Sarcopenia in aging, obesity, and cancer

Recent Update on the Prevalence of Sarcopenia in Koreans: Findings from the Korea National Health and Nutrition Examination Survey

BACKGROUND

As recognized by the World Health Organization in 2016 with its inclusion in the International Classification of Diseases, Tenth Revision as M62.84, and by South Korea in 2021 as M62.5, the diagnostic guidelines for sarcopenia vary globally. Despite its prevalence in older populations, data on sarcopenia in Koreans aged 60 and above is scarce, highlighting the need for research on its prevalence in this demographic.

METHODS

Utilizing the 2022 Korea National Health and Nutrition Examination Survey dataset, sarcopenia was assessed among 1,946 individuals aged 60 or older according to the Asian Working Group for Sarcopenia 2019 criteria, incorporating grip strength and bioelectrical impedance analysis measurements. Statistical analyses were performed to differentiate categorical and continuous variables using logistic regression and Student's t-tests, respectively.

RESULTS

The prevalence of sarcopenia was found to increase with age, with the highest prevalence observed in the oldest age group (80 years and older). The overall prevalence of sarcopenia in our study population was 6.8%. Among men, the prevalence of sarcopenia was 5.5% in the 60 or older age group, 9.6% in the 70 or older age group, and 21.5% in the 80 or older age group. Among women, the prevalence of sarcopenia was 7.9%, 10.5%, and 25.9%, respectively.

CONCLUSIONS

This study highlights the significant burden of sarcopenia in elderly Koreans, particularly among the oldest individuals. These findings call for targeted interventions to manage and prevent sarcopenia, along with further research on its risk factors, consequences, and effective mitigation strategies.

Transcriptome-based deep learning analysis identifies drug candidates targeting protein synthesis and autophagy for the treatment of muscle wasting disorder

Sarcopenia, the progressive decline in skeletal muscle mass and function, is observed in various conditions, including cancer and aging. The complex molecular biology of sarcopenia has posed challenges for the development of FDA-approved medications, which have mainly focused on dietary supplementation. Targeting a single gene may not be sufficient to address the broad range of processes involved in muscle loss. This study analyzed the gene expression signatures associated with cancer formation and 5-FU chemotherapy-induced muscle wasting. Our findings suggest that dimenhydrinate, a combination of 8-chlorotheophylline and diphenhydramine, is a potential therapeutic for sarcopenia. In vitro experiments demonstrated that dimenhydrinate promotes muscle progenitor cell proliferation through the phosphorylation of Nrf2 by 8-chlorotheophylline and promotes myotube formation through diphenhydramine-induced autophagy. Furthermore, in various in vivo sarcopenia models, dimenhydrinate induced rapid muscle tissue regeneration. It improved muscle regeneration in animals with Duchenne muscular dystrophy (DMD) and facilitated muscle and fat recovery in animals with chemotherapy-induced sarcopenia. As an FDA-approved drug, dimenhydrinate could be applied for sarcopenia treatment after a relatively short development period, providing hope for individuals suffering from this debilitating condition.

The Role of Exercise in Cancer-Related Sarcopenia and Sarcopenic Obesity

One of the most common adverse effects of cancer and its therapeutic strategies is sarcopenia, a condition which is characterised by excess muscle wasting and muscle strength loss due to the disrupted muscle homeostasis. Moreover, cancer-related sarcopenia may be combined with the increased deposition of fat mass, a syndrome called cancer-associated sarcopenic obesity. Both clinical conditions have significant clinical importance and can predict disease progression and survival. A growing body of evidence supports the claim that physical exercise is a safe and effective complementary therapy for oncology patients which can limit the cancer- and its treatment-related muscle catabolism and promote the maintenance of muscle mass. Moreover, even after the onset of sarcopenia, exercise interventions can counterbalance the muscle mass loss and improve the clinical appearance and quality of life of cancer patients. The aim of this narrative review was to describe the various pathophysiological mechanisms, such as protein synthesis, mitochondrial function, inflammatory response, and the hypothalamic-pituitary-adrenal axis, which are regulated by exercise and contribute to the management of sarcopenia and sarcopenic obesity. Moreover, myokines, factors produced by and released from exercising muscles, are being discussed as they appear to play an important role in mediating the beneficial effects of exercise against sarcopenia.

The relationship between sarcopenia and serum irisin and TNF-α levels in newly diagnosed cancer patients

OBJECTIVE

Sarcopenia in patients with cancer makes patients physically weak and adversely affects their compliance with treatment. In this study, we investigated the relationship between sarcopenia in patients with cancer and circulating irisin and tumor necrosis factor-alpha (TNF-α) levels.

MATERIAL AND METHOD

A total of 141 patients with different types of newly diagnosed cancer were divided into two groups, sarcopenia (n = 72) and non-sarcopenia (n = 69) groups. The body compositions of the patients were measured using bioelectrical impedance (BIA) and muscle strength using hand grip strength (HGS) tests. Serum irisin and TNF-α levels were measured using an enzyme-linked immunosorbent assay.

RESULTS

In our study, serum irisin levels were found to be significantly lower (p < 0.01) and TNF-α levels were found to be significantly higher (p = 0.014) in the sarcopenia group. Skeletal muscle index (SMI) and HGS values and serum irisin levels were positively correlated [(r: 0.451, p < 0.001), (r: 0.469, p < 0.001)], and SMI and HGS values and serum TNF-α levels were negatively correlated [(r: -0.181, p = 0.032) and (r: -0.143, p = 0.090), respectively]. In addition, multiple linear regression analysis showed that serum irisin and TNF-α levels were independent predictors of sarcopenia.

CONCLUSION

Serum irisin levels were found to be significantly lower in patients with cancer with sarcopenia, and TNF-α levels were found to be significantly higher. These two markers can be used as potential biomarkers for the diagnosis of sarcopenia in patients with cancer. The efficacy and possible mechanisms of action of irisin and TNF-α in the diagnosis of sarcopenia should be investigated with larger patient groups.

Normative reference values, determinants and regression equations for the incremental shuttle walk test (ISWT) in healthy Asian population aged 21 to 80 years

BACKGROUND

The validated Incremental Shuttle Walk Test (ISWT) is widely used for evaluating maximal exercise capacity, with the distance-walked (IWSD) as the primary outcome. However, there are no normative reference values (NRV) and reference equations to predict ISWD for the Singaporean population.

OBJECTIVES

This study aims to establish the NRV and reference equations for ISWD in healthy Singaporeans aged 21 to 80 and investigate the determining variables during ISWT.

METHODS

This cross-sectional study recruited community-dwelling healthy subjects aged 21-80 from the community via convenience sampling. Each subject completed two trials of the ISWT according to the standard protocol. Variables measured during the trials included ISWD, pre-and post-test heart rate (HR), oxygen saturation, blood pressure (BP), modified Borg's dyspnoea score and Borg's rate of perceived exertion (RPE).

RESULTS

199 healthy Singaporean (females = 114, males = 85) participated in the study. The overall median ISWD was 660.0 metres (m) [interquartile range (IQR):440.0-850.0]. The age-stratified mean ISWD ranged from 430.0 m (IQR:350.0-450.0) (aged 60-80) to 480.0 m (IQR:438.0-650.0) (aged 40-59) to 780.0 m (IQR:670.0-960.0) (aged 21-39). Gender, age, weight, height and HR change (highest post-test HR minus pre-test HR) were the most significant variables (p < 0.001). IWSD (m) = 651.4(Height, m) +89.7(Gender, male = 1; female = 0) -6.31(Age, years) -3.61(Weight, kilograms) +2.54(HR change, beats per minute); R2 = 0.741. Previously published ISWT reference equations cannot accurately predict the ISWD in the Singaporean population.

CONCLUSIONS

This study investigated the ISWD NRV and established reference equations for healthy Singaporeans aged 21-80. The information would be beneficial in setting performance benchmarks to guide physical assessment, intervention and rehabilitation.

The Pathways to Prevention program: nutrition as prevention for improved cancer outcomes

Adequate nutrition is central to well-being and health and can enhance recovery during illness. Although it is well known that malnutrition, both undernutrition and overnutrition, poses an added challenge for patients with cancer diagnoses, it remains unclear when and how to intervene and if such nutritional interventions improve clinical outcomes. In July 2022, the National Institutes of Health convened a workshop to examine key questions, identify related knowledge gaps, and provide recommendations to advance understanding about the effects of nutritional interventions. Evidence presented at the workshop found substantial heterogeneity among published randomized clinical trials, with a majority rated as low quality and yielding mostly inconsistent results. Other research cited trials in limited populations that showed potential for nutritional interventions to reduce the adverse effects associated with malnutrition in people with cancer. After review of the relevant literature and expert presentations, an independent expert panel recommends baseline screening for malnutrition risk using a validated instrument following cancer diagnosis and repeated screening during and after treatment to monitor nutritional well-being. Those at risk of malnutrition should be referred to registered dietitians for more in-depth nutritional assessment and intervention. The panel emphasizes the need for further rigorous, well-defined nutritional intervention studies to evaluate the effects on symptoms and cancer-specific outcomes as well as effects of intentional weight loss before or during treatment in people with overweight or obesity. Finally, although data on intervention effectiveness are needed first, robust data collection during trials is recommended to assess cost-effectiveness and inform coverage and implementation decisions.

Respiratory Movements at Different Ages

Background and Objectives: The current study aimed to better understand the changes in respiration that occur with aging in men and women to provide accurate recommendations for breathing exercises to improve health. Materials and Methods: A total of 610 healthy subjects, aged 20 to 59, participated in the study. They performed quiet breathing while wearing two respiration belts (Vernier, Beaverton, OR, USA) at the height of the navel and at the xiphoid process to record abdominal motion (AM) and thoracic motion (TM), respectively. Vital capacity, representing maximal inhalation movement, was measured using a spirometer (Xindonghuateng, Beijing, China). After exclusion, 565 subjects (164 men, aged 41 ± 11; 401 women, aged 42 ± 9) were included for statistical analysis using the Kruskal-Wallis U test and stepwise multiple linear regression. Results: Abdominal motion and its contribution to spontaneous breathing were significantly larger for older men, while the contribution of thoracic motion was smaller for older men. There was no significant difference in thoracic motion between the younger and older men. The differences in women's respiratory movements among various ages were mild and negligible. The contribution of thoracic motion to spontaneous breathing in women was larger than in men for those of older ages (40-59 years), but not for those of younger ages (20-39 years). Additionally, men's and women's vital capacities were less in those of older ages, and the men's were larger than the women's. Conclusions: The findings indicate that men's abdominal contribution to spontaneous breathing increased from 20 to 59 years of age due to increased abdominal motion. Women's respiratory movements did not change much with aging. The maximal inhalation movement became smaller with aging for men and women. Healthcare professionals should focus on improving thoracic mobility when addressing health concerns about aging.

Surrogates of Muscle Mass on Cardiac MRI Correlate with Exercise Capacity in Patients with Fontan Circulation

BACKGROUND

Sarcopenia is an increasingly recognized marker of frailty in cardiac patients. Patients with a history of congenital heart disease and Fontan procedure have a higher risk of developing progressive muscle wasting. Our objective was to determine if we could use routine cardiac MRI (CMR) for the surveillance of muscle wasting.

METHODS

A retrospective study of all Fontan patients (n = 75) was conducted at our institution, with CMR performed from 2010 to 2022 and exercise stress testing performed within 12 months (4.3 ± 4.2 months). The skeletal muscle area (SMA) for the posterior paraspinal and anterior thoracic muscles were traced and indexed for body surface area (BSA). Patients were stratified by percentile into the upper and lower quartiles, and the two groups were compared. Multivariable regression was performed to control for sex and age.

RESULTS

There was a significant positive association of both anterior (r = 0.34, p = 0.039) and paraspinal (r = 0.43, p = 0.007) SMA to peak VO2. Similarly, paraspinal but not anterior SMA was negatively associated with the VE/VCO2 (r = -0.45, p = 0.006). The upper quartile group had significantly more males (18/19 vs. 8/20; p = 0.0003) and demonstrated a significantly higher peak VO2 (32.2 ± 8.5 vs. 23.8 ± 4.7, p = 0.009), a higher peak RER (1.2 ± 0.1 vs. 1.1 ± 0.04, p = 0.007), and a significantly lower VE/VCO2 (32.9 ± 3.6 vs. 40.2 ± 6.2, p = 0.006) compared to the lowest quartile. The association of SMA to VO2 peak and VE/VCO2 was redemonstrated after controlling for sex and age.

CONCLUSION

Thoracic skeletal muscle area may be an effective surrogate of muscle mass and is correlated to several measures of cardiorespiratory fitness post-Fontan. CMR would be an effective tool for the surveillance of sarcopenia in post-Fontan patients given its accessibility and routine use in these 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 evaluation of the association between preoperative sarcopenia and postoperative pneumonia and factors for preoperative sarcopenia in patients undergoing thoracoscopic-laparoscopic esophagectomy for esophageal cancer

PURPOSE

This study identified the relationship between postoperative pneumonia and preoperative sarcopenia as well as the factors for preoperative sarcopenia in patients with esophageal cancer.

METHODS

In this retrospective, single-center, observational study, we evaluated the data of 274 patients who were scheduled for thoracoscopic-laparoscopic esophagectomy. Sarcopenia was defined using the skeletal muscle index, handgrip strength, and gait speed. The physical activity and nutritional status were evaluated. A multivariate logistic regression analysis was performed to confirm the association between sarcopenia and postoperative pneumonia and identify sarcopenia-related factors. A Spearman's correlation analysis was used to identify the relationship between physical activity and nutritional status.

RESULTS

Age, male sex, sarcopenia, and postoperative recurrent laryngeal nerve palsy were significantly associated with postoperative pneumonia. Age, male sex, physical activity, and nutritional status were significantly associated with preoperative sarcopenia. There was a significant correlation between physical activity and nutritional status.

CONCLUSIONS

Preoperative sarcopenia was confirmed to be a predictor of postoperative pneumonia. Furthermore, age, sex, physical activity, and nutritional status were significantly associated with preoperative sarcopenia. Physical activity and nutritional status are closely associated with each other in patients with esophageal cancer. A multidisciplinary approach to preoperative sarcopenia, taking exercise and nutrition into account, is recommended.

Disruption of mitochondrial dynamics triggers muscle inflammation through interorganellar contacts and mitochondrial DNA mislocation

Some forms of mitochondrial dysfunction induce sterile inflammation through mitochondrial DNA recognition by intracellular DNA sensors. However, the involvement of mitochondrial dynamics in mitigating such processes and their impact on muscle fitness remain unaddressed. Here we report that opposite mitochondrial morphologies induce distinct inflammatory signatures, caused by differential activation of DNA sensors TLR9 or cGAS. In the context of mitochondrial fragmentation, we demonstrate that mitochondria-endosome contacts mediated by the endosomal protein Rab5C are required in TLR9 activation in cells. Skeletal muscle mitochondrial fragmentation promotes TLR9-dependent inflammation, muscle atrophy, reduced physical performance and enhanced IL6 response to exercise, which improved upon chronic anti-inflammatory treatment. Taken together, our data demonstrate that mitochondrial dynamics is key in preventing sterile inflammatory responses, which precede the development of muscle atrophy and impaired physical performance. Thus, we propose the targeting of mitochondrial dynamics as an approach to treating disorders characterized by chronic inflammation and mitochondrial dysfunction.

The impact of sarcopenia on the postoperative outcome in colorectal cancer surgery

Background and aim

Malnutrition-induced sarcopenia predicts poorer clinical outcomes for patients with cancer. Postoperative complications such as wound infection, anastomotic leak (AL), cardiorespiratory events are the most frequent and devastating postoperative complications in colorectal cancer surgery and are frequently associated with malnutrition.

Methods

We reviewed the recent available literature to assess the relationship between the patient nutritional status and sarcopenia in colorectal surgery. The PubMed database was searched for publications. The included studies were original articles, prospective and randomized trials, clinical, systematic reviews and meta-analyses. The information was structured in a narrative review form.

Results

A simple method to assess malnutrition is to define the presence of sarcopenia (skeletal muscle mass reduction and modified composition) by radiological image analysis. Quantifying the material composition and quality is a novel method in patient-specific therapy. This could be a new perspective in colorectal surgery to reduce postoperative mortality, improve surgical planning, and enhance clinical outcomes. A few recent studies have objectively investigated the presence of sarcopenia in colorectal cancer and its impact on morbidity and mortality, but sometimes the results are contradictory.

Conclusion

There is evolving research to find the most appropriate management method, surgeons must be aware of the existence of sarcopenia to identify this risk factor in the occurrence of postoperative complications in colorectal cancer surgery.

Role of 18F-FDG PET/CT and sarcopenia in untreated non-small cell lung cancer with advanced stage

BACKGROUND

Sarcopenia is essential in managing advanced stage (III-IV) non-small cell lung cancer (NSCLC) but is laborious to diagnose using currently available method. This study aimed to establish a simple approach to predict sarcopenia using ¹⁸F-FDG PET/CT parameters and clinical characteristics and determine their roles in prognostication in advanced stage NSCLC.

METHODS

Untreated 202 NSCLC patients with stage III-IV were retrospectively reviewed. Sarcopenia was defined using the skeletal muscle index (SMI) measured at the third lumbar vertebra (L3). ¹⁸F-FDG PET/CT metabolic parameters of maximum standard uptake value, metabolic tumor volume, and total lesion glycolysis of the primary tumor (SUVmax_T, MTV_T, and TLG_T) and of whole-body lesions (MTV_WB and TLG_WB) were measured. Besides, SUVmax of the psoas major muscle (SUVmax_Muscle) was measured at the L3 level. The diagnostic endpoint was the probability of sarcopenia, and the survival endpoints included progression-free survival (PFS) and overall survival (OS).

RESULTS

Among the enrolled 202 patients, 82 (40.6%) were diagnosed with sarcopenia. Higher age, male, lower BMI, and lower SUVmax_Muscle were correlated with a higher incidence of sarcopenia (P < 0.05), while age, sex, BMI, and SUVmax_Muscle were independently predictive of sarcopenia, and thus were utilized to construct a nomogram model. Multivariate Cox regression analysis revealed that sarcopenia score derived from the nomogram model, sarcopenia, stage, and TLG_WB were independently predictive of both PFS and OS.

CONCLUSION

The incidence of sarcopenia increased with declining SUVmax_Muscle in advanced stage NSCLC. Our model using age, sex, BMI, and SUVmax_Muscle might be substituted for the complicated measurement of SMI. After adjustment by stage and TLG_WB, both sarcopenia score and sarcopenia were found to be independently predictive of PFS and OS.

Normative reference values and regression equations to predict the 6-minute walk distance in the Asian adult population aged 21-80 years

SUMMARY AT A GLANCE

The 6-min walk test (6MWT) is a widely used field walking test. This study reports the normative reference values (NRV) of distance walked during 6MWT (6MWD) in healthy Singaporeans (aged 21-80) and updates the 6MWD reference equations. This information may facilitate the interpretation of the 6MWD in clinical populations.

ETHICS APPROVAL

The Singapore Institute of Technology-Institutional Review Board (SIT-IRB Project Number: 2019099) approved this study to be carried out from June 2019 to January 2021. All participants gave written informed consent before data collection began.

BACKGROUND

The six-minute walk test (6MWT) is a widely adopted submaximal field-walking test to evaluate functional exercise capacity. This validated test is a reliable, safe, inexpensive, and straightforward assessment tool commonly used as an outcome measure, using the distance walked (6MWD) as the primary outcome. An earlier study has established the normative reference values (NRV) and equation in healthy Singaporeans - however, the small sample size and narrow age range curb adequate representation of the adult population profile.

OBJECTIVES

This study aims to update the NRV and reference equations to predict the distance walked during 6MWT (6MWD) for healthy Singaporeans aged 21-80.

METHODS

This cross-sectional study recruited community-dwelling healthy subjects aged 21-80 via convenience sampling. Each subject completed two trials of 6MWT according to the standard protocol. Primary outcome measures included 6MWD, pre-and post-test heart rate (HR), oxygen saturation, and blood pressure (BP).

RESULTS

172 healthy Singaporeans (females = 90 , males = 82 ) participated. The overall mean 6MWD was 578 . 00 ± 75 . 38 metres. The age-stratified mean 6MWD ranged from 601 . 3 ± 71 . 79 metres (aged 21-39) to 519 . 02 ± 55 . 42 metres (aged 60-80). Age, gender, and percentage maximum HR predicted (%PredHRmax) were the most significant variables (p < 0 . 001 ). 6MWD reference equation = 288 . 282 ( height , m )+ 27 . 463 × Gender ( male = 1 ; female = 0 )+ 4 . 349 ( % predHRmax )+ 1 . 191 (HR reserve, bpm) - 185 . 431 - 1 . 343 ( age , years )- 1 . 614 (weight, kg), R 2 = 58 % . Applying equations from other studies to the Singaporean population resulted in an overestimation of the 6MWD.

CONCLUSION

This study updated the NRV and reference equations of 6MWD for healthy Singaporeans aged between 21-80 years. This update revises the local benchmarks of 6MWD in Singapore, a widely adopted outcome measure.

Review of Sarcopenia and Testosterone Deficiency With Chronic Liver Disease and Postoperative Liver Transplant Utility of Short-Term Testosterone Replacement Therapy

OBJECTIVES

Chronic liver disease is often associated with testosterone deficiency. However, testosterone replacement does not improve hepatic function or survival with diseased liver. So far, to our knowledge, testosterone replacement therapy after successful livertransplantforfunctional sarcopenia has not been studied. We had 3 goals: (1) define postoperative functional sarcopenia afterlivertransplant with serum testosterone level; (2) examine the role of short-term testosterone replacement therapy with active in-bed exercise of upper and lower extremity joints; and (3) correlate functional sarcopenia with skeletal muscle index and skeletal muscle density in relation to ascites, pleural effusion subtracted body mass index.

MATERIALS AND METHODS

We evaluated 16 liver transplant recipients who had been receiving posttransplanttestosterone replacementtherapy with functional sarcopenia. Preoperative and postoperative demographics and laboratory and radiological data were retrieved; body mass index, skeletal muscle index, and skeletal muscle density were calculated. For this retrospective study, institutional review board approval was obtained before the electronic database was reviewed and analyzed.

RESULTS

Mean testosterone level was 28.3 ng/dL (<5% of expected). Twelve patients received 1 dose, and the remaining 4 patients received >1 dose oftestosterone cypionate, 200 mg. Mean hospital stay was 26 days. Seven patients were discharged home, with the remaining patients to a rehabilitation facility or nursing home. One patient died from a cardiac event, and another patient died from recurrent metastatic malignancy. The 1-year and 5-year actuarial patient and graft survival rates were 93.8% and 87.5%, respectively. Overall, 5 patients were sarcopenic by skeletal muscle index, and 6 patients had poor muscle quality by skeletal muscle density.

CONCLUSIONS

Testosterone deficiency after liver transplant exists with functional sarcopenia. Two- thirds of such recipients have low skeletal muscle index and/or have low skeletal muscle density. Short- term testosterone replacement therapy with in-bed active exercise provides 5-year patient and graft survival of 87.5%.

Multi-Contrast MRI Segmentation Trained on Synthetic Images

In our comprehensive experiments and evaluations, we show that it is possible to generate multiple contrast (even all synthetically) and use synthetically generated images to train an image segmentation engine. We showed promising segmentation results tested on real multi-contrast MRI scans when delineating muscle, fat, bone and bone marrow, all trained on synthetic images. Based on synthetic image training, our segmentation results were as high as 93.91%, 94.11%, 91.63%, 95.33%, for muscle, fat, bone, and bone marrow delineation, respectively. Results were not significantly different from the ones obtained when real images were used for segmentation training: 94.68%, 94.67%, 95.91%, and 96.82%, respectively. Clinical relevance- Synthetically generated images could potentially be used in large-scale training of deep networks for segmentation purpose. Small data set problem of many clinical imaging problems can potentially be addressed with the proposed algorithm.

Cancer, Phase Angle and Sarcopenia: The Role of Diet in Connection with Lung Cancer Prognosis

Lung cancer is the most common cause of cancer death and is associated with malnutrition and sarcopenia. The detection of sarcopenia and conduction of simple body composition measurements, such as the phase angle (PhA) deriving from bioelectrical impedance analysis (BIA), can help to early identify, monitor, prevent and treat malnutrition. The present review aims to clarify the relationship between PhA and sarcopenia with the pathophysiology, clinical outcomes, and therapeutic aspects of lung cancer. PhA and sarcopenia are connected to lung cancer prognosis through various mechanisms including inflammation and oxidative stress, although more research is needed to identify the critical thresholds for increased mortality risk. Moreover, emphasis is given on the role of dietary interventions (oral nutritional supplementation, and dietary counseling) to manage sarcopenia and related variables in patients with lung cancer. Oral nutritional supplements and/or those containing n - 3 polyunsaturated fatty acids may have a positive effect on physical strength measures and muscle mass if administered at the beginning of chemotherapy. Data on sole dietary counseling or multimodal interventions are less promising so far. In the future, sophisticated body composition phenotypes deriving from the described methods along with artificial intelligence techniques could be used to design personalized nutrition interventions and timely treat these patients.

Endothelin-1-mediated miR-let-7g-5p triggers interlukin-6 and TNF-α to cause myopathy and chronic adipose inflammation in elderly patients with diabetes mellitus

Background: Diabetes and sarcopenia are verified as mutual relationships, which seriously affect the quality of life of the elderly. Endothelin-1 is well investigated, is elevated in patients with diabetes, and is related to muscle cellular senescence and fibrosis. However, the mechanism of ET-1 between diabetes and myopathy is still unclear. The aim of this study was to evaluate the prevalence of sarcopenia in the elderly with diabetes and to clarify its relationship with ET-1 molecular biological mechanism, progress as well as changes in muscle and fat.

Methods: We recruited 157 type 2 diabetes patients over 55 years old and investigated the prevalence of sarcopenia in diabetes patients and examined the association of ET-1 alterations with HbA1c, creatinine, or AMS/ht2. Next, sought to determine how ET-1 regulates inflammation in muscle cells by western blot and qPCR assay. Using XF Seahorse Technology, we directly quantified mitochondrial bioenergetics in 3T3-L1 cells.

Results: ET-1 was positively correlated with HbA1c, creatinine levels, and duration of disease, and negatively correlated with AMS/ht2. We found that ET-1 dose-dependently induces tumor necrosis factor-α (TNF-α) and interleukin (IL)-6β expression through the PI3K/AKT, and NF-κB signaling pathways in C2C12 cells. Also identified that TNF-α, IL-6β, and visfatin releases were found in co-cultured with conditioned medium of ET-1/C2C12 in 3T3-L1 cells. ET-1 also reduces the energy metabolism of fat and induces micro-environment inflammation which causes myopathy. ET-1 also suppresses miR-let-7g-5p expression in myocytes and adipocytes.

Conclusion: We describe a new mechanism of ET-1 triggering chronic inflammation in patients with hyperglycemia.

Insulin and cancer: a tangled web

For a century, since the pioneering work of Otto Warburg, the interwoven relationship between metabolism and cancer has been appreciated. More recently, with obesity rates rising in the U.S. and worldwide, epidemiologic evidence has supported a link between obesity and cancer. A substantial body of work seeks to mechanistically unpack the association between obesity, altered metabolism, and cancer. Without question, these relationships are multifactorial and cannot be distilled to a single obesity- and metabolism-altering hormone, substrate, or factor. However, it is important to understand the hormone-specific associations between metabolism and cancer. Here, we review the links between obesity, metabolic dysregulation, insulin, and cancer, with an emphasis on current investigational metabolic adjuncts to standard-of-care cancer treatment.

Nutritional status of patients with lymphoproliferative neoplasms before and after the first-line treatment

BACKGROUND

Nutritional disorders in cancer patients, including lymphoproliferative neoplasms, occur with varying frequency.

OBJECTIVES

The primary aim of the study was to analyze the changes in the nutritional status of patients with lymphoproliferative neoplasms following first-line chemotherapy.

MATERIALS AND METHODS

46 patients, with a median age of 62 years, participated in a prospective single-center study. Their demographic, biochemical and clinical features were analyzed. The study consisted of several stages that were conducted at two time points. P values < 0.05 were considered statistically significant.

RESULTS

The study included patients with multiple myeloma (48%), non-Hodgkin's lymphoma (28%) or chronic lymphocytic leukemia (24%). After the end of the first-line chemotherapy, a decrease in the concentration of albumin (p = 0.04), transferrin (p = 0.38) and total cholesterol (p = 0.76) were found. Statistically greater unintended weight loss occurred before treatment initiation (p < 0.001). Moreover, a significant decrease in the mean values ​​of the phase angle (p < 0.01) was noted.

CONCLUSIONS

Most patients before the oncological therapy did not show clinical or biochemical symptoms of malnutrition. However, after the treatment was completed, the parameters of the nutritional status showed its deterioration.

Muscle Mass and Inflammation in Older Adults: Impact of the Metabolic Syndrome

Background

Inflammatory processes are a cause of accelerated loss of muscle mass. Metabolic syndrome (MetS) is a highly prevalent age-related condition, which may promote and be promoted by inflammation. However, whether inflammation in MetS (metaflammation) is associated with lower muscle mass is still unclear.

Methods

Complete cross-sectional data on body composition, MetS, and the inflammatory markers interleukin (IL)-1β, IL-6, IL-10, tumor necrosis factor (TNF), and C-reactive protein (CRP) were available for 1,377 BASE-II participants (51.1% women; 68 ± 4 years old). Appendicular lean mass (ALM) was assessed by dual-energy X-ray absorptiometry. Low muscle mass (low ALM-to-BMI ratio [ALMBMI]) was defined according to the Foundation for the National Institutes of Health (FNIH) Sarcopenia Project. Regression models, adjusted for an increasing number of confounders (sex, age, physical activity, morbidities, diabetes mellitus type II, TSH, albumin, HbA1c, smoking habits, alcohol intake, education, and energy intake/day), were used to calculate the association between low ALMBMI and high inflammation (tertile 3) according to MetS.

Results

MetS was present in 36.2% of the study population, and 9% had low ALMBMI. In the whole study population, high CRP (odds ratio [OR]: 2.7 [95% CI: 1.6–4.7; p = 0.001]) and high IL-6 (OR: 2.1 [95% CI: 1.2–1.9; p = 0.005]) were associated with low ALMBMI. In contrast, no significant association was found between TNF, IL-10, or IL-1β with low ALMBMI. When participants were stratified by MetS, results for IL-6 remained significant only in participants with MetS.

Conclusions

Among BASE-II participants, low ALMBMI was associated with inflammation. Low-grade inflammation triggered by disease state, especially in the context of MetS, might favor loss of muscle mass, so a better control of MetS might help to prevent sarcopenia. Intervention studies to test whether strategies to prevent MetS might also prevent loss of muscle mass seem to be promising.

Aberrant mitochondrial homeostasis at the crossroad of musculoskeletal ageing and non-small cell lung cancer

Cancer cachexia is accompanied by muscle atrophy, sharing multiple common catabolic pathways with sarcopenia, including mitochondrial dysfunction. This study investigated gene expression from skeletal muscle tissues of older healthy adults, who are at risk of age-related sarcopenia, to identify potential gene biomarkers whose dysregulated expression and protein interference were involved in non-small cell lung cancer (NSCLC). Screening of the literature resulted in 14 microarray datasets (GSE25941, GSE28392, GSE28422, GSE47881, GSE47969, GSE59880 in musculoskeletal ageing; GSE118370, GSE33532, GSE19804, GSE18842, GSE27262, GSE19188, GSE31210, GSE40791 in NSCLC). Differentially expressed genes (DEGs) were used to construct protein-protein interaction networks and retrieve clustering gene modules. Overlapping module DEGs were ranked based on 11 topological algorithms and were correlated with prognosis, tissue expression, and tumour purity in NSCLC. The analysis revealed that the dysregulated expression of the mammalian mitochondrial ribosomal proteins, Mitochondrial Ribosomal Protein S26 (MRPS26), Mitochondrial Ribosomal Protein S17 (MRPS17), Mitochondrial Ribosomal Protein L18 (MRPL18) and Mitochondrial Ribosomal Protein L51 (MRPL51) were linked to reduced survival and tumour purity in NSCLC while tissue expression of the same genes followed an opposite direction in healthy older adults. These results support a potential link between the mitochondrial ribosomal microenvironment in ageing muscle and NSCLC. Further studies comparing changes in sarcopenia and NSCLC associated cachexia are warranted.

Sarcopenia and Ghrelin System in the Clinical Outcome and Prognosis of Gastroenteropancreatic Neuroendocrine Neoplasms

Simple Summary

Malnutrition and sarcopenia affect clinical outcomes in cancer patients. Nutritional evaluation in patients with neuroendocrine neoplasms (NENs) is not routinely performed. Currently, the evaluation of sarcopenia using CT scans is the gold standard in cancer patients, additionally, anthropometric, biochemical and molecular analysis of patients with gastroenteropancreatic NENs at diagnosis was perfomed. The expression levels of key ghrelin system components were assessed in 63 tumor samples. Results: Nutritional parameters were similar in GEP-NEN tumors of different origin. Relapsed disease was associated with decreased BMI. Patients who presented with weight loss at diagnosis had significantly lower overall survival (108 (25–302) vs. 263 (79–136) months). Ghrelin O-acyltransferase (GOAT) enzyme expression was higher in these patients. The prevalence of sarcopenia using CT images reached 87.2%. Mortality was observed only in patients with sarcopenia. Muscle evaluation was correlated with biochemical parameters but not with the expression of ghrelin system components. Conclusion: Survival is related to the nutritional status of patients with GEP-NENs and also to the molecular expression of some relevant ghrelin system components. Routine nutritional evaluation should be performed in these patients, in order to prescribe appropriate nutritional support, when necessary, for increasing quality of life and improving clinical outcomes.

Abstract

Background: Malnutrition and sarcopenia affect clinical outcomes and treatment response in cancer patients. Patients with neuroendocrine neoplasms (NENs) may present with additional symptoms related to tumor localization in the gastrointestinal tract and hormone secretion, increasing the risk and effects of sarcopenia. Aim: To explore the presence of malnutrition and sarcopenia in gastroenteropancreatic (GEP)-NEN patients, their relation to tumor characteristics, patient outcomes, survival and the molecular expression of ghrelin system components in the tumor. Patients and methods: One-hundred-and-four patients were included. Anthropometric, biochemical and CT-scans at diagnosis were evaluated. The expression levels of key ghrelin system components were assessed in 63 tumor samples. Results: Nutritional parameters were similar in GEP-NEN tumors of different origin. Relapsed disease was associated with decreased BMI. Patients who presented with weight loss at diagnosis had significantly lower overall survival (108 (25–302) vs. 263 (79–136) months). Ghrelin O-acyltransferase (GOAT) enzyme expression was higher in these patients. The prevalence of sarcopenia using CT images reached 87.2%. Mortality was observed only in patients with sarcopenia. Muscle evaluation was correlated with biochemical parameters but not with the expression of ghrelin system components. Conclusion: Survival is related to the nutritional status of patients with GEP-NENs and also to the molecular expression of some relevant ghrelin system components. Routine nutritional evaluation should be performed in these patients, in order to prescribe appropriate nutritional support, when necessary, for increasing quality of life and improving clinical outcomes.

CT-defined low-skeletal muscle mass as a prognostic marker for survival in prostate cancer: A systematic review and meta-analysis

BACKGROUND

Low-skeletal muscle mass (LSMM) is defined as progressive skeletal muscle loss, which can be assessed by imaging modalities. It was shown that this parameter is predictive and prognostic of several clinically relevant factors in several tumor entities. Our aim was to establish the effect of LSMM on overall survival (OS) in prostate cancer patients based on a large patient sample.

METHODS

MEDLINE library, EMBASE and SCOPUS databases were screened for the associations between LSMM and mortality in prostate cancer patients up to April 2021. The primary endpoint of the systematic review was the hazard ratio of LSMM on OS. In total, five studies were suitable for the analysis and included into the present study.

RESULTS

The included studies comprised over all 1221 patients. The identified frequency of LSMM was 61.02%. The pooled hazard ratio for the effect of LSMM on OS was 1.4 [95% CI 0.7-2.5] in univariate analysis and was 1.6 [95% CI 1.2-2.1] in multivariate analysis.

CONCLUSION

CT-defined LSMM has a frequency of 61% in patients with PC and shows a positive association with the overall survival with a hazard ratio of 1.4. LSMM assessment should therefore be included into clinical routine as a relevant prognostic biomarker.

Gut microbiota and motoric-cognitive frailty in hospitalized older persons

PURPOSE OF REVIEW

In older people, many systems spontaneously change without diseases. Because of the ageing process, the gut microbiota undergoes a reduced species richness, altered balance between species, with an increased interindividual variability. The result is the reduced resilience in the presence of diseases and medications. These changes are more evident in older persons with neurodegenerative diseases and cognitive-motoric frailty.

RECENT FINDINGS

A relationship between liver alteration, gut microbiota and the presence of viruses and gram-bacteria is conceivable. They determine the acceleration of neurodegenerative diseases with cognitive and motoric frailty. Hospitalization represents one of the stressors for the gut microbiota, producing dysbiosis and increasing the representation of pathobionts. The gut microbiota alterations during hospitalization may be associated with negative clinical outcomes. This phenomenon together with liver dysfunction could produce an acceleration of the trajectory of cognitive-motoric frailty towards disability and mortality. The observation that predisability is associated of both losses of cognition and motoric performance, has allowed introducing a new syndrome, the motoric-cognitive risk syndrome, which is a condition of increased risk of dementia and mobility-disability.

SUMMARY

The interaction between liver and gut microbiota may accelerate the neurodegenerative diseases and represents a promising marker of prognostic trajectories in older patients.

The Role of Sarcopenic Obesity in Cancer and Cardiovascular Disease: A Synthesis of the Evidence on Pathophysiological Aspects and Clinical Implications

Obesity is globally a serious public health concern and is associated with a high risk of cardiovascular disease (CVD) and various types of cancers. It is important to evaluate various types of obesity, such as visceral and sarcopenic obesity. The evidence on the associated risk of CVD, cancer and sarcopenic obesity, including pathophysiological aspects, occurrence, clinical implications and survival, needs further investigation. Sarcopenic obesity is a relatively new term. It is a clinical condition that primarily affects older adults. There are several endocrine-hormonal, metabolic and lifestyle aspects involved in the occurrence of sarcopenic obesity that affect pathophysiological aspects that, in turn, contribute to CVD and neoplasms. However, there is no available evidence on the role of sarcopenic obesity in the occurrence of CVD and cancer and its pathophysiological interplay. Therefore, this review aims to describe the pathophysiological aspects and the clinical and epidemiological evidence on the role of sarcopenic obesity related to the occurrence and mortality risk of various types of cancer and cardiovascular disease. This literature review highlights the need for further research on sarcopenic obesity to demonstrate the interrelation of these various associations.

Different Impact of Definitions of Sarcopenia in Defining Frailty Status in a Population of Older Women with Early Breast Cancer

Sarcopenia is a geriatric syndrome characterized by losses of quantity and quality of skeletal muscle, which is associated with negative outcomes in older adults and in cancer patients. Different definitions of sarcopenia have been used, with quantitative data more frequently used in oncology, while functional measures have been advocated in the geriatric literature. Little is known about the correlation between frailty status as assessed by comprehensive geriatric assessment (CGA) and sarcopenia in cancer patients. We retrospectively analyzed data from 96 older women with early breast cancer who underwent CGAs and Dual X-ray Absorptiometry (DXA) scans for muscle mass assessment before cancer treatment at a single cancer center from 2016 to 2019 to explore the correlation between frailty status as assessed by CGA and sarcopenia using different definitions. Based on the results of the CGA, 35 patients (36.5%) were defined as frail. Using DXA Appendicular Skeletal Mass (ASM) or the Skeletal Muscle Index (SMI=ASM/height^2), 41 patients were found to be sarcopenic (42.7%), with no significant difference in prevalence between frail and nonfrail subjects. Using the European Working Group on Sarcopenia in Older People (EWGSOP2) definition of sarcopenia (where both muscle function and mass are required), 58 patients were classified as "probably" sarcopenic; among these, 25 were sarcopenic and 17 "severely" sarcopenic. Only 13 patients satisfied both the requirements for being defined as sarcopenic and frail. Grade 3-4 treatment-related toxicities (according to Common Terminology Criteria for Adverse Events) were more common in sarcopenic and frail sarcopenic patients. Our data support the use of a definition of sarcopenia that includes both quantitative and functional data in order to identify frail patients who need tailored treatment.

Food, Nutrition, Physical Activity and Microbiota: Which Impact on Lung Cancer?

Lung cancer still represents the leading cause of cancer-related death, globally. Likewise, malnutrition and inactivity represent a major risk for loss of functional pulmonary capacities influencing overall lung cancer severity. Therefore, the adhesion to an appropriate health lifestyle is crucial in the management of lung cancer patients despite the subtype of cancer. This review aims to summarize the available knowledge about dietary approaches as well as physical activity as the major factors that decrease the risk towards lung cancer, and improve the response to therapies. We discuss the most significant dietary schemes positively associated to body composition and prognosis of lung cancer and the main molecular processes regulated by specific diet schemes, functional foods and physical activity, i.e., inflammation and oxidative stress. Finally, we report evidence demonstrating that dysbiosis of lung and/or gut microbiome, as well as their interconnection (the gut–lung axis), are strictly related to dietary patterns and regular physical activity playing a key role in lung cancer formation and progression, opening to the avenue of modulating the microbiome as coadjuvant therapy. Altogether, the evidence reported in this review highlights the necessity to consider non-pharmacological interventions (nutrition and physical activity) as effective adjunctive strategies in the management of lung cancer.