Different nutritional assessment tools as predictors of postoperative complications in patients undergoing colorectal cancer resection

Comparison of the Global Leadership Initiative on Malnutrition and the Patient-Generated Subjective Global Assessment for diagnosing malnutrition in patients undergoing surgery for hepatobiliary and pancreatic malignancies

OBJECTIVE

to analyse the differences in malnutrition assessment between the Global Leadership Initiative on Malnutrition (GLIM) criteria and the Patient-Generated Subjective Global Assessment (PG-SGA) among patients with hepatobiliary and pancreatic malignancies.

METHOD

this study was a cross-sectional study and included 126 hospitalised patients who underwent surgery for hepatobiliary and pancreatic malignancies between November 1, 2019 and August 1, 2020. The patients' clinical data were collected, and malnutrition assessments were completed using the different nutritional assessment tools. The consistency of both tools was analysed using Cohen's kappa coefficient.

RESULTS

the prevalence of malnutrition showed a difference in diagnosis results between the GLIM criteria (36.51 %) and the PG-SGA (55.56 %). The two methods had moderate consistency (kappa = 0.590, p < 0.01). The sensitivity of a malnutrition diagnosis using a combination of GLIM and PG-SGA was 65.7 % (53.3 % and 76.4 %, respectively), and specificity was 100 % (92 % and 100 %, respectively). When malnutrition was evaluated using only PG-SGA, sensitivity was 88.9 % (95 % confidence interval (CI) 63.9 % to 98.1 %), whereas when only the GLIM score was used for malnutrition evaluation, sensitivity was 98.2 % (95 % CI, 92.8 % to 99.7 %). In addition, the PG-SGA score and the GLIM score had significant correlations.

CONCLUSION

GLIM performed better than PG-SGA in the correlation analysis of nutritional indicators. GLIM is more suitable for patients with hepatobiliary and pancreatic malignancies than PG-SGA.

Association between risk of malnutrition defined by patient-generated subjective global assessment and adverse outcomes in patients with cancer: a systematic review and meta-analysis

OBJECTIVE

To assess the association between the risk of malnutrition, as estimated by the Patient-Generated Subjective Global Assessment (PG-SGA) numerical scores, and adverse outcomes in oncology patients.

DESIGN

Systematic review and meta-analysis.

SETTINGS

A comprehensive search was conducted in PubMed, Web of Science, Embase, CKNI, VIP, Sinomed and Wanfang databases. Studies that examined the association between the risk of malnutrition, as estimated by the PG-SGA numerical scores, and overall survival (OS) or postoperative complications in oncology patients were included. Patients were classified as low risk (PG-SGA ≤ 3), medium risk (PG-SGA 4-8) and high risk of malnutrition (PG-SGA > 8).

SUBJECT

Nineteen studies reporting on twenty articles (n 9286 patients).

RESULTS

The prevalence of medium and high risk of malnutrition ranged from 16·0 % to 71·6 %. A meta-analysis showed that cancer patients with medium and high risk of malnutrition had a poorer OS (adjusted hazard ratios (HR) 1·98; 95 % CI 1·77, 2·21) compared with those with a low risk of malnutrition. Stratified analysis revealed that the pooled HR was 1·55 (95 % CI 1·17, 2·06) for medium risk of malnutrition and 2·65 (95 % CI 1·90, 3·70) for high risk of malnutrition. Additionally, the pooled adjusted OR for postoperative complications was 4·65 (95 % CI 1·61, 13·44) for patients at medium and high risk of malnutrition.

CONCLUSIONS

The presence of medium and high risk of malnutrition, as estimated by the PG-SGA numerical scores, is significantly linked to poorer OS and an increased risk of postoperative complications in oncology patients.

Nutritional status and post-operative complications in patients undergoing surgery for advanced pharyngeal or laryngeal cancer

PURPOSE

Malnutrition is an important prognostic indicator of post-operative outcomes in patients undergoing surgery for head and neck cancer, however, limited studies utilize validated nutrition assessment tools to accurately assess risk. The aim of this study was to determine the relationship between nutritional status on post-operative complications and length of stay for patients undergoing either a laryngectomy, pharyngectomy or pharyngolaryngectomy for head and neck cancer.

METHODS

Patients with head and neck cancer undergoing a laryngectomy, pharyngectomy or pharyngolaryngectomy at a tertiary hospital in Australia were eligible for this retrospective cohort study (n = 40). Nutritional status was assessed by the dietitian on admission using the validated Subjective Global Assessment tool. Clinical outcomes were collected via retrospective chart review and included length of stay and post-operative complications.

RESULTS

Pre-operative malnutrition incidence was 40%. Malnourished patients had higher incidences of any type of complication (57% vs 44%, p = 0.013) and pressure injury (86% vs 14%, p = 0.011) compared to well-nourished patients. Well-nourished patients had a clinically important shorter median length of stay compared to malnourished patients (17.5 vs 20 days).

CONCLUSION

Early identification and management of malnutrition is essential to minimize risk of post-operative complications and reduce length of stay and should be considered a key component of prehabilitation programs.

A global analysis of nutrition support practices in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy

BACKGROUND

Perioperative nutritional care has been identified as an important factor in the management of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, there is no published consensus on best practice for nutritional management specific to this patient group. The purpose of this study was to identify the current nutrition care practices among international centres performing CRS and HIPEC for patients with peritoneal malignancy.

METHODS

An online survey was developed and sent to experienced CRS and HIPEC centres. The survey questions covered clinician and institution demographics, formal nutrition care pathways, pre-operative nutrition care, post-operative nutrition support and post-discharge nutritional follow-up.

RESULTS

Eighty-two centres were contacted, and 42 responses were received. Respondents were from 20 different countries and were mostly dietitians (71%). Nutrition assessments were frequently completed (52% pre-operatively and 86% post-operatively) and most centres used a validated nutrition screening or assessment tool (79%). Perioperative nutrition support with respect to the use of enteral nutrition, parenteral nutrition and enhanced recovery after surgery varied widely between centres. The use of routine parenteral and enteral nutrition was significantly higher in Europe compared with other locations (p = 0.028).

CONCLUSIONS

Nutrition care is pivotal and has been positively integrated into the complex management of patients undergoing CRS and HIPEC globally, however variation in practice is evident. The findings highlight a unique opportunity to collaboratively investigate the role nutrition plays in determining outcomes and to identify the most appropriate nutrition support methods to achieve improved clinical outcomes for these high-risk patients.

Prevalence of Malnutrition and the Value of Predicting Pancreatic Fistula in Patients with Laparoscopic Pancreatoduodenectomy

Background: Pancreatoduodenectomy is a standard surgical procedure for periampullary tumors. With recent improvements in perioperative management, postoperative mortality has decreased significantly in recent years; however, postoperative pancreatic fistula (POPF) is still one of the most prevalent and dangerous complications. The purpose of this study was to analyze the prevalence of malnutrition and the value of predicting POPF in patients with laparoscopic pancreatoduodenectomy (LPD). Methods: We retrospectively analyzed the perioperative data of 747 patients undergoing LPD in the Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, China. Simultaneously, we analyzed the prevalence rate of malnutrition with three different nutritional assessment scores and explored the independent risk variables for POPF to identify potential predictive value. Results: Malnutrition was observed in 20.1% of patients with the prognostic nutritional index (PNI), 85.0% of patients with the controlling nutritional status (CONUT) score, and 73.1% of patients with the NRI score. Univariate and multivariate analyses all showed that the risk factors for POPF were pancreatic texture, pancreatic duct diameter, abdominal infection, body mass index (BMI), nomogram-revised risk index (NRI), and PNI. The receiver operating characteristic curve indicated that the BMI/PNI ratio was capable of predicting the occurrence of clinical POPF following LPD, with an area under the curve of 0.708. Conclusions: Compared with no malnourished patients, malnutrition is associated with a higher risk of POPF among patients with LPD. In addition, the BMI/PNI ratio has some predictive value in the development of POPF following LPD.

Prediction of survival of preoperative colorectal patients: A new tool to assess the interaction of nutritional status and inflammation

BACKGROUND

Colorectal cancer (CRC) is responsible for the second leading cause of cancer death worldwide. Thus, the aim of this study was to investigate the application of a new nutritional status and inflammatory tool to predict overall survival (OS) in patients with CRC in the preoperative period.

METHODS

Retrospective cohort study with CRC patients of both sexes treated at a hospital unit, aged ≥20 years. Data were extracted between 2007 and 2015. Multivariate Cox's models were employed to predict OS utilizing a new grade classification system (body mass index vs. percentage weight loss - BMI/%WL), inflammatory markers and clinical data.

RESULTS

We evaluated 361 patients. BMI/%WL grade 3-4 (HR: 2.01; p = 0.001; 95% CI: 1.34-3.02) were independent predictors of poor OS. Moreover, BMI/%WL grade 3-4 + neutrophil-to-lymphocyte ratio (NLR) ≥2.4 (HR: 2.79; p = 0.001; 95% CI: 1.54-5.03) increased the death risk in 5-years. However, low NLR (<2.4) altered the OS prognostic ability of the BMI/%WL (HR: 1.72; p = 0.099; 95% CI: 0.90-3.28).

CONCLUSION

BMI/%WL was independent predictors of poor OS and the interaction with NLR produced an adjustment effect. These associated tools may be useful in the clinical management of preoperative patients with CRC.

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.

Long-term variation in psoas muscle mass index is affected by short-term loss after esophagectomy in survivors of esophageal cancer

Changes in muscle mass may be an objective approach toward measuring the quality of life after surgery, but long-term changes due to surgery without the effect of cachexia remain unclear. Patients with esophageal cancer who underwent esophagectomy and did not experience cancer recurrence for 3 years were analyzed. The psoas muscle mass index (PMI) was assessed before surgery and 7 days, 1 year, and 3 years after surgery. Patients with no change or increased PMI within 7 days after surgery were categorized into the Nondecreasing-PMI group, whereas those with decreased PMI were categorized into the Decreasing-PMI group. Eighty-four and 51 patients were categorized into the Nondecreasing- and Decreasing-PMI groups, respectively. The Decreasing-PMI group had a higher incidence rate of anastomotic leakage than the Nondecreasing-PMI group (25% vs. 12%, respectively; P = 0.042). Moreover, the Decreasing-PMI group showed a significantly greater decrease in the PMI 1 year after surgery than the Nondecreasing-PMI group (-9.2% vs. -4.0%, respectively; P = 0.048). However, although the Decreasing-PMI group had a greater decrease in the PMI than the Nondecreasing-PMI group, no significant difference was observed 3 years after surgery (-9.8% vs. -5.3%, respectively; P = 0.115). A decrease in PMI in the acute phase after esophagectomy may contribute to a long-term decrease in the PMI. Intensive interventions may be beneficial for these patients to improve their long-term quality of life.

Exploratory Assessment of Nutritional Evaluation Tools as Predictors of Complications and Sarcopenia in Patients with Colorectal Cancer

BACKGROUND

Patients with colorectal cancer (CRC) are largely malnourished, which decreases overall survival and treatment efficacy and increases mortality rates. We hypothesize that angle phase might be associated with the risk of sarcopenia as well as cancer complications in patients with CRC. The inclusion of various nutritional status indicators and clinical cancer outcomes can result in significant variability. Therefore, the objective of this study was to perform an exploratory analysis of nutritional evaluation tools used to assess body composition and muscle quality in patients with CRC, in order to predict cancer complications and survival rate.

METHODS

A total of 127 patients with CRC were included in this study. Bioelectrical impedance analysis and body composition were performed, which we used to obtain phase angle (PhA) values. Muscle function was assessed by hand-grip strength (HGS) and muscle quality and adipose tissue depot were performed using ultrasound techniques.

RESULTS

This study showed that there were significant differences in body composition between females and males, as well as in muscle quantity and quality. PhA was highly correlated with quadriceps rectus femoris of cross-sectional area (RF-CSA), circumference of quadriceps rectus femoris (RF-CIR), superficial subcutaneous abdominal fat (S-SAT), as well as HGS (p < 0.05). PhA was also correlated with water content in females, and with muscle mass and quality in males (p < 0.05). Specifically, we found that PhA was a good predictor for cancer complications in women and the risk of sarcopenia in men. In the linear model controlled for age and body mass index (BMI), high PhA value was associated with a decreased risk of complications in females (Odds Ratio (OR) = 0.15, 95% CI: 0.03-0.81, p < 0.05). High PhA value was associated with a decreased risk of sarcopenia in males (OR = 0.42, 95% CI: 0.19-0.95, p < 0.05). In addition, Receiving Operating Characteristics (ROC) curve analysis showed that PhA had a good diagnostic accuracy for detecting cancer complications in females (Area under curve (AUC) = 0.894, 95% CI: 0.88-0.89, p < 0.05) and the risk of sarcopenia in males (AUC = 0.959, 95% CI: 0.91-0.92, p < 0.05).

CONCLUSIONS

PhA can accurately predict oncological complications in women and sarcopenia in men. These differences are relevant to understanding the nutritional status of patients with CRC and their personalized nutritional treatment.

Role of perioperative nutritional status and enteral nutrition in predicting and preventing post-operative complications in patients with Crohn's disease

Background

Perioperative immune-nutritional status is correlated with post-operative outcomes. This study aimed to evaluate whether pre-operative nutritional status could predict post-operative complications in patients with Crohn's disease (CD) and whether pre-operative enteral nutrition (EN) can prevent post-operative complications.

Methods

This retrospective cohort study analyzed the electronic health records of 173 patients diagnosed with CD in Ruijin Hospital, Shanghai, China, between August 2015 and May 2021: 122 patients had pre-operative nutritional support while 51 patients underwent surgery without pre-operative nutritional support. The pre-operative nutritional status, disease activity index, disease-related data, frequency of multiple surgery, operative data, and post-operative characters in each group were compared to determine whether the nutritional support and status could significantly affect post-operative outcome. One-to-one propensity score matching (PSM) was performed to limit demographic inequalities between the two groups.

Results

After PSM, no statistically significant differences were found in pre-operative patient basic characteristics between the two groups of 47 patients (98 patients in all) included in this study. Overall, 21 patients developed 26 post-operative complications. In terms of pre-operative nutritional status, the level of serum albumin (ALB), pre-albumin (pre-ALB), and hemoglobin (Hb) in the nutrition group were statistically higher than that in the control group. We also observed a statistically significant decrease in post-operative complications, need for emergency surgery, and staged operations, while the rate of laparoscopic surgery was higher in the nutrition group compared to the non-nutritional group. Post-operative complications were related to pre-operative nutritional condition, which indicated that EN may improve the nutritional status and reduced the rate of post-operative complications.

Conclusion

Pre-operative nutritional status is correlated with post-operative outcomes while EN plays a positive role in preventing the post-operative complications. EN is useful for improving the pre-operative nutritional status and reducing the post-operative adverse events for CD patients undergoing surgery.

The Role of Standardized Phase Angle in the Assessment of Nutritional Status and Clinical Outcomes in Cancer Patients: A Systematic Review of the Literature

Compared with the phase angle (PA), the predictive ability of the standardized phase angle (SPA) in assessing nutritional status and clinical outcomes in cancer patients remains uncertain. This review aimed to assess (1) the relationship between SPA and nutritional status and clinical outcomes (including complications and survival) in cancer patients; (2) the predictive ability of SPA alone and in comparison with the predictive ability of PA; and (3) the cut-off value of SPA in cancer patients. Studies that addressed the relationship of SPA use to nutritional status, complications, and survival in cancer patients were searched and identified from six electronic databases (PubMed, Medline, CINAHL, Embase, Web of Science, and the Cochrane Library). The included studies were considered to meet the following criteria: English studies with original data that reflected the effects of SPA on nutritional status and clinical outcomes (including complications and survival) and reported a cut-off value of SPA in cancer patients aged ≥18. Thirteen studies that included a total of 2787 participants were evaluated. Five studies assessed the relationship between SPA and nutritional status, and four of them reported a positive relationship between SPA and nutritional status in cancer patients, even considering SPA as a predictor. Twelve studies assessed the relationship between SPA and clinical outcomes in cancer patients. Two-thirds of the studies that evaluated complications reported the predictive ability of SPA; 30% of survival studies reported a positive relationship, 40% reported SPA as a predictor, and 30% reported no relationship. The standard cut-off value for SPA has not yet been determined. Data from the selected studies suggest that SPA might be a predictor of nutritional status. Further studies are needed to determine the value of SPA in predicting nutritional status and clinical outcomes in cancer patients.

The geriatric nutritional risk index is an effective tool to detect GLIM-defined malnutrition in rectal cancer patients

Background

This study aimed to investigate the value of the Geriatric Nutritional Risk Index (GNRI), prognostic nutritional index (PNI), and advanced lung cancer inflammation index (ALI) scores in detecting malnutrition in patients with rectal cancer; the Global Leadership Initiative on Malnutrition (GLIM) was used as the reference criterion.

Materials and methods

This study included patients with rectal cancer who underwent proctectomy. GNRI, PNI, and ALI were calculated to detect the GLIM-defined malnutrition using the Receiver operating characteristic (ROC) curves. Univariate and multivariate logistic regression analyses were used to evaluate the association between the nutritional tools and postoperative complications. Kaplan-Meier survival curves, log-rank tests, and univariate and multivariate Cox regression analyses were used to clarify the relationship between nutritional tools and overall survival (OS).

Results

This study enrolled 636 patients with rectal cancer. The GNRI demonstrated the highest sensitivity (77.8%), pretty specificity (69.0%), and the largest AUC (0.734). The GNRI showed good property in predicting major postoperative complications. All three nutritional tools were independent predictors of OS.

Conclusion

The GNRI can be used as a promising alternative to the GLIM and is optimal in perioperative management of patients with rectal cancer.

Prognosis-Related Nutritional Score for Cancer Patients (PRNS): a clinical nutritional score derived from a retrospective cohort study

Background

Nutritional assessment and quality of life (QOL) have become important indices for therapeutic efficacy in patients with malignancies. We aim to develop and validate an easy-to-use questionnaire with prognostic value to assess nutritional status in hospitalized cancer patients.

Methods

A comprehensive survey focused on patient-generated subjective global assessment (PG-SGA) and 30-item European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30 Chinese version) was performed in a cohort of 22,776 patients derived from the INSCOC study. Among them, 1948 patients were followed for 3 years after admission. An observational, retrospective, cross-sectional cohort study was conducted in accordance with TRIPOD statement. Breiman's random forest model was applied to calculate variable importance (VIMP) for items in PG-SGA and EORTC QLQ-C30 (Chinese version) for nutritional recommendation. Cox regression model was employed to construct Prognosis-Related Nutritional Score for Cancer Patients (PRNS). Kaplan–Meier Survival curve, ROC and DCA were calculated to evaluate prognostic value of nutritional status categorized by PRNS, and compared with PG-SGA.

Results

Nutritional status was classified into 4 levels by PRNS scores: well nourished (≤ 4.5 points), mild malnourished (5–7.5 points), moderate malnourished (8–14.5 points), and severe malnourished (≥ 15 points). Significant median overall survival differences were found among nutritional status groups stratified by the PRNS (all Ps < 0.05). Compared with PG-SGA, PRNS had better prognostic value for survival stratified by nutritional status. The external, internal validity, test–retest reliability and rater reliability were satisfactory.

Conclusions

We systematically developed and validated PRNS as a nutrition screening tool for cancer patients. Compared with PG-SGA, PRNS has better prognostic value and simpler operation.

Trial registration

Investigation on Nutrition Status and its Clinical Outcome of Common Cancers, ChiCTR1800020329. Registered 24 December 2018—Retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=31813

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03696-x.

Predictive value of preoperative handgrip strength on postoperative outcomes in patients with gastrointestinal tumors: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to explore the predictive value of preoperative handgrip strength on postoperative outcomes in patients with gastrointestinal tumors.

METHODS

Databases including Cochrane Library, Pubmed, Embase, Web of Science, and CINAHL Complete were searched for articles published from the establishment of database until August 7, 2021. Two researchers independently screened the literature, extracted the data, and evaluated the quality.

RESULTS

Eight studies were included, involving five prospective and three retrospective cohort studies with 2291 participants. The prevalence of preoperative low handgrip strength ranged from 11.8 to 62.7%. Preoperative low handgrip strength was associated with an increased risk of total complications (OR = 2.23, 95%CI = 1.43-3.50), pneumonia (OR = 5.16, 95%CI = 3.17-8.38), ileus (OR = 2.48, 95%CI = 1.09-5.65), and short-term mortality (OR = 7.28, 95%CI = 1.90-27.92).

CONCLUSION

This systematic review and meta-analysis indicated that preoperative HGS had important value to predict certain adverse postoperative outcomes among patients with GI tumors. Low handgrip strength criteria, definition of total complications, and country are the potential sources of heterogeneity, and more research are required to test and update these results.

Use of computed tomography for the diagnosis of surgical sarcopenia: Review of recent research advances

Sarcopenia, also known as muscle decay, is associated with high morbidity among surgical patients. It is highly correlated with adverse clinical outcomes, such as increased postoperative complications, prolonged hospital stay, and increased mortality. Computed tomography (CT) is one of the main methods for diagnosing sarcopenia, which has the advantages of intuitiveness, rapidity, and accuracy. Clinical studies have shown that CT-defined sarcopenia can help predict the clinical outcomes and prognosis of surgical patients and provide an important reference for the formulation of antitumor treatment protocols. In recent years, some scholars have tried to construct an intelligent CT-based diagnostic model, which is expected to improve the diagnostic efficiency and establish standardized diagnostic criteria for CT-defined sarcopenia. In this review, we summarize the recent progress in the understanding of the diagnosis of sarcopenia and its potential prognostic value in surgery.

Development and validation of a Modified Patient-Generated Subjective Global Assessment as a nutritional assessment tool in cancer patients

BACKGROUND

Completing Patient-Generated Subjective Global Assessment (PG-SGA) questionnaires is time consuming. This study aimed to develop and validate an easy-to-use modified PG-SGA (mPG-SGA) for cancer patients.

METHODS

Seventy professionals assessed the content validity, comprehensibility, and difficulty of the full PG-SGA. A survey including the PG-SGA and other questionnaires was completed by 34 071 adult hospitalized cancer patients with first cancer diagnosis or recurrent disease with any tumour comorbidities from the INSCOC study. Among them, 1558 patients were followed for 5 years after admission. Reliability and rank correlation were estimated to assess the consistency between PG-SGA items and to select mPG-SGA items. The external and internal validity, test-retest reliability, and predictive validity were tested for the mPG-SGA via comparison with both the PG-SGA and abridged PG-SGA (abPG-SGA).

RESULTS

After deleting items that more than 50% of professionals considered difficult to evaluate (Worksheet 4) and items with an item-total correlation <0.1, the mPG-SGA was constructed. Nutritional status was categorized using mPG-SGA scores as well-nourished (0 points) or mildly (1-2 points), moderately (3-6 points), or severely malnourished (≥7 points) based on the area under curve (0.962, 0.989, and 0.985) and maximal sensitivity (0.924, 0.918, and 0.945) and specificity (1.000, 1.000, and 0.938) of the cut-off scores. The external and internal validity and test-retest reliability were good. Significant median overall survival differences were found among nutritional status groups categorized by the mPG-SGA: 24, 18, 14, and 10 months for well-nourished, mildly malnourished, moderately malnourished, and severely malnourished, respectively (all Ps < 0.05). Neither the PG-SGA nor the abridged PG-SGA could discriminate the median overall survival differences between the well-nourished and mildly malnourished groups.

CONCLUSIONS

We systematically developed and validated the mPG-SGA as an easier-to-use nutritional assessment tool for cancer patients. The mPG-SGA appears to have better predictive validity for survival than the PG-SGA and abridged PG-SGA.

Early identification of cancer-related malnutrition in patients with colorectal cancer before and after surgery: a literature review

PURPOSE

The aim of this literature review is to provide a comprehensive overview of methods for early identification of cancer-related malnutrition and/or risk of malnutrition in patients with colorectal cancer. The focus is also on applicability and feasibility of the use of nutritional tools in oncology clinical practice.

METHODS

The literature search was conducted from November to December 2020 in the health science databases by two independent persons. Inclusion criteria were English and German language and articles from 2010 to 2020. Data analysis was carried out through a structured procedure. The research questions guided the literature review.

RESULTS

After removing duplicates and screening titles and abstracts, a total of 35 studies were identified as suitable publications and further analyzed. Eventually, nine original studies, with a total of 926 patients with colorectal cancer before or before and after surgery, addressed assessment measures for early identification of the risk or presence of malnutrition. The following types of nutritional assessment have been described: nutritional anthropometric measurements, laboratory chemistry diagnostics for malnutrition, and several validated nutritional screening and assessment tools. The nutritional tools demonstrate differences in terms of application and content. None of the reviewed studies was a randomized trial. There is little scientific evidence to underpin their specific application in identifying early cancer-related malnutrition in patients with colorectal cancer.

CONCLUSION

The early assessment of nutritional status in this patient group seems to lack evidence-based standardization in oncology clinical practice. Different groups of health professionals are involved; however, studies do not describe standardized roles. Physical activity as part of nutritional screening is not yet included in the analyzed screening tools.

Comparisons and Impacts of the Basic Components of Sarcopenia Definition and Their Pairwise Combinations in Gastric Cancer: A Large-Scale Study in a Chinese Population

Background and Aims: Sarcopenia is negatively associated with clinical outcomes. However, the definitions of sarcopenia are inconsistent across international consensuses. Thus, the purpose of this study is to compare the impact of the basic definition components of sarcopenia and their combinations in post-operative complications and overall survival, aiming to find the best sarcopenia definition to stratify the prognosis in an Asian population.

Methods: A total of 1,307 patients who underwent curative surgery for gastric cancer from July 2014 to May 2019 were prospectively included. The basic sarcopenia components were measured pre-operatively, including low skeletal muscle mass index (LSMI), low skeletal muscle radiodensity (LSMD), low handgrip strength (LHGS), and low gait speed (LGS). Among them, LSMI and LSMD were measured using a CT post-processing software, LHGS was measured using an electronic hand dynamometer, and LGS was represented by a 6-m walk speed.

Results: For the single basic component, the muscle function parameters (LHGS or LGS) but not the muscle composition parameters (LSMI or LSMD) showed associations with post-operative complications and mortality. For the combination of the basic combinations, all statistically significant combinations included at least one muscle function parameter. The combination of muscle composition (LSMI or LSMD) and muscle function (LHGS or LGS) had a significantly higher area under the curve in the prediction of post-operative complications compared with the combinations of two muscle function parameters (LSMI plus LSMD) or two muscle composition parameters (LHGS plus LGS).

Conclusions: Compared with muscle composition parameters (LSMI and LSMD), muscle function parameters (LHGS and LGS) are better predictors of post-operative complications and overall survival, which should be considered as the principal determinant in the sarcopenia definition. The definition of sarcopenia consists of muscle function (LHGS or LGS) and muscle composition (LSMI or LSMD) separately, which is better than the combination of the two muscle function parameters (LHGS plus LGS) or two muscle composition parameters (LSMI plus LSMD).

CT-Determined Sarcopenia in GLIM-Defined Malnutrition and Prediction of 6-Month Mortality in Cancer Inpatients

Our objective was to evaluate the clinical application of third lumbar vertebra (L3)-computer tomography (CT)-determined sarcopenia as a marker of muscle mass in cancer inpatients diagnosed with malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and to establish its association with 6-month mortality. Methods: This was an observational, prospective study in patients from an inpatient oncology unit. We performed a nutritional assessment according to GLIM criteria, including muscle cross-sectional area at L3 by CT and skeletal muscle index (SMI). Six-month mortality was evaluated. Results: A total of 208 patients were included. The skeletal muscle cross-sectional area at L3 was 136.2 ± 32.5 cm² in men and 98.1 ± 21.2 cm² in women. The SMI was 47.4 ± 12.3 cm²/m² in men and 38.7 ± 8.3 cm²/m² in women. Sarcopenia (low SMI) was detected in 59.6% of the subjects. Using SMI as a marker of low muscle mass in application of GLIM criteria, we found 183 (87.9%) malnourished patients. There were 104 deaths (50%) at 6 months. The deceased patients had a lower skeletal muscle cross-sectional area (112.9 ± 27.9 vs. 126.1 ± 37.8 cm²; p = 0.003) and a lower SMI (41.3 ± 9.5 vs. 45.7 ± 12.9 cm²/m²; p = 0.006). An increased risk of 6-month mortality was found in malnourished patients according to GLIM criteria using SMI (HR 2.47; 95% confidence interval 1.07–5.68; p = 0.033). Conclusions: Low muscle mass, assessed by L3-CT, was observed to affect more than half of cancer inpatients. The deceased patients at 6 months had a lower skeletal muscle cross-sectional area and SMI. Malnutrition according to GLIM criteria using CT-determined sarcopenia was shown to adequately predict 6-month mortality.

Sarcopenia predicts worse postoperative outcomes and decreased survival rates in patients with colorectal cancer: a systematic review and meta-analysis

PURPOSE

Previous studies have shown an association of sarcopenia with adverse short- and long-term outcomes in multiple gastrointestinal cancer types. We aimed to investigate the prognostic value of sarcopenia on the postoperative outcomes and survival rates of patients with colorectal cancer (CRC).

METHODS

A systematic literature search was performed using the PubMed, Embase, Cochrane, Google Scholar, and Scopus databases. We included studies that compared postoperative outcomes or survival rates in sarcopenic and non-sarcopenic patients with CRC.

RESULTS

A total of 44 observational studies, comprising 18,891 patients, were included. The pooled prevalence of sarcopenia was 37% (n = 7009). The pooled analysis revealed an association between sarcopenia and higher risk of total postoperative complications (23 studies, OR = 1.84; 95% CI 1.35-2.49), postoperative severe complications (OR = 1.72; 95% CI 1.10-2.68), postoperative mortality (OR = 3.21; 95% CI 2.01-5.11), postoperative infections (OR = 1.40; 95% CI 1.12-1.76), postoperative cardiopulmonary complications (OR = 2.92; 95% CI 1.96-4.37), and prolonged length of stay (MD = 0.77; 95% CI 0.44-1.11) after colorectal cancer surgery. However, anastomotic leakage showed comparable occurrence between sarcopenic and non-sarcopenic patients (OR = 0.99; 95% CI 0.72 to 1.36). Regarding survival outcomes, sarcopenic patients had significantly shorter overall survival (25 studies, HR = 1.83; 95% CI = 1.57-2.14), disease-free survival (HR = 1.55; 95% CI = 1.29-1.88), and cancer-specific survival (HR = 1.77; 95% CI 1.40-2.23) as compared with non-sarcopenic patients.

CONCLUSION

Among patients with colorectal cancer, sarcopenia is a strong predictor of increased postoperative complications and worse survival outcomes.

A novel model with nutrition-related parameters for predicting overall survival of cancer patients

BACKGROUND

Increasing evidence indicates that nutritional status could influence the survival of cancer patients. This study aims to develop and validate a nomogram with nutrition-related parameters for predicting the overall survival of cancer patients.

PATIENTS AND METHODS

A total of 8749 patients from the multicentre cohort study in China were included as the primary cohort to develop the nomogram, and 696 of these patients were recruited as a validation cohort. Patients' nutritional status were assessed using the PG-SGA. LASSO regression models and Cox regression analysis were used for factor selection and nomogram development. The nomogram was then evaluated for its effectiveness in discrimination, calibration, and clinical usefulness by the C-index, calibration curves, and decision curve analysis. Kaplan-Meier survival curves were used to compare the survival rate.

RESULTS

Seven independent prognostic factors were identified and integrated into the nomogram. The C-index was 0.73 (95% CI, 0.72 to 0.74) and 0.77 (95% CI, 0.74 to 0.81) for the primary cohort and validation cohort, which were both higher than 0.59 (95% CI, 0.58 to 0.61) of the TNM staging system. DCA demonstrated that the nomogram was higher than the TNM staging system and the TNM staging system combined with PG-SGA. Significantly median overall survival differences were found by stratifying patients into different risk groups (score < 18.5 and ≥ 18.5) for each TNM category (all Ps < 0.001).

CONCLUSION

Our study screened out seven independent prognostic factors and successfully generated an easy-to-use nomogram, and validated and shown a better predictive validity for the overall survival of cancer patients.

Preoperative nutritional status impacts clinical outcome and hospital length of stay in pelvic exenteration patients - a retrospective study

BACKGROUND

Preoperative malnutrition is common in surgical oncology patients and can have negative effects on postoperative outcomes. Pelvic exenteration is major surgery associated with high morbidity rates. Associations between preoperative malnutrition, determined using the patient-generated subjective global assessment, and postoperative outcomes in this patient cohort has not yet been investigated.

AIM

To determine if preoperative nutritional status is associated with postoperative surgical and quality of life (QoL) outcomes after pelvic exenteration surgery.

METHODS

A retrospective cohort study was conducted at a quaternary hospital investigating 123 patients who had pelvic exenteration surgery from January 2017 to August 2019. Preoperative nutritional status and postoperative surgical and QoL outcomes were collected and analysed to determine any associations.

RESULTS

Overall, 49.6% of patients were female with a median age of 59 years. Forty patients (32.5%) were malnourished and 83 (67.5%) were well nourished before surgery. Well-nourished patients had a shorter length of hospital stay (p = 0.034) and at 6 months post-surgery, presented with a significantly better physical and mental QoL score (p = 0.038 and p = 0.001 respectively). The regression analyses showed that intensive care unit (ICU) readmission rates were 7.19 times more likely to occur in malnourished patients (p = 0.022).

CONCLUSIONS

Preoperative malnutrition is associated with increased length of stay, ICU readmissions and poorer QoL following pelvic exenteration. Nutrition screening, assessment and optimisation of management are essential in this patient cohort to improve patient outcomes. Future studies are needed to measure the effect of interventions and identify the most beneficial model of care for this complex patient group.

The use of bioelectrical impedance analysis to predict post-operative complications in adult patients having surgery for cancer: A systematic review

BACKGROUND

Patients undergoing surgery for cancer are at particular risk of post-operative complications. The pre-operative period is an opportunity to identify and mitigate risk factors and improve outcome. Bioelectrical impedance analysis (BIA) may offer an additional means of identifying patients at risk of post-operative morbidity.

AIMS

The aim of this systematic review was to assess the use of measures and estimates of body composition determined by BIA as markers of peri-operative risk in adult patients undergoing elective surgery for cancer.

METHODS

This review was performed in accordance with the PRISMA guidelines. The electronic databases of MEDLINE, EMBASE, CINAHL, CENTRAL and the Web of Science were searched from inception. Studies of adult participants having elective surgery for cancer were included if participants underwent BIA in the peri-operative period and were assessed for post-operative complications.

RESULTS

2578 studies were identified, of which 12 were eligible for inclusion. In total the studies report data from 1508 subjects. Five studies examined phase angle or standardized phase angle, six examined derived measures and one examined both. Eight of the 12 demonstrated an association between phase angle and/or body composition and an increased risk of post-operative complications.

CONCLUSIONS

Bioelectrical impedance analysis in the peri-operative period may be useful in predicting the risk of complications following elective cancer surgery. Phase angle more consistently demonstrates an association than derived estimates. Further high quality studies are needed and should report the raw impedance values, standardized phase angle and the equations used to derive body composition.

Low skeletal muscle radiodensity is the best predictor for short-term major surgical complications in gastrointestinal surgical cancer: A cohort study

The aim of this study was to evaluate whether body composition, muscle function, and their association are predictive factors for short-term postoperative complications in patients with gastric and colorectal cancer. A prospective cohort study was conducted with patients undergoing resection of gastric and colorectal tumors. Nutritional status was assessed using Patient-Generated Subjective Global Assessment (PG-SGA) and anthropometric techniques. Low handgrip strength (HGS) was observed when <16kg for women, and <27kg for men. Computed tomography images were used to measure visceral adipose tissue, skeletal muscle index (SMI), and skeletal muscle radiodensity (SMD). Complications of grade II or above (according to Clavien-Dindo's classification) were considered in a follow-up period of up to 30 days after surgery. Major complications were defined when they reached grade III or above. A total of 84 patients were analyzed (57.1% female, 59.7 ± 12.6 years) and 19% were diagnosed with low HGS + low SMI or SMD. Postoperative complications occurred in 51.2%, and these patients presented significantly longer duration of surgery and hospital stay. Major complications were observed in 16.7% of the total number of patients. Binary logistic regression adjusted by age, sex, and tumor staging showed that low SMD, low HGS + low SMI or SMD, and obesity were independent risk factors for postoperative complications, but only low SMD was an independent risk factor for major postoperative complications. Low SMD is an independent risk factor for short-term major complications following surgery in patients with gastric and colorectal cancer.

Preoperative Fasting Abbreviation With Whey Protein Reduces the Occurrence of Postoperative Complications in Patients With Head and Neck Cancer: A Randomized Clinical Trial

BACKGROUND

Surgery has become the treatment of choice for head and neck cancer (HNC) in most cases. Preoperative fasting abbreviation and nutrition screening have been suggested to reduce the occurrence of postoperative complications. This study aimed to evaluate the addition of whey protein in the preoperative fasting abbreviation and to analyze the association of nutrition status on postoperative complications in patients with HNC.

METHODS

A randomized, single-blind clinical trial was performed. Patients recruited from March to November 2018 at a national cancer reference center in Brazil were divided into 2 groups: intervention group (clear fluids with carbohydrate plus whey protein [CHO-P]) and control group (clear fluids with carbohydrate only [CHO]). All patients were evaluated by the Patient-Generated Subjective Global Assessment (PG-SGA) and body mass index. Logistic regression analyses were performed to assess associations between the studied variables, generating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 49 patients met the eligibility criteria and enrolled in the study. A PG-SGA score of 4-8, indicating moderate malnutrition (OR, 10.91; 95% CI, 1.05-112.91), was an independent factor that increased the risk of postoperative complication, whereas the CHO-P group (OR, 0.04; 95% CI, 0.01-0.26) was found to be an independent factor in reducing such risk.

CONCLUSION

The addition of whey protein to clear fluids (CHO-P group) was associated with a reduced risk of postoperative complications compared with the CHO group. Furthermore, moderate malnourishment was associated with an increased risk of postoperative complications for patients with HNC.

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.

Lessons Learned in Nutrition Therapy in Patients With Severe COVID-19

The coronavirus disease 2019 (COVID‐19) pandemic has reached worldwide, and until a vaccine is found, it will continue to cause significant morbidity and mortality. The clinical presentation of COVID‐19 ranges from that of being asymptomatic to developing a fatal illness characterized by multiple organ involvement. Approximately 20% of the patients will require hospitalization; one‐quarter of hospitalized patients will develop severe COVID‐19 requiring admission to the intensive care unit, most frequently, with acute respiratory failure. An ongoing effort is being made to identify the patients that will develop severe COVID‐19. Overall, patients present with 3 different phenotypes of nutrition risk: (1) the frail older patient, (2) the patient with severe ongoing chronic illness, and (3) the patient with severe and morbid obesity. These 3 phenotypes represent different nutrition risks and diverse nutrition interventions. This article explores the different potential approaches to nutrition intervention in patients with COVID‐19, evaluating, in this process, the challenges faced in the implementation of guidelines written by different societies.

Is perioperative fasting associated with complications, length of hospital stay and mortality among gastric and colorectal cancer patients? A cohort study

BACKGROUND

During a surgical procedure, patients are often subjected to fasting for times that are more prolonged than the ideal, which may lead to complications.

OBJECTIVE

To evaluate the duration of perioperative fasting and its association with postoperative complications, length of hospital stay (LOS) and mortality among gastric and colorectal cancer patients.

DESIGN AND SETTING

Cohort study developed in a surgical oncology hospital in the city of Natal (Rio Grande do Norte, Brazil).

METHODS

Patients aged over 18 years were included. The Clavien-Dindo surgical complication scale was used to evaluate occurrences of postoperative complications. LOS was defined as the number of days for which patients stayed in the hospital after surgery, or until the day of death.

RESULTS

Seventy-seven patients participated (59.8 ± 11.8 years; 54.5% females; 70.1% with bowel tumor). The incidences of postoperative complications and death were 59.7% and 3.9%, respectively. The duration of perioperative fasting was 59.0 ± 21.4 hours, and it was higher among non-survivors and among patients with prolonged hospital stay (≥ 6 days). For each one-hour increase in the durations of perioperative and postoperative fasting, the odds of prolonged hospitalization increased by 12% (odds ratio, OR = 1.12; 95% confidence interval, CI 1.04-1.20) and 5% (OR = 1.05; 95% CI 1.02-1.08), respectively.

CONCLUSION

Prolonged perioperative fasting, especially in the postoperative period, was observed in a sample of patients with gastric and colorectal cancer, and this was an independent predictor of LOS.

Impact of phase angle on postoperative prognosis in patients with gastrointestinal and hepatobiliary-pancreatic cancer

OBJECTIVE

Phase angle (PhA), by bioelectrical impedance analysis, has been used in patients with several diseases; however, its prognostic value in patients with gastrointestinal (GI) and hepatobiliary-pancreatic (HBP) cancer is unclear. The aim of the present study was to investigate the effects of PhA on postoperative short- outcomes and long-term survival in these patients.

METHODS

This retrospective study reviewed data from 501 patients with GI and HBP cancers who underwent first resection surgery. The data were divided into the following groups according to the preoperative PhA quartile values by sex: high-PhA group with the highest quartile (Q4), normal-PhA group with middle quartiles (Q3 and Q2), and low-PhA group with the lowest quartile (Q1). Preoperative nutritional statuses, postoperative short-term outcomes during hospitalization, and 5-y survival between three groups were compared. Cox proportional hazard models were used to evaluate the prognostic effect of PhA.

RESULTS

PhA positively correlated with body weight, skeletal muscle mass, and handgrip strength, and negatively correlated with age and levels of C-reactive protein. The low-PhA group showed a higher prevalence of malnutrition (48%) than normal-PhA (25%), and high-PhA groups (9%; P < 0.001). The incidence of postoperative severe complications was 10% for all patients (14% in low-PhA, 12% in normal-PhA, and 4% in high-PhA; P = 0.018). The incidence of prolonged stays in a postoperative high-care or intensive care unit was 8% in all patients (16% in low-PhA, 8% in normal-PhA, and 2% in high-PhA; P < 0.001). The 5-y survival rate was 74% in all patients (68% in low-PhA, 74% in normal-PhA, and 79% in high-PhA; P < 0.001). The multivariate analysis demonstrated that a low-PhA group was an independent risk factor for mortality (hazard ratio, 1.99; 95% confidence interval, 1.05-3.90; P = 0.034).

CONCLUSION

PhA is a useful short-term and long-term postoperative prognostic marker for patients with GI and HBP cancers.

The relationship between the BMI-adjusted weight loss grading system and quality of life in patients with incurable cancer

BACKGROUND

Weight loss (WL) has long been recognized as an important factor associated with reduced quality of life (QoL) and reduced survival in patients with cancer. The body mass index (BMI)-adjusted weight loss grading system (WLGS) has been shown to be associated with reduced survival. However, its impact on QoL has not been established. The aim of this study was to assess the relationship between this WLGS and QoL in patients with advanced cancer.

METHODS

A biobank analysis was undertaken of adult patients with advanced cancer. Data collected included patient demographics, Eastern Cooperative Oncology Group performance status, and anthropometric parameters (BMI and %WL). Patients were categorized according to the BMI-adjusted WLGS into one of five distinct WL grades (grades 0-4). QoL was collected using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30. The Kruskal-Wallis test and multivariate logistic regression analyses were used to assess the relationship between the WLGS and QoL scores. Overall survival was assessed using Kaplan-Meier curve and Cox proportional hazard models.

RESULTS

A total of 1027 patients were assessed (51% male, median age: 66 years). Gastrointestinal cancer was most prevalent (40%), and 87% of patients had metastatic disease. Half (58%) of patients had a WL grade of 0-1, while 12%, 20%, and 10% had WL grades of 2, 3, and 4, respectively. Increasing WL grades were significantly associated with poorer QoL functioning and symptoms scales (all P < 0.05). Physical, role, and emotional functioning decreased by a median of >20 points between WL grade 0 and WL grade 4, while appetite loss, pain, dyspnoea, and fatigue increased by a median score >20 points, indicative of a large clinical significant difference. Increasing WL grades were associated with deteriorating QoL summary score. WL grades 2, 3, and 4 were independently associated with a QoL summary score below the median (<77.7) [odds ratio (OR) 1.69, P = 0.034; OR 2.06, P = 0.001; OR 4.29, P < 0.001, respectively]. WL grades 3 and 4 were independently associated with reduced overall survival [hazard ratio 1.54 (95% confidence interval: 1.22-1.93), P < 0.001 and hazard ratio 1.87 (95% confidence interval: 1.42-2.45), P < 0.001, respectively].

CONCLUSIONS

Our findings support that the WLGS is useful in identifying patients at risk of poor QoL that deteriorates with increasing WL grades. WL grade 4 is independently associated with a particularly worse prognosis and increased symptom burden. Identification and early referral to palliative care services may benefit these patients.

Automated body composition analysis of clinically acquired computed tomography scans using neural networks

BACKGROUND & AIMS

The quantity and quality of skeletal muscle and adipose tissue is an important prognostic factor for clinical outcomes across several illnesses. Clinically acquired computed tomography (CT) scans are commonly used for quantification of body composition, but manual analysis is laborious and costly. The primary aim of this study was to develop an automated body composition analysis framework using CT scans.

METHODS

CT scans of the 3rd lumbar vertebrae from critically ill, liver cirrhosis, pancreatic cancer, and clear cell renal cell carcinoma patients, as well as renal and liver donors, were manually analyzed for body composition. Ninety percent of scans were used for developing and validating a neural network for the automated segmentation of skeletal muscle and adipose tissues. Network accuracy was evaluated with the remaining 10 percent of scans using the Dice similarity coefficient (DSC), which quantifies the overlap (0 = no overlap, 1 = perfect overlap) between human and automated segmentations.

RESULTS

Of the 893 patients, 44% were female, with a mean (±SD) age and body mass index of 52.7 (±15.8) years old and 28.0 (±6.1) kg/m², respectively. In the testing cohort (n = 89), DSC scores indicated excellent agreement between human and network-predicted segmentations for skeletal muscle (0.983 ± 0.013), and intermuscular (0.900 ± 0.034), visceral (0.979 ± 0.019), and subcutaneous (0.986 ± 0.016) adipose tissue. Network segmentation took ~350 milliseconds/scan using modern computing hardware.

CONCLUSIONS

Our network displayed excellent ability to analyze diverse body composition phenotypes and clinical cohorts, which will create feasible opportunities to advance our capacity to predict health outcomes in clinical populations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of Baseline Nutrition and Exercise Status on Toxicity and Outcomes in Phase I and II Oncology Clinical Trial Participants

BACKGROUND

Malnutrition and physical inactivity are common in patients with advanced cancer and are associated with poor outcomes. There are increasing data that altered body composition is related to the pharmacokinetic properties of cancer therapies. These adverse conditions may impact outcomes in early-phase oncology clinical trials.

MATERIALS AND METHODS

We aimed to understand the relationships between baseline nutrition and exercise status with important trial endpoints including treatment-related toxicity and survival. Baseline assessments of nutrition and exercise status were conducted in patients prior to initiation of phase I and II oncology clinical trials. Patients were followed prospectively for the onset of adverse events. Tumor response and survival data were also obtained. Fisher's exact test and chi-square analysis were used to determine statistical significance. Kaplan-Meier curves were used to compare patient duration on study and survival.

RESULTS

One hundred patients were recruited, of whom 87 were initiating a phase I trial. Sixty percent were initiating trials studying immunotherapeutic agents. Critical malnutrition was found in 39% of patients, and 52% were sedentary. Patients who were malnourished had significantly increased rates of grade ≥ 3 toxicity (p = .001), hospitalizations (p = .001), and inferior disease control rate (p = .019). Six-month overall survival was significantly reduced in malnourished patients versus nonmalnourished patients (47% vs. 84%; p = .0003), as was median duration on study (48 days vs. 105 days; p = .047). Being sedentary at baseline was associated with decreased duration on study (57 days vs. 105 days; p = .019).

CONCLUSION

Malnutrition and sedentary lifestyle are highly prevalent in patients enrolling on early-phase oncology clinical trials and are associated with poor outcomes. The quality of data from these studies may be compromised as a result of these pre-existing conditions.

IMPLICATIONS FOR PRACTICE

Phase I and II trials are critical steps in the development of effective cancer therapeutics, yet only a small percentage of agents are ultimately approved for human cancer care. Despite increasing awareness of the interactions between malnutrition, sarcopenia, and treatment-related outcomes such as toxicity and response, these factors are not commonly incorporated into therapeutic decision making at the time of clinical trial consideration. Nutritional status and physical performance may be key biomarkers of mechanisms mediating treatment-related toxicity, dose modifications, risk of hospitalizations, and success of novel agents. This study advocates that a baseline nutritional assessment and early nutritional support may improve tolerability and response to experimental therapies.

Comparative Analysis Between Computed Tomography and Surrogate Methods to Detect Low Muscle Mass Among Colorectal Cancer Patients

BACKGROUND

We aimed to evaluate the agreement between computed tomography (CT) and surrogate methods applied in clinical practice for the assessment of low muscle mass. In addition, we assessed the association between different muscle-assessment methods and nutrition status, as well as the prognostic value of low muscle mass on survival in patients with colorectal cancer (CRC).

METHODS

This is a cohort including 188 CRC patients with 17 months' follow-up (interquartile range: 12-23 months) for mortality. Low muscle mass was evaluated by corrected mid-upper arm muscle area (AMAc) and calf circumference, skeletal muscle mass by bioelectrical impedance analysis (BIA), muscle deficit by physical examination with the Patient-Generated Subjective Global Assessment (PG-SGA), and lumbar muscle cross-sectional area by CT (reference method).

RESULTS

The prevalence of low muscle mass ranged from 9.6% to 54.3% according to the method used. The physical examination had the highest κ coefficient compared with CT. Low muscularity was associated with the presence of malnutrition, lower body fat, and low phase angle. The Cox regression models-adjusted for age, sex, and treatment 3 months before study inclusion-showed that severe muscle loss measured by BIA and CT and low muscle mass measured by PG-SGA predicted higher mortality rates.

CONCLUSIONS

Compared with CT, the physical examination had the best agreement to assess low muscle mass. Low muscle mass assessed by PG-SGA, BIA, and CT showed similar prognostic values for survival.

Nutritional status in patients with advanced lung cancer undergoing chemotherapy: a prospective observational study

Purpose: The consequences of malnutrition include increased risk of many complications. The assessment and management of nutritional problems are essential in supportive care of patients undergoing therapy. The primary objective of the present study was to assess changes in the nutritional status in lung cancer patients who had undergone chemotherapy.Patients and methods: Preliminary and post-chemotherapy assessments of patients' nutritional status and medical characteristics were conducted using the Patient-Generated Subjective Global Assessment (PG-SGA) from July 2014 to May 2016 at Harbin Medical University Cancer Hospital. Four hundred sixty-five advanced lung cancer patients (51.8% men and 48.2% women with a mean (SD) age of 60.2 ± 9.8 years) participated in the present study. PG-SGA was assessed prior to the initiation of chemotherapy and after four cycles of chemotherapy.Results: We found that 11.4% of the patients were severely malnourished and 65.6% of the patients were moderately malnourished prior to chemotherapy. After chemotherapy, 52.9% of the patients were considered moderately malnourished, whereas 33.8% were severely malnourished. The nutritional status had deteriorated in the majority of patients. After chemotherapy, there was a rise in the prevalence of nutrition impact symptoms.Conclusions: A deteriorated nutritional status was the result of the side effects caused by chemotherapy in the patients of the present study. These findings highlight that more attention should be paid to improve the nutritional status in patients with advanced lung cancer undergoing chemotherapy, and proper nutrition education and nutritional support should be provided to these patients.

Preoperative Nutrition Status and Postoperative Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex surgery to treat peritoneal surface malignancy (PSM). PSM and gastrointestinal (GI) resection from CRS can lead to significant GI symptoms and malnutrition. There is limited research into the nutrition status of this patient group and the impact of malnutrition on morbidity.

OBJECTIVE

This study aims to determine if preoperative malnutrition, assessed using the Subjective Global Assessment (SGA), is associated with postoperative morbidity and increased length of stay (LOS) in patients undergoing CRS/HIPEC for PSM.

METHODS

This study prospectively assessed the nutritional status of patients undergoing CRS/HIPEC using a validated nutrition assessment tool. Preoperative clinical symptoms, Peritoneal Cancer Index (PCI), intraoperative blood transfusions, operative time, GI resections, postoperative morbidity, and LOS, as well as pre- and postoperative nutritional interventions, were recorded. The impact of preoperative nutritional status was assessed in relation to postoperative complications and hospital LOS.

RESULTS

The study included 102 participants; 34 patients (33%) were classified as malnourished (SGA = B or C). Preoperative weight loss (15% vs. 74%; p ≤ 0.001) and the presence of clinical symptoms (18% vs. 47%; p = 0.002) were significantly higher in malnourished patients. While PCI, intraoperative blood transfusions, and GI resections were independent predictors of morbidity, malnutrition was significantly associated with infectious complications and LOS. For each grade of worsening malnutrition, LOS increased by an average of 7.65 days.

CONCLUSIONS

Preoperative malnutrition is prevalent in patients undergoing CRS/HIPEC and postoperative morbidity is common. Malnutrition is linked to LOS and plays a role in postoperative outcomes such as infection. Clear pre- and postoperative nutrition pathways are needed to optimize nutrition support and postoperative recovery.

Changes in body weight, skeletal muscle and adipose tissue after gastrectomy: a comparison between proximal gastrectomy and total gastrectomy

BACKGROUND

Proximal gastrectomy (PG) offers a well-preserved digestive function after surgery, which may result in a better nutritional outcome in comparison to total gastrectomy (TG). The aim of this study was to clarify the advantage of PG over TG by evaluating the longitudinal changes in body weight (BW) and body composition after surgery.

METHODS

A total of 112 patients undergoing PG with a reconstruction preserving food passage through the duodenum (n = 39) or TG with a reconstruction bypassing the duodenum (n = 73) for clinical stage IA gastric cancer were included. Changes in BW, psoas muscle and subcutaneous (SAT) and visceral adipose tissue were assessed before surgery, and at 1 and 3 years after surgery and were compared between the two groups.

RESULTS

BW and SAT decreased significantly in both groups, but the rate of reduction was significantly lower in the PG group (P < 0.001 and P < 0.001, respectively). There were no significant differences between the groups with regard to skeletal muscle or visceral adipose tissue (P = 0.110 and 0.710, respectively), although they both significantly decreased throughout the course of the study.

CONCLUSIONS

The losses of BW and SAT were significantly smaller in the PG group. PG may be superior to TG in preserving BW and SAT in patients with clinical stage IA gastric cancer.

Implications of low muscle mass across the continuum of care: a narrative review

Abnormalities in body composition can occur at any body weight. Low muscle mass is a predictor of poor morbidity and mortality and occurs in several populations. This narrative review provides an overview of the importance of low muscle mass on health outcomes for patients in inpatient, outpatient and long-term care clinical settings. A one-year glimpse at publications that showcases the rapidly growing research of body composition in clinical settings is included. Low muscle mass is associated with outcomes such as higher surgical and post-operative complications, longer length of hospital stay, lower physical function, poorer quality of life and shorter survival. As such, the potential clinical benefits of preventing and reversing this condition are likely to impact patient outcomes and resource utilization/health care costs. Clinically viable tools to measure body composition are needed for routine screening and intervention. Future research studies should elucidate the effectiveness of multimodal interventions to counteract low muscle mass for optimal patient outcomes across the healthcare continuum. Key messages Low muscle mass is associated with several negative outcomes across the healthcare continuum. Techniques to identify and counteract low muscle mass in clinical settings are needed.