Body composition changes differ by gender in stomach, colorectal, and biliary cancer patients with cachexia: Results from a pilot study

Autophagic signaling promotes systems-wide remodeling in skeletal muscle upon oncometabolic stress by D2-HG

OBJECTIVES

Cachexia is a metabolic disorder and comorbidity with cancer and heart failure. The syndrome impacts more than thirty million people worldwide, accounting for 20% of all cancer deaths. In acute myeloid leukemia, somatic mutations of the metabolic enzyme isocitrate dehydrogenase 1 and 2 cause the production of the oncometabolite D2-hydroxyglutarate (D2-HG). Increased production of D2-HG is associated with heart and skeletal muscle atrophy, but the mechanistic links between metabolic and proteomic remodeling remain poorly understood. Therefore, we assessed how oncometabolic stress by D2-HG activates autophagy and drives skeletal muscle loss.

METHODS

We quantified genomic, metabolomic, and proteomic changes in cultured skeletal muscle cells and mouse models of IDH-mutant leukemia using RNA sequencing, mass spectrometry, and computational modeling.

RESULTS

D2-HG impairs NADH redox homeostasis in myotubes. Increased NAD+ levels drive activation of nuclear deacetylase Sirt1, which causes deacetylation and activation of LC3, a key regulator of autophagy. Using LC3 mutants, we confirm that deacetylation of LC3 by Sirt1 shifts its distribution from the nucleus into the cytosol, where it can undergo lipidation at pre-autophagic membranes. Sirt1 silencing or p300 overexpression attenuated autophagy activation in myotubes. In vivo, we identified increased muscle atrophy and reduced grip strength in response to D2-HG in male vs. female mice. In male mice, glycolytic intermediates accumulated, and protein expression of oxidative phosphorylation machinery was reduced. In contrast, female animals upregulated the same proteins, attenuating the phenotype in vivo. Network modeling and machine learning algorithms allowed us to identify candidate proteins essential for regulating oncometabolic adaptation in mouse skeletal muscle.

CONCLUSIONS

Our multi-omics approach exposes new metabolic vulnerabilities in response to D2-HG in skeletal muscle and provides a conceptual framework for identifying therapeutic targets in cachexia.

Prognostic value of overhydration and bioelectrical impedance vector on short- and long-term outcomes in hospitalized patients with cancer

BACKGROUND & AIMS

Water, an essential component of body composition, appears to be a significant predictor of adverse outcomes in clinical populations, despite being frequently underexplored. Bioelectrical impedance analysis (BIA) and vector analysis (BIVA) are easy and cost-effective bedside tools for estimating body composition, particularly water content. Therefore, our study aimed to assess the impact of hydration and fluid status using both BIA and BIVA on outcomes in hospitalized patients with cancer.

METHODS

A prospective cohort study involving hospitalized individuals with cancer was conducted. Total body water (TBW) was estimated using BIA. Extracellular-water/TBW (ECW/TBW) and ECW/intracellular-water (ECW/ICW) ratios were calculated. BIVA ellipses vectors were constructed to enhance our analysis of hydration status. Participants were followed during their hospital stay and up to six months after discharge to assess outcomes, including in-hospital mortality, 6-month non-elective rehospitalization, and 6-month mortality.

RESULTS

TBW, ECW/TBW, ECW/ICW ratios, and BIVA plots were not associated with non-elective rehospitalization during the follow-up period. However, TBW and an elevated ECW/ICW ratio were independent predictors of in-hospital mortality [hazard ratio (HR): 1.07 (1.01; 1.13) p = 0.020; HR: 4.23 (1.69; 10.58) p = 0.002]. Elevated ratios ECW/TBW and ECW/ICW were independent predictors of 6-month mortality [HR: 1.87 (1.10; 3.21) p = 0.022; HR: 2.49 (1.37; 4.51) p = 0.003]. BIVA vectors for in-hospital and 6-month mortality shifted significantly to the right, leading to cachexia and overhydration quadrants (p < 0.05).

CONCLUSION

Abnormalities related to overhydration were important predictors of short- and long-term mortality in hospitalized patients with cancer.

Dynamic Changes in Body Composition and Protein Intake in Epithelial Ovarian Cancer Patients Undergoing Chemotherapy: A Preliminary Study

BACKGROUND

Ovarian cancer patients often face poor nutritional status, with body composition (BC) serving as a significant prognostic indicator. Skeletal muscle mass (SMM) and fat-free mass (FFM) are crucial predictors of both survival and hospitalization duration. Increasing protein intake has been linked to improvements in SMM and FFM.

OBJECTIVE

This study aimed to document the alterations in BC parameters among ovarian cancer patients undergoing chemotherapy and correlate these changes with their nutrient intake.

METHODS

Twelve female patients with stage III ovarian cancer who received first-line chemotherapy were categorized based on their body mass indices (BMI). BC parameters were assessed using an 8-point bioelectrical impedance analysis with a frequency of 50 Hz-60 Hz and measurement impedance range of 10 Ω-1000 Ω. Nutrient intake (energy, protein, fat, and carbohydrate) was assessed before (T0), during the 3rd (T3), and 6th cycle of chemotherapy (T6) through 24-hour food recall.

RESULTS

Significant increases in body weight (BW)were observed in the underweight group (from 40.9 to 46.8 kg, p=0.001), concomitant with enhancements in all BC parameters. While changes were noted in SMM, they were not statistically significant (p=0.105).Among the underweight group, a protein intake above 1.2 g/kg BW led to an uptrend trend in SMM. Conversely, FFM in overweight/obese patients decreased significantly (from 37.6 to 36.4 kg, p=0.005) due to a a reduction in body water. Throughout chemotherapy, fat mass (FM), visceral fat (VAT), and phase angle (PhA) increased in all patient groups, reflecting heightened fat and carbohydrate intake.

CONCLUSION

Among stage III ovarian cancer patients, BC undergoes dynamic changes dynamically during the course of chemotherapy, with more pronounced enhancements observed in FFM among underweight patients. Notably, improvements in PhA, SMM or FFM were particularly evident among underweight patients with a protein intake above 1.2 g/kg BW.

Association between ICW/TBW ratio and cancer prognosis: Subanalysis of a population-based retrospective multicenter study

BACKGROUND & AIMS

Disease burden is known to alter cellular integrity and water balance. Therefore, the intracellular water/total body water (ICW/TBW) ratio is used as an adjunctive indicator to predict disease severity and prognosis. The ICW/TBW ratio of patients with cancer, who typically present with low muscle mass, poor nutritional status, and high inflammatory response, reportedly differs from that of the healthy population. Herein, we aimed to evaluate the effect of the ICW/TBW ratio on the prognosis of different subgroups of patients with cancer.

METHODS

This multicenter cohort study included 2787 patients with malignancies between June 2014 and December 2018. The association between covariates and overall survival (OS) was assessed using restricted cubic spline models. The multivariate Cox regression model included variables demonstrating a statistical significance in the univariate Cox regression analysis (P < 0.05) without multicollinearity. The generated nomogram used the C-index and calibration curves to validate the predictive accuracy of the scoring system.

RESULTS

The optimal cut-off value for the ICW/TBW ratio was 0.61. The ICW/TBW ratio was an independent prognostic factor (hazard ratio [HR]: 0.621; 95 % confidence interval [CI]: 0.537-0.719, P < 0.001). Moreover, the ICW/TBW ratio had a greater impact on the prognosis of patients receiving chemoradiotherapy than on those receiving chemotherapy alone (chemoradiotherapy: HR = 0.495, P = 0.005 vs. chemotherapy: HR = 0.646, P < 0.001). Multivariate Cox regression analysis showed that sex, age, tumor stage, body mass index, neutrophil-to-lymphocyte ratio (NLR), and ICW/TBW ratio were associated with OS. Subsequently, a nomogram was developed incorporating these variables and yielded a C-index of 0.743.

CONCLUSIONS

The ICW/TBW ratio was associated with muscle mass, nutritional status, and inflammation. A low ICW/TBW ratio is an independent risk factor for poor prognosis in patients with cancer, especially when they are female, have advanced cancer stage, have sarcopenia, and are receiving radiotherapy.

Extracellular water to total body water ratio, a novel predictor of recurrence in patients with colorectal cancer

Background

Total body water (TBW) fraction, which accounts for 60% of body weight, is an important indicator of body composition, and the extracellular water to TBW ratio (ECW/TBW) is reportedly useful in predicting clinical outcomes of patients with organ disorders. We aimed to clarify the clinical impact of preoperative ECW/TBW status on survival outcomes in cancer patients.

Methods

We used a database of 320 colorectal cancer (CRC) patients who underwent potentially curative resections. Preoperative ECW/TBW was measured using a bioelectrical impedance analysis (BIA), and its correlation with patient survival outcomes, clinicopathological factors, laboratory data, and comorbidities were analyzed.

Results

A high preoperative ECW/TBW was significantly associated with poorer relapse-free survival (RFS; p = 0.001) and overall survival (OS; p = 0.003). A high ECW/TBW ratio was significantly associated with older age (p < 0.001), low BMI (p = 0.009), and right-sided tumors (p = 0.03). In a multivariate analysis, a high ECW/TBW significantly predicted a higher RFS mortality (HR: 2.07, 95% CI: 1.10-3.88, p = 0.024) and OS mortality (HR: 3.23, 95% CI: 1.25-8.36, p = 0.016). Furthermore, a high ECW/TBW was significantly associated with lower hemoglobin (p < 0.001) and albumin levels (p < 0.001), but not comorbidities.

Conclusions

A high preoperative ECW/TBW was a predictive factor for recurrence and poorer overall survival independent of the tumor, node, and metastasis (TNM) stage. Our data suggest that preoperative evaluation of ECW/TBW using BIA might serve as a novel tool for developing CRC treatment strategies.

Prognostic value of the combined effect of nutritional status and body water component in patients with colorectal cancer

The aim of this study was to explore the impact of Geriatric Nutritional Risk Index (GNRI) and body water component (BWC) on the survival of colorectal cancer (CRC) patients and whether the combined effect had a potential prognostic and predictive efficacy. We evaluated the accuracy of GNRI for malnutrition and estimated the predictive capacity of BWC for survival. Kaplan-Meier survival curves and cox regression analyses were used to examine the prognostic effects. A nutrition-water score (NWS) model was developed and evaluated the survival predictive power. GNRI and extracellular water-to-intracellular water ratio (ECW/ICW) were integrated, with the cut-off values of 103.5 and 63.7%. Lower GNRI and higher ECW/ICW were independent risk factors for poor prognosis in CRC patients. The combination of the two into the NWS model demonstrated a higher risk of death for patients with NWS ≥ 1 compared to those with NWS of 0. NWS showed a better predictive capability compared to GNRI and ECW/ICW, with the concordance index of 0.681. Our study demonstrates GNRI and ECW/ICW's prognostic utility in CRC, with their combination improving survival prediction to help guide patient-centered treatment.

Exploratory Assessment of Nutritional Evaluation Tools as Predictors of Complications and Sarcopenia in Patients with Colorectal Cancer

BACKGROUND

Patients with colorectal cancer (CRC) are largely malnourished, which decreases overall survival and treatment efficacy and increases mortality rates. We hypothesize that angle phase might be associated with the risk of sarcopenia as well as cancer complications in patients with CRC. The inclusion of various nutritional status indicators and clinical cancer outcomes can result in significant variability. Therefore, the objective of this study was to perform an exploratory analysis of nutritional evaluation tools used to assess body composition and muscle quality in patients with CRC, in order to predict cancer complications and survival rate.

METHODS

A total of 127 patients with CRC were included in this study. Bioelectrical impedance analysis and body composition were performed, which we used to obtain phase angle (PhA) values. Muscle function was assessed by hand-grip strength (HGS) and muscle quality and adipose tissue depot were performed using ultrasound techniques.

RESULTS

This study showed that there were significant differences in body composition between females and males, as well as in muscle quantity and quality. PhA was highly correlated with quadriceps rectus femoris of cross-sectional area (RF-CSA), circumference of quadriceps rectus femoris (RF-CIR), superficial subcutaneous abdominal fat (S-SAT), as well as HGS (p < 0.05). PhA was also correlated with water content in females, and with muscle mass and quality in males (p < 0.05). Specifically, we found that PhA was a good predictor for cancer complications in women and the risk of sarcopenia in men. In the linear model controlled for age and body mass index (BMI), high PhA value was associated with a decreased risk of complications in females (Odds Ratio (OR) = 0.15, 95% CI: 0.03-0.81, p < 0.05). High PhA value was associated with a decreased risk of sarcopenia in males (OR = 0.42, 95% CI: 0.19-0.95, p < 0.05). In addition, Receiving Operating Characteristics (ROC) curve analysis showed that PhA had a good diagnostic accuracy for detecting cancer complications in females (Area under curve (AUC) = 0.894, 95% CI: 0.88-0.89, p < 0.05) and the risk of sarcopenia in males (AUC = 0.959, 95% CI: 0.91-0.92, p < 0.05).

CONCLUSIONS

PhA can accurately predict oncological complications in women and sarcopenia in men. These differences are relevant to understanding the nutritional status of patients with CRC and their personalized nutritional treatment.

Usefulness of Nutrition and Inflammation Assessment Tools in Esophageal Cancer Treatment

Multidisciplinary treatment for esophageal cancer leads to nutritional and inflammatory changes. Recent studies showed that nutritional and inflammatory changes during multidisciplinary treatment affect both short and long-term oncological outcomes in esophageal cancer treatment. Therefore, evaluation of the nutritional and inflammatory status during treatment is necessary in order to optimize and utilize multidisciplinary therapy for esophageal cancer. If patients with esophageal cancer are able to determine their nutritional and inflammatory status, they will be able to select the optimal esophageal cancer, anti-inflammation, and nutritional treatments. Various types of nutrition and inflammation assessment tools have been developed and reported for esophageal cancer, with each tool having its own clinical characteristics, which must be understood before being applied in clinical practice. This review summarizes the background, current status, and future perspectives on the application of nutrition and inflammation assessment tools in esophageal cancer treatment.

Morfo-functional nutritional status in patients with gastroenteropancreatic neuroendocrine tumors (GEPNET)

INTRODUCTION

Patients with gastroenteropancreatic neuroendocrine tumors (GEPNET) can suffer from malnutrition. This is the first descriptive study of morfo-functional evaluation in GEPNET.

OBJETIVES

To describe a morfo-functional evaluation, and to compare with reference population available, and to correlate different nutritional parameters. Moreover, to compare nutritional evaluation in our study with another same location non-neuroendocrine tumors.

MATERIALS AND METHODS

A retrospective observational study, 50 patients with GEPNET, medium age 61 years. It was collected clinico-pathological characteristics and nutritional status was assessed by anthropometric, laboratory test, bioelectrical impedance analysis, phase angle, hand grip strength, and rectus femoris ultrasound for the assessment of muscle mass. We used SPSS statistics to describe and to analyze correlations of different variables.

RESULTS

Most frequent location of tumor was pancreas and small bowel, tumor grade 1 and advance stage. In morfo-functional evaluation highlighted: a low fat mass percentage (23,5 vs 34,4%), low muscle mass percentage (36,5 vs 41,2%) and low body mass cell percentage (40,4 vs 48,8%) compared with reference population available by sex and age. Standarized phase angle by sex and age result as positive (+0,851). There was no difference in hand grip strength compared with reference population. After a review of differents studies available, phase angle and hand grip strength of non neuroendocrine tumors in same location, could suggest a minor affection of nutritional state in our GEPNET sample. A positive correlation was observed between non classic methods of nutritional evaluation such as bioelectrical impedance analysis, hand grip strength and rectus femoris ultrasound.

CONCLUSION

Patients with gastroenteropancreatic neuroendocrine tumors (GEPNET) show a moderate affection of nutritional status in comparison to general population. Morphofunctional assessment provide us a precise knowledge about nutritional status.

Agreement between maximum and mean handgrip strength measurements in cancer patients

BACKGROUND AND AIM

Handgrip strength (HGS) can be used to identify probable sarcopenia, by measuring maximum strength and/or through the average of three measurements. This study analyzed the agreement between maximum and mean HGS measurements in identifying probable sarcopenia in cancer patients.

METHODS

Adult individuals of both sexes diagnosed with malignant neoplasm were evaluated. HGS (kg/f) was measured in both hands and nutritional status defined by the Patient-Generated Subjective Global Assessment (PG-SGA). Bland-Altman, Intraclass Correlation Coefficient (ICC), and Cronbach's Alpha tests were applied to assess the agreement between measurements.

RESULTS

One hundred forty-one patients aged 60.0 ± 14.2 years were evaluated. There was a predominance of elderly (57.4%), male (53.2%), and non-white (58.2%) individuals, with tumors located in the lower gastrointestinal tract (GIT) (36.9%) and with suspected or some degree of malnutrition (61.0%). For men, the Bland-Altman test showed a mean error of 1.37 (95% CI-1.03 to 3.80) for dominant HGS (DHGS) and 1.50 (95% CI-1.60 to 4.60) for non-dominant HGS (NDHGS), while for women the values were 1.34 (95% CI-0.27 to 2.95) and 1.14 (95% CI-1.10 to 3.39), respectively. The ICC showed excellent reproducibility (> 0.90) and the Cronbach's Alpha was satisfactory (0.99).

CONCLUSION

Despite the satisfactory agreement observed between maximum and mean HGS values, in this study, individuals of both sexes with probable sarcopenia were better identified through mean values.

Proteomics of the phase angle: Results from the population-based KORA S4 study

BACKGROUND & AIMS

The phase angle (PhA) measured with bioelectrical impedance analysis is considered to reflect the interrelated components body cell mass and fluid distribution based on technical and physical aspects of the PhA measurement. However, the biomedical meaning of the PhA remains vague. Previous studies mainly assessed associations of the PhA with numerous diseases and health outcomes, but few connected protein markers to the PhA. To broaden our understanding of the biomedical background of the PhA, we aimed to explore a proteomics profile associated with the PhA and related biological factors.

METHODS

The study sample encompassed 1484 participants (725 women and 759 men) aged 55-74 years from the population-based Cooperative Health Research in the Region of Augsburg (KORA) S4 study. Proteomics measurements were performed with a proximity extension assay. We employed boosting with stability selection to establish a set of markers that was strongly associated with the PhA from a group of 233 plasma protein markers. We integrated the selected protein markers into a network and enrichment analysis to identify gene ontology (GO) terms significantly overrepresented for the selected PhA protein markers.

RESULTS

Boosting with stability selection identified seven protein markers that were strongly and independently associated with the PhA: N-terminal prohormone brain natriuretic peptide (NT-proBNP), insulin-like growth factor-binding protein 2 (IGFBP2), adrenomedullin (ADM), myoglobin (MB), matrix metalloproteinase-9 (MMP9), protein-glutamine gamma-glutamyltransferase 2 (TGM2), and fractalkine (CX3CL1) [beta coefficient per 1 standard deviation increase in normalized protein expression values on a log 2 scale (95% confidence interval): -0.12 (-0.15, -0.08), -0.13 (-0.17, -0.09), -0.14 (-0.18, -0.10), 0.10 (0.07, 0.14), 0.07 (0.04, 0.10), 0.08 (0.05, 0.11), -0.06 (-0.10, -0.03), respectively]. According to the enrichment analysis, this protein profile was significantly overrepresented in the following top five GO terms: positive regulation of cell population proliferation (p-value: 1.32E-04), extracellular space (p-value: 1.34E-04), anatomical structure formation involved in morphogenesis (p-value: 2.92E-04), regulation of multicellular organismal development (p-value: 5.72E-04), and metal ion homeostasis (p-value: 8.86E-04).

CONCLUSION

Implementing a proteomics approach, we identified six new protein markers strongly associated with the PhA and confirmed that NT-proBNP is a key PhA marker. The main biological processes that were related to this PhA's protein profile are involved in regulating the amount and growth of cells, reinforcing, from a biomedical perspective, the current technical-based consensus of the PhA to reflect body cell mass.

Relationships between Body Composition Parameters and Phase Angle as Related to Lifestyle among Young People

The aim of the study was to indicate which body composition parameters and which lifestyle components affect the phase angle (PA) value in young adults. Two-hundred-and-eighty-one students at Wroclaw Medical University participated in the study. A survey on respondent lifestyles was followed by anthropometric measurements, body composition analysis, and basal metabolic rate (BMR) calculation. The differences in the body composition of men and women corresponded to their sexual anatomy and physiology. Sex-dependent differences in lifestyle were also reported. The study revealed a relationship between PA and height, weight, BMR, BMI (body mass index), FFM (fat-free body mass), bone mass, water mass, muscle mass (r~0.4–0.7), ECW/ICW (extracellular water/intracellular water) and fat mass (r~−(0.4–0.6)) for the entire studied group. The relationship between PA values and lifestyle components concerned consumption of energy drinks, cola, alcohol, water, vegetables and fruits, meat, and also intervals between meals, time for physical exercises, and screen time (r~±0.2). The research shows that the PA value increases with an increase in positive body composition parameters. Following the principles of proper nutrition and physical activity increases PA values in most cases.

Serial measurements of body composition using bioelectrical impedance and clinical usefulness of phase angle in colorectal cancer

BACKGROUND

Although body composition (BC) can be measured easily using bioelectrical impedance analysis (BIA), there are few studies of serial BC measurements in colorectal cancer (CRC). The purpose of the present study was to observe the serial change of BC in patients with CRC surgery from the initiation to the end of chemotherapy and to evaluate its clinical usefulness.

METHODS

From July 2018 to November 2019, patients undergoing elective CRC surgery were enrolled. All clinical data were reviewed retrospectively. BIA data were collected prospectively at four time points (initial, discharge day, first chemotherapy, and 6 months later). BC was measured using a commercial BIA device.

RESULTS

A total of 160 patients were enrolled, and 110 (68.8%) patients were followed. Most BC measurements, such as weight, body mass index, skeletal muscle mass, skeletal muscle index, and fat mass index, were lowest at the first chemotherapy and rebounded after 6 months. Phase angle (PhA) and the ratio of extracellular water to total body water (ECW/TBW) were "V" shaped and inverted "V" shaped, respectively, and the peaks were on discharge days. This pattern of BC showed significant difference according to sarcopenia, old age (>70 years), and advanced stage (III or IV). The change of PhA and ECW/TBW sensitively pattern differences according to clinical aspect.

CONCLUSIONS

Using BIA, serial BC measurements were taken to establish a pattern based on clinical characteristics. PhA showed the most sensitive change according to the patient's clinical aspect.

Imaging modalities for diagnosis and monitoring of cancer cachexia

Cachexia, a multifactorial wasting syndrome, is highly prevalent among advanced-stage cancer patients. Unlike weight loss in healthy humans, the progressive loss of body weight in cancer cachexia primarily implicates lean body mass, caused by an aberrant metabolism and systemic inflammation. This may lead to disease aggravation, poorer quality of life, and increased mortality. Timely detection is, therefore, crucial, as is the careful monitoring of cancer progression, in an effort to improve management, facilitate individual treatment and minimize disease complications. A detailed analysis of body composition and tissue changes using imaging modalities—that is, computed tomography, magnetic resonance imaging, (¹⁸F) fluoro-2-deoxy-d-glucose (¹⁸FDG) PET and dual-energy X-ray absorptiometry—shows great premise for charting the course of cachexia. Quantitative and qualitative changes to adipose tissue, organs, and muscle compartments, particularly of the trunk and extremities, could present important biomarkers for phenotyping cachexia and determining its onset in patients. In this review, we present and compare the imaging techniques that have been used in the setting of cancer cachexia. Their individual limitations, drawbacks in the face of clinical routine care, and relevance in oncology are also discussed.

The Role of Nurse in the Multidisciplinary Management of Cancer Cachexia

Cancer cachexia is a complex syndrome for which multidisciplinary management through collaboration has the potential to improve patient outcomes and efficiency of care, through the integration of nursing into practice. These authors conducted a literature review of PubMed, EBSCO, OVID, and ProQuest for publications on the roles and responsibilities of nurses who are working in multidisciplinary teams for the management of cancer cachexia. We limited our search parameters for the literature review such that: (1) the included papers were published in the English language from January 2000 to February 2021 and (2) the included papers featured an adult patient population. Based on this review, cancer cachexia can be characterized as an involuntary loss of body weight that is combined with a dysregulation in the control of energy homeostasis and protein loss, which leads to poor clinical outcomes in patients. Cancer cachexia has been recognized as having multidimensional etiologies that are related to the nutritional and metabolic systems, as well as other physical and physiological systems, and to symptoms that manifest concurrently to the cachexia. While the clinical identification and taxonomic classification of cancer cachexia are usually associated with an observable degree of weight loss and muscular atrophy in a patient, clinical evidence of inflammation and related symptoms should be considered (in addition to the weight loss and muscular atrophy) in the diagnosis and evaluation of cancer cachexia, as will be argued in this paper. Early diagnosis, appropriate clinical assessment, and evaluation of cancer cachexia are crucial to predicting the onset of the condition and managing its symptoms when it occurs. Various tools have been developed for the clinical evaluation and diagnosis of cancer cachexia which reflect the multitudinous manifestations of the condition. Due to the diversity of its manifestations, multimodal therapy has gained popularity for the management of cancer cachexia. Multimodal therapy includes combined pharmacologic intervention, nutrition supplements, nutritional consultation, physical exercise, and symptom control. As these authors will demonstrate in this paper, this mode of multidisciplinary team management is increasingly supported by scientific evidence and as such, can be seen as essential for high-quality cancer cachexia management. Nursing plays an important role in the multidisciplinary care team model for cancer cachexia management, as nurses are well situated to perform screening, referral, coordination, nutritional consultation, physical exercise consultation, direct nutritional nursing, psychosocial support, symptom control, and hospice care. However, an increased focus on education, skills training, and tool development (as well as adoption of tools) on the part of nurses and other multidisciplinary team members is required to meet the goal of efficient care and improved outcomes for patients with cancer cachexia. These authors demonstrate that increasing roles and responsibilities for nurses in the management of cancer cachexia is a valuable area to explore in the literature and to implement in clinical practice. Our review aims to summarize the etiology and epidemiology, mechanisms-of-action, and multitudinous manifestations of cancer cachexia, the therapies that are used in cancer cachexia care and the management approaches by which this care is organized. Finally, these authors emphasize nurses' responsibilities in this mode of cancer cachexia multidisciplinary team management, which represents a fruitful benefit both in the research literature and in clinical settings.

Effect of cachexia on bone turnover in cancer patients: a case-control study

Background

Increased bone turnover is frequently observed in advanced cancer and predominantly related to bone metastases or therapy. Cachexia represents an important cause of morbidity and mortality in cancer patients. Key features are weight loss, muscle wasting and chronic inflammation, which induce profound metabolic changes in several organs, including the bone. However, whether cachexia contributes to abnormal bone metabolism in cancer patients is unknown. Aim of the present study was to determine the potential correlation of bone turnover markers with body composition and laboratory parameters in treatment-naïve cancer patients.

Methods

In this cross-sectional study we measured the levels of carboxy terminal telopeptide of collagen (CTX), an indicator of bone resorption, as well as osteocalcin (Ocn) and procollagen type I N-terminal propeptide (PINP), indicators of bone formation, in 52 cancer patients and correlated with body composition and laboratory parameters. Univariate and multivariate logistic analysis were performed to identify determinants of negative bone remodeling balance, estimated by CTX/Ocn and CTX/PINP ratio.

Results

Based on weight loss, body mass index and muscle mass, patients were divided into a cachectic (59.6%) and a control (40.4%) group. After correcting for the presence of bone metastases, our results showed a significant upregulation of CTX in cachectic patients compared to non-cachectic cancer patients (median 0.38 vs 0.27 ng/mL, p < 0.05), with no difference in Ocn and PINP levels (mean 14 vs. 16 ng/ml, p = 0.2 and median 32 vs. 26 μg/L, p = 0.5, respectively). In addition, the CTX/Ocn and the CTX/PINP ratio were indicative of bone resorption in 68% and 60% of cachexia patients, respectively (vs. 20% and 31% in the control group, p = 0.002 and p = 0.06). The main determinants of the unbalanced bone turnover were hypoalbuminemia for the CTX/Ocn ratio (OR 19.8, p < 0.01) and high CRP for the CTX/PINP ratio (OR 5.3, p < 0.01) in the multivariate regression analysis.

Conclusions

CTX is substantially higher in cachectic patients compared to non-cachectic oncological patients and hypoalbuminemia as well as elevated CRP concentrations are independent predictors of a negative bone remodeling balance in cancer patients. These results strongly indicate that cachexia correlates with exacerbated bone turnover in cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08518-9.

Phase angle cutoff value as a marker of the health status and functional capacity in breast cancer survivors

Accurate predictive tools are key factors for cancer care. Phase angle (PhA) has been proposed as a marker of cellular health, particularly of cell-membrane integrity. Cutoff values have been proposed, including for cancer survivors. This study aimed to assess the usefulness of the proposed PhA cutoff, as a marker of bioelectrical impedance analysis (BIA) assessed health-status, and functional capacity in breast cancer (BC) survivors. This cross-sectional study included 25 women (50.6 ± 8.6 yrs) survivors of BC, divided into two groups according to the PhA reference value of 5.6° (group 1 [G1]: PhA ≤ 5.6° [n=13]; group 2 [G2]: PhA > 5.6° [n=12]) (Gupta et al. 2008). BIA-assessed health status parameters included: extracellular water (ECW), intracellular water (ICW), total body water (TBW), PhA, body mass, fat-free mass, muscle mass, body cell mass (BCM). Four functional tests were performed: 30 s chair-stand test, timed up and go test, ball throw test and 6-minute walking test. Results showed G2 had lower ECW/ICW ratio (p=0.001; ES=1.2), ECW/BCM ratio (p=0.001; ES=3.2) and ECW/TBW ratio (p=0.001; ES=4.8). There was no difference in functional capacity between groups. The results of the present study show that patients with higher PhA values have a higher ICW values and preservation in the ECW/ICW ratio, suggesting it's a better cell membrane quality and integrity. Relation of both PhA and cell membrane integrity with functional capacity warrants further research.

Biomarkers for Cancer Cachexia: A Mini Review

Cancer cachexia is a common condition in many cancer patients, particularly those with advanced disease. Cancer cachexia patients are generally less tolerant to chemotherapies and radiotherapies, largely limiting their treatment options. While the search for treatments of this condition are ongoing, standards for the efficacy of treatments have yet to be developed. Current diagnostic criteria for cancer cachexia are primarily based on loss of body mass and muscle function. However, these criteria are rather limiting, and in time, when weight loss is noticeable, it may be too late for treatment. Consequently, biomarkers for cancer cachexia would be valuable adjuncts to current diagnostic criteria, and for assessing potential treatments. Using high throughput methods such as "omics approaches", a plethora of potential biomarkers have been identified. This article reviews and summarizes current studies of biomarkers for cancer cachexia.

Cancer cachexia and skeletal muscle atrophy in clinical studies: what do we really know?

Research investigators have shown a growing interest in investigating alterations underlying skeletal muscle wasting in patients with cancer. However, skeletal muscle dysfunctions associated with cancer cachexia have mainly been studied in preclinical models. In the present review, we summarize the results of clinical studies in which skeletal muscle biopsies were collected from cachectic vs. non-cachectic cancer patients. Most of these studies suggest the presence of significant physiological alterations in skeletal muscle from cachectic cancer patients. We suggest a hypothesis, which connects structural and metabolic parameters that may, at least in part, be responsible for the skeletal muscle atrophy characteristic of cancer cachexia. Finally, we discuss the importance of a better standardization of the diagnostic criteria for cancer cachexia, as well as the requirement for additional clinical studies to improve the robustness of these conclusions.

Prognostic Impact of Preoperative Nutritional Risk in Patients Who Undergo Surgery for Pancreatic Adenocarcinoma

BACKGROUND

Nutritional derangements are common hallmarks of pancreatic cancer (PC). Their early detection and management are usually overlooked in routine practice. This study aimed to explore preoperative nutritional status and its prognostic value in patients undergoing surgery for PC.

METHODS

Data from 73 patients who underwent surgery for PC from November 2015 to January 2018 at the General and Pancreatic Surgery Unit, The Pancreas Institute, University Hospital of Verona Hospital, Verona, Italy, were retrospectively evaluated. The Nutritional Risk Screening (NRS)-2002 was used to evaluate the preoperative nutritional risk. Body composition was assessed using bioimpedance vectorial analysis (BIVA) on the day prior to surgery. The effect of clinical, pathological, and nutritional characteristics on overall survival (OS) was investigated using a Cox and logistic regression model. Kaplan-Meier curves were compared using the log-rank test.

RESULTS

Most patients (80.8%) were at preoperative risk of malnutrition (NRS-2002 ≥ 3) despite a mean BMI of 24.1 kg/m²(± 4.3). Twenty-four patients (32.9%) received neoadjuvant therapy prior to surgery. Preoperative NRS-2002 was significantly higher in this subset of patients (p = 0.026), with a significant difference by chemotherapy regimens (in favor of FOLFIRINOX, p = 0.035). In a multivariate analysis, the only independent prognostic factor for OS was the NRS-2002 score (HR 5.24, p = 0.013). Particularly, the likelihood of 2-year survival was higher in NRS < 3 (p = 0.009).

CONCLUSIONS

Our analysis confirms that preoperative malnutrition has a detrimental impact on OS in PC patients undergoing radical surgery for PC. Careful preoperative nutritional evaluation of PC patients should be mandatory, especially in those who are candidates for neoadjuvant therapy.

Impact of Body Composition Status on 90-Day Mortality in Cancer Patients with Septic Shock: Sex Differences in the Skeletal Muscle Index

Abnormalities in body composition are associated with poor prognosis in cancer patients. We investigated the association between body composition and 90-day mortality in cancer patients who developed septic shock. We included consecutive septic shock patients with active cancer from 2010 to 2017. The muscle area at the level of the third lumbar vertebra was measured by computed tomography upon emergency department admission and adjusted by height squared, yielding the Skeletal Muscle Index (SMI). Hazard ratios (HRs) and 95% confidence intervals (CIs) for 90-day mortality were estimated using a Cox proportional hazards model. Among 478 patients, the prevalence of muscle depletion was 87.7%. Among markers of body composition, the SMI only differed significantly between non-survivors and survivors (mean, 35.48 vs. 33.32 cm²/m²; P = 0.002) and was independently associated with lower 90-day mortality (adjusted HR, 0.970; P = 0.001). The multivariable-adjusted HRs (95% CI) for 90-day mortality comparing quartiles 2, 3, and 4 of the SMI to the lowest quartile were 0.646 (0.916–1.307), 0.620 (0.424–0.909), and 0.529 (0.355–0.788), respectively. The associations were evident in male patients, but not in female patients. The SMI was independently associated with 90-day mortality in cancer patients with septic shock. The graded association between the SMI and 90-day mortality was observed in male patients.

Differential response to targeted acupuncture by gender in patients with gastrointestinal cancer cachexia: secondary analysis of a randomized controlled trial

BACKGROUND

Cancer cachexia (CC) is a significant contributor to mortality and morbidity in patients with gastrointestinal (GI) cancer. Treatment options to prevent or halt the progression of CC are limited. Targeted acupuncture (TA) was used in GI patients with CC to evaluate for a potential gender effect.

PATIENTS AND METHODS

Participants (n = 30) were recruited from two outpatient clinics in the northern central part of Florida. All participants were diagnosed with CC and GI cancers. A randomized, single-blind, placebo-controlled clinical trial was used to compare TA to non-targeted acupuncture (NTA) over the course of 8 weeks. Primary endpoints were weight and body composition changes measured by bioelectrical impedance analysis (BIA) and biomarker analysis (tumor necrosis factor (TNF)-α and leptin). Herein, gender differences across and within TA and NTA groups were examined as a secondary analysis.

RESULTS

A significant (p = 0.026) interaction between weight and gender was noted, which manifested in a non-significant increase in the male intervention (MI) group, while TNF-α levels significantly increased by gender (p = 0.028) and group (p = 0.006) over the course of the study. All other groups either lost or did not change weight. The extracellular-to-intracellular water (ECW/ICW) ratio was significantly elevated for the TA group (p = 0.02) and for males (p = 0.009) at completion of the study. TNF-α and leptin levels were positively correlated within the MI group at the end of the study.

CONCLUSION

A decrease in leptin in the MI group corresponded to higher appetite and weight gain. The elevated ECW/ICW ratio indicates an inflammatory response in the MI group. This gender-specific response may be based on hormone-specific regulation of food intake. Further studies with larger sample sizes are required to support the results.

Body composition changes assessment by bioelectrical impedance vectorial analysis in right heart failure and left heart failure

BACKGROUND

Heart Failure (HF) patients developed changes in body composition as overhydration, muscle-skeletal wear and cardiac cachexia (CC). The possible factors involved in the development of CC in Right Heart Failure (RHF) patients are venous congestion, nutrient malabsorption. However, in HF, the overhydration obscure the loss of fat-free mass and difficult the body composition assessment. Bioelectrical impedance vectorial analysis (BIVA) is a method validated and used for hydration status and body composition assessment in HF. The aim of this study was to investigate the body compositions changes assessment by BIVA in the subjects with and without RHF and evaluate the risk factors for devolvement CC in HF subjects.

MATERIAL AND METHODS

Prospective cohort study. Subjects with confirmed diagnoses of HF, >18 years old without CC according to BIVA criteria were included. Subjects with congenital heart disease, cancer, HIV, and end-stage renal disease were excluded. Body composition was an assessment by BIVA. 288 HF patients were evaluated. RHF subjects had an impedance vector reduction (9.26 dR/H and -1.92 dXc/H, T2=14.9, D = 0.45, p<0.001), while subjects without RHF no-showed statistically significant changes (7.57 dR/H and 0.72 dXc/H, T2=3, D = 0.17, p = 0.200). The risks factors to development CC were age, RHF, phase angle < 5°, total body water were risks factors while handgrip strength was a protector factor.

CONCLUSIONS

RHF has greater disturbances in body composition and is a risk factor to development CC.

The Effect of Estradiol Administration on Muscle Mass Loss and Cachexia Progression in Female Apc Min/+ Mice

Cancer cachexia is a multifactorial muscle wasting condition characterized by severe body weight and muscle mass loss which is secondary to chronic disease. The mechanistic examination of cachexia has predominately focused on the male phenotype and created significant gaps in understanding cachexia progression in the female. Female hypogonadism can accompany cancer cachexia and is characterized by reduced circulating 17ß-estradiol and uterine atrophy. Estrogen has known functions in skeletal muscle homeostasis involving the regulation of muscle protein turnover, cellular stressors, and oxidative metabolism. However, 17ß-estradiol's ability to regulate cachexia progression in the female is not known. The purpose of this study was to determine the effect of gonadal function and estradiol administration on muscle mass loss and cachexia progression in female Apc ^Min/+ mice. Methods: Female C57BL/6 (B6; N = 82) and Apc ^Min/+ (MIN; N = 88) mice were used in two separate experiments. In experiment 1, mice were sacrificed at either 12 (N = 20) or 20 (N = 41) weeks of age. Body weight and estrous cycle presence was determined weekly. In experiment 2, B6 and MIN mice were randomly allocated to: Control (N = 17), received E2 pellet (E2, N = 18), ovariectomy surgery (OVX; N = 19) or ovariectomy surgery with E2 pellet (OVX + E2; N = 21). 17ß-estradiol was administered through an implanted slow-releasing pellet (0.1 mg). In estrogen and ovariectomy experiments, food intake, and functional outcomes were recorded 1 week prior to sacrifice. Results: We report that E2 administration prevented body weight loss, muscle mass loss, cage inactivity, and grip strength loss associated with cachexia. In skeletal muscle, E2 reduced skeletal muscle AMPK phosphorylation, improved mTORC1 signaling, and prevented mitochondrial dysfunction. Conclusion: Our results demonstrate a role for 17ß-estradiol for the prevention of skeletal muscle mass loss in female tumor bearing mice. Furthermore, 17ß-estradiol prevented cachexia's disruption in skeletal muscle signaling involving AMPK and mTORC1, in addition to improving mitochondrial function in female tumor bearing mice.

Understanding sex differences in the regulation of cancer-induced muscle wasting

PURPOSE OF REVIEW

We highlight evidence for sexual dimorphism in preclinical and clinical studies investigating the cause and treatment of cancer cachexia.

RECENT FINDINGS

Cancer cachexia is unintended bodyweight loss occurring with cancer, and skeletal muscle wasting is a critical predictor of negative outcomes in the cancer patient. Skeletal muscle exhibits sexual dimorphism in fiber type, function, and regeneration capacity. Sex differences have been implicated in skeletal muscle metabolism, mitochondrial function, immune response to injury, and myogenic stem cell regulation. All of these processes have the potential to be involved in cancer-induced muscle wasting. Unfortunately, the vast majority of published studies examining cancer cachexia in preclinical models or cancer patients either have not accounted for sex in their design or have exclusively studied males. Preclinical studies have established that ovarian function and estradiol can affect skeletal muscle function, metabolism and mass; ovarian function has also been implicated in the sensitivity of circulating inflammatory cytokines and the progression of cachexia.

SUMMARY

Females and males have unique characteristics that effect skeletal muscle's microenvironment and intrinsic signaling. These differences provide a strong rationale for distinct causes for cancer cachexia development and treatment in males and females.

Body composition changes differ by gender in stomach, colorectal, and biliary cancer patients with cachexia: Results from a pilot study

Few studies have examined the possibility that cachexia may affect men and women differently. This pilot study assessed gender differences in body composition in stomach, colorectal, and biliary cancer patients with cachexia. A sample of 38 participants (Female: Male = 17:21, mean age 57.4 years) were included if they were undergoing chemotherapy and experienced weight loss of 5% or more over a 6-month period. Bioelectrical impedance analysis (BIA) was applied to measure body composition. Phase angle (PA) and levels of extra-/intracellular water (ECW; ICW) were determined. Data were analyzed first by gender and then compared to age- and gender-matched healthy controls from the NHANES-III dataset. PA was lower (P < .01) in both genders compared with healthy controls, and PA was lower in female patients compared with male patients (P = .03). Male cancer patients with lower PA also had lower ICW levels compared with healthy controls (r = .98, P < .01). For female patients, PA and ICW were negatively correlated (r = .897, P < .01). A lower ECW/ICW ratio was highly correlated (r = .969 for men, r = .639 for women) with increased PA in cancer patients. ICW changes are gender-specific in patients with GI cancer. ECW/ICW ratios and PA may be suitable surrogate markers for gender-specific changes in cell composition and health status.