Impact of sarcopenia in the management of urological cancer patients

Prognostic value of preoperative albumin-to-alkaline phosphatase ratio in patients with surgically treated urological cancer: a systematic review and meta-analysis

Objective

A novel albumin-to-alkaline phosphatase ratio (AAPR) is associated with the prognosis of several cancers. In the present study, we evaluate the prognostic significance of perioperative AAPR in urological cancers.

Method

Relevant studies were searched comprehensively from CNKI, PubMed, Embase and Web of Science up to March 2023. The pooled hazard ratio (HR) and 95% confidence interval (CI) were extracted from each study to evaluate the prognostic value of perioperative AAPR in patients with surgically treated urological cancers.

Results

A total of 8 studies consisting of 3,271 patients were included in the final results. A low AAPR was significantly associated with a worse OS (HR=2.21; P<0.001), CSS (HR=2.61; P<0.001) and RFS/DFS (HR=2.87; P=0.001). Stratified by disease, a low AAPR was also associated with worse OS in renal cell carcinoma (HR=2.01; P<0.001), bladder cancer (HR=3.37; P<0.001) and upper tract urothelial carcinoma (HR=1.59; P=0.002).

Conclusion

In conclusion, low AAPR could serve as an unfavorable factor in patients with surgically treated urological cancers. Stratified by tumor type, the low AAPR was also associated with inferior survival. While more prospective and large-scale studies are warranted to validate our findings.

Establishing a common metric for physical function: Linking SARC-F and PROMIS® physical function

INTRODUCTION

Aligned with the increasing need for standardized assessment of physical function in older individuals with cancer and other conditions, several patient-reported outcome measures (PROMs) have been developed and published. The aim of this study is to link the Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falls questionnaire (SARC-F), and the Patient-Reported Outcomes Measurement Information System® (PROMIS®) Physical Function Short Form 8c (PROMIS PF 8c), and make their scores convertible, in order to expand the use of both instruments in research and inform clinicians and researchers about the interchangeability of critical cut-off scores.

MATERIALS AND METHODS

The sample included 300 participants recruited from an online panel. Participants were included if they had received a cancer diagnosis from a clinician and reported receiving anti-cancer treatment. We conducted five linking procedures and selected an optimal one to generate the crosswalk table between the two measures.

RESULTS

The linked T scores of all five methods showed acceptably small mean differences from the observed T scores, and the standard deviation (SD), and root-mean-squared deviation (RMSD) of the differences were generally similar across all methods. After comparing across all statistics, the Stocking-Lord approach was considered as the optimal approach to compute the crosswalk table for converting SARC-F raw scores to PROMIS PF 8c scores. The crosswalk table shows that the SARC-F cut-off value of 4 between healthy versus symptomatic with a corresponding score of 37 fell in the range of moderate physical function limitation from 30 to 39 on the PROMI PF 8c T score metric.

DISCUSSION

The linkage in this study has potential for improving clinical and research activities for people with cancer and perhaps others with a similar range of physical function. It facilitates the interpretability in scores of both measures on a common metric anchored on general population for further group-level analysis. Researchers can use this crosswalk to harmonize data collected from either instrument without requiring all cohorts to administer the same instrument for a prospective data collection or retrospective data analysis purpose or for a cross-study effectiveness study.

A hint for the obesity paradox and the link between obesity, perirenal adipose tissue and Renal Cell Carcinoma progression

Increasing evidence supports a role for local fat depots in cancer outcomes. Despite the robust positive association of obesity with renal cell carcinoma (RCCa) diagnosis, increased adiposity is inversely related to RCCa oncological outcomes. Here, we sought to ascertain whether imagiologically assessed local fat depots associate with RCCa progression and survival and account for this apparent paradox. A retrospective cohort of renal carcinoma patients elective for nephrectomy (n = 137) were included. Beyond baseline clinicopathological characteristics, computed tomography (CT)-scans at the level of renal hilum evaluated areas and densities of different adipose tissue depots (perirenal, subcutaneous, visceral) and skeletal muscle (erector spinae, psoas and quadratus lumborum muscles) were analyzed. Univariate and multivariable Cox proportional hazards models were estimated following empirical analysis using stepwise Cox regression. Age, visceral adipose tissue (VAT) area and body mass index (BMI) predicted tumour-sided perirenal fat area (R² = 0.584), which presented upregulated UCP1 expression by 27-fold (P = 0.026) and smaller adipocyte areas, compared with subcutaneous depot. Multivariate analyses revealed that increased area of perirenal adipose tissue (PRAT) on the contralateral and tumour side associate with improved progression-free survival (HR = 0.3, 95CI = 0.1-0.8, P = 0.019) and overall survival (HR = 0.3, 95CI = 0.1-0.7, P = 0.009). PRAT measurements using CT, might become a possible tool, well correlated with other measures of obesity such as VAT and BMI, that will improve determination of obesity and contribute to assess the risk for disease progression and mortality in renal cancer patients. Present data supports the obesity paradox in RCCa, assumed that larger PRAT areas seem to protect from disease progression and death.

Preoperative sarcopenia and systemic immune-inflammation index can predict response to intravesical Bacillus Calmette-Guerin instillation in patients with non-muscle invasive bladder cancer

Background

To explore the prognostic significance of sarcopenia and systemic immune-inflammation index (SII) for response to intravesical Bacillus Calmette-Guerin (BCG) in patients with intermediate-, and high-risk non-muscle invasive bladder cancer (NMIBC).

Methods

We retrospectively analyzed 183 consecutive patients treated in Qilu hospital of Shandong University for a first diagnosis of intermediate and high risk NMIBC. Using computed tomography scans at the third lumbar vertebra level, we calculated skeletal muscle index (SMI). Sarcopenia was defined as SMI <43 cm²/m² for males with BMI < 25 kg/m², <53 cm²/m² for males with BMI ≥ 25 kg/m², and <41 cm²/m² for females. The response to intravesical BCG immunotherapy and relapse-free survival (RFS) were analyzed.

Results

Compared with BCG responders, BCG non-responders were associated with sarcopenia (P < 0.001), carcinoma in situ (P < 0.001), T1 stage (P < 0.001), multiple tumor (P < 0.001), tumor diameter >=3cm (P < 0.001), and have a significant increase of neutrophil-to-lymphocyte ratio (NLR) (P < 0.001), platelet to lymphocyte ratio (PLR) (P = 0.004), SII (P < 0.001). The area under the ROC curve (AUC) of the BMI, NLR, PLR, and SII for response to intravesical BCG immunotherapy were 0.425, 0.693, 0.631, and 0.702 respectively. Logistic regression analysis demonstrated that sarcopenia and SII were predictors of response to intravesical BCG immunotherapy. The Kaplan-Meier survival analysis showed that the RFS of patients with BCG response, lower SII and no sarcopenia was significantly increased compared with that of patients with BCG non-response, higher SII and sarcopenia, respectively. Subgroup analysis demonstrated that the RFS of patients with high SII and sarcopenia was significantly decreased compared with those with low SII and no sarcopenia in Ta stage subgroup, T1 stage subgroup, non-Cis subgroup, multiple tumor subgroup, single tumor subgroup, tumor diameter≥3cm subgroup and tumor diameter<3cm subgroup, respectively (P < 0.05). However, there was no significant difference in RFS for patients in CIS subgroup (P > 0.05). Multivariate Cox analysis shown that sarcopenia (p=0.005) and high SII (p = 0.003) were significantly associated with poor RFS.

Conclusions

Both sarcopenia and high SII are useful predictors of response to intravesical BCG in intermediate- and high-risk NMIBC patients. Patients with intermediate- and high-risk NMIBC that had sarcopenia or high SII at diagnosis were associated with poor RFS, and the combination of sarcopenia and SII may be a better predictor of RFS.

Impact of sarcopenia in bladder preservation therapy for muscle-invasive bladder cancer patients: a narrative review

BACKGROUND AND OBJECTIVE

Muscle-invasive bladder cancer (MIBC) is a biologically aggressive disease and its prognosis is poor. Radical cystectomy (RC) with urinary diversion and lymph node dissection is the gold standard treatment for MIBC patients. Accumulating evidence indicates that sarcopenia, the degenerative and systemic loss of skeletal muscle mass, is a significant predictor of higher rates of mortality and perioperative complications following RC. Recently, bladder preservation therapy has been offered as an alternative in appropriately selected MIBC patients who desire to preserve their bladders and those unfit or unwilling for RC. Here, we performed a narrative review on the impact of sarcopenia on oncological outcomes and complication rates in MIBC patients treated with bladder preservation therapy.

METHODS

A literature review was performed using the PubMed and Scopus databases.

KEY CONTENT AND FINDINGS

We identified two studies reported the impact of sarcopenia on responses to trimodal therapy and survival outcomes in MIBC patients. Consolidative partial cystectomy was performed in patients who achieved clinical complete response (CR) to trimodal therapy in one of the two studies. In both studies, CR rates to trimodal therapy are comparable between sarcopenic and non-sarcopenic patients. Sarcopenia was not significantly associated with shorter survival after completing bladder preservation therapy in either study. For complication rates of bladder preservation therapy, one study showed equivalent complication rates of consolidative partial cystectomy between sarcopenic and non-sarcopenic patients. In addition, in another small series of trimodal therapy, sarcopenic patients showed a higher rate of complications of trimodal therapy compared with non-sarcopenic patients.

CONCLUSIONS

According to the result of our literature review, sarcopenia would not affect responses to trimodal therapy and prognosis in MIBC patients treated with bladder preservation therapy. Although the effect of sarcopenia on complication rates of bladder preservation therapy is inconclusive due to limited evidence, bladder preservation therapy could be a viable alternative option in carefully selected MIBC patients regardless of the presence of sarcopenia.

The Key Role of Nutritional Elements on Sport Rehabilitation and the Effects of Nutrients Intake

Adequate nutrition is of utmost importance for athletes, especially during rehabilitation after injury in order to achieve fast healing and return to sports. The aim of this narrative review is to define the proper nutritional elements for athletes to meet their needs and facilitate their fast return to sports after surgery or injury, as well as determine the effects of specific nutrients intake. Studies on antioxidants, which are substances that protect against free radicals, for the injured athlete are few and unclear, yet poly-phenols and especially flavonoids might improve healing and inflammation following an injury. Benefits of vitamin C or E on muscle damage are disputable in relevant studies, while optimal levels of vitamin D and calcium contribute to bone healing. Minerals are also essential for athletes. Other supplements suggested for muscle damage treatment and protein synthesis include leucine, creatine, and hydroxymethylbutyrate. Diets that include high-quality products, rich in micronutrients (like vitamins, minerals, etc.) bio-active compounds and other nutritional elements (like creatine) are suggested, while an individualized nutrition program prescribed by a trained dietitian is important. Further studies are needed to clarify the underlying mechanisms of these nutritional elements, especially regarding injury treatment.

Cancer, Phase Angle and Sarcopenia: The Role of Diet in Connection with Lung Cancer Prognosis

Lung cancer is the most common cause of cancer death and is associated with malnutrition and sarcopenia. The detection of sarcopenia and conduction of simple body composition measurements, such as the phase angle (PhA) deriving from bioelectrical impedance analysis (BIA), can help to early identify, monitor, prevent and treat malnutrition. The present review aims to clarify the relationship between PhA and sarcopenia with the pathophysiology, clinical outcomes, and therapeutic aspects of lung cancer. PhA and sarcopenia are connected to lung cancer prognosis through various mechanisms including inflammation and oxidative stress, although more research is needed to identify the critical thresholds for increased mortality risk. Moreover, emphasis is given on the role of dietary interventions (oral nutritional supplementation, and dietary counseling) to manage sarcopenia and related variables in patients with lung cancer. Oral nutritional supplements and/or those containing n - 3 polyunsaturated fatty acids may have a positive effect on physical strength measures and muscle mass if administered at the beginning of chemotherapy. Data on sole dietary counseling or multimodal interventions are less promising so far. In the future, sophisticated body composition phenotypes deriving from the described methods along with artificial intelligence techniques could be used to design personalized nutrition interventions and timely treat these patients.

The effect of sarcopenia on outcomes following orthopaedic surgery : a systematic review

AIMS

Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, and Google Scholar databases according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies involving sarcopenic patients who underwent defined orthopaedic surgery and recorded postoperative outcomes were included. The quality of the criteria by which a diagnosis of sarcopenia was made was evaluated. The quality of the publication was assessed using Newcastle-Ottawa Scale.

RESULTS

A total of 365 studies were identified and screened, 26 full-texts were reviewed, and 19 studies were included in the review. A total of 3,009 patients were included, of whom 2,146 (71%) were female and 863 (29%) were male. The mean age of the patients was 75.1 years (SD 7.1). Five studies included patients who underwent spinal surgery, 13 included hip or knee surgery, and one involved patients who underwent fixation of a distal radial fixation. The mean follow-up was 1.9 years (SD 1.9; 5 days to 5.6 years). There was wide heterogeneity in the measurement tools which were used and the parameters for the diagnosis of sarcopenia in the studies. Sarcopenia was associated with at least one deleterious effect on surgical outcomes in all 19 studies. The postoperative rate of mortality was reported in 11 studies (57.9%) and sarcopenia was associated with poorer survival in 73% (8/11) of these. The outcome was most commonly assessed using the Barthel Index (4/19), and sarcopenic patients recorded lower scores in 75% (3/4) of these. Sarcopenia was defined using the gold-standard three parameters (muscle strength, muscle quantity or quality, and muscle function) in four studies (21%), using two parameters in another four (21%) and one in the remaining 11 (58%). The methodological quality of the studies was moderate to high.

CONCLUSION

There is much heterogeneity in the reporting of the parameters which are used for the diagnosis of sarcopenia, and evaluating the outcome of orthopaedic surgery in sarcopenic patients. However, what data exist suggest that sarcopenia impairs recovery and increases postoperative mortality, especially in patients undergoing emergency surgery. Further research is required to develop processes that allow the accurate diagnosis of sarcopenia in orthopaedics, which may facilitate targeted pre- and postoperative interventions that would improve outcomes. Cite this article: Bone Joint J 2022;104-B(3):321-330.

Early cancer cachexia phenotype predicts survival of advanced urothelial cancer patients treated with pembrolizumab

AIM

We aimed to explore the association between cancer cachexia phenotypes in the early phase of treatment induction and the prognosis of advanced urothelial cancer (aUC) patients receiving pembrolizumab.

METHODS

This retrospective study included 31 aUC patients treated with pembrolizumab as a second- or later-line therapy. Patients were categorized into three early cancer cachexia phenotypes by changes in skeletal muscle and total adipose indices calculated using computed tomography images taken immediately before and within 3 months after the initiation of pembrolizumab: No Wasting (NW, 11 patients), Fat-Only Wasting (FW, 13), and Muscle and Fat Wasting (MFW, seven). Its association with objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were evaluated.

RESULTS

The median follow-up period was 5.7 months. The median number of cycles of pembrolizumab was five. The ORR in NW/FW/MFW was 86%/38%/0%, respectively (p = 0.001). The PFS and OS rates were the best in NW, followed in order by FW and MFW (PFS, 69%/45%/0% at 12 months, p = 0.008; OS, 100%/65%/0% at 12 months, p < 0.001). In multivariate analysis including posttherapeutic cachexia-associated parameters, cancer cachexia phenotype (MFW vs. FW/NW) was an independent predictor of poor OS (hazard ratio 8.59, p < 0.001) along with an increase in neutrophil-lymphocyte ratio (p = 0.028).

CONCLUSION

Early cancer cachexia phenotypes were significantly associated with the survival of aUC patients treated with pembrolizumab. In contrast to the very early progression and poor prognosis in the MFW group, long-term survival can be expected in the NW/FW groups.

Does sarcopenia affect outcomes in pediatric surgical patients? A scoping review

OBJECTIVE

Adults with sarcopenia have a greater risk of postoperative complications, a higher rate of ICU admission, and an increased length of hospital stay. Few studies have explored the prevalence or importance of sarcopenia in the pediatric population. This study reviews the published literature on sarcopenia in the pediatric population, including pediatric surgery.

METHODS

Original studies related to sarcopenia in children were identified using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines and the PubMed database.

RESULTS

A total of 390 articles were screened, with 28 meeting inclusion criteria. Twenty (71%) studies provided a means to define abnormal and 18 studies (64%) showed that a specific disease process could impact lean muscle mass in children. Only 4 (14%) studies associated the change in muscle mass with an outcome. Two studies investigated sarcopenia and outcomes in the pediatric surgical patient and demonstrated associations with worse outcomes.

CONCLUSION

Despite studies showing an association between sarcopenia and negative outcomes in the adult surgical population, there remains a paucity of evidence regarding the impact of sarcopenia on the pediatric population. Future studies are needed to ascertain the relationship between muscle mass and outcomes in pediatric surgical patients.

Temporal muscle thickness as a prognostic marker in newly diagnosed glioblastoma patients: translational imaging analysis of the CENTRIC EORTC 26071-22072 and CORE trials

PURPOSE

To investigate the prognostic relevance of temporal muscle thickness (TMT) as a surrogate parameter of skeletal muscle status in patients with newly diagnosed glioblastoma.

METHODS

We assessed TMT in cranial magnetic resonance images (MRI) of 755 patients enrolled in the CENTRIC EORTC 26071-22072 study (n=508) and CORE study (n=247). We used predefined sex-specific TMT cutoff values to categorize "patients at risk of sarcopenia" and "patients with normal muscle status" at baseline. Furthermore, we categorized patients according to the extent of TMT loss over time. Associations with progression-free survival (PFS) and overall survival (OS) were evaluated using the Cox model adjusted for other exploratory variables.

RESULTS

Patients at risk of sarcopenia (CENTRIC; n=158/508, 31.1%; CORE; n=87/247, 35.2%) at baseline had significantly higher risk of progression and death than patients with normal muscle status in both study cohorts (CENTRIC: PFS=HR 0.16, 95% CI: 0.12, 0.21, p<0.001; OS=HR 0.341, 95% CI: 0.27, 0.44, p < 0.001; CORE: PFS=HR 0.29, 95% CI: 0.21, 0.39, p<0.001; OS=HR 0.365, 95% CI: 0.27, 0.49, p<0.001). Similar results were obtained in multivariate Cox models adjusted for other important prognostic parameters. The extent of TMT loss over time showed a significant inverse correlation with median OS times in patients at risk for sarcopenia (CENTRIC: p<0.001, CORE: p=0.005), but not in patients with normal baseline muscle mass (CENTRIC: p=0.538, CORE: p=0.28).

CONCLUSION

TMT identifies ambulatory patients with newly diagnosed glioblastoma at risk for progressive sarcopenia and adverse outcomes. Early intervention may prevent skeletal muscle loss and improve patient outcome.

Low skeletal muscle mass by computerized tomography is associated with increased mortality risk in end-stage kidney disease patients on hemodialysis

BACKGROUND AND AIMS

Skeletal muscle (SM) area, as measured by abdominal CT at the level of the third lumbar vertebra (L3), has been proposed as a proxy of whole body muscle mass. However, population-specific reference values are lacking. In the present study we aimed at: (1) detecting low SM area on abdominal CT images in patients on hemodialysis by applying cut-offs derived from a group of healthy subjects, and (2) estimating the independent risk of all-cause mortality associated with low SM area.

METHODS

We retrospectively enrolled 212 adult patients on hemodialysis, undergoing abdominal CT scan (study group), and 87 healthy kidney donors (reference group). We obtained the gender-specific 5th percentile values of the abdominal SM area distribution from both the whole control group and the subgroup of younger (29-60 years) subjects, which we used as reference cut-offs. Then we applied those cut-offs in the study group to identify patients with low SM area. We used survival and Cox regression analysis to evaluate the risk of all-cause mortality associated with low abdominal SM area.

RESULTS

In the fully adjusted Cox regression analysis, the patients with low abdominal SM area had a higher risk of death than the patients with values above the reference cut-off derived in the subgroup of younger controls (adjHR = 1.79 (1.21; 2.67), P = 0.004).

CONCLUSIONS

Abdominal CT imaging can be used to detect low abdominal SM area in patients on hemodialysis by applying cut-offs derived from healthy subjects sharing a similar ethnic background. Low SM area as assessed by CT is independently associated with all-cause mortality in ESKD patients on hemodialysis.

Impact of Body Composition in Overweight and Obese Patients With Localised Renal Cell Carcinoma

BACKGROUND/AIM

To investigate the impact of body composition on morbidity and mortality at the initial diagnosis of localised renal cell carcinoma (RCC) in patients with overweight or obesity.

PATIENTS AND METHODS

Sarcopenia was defined using sex-specific cut-off points and other body composition parameters by median values with computed tomography imaging.

RESULTS

Among the 96 patients, 40 had sarcopenia (43.0%) at diagnosis. Body composition had no effect on morbidity and 5-year disease-free survival contrary to the classic factors (p<0.05). In the subgroup of obese patients, those with sarcopenia had a poor prognosis (p=0.04) but not in the population with overweight (p=0.9).

CONCLUSION

Sarcopenia was frequently associated with localised RCC at the initial diagnosis. Body composition did not affect morbidity or outcomes. BMI was involved in morbidity and there was paradoxically longer survival in the obesity group.

Impact of sarcopenia on the efficacy of pembrolizumab in patients with advanced urothelial carcinoma: a preliminary report

Sarcopenia, the degenerative and systemic loss of skeletal muscle mass, is a multifactorial syndrome reflecting frailty, poor general health status, and the possible presence of cancer cachexia. Here, we aimed to investigate the effect of sarcopenia on the efficacy of pembrolizumab in patients with advanced urothelial carcinoma (aUC). This retrospective study included 28 patients with aUC treated with pembrolizumab as a second or later-line therapy. Sarcopenia was determined based on computed tomography images. Associations of sarcopenia with objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were evaluated. In total, 19 (68%) patients had sarcopenia. ORR was 21% in the patients with sarcopenia, while those without sarcopenia showed significantly higher ORR (67%, P = 0.019). PFS was significantly shorter in patients with sarcopenia than in those without (median, 3 vs. 15 months, P = 0.038). Although the statistical significance was not reached, OS was shorter in patients with sarcopenia than in those without (median, 7 months vs. not reached; P = 0.086). Our preliminary results demonstrated that more than half of patients with aUC who received pembrolizumab had sarcopenia, which was significantly associated with poor therapeutic efficacy. This indicates the clinical relevance of sarcopenia in pembrolizumab therapy for patients with aUC.

Impact of cachexia on oncologic outcomes of sarcopenic patients with upper tract urothelial carcinoma after radical nephroureterectomy

Objectives

To investigate the prognostic significance of sarcopenic cachexia compared to sarcopenia without cachexia in the outcomes of upper urinary tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy (RNU).

Materials and methods

Between 2011 and 2016, 163 patients with UTUC who received RNU at a tertiary medical center were included. Pre-operatively clinical data, history, and abdominal computer tomography scans were analyzed retrospectively. The diagnosis of sarcopenia was based on abdominal computed tomography data on the patient’s skeletal muscles. Outcomes of relapse-free, cancer-specific, and overall survival were analyzed by multivariate Cox regression.

Results

After adjusting for age, sex, pre-operatively estimated glomerular filtration rate, body mass index, underlying diseases, tumor grade, and tumor stage, cachexia was a significant poor prognostic factor for relapse-free survival (hazard ratio [HR]: 18.5, 95% confidence interval [CI]: 2.87–118, p = 0.002) and cancer-specific survival (HR: 26.6, 95% CI: 4.04–175, p = 0.001). In contrast, sarcopenia without cachexia was not a significant predictor of cancer outcomes.

Conclusions

To date, this is the first study to investigate the effect of cachexia among sarcopenic patients with UTUC treated with RNU. We identified the prognostic significance of cachexia on outcomes. Indeed, when UTUC is treated with RNU, we should evaluate not only sarcopenia status but also cachexia. The low survival rate among patients with UTUC complicated with cachexia deserves attention.

Ultrasonographic Size of the Thenar Muscles of the Nondominant Hand Correlates with Total Body Lean Mass in Healthy Subjects

RATIONALE AND OBJECTIVES

Sarcopenia is associated with adverse outcomes in clinical situations such as elderly population, in-hospital setting and oncologic patients. However, no direct measurement of muscular mass is routinely available for clinicians. The aim of this study was to assess the correlation between thenar musculature of the nondominant hand evaluated by ultrasound and body fat-free mass.

MATERIALS AND METHODS

In this one-center, cross-sectional, observational study, the width and depth of thenar muscles of both hands was assessed by ultrasonography. Nondominant hand musculature was taken as reference as a better estimator of total body muscular mass. These data were compared to body composition by bioimpedance analysis and dual-energy X-ray absorptiometry (DXA), hand grip strength, arm muscular area and physical activity (with International Physical Activity Questionnaire ). Statistical correlation was determined for each parameter.

RESULTS

We obtained ultrasonographic measurements, International Physical Activity Questionnaire and hand grip strength from 83 subjects, whereas bioimpedance was performed in 64 subjects and DXA in 29 subjects. The strongest correlations were found between longitudinal thenar depth vs fat-free mass index (fat-free mass in DXA [kg]/height² [m]) (r = 0.63, p < 0.001, 95%CI 0.34-0.81), longitudinal depth and hand dynamometry (r = 0.72, p < 0.001, 95%CI 0.59-0.81), longitudinal depth and DXA fat-free total mass (r = 0.76, p < 0.001, 95%CI 0.54-0.88), transversal thenar depth vs fat-free mass index (r = 0.67, p < 0.001, 95%CI 0.41-0.83), transversal width and DXA fat-free total mass (r = 0.62, p < 0.001, 95%CI 0.33-0.8), transversal depth and DXA nonfat total mass (r = 0.81, p < 0.001, 95%CI 0.63-0.91).

CONCLUSION

Ultrasonographic examination of the nondominant thenar musculature is a fast and simple way of assessing total body fat-free mass, showing a good correlation with body composition measured by bioimpedance analysis and DXA, hand grip strength and arm muscular area.

Sarcopenia in cancer: Risking more than muscle loss

Sarcopenia is characterised by progressive and extensive skeletal muscle degeneration and is associated with functional decline. Sarcopenia has primary and secondary aetiology, arising as a result of the ageing process or through chronic cytokine-mediated inflammation (associated with health conditions including cancer), respectively. Diagnosis of sarcopenia is dependent upon detection of reduced skeletal muscle strength, mass and performance. A combination of non-radiological and radiological methods can be used to assess each of these in turn to accurately diagnose sarcopenia. Sarcopenia is known to adversely affect outcomes of patients with various forms of cancer. Early identification of sarcopenia is imperative in improving patient care and overall prognosis. Various interventions, such as resistance exercise, nutritional support, and amino acid and vitamin supplementation have shown promise in the management of sarcopenia. However, further insight into novel interventions and indeed, assessment of the benefits of management of sarcopenia in terms of survival, are required to better support cancer patients.

Muscle mass assessment in renal disease: the role of imaging techniques

Muscle wasting is a frequent finding in patients with chronic kidney disease (CKD), especially in those with end-stage kidney disease (ESKD) on chronic dialysis. Muscle wasting in CKD is a main feature of malnutrition, and results principally from a vast array of metabolic derangements typical of the syndrome, that converge in determining reduced protein synthesis and accelerated protein catabolism. In this clinical setting, muscle wasting is also frequently associated with disability, frailty, infections, depression, worsened quality of life and increased mortality. On these grounds, the evaluation of nutritional status is crucial for an adequate management of renal patients, and consists of a comprehensive assessment allowing for the identification of malnourished patients and patients at nutritional risk. It is based essentially on the assessment of the extent and trend of body weight loss, as well as of spontaneous dietary intake. Another key component of this evaluation is the determination of body composition, which, depending on the selected method among several ones available, can identify accurately patients with decreased muscle mass. The choice will depend on the availability and ease of application of a specific technique in clinical practice based on local experience, staff resources and good repeatability over time. Surrogate methods, such as anthropometry and bioimpedance analysis (BIA), represent the most readily available techniques. Other methods based on imaging modalities [dual-energy X-ray absorptiometry (DXA), magnetic resonance imaging (MRI), and whole body computed tomography (CT)] are considered to be the "gold standard" reference methods for muscle mass evaluation, but their use is mainly confined to research purposes. New imaging modalities, such as segmental CT scan and muscle ultrasound have been proposed in recent years. Particularly, ultrasound is a promising technique in this field, as it is commonly available for bedside evaluation of renal patients in nephrology wards. However, more data are needed before a routine use of ultrasound for muscle mass evaluation can be recommended in clinical practice.

Metabolic and Molecular Basis of Sarcopenia: Implications in the Management of Urothelial Carcinoma

Sarcopenia, which represents the degenerative and systemic loss of skeletal muscle mass, is a multifactorial syndrome caused by various clinical conditions. Sarcopenia reflects not only frailty and poor general health status, but also the possible presence of advanced or progressive cancer or cancer cachexia. Therefore, sarcopenia affects the management of cancer-bearing patients, including those with urothelial carcinoma. Recently, growing evidence has shown that sarcopenia is significantly associated with higher rates of treatment-related complications and worse prognosis in patients with urothelial carcinoma, including muscle-invasive bladder cancer, upper tract urothelial carcinoma, and advanced urothelial carcinoma. Moreover, several studies reported that a post-therapeutic increase in skeletal muscle mass predicts favorable prognosis in urothelial carcinoma patients. To further explore the role of sarcopenia in the management of urothelial carcinoma patients, comprehensive understanding of its pathophysiology is vital. In this article, we reviewed the metabolic and molecular basis of cancer cachexia and sarcopenia. From this viewpoint, we discussed the possible mechanism of changes in skeletal muscle mass during the course of treatment.

Impact of Sarcopenia as a Prognostic Biomarker of Bladder Cancer

Sarcopenia, the degenerative and systemic loss of skeletal muscle mass, indicates patient frailty and impaired physical function. Sarcopenia can be caused by multiple factors, including advanced age, lack of exercise, poor nutritional status, inflammatory diseases, endocrine diseases, and malignancies. In patients with cancer cachexia, anorexia, poor nutrition and systemic inflammation make the metabolic state more catabolic, resulting in sarcopenia. Thus, sarcopenia is considered as one of manifestations of cancer cachexia. Recently, growing evidence has indicated the importance of sarcopenia in the management of patients with various cancers. Sarcopenia is associated with not only higher rates of treatment-related complications but also worse prognosis in cancer-bearing patients. In this article, we summarized metabolic backgrounds of cancer cachexia and sarcopenia and definitions of sarcopenia based on computed tomography (CT) images. We conducted a systematic literature review regarding the significance of sarcopenia as a prognostic biomarker of bladder cancer. We also reviewed recent studies focusing on the prognostic role of changes in skeletal muscle mass during the course of treatment in bladder cancer patients. Lastly, we discussed the impact of nutritional support, medication, and exercise on sarcopenia in cancer-bearing patients.

Effect of Preoperative Bacteriuria and Pyuria on Intravesical Recurrence in Patients with Upper Tract Urothelial Carcinoma Undergoing Radical Nephroureterectomy

BACKGROUND/AIM

We investigated the effect of bacteriuria and pyuria on intravesical recurrence (IVR) in patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU).

PATIENTS AND METHODS

Preoperative bacteriuria and pyuria were defined as urine containing ≥5 bacteria/high-power field (HPF) and >5 white blood cells/HPF, respectively. Their associations with IVR were evaluated in 97 patients with UTUC undergoing RNU.

RESULTS

Preoperative bacteriuria [n=15 (15%)] was significantly associated with preoperative pyuria [n=42 (43%), p<0.001]. During follow-up (median of 19 months), 45 (46%) patients developed IVR (median IVR-free survival=38 months). On multivariate analysis, preoperative bacteriuria was an independent predictor for reduced risk of IVR (hazard ratio=0.23, p=0.010). The 2-year IVR-free survival of patients with preoperative bacteriuria and pyuria was significantly longer than that of patients without preoperative bacteriuria (83% vs. 54%, p=0.028) and pyuria (69% vs. 50%, p=0.024), respectively.

CONCLUSION

Bacteriuria and pyuria may reduce the risk of IVR in patients with UTUC undergoing RNU.

Posttherapeutic skeletal muscle mass recovery predicts favorable prognosis in patients with advanced urothelial carcinoma receiving first-line platinum-based chemotherapy

OBJECTIVES

Sarcopenia, decreased skeletal muscle mass (SMM), is an adverse prognostic factor in patients with advanced urothelial carcinoma (aUC). Given that SMM is variable depending on disease and patient conditions, changes in SMM over the course of treatments may be also prognostic. We investigated the prognostic role of posttherapeutic SMM recovery (PSR) in patients with aUC receiving first-line platinum-based chemotherapy.

MATERIALS AND METHODS

This retrospective study included 72 consecutive patients with aUC receiving first-line platinum-based chemotherapy. Skeletal muscle index (SMI) was measured on computed tomography images taken before the initiation of and immediately after 2 cycles of chemotherapy. ΔSMI was calculated as [(posttherapeutic SMI - pretherapeutic SMI)/pretherapeutic SMI] × 100, and PSR was defined as ΔSMI >0. Variables associated with progression-free survival (PFS) and overall survival (OS) were evaluated.

RESULTS

During the follow-up (median, 18mo for survivors), 60 (83%) patients progressed (2-year PFS, 17%) and 55 (76%) died (2-year OS, 24%). ΔSMI was significantly associated with chemotherapy response (P = 0.012), and was an independent predictor for both PFS (hazard ratio [HR] = 0.94, P<0.001) and OS (HR = 0.93, P<0.001). A total of 15 (21%) patients with PSR demonstrated significantly longer PFS and OS than those without PSR (both P<0.001). On multivariate analysis, PSR was an independent favorable predictor for both PFS (HR = 0.24, P<0.001) and OS (HR = 0.21, P<0.001). Incorporation of PSR into the Bajorin's and Galsky's models improved their c-indices (0.611-0.650, and 0.690-0.708, respectively).

CONCLUSIONS

PSR is a novel prognostic factor in patients with aUC receiving first-line platinum-based chemotherapy.