Inverse association between visceral obesity and lymph node metastasis in gastric cancer

Impact of Body Mass Index on Survival Depending on Sex in 14,688 Patients with Gastric Cancer in a Tertiary Hospital in South Korea

Background/Aims

The incidence and prognosis of gastric cancer (GC) shows sex difference. This study aimed to evaluate the effect of body mass index (BMI) on GC survival depending on sex.

Methods

The sex, age, location, histology, TNM stages, BMI, and survival were analyzed in GC patients from May 2003 to February 2020 at the Seoul National University Bundang Hospital.

Results

Among 14,688 patients, there were twice as many males (66.6%) as females (33.4%). However, under age 40 years, females (8.6%) were more prevalent than males (3.1%). Cardia GC in males showed a U-shaped distribution for underweight (9.6%), normal (6.4%), overweight (6.1%), obesity (5.6%), and severe obesity (9.3%) but not in females (p=0.003). Females showed decreased proportion of diffuse-type GC regarding BMI (underweight [59.9%], normal [56.8%], overweight [49.5%], obesity [44.8%], and severe obesity [41.7%]), but males did not (p<0.001). Both sexes had the worst prognosis in the underweight group (p<0.001), and the higher BMI, the better prognosis in males, but not females. Sex differences in prognosis according to BMI tended to be more prominent in males than in females in subgroup analysis of TNM stages I, II, and III and the operative treatment group.

Conclusions

GC-specific survival was affected by BMI in a sex-dependent manner. These differences may be related to genetic, and environmental, hormonal factors; body composition; and muscle mass (Trial registration number: NCT04973631).

Association of visceral adipose tissue with postoperative outcome in upper gastrointestinal cancer: a systematic review and meta-analysis

BACKGROUND

There is no consensus on the relation between visceral fat mass and long-term postoperative prognosis in patients with upper gastrointestinal (GI) cancer.

OBJECTIVES

The purpose of this study was to investigate the association of preoperative visceral fat mass with postoperative complications and overall survival (OS) in patients with upper GI cancer.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE (Dialog), the WHO International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception through 20 July 2022. We conducted a systematic review and random-effects meta-analysis of studies including patients who were surgically treated for upper GI cancer and whose visceral fat mass was assessed on the basis of body composition. We independently assessed the risk of bias and quality of evidence using the Quality In Prognosis Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. The primary outcome was OS. HRs and 95% CIs for OS were pooled.

RESULTS

Ninety-one studies (n = 20,583) were included. All studies used computed tomography (CT) to assess the body composition of patients. Twenty-four studies reported the relation between high visceral fat and postoperative outcomes, and their results were synthesized. Compared with low visceral adipose tissue, high visceral adipose tissue assessed by CT may improve OS (HR: 0.69; 95% CI: 0.55, 0.87; I2 = 65%; n = 3407). The risk of bias for OS in each study was moderate or high. The certainty of evidence for OS was very low because of inconsistency in the forest plot, the moderate or high risk of bias, and publication bias.

CONCLUSIONS

High visceral fat may be associated with improved OS after radical resection in patients with upper GI cancer. Further studies are needed to confirm these findings and mitigate the risk.

Obesity promotes lipid accumulation in lymph node metastasis of gastric cancer: a retrospective case‒control study

Background

The connection between obesity, lipid accumulation, and lymph node metastasis (LNM) in gastric cancer (GC) is unclear.

Methods

The association of body mass index (BMI) and serum lipid levels with LNM was measured by calculating the odds ratio (OR) and 95% confidence interval (CI) in 1,058 eligible GC patients with a mean age of 61.4 years. Meanwhile, differentially expressed genes (DEGs) were identified between lymph node metastasis-positive (N +) and -negative (N0) groups using public RNA-seq data. Neutral lipids in human GC samples were detected by Oil red O staining. The expression of cluster of differentiation 36 (CD36), fatty acid synthase (FASN), and lipoprotein lipase (LPL) was detected by immunohistochemistry (IHC) and quantitative real-time PCR.

Results

Compared with normal-weight patients, overweight (OR = 2.02, 95% CI = 1.26–3.23) and obese (OR = 1.83, 95% CI = 1.15–2.91) patients showed increased ORs for LNM. However, no significant results were obtained for serum lipids in the multivariable-adjusted model (P > 0.05). Subgroup analysis suggested that increased low-density lipoprotein cholesterol was a risk factor in females (OR = 1.27, 95% CI = 1.02–1.59). Functional enrichment analysis of DEGs revealed a connection between lipid metabolism and LNM. Meanwhile, lipid staining showed a mass of lipids in obese N + tumor samples, and IHC analysis indicated an increase in LPL and CD36 expression in N + cases, implying a crucial role for exogenous lipid supply in LNM.

Conclusions

High BMI significantly increases the risk of LNM in GC and promotes lipid accumulation in GC cells in LNM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12944-022-01734-7.

The Association Between Visceral Obesity and Postoperative Outcomes in Elderly Patients With Colorectal Cancer

Background

The impact of visceral obesity on the postoperative complications of colorectal cancer in elderly patients has not been well studied. This study aims to explore the influence of visceral obesity on surgical outcomes in elderly patients who have accepted a radical surgery for colorectal cancer.

Methods

Patients aged over 65 year who had undergone colorectal cancer resections from January 2015 to September 2020 were enrolled. Visceral obesity is typically evaluated based on visceral fat area (VFA) which is measured by computed tomography (CT) imaging. Univariate and multivariate analyses were performed to analyze parameters related to short-term outcomes.

Results

A total of 528 patients participated in this prospective study. Patients with visceral obesity exhibited the higher incidence of total (34.1% vs. 18.0%, P &lt; 0.001), surgical (26.1% vs. 14.6%, P = 0.001) and medical (12.6% vs. 6.7%, P = 0.022) complications. Based on multivariate analysis, visceral obesity and preoperative poorly controlled hypoalbuminemia were considered as independent risk factors for postoperative complications in elderly patients after colorectal cancer surgery.

Conclusions

Visceral obesity, evaluated by VFA, was a crucial clinical predictor of short-term outcomes after colorectal cancer surgery in elderly patients. More attentions should be paid to these elderly patients before surgery.

Visceral-to-subcutaneous fat ratio independently predicts the prognosis of locally advanced gastric cancer----- highlighting the role of adiponectin receptors and PPARα, β/ δ, ɤ

BACKGROUND

Results of computed tomography body composition (CTBC) predicting long-term outcomes of gastric cancer have been mixed and the plausible mechanism remains elusive.

METHODS

We retrospectively enrolled a cohort of stage III gastric cancer who had undergone curative-intent gastrectomy. Clinicopathological variables, preoperative CTBC including abdominal muscle, subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT), and nutritional and inflammatory index were taken together to construct prognostic analysis. In vitro tests using co-culture system of gastric cancer cell lines and visceral adipocytes were conducted.

RESULTS

A total of 191 eligible patients were enrolled. By multivariate analysis, SAT and VAT/ SAT ratio were prognostic factors of disease-free survival, while sarcopenia was not. SAT remained as a prognostic factor of overall survival. SAT index was positively correlated with prognostic nutritional index, while VAT HU was positively correlated with platelet-to-lymphocyte ratio. Expression of adiponectin receptor 1 and 2 (AdipoR1, R2), and peroxisome proliferator-activated receptor (PPAR) α, β/δ, ɤ of patients with higher VAT/SAT ratio were decreased as compared to those with lower VAT/SAT ratio. Proliferation of gastric cancer cells co-cultured with adipocytes was increased by 50-100% and accompanied by down-regulation of mRNAs of AdipoR1, 2, PPARα, β/δ, ɤ, and pro-apoptotic genes, as compared to their controls.

CONCLUSION

SAT and VAT played exactly opposite prognostic roles of locally advanced gastric cancers, which might work through modulation of AdipoR1, 2 and PPARα, β/δ, ɤ. Preoperative CTBC, supplementary to classic TNM system, helps clinicians tailor individualized adjuvant therapy and/or nutritional support.

Clear cell renal cell carcinoma: the value of sex-specific abdominal visceral fat measured on CT for prediction of Fuhrman nuclear grade

OBJECTIVE

To explore whether sex-specific abdominal visceral fat composition on CT can predict the Fuhrman nuclear grade of clear cell renal cell carcinoma (ccRCC).

METHODS

One hundred seventy-one patients (123 males and 48 females) from four hospitals (multicentre group) and 159 patients (109 males and 50 females) from the cancer imaging archive (TCIA-KIRC group) with pathologically proven ccRCC (multicentre: 124 low grade and 47 high grade; TCIA-KIRC: 79 low grade and 80 high grade) were retrospectively included. Abdominal fat was segmented into subcutaneous fat area (SFA) and visceral fat area (VFA) on CT using ImageJ. The total fat area (TFA) and relative VFA (rVFA) were then calculated. Clinical characteristics (age, sex, waist circumference and maximum tumour diameter) were also assessed. Univariate and multivariate logistic regression analyses were performed to identify the association between general or sex-specific visceral fat composition and Fuhrman grade.

RESULTS

Females with high-grade ccRCC from the multicentre group had a higher rVFA (42.4 vs 31.3, p = 0.001) than those with low-grade ccRCC after adjusting for age. There was no significant difference in males. The rVFA remained a stable and independent predictor for females high-grade ccRCC in both the univariate (multicentre: OR 1.205, 95% CI 1.074-1.352, p = 0.001; TCIA-KIRC: OR 1.171, 95% CI 1.016-1.349, p = 0.029) and multivariate (multicentre: OR 1.095, 95% CI 1.024-1.170, p = 0.003; TCIA-KIRC: OR 1.103, 95% CI 1.024-1.187, p = 0.010) models.

CONCLUSIONS

Sex-specific visceral fat composition has different values for predicting high-grade ccRCC and could be used as an independent predictor for females with high-grade ccRCC.

KEY POINTS

• Visceral fat measurement (rVFA) as an independent predictor for high-grade ccRCC had good predictive power in females, but not in males. • Sex-specific visceral fat composition was significantly associated with high-grade ccRCC in females only. • The rVFA could be considered one of the risk factors for high-grade ccRCC for females.

Body mass index and mortality in patients with gastric cancer: a large cohort study

BACKGROUND

The effects of obesity on prognosis in gastric cancer are controversial.

AIMS

To evaluate the association between body mass index (BMI) and mortality in patients with gastric cancer.

METHODS

A single-institution cohort of 7765 patients with gastric cancer undergoing curative gastrectomy between October 2000 and June 2016 was categorized into six groups based on BMI: underweight (< 18.5 kg/m²), normal (18.5 to < 23 kg/m²), overweight (23 to < 25 kg/m²), mildly obese (25 to < 28 kg/m²), moderately obese (28 to < 30 kg/m²), and severely obese (≥ 30 kg/m²). Hazard ratios (HRs) for overall survival (OS) and disease-specific survival (DSS) were calculated using Cox proportional hazard models.

RESULTS

We identified 1279 (16.5%) all-cause and 763 (9.8%) disease-specific deaths among 7765 patients over 83.05 months (range 1.02-186.97) median follow-up. In multivariable analyses adjusted for statistically significant clinicopathological characteristics, preoperative BMI was associated with OS in a non-linear pattern. Compared with normal-weight patients, underweight patients had worse OS [HR 1.42; 95% confidence interval (CI) 1.15-1.77], whereas overweight (HR 0.84; 95% CI 0.73-0.97), mildly obese (HR 0.77; 95% CI 0.66-0.90), and moderately obese (HR 0.77; 95% CI 0.59-1.01) patients had better OS. DSS exhibited a similar pattern, with lowest mortality in moderately obese patients (HR 0.58; 95% CI 0.39-0.85). Spline analysis showed the lowest all-cause mortality risk at a BMI of 26.67 kg/m².

CONCLUSION

In patients undergoing curative gastric cancer surgery, those who were overweight or mildly-to-moderately obese (BMI 23 to < 30 kg/m²) preoperatively had better OS and DSS than normal-weight patients.

Implication of visceral obesity in patients with esophageal squamous cell carcinoma

PURPOSE

Visceral obesity is considered to be associated not only with chronic systemic inflammation but also with aggressive cancer behavior. However, the implication of visceral obesity in patients with esophageal squamous cell carcinoma (ESCC) is unclear.

METHODS

Computed tomography volumetry was performed in 364 patients who underwent esophagectomy for ESCC. We calculated the ratio of the visceral fat area to the subcutaneous fat area (VS ratio), which is a valuable parameter of visceral obesity. Then, the clinicopathological characteristics were compared between patients with low VS ratio and those with high VS ratio.

RESULTS

Overall and disease-specific survivals of patients with high VS ratio were significantly worse than those with low VS ratio (P < 0.001 in both). Patients with high VS ratio had considerably more advanced pN factor, higher prevalence of lymphatic invasion, and more number of metastatic lymph nodes than those with low VS ratio (P = 0.044, < 0.001, and 0.006, respectively). Among patients who received preoperative treatment, high VS ratio correlated with poor response to preoperative treatment (P = 0.040).

CONCLUSIONS

Visceral obesity was associated with lymphatic invasiveness and poor response to preoperative treatment in patients with ESCC, which may negatively influence their prognosis.

A prospective appraisal of preoperative body mass index in D2-resected patients with non-metastatic gastric carcinoma and Siewert type II/III adenocarcinoma of esophagogastric junction: results from a large-scale cohort

Objective

To prospectively investigate associations of presurgical body mass index (BMI) with clinicopathological factors and its prognostic significance in radically D2-resected patients with non-metastasized gastric cancer (GC) and Siewert type II/III adenocarcinoma of esophagogastric junction (AEG).

Methods

A large prospective cohort consisting of radically-resected GC and AEG patients was analyzed. Follow-up was successful in 671 out of 700 patients, who were categorized into underweight (BMI<18.5), normal-weight (BMI=18.5-22.9), overweight (BMI=23-24.9), and obese (BMI≥25) groups according to Asian standards. BMI-associated factors were explored using multivariable logistic regression with adjustment. Cancer-specific survival analyses were conducted applying both univariable and multivariable Cox regression methods.

Results

Pre-operation, higher hemoglobin levels and smaller anemia proportions were observed in larger BMI groups. Higher BMI tended to be associated with higher neutrophil-lymphocyte ratios (NLRs). Patients with higher BMI had smaller tumors and more often stage I tumors, but longer surgical time and postsurgical stay. In multivariable analyses, higher hemoglobin levels, upper tumor location, poorer differentiation, and higher NLR were significantly associated with higher BMI. Overall, survival analyses revealed no significant role of BMI. However, in further stratifications after adjustment, compared to patients with normal BMI, obese patients had better survival in women, but worse in those with AEG; underweight was associated with reduced mortality risk in tumors differentiated well to moderately; overweight patients had increased death hazard when having thrombocytopenia.

Conclusion

Overall, preoperative BMI had limited prognostic significance in operated GC patients. However, under specific conditions (e.g., female, AEG, good differentiation, and thrombocytopenia), BMI might indicate postoperative survival.

Which Factors Are Important for Successful Sentinel Node Navigation Surgery in Gastric Cancer Patients? Analysis from the SENORITA Prospective Multicenter Feasibility Quality Control Trial

Background

We investigated the results of quality control study prior to phase III trial of sentinel lymph node navigation surgery (SNNS).

Methods

Data were reviewed from 108 patients enrolled in the feasibility study of laparoscopic sentinel basin dissection (SBD) in gastric cancer. Seven steps contain tracer injection at submucosa (step 1) and at four sites (step 2) by intraoperative esophagogastroduodenoscopy (EGD), leakage of tracer (step 3), injection within 3 minutes (step 4), identification of at least one sentinel basin (SB) (step 5), evaluation of sentinel basin nodes (SBNs) by frozen biopsy (step 6), and identification of at least five SBNs at back table and frozen sections (step 7).

Results

Failure in step 7 (n = 23) was the most common followed by step 3 (n = 15) and step 6 (n = 13). We did not find any differences of clinicopathological factors between success and failure group in steps 1~6. In step 7, body mass index (BMI) was only the significant factor. The success rate was 97.1% in patients with BMI  <  23 kg/m² and 80.3% in those with BMI ≥ 23 kg/m² (P = 0.028).

Conclusions

Lower BMI group showed higher success rate in step 7. Surgeons doing SNNS should be cautious when evaluating sufficient number of SBN in obese patients.