Can pancreatic cancer behavior be predicted based on computed tomography measurements of fat and muscle mass?

Are muscle and fat loss predictive of clinical events in pancreatic cancer? The importance of precision metrics

BACKGROUND

Muscle and fat loss from cancer may have prognostic significance. Skeletal muscle and fat areas measured at L3 on a CT scan correlate with body muscle and fat mass. We wished to know if reduced skeletal muscle area or fat on diagnostic CT scans or changes from initial CT scans in patients with pancreatic cancer who died in 2018 and 2019 predicted mortality.

METHOD

eEectronic records of 112 patients with locally advanced or metastatic pancreatic cancer were used to extract stage, age, gender, comorbidities, weight, and height at the time of the first CT scan. Survival (in days) was defined from the first CT scan to the death date. Patients had at least one CT scan of the abdomen. I. Two trained medical students read scans independently using TeraRecon software (Durham, NC). Results were averaged, and the differences determined precision. Interclass correlation coefficient (ICC), coefficient of variation, and least significant change determined the precision between readers. Independent prognostic modeling included age and BMI.

RESULTS

An evaluable sample of 104 with an average age of 67, 56 were male. Nearly half had a TNM Stage of IV (45%). The average Charlson Comorbidity index is 7.2. In those undergoing repeat scans, most were in the timeframe of 60-120 days. Changes in visceral fat in men in the unadjusted Cox proportional hazard model and reduced skeletal muscle area in the age-adjusted model of men predicted mortality. In contrast, myosteatosis in women marginally predicted improved survival. ICC's precision between readers was adequate but by least significant change would have missed subtle, clinically important changes.

DISCUSSION

Muscle loss during chemotherapy in men predicted mortality in men but not women. Precision is an important metric when measuring body composition.

CONCLUSION

Muscle loss in men during chemotherapy of pancreatic cancer predicts mortality.

Is Weight Loss During Chemotherapy for Pancreatic Cancer Prognostic?

BACKGROUND

Predicting poor survival outcomes early in palliative chemotherapy is important to the timing of palliative care. Weight loss during chemotherapy if prognostic would lead to early palliative care.

METHOD

We collected demographics, stage, chemotherapy, chemotherapy cycles, weight, healthcare utilization, comorbidities (Charleson Comorbid Index), tumor markers, and weight changes over 60 days. We defined 3 groups of patients: 1. Weight gain to <.5% weight loss, 2. Weight loss< 2% and 3. Weight loss of >2%. A Chi-square test assessed differences in weight during treatment. Time-to-event analysis was expressed in a Kaplan Meier curve.

RESULTS

93 individuals died of pancreatic cancer in 2018 and 2019. The median age was 71.2 years. Forty-three had stage I and II, 40 stages III and IV cancers, and 10 had unknown stages. Most received FOLFIRINOX and gemcitabine/nab-paclitaxel chemotherapy. Thirty-six gained to lost < .5% during chemotherapy,8 lost < 2% and 49 patients lost > 2% of their weight. Mortality was available in 55 of 93 patients. Median survival was 16.6 months in those with weight gain to < .5% weight loss, 17.28 months for those with < 2% weight loss, and 20.5 months for those with > 2% weight loss (P = .42).

DISCUSSION

Weight loss over 60 days did not predict a poor prognosis in this small retrospective study; larger prospective studies may clarify the prognostic importance of weight loss during chemotherapy.

CONCLUSION

In this small retrospective study, weight loss over 60 days did not predict poor survival.

The Prognostic Value of Low Muscle Mass in Pancreatic Cancer Patients: A Systematic Review and Meta-Analysis

Low muscle mass is associated with reduced survival in patients with different cancer types. The interest in preoperative sarcopenia and pancreatic cancer has risen in the last decade as muscle mass loss seems to be associated with poorer survival, higher postoperative morbidity, and mortality. The aim of the present study was to review the literature to compare the impact of low muscle mass on the outcomes of patients undergoing surgery for pancreatic adenocarcinoma. An extensive literature review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and 10 articles were analyzed in detail and included in the meta-analysis. Data were retrieved on 2811 patients undergoing surgery for pancreatic cancer. Meta-analysis identified that patients with low muscle mass demonstrated a significantly reduced OS when compared to patients without alterations of the muscle mass (ROM 0.86; 95% CI: 0.81-0.91, p < 0.001), resulting in a 14% loss for the former. Meta-analysis failed to identify an increase in the postoperative complications and length of stay of patients with low muscle mass. Our analysis confirms the role of low muscle mass in influencing oncologic outcomes in pancreatic cancer. Its role on surgical outcomes remains to be established.

Impact of progressive resistance training on CT quantified muscle and adipose tissue compartments in pancreatic cancer patients

Objectives

Loss of body weight is often seen in pancreatic cancer and also predicts poor prognosis. Thus, maintaining muscle mass is an essential treatment goal. The primary aim was to investigate whether progressive resistance training impacts muscle and adipose tissue compartments. Furthermore, the effect of body composition on overall survival (OS) was investigated.

Methods

In the randomized SUPPORT-study, 65 patients were assigned to 6-month resistance training (2x/week) or a usual care control group. As secondary endpoint, muscle strength of the upper and lower extremities was assessed before and after the intervention period. Routine CT scans were assessed on lumbar L3/4 level for quantification of total-fat-area, visceral-fat-area, subcutaneous-fat-area, intramuscular-fat-area, visceral-to-subcutaneous fat ratio (VFR), muscle-area (MA), muscle-density and skeletal-muscle-index (SMI). OS data were retrieved.

Results

Of 65 patients, 53 had suitable CT scans at baseline and 28 completed the intervention period with suitable CT scans. There were no significant effects observed of resistance training on body composition (p>0.05; effect sizes ω²_p <0.02). Significant moderate to high correlations were found between MA and muscle strength parameters (r = 0.57–0.85; p<0.001). High VFR at baseline was a predictor of poor OS (VFR≥1.3 vs. <1.3; median OS 14.6 vs. 45.3 months; p = 0.012). Loss of muscle mass was also a predictor of poor OS (loss vs. gain of SMI; median OS 24.6 vs. 50.8 months; p = 0.049).

Conclusion

There is anabolic potential in patients with resectable pancreatic cancer. A progressive resistance training may help patients to maintain their muscle mass and avoid muscle depletion. CT-quantified muscle mass at the level of L3/4 showed a good correlation to muscle strength. Therefore, maintaining muscle mass and muscle strength through structured resistance training could help patients to maintain their physical functioning. A high VFR at baseline and a high loss of muscle mass are predictors of poor OS. Registered on ClinicalTrials.gov (NCT01977066).

Power of computed-tomography-defined sarcopenia for prediction of morbidity after pancreaticoduodenectomy

BACKGROUND

The goal of our study was to evaluate the current approach in prediction of postoperative major complications after pancreaticoduodenectomy (PD), especially symptomatic pancreatic fistula (POPF), using parameters derived from computed tomography (CT).

METHODS

Patients after PD were prospectively collected in a database of the local department of surgery and all patients with CT scans available were assessed in this study. CT parameters were measured at the level of the intervertebral disc L3/L4 and consisted of the areas of the visceral adipose tissue (AVAT), the diameters of the pancreatic parenchyma (DPP) and the pancreatic duct (DPD), the areas of ventral abdominal wall muscle (AMVEN), psoas muscle (AMPSO), paraspinal muscle (AMSPI), total muscle (AMTOT), as well as the mean muscle attenuation (MA) and skeletal muscle index (SMI). Mann-Whitney-U Test for two independent samples and binary logistic regression were used for statistical analysis.

RESULTS

One hundred thirty-nine patients (55 females, 84 males) were included. DPD was 2.9 mm (Range 0.7-10.7) on median and more narrow in patients with complications equal to or greater stadium IIIb (p < 0.04) and severe POPF (p < 0.01). DPP median value was 17 (6.9-37.9) mm and there was no significant difference regarding major complications or POPF. AVAT showed a median value of 127.5 (14.5-473.0) cm2 and was significantly larger in patients with POPF (p < 0.01), but not in cases of major complications (p < 0.06). AMPSO, AMSPI, AMVEN and AMTOT showed no significant differences between major complications and POPF. MA was both lower in groups with major complications (p < 0.01) and POPF (p < 0.01). SMI failed to differentiate between patients with or without major complications or POPF.

CONCLUSION

Besides the known factors visceral obesity and narrowness of the pancreatic duct, the mean muscle attenuation can easily be examined on routine preoperative CT scans and seems to be promising parameter to predict postoperative complications and POPF.

L3 skeletal muscle index (L3SMI) is a surrogate marker of sarcopenia and frailty in non-small cell lung cancer patients

Background: Non-small cell lung cancer (NSCLC) is a common and highly lethal disease. As advanced treatment modalities are being developed, improved prognostication methods are sought. L3 skeletal muscle index (L3SMI) and alanine aminotransferase (ALT) levels are accepted surrogate markers of sarcopenia and related frailty. We aimed to evaluate the potential association of these markers with NSCLC patients’ survival.

Methods: A retrospective, single-center study of an NSCLC patients’ cohort. L3SMI was calculated based on skeletal muscle area on computed tomography scans at the level of the L3 vertebra. Clinical data were extracted from clinical charts.

Results: A total of 140 patients (56.4% males, median age 66 [range 37–86]) were included in this study, 32% were diagnosed at stage 3 and 45% at stage 4. During the follow-up duration (median of 1.9 years; range 1 month to 6.4 years), 102 patients (72.8%) died. Patients’ characteristics that were found to be associated with increased mortality were performance status, albumin and tumor stage at diagnosis. Sarcopenia, defined as low L3SMI (lower than 41 cm²/m² for women and lower than 53 cm²/m² for men) was significantly associated with higher risk of mortality compared with patients with normal L3SMI values (77.2%, vs 64.6%, p=0.013) in univariate analysis, but not in a multiple regression analysis.

Conclusion: Low L3SMI could serve as a surrogate marker for sarcopenia and frailty and, as such, facilitate the prognostication process of NSCLC patients.