Masticatory muscle index for indicating skeletal muscle mass in patients with head and neck cancer

Masseter muscle thickness is predictive of cancer cachexia in patients with head and neck cancer

BACKGROUND

Cancer cachexia is prevalent in head and neck cancer patients. The L3 skeletal muscle index (SMI) is often used to assess sarcopenia and cachexia but is infrequently able to be measured in this population. Masseter muscle thickness (MT) may serve as an alternative predictor of cachexia.

METHODS

SMI and MT were calculated from 20 trauma (CTRL) and 40 cachectic (CA-CX) and non-cachectic (CA-NCX) head and neck cancer patients. Area Under the Curve of the Receiver Operating Characteristics (AUC-ROC) analysis was performed for SMI and MT.

RESULTS

Both SMI and MT were significantly decreased in CA-CX patients (vs. CA-NCX mean difference -19.5 cm2/m2 and -2.06 mm, respectively) and significant predictors of CA-CX (AUC = 0.985 and 0.805, respectively). When analyzed by sex, the same findings were observed for MT in males and trended toward significance in females.

CONCLUSIONS

Compared with SMI, MT is a good alternative prognostic biomarker to determine CA-CX status in HNC patients.

Prevalence and Association of Sarcopenia with Mortality in Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

The objective of this meta-analysis was to assess the association of sarcopenia defined on computed tomography (CT) head and neck with survival in head and neck cancer patients.

METHODS

Following a PROSPERO-registered protocol, two blinded reviewers extracted data and evaluated the quality of the included studies using the Quality In Prognostic Studies (QUIPS) tool, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. A meta-analysis was conducted using maximally adjusted hazard ratios (HRs) with the random-effects model. Heterogeneity was measured using the I2 statistic and was investigated using meta-regression and subgroup analyses where appropriate.

RESULTS

From 37 studies (11,181 participants), sarcopenia was associated with poorer overall survival (HR 2.11, 95% confidence interval [CI] 1.81-2.45; p < 0.01), disease-free survival (HR 1.76, 95% CI 1.38-2.24; p < 0.01), disease-specific survival (HR 2.65, 95% CI 1.80-3.90; p < 0.01), progression-free survival (HR 2.24, 95% CI 1.21-4.13; p < 0.01) and increased chemotherapy or radiotherapy toxicity (risk ratio 2.28, 95% CI 1.31-3.95; p < 0.01). The observed association between sarcopenia and overall survival remained significant across different locations of cancer, treatment modality, tumor stages and geographical region, and did not differ between univariate and multivariate HRs. Statistically significant correlations were observed between the C3 and L3 cross-sectional area, skeletal muscle mass, and skeletal muscle index.

CONCLUSIONS

Among patients with head and neck cancers, CT-defined sarcopenia was consistently associated with poorer survival and greater toxicity.

Correction: Masticatory muscle index for indicating skeletal muscle mass in patients with head and neck cancer

[This corrects the article DOI: 10.1371/journal.pone.0251455.].

Feasibility of using cross-sectional area of masticatory muscles to predict sarcopenia in healthy aging subjects

Determination of sarcopenia is crucial in identifying patients at high risk of adverse health outcomes. Recent studies reported a significant decline in masticatory muscle (MM) function in patients with sarcopenia. This study aimed to analyze the cross-sectional area (CSA) of MMs on computed tomography (CT) images and to explore their potential to predict sarcopenia. The study included 149 adult subjects retrospectively (59 males, 90 females, mean age 57.4 ± 14.8 years) who underwent head and neck CT examination for diagnostic purposes. Sarcopenia was diagnosed on CT by measuring CSA of neck muscles at the C3 vertebral level and estimating skeletal muscle index. CSA of MMs (temporal, masseter, medial pterygoid, and lateral pterygoid) were measured bilaterally on reference CT slices. Sarcopenia was diagnosed in 67 (45%) patients. Univariate logistic regression analysis demonstrated a significant association between CSA of all MMs and sarcopenia. In the multivariate logistic regression model, only masseter CSA, lateral pterygoid CSA, age, and gender were marked as predictors of sarcopenia. These parameters were combined in a regression equation, which showed excellent sensitivity and specificity in predicting sarcopenia. The masseter and lateral pterygoid CSA can be used to predict sarcopenia in healthy aging subjects with a high accuracy.

Assessing thickness and stiffness of superficial/deep masticatory muscles in orofacial pain: an ultrasound and shear wave elastography study

INTRODUCTION

Sonoelastography has been increasingly used for non-invasive evaluation of the mechanical features of human tissues. The interplay between orofacial pain and regional muscle activity appears clinically paramount, although only few imaging studies have investigated this association. Using shear wave sonoelastography (SWS), this study ascertained whether orofacial pain induced alterations in the stiffness of superficial and deep masticatory muscles.

METHODS

All participants were systematically evaluated for oral/facial-related conditions, including the area and intensity of pain. SWS was applied to measure the stiffness of the bilateral masseter, temporalis, and lateral pterygoid muscles. The association between orofacial pain and muscle stiffness/thickness was investigated using a generalized estimating equation for adjusting the influence of age, sex, laterality, and body mass index on muscle thickness/stiffness.

RESULTS

A total of 98 participants were included in the present study: 48 asymptomatic controls, 13 patients with unilateral pain, and 37 patients with bilateral orofacial pain. The reliability, quantified by the intraclass correlation coefficient for muscle stiffness measurement, ranged from 0.745 to 0.893. Orofacial pain at the individual muscle level was significantly associated with masseter muscle stiffness. A trend of increased stiffness (p = 0.06) was also observed in relation to the painful side of the temporalis muscle. No significant correlation was identified between the numeric rating scales for pain and stiffness measurements.

CONCLUSIONS

SWS provides reliable stiffness measurements for the superficial and deep masticatory muscles. The ipsilateral masseter and temporalis muscles might be stiffer than those on the side without orofacial pain. Future studies using the present sonoelasotography protocol can be designed to investigate the stiffness changes in the target muscles after interventions.

Role of sarcopenia on survival and treatment-related toxicity in head and neck cancer: a narrative review of current evidence and future perspectives

PURPOSE

The purpose of this article is to provide an up-to-date summary of sarcopenia and its clinical implications for patients with head and neck cancer (HNC).

METHODS

We conducted a literature review of recent studies investigating the prevalence of sarcopenia in HNC patients, its detection using MRI or CT scans, and its association with clinical outcomes such as disease-free and overall survival time, radiotherapy-related side effects, cisplatin toxicity, and surgical complications.

RESULTS

Sarcopenia, characterized by low skeletal muscle mass (SMM), is a prevalent condition in HNC patients and can be effectively detected using routine MRI or CT scans. Low SMM in HNC patients is associated with increased risks of shorter disease-free and overall survival times, as well as radiotherapy-related side effects such as mucositis, dysphagia, and xerostomia. In addition, cisplatin toxicity is more severe in HNC patients with low SMM, leading to higher dose-limiting toxicity and treatment interruptions. Low SMM may also predict higher risks of surgical complications in head and neck surgery. Identifying sarcopenic patients can aid physicians in better riskstratifying HNC patients for therapeutic or nutritional interventions to improve clinical outcomes.

CONCLUSIONS

Sarcopenia is a significant concern for HNC patients and can impact their clinical outcomes. Routine MRI or CT scans can effectively detect low SMM in HNC patients. Identifying sarcopenic patients can aid physicians in better risk-stratifying HNC patients for therapeutic or nutritional interventions to improve clinical outcomes. Further research is needed to explore the potential of interventions to mitigate the negative effects of sarcopenia in HNC patients.

Prognostic Impact of Sarcopenia's Occurrence during Radiotherapy in Oropharyngeal Cancer Patients

The current study aims to profile sarcopenic condition (both at baseline and developed during treatment) in oropharyngeal carcinoma (OPC) patients treated with curative radiotherapy (RT) +/- chemotherapy and to evaluate its impact on oncological outcomes and toxicity. A total of 116 patients were included in this retrospective single-center study. Sarcopenia assessment at baseline and at 50 Gy re-evaluation CT was obtained from two different methodologies: (i) the L3-skeletal muscle index (SMI) derived from the contouring of the cross-sectional area (CSA) of the masticatory muscles (CSA-MM); and (ii) the paravertebral and sternocleidomastoid muscles at the level of the third cervical vertebra (CSA-C3). Based on L3-SMI from CSA-MM, developing sarcopenic condition during RT (on-RT sarcopenia) was associated with worse progression-free survival (PFS) (p = 0.03) on multivariable analysis and a trend of correlation with overall survival (OS) was also evident (p = 0.05). According to L3-SMI derived from CSA-C3, on-RT sarcopenia was associated with worse PFS (p = 0.0096) and OS (p = 0.013) on univariate analysis; these associations were not confirmed on multivariable analysis. A significant association was reported between becoming on-RT sarcopenia and low baseline haemoglobin (p = 0.03) and the activation of nutritional counselling (p = 0.02). No significant associations were found between sarcopenia and worse RT toxicity. Our data suggest that the implementation of prompt nutritional support to prevent the onset of sarcopenia during RT could improve oncological outcomes in OPC setting.

Sarcopenia in head and neck cancer: A scoping review

OBJECTIVES

In those undergoing treatment for head and neck cancer (HNC), sarcopenia is a strong prognostic factor for outcomes and mortality. This review identified working definitions and methods used to objectively assess sarcopenia in HNC.

METHOD

The scoping review was performed in accordance with Arksey and O'Malley's five-stage methodology and the Joanna Briggs Institute guidelines.

INFORMATION SOURCES

Eligible studies were identified using MEDLINE, Embase, Scopus, Cochrane Library, and CINAHL databases.

STUDY SELECTION

Inclusion criteria represented studies of adult HNC patients in which sarcopenia was listed as an outcome, full-text articles written in English, and empirical research studies with a quantitative design.

DATA EXTRACTION

Eligible studies were assessed using a proprietary data extraction form. General information, article details and characteristics, and details related to the concept of the scoping review were extracted in an iterative process.

RESULTS

Seventy-six studies published internationally from 2016 to 2021 on sarcopenia in HNC were included. The majority were retrospective (n = 56; 74%) and the prevalence of sarcopenia ranged from 3.8% to 78.7%. Approximately two-thirds of studies used computed tomography (CT) to assess sarcopenia. Skeletal muscle index (SMI) at the third lumbar vertebra (L3) (n = 53; 70%) was the most prevalent metric used to identify sarcopenia, followed by SMI at the third cervical vertebra (C3) (n = 4; 5%).

CONCLUSIONS

Currently, the most effective strategy to assess sarcopenia in HNC depends on several factors, including access to resources, patient and treatment characteristics, and the prognostic significance of outcomes used to represent sarcopenia. Skeletal muscle mass (SMM) measured at C3 may represent a practical, precise, and cost-effective biomarker for the detection of sarcopenia. However, combining SMM measurements at C3 with other sarcopenic parameters-including muscle strength and physical performance-may provide a more accurate risk profile for sarcopenia assessment and allow for a greater understanding of this condition in HNC.

Integrated bioinformatics, network pharmacology, and artificial intelligence to predict the mechanism of celastrol against muscle atrophy caused by colorectal cancer

Muscle atrophy due to colorectal cancer severely reduces the quality of life and survival time of patients. However, the underlying causative mechanisms and therapeutic agents are not well understood. The aim of this study was to screen and identify the microRNA (miRNA)–mRNA regulatory network and therapeutic targets of celastrol in colorectal cancer causing muscle atrophy via blood exosomes. Datasets were downloaded from the Gene Expression Omnibus online database. Differential expression analysis was first performed using the blood exosome dataset GSE39833 from colorectal cancer and normal humans to identify differentially expressed (DE) miRNAs, and then, transcriptional enrichment analysis was performed to identify important enriched genes. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed by FunRich software. Using the muscle atrophy sample GSE34111, the DE mRNAs in the muscle atrophy sample were analyzed, a regulatory network map was established based on miRNA‒mRNA regulatory mechanisms, further GO and KEGG enrichment analyses were performed for the DE genes in muscle atrophy via Cytoscape’s ClueGO plug-in, and the network pharmacology pharmacophore analysis method was used to analyze the celastrol therapeutic targets, taking intersections to find the therapeutic targets of celastrol, using the artificial intelligence AlphaFold2 to predict the protein structures of the key targets, and finally using molecular docking to verify whether celastrol and the target proteins can be successfully docked. A total of 82 DE miRNAs were obtained, and the top 10 enriched target genes were identified. The enrichment of the 82 miRNAs showed a close correlation with muscle atrophy, and 332 DE mRNAs were found by differential expression analysis in muscle atrophy samples, among which 44 mRNA genes were involved in miRNA‒mRNA networks. The DE genes in muscle atrophy were enriched for 30 signaling pathways, and 228 target genes were annotated after pharmacophore target analysis. The NR1D2 gene, the target of treatment, was found by taking intersections, the protein structure of this target was predicted by AlphaFold2, and the structure was successfully docked and validated using molecular docking. In our present study, colorectal cancer likely enters the muscle from blood exosomes and regulates skeletal muscle atrophy through miRNA‒mRNA regulatory network mechanisms, and celastrol treats muscle through NR1D2 in the miRNA‒mRNA regulatory network.

Sex-Specific Cut-Off Values for Low Skeletal Muscle Mass to Identify Patients at Risk for Treatment-Related Adverse Events in Head and Neck Cancer

A low skeletal muscle index (SMI), defined with cut-off values, is a promising predictor for adverse events (AEs) in head and neck squamous cell cancer (HNSCC) patients. The aim was to generate sex-specific SMI cut-off values based on AE to diagnose low SMI and to analyse the relationship between low SMI and AEs in HNSCC patients. In this present study, HNSCC patients were prospectively included in a large oncological data-biobank and SMI was retrospectively measured using baseline neck scans. In total, 193 patients were included and were stratified according to treatment modality: (chemo-)radiotherapy ((C)RT) (n = 135) and surgery (n = 61). AE endpoints were based on the occurrence of clinically relevant toxicities (Common Terminology Criteria for Adverse Events grade ≥ III) and postoperative complications (Clavien–Dindo Classification grade ≥ II). Sex-specific SMI cut-off values were generated with receiver operating characteristic curves, based on the AE endpoints. The relationship of the baseline characteristics and AEs was analysed with logistic regression analysis, with AEs as the endpoint. Multivariable logistic analysis showed that low SMI (OR 3.33, 95%CI 1.41–7.85) and tumour stage (OR 3.45, 95%CI 1.28–9.29) were significantly and independently associated to (C)RT toxicity. Low SMI was not related to postoperative complications. To conclude, sex-specific SMI cut-off values, were generated based on the occurrence of AEs. Low SMI and tumour stage were independently related to (C)RT toxicity in HNSCC patients.

Measurement of Sarcopenia in Head and Neck Cancer Patients and Its Association With Frailty

In head and neck cancer (HNC) there is a need for more personalized treatment based on risk assessment for treatment related adverse events (i.e. toxicities and complications), expected survival and quality of life. Sarcopenia, defined as a condition characterized by loss of skeletal muscle mass and function, can predict adverse outcomes in HNC patients. A review of the literature on the measurement of sarcopenia in head and neck cancer patients and its association with frailty was performed. Skeletal muscle mass (SMM) measurement only is often used to determine if sarcopenia is present or not. SMM is most often assessed by measuring skeletal muscle cross-sectional area on CT or MRI at the level of the third lumbar vertebra. As abdominal scans are not always available in HNC patients, measurement of SMM at the third cervical vertebra has been developed and is frequently used. Frailty is often defined as an age-related cumulative decline across multiple physiologic systems, with impaired homeostatic reserve and a reduced capacity of the organism to withstand stress, leading to increased risk of adverse health outcomes. There is no international standard measure of frailty and there are multiple measures of frailty. Both sarcopenia and frailty can predict adverse outcomes and can be used to identify vulnerable patients, select treatment options, adjust treatments, improve patient counselling, improve preoperative nutritional status and anticipate early on complications, length of hospital stay and discharge. Depending on the definitions used for sarcopenia and frailty, there is more or less overlap between both conditions. However, it has yet to be determined if sarcopenia and frailty can be used interchangeably or that they have additional value and should be used in combination to optimize individualized treatment in HNC patients.

Prognostic Role of Preoperative Sarcopenia Evaluation of Cervical Muscles with Long-Term Outcomes of Patients with Oral Squamous Cell Carcinoma

Accumulating evidence has shown that sarcopenia in patients with oral squamous cell carcinoma (OSCC) is at a risk of poor prognosis. There is no universal consensus on how to assess sarcopenia in patients with OSCC in daily practice. It is important to validate the usefulness of sarcopenia assessment from cervical muscles, which are frequently used in routine clinical practice in patients with OSCC. In this study, we investigated whether preoperative lumbar (L3) skeletal muscle mass and adiposity in OSCC patients were associated with cervical (C3) skeletal muscle mass and adiposity from CT measurements. We also investigated whether skeletal muscle mass and adiposity in the C3 muscles were associated with survival rates in patients with OSCC. We demonstrated that both the quality and quantity of muscle between the C3 and L3 levels were positively correlated with each other. We also demonstrated that the survival rates in patients with low sternocleidomastoid muscle mass index, high processus spinosus muscle-intramuscular adipose tissue content, and the combination of both were significantly lower than those in the controls. These results suggest that the assessment of sarcopenia from multiple neck muscles by preoperative CT measurements may be useful in predicting the prognosis of patients with OSCC.