Incidence and risk factor analysis for sarcopenia in patients with cancer

A Multicenter Evaluation of Treatment-associated Changes in Body Composition in Men With Germ Cell Tumors of the Testis: Implications for Adverse Events and Complications

OBJECTIVE

To characterize changes in body composition following cytotoxic chemotherapy for germ cell carcinoma of the testis (GCT) and quantify associations between body composition metrics and chemotherapy-associated adverse events (AEs) and post-retroperitoneal lymph node dissection (RPLND) complications.

MATERIALS AND METHODS

This retrospective multi-center study included 216 men with GCT treated with cytotoxic chemotherapy and/or RPLND (2005-2020). We measured body composition including skeletal muscle (SMI), visceral adipose (VAI,), subcutaneous adipose (SAI), and fat mass (FMI) indices on computed tomography. We quantified chemotherapy-associated changes in body composition and evaluated associations between body composition and incidence of grade 3 + AEs and post-RPLND complications on multivariable logistic regression analyses.

RESULTS

One hundred and eighty-two men received a median of 3 cycles of cisplatin-based chemotherapy. Following chemotherapy, median change in SMI was -6% (P = <.0001), while VAI, SAI, and FMI increased by +13% (P = <.0001), +11% (P = <.0001), and +6% (P = <.0001), respectively. Seventy-nine patients (43%) experienced at least one grade 3 + AE. A decrease in SMI following chemotherapy was associated with increased risk of grade 3 + AEs (P = .047). One hundred and 3 men with a median age of 28.5 years (IQR 23-35.5) underwent RPLND of whom 22 (21.3%) experienced at least 1 grade 3 + post-RPLND complication. No baseline body composition metrics were associated with post-RPLND complications.

CONCLUSION

In men with GCT of the testis, chemotherapy was associated with 6% loss of lean muscle mass and gains in adiposity. Lower skeletal muscle was associated with a higher incidence of chemotherapy-associated AEs. Body composition was not associated with the incidence of post-RPLND complications.

Sarcopenia Identification Using Alternative Vertebral Landmarks in Individuals with Lung Cancer

Background

(1)Sarcopenia, or low skeletal mass index (SMI), contributes to higher lung cancer mortality. The SMI at third lumbar vertebrae (L3) is the reference standard for body composition analysis. However, there is a need to explore the validity of alternative landmarks in this population. We compared the agreement of sarcopenia identification at the first lumbar (L1) and second lumbar (L2) to L3 in non-Hispanic Black (NHB) and White (NHW) individuals with lung cancer.

Methods

(2)This retrospective, cross-sectional study included 214 NHB and NHW adults with lung cancer. CT scans were analyzed to calculate the SMI at L1, L2, and L3. T-tests, chi-square, Pearson's correlation, Cohen's kappa, sensitivity, and specificity analysis were used.

Results

(3)Subjects presented with a mean age of 68.4 ± 9.9 years and BMI of 26.3 ± 6.0 kg/m2. Sarcopenia prevalence varied from 19.6% at L1 to 39.7% at L3. Cohen's kappa coefficient was 0.46 for L1 and 0.64 for L2, indicating weak and moderate agreement for the identification of sarcopenia compared to L3.

Conclusions

(4)Sarcopenia prevalence varied greatly depending on the vertebral landmark used for assessment. Using L2 or L1 alone resulted in a 16.8% and 23.8% misclassification of sarcopenia in this cohort of individuals with lung cancer.

Creatine Supplementation and Resistance Training in Patients With Breast Cancer (CaRTiC Study): Protocol for a Randomized Controlled Trial

BACKGROUND

Creatine supplementation is an effective ergogenic nutrient for athletes, as well as for people starting a health or fitness program. Resistance training has previously been identified as an important method of increasing muscle mass and strength, especially in people with cancer to avoid sarcopenia. The potential of creatine supplementation for adaptations produced by resistance training in patients with cancer is still unknown. The primary aim of this study is to evaluate the effectiveness of a supervised resistance training program intervention with and without creatine supplementation in patients with breast cancer.

METHODS

Is a multicentre, randomized, blind, placebo-controlled study. Patients will be randomly assigned to a control group and 2 experimental groups. The first training resistance group (RG) will perform resistance training, while the second experimental resistance-creatine group will perform the same resistance training as the RG and will also receive a 5 g/d creatine supplementation during the intervention. RG participants will follow the same daily dosing protocol, but in their case, with dextrose/maltodextrin. Resistance training will be a 16-week supervised workout that will consist of a series of resistance exercises (leg press, knee extension, knee bends, chest press, sit-ups, back extensions, pull-ups, and shoulder press) that involve the largest muscle groups, performed 3 times a week on nonconsecutive days. Both the RG and the resistance-creatine group will receive a supplement of soluble protein powder (20 to 30 g) daily.

CONCLUSION

This intervention will help to better understand the potential of nonpharmacological treatment for improving strength and well-being values in patients with breast cancer with and without creatine supplementation.

[Sarcopenia in patients with pancreatic cancer, an independant prognostic factor]

BACKGROUND

Pancreatic cancer is despite modern diagnostic tools and treatment regimen associated with poor outcome. Many patients show cachexia and sarcopenia.

METHODS

In a retrospective analysis the SMI (cm²/m²) was measured by determining the skelettal muscle area in a computed tomography image at lumbar vertebrae 3. Further clinical parameters were measured to determine the outcome.

RESULTS

The mean survival after diagnosis in the population with sarcopenia was significantly lower (14,4 vs 17,7 months, p=0,046). Significantly shorter survival was also seen for higher age (p=0,006), no tumor resection (p=0,004), metastases (p=0,002) and high CA19-9 level (p=0,002) CONCLUSION: Sarcopenia is an indipendant prognostic factor in patients with pancreatic cancer. SMI should be measured clinical practice and further studies are necessary to asses a potential therapeutic strategy.

Feasibility and safety of exercise during chemotherapy in people with gastrointestinal cancers: a pilot study

PURPOSE

Sarcopenia is a poor prognostic factor in cancer patients, and exercise is one of the treatments to improve sarcopenia. However, there is currently insufficient evidence on whether exercise can improve sarcopenia in patients with advanced cancers. This study examined the feasibility of exercise in advanced gastrointestinal (GI) cancer patients treated with palliative chemotherapy.

METHODS

Between 2020 and 2021, 30 patients were enrolled in a resistance and aerobic exercise program for six weeks. The exercise intervention program (EIP) consisted of low, moderate, and high intensity levels. Patients were asked to select the intensity level according to their ability. The primary endpoint was the feasibility of the EIP measured by compliance during the six weeks. A compliance of over 50% was considered acceptable. The secondary endpoints were changes in weight and muscle mass, safety, quality of life (QoL) and overall survival (OS).

RESULTS

The median age of the study's participants was 60 (30-77). The total compliance to the EIP was 63.3% (19/30 patients). Sixteen (53.3%) patients had a compliance of over 80%. The attrition rate was 30.0% (9/30). The mean exercise time was 41.4 min, and the aerobic exercise was 92.3% and the resistant exercise was 73.7%, and both exercise was 66.5%. Most patients performed the moderate intensity level exercises at home or near their home. The mean skeletal muscle index (SMI) was 43.5 cm2/m2 pre-chemotherapy and 42.2 cm2/m2 after six weeks of chemotherapy, with a decrease of -1.2 ± 2.8 cm2/m2 (-3.0%) (p = 0.030). In the poor compliance group, the mean SMI decrease was -2.8 ± 3.0 cm2/m2 which was significantly different (p = 0.033); however, in the good compliance group, the mean SMI decrease was -0.5 ± 2.5 cm2/m2 which was maintained over the six weeks (p = 0.337). The good compliance group had a significantly longer median OS compared with the poor compliance group (25.3 months vs. 7.9 months, HR = 0.306, 95% CI = 0.120-0.784, p = 0.014). The QoL showed a better score for insomnia (p = 0.042). There were no serious adverse events.

CONCLUSIONS

The EIP during palliative chemotherapy in advanced GI cancer patients showed good compliance. In the good compliance group, muscle mass and physical functions were maintained for six weeks. The EIP was safe, and the QoL was maintained. Based on this study, further research in exercise intervention in advanced cancer patients is needed.

CLINICAL TRIAL REGISTRATION

The clinical trial registration number is KCT 0005615 (CRIS, https://cris.nih.go.kr/cris/en/ ); registration date, 23rd Nov 2020.

The Modulation of Adipokines, Adipomyokines, and Sleep Disorders on Carcinogenesis

Obesity and sarcopenia, i.e., decreased skeletal muscle mass and function, are global health challenges. Moreover, people with obesity and sedentary lifestyles often have sleep disorders. Despite the potential associations, metabolic disturbances linking obesity, sarcopenia, and sleep disorders with cancer are neither well-defined nor understood fully. Abnormal levels of adipokines and adipomyokines originating from both adipose tissue and skeletal muscles are observed in some patients with obesity, sarcopenia and sleep disorders, as well as in cancer patients. This warrants investigation with respect to carcinogenesis. Adipokines and adipomyokines may exert either pro-carcinogenic or anti-carcinogenic effects. These factors, acting independently or together, may significantly modulate the incidence and progression of cancer. This review indicates that one of the possible pathways influencing the development of cancer may be the mutual relationship between obesity and/or sarcopenia, sleep quantity and quality, and adipokines/adipomyokines excretion. Taking into account the high proportion of persons with obesity and sedentary lifestyles, as well as the associations of these conditions with sleep disturbances, more attention should be paid to the individual and combined effects on cancer pathophysiology.

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

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

Acute Sarcopenia after Elective and Emergency Surgery

Sarcopenia is an increasingly recognised condition of loss of muscle mass and function. The European Working Group on Sarcopenia in Older People 2 (EWSOP2) updated their definition in 2018, emphasising the importance of low muscle strength in diagnosis. Acute sarcopenia has been arbitrarily defined as sarcopenia lasting less than 6 months. This review highlights the pathophysiology involved in muscle wasting following surgery, focussing on hormonal factors, inflammation, microRNAs, and oxidative stress. Biomarkers such as GDF-15, IGF-1 and various microRNAs may predict post-surgical muscle loss. The impact of existing sarcopenia on various types of surgery and incident muscle wasting following surgery is also described. The gaps in research found include the need for longitudinal studies looking in changes in muscle strength and quantity following surgery. Further work is needed to examine if biomarkers are replicated in other surgery to consolidate existing theories on the pathophysiology of muscle wasting.

Combined systemic inflammatory immunity index and prognostic nutritional index scores as a screening marker for sarcopenia in patients with locally advanced gastric cancer

Background

Sarcopenia is associated with poor clinical outcomes in patients with locally advanced gastric cancer (LAGC). Currently, the diagnostic criteria for sarcopenia are complex and laborious. Increased evidence suggests the inflammatory state of the body is closely associated with the development of sarcopenia. The systemic immune-inflammatory index (SII) and the prognostic nutritional index (PNI) are representative blood indicators of the status of the systemic inflammatory response, but the clinical significance of the combined testing of these two indicators remains unclear. We aimed to develop a simple and practical risk score (SII-PNI score) to screen patients with LAGC for sarcopenia on admission for early diagnosis.

Methods

We registered a prospective clinical study from January 2011 to May 2016 involving 134 patients with LAGC undergoing radical surgical resection. All patients followed the definition of sarcopenia in the Asian Working Group on Sarcopenia (AWGS) guidelines and were divided into sarcopenia and non-sarcopenia groups. SII-PNI score 0-2 was scored as 2 for high SII (≥432.9) and low PNI ( ≤ 49.5); score 1, either high SII or low PNI; score 0, no high SII or low PNI.

Results

All patients underwent radical surgery, including 31 patients (23.13%) with sarcopenia according to AWGS criteria. The SII-PNI score was significantly lower in the non-sarcopenic patients than in the sarcopenic patients (p < 0.001). Logistic multivariate analysis showed that the SII-PNI score predicted an independent prognostic factor for sarcopenia (p < 0.001). Patients with high SII-PNI scores had significantly worse prognosis than those with low SII-PNI scores (p < 0.001). The SII-PNI score was an independent prognostic factor for predicting overall survival and disease-free survival (p = 0.016, 0.023).

Conclusion

Peripheral blood parameters SII-PNI scores accurately identify sarcopenia in patients with LAGC and could be used as potential systemic markers.

Fasting-Mimicking-Diet does not reduce skeletal muscle function in healthy young adults: a randomized control trial

PURPOSE

The aim of this study was to evaluate the short- and long-term effects of the Fasting-Mimicking-Diet (FMD) intervention on neuromuscular parameters of force production in healthy young men.

METHODS

Twenty-four physically active men completed the study. Participants were randomly assigned to Fasting-Mimicking (FMD) or Normal Diet (ND) and asked to follow three cycles of dietary intervention. Neuromuscular parameters of force production during maximal voluntary isometric contractions (MVCs) with the leg extensors muscles and anthropometrics were measured at baseline (T0), at the end of the first cycle (T1), and 7-10 days after the 3rd cycle of the nutritional intervention (T2). The study was registered on Clinicaltrials.gov (No. NCT04476615).

RESULTS

There was a significant decrease in body mass at T1 for FMD (- 2.6 kg, ∆ from baseline, on average; p < 0.05) but not in ND (- 0.1 kg;). Neuromuscular parameters of force production, muscle volume, and MVC torque did not change or differ between groups across visits. Results were similar even when parameters were normalized by muscle volume.

CONCLUSION

The consumption of FMD in a group of young healthy male subjects showed to be feasible, and it did not affect neuromuscular parameters of force production. The results suggest that FMD could be safely adopted by strength athletes without detrimental effects on force and muscle volume. Further research in clinical population at risk of muscle mass loss, such as elderly and obese subjects with sarcopenia, is warranted.

Psoas Muscle Index Defined by Computer Tomography Predicts the Presence of Postoperative Complications in Colorectal Cancer Surgery

Background and Objectives: Sarcopenia is a recognized prognostic factor for both complications and survival in cancer patients. This study aims to analyze the relationship between sarcopenia measured by psoas muscle index on computer tomography scans and the presence of postoperative complications in colorectal cancer surgery. Materials and Methods: In a prospective study we recorded data from 51 patients who underwent colorectal cancer surgery in the Mures County Clinical Hospital, Romania. Total psoas muscle area and psoas density were measured at the level of the third lumbal vertebra (L3) for further index calculation. We also evaluated the general characteristics and laboratory analyses to obtain more information about status of the patients. Short-term postoperative complications were scored according to the Clavien-Dindo classification. Results: The majority of the 51 patients were male (61%) and the median age was 65 years. More than half of the cancer was located in the rectum (56.9%), a quarter in the right colon (25.5%), the rest in the sigmoid (11.8%), and the left colon (5.9%). Twenty-one patients (41.2%) developed a complication, five (9.8%) of these were Clavien-Dindo grade 3, 4 or 5 (high grade) and sixteen (31.3%) grade 1 or 2 (low grade). The low- and high-grade groups showed a significantly lower right psoas muscle area, left psoas muscle area, total psoas muscle area, and psoas muscle index (p < 0.001 in all cases). Among laboratory analyses, a significantly lower perioperative hematocrit, hemoglobin, and albumin level were found in patients who developed complications. Furthermore we observed that an elevated serum C-reactive protein level was associated with a higher grade of complication (p < 0.043). Conclusions: The psoas muscle index (PMI) influence on the postoperative outcome is an important factor in our single center prospective study and it appears to be a good overall predictor in colorectal surgery. A lower PMI is directly associated with a low or high grade complication by Clavien-Dindo classification. Perioperative inflammatory and nutritional status evidenced by serum C-reactive protein (CRP) and albumin level influences the presence of postoperative complications.

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

BACKGROUND

A typical assessment for sarcopenia involves the use of abdominal computed tomography (CT) for calculating the skeletal muscle index (SMI) at the level of the third lumbar vertebra (L3). However, abdominal CT is not regularly performed on patients with head and neck cancer (HNC). We investigated whether masticatory SMI (M-SMI) measurements based on head and neck CT scans can be used to conduct sarcopenia assessments by evaluating whether M-SMI is correlated with L3-SMI.

METHODS

Abdominal and head and neck CT images of patients with trauma (n = 50) and HNC (n = 52) were analyzed retrospectively. Both manual delineation and threshold selection methods were used to measure cross-sectional areas of masticatory muscles and those of muscles at the L3 level on CT images. Muscle cross-sectional areas were normalized to height squared to calculate SMI, and a multivariate linear regression model was established to evaluate the correlation between the M-SMI and L3-SMI. Receiver operating characteristic curve analysis was used to assess the ability of the M-SMI to identify sarcopenia, and Cox logistic regression was used to identify predictors of sarcopenia.

RESULTS

Patients with HNC had significantly lower M-SMI and L3-SMI than did patients with trauma (p = 0.011 and 0.03, respectively). M-SMI and L3-SMI were strongly correlated (r = 0.901, p < 0.001); in the multivariate model that included sex, the correlation was stronger (r = 0.913, p < 0.001). The associations of sarcopenia with a lower M-SMI (p < 0.001), male sex (p = 0.028), and advanced age (p = 0.011) were significant, and multivariate logistic analysis demonstrated that an M-SMI of <5.5 was an independent predictor of sarcopenia (hazard ratio = 5.37, p < 0.001).

CONCLUSIONS

M-SMI assessment in routine head and neck CT scans is feasible and can be an alternative for detecting sarcopenia in patients with HNC.

A Powerful Nomogram Based on the Novel D-Index to Predict Prognosis After Surgical Resection of Hepatocellular Carcinoma

Purpose

Conventional staging and scoring systems such as the Tumor, Node, and Metastasis; Cancer of the Liver Italian Program; Barcelona Clinic Liver Cancer; and Okuda have failed to predict overall survival (OS) in patients with resected primary hepatocellular carcinoma. Thus, we aimed to establish a novel D-index and nomogram to improve prognostic accuracy.

Patients and Methods

We selected 396 patients who underwent liver resection between January 2007 and February 2015 at the First Affiliated Hospital of Wenzhou Medical University. These patients were randomly divided into the training and validation groups in a ratio of 7:3.

Results

We generated a nomogram using five independent risk factors, including the D-index (calculated by total bilirubin × tumor size/the ratio of fat-to-muscle area ^0.5) in the training set. The predictive performance of the nomogram was similar in both the training and validation cohorts according to the concordance index. The nomogram demonstrated the strongest predictive power for 1-year, 3-year, and 5-year OS, with the area under the receiving operating characteristic curve being 0.8486, 0.7785, and 0.752, respectively. The calibration curves exhibited stable capabilities in both cohorts. The stratification of the Kaplan-Meier curve was significant (P < 0.001).

Conclusion

The associated nomogram of the D-index demonstrated a powerful and accurate predictive ability for OS in patients with primary hepatocellular carcinoma.

Loss of skeletal muscle mass during palliative chemotherapy is a poor prognostic factor in patients with advanced gastric cancer

Cancer causes muscle mass loss, which is associated with a poor prognosis. Chemotherapy may also reduce muscle mass. We investigated skeletal muscle mass change during palliative chemotherapy for advanced gastric cancer (AGC) and its association with treatment outcomes. We retrospectively reviewed 111 consecutive AGC patients who underwent first-line palliative chemotherapy. Skeletal muscle area was measured before and after chemotherapy at the third lumbar vertebra level using computed tomography scans. We compared skeletal muscle index (SMI), body mass index (BMI), and body weight changes to chemotherapy response and survival. The 80 male and 31 female patients’ median age was 65 (range 31–87) years, and 46.8% had sarcopenia at baseline. Median pre-chemotherapy to post-chemotherapy SMI, BMI, and body weight decreases were − 4.5 cm²/m² (− 11.3%) (P < 0.001); − 0.7 kg/m² (− 3.2%) (P < 0.001); and − 2.0 kg (− 3.5%) (P < 0.001), respectively. Median SMI decreases for patients with objective response, stable disease, and disease progression were − 4.0 cm²/m² (range − 20.1 ~ 9.5); − 4.5 cm²/m² (range − 19.8 ~ 0.8); and − 3.8 cm²/m² (range: − 17.6 ~ 0.1), respectively. Response to chemotherapy was not associated with SMI decrease (P = 0.463). In multivariable analysis, sarcopenia at baseline (HR 1.681; 95% CI 1.083–2.609, P = 0.021), decreased SMI (HR 1.620; 95% CI 1.041–2.520; P = 0.032) were significant poor prognostic factors for survival. Skeletal muscle mass decreased significantly during chemotherapy in AGC patients, but was not associated with chemotherapy response. Decreased SMI was a poor prognostic factor in AGC patients during first-line palliative chemotherapy.

Sarcopenia: looking to muscle mass to better manage pancreatic cancer patients

PURPOSE OF REVIEW

Overall survival of patients with pancreatic cancer is strongly conditioned by tumor biology and the incidence of malnutrition and metabolic disorders. In this landscape, the assessment of body composition is crucial to properly manage the clinical implications of muscle wasting. The pathogenesis of this condition is the result of a complex interplay between cancer and the host. In particular, sarcopenia is induced by an inadequate nutritional intake, hormonal abnormalities, inflammation and imbalance between anabolic and catabolic pathways.

RECENT FINDINGS

Recent evidences have highlighted the role of sarcopenia in cancer patients, revealing a prognostic impact on morbidity, mortality and survival.

SUMMARY

The occurrence of sarcopenia could amplify chemotherapy-induced toxicities, prolong hospitalizations and reduce adherence to anticancer treatment, worsening quality of life and survival. Although considerable efforts have been made to develop treatment strategies, no effective interventions have been identified so far. Nevertheless, if promptly and adequately supported, pancreatic cancer might benefit from adopted dietary intervention to avoid further loss of lean mass.

Combined Effect of Sarcopenia and Systemic Inflammation on Survival in Patients with Advanced Stage Cancer Treated with Immunotherapy

Background

Sarcopenia and inflammation have been associated with poor survival in patients with cancer. We explored the combined effects of these variables on survival in patients with cancer treated with immunotherapy.

Methods

We performed a retrospective review of 90 patients enrolled on immunotherapy‐based phase I clinical trials at Emory University from 2009 to 2017. Baseline neutrophil‐to‐lymphocyte ratio, monocyte‐to‐lymphocyte ratio, and platelet‐to‐lymphocyte ratio (PLR) were used as surrogates of inflammation. The skeletal muscle index (SMI) was derived from the skeletal muscle density calculated from baseline abdominal computed tomography images. Optimal cutoffs for continuous inflammation biomarkers and SMI were determined by bias‐adjusted log‐rank test. A four‐level risk stratification was used to create low‐risk (PLR <242 and nonsarcopenic), intermediate‐risk (PLR <242 and sarcopenic), high‐risk (PLR ≥242 and nonsarcopenic), and very‐high‐risk (PLR ≥242 and sarcopenic) groups with subsequent association with survival.

Results

Most patients (59%) were male, and the most common cancers were melanoma (33%) and gastrointestinal (22%). Very high‐risk, high‐risk, and intermediate‐risk patients had significantly shorter overall survival (hazard ratio [HR], 8.46; 95% confidence interval [CI], 2.65–27.01; p < .001; HR, 5.32; CI, 1.96–14.43; p = .001; and HR, 4.01; CI, 1.66–9.68; p = .002, respectively) and progression‐free survival (HR, 12.29; CI, 5.15–29.32; p < .001; HR, 3.51; CI, 1.37–9.02; p = .009; and HR, 2.14; CI, 1.12–4.10; p = .022, respectively) compared with low‐risk patients.

Conclusion

Baseline sarcopenia and elevated inflammatory biomarkers may have a combined effect on decreasing survival in immunotherapy‐treated patients in phase I trials. These data may be immediately applicable for medical oncologists for the risk stratification of patients beginning immunotherapeutic agents.

Implications for Practice

Sarcopenia and inflammation have been associated with poor survival in patients with cancer, but it is unclear how to apply this information to patient care. The authors created a risk‐stratification system that combined sarcopenia and platelet‐to‐lymphocyte ratio as a marker of systemic inflammation. The presence of sarcopenia and systemic inflammation decreased progression‐free survival and overall survival in our cohort of 90 patients who received immunotherapy in phase I clinical trials. The data presented in this study may be immediately applicable for medical oncologists as a way to risk‐stratify patients who are beginning treatment with immunotherapy.

The interaction between chronic inflammation and body composition is particularly important in the era of immunotherapy, considering that immune checkpoint inhibitors rely on the host immune system for their efficacy. This article reports on the combined effects of inflammation and sarcopenia on clinical outcomes in patients with solid tumors treated with immunotherapy‐based regimens.

Timed Stair-Climbing as a Surrogate Marker for Sarcopenia Measurements in Predicting Surgical Outcomes

BACKGROUND

Estimating sarcopenia by measuring psoas muscle density (PMD) has been advocated as a method to accurately predict post-operative morbidity. The aim of the present study was to determine whether the Timed Stair Climb (TSC) could be used to replace PMD measurements in predicting morbidity.

METHODS

Patients were prospectively enrolled from March 2014-2015 and were eligible if they were undergoing an abdominal operation. PMD was measured using pre-operative CT scans obtained within 90 days of surgery. Ninety-day complications were assessed using the Accordion Severity Grading System. Multivariable analysis was performed to identify risk factors associated with operative morbidity.

RESULTS

Of the patients, 298 were enrolled and completed TSC prior to undergoing an operation. Using the According Grading System, a grade 2 or higher complication occurred in 72 (24. 2%) patients with 8 (2.7%) deaths. There was an indirect relationship between PMD and TSC (P < 0.0001) and a direct relationship between TSC and complications (P = 0.04). On multivariable analysis decreasing PMD (P = 0.018) and increasing TSC (P = 0.026) were predictive of post-operative morbidity. Receiver operating characteristic curves demonstrated that the TSC was superior to both the ACS NSQIP Risk Calculator and PMD in predicting outcomes (TSC vs. PMD, P = 0.012; PMD vs. ACS NSQIP, P = 0.013; TSC vs. ACS NSQIP, P < 0.0001).

CONCLUSION

TSC, PMD, and the ACS NSQIP calculator are all useful tools; however, the TSC is superior in predicting post-operative morbidity.

The IMPACT study: early loss of skeletal muscle mass in advanced pancreatic cancer patients

BACKGROUND

Pancreatic cancer (PC) patients have multiple risk factors for sarcopenia and loss of skeletal muscle mass (LSMM), which may cause greater treatment toxicities, reduced response to cancer therapy, prolonged hospitalization, impaired quality of life, and worse prognosis.

METHODS

This is a retrospective study on advanced PC patients treated at the Department of Oncology of Udine, Italy, from January 2012 to November 2017. Among 162 patients who received chemotherapy, 94 consecutive patients with an available computed tomography (CT) scan were retrospectively analyzed. The primary objective of our study was to explore if an early LSMM ≥ 10% (measured at first radiological evaluation and compared with baseline) and/or baseline sarcopenia may impact prognosis. Baseline sarcopenia was defined according to Prado's criteria. Skeletal muscle area was measured as cross-sectional areas (cm² ) using CT scan data through the Picture archiving and communication system (PACS) image system.

RESULTS

In the whole cohort, 48% of patients were ≤70 years old, and 50% had metastatic disease. At baseline, 73% of patients had sarcopenia, and 16% presented a visceral fat area ≥ 44 cm² /m² . Overall, 21% experienced an early LSMM ≥ 10%. Approximately 33% of sarcopenic patients at baseline and ~35% of patients with early LSMM ≥ 10% had a body mass index > 25 kg/m² . Of note, 71% of patients were evaluated by a nutritionist, and 56% received a dietary supplementation (oral and/or parenteral). After a median follow-up of 30.44 months, median overall survival (OS) was 11.28 months, whereas median progression-free survival (PFS) was 5.72 months. By multivariate analysis, early LSMM ≥ 10% was significantly associated with worse OS [hazard ratio (HR): 2.16; 95% confidence interval (CI) 1.23-3.78; P = 0.007] and PFS (HR: 2.31; 95% CI 1.30-4.09; P = 0.004). Moreover, an exploratory analysis showed that inflammatory indexes, such as neutrophil-lymphocyte ratio variation, impact early LSMM ≥ 10% (odds ratio 1.31, 95% CI 1.06-1.61, P = 0.010).

CONCLUSIONS

Early LSMM ≥ 10% has a negative prognostic role in advanced PC patients. Further prospective investigations are needed to confirm these preliminary data.

A Ketogenic Diet Reduces Central Obesity and Serum Insulin in Women with Ovarian or Endometrial Cancer

Background

The glycolytic nature of cancer cells presents a potential treatment target that may be addressed by a ketogenic diet (KD).

Objective

We hypothesized that a KD would improve body composition and lower serum insulin and insulin-like growth factor-I (IGF-I) in women with ovarian or endometrial cancer.

Methods

In this randomized controlled trial, women with ovarian or endometrial cancer [age: ≥19 y; body mass index (kg/m2): ≥18.5] were randomly assigned to a KD (70:25:5 energy from fat, protein, and carbohydrate) or the American Cancer Society diet (ACS; high-fiber, low-fat). Body composition (DXA) and fasting serum insulin, IGF-I, and β-hydroxybutyrate were obtained at baseline and at 12 wk; urinary ketones were also measured throughout the intervention. We assessed differences between the diets with ANCOVA and independent t tests. We used correlation analyses to estimate associations between changes in serum analytes and body composition.

Results

After 12 wk, the KD (compared with ACS) group had lower adjusted total (35.3 compared with 38.0 kg, P < 0.05) and android (3.0 compared with 3.3 kg, P < 0.05) fat mass. Percentage of change in visceral fat was greater in the KD group (compared with the ACS group; -21.2% compared with -4.6%, P < 0.05). Adjusted total lean mass did not differ between the groups. The KD (compared with ACS) group had lower adjusted fasting serum insulin (7.6 compared with 11.2 µU/mL, P < 0.01). There was a significant inverse association between the changes in serum β-hydroxybutyrate and IGF-I concentrations (r = -0.57; P < 0.0001).

Conclusions

In women with ovarian or endometrial cancer, a KD results in selective loss of fat mass and retention of lean mass. Visceral fat mass and fasting serum insulin also are reduced by the KD, perhaps owing to enhanced insulin sensitivity. Elevated serum β-hydroxybutyrate may reflect a metabolic environment inhospitable to cancer proliferation. This trial was registered at www.clinicaltrials.gov as NCT03171506.

Histologic subtypes are not associated with the presence of sarcopenia in lung cancer

Background

Sarcopenia is prevalent and a known adverse prognostic effector in lung cancer (LCA). However, the relationship between sarcopenia and histology remains uncertain in LCA.

Methods

Consecutive patients with newly diagnosed LCA (n = 778) between June 2012 and February 2015 were retrospectively reviewed to identify factors associated with sarcopenia. Sarcopenia was defined as CT-determined L3 muscle index (muscle area at L3/height²) of < 55 cm²/m² for men and < 39 cm²/m² for women.

Results

Mean patient age was 67.7 ± 10.8 years, and most (73.1%) were male. The most prevalent histology was adenocarcinoma (44.0%) and 71.6% of patients had stage III or IV disease. The overall prevalence of sarcopenia was 48.2% (60.3% in men, and 15.3% in women). Univariable analysis showed sarcopenia was significantly associated with male gender, age (≥ 65 years), smoking status, lower BMI (< 23 kg/m²), advanced stage (III and IV), and high comorbidity score (Charlson index ≥ 3). Furthermore, the prevalence of sarcopenia was higher in squamous cell carcinoma (54.9%) and small cell LCA (56.4%) than in adenocarcinoma (39.8%). Multivariable analyses showed sarcopenia was independently associated with a male gender (odds ratio [OR], 11.13), elderly (OR, 2.02) and low BMI (OR, 6.28), stage IV (OR, 1.98), and high comorbidity (OR, 1.93). However, no significant association was found between histologic subtypes and sarcopenia.

Conclusions

Sarcopenia was found to be significantly associated with old age, male gender, an advanced stage, comorbidities, and low BMI in LCA. However, histology subtype was not an independent factor for the presence of sarcopenia.

Epidemiology of Sarcopenia: Determinants Throughout the Lifecourse

Sarcopenia is an age-related syndrome characterised by progressive and generalised loss of skeletal muscle mass and strength; it is a major contributor to the risk of physical frailty, functional impairment in older people, poor health-related quality of life and premature death. Many different definitions have been used to describe sarcopenia and have resulted in varying estimates of prevalence of the condition. The most recent attempts of definitions have tried to integrate information on muscle mass, strength and physical function and provide a definition that is useful in both research and clinical settings. This review focuses on the epidemiology of the three distinct physiological components of sarcopenia, and highlights the similarities and differences between their patterns of variation with age, gender, geography and time and the individual risk factors that cluster selectively with muscle mass, strength and physical function. Methods used to measure muscle mass, strength and physical functioning and how differences in these approaches can contribute to the varying prevalence rates will also be described. The evidence for this review was gathered by undertaking a systematic search of the literature. The descriptive characteristics of muscle mass, strength and function described in this review point to the urgent need for a consensual definition of sarcopenia incorporating these parameters.

Sarcopenia related to neoadjuvant chemotherapy and perioperative outcomes in resected gastric cancer: a multi-institutional analysis

BACKGROUND

This study's objective was to evaluate the change in sarcopenia score following neoadjuvant chemotherapy (NAC) and to correlate both sarcopenia and change in score with perioperative outcomes in patients with advanced resected gastric cancer.

METHODS

Multi-institutional analysis of patients with gastric cancer who underwent NAC and resection from 2000-2015 was performed. Demographic and perioperative data were included. Sarcopenia score was defined as CT measurement of total psoas muscle at L3, stratified by height (m). Sarcopenia was defined as a score <385 mm²/m² in women and <545 mm²/m² in men.

RESULTS

Of 36 patients, 19% were sarcopenic prior to NAC. Following NAC, 31% were sarcopenic, with 14% developing sarcopenia during NAC. One patient (3%) became non-sarcopenic. There were no significant differences in patient, disease, or surgery characteristics between patients who were sarcopenic vs. not. Patients with sarcopenia were more likely to have post-operative complications (P=0.05). There was no significant difference in hospital stay (P=0.7402) or survival (P=0.2317).

CONCLUSIONS

A significant number of patients with gastric cancer become sarcopenic during NAC. Although patients with sarcopenia were nearly twice as likely to develop post-operative complications, this did not appear to impact length of stay (LOS) or survival.

Epidemiology of sarcopenia and insight into possible therapeutic targets

Musculoskeletal ageing is a major public health concern owing to demographic shifts in the population. Sarcopenia, generally defined as the age-related loss of muscle mass and function, is associated with considerable risk of falls, loss of independence in older adults and hospitalization with poorer health outcomes. This condition is therefore associated with increased morbidity and health care costs. As with bone mass, muscle mass and strength increase during late adolescence and early adulthood, but begin to decline substantially from ∼50 years of age. Sarcopenia is characterized by many features, which include loss of muscle mass, altered muscle composition, infiltration with fat and fibrous tissue and alterations in innervation. A better understanding of these factors might help us to develop strategies that target these effects. To date, however, methodological challenges and controversies regarding how best to define the condition, in addition to uncertainty about what outcome measures to consider, have delayed research into possible therapeutic options. Most pharmacological agents investigated to date are hormonal, although new developments have seen the emergence of agents that target myostatin signalling to increase muscle mass. In this review we consider the current approaching for defining sarcopenia and discuss its epidemiology, pathogenesis, and potential therapeutic opportunities.

Sarcopenia is a risk factor for cardiovascular events experienced by patients with critical limb ischemia

BACKGROUND

Prognosis is poor for patients with critical limb ischemia (CLI), and the most frequent cause of death is cardiovascular disease. Low grip strength is a risk factor for cardiovascular events, and sarcopenia may be associated as well. Thus, we hypothesized that sarcopenia is a risk factor for cardiovascular events experienced by patients with CLI. If this is true and appropriate therapy becomes available, the prognosis of patients with CLI will improve with appropriate risk management strategies to prevent cardiovascular events. Therefore, the aim of this study was to verify this hypothesis.

METHODS

We studied 114 patients who underwent revascularization and computed tomography between January 2002 and December 2012 in the Department of Surgery and Sciences at Kyushu University in Japan. Sarcopenia was defined as skeletal muscle area measured by L3-level computed tomography scan <114.0 cm² and <89.8 cm² for men and women, respectively. Clinical characteristics, cardiovascular event-free survival, <2-year death, causes of death, and effective treatments for sarcopenia were investigated.

RESULTS

We identified 53 (46.5%) patients with sarcopenia. Three-year cardiovascular event-free survival rates were 43.1% and 91.2% for patients with and without sarcopenia, respectively (P < .01). During follow-up, cardiovascular disease caused the deaths of 4 and 15 patients without and with sarcopenia (P < .01), respectively, and in particular, ischemic heart disease caused the deaths of 0 and 5 patients without or with sarcopenia (P < .05), respectively. Single antiplatelet therapy (SAPT; hazard ratio, 0.46; 95% confidence interval, 0.24-0.82; P < .01) and statin therapy (hazard ratio, 0.38; 95% confidence interval, 0.16-0.78; P < .01) were independent factors associated with improved cardiovascular event-free survival. Three-year cardiovascular event-free survival rates for patients with sarcopenia who received SAPT, dual antiplatelet therapies, and no antiplatelet therapy were 75.3%, 21.1%, and 29.5%, respectively (P < .01).

CONCLUSIONS

Sarcopenia is a risk factor for worse cardiovascular event-free survival, and SAPT and statin therapy reduced this risk for patients with CLI. Furthermore, SAPT but not dual antiplatelet therapy increased cardiovascular event-free survival in patients with sarcopenia.