definition of the Global Leadership Initiative in Sarcopenia (GLIS) on mortality in esophageal cancer (EC) patients, postesophagectomy, within a Chinese cohort and to validate the effectiveness of a new GLIS framework in oncology.

METHODS

We performed an observational real-world cohort study in a single center at Daping Hospital of the Army Medical University in China, spanning from December 2014 to July 2022. We used the combined definition of muscle mass and muscle strength in a new GLIS framework for the diagnosis of sarcopenia. Potential covariates were identified through univariate and multivariate analyses. The association between GLIS-defined sarcopenia and mortality was estimated using Kaplan-Meier curves and Cox models. We also conducted stratified analyses to assess the stability of multivariable Cox models.

RESULTS

A total of 520 EC patients were included in the study, with a median follow-up of 48.7 months. A total of 229 EC patients (44.0%) were identified with GLIS-defined sarcopenia. Patients with GLIS-defined sarcopenia had significantly worse overall survival in Kaplan-Meier curves (log-rank P = 0.015). Age; sex; tumor, node, metastasis stage; blood glucose; bleeding volume in operation; and operating time were introduced as covariates in a fully adjusted Cox model. Multivariable-adjusted Cox models revealed that GLIS-defined sarcopenia was an independent prognostic factor for EC patients postesophagectomy (hazard ratio, 1.87, 95% confidence interval, 1.28-2.74, P = 0.001). Stratified analyses confirmed the stability of the relationship between GLIS-defined sarcopenia and mortality in EC patients.

CONCLUSIONS

GLIS-defined sarcopenia is prevalent among Chinese EC patients and is linked to increased mortality risk postesophagectomy. This finding offers compelling evidence and serves as a valuable reference for the establishment of an operational definition of GLIS sarcopenia.

Effect of Perioperative Physical Activity on Skeletal Muscle Loss 6 Months After Esophageal Cancer Surgery

Background/Aim

Sarcopenia contributes to a poor prognosis in patients with esophageal cancer; thus, any clinical support that prevents loss of skeletal muscle mass preoperatively and postoperatively should be actively investigated. This study aimed to evaluate physical activity during the perioperative period and its impact on postoperative skeletal muscle mass.

Patients and Methods

Sixty-two patients who underwent esophagostomy at the Hamamatsu University School of Medicine between 2019 and 2023 were evaluated. The physical activity (measured by the step count) of patients scheduled for esophagectomy was assessed preoperatively using a fitness tracker. The percentage change in skeletal muscle mass index (SMI) was calculated preoperatively and 6 months postoperatively. Factors associated with decreased SMI 6 months after esophagectomy were analyzed using multivariate analysis.

Results

The median decrease in SMI was -6.2%. Multivariate analysis revealed that factors associated with the reduction of SMI were age >69 years [odds ratio (OR)=7.21, 95% confidence interval (CI)=1.36-38.19, p=0.020], preoperative step count <7,800 steps/day (OR=5.17, 95% CI=1.38-19.33, p=0.015), and postoperative step count <2,400 steps/day (OR=3.55, 95% CI=1.01-12.45, p=0.048).

Conclusion

A low perioperative step count and older age were significant risk factors for skeletal muscle loss in patients with esophageal cancer undergoing surgery. For patients with a low number of steps in the perioperative period or for older patients, interventions to increase the number of steps may prevent skeletal muscle loss.

Clinical impact of postoperative changes in body composition on long-term outcomes in patients with esophageal cancer

BACKGROUND & AIMS

This study aimed to investigate the temporal changes in body composition following esophagectomy in patients with esophageal cancer using bioelectrical impedance analysis and to assess the prognostic implications of these changes.

METHODS

Our study included 528 patients who underwent esophagectomy and preoperative body composition measurements between January 2013 and June 2020. Postoperative body composition was measured in 493 patients at discharge as follows: 184 at 1 month, 144 at 2 months, 143 at 3 months, 103 at 6 months, 58 at 9 months, and 78 at 12 months.

RESULTS

Body weight (BW) continuously decreased until the 6 postoperative months (POMs), reaching -11.5% compared with preoperative levels. Subsequently, almost no change was observed at 12 POMs. Skeletal muscle mass (SMM) decreased until 3 POMs but gradually recovered after 3 POMs. Conversely, body fat mass (BFM) consistently decreased over time post-esophagectomy. The patients were categorized into moderate (>-10%) and severe (≤-10%) groups based on % BW, % SMM, and % BFM losses at 3 POMs. Severe SMM loss at 3 POMs correlated with reduced overall survival (OS) (3-year OS: 85.9% in moderate vs. 75.1% in severe, p = 0.035). BFM loss was associated with reduced recurrence-free survival (3-year RFS: 83.3% in moderate vs. 62.0% in severe, p = 0.011). Multivariate analysis identified pStages Ⅲ and Ⅳ, % SMM loss ≤ -10%, and % BFM loss ≤ -10% as independent factors for worse OS.

CONCLUSION

Post-esophagectomy, distinct temporal changes in BW, SMM, and BFM are observed. Significant reductions in SMM and BFM 3 POMs indicate a poor long-term prognosis.

Impact of the serum creatinine and cystatin C ratio for prediction of sarcopenia and prognosis in biliary tract cancer

BACKGROUND

Sarcopenia is a poor prognostic factor in cancer patients. In recent years, there have been reports that serum creatinine and cystatin C (Cr/CysC) ratio is associated with sarcopenia. However, the prognostic value of the Cr/CysC ratio in biliary tract cancer is unclear. We evaluated the impact of the Cr/CysC ratio on sarcopenia and prognosis in biliary tract cancer.

METHODS

We retrospectively reviewed the records of 190 patients with biliary tract cancer who had undergone surgical resection from January 2017 to March 2023. Frozen serum samples collected at the time of surgery were used to measure CysC. We calculated the Cr/CysC ratio and investigated the relationship with sarcopenia and the prognostic significance.

RESULTS

We calculated the cutoff value of the Cr/CysC ratio for low skeletal muscle index (SMI) (< 42 cm2/m2 for males and < 38 cm2/m2 for females). The optimal cutoff value of the Cr/CysC ratio was 0.848. The low Cr/CysC ratio group was significantly associated with higher preoperative CRP and lower albumin, lower SMI, lower handgrip strength, and higher intramuscular adipose tissue content. In multivariate analysis, patients with a low Cr/CysC ratio showed poorer overall survival (hazard ratio 2.60, 95% confidence interval 1.07-6.29, p = 0.033), which was significantly worse than in those with a high Cr/CysC ratio.

CONCLUSIONS

In patients with biliary tract cancer, the Cr/CysC ratio showed weak correlation with sarcopenic indicators. However, the Cr/CysC ratio could be strong prognostic factor in biliary tract cancer.

Correlation between sarcopenia and esophageal cancer: a narrative review

BACKGROUND

In recent years, the research on the relationship between sarcopenia before and after the treatment of esophageal cancer, as well as its impact on prognosis of esophageal cancer, has increased rapidly, which has aroused people's attention to the disease of patients with esophageal cancer complicated with sarcopenia. This review examines the prevalence of sarcopenia in patients with esophageal cancer, as well as the relationship between sarcopenia (before and after surgery or chemotherapy) and prognosis in patients with esophageal cancer. Moreover, we summarized the potential pathogenesis of sarcopenia and pharmacologic and non-pharmacologic therapies.

METHODS

A narrative review was performed in PubMed and Web of Science using the keywords ("esophageal cancer" or "esophageal neoplasm" or "neoplasm, esophageal" or "esophagus neoplasm" or "esophagus neoplasms" or "neoplasm, esophagus" or "neoplasms, esophagus" or "neoplasms, esophageal" or "cancer of esophagus" or "cancer of the esophagus" or "esophagus cancer" or "cancer, esophagus" or "cancers, esophagus" or "esophagus cancers" or "esophageal cancer" or "cancer, esophageal" or "cancers, esophageal" or "esophageal cancers") and ("sarcopenia" or "muscular atrophy" or "aging" or "senescence" or "biological aging" or "aging, biological" or "atrophies, muscular" or "atrophy, muscular" or "muscular atrophies" or "atrophy, muscle" or "atrophies, muscle" or "muscle atrophies"). Studies reporting relationship between sarcopenia and esophageal cancer were analyzed.

RESULTS

The results of the review suggest that the average prevalence of sarcopenia in esophageal cancer was 46.3% ± 19.6% ranging from 14.4 to 81% and sarcopenia can be an important predictor of poor prognosis in patients with esophageal cancer. Patients with esophageal cancer can suffer from sarcopenia due to their nutritional deficiencies, reduced physical activity, chemotherapy, and the effects of certain inflammatory factors and pathways. When classic diagnostic values for sarcopenia such as skeletal muscle index (SMI) are not available clinically, it is also feasible to predict esophageal cancer prognosis using simpler metrics, such as calf circumference (CC), five-count sit-up test (5-CST), and six-minute walk distance (6MWD).

CONCLUSIONS

Identifying the potential mechanism of sarcopenia in patients with esophageal cancer and implementing appropriate interventions may hold the key to improving the prognosis of these patients.

The impact of sarcopenia on esophagectomy for cancer: a systematic review and meta-analysis

BACKGROUND

Esophagectomy is the gold-standard treatment for locally advanced esophageal cancer but has high morbimortality rates. Sarcopenia is a common comorbidity in cancer patients. The exact burden of sarcopenia in esophagectomy outcomes remains unclear. Therefore, this systematic review and meta-analysis were performed to establish the impact of sarcopenia on postoperative outcomes of esophagectomy for cancer.

METHODS

We performed a systematic review and meta-analysis comparing sarcopenic with non-sarcopenic patients before esophagectomy for cancer (Registration number: CRD42021270332). An electronic search was conducted on Embase, PubMed, Cochrane, and LILACS, alongside a manual search of the references. The inclusion criteria were cohorts, case series, and clinical trials; adult patients; studies evaluating patients with sarcopenia undergoing esophagectomy or gastroesophagectomy for cancer; and studies that analyze relevant outcomes. The exclusion criteria were letters, editorials, congress abstracts, case reports, reviews, cross-sectional studies, patients undergoing surgery for benign conditions, and animal studies. The meta-analysis was synthesized with forest plots.

RESULTS

The meta-analysis included 40 studies. Sarcopenia was significantly associated with increased postoperative complications (RD: 0.08; 95% CI: 0.02 to 0.14), severe complications (RD: 0.11; 95% CI: 0.04 to 0.19), and pneumonia (RD: 0.13; 95% CI: 0.09 to 0.18). Patients with sarcopenia had a lower probability of survival at a 3-year follow-up (RD: -0.16; 95% CI: -0.23 to -0.10).

CONCLUSION

Preoperative sarcopenia imposes a higher risk for overall complications and severe complications. Besides, patients with sarcopenia had a lower chance of long-term survival.

Association between preoperative diagnosis of sarcopenia and postoperative pneumonia in resectable esophageal squamous cell carcinoma patients: a retrospective cohort study

Background

Postoperative outcomes for patients suffering from resectable esophageal squamous cell carcinoma (ESCC) are related to sarcopenia. In patients with resectable ESCC, this study investigated the link between sarcopenia and postoperative pneumonia.

Methods

The McKewon procedure was the only one used to treat resectable ESCC patients from January 2018 to December 2021 in this retrospective analysis. Sarcopenia was assessed using skeletal muscles at L3 and planning CT scans. It was defined when PMI was below 6.36 cm²/m² and 3.92 cm²/m² for men and women, separately. Analyses of multivariate and univariate logistic regression were applied for identifying the risk factors for postoperative pneumonia.

Results

The study included 773 patients with resectable ESCC in total. Sarcopenia was an independent risk factor for postoperative pneumonia in individuals with resectable ESCC based on univariate and multivariate analysis (P < 0.05). The stratified analysis indicated that neither of the clinical outcomes in the logistic regression model were affected by gender, age, BMI, smoking, or pre-albumin (P for interaction > 0.006).

Conclusion

Following the McKewon procedure, patients with resectable ESCC who were sarcopenic had a higher postoperative pneumonia rate. To prevent the development of postoperative pneumonia during the perioperative period, it may be important to control the incidence of sarcopenia.

A Novel Frailty Grade Combined with Cachexia Index and Osteopenia in Esophagectomy

BACKGROUNDS

The optimal method for evaluating frailty grade in patients with cancer has not been established in patients undergoing esophagectomy for esophageal cancer. This study aimed to clarify the impact of cachexia index (CXI) and osteopenia on survival in esophagectomized patients for esophageal cancer to develop frailty grade for risk stratification of the prognosis.

METHODS

A total of 239 patients who underwent esophagectomy were analyzed. CXI was calculated as follows: skeletal muscle index × serum albumin/neutrophil-to-lymphocyte ratio. Meanwhile, osteopenia was defined as below the cutoff value of bone mineral density (BMD) calculated by the receiver operating characteristic curve. We evaluated the average Hounsfield unit within a circle in the lower midvertebral core of the 11th thoracic vertebra on preoperative computed tomography as BMD.

RESULTS

Multivariate analysis revealed that low CXI (Hazard ratio [HR], 1.95; 95% confidence interval [CI], 1.25-3.04) and osteopenia (HR, 1.86; 95% CI, 1.19-2.93) were independent prognostic factors for overall survival. Meanwhile, low CXI (HR, 1.58; 95% CI, 1.06-2.34) and osteopenia (HR, 1.57; 95% CI, 1.05-2.36) were also significant prognostic factors for relapse-free survival. A frailty grade combined with CXI and osteopenia stratified into four groups by their prognosis.

CONCLUSIONS

Low CXI and osteopenia predict poor survival in patients undergoing esophagectomy for esophageal cancer. Furthermore, a novel frailty grade combined with CXI and osteopenia stratified the patients into four groups according to their prognosis.