Sarcopenia is a risk factor for the recurrence of hepatocellular carcinoma after curative treatment

Association of Omega-3 Polyunsaturated Fatty Acids with Sarcopenia in Liver Cirrhosis Patients with Hepatocellular Carcinoma

Background and Aims

Sarcopenia is associated with the prognosis of patients with liver cirrhosis and hepatocellular carcinoma (HCC). Given their diverse physiological activities, we hypothesized that plasma fatty acids might influence the progression of sarcopenia. This study aimed to clarify the association between fatty acids and sarcopenia in cirrhotic patients with HCC.

Methods

In this single-center retrospective study, we registered 516 cases and analyzed 414 cases of liver cirrhosis and HCC. The skeletal muscle mass index was measured using a transverse computed tomography scan image at the third lumbar vertebra. The cutoff value for sarcopenia followed the criteria set by the Japan Society of Hepatology. Fatty acid concentrations were measured by gas chromatography.

Results

Fatty acid levels, particularly omega-3 (n-3) polyunsaturated fatty acid (PUFA), were lower in patients with poor liver function (Child-Pugh grade B/C) and were negatively correlated with the albumin-bilirubin score (p<0.0001). The prognosis of HCC patients with low PUFA levels was significantly worse. Among the different fatty acid fractions, only n-3 PUFAs significantly correlated with skeletal muscle mass index (p=0.0026). In the multivariate analysis, the n-3 PUFA level was an independent variable associated with sarcopenia (p=0.0006).

Conclusions

A low level of n-3 PUFAs was associated with sarcopenia in patients with liver cirrhosis and HCC.

Association of magnetic resonance imaging-derived sarcopenia with outcomes of patients with hepatocellular carcinoma after hepatectomy

PURPOSE

To evaluate whether sarcopenia, diagnosed by magnetic resonance imaging (MRI) protocol, constitutes a prognosis-associated risk factor in patients with hepatocellular carcinoma (HCC) after hepatectomy.

METHODS

One hundred and ninety-three patients who underwent hepatectomy for HCC were retrospectively enrolled. The areas of the total skeletal muscle (SM) and psoas muscle (PM) were evaluated at the third lumbar vertebra in the preoperative MR images, and divided by the square of height in order to obtain the skeletal muscle index (SMI) and psoas muscle mass index (PMI). Sarcopenia was diagnosed respectively on the definitions based on the SMI or PMI. The potential of muscle-defined sarcopenia as a prognostic factor for overall survival (OS) and recurrence-free survival (RFS) was investigated in these patients.

RESULTS

The areas of SM and PM, and SMI and PMI were significantly higher in the men than in the women (all p < 0.05). Notably, SMI-defined sarcopenia displayed a significant sex difference (p = 0.003), while PMI-defined sarcopenia did not (p = 0.370). Through univariate and multivariate analyses, PMI-defined sarcopenia remained an independent predictor for OS and RFS (HR = 3.486, 95% CI: 1.700-7.145, p = 0.001 and HR = 1.993, 95% CI: 1.246-3.186, p = 0.004), even after adjusting for other clinical variables. Moreover, Kaplan-Meier analysis demonstrated significantly poorer OS and RFS for patients with sarcopenia defined by using PMI, but not SMI, compared to those without sarcopenia (p < 0.001 and p = 0.006, respectively).

CONCLUSION

MRI-derived, sarcopenia defined by using PMI, not SMI, may serve as a significant risk factor for RFS and OS in patients with HCC after hepatectomy.

Shining a spotlight on sarcopenia and myosteatosis in liver disease and liver transplantation: Potentially modifiable risk factors with major clinical impact

Muscle-wasting and disease-related malnutrition are highly prevalent in patients with chronic liver diseases (CLD) as well as in liver transplant (LT) candidates. Alterations of body composition (BC) such as sarcopenia, myosteatosis and sarcopenic obesity and associated clinical frailty were tied to inferior clinical outcomes including hospital admissions, length of stay, complications, mortality and healthcare costs in various patient cohorts and clinical scenarios. In contrast to other inherent detrimental individual characteristics often observed in these complex patients, such as comorbidities or genetic risk, alterations of the skeletal muscle and malnutrition are considered as potentially modifiable risk factors with a major clinical impact. Even so, there is only limited high-level evidence to show how these pathologies should be addressed in the clinical setting. This review discusses the current state-of-the-art on the role of BC assessment in clinical outcomes in the setting of CLD and LT focusing mainly on sarcopenia and myosteatosis. We focus on the disease-related pathophysiology of BC alterations. Based on these, we address potential therapeutic interventions including nutritional regimens, physical activity, hormone and targeted therapies. In addition to summarizing existing knowledge, this review highlights novel trends, and future perspectives and identifies persisting challenges in addressing BC pathologies in a holistic way, aiming to improve outcomes and quality of life of patients with CLD awaiting or undergoing LT.

The Negative Impact of Sarcopenia on Hepatocellular Carcinoma Treatment Outcomes

INTRODUCTION

Hepatocellular carcinoma (HCC) represents a major global health concern, characterized by evolving etiological patterns and a range of treatment options. Among various prognostic factors, sarcopenia, characterized by loss of skeletal muscle mass, strength, and function, has emerged as a pivotal contributor to HCC outcomes. Focusing on liver transplantation, surgical resection, locoregional treatments, and systemic therapies, this review aims to analyze the impact of sarcopenia on HCC treatment outcomes, shedding light on an underexplored subject in the pursuit of more personalized management.

METHODS

A comprehensive literature review was conducted by searching peer-reviewed articles on sarcopenia and treatment outcomes in patients with HCC from inception up to October 2023.

RESULTS

Sarcopenia was found to be prevalent among HCC patients, exhibiting different occurrence, possibly attributable to diverse diagnostic criteria. Notably, despite variations in studies utilizing skeletal muscle indices, sarcopenia independently correlated with lower overall survival (OS), recurrence-free survival (RFS), and progression-free survival (PFS) across surgical (both transplantation and resection), locoregional, and systemic therapies, including tyrosine-kinase inhibitors (TKIs) and immune-checkpoint inhibitors (ICIs). Moreover, a link between sarcopenia and increased rate and severity of adverse events, particularly in surgery and TKIs recipients, and larger tumor size at diagnosis was observed. While baseline sarcopenia negatively influenced treatment outcomes, alterations in muscle mass post-treatment emerged as primary determinants of reduced OS.

CONCLUSIONS

Sarcopenia, either present before or after HCC treatment, negatively correlates with response to it, across all etiologies and therapeutic strategies. Although only a few studies have evaluated the impact of supervised physical activity training on muscle mass and OS after HCC treatment, it is crucial to evaluate the presence of sarcopenia before treatment initiation, to better stratify patients' prognosis, thus performing a more tailored approach, and identify therapies able to restore muscle mass in HCC patients. Conversely, the impact of sarcopenia on HCC recurrence and extrahepatic spread remains inadequately explored.

The Impact of Imaging-Diagnosed Sarcopenia on Long-term Prognosis After Curative Resection for Hepatocellular Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

Recent research suggests that sarcopenia potentially influences the long-term postoperative prognosis of malignant tumors. Thus, the primary objective of this study was to investigate the impact of imaging-diagnosed sarcopenia on the long-term prognosis of hepatocellular carcinoma (HCC) patients after curative resection.

METHODS

In our approach, all studies incorporated in this study employed Cox proportional hazards models with multivariable adjusted hazard ratios. The meta-analysis was performed using R statistical software. The primary outcomes were quantified using hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

This study analyzed 30 studies, involving 7352 HCC patients after curative resection (2695 in the sarcopenia group and 4657 in the non-sarcopenia group). The meta-analysis of 28 studies indicated that patients in the sarcopenia group demonstrated notably inferior overall survival (OS) compared with the non-sarcopenia group (HR=2.20; 95% CI, 1.88-2.58; p < 0.01). Similarly, sarcopenia exhibits a significant association with poor recurrence-free survival (RFS) and disease-free survival (DFS) based on 16 and 6 studies (HR=1.50; 95% CI, 1.39-1.63; p < 0.01 and HR=1.96; 95% CI, 1.83-2.10; p < 0.01, respectively).

CONCLUSION

In conclusion, imaging-diagnosed sarcopenia adversely affects the long-term prognosis, including OS, RFS, and DFS, in HCC patients after curative resection. The findings hold considerable importance in guiding comprehensive healthcare procedures for HCC patients after surgery.

Assessing recent recurrence after hepatectomy for hepatitis B-related hepatocellular carcinoma by a predictive model based on sarcopenia

BACKGROUND

Sarcopenia may be associated with hepatocellular carcinoma (HCC) following hepatectomy. But traditional single clinical variables are still insufficient to predict recurrence. We still lack effective prediction models for recent recurrence (time to recurrence < 2 years) after hepatectomy for HCC.

AIM

To establish an interventable prediction model to estimate recurrence-free survival (RFS) after hepatectomy for HCC based on sarcopenia.

METHODS

We retrospectively analyzed 283 hepatitis B-related HCC patients who underwent curative hepatectomy for the first time, and the skeletal muscle index at the third lumbar spine was measured by preoperative computed tomography. 94 of these patients were enrolled for external validation. Cox multivariate analysis was per-formed to identify the risk factors of postoperative recurrence in training cohort. A nomogram model was developed to predict the RFS of HCC patients, and its predictive performance was validated. The predictive efficacy of this model was evaluated using the receiver operating characteristic curve.

RESULTS

Multivariate analysis showed that sarcopenia [Hazard ratio(HR) = 1.767, 95%CI: 1.166-2.678, P < 0.05], alpha-fetoprotein ≥ 40 ng/mL (HR = 1.984, 95%CI: 1.307-3.011, P < 0.05), the maximum diameter of tumor > 5 cm (HR = 2.222, 95%CI: 1.285-3.842, P < 0.05), and hepatitis B virus DNA level ≥ 2000 IU/mL (HR = 2.1, 95%CI: 1.407-3.135, P < 0.05) were independent risk factors associated with postoperative recurrence of HCC. Based on the sarcopenia to assess the RFS model of hepatectomy with hepatitis B-related liver cancer disease (SAMD) was established combined with other the above risk factors. The area under the curve of the SAMD model was 0.782 (95%CI: 0.705-0.858) in the training cohort (sensitivity 81%, specificity 63%) and 0.773 (95%CI: 0.707-0.838) in the validation cohort. Besides, a SAMD score ≥ 110 was better to distinguish the high-risk group of postoperative recurrence of HCC.

CONCLUSION

Sarcopenia is associated with recent recurrence after hepatectomy for hepatitis B-related HCC. A nutritional status-based prediction model is first established for postoperative recurrence of hepatitis B-related HCC, which is superior to other models and contributes to prognosis prediction.

The association between hemoglobin level and sarcopenia in Chinese patients with Crohn's disease

Sarcopenia and anemia are common complications in patients with Crohn's Disease (CD). However, few studies have shown the association between sarcopenia and hemoglobin levels in CD patients. This retrospective study aimed to explore such association in Chinese patients with CD. Two hundred and twelve adult CD inpatients who underwent computed tomography (CT) or magnetic resonance imaging (MRI) examinations from July 2019 to December 2021 were included in the study. Sarcopenia was defined according to the cutoff value of skeletal muscle index of lumbar spine 3 (SMI-L3) (< 44.77cm2/m2 for males and < 32.5cm2/m2 for females). The CD patients were divided into two groups based on the presence or absence of sarcopenia. Clinical data, hemoglobin levels, and other laboratory data were retrospectively collected. The association between hemoglobin levels and sarcopenia was analyzed by univariable and multivariable logistic regression analysis. Sarcopenia occurred in 114 CD patients (53.8%). Compared to patients without sarcopenia, patients with sarcopenia had a lower proportion of L1 (30.7% vs. 45.8%, p = 0.032) and B1 classification (58.8% vs. 72.4%, p = 0.037). Patients with sarcopenia had significantly lower levels of hemoglobin (Hb) (116.5 ± 22.8 vs. 128.1 ± 21.0, p < 0.001). The prevalence of sarcopenia increased with the decrease in hemoglobin level (p for trend < 0.05). Linear regression analysis showed that hemoglobin levels were associated with SMI-L3 (β = 0.091, p = 0.001). Multivariable logistic regression analysis found that higher hemoglobin levels (OR:0.944; 95% CI: 0.947,0.998; p = 0.036) were independent protective factors for sarcopenia. Lower hemoglobin levels are independently associated factors of sarcopenia in adult Chinese patients with CD.

Ultrasound Evaluation of Sarcopenia in Patients with Hepatocellular Carcinoma: A Faster and Easier Way to Detect Patients at Risk

The condition of sarcopenia, defined as a progressive loss of musculoskeletal mass and muscular strength, is very common in patients with hepatocellular carcinoma (HCC) and presents a remarkable association with its prognosis. Thus, the early identification of sarcopenic patients represents one of the potential new approaches in the global assessment of HCC, and there is increasing interest regarding the potential therapeutic implications of this condition. The gold standard for the quantification of muscle mass is magnetic resonance imaging (MRI) or computed tomography (CT), but these techniques are not always feasible because of the high-cost equipment needed. A new possibility in sarcopenia identification could be muscle ultrasound examination. The measurement of specific parameters such as the muscle thickness, muscular fascicles length or pennation angle has shown a good correlation with CT or MRI values and a good diagnostic accuracy in the detection of sarcopenia. Recently, these results were also confirmed specifically in patients with chronic liver disease. This review summarizes the role of imaging for the diagnosis of sarcopenia in patients with HCC, focusing on the advantages and disadvantages of the diagnostic techniques currently validated for this aim and the future perspectives for the identification of this condition.

Impact of sarcopenia and sarcopenic obesity on survival in patients with primary liver cancer: a systematic review and meta-analysis

Background

Sarcopenia and sarcopenic obesity are associated with an increased possibility of adverse clinical outcomes; however, the effects of sarcopenia and sarcopenic obesity on patients with primary liver cancer remain controversial. Therefore, the present study aimed to determine the impact of sarcopenia and sarcopenic obesity on survival in patients with primary liver cancer.

Methods

We searched studies published in English in PubMed, Embase, Web of Science, and Cochrane Library databases up to 13 November 2022. Cohort studies that reported the association among sarcopenia, sarcopenic obesity, and patient survival were included.

Results

A total of 64 cohort studies with data on 11,970 patients with primary liver cancer were included in the meta-analysis. Sarcopenia was associated with poor overall survival in patients with primary liver cancer [adjusted hazard ratio (HR) 2.11, 95% confidence interval (CI): 1.89-2.36, P < 0.0001], with similar findings for sarcopenic obesity (adjusted HR: 2.87, 95% CI: 2.23-3.70, P < 0.0001). Sarcopenia was also associated with poor overall survival across the subgroups analyzed by ethnicity, type of liver cancer, treatment modalities, method used to define sarcopenia, and etiology of liver cancer. We also found a negative correlation among sarcopenia, sarcopenic obesity, and recurrence-free/disease-free survival (adjusted HR: 1.73, 95% CI: 1.50-1.99, P < 0.001; adjusted HR: 2.28, 95% CI: 1.54-3.35, P < 0.001, respectively).

Conclusion

Sarcopenia and sarcopenic obesity were significantly associated with poor overall survival and recurrence-free/disease-free survival in patients with primary liver cancer.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=378433, PROSPERO [42022378433].

Investigation of Changes in Skeletal Muscle Mass and Muscle Quality and Factors Affecting Changes in Deceased Donor Liver Transplantation

BACKGROUND

In Japan, there are very few cases of deceased donor liver transplantation (DDLT) and even fewer studies on the effects of DDLT on sarcopenia. This study examined the changes in skeletal muscle mass and quality in DDLT, the factors related to these changes, and survival rates.

METHODS

Using computed tomography (CT), we retrospectively measured L3 skeletal muscle index (L3SMI) and intramuscular adipose tissue content (IMAC) at admission, discharge, and 1-year post-DDLT in 23 patients with DDLT from our hospital between 2011 and 2020. We investigated the relationships between changes in L3SMI and IMAC associated with DDLT and between various admission factors and survival.

RESULTS

Patients with DDLT showed significant decreases in L3SMI during hospitalization (P < .05). Although L3SMI tended to increase postdischarge, in 11 (73%) cases, it was lower at 1-year post-DDLT than that on admission. Moreover, decreases in L3SMI during hospitalization were correlated to L3SMI on admission (r = 0.475, P < 0.05). Intramuscular adipose tissue content increased from admission to discharge and decreased 1-year post-DDLT. Admission L3SMI and IMAC were not significantly correlated with survival.

CONCLUSIONS

This study suggests that the skeletal muscle mass of DDLT patients decreased during hospitalization and showed a slight tendency to improve after discharge, but the decrease tended to be prolonged. In addition, patients with higher skeletal muscle mass at admission tended to lose more skeletal muscle mass during hospitalization. Deceased donor liver transplantation was identified as a potential contributor to improved muscle quality, whereas skeletal muscle mass and quality on admission did not affect post-DDLT survival.

Prevalence of sarcopenia among patients with hepatocellular carcinoma: A systematic review and meta‑analysis

Sarcopenia is a common condition in patients with hepatocellular carcinoma (HCC). Sarcopenia affects the prognosis of patients with HCC and reduces their quality of life. However, to date, there has been no systematic review and meta-analysis to assess the prevalence of sarcopenia in patients with HCC, to the best of our knowledge. PubMed, Embase, Web of Science and the Cochrane Library were comprehensively screened for relevant literature published from March 2001 to June 2022. A random effect analysis was conducted to pool the incidence rates for each study. Subgroup and meta-regression analyses were used to investigate the latent sources of heterogeneities. The Newcastle-Ottawa Scale was used to estimate the quality of the included studies. The I² statistic was used to evaluate heterogeneity between studies. In total, 48 studies encompassing 8,959 patients were included in the meta-analysis. The results of the present meta-analysis showed that nearly half (42%) of the patients with HCC had sarcopenia (95% CI, 0.36-0.48). The morbidity of sarcopenia in studies with a high proportion of males (45%) was higher compared with the morbidity observed in studies with a lower proportion of males (37%). In addition, the incidence rate in younger patients (46%) was found to be higher compared with the incidence rate in older patients (39%). In conclusion, the findings in the present systematic review revealed that a large number of patients with HCC suffer from sarcopenia, indicating the necessity of developing screening and intervention measures to improve the outcome in these patients.

Usefulness of the Measurement of Psoas Muscle Volume for Sarcopenia Diagnosis in Patients with Liver Disease

Computed tomography (CT) is often used in the diagnosis of sarcopenia. In this study, we validated the assessment of sarcopenia by the psoas muscle volume using versatile software. The study involved a retrospective analysis of data from 190 patients with liver disease who underwent grip-strength testing and abdominal pelvic computed tomography. To assess sarcopenia, SYNAPSE 3D was used to obtain the skeletal muscle index, the psoas muscle index (PMI), and the simple method. We also used the recently proposed PMI cutoff values, for which the usefulness has been evaluated (O-PMI). The cutoff value of the psoas muscle volume index (PMVI) was determined using one of the diagnostic methods as the gold standard. All diagnostic methods showed that patients with sarcopenia had shorter survival, with O-PMI having the highest hazard ratio (HR) (HR, 6.12; 95% confidence interval [CI], 2.6–14.41; p < 0.001). Even when sarcopenia could not be diagnosed by O-PMI, low PMVI was associated with shorter survival (HR, 3.53; 95% CI, 1.34–9.32; p = 0.01). PMVI may be useful in the evaluation of sarcopenia, including the identification of poor overall survival in cases that cannot be diagnosed by O-PMI, which is considered more useful than PMI.

Association between sarcopenia and clinical outcomes in patients with hepatocellular carcinoma: an updated meta-analysis

Although numerous studies have reported the association between sarcopenia and the prognosis of hepatocellular carcinoma (HCC) patients, there is lack of a newer and more comprehensive meta-analysis. Herein, a comprehensive literature search was performed on PubMed, Web of Science, the Cochrane Library, and Embase databases to identify relevant studies published up to February 2022. The outcomes were overall survival (OS), recurrence, progression-free survival, tumor response, severe postoperative complications, and toxicity of drugs. A total of 57 studies involving 9790 HCC patients were included in the meta-analysis. The pooled prevalence of sarcopenia in HCC patients was 41.7% (95% CI 36.2-47.2%). Results demonstrated that sarcopenia was significantly associated with impaired OS (HR: 1.93, 95% CI 1.73-2.17, P < 0.001), higher risk of tumor recurrence (HR: 1.75, 95% CI 1.56-1.96, P < 0.001), lower objective response rate (OR: 0.37 95% CI 0.17-0.81, P = 0.012), and more drug-related adverse events (OR: 2.23, 95% CI 1.17-4.28, P = 0.015) in HCC patients. The subgroup analyses revealed that the OS of patients at the early stage of tumor was more severely affected by sarcopenia than for patients at other stages. Moreover, the presence of cirrhosis and Child Pugh class B increased the hazard of mortality from sarcopenia. This study has shown that sarcopenia is highly associated with poor prognosis in HCC patients. In addition, cirrhosis and poor liver functional reserve increase the danger of sarcopenia. OS was more impaired in HCC patients with sarcopenia at early stage of tumor than at other tumor stages.

Imaging based body composition profiling and outcomes after oncologic liver surgery

Body composition profiling is gaining attention as a pre-operative factor that can play a role in predicting the short- and long- term outcomes of patients undergoing oncologic liver surgery. Existing evidence is mostly limited to retrospective and single-institution series and in many of these studies, the evaluation of body composition is based on parameters which are derived from CT-scan imaging. Among body composition phenotypes, sarcopenia is the most well studied but this is only one of the possible profiles which can impact the outcomes of oncologic hepatic surgery. Interest has recently grown in studying the effect of sarcopenic obesity, central obesity, or visceral fat amount, myosteatosis, and bone mineral density on -such patients. The objective of this review is to summarize the current evidence on whether imaging-based parameters of body composition have an impact on the outcome of patients undergoing liver surgery for each of the most frequent indications for liver resection in clinical practice: hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and colorectal liver metastases (CRLM).

CT-based skeletal muscle loss for predicting poor survival in patients with hepatocellular carcinoma experiencing curative hepatectomy plus adjuvant transarterial chemoembolization: a preliminary retrospective study

Background

To evaluate the prognostic value of skeletal muscle index (SMI) and its change in patients with hepatocellular carcinoma (HCC) experiencing curative hepatectomy plus adjuvant transarterial chemoembolization (TACE).

Materials and methods

A total of 62 patients with HCC who underwent adjuvant TACE after curative hepatectomy were analysed retrospectively. Skeletal muscle area at the third lumbar level was quantitated using computed tomography images and was normalized for height squared to obtain skeletal muscle index (SMI). Skeletal muscle loss (SML) over 6 months was computed with two SMIs before and after hepatectomy plus adjuvant TACE. Correlation analyses were preformed to investigate factors associated with SML. The curves of cause-specific survival (CSS) were analysed using the Kaplan–Meier method. A Cox proportional hazards model was used to assess prognostic factors.

Results

Low SMI was diagnosed in 23(37.1%) patients preoperatively. The median SML standardized by 6 months was − 1.6% in the entire cohort. Liver cirrhosis and microvascular invasion correlated negatively with SML, respectively (r = − 0.320, P = 0.002; r = − 0.243, P = 0.021). Higher SML (< − 2.42%) predicted a significant reduction in CSS (P = 0.001), whereas low SMI did not(P = 0.687). Following the multivariate analysis for CSS, AFP > 400 ng/ml (HR, 5.643; 95%CI, 3.608–17.833; P < 0.001) and SML < − 2.42%(HR, 6.586; 95%CI, 3.610–22.210; P < 0.001) were independent predictors for poor CSS.

Conclusions

Skeletal muscle loss during hepatectomy plus adjuvant TACE was remarkable. Higher SML was an independent risk factor for CSS in patients with HCC, especially those with liver cirrhosis.

What Is the Role of Body Composition Assessment in HCC Management?

In the last decade, body composition (BC) assessment has emerged as an innovative tool that can offer valuable data concerning nutritional status in addition to the information provided by the classical parameters (i.e., body mass index, albumin). Furthermore, published data have revealed that different types of body composition are associated with different outcomes. For example, abnormalities of skeletal muscle, a common finding in cirrhotic and oncologic patients, are associated with poor outcome (i.e., high morbidity and high mortality). The disposition (visceral/subcutaneous adipose tissue) and radiodensity of adipose tissue proved to also be determinant factors for HCC outcome. Despite all the advantages, BC assessment is not part of the standard pre-therapeutic workup. The main reasons are the high heterogeneity of data, the paucity of prospective studies, the lack of a standard assessment method, and the interpopulation variation of BC. This paper aims to review the available evidence regarding the role of BC as a prognostic tool in the HCC population undergoing various therapies.

Prevalence of sarcopenia in patients with gynecological cancer

BACKGROUND

The aim of the study was to investigate a prevalence of sarcopenia in patients with gynecological cancer in accordance with current diagnostic criteria of sarcopenia.

METHODS

A series of 513 patients with gynecological cancer who were intended to newly receive initial or salvage treatment were recruited in a prospective study. Eligible patients were examined with dual energy X-ray absorptiometry and underwent handgrip strength test and the Short Physical Performance Battery before treatment. Sarcopenia was defined as both low skeletal muscle mass (skeletal muscle mass index) and low muscle strength (handgrip strength of <18.0 kg) or both low skeletal muscle mass index and low physical performance (Short Physical Performance Battery score of ≤9).

RESULTS

A total of 475 patients (92.6%) were completely assessed in this study. Eligible patients' median age was 60 years (range: 29-89 years). Frequencies of patients with low skeletal muscle mass index, low hand grip strength and low Short Physical Performance Battery were 118 (24.8%), 70 (14.7%) and 80 (16.8%), respectively. Sarcopenia was finally identified in 45 patients (9.5%), which accounted for 38.1% of patients with low skeletal muscle mass index, 64.3% of the patients with low hand grip strength and 56.3% of the patients with low physical performance, respectively.

CONCLUSIONS

The prevalence of sarcopenia of 9.5% in patients with gynecological malignancy who were scheduled to newly receive an initial or a salvage treatment. A large-scale, nation-wide study might be planned to elucidate an accurate prevalence of sarcopenia among gynecologic cancer patients.

Sarcopenia Predicts Major Complications after Resection for Primary Hepatocellular Carcinoma in Compensated Cirrhosis

Simple Summary

Sarcopenia, which is defined as a loss of skeletal muscle mass, function and strength, is the result of major metabolic changes often observed in advanced liver disease. Its evaluation mirrors the nutritional and functional status of the patients, and thus has been recently implicated as an outcome predictor of patients with liver diseases and hepatocellular carcinoma. This study provides evidence that sarcopenia, as assessed by the skeletal muscle index, is associated with age and body mass index in liver surgery candidates. More importantly, it is associated with higher rates of major complications (Clavien-Dindo grade III or IV) in patients with compensated advanced chronic liver disease and/or portal hypertension undergoing liver resection for primary hepatocellular carcinoma.

Abstract

The burden of post-operative complications of patients undergoing liver resection for hepatocellular carcinoma (HCC) is a cause of morbidity and mortality. Recently, sarcopenia has been reported to influence the outcome of patients with cirrhosis. We aimed to assess factors associated with sarcopenia and its prognostic role in liver surgery candidates. We included all patients with compensated advanced chronic liver disease (cACLD) undergoing liver resection for primary HCC consecutively referred to the University of Bologna from 2014 to 2019 with an available preoperative abdominal CT-scan performed within the previous three months. A total of 159 patients were included. The median age was 68 years, and 80.5% of the patients were male. Sarcopenia was present in 82 patients (51.6%). Age and body mass index (BMI) were associated with the presence of sarcopenia at multivariate analysis. Thirteen (8.2%) patients developed major complications and 14 (8.9%) presented PHLF grade B-C. The model for end-stage liver disease score was associated with the development of major complications, whereas cACLD presence, thrombocytopenia, portal hypertension (PH), Child-Pugh score and Albumin-Bilirubin score were found to be predictors of clinically significative PHLF. The rate of major complications was 11.8% in sarcopenic patients with cACLD compared with no complications (0%) in patients without sarcopenia and cACLD (p = 0.032). The rate of major complications was significantly higher in patients with (16.3%) vs. patients without (0%) sarcopenia (p = 0.012) in patients with PH. In conclusion, sarcopenia, which is associated with age and BMI, may improve the risk stratification of post-hepatectomy major complications in patients with cACLD and PH.

Prognostic significance of sarcopenia in patients with hepatocellular carcinoma treated with lenvatinib: A retrospective analysis

Our study investigated the correlation between sarcopenia and clinical outcomes in patients with hepatocellular carcinoma (HCC) treated with lenvatinib. We retrospectively evaluated 40 consecutive patients with unresectable HCC receiving lenvatinib between November 2018 and May 2020 at the First Hospital of Jilin University. Skeletal muscle mass was measured before treatment initiation. Prognostic significance was assessed with univariate and multivariate Cox proportional hazards models. Overall survival (OS) and progression-free survival (PFS) were evaluated for patients with and without sarcopenia. Sarcopenia was present in 23/40 patients (57.5%). After a median follow-up of 9.2 months, patients with sarcopenia had significantly worse OS and PFS compared with those without sarcopenia (OS: 8.4 months [m] vs 14.7 m, P = .02; PFS: 4.2 m vs 9.0 m, P = .04). Multivariate Cox proportional hazards models identified presence of sarcopenia as an independent risk factor for shorter OS (hazard ratio [HR], 0.257; 95% confidence interval [CI], 0.083-0.794; P = .02). In subgroup analysis, sarcopenia was associated with worse survival than non-sarcopenic patients, irrespective of age, Barcelona clinic liver cancer stage, or albumin-bilirubin grade. Our results show sarcopenia may be a predictor of poor prognosis in patients with HCC receiving lenvatinib. Management of sarcopenia is a vital factor for improving survival outcomes in patients with HCC.

Defining reference values for low skeletal muscle index at the L3 vertebra level based on computed tomography in healthy adults: A multicentre study

BACKGROUND & AIMS

Skeletal muscle mass loss is an important aspect of malnutrition and is closely related to adverse clinical outcomes. Computed tomography (CT) is the gold standard for analysing muscle mass, and the skeletal muscle index at the third lumbar vertebra (L3-SMI), measured using CT, is an important indicator to evaluate total skeletal tissue. The aims of this study were to establish reference values for low L3-SMI in Northern China, and to investigate the correlation between L3-SMI and age, and the correlation between L3-SMI and body mass index (BMI).

METHODS

This was a multicentre, retrospective, cross-sectional study. A search of abdominal CT imaging reports, using specific keywords, was conducted in four representative cities in northern China, from January 2016 to March 2021. Transverse CT images at the level of the third lumbar vertebra (L3) were identified, exported from the Radiology Information System, and measured using the analysis software SliceOmatic. Statistical analyses were performed using SPSS 24.0, and significance level was set at p < 0.05. Mean, standard deviations (SD) and percentiles (p5, p10, p25, p50, p75, p90, p95) were used to describe the distribution of L3-SMI in the study population. Low skeletal muscle index was defined as a 5% percentile, or two standard deviations below the mean value of younger healthy individuals (age 20-39 years).

RESULTS

The study included 1787 healthy individuals, with a median age of 45 (25) years (range 20-88 years), and a median BMI of 23.1 (4.1) kg/m² (range 18.5-38.7 kg/m²). Among them, 700 healthy individuals (39.1%) were aged 20-39 years. L3-SMI had a negative linear correlation with age, and a positive linear correlation with BMI. The L3-SMI reference values used to define low skeletal muscle mass loss in the Northern Chinese population, using the 5% percentile, were 40.2 cm²/m² in men, and 31.6 cm²/m² in women. Using the mean minus two standard deviations protocol, the reference values were 37.9 cm²/m² and 28.6 cm²/m² in men and women, respectively.

CONCLUSIONS

This study analysed the human body composition of 1787 healthy people in four cities in northern China, using CT, and established diagnostic thresholds of skeletal muscle mass depletion based on 700 younger healthy adults, using the 5% percentile and mean-2SD methods. These reference values can be used to diagnose malnutrition in patients and may aide clinicians in predicting prognosis and improving nutritional therapy. Further research is warranted to determine the prognostic role of reference values against clinical outcomes in different disease populations.

Clinical practice advice on lifestyle modification in the management of nonalcoholic fatty liver disease in Japan: an expert review

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver diseases worldwide, including in Japan. The Japanese Society of Gastroenterology (JSGE) and the Japanese Society of Hepatology (JSH) have established the Japanese NAFLD/NASH guidelines in 2014 and revised these guidelines in 2020. As described in these guidelines, weight reduction by diet and/or exercise therapy is important for the treatment of NAFLD patients. The I148M single nucleotide polymorphism (rs738409 C > G) of PNPLA3 (patatin-like phospholipase domain-containing 3 protein) is widely known to be associated with the occurrence and progression of NAFLD. In the Japanese, the ratio of PNPLA3 gene polymorphisms found is approximately 20%, which is higher than that found in Westerners. In addition, the ratio of lean NAFLD patients is also higher in Japan than in Western countries. Therefore, the method for lifestyle guidance for the NAFLD patients in Japan would be different from that for the people in Western countries. The problems in the treatment of NAFLD patients include alcohol consumption and sarcopenia. Therefore, guidelines that can help clinicians treat Japanese patients with NAFLD are needed. In this expert review, we summarize evidence-based interventions for lifestyle modification (diet, exercise, alcohol, and sarcopenia) for the treatment of patients with NAFLD, especially from Japan and Asian countries.

Correlation between L3 skeletal muscle index and prognosis of patients with stage IV gastric cancer

Background

To explore the relationship between L3 skeletal muscle index (SMI) and the prognosis of patients with stage IV gastric cancer (GC).

Methods

A total of 27 patients with stage IV GC requiring chemotherapy admitted to our hospital from 1 April 2015 to 20 May 2019 were selected as participants. The Kaplan-Meier method was used to describe the survival time of all participants. By evaluating the L3 plane CT images, the mass index (cm²/m²) of L3 skeletal muscle (including psoas major, erector spinae, quadratus psoas, transversus abdominis, external oblique abdominis, and internal oblique abdominis) was calculated to study the changes of L3 SMI during treatment and the correlation between L3 SMI and clinical features. The log-rank method was used to analyze the correlativity between the survival time of patients and their general data, L3 SMI, or other indicators.

Results

The survival time of 27 patients with stage IV GC was 7.4-49.9 months, with a mean survival time of 19.72 months and a median survival time of 16.17 months. The 1-year survival rate was 77.78%, and the 3-year survival rate was 7.41%. During treatment, L3 SMI continued to decline in 20 of the 27 participants (74.07%). After the first chemotherapy, 17 participants (62.96%) met the criteria of sarcopenia syndrome, and after the fourth chemotherapy, 19 participants (70.37%) met the criteria of sarcopenia syndrome. The L3 SMI was shown to be significantly correlated with body mass index (BMI) and Onodera's prognostic nutritional index (OPNI) (both P<0.05), but not with age, gender, dietary intake, and primary site (all P>0.05). Log-rank test showed that there was a correlation between L3 SMI and survival time of patients (P<0.05). The average survival time of participants with sarcopenia syndrome (16.78 months) was significantly lower than that of those without sarcopenia syndrome (25.58 months) (P<0.05).

Conclusions

There is a significant correlation between L3 SMI and survival time, and L3 SMI can be used as a potential index to evaluate the prognosis of patients with stage IV GC.

Excessive alcohol intake and liver fibrosis are associated with skeletal muscle mass reduction in elderly men: the Wakayama study

BACKGROUND

Excessive alcohol intake complicated by liver dysfunction has been presumed to affect skeletal muscles. This study aimed to examine the association between excessive alcohol intake, liver fibrosis, and loss of skeletal muscle mass in elderly men.

METHODS

The study participants comprised 799 community-dwelling elderly men (age, 71 ± 3 years) with no history of treatment for liver disease. Bioelectrical impedance analysis was performed to estimate the appendicular skeletal muscle mass (ASM) of each participant. The ASM values were also normalized for height (ASM index). Liver fibrosis was evaluated using the Fib4 index, which was calculated using participant age, AST level, ALT level, and platelet count. Usual alcohol intake was estimated based on the type of alcohol, frequency of drinking, and amount of alcohol consumed per day.

RESULTS

Among the excess drinkers (≥ 20 g/day), the ASM index of the subgroup with liver fibrosis (Fib4 index ≥ 2.67) was significantly lower than that of the subgroup with no liver fibrosis (Fib4 index < 2.67). However, no significant difference between the subgroups was found in the non-drinkers and moderate drinkers (< 20 g/day). In multiple regression analysis, the Fib4 index was significantly associated with the ASM index, independent of potential confounding factors. The association between the Fib4 index and ASM index was more pronounced in excess drinkers than in non-drinkers and moderate drinkers.

CONCLUSION

These results suggest that liver fibrosis is associated with loss of skeletal muscle mass in elderly men, and excessive alcohol intake combined with liver fibrosis may lead to greater muscle mass reduction than each individual condition.

Biomarkers in Hepatobiliary Cancers: What is Useful in Clinical Practice?

Hepatocellular carcinoma (HCC) and biliary tract cancers (BTC) exhibit a poor prognosis with 5-year overall survival rates around 15%, all stages combined. Most of these primary liver malignancies are metastatic at diagnostic, with only limited therapeutic options, relying mainly on systemic therapies. Treatment modalities are different yet partially overlapping between HCC and BTC. The complex molecular profile of BTC yields to several actionable therapeutic targets, contrary to HCC that remains the field of antiangiogenic drugs in non-molecularly selected patients. Immunotherapy is now validated in the first line in HCC in combination with bevacizumab, while clinical activity of single agent immunotherapy appears limited to a subset of patients in BTC, still poorly characterized, and combinations are currently under investigation. In this review, we provide a critical evaluation and grading of clinical relevance on (i) the main prognostic biomarkers in HCC and BTC, (ii) the main theragnostic biomarkers in both tumors, and lastly (iii) what is recommended in clinical practice.

Clinical implication of psoas muscle mass measurement for predicting death within 3 months in patients with incurable uterine cervical or corpus malignancy

OBJECTIVE

The aim of this study was to find a clinical marker for identifying refractory cancer cachexia.

METHODS

We analyzed computed tomography imaging data, which included the third lumbar vertebra, from 94 patients who died of uterine cervix or corpus malignancy. The time between the date of examination and date of death was the most important attribute for this study, and the computed tomography images were classified into >3 months before death and ≤ 3 months before death. Psoas muscle mass index was defined as the left-right sum of the psoas muscle areas (cm2) at the level of third lumbar vertebra, divided by height squared (m2).

RESULTS

A data set of 94 computed tomography images was obtained at baseline hospital visit, and a data set of 603 images was obtained at other times. One hundred (16.6%) of the 603 non-baseline images were scanned ≤3 months before death. Mean psoas muscle mass index change rates at >3 months before death and ≤3 months before death were -1.3 and -20.1%, respectively (P < 0.001). Receiver operating characteristic curve analysis yielded a cutoff value of -13.0%. The area under the curve reached a moderate accuracy level (0.777, 95% confidence interval 0.715-0.838). When we used the cutoff value to predict death within 3 months, sensitivity and specificity were 74.0 and 82.1%, respectively.

CONCLUSIONS

Measuring change in psoas muscle mass index might be useful for predicting cancer mortality within 3 months. It could become a potential tool for identifying refractory cancer cachexia.

Prognostic value and association of sarcopenic obesity and systemic inflammatory indexes in patients with hepatocellular carcinoma following hepatectomy and the establishment of novel predictive nomograms

Background

The specific impacts of sarcopenic obesity (SO) on hepatocellular carcinoma (HCC) and the association between SO and systemic inflammation remain unclear. This study aimed to investigate the prognostic value and association of SO and systemic inflammation with outcomes after hepatectomy for HCC and develop novel nomograms based on SO and inflammatory indexes for survival prediction.

Methods

We retrospectively enrolled 452 patients with HCC who underwent radical hepatectomy between January 2012 and March 2015 in Fujian Provincial Hospital as the training cohort. In addition, 275 patients during the same period were enrolled as the external validation cohort. Patients were classified into different groups according to the presence of sarcopenia and obesity. Different inflammation indexes were evaluated to select the best predictor of overall survival (OS) and recurrence-free survival (RFS). Univariate and multivariate logistic regression were performed to investigate the associations between inflammatory indexes and SO. The inflammatory indexes with the highest predictive values and SO were selected for subgroup analyses to establish a novel classification system: the SOLMR grade. SOLMR grades identified in the multivariate Cox analysis were selected to construct novel nomograms for OS and RFS.

Results

SO (P<0.001) was an independent risk factor for OS and RFS. The lymphocyte-monocyte ratio (LMR) had the highest areas under the receiver operating characteristic (ROC) curves (AUCs) for OS (P<0.001) and RFS (P<0.001) and was identified as an independent factor of SO (P=0.001). SO and the LMR were selected to establish the SOLMR grade. Multivariate Cox analysis revealed that SOLMR grade was a significant independent predictor of OS (P<0.001) and RFS (P<0.001). Nomograms based on SOLMR grades were generated and accurately predicted 1-, 3- and 5-year OS and RFS in HCC patients. The C-index of the novel nomograms was higher than those of the other conventional staging systems (P<0.001).

Conclusions

Both SO and the LMR were independent risk factors for OS and RFS in HCC patients after hepatectomy. The LMR was an independent factor of SO. The novel nomograms developed from the SOLMR grading system combining SO with the LMR provide good prognostic estimates of the outcomes of HCC patients.

Clinical impact of sarcopenia assessment in patients with liver cirrhosis

Introduction: Sarcopenia is defined as loss of skeletal muscle mass, strength, and function, and it is associated with increased morbidity and mortality in patients with chronic liver disease.Areas covered: The aim of this review is to provide a detailed report on the pathophysiological mechanisms underlying sarcopenia in cirrhotic patients, the several imaging methods available for the assessment of sarcopenia and the clinical studies evaluating the prognostic role of sarcopenia presence in cirrhotic patients.Expert opinion: Sarcopenia pathogenesis is complex and multifaceted, as chronic catabolic conditions, increased energy expenditure, reduced appetite, side effects of multiple therapies, alterations in circulating levels of hormones, low protein synthesis, presence of ascites or portosystemic shunts are all factors contributing to muscle atrophy in cirrhotic patients. Computed tomography scan is the most validated method to evaluate muscle mass and quality. Sarcopenia is associated with a higher rate waitlist mortality, hepatic encephalopathy, and lower quality of life in patients with liver cirrhosis. Future studies should make an effort to unify and validate liver disease-specific cutoffs for the definition of sarcopenia.

Validity of measuring psoas muscle mass index for assessing sarcopenia in patients with gynecological cancer

OBJECTIVE

The current study evaluated the performance of psoas muscle mass measurement for detecting low skeletal muscle mass quantity.

METHODS

A sample of 82 consecutive patients with gynecological cancers was examined using computed tomography and dual energy X-ray absorptiometric scan before treatment. Skeletal muscle mass index was measured by dual energy X-ray absorptiometric scan and its cut-off value was set at 5.40 kg/m2 for detecting low skeletal muscle mass. Psoas muscle mass index was manually measured with cross-sectional computed tomography imaging at the level of L3 by six evaluators.

RESULTS

Low skeletal muscle mass index was identified in 23 (28.0%) patients. Two-way analysis of variance confirmed a significant main effect of skeletal muscle mass index on mean psoas muscle mass index values (P < 0.0001). A receiver operating characteristic curve obtained from a total of 492 psoas muscle mass index data points gathered from six evaluators produced an area under the curve value of 0.697 (95% confidence interval 0.649-0.744) and a cut-off value of 3.52 cm2/m2, with sensitivity of 79.0% and specificity of 59.6%. Using the cut-off value, the kappa coefficient for evaluating diagnostic agreement between skeletal muscle mass index (low vs. normal) and psoas muscle mass index (low vs. normal) was 0.308 (95% confidence interval 0.225-0.392), suggesting poor agreement. Fleiss' kappa produced a coefficient of 0.418 (95% confidence interval 0.362-0.473), suggesting moderate agreement.

CONCLUSIONS

Although relevance between skeletal muscle mass index and psoas muscle mass index was confirmed, intensity of relevance between them was weak. Psoas muscle mass index measurement should be subordinated to skeletal muscle mass index measurement for detection of low skeletal muscle mass.

Systematic review and meta-analysis of lean mass and mortality: Rationale and study description

Objectives

Muscle mass is one of the key components in defining sarcopenia and is known to be important for locomotion and body homeostasis. Lean mass is commonly used as a surrogate of muscle mass and has been shown to be associated with increased mortality. However, the relationship of lean mass with mortality may be affected by different clinical conditions, modalities used, cut-off point to define low or normal lean mass, and even types of cancer among cancer patients. Thus, we aim to perform a comprehensive meta-analysis of lean mass with mortality by considering all these factors.

Methods

Systematic search was done in PubMed, Cochrane Library and Embase for articles related to lean mass and mortality. Lean mass measured by dual X-ray absorptiometry, bioelectrical impedance analysis, and computerized tomography were included.

Results

The number of relevant studies has increased continuously since 2002. A total of 188 studies with 98 468 people were included in the meta-analysis. The association of lean mass with mortality was most studied in cancer patients, followed by people with renal diseases, liver diseases, elderly, people with cardiovascular disease, lung diseases, and other diseases. The meta-analysis can be further conducted in subgroups based on measurement modalities, site of measurements, definition of low lean mass adopted, and types of cancer for studies conducted in cancer patients.

Conclusions

This series of meta-analysis provided insight and evidence on the relationship between lean mass and mortality in all directions, which may be useful for further study and guideline development.

Sarcopenia and visceral adiposity predict poor overall survival in hepatocellular carcinoma patients after curative hepatic resection

Background

This study investigated the association of 3 components of body composition (sarcopenia, intramuscular fat deposition and visceral adiposity) with the overall or recurrence-free survival of hepatocellular carcinoma (HCC) patients who underwent curative hepatic resection.

Methods

One hundred sixty newly diagnosed and surgically treated HCC patients were retrospectively enrolled from 2003 to 2011. Three items of body composition were measured using the 3^rd lumbar level image of preoperative computed tomography (CT): psoas muscle index (PMI), psoas muscle attenuation (PMA), and visceral adipose tissue index (VATI). Sex-specific optimal cut-off for each item was determined from receiver-operating characteristic curves.

Results

The HCC patients showed a median age of 55 years, 75% of male, 78% of hepatitis B surface antigen positivity, and 96% of Child-Pugh A. The sarcopenic group (PMI less than the sex-specific cutoff of 3.33 cm²/m² for men and 2.38 cm²/m² for women) had 17.5% of the patients with a lower PMA (more fat deposition) but similar VATI compared to the non-sarcopenic group. PMI showed a positive correlation with PMA (ρ=0.493, P<0.001), while there was no significant correlation between PMI and VATI, and between PMA and VATI. On the multivariate analysis, a high PMI and low VATI were independent factors affecting overall survival while PMA was not. Nevertheless, PMI and VATI were not independent factors for recurrence-free survival.

Conclusions

In curatively resected HCC patients, sarcopenia and high visceral adiposity predict poor overall survival but not recurrence-free survival, while PMA did not predict overall survival.

Impact of musculoskeletal degradation on cancer outcomes and strategies for management in clinical practice

The prevalence of malnutrition in patients with cancer is one of the highest of all patient groups. Weight loss (WL) is a frequent manifestation of malnutrition in cancer and several large-scale studies have reported that involuntary WL affects 50-80% of patients with cancer, with the degree of WL dependent on tumour site, type and stage of disease. The study of body composition in oncology using computed tomography has unearthed the importance of both low muscle mass (sarcopenia) and low muscle attenuation as important prognostic indications of unfavourable outcomes including poorer tolerance to chemotherapy; significant deterioration in performance status and quality of life (QoL), poorer post-operative outcomes and shortened survival. While often hidden by excess fat and high BMI, muscle abnormalities are highly prevalent in patients with cancer (ranging from 10 to 90%). Early screening to identify individuals with sarcopenia and decreased muscle quality would allow for earlier multimodal interventions to attenuate adverse body compositional changes. Multimodal therapies (combining nutritional counselling, exercise and anti-inflammatory drugs) are currently the focus of randomised trials to examine if this approach can provide a sufficient stimulus to prevent or slow the cascade of tissue wasting and if this then impacts on outcomes in a positive manner. This review will focus on the aetiology of musculoskeletal degradation in cancer; the impact of sarcopenia on chemotherapy tolerance, post-operative complications, QoL and survival; and outline current strategies for attenuation of muscle loss in clinical practice.

Baseline Sarcopenia is Associated with Lack of Response to Therapy, Liver Decompensation and High Mortality in Hepatocellular Carcinoma Patients

OBJECTIVE

hepatocellular carcinoma (HCC) is a dreadful complication of liver cirrhosis. Aim was to study the effect of sarcopenia on the survival in patients with HCC.

METHODS

we included 262 patients and were followed up for 12 months. Sarcopenia was calculated by skeletal muscle index (SMI). Sarcopenia was defined by SMI ≤39 cm2/m2 for women and ≤50 cm2/m2 for men.

RESULTS

patients with sarcopenia (n= 113, 43.1%) were older, mainly males, Child-Pugh class B and smokers. Patients with sarcopenia had lower survival than those without (10.09 vs. 11.72 months). Survival was also lower in Barcelona clinic liver cancer stage C than B and A (9.02 vs. 11.21 vs. 11.89 months). Age and sarcopenia were hazardous of mortality (p <0.05). There was statistically significant difference of serial SMI in patients without baseline sarcopenia unlike patients with baseline sarcopenia. On follow up patients with sarcopenia had higher incidence of ascites (45% vs. 20.4%), spontaneous bacterial peritonitis (21.7% vs. 11.6%), hepatic encephalopathy (28% vs. 11.5%) and bleeding (22.9% vs. 12.7%). Totally patients with sarcopenia had higher incidence of progressive HCC (39% vs. 25.5%).

CONCLUSION

Sarcopenia is associated with lack of response to therapy, liver decompensation and higher mortality in hepatocellular carcinoma patients.
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Impact of low skeletal muscle mass index and perioperative blood transfusion on the prognosis for HCC following curative resection

BACKGROUND

This study aimed to assess the prognostic factors including low skeletal muscle mass index (SMI) and perioperative blood transfusion for patients with hepatocellular carcinoma (HCC) following curative surgery.

METHODS

This study included 139 patients with HCC who underwent hepatectomy between 2005 and 2016. Univariate and multivariate analyses were performed to identify variables associated with overall survival (OS) and recurrence-free survival (RFS).

RESULTS

Low SMI was significantly related with poor OS, while blood transfusion had a strong impact on RFS. The male ratio and body mass index in the low SMI group were significantly higher than those in the high SMI group. There were no significant differences in age, virus etiology, laboratory data, liver function, tumor makers, and operative variables between the groups. Tumor factors such as tumor diameter, tumor number, poor differentiation, and intrahepatic metastasis (IM) did not significantly differ between the two groups. Operation time, intraoperative blood loss volume, and recurrence ratio were significantly higher in the blood transfusion group than in the non-transfusion group. IM was associated with poor OS and RFS.

CONCLUSIONS

Low SMI and blood transfusion were independently related with long-term prognosis in patients with HCC following curative surgery.

Plasma free amino acids are associated with sarcopenia in the course of hepatocellular carcinoma recurrence

OBJECTIVE

Sarcopenia worsens the prognosis of patients with hepatocellular carcinoma (HCC). The aim of this study was to elucidate the plasma free amino acids (PFAAs) associated with sarcopenia or myosteatosis in the course of HCC recurrence.

METHODS

In this cross-sectional study, 187 patients were enrolled retrospectively. All patients experienced more than one hospitalization (mean times, 2.65) owing to HCC recurrence. The skeletal muscle index (SMI) and muscle attenuation (MA) were measured by a transverse computed tomography (CT) scan image at the third lumbar vertebra (L3). The changes in the concentration of 24 PFAAs, SMI, and MA in the same patient between recurrences were defined as Δ. The associations between sarcopenia, myosteatosis, and PFAAs were evaluated by a logistic regression model. The ΔSMI and ΔMA were compared between the patients who received branched-chain amino acids (BCAAs) formulation and those who did not.

RESULTS

Patients with sarcopenia showed lower survival rate; the 1-, 3-, and 5-y survival rates were 85%, 42%, and 9%, respectively. Multivariate analysis revealed that the level of total BCAAs was significantly associated with sarcopenia. The correlation coefficient value between the change of leucine (ΔLeu) and ΔSMI was highest (R = 0.256; P < 0.001) among the PFAAs. In the Child-Pugh grade B or C, the decrease of SMI was significantly more suppressed in the patients with the BCAAs formulation than in those without BCAAs formulation (ΔSMI: mean change -0.98 versus -3.45 cm²/m²; P = 0.038).

CONCLUSION

Among the PFAAs, the level of BCAAs was associated with sarcopenia in the course of HCC recurrence.

Urinary titin N-terminal fragment concentration is an indicator of preoperative sarcopenia and nutritional status in patients with gastrointestinal tract and hepatobiliary pancreatic malignancies

OBJECTIVES

Recent reports indicate that preoperative patients with gastrointestinal malignancies often have sarcopenia. The diagnosis of sarcopenia is generally done by evaluation of walking speed, grip strength, and skeletal muscle volume of the limbs on computed tomography (CT). However, these parameters are objective indices, and new indicators for diagnosis, such as molecular biomarkers, have been anticipated. The aim of this study was to investigate whether titin, a muscular contractile protein present in sarcomeres, is an indicator of sarcopenia.

METHODS

We analyzed 39 patients with gastrointestinal tract and hepatobiliary pancreatic malignancies who underwent surgery. We compared urinary titin n-terminal fragment concentration (UTF) with clinical factors, subcutaneous fat volume, and skeletal muscle volume index, and also compared UTF levels between patients with and without sarcopenia.

RESULTS

The patients comprised 24 men and 15 women, with a mean age of 72 y (range: 35-85 y). Cancer locations were the pancreas (n = 17), liver (n = 9), stomach (n = 5), colorectum (n = 5), and esophagus (n = 3). UTF was significantly higher in patients with sarcopenia (P = 0.04), and showed statistically significant negative correlations with albumin (r = -2.61, P = 0.001), pre-albumin (r = -2.14, P = 0.02), body mass index (r = -0.49, P = 0.007), cholinesterase (r = -0.02, P = 0.01, skeletal muscle volume index (r = -0.16, P = 0.04), and subcutaneous fat volume (r = -0.03, P = 0.007).

CONCLUSION

UTF may be a new index for preoperative nutritional assessment in patients with gastrointestinal malignancies.

Resection of NAFLD-Associated HCC: Patient Selection and Reported Outcomes

Global prevalence of non-alcoholic fatty liver disease (NAFLD) has been growing in the last decades, especially in western countries, due to increased prevalence of diabetes, obesity or other components of metabolic syndrome. NAFLD recently became an important cause of hepatocellular carcinoma (HCC), even in non-cirrhotic patients. Patients with HCC-NAFLD are usually older, with more morbidities (especially cardiovascular diseases and metabolic disorders) and have advanced disease at the diagnosis due to the absence of surveillance, which is considered not cost-effective in patients without advanced fibrosis/cirrhosis, given the large prevalence of NAFLD in the general population. For these reasons, patients with HCC-NAFLD unlikely underwent curative treatments, and have been reported to have lower overall survival (OS) compared to individuals with HCC related to other aetiologies. However, this difference is not confirmed by data of patient subgroups who received curative treatment. In our review, we selected studies published over the past 8 years that analyse characteristics and outcomes of HCC-NAFLD patients who underwent surgery with the aim of identifying features that could predict outcomes and potential selection criteria. All the studies confirm that patients with HCC-NAFLD are older, with many comorbidities and that HCC occurs frequently even in non-cirrhotic livers. There is no agreement about intraoperative and perioperative complications. Regarding outcomes, all papers agree that patients with HCC in NAFLD who undergo surgery have a better OS compared to other aetiologies. Summarizing, surgery is a good curative option for patients with HCC-NAFLD, perhaps even better than transplantation in terms of OS. In this group of patients, it seems to be essential to evaluate cardio-pulmonary and general operative risk, in addition to the normal risk assessment related to liver function to avoid an underestimation, especially for patients without severe underlying fibrosis.

Pre-sarcopenia is the prognostic factor of overall survival in early-stage hepatoma patients undergoing radiofrequency ablation

Sarcopenia might have impact on the outcome of patients with hepatoma carcinoma (HCC). This study was to determine whether pre-sarcopenia is associated with the outcome of HCC patients undergoing radiofrequency ablation (RFA).Patients with newly diagnosed HCC undergoing RFA were enrolled. We excluded patients without pre-RFA abdominal computed tomography or with incomplete ablation. Psoas muscle area index was calculated at the mid-lumbar 3 level of computed tomography images with the manual trace method. Pre-sarcopenia was defined as psoas muscle area index less than 4.24 and 2.50 cm/m for males and females respectively. The demographics and clinical characteristics were recorded before RFA.All patients were followed regularly until death or end of 2018. A total of 136 patients, including - BCLC stage 0 (n = 44, 32.4%) and - stage A (n = 92, 67.6%), were enrolled (males/females: 78/58, age: 65.4 years) with a mean follow-up period of 3.84 years. There were 75 patients (55.1%) with HCC recurrence and 47 patients (34.6%) with mortality during follow-up. Twenty-two (16.2%) patients were diagnosed with pre-sarcopenia. Multivariate analysis showed pre-sarcopenia (HR: 2.110 (1.092-4.078); P = .026) was the only factor significantly associated with overall survival (OS); however, there were no factors associated with HCC recurrence.For patients without and with pre-sarcopenia, the 1-, 3-, and 5-year OS rates were 92.0%, 77.6%, 68.9%, and 81.8%, 54.5%, 44.1% respectively (P = .007). For early-stage HCC patients undergoing RFA, pre-sarcopenia is the prognostic factor of OS, but not of recurrence, with a worse 5-year OS rate of 44.1%.

Analysis of the optimal psoas muscle mass index cut-off values, as measured by computed tomography, for the diagnosis of loss of skeletal muscle mass in Japanese people

This study aimed to determine the optimal psoas muscle mass index (PMI) cut-off values for diagnosis of skeletal muscle mass loss.

METHODS

We evaluated PMI in two groups of normal controls: a medical check-up group and a liver donation candidate group. We analyzed two novel PMI cut-off values, one based on the mean - two standard deviations (2SD) and one based on the lower 5%. Skeletal muscle mass index (SMI) evaluations using computed tomography (sliceOmatic; TomoVision) and bioelectrical impedance analysis and PMI evaluation were undertaken simultaneously. We analyzed the correlation between our PMI cut-off values and the Japan Society of Hepatology-defined SMI cut-off values. The prevalence of skeletal muscle mass loss in patients with liver disease was assessed using the novel PMI cut-off values.

RESULTS

In 504 normal controls aged ≤50 years, the PMI cut-off values based on mean -2SD and the lower 5% were set at 3.30 cm² /m² for men and 1.69 cm² /m² for women and 3.74 cm² /m² for men and 2.29 cm² /m² for women, respectively. The PMI cut-off values based on the lower 5% alone showed that skeletal muscle mass loss increased with age. Furthermore, they correlated well with Japan Society of Hepatology-defined SMI (sliceOmatic) cut-off values and showed a significantly higher prevalence of skeletal muscle mass loss in patients with liver cirrhosis than those without liver cirrhosis.

CONCLUSIONS

We propose the following PMI cut-off values: 3.74 cm² /m² for male individuals and 2.29 cm² /m² for female individuals. These cut-off values can facilitate accurate diagnosis and management of sarcopenia in patients with chronic liver disease.

Sarcopenia in chronic liver diseases: a translational overview

INTRODUCTION

Sarcopenia refers to a progressive and generalized muscle mass and strength loss. In liver diseases, it has been related to worse outcomes and high risk of decompensations.

AREAS COVERED

Sarcopenia is caused by a set of cellular processes in the muscle such as denervation, mitochondrial dysfunction, endotoxemia and inflammation; which are manifested through the alteration of several proteolytic pathways such as lysosomal, proteasomal and caspase systems. In autophagy, myostatin and oxidative stress; such as hyperammonemia, contributes importantly to liver sarcopenia through loss of muscle mass already demonstrated in in vitro and in vivo models. In addition, hormones and the regulation of the intestinal microbiota, influence in a not less important magnitude. In the clinical setting, early identification of sarcopenia has been established as a mandatory item to prevent progression of muscle mass loss; however, diagnostic methods have extreme variation according to methodology, population, etiology and severity of liver disease. Reversing sarcopenia should be an integral therapeutic strategy.

EXPERT OPINION

Clinical and nutritional interventions should be adapted to liver injury etiology and stage of disease, each of them shares a similar sarcopenia development pathway. There are specific biomarkers that condition or exacerbate loss of skeletal muscle.

Clinical impact of sarcopenia assessment in patients with hepatocellular carcinoma undergoing treatments

Changes in body composition are associated with poor outcomes in cancer patients including hepatocellular carcinoma (HCC). Sarcopenia, defined as the loss of skeletal muscle mass, quality and function, has been associated with a higher rate of complications and recurrences in patients with cirrhosis and HCC. The assessment of patient general status before HCC treatment, including the presence of sarcopenia, is a key-point for achieving therapy tolerability and to avoid short- and long-term complications leading to poor patients' survival. Thus, we aimed to review the current literature evaluating the role of sarcopenia assessment related to HCC treatments and to critically provide the clinicians with the most recent and valuable evidence. As a result, sarcopenia can be predictive of poor outcomes in patients undergoing liver resection, transplantation and systemic therapies, offering the chance to clinicians to improve the muscular status of these patients, especially those with high-grade sarcopenia at high risk of mortality. Further studies are needed to clarify the predictive value of sarcopenia in other HCC treatment settings and to evaluate its role as an additional staging tool for identifying the most appropriate treatment. Besides, interventional studies aiming at increasing the skeletal muscle mass for reducing complications and increasing the survival in patients with HCC are needed.

Efficacy of Physical Activity in Prevention of Muscle Weakness in Patients With Chronic Liver Disease

Background

Sarcopenia is a prognostic factor for patients with liver cirrhosis and hepatocellular carcinoma, and it affects the onset of hepatic encephalopathy. Therefore, the prevention of sarcopenia contributes to the improvement of the prognosis of patients with chronic liver disease (CLD). We focused on changes of hand grip strength (HGS), one of the indicators of sarcopenia. However, there are little data investigating the impact of physical activity (PA) on HGS in patients with CLD. This study aimed to clarify whether PA contributes to the prevention of muscle weakness in patients with CLD.

Methods

This was a prospective observational study. We examined the effect of PA on changes in HGS from the baseline to the endpoint in each group. Metabolic equivalents-hour/week (METs-h/w) was used to evaluate PA. In total, 183 outpatients with CLD were analyzed. We divided participants into four groups (low PA in younger patients (n = 20), high PA in younger patients (n = 33), low PA in elderly patients (n = 47), and high PA in elderly patients (n = 83)).

Results

Fifty-eight percent of patients were men, and the median (interquartile range) age was 69.0 (63.0, 75.0) years. The most common etiology of liver disease was hepatitis C (38%). The frequency of living alone and low exercise habit was significantly high, and sarcopenia was more obvious in elderly patients with low PA than in those with high PA. Additionally, the elderly with low PA showed significantly reduced HGS compared to that of the elderly with high PA (-1.00 (-2.27, 0.55) kg vs. 0.10 (-1.40, 1.10) kg, P < 0.05). However, changes in HGS in younger patients were not significant (-0.02 (1.83, 1.47) kg vs. 0.25 (-2.45, 2.05) kg, P = 0.96). Logistic regression analyses identified PA as the independent factor for prevention of decrease in HGS (odds ratio: 1.91, 95% confidence interval: 1.00 - 3.62, P = 0.049).

Conclusions

Young patients with low PA were characterized by a long sedentary time; however, there was no loss of HGS. In contrast, elderly patients with CLD and low PA had significantly reduced HGS compared to that in elderly patients with CLD and high PA.

Impact of Body Composition on the Risk of Hepatocellular Carcinoma Recurrence After Liver Transplantation

BACKGROUND

Body composition parameters are reported to influence the risk of hepatocellular carcinoma (HCC) recurrence after liver resection, yet data on patients undergoing liver transplantation are scarce. The aim of this study was to evaluate the impact of the amount of abdominal adipose tissue and skeletal muscles on the risk of HCC recurrence after liver transplantation.

METHODS

This was a retrospective observational study performed on 77 HCC patients after liver transplantation. Subcutaneous fat area (SFA), visceral fat area, psoas muscle area and total skeletal muscle area were assessed on computed tomography on the level of L3 vertebra and divided by square meters of patient height. The primary outcome measure was five-year recurrence-free survival.

RESULTS

Recurrence-free survival in the entire cohort was 95.7%, 90.8%, and 86.5% after one, three, and five years post-transplantation, respectively. SFA was significantly associated with the risk of HCC recurrence (p = 0.013), whereas no significant effects were found for visceral fat and skeletal muscle indices. The optimal cut-off for SFA for prediction of recurrence was 71.5 cm²/m². Patients with SFA < 71.5 cm²/m² and ≥71.5 cm²/m² exhibited five-year recurrence-free survival of 96.0% and 55.4%, respectively (p = 0.001).

CONCLUSIONS

Excessive amount of subcutaneous adipose tissue is a risk factor for HCC recurrence after liver transplantation and may be considered in patient selection process.

Prognostic value of the third lumbar skeletal muscle mass index in patients with liver cirrhosis and ascites

BACKGROUND & AIMS

The objective nutritional assessment indicators, body mass index (BMI), upper arm muscle circumference (MAMC), and triceps skinfold thickness (TSF), are often limited due to ascites. This study investigated the prognostic value of the third lumbar vertebrae skeletal muscle mass index (L3 SMI) in addition to the objective nutritional evaluation indicators (BMI, MAMC and TSF) in patients with liver cirrhosis and ascites.

METHODS

In this retrospective analysis, a total of 147 patients with liver cirrhosis and ascites were included. The L3 SMI, BMI, MAMC and TSF were detected in all patients. The severity of liver disease was assessed by the Model End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) classification. These variables were compared between non-surviving and surviving patients who were classified according to 5-year mortality.

RESULTS

Of the 147 patients, 62 (42.2%) died and 85 (57.8%) survived within 5 years. The L3 SMI of patients was significantly lower than that of the normal control group (39.58 ± 7.18 cm²/m² vs. 53.73 ± 7.92 cm²/m,²p < 0.001). The L3 SMI (OR 4.02; 95% CI 2.17-9.63; p < 0.001), MELD score (OR 2.11; 95% CI 1.12-4.13; p < 0.001) and CTP class (OR 2.69; 95% CI 1.09-5.06; p < 0.001) were independent predictive indicators of 5-year mortality. Furthermore, the performance of the two variables (L3 SMI and MELD) together (AUROC: 0.812) was significantly better than that of MELD alone (AUROC: 0.787) for prediction of 5-year mortality (p < 0.001).

CONCLUSION

Compared with MAMC, TSF and BMI, L3 SMI is an independent risk factor for 5-year mortality in patients with liver cirrhosis and ascites. Further nutritional intervention studies are needed to confirm the impact of the L3 SMI index on clinical outcomes.

Effects of weight loss and sarcopenia on response to chemotherapy, quality of life, and survival

It has frequently been shown that patients with cancer are one of the largest hospital patient groups with a prevalence for malnutrition. Weight loss is a frequent manifestation of malnutrition in patients with cancer. Several large-scale studies over the past 35 y have reported that involuntary weight loss affects 50% to 80% of these patients with the degree of weight loss dependent on tumor site and type and stage of disease. The aim of this review was to determine the consequences of malnutrition, weight loss, and muscle wasting in relation to chemotherapy tolerance, postoperative complications, quality of life, and survival in patients with cancer. The prognostic impact of weight loss on overall survival has long been recognised with recent data suggesting losses as little as 2.4% predicts survival independent of disease, site, stage or performance score. Recently the use of gold-standard methods of body composition assessment, including computed tomography, have led to an increased understanding of the importance of muscle abnormalities, such as low muscle mass (sarcopenia), and more recently low muscle attenuation, as important prognostic indicators of unfavourable outcomes in patients with cancer. Muscle abnormalities are highly prevalent (ranging from 10-90%, depending on cancer site and the diagnostic criteria used). Both low muscle mass and low muscle attenuation have been associated with poorer tolerance to chemotherapy; increased risk of postoperative complications; significant deterioration in a patients' performance status, and poorer psychological well-being, overall quality of life, and survival.

[Liver Fibrosis is Associated with Loss of Skeletal Muscle Mass in Community-Dwelling Older Adults with No History of Liver Diseases]

OBJECTIVES

In this study, we aimed to examine the possible association between liver fibrosis and loss of skeletal muscle mass (SM) in community-dwelling older adults with no history of liver diseases.

METHODS

A total of 2,028 older adults (mean age, 69.8 ± 5.2 years) who had not received any treatment for liver diseases and had participated in a comprehensive health survey for community residents in Wakayama, Japan were included in this study. We carried out bioelectrical impedance analysis to estimate the SM of the whole body including the arms, legs, and trunk of the subjects. Liver fibrosis was evaluated by calculating the Fib4 index based on the subject's age, AST level, ALT level, and platelet counts.

RESULTS

The subjects were divided into three groups according to cutoff values of the Fib4 index (low: <1.30, medium: 1.30-2.66, high: ≥2.67). The SM index (kg/m²) was the lowest among subjects in the high-Fib4-index category, followed by the medium- and low-Fib4-index categories. This dose-response reduction in the SM index was more pronounced among individuals with lower blood albumin level (low nutrition) and in those with more sedentary behavior (physical inactivity). Among the selected 262 subjects who underwent SM measurement twice with an interval of 3 years, the subjects with a high Fib4 index showed greater reduction in the SM index than those with medium and low Fib4 indices. Multiple regression analysis revealed that the Fib4 index was significantly associated with the SM index, independent of age, sex, albumin level, sedentary behavior, diabetes mellitus, alcohol intake, and smoking status.

CONCLUSIONS

The present findings suggest that the potential progression of liver fibrosis is associated with the excessive loss of SM among apparently healthy older adults without any treatment for liver diseases.

Body composition and sarcopenia: The next-generation of personalized oncology and pharmacology?

Body composition has gained increasing attention in oncology in recent years due to fact that sarcopenia has been revealed to be a strong prognostic indicator for survival across multiple stages and cancer types and a predictive factor for toxicity and surgery complications. Accumulating evidence over the last decade has unraveled the "pharmacology" of sarcopenia. Lean body mass may be more relevant to define drug dosing than the "classical" body surface area or flat-fixed dosing in patients with cancer. Since sarcopenia has a major impact on patient survival and quality of life, therapeutic interventions aiming at reducing muscle loss have been developed and are being prospectively evaluated in randomized controlled trials. It is now acknowledged that this supportive care dimension of oncological management is essential to ensure the success of any anticancer treatment. The field of sarcopenia and body composition in cancer is developing quickly, with (i) the newly identified concept of sarcopenic obesity defined as a specific pathophysiological entity, (ii) unsolved issues regarding the best evaluation modalities and cut-off for definition of sarcopenia on imaging, (iii) first results from clinical trials evaluating physical activity, and (iv) emerging body-composition-tailored drug administration schemes. In this context, we propose a comprehensive review providing a panoramic approach of the clinical, pharmacological and therapeutic implications of sarcopenia and body composition in oncology.