The advantages and limitations of cross-sectional body composition analysis

Advantages and Limitations of the Body Mass Index (BMI) to Assess Adult Obesity

Obesity reflects excessive fat deposits. At-risk individuals are guided by healthcare professionals to eat fewer calories and exercise more, often using body mass index (BMI; weight/height2) thresholds for screening and to guide progress and prognosis. By conducting a mini-narrative review of original articles, websites, editorials, commentaries, and guidelines, we sought to place BMI in the context of its appropriate use in population health, clinical screening, and monitoring in clinical care. The review covers studies and publications through 2023, encompassing consensus reviews and relevant literature. Recent consensus reviews suggest that BMI is a valuable tool for population surveys and primary healthcare screening but has limitations in predicting the risk of chronic diseases and assessing excess fat. BMI can guide nutritional and exercise counseling, even if it is inadequate for reliable individual risk prediction. BMI cut-offs must be reconsidered in populations of varying body build, age, and/or ethnicity. Since BMI-diagnosed overweight persons are sometimes physically and physiologically fit by other indicators, persons who are overweight on BMI should be more fully evaluated, diagnosed, and monitored with combined anthropometric and performance metrics to better clarify risks. The use of combined anthropometric and performance metrics involves integrating measurements of body composition with assessments of physical function and fitness to provide a more comprehensive evaluation of an individual's health and fitness status. Eligibility for bariatric surgery or semaglutide satiety/appetite-reduction medications should not be determined by BMI alone. Awareness of the advantages and limitations of using BMI as a tool to assess adult obesity can maximize its appropriate use in the context of population health and in rapid clinical screening and evaluation.

Body adipose tissue depots and treatment outcomes for women with breast cancer: A systematic review

BACKGROUND & AIMS

Excessive adipose tissue is associated with poorer prognosis in women with breast cancer (BC). However, several body adiposity depots, such as visceral (VAT), subcutaneous (SAT), intermuscular (IMAT), and gluteofemoral adipose tissues (GFAT) may have heterogeneous metabolic roles and health effects in these patients. This systematic review aims to evaluate the impact of different body adipose tissue depots, assessed via computed tomography (CT), on treatment outcomes for women with BC. We hypothesize that distinct body adipose tissue depots may be associated differently with outcomes in patients with BC.

METHODS

A comprehensive bibliographical search was conducted using PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases (until January 2024). The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

The final sample comprised 23 retrospective studies (n = 12,462), with fourteen presenting good quality. A lack of standardization in CT body adipose tissue depots measurement and outcome presentation precluded quantitative analysis. Furthermore, most included studies had heterogeneous clinical characteristics. Survival and treatment response were the most prevalent outcomes. VAT (n = 19) and SAT (n = 17) were the most frequently evaluated depots and their increase was associated with worse outcomes, mainly in terms of survival. IMAT (n = 4) presented contradictory findings and a higher GFAT (n = 1) was associated with better outcomes.

CONCLUSION

This systematic review found an association between increased VAT and SAT with worse outcomes in patients with BC. However, due to the heterogeneity of the included studies, further research with homogeneous methodologies is necessary to better understand the impact of body adipose tissue depots on treatment outcomes. Such knowledge could lead to improved care for this patient population.

Associations Between Visceral Fat, Abdominal Muscle, and Coronary Artery Calcification: A Cross-Sectional Analysis of the Multi-Ethnic Study of Atherosclerosis

The associations of body composition components, including muscle and adipose tissue, and markers of subclinical coronary artery disease are unclear. We examined the relation between abdominal computed tomography (CT)-derived measures of the area and density of fat and muscle with coronary artery calcification (CAC), using data from the Multi-Ethnic Study of Atherosclerosis (MESA). A total of 1,974 randomly selected MESA participants free of coronary heart disease underwent abdominal CT scans at examinations 2 or 3, with the resulting images interrogated for abdominal body composition. Using 6 cross-sectional slices spanning L2 to L5, the Medical Imaging Processing Analysis and Visualization software was used to determine abdominal muscle and fat composition using appropriate Hounsfield units ranges. CT chest scans were used to obtain CAC scores, calculated using the Agatston method and spatially weighted calcium score. Multivariable linear and logistic regression analyses were performed to assess the relation between abdominal visceral fat and muscle area and density to prevalent CAC. A total of 1,089 participants had a CAC >0, with an average CAC score of 310. In the fully adjusted model, for every 10-cm2 increase in visceral fat area, the likelihood of having a CAC greater than 0 increased by 0.60% (p <0.001). In the minimally adjusted model, abdominal muscle area was significantly associated with CAC >0, which became nonsignificant in the fully adjusted model. For the density of visceral fat, every 1-Hounsfield unit increase (less lipid-dense fat tissue), the likelihood of having a CAC score >0 decreased by 0.29% (p <0.05). No significant relation was observed between density of abdominal muscle and CAC >0. A greater area and higher lipid density of abdominal visceral fat were associated with an increased likelihood of having CAC, whereas there was no significant relation between abdominal muscle area or density and CAC. The quantity and the quality of fat have associations, with an important marker of subclinical atherosclerosis, CAC, and their significance with respect to cardiovascular outcomes, require further evaluation.

Quantifying the severity of sarcopenia in patients with cancer of the head and neck

BACKGROUND & AIMS

Existing skeletal muscle index (SMI) thresholds for sarcopenia are inconsistent, and do not reflect severity of depletion. In this study we aimed to define criterion values for moderate and severe skeletal muscle depletion based on the risk of mortality in a population of patients with head and neck cancer (HNC). Additionally, we aimed to identify clinical and demographic predictors of skeletal muscle depletion, evaluate the survival impact of skeletal muscle depletion in patients with minimal nutritional risk or good performance status, and finally, benchmarking SMI values of patients with HNC against healthy young adults.

METHODS

Population cohort of 1231 consecutive patients and external validation cohorts with HNC had lumbar SMI measured by cross-sectional imaging. Optimal stratification determined sex-specific thresholds for 2-levels of SMI depletion (Class I and II) based on overall survival (OS). Adjusted multivariable regression analyses (tumor site, stage, performance status, age, sex, dietary intake, weight loss) determined relationships between 2-levels of SMI depletion and OS.

RESULTS

Mean SMI (cm2/m2) was 51.7 ± 9.9 (males) and 39.8 ± 7.1 (females). The overall and sex-specific population demonstrated an increased risk of mortality associated with decreasing SMI. Sex-specific SMI (cm2/m2) depletion thresholds for 2-levels of muscle depletion determined by optimal stratification for males and females, respectively (male: 45.2-37.5, and <37.5; female: 40.9-34.2, and <34.2). In the overall population, Normal SMI, Class I and II SMI depletion occurred in 65.0%, 24.0%, and 11.0%, respectively. Median OS was: Normal SMI (114 months, 95% CI, 97.1-130.8); Class I SMI Depletion (42 months, 95% CI, 28.5-55.4), and Class II SMI Depletion (15 months, 95% CI, 9.8-20.1). Adjusted multivariable analysis compared with Normal SMI (reference), Class I SMI Depletion (HR, 1.49; 95% CI, 1.18-1.88; P < .001), Class II SMI Depletion (HR, 1.91; 95% CI, 1.42-2.58; P < .001).

CONCLUSIONS

Moderate and severe SMI depletion demonstrate discrimination in OS in patients with HNC. Moderate and severe SMI depletion is prevalent in patients with minimal nutrition risk and good performance status. Benchmarking SMI values against healthy young adults exemplifies the magnitude of SMI depletion in patients with HNC and may be a useful method in standardizing SMI assessment.

Association between increased Subcutaneous Adipose Tissue Radiodensity and cancer mortality: Automated computation, comparison of cancer types, gender, and scanner bias

PURPOSE

Body composition analysis using computed tomography (CT) is proposed as a predictor of cancer mortality. An association between subcutaneous adipose tissue radiodensity (SATr) and cancer-specific mortality was established, while gender effects and equipment bias were estimated.

METHODS

7,475 CT studies were selected from 17 cohorts containing CT images of untreated cancer patients who underwent follow-up for a period of 2.1-118.8 months. SATr measures were collected from published data (n = 6,718) or calculated according to CT images using a deep-learning network (n = 757). The association between SATr and mortality was ascertained for each cohort and gender using the p-value from either logistic regression or ROC analysis. The Kruskal-Wallis test was used to analyze differences between gender distributions, and automatic segmentation was evaluated using the Dice score and five-point Likert quality scale. Gender effect, scanner bias and changes in the Hounsfield unit (HU) to detect hazards were also estimated.

RESULTS

Higher SATr was associated with mortality in eight cancer types (p < 0.05). Automatic segmentation produced a score of 0.949 while the quality scale measurement was good to excellent. The extent of gender effect was 5.2 HU while the scanner bias was 10.3 HU. The minimum proposed HU change to detect a patient at risk of death was between 5.6 and 8.3 HU.

CONCLUSIONS

CT imaging provides valuable assessments of body composition as part of the staging process for several cancer types, saving both time and cost. Gender specific scales and scanner bias adjustments should be carried out to successfully implement SATr measures in clinical practice.

Body composition and cancer survival: a narrative review

Interest in understanding the relationship between body composition and cancer survival has remained strong for decades, with a number of recent systematic reviews on the topic. However, the current state of evidence is based on heterogeneous exposure definitions based on anthropometry, yielding inconsistent findings with regard to this association. Recently the field has taken an exciting direction with the application of radiological assessments to measure specific aspects of body composition, yet reconciliation of findings from these modern assessment tools with those from the historic use of anthropometric data proves challenging. In this paper, I briefly review the biological basis for a link between body composition and cancer survival and summarize the epidemiological evidence with consideration to specific exposure measures. As enthusiasm is building around novel assessments, I conclude with a discussion of issues that researchers should be aware of when interpreting results from these new modalities.

CT-based screening of sarcopenia and its role in cachexia syndrome in pancreatic cancer

Since computed tomography (CT) is a part of standard diagnostic protocol in pancreatic ductal adenocarcinoma (PDAC), we have evaluated the value of CT for sarcopenia screening in patients with PDAC, intending to expand the diagnostic value of tomographic studies. In our study, we included 177 patients with available CT images. Two groups were formed: Group 1 consisted of 117 patients with PDAC in various locations and stages and Group 2, or the control group, consisted of 60 "nominally healthy" patients with other somatic non-oncological diseases. The body mass index (BMI) was defined as a ratio of patient's weight to the square of their height (kg/m2). CT-based body composition analysis was performed using commercially available software with evaluation of sarcopenia using skeletal muscle index (SMI, cm2/m2). Based on the SMI values, sarcopenia was found in 67.5% of patients (79 out of 117) in the first patient group. It was found more frequently in males (42 out of 56; 75%) than in females (37 out of 61; 60.6%). Additionally, we observed a decrease in muscle mass (hidden sarcopenia) in 79.7% in patients with a normal BMI. Even in overweight patients, sarcopenia was found in 50% (sarcopenic obesity). In patients with reduced BMI sarcopenia was found in all cases (100%). Statistically significant difference of SMI between two groups was revealed for both sexes (p = 0,0001), with no significant difference between groups in BMI. BMI is an inaccurate value for the assessment of body composition as it does not reflect in the details the human body structure. As SMI may correlate with the prognosis, decreased muscle mass- especially "hidden" sarcopenia or sarcopenic obesity- should be reported. The use of CT-based evaluation of sarcopenia and sarcopenic obesity will allow for a better treatment response assessment in patients with cancer cachexia.

Mechanisms of Ovarian Cancer-Associated Cachexia

Cancer-associated cachexia occurs in 50% to 80% of cancer patients and is responsible for 20% to 30% of cancer-related deaths. Cachexia limits survival and treatment outcomes, and is a major contributor to morbidity and mortality during cancer. Ovarian cancer is one of the leading causes of cancer-related deaths in women, and recent studies have begun to highlight the prevalence and clinical impact of cachexia in this population. Here, we review the existing understanding of cachexia pathophysiology and summarize relevant studies assessing ovarian cancer-associated cachexia in clinical and preclinical studies. In clinical studies, there is increased evidence that reduced skeletal muscle mass and quality associate with worse outcomes in subjects with ovarian cancer. Mouse models of ovarian cancer display cachexia, often characterized by muscle and fat wasting alongside inflammation, although they remain underexplored relative to other cachexia-associated cancer types. Certain soluble factors have been identified and successfully targeted in these models, providing novel therapeutic targets for mitigating cachexia during ovarian cancer. However, given the relatively low number of studies, the translational relevance of these findings is yet to be determined and requires more research. Overall, our current understanding of ovarian cancer-associated cachexia is insufficient and this review highlights the need for future research specifically aimed at exploring mechanisms of ovarian cancer-associated cachexia by using unbiased approaches and animal models representative of the clinical landscape of ovarian cancer.

Sarcopenic obesity research perspectives outlined by the sarcopenic obesity global leadership initiative (SOGLI) - Proceedings from the SOGLI consortium meeting in rome November 2022

The European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO) launched the Sarcopenic Obesity Global Leadership Initiative (SOGLI) to reach expert consensus on a definition and diagnostic criteria for Sarcopenic Obesity (SO). The present paper describes the proceeding of the Sarcopenic Obesity Global Leadership Initiative (SOGLI) meeting that was held on November 25th and 26th, 2022 in Rome, Italy. This consortium involved the participation of 50 researchers from different geographic regions and countries. The document outlines an agenda advocated by the SOGLI expert panel regarding the pathophysiology, screening, diagnosis, staging and treatment of SO that needs to be prioritized for future research in the field.

Prevalence and Impact of Computed Tomography-Defined Sarcopenia on Survival in Patients with Human Papillomavirus-Positive Oropharyngeal Cancer: A Systematic Review

Sarcopenia is a known independent prognostic factor for decreased survival in patients with head and neck cancer; yet, its importance for the growing number of younger patients diagnosed with human papillomavirus (HPV)-positive oropharyngeal carcinoma (OPC+) has not been established. This systematic literature review aimed to determine the prevalence and impact of computed tomography (CT)-defined sarcopenia on survival outcomes for adult OPC+ patients (>18 y) undergoing any treatment modality. Prospective studies were searched using PubMed, Embase, CENTRAL, CINAHL, and Web of Science up until and including February 2022. Bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. In total, 9 studies (total pooled OPC+ patients, n  = 744) were identified and included in this review; 2 at low, 6 at moderate, and 1 at high risk of bias. All studies varied in sarcopenia assessment methods and skeletal muscle index threshold cutoff values. These studies demonstrated the cumulative prevalence of sarcopenia for OPC+ patients to be 42.9% (95% CI: 37.8%, 47.9%). While overall survival (3 studies, n = 253) and progression-free survival (1 study, n = 117) was lower in sarcopenic OPC+ patients, this was not statistically significant. GRADE certainty of evidence for impact of pretreatment sarcopenia on overall survival was low and progression-free survival was very low. Although these studies showed there to be a high prevalence of pretreatment sarcopenia in patients with OPC+, which may decrease survival, the impact on progression-free survival is very uncertain. Further, high-quality research utilizing consistent sarcopenia definitions and assessment methods that are conducted specifically in OPC+ is required to strengthen evidence certainty and determine if sarcopenia is an independent prognostic factor for this population.

Assessing Visceral Obesity and Abdominal Adipose Tissue Distribution in Healthy Populations Based on Computed Tomography: A Large Multicenter Cross-Sectional Study

Objective

Abdominal adipose is closely related to many endocrine and metabolic diseases. The aim of this study was to analyze the distribution of abdominal adipose tissue in a healthy population in northern China determined by abdominal computed tomography (CT).

Methods

Data for this study were obtained from a multicenter, retrospective, cross-sectional study that collected abdominal CT scans of 1787 healthy individuals from 4 representative cities in northern China. Areas of visceral adipose tissue (VATA) and subcutaneous adipose tissue (SATA) were obtained by measuring CT images at the level of the 3rd lumbar vertebra. Visceral adipose tissue index (VATI) and subcutaneous adipose index (SATI) were obtained by normalizing the square of height to analyze the distribution of the above indexes and visceral obesity among different body mass index (BMI), gender and age.

Results

The mean age of this healthy population was 45.3 ± 15.2 years and the mean BMI was 23.5 ± 3.2 kg/m², with 902 men and 885 women. Compared with women, men had a significantly higher median VATA (120.9 vs. 67.2 cm²), VATI (39.1 vs. 25.6 cm²/m²) and a significantly higher percentage of visceral adiposity (VATA ≥ 100 cm²) (60.8 vs. 30.4%), while women had significantly higher SATA (116.9 vs. 146.7 cm²) and SATI (38.8 vs. 55.8 cm²/m²) than men. Whether men or women, VATI was positively correlated with age. Interestingly, SATI was weakly positively correlated with age in women, while SATI was weakly negatively correlated with age in men. In persons with a normal BMI, the proportion of visceral adiposity increases with age, whereas in men with a normal BMI, the proportion of visceral adiposity decreases after the age of 60 years but remains >50%.

Conclusions

The distribution of abdominal visceral and subcutaneous adipose tissue parameters measured by CT differed among gender, age, and BMI. Even men and women with normal BMI have a high proportion of visceral obesity.

Evaluation of a Fully Automatic Deep Learning-Based Method for the Measurement of Psoas Muscle Area

Background

Manual muscle mass assessment based on Computed Tomography (CT) scans is recognized as a good marker for malnutrition, sarcopenia, and adverse outcomes. However, manual muscle mass analysis is cumbersome and time consuming. An accurate fully automated method is needed. In this study, we evaluate if manual psoas annotation can be substituted by a fully automatic deep learning-based method.

Methods

This study included a cohort of 583 patients with severe aortic valve stenosis planned to undergo Transcatheter Aortic Valve Replacement (TAVR). Psoas muscle area was annotated manually on the CT scan at the height of lumbar vertebra 3 (L3). The deep learning-based method mimics this approach by first determining the L3 level and subsequently segmenting the psoas at that level. The fully automatic approach was evaluated as well as segmentation and slice selection, using average bias 95% limits of agreement, Intraclass Correlation Coefficient (ICC) and within-subject Coefficient of Variation (CV). To evaluate performance of the slice selection visual inspection was performed. To evaluate segmentation Dice index was computed between the manual and automatic segmentations (0 = no overlap, 1 = perfect overlap).

Results

Included patients had a mean age of 81 ± 6 and 45% was female. The fully automatic method showed a bias and limits of agreement of -0.69 [-6.60 to 5.23] cm2, an ICC of 0.78 [95% CI: 0.74-0.82] and a within-subject CV of 11.2% [95% CI: 10.2-12.2]. For slice selection, 84% of the selections were on the same vertebra between methods, bias and limits of agreement was 3.4 [-24.5 to 31.4] mm. The Dice index for segmentation was 0.93 ± 0.04, bias and limits of agreement was -0.55 [1.71-2.80] cm2.

Conclusion

Fully automatic assessment of psoas muscle area demonstrates accurate performance at the L3 level in CT images. It is a reliable tool that offers great opportunities for analysis in large scale studies and in clinical applications.

Piloting a training program in computed tomography (CT) skeletal muscle assessment for Registered Dietitians

BACKGROUND

Consensus definitions for disease-associated malnutrition and sarcopenia include reduced skeletal muscle mass as a diagnostic criterion. There is a need to develop and validate techniques to assess skeletal muscle in clinical practice. Skeletal muscle mass can be precisely quantified from computed tomography (CT) images. This pilot study aimed to train Registered Dietitians (RD) to complete precise skeletal muscle measurements using CT.

METHODS

Purposive sampling identified RDs employed in clinical areas where CT scans are routinely performed. CT training included: 1) a 3-day training session focused on manual segmentation of skeletal muscle cross-sectional areas (cm² ) from abdominal CT images at the third lumber (L3) vertebra, using SliceOmatic® software, and 2) a precision assessment to quantify the intra- and inter-observer precision error of repeated skeletal muscle measurements (30 images in duplicate). Precision error is reported as the root mean standard deviation (cm² ) and % coefficient of variation (%CV), our primary performance indicator was defined as a precision error <2%.

RESULTS

Five RDs completed CT training. RDs were from three clinical areas (cancer care (N=1), surgery (N=2), and critical care (N=1). RDs precision error was low and below the minimal acceptable error of <2%; intra-observer error was ≤1.8 cm² (range 0.8 - 1.8 cm² ) or ≤1.5% (range 0.8 - 1.5%) and inter-observer error was 1.2 cm² or 1.1%.

CONCLUSION

RDs can be trained to perform precise CT skeletal muscle measurements. Increasing capacity to assess skeletal muscle is a first step toward developing this technique for use in clinical practice.

CLINICAL RELEVANCE STATEMENT

There is significant interest from both researchers and clinicians to undertake the measurement of skeletal muscle. Reduced skeletal muscle mass places individuals at risk of experiencing adverse outcomes and is a diagnostic criterion for disease-associated malnutrition and sarcopenia. In this study we piloted a training program in computed tomography (CT)-skeletal muscle assessments for RDs, and demonstrated after completion of the program RDs were able to perform CT skeletal muscle measurements with high precision. The addition of new tools to the comprehensive nutrition assessment tool box may benefit clinical practice in multiple ways including improved identification of patients with reduced skeletal muscle mass, individualization of interventions, and monitoring effectiveness of interventions over time. Other clinicians may also benefit from knowing about their patients' skeletal muscle mass to help identify risk and make treatment decisions. This article is protected by copyright. All rights reserved.

Definition and Diagnostic Criteria for Sarcopenic Obesity: ESPEN and EASO Consensus Statement

INTRODUCTION

Loss of skeletal muscle mass and function (sarcopenia) is common in individuals with obesity due to metabolic changes associated with a sedentary lifestyle, adipose tissue derangements, comorbidities (acute and chronic diseases) and during the ageing process. Co-existence of excess adiposity and low muscle mass/function is referred to as sarcopenic obesity (SO), a condition increasingly recognized for its clinical and functional features that negatively influence important patient-centred outcomes. Effective prevention and treatment strategies for SO are urgently needed, but efforts are hampered by the lack of a universally established SO definition and diagnostic criteria. Resulting inconsistencies in the literature also negatively affect the ability to define prevalence as well as clinical relevance of SO for negative health outcomes.

AIMS AND METHODS

The European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO) launched an initiative to reach expert consensus on a definition and diagnostic criteria for SO. The jointly appointed international expert panel proposes that SO is defined as the co-existence of excess adiposity and low muscle mass/function. The diagnosis of SO should be considered in at-risk individuals who screen positive for a co-occurring elevated body mass index or waist circumference, and markers of low skeletal muscle mass and function (risk factors, clinical symptoms, or validated questionnaires). Diagnostic procedures should initially include assessment of skeletal muscle function, followed by assessment of body composition where presence of excess adiposity and low skeletal muscle mass or related body compartments confirm the diagnosis of SO. Individuals with SO should be further stratified into stage I in the absence of clinical complications or stage II if cases are associated with complications linked to altered body composition or skeletal muscle dysfunction.

CONCLUSIONS

ESPEN and EASO, as well as the expert international panel, advocate that the proposed SO definition and diagnostic criteria be implemented into routine clinical practice. The panel also encourages prospective studies in addition to secondary analysis of existing data sets, to study the predictive value, treatment efficacy and clinical impact of this SO definition.

Contributing effects of individual characteristics, behavioural and job-related factors on occurrence of mining-related injuries: A systematic review

BACKGROUND

Occupational health and safety (OHS) is a complex system due to its three components, namely human, technological and organizational factors. The interplay between the three systems causes workplace accidents and, subsequently, injuries. The body of research currently available demonstrates a disparity in the focus on contributors that cause mining-related injuries beyond the presence of hazards.

OBJECTIVE

The aim of this paper was to systematically review and synthesise peer-reviewed published studies that have investigated whether certain individual characteristics, behavioural factors and job-related factors predict mining-related injuries.

METHODS

Databases were searched and peer-reviewed publications from 2004 to 2020 were retrieved and analysed. Only 24 from 3073 identified articles were retained for review and synthesis following careful screening. Most identified studies were either cross-sectional or case-control studies, and they were rated as moderate-to-good quality.

RESULTS

The review results showed that there is a diverging view in relation to risk factors that cause mining-related injuries. Some publications suggested that old age, male miners, married miners, less educated miners, less experienced miners, alcohol and drug usage, poor working conditions, poor management or supervision, job dissatisfaction and job stress predict injury events while other studies found contradictory relationships or insignificant statistical associations.

CONCLUSIONS

Despite the fact that studied risk factors have been well-established in other industries, there is a significant gap in mining that needs further examination. It is imperative that health and safety intervention strategies are devised and implemented for vulnerable groups.

Nutritional status and skeletal muscle status in patients with head and neck cancer: Impact on outcomes

BACKGROUND

Computed tomography (CT)-defined skeletal muscle depletion and malnutrition are demonstrated as poor prognostic factors in patients with head and neck cancer (HNC), however to date, have only been explored in isolation. We aimed to describe body composition profile and examine the impact of nutritional status as well as independently and concurrently occurring body composition features on overall survival, treatment completion, unplanned admissions and length of stay (LOS) in patients undergoing radiotherapy (RT) or chemoradiotherapy (CRT) of curative intent for HNC.

METHODS

This work is a retrospective, observational study of patients who had completed treatment of curative intent for HNC. Scored Patient-Generated Subjective Global Assessment (PG-SGA) was used to determine nutritional status. Tissue-density data were derived at the third lumbar vertebra (L3) with sarcopenia and myosteatosis defined by published, sex-specific threshold values stratified by body mass index for skeletal muscle index (cm2 /m2 ) and skeletal muscle radiodensity (SMR, Hounsfield Unit).

RESULTS

Pre-treatment data (n = 277: 78% male, mean (SD) age 60 (13) years) revealed the prevalence of malnutrition (24.9%), sarcopenia (52.3%), myosteatosis (82.3%), and concurrently occurring sarcopenia and myosteatosis (39.7%). Malnutrition was independently associated with reduced OS for patients with moderate [hazard ratio (HR) 2.57; 95% confidence interval (CI) 1.45-4.55, P = 0.001] and severe (HR 3.19; 95% CI 1.44-7.07, P = 0.004) malnutrition on multivariable analysis but not sarcopenia (HR 1.09; 95% CI 0.70-1.71), P = 0.700 or myosteatosis (HR 1.28; 95% CI 0.57-2.84), P = 0.500). Malnutrition was associated with treatment discontinuation (P < 0.001), not completing RT as planned (P < 0.001), unplanned hospital admission (P = 0.021), and greater LOS (P < 0.001). Skeletal muscle status features were associated with unplanned hospital admissions for those with no features (32%), with sarcopenia only (50%), myosteatosis only (25%), and concurrent sarcopenia and myosteatosis (50%), P < 0.001. Similarly, a clinically relevant greater median (Q1, Q3) LOS was observed for those with sarcopenia only [5 (3, 32)], myosteatosis only [10 (5, 30)], concurrent sarcopenia, and myosteatosis [14 (4, 33)] days vs. those with no features [3 (2, 11)] days, P = 0.2.

CONCLUSIONS

Malnutrition was a more powerful prognostic indicator than CT-defined skeletal muscle depletion and was independently associated with reduced OS in patients undergoing RT or CRT of curative intent for HNC. CT-defined skeletal muscle depletion studies should recognize the multifaceted nature of human body composition and also measure nutritional status using validated methods in order to move towards developing a typology of high risk criteria for this complex patient group.

Skeletal muscle radiodensity and cancer outcomes: A scoping review of the literature

Patients with cancer are more prone to experience myosteatosis than healthy individuals. The aim of this review was to summarize the methodologies applied for low skeletal muscle radiodensity (SMD) assessment in oncology patients, as well as to describe the major findings related to SMD and cancer outcomes. This scoping review included studies that were published until November 2020 in English, Portuguese, or Spanish; were performed in humans diagnosed with cancer, adult and/or elderly, of both sexes; investigated SMD through computed tomography of the region between the third and fifth lumbar vertebrae, considering at least two muscular groups; and evaluated clinical and/or surgical outcomes. Eighty-eight studies met the inclusion criteria (n = 37,583 patients). Survival was the most evaluated outcome. Most studies reported a significant association between low SMD and unfavorable outcomes. However, this relationship was not clear for survival, antineoplastic treatment, and surgical complications, potentially because of the unstandardized approaches for the assessment of SMD and inadequate study design. Future studies should address these issues to provide an in-depth understanding of the clinical relevance of SMD in cancer outcomes as well as how SMD is influenced by individuals and tumor-related characteristics in patients with cancer.

Perturbed BMP signaling and denervation promote muscle wasting in cancer cachexia

Most patients with advanced solid cancers exhibit features of cachexia, a debilitating syndrome characterized by progressive loss of skeletal muscle mass and strength. Because the underlying mechanisms of this multifactorial syndrome are incompletely defined, effective therapeutics have yet to be developed. Here, we show that diminished bone morphogenetic protein (BMP) signaling is observed early in the onset of skeletal muscle wasting associated with cancer cachexia in mouse models and in patients with cancer. Cancer-mediated factors including Activin A and IL-6 trigger the expression of the BMP inhibitor Noggin in muscle, which blocks the actions of BMPs on muscle fibers and motor nerves, subsequently causing disruption of the neuromuscular junction (NMJ), denervation, and muscle wasting. Increasing BMP signaling in the muscles of tumor-bearing mice by gene delivery or pharmacological means can prevent muscle wasting and preserve measures of NMJ function. The data identify perturbed BMP signaling and denervation of muscle fibers as important pathogenic mechanisms of muscle wasting associated with tumor growth. Collectively, these findings present interventions that promote BMP-mediated signaling as an attractive strategy to counteract the loss of functional musculature in patients with cancer.

Benefit of Sarcopenia Screening in Older Patients Undergoing Surgical Aortic Valve Replacement

BACKGROUND

Sarcopenia, known as physical frailty, is highly prevalent in older patients and is related to adverse outcomes post-cardiac surgery. However, whether sarcopenia assessment can reclassify an individual patients' risk, which is estimated by Society of Thoracic Surgeons-predicted risk of mortality scores in patients who undergo surgical aortic valve replacement, is unclear.

METHODS

This retrospective, single center, cohort study comprised 874 patients aged ≥65 years who underwent surgical aortic valve replacement between 2009 and 2016. Total skeletal muscle area was calculated using height-squared and was measured by preoperative computed tomography at the third lumbar vertebra inferior border using machine learning-based analysis. Sex-specific Z-scores were calculated and patients in the lowest Z-score tertile were considered to have sarcopenia. The primary endpoint was 30-day mortality, and secondary endpoints were in-hospital events, 1-year mortality, and long-term mortality.

RESULTS

Thirty-day mortality, 30-day in-hospital events, and one-year mortality rates were 4.7%, 17.6%, and 8.0%, respectively. As the Z-score decreased, early adverse event odds showed a stepwise increase. Sarcopenia were independently associated with higher 30-day mortality, 30-day in-hospital events, and 1-year mortality. Reclassification analyses showed improvements in the ability to predict early adverse events after adding the Z-scores over and above the Society of Thoracic Surgeons-predicted risk of mortality scores (All, p <0.005).

CONCLUSIONS

Sarcopenic patients had significantly higher risks of early adverse events and long-term mortality after undergoing surgical aortic valve replacement than non-sarcopenic patients. Sarcopenia determined by preoperative computed tomography can enhance the prediction of postoperative outcome risk.

Assessment of Acute Pancreatitis Severity and Prognosis with CT-Measured Body Composition

Objective

The aim of this study was to investigate the possible association of muscle and adipose parameters with the severity and prognosis of patients hospitalized with acute pancreatitis (AP).

Methods

A total of 392 hospitalized patients and 309 controls were enrolled in the study analysis from April 1, 2016, to February 1, 2021. The computed tomography scans of each population were evaluated for muscle and adipose parameters. The effects of parameters on developing moderately severe acute pancreatitis (MSAP) or severe acute pancreatitis (SAP) were evaluated using univariate and multivariate logistic regression analyses. Associations with disease recurrence and death were analyzed through Cox regression analysis.

Results

The AP patients had higher levels of visceral adipose tissue (144.25 vs 97.81 cm², p < 0.001) and subcutaneous adipose tissue (135 vs 120 cm², p < 0.001) but lower levels of adipose tissue attenuation (visceral and subcutaneous) and skeletal muscle attenuation (SMA) than the controls (p < 0.05, respectively). Visceral adipose tissue (VAT) and SMA differed significantly with p-values of 0.014 and 0.003 in the different severity groups of AP. In multivariate analysis, VAT and SMA were associated with MSAP or SAP, with odds ratios of 1.003 and 0.973, respectively (95% CI 1.000-1.006, p = 0.041; 95% CI 0.953-0.993, p = 0.010). Cox regression analysis showed that low SMA was strongly associated with an increased mortality in MSAP and SAP patients (HR 10.500, 95% CI 1.344-82.025, p = 0.025). Regression analysis also showed an association of VAT loss of more than 17% with reduced 1-year recurrence of acute pancreatitis (HR 0.427, 95% CI 0.189-0.967, p = 0.041).

Conclusion

VAT and SMA were influential factors for the severity and prognosis of patients with AP. Patients should proper diet and exercise after discharge to reduce VAT and strengthen muscle function to improve prognosis.

The Utility of Body Composition Assessment in Nutrition and Clinical Practice: An Overview of Current Methodology

Body composition is a key component for maintaining good general health and longevity. It can be influenced by a variety of factors, including genetics, environment, and lifestyle choices. The assessment of body composition is an essential tool for nutrition specialists to effectively evaluate nutritional status and monitor progression during dietary interventions. As humans age, there is a natural increase in fat mass coupled with a gradual decline in lean mass, specifically in bone and muscle mass. Individuals with a high body fat percentage are at a greater risk of cardiovascular diseases, type 2 diabetes, several types of cancer, and early mortality. Significant decreases in bone mineral density signify osteopenia and osteoporosis, while reductions in skeletal muscle mass increase the risk of developing sarcopenia. Moreover, undernutrition exacerbates the effects of many medical conditions and is important to address. Though weight tracking and calculation of BMI are used commonly by clinicians and dietitians, these measures do not provide insight on the relative contributions of fat mass and fat-free mass or the changes in these compartments that may reflect disease risk. Therefore, it is important that healthcare professionals have a critical understanding of body composition assessment and the strengths and limitations of the methods available.

Sex Comparison of Knee Extensor Size, Strength, and Fatigue Adaptation to Sprint Interval Training

ABSTRACT

Bagley, L, Al-Shanti, N, Bradburn, S, Baig, O, Slevin, M, and McPhee, JS. Sex comparison of knee extensor size, strength, and fatigue adaptation to sprint interval training. J Strength Cond Res 35(1): 64-71, 2021-Regular sprint interval training (SIT) improves whole-body aerobic capacity and muscle oxidative potential, but very little is known about knee extensor anabolic or fatigue resistance adaptations, or whether effects are similar for men and women. The purpose of this study was to compare sex-related differences in knee extensor size, torque-velocity relationship, and fatigability adaptations to 12-week SIT. Sixteen men and 15 women (mean [SEM] age: 41 [±2.5] years) completed measurements of total body composition assessed by dual energy X-ray absorptiometry, quadriceps muscle cross-sectional area (CSAQ) assessed by magnetic resonance imaging, the knee extensor torque-velocity relationship (covering 0-240°·s-1) and fatigue resistance, which was measured as the decline in torque from the first to the last of 60 repeated concentric knee extensions performed at 180°·s-1. Sprint interval training consisted of 4 × 20-second sprints on a cycle ergometer set at an initial power output of 175% of power at V̇o2max, 3 times per week for 12 weeks. Quadriceps muscle cross-sectional area increased by 5% (p = 0.023) and fatigue resistance improved 4.8% (p = 0.048), with no sex differences in these adaptations (sex comparisons: p = 0.140 and p = 0.282, respectively). Knee extensor isometric and concentric torque was unaffected by SIT in both men and women (p > 0.05 for all velocities). Twelve-week SIT, totaling 4 minutes of very intense cycling per week, significantly increased fatigue resistance and CSAQ similarly in men and women, but did not significantly increase torque in men or women. These results suggest that SIT is a time-effective training modality for men and women to increase leg muscle size and fatigue resistance.

The Association Between Computed Tomography-Defined Sarcopenia and Outcomes in Adult Patients Undergoing Radiotherapy of Curative Intent for Head and Neck Cancer: A Systematic Review

BACKGROUND

Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic factor in patients with cancer; however, its influence on outcomes for patients with head and neck cancer (HNC) has not been established.

OBJECTIVE

This review synthesizes current knowledge regarding the association between CT-defined sarcopenia and outcomes for adult patients undergoing radiotherapy with or without other treatment modalities of curative intent for HNC.

METHODS

A systematic review of the literature published between January 2004 and June 2019 was conducted in Medline, Embase, Cumulative Index of Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and PubMed. Empirical studies of CT-defined sarcopenia in adult patients (≥18 years) with HNC who had completed radiotherapy of curative intent with or without other treatment modalities were included. Outcomes reported included survival, prolonged radiotherapy breaks, and chemotherapy toxicity. Study quality was assessed using the American Academy of Nutrition and Dietetics Quality Criteria Checklist. Synthesis of outcomes and clinical relevance was performed using the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Of 11 studies (n = 3,461) identified, 3 were positive and 8 were neutral quality. Studies were heterogeneous in HNC diagnosis, ethnicity, definition of sarcopenia, CT level of evaluation, and skeletal muscle index threshold value. Eight definitions for sarcopenia were identified with pretreatment prevalence of 6.6% to 70.9% and posttreatment prevalence of 12.4% to 65.8%. Pretreatment sarcopenia was independently associated with reduced: overall survival (OS), 3-year OS, disease-free survival, prolonged radiotherapy breaks, and chemotherapy-related toxicities. Posttreatment sarcopenia was independently associated with reduced OS and 5-year OS. The overall certainty of evidence according to Grading of Recommendations Assessment, Development and Evaluation criteria was low for OS; 3-year, 5-year, and 10-year OS; locoregional control; locoregional failure; progression-free survival; metastasis-free survival, disease-specific survival; and disease-free survival and very low for distant metastasis, prolonged radiotherapy breaks, and chemotherapy toxicity-related outcomes.

CONCLUSIONS

CT-defined sarcopenia is independently associated with reduced OS and treatment completion in patients with HNC and holds a clinically meaningful prognostic value. The certainty of the evidence requires strengthening with further research. Understanding the impact sarcopenia has on outcomes for these patients has implications for informing potential nutrition interventions and facilitating individualized care.

The association between sarcopenia and quality of life in patients undergoing colorectal cancer surgery: an exploratory study

OBJECTIVE

To describe changes in health-related quality of life (QoL) from before colorectal cancer (CRC) surgery to 1 and 3-month post-surgery in patients diagnosed pre-operatively as sarcopenic or non-sarcopenic by computed tomography (CT) analysis.

METHODS

Secondary analysis of a prospective observational cohort study with one pre-operative and two post-operative assessments. Patient-reported outcome measures (PROMs) were collected at each timepoint using Functional Assessment of Cancer Therapy-Colorectal and the EuroQol-5D (EQ-5D) questionnaires. Pre-operative staging CT scans of the third lumbar vertebra (axial slice) were analysed using Slice-O-Matic Software to determine if patients had CT defined sarcopenia by employing sex-specific threshold values for skeletal muscle index. Patient-reported outcome measure scores were compared with minimal clinical important difference estimates to determine if changes were clinically significant.

RESULTS

Twenty-five of 40 patients were found to be sarcopenic. The difference between sarcopenic groups on the EQ-5D was medium-sized and clinically significant, with the sarcopenic group reporting lower health status. The non-sarcopenic group displayed a clinically significant reduction in physical wellbeing post-operatively. The sarcopenic group did not demonstrate a clinically important reduction in physical wellbeing. For functional wellbeing, the sarcopenic group recorded a clinically significant reduction at the 1-month timepoint, trending back towards baseline by the 3-month timepoint. The non-sarcopenic group recorded almost no change in functional scores.

CONCLUSION

This study explored the novel concept of the effect of sarcopenia on QoL in the CRC surgical setting. Clinically significant changes were identified at both post-operative timepoints. This highlights an important proof of concept that PROMs can detect meaningful clinical change in CRC patients in the context of sarcopenia and should be further explored.

Power Comparisons and Clinical Meaning of Outcome Measures in Assessing Treatment Effect in Cancer Cachexia: Secondary Analysis From a Randomized Pilot Multimodal Intervention Trial

Background: New clinical trials in cancer cachexia are essential, and outcome measures with high responsiveness to detect meaningful changes are crucial. This secondary analysis from a multimodal intervention trial estimates sensitivity to change and between treatment effect sizes (ESs) of outcome measures associated with body composition, physical function, metabolism, and trial intervention.

Methods: The study was a multicenter, open-label, randomized pilot study investigating the feasibility of a 6-week multimodal intervention [exercise, non-steroidal anti-inflammatory drugs, and oral nutritional supplements containing polyunsaturated fatty acids (n−3 PUFAs)] vs. standard cancer care in non-operable non-small-cell lung cancer and advanced pancreatic cancer. Body composition measures from computerized tomography scans and circulating biomarkers were analyzed.

Results: Forty-six patients were randomized, and the analysis included 22 and 18 patients in the treatment and control groups, respectively. The between-group ESs were high for body weight (ES = 1.2, p < 0.001), small for body composition and physical function [handgrip strength (HGS)] measures (ES < 0.25), moderate to high for n-3 PUFAs and 25-hydroxyvitamin D (25-OH vitamin D) (ES range 0.64–1.37, p < 0.05 for all), and moderate for serum C-reactive protein (ES = 0.53, p = 0.12). Analysis within the multimodal treatment group showed high sensitivity to change for adiponectin (ES = 0.86, p = 0.001) and n-3 PUFAs (ES > 0.8, p < 0.05 for all) and moderate for 25-OH vitamin D (ES = 0.49, p = 0.03). In the control group, a moderate sensitivity to change for body weight (ES = −0.84, p = 0.002) and muscle mass (ES = −0.67, p = 0.016) and a high sensitivity to change for plasma levels of 25-OH vitamin D (ES = −0.88, p = 0.002) were found.

Conclusion: Demonstrating high sensitivity to change and between treatment ES and body composition measures, body weight still stands out as a clinical and relevant outcome measure in cancer cachexia. Body composition and physical function measures clearly are important to address but demand large sample sizes to detect treatment group differences.

Trial registration:ClinicalTrials.gov identifier: NCT01419145.

Population-Scale CT-based Body Composition Analysis of a Large Outpatient Population Using Deep Learning to Derive Age-, Sex-, and Race-specific Reference Curves

Background Although CT-based body composition (BC) metrics may inform disease risk and outcomes, obtaining these metrics has been too resource intensive for large-scale use. Thus, population-wide distributions of BC remain uncertain. Purpose To demonstrate the validity of fully automated, deep learning BC analysis from abdominal CT examinations, to define demographically adjusted BC reference curves, and to illustrate the advantage of use of these curves compared with standard methods, along with their biologic significance in predicting survival. Materials and Methods After external validation and equivalency testing with manual segmentation, a fully automated deep learning BC analysis pipeline was applied to a cross-sectional population cohort that included any outpatient without a cardiovascular disease or cancer who underwent abdominal CT examination at one of three hospitals in 2012. Demographically adjusted population reference curves were generated for each BC area. The z scores derived from these curves were compared with sex-specific thresholds for sarcopenia by using χ² tests and used to predict 2-year survival in multivariable Cox proportional hazards models that included weight and body mass index (BMI). Results External validation showed excellent correlation (R = 0.99) and equivalency (P < .001) of the fully automated deep learning BC analysis method with manual segmentation. With use of the fully automated BC data from 12 128 outpatients (mean age, 52 years; 6936 [57%] women), age-, race-, and sex-normalized BC reference curves were generated. All BC areas varied significantly with these variables (P < .001 except for subcutaneous fat area vs age [P = .003]). Sex-specific thresholds for sarcopenia demonstrated that age and race bias were not present if z scores derived from the reference curves were used (P < .001). Skeletal muscle area z scores were significantly predictive of 2-year survival (P = .04) in combined models that included BMI. Conclusion Fully automated body composition (BC) metrics vary significantly by age, race, and sex. The z scores derived from reference curves for BC parameters better capture the demographic distribution of BC compared with standard methods and can help predict survival. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Summers in this issue.

Associations between body composition and prognosis of patients admitted because of acute pancreatitis: a retrospective study

OBJECTIVES

To investigate the possible associations of muscle and visceral fat mass with the prognosis of patients hospitalized with acute pancreatitis.

METHODS

Body composition analysis (Sliceomatic, TomoVision, Montreal, Canada) was performed on CT images at the L3 level in patients admitted with acute pancreatitis during 2008-2014. Regression analysis was used to examine associations of body composition with 1-year mortality and 1-year readmission rates.

RESULTS

A total of 158 patients were included (mean age 63.7 ± 17.4 years, 91 (57.6%) were male). Fat was the most abundant tissue (408 ± 180 cm² surface area). None of the prognostic factors examined were associated with 1-year mortality. Values below compared to above the medians for muscle mass and visceral fat were associated with higher mean 1-year readmissions: 1.7 versus 1.0, p = 0.02 and 1.6 versus 1.1, p = 0.09, respectively. Logistic regression analysis showed an association of high visceral fat with reduced 1-year readmission (OR 0.995, 95% CI 0.991-1.000, p = 0.03). Linear regression analysis showed an inverse correlation of visceral fat mass with the number of 1-year readmissions (HR -0.004, 95% CI -0.008-000, p = 0.070).

CONCLUSIONS

Higher amounts of visceral fat and muscle mass were positively associated with lower recurrent hospitalizations in patients admitted with acute pancreatitis. These results support the importance of nutritional rehabilitation in patients after admission due to acute pancreatitis.

Is sarcopenia a predictor of prognosis for patients undergoing radiotherapy for head and neck cancer? A meta-analysis

INTRODUCTION

Computed tomography (CT)-defined sarcopenia is a demonstrated poor prognostic factor for survival in patients with cancer, however, its impact in patients with head and neck cancer (HNC) has only recently been explored. This study aimed to determine the prognostic impact of CT-defined sarcopenia at the level of the third lumbar vertebra (L3) on overall survival in patients with HNC undergoing radiotherapy ± other treatment modality of curative intent.

METHODS

A systematic review of the literature published between January 2004 and May 2020 was conducted in Medline, Embase, CINAHL, AMED and PubMed. Empirical studies in adults (≥18 years) who had completed radiotherapy of curative intent ± other treatment modalities that evaluated sarcopenia using the gold standard method at L3 and applied sex-specific cut-offs were included. Outcome of interest was overall survival. Study quality was assessed using the Quality In Prognosis Studies (QUIPS) tool. Hazard ratios with 95% confidence intervals derived from multivariate analysis were extracted directly from studies. Random-effects meta-analysis was used to determine the pooled hazard ratio for overall survival in patients with sarcopenia versus those without using RevMan (Version 5.3). The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

A total of 6211 studies were identified and screened from which seven studies met the inclusion criteria with 1059 pooled patients. All studies defined sarcopenia as low muscle mass but varied in skeletal muscle index (SMI) threshold values applied and ethnicity. Sarcopenia prevalence ranged from 6.6 to 64.6% pre-treatment and 12.4 to 65.8% post-treatment. Pre-treatment sarcopenia was associated with reduced overall survival (HR 2.07; 95%CI, 1.47-2.92, p < 0.0001, I² = 49%) with similar findings for post-treatment sarcopenia (HR 2.93; 95%CI, 2.00-4.29, p < 0.00001, I² = 0%) with moderate to low heterogeneity exhibited amongst studies respectively. The certainty of evidence for overall survival according to GRADE was low for pre-treatment sarcopenia and moderate for post-treatment sarcopenia.

CONCLUSIONS

CT-defined sarcopenia is independently associated with reduced overall survival in patients with HNC and holds a clinically meaningful prognostic value. Consensus regarding sarcopenia assessment and definitions is warranted in order to substantiate these findings and support implementation of body composition assessment as a clinically meaningful prognostic tool into practice.

The association between changes in muscle mass and quality of life in patients with metastatic colorectal cancer

BACKGROUND

Skeletal muscle mass (SMM) loss is common in metastatic colorectal cancer (mCRC) patients and associated with poor clinical outcomes, including increased treatment-related toxicities and reduced survival. Muscle loss may contribute to reduced health-related quality of life (HRQoL), including fatigue. Our aim was to study associations between changes in SMM and concomitant changes in patient-reported HRQoL.

METHODS

This was a secondary analysis of mCRC patients in the CAIRO3 randomized clinical trial who were-after initial treatment-randomized between maintenance treatment with capecitabine plus bevacizumab (CAP-B) and observation until first disease progression (PD1). Included patients had computed tomography images for SMM quantification, together with HRQoL assessments available at randomization and PD1. Changes in SMM (categorized as >2% loss, stable, and >2% gain) and HRQoL were computed between randomization and PD1. Changes in HRQoL score >10 points were considered clinically relevant. Associations between SMM and HRQoL changes were studied by multiple linear regression models. We also investigated whether associations differed by treatment arm for global health and the 13 other HRQoL subscales.

RESULTS

Of 221 patients included (mean age 63.5 ± 8.4 years), 24% lost, 27% remained stable, and 49% gained SMM. At randomization, mean global health status was 73.5 ± 15.9 in the CAP-B arm and 75.1 ± 17.5 in the observation arm (P = 0.48). A stable or gain in SMM was significantly associated with a clinically relevant improvement in global health status (9.9 and 14.7 points, respectively), compared with patients who lost SMM. From the subscales that did not show significant differences between the two treatment arms, we found significant and clinically relevant associations for stable or gain in SMM with improved role functioning (12.0 and 17.9, respectively) and with less fatigue (-10.0 and -15.0, respectively) and pain (-16.3 for SMM gain). From the subscales that did show significantly different associations with SMM between the two treatment arms, we only found significant results in the observation arm. Here, associations were found for stable or gain in SMM with clinically relevant improved physical (12.4 for SMM gain), cognitive (10.7 and 9.7, respectively), and social functioning (15.5 and 15.6, respectively) as well as reduced appetite loss (-28.5 and -30.7, respectively).

CONCLUSIONS

In mCRC, SMM preservation during CAP-B and observation treatment is associated with significant and clinically relevant improvements in global health status and multiple functional and symptom scales. Studies are warranted to investigate whether interventions targeting SMM lead to improved HRQoL, fewer symptoms, and better functioning.

Sarcopenia and myosteatosis in patients undergoing curative radiotherapy for head and neck cancer: Impact on survival, treatment completion, hospital admission and cost

BACKGROUND

Computed tomography (CT) is the gold standard of body composition analysis at the tissue-organ level. The present study aimed to determine the impact of CT-defined sarcopenia and myosteatosis on outcomes, including overall survival, unplanned hospital admissions and related costs, in patients who had completed treatment of curative intent for head and neck cancer (HNC).

METHODS

Retrospective observational study of patients undergoing radiotherapy of curative intent ± other treatment modalities for HNC. Tissue density data derived at the third lumbar vertebra (L3) were evaluated with sarcopenia defined per sex-specific published threshold values for skeletal muscle index, stratified by body mass index and mean skeletal muscle attenuation in HU (Hounsfield units).

RESULTS

Pre- or post-treatment images were available for 79/98 patients (80.6%) and 61/98 patients (62.2%), respectively. Sarcopenia was present in 42/79 patients pre-treatment and 36/61 patients post-treatment, whereas myosteatosis was present in 63/79 patients pre-treatment and 48/61 patients post-treatment. In patients with pre- and post-treatment images (n = 60), the median (range) percentage weight change was -8.5% (-29.9 to +11.7). On multivariable analysis, a post-treatment sarcopenia hazard ratio of 3.87 (95% confidence interval = 1.22-12.24, P = 0.021) and a pre-treatment myosteatosis hazard ratio of 8.86 (95% confidence interval = 1.12-69.88, P = 0.038) were independent predictors of reduced overall survival. There was no difference in radiotherapy or chemotherapy treatment completion based on pre-treatment sarcopenia status. The mean (SD) difference unplanned hospital admission cost was $15 846 ($17 707) for patients without sarcopenia versus $47 945 ($82 688) for patients with sarcopenia at any time point (P = 0.077).

CONCLUSIONS

As CT-defined sarcopenia and myosteatosis hold clinically meaningful prognostic value, muscle status evaluation is recommended in routine clinical practice.

Assessing skeletal muscle radiodensity by computed tomography: An integrative review of the applied methodologies

Low-radiodensity skeletal muscle has been related to the degree of muscle fat infiltration and seems to be associated with worse outcomes. The aim of this study was to summarize the methodologies used to appraise skeletal muscle radiodensity by computed tomography, to describe the terms used in the literature to define muscle radiodensity and to give recommendations for its measurement standardization. An integrative bibliographic review in four databases included studies published until August 2019 in Portuguese, English or Spanish and performed in humans, adults and/or the elderly, of both sex, which investigated skeletal muscle radiodensity through computed tomography (CT) of the region between the third and fifth lumbar vertebrae and evaluated at least two muscular groups. One hundred and seventeen studies were selected. We observed a trend towards selecting all abdominal region muscle. A significant methodological variation in terms of contrast use, selection of skeletal muscle areas, radiodensity ranges delimitation and their cut-off points, as well as the terminologies used, was also found. The methodological differences detected are probably due to the lack of more precise information about the correlation between skeletal muscle radiodensity by CT and its molecular composition, among others. Therefore, until the gaps are addressed in future studies, authors should avoid arbitrary approaches when reporting skeletal muscle radiodensity, especially when it comes to prognosis inference. Studies using both CT and direct methods of muscle composition evaluation are encouraged, to enable the definition and validation of the best approach to classify fat-infiltrated muscle tissue, which will favour the nomenclature uniformization.

Radiologically Defined Sarcopenia Affects Survival in Head and Neck Cancer: A Meta-Analysis

OBJECTIVE

To determine whether radiologically defined sarcopenia at the C3 or L3 level as measured by computed tomography or magnetic resonance imaging is prognostic of overall survival (OS) in head and neck cancers (HNCs).

METHODS

Literature searches of PubMed, Embase, and Scopus were conducted on July 12, 2019, to include articles written in the English language with no constraints on publication date. To be included in the analysis, articles had to report the prognostic impact of skeletal muscle mass measured radiologically at the C3 or L3 vertebral level in HNC patients; hazard ratios (HRs) for OS; 95% confidence intervals (CIs); be from a clinical trial, cohort, or case-control study; and have English full-text availability. Articles were reviewed in consensus by two reviewers, with disagreements reviewed by a third reviewer. Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis Of Observational Studies in Epidemiology Checklist guidelines were used for reporting. Study quality assessment was performed using Quality In Prognosis Studies tool. The random-effects DerSimonian and Laird method was used for meta-analysis.

RESULTS

Ten articles, nine retrospective and one prospective, were included in this meta-analysis (n = 2,181 patients). Significant differences were found in OS for HNC patients with sarcopenia (HR = 1.98; 95% CI: 1.64-2.39; P < .00001). No heterogeneity was detected in either the overall or subgroup analyses.

CONCLUSIONS

Radiologically defined sarcopenia is a negative predictor of OS in patients with HNC. Early detection of sarcopenia in cancer patients may help guide nutritional and adjuvant support to improve treatment outcomes.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:333-341, 2021.

Reference Values for Skeletal Muscle Mass - Current Concepts and Methodological Considerations

Assessment of a low skeletal muscle mass (SM) is important for diagnosis of ageing and disease-associated sarcopenia and is hindered by heterogeneous methods and terminologies that lead to differences in diagnostic criteria among studies and even among consensus definitions. The aim of this review was to analyze and summarize previously published cut-offs for SM applied in clinical and research settings and to facilitate comparison of results between studies. Multiple published reference values for discrepant parameters of SM were identified from 64 studies and the underlying methodological assumptions and limitations are compared including different concepts for normalization of SM for body size and fat mass (FM). Single computed tomography or magnetic resonance imaging images and appendicular lean soft tissue by dual X-ray absorptiometry (DXA) or bioelectrical impedance analysis (BIA) are taken as a valid substitute of total SM because they show a high correlation with results from whole body imaging in cross-sectional and longitudinal analyses. However, the random error of these methods limits the applicability of these substitutes in the assessment of individual cases and together with the systematic error limits the accurate detection of changes in SM. Adverse effects of obesity on muscle quality and function may lead to an underestimation of sarcopenia in obesity and may justify normalization of SM for FM. In conclusion, results for SM can only be compared with reference values using the same method, BIA- or DXA-device and an appropriate reference population. Limitations of proxies for total SM as well as normalization of SM for FM are important content-related issues that need to be considered in longitudinal studies, populations with obesity or older subjects.

Concurrent losses of skeletal muscle mass, adipose tissue and bone mineral density during bevacizumab / cytotoxic chemotherapy treatment for metastatic colorectal cancer

BACKGROUND

Changes in skeletal muscle mass (SMM), total adipose tissue mass (TAT) or bone mineral density (BMD) have been described in patients with cancer undergoing various treatments; simultaneous variations of all 3 tissues has not been reported.

METHODS

Data were prospectively collected in a clinical study (NCT00489697) including patients with liver metastases of colorectal cancer who received 4 cycles of bevacizumab in combination with cytotoxic chemotherapy. Computerized tomography (CT) at baseline and after chemotherapy was used to quantify skeletal muscle and adipose tissue cross-sectional areas, and mean lumbar spine BMD using validated approaches.

RESULTS

After exclusion of patients lacking adequate CT images or missing data, 72 subjects were included. Patients were 63% male, aged 63.2 ± 10.3 years, 100% had liver metastases and 54%, 24% and 22% respectively has 0, 1 and ≥2 extrahepatic metastases. 100% tolerated 4 cycles of treatment and none showed progressive disease at the end of treatment. The scan interval was 70 days (95% CI, 62.3 to 80.5). Thresholds for loss of tissue were defined as loss ≥ measurement error. 10% of patients showed no loss of any tissue and a further 43% lost one tissue (SMM, TAT or BMD); 47% of patients lost 2 tissues (16.5% lost SMM + TAT, 8% lost SMM + BMD, 10% lost TAT + BMD) or all 3 tissues (12.5%). Catabolic behavior (2 or 3 tissue loss vs 0 or 1 tissue loss) associated with disease burden, including unresectable primary tumor (p = 0.010), presence of extrahepatic (EH) metastases (p = 0.039) and number of EH metastases (p = 0.004). No association was found between the number of tissues lost and treatment response, which was uniformly high, or treatment toxicity, which was uniformly low.

CONCLUSION

Multiple tissues can be measured in routine CT images and these show considerable inter-individual variation. Substantial losses in some individuals appear to associate with disease burden.

The effect of nutritional counseling on muscle mass and treatment outcome in patients with metastatic colorectal cancer undergoing chemotherapy: A randomized controlled trial

BACKGROUND & AIMS

A low muscle mass before start of treatment and loss of muscle mass during chemotherapy is related to adverse outcomes in patients with cancer. In this randomized controlled trial, the effect of nutritional counseling on change in muscle mass and treatment outcome in patients with metastatic colorectal cancer during first-line chemotherapy was studied.

METHODS

Patients scheduled for first-line chemotherapy (n = 107) were randomly assigned to individualized nutritional counseling by a dietitian (NC) or usual care (UC). NC was aimed at sufficient protein- and energy intake, supported by oral supplements or enteral feeding if indicated. Furthermore, physical activity was encouraged. Outcomes were assessed at baseline (T0) and the time of the first (T1) and second (T2) regular follow-up computed tomography scans. The proportion of patients with a clinically relevant decrease in skeletal muscle area of ≥6.0 cm², measured by computed tomography, was the primary outcome. Secondary outcomes included body weight, quality of life, treatment toxicity and progression free and overall survival.

RESULTS

A total of 107 patients were enrolled (mean age, 65 years (SD, 11 years), 63% male). Mean change in skeletal muscle area from T0 till T1 was -2.5 (SD, 9.5) cm², with no difference between NC versus UC (p = 0.891). The proportion of patients with a clinically relevant decrease in skeletal muscle area of ≥6.0 cm² did not differ (NC 30% versus UC 31%, p = 0.467). NC compared with UC had a significant positive effect on body weight (B coefficient 1.7, p = 0.045), progression free survival (p = 0.039) and overall survival (p = 0.046).

CONCLUSIONS

NC of patients undergoing chemotherapy for metastatic colorectal cancer had no effect on muscle mass. However, we found that NC may increase body weight and improve progression free survival and overall survival compared to UC in this group of patients. These findings need further evaluation in future clinical trials.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov NCT01998152; Netherlands Trial Register NTR4223.

Reproducibility of semiautomated body composition segmentation of abdominal computed tomography: a multiobserver study

Background

Segmentation of computed tomography (CT) images provides quantitative data on body tissue composition, which may greatly impact the development and progression of diseases such as type 2 diabetes mellitus and cancer. We aimed to evaluate the inter- and intraobserver variation of semiautomated segmentation, to assess whether multiple observers may interchangeably perform this task.

Methods

Anonymised, unenhanced, single mid-abdominal CT images were acquired from 132 subjects from two previous studies. Semiautomated segmentation was performed using a proprietary software package. Abdominal muscle compartment (AMC), inter- and intramuscular adipose tissue (IMAT), visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) were identified according to pre-established attenuation ranges. The segmentation was performed by four observers: an oncology resident with extensive training and three radiographers with a 2-week training programme. To assess interobserver variation, segmentation of each CT image was performed individually by two or more observers. To assess intraobserver variation, three of the observers did repeated segmentations of the images. The distribution of variation between subjects, observers and random noise was estimated by a mixed effects model. Inter- and intraobserver correlation was assessed by intraclass correlation coefficient (ICC).

Results

For all four tissue compartments, the observer variations were far lower than random noise by factors ranging from 1.6 to 3.6 and those between subjects by factors ranging from 7.3 to 186.1. All interobserver ICC was ≥ 0.938, and all intraobserver ICC was ≥ 0.996.

Conclusions

Body composition segmentation showed a very low level of operator dependability. Multiple observers may interchangeably perform this task with highly reproducible results.

Electronic supplementary material

The online version of this article (10.1186/s41747-019-0122-5) contains supplementary material, which is available to authorized users.

The effects of testosterone administration on muscle areas of the trunk and pelvic floor in hysterectomized women with low testosterone levels: proof-of-concept study

OBJECTIVE

The aim of this study was to determine the effect of testosterone administration on trunk and pelvic floor muscle area in women with low testosterone levels.

METHODS

Participants were hysterectomized women with total testosterone<31 ng/dL and/or free testosterone<3.5 pg/mL; participating in the Testosterone Dose Response in Surgically Menopausal Women (TDSM) trial. All participants received a standardized transdermal estradiol regimen during the 12-week run-in period, and were then randomized to receive weekly intramuscular injections of placebo, or 3, 6.25, 12.5, or 25 mg testosterone enanthate for 24 weeks. Muscle areas of the trunk and pelvis were measured at baseline and end of treatment using 1.5 Tesla magnetic resonance imaging. Total and free testosterone levels were measured by liquid chromatography-tandem mass spectrometry and equilibrium dialysis, respectively. Testosterone effect on muscle areas was analyzed using linear regression models.

RESULTS

A total of 24 women who had available baseline and posttreatment magnetic resonance imaging were included in the analysis. Increased cross-sectional areas of the paraspinal, psoas, and abdominal wall muscles were seen after testosterone administration. The estimated mean change (95% CI; P value) between treatment groups was 4.07 cm (1.26-6.88; P = 0.007) for paraspinal, 1.60 cm (0.10-3.09; P = 0.038) for psoas major, and 7.49 cm (1.96-13.02; P = 0.011) for abdominal wall muscles. Increases in psoas muscle area were significantly associated with changes in free testosterone concentrations. No significant changes in obturator internus and pelvic floor muscle areas were observed.

CONCLUSION

Short-term testosterone administration in women with low testosterone levels was associated with increased trunk muscle area.

Identifying critically ill patients with low muscle mass: Agreement between bioelectrical impedance analysis and computed tomography

BACKGROUND & AIMS

Low muscle mass and -quality on ICU admission, as assessed by muscle area and -density on CT-scanning at lumbar level 3 (L3), are associated with increased mortality. However, CT-scan analysis is not feasible for standard care. Bioelectrical impedance analysis (BIA) assesses body composition by incorporating the raw measurements resistance, reactance, and phase angle in equations. Our purpose was to compare BIA- and CT-derived muscle mass, to determine whether BIA identified the patients with low skeletal muscle area on CT-scan, and to determine the relation between raw BIA and raw CT measurements.

METHODS

This prospective observational study included adult intensive care patients with an abdominal CT-scan. CT-scans were analysed at L3 level for skeletal muscle area (cm²) and skeletal muscle density (Hounsfield Units). Muscle area was converted to muscle mass (kg) using the Shen equation (MM_CT). BIA was performed within 72 h of the CT-scan. BIA-derived muscle mass was calculated by three equations: Talluri (MM_Talluri), Janssen (MM_Janssen), and Kyle (MM_Kyle). To compare BIA- and CT-derived muscle mass correlations, bias, and limits of agreement were calculated. To test whether BIA identifies low skeletal muscle area on CT-scan, ROC-curves were constructed. Furthermore, raw BIA and CT measurements, were correlated and raw CT-measurements were compared between groups with normal and low phase angle.

RESULTS

110 patients were included. Mean age 59 ± 17 years, mean APACHE II score 17 (11-25); 68% male. MM_Talluri and MM_Janssen were significantly higher (36.0 ± 9.9 kg and 31.5 ± 7.8 kg, respectively) and MM_Kyle significantly lower (25.2 ± 5.6 kg) than MM_CT (29.2 ± 6.7 kg). For all BIA-derived muscle mass equations, a proportional bias was apparent with increasing disagreement at higher muscle mass. MM_Talluri correlated strongest with CT-derived muscle mass (r = 0.834, p < 0.001) and had good discriminative capacity to identify patients with low skeletal muscle area on CT-scan (AUC: 0.919 for males; 0.912 for females). Of the raw measurements, phase angle and skeletal muscle density correlated best (r = 0.701, p < 0.001). CT-derived skeletal muscle area and -density were significantly lower in patients with low compared to normal phase angle.

CONCLUSIONS

Although correlated, absolute values of BIA- and CT-derived muscle mass disagree, especially in the high muscle mass range. However, BIA and CT identified the same critically ill population with low skeletal muscle area on CT-scan. Furthermore, low phase angle corresponded to low skeletal muscle area and -density.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02555670).

Nutritional Risk Screening and Assessment

Malnutrition is an independent risk factor that negatively influences patients’ clinical outcomes, quality of life, body function, and autonomy. Early identification of patients at risk of malnutrition or who are malnourished is crucial in order to start a timely and adequate nutritional support. Nutritional risk screening, a simple and rapid first-line tool to detect patients at risk of malnutrition, should be performed systematically in patients at hospital admission. Patients with nutritional risk should subsequently undergo a more detailed nutritional assessment to identify and quantify specific nutritional problems. Such an assessment includes subjective and objective parameters such as medical history, current and past dietary intake (including energy and protein balance), physical examination and anthropometric measurements, functional and mental assessment, quality of life, medications, and laboratory values. Nutritional care plans should be developed in a multidisciplinary approach, and implemented to maintain and improve patients’ nutritional condition. Standardized nutritional management including systematic risk screening and assessment may also contribute to reduced healthcare costs. Adequate and timely implementation of nutritional support has been linked with favorable outcomes such as a decrease in length of hospital stay, reduced mortality, and reductions in the rate of severe complications, as well as improvements in quality of life and functional status. The aim of this review article is to provide a comprehensive overview of nutritional screening and assessment methods that can contribute to an effective and well-structured nutritional management (process cascade) of hospitalized patients.

Low Muscularity as Assessed by Abdominal Computed Tomography on Intensive Care Unit Admission Is Associated With Mortality in a Critically Ill Asian Population

BACKGROUND

Low muscularity (LM) is associated with high mortality in the Caucasian critically ill population. Muscularity can be accurately measured by the skeletal muscle index (SMI; cm² /m² ) generated by computed tomography (CT). This study aimed to establish the overall and sex-specific cutoff values that predict hospital mortality in an Asian critically ill population.

METHODS

This single-center, retrospective, observational study included patients aged ≥18 years with an abdominal CT conducted within 72 hours of admission to the intensive care unit. SMI generated from CT images at the level of the mid-third lumbar vertebra were extracted from the medical records. Area under the receiver operating characteristic curves (AUC) was generated to determine the SMI cutoff values for hospital mortality. Association between LM (defined by SMI cutoff value) and hospital mortality was further evaluated by multivariable logistic regression.

RESULTS

In a sample of 228 patients, the overall SMI cutoff value (cm² /m² ) for hospital mortality was 42.0 (AUC: 0.637; sensitivity: 66.7%, specificity: 56.8%), whereas it was 46.5 in males and 35.3 in females. More males than females had LM (51.4% vs 37.5%), and >40% of overweight/obese patients had LM. Patients with LM were older and had a longer duration of mechanical ventilation and hospitalization. After adjusting for known confounders, LM independently predicted hospital mortality in the overall sample (adjusted odds ratio: 2.42; 95% CI 1.16-5.03; P = 0.003) and in both sexes.

CONCLUSION

This study established a set of SMI cutoff values that predict hospital mortality. LM is independently associated with hospital mortality.

Correlation between muscle mass and handgrip strength in digestive cancer patients undergoing chemotherapy

Background

FIGHTDIGO study has shown the feasibility of handgrip strength (HGS) measurements in 201 consecutive digestive cancer patients undergoing chemotherapy.

Objective

This study focuses on a secondary aim of FIGHTDIGO study: the relationship between muscle mass and HGS.

Design

Two consecutive bilateral measures of HGS were performed using a Jamar dynamometer before the start of each chemotherapy. The highest value was chosen for final evaluation. Dynapenia (loss of muscle strength) was defined as HGS < 30 kg (men) and < 20 kg (women). Muscle mass was measured at lumbar level (L3) on Computed Tomography (CT) scans performed less than 3 weeks before or after the measurement of HGS. Muscle mass loss was defined by skeletal muscle index (SMI) < 53 cm²/m² (in men with a body mass index (BMI)> 25 kg/m²), < 43 cm²/m² (in men with a BMI < 25 kg/m²), and < 41 cm²/m² (in women regardless of BMI). Sarcopenia was defined by the association of a dynapenia and a loss of muscle mass.

Results

A total of 150 patients were included in this analysis (mean age: 65.6 ± 10.9 years, 87 males (58%), colorectal cancer (47.3%), metastatic stage (76.7%)). A total of 348 CT scans were evaluated. For the 348 measurements, mean SMI and HGS were 41.8 ± 8.7 cm²/m² and 32.1 ± 11.0 kg, respectively. Muscle mass loss, dynapenia, or sarcopenia were reported at least once, in 120 (80%), 45 (30%), and 30 (20%) patients, respectively. SMI was significantly correlated with HGS (Pearson coefficient = 0.53, P < 0.0001). At concordance analysis, 188 dyad SMI/HGS (54%) were in agreement (Kappa = 0.14 [95% CI, 0.07‐0.21]).

Conclusion

Correlation between the measurements of HGS and SMI is strong but the concordance between dynapenia and muscle mass loss is poor. Further studies should be performed to confirm the diagnostic thresholds, and to study the chronology of dynapenia and loss of muscle mass.

Ankle strength, muscle size, and adipose content following unilateral tibiotalar arthrodesis

Tibiotalar arthrodesis is commonly used to treat end-stage ankle osteoarthritis. Post-operative impairments are often attributed to limited ankle motion. However, whether muscular deficits also exist, thereby potentially contributing to impairments, is unknown. This study aimed to identify post-operative deficits in ankle musculature by examining range of motion, strength (maximum isometric ankle joint torque), and leg composition (cross-sectional area of individual tissue types: bone, subcutaneous adipose, intramuscular adipose, muscle). Ten individuals with unilateral tibiotalar arthrodesis participated. Paired t-tests (p < 0.05) identified differences between the fused and contralateral, control limb. The results indicate that individuals with tibiotalar arthrodesis have profound losses of range of motion and strength. Across participants, range of motion in the fused limb was 53.5 ± 11.7%, 66.8 ± 6.3%, 38.2 ± 18.7%, 37.8 ± 13.6% less than the control for dorsiflexion, plantarflexion, inversion, and eversion, respectively. The largest strength deficit was in dorsiflexion, with the fused limb producing 47.2 ± 9.4% less torque than the control. The quantity and quality of muscle tissue was also negatively affected in individuals following tibiotalar arthrodesis. The total cross-sectional area of the fused limb was 11.4 ± 5.4% smaller than the control limb. This change was primarily due to the 16.1 ± 6.7% decrease in muscle cross-sectional area. However, intramuscular adipose was significantly increased. Although the posterior compartment demonstrated a significant decrease in cross-sectional area, when accounting for differences in total cross-sectional area, the relative sizes of the four muscle compartments were consistent between limbs. This cross-sectional study motivates longitudinal research examining muscular deficits and whether these deficits are reversible with exercise and rehabilitation. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Muscles of the trunk and pelvis are responsive to testosterone administration: data from testosterone dose-response study in young healthy men

Testosterone dose-dependently increases appendicular muscle mass. However, the effects of testosterone administration on the core muscles of the trunk and the pelvis have not been evaluated. The present study evaluated the effects of testosterone administration on truncal and pelvic muscles in a dose-response trial. Participants were young healthy men aged 18-50 years participating in the 5α-Reductase (5aR) Trial. All participants received monthly injections of 7.5 mg leuprolide acetate to suppress endogenous testosterone production and weekly injections of 50, 125, 300, or 600 mg of testosterone enanthate and were randomized to receive either 2.5 mg dutasteride (5aR inhibitor) or placebo daily for 20 weeks. Muscles of the trunk and the pelvis were measured at baseline and the end of treatment using 1.5-Tesla magnetic resonance imaging. The dose effect of testosterone on changes in the psoas major muscle area was the primary outcome; secondary outcomes included changes in paraspinal, abdominal, pelvic floor, ischiocavernosus, and obturator internus muscles. The association between changes in testosterone levels and muscle area was also assessed. Testosterone dose-dependently increased areas of all truncal and pelvic muscles. The estimated change (95% confidence interval) of muscle area increase per 100 mg of testosterone enanthate dosage increase was 0.622 cm² (0.394, 0.850) for psoas; 1.789 cm² (1.317, 2.261) for paraspinal muscles, 2.530 cm² (1.627, 3.434) for total abdominal muscles, 0.455 cm² (0.233, 0.678) for obturator internus, and 0.082 cm² (0.003, 0.045) for ischiocavernosus; the increase in these volumes was significantly associated with the changes in on-treatment total and free serum testosterone concentrations. In conclusion, core muscles of the trunk and pelvis are responsive to testosterone administration. Future trials should evaluate the potential role of testosterone administration in frail men who are predisposed to falls and men with pelvic floor dysfunction.

Muscle morphology and performance in master athletes: A systematic review and meta-analyses

INTRODUCTION

The extent to which chronic exercise training preserves age-related decrements in physical function, muscle strength, mass and morphology is unclear. Our aim was to conduct a systematic review of the literature to determine to what extent chronically trained master athletes (strength/power and endurance) preserve levels of physical function, muscle strength, muscle mass and morphology in older age, compared with older and younger controls and young trained individuals.

METHODS

The systematic data search included Medline, EMBASE, SPORTDiscus, CINAHL and Web of Science databases.

INCLUSION CRITERIA

i) master athletes mean exercise training duration ≥20 years ii) master athletes mean age of cohort >59 years) iii) at least one measurement of muscle mass/volume/fibre-type morphology and/or strength/physical function.

RESULTS

Fifty-five eligible studies were identified. Meta-analyses were carried out on maximal aerobic capacity, maximal voluntary contraction and body composition. Master endurance athletes (42.0 ± 6.6 ml kg^-1 min^-1) exhibited VO_2max values comparable with young healthy controls (43.1 ± 6.8 ml kg^-1 min^-1, P = .84), greater than older controls (27.1 ± 4.3 ml kg^-1 min^-1, P < 0.01) and master strength/power athletes (26.5 ± 2.3 mlkg^-1 min^-1, P < 0.01), and lower than young endurance trained individuals (60.0 ± 5.4 ml kg^-1 min^-1, P < 0.01). Master strength/power athletes (0.60 (0.28-0.93) P < 0.01) and young controls (0.71 (0.06-1.36) P < 0.05) were significantly stronger compared with the other groups. Body fat% was greater in master endurance athletes than young endurance trained (-4.44% (-8.44 to -0.43) P < 0.05) but lower compared with older controls (7.11% (5.70-8.52) P < 0.01).

CONCLUSION

Despite advancing age, this review suggests that chronic exercise training preserves physical function, muscular strength and body fat levels similar to that of young, healthy individuals in an exercise mode-specific manner.

Sarcopenic obesity: hidden muscle wasting and its impact for survival and complications of cancer therapy

Body composition, defined as the proportions and distribution of lean and fat tissues in the human body, is an emergent theme in clinical oncology. Severe muscle depletion (sarcopenia) is most easily overlooked in obese patients; the advent of secondary analysis of oncologic images provides a precise and specific assessment of sarcopenia. Here, we review the definitions, prevalence and clinical implications of sarcopenic obesity (SO) in medical and surgical oncology. Reported prevalence of SO varies due to the heterogeneity in the definitions and the variability in the cut points used to define low muscle mass and high fat mass. Prevalence of SO in advanced solid tumor patient populations average 9% (range 2.3%-14.6%) overall, and one in four (24.7%, range 5.9%-39.2%) patients with body mass index ≥ 30 kg/m2 are sarcopenic. SO is independently associated with higher mortality and higher rate of complications in systemic and surgical cancer treatment, across multiple cancer sites and treatment plans. These associations remain unexplained, however, it has been hypothesized that patients with sarcopenia are generally unfit and unable to tolerate stress. Another proposed mechanism relates to increased exposure to antineoplastic therapy, i.e. a large fat mass would be expected to inflate drug dose in BSA-based treatments, causing an increased rate of dose-limiting toxicity. Pharmacokinetic data are needed to confirm or refute this hypothesis. Old age, deconditioning, cancer progression, acute or chronic nonmalignant disease and drug side-effects are suggested causes of muscle loss, and it is unknown the degree to which this can be reversed. Sarcopenia can be readily detected before start of cancer treatment, however, clinical management protocols for SO patients require development. Studies of cancer treatment dose-modulation are in progress.

Visceral adiposity but not subcutaneous fat associated with improved outcome of patients with acute cholecystitis

BACKGROUND

The aim of this study to study the effect of visceral and subcutaneous fat tissue mass on short- and long-term prognosis of patients with acute calculus cholecystitis (ACC).

METHODS

Retrospective analysis of medical records. Included were all patients admitted because of ACC. Computed tomography images at the level of L3 were analyzed for body composition using designated software (Slice-O-matic; TomoVision, Montreal, Quebec, Canada). General linear model was used to analyze the effect of body composition on length of hospital stay, and Cox regression analysis was used to ascertain the effect of the different parameters on 1-y survival.

RESULTS

Included were 159 patients (mean age: 71.7 ± 15.8 y, 54.7% males). Fat was the most abundant tissue (401 ± 175 cm² of the computed tomography slices surface area), and visceral fat was 45.8 ± 14.1% of the fat area measured. Using the general linear model, we found that American Society of Anesthesiologists score, disease severity index, and age were positively associated with higher length of stay, whereas high visceral fat was associated with lower length of stay (estimated marginal means at 7.4 ± 1.4 d compared to 12.7 ± 1.4 d among patients with lower visceral fat surface area, P = 0.010). The Cox regression model showed that 1-y survival risk was significantly reduced by age, the Charlson Comorbidity Index and high muscle mass. High visceral adiposity was associated with improved survival (odds ratio: 0.216, 95% confidence interval: 0.064-0.724, P = 0.013). Subcutaneous adiposity did not affect prognosis.

CONCLUSIONS

Visceral adiposity is associated with shorter length of stay and improved 1-y survival among patients hospitalized with ACC.

Percentiles for skeletal muscle index, area and radiation attenuation based on computed tomography imaging in a healthy Caucasian population

Background/objectives

Muscle mass is a key determinant of nutritional status and associated with outcomes in several patient groups. Computed tomography (CT) analysis is increasingly used to assess skeletal muscle area (SMA), skeletal muscle index (SMI) and muscle radiation attenuation (MRA). However, interpretation of these muscle parameters is difficult since values in a healthy population are lacking. The aim of this study was to provide sex specific percentiles for SMA, SMA and MRA in a healthy Caucasian population and to examine the association with age and BMI in order to define age- and BMI specific percentiles.

Subjects/methods

In this retrospective cross-sectional study CT scans of potential kidney donors were used to assess SMA, SMI and MRA at the level of the third lumbar vertebra. Sex specific distributions were described and, based on the association between age/BMI and muscle parameters, age, and BMI specific predicted percentiles were computed. The 5th percentile was considered as cut-off.

Results

CT scans of 420 Individuals were included (age range 20–82 years and BMI range 17.5–40.7 kg/m²). Sex specific cut-offs of SMA, SMI and MRA were 134.0 cm², 41.6 cm²/m² and 29.3 HU in men and 89.2 cm², 32.0 cm²/m² and 22.0 HU in women, respectively. Correlations were negative between age and all three muscle parameters, positive between BMI and SMA/SMI and negative between BMI and MRA, resulting in age- and BMI specific percentiles.

Conclusions

This study provides sex specific percentiles for SMA, SMI, and MRA. In addition, age- and BMI specific percentiles have been established.