Skeletal muscle mass as a marker to predict outcomes in children and young adults with cancer

Diagnostic criteria, prevalence, and clinical outcomes of pediatric sarcopenia: A scoping review

BACKGROUND & AIMS

Sarcopenia, characterized by loss of muscle mass and decreased muscle strength, significantly affects adults but also influences pediatric health. However, definitions for low muscle mass, decreased strength, and sarcopenia in children are less established, impacting interventions for improving health outcomes. The objective of this scoping review is synthesize the existing literature on the diagnostic criteria, prevalence and clinical outcomes of sarcopenia.

METHODS

A scoping review, following the PRISMA extension for scoping reviews, examined pediatric sarcopenia literature until June 2023. The literature search was performed using MEDLINE and the Cochrane Central Register of Controlled Trials with the last search conducted on June 30, 2023. Criteria included studies on aged 0-20 years, covering healthy subjects, acutely ill patients, and chronic disease cases excluding specific conditions like neuromuscular diseases or prematurity.

RESULTS

Initial search found 503 studies, finally, we included 56 studies. Most studies diagnosed sarcopenia using skeletal muscle mass indicators like total psoas muscle area from Computed Tomography or Magnetic Resonance Imaging. Around half of the longitudinal studies highlighted sarcopenia as a risk factor for various clinical outcomes, predominantly in hospitalized patients. However, cutoff values for sarcopenia indicators lacked consistency, with studies employing diverse percentile-based measurements or z-scores.

CONCLUSION

Pediatric sarcopenia diagnosis primarily relies on skeletal muscle mass, with identified links to future clinical outcomes in specific conditions. The lack of standardized cutoffs for sarcopenia indicators underscores the necessity for age, gender, and race-specific cutoff values derived from studies establishing reference values for muscle mass and strength across diverse pediatric populations.

Relationship among low baseline muscle mass, skeletal muscle quality, and mortality in critically ill children

BACKGROUND

Studies in adults have shown that low baseline muscle mass at intensive care unit (ICU) admission was associated with poor clinical outcomes. However, no information on the relationship between baseline muscle quality or mass and clinical outcomes in critically ill children was found.

METHODS

3775 children were admitted to the pediatric ICU (PICU), 262 were eligible for inclusion. Abdominal computed tomography was performed to assess baseline skeletal muscle mass and quality. Patients were categorized to normal or low group based on the cutoff value for predicting hospital mortality of the skeletal muscle index (SMI; 30.96 cm2/m2) and skeletal muscle density (SMD; 41.21 Hounsfield units).

RESULTS

Body mass index (BMI) (18.07 ± 4.44 vs 15.99 ± 4.51) and BMI-for-age z score (0.46 [-0.66 to 1.74] vs -0.87 [-1.69 to 0.05]) were greater in the normal-SMI group, the length of PICU stay was longer in the low-SMI group (16.00 days [8.50-32.50] vs 13.00 days [7.50-20.00]), and the in-PICU mortality rate in the normal-SMI group (10.00%) was lower than the low-SMI group (22.6%). Children with low SMD had a higher in-PICU mortality rate (25.6% vs 7.7%), were younger (36.00 months [12.00-120.00] vs 84.00 months [47.50-147.50]) and weighed less (16.40 kg [10.93-37.25] vs 23.00 kg [16.00-45.00]). Mortality was greater in patients with lower SMD and prolonged hospital stay (log-rank, P = 0.007). SMD was an independent predictor for length of PICU stay and in-PICU mortality.

CONCLUSIONS

Low baseline skeletal muscle quality in critically ill children is closely tied with a higher in-PICU mortality and longer PICU stay and is an independent risk factor for unfavorable clinical outcomes.

Challenges and physiological implications of sarcopenia in children and youth in health and disease

PURPOSE OF REVIEW

Highlight the controversies and challenges associated with a sarcopenia diagnosis in infants and children and the potential physiological mechanisms contributing to this disorder.

RECENT FINDINGS

Sarcopenia has been recently identified in infants and children with chronic diseases such as liver, cardiac, gastrointestinal, cancer and organ transplant recipients. However, there is no consensus regarding the definition of pediatric sarcopenia. Different sarcopenic phenotypes (sarcopenia and sarcopenic obesity) have been identified in healthy children and children with chronic disease. Both conditions have been associated with adverse clinical outcomes (e.g. delayed growth, increased hospitalization) in children and youth with chronic disease. The etiology of pediatric sarcopenia is likely multifactorial associated with malnutrition, physical inactivity and altered metabolic environments influencing skeletal muscle mass accumulation and function. Gaps in the literature include the lack of standard tools that should be used for the evaluation of skeletal muscular fitness and body composition in sarcopenia, particularly in infants and young children (<4years).

SUMMARY

Longitudinal evaluation of sarcopenia expression and the underlying physiological and lifestyle factors contributing to pediatric sarcopenia are important to understand to ensure effective rehabilitation strategies can be developed and to avoid the adverse clinical consequences in children.

Association Between Preoperative Sarcopenia and Early Postoperative Outcomes in Pediatric Patients Undergoing Total Correction of Tetralogy of Fallot: A Retrospective Cohort Study

OBJECTIVES

To identify the association between preoperative low muscle mass and early postoperative outcomes in pediatric patients undergoing total correction of tetralogy of Fallot (TOF).

DESIGN

A retrospective cohort study.

SETTING

A single university hospital in Seoul, South Korea.

PARTICIPANTS

Pediatric patients (≤3 years) who underwent total correction of TOF between May 2008 and February 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Cross-sectional areas of the pectoralis and erector spinae muscles were measured using preoperative chest computed tomography (CT) scans, and adjusted to body surface area to define muscle mass index. The patients were divided into sarcopenia, presarcopenia, and no sarcopenia groups based on cutoff values determined using the mean and SD of the muscle mass index in the third z-weight quintile. Of a total of 330 patients included in the final analysis, 13 were associated with the sarcopenia group, 57 in the presarcopenia group, and 260 in the no sarcopenia group. The sarcopenia group exhibited a higher incidence of major adverse events than the presarcopenia and no sarcopenia groups, respectively (38% v 25% v 18%; p = 0.033). Logistic regression analyses revealed that only younger age at the time of surgery was significantly associated with major adverse events (odds ratio 0.82; 95% CI 0.72-0.94, p = 0.003).

CONCLUSIONS

The incidence of sarcopenia, as assessed by preoperative chest CT, was low in pediatric patients undergoing total correction of TOF, and preoperative sarcopenia did not predict early postoperative major adverse events.

Pilot study on the effect of supplementation with long-chain ω-3 polyunsaturated fatty acids on body composition in children with acute lymphoblastic leukemia: randomized clinical trial

BACKGROUND

N-3 polyunsaturated fatty acids (LCPUFA-ω3), particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) might have beneficial effects on lean mass and fat mass synthesis.

OBJECTIVE

To investigate the effect of LCPUFA-ω3 supplementation on body composition changes in children with acute lymphoblastic leukemia (ALL) at remission and three months (3 mo) after supplementation.

METHODS

This randomized controlled trial enrolled 72 children (3-13 y) with newly diagnosed ALL (placebo group [500 mg sunflower oil]: 36 patients; LCPUFA-ω3 group [225 mg DHA, 45 mg EPA]: 36 patients). LCPUFA-ω3 was administered at 0.100 g/kg of body weight/day for 3 mo. Both groups were provided with an oral milkshake supplement.

MAIN OUTCOMES AND MEASURES

Body composition was measured at diagnosis, remission, and 3 months after supplementation by dual-energy X-ray absorptiometry (DXA). Red blood cell fatty acid analyses were performed with gas chromatography. Student's t test compared the percentage changes in body weight, total body fat percentage (TBFP), and lean body mass (LBM) between the groups. The Mann-Whitney U test was used to compare the groups, and the Friedman range test and Wilcoxon signed rank test were used for intratreatment comparisons. Spearman correlation coefficients were calculated for LBM and erythrocyte LCPUFA-ω3 content.

RESULTS

LBM decreased significantly in both groups. This loss was greater in the placebo group than in the LCPUFA-ω3 group at remission (p = 0.044) and at 3 months of supplementation (p = 0.039). There were significant and progressive increases in DHA and EPA concentrations in the LCPUFA-ω3 group (p < 0.001). LBM at remission was directly correlated with increased DHA (r = 0.487, p = 0.034) and EPA (r = 0.499, p = 0.030) erythrocytes in the LCPUFA-ω3 group.

CONCLUSION

At ALL diagnosis and during the first three months of treatment, 100 mg/kg of body weight/d DHA and EPA decreased LBM loss and allowed the incorporation of fatty acids into cell membranes (clinicaltriasl.gov #: NCT01051154).

Association between preoperative diagnosis of sarcopenia and postoperative pneumonia in resectable esophageal squamous cell carcinoma patients: a retrospective cohort study

BACKGROUND

Postoperative outcomes for patients suffering from resectable esophageal squamous cell carcinoma (ESCC) are related to sarcopenia. In patients with resectable ESCC, this study investigated the link between sarcopenia and postoperative pneumonia.

METHODS

The McKewon procedure was the only one used to treat resectable ESCC patients from January 2018 to December 2021 in this retrospective analysis. Sarcopenia was assessed using skeletal muscles at L3 and planning CT scans. It was defined when PMI was below 6.36 cm2/m2 and 3.92 cm2/m2 for men and women, separately. Analyses of multivariate and univariate logistic regression were applied for identifying the risk factors for postoperative pneumonia.

RESULTS

The study included 773 patients with resectable ESCC in total. Sarcopenia was an independent risk factor for postoperative pneumonia in individuals with resectable ESCC based on univariate and multivariate analysis (P < 0.05). The stratified analysis indicated that neither of the clinical outcomes in the logistic regression model were affected by gender, age, BMI, smoking, or pre-albumin (P for interaction > 0.006).

CONCLUSION

Following the McKewon procedure, patients with resectable ESCC who were sarcopenic had a higher postoperative pneumonia rate. To prevent the development of postoperative pneumonia during the perioperative period, it may be important to control the incidence of sarcopenia.

The impact of sarcopenia and sarcopenic obesity on survival in children with Ewing sarcoma and osteosarcoma

BACKGROUND

Sarcopenia is an indicator of negative outcomes in many diseases in adults. Reports indicate this might also be true in children.

OBJECTIVE

To evaluate the effect of sarcopenia and sarcopenic obesity on event-free survival (EFS) and overall survival (OS) in children with Ewing sarcoma and osteosarcoma.

MATERIALS AND METHODS

We retrospectively measured total muscle areas of the pectoralis, paraspinal (T12 level) and psoas (L4 level) muscles and total abdominal muscle area (L3 level) on computed tomography images in 60 children diagnosed with either Ewing sarcoma (n = 34) or osteosarcoma (n = 26). Skeletal muscle indices (SMI) were calculated by normalizing muscle area to patient height. Vertebral morphologic parameters of T12 and L4 vertebrae were measured and correlated to patient height to use as a substitute in cases of missing height data (SMI_T12 and SMI_L4). We calculated sarcopenic obesity index by dividing SMI by body mass index. We subdivided children into two groups according to the median value of each parameter and assessed the differences in survival between the groups.

RESULTS

No skeletal muscle index or sarcopenic obesity index parameter significantly affected event-free or overall survival in the total group analysis. In the non-metastatic group, higher values of SMI-paraspinal and SMI_T12-psoas were correlated with longer event-free survival and no patient died in this group. Boys and children in the metastatic group with higher SMI_T12-paraspinal values had significantly longer event-free survival and both event-free and overall survival, respectively.

CONCLUSION

Although some parameters were correlated with event-free and overall survival, neither sarcopenia nor sarcopenic obesity were reliably associated with survival in children with Ewing sarcoma or osteosarcoma.

Impact of psoas muscle evaluation on clinical outcomes in patients undergoing left ventricular assist device implantation

AIMS

The measurement of muscle mass reflects the physical components of frailty, which might affect postoperative outcomes in patients undergoing left ventricular assist device (LVAD) implantation. The aim of this study was to investigate the relationship between preoperative skeletal muscle evaluation and clinical outcomes in patients undergoing LVAD implantation.

METHODS

From January 2010 to December 2017, a total of 63 patients were enrolled in this single-centre study. A retrospective analysis of preoperative abdominal computed tomography (CT) for psoas muscle index (PSMI) and Hounsfield-Units of the Psoas Muscle (PSHU) at the level of the mid-L4 vertebra was performed.

RESULTS

Sixty-three patients (male; n = 49, 78%), with a mean age of 58.0 ± 11.8 years, were treated with LVAD due to dilated (32%) or ischemic cardiomyopathy (68%). Among them, 43 patients (68.3%) were categorized in the Interagency Registry for Mechanically Assisted Circulatory Support profile I. The survival rate was 73.0% at 30 days and 44.4% at 1 year. Receiver-operating characteristic (ROC) curve analyses revealed that PSMI was a significant numeric predictor of 1-year mortality (P = 0.04). In contrast, PSHU displayed a significant predictive potential for pericardial effusion (P = 0.03) and respiratory insufficiency (P = 0.01). In addition, comparative ROC curve analysis revealed no significant difference in the predictive potential of PSMI and PSHU.

CONCLUSION

Preoperative PSMI might be a predictor of 1-year mortality in patients undergoing LVAD implantation. In contrast, the PSHU seemed to potentially assume postoperative adverse events in this study. Thus, the evaluation of the preoperative psoas muscle using CT appears to be promising.