Impact of body fat distribution and sarcopenia on the overall survival in patients with spinal metastases receiving radiotherapy treatment: a prospective cohort study

Malnutrition in Spine Oncology: Where Are We and What Are We Measuring?

STUDY DESIGN

Scoping review.

OBJECTIVE

To identify which markers are used as surrogates for malnutrition in metastatic spine disease and which are the most studied outcomes associated with it.

METHODS

A scoping review was performed by searching the PubMed/Medline, EMBASE, and Web of Science databases up to July 2022. We searched for articles exploring markers of malnutrition in spine oncology patients including but not limited to albumin, body weight, weight loss, and nutrition indices. A narrative synthesis was performed.

RESULTS

A total of 61 articles reporting on 31,385 patients met inclusion criteria. There were 13 different surrogate markers of nutrition, with the most common being albumin in 67% of studies (n = 41), body weight/BMI in 34% (n = 21), and muscle mass in 28% (n = 17). The most common studied outcomes were survival in 82% (n = 50), complications in 28% (n = 17), and length of stay in 10% (n = 6) of studies. Quality of life and functional outcomes were assessed in 2% (n = 1) and 3% (n = 2) of studies, respectively. Out of 61 studies, 18% (n = 11) found no association between the examined markers and outcome.

CONCLUSION

Assessment of nutritional status in patients with spinal metastases is fundamental. However, there is lack of a comprehensive and consistent way of assessing malnutrition in oncologic spine patients and therefore inconsistency in its relationship with outcomes. A consensus agreement on the assessment and definition of malnutrition in spine tumor patients is needed.

Sarcopenia Is a Prognostic Factor of Adverse Effects and Mortality in Patients With Tumour: A Systematic Review and Meta-Analysis

BACKGROUND

The relationship between sarcopenia and the prognosis of patients with tumours who received radio- and/or chemotherapy still needs to be determined. In this study, we aim to investigate the relationship between sarcopenia and adverse effects and mortality in patients with tumours that received radio- and/or chemotherapy, stratified by study design, tumour category, the method sarcopenia assessed, treatment options, study location and among other factors.

METHODS

PubMed, Web of Science and Embase were searched from inception to 15 August 2024, without language restrictions and with a manual search of references for additional articles retrieval. Cohort studies of ≥ 100 patients with tumours that evaluated the association between sarcopenia or muscle mass and the adverse effects or overall survival induced by radio- and/or chemotherapy were included.

RESULTS

Thirty-nine studies were included, involving 8966 patients with tumours, including 3383 patients with sarcopenia. The pooled prevalence of sarcopenia in patients with tumours was 0.42 (95% CI 0.36-0.48, p < 0.001) overall. The prevalence of sarcopenia is higher in Oceania patients 0.60 (95% CI 0.28-0.89, p < 0.001), those with reproductive tumour 0.57 (95% CI 0.30-0.83, p < 0.001), and sarcopenia assessed by the lumbar-skeletal muscle index 0.46 (95% CI 0.39-0.53, p < 0.001) than in other subgroups, but not show significant differences in sex. Sarcopenia was associated with an increased risk of adverse effects in patients who received radio- and/or chemotherapy, with a relative risk (RR) of 1.44 (95% CI 1.21-1.71, p < 0.001). Retrospective studies (RR = 1.49; 95% CI 1.24-1.79; p < 0.001), sarcopenia assessed by other methods (RR = 2.98; 95% CI 1.52-5.87; p < 0.001), and patients in Europe (RR = 1.92; 95% CI 1.15-3.22; p = 0.013), received chemoradiotherapy (RR = 1.47; 95% CI 1.23-1.76; p < 0.001), and with head and neck tumours (RR = 1.54; 95% CI 1.17-2.01; p = 0.010) had higher relative risk than other subgroups. Sarcopenia was also associated with reduced overall survival in patients with tumours, with a pooled hazard ratio (HR) of 1.66 (95% CI 1.40-1.96, p < 0.001). Prospective studies (HR = 1.72; 95% CI 0.97-3.07; p = 0.065), sarcopenia assessed by the cervical-skeletal muscle index (HR = 2.66; 95% CI 1.73-4.09; p < 0.001), and patients in Asia (HR = 1.91; 95% CI 1.50-2.42; p < 0.001), received chemoradiotherapy (HR = 1.85; 95% CI 1.46-2.45; p < 0.001) and with head and neck tumours (HR = 2.35; 95% CI 1.88-2.95; p < 0.001) had higher HR than other subgroups.

CONCLUSIONS

Sarcopenia was associated with a higher risk of adverse effects and mortality in patients with tumours received radio- and/or chemotherapy.

The Magnetic Resonance Imaging of the Psoas Muscle Area as the Prognostic Factor for Survival and Adverse Events in Spinal Metastasis Surgery

STUDY DESIGN

Retrospective study.

OBJECTIVE

This study aimed to evaluate the ability of the mortality and adverse events prediction following metastatic spinal surgery of MRI-based cross-sectional psoas muscle area (PMA).

METHODS

A retrospective chart review, 120 patients who had undergone metastatic spinal surgery were included. The cross-sectional area identified the PMA under MR-imaging at the L3 or L4 pedicle level, which was classified into 3 tertiles. We used univariate and multivariate cox proportional hazard regression to assess whether PMA was associated with 30-day, 90-day, 1-year, and overall mortality.

RESULTS

The small psoas tertile group populations had a higher mortality rate than the large psoas tertile group. PMA in T1 and T2 had a probability of a higher 90-d mortality rate than PMA in T3 (T1 VS T3: P = .29 and T2 VS T3: P = .12). The median survival time was 7 months, 9 months, and 10 months in PMA T1, T2, and T3, respectively. PMA in tertile 2 had a significantly higher mortality rate of 38% compared to PMA in tertile 3 (HR 1.38, 95% CI .83-2.32, P = .02). Considering PMA as a continuous variable, every 1 mm2 increment of PMA resulted in the increase survivorship of 1% (HR .99 with 95% CI .99-1).

CONCLUSION

The MRI-based cross-sectional PMA tends to predict the 90-d mortality rate and overall mortality rate in spinal metastasis patients who underwent spinal surgery. The PMA should be considered one of the prognostic factors in the treatment of metastatic spinal patients.

Pre-Therapeutic Sarcopenia among Cancer Patients: An Up-to-Date Meta-Analysis of Prevalence and Predictive Value during Cancer Treatment

This study will address the prevalence of pre-therapeutic sarcopenia (PS) and its clinical impact during cancer treatment among adult cancer patients ≥ 18 years of age. A meta-analysis (MA) with random-effect models was performed via a MEDLINE systematic review, according to the PRISMA statement, focusing on articles published before February 2022 that reported observational studies and clinical trials on the prevalence of PS and the following outcomes: overall survival (OS), progression-free survival (PFS), post-operative complications (POC), toxicities (TOX), and nosocomial infections (NI). A total of 65,936 patients (mean age: 45.7-85 y) with various cancer sites and extensions and various treatment modes were included. Mainly defined by CT scan-based loss of muscle mass only, the pooled prevalence of PS was 38.0%. The pooled relative risks were 1.97, 1.76, 2.70, 1.47, and 1.76 for OS, PFS, POC, TOX, and NI, respectively (moderate-to-high heterogeneity, I²: 58-85%). Consensus-based algorithm definitions of sarcopenia, integrating low muscle mass and low levels of muscular strength and/or physical performance, lowered the prevalence (22%) and heterogeneity (I² < 50%). They also increased the predictive values with RRs ranging from 2.31 (OS) to 3.52 (POC). PS among cancer patients is prevalent and strongly associated with poor outcomes during cancer treatment, especially when considering a consensus-based algorithm approach.

Sarcopenia in Patients With Spinal Metastasis: A Systematic Review and Meta-Analysis of Retrospective Cohort Studies

Background

As a metastasis cancer that happens up to 70% of the cancer patients, spinal metastasis is drawing attention for its significant impairment to health. There exist several predictive models designed to estimate mortality in spinal metastasis patients but they are reported with limited accuracy. In recent years, some retrospective cohort studies have been carried out to associate sarcopenia with mortality in spinal metastasis.

Introduction

As a risk factor leading to adverse events in many diseases, sarcopenia was considered to significantly impact on patients with spinal metastasis in mortality by some scientists. We aimed to look through the current evidence and use statistic measures to value the role of sarcopenia in spinal metastasis. In this study, we are going to perform a systematic review and meta-analysis of available retrospective cohort studies where sarcopenia is assessed for outcomes in spinal metastasis patients.

Methods

On October 7, 2021, we performed a search in PubMed, Embase, and the Cochrane Library. We set no restrictions on language, date or areas. Results were expressed as hazard ratio (HR) or odds ratio (OR) with 95% CI by random effects model. Sensitivity analyses were performed to explore sources of heterogeneity and stability of results.

Results

Of the 4,196 papers screened, 10 retrospective cohort studies were included, with a total of 1,674 patients. Results showed that sarcopenia was associated with higher overall mortality (OR, 1.60; 95% CI 1.35–1.90) and lower overall survival (HR, 2.08; 95% CI 1.55–2.80). The sensitivity analysis proved the stability of results in terms of publication years, region, time of diagnosis, sample size, female rate, measurement and follow up period.

Conclusions

Sarcopenia is a robust indicator of mortality in spinal metastasis patients and it might be applied to decision-making tools to assess survival probability and adjust the extent of treatment, while a lack of higher level of evidence is existing.

Systematic Review Registration

PROSPERO CRD42021283348.

Body composition predictors of mortality on computed tomography in patients with spinal metastases undergoing surgical treatment

BACKGROUND CONTEXT

Although survival of patients with spinal metastases has improved over the last decades due to advances in multi-modal therapy, there are currently no reliable predictors of mortality. Body composition measurements obtained using computed tomography (CT) have been recently proposed as biomarkers for survival in patients with and without cancer. Patients with cancer routinely undergo CT for staging or surveillance of therapy. Body composition assessed using opportunistic CTs might be used to determine survival in patients with spinal metastases.

PURPOSE

The purpose of this study was to determine the value of body composition measures obtained on opportunistic abdomen CTs to predict 90-day and 1-year mortality in patients with spinal metastases undergoing surgery. We hypothesized that low muscle and abdominal fat mass were positive predictors of mortality.

STUDY DESIGN

Retrospective study at a single tertiary care center in the United States.

PATIENT SAMPLE

This retrospective study included 196 patients between 2001 and 2016 that were 18 years of age or older, underwent surgical treatment for spinal metastases, and had a preoperative CT of the abdomen within three months prior to surgery.

OUTCOME MEASURES

Ninety-day and 1-year mortality by any cause.

METHODS

Quantification of cross-sectional areas (CSA) and CT attenuation of abdominal subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and paraspinous and abdominal skeletal muscle were performed on CT images at the level of L4 using an in-house automated algorithm. Sarcopenia was determined by total muscle CSA (cm²) divided by height squared (m²) with cutoff values of <52.4 cm²/m² for men and <38.5 cm²/m² for women. Bivariate and multivariate Cox proportional-hazard analyses were used to determine the associations between body compositions and 90-day and 1-year mortality.

RESULTS

The median age was 62 years (interquartile range=53-70). The mortality rate for 90-day was 24% and 1-year 54%. The presence of sarcopenia was associated with an increased 1-year mortality rate of 66% compared with a 1-year mortality rate of 41% in patients without sarcopenia (hazard ratio, 1.68; 95% confidence interval, 1.08-2.61; p=.02) after adjusting for various clinical factors including primary tumor type, ECOG performance status, additional metastases, neurology status, and systemic therapy. Additional analysis showed an association between sarcopenia and increased 1-year mortality when controlling for the prognostic modified Bauer score (HR, 1.58; 95%CI, 1.04-2.40; p=.03). Abdominal fat CSAs or muscle attenuation were not independently associated with mortality.

CONCLUSIONS

The presence of sarcopenia is associated with an increased risk of 1-year mortality for patients surgically treated for spinal metastases. Sarcopenia retained an independent association with mortality when controlling for the prognostic modified Bauer score. This implies that body composition measurements such as sarcopenia could serve as novel biomarkers for prediction of mortality and may supplement other existing prognostic tools to improve shared decision making for patients with spinal metastases that are contemplating surgical treatment.

Decreased psoas muscle area is a prognosticator for 90-day and 1-year survival in patients undergoing surgical treatment for spinal metastasis

BACKGROUND AND AIMS

Survival estimation for patients with spinal metastasis is crucial to treatment decisions. Psoas muscle area (PMA), a surrogate for total muscle mass, has been proposed as a useful survival prognosticator. However, few studies have validated the predictive value of decreased PMA in an Asian cohort or its predictive value after controlling for existing preoperative scoring systems (PSSs). In this study, we aim to answer: (1) Is PMA associated with survival in Han Chinese patients with spinal metastasis? (2) Is PMA a good prognosticator according to concordance index (c-index) and decision curve analysis (DCA) after controlling for six existing and commonly used PSSs?

METHODS

This study included 180 adult (≥18 years old) Taiwanese patients with a mean age of 58.3 years (range: 22-85) undergoing surgical treatment for spinal metastasis. A patient's PMA was classified into decreased, medium, and large if it fell into the lower (0-33%), middle (33-67%), and upper (67-100%) 1/3 in the study cohort, respectively. We used logistic and cox proportional-hazard regressions to assess whether PMA was associated with 90-day, 1-year, and overall survival. The model performance before and after addition of PMA to six commonly used PSSs, including Tomita score, original Tokuhashi score, revised Tokuhashi score, modified Bauer score, New England Spinal Metastasis Score, and Skeletal Oncology Research Group machine learning algorithms (SORG-MLAs), was compared by c-index and DCA to determine if PMA was a useful survival prognosticator.

RESULTS

Patients with a larger PMA is associated with better 90-day, but not 1-year, survival. The model performance of 90-day survival prediction improved after PMA was incorporated into all PSSs except SORG-MLAs. PMA barely improved the discriminatory ability (c-index, 0.74; 95% confidence interval [CI], 0.67-0.82 vs. c-index, 0.74; 95% CI, 0.66-0.81) and provided little gain of clinical net benefit on DCA for SORG-MLAs' 90-day survival prediction.

CONCLUSIONS

PMA is a prognosticator for 90-day survival and improves the discriminatory ability of earlier-proposed PSSs in our Asian cohort. However, incorporating PMA into more modern PSSs such as SORG-MLAs did not significantly improve its prediction performance.

Older cancer patients receiving radiotherapy: a systematic review for the role of sarcopenia in treatment outcomes

BACKGROUND

Previous studies have evaluated the prognostic effects of sarcopenia in cancer patients receiving various treatments, including chemotherapy and surgery, but few studies have focused on radiotherapy (RT).

AIMS

We aimed to investigate the prevalence of sarcopenia and the relationship between sarcopenia and outcomes in older cancer patients who underwent RT without chemotherapy.

METHODS

A systematic review of the literature was conducted in Pubmed/Medline and Cochrane databases in September 2021. We used the search terms and medical subject heading terms "sarcopenia," "low muscle mass (LMM)," "low muscle strength," "LMM and low muscle strength," "LMM and low muscle strength and low physical performance," and "RT." Outcomes were overall survival (OS), progression-free survival, non-cancer death, cancer death, disease-specific survival, local failure-free survival, distant failure-free survival, and RT-related toxicities.

RESULTS

Among 460 studies, 8 studies were eligible for inclusion. The prevalence of sarcopenia was between 42.8% and 72%. Sarcopenia was not associated with OS or OS at 3 years in seven studies in which it was defined as the presence of LMM, while it was related in one study, in which it was defined as the concomitant presence of LMM and muscle strength/function.

DISCUSSION

There was heterogeneity between the studies because there was diversity in their inclusion criteria, definition and assessment methods used for detection of sarcopenia, considered cutoffs for low muscle mass and strength, cross-sectional locations on imaging to assess muscle mass and included covariates. The discrepancy in the results of the studies may also result from the variations in diagnoses, sample sizes, and treatment modalities. The low number of included studies and a small number of patients in each study limited generalizability.

CONCLUSIONS

Sarcopenia may be a prognostic factor, especially in OS when low muscle strength/function is integrated into its definition. We suggest that clinicians focus on muscle strength/function while considering sarcopenia and its association with cancer and RT-related outcomes.

International Validation of the SORG Machine-learning Algorithm for Predicting the Survival of Patients with Extremity Metastases Undergoing Surgical Treatment

BACKGROUND

The Skeletal Oncology Research Group machine-learning algorithms (SORG-MLAs) estimate 90-day and 1-year survival in patients with long-bone metastases undergoing surgical treatment and have demonstrated good discriminatory ability on internal validation. However, the performance of a prediction model could potentially vary by race or region, and the SORG-MLA must be externally validated in an Asian cohort. Furthermore, the authors of the original developmental study did not consider the Eastern Cooperative Oncology Group (ECOG) performance status, a survival prognosticator repeatedly validated in other studies, in their algorithms because of missing data.

QUESTIONS/PURPOSES

(1) Is the SORG-MLA generalizable to Taiwanese patients for predicting 90-day and 1-year mortality? (2) Is the ECOG score an independent factor associated with 90-day and 1-year mortality while controlling for SORG-MLA predictions?

METHODS

All 356 patients who underwent surgery for long-bone metastases between 2014 and 2019 at one tertiary care center in Taiwan were included. Ninety-eight percent (349 of 356) of patients were of Han Chinese descent. The median (range) patient age was 61 years (25 to 95), 52% (184 of 356) were women, and the median BMI was 23 kg/m2 (13 to 39 kg/m2). The most common primary tumors were lung cancer (33% [116 of 356]) and breast cancer (16% [58 of 356]). Fifty-five percent (195 of 356) of patients presented with a complete pathologic fracture. Intramedullary nailing was the most commonly performed type of surgery (59% [210 of 356]), followed by plate screw fixation (23% [81 of 356]) and endoprosthetic reconstruction (18% [65 of 356]). Six patients were lost to follow-up within 90 days; 30 were lost to follow-up within 1 year. Eighty-five percent (301 of 356) of patients were followed until death or for at least 2 years. Survival was 82% (287 of 350) at 90 days and 49% (159 of 326) at 1 year. The model's performance metrics included discrimination (concordance index [c-index]), calibration (intercept and slope), and Brier score. In general, a c-index of 0.5 indicates random guess and a c-index of 0.8 denotes excellent discrimination. Calibration refers to the agreement between the predicted outcomes and the actual outcomes, with a perfect calibration having an intercept of 0 and a slope of 1. The Brier score of a prediction model must be compared with and ideally should be smaller than the score of the null model. A decision curve analysis was then performed for the 90-day and 1-year prediction models to evaluate their net benefit across a range of different threshold probabilities. A multivariate logistic regression analysis was used to evaluate whether the ECOG score was an independent prognosticator while controlling for the SORG-MLA's predictions. We did not perform retraining/recalibration because we were not trying to update the SORG-MLA algorithm in this study.

RESULTS

The SORG-MLA had good discriminatory ability at both timepoints, with a c-index of 0.80 (95% confidence interval 0.74 to 0.86) for 90-day survival prediction and a c-index of 0.84 (95% CI 0.80 to 0.89) for 1-year survival prediction. However, the calibration analysis showed that the SORG-MLAs tended to underestimate Taiwanese patients' survival (90-day survival prediction: calibration intercept 0.78 [95% CI 0.46 to 1.10], calibration slope 0.74 [95% CI 0.53 to 0.96]; 1-year survival prediction: calibration intercept 0.75 [95% CI 0.49 to 1.00], calibration slope 1.22 [95% CI 0.95 to 1.49]). The Brier score of the 90-day and 1-year SORG-MLA prediction models was lower than their respective null model (0.12 versus 0.16 for 90-day prediction; 0.16 versus 0.25 for 1-year prediction), indicating good overall performance of SORG-MLAs at these two timepoints. Decision curve analysis showed SORG-MLAs provided net benefits when threshold probabilities ranged from 0.40 to 0.95 for 90-day survival prediction and from 0.15 to 1.0 for 1-year prediction. The ECOG score was an independent factor associated with 90-day mortality (odds ratio 1.94 [95% CI 1.01 to 3.73]) but not 1-year mortality (OR 1.07 [95% CI 0.53 to 2.17]) after controlling for SORG-MLA predictions for 90-day and 1-year survival, respectively.

CONCLUSION

SORG-MLAs retained good discriminatory ability in Taiwanese patients with long-bone metastases, although their actual survival time was slightly underestimated. More international validation and incremental value studies that address factors such as the ECOG score are warranted to refine the algorithms, which can be freely accessed online at https://sorg-apps.shinyapps.io/extremitymetssurvival/.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Body composition predictors of mortality in patients undergoing surgery for long bone metastases

Background and Objectives

Body composition measurements using computed tomography (CT) may serve as imaging biomarkers of survival in patients with and without cancer. This study assesses whether body composition measurements obtained on abdominal CTs are independently associated with 90‐day and 1‐year mortality in patients with long‐bone metastases undergoing surgery.

Methods

This single institutional retrospective study included 212 patients who had undergone surgery for long‐bone metastases and had a CT of the abdomen within 90 days before surgery. Quantification of cross‐sectional areas (CSA) and CT attenuation of abdominal subcutaneous adipose tissue, visceral adipose tissue, and paraspinous and abdominal muscles were performed at L4. Multivariate Cox proportional‐hazards analyses were performed.

Results

Sarcopenia was independently associated with 90‐day mortality (hazard ratio [HR] = 1.87; 95% confidence interval [CI] = 1.11–3.16; p = 0.019) and 1‐year mortality (HR = 1.50; 95% CI = 1.02–2.19; p = 0.038) in multivariate analysis while controlling for clinical variables such as primary tumors, comorbidities, and chemotherapy. Abdominal fat CSAs and muscle attenuation were not associated with mortality.

Conclusions

The presence of sarcopenia assessed by CT is predictive of 90‐day and 1‐year mortality in patients undergoing surgery for long‐bone metastases. This body composition measurement can be used as novel imaging biomarker supplementing existing prognostic tools to optimize patient selection for surgery and improve shared decision making.

The association of body composition parameters and adverse events in women receiving chemotherapy for early breast cancer

BACKGROUND

Body composition metrics as predictors of adverse events are a growing area of interest in oncology research. One barrier to the use of these metrics in clinical practice is the lack of standardized cut points for identifying patients with at-risk body composition profiles. We examined the association of chemotherapy adverse events with several body composition measures, using alternative cut points from published studies.

METHODS

This is a retrospective study of women diagnosed with early breast cancer (EBC). Axial computerized tomography (CT) images from lumbar L3 segments were analyzed for the following body composition measures: myosteatosis (low Skeletal Muscle Density/SMD), sarcopenia (low Skeletal Muscle Index/SMI), and high Visceral Adipose Tissue (VAT). Adverse events during chemotherapy were dose reduction, early treatment discontinuation, and hospitalization. Log-binomial modeling was used to evaluate associations between body composition measures at different cut points with adverse events, adjusting for age, race, Body Mass Index/BMI, and comorbidities. Relative risks were reported as the measure of association.

RESULTS

In a sample of 338 women, mean age was 51, 14% were age 65 or older, 32% were non-white, 40% had obesity (/BMI ≥ 30 kg/m²), and mean number of comorbidities was 1.56. In multivariable analysis (MV), all three SMD cut points for myosteatosis had significant associations with total number of adverse events, as well as different cut points having significant associations with either dose reduction, early treatment discontinuation or hospitalization. SMI and VAT were not significant in the MV analysis; however, in some models, age and total comorbidities were significant for adverse events.

CONCLUSIONS

Among CT-derived measures of body composition, myosteatosis determined at any of three SMD cut points was associated with total and individual adverse events during chemotherapy for early breast cancer.