Nutritional status, cachexia and survival in patients with advanced colorectal carcinoma. Different assessment criteria for nutritional status provide unequal results. Clin Nutr. 2013;32:65-72. [PMID: 22695408 DOI: 10.1016/j.clnu.2012.05.009]

Diversity in chemotherapy-induced cachexia

Preclinical and clinical studies suggest that chronic administration of cytotoxic drugs (e.g., chemotherapy) may contribute to the occurrence of skeletal muscle wasting and weakness/fatigue (i.e., cachexia). Doxorubicin, folfiri, and cisplatin are known to promote cachexia by triggering common alterations such as skeletal muscle atrophy, protein breakdown, and mitochondrial dysfunction, whereas each also possesses distinguishing features in terms of the activated molecular pathways. Similarly, commonalities exist between different cancer types including the development of muscle wasting early in treatment that can persist for years. The impact of treatment for gastrointestinal, head and neck, and nonsmall cell lung cancers (NSCLCs) on the development of cachexia and survival outcomes is well documented. However, a disconnect occurs between preclinical studies on cachexia, which are often performed on younger mice, and clinical studies on cachexia, which are focused on patients over 60 yr old. Yet, several preclinical studies have examined the impact of age on chemotherapy-induced cachexia. Finally, sex differences have been identified in both preclinical and clinical studies focused on the onset of cachexia consequential to chemotherapy administration and raise the question of whether treatments for this condition should be based on sex specificities. In conclusion, although cancer cachexia has been widely studied for its impact on patients affected by various malignancies, the effects of chemotherapy on the development of cachexia are less explored. Here, we examine diversity in chemotherapy-induced cachexia with respect to specific types of chemotherapy regimens and cancer, and differences based on age and sex.

Everolimus Through Plasmatic Concentrations in Cancer Patients: Prospective Longitudinal Observational Multicentric Study (DIANA-1 Project)

Background: Everolimus, an oral inhibitor of the mammalian target of rapamycin (mTOR), is actually used to prevent organ transplant rejection and treat metastatic breast, renal, and neuroendocrine cancers. Despite significant pharmacokinetic variability among patients, routine therapeutic drug monitoring (TDM) is not commonly used in oncology. Methods: The aim of this multicenter, prospective observational cohort study is to assess the prevalence of everolimus minimum concentration at a steady state (Cminss) falling outside the therapeutic range (10-26.3 ng/mL) during a routine TDM programme. Sixty patients with metastatic breast, neuroendocrine, or renal cancers, either starting or continuing everolimus treatment according to hospital protocols, are to be included between 1st of January 2024 and 31st of December 2025 (patients undergoing clinical trials are excluded). We hypothesize that 30-50% of our patients and their blood samples will not achieve the target optimal plasma concentrations. Blood samples are collected every 4-6 weeks to monitor drug levels. The secondary goal is to explore correlation between out-of-range everolimus levels and factors such as demographic and anthropometric data, treatment specifics, lab results, genetic polymorphisms, and the presence of toxicity. Conclusions: This study could offer valuable insights into optimizing dosing strategies and may contribute to future research on personalizing everolimus and other anticancer treatments. This personalized approach seeks to tailor therapy not only to the tumour's molecular profile but also to the individual characteristics of each patient, improving both drug selection and dosing precision.

Prognostic value of the fat-free mass index-based cachexia index in patients with colorectal cancer

Studies have shown that the cachexia index (CXI) is a useful predictor of cachexia in patients with colorectal cancer. However, the application of the CXI is limited stemming from the intricacy and additional cost of radiographic examinations. This study aimed to develop an easy-to-use and practical CXI based on fat-free mass index (FFMI-CXI) to evaluate the prognostic value of FFMI-CXI in CRC. A total of 656 patients with CRC were enrolled in the Investigation on Nutrition Status and Clinical Outcome of Common Cancers (INSCOC) study. The FFMI-CXI was calculated as [FFMI (kg)/height (m)2 × serum albumin (g/L)]/neutrophil-lymphocyte ratio. The cutoff value for FFMI-CXI was determined through the analysis of ROC curves and Youden's index for both male and female cohorts. Kaplan-Meier survival curves with log-rank tests were conducted to compare time-event relationships between different groups. Cox proportional hazards regression models incorporating both univariate and multivariate variables were employed to explore the independent prognostic factors associated with OS. Logistic regression analysis was performed to assess the association of the FFMI-CXI with secondary outcomes. The major outcome was 5-year overall survival (OS). Based on the cutoff values, 331 patients had low FFMI-CXI, and 325 patients had high FFMI-CXI. Patients in the low FFMI-CXI subgroup were significantly older and had advanced TNM stage, malnutrition, high systemic inflammation, long hospitalizations, high hospitalization costs, adverse short-term outcomes, and all-cause mortality. Multivariate Cox regression analyses revealed that FFMI-CXI (HR 0.47, 95% CI 0.33-0.66; p < 0.001) and TNM stage (HR 3.38, 95% CI 2.63-4.35; p < 0.001) were independently associated with OS in CRC patients. K-M survival curves revealed that the CRC patients with a high FFMI-CXI had significantly more favorable OS than those with low FFMI-CXI (62.84% vs. 84.31%; log-rank p < 0.001). Furthermore, the FFMI-CXI was valuable for predicting 90-day outcomes, malnutrition, cancer cachexia, length of hospitalization, and hospitalization expenses. This study revealed that the FFMI-CXI can be used as a prognostic indicator in patients with CRC. Patients with low FFMI-CXI should receive more attention.

Prevalence of and Survival with Cachexia among Patients with Cancer: A Systematic Review and Meta-Analysis

Cachexia is associated with lower overall survival (OS) in patients with cancer; however, the relationship between the two is reported to differ according to the definitive criteria for diagnosing cachexia. We aimed to investigate 1) the difference in the prevalence of cachexia in patients with cancer and 2) the association between cachexia and OS, depending on the definitive criteria for diagnosing cachexia in patients with cancer. We searched PubMed and Web of Science from their inception until July 31, 2023, to identify eligible studies. We conducted a systematic review of the prevalence of cachexia in patients with cancer and performed a meta-analysis to investigate its relationship with OS. A total of 125 articles comprising 137,960 patients were included in the systematic review, and 26 articles consisting of 11,118 patients underwent meta-analysis. The overall prevalence of cachexia in patients with cancer was 33.0% (95% confidence interval [CI]: 32.8, 33.3); however, it varied according to the definitive criteria for diagnosing cachexia (13.9%-56.5%). According to the Fearon 2011 criteria, the prevalence of cachexia was associated with a high hazard ratio (HR) for OS compared with that of noncachexia [HR: 1.58 (95% CI: 1.45, 1.73)]; according to the other criteria, the HR was 2.78 (95% CI: 1.88, 4.11), indicating significant subgroup differences (P = 0.006). The dose-response curve indicated that the HR for OS plateaued at a cachexia prevalence range of 40%-50% (l-shaped relationship). The prevalence of cachexia in patients with cancer may vary depending on the definitive criteria used to diagnose cachexia. The HR for OS was higher for low cachexia prevalence. The definitive criteria should be carefully considered when assessing cachexia in patients with cancer. This trial was registered at the PROSPERO as CRD42023435474.

Evaluation of postoperative results after a presurgical optimisation programme

BACKGROUND

Presurgical optimisation programmes decrease the risk of postoperative complications, reduce hospital stays and speed up patient recovery. They usually involve a multidisciplinary team addressing physical, nutritional and psychosocial issues. The objective of this study was to assess the results of implementing a presurgical optimisation programme led by a liaison nurse in patients undergoing major surgery in a primary general hospital.

METHODS

An observational, retrospective, descriptive, cross-sectional, comparative study based on the revision of patients' health records undergoing major surgery between January 2019 and December 2022. Patients entering the presurgical optimisation programme (intervention group) were compared with patients receiving usual medical care (control group). The presurgical optimisation programme consisted of oral nutritional supplementation, physical exercise, strengthening of lung capacity and psychological and emotional support. Frequency (%) of surgery complications and use of healthcare resources (duration of hospitalisation, time spent in the intensive care unit (ICU), and readmission) at day 30 were recorded. Descriptive statistics were applied.

RESULTS

Two hundred eleven patients (58.5% men, mean age: 65.76 years (SD 11.5), 75.2%. non-smokers; mean body mass index (BMI): 28.32 (SD 5.38); mean Nutritional Risk Score (NRS) 3.71 (SD 1.35; oncology diagnosis: 88.6%) were included: 135 in the intervention group, and 76 in the control group. The average duration of the presurgical optimisation programme was 20 days (SD 5). Frequency of postoperative complications was 25% (n = 33) in the intervention group and 52.6% (n = 40) in the control group (p < 0.001) [odds ratio (OR) = 3.4; 95% confidence interval (CI) (1.8; 6.2)]. 14.5% (n = 19) of patients in the intervention group and 34.2% (n = 26) in the control group had remote postoperative complications [OR = 3.1; 95% CI (1.6; 6.2)]. Patients in the intervention group spent fewer days in the hospital [mean 8.34 (SD 6.70) vs 11.63 (SD 10.63)], and there were fewer readmissions at 30 days (7.6% vs 19.7%) compared with the control group.

CONCLUSIONS

A presurgical optimisation programme led by a liaison nurse decreases the rate of immediate and late surgical complications and reduces hospital stays and readmissions in patients undergoing major surgery.

The Impact of Non-bone Metastatic Cancer on Musculoskeletal Health

PURPOSE OF REVIEW

The purpose of this review is to discuss the musculoskeletal consequences of cancer, including those that occur in the absence of bone metastases.

RECENT FINDINGS

Cancer patients frequently develop cachexia, a debilitating condition reflected by weight loss and skeletal muscle wasting. The negative effects that tumors exert on bone health represents a growing interest amongst cachexia researchers. Recent clinical and pre-clinical evidence demonstrates cancer-induced bone loss, even in the absence of skeletal metastases. Together with muscle wasting, losses in bone demonstrates the impact of cancer on the musculoskeletal system. Identifying therapeutic targets that comprehensively protect musculoskeletal health is essential to improve the quality of life in cancer patients and survivors. IL-6, RANKL, PTHrP, sclerostin, and TGF-β superfamily members represent potential targets to counteract cachexia. However, more research is needed to determine the efficacy of these targets in protecting both skeletal muscle and bone.

Comparison of the cachexia index based on hand-grip strength (H-CXI) with the original CXI for the prediction of cancer cachexia and prognosis in patients who underwent radical colectomy for colorectal cancer

Background and aims

The cachexia index (CXI) is a novel biomarker for estimating cancer cachexia. The cachexia index based on hand-grip strength (H-CXI) has been recently developed as a simple proxy for CXI. The present study aims to compare both the H-CXI and CXI for the prediction of cancer cachexia and postoperative outcomes in patients who underwent radical colectomy for colorectal cancer.

Methods

Patients who underwent radical operations for colorectal cancer were included in this study. Cancer cachexia was diagnosed according to the international consensus outlined by Fearon et al. The cachexia index (CXI) was calculated as [skeletal muscle index (SMI) × serum albumin/neutrophil-to-lymphocyte ratio (NLR)]. The H-CXI was calculated as [hand-grip strength (HGS)/height2 × serum albumin/NLR]. The SMI was measured based on the preoperative CT images at the third lumbar vertebra (L3) level. HGS was measured before surgery.

Results

From July 2014 to May 2021, a total of 1,411 patients were included in the present study, of whom 361 (25.6%) were identified as having cancer cachexia. Patients with cachexia had a lower CXI (p < 0.001) and lower H-CXI (p < 0.001) than those without cachexia. A low CXI but not low H-CXI independently predicted cancer cachexia in the multivariate analysis (OR 1.448, p = 0.024). Both a low CXI (HR 1.476, p < 0.001 for OS; HR 1.611, p < 0.001 for DFS) and low H-CXI (HR 1.369, p = 0.007 for OS; HR 1.642, p < 0.001 for DFS) were independent predictors for overall survival (OS) and disease-free survival (DFS) after adjusting for the same covariates. A low H-CXI but not low CXI was an independent risk factor for postoperative complications (OR 1.337, p = 0.044). No significant association was found between cancer cachexia and postoperative complications.

Conclusion

The CXI and H-CXI exhibited better prognostic value than cancer cachexia for the prediction of postoperative outcomes in patients who underwent radical colectomy for colorectal cancer. The H-CXI was a superior index over the CXI in predicting short-term clinical outcomes, whereas the CXI demonstrated a closer correlation with Fearon's criteria for cancer cachexia. Ideal tools for the assessment of cancer cachexia should incorporate not only weight loss but also muscle mass, physical function, and inflammatory state.

Nutritional status of elderly patients previously ill with COVID-19: Assessment with nutritional risk screening 2002 (NRS-2002) and mini nutritional assessment (MNA-sf)

BACKGROUND

Long-term effects of COVID-19 showed a wide range of symptoms. Also, it was found that older patients were five times more likely than younger patients to develop long-COVID symptoms (1). This study aimed to investigate the use of Nutrition Risk Screening 2002 (NRS-2002) and the Mini Nutrition Assessment-Short Form (MNA-sf) among COVID-19 in elderly patients in Saudi Arabia.

METHODS

A total of (n = 159) COVID-19 elderly patients were recruited in the study; the relationship between patients' characteristics, including age, gender, Body Mass Index (BMI), infection history, vaccination and chronic disease were evaluated using NRS-2002 and MNA-sf. Multivariate logistic regression to estimate the Odd Ratio (OR) by comparing the OR of different variables between normal nutritional Status and at-risk and Cohen's kappa (κ) coefficient was assessed to analyse the agreement between both tools.

RESULTS

MNA-sf showed a positive association between age and malnutrition risk ≥ 66 years old P = 0.035. Both tools showed a negative association between BMI (P < 0.001 and P = 0.046), respectively and vaccination (P = 0.002 and P = 0.01), respectively, with risk for malnutrition. There was no significant association between Diabetes (DM) and malnutrition risk, but elderly Cardiovascular Disease (CVD) were at malnutrition risk using the NRS- 2002 tool P = 0.003. Inversely, people infected six months or more before malnutrition assessment have a lower risk of malnutrition P = 0.05.

CONCLUSIONS

Both tools were valuable and practical tools for screening elderly people with COVID-19 who are at nutritional risk and those in need of additional nutritional intervention. Further research needed to be applied in the relationship between nutritional status during and post-infectious disease for elderly people using cross-sectional and intervention studies in order to prevent malnutrition complications in Saudi Arabia.

The PG-SGA outperforms the NRS 2002 for nutritional risk screening in cancer patients: a retrospective study from China

BACKGROUND AND AIMS

As a chronic wasting disease, cancer can lead to metabolic and physiological changes in patients, resulting in severe malnutrition. Therefore, accurate assessment of nutritional status and adoption of scientifically sound nutritional interventions are of great importance for patients with cancer. This study aimed to assess the necessity of implementing the Nutrition Risk Screening 2002 (NRS 2002) tool in conjunction with the Patient-Generated Subjective Global Assessment (PG-SGA) in patients with cancer.

METHODS

This retrospective study collected the clinical data of cancer patients from November 2011 to December 2018 in the Department of Oncology, Cancer Center, First Hospital of Jilin University. The NRS 2002 and the PG-SGA were used as screening tools for malnutrition. Clinical characteristics and laboratory results were detected. Anthropometric indices including hand-grip strength (HGS), visceral fat area (VFA), calf circumstance (CC), and appendicular skeletal muscle mass index (ASMI) were also collected. The diagnostic results from the NRS 2002 were compared to the malnutrition diagnosis using the PG-SGA.

RESULTS

Of the 2,645 patients included in this retrospective study, the nutritional risk was found in 1763 (66.6%) patients based on the PG-SGA, and in 240 (9.1%) patients based on the NRS 2002, respectively. Among the 240 patients evaluated by the NRS 2002 for risk of malnutrition, 230 were also assessed by the PG-SGA as malnourished. There were no significant differences observed in the clinical characteristics and laboratory parameters between the two groups.

CONCLUSION

The PG-SGA is effective and had a higher positive rate in screening malnutrition for patients with cancer. The NRS 2002 is not necessary for patients who are to be assessed with the PG-SGA.

Exploring the Association between Delirium and Malnutrition in COVID-19 Survivors: A Geriatric Perspective

Older individuals face an elevated risk of developing geriatric syndromes when confronted with acute stressors like COVID-19. We assessed the connection between in-hospital delirium, malnutrition, and frailty in a cohort of COVID-19 survivors. Patients aged ≥65, hospitalized in a tertiary hospital in Milan for SARS-CoV-2 pneumonia, were enrolled and screened for in-hospital delirium with the 4 'A's Test (4AT) performed twice daily (morning and evening) during hospital stay. Malnutrition was assessed with the malnutrition universal screening tool (MUST) at hospital admission and with the mini-nutritional assessment short-form (MNA-SF) one month after hospital discharge. Frailty was computed with the frailty index one month after hospital discharge. Fifty patients (median age 78.5, 56% male) were enrolled. At hospital admission, 10% were malnourished. The 13 patients (26%) who developed delirium were frailer (7 vs. 4), experienced a higher in-hospital mortality (5 vs. 3), and were more malnourished one month after discharge (3 of the 4 patients with delirium vs. 6 of the 28 patients without delirium who presented at follow up). The 4AT scores correlated with the MNA-SF scores (r = -0.55, p = 0.006) and frailty (r = 0.35, p = 0.001). Frailty also correlated with MUST (r = 0.3, p = 0.04), MNA-SF (r = -0.42, p = 0.02), and hospitalization length (r = 0.44, p = 0.001). Delirium, malnutrition, and frailty are correlated in COVID-19 survivors. Screening for these geriatric syndromes should be incorporated in routine clinical practice.

Comparison of the performance of the GLIM criteria, PG-SGA and mPG-SGA in diagnosing malnutrition and predicting survival among lung cancer patients: A multicenter study

BACKGROUND & AIMS

The present study aimed to compare the ability of the GLIM criteria, PG-SGA and mPG-SGA to diagnose malnutrition and predict survival among Chinese lung cancer (LC) patients.

METHODS

This was a secondary analysis of a multicenter, prospective, nationwide cohort study, 6697 LC inpatients were enrolled between July 2013 and June 2020. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), area under the curve (AUC), and quadratic weighted Kappa coefficients were calculated to compare the ability to diagnose malnutrition. There were 754 patients who underwent follow-up for a median duration of 4.5 years. The associations between the nutritional status and survival were analyzed by the Kaplan-Meier method and multivariable Cox proportional hazard regression models.

RESULTS

The median age of LC patients was 60 (53, 66), and 4456 (66.5%) were male. There were 617 (9.2%), 752 (11.2%), 1866 (27.9%), and 3462 (51.7%) patients with clinical stage Ⅰ, Ⅱ, Ⅲ, and Ⅳ LC, respectively. Malnutrition was present in 36.1%-54.2% (as evaluated using different tools). Compared with the PG-SGA (used as the diagnostic reference), the sensitivity of the mPG-SGA and GLIM was 93.7% and 48.3%; the specificity was 99.8% and 78.4%; and the AUC was 0.989 and 0.633 (P < 0.001). The weighted Kappa coefficients were 0.41 for the PG-SGA vs. GLIM, 0.44 for the mPG-SGA vs. GLIM, and 0.94 for the mPG-SGA vs PG-SGA in patients with stage Ⅰ-Ⅱ LC. These values were respectively 0.38, 0.39, and 0.93 in patients with stage Ⅲ-Ⅳ of LC. In a multivariable Cox analysis, the mPG-SGA (HR = 1.661, 95%CI = 1.348-2.046, P < 0.001), PG-SGA (HR = 1.701, 95%CI = 1.379-2.097, P < 0.001) and GLIM (HR = 1.657, 95%CI = 1.347-2.038, P < 0.001) showed similar death hazard ratios.

CONCLUSIONS

The mPG-SGA provides nearly equivalent power to predict the survival of LC patients as the PG-SGA and the GLIM, indicating that all three tools are applicable for LC patients. The mPG-SGA has the potential to be an alternative replacement for quick nutritional assessment among LC patients.

GLIM criteria as a valid tool for nutrition assessment and mortality prediction in treatment-naïve patients with cancer

BACKGROUND

Clinical care of patients with cancer mostly focuses on medical management with less attention on disease-related malnutrition. The Global Leadership Initiative on Malnutrition (GLIM) released new criteria for diagnosing malnutrition, but the validation of these criteria in treatment-naïve patients with cancer is not well documented. This study aimed to investigate the application of the GLIM criteria in nutrition assessment and mortality prediction in treatment-naïve patients with cancer.

METHODS

A total of 267 patients newly diagnosed with different types of cancer were enrolled. Nutrition status was assessed with the Patient-Generated Subjective Global Assessment (PG-SGA) at outpatient clinic admission during the data collection period. Furthermore, after the GLIM criteria publication, nutrition status was assessed retrospectively using the GLIM criteria in the same cohort to assess validity. The agreement between the tools was calculated using kappa statistics, and the association of malnutrition according to each tool and mortality was analyzed using logistic regression analysis.

RESULTS

The mean age of the patients was 58.06 ± 12.6 years, and 42.7% were women. The prevalence of malnutrition was 60.3% with GLIM criteria and 53.6% with PG-SGA. Agreement between tools was moderate (κ = 0.483, P < 0.001). During a median follow-up period of 23.6 months, 99 deaths occurred. Both GLIM-defined and PG-SGA-defined malnutrition was independently associated with 2-year mortality after adjusting for age, sex, presence of comorbidities, and stage of cancer.

CONCLUSIONS

Our findings support the validation of GLIM in diagnosing malnutrition and predicting 2-year mortality among treatment-naïve patients with cancer.

Diagnosis, prevalence, and outcomes of sarcopenia in kidney transplantation recipients: A systematic review and meta-analysis

The prevalence of sarcopenia and its clinical predictors and clinical impact vary among kidney transplant recipients (KTRs), in part because of different diagnostic criteria. This study aimed to assess the reported diagnosis criteria of sarcopenia and compare them in terms of prevalence, clinical predictors, and impact of sarcopenia. The Medline, Embase, and Cochrane Library were searched for the full-length reports published until 28 January 2022. The subgroup analysis, meta-regression, and sensitivity analysis were performed and heterogeneity was assessed using the I² . A total of 681 studies were retrieved, among which only 23 studies (including 2535 subjects, 59.7% men, mean age 49.8 years) were eventually included in the final analysis. The pooled prevalence in these included studies was 26% [95% confidence interval (95% CI): 20-34%, I²  = 93.45%], including 22% (95% CI: 14-32%, I²  = 88.76%) in men and 27% (95% CI: 14-41%, I²  = 90.56%) in women (P = 0.554 between subgroups). The prevalence of sarcopenia diagnosed using low muscle mass was 34% (95% CI: 21-48%, I²  = 95.28%), and the prevalence of using low muscle mass in combination with low muscle strength and/or low physical performance was 21% (95% CI: 15-28%, I²  = 90.37%) (P = 0.08 between subgroups). In meta-regression analyses, the mean age (regression coefficient: 1.001, 95% CI: 0.991-1.011) and percentage male (regression coefficient: 0.846, 95% CI: 0.367-1.950) could not predict the effect size. Lower body mass index (odds ratio (OR): 0.57, 95% CI: 0.39-0.84, I²  = 61.5%), female sex (OR: 0.31, 95% CI: 0.16-0.61, I²  = 0.0%), and higher age (OR: 1.08, 95% CI: 1.05-1.10, I²  = 10.1%) were significantly associated with a higher risk for sarcopenia in KTRs, but phase angle (OR: 0.81, 95% CI: 0.16-4.26, I²  = 84.5%) was not associated with sarcopenia in KTRs. Sarcopenia was not associated with rejections (risk ratio (RR): 0.67, 95% CI: 0.23-1.92, I²  = 12.1%), infections (RR: 1.03, 95% CI: 0.34-3.12, I²  = 87.4%), delayed graft functions (RR: 0.81, 95% CI: 0.46-1.43, I²  = 0.0%), and death (RR: 0.95, 95% CI: 0.32-2.82, I²  = 0.0%) in KRTs. Sarcopenia was found to be very common in KRTs. However, we have not found that sarcopenia had a negative impact on clinical health after kidney transplantation. Large study cohorts and multicentre longitudinal studies in the future are urgently needed to explore the prevalence and prognosis of sarcopenia in kidney transplant patients.

Targeting Mitochondria and Oxidative Stress in Cancer- and Chemotherapy-Induced Muscle Wasting

Significance: Cancer is frequently associated with the early appearance of cachexia, a multifactorial wasting syndrome. If not present at diagnosis, cachexia develops either as a result of tumor progression or as a side effect of anticancer treatments, especially of standard chemotherapy, eventually representing the direct cause of death in up to one-third of all cancer patients. Cachexia, within its multiorgan affection, is characterized by severe loss of muscle mass and function, representing the most relevant subject of preclinical and clinical investigation. Recent Advances: The pathogenesis of muscle wasting in cancer- and chemotherapy-induced cachexia is complex, and encompasses heightened protein catabolism and reduced anabolism, disrupted mitochondria and energy metabolism, and even neuromuscular junction dismantling. The mechanisms underlying these alterations are still controversial, especially concerning the molecular drivers that could be targeted for anticachexia therapies. Inflammation and mitochondrial oxidative stress are among the principal candidates; the latter being extensively discussed in the present review. Critical Issues: Several approaches have been tested to modulate the redox homeostasis in tumor hosts, and to counteract cancer- and chemotherapy-induced muscle wasting, from exercise training to distinct classes of direct or indirect antioxidants. We herein report the most relevant results obtained from both preclinical and clinical trials. Future Directions: Including the assessment and the treatment of altered redox balance in the clinical management of cancer patients is still a big challenge. The available evidence suggests that fortifying the antioxidant defenses by either pharmacological or nonpharmacological strategies will likely improve cachexia and eventually the outcome of a broad cancer patient population. Antioxid. Redox Signal. 38, 352-370.

Comparison of nutritional risk screening with NRS2002 and the GLIM diagnostic criteria for malnutrition in hospitalized patients

Nutritional risk screening, to identify patients at risk of malnutrition, is the first step in the prevention and treatment of malnutrition in hospitalized patients, and should be followed by a thorough nutritional assessment resulting in a diagnosis of malnutrition and subsequent treatment. In 2019, a consensus on criteria has been suggested for the diagnosis of malnutrition by the Global Leadership Initiative for Malnutrition (GLIM). This study investigates the diagnosis of malnutrition in hospitalized patients using nutritional risk screening and the diagnostic assessment suggested by GLIM. Hospitalized patients (excluding cancer, intensive care, and transmissible infections) who underwent nutritional risk screening (by NRS2002) were included. Nutritional risk screening was followed by anthropometric measurements including measurement of muscle mass, assessment of dietary intake and measurement of serum C-reactive protein (CRP) for inflammation in all patients. Malnutrition was diagnosed according to the GLIM-criteria. In total, 328 patients (median age 71 years, 47% women, median length of stay 7 days) were included. Nutritional risk screening identified 143 patients as at risk of malnutrition, while GLIM criteria led to a diagnosis of malnutrition in 114 patients. Of these 114 patients, 77 were also identified as at risk of malnutrition by NRS2002, while 37 patients were not identified by NRS2002. Malnutrition was evident in fewer patients than at risk of malnutrition, as expected. However, a number of patients were malnourished who were not identified by the screening procedure. More studies should investigate the importance of inflammation and reduced muscle mass, which is the main difference between nutritional risk screening and GLIM diagnostic assessment.

Cardiovascular and metabolic determinants of quality of life in patients with cancer

AIMS

Maintaining quality of life (QoL) in patients with cancer has gathered significant interest, but little is known about its major determinants. We sought to identify determinants of QoL in patients undergoing cancer treatment as well as in treatment-naïve patients about to commence such therapy.

METHODS AND RESULTS

QoL was assessed in 283 patients with cancer using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 questionnaire. All patients underwent a battery of tests including physical examination, resting electrocardiogram, hand grip strength, and biochemistry assessment. Using multivariable logistic regression, we found that age [odds ratio (OR) 0.954, 95% confidence interval (CI) 0.916-0.994], resting heart rate (OR 1.036, 95% CI 1.004-1.068), hand grip strength (OR 0.932, 95% CI 0.878-0.990), and the presence of cachexia (OR 4.334, 95% CI 1.767-10.631) and dyspnoea (OR 3.725, 95% CI 1.540-9.010; all P < 0.05) remained independently predictive of reduced QoL.

CONCLUSIONS

Therefore, it may be reasonable to address circumstances that are affecting muscle mass, body weight, and heart rate to maintaining QoL; however, prospective studies to test these endpoints are required.

Prognostic value of cachexia index in patients with colorectal cancer: A retrospective study

Background

Current diagnostic criteria for cancer cachexia are inconsistent, and arguments still exist about the impact of cachexia on the survival of patients with colorectal cancer. In this study, we aim to investigate the prognostic value of a novel cachexia indicator, the cachexia index (CXI), in patients with colorectal cancer.

Methods

The CXI was calculated as skeletal muscle index (SMI) × serum albumin/neutrophil-lymphocyte ratio. The cut-off value of CXI was determined by the receiver operating characteristic (ROC) curves and Youden’s index. The major outcomes were major complications, overall survival (OS), and recurrence-free survival (RFS).

Results

A total of 379 patients (234 men and 145 women) were included. The ROC curves indicated that CXI had a significantly diagnostic capacity for the detection of major complications. Based on Youden’s index, there were 231 and 148 patients in the low and high CXI groups, respectively. Patients in the low CXI group had significantly older age, lower BMI, and a higher percentage of cachexia and TNM stage II+III. Besides, Patients in low CXI group were associated with a significantly higher rate of major complications, blood transfusion, and longer length of stay. Logistic regression analysis indicated that low CXI, cachexia, and coronary heart disease were independent risk factors for the major complications. Kaplan Meier survival curves indicated that patients with high CXI had a significantly more favorable OS than those with low CXI, while no significant difference was found in RFS between the two groups. Besides, there were no significant differences in OS or RFS between patients with and without cachexia. The univariate and multivariate Cox regression analysis indicated that older age, low CXI, and coronary heart disease instead of cachexia were associated with a decreased OS.

Conclusion

CXI was better than cachexia in predicting OS and could be a useful prognostic indicator in patients with colorectal cancer, and greater attention should be paid to patients with low CXI.

Attenuation of Muscle Damage, Structural Abnormalities, and Physical Activity in Respiratory and Limb Muscles following Treatment with Rucaparib in Lung Cancer Cachexia Mice

Simple Summary

Muscle wasting and cachexia are common in patients with cancer. Several mechanisms underlie muscle physiological and structural alterations in cancer-induced cachexia. Poly (ADPribose) polymerases (PARPs) are involved in muscle metabolism and in cancer. Selective inhibitors of PARP activity improve muscle function and structure. This study sought to investigate whether rucaparib (PARP inhibitor) may attenuate muscle damage in a mouse model of lung-cancer-induced cachexia. Rucaparib was administered to cancer-cachectic mice. Physiological and biological parameters were determined in the respiratory and limb muscles of the animals. In cancer cachexia mice compared to non-cachexia controls, body weight and body weight gain, muscle weight, limb strength, physical activity, and muscle fiber size significantly declined, while levels of PARP activity, plasma troponin I, muscle damage, and proteolytic and autophagy markers increased. Treatment with rucaparib elicited a significant improvement in body weight gain, tumor size and weight, physical activity, muscle damage, troponin I, and proteolytic and autophagy levels.

Abstract

Overactivation of poly (ADPribose) polymerases (PARPs) is involved in cancer-induced cachexia. We hypothesized that the PARP inhibitor rucaparib may improve muscle mass and reduce damage in cancer cachexia mice. In mouse diaphragm and gastrocnemius (LP07 lung adenocarcinoma) treated with PARP inhibitor (rucaparib,150 mg/kg body weight/24 h for 20 days) and in non-tumor control animals, body, muscle, and tumor weights; tumor area; limb muscle strength; physical activity; muscle structural abnormalities, damage, and phenotype; PARP activity; and proteolytic and autophagy markers were quantified. In cancer cachexia mice compared to non-cachexia controls, body weight and body weight gain, muscle weight, limb strength, physical activity, and muscle fiber size significantly declined, while levels of PARP activity, plasma troponin I, muscle damage, and proteolytic and autophagy markers increased. Treatment with the PARP inhibitor rucaparib elicited a significant improvement in body weight gain, tumor size and weight, physical activity, muscle damage, troponin I, and proteolytic and autophagy levels. PARP pharmacological inhibition did not exert any significant improvements in muscle weight, fiber size, or limb muscle strength. Treatment with rucaparib, however, improved muscle damage and structural abnormalities and physical activity in cancer cachexia mice. These findings suggest that rucaparib exerts its beneficial effects on cancer cachexia performance through the restoration of muscle structure.

Quantification of Coronary Artery Atherosclerotic Burden and Muscle Mass: Exploratory Comparison of Two Freely Available Software Programs

Coronary artery calcification and sarcopenia may have a relevant prognostic impact in oncological and non-oncological patients. The use of freeware software is promising for quantitative evaluation of these parameters after whole-body positron emission tomography (PET)/computed tomography (CT) and might be useful for one-stop shop risk stratification without additional radiation ionizing burden and further charges to health care costs. In this study, we compared two semiautomatic freeware software tools (Horos Medical Image software and LIFEx) for the assessment of coronary artery calcium (CAC) score and muscle mass in 40 patients undergoing whole-body PET/CT. The muscle areas obtained by the two software programs were comparable, showing high correlation with Lin’s concordance coefficient (0.9997; 95% confidence intervals: 0.9995–0.9999) and very good agreement with Bland–Altman analysis (mean difference = 0.41 cm2, lower limit = −1.06 cm2, upper limit = 1.89) was also found. For CAC score, Lin’s concordance correlation coefficient was 0.9976 (95% confidence intervals: 0.9965–0.9984) and in a Bland–Altman analysis an increasing mean difference from 8 to 78 by the mean values (intercept = −0.050; slope = 0.054; p < 0.001) was observed, with a slight overestimation of Horos CAC score as compared to LIFEx, likely due to a different calculation method of the CAC score, with the ROI being equal for the two software programs. Our results demonstrated that off-line analysis performed with freeware software may allow a comprehensive evaluation of the oncological patient, making available the evaluation of parameters, such as muscle mass and calcium score, that may be relevant for the staging and prognostic stratification of these patients, beside standard data obtained by PET/CT imaging. For this purpose, the Horos and LIFEx software seem to be interchangeable.

MicroRNAs: Novel players in the diagnosis and treatment of cancer cachexia (Review)

Cachexia denotes a complex metabolic syndrome featuring severe loss of weight, fatigue and anorexia. In total, 50-80% of patients suffering from advanced cancer are diagnosed with cancer cachexia, which contributes to 40% of cancer-associated mortalities. MicroRNAs (miRNAs) are non-coding RNAs capable of regulating gene expression. Dysregulated miRNA expression has been observed in muscle tissue, adipose tissue and blood samples from patients with cancer cachexia compared with that of samples from patients with cancer without cachexia or healthy controls. In addition, miRNAs promote and maintain the malignant state of systemic inflammation, while inflammation contributes to cancer cachexia. The present review discusses the role of miRNAs in the progression of cancer cachexia, and assess their diagnostic value and potential therapeutic value.

The Relationship between Unintentional Weight Loss, Grading System and Overall Survival in Gastric Cancer Patients

Cancer patients are highly vulnerable to weight loss and malnutrition, before chemotherapy, thus reducing overall survival (OS). The objective was assessing weight loss and OS prognostication in gastric cancer patients at baseline of chemotherapy treatment. Observational retrospective study with patients who were treating in cancer public clinic in Brazil, was evaluated weight loss and cachexia. It was evaluated by sex, BMI, grade system classification (GSC) and stage the OS by Kaplan-Meier method and Cox proportional hazards model. Ninety-two patients, 73.9% were male. At baseline chemotherapy patients have presented 15.3% of body weight loss, 28.3% were malnourished, 86.8% classified witch cachexia, 80.3% were grade 3-4 in GSC and 86.9% at cancer stage 3-4. OS was lower for male (15.9 mo.), malnourished (12.0 mo.), GCS-4 (16.3 mo.) and Stage 4 (13.3 mo.) patients. GSC grade four and BMI classification to underweight comparing obesity are associated with reduced OS, together to male sex and cancer stage 4, have gotten together shown that seems to confer a survival disadvantage to other patients in these parameters too. Cox regression analysis have not shown statistical significance for sex, Initial BMI Class, GSC, cancer stage. Gastric cancer patients at chemotherapy treatment outset present high weight loss, cachexia prevalence and OS reduction.

Tumor cell anabolism and host tissue catabolism-energetic inefficiency during cancer cachexia

Cancer-associated cachexia (CC) is a pathological condition characterized by sarcopenia, adipose tissue depletion, and progressive weight loss. CC is driven by multiple factors such as anorexia, excessive catabolism, elevated energy expenditure by growing tumor mass, and inflammatory mediators released by cancer cells and surrounding tissues. In addition, endocrine system, systemic metabolism, and central nervous system (CNS) perturbations in combination with cachexia mediators elicit exponential elevation in catabolism and reduced anabolism in skeletal muscle, adipose tissue, and cardiac muscle. At the molecular level, mechanisms of CC include inflammation, reduced protein synthesis, and lipogenesis, elevated proteolysis and lipolysis along with aggravated toxicity and complications of chemotherapy. Furthermore, CC is remarkably associated with intolerance to anti-neoplastic therapy, poor prognosis, and increased mortality with no established standard therapy. In this context, we discuss the spatio-temporal changes occurring in the various stages of CC and highlight the imbalance of host metabolism. We provide how multiple factors such as proteasomal pathways, inflammatory mediators, lipid and protein catabolism, glucocorticoids, and in-depth mechanisms of interplay between inflammatory molecules and CNS can trigger and amplify the cachectic processes. Finally, we highlight current diagnostic approaches and promising therapeutic interventions for CC.

Evaluation of different tools for body composition assessment in colorectal cancer - a systematic review

BACKGROUND

The nutritional status of patients with colorectal cancer (CRC) impacts on treatment response and morbidity. An effective evaluation of the body composition includes the measurements of fat and visceral fat-free mass and is currently being used in the diagnosis of the nutritional status. The better understanding regarding nutritional tools for body composition evaluation in CRC patients may impact on the outcome.

METHODS

Systematic review conducted according to Preferred Items of Reports for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A literature search was performed using the BVS (LILACS), PubMed, Embase, Cochrane, Scopus, and Web of Science databases.

RESULTS

For the initial search, 97 studies were selected and 51 duplicate manuscripts were excluded. Thus, 46 were reviewed and seven studies included with a total of 4,549 patients. Among them were one clinical trial, one prospective study (cohort), two retrospective cohort and two cross-sectional studies. All studies included body composition evaluated by computed tomography, one with bioelectrical impedance, one with handgrip strength, and two employed mid-arm muscle circumference and body mass index.

CONCLUSION

Current evidence suggests that computed tomography has better accuracy in the diagnosis of sarcopenia, visceral fat, and myopenia among individuals with CRC. Further studies are needed to identify cutoff points for these changes aggravated by CRC.

Sarcopenia and systemic inflammation are associated with decreased survival after cytoreductive nephrectomy for metastatic renal cell carcinoma

BACKGROUND

This study was aimed at assessing the associations of sarcopenia, muscle density, adiposity, and inflammation with overall survival (OS) after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma.

METHODS

In all, 158 patients undergoing CN from 2001 to 2014 had digitized preoperative imaging for tissue segmentation via Slice-O-Matic software (version 5.0) at the mid-L3 level. The skeletal muscle index was calculated with the skeletal muscle area (cm² ) normalized for height (m² ), and the skeletal muscle density (SMD) was calculated with average Hounsfield units. Adiposity was measured with the cross-sectional area (cm² ) of visceral, subcutaneous, and intramuscular adiposity compartments and was similarly normalized for height. The average fat density was obtained in Hounsfield units. OS was estimated with the Kaplan-Meier method. Associations between body composition, inflammation metrics, and relevant clinicopathology and OS were assessed with univariable and multivariate Cox analyses.

RESULTS

Seventy-six of the 158 patients (48%) were sarcopenic. Sarcopenia was associated with elevated neutrophil to lymphocyte ratios (NLRs; P = .02), increased age (P = .001), lower body mass indices (P = .009), greater modified Motzer scores (P = .019), and lower SMD (P = .006). The median OS was 15.0 and 29.4 months for sarcopenic and nonsarcopenic patients, respectively (P = .04). Elevated inflammation (NLR or C-reactive protein), in addition to sarcopenia, was independently associated with OS, with an elevated NLR ≥ 3.5 and sarcopenia associated with the poorest OS at 10.2 months. No associations were observed between measurements of muscle density or adiposity and OS.

CONCLUSIONS

Sarcopenia and measures of high systemic inflammation are additively associated with inferior OS after CN and may be of use in preoperative risk stratification.

LAY SUMMARY

Body composition and sarcopenia (a deficiency in skeletal musculature) have been shown to affect outcomes in cancer. We found that sarcopenic patients had poor survival in comparison with nonsarcopenic patients in the setting of metastatic renal cell carcinoma (mRCC). Patients with both elevated inflammation and sarcopenia had the poorest survival. Sarcopenia is an objective measure of nutrition that can assist in therapeutic counseling and decision-making for individualized treatment in mRCC.

Methodology, clinical applications, and future directions of body composition analysis using computed tomography (CT) images: A review

PURPOSE OF THE REVIEW

We aim to review the methods, current research evidence, and future directions in body composition analysis (BCA) with CT imaging.

RECENT FINDINGS

CT images can be used to evaluate muscle tissue, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) compartments. Manual and semiautomatic segmentation methods are still the gold standards. The segmentation of skeletal muscle tissue and VAT and SAT compartments is most often performed at the level of the 3rd lumbar vertebra. A decreased amount of CT-determined skeletal muscle mass is a marker of impaired survival in many patient populations, including patients with most types of cancer, some surgical patients, and those admitted to the intensive care unit (ICU). Patients with increased VAT are more susceptible to impaired survival / worse outcomes; however, those patients who are critically ill or admitted to the ICU or who will undergo surgery appear to be exceptions. The independent significance of SAT is less well established. Recently, the roles of the CT-determined decrease of muscle mass and increased VAT area and epicardial adipose tissue (EAT) volume have been shown to predict a more debilitating course of illness in patients suffering from severe acute respiratory syndrome coronavirus 2 (COVID-19) infection.

SUMMARY

The field of CT-based body composition analysis is rapidly evolving and shows great potential for clinical implementation.

Cachexia Versus Sarcopenia in Clinical Characteristics and Prognostic Value After Radical Gastrectomy for Gastric Cancer: A Large-Scale Prospective Study

BACKGROUND

Sarcopenia and cachexia are two predictors of adverse clinical outcomes, but they are partly overlapping. We aimed to compare the characteristics and prognostic value of cachexia and sarcopenia in patients after gastrectomy.

METHODS

From 2014 to 2019, a total of 1215 gastric cancer patients were enrolled. Cachexia and sarcopenia were diagnosed according to the most recent consensus definitions. Baseline characteristics and clinical outcomes were compared between the two groups. Risk factors of survival were evaluated by Cox regression analysis.

RESULTS

Of all patients, 26.5% were diagnosed with cachexia and 19.8% were diagnosed with sarcopenia. Sarcopenia was more prevalent in elderly patients, while cachexia was prone to occur in patients with TMN stage III. Survival curves showed that sarcopenia had adverse effects in patients with TMN stage I and II-III, while cachexia was only associated with poor survival at stages II-III. For the entire cohort, both cachexia and sarcopenia were adverse factors for prognosis. However, for stage I patients, sarcopenia was an independent predictor for overall survival (OS) (HR = 4.939, P < 0.001) and disease-free survival (DFS) (HR = 4.256, P < 0.001), but not cachexia; for stage II-III patients, cachexia was an independent predictor for OS (HR = 1.538, P < 0.001) and DFS (HR = 1.473, P = 0.001), but not sarcopenia.

CONCLUSIONS

Sarcopenia and cachexia have different clinical characteristics and prognostic values. For patients with early stage gastric cancer, detection for sarcopenia was more meaningful than cachexia. However, the prognostic significance of cachexia exceeded sarcopenia in advanced cancer.

Skeletal muscle loss during chemotherapy and its association with survival and systemic treatment toxicity in metastatic colorectal cancer: An AGEO prospective multicenter study

PURPOSE

We showed in a previous study that the PG-SGA score is associated with survival and chemotherapy-related toxicities in metastatic colorectal cancer (mCRC) patients. The objective was to evaluate the association between pretherapeutic sarcopenia and variation in skeletal muscle index (SMI) during treatment with these outcomes in the same population.

METHODS

This prospective, multicenter, observational study enrolled non-pretreated mCRC patients. SMI was measured on routine CT scan at day 0 (D0) and day 60 (D60). Nutritional factors were collected at D0. Progression-free survival (PFS) and overall survival (OS) were calculated from treatment start.

RESULTS

149 patients were included from 7/2013 to 11/2016. Pretherapeutic sarcopenia was not significantly associated with survival or chemotherapy-related toxicities. The decrease in SMI > 14% was significantly associated with shorter PFS (6 vs 9 mo; HR 1.8, 95% CI 1.1-3.1, p = 0.02) and OS (8.5 vs 26 mo; HR 2.6, 95% CI 1.4-4.8, p = 0.002), independently of hypoalbuminemia and malnutrition defined by PG-SGA. Patients with a SMI decrease > 14% had a higher rate of grade ≥ 2 clinical toxicities (40% vs 22%, OR 3.0, 95% CI 1.2-7.7, p = 0.02), but the difference was not statistically significant in multivariable analysis.

CONCLUSION

To our knowledge, this is the first study to assess prospectively the association of skeletal muscle loss with survival and treatment toxicities in non-pretreated patients with mCRC. Pretherapeutic sarcopenia was not associated with poor outcomes, but the loss of skeletal muscle mass within 60 days from treatment start was highly prognostic, independently of other prognostic and nutritional factors.

Agreement between the GLIM criteria and PG-SGA in a mixed patient population at a nutrition outpatient clinic

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) criteria is a step-wise process including a screening tool of choice for risk assessment of malnutrition before assessment of diagnosis and grading of malnutrition severity. The agreement between GLIM and the established malnutrition assessment method Patient Generated-Subjective Global Assessment (PG-SGA) is uncertain. Also, several aspects of GLIM remain to be clearly defined. In this study, we compared diagnosis of malnutrition with the GLIM criteria to the PG-SGA, and explored the differences between the methods.

METHODS

This cross-sectional study was conducted at the Nutrition Outpatient Clinic at Oslo University Hospital, Norway. Patients were included from September-December 2019. Nutritional Risk Screening 2002 (NRS-2002) was used as the screening tool in the GLIM process before diagnosing and grading the severity of malnutrition. Results are presented with and without the initial risk screening. The diagnostic results from the GLIM process were compared to the malnutrition diagnosis using the PG-SGA.

RESULTS

In total, 144 patients, median age 58 years, participated in the study. The full GLIM process identified 36% of the patients as malnourished, while the PG-SGA identified 69% of the patients as malnourished. Comparison of GLIM and PG-SGA showed fair agreement, however the agreement was better when the NRS-2002 screening was excluded. Considering the PG-SGA a gold standard, GLIM had a sensitivity of 51% and a specificity of 98%. The introduction of new cut-off values for fat-free mass did not considerably alter the diagnosis of malnutrition within GLIM.

CONCLUSIONS

The GLIM criteria showed only fair agreement with the PG-SGA, however the agreement was better when the initial NRS-2002 screening was excluded. A joint consensus on how to perform the GLIM process is needed for comparisons of future studies, and before routine use in clinical practice.

Impact of sarcopenia on clinical outcomes of patients undergoing simultaneous liver and kidney transplantation: a cohort study

BACKGROUND

The impact of sarcopenia in patients undergoing simultaneous liver and kidney transplantation (SLKT) has not been fully delineated. The aim of this single-centre-cohort-study was to evaluate the impact of sarcopenia on the clinical outcomes.

METHODS

Between 2003 and 2018, 79 patients underwent SLKT. Sarcopenia was assessed via the total psoas muscle area (TPA) at the level of the 3rd. lumbar vertebra. Sarcopenia threshold was TPA < 1460 mm² (women) and <1560 mm² (men). We identified post-operative biliary, vascular and digestive complications. Survival analysis was performed by the Kaplan Meier method (log-rank test).

RESULTS

We included 43/79 SLKT recipients (56%male, median age of 58 [53-63] years). The prevalence of cirrhosis was 74% (n = 32) with median MELD-score of 21 (20-22) and that of polycystic-liver-disease was 26% (n = 11). End-stage-renal-disease of unknown origin was 36.2% (n = 12). Dialysis before transplantation was performed in 54,8% (n = 23) of patients. The median TPA was 1138 (926-1510) mm², and sarcopenia was detected in 72% of patients (n = 31). No difference in patient or death-censored graft-survival between sarcopenic and non-sarcopenic groups at 1 year was reported. Also, no differences at 6-months' post-transplant-complication-free and infection-free-survival rates were found.

CONCLUSION

In this cohort of patients, no differences were observed in patients, grafts, complications or infection-free survival between sarcopenic or no sarcopenic SLKT patients. Future multi-centre studies are needed to validate and extend the generalisability of these findings.

The effect of a chemotherapy drug cocktail on myotube morphology, myofibrillar protein abundance, and substrate availability

Cachexia, a condition prevalent in many chronically ill patients, is characterized by weight loss, fatigue, and decreases in muscle mass and function. Cachexia is associated with tumor burden and disease-related malnutrition, but other studies implicate chemotherapy as being causative. We investigated the effects of a chemotherapy drug cocktail on myofibrillar protein abundance and synthesis, anabolic signaling mechanisms, and substrate availability. On day 4 of differentiation, L6 myotubes were treated with vehicle (1.4 μl/ml DMSO) or a chemotherapy drug cocktail (a mixture of cisplatin [20 μg/ml], leucovorin [10 μg/ml], and 5-fluorouracil [5-FLU; 50 μg/ml]) for 24-72 h. Compared to myotubes treated with vehicle, those treated with the drug cocktail showed 50%-80% reductions in the abundance of myofibrillar proteins, including myosin heavy chain-1, troponin, and tropomyosin (p < 0.05). Cells treated with only a mixture of cisplatin and 5-FLU had identical reductions in myofibrillar protein abundance. Myotubes treated with the drug cocktail also showed >50% reductions in the phosphorylation of AKTSer473 and of mTORC1 substrates ribosomal protein S6Ser235/236 , its kinase S6K1Thr389 and eukaryotic translation initiation factor 4E-binding protein 1 (all p < 0.05). Drug treatment impaired peptide chain initiation in myofibrillar protein fractions and insulin-stimulated glucose uptake (p = 0.06) but increased the expression of autophagy markers beclin-1 and microtubule-associated proteins 1A/1B light chain 3B (p < 0.05), and of apoptotic marker, cleaved caspase 3 (p < 0.05). Drug treatment reduced the expression of mitochondrial markers cytochrome oxidase and succinate dehydrogenase (p < 0.05). The observed profound negative effects of this chemotherapy drug cocktail on myotubes underlie a need for approaches that can reduce the negative effects of these drugs on muscle metabolism.

Reduced rDNA transcription diminishes skeletal muscle ribosomal capacity and protein synthesis in cancer cachexia

Muscle wasting in cancer is associated with deficits in protein synthesis, yet, the mechanisms underlying this anabolic impairment remain poorly understood. The capacity for protein synthesis is mainly determined by the abundance of muscle ribosomes, which is in turn regulated by transcription of the ribosomal (r)RNA genes (rDNA). In this study, we investigated whether muscle loss in a preclinical model of ovarian cancer is associated with a reduction in ribosomal capacity and was a consequence of impaired rDNA transcription. Tumor bearing resulted in a significant loss in gastrocnemius muscle weight and protein synthesis capacity, and was consistent with a significant reduction in rDNA transcription and ribosomal capacity. Despite the induction of the ribophagy receptor NUFIP1 mRNA and the loss of NUFIP1 protein, in vitro studies revealed that while inhibition of autophagy rescued NUFIP1, it did not prevent the loss of rRNA. Electrophoretic analysis of rRNA fragmentation from both in vivo and in vitro models showed no evidence of endonucleolytic cleavage, suggesting that rRNA degradation may not play a major role in modulating muscle ribosome abundance. Our results indicate that in this model of ovarian cancer-induced cachexia, the ability of skeletal muscle to synthesize protein is compromised by a reduction in rDNA transcription and consequently a lower ribosomal capacity. Thus, impaired ribosomal production appears to play a key role in the anabolic deficits associated with muscle wasting in cancer cachexia.

Prognostic role of sarcopenia in metastatic colorectal cancer patients during first-line chemotherapy: A retrospective study

BACKGROUND

Sarcopenia is a condition characterized by decreased skeletal muscle mass due to physiological ageing or to a concomitant disease such as neoplasia. In cancer patients, a low lean body mass is suggested to be a negative prognostic factor for survival and for the development of dose-limiting chemotherapy toxicities irrespective of disease stage.

AIM

To evaluate the prognostic role of sarcopenia in patients with metastatic colorectal cancer (mCRC) undergoing first-line chemotherapy.

METHODS

Our retrospective analysis included 56 mCRC patients who received first-line chemotherapy from 2014 to 2017 at the Medical Oncology Unit of our hospital. Computerized scans were performed before starting chemotherapy and at the first disease reassessment. Sarcopenia was assessed using the skeletal mass index = muscle area in cm²/(height in m²) calculated at the L3 vertebra. Overall survival and objective response rate were evaluated. Toxicities were analyzed during the first four cycles of therapy and graded according to Common Terminology Criteria for Adverse Events version 4.0. A loss of skeletal muscle mass ≥ 5% was considered indicative of deterioration in muscle condition.

RESULTS

Median age was 67 years and 35.7% of patients were ≥ 70 years old. Fourteen patients (25%) were sarcopenic at baseline computed tomography (CT) scan (7/33 men; 7/23 women); 5/14 sarcopenic patients were ≥ 70 years old. Median follow-up was 26.8 mo (3.8-66.8 mo) and median overall survival was 27.2 mo (95%CI: 23.3-37.3). Sarcopenia was not correlated to overall survival (P = 0.362), to higher toxicities reported during the first 4 cycles of chemotherapy (P = 1.0) or to response to treatment (P = 0.221). At the first disease reassessment, a skeletal muscle loss (SML) ≥ 5% was found in 17 patients (30.3%) 3 of whom were already sarcopenic at baseline CT scan, while 7 patients became sarcopenic. SML was not correlated to overall survival (P = 0.961). No statistically significant correlation was found between baseline sarcopenia and age (P = 1.0), body mass index (P = 0.728), stage at diagnosis (P = 0.355) or neutrophil/lymphocyte ratio (P = 0.751).

CONCLUSION

Neither baseline sarcopenia nor SML affected survival. In addition, baseline sarcopenia was not related to worse treatment toxicity. However, these results must be interpreted with caution due to the limited sample size.

Impact of Sarcopenia on Two-Year Mortality in Patients with HCV-Associated Hepatocellular Carcinoma After Radiofrequency Ablation

Purpose

Radiofrequency ablation (RFA) appears effective for the treatment of hepatocellular carcinoma (HCC). Evaluation of prognostic factors is imperative for patient selection and improving treatment efficacy. This study aimed to assess sarcopenia as a predictor of the outcome of RFA in patients with HCC.

Methods

This prospective study included all patients with HCC on top of HCV-related cirrhosis who underwent RFA and followed up for a minimum of two years. CT scan was used to determine the skeletal muscle index at the psoas, erector spinae, quadratus lumborum, transversus abdominis, external and internal obliques, and rectus abdominis muscles. Cross-sectional areas were calculated to obtain a lumbar skeletal muscle index (L3-SMI).

Results

A total of 97 patients were enrolled in the study. The L3-SMI was 46.2±12.1 cm²/m². Older age was the only risk factor associated with sarcopenia (p = 0.001). The overall survival at two years for the whole group was 65.2%. Sarcopenia and MELD score were independent predictors of OS at two years with HR of 7.6 (95% CI: 3.1-18.7) and 2.2 (95% CI: 1.0-4.8), respectively. Recurrence-free survival was 84.1% at two years. Recurrence was not affected by all factors, including sarcopenia.

Conclusion

Sarcopenia is a surrogate predictor of overall survival at two years in HCC patients after RFA. Sarcopenia assessment might be an additional prognostic indicator with conventional biomarkers to optimize the selection criteria for receiving RFA for early-stage HCC.

Relationship between nutritional status and immediate complications in patients undergoing colorectal surgery

Introduction several complications may occur during colorectal surgical procedures and factors, such as nutritional status, substantially contribute to this problem.

Objective evaluate the relationship between nutritional status (determined by different tools) and the emergence of early postoperative complications, as well as analyze social parameters, lifestyle, food intake, and time to diet reintroduction.

Methods case series study conducted in the surgical proctologic ward of the Hospital Barão de Lucena, Recife, Pernambuco, with individuals of both sexes diagnosed with colorectal cancer who underwent a surgical procedure involving at least one anastomosis. Social, demographic and clinical data, life style, dietary intake, nutritional status, and the immediate postsurgical complications were evaluated.

Results among the 31 patients studied, there was a higher prevalence of females (74.2%), mean age of 61.9 ± 12.4 years old, and the rectum was the primary site of cancer in 54.8%. Most patients came from the countryside, were retirees, had lower education, consumed too much red meat, processed meats, and fats, with low consumption of fruits and vegetables, and were sedentary. Regarding nutritional status, nutritional risk was found in 58.1%, mean BMI of 25.7 ± 6.8 kg/m2, and 54.8% had significant weight loss. Additionally, 38.7% had some of the immediate complications, particularly paralytic ileus and abdominal distension. There was a delay in the onset of renourishment, and there was no association between nutritional status and immediate complications.

Conclusion colorectal cancer is closely related to eating habits and lifestyle. Patients with this malignancy have a marked weight loss; however, in this study, we found no association between nutritional status and the incidence of postoperative complications.

Systematic review and meta-analysis of lean mass and mortality: Rationale and study description

Objectives

Muscle mass is one of the key components in defining sarcopenia and is known to be important for locomotion and body homeostasis. Lean mass is commonly used as a surrogate of muscle mass and has been shown to be associated with increased mortality. However, the relationship of lean mass with mortality may be affected by different clinical conditions, modalities used, cut-off point to define low or normal lean mass, and even types of cancer among cancer patients. Thus, we aim to perform a comprehensive meta-analysis of lean mass with mortality by considering all these factors.

Methods

Systematic search was done in PubMed, Cochrane Library and Embase for articles related to lean mass and mortality. Lean mass measured by dual X-ray absorptiometry, bioelectrical impedance analysis, and computerized tomography were included.

Results

The number of relevant studies has increased continuously since 2002. A total of 188 studies with 98 468 people were included in the meta-analysis. The association of lean mass with mortality was most studied in cancer patients, followed by people with renal diseases, liver diseases, elderly, people with cardiovascular disease, lung diseases, and other diseases. The meta-analysis can be further conducted in subgroups based on measurement modalities, site of measurements, definition of low lean mass adopted, and types of cancer for studies conducted in cancer patients.

Conclusions

This series of meta-analysis provided insight and evidence on the relationship between lean mass and mortality in all directions, which may be useful for further study and guideline development.

The Role of Tumor Microenvironment Cells in Colorectal Cancer (CRC) Cachexia

Cancer cachexia (CC) is a multifactorial syndrome in patients with advanced cancer characterized by weight loss via skeletal-muscle and adipose-tissue atrophy, catabolic activity, and systemic inflammation. CC is correlated with functional impairment, reduced therapeutic responsiveness, and poor prognosis, and is a major cause of death in cancer patients. In colorectal cancer (CRC), cachexia affects around 50–61% of patients, but remains overlooked, understudied, and uncured. The mechanisms driving CC are not fully understood but are related, at least in part, to the local and systemic immune response to the tumor. Accumulating evidence demonstrates a significant role of tumor microenvironment (TME) cells (e.g., macrophages, neutrophils, and fibroblasts) in both cancer progression and tumor-induced cachexia, through the production of multiple procachectic factors. The most important role in CRC-associated cachexia is played by pro-inflammatory cytokines, including the tumor necrosis factor α (TNFα), originally known as cachectin, Interleukin (IL)-1, IL-6, and certain chemokines (e.g., IL-8). Heterogeneous CRC cells themselves also produce numerous cytokines (including chemokines), as well as novel factors called “cachexokines”. The tumor microenvironment (TME) contributes to systemic inflammation and increased oxidative stress and fibrosis. This review summarizes the current knowledge on the role of TME cellular components in CRC-associated cachexia, as well as discusses the potential role of selected mediators secreted by colorectal cancer cells in cooperation with tumor-associated immune and non-immune cells of tumor microenvironment in inducing or potentiating cancer cachexia. This knowledge serves to aid the understanding of the mechanisms of this process, as well as prevent its consequences.

Comparison of Nutrition Risk Screening 2002 and Subjective Global Assessment Form as Short Nutrition Assessment Tools in Older Hospitalized Adults

The aim of the present study was to compare two widely recommended short nutrition assessment tools—Nutrition Risk Screening 2002 (NRS-2002) and Subjective Global Assessment Form (SGA)—with other Comprehensive Geriatric Assessment (CGA) measurements. The study included 622 consecutively hospitalized older subjects, aged 81.7 ± 7.8 years. The criteria to participate were the ability to communicate and given consent. Both NRS-2002 and SGA were inversely related to anthropometric measurements, functional assessment tests, Mini-Mental State Examination (MMSE) and positively associated with the Vulnerable Elders Survey-13 (VES-13) score. Results of SGA and NRS-2002 were not related to sex and 15-item Geriatric Depression Scale (GDS) score. Comparison of well-nourished subjects and patients with suggested problems with nutrition according to NRS-2002 (0–2 vs. 3–7) and SGA (A vs. B + C) gave comparable results. Both nutritional scales at given cut-off points similarly discriminated anthropometric data and other CGA tools in the populations of well-nourished vs. malnourished hospitalized older subjects. In conclusion, we can recommend using both NRS-2002 and SGA to detect malnutrition or risk of malnutrition in a routine clinical practice of the geriatric department ward.

Computed-Tomography Body Composition Analysis Complements Pre-Operative Nutrition Screening in Colorectal Cancer Patients on an Enhanced Recovery after Surgery Pathway

Pre-operative nutrition screening is recommended to identify cancer patients at risk of malnutrition, which is associated with poor outcomes. Low muscle mass (sarcopenia) and lipid infiltration to muscle cells (myosteatosis) are similarly associated with poor outcomes but are not routinely screened for. We investigated the prevalence of sarcopenia and myosteatosis across the nutrition screening triage categories of the Patient-Generated Subjective Global Assessment Short Form (PG-SGA_SF) in a pre-operative colorectal cancer (CRC) cohort. Data were prospectively collected from patients scheduled for surgery at two sites in Edmonton, Canada. PG-SGA_SF scores ≥ 4 identified patients at risk for malnutrition; sarcopenia and myosteatosis were identified using computed-tomography (CT) analysis. Patients (n = 176) with a mean age of 63.8 ± 12.0 years, 52.3% male, 90.3% with stage I–III disease were included. Overall, 25.2% had PG-SGA_SF score ≥ 4. Sarcopenia alone, myosteatosis alone or both were identified in 14.0%, 27.3%, and 6.4% of patients, respectively. Sarcopenia and/or myosteatosis were identified in 43.4% of those with PG-SGA_SF score < 4 and in 58.5% of those with score ≥ 4. Overall, 32.9% of the cohort had sarcopenia and/or myosteatosis with PG-SGA_SF score < 4. CT-defined sarcopenia and myosteatosis are prevalent in pre-operative CRC patients, regardless of the presence of traditional nutrition risk factors (weight loss, problems eating); therefore, CT image analysis effectively adds value to nutrition screening by identifying patients with other risk factors for poor outcomes.

ACVR2B antagonism as a countermeasure to multi-organ perturbations in metastatic colorectal cancer cachexia

BACKGROUND

Advanced colorectal cancer (CRC) is often accompanied by the development of liver metastases, as well as cachexia, a multi-organ co-morbidity primarily affecting skeletal (SKM) and cardiac muscles. Activin receptor type 2B (ACVR2B) signalling is known to cause SKM wasting, and its inhibition restores SKM mass and prolongs survival in cancer. Using a recently generated mouse model, here we tested whether ACVR2B blockade could preserve multiple organs, including skeletal and cardiac muscle, in the presence of metastatic CRC.

METHODS

NSG male mice (8 weeks old) were injected intrasplenically with HCT116 human CRC cells (mHCT116), while sham-operated animals received saline (n = 5-10 per group). Sham and tumour-bearing mice received weekly injections of ACVR2B/Fc, a synthetic peptide inhibitor of ACVR2B.

RESULTS

mHCT116 hosts displayed losses in fat mass ( - 79%, P < 0.0001), bone mass ( - 39%, P < 0.05), and SKM mass (quadriceps: - 22%, P < 0.001), in line with reduced muscle cross-sectional area ( - 24%, P < 0.01) and plantarflexion force ( - 28%, P < 0.05). Further, despite only moderately affected heart size, cardiac function was significantly impaired (ejection fraction %: - 16%, P < 0.0001; fractional shortening %: - 25%, P < 0.0001) in the mHCT116 hosts. Conversely, ACVR2B/Fc preserved fat mass ( + 238%, P < 0.001), bone mass ( + 124%, P < 0.0001), SKM mass (quadriceps: + 31%, P < 0.0001), size (cross-sectional area: + 43%, P < 0.0001) and plantarflexion force ( + 28%, P < 0.05) in tumour hosts. Cardiac function was also completely preserved in tumour hosts receiving ACVR2B/Fc (ejection fraction %: + 19%, P < 0.0001), despite no effect on heart size. RNA sequencing analysis of heart muscle revealed rescue of genes related to cardiac development and contraction in tumour hosts treated with ACVR2B/Fc.

CONCLUSIONS

Our metastatic CRC model recapitulates the multi-systemic derangements of cachexia by displaying loss of fat, bone, and SKM along with decreased muscle strength in mHCT116 hosts. Additionally, with evidence of severe cardiac dysfunction, our data support the development of cardiac cachexia in the occurrence of metastatic CRC. Notably, ACVR2B antagonism preserved adipose tissue, bone, and SKM, whereas muscle and cardiac functions were completely maintained upon treatment. Altogether, our observations implicate ACVR2B signalling in the development of multi-organ perturbations in metastatic CRC and further dictate that ACVR2B represents a promising therapeutic target to preserve body composition and functionality in cancer cachexia.

A Retrospective Cohort Study to Investigate the Incidence of Cachexia During Chemotherapy in Patients with Colorectal Cancer

Introduction

This retrospective study focused on cancer cachexia in clinical practice. We evaluated the incidence of cancer cachexia and the relationship between cancer cachexia and overall survival (OS) or toxicities in patients with advanced colorectal cancer after undergoing first-line systemic chemotherapy.

Methods

We examined 150 patients with colorectal cancer who underwent first-line systemic chemotherapy between February 1, 2010 and August 31, 2016 at Shizuoka Cancer Center Hospital and Kurume University Hospital. Cancer cachexia was defined as > 5% weight loss or > 2% weight loss with a body mass index of < 20 kg/m² within the past 6 months according to the European Palliative Care Research Collaborative criteria.

Results

One hundred patients from Shizuoka Cancer Center and 50 from Kurume University Hospital were registered. Median age and body mass index were 65 years (range 29–85) and 21.7 kg/m² (14.8–32.5), respectively. Cumulative incidence of cancer cachexia was 50.7% at 24 weeks, and reached 91.3% over the whole study period. OS was significantly different between patients with and without cancer cachexia within 24 weeks after starting first-line treatment, although the onset of cancer cachexia within 24 weeks could not be considered as an independent prognostic factor for OS. Severe appetite loss and fatigue tended to occur more frequently in patients with cancer cachexia within 24 weeks.

Conclusion

Cancer cachexia appears to have an onset in approximately half of patients with advanced colorectal cancer within 24 weeks after starting first-line treatment. Although causal relationships were controversial, the onset of cancer cachexia within 24 weeks tends to be related to worse outcomes. Thus, it would be better to monitor weight loss leading to cachexia in patients with advanced colorectal cancer, especially within 24 weeks after starting first-line chemotherapy.

Trial Registration

University Hospital Medical Information Network Clinical Trials Registry (UMIN000035002).

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01516-6) contains supplementary material, which is available to authorized users.

The Impact of Body Mass Index on the Clinicopathological and Prognostic Factors of Colorectal Cancer in Saudi Arabia

Background Obesity is a known risk factor of colorectal cancer (CRC); however, the relationship between obesity and clinicopathologic characteristics and prognosis of CRC remains unclear. This study aimed to investigate the relationship between body mass index (BMI) and clinicopathological and prognostic factors of CRC in Saudi Arabia. Method This was a retrospective cross-sectional study of patients with CRC diagnosed between 2014 and 2018 at King Abdulaziz University Hospital in Jeddah, Saudi Arabia. BMI was calculated by dividing the patient's weight in kilograms by height in meter squared and was classified according to the World Health Organization criteria. Statistical tests, including analysis of variance and chi-square tests, were used to investigate the relationship of each BMI category with clinicopathologic (histological type, degree of differentiation, tumor location, and medical comorbidities) and prognostic variables (TNM stage, lymph nodes involvement, and lymph nodes yield). Results Of 233 patients who were included, 60.1% were male and 39.9% were female patients, with a mean age (standard deviation) of 58.8 ± 13.7 (range: 26-99) years. The median BMI was 26.5 kg/m². Overall, 3%, 34.3%, 33.0%, and 29.6% patients were classified as underweight, normal weight, overweight, and obese, respectively. Furthermore, 57.1% (4/7), 39.2% (31/80), 38.7% (29/77), and 25.8% (17/69) of underweight, normal, overweight, and obese patients had Stage IV disease (p = 0.20). Of 16 patients with transverse colon cancer, 8 (50%) were obese (p = 0.38), and 1 (6%), 5 (31%), and 2 (13%) were underweight, normal weight, and overweight, respectively. Conclusion Underweight patients are more likely to present with metastatic CRC, while obese patients are more likely to present at earlier stages, although the difference was not statistically significant. BMI is not related to lymph node yield, histological type, or the degree of differentiation.

Impact of musculoskeletal degradation on cancer outcomes and strategies for management in clinical practice

The prevalence of malnutrition in patients with cancer is one of the highest of all patient groups. Weight loss (WL) is a frequent manifestation of malnutrition in cancer and several large-scale studies have reported that involuntary WL affects 50-80% of patients with cancer, with the degree of WL dependent on tumour site, type and stage of disease. The study of body composition in oncology using computed tomography has unearthed the importance of both low muscle mass (sarcopenia) and low muscle attenuation as important prognostic indications of unfavourable outcomes including poorer tolerance to chemotherapy; significant deterioration in performance status and quality of life (QoL), poorer post-operative outcomes and shortened survival. While often hidden by excess fat and high BMI, muscle abnormalities are highly prevalent in patients with cancer (ranging from 10 to 90%). Early screening to identify individuals with sarcopenia and decreased muscle quality would allow for earlier multimodal interventions to attenuate adverse body compositional changes. Multimodal therapies (combining nutritional counselling, exercise and anti-inflammatory drugs) are currently the focus of randomised trials to examine if this approach can provide a sufficient stimulus to prevent or slow the cascade of tissue wasting and if this then impacts on outcomes in a positive manner. This review will focus on the aetiology of musculoskeletal degradation in cancer; the impact of sarcopenia on chemotherapy tolerance, post-operative complications, QoL and survival; and outline current strategies for attenuation of muscle loss in clinical practice.

Skeletal Muscle Loss during Multikinase Inhibitors Therapy: Molecular Pathways, Clinical Implications, and Nutritional Challenges

In cancer patients, loss of muscle mass is significantly associated with low tolerability of chemotherapy and poor survival. Despite the great strides in the treatment of cancer, targeted therapies such as tyrosine kinase inhibitors (TKIs) could exacerbate muscle wasting. Over recent years, the impact of skeletal muscle loss during TKI therapy on clinical outcomes has been in the spotlight. In this review, we focus on the different molecular pathways of TKIs potentially involved in muscle wasting. Then, we report the results of the studies assessing the effects of different TKI therapies—such as sorafenib, regorafenib, sunitinib, and lenvatinib—on muscle mass, and highlight their potential clinical implications. Finally, we discuss an integrative nutritional approach to be adopted during TKI treatment. The assessment of muscle mass from computerized tomography imaging could be helpful in predicting toxicity and prognosis in patients treated with TKI such as sorafenib. Early recognition of low muscle mass and effective personalized nutritional support could prevent or attenuate muscle mass wasting. However, the role of nutrition is still overlooked, and future clinical trials are needed to find the optimal nutritional support to countermeasure muscle mass depletion during TKI therapy.

Determining the prevalence and severity of cancer cachexia in advanced non-small cell lung cancer and its relationship with chemotherapy outcomes

PURPOSE

Cancer cachexia (CC) is a syndrome characterised by an ongoing loss of skeletal muscle mass associated with reduced tolerance to treatment. This study explored the prevalence and severity of CC in advanced non-small cell lung cancer (NSCLC) patients and determined its relationship with chemotherapy outcomes.

METHODS

CC was classified into a four-stage model: no cachexia, pre-cachexia (PC), cachexia and refractory cachexia (RC) with categorisation determined from biochemical and body composition and performance assessment. Associations between the stage of cachexia and chemotherapy outcomes including radiological response, the number of chemotherapy cycles completed and the number of cycles delayed or dose reduced were explored.

RESULTS

Twenty-four patients were included with 4 (18%) classified as having no cachexia, 4 (18%) PC, 3 (14%) cachexia (13.6%), and 11 (50%) RC. No association was observed between the stage of cachexia and the radiological response to chemotherapy number of cycles delayed or the number of cycle's dose reduced; however, there was an association with the number of cycles completed (p = 0.030). An association between C-reactive protein (CRP) and the number of chemotherapy cycles completed (p = 0.044) and the number of dose reductions (p = 0.044) was also identified.

CONCLUSIONS

Limited conclusions can be drawn given the small sample size. However, the majority of patients presented with some degree of cachexia at diagnosis. A relationship was identified between the increasing severity of cachexia and a lower number of chemotherapy cycles completed, as well as between CRP and the number of chemotherapy cycles completed and the number of dose reductions required, and therefore warrants further exploration in larger studies.