Pre-Disease and Pre-Surgery BMI, Weight Loss and Sarcopenia Impact Survival of Resected Lung Cancer Independently of Tumor Stage

The prognostic value and model construction of inflammatory markers for patients with non-small cell lung cancer

The aim of this study was to investigate and analyse the predictive value of systemic inflammatory markers based on peripheral blood biomarkers for the prognosis of non-small cell lung cancer (NSCLC) patients. Based on a retrospective monitoring cohort of 973 NSCLC patients from an Affiliated Tumor Hospital from 2012 to 2023. The log-rank test and Cox proportional risk regression model were used to identify independent prognostic inflammatory markers. Subsequently, a nomogram prediction model was constructed and evaluated. The results of multivariate Cox regression analysis showed that patients with high NLR group (HR = 1.238, 95% CI 1.015-1.510, P = 0.035), and high CAR group (HR = 1.729, 95% CI 1.408-2.124, P < 0.001) were risk factors affecting the prognosis of NSCLC patients. The nomogram that includes age, tumor stage, smoking history, BMI, NLR, and CAR can effectively predict the prognosis of NSCLC patients.The inflammatory markers NLR and CAR, which combine inflammatory and nutritional status, are effective predictors of the prognosis of NSCLC patients. The combination of clinical information and these easily accessible inflammatory markers has significant research value for prognostic assessment, clinical treatment, and follow-up monitoring of NSCLC patients.

Protective effect of height on long-term survival of resectable lung cancer: a new feature of the lung cancer paradox

INTRODUCTION

Unlike most malignancies, higher body mass index (BMI) is associated with a reduced risk of lung cancer and improved prognosis after surgery. However, it remains controversial whether height, one of determinants of BMI, is associated with survival independently of BMI and other confounders.

METHODS

We extracted data on all consecutive patients with resectable non-small cell lung cancer included in Epithor, the French Society of Thoracic and Cardiovascular Surgery database, over a 16-year period. Height was analysed as a continuous variable, and then categorised into four or three categories, according to sex-specific quantiles. Cox proportional hazards regression was used to estimate the association of height with survival, adjusted for age, tobacco consumption, forced expiratory volume in one second (FEV1), WHO performance status (WHO PS), American Society of Anesthesiologists (ASA) score, extent of resection, histological type, stage of disease and centre as a random effect, as well as BMI in a further analysis.

RESULTS

The study included 61 379 patients. Higher height was significantly associated with better long-term survival after adjustment for other variables (adjusted HR 0.97 per 10 cm higher height, 95% CI 0.95 to 0.99); additional adjustment for BMI resulted in an identical HR. The prognostic impact of height was further confirmed by stratifying by age, ASA class, WHO PS and histological type. When stratifying by BMI class, there was no evidence of a differential association (p=0.93). When stratifying by stage of disease, the prognostic significance of height was maintained for all stages except IIIB-IV.

CONCLUSIONS

Our study shows that height is an independent prognostic factor of resectable lung cancer.

Predictors of Long-Term Survival of Thoracoscopic Lobectomy for Stage IA Non-Small Cell Lung Cancer: A Large Retrospective Cohort Study

The standard of care for patients with early-stage non-small cell lung cancer (NSCLC) is anatomical lung resection with lymphadenectomy. This multicenter, retrospective, cohort study aimed to identify predictors of 5-year survival in patients after thoracoscopic lobectomy for stage IA NSCLC. The study included 1249 patients who underwent thoracoscopic lobectomy for stage IA NSCLC between 17 April 2007, and December 28, 2016. The 5-year survival rate equaled 77.7%. In the multivariate analysis, higher age (OR, 1.025, 95% CI: 1.002 to 1.048; p = 0.032), male sex (OR, 1.410, 95% CI: 1.109 to 1.793; p = 0.005), chronic obstructive pulmonary disease (OR, 1.346, 95% CI: 1.005 to 1.803; p = 0.046), prolonged postoperative air leak (OR, 2.060, 95% CI: 1.424 to 2.980; p < 0.001) and higher pathological stage (OR, 1.271, 95% CI: 1.048 to 1.541; p = 0.015) were related to the increased risk of death within 5 years after surgery. Lobe-specific mediastinal lymph node dissection (OR, 0.725, 95% CI: 0.548 to 0.959; p = 0.024) was related to the decreased risk of death within 5 years after surgery. These findings provide valuable insights for clinical practice and may contribute to improving the quality of treatment of early-stage NSCLC.

Evaluation of Efficacy of ALK Inhibitors According to Body Mass Index in ALK Rearranged NSCLC Patients-A Retrospective Observational Study

No evidence exists as to whether body mass index (BMI) impairs clinical outcomes from ALK inhibitors (ALKi) in patients with ALK-rearranged non-small cell lung cancer (NSCLC). Retrospective data of patients affected by metastatic ALK-rearranged NSCLC treated with ALKi were collected. We divided patients into "low- BMI" (≤25 kg/m²) and "high- BMI" (>25 kg/m²) categories and correlated them with overall survival (OS) and progression-free survival (PFS). We included 40 patients treated with ALKi. We observed a 3-year OS of 81.5% in high-BMI vs. 49.6% in low-BMI categories (p = 0.049); the 3-year first-line PFS was superior in high-BMI vs. low-BMI patients (47% vs. 19%, p = 0.019). As expected, patients treated with Alectinib had a 55.6% 3-year PFS vs. 7.1% for others treated with ALKi (p = 0.025). High-BMI was associated with a 100% 3-year PFS rate vs. 25.4% in low-BMI Alectinib patients (p = 0.03). BMI was independently correlated with first-line PFS and OS at multivariate analysis with PS (HR 0.39, CI 95% 0.16-0.96, p = 0.042; HR 0.18, CI 95% 0.05-0.61, p = 0.006). High-BMI was associated with higher efficacy in ALK-rearranged patients. These results are particularly exciting for Alectinib and could be correlated to mechanisms that should be investigated in subsequent prospective studies.

The effect of perioperative immunonutritional support on nutritional and inflammatory status in patients undergoing lung cancer surgery: a prospective, randomized controlled study

PURPOSE

Nutritional status is affected in patients who undergo lung cancer surgery (LCS). This study is aimed at investigating the effects of the use of immunonutritional support in the perioperative period on nutritional and inflammatory status in patients undergoing LCS.

METHODS

A single-center, prospective, randomized controlled clinical trial was conducted with seventy patients planning to have LCS and randomized into treatment (TG) and control groups (CG). Immunonutritional support was given orally twice a day for ten days before the operation and five days after the operation in the treatment group. The nutritional status of the patients was screened with the Patient-Generated Subjective Global Assessment (PG-SGA); the Prognostic Nutrition Index (PNI) and the Systemic Inflammation Index (SII) were calculated. The physical activity status was assessed with the Eastern Cooperative Oncology Group Performance Status (ECOG-PS).

RESULTS

Post-op nutritional status of the TG patients was better than the CG group (p = 0.009). Post-operative PG-SGA score was higher than preoperative PG-SGA score in both groups (p < 0.001). In the post-operative period, nutritional status (in terms of PG-SGA score category) in the patients in the TG was better than the CG (p = 0.046). In both groups, post-op ECOG score was higher than the pre-op ECOG score (p < 0.001). Post-op physical performance status was found to be better in the TG compared to the CG (p = 0.001). PNI level decreased statistically and significantly in the post-op period compared to the pre-op period, SII levels increased.

CONCLUSION

Patients who will undergo LCS should be supported in terms of immunonutrition starting from the preoperative period.

Usefulness of 18 F-FDG PET/computed tomography metabolic parameters in predicting sarcopenia and prognosis of treatment-naive patients with non-small cell lung cancer

PURPOSE

Sarcopenia tremendously impacts the quality of life but remains debatable in prognostication in treatment-naive patients with non-small cell lung cancer (NSCLC). Hence, this study aimed to find a clinically feasible approach using 18 F-FDG PET/computed tomography (CT) imaging parameters and clinical characteristics to predict sarcopenia and determine independent prognostic factors.

METHODS

Clinical characteristics and 18 F-FDG PET/CT metabolic parameters, including maximum standard uptake value, metabolic tumor volume, and total lesion glycolysis of primary tumor (SUVmax_P, MTV_P, and TLG_P) and combination of whole-body lesions (MTV_C and TLG_C) were collected in 344 treatment-naive patients with NSCLC. Skeletal muscle index at the third lumbar vertebra was calculated to determine sarcopenia. SUVmax of the psoas major muscle (SUVmax_M) was measured at the third lumbar vertebra as well. The diagnostic endpoint is the probability of sarcopenia, and the survival endpoints include progression-free survival (PFS) and overall survival (OS).

RESULTS

Among 344 patients with NSCLC there were 271 patients with adenocarcinoma and 73 with squamous cell carcinoma (SCC). One hundred forty-seven patients (42.7%) were diagnosed with sarcopenia. Higher age, male, lower BMI, SCC, and lower SUVmax_M were correlated with a higher incidence of sarcopenia ( P  < 0.05), while age, sex and SUVmax_M were independently predictive of sarcopenia. Multivariate Cox-regression analysis revealed that BMI, advanced stage and TLG_C were independent predictors of PFS and OS, while sex was independently predictive of OS.

CONCLUSIONS

The incidence of sarcopenia increased with declining SUVmax of muscle. BMI, tumor stage, and TLG_C, but not sarcopenia, were found independently predictive of both PFS and OS.

Physiological relationship between cardiorespiratory fitness and fitness for surgery: a narrative review

Epidemiological evidence has highlighted a strong relationship between cardiorespiratory fitness and surgical outcomes; specifically, fitter patients possess heightened resilience to withstand the surgical stress response. This narrative review draws on exercise and surgical physiology research to discuss and hypothesise the potential mechanisms by which higher fitness affords perioperative benefit. A higher fitness, as indicated by higher peak rate of oxygen consumption and ability to sustain metabolic homeostasis (i.e. higher anaerobic threshold) is beneficial postoperatively when metabolic demands are increased. However, the associated adaptations with higher fitness, and the related participation in regular exercise or physical activity, might also underpin the observed perioperative benefit through a process of hormesis, a protective adaptive response to the moderate and intermittent stress of exercise. Potential mediators discussed include greater antioxidant capacity, metabolic flexibility, glycaemic control, lean body mass, and improved mood.

Overweight and Obesity are Associated with Poorer Survival Among Patients with Advanced Non-Small Cell Lung Cancer Receiving Platinum-Based Chemotherapy

Background and Aim

Most patients with non-small cell lung cancer (NSCLC) are diagnosed in advanced-stage disease and therefore have poor overall survival. It remains unclear whether nutritional status affects response rate and overall survival in NSCLC patients. This study aimed to evaluate the association of nutritional status with treatment response and overall survival in patients with advanced stage of NSCLC.

Methods

Patients aged ≥18 years with stage II-IV NSCLC (January-June 2018) in a national cancer center in Indonesia were enrolled in this study. The patients were followed up for 2 years since NSCLC diagnosis was established. Clinical data including age, sex, histology of cancer, disease stage, cachexia, and weight status before chemotherapy were reviewed and analyzed. Logistic regression and Cox regression analyses were performed.

Results

A total of 174 patients (71% males, mean age = 58±9.4 years) was included. Complete response was found in <1% patients, partial response 41%, stable disease 33%, and progressive disease 25%. Median survival was 12 months (95% CI: 11-13 months). Mortality rate was 5.7 per 100 person-months. Poor survival was associated with being males (HR: 1.77, 95% CI: 1.15-2.72, P = 0.009), and overweight or obesity (HR 1.67, 95% CI: 1.04-2.69, P = 0.034). These associations were independent of sex, age, staging, histopathology, performance status and D-dimer level at baseline. Cachexia and BMI at baseline were not associated with treatment response.

Conclusion

Males and having overweight or obesity are independently associated with lower survival in patients with advanced stage of NSCLC undergoing platinum-based chemotherapy.

The Effect of Body Mass Index on Survival in Lung Cancer

The prognostic significance of body mass index in lung cancer and the direction of this relationship are not yet clear. This study aimed to evaluate the relationship between BMI and overall survival time of advanced-stage lung cancer patients treated in a center in Turkey, a developing country. In this study, the data of 225 patients diagnosed with stage III or stage IV lung cancer between 2016 and 2020 were analyzed. The effects of BMI and other variables on survival were examined by Cox regression analysis for NSCLC and SCLC. For NSCLC and SCLC, being underweight compared to the normal group, being diagnosed at a more advanced stage, and having a worse performance score were associated with a significantly higher risk of death. Other variables significantly associated with survival were gender, type of radiotherapy for NSCLC, age group, and family history for SCLC. This study showed that being underweight relative to the normal group was associated with worse survival for NSCLC and SCLC but did not support the obesity paradox. Studies that are representative of all BMI categories and free of bias are needed to understand the BMI-lung cancer survival relationship clearly.

Prognostic score and sex-specific nomograms to predict survival in resectable lung cancer: A French nationwide study from the Epithor cohort database

Background

Prognostic assessment in patients undergoing cancer treatments is of paramount importance to plan subsequent management. In resectable lung cancer availability of an easy-to use nomogram to predict long-term outcome would be extremely useful to identify high-risk patients in the era of perioperative targeted and immune therapies.

Methods

We retrieved clinical, surgical and pathological data of all consecutive patients included in Epithor, the database of French Society of Thoracic and Cardiovascular Surgery, and operated on between 2003 and 2020 for non-small cell lung cancer in a curative intent. The primary endpoint was overall survival up to 5 years. We assessed prognostic significance of available variables using Cox modelling, in the whole dataset, and in men and in women separately, and performed temporal validation. Finally, we constructed two sex-specific nomograms. Survivals by fifths of score were assessed in the development and temporal validation sets.

Findings

The study included 62,633 patients (43,551 men and 19,082 women). Median survival time was 9.2 years. Nine factors had strong prognostic impact and were used to construct nomograms. The optimism-corrected c statistic for the prognostic score was 0.689 in the development sample, and 0.726 (95% CI 0.718-0.735) in the temporal validation sample. All differences between adjacent fifths of score were significant (P < 0.0001). Figures of 3-year OS by fifths of score were 92.2%, 83.0%, 74.3%, 64.0%, and 43.4%, respectively, in the development set and 93.3%, 88.4%, 81.0%, 73.7%, 55.7% in the temporal validation set. Performance of score was maintained when stratifying by stage of diseases.

Interpretation

In the present work, we report evidence that long-term overall survival after resection of NSCLC can be predicted by an easy to construct and use composite score taking into account both host and tumour related factors.

Funding

Epithor is funded by FSTCVS.

Impact of sarcopenia on the prognosis and treatment of lung cancer: an umbrella review

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality worldwide. Sarcopenia, defined as the loss of muscle mass and function, is known to cause adverse health outcomes. The purpose of this umbrella review was to integrate published systematic reviews and meta-analyses exploring sarcopenia and lung cancer to provide comprehensive knowledge on their relationship.

METHODS

Eligible studies were searched from scientific databases until June 28, 2022. Critical appraisal was performed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2. The impact of sarcopenia on the pathophysiology, prevalence, and prognosis of lung cancer is summarized at the level of systematic reviews or meta-analyses.

RESULTS

Fourteen reviews and meta-analyses were conducted. The methodological quality was high for one review, low for nine, and critically low for four. The most common standard for diagnosing sarcopenia in the lung cancer population is computed tomography (CT) to measure the skeletal muscle index at the third lumbar vertebra (L3). Sarcopenia was highly prevalent among patients with lung cancer, with a pooled prevalence ranging from 42.8% to 45.0%. The association between sarcopenia and increased postoperative complications and decreased disease control rates with immune checkpoint inhibitors has been demonstrated. Mortality was significantly higher in sarcopenic patients than in non-sarcopenic patients with lung cancer, regardless of the stage of disease or type of treatment.

CONCLUSIONS

Sarcopenia is a poor prognostic factor for lung cancer. Future studies are necessary to clarify the pathophysiology of sarcopenia and develop effective interventions for sarcopenia in patients with lung cancer.

Feasibility study of a randomised controlled trial of preoperative and postoperative nutritional supplementation in major lung surgery

OBJECTIVES

Malnutrition and weight loss are important risk factors for complications after lung surgery. However, it is uncertain whether modifying or optimising perioperative nutritional state with oral supplements results in a reduction in malnutrition, complications or quality of life.

DESIGN

A randomised, open label, controlled feasibility study was conducted to assess the feasibility of carrying out a large multicentre randomised trial of nutritional intervention. The intervention involved preoperative carbohydrate-loading drinks (4×200 mL evening before surgery and 2×200 mL the morning of surgery) and early postoperative nutritional protein supplement drinks two times per day for 14 days compared with the control group receiving an equivalent volume of water.

SETTING

Single adult thoracic centre in the UK.

PARTICIPANTS

All adult patients admitted for major lung surgery. Patients were included if were able to take nutritional drinks prior to surgery and give written informed consent. Patients were excluded if they were likely unable to complete the study questionnaires, they had a body mass index <18.5 kg/m², were receiving parenteral nutrition or known pregnancy.

RESULTS

All patients presenting for major lung surgery were screened over a 6-month period, with 163 patients screened, 99 excluded and 64 (41%) patients randomised. Feasibility criteria were met and the study completed recruitment 5 months ahead of target. The two groups were well balanced and tools used to measure outcomes were robust. Compliance with nutritional drinks was 97% preoperatively and 89% postoperatively; 89% of the questionnaires at 3 months were returned fully completed. The qualitative interviews demonstrated that the trial and the intervention were acceptable to patients. Patients felt the questionnaires captured their experience of recovery from surgery well.

CONCLUSION

A large multicentre randomised controlled trial of nutritional intervention in major lung surgery is feasible and required to test clinical efficacy in improving outcomes after surgery.

TRIAL REGISTRATION NUMBER

ISRCTN16535341.

Association Between Obesity and Poor Prognosis in Patients Receiving Anlotinib for Advanced Non-Small Cell Lung Cancer

Background: Anlotinib is a novel anti-angiogenesis drug. In non-small cell lung cancer (NSCLC), high body mass index (BMI) was not associated with worse survival in patients treated with bevacizumab compared with those with normal or low BMI. However, it remains unknown whether such an association still exists in NSCLC patients receiving anlotinib therapy. Hence, we conducted this study to investigate whether BMI is associated with clinical outcomes in patients treated with anlotinib for advanced NSCLC. Methods: Data of 554 patients from the ALTER-0302 and the ALTER-0303 trials were analyzed in this study. The patients were classified into non-obesity (BMI <28 kg/m²) and obesity (BMI ≥28 kg/m²) subgroups. The primary endpoint was overall survival (OS). The secondary endpoints included progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR). OS was defined as the interval between the first drug administration and death. PFS was defined as the time span from the date of initiating the treatment to the first documented progression or death from any cause, whichever occurred first. ORR included complete response (CR) and partial response (PR). Results: There were 354 patients (63.9%) who received anlotinib in this study. Restricted cubic spline model showed a U-shaped relation between BMI and the risk of death in the anlotinib group. In a multivariable Cox regression model, a trend of worse overall survival was observed in obese patients who received anlotinib compared with placebo (HR, 2.33; 95% CI, 0.77-7.06; p = 0.136). The interaction between BMI stratification and treatment was significant for OS (P for interaction = 0.038). Conclusion: Our results revealed a U-shaped relationship between BMI and risk of death in patients receiving anlotinib for advanced NSCLC. More importantly, obesity (BMI ≥28 kg/m²) might be a potential predictor of use of anlotinib in advanced NSCLC.

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.

Updated Prognostic Factors in Localized NSCLC

Lung cancer is the most common cause of cancer mortality worldwide, and non-small cell lung cancer (NSCLC) represents 80% of lung cancer subtypes. Patients with localized non-small cell lung cancer may be considered for upfront surgical treatment. However, the overall 5-year survival rate is 59%. To improve survival, adjuvant chemotherapy (ACT) was largely explored and showed an overall benefit of survival at 5 years < 7%. The evaluation of recurrence risk and subsequent need for ACT is only based on tumor stage (TNM classification); however, more than 25% of patients with stage IA/B tumors will relapse. Recently, adjuvant targeted therapy has been approved for EGFR-mutated resected NSCLC and trials are evaluating other targeted therapies and immunotherapies in adjuvant settings. Costs, treatment duration, emergence of resistant clones and side effects stress the need for a better selection of patients. The identification and validation of prognostic and theranostic markers to better stratify patients who could benefit from adjuvant therapies are needed. In this review, we report current validated clinical, pathological and molecular prognosis biomarkers that influence outcome in resected NSCLC, and we also describe molecular biomarkers under evaluation that could be available in daily practice to drive ACT in resected NSCLC.

C-Reactive Protein to Albumin Ratio as Prognostic Marker in Locally Advanced Non-Small Cell Lung Cancer Treated with Chemoradiotherapy

Despite the implementation of consolidative immune checkpoint inhibition after definitive chemoradiotherapy (CRT), the prognosis for locally advanced non-small-cell lung cancer (NSCLC) remains poor. We assessed the impact of the C-reactive protein (CRP) to albumin ratio (CAR) as an inflammation-based prognostic score in patients with locally advanced NSCLC treated with CRT. We retrospectively identified and analyzed 52 patients with primary unresectable NSCLC (UICC Stage III) treated with definitive/neoadjuvant CRT between 2014 and 2019. CAR was calculated by dividing baseline CRP by baseline albumin levels and correlated with clinicopathologic parameters to evaluate prognostic impact. After dichotomizing patients by the median, univariate and multivariate Cox regression analyses were performed. An increased CAR was associated with advanced T-stage (p = 0.018) and poor performance status (p = 0.004). Patients with pre-therapeutic elevated CAR had significantly lower hemoglobin and higher leukocyte levels (hemoglobin p = 0.001, leukocytes p = 0.018). High baseline CAR was shown to be associated with worse local control (LPFS, p = 0.006), shorter progression-free survival (PFS, p = 0.038) and overall survival (OS, p = 0.022), but not distant metastasis-free survival (DMFS). Multivariate analysis confirmed an impaired outcome in patients with high CAR (LPFS: HR 3.562, 95% CI 1.294–9.802, p = 0.011). CAR is an easily available and independent prognostic marker after CRT in locally advanced NSCLC. CAR may be a useful biomarker for patient stratification to individualize treatment concepts.

Twenty-Year Survival of Patients Operated on for Non-Small-Cell Lung Cancer: The Impact of Tumor Stage and Patient-Related Parameters

Surgery is the mainstay treatment of non-small-cell lung cancer (NSCLC), but its impact on very-long-term survival (beyond 15 years) has never been evaluated.

METHODS

All patients operated on for major lung resection (Jun. 2001-Dec. 2002) for NSCL in the Thoracic Surgery Department at Paris-Hôtel-Dieu-University-Hospital were included. Patients' characteristics were prospectively collected. Vital status was obtained by checking INSEE database and verifying if reported as "non-death" by the hospital administrative database and direct phone interviews with patients of families.

RESULTS

345 patients were included. The 15- and 20-year survival rates were 12.2% and 5.7%, respectively. At univariate analysis, predictors of worse survivals were: increasing age at surgery (p = 0.0042), lower BMI (p = 0.009), weight loss (p = 0.0034), higher CRP (p = 0.049), pathological stage (p = 0.00000042), and, among patients with adenocarcinoma, higher grade (p = 0.028). Increasing age (p = 0.004), cumulative smoking (p = 0.045), lower BMI (0.046) and pathological stage (p = 0.0026), were independent predictors of long-term survival at Cox multivariate analysis. In another model, increasing age (p = 0.013), lower BMI (p = 0.02), chronic bronchitis (p = 0.03), lower FEV1% (p = 0.00019), higher GOLD class of COPD (p = 0.0079), and pathological stage (p = 0.000024), were identified as independent risk factors.

CONCLUSIONS

Very-long-term survivals could be achieved after surgery of NSCLC, and factors classically predicting 5- and 10-years survival also determined longer outcomes suggesting that both initial tumor aggressiveness and host's characteristics act beyond the period usually taken into account in oncology.

Multimodal analysis suggests differential immuno-metabolic crosstalk in lung squamous cell carcinoma and adenocarcinoma

Immunometabolism within the tumor microenvironment is an appealing target for precision therapy approaches in lung cancer. Interestingly, obesity confers an improved response to immune checkpoint inhibition in non-small cell lung cancer (NSCLC), suggesting intriguing relationships between systemic metabolism and the immunometabolic environment in lung tumors. We hypothesized that visceral fat and ¹⁸F-Fluorodeoxyglucose uptake influenced the tumor immunometabolic environment and that these bidirectional relationships differ in NSCLC subtypes, lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC). By integrating ¹⁸F-FDG PET/CT imaging, bulk and single-cell RNA-sequencing, and histology, we observed that LUSC had a greater dependence on glucose than LUAD. In LUAD tumors with high glucose uptake, glutaminase was downregulated, suggesting a tradeoff between glucose and glutamine metabolism, while in LUSC tumors with high glucose uptake, genes related to fatty acid and amino acid metabolism were also increased. We found that tumor-infiltrating T cells had the highest expression of glutaminase, ribosomal protein 37, and cystathionine gamma-lyase in NSCLC, highlighting the metabolic flexibility of this cell type. Further, we demonstrate that visceral adiposity, but not body mass index (BMI), was positively associated with tumor glucose uptake in LUAD and that patients with high BMI had favorable prognostic transcriptional profiles, while tumors of patients with high visceral fat had poor prognostic gene expression. We posit that metabolic adjunct therapy may be more successful in LUSC rather than LUAD due to LUAD's metabolic flexibility and that visceral adiposity, not BMI alone, should be considered when developing precision medicine approaches for the treatment of NSCLC.

The development of a nomogram and the prognostic prediction value of patients with esophageal squamous cell carcinoma undergoing radical radiotherapy

Aim: This study aimed to explore the role of the developed nomogram in the prognosis of esophageal squamous cell carcinoma (ESCC). Methods: A total of 181 ESCC patients were randomly divided into a training cohort (n = 141) and a validation cohort (n = 40). Significant factors impacting overall survival (OS) were identified in the training set and integrated into the nomogram based on Cox proportional hazards regression. Results: In the training cohort, the median OS in the high group (≥222) was 49.9 months and the median OS in the low group (<222) was 14.4 months. Multivariate analysis revealed that age, Karnofsky performance status score, tumor stage, chemotherapy, BMI, cervical esophageal carcinoma index and neutrophil to lymphocyte ratio were predictors of OS. Conclusion: The developed nomogram can effectively predict the survival prognosis of ESCC patients.

Sarcopenia, Precardial Adipose Tissue and High Tumor Volume as Outcome Predictors in Surgically Treated Pleural Mesothelioma

Background: We evaluated the prognostic value of Sarcopenia, low precardial adipose-tissue (PAT), and high tumor-volume in the outcome of surgically-treated pleural mesothelioma (PM). Methods: From 2005 to 2020, consecutive surgically-treated PM-patients having a pre-operative computed tomography (CT) scan were retrospectively included. Sarcopenia was assessed by CT-based parameters measured at the level of the fifth thoracic vertebra (TH5) by excluding fatty-infiltration based on CT-attenuation. The findings were stratified for gender, and a threshold of the 33rd percentile was set to define sarcopenia. Additionally, tumor volume as well as PAT were measured. The findings were correlated with progression-free survival and long-term mortality. Results: Two-hundred-seventy-eight PM-patients (252 male; 70.2 ± 9 years) were included. The mean progression-free survival was 18.6 ± 12.2 months, and the mean survival time was 23.3 ± 24 months. Progression was associated with chronic obstructive pulmonary disease (COPD) (p = <0.001), tumor-stage (p = 0.001), and type of surgery (p = 0.026). Three-year mortality was associated with higher patient age (p = 0.005), presence of COPD (p < 0.001), higher tumor-stage (p = 0.015), and higher tumor-volume (p < 0.001). Kaplan-Meier statistics showed that sarcopenic patients have a higher three-year mortality (p = 0.002). While there was a negative correlation of progression-free survival and mortality with tumor volume (r = 0.281, p = 0.001 and r = −0.240, p < 0.001; respectively), a correlation with PAT could only be shown for epithelioid PM (p = 0.040). Conclusions: Sarcopenia as well as tumor volume are associated with long-term mortality in surgically treated PM-patients. Further, while there was a negative correlation of progression-free survival and mortality with tumor volume, a correlation with PAT could only be shown for epithelioid PM.

Cachexia Versus Sarcopenia in Clinical Characteristics and Prognostic Value After Radical Gastrectomy for Gastric Cancer: A Large-Scale Prospective Study

BACKGROUND

Sarcopenia and cachexia are two predictors of adverse clinical outcomes, but they are partly overlapping. We aimed to compare the characteristics and prognostic value of cachexia and sarcopenia in patients after gastrectomy.

METHODS

From 2014 to 2019, a total of 1215 gastric cancer patients were enrolled. Cachexia and sarcopenia were diagnosed according to the most recent consensus definitions. Baseline characteristics and clinical outcomes were compared between the two groups. Risk factors of survival were evaluated by Cox regression analysis.

RESULTS

Of all patients, 26.5% were diagnosed with cachexia and 19.8% were diagnosed with sarcopenia. Sarcopenia was more prevalent in elderly patients, while cachexia was prone to occur in patients with TMN stage III. Survival curves showed that sarcopenia had adverse effects in patients with TMN stage I and II-III, while cachexia was only associated with poor survival at stages II-III. For the entire cohort, both cachexia and sarcopenia were adverse factors for prognosis. However, for stage I patients, sarcopenia was an independent predictor for overall survival (OS) (HR = 4.939, P < 0.001) and disease-free survival (DFS) (HR = 4.256, P < 0.001), but not cachexia; for stage II-III patients, cachexia was an independent predictor for OS (HR = 1.538, P < 0.001) and DFS (HR = 1.473, P = 0.001), but not sarcopenia.

CONCLUSIONS

Sarcopenia and cachexia have different clinical characteristics and prognostic values. For patients with early stage gastric cancer, detection for sarcopenia was more meaningful than cachexia. However, the prognostic significance of cachexia exceeded sarcopenia in advanced cancer.

Sarcopenia increases the risk of post-operative recurrence in patients with non-small cell lung cancer

Background

Sarcopenia is among the most prevalent and serious cancer-related symptom, and is strongly correlated with a poor prognosis. Moreover, it reportedly predicts poor prognosis after surgery in patients with lung cancer. However, it is unclear whether sarcopenia directly affects post-operative recurrence. The purpose of this study was to evaluate whether sarcopenia can be a risk indicator for post-operative recurrence, and whether it suppresses anti-tumor immunity, in a cohort of patients with resected non-small cell lung cancer.

Methods

This study retrospectively reviewed the data of 256 consecutive patients who underwent curative lobectomy and lymph node dissection for non-small cell lung cancer at our institution. The psoas muscle mass index was calculated as the total psoas muscle area at the third lumbar vertebral level/height² (cm²/m²). Sarcopenia was defined by a psoas muscle mass index of under 5.03 cm²/m² and 3.17 cm²/m² in male and female patients, respectively. Post-operative prognosis and cumulative incidence of recurrence rates were calculated.

Results

The 5-year overall survival and disease-free survival rates post-surgery were 59.5% and 38.6%, respectively, in patients with sarcopenia versus 81.1% and 72.1%, respectively, in patients without sarcopenia (p < 0.001). The 5-year cumulative incidence of recurrence rate in patients with sarcopenia was significantly higher than those without sarcopenia (49.9% versus 22.4%, respectively) in every pathological stage. Pathological stages II and III (hazard ratio, 3.36; p = 0.004), histological type (hazard ratio, 2.31; p = 0.025), and sarcopenia (hazard ratio, 2.52; p = 0.001) were independent risk factors for post-operative recurrence according to multivariate analysis.

Conclusion

Sarcopenia is a risk indicator for post-operative recurrence in patients with non-small cell lung cancer.

The Reality of Lung Cancer Paradox: The Impact of Body Mass Index on Long-Term Survival of Resected Lung Cancer. A French Nationwide Analysis from the Epithor Database

Obesity could have a protective effect in patients with lung cancer. We assessed the prognostic role of preoperative BMI on survival in patients who underwent lung resection for NSCLC. A total of 54,631 consecutive patients with resectable lung cancer within a 15-year period were extracted from Epithor (the French Society of Thoracic and Cardiovascular Surgery database). Patient subgroups were defined according to body mass index (BMI): underweight (BMI < 18.5 kg/m²), normal weight (18.5 ≤ BMI < 25 kg/m²), overweight (25 ≤ BMI < 30 kg/m²), and obese (BMI ≥ 30 kg/m²). Underweight was associated with lower survival (unadjusted HRs 1.24 (1.16-1.33)) compared to normal weight, whereas overweight and obesity were associated with improved survival (0.95 (0.92-0.98) and 0.88 (0.84-0.92), respectively). The impact of BMI was confirmed when stratifying for sex or Charlson comorbidities index (CCI). Among patients with obesity, a higher BMI was associated with improved survival. After adjusting for period of study, age, sex, WHO performance status, CCI, side of tumor, extent of resection, histologic type, and stage of disease, the HRs for underweight, overweight, and obesity were 1.51 (1.41-1.63), 0.84 (0.81-0.87), and 0.80 (0.76-0.84), respectively. BMI is a strong and independent predictor of survival in patients undergoing surgery for NSCLC.

Good performance of the Global Leadership Initiative on Malnutrition criteria for diagnosing and classifying malnutrition in people with esophageal cancer undergoing esophagectomy

OBJECTIVES

This study aimed to investigate the performance of the Global Leadership Initiative on Malnutrition (GLIM) criteria for malnutrition assessment in people with esophageal cancer undergoing esophagectomy.

METHODS

A prospective institutional database of 212 patients with esophageal cancer was reviewed for malnutrition assessment using the GLIM criteria. Perioperative metabolic characteristics, postoperative morbidities, and survival outcomes were investigated for GLIM-defined malnutrition. The performance of the two-step approach in implementing the GLIM criteria was evaluated.

RESULTS

One hundred eighty-nine patients were identified. The preoperative proportions of moderate and severe malnutrition diagnosed by the GLIM criteria were 45.0% and 30.7%, respectively. Patients with severe malnutrition showed lower levels of serum albumin, prealbumin, and total lymphocyte count on postoperative days 1, 3, and 5 (all Ps < 0.05). Severe malnutrition was not only predictive of overall complications (odds ratio, 8.75; P < 0.001), major complications (odds ratio, 15.6; P < 0.001), and delayed hospital discharge (odds ratio, 7.38; P = 0.001) but was also associated with poor overall and disease-free survival (respectively: hazard ratio, 3.75; P = 0.015; and hazard ratio, 4.18; P = 0.028). Notably, patients with severe malnutrition were more clinically impaired than those with moderate malnutrition. Regarding the two-step approaches, the Malnutrition Universal Screening Tool and Nutritional Risk Screening 2002 simplified malnutrition assessments using the GLIM criteria, and the prognostic nutritional index promoted the clinical significance of the GLIM criteria.

CONCLUSIONS

The GLIM criteria showed good performance in diagnosing and classifying malnutrition in people with esophageal cancer undergoing esophagectomy. The Malnutrition Universal Screening Tool, Nutritional Risk Screening 2002, and prognostic nutritional index could be appropriately used to implement the two-step approach to the GLIM criteria.

New Therapeutic Strategies for Lung Cancer

Non-small cell lung cancer (NSCLC) accounts for approximately 27% of all cancer-related deaths worldwide, thus representing a major health problem [...].

Total Psoas Area and Total Muscular Parietal Area Affect Long-Term Survival of Patients Undergoing Pneumonectomy for Non-Small Cell Lung Cancer

There is no standardization in methods to assess sarcopenia; in particular the prognostic significance of muscular fatty infiltration in lung cancer patients undergoing surgery has not been evaluated so far. We thus performed several computed tomography (CT)-based morphometric measurements of sarcopenia in 238 consecutive non-small cell lung-cancer patients undergoing pneumonectomy from 1 January 2007 to 31 December 2015. Sarcopenia was assessed by the following CT-based parameters: cross-sectional total psoas area (TPA), cross-sectional total muscle area (TMA), and total parietal muscle area (TPMA), defined as TMA without TPA. Measures were performed at the level of the third lumbar vertebra and were obtained for the entire muscle surface, as well as by excluding fatty infiltration based on CT attenuation. Findings were stratified for gender, and a threshold of the 33rd percentile was set to define sarcopenia. Furthermore, we assessed the possibility of being sarcopenic at both the TPA and TPMA level, or not, by taking into account of not fatty infiltration. Five-year survival was 39.1% for the whole population. Lower TPA, TMA, and TPA were associated with lower survival at univariate analysis; taking into account muscular fatty infiltration did not result in more powerful discrimination. Being sarcopenic at both psoas and parietal muscle level had the optimum discriminating power. At the multivariable analysis, being sarcopenic at both psoas and parietal muscles (considering the whole muscle areas, including muscular fat), male sex, increasing age, and tumor stage, as well as Charlson Comorbidity Index (CCI), were independently associated with worse long-term outcomes. We conclude that sarcopenia is a powerful negative prognostic factor in patients with lung cancer treated by pneumonectomy.

Does sarcopenia affect postoperative short- and long-term outcomes in patients with lung cancer?-a systematic review and meta-analysis

Background

Lung cancer patients frequently suffer from sarcopenia, and reports on the association of resectable lung cancer and their postoperative outcomes are increasing. Information on whether sarcopenia has any impact on short- and long-term postoperative outcomes in patients surgically treated for non-small cell lung cancer remains insufficient. Furthermore, reports vary regarding the pathological stage, surgical procedure, diagnostic tool of sarcopenia, cut-off value, prognosis, and postoperative complications. We believe that sarcopenia assessment should be included as one of the factors which affect the surgical outcomes of lung cancer. Thus, we conducted a review and meta-analysis to ascertain the association between sarcopenia and postoperative outcomes.

Methods

We performed a systematic literature search in PubMed/MEDLINE. Studies included cases defined sarcopenia, received lung cancer surgery, assessed postoperative complications, and prognosis. The pooled odds ratios for survival and postoperative complications, with 95% confidence intervals, were generated using Review manager 5.3.

Results

A total of ten retrospective studies were eligible for this meta-analysis, including a total of 2,643 non-small cell lung cancer patients. All reviews used skeletal muscle mass as a diagnostic tool for sarcopenia. Sarcopenia was associated with worse survival outcomes and increased postoperative complications in patients with resected lung cancer.

Conclusions

Sarcopenia is an independent risk factor for postoperative death and postoperative complications in patients who have undergone surgery. It is necessary to explore the mechanism of sarcopenia and optimal intervention, such as exercise, nutrition, or drug therapy.

Prospective Evaluation of Sarcopenia in Head and Neck Cancer Patients Treated with Radiotherapy or Radiochemotherapy

Simple Summary

Radiation therapy (RT) is a key treatment for head and neck squamous cell carcinoma (HNSCC) patients. RT generates acute toxicity and weight loss, especially when combined with chemotherapy. Frail patients (malnourished or with poor performance status) have poor outcomes and increased toxicity when treated by RT. Among non-frail patients, predicting RT outcome is a challenge. Loss of muscle mass, also known as sarcopenia, is associated with poor outcome in HNSCC patients treated by RT and chemotherapy, but the level of evidence remains weak. Conflicting results exist regarding the impact of sarcopenia on acute RT toxicity. This prospective study confirmed that in non-frail HNSCC patients baseline sarcopenia is frequent (37%) and is associated with decreased overall and disease-free survival, but not with acute toxicity. Interestingly, a worse impact of sarcopenia occurred despite optimal nutritional support and even when patients were treated by RT without chemotherapy. Sarcopenia should be regarded as an independent prognostic factor in that setting.

Abstract

Highlights: Sarcopenia is frequent in patients treated with radiation therapy (RT) or radiochemotherapy (RTCT) for head and neck squamous cell carcinomas. Sarcopenia is associated with poor disease-free survival and overall survival outcomes. Sarcopenia is not associated with a higher rate of treatment-related toxicity. Background: Sarcopenia occurs frequently with the diagnosis of head and neck squamous cell carcinoma (HNSCC). We aimed to assess the impact of sarcopenia on survival among HNSCC patients treated with radiotherapy (RT) or radiochemotherapy (RTCT). Methods: Patients treated between 2014 and 2018 by RT or RTCT with curative intent were prospectively included (NCT02900963). Optimal nutritional support follow-up, including weekly consultation with a dietician and an oncologist and daily weight monitoring, was performed. Sarcopenia was determined by measuring the skeletal muscles at the L3 vertebra on the planning CT scan for radiotherapy. For each treatment group (RT or RTCT), we assessed the prognostic value of sarcopenia for disease-free survival (DFS) and overall survival (OS) and its impact on treatment-related toxicity. Results: Two hundred forty-three HNSCC patients were included: 116 were treated by RT and 127 were treated by RTCT. Before radiotherapy, eight (3.3%) patients were considered malnourished according to albumin, whereas 88 (36.7%) patients were sarcopenic. Overall, sarcopenia was associated with OS and DFS in a multivariate analysis (HR 1.9 [1.1–3.25] and 1.7 [1.06–2.71], respectively). It was similar for patients treated with RT (HR 2.49 [1.26–4.9] for DFS and 2.24 [1.03–4.86] for OS), whereas for patients treated with RTCT sarcopenia was significantly associated with OS and DFS in univariate analysis only. Sarcopenia was not related to higher treatment-related toxicity. Conclusions: Pretherapeutic sarcopenia remains frequent and predicts OS and DFS for non-frail patients treated with curative intent and adequate nutritional support.

Nutritional Support in Lung Cancer Patients: The State of the Art

Lung cancer (LC) represents the most commonly diagnosed neoplasm worldwide for both sexes and is the leading cause of cancer mortality. Malnutrition is a comorbidity frequently found in neoplastic patients, but it remains often underestimated and thus undertreated. In this review, we aimed to investigate the incidence of malnutrition among LC patients according to different screening and assessment tools, to evaluate the impact of weight loss and body composition on survival, and to analyze the efficacy of different nutritional interventions in this setting. Although malnutrition, weight loss, and body composition changes can affect survival and other clinical outcomes in LC patients, the role of nutritional interventions is not yet strongly proven, and further studies are recommended. Nevertheless, screening, assessing, and eventually treating malnutrition in LC patients are strongly recommended, according to the most recent nutritional intervention guidelines for oncology patients.

Preoperative Body Weight and Albumin Predict Survival in Patients With Resectable Lung Neoplasms: Role of COPD

INTRODUCTION

The impact of preoperative nutritional status on survival in lung cancer (LC) patients with underlying chronic obstructive pulmonary disease (COPD) is still unclear. We hypothesized that presurgical nutritional assessment may differentially predict mortality in patients with resectable LC with moderate COPD and relatively well-preserved nutritional status.

METHODS

Nutritional assessment [body mass index (BMI), blood parameters including albumin and protein levels, and body weight loss], and other clinical parameters [cigarette smoking (CS) history, LC staging and histological subtypes, COPD severity, lung function, and adjuvant therapy] were evaluated in 125 patients from the LC Mar Prospective Cohort: 87 LC-COPD patients and 38 LC patients without COPD before thoracotomy. Ten-year overall survival (OS) was analyzed in all patients.

RESULTS

Prior to thoracotomy, in LC-COPD patients compared to LC, BMI and albumin declined relatively, low levels of the parameters BMI, albumin, and total proteins were associated with poorer 10-year survival, especially in the LC-COPD. CS burden also correlated with impaired survival. COPD per se worsened the prognosis in LC patients.

CONCLUSIONS

In the present cohort of LC patients with resectable tumors and relatively well-preserved nutritional status, the parameters BMI and blood albumin and protein levels measured prior to thoracotomy predicted OS, especially in those with COPD. These are clinically relevant findings, since values of those nutritional parameters were within the normal ranges in the majority of the analyzed patients. A thorough nutritional preoperative assessment should be included in the study of patients with resectable LC, particularly in those with chronic airway obstruction.

Does prehabilitation modify muscle mass in patients with rectal cancer undergoing neoadjuvant therapy? A subanalysis from the REx randomised controlled trial

BACKGROUND

Patients with rectal cancer who present with sarcopenia (low muscle mass) are at significantly greater risk of postoperative complications and reduction in disease-free survival. We performed a subanalysis of a randomised controlled study [the REx trial; www.isrctn.com ; 62859294] to assess the potential of prehabilitation to modify muscle mass in patients having neoadjuvant chemoradiotherapy (NACRT).

METHODS

Patients scheduled for NACRT, then potentially curative surgery (August 2014-March 2016) had baseline physical assessment and psoas muscle mass measurement (total psoas index using computed tomography-based measurements). Participants were randomised to either the intervention (13-17-week telephone-guided graduated walking programme) or control group (standard care). Follow-up testing was performed 1-2 weeks before surgery.

RESULTS

The 44 patients had a mean age of 66.8 years (SD 9.6) and were male (64%); white (98%); American Society of Anesthesiologists class 2 (66%); co-morbid (58%); overweight (72%) (body mass index ≥ 25 kg/m²). At baseline, 14% were sarcopenic. At follow-up, 13 (65%) of patients in the prehabilitation group had increased muscle mass versus 7 (35%) that experienced a decrease. Conversely, 16 (67%) controls experienced a decrease in muscle mass and 8 (33%) showed an increase. An adjusted linear regression model estimated a mean treatment difference in Total Psoas Index of 40.2mm²/m² (95% CI - 3.4 to 83.7) between groups in change from baseline (p = 0.07).

CONCLUSIONS

Prehabilitation improved muscle mass in patients with rectal cancer who had NACRT. These results need to be explored in a larger trial to determine if the poorer short- and long-term patient outcomes associated with low muscle mass can be minimised by prehabilitation.