Clinical significance of skeletal muscle density and sarcopenia in patients with pancreatic cancer undergoing first-line chemotherapy: a retrospective observational study

Are Muscle and Fat Loss Predictive of Clinical Events in Pancreatic Cancer? The Importance of Precision Metrics

CONTEXT

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

METHOD

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Influence of myosteatosis on survival of patients with pancreatic cancer: A systematic review and meta-analysis

The present meta-analysis aims to evaluate the impact of myosteatosis on overall survival (OS) and progression-free survival (PFS) in patients with pancreatic cancer (PC). A comprehensive literature search was conducted in the Medline, Web of Science, and Embase databases. The hazard ratio (HR) and corresponding 95% confidence interval (CI) for the association between myosteatosis and survival outcomes were pooled using a random-effects model. A total of 14 studies were included. The pooled analysis demonstrated that myosteatosis was significantly associated to poorer OS (HR: 1.50, 95% CI: 1.35-1.67, p < 0.001; I 2  = 0%). The subgroup analysis revealed consistent results across various study characteristics, including geographic regions, cancer stages, follow-up durations, and study quality. In addition, myosteatosis was associated to worse PFS (HR: 1.34, 95% CI: 1.15-1.57, p < 0.001; I 2  = 34%). The present meta-analysis indicates that myosteatosis is associated to significantly worse OS and PFS in patients with PC.

Effectiveness of exercise therapy on chemotherapy-induced peripheral neuropathy in patients with ovarian cancer: A scoping review

BACKGROUND & AIMS

Exercise therapy is a potentially beneficial treatment option for chemotherapy-induced peripheral neuropathy (CIPN). However, there is a lack of consensus on the management of CIPN in patients with ovarian cancer. The purpose of this scoping review was to evaluate the evidence on the effectiveness of exercise therapy in patients with ovarian cancer and explore key physical fitness parameters.

METHODS

A systematic electronic search was conducted using the MEDLINE, CINAHL, Web of Science, PEDro, and ClinicalTrials.gov databases. Two independent reviewers summarized the features and data from the literature regarding the effectiveness of exercise therapy for CIPN and the association between CIPN and physical fitness parameters.

RESULTS

Ten articles involving 3402 participants were reviewed. The study design included one randomized controlled trial, one single-arm trial, one prospective cohort study, five retrospective cohort studies, and two cross-sectional studies. The mean patient age was >60 years in three studies and 50-60 years in six studies. The mean body mass index was >25.0 kg/m2 in six studies and not stated in four studies. In six references, patients received platinum and taxane-based chemotherapy. The effectiveness of an exercise therapy program for CIPN was reported in a randomized controlled trial. Two cross-sectional studies highlighted the association between daily physical inactivity and CIPN; two retrospective cohort studies showed an association between low skeletal muscle density and CIPN; one article demonstrated an association between physical dysfunction and CIPN.

CONCLUSION

This scoping review indicates that although evidence is lacking, exercise intervention programs for CIPN in patients with ovarian cancer have potential benefits, especially when focused on daily physical activity, skeletal muscle density, and physical function.

The prognostic value of myosteatosis in pancreatic cancer: A systematic review and meta-analysis

BACKGROUND AND AIMS

The phenomenon of myosteatosis, characterized by the accumulation of ectopic fat within and surrounding skeletal muscle, has been identified as a potential adverse factor in the prognosis of individuals with cancer. This systematic review and meta-analysis sought to examine the association between myosteatosis and survival rates as well as postoperative complications in patients diagnosed with pancreatic cancer (PC).

METHODS

A systematic search was conducted on Web of Science, Embase, and Pubmed until March 25, 2024, to identify pertinent articles assessing the prognostic significance of myosteatosis in patients with PC, utilizing the search terms: myosteatosis, PC, and prognosis. The selected studies were utilized to investigate the prognostic impact of myosteatosis on the survival of PC patients. Forest plots and pooled effects models were employed to present the findings of this meta-analysis. The quality of the included studies was evaluated using the Newcastle-Ottawa Scale (NOS). A total of 565 studies were initially identified from the three databases, with 14 retrospective cohort studies ultimately included in the final quantitative analysis.

RESULTS

The meta-analysis revealed a significant association between myosteatosis and both overall survival (OS) [Hazard Ratio (HR): 1.55, 95 % Confidence Interval (CI): 1.40-1.72, P < 0.001, I2 = 0.0 %] and recurrence-free survival (RFS) (HR 1.48, 95 % CI: 1.17-1.86, P = 0.001, I2 = 0.0 %) in patients diagnosed with PC. Subgroup analyses revealed that myosteatosis continued to be a negative prognostic factor in PC across various treatment modalities, patient populations, and myosteatosis assessment methods. Additionally, myosteatosis was identified as a risk factor for postoperative complications, with a pooled odds ratio of 2.20 (95 % CI: 1.45-3.35, P < 0.001, I2 = 37.5 %). All included studies achieved NOS scores of 6 or higher, indicating a relatively high level of methodological quality.

CONCLUSION

These results suggest that myosteatosis is significantly associated with both survival outcomes and postoperative complications in patients with PC.

The impact of myosteatosis on postoperative outcomes and survival of patients undergoing pancreatoduodenectomy for suspected/confirmed malignancy

Backgrounds/Aims

While the effects of myosteatosis are emerging, the evidence for its use as a predictor of outcomes in patients undergoing pancreatoduodenectomy (PD) still needs to be established. The study aims to evaluate the effect of myosteatosis on the shortand long-term outcomes of PD.

Methods

We analyzed the effect of myosteatosis on the short- and long-term outcomes of patients who underwent PD between July 2006 and May 2013. Myosteatosis was measured retrospectively from preoperative computed tomography (CT) at the L3 vertebra level, and dichotomized as a binary exposure variable as < 38.5 Hounsfield unit (HU) for males, and < 36.1 HU for females.

Results

A total of 214 patient (median age 62 years, range: 41-80 years) CTs were analyzed for myosteatosis. Overall, 120/214 (56.1%) patients were classed as having myosteatosis. Both groups had similar comorbidity profiles. The presence of myosteatosis was not shown to increase the rate of any short- or long-term complication. However, pancreatic leak (29.8% vs. 13.3%; p = 0.006) and postoperative bleeding (13.8% vs. 5.0%; p = 0.034) were higher in the non-myosteatosis group. The median intensive care (2 days) and hospital stay (12 days) were the same in both groups. The 30-day mortality (myosteatosis: 3.3% vs. non-myosteatosis: 3.2%; p = 0.95), and 5-year overall survival (myosteatosis: 26.7% vs. non-myosteatosis: 31.9%; p = 0.5), were similar in both groups.

Conclusions

We have found no evidence supporting myosteatosis affecting either the short-term or long-term outcomes of patients undergoing PD for suspected/confirmed malignant tumors.

Artificial intelligence measured 3D lumbosacral body composition and clinical outcomes in rectal cancer patients

INTRODUCTION

Patient body composition (BC) has been shown to help predict clinical outcomes in rectal cancer patients. Artificial intelligence algorithms have allowed for easier acquisition of BC measurements, creating a comprehensive BC profile in patients using data from an entire three-dimensional (3D) region of the body. This study has utilized AI technology to measure BC from the entire lumbosacral (L1-S5) region and assessed the associations between BC and clinical outcomes in rectal cancer patients who have undergone neoadjuvant therapy followed by surgery.

METHODS

A retrospective, cross sectional analysis was performed on locally advanced rectal cancer (LARC) patients treated with neoadjuvant long-course chemoradiotherapy followed by curative resection with total mesorectal excision at a tertiary referral centre, Western Health, Melbourne, Australia. A pre-trained and validated in-house AI segmentation model was used to automatically segment and measure intramuscular adipose tissue (IMAT), visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and skeletal muscle (SM) from CT slices across the entire L1-S5 level of each patient. Multivariate analysis between patient BC and clinical outcomes was performed.

RESULTS

Two hundred and fourteen patients were included in the study. One hundred and fifty-one (70.6%) patients were male and 63 (29.4%) patients were female. The average age at diagnosis was 62.4 (±12.7) years. SM density, but not volume, was associated with better overall survival (OS) (HR 0.24, P = 0.029), recurrence-free survival (RFS) (HR 0.45, P = 0.048) and decreased length of stay (LoS) (HR 1.58, P = 0.036). Both IMAT volume (HR 0.13, P = 0.008) and density (HR 0.26, P = 0.006) were associated with better OS.

CONCLUSION

This study measured 3D BC from the entire lumbosacral region of rectal cancer patients. SM density was the most significant BC parameter, and was associated with improved OS, RFS and LoS. This adds to growing evidence that SM is a key component of BC in cancer patients and should be optimized prior to treatment. IMAT was also a prognostic factor, giving rise to avenues of future research into the role of adiposity on nutrition and tumour immunology.

Dynamic Anthropometrics in Pancreatic Cancer: Associations Between Body Composition Changes During Neoadjuvant Therapy and Survival Outcomes After Resection

BACKGROUND

Assessment of individual tumor biology and response to systemic therapy in pancreatic ductal adenocarcinoma (PDAC) remains a clinical challenge. The significance of anthropometric (body composition) changes during chemotherapy as a surrogate for tumor biology in the setting of localized PDAC is unknown.

METHODS

A retrospective, single-institution analysis of patients with PDAC who received neoadjuvant therapy (NAT) and pancreatectomy from 2017 to 2021 was performed. Radiologic anthropometric analysis used artificial intelligence-driven software to segment and compute total and sub-compartment muscle area, adipose tissue area, and attenuation values at the level of the L3 vertebra. Kaplan-Meier survival estimates, log-rank tests, and multivariable Cox regression models were used in survival analyses.

RESULTS

The inclusion criteria were met by 138 patients. Although decreases in muscle and adipose tissue areas during NAT were predominant, a subset of patients experienced an increase in these compartments. Increases in muscle greater than 5% (hazard ratio [HR], 0.352; 95% confidence interval [CI] 0.135-0.918; p = 0.033) and increases in adipose tissue greater than 15% (HR, 0.375; 95% CI 0.144-0.978; p = 0.045), were significantly associated with improved survival, whereas loss of visceral fat greater than 15% was detrimental (HR 1.853; CI 1.099-3.124; p = 0.021). No significant associations with single time-point anthropometrics were observed. Gains in total muscle and adipose mass were associated with improved pathologic response to systemic therapy and less advanced pathologic tumor stage.

CONCLUSIONS

Dynamic anthropometric analysis during NAT for PDAC is a stronger prognostic indicator than measurements taken at a single point in time. Repeated anthropometric analysis during preoperative chemotherapy may serve as a biomarker for individual tumor biology and response to therapy.

Evaluating the role of sarcopenia and [18F]FDG PET/CT parameters in prognosis of pancreatic ductal adenocarcinoma

This study investigates the relationship between 18F-fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) metabolic parameters, clinicopathological characteristics, and sarcopenia in patients with pancreatic ductal adenocarcinoma (PDAC) and evaluates their prognostic roles.

MATERIAL AND METHODS

The primary tumor's maximum standard uptake (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) values, as well as clinicopathological factors, were evaluated retrospectively. Computed tomography (CT) was used to assess the skeletal muscle index (SMI). Sarcopenia was defined based on SMI calculated at the third lumbar vertebra (L3). SMI cut-off values ​​for sarcopenia were accepted as 44.77 cm2/m2 for men and 32.50 cm2/m2 for women. The primary endpoint was the overall survival (OS). OS data were analyzed by the Kaplan-Meier method and compared using the log-rank test. To identify predictive factors for sarcopenia, multivariable logistic regression was used following univariable logistic regression. Cox proportional hazards regression analyses were used to find predictors of OS.

RESULTS

Of the 86 patients included in the study, 37 (43%) were diagnosed with sarcopenia. Compared with non-sarcopenic patients, sarcopenia was observed in older patients (P=0,028) and patients with lower body mass index (BMI) (p=0,001). Age and BMI independently predicted sarcopenia. Univariate analysis identified sarcopenia, advanced stage, and higher primary tumor TLG as significant predictors of overall survival. Multivariate Cox regression analysis revealed that the advanced tumor stage (p=0.017) and higher TLG (p=0,042) independently predicted OS. The median OS was 9.4 months in non-sarcopenic patients and 5.0 months in sarcopenic patients (p=0,021).

CONCLUSION

In this study cohort, advanced-stage disease and higher primary tumor TLG were identified as independent predictors of OS in patients with PDAC. Additionally, we emphasize the importance of incorporating [18F]FDG PET/CT-derived sarcopenia assessments into the prognostic evaluation and clinical management of PDAC patients. While sarcopenia was associated with shorter OS in univariate analysis, it was not an independent predictor in multivariate analysis.

Prognostic Value of Myosteatosis and Albumin-Bilirubin Grade for Survival in Hepatocellular Carcinoma Post Chemoembolization

OBJECTIVE

This study aimed to investigate the prognostic value of preoperative myosteatosis and the albumin-bilirubin (ALBI) grade in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE) and develop a robust prognostic score based on these factors.

METHODS

Patients with HCC who underwent TACE between January 2009 and December 2020 were included. Multivariate Cox regression analysis identified prognostic factors. CT-based body composition parameters were acquired from baseline abdominal CT images at the level of the third lumbar vertebra. A prognostic score (Myo-ALBI) was developed based on the presence of preoperative myosteatosis and the ALBI grade, and its prognostic value was evaluated.

RESULTS

Of 446 patients, 63% were male, and the mean age was 62.4 years. Preoperative myosteatosis was present in 41.5% of patients. The BCLC stages were mostly B (67.9%). Multivariate analysis shows that preoperative myosteatosis, ALBI grade 2, and ALBI grade 3 were independent prognostic factors. The Myo-ALBI grade was incorporated into a prognostic model, including alpha-fetoprotein and up-to-seven criteria, to generate a nomogram. The C-index of the nomogram based on the Myo-ALBI grade (0.743) was significantly higher than the non-Myo-ALBI nomogram (0.677), the up-to-seven criteria (0.653), the ALBI grade (0.616), and the Child-Pugh class (0.573) (all p < 0.05). The t-ROC curve for the nomogram was consistently superior to the other models throughout the observation period in all patients and the BCLC-B subgroup.

CONCLUSIONS

The combination of preoperative CT-derived myosteatosis and ALBI grade enhances prognostication for patients with unresectable HCC undergoing TACE. The Myo-ALBI nomogram constructed in this study could support individualized prognosis prediction, assisting in treatment decision-making for HCC patients.

Prevalence of Sarcopenia Determined by Computed Tomography in Pancreatic Cancer: A Systematic Review and Meta-Analysis of Observational Studies

Introduction: Sarcopenia, a condition characterized by a loss of skeletal muscle mass, is increasingly recognized as a significant factor influencing patient outcomes in pancreatic cancer (PC). This systematic review and meta-analysis aimed to estimate the prevalence of sarcopenia in patients with PC using computed tomography and to explore how different measurement methods and cut-off values impact such prevalence. Materials and Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive search of PubMed, Web of Science, and EMBASE databases was performed, identifying 48 observational studies involving 9063 patients. Results: The overall pooled prevalence of sarcopenia was 45% (95% CI, 40-50%), but varied significantly by the method used: 47% when measured with the skeletal muscle index and 33% when assessed with the total psoas area. In addition, in studies using SMI, sarcopenia prevalence was 19%, 45%, and 57% for cutoff values <40 cm2/m2, 40-50 cm2/m2, and >50 cm2/m2, respectively. Moreover, the prevalence was higher in patients receiving palliative care (50%) compared to those treated with curative intent (41%). High heterogeneity was observed across all analyses, underscoring the need for standardized criteria in sarcopenia assessment. Conclusions: Our findings highlight the substantial variability in sarcopenia prevalence, which could influence patient outcomes, and stress the importance of consensus in measurement techniques to improve clinical decision making and research comparability.

Pancreatic cancer and sarcopenia: a narrative review of the current status

Pancreatic cancer is still a difficult disease to treat, despite recent advances in surgical techniques and chemotherapeutic drugs. Its incidence continues to rise, as does the number of older patients. Sarcopenia is defined as a progressive and generalized loss of skeletal muscle mass and strength. Sarcopenia is present in approximately 40% in patients with pancreatic cancer. Sarcopenia is primarily diagnosed through imaging, and progress is being made in the development of automated methods and artificial intelligence, as well as biomarker research. Sarcopenia has been linked to a poor prognosis in pancreatic cancer patients. However, some studies suggest that sarcopenia is not always associated with a poor prognosis, depending on the resectability of pancreatic cancer and the nature of treatment, such as surgery or chemotherapy. Recent meta-analyses have found that sarcopenia is not linked to postoperative complications. It is still debated whether there is a link between sarcopenia and drug toxicity during chemotherapy. The relationship between sarcopenia and immunity has been investigated, but the mechanism is still unknown.

Age-adjusted Charlson comorbidity index and its association with body composition and overall survival in patients with colorectal cancer

OBJECTIVE

To examine the relationship between the age-adjusted Charlson comorbidity index (A-CCI) with body composition and overall survival in patients newly diagnosed with colorectal cancer (CRC).

RESEARCH METHODS AND PROCEDURES

In this cohort study, patients (≥ 18 years old) with CRC were followed for 36 months. Computed tomography images of the third lumbar were analyzed to determine body composition, including skeletal muscle area (SMA), skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Phenotypes based on comorbidity burden assessed by A-CCI and body composition parameters were established.

RESULTS

A total of 436 participants were included, 50% male, with a mean age of 61 ± 13.2 years. Approximately half of the patients (50.4%) had no comorbidity, and the A-CCI median score was 4 (interquartile range: 3-6). A higher A-CCI score was a risk factor for 36-month mortality (HR = 3.59, 95% CI = 2.17-5.95). Low SMA and low SMD were associated with a higher A-CCI. All abnormal phenotypes (high A-CCI and low SMA; high A-CCI and low SMD; high A-CCI and high VAT) were independently associated with higher 36-month mortality hazard (adjusted HR 5.12, 95% CI 2.73-9.57; adjusted HR 4.58, 95% CI 2.37-8.85; and adjusted HR 2.36, 95% CI 1.07-5.22, respectively).

CONCLUSION

The coexistence of comorbidity burden and abnormal body composition phenotypes, such as alterations in muscle or fat compartments, may pose an additional risk of mortality in patients newly diagnosed with CRC. Early assessment and management of these phenotypes could be crucial in optimizing outcomes in such patients.

Body composition measures as a determinant of Alpelisib related toxicity

BACKGROUND

Body composition has emerged as an important prognostic factor in patients treated with cancer. Severe depletion of skeletal muscle, sarcopenia, has been associated with poor performance status and worse oncological outcomes. We studied patients with metastatic breast cancer receiving alpelisib, to determine if sarcopenia and additional body composition measures accounting for muscle and adiposity are associated with toxicity.

METHODS

A retrospective observational analysis was conducted, including 38 women with metastatic breast cancer and a PIK3CA mutation, treated with alpelisib as advanced line of therapy. Sarcopenia was determined by measuring skeletal muscle cross-sectional area at the third lumbar vertebra using computerized tomography. Various body composition metrics were assessed along with drug toxicity, dose reductions, treatment discontinuation, hospitalizations, time to treatment failure and overall survival.

RESULTS

Sarcopenia was observed in half of the patients (n = 19, 50%), spanning normal weight, overweight, and obese individuals. Among the body composition measures, lower skeletal muscle density (SMD) was associated with an increased risk of treatment-related hyperglycaemia (P = 0.03). Additionally, lower visceral adipose tissue (VAT) was associated with alpelisib-induced rash (P = 0.04) and hospitalizations (P = 0.04). Notably, alpelisib treatment discontinuation was not impacted by alpelisib toxicity.

CONCLUSION

Body composition measures, specifically SMD and VAT may provide an opportunity to identify patients at higher risk for severe alpelisib related hyperglycemia, and cutaneous toxicity. These findings suggest the potential use of body composition assessment to caution toxicity risk, allowing for personalized therapeutic observation and intervention.

Using maximum plasma concentration (Cmax) to personalize taxane treatment and reduce toxicity

Taxanes are a widely used class of anticancer agents that play a vital role in the treatment of a variety of cancers. However, toxicity remains a major concern of using taxane drugs as some toxicities are highly prevalent, they can not only adversely affect patient prognosis but also compromise the overall treatment plan. Among all kinds of factors that associated with taxane toxicity, taxane exposure has been extensively studied, with different pharmacokinetic (PK) parameters being used as toxicity predictors. Compared to other widely used predictors such as the area under the drug plasma concentration curve versus time (AUC) and time above threshold plasma drug concentration, maximum plasma concentration (Cmax) is easier to collect and shows promise for use in clinical practice. In this article, we review the previous research on using Cmax to predict taxane treatment outcomes. While Cmax and toxicity have been extensively studied, research on the relationship between Cmax and efficacy is lacking. Most of the articles find a positive relationship between Cmax and toxicity but several articles have contradictory findings. Future clinical trials are needed to validate the relationship between Cmax and treatment outcome and determine whether Cmax can serve as a useful surrogate endpoint of taxane treatment efficacy.

Osteosarcopenia impacts treatment outcomes for Barcelona Cancer Liver Classification stage A hepatocellular carcinoma

AIM

To study the effect of preoperative osteosarcopenia (OSP) on the prognosis of treatment (surgery or radiofrequency ablation (RFA)) in patients with Barcelona Cancer Liver Classification stage A hepatocellular carcinoma (BCLC A HCC).

METHODS

This study enrolled 102 patients with BCLC A HCC who underwent surgical resection (n = 45) and RFA (n = 57); the patients were divided into two groups: OSP (n = 33) and non-OSP (n = 69). Overall survival (OS) and disease-free survival (DFS) curves for both the groups and treatment methods (surgery and RFA) were generated using the Kaplan-Meier method and compared using the log-rank test. Univariate analyses for OS and DFS were performed using log-rank test. Multivariate analyses were performed for factors that were significant at univariate analysis by Cox proportional hazard model.

RESULTS

Multivariate analysis showed that OSP (HR 2.44; 95 % CI 1.30-4.55; p < 0.01) and treatment (HR 0.57; 95 % CI 0.31-0.99; p = 0.05) were significant independent predictors of DFS; and treatment (HR, 0.30; 95 % CI 0.10-0.85; p = 0.03) was a significant independent predictor of OS in the non-OSP group, in which the OS rate was significantly lower in patients treated with RFA than in those treated by resection (p = 0.01).

CONCLUSIONS

OSP is a prognostic factor for BCLC A HCC treatment. Surgical approach was associated with a significantly better prognosis in patients without OSP compared to those who underwent RFA.

Influence of skeletal muscle and intermuscular fat on postoperative complications and long-term survival in rectal cancer patients

BACKGROUND

The body composition of patients with rectal cancer potentially affects postoperative outcomes. This study explored the correlations between skeletal muscle and adipose tissue quantified by computed tomography (CT) with postoperative complications and long-term prognosis in patients with rectal cancer after surgical resection.

METHODS

This retrospective cohort study included patients with rectal cancer who underwent surgical resection at the Wuhan Union Hospital between 2014 and 2018. CT images within 3 months prior to the surgery were used to quantify the indices of skeletal muscle and adipose tissue at the levels of the third lumbar vertebra (L3) and umbilicus. Optimal cut-off values for each index were defined separately for males and females. Associations between body composition and postoperative complications, overall survival (OS), and disease-free survival (DFS) were evaluated using logistic and Cox proportional hazards models.

RESULTS

We included 415 patients (240 males and 175 females; mean age: 57.8 ± 10.5 years). At the L3 level, a high skeletal muscle density (SMD; hazard ratio [HR]: 0.357, 95% confidence interval [CI]: 0.191-0.665, P = 0.001; HR: 0.571, 95% CI: 0.329-0.993, P = 0.047) and a high skeletal muscle index (SMI; HR: 0.435, 95% CI 0.254-0.747, P = 0.003; HR: 0.568, 95% CI: 0.359-0.897, P = 0.015) were independent prognostic factors for better OS and DFS. At the umbilical level, a large intermuscular fat area (IMFA; HR: 1.904, 95% CI: 1.068-3.395, P = 0.029; HR: 2.064, 95% CI: 1.299-3.280, P = 0.002) was an independent predictive factor for worse OS and DFS, and a high SMI (HR: 0.261, 95% CI: 0.132-0.517, P < 0.001; HR: 0.595, 95% CI: 0.387-0.913, P = 0.018) was an independent prognostic factor for better OS and DFS. The models combining body composition and clinical indicators had good predictive abilities for OS. The receiver operating characteristic areas under the curve were 0.848 and 0.860 at the L3 and umbilical levels, respectively (both P < 0.05).

CONCLUSIONS

No correlations existed between CT-quantified body composition parameters and postoperative complications. However, a high SMD and high SMI were significantly associated with longer OS and DFS at the L3 level, whereas a large IMFA and low SMI were associated with worse OS and DFS at the umbilical level. Combining CT-quantified body composition and clinical indicators could help physicians predict the prognosis of patients with rectal cancer after surgery.

Body composition measurements and clinical outcomes in patients with resectable pancreatic adenocarcinoma - analysis from SWOG S1505

BACKGROUND

Sarcopenic obesity and muscle attenuation have been associated with survival in patients with borderline resectable and advanced pancreatic ductal adenocarcinoma (PDA); however, these relationships are unknown for patients with resectable PDA. This study examined the associations between skeletal muscle and adipose tissue as measured on baseline computed tomography (CT) and the overall survival (OS) of participants with resectable PDA in a secondary analysis of the Southwest Oncology Group S1505 clinical trial (identifier: NCT02562716).

METHODS

The S1505 phase II clinical trial enrolled patients with resectable PDA who were randomized to receive modified FOLFIRINOX or gemcitabine and nab-paclitaxel as perioperative chemotherapy, followed by surgical resection. Baseline axial CT images at the L3 level were analyzed with externally validated software, and measurements were recorded for skeletal muscle area and skeletal muscle density, visceral adipose tissue area (VATA) and density, and subcutaneous adipose tissue area and density. The relationships between CT metrics and OS were analyzed using Cox regression models, with adjustment for baseline participant characteristics.

RESULTS

Of 98 eligible participants with available baseline abdominal CT, 8 were excluded because of imaging quality (eg, orthopedic hardware), resulting in 90 evaluable cases: 51 men (57.0%; mean age, 63.2 years [SD, 8.5]; mean body mass index [BMI], 29.3 kg/m2 [SD, 6.4]), 80 White (89.0%), 6 Black (7.0%), and 4 unknown race (4.0%). Sarcopenia was present in 32 participants (35.9%), and sarcopenic obesity was present in 10 participants (11.2%). Univariable analyses for the 6 variables of interest indicated that the standardized mean difference (hazard ratio [HR], 0.75; 95% CI, 0.57-0.98; P = .04) was statistically significantly associated with OS. In models adjusted for sex, race, age, BMI, performance score, contrast use, sarcopenia, and sarcopenic obesity, VATA was statistically significantly associated with OS (HR, 1.58; 95% CI, 1.00-2.51; P = .05). No difference was observed in OS between participants according to sarcopenic obesity or sarcopenia categories. The median OS estimates were 25.1 months for participants without sarcopenic obesity, 18.6 months for participants with sarcopenic obesity, 23.6 months for participants without sarcopenia, and 27.9 months for participants with sarcopenia.

CONCLUSION

This was the first study to systematically evaluate body composition parameters in a prospective multicenter trial of patients with resectable PDA who received perioperative chemotherapy. Visceral adipose tissue was associated with survival; however, there was no association between OS and sarcopenia or sarcopenic obesity. Further studies should evaluate these findings in more detail.

Prognostic Significance of Sarcopenia and Eicosapentaenoic Acid (EPA) Levels in Patients With Unresectable Pancreatic or Biliary Tract Cancer

Background/Aim

This study aimed to investigate the relationship between prechemotherapy blood eicosapentaenoic acid (EPA) levels, sarcopenia, and overall survival in patients with pancreatic and biliary tract cancer undergoing chemotherapy.

Patients and Methods

Forty-five patients with recurrent, non-resected pancreatic or biliary tract cancer undergoing chemotherapy were retrospectively analyzed. The skeletal muscle mass was measured at the third lumbar vertebra. Sarcopenia cut-off values were based on the Japanese Society of Hepatology sarcopenia assessment criteria. Two months after starting chemotherapy, the patients received enteral nutrition containing omega-3 fatty acids.

Results

Patients with pancreatic and biliary tract cancers with low pre-treatment blood EPA levels had significantly more intense sarcopenia than those with high EPA levels (p=0.023). Patients with sarcopenia before chemotherapy had significantly lower overall survival than those without sarcopenia. Multivariate analysis revealed blood EPA concentration as an independent prognostic factor (p<0.01). Lumbar muscle volume, a marker of sarcopenia, showed a clear positive correlation with prechemotherapy EPA concentration (p=0.008). In patients administered with enteral nutrition containing omega-3 fatty acids, both EPA concentration and lumbar muscle volume were significantly higher than those prior to intervention, indicating sarcopenia improvement due to the intervention.

Conclusion

In patients with recurrent non-resected pancreatic and biliary tract cancer, low blood EPA levels before chemotherapy are associated with sarcopenia and poor prognosis.

Association between preoperative sarcopenia and prognosis of pancreatic cancer after curative-intent surgery: a updated systematic review and meta-analysis

BACKGROUND

Sarcopenia is associated with poor outcomes in many malignancies. However, the relationship between sarcopenia and the prognosis of pancreatic cancer has not been well understood. The aim of this meta-analysis was to identify the prognostic value of preoperative sarcopenia in patients with pancreatic cancer after curative-intent surgery.

METHODS

Database from PubMed, Embase, and Web of Science were searched from its inception to July 2023. The primary outcomes were overall survival (OS), progression-free survival (PFS), and the incidence of major complications. The hazard ratio (HR), odds ratio (OR), and 95% confidence intervals (CIs) were used to assess the relationship between preoperative sarcopenia and the prognosis of patients with pancreatic cancer. All statistical analyses were conducted by Review Manager 5.3 and STATA 17.0 software.

RESULTS

A total of 23 retrospective studies involving 5888 patients were included in this meta-analysis. The pooled results demonstrated that sarcopenia was significantly associated with worse OS (HR = 1.53, P < 0.00001) and PFS (HR = 1.55, P < 0.00001). However, this association was not obvious in regard to the incidence of major complications (OR = 1.33, P = 0.11).

CONCLUSION

Preoperative sarcopenia was preliminarily proved to be associated with the terrible prognosis of pancreatic cancer after surgery. However, this relationship needs to be further validated in more prospective studies.

Clinical Significance of Increased Skeletal Muscle Mass During Nab-Paclitaxel Plus Gemcitabine Treatment in Patients With Advanced Pancreatic Cancer

OBJECTIVES

The clinical significance of increased skeletal muscle mass during nab-paclitaxel plus gemcitabine (AG) treatment in patients with advanced pancreatic cancer (APC) remains unknown. Therefore, we retrospectively investigated the characteristics of patients after AG treatment to evaluate the clinical significance of increased skeletal muscle mass during treatment.

METHODS

From January 2015 to August 2021, 67 patients with APC received AG as first-line chemotherapy at Higashiosaka City Medical Center. Of these patients, 39 received second-line (2L) chemotherapy after AG therapy, and 28 received best supportive care. Patients' characteristics at the end of AG treatment were compared retrospectively between these 2 groups, and the relevant factors at the end of first-line treatment for 2L chemotherapy induction were analyzed.

RESULTS

A performance status of 0 to 1 and increased skeletal muscle mass during AG therapy were independently associated with 2L chemotherapy induction in multivariate analysis. A high relative dose intensity (≥50%) in the first 8 weeks of AG treatment was more frequently found in patients with increased skeletal muscle mass during treatment ( P = 0.037).

CONCLUSIONS

Increased skeletal muscle mass during AG treatment might contribute to the higher prevalence of 2L chemotherapy induction in patients with APC.

Low skeletal muscle quality extracted from CT is associated with poor outcomes in severe acute pancreatitis patients

PURPOSE

To evaluate the association between body composition parameters derived from computed tomography (CT) scans and clinical outcomes in patients with severe acute pancreatitis (AP).

METHODS

Patients who have been diagnosed AP with a CT scan at ICU admission were included. Body composition parameters were measured on a single slice at L2-3 of the unenhanced CT scans. The intermuscular adipose tissue (IMAT), visceral adipose tissue (VAT), skeletal muscle area (SMA) and skeletal muscle density (SMD) were assessed using HUs by image analysis software. Univariable and multivariable analyses were performed to analyze the association between body composition parameters and clinical outcomes including all-cause mortality or prolonged ICU stay. The area under the curve (AUC) of a receiver operating characteristic curve was used to explore the predictive value of the body composition on treatment clinical outcomes.

RESULTS

A total of 158 patients were included. The IMAT (8.3 cm2 vs 6.0 cm2, P = 0.001) and VAT (190.3 cm2 vs 143.7 cm2, P < 0.001) were significantly higher in the severe AP group than in the moderately severe group, but were notassociatedwithoutcomes. For 1 HU of SMD increased, the risk of poor clinical outcomes decresed 11 % (adjusted OR 0.892, 95 %CI 0.806-0.987, P = 0.026), while an SMD below the median value (32.1 HU for males and 28.5 HU for females) was independently associated with worse outcomes in the multivariable analysis (adjusted OR 8.868, 95 % CI 2.146-36.650, P = 0.003). The SMD had a good predictive ability for clinical outcomes, AUC was 0.824 (95 % CI, 0.715-0.933) for males and 0.803 (95 % CI, 0.639-0.967) for females.

CONCLUSION

Low SMD was associated with poor outcomes in patients with severe and moderately severe AP and might be used as a novel marker to predict outcomes in patients suffering from severe and moderately severe AP.

The impact of sarcopenia on prognosis of patients with pancreatic cancer: A systematic review and meta-analysis

OBJECTIVE

To summarize recent findings on the association of low skeletal muscle mass and muscle quality with overall survival and recurrence-free survival in patients with pancreatic cancer.

METHODS

A systematic search was conducted using Medline (via PubMed), Embase and Scopus databases for observational studies reporting on the overall survival and recurrence-free survival. Pooled effect sizes were reported as hazards ratio along with 95% confidence intervals.

RESULTS

A total of 34 studies were included. Low skeletal muscle index (indicating muscle mass) was associated with poor overall survival (hazards ratio: 1.50; 95% confidence interval: 1.34, 1.67) and lower recurrence-free survival (hazards ratio: 1.28, 95% confidence interval: 1.15, 1.43). Low skeletal muscle attenuation (indicating muscle quality) was associated with poor overall survival (hazards ratio: 1.32; 95% confidence interval: 1.05, 1.66). Recurrence-free survival was similar in patients with low and normal/high skeletal muscle attenuation (hazards ratio: 1.12, 95% confidence interval: 0.89, 1.40).

CONCLUSION

Both low skeletal muscle mass and poor muscle quality are associated with poor long-term survival. Low skeletal muscle index, but not low skeletal muscle attenuation, are associated with poor recurrence-free survival.

Correcting Posterior Paraspinal Muscle Computed Tomography Density for Intravenous Contrast Material Independent of Sex and Vascular Phase

PURPOSE

Intravenous contrast poses challenges to computed tomography (CT) muscle density analysis. We developed and tested corrections for contrast-enhanced CT muscle density to improve muscle analysis and the utility of CT scans for the assessment of myosteatosis.

MATERIALS AND METHODS

Using retrospective images from 240 adults who received routine abdominal CT imaging from March to November 2020 with weight-based iodine contrast, we obtained paraspinal muscle density measurements from noncontrast (NC), arterial, and venous-phase images. We used a calibration sample to develop 9 different mean and regression-based corrections for the effect of contrast. We applied the corrections in a validation sample and conducted equivalence testing.

RESULTS

We evaluated 140 patients (mean age 52.0 y [SD: 18.3]; 60% female) in the calibration sample and 100 patients (mean age 54.8 y [SD: 18.9]; 60% female) in the validation sample. Contrast-enhanced muscle density was higher than NC by 8.6 HU (SD: 6.2) for the arterial phase (female, 10.4 HU [SD: 5.7]; male, 6.0 HU [SD:6.0]) and by 6.4 HU [SD:8.1] for the venous phase (female, 8.0 HU [SD: 8.6]; male, 4.0 HU [SD: 6.6]). Corrected contrast-enhanced and NC muscle density was equivalent within 3 HU for all correctionns. The -7.5 HU correction, independent of sex and phase, performed well for arterial (95% CI: -0.18, 1.80 HU) and venous-phase data (95% CI: -0.88, 1.41 HU).

CONCLUSIONS

Our validated correction factor of -7.5 HU renders contrast-enhanced muscle density statistically similar to NC density and is a feasible rule-of-thumb for clinicians to implement.

Is Computed-Tomography-Based Body Composition a Reliable Predictor of Chemotherapy-Related Toxicity in Pancreatic Cancer Patients?

BACKGROUND

Malnutrition, loss of weight and of skeletal muscle mass are frequent in pancreatic cancer patients, a majority of which will undergo chemotherapy over the course of their disease. Available data suggest a negative prognostic role of these changes in body composition on disease outcomes; however, it is unclear whether tolerance to chemotherapeutic treatment is similarly and/or negatively affected. We aimed to explore this association by retrospectively assessing changes in body composition and chemotherapy-related toxicity in a cohort of advanced pancreatic cancer patients.

METHODS

Body composition was evaluated through clinical parameters and through radiological assessment of muscle mass, skeletal muscle area, skeletal muscle index and skeletal muscle density; and an assessment of fat distribution by subcutaneous adipose tissue and visceral adipose tissue. We performed descriptive statistics, pre/post chemotherapy comparisons and uni- and multivariate analyses to assess the relation between changes in body composition and toxicity.

RESULTS

Toxicity risk increased with an increase of skeletal muscle index (OR: 1.03) and body mass index (OR: 1.07), whereas it decreased with an increase in skeletal muscle density (OR: 0.96). Multivariate analyses confirmed a reduction in the risk of toxicity only with an increase in skeletal muscle density (OR: 0.96).

CONCLUSIONS

This study suggests that the retrospective analysis of changes in body composition is unlikely to be useful to predict toxicity to gemcitabine-nab-paclitaxel.

Prognostic value of pretreatment skeletal muscle index in pancreatic carcinoma patients: A meta-analysis

BACKGROUND

The association between pretreatment skeletal muscle index (SMI) and long-term survival of pancreatic carcinoma patients remains unclear up to now.

METHODS

The PubMed, Web of Science and EMBASE databases were searched up to March 1, 2022 for relevant studies. The primary and secondary outcomes were overall survival and progression-free survival, respectively. The hazard ratios (HRs) and 95% confidence intervals (CIs) were combined to assess the relationship between pretreatment SMI and prognosis of pancreatic carcinoma patients. All statistical analysis was conducted by STATA 15.0 software.

RESULTS

Twenty retrospective studies involving 3765 patients were included. The pooled results demonstrated that lower pretreatment SMI was significantly related to poorer overall survival (HR = 1.42, 95% CI: 1.25-1.62, P < .001) and progression-free survival (HR = 1.41, 95% CI: 1.08-1.84, P = .012). Besides subgroup analysis based on the treatment (non-surgery vs surgery) and tumor stage (advanced vs early stage) showed similar results.

CONCLUSION

Pretreatment SMI could serve as a promising and reliable prognostic factor for pancreatic carcinoma patients and lower pretreatment SMI predicted worse prognosis.

Association of myosteatosis with treatment response and survival in patients with hepatocellular carcinoma undergoing chemoembolization: a retrospective cohort study

Patients with hepatocellular carcinoma (HCC) have poor prognosis and have frequent treatment-related toxicities resulting in cancer-associated cachexia. This study aimed to determine the association of myosteatosis and sarcopenia on mortality in patients with HCC treated with transarterial chemoembolization (TACE). Six hundred and eleven patients diagnosed with HCC and underwent TACE at a tertiary care center between 2008 and 2019 were included. Body composition was assessed using axial CT slices at level L3 to calculate the skeletal muscle density for myosteatosis and skeletal muscle index for sarcopenia. The primary outcome was overall survival while the secondary outcome was TACE response. Patients with myosteatosis had a poorer TACE response than patients without myosteatosis (56.12% vs. 68.72%, adjusted odds ratio [OR] 0.49, 95% confidence interval [CI] 0.34-0.72). The rate of TACE response in patients with sarcopenia was not different from those without sarcopenia (60.91% vs. 65.22%, adjusted OR 0.79, 95% CI 0.55-1.13). Patients with myosteatosis had shorter overall survival than without myosteatosis (15.9 vs. 27.1 months, P < 0.001). In the multivariable Cox regression analysis, patients with myosteatosis or sarcopenia had higher risk of all-cause mortality than their counterparts (adjusted hazard ratio [HR] for myosteatosis versus no myosteatosis 1.66, 95% CI 1.37-2.01, adjusted HR for sarcopenia versus no sarcopenia 1.26, 95% CI 1.04-1.52). Patients with both myosteatosis and sarcopenia had the highest 7 year mortality rate at 94.45%, while patients with neither condition had the lowest mortality rate at 83.31%. The presence of myosteatosis was significantly associated with poor TACE response and reduced survival. Identifying patients with myosteatosis prior to TACE could allow for early interventions to preserve muscle quality and might improve prognosis in HCC patients.

Preoperative Psoas Muscle Thickness to Height Ratio Predicts Poor Survival After Resection of Biliary Tract Cancer

BACKGROUND/AIM

Accumulating evidence suggests that muscle mass depletion (sarcopenia) has a negative impact on survival in several malignancies, including biliary tract cancer (BTC). Computed tomography (CT)-measured psoas muscle thickness to height ratio (PMTH) has been reported as a surrogate measure for muscle mass that does not require specialized equipment or software. The aim of this retrospective study was to investigate whether preoperative PMTH predicts oncological outcomes of patients undergoing surgical resection for BTC.

PATIENTS AND METHODS

PMTH was assessed in 211 patients by analyzing axial CT images at the level of the umbilicus. The most predictive cutoff of PMTH was determined by survival classification and regression tree analysis. Propensity score-based inverse probability weighting (IPW) was used to balance characteristics between the low and high PMTH groups.

RESULTS

Applying a PMTH cutoff of 17.5 mm/m, the low PMTH group comprised 114 patients (54%). Low PMTH was associated with female sex, non-obesity, CA19-9 elevation, and lymph node metastasis. After IPW adjustment, the low PMTH group had a significantly shorter disease-specific survival (p<0.001) and relapse-free survival (p<0.001) than the high PMTH group. IPW-adjusted regression analysis revealed that a low PMTH was independently associated with worse disease-specific survival (hazard ratio=2.98, p<0.001) and relapse-free survival (hazard ratio=2.49, p<0.001), in addition to other factors such as tumor differentiation, perineural invasion, and resection margin status.

CONCLUSION

Preoperative PMTH may be a simple and feasible index of sarcopenia for predicting poor survival after resection of BTC.

The association between low skeletal muscle mass and low skeletal muscle radiodensity with functional impairment, systemic inflammation, and reduced survival in patients with incurable cancer

BACKGROUND AND AIMS

Factors associated with the concomitant occurrence of low muscle mass and low muscle radiodensity are unclear. This study investigated whether different skeletal muscle phenotypes are associated with functional impairment, serum inflammatory markers, and survival in patients with incurable cancer.

METHODS

Three hundred and twenty-six patients (median age, 60 years; 67.5% female) who had abdominal or pelvic computed tomography (CT) scans up to 30 days before the initial assessment were enrolled in the study. CT images were used for the assessment of skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD). Optimal stratification analysis was used to derive cohort-specific cutoff points to define SMI and SMD groups with a higher risk for mortality (SMI, males <45.0 cm² /m² and females <44.0 cm² /m² ; SMD, males <34 Hounsfield units [HU] and females <30 HU). Based on these cutoffs, participants were classified into four phenotypes: low-risk SMI + low-risk SMD, high-risk SMI + low-risk SMD, low-risk SMI + high-risk SMD, and high-risk SMI + high-risk SMD.

RESULTS

Phenotypes with high-risk SMI or high-risk SMD, especially when combined, were associated with low handgrip strength, poor performance status, higher C-reactive protein, and lower serum albumin levels. The phenotypes with high-risk SMD, regardless of low-risk SMI (hazard ratio [HR], 1.74; 95% CI, 1.05-2.88) or high-risk SMI (HR, 1.99; 95% CI, 1.29-3.05) were associated with higher 90 days' mortality risk.

CONCLUSION

In patients with incurable cancer, phenotype groups with high-risk SMI and high-risk SMD, particularly when combined, were associated with worse functional impairment and inflammation. Moreover, high-risk SMD was associated with increased mortality risk.

Sarcopenia - Definition, Radiological Diagnosis, Clinical Significance

BACKGROUND

 Sarcopenia is an age-related syndrome characterized by a loss of muscle mass and strength. As a result, the independence of the elderly is reduced and the hospitalization rate and mortality increase. The onset of sarcopenia often begins in middle age due to an unbalanced diet or malnutrition in association with a lack of physical activity. This effect is intensified by concomitant diseases such as obesity or metabolic diseases including diabetes mellitus.

METHOD

 With effective preventative diagnostic procedures and specific therapeutic treatment of sarcopenia, the negative effects on the individual can be reduced and the negative impact on health as well as socioeconomic effects can be prevented. Various diagnostic options are available for this purpose. In addition to basic clinical methods such as measuring muscle strength, sarcopenia can also be detected using imaging techniques like dual X-ray absorptiometry (DXA), computed tomography (CT), magnetic resonance imaging (MRI), and sonography. DXA, as a simple and cost-effective method, offers a low-dose option for assessing body composition. With cross-sectional imaging techniques such as CT and MRI, further diagnostic possibilities are available, including MR spectroscopy (MRS) for noninvasive molecular analysis of muscle tissue. CT can also be used in the context of examinations performed for other indications to acquire additional parameters of the skeletal muscles (opportunistic secondary use of CT data), such as abdominal muscle mass (total abdominal muscle area - TAMA) or the psoas as well as the pectoralis muscle index. The importance of sarcopenia is already well studied for patients with various tumor entities and also infections such as SARS-COV2.

RESULTS AND CONCLUSION

 Sarcopenia will become increasingly important, not least due to demographic changes in the population. In this review, the possibilities for the diagnosis of sarcopenia, the clinical significance, and therapeutic options are described. In particular, CT examinations, which are repeatedly performed on tumor patients, can be used for diagnostics. This opportunistic use can be supported by the use of artificial intelligence.

KEY POINTS

· Sarcopenia is an age-related syndrome with loss of muscle mass and strength.. · Early detection and therapy can prevent negative effects of sarcopenia.. · In addition to DEXA, cross-sectional imaging techniques (CT, MRI) are available for diagnostic purposes.. · The use of artificial intelligence (AI) offers further possibilities in sarcopenia diagnostics..

CITATION FORMAT

· Vogele D, Otto S, Sollmann N et al. Sarcopenia - Definition, Radiological Diagnosis, Clinical Significance. Fortschr Röntgenstr 2023; DOI: 10.1055/a-1990-0201.

Sarcopenia in pancreatic cancer: Effect on patient outcomes

Pancreatic cancer is a challenging disease with an increasing incidence and extremely poor prognosis. The clinical outcomes of pancreatic cancer depend on tumor biology, responses to treatments, and malnutrition or cachexia. Sarcopenia represents a severe catabolic condition defined by the age-related loss of muscle mass and strength and affects as much as 70% of malnourished pancreatic cancer patients. The lumbar skeletal muscle index, defined as the total abdominal muscle area at the L3 vertebral level adjusted by the square of the height, is widely used for assessing sarcopenia in patients with pancreatic cancer. Several studies have suggested that sarcopenia may be a risk factor for perioperative complications and decreased recurrence-free or overall survival in patients with pancreatic cancer undergoing surgery. Sarcopenia could also intensify chemotherapy-induced toxicities and worsen the quality of life and survival in the neoadjuvant or palliative chemotherapy setting. Sarcopenia, not only at the time of diagnosis but also during treatment, decreases survival in patients with pancreatic cancer. Theoretically, multimodal interventions may improve sarcopenia and clinical outcomes; however, no study has reported positive results. Further prospective studies are needed to confirm the prognostic role of sarcopenia and the effects of multimodal interventions in patients with pancreatic cancer.

Determinants of muscle density and clinical outcomes: Findings from the Hertfordshire Cohort Study

PURPOSE

The age-related loss of skeletal muscle mass and strength is associated with adverse health outcomes. However, to date, peripheral quantitative computed tomography (pQCT)-derived muscle density has been little studied. We used a well characterised cohort of older adults to identify lifestyle and anthropometric determinants of pQCT-derived muscle density measured 11 years later, and to report relationships between pQCT-derived muscle density with history of falls and prevalent fractures.

METHODS

A lifestyle questionnaire was administered to 197 men and 178 women, aged 59-70 at baseline. After a median of 11.5 (IQR 10.9, 12.3) years, pQCT (Stratec XCT2000) of the radius and tibia was performed to measure forearm muscle density (FMD) and calf muscle density (CMD). Presence of falls and fractures since the age of 45 were determined through participant recall; vertebral fractures were also ascertained through vertebral fracture assessment using iDXA. Total hip BMD (TH aBMD) was assessed using DXA. Baseline characteristics in relation to muscle density at follow-up were examined using linear regression; associations between muscle density and prior falls and fractures were investigated using logistic regression. All analyses were adjusted for sex and age.

RESULTS

Mean (SD) age at muscle density measurement was 76.3 (2.6) years. Mean (SD) FMD was 79.9 (3.1) and 77.2 (3.2) among males and females, respectively; CMD was 80.7 (2.6) and 78.5 (2.6) among males and females, respectively. Significant sex-differences in muscle density were observed at each site (p < 0.001). Female sex, lower weight, and lower body mass index were associated (p < 0.05) with both lower FMD and CMD. Additional correlates of lower CMD included older age and shorter stature. Lifestyle measures were not associated with muscle density in this cohort. Lower FMD was related to increased risk of previous fracture (odds ratio (95 % CI) per SD lower FMD: 1.42 (1.07, 1.89), p = 0.015) but not after adjustment for TH aBMD (p > 0.08). No significant relationships were seen between muscle density and falls.

CONCLUSION

Female sex, older age, and lower BMI were associated with subsequent lower muscle density in older community-dwelling adults. Lower FMD was related to increased risk of previous fracture. Changes in muscle density over time might precede adverse outcomes such as falls and fractures and may be a long-term predictor of frailty. It could be also suggested that muscle density could be a more clinically meaningful surrogate of functional decline and disability than muscle size or mass, but more studies are needed to support this notion.

Internal calibration for opportunistic computed tomography muscle density analysis

INTRODUCTION

Muscle weakness can lead to reduced physical function and quality of life. Computed tomography (CT) can be used to assess muscle health through measures of muscle cross-sectional area and density loss associated with fat infiltration. However, there are limited opportunities to measure muscle density in clinically acquired CT scans because a density calibration phantom, allowing for the conversion of CT Hounsfield units into density, is typically not included within the field-of-view. For bone density analysis, internal density calibration methods use regions of interest within the scan field-of-view to derive the relationship between Hounsfield units and bone density, but these methods have yet to be adapted for muscle density analysis. The objective of this study was to design and validate a CT internal calibration method for muscle density analysis.

METHODOLOGY

We CT scanned 10 bovine muscle samples using two scan protocols and five scan positions within the scanner bore. The scans were calibrated using internal calibration and a reference phantom. We tested combinations of internal calibration regions of interest (e.g., air, blood, bone, muscle, adipose).

RESULTS

We found that the internal calibration method using two regions of interest, air and adipose or blood, yielded accurate muscle density values (< 1% error) when compared with the reference phantom. The muscle density values derived from the internal and reference phantom calibration methods were highly correlated (R2 > 0.99). The coefficient of variation for muscle density across two scan protocols and five scan positions was significantly lower for internal calibration (mean = 0.33%) than for Hounsfield units (mean = 6.52%). There was no difference between coefficient of variation for the internal calibration and reference phantom methods.

CONCLUSIONS

We have developed an internal calibration method to produce accurate and reliable muscle density measures from opportunistic computed tomography images without the need for calibration phantoms.

Body composition as a predictor of chemotherapy-related toxicity in pancreatic cancer patients: A systematic review

Objectives

The objective of this systematic review was to assess associations between quantitative body composition measures extracted from imaging examinations and chemotherapy-related toxicity in pancreatic cancer patients. A secondary objective was to evaluate the different definitions of sarcopenia across included studies.

Methods

This systematic review was conducted according to the PRISMA statement. A comprehensive literature search of three electronic databases was performed by two authors. For each eligible article, information was collected concerning the clinical setting; basic study; population characteristics; technical; body composition features evaluated; CA 19.9 tumor marker levels; chemotherapy drugs administered; toxicities (hematologic, nausea/vomiting, diarrhea, neuropathy, reduction of number of cycles, overall toxicity); association of body composition values with toxicities. The overall quality of the included studies was critically evaluated.

Results

After the initial retrieval of 1137 articles, the systematic review included 12 articles (1/12 in the neo-adjuvant setting; 2/12 in the adjuvant setting; 3/12 in the metastatic setting; 2/12 in the unresectable setting; the other 4/12 included more than one clinical setting). The number of patients included ranged between 17 and 251; mean/median age ranged between 63 and 77 years; the percentage of sarcopenic patients ranged between 23 and 76%. The most frequent body composition parameter evaluated was skeletal muscle index (11/12). Chemotherapy regimens included gemcitabine (as monotherapy or in combination with other drugs); FOLFIRINOX and S-1. Among the trials including gemcitabine, 2/9 demonstrated an association with toxicity, whereas 7/9 did not; among those including FOLFIRINOX, one demonstrated associated toxicity whereas the others did not. Altogether, 4/12 papers demonstrated an association between the body composition values and the development of chemotherapy-related toxicities.

Conclusions

There is a wide variability of results about the association of body composition and chemotherapy-related toxicity in PC patients. Furthermore, cut-off values to define sarcopenia in PC patients are not yet uniformly defined.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022337753, identifier CRD42022337753.

Prognostic significance of sarcopenia as determined by bioelectrical impedance analysis in patients with advanced pancreatic cancer receiving gemcitabine plus nab‑paclitaxel: A retrospective study

Sarcopenia often affects patients with various types of cancer, and has been reported to affect patient prognosis and therapeutic effects. However, to the best of our knowledge, there are no reports on the relationship between gemcitabine plus nab-paclitaxel combination therapy (GnP) and sarcopenia in patients with unresectable pancreatic cancer. The present study analyzed the relationship between overall survival (OS), progression-free survival (PFS), response rate, disease control rate, adverse events (AEs) and sarcopenia in patients with pancreatic cancer treated with GnP. A total of 121 consecutive patients with advanced pancreatic cancer who received GnP as first-line chemotherapy between January 2015 and December 2017 were retrospectively analyzed. GnP consisted of 1,000 mg/m² gemcitabine and 125 mg/m² nab-paclitaxel, which were administered on days 1, 8 and 15 every 4 weeks. The skeletal muscle index (SMI) was calculated using bioimpedance analysis (BIA) as an index of sarcopenia prior to GnP. The patients were divided into sarcopenia (n=41) and non-sarcopenia (n=80) groups using cutoff values of 8.87 and 6.42 kg/m² for male and female patients, respectively. The sarcopenia and non-sarcopenia groups had a median OS of 8.1 and 13.9 months, respectively [hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.53-1.20], and a median PFS of 4.3 and 6.3 months, respectively (HR 0.63; 95% CI 0.42-0.95). The response and disease controls rate were not statistically different between the groups (20 vs. 32%, P=0.20; 81 vs. 80%, P=1.0). In addition, comparison of common grade 3 and 4 AEs between the two groups revealed no statistically significant differences. In conclusion, the results of the present study indicated that SMI obtained by BIA may be a predictor of treatment response and prognosis in patients with advanced pancreatic cancer who undergo GnP.

Validation of automated body composition analysis using diagnostic computed tomography imaging in patients with pancreatic cancer

BACKGROUND

Sarcopenia is associated with complications and inferior oncologic outcomes in solid tumors. Axial computed tomography (CT) scans can be used to evaluate sarcopenia, however manual quantification is laborious. We sought to validate an automated method of quantifying muscle cross-sectional area (CSA) in patients with pancreatic adenocarcinoma (PDAC).

METHODS

Mid-L3 CT images from patients with PDAC were analyzed: CSAs of skeletal muscle (SM) were measured using manual segmentation and the software AutoMATiCA, and then compared with linear regression.

RESULTS

Five-hundred-twenty-five unique scans were analyzed. There was robust correlation between manual and automated segmentation for L3 CSA (R2 0.94, P < 0.001). Bland-Altman analysis demonstrated a consistent overestimation of muscle CSA by AutoMATiCA with a mean difference of 5.7%. A correction factor of 1.06 was validated using a unique test dataset of 36 patients with non-PDAC peripancreatic malignancies.

CONCLUSIONS

Automated muscle CSA measurement with AutoMATiCA is highly efficient and yields results highly correlated with manual measurement. These findings support the potential use of high-throughput sarcopenia analysis with abdominal CT scans for both clinical and research purposes.

Colorectal Cancer Chemotherapy Drug Bevacizumab May Induce Muscle Atrophy Through CDKN1A and TIMP4

The muscle in the organism has the function of regulating metabolism. Long-term muscle inactivity or the occurrence of chronic inflammatory diseases are easy to induce muscle atrophy. Bevacizumab is an antiangiogenic drug that prevents the formation of neovascularization by inhibiting the activation of VEGF signaling pathway. It is used in the first-line treatment of many cancers in clinic. Studies have shown that the use of bevacizumab in the treatment of tumors can cause muscle mass loss and may induce muscle atrophy. Based on bioinformatics analysis, this study sought the relationship and influence mechanism between bevacizumab and muscle atrophy. The differences of gene and sample expression between bevacizumab treated group and control group were studied by RNA sequencing. WGCNA is used to find gene modules related to bevacizumab administration and explore biological functions through metascape. Differential analysis was used to analyze the difference of gene expression between the administration group and the control group in different muscle tissues. The key genes timp4 and CDKN1A were obtained through Venn diagram, and then GSEA was used to explore their biological functions in RNA sequencing data and geo chip data. This study studied the role of bevacizumab in muscle through the above methods, preliminarily determined that timp4 and CDKN1A may be related to muscle atrophy, and further explored their functional mechanism in bevacizumab myotoxicity.

The Differential Clinical Impacts of Cachexia and Sarcopenia on the Prognosis of Advanced Pancreatic Cancer

Simple Summary

Pancreatic cancer (PC) is one of the most lethal malignancies across the world. More than 80% patients are diagnosed at an advanced stage with limited treatment options. PC has the highest frequency of developing cancer cachexia (CC)–sarcopenia (SC) syndrome, but there is no optimal efficient intervention for CC or SC targeting their complicated biological and irreversible processes. As a result, identifying the clinicopathological features and patient characteristics in each advanced PC patient with CC and/or SC is urgently needed to distinguish different wasting phenotypes or body composition and thus support precision medicine and achieve optimal outcomes. We performed a retrospective cohort study of 232 advanced PC patients to determine the differential clinical characteristics of CC and SC and the overlap of CC- or SC-related factors in each patient. The impacts of CC, SC, and their relevant factors on the outcomes of PC patients were also evaluated.

Abstract

Pancreatic cancer (PC) has the highest frequency of developing cancer cachexia (CC)–sarcopenia (SC) syndrome, which negatively influences patients’ outcome, quality of life, and tolerance/response to treatments. However, the clinical impacts of CC, SC, and their associated factors on outcomes for advanced PC has yet to be fully investigated. A total of 232 patients were enrolled in this study for the retrospective review of their clinical information and the measurement of skeletal muscle areas at the third lumber vertebra by computed tomography scan to identify CC or SC. The association and concurrent occurrence of clinicopathological features in each patient, prevalence rates, and prognosis with the CC or SC were calculated. CC and SC were observed in 83.6% (n = 194) and 49.1% (n = 114) of PC patients, respectively. Low hemoglobin levels more often occurred in CC patients than in non-CC patients (p = 0.014). Older age (p = 0.000), female gender (p = 0.024), low body mass index (BMI) values (p = 0.004), low hemoglobin levels (p = 0.036), and low albumin levels (p = 0.001) were more often found in SC patients than in non-SC patients. Univariate and multivariate analyses showed that CC was an independent poor prognostic factor of overall survival (OS) and progression-free survival for all patients, the chemotherapy (C/T) subgroup, and the high BMI subgroup. Meanwhile, SC was an independent predictor of poor OS for the subgroups of C/T or high BMI but not for all patients. These findings reveal the clinical differences for CC and SC and provide useful information for predicting the prognosis of advanced PC patients and conducting personalized medicine.

Baseline Factors Predictive of the Receipt of Second-Line Chemotherapy After Nab-Paclitaxel Plus Gemcitabine for Patients With Advanced Pancreatic Cancer

OBJECTIVE

Second-line (2L) chemotherapy is important for improved survival in patients with advanced pancreatic cancer (APC). However, approximately half of patients with APC do not receive 2L chemotherapy because of disease progression or adverse events. Baseline factors predictive of the receipt of 2L chemotherapy remain unknown. Therefore, we investigated predictive factors for the receipt of 2L chemotherapy in patients with APC.

METHODS

Between January 2015 and March 2020, 53 patients with APC received nab-paclitaxel plus gemcitabine (AG) as first-line chemotherapy at our institute. Of these 53 patients, 29 patients received 2L chemotherapy, and 23 patients received best supportive care. Patients' characteristics were compared retrospectively, and predictive factors for the receipt of 2L chemotherapy were evaluated.

RESULTS

Sarcopenia and hypoalbuminemia at baseline were independent negative predictive factors for the receipt of 2L chemotherapy in multivariate analysis. Although the presence of sarcopenia did not affect the relative dose intensity through 8 weeks of AG therapy, patients with hypoalbuminemia had a significantly lower relative dose intensity.

CONCLUSIONS

Sarcopenia and hypoalbuminemia at baseline might be negative predictive factors for the receipt of 2L chemotherapy after AG treatment in patients with APC.

Association between sarcopenia and survival in patients with gynecologic cancer: A systematic review and meta-analysis

Background

Despite prior attempts to evaluate the effects of sarcopenia on survival among patients with gynecologic cancer, the results of these studies have not been consistent. The present study evaluated the association between sarcopenia and survival among patients with gynecologic cancer by aggregating multiple studies.

Methods

We performed a literature search using computerized databases and identified additional studies included in the bibliographies of retrieved articles. The quality of each study was evaluated using the Newcastle-Ottawa Scale, and meta-analyses were performed to evaluate overall survival (OS) and progression-free survival (PFS). We constructed a forest plot for each outcome and assessed publication bias using Begg's test. Heterogeneity was assessed using I² statistics.

Results

From the 5,933 initially identified articles, 16 studies describing 2,031 participants with a mean age of 60.34 years were included in the meta-analysis. We found that compared with patients with gynecologic cancer but without sarcopenia, patients with sarcopenia had worse OS, with a pooled hazard ratio (HR) of 2.61 (95% confidence interval [CI]:1.52-4.46), and worse PFS (HR: 1.37, 95% CI: 1.09-1.73). The quality of studies was generally good, and no publication bias was detected among studies for either OS or PFS. Although 4 of 12 studies were of fair quality, we conducted a sensitivity analysis excluding studies or fair quality and obtained similar results.

Conclusions

These meta-analysis results suggest that sarcopenia is associated with worse OS and PFS among patients with gynecologic cancer. The use of different case definitions appeared to be a major source of heterogeneity among the studies. Further studies remain necessary to confirm our findings, especially those examining OS and PFS, because publication bias was identified.

Myosteatosis reduces overall survival in patients with digestive system malignancies: a meta-analysis with trial sequential analysis

The impact of myosteatosis on the outcomes of digestive malignancies has gained great attention recently. However, studies on the impact of myosteatosis show inconsistent results. We conducted a meta-analysis to clarify the relationship between myosteatosis and the overall survival of digestive cancer patients. The systematic literature search was conducted on PubMed/MEDLINE, Web of Science, and Embase from inception through March 27, 2021. Meta-analysis was performed using the random-effects model. Out of 3451 studies screened, 47 studies including 21,194 patients passed the screening criteria. The average prevalence of myosteatosis was 46.4%. Patients with myosteatosis had 44% increased mortality risk compared with non-myosteatosis patients (HR: 1.44, 95% CI: 1.33-1.55, P < .05). The predictive value of myosteatosis held regardless of country zone, study design, statistical model, Newcastle-Ottawa Scale (NOS) scores, treatment, sample size, and tumor stage. Nevertheless, the predictive value of myosteatosis was only evident for patients with esophagogastric cancers, cholangiocarcinoma/pancreatic cancers, or colorectal cancers. Overall, the results of this meta-analysis were robust based on sensitivity, subgroup, meta-regression, and trial sequential analyses and suggested that myosteatosis predicted worse overall survival (OS) in digestive malignancies patients.

Low skeletal muscle mass is a predictor of treatment related toxicity in oncologic patients. A meta-analysis

BACKGROUND & AIMS

The purpose of this meta-analysis was to summarize the published data regarding associations between occurrence of severe treatment related toxicity and low skeletal muscle mass (LSMM) in oncologic patients and to perform a meta-analysis based on a large sample.

METHODS

MEDLINE, Cochrane, and SCOPUS databases were screened for associations between LSMM and treatment related toxicity in oncologic patients up to June 2021. Overall, 48 studies met the inclusion criteria. The following data were extracted: authors, year of publication, study design, number of patients, influence of LSMM on treatment toxicity (odds ratios and confidence intervals). The methodological quality of the involved studies was checked according to the QUADAS instrument. The meta-analysis was undertaken by using RevMan 5.4 software. DerSimonian and Laird random-effects models with inverse-variance weights were used to account for the heterogeneity between the studies.

RESULTS

The included 48 studies comprised 4803 patients with different malignant diseases. LSMM occurred in 1966 patients (40.9%). LSMM was associated with therapy toxicity (simple logistic regression) with an odds ratio OR = 2.19, CI95%= (1.78-2.68). LSMM was associated with DLT in patients underwent curative treatment (16 studies, 2381 patients) with OR = 2.48, CI95%= (1.77-3.48). LSMM predicted DLT in patients underwent palliative chemotherapy (30 studies, 2337 patients)with OR = 2.06, CI95%= (1.56-2.74). In the subgroups received different palliative therapies, relationships between LSMM and DLT were as follows: conventional chemotherapies (7 studies, 600 patients) OR = 2.14, CI95%= (1.38-3.31); different kinases inhibitors (13 studies, 906 patients) OR = 3.08, CI95%= (1.87-5.09); checkpoint inhibitors (7 studies, 557 patients) OR = 1.30, CI95%= (0.79-2.11).

CONCLUSIONS

LSMM is an essential factor of treatment toxicity in oncologic patients. Association between LSMM and DLT is strongest in patients received therapy with kinases inhibitors. The influence of LSMM on DLT is lowest in patients underwent treatment with checkpoint inhibitors. The presence of LSMM should be included into radiological reports and provided to oncologists to optimize chemotherapy. LSMM should be included into dose calculation for chemotherapy.

Computed tomography-defined low skeletal muscle mass as a prognostic marker for short-term mortality in critically ill patients: A systematic review and meta-analysis

OBJECTIVE

Low skeletal muscle mass (LSMM) can be assessed by imaging modalities and is associated with several clinically relevant factors in critically ill patients. Our aim was to establish the effect of computed tomography (CT)-defined LSMM on short-term mortality in critically ill patients based on a large patient sample.

METHODS

The MedLine library and the Cochrane and SCOPUS databases were screened for associations between CT-defined LSMM and short-term mortality in critically ill patients up to May 2021. The primary endpoint of the systematic review was the odds ratio of sarcopenia on mortality. In total, nine studies were selected as suitable for the analysis and included into the present analysis.

RESULTS

The studies included a total of 1563 critically ill patients with different underlying diagnoses. The pooled overall prevalence of LSMM was 50.9%. The pooled odds ratio for the effect of sarcopenia on short-term mortality was 2.78 (95% confidence interval, 2.05-3.75).

CONCLUSIONS

CT-defined LSMM is highly prevalent in critically ill patients, has a relevant effect on short-term mortality, and should be included as a relevant prognostic biomarker in clinical routines.