Impact of sarcopenia on the prognosis and treatment of lung cancer: an umbrella review

Tumor metabolic activity is associated with subcutaneous adipose tissue radiodensity and survival in non-small cell lung cancer

BACKGROUND

Cachexia-associated body composition alterations and tumor metabolic activity are both associated with survival of cancer patients. Recently, subcutaneous adipose tissue properties have emerged as particularly prognostic body composition features. We hypothesized that tumors with higher metabolic activity instigate cachexia related peripheral metabolic alterations, and investigated whether tumor metabolic activity is associated with body composition and survival in patients with non-small-cell lung cancer (NSCLC), focusing on subcutaneous adipose tissue.

METHODS

A retrospective analysis was performed on a cohort of 173 patients with NSCLC. 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) scans obtained before treatment were used to analyze tumor metabolic activity (standardized uptake value (SUV) and SUV normalized by lean body mass (SUL)) as well as body composition variables (subcutaneous and visceral adipose tissue radiodensity (SAT/VAT radiodensity) and area; skeletal muscle radiodensity (SM radiodensity) and area). Subjects were divided into groups with high or low SAT radiodensity based on Youden Index of Receiver Operator Characteristics (ROC). Associations between tumor metabolic activity, body composition variables, and survival were analyzed by Mann-Whitney tests, Cox regression, and Kaplan-Meier analysis.

RESULTS

The overall prevalence of high SAT radiodensity was 50.9% (88/173). Patients with high SAT radiodensity had shorter survival compared with patients with low SAT radiodensity (mean: 45.3 vs. 50.5 months, p = 0.026). High SAT radiodensity was independently associated with shorter overall survival (multivariate Cox regression HR = 1.061, 95% CI: 1.022-1.101, p = 0.002). SAT radiodensity also correlated with tumor metabolic activity (SULpeak rs = 0.421, p = 0.029; SUVpeak rs = 0.370, p = 0.048). In contrast, the cross-sectional areas of SM, SAT, and VAT were not associated with tumor metabolic activity or survival.

CONCLUSION

Higher SAT radiodensity is associated with higher tumor metabolic activity and shorter survival in patients with NSCLC. This may suggest that tumors with higher metabolic activity induce subcutaneous adipose tissue alterations such as decreased lipid density, increased fibrosis, or browning.

Exploring previously used thresholds for computed tomography-defined low skeletal muscle mass in predicting functional limitations among lung cancer patients

BACKGROUND

Various cutoffs have been used to diagnose computed tomography (CT)-defined low skeletal muscle mass; however, the impact of this variability on predicting physical functional limitations (PFL) remains unclear. In the present study we aimed to evaluate the diagnostic test metrics for predicting PFLs using a fixed cutoff value from previous reports and sought to create a prediction score that incorporated the skeletal muscle index (SMI) and other clinical factors.

METHODS

In this cross-sectional study including 237 patients with lung cancer, the SMI was assessed using CT-determined skeletal muscle area at the third lumbar vertebra. Physical function was assessed using the short physical performance battery (SPPB) test, with PFL defined as an SPPB score ≤9. We analyzed the diagnostic metrics of the five previous cutoffs for CT-defined low skeletal muscle mass in predicting PFL.

RESULTS

The mean age of participants was 66.0 ± 10.4 years. Out of 237 patients, 158 (66.7%) had PFLs. A significant difference was observed in SMI between individuals with and without PFLs (35.7 cm2/m2 ± 7.8 vs. 39.5 cm2/m2 ± 8.4, p < 0.001). Diagnostic metrics of previous cutoffs in predicting PFL showed suboptimal sensitivity (63.29%-91.77%), specificity (11.39%-50.63%), and area under the receiver operating characteristic curve (AUC) values (0.516-0.592). Age and the SMI were significant predictors of PFL; therefore, a score for predicting PFL (age - SMI + 21) was constructed, which achieved an AUC value of 0.748.

CONCLUSION

Fixed cutoffs for CT-defined low skeletal muscle mass may inadequately predict PFLs, potentially overlooking declining physical functions in patients with lung cancer.

Predictive role of preoperative sarcopenia for long-term survival in rectal cancer patients: A meta-analysis

PURPOSE

To identify the predictive role of sarcopenia in long-term survival among rectal cancer patients who underwent surgery based on available evidence.

METHODS

The Medline, EMBASE and Web of Science databases were searched up to October 20, 2023, for relevant studies. Overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS) were the endpoints. Hazard ratios (HRs) and 95% confidence intervals (CIs) were combined to evaluate the association between sarcopenia and survival.

RESULTS

Fifteen studies with 4283 patients were included. The pooled results demonstrated that preoperative sarcopenia significantly predicted poorer OS (HR = 2.07, 95% CI = 1.67-2.57, P<0.001), DFS (HR = 1.85, 95% CI = 1.39-2.48, P<0.001) and CSS (HR = 1.83, 95% CI = 1.31-2.56, P<0.001). Furthermore, subgroup analysis based on neoadjuvant therapy indicated that sarcopenia was a risk factor for worse OS and DFS in patients who received (OS: HR = 2.44, P<0.001; DFS: HR = 2.16, P<0.001) but not in those who did not receive (OS: HR = 2.44, P<0.001; DDFS: HR = 1.86, P = 0.002) neoadjuvant chemoradiotherapy. In addition, subgroup analysis based on sample size and ethnicity showed similar results.

CONCLUSION

Preoperative sarcopenia is significantly related to poor survival in surgical rectal cancer patients and could serve as a novel and valuable predictor of long-term prognosis in these patients.

Bioelectrical impedance analysis-derived phase angle (PhA) in lung cancer patients: a systematic review

BACKGROUND

Lung cancer is the second most diagnosed cancer in the world. Up to 84% of diagnosed patients have malnutrition, which can negatively affect quality of life and survival and may worsen with neoadjuvant treatment. Bioelectrical Impedance Analysis-Derived Phase Angle (PhA) in these patients could be a valid tool to assess the nutritional status in order to improve their condition.

METHODS

This review provides an update on PhA assessment in lung cancer patients over the past twenty years. We searched PubMed, Embase, Scopus, Web of Science, and Cochrane, for articles regarding the PhA obtained from Bioelectrical Impedance Analysis in lung cancer patients. The authors independently performed a literature search: sample size, patient population, study type, study dates, survival and interventions were evaluated. The final review included 11 studies from different countries.

RESULTS

Eight studies only considered patients with lung cancer, while three studies considered patients with different kind of cancer, including lung. Correlation data between PhA and age are conflicting. In patients undergoing clinical treatment and patients undergoing surgical treatment lower PhA was observed. A lower PhA is associated with a shorter survival. In three studies emerged a relationship between Karnofski Performance Status and Handgrip Strenght with PhA. From one study, univariate logistic regression analysis showed that higher PhA values represent a protective factor for sarcopenia.

CONCLUSION

Our research underlined interesting, but not conclusive, results on this topic; however more researches are needed to understand the clinical meaning of PhA.

Frailty and prognosis in lung cancer: systematic review and meta-analysis

Lung cancer is one of the most common malignant tumours. Patients are frequently at risk of frailty as lung cancer progresses. The meta-analysis aims to explore the impact of frailty on the long-term prognosis and the incidence of short-term chemotherapy toxicity in patients with lung cancer. This study was designed adhered to the criteria of Cochrane Handbook for Systematic Reviews. Systematic searches were performed on PubMed, Embase, Web of Science and Cochrane Library databases for relevant studies until December 2022. The outcome measures were overall survival, progression-free survival, chemotherapy toxicity and all-cause mortality. We then performed sensitivity analyses, subgroup analyses and evidence quality. This meta-analysis was performed using Review Manager V.5.4 software. Of the included studies, six were retrospective and five were prospective. There was a statistically significant difference between the frail and non-frail groups in overall survival (HR 2.27, 95% CI 1.24 to 4.15, p=0.008), all-cause mortality (HR 1.63, 95% CI 1.00 to 2.65, p=0.05) and chemotherapy toxicity (OR 3.73, 95% CI 1.99 to 7.00, p<0.0001). We conducted a sensitivity analysis, and the result was stable. The study revealed frail group had shorter survival and experienced more severe adverse effects than the non-frail group. Frailty affects the long-term prognosis and the incidence of short-term chemotherapy toxicity of patients with lung cancer. Consequently, medical professionals should focus on frailty screening in patients with lung cancer and implement active intervention measures. PROSPERO registration number is CRD42023398606.

Transcriptome-based deep learning analysis identifies drug candidates targeting protein synthesis and autophagy for the treatment of muscle wasting disorder

Sarcopenia, the progressive decline in skeletal muscle mass and function, is observed in various conditions, including cancer and aging. The complex molecular biology of sarcopenia has posed challenges for the development of FDA-approved medications, which have mainly focused on dietary supplementation. Targeting a single gene may not be sufficient to address the broad range of processes involved in muscle loss. This study analyzed the gene expression signatures associated with cancer formation and 5-FU chemotherapy-induced muscle wasting. Our findings suggest that dimenhydrinate, a combination of 8-chlorotheophylline and diphenhydramine, is a potential therapeutic for sarcopenia. In vitro experiments demonstrated that dimenhydrinate promotes muscle progenitor cell proliferation through the phosphorylation of Nrf2 by 8-chlorotheophylline and promotes myotube formation through diphenhydramine-induced autophagy. Furthermore, in various in vivo sarcopenia models, dimenhydrinate induced rapid muscle tissue regeneration. It improved muscle regeneration in animals with Duchenne muscular dystrophy (DMD) and facilitated muscle and fat recovery in animals with chemotherapy-induced sarcopenia. As an FDA-approved drug, dimenhydrinate could be applied for sarcopenia treatment after a relatively short development period, providing hope for individuals suffering from this debilitating condition.

Risk factors and a nomogram for predicting cognitive frailty in Chinese patients with lung cancer receiving drug therapy: A single-center cross-sectional study

BACKGROUND

To identify independent factors of cognitive frailty (CF) and construct a nomogram to predict cognitive frailty risk in patients with lung cancer receiving drug therapy.

METHODS

In this cross-sectional study, patients with lung cancer undergoing drug therapy from October 2022 to July 2023 were enrolled. The data collected includes general demographic characteristics, clinical data characteristics and assessment of tools for cognitive frailty and other factors. Logistic regression was harnessed to determine the influencing factors, R software was used to establish a nomogram model to predict the risk of cognitive frailty. The enhanced bootstrap method was employed for internal verification of the model. The performance of the nomogram was evaluated by using calibration curves, the area under the receiver operating characteristic curve, and decision curve analysis.

RESULTS

A total of 372 patients were recruited, with a cognitive frailty prevalence of 56.2%. Age, education background, diabetes mellitus, insomnia, sarcopenia, and nutrition status were identified as independent factors. Then, a nomogram model was constructed and patients were classified into high- and low-risk groups with a cutoff value of 0.552. The internal validation results revealed good concordance, calibration and discrimination. The decision curve analysis presented prominent clinical utility.

CONCLUSIONS

The prevalence of cognitive frailty was higher in lung cancer patients receiving drug therapy. The nomogram could identify the risk of cognitive frailty intuitively and simply in patients with lung cancer, so as to provide references for early screening and intervention for cognitive frailty at the early phases of drug treatment.

The association between cardiopulmonary exercise testing and postoperative outcomes in patients with lung cancer undergoing lung resection surgery: A systematic review and meta-analysis

BACKGROUND

Exercise capacity should be determined in all patients undergoing lung resection for lung cancer surgery and cardiopulmonary exercise testing (CPET) remains the gold standard. The purpose of this study was to investigate associations between preoperative CPET and postoperative outcomes in patients undergoing lung resection surgery for lung cancer through a review of the existing literature.

METHODS

A search was conducted on PubMed, Scopus, Cochrane Library and CINAHL from inception until December 2022. Studies investigating associations between preoperative CPET and postoperative outcomes were included. Risk of bias was assessed using the QUIPS tool. A random effect model meta-analysis was performed. I2 > 40% indicated a high level of heterogeneity.

RESULTS

Thirty-seven studies were included with 6450 patients. Twenty-eight studies had low risk of bias. [Formula: see text] peak is the oxygen consumption at peak exercise and serves as a marker of cardiopulmonary fitness. Higher estimates of [Formula: see text] peak, measured and as a percentagege of predicted, showed significant associations with a lower risk of mortality [MD: 3.66, 95% CI: 0.88; 6.43 and MD: 16.49, 95% CI: 6.92; 26.07] and fewer complications [MD: 2.06, 95% CI: 1.12; 3.00 and MD: 9.82, 95% CI: 5.88; 13.76]. Using a previously defined cutoff value of > 15mL/kg/min for [Formula: see text] peak, showed evidence of decreased odds of mortality [OR: 0.55, 95% CI: 0.28-0.81] and but not decreased odds of postoperative morbidity [OR: 0.82, 95% CI: 0.64-1.00]. There was no relationship between [Formula: see text] slope, which depicts ventilatory efficiency, with mortality [MD: -9.60, 95% CI: -27.74; 8.54] however, patients without postoperative complications had a lower preoperative [Formula: see text] [MD: -2.36, 95% CI: -3.01; -1.71]. Exercise load and anaerobic threshold did not correlate with morbidity or mortality. There was significant heterogeneity between studies.

CONCLUSIONS

Estimates of cardiopulmonary fitness as evidenced by higher [Formula: see text] peak, measured and as a percentage of predicted, were associated with decreased morbidity and mortality. A cutoff value of [Formula: see text] peak > 15mL/kg/min was consistent with improved survival but not with fewer complications. Ventilatory efficiency was associated with decreased postoperative morbidity but not with improved survival. The heterogeneity in literature could be remedied with large scale, prospective, blinded, standardised research to improve preoperative risk stratification in patients with lung cancer scheduled for lung resection surgery.

Enhanced serum levels of tumor necrosis factor-α, interleukin-1β, and -6 in sarcopenia: alleviation through exercise and nutrition intervention

BACKGROUND

Limited research has been conducted on the post-intervention inflammatory status in sarcopenic patients, despite previous studies revealing elevated pro-inflammatory markers. This study aimed to investigate the potential elevation of specific pro-inflammatory cytokines in sarcopenic patients and evaluate the effects of exercise and nutritional support interventions on these cytokine levels.

METHODS

In this post-hoc analysis of a randomized controlled trial (RCT), 57 individuals with sarcopenia from the RCT and 57 non-sarcopenic participants from the same geriatric community cohort that did not participate in the RCT were enrolled. Grip strength and body composition measurements were recorded. Tumor necrotizing factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-15 levels were assessed at baseline for both groups and after a 12-week intervention consisting of resistive exercise and supplementation with branched-chain amino acids, calcium, and vitamin D3 in the patients with sarcopenia.

RESULTS

The sarcopenic group demonstrated significantly lower body weight, body mass index, grip strength, and skeletal muscle mass index. Moreover, sarcopenic patients exhibited higher levels of TNF-α (p=0.007), IL-1β (p<0.001), and IL-6 (p<0.001), while no significant difference was observed in IL-15 (p=0.345) between participants with and those without sarcopenia. Following the intervention, the sarcopenic group experienced significant improvements in grip strength and skeletal muscle mass index with a notable reduction in TNF-α (p=0.003), IL-1β (p=0.012) and IL-6 (p=0.001) levels.

CONCLUSIONS

Sarcopenic patients exhibit elevated levels of TNF-α, IL-1β, and IL-6, which declined after nutrition support and exercise interventions. However, further research is necessary to evaluate the long-term impact of these interventions on cytokine levels.

The negative effect of concomitant medications on immunotherapy in non-small cell lung cancer: An umbrella review

BACKGROUND

Conflicting results about the effect of concomitant medications on immunotherapy in non-small cell lung cancer (NSCLC) were reported by many meta-analyses (MAs), and the certainty of evidence linking concomitant medications with immunotherapy efficacy has not been quantified, which may cause some evidence to be misinterpreted.

METHODS

Four databases including Embase, Cochrane Library, PubMed, and Web of Science were searched from inception to January 2023 in English. Based on prospective or retrospective clinical controlled trials including immunotherapy with concomitant medications or not in NSCLC, quantitative MAs reporting the efficacy of immunotherapy with binary direct comparison and enough extractable data were collected. The methodological quality, reporting quality, and risk of bias of included MAs were evaluated respectively. New meta-analyses were conducted and their evidence certainty was classified as nonsignificant, weak, suggestive, highly suggestive, or convincing.

RESULTS

Fifteen MAs with 5 medications were included. After being assessed by AMSTAR-2, PRISMA, and ROBIS, the major shortcomings were focused on the registration of protocol, literature retrieval or data extraction, implementation of sensitivity analysis or evidence certainty assessment, and incomplete reporting in the section of method and result. New pooled analyses indicated that antibiotics (HR = 1.545[1.318-1.811]), steroids (HR = 1.784[1.520-2.093]), proton pump inhibitors (PPIs) (HR = 1.303[1.048-1.621]) and opioids (HR = 1.910[1.213-3.006]) could shorten overall survival (OS) in patients with NSCLC receiving immunotherapy. Besides, antibiotics (HR = 1.285[1.129-1.462]) and steroids (HR = 1.613[1.315-1.979]) were harmful to progression-free survival (PFS) in these patients significantly. No negative effect was found in nonsteroidal anti-inflammatory drugs and the objective response rate of all medications. High-level evidence suggested that using PPIs before or after the initiation of immunotherapy and using steroids during the first-course immunotherapy could weaken the OS of patients with NSCLC. Meanwhile, the negative effects of antibiotics and opioids on OS or PFS were only supported by moderate or low-level evidence.

CONCLUSIONS

The concurrent usage of PPIs or steroids adversely affects the survival of patients with NSCLC receiving immunotherapy. Future investigations are required to ascertain whether these adverse effects are primarily attributed to the comorbidities or the concurrent medications.

Management of diarrhea induced by EGFR-TKIs in advanced lung adenocarcinoma

The identification of Epidermal Growth Factor Receptor (EGFR) mutations in lung adenocarcinoma has facilitated the development of personalized medicine based on oncogenic drivers. EGFR-Tyrosine Kinase Inhibitors (TKIs) are part of the targeted therapy; they impede the phosphorylation of the intracellular tyrosine kinase component of EGFR and consequently block signal transduction pathways. These drugs inhibit the proliferation and survival of tumor cells, leading to long-term progression-free survival and overall survival. Diarrhea is one of the most frequent adverse events associated with EGFR-TKIs, affecting at least 18% of patients and reaching up to 95% in some cases. Diarrhea should be managed carefully given its association with important complications, treatment interruptions, and dose reductions. Moreover, nutritional status and quality of life (QoL) can deteriorate due to severe diarrhea. Changes in diet, such as increment of fiber, supplementation with glutamine, and use of probiotics, may contribute to a decrease in the incidence of diarrhea. Improving the control of diarrhea can provide a significant benefit to the QoL of patients.

Predictive role of pretreatment skeletal muscle mass index for long-term survival of bladder cancer patients: A meta-analysis

PURPOSE

To identify the predictive role of pretreatment skeletal muscle mass index (SMI) for long-term survival of bladder cancer patients.

METHODS

Several databases were searched for studies investigating the relationship between pretreatment SMI and prognosis in bladder cancer. The overall survival (OS) and cancer-specific survival (CSS) were defined as primary and secondary outcomes, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) were combined.

RESULTS

Nine studies involving 1476 cases were included. The results demonstrated that a lower pretreatment SMI was significantly related to poorer OS (HR = 1.56, 95% CI: 1.33-1.82, P<0.001) and subgroup analysis based on thresholds of SMI revealed similar results. Besides, pretreatment SMI was also obviously related to CSS (HR = 1.75, 95% CI: 1.36-2.25, P<0.001).

CONCLUSION

Lower pretreatment SMI was associated with worse long-term survival of bladder cancer patients.

Sarcopenia in Lung Cancer: A Narrative Review

It has been over 10 years since the relationship between sarcopenia and lung cancer was first explored. Since then, sarcopenia research has progressed substantially, and the prognostic value of this condition is becoming increasingly apparent. Prior systematic reviews and meta-analyses have established sarcopenia to be negatively associated with disease-free and overall-survival, as well as a major risk factor for post-operative complications. The bulk of the literature has explored sarcopenia in the resectable setting, with less emphasis placed on studies evaluating this condition in advanced disease. In this up-to-date review, an examination of the literature exploring the association between sarcopenia and long-term outcomes in advanced lung cancer is provided. We further explore the association between adverse events of medical therapy and the role of sarcopenia as a predictor of tumor response. Finally, the interventions on sarcopenia and cancer cachexia are reviewed, with an emphasis placed on prospective studies.

Measurement of sarcopenia in lung cancer inpatients and its association with frailty, nutritional risk, and malnutrition

Background

Sarcopenia, frailty, and malnutrition are associated with undesirable clinical outcomes in cancer patients. Sarcopenia-related measurements may be promising fast biomarkers for frailty. Our objectives were to assess the prevalence of nutritional risk, malnutrition, frailty, and sarcopenia in lung cancer inpatients, and describe the relationship of them.

Methods

Stage III and IV lung cancer inpatients were recruited before chemotherapy. The skeletal muscle index (SMI) was assessed by multi-frequency bioelectric impedance analysis (m-BIA). Sarcopenia, frailty, nutritional risk, and malnutrition were diagnosed according to the Asian Working Group for Sarcopenia 2019 (AWGS 2019), Fried Frailty Phenotype (FFP), nutritional risk screening-2002 (NRS-2002), and Global Leadership Initiative on Malnutrition criteria (GLIM), and correlation analysis was performed between them with Pearson's r correlation coefficients. A univariate and multivariate logistic regression analysis was conducted for all patients, gender and age-stratified subgroups to obtain odds ratios (ORs) and 95% confidence intervals (95%CIs).

Results

The cohort included 97 men (77%) and 29 women (23%), with mean age of 64.8 ± 8.7 years. Among the 126 patients, 32 (25.4%) and 41 (32.5%) had sarcopenia and frailty, and the prevalence of nutritional risk and malnutrition was 31.0% (n = 39) and 25.4% (n = 32). Adjusted for age and gender, SMI was correlated with FFP (r = -0.204, p = 0.027), and did not remain significantly when stratified by gender. Stratification according to age revealed in ≥65-years-old population, SMI and FFP were significantly correlated (r = -0.297, p = 0.016), which is not seen in <65-years-old group (r = 0.048, p = 0.748). The multivariate regression analysis showed FFP, BMI, and ECOG were the independent variables associated with sarcopenia (OR 1.536, 95%CI 1.062-2.452, p = 0.042; OR 0.625, 95%CI 0.479-0.815, p = 0.001; OR 7.286, 95%CI 1.779-29.838, p = 0.004).

Conclusion

Comprehensively assessed sarcopenia is independently associated with frailty based on FFP questionnaire, BMI, and ECOG. Therefore, sarcopenia assessment including m-BIA based SMI, and muscle strength and function could be used to indicate frailty to help select the targeting patients for care. Moreover, in addition to muscle mass, muscle quality should not be ignored in clinical practice.