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Purcell SA, Elliott SA, Walter PJ, Preston T, Cai H, Skipworth RJE, Sawyer MB, Prado CM. Total energy expenditure in patients with colorectal cancer: associations with body composition, physical activity, and energy recommendations. Am J Clin Nutr 2019; 110:367-376. [PMID: 31225583 PMCID: PMC6669058 DOI: 10.1093/ajcn/nqz112] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 05/06/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Total energy expenditure (TEE) data in patients with early-stage cancer are scarce, precluding an understanding of energy requirements. OBJECTIVE The objective was to cross-sectionally characterize TEE in patients with colorectal cancer (CRC) and to compare measured TEE with energy recommendations. It was hypothesized that TEE would differ according to body mass, body composition, and physical activity level (PAL) and current energy recommendations would have poor individual-level accuracy. METHODS Patients with newly diagnosed CRC had resting energy expenditure (REE) measured by indirect calorimetry and TEE by doubly labeled water. Hypermetabolism was defined as REE > 110% of that predicted from the Mifflin St.-Jeor equation. Body composition was assessed via DXA. Physical activity was determined as the ratio of TEE to REE (TEE:REE) (PAL) and residual activity energy expenditure (RAEE). TEE was compared with energy recommendations of 25-30 kcal/d and Dietary Reference Intakes (DRIs) using Bland-Altman analyses. Patients were stratified according to median BMI, PAL, and sex-specific ratio of fat mass (FM) to fat-free mass (FFM). RESULTS Twenty-one patients (M:F 14:7; mean ± SD BMI: 28.3 ± 4.9 kg/m2, age: 57 ± 12 y) were included. Most (n = 20) had stage II-III disease; 1 had stage IV. Approximately half (n = 11) were hypermetabolic; TEE was not different in those with hypermetabolism and REE as a percentage of predicted was not correlated with TEE. Mean ± SD TEE was 2473 ± 499 kcal/d (range: 1562-3622 kcal/d), or 29.7 ± 6.3 kcal/kg body weight (range: 20.4-48.5 kcal/kg body weight). Mean ± SD PAL was 1.43 ± 0.27. The energy recommendation of 25 kcal/kg underestimated TEE (-12.6% ± 16.5%, P = 0.002); all energy recommendations had wide limits of agreement (the smallest was DRI with measured PAL: -21.2% to 29.3%). Patients with higher BMI and FM:FFM had higher bias using kilocalories per kilogram recommendations; bias from several recommendations was frequently lower (i.e. underestimation) in patients with higher PAL and RAEE. CONCLUSIONS TEE variability was not reflected in energy recommendations and error was related to body weight, body composition, and physical activity. This trial was registered at clinicaltrials.gov as NCT03131921.
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Purcell SA, Elliott SA, Baracos VE, Chu QSC, Sawyer MB, Mourtzakis M, Easaw JC, Spratlin JL, Siervo M, Prado CM. Accuracy of Resting Energy Expenditure Predictive Equations in Patients With Cancer. Nutr Clin Pract 2019; 34:922-934. [PMID: 31347209 DOI: 10.1002/ncp.10374] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Our purpose was to assess the accuracy of resting energy expenditure (REE) equations in patients with newly diagnosed stage I-IV non-small cell lung, rectal, colon, renal, or pancreatic cancer. METHODS In this cross-sectional study, REE was measured using indirect calorimetry and compared with 23 equations. Agreement between measured and predicted REE was assessed via paired t-tests, Bland-Altman analysis, and percent of estimations ≤ 10% of measured values. Accuracy was measured among subgroups of body mass index (BMI), stage (I-III vs IV), and cancer type (lung, rectal, and colon) categories. Fat mass (FM) and fat-free mass (FFM) were assessed using dual x-ray absorptiometry. RESULTS Among 125 patients, most had lung, colon, or rectal cancer (92%, BMI: 27.5 ± 5.6 kg/m2 , age: 61 ± 11 years, REE: 1629 ± 321 kcal/d). Thirteen (56.5%) equations yielded REE values different than measured (P < 0.05). Limits of agreement were wide for all equations, with Mifflin-St. Jeor equation having the smallest limits of agreement, -21.7% to 11.3% (-394 to 203 kcal/d). Equations with FFM were not more accurate except for one equation (Huang with body composition; bias, limits of agreement: -0.3 ± 11.3% vs without body composition: 2.3 ± 10.1%, P < 0.001). Bias in body composition equations was consistently positively correlated with age and frequently negatively correlated with FM. Bias and limits of agreement were similar among subgroups of patients. CONCLUSION REE cannot be accurately predicted on an individual level, and bias relates to age and FM.
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Purcell SA, Baracos VE, Chu QSC, Sawyer MB, Severin D, Mourtzakis M, Lieffers JR, Prado CM. Profiling Determinants of Resting Energy Expenditure in Colorectal Cancer. Nutr Cancer 2019; 72:431-438. [PMID: 31282744 DOI: 10.1080/01635581.2019.1635172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: Understanding resting energy expenditure (REE) is important for determining energy requirements; REE might be altered in individuals with cancer. The objective of this study was to characterize determinants of REE in patients with stages II-IV colorectal cancer (CRC).Methods: REE was measured via indirect calorimetry in patients with newly diagnosed CRC. Computerized tomography images from medical records ascertained skeletal muscle and total adipose tissue cross-sectional areas, which were then transformed to lean soft tissue (LST) and fat mass (FM) values (in kg). Linear regression assessed determinants of REE.Results: 86 patients were included (n = 55, 64.0% male; 60 ± 12 years old; median body mass index: 27.6, interquartile range: 24.3-31.2 kg/m2), with most (n = 40) having stage III disease. Age, sex, and weight were significant predictors of REE [R2 = 0.829, standard error of the estimate (SEE): 128 kcal/day, P < 0.001]. Replacing weight with LST and FM yielded a similar model, with age, sex, LST, and FM predictive of REE (R2 = 0.820, SEE: 129 kcal/day, p < 0.001).Conclusion: Age, sex, weight, LST, and FM were the main contributors to REE. Further investigation of REE changes over time and its relationship to total energy expenditure, dietary intake, and clinical outcomes should be explored.
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Mercade TM, Moreno V, John B, Morris JC, Sawyer MB, Yong WP, Gutierrez M, Karasic TB, Sangro B, Sheng-Shun Y, Gentry C, Kim A, Kumar P, MacKenzie C, Rioux N, Schindler J, Selvaraj A, Finn RS. A phase I study of H3B-6527 in hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC) patients (pts). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.4095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4095 Background: FGF19 overexpression is hypothesized to hyperactivate FGFR4 and its downstream signaling pathway leading to enhanced tumor growth in HCC/ICC. Targeting FGFR4 may have therapeutic benefit in HCC/ICC with altered FGF19 signaling. A phase 1 study (NCT02834780) was initiated to assess H3B-6527, an investigational highly selective covalent FGFR4 inhibitor. Methods: Adult pts with advanced HCC or ICC, ECOG PS 0-1, well compensated liver function, and who progressed after at least one prior therapy, were administered H3B-6527 orally QD (once daily) on a 21-day cycle following a 3+3 design. Patients in the dose escalation phase were treated regardless of FGF19 status. Adverse events (AEs), pharmacokinetics (PK), and pharmacodynamics (PD) were assessed. Response was determined by RECIST 1.1 or modified RECIST every 6 weeks. Results: As of 06-Jan-2019, 37 pts have been treated with H3B-6527 at doses of 300 to 1400 mg QD (23 pts in escalation; 14 in expansion). In dose escalation, a total of 17 patients with HCC, Child-Pugh A received prior systemic therapy including 100% with prior TKI and 35% with prior IO. 12% had hepatitis B virus and 47% had hepatitis C virus. H3B-6527 plasma levels increased with dose from 300 to 1000 mg QD and plateaued. H3B-6527 was rapidly absorbed with a tmax of ~2-3 h and showed a terminal half-life of ~4-5 h, following administration of 1000 mg (fasted). No dose-limiting toxicities or ≥ Grade 3 treatment-related AEs (TRAE) have been observed in escalation. Most common TRAEs (≥ 10%) were diarrhea, nausea, and vomiting. Based on safety, PK, and PD, 1000 mg QD was the recommended phase 2 dose. Durable stable disease and partial responses (PR) have been observed on the once daily fasted schedule; 2 of 17 pts with HCC achieved PRs and an additional 7 with stable disease were on treatment for ≥ 5 months. Conclusions: H3B-6527 is well tolerated and demonstrates early signs of clinical activity. Dose expansion on QD schedule and exploration of BID (twice daily) schedule is ongoing. Clinical trial information: NCT02834780.
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Juergens RA, Chu QS, Renouf DJ, Laurie SA, Purcea D, McWhirter E, Arndt D, Gelmon KA, Hilton J, Gavillet B, Ellis PM, Sawyer MB, Kollmannsberger CK, Andrews Wright N, Rouits E, Brichory F, Vuagniaux G, Szyldergemajn SA, Goss G. A dose-finding study of the SMAC mimetic Debio 1143 when given in combination with avelumab to patients with advanced solid malignancies. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.2599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2599 Background: Second mitochondria-derived activator of caspase (SMAC) mimetics regulate apoptosis and modulate NFκB signaling which drives the expression of genes involved in immune and inflammatory responses. In patient (pt) tumors, Debio 1143 increased PD-1/PD-L1 expression and tumor infiltrating lymphocytes. In pre-clinical models, it synergizes in vitro and in vivo with PD1/PD-L1 checkpoint inhibitors (CPIs). Methods: In a phase I study, using a mCRM model, avelumab (10 mg/kg i.v. on D1&15 q4w) was combined with escalating doses of Debio 1143 (100 mg/d to 250 mg/d orally, D1-10 & D15-24 q4w) to define the RP2D. Consenting adult pts with advanced solid tumors, normal organ function, and PS-ECOG = 0-1 were eligible provided none received prior CPI. Dose-limiting toxicities (DLTs), efficacy, safety, PK, PD and biomarkers were assessed. Results: As of DEC’18, 16 pts were treated; M/F: 8/8; ECOG = 0 in 6 (38%); median age = 58 (28-79); 5 pts had NSCLC, 2 MPM, 2 ovarian and 7 had other tumors (n = 1 each). Common AEs were: nausea (69%); fatigue (62%); vomiting (50%); cough, dyspnea, myalgia (44% each); diarrhea, anorexia (38% each); pruritus and constipation (31% each). These were generally grade 1-2, occasionally grade 3. One pt had a DLT at 250 mg/d dose: a grade 3 AST/ALT increase. No treatment-related AEs grade 4 or higher occurred. No dose-relationships for laboratory abnormalities were observed, except for ALT/AST increases, which at 200 mg/d were all grade 1 and asymptomatic. Maximal tolerated dose was not reached and there were no dose reductions. In 15 evaluable pts, 1 PR (NSCLC) and 5 SD (RECIST v1.1) were observed. Tumor shrinkage > 15% was seen in 2 other NSCLC pts. PK showed high interpatient variability and dose-proportional increase. TNFα and IFNγ peaked in plasma following Debio 1143 dose on D1 after 8 hrs, and on D17/22, in a dose-proportional manner. Four pts developed anti-avelumab antibodies. Conclusions: Debio 1143 at 200 mg/d can be safely combined with avelumab. Toxicity was predictable and mild. Clinical activity was observed in NSCLC pts. PK was linear; no drug interaction was suspected. PD and biomarker analysis is ongoing. Expansion at this RP2D is ongoing in NSCLC. Clinical trial information: NCT03270176.
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Overman MJ, Lonardi S, Wong KYM, Lenz HJ, Gelsomino F, Aglietta M, Morse M, Van Cutsem E, McDermott RS, Hill AG, Sawyer MB, Hendlisz A, Neyns B, Svrcek M, Atasoy A, Zhao H, Lei M, Kopetz S, Andre T. Nivolumab (NIVO) + low-dose ipilimumab (IPI) in previously treated patients (pts) with microsatellite instability-high/mismatch repair-deficient (MSI-H/dMMR) metastatic colorectal cancer (mCRC): Long-term follow-up. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.4_suppl.635] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
635 Background: In the phase II CheckMate-142 trial, NIVO + low-dose IPI (1 mg/kg) provided meaningful clinical benefit in previously treated MSI-H/dMMR mCRC pts after a median follow-up of 13.4 mo. Here, we present long-term follow-up (median 25.4 mo) of these pts. Methods: Pts received NIVO 3 mg/kg + low-dose IPI Q3W (4 doses) followed by NIVO 3 mg/kg Q2W until disease progression. Primary endpoint was investigator (INV)-assessed objective response rate (ORR; RECIST v1.1). Results: Of 119 treated pts, 76% had ≥ 2 prior lines of therapy. ORR and disease control rates (DCR) were 58 and 81%, respectively (Table). Complete response (CR) rate increased with long-term follow-up from 3 (13.4 mo) to 6% (25.4 mo). Median duration of response (DOR) was not reached, with 68% of responses ongoing at data cutoff. At 24 mo, progression-free survival (PFS) and overall survival (OS) rates were 60 and 74%, respectively; OS rates were 96, 56, and 29% in pts with CR or partial response (PR), stable disease (SD), and progressive disease (PD), respectively. Grade 3–4 treatment-related adverse events (TRAEs) occurred in 31% of pts; 10% (grade 3–4) and 13% (any grade) of pts had TRAEs leading to discontinuation. Conclusions: Long-term follow-up with NIVO + low-dose IPI provides durable clinical benefit with deepening of response and a manageable safety profile with no new safety signals, demonstrating long-term benefit of NIVO + low-dose IPI for previously treated pts with MSI-H/dMMR mCRC. Clinical trial information: NCT02060188. [Table: see text]
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Martin L, Hopkins J, Malietzis G, Jenkins JT, Sawyer MB, Brisebois R, MacLean A, Nelson G, Gramlich L, Baracos VE. Assessment of Computed Tomography (CT)-Defined Muscle and Adipose Tissue Features in Relation to Short-Term Outcomes After Elective Surgery for Colorectal Cancer: A Multicenter Approach. Ann Surg Oncol 2018; 25:2669-2680. [PMID: 30006691 DOI: 10.1245/s10434-018-6652-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sarcopenia, visceral obesity (VO), and reduced muscle radiodensity (myosteatosis) are suggested risk factors for postoperative morbidity in colorectal cancer (CRC), but usually are not concurrently assessed. Published thresholds used to define these features are not CRC-specific and are defined in relation to mortality, not postoperative outcomes. This study aimed to evaluate body composition in relation to length of hospital stay (LOS) and postoperative outcomes. METHODS Pre-surgical computed tomography (CT) images were assessed for total area and radiodensity of skeletal muscle and visceral adipose tissue in a pooled Canadian and UK cohort (n = 2100). Sex- and age-specific values for these features were calculated. For 1139 of 2100 patients, LOS data were available, and sex- and age-specific thresholds for sarcopenia, myosteatosis, and VO were defined on the basis of LOS. Association of CT-defined features with LOS and readmissions was explored using negative binomial and logistic regression models, respectively. RESULTS In the multivariable analysis, the predictors of LOS (P < 0.001) were age, surgical approach, major complications (incidence rate ratio [IRR] 2.42; 95% confidence interval [CI] 2.18-2.68), study cohort, and three body composition profiles characterized by myosteatosis combined with either sarcopenia (IRR, 1.27; 95% CI 1.12-1.43) or VO (IRR, 1.25; 95% CI 1.10-1.42), and myosteatosis combined with both sarcopenia and VO (IRR, 1.58; 95% CI 1.29-1.93). In the multivariable analysis, risk of readmission was associated with VO alone (odds ratio [OR] 2.66; 95% CI 1.18-6.00); P = 0.018), VO combined with myosteatosis (OR, 2.72; 95% CI 1.36-5.46; P = 0.005), or VO combined with myosteatosis and sarcopenia (OR, 2.98; 95% CI 1.06-5.46; P = 0.038). Importantly, the effect of body composition profiles on LOS and readmission was independent of major complications. CONCLUSION The findings showed that CT-defined multidimensional body habitus is independently associated with LOS and hospital readmission.
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Damaraju VL, Kuzma M, Cass CE, Putman CT, Sawyer MB. Multitargeted kinase inhibitors imatinib, sorafenib and sunitinib perturb energy metabolism and cause cytotoxicity to cultured C2C12 skeletal muscle derived myotubes. Biochem Pharmacol 2018; 155:162-171. [PMID: 29983397 DOI: 10.1016/j.bcp.2018.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/01/2018] [Indexed: 12/12/2022]
Abstract
Tyrosine kinase inhibitors (TKIs) have advanced cancer treatment and prognosis but have also resulted in adverse effects such as fatigue, diarrhea, hypothyroidism, and other toxicities. We investigated TKI effects on skeletal muscle as a possible explanation of TKI induced fatigue. Changes in mitochondrial function due to inhibition of oxidative phosphorylation complexes, generation of superoxides, and inhibition of key transporters involved in uptake of glucose and/or nucleosides may result in alteration of energy metabolism and/or mitochondrial function. We investigated effects of imatinib, sorafenib and sunitinib on these processes in cultured C2C12 murine skeletal muscle cells. Imatinib, sorafenib and sunitinib were cytotoxic to C2C12 cells with IC50 values of 20, 8 and 8 µM, respectively. Imatinib stimulated glucose uptake and inhibited complex V activity by 35% at 50 µM. Sorafenib inhibited complex II/III and V with IC50 values of 32 and 28 µM, respectively. Sorafenib caused activation of caspase 3/7 and depolarization of mitochondrial membranes occurred very rapidly with complete loss at 5-10 µM. Sunitinib inhibited Complex I with an IC50 value of 38 µM and caused ATP depletion, caspase 3/7 activation, an increase in reactive oxygen species (ROS), and decreased nucleoside and glucose uptake. In conclusion, imatinib, sunitinib and sorafenib caused changes in mitochondrial complex activities, glucose and nucleoside uptake leading to decreased energy production and mitochondrial function in a skeletal muscle cell model, suggesting that these changes may play a role in fatigue, one of the most common adverse effects of TKIs.
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Hopkins JJ, Sawyer MB. Interactions of lean soft-tissue and chemotherapy toxicities in patients receiving anti-cancer treatments. Cancer Chemother Pharmacol 2018; 82:1-29. [PMID: 29876640 DOI: 10.1007/s00280-018-3614-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/29/2018] [Indexed: 01/06/2023]
Abstract
Use of cross-sectional imaging to identify whole-body lean soft-tissue mass has recently emerged as an attractive prognostic factor for chemotherapy toxicities. Beyond that, there is increasing interest in use of lean soft-tissue mass as a more accurate method for dosing chemotherapy, as compared to body surface area. In this review, we summarize the current evidence that supports interactions between skeletal muscle and chemotherapy, the role of lean soft tissue in predicting chemotherapy toxicities and potential use of an alternate method of chemotherapeutic dosing, all based on quantification of skeletal muscle mass by computed tomography.
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Purcell SA, Elliott SA, Ryan AM, Sawyer MB, Prado CM. Accuracy of a Portable Indirect Calorimeter for Measuring Resting Energy Expenditure in Individuals With Cancer. JPEN J Parenter Enteral Nutr 2018; 43:145-151. [DOI: 10.1002/jpen.1310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/26/2018] [Indexed: 01/09/2023]
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Sawyer MB, Hopkins J, Reif R, Bigam D, Baracos VE, Eurich D. The impact of skeletal muscle and adipose tissue on long-term survival in patients with resectable colorectal cancer. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.3585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wong G, Ha V, Chu MP, Dersch-Mills D, Ghosh S, Chambers C, Sawyer MB. Effects of proton pump inhibitors (PPIs) on FOLFOX and XELOX regimens in colorectal cancer (CRC). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.3614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Spreafico A, Sawyer MB, Siu LL, Huang F, Reschke S, Xia C, Yan Z, Genvresse I, Cisternas G, Kelly A, Khan F, Reif S, Granvil C. Effects of rifampin on the pharmacokinetics of copanlisib, a novel pan-class I phosphatidylinositol-3-kinase (PI3K) inhibitor in cancer patients. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e14559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Montano-Loza AJ, Mazurak VC, Ebadi M, Meza-Junco J, Sawyer MB, Baracos VE, Kneteman N. Visceral adiposity increases risk for hepatocellular carcinoma in male patients with cirrhosis and recurrence after liver transplant. Hepatology 2018; 67:914-923. [PMID: 29023899 DOI: 10.1002/hep.29578] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/30/2017] [Accepted: 10/03/2017] [Indexed: 12/21/2022]
Abstract
UNLABELLED Visceral adipose tissue (VAT) is a metabolically active organ, associated with higher risk of malignancies. We evaluated whether VAT is associated with the risk of hepatocellular carcinoma (HCC) in patients presenting with cirrhosis as well as HCC recurrence after liver transplantation (LT). Patients with cirrhosis (n = 678; 457 male) who were assessed for LT (289 with HCC) were evaluated for body composition analysis. Patients who underwent LT (n = 247, 168 male) were subsequently evaluated for body composition, and 96 of these patients (78 male) had HCC. VAT, subcutaneous adipose tissues, and total adipose tissues were quantified by computed tomography at the level of the third lumbar vertebra and reported as indexes (cross-sectional area normalized for height [square centimeters per square meter]). At the time of LT assessment, the VAT index (VATI) was higher in male patients with HCC compared to non-HCC patients (75 ± 3 versus 60 ± 3 cm2 /m2 , P = 0.001). The VATI, subcutaneous adipose tissue index, and total adipose tissue index were higher in male patients with HCC compared to non-HCC patients. By multivariate analysis, male patients with VATI ≥65 cm2 /m2 had a higher risk of HCC (hazard ratio, 1.90; 95% confidence interval, 1.31-2.76; P = 0.001). In male patients with HCC who underwent LT, a VATI ≥65 cm2 /m2 adjusted for Milan criteria was independently associated with higher risk of HCC recurrence (hazard ratio, 5.34; 95% confidence interval, 1.19-23.97; P = 0.03). CONCLUSION High VATI is an independent risk factor for HCC in male patients with cirrhosis and for recurrence of HCC after LT. (Hepatology 2018;67:914-923).
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Johnson Stoklossa CA, Ghosh SS, Forhan M, Sharma AM, Terada T, Siervo M, Baracos VE, Padwal RS, Hung PA, Sawyer MB, Maia YLM, Prado CM. Poor Physical Function as a Marker of Sarcopenia in Adults with Class II/III Obesity. Curr Dev Nutr 2018; 2:nzx008. [PMID: 30377678 PMCID: PMC6201683 DOI: 10.3945/cdn.117.001743] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/12/2017] [Accepted: 12/18/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adults with class II/III obesity [body mass index (in kg/m2) ≥35] may present with a phenotype characterized by low lean mass and excess fat mass, a condition known as sarcopenic obesity (SO). Little is known about the prevalence and relevance of SO in these individuals, primarily due to a lack of relevant diagnostic criteria. OBJECTIVE Here, we explored the definition of SO based on physical function as an outcome of interest in adults with class II/III obesity and applied this definition to compare clinical characteristics between SO and non-SO patients. METHODS In this cross-sectional analysis, patients' demographic, anthropometric, and biochemical characteristics, as well as comorbidities and physical activity levels, were collected at an obesity specialty clinic prior to any treatment. Body composition was assessed by dual-energy X-ray absorptiometry. Physical function was assessed by self-reported difficulties with activities of daily living (ADLs) from an 11-item questionnaire. Five SO definitions were tested against reported difficulty with ADLs with the use of receiver operating characteristic (ROC) analysis. RESULTS A total of 120 subjects (86% women) aged 46 ± 11 y were included. Based on ROC analysis, SO was best defined by an appendicular skeletal mass (ASM)/weight x 100 (%) <19.35% for women and <24.33% for men, resulting in a prevalence of 25% (n = 30, women 22.3%, men 41.2%). SO was significantly associated with older age, higher waist circumference, higher triglycerides, greater use of antihypertensive medications, and lower physical activity. CONCLUSIONS In this sample of adults with class II/III obesity, difficulties with ADLs were best associated with measures of ASM in relation to total body weight. Patients identified with SO using this criterion presented with poorer clinical outcomes such as factors of elevated cardiometabolic risk.
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Hopkins JJ, Skubleny D, Bigam DL, Baracos VE, Eurich DT, Sawyer MB. Barriers to the Interpretation of Body Composition in Colorectal Cancer: A Review of the Methodological Inconsistency and Complexity of the CT-Defined Body Habitus. Ann Surg Oncol 2018; 25:1381-1394. [PMID: 29488190 DOI: 10.1245/s10434-018-6395-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Measurement of body composition by computed tomography (CT) is an advancing field. Sarcopenia, myosteatosis, and visceral obesity (VO) have been identified as predictive of survival in colorectal cancer (CRC). We performed a systematic review of contemporary studies to characterize this association and highlight methodological inconsistencies. METHODS MEDLINE and PubMed were queried for articles published from January 2000 on, with populations of resectable CRC and with CT-measured body composition and survival data. The study quality was assessed by two independent reviewers using the Newcastle-Ottawa Scale. RESULTS Twenty studies met inclusion criteria, with a total of 8895 patients. Only two of the studies scored as high quality and nine as moderate quality. The remaining nine studies scored as low quality. Ten studies considered sarcopenia and 12 considered visceral obesity (VO). Cutoff points to define sarcopenia, myosteatosis, and VO were identified by optimal stratification, quartiles, or median values. The prevalence of sarcopenia varied from 15 to 60%, which based on study population and cutoff value used. Sarcopenia was associated with worse overall and disease-free survival in eight of the included studies. Myosteatosis was considered in three studies with a prevalence of 19-78%. It was significantly predictive of worse overall and disease-free survival in all three studies. VO had a prevalence of 14-70% and was inconsistently predictive of survival outcomes. CONCLUSIONS There is a lack of methodological consistency within the currently published literature. Despite this, sarcopenia and myosteatosis, but not VO, are consistently associated with worse survival outcomes, when population and cancer-specific cutoffs are utilized.
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Andre T, Lonardi S, Wong M, Lenz HJ, Gelsomino F, Aglietta M, Morse M, Van Cutsem E, McDermott RS, Hill AG, Sawyer MB, Hendlisz A, Neyns B, Svrcek M, Moss RA, Ledeine JM, Cao ZA, Kamble S, Kopetz S, Overman MJ. Nivolumab + ipilimumab combination in patients with DNA mismatch repair-deficient/microsatellite instability-high (dMMR/MSI-H) metastatic colorectal cancer (mCRC): First report of the full cohort from CheckMate-142. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.553] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
553 Background: Nivolumab (NIVO) provided durable responses (investigator-assessed [INV] ORR, 31%) and disease control (DCR, 69%) in pretreated pts with dMMR/MSI-H mCRC in CheckMate-142 (NCT02060188; Overman et al Lancet Oncol 2017). An interim analysis of the NIVO + ipilimumab (IPI) combination cohort of CheckMate-142 reported a preliminary ORR of 55% and manageable safety profile in a subset of pts (n = 84) with dMMR/MSI-H mCRC and ≥ 6 mo of follow-up (André et al ASCO 2017). Here we report for the first time efficacy and safety from the complete population (N = 119) of the NIVO + IPI cohort of CheckMate-142, which is the largest single-study report of an immunotherapy regimen in pts with dMMR/MSI-H mCRC. Methods: Pts with dMMR/MSI-H mCRC received NIVO 3 mg/kg + IPI 1 mg/kg Q3W for 4 doses followed by NIVO 3 mg/kg Q2W. Primary endpoint was ORR (INV; RECIST 1.1). Other endpoints were DOR, PFS, OS, and safety/tolerability. Results: Of 119 treated pts, 76% had ≥ 2 prior lines of therapy. Median follow-up was 13.4 mo. The ORR was 55% and DCR was 80% (Table). Notably, ORR in pts with a BRAF mutation was 55%. Among all responders, median DOR was not reached (NR), with 94% of responses ongoing at data cutoff. Tumor burden was reduced from baseline in 77% of pts. The 9-mo PFS and OS rates were 76% and 87%, respectively. Gr 3–4 TRAEs occurred in 32% of pts; 13% (any gr) and 10% (gr 3–4) of pts had TRAEs that led to discontinuation. No treatment-related deaths were reported. Results including a similar follow-up of the NIVO arm will also be presented. Conclusions: In the largest cohort of dMMR/MSI-H pts treated with an immunotherapy regimen, NIVO + IPI built on the efficacy reported with NIVO monotherapy, demonstrating enhanced clinical benefit and manageable safety, and may represent a new standard of care in pts with dMMR/MSI-H mCRC. Clinical trial information: NCT02060188. [Table: see text]
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Wong G, Ha V, Chu MP, Dersch-Mills D, Ghosh S, Chambers C, Sawyer MB. Effects of proton pump inhibitors (PPIs) on FOLFOX and XELOX regimens in colorectal cancer (CRC). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
621 Title: Effects of Proton Pump Inhibitors (PPIs) on FOLFOX and XELOX Regimens in Colorectal Cancer (CRC) Background: First-line adjuvant chemotherapy options for stage II-III CRC include XELOX (capecitabine (cape), oxaliplatin) and FOLFOX (oxaliplatin, leucovorin, 5FU). Cape is an oral 5FU prodrug, and recent studies suggested that PPIs may detrimentally affect cape efficacy. Conversely, some literature posits that PPIs may negatively impact CRC itself. Our primary objective was to compare 3-year recurrence-free survival (RFS) rates between XELOX-treated PPI-users and non-PPI users, and FOLFOX-treated PPI users and non-PPI users. Our main secondary objective was to compare overall survival (OS). Methods: We conducted a retrospective chart review of 389 stage II-III CRC patients (pts) who received adjuvant XELOX or FOLFOX from a tertiary cancer center in Alberta, Canada between 2004-2013. Information regarding PPI use, cancer treatment, and pt outcomes were gathered and analyzed from pharmacy databases. Results: 23.4% of XELOX-treated pts and 28.0% of FOLFOX -treated pts used PPIs concurrently with treatment. 3-year RFS was significantly lower in XELOX-treated PPI pts than non-PPI pts (69.5 vs. 82.6%, P=0.029). Unadjusted analysis showed that XELOX-treated PPI pts were twice as likely to experience cancer recurrence or death as XELOX-treated non-PPI pts (HR 2.03, P=0.033). FOLFOX-treated PPI pts had a non-significant increase in three-year RFS versus non-PPI pts (82.9 vs. 61.7%, P=0.066), and no significant difference in recurrence or death (HR 0.51, P=0.071). No significant differences were seen in OS. Conclusions: Our results suggest that PPIs negatively impacted RFS in early-stage XELOX-treated CRC pts, and yielded no significant effect amongst FOLFOX-treated patients. Further studies are required to corroborate our findings. [Table: see text]
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Chu MP, Sawyer MB. Factors Affecting the Association of Proton Pump Inhibitors and Capecitabine Efficacy in Advanced Gastroesophageal Cancer—Reply. JAMA Oncol 2018; 4:265. [DOI: 10.1001/jamaoncol.2017.3410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Hopkins J, Baracos VE, Bigam D, Eurich D, Sawyer MB. Clinical implications of muscle mass and quality in early-stage colorectal cancer (CRC). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
648 Background: Body composition has emerged as a potential prognostic factor for outcomes in early-stage CRC. Specifically, muscle mass and quality and visceral fat have been shown to be related to overall survival (OS) and disease-free survival (DFS). The objective of this study was to determine associations of sarcopenia, reduced skeletal muscle radiodensity (SMR) and visceral obesity (VO) with 5-year OS and DFS. Methods: Muscle and visceral fat at the time of diagnosis were quantified in a retrospective cohort of consecutive, early-stage CRC patients (pts), identified from a prospectively collected cancer database. Skeletal muscle area on computed tomography (CT) was measured and normalized by height (m2) in order to compare skeletal muscle index (SMI) between pts. Mean SMR and visceral fat area were measured. All parameters were analyzed using Kaplan-Meier curves and univariate Cox regression. Sarcopenia was defined as SMI < 41 cm2/m2 in females and < 43 cm2/m2 in males with BMI < 25 kg/m2 and < 53 cm2/m2 with BMI > 25 kg/m2. Reduced SMR was defined as < 41 HU if BMI < 25 kg/m2 and < 33 HU if BMI > 25 kg/m2. VO was defined as VAT > 160cm2 in males and > 80cm2 in females. Results: We identified 968 pts with available CTs and anthropometric data. Prevalence of sarcopenia was 44.5% in males and 59.6% in females. Myosteatosis was present in 60.9% of pts. The mean length of follow up was 5.0 years, with 254 patients developing recurrent disease and 351 deaths. Males with sarcopenia and myosteatosis had worse overall survival (HR, 0.69, p = 0.005; HR 0.49, p < 0.001) but no difference in DFS. Presence of VO was not associated with worse OS or DFS. There was no difference in OS for females with sarcopenia or VO, but myosteatosis predicted reduced OS (HR 0.53, p = 0.004). There was no difference in DFS for females by presence of sarcopenia, myosteatosis or VO. Conclusions: Body composition, specifically sarcopenia and myosteatosis, are highly prevalent in CRC pts treated with curative intent, and their presence is associated with reduced OS. Therefore, skeletal muscle mass and radiodensity are important prognostic factors in CRC outcomes, which are easily attained in a clinical setting.
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Overman MJ, Lonardi S, Wong KYM, Lenz HJ, Gelsomino F, Aglietta M, Morse MA, Van Cutsem E, McDermott R, Hill A, Sawyer MB, Hendlisz A, Neyns B, Svrcek M, Moss RA, Ledeine JM, Cao ZA, Kamble S, Kopetz S, André T. Durable Clinical Benefit With Nivolumab Plus Ipilimumab in DNA Mismatch Repair-Deficient/Microsatellite Instability-High Metastatic Colorectal Cancer. J Clin Oncol 2018; 36:773-779. [PMID: 29355075 DOI: 10.1200/jco.2017.76.9901] [Citation(s) in RCA: 1315] [Impact Index Per Article: 219.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose Nivolumab provides clinical benefit (objective response rate [ORR], 31%; 95% CI, 20.8 to 42.9; disease control rate, 69%; 12-month overall survival [OS], 73%) in previously treated patients with DNA mismatch repair-deficient (dMMR)/microsatellite instability-high (MSI-H) metastatic colorectal cancer (mCRC); nivolumab plus ipilimumab may improve these outcomes. Efficacy and safety results for the nivolumab plus ipilimumab cohort of CheckMate-142, the largest single-study report of an immunotherapy combination in dMMR/MSI-H mCRC, are reported. Patients and Methods Patients received nivolumab 3 mg/kg plus ipilimumab 1 mg/kg once every 3 weeks (four doses) followed by nivolumab 3 mg/kg once every 2 weeks. Primary end point was investigator-assessed ORR. Results Of 119 patients, 76% had received ≥ two prior systemic therapies. At median follow-up of 13.4 months, investigator-assessed ORR was 55% (95% CI, 45.2 to 63.8), and disease control rate for ≥ 12 weeks was 80%. Median duration of response was not reached; most responses (94%) were ongoing at data cutoff. Progression-free survival rates were 76% (9 months) and 71% (12 months); respective OS rates were 87% and 85%. Statistically significant and clinically meaningful improvements were observed in patient-reported outcomes, including functioning, symptoms, and quality of life. Grade 3 to 4 treatment-related adverse events (AEs) occurred in 32% of patients and were manageable. Patients (13%) who discontinued treatment because of study drug-related AEs had an ORR (63%) consistent with that of the overall population. Conclusion Nivolumab plus ipilimumab demonstrated high response rates, encouraging progression-free survival and OS at 12 months, manageable safety, and meaningful improvements in key patient-reported outcomes. Indirect comparisons suggest combination therapy provides improved efficacy relative to anti-programmed death-1 monotherapy and has a favorable benefit-risk profile. Nivolumab plus ipilimumab provides a promising new treatment option for patients with dMMR/MSI-H mCRC.
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Chu MP, Hecht JR, Slamon D, Wainberg ZA, Bang YJ, Hoff PM, Sobrero A, Qin S, Afenjar K, Houe V, King K, Koski S, Mulder K, Hiller JP, Scarfe A, Spratlin J, Huang YJ, Khan-Wasti S, Chua N, Sawyer MB. Association of Proton Pump Inhibitors and Capecitabine Efficacy in Advanced Gastroesophageal Cancer: Secondary Analysis of the TRIO-013/LOGiC Randomized Clinical Trial. JAMA Oncol 2017; 3:767-773. [PMID: 27737436 DOI: 10.1001/jamaoncol.2016.3358] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Capecitabine is an oral cytotoxic chemotherapeutic commonly used across cancer subtypes. As with other oral medications though, it may suffer from drug interactions that could impair its absorption. Objective To determine if gastric acid suppressants such as proton pump inhibitors (PPIs) may impair capecitabine efficacy. Design, Setting, and Participants This secondary analysis of TRIO-013, a phase III randomized trial, compares capecitabine and oxaliplatin (CapeOx) with or without lapatinib in 545 patients with ERBB2/HER2-positive metastatic gastroesophageal cancer (GEC); patients were randomized 1:1 between CapeOx with or without lapatinib. Proton pump inhibitor use was identified by medication records. Progression-free survival (PFS) and overall survival (OS) were compared between patients treated with PPIs vs patients who were not. Specific subgroups were accounted for, such as younger age (<60 years), Asian ethnicity, female sex, and disease stage (metastatic/advanced) in multivariate Cox proportional hazards modeling. The TRIO-013 trial accrued and randomized patients between June 2008 and January 2012; this analysis took place in January 2014. Interventions Patients were divided based on PPI exposure. Main Outcomes and Measures Primary study outcome was PFS and OS between patients treated with PPIs vs patients who were not. Secondary outcomes included disease response rates and toxicities. Results Of the 545 patients with GEC (median age, 60 years; 406 men [74%]) included in the study, 229 received PPIs (42.0%) and were evenly distributed between arms. In the placebo arm, PPI-treated patients had poorer median PFS, 4.2 vs 5.7 months (hazard ratio [HR], 1.55; 95% CI, 1.29-1.81, P < .001); OS, 9.2 vs 11.3 months (HR, 1.34; 95% CI, 1.06-1.62; P = .04); and disease control rate (83% vs 72%; P = .02) vs patients not treated with PPIs. In multivariate analysis considering age, race, disease stage, and sex, PPI-treated patients had poorer PFS (HR, 1.68; 95% CI, 1.42-1.94; P < .001) and OS (HR, 1.41; 95% CI, 1.11-1.71; P = .001). In patients treated with CapeOx and lapatinib, PPIs had less effect on PFS (HR, 1.08; P = .54) and OS (HR, 1.26; P = .10); however, multivariate analysis in this group demonstrated a significant difference in OS (HR, 1.38; 95% CI, 1.06-1.66; P = .03). Conclusions and Relevance Proton pump inhibitors negatively effected capecitabine efficacy by possibly raising gastric pH levels, leading to altered dissolution and absorption. These results are consistent with previous erlotinib and sunitinib studies. Whether PPIs affected lapatinib is unclear given concurrent capecitabine. Given capecitabine's prevalence in treatment breast cancer and colon cancer, further studies are under way. Trial Registration clinicaltrials.gov Identifier: NCT00680901.
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Abstract
INTRODUCTION Body surface area dosing of chemotherapeutic agents is based on limited scientific data, and often results in unpredictable plasma drug levels. Cross-sectional computed tomography (CT) imaging provides an accurate measurement of lean mass. This review summarizes emerging roles of lean mass in predicting pharmacokinetics and drug toxicities in cancer patients. Areas covered: A concise review of body composition measurement with CT cross-sectional imaging and its relationship to drug pharmacokinetics and toxicities. A comprehensive review of the predictive value of low lean mass (sarcopenia) in dose-limiting toxicities is also included. Expert commentary: Drug dosing in medical oncology faces many challenges, including heterogeneous body composition profiles. The emerging role of sarcopenia in predicting lean mass may provide the tool needed to more accurately dose patients and prevent dose-limiting toxicities.
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Cherniawsky HM, Sawyer MB, Ghosh S, Cheung WY, Ho MY. Utility of PET/CT in primary identification and management of cancers of unknown primary. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e18219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18219 Background: The role of PET/CT in staging and management of cancers of unknown primary (CUP) is poorly defined. Our study sought to evaluate PET/CT versus standard CT in determining the primary site, lymph node status and solid organ metastases, and assess whether results of PET scans altered management of patients with CUP. Methods: We conducted a retrospective chart review of CUP patients to measure concordance of PET/CT and CT scans in patients diagnosed with CUP at two Western Canadian academic centres; the Cross Cancer Institute and BC Cancer Agencies from 2008 to 2015. Results: We identified 244 patients who had standard CT and PET/CT during their work-up. Of the 70 patients whose primary identification status was recorded, standard CT imaging detected 16.1% of primaries compared to 12.1% on PET/CT. 63.3% of primaries were concordantly identified on both modalities. PET/CT identified 2 primaries not seen on CT whereas standard CT identified 9 primaries not seen on PET/CT. Concordance rates between PET/CTs and standard CTs were 77.9% and 93.9% regarding lymph node status and extent of metastases, respectively. PET/CT identified a greater extent lymph node involvement in patients; 93.8% versus 79.0%. (CCOR = 2.92, 95% CI = 0.87-9.72) and identified a greater extent of solid organ involvement; 96.5% versus 92.4%. (CCOR = 45.25, 95% CI = 7.79-262.78). Data from the CCI of patients who had discordant imaging in either domain or identification of primary showed no cases in which PET/CT alone provided information that changed patient management. Conclusions: Our results suggest PET/CT scans do not provide additional diagnostic information with respect to identifying the primary site but may be superior in clarifying extent of metastases and nodal status though this did not alter therapy. Future studies investigating the impact of PET/CT scans on management and cost effectiveness in CUP are critical.
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Chu MP, Lieffers J, Ghosh S, Belch A, Chua NS, Fontaine A, Sangha R, Turner RA, Baracos VE, Sawyer MB. Skeletal muscle density is an independent predictor of diffuse large B-cell lymphoma outcomes treated with rituximab-based chemoimmunotherapy. J Cachexia Sarcopenia Muscle 2017; 8:298-304. [PMID: 27897411 PMCID: PMC5377388 DOI: 10.1002/jcsm.12161] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 09/21/2016] [Accepted: 09/27/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND While much cancer research focuses on tumours and their microenvironment, malignancies cause widespread physiologic changes. Cancer and treatment-related sarcopenia, measured with quantitative imaging or as a decrease in overall body mass, are indicative of poor prognosis in elderly diffuse large B-cell lymphoma (DLBCL) patients, skeletal muscle radiodensity (SMD) may be a better prognostic marker. SMD, a measure of muscle radiation attenuation on CT imaging, is more prognostic than sarcopenia or International Prognostic Index (IPI) scores in follicular lymphoma and multiple solid organ malignancies. Low SMD appears to correlate with fat accumulation in muscle and is associated with inflammation. This study set out to examine SMD's prognostic ability in DLBCL. METHODS All DLBCL patients treated with rituximab-containing therapy between 2004 and 2009 were compared to determine SMD's prognostic ability in this single centre, retrospective study. Pre-treatment CT scans were used to measure SMD and muscle cross-sectional area. Primary endpoints included progression free (PFS) and overall survival (OS) while objective response rates (ORR) were secondary. RESULTS Of 224 evaluable patients, 116 were identified as having low SMD. Low SMD predicted poorer 5 year PFS, 60 vs. 81% (p = 0.001) and OS, 58 vs. 86% (p < 0.0001). SMD's prognostic ability retained significance in multivariate analysis taking into consideration the Revised International Prognostic Index (R-IPI) and sex. Although high SMD was not predictive of ORR (95.4 vs. 91.4%, p = 0.17), it was strongly associated with radiographic complete response (85 vs. 66%, p = 0.0007). Contrary to previous findings, sarcopenia did not predict for poorer OS but suggested improved OS in elderly DLBCL patients (HR 0.38, p = 0.01). CONCLUSIONS SMD is a novel prognostic (and potentially treatment predictive) marker independent of R-IPI in DLBCL. It presents an inexpensive yet complementary assessment to R-IPI for prognosticating DLBCL outcomes.
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