Skeletal muscle mass is associated with severe dysphagia in cancer patients

Prevalence and prognosis of cachexia according to the Asian Working Group for Cachexia criteria in sarcopenic dysphagia: A retrospective cohort study

OBJECTIVE

The aim to examine the prevalence and prognosis of cachexia according to the Asian Working Group for Cachexia (AWGC) criteria in patients with sarcopenic dysphagia.

METHODS

A retrospective cohort study was conducted with 271 patients diagnosed with sarcopenic dysphagia out of 467 patients enrolled in the Japanese sarcopenic dysphagia database. Cachexia was diagnosed by the AWGC criteria. The AWGC criteria includes chronic diseases, either or both weight loss (2% or more over 3-6 mo) or low BMI (<21 kg/m2), and at least one of the following: anorexia, decreased grip strength (<28 kg in men and <18 kg in women), or elevated C-reactive protein levels (>0.5 mg/dL). Outcomes were death, swallowing function as assessed by the Food Intake LEVEL Scale (FILS), and activities of daily living as assessed by the Barthel Index (BI) at follow-up.

RESULTS

The mean age was 84 (±8) y; 152 (56%) were female, and 97 (36%) had cachexia. In univariate analysis, death was significantly more common in the cachexia group (15% versus 2%, P ≤ 0.001). Logistic regression analysis showed that cachexia was independently associated with death (odds ratio: 3.557, 95% confidence interval: 1.010, 12.529). No significant differences were found in the presence or absence of cachexia in the FILS (7 versus 8, P = 0.849) and BI (55 versus 52.5, P = 0.892).

CONCLUSIONS

Cachexia was found in 36% of patients with sarcopenic dysphagia, and death was significantly higher in cachexia.

Association between adductor pollicis muscle thickness and low skeletal muscle mass index in community-dwelling older women undergoing outpatient rehabilitation

OBJECTIVE

The performance of sarcopenia diagnosis using adductor pollicis muscle thickness (APMT) has been reported. However, the relationship between APMT and low skeletal muscle mass index (SMI) is unclear. The purpose of this study is to investigate the relationship between APMT and low SMI and APMT performance to diagnose low SMI in community-dwelling older women undergoing outpatient rehabilitation.

METHODS

This study included 65 older women (mean age: 86.4 years). Subjects were received outpatient rehabilitation one to three times a week. The main outcomes were low SMI as diagnosed using the Asian working group for sarcopenia 2019 and APMT. Logistic regression analysis was performed with low SMI as the dependent variable, APMT, and propensity score calculated using age, sex, number of medications, and updated Charlson comorbidity index as the independent variable. A receiver operating characteristic (ROC) curve of APMT for low SMI was created. A cut-off value was calculated using the Youden index.

RESULTS

Among the 65 subjects, 45 (69.2 %) had low SMI. The results of the logistic regression analysis showed a significant association between APMT and low SMI (odds ratio: 0.482 {95 % confidence interval [CI]: 0.313-0.744}). The cut-off value of APMT calculated from the ROC curve was 13 mm. The sensitivity and specificity of this cut-off value were 0.800 (95 % CI: 0.654-0.904) (36 out of 45 subjects) and 0.850 (95 % CI: 0.621-0.968) (17 out of 20 subjects), respectively. The positive predictive value, negative predictive value, and area under the curve were 0.923 (95 % CI: 0.791-0.984), 0.654 (95 % CI: 0.443-0.828), and 0.843 (95 % CI: 0.731-0.955), respectively. The APMT cut-off value of 13 mm is good to identify low SMI.

CONCLUSIONS

The results of this study show that APMT is associated with low SMI. Furthermore, the cut-off value of APMT for diagnosing low SMI was 13 mm. The APMT cut-off value of 13 mm is good to identify low SMI. Our findings indicate that measuring APMT is useful for diagnosing low SMI in community-dwelling older women undergoing outpatient rehabilitation.

Long-term impact of sarcopenia in older patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis

Background

Sarcopenia is an inevitable problem in older patients. After gastrectomy, patients often have an inadequate dietary intake and easily fall into sarcopenia. However, the impact of preoperative sarcopenia on long-term outcomes after gastrectomy has not been analyzed.

Methods

A systematic review was conducted for all relevant articles identified on PubMed, the Cochrane Library, Web of Science, and ClinicalTrials.gov until April 2023. Adjusted hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the fixed or random effects model according to the heterogeneity. The Newcastle-Ottawa Scale was used to quantify study quality.

Results

Seven studies involving 1,831 patients aged ≥65 years who underwent gastrectomy for gastric cancer were analyzed. Four hundred twelve patients (22.5%) were diagnosed with sarcopenia. The analysis showed that preoperative sarcopenia was significantly associated with poor overall survival (OS) (HR =1.93; 95% CI:1.60-2.34; P<0.001). Two of the included studies also showed that preoperative sarcopenia was significantly correlated with disease-related survival: one with disease-specific survival (DSS) (HR =4.00; 95% CI: 1.20-13.3, P=0.024) and the other with non-cancer specific survival (HR =3.27; 95% CI: 1.61-6.67; P=0.001). Furthermore, sarcopenic patients experienced more severe complications than non-sarcopenic patients (OR =1.80; 95% CI: 1.10-2.95; P=0.019).

Conclusions

This meta-analysis suggested that preoperative sarcopenia is useful as a prognostic factor of impaired OS in older patients after gastrectomy. Preoperative evaluation and intervention for skeletal muscle loss should be considered. Further studies of sarcopenic impact on disease-related survival are required.

Temporalis and masseter muscle thickness as predictors of post-stroke dysphagia after endovascular thrombectomy

PURPOSE

Post-stroke dysphagia (PSD) is a common sequela of stroke. Given the association between dysphagia and sarcopenia, we aimed to investigate the association between PSD and temporal muscle thickness (TMT) and masseter muscle thickness (MMT) following endovascular thrombectomy (EVT) in patients with large-vessel occlusion (LVO).

METHODS

This retrospective cohort study included hospitalized patients with LVO stroke who underwent EVT between January 1, 2018, and October 31, 2022. TMT and MMT were measured using brain computed tomography (CT) angiography. The correlation between relevant clinicodemographic factors and both TMT and MMT was examined. The relationship between each of two parameters (TMT and MMT) and PSD, which was defined as the retention of the nasogastric (NG) tube at 4 and 12 weeks, was evaluated in adjusted logistic regression models.

RESULTS

Among the 148 participants, the mean TMT and MMT was 5.9 ± 1.6 and 11.2 ± 2.3 mm, respectively. Lower age, male sex, higher body mass index (BMI), higher albumin levels, and a lower initial National Institute of Health Stroke Scale (NIHSS) score were associated with higher TMT and MMT (p < 0.05). In the logistic regression analysis adjusted for age, sex, BMI, serum albumin, and NIHSS score, lower TMT and MMT significantly correlated with PSD at weeks 4 and 12 (p < 0.001).

CONCLUSION

TMT and MMT are associated with age, sex, BMI, albumin, and the initial NIHSS score. Both TMT and MMT are independent indicators of post-EVT PSD in stroke patients and serve as reliable predictors of NG removal.

Negative impact of computed tomography-based low skeletal muscle mass on swallowing recovery in patients with post-stroke dysphagia

OBJECTIVES

Dysphagia due to stroke has a high prevalence, and evaluating the swallowing function of dysphagia and promoting oral intake is essential in patients with stroke. The psoas muscle mass index（cm2/height2（m2））, calculated by the psoas muscle area at the L3 level via abdominal computed tomography （CT）, can predict the development of dysphagia. However, knowledge about the impact of CT-based skeletal muscle mass on swallowing recovery, remains unknown. Therefore, we investigated whether CT-based low skeletal muscle mass impacted swallowing recovery.

METHODS

A retrospective cohort study was conducted on patients with post-stroke dysphagia who underwent acute treatments along with a videofluoroscopic swallowing study（VFSS）. Swallowing recovery was identified as the improvement of the Functional Oral Intake Scale （FOIS） from the time of VFSS to discharge（observational period: ObPd）. The psoas muscle mass index's cut-off values for low skeletal muscle mass were 3.74 cm2/m2 and 2.29 cm2/m2 for men and women respectively.

RESULTS

There were 53 subjects （36 male, median age 73.9）. The median during the ObPd was 26 days, and the median days from onset to admission and admission to VFSS were 0 and 18, respectively. Sixteen patients had low skeletal muscle mass. The median improvement of FOIS during the ObPd was 2, and the median length of hospital stay was 51 days. In the stepwise multiple linear regression analysis for the improvement of FOIS during the ObPd, low skeletal muscle mass （β - 0.245; 95% confidence interval - 2.248 to - 0.127; p = 0.029） was a significant factor, even adjusted for serum albumin at admission, disturbance of consciousness at VFSS, FOIS at VFSS, and aspiration during VFSS.

CONCLUSION

CT-based low skeletal muscle mass negatively impacted swallowing recovery during the ObPd in patients with post-stroke dysphagia.

Oropharyngeal dysphagia and cachexia: Intertwined in head and neck cancer

BACKGROUND

This study aims to investigate the relationship between cancer cachexia and oropharyngeal dysphagia (OD) in patients with head and neck cancer (HNC) prior to chemoradiotherapy or bioradiotherapy (CRT/BRT).

METHODS

A prospective cohort study with patients with HNC undergoing CRT/BRT (2018-2021) was conducted. Body composition and skeletal muscle function were evaluated using bioelectrical impedance analysis, handgrip strength, and the short physical performance battery (SPPB). The M. D. Anderson Dysphagia Inventory (MDADI), Eating Assessment Tool (EAT)-10 questionnaire, and patient characteristics were collected. A standardized videofluoroscopic swallowing study was offered to patients.

RESULTS

Sixty-six patients were included. Twenty-six patients scored EAT-10 ≥ 3 and seventeen were cachectic. ACE-27 score >1, cachexia, abnormal SPPB-derived repeated chair-stand test, lower MDADI scores, and higher overall stage grouping showed potential predictive value (p ≤ 0.10) for EAT-10 ≥ 3. Using multivariable regression analysis, only cachexia remained a significant predictor of EAT-10 ≥ 3 (HR 9.000 [95%CI 2.483-32.619], p = 0.001).

CONCLUSION

Cachexia independently predicted the presence of patient-reported OD.

Associations of Trunk Muscle Mass and Muscle Quality Indicators with Self-Reported Dysphagia in Older Inpatients

Recent studies have correlated dysphagia with ultrasound-measured quadriceps muscle mass and quality. Computed tomography (CT) is more precise than ultrasound for estimating muscle mass and quality. We aimed to investigate the possible associations of chest CT-determined trunk muscle mass and quality with dysphagia. A cross-sectional study. Older inpatients in a geriatric department of a university hospital. Self-reported dysphagia was determined by the Dysphagia Handicap Index. Unenhanced chest CT images were segmented to calculate skeletal muscle area (SMA) and intermuscular adipose tissue (IMAT). Skeletal muscle index (SMI) was calculated via SMA/ height squared. The percentage of IMAT (IMAT%) was calculated by IMAT% = IMAT/ (SMA + IMAT) × 100%. Mimics software was applied to calculate the mean skeletal muscle radio density (SMD).The semiquantitative food frequency method, the Barthel Index (BI), and the Mini Nutritional Assessment Short-Form (MNA-SF) were used to evaluate energy intake, activities of daily living, and nutrition status, respectively. Among the 212 participants (mean age: 84 years), 89 (42%) had self-reported dysphagia. After adjustment for age, nutrition status, energy intake, and other confounders, the SMI (adjusted OR 0.91, 95% CI 0.86, 0.96) was negatively associated with dysphagia, whereas the IMAT (adjusted OR 1.08, 95% CI 1.01, 1.16) and the IMAT% (adjusted OR 1.10, 95% CI 1.04,1.17) were positively associated with dysphagia. However, the SMD (adjusted OR 0.99, 95% CI 0.94, 1.05) was not significantly associated with dysphagia. The subgroup analyses indicated that only the SMI (adjusted OR 0.92, 95% CI 0.86, 0.97) and the IMAT% (adjusted OR 1.08, 95% CI 1.01, 1.17) were significantly associated with dysphagia in men. None of these indicators was significantly associated with dysphagia in women. Trunk muscle mass and quality (estimated by chest CT-derived SMI and IMAT%, respectively) were significantly associated with self-reported dysphagia in older inpatients, especially in men. IMAT% might be a more sensitive muscle quality indicator than IMAT (or SMD). These results merit further investigation in prospective studies.

The concept of aggressive nutrition therapy and clinical indication: A position paper

Aggressive nutrition therapy is a nutritional management method that sets energy intake requirements by adding the amount of energy accumulated to energy consumption. It is used to treat patients with undernutrition and sarcopenia. However, evidence for aggressive nutrition therapy is insufficient, and validation through high-quality clinical research is essential. Therefore, this paper aimed to clarify the concept of aggressive nutrition therapy, present indications and contraindications; and describe the effects, limitations, and the need to individualize aggressive nutrition therapy for different pathological conditions. Aggressive nutrition therapy should be accompanied by the etiology of undernutrition, sarcopenia, and nutritional metabolism in various states. In addition to calculating nutritional requirements, the nutritional management methods of oral intake, tube feeding, and parenteral nutrition should be appropriately selected. A nutrition plan with the amount of energy accumulated should also be a vital issue. This position paper was authored by the Registered Dietitian Subcommittee of the Japanese Association of Rehabilitation Nutrition and was approved by the Japanese Association of Rehabilitation Nutrition.

Association of Existence of Sarcopenia and Poor Recovery of Swallowing Function in Post-Stroke Patients with Severe Deglutition Disorder: A Multicenter Cohort Study

BACKGROUND

The effect of sarcopenia on the recovery of swallowing function, and the interaction among sarcopenia, nutrition care, and rehabilitation therapy are inconclusive.

METHODS

This multicenter cohort study was conducted between November 2018 and October 2020 in convalescent rehabilitation hospitals in Japan and included post-stroke patients aged ≥65 years with dysphagia. All participants were assigned to sarcopenia and non-sarcopenia groups. The primary outcome was the achievement of ≥2 Food Intake Level Scale [FILS] gain, and the secondary outcomes included Functional Independence Measure (FIM) gain and efficiency. Considering the effect modification of energy intake and rehabilitation duration, logistic regression analyses were performed.

RESULTS

Overall, 153 participants with (median age, 82 years; 57.5% women) and 40 without (median age 75 years; 35.0% women) sarcopenia were included. The non-sarcopenia group had more patients who achieved an FILS gain of ≥2 (75.0%) than the sarcopenia group (51.0%). Sarcopenia was independently associated with a poor FILS gain (odds ratio:0.34, 95% confidence intervals: 0.13-0.86) but not associated with FIM gain or efficiency. This association was not affected by the rehabilitation duration or energy intake.

CONCLUSIONS

In conclusion, sarcopenia was negatively associated with the recovery of swallowing function in stroke patients without interaction by energy intake and rehabilitation duration.

Handgrip strength predicts early postoperative dysphagia after thoracoscopic-laparoscopic esophagectomy in male patients with esophageal cancer

BACKGROUND

Dysphagia after esophagectomy, especially in the early postoperative period, remains a severe complication. The association between sarcopenia and dysphagia has received attention in geriatric non-cancer populations. This study aimed to determine the associations between sarcopenia parameters and early postoperative dysphagia after esophagectomy.

METHODS

This retrospective observational study included 201 consecutive male patients undergoing thoracoscopic-laparoscopic esophagectomy (TLE) for esophageal cancer between October 2018 and December 2020. We used three sarcopenia parameters: handgrip strength (HGS), skeletal muscle index, and gait speed. Postoperative swallowing function was assessed by videofluoroscopy using the penetration-aspiration scale (PAS; range 1-8). Logistic regression analyses were used to predict factors associated with postoperative aspiration (PAS 6-8). Furthermore, we compared values in patients with symptomatic aspiration (PAS 6-7) and with silent aspiration (PAS 8).

RESULTS

Aspiration occurred in 38 of 201 patients (18.9%). On multivariate analysis, significant predictors of aspiration included age [odds ratio (OR) 1.11; 95% confidence interval (CI) 1.05-1.17; p < 0.001], low HGS (OR 3.05; 95% CI 1.06-8.78; p = 0.039), upper third esophageal cancer (OR 2.79; 95% CI 1.03-7.54; p = 0.044) and recurrent laryngeal nerve palsy (OR 2.98; 95% CI 1.26-7.06; p = 0.013). Furthermore, among patients with aspiration (PAS 6-8), low HGS was significantly associated with silent aspiration (OR 6.43; 95% CI 1.06-39.00; p = 0.043).

CONCLUSIONS

Low HGS was significantly associated with early postoperative aspiration and impairment of airway protective reflexes after TLE.

Use of Facial Morphology to Determine Nutritional Status in Older Adults: Opportunities and Challenges

Undiagnosed malnutrition is a significant problem in high-income countries, which can reduce the quality of life of many individuals, particularly of older adults. Moreover, it can also inflate the costs of existing health care systems because of the many metabolic complications that it can cause. The current methods for assessing malnutrition can be cumbersome. A trained practitioner must be present to conduct an assessment, or patients must travel to facilities with specialized equipment to obtain their measurements. Therefore, digital health care is a possible way of closing this gap as it is rapidly gaining traction as a scalable means of improving efficiency in the health care system. It allows for the remote monitoring of nutritional status without requiring the physical presence of practitioners or the use of advanced medical equipment. As such, there is an increasing interest in expanding the range of digital applications to facilitate remote monitoring and management of health issues. In this study, we discuss the feasibility of a novel digital remote method for diagnosing malnutrition using facial morphometrics. Many malnutrition screening assessments include subjective assessments of the head and the face. Facial appearance is often used by clinicians as the first point of qualitative indication of health status. Hence, there may be merit in quantifying these subtle but observable changes using facial morphometrics. Modern advancements in artificial intelligence, data science, sensors, and computing technologies allow facial features to be accurately digitized, which could potentially allow these previously intuitive assessments to be quantified. This study aims to stimulate further discussion and discourse on how this emerging technology can be used to provide real-time access to nutritional status. The use of facial morphometrics extends the use of currently available technology and may provide a scalable, easily deployable solution for nutritional status to be monitored in real time. This will enable clinicians and dietitians to keep track of patients remotely and provide the necessary intervention measures as required, as well as providing health care institutions and policy makers with essential information that can be used to inform and enable targeted public health approaches within affected populations.

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.

Association between Inflammation and Functional Outcome in Patients with Sarcopenic Dysphagia

OBJECTIVES

This study aimed to investigate whether inflammation affects the outcome of swallowing ability to improve treatment for sarcopenic dysphagia.

DESIGN

A retrospective observational cohort study was performed using data from the Japanese sarcopenic dysphagia database.

SETTING

The database was constructed using data from 19 hospitals and one home visiting rehabilitation team.

PARTICIPANTS

Patients with sarcopenic dysphagia with measurements of C-reactive protein (CRP) and serum albumin (Alb) were included.

MEASUREMENTS

Patients were assigned to two groups using CRP, Alb, and the Japanese modified Glasgow Prognostic Score (mGPS). The Food Intake LEVEL Scale (FILS) was measured at the times of admission and follow-up (FILS follow-up) to assess swallowing function.

RESULTS

A total of 197 patients were included. Mean or median values of each parameter were as follows: age: 83.8±8.7, Alb: 3.2 ± 0.6 g/dL, CRP: 8.0 [3.0, 29.0] mg/L, mGPS: 1 [1-2], FILS: 7 [6-8], FILS follow-up: 8 [7-8], and duration of follow-up: 57.0 [27.0, 85.0] days. The FILS score at follow-up was significantly lower in the high CRP group (≥ 5.0 mg/L) than in the low CRP group (< 5.0 mg/L) (p = 0.01). Further, the FILS score at follow-up was significantly lower in the high mGPS group (class; 2) than in the low mGPS group (class; 0 and 1) (p = 0.03). In the multiple linear regression analyses without FILS at baseline, CRP and mGPS were independent risk factors for FILS follow-up. When FILS at baseline was entered, CRP and mGPS were not an independent risk factors for FILS follow-up.

CONCLUSIONS

Inflammation could modify the outcome of the patients with sarcopenic dysphagia. Inflammation may be an important risk factor in evaluating patients with sarcopenic dysphagia.

Sarcopenic Dysphagia: A Narrative Review from Diagnosis to Intervention

Sarcopenia, defined as a decline in muscle mass and function related to aging, affects both limb and swallowing-related muscles. Sarcopenic dysphagia is characterized by decreased swallowing function; therefore, early detection of subclinical dysphagia and subsequent intervention appear to be crucial in the elderly. Numerous tools have been employed to measure the function, strength, and mass of swallowing-related muscles in sarcopenic elderly. The swallowing function can be evaluated by questionnaires like Eating Assessment Tool, Functional Oral Intake Scale, and Food Intake Level Scale, and tests such as the modified water swallowing test and videofluoroscopic swallowing study. Surface electromyography and high-resolution manometry can be applied for quantifying swallowing-related muscle strength. Modalities such as ultrasonography and magnetic resonance imaging are capable of estimating the swallowing muscle mass. In patients with sarcopenic dysphagia, a thorough assessment should be given followed by an integrated intervention combining swallowing muscle strengthening, nutrition support, food texture modification, physical, and occupational therapies. This article aimed to comprehensively summarize the diagnostic criteria/tools as well as their associations/performance in sarcopenic dysphagia. The intervention strategy will also be narrated in this review.

Association of preoperative sarcopenia with postoperative dysphagia in patients with thoracic esophageal cancer

BACKGROUND

The purpose of the current study was to clarify the relationship between clinical features of dysphagia after esophagectomy and preoperative sarcopenia.

METHODS

A total of 187 cases were included in the current study. The psoas cross-sectional area on pre-treatment computed tomography was measured in thoracic esophageal cancer patients who underwent curative resection. The psoas muscle index (PMI) cut-off levels for sarcopenia were 6.36 cm2/m2 for men and 3.92 cm2/m2 for women. Swallowing function was evaluated using videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) at postoperative days 7-15, and classified according to the food intake level scale (FILS). Perioperative swallowing rehabilitation was performed in all cases.

RESULTS

In the 187 included patients, the median PMI was 5.42 cm2/m2 for men and 3.43 cm2/m2 for women, and 133 cases (71%) met the sarcopenia criteria. The FILS <4 (no oral intake) was 15% in the non-sarcopenia group, and 38% in the sarcopenia group (P = 0.003). There was no significant difference in the incidence of postoperative complications, including pneumonia and re-admission due to pneumonia, between the two groups. Preoperative sarcopenia and recurrent laryngeal nerve palsy were be independent risk factors for postoperative dysphagia.

CONCLUSIONS

Sarcopenic patients with esophageal cancer develop postoperative dysphagia more often than non-sarcopenic patients. Prehabilitation and nutritional support for patients with preoperative sarcopenia could play an important role to mitigate postoperative dysphagia.

Molecular and Neural Mechanism of Dysphagia Due to Cancer

Cancer is one of the most common causes of death worldwide. Along with the advances in diagnostic technology achieved through industry–academia partnerships, the survival rate of cancer patients has improved dramatically through treatments that include surgery, radiation therapy, and pharmacotherapy. This has increased the population of cancer “survivors” and made cancer survivorship an important part of life for patients. The senses of taste and smell during swallowing and cachexia play important roles in dysphagia associated with nutritional disorders in cancer patients. Cancerous lesions in the brain can cause dysphagia. Taste and smell disorders that contribute to swallowing can worsen or develop because of pharmacotherapy or radiation therapy; metabolic or central nervous system damage due to cachexia, sarcopenia, or inflammation can also cause dysphagia. As the causes of eating disorders in cancer patients are complex and involve multiple factors, cancer patients require a multifaceted and long-term approach by the medical care team.

The Impact of Preoperative Sarcopenia on Survival Prognosis in Patients Receiving Neoadjuvant Therapy for Esophageal Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Sarcopenia is a poor prognostic factor in patients with esophageal cancer (EC). It can be aggravated by neoadjuvant therapy (NAT) that improves the prognosis of patients with EC. Until now, the impact of preoperative sarcopenia on survival prognosis in patients receiving NAT for EC remains unclear.

METHODS

We systematically researched relevant studies in the PubMed, EMBASE, Web of Science, the Cochrane Library databases up to March 8, 2020. Prevalence of sarcopenia before and after NAT, overall survival (OS) and disease-free survival (DFS) were collected for analysis. Finally, eleven cohort studies were included.

RESULTS

Pooled analysis indicated that preoperative sarcopenia was negatively associated with OS. (HR = 1.290; 95% CI [1.078-1.543]; P = 0.005; I 2 = 0.0%) and DFS (HR = 1.554; 95% CI [1.177-2.052]; P = 0.002; I 2 = 0.0%) in the patients with EC receiving NAT. The prevalence of sarcopenia increased by 15.4% following NAT (95%CI [12.9%-17.9%]). Further subgroup analysis indicated that sarcopenia diagnosed following NAT (HR = 1.359; 95% CI [1.036-1.739]; P = 0.015; I 2 = 6.9%) and age >65 years (HR = 1.381; 95% CI [1.090- 1.749]; P = 0.007; I 2 = 0.0%) were the independent risk factors for decreased OS.

CONCLUSIONS

Clinicians should strengthen the screening of preoperative sarcopenia in patients of EC both receiving NAT and older than 65 years and give active nutritional support to improve the prognosis of patients.

SYSTEMATIC REVIEW REGISTRATION

International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY), identifier INPLASY202050057.

Temporal muscle thickness is associated with the severity of dysphagia in patients with acute stroke

BACKGROUND

Post-stroke dysphagia is a common and expensive complication of acute stroke. The relationship between dysphagia and skeletal muscle loss (sarcopenia) has been recently highlighted. This study aimed to determine the relationship between temporal muscle thickness (TMT) measured by head magnetic resonance imaging (MRI) and dysphagia in patients with acute stroke.

METHODS

Seventy participants (43 men and 27 women; mean age, 75.6 ± 12.7 years) were included in this study. TMT was measured by T2-magnetic resonance images within seven days of hospitalization. The severity of dysphagia was assessed using the Functional Oral Intake Scale (FOIS). Participants were classified into three categories according to the severity of dysphagia (severe: FOIS score, 1-3; mild: FOIS score, 4-6; normal: FOIS score, 7). Linear regression analysis was used to determine the independent explanators of dysphagia severity.

RESULTS

Twenty participants (28.6%) had severe dysphagia, 31 participants (44.3%) had mild dysphagia, and 19 participants (27.1%) had normal swallowing function at discharge. The results of the linear regression analysis showed that TMT was a significant explanator of dysphagia severity following stroke, along with age and National Institute of Health Stroke Scale (NIHSS) score (P < 0.05, effect size: f² = 0.72).

CONCLUSIONS

TMT was an independent risk factor for dysphagia in patients with acute stroke. Skeletal muscle loss may be secondarily involved in dysphagia with acute stroke, and measurement of TMT with head MRI is a useful method to assess skeletal muscle loss.

Masticatory muscle index for indicating skeletal muscle mass in patients with head and neck cancer

BACKGROUND

A typical assessment for sarcopenia involves the use of abdominal computed tomography (CT) for calculating the skeletal muscle index (SMI) at the level of the third lumbar vertebra (L3). However, abdominal CT is not regularly performed on patients with head and neck cancer (HNC). We investigated whether masticatory SMI (M-SMI) measurements based on head and neck CT scans can be used to conduct sarcopenia assessments by evaluating whether M-SMI is correlated with L3-SMI.

METHODS

Abdominal and head and neck CT images of patients with trauma (n = 50) and HNC (n = 52) were analyzed retrospectively. Both manual delineation and threshold selection methods were used to measure cross-sectional areas of masticatory muscles and those of muscles at the L3 level on CT images. Muscle cross-sectional areas were normalized to height squared to calculate SMI, and a multivariate linear regression model was established to evaluate the correlation between the M-SMI and L3-SMI. Receiver operating characteristic curve analysis was used to assess the ability of the M-SMI to identify sarcopenia, and Cox logistic regression was used to identify predictors of sarcopenia.

RESULTS

Patients with HNC had significantly lower M-SMI and L3-SMI than did patients with trauma (p = 0.011 and 0.03, respectively). M-SMI and L3-SMI were strongly correlated (r = 0.901, p < 0.001); in the multivariate model that included sex, the correlation was stronger (r = 0.913, p < 0.001). The associations of sarcopenia with a lower M-SMI (p < 0.001), male sex (p = 0.028), and advanced age (p = 0.011) were significant, and multivariate logistic analysis demonstrated that an M-SMI of <5.5 was an independent predictor of sarcopenia (hazard ratio = 5.37, p < 0.001).

CONCLUSIONS

M-SMI assessment in routine head and neck CT scans is feasible and can be an alternative for detecting sarcopenia in patients with HNC.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Impact of geniohyoid and masseter muscle masses on dysphagia after salvage surgery and radiotherapy in head and neck cancer

This study aimed to determine whether geniohyoid and/or masseter muscle mass can predict the severity of dysphagia after salvage surgery for head and neck cancer. We conducted a retrospective cohort study of 45 male patients with head and neck cancer (median age, 68 years) who underwent salvage surgery. The preoperative geniohyoid and masseter muscle masses were evaluated using computed tomography and the severity of dysphagia was evaluated by Penetration Aspiration Scale (PAS), Functional Oral Intake Scale (FOIS) and Oropharyngeal swallow efficiency (OPSE). The median PAS, FOIS and OPSE scores after surgery were 7 (interquartile range [IQR] 1–8), 6 (IQR 2–7) and 95.8 (IQR 67.1–116.2), respectively. The mean geniohyoid muscle masses were 3.13 ± 0.78 cm² and the mean masseter muscle masses were 4.37 ± 0.99 cm², respectively. The multivariate analysis showed that the geniohyoid muscle mass was significantly associated with the PAS, FOIS and OPSE scores. Conversely, the masseter muscle mass was not significantly associated with the PAS score but was significantly associated with the FOIS and OPSE scores. Geniohyoid muscle mass may predict the severity of dysphagia after salvage surgery.

Prognostic Value of Third Cervical Vertebra Skeletal Muscle Index in Oral Cavity Cancer: A Retrospective Study

OBJECTIVES/HYPOTHESIS

To assess the prognostic utility of third cervical vertebra skeletal muscle index (C3 SMI) measured from preoperative head and neck computed tomography (CT) in patients with oral cavity squamous cell carcinoma (OSCC).

STUDY DESIGN

Retrospective study.

METHODS

We retrospectively reviewed the medical records of 125 patients who underwent primary curative surgery for OSCC between 2009 and 2017. Their preoperative C3 SMI was calculated by adjusting the C3 cross-sectional area delineated on head and neck CT by body height squared. A Cox proportional hazard model was employed to identify prognostic factors, and a novel nomogram based on C3 SMI was built for individualized survival prediction.

RESULTS

In Kaplan-Meier analysis, high C3 SMI was significantly associated with higher 5-year disease-free survival (DFS) and overall survival (OS) than low C3 SMI. In multivariate analysis, low C3 SMI was an independent risk factor for poor DFS and OS (hazard ratio [HR]: 2.197; 95% confidence interval [CI], 1.170-4.512, P = .032 and HR: 2.143; 95% CI, 1.232-3.728, P = .007, respectively). The concordance-index (C-index) of the nomogram based on C3 SMI was 0.814 for OS, higher than that of the nomogram based on tumor-node-metastasis staging alone (C-index = 0.731).

CONCLUSIONS

C3 SMI might serve as a novel prognosticator in OSCC patients undergoing curative surgery, and the nomogram based on C3 SMI might provide good prognostic discrimination ability for individualized survival prediction.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E2257-E2265, 2021.

Pathophysiological mechanisms explaining poor clinical outcome of older cancer patients with low skeletal muscle mass

Low skeletal muscle mass is highly prevalent in older cancer patients and affects 5% to 89% depending on the type and stage of cancer. Low skeletal muscle mass is associated with poor clinical outcomes such as post-operative complications, chemotherapy toxicity and mortality in older cancer patients. Little is known about the mediating pathophysiological mechanisms. In this review, we summarize proposed pathophysiological mechanisms underlying the association between low skeletal muscle mass and poor clinical outcomes in older cancer patients including a) systemic inflammation; b) insulin-dependent glucose handling; c) mitochondrial function; d) protein status and; e) pharmacokinetics of anticancer drugs. The mechanisms of altered myokine balance negatively affecting the innate and adaptive immune system, and altered pharmacokinetics of anticancer drugs leading to a relative overdosage of anticancer drugs are best-substantiated. The effects of glucose intolerance and circulating mitochondrial DNA as a consequence of low skeletal muscle mass are topics of interest for future research. Restoring myokine balance through physical exercise, exercise mimetics, neuro-muscular activation and adapting anticancer drug dosing on skeletal muscle mass could be targeted approaches to improve clinical outcomes in older cancer patients with low skeletal muscle mass.

Digastric muscle mass and intensity in older patients with sarcopenic dysphagia by ultrasonography

AIM

The aim of this study was to investigate digastric muscle mass and intensity between no sarcopenic dysphagia and sarcopenic dysphagia.

METHODS

Patients aged ≥65 years were enrolled. According to the diagnostic algorithm for sarcopenic dysphagia, the patients were divided into two groups, no sarcopenic dysphagia and sarcopenic dysphagia. Handgrip strength, gait speed, skeletal muscle mass, tongue pressure, Mini Nutritional Assessment-Short Form and Food Intake LEVEL Scale were investigated. Digastric muscle mass and intensity were examined by ultrasonography. Univariate and multivariate analyses were performed to analyze two groups. Multivariate logistic regression analysis was performed to determine independent factors for the presence of sarcopenic dysphagia. To estimate the accuracy of diagnosing sarcopenic dysphagia, a receiver operating characteristic curve analysis was performed for digastric muscle mass and intensity.

RESULTS

Forty-five patients (mean ± SD, 84.3 ± 7.8 years, 22 men, 23 women) including 19 no sarcopenic dysphagia and 26 sarcopenic dysphagia were examined. In sarcopenic dysphagia, lower BMI, Food Intake LEVEL Scale, Mini Nutritional Assessment-Short Form and smaller muscle mass and greater muscle intensity were found compared with no sarcopenic dysphagia. In multivariate logistic regression analysis, digastric muscle mass and intensity were identified as independent factors for sarcopenic dysphagia. The cut-off value of muscle mass was 75.1 mm² (area under curve: 0.731, sensitivity: 0.692, specificity: 0.737) and muscle intensity was 27.8 (area under curve: 0.823, sensitivity: 0.923, specificity: 0.632).

CONCLUSIONS

Digastric muscle mass was smaller and muscle intensity was greater in sarcopenic dysphagia than no sarcopenic dysphagia. Ultrasonography of digastric muscle, as well as the tongue and geniohyoid muscle, is useful. Geriatr Gerontol Int 2021; 21: 14-19.

Impacts of Preoperative Psoas Muscle Mass and Visceral Fat Area on Postoperative Short- and Long-Term Outcomes in Patients with Gastric Cancer

BACKGROUND

Sarcopenia and obesity are associated with outcomes after surgery. However, few studies have investigated which more accurately predicts postoperative complications or prognosis in patients with gastric cancer.

METHODS

A total of 567 consecutive patients with gastric cancer who underwent gastrectomy between 2010 and 2015 were retrospectively reviewed. Psoas muscle mass index (PMI) and visceral fat area (VFA) were measured by CT scan. Patients were divided into two groups based on PMI (PMI-H group: male ≥ 6.36 cm²/m², female ≥ 3.92 cm²/m²; and PMI-L group: male < 6.36 cm²/m², female < 3.92 cm²/m²) and two groups based on VFA (VFA-H group: ≥ 100 cm²; VFA-L group: < 100 cm²). The incidence of postoperative complications and the recurrence-free survival (RFS) were compared between the two groups.

RESULTS

The incidence of postoperative complications was significantly higher in the VFA-H group than in the VFA-L group (35.1% vs. 20.3%; P < 0.001), whereas there was no significant difference between the PMI-H and PMI-L groups. Multivariate analysis showed that PMI-L and VFA-H were independent risk factors for pneumonia (odds ratio, 4.49; P = 0.018) and intra-abdominal abscess (odds ratio, 5.19; P = 0.004), respectively. While there was no significant difference in RFS between the VFA-H and VFA-L groups, the PMI-L group showed significantly worse RFS than the PMI-H group (P < 0.001).

CONCLUSIONS

PMI and VFA were useful predictive factors for postoperative pneumonia and intra-abdominal abscess, respectively. PMI might be a useful prognostic factor in patients with gastric cancer, but VFA is not.

Using GLIM criteria, cutoff value for low BMI in Asian populations discriminates high or low muscle mass: A cross-sectional study

OBJECTIVES

The aim of this study was to examine whether differences in muscle mass and intramuscular adipose tissue are present between patients with a moderately and severely low body mass index (BMI) as discriminated by the cutoff value for a low BMI among patients ≥70 y of age in Asian populations according to the Global Leadership Initiative on Malnutrition (GLIM) criteria.

METHODS

This cross-sectional study included 345 inpatients ≥70 y of age. The participants were placed into one of the following three groups: severely low BMI (<17.8 kg/m²; n = 96), moderately low BMI (≥17.8 to <20 kg/m²; n = 81), and normal BMI (≥20 kg/m²; n = 168). Ultrasound images were obtained with B-mode ultrasound imaging. Muscle mass and intramuscular adipose tissue of the quadriceps were assessed based on the muscle thickness and echo intensity, respectively. Analysis of covariance was used to examine the differences in the quadriceps thickness and echo intensity among the three groups.

RESULTS

The quadriceps thickness and echo intensity in the severely low, moderately low, and normal BMI groups were 0.9 ± 0.3, 1.1 ± 0.4, and 1.4 ± 0.5 cm and 93.3 ± 20.8, 91.3 ± 19.3, 80.1 ± 21.6, respectively. The quadriceps thickness in the severely low BMI group was statistically significantly lower than that in the moderately low BMI (P < 0.001) and normal BMI (P < 0.001) groups, and the quadriceps thickness in the moderately low BMI group was also statistically significantly lower than that in the normal BMI group (P < 0.001). The quadriceps echo intensity showed no significant differences among the three groups.

CONCLUSIONS

The cutoff value for a low BMI discriminates high or low muscle mass. Results of this study supported the validity of 17.8 kg/m² as the cutoff value for a low BMI with which to grade the severity of malnutrition in Asian populations ≥70 y of age according to the GLIM criteria from the perspective of muscle mass.

Decreased Tongue Volume Post Radiation

OBJECTIVES

To evaluate volume changes within the tongue post chemoradiation therapy (CRT).

STUDY DESIGN

Retrospective review.

SETTING

Academic Medical Center.

SUBJECTS AND METHODS

Subjects included 19 patients that received CRT as the primary treatment for tonsillar or hypopharynx squamous cell carcinoma. Tongue volumes were calculated by three raters from thin slice computed tomography images collected before treatment and up to 29 months post-CRT. Body mass index (BMI) was also collected at each time point.

RESULTS

Inter-rater reliability was high with an ICC of 0.849 (95% CI = 0.773, 0.905). Linear mixed effects modeling showed a mean decrease of 0.45 cm³ (standard error of the mean [SEM] = 0.11) in tongue volume per month post-CRT (P < .001). However, the addition of BMI to the model was significant (χ² (4) = 25.0, P < .001), indicating that BMI was a strong predictor of tongue volume, with a mean decrease of 1.75 cm³ (SEM = 0.49) in tongue volume per unit decrease in BMI (P < .001) and reducing the post-CRT effect on tongue volume decrease per month to 0.23 cm³ (P = .02). BMI significantly (P < .001) decreased by 0.11 units (SEM = 0.02) per month post radiation.

CONCLUSION

Tongue dysfunction and decreased tongue strength are significant contributors to the dysphagia that patients experience after receiving CRT. In this study, both tongue volume and BMI decreased post-CRT; therefore, BMI could potentially be used as a predictor of tongue volume post-CRT.

Self Reported Dysphagia is not Associated with Sarcopenia Defined by the Revised EWGSOP2 Criteria and Regional Thresholds at the Hospital Among Ambulatory Older Patients

Introduction:

Dysphagia and sarcopenia are geriatric syndromes, and they are shown to be related. There is no study on dysphagia and sarcopenia with the revised European Working Group on Sarcopenia in Older People (EWGSOP)2 criteria.

Aim:

We aimed to evaluate dysphagia and sarcopenia with the revised criteria implementing regional thresholds for skeletal muscle mass (SMM) in hospitalized older patients.

Methods:

Ambulatory patients ≥60 years of age from the Internal Medicine Department of our hospital were taken into the study. Grip strength, SMM via bioelectrical impedance analysis, nutritional status, dysphagia screening with Eating Assessment Tool-10, prior hospitalizations and diet were evaluated. Sarcopenia was defined by EWGSOP2 criteria using regional SMM thresholds adjusted to body mass index (BMI) (SMMI (BMI)).

Results:

Out of 112, 61 patients were enrolled. Sarcopenia, nutritional risk, and dysphagia were shown in 36.1%, 88.5%, and 14.8% of the patients. The risk of dysphagia was not associated with sarcopenia (p=0.263). Hospitalizations (≥1) in one year with pneumonia, modified diet, malnutrition, and low SMMI (BMI) were more common in patients with dysphagia risk than in the patients without (p=0.001, p<0.01, p=0.011, p=0.008, respectively). The median age and BMI were higher where SMMI (BMI) was lower in the group with dysphagia risk than in the group without (p=0.016, p=0.034, p=0.032), respectively.

Conclusion:

We found that self-reported dysphagia was not associated with sarcopenia defined by the EWGSOP2 criteria in ambulatory hospitalized patients over 60 years of age. Further studies using revised criteria, different adjustments and thresholds are needed to reveal possible differences.

Associations between tongue strength and skeletal muscle mass under dysphagia rehabilitation for geriatric out patients

PURPOSE

The purpose of this study was to examine how skeletal muscle mass influences the effectiveness of dysphagia rehabilitation.

METHODS

The cross-sectional study and the prospective cohort study were conducted in a clinic, specialized in rehabilitation of patients with dysphagia, located in Tokyo, Japan. Skeletal muscle mass measurement by bioelectrical impedance analysis and tongue strength measurement were performed on 178 outpatients with dysphagia. In addition, the Barthel Index, Mini Nutritional Assessment-Short Form, and Functional Oral Intake Scale values were measured. Dysphagia rehabilitation was performed, and 88 of the patients who were available for follow-up one year later were included in a follow-up study. In the cross-sectional study, the associations between tongue strength and other factors were examined. In the follow-up study, factors associated with rehabilitation effectiveness, shown by tongue strength, were examined.

RESULTS

Tongue strength and skeletal muscle mass were correlated, and both decreased as eating and swallowing function level decreased. After one year of dysphagia rehabilitation, tongue strength and skeletal muscle mass increased. The factors associated with the amount of increase in tongue strength were initial tongue strength and skeletal muscle mass.

CONCLUSIONS

For patients with dysphagia, maintenance of skeletal muscle mass was associated with improvement of tongue strength in rehabilitation. This indicates that prevention of sarcopenia in dysphagia patients contributes to the effect of rehabilitation.

Effect of Chemotherapy on Dual-Energy X-ray Absorptiometry (DXA) Body Composition Precision Error in Head and Neck Cancer Patients

BACKGROUND

Precision error in dual-energy X-ray absorptiometry (DXA) is defined as difference in results due to instrumental and technical factors given no biologic change. The aim of this study is to compare precision error in DXA body composition scans in head and neck cancer patients before and 2 months after chemotherapy.

METHODOLOGY

A total of 34 male head and neck cancer patients with normal body mass index (BMI) were prospectively enrolled and all patients received 2 consecutive DXA scans both before and after 2 months of chemotherapy for a total of 4 scans. The precision error of 3 DXA body composition values (lean mass, fat mass, and bone mineral content) was calculated for total body and 5 body regions (arms, legs, trunk, android, and gynoid). Precision errors before and after treatment were compared using generalized estimating equation model.

RESULTS

There was no significant change in precision error for the DXA total body composition values following chemotherapy; lean mass (0.33%-0.40%, p = 0.179), total fat mass (1.39%-1.70%, p = 0.259) and total bone mineral content (0.42%-0.56%, p = 0.243). However, there were significant changes in regional precision error; trunk lean mass (1.19%-1.77%, p = 0.014) and android fat mass (2.17%-3.72%, p = 0.046).

CONCLUSIONS

For head and neck cancer patients, precision error of DXA total body composition values did not change significantly following chemotherapy; however, there were significant changes in fat mass in the android and lean mass in the trunk. Caution should be exercised when interpreting longitudinal DXA body composition data in those body parts.

A review of nutrition screening tools used to assess the malnutrition-sarcopenia syndrome (MSS) in the older adult

BACKGROUND

Malnutrition and sarcopenia are common in older adults. A new clinical syndrome has been suggested - the Malnutrition Sarcopenia Syndrome (MSS) - that may provide improved management, by highlighting two older adult conditions that can interact in a cumulative way to affect functional independence and health outcomes. This paper evaluates the published literature reporting data on both nutrition and sarcopenia evaluation simultaneously in the population studied, and creates a diagnostic algorithm.

METHODS

An inclusive, systematic literature search was done for articles including a simultaneous standardised evaluation of sarcopenia and nutritional status, from 1990-date. Sarcopenic status needed to be evaluated using accepted guidelines published by international guideline committees which include a functional muscle evaluation and a quantitative evaluation using bioimpedence assay or dual energy X-ray absorptiometry. Nutritional status needed to evaluated with a standardised, validated nutritional screening tool that was not disease specific.

RESULTS

11 studies met these criteria. They differed in their methodology for screening both sarcopenia and nutritional issues. They differed as to the population studied (community versus institutionalised versus hospitalised).

CONCLUSIONS

No one methodology was consistent for evaluation of sarcopenia or malnutrition. The concept of the Malnutrition Sarcopenia Syndrome intuitively makes sense to clinicians. This opinion paper suggests a possible clinical approach. The management and interventions for both conditions are likely to have considerable overlap. There needs to be some consensus on how to evaluate it, in order to be able to accurately interpret the impact of interventions that may be undertaken for one or both conditions simultaneously.

CoreSlicer: a web toolkit for analytic morphomics

BACKGROUND

Analytic morphomics, or more simply, "morphomics," refers to the measurement of specific biomarkers of body composition from medical imaging, most commonly computed tomography (CT) images. An emerging body of literature supports the use of morphomic markers measured on single-slice CT images for risk prediction in a range of clinical populations. However, uptake by healthcare providers been limited due to the lack of clinician-friendly software to facilitate measurements. The objectives of this study were to describe the interface and functionality of CoreSlicer- a free and open-source web-based interface aiming to facilitate measurement of analytic morphomics by clinicians - and to validate muscle and fat measurements performed in CoreSlicer against reference software.

RESULTS

Measurements of muscle and fat obtained in CoreSlicer show high agreement with established reference software. CoreSlicer features a full set of DICOM viewing tools and extensible plugin interface to facilitate rapid prototyping and validation of new morphomic markers by researchers. We present published studies illustrating the use of CoreSlicer by clinicians with no prior knowledge of medical image segmentation techniques and no formal training in radiology, where CoreSlicer was successfully used to predict operative risk in three distinct populations of cardiovascular patients.

CONCLUSIONS

CoreSlicer enables extraction of morphomic markers from CT images by non-technically skilled clinicians. Measurements were reproducible and accurate in relation to reference software.

Rehabilitation Nutrition for Iatrogenic Sarcopenia and Sarcopenic Dysphagia

Sarcopenia is a very important issue in rehabilitation medicine and nutritional care. The prevalence of sarcopenia in older people is approximately 50% in the rehabilitation setting, and also approximately 15% of inpatients without sarcopenia upon admission developed sarcopenia during hospitalization. There is a concern that secondary sarcopenia may occur iatrogenically during hospitalization. Iatrogenic sarcopenia is defined as sarcopenia caused by the activities of medical staff including doctors, nurses, or other health care professionals in healthcare facilities. Iatrogenic sarcopenia is categorized into activity-related, nutrition-related and disease-related-iatrogenic sarcopenia. Especially in acute phase hospitals, concentrating on the treatment of diseases with less attention to nutrition and activity is more likely to cause iatrogenic sarcopenia. Sarcopenic dysphagia is also an important aspect in rehabilitation medicine and nutritional care. Sarcopenic dysphagia is characterized by swallowing difficulty because of a loss of mass and function in whole-body skeletal and swallowing muscles. Sarcopenic dysphagia can be diagnosed using a 5-step algorithm for the condition. Iatrogenic sarcopenia and sarcopenic dysphagia are affected by nutrition, activity and diseases in a complex manner. Therefore, treatment of iatrogenic sarcopenia and sarcopenic dysphagia requires comprehensive interventions through nutrition management and rehabilitation. Rehabilitation nutrition is effective for preventing and treating iatrogenic sarcopenia and sarcopenic dysphagia. Rehabilitation nutrition can be practiced more effectively and comprehensively by using the rehabilitation nutrition care process, which is a systematic problem-solving method. Further research is required to verify the efficacy of rehabilitation nutrition for preventing or improving iatrogenic sarcopenia and/or sarcopenic dysphagia.

Oropharyngeal Dysphagia Evaluation Tools in Adults with Solid Malignancies Outside the Head and Neck and Upper GI Tract: A Systematic Review

Dysphagia is often associated with head and neck and upper gastrointestinal (GI) tract cancers. Evidence suggests that those with solid malignancies in other primary sites may also have swallowing difficulties. Timely and accurate identification of dysphagia is important given the impact it has on hydration, medical treatment, nutrition, prognosis, and quality of life. A systematic review was conducted to identify swallow screening, evaluation, and quality of life tools for those with solid malignancies outside the head and neck and upper GI tract. Ten electronic databases, one journal and two published conference proceedings were searched. Following deduplication, 7435 studies were examined for relevance. No tools were validated solely in this cancer population, though some included this group in larger cohorts. Comments are provided on the diagnostic properties and applicability of these tools. In the absence of appropriate diagnostic instruments, the exact prevalence of dysphagia and its impact on clinical and psychosocial well-being remain unknown. Accurate and adequate measurement of therapeutic intervention is also compromised. This review establishes the need for validated dysphagia evaluation tools for this clinical population.

Systematic Review and Meta-Analysis of the Association between Sarcopenia and Dysphagia

OBJECTIVES

Sarcopenia, an age-related decrease in muscle mass and function, is associated with several potential adverse health outcomes. Its association with another age-related syndrome, dysphagia remains unclear. This systematic review and meta-analysis aims to explore the association between sarcopenia and dysphagia.

METHODS

PubMed, Embase, Scopus and CINAHL were searched for cross-sectional, case-control and cohort studies that investigated the association between sarcopenia and dysphagia. First author, publication year, study type, sample size, inclusion and exclusion criteria, participant demographics, definition and measurement for evaluation of sarcopenia and dysphagia, main outcomes were retrieved. The association between sarcopenia and dysphagia were expressed by odds ratio (OR) and 95% confidence interval (CI).

RESULTS

9 studies are eligible in the systematic review, and 5 cross-sectional studies comprising 913 participants which showed dichotomous classification of sarcopenia and dysphagia were included in the meta-analysis. The crude odds ratios (ORs) were extracted from 5 studies, and 4 of them also provide adjusted ORs. The crude ORs between sarcopenia and dysphagia is 6.17 (95% CI, 3.81- 10.00), after adjusting for some confounders, such as age, sex, Barthel Index score, nutritional status, sarcopenia is also have an association with dysphagia (adjusted ORs, 4.06; 95% CI, 2.27-7.29). The subgroup analysis showed that there was no significant difference between different sarcopenia diagnostic criteria, assessment tools of skeletal muscle mass and dysphagia.

CONCLUSION

Sarcopenia was positively associated with dysphagia. Prevention and screening of dysphagia is essential among sarcopenic old patients. The causal relationship requires more prospective cohort study for confirmation.

Impact of Sarcopenia on Unplanned Readmission and Survival After Esophagectomy in Patients with Esophageal Cancer

BACKGROUND

Although sarcopenia increases postoperative complications following esophagectomy, its effects on prognosis remain unclear. This study was performed to identify the effect of sarcopenia on 90-day unplanned readmission and overall survival (OS) after esophagectomy.

METHODS

Ninety-eight patients with esophageal cancer who underwent esophagectomy were enrolled in this study. Unplanned readmission was defined as any emergent hospitalization within 90 days after discharge. Sarcopenia, defined as low muscle mass plus low muscle strength and/or low physical performance according to the Asian consensus definition, was assessed prior to esophagectomy. Multivariate logistic regression analysis was performed to identify factors that contributed to 90-day unplanned readmission. OS was estimated using the Kaplan-Meier method, and a Cox proportional hazards model was used to assess the relationship between sarcopenia and OS.

RESULTS

Thirty-one patients (31.6%) were diagnosed with sarcopenia. The 90-day unplanned readmission rate was significantly higher in patients with sarcopenia than those without (42.9% vs. 16.4%, respectively; p = 0.01). Multivariable logistic regression analysis showed that sarcopenia was an independent predictor of 90-day unplanned readmission [odds ratio 3.71, 95% confidence interval (CI) 1.29-11.05; p = 0.02], and the log-rank test showed that sarcopenia was associated with OS (p = 0.01). Moreover, sarcopenia was a significant predictor of OS after adjustment for age, sex, and pathological stage (hazard ratio 2.35, 95% CI 1.21-4.54; p = 0.01).

CONCLUSIONS

Sarcopenia is a risk factor for 90-day unplanned readmission and OS following esophagectomy. Assessment of sarcopenia could help to identify patients at higher risk of a poor prognosis after esophagectomy.

Casting the net broader to confirm our imaginations: the long road to treating wasting disorders

Wasting embraces muscle and tissue wasting in sarcopenia and cachexia. This article describes recent advances in the field published in the Journal of Cachexia, Sarcopenia and Muscle concerning diagnostic tools, biomarker development, pathophysiology, and treatment. Studies discussed herein embrace those on sarcopenia and cachexia in heart failure, chronic obstructive pulmonary disease, and cancer including also animal models.

An analysis of the types of recently published research in the field of cachexia

Introduction Cachexia is a common complication of many and varied chronic disease processes, yet it has received very little attention as an area of clinical research effort until recently. We sought to survey the contemporary literature on published research into cachexia to define where it is being published and the proportion of output classified into the main types of research output. Methods I searched the PubMed listings under the topic research term "cachexia" and related terms for articles published in the calendar years of 2015 and 2016, regardless of language. Searches were conducted and relevant papers extracted by two observers, and disagreements were resolved by consensus. Results There were 954 publications, 370 of which were review articles or commentaries, 254 clinical observations or non-randomised trials, 246 original basic science reports and only 26 were randomised controlled trials. These articles were published in 478 separate journals but with 36% of them being published in a core set of 23 journals. The H-index of these papers was 25 and there were 147 papers with 10 or more citations. Of the top 100 cited papers, 25% were published in five journals. Of the top cited papers, 48% were review articles, 18% were original basic science, and 7% were randomised clinical trials. Discussion This analysis shows a steady but modest increase in publications concerning cachexia with a strong pipeline of basic science research but still a relative lack of randomised clinical trials, with none exceeding 1000 patients. Research in cachexia is still in its infancy, but the solid basic science effort offers hope that translation into randomised controlled clinical trials may eventually lead to effective therapies for this troubling and complex clinical disease process.