Cachexia and Sarcopenia in Older Adults with Cancer: A Comprehensive Review

An Annual Symposium on Disparities in Milwaukee, WI, with a 2023 Focus on Older Adults with Cancer

PURPOSE OF REVIEW

Cancer-related inequities are prevalent in Wisconsin, with lower survival rates for breast, colorectal, and lung cancer patients from marginalized communities. This manuscript describes the ongoing efforts at the Medical College of Wisconsin and potential pathways of community engagement to promote education and awareness in reducing inequities in cancer care.

RECENT FINDINGS

While some cancer inequities are related to aggressive disease biology, health-related social risks may be addressed through community-academic partnerships via an open dialogue between the community members and academic faculty. To develop potential pathways of community-academic partnerships, an annual Cancer Disparities Symposium concept evolved as a pragmatic and sustainable model in an interactive learning environment. In this manuscript, we describe the programmatic development and execution of the annual Cancer Disparities Symposium, followed by highlights from this year's meeting focused on geriatric oncology as discussed by the speakers.

Using CT-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery

BACKGROUND

A complete total mesorectal excision is the criterion standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively the difficulty of proctectomy is largely unexplored.

OBJECTIVE

To determine pelvic structural factors associated with incomplete total mesorectal excision after curative proctectomy and build a predictive model for total mesorectal excision quality.

DESIGN

Retrospective cohort study.

SETTING

A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017).

PATIENTS

Curative-intent proctectomy for rectal adenocarcinoma.

INTERVENTIONS

All radiological measurements were obtained from preoperative CT images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports.

MAIN OUTCOME MEASURES

Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality.

RESULTS

Of the 410 cases meeting inclusion criteria, 362 underwent a complete total mesorectal excision (88%). Multivariable regression identified a deeper sacral curve (per 100 mm 2 [OR: 1.14; 95% CI, 1.06-1.23; p < 0.001]) and a greater transverse distance of the pelvic outlet (per 10 mm [OR:1.41, 95% CI, 1.08-1.84; p = 0.012]) to be independently associated with incomplete total mesorectal excision. An increased area of the pelvic inlet (per 10 cm 2 [OR: 0.85; 95% CI, 0.75-0.97; p = 0.02) was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs <0.4) between BMI (<30 vs ≥30) and sex was identified. A model was built to predict mesorectal quality using the following variables: depth of sacral curve, area of pelvic inlet, and transverse distance of the pelvic outlet.

LIMITATIONS

Retrospective analysis is not controlled for the choice of surgical approach.

CONCLUSIONS

Pelvimetry predicts total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in the comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract .

USO DE MEDICIONES DE PELVIMETRA Y OBESIDAD VISCERAL BASADAS EN TC PARA PREDECIR LA CALIDAD DE TME EN PACIENTES SOMETIDOS A CIRUGA DE CNCER DE RECTO

ANTECEDENTES:Una escisión mesorrectal total y completa es el estándar de oro en la cirugía curativa del cáncer de recto. Garantizar la calidad es un desafío en una pelvis estrecha y la obesidad amplifica las dificultades técnicas. La pelvimetría es la medición de las dimensiones pélvicas, pero su papel para medir la dificultad preoperatoria de la proctectomía está en gran medida inexplorado.OBJETIVO:Determinar los factores estructurales pélvicos asociados con la escisión mesorrectal total incompleta después de una proctectomía curativa y construir un modelo predictivo para la calidad de la escisión mesorrectal total.DISEÑO:Estudio de cohorte retrospectivo.ÁMBITO:Base de datos de un centro de referencia cuaternario de pacientes diagnosticados con adenocarcinoma de recto (2009-2017).PACIENTES:Proctectomía con intención curativa para adenocarcinoma de recto.INTERVENCIONES:Todas las mediciones radiológicas se obtuvieron a partir de imágenes de TC preoperatorias utilizando herramientas de software de procesamiento de imágenes validadas. La integridad de la escisión mesorrectal total se obtuvo a partir de informes histológicos.PRINCIPALES MEDIDAS DE VALORACIÓN:Capacidad de la pelvimetría radiológica y las mediciones de obesidad para predecir la calidad total de la escisión mesorrectal.RESULTADOS:De los 410 casos que cumplieron los criterios de inclusión, 362 tuvieron una escisión mesorrectal total completa (88%). Una regresión multivariable identificó una curva sacra más profunda (por 100 mm2); OR:1,14,[IC95%:1,06-1,23,p<0,001], y mayor distancia transversal de salida pélvica (por 10mm); OR:1,41, [IC 95%:1,08-1,84,p=0,012] como asociación independiente con escisión mesorrectal total incompleta. Un área aumentada de entrada pélvica (por 10 cm2); OR:0,85, [IC95%:0,75-0,97,p=0,02] se asoció con una mayor tasa de escisión mesorrectal completa. No se identificaron diferencias en la proporción de obesidad visceral y la obesidad visceral (proporción>0,4 vs.<0,4) entre el índice de masa corporal (<30 vs.>=30) o el sexo. Se construyó un modelo para predecir la calidad mesorrectal utilizando variables: profundidad de la curva sacra, área de la entrada pélvica y distancia transversal de la salida pélvica.LIMITACIONES:Análisis retrospectivo no controlado por la elección del abordaje quirúrgico.CONCLUSIONES:La pelvimetría predice la calidad de la escisión mesorrectal total en la cirugía del cáncer de recto y puede alertar a los cirujanos preoperatoriamente sobre casos de dificultad inusual. Este modelo predictivo puede contribuir a la estrategia de tratamiento y ayudar en la comparación de resultados entre técnicas tradicionales y novedosas de escisión mesorrectal total. (Traducción- Dr. Ingrid Melo).

Emerging Therapeutic Strategies in Sarcopenia: An Updated Review on Pathogenesis and Treatment Advances

Sarcopenia is a prevalent degenerative skeletal muscle condition in the elderly population, posing a tremendous burden on diseased individuals and healthcare systems worldwide. Conventionally, sarcopenia is currently managed through nutritional interventions, physical therapy, and lifestyle modification, with no pharmaceutical agents being approved for specific use in this disease. As the pathogenesis of sarcopenia is still poorly understood and there is no treatment recognized as universally effective, recent research efforts have been directed at better comprehending this illness and diversifying treatment strategies. In this respect, this paper overviews the new advances in sarcopenia treatment in correlation with its underlying mechanisms. Specifically, this review creates an updated framework for sarcopenia, describing its etiology, pathogenesis, risk factors, and conventional treatments, further discussing emerging therapeutic approaches like new drug formulations, drug delivery systems, stem cell therapies, and tissue-engineered scaffolds in more detail.

Modelling the micro- and macro- environment of pancreatic cancer: from patients to pre-clinical models and back

Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy with very low survival rates. Over the past 50 years, improvements in PDAC survival have significantly lagged behind the progress made in other cancers. PDAC's dismal prognosis is due to typical late-stage diagnosis combined with lack of effective treatments and complex mechanisms of disease. We propose that improvements in survival are partly hindered by the current focus on largely modelling and targeting PDAC as one disease, despite it being heterogeneous. Implementing new disease-representative pre-clinical mouse models that capture this complexity could enable the development of transformative therapies. Specifically, these models should recapitulate human PDAC late-stage biology, heterogeneous genetics, extensive non-malignant stroma, and associated risk factors and comorbidities. In this Perspective, we focus on how pre-clinical mouse models could be improved to exemplify key features of PDAC micro- and macro- environments, which would drive clinically relevant patient stratification, tailored treatments and improved survival.

Cancer cachexia: biomarkers and the influence of age

Cancer cachexia (Ccx) is a complex metabolic condition characterized by pronounced muscle and fat wasting, systemic inflammation, weakness and fatigue. Up to 30% of cancer patients succumb directly to Ccx, yet therapies that effectively address this perturbed metabolic state are rare. In recent decades, several characteristics of Ccx have been established in mice and humans, of which we here highlight adipose tissue dysfunction, muscle wasting and systemic inflammation, as they are directly linked to biomarker discovery. To counteract cachexia pathogenesis as early as possible and mitigate its detrimental impact on anti-cancer treatments, identification and validation of clinically endorsed biomarkers assume paramount importance. Ageing was recently shown to affect both the validity of Ccx biomarkers and Ccx development, but the underlying mechanisms are still unknown. Thus, unravelling the intricate interplay between ageing and Ccx can help to counteract Ccx pathogenesis and tailor diagnostic and treatment strategies to individual needs.

Exploring the Prospective Role of Propolis in Modifying Aging Hallmarks

Aging populations worldwide are placing age-related diseases at the forefront of the research agenda. The therapeutic potential of natural substances, especially propolis and its components, has led to these products being promising agents for alleviating several cellular and molecular-level changes associated with age-related diseases. With this in mind, scientists have introduced a contextual framework to guide future aging research, called the hallmarks of aging. This framework encompasses various mechanisms including genomic instability, epigenetic changes, mitochondrial dysfunction, inflammation, impaired nutrient sensing, and altered intercellular communication. Propolis, with its rich array of bioactive compounds, functions as a potent functional food, modulating metabolism, gut microbiota, inflammation, and immune response, offering significant health benefits. Studies emphasize propolis' properties, such as antitumor, cardioprotective, and neuroprotective effects, as well as its ability to mitigate inflammation, oxidative stress, DNA damage, and pathogenic gut bacteria growth. This article underscores current scientific evidence supporting propolis' role in controlling molecular and cellular characteristics linked to aging and its hallmarks, hypothesizing its potential in geroscience research. The aim is to discover novel therapeutic strategies to improve health and quality of life in older individuals, addressing existing deficits and perspectives in this research area.

Older adults, appendicular anthropometric measurements, and poor functional performance are predictors of sarcopenia in individuals with head and neck squamous cell carcinoma

OBJECTIVE

To identify predictors of sarcopenia (demographical, anthropometric measurements, tumor-related clinical characteristics, performance status, and serum C-reactive protein (CRP) and albumin levels in individuals with head and neck squamous cell carcinoma (HNSCC).

MATERIAL AND METHODS

This cross-sectional study selected diagnosed with HNSCC (n = 125). Sarcopenia was defined as low muscle strength and low physical performance. Association between sarcopenia and anthropometric assessments (weight, height, body mass index, triceps skinfold, mid-upper arm circumference [MUAC], mid-upper arm muscle circumference, mid-upper arm fat area [UFA], mid-upper arm bone free muscle area, calf circumference, and appendicular skeletal muscle mass and index), tumor clinical characteristics (anatomical site, tumor size, and cervical metastasis), performance status scale (Eastern Cooperative Oncology Group Performance Status [ECOG-PS]), and CRP and albumin levels was analyzed using binary logistic regression models.

RESULTS

The diagnosis of sarcopenia was identified in 28 (22.4%) individuals with HNSCC. Being an older adult increases the odds of association with sarcopenia in individuals with HNSCC (odds ratio [OR] = 1.05). Increments in MUAC measurement reduce the odds of association with sarcopenia (OR = 0.69), while the increase in the UFA measurement increases the odds of association with sarcopenia (OR = 1.33). Poor ECOG-PS scores increase the odds of association with sarcopenia in individuals with HNSCC (OR = 5.54).

CONCLUSION

Early identification of easy-to-perform, cost-effective predictors of sarcopenia tends to favor the implementation of personalized therapeutic and supportive interventions in individuals with HNSCC.

Epigenetic and inflammatory markers in older adults with cancer: A Young International Society of Geriatric Oncology narrative review

The number of adults aged ≥ 65 years with cancer is rapidly increasing. Older adults with cancer are susceptible to treatment-related acute and chronic adverse events, resulting in loss of independence, reduction in physical function, and decreased quality of life. Nevertheless, evidence-based interventions to prevent or treat acute and chronic adverse events in older adults with cancer are limited. Several promising blood-based biomarkers related to inflammation and epigenetic modifications are available to identify older adults with cancer who are at increased risk of accelerated aging and physical, functional, and cognitive impairments caused by the cancer and its treatment. Inflammatory changes and epigenetic modifications can be reversible and targeted by lifestyle changes and interventions. Here we discuss ways in which changes in inflammatory and epigenetic pathways influence the aging process and how these pathways can be targeted by interventions aimed at reducing inflammation and aging-associated biological markers. As the number of older adults with cancer entering survivorship continues to increase, it is becoming progressively more important to understand ways in which the benefit from treatment can be enhanced while reducing the effects of accelerated aging.

Sarcopenia as a prognostic indicator in colorectal cancer: an updated meta-analysis

Background

Sarcopenia, often observed in the elderly, is associated with declining skeletal muscle mass and impaired muscle function. This condition has been consistently linked to a less favorable prognosis in various malignancies. Computed tomography (CT) is a frequently employed modality for evaluating skeletal muscle mass, enabling the measurement of the skeletal muscle index (SMI) at the third lumbar vertebra (L3) level. This measurement serves as a defining criterion for sarcopenia. The meta-analysis dealt with evaluating the promise sarcopenia held as a prognostic indicator in individuals with colorectal cancer.

Methods

Research relevant to the subject was determined by systematically searching PubMed, Embase, Web of Science, WANFANG, and CNKI (up to June 11, 2023, published studies). In this meta-analysis, the incidence of sarcopenia in individuals with colorectal cancer was combined to analyze the disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) of these individuals with and without sarcopenia. The included research was evaluated for quality per the Newcastle-Ottawa Scale (NOS) score. In the multivariate analysis of each study, the direct extraction of hazard ratio (HR) with a 95% confidence interval (CI) was executed. STATA 11.0 was applied to integrate and statistically analyze the data.

Results

Overall 20 articles participated in this meta-analysis. A 34% incidence of sarcopenia was noted in colorectal cancer. The presence of sarcopenia denoted a decrease in OS (HR=1.72,95% CI=1.45-2.03), DFS (HR=1.42,95% CI=1.26-1.60) and CSS (HR=1.48,95% CI=1.26-1.75) in individuals with colorectal cancer. In addition, the subgroup analysis depicted a pattern consistent with the overall analysis results.

Conclusion

CT-defined sarcopenia exhibits promise as an indicator of survival prognosis in individuals with colorectal cancer. Future studies need a more rigorous definition of sarcopenia to further verify these findings.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023431435.

Possible cancer-causing capacity of COVID-19: Is SARS-CoV-2 an oncogenic agent?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has shown diverse life-threatening effects, most of which are considered short-term. In addition to its short-term effects, which has claimed many millions of lives since 2019, the long-term complications of this virus are still under investigation. Similar to many oncogenic viruses, it has been hypothesized that SARS-CoV-2 employs various strategies to cause cancer in different organs. These include leveraging the renin angiotensin system, altering tumor suppressing pathways by means of its nonstructural proteins, and triggering inflammatory cascades by enhancing cytokine production in the form of a "cytokine storm" paving the way for the emergence of cancer stem cells in target organs. Since infection with SARS-CoV-2 occurs in several organs either directly or indirectly, it is expected that cancer stem cells may develop in multiple organs. Thus, we have reviewed the impact of coronavirus disease 2019 (COVID-19) on the vulnerability and susceptibility of specific organs to cancer development. It is important to note that the cancer-related effects of SARS-CoV-2 proposed in this article are based on the ability of the virus and its proteins to cause cancer but that the long-term consequences of this infection will only be illustrated in the long run.

Assessment of correlation between conventional anthropometric and imaging-derived measures of body fat composition: a systematic literature review and meta-analysis of observational studies

BACKGROUND

In studies of the association of adiposity with disease risk, widely used anthropometric measures of adiposity (e.g. body-mass-index [BMI], waist circumference [WC], waist-hip ratio [WHR]) are simple and inexpensive to implement at scale. In contrast, imaging-based techniques (e.g. magnetic resonance imaging [MRI] and dual x-ray absorptiometry [DXA]) are expensive and labour intensive, but can provide more accurate quantification of body fat composition. There is, however, limited evidence about the relationship between conventional and imaging-derived measures of adiposity.

METHODS

We searched Scopus and Web of Science for published reports in English of conventional versus imaging-derived measurements of adiposity. We identified 42 articles (MRI = 22; DXA = 20) that met selection criteria, involving 42,556 (MRI = 15,130; DXA = 27,426) individuals recruited from community or hospital settings. Study-specific correlation coefficients (r) were transformed using Fisher's Z transformation, and meta-analysed to yield weighted average correlations, both overall and by ancestry, sex and age, where feasible. Publication bias was investigated using funnel plots and Egger's test.

RESULTS

Overall, 98% of participants were 18 + years old, 85% male and 95% White. BMI and WC were most strongly correlated with imaging-derived total abdominal (MRI-derived: r = 0.88-; DXA-derived: 0.50-0.86) and subcutaneous abdominal fat (MRI-derived: 0.83-0.85), but were less strongly correlated with visceral abdominal fat (MRI-derived: 0.76-0.79; DXA-derived: 0.80) and with DXA-derived %body fat (0.76). WHR was, at best, strongly correlated with imaging-derived total abdominal (MRI-derived: 0.60; DXA-derived: 0.13), and visceral abdominal fat (MRI-derived: 0.67; DXA-derived: 0.65), and moderately with subcutaneous abdominal (MRI-derived: 0.54), and with DXA-derived %body fat (0.58). All conventional adiposity measures were at best moderately correlated with hepatic fat (MRI-derived: 0.36-0.43). In general, correlations were stronger in women than in men, in Whites than in non-Whites, and in those aged 18 + years.

CONCLUSIONS

In this meta-analysis, BMI and WC, but not WHR, were very strongly correlated with imaging-derived total and subcutaneous abdominal fat. By comparison, all three measures were moderately or strongly correlated with imaging-based visceral abdominal fat, with WC showing the greatest correlation. No anthropometric measure was substantially correlated with hepatic fat. Further larger studies are needed to compare these measures within the same study population, and to assess their relevance for disease risks in diverse populations.

Advances in the relationship between temporal muscle thickness and prognosis of patients with glioblastoma: a narrative review

The most dangerous variety of glioma, glioblastoma, has a high incidence and fatality rate. The prognosis for patients is still bleak despite numerous improvements in treatment approaches. We urgently need to develop clinical parameters that can evaluate patients' conditions and predict their prognosis. Various parameters are available to assess the patient's preoperative performance status and degree of frailty, but most of these parameters are subjective and therefore subject to interobserver variability. Sarcopenia can be used as an objective metric to measure a patient's physical status because studies have shown that it is linked to a bad prognosis in those with cancers. For the purpose of identifying sarcopenia, temporal muscle thickness has demonstrated to be a reliable alternative for a marker of skeletal muscle content. As a result, patients with glioblastoma may use temporal muscle thickness as a potential marker to correlate with the course and fate of their disease. This narrative review highlights and defines the viability of using temporal muscle thickness as an independent predictor of survival in glioblastoma patients, and it evaluates recent research findings on the association between temporal muscle thickness and prognosis of glioblastoma patients.

Measuring What Is Meaningful in Cancer Cachexia Clinical Trials: A Path Forward With Digital Measures of Real-World Physical Behavior

PURPOSE

The burden of cancer cachexia on patients' health-related quality of life, specifically their physical functioning, is well documented, but clinical trials thus far have failed to show meaningful improvement in physical functioning. The purpose of this review is to summarize existing methods of assessing physical function in cancer cachexia, outline a path forward for measuring what is meaningful to patients using digital measures derived from digital health technologies (DHTs), and discuss the current landscape of digital measures from the clinical and regulatory standpoint.

DESIGN

For this narrative review, peer-reviewed articles were searched on PubMed, clinical trials records were searched on clinicaltrials.gov, and records of digital measures submitted for regulatory qualification were searched on the US Food and Drug Administration's Drug Development Tool Qualification Program database.

RESULTS

There are gaps in assessing aspects of physical function that matter to patients. Existing assessment methods such as patient-reported outcomes and objective performance outcomes have limitations, including their episodic nature and burden to patients. DHTs such as wearable sensors can capture real-world physical behavior continuously, passively, and remotely, and may provide a more comprehensive picture of patients' everyday functioning. Recent regulatory submissions showcase potential clinical implementation of digital measures in various therapeutic areas.

CONCLUSION

Digital measures of real-world physical behavior present an opportunity to detect and demonstrate improvements in physical functioning in cancer cachexia, but evidence-based development is critical. For their use in clinical and regulatory decision making, studies demonstrating meaningfulness to patients as well as feasibility and validation are necessary.

Development and Validation of an Automated Image-Based Deep Learning Platform for Sarcopenia Assessment in Head and Neck Cancer

Importance

Sarcopenia is an established prognostic factor in patients with head and neck squamous cell carcinoma (HNSCC); the quantification of sarcopenia assessed by imaging is typically achieved through the skeletal muscle index (SMI), which can be derived from cervical skeletal muscle segmentation and cross-sectional area. However, manual muscle segmentation is labor intensive, prone to interobserver variability, and impractical for large-scale clinical use.

Objective

To develop and externally validate a fully automated image-based deep learning platform for cervical vertebral muscle segmentation and SMI calculation and evaluate associations with survival and treatment toxicity outcomes.

Design, Setting, and Participants

For this prognostic study, a model development data set was curated from publicly available and deidentified data from patients with HNSCC treated at MD Anderson Cancer Center between January 1, 2003, and December 31, 2013. A total of 899 patients undergoing primary radiation for HNSCC with abdominal computed tomography scans and complete clinical information were selected. An external validation data set was retrospectively collected from patients undergoing primary radiation therapy between January 1, 1996, and December 31, 2013, at Brigham and Women's Hospital. The data analysis was performed between May 1, 2022, and March 31, 2023.

Exposure

C3 vertebral skeletal muscle segmentation during radiation therapy for HNSCC.

Main Outcomes and Measures

Overall survival and treatment toxicity outcomes of HNSCC.

Results

The total patient cohort comprised 899 patients with HNSCC (median [range] age, 58 [24-90] years; 140 female [15.6%] and 755 male [84.0%]). Dice similarity coefficients for the validation set (n = 96) and internal test set (n = 48) were 0.90 (95% CI, 0.90-0.91) and 0.90 (95% CI, 0.89-0.91), respectively, with a mean 96.2% acceptable rate between 2 reviewers on external clinical testing (n = 377). Estimated cross-sectional area and SMI values were associated with manually annotated values (Pearson r = 0.99; P < .001) across data sets. On multivariable Cox proportional hazards regression, SMI-derived sarcopenia was associated with worse overall survival (hazard ratio, 2.05; 95% CI, 1.04-4.04; P = .04) and longer feeding tube duration (median [range], 162 [6-1477] vs 134 [15-1255] days; hazard ratio, 0.66; 95% CI, 0.48-0.89; P = .006) than no sarcopenia.

Conclusions and Relevance

This prognostic study's findings show external validation of a fully automated deep learning pipeline to accurately measure sarcopenia in HNSCC and an association with important disease outcomes. The pipeline could enable the integration of sarcopenia assessment into clinical decision making for individuals with HNSCC.

Real-World Analysis of Clinical Characteristics and Survival Outcomes in Patients With Extensive-Stage SCLC Treated With First-Line Chemoimmunotherapy

Introduction

There are no clinically validated prognostic biomarkers in the management of extensive-stage SCLC (ES-SCLC). We explored the association between clinical characteristics and survival outcomes in patients with ES-SCLC treated with chemoimmunotherapy.

Methods

In this retrospective cohort study, patients with ES-SCLC treated with first-line platinum-etoposide chemotherapy and atezolizumab were identified from medical records. Pretreatment clinical characteristics, biochemical parameters, and tumor and treatment characteristics were collected. Univariate and multivariate Cox regression were used to evaluate treatment effect on progression-free survival (PFS) and overall survival (OS).

Results

We evaluated 75 patients in total. The median PFS and OS were 6.1 months and 9.2 months, respectively. Statistically significant associations were found with lower lactate dehydrogenase and improved OS (hazard ratio [HR] = 1.0, 95% confidence interval [CI]: 1.0-1.01, p = 0.006), whereas higher age (HR = 0.94, 95% CI: 0.90-0.98, p = 0.006) and lower neutrophil-to-lymphocyte ratio (HR = 1.08, 95% CI: 1.02-1.14, p = 0.005) were associated with improved PFS. The number of chemotherapy cycles received were associated with both an improved PFS (HR = 0.57, 95% CI: 0.37-0.89, p = 0.011) and OS (HR = 0.5, 95% CI: 0.30-0.84, p = 0.008).

Conclusions

This study highlights the important effect of chemotherapy on survival. Furthermore, the association between lactate dehydrogenase and neutrophil-to-lymphocyte ratio on survival further suggests that baseline tumor burden and optimizing sarcopenia are important factors for clinicians to consider as we seek to develop personalized treatment for this disease.

Diagnostic Value of Serum Creatinine and Cystatin-C-Based Indices and Ishii Score in Cancer-Related Sarcopenia

BACKGROUND

Sarcopenia is a key factor affecting the prognosis of cancer patients; however, identifying patients at risk remains challenging. The serum creatinine/cystatin C ratio (CCR) and the sarcopenia index (SI) are new biomarkers for sarcopenia screening. The Ishii test score is an equation based on age, grip strength, and calf circumference for sarcopenia screening. However, their performances in advanced cancer patients have not been thoroughly studied. We aimed to evaluate and compare the accuracy of three screening tools in diagnosing cancer-related sarcopenia.

METHODS

A total of 215 cancer patients with a median age of 60.5 y were enrolled in this cross-sectional study. The Asian Working Group for Sarcopenia 2019 (AWGS2019) criteria were used as a standard. The diagnostic accuracies of the CCR, SI, and Ishii screening test were analyzed in terms of sensitivity, specificity, negative and positive predictive values, the Youden index, and the receiver operating characteristic (ROC) curve.

RESULTS

According to the AWGS2019 criteria, the prevalence of sarcopenia and severe sarcopenia was 47.9% and 18.6%, respectively. The CCR, SI (positively), and Ishii scores (negatively) were correlated with muscle mass. Accordingly, sarcopenia was negatively correlated with CCR and SI, while it was significantly positively correlated with the Ishii score. In males, the AUCs of the CCR, SI, and Ishii scores were 0.743 (95%CI 0.65-0.836), 0.758 (95%CI 0.665-0.852), and 0.833 (95%CI 0.751-0.909), respectively. In females, the AUCs of the CCR, SI, and Ishii scores were 0.714 (95%CI 0.61-0.818), 0.737 (95%CI 0.635-0.839), and 0.849 (95%CI 0.775-0.932), respectively. The AUC of the Ishii score was significantly higher than that of the other screening tools (p < 0.001). The cut-off value of the optimal Ishii score was 102.3 (sensitivity: 93.2%, specificity: 59.1%) for males and 98.3 (sensitivity: 93.3%, specificity: 64.7%) for females.

CONCLUSIONS

The CCR and SI based on serum CysC and creatinine had a remarkably similar overall diagnostic accuracy for sarcopenia in advanced cancer. Among the above three sarcopenia screening tools, the Ishii score chart seemed to have better predictive values of sarcopenia in cancer patients.

Accurate SARC-F Score in Patients with Liver Disease

SARC-F is a well-accepted screening tool for sarcopenia. A SARC-F value of 1 point is reported to be more discriminating in identifying sarcopenia than 4 points (recommended cutoff point). The prognostic impact of the SARC-F score was investigated in patients with liver disease (LD, n = 269, median age = 71 years, 96 hepatocellular carcinoma (HCC) cases). Factors associated with SARC-F ≥ 4 points and SARC-F ≥ 1 point were also examined. In the multivariate analysis, age (p = 0.048), and Geriatric Nutritional Risk Index (GNRI) score (p = 0.0365) were significant factors linked to SARC-F ≥ 1 point. In our patients with LD, the SARC-F score is well correlated with the GNRI score. The 1-year cumulative overall survival ratio in patients with SARC-F ≥ 1 (n = 159) and SARC-F 0 (n = 110) was 78.3% and 90.1% (p = 0.0181). After excluding 96 HCC cases, similar tendencies were found (p = 0.0289). In the receiver operating curve (ROC) analysis based on the prognosis for the SARC-F score, the area under the ROC was 0.60. The sensitivity was 0.57, the specificity was 0.62, and the optimal cutoff point of the SARC-F score was 1. In conclusion, sarcopenia in LDs can be affected by nutritional conditions. A SARC-F score of ≥1 is more useful than a score of 4 in predicting the prognosis of patients with LD.

Efficacy of PD-1/PD-L1 inhibitors in advanced gastroesophageal cancer based on characteristics: a meta-analysis

Objective: Evaluate the potency of anti-PD-1/PD-L1 antibodies in advanced gastroesophageal cancer patients with different clinical features. Methods: Randomized, controlled trials comparing anti-PD-1/PD-L1 antibodies with chemotherapy in individuals with gastroesophageal cancer were retrieved. Results: 15 trials involving 9194 individuals were included. PD-1/PD-L1 inhibitors significantly improved overall survival (OS) but not progression-free survival. Significantly improved OS was observed in PD-L1 combined positive score ≥1, primary esophageal cancer, primary gastric cancer and Asian patients. Subgroup analysis revealed significant OS benefit achieved for esophageal squamous cell carcinoma, but not for esophageal adenocarcinoma. Conclusion: PD-1/PD-L1 inhibitors improved OS in advanced gastroesophageal carcinoma, especially in patients with esophageal cancer. Race, primary tumor sites and PD-L1 combined positive score can be used to predict the potency of immune checkpoint inhibitors.

Intermittent fasting interventions to leverage metabolic and circadian mechanisms for cancer treatment and supportive care outcomes

Intermittent fasting entails restricting food intake during specific times of day, days of the week, religious practice, or surrounding clinically important events. Herein, the metabolic and circadian rhythm mechanisms underlying the proposed benefits of intermittent fasting for the cancer population are described. We summarize epidemiological, preclinical, and clinical studies in cancer published between January 2020 and August 2022 and propose avenues for future research. An outstanding concern regarding the use of intermittent fasting among cancer patients is that fasting often results in caloric restriction, which can put patients already prone to malnutrition, cachexia, or sarcopenia at risk. Although clinical trials do not yet provide sufficient data to support the general use of intermittent fasting in clinical practice, this summary may be useful for patients, caregivers, and clinicians who are exploring intermittent fasting as part of their cancer journey for clinical outcomes and symptom management.

CT-defined pectoralis muscle mass and muscle density are associated with mortality in acute pulmonary embolism. A multicenter analysis

BACKGROUND & AIMS

Computed tomography (CT) defined muscle mass can be used as a surrogate parameter for sarcopenia. The present study used thoracic CT to assess pectoralis muscle area and density as an imaging biomarker for prognosis of 30-day mortality in patients with acute pulmonary embolism (PE) METHODS: The clinical database was retrospectively screened for patients with thoracic CT in 3 centers. Pectoralis musculature was measured on axial slices of the thoracic CT at the level of T4 of contrast enhanced pulmonary angiography CT. Skeletal muscle area (SMA), skeletal muscle index (SMI), muscle density and gauge were calculated.

RESULTS

Overall, 981 patients (440 female, 44.9%) with a mean age of 63.5 ± 15.9 years were included into the study and 144 patients (14.6%) died within the 30-days period. Every pectoral muscle value was higher in survivors compared to non-survivors (exemplarily for SMI 9.9 ± 3.5 cm²/m² versus 7.8 ± 2.6 cm²/m², p < 0.001). Moreover, 91 patients were defined as hemodynamically instable (9.3%). Comparable, every pectoral muscle parameter was higher in patients with hemodynamically stable course compared to instable course. Different muscle variables are related to 30-day mortality: SMA, OR = 0.94 (95%CI= (0.92; 0.96), p < 0.001); SMI, OR = 0.78 (95%CI= (0.72; 0.84), p < 0.001); muscle density, OR = 0.96 (95%CI = (0.94; 0.97), p < 0.001); muscle gauge OR = 0.96 (95%CI = (0.94; 0.99), p < 0.001). SMI and muscle density were independently associated with 30-days mortality: SMI, OR = 0.81 (95%CI = (0.75; 0.88), p < 0.001); muscle density: OR = 0.96 (95%CI= (0.95; 0.98), p < 0.001).

CONCLUSION

Parameters of the pectoralis musculature are associated with 30-day mortality in patients with acute PE. These findings should lead to an independent validation study and ultimately to the inclusion into clinical routine as a prognostic factor.

Androgen Deprivation Therapy for Prostate Cancer Influences Body Composition Increasing Risk of Sarcopenia

Computed tomography (CT) scans used in treatment response assessment in prostate cancer (PCa) patients are a useful tool for nutritional status evaluation. The aim of this study was to assess the nutritional status, including sarcopenia development based on CT scans, in PCa patients and its association with progression-free survival (PFS). Sixty-four PCa patients were included (group 1: 34 patients undergoing androgen deprivation therapy (ADT) with docetaxel due to newly diagnosed, hormone-sensitive, metastatic PCa and group 2: 30 patients with castration-resistant metastatic PCa continuing ADT therapy with enzalutamide or abiraterone acetate). Nutritional status was evaluated with anthropometrical parameters, Nutritional Risk Score (NRS), and CT scans at the L3 vertebrae. Survival analyses were performed. According to NRS, nutritional status was significantly related to PFS. In both groups, there was a significant reduction in muscle tissue (total muscle tissue and skeletal muscle index). A significant increase in the distribution of adipose tissue (subcutaneous fat, visceral fat, subcutaneous adipose tissue index, and visceral adipose tissue index) in group one was observed. Sarcopenia was diagnosed in patients but with no influence on PFS. Significant reduction in muscle mass and increase in fat mass was observed in patients treated for PCa with no impact on PFS. The NRS was related to PFS in PCa patients and associated with body composition, assessed by CT after the castration therapy. Long-term castration combined with abiraterone therapy with prednisone or enzalutamide significantly influenced muscle tissue and may lead to sarcopenia development.

The differential effects of sarcopenia and cachexia on overall survival for pancreatic ductal adenocarcinoma patients following pancreatectomy: A retrospective study based on a large population

OBJECTIVES

Both cachexia and sarcopenia have been considered adverse predictors for prognosis in patients with pancreatic cancer; although sarcopenia and cachexia share some similarities, they are still defined as distinct nutritional conditions. We aimed to explore the differential impacts of sarcopenia and cachexia on prognosis for pancreatic ductal adenocarcinoma (PDAC) patients following radical excision.

METHODS

From January 2015 to May 2022, 614 patients undergoing surgery for PDAC were retrospectively included. Sarcopenia was defined as the L3 total skeletal muscle index below 52.4 cm² /m² (men) and 38.5 cm² /m² (women). Cachexia was classified according to the following criteria: involuntary weight loss >5% over the past 6 months, or weight loss >2% and BMI <20 kg/m² , or weight loss >2% and sarcopenia.

RESULTS

Of the 614 patients included in the analysis, 62% and 48% were diagnosed with sarcopenia and cachexia, respectively. Kaplan-Meier analysis showed that sarcopenia and/or cachexia were significantly associated with worse overall survival (OS) rather than worse recurrence-free survival (RFS). Moreover, Cox regression analysis revealed that cachexia rather than sarcopenia was an adverse factor for OS in all PDAC patients. For poorly differentiated PDAC, both cachexia and sarcopenia were significantly associated with shorter OS. However, for moderately/well-differentiated PADC, cachexia was an independent factor for adverse OS, but not sarcopenia.

CONCLUSIONS

Sarcopenia and cachexia have different effects on OS for PDAC patients undergoing radical excision. This difference may provide some important information for preoperative management.

Fully-automated sarcopenia assessment in head and neck cancer: development and external validation of a deep learning pipeline

Purpose

Sarcopenia is an established prognostic factor in patients diagnosed with head and neck squamous cell carcinoma (HNSCC). The quantification of sarcopenia assessed by imaging is typically achieved through the skeletal muscle index (SMI), which can be derived from cervical neck skeletal muscle (SM) segmentation and cross-sectional area. However, manual SM segmentation is labor-intensive, prone to inter-observer variability, and impractical for large-scale clinical use. To overcome this challenge, we have developed and externally validated a fully-automated image-based deep learning (DL) platform for cervical vertebral SM segmentation and SMI calculation, and evaluated the relevance of this with survival and toxicity outcomes.

Materials and Methods

899 patients diagnosed as having HNSCC with CT scans from multiple institutes were included, with 335 cases utilized for training, 96 for validation, 48 for internal testing and 393 for external testing. Ground truth single-slice segmentations of SM at the C3 vertebra level were manually generated by experienced radiation oncologists. To develop an efficient method of segmenting the SM, a multi-stage DL pipeline was implemented, consisting of a 2D convolutional neural network (CNN) to select the middle slice of C3 section and a 2D U-Net to segment SM areas. The model performance was evaluated using the Dice Similarity Coefficient (DSC) as the primary metric for the internal test set, and for the external test set the quality of automated segmentation was assessed manually by two experienced radiation oncologists. The L3 skeletal muscle area (SMA) and SMI were then calculated from the C3 cross sectional area (CSA) of the auto-segmented SM. Finally, established SMI cut-offs were used to perform further analyses to assess the correlation with survival and toxicity endpoints in the external institution with univariable and multivariable Cox regression.

Results

DSCs for validation set (n = 96) and internal test set (n = 48) were 0.90 (95% CI: 0.90 - 0.91) and 0.90 (95% CI: 0.89 - 0.91), respectively. The predicted CSA is highly correlated with the ground-truth CSA in both validation (r = 0.99, p < 0.0001) and test sets (r = 0.96, p < 0.0001). In the external test set (n = 377), 96.2% of the SM segmentations were deemed acceptable by consensus expert review. Predicted SMA and SMI values were highly correlated with the ground-truth values, with Pearson r β 0.99 (p < 0.0001) for both the female and male patients in all datasets. Sarcopenia was associated with worse OS (HR 2.05 [95% CI 1.04 - 4.04], p = 0.04) and longer PEG tube duration (median 162 days vs. 134 days, HR 1.51 [95% CI 1.12 - 2.08], p = 0.006 in multivariate analysis.

Conclusion

We developed and externally validated a fully-automated platform that strongly correlates with imaging-assessed sarcopenia in patients with H&N cancer that correlates with survival and toxicity outcomes. This study constitutes a significant stride towards the integration of sarcopenia assessment into decision-making for individuals diagnosed with HNSCC.

SUMMARY STATEMENT

In this study, we developed and externally validated a deep learning model to investigate the impact of sarcopenia, defined as the loss of skeletal muscle mass, on patients with head and neck squamous cell carcinoma (HNSCC) undergoing radiotherapy. We demonstrated an efficient, fullyautomated deep learning pipeline that can accurately segment C3 skeletal muscle area, calculate cross-sectional area, and derive a skeletal muscle index to diagnose sarcopenia from a standard of care CT scan. In multi-institutional data, we found that pre-treatment sarcopenia was associated with significantly reduced overall survival and an increased risk of adverse events. Given the increased vulnerability of patients with HNSCC, the assessment of sarcopenia prior to radiotherapy may aid in informed treatment decision-making and serve as a predictive marker for the necessity of early supportive measures.

Interventions to improve nutritional status for older patients with cancer - a holistic approach is needed

PURPOSE OF REVIEW

Older adults with cancer frequently experience malnutrition and sarcopenia resulting in lower treatment efficacy, increased risk of toxicities and healthcare costs, lower quality of life and shorter survival. Improving nutritional status in this rapidly growing population is an urgent need globally. We reviewed randomized controlled trials from the last 18 months focusing on nutritional status and applying multimodal interventions in older adults with cancer.

RECENT FINDINGS

Several randomized controlled trials have been reported recently elucidating the impact of nutritional interventions as a part of multimodal interventions through different stages of cancer care. Although multimodal interventions rarely demonstrate survival benefit, they improve several important aspects of cancer care, including patient-centred endpoints such as physical functioning, adherence, patient satisfaction and quality of life.

SUMMARY

Multimodal interventions including nutrition have the potential to improve patient-centred outcomes in older adults with cancer during the continuum of care, from prehabilitation to palliative care. Early, integrated supportive care applying the right intervention in the right setting at the proper time along with personalized antitumor treatment is the cornerstone of optimal holistic cancer care.

Visceral to subcutaneous fat ratio predicts short-term mortality in patients with Covid 19. A multicenter study

OBJECTIVE

To evaluate the association of body composition parameters with outcomes in Covid-19.

METHODS

173 patients hospitalized for Covid-19 infection in 6 European centers were included in this retrospective study. Measurements were performed at L3-level and comprised skeletal muscle index (SMI), muscle density (MD), and adipose tissue measurements [visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), intramuscular adipose tissue (IMAT), visceral-to-subcutaneous-adipose-tissue-area-ratio (VSR)]. The association with mortality, the need for intubation (MV), and the need for admission to ICU within 30 days were evaluated.

RESULTS

Higher SAT density was associated with a greater risk of MV (OR = 1.071, 95%CI=(1.034;1.110), p < 0.001). Higher VAT density was associated with admission to ICU (OR = 1.068, 95%CI=(1.029;1.109), p < 0.001). Higher MD was a protective factor for MV and ICU admission (OR = 0.914, 95%CI=(0.870;0.960), p < 0.001; OR = 0.882, 95%CI=(0.832;0.934), p = 0.028). Higher VSR was associated with mortality (OR = 2.147, 95%CI=(1.022;4.512), p = 0.044). Male sex showed the strongest influence on the risk of ICU admission and MV. SMI was not associated with either parameter.

CONCLUSION

In patients hospitalized for Covid-19 infection, higher VSR seems to be a strong prognostic factor of short-term mortality. Weak associations with clinical course were found for MD and adipose tissue measurements. Male sex was the strongest prognostic factor of adverse clinical course.

ADVANCES IN KNOWLEDGE

VSR is a prognostic biomarker for 30-day mortality in patients hospitalized for Covid-19 disease.

Sarcopenia and loss of muscle mass in patients with lung cancer undergoing chemotherapy treatment: a systematic review and meta-analysis

BACKGROUND

In patients with cancer, sarcopenia is associated with treatment related complications, treatment cessation, poor quality of life and reduced overall survival. Despite this, there is limited knowledge about changes in skeletal muscle mass during chemotherapy. The aim of this systematic review and meta-analysis was to investigate the change of skeletal muscle mass and sarcopenia during chemotherapy treatment among patients with lung cancer.

METHODS

A systematic literature search was conducted in three databases, PubMed, EMBASE and Web of Science. Observational studies with patients with lung cancer were eligible for inclusion if skeletal muscle mass was measured before and after receiving chemotherapy treatment.

RESULTS

Ten cohort studies with a total of 867 participants met the inclusion criteria. During 5.2 ± 2.9 months of chemotherapy treatment, patients with lung cancer experienced a significant loss of skeletal muscle mass with a standardized mean difference (SMD) of: -0.25 (95% CI -0.47 to -0.03). The pretreatment prevalence of sarcopenia varied across studies from 35% to 74%. Only one study reported prevalence of sarcopenia both before and after chemotherapy treatment with an increase from 35% to 59%.

CONCLUSION

The present data demonstrate a marked loss of skeletal muscle mass in patients with lung cancer undergoing chemotherapy treatment, as well as a high prevalence of sarcopenia. As sarcopenia is associated with poor clinical outcomes, it seems important to include and use assessments of skeletal muscle mass in clinical practice to identify patients in need for interventions. Moreover, interventional studies to hinder development of sarcopenia are needed.

Relationship Between Cachexia and the Functional Progress of Patients With Cancer in Inpatient Rehabilitation

PURPOSE

Although inpatient rehabilitation can improve functional independence in patients with cancer, the role of cachexia in this population is unknown. Our objectives were to:1) Establish prevalence of cachexia in a cohort of cancer patients receiving inpatient rehabilitation and its association with demographic and oncological history.2) Determine the relationship between the presence of cachexia and functional recovery and whether these patients in inpatient rehabilitation have a distinct prognosis.

METHODS

This is a retrospective cohort study of 250 patients over 330 admissions to an inpatient rehabilitation facility. Body weight loss threshold and Weight Loss Grading Scale identified patients with and without cachexia. Main outcomes were functional independence measure scores, discharge destination, and 6-mo survival.

RESULTS

Prevalence of cachexia in inpatient rehabilitation was 59% using consensus body weight loss criteria, and 77% of cancer patients had a Weight Loss Grading Scale score greater than 0. Patients with and without cachexia had similar motor and cognitive gains, although patients with severe cachexia had more limited functional gains ( P < 0.05) and increased odds of acute care return ( P < 0.01). Patients with a Weight Loss Grading Scale score of 4 had decreased survival at 6 mos ( P < 0.05) compared with noncachectic patients.

CONCLUSIONS

These data suggest that there is a relationship between cachexia and recovery for cancer patients that should be further studied in rehabilitation settings.

Sarcopenia indicate poor survival in patients undergoing transarterial chemoembolization (TACE) for hepatic malignancies

BACKGROUND

Patient selection for transarterial chemoembolization (TACE) has remained challenging. Currently used markers mainly reflect liver function and turned out as less reliable in larger clinical trials. The patients´ body composition has been linked with patient outcome in different cancers. Now, we analyzed the function of different parameters of the patient's body composition as prognostic and/ or predictive parameters in patients that received TACE.

METHODS

CT scans were used to assess five parameters of the individual body composition (skeletal muscle index (SMI), median muscular attenuation (MMA), bone mineral density (BMD) as well as the visceral and subcutaneous fat area) in 89 patients undergoing TACE. Results were correlated with tumor response to TACE and outcome of patients.

RESULTS

SMI and visceral fat area were significantly higher in male patients and among patients undergoing TACE for HCC compared to patients with liver metastases. While all parameters of the body composition did not predict response to TACE, patients with an SMI below the ideal cutoff value of 37.76 cm²/m² had a significantly reduced long-term outcome with a median overall survival of 404 days compared to 1321 days for patients with a high SMI. Moreover, the pre-interventional SMI turned out as an independent prognostic factor in a multivariate Cox regression model including clinicopathological parameters and laboratory markers of organ dysfunction and systemic inflammation (HR: 0.899, 95% CI 0.827-0.979, p = 0.014).

CONCLUSION

The pre-interventional SMI represents an independent prognostic factor for overall survival following TACE. Assessment of the individual body composition using routine CT scan might help to identify the ideal patients for TACE.

Evaluation of a Clinic-Based Exercise Program in Patients with Pancreatic Cancer Undergoing Nonsurgical Treatment

INTRODUCTION

Evidence regarding the role of exercise in pancreatic cancer (PanCa) is limited and is derived exclusively under tightly controlled research conditions. This study aimed to quantify adherence, adverse events, and changes in physical and psychological outcomes in any patients with PanCa referred to undertake exercise during nonsurgical treatment.

METHODS

The study involved 22 patients with localized or metastatic PanCa undertaking a clinic-based exercise program during chemotherapy or chemoradiotherapy. The program included supervised aerobic and resistance exercise undertaken twice weekly for 12 wk and a 12-wk follow-up with supervised exercise optional dependent on patient preference and condition. Patients were monitored for adherence and adverse events. Objective and patient-reported outcomes were assessed at baseline, 12 wk, and 24 wk.

RESULTS

A total of 251 sessions were attended by 19 patients over the first 12 wk (attendance rate, 55%). Complete case analyses indicated significant ( P < 0.05) improvements in functional ability (5.2%-17.2%), muscle strength (16.9%-25.1%), and static balance (6.8%). There were no significant changes in body composition or patient-reported outcomes except for sleep quality, which deteriorated; however, at an individual level, several patients had clinically relevant improvements in cancer-related fatigue and quality of life. Patients who continued with supervised exercise to week 24 largely preserved improvements in functional ability, muscle strength, and static balance. No serious adverse events resulted from the exercise program.

CONCLUSIONS

Individualized, supervised aerobic and resistance exercise in a clinic-based setting appears to be safe and may improve or maintain physical and psychological health in patients with PanCa undergoing nonsurgical treatment.

Effectiveness of combined nutrition and exercise interventions on body weight, lean mass, and fat mass in adults diagnosed with cancer: a systematic review and meta-analysis

CONTEXT

Changes in body weight and composition (fat and lean mass) are prominent side effects of cancer treatment. Nutrition and exercise interventions are both key strategies to protect against these adverse effects, yet their impact when combined has not been comprehensively reviewed in adults with cancer.

OBJECTIVE

This systematic review and meta-analysis aims to assess the effects of combined nutrition and exercise interventions on body weight and composition in adults with cancer.

DATA SOURCES

Four databases were searched until January 2021. Combined nutrition and exercise randomized controlled trials that detailed the nutrition and exercise prescription and reported body weight and composition outcomes were eligible.

DATA EXTRACTION

Risk of bias was assessed through the Cochrane Collaboration tool. The number of participants, mean values, and standard deviations of the outcome variables were extracted. Mean differences (MDs) were pooled using random-effects models. Predetermined subgroup analyses included cancer type, intervention intent, exercise modality, and use of behavior change strategies.

DATA ANALYSIS

Twenty-three RCTs were included. Nutrition plus exercise interventions significantly reduced body weight (MD -  2.13 kg; 95%CI, - 3.07 to - 1.19), fat mass (MD - 2.06 kg; 95%CI, - 3.02 to - 1.09), and lean mass (MD - 0.43; 95%CI, - 0.82 to - 0.04). Subgroup analyses in women with breast cancer showed that weight loss interventions and interventions incorporating behavior change strategies significantly reduced body weight and fat mass but also reduced lean mass. Interventions aiming to maintain body weight showed no changes in body weight, as intended.

CONCLUSION

Combined nutrition and exercise interventions successfully reduce body weight and fat mass in adults with cancer but also reduce lean mass. In contrast, weight loss-focused interventions are associated mostly with reduced lean mass.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020161805.

Ultrasonography for Assessment of Sarcopenia: A Primer

The human skeletal muscle has a pivotal role in preserving health by maintaining mobility, balance, and metabolic homeostasis. Significant muscle loss as a part of aging and accelerated by disease leads to sarcopenia which becomes an important predictor of quality of life in older persons. Therefore, clinical screening for sarcopenia and validation by precise qualitative and quantitative measurement of skeletal muscle mass (MM) and function is at the center-stage of translational research. Many imaging modalities are available, each having their strengths and limitations, either in interpretation, technical processes, time constraints, or expense. B-mode ultrasonography (US) is a relatively novel approach to evaluating muscle. It can measure several parameters such as MM and architecture simultaneously including muscle thickness, cross-sectional area, echogenicity, pennate angle, and fascicle length. It can also evaluate dynamic parameters like muscle contraction force and muscle microcirculation. US has not gained global attention due to a lack of consensus on standardization and diagnostic threshold values to diagnose sarcopenia. However, it is an inexpensive and widely available technique with clinical applicability. The ultrasound-derived parameters correlate well with strength and functional capacity and provide potential prognostic information. Our aim is to present an update on the evidence-based role of this promising technique in sarcopenia, its advantages over the existing modalities, and its limitations in actual practice with the hope that it may emerge as the "stethoscope" for community diagnosis of sarcopenia.

Frailty in Patients Undergoing Surgery for Brain Tumors: A Systematic Review of the Literature

BACKGROUND

Emerging literature suggests that frailty may be an important driver of postoperative outcomes in patients undergoing surgery for brain tumors. We systematically reviewed the literature on frailty in patients with brain tumor with respect to 3 questions: What methods of frailty assessment have been applied to patients with brain tumor? What thresholds have been defined to distinguish between different levels of frailty? What clinical outcomes does frailty predict in patients with brain tumor?

METHODS

A literature search was conducted using PubMed, Embase, The Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov. Included studies were specific to patients with brain tumor, used a validated instrument to assess frailty, and measured the impact of frailty on postoperative outcomes.

RESULTS

Of 753 citations, 21 studies met our inclusion criteria. Frailty instruments were studied, in order of frequency reported, including the 5-factor modified frailty index, 11-factor modified frailty index, Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator, and Hopkins Frailty Score. Multiple different conventions and thresholds were reported for distinguishing the levels of frailty. Clinical outcomes associated with frailty included mortality, survival, complications, length of stay, charges, costs, discharge disposition, readmissions, and operative time.

CONCLUSIONS

Frailty is an increasingly popular concept in patients with brain tumor that is associated with important clinical outcomes. However, the extant literature is largely comprised of retrospective studies with heterogeneous definitions of frailty, thresholds for defining levels of frailty, and patient populations. Further work is needed to understand best practices in assessing frailty in patients with brain tumor and applying these concepts to clinical practice.

The Interplay Among Pancreatic Cancer, Cachexia, Body Composition, and Diabetes

Pancreatic ductal adenocarcinoma (PDAC) is associated with complex changes in body composition. Visceral obesity and type 2 diabetes mellitus are established risk factors for developing PDAC; however, clinical and metabolic features of PDAC commonly lead to cancer cachexia, a hypermetabolic syndrome characterized by weight loss secondary to muscle and adipose tissue wasting. Reduction in muscle mass in patients with PDAC is associated with poorer survival in patients undergoing surgical resection and increased chemotherapy toxicity. Although no standardized treatment exists, a multidisciplinary, tailored, symptom-based approach is recommended to improve outcomes and quality of life for patients with PDAC and cachexia.

Association between Temporal Muscle Thickness and Overall Survival in Non-Small Cell Lung Cancer Patients with Brain Metastasis

Temporal muscle thickness (TMT) has recently been suggested as a novel biomarker of sarcopenia in head and neck malignancies. However, few studies have evaluated TMT as a prognostic marker in patients with brain metastasis. This study investigated the association of TMT with overall survival (OS) in non-small cell lung cancer (NSCLC) patients with brain metastasis. The records of all NSCLC patients with brain metastasis between 2009 and 2018 at St. Vincent’s Hospital were reviewed retrospectively. A total of 221 patients met our eligibility criteria. In the group with TMT thicker than the median, OS was longer than the group with TMT thinner than the median (240 days versus 139 days, p = 0.014). In multivariate analysis, the thicker TMT group had longer survival (HR 0.73 CI 0.56−0.96, p = 0.024). Male (HR 1.58 CI 1.19−2.09, p = 0.002) and older age (≥65 years) (HR 2.05 CI 1.53−2.74, p < 0.001) also showed statistical significance. We also performed subgroup analysis in older patients (≥65 years). In this subgroup of 107 patients, the thicker TMT group also showed longer OS than the thinner TMT group (209 days versus 82 days, p = 0.009). Our findings suggest that TMT can be a useful biomarker for OS in NSCLC patients with brain metastasis.

Coexistence of GLIM-defined malnutrition and sarcopenia have negative effect on the clinical outcomes in the elderly gastric cancer patients after radical gastrectomy

Background

Malnutrition and sarcopenia are common in elderly gastric cancer patients, which are also interrelated and affect each other. We aimed to determine the characteristics of coexistence of malnutrition and sarcopenia in the elderly gastric cancer patients and investigate the predictive roles of malnutrition and sarcopenia on clinical outcomes.

Methods

Between 2014 and 2019, a total of 742 elderly gastric cancer patients were enrolled. Malnutrition and sarcopenia were diagnosed according to the most recent diagnostic criteria. Patients were divided into four groups according to presence of these two symptoms. Clinical characteristics, short- and long-term outcomes were compared among four groups. The independent risk factors for complications and survival were evaluated using univariate and multivariate analyses.

Results

Of all patients, 34.8% were diagnosed with malnutrition and 34.0% were diagnosed with sarcopenia. Patients with both malnutrition and sarcopenia had the highest rate of total (P < 0.001), surgical (P = 0.003), and medical complications (P = 0.025), and the highest postoperative hospital stays (P < 0.001) and hospitalization costs (P < 0.001). They also had the worst overall survival (P < 0.0001) and disease-free survival (P < 0.0001). Sarcopenia and Charlson Comorbidity Index (≥2) were independent risk factors for total complications. Hypoalbuminemia and malnutrition were non-tumor-related independent risk factors for overall survival and disease-free survival.

Conclusions

Malnutrition and sarcopenia had superimposed negative effects on elderly gastric cancer patients. Preoperative geriatric evaluation including screening for malnutrition and sarcopenia are recommended for all elderly gastric cancer patients for accurate treatment strategy.

The association between geriatric assessment, muscle measures, and treatment-related toxicity in older adults with cancer: An Israeli prospective study

INTRODUCTION

We investigated the associations among frailty, as determined via the comprehensive geriatric assessment (CGA), muscle measures (i.e., sarcopenia), and treatment-related toxicity in older adults with cancer in Israel.

MATERIALS AND METHODS

This prospective cohort study enrolled patients ≥65 years with newly-diagnosed stage IV lung, breast, or genitourinary cancer. Patients were enrolled and completed CGA before their first line of systemic therapy (chemotherapy, biologic therapy, immunologic therapy, or a combination thereof). CGA was used to classify patients as robust, pre-frail, or frail, and routine pre-treatment computed tomography (CT) images were used to quantify skeletal muscle index (SMI) and skeletal muscle density (SMD) at L3 cross-section. Two sarcopenia definitions were used: i. for women SMI <41 cm²/m² regardless of body mass index (BMI), and for men SMI <43 cm²/m² for those with BMI of <25 and < 53 cm²/m² for those with BMI ≥25; and ii. SMI <38 cm²/m² for women and < 41 cm²/m² for men, regardless of BMI. The associations between frailty and muscle measures with the occurrence of at least one adverse event (AE) grade ≥ 2 were examined using the chi-square test, and logistic regression to determine odds ratio (OR) and 95% confidence interval (CI).

RESULTS

In total, 51 patients were included in the analysis. The median (interquartile range) age was 72 (68-76) years, 30 (59%) were male, and 26 (51%) had lung cancer. CGA data were available for 48 patients: fifteen (31%), thirteen (27%), and twenty (42%) were defined as robust, pre-frail, and frail, respectively. Overall, 33 (65%) were sarcopenic by the first aforementioned definition, and sixteen (31%) by the second. No statistically significant associations were identified between frailty and having at least one AE grade ≥ 2, or between frailty and sarcopenia. Statistically significant associations were found between having sarcopenia (the second definition) and having at least one AE grade ≥ 2 (P = 0.0217). The corresponding odds ratio (95% CI) was 4.2 (1.2-15.0), P = 0.026.

DISCUSSION

Our findings suggests that sarcopenia is significantly associated with treatment-related toxicity. Further studies with larger sample sizes are warranted.

Shared and Divergent Epigenetic Mechanisms in Cachexia and Sarcopenia

Significant loss of muscle mass may occur in cachexia and sarcopenia, which are major causes of mortality and disability. Cachexia represents a complex multi-organ syndrome associated with cancer and chronic diseases. It is often characterized by body weight loss, inflammation, and muscle and adipose wasting. Progressive muscle loss is also a hallmark of healthy aging, which is emerging worldwide as a main demographic trend. A great challenge for the health care systems is the age-related decline in functionality which threatens the independence and quality of life of elderly people. This biological decline can also be associated with functional muscle loss, known as sarcopenia. Previous studies have shown that microRNAs (miRNAs) play pivotal roles in the development and progression of muscle wasting in both cachexia and sarcopenia. These small non-coding RNAs, often carried in extracellular vesicles, inhibit translation by targeting messenger RNAs, therefore representing potent epigenetic modulators. The molecular mechanisms behind cachexia and sarcopenia, including the expression of specific miRNAs, share common and distinctive trends. The aim of the present review is to compile recent evidence about shared and divergent epigenetic mechanisms, particularly focusing on miRNAs, between cachexia and sarcopenia to understand a facet in the underlying muscle wasting associated with these morbidities and disclose potential therapeutic interventions.

Prognostic value of sarcopenia in patients with rectal cancer: A meta-analysis

Background

Sarcopenia is usually characterized by the loss of skeletal muscle mass and impaired muscle function which is commonly seen in the elderly. It has been found to be associated with poorer prognoses in many types of cancer. Computed tomography (CT) scan is frequently used to assess skeletal muscle mass and further calculate skeletal muscle index (SMI) at the third lumbar vertebra level (L3), which is used to define sarcopenia. The purpose of this meta-analysis was to assess the prognostic value of sarcopenia for overall survival (OS) in patients with rectal cancer.

Methods

We performed a systematic search to find relevant studies published up to 14 January 2021 in PubMed, Embase, Web of science and Scopus. In our meta-analysis, studies comparing OS in rectal cancer patients with sarcopenia versus those without were included. Quality assessment for included studies was evaluated according to the Quality in Prognosis Studies (QUIPS) tool. We directly extracted hazard ratios (HRs) with 95% confidence intervals (CIs) in both univariate and multivariate analyses from each study. The Cochrane Collaboration’s Review Manager 5.4 software was applied to analyze data. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines and website GRADEpro.

Results

Finally, a total of 7 studies involving 2377 patients were included. The pooled HRs were 2.10 (95% CI 1.33–3.32, P = 0.001) and 2.37 (95% CI 1.13–4.98, P = 0.02) using random-effects models in univariate and multivariate analyses, respectively. The results showed a significant association between sarcopenia and OS in patients with rectal cancer. The quality of the evidence for OS was moderate for both univariate and multivariate analyses.

Conclusion

CT-defined sarcopenia is an independent predictor for worse OS in patients with rectal cancer. Future studies with a more stringent definition of sarcopenia are required to further confirm our findings.

A Review of the Clinical Implications of Cachexia, Sarcopenia, and BMI in Patients with Peritoneal Carcinomatosis Receiving Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Simple Summary

Patients with peritoneal carcinomatosis from varying cancers may be affected by weight loss and decreased muscle mass, the hallmarks of cachexia. These patients can undergo surgical management via cytoreductive surgery and hyperthermic intraperitoneal chemotherapy to improve their overall survival. Here, we review the current literature investigating the impact of sarcopenia, cachexia, and body mass index on outcomes in a patient population that undergo surgical treatment. The results vary across the studies suggesting that further investigation is necessary to better understand the impact of these entities on postoperative outcomes and survival.

Abstract

Peritoneal carcinomatosis (PC) is the dissemination of cancer throughout the peritoneal cavity. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the surgical treatment of choice in highly selected patients. The aim of this narrative review was to assess the impact of cachexia, sarcopenia, and body mass index (BMI) on patient outcomes for patients undergoing CRS and HIPEC for peritoneal carcinomatosis. A narrative review was performed and articles pertaining to cachexia, sarcopenia, BMI, peritoneal carcinomatosis, and CRS/HIPEC were reviewed and selected. In total, 3041 articles were screened and seven original studies met the inclusion criteria. In summary, obesity was found to not be a contraindication to surgery, but the impact of BMI was variable across the spectrum. Decreased skeletal muscle mass was found to be associated with poorer postoperative outcomes in three studies and with worse overall survival in two. With limited data, evaluating the impact of BMI, sarcopenia, and cachexia on patients with PC undergoing CRS and HIPEC was difficult as most studies included heterogeneous cancer patient populations; thus, postoperative outcomes and survival were inconsistent across studies. More research is needed to better understand its impact and to better generalize the results for each cancer subset treated with CRS and HIPEC across diverse patient populations.

Imaging of Sarcopenia

Sarcopenia is currently underdiagnosed and undertreated, but this is expected to change because sarcopenia is now recognized with a specific diagnosis code that can be used for billing in some countries, as well as an expanding body of research on prevention, diagnosis, and management. This article focuses on practical issues of increasing interest by highlighting 3 hot topics fundamental to understanding sarcopenia in older adults: definitions and terminology, current diagnostic imaging techniques, and the emerging role of opportunistic computed tomography.

Patient reported outcomes in oncology: changing perspectives-a systematic review

In public health context, oncology is associated with severe negative impact on patients and on their relatives’ quality of life. Over the last decades, survival has remained at 50% worldwide for some tumor locations. Patient reported outcomes (PROs) assessment and, the corresponding use in clinical practice, help establishing patient individualized profiling involving caregivers. The purpose of this systematic review was to examine critical success factors for PROs assessment in daily clinical oncology practice. Additionally, we investigated how PROs collection can change oncology perspectives for patients and caregivers. According to PRISMA guidelines, 83 studies were included in this systematic review, whether related with implementation in daily clinical practice or associated with its use in oncology. PROs assessment gathers multi-professional teams, biomedical and clinical expertise, patients, families and caregivers. Institutional involvement, first line for caregiver’s adherence, team continuous formation, encompassing training and support, design of clear workflows, continuous monitoring, and data analysis are crucial for implementation. PROs measures are decisive in oncology. Several items were improved, including caregiver–patient–physician communication, patient risk groups identification, unmet problems and needs detection, disease course and treatment tracking, prognostic markers, cost-effectiveness measurement and comfort/support provision for both patients and caregivers. Routine assessment and implementation of PROs in clinical practice are a major challenge and a paradigm transformation for future.

Low skeletal muscle mass and post-operative complications after surgery for liver malignancies: a meta-analysis

Purpose

To assess the influence of low skeletal muscle mass (LSMM) on post-operative complications in patients with hepatic malignancies grade (Clavien Dindo ≥ 3) undergoing resection.

Methods

MEDLINE, Cochrane, and SCOPUS databases were screened for associations between sarcopenia and major post-operative complications (≥ grade 3 according to Clavien-Dindo classification) after resection of different malignant liver tumors. RevMan 5.3 software was used to perform the meta-analysis. The methodological quality of the included studies was assessed according to the QUIPS instrument.

Results

The analysis included 17 studies comprising 3157 patients. Subgroup analyses were performed for cholangiocarcinoma (CCC), colorectal cancer (CRC) liver metastases, and hepatocellular carcinoma (HCC). LSMM as identified on CT was present in 1260 patients (39.9%). Analysis of the overall sample showed that LSMM was associated with higher post-operative complications grade Clavien Dindo ≥ 3 (OR 1.56, 95% CI 1.25–1.95, p < 0.001). In the subgroup analysis, LSMM was associated with post-operative complications in CRC metastases (OR 1.60, 95% CI 1.11–2.32, p = 0.01). In HCC and CCC sub-analyses, LSMM was not associated with post-operative complications in simple regression analysis.

Conclusion

LSMM is associated with major post-operative complications in patients undergoing surgery for hepatic metastases and it does not influence major post-operative complications in patients with HCC and CCC.

A Cross-Sectional Study on the Relationship between Oral Function and Sarcopenia in Japanese Patients with Regular Dental Maintenance

We aimed to clarify the relationship between oral function assessments regarding oral hypofunction and sarcopenia in patients who had completed treatment for organic dental problems, including oral pain, removable denture fit, and tooth loss. This cross-sectional study included 269 patients aged ≥65 years (mean age 74.9 ± 6.50 years, 133 men, 136 women) who visited a dental clinic between June 2019 and March 2021. We evaluated oral function and sarcopenia and analyzed their relationship using the Jonckheere–Terpstra test, Mantel–Haenszel trend test, and Poisson regression analysis. We diagnosed 132 (49.07%) patients with oral hypofunction, 30 (11.2%) with sarcopenia, and 24 (8.9%) with severe sarcopenia. The number of oral hypofunction items (prevalence rate ratio [PRR] = 1.39, 95%Wald = 0.11 to 0.56) was significantly associated with sarcopenia. For each of the items, tongue-lip motor function [ta] (PRR = 0.80, 95%Wald = −0.44 to −0.02)] [ka] (PRR = 0.76, 95%Wald = −0.53 to −0.03) and tongue pressure (PRR = 0.95, 95%Wald = −0.09 to −0.02) showed a significant association with sarcopenia. However, no significant association was found for other variables. Dentists should not only treat organic dental problems but also consider the relationship between oral function and sarcopenia.

Impact of Skeletal Muscle Measurements by Chest Computed Tomography on Survival and Postoperative Complications in Patients with Soft Tissue Sarcoma

This study aims to evaluate whether sarcopenia, measured by chest computed tomography (CT), affects survival outcomes and postoperative complications in soft tissue sarcoma (STS) patients undergoing surgery. In this retrospective study, CT scans of 79 patients were reviewed to measure pectoralis and T12 vertebra muscle area. Both were then adjusted for height (cm²/m²) as pectoralis muscle index (PMI) and T12 vertebra muscle index (TMI). Analyses were performed by dichotomizing muscle indices at gender-specific 50th percentile; PMI and TMI < 50th percentile were defined as low, and ≥50th percentile as high. Overall postsurgical complication rate (PCR) was 16%. Median length of hospital stay (LOHS) was 10 days (3-90). PMI and TMI were significantly lower in women (p = 0.02, p = 0.04). Median body mass index was significantly higher in high PMI and TMI groups (p = 0.01 for both). PCR and LOHS were similar between low and high PMI and TMI groups. Median follow-up was 29 months, 37 patients had recurrence and 23 died. No significant difference was noted between low and high PMI and TMI groups, in terms of disease-free or overall survival. PMI and TMI as measured by chest CT had no impact on survival outcomes or postoperative complications in localized STS.

Grip Strength in Patients with Gastrointestinal Diseases

We sought to elucidate factors contributing to the grip strength (GS) decline in patients with gastrointestinal diseases (Ga-Ds, n = 602, 379 males, median age = 72 years). The GS decline in males and females was defined as <28 kg and <18 kg, respectively, following the current Asian guidelines. The median GS (male) was 28.8 kg, and GS decline (male) was found in 169 patients (44.6%). The median GS (female) was 17.5 kg, and GS decline (female) was found in 122 patients (54.7%). Advanced cancer was identified in 145 patients (24.1%). In terms of the univariate analysis of parameters of the GS decline, age (p < 0.0001), gender (p = 0.0181), body mass index (BMI, p = 0.0002), ECOG-PS (p < 0.0001), SARC-F score (p < 0.0001), hemoglobin value (p < 0.0001), total lymphocyte count (p < 0.0001), serum albumin value (p < 0.0001), C reactive protein (CRP) value (p < 0.0001), and estimated glomerular filtration rate were statistically significant. In terms of the multivariate analysis, age (p < 0.0001), BMI (p = 0.0223), hemoglobin value (p = 0.0186), serum albumin value (p = 0.0284), the SARC-F score (p = 0.0003), and CRP value (p < 0.0001) were independent parameters. In conclusion, the GS decline in patients with Ga-Ds is closely associated with not only the primary factor (i.e., aging) but also secondary factors such as inflammatory factors and nutritional factors.