A low psoas muscle volume correlates with a longer hospitalization after radical cystectomy

Malnutrition risk screening in adult oncology outpatients: An ASPEN systematic review and clinical recommendations

BACKGROUND

Malnutrition screening is not widely practiced in outpatient cancer centers. This review aims to determine the validity of malnutrition screening tools and provide recommendations for clinical use.

METHODS

Studies identified by a systematic review assessed the general validity of screening tools in adult oncology outpatients from five databases through 2022. The American Society for Parenteral and Enteral Nutrition (ASPEN) convened a working group of members from the Academy of Nutrition and Dietetics, Academy of Oncology Nurse and Patient Navigators, American Cancer Society, American Society for Clinical Oncology, American Society for Nutrition, American Society for Radiation Oncology, Association of Cancer Care Centers, and Oncology Nursing Society to answer the following questions: (1) should clinicians screen for malnutrition, (2) which malnutrition screening tools are recommended, and (3) what are the clinical applications for malnutrition risk screening in adult oncology outpatients?

RESULTS

Twenty of 738 studies met the criteria and were reviewed. Six screening tools with specific cut-points demonstrated validity and are recommended, including the Mini Nutritional Assessment (≤23.5), Malnutrition Screening Tool (MST; MST ≥ 2 and patient-led MST ≥ 2), Malnutrition Universal Screening Tool (MUST; MUST ≥ 1 and MUST ≥ 2), Nutrition Risk Screening-2002 (NRS-2002; NRS-2002 ≥ 2 and NRS-2002 ≥ 3), NUTRISCORE ≥ 5, and Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF; PG-SGA SF ≥ 7 and PG-SGA SF ≥ 8).

CONCLUSION

Six screening tools are valid for malnutrition risk identification in oncology ambulatory settings and recommended before treatment initiation and regularly thereafter, depending on treatment course. Research is needed to understand to what extent early diagnosis and management of malnutrition improves the clinical care of oncology patients.

Skeletal muscle size and quality in healthy kidney donors, normal range and clinical associations

The gold standard to estimate muscle mass and quality is computed tomography (CT) scan. Lower mass and density (intramuscular fat infiltration) of skeletal muscles are markers of sarcopenia, associated with increased mortality risk, impaired physical function, and poorer prognosis across various populations and medical conditions. We aimed to describe standard reference values in healthy population, prospective kidney donors, and correlate clinical parameters to muscle mass and density. Included in the cohort 384 consecutive kidney donors. Mean age was 44.6 ± 11.5 (range 18.4-74.2), 46% were female and mean BMI was 25.6 ± 3.8 kg/m2. Our quantified reference values for psoas cross -sectional area (CSA) index at L3 level (males/females respectively) were 6.3 ± 1.8 and 4.8 ± 1.9 cm2 /m2, and density was 46.1 ± 5 and 41 ± 5 HU at that level. Older age (standardized beta coefficient - 0.12, p = 0.04), sex (- 0.32, p < 0.001) and BMI (0.17, p = 0.002) were significantly associated with CSA index of psoas at L3. Density, however, was associated with triglycerides level (- 0.21, p < 0.001), in addition to age (- 0.22, p < 0.0001), sex (- 0.27, p < 0.001) and BMI (- 0.1, p = 0.05). Our study validates the normative values of psoas muscle mass and density in healthy individuals and suggests correlations with clinical parameters. We demonstrate the significance of measuring not only the mass of the muscle, but also its density, as it has a valid association with metabolic parameters, including BMI and lipid level, even in healthy individuals and in the normal range of the tests.

Prognostic Effects of Sarcopenia on Patients with Bladder Cancer: A Systematic Review and Meta-Analysis

Sarcopenia can negatively impact the survival of cancer patients. This study intends to delve into the correlation of sarcopenia with survival and complications in patients with bladder cancer (BC) after surgery. Web of Science, Cochrane Library, Embase, and PubMed databases were retrieved up to April 7, 2023, to collect studies on the impact of sarcopenia on the prognosis of adults with BC. Primary outcomes encompassed overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). The secondary outcome consisted of postoperative complications. A meta-analysis was conducted using Stata. Forest plots and summary effect models were employed to present the results. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale (NOS). Initially, 1713 studies were identified through searches across four databases, and 26 studies were ultimately included in the analysis. Sarcopenia was significantly associated with OS (HR:1.62; 95% CI: 1.43-1.83; P < 0.001, I2 = 0.9%), CSS (HR: 1.81, 95% CI: 1.52-2.15, P < 0.001, I2 = 0.0%), and RFS (HR: 1.76, 95% CI: 1.21-2.56, P = 0.003, I2 = 0.0%) in BC patients. Subgroup analyses revealed that sarcopenia is strongly linked to prognosis and postoperative complications in BC patients.

Association between psoas major muscle mass and CPET performance and long-term survival following major colorectal surgery: A retrospective cohort study

OBJECTIVES

To evaluate whether computed tomography (CT)-derived psoas major muscle measurements could predict preoperative cardiopulmonary exercise testing (CPET) performance and long-term mortality in patients undergoing major colorectal surgery and to compare predictive performance of psoas muscle measurements using 2D approach and 3D approach.

METHODS

A retrospective cohort study compliant with STROCSS standards was conducted. Consecutive patients undergoing major colorectal surgery between January 2011 and January 2017 following CPET as part of their preoperative assessment were included. Regression analyses were modelled to investigate association between the CT-derived psoas major muscle mass variables [total psoas muscle area (TPMA), total psoas muscle volume (TPMV) and psoas muscle index (PMI)] and CPET performance and mortality (1-year and 5-year). Discriminative performances of the variables were evaluated using Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

A total of 457 eligible patients were included. The median TPMA and TPMV were 21 ​cm2 (IQR: 15-27) and 274 ​cm3 (IQR: 201-362), respectively. The median PMI measured via 2D and 3D approaches were 7 ​cm2/m2 (IQR: 6-9) and 99 ​cm3/m2 (IQR: 76-120), respectively. The risks of 1-year and 5-year mortality were 7.4% and 27.1%, respectively. Regression analyses showed TPMA, TPMV, and PMI can predict preoperative CPET performance and long-term mortality. However, ROC curve analyses showed no significant difference in predictive performance amongst TPMA, TPMV, and PMI.

CONCLUSION

Radiologically-measured psoas muscle mass variables may predict preoperative CPET performance and may be helpful with informing more objective selection of patients for preoperative CPET and prehabilitation.

Impact of sarcopenia on outcomes of bladder cancer undergoing radical cystectomy: A systematic review and meta-analysis

OBJECTIVE

To provide synthesized evidence on the association between sarcopenia and risk of mortality, recurrence and postoperative complications in patients with bladder cancer and undergoing radical cystectomy (RC).

METHODS

Only studies with observational design that investigated the association between sarcopenia and outcomes of interest among patients with bladder cancer undergoing RC were included. The outcomes of interest were mortality, recurrence, and postoperative complications. The systematic search was conducted using three large databases, that is, PubMed, EMBASE, and Scopus. A random effects model was used for the analysis and pooled effect sizes were reported as odds ratio (OR) or hazards ratio (HR) along with 95% confidence intervals (CIs).

RESULTS

A total of 21 studies with 4997 patients were included. Compared to non-sarcopenic subjects, those with sarcopenia had increased risk of all-cause mortality (HR 1.45, 95% CI: 1.32, 1.61), cancer-specific mortality (HR 1.74, 95% CI: 1.49, 2.03) and a lower recurrence free survival (HR 1.84, 95% CI: 1.30, 2.62). Patients with sarcopenia also had higher risk of developing complications within 90 days postoperatively (OR 1.77, 95% CI: 1.23, 2.55).

CONCLUSION

Sarcopenia among patients with bladder cancer and managed using RC is associated with adverse survival outcomes and an increased risk of postoperative complications.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

BACKGROUND

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

METHODS

The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

RESULTS

A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

CONCLUSION

Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Total Psoas Area is a Measure for Deconditioning in Colorectal Surgery Patients

INTRODUCTION

Physical fitness is an important prognostic indicator for surgical outcomes. An objective measure of deconditioning is needed to determine patient fitness. This study aims to describe a methodology to standardize psoas measurements and correlate them with postoperative outcomes.

METHODS

After obtaining IRB approval, the ACS-NSQIP database was queried for patients over 18 years, undergoing colectomies for non-trauma indications from 1/1/2013 to 12/31/2018. Upon CT imaging, the psoas muscle was identified at the lumbosacral joint. Imaging software calculated the total cross-sectional area of the left and right psoas muscle and was normalized by dividing by height squared to achieve our Total Psoas Index (TPI) in cm2/m2.

RESULTS

1173 patients met study criteria; all had TPI calculated. A TPI equal to or below the gender-specific 25th percentile defined sarcopenia. In total, 151 females (24.6%) and 137 males (24.5%) were classified as sarcopenic. TPI was significantly associated with multiple NSQIP 30-day outcomes and mortality in our study population.

CONCLUSIONS

Measuring TPI at the lumbosacral joint is an appropriate method for determining sarcopenia.

Muscle mass ratio in male gastric cancer patients as an independent predictor of postoperative complications after minimally invasive distal gastrectomy

BACKGROUND

The current study aimed to investigate the relationship between muscle mass proportion and the incidence of total complications in male gastric cancer (GC) patients after minimally invasive distal gastrectomy (MIDG).

METHODS

Between March 2017 and March 2020, 152 male GC patients with clinical stage III or lower GC who underwent MIDG were enrolled in this study. The muscle mass ratio (MMR) was calculated by dividing the total muscle weight obtained from bioelectrical impedance analysis by the whole-body weight. Thereafter, the association between MMR and surgical outcomes was determined.

RESULTS

Based on the optimal MMR cutoff value of 0.712 obtained using the receiver operating characteristic (ROC) curve, patients were divided into two groups (69 and 83 patients in the MMR-L and MMR-H groups). The MMR-L group had a significantly higher total complication rate compared to the MMR-H group (MMR-L, 24.6% vs. MMR-H, 7.2%; P = 0.005). Multivariate analysis also identified MMR-L as a significant independent risk factor for total complications and intra-abdominal infectious complications after MIDG.

CONCLUSIONS

The MMR calculated using bioelectrical impedance analysis can be a useful predictor for postoperative complications after MIDG in male GC patients.

Early volume loss of skeletal muscle after esophagectomy: a risk for late-onset postoperative pneumonia

Late-onset postoperative pneumonia (LOPP) after esophagectomy is poorly understood. This study was designed to clarify the features and risk factors for this event. Patients who underwent esophagectomy for esophageal cancer between 2006 and 2016 were included. LOPP was defined as radiologically proven pneumonia that occurred over 3 months after surgery, and clinically relevant late-onset postoperative pneumonia (CR-LOPP) was defined as LOPP that required administration of oxygen and antibiotics in the hospital and/or more intensive treatment. The total psoas muscle area (TPA) was measured using preoperative and postoperative (at 3 months after surgery) computed tomography scan images. Potential risk factors for CR-LOPP were investigated. Among 175 study patients, 46 (26.3%) had LOPP, 29 (16.6%) of whom exhibited CR-LOPP with a cumulative incidence of 15.6% at 3 years and 22.4% at 5 years. Four (13.8%) of these patients died of LOPP. Univariable analysis showed that clinical stage ≥III (P = 0.005), preoperative prognostic nutritional index (PNI) <45 (P = 0.035), arrhythmia (P = 0.014), postoperative hospital stay ≥40 days (P = 0.003), and percent decrease of TPA more than 5% (P < 0.001) were associated with CR-LOPP but not early onset postoperative pneumonia. Multivariable analysis revealed that clinical stage ≥III (hazard ratio [HR] 3.01, P = 0.004), postoperative hospital stay ≥40 days (HR 2.51, P = 0.015), and percent decrease of TPA >5% (HR 9.93, P < 0.001) were independent risk factors for CR-LOPP. CR-LOPP occurred in over 20% of patients at 5 years, and early postoperative loss of TPA was a potential trigger for this delayed complication.

Preoperative sarcopenia and systemic immune-inflammation index can predict response to intravesical Bacillus Calmette-Guerin instillation in patients with non-muscle invasive bladder cancer

Background

To explore the prognostic significance of sarcopenia and systemic immune-inflammation index (SII) for response to intravesical Bacillus Calmette-Guerin (BCG) in patients with intermediate-, and high-risk non-muscle invasive bladder cancer (NMIBC).

Methods

We retrospectively analyzed 183 consecutive patients treated in Qilu hospital of Shandong University for a first diagnosis of intermediate and high risk NMIBC. Using computed tomography scans at the third lumbar vertebra level, we calculated skeletal muscle index (SMI). Sarcopenia was defined as SMI <43 cm²/m² for males with BMI < 25 kg/m², <53 cm²/m² for males with BMI ≥ 25 kg/m², and <41 cm²/m² for females. The response to intravesical BCG immunotherapy and relapse-free survival (RFS) were analyzed.

Results

Compared with BCG responders, BCG non-responders were associated with sarcopenia (P < 0.001), carcinoma in situ (P < 0.001), T1 stage (P < 0.001), multiple tumor (P < 0.001), tumor diameter >=3cm (P < 0.001), and have a significant increase of neutrophil-to-lymphocyte ratio (NLR) (P < 0.001), platelet to lymphocyte ratio (PLR) (P = 0.004), SII (P < 0.001). The area under the ROC curve (AUC) of the BMI, NLR, PLR, and SII for response to intravesical BCG immunotherapy were 0.425, 0.693, 0.631, and 0.702 respectively. Logistic regression analysis demonstrated that sarcopenia and SII were predictors of response to intravesical BCG immunotherapy. The Kaplan-Meier survival analysis showed that the RFS of patients with BCG response, lower SII and no sarcopenia was significantly increased compared with that of patients with BCG non-response, higher SII and sarcopenia, respectively. Subgroup analysis demonstrated that the RFS of patients with high SII and sarcopenia was significantly decreased compared with those with low SII and no sarcopenia in Ta stage subgroup, T1 stage subgroup, non-Cis subgroup, multiple tumor subgroup, single tumor subgroup, tumor diameter≥3cm subgroup and tumor diameter<3cm subgroup, respectively (P < 0.05). However, there was no significant difference in RFS for patients in CIS subgroup (P > 0.05). Multivariate Cox analysis shown that sarcopenia (p=0.005) and high SII (p = 0.003) were significantly associated with poor RFS.

Conclusions

Both sarcopenia and high SII are useful predictors of response to intravesical BCG in intermediate- and high-risk NMIBC patients. Patients with intermediate- and high-risk NMIBC that had sarcopenia or high SII at diagnosis were associated with poor RFS, and the combination of sarcopenia and SII may be a better predictor of RFS.

Malnutrition management in oncology: An expert view on controversial issues and future perspectives

Cancer and anticancer treatments can lead to several negative side effects, including malnutrition. Despite the recognized need for adequate nutritional support in cancer patients, in daily clinical practice, nutrition is still not considered one of the first aspects to be considered. Malnutrition negatively affects the clinical outcomes, treatment response, and overall survival of cancer patients. In this study, three of the most controversial issues related to malnutrition, which emerged during an Italian Consensus Conference, were addressed specifically for patients with head and neck as well as gastrointestinal cancer. The timing of nutritional evaluation and intervention, extension of the Enhanced Recovery after Surgery (ERAS^®) protocols, and cost-effectiveness of nutritional interventions have been considered. This study aimed to illustrate the state-of-the art of each issue and hypothesize future perspectives and actions to be taken, trying to suggest a new nutritional management model for cancer patients in Italy that overcomes the critical issues encountered. Of note, the timely diagnosis of nutritional issue appears to be essential to ensure the correct management of malnourished cancer patients as well as those who are at high risk of malnutrition. Standardized protocols, screening tests, and the inclusion of nutritional parameters in patient medical records would help to achieve good clinical outcomes. Finally, appropriate nutritional support is also associated with cost savings, and it seems necessary to promote its clinical and economic value to obtain improvements in both outcomes and management costs.

Sarcopenia in Urinary Bladder Cancer: Definition, Prevalence and Prognostic Value in Survival

Sarcopenia, defined as the systemic loss of muscle function and mass, is commonly seen in advanced oncologic states, usually in conjunction with cancer cachexia. Bladder cancer represents one of the most common neoplasms worldwide and affects mainly the elderly who are already frail. The purpose of this study is to review the potential association between sarcopenia and bladder cancer in patients receiving different types of treatments. A thorough MEDLINE/PubMed non-systematic literature review was conducted from 1990 to January 2022, using the following search terms: "sarcopenia and bladder cancer" and "low muscle mass and bladder cancer". Sarcopenia probably poses a negative impact on the prognosis of patients at any stage of bladder cancer, as it is linked with overall worse survival, cancer specific survival and progression-free survival in those treated, with either radical cystectomy or chemotherapy. In addition, sarcopenia seems to be a strong predictor concerning complications and a negative prognostic factor following chemotherapy and surgery for bladder cancer. On the other hand, it seems that sarcopenic patients who receive radiotherapy or immunotherapy are not so severely affected.

Role of prehabilitation following major uro-oncologic surgery: a narrative review

PURPOSE

Functional status and physical independence play a key role in terms of quality of life, access to treatment, and continuity of care. Surgery, a central component of cancer treatments, leads to detrimental effects on functional capacity, which can be peculiarly relevant in vulnerable patients undergoing major procedures. Prehabilitation is a multidisciplinary intervention that uses the preoperative period to prevent or attenuate treatment-related functional decline and its subsequent consequences. This paper narratively reviews the rationale and the evidence of prehabilitation for uro-oncologic surgery.

METHODS

A narrative review was conducted in August 2020, aiming to: (1) identify and discuss the impact of modifiable determinants of postoperative outcomes in urology and (2) review randomized controlled trials (RCT) exploring the role of preoperative exercise, nutrition, and psychological interventions in uro-oncologic surgery.

RESULTS

Eight RCTs on preoperative conditioning interventions met the inclusion criteria, focusing on radical cystectomy for bladder cancer (RC) and radical prostatectomy for prostate cancer (RP). There is strong evidence that poor physical, nutritional and psychosocial status negatively impacts on surgical outcomes. Single modality interventions, such as preoperative exercise or nutrition alone, had no effect on 'traditional' surgical outcomes as length of stay or complication. However, multimodal approaches targeting postoperative functional status have shown to be effective and safe.

CONCLUSION

There is initial evidence on the effectiveness and safety of multimodal prehabilitation in preserving functional capacity following RC and RP. However, to date, outcomes such as complications and length of stay seem to be not affected by prehabilitation.

Cachexia and bladder cancer: clinical impact and management

PURPOSE OF REVIEW

The purpose of this review is to describe the causes, management, and clinical outcomes associated with cachexia and related components including sarcopenia, among patients with bladder cancer (BCa).

RECENT FINDINGS

Cachexia in patients with BCa is associated with poorer outcomes after radical cystectomy (RC), radiation, and chemotherapy. Nutritional supplements and novel pharmaceutical agents including magnolol, flucoidan and Anamorelin are currently undergoing investigation for their potential use in BCa patients with cachexia.

SUMMARY

Cachexia is a hypercatabolic state thought to be caused by an immune-regulated release of cytokines and disruptions of molecular pathways within the tumor microenvironment and systemically. Nutritional deficiencies in patients with BCa also contribute to cachexia and sarcopenia. Patients with BCa -related cachexia and sarcopenia experience worse survival and therapeutic outcomes after RC, chemotherapy, and radiation therapy. Patients with cachexia also experience more postoperative complications after RC. The management of cachexia in patients with BCa remains challenging and requires timely identification, and multidisciplinary management including nutritional supplementation, physical therapy, palliative care, and pharmacological agents. Clinical trials and human studies are still required to determine which pharmacological agents are optimal for BCa cachexia.

Impact of sarcopenia on outcomes of patients treated with trimodal therapy for muscle invasive bladder cancer

OBJECTIVE

We sought to investigate the incidence of sarcopenia and its impact on main oncological outcomes in patients with muscle invasive bladder cancer (MIBC) treated with trimodal therapy (TMT).

PATIENTS AND METHODS

This was a retrospective analysis of 141 MIBC patients treated with TMT in the period 2002 to 2018. Sarcopenia was identified through pretreatment computed tomography scans and defined as a skeletal muscle index of <55 cm²/m² for men and <39 cm²/m² for women. Body mass index (BMI)-adjusted definition of sarcopenia was used to evaluate for sarcopenic obesity. Uni- and multivariable analyses were performed to assess the impact of sarcopenia on initial complete response and overall survival (OS) to TMT.

RESULTS

Median age at diagnosis was 73 years [range: 65-81] and median follow up was 32 months (Inter Quartile Range: 18-66). Median OS was 67 months (95% CI: 53-83). The incidence of sarcopenia and BMI-adjusted sarcopenia was 56.7% and 40.4%, respectively. On multivariable analysis, Eastern Cooperative Oncology Group performance status (HR = 2.37, 95% CI: 2.1-5.67, P = 0.001) and complete response to treatment (HR = 0.26, 95% CI: 0.14-0.049, P = 0.001] were independently associated with improved OS. Sarcopenia and BMI-adjusted sarcopenia were not independently associated with either complete response to TMT or OS. Similarly, in a subpopulation of 74 patients considered fit for radical cystectomy, we found that neither sarcopenia (P = 0.49) nor BMI-adjusted sarcopenia (P = 0.22) had an impact on OS.

CONCLUSION

Sarcopenia and BMI-adjusted sarcopenia are prevalent in patients with MIBC undergoing TMT. TMT is a suitable treatment modality for patients with MIBC irrespective of their sarcopenia status.

Prognostic Effect of Preoperative Psoas Muscle Hounsfield Unit at Radical Cystectomy for Bladder Cancer

Radical cystectomy (RC) is the standard treatment for patients with advanced bladder cancer. Since RC is a highly invasive procedure, the surgical indications in an aging society must be carefully judged. In recent years, the concept of "frailty" has been attracting attention as a term used to describe fragility due to aging. We focused on the psoas muscle Hounsfield unit (PMHU) and analyzed its appropriateness as a prognostic factor together with other clinical factors in patients after RC. We retrospectively analyzed the preoperative prognostic factors in 177 patients with bladder cancer who underwent RC between 2008 and 2020. Preoperative non-contrast computed tomography axial image at the third lumbar vertebral level was used to measure the mean Hounsfield unit (HU) and cross-sectional area (mm²) of the psoas muscle. Univariate analysis showed significant differences in age, sex, clinical T stage, and PMHU. In multivariate analysis using the Cox proportional hazards model, age (hazard ratio (HR) = 1.734), sex (HR = 2.116), cT stage (HR = 1.665), and PMHU (HR = 1.758) were significant predictors for overall survival. Furthermore, using these four predictors, it was possible to stratify the prognosis of patients after RC. Finally, PMHU was useful as a simple and significant preoperative factor that correlated with prognosis after RC.

Sarcopenia is associated with survival in patients with urothelial carcinoma treated with systemic chemotherapy

BACKGROUND

Sarcopenia impacts perioperative outcomes and prognosis in various carcinomas. We aimed to investigate whether sarcopenia at the time of chemotherapy induction in patients with urothelial carcinoma is associated with prognosis.

METHODS

We evaluated patients treated with chemotherapy for urothelial carcinoma between April 2013 and February 2018 at our institution and affiliated centers. Skeletal muscle mass (total psoas muscle, paraspinal muscle, and total skeletal muscle areas) were used to calculate the total psoas muscle index, paraspinal muscle index, and skeletal muscle index. All participants were grouped as per cutoff points set at the median value for each sex. Overall survival was evaluated using Cox regression analysis.

RESULTS

Of the 240 patients, 171 were men and 69 were women; mean age during chemotherapy was 71 years (range: 43-88); and 36, 56, and 148 patients were at stages II, III, and IV, respectively. Paraspinal muscle index was most associated with the prognosis; groups with lower paraspinal muscle index were defined as sarcopenic (men: ≤ 20.9 cm²/m², women: ≤ 16.8 cm²/m²). The overall survival was significantly longer in the non-sarcopenia group including all stages (p = 0.001), and in stage III (p = 0.048) and IV (p = 0.005) patients. There was no significant difference among stage II patients (p = 0.648). After propensity score matching, survival was still significantly longer in the non-sarcopenia group (p = 0.004).

CONCLUSIONS

Paraspinal muscle index measurements obtained during chemotherapy induction for urothelial carcinoma were independent prognostic factors. The absence of sarcopenia may lead to long-term survival in patients undergoing chemotherapy for urothelial carcinoma.

Sarcopenia as an independent predictor for venous thromboembolism events in bladder cancer patients undergoing radical cystectomy

BACKGROUND

Sarcopenia has been proved to be related to the prognosis of patients with bladder cancer (BC) after radical cystectomy (RC). The relationship between sarcopenia and the occurrence of venous thromboembolism (VTE) after RC is unclear.

METHODS

We collected data of 252 BC patients treated with RC at our institution. Data was obtained from the electronic medical record database. Sarcopenia was defined by the third lumbar vertebra skeletal muscle index (SMI) which was measured using preoperative computed tomography. The primary outcome was the incidence of VTE within 30 days after the surgery in sarcopenia and non-sarcopenia groups. Outcomes between the two cohorts were compared using univariate analysis. Multivariate logistic regression was used to control for differences between cohorts.

RESULTS

Two hundred fifty-two patients were enrolled, of which 85 (33.7%) patients were in sarcopenia group, while 167 (66.3%) patients were not in sarcopenia group. The incidence of total VTE in sarcopenia group was higher than that in the extended group (10.6% vs. 1.8%, p = 0.005). Sarcopenia did not cause an increase in other postoperation 30 days complications (all p > 0.05). Multivariate analysis confirmed sarcopenia was independently associated with increased odds of VTE (OR = 4.18, 95% CI [1.01-17.27]; p = 0.048). Subgroup analysis showed that patients with VTE tended to be older (76.5 vs 66.0, p = 0.025) and have higher proportion of diabetes (58.3% vs 14.2%, p < 0.001) as well as lower level of serum albumin (35.0 g/L vs 40.4 g/L, p = 0.023) compared with those without VTE.

CONCLUSIONS

Sarcopenia was an independent predictor for VTE with patients undergoing RC for BC.

Psoas Muscle Mass can Predict Postsurgical Outcomes in Patients Who Undergo Radical Cystectomy and Urinary Diversion Reconstruction

OBJECTIVE

To morphometrically measure to muscle mass which may reflect physical components of frailty. Hence, we evaluated the association between L4 total psoas area (TPA) and operative outcome after radical cystectomy (RC) for bladder cancer.

METHODS

In a retrospective single-center study, bladder cancer patients who underwent RC and urinary diversion between 2007 and 2012 were enrolled. TPA was evaluated in the cross-sectional imaging. The psoas muscles were normalized with the height. Male patients with a psoas mass index ≤7.4 cm²/m² and female patients with a psoas mass index ≤5.2 cm²/m² were classified as sarcopenic. Outcome measures were 30- and 90-day readmission and complications, and survival. Multivariable logistic and Cox proportional-hazards regression models were used to determine relevant predictors.

RESULTS

The median age of the 441 participants and follow up time was 68 years (IQR 59-75) and 1.2 years (IQR 0.5-1.9), respectively. One hundred forty-three patients (32.4%) were sarcopenic. The 30-day readmission and the complication rates were 13.8% and 44.7%, respectively. The 90-day readmission and complication rates were 23.9% and 53.1%, respectively. The 1-year mortality rate was 11.6% (95%CI 8.7-15.4). Multivariable logistic regression analysis revealed an association between increased TPA and lower odds of 30-day complications after RC (OR 0.95, 95%CI 0.92-0.99, P = .02); similarly, an increase in TPA was of prognostic value, although not statistically significant in the multivariable model (P = .05) once adjusting for other patient factors.

CONCLUSION

Sarcopenia predicted early complications and showed an informative trend for overall survival after RC, and thus may inform models predicting postsurgical outcomes.

Curative Radiotherapy in Elderly Patients With Muscle Invasive Bladder Cancer: The Prognostic Role of Sarcopenia

BACKGROUND/AIM

To evaluate the impact of sarcopenia in muscle invasive bladder cancer (MIBC) elderly patients submitted to curative radiotherapy.

PATIENTS AND METHODS

Patients received radiotherapy between 2013 and 2018, and the skeletal muscle index was calculated to classify them as sarcopenic or non-sarcopenic. Primary endpoints were overall survival (OS), cancer specific survival (CSS), 90-day mortality and toxicity.

RESULTS

A total of 28 patients with a median age of 85 years met our inclusion criteria and 8 of them were sarcopenic. With a median prescribed dose of 61 Gy and a median follow-up of 24.5 months, OS rates in the sarcopenic and non-sarcopenic groups were 100% and 84.4% at 3 months, 57.1% and 56.6% at 12 months, 38.1% and 50.3% at 24 months and 38.1% and 33.5% at 48 months, respectively; the CSS rates were 100% and 94.1% at 3 months and 68.6% and 88.2% at 12, 24 and 48 months, respectively. The actuarial 90-day mortality rate was 17.9% for the whole cohort, and 20% and 12.5% for the non-sarcopenic and sarcopenic groups, respectively. The radio-induced toxicity was similar in both groups.

CONCLUSION

Sarcopenia cannot be considered a negative prognostic factor for MIBC elderly patients treated with external beam radiotherapy. Irradiation is therefore a feasible and effective choice for these patients, especially if unfit for surgery.

Comparison of major definitions of sarcopenia based on the skeletal muscle index in patients with urothelial carcinoma

For the past decade, sarcopenia has been actively investigated in various cancers, including urothelial carcinoma (UC). Although skeletal muscle index (SMI) is the main parameter used to evaluate sarcopenia in oncology, the optimal definition of SMI-based sarcopenia is not entirely standardized. We recently highlighted the potential limitations of current definitions of SMI-based sarcopenia in another journal. In this study, we reviewed studies that assessed sarcopenia in UC patients. We then performed a comparative validation of three major SMI-based definitions of sarcopenia, including Prado's, the international and Martin's definitions in metastatic UC patients. We believe that the standardization of the sarcopenia definition is an urgent issue in oncology, and this paper discusses a possible new direction to address this issue.

Predicting morbidity and mortality after radical cystectomy using risk calculators: A comprehensive review of the literature

INTRODUCTION

Radical cystectomy (RC) with urinary diversion is associated with significant perioperative morbidity and mortality, varying between 30% and 70% and between 0.3% and 10.6%, respectively. Risk calculators have been extensively studied in the general surgery literature to predict 30- and 90-day postoperative morbidity and mortality but have not been widely accepted in the RC literature.

MATERIALS AND METHODS

We performed a search of MEDLINE and Embase databases during May 2020 to identify all relevant studies using the following keywords: radical cystectomy, surgical complication predictive model, surgical complication predictive equation, surgical complication predictive nomogram, surgical risk calculator, morbidity, and mortality. We determined the existing surgical predictive nomograms, calculators, and indices and their accuracy in predicting morbidity, mortality, and major complications after RC.

RESULTS

National Surgical Quality Improvement Program had poor accuracy at predicting 30-day morbidity at mortality (AUC 0.5-0.6). LACE index showed good discrimination at predicting 90-day mortality (AUC 0.7). The various frailty and sarcopenia indices have shown poor to fair accuracy at predicting (AUC 0.5-0.7). The Isbarn and Aziz nomograms have equivalent accuracy at predicting 90-day mortality (AUC 0.7) but are limited by inclusion of tumor histology and presence of metastatic disease as variables. POSSUM and P-POSSUM have poor ability at predicting morbidity and mortality (AUC 0.5) and are cumbersome calculators. The surgical Apgar score has been able to predict 30-day morbidity and mortality but can only be used in the postoperative setting.

DISCUSSION

The currently available surgical risk calculators have either poor accuracy at predicting post-RC morbidity and mortality or are limited by types of variables included. An ideal risk calculator would be comprised of preoperative factors only and have a high accuracy to serve as a tool for preoperative patient counseling prior to surgery.

CONCLUSION

There exists a strong need to develop a comprehensive and accurate preoperative risk calculator that predicts morbidity and mortality after RC.

Large-scale analysis of iliopsoas muscle volumes in the UK Biobank

Psoas muscle measurements are frequently used as markers of sarcopenia and predictors of health. Manually measured cross-sectional areas are most commonly used, but there is a lack of consistency regarding the position of the measurement and manual annotations are not practical for large population studies. We have developed a fully automated method to measure iliopsoas muscle volume (comprised of the psoas and iliacus muscles) using a convolutional neural network. Magnetic resonance images were obtained from the UK Biobank for 5000 participants, balanced for age, gender and BMI. Ninety manual annotations were available for model training and validation. The model showed excellent performance against out-of-sample data (average dice score coefficient of 0.9046 ± 0.0058 for six-fold cross-validation). Iliopsoas muscle volumes were successfully measured in all 5000 participants. Iliopsoas volume was greater in male compared with female subjects. There was a small but significant asymmetry between left and right iliopsoas muscle volumes. We also found that iliopsoas volume was significantly related to height, BMI and age, and that there was an acceleration in muscle volume decrease in men with age. Our method provides a robust technique for measuring iliopsoas muscle volume that can be applied to large cohorts.

Establishment of normative biometric data for body composition based on computed tomography in a North American cohort

BACKGROUND & AIMS

Accurate and reproducible biomarkers are required to allow a more personalized approach to patient care. Body composition is one such biomarker affecting outcomes in a range of surgical and oncological conditions. The aim of this study is to determine the age and sex specific distribution of body composition data, based on information gathered from computed tomography (CT).

METHODS

This prospective study used healthy subjects from the medical records linkage of the Rochester Epidemiology Project, based in Minnesota, USA. Each patient had a CT scan without intravenous contrast performed between 1999 and 2001. Quantification was performed using previously validated semi-automated in-house developed software for body composition analysis. Subcutaneous adipose tissue area, visceral adipose tissue area, intermuscular adipose tissue area and skeletal muscle area were measured and indexed to subject height. Generalized Additive Models for Location, Scale and Shape were used to assess the location, scale, and shape of each variable across age, stratified by sex. Z-scores specific to sex were assessed for each of the parameters analyzed. Age-specific z-scores were calculated using the formula: Z = (Index Variable - μ)/σ or Z = (√ (Index Variable) - μ)/σ.

RESULTS

There were 692 subjects enrolled in the study. The fitted model equation was offered for each variable with values presented for μ and σ. Modelling with penalized splines was performed for VAT index, IMAT index and total adipose tissue index. Scatterplots of each variable were produced with lines of Z-scores as a visual representation.

CONCLUSION

This study offers comparative data to allow comparison amongst multiple populations. This will form an important reference for future research and clinical practice.

Skeletal Muscle Index as a Prognostic Marker for Kidney Transplantation in Older Patients

OBJECTIVE

Low skeletal muscle mass has emerged as a risk factor for mortality after liver transplantation. We evaluated the prognostic value of muscle mass on length of hospitalization and adverse outcomes after kidney transplantation in aging end-stage renal disease patients.

METHODS

One hundred twenty-two patients aged 60 years or older at the time of transplantation were retrospectively analyzed. Skeletal muscle index (SMI), evaluated by computed tomography scan, was calculated from total muscle surface area at L3 vertebral level divided by body height squared. Outcomes were compared according to SMI (namely, length of hospitalization, wound complications, combined endpoint comprising all-cause mortality, and graft failure within 1 year).

RESULTS

In male patients, by multivariate analysis, a low SMI (<42 cm²/m²) was associated with longer immediate post-transplantation hospitalization (β = 17.03 ± 4.3; P = .0002), longer total hospitalization during the first year (β = 34.3 ± 10.7; P = .002), higher rate of wound complications (odds ratio = 12.1 [1.9-77.0]; P = .008), and higher rate of the combined endpoint of graft loss or death (odds ratio = 3.4 [3.0-399.5]; P = .004). In female patients, low SMI was not associated with length of hospitalization or adverse outcomes after transplantation.

CONCLUSION

SMI is an independent marker of morbidity and mortality after kidney transplantation in older men and could help thereby nephrologists better select aging candidates for kidney transplantation with a view to improving post-transplant outcomes.

A low psoas muscle volume is associated with a poor prognosis in penile cancer

Background: Sarcopenia was initially recognized as a marker representing the nutritional condition or aging. Recently, sarcopenia has been associated with a poor prognosis and postoperative complications. We examined the importance of sarcopenia as a predictive marker of the prognosis in penile cancer.

Materials and Methods: A total of 25 patients diagnosed with penile cancer who underwent penile resection from 2000 to 2010 were analyzed in this study. The psoas muscle index (PMI) was calculated based on psoas area using preoperative axial computed tomography images at the right L3 level divided by the square of the body height.

Results: Nineteen (76.0%) patients underwent partial penectomy, and 6 (24.0%) underwent total penectomy. The median (mean ± standard deviation) age was 69.3 (69.0 ± 10.1) years old. Regarding the site of penile cancer, 17 (76.0%) cases were in the glans, 6 (24.0%) were in the foreskin, and 2 (8.0%) were in the shaft. Lymph node metastasis were seen in 6 cases (24.0%), and distant metastasis was seen in 1 case (4.0%). The lower PMI group (< 320.0) showed a significantly poorer progression-free survival than the higher PMI group (≥ 320.0) (p = 0.030), although no significant difference in the overall survival was noted (p = 0.076).

Conclusions: Sarcopenia might be a useful prognostic factor in penile cancer patients.

Clinical impact of psoas muscle volume on the development of inguinal hernia after robot-assisted radical prostatectomy

BACKGROUND

Sarcopenia, a syndrome characterized by the loss of skeletal muscle mass, has attracted attention in the field of oncology, as it reflects poor nutritional status. The present study aimed to determine the risk factors for postoperative inguinal hernia (PIH) development after robot-assisted laparoscopic radical prostatectomy (RARP) for prostate cancer, and discuss whether sarcopenia could be used as a sensitive predictor of PIH.

METHODS

We reviewed the medical records of 147 patients who underwent RARP at our institution. The psoas muscle volume (PMV), as an indicator of sarcopenia, was quantified from computed tomography images using a 3-dimensional image analysis system. Multivariate cox regression analyses were performed to identify independent predictors of PIH, including pre- and peri-operative factors.

RESULTS

The mean PMV was 393 cm³, and the correlation coefficient between PMV and body mass index was 0.37 (p < 0.01). The PIH-free rate at 2 years postoperatively was 78.2% among all patients. The multivariate analysis revealed that a PMV < 350 cm³ was a significant risk factor for PIH (p = 0.03; hazard ratio 2.19). Body mass index, age, prostate volume, lymph node dissection, nerve sparing, rectus muscle thickness, and console time were not related to PIH development. The PIH-free rate at 2 years postoperatively was 83.4% and 68.9% in patients with a PMV ≥ 350 cm³ and < 350 cm³, respectively (p < 0.05).

CONCLUSIONS

PIH occurred significantly more frequently in patients with a PMV < 350 cm³ than in patients with a PMV ≥ 350 cm³, and a low PMV was an independent risk factor for PIH. Thus, urologists should pay attention to the cumulative incidence of IH after RARP, especially in patients with a PMV < 350 cm³.

The impact of preoperative nutritional status on post-surgical complication and mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review of the literature

PURPOSE

To investigate the impact of preoperative nutritional factors [body mass index (BMI)], hypoalbuminemia (< 3.5 g/dL, sarcopenia) on complication and mortality rates after radical cystectomy (RC) for bladder cancer.

METHODS

The PubMed database was systematically searched for studies investigating the effect of nutritional status on postoperative outcomes after RC. English-language articles published between March 2010 and March 2020 were reviewed. For statistical analyses odds ratios (ORs) and hazard ratios (HRs) weighted mean was applied.

RESULTS

Overall, 81 studies were included. Twenty-nine studies were enrolled in the final analyses. Patients with a 25-29.9 kg/m² BMI (OR 1.55, 95% confidence interval [CI] 1.14-2.07) and those with a BMI ≥ 30 kg/m² (OR 1.73, 95% CI 1.29-2.40) had a significantly increased risk of 30 day complications after RC. Preoperative hypoalbuminemia increased the risk of 30 day complications (OR 1.56, 95% CI 1.07-2.35); it was a predictor of worse 3 year overall survival (OS) (HR 1.86, 95% CI 1.32-2.66). Sarcopenic patients had a higher risk of 90 day complications than non-sarcopenic ones (OR 2.49, 95% CI 1.22-5.04). Sarcopenia was significantly associated with unfavorable 5 year cancer-specific survival (CSS) (HR 1.73, 95% CI 1.07-2.80), and OS (HR 1.60, 95% CI 1.13-2.25).

CONCLUSION

High BMI, hypoalbuminemia, and sarcopenia significantly increased the complication rate after RC. Hypoalbuminemia predicted worse 3 year OS and sarcopenia predicted unfavorable 5 year CSS and OS. Preoperative assessment of RC patients' nutritional status is a useful tool to predict perioperative and survival outcomes.

Impact of body size and body composition on bladder cancer outcomes: Risk stratification and opportunity for novel interventions

Body size is emerging as a novel and clinically-relevant patient factor in bladder cancer research. Historically, a patient's body mass index (BMI) has been used as a proxy for obesity but it shows inconsistent associations with risk of developing the disease as well as with most clinical outcomes. More specific body composition features can be derived for patients using a variety of methods. To date, skeletal muscle measurements derived from preoperative computed tomography scans have shown the most consistent associations with clinical outcomes. Importantly, skeletal muscle can potentially be modified through resistance training and/or nutritional interventions. Large scale studies that evaluate the prognostic impact of not only body composition features at baseline but also describe changes in body composition post-treatment are needed to move the field forward to ultimately improve clinical outcomes for bladder cancer patients.

A lower psoas muscle volume was associated with a higher rate of recurrence in male clear cell renal cell carcinoma

BACKGROUND

Sarcopenia is defined as a low skeletal muscle volume. Recent studies have reported that sarcopenia is associated with a poor prognosis in various cancers. The purpose of this study is to evaluate the correlation between the psoas muscle volume and recurrence-free survival in patients with localized clear cell renal cell carcinoma (ccRCC).

METHODS

A total of 316 male patients with localized ccRCC who underwent radical nephrectomy at Yokohama City University Hospital (Yokohama, JAPAN) and Kanagawa Cancer Center (Yokohama, JAPAN) between 2002 and 2018 were enrolled in this study. The psoas muscle index (PMI) was calculated by normalizing the psoas muscle area on the contralateral side of the tumor on axial CT, which was calculated at the level of L4 (mm2) divided by the square of the body height (m2). We divided patients into two groups based on the median PMI (409.64mm2/m2).

RESULTS

The lower PMI group showed poorer recurrence-free survival (RFS) than the higher PMI group (p = 0.030). Regarding 5-year RFS, a lower PMI was a significant predictor of recurrence (p = 0.022, hazard ratio (HR): 2.306) and a multivariate analysis revealed that a lower PMI (<median, p = 0.035, HR: 2.167), tumor size >4 cm (p = 0.044, HR: 2.341), and pathological stage >2 (p<0.001, HR: 3.660) were independent risk factors for poor RFS.

CONCLUSIONS

The presence of sarcopenia (lower PMI) was found to be associated with poor RFS in male ccRCC patients. The PMI might serve as a measure of patient frailty and might be useful for prognostic risk stratification in ccRCC.

[Is sarcopenia a morbi-mortality factor in the treatment of localized muscle-invasive bladder cancer?]

INTRODUCTION

Sarcopenia evaluated from the measurement of skeletal muscle index (SMI) has been evaluated as a predictive factor of morbidity and mortality after surgery. The objective of this study was to evaluate whether it was predictive of morbidity and mortality in patients managed by cystectomy or tri-modality therapy (TMT), combining radiotherapy and chemotherapy after endoscopic resection of the tumour, for localized muscle-invasive bladder cancer.

MATERIALS AND METHODS

In all, 146 consecutive patients from 2 university hospital centres treated by cystectomy between January 2012 and April 2017 or TMT between October 2008 and October 2014 were included. The SMI was measured on axial computed-tomography at the level of the transverse process of L3, before treatment. Sarcopenia was assessed in two ways: either by SMI without muscle mass adjustment or according to the definition by Martin and al. based on gender and patient BMI, then called "adjusted sarcopenia". The primary endpoint was overall survival (OS) for sarcopenia. The secondary endpoints were OS, progression-free survival (PFS) and survival without re-admission (SRH) for the total population and for each treatment group. Survival analyses were performed using the Cox model. The association between sarcopenia and complications has been investigated by the Chi² test.

RESULTS

The characteristics of sarcopenic (n=67) and non-sarcopenic (n=79) patients were comparable except for 2 criteria: older patients in the sarcopenic group and a higher proportion of neo-adjuvant chemotherapy in non-sarcopenic patients. Sarcopenia was not significantly associated with any type of survival. Sarcopenia was not associated with the proportion or severity of complications.

CONCLUSION

Unlike unadjusted SMI, sarcopenia was not associated with survival or complications.

LEVEL OF EVIDENCE

3.

From guidelines to clinical practice: a roadmap for oncologists for nutrition therapy for cancer patients

Tackling malnutrition in cancer patients remains one of the most challenging tasks in clinical practice. Even though robust evidence exists stressing the role of nutritional status in relation to treatment outcome, its appropriate consideration in clinical practice is often lacking.

In this review, we discuss the significance of nutritional status and of malnutrition for the cancer patient. Drawn from experience and from current recommendations of the European Society for Clinical Nutrition and Metabolism (ESPEN), we propose concrete and manageable steps to routinely incorporate nutritional aspects in today’s oncological clinical practice.

Sarcomatoid Variant of Bladder Carcinoma: A Case Report

A 59-year-old man was referred to our hospital complaining of asymptomatic gross hematuria. Cystoscopy revealed a papillary tumor 8 cm in diameter filling the bladder. The patient underwent transurethral resection of the bladder tumor. The pathological findings revealed the sarcomatoid variant of urothelial carcinoma with a heterologous osteosarcomatous element. He had no metastasis according to our imaging analyses; thus, we planned radical cystectomy after two courses of neoadjuvant chemotherapy (gemcitabine and cisplatin). Following chemotherapy, enlarged pelvic lymph nodes were noted, and extremely aggressive local progression of the bladder tumor was confirmed. The patient ultimately died 6 months after his initial visit to our hospital.

Impact of Sarcopenia as a Prognostic Biomarker of Bladder Cancer

Sarcopenia, the degenerative and systemic loss of skeletal muscle mass, indicates patient frailty and impaired physical function. Sarcopenia can be caused by multiple factors, including advanced age, lack of exercise, poor nutritional status, inflammatory diseases, endocrine diseases, and malignancies. In patients with cancer cachexia, anorexia, poor nutrition and systemic inflammation make the metabolic state more catabolic, resulting in sarcopenia. Thus, sarcopenia is considered as one of manifestations of cancer cachexia. Recently, growing evidence has indicated the importance of sarcopenia in the management of patients with various cancers. Sarcopenia is associated with not only higher rates of treatment-related complications but also worse prognosis in cancer-bearing patients. In this article, we summarized metabolic backgrounds of cancer cachexia and sarcopenia and definitions of sarcopenia based on computed tomography (CT) images. We conducted a systematic literature review regarding the significance of sarcopenia as a prognostic biomarker of bladder cancer. We also reviewed recent studies focusing on the prognostic role of changes in skeletal muscle mass during the course of treatment in bladder cancer patients. Lastly, we discussed the impact of nutritional support, medication, and exercise on sarcopenia in cancer-bearing patients.

A low psoas muscle volume predicts longer hospitalization and cancer recurrence in upper urinary tract urothelial carcinoma

The aging population is becoming a primary global problem. The most important alteration that occurs in the body with age, is the loss of skeletal muscle. Previously, sarcopenia, which is associated with the loss of skeletal muscle, has been reported to be associated with the prognosis of cancer and complications. The present study investigated the importance of sarcopenia with regard to the prognosis or postoperative complications of upper urothelial cancer patients who underwent nephro-ureterectomy. A total of sixty patients (male, n=44; female, n=16) underwent nephro-ureterectomy for upper urothelial carcinoma. The psoas muscle volume was calculated at the level of the umbilicus using axial computed tomography images obtained prior to nephro-ureterectomy. The psoas muscle index (PMI) was calculated by the following formula: (right side psoas muscle area at the level of the umbilicus mm²)/(body height m)². The median and mean (± standard deviation) ages of the 44 patients were 71 and 68.0 years (± 12.2 years). The lower PMI group demonstrated a significantly poorer recurrence-free survival compared with the higher PMI group (634 vs. 2,317 days, P=0.005). In terms of the duration of postoperative admission, the long-admission group (≥13 days) demonstrated a significantly lower PMI compared with the short-admission group (≤12 days) (383.0 vs. 433.1, P=0.039). Although the overall survival of the two groups did not differ significantly, the lower PMI group tended to have a shorter survival period compared with the higher PMI group (P=0.080). Of the patients with upper urothelial carcinoma, the lower PMI group exhibited a longer postoperative admission period and poorer recurrence-free survival compared with the higher PMI group. The present findings suggest that sarcopenia is a meaningful factor that should be considered when selecting therapy for upper urothelial carcinoma.