Muscle radiodensity loss during cancer therapy is predictive for poor survival in advanced endometrial cancer

Myosteatosis predicts postoperative complications and long-term survival in robotic gastrectomy for gastric cancer: A propensity score analysis

BACKGROUND

Robotic gastrectomy is increasingly utilized for gastric cancer, but high morbidity remains a concern. Myosteatosis or low skeletal muscle density reflecting fatty infiltration, associates with complications after other cancer surgeries but has not been evaluated for robotic gastrectomy.

METHODS

This retrospective study analysed 381 patients undergoing robotic gastrectomy for gastric cancer from September 2019 to October 2022. Myosteatosis was quantified on preoperative computed tomography (CT) images at lumbar 3 (L3). Propensity score matching addressed potential confounding between myosteatosis and non-myosteatosis groups. Outcomes were postoperative complications, 30 days mortality, 30 days readmissions and survival.

RESULTS

Myosteatosis was present in 33.6% of patients. Myosteatosis associated with increased overall (47.7% vs. 26.5%, p < 0.001) and severe complications (12.4% vs. 4.9%, p < 0.001). After matching, myosteatosis remained associated with increased overall complications, major complications, intensive care unit (ICU) transfer and readmission (all p < 0.05). Myosteatosis independently predicted overall [odds ratio (OR) = 2.86, 95% confidence interval (CI): 1.57-5.20, p = 0.001] and severe complications (OR = 4.81, 95% CI: 1.51-15.27, p = 0.008). Myosteatosis also associated with reduced overall (85.0% vs. 93.2%, p = 0.015) and disease-free survival (80.3% vs. 88.4%, p=0.029). On multivariate analysis, myosteatosis independently predicted poorer survival [hazard ratio (HR) = 2.83, 95% CI: 1.32-6.08, p=0.012] and disease-free survival (HR = 1.83, 95% CI: 1.01-3.30, p=0.032).

CONCLUSION

Preoperative CT-defined myosteatosis independently predicts increased postoperative complications and reduced long-term survival after robotic gastrectomy for gastric cancer. Assessing myosteatosis on staging CT could optimize preoperative risk stratification.

Interpretable machine learning model based on clinical factors for predicting muscle radiodensity loss after treatment in ovarian cancer

PURPOSE

Muscle radiodensity loss after surgery and adjuvant chemotherapy is associated with poor outcomes in ovarian cancer. Assessing muscle radiodensity is a real-world clinical challenge owing to the requirement for computed tomography (CT) with consistent protocols and labor-intensive processes. This study aimed to use interpretable machine learning (ML) to predict muscle radiodensity loss.

METHODS

This study included 723 patients with ovarian cancer who underwent primary debulking surgery and platinum-based chemotherapy between 2010 and 2019 at two tertiary centers (579 in cohort 1 and 144 in cohort 2). Muscle radiodensity was assessed from pre- and post-treatment CT acquired with consistent protocols, and a decrease in radiodensity ≥ 5% was defined as loss. Six ML models were trained, and their performances were evaluated using the area under the curve (AUC) and F1-score. The SHapley Additive exPlanations (SHAP) method was applied to interpret the ML models.

RESULTS

The CatBoost model achieved the highest AUC of 0.871 (95% confidence interval, 0.870-0.874) and F1-score of 0.688 (95% confidence interval, 0.685-0.691) among the models in the training set and outperformed in the external validation set, with an AUC of 0.839 and F1-score of 0.673. Albumin change, ascites, and residual disease were the most important features associated with a higher likelihood of muscle radiodensity loss. The SHAP force plot provided an individualized interpretation of model predictions.

CONCLUSION

An interpretable ML model can assist clinicians in identifying ovarian cancer patients at risk of muscle radiodensity loss after treatment and understanding the contributors of muscle radiodensity loss.

Sarcopenia diagnosis in patients with colorectal cancer: a review of computed tomography-based assessments and emerging ways to enhance practicality

Traditionally, cancer treatment has focused on the stages of the disease; however, recent studies have highlighted the importance of considering the overall health status of patients in the prognosis of cancer. Loss of skeletal muscle, known as sarcopenia, has been found to significantly affect outcomes in many different types of cancers, including colorectal cancer. In this review, we discuss the guidelines for diagnosing sarcopenia, with a specific focus on CT-based assessments. Many groups worldwide, including those in Europe and Asia, have introduced their own diagnostic guidelines for sarcopenia. Seemingly similar yet subtle discrepancies, particularly in the cutoff values used, limit the use of these guidelines in the general population, warranting a more universal guideline. Although CT-based measurements, such as skeletal muscle index and radiodensity, have shown promise in predicting outcomes, the lack of standardized values in these measurements hinders their universal adoption. To overcome these limitations, innovative approaches are being developed to assess changes in muscle mass trajectories and introduce new indices, such as skeletal and appendicular muscle gauges. Additionally, machine learning models have shown superior performance in predicting sarcopenic status, providing an alternative to CT-based diagnosis, particularly after surgery. CT has tremendous benefits and a significant role in visually as well as quantitatively retrieving information on patient body composition. In order to compensate for the limitation of standard cutoff value, 3-dimensional analysis of the CT, artificial intelligence-based body composition analysis, as well as machine learning algorithms for data interpretation and analysis have been proposed and are being utilized. In conclusion, despite the varying definitions of sarcopenia, CT-based measurements coupled with machine-learning models are promising for evaluating patients with cancer. Standardization efforts can improve diagnostic accuracy, reduce the reliance on CT examinations, and make sarcopenia assessments more accessible in clinical settings.

Association of body composition and survival in patients with locally advanced breast cancer: a historical cohort study

BACKGROUND

Altered body composition has been attributed to major health problems globally, particularly in patients with cancer. To date, there have not been sufficient indices for body compositions in predicting the survival of locally advanced breast cancer (LABC).

PURPOSE

To assess the association between body composition and overall survival (OS) as well as disease-free survival (DFS) in patients with LABC.

MATERIAL AND METHODS

A retrospective study was conducted of patients with LABC diagnosed between 2010 and 2018. Body composition parameters, including skeletal muscle and adiposity parameters, were measured using computed tomography at the L3 vertebra using in-house software developed by MATLAB and freeware Python 3.6.13. The association between body composition and OS and DFS were analyzed using a log-rank test and multivariate Cox-proportional hazard regression.

RESULTS

Of 199 patients, 72 (36%) died during the follow-up period (range = 3.8-150.7 months). Median survival was 101 months. Low visceral-to-subcutaneous ratio ≤0.3 (adjusted hazard ratio [aHR] = 2.57, 95% confidence interval [CI] = 1.51-4.37; aHR = 2.46, 95% CI = 1.33-4.56), and high composite fat (aHR = 3.26, 95% CI = 1.69-6.29; aHR = 2.19, 95% CI = 1.11-4.3) were associated with lower OS and DFS. Positive lymph nodes ≥3, progesterone receptor negative, and total radiation dose >5000 cGy significantly decreased both OS and DFS. A history of previous treatment before body composition assessment and surgery had a protective effect on OS and DFS. No association of sarcopenia, body mass index, and adiposity areas with survival outcomes was observed.

CONCLUSION

Low visceral-to-subcutaneous ratio and high composite fat were independent prognostic factors for OS and DFS in patients with LABC. However, other body composition parameters showed no effect on survival.

Assessment of myosteatosis and functionality in pretreatment gynecological cancer patients

PURPOSE

We aimed to investigate the relationship between pretreatment gynecologic cancer survival and the physical function of patients with myosteatosis. Understanding this relationship prior to treatment would help healthcare providers identify and refer patients with poor muscle quality to an exercise program prior to treatment.

METHODS

We conducted a cross-sectional analysis of 73 GC patients. Physical function was quantified using handgrip strength and an adapted version of the Senior Fitness Test (aerobic endurance not included). The EORTC QLC-C30 was used to evaluate general health quality. Myosteatosis (values below the median muscle radiodensity), muscle mass, and adipose tissue variables were calculated from the computed tomography (CT) scan at the third lumbar vertebra using specific software.

RESULTS

Seventy patients (50.9 ± 15.2) were included; 41.5% had stage III or IV disease, and 61.4% had cervical cancer. The myosteatosis group was 11.9 years older and showed reduced functioning compared to the normal-radiodensity group. Age and Timed Up and Go (TUG) test results were shown to be the most reliable predictors of muscle radiodensity in pretreatment gynecological patients according to multivariate regression analysis (R2 = 0.314).

CONCLUSION

Gynecological healthcare professionals should be aware that prompt exercise programs might be especially beneficial for older patients with reduced TUG performance to preserve muscle function and quality.

Sarcopenia in gynaecological cancers

Gynaecological cancers (GCs) comprise a group of cancers that originate in the female reproductive organs. Each GC is unique, with different signs and symptoms, risk factors and therapeutic strategies. Worldwide, the majority of GCs are still associated with high mortality rates, especially ovarian, due to difficulty in early detection. Despite numerous studies on the underlying pathophysiology, research in the field of GCs poses unique scientific and technological challenges. These challenges require a concerted multi- and inter-disciplinary effort by the clinical, scientific and research communities to accelerate the advancement of prognostic, diagnostic, and therapeutic approaches. Sarcopenia is a multifactorial disease which leads to the systemic loss of skeletal muscle mass and function. It can be caused by malignancies, as well as due to malnutrition, physical inactivity, ageing and neuromuscular, inflammatory, and/or endocrine diseases. Anorexia and systemic inflammation can shift the metabolic balance of patients with cancer cachexia towards catabolism of skeletal muscle, and hence sarcopenia. Therefore, sarcopenia is considered as an indicator of poor general health status, as well as the possible indicator of advanced cancer. There is a growing body of evidence showing the prognostic significance of sarcopenia in various cancers, including GCs. This review will outline the clinical importance of sarcopenia in patients with GCs.

Nomograms combining computed tomography-based body composition changes with clinical prognostic factors to predict survival in locally advanced cervical cancer patients

OBJECTIVE

To explore the value of body composition changes (BCC) measured by quantitative computed tomography (QCT) for evaluating the survival of patients with locally advanced cervical cancer (LACC) underwent concurrent chemoradiotherapy (CCRT), nomograms combined BCC with clinical prognostic factors (CPF) were constructed to predict overall survival (OS) and progression-free survival (PFS).

METHODS

Eighty-eight patients with LACC were retrospectively selected. All patients underwent QCT scans before and after CCRT, bone mineral density (BMD), subcutaneous fat area (SFA), visceral fat area (VFA), total fat area (TFA), paravertebral muscle area (PMA) were measured from two sets of computed tomography (CT) images, and change rates of these were calculated.

RESULTS

Multivariate Cox regression analysis showed ΔBMD, ΔSFA, SCC-Ag, LNM were independent factors for OS (HR = 3.560, 5.870, 2.702, 2.499, respectively, all P < 0.05); ΔPMA, SCC-Ag, LNM were independent factors for PFS (HR = 2.915, 4.291, 2.902, respectively, all P < 0.05). Prognostic models of BCC combined with CPF had the highest predictive performance, and the area under the curve (AUC) for OS and PFS were 0.837, 0.846, respectively. The concordance index (C-index) of nomograms for OS and PFS were 0.834, 0.799, respectively. Calibration curves showed good agreement between the nomograms' predictive and actual OS and PFS, decision curve analysis (DCA) showed good clinical benefit of nomograms.

CONCLUSION

CT-based body composition changes and CPF (SCC-Ag, LNM) were associated with survival in patients with LACC. The prognostic nomograms combined BCC with CPF were able to predict the OS and PFS in patients with LACC reliably.

Prognostic value of computed tomography associated body composition measurement changes in metastatic colorectal cancer patients

BACKGROUND

Sarcopenia is associated with poor prognosis in metastatic colorectal cancer (mCRC) patients.

PURPOSE

To investigate the prognostic value of body composition measurement changes measured by computed tomography (CT) in mCRC patients.

MATERIAL AND METHODS

The abdominal skeletal muscle density (SMD) and skeletal muscle (SMI) indices, as well as the visceral (VATI) and subcutaneous fat tissue (SATI) indices, were calculated by automatic segmentation method on the abdominal CT images obtained before (n = 71) and after chemotherapy (n = 52). Skeletal muscle gauge (SMG = SMD × SMI) was calculated. We calculated the percentage change of body composition measurements with respect to the first measurements. The cutoff value for the change in SMG was calculated by receiver operating characteristic analysis. Kaplan-Meier and Cox regression analyses were performed to calculate the prognostic value of age, gender, tumor location, metastasis site and carcinoembriogenic antigen (CEA) elevation, hypoalbuminemia, body mass index classification, presence of sarcopenia and SMG changes in terms of overall survival.

RESULTS

There was a significant association between SMG change and mortality (P = 0.037). According to survival analyses, highly decreased SMG, hypoalbuminemia and CEA variables of the patients were the significant factors (P < 0.001, P = 0.015 and P = 0.019, respectively). According to multivariate regression analysis, hypoalbuminemia (P = 0.004, hazard ratio = 3.60) and highly decreased SMG (P < 0.001, hazard ratio = 14.98) were found to be significant prognostic factors together.

CONCLUSION

In mCRC patients, hypoalbuminemia and highly decreased SMG are significant prognostic factors for overall survival. Therefore, we suggest that the change in SMG calculated in follow-up images should also be evaluated in the prognosis estimation of this patient group.

Skeletal muscle gauge prediction by a machine learning model in patients with colorectal cancer

OBJECTIVES

Skeletal muscle gauge (SMG) was recently introduced as an imaging indicator of sarcopenia. Computed tomography is essential for measuring SMG; thus, the use of SMG is limited to patients who undergo computed tomography. We aimed to develop a machine learning algorithm using clinical and inflammatory markers to predict SMG in patients with colorectal cancer.

METHODS

The least absolute shrinkage and selection operator regression model was applied for variable selection and predictive signature building in the training set. The predictive accuracy of the least absolute shrinkage and selection operator model, defined as linear predictor (LP)-SMG, was compared using the area under the receiver operating characteristic curve and decision curve analysis in the test set.

RESULTS

A total of 1094 patients with colorectal cancer were enrolled and randomly categorized into training (n = 656) and test (n = 438) sets. Low SMG was identified in 142 (21.6%) and 90 (20.5%) patients in the training and test sets, respectively. According to multivariable analysis of the test sets, LP-SMG was identified as an independent predictor of low SMG (odds ratio = 1329.431; 95% CI, 271.684-7667.996; P < .001). Its predictive performance was similar in the training and test sets (area under the receiver operating characteristic curve = 0.846 versus 0.869; P = .427). In the test set, LP-SMG had better outcomes in predicting SMG than single clinical variables, such as sex, height, weight, and hemoglobin.

CONCLUSIONS

LP-SMG had superior performance than single variables in predicting low SMG. This machine learning model can be used as a screening tool to detect sarcopenic status without using computed tomography during the treatment period.

Association of malignant ascites with systemic inflammation and muscle loss after treatment in advanced-stage ovarian cancer

BACKGROUND

Malignant ascites is prevalent in advanced-stage ovarian cancer and may facilitate identification of the drivers of muscle loss. This study aimed to evaluate the association of ascites with changes in systemic inflammation and muscle after treatment of advanced-stage ovarian cancer.

METHODS

We evaluated 307 patients with advanced-stage (III/IVA) ovarian cancer who underwent primary debulking surgery and adjuvant platinum-based chemotherapy between 2010 and 2019. The changes in skeletal muscle index (SMI) and radiodensity (SMD) were measured using pre-surgery and post-chemotherapy portal-venous phase contrast-enhanced computed tomography scans at L3. Systemic inflammation was measured using albumin levels, prognostic nutritional index (PNI), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR). Primary endpoint was the changes in SMI and SMD after treatment. Linear regression analysis was used to test associations between muscle change and other covariates. Mediation analysis was used to determine the mediator.

RESULTS

The median (range) age was 53 (23-83) years. The median duration (range) of follow-up was 5.2 (1.1-11.3) years. Overall, 187 (60.9%) patients had ascites. The changes in muscle and systemic inflammatory markers after treatment were significantly different between patients with and without ascites (SMI: -3.9% vs. 2.2%, P < 0.001; SMD: -4.0% vs. -0.4%, P < 0.001; albumin: -4.4% vs. 2.1%, P < 0.001; PNI: -8.4% vs. -0.1%, P < 0.001; NLR: 20.6% vs. -29.4%, P < 0.001; and PLR: 1.7% vs. -19.4%, P < 0.001). The changes in SMI and SMD were correlated with the changes in albumin, PNI, NLR, and PLR (all P < 0.001). In multiple linear regression, ascites and NLR changes were negatively while albumin change was positively correlated with SMI change (ascites: β = -3.19, P < 0.001; NLR change: β = -0.02, P = 0.003; albumin change: β = 0.37, P < 0.001). Ascites and NLR changes were negatively while PNI change was positively correlated with SMD change (ascites: β = -1.28, P = 0.02; NLR change: β = -0.02, P < 0.001; PNI change: β = 0.11, P = 0.04). In mediation analysis, ascites had a direct effect on SMI change (P < 0.001) and an indirect effect mediated by NLR change (indirect effects = -1.61, 95% confidence interval [CI]: -2.22 to -1.08) and albumin change (indirect effects = -2.92, 95% CI: -4.01 to -1.94). Ascites had a direct effect on SMD change (P < 0.001) and an indirect effect mediated by NLR change (indirect effects = -1.76, 95% CI: -2.34 to -1.22) and PNI change (indirect effects = -2.00, 95% CI: -2.79 to -1.36).

CONCLUSIONS

Malignant ascites was associated with enhanced systemic inflammation and muscle loss after primary debulking surgery and adjuvant chemotherapy in advanced-stage ovarian cancer. The association between ascites and muscle loss may be mediated by systemic inflammation.

Association of prognostic nutritional index with muscle loss and survival in patients with ovarian cancer treated with primary debulking surgery and chemotherapy

PURPOSE

Sarcopenia is prevalent in ovarian cancer and contributes to poor survival. This study is aimed at investigating the association of prognostic nutritional index (PNI) with muscle loss and survival outcomes in patients with ovarian cancer.

METHODS

This retrospective study analyzed 650 patients with ovarian cancer treated with primary debulking surgery and adjuvant platinum-based chemotherapy at a tertiary center from 2010 to 2019. PNI-low was defined as a pretreatment PNI of < 47.2. Skeletal muscle index (SMI) was measured on pre- and posttreatment computed tomography (CT) at L3. The cut-off for the SMI loss associated with all-cause mortality was calculated using maximally selected rank statistics.

RESULTS

The median follow-up was 4.2 years, and 226 deaths (34.8%) were observed. With a median duration of 176 days (interquartile range: 166-187) between CT scans, patients experienced an average decrease in SMI of 1.7% (P < 0.001). The cut-off for SMI loss as a predictor of mortality was - 4.2%. PNI-low was independently associated with SMI loss (odds ratio: 1.97, P = 0.001). On multivariable analysis of all-cause mortality, PNI-low and SMI loss were independently associated with all-cause mortality (hazard ratio: 1.43, P = 0.017; hazard ratio: 2.27, P < 0.001, respectively). Patients with both SMI loss and PNI-low (vs. neither) had triple the risk of all-cause mortality (hazard ratio: 3.10, P < 0.001).

CONCLUSIONS

PNI is a predictor of muscle loss during treatment for ovarian cancer. PNI and muscle loss are additively associated with poor survival. PNI can help clinicians guide multimodal interventions to preserve muscle and optimize survival outcomes.

Chemotherapy-Induced Molecular Changes in Skeletal Muscle

Paraneoplastic conditions such as cancer cachexia are often exacerbated by chemotherapy, which affects the patient’s quality of life as well as the response to therapy. The aim of this narrative review was to overview the body-composition-related changes and molecular effects of different chemotherapy agents used in cancer treatment on skeletal-muscle remodeling. A literature search was performed using the Web of Science, Scopus, and Science Direct databases and a total of 77 papers was retrieved. In general, the literature survey showed that the molecular changes induced by chemotherapy in skeletal muscle have been studied mainly in animal models and mostly in non-tumor-bearing rodents, whereas clinical studies have essentially assessed changes in body composition by computerized tomography. Data from preclinical studies showed that chemotherapy modulates several molecular pathways in skeletal muscle, including the ubiquitin–proteasome pathway, autophagy, IGF-1/PI3K/Akt/mTOR, IL-6/JAK/STAT, and NF-κB pathway; however, the newest chemotherapy agents are underexplored. In conclusion, chemotherapy exacerbates skeletal-muscle wasting in cancer patients; however, the incomplete characterization of the chemotherapy-related molecular effects on skeletal muscle makes the development of new preventive anti-wasting strategies difficult. Therefore, further investigation on molecular mechanisms and clinical studies are necessary.

The impact of myosteatosis on outcomes following surgery for gastrointestinal malignancy: a meta-analysis

INTRODUCTION

The aim of this review was to evaluate the impact of preoperative myosteatosis on long-term outcomes following surgery for gastrointestinal malignancy.

METHODS

We conducted a systematic search of the electronic information sources, including PubMed MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL and AMED. Studies were included if they reported the impact of preoperatively defined myosteatosis, or a similar term, on long-term survival outcomes following surgery for gastrointestinal malignancy. A subgroup analysis was performed for those studies reporting outcomes for colorectal cancer patients only.

FINDINGS

Thirty-nine full-text articles were reviewed for inclusion, with 19 being retained after the inclusion criteria were applied. The total number of included patients across all studies was 14,481. Patients with myosteatosis had significantly poorer overall survival, according to univariate (hazard ratio (HR) 1.82, 95% confidence interval (CI) 1.67-1.99) and multivariable (HR 1.66, 95% CI 1.49-1.86) analysis. This was also demonstrated for cancer-specific survival (univariate HR 1.62, 95% CI 1.18-2.22; multivariable HR 1.73, 95% CI 1.48-2.03) and recurrence-free survival (univariate HR 1.28, 95% CI 1.10-1.48; multivariable HR 1.38, 95% CI 1.07-1.77).

CONCLUSIONS

This meta-analysis demonstrates that patients with preoperative myosteatosis have poorer long-term survival outcomes following surgery for gastrointestinal malignancy. Therefore, myosteatosis should be used for preoperative optimisation and as a prognostic tool before surgery. More standardised definitions of myosteatosis and further cohort studies of patients with non-colorectal malignancies are required.

Diagnostic Value of Sarcopenia Computed Tomography Metrics for Older Patients with or without Cancers with Gastrointestinal Disorders

OBJECTIVES

The diagnostic utility of poor body composition measures in sarcopenia remains unclear. We hypothesize that the skeletal muscle gauge [combination of skeletal muscle index (SMI) and skeletal muscle density (SMD); SMG = SMI × SMD] would have significant diagnostic and predictive value in certain muscle regions and populations.

DESIGN

Prospective cross-sectional study.

SETTING AND PARTICIPANTS

We examined inpatients age ≥60 years with or without cancer and with gastrointestinal disorders.

METHODS

We used computed tomography (CT) image metrics in the 12th thoracic (T12), third lumbar (L3), erector spinae muscle (ESM), and psoas muscle (PM) regions to establish correlations with the 2019 Asian Working Group for Sarcopenia Consensus and used receiver operating characteristic area under the curve (AUC) to compare differences between metrics. Associations between CT metrics and mortality were reported as relative risk after adjustments.

RESULTS

We evaluated 385 patients (median age, 69.0 years; 60.8% men) and found consistent trends in cancer (49.6%) and noncancer (50.4%) cohorts. SMG had a stronger correlation with muscle mass than SMD [mean rho: 0.68 (range, 0.59‒0.73) vs 0.39 (range, 0.28‒0.48); all P < .01] in T12, L3, and PM regions and a stronger correlation with muscle function than SMI [mean rho: 0.60 (range, 0.50‒0.77) vs 0.36 (range, 0.22‒0.58); all P < .05] in T12, ESM, and L3 regions. SMG outperformed SMI in diagnostic accuracy in all regions, particularly for L3 (AUC: 0.87‒0.88 vs 0.80‒0.82; both P < .05). PMG (PM gauge) and L3SMG did not differ, whereas EMG (ESM gauge) or T12SMG and L3SMG did (AUC: 0.80‒0.82 vs 0.87‒0.88; all P < .05). L3SMI, L3SMD, T12SMG, EMG, and PMG showed no association with 1-year cancer-related mortality after adjusting for confounders; however, L3SMG [relative risk = 0.92 (0.85‒0.99); P = .023) was.

CONCLUSIONS AND IMPLICATIONS

L3SMG covers all features of sarcopenia with more diagnostic value than other metrics, allowing a complete sarcopenia assessment with CT alone and not just in populations with cancer.

The prognostic impact of myosteatosis on overall survival in gynecological cancer patients: A meta-analysis and trial sequential analysis

Myosteatosis is a novel imaging biomarker for survival in gynecological cancer patients; however, the evidence is inconsistent. This meta-analysis aims to investigate the impact of myosteatosis on overall survival in the gynecological oncology setting. Three databases (PubMed, EMBASE, and Web of Science) were systematically searched for relevant literature up to October 30th, 2021. A random-effects model was used to evaluate the predictive effect of myosteatosis on overall survival in the gynecological cancer population. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. Trial sequential analysis was used to control the risk of random errors. Twelve studies with a total of 2519 patients were included. Myosteatosis was associated with a 50% increased mortality risk (HR 1.50, 95% CI 1.24-1.82, P < 0.001) in gynecological cancer patients. Subgroup analyses stratified by study design, statistical model, treatment, sample size, and stage confirmed the predictive value of myosteatosis on survival. However, the prognostic ability of myosteatosis only was held in the American and European populations but lost in Asians. Additionally, myosteatosis was not associated with the increased mortality in endometrial and cervical cancers, except for ovarian cancers. Overall, myosteatosis is a powerful predictor of reduced overall survival in gynecological cancer patients. This article is protected by copyright. All rights reserved.

Preoperative Pectoralis Muscle Index Predicts Distant Metastasis-Free Survival in Breast Cancer Patients

Background

Breast cancer is one of the most commonly diagnosed cancers, and the fourth leading cause of cancer deaths in females worldwide. Sarcopenia is related to adverse clinical outcomes in patients with malignancies. Muscle index is a key parameter in evaluating sarcopenia. However, there is no data investigating the association between muscle index and distant metastasis in breast cancer. The aim of this study was to explore whether muscle index can effectively predict distant metastasis and death outcomes in breast cancer patients.

Study Design

The clinical data of 493 breast cancer patients at the Harbin Medical University Cancer Hospital between January 2014 and December 2015 were retrospectively analyzed. Quantitative measurements of pectoralis muscle area and skeletal muscle area were performed at the level of the fourth thoracic vertebra (T4) and the eleventh thoracic vertebra (T11) of the chest computed tomography image, respectively. The pectoralis muscle index (PMI) and skeletal muscle index (SMI) were assessed by the normalized muscle area (area/the square of height). Survival analysis was performed using the log-rank test and Cox proportional hazards regression analysis.

Result

The patients with metastases had lower PMI at T4 level (PMI/T4) and SMI at T11 level (SMI/T11) compared with the patients without metastases. Moreover, there were significant correlations between PMI/T4 and lymphovascular invasion, Ki67 expression, multifocal disease, and molecular subtype. In addition, multivariate analysis revealed that PMI/T4, not SMI/T11, was an independent prognostic factor for distant metastasis-free survival (DMFS) and overall survival (OS) in breast cancer patients.

Conclusions

Low PMI/T4 is associated with worse DMFS and OS in breast cancer patients. Future prospective studies are needed.

Pre-treatment sarcopenic assessments as a prognostic factor for gynaecology cancer outcomes: systematic review and meta-analysis

INTRODUCTION

Gynaecology cancers, including ovarian (OC), endometrial (EC), and cervical (CC), are prevalent with high mortality. Sarcopenia is found in 38.7% of cancer patients, adversely affecting prognosis. Computed tomography (CT) is performed routinely in oncology, yet CT assessments of sarcopenia are not commonly used to measure prognosis. This systematic review and meta-analysis aimed to evaluate the prognostic potential of pre-treatment sarcopenia assessments on overall survival (OS) and progression free survival (PFS) in gynaecology cancer.

METHODOLOGY

Four electronic databases were systematically searched from 2000 to May 2020 in English: Ovid Medline, EMBASE, Web of Science, and CINAHL plus. Titles and abstracts were screened, eligible full-texts were reviewed, and data from included studies was extracted. Meta-analyses were conducted on homogenous survival data, heterogenous data were narratively reported.

RESULTS

The initial search yielded 767 results; 27 studies were included in the systematic review (n = 4286), all published between 2015 and 2020. Meta-analysis of unadjusted results revealed a negative effect of pre-treatment sarcopenia on OS in OC (HR: 1.40, 1.20-1.64, p < 0.0001) (n = 10), EC (HR: 1.42, 0.97-2.10, p = 0.07) (n = 4) and CC (HR: 1.10, 0.93-1.31, p = 0.28) (n = 5), and a negative effect on PFS in OC (HR: 1.28, 1.11-1.46, p = 0.0005) (n = 8), EC (HR: 1.51, 1.03-2.20, p = 0.03) (n = 2) and CC (HR: 1.14, 0.85-1.53, p = 0.37) (n = 2). Longitudinal analysis indicated negative effects of muscle loss on survival. Overall, there was a high risk of bias.

CONCLUSION

Pre-treatment sarcopenia negatively affected survival in gynaecology cancers. Incorporating such assessments into cancer management may be beneficial. Heterogeneity in sarcopenia assessments makes data interpretation challenging. Further research in prospective studies is required.

Postoperative Loss of Skeletal Muscle Mass Predicts Poor Survival After Gastric Cancer Surgery

Background

Skeletal muscle mass deterioration is common in gastric cancer (GC) patients and is linked to poor prognosis. However, information regarding the effect of skeletal muscle mass changes in the postoperative period is scarce. This study was to investigate the link between postoperative loss of skeletal muscle mass and survival following GC surgery.

Methods

Patients who underwent GC surgery between January 2015 and December 2016 were recruited into the study. Computed tomography at L3 vertebral level was used to examine skeletal muscle index prior to surgery and about 6 months after surgery. Skeletal muscle index changes were categorized as presence or absence of ≥5% loss. Overall survival (OS) and disease-free survival (DFS) were analyzed, and Cox proportional hazard models used to identify their predictors.

Results

The study comprised of 318 gastric cancer patients of which 63.5% were male. The group's mean age was 58.14 ± 10.77 years. Sixty-five patients experienced postoperative skeletal muscle index loss ≥5% and had poorer OS (P = 0.004) and DFS (P = 0.020). We find that postoperative skeletal muscle index loss ≥ 5% predicts OS [hazard ratio (HR): 2.769, 95% confidence interval (CI): 1.865–4.111; P < 0.001] and DFS (HR: 2.533, 95% CI: 1.753–3.659; P < 0.001).

Conclusions

Loss of skeletal muscle mass postoperatively is linked to poor survival following GC surgery. Further studies are needed to determine whether stabilizing or enhancing skeletal muscle mass after surgery improves survival.

Progressive Skeletal Muscle Loss After Surgery and Adjuvant Radiotherapy Impact Survival Outcomes in Patients With Early Stage Cervical Cancer

The effect of skeletal muscle loss associated with surgery and adjuvant radiotherapy on survival outcomes in patients with early-stage cervical cancer remains unclear. We analyzed the data of 133 patients with early-stage cervical cancer who underwent surgery and adjuvant radiotherapy between 2013 and 2018 at two tertiary centers. Skeletal muscle changes were measured using computed tomography scans at baseline, at simulation for radiotherapy, and at 3 months post-treatment. A decrease of ≥5% in the skeletal muscle was defined as “muscle loss.” The Patient-Reported Outcome version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) was used to assess gastrointestinal toxicity. The Patient-Generated Subjective Global Assessment (PG-SGA) was used for nutritional assessment. Predictors of overall survival were identified using the Cox regression models. The median follow-up period was 3.7 years. After treatment, 32 patients (24.1%) experienced muscle loss. The rate of muscle loss was higher in patients with PRO-CTCAE score ≥3 or PG-SGA score ≥4 at the end of radiotherapy than in patients with PRO-CTCAE score ≤2 or PG-SGA score 0–3 (75.0 vs. 10.5%, p < 0.001; 71.4 vs. 2.2%, p < 0.001). The 3-year overall survival was significantly lower in patients with muscle loss than in those with muscle preserved (65.6 vs. 93.9%, p < 0.001). Multivariate analysis showed that muscle loss was independently associated with poor overall survival (hazard ratio, 4.55; 95% confidence interval: 1.63–12.72; p < 0.001). Muscle loss after surgery and adjuvant radiotherapy was associated with poor overall survival in patients with early-stage cervical cancer. Muscle loss is associated with patient-reported gastrointestinal toxicity and deterioration in nutritional status.

Nomogram of Combining CT-Based Body Composition Analyses and Prognostic Inflammation Score: Prediction of Survival in Advanced Epithelial Ovarian Cancer Patients

PURPOSE

To investigate the value of body composition changes measured by quantitative computer tomography (QCT) in evaluating the prognosis of advanced epithelial ovarian cancer (AEOC) patients who underwent primary debulking surgery (PDS) and adjuvant platinum-based chemotherapy, and constructed a nomogram model for predicting survival in combination with prognostic inflammation score (PIS).

METHOD

Fifty-seven patients with AEOC between 2012 and 2016 were retrospectively enrolled. Pre- and post-treatment CT images were used to analyze the body composition biomarkers. The subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), cross-sectional area of paraspinal skeletal muscle area (PMA), skeletal muscle density (SMD), body mineral density (BMD) were measured from two sets of CT images.

RESULTS

In multivariate analyses, VFA gain, PMA loss, BMD loss, and PIS were independent risk factors of overall survival (OS) (HR = 3.7, 3.0, 2.8, 1.9, respectively, all p < 0.05). Receiver operating characteristic (ROC) curves showed that the prognostic model combining body composition changes (BCC) and PIS had the highest predictive performance (area under the curve = 0.890). The concordance index (C-index) of the prognostic nomogram was 0.779 (95% CI, 0.673-0.886). Decision curve analysis (DCA) demonstrated the prognostic nomogram had a great distinguishing performance.

CONCLUSION

CT-based body composition analyses and PIS were associated with poor OS for AEOC patients who underwent PDS and adjuvant platinum-based chemotherapy. The prognostic nomogram with a combination of BCC and PIS was dependable in predicting survival for AEOC patients during treatment.

Prognostic role of computed tomography-based, artificial intelligence-driven waist skeletal muscle volume in uterine endometrial carcinoma

OBJECTIVES

To investigate the impact of computed tomography (CT)-based, artificial intelligence-driven waist skeletal muscle volume on survival outcomes in patients with endometrial cancer.

METHODS

We retrospectively identified endometrial cancer patients who received primary surgical treatment between 2014 and 2018 and whose pre-treatment CT scans were available (n = 385). Using an artificial intelligence-based tool, the skeletal muscle area (cm2) at the third lumbar vertebra (L3) and the skeletal muscle volume (cm3) at the waist level were measured. These values were converted to the L3 skeletal muscle index (SMI) and volumetric SMI by normalisation with body height. The relationships between L3, volumetric SMIs, and survival outcomes were evaluated.

RESULTS

Setting 39.0 cm2/m2 of L3 SMI as cut-off value for sarcopenia, sarcopenia (< 39.0 cm2/m2, n = 177) and non-sarcopenia (≥ 39.0 cm2/m2, n = 208) groups showed similar progression-free survival (PFS; p = 0.335) and overall survival (OS; p = 0.241). Using the median value, the low-volumetric SMI group (< 206.0 cm3/m3, n = 192) showed significantly worse PFS (3-year survival rate, 77.3% vs. 88.8%; p = 0.004) and OS (3-year survival rate, 92.8% vs. 99.4%; p = 0.003) than the high-volumetric SMI group (≥ 206.0 cm3/m3, n = 193). In multivariate analyses adjusted for baseline body mass index and other factors, low-volumetric SMI was identified as an independent poor prognostic factor for PFS (adjusted HR, 1.762; 95% CI, 1.051-2.953; p = 0.032) and OS (adjusted HR, 5.964; 95% CI, 1.296-27.448; p = 0.022).

CONCLUSIONS

Waist skeletal muscle volume might be a novel prognostic biomarker in patients with endometrial cancer. Assessing body composition before treatment can provide important prognostic information for such patients.

Association between low skeletal muscle mass and subclinical coronary atherosclerosis in asymptomatic individuals evaluated by CT

AIM

To investigate the associations of skeletal muscle area and density with coronary atherosclerotic plaques and significant stenosis in asymptomatic adults.

MATERIALS AND METHODS

A total of 243 consecutive subjects who had voluntarily undergone abdominal unenhanced computed tomography (CT) and coronary CT angiography (CCTA) as part of a general health examination were investigated retrospectively. Skeletal muscle area index (SMI) and skeletal muscle density (SMD) was assessed using CT. Coronary atherosclerotic plaques and stenosis on CCTA were evaluated. The associations of low SMI and low SMD with coronary atherosclerotic plaques and significant stenosis were determined by logistic regression analysis.

RESULTS

After adjustment for cardiovascular risk factors, there were significant associations of low SMI or low SMD with atherosclerotic plaque, total significant stenosis, and significant stenosis caused by calcified or mixed plaques (for all p<0.05). In addition, multivariate regression analysis also showed that low SMI was independently associated with calcified plaque (p=0.038) and non-calcified plaque (p=0.006), and individuals with low SMD were more likely to have mixed plaque (p=0.001).

CONCLUSION

Assessment of the skeletal muscle on CT help to identify asymptomatic adults at risk for coronary atherosclerosis.

Skeletal muscle radiodensity and cancer outcomes: A scoping review of the literature

Patients with cancer are more prone to experience myosteatosis than healthy individuals. The aim of this review was to summarize the methodologies applied for low skeletal muscle radiodensity (SMD) assessment in oncology patients, as well as to describe the major findings related to SMD and cancer outcomes. This scoping review included studies that were published until November 2020 in English, Portuguese, or Spanish; were performed in humans diagnosed with cancer, adult and/or elderly, of both sexes; investigated SMD through computed tomography of the region between the third and fifth lumbar vertebrae, considering at least two muscular groups; and evaluated clinical and/or surgical outcomes. Eighty-eight studies met the inclusion criteria (n = 37,583 patients). Survival was the most evaluated outcome. Most studies reported a significant association between low SMD and unfavorable outcomes. However, this relationship was not clear for survival, antineoplastic treatment, and surgical complications, potentially because of the unstandardized approaches for the assessment of SMD and inadequate study design. Future studies should address these issues to provide an in-depth understanding of the clinical relevance of SMD in cancer outcomes as well as how SMD is influenced by individuals and tumor-related characteristics in patients with cancer.

Skeletal muscle gauge as a prognostic factor in patients with colorectal cancer

Background

Although skeletal muscle index (SMI) and radiodensity (SMD) are well‐known prognostic factors, the clinical impact of the integrated measure, known as skeletal muscle gauge (SMG), has been limited in patients with colorectal cancer (CRC).

Patients and Methods

A total of 727 and 268 patients with CRC at two tertiary centers were included and allocated into the training and test sets, respectively. Preoperative slice computed tomography images of the third lumbar area were evaluated for SMI and SMD. SMG was calculated as SMI × SMD and expressed as an arbitrary unit (AU). The optimal cutoff SMG value was determined to maximize the overall survival (OS) difference between the groups with respect to sex in the training set. The multivariate Cox proportional hazard model evaluated the association of its clinical significance.

Results

With regard to SMG, 1640 and 1523 AU were identified as cutoff values for males and females, respectively. The patients with low SMG values showed significantly worse 5‐year OS than those with high SMG values in the two datasets (both p < 0.001). In the multivariate analysis, low SMG was identified as an independent poor prognostic factor of OS in the training set (hazard ratio 2.18, 95% confidence interval 1.43–3.32, p < 0.001) and test set (hazard ratio 1.79, 95% confidence interval 1.07–3.00, p = 0.025), whereas SMI and SMD were not.

Conclusion

SMG acts synergistically to improve its prognostic predictive accuracy as compared with SMI or SMD alone in patients with CRC. Additional research is warranted to define its significance in different ethnic groups.

Muscle Loss During Androgen Deprivation Therapy Is Associated With Higher Risk of Non-Cancer Mortality in High-Risk Prostate Cancer

The changes in body composition are early adverse effects of androgen deprivation therapy (ADT); however, their prognostic impact remains unclear in prostate cancer. This study aimed to evaluate the association between body composition changes and survival in patients with high-risk prostate cancer. We measured the skeletal muscle index (SMI) and total adipose tissue index (TATI) at the L3 vertebral level using computed tomography at baseline and within one year after initiating ADT in 125 patients with high-risk prostate cancer treated with radiotherapy and ADT between 2008 and 2018. Non-cancer mortality predictors were identified using Cox regression models. The median follow-up was 49 months. Patients experienced an average SMI loss of 5.5% over 180 days (95% confidence interval: -7.0 to -4.0; p<0.001) and TATI gain of 12.6% over 180 days (95% confidence interval: 9.0 to 16.2; p<0.001). Body mass index changes were highly and weakly correlated with changes in TATI and SMI, respectively (Spearman ρ for TATI, 0.78, p<0.001; ρ for SMI, 0.27, p=0.003). As a continuous variable, each 1% decrease in SMI was independently associated with a 9% increase in the risk of non-cancer mortality (hazard ratio: 1.09; p=0.007). Moreover, the risk of non-cancer mortality increased 5.6-fold in patients with SMI loss ≥5% compared to those with unchanged SMI (hazard ratio: 5.60; p=0.03). Body mass index and TATI were not associated with non-cancer mortality. Muscle loss during ADT is occult, independent of weight change, and independently associated with increased non-cancer mortality in patients with high-risk prostate cancer.

Body Composition Changes in Hepatocellular Carcinoma: Prediction of Survival to Transcatheter Arterial Chemoembolization in Combination With Clinical Prognostic Factors

Treatment-related toxicities and decreased levels of patient performance during cancer therapy might contribute to body composition changes (BCC) and thereby impact outcomes. This study investigated the association between BCC during transcatheter arterial chemoembolization (TACE) and outcome in patients with hepatocellular carcinoma (HCC), and developed a nomogram for predicting survival in combination with clinical prognostic factors (CPF). Pretreatment and posttreatment computed tomography (CT) images of 75 patients with HCC who were treated between 2015 and 2018 were analyzed. The bone mineral density (BMD), cross-sectional area of paraspinal muscles (CSA_muscle), subcutaneous fat area (SFA), and visceral fat area (VFA) were measured from two sets of CT images. Count the changes in body composition during treatment and sort out the CPF of patients. Using cox regression models, CSA_muscle change, SFA change, VFA change, child-push class, and portal vein thrombosis were independent prognostic factors for overall survival (OS) (HR=5.932, 2.384, 3.140, 1.744, 1.794, respectively. P < 0.05). Receiver operating characteristic curves (ROCs) showed the prediction model combination of BCC and CPF exhibited the highest predictive performance (AUC=0.937). Independent prognostic factors were all contained into the prognostic nomogram, the concordance index (C-index) of prognostic nomogram was 0.787 (95% CI, 0.675−0.887). Decision curve analysis (DCA) demonstrated that the prognostic nomogram was clinically useful. Nomogram-based risk classification systems were also constructed to facilitate risk stratification in HCC for optimization of clinical management. In conclusion, we identified CSA_muscle change, SFA change, VFA change, Child-Pugh class, and portal vein thrombosis were independent prognostic factors for HCC. The prognostic nomogram with a combination of BCC and CPF that can be applied in the individualized prediction of survival in patients with HCC after TACE.

The influence process of sarcopenia on female cancer: A systematic review and meta-analysis

BACKGROUND

Sarcopenia is one of the early pathological manifestations of cancer cachexia. This change in quality and function has a general and special impact on the prognosis of many types of tumors. However, there are few studies to evaluate the overall impact of sarcopenia on the prognosis of gynecological tumors in sufficient follow-up period.

METHODS

This study systematically searched PubMed, EMBASE, web of science, and MEDLINE databases for related studies and related references since April 15, 2021. The 1-year, 5-year overall survival (OS), progression-free survival (PFS), hazard ratio (HR), and 95% confidence interval (CI) were analyzed by Stata 14.0.(CRD 42021236036).

RESULTS

A total of 23 observational studies involving 3495 female patients were included in the analysis, with an average prevalence of 46.9% (38.5%-55.3%). Meta-analysis showed that the 1-year OS (RR: 1.60, 95% CI = [1.04, 2.46]) of patients with sarcopenia was significantly lower than that of patients without sarcopenia, and then this effect gradually decreased. The results showed that sarcopenia was an independent predictor of OS (HR: 1.78, 95% CI = [1.38, 2.30]) and PFS (HR: 1.32, 95% CI = [1.02, 1.70]) in gynecological cancer patients. Subgroup analysis showed that sarcopenia was significant in Asian population (HR: 1.93, 95% CI = [1.18, 3.17]) and cervical cancer patients (HR: 5.07, 95% CI = [2.82, 9.56]).

CONCLUSION

The survival and recurrence outcome of patients with sarcopenia independently related to surgery, and its impact is very obvious in the short term. In addition, Asian participants with sarcopenia face a greater risk of death than Western participants.

Association of Patient-Reported Outcomes and Nutrition with Body Composition in Women with Gynecologic Cancer Undergoing Post-Operative Pelvic Radiotherapy: An Observational Study

Pelvic radiotherapy is associated with gastrointestinal toxicities and deterioration of nutritional status. This study aimed to investigate the association of patient-reported outcomes (PROs) and nutritional status with body composition changes in women who underwent hysterectomy and post-operative radiotherapy for gynecologic cancer. We analyzed data of 210 patients treated with post-operative pelvic radiotherapy for gynecologic cancer between 2013 and 2018. The PRO version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) was used for gastrointestinal toxicity assessment. The Patient-Generated Subjective Global Assessment (PG-SGA) was used for nutritional assessment. Skeletal muscle index was measured from computed tomography scans at the L3 vertebral level. A reduction in skeletal muscle index ≥ 5% was classified as muscle loss. Odds ratios were calculated through logistic regression models. The PG-SGA score increased from the beginning to the end of radiotherapy (1.4 vs. 3.7, p < 0.001). Patients with PRO-CTCAE scores ≥ 3 had significantly higher PG-SGA scores at the end of radiotherapy than those with PRO-CTCAE scores ≤ 2 (8.1 vs. 2.3, p < 0.001). On multivariable analysis, PRO-CTCAE scores ≥ 3 and PG-SGA scores ≥ 4 at the end of radiotherapy were independently associated with increased risk of muscle loss (odds ratio: 8.81, p < 0.001; odds ratio: 72.96, p < 0.001, respectively). PROs and PG-SGA may be considered as markers of muscle loss after post-operative pelvic radiotherapy for gynecologic cancer.

Comparison of Shear Wave Elastography and Dynamometer Test in Muscle Tissue Characterization for Potential Medical and Sport Application

Skeletal muscle status and its dynamic follow up are of particular importance in the management of several diseases where weight and muscle mass loss and, consequently, immobilization occurs, as in cancer and its treatment, as well as in neurodegenerative disorders. But immobilization is not the direct result of body and muscle mass loss, but rather the loss of the maximal tension capabilities of the skeletal muscle. Therefore, the development of a non-invasive and real-time method which can measure muscle tension capabilities in immobile patients is highly anticipated. Our aim was to introduce and evaluate a special ultrasound measurement technique to estimate a maximal muscle tension characteristic which can be used in medicine and also in sports diagnostics. Therefore, we determined the relationship between the results of shear wave elastography measurements and the dynamometric data of individuals. The measurements were concluded on the m. vastus lateralis. Twelve healthy elite athletes took part in our preliminary proof of principle study—five endurance (S) and seven strength (F) athletes showing unambiguously different muscle composition features, nine healthy subjects (H) without prior sports background, and four cancer patients in treatment for a stage 3 brain tumor (T). Results showed a high correlation between the maximal dynamometric isometric torque (Mmax) and mean elasticity value (E) for the non-athletes [(H + T), (r = 0.795)] and for the athletes [(S + F), (r = 0.79)]. For the athletes (S + F), the rate of tension development at contraction (RTDk) and E correlation was also determined (r = 0.84, p < 0.05). Our measurements showed significantly greater E values for the strength athletes with fast muscle fiber dominance than endurance athletes with slow muscle fiber dominance (p < 0.05). Our findings suggest that shear wave ultrasound elastography is a promising method for estimating maximal muscle tension and, also, the human skeletal muscle fiber ratio. These results warrant further investigations with a larger number of individuals, both in medicine and in sports science.

Computed Tomography-Derived Skeletal Muscle Radiodensity Predicts Peak Weight-Corrected Jump Power in Older Adults: The Korean Urban Rural Elderly (KURE) Study

Computed tomography (CT)-derived skeletal muscle area (SMA) and skeletal muscle radiodensity (SMD) reflect distinctive quantitative and qualitative characteristics of skeletal muscles. However, data on whether CT-based muscle parameters, especially SMD, can predict muscle function is limited. In a prospective cohort, 1523 community-dwelling older adults who underwent abdominal CT scans and the countermovement two-legged jumping test on a ground reaction force platform were analyzed (mean age 74.7 years, 65.1% women). SMA and SMD were measured at third lumbar vertebra level (L3). Individuals with low jump power (peak weight-corrected jump power < 23.8 W/kg in men and < 19.0 W/kg in women using clinically validated threshold) were older; had lower SMA, SMD, and maximal grip strength values; and had lower chair rise test and timed up and go test performance than those without low jump power. SMD was positively associated with peak weight-corrected jump power (adjusted β = 0.33 and 0.23 per 1 HU increase in men and women, respectively, p < 0.001). One HU decrement in SMD was associated with 10% elevated odds of low jump power (adjusted OR [aOR] 1.10, p < 0.001) after adjusting for age, sex, height, inflammation, and insulin resistance markers, whereas the association of SMA with low jump power was attenuated (aOR 1.00, p = 0.721). SMD showed better discrimination for low jump power than SMA (AUC 0.699 vs. 0.617, p < 0.001), with additional improvement when added to SMA and conventional risk factors (AUC 0.745 to 0.773, p < 0.001). Therefore, CT-measured L3 SMD can be a sensitive surrogate marker for muscle function along with SMA in older adults, which merits further investigation.

The Role of Home-Based Exercise in Maintaining Skeletal Muscle During Preoperative Pancreatic Cancer Treatment

Loss of skeletal muscle and inferior muscle quality are associated with poor prognosis in patients undergoing preoperative treatment for pancreatic cancer, so maintaining skeletal muscle health before surgery may help accelerate patients' functional recovery and improve their quality of life following surgery. While exercise helps maintain or increase skeletal muscle in individuals undergoing cancer treatment, its efficacy during pancreatic cancer treatment is unclear. Accordingly, in this study we compared changes in skeletal muscle quantity (skeletal muscle index [SMI]) and quality (skeletal muscle density [SMD]) during preoperative pancreatic cancer treatment in participants in a home-based exercise program (EP) and a historical cohort of patients who received the usual care (UC) with no formal exercise programming. Recommendations for the EP cohort included both aerobic and resistance exercise. We assessed changes in SMI and SMD using computed tomography scans administered at treatment planning (T0, prior to EP enrollment) and preoperative restaging (T1) for 33 EP and 64 UC patients and compared changes between groups. The UC patients had statistically significant SMI decreases from T0 to T1 (-1.4 ± 3.8 cm²/m²; p = .005), while the EP patients did not (0.2 ± 3.2 cm²/m²; p = .7). The SMI loss was significantly worse for the UC than for the EP patients (p = .03). Neither group demonstrated statistically significant changes in SMD from T0 to T1, nor did the groups differ in the amount of change in SMD. An adjusted linear regression model demonstrated that EP participation was significantly associated with better SMI maintenance (p = .02). These results suggest that participation in a home-based EP during preoperative treatment may help improve skeletal muscle health and clinical and quality of life outcomes for pancreatic cancer survivors.

Association of bowel radiation dose-volume with skeletal muscle loss during pelvic intensity-modulated radiotherapy in cervical cancer

BACKGROUND

Radiation-induced bowel damage may compromise nutrient absorption and digestion and affect body composition during pelvic radiotherapy in patients with locally advanced cervical cancer (LACC). This study aimed to evaluate the relationship between bowel radiation dose-volume and body composition changes during pelvic radiotherapy.

METHODS

Data of 301 LACC patients treated with chemoradiotherapy were analyzed. Changes in skeletal muscle index (SMI) and density (SMD), and total adipose tissue index (TATI) were measured from computed tomography images at the L3 vertebral level. A reduction in SMI, SMD, or TATI of ≥10% was classified as "loss." Bowel V45 indicates the bowel volume (mL) receiving a radiation dose of ≥45 Gy. The relationship between body composition and bowel V45 was analyzed using logistic regression models.

RESULTS

After treatment, 61 (20.3%), 81 (26.9%), and 97 (32.2%) patients experienced SMI, SMD, and TATI loss, respectively. Increased bowel V45 was independently associated with increased odds of SMI loss (odds ratio [OR]: 1.012; 95% confidence interval [CI]: 1.007-1.018; p<0.001) and TATI loss (OR: 1.006; 95% CI: 1.001-1.010; p=0.01), but not with SMD loss (OR: 1.005; 95% CI: 1.000-1.009; p=0.054). The cut-off value with the highest accuracy for predicting SMI loss was V45 ≥222 mL; a higher rate of SMI loss was noted in 40.0% of patients with V45 ≥222 mL than in 13.7% of patients with V45 <222 mL (p<0.001).

CONCLUSIONS

Higher bowel dose-volume was significantly associated with muscle loss during pelvic radiotherapy. Bowel dose-volume consideration is required in individualized nutritional counseling and supportive care in clinical practice.

Progressive muscle loss is an independent predictor for survival in locally advanced oral cavity cancer: A longitudinal study

BACKGROUND AND PURPOSE

To investigate the association between progressive muscle loss and survival outcomes of patients with advanced-stage oral squamous cell carcinoma (OSCC) undergoing surgery and adjuvant (chemo)radiotherapy.

METHODS

We analyzed the computed tomography (CT) scans of 155 patients with stage III-IVB OSCC at baseline, at simulation CT for radiotherapy, and at 3- and 9-months post-treatment. Skeletal muscle index (SMI) was measured using CT at the C3 vertebral level. The predictors of overall survival (OS) and recurrence-free survival (RFS) were evaluated using Cox regression models.

RESULTS

The median follow-up period was 75.0 months. Fifty-one patients (32.9%) developed recurrence, with the median time from the fourth CT to recurrence being 9.1 months. The SMI progressively decreased from baseline to simulation CT by 1.1% (p = 0.006), to 3 months post-treatment by 5.1% (p < 0.001), and to 9 months post-treatment by 15.6% (p < 0.001) in patients developing recurrence. Patients without recurrence lost SMI at the simulation CT by 0.7% (p = 0.001) and at 3 months post-treatment by 2.1% (p < 0.001); their SMI returned to the baseline level at 9 months post-treatment. SMI changes were weakly correlated with changes in body mass index (BMI) (Spearman ρ, 0.13; p = 0.11). In multivariate analysis, SMI changes (per 5% decrease) were independently associated with significantly worse OS (hazard ratio: 1.88, 95% confidence interval: 1.58-2.23; p < 0.001) and RFS (hazard ratio: 1.89, 95% confidence interval: 1.61-2.20; p < 0.001).

CONCLUSION

Progressive muscle loss was independently associated with worse survival outcomes in patients with stage III-IVB OSCC. Muscle loss might not be detected by changes in BMI.

An overview of anamorelin as a treatment option for cancer-associated anorexia and cachexia

INTRODUCTION

Cancer cachexia is a complex multifaceted syndrome involving functional impairment, changes in body composition, and nutritional disorders. The treatment of cancer cachexia can be based on these three domains of the syndrome. Phase II and III trials of anamorelin, a ghrelin mimetic agent, have been shown to increase body weight in patients with cancer cachexia, mainly by increasing muscle and fat mass. Anamorelin has been shown to improve anorexia scores.

AREAS COVERED

This review aims to outline the effect of anamorelin on body composition and functional parameters as well as to discuss the clinical importance of these alterations in patients with cancer cachexia.

EXPERT OPINION

To date, there is no treatment approved to enhance body composition and functional parameters in patients with cancer cachexia. Anamorelin, the most advanced therapy to treat cachexia, has not yielded convincing results in all aspects of the syndrome. In particular, no effect has been noted on physical function and long-term survival. Along with these essential improvements for future interventions with anamorelin, subsequent studies must address other etiologies of cancer, rather than non-small cell lung cancer, and add complementary therapies, such as exercise training and nutritional interventions, in an attempt to overcome cancer cachexia.

Sarcopenia and low muscle radiodensity associate with impaired FEV1 in allogeneic haematopoietic stem cell transplant recipients

BACKGROUND

Quantification of skeletal muscle using computed tomography (CT) is accessible using cancer patients' standard oncologic images. Reduced muscle mass may be related to reduced respiratory muscle strength; however, the impact of this on lung functional parameters is not characterized in adult allogeneic haematopoietic stem cell transplant (alloHCT) recipients.

METHODS

A consecutive retrospective series (n = 296) of patients who had alloHCT at a comprehensive cancer centre between March 2005 and April 2015 were included. Pre-transplant CT scans were used to quantify skeletal muscle and adipose tissue at the fourth thoracic (T4) and/or third lumbar (L3) level. Tumour and patient characteristics were recorded, including forced expiratory volume in 1 second (FEV1 ) by spirometry. Regression models were created to characterize predictive relationships.

RESULTS

A total of 296 patients (♂n = 161; ♀n = 135) were included, all of whom had chest CT as part of standard care; a subset of these (n = 215, 72.6%) also had abdominal CT. Diagnoses were non-Hodgkins lymphoma (n = 165), acute myeloid leukaemia (n = 66), Hodgkin's disease (n = 14), acute lymphocytic leukaemia (n = 14), myelodysplastic syndromes (n = 18), and other (n = 19). In multivariable linear regression adjusted for sex (P < 0.0001), age (P < 0.0001), haematopoietic cell transplantation-specific co-morbidity index (P = 0.010), and parameters of pulmonary function testing (defined by spirometry, P < 0.0001), both T4 muscle index [β 0.127 (95% confidence interval 0.019; 0.252), P < 0.0001] and T4 muscle radiodensity [β 0.132 (95% confidence interval 0.087; 0.505), P = 0.006] were independently associated with FEV1 ; disease risk index (P = 0.877) and Karnofsky performance status (P = 0.548) were not associated with FEV1 . Similar conclusions were obtained when L3 muscle index and radiodensity were considered. Unlike T4, L3 muscle index values can be compared with published cut-off values for sarcopenia. Overall rates of sarcopenia were uniformly higher in the HCT population than in age-matched and sex-matched patients with solid tumours [alloHCT ♂64.7% vs. solid tumour ♂56.6% (P < 0.001); alloHCT ♀57.6% vs. solid tumour ♀36.0% (P < 0.001)]. Significant but moderate correlations (P < 0.001) were found for muscle area and radiodensity between L3 and T4, for both men and women; adipose tissue quantity also correlated significantly (P < 0.001) between L3 and T4 for both men and women.

CONCLUSIONS

Lumbar or thoracic CT images are useful for body composition assessment in this population and reveal high rates of sarcopenia, similar to those reported in very elderly patients. Reduced muscle mass and radiodensity associate with impaired FEV1 even after adjustment for clinical covariables including co-morbidities, performance status, disease risk, and mild intrinsic pulmonary disease (chronic obstructive pulmonary disease) defined by spirometry.

Sarcopenia and Systemic Inflammation Synergistically Impact Survival in Oral Cavity Cancer

OBJECTIVES

Sarcopenia and systemic inflammation can affect survival of advanced-stage oral squamous cell carcinoma (OSCC) patients; however, their reciprocal associations with survival outcomes are yet to be investigated.

STUDY DESIGN

Retrospective review at a tertiary cancer center.

METHODS

Patients with stage III-IVB OSCC that underwent surgery and (chemo)radiotherapy at our institution between 2010 and 2015 were reviewed. Skeletal muscle index (SMI) was assessed using computed tomography scans at the C3 vertebra. Sarcopenia was defined at the lowest sex-specific tertile for SMI. Systemic inflammation was estimated using the modified Glasgow prognostic score (mGPS), which ranges from 0 to 2 based on serum C-reactive protein and albumin levels. The predictors of overall survival (OS) were evaluated using Cox regression models.

RESULTS

A total of 174 patients were included in the study. The cut-off values for sarcopenia were set at SMI <52.4 cm² /m² (men) and < 36.2 cm² /m² (women) corresponding to the lowest sex-specific tertile. An mGPS 1-2 was independently associated with sarcopenia (odds ratio: 2.05; 95% confidence interval: 1.06-3.97; P = .03). On multivariate analysis for OS, sarcopenia and mGPS 1-2 independently predicted OS (hazard ratio: 2.12; 95% confidence interval: 1.17-3.85; P = .01 and hazard ratio: 7.85; 95% confidence interval: 3.7-16.65; P < .001, respectively). Patients with both sarcopenia and mGPS 1-2 (vs. neither) had worse OS (hazard ratio: 16.80; 95% confidence interval: 6.01-46.99; P < .001).

CONCLUSIONS

Sarcopenia and systemic inflammation may exert a negative synergistic prognostic impact in advanced-stage OSCC patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1530-E1538, 2021.

Sarcopenia: An important prognostic factor for males treated for a locally advanced esophageal carcinoma

INTRODUCTION

Sarcopenia is a prognostic factor of esophageal carcinoma (EC) before surgery, with less convincing data reported before chemoradiotherapy (CRT).

MATERIAL AND METHODS

All patients with a locally advanced EC who had been treated with upfront CRT, between 2010 and 2015, were included. The decision of surgery was made after CRT (40-50 Gy). Muscle mass was measured on a single third lumbar vertebra CT-scan slice. Sarcopenia was internationally defined as skeletal muscle index of ≤39cm2/m2 for women and ≤55cm2/m2 for men. Results were additionally analyzed according to clinical parameters, with a cut-off based on the mean skeletal muscle lumbar index (SMI) of the population studied.

RESULTS

Overall, 104 patients were included (male: 69%). Mean SMI was 35cm2/m2 for women and 46cm2/m2 for men, with 81% of patients being sarcopenic (n = 84). The 3-year overall survival (OS) rate, of 34.6%, was not significantly associated with sarcopenia in the whole population. In men, there was, however, a highly significant correlation between SMI and OS (p = 0.003), which remained significant upon multivariate analysis (p = 0.02). When using the mean SMI as cut-off, sarcopenia was significantly associated with 3-year OS (43.3% vs. 26.2%, p = 0.02).

CONCLUSION

A high sarcopenia level appears negatively associated with OS in male EC patients treated with upfront CRT.

Percentiles for body composition parameters based on computed tomography in patients with endometrial cancer

OBJECTIVES

The aim of this study was to provide the percentiles of distribution of body composition parameters according to cancer staging and body mass index (BMI) stratum, as well as to identify the contribution of age, BMI, and cancer staging in the variation of the different parameters of body composition in a population of patients with endometrial cancer.

METHODS

We enrolled 545 patients who had pretreatment computed tomography images, which were used to assess total skeletal muscle (SM); low- and high-radiodensity SM; visceral, subcutaneous, and intramuscular adipose tissue; and mean skeletal muscle radiodensity (SMD). All the body composition parameters were normalized by the square of the stature. They were then presented on average and at the 5th, 50th and 95th percentiles. The correlation of these parameters with age, BMI, and cancer stage was tested, and then a multiple linear regression analysis was performed. P ≤ 0.05 was accepted as statistically significant.

RESULTS

BMI was associated with body fat parameters and low-radiodensity SM index; cancer stage was associated with SM index, mean SMD, and high-radiodensity SM index.

CONCLUSION

This study provides age, stage, and BMI specific percentiles for body composition parameters, which allowed an in-depth interpretation of how such body compartments, especially the low/high SM sub-ranges, varies according to these stratification variables.

Lymph Node Number Predicts the Efficacy of Adjuvant Chemoradiotherapy in Node-Positive Endometrial Cancer Patients

This study aimed to evaluate the value of lymph node (LN) number as a predictor for adjuvant treatment in node-positive endometrial cancer. Data of 441 patients diagnosed with International Federation of Gynaecology and Obstetrics (FIGO) stage IIIC endometrial cancer and who underwent adjuvant chemotherapy alone or chemoradiotherapy between 2009 and 2015 from the Taiwan Cancer Registry were reviewed. The patients were stratified based on the number of positive LN as follows: 1, 2-5, and ≥ 6. The overall survival (OS) was analysed using the Kaplan-Meier method and the Cox proportional hazards model. In multivariable analysis, chemoradiotherapy was independently associated with improved OS (hazard ratio [HR]: 0.62, 95% confidence interval [CI]: 0.43-0.90; p = 0.01) compared with chemotherapy alone. Patients with ≥ 6 positive LNs were associated with a worse OS (HR: 2.22, 95% CI: 1.25-3.95; p = 0.006) and those with 2-5 LNs were not associated with a worse OS (HR: 1.56, 95% CI: 0.94-2.59; p = 0.09) compared to patients with one LN. When stratified based on LN number, chemoradiotherapy was found to significantly improve the 5-year OS of patients with ≥ 6 positive LNs compared to chemotherapy alone (35.9% vs. 70.0%, p < 0.001). No significant differences between chemotherapy alone and chemoradiotherapy were observed in 5-year OS among patients with one LN (73.1% vs. 80.8%, p = 0.31) or 2-5 positive LNs (71.4% vs. 75.7%, p = 0.68). Lymph node number may be used to identify node-positive endometrial cancer patients who are likely to have improved OS with intensification of adjuvant therapy.

Interleukin-4 administration improves muscle function, adult myogenesis, and lifespan of colon carcinoma-bearing mice

BACKGROUND

Anorexia, body wasting, inflammation, muscle, and adipose tissue loss are hallmarks of cancer cachexia, a syndrome that affects the majority of cancer patients, impairing their ability to endure chemotherapeutic therapies and reducing their lifespan. In the last 10 years, alterations of protein turnover and impairment of adult myogenesis have been proposed as major contributing factors.

METHODS

Muscle stem cells, including satellite cells, mesoangioblasts, and fibroadipogenic progenitors, were isolated and characterized from C26 colon carcinoma-bearing (C26) mice. Circulating levels of interleukin-4/13 (IL4/IL13) were analysed by ELISA, and the effects of IL4 on muscle mass and function, protein synthesis, muscle regeneration, and myogenic progenitor cell number were analysed at both functional (treadmill and grip test) and molecular levels (qRT-PCR, immunofluorescence analysis, surface sensing of translation, and western blot). The Kaplan-Meier test was used to analyse the survival curve of IL4-treated and IL4-untreated C26 mice.

RESULTS

The administration of IL4 to C26 mice rescued muscle mass by increasing protein synthesis. The IL4 treatment improved performances and prolonged survival of C26 mice. IL4 administration re-established both number and function of satellite cells and fibroadipogenic progenitors without affecting mesoangioblasts in C26 mice, rescuing myogenesis. Upon IL4 treatment, a high number of cytotoxic lymphocytes and type II macrophages were observed with a subsequent increase in necrotic areas of C26 tumours.

CONCLUSIONS

The results here presented shed new light on IL4 signalling during muscle wasting and early stages of muscle regeneration that explain the beneficial effect observed in IL4-treated C26 mice. These findings might aid to develop therapeutic approaches to improve mobility and quality of life in cachectic patients.

Assessing skeletal muscle radiodensity by computed tomography: An integrative review of the applied methodologies

Low-radiodensity skeletal muscle has been related to the degree of muscle fat infiltration and seems to be associated with worse outcomes. The aim of this study was to summarize the methodologies used to appraise skeletal muscle radiodensity by computed tomography, to describe the terms used in the literature to define muscle radiodensity and to give recommendations for its measurement standardization. An integrative bibliographic review in four databases included studies published until August 2019 in Portuguese, English or Spanish and performed in humans, adults and/or the elderly, of both sex, which investigated skeletal muscle radiodensity through computed tomography (CT) of the region between the third and fifth lumbar vertebrae and evaluated at least two muscular groups. One hundred and seventeen studies were selected. We observed a trend towards selecting all abdominal region muscle. A significant methodological variation in terms of contrast use, selection of skeletal muscle areas, radiodensity ranges delimitation and their cut-off points, as well as the terminologies used, was also found. The methodological differences detected are probably due to the lack of more precise information about the correlation between skeletal muscle radiodensity by CT and its molecular composition, among others. Therefore, until the gaps are addressed in future studies, authors should avoid arbitrary approaches when reporting skeletal muscle radiodensity, especially when it comes to prognosis inference. Studies using both CT and direct methods of muscle composition evaluation are encouraged, to enable the definition and validation of the best approach to classify fat-infiltrated muscle tissue, which will favour the nomenclature uniformization.

Muscle loss during primary debulking surgery and chemotherapy predicts poor survival in advanced-stage ovarian cancer

BACKGROUND

Sarcopenia is commonly observed in patients with advanced-stage epithelial ovarian cancer (EOC). However, the effect of body composition changes-during primary debulking surgery (PDS) and adjuvant platinum-based chemotherapy-on outcomes of patients with advanced-stage EOC is unknown. This study aimed to evaluate the association between body composition changes and outcomes of patients with stage III EOC treated with PDS and adjuvant platinum-based chemotherapy.

METHODS

Pre-treatment and post-treatment computed tomography (CT) images of 139 patients with stage III EOC were analysed. All CT images were contrast-enhanced scans and were acquired according to a standardized protocol. The skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), and total adipose tissue index were measured using CT images obtained at the L3 vertebral level. Predictors of overall survival were identified using Cox regression models.

RESULTS

The median follow-up was 37.9 months. The median duration between pre-treatment and post-treatment CT was 182 days (interquartile range: 161-225 days). Patients experienced an average SMI loss of 1.8%/180 days (95% confidence interval: -3.1 to -0.4; P = 0.01) and SMD loss of 1.7%/180 days (95% confidence interval: -3.3 to -0.03; P = 0.046). SMI and SMD changes were weakly correlated with body mass index changes (Spearman ρ for SMI, 0.15, P = 0.07; ρ for SMD, 0.02, P = 0.82). The modified Glasgow prognostic score was associated with SMI loss (odds ratio: 2.42, 95% confidence interval: 1.03-5.69; P = 0.04). The median time to disease recurrence was significantly shorter in patients with SMI loss ≥5% after treatment than in those with SMI loss <5% or gain (5.4 vs. 11.2 months, P = 0.01). Pre-treatment SMI (1 cm² /m² decrease; hazard ratio: 1.08, 95% confidence interval: 1.03-1.11; P = 0.002) and SMI change (1%/180 days decrease; hazard ratio: 1.04, 95% confidence interval: 1.01-1.08; P = 0.002) were independently associated with poorer overall survival. SMD, body mass index, and total adipose tissue index at baseline and changes were not associated with overall survival.

CONCLUSIONS

Skeletal muscle index decreased significantly during treatment and was independently associated with poor overall survival in patients with stage III EOC treated with PDS and adjuvant platinum-based chemotherapy. The modified Glasgow prognostic score might be a predictor of SMI loss during treatment.

Muscle Loss after Chemoradiotherapy as a Biomarker of Distant Failures in Locally Advanced Cervical Cancer

This study aimed to evaluate whether computed tomography (CT)-based muscle measurement predicts distant failure in patients with locally advanced cervical cancer (LACC). Data from 278 patients with LACC who underwent chemoradiation therapy (CCRT) between 2004 and 2017 were analysed. Changes in the skeletal muscle index (SMI), skeletal muscle density, and total adipose tissue index during CCRT were calculated from CT images taken at the baseline and after CCRT. The predictive capability of CT-based muscle measurement for distant failure was evaluated using Cox proportional hazards regression, Harrell’s concordance index (C-index), and time-dependent receiver operating characteristic curves. SMI loss ≥ 5% was independently associated with worse distant recurrence-free survival (DRFS) (HR: 6.31, 95% CI: 3.18–12.53; p < 0.001). The addition of muscle change to clinical models, including International Federation of Gynaecology and Obstetrics (FIGO) stage, lymph nodes, pathology, and squamous cell carcinoma-antigen, achieved higher C-indices (0.824 vs. 0.756; p < 0.001). Models including muscle change had superior C-indices than those including weight change (0.824 vs. 0.758; p < 0.001). The area under the curve for predicting 3-year DRFS was the highest for the muscle-loss model (0.802, muscle-loss model; 0.635, clinical model; and 0.646, weight-loss model). Our study demonstrated that muscle loss after CCRT was independently associated with worse DRFS and that integrating muscle loss into models including classical prognostic factors improved the prediction of distant failure.

Changes in Body Composition During Adjuvant FOLFOX Chemotherapy and Overall Survival in Non-Metastatic Colon Cancer

The impact of longitudinal anthropometric changes during adjuvant chemotherapy on long-term survival in non-metastatic colon cancer is unclear. Herein, we analyzed the prognostic significance of computed tomography (CT)-measured body composition changes in colon cancer patients who underwent surgery followed by adjuvant FOLFOX (folinic acid, 5-fluorouracil, oxaliplatin) chemotherapy. Data of 167 patients with stage III or high-risk stage II colon cancer were analyzed. Skeletal muscle index (SMI), skeletal muscle radiodensity (SMR), visceral fat index (VFI), subcutaneous fat index (SFI), and total fat index (TFI) changes during chemotherapy were calculated using preoperative and postchemotherapy CT image data. The Cox proportional hazard model was used to determine the correlation between changes in anthropometric values and overall survival (OS). The median changes (%) in SMI, SMR, VFI, SFI, and TFI over 210 days during chemotherapy were 8.7% (p < 0.001), 3.4% (p = 0.001), -19% (p < 0.001), -3.4% (p = 0.936), and -11.9% (p < 0.001), respectively. Cut-off values of changes in SMI (skeletal muscle index change, SMIC) and SMR (skeletal muscle radiodensity change, SMRC) were defined at -2% and -2 Hounsfield units (HU) respectively, whereas those of changes in VFI (visceral fat index change, VFIC), SFI (subcutaneous fat index change, SFIC), and TFI (total fat index change, TFIC) were based on values that provided the largest χ2 on the Mantel-Cox test. Multivariable analysis revealed that low SMR measured on a postchemotherapy CT scan (hazard ratio, HR: 0.32, 95% confidence interval, CI: 0.15-0.70, p = 0.004) and visceral fat loss of at least 46.57% (HR: 0.31, 95% CI: 0.14-0.69, p = 0.004) were independent poor prognostic factors for OS. Severe visceral fat loss during FOLFOX chemotherapy and low skeletal muscle radiodensity measured on postchemotherapy CT scans are associated with poor OS in stage III and high-risk stage II colon cancer patients.

Myosteatosis and prognosis in cancer: Systematic review and meta-analysis

BACKGROUND

The evidence that body composition parameters influence multiple cancer outcomes is rapidly expanding. Excess adiposity deposits in muscle tissue, termed myosteatosis, can be detected in CT scans through variations in the density of muscle tissues (Hounsfield Units). Patients with similar muscle mass but different amounts of intramuscular adipose infiltration have increased chemotherapy toxicity, time to tumor progression and other adverse outcomes among different cancer types. Our review examines the impact of myosteatosis on overall survival (OS) in patients with cancer.

METHODS

A systematic search of the literature was conducted on PubMed/ MEDLINE, Cochrane CENTRAL, and EMBASE. Meta-analysis was conducted using a random-effects model. Risk of bias was evaluated using the Newcastle-Ottawa Quality assessment for cohort studies, funnel plot (publication bias), and GRADE summary of findings tool from Cochrane.

RESULTS

A total of 4880 articles were screened from which 40 articles selected, including 21,222 patients. The overall mean proportion of patients with myosteatosis was 48 % (range 11-85 %). Using skeletal muscle density (SMD), patients classified as having myosteatosis had 75 % greater mortality risk compared to non-myosteatosis patients (HR 1.75 95 % CI 1.60-1.92, 40 studies) (p < .00001) (i2 = 62 %). Specifically, myosteatosis was prognostic for worse OS in patients with gynecological, renal, periampullary/pancreatic, hepatocellular, gastroesophageal, and colorectal carcinoma, and lymphomas.

CONCLUSION

Our analysis of the literature shows that cancer patients with myosteatosis have shorter survival. Our findings suggest that in oncological practice, muscle density assessment is valuable as a prognostic parameter.

Prognostic value of muscle measurement using the standardized phase of computed tomography in patients with advanced ovarian cancer

OBJECTIVES

The prognostic role of sarcopenia or myosteatosis is controversial in advanced-stage epithelial ovarian cancer (EOC). The phase of computed tomography (CT) could influence muscle measurement and confound its association with outcomes. This study evaluated the prognostic value of muscle measurement in patients with stage III EOC using a standardized phase of computed tomography.

METHODS

Pretreatment CT images of 147 patients with stage III EOC were analyzed. All CT images were contrast-enhanced and acquired according to the standardized protocol. Skeletal muscle index (SMI) and radiodensity (SMD) were measured using CT images at the level of the third lumbar vertebra. The skeletal muscle gauge (SMG) was calculated by multiplying SMI and SMD. Harrell's concordance index (C-index) and time-dependent receiver operating characteristic curves were used to measure the predictive value of the models.

RESULTS

The median follow-up period was 37.5 mo. SMI, SMD, and SMG were independently associated with overall survival when adjusted for clinical variables. Adding SMG to the model including stage, residual tumor, and malignant ascites significantly improved C-indices (0.704 vs. 0.629; P < 0.001). Models including SMG had a superior C-index compared with models including SMI and SMD (0.704 vs. 0.668; P = 0.01). The SMG model achieved the highest area under the curve for 5-year overall survival prediction (0.619 for clinical model, 0.702 for SMI model, and 0.710 for SMG model).

CONCLUSIONS

Muscle measurements obtained from a standardized phase of CT images were associated with survival in advanced-stage EOC. The integration of SMI and SMD into SMG may improve prognostication and unify findings in future studies.

Multiplatform Urinary Metabolomics Profiling to Discriminate Cachectic from Non-Cachectic Colorectal Cancer Patients: Pilot Results from the ColoCare Study

Cachexia is a multifactorial syndrome that is characterized by loss of skeletal muscle mass in cancer patients. The biological pathways involved remain poorly characterized. Here, we compare urinary metabolic profiles in newly diagnosed colorectal cancer patients (stage I-IV) from the ColoCare Study in Heidelberg, Germany. Patients were classified as cachectic (n = 16), pre-cachectic (n = 13), or non-cachectic (n = 23) based on standard criteria on weight loss over time at two time points. Urine samples were collected pre-surgery, and 6 and 12 months thereafter. Fat and muscle mass area were assessed utilizing computed tomography scans at the time of surgery. N = 152 compounds were detected using untargeted metabolomics with gas chromatography-mass spectrometry and n = 154 features with proton nuclear magnetic resonance spectroscopy. Thirty-four metabolites were overlapping across platforms. We calculated differences across groups and performed discriminant and overrepresentation enrichment analysis. We observed a trend for 32 compounds that were nominally significantly different across groups, although not statistically significant after adjustment for multiple testing. Nineteen compounds could be identified, including acetone, hydroquinone, and glycine. Comparing cachectic to non-cachectic patients, higher levels of metabolites such as acetone (Fold change (FC) = 3.17; p = 0.02) and arginine (FC = 0.33; p = 0.04) were observed. The two top pathways identified were glycerol phosphate shuttle metabolism and glycine and serine metabolism pathways. Larger subsequent studies are needed to replicate and validate these results.

Muscle radiodensity loss during cancer therapy is predictive for poor survival in advanced endometrial cancer

BACKGROUND

Treatment-related toxicities and decreased levels of patient performance during cancer therapy might contribute to body composition changes and thereby impact outcomes. However, the effect of longitudinal body composition changes on outcomes in patients with advanced endometrial cancer is unknown. This study investigated the association between body composition changes during staging surgery and adjuvant chemoradiotherapy and outcomes in patients with stage III endometrial cancer.

METHODS

Pretreatment and post-treatment computed tomography (CT) images of 131 patients with stage III endometrial cancer who were treated between 2008 and 2016 were analysed. All CT images were contrast enhanced and acquired according to the standardized protocol. The skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), and total adipose tissue index were measured from two sets of CT images obtained at the level of the third lumbar vertebra. The skeletal muscle gauge was calculated by multiplying SMI by SMD (SMI × SMD). Predictors of overall survival and progression-free survival were identified using Cox regression models.

RESULTS

The median follow-up was 50.6 (range 12.1-117.0) months. Overall, body mass index (BMI) changes during treatment were 0.4% per 210 days (95% confidence interval: -0.6 to 1.4; P = 0.41), and patients experienced an average SMD loss of 2.1% per 210 days (95% confidence interval: -4.0 to -0.2; P = 0.03). Weight loss and SMD loss ≥5% were observed in 23 (17.6%) and 54 (41.2%) patients, respectively. The changes in SMD did not correlate with those in BMI (Spearman's ρ for SMD, -0.13; P = 0.13). SMD change (per 1 Hounsfield unit/210 days decrease) was independently associated with poorer overall survival (hazard ratio: 1.32, 95% confidence interval: 1.14-1.52; P < 0.001) and progression-free survival (hazard ratio: 1.28, 95% confidence interval: 1.12-1.43; P < 0.001). Our results did not show association between survival and pretreatment myosteatosis and sarcopenia or changes in SMI and total adipose tissue index during treatment. The pretreatment skeletal muscle gauge was associated with treatment modifications such as delays, dose reductions, and discontinuation of chemotherapy.

CONCLUSIONS

Skeletal muscle radiodensity decreased significantly during treatment and was independently associated with poorer survival in patients with stage III endometrial cancer who underwent staging surgery and adjuvant chemoradiotherapy. SMD loss was occult and occurred independently of BMI change.