Skeletal muscle mass and quality as risk factors for postoperative outcome after open colon resection for cancer

Association of computed tomography-derived body composition and complications after colorectal cancer surgery: A systematic review and meta-analysis

The prediction of the risk of developing complications after colorectal surgery for colorectal carcinoma remains imprecise. Body composition measurements on a computed tomography (CT) scan can potentially contribute to a better preoperative risk assessment. The aim of this systematic review is to evaluate the evidence for the use of body composition measurements on CT scans to predict short-term complications after colorectal cancer surgery. A literature search (in PubMed, Embase and Web of Science) was performed up to 1 August 2022. Two researchers independently screened the articles, extracted data and assessed the quality of the studies using the Quality in Prognosis Studies tool. The primary outcome measure was the occurrence of complications within 30 days after surgery. Meta-analysis was conducted using a random-effects model to synthesize a pooled odds ratio (OR). The study protocol was registered in PROSPERO (CRD42021281010). Forty-five articles with a total of 16 537 patients were included. In total, 26 body composition measures were investigated: 8 muscle-related measures, 11 adipose tissue measures, 4 combined muscle and adipose tissue measures, and 3 other measures. These were investigated as potential predictors for more than 50 differently defined postoperative complications. Meta-analysis was only possible for two measurements and showed that higher amounts of visceral fat increase the risk of developing overall complications (OR: 2.52 [1.58-4.00], P < 0.0001) and anastomotic leakage (OR: 1.76 [1.17-2.65], P = 0.006). A wide variety of body composition measurements on preoperative CT scans have been investigated as a predictive factor for postoperative complications. Visceral fat appeared to be associated with overall complications and anastomotic leakage; however, the association is weak, and its clinical relevance or applicability is questionable. The current evidence is limited by methodological heterogeneity and the risk of bias. To improve comparability of results across studies and improve decision-making, future studies should use standardized methods for measuring body composition on CT scans, outcome definitions and statistical analyses.

Muscle matters: Skeletal muscle index and body mass index impact on complications and survival in renal cancer

Objective

The objective of this study is to independently assess skeletal muscle index (SMI) and body mass index (BMI) as prognostic determinants for renal cell carcinoma (RCC) and investigate their correlation with surgical outcomes.

Patients and methods

A retrospective cohort study of 524 RCC patients diagnosed between August 2010 and July 2018 was conducted using data from the Zealand University Hospital Renal Cancer Database in Denmark. Patient information was extracted from electronic patient records and the National Cancer Registry and encompassed demographics, clinical factors, tumour characteristics and surgical details. SMI was calculated from a single third lumbar vertebra (L3) axial computed tomography (CT) image via CoreSlicer software and classified into high using gender-specific thresholds. Primary outcomes focused on complications within 90 days as well as survival outcomes, and their relation with both SMI and BMI. Multivariable analysis assessed SMI's independent prognostic significance in RCC.

Results

Among 524 patients, 18.5% experienced complications, with high SMI correlating significantly (p = 0.018) with a 72% higher complication risk. High SMI patients had a 22.7% complication rate compared to 14.5% in the low SMI group. High SMI was also linked to prolonged survival (110.95 vs. 94.87 months; p = 0.001), whereas BMI showed no significant survival differences (p = 0.326). Multivariable analysis (n = 522) revealed high SMI associated with improved survival (hazard ratio [HR] = 0.738; 95% CI, 0.548-0.994; p = 0.046). Advanced T-stage significantly impacted mortality (T2: HR = 2.057; T3: HR = 4.361; p < 0.001), and each additional year of age raised mortality risk by 4.3% (HR = 1.043; p < 0.001).

Conclusions

Higher SMI increases the risk of postoperative complications, yet it significantly improves overall survival rates. Different BMI categories lack RCC prognostic significance. The increasing incidence in RCC calls for the use of CT scan to assess SMI and aid treatment planning in patients who might benefit from preoperative interventions.

Thigh muscle by CT images as a predictor of mortality in patients with newly diagnosed colorectal cancer

This study aimed to evaluate the prognostic value of thigh muscle assessed by CT images to predict overall mortality in patients with colorectal cancer (CRC). This was a multicenter cohort study including adults (≥ 18 years old) newly diagnosed with CRC, who performed a diagnostic computed tomography (CT) exam including thigh regions. CT images were analyzed to evaluate skeletal muscle (SM in cm2), skeletal muscle index (SMI in cm2/m2), and skeletal muscle density (SMD in HU). Muscle abnormalities (low SM, SMI, and SMD) were defined as the values below the median by sex. Kaplan-Meyer curves and hazard ratios (HRs) for low SM, SMI and SMD were evaluated for overall mortality, stratified by sex. A total of 257 patients were included in the final analysis. Patients' mean age was 62.6 ± 12.1 years, and 50.2% (n = 129) were females. In males, low thigh SMI was associated with shorter survival (log-rank P = .02). Furthermore, this low thigh SMI (cm2/m2) was independently associated with higher mortality rates (HR adjusted 2.08, 95% CI 1.03-4.18). Our additional findings demonstrated that low SMD was independently associated with overall mortality among early-stage patients (I-III) (HR adjusted 2.78, 95% CI 1.26-6.15).

Automated CT Analysis of Body Composition as a Frailty Biomarker in Abdominal Surgery

Importance

Prior studies demonstrated consistent associations of low skeletal muscle mass assessed on surgical planning scans with postoperative morbidity and mortality. The increasing availability of imaging artificial intelligence enables development of more comprehensive imaging biomarkers to objectively phenotype frailty in surgical patients.

Objective

To evaluate the associations of body composition scores derived from multiple skeletal muscle and adipose tissue measurements from automated segmentation of computed tomography (CT) with the Hospital Frailty Risk Score (HFRS) and adverse outcomes after abdominal surgery.

Design, Setting, and Participants

This retrospective cohort study used CT imaging and electronic health record data from a random sample of adults who underwent abdominal surgery at 20 medical centers within Kaiser Permanente Northern California from January 1, 2010, to December 31, 2020. Data were analyzed from April 1, 2022, to December 1, 2023.

Exposure

Body composition derived from automated analysis of multislice abdominal CT scans.

Main Outcomes and Measures

The primary outcome of the study was all-cause 30-day postdischarge readmission or postoperative mortality. The secondary outcome was 30-day postoperative morbidity among patients undergoing abdominal surgery who were sampled for reporting to the National Surgical Quality Improvement Program.

Results

The study included 48 444 adults; mean [SD] age at surgery was 61 (17) years, and 51% were female. Using principal component analysis, 3 body composition scores were derived: body size, muscle quantity and quality, and distribution of adiposity. Higher muscle quantity and quality scores were inversely correlated (r = -0.42; 95% CI, -0.43 to -0.41) with the HFRS and associated with a reduced risk of 30-day readmission or mortality (quartile 4 vs quartile 1: relative risk, 0.61; 95% CI, 0.56-0.67) and 30-day postoperative morbidity (quartile 4 vs quartile 1: relative risk, 0.59; 95% CI, 0.52-0.67), independent of sex, age, comorbidities, body mass index, procedure characteristics, and the HFRS. In contrast to the muscle score, scores for body size and greater subcutaneous and intermuscular vs visceral adiposity had inconsistent associations with postsurgical outcomes and were attenuated and only associated with 30-day postoperative morbidity after adjustment for the HFRS.

Conclusions and Relevance

In this study, higher muscle quantity and quality scores were correlated with frailty and associated with 30-day readmission and postoperative mortality and morbidity, whereas body size and adipose tissue distribution scores were not correlated with patient frailty and had inconsistent associations with surgical outcomes. The findings suggest that assessment of muscle quantity and quality on CT can provide an objective measure of patient frailty that would not otherwise be clinically apparent and that may complement existing risk stratification tools to identify patients at high risk of mortality, morbidity, and readmission.

Evolving concepts on perioperative nutrition of sarcopenic cancer patients

The recent recognition of the association of sarcopenia with an increased risk of complications after a surgical procedure calls for rethinking the proper approach of the perioperative care in cancer patients. Sarcopenia is broadly considered in literature according to three different definitions: loss of muscle mass, loss of muscle mass plus reduced muscle function and myosteatosis. The aim of this short review on this issue is to define the excess of risk by type of primary and of surgical procedure, depending on the definition of sarcopenia, to speculate on this association (casual versus causal) and to examine the current therapeutical approaches. The analysis of the data shows that sarcopenia, defined as loss of muscle mass plus reduced muscle function, has the higher predictive power for the occurrence of postoperative complications than the two other definitions, and any definition of sarcopenia works better than the usual indexes or scores of surgical risk. Our analysis supports the concept that: a) sarcopenia is frequently associated with inflammation, but inflammation cannot be considered the only or the absolute cause for sarcopenia, b) sarcopenia is not a simple marker of risk but can have a direct role in the increase of risk. Data on perioperative care of sarcopenic cancer patients are scanty but a correct approach cannot rely on nutritional support alone but on a combined approach of optimized nutrition and exercise, hopefully associated with an anti-inflammatory treatment. This strategy should be applied proactively in keeping with the recent recommendations of the American Society of Clinical Oncology for the medical treatment of advanced cancer patients even if a clear demonstration of effectiveness is still lacking.

Sarcopenia and Neuroendocrine Neoplasms

PURPOSE OF THE REVIEW

To summarise the current literature regarding the presence of sarcopenia in patients with neuroendocrine neoplasms (NENs). These are uncommon cancers separated into well-differentiated neuroendocrine tumours (NETs) and poorly differentiated neuroendocrine carcinoma (NECs). For the diagnosis of sarcopenia, there needs to be low muscle strength and low muscle quantity/quality.

RECENT FINDINGS

Five studies exist describing either low muscle strength or low muscle quantity in patients with NETs. The studies used different techniques to analyse muscle strength and muscle quantity, included heterogeneous populations, and performed the analysis at different time points following the diagnosis of the NET. Only 2 studies regarding patients with NECs could be found, both included mainly patients with a mixed adenoneuroendocrine carcinoma (MiNEN) and are, therefore, difficult to interpret for patients with a NEC. The main findings of this review are to describe the presence of sarcopenia in patients with NENs. However, results should be interpreted with caution, and future research should focus on the correct technique, homogenous population and same time point.

Age as a modifier of the effects of sarcopenia on survival among colon cancer patients after surgery

BACKGROUND

Studies have been conducted to evaluate whether sarcopenia is a predictor for survival in patients with colon cancer postsurgery, but findings have been inconsistent, and effects of age were seldom evaluated.

METHODS

We recruited 133 patients with resectable colon cancer who underwent surgery between January 2014 and December 2017 at a teaching hospital to evaluate the effects of sarcopenia on survival, after adjusting for age and other potential predictors, including visceral adiposity (VA).

RESULTS

Preoperative sarcopenia was associated with worse overall survival (OS: 62.3% vs. 83.8%, p = 0.04) and longer hospital stay (20.6 vs. 14.9 days, p < 0.01) while VA was not. Cox proportional hazards regressions showed that sarcopenia was associated with an adjusted hazard ratio (HR) of 2.91 (95% confidence interval [CI]: 1.08-7.86) after adjustment for other independent risk factors, but was not associated with disease free survival. In stratified analyses, we found that sarcopenia was an independent factor for worse OS (adjusted HR = 1.94; 95% CI: 1.11-3.38) among patients >70 years, but not among patients ≤70 years (HR = 0.48; 95% CI: 0.55-4.55).

CONCLUSIONS

Age appeared to be a modifier of the effects of sarcopenia on OS among colon cancer patients postsurgery.

Diagnosis and prevalence of sarcopenic obesity in patients with colorectal cancer: A scoping review

BACKGROUND & AIMS

Sarcopenic obesity (SO) is associated with worse outcomes in patients with colorectal cancer (CRC); however, the diagnostic methods and prevalence of SO vary among studies. Therefore, we conducted this scoping review to investigate the diagnosis of SO in CRC, identify the associated problems, and determine its prevalence.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guidelines. A literature search was performed by two independent reviewers on studies that diagnosed SO in CRC using the MEDLINE, EMBASE, CINAHL, CENTRAL, Web of Science, and Ichushi-Web (in Japanese) databases. Observational, longitudinal, cross-sectional, and clinical trials written in English or Japanese as of July 2022 were included. Studies that did not define SO were excluded from the analysis. The study protocol was pre-registered in Figshare.

RESULTS

In total, 670 studies were identified, 22 of which were included. Eighteen studies used sarcopenia in combination with obesity to diagnose SO. Sarcopenia was mainly diagnosed using skeletal muscle mass index (SMI), and only one combined with grip strength or gait speed. Obesity was diagnosed based on the body mass index (BMI; n = 11), followed by visceral fat area (VFA; n = 5). The overall prevalence of SO in patients with CRC was 15% (95%CI, 11-21%). The prevalence of SO in surgical resection and colorectal cancer liver metastases was 18% (95%CI, 12-25%) and 11% (95%CI, 3-36%), respectively.

CONCLUSIONS

SO in patients with CRC was mainly diagnosed based on a combination of SMI and BMI, and muscle strength and body composition were rarely evaluated. The prevalence of SO was approximately 15%, depending on the diagnostic methods used. Since SO in patients with CRC is associated with poor prognosis, further research on diagnostic methods for the early detection of SO and its clinical outcomes is needed.

Preoperative evaluation of sarcopenia in patients with colorectal cancer: a prospective study

OBJECTIVE

Colorectal cancer is the third most diagnosed malignant neoplasm in the world and the fourth leading cause of cancer mortality. The loss of muscle mass in oncological patients is the main aspect of cancer-related malnutrition. Associations between sarcopenia and poor outcomes, such as high postoperative mortality, chemotherapy toxicity, and reduced survival, have been recently described. The aim of this study was to prospectively assess the prevalence of preoperative sarcopenia in patients with colorectal cancer using validated methods to evaluate muscle strength, muscle mass, and physical performance.

METHODOLOGY

This study included patients with colorectal cancer undergoing oncological staging at a Cancer Center in Brazil from May 2019 to March 2020 who had images from abdominal computed tomography available for analysis of body composition. The muscle strength test, physical performance, referred fatigue, and clinical and nutritional data were evaluated.

RESULTS

A total of 31 patients were included, and most were diagnosed with colon cancer (77.4%) and clinical stage II in 41.9% of cases. The prevalence of probable sarcopenia was 22.6%; of these patients, sarcopenia was confirmed in 19.4%, and ultimately, 9.7% of the sample was classified as severe sarcopenia. We did not find a significant association between the presence of sarcopenia in our sample and age, sex, tumor staging, nutritional characteristics, referred patient fatigue, or postoperative complications.

CONCLUSION

Considering the criteria established by the EWGSOP, the prevalence of preoperative sarcopenia in colorectal cancer patients was 19.4%.

Surgery-Related Muscle Loss after Pancreatic Resection and Its Association with Postoperative Nutritional Intake

To study the occurrence of surgery-related muscle loss (SRML) and its association with in-hospital nutritional intake, we conducted a prospective observational cohort study including patients who underwent pancreatic surgery because of (suspected) malignant diseases. Muscle diameter was measured by using bedside ultrasound 1 day prior to surgery and 7 days postoperatively. Clinically relevant SRML was defined as ≥10% muscle diameter loss in minimally one arm and leg muscle within 1 week after surgery. Protein and caloric intake was measured by nutritional diaries. The primary endpoint included the number of patients with SRML. Secondary endpoints included the association between SRML and postoperative nutritional intake. Of the 63 included patients (60.3% men; age 67.1 ± 10.2 years), a total of 24 patients (38.1%) showed SRML. No differences were observed in severe complication rate or length of hospital stay between patients with and without SRML. During the first postoperative week, patients with clinically relevant SRML experienced more days without any nutritional intake compared with the non-SRML group (1 [0-4] versus 0 [0-1] days, p = 0.007). Significantly lower nutritional intake was found in the SRML group at postoperative days 2, 3 and 5 (p < 0.05). Since this study shows that SRML occurred in 38.1% of the patients and most of the patients failed to reach internationally set nutritional goals, it is suggested that more awareness concerning direct postoperative nutritional intake is needed in our surgical community.

Negative prognostic impact of sarcopenia before and after neoadjuvant chemotherapy for pancreatic cancer

OBJECTIVES

To elucidate the prognostic impact of sarcopenia before and after neoadjuvant chemotherapy (NAC) for pancreatic cancer (PC).

METHODS

We retrospectively studied 75 consecutive PC patients who underwent neoadjuvant gemcitabine plus S-1 combination therapy followed by pancreatectomy between 2008 and 2016. According to the skeletal muscle volume index (SMI), the patients were divided into the muscle attenuation group (MAG) and normal group (NG) before or after NAC. Prognostic factors for overall survival (OS) were analyzed by Cox proportional hazards models.

RESULTS

The MAG showed significantly poorer OS than the NG before and after NAC. Pre-NAC, median OS was 20.0 months in the MAG versus 49.0 months in the NG (p = 0.006). Post-NAC, median OS was 21.3 months in the MAG versus 48.8 months in the NG (p = 0.014). Multivariate analysis, excluding muscle attenuation after NAC because of confounding factors and lower hazard ratio (2.08, 95% confidence interval: 1.14-3.78, p = 0.016) than that before NAC (2.14, 1.23-3.70, p = 0.007) by univariate analysis, revealed the following independent prognostic factors: muscle attenuation pre-NAC (2.25, 1.26-4.05, p = 0.007); borderline resectability (1.96, 1.04-3.69, p = 0.038); operative blood loss (2.60, 1.38-4.88, p = 0.003); and distant metastasis (3.31, 1.40-7.82, p = 0.006).

CONCLUSIONS

Sarcopenia before and after NAC for PC is suggested to be a poor prognostic factor, with a stronger impact before than after NAC.

Impact of Preoperative Handgrip Strength on Postoperative Outcome after Radical Gastrectomy for Gastric Cancer Patients

In this study, we investigated whether preoperative low-handgrip strength (HGS) defined by the Asian working group for sarcopenia could be a predictor of postoperative outcomes in patients with gastric cancer. A total of 327 patients who underwent radical gastrectomy for c-stage I-III primary gastric cancer with pre-operative HGS records were included. The cut-off values of HGS were defined as 28 kg for males and 18 kg for females, with values below and above the cut-off defined as low-HGS and high-HGS, respectively. The primary outcome was infectious complications. We compared the postoperative outcomes of the groups after adjusting for the background using propensity score matching. Of the 327 patients, 246 (75.2%) and 81 (24.8%) were in the high and low-HGS groups, respectively. After adjusting for background, there were 57 patients in both groups. After matching, the low-HGS group had significantly more infectious complications (17.5% vs. 1.8%, p = 0.008). Multivariate analysis of infectious complications in the low-HGS group demonstrated chronic kidney disease and diabetes as independent risk factors (odds ratio 4.390, 95% confidence interval 1.120-17.20, p = 0.034). Preoperative low-HGS according to the Asian criteria was associated with infectious complications after gastrectomy. Chronic kidney disease and diabetes were independent risk factors for infectious complications among patients with low-HGS.

Thickness of Biceps and Quadriceps Femoris Muscle Measured Using Point-of-Care Ultrasound as a Representation of Total Skeletal Muscle Mass

Generalized loss of muscle mass is associated with increased morbidity and mortality in patients with cancer. The gold standard to measure muscle mass is by using computed tomography (CT). However, the aim of this prospective observational cohort study was to determine whether point-of-care ultrasound (POCUS) could be an easy-to-use, bedside measurement alternative to evaluate muscle status. Patients scheduled for major abdominal cancer surgery with a recent preoperative CT scan available were included. POCUS was used to measure the muscle thickness of mm. biceps brachii, mm. recti femoris, and mm. vasti intermedius 1 day prior to surgery. The total skeletal muscle index (SMI) was derived from patients’ abdominal CT scan at the third lumbar level. Muscle force of the upper and lower extremities was measured using a handheld dynamometer. A total of 165 patients were included (55% male; 65 ± 12 years). All POCUS measurements of muscle thickness had a statistically significant correlation with CT-derived SMI (r ≥ 0.48; p < 0.001). The strongest correlation between POCUS muscle measurements and SMI was observed when all POCUS muscle groups were added together (r = 0.73; p < 0.001). Muscle strength had a stronger correlation with POCUS-measured muscle thickness than with CT-derived SMI. To conclude, this study indicated a strong correlation between combined muscle thickness measurements performed by POCUS- and CT-derived SMI and measurements of muscle strength. These results suggest that handheld ultrasound is a valid tool for the assessment of skeletal muscle status.

Associations between muscle mass/strength and healthcare costs/use for patients with cancer: A systematic literature review

PURPOSE

To review published scientific evidence evaluating the potential associations between muscle mass/strength and healthcare use/costs for patients with cancer.

METHODS

In accordance with the predefined protocol for a systematic literature review, studies assessing potential associations between muscle mass/strength and healthcare costs/use in cancer patients were searched on MEDLINE (via Ovid) and on the NHS Economic Evaluation Database in September 2021. Study selection, data extraction and quality assessment were performed by two independent reviewers.

RESULTS

Of 613 studies identified, five met our inclusion criteria. Various outcomes were investigated: for length of hospital stay, one out of three studies reported an association between lower muscle mass and longer hospital stay; for hospital admission, the two identified studies did not highlight muscle weakness as a predictor of hospital admission; for hospital readmission, one out of two studies reported that patients with lower muscle mass had higher rates of hospital readmission; for costs and cost-effectiveness, results of two randomized controlled trials were mixed, with total costs of the intervention higher in one study and lower in the other, leading to opposite cost-effectiveness results.

CONCLUSION

Only five studies evaluating potential associations between mass/strength and healthcare use/costs have been highlighted within this systematic review. The amount of evidence is limited but the studies are also very heterogeneous in regards of study designs, sample size, and type of population included. This important heterogeneity prevents drawing strong conclusions. Because of limited data available, more high quality longitudinal studies are needed to further investigate the relationship between muscle mass/strength and healthcare costs/use.

Sarcopenic obesity and therapeutic outcomes in gastrointestinal surgical oncology: A meta-analysis

Background

Sarcopenic obesity (SO) has been indicated as a scientific and clinical priority in oncology. This meta-analysis aimed to investigate the impacts of preoperative SO on therapeutic outcomes in gastrointestinal surgical oncology.

Methods

We searched the PubMed, EMBASE, and Cochrane Library databases through March 4th 2022 to identify cohort studies. Endpoints included postoperative complications and survival outcomes. Newcastle Ottawa Scale was used for quality assessment. Heterogeneity and publication bias were assessed. Subgroup analyses and sensitivity analyses were performed.

Results

Twenty-six studies (8,729 participants) with moderate to good quality were included. The pooled average age was 65.6 [95% confidence interval (CI) 63.7-67.6] years. The significant heterogeneity in SO definition and diagnosis among studies was observed. Patients with SO showed increased incidences of total complications (odds ratio 1.30, 95% CI: 1.03-1.64, P = 0.030) and major complications (Clavien-Dindo grade ≥ IIIa, odds ratio 2.15, 95% CI: 1.39-3.32, P = 0.001). SO was particularly associated with the incidence of cardiac complications, leak complications, and organ/space infection. SO was also predictive of poor overall survival (hazard ratio 1.73, 95% CI: 1.46-2.06, P < 0.001) and disease-free survival (hazard ratio 1.41, 95% CI: 1.20-1.66, P < 0.001). SO defined as sarcopenia in combination with obesity showed greater association with adverse outcomes than that defined as an increased ratio of fat mass to muscle mass. A low prevalence rate of SO (< 10%) was associated with increased significance for adverse outcomes compared to the high prevalence rate of SO (> 20%).

Conclusion

The SO was associated with increased complications and poor survival in gastrointestinal surgical oncology. Interventions aiming at SO have potentials to promote surgery benefits for patients with gastrointestinal cancers. The heterogeneity in SO definition and diagnosis among studies should be considered when interpreting these findings.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=255286], identifier [CRD42021255286].

Association between Masseter Muscle Area and Thickness and Outcome after Carotid Endarterectomy: A Retrospective Cohort Study

Low muscle mass is associated with adverse outcomes after surgery. This study examined whether facial muscles, such as the masseter muscle, could be used as a proxy for generalized low muscle mass and could be associated with deviant outcomes after carotid endarterectomy (CEA). As a part of the Vascular Ageing study, patients with an available preoperative CT-scan, who underwent an elective CEA between December 2009 and May 2018, were included. Bilateral masseter muscle area and thickness were measured on preoperative CT scans. A masseter muscle area or thickness of one standard deviation below the sex-based mean was considered low masseter muscle area (LMA) or low masseter muscle thickness (LMT). Of the 123 included patients (73.3% men; mean age 68 (9.7) years), 22 (17.9%) patients had LMA, and 18 (14.6%) patients had LMT. A total of 41 (33.3%) patients had a complicated postoperative course and median length of hospital stay was four (4–5) days. Recurrent stroke within 5 years occurred in eight (6.6%) patients. Univariable analysis showed an association between LMA, complications and prolonged hospital stay. LMT was associated with a prolonged hospital stay (OR 8.78 [1.15–66.85]; p = 0.036) and recurrent stroke within 5 years (HR 12.40 [1.83–84.09]; p = 0.010) in multivariable logistic regression analysis. Masseter muscle might be useful in preoperative risk assessment for adverse short- and long-term postoperative outcomes.

Clinical Relevance of Myopenia and Myosteatosis in Colorectal Cancer

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

Association of Sarcopenia and Low Nutritional Status with Unplanned Hospital Readmission after Radical Gastrectomy in Patients with Gastric Cancer: A Case-Control Study

Objective. Sarcopenia is one of the influencing factors of poor prognosis in patients with gastric cancer but the association with readmission are unknown. We aimed to explore factors associated with readmission after gastrectomy and to determine whether preoperative sarcopenia is a common outcome in readmitted patients. Methods. In this case-control study, patients who underwent gastric resection in the First Affiliated Hospital of Wenzhou Medical University between April 2016 and September 2017 were included. The reasons of readmission patients were described. The readmission patients and non-readmission patients were matched by propensity score matching (PSM). The univariate analysis was applied for the baseline characteristics, operative details, postoperative prognosis and discharge disposition, and multiple logistic regression analysis for the independent risk factors of readmission. Results. The unplanned readmission rate within 30 days of radical gastrectomy for gastric cancer was 6.5% (43/657). The average time interval from discharge to readmission was 13 days. Delayed gastric evacuation was the main cause of readmission (18.6%, 8/43). Body mass index (BMI), nutritional risk screening (NRS) 2002 score, history of abdominal surgery, sarcopenia, and preoperative albumin were included in the multivariate logistic regression analysis. NRS 2002 (OR = 3.43, 95% CI: 1.10–10.72, $P=0.034$ ) and sarcopenia (OR = 4.25, 95% CI: 1.13–16.02, $P=0.033$ ) were found to be independently associated with unplanned readmission within 30 days of radical gastrectomy for cancer. Other factors such as age, sex, BMI, American Society of Anesthesiologists grade, surgical method, operation and reconstruction type, TNM stage, surgical duration, previous abdominal surgery, and preoperative albumin and hemoglobin level were not associated with unplanned readmission after radical gastrectomy for cancer. Conclusions. Sarcopenia and low nutritional status are independently associated with unplanned readmission within 30 days of radical gastrectomy for cancer.

Myosteatosis Significantly Predicts Persistent Dyspnea and Mobility Problems in COVID-19 Survivors

Background

Persistent symptoms including dyspnea and functional impairment are common in COVID-19 survivors. Poor muscle quality (myosteatosis) associates with poor short-term outcomes in COVID-19 patients. The aim of this observational study was to assess the relationship between myosteatosis diagnosed during acute COVID-19 and patient-reported outcomes at 6 months after discharge.

Methods

Myosteatosis was diagnosed based on CT-derived skeletal muscle radiation attenuation (SM-RA) measured during hospitalization in 97 COVID-19 survivors who had available anthropometric and clinical data upon admission and at the 6-month follow-up after discharge. Dyspnea in daily activities was assessed using the modified Medical Research Council (mMRC) scale for dyspnea. Health-related quality of life was measured using the European quality of life questionnaire three-level version (EQ-5D-3L).

Results

Characteristics of patients with (lowest sex- and age-specific tertile of SM-RA) or without myosteatosis during acute COVID-19 were similar. At 6 months, patients with myosteatosis had greater rates of obesity (48.4 vs. 27.7%, p = 0.046), abdominal obesity (80.0 vs. 47.6%, p = 0.003), dyspnea (32.3 vs. 12.5%, p = 0.021) and mobility problems (32.3 vs. 12.5%, p = 0.004). Myosteatosis diagnosed during acute COVID-19 was the only significant predictor of persistent dyspnea (OR 3.19 [95% C.I. 1.04; 9.87], p = 0.043) and mobility problems (OR 3.70 [95% C.I. 1.25; 10.95], p = 0.018) at 6 months at logistic regression adjusted for sex, age, and BMI.

Conclusion

Myosteatosis diagnosed during acute COVID-19 significantly predicts persistent dyspnea and mobility problems at 6 months after hospital discharge independent of age, sex, and body mass.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT04318366].

Linear Skeletal Muscle Index and Muscle Attenuation May Be New Prognostic Factors in Colorectal Carcinoma Treated by Radical Resection

Objective

This study evaluated the association between body composition and clinical parameters and prognosis in patients with colorectal cancer (CRC) treated by radical resection.

Methods

Baseline data on patient age, body mass index (BMI), bowel obstruction and tumor-related factors were collected retrospectively. Body composition parameters such as visceral fat area (VFA), total abdominal muscle area (TAMA), muscle attenuation (MA), posterior renal fat thickness (PPNF) and intermuscular fat area (IMF) are measured using Computed tomography (CT) scans. We also propose a new predictor of linear skeletal muscle index (LSMI) that can be easily measured clinically at CT. Follow-up endpoints were disease-free survival and all-cause death. We follow up with patients in hospital or by telephone. Univariate and multifactorial Cox proportional hazards analyses were performed to identify risk factors associated with prognosis. Survival analysis was performed using the Kaplan-Meier method and a nomogram was established to predict survival.

Results

A total of 1761 patients (median age 62 years) with CRC were enrolled in our study, of whom 201 had intestinal obstruction and 673 had a BMI > 24.0. Among all patients, the 3- and 5-year disease-free survival rates were 84.55% and 68.60% respectively, and the overall survival rates were 88.87% and 76.38%. Overall survival was significantly correlated with MA, LSMI, SMI, Tumor size, N stage, metastasis and adjuvant therapy by Cox regression analysis (p < 0.05). The risk of tumor progression was significantly associated with MA, VFA, LSMI, SMI, Male, N stage, metastasis and adjuvant therapy (p < 0.05). In addition, based on the Chinese population, we found that female patients with MA < 30.0 HU, LSMI < 18.2, and SMI < 38.0 had a worse prognosis, male patients with MA < 37.6 HU, LSMI < 21.9, and SMI < 40.3 had a poorer prognosis.

Conclusion

Our findings suggest that linear skeletal muscle index and MA can be used as new independent predictors for colorectal cancer patients treated with radical surgery, and that baseline data such as body composition parameters, LSMI and tumor-related factors can collectively predict patient prognosis. These results could help us to optimize the management and treatment of patients after surgery.

Impact of sarcopenia on surgical and oncologic outcomes of laparoscopic surgery for colorectal cancer

BACKGROUND

The study aimed to evaluate the impact of sarcopenia on short- and long-term outcomes for laparoscopic colorectal cancer surgery.

METHODS

Study participants were 209 patients who underwent laparoscopic surgery for any stage of colorectal cancer between 2016 and 2017. Skeletal muscle indices were calculated with preoperative computed tomography. Patients were divided into sarcopenic and non-sarcopenic groups based on index cut-off values and variables were compared.

RESULTS

The prevalence of sarcopenia was 41.1%. Sarcopenic patients experienced shorter operative times and a lower incidence of surgical site infections; however, the incidence of severe postoperative complications and readmission were increased for this group. Although the 3-year disease-free survival rate was not statistically different between groups, sarcopenic patients had a significantly worse 3-year overall survival rate compared with than the non-sarcopenic group.

CONCLUSION

Sarcopenia has both favorable and unfavorable effects on patients who underwent laparoscopic colorectal cancer surgery.

Impact of Sarcopenia on Postoperative Complications in Obstructive Colorectal Cancer Patients Who Received Stenting as a Bridge to Curative Surgery

Objectives:

Understanding the relationship between sarcopenia and malignancy is increasingly important since they inevitably affect the aging population. We investigated the clinical significance of sarcopenia in nonmetastatic obstructive colorectal cancer (OCRC) patients who were inserted self-expandable metallic stent and underwent curative surgery.

Methods:

Plain cross-sectional CT images obtained before stenting were retrospectively analyzed in 92 patients. Muscle volume loss (myopenia) and decreased muscle quality (myosteatosis) were evaluated as skeletal muscle index (SMI) and intramuscular adipose tissue content (IMAC), respectively.

Results:

This study included 54 men and 38 women, with a median age of 70.5 years. The median interval between SEMS placement and the surgery was 17 days (range, 5-47). There were 35 postoperative complications. The median postoperative hospital stay was 15.5 days (range, 8-77). Twenty-eight patients (41.3%) were classified as SMI-low, and 31 (34.1%) patients were classified as IMAC-high. In multivariate analysis, IMAC-high [hazard ratio (HR) = 7.68, 95% confidence interval (CI) 2.22-26.5, P = 0.001] and right-sided tumor (HR = 5.79, 95% CI 1.36-24.7, P = 0.018) were independent predictors of postoperative complications. IMAC-high (HR = 23.2, 95% CI 4.11-131, P < 0.001) and elevated modified Glasgow prognostic score (mGPS) (HR = 5.85, 95% CI 1.22-28.1, P = 0.027) were independent predictors of infectious complications. Relapse-free survival and overall survival were not significantly different regardless of the SMI or IMAC status.

Conclusions:

IMAC was associated with postoperative complications and infectious complications. Myosteatosis might be a stronger predictor of postoperative complications than myopenia.

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.

Sarcopenia assessed by skeletal muscle mass volume is a prognostic factor for oncological outcomes of rectal cancer patients undergoing neoadjuvant chemoradiotherapy followed by surgery

INTRODUCTION

Recently, sarcopenia has been reported to be associated with poor postoperative outcomes in various cancers. However, its clinical significance for rectal cancer patients undergoing neoadjuvant chemoradiotherapy (NACRT) followed by surgery remains unknown.

MATERIALS AND METHODS

This study included 46 patients with locally advanced rectal cancer who underwent curative surgery after NACRT. Sarcopenia was assessed by measuring the cross-sectional psoas muscle area (PA) at L3 and total bilateral psoas muscle volume (PV). Patients with a lower PV or PA value than the median were assigned to the sarcopenia group while others were assigned to the non-sarcopenia group. Clinical outcomes were then compared between groups.

RESULTS

The sarcopenia group included 22 patients. The rate of overall postoperative complications did not differ between groups. Five-year relapse-free survival (RFS) was significantly lower in the sarcopenia group when sarcopenia was assessed by PV after NACRT (44.0% vs. 82.6%, P = 0.00494). In contrast, RFS did not differ between groups when sarcopenia was assessed by PA. Multivariable analysis identified PV after NACRT as the most significant risk factor for RFS (hazard ratio 4.00; 95% CI 1.27-12.66, P = 0.018).

CONCLUSION

Sarcopenia assessed by total PV after NACRT may be an accurate and reliable predictor of poor oncological outcomes in rectal cancer patients.

Sarcopenia and primary tumor location influence patients outcome after liver resection for colorectal liver metastases

INTRODUCTION

Right-sided and left-sided colorectal cancer (CRC) is known to differ in their molecular carcinogenic pathways. The prevalence of sarcopenia is known to worsen the outcome after hepatic resection. We sought to investigate the prevalence of sarcopenia and its prognostic application according to the primary CRC tumor site.

METHODS

355 patients (62% male) who underwent liver resection in our center were identified. Clinicopathologic characteristics and long-term outcomes were stratified by sarcopenia and primary tumor location (right-sided vs. left-sided). Tumors in the coecum, right sided and transverse colon were defined as right-sided, tumors in the left colon and rectum were defined as left-sided. Sarcopenia was assessed using the skeletal muscle index (SMI) with a measurement of the skeletal muscle area at the level L3.

RESULTS

Patients who underwent right sided colectomy (n = 233, 65%) showed a higher prevalence of sarcopenia (35.2% vs. 23.9%, p = 0.03). These patients also had higher chances for postoperative complications with Clavien Dindo >3 (OR 1.21 CI95% 0.9-1.81, p = 0.05) and higher odds for mortality related to CRC (HR 1.2 CI95% 0.8-1.8, p = 0.03).On multivariable analysis prevalence of sarcopenia remained independently associated with worse overall survival and disease free survival (overall survival: HR 1.47 CI 95% 1.03-2.46, p = 0.03; HR 1.74 CI95% 1.09-3.4, p = 0.05 respectively).

CONCLUSION

Sarcopenia is known to have a worse prognosis in patients with CRLM and CRC. Depending on the primary location sarcopenia has a variable effect on the outcome after liver resection.

Impact of preoperative muscle quality on postoperative severe complications after radical gastrectomy for gastric cancer patients

BACKGROUND

Preoperative sarcopenia is an important risk factor for postoperative complications in patients with gastric cancer. However, the relationship between muscle quality and postoperative complications in patients with gastric cancer is inadequately studied. Therefore, we investigated the impact of preoperative muscle quality on severe postoperative complications after radical gastrectomy.

METHODS

A total of 840 patients who underwent radical gastrectomy for p-stages I-III primary gastric cancer between April 2008 and June 2018 with preoperative computed tomography (CT) scans and body composition analysis were included. We measured intramuscular adipose tissue content (IMAC) as an indicator of muscle quality. A higher IMAC signified a poorer quality. All statistical analyses were performed with EZR, and a P-value < 0.05 was considered statistically significant.

RESULTS

The low-IMAC and high-IMAC groups had 422 (50.2%) and 418 (49.8%) patients, respectively. The latter were older (P < 0.001), had higher body mass index (BMI) (P < 0.001), and higher rates of chronic kidney disease (CKD) (P = 0.002) and diabetes (P < 0.001). They had lower skeletal muscle indexes (SMI) (P = 0.011) and higher visceral fat areas (VFA) (P < 0.001). They also experienced more intraoperative blood loss (P < 0.001) and greater complications (P = 0.016). Multivariate analysis showed that high-IMAC was an independent risk factor for severe complications (odds ratio: 2.260, 95% confidence interval: 1.220-4.190, P = 0.010).

CONCLUSIONS

Poor preoperative muscle quality is an independent risk factor for severe postoperative complications after radical gastrectomy in patients with gastric cancer.

Sarcopenia predicts worse postoperative outcomes and decreased survival rates in patients with colorectal cancer: a systematic review and meta-analysis

PURPOSE

Previous studies have shown an association of sarcopenia with adverse short- and long-term outcomes in multiple gastrointestinal cancer types. We aimed to investigate the prognostic value of sarcopenia on the postoperative outcomes and survival rates of patients with colorectal cancer (CRC).

METHODS

A systematic literature search was performed using the PubMed, Embase, Cochrane, Google Scholar, and Scopus databases. We included studies that compared postoperative outcomes or survival rates in sarcopenic and non-sarcopenic patients with CRC.

RESULTS

A total of 44 observational studies, comprising 18,891 patients, were included. The pooled prevalence of sarcopenia was 37% (n = 7009). The pooled analysis revealed an association between sarcopenia and higher risk of total postoperative complications (23 studies, OR = 1.84; 95% CI 1.35-2.49), postoperative severe complications (OR = 1.72; 95% CI 1.10-2.68), postoperative mortality (OR = 3.21; 95% CI 2.01-5.11), postoperative infections (OR = 1.40; 95% CI 1.12-1.76), postoperative cardiopulmonary complications (OR = 2.92; 95% CI 1.96-4.37), and prolonged length of stay (MD = 0.77; 95% CI 0.44-1.11) after colorectal cancer surgery. However, anastomotic leakage showed comparable occurrence between sarcopenic and non-sarcopenic patients (OR = 0.99; 95% CI 0.72 to 1.36). Regarding survival outcomes, sarcopenic patients had significantly shorter overall survival (25 studies, HR = 1.83; 95% CI = 1.57-2.14), disease-free survival (HR = 1.55; 95% CI = 1.29-1.88), and cancer-specific survival (HR = 1.77; 95% CI 1.40-2.23) as compared with non-sarcopenic patients.

CONCLUSION

Among patients with colorectal cancer, sarcopenia is a strong predictor of increased postoperative complications and worse survival outcomes.

Impact of cachexia on oncologic outcomes of sarcopenic patients with upper tract urothelial carcinoma after radical nephroureterectomy

Objectives

To investigate the prognostic significance of sarcopenic cachexia compared to sarcopenia without cachexia in the outcomes of upper urinary tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy (RNU).

Materials and methods

Between 2011 and 2016, 163 patients with UTUC who received RNU at a tertiary medical center were included. Pre-operatively clinical data, history, and abdominal computer tomography scans were analyzed retrospectively. The diagnosis of sarcopenia was based on abdominal computed tomography data on the patient’s skeletal muscles. Outcomes of relapse-free, cancer-specific, and overall survival were analyzed by multivariate Cox regression.

Results

After adjusting for age, sex, pre-operatively estimated glomerular filtration rate, body mass index, underlying diseases, tumor grade, and tumor stage, cachexia was a significant poor prognostic factor for relapse-free survival (hazard ratio [HR]: 18.5, 95% confidence interval [CI]: 2.87–118, p = 0.002) and cancer-specific survival (HR: 26.6, 95% CI: 4.04–175, p = 0.001). In contrast, sarcopenia without cachexia was not a significant predictor of cancer outcomes.

Conclusions

To date, this is the first study to investigate the effect of cachexia among sarcopenic patients with UTUC treated with RNU. We identified the prognostic significance of cachexia on outcomes. Indeed, when UTUC is treated with RNU, we should evaluate not only sarcopenia status but also cachexia. The low survival rate among patients with UTUC complicated with cachexia deserves attention.

Association between postoperative muscle wasting and survival in older patients undergoing surgery for non-metastatic colorectal cancer

BACKGROUND

Preoperative sarcopenia in older patients is a risk factor for adverse outcomes after colorectal cancer (CRC) surgery. Longitudinal changes in muscle mass in this group have not been studied previously although muscle wasting may have prognostic significance regarding survival. We aimed to determine the association between muscle wasting and overall survival (OS) in older patients who underwent surgery for CRC.

METHODS

Patients ≥70 years who underwent surgery for non-metastatic CRC in Gelre hospitals, The Netherlands, between 2011 and 2015 were included. Cross-sectional area of skeletal muscle was measured at the level of the 3rd lumbar vertebra on preoperative and postoperative abdominal CT-scans. Patients who had >1 standard deviation decrease in muscle mass were considered to have muscle wasting. Cox regression analysis was used to evaluate associations between muscle wasting and OS.

RESULTS

233 patients were included (40% female, median age 76 years). Thirty-four patients had muscle wasting. After a median follow-up of 4.7 years, 53 (23%) patients died. The 3-year mortality rate was higher in patients with muscle wasting (27% vs 14%, p = .05). In multivariable analysis adjusted for age, recurrent disease and preoperative muscle mass, muscle wasting was associated with reduced OS (HR 2.8, 95% CI 1.5-5.4, p = .002).

CONCLUSION

Muscle wasting predicted poorer survival in older patients who underwent CRC surgery. Measuring changes in muscle mass may improve risk prediction in this patient group. Future studies should address the etiology of muscle wasting in older patients with CRC. Whether perioperative exercise interventions can prevent muscle wasting also warrants further study.

Computed tomography-measured body composition parameters do not influence survival in non-metastatic colorectal cancer

BACKGROUND

There is an increasing interest in studying the impact of altered body composition parameters and colorectal cancer (CRC) treatment outcomes. The aim of this study is to explore the impact of computed tomography (CT)-measured visceral obesity, sarcopenia and myosteatosis on survival of non-metastatic CRC.

METHODS

Consecutive patients with stage I-III CRC who underwent curative-intent treatment between January 2010 and December 2015 were included. By measuring the visceral fat area, and the skeletal muscle index and radiodensity in the pre-operative staging CT, patients were classified as visceral obese, sarcopenic or myosteatotic. The associations between CT-based body composition parameters and survival were assessed using log-rank tests and a Cox regression analysis.

RESULTS

Of 359 patients, 263 (73.3%) were visceral obese, 85 (23.7%) sarcopenic and 80 (22.3%) myosteatotic. Overall (OS), cancer-specific (CSS) and disease-free survivals (DFS) at 5 years were 78.8%, 84.7% and 75%, respectively. Myosteatosis and the combination of myosteatosis and visceral obesity were associated with a reduced DFS (hazard ratio 1.67; 95% confidence interval 1.06-2.61 and hazard ratio 1.85; 95% confidence interval 1.15-2.96, respectively). However, after performing a multivariate analysis including other relevant clinicopathological factors, none of the body composition parameters were associated with any long-term outcome measures, even after stratifying by cancer stage.

CONCLUSIONS

CT-measured body composition parameters do not independently influence survival in non-metastatic CRC. There is a need for larger cohort studies with standardized patient selection and methodology to confirm these findings.

Systematic review and meta-analysis of lean mass and mortality: Rationale and study description

Objectives

Muscle mass is one of the key components in defining sarcopenia and is known to be important for locomotion and body homeostasis. Lean mass is commonly used as a surrogate of muscle mass and has been shown to be associated with increased mortality. However, the relationship of lean mass with mortality may be affected by different clinical conditions, modalities used, cut-off point to define low or normal lean mass, and even types of cancer among cancer patients. Thus, we aim to perform a comprehensive meta-analysis of lean mass with mortality by considering all these factors.

Methods

Systematic search was done in PubMed, Cochrane Library and Embase for articles related to lean mass and mortality. Lean mass measured by dual X-ray absorptiometry, bioelectrical impedance analysis, and computerized tomography were included.

Results

The number of relevant studies has increased continuously since 2002. A total of 188 studies with 98 468 people were included in the meta-analysis. The association of lean mass with mortality was most studied in cancer patients, followed by people with renal diseases, liver diseases, elderly, people with cardiovascular disease, lung diseases, and other diseases. The meta-analysis can be further conducted in subgroups based on measurement modalities, site of measurements, definition of low lean mass adopted, and types of cancer for studies conducted in cancer patients.

Conclusions

This series of meta-analysis provided insight and evidence on the relationship between lean mass and mortality in all directions, which may be useful for further study and guideline development.

Association of Low Muscle Mass and Low Muscle Radiodensity With Morbidity and Mortality for Colon Cancer Surgery

Importance

Given the risks of postoperative morbidity and its consequent economic burden and impairment to patients undergoing colon resection, evaluating risk factors associated with complications will allow risk stratification and the targeting of supportive interventions. Evaluation of muscle characteristics is an emerging area for improving preoperative risk stratification.

Objective

To examine the associations of muscle characteristics with postoperative complications, length of hospital stay (LOS), readmission, and mortality in patients with colon cancer.

Design, Setting, and Participants

This population-based retrospective cohort study was conducted among 1630 patients who received a diagnosis of stage I to III colon cancer from January 2006 to December 2011 at Kaiser Permanente Northern California, an integrated health care system. Preliminary data analysis started in 2017. Because major complication data were collected between 2018 and 2019, the final analysis using the current cohort was conducted between 2019 and 2020.

Exposures

Low skeletal muscle index (SMI) and/or low skeletal muscle radiodensity (SMD) levels were assessed using preoperative computerized tomography images.

Main Outcomes and Measures

Length of stay, any complication (≥1 predefined complications) or major complications (Clavien-Dindo classification score ≥3), 30-day mortality and readmission up to 30 days postdischarge, and overall mortality.

Results

The mean (SD) age at diagnosis was 64.0 (11.3) years and 906 (55.6%) were women. Patients with low SMI or low SMD were more likely to remain hospitalized 7 days or longer after surgery (odds ratio [OR], 1.33; 95% CI, 1.05-1.68; OR, 1.39; 95% CI, 1.05-1.84, respectively) and had higher risks of overall mortality (hazard ratio, 1.40; 95% CI, 1.13-1.74; hazard ratio, 1.44; 95% CI, 1.12-1.85, respectively). Additionally, patients with low SMI were more likely to have 1 or more postsurgical complications (OR, 1.31; 95% CI, 1.04-1.65) and had higher risk of 30-day mortality (OR, 4.85; 95% CI, 1.23-19.15). Low SMD was associated with higher odds of having major complications (OR, 2.41; 95% CI, 1.44-4.04).

Conclusions and Relevance

Low SMI and low SMD were associated with longer LOS, higher risk of postsurgical complications, and short-term and long-term mortality. Research should evaluate whether targeting potentially modifiable factors preoperatively, such as preserving muscle mass, could reverse the observed negative associations with postoperative outcomes.

Sarcopenia is associated with increased severe postoperative complications after colon cancer surgery

INTRODUCTION

Studies have shown that sarcopenia is associated with poor outcomes in patients with gastrointestinal cancer undergoing surgery. We aimed to investigate the relationship between postoperative complications of sarcopenic patients who had been operated on for colon cancer and the effects on short-term mortality.

MATERIAL AND METHODS

In this study, patients who had undergone colon cancer surgery between January 2013 and December 2018 were collected retrospectively. Sarcopenia was diagnosed by the skeletal muscle index (SMI) derived from a preoperative computed tomography scan. Multiple logistic regression analysis was performed to determine whether sarcopenia is associated with postoperative major complications (POMC).

RESULTS

The study included 160 patients with a mean age of 62.4 ±12.6 years. Clavien-Dindo grade 1-2 (minor) complications were not significantly different between the groups (p = 0.896). However, grade ≥ 3 (major) complications were detected in 13 (17.8%) patients in the sarcopenic group (SG) and in 5 patients in the non-sarcopenic group (NSG) (5.7%) (p = 0.016). Length of intensive care unit (ICU) stay was longer in SG (p = 0.002) and there was no difference between 1-month and 6-month mortality rates (p = 0.273 and p = 0.402, respectively). According to univariate analyses, sarcopenia and age over 65 years were related to POMC. In multivariate analyses, sarcopenia (odds ratio = 3.039; 95% confidence interval 1.008-9.174; p = 0.048) and advanced age (odds ratio = 3.246; 95% confidence interval 1.078-9.803; p = 0.036) were found to be independent risk factors for POMC.

CONCLUSIONS

This study showed that while sarcopenia is a risk factor for POMC, sarcopenia also prolongs the duration of ICU stay. Also sarcopenia has no effect on short-term mortality.

Myosteatosis Differentially Affects the Prognosis of Non-Metastatic Colon and Rectal Cancer Patients: An Exploratory Study

Body composition performed by computed tomography (CT) impacts on cancer patients' prognoses and responses to treatment. Myosteatosis has been related to overall survival (OS) and disease-specific survival in colorectal cancer (CRC); however, the independent impact of the association of myosteatosis with prognosis in colon cancer (CC) and rectal cancer (RC) is still unclear. CT was performed at the L3 level to assess body composition features in 227 patients with CRC. Clinical parameters were collected. Overall survival (OS) was the primary outcome, and the secondary outcome was disease-free survival (DFS). Skeletal muscle attenuation and intramuscular adipose tissue area were associated with DFS (p = 0.003 and p = 0.011, respectively) and OS (p < 0.001 and p < 0.001, respectively) in CC patients but not in RC patients. Only the skeletal muscle area was associated with better prognosis related to OS in RC patients (p = 0.009). When CC and RC were analyzed separately, myosteatosis influenced survival negatively in CC patients, worsening DFS survival (hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.07-6.82; p = 0.035) and OS (HR, 5.76; 95% CI, 1.31-25.40; p = 0.021). By contrast, the presence of myosteatosis did not influence DFS (HR, 1.02; 95% CI, 0.52-2.03; p = 0.944) or OS (HR, 0.76; 95% CI, 0.33-1.77; p = 0.529) in RC patients. Our study revealed the interference of myosteatosis in the therapy and survival of patients with CC but not in those with RC, strengthening the value of grouping the two types of cancer in body composition analyses.

Handgrip Strength and Phase Angle Predict Outcome After Bariatric Surgery

BACKGROUND

The amount of postoperative weight loss after bariatric surgery varies interindividually. The quality of the pre- and postoperative body composition is an important predictor of success. The aim of this study was to investigate the role of preoperative handgrip strength and phase angle (PhA) as predictors of sustained postoperative weight loss in order to assess the influence of body composition on the postoperative outcome after bariatric surgery.

METHOD

In a prospective cohort study, bioelectrical impedance and follow-up data of 198 patients after laparoscopic sleeve gastrectomy (SG; n = 68) and Roux-en-Y gastric bypass (GB; n = 130) were analyzed for a period of 36 months postoperatively.

RESULTS

The mean preoperative handgrip strength (31.48 kg, SD 9.97) correlates significantly with the postoperative body composition up to 24 months after surgery. Preoperative PhA, gender, size, and body weight influenced postoperative weight loss significantly. A significant correlation between preoperative PhA (mean 6.18°, SD 0.89°) and total weight loss (%TWL) was observed up to 3 months after SG (r = 0.31444, p = 0.0218) and up to 12 months after GB (r = 0.19184, p = 0.0467). The optimum cutoff for the prediction of a response of less than 50% excess weight loss was a preoperative PhA of 6.0°.

CONCLUSIONS

The preoperative handgrip strength confirmed its suitability for use as a predictor of postoperative body composition, whereas the preoperative PhA predicts postoperative weight loss after bariatric surgery. Further research is necessary to identify the role of these parameters for preconditioning.

Importance of "muscle" and "intestine" training before major HPB surgery: A review

Major hepato-pancreato-biliary (HPB) surgery is one of the most invasive abdominal surgeries. Through the experiences of several clinical trials, including those involving patients undergoing major HPB surgery, we have recognized the importance of "muscle" and "intestine" training before surgery. This review article summarizes the results of our clinical trials, specifically focusing on the importance of "muscle" and "intestine". The patients with low skeletal muscle mass or those with low functional exercise capacity showed a significantly worse postoperative course and poor long-term survival after surgery for HPB malignancy. The introduction of prehabilitation (preoperative physical and nutritional support) improved nutritional status and functional exercise capacity, even in patients with malignancy. Daily physical activity was correlated with nutritional status before surgery. These results indicated the usefulness of prehabilitation. The intestinal microenvironment, which is extrapolated from the fecal concentrations of short-chain fatty acids (SCFAs), showed a significant association with the incidence of surgery-induced bacterial translocation and postoperative infectious complications (POICs). The use of perioperative synbiotics not only increased the fecal levels of SCFAs but also prevented the incidence of POICs. A recent study also indicated that there are correlations between muscle mass and the intestinal microenvironment. Further investigation is required to determine the best "muscle" and "intestine" training protocol to improve the outcomes of major HPB surgeries.

Are computed tomography-based measures of specific abdominal muscle groups predictive of adverse outcomes in older cancer patients?

PURPOSE

It is unknown whether computed tomography (CT)-based total abdominal muscle measures are representative of specific abdominal muscle groups and whether analysis of specific abdominal muscle groups are predictive of the risk of adverse outcomes in older cancer patients.

METHODS

Retrospective single-center cohort study in elective colon cancer patients aged ≥65 years. CT-based skeletal muscle (SM) surface area, muscle density and intermuscular adipose tissue (IMAT) surface area were determined for rectus abdominis; external- and internal oblique and transversus abdominis (lateral muscles); psoas; and erector spinae and quadratus lumborum (back muscles). Outcomes were defined as severe postoperative complications (Clavien-Dindo score >2) and long-term survival (median follow-up 5.2 years).

RESULTS

254 older colon cancer patients were included (median 73.6 years, 62.2% males). Rectus abdominis showed the lowest SM surface area and muscle density and the back muscles showed the highest IMAT surface area. Psoas muscle density, and lateral muscle density and percentage IMAT were associated with severe postoperative complications independent of gender, age and cancer stage.

CONCLUSIONS

CT-based total abdominal muscle quantity and quality do not represent the heterogeneity that exists between specific muscle groups. The potential added value of analysis of specific muscle groups in predicting adverse outcomes in older (colon) cancer patients should be further addressed in prospective studies.

The clinical relevance and mechanism of skeletal muscle wasting

Skeletal muscle wasting occurs in both chronic and acute diseases. Increasing evidence has shown this debilitating process is associated with short- and long-term outcomes in critical, cancer and surgical patients. Both muscle quantity and quality, as reflected by the area and density of a given range of attenuation in CT scan, impact the patient prognosis. In addition, ultrasound and bioelectrical impedance analysis (BIA) are also widely used in the assessment of body composition due to their bedside viability and no radioactivity. Mechanism researches have revealed complicated pathways are involved in muscle wasting, which include altered IGF1-Akt-FoxO signaling, elevated levels of myostatin and activin A, activation of NF-κB pathway and glucocorticoid effects. Particularly, central nervous system (CNS) has been proven to participate in regulating muscle wasting in various conditions, such as infection and tumor. Several promising therapeutic agents have been under developing in the treatment of muscle atrophy, such as myostatin antagonist, ghrelin analog, non-steroidal selective androgen receptor modulators (SARMs). Notably, nutritional therapy is still the fundamental support in combating muscle wasting. However, the optimizing and tailored nutrition regimen relies on accurate metabolism measurement and large clinical trials in the future. Here, we will discuss the current understanding of muscle wasting and potential treatment in clinical practice.

Skeletal muscle index is an independent predictor of early recurrence in non-obese colon cancer patients

Purpose

Progressive loss (sarcopenia) and fatty infiltration of muscle mass (myosteatosis) are well-established risk factors for an adverse clinical outcome in obese patients. Data concerning non-obese sarcopenic patients in oncologic surgery are scarce and heterogeneous. The aim of this study was to determine the impact of sarcopenia and myosteatosis in non-obese patients with cancer of the right colon on clinical outcome.

Methods

This study comprised 85 patients with a BMI < 30 kg/m², who underwent surgery for right colon cancer in a single center. Skeletal muscle area (SMA), visceral fat area (VFA), and myosteatosis were retrospectively assessed using preoperative abdominal CT images. Univariate und multivariate analysis was performed to evaluate the association between body composition, complications, and oncologic follow-up.

Results

Traditional risk factors such as visceral fat (p = 0.8653), BMI (p = 0.8033), myosteatosis (p = 0.7705), and sarcopenia (p = 0.3359) failed to show any impact on postoperative complications or early recurrence. In our cohort, the skeletal muscle index (SMI) was the only significant predictor for early cancer recurrence (p = 0.0467).

Conclusion

SMI is a significant prognostic factor for early cancer recurrence in non-obese colon cancer patients. Our study shows that conventional thresholds for sarcopenia and BMI do not seem to be reliable across various cohorts. Target prehabilitation programs could be useful to improve outcome after colorectal surgery.

Trial Registration

DRKS00014655, www.apps.who.int/trialsearch

Sarcopenia, as Assessed by Psoas Cross-Sectional Area, Is Predictive of Adverse Postoperative Outcomes in Patients Undergoing Colorectal Cancer Surgery

BACKGROUND

Frailty and sarcopenia are important concepts in surgical practice because of their association with adverse postoperative outcomes. Radiologically assessed psoas muscle mass has been proposed as a surrogate for sarcopenia and may be predictive of poor postoperative outcomes.

OBJECTIVE

This study aimed to determine the association between sarcopenia, as assessed by psoas cross-sectional area, and postoperative outcomes in patients undergoing colorectal cancer surgery.

DESIGN

This was a retrospective review of patient records from 2014 to 2016.

SETTINGS

This study was conducted at a single tertiary center.

PATIENTS

Patients undergoing elective resection of colorectal cancer were included.

MAIN OUTCOME MEASURES

Sarcopenia was assessed using the total psoas index, calculated by measuring the cross-sectional area of the psoas muscle at the third lumbar vertebra and normalized for patient height. Preoperative and intraoperative variables, including the presence of preoperative sarcopenia, were evaluated as potential risk factors for adverse postoperative outcomes.

RESULTS

Of 350 patients, 115 (32.9%) were identified as sarcopenic. Sarcopenia was associated with a significantly increased length of stay (13 days vs 7 days; OR, 1.31; 95% CI, 1.23-1.42; p < 0.01) and 1-year mortality (13.9% vs 0.9%; OR, 16.2; 95% CI, 4.34-83.4; p < 0.01). Sarcopenia was also associated with a significant increased risk of any complication (85.2% vs 34.5%; OR, 15.4; 95% CI, 8.39-29.7; p < 0.01) and of major complications (30.4% vs 8.9%; OR, 15.1; 95% CI, 7.16-33.2; p < 0.01).

LIMITATIONS

This study was limited by its retrospective design and by being conducted in a single institution. Although reduced muscle mass is suggestive of sarcopenia, it does not assess a patient's physical function or other components of the frailty phenotype.

CONCLUSION

Radiological sarcopenia is an important predictive risk factor for adverse postoperative outcomes in surgical patients. Computed tomography scans, which are routinely performed as part of staging, provide an opportunity to assess for sarcopenia preoperatively. See Video Abstract at http://links.lww.com/DCR/B201. LA SARCOPENIA, EVALUADA POR EL ÁREA TRANSVERSAL DE PSOAS, PREDICE RESULTADOS POSTOPERATORIOS ADVERSOS EN PACIENTES SOMETIDOS A CIRUGÍA DE CÁNCER COLORECTAL: La fragilidad y la sarcopenia son conceptos importantes en la práctica quirúrgica debido a su asociación con los resultados postoperatorios adversos. La masa muscular del psoas evaluada radiológicamente se ha propuesto como un sustituto de la sarcopenia y puede predecir resultados postoperatorios deficientes.Determinar la asociación entre la sarcopenia, según lo evaluado por el área transversal del psoas, y los resultados postoperatorios en pacientes sometidos a cirugía de cáncer colorrectal.Esta fue una revisión retrospectiva de los registros de pacientes de 2014 a 2016.Este estudio se llevo a cabo en un solo centro terciario.Se incluyeron pacientes sometidos a resección electiva de cáncer colorrectal.La sarcopenia se evaluó utilizando el índice de psoas total (TPI), calculado midiendo el área de la sección transversal del músculo psoas en la tercera vértebra lumbar y normalizado para la altura del paciente.Se evaluaron las variables preoperatorias e intraoperatorias, incluida la presencia de sarcopenia preoperatoria, como posibles factores de riesgo de resultados postoperatorios adversos.De 350 pacientes, 115 (32,9%) fueron identificados como sarcopénicos. La sarcopenia se asoció con un aumento significativo de la duración de la estancia (13 días frente a 7 días, OR 1.31, IC 95% 1.23-1.42, p < 0.01) y de la mortalidad al año (13.9% vs 0.9%, OR 16.2, IC 95% 4.34-83.4, p < 0.01). La sarcopenia también se asoció con un aumento significativo del riesgo de cualquier complicación (85.2% vs 34.5%, OR 15.4, IC 95% 8.39-29.7, p < 0.01) y de complicaciones mayores (30.4% vs 8.9%, OR 15.1 IC 95% 7.16-33,2, p < 0,01).Este estudio estuvo limitado por su diseño retrospectivo y por el hecho de que se realizó en una sola institución. Aunque la reducción de la masa muscular es un indicio de sarcopenia, no evalúa la función física del paciente ni otros componentes del fenotipo de fragilidad.La sarcopenia radiológica es un importante factor de riesgo predictivo para resultados postoperatorios adversos en pacientes quirúrgicos. Las tomografías computarizadas, que se realizan rutinariamente como parte de la estadificación, brindan la oportunidad de evaluar la sarcopenia antes de la operación. Consulte Video Resumen en http://links.lww.com/DCR/B201. (Traducción-Dr. Gonzalo Hagerman).

The value of L3 skeletal muscle index in evaluating preoperative nutritional risk and long-term prognosis in colorectal cancer patients

L3 skeletal muscle index (L3SMI) was reportedly related to postoperative outcomes. We aimed to investigate the value of L3SMI in evaluating preoperative nutritional risk and long-term prognosis in colorectal cancer (CRC) patients. We retrospectively enrolled 400 CRC patients who underwent surgery from January 2012 to December 2014. The L3SMI was calculated by preoperative computed tomography (CT) and classified into two groups by gender quartile method. We found that the CT diagnostic criteria of sarcopenia in South China population was: male ≤38.89cm²/m², female ≤33.28cm²/m². Multivariate logistic regression analysis showed that low L3SMI was an independent risk factor for preoperative nutritional risk (p < 0.001). Kaplan-Meier survival curves showed that low status group had significantly lower disease-free survival (p = 0.004) and overall survival (p = 0.001), especially in TNM II stage. Multivariate Cox regression analysis revealed preoperative low L3SMI adversely affected disease-free survival (p < 0.001, HR 1.894 (95% CI: 1.330–2.698)), and overall survival (p < 0.001, HR 2.030 (95% CI: 1.420–2.902)). In conclusion, L3SMI is a useful supplement for screening preoperative nutritional risk and diagnosing sarcopenia, and a potential clinical indicator that can be used to predict the prognosis of CRC patients, especially TNM stage II patients.

Sarcopenia as a Risk Factor of Morbimortality in Colorectal Cancer Surgery

Background: Colorectal cancer (CRC) surgery is associated with high rates of postoperative morbimortality. Sarcopenia has been identified as an independent predictor of these surgical outcomes. Methods: A sample of 272 patients who underwent CRC surgery between January 2005 and May 2010 at Braga Hospital, was selected. Sarcopenia was defined by the skeletal muscle mass index, measured by preoperative computed tomography (CT), at L3 level, using ImageJ® software. Associations between sarcopenia and qualitative variables were analyzed by Chi-Square Test (χ2) or Fisher’s Exact Test and, for quantitative variables, by Mann-Whitney Test. A multivariate logistic regression was performed to assess if sarcopenia was an independent predictor of major morbidity. The overall and recurrence-free survivals were analyzed by Kaplan-Meier method and multivariate Cox regression was performed for recurrence-free survival. Results: The prevalence of sarcopenia was 19.1%. Sarcopenia was associated with male gender, no CRC family history and colon tumour (p < 0.001, p = 0.029 and p = 0.017, respectively). The presence of sarcopenia was associated with postoperative morbidity Clavien–Dindo classification (p = 0.003), and sarcopenia was an independent predictor for major complications (grade ≥ III) (p = 0.003). Conclusions: The evaluation of sarcopenia in patients undergoing CRC surgical resection allows to predict a higher probability of major postoperative morbimortality.

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.

The impact of sarcopenia and myosteatosis on postoperative outcomes and 5-year survival in curatively operated colorectal cancer patients - A retrospective register study

BACKGROUND

The aim of this study was to evaluate whether sarcopenia or myosteatosis have an impact on short- and long-term results in patients who were surgically treated for colorectal cancer.

METHODS

During 2007-2011 curatively treated colorectal cancer patients (n = 348) were included in the study. Clinical data was collected retrospectively from patient registers. Skeletal muscle mass was measured at the L3 level via venous-phase computed tomography and patients were divided into sarcopenic and non-sarcopenic and into myosteatotic and non-myosteatotic. Postoperative morbidity and mortality were analysed in these groups.

RESULTS

Sarcopenia was found in 208 patients (59.8%) and myosteatosis was found in 108 patients (31.2%). Sarcopenia was associated with increased risk of postoperative pneumonia (6.7% vs. 1.4%, p = 0.021). Sarcopenic colon cancer patients had higher rate of cardiorespiratory complications than non-sarcopenic (6.3% vs. 0.0%, p = 0.023) and sarcopenic rectum cancer patients had more often pneumonia than non-sarcopenic (8.5% vs. 0.0%, p = 0.041). Discharge to home was less common in myosteatotic patients than in non-myosteatotic patients (47.7% vs. 76.9%, p < 0.001) and also in sarcopenic patients than in non-sarcopenic patients (62.7% vs. 75.5%, p = 0.013). Myosteatotic patients had decreased overall survival according to a Kaplan-Meier analysis (p = 0.002) and in the multivariable-adjusted Cox model (HR = 1.6, p = 0.034).

CONCLUSIONS

Sarcopenia increases the pneumonia and cardiorespiratory complication rates. Sarcopenia and myosteatosis predicts the need for institutional care after colorectal cancer surgery. Sarcopenia and myosteatosis seem to be negative factors for colorectal cancer patients' survival. Myosteatosis is an independent risk factor for poor overall 5-year survival.