The impact of sarcopenia on survival and complications in surgical oncology: A review of the current literature--Author response

The combination of sarcopenia and biochemical factors can predict the survival of hepatocellular carcinoma patients receiving transarterial chemoembolization

Background

Transarterial chemoembolization(TACE) is the suggested treatment for hepatocellular carcinoma (HCC) not amenable to curative treatments. We investigated the role of sarcopenia on overall survival in HCC patients receiving TACE and proposed a new prognostic scoring system incorporating sarcopenia.

Materials and methods

We retrospectively analyzed 260 HCC patients who received TACE between 2010 and 2015. Total psoas muscle was measured on a cross-sectional CT image before the first TACE session. Sarcopenia was defined by the pre-determined sex-specific cutoff value. We assessed the impact of sarcopenia and other biochemical factors on the overall survival and compared the new scoring system with other prognostic scoring systems.

Results

One hundred and thirty patients (50%) were classified as sarcopenia before the first TACE. They were older with a higher male tendency and a significantly lower body mass index (BMI). Cox regression multivariate analysis demonstrated that sarcopenia, multiple tumors, maximal tumor diameter≥ 5cm, major venous thrombosis, sarcopenia, AFP ≥ 200 ng/ml, and albumin<3.5mg/dL were independent poor prognostic factors for overall survival in HCC patients receiving TACE. Our scoring system comprising these factors outperformed other major scoring systems in terms of predicting survival after TACE.

Conclusion

The current study demonstrated that sarcopenia was an independent prognostic factor for HCC undergoing TACE therapy. Our newly developed scoring system could effectively predict patient survival after TACE. Physicians could, based on the current score model, carefully select candidate patients for TACE treatment in order to optimize their survival. Further studies are warranted to validate our findings.

Clinical Impact of Sarcopenia 1 Year After Surgery for Patients with Early-Stage Non-small Cell Lung Cancer

BACKGROUND

Sarcopenia is associated with prognostic outcomes for patients with various solid tumors, whereas the clinical significance of sarcopenia 1 year after surgery (post-sarcopenia) for non-small cell lung cancer (NSCLC) has not been investigated. This study aimed to clarify the clinical impact of post-sarcopenia and factors associated with post-sarcopenia in NSCLC patients without preoperative sarcopenia.

METHODS

This study enrolled 443 patients with clinical stage 1 or 2 NSCLC (234 patients without preoperative sarcopenia [NS group] and 209 patients with preoperative sarcopenia [S group]) who underwent computed tomography (CT) at two time points (before surgery and a year afterward) or more. The study assessed CT images at the L3 level to calculate the psoas muscle area index (PAI). The PAI cutoff value for sarcopenia was defined as 6.36 cm²/m² for the men and 3.92 cm²/m² for the women.

RESULTS

In the NS group, the diagnosis for 40.1% of the women and 52.6% of the men was post-sarcopenia (NS-S group). The overall survival (OS) for the S and NS-S cohorts was worse than for the non-sarcopenic patients before and after surgery (p < 0.001 and p = 0.017, respectively). In the multivariable analysis, sarcopenia, either before or after surgery (hazard ratio, 3.272; p = 0.002), in the NS group was independently associated with OS, whereas the factors associated with post-sarcopenia were male sex (p = 0.002), aging (p < 0.001), and low body mass index (p < 0.001).

CONCLUSIONS

Sarcopenia, either before or after surgery, is prognostic in early-stage NSCLC. Male sex, aging, and low body mass index (BMI) are associated with post-sarcopenia.

Sarcopenia after induction therapy is associated with reduced survival in patients undergoing esophagectomy for locally-advanced esophageal cancer

Background

The impact of sarcopenia on the outcome of esophageal cancer patients remains unknown in North American populations. The current study aims to investigate if sarcopenia at the time of esophagectomy for locally-advanced esophageal cancer (LAEC) is associated with survival.

Methods

Patients who underwent induction therapy followed by esophagectomy for LAEC between 2010–2018 at a single institution were identified. Exclusion criteria included follow-up less than 90 days and distant metastatic disease at the time of surgery. Demographic, treatment, and outcome data were retrospectively collected. Computed tomography (CT) scans following induction therapy were analyzed to calculate skeletal muscle index (SMI). Overall survival (OS) and disease-free survival (DFS) were examined using Kaplan-Meier and Cox Proportional Hazard regression analysis.

Results

Overall, 52 patients met inclusion criteria with a median BMI of 25 (IQR, 22.4–29.1) kg/m² and age of 65 (IQR, 57–70) years. Sarcopenia was present in 75% (39/52) of patients at the time of surgery. Sarcopenic patients had a lower median BMI and higher median age when compared to non-sarcopenic patients. There was no difference in gender, race, stage, operative technique, post-operative complications, or hospital length of stay between sarcopenic and non-sarcopenic patients. With a median follow-up of 24.9 months, patients with sarcopenia at the time of esophagectomy had worse OS [median 24.3 (IQR, 9.9–34.5) vs. 50.9 (IQR, 25.6–50.9) months, P=0.0292] and DFS [median 11.7 (IQR, 6.4–25.8) vs. 29.4 (IQR, 12.8–26.7) months, P=0.0387] compared to non-sarcopenic patients.

Conclusions

Sarcopenia is associated with reduced overall and DFS in patients undergoing esophagectomy for LAEC.

Normalized Hand Grip and Back Muscle Strength as Risk Factors for Incident Type 2 Diabetes Mellitus: 16 Years of Follow-Up in a Population-Based Cohort Study

PURPOSE

Muscle strength is associated with type 2 diabetes mellitus (T2DM). However, it is controversial whether muscle strength and normalized muscle strength is a risk factor for T2DM. Moreover, the relationship of back muscle strength (BMS) and incident T2DM has not been reported. In this study, we investigated the relationship between HGS, BMS, normalized HGS and BMS, and incident T2DM.

METHODS

A total of 2699 non-diabetes subjects aged 40-69 years (1313 women and 1386 men) in the Korean Genome and Epidemiology Study (KoGES) Ansan cohort were followed for 16 years. At the baseline and biennial follow-up visits, fasting glucose, postprandial 2-h glucose, clinical examinations, HGS, and BMS were measured by trained interviewers and examiners. HGS and BMS were measured at baseline. The relationships between incident T2DM, HGS, BMS, and normalized HGS and BMS were estimated using Cox proportional hazard regression models after adjusting for the confounding factors.

RESULTS

HGS and BMS were not associated with incident T2DM in multivariate analysis. However, the hazard ratio (HR) per one standard deviation (SD) increase in the body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR)-normalized HGS, and BMS was associated with a lower risk for incident T2DM in both women and men after adjusting for the confounding factors (HR = 0.842-0.880-fold for women, p ≤ 0.015; HR = 0.887-0.903-fold for men, p ≤ 0.024). In the sub-analysis of menopause status, the HR per one SD increase in BMI, weight^2/3, WC, and WHR-normalized HGS was associated with a lower risk for incident T2DM in both pre- and post-menopausal women after adjusting for the confounding factors (HR = 0.860-0.820-fold for premenopausal, P ≤ 0.006; HR = 0.900-0.867-fold for postmenopausal, p ≤ 0.024). Additionally, we confirmed that the quartile group with higher muscle strength was associated with a lower risk for incident T2DM.

CONCLUSION

The present study suggested that normalized HGS and BMS were associated with a lower risk for the future development of T2DM. Moreover, weak muscle strength in premenopausal women may be the cause of T2DM. Further research is needed to determine whether efforts to improve muscle strength, such as exercise can reduce the risk of T2DM.

Pre-treatment psoas major volume is a predictor of poor prognosis for patients with epithelial ovarian cancer

Low skeletal muscle mass (sarcopenia) is an important prognostic risk factor for the outcome of a variety of cancer types. The current study investigated whether skeletal muscle area (SMA), psoas area (PA) and psoas major volume (PV) are associated with progression-free survival (PFS) and overall survival (OS) in patients with epithelial ovarian cancer (OC). A total of 92 OC patients were enrolled in the present study. Pre-treatment with SMA and PA was assessed using computed tomography (CT) and PV was calculated using a three-dimensional-CT (3D-CT). The clinical factors associated with sarcopenia and prognosis were retrospectively evaluated. For all patients, the median PFS and OS were 19 and 32 months, respectively. Patients exhibiting lower PV (<195.6 cm³) had significantly poorer PFS and OS compared with patients exhibiting higher PV (≥195.6 cm³; P=0.018 and P=0.006), while those with low SMA (<92.92 cm²) had significantly worse OS than patients with higher SMA (≥92.92 cm²; P=0.030). PV was also demonstrated to be superior to SMA and PA in prognosis prediction. PV by 3D-CT can serve as an indicator of poor prognosis in patients with OC.

Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction

Abdominoperineal resection (APR) carries a high risk of morbidity. Preoperative risk assessment can help with patient counseling, minimize adverse outcomes, and guide surgeons in their choice of reconstruction. This study examined the impact of sarcopenia (low lean muscle mass) on postoperative complications after APR.

Type 2 diabetes mellitus is associated with increased risks of sarcopenia and pre-sarcopenia in Chinese elderly

Sarcopenia is a condition characterized by progressive and generalized loss of skeletal muscle mass and function. In this study, we used a cross-sectional study with 1090 community-dwelling Chinese citizens aged 60 years and older to evaluate the association of type 2 diabetes mellitus (T2DM) with the risk of sarcopenia and pre-sarcopenia. Sarcopenia was defined using the Asian Working Group for Sarcopenia (AWGS) criteria that include both muscle mass and muscle function/physical activity. Pre-sarcopenia was defined as having low skeletal muscle index but with normal muscle/physical activity. The prevalence of sarcopenia and pre-sarcopenia was significantly higher in T2DM patients than in healthy controls (14.8% vs. 11.2%, p = 0.035 for sarcopenia, and 14.4% vs. 8.4%, p = 0.002 for pre-sarcopenia). In multivariate logistic regression analyses adjusting by age, gender, anti-diabetic medication, energy intake, protein intake, physical activity, and visceral fat area, we found that Chinese elderly with T2DM exhibited significantly increased risks of sarcopenia (OR = 1.37, 95% CI = 1.02-2.03) and pre-sarcopenia (OR = 1.73, 95% CI = 1.10-2.83) compared to non-diabetic individuals. This is the first study to evaluate the association of T2DM with the risks of sarcopenia and pre-sarcopenia in China. Among a group of community-dwelling Chinese elderly, T2DM was significantly associated with increased risks of sarcopenia and pre-sarcopenia.

Is surgery indicated for elderly patients with early stage nonsmall cell lung cancer, in the era of stereotactic body radiotherapy?

BACKGROUND

The aim of this article is to assess the influence of comorbidities among elderly patients (at least 70 year old) undergoing surgery for early stage nonsmall cell lung cancer (NSCLC) and to explore the tolerability and efficacy of surgery in relation to stereotactic body radiotherapy (SBRT) in this patient population.

METHODS

A review of the literature on the prevalence of comorbidities among elderly patients with early stage NSCLC, and the impact of comorbidity factors on survival following surgery was conducted. Survival rates and the incidence of complications following SBRT for this patient population were also identified.

RESULTS

Comorbidities in elderly patients with early stage NSCLC may preclude surgery or lead to poor survival following surgery. However, chronological age alone should not be used as a deciding factor to deny curative treatment in elderly, but fit patients. Stereotactic body radiotherapy is well tolerated by elderly lung cancer patients and may result in survival rates similar to that following surgery.

CONCLUSION

SBRT should be the treatment of choice for early stage NSCLC in elderly patients with multiple comorbidities that preclude surgery. The roles of surgery and SBRT for elderly, -fit patients with early stage NSCLC needs to be further defined in future prospective trials.