The role of sarcopenia in patients with intrahepatic cholangiocarcinoma: Prognostic marker or hyped parameter?

AI-derived body composition parameters as prognostic factors in patients with HCC undergoing TACE in a multicenter study

Background & Aims

Body composition assessment (BCA) parameters have recently been identified as relevant prognostic factors for patients with hepatocellular carcinoma (HCC). Herein, we aimed to investigate the role of BCA parameters for prognosis prediction in patients with HCC undergoing transarterial chemoembolization (TACE).

Methods

This retrospective multicenter study included a total of 754 treatment-naïve patients with HCC who underwent TACE at six tertiary care centers between 2010-2020. Fully automated artificial intelligence-based quantitative 3D volumetry of abdominal cavity tissue composition was performed to assess skeletal muscle volume (SM), total adipose tissue (TAT), intra- and intermuscular adipose tissue, visceral adipose tissue, and subcutaneous adipose tissue (SAT) on pre-intervention computed tomography scans. BCA parameters were normalized to the slice number of the abdominal cavity. We assessed the influence of BCA parameters on median overall survival and performed multivariate analysis including established estimates of survival.

Results

Univariate survival analysis revealed that impaired median overall survival was predicted by low SM (p <0.001), high TAT volume (p = 0.013), and high SAT volume (p = 0.006). In multivariate survival analysis, SM remained an independent prognostic factor (p = 0.039), while TAT and SAT volumes no longer showed predictive ability. This predictive role of SM was confirmed in a subgroup analysis of patients with BCLC stage B.

Conclusions

SM is an independent prognostic factor for survival prediction. Thus, the integration of SM into novel scoring systems could potentially improve survival prediction and clinical decision-making. Fully automated approaches are needed to foster the implementation of this imaging biomarker into daily routine.

Impact and implications

Body composition assessment parameters, especially skeletal muscle volume, have been identified as relevant prognostic factors for many diseases and treatments. In this study, skeletal muscle volume has been identified as an independent prognostic factor for patients with hepatocellular carcinoma undergoing transarterial chemoembolization. Therefore, skeletal muscle volume as a metaparameter could play a role as an opportunistic biomarker in holistic patient assessment and be integrated into decision support systems. Workflow integration with artificial intelligence is essential for automated, quantitative body composition assessment, enabling broad availability in multidisciplinary case discussions.

Impact of sarcopenia on the short-term and long-term outcomes of intrahepatic cholangiocarcinoma undergoing hepatectomy: A multi-center study

BACKGROUND

Sarcopenia is associated with adverse prognosis of intrahepatic cholangiocarcinoma (iCCA) after surgery.

METHODS

321 patients with iCCA undergoing surgery were retrospectively recruited and assigned to training and validation cohort. Skeletal muscle index (SMI) was assessed to define sarcopenia. Logistic regression and cox regression analysis were used to identify risk factors. A novel sarcopenia-based nomogram was constructed and validated by ROC curves, calibration curves, and DCA curves.

RESULTS

260 patients were included for analysis. The median age was 63.0 years and 161 patients (61.9%) were diagnosed with sarcopenia. Patients with sarcopenia exhibited a higher rate of postoperative complications, a worse OS and RFS than patients without sarcopenia. Sarcopenia, low albumin and intraoperative blood transfusion were independent risk factors of postoperative complications, while sarcopenia and low albumin were risk factors of high CCI≥26.2. Sarcopenia, high PS score, low-undifferentiated differentiation, perineural invasion, TNM stage III-IV were risk factors of OS, and a novel nomogram based on these five factors was built to predict the 12-, 24-, and 36-months OS, with the mean AUC > 0.6.

CONCLUSION

Sarcopenia is negatively associated with both postoperative complications and survival prognosis of iCCA undergoing hepatectomy.

Prevalence and predictive value of sarcopenia in surgically treated cholangiocarcinoma: a comprehensive review and meta-analysis

Background

Sarcopenia, marked by a reduction in skeletal muscle mass and function, is a condition that can manifest in elderly patients with cancer and has been recognized as a possible adverse factor affecting the survival of individuals diagnosed with malignant tumors. This systematic review and meta-analysis aimed to examine the prevalence of sarcopenia in individuals with cholangiocarcinoma while concurrently investigating the potential correlations between the presence of sarcopenia and various critical factors, including survival outcomes and postoperative complications.

Methods

A comprehensive search was conducted across multiple databases, including EMBASE, PubMed, Web of Science, Cochrane Library, and CNKI, employing keywords such as sarcopenia, cholangiocarcinoma, and prognosis. This research explored the prognostic value of sarcopenia on the survival of cholangiocarcinoma. The findings of this meta-analysis were presented using forest plots and a summarized effects model. The Newcastle-Ottawa Scale (NOS) was employed to evaluate the quality of the studies included in the analysis.

Results

A total of 33 articles from five databases were in in the quantitative analysis. A comprehensive meta-analysis revealed that the overall prevalence of sarcopenia among individuals diagnosed with cholangiocarcinoma was43%. Moreover, the analysis revealed a significant and noteworthy correlation between sarcopenia and key clinical parameters such as overall survival (OS), Recurrence-Free Survival (RFS), and Disease-Free Survival (DFS) in patients with cholangiocarcinoma. Subgroup analysis revealed that, when categorized by various ethnicities, diagnostic techniques, and tumor locations, sarcopenia consistently retained its status as a negative predictive factor. Furthermore, sarcopenia has emerged as a risk factor for postoperative complications. All included studies had an NOS score greater than 5, indicating a high quality of evidence.

Conclusion

The results suggest that sarcopenia is significantly related to survival outcomes and postoperative complications in cholangiocarcinoma. Appropriate diagnosis and treatment of sarcopenia should be implemented to improve the prognosis of individuals with cholangiocarcinoma.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023479866, identifier CRD42023479866.

Prognostic impact of preoperative skeletal muscle change from diagnosis to surgery in patients with perihilar cholangiocarcinoma

Background

Loss of skeletal muscle mass is a prognostic factor after surgery for gastrointestinal cancers. The treatment for perihilar cholangiocarcinoma (PHC) is a highly invasive surgery. Biliary drainage and portal vein embolization, which can prolong the preoperative waiting time (PWT), are often required before surgery. Assuming that the skeletal muscle mass can change during PWT, we investigated the clinical effect of skeletal muscle change on surgical outcomes of PHC.

Methods

We retrospectively reviewed the medical records of 89 patients who underwent curative surgery for PHC from January 2013 to December 2019. We defined the psoas muscle area (PMA) at the third lumbar vertebra as the skeletal muscle mass. The PMA just before surgery was divided by that at the time of diagnosis, and we defined it as the rate of change of PMA (CPMA). Patients were divided into two groups according to CPMA: wasting (n = 44, below the median CPMA) and no-change (n = 45, above the median CPMA).

Results

The median PWT was 63 d, and CPMA was 96.1%. The median recurrence-free survival and overall survival were significantly shorter in the wasting group than in the no-change group (8.0 vs 33.2 mo, P = 0.001 and 14.2 vs 48.7 mo, P < 0.001, respectively). Multivariate analysis revealed that histological differentiation, R1 resection, lymph node metastasis, and preoperative skeletal muscle wasting were independent prognostic factors of PHC.

Conclusion

This study suggests that preoperative skeletal muscle wasting in patients with PHC has a negative effect on survival outcomes.

Low skeletal muscle mass in cholangiocarcinoma treated by surgical resection. A meta-analysis

BACKGROUND

To date, the role of low skeletal muscle mass (LSMM) in cholangiocarcinoma (CC) is unclear. Our purpose was to analyze the influence of LSMM on survival in patients with CC treated by surgical resection.

METHODS

MEDLINE, Cochrane, and SCOPUS databases were screened for associations between LSMM and survival in CC up to June 2021. Overall, 16 studies met the inclusion criteria. The methodological quality of the involved studies was analyzed using the QUADAS instrument. The meta-analysis was undertaken using RevMan 5.4 software.

RESULTS

The prevalence of LSMM was 48.40%. LSMM was associated with lower overall survival (OS): HR = 2.44, 95%CI = (2.01-2.96) (simple regression); HR = 2.39, 95%CI = (1.83-3.13) (multiple regression). In extrahepatic CC, sarcopenic patients had lower OS, simple regression: HR = 2.11, 95%CI = (1.39-3.20); multiple regression: HR = 2.28, 95%CI = (1.41-3.70). In intrahepatic CC, LSMM predicted recurrence free survival: HR = 2.33, 95%CI = (1.93-2.81) (simple regression); HR = 2.23, 95%CI = (1.73-2.88) (multiple regression). LSMM predicted OS in intrahepatic CC, simple regression: HR = 2.69, 95%CI = (2.24-3.24); multiple regression: HR = 2.43, 95%CI = (1.73-3.41).

CONCLUSION

LSMM is a risk factor for OS in patients with CC treated by surgical resection. LSMM is a predictor of RFS in patients with intrahepatic CC.

Clinical Impact of Sarcopenia on Cholangiocarcinoma

Sarcopenia is considered an important factor affecting the prognosis of cancer patients. Only complete surgical resection confers the chance of curing cholangiocarcinoma with sarcopenia. However, the prognosis is poor, even for patients who undergo surgical resection. Data from 13 trials of patients with sarcopenia and intrahepatic cholangiocarcinoma (ICC) or perihilar cholangiocarcinoma (PHC) were collected and reviewed. During all trials, sarcopenia was assessed using the psoas muscle or total skeletal muscle at the L3 level on cross-sectional images. The data showed heterogeneity among the subjects and treatment options and discrepancies in methods of measuring muscle mass and setting the cut-off level. Despite conflicting results regarding morbidity, mortality, and recurrence, sarcopenia may be associated with poor overall survival and recurrence-free survival (RFS) for ICC patients. The impact of sarcopenia on the morbidity of ICC patients remains unclear. The impact of PHC on morbidity, mortality, and RFS is also unclear. Further well-designed studies are needed to elucidate the effects of sarcopenia on ICC and PHC.

Sarcopenia Predicts Relevant Clinical Outcomes in Biliary Tract Cancer Patients: A Systematic Review and Meta-Analysis

The purpose of this meta-analysis was to analyze the influences of sarcopenia on clinical outcomes in patients with biliary tract cancer (BTC). A systematic literature search was performed in November 2021. Some studies that reported the impacts of sarcopenia on the prognosis of patients with BTC were included. The overall hazard ratios (HRs), overall survival (OS), recurrence-free survival (RFS), and odds ratio (OR) for major postoperative complications were calculated using a fixed- or random effects. In the 18 studies, 3261 patients were enrolled for analysis. Based on defining sarcopenia by muscle mass, sarcopenia predicted OS, and based on defining sarcopenia by muscle density, HR was 2.10 (95% CI 1.72-2.56) and HR was 2.12 (95% CI 1.46- 3.10). Patients with sarcopenia had poorer RFS, and HR was 2.18 (95% CI 1.75-2.71). The incidence rate of major postoperative complication increased compared with those without sarcopenia (OR, 1.45; 95% Cl, 1.07-1.96). Sarcopenia is an independent risk factor for poor OS and RFS in patients with BTC. Sarcopenia is associated with the occurrence of major postoperative complications. This study provides advice that clinicians should provide importance to the assessment of skeletal muscle status and provide suitable nutritional supports and exercise program to reduce the sarcopenia in patients with BTC.

Preoperative Assessment of Skeletal Muscle Mass and Muscle Quality Using Computed Tomography: Incidence of Sarcopenia in Patients with Intrahepatic Cholangiocarcinoma Selected for Liver Resection

Background: Sarcopenia is considered a predictor of poor postoperative and long-term results following liver resection for intrahepatic cholangiocarcinoma (ICC). The aim of our study was to assess the incidence of sarcopenia in patients resected for ICC and its relation to preoperative clinical factors. Methods: Patients resected for ICC in our unit, with available preoperative CT scans within one month before operation, were enrolled in the study. Skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD) were assessed for each patient. Results: Thirty patients matched all inclusion criteria. Low SMI values were documented in 15 patients (50.0%), and low SMD values were documented in 10 patients (33.3%). SMI was significantly greater in males (p < 0.001). In patients who were underweight, the incidence of low SMI was significantly higher than that of high SMI (p = 0.031). In patients who were overweight/obese, the incidence of high SMI was significantly higher than that of low SMI (p = 0.003) and the incidence of low SMD was significantly higher than that of high SMD (p = 0.038). In the univariate analysis, no preoperative factors (clinical and tumor-related factors), in particular BMI, were found to be independent predictors of low SMI. Conclusions: The incidence of sarcopenia was 50.0% in patients selected for liver resection for ICC and was not related to the preoperative clinical factors. A multidisciplinary evaluation of the nutritional status is fundamental before liver resection in patients.

Body composition assessment and sarcopenia in patients with biliary tract cancer: A systematic review and meta-analysis

BACKGROUND

Sarcopenia, as assessed by body composition, can affect morbidity and survival in several gastrointestinal cancer. However, the impact of sarcopenia, referring to both quantity and quality of skeletal muscle, in biliary tract cancer (BTC) is debatable. We aimed to investigate the impact of sarcopenia on morbidity and mortality in patients with BTC.

METHODS

Electronic databases and trial registries were searched through July 2021 to perform random-effects meta-analyses. Study selection, data abstraction and quality assessment were independently performed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Twenty-nine studies (4443 patients) were included; 28 used computed tomography and one used dual-energy X-ray absorptiometry to assess body composition. Eighteen studies reported the impact of pre-operative sarcopenia on postoperative outcomes; namely, sarcopenia increased postoperative complications (risk ratio = 1.23, 95% confidence interval [CI] = 1.07 to 1.41; I² = 2%), and decreased recurrence-free survival (hazard ratio [HR] = 2.20, 95% CI = 1.75 to 2.75; I² = 0%) in multivariable analyses. Low muscle quantity (HR = 2.26, 95% CI = 1.75 to 2.92; I² = 66%) and quality (HR = 1.75, 95% CI = 1.33 to 2.29; I² = 50%) decreased overall survival in multivariable analyses. The certainty of the evidence was low because of heterogeneity and imprecision.

CONCLUSIONS

In sarcopenia, low muscle quantity and quality by body composition conferred an independent risk of morbidity and mortality in patients with BTC. Further studies are needed to confirm these findings and mitigate risk.

A Novel Clinical-Radiomics Model Based on Sarcopenia and Radiomics for Predicting the Prognosis of Intrahepatic Cholangiocarcinoma After Radical Hepatectomy

Background

Intrahepatic cholangiocarcinoma (ICC) is a highly aggressive malignant tumor with a poor prognosis. This study aimed to establish a novel clinical-radiomics model for predicting the prognosis of ICC after radical hepatectomy.

Methods

A clinical-radiomics model was established for 82 cases of ICC treated with radical hepatectomy in our hospital from May 2011 to December 2020. Radiomics features were extracted from venous-phase and arterial-phase images of computed tomography. Kaplan-Meier survival analysis was generated to compare overall survival (OS) between different groups. The independent factors were identified by univariate and multivariate Cox regression analyses. Nomogram performance was evaluated regarding discrimination, calibration, and clinical utility. C-index and area under the curve (AUC) were utilized to compare the predictive performance between the clinical-radiomics model and conventional staging systems.

Results

The radiomics model included five features. The AUC of the radiomics model was 0.817 in the training cohort, and 0.684 in the validation cohort. The clinical-radiomics model included psoas muscle index, radiomics score, hepatolithiasis, carcinoembryonic antigen, and neutrophil/lymphocyte ratio. The reliable C-index of the model was 0.768, which was higher than that of other models. The AUC of the model for predicting OS at 1, and 3 years was 0.809 and 0.886, which was significantly higher than that of the American Joint Committee on Cancer 8^th staging system (0.594 and 0.619), radiomics model (0.743 and 0.770), and tumor differentiation (0.645 and 0.628). After stratification according to the constructed model, the median OS was 59.8 months for low-risk ICC patients and 10.1 months for high-risk patients (p < 0.0001).

Conclusion

The clinical-radiomics model integrating sarcopenia, clinical features, and radiomics score was accurate for prognostic prediction for mass-forming ICC patients. It provided an individualized prognostic evaluation in patients with mass-forming ICC and could helped surgeons with clinical decision-making.

Sarcopenia predicts an adverse prognosis in patients with combined hepatocellular carcinoma and cholangiocarcinoma after surgery

Background

The prognostic value of sarcopenia in combined hepatocellular carcinoma and cholangiocarcinoma (cHCC‐CC) patients after surgery has not been evaluated, while the efficacy of the available tumor stage for cHCC‐CC remains controversial.

Methods

All consecutive cHCC‐CC patients after surgery were retrieved. The patients were stratified by the sex‐specific medians of the psoas muscle index into groups with or without sarcopenia. Prognosis was analyzed using the Kaplan–Meier (K–M) method, and the K–M curves were adjusted by inverse probability weighting (IPW). A nomogram based on Cox regression analysis was established and further compared with primary liver cancer (PLC) stages by internal validation based on bootstrap resampling and k‐fold cross‐validation.

Results

A total of 153 patients were stratified into sarcopenia and non‐sarcopenia groups. The sarcopenia group revealed statistically worse overall survival (OS) and disease‐free survival (DFS) using the K–M method and K–M curves adjusted by IPW. Multivariate Cox regression analyses suggested sarcopenia as an independent risk factor for OS (HR = 1.55; p = 0.040) and DFS (HR = 1.55; p = 0.019). Subgroup analysis based on baseline variables showed sarcopenia as a stable risk factor for the prognosis. Our nomogram outperformed PLC stages in prognostic prediction, as evidenced by the best c‐index, area under the curve, and positive improvement of the net reclassification index and integrated discrimination improvement. A fivefold cross‐validation revealed consistent results. Decision curve analysis revealed higher net benefits of the nomogram than PLC stages.

Conclusions

Sarcopenia is an independent and stable risk factor for the prognosis of cHCC‐CC patients after surgery. Our nomogram might aid high‐risk patient identification and clinical decisions.

The prognostic value of sarcopenia combined with preoperative fibrinogen-albumin ratio in patients with intrahepatic cholangiocarcinoma after surgery: A multicenter, prospective study

BACKGROUND

To explore the prognostic value of the fibrinogen-albumin ratio (FAR) combined with sarcopenia in intrahepatic cholangiocarcinoma (ICC) patients after surgery and to develop a nomogram for predicting the survival of ICC patients.

MATERIALS AND METHODS

In this prospective cohort study, 116 ICC patients who underwent radical surgery were enrolled as the discovery cohort and another independent cohort of 68 ICC patients was used as the validation cohort. Kaplan-Meier method was used to analyze prognosis. The independent predictor of overall survival (OS) and recurrence-free survival (RFS) was evaluated by univariable and multivariable Cox regression analyses, then developing nomograms. The performance of nomograms was evaluated by concordance index (C-index), calibration curve, receiver operating characteristic curve analysis (ROC), and decision curve analysis (DCA).

RESULTS

Patients with high FAR had lower OS and RFS. FAR and sarcopenia were effective predictors of OS and RFS. Patients with high FAR and sarcopenia had a poorer prognosis than other patients. OS nomogram was constructed based on age, FAR, and sarcopenia. RFS nomogram was constructed based on FAR and sarcopenia. C-index for the nomograms of OS and RFS was 0.713 and 0.686. Calibration curves revealed great consistency between actual survival and nomogram prediction. The area under ROC curve (AUC) for the nomograms of OS and RFS was 0.796 and 0.791 in the discovery cohort, 0.823 and 0.726 in the validation cohort. The clinical value of nomograms was confirmed by the DCA.

CONCLUSIONS

ICC patients with high FAR and sarcopenia had a poor prognosis, the nomograms developed based on these two factors were accurate and clinically useful in ICC patients who underwent radical resection.

Survival Prediction in Intrahepatic Cholangiocarcinoma: A Proof of Concept Study Using Artificial Intelligence for Risk Assessment

Several scoring systems have been devised to objectively predict survival for patients with intrahepatic cholangiocellular carcinoma (ICC) and support treatment stratification, but they have failed external validation. The aim of the present study was to improve prognostication using an artificial intelligence-based approach. We retrospectively identified 417 patients with ICC who were referred to our tertiary care center between 1997 and 2018. Of these, 293 met the inclusion criteria. Established risk factors served as input nodes for an artificial neural network (ANN). We compared the performance of the trained model to the most widely used conventional scoring system, the Fudan score. Predicting 1-year survival, the ANN reached an area under the ROC curve (AUC) of 0.89 for the training set and 0.80 for the validation set. The AUC of the Fudan score was significantly lower in the validation set (0.77, p < 0.001). In the training set, the Fudan score yielded a lower AUC (0.74) without reaching significance (p = 0.24). Thus, ANNs incorporating a multitude of known risk factors can outperform conventional risk scores, which typically consist of a limited number of parameters. In the future, such artificial intelligence-based approaches have the potential to improve treatment stratification when models trained on large multicenter data are openly available.

Prognostic biomarkers for cholangiocarcinoma (CCA): state of the art

Introduction:Although advances in understanding the molecular basis of cholangiocarcinoma (CCA) have been made, surgery is the only curative therapy option and the overall prognosis of patients suffering from the disease remains poor. Therefore, estimation of prognosis based on known and novel biomarkers is essential for therapy guidance of CCA in both, curative and palliative settings.Areas covered:An extensive literature search on biomarkers for CCA with special emphasis on prognosis was performed. Based on this, prognostic biomarkers from serum, tumor tissue and other compartments that are currently in use or under evaluation for CCA were summarized in this review. Furthermore, an overview of new biomarkers was provided including those determined from extracellular vesicles (EVs), metabolites and nucleic acids. Finally, prognostic markers associated with potential new therapy options for the treatment of CCA were summed up.Expert opinion:So far, an optimal prognostic biomarker for CCA has not been described. However, based on the increasing knowledge about the molecular basis of CCA but also due to novel, innovative technologies, a plethora of novel prognostic biomarkers is currently under evaluation and will be available for CCA in future.

Preoperative computed tomography-assessed skeletal muscle index is a novel prognostic factor in patients with hepatocellular carcinoma following hepatectomy: a meta-analysis

Background

Recently, several studies have examined the association between preoperative sarcopenia and prognosis evaluation in patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. However, their conclusions remain ambiguous and controversial. Thus, we conducted a meta-analysis to assess the prognostic role of preoperative sarcopenia in patients with HCC undergoing hepatectomy.

Methods

We searched the existing literature reporting on the prognostic value of preoperative computed tomography (CT)-assessed sarcopenia for the survival of patients with HCC undergoing hepatectomy. The pooled hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) of overall survival (OS) and disease-free survival (DFS) were used to assess the prognostic value of preoperative sarcopenia in HCC patients. The associations between preoperative sarcopenia and clinicopathological characteristics were also evaluated.

Results

A total of six studies with 1,420 patients (including 458 sarcopenia and 962 non-sarcopenia patients) were included in the meta-analysis. The results showed that preoperative sarcopenia was significantly associated with poor OS (HR =1.572, 95% CI: 1.342-1.840, P=0) and shorter DFS (HR =1.544, 95% CI: 1.178-2.024, P=0.002) in patients with HCC undergoing hepatectomy. Preoperative sarcopenia was also significantly related to larger diameter tumors (WMD =0.598, 95% CI: 0.216-0.980, P=0.002). The results of the sensitivity analysis were stable in this meta-analysis. Egger's tests revealed that there was no significant publication bias.

Conclusions

Sarcopenia appears to have significant adverse impacts on postoperative outcomes in patients with hepatocellular carcinoma following hepatectomy. However, further large-scale prospective studies are needed to confirm our findings.

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.

Distant Metastases in Patients with Intrahepatic Cholangiocarcinoma: Does Location Matter? A Retrospective Analysis of 370 Patients

Background

Intrahepatic cholangiocarcinoma (ICC) is an aggressive tumor entity, and distant metastases are common. However, studies investigating patterns and clinical relevance of distant metastases are rare. Therefore, we aimed to analyze occurrence, location, and prognostic impact of distant metastases on overall survival (OS).

Methods

Between 1997 and 2018, 417 patients with ICC were treated at our tertiary care center. Distant metastases and intrahepatic tumor burden were retrospectively evaluated in a longitudinal approach using volumetric assessment of cross-sectional imaging studies and all available medical/histopathological reports.

Results

Finally, 370 patients with histopathologically confirmed ICC were included. Of these, 186 showed distant metastases, either initially (n = 59) or during follow-up (n = 127). The most common metastatic sites were the lung (n = 105), peritoneum (n = 81), and bone (n = 50). After detection of lung metastases, the residual median OS was 5.3 months; followed by peritoneal metastases, 4.5 months, and bone metastases, 4.4 months (P=0.17). At the time of first metastatic occurrence, residual OS according to intrahepatic tumor burden of <25%, 25–50%, and >50% was 6.5 months, 4.9 months, and 1.2 months, respectively (P < 0.001). In multivariate hazard regression, hepatic tumor burden, liver function, and subsequent treatment were significant predictors of survival.

Conclusions

During the disease course, every second patient developed extrahepatic metastases. While the presence of distant metastases was associated with poor patient outcomes, there was no significant difference between metastatic sites. However, hepatic tumor burden was the life-limiting risk factor in a majority of patients at the time of distant metastatic disease.

The prognostic value of sarcopenia combined with hepatolithiasis in intrahepatic cholangiocarcinoma patients after surgery: A prospective cohort study

INTRODUCTION

Intrahepatic Cholangiocarcinoma (ICC) is the second most common primary liver cancer with dismal survival rates. This study aimed to explore the prognostic value of sarcopenia combine with hepatolithiasis in surgically treated ICC patients and develop a prognostic nomogram to help make clinical decisions.

MATERIALS AND METHODS

A prospective cohort study was conducted including patients who underwent hepatectomy for ICC between August 2012 and October 2019. The association between the sarcopenia combined with hepatolithiasis and survival, including overall survival (OS) and recurrence-free survival (RFS) was investigated using the Kaplan-Meier (K-M) method. Univariable and multivariable Cox regression analysis was performed to determine the independent prognostic factors and a nomogram establishment was undertaken based on the multivariable analysis.

RESULTS

A total of 121 ICC patients were included in the study. K-M analysis revealed that ICC patients with sarcopenia and hepatolithiasis have worse OS and RFS than those without sarcopenias and/or hepatolithiasis (p < 0.01). Multivariable analysis showed that age, serum CEA, hepatolithiasis, sarcopenia and diabetes were independent prognostic factors for OS(p < 0.05). Finally, a nomogram with good performance in survival prediction was established (C-index was 0.721; the area under the curve of OS was 0.837). The stratified analysis based on the nomogram disclosed that the median OS was 11.9 months in high-risk patients and 51.2 months in low-risk patients (p < 0.001).

CONCLUSIONS

ICC patients with sarcopenia and hepatolithiasis have worse OS and RFS. The nomogram we developed is a practical tool that can provide a more individualized risk assessment for surgically treated ICC patients.

Risk Stratification in Advanced Biliary Tract Cancer: Validation of the A.L.A.N. Score

Background

In addition to the clinical parameters, immune-inflammatory markers have emerged as prognostic factors in patients with advanced biliary tract cancer (ABC). The recently proposed A.L.A.N. score combines both in an easily applicable manner. The aim of this study was to perform the first external evaluation of this score.

Methods

All patients from our clinical registry unit who had unresectable ABC underwent first-line chemotherapy from 2006 to 2018 and met the inclusion criteria of the original study were included (n =  74). The A.L.A.N. score comprises the following parameters: actual neutrophil count, lymphocyte-to-monocyte ratio, albumin, and neutrophil-to-lymphocyte ratio (A.L.A.N.). Univariate and multivariate hazard regression analyses were performed to evaluate the score's parameters regarding overall survival (OS). The concordance index (C-index) and integrated Brier score (IBS) were calculated to evaluate the score's predictive performance.

Results

Low, intermediate, and high A.L.A.N. scores corresponded to median OS of 21.9, 11.4, and 4.3 months, respectively, resulting in a significant risk stratification (log-rank p=0.017). In multivariate analysis, a high-risk A.L.A.N. score remained an independent predictor of poor survival (p=0.016). Neutrophil-to-lymphocyte ratio was not a significant factor for poor OS in the analyses in the cohort. The score's ability to predict individual patient survival was only moderate with a C-index of 0.63.

Conclusions

The A.L.A.N. score can be used to identify risk groups with a poor prognosis prior to the start of chemotherapy. However, the ability of the score to predict individual patient outcome was only moderate; thus, it may only serve as a minor component in the complex interdisciplinary discussion.