Sarcopenia predicts a poor treatment outcome in patients with head and neck squamous cell carcinoma receiving concurrent chemoradiotherapy

Sarcopenia Index Predicts Short-Term Prognosis of Head and Neck Squamous Cell Carcinoma

The sarcopenia index (SI), calculated as [(serum creatinine/serum cystatin C) × 100], maybe a simpler alternative for measuring muscle mass than computed tomography (CT) and bioelectrical impedance analysis (BIA). We enrolled 112 patients with head and neck cancers (HNC). The correlation of the SI with muscle surface area measured by CT (CTMSA, n = 82) and muscle mass by BIA (BIA-MM, n = 41) was tested. Cutoff values were set for SI, CTMSA, and BIA-MM. Overall survival (OS) was compared between the high- and low-SI/CTMSA/BIA-MM groups. The SI was correlated with CTMSA (r = 0.43) and BIA-MM (r = 0.52). The optimal cutoff values of SI, CTMSA, and BIA-MM were 76.1 (area under the curve [AUC] = 0.67), 129.2 (AUC = 0.59), and 46.1 (AUC = 0.62), respectively. OS was significantly lower in the low-SI group (78% at 1 year and 69% at 2 years) than in the high-SI group (94% at 1 year and 86% at 2 years; p = 0.006). There was no significant difference in OS between the low-and high-CTMSA and -BIA-MM groups. The SI, which only requires a blood sample, is a useful marker of muscle mass that correlates with short-term prognosis in patients with HNC.

Development and validation of equations for predicting appendicular skeletal muscle mass in male patients with head and neck cancer and normal hydration status

OBJECTIVE

Muscle mass is typically assessed by abdominal computed tomography, magnetic resonance imaging, and dual-energy x-ray absorptiometry. However, these tests are not routinely performed in patients with head and neck cancer (HNC), making sarcopenia assessment difficult. The aim of this study was to develop and validate equations for predicting appendicular skeletal muscle mass (ASM) from data obtained in daily medical practice, with bioelectrical impedance analysis (BIA)-measured appendicular skeletal muscle mass (BIA-ASM) as a reference.

METHODS

This cross-sectional study included 103 men with HNC who were randomly placed into development and validation groups. The prediction equations for BIA-ASM were developed by multiple regression analysis and validated by Bland-Altman analyses. The estimated skeletal muscle mass index (eSMI) was also statistically evaluated to discriminate the cutoff value for BIA-measured SMI according to the Asian Working Groups for Sarcopenia.

RESULTS

Two practical equations, which included 24-h urinary creatinine excretion volume (24hUCrV), handgrip strength (HGS), body weight (BW), and body height (BHt), were developed: ASM (kg) = -39.46 + (3.557 × 24hUCrV [g]) + (0.08872 × HGS [kg]) + (0.1263 × BW [kg]) + (0.2661 × BHt [cm]) if available for 24hUCrV (adjusted R2 = 0.8905), and ASM (kg) = -42.60 + (0.1643 × HGS [kg]) + (0.1589 × BW [kg]) + (0.2807 × BHt [cm]) if not (adjusted R2 = 0.8589). ASM estimated by these two equations showed a significantly strong correlation with BIA-ASM (R > 0.900). Bland-Altman analyses showed a good agreement, and eSMI accuracy was high (>80%) in both equations.

CONCLUSIONS

These two equations are a valid option for estimating ASM and diagnosing sarcopenia in patients with HNC in all facilities without special equipment.

Accurate estimation of skeletal muscle mass by comparison of computed tomographic images of the third lumbar and third cervical vertebrae in Japanese patients with oral squamous cell carcinoma

OBJECTIVES

We evaluated the accuracy of estimating the cross-sectional area (CSA) at the third lumbar vertebra (L3) based on the CSA at the third cervical vertebra (C3) using computed tomographic images, and we identified the sources of error and bias using the evaluation of absolute reliability in 89 Japanese patients with oral squamous cell carcinoma.

METHODS

Skeletal muscle CSA was measured at the C3 and L3 on pretreatment computed tomographic images. We used the CSA at the C3 to estimate CSA at the L3 in an existing prediction formula. Correlation coefficients were used to evaluate the relative reliability of the estimate, and Bland-Altman analysis and minimum detectable change (MDC) were used to evaluate its absolute reliability.

RESULTS

Estimated and actual CSAs at L3 were strongly correlated (r = 0.885, p < 0.001). The mean difference between the estimated and actual CSAs was - 1.0887 cm², the 95% confidence interval was - 4.09 to 1.91 cm² (p = 0.472), and the 95% limits of agreement were - 29.0 and 26.8 cm². The MDC at the 95% level of confidence in estimated and actual CSAs was 27.9 cm².

CONCLUSIONS

The estimation of CSA at the L3 from the existing prediction formula with the CSA at the C3 had no systematic biases, but it did have random errors. Random errors resulted from measurement errors and biological variation. Usefulness of the existing formula is limited by physical differences in populations.

The impact of sarcopenia on survival and treatment tolerance in patients with head and neck cancer treated with chemoradiotherapy

BACKGROUND

Sarcopenia appears to be a negative prognostic factor for poor survival outcomes and worse treatment tolerance in patients with head-and-neck squamous cell carcinoma (HNSCC). We evaluated sarcopenia's impact on overall survival (OS), disease-free survival (DFS) and chemo-radiation tolerance in patients with head-and-neck cancer (HNC) treated with chemoradiotherapy (CRT) from a monocentric observational study.

METHODS

We identified patients with HNC treated by CRT between 2009 and 2018 with pretreatment imaging using positron emission tomography-computed tomography scans (PET/CT). Sarcopenia was measured using the pretreatment PET/CT at the L3 vertebral body using previously published methods. Clinical variables were retrospectively retrieved.

RESULTS

Of 216 patients identified, 54 patients (25.47%) met the criteria for sarcopenia. These patients had a lower mean body mass index before treatment (21.92 vs. 25.65 cm/m² , p < 0.001) and were more likely to have a history of smoking (88.89% vs. 71.52%, p = 0.01), alcohol use (55.56% vs. 38.61%, p = 0.03) and positive human papilloma virus status (67.74% vs. 41.75%, p = 0.011). At 3 years of follow-up, OS and DFS were 75% and 70% versus 82% and 85% for sarcopenic and non-sarcopenic patients, respectively (p = 0.1 and p = 0.00015). On multivariate analysis, sarcopenia appeared as a pejorative factor on DFS (hazard ratio 2.174, p = 0.0001) in the overall cohort. Sarcopenic patients did not require more chemotherapy and radiation-treatment interruptions and did not suffer from more chemo-induced and radiation-induced grade 3-4 toxicities than their non-sarcopenic counterparts.

CONCLUSION

Sarcopenia in HNSCC patients is an independent adverse prognostic factor for DFS after definitive chemoradiotherapy.

Prognostic Impact of Sarcopenia's Occurrence during Radiotherapy in Oropharyngeal Cancer Patients

The current study aims to profile sarcopenic condition (both at baseline and developed during treatment) in oropharyngeal carcinoma (OPC) patients treated with curative radiotherapy (RT) +/- chemotherapy and to evaluate its impact on oncological outcomes and toxicity. A total of 116 patients were included in this retrospective single-center study. Sarcopenia assessment at baseline and at 50 Gy re-evaluation CT was obtained from two different methodologies: (i) the L3-skeletal muscle index (SMI) derived from the contouring of the cross-sectional area (CSA) of the masticatory muscles (CSA-MM); and (ii) the paravertebral and sternocleidomastoid muscles at the level of the third cervical vertebra (CSA-C3). Based on L3-SMI from CSA-MM, developing sarcopenic condition during RT (on-RT sarcopenia) was associated with worse progression-free survival (PFS) (p = 0.03) on multivariable analysis and a trend of correlation with overall survival (OS) was also evident (p = 0.05). According to L3-SMI derived from CSA-C3, on-RT sarcopenia was associated with worse PFS (p = 0.0096) and OS (p = 0.013) on univariate analysis; these associations were not confirmed on multivariable analysis. A significant association was reported between becoming on-RT sarcopenia and low baseline haemoglobin (p = 0.03) and the activation of nutritional counselling (p = 0.02). No significant associations were found between sarcopenia and worse RT toxicity. Our data suggest that the implementation of prompt nutritional support to prevent the onset of sarcopenia during RT could improve oncological outcomes in OPC setting.

Physical Activity Program for the Survival of Elderly Patients With Lymphoma: Study Protocol for Randomized Phase 3 Trial

BACKGROUND

The practice of regular physical activity can reduce the incidence of certain cancers (colon, breast, and prostate) and improve overall survival after treatment by reducing fatigue and the risk of relapse. This impact on survival has only been demonstrated in active patients with lymphoma before and after treatment. As poor general health status reduces the chances of survival and these patients are most likely to also have sarcopenia, it is important to be able to improve their physical function through adapted physical activity (APA) as part of supportive care management. Unfortunately, APA is often saved for patients with advanced blood cancer. As a result, there is a lack of data regarding the impact of standardized regular practice of APA and concomitant chemotherapy as first-line treatment on lymphoma survival.

OBJECTIVE

This study aimed to assess the impact of a new and open rehabilitation program suitable for a frail population of patients treated for diffuse large B-cell lymphoma (DLBCL).

METHODS

PHARAOM (Physical Activity Program for the Survival of Elderly Patients with Lymphoma) is a phase 3 randomized (1:1) study focusing on a frail population of patients treated for DLBCL. The study will include 186 older adult patients with DLBCL (aged >65 years) receiving rituximab and chemotherapy. Overall, 50% (93/186) of patients (investigational group) will receive APA along with chemotherapy, and they will be supervised by a dedicated qualified kinesiologist. The APA program will include endurance and resistance training at moderate intensity 3 times a week during the 6 months of chemotherapy. The primary end point of this study will be event-free survival of the patients. The secondary end points will include the overall survival, progression-free survival, prevalence of sarcopenia and undernutrition, and patients' quality of life. This study will be conducted in accordance with the principles of the Declaration of Helsinki.

RESULTS

Recruitment, enrollment, and data collection began in February 2021, and 4 participants have been enrolled in the study as of July 2022. Data analysis will begin after the completion of data collection. Future outcomes will be published in peer-reviewed health-related research journals and presented at national congress, and state professional meetings. This publication is based on protocol version 1.1, August 3, 2020.

CONCLUSIONS

The PHARAOM study focuses on highlighting the benefits of APA intervention on survival during the period of first-line treatment of patients with DLBCL. This study could also contribute to our understanding of how an APA program can reduce complications such as sarcopenia in patients with lymphoma and improve their quality of life. By documenting the prevalence and relationship between sarcopenia and exercise load, we might be able to help physicians plan better interventions in the care of patients with DLBCL.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04670029; https://clinicaltrials.gov/ct2/show/NCT04670029.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40969.

R-CSS: A clinically applicable score to classify cachexia stages in patients with cancer undergoing intensity-modulated radiation therapy

Objective

Accurate cachexia staging is the key to its management. However, there is currently a lack of tools to distinguish the staging of cachexia in patients with cancer undergoing radiotherapy. The Radiotherapy Cachexia Staging Scale (R-CSS) was developed for the stratification of cachexia in patients undergoing cancer radiotherapy.

Methods

Patients with cancer undergoing radiotherapy were divided into four stages - noncachexia, precachexia, cachexia, and refractory cachexia - by the R-CSS scale, and the clinical outcomes of the four groups were compared.

Results

A total of 270 patients with cancer undergoing radiation therapy were included in the study. All participants were classified into four stages of cachexia: stage 0, I, II, and III. Patients with a higher cachexia stage had a higher prevalence of sarcopenia (P ​= ​0.015). Scores on the 16-item M. D. Anderson Symptom Inventory were higher in patients with higher cachexia stages (P ​< ​0.05), but levels of forgetfulness, numbness, and shortness of breath were not higher in these patients (P ​> ​0.05). Patients with higher cachexia stages exhibited better scores on the QLQ-C30 scale (P ​< ​0.05), except for in the domains of cognitive functioning, diarrhea, and dyspnea (P ​> ​0.05). The incidence of treatment-related events (any grade III or higher grade of [non-]hematologic adverse events, the need for hospitalization, emergency room admission) was higher in patients with higher cachexia stages.

Conclusions

The R-CSS scale is a screening tool that can simultaneously distinguish different stages of cachexia.

Everything You Always Wanted to Know about Sarcopenia but Were Afraid to Ask: A Quick Guide for Radiation Oncologists (Impact of Sarcopenia in Radiotherapy: The AFRAID Project)

Sarcopenia (SP) is a syndrome characterized by age-associated loss of skeletal muscle mass and function. SP worsens both acute and late radiation-induced toxicity, prognosis, and quality of life. Myosteatosis is a pathological infiltration of muscle tissue by adipose tissue which often precedes SP and has a proven correlation with prognosis in cancer patients. Sarcopenic obesity is considered a "hidden form" of SP (due to large fat mass) and is independently related to higher mortality and worse complications after surgery and systemic treatments with worse prognostic impact compared to SP alone. The evaluation of SP is commonly based on CT images at the level of the middle of the third lumbar vertebra. On this scan, all muscle structures are contoured and then the outlined surface area is calculated. Several studies reported a negative impact of SP on overall survival in patients undergoing RT for tumors of the head and neck, esophagus, rectum, pancreas, cervix, and lung. Furthermore, several appetite-reducing side effects of RT, along with more complex radiation-induced mechanisms, can lead to SP through, but not limited to, reduced nutrition. In particular, in pediatric patients, total body irradiation was associated with the onset of SP and other changes in body composition leading to an increased risk of cardiometabolic morbidity in surviving adults. Finally, some preliminary studies showed the possibility of effectively treating SP and preventing the worsening of SP during RT. Future studies should be able to provide information on how to prevent and manage SP before, during, or after RT, in both adult and pediatric patients.

Sex-Specific Cut-Off Values for Low Skeletal Muscle Mass to Identify Patients at Risk for Treatment-Related Adverse Events in Head and Neck Cancer

A low skeletal muscle index (SMI), defined with cut-off values, is a promising predictor for adverse events (AEs) in head and neck squamous cell cancer (HNSCC) patients. The aim was to generate sex-specific SMI cut-off values based on AE to diagnose low SMI and to analyse the relationship between low SMI and AEs in HNSCC patients. In this present study, HNSCC patients were prospectively included in a large oncological data-biobank and SMI was retrospectively measured using baseline neck scans. In total, 193 patients were included and were stratified according to treatment modality: (chemo-)radiotherapy ((C)RT) (n = 135) and surgery (n = 61). AE endpoints were based on the occurrence of clinically relevant toxicities (Common Terminology Criteria for Adverse Events grade ≥ III) and postoperative complications (Clavien–Dindo Classification grade ≥ II). Sex-specific SMI cut-off values were generated with receiver operating characteristic curves, based on the AE endpoints. The relationship of the baseline characteristics and AEs was analysed with logistic regression analysis, with AEs as the endpoint. Multivariable logistic analysis showed that low SMI (OR 3.33, 95%CI 1.41–7.85) and tumour stage (OR 3.45, 95%CI 1.28–9.29) were significantly and independently associated to (C)RT toxicity. Low SMI was not related to postoperative complications. To conclude, sex-specific SMI cut-off values, were generated based on the occurrence of AEs. Low SMI and tumour stage were independently related to (C)RT toxicity in HNSCC patients.

Impact of sarcopenia on acute radiation-induced toxicity in head and neck cancer patients

BACKGROUND AND PURPOSE

Sarcopenia is related to late radiation-induced toxicities and worse survival in head and neck cancer (HNC) patients. This study tested the hypothesis that sarcopenia improves the performance of current normal tissue complication probability (NTCP) models of radiation-induced acute toxicity in HNC patients.

MATERIAL/METHODS

This was a retrospective analysis in a prospective cohort of HNC patients treated from January 2007 to December 2018 with (chemo)radiotherapy. Planning CT-scans were used for evaluating skeletal muscle mass. Characteristics of sarcopenic and non-sarcopenic patients were compared. The impact of sarcopenia was analysed by adding sarcopenia to the linear predictors of current NTCP models predicting physician- and patient-rated acute toxicities.

RESULTS

The cut-off values of sarcopenia in the study population (n=977) were established at skeletal muscle index <42.0 cm2/m2 (men) and <31.2 cm2/m2 (women), corresponding to the lowest sex-specific quartile. Compared to non-sarcopenic patients, sarcopenic patients were more frequently smokers (61% vs. 48%, p<0.001), had more often advanced stage of disease (stage III-IV, p=0.004), higher age (67 vs. 63 years, p<0.001) and experienced more pretreatment complaints, such as dysphagia (grade ≥2, p<0.001). Sarcopenia remained statistically significant, next to the linear predictor, only for physician-rated grade ≥3 dysphagia (week 3-6 during RT, p<0.01). However, sarcopenia did not improve the performance of these NTCP models (p>0.99).

CONCLUSION

Sarcopenia in HNC patients was an independent prognostic factor for radiation-induced physician-rated acute grade ≥3 dysphagia, which might be explained by its impact on swallowing muscles. However, addition of sarcopenia did not improve the NTCP model performance.

Prognostic impact of sarcopenia in patients with head and neck cancer treated with surgery or radiation: A meta-analysis

BACKGROUND

The objective of this study was to compare the prognostic impact of sarcopenia in patients with head and neck cancer (HNC) treated with surgery or radiation.

METHODS

We systematically searched electronic databases to identify articles reporting the impact of sarcopenia on the prognosis of patients with HNC. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) were extracted and pooled. HR according to treatment modality were estimated using random-effects models. Statistical analyses were carried out using the Comprehensive Meta-Analysis software.

RESULTS

In total, 18 studies enrolling 3,233 patients were included. Sarcopenia was associated with poor OS in both surgery and radiotherapy groups (hazard ratio [HR] 2.50, 95% confidence interval [CI] 1.95-3.21; HR 1.63, 95% CI 1.40-1.90, respectively). The HR was significantly higher in the surgery group than in the radiotherapy group (p = 0.004), with similar results obtained for DFS (HR 2.59, 95% CI 1.56-4.31; HR 1.56, 95% CI 1.24-1.97 for the surgery and radiotherapy groups, respectively) and DSS (HR 2.96, 95% CI 0.73-11.95; HR 2.67, 95% CI 1.51-4.73 for the surgery and RT groups, respectively).

CONCLUSIONS

Sarcopenia was a poor prognostic factor for HNC, regardless of the treatment modality. However, the adverse effects of sarcopenia on survival were more prominent in the surgery group than in the radiotherapy group. Sarcopenia assessment is required for appropriate treatment decision-making.

The association of pretreatment low skeletal muscle mass with chemotherapy dose-limiting toxicity in patients with head and neck cancer undergoing primary chemoradiotherapy with high-dose cisplatin

Background

Low skeletal muscle mass (SMM) is an adverse prognostic factor for chemotherapy dose‐limiting toxicity (CDLT). In patients with locally advanced head and neck squamous cell carcinoma (HNSCC) undergoing chemoradiotherapy (CRT), low SMM is a predictor for CDLT. We aimed to validate these findings.

Methods

Consecutive LA‐HNSCC patients treated with primary CRT with high‐dose cisplatin were retrospectively included. SMM was measured on pre‐treatment CT‐imaging. A cumulative cisplatin dose below 200 mg/m² was defined as CDLT.

Results

One hundred and fifty three patients were included; 37 (24.2%) experienced CDLT, and 84 had low SMM (54.9%). Patients with low SMM experienced more CDLT than patients with normal SMM (35.7% vs. 10.1%, p < 0.01). Low SMM (OR 3.99 [95% CI 1.56–10.23], p = 0.01) and an eGFR of 60–70 ml/min (OR 5.40 [95% CI 1.57–18.65], p < 0.01) were predictors for CDLT.

Conclusion

Pre‐treatment low SMM is associated with CDLT in LA‐HNSCC patients treated with primary CRT. Routine SMM assessment may allow for CDLT risk assessment and treatment optimization.

Low skeletal muscle mass predicts relevant clinical outcomes in head and neck squamous cell carcinoma. A meta analysis

Background:

The purpose of this meta-analysis was to analyze the influence of sarcopenia, defined as low skeletal muscle mass, on clinical outcomes in patients with head and neck squamous cell carcinoma (HNSCC) based on a large sample.

Methods:

The MEDLINE, EMBASE, and SCOPUS databases were screened for associations between sarcopenia and clinical outcomes in HNSCC up to December 2020. Overall, 27 studies met the inclusion criteria. The methodological quality of the studies involved was checked according to the QUADAS instrument. The meta-analysis was undertaken using RevMan 5.3 software. DerSimonian and Laird random-effects models with inverse-variance weights were used to account for heterogeneity between the studies.

Results:

The 27 included studies comprised 7704 patients with different HNSCCs. The cumulative calculated frequency among the studies was 42.0% [95% confidence interval (CI) 35.34–48.65]. Sarcopenia was associated with occurrence of severe postoperative complications, odds ratio (OR) 4.79, 95% CI (2.52–9.11), p < 0.00001. Sarcopenia predicted disease-free survival (DFS), simple regression: hazard ratio (HR) 2.00, 95% CI (1.63–2.45), p < 0.00001, multiple regression: HR 1.64, 95% CI (1.33–2.03), p < 0.00001. Also, sarcopenia was associated with lower overall survival (OS), simple regression: HR 1.96, 95% CI (1.71–2.24), p < 0.00001, multiple regression: HR = 1.87, 95% CI (1.53–2.29), p < 0.00001. In patients who underwent definitive chemotherapy and/or radiation, sarcopenia predicted lower OS (simple regression), HR 1.95, 95% CI (1.61–2.36), p < 0.00001, multiple regression: HR = 1.51, 95% CI (1.17–1.94), p < 0.002). In patients with primary surgical strategy with or without adjuvant radio-chemotherapy, sarcopenia was associated with lower OS (simple regression), HR 2.21, 95% CI (1.72–2.84), p < 0.00001, multiple regression: HR = 2.05, 95% CI (1.55–2.72), p < 0.00001).

Conclusion:

The cumulative prevalence of sarcopenia in HNSCC is 42.0%. Sarcopenia is an independent risk factor for OS and DFS in patients with HNSCC who undergo curative therapy. Sarcopenia is associated with the occurrence of severe postoperative complications.

Prospective Evaluation of Sarcopenia in Head and Neck Cancer Patients Treated with Radiotherapy or Radiochemotherapy

Simple Summary

Radiation therapy (RT) is a key treatment for head and neck squamous cell carcinoma (HNSCC) patients. RT generates acute toxicity and weight loss, especially when combined with chemotherapy. Frail patients (malnourished or with poor performance status) have poor outcomes and increased toxicity when treated by RT. Among non-frail patients, predicting RT outcome is a challenge. Loss of muscle mass, also known as sarcopenia, is associated with poor outcome in HNSCC patients treated by RT and chemotherapy, but the level of evidence remains weak. Conflicting results exist regarding the impact of sarcopenia on acute RT toxicity. This prospective study confirmed that in non-frail HNSCC patients baseline sarcopenia is frequent (37%) and is associated with decreased overall and disease-free survival, but not with acute toxicity. Interestingly, a worse impact of sarcopenia occurred despite optimal nutritional support and even when patients were treated by RT without chemotherapy. Sarcopenia should be regarded as an independent prognostic factor in that setting.

Abstract

Highlights: Sarcopenia is frequent in patients treated with radiation therapy (RT) or radiochemotherapy (RTCT) for head and neck squamous cell carcinomas. Sarcopenia is associated with poor disease-free survival and overall survival outcomes. Sarcopenia is not associated with a higher rate of treatment-related toxicity. Background: Sarcopenia occurs frequently with the diagnosis of head and neck squamous cell carcinoma (HNSCC). We aimed to assess the impact of sarcopenia on survival among HNSCC patients treated with radiotherapy (RT) or radiochemotherapy (RTCT). Methods: Patients treated between 2014 and 2018 by RT or RTCT with curative intent were prospectively included (NCT02900963). Optimal nutritional support follow-up, including weekly consultation with a dietician and an oncologist and daily weight monitoring, was performed. Sarcopenia was determined by measuring the skeletal muscles at the L3 vertebra on the planning CT scan for radiotherapy. For each treatment group (RT or RTCT), we assessed the prognostic value of sarcopenia for disease-free survival (DFS) and overall survival (OS) and its impact on treatment-related toxicity. Results: Two hundred forty-three HNSCC patients were included: 116 were treated by RT and 127 were treated by RTCT. Before radiotherapy, eight (3.3%) patients were considered malnourished according to albumin, whereas 88 (36.7%) patients were sarcopenic. Overall, sarcopenia was associated with OS and DFS in a multivariate analysis (HR 1.9 [1.1–3.25] and 1.7 [1.06–2.71], respectively). It was similar for patients treated with RT (HR 2.49 [1.26–4.9] for DFS and 2.24 [1.03–4.86] for OS), whereas for patients treated with RTCT sarcopenia was significantly associated with OS and DFS in univariate analysis only. Sarcopenia was not related to higher treatment-related toxicity. Conclusions: Pretherapeutic sarcopenia remains frequent and predicts OS and DFS for non-frail patients treated with curative intent and adequate nutritional support.