Sarcopenia and Response to Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer

Sarcopenia among treated cancer patients before and after neoadjuvant chemotherapy: a systematic review and meta-analysis of high-quality studies

BACKGROUND

Neoadjuvant chemotherapy, used to shrink tumors before surgery, is increasingly applied in clinical practice. However, retrospective studies indicate that it may increase sarcopenia rates and consequently result in an elevated occurrence rate of postoperative severe complications such as severe surgical incision infection, severe respiratory failure, and severe postoperative hemorrhage, especially in the elderly population. Currently, no systematic analysis examines the association between neoadjuvant chemotherapy and sarcopenia. This study aims to fill this gap with a comprehensive meta-analysis focused on this critical aspect of the field.

METHODS

A systematic literature search was conducted in the PubMed and Web of Science databases from their inception to January 2024. The included studies encompassed patients who received neoadjuvant chemotherapy and underwent computed tomography (CT) scans both before and after treatment to calculate skeletal muscle index (SMI) or categorize them for the presence of sarcopenia. The determination of sarcopenia status was based on well-established and validated threshold criteria. Data extraction was performed independently by two reviewers. A meta-analysis was employed to estimate the pooled odds ratio (OR) and its corresponding 95% confidence interval (95% CI) to assess the risk of neoadjuvant chemotherapy-induced muscle reduction.

RESULTS

In the 14 studies with complete categorical variable data, comprising 1853 patients, 773 patients were identified as having sarcopenia before neoadjuvant treatment and 941 patients had sarcopenia after neoadjuvant therapy. The OR and its 95% CI was calculated as 1.51 [1.31, 1.73]. Among these, 719 patients had digestive system cancer, with 357 patients having sarcopenia before neoadjuvant treatment and 447 patients after, resulting in an OR of 1.74 [1.40, 2.17]. In the remaining 1134 patients with non-digestive system cancers, 416 were identified as having sarcopenia before neoadjuvant treatment, and 494 patients had sarcopenia after, with an OR of 1.37 [1.15, 1.63]. Additionally, in seven studies with complete continuous variable data, including 1228 patients, the mean difference in the change of SMI before and after neoadjuvant treatment was  - 1.13 [- 1.65,  - 0.62]. After excluding low-quality small-sample studies with fewer than 50 patients, the same trend was observed in the analysis.

CONCLUSION

The risk of muscle reduction significantly increases in cancer patients after neoadjuvant chemotherapy and digestive system cancers tend to have a higher risk of developing sarcopenia post-treatment compared to non-digestive system cancers.

Prognostic Effects of Sarcopenia on Patients with Bladder Cancer: A Systematic Review and Meta-Analysis

Sarcopenia can negatively impact the survival of cancer patients. This study intends to delve into the correlation of sarcopenia with survival and complications in patients with bladder cancer (BC) after surgery. Web of Science, Cochrane Library, Embase, and PubMed databases were retrieved up to April 7, 2023, to collect studies on the impact of sarcopenia on the prognosis of adults with BC. Primary outcomes encompassed overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). The secondary outcome consisted of postoperative complications. A meta-analysis was conducted using Stata. Forest plots and summary effect models were employed to present the results. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale (NOS). Initially, 1713 studies were identified through searches across four databases, and 26 studies were ultimately included in the analysis. Sarcopenia was significantly associated with OS (HR:1.62; 95% CI: 1.43-1.83; P < 0.001, I2 = 0.9%), CSS (HR: 1.81, 95% CI: 1.52-2.15, P < 0.001, I2 = 0.0%), and RFS (HR: 1.76, 95% CI: 1.21-2.56, P = 0.003, I2 = 0.0%) in BC patients. Subgroup analyses revealed that sarcopenia is strongly linked to prognosis and postoperative complications in BC patients.

Prognostic value of preoperative CT scan derived body composition measures in resected pancreatic cancer

BACKGROUND

It remains unclear whether preoperative body composition may affect the prognosis of pancreatic cancer patients undergoing surgery. The aim of the present study was to assess the extent to which preoperative body composition impacts on postoperative complication severity and survival in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC).

METHODS

A retrospective cohort study was performed on consecutive patients who underwent pancreatoduodenectomy with preoperative CT scan imaging available. Body composition parameters including total abdominal muscle area (TAMA), visceral fat area (VFA), subcutaneous fat area and liver steatosis (LS) were assessed. Sarcopenic obesity was defined as a high VFA/TAMA ratio. Postoperative complication burden was evaluated with the comprehensive complication index (CCI).

RESULTS

Overall, 371 patients were included in the study. At 90 days after surgery, 80 patients (22%) experienced severe complications. The median CCI was 20.9 (IQR 0-30). At multivariate linear regression analysis, preoperative biliary drainage, ASA score ≥3, fistula risk score and sarcopenic obesity (37% increase; 95%CI 0.06-0.74; p = 0.046) were associated to an increase in CCI. Patient characteristics associated to sarcopenic obesity were older age, male gender and preoperative LS. At a median follow-up of 25 months (IQR 18-49), median disease-free survival (DFS) was 19 months (IQR 15-22). At cox-regression analysis, only pathological features were associated with DFS, while LS and other body composition measures did not show any prognostic role.

CONCLUSION

The combination of sarcopenia and visceral obesity was significantly associated with increased complication severity after pancreatoduodenectomy for cancer. Patients' body composition did not affect disease free survival after pancreatic cancer surgery.

Impact of sarcopenia on outcomes of bladder cancer undergoing radical cystectomy: A systematic review and meta-analysis

OBJECTIVE

To provide synthesized evidence on the association between sarcopenia and risk of mortality, recurrence and postoperative complications in patients with bladder cancer and undergoing radical cystectomy (RC).

METHODS

Only studies with observational design that investigated the association between sarcopenia and outcomes of interest among patients with bladder cancer undergoing RC were included. The outcomes of interest were mortality, recurrence, and postoperative complications. The systematic search was conducted using three large databases, that is, PubMed, EMBASE, and Scopus. A random effects model was used for the analysis and pooled effect sizes were reported as odds ratio (OR) or hazards ratio (HR) along with 95% confidence intervals (CIs).

RESULTS

A total of 21 studies with 4997 patients were included. Compared to non-sarcopenic subjects, those with sarcopenia had increased risk of all-cause mortality (HR 1.45, 95% CI: 1.32, 1.61), cancer-specific mortality (HR 1.74, 95% CI: 1.49, 2.03) and a lower recurrence free survival (HR 1.84, 95% CI: 1.30, 2.62). Patients with sarcopenia also had higher risk of developing complications within 90 days postoperatively (OR 1.77, 95% CI: 1.23, 2.55).

CONCLUSION

Sarcopenia among patients with bladder cancer and managed using RC is associated with adverse survival outcomes and an increased risk of postoperative complications.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2023 Guidelines

CONTEXT

We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).

OBJECTIVE

To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the MMIBC guidelines has been performed annually since 2017. Searches cover the Medline, EMBASE, and Cochrane Libraries databases for yearly guideline updates. A level of evidence and strength of recommendation are assigned. The evidence cutoff date for the 2023 MIBC guidelines was May 4, 2022.

EVIDENCE SYNTHESIS

Patients should be counselled regarding risk factors for bladder cancer. Pathologists should describe tumour and lymph nodes in detail, including the presence of histological subtypes. The importance of the presence or absence of urothelial carcinoma (UC) in the prostatic urethra is emphasised. Magnetic resonance imaging (MRI) of the bladder is superior to computed tomography (CT) for disease staging, specifically in differentiating T1 from T2 disease, and may lead to a change in treatment approach in patients at high risk of an invasive tumour. Imaging of the upper urinary tract, lymph nodes, and distant metastasis is performed with CT or MRI; the additional value of flurodeoxyglucose positron emission tomography/CT still needs to be determined. Frail and comorbid patients should be evaluated by a multidisciplinary team. Postoperative histology remains the most important prognostic variable, while circulating tumour DNA appears to be an interesting predictive marker. Neoadjuvant systemic therapy remains cisplatin-based. In motivated and selected women and men, sexual organ-preserving cystectomy results in better functional outcomes without compromising oncological outcomes. Robotic and open cystectomy have comparable outcomes and should be combined with (extended) lymph node dissection. The diversion type is an individual choice after taking patient and tumour characteristics into account. Radical cystectomy remains a highly complex procedure with considerable morbidity and risk of mortality, although lower rates are observed for higher hospital volumes (>20 cases/yr). With proper patient selection, trimodal therapy (chemoradiation) has comparable outcomes to radical cystectomy. Adjuvant chemotherapy after surgery improves disease-specific survival and overall survival (OS) in patients with high-risk disease who did not receive neoadjuvant treatment, and is strongly recommended. There is a weak recommendation for adjuvant nivolumab, as OS data are not yet available. Health-related quality of life should be assessed using validated questionnaires at baseline and after treatment. Surveillance is needed to monitor for recurrent cancer and functional outcomes. Recurrences detected on follow-up seem to have better prognosis than symptomatic recurrences.

CONCLUSIONS

This summary of the 2023 EAU guidelines provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology guidelines panel on muscle-invasive and metastatic bladder cancer has released an updated version of the guideline containing information on diagnosis and treatment of this disease. Recommendations are based on studies published up to May 4, 2022. Surgical removal of the bladder and bladder preservation are discussed, as well as updates on the use of chemotherapy and immunotherapy in localised and metastatic disease.

Preoperative optimization of the radical cystectomy patient: Current state and future directions

Radical cystectomy (RC) is associated with high rates of morbidity and mortality despite adoption of robotics and implementation of enhanced recovery after surgery protocols. There have been increased efforts to investigate preoperative optimization through comprehensive nutritional evaluation, preoperative supplementation, and prehabilitation outside of previously described enhanced recovery after surgery protocols to reduce mortality and morbidity from RC. In this review, we summarize and evaluate the current literature on preoperative assessment and optimization in RC.

Body composition as a predictor of oncological outcome in patients with non-muscle-invasive bladder cancer receiving intravesical instillation after transurethral resection of bladder tumor

Introduction

Body status, categorized as sarcopenia or obesity and assessed using body mass index and body composition, affects the outcome of bladder cancer patients. However, studies comparing disease progression, recurrence, or overall survival in patients with non-muscle-invasive bladder cancer (NMIBC) with different body compositions are lacking. Therefore, we conducted a retrospective study to identify the impact of body composition, sarcopenia, and obesity on the oncological prognosis of patients with NMIBC who underwent transurethral resection of bladder tumor (TURBT) with Bacillus Calmette-Guerin (BCG) intravesical instillation (IVI).

Methods

Patients with NMIBC who had undergone TURBT with adjuvant IVI with BCG from March 2005 to April 2021 were included. Body composition parameters were evaluated using computed tomography images of the third lumbar vertebrae and further categorized by sarcopenia and obesity. Oncological outcomes including recurrence-free survival (RFS), progression-free survival, and overall survival (OS) after treatment were analyzed.

Results

A total of 269 patients were enrolled. Subcutaneous adipose tissue (SAT) density was a significant predictor of RFS, whereas psoas muscle density was a significant predictor of OS in the multivariate analysis. Patients with sarcopenia but without obesity tolerated significantly fewer BCG IVIs than patients without sarcopenia or obesity. Patients with sarcopenia had poorer RFS and OS than those without sarcopenia. In contrast, patients with obesity had better OS than those without obesity.

Discussion

Body composition parameters, including SAT density and psoas muscle density, emerged as significant predictors of OS and RFS, respectively. Hence, our findings indicate that body composition is a helpful measurement to assess the oncological outcomes of patients with NMIBC.

Chemotherapy-Induced Molecular Changes in Skeletal Muscle

Paraneoplastic conditions such as cancer cachexia are often exacerbated by chemotherapy, which affects the patient’s quality of life as well as the response to therapy. The aim of this narrative review was to overview the body-composition-related changes and molecular effects of different chemotherapy agents used in cancer treatment on skeletal-muscle remodeling. A literature search was performed using the Web of Science, Scopus, and Science Direct databases and a total of 77 papers was retrieved. In general, the literature survey showed that the molecular changes induced by chemotherapy in skeletal muscle have been studied mainly in animal models and mostly in non-tumor-bearing rodents, whereas clinical studies have essentially assessed changes in body composition by computerized tomography. Data from preclinical studies showed that chemotherapy modulates several molecular pathways in skeletal muscle, including the ubiquitin–proteasome pathway, autophagy, IGF-1/PI3K/Akt/mTOR, IL-6/JAK/STAT, and NF-κB pathway; however, the newest chemotherapy agents are underexplored. In conclusion, chemotherapy exacerbates skeletal-muscle wasting in cancer patients; however, the incomplete characterization of the chemotherapy-related molecular effects on skeletal muscle makes the development of new preventive anti-wasting strategies difficult. Therefore, further investigation on molecular mechanisms and clinical studies are necessary.

Efficacy of long-term extended nursing services combined with atezolizumab in patients with bladder cancer after endoscopic bladder resection

BACKGROUND

Nursing has been reported to effectively ameliorate physical movement, significantly decrease postoperative complications, and markedly improve the quality of life in patients with bladder cancer after endoscopic bladder resection. Atezolizumab (ATZ) has been approved as effective therapy for patients with bladder cancer. This study was aimed to assess the efficacy of long-term extended nursing services combined with ATZ in patients with bladder cancer after endoscopic bladder resection.

METHODS

A total of one 126 patients diagnosed with bladder cancer underwent endoscopic bladder resection were recruited in this study. Patients were randomly allocated into the long-term conventional nursing plus atezolizumab (LTCN-ATZ) (n = 60) and long-term extended nursing services plus atezolizumab (LTENS-ATZ) groups (n = 66). The renal function, physical movement, postoperative complications, the quality of life, survival, and recurrence were examined in patients in LTCN-ATZ and LTENS-ATZ groups during 36-month follow up.

RESULTS

Data in the current study demonstrated that the renal function, quality of life, satisfaction anxiety and depression for LTENS-ATZ group was significantly improved compared with that of LTCN-ATZ group. The occurrence rate was significantly lower, and the length of hospital stay was shorter for LTENS-ATZ than that of LTCN-ATZ group. Outcomes demonstrated that LTENS-ATZ increased survival and decreased the occurrence compared to those patients in LTENS-ATZ group.

CONCLUSION

In conclusion, outcomes in this study indicate that LTENS-ATZ improves renal function, and quality of life and prognosis in patients with bladder cancer after endoscopic bladder resection.

Body Composition Is a Predictor for Postoperative Complications After Gastrectomy for Gastric Cancer: a Prospective Side Study of the LOGICA Trial

PURPOSE

There is a lack of prospective studies evaluating the effects of body composition on postoperative complications after gastrectomy in a Western population with predominantly advanced gastric cancer.

METHODS

This is a prospective side study of the LOGICA trial, a multicenter randomized trial on laparoscopic versus open gastrectomy for gastric cancer. Trial patients who received preoperative chemotherapy followed by gastrectomy with an available preoperative restaging abdominal computed tomography (CT) scan were included. The CT scan was used to calculate the mass (M) and radiation attenuation (RA) of skeletal muscle (SM), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). These variables were expressed as Z-scores, depicting how many standard deviations each patient's CT value differs from the sex-specific study sample mean. Primary outcome was the association of each Z-score with the occurrence of a major postoperative complication (Clavien-Dindo grade ≥ 3b).

RESULTS

From 2015 to 2018, a total of 112 patients were included. A major postoperative complication occurred in 9 patients (8%). A high SM-M Z-score was associated with a lower risk of major postoperative complications (RR 0.47, 95% CI 0.28-0.78, p = 0.004). Furthermore, high VAT-RA Z-scores and SAT-RA Z-scores were associated with a higher risk of major postoperative complications (RR 2.82, 95% CI 1.52-5.23, p = 0.001 and RR 1.95, 95% CI 1.14-3.34, p = 0.015, respectively). VAT-M, SAT-M, and SM-RA Z-scores showed no significant associations.

CONCLUSION

Preoperative low skeletal muscle mass and high visceral and subcutaneous adipose tissue radiation attenuation (indicating fat depleted of triglycerides) were associated with a higher risk of developing a major postoperative complication in patients treated with preoperative chemotherapy followed by gastrectomy.

Cachexia and bladder cancer: clinical impact and management

PURPOSE OF REVIEW

The purpose of this review is to describe the causes, management, and clinical outcomes associated with cachexia and related components including sarcopenia, among patients with bladder cancer (BCa).

RECENT FINDINGS

Cachexia in patients with BCa is associated with poorer outcomes after radical cystectomy (RC), radiation, and chemotherapy. Nutritional supplements and novel pharmaceutical agents including magnolol, flucoidan and Anamorelin are currently undergoing investigation for their potential use in BCa patients with cachexia.

SUMMARY

Cachexia is a hypercatabolic state thought to be caused by an immune-regulated release of cytokines and disruptions of molecular pathways within the tumor microenvironment and systemically. Nutritional deficiencies in patients with BCa also contribute to cachexia and sarcopenia. Patients with BCa -related cachexia and sarcopenia experience worse survival and therapeutic outcomes after RC, chemotherapy, and radiation therapy. Patients with cachexia also experience more postoperative complications after RC. The management of cachexia in patients with BCa remains challenging and requires timely identification, and multidisciplinary management including nutritional supplementation, physical therapy, palliative care, and pharmacological agents. Clinical trials and human studies are still required to determine which pharmacological agents are optimal for BCa cachexia.

Sarcopenia is associated with survival in patients with urothelial carcinoma treated with systemic chemotherapy

BACKGROUND

Sarcopenia impacts perioperative outcomes and prognosis in various carcinomas. We aimed to investigate whether sarcopenia at the time of chemotherapy induction in patients with urothelial carcinoma is associated with prognosis.

METHODS

We evaluated patients treated with chemotherapy for urothelial carcinoma between April 2013 and February 2018 at our institution and affiliated centers. Skeletal muscle mass (total psoas muscle, paraspinal muscle, and total skeletal muscle areas) were used to calculate the total psoas muscle index, paraspinal muscle index, and skeletal muscle index. All participants were grouped as per cutoff points set at the median value for each sex. Overall survival was evaluated using Cox regression analysis.

RESULTS

Of the 240 patients, 171 were men and 69 were women; mean age during chemotherapy was 71 years (range: 43-88); and 36, 56, and 148 patients were at stages II, III, and IV, respectively. Paraspinal muscle index was most associated with the prognosis; groups with lower paraspinal muscle index were defined as sarcopenic (men: ≤ 20.9 cm²/m², women: ≤ 16.8 cm²/m²). The overall survival was significantly longer in the non-sarcopenia group including all stages (p = 0.001), and in stage III (p = 0.048) and IV (p = 0.005) patients. There was no significant difference among stage II patients (p = 0.648). After propensity score matching, survival was still significantly longer in the non-sarcopenia group (p = 0.004).

CONCLUSIONS

Paraspinal muscle index measurements obtained during chemotherapy induction for urothelial carcinoma were independent prognostic factors. The absence of sarcopenia may lead to long-term survival in patients undergoing chemotherapy for urothelial carcinoma.

Chemotherapy for Muscle-invasive Bladder Cancer: Impact of Cisplatin Delivery on Renal Function and Local Control Rate in the Randomized Phase III VESPER (GETUG-AFU V05) Trial

BACKGROUND

Cisplatin-based combination chemotherapy before surgery is the standard of care for muscle-invasive bladder cancer. However, the optimal chemotherapy modalities have not been precisely defined to date.

PATIENTS AND METHODS

In the VESPER trial, patients received after randomization either gemcitabine and cisplatin (GC, 4 cycles) or methotrexate, vinblastine, doxorubicin and cisplatin (dose dense [dd]-MVAC, 6 cycles). Creatinine clearance (CrCl) was calculated before each cycle according to the Cockroft and Gault formula. Definition criteria for local control after neoadjuvant chemotherapy included pathological complete response (ypT0N0), pathological downstaging (<ypT2N0) and organ-confined disease (<ypT3N0) at cystectomy. Baseline and treatment characteristics were studied in multivariate logistic models to determine their potential role for each type of pathological responses.

RESULTS

A total of 2128 cycles of chemotherapy were delivered, including 2120 (99.6%) with cisplatin. Full doses of cisplatin were given in 1866 (88%) cycles. Twenty-three (4.7%) patients had to stop chemotherapy (12 GC, 11 dd-MVAC) because of renal failure. No difference in CrCl median values was observed between the 2 regimens during the first 4 cycles. A mild decrease occurred thereafter in patients treated with 2 additional cycles of dd-MVAC. A minimum total dose of 270 mg/m² for cisplatin was mandatory to optimize pathological complete responses.

CONCLUSION

At least 4 cycles of cisplatin-based chemotherapy should be delivered before cystectomy. Increasing the number of cycles beyond 4 cycles does not lead to a clinically significant deterioration in renal function but without obvious gain on local control.

Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations

The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Psoas Muscle Mass can Predict Postsurgical Outcomes in Patients Who Undergo Radical Cystectomy and Urinary Diversion Reconstruction

OBJECTIVE

To morphometrically measure to muscle mass which may reflect physical components of frailty. Hence, we evaluated the association between L4 total psoas area (TPA) and operative outcome after radical cystectomy (RC) for bladder cancer.

METHODS

In a retrospective single-center study, bladder cancer patients who underwent RC and urinary diversion between 2007 and 2012 were enrolled. TPA was evaluated in the cross-sectional imaging. The psoas muscles were normalized with the height. Male patients with a psoas mass index ≤7.4 cm²/m² and female patients with a psoas mass index ≤5.2 cm²/m² were classified as sarcopenic. Outcome measures were 30- and 90-day readmission and complications, and survival. Multivariable logistic and Cox proportional-hazards regression models were used to determine relevant predictors.

RESULTS

The median age of the 441 participants and follow up time was 68 years (IQR 59-75) and 1.2 years (IQR 0.5-1.9), respectively. One hundred forty-three patients (32.4%) were sarcopenic. The 30-day readmission and the complication rates were 13.8% and 44.7%, respectively. The 90-day readmission and complication rates were 23.9% and 53.1%, respectively. The 1-year mortality rate was 11.6% (95%CI 8.7-15.4). Multivariable logistic regression analysis revealed an association between increased TPA and lower odds of 30-day complications after RC (OR 0.95, 95%CI 0.92-0.99, P = .02); similarly, an increase in TPA was of prognostic value, although not statistically significant in the multivariable model (P = .05) once adjusting for other patient factors.

CONCLUSION

Sarcopenia predicted early complications and showed an informative trend for overall survival after RC, and thus may inform models predicting postsurgical outcomes.

Development of Sarcopenia in Patients With Bladder Cancer: A Systematic Review

OBJECTIVE

Sarcopenia is known to influence cancer-related complications and overall survival. However, the effect of cancer treatment on the development or progression of sarcopenia is relatively unknown. The primary aim of this systematic review was to determine the prevalence and development of sarcopenia among people with bladder cancer.

DATA SOURCES

A systematic search was performed in PubMed, Web of Science, and EMBASE. Studies with ≥2 assessments of sarcopenia were eligible for inclusion. Five retrospective cohorts were included with a total of 438 participants. The baseline prevalence of sarcopenia across studies varied from 25% to 69% and post-treatment prevalence from 50% to 81%. The average loss of muscle mass was 2.2% to 10% during a time course of 3 to 12 months.

CONCLUSION

The prevalence of sarcopenia markedly increased during cancer treatment in patients with bladder cancer. Further research into the effect of different treatment regimens on the development of sarcopenia, and how these changes might affect functional capacity and survival is needed.

IMPLICATIONS FOR NURSING PRACTICE

The development of sarcopenia is important to understand because of its negative affect on quality of life, complications, and mortality. Further, understanding how sarcopenia develops during treatment could potentially strengthen nurses' future care plans for patients with bladder cancer.

Impact of body composition on clinical outcomes in people with gastric cancer undergoing radical gastrectomy after neoadjuvant treatment

OBJECTIVES

The influence of body composition on clinical outcomes in individuals with gastric cancer (GC) undergoing radical gastrectomy after neoadjuvant treatment (NT) remains unclear. The purpose of this retrospective study was to investigate the association between body composition before NT or after NT and clinical outcomes in individuals with GC receiving multimodal treatments.

METHODS

This retrospective study included individuals with GC who received NT followed by radical gastrectomy between January 2016 and December 2018. Skeletal muscle, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) were measured by cross-sectional areas at the level of third lumbar vertebra based on single-slice computed tomography scan prior to NT and prior to the surgical operation. Sarcopenia, high VAT, and high SAT were defined using cutoff points of skeletal muscle index, visceral fat area, and subcutaneous fat area. Univariate and multivariate analyses were performed to evaluate risk factors of NT-related adverse events, postoperative complications and predictors of long-term survival.

RESULTS

A total of 110 individuals with GC were enrolled in this study. Sarcopenia was present in 62.7% of them before NT and in 56.4% after NT. Sarcopenia before NT was associated with more NT-related adverse events (odds ratio, 2.901; 95% confidence interval [CI], 1.205-6.983; P = 0.018). High VAT after NT (≥106 cm²) was associated with an increasing incidence of postoperative complications (odds ratio, 4.261; 95% CI, 1.332-13.632; P = 0.015). No body-composition parameter was relevant to tumor pathologic response to NT. As for long-term survival, poor overall survival was associated with both low VAT before NT (<120 cm²; hazard ratio [HR], 2.542; 95% CI, 1.111-5.817; P = 0.027) and low SAT after NT (<99.5 cm²; HR, 2.743; 95% CI, 1.248-6.027; P = 0.012). Similarly, shorter disease-free survival was associated with low VAT before NT (<120 cm²; HR, 2.502; 95% CI, 1.222-5.124; P = 0.012) and low VAT after NT (<106 cm²; HR, 2.505; 95% CI, 1.172-5.358; P = 0.018).

CONCLUSIONS

Body composition measured by computed tomography could predict NT-related adverse events, postoperative complications, and long-term survival in multimodal treatments for GC. More meaningfully, adipose-tissue status has significant prognostic value for individuals with advanced GC.

Smoking status and pathological response to neoadjuvant chemotherapy among patients with bladder cancer: a pooled analysis

Background

Smoking status has been confirmed as an independent prognostic factor for bladder cancer. However, for patients who received neoadjuvant chemotherapy (NAC), the influence of smoking status on the pathological response and prognosis remains unclear. This pooled analysis aimed to investigate whether smoking status is an independent risk factor for pathological response, recurrence, and prognosis in patients with bladder cancer who undergo NAC.

Methods

We searched PubMed, Web of Science, Embase, Cochrane Library, and Google Scholar for related studies published between 1990 and 2017. In total, 10 studies comprising 1,382 patients with muscle-invasive bladder cancer were included. The odds ratio (OR) and 95% confidence interval (CI) of complete pathological response, partial pathological response, overall survive (OS), recurrence, and cancer-specific mortality (CSM) were chosen as outcome measures. Analyses were performed using Review Manager (version 5.3, The Cochrane Collaboration, UK) and Stata statistical software (version 15, Stata Corp., USA).

Results

Compared to nonsmokers, smokers were less likely to have a complete pathologic response (OR =0.55, 95% CI: 0.35–0.87) and partial pathological response (OR =0.57, 95% CI: 0.37–0.88). However, we found no significant association between smoking status and overall survival (OR =0.71, 95% CI: 0.28–1.80), recurrence (OR =1.35, 95% CI: 0.97–1.88), and cancer-specific mortality (OR =0.90, 95% CI: 0.62–1.32).

Conclusions

Smoking reduces both complete and partial pathological response rate to NAC in patients with bladder cancer. Thus, smoking status should be given more importance when developing treatment plans and evaluating efficacy, particularly of NAC, among bladder cancer patients.

Comparison of major definitions of sarcopenia based on the skeletal muscle index in patients with urothelial carcinoma

For the past decade, sarcopenia has been actively investigated in various cancers, including urothelial carcinoma (UC). Although skeletal muscle index (SMI) is the main parameter used to evaluate sarcopenia in oncology, the optimal definition of SMI-based sarcopenia is not entirely standardized. We recently highlighted the potential limitations of current definitions of SMI-based sarcopenia in another journal. In this study, we reviewed studies that assessed sarcopenia in UC patients. We then performed a comparative validation of three major SMI-based definitions of sarcopenia, including Prado's, the international and Martin's definitions in metastatic UC patients. We believe that the standardization of the sarcopenia definition is an urgent issue in oncology, and this paper discusses a possible new direction to address this issue.

Impact of body size and body composition on bladder cancer outcomes: Risk stratification and opportunity for novel interventions

Body size is emerging as a novel and clinically-relevant patient factor in bladder cancer research. Historically, a patient's body mass index (BMI) has been used as a proxy for obesity but it shows inconsistent associations with risk of developing the disease as well as with most clinical outcomes. More specific body composition features can be derived for patients using a variety of methods. To date, skeletal muscle measurements derived from preoperative computed tomography scans have shown the most consistent associations with clinical outcomes. Importantly, skeletal muscle can potentially be modified through resistance training and/or nutritional interventions. Large scale studies that evaluate the prognostic impact of not only body composition features at baseline but also describe changes in body composition post-treatment are needed to move the field forward to ultimately improve clinical outcomes for bladder cancer patients.

Impact of sarcopenia status of muscle-invasive bladder cancer patients on kidney function after neoadjuvant chemotherapy

BACKGROUND

Sarcopenia is suspected to influence the complication rates in patients undergoing radical cystectomy (RC). The aim of our study was to assess variations in sarcopenia in patients scheduled for neoadjuvant cisplatin-based chemotherapy (NAC) and RC for muscle invasive bladder cancer (MIBC) and to explore the impact of sarcopenia on complications linked to NAC or surgery.

METHODS

Between 2012 and 2017, 82 consecutive patients who underwent NAC and RC for cT2-T4 N0 MIBC were retrospectively selected. Using CT scan before and after NAC, Lumbar Skeletal Muscle Index (SMI) was assessed by two observers. We defined severe sarcopenia as SMI <50 cm²/m² for men and SMI <35 cm²/m² for women. We evaluated pre- and post-NAC cisplatin-based chemotherapy renal function and post-operative complication rates after cystectomy using the Clavien-Dindo classification. We explored risk factors of complications by logistic regression models.

RESULTS

According to the SMI, 47 patients (57.3%) were classified as sarcopenic and 35 patients (42.7%) non-sarcopenic. Patients' characteristics between sarcopenic and non-sarcopenic patients were not significantly different except for BMI (P<0.001). Among patients non-sarcopenic before NAC, nine (25.7%) became sarcopenic after NAC. In multivariate analysis, sarcopenia was an independent significant predictor of renal impairment after NAC (P=0.02). Moreover, sarcopenia and ASA score were independent significant predictors of postoperative early complications (P=0.01 and P=0.03, respectively).

CONCLUSIONS

We observed significant changes in sarcopenic status during NAC. Sarcopenia, estimated by the lumbar SMI measurement, was an independent predictor associated with the risk of renal impairment during NAC and early postoperative complications after RC.