Sarcopenia predicts worse postoperative outcomes and decreased survival rates in patients with colorectal cancer: a systematic review and meta-analysis

Comparing A-mode ultrasound and computed tomography for assessing cancer-related sarcopenia: A cross-sectional study

BACKGROUND

A-mode ultrasound (US) is a potential method for directly measuring muscle thickness in patients with cancer, but its utility remains underexplored. We aimed to evaluate the feasibility of using A-mode US to assess muscle thickness, compare it with computed tomography (CT)-derived results, and assess its ability to diagnose sarcopenia.

METHODS

A cross-sectional analysis was conducted with hospitalized patients with cancer. Muscle cross-sectional area (CSA) was derived from CT scans. Biceps muscle thickness (BMT) and thigh muscle thickness (TMT) by A-mode US were assessed. BMT + TMT were also combined as an additional phenotype. Muscle strength was assessed using handgrip strength (HGS) test. Sarcopenia was defined as low muscle mass (CT- and US-derived) + low HGS.

RESULTS

We included 120 patients (53.3% women, 45% older adults, and 85.8% with disease stages III-IV). TMT alone and the combined approach (BMT + TMT) were weak and positively correlated and significantly associated with muscle CSA, explaining 35% of CSA variability (R2 = 0.35). TMT individual and combined with BMT exhibited the highest accuracy for men (area under the curve >0.70). Sarcopenia diagnosed by BMT + TMT exhibited the highest frequency (34%) and moderate agreement with CT-derived sarcopenia (κ = 0.48).

CONCLUSION

A-mode US has the potential to be a feasible tool for diagnosing sarcopenia in clinical practice at the bedside for patients with cancer despite the need for further improvements in the tool's accuracy. Our main findings suggest that combining measurements of BMT and TMT may enhance its clinical significance in diagnosing sarcopenia.

The Impact of Sarcopenia on Postoperative Outcomes in Colorectal Cancer Surgery: An Updated Systematic Review and Meta-Analysis

Sarcopenia is thought to be a marker for underlying frailty and malnutrition, contributing to poor functional status and suboptimal healing postoperatively. We aimed to complete an updated systematic review and meta-analysis evaluating the impact of sarcopenia on short- and long-term outcomes following colorectal cancer surgery. We searched MEDLINE, Embase, and CENTRAL up to September 2023. Studies that compared sarcopenic and non-sarcopenic patients' short- and long-term outcomes following curative intent elective surgery for colorectal cancer were included. The main outcomes included postoperative morbidity, postoperative mortality, and length of stay (LOS), among others. Inverse variance random effects meta-analyses was performed. Risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE. After screening 215 studies, we included 40 non-randomized studies, totalling 13,422 patients, of which 5,432 (40.4%) were classified as sarcopenic. Across 27 studies, patients with sarcopenia were more likely to experience 30-day postoperative morbidity (40% vs 33%, RR 1.30, 95% CI 1.12-1.50, P < 0.01, I2 79%). The mean LOS was 1.46 days longer for sarcopenic patients (26 studies, 95% CI 0.85-2.07, P < 0.01, I2 82%). Upon pooling data from 13 studies, sarcopenic patients had increased risk of 30-day postoperative mortality (2.8% vs 1.0%, RR 2.74, 95% CI 1.63-4.62, P < 0.01, I2 0%). The findings from this systematic review suggest with low to very-low certainty evidence that in patients who are undergoing curative intent surgery for colorectal cancer, preoperative sarcopenia is associated with poor postoperative outcomes.

The Ratio of Visceral to Subcutaneous Adipose Tissue Is Associated With Postoperative Anastomotic Leakage in Patients With Rectal Cancer With Gender Differences in Opposite Direction

BACKGROUND

Anastomotic leakage (AL) is a severe postoperative complication in colorectal cancer and exerts negative impacts on patients' outcomes. Studies have found that body composition measured by CT images was associated with increased overall postoperative complications in colorectal cancer; however, few focused on postoperative AL in rectal cancer. This study aimed to explore the association between body composition parameters measured by CT images and postoperative AL in patients with rectal cancer, with an emphasis on subgroup analysis by gender.

METHODS

From February 2014 to January 2020, a total of 444 patients with rectal adenocarcinoma who underwent radical proctectomy were included. Out of all patients, 21 developed AL after surgery. Body composition parameters, including the areas, mean CT values, height-normalized indices of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), intramuscular adipose tissue (IMAT) and skeletal muscle (SM) were derived from preoperative contrast-enhanced arterial phase CT images at the third lumbar level. The ratio of visceral to subcutaneous adipose tissue (VSR) was calculated. Clinical and body composition parameters were compared between the AL group and the non-AL group in all patients and separately in different genders.

RESULTS

Body composition parameters were not significantly different in the AL group and the non-AL group in all patients. However, most body composition parameters were significantly different between male and female patients. After separately analyzing by gender, VSR was significantly associated with postoperative AL in male and female. After multivariate regression, VSR remained an independent predictor for AL (OR: 0.1, p = 0.041 for male and OR: 39.1, p = 0.045 for female).

CONCLUSION

The VSR measured by CT images is an independent predictor for postoperative AL in patients with rectal cancer; however, it shows gender differences in opposite directions, serving as a protective factor in males, whereas as a risk factor in females.

A systematic review on the prognostic role of radiologically-proven sarcopenia on the clinical outcomes of patients with acute pancreatitis

BACKGROUND

Sarcopenia is a known risk factor for poor prognosis in chronic pancreatitis, however the impact of sarcopenia in acute pancreatitis (AP) is unknown. This systematic review examines the prognostic impact of sarcopenia on clinical outcomes in patients with acute pancreatitis.

METHODS

A systematic literature of Medline, EMBASE, Cochrane, and the World Health Organisation International Clinical Trials Registry Platform was undertaken to identify articles relating to sarcopenia, AP, and computed tomography imaging. Data collected was related to studies' demographic population, presence of sarcopenia, sarcopenia assessment methodology, obesity, pancreatitis severity, and short- and long-term complications of AP.

RESULTS

A total of four out of 114 unique peer-review articles were included in this review, encompassing 947 patients in total. Of the analysable data, 200 patients had sarcopenia and 640 did not. There was marked heterogeneity in the determination of the presence of sarcopenia between studies. No significant association was found between sarcopenia and pancreatic necrosis, organ failure, venous thromboembolism, recurrent acute pancreatitis, or mortality.

CONCLUSION

Sarcopenia remains highly prevalent in patients suffering from acute pancreatitis. There is insufficient evidence to suggest sarcopenia is associated with poorer outcomes in patients with acute pancreatitis. More high-powered studies are required to further characterise the impact of sarcopenia on patients with acute pancreatitis.

Primary tumor location is a risk factor for postoperative development of sarcopenia as a predictive marker for unfavorable outcomes in patients with colorectal cancer

BACKGROUND

The impact of the skeletal muscle volume after colorectal cancer surgery is unclear. Thus, we investigated the change of skeletal muscle mass after surgery and its effects on long-term outcomes.

METHODS

This retrospective analysis included clinical stage I-IV colorectal cancer patients who underwent curative resection between April 2012 and March 2014 in our hospital. The psoas muscle area at the third lumbar vertebra level was evaluated by computed tomography and was divided by the square of height to obtain the psoas muscle mass index (PMI). Sarcopenia was defined using the PMI cut-off values for Asian adults of 6.36 cm2/m2 for males and 3.92 cm2/m2 for females.

RESULTS

Among eligible 354 patients, 166 and 145 had pre- and postoperative sarcopenia one year after surgery, respectively. Five-year disease-free survival (DFS) and overall survival (OS) rates were 81.7% and 94.5%, respectively. In multivariate analysis, postoperative sarcopenia was an independent risk factor for shorter DFS [hazard ratio (HR) 1.71, p = 0.0171] and OS (HR 2.42, p = 0.0455), respectively, but preoperative sarcopenia was not a prognosticactor for either. One year after colorectal resection, 24 patients (6.8%) were newly diagnosed with sarcopenia, while 45 (12.7%) recovered from sarcopenia. Rectal cancer was identified as an independent risk factor for the postoperative development of sarcopenia (odds ratio 3.12, p = 0.0440).

CONCLUSION

Postoperative sarcopenia one year after surgery was associated with poor DFS and OS. Thus, clinicians need to consider skeletal muscle loss during postoperative surveillance, particularly in rectal cancer patients without sarcopenia before surgery.

New research progress of sarcopenia in surgically resectable malignant tumor diseases

With the aging global population, the decline in muscle mass and function among the elderly has emerged as a significant concern. This systemic progressive generalized loss of muscle function and mass is referred to as sarcopenia (SP). In recent years, a growing number of studies have investigated SP, revealing that many tumor diseases, especially in the digestive system, promote its occurrence due to the influence of the disease itself, diet, and other factors. Moreover, SP patients tend to have poorer postoperative recovery. At present, many diagnostic methods have been developed for SP, but no unified standard has been established. Furthermore, the cutoff values of many diagnostic methods for different populations are still in the exploratory stage, and additional clinical studies are required to explore these issues. This article comprehensively and systematically summarizes the diagnostic methods and criteria mentioned in previous research, focusing on the impact of SP on post-surgical patients with various malignant tumors.

Geriatric Nutritional Risk Index Predicts Postoperative Complications in Elderly Patients Undergoing Robot-Assisted Radical Cystectomy

OBJECTIVE

Malnutrition is a common condition among elderly cancer patients. The Geriatric Nutritional Risk Index (GNRI) is a simple screening tool used to predict the risk of postoperative complications in patients undergoing radical cystectomy. This study aimed to evaluate the effectiveness of preoperative GNRI as a marker for predicting 90-day postoperative complications in elderly patients undergoing robot-assisted radical cystectomy (RARC).

METHODS

We retrospectively evaluated 385 patients who underwent RARC at four affiliated institutes of Tokushima University between 2014 and 2023. Patient background characteristics, pathological findings, and 90-day postoperative complications were analyzed. Preoperative GNRI was calculated using serum albumin and body mass index, with an abnormal nutritional status defined as GNRI < 92.

RESULTS

A total of 166 patients aged ≥ 75 years who underwent RARC were included in the study. Among these, 26 patients (15.7%) had an abnormal GNRI. Eighty-four patients (50.6%) experienced complications within 90 days postoperatively, including 29 patients (17.5%) with major complications (Clavien-Dindo classification ≥ 3). The 90-day postoperative mortality rate was 3.0% (five patients). Patients with an abnormal GNRI had a significantly higher rate of 90-day postoperative complications (p < 0.001). Multivariable logistic regression analysis identified abnormal GNRI as a significant predictor of 90-day postoperative complications (odds ratio: 9.963; 95% confidence interval: 2.125-46.718; p = 0.004).

CONCLUSIONS

Poor nutritional status is associated with a higher rate of 90-day postoperative complications in elderly patients undergoing RARC. Preoperative GNRI may be a useful tool for assessing the risk of complications in this patient population.

Sarcopenia defined by the global leadership initiative in sarcopenia (GLIS) consensus predicts adverse postoperative outcomes in patients undergoing radical gastrectomy for gastric cancer: analysis from a prospective cohort study

BACKGROUND

Global Leadership Initiative in Sarcopenia (GLIS) has recently established a conceptional definition of sarcopenia, which incorporated muscle strength, mass, and muscle-specific strength as three components of sarcopenia. The present study aimed to investigate the value of sarcopenia defined by the GLIS consensus in predicting the postoperative outcomes.

METHODS

Clinical data of 1654 patients who underwent radical gastrectomy for gastric cancer were prospectively collected. Muscle strength was measured by the grip strength test. Muscle mass was measured by calculating skeletal muscle index (SMI) using abdominal computed tomography images. Muscle-specific strength was determined by the ratio of grip strength to SMI. Sarcopenia was diagnosed by having low muscle-specific strength (criteria 1), or low muscle strength plus low muscle mass (criteria 2), or low muscle strength plus either low muscle mass or low muscle-specific strength (criteria 3).

RESULTS

The incidence of sarcopenia identified by criteria 1, 2, and 3 were 24.2%, 17.0%, and 32.5%, respectively. All three criteria showed significant association with postoperative total complications, overall survival (OS), and disease-free survival (DFS). However, criteria 1 showed no significant association with severe complications. Criteria 2 did not remain significant in predicting DFS in the multivariate analyses. Criteria 3 showed the largest Youden index and area under receiver operating characteristic curve (AUC) in predicting total complications, 3-year and 5-year mortality, and low physical performance.

CONCLUSION

Sarcopenia defined by low muscle strength plus either low muscle mass or low muscle-specific strength showed optimal predictive value for postoperative outcomes in patients with gastric cancer.

Malnutrition outweighs sarcopenia and adiposity as a predictor of survival in colorectal cancer patients

Colorectal cancer (CRC) patients often face nutritional disturbances, including malnutrition, changes in skeletal muscle index (SMI), and adipose tissue. We hypothesized that malnutrition, sarcopenia and nutritional disorders, as low muscle strength, low SMI, and reduced adipose tissue can negatively impact survival. This study aimed to assess the impact of malnutrition, SMI, muscle strength, sarcopenia, and adipose tissue on CRC patient survival. We analyzed 2 cohorts of CRC patients in this longitudinal study. Nutritional status was assessed by Patient-Generated Subjective Global Assessment (PG-SGA) and those classified as B and C were considered with malnutrition. Computed tomography (CT) scans of the third lumbar vertebra (L3) measured SMI and various adipose tissue fractions (visceral, subcutaneous, intramuscular, and total). Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2). The primary outcome was 5-year overall survival. Of 266 patients (mean age 60.7 years, 53.0% male), 11.3% had sarcopenia, 27.0% were malnourished, and 40.0% died. After adjusting for clinical variables, Cox regression analysis showed that only Malnutrition (HR: 1.96; CI: 1.35-2.84; P ≤ .001) significantly impacted survival. In CRC patients, Malnutrition outweighs sarcopenia and adiposity as a predictor of survival in colorectal cancer patients.

Postoperative changes in body composition after laparoscopic and open resection of colorectal liver metastases: data from the randomized OSLO-COMET trial

BACKGROUND

Low muscle mass is negatively associated with survival in patients undergoing surgery for colorectal cancer. Current evidence is limited regarding whether the surgical approach for liver resection of colorectal metastasis impacts postoperative changes in body composition and whether preoperative body composition can impact complication rate and survival.

METHOD

This study included patients previously included in the randomized OSLO-COMET trail where patients was allocated to laparoscopic or open liver resection for colorectal liver metastasis. CT scans 0-3 months before and 2-6 months after liver resection were segmented with the artificial intelligence-based tool BodySegAI to measure skeletal muscle mass (SM), visceral adipose tissue (VAT), and inter- and intramuscular adipose tissue (IMAT). SM, VAT and IMAT was compared between the open and laparoscopic group and as predictors for 5-year survival and postoperative complications.

RESULTS

This study included 216 patients, median age was 67, 127 (59%) were male, 91 (42%) had primary tumor in rectum and 86 (40%) had multiple liver metastasis. There was no significant difference in postoperative change in SM, VAT or IMAT between those undergoing laparoscopy or open surgery. In multivariate analysis, high preoperative IMAT was a predictor for increased risk of postoperative complications (HR (95% CI): 1.045 (CI 95%: 1.003-1.089), p = 0.034). Moreover, postoperative increase in IMAT was a negative predictor for 5-year survival (HR (95%CI):1.009 (1.003-1.016), p = 0.003).

CONCLUSION

Postoperative change in body composition did not differ between patients randomly assigned to open or laparoscopic liver resection for colorectal metastasis. High preoperative IMAT was associated with an increased risk of postoperative complications.

Effects of the Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls score on postoperative clinical outcomes following colorectal cancer surgery: a retrospective study

BACKGROUND/OBJECTIVES

Sarcopenia has known negative effects on clinical and oncological outcomes in patients with colorectal cancer (CRC). The use of the Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls (SARC-F) questionnaire to determine the effects of sarcopenia on postoperative complications of CRC has not been reported to date. Therefore, this study aimed to investigate the relationship of SARC-F score with clinicopathologic outcomes after CRC surgery.

SUBJECTS/METHODS

We retrospectively included 285 patients who completed SARC-F questionnaires before CRC surgery between July 2019 and March 2022. Patients with an SARC-F score ≥4 (total score: 10) were classified in the high SARC-F group.

RESULTS

Overall, 34 (11.9%) patients had high SARC-F scores. These patients were older (76.9 ± 8.5 vs. 64.5 ± 11.4 years, p < 0.001) and had a higher preoperative CRP (2.5 ± 3.9 vs. 0.8 ± 1.6 mg/L, p = 0.019), lower body mass index (21.7 ± 3.4 vs. 24.0 ± 3.8 kg/m2, p = 0.001), and higher pan-immune-inflammation value (632.3 ± 615.5 vs. 388.9 ± 413.8, p = 0.031). More postoperative complications were noted in the high SARC-F group than in the low SARC-F group (58.8% vs. 35.6%, p = 0.009). High SARC-F scores were significantly associated with higher nodal stage, higher number of harvested lymph nodes, and larger tumor size. Univariate and multivariate analyses revealed high SARC-F score and operation time as independent risk factors associated with postoperative complications (odds ratio, 2.212/1.922; 95% confidence interval, 1.021-4.792/1.163-3.175; p = 0.044/0.011, respectively).

CONCLUSIONS

Preoperative SARC-F score was an independent risk factor associated with postoperative complications following colorectal cancer surgery.

The predictive values of sarcopenia screening tools in preoperative elderly patients with colorectal cancer: applying the diagnostic criteria of EWGSOP2 and AWGS2019

BACKGROUND

Sarcopenia predicts worse postoperative outcomes and lower survival rates in patients with colorectal cancer (CRC). There is a scarcity of studies on the most effective assessment tools for detecting sarcopenia in preoperative elderly patients with CRC. Our objective was to compare the diagnostic accuracy of various tools such as calf circumference (CC), strength, need for assistance with walking, rising from a sitting position, climbing stairs, and the incidence of falls (SARC-F), SARC-F plus CC (SARC-CalF), the short version of mini sarcopenia risk assessment (MSRA-5), the full version of mini sarcopenia risk assessment (MSRA-7), and Ishii score chart in screening sarcopenia in preoperative elderly patients with CRC.

METHODS

During the period of April 2021 to September 2023, we conducted a cross-sectional study involving consecutive elderly patients who were undergoing colorectal surgery. Sarcopenia was defined using the diagnostic criteria proposed by the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) and the 2019 Asian Working Group for Sarcopenia (AWGS2019). The screening tools' performances were evaluated through receiver operating characteristic (ROC) curves, area under the ROC curves (AUC), and sensitivity/specificity analyses, based on the criteria proposed by EWGSOP2 and AWGS2019.

RESULTS

We enrolled 482 patients with an average age of 71.86 ± 5.60 years. According to the EWGSOP2 and AWGS2019 diagnostic standards, the incidence of sarcopenia was 19.5% and 21.6% respectively. The sensitivity of SARC-F, SARC-CalF, MSRA-5, MSRA-7, and Ishii score chart ranged from 51.92 to 56.38%, 84.62-85.11%, 86.54-88.30%, 65.96-67.31%, and 73.08-74.47% respectively, while the specificity ranged from 84.92 to 85.05%, 70.36-71.69%, 36.86-37.04%, 60.57-61.64%, and 77.32-78.31% respectively. Regardless of the sarcopenia diagnostic criteria used, the AUCs of Ishii score chart (0.87 to 0.88) and SARC-CalF (0.89 to 0.90) were significantly larger than those of other tools (P<0.05). There was no significant difference in AUCs among SARC-F, SARC-CalF, and Ishii score chart in females.

CONCLUSION

Among the five sarcopenia screening tools, Ishii score chart and SARC-CalF had the largest overall diagnostic accuracy for sarcopenia in preoperative elderly patients with CRC.

Sarcopenia as a Prognostic Factor for the Outcomes of Surgical Treatment of Colorectal Carcinoma

Background/Objectives: Sarcopenia, defined as the progressive loss of muscle mass and function, is increasingly associated with worse outcomes in the surgical treatment of colorectal cancer (CRC). This paper focuses on analyzing the impact of sarcopenia as a prognostic factor on postoperative outcomes in CRC patients. The aim of the study is to identify the main factors influencing postoperative results. This will be accomplished via bibliometric analysis and highlighting the significance of muscle condition in the preoperative assessment of patients. Methods: The methodological approach involves analyzing bibliographic data from relevant scientific databases focused on sarcopenia and oncological surgery. The study employs a quantitative analysis of citations and collaborations among authors and institutions. The focus will be on research publications from 2013, when we first identified references to sarcopenia in the examined context. Results: The results show that sarcopenia significantly increases the risk of postoperative morbidity and mortality in CRC patients. Network analysis and keyword mapping reveal dominant research topics such as muscle condition, mortality, and postoperative complications. Meanwhile, we identify the need for standardized diagnostic methods for sarcopenia and their integration into clinical practice to improve predictive models and clinical approaches. Conclusions: These findings underscore the importance of interdisciplinary collaboration, preoperative assessment of muscle condition, and the implementation of standardized approaches to improve clinical outcomes for patients.

Sarcopenia is a negative prognostic factor in localized extremities/trunk wall soft tissue sarcomas

OBJECTIVE

Sarcopenia is an emerging determinant of oncologic patients' prognosis, but few data are available in extremities and trunk wall soft tissue sarcomas (ESTS). The aim was to evaluate sarcopenia impact on outcomes of patients affected by ESTS.

METHODS

Through SliceOMatic software we selected cross-sectional skeletal muscle area (SMA), subcutaneous fat area (SFA) and visceral fat area (VFA) on a basal CT-slice at level of the third lumbar vertebra. Muscle density (MD) was computed in Hounsfield units (HU). Skeletal mass index (SMI, cm2/m2) was computed by normalizing SMA for the square of patient's height. Cut-offs for SMI were 52 and 39 cm2/m2 for men and women, respectively, while we used median values for MD, SFA and VFA. We explored the correlation of the different parameters with post-surgical complications and survival outcomes (Kaplan-Meier method).

RESULTS

268 patients were included. Median SMAs, SMIs and MD were 155.7 cm2, 51.2 cm2/m2, and 33.8 HU for men, 91.4 cm2, 39.2 cm2/m2, and 30.4 HU for women. Sarcopenia rate was not significantly higher in patients ≥65 years nor according to baseline prognostic factors (Sarculator app). Overall survival (OS) was significantly worse for sarcopenic patients: median OS 111.7 months (95%CI 72.8-150.6) vs not reached (NR; HR = 1.55, 95%CI:1.00-2.41, p = 0.049) for low-vs high-SMI; median OS 79.6 months (38.6-120.6) vs NR (HR 2.11, 1.34-3.34, p = 0.001) for low-vs high-MD, respectively. Sarcopenic patients showed increased post-surgical complications (30.5 % vs 17.0 %, p = 0.073).

CONCLUSION

Although retrospective, our study suggests to further explore sarcopenia as a negative prognostic factor in ESTS patients.

Impact of Preoperative CT-Measured Sarcopenia on Clinical, Pathological, and Oncological Outcomes After Elective Rectal Cancer Surgery

Background: Patients with rectal cancer may be exposed to a loss of muscle strength and quality. This study aimed to assess the role of preoperative CT-based sarcopenia on postoperative clinical, pathological, and oncological outcomes after rectal cancer surgery. Methods: This retrospective monocentric study included patients who underwent elective oncologic resection for rectal adenocarcinoma between 01/2014 and 03/2022. The skeletal muscle index (SMI) was measured using CT at the third lumbar vertebral level, and sarcopenia was defined based on pre-established sex-specific cut-offs. Patients with sarcopenia were compared to those without sarcopenia in terms of outcomes. A Cox proportional hazard regression analysis was used to determine the independent prognostic factors of disease-free survival (DFS) and overall survival (OS). Results: A total of 208 patients were included, and 123 (59%) had preoperative sarcopenia. Patients with sarcopenia were significantly older (66 vs. 61 years, p = 0.003), had lower BMI (24 vs. 28 kg/m2, p < 0.001), and were mainly men (76 vs. 48%, p < 0.001). There was no difference in overall and major complication rates between the sarcopenia and non-sarcopenia group (43 vs. 37%, p = 0.389, and 17 vs. 17%, p = 1.000, respectively). Preoperative and postoperative features related to rectal surgery were comparable. The only predictive factor impacting OS was R1/R2 resection (HR 4.915, 95% CI, 1.141-11.282, p < 0.001), while sarcopenia (HR 2.013, 95% CI 0.972-4.173, p = 0.050) and T3/T4 status (HR 2.108, 95% CI 1.058-4.203, p = 0.034) were independently associated with DFS. Conclusions: A majority of patients undergoing rectal cancer surgery had preoperative CT-based sarcopenia. In this cohort, sarcopenia had no impact on postoperative morbidity and OS but was independently associated with DFS.

[Prognostic value of body composition in oncological visceral surgery]

Screening of nutritional status of cancer patients plays a crucial role in the perioperative management and is mandatory for the certification of oncological centers by the German Cancer Society (DKG). The available screening tools do not differentiate between muscle and adipose tissue. Recent advances in computed tomography (CT) and magnetic resonance imaging (MRI) as well as the automatic picture archiving communication system (PACS) imaging analysis by high performance reconstruction systems have recently enabled a detailed analysis of adipose tissue and muscle quality. Rapidly growing evidence shows that body composition parameters, especially reduced muscle mass, are associated with adverse outcomes in cancer patients and have been reported to negatively affect overall survival (OS), disease-free survival (DFS), toxicity associated with chemotherapy and surgical complications. In this article, we summarize the recent literature and present the clinical influence of body composition in oncological visceral diseases.

A Scoping Review of the Implications and Applications of Body Composition Assessment in Locally Advanced and Locally Recurrent Rectal Cancer

Background: A strong body of evidence exists demonstrating deleterious relationships between abnormal body composition (BC) and outcomes in non-complex colorectal cancer. Complex rectal cancer (RC) includes locally advanced and locally recurrent tumours. This scoping review aims to summarise the current evidence examining BC in complex RC. Methods: A literature search was performed on Ovid MEDLINE, EMBASE, and Cochrane databases. Original studies examining BC in adult patients with complex RC were included. Two authors undertook screening and full-text reviews. Results: Thirty-five studies were included. Muscle quantity was the most commonly studied BC metric, with sarcopenia appearing to predict mortality, recurrence, neoadjuvant therapy outcomes, and postoperative complications. In particular, 10 studies examined relationships between BC and neoadjuvant therapy response, with six showing a significant association with sarcopenia. Only one study examined interventions for improving BC in patients with complex RC, and only one study specifically examined patients undergoing pelvic exenteration. Marked variation was also observed in terms of how BC was quantified, both in terms of anatomical location and how cut-off values were defined. Conclusions: Sarcopenia appears to predict mortality and recurrence in complex RC. An opportunity exists for a meta-analysis examining poorer BC and neoadjuvant therapy outcomes. There is a paucity of studies examining interventions for poor BC. Further research examining BC specifically in patients undergoing pelvic exenteration surgery is also lacking. Pitfalls identified include variances in how BC is measured on computed tomography and whether external cut-off values for muscle and adipose tissue are appropriate for a particular study population.

Changes in nutritional status and effectiveness of the dietary intervention of multimodal prehabilitation for patients with colorectal cancer: A secondary analysis of the PREHAB randomized clinical trial

BACKGROUND & AIMS

Prehabilitation is a preoperative multimodal program including exercise, nutritional, and psychological support. Little is known about changes in nutritional status during prehabilitation.

METHODS

This secondary analysis of the PREHAB trial aims to assess changes in nutritional status and explore the effectiveness of a four-week nutritional intervention. Data were collected at baseline and preoperatively (end of the program), including body composition with bioelectrical impedance analysis (single frequency, 50 kHz), muscle strength (indirect 1RM leg press), three-day food diaries and the scored PG-SGA. Protein requirements were set at 1.5 g/kg body weight.

RESULTS

Sixty-seven participants were enrolled, 34 to standard care and 33 to four-week prehabilitation. Nutritional status improved in both groups: -1 point change in the standard care group (p = , 0.027), and -1.5 point in the prehabilitation group (p = 0.015). Those who received prehabilitation statistically increased fat free mass (0.9 kg, p = 0.017) and appendicular skeletal muscle mass (0.5 kg, p = 0.007. In contrast, an increase in fat mass (0.6 kg, p = 0.016) was observed within the standard care group only. Participants in the prehabilitation group had a substantial increase of 27 % muscle strength (p = <0.001). Optimal protein intake was more often achieved within the prehabilitation group (47 %, p = <0.001).

CONCLUSION

Our study provides evidence for the positive impact of multimodal prehabilitation on preoperative nutritional status in adult patients with CRC, especially in body composition and muscle strength. Achieving optimal protein intake was challenging, both dietary counseling and supplements are recommended to improve intake.

TRIAL REGISTER

PREHAB RCT: NTR5947.

The prognostic significance of sarcopenia in patients treated with definitive radiotherapy: A systematic review

Sarcopenia describes the degenerative loss of muscle mass and strength, and is emerging as a pan-cancer prognostic biomarker. It is linked with increased treatment toxicity, decreased survival and significant healthcare financial burden. Systematic analyses of sarcopenia studies have focused on outcomes in patients treated surgically or with systemic therapies. There are few publications concerning patients treated with radiotherapy. This manuscript presents a pan-cancer systematic review of the association between sarcopenia and survival outcomes in patients treated with definitive (chemo-)radiotherapy. A literature search was performed, with 26 studies identified, including a total of 5,784 patients. The prognostic significance of sarcopenia was mixed. This may reflect lack of consensus in methods used to measure skeletal muscle mass and define sarcopenia. Many papers analyse small samples and present sarcopenia cutoffs optimised on the local population, which may not generalise to external populations. Recent advances in artificial intelligence allow for automatic measurement of body composition by segmenting the muscle compartment on routinely collected imaging. This provides opportunity for standardisation of measurement methods and definitions across populations. Adopting sarcopenia diagnosis into clinical workflows could reduce futile treatments and associated financial burden, by reducing treatment toxicities, and improving treatment completion, patient survival, and quality-of-life after cancer.

Prognostic Impact of Sarcopenic Obesity on Postoperative Outcomes in Colorectal Cancer Patients Undergoing Surgery: A Systematic Review and Meta-Analysis

Sarcopenic obesity is a condition in which the coexistence of sarcopenia and obesity may have unfavorable prognostic implications in cancer. This meta-analysis aims to evaluate the effects of sarcopenic obesity on postoperative outcomes in patients undergoing colorectal cancer surgery. A systematic literature search was conducted in the Scopus, PubMed, and Web of Science databases for articles up to February 8, 2024. The primary outcomes were overall and major complications and overall survival. A random- or fixed-effects model was used in each case based on heterogeneity, and both subgroup and sensitivity analyses were performed. Twenty studies with 11,264 patients were included. The prevalence of sarcopenic obesity was 14.5%. Sarcopenic obesity was found to be a risk factor for overall complications [pooled OR: 1.69 (95% CI: 1.26-2.26); p < 0.001] and major complications [pooled OR: 1.64 (95% CI: 1.06-2.55); p = 0.028]. The effect on overall survival was not significant [pooled HR: 1.24 (95% CI: 0.98-1.56); p = 0.076], but significance varied in some subgroups. Furthermore, sarcopenic obesity was associated with an increased risk of 30-day mortality, but not with prolonged hospitalization. In conclusion, sarcopenic obesity is associated with unfavorable outcomes after colorectal cancer surgery; therefore, it may be useful to include a diagnosis of sarcopenic obesity when formulating the disease prognosis.

Low skeletal muscle mass as a proxy marker of sarcopenia is a risk factor for major complications in older patients undergoing curative colon resections for colon cancer

Introduction

Various reports have confirmed that low skeletal muscle mass, a proxy marker of sarcopenia, can be a risk factor for surgical and oncological outcomes in colon cancer. We aimed to investigate the effects of skeletal muscle mass index (SMMI) on postoperative complications, overall survival (OS), and disease-free survival (DFS) in older patients with colon cancer who underwent elective curative colon resections.

Materials and methods

Patients over 65 years old with stage I-III colon cancer who underwent elective curative colon resections between January 2015 and December 2023 were included in this single-center retrospective longitudinal study. Demographics, comorbidities, laboratory data, pathological features, malignant lymph node ratio (MLNR), OS, and DFS were recorded. Controlling Nutritional Status (CONUT) Score was used to assess the nutritional status. An axial portal-phase image was obtained at the level of the third lumbar vertebra, and muscle areas were calculated. SMMI was calculated by dividing the muscle area (cm2) by the square of the patient's height (m2). Low SMMI was defined as SMMI<41 cm2/m2 in women and < 43 cm2/m2 in men with body mass index (BMI) <25 kg/m2, and as SMMI <53 cm2/m2 in patients with a BMI >25 kg/m2. Postoperative complications were classified according to the Clavien-Dindo system. Univariate and multivariate analyses were performed to investigate the factors related to the postoperative complications, OS and DFS.

Results

In total, 98 cases (mean age 75.2 ± 6.9, 55.1% male) were included in the study. The median follow-up time was 38.3 (0.5-113) months. There were 64 patients (65.3%) in the Low SMMI group and 34 patients (34.7%) in the Normal SMMI group. Logistic regression analysis demonstrated that low SMMI was associated with a higher risk of major complications, with an odds ratio of 5.3 (95% CI, 1.1-20.1; p = 0.037). Cox regression analysis revealed no significant differences in OS and DFS.

Conclusion

Low SMMI as a proxy marker of sarcopenia was found to be an independent risk factor for postoperative major complications. Additional prospective studies are warranted to obtain more reliable results.

Evaluation of preoperative visceral fat area / psoas muscle area ratio and prognosis in patients with colorectal cancer

Background

Recent research has focused on the prognostic relevance of preoperative sarcopenia and sarcopenic obesity in various cancers. In this study we investigated the relationship between visceral fat area (VFA), psoas muscle area (PMA), and the prognosis of patients undergoing colorectal cancer surgery.

Methods

Patients with stage III colorectal cancer who underwent surgery between July 2013 and April 2020 were included. The analysis was performed on 151 patients who met the criteria. The VFA and PMA were measured at the level of the third lumbar vertebra on computed tomography (CT) scans, and the ratio of VFA to PMA (V/P ratio) was determined.

Results

Patients with high V/P ratios were significantly older (p = 0.0213), had a higher body mass index (BMI) (p < 0.0001), a higher percentage of sarcopenic obesity (p < 0.0001), and more diabetes complications (p < 0.0001). Prognostic analysis showed that the overall survival (OS) (p = 0.0154) and relapse-free survival (RFS) (p = 0.0378) were significantly worse in patients with a high V/P ratio. Multivariate analysis revealed that a high V/P ratio was an independent poor prognostic factor for OS. Subgroup analysis was then performed in patients with BMI < 25 kg/m2. OS (p = 0.0259) and RFS (p = 0.0275) were significantly worse in the high V/P ratio group. A high V/P ratio was an independent poor prognostic factor in the multivariate analysis.

Conclusion

In colorectal cancer, the preoperative V/P ratio is an independent factor for poor prognosis. Preoperative evaluation of the V/P ratio may identify a wide range of high-risk patients because it is an independent poor prognostic factor in patients without obesity.

The prognostic value of pre-treatment sarcopenia in overall survival in head and neck cancer patients: a systematic review

The aim of this study was to determine the prognostic value of pre-treatment sarcopenia, defined radiologically (cervical (C3) or lumbar (L3) region), in adult head and neck cancer (HNC) patients undergoing treatment with curative intent. A systematic search of the PubMed and Scopus databases was performed up to March 2024. Inclusion criteria were adult patients with locally advanced HNC, sarcopenia defined radiologically at the C3 and/or L3 level, and patients receiving primary treatment with curative intent. Risk of bias was assessed using the ROBINS-I tool non-randomised studies. Thirty studies involving a total of 6924 adult patients with HNC were included in this review. Pre-treatment sarcopenia was significantly associated with worse overall survival outcomes in 26 of the 30 studies (87%), across all treatment modalities with curative intent. The most frequent sex-specific SMI cut-off values were <52.4 cm2/m2 for males and <38.5 cm2/m2 for females. The findings of this review suggest that sarcopenia is a strong prognostic factor of overall survival in HNC patients undergoing primary curative treatment. Sarcopenia evaluation appears to be a good prognostic marker in the HNC population. Future nutritional interventional studies might focus on reversing the muscle loss and improving overall outcomes in identified sarcopenic individuals.

Evaluating the Impact of Multimodal Prehabilitation with High Protein Oral Nutritional Supplementation (HP ONS) with Beta-Hydroxy Beta-Methylbutyrate (HMB) on Sarcopenic Surgical Patients-Interim Analysis of the HEROS Study

BACKGROUND

Multimodal prehabilitation programs, which may incorporate nutritional supplementation and exercise, have been developed to combat sarcopenia in surgical patients to enhance post-operative outcomes. However, the optimal regime remains unknown. The use of beta-hydroxy beta-methylbutyrate (HMB) has beneficial effects on muscle mass and strength. However, its effect on muscle quality in the perioperative setting has yet to be established. This study aims to explore the impact of a multimodal prehabilitation program using a bundle of care that includes high-protein oral nutritional supplementation (HP ONS) with HMB and resistance exercise on muscle quality and functional outcomes in sarcopenic surgical patients.

METHODS

Sarcopenic adult patients undergoing elective major gastrointestinal surgeries were recruited for this pilot interventional cohort study. They were enrolled in a 2-4-week multimodal prehabilitation program comprising resistance exercise, nutritional supplementation, vitamin supplementation, comorbid optimization and smoking cessation. Participants were provided three units of HP ONS with HMB per day pre-operatively. The primary outcome was changes in intramuscular adipose tissue (IMAT) as a proxy of muscle quality, assessed using Artificial Intelligence (AI)-aided ultrasonography. Secondary outcomes include changes in anthropometric measurements and functional characteristics. Outcomes were measured before prehabilitation, after prehabilitation and 1 month post-operatively.

RESULTS

A total of 36 sarcopenic patients, with a median age of 71.5 years, were included in this study. There was an increase in the IMAT index after two weeks of prehabilitation (p = 0.032) to 1 month after surgery (p = 0.028). Among functional parameters, improvement was observed in gait speed (p = 0.01) after two weeks of prehabilitation, which returned to baseline post-operatively. The median length of hospital stay was 7 (range: 2-75) days.

CONCLUSIONS

The increase in the IMAT index in a sarcopenic surgical cohort undergoing prehabilitation may be due to altered muscle metabolism in elderly sarcopenic patients. A prehabilitation regime in sarcopenic patients incorporating HP ONS with HMB and resistance exercise is feasible and is associated with increased gait speed.

Serum tumor marker and CT body composition scoring system predicts outcomes in colorectal cancer surgical patients

OBJECTIVE

To investigate the prognostic value of preoperative body composition and serum tumor markers (STM) in patients undergoing surgical treatment for colorectal cancer (CRC) and to establish the prognostic score for patients with CRC.

METHODS

This study enrolled 365 patients (training set 245, validation set 120) with CRC who underwent surgical resection. The predictive value of various body composition features and STM for determining CRC prognosis were compared. A novel index score based on the independent risk factors from Cox regression for CRC patients was established and evaluated for its usefulness.

RESULTS

Multivariate Cox regression showed that low skeletal muscle radiodensity (SMD) (p = 0.020), low subcutaneous fat area (SFA) (p = 0.029), high carcinoembryonic antigen (CEA) (p = 0.008), and high alpha-fetoprotein (AFP) (p = 0.039) were all independent prognostic factors for poor overall survival (OS). The multifactorial analysis indicated that high intermuscular fat area (IMFA) (p = 0.033) and high CEA (p = 0.009) were independent prognostic factors for poor disease-free survival (DFS). Based on these findings, two scoring systems for OS and DFS were established in the training datasets. CRC patients who scored higher on the new scoring systems had lower OS and DFS (both p < 0.001) as shown in the Kaplan-Meier survival curves in the training and validation datasets.

CONCLUSION

In predicting the prognosis of CRC patients, SFA and SMD are superior to other body composition measurements. A scoring system based on body composition and STM can have prognostic value and clinical applicability.

CLINICAL RELEVANCE STATEMENT

This scoring system, combining body composition and serum tumor markers, may help predict postoperative survival of CRC patients and help clinicians make well-informed decisions regarding the treatment of patients.

KEY POINTS

Colorectal cancer prognosis can be related to body composition. High intermuscular fat area and CEA were independent prognostic factors for poor disease-free survival. This scoring system, based on body composition and tumor markers, can prognosticate for colorectal cancer patients.

Feasibility, acceptability and prognostic value of muscle mass and strength measurement in patients with hip fracture: a systematic review

PURPOSE

Sarcopenia is diagnosed on the basis of low muscle strength, with low muscle mass used to confirm diagnosis. The added value of measuring muscle mass is unclear. We undertook a systematic review to assess whether muscle mass measurement in patients with hip fracture was acceptable, feasible and independently associated with adverse outcomes.

METHODS

Electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL, Clinicaltrials.gov) were searched for studies of patients with hip fracture aged ≥ 60 with perioperative muscle mass or strength assessments. Associations with postoperative outcomes including death, length of stay and activities of daily living were extracted. Risk-of-bias was assessed using the AXIS and ROBINS-I tools. Due to the degree of study heterogeneity, data were analysed by narrative synthesis.

RESULTS

The search strategy identified 3317 records. 36 studies were included with 7860 participants. Acceptability of muscle mass measurement was not assessed, but measurement appeared feasible using biompedance, dual energy x-ray absorptiometry and computed tomography. Univariate analyses indicated that lower muscle mass was associated with higher death rates at 30 days, worse mobility, worse activity of daily living metrics and worse physical performance but there was no significant association with length of stay or postoperative complications. Four studies included both muscle mass and strength in multivariable analyses; muscle mass was a significant independent predictor of only one adverse outcome in a single study after adjustment for muscle strength and other predictor variables.

CONCLUSION

Current data suggest that muscle mass assessment offers no additional prognostic information to muscle strength measures in patients with hip fracture.

Role of sarcopenia in complex abdominal wall surgery: does it increase postoperative complications and mortality?

BACKGROUND

Sarcopenia is defined as the loss of skeletal muscle mass and is associated with an increased risk or morbidity and mortality in complex surgical patient populations. Its role in complex abdominal wall surgery (AWS) is yet to be determined. The aim of this study is to establish if sarcopenia has an impact on postoperative complications, mortality and hernia recurrence.

METHODS

Retrospective study of patients undergoing elective surgery for complex incisional hernias > 10 cm (W3 of European Hernia Society classification) between 2014-2023. Sarcopenia was stablished as the skeletal muscle index (SMI), measured at L3 transversal section of a preoperative CT-scan. Previously defined literature-based SMI cutoff values were used: men ≤ 52.4 cm2/m2, women ≤ 38.5 cm2/m2.

RESULTS

135 patients undergoing complex AWS were included. Of them, 38 were sarcopenic (28.1%). The median follow-up time was 13 months (IQR 12-25). In total, 11 patients died (8.1%). We found that sarcopenia was associated with a higher risk of mortality [HR 7.494 (95% CI 1.985-28.289); p 0.003]. There were no statistically significant differences in postoperative complications or hernia recurrence between both groups.

CONCLUSION

Although sarcopenia does not seem to have an influence on hernia recurrence or the development of postoperative complications, whether local or systemic, in our study sarcopenia is associated with a higher risk of mortality after complex abdominal wall surgery. Nonetheless, with the results obtained in our study, we think that prehabilitation programs before complex AWS is advisable.

The impact of sarcopenia on postoperative complications and survival outcomes after robotic colorectal cancer surgery: a study based on single-center propensity score matching

Sarcopenia is more common in elderly individuals and is often associated with functional limitations, which can affect postoperative clinical efficacy and mortality rates in cancer surgery. Yet, the precise effects of sarcopenia on individuals receiving robotic colorectal cancer surgery (RCRC) remain insufficiently explored. Our objective was to evaluate the value of preoperative skeletal muscle status on patients receiving RCRC about postoperative complications and long-term prognosis. Data were gathered retrospectively for patients with well-defined conditions. Clinical records of patients who underwent RCRC at a single center between January 2019 and September 2022 were analyzed. Sarcopenia was defined using preoperative computed tomography (CT) body composition analysis of the L3 vertebral level muscle index with cutoff values of < 29 cm2/m2 for females and < 36 cm2/m2 for males. In this retrospective study, 432 patients were sequentially sampled, and 127 pairs were formed through propensity score matching to contrast sarcopenic and non-sarcopenic patients. Relative to the non-sarcopenia group (NSCA), the sarcopenia group (SCA) showed increased rates of complications after matching (P = 0.045), especially in cases of wound and pulmonary infections (P = 0.0408). Compared to the NSCA group, the SCA group exhibited reduced rates of 3-year overall survival (OS) and disease-free survival (DFS) (P = 0.048, 0.036). Additionally, the SCA group experienced extended hospitalizations (P = 0.04) and heightened inflammatory indices before and after surgery (P = 0.028, 0.049). Sarcopenia before surgery in RCRC patients correlates with heightened post-surgery complications and lower rates of short-term survival. Conducting sarcopenia screenings before surgery could assist in evaluating risks and developing post-surgery management approaches for these patients.

Predictors of perioperative morbidity in elderly patients undergoing colorectal cancer resection

AIM

Colorectal cancer resection in the elderly may be associated with significant morbidity. This study aimed to assess perioperative morbidity in elderly patients undergoing colorectal cancer resection and to investigate risk factors for postoperative complications.

MATERIALS AND METHODS

Consecutive patients aged ≥ 75 years undergoing colorectal cancer resection with curative intent between January 2014 and December 2021 at our institution were included. We evaluated risk factors for postoperative complications, length of hospital stays (LOS), 30-day readmission, and 90-day mortality rates.

RESULTS

A total of 843 patients underwent colorectal cancer resection during the study period, of whom 202 patients were 75 years or older. Advanced age was associated with postoperative complications (Clavien-Dindo score > 3b, p = 0.001). Sarcopenia, preoperative plasma albumin < 3.5 g/dL, and open and urgent surgery were significantly correlated with major complications (p = 0.015, p = 0.022, p = 0.003, and p < 0.001, respectively). LOS was longer in elderly patients with a modified 5-item Frailty Index (5-mFI) ≥ 2 and low preoperative serum albumin levels, as well as following open surgery (p = 0.006, p = 0.001 and p < 0.001, respectively). Sarcopenia and preoperative plasma albumin < 3.5 g/dL were predictors for 90-day mortality (p = 0.004 and p > 0.001).

CONCLUSION

Advanced age, sarcopenia, preoperative hypoalbuminemia, 5-mFI ≥ 2, and open or urgent surgery may serve as predictors for postoperative morbidity in the elderly population.

Myosteatosis Evaluated Based on Intramuscular Adipose Tissue Content Is a Risk Factor for Postoperative Complications in Crohn's Disease

BACKGROUND

Crohn's disease causes acute and chronic inflammation that often make the preoperative evaluation of surgical risks difficult. Myosteatosis is used for the evaluation of muscle quality to assess sarcopenia. However, data on the relationship between myosteatosis and surgical outcomes in patients with Crohn's disease are lacking.

METHODS

Among patients with Crohn's disease who underwent surgery between 2007 and 2022, we investigated the impact of myosteatosis on postoperative complications using intramuscular adipose tissue content (IMAC). Our study included data from 97 patients who underwent analysis for cutoff values and factors associated with IMAC and 72 who underwent analysis for risk factors of postoperative complications.

RESULTS

Body mass index (BMI; P < .001) and visceral adipose tissue/height index (P < .001) were significantly correlated with IMAC. High BMI (P < .001) and a history of abdominal surgery for Crohn's disease (P = .012) were identified as factors affected with high IMAC. Multivariate analysis revealed high IMAC and external fistulas as independent risk factors for postoperative complications (odds ratio [OR], 5.010; 95% CI, 1.300-19.30; P = .019 and OR, 7.850; 95% CI, 1.640-37.50; P = .010, respectively), especially infectious complications.

CONCLUSIONS

This study established IMAC as a valuable marker for sarcopenic obesity and predicting postoperative complications in patients with Crohn's disease. Furthermore, evaluating myosteatosis using IMAC will facilitate the decision of the optimal timing of surgery, prediction of complications, and treatment of sarcopenia in patients with Crohn's disease.

The role of sarcopenia in pre- and postoperative inflammation: implications of outcomes in patients with colorectal cancer

BACKGROUND

Patients with colorectal cancer (CRC) with sarcopenia often have a poor prognosis, and the timing of preoperative intervention to improve sarcopenia is unclear. Sarcopenia can affect the body's overall inflammatory status. This study aimed to investigate whether sarcopenia exacerbates the inflammatory response in patients with CRC after surgical stimulation and its effect on the prognosis.

METHODS

A retrospective analysis was conducted on a cohort of 215 patients with CRC who were categorized into either the sarcopenia group or the nonsarcopenia group based on their skeletal muscle index values. Inflammation-related indicators were collected from patients before and after surgery, allowing for the calculation of the differences in preoperative and postoperative changes. In addition, the correlation between inflammatory markers and postoperative complications was assessed. All patients were followed up for a period ranging from 2 to 5 years, with an average follow-up duration of 3 years, during which their recurrence and mortality rates were recorded. In addition, the relationship between inflammation indicators was explored.

RESULTS

Of note, 45 of 215 patients with sarcopenia had higher levels of preoperative baseline inflammation markers, such as C-reactive protein (P = .002), immune-inflammation index (IBI; P < .001), systemic inflammatory response index (SIRI; P = .009), and systemic immune-inflammation index (SII; P = .002) than patients without sarcopenia. There was a significant difference in inflammatory indicators before and after surgery between dIBI, dSIRI, and dSII, with the largest effect observed. In addition, the predictive capabilities of dIBI, dSIRI, and dSII for postoperative complications, as measured using the area under the receiver operating characteristic curve, were found to be 0.938, 0.877, and 0.818, respectively. Furthermore, survival analysis indicated that the differences in preoperative and postoperative alterations in IBI (dIBI), SIRI (dSIRI), and SII (dSII) were effective in predicting long-term postoperative mortality.

CONCLUSION

Our findings suggest that sarcopenia plays a significant role in exacerbating postoperative inflammatory response in patients with CRC, leading to an increased risk of postoperative complications and influencing long-term survival outcomes.

Financial implications of sarcopenia in colorectal cancer surgery: a cost analysis in an Australian public hospital

INTRODUCTION

Sarcopenia has a detrimental impact on patient outcomes following colorectal surgery, increasing financial strain on the healthcare system. Given the absence of specific Australian data, this study aimed to measure the cost of sarcopenia in the context of colorectal surgery in an Australian public hospital.

METHODS

A retrospective cost analysis, following CHEERS guidelines, was conducted on major elective colorectal cancer surgical cases at the Royal Adelaide Hospital between 2018 and 2022. The cross-sectional psoas area was measured through computed tomography (CT) imaging at the level of the third lumbar vertebrae, and sarcopenia was determined using gender-specific thresholds. Hospital billing data was used to gather costings (AU$).

RESULTS

Out of 271 patients, 57 (21.0%) comprised the sarcopenic group (SG). SG patients were older (74 vs. 69 years, P < 0.001), had a higher American Society of Anaesthesiologists (>II, 71.9% vs. 53.7%, P = 0.014) and a lower median body mass index (24.8 vs. 28.7 kg/m2, P < 0.001). The SG exhibited a greater likelihood of complications (84.2 vs. 68.7%, P = 0.020) and prolonged hospital stay by 1 day (median 7 vs. 6 days, P = 0.027). Despite an increased mean total cost of hospital admission, no statistically significant difference was found (AU$37 712 vs. $34 845, P = 0.296). Multivariate analysis revealed hypoalbuminemia, prolonged operative time, postoperative ileus, return to theatre, Clavien-Dindo grade ≥3 complications, and prolonged stay increased overall cost (P < 0.05).

CONCLUSION

Sarcopenia was not associated with a significantly increased cost of colorectal surgery in our institution. Future studies examining the cost-effectiveness of prehabilitation programmes targeting sarcopenia should be considered.

Abdominal aortic calcification among gastroenterological and transplant surgery

This review discusses the increasing global trend towards an aging population, which has resulted in a growing number of surgeries being performed on elderly patients, particularly those living with cancer. The focus was on the implications of abdominal aortic calcification (AAC), an indicator of systemic atherosclerosis, in these patients. This comprehensive review provided evidence detailing the complex processes of atherosclerosis and vascular calcification and various approaches to assess this condition. The prevalence of AAC is related to multiple factors, including cardiovascular disease, inflammation, frailty in various types of gastroenterological surgery. Additionally, notable links were found between AAC, postoperative complications, and patient survival following gastroenterological surgery. This study highlights how AAC could negatively impact the health status of elderly patients and undermine treatment efficacy, stressing the need for more research in this domain to improve patient outcomes.

Examination of Sarcopenia with Obesity as a Prognostic Factor in Patients with Colorectal Cancer Using the Psoas Muscle Mass Index

Background: Sarcopenia, the age-related loss of muscle mass, is a negative prognostic factor in gastrointestinal cancer. Sarcopenia combined with visceral obesity (sarcopenic obesity) is associated with poor outcomes. We explored the influence of obesity and other factors on the prognosis of patients with colorectal cancer diagnosed with sarcopenia. Methods: We enrolled 211 patients with colorectal cancer diagnosed with preoperative sarcopenic obesity who underwent radical resection at Osaka University Hospital between January 2009 and January 2012. Muscle mass was assessed using the psoas muscle mass index. Obesity was evaluated by measuring the visceral fat area in the umbilical region. Patients were categorized into two groups: sarcopenia with obesity (SO) and sarcopenia without obesity (non-SO). Overall survival, cancer-specific survival, and cancer-related relapse-free survival (CRRFS) were compared between the two groups. Patient characteristics, including age, sex, body mass index, serum albumin, C-reactive protein, tumor markers, prognostic nutritional index (PNI), modified Glasgow prognostic score (mGPS), and geriatric nutritional risk index (GNRI), were also analyzed. Results: CRRFS was significantly shorter in the SO group than in the non-SO group (p = 0.028). PNI, mGPS, and GNRI were not identified as significant prognostic factors for CRRFS. Multivariate analysis highlighted sarcopenic obesity, elevated carcinoembryonic antigen levels, and unfavorable histological types as significant predictors of poor CRRFS outcomes. Conclusions: Sarcopenic obesity is an independent predictor of poor prognosis in patients with CRC. Thus, interventions aimed at increasing muscle mass and reducing visceral fat could potentially improve the prognosis of these patients.

Sarcopenia is independently associated with poor preoperative physical fitness in patients undergoing colorectal cancer surgery

BACKGROUND

Accurate preoperative risk assessment for major colorectal cancer (CRC) surgery remains challenging. Body composition (BC) and cardiopulmonary exercise testing (CPET) can be used to evaluate risk. The relationship between BC and CPET in patients undergoing curative CRC surgery is unclear.

METHODS

Consecutive patients undergoing CPET prior to CRC surgery between 2010 and 2020 were identified between two different UK hospitals. Body composition phenotypes such as sarcopenia, myosteatosis, and visceral obesity were defined using widely accepted thresholds using preoperative single axial slice CT image at L3 vertebrae. Relationships between clinicopathological, BC, and CPET variables were investigated using linear regression analysis.

RESULTS

Two hundred eighteen patients with stage I-III CRC were included. The prevalence of sarcopenia, myosteatosis, and visceral obesity was 62%, 33%, and 64%, respectively. The median oxygen uptake at anaerobic threshold (VO2 at AT) was 12.2 mL/kg/min (IQR 10.6-14.2), and oxygen uptake at peak exercise (VO2 peak) was 18.8 mL/kg/min (IQR 15.4-23). On univariate linear regression analysis, male sex (P < 0.001) was positively associated with VO2 at AT. While ASA grade (P < 0.001) and BMI (P = 0.007) were negatively associated with VO2 at AT, on multivariate linear regression analysis, these variables remained significant (P < 0.05). On univariate linear regression analysis, male sex (P < 0.001) was positively associated with VO2 peak, whereas age (P < 0.001), ASA grade (P < 0.001), BMI (P = 0.003), sarcopenia (P = 0.015), and myosteatosis (P < 0.001) were negatively associated with VO2 peak. On multivariate linear regression analysis age (P < 0.001), ASA grade (P < 0.001), BMI (P < 0.001), and sarcopenia (P = 0.006) were independently and negatively associated with VO2 peak.

CONCLUSIONS

The novel finding that sarcopenia is independently associated with reduced VO2 peak performance in CPET supports the supposition that reduced muscle mass relates to poor physical function in CRC patients. Further work should be undertaken to assess whether sarcopenia diagnosed on CT can act as suitable surrogate for CPET to further enhance personalized risk stratification.

Use of automated assessment for determining associations of low muscle mass and muscle loss with overall survival in patients with colorectal cancer - A validation study

BACKGROUND

Low muscle mass and skeletal muscle mass (SMM) loss are associated with adverse patient outcomes, but the time-consuming nature of manual SMM quantification prohibits implementation of this metric in clinical practice. Therefore, we assessed the feasibility of automated SMM quantification compared to manual quantification. We evaluated both diagnostic accuracy for low muscle mass and associations of SMM (change) with survival in colorectal cancer (CRC) patients.

METHODS

Computed tomography (CT) images from CRC patients enrolled in two clinical studies were analyzed. We compared i) manual vs. automated segmentation of preselected slices at the third lumbar [L3] vertebra ("semi-automated"), and ii) manual L3-slice-selection + manual segmentation vs. automated L3-slice-selection + automated segmentation ("fully-automated"). Automated L3-selection and automated segmentation was performed with Quantib Body Composition v0.2.1. Bland-Altman analyses, within-subject coefficients of variation (WSCVs) and Intraclass Correlation Coefficients (ICCs) were used to evaluate the agreement between manual and automatic segmentation. Diagnostic accuracy for low muscle mass (defined by an established sarcopenia cut-off) was calculated with manual assessment as the "gold standard". Using either manual or automated assessment, Cox proportional hazard ratios (HRs) were used to study the association between changes in SMM (>5% decrease yes/no) during first-line metastatic CRC treatment and mortality adjusted for prognostic factors. SMM change was also assessed separately in weight-stable (<5%, i.e. occult SMM loss) patients.

RESULTS

In total, 1580 CT scans were analyzed, while a subset of 307 scans were analyzed in the fully-automated comparison. Included patients (n = 553) had a mean age of 63 ± 9 years and 39% were female. The semi-automated comparison revealed a bias of -2.41 cm2, 95% limits of agreement [-9.02 to 4.20], a WSCV of 2.25%, and an ICC of 0.99 (95% confidence intervals (CI) 0.97 to 1.00). The fully-automated comparison method revealed a bias of -0.08 cm2 [-10.91 to 10.75], a WSCV of 2.85% and an ICC of 0.98 (95% CI 0.98 to 0.99). Sensitivity and specificity for low muscle mass were 0.99 and 0.89 for the semi-automated comparison and 0.96 and 0.90 for the fully-automated comparison. SMM decrease was associated with shorter survival in both manual and automated assessment (n = 78/280, HR 1.36 [95% CI 1.03 to 1.80] and n = 89/280, HR 1.38 [95% CI 1.05 to 1.81]). Occult SMM loss was associated with shorter survival in manual assessment, but not significantly in automated assessment (n = 44/263, HR 1.43 [95% CI 1.01 to 2.03] and n = 51/2639, HR 1.23 [95% CI 0.87 to 1.74]).

CONCLUSION

Deep-learning based assessment of SMM at L3 shows reliable performance, enabling the use of CT measures to guide clinical decision making. Implementation in clinical practice helps to identify patients with low muscle mass or (occult) SMM loss who may benefit from lifestyle interventions.

Sarcopenic obesity predicts short- and long-term outcomes after neoadjuvant chemotherapy and surgery for gastric cancer

BACKGROUND

Sarcopenic obesity (SO) affects outcomes in various malignancies. However, its clinical significance in patients undergoing neoadjuvant chemotherapy (NAC) for locally advanced gastric cancer (LAGC) remains unclear. This study investigated the impact of pre- and post-NAC SO on postoperative morbidity and survival.

METHODS

Data from 207 patients with LAGC, who underwent NAC followed by radical gastrectomy between January 2010 and October 2019, were reviewed. Skeletal muscle mass and visceral fat area were measured pre- and post-NAC using computed tomography to define sarcopenia and obesity, the coexistence of which was defined as SO.

RESULTS

Among the patients, 52 (25.1%) and 38 (18.4%) developed SO before and after NAC, respectively. Both pre- (34.6%) and post- (47.4%) NAC SO were associated with the highest postoperative morbidity rates; however, only post-NAC SO was an independent risk factor for postoperative morbidity [hazard ratio (HR) = 9.550, 95% confidence interval (CI) = 2.818-32.369; P < .001]. Pre-NAC SO was independently associated with poorer 3-year overall [46.2% vs. 61.3%; HR = 1.258 (95% CI = 1.023-1.547); P = .049] and recurrence-free [39.3% vs. 55.4%; HR 1.285 (95% CI 1.045-1.579); P = .017] survival.

CONCLUSIONS

Pre-NAC SO was an independent prognostic factor in patients with LAGC undergoing NAC; post-NAC SO independently predicted postoperative morbidity.

Advancing body composition assessment in patients with cancer: First comparisons of traditional versus multicompartment models

BACKGROUND AND AIMS

Measurement of body composition using computed tomography (CT) scans may be a viable clinical tool for low muscle mass assessment in oncology. However, longitudinal assessments are often infeasible with CT. Clinically accessible body composition technologies can be used to track changes in fat-free mass (FFM) or muscle, though their accuracy may be impacted by cancer-related physiological changes. The purpose of this study was to examine the agreement among accessible body composition method with criterion methods for measures of whole-body FFM measurements and, when possible, muscle mass for the classification of low muscle in patients with cancer.

METHODS

Patients with colorectal cancer were recruited to complete measures of whole-body DXA, air displacement plethysmography (ADP), and bioelectrical impedance analysis (BIA). These measures were used alone, or in combination to construct the criterion multicompartment (4C) mode for estimating FFM. Patients also underwent abdominal CT scans as part of routine clinical assessment. Agreement of each method with 4C model was analyzed using mean constant error (CE = criterion - alternative), linear regression including root mean square error (RMSE), Bland-Altman limits of agreement (LoA) and mean percentage difference (MPD). Additionally, appendicular lean soft tissue index (ALSTI) measured by DXA and predicted by CT were compared for the absolute agreement, while the ALSTI values and skeletal muscle index by CT were assessed for agreement on the classification of low muscle mass.

RESULTS

Forty-five patients received all measures for the 4C model and 25 had measures within proximity of clinical CT measures. Compared to 4C, DXA outperformed ADP and BIA by showing the strongest overall agreement (CE = 1.96 kg, RMSE = 2.45 kg, MPD = 98.15 ± 2.38%), supporting its use for body composition assessment in patients with cancer. However, CT cutoffs for skeletal muscle index or CT-estimated ALSTI were lower than DXA ALSTI (average 1.0 ± 1.2 kg/m2) with 24.0% to 32.0% of patients having a different low muscle classification by CT when compared to DXA.

CONCLUSIONS

Despite discrepancies between clinical body composition assessment and the criterion multicompartment model, DXA demonstrates the strongest agreement with 4C. Disagreement between DXA and CT for low muscle mass classification prompts further evaluation of the measures and cutoffs used with each technique. Multicompartment models may enhance our understanding of body composition variations at the individual patient level and improve the applicability of clinically accessible technologies for classification and monitoring change over time.

Prevalence and impact of frailty in patients undergoing colorectal cancer surgery: A systematic review and meta-analysis based on modified frailty index

Frailty has been linked to unfavorable postoperative outcomes in patients with colorectal cancer (CRC). However, the prevalence of frailty among CRC surgery patients and its association with mortality and postoperative complications, as evaluated by the modified frailty index (mFI), have not been thoroughly investigated and necessitate clarification. PubMed, Web of Science, Embase, and CBM databases were systematically searched for relevant studies (up to January 2024), and the pooled prevalence and odds ratio (OR) estimate were calculated. A total of 16 studies containing 245 747 patients undergoing CRC surgery were included. The prevalence of frailty among CRC surgery patients was 31% (95% confidence interval [CI] = 20%-42%; I2 = 100%, p < 0.001). In patients undergoing CRC surgery, frailty was associated with a higher incidence of postoperative complications (OR = 1.94; 95% CI = 1.47-2.56; I2 = 91.9%, p < 0.001), but it did not exhibit any significant correlation with the 30-day mortality (OR = 5.17; 95% CI = 0.39-68.64; I2 = 94.4%, p < 0.001). Frailty is common in CRC surgery and exerts a significant negative impact on the postoperative outcomes. Future research could explore the potential of the mFI to facilitate a more streamlined and precise quantification of frailty, thereby establishing a refined understanding of its correlation with surgery prognosis.

Prognostic value of body composition in patients with digestive tract cancers: A prospective cohort study of 8,267 adults from China

BACKGROUND & AIMS

The characterization and prognostic value of body composition parameter/phenotype based on computed tomography (CT) in patients with digestive tract cancers remain incomplete. This study aimed to investigate the relationship between parameter/phenotype and clinical outcomes in patients with digestive tract cancers.

METHODS

In this prospective cohort study, 8267 patients with digestive tract cancers were assessed using CT scans to determine body composition. Body composition data, including areas of skeletal muscle (SM), subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT), were collected at the third lumbar level on CT images obtained within 30 days before surgery. Body composition phenotypes (sarcopenia, cancer cachexia, sarcopenic obesity) were determined based on SM, SAT, and VAT areas. The primary endpoint was overall survival, obtained from electronic medical records and telephone follow-up surveys. Kaplan-Meier and log-rank analyses were employed to compare unadjusted survival, while multivariate survival analyses were conducted using a proportional hazards model adjusted for age, gender, and cancer-node-metastasis (TNM) stages.

RESULTS

Adjusted hazard ratios (HRs) for all-cause mortality were calculated for the second (Q2), third (Q3), and fourth (Q4) quantiles relative to the first quantile (Q1) for SM areas, revealing adjusted summary HRs of 0.575 (95% CI, 0.361-0.916), 0.419 (95% CI, 0.241-0.729), and 0.384 (95% CI, 0.203-0.726), respectively. Sarcopenia-adjusted summary HRs were 1.795 (95% CI: 1.012-3.181) for male patients and 1.925 (95% CI: 1.065-3.478) for female patients. Cancer cachexia-adjusted summary HRs were 1.542 (95% CI: 1.023-2.324) for male patients and 1.569 (95% CI: 0.820-3.001) for female patients. Sarcopenic obesity-adjusted summary HRs were 1.122 (95% CI: 0.759-1.657) for male patients and 1.303 (95% CI: 0.623-2.725) for female patients. Subgroup analyses indicated varying prognostic values of body composition parameter/phenotype among different cancer types.

CONCLUSIONS

Our findings suggest a large SM area is a favorable prognostic indicator, while cancer cachexia and sarcopenia signify poor prognosis in patients with digestive tract cancers. These findings have important implications for the personalized preoperative assessment of body composition in patients with digestive tract cancers.

Perioperative management of sarcopenia in patients undergoing major surgeries in Singapore: a modified Delphi consensus

BACKGROUND

Ageing population is a worldwide phenomenon with correspondingly higher proportion of older patients being treated in the hospital setting. Sarcopenia, which increases with age, has serious negative implications on health, hospitalisation, and overall postoperative recovery. There is no mutual consensus on perioperative management of sarcopenia in surgical patients in Singapore. The purpose of this study is to create greater clarity pertaining to the recognition of sarcopenia, the application of assessment criteria of sarcopenia and perioperative management of surgical patients in Singapore.

METHODS

A modified Delphi consensus consisting of a panel of experts from Singapore forming a multidisciplinary team, including surgeons, geriatricians, anesthesiologists, physiotherapists, and dieticians. Eight recommendations were proposed by the steering committee. Literature search from MEDLINE, Embase, and Scopus for articles up till June 2023 were performed to support recommendation statements. The expert panel voted on agreement to recommendation statements and graded the level of evidence supporting each statement through surveys to achieve consensus, set at 85% a priori.

RESULTS

The panellists underwent two rounds of anonymized, independent voting before reaching consensus for all eight statements. After the first round, seven statements reached consensus, including the corresponding grading for level of evidence. The statement which did not achieve consensus was revised with supporting literature and after the second round of survey, all eight statements and level of evidence reached consensus, completing the Delphi process. These eight statements covered themes to (1) encourage the identification of sarcopenia, (2) guide preoperative, and (3) postoperative management of sarcopenia.

CONCLUSION

With the varying approaches in perioperative management, poor understanding of and identification of sarcopenia can result in suboptimal management of sarcopenia in surgical patients. Given the abundance of evidence linking beneficial impact on recovery and postoperative complications with prudent management of sarcopenia, it is imperative and urgent to achieve awareness and consensus.

The impact of sarcopenia in the treatment for patients with head and neck cancer

Sarcopenia is a disease in which a decline in muscle mass with age is associated with a decline in physical performance. In the field of otorhinolaryngology, head and neck surgery, sarcopenia is gaining attention as a cause of swallowing disorders and as a problem in the treatment of head and neck cancer. Head and neck cancer occurs in anatomical sites related to swallowing, so patients with head and neck cancer are prone to swallowing disorders and "nutrition-related sarcopenia." Since it is a cancer, it also becomes a "disease-related sarcopenia," making it easy for patients to develop secondary sarcopenia. Medical intervention against sarcopenia is important in order to decrease the number of adverse events related to treatments for cases with sarcopenia, with reports stating that proactive exercise and nutritional therapy prior to treatment for cases with sarcopenia contributes to a decrease in serious complications as well as improving the survival rate. It is the same for head and neck cancer patients with sarcopenia, so intervention prior to treatment of head and neck cancer is an area that is expected to see reports in the future. However, if the disease is malignant, it is highly likely that sarcopenia cannot be sufficiently improved due to the short period of time from diagnosis to the beginning of treatment. In this case, choosing a treatment that takes sarcopenia into consideration is another way to handle it. Assessing sarcopenia prior to treatment may help avoid post-treatment pneumonia related to sarcopenia, postoperative complications including fistula, radiation-induced toxicity including swallowing disorders, and chemotherapy-related toxicity, and it is believed to greatly contribute to the prognosis of the overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS).

Unraveling the role of computed tomography derived body composition metrics on anastomotic leakages rates in rectal cancer surgery: A protocol for a systematic review and meta-analysis

INTRODUCTION

Anastomotic leakage is a major concern following total mesorectal excision for rectal cancer, affecting oncological outcomes, morbidity an treatment costs. Body composition has been suggested to influence anastomotic leakage rates. However, literature on how body composition impact anastomotic leakage rates is conflicting. This systematic review aims to evaluate the role of computed tomography derived body composition metrics on anastomotic leakage rates in rectal cancer patients.

METHODS

Databases PubMed/MEDLINE, Cochrane Library, web of science, and EMBASE, will be systematically searched for papers from January 2010 onwards. Study selection, data collection and quality assessment will be independently performed by three research fellows. Outcomes described in three or more studies will be included in the meta-analysis. The Q-test and I2 statistic will be used to assess statistical heterogeneity between studies. Publication bias will be examined by visual inspection of funnel plots and quantified by Egger's test. Sensitivity analyses will be conducted to examine the robustness of the meta-analysis. Reporting of the findings will be in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines.

CONCLUSIONS

This systematic review will synthesize the current evidence and will identify knowledge gaps. Results of the systematic review will aid health care professional in pre-operative decision making and will be distributed through a peer-reviewed publication and presentation of results at international meetings.

TRIAL REGISTRATION

PROSPERO protocol number: CRD42023471537.

Machine learning prediction model for postoperative ileus following colorectal surgery

BACKGROUND

Postoperative ileus (POI) continues to be a major cause of morbidity following colorectal surgery. Despite best efforts, the incidence of POI in colorectal surgery remains high (~30%). This study aimed to investigate machine learning techniques to identify risk factors for POI in colorectal surgery patients, to help guide further preventative strategies.

METHODS

A TRIPOD-guideline-compliant retrospective study was conducted for major colorectal surgery patients at a single tertial care centre (2018-2022). The primary outcome was the occurrence of POI, defined as not achieving GI-2 (outcome measure of time to first stool and tolerance of oral diet) by day four. Multivariate logistic regression, decision trees, radial basis function and multilayer perceptron (MLP) models were trained using a random allocation of patients to training/testing data sets (80/20). The area under the receiver operating characteristic (AUROC) curves were used to evaluate model performance.

RESULTS

Of 504 colorectal surgery patients, 183 (36%) experienced POI. Multivariate logistic regression, decision trees, radial basis function and MLP models returned an AUROC of 0.722, 0.706, 0.712 and 0.800, respectively. The MLP model had the highest sensitivity and specificity values. In addition to well-known risk factors for POI, such as postoperative hypokalaemia, surgical approach, and opioid use, the MLP model identified sarcopenia (ranked 4/30) as a potentially modifiable risk factor for POI.

CONCLUSION

MLP outperformed other models in predicting POI. Machine learning can provide valuable insights into the importance and ranking of specific predictive variables for POI. Further research into the predictive value of preoperative sarcopenia for POI is required.

Strength-to-muscle radiodensity: A potential new index for muscle quality

BACKGROUND & AIMS

Although it is widely recognized that muscle quality significantly influences adverse outcomes in patients with cancer, the precise definition of muscle quality remains elusive. The muscle quality index (MQI), also known as muscle-specific strength, is a relatively recent functional concept of muscle quality. It is obtained through the ratio of muscle strength to muscle mass, but its predictive value in patients with cancer remains unknown. In this study, we explored the prognostic significance of MQI in patients with cancer. Furthermore, we introduce and assess the prognostic potential of a novel muscle quality metric: the strength-to-muscle-radiodensity index (SMRi).

METHODS

A secondary analysis was conducted on a prospective cohort study. CT scans were opportunistically used to assess body composition parameters, including skeletal muscle mass (SM in cm2) and muscle radiodensity (SMD in HU) at the third lumbar vertebra (L3). Handgrip strength (HGS) was measured. MQICT was calculated using the ratio of HGS to SM (cm2). SMRi was calculated as the ratio of HGS to SMD (HU). For analysis purposes, low MQICT and SMRi were defined using two approaches: statistical cutoffs associated with survival, and median-based distribution data.

RESULTS

A total of 250 patients were included (52.8% females, 52% adults, 20-90 years). Gastrointestinal tumors and stage III-IV were the most frequent diagnosis and stages. SMRi and MQICT were strongly positively correlated (ρ = 0.71 P < 0.001). Individual components of MQICT and SMRi were also positively correlated. Patients with both low MQICT and SMRi had shorter survival (log-rank P = 0.023 and P = 0.003, respectively). When applying median distribution cutoffs, SMRi emerged as the most accurate predictor of mortality (HR adjusted 3.18, 95% CI 1.50 to 6.75, C-index: 0.71), when compared to MQICT (HR adjusted 1.49, 95% CI 0.77 to 2.87, C-index: 0.68).

CONCLUSION

This study introduces the concept and potential prognostic significance of the SMRi. The physiological and clinical implications of this new index warrant further investigation across a spectrum of diseases, including cancer.

Prognostic significance of Ishii's sarcopenia screening score for patients undergoing curative surgery for obstructive colorectal cancer after intraluminal decompression

PURPOSE

Sarcopenia influences the short- and long-term outcomes of various medical conditions including malignancy. Ishii's screening test estimates the probability of sarcopenia based on a score calculated by three simple variables: age, grip strength, and calf circumference. We investigated the clinical significance of Ishii's score for patients with non-metastatic obstructive colorectal cancer (OCRC) who underwent curative surgery after intraluminal decompression.

METHODS

Ishii's score was calculated in 79 patients with OCRC. Muscle volume loss and decreased muscle quality were evaluated by computed tomography (CT) images as skeletal muscle index (SMI) and intramuscular adipose tissue content (IMAC), respectively.

RESULTS

There were 46 men and 33 women, with a median age of 70 years old. The cutoff value for Ishii's score was 155.1 and 15 patients were in the high-score group. The high-score group was significantly associated with worse time to recurrence (TTR) and overall survival (OS), and a high Ishii's score was an independent negative prognostic factor for TTR (hazard ratio = 2.93, P = 0.015). A high Ishii's score was significantly associated with a low SMI value but not with the IMAC value.

CONCLUSION

A high Ishii's score was independently associated with poorer TTR in patients with non-metastatic OCRC.

Feasibility of two levels of protein intake in patients with colorectal cancer: findings from the Protein Recommendation to Increase Muscle (PRIMe) randomized controlled pilot trial

BACKGROUND

Low muscle mass (MM) predicts unfavorable outcomes in cancer. Protein intake supports muscle health, but oncologic recommendations are not well characterized. The objectives of this study were to evaluate the feasibility of dietary change to attain 1.0 or 2.0 g/kg/day protein diets, and the preliminary potential to halt MM loss and functional decline in patients starting chemotherapy for stage II-IV colorectal cancer.

PATIENTS AND METHODS

Patients were randomized to the diets and provided individualized counseling. Assessments at baseline, 6 weeks, and 12 weeks included weighed 3-day food records, appendicular lean soft tissue index (ALSTI) by dual-energy X-ray absorptiometry to estimate MM, and physical function by the Short Physical Performance Battery (SPPB) test.

RESULTS

Fifty patients (mean ± standard deviation: age, 57 ± 11 years; body mass index, 27.3 ± 5.6 kg/m2; and protein intake, 1.1 ± 0.4 g/kg/day) were included at baseline. At week 12, protein intake reached 1.6 g/kg/day in the 2.0 g/kg/day group and 1.2 g/kg/day in the 1.0 g/kg/day group (P = 0.012), resulting in a group difference of 0.4 g/kg/day rather than 1.0 g/kg/day. Over one-half (59%) of patients in the 2.0 g/kg/day group maintained or gained MM compared with 44% of patients in the 1.0 g/kg/day group (P = 0.523). Percent change in ALSTI did not differ between groups [2.0 g/kg/day group (mean ± standard deviation): 0.5% ± 4.6%; 1.0 g/kg/day group: -0.4% ± 6.1%; P = 0.619]. No differences in physical function were observed between groups. However, actual protein intake and SPPB were positively associated (β = 0.37; 95% confidence interval 0.08-0.67; P = 0.014).

CONCLUSION

Individualized nutrition counselling positively impacted protein intake. However, 2.0 g/kg/day was not attainable using our approach in this population, and group contamination occurred. Increased protein intake suggested positive effects on MM and physical function, highlighting the potential for nutrition to attenuate MM loss in patients with cancer. Nonetheless, muscle anabolism to any degree is clinically significant and beneficial to patients. Larger trials should explore the statistical significance and clinical relevance of protein interventions.

The Effects of Sarcopenia on Overall Survival and Postoperative Complications of Patients Undergoing Hepatic Resection for Primary or Metastatic Liver Cancer: A Systematic Review and Meta-Analysis

Background: Colorectal cancer is the third most common cancer worldwide, and 20-30% of patients will develop liver metastases (CRLM) during their lifetime. Hepatocellular carcinoma (HCC) is also one of the most common cancers worldwide with increasing incidence. Hepatic resection represents the most effective treatment approach for both CRLM and HCC. Recently, sarcopenia has gained popularity as a prognostic index in order to assess the perioperative risk of hepatectomies. The aim of this study is to assess the effects of sarcopenia on the overall survival (OS), complication rates and mortality of patients undergoing liver resections for HCC or CRLM. Methods: A systematic literature search was performed for studies including patients undergoing hepatectomy for HCC or CRLM, and a meta-analysis of the data was performed. Results: Sarcopenic patients had a significantly lower 5-year OS compared to non-sarcopenic patients (43.8% vs. 63.6%, respectively; p < 0.01) and a significantly higher complication rate (35.4% vs. 23.1%, respectively; p = 0.002). Finally, no statistical correlation was found in mortality between sarcopenic and non-sarcopenic patients (p > 0.1). Conclusions: Sarcopenia was significantly associated with decreased 5-year OS and increased morbidity, but no difference was found with regard to postoperative mortality.

Prognostic impact of myosteatosis in patients with colorectal cancer undergoing curative surgery: an updated systematic review and meta-analysis

Background

Colorectal cancer (CRC) is a global health concern, and identifying prognostic factors can improve outcomes. Myosteatosis is fat infiltration into muscles and is a potential predictor of the survival of patients with CRC.

Methods

This systematic review and meta-analysis aimed to assess the prognostic role of myosteatosis in CRC. PubMed, Embase, and Cochrane CENTRAL were searched up to 1 August 2023, for relevant studies, using combinations of the keywords CRC, myosteatosis, skeletal muscle fat infiltration, and low skeletal muscle radiodensity. Case-control, prospective, and retrospective cohort studies examining the association between myosteatosis and CRC outcomes after curative intent surgery were eligible for inclusion. Primary outcomes were overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS).

Results

A total of 10 studies with a total of 9,203 patients were included. The pooled hazard ratio (HR) for OS (myosteatosis vs. no myosteatosis) was 1.52 [95% confidence interval (CI), 1.38-1.67); for CSS, 1.67 (95% CI, 1.40-1.99); and for DFS, 1.89 (95% CI, 1.35-2.65).

Conclusion

In patients with CRC undergoing curative intent surgery, myosteatosis is associated with worse OS, CSS, and DFS. These findings underscore the importance of evaluating myosteatosis in patients with CRC to improve outcomes.