Role of frailty and nutritional status in predicting complications following total gastrectomy with D2 lymphadenectomy in patients with gastric cancer: a prospective study

Benefits of jejunostomy feeding in patients who underwent gastrectomy for cancer treatment

BACKGROUND

Gastric cancer is associated with significant undernutrition responsible for an increase in morbidity and mortality after gastrectomy.

AIM

To evaluate the impact of enteral nutrition by jejunostomy feeding in patients undergoing gastrectomy for cancer.

METHODS

Between 2003 and 2017, all patients undergoing gastrectomy for cancer treatment were included retrospectively. A group with jejunostomy (J + group) and a group without jejunostomy (J - group) were compared.

RESULTS

Of the 172 patients included, 60 received jejunostomy. Preoperatively, the two groups were comparable with respect to the nutritional parameters studied (body mass index, albumin, etc.). In the postoperative period, the J + group lost less weight and albumin: 5.74 ± 8.4 vs 9.86 ± 7.5 kg (P = 0.07) and 7.2 ± 5.6 vs 14.7 ± 12.7 g/L (P = 0.16), respectively. Overall morbidity was 25% in the J + group and 36.6% in the J - group (P = 0.12). The J + group had fewer respiratory, infectious, and grade 3 complications: 0% vs 5.4% (P = 0.09), 1.2% vs 9.3% (P = 0.03), and 0% vs 4.7% (P = 0.05), respectively. The 30-day mortality was 6.7% in the J + group and 6.3% in the J - group (P = 0.91).

CONCLUSION

Jejunostomy feeding after gastrectomy improves nutritional characteristics and decreases postoperative morbidity. A prospective study could confirm our results.

Frailty and Health-Related Quality of Life in Elderly Patients Undergoing Esophageal Cancer Surgery: A Longitudinal Study

PURPOSE

This study aims to elucidate the longitudinal alterations in frailty and health-related quality of life experienced by elderly patients undergoing surgical treatment for esophageal cancer. Additionally, it seeks to ascertain the impact of preoperative frailty on postoperative health-related quality of life over time.

METHODS

131 patients were included in the prospective study. Patients' frailty and health-related quality-of-life were assessed utilizing the Tilburg and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 at preoperative, 1 week, 1 month, and 3 months, postoperatively. Statistical analyses were performed using generalized estimating equations, repeated-measures analysis of variance, and linear mixed models (LMMs).

RESULTS

Out of 131 patients, 28.2% had frailty before surgery, and the prevalence of frailty consistently higher after surgery compared with baseline (67.9%, 51.9%, and 39.7%). There was no significant change in frailty scores in preoperative frail patients within 3 months following surgery (p = .496, p < .999, p < .999); whereas in preoperative non-frail patients, the frailty scores increased at 1 week (p < .001) and then decreased at 1 month (p = .014), followed by no change at 3 months. In addition, preoperative frail patients had significantly worse global quality-of-life (β = -4.24 (-8.31; -.18), p = .041), physical functioning (β = -9.87 (-14.59; -5.16), p < .001), role functioning (β = -10.04 (-15.76; -4.33), p = .001), and social functioning (β = -8.58 (-15.49; -1.68), p = .015), compared with non-frail patients.

CONCLUSIONS

A significant proportion of participants exhibited a high prevalence of preoperative frailty. These patients, who were preoperatively frail, exhibited a marked reduction in health-related quality-of-life, a more gradual recovery across various functional domains, and an increased symptom burden during the follow-up period. Therefore, it is crucial to meticulously identify and closely monitor patients with preoperative frailty for any changes in their postoperative physiology, role, and social functioning.

Frailty combined with nutritional risk score in predicting postoperative complications of elderly patients with gastrointestinal malignancies

OBJECTIVE

Exploring the predictive power of frailty combined with nutritional risk on postoperative complications in elderly gastrointestinal malignancies patients.

METHODS

Elderly patients who underwent gastrointestinal cancer surgery at Gastrointestinal Surgery Department of the Affiliated Hospital of Binzhou Medical University from August 2021 to June 2022 were selected as the research subjects. The patients' frailty and nutritional status were assessed using the Fried Frailty Scale and the NRS2002 Nutritional Risk Scale within 24 h of admission. Observing and recording the diagnosis and treatment of postoperative complications during the hospitalization.

RESULTS

202 patients were enrolled, including 119 patients (58.91%) with nutritional risk and 89 patients (44.06%) with frailty. Frailty was an independent risk factor for postoperative complications [OR = 5.904, 95%CI (3.103, 11.233)]. The AUC value of frailty assessment was 0.780, which was greater than the AUC value of NRS2002 score of 0.705 (P < 0.01). The AUC value of frailty assessment combined with NRS-2002 score was 0.844, which was significantly higher than that alone (P < 0.01).

CONCLUSIONS

The ability of frailty to predict postoperative complications is better than the NRS-2002 score. Frailty combined with nutritional risk assessment can increase the predictive power of postoperative complications in elderly gastrointestinal malignancies patients.

A continuous muscle-sparing advantage of pylorus-preserving gastrectomy for older patients with cT1N0M0 gastric cancer in the middle third of the stomach

In older patients with cT1N0M0 gastric cancer in the middle third of the stomach, LPPG has advantages over LDGB1 in maintaining skeletal muscle mass.

BACKGROUND

Laparoscopic pylorus-preserving gastrectomy (LPPG) for early gastric cancer in the middle third of the stomach is expected to be an alternative procedure to laparoscopic distal gastrectomy (LDG). However, whether LPPG is safe and more useful than LDG in older patients is unclear because of their comorbidities and organ dysfunctions.

METHODS

We retrospectively analyzed the data of consecutive patients aged 75 or over who underwent LDG with Billroth I reconstruction (LDGB1) or LPPG for cT1N0M0 gastric cancer in the middle third of the stomach between 2005 and 2019. After propensity score matching was used to improve the comparability between the LDGB1 and LPPG groups, we compared surgical and postoperative nutritional outcomes, including the postoperative trends of bodyweight (%BW) and skeletal muscle index (%SMI).

RESULTS

A total of 132 patients who underwent LDGB1 (n = 88) and LPPG (n = 44) were collected for this study. No significant difference in postoperative complications was observed. The total protein levels after LPPG were significantly higher than those after LDGB1 for 4 postoperative years. Both %BW and %SMI after LPPG were significantly maintained compared with those after LDGB1 during the first year after surgery. For the subsequent years, %BW after LPPG became similar to that after LDGB1, while %SMI after LPPG was significantly larger than LDGB1 continuously.

CONCLUSIONS

LPPG has a great advantage in maintaining the postoperative skeletal muscle mass as well as the nutritional parameters of older patients. LPPG is expected to be an alternative to LDG in older patients.

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.

The impact of nutritional risk factors and sarcopenia on survival in patients treated with pelvic exenteration for recurrent gynaecological malignancy: a retrospective cohort study

Purpose

The aim of the present study is to investigate the prognostic significance of nutritional risk factors and sarcopenia on the outcome of patients with recurrent gynaecological malignancies treated by pelvic exenteration.

Methods

We retrospectively evaluated muscle body composite measurements based on pre-operative CT scans, nutritional risk factors as assessed by a validated pre-operative questionnaire, and clinical–pathological parameters in 65 consecutive patients with recurrent gynaecological malignancies, excluding ovarian cancer, treated by pelvic exenteration at the Royal Marsden Hospital London. Predictive value for postoperative morbidity was investigated by logistic regression analyses. Relevant parameters were included in uni- and multivariate survival analyses.

Results

We found only (1) low muscle attenuation (MA)—an established factor for muscle depletion—and (2) moderate risk for malnutrition to be independently associated with shorter overall survival (p = 0.006 and p = 0.008, respectively). MA was significantly lower in overweight and obese patients (p = 0.04). Muscle body composite measurements were not predictive for post-operative morbidity.

Conclusion

The study suggests that pre-operative low MA and moderate risk for malnutrition are associated with shorter survival in patients with recurrent gynaecological malignancies treated with pelvic exenteration. Further studies are needed to validate these findings in larger cohorts.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06273-7.

Depletion of skeletal muscle mass adversely affects long-term outcomes for men undergoing gastrectomy for gastric cancer

BACKGROUND

Although low skeletal muscle mass has an adverse impact on the treatment outcomes of cancer patients, whether the relationship between preoperative skeletal muscle mass and gastrectomy outcomes in gastric cancer (GC) differs between men and women is unclear. The study aimed to clarify this relationship based on gender.

METHODS

Between January 2007 and December 2015, 1054 patients who underwent gastrectomy for GC at Osaka City General Hospital were enrolled in this study. We evaluated sarcopenia by the skeletal muscle index (SMI), which was measured by computed tomography (CT) using areas of muscle in the third lumbar vertebral body (L3). Male and female patients were each divided into two groups (low skeletal muscle and high skeletal muscle).

RESULTS

The SMI emerged as an independent predictor of 5-year overall survival (OS) in male GC patients (Hazard ratio 2.51; 95% confidence interval (CI) 1.73-3.63, p < 0.001) based on multivariate analysis. However, this index was not an independent predictive determinant of 5-year cancer-specific survival (CSS). The SMI was not an independent predictor of either OS or CSS in female GC patients. The incidence of leakage and major complication (Clavien Dindo grade ≧ 3) did not differ significantly across groups.

CONCLUSIONS

Preoperative skeletal muscle mass is a valuable prognostic predictor of OS in male GC patients.

Relationship between frailty and mortality after gastrectomy in older patients with gastric cancer

OBJECTIVES

Frail older adults with gastric cancer are at an increased risk of poor postoperative outcomes. We assessed whether geriatric frailty assessed using the Study of Osteoporotic Fractures (SOF) index could predict post-gastrectomy mortality.

MATERIALS AND METHODS

We retrospectively assessed older adults (age ≥ 65 years) who underwent gastrectomy for gastric cancer between April 2012 and September 2015. Frailty status was assessed using the SOF index (range, 0-3) and categorized as robust (0), pre-frail (1), and frail (2-3). The Kaplan-Meier method and log-rank tests were used to compare survival between frailty groups. Univariate and multivariate analyses were used to identify mortality-associated risk factors.

RESULTS

Among 231 patients (the median age 72.04 years and 140 (60.6%) men), 138 (59.7%) were robust, 58 (25.1%) were pre-frail, and 35 (15.2%) were frail. The mortality rate was 14.5% among robust patients, 20.7% among pre-frail patients, and 20.0% among frail patients (log-rank test, P = 0.032). Frail patients had more than a 3-fold increased risk of mortality compared with robust patients (adjusted HR = 3.331; 95% CI, 1.161-9.559). Multivariate analysis revealed that the SOF index and TNM stage were associated with increased mortality.

CONCLUSIONS

SOF index predicted post-gastrectomy mortality among older patients independently of age, sex, TNM stage, type of approach, gastrectomy type, and extent of lymph node dissection. SOF index may be used with ease to assess frailty status among older patients with gastric cancer in busy clinics and subgroups that may benefit from targeted frailty interventions before cancer treatments.

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.

Clinical Impact of a Perioperative Exercise Program for Sarcopenia and Overweight/Obesity Gastric Cancer

Gastrectomy with D2 lymph node dissection and perioperative adjuvant treatment is the standard treatment for locally advanced gastric cancer. However, the morality rate is reported to be 20%-40% after gastrectomy for gastric cancer. Perioperative sarcopenia and obesity are strongly related to postoperative surgical complications after gastrectomy. Furthermore, recent studies have shown that postoperative surgical complications are related to long-term oncological outcomes. If we can prevent or improve perioperative sarcopenia or obesity in gastric cancer patients, the rate of postoperative surgical complications in these patients might be reduced, thereby improving the long-term oncological outcomes. Given this hypothesis, recent studies have focused on enacting perioperative exercise programs for gastric cancer patients with sarcopenia and overweight/obesity. Such exercise programs have proven promising and demonstrated some clinical benefits for gastric cancer patients with sarcopenia and overweight/obesity. However, whether or not perioperative exercise programs have clinical benefits with regard to long-term oncological outcomes in gastric cancer patients is unclear. To optimize these perioperative exercise programs for gastric cancer patients, it is necessary to clarify the benefits with regard to the long-term oncological outcomes in these patients and establish an optimal perioperative exercise program.

Personalized trimodal prehabilitation for gastrectomy

BACKGROUND

Surgery is the only potentially curative treatment for gastric cancer, however, it bears a high postoperative morbidity and mortality rate. A recent randomized control trial proposed prehabilitation to reduce the postoperative morbidity in patients undergoing major abdominal surgery. Currently, there is a lack of evidence of using prehabilitation for patients undergoing gastrectomy for gastric cancer. The aim of our study is to demonstrate that home-based prehabilitation can reduce postoperative morbidity after gastrectomy for gastric cancer.

METHODS

PREFOG is a multi-center, open-label randomized control trial comparing 90-days postoperative morbidity rate after gastrectomy for gastric cancer between patients with or without prehabilitation. One-hundred twenty-eight patients will be randomized into an intervention or control group. The intervention arm will receive trimodal home-based prehabilitation including nutritional, psychological and exercise interventions. Secondary outcomes of the study will include physical and nutritional status, anxiety and depression level, quality of life, postoperative mortality rates and full completion of the oncological treatment as determined by the multidisciplinary tumor board.

DISCUSSION

PREFOG study will show if home-based trimodal prehabilitation is effective to reduce postoperative morbidity after gastrectomy for gastric cancer. Moreover, this study will allow us to determine whether prehabilitation can improve physical fitness and activity levels, nutritional status and quality of life as well as reducing anxiety and depression levels after gastrectomy for gastric cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04223401 (First posted: 10 January 2020).

Role of Frailty and Comorbidity Status in Predicting Morbidity and Mortality in Patients with Acute Mesenteric Ischemia

BACKGROUND

This study was performed to determine the association of frailty and comorbidity status with postoperative morbidity and mortality in patients with acute mesenteric ischemia (AMI).

METHODS

Patients diagnosed with AMI between April 2006 and September 2019 were enrolled in this study. Frailty was evaluated by sarcopenia which was diagnosed by third lumbar vertebra psoas muscle area (PMA). Comorbidity status was evaluated by the Charlson Comorbidity Index (CCI) score. Univariate and multivariate analyses evaluating the risk factors for postoperative morbidity and mortality were performed.

RESULTS

Of the 174 patients, 86 were managed conservatively and 88 underwent surgery. In surgically managed patients, 39.8% developed complications within 30 days of surgery. Ten patients died within 30 days of the operation. In the univariate analyses, white blood cell >10 g/L, low PMA, CCI score ≥2, and bowel resection were associated with postoperative complications. Multivariate analysis revealed that low PMA, CCI score ≥2, and bowel resection were independent predictors of postoperative complications.

CONCLUSIONS

This study demonstrated that low PMA, CCI score ≥2, and bowel resection were independent risk factors for postoperative complications in patients with AMI. Preoperative assessment of frailty using PMA and the evaluation of comorbidity status using CCI may serve as helpful tools in preoperative risk assessment and should be integrated into scoring systems for surgically treated AMI.

CT-assessed sarcopenia is a predictive factor for both long-term and short-term outcomes in gastrointestinal oncology patients: a systematic review and meta-analysis

BACKGROUND

The impact of sarcopenia on the outcome of gastrointestinal (GI) oncological patients is still controversial. We aim to discuss the prevalence of sarcopenia and its relation to the oncological outcome.

METHODS

Embase, Medline, PubMed, and the Cochrane library were systematically searched for related keywords. Studies using CT to assess sarcopenia and evaluate its relationship with the outcome of GI oncological patients were included. Long-term outcomes, including overall survival and disease-free survival, were compared by hazard ratios (HRs) with 95% confidence intervals (CIs). Short-term outcomes, including total complications and major complications (Clavien-Dindo ≥IIIa) after curable surgery, were compared by the risk ratio (RR) and 95% CI.

RESULTS

A total of 70 studies including 21,875 patients were included in our study. The median incidence of sarcopenia was 34.7% (range from 2.1 to 83.3%). A total of 88.4% of studies used skeletal muscle index (SMI) in the third lumbar level on CT to define sarcopenia, and a total of 19 cut-offs were used to define sarcopenia. An increasing trend was found in the prevalence of sarcopenia when the cut-off of SMI increased (β = 0.22, 95% CI = 0.12-0.33, p < 0.001). The preoperative incidence of sarcopenia was associated both with an increased risk of overall mortality (HR = 1.602, 95% CI = 1.369-1.873, P < 0.001) and with disease-free mortality (HR = 1.461, 95% CI = 1.297-1.646, P < 0.001). Moreover, preoperative sarcopenia was a risk factor for both total complications (RR = 1.188, 95% CI = 1.083-1.303, P < 0.001) and major complications (RR = 1.228, 95% CI = 1.042-1.448, P = 0.014).

CONCLUSION

The prevalence of sarcopenia depends mostly on the diagnostic cut-off points of different criteria. Preoperative sarcopenia is a risk factor for both long-term and short-term outcomes.

Epidemiology of weight loss, malnutrition and sarcopenia: A transatlantic view

Malnutrition is a common comorbidity in patients with cancer, with determinants linked to the patients, the tumor, and the treatment. Cancer malnutrition, also called cachexia, represents the chronic form of disease-related malnutrition with chronic inflammation, and strongly impairs the prognosis. Reduced muscle mass, otherwise called sarcopenia in these patients, is a feature of malnutrition and thus of cancer cachexia that may appear before weight loss, and has a strong negative effect on prognosis, as well. The reported global prevalence of loss of muscle mass is 39%, whereas the prevalence of malnutrition in important cohorts varies from 25% to 70%. This is mostly due to the very different screening and diagnostic tools used throughout the world. The recent Global Leadership Initiative on Malnutrition has become a consensus alternative to standardize how malnutrition may be diagnosed based on etiologic and phenotypic criteria available everywhere, from rich to poor countries. This will lead to an easier diagnosis of cancer malnutrition that itself will help us speak the same language worldwide.

Body composition assessment and sarcopenia in patients with gastric cancer: a systematic review and meta-analysis

INTRODUCTION

There has recently been increased interest in the assessment of body composition in patients with gastric cancer for the purpose of prognostication. This systematic review and meta-analysis aim to evaluate the current literature on body composition assessment in patients with gastric cancer and its impact on peri-operative outcomes.

METHODS

A systematic literature search was conducted for studies reporting assessment of body composition in patients with gastric cancers. Meta-analysis of postoperative outcomes (overall and major complications, anastomotic leaks, pulmonary complications) and survival was performed using random effects models.

RESULTS

Thirty-nine studies reported the assessment of body composition in 8402 patients. Methods used to assess body composition in patients with gastric cancers were computerized tomography (n = 26), bioelectrical impedance analysis (n = 9), and dual-energy-X-ray-absorptiometry (n = 3). Only 21 studies reported the impact of pre-operative sarcopenia on post-operative outcomes. Sarcopenic patients have significantly higher rates of postoperative major complications (n = 12, OR 1.67, CI_95% 1.14-2.46, p = 0.009), and pulmonary (n = 8, OR 4.01, CI_95% 2.23-7.21, p < 0.001) complications after gastrectomy. Meta-analysis of nine studies reporting overall survival after gastrectomy identified significantly worse survival in patients with pre-operative sarcopenia (HR 2.12, CI_95% 1.89-2.38, p < 0.001).

CONCLUSIONS

Assessment of body composition has the potential to become a clinically useful tool that could support decision-making in patients with gastric cancer. However, variation in methods of assessing and reporting body composition in this patient group limits assessment of current post-operative outcomes.

Predictive Value of Preoperative Sarcopenia in Patients with Gastric Cancer: a Meta-analysis and Systematic Review

PURPOSE

The impact of preoperative sarcopenia on postoperative complications and overall survival has been recently debated. Our meta-analysis aims to ascertain whether preoperative sarcopenia increases the risk of poor outcomes and to attempt to provide new ideas for the prognosis of outcomes for patients with gastric cancer.

METHODS

We searched for all relevant articles on PubMed, the EMBASE database, and Web of Science (up to September 1, 2017). Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

RESULTS

Thirteen studies involving 4262 patients who underwent gastrectomy for gastric cancer were analyzed (sarcopenia group = 1234; non-sarcopenia group = 3028). The results showed that preoperative sarcopenia significantly associated with poor pathological staging (high pT: OR = 1.86, 95% CI = 1.49-2.31; P < 0.01; pN+: OR = 1.61, 95% CI = 1.33-1.94; P < 0.01; high TNM category: OR = 1.84, 95% CI = 1.53-2.22; P < 0.01). Patients with preoperative sarcopenia had an increased risk of total postoperative complications (OR = 2.17, 95% CI = 1.53-3.08; P < 0.01), severe complications (OR = 1.65, 95% CI = 1.09-2.50; P = 0.02), and poorer OS (HR = 1.70, 95% CI = 1.45-1.99; P < 0.01). The results of subgroup analyses revealed that patients with preoperative sarcopenia over 65 years old and those from Asian populations had higher risks for total postoperative complications and severe complications.

CONCLUSION

This meta-analysis reveals that preoperative sarcopenia may be used as a new indicator of poor pathological staging, impaired overall survival, and increased postoperative complications. Notably, patients with gastric cancer who are over 65 years old and from Asia should be routinely screened for sarcopenia before surgery to adequately assess the risk of postoperative complications in clinical practice.

Prognostic significance of CT-determined sarcopenia in patients with advanced gastric cancer

Background

Sarcopenia, defined as decreased skeletal muscle mass, is prevalent and associated with poor prognosis in various solid tumors. This study aimed to determine the prognostic role of sarcopenia in patients with advanced gastric cancer (AGC).

Methods

This retrospective study consisted of 140 consecutive patients who underwent palliative chemotherapy for AGC. A cross-sectional area of muscle at the level of the third lumbar vertebra (L3) was measured using baseline computed tomography (CT) scans. Sarcopenia was defined as a L3 skeletal muscle index of ≤ 49 cm²/m² for men and ≤ 31 cm²/m² for women using Korean-specific cutoffs. We compared the overall survival (OS) and clinical characteristics of patients with and without sarcopenia.

Results

The median age was 67 years, and 133 (95%) patients had metastatic disease. Sarcopenia was present in 67 patients (47.9%) and was significantly related to male sex (p < 0.001) and low body mass index (p = 0.002). Patients with sarcopenia had a significantly shorter OS than those without sarcopenia (median, 6.8 months vs. 10.3 months, respectively; p = 0.033). In the multivariable analysis, sarcopenia was an independent prognostic factor of poor OS (hazard ratio, 1.51, p = 0.029); no response to chemotherapy (p < 0.001), no second-line chemotherapy (p < 0.001), metastatic sites ≥ 3 (p < 0.001), and low serum albumin level (p = 0.033) were also independent prognostic factors of poor OS.

Conclusion

Sarcopenia, as determined by baseline CT, can be used to predict poor prognosis in AGC patients treated with palliative chemotherapy.

Barriers to the Interpretation of Body Composition in Colorectal Cancer: A Review of the Methodological Inconsistency and Complexity of the CT-Defined Body Habitus

BACKGROUND

Measurement of body composition by computed tomography (CT) is an advancing field. Sarcopenia, myosteatosis, and visceral obesity (VO) have been identified as predictive of survival in colorectal cancer (CRC). We performed a systematic review of contemporary studies to characterize this association and highlight methodological inconsistencies.

METHODS

MEDLINE and PubMed were queried for articles published from January 2000 on, with populations of resectable CRC and with CT-measured body composition and survival data. The study quality was assessed by two independent reviewers using the Newcastle-Ottawa Scale.

RESULTS

Twenty studies met inclusion criteria, with a total of 8895 patients. Only two of the studies scored as high quality and nine as moderate quality. The remaining nine studies scored as low quality. Ten studies considered sarcopenia and 12 considered visceral obesity (VO). Cutoff points to define sarcopenia, myosteatosis, and VO were identified by optimal stratification, quartiles, or median values. The prevalence of sarcopenia varied from 15 to 60%, which based on study population and cutoff value used. Sarcopenia was associated with worse overall and disease-free survival in eight of the included studies. Myosteatosis was considered in three studies with a prevalence of 19-78%. It was significantly predictive of worse overall and disease-free survival in all three studies. VO had a prevalence of 14-70% and was inconsistently predictive of survival outcomes.

CONCLUSIONS

There is a lack of methodological consistency within the currently published literature. Despite this, sarcopenia and myosteatosis, but not VO, are consistently associated with worse survival outcomes, when population and cancer-specific cutoffs are utilized.

ECCO essential requirements for quality cancer care: Oesophageal and gastric cancer

BACKGROUND

ECCO essential requirements for quality cancer care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe.

OESOPHAGEAL AND GASTRIC

ESSENTIAL REQUIREMENTS FOR QUALITY CARE: CONCLUSION: Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality OG cancer service. The ERQCC expert group is aware that it is not possible to propose a 'one size fits all' system for all countries, but urges that access to multidisciplinary units or centres must be guaranteed for all those with OG cancer.

The impact of frailty and sarcopenia on postoperative outcomes in older patients undergoing gastrectomy surgery: a systematic review and meta-analysis

BACKGROUND

Gastric cancer is a major health problem, and frailty and sarcopenia will affect the postoperative outcomes in older people. However, there is still no systematic review to determine the role of frailty and sarcopenia in predicting postoperative outcomes among older patients with gastric cancer who undergo gastrectomy surgery.

METHODS

We searched Embase, Medline through the Ovid interface and PubMed websites to identify potential studies. All the search strategies were run on August 24, 2016. We searched the Google website for unpublished studies on June 1, 2017. The data related to the endpoints of gastrectomy surgery were extracted. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled to estimate the association between sarcopenia and adverse postoperative outcomes by using Stata version 11.0. PRISMA guidelines for systematic reviews were followed.

RESULTS

After screening 500 records, we identified eight studies, including three prospective cohort studies and five retrospective cohort studies. Only one study described frailty, and the remaining seven studies described sarcopenia. Frailty was statistically significant for predicting hospital mortality (OR 3.96; 95% CI: 1.12-14.09, P = 0.03). Sarcopenia was also associated with postoperative outcomes (pooled OR 3.12; 95% CI: 2.23-4.37). No significant heterogeneity was observed across these pooled studies (Chi² = 3.10, I² = 0%, P = 0.685).

CONCLUSION

Sarcopenia and frailty seem to have significant adverse impacts on the occurrence of postoperative outcomes. Well-designed prospective cohort studies focusing on frailty and quality of life with a sufficient sample are needed.

Integration of Geriatric Assessment in the Care of Patients with Gastrointestinal Malignancies

BACKGROUND

The majority of patients with gastrointestinal (GI) malignancies are older. Recently, it has become evident that elements from a geriatric assessment (GA) are powerful predictors of outcomes such as postoperative morbidity and mortality, length of stay, type of treatment received, and survival across several GI tumor types in older adults. A GA is a systematic evaluation of functional status, comorbidities, polypharmacy, cognition, nutritional status, emotional status, and social support.

METHODS

A PubMed search was performed in order to identify clinical studies investigating the association between GA and outcomes in patients with GI malignancies.

RESULTS

A total of 31 studies were included in this review. For colorectal cancer, the evidence linking GA variables and frailty to negative outcomes is substantial and consistent. The data regarding other GI malignancies is more limited, but generally shows the same findings.

CONCLUSION

Increasing data shows that elements from a GA and frailty are consistently associated with negative short- and long-term treatment outcomes in older patients with GI malignancies. Future studies should investigate the impact of geriatric interventions on outcomes.

Sarcopenia related to neoadjuvant chemotherapy and perioperative outcomes in resected gastric cancer: a multi-institutional analysis

BACKGROUND

This study's objective was to evaluate the change in sarcopenia score following neoadjuvant chemotherapy (NAC) and to correlate both sarcopenia and change in score with perioperative outcomes in patients with advanced resected gastric cancer.

METHODS

Multi-institutional analysis of patients with gastric cancer who underwent NAC and resection from 2000-2015 was performed. Demographic and perioperative data were included. Sarcopenia score was defined as CT measurement of total psoas muscle at L3, stratified by height (m). Sarcopenia was defined as a score <385 mm²/m² in women and <545 mm²/m² in men.

RESULTS

Of 36 patients, 19% were sarcopenic prior to NAC. Following NAC, 31% were sarcopenic, with 14% developing sarcopenia during NAC. One patient (3%) became non-sarcopenic. There were no significant differences in patient, disease, or surgery characteristics between patients who were sarcopenic vs. not. Patients with sarcopenia were more likely to have post-operative complications (P=0.05). There was no significant difference in hospital stay (P=0.7402) or survival (P=0.2317).

CONCLUSIONS

A significant number of patients with gastric cancer become sarcopenic during NAC. Although patients with sarcopenia were nearly twice as likely to develop post-operative complications, this did not appear to impact length of stay (LOS) or survival.

Body Composition as a Prognostic Factor of Neoadjuvant Chemotherapy Toxicity and Outcome in Patients with Locally Advanced Gastric Cancer

Purpose

Neoadjuvant chemotherapy has been shown to improve survival in locally advanced gastric cancer, but it is associated with significant toxicity. Sarcopenia and sarcopenic obesity have been studied in several types of cancers and have been reported to be associated with higher chemotherapy toxicity and morbi-mortality. The aim of this study was to assess the prevalence of sarcopenia/sarcopenic obesity in patients with gastric cancer, as well as its association with chemotherapy toxicity and long-term outcomes.

Materials and Methods

A retrospective analysis was performed using an academic cancer center patient cohort diagnosed with locally advanced gastric cancer between January 2012 and December 2014 and treated with neoadjuvant chemotherapy. We analyzed body composition (skeletal muscle and visceral fat index) in axial computed tomography images.

Results

A total of 48 patients met the inclusion criteria. The mean age was 68±10 years, and 33 patients (69%) were men. Dose-limiting toxicity was observed in 22 patients (46%), and treatment was terminated early owing to toxicity in 17 patients (35%). Median follow-up was 17 months. Sarcopenia and sarcopenic obesity were found at diagnosis in 23% and 10% of patients, respectively. We observed an association between termination of chemotherapy and both sarcopenia (P=0.069) and sarcopenic obesity (P=0.004). On multivariate analysis, the odds of treatment termination were higher in patients with sarcopenia (odds ratio=4.23; P=0.050). Patients with sarcopenic obesity showed lower overall survival (median survival of 6 months [95% confidence interval {CI}=3.9–8.5] vs. 25 months [95% CI=20.2–38.2]; log-rank test P=0.000).

Conclusions

Sarcopenia and sarcopenic obesity were associated with early termination of neoadjuvant chemotherapy in patients with gastric cancer; additionally, sarcopenic obesity was associated with poor survival.

The Preoperative Frailty Versus Inflammation-Based Prognostic Score: Which is Better as an Objective Predictor for Gastric Cancer Patients 80 Years and Older?

BACKGROUND

Due to increased life expectancy, the number of elderly patients with gastric cancer is increasing. This study was designed to determine the role of preoperative frailty (PF) as a risk factor for postoperative complications and prognosis in the oldest elderly gastric cancer patients undergoing curative resection.

METHODS

A total of 165 patients older than 80 years who underwent radical gastrectomy for primary gastric cancer between 2000 and 2012 were analyzed. We collected data on the inflammation-nutritional status, morbidity, and survival of these patients. The relationship between postoperative complications and PF was analyzed by logistic regression, and a Cox proportional hazards model was performed to identify the prognostic factors.

RESULTS

A total of 54 (32.7%) patients were considered frail. PF was associated with an increased risk for postoperative complications [odds ratio (OR) 3.396; 95% confidence interval (CI) 1.046-11.025; P = 0.042]. With a median follow-up of 37.0 (range 1.0-77.8) months, the 3 year overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS) rates in the entire cohort were 46.1, 34.4, and 49.2%, respectively. A multivariate analysis of the inflammation-based prognostic factors showed that only PF was independently associated with OS (OR 1.613; 95% CI 1.052-2.473; P = 0.028), RFS (OR 1.859; 95% CI 1.279-2.703; P = 0.001), and CSS (OR 1.859; 95% CI 1.279-2.703; P = 0.001).

CONCLUSIONS

Frailty based on an easily calculable preoperative measure is a useful marker to identify patients at increased risk for postoperative complications and is more predictive of survival than an inflammation-based prognostic score after gastrectomy. Thus, PF status should be included in the routine assessment of the oldest elderly patients with gastric cancer.