Visceral Adiposity is a Risk Factor for Poor Prognosis in Colorectal Cancer Patients Receiving Adjuvant Chemotherapy

Longitudinal changes in body composition during palliative systemic chemotherapy and survival outcomes in metastatic colorectal cancer

BACKGROUND

In patients with metastatic colorectal cancer, chemotherapy may lead to changes in body composition, including skeletal muscle quantity and quality, and body fat area and distribution. Longitudinal follow-up data in a homogeneous population are required to understand these changes better.

AIM

To comprehensively evaluate changes in body composition and their prognostic value in patients with metastatic colorectal cancer undergoing palliative chemotherapy.

METHODS

This retrospective study included patients with recurrent or metastatic colorectal cancer who received palliative chemotherapy between 2008 and 2017. Computed tomography scans were analyzed at multiple time points (before each new chemotherapy regimen and after discontinuing all chemotherapy). Body composition was analyzed from each scan using artificial intelligence software (AID-UTM, iAID Inc.), and its association with survival was evaluated through time-dependent Cox regression to adjust for time-varying effects.

RESULTS

This analysis included 1805 patients, with a median age at diagnosis of 57 years, and 62% were male. At first-line chemotherapy initiation, 4.7%, 30.9%, 36.5%, and 37.1% of the patients had sarcopenia, myosteatosis, and visceral and subcutaneous obesity, respectively. During treatment, approximately 54.5% of the patients experienced significant changes in body composition, with 9.1% and 19.2% developing new sarcopenia and myosteatosis, respectively. Sarcopenia and myosteatosis were associated with poorer survival outcomes [hazard ratio (HR) for sarcopenia, 2.55 (95%CI: 2.06-3.16, P < 0.001; HR for myosteatosis, 2.37 (95%CI: 2.00-2.82), P < 0.001]. In contrast, visceral and subcutaneous obesity were associated with improved survival [HR for visceral obesity, 0.69 (95%CI: 0.57-0.82), P < 0.001; HR for subcutaneous obesity, 0.78 (95%CI: 0.64-0.95), P = 0.015], with no negative impacts observed at higher fat levels. These changes correlated with end-of-life survival time.

CONCLUSION

Abnormalities and body composition changes were frequently observed during palliative chemotherapy for advanced colorectal cancer; myosteatosis was common. Comprehensive body composition assessment offers valuable prognostic insights without requiring additional testing.

[Cancer and nutritional management of overweight and obesity: Practice evaluation]

CONTEXT

The aim of this practice evaluation was to assess weight trends during and after a nutritional intervention in cancer patients and survivors.

METHODS

This retrospective study was conducted between January 2014 and October 2020 in adults with different cancer types managed at the Léon-Bérard Cancer Center, undergoing treatment or during post-treatment follow-up, with a BMI≥25kg/m2 and who had at least 3 consultations with a nutrition physician. Nutritional management focused on behavioral, metabolic and nutritional aspects. Anthropometrics measurements, i.e., waist circumference, weight and BMI, were monitored prospectively during the nutritional consultation. The aim of this study was to evaluate the impact of the nutritional intervention on the anthropometrics measurements.

RESULTS

Overall, 247 patients were included in the analysis. The median duration of the nutritional intervention was 7.2months. Between the first and the last nutrition consultation, waist circumference was reduced in 97.2% of the patients, with a median loss of 10cm; weight and BMI were reduced in 85.0% and 83.8% of the patients respectively. Six months after the end of the nutritional intervention, 53.7% of patients had stable or continued reduced weight.

CONCLUSION

This analysis of practice shows the positive impact of a nutritional intervention during cancer treatments on anthropometric parameters, and maintenance or continued weight loss at distance from the intervention in half of the patients.

Improving the prediction of chemotherapy dose-limiting toxicity in colon cancer patients using an AI-CT-based 3D body composition of the entire L1-L5 lumbar spine

PURPOSE

Chemotherapy dose-limiting toxicities (DLT) pose a significant challenge in successful colon cancer treatment. Body composition analysis may enable tailored interventions thereby supporting the mitigation of chemotherapy toxic effects. This study aimed to evaluate and compare the effectiveness of using three-dimensional (3D) CT body composition measures from the entire lumbar spine levels (L1-L5) versus a single vertebral level (L3), the current gold standard, in predicting chemotherapy DLT in colon cancer patients.

METHODS

Retrospective analysis of 184 non-metastatic colon cancer patients receiving adjuvant chemotherapy was performed. DLT was defined as any occurrence of dose reduction or discontinuation due to chemotherapy toxicity. Using artificial intelligence (AI) auto-segmentation, 3D body composition measurements were obtained from patients' L1-L5 levels on CT imaging. The effectiveness of patients' 3D L3 body composition measurement and incorporating data from the entire L1-L5 (including L3) region in predicting DLT was examined.

RESULTS

Of the 184 patients, 112 (60.9%) experienced DLT. Neuropathy was the most common toxicity (49/112, 43.8%) followed by diarrhea (35.7%) and nausea/vomiting (33%). Patients with DLT had lower muscle volume at all lumbar levels compared to those without. The machine learning model incorporating L1-L5 data and patient clinical data achieved high predictive performance (AUC = 0.75, accuracy = 0.75), outperforming the prediction using single L3 level (AUC = 0.65, accuracy = 0.65).

CONCLUSION

Evaluating a patient's body composition allowed prediction of chemotherapy toxicities for colon cancer. Incorporating fully automated body composition analysis of CT slices from the entire lumbar region offers promising performance in early identification of high-risk individuals, with the ultimate aim of improving patient's quality of life.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The association of body composition on chemotherapy toxicities in non-metastatic colorectal cancer patients: a systematic review

BACKGROUND

In recent years, certain body composition measures, assessed by computed tomography (CT), have been found to be associated with chemotherapy toxicities. This review aims to explore available data on the relationship between skeletal muscle and adiposity, including visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), intramuscular and intermuscular adipose tissue and their association with chemotherapy toxicity in non-metastatic colorectal cancer (CRC) patients.

METHODS

A systematic literature search following PRISMA guidelines was conducted in Medline, Embase, Cochrane and Web of Science, for papers published between 2011 and 2023. The search strategy combined keywords and MESH terms relevant to 'body composition', 'chemotherapy toxicities', and 'non-metastatic colorectal cancer'.

RESULTS

Out of 3868 studies identified, six retrospective studies fulfilled the inclusion criteria with 1024 eligible patients. Low skeletal muscle mass was strongly associated with increased incidence of both chemotherapy toxicities and dose-limiting toxicity (DLT). The association of VAT, intramuscular and intermuscular adiposity was heterogeneous and inconclusive. There was no association between SAT and chemotherapy intolerance. No universal definitions or cut-offs for sarcopenia and obesity were noted. All studies utilized 2-dimensional (2D) CT slices for CT body composition assessment with varied selection on the vertebral landmark and inconsistent reporting of tissue-defining Hounsfield unit (HU) measurements.

CONCLUSION

Low skeletal muscle is associated with chemotherapy toxicities in non-metastatic CRC. However, quality evidence on the role of adiposity is limited and heterogeneous. More studies are needed to confirm these associations with an emphasis on a more coherent body composition definition and an approach to its assessment, especially regarding sarcopenia.

Can AI-based body composition assessment outperform body surface area in predicting dose-limiting toxicities for colonic cancer patients on chemotherapy?

PURPOSE

Gold standard chemotherapy dosage is based on body surface area (BSA); however many patients experience dose-limiting toxicities (DLT). We aimed to evaluate the effectiveness of BSA, two-dimensional (2D) and three-dimensional (3D) body composition (BC) measurements derived from Lumbar 3 vertebra (L3) computed tomography (CT) slices, in predicting DLT in colon cancer patients.

METHODS

203 patients (60.87 ± 12.42 years; 97 males, 47.8%) receiving adjuvant chemotherapy (Oxaliplatin and/or 5-Fluorouracil) were retrospectively evaluated. An artificial intelligence segmentation model was used to extract 2D and 3D body composition measurements from each patients' single mid-L3 CT slice as well as multiple-L3 CT scans to produce a 3D BC report. DLT was defined as any incidence of dose reduction or discontinuation due to chemotherapy toxicities. A receiver operating characteristic (ROC) analysis was performed on BSA and individual body composition measurements to demonstrate their predictive performance.

RESULTS

A total of 120 (59.1%) patients experienced DLT. Age and BSA did not vary significantly between DLT and non-DLT group. Females were significantly more likely to experience DLT (p = 4.9 × 10-3). In all patients, the predictive effectiveness of 2D body composition measurements (females: AUC = 0.50-0.54; males: AUC = 0.50-0.61) was equivalent to that of BSA (females: AUC = 0.49; males: AUC = 0.58). The L3 3D skeletal muscle volume was the most predictive indicator of DLT (AUC of 0.66 in females and 0.64 in males).

CONCLUSION

Compared to BSA and 2D body composition measurements, 3D L3 body composition measurements had greater potential to predict DLT in CRC patients receiving chemotherapy and this was sex dependent.

Visceral fat percentage for prediction of outcome in uterine cervical cancer

OBJECTIVE

The prognostic role of adiposity in uterine cervical cancer (CC) is largely unknown. Abdominal fat distribution may better reflect obesity than body mass index. This study aims to describe computed tomography (CT)-assessed abdominal fat distribution in relation to clinicopathologic characteristics, survival, and tumor gene expression in CC.

METHODS

The study included 316 CC patients diagnosed during 2004-2017 who had pre-treatment abdominal CT. CT-based 3D segmentation of total-, subcutaneous- and visceral abdominal fat volumes (TAV, SAV and VAV) allowed for calculation of visceral fat percentage (VAV% = VAV/TAV). Liver density (LD) and waist circumference (at L3/L4-level) were also measured. Associations between CT-derived adiposity markers, clinicopathologic characteristics and disease-specific survival (DSS) were explored. Gene set enrichment of primary tumors were examined in relation to fat distribution in a subset of 108 CC patients.

RESULTS

High TAV, VAV and VAV% and low LD were associated with higher age (≥44 yrs.; p ≤ 0.017) and high International Federation of Gynecology and Obstetrics (FIGO) (2018) stage (p ≤ 0.01). High VAV% was the only CT-marker predicting high-grade histology (p = 0.028), large tumor size (p = 0.016) and poor DSS (HR 1.07, p < 0.001). Patients with high VAV% had CC tumors that exhibited increased inflammatory signaling (false discovery rate [FDR] < 5%).

CONCLUSIONS

High VAV% is associated with high-risk clinical features and predicts reduced DSS in CC patients. Furthermore, patients with high VAV% had upregulated inflammatory tumor signaling, suggesting that the metabolic environment induced by visceral adiposity contributes to tumor progression in CC.

The impact of mesorectal fat area on recurrence following total mesorectal excision for lower rectal cancer

BACKGROUND

The mesorectal fat area (MFA) at the tip of the ischial spines on magnetic resonance imaging has been used to characterize mesorectal morphology. Recent studies reported that a larger MFA correlated with difficulties in rectal cancer surgery. However, the relationship between MFA and rectal cancer prognosis remains unclear. This study evaluated the impact of MFA on recurrence following robotic total mesorectal excision (TME) for rectal cancer.

METHODS

Patients who underwent robotic TME for lower rectal cancer from December 2011 to December 2016 were enrolled. Cox regression analysis was performed to determine variables associated with relapse-free survival (RFS). Patients were divided into groups based on MFA, and RFS was compared.

RESULTS

Of 230 patients, 173 (75.3%) were male. The median age was 63 years, and median MFA was 19.7 cm2. In multivariate analysis, smaller MFA (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.88-0.97; p < 0.01), p/yp stage II (HR, 3.81; 95% CI, 1.40-10.35; p < 0.01), and p/yp stage III (HR, 5.35; 95% CI, 1.88-15.27; p < 0.01) were independently associated with worse RFS. Sex, body mass index, and visceral fat area were not correlated with RFS. In the median follow-up period of 60.8 months, patients with MFA < 19.7 cm2 had a significantly lower 5-year RFS rate (72.7%) than those with MFA ≥ 19.7 cm2 (85.0%).

CONCLUSIONS

Smaller MFA was associated with worse RFS in patients undergoing robotic TME for lower rectal cancer. MFA is considered to be a prognostic factor in rectal cancer.

Adiposity and cancer survival: a systematic review and meta-analysis

PURPOSE

The increasing availability of clinical imaging tests (especially CT and MRI) that directly quantify adipose tissue has led to a rapid increase in studies examining the relationship of visceral, subcutaneous, and overall adiposity to cancer survival. To summarize this emerging body of literature, we conducted a systematic review and meta-analysis of imaging-measured as well as anthropometric proxies for adipose tissue distribution and cancer survival across a wide range of cancer types.

METHODS

Using keywords related to adiposity, cancer, and survival, we conducted a systematic search of the literature in PubMed and MEDLINE, Embase, and Web of Science Core Collection databases from database inception to 30 June 2021. We used a random-effect method to calculate pooled hazard ratios (HR) and corresponding 95% confidence intervals (CI) within each cancer type and tested for heterogeneity using Cochran's Q test and the I2 test.

RESULTS

We included 203 records for this review, of which 128 records were utilized for quantitative analysis among 10 cancer types: breast, colorectal, gastroesophageal, head and neck, hepatocellular carcinoma, lung, ovarian, pancreatic, prostate, and renal cancer. We found that imaging-measured visceral, subcutaneous, and total adiposity were not significantly associated with increased risk of overall mortality, death from primary cancer, or cancer progression among patients diagnosed with these 10 cancer types; however, we found significant or high heterogeneity for many cancer types. For example, heterogeneity was similarly high when the pooled HRs (95% CI) for overall mortality associated with visceral adiposity were essentially null as in 1.03 (0.55, 1.92; I2 = 58%) for breast, 0.99 (0.81, 1.21; I2 = 71%) for colorectal, versus when they demonstrated a potential increased risk 1.17 (0.85, 1.60; I2 = 78%) for hepatocellular carcinoma and 1.62 (0.90, 2.95; I2 = 84%) for renal cancer.

CONCLUSION

Greater adiposity at diagnosis (directly measured by imaging) is not associated with worse survival among cancer survivors. However, heterogeneity and other potential limitations were noted across studies, suggesting differences in study design and adiposity measurement approaches, making interpretation of meta-analyses challenging. Future work to standardize imaging measurements and data analyses will strengthen research on the role of adiposity in cancer survival.

The obesity paradox in patients with colorectal cancer: a systematic review and meta-analysis

CONTEXT

Obesity is widely regarded as an established risk factor for colorectal cancer (CRC). However, recent studies have shown that lower mortality and better cancer-specific survival were observed in CRC patients with elevated body mass index (BMI), an example of the obesity paradox, which is the inverse correlation between obesity and mortality in some populations.

OBJECTIVE

The aim of this systematic review and meta-analysis was to investigate the association between BMI and CRC outcomes.

DATA SOURCES

PubMed, Web of Science, MEDLINE, the Cochrane Library, and Embase databases were searched for relevant articles published from inception to December 31, 2020.

STUDY SELECTION

Studies comparing the prognosis of CRC patients with obesity or overweight with that of normal-weight CRC patients were eligible.

DATA EXTRACTION

Data were extracted by 2 reviewers independently; differences were resolved by a third reviewer. BMI was classified according to WHO categories.

DATA ANALYSIS

To assess the prognostic effects of different BMI categories in CRC patients, hazard ratios and 95%CIs of overall survival, disease-free survival, and cancer-specific survival were extracted from included articles.

RESULTS

Sixteen studies (55 391 patients in total) were included. Higher BMI was significantly associated with more favorable CRC outcomes. Compared with normal-weight patients, underweight patients had worse overall survival (HR = 1.26; 95%CI, 1.15-1.37) and disease-free survival (HR = 1.19; 95%CI, 1.11-1.27, while patients with overweight had better overall survival (HR = 0.92; 95%CI, 0.86-0.99), disease-free survival (HR = 0.96; 95%CI, 0.93-1.00), and cancer-specific survival (HR = 0.86; 95%CI, 0.76-0.98). Patients with morbid obesity had worse overall survival (HR = 1.12; 95%CI, 1.02-1.22) and disease-free survival (HR = 1.15; 95%CI, 1.07-1.24) than normal-weight patients. There was no significant difference in cancer-specific survival between patients with obesity (HR = 0.94; 95%CI, 0.76-1.16) and patients with normal weight, nor between patients with underweight and patients with normal weight (HR = 1.14; 95%CI, 0.82-1.58).

CONCLUSIONS

CRC patients with a higher BMI appear to have reduced mortality compared with normal-weight CRC patients, even though higher BMI/obesity is an established determinant for the development of CRC.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020202320.

Skeletal muscle is prognostic in resected stage III malignant melanoma

BACKGROUND

Sarcopenia (low skeletal muscle index, SMI) and myosteatosis (low skeletal muscle radiodensity, SMD) have been associated with worse survival in cancer. This study evaluated associations of body composition with survival in patients with resected stage III melanoma.

METHODS

A retrospective review was performed of resected stage III melanoma patients in Alberta, Canada from 2007 to 2017. Preoperative CT scans were analyzed to determine SMI and SMD. Cohort-specific SMI and SMD cut-offs that optimally predicted overall survival (OS) were identified through stratification, in addition to testing cut-offs previously established in the literature. Overall (OS), melanoma-specific (MSS), and recurrence-free survival (RFS) were determined from date of surgery and analysed using multivariable Cox regressions with age, sex, BMI, stage subgroup, ECOG PS, and tumor location as covariates.

RESULTS

We included 330 patients in the final analysis. Mean age was 56 years and 62.4% of patients were male. At time of censoring 150 patients (45.6%) had died. Sarcopenia based on literature cut-offs was associated with decreased OS (HR 1.55, 95% CI 1.00-2.21, p = 0.016). Using cohort-specific cut-offs, sarcopenic patients also had significantly decreased OS (HR 1.87, 95% CI 1.27-2.76, p = 0.002). Myosteatosis defined using cohort-specific cut-offs predicted worse OS (HR 2.15, 95% CI 1.42-3.25, p < 0.001), MSS (HR 2.29, 95% CI 1.40-3.75, p = 0.001) and RFS (HR 1.52, 95% CI 1.02-2.27, p = 0.041). Increased BMI ( ≥ 25) and visceral fat index were not significantly associated with survival.

CONCLUSIONS

Sarcopenia and myosteatosis, defined using two sets of cut-offs, are associated with decreased OS and MSS in resected stage III melanoma.

Role of Perirectal Fat in the Carcinogenesis and Development of Early-Onset Rectal Cancer

Purpose

The incidence of early-onset rectal cancer (EORC) has been increasing since the past decade, while its underlying cause remained unknown. This study was aimed at clarifying the relationship between perirectal fat area (PFA) and EORC. Patients and Methods. All patients with rectal cancer who received radical excision between January 2016 and December 2017 at our hospital were included. The fat series images of pelvic magnetic resonance imaging scans were obtained and PFA at the ischial spine level was calculated using the ImageJ software.

Results

A total of 303 patients were finally included and divided into two groups according to the median PFA: Group 1 (<20.2 cm², n = 151) and Group 2 (≥20.2 cm², n = 152). PFA positively correlated with body weight and body mass index. PFA increased with invasion depth, lymph node metastasis, TNM stage, tumor deposits, and vascular invasion. Patients with EORC had higher PFA than those with late-onset rectal cancer (LORC; P = 0.009). Among patients with stage I–III rectal cancers, those in Group 2 had significantly shorter disease-free survival (P = 0.010) and overall survival (P = 0.034) than those in Group 1, and PFA was an independent predictor of disease-free survival (OR: 1.683 [1.126-3.015], P = 0.035) and overall survival (OR: 1.678 [1.022-2.639], P = 0.046).

Conclusions

Patients with EORC had significantly higher PFA than those with LORC. PFA is positively correlated with T stage, N stage, TNM stage, tumor deposit, and vascular invasion and is an independent predictor of disease-free survival and overall survival. Therefore, perirectal fat may be involved in the carcinogenesis and development of EORC.

CT-based assessment of body composition and skeletal muscle in melanoma: A systematic review

BACKGROUND/OBJECTIVES

Sarcopenia (low skeletal muscle index) and myosteatosis (low skeletal radiodensity) have been associated with poor outcomes in melanoma. This systematic review was performed to summarize and critically evaluate current literature surrounding body composition in melanoma.

METHODS

MEDLINE and Embase databases were searched for studies of melanoma patients with computed tomography (CT) based body composition analysis from 2000 to 2020. Outcomes of interest were survival, including overall survival (OS), progression-free survival (PFS), and disease-free survival (DFS), as well as treatment-related adverse events (AEs).

RESULTS

Nine studies of 914 patients were included in the final review. The majority of studies were of metastatic melanoma patients treated with immunotherapy. Studies demonstrated a variety of CT analysis techniques and cut-offs to define sarcopenia and myosteatosis. Associations of sarcopenia or myosteatosis with survival (OS, PFS, DFS) or risk of treatment-related AEs were conflicting. Multiple studies had low quality of evidence due to small sample sizes, use of non-validated CT measures, and lack of multivariable analyses.

CONCLUSIONS

Due to methodologic heterogeneity and low quality of evidence, impacts of CT-derived body composition parameters on outcomes in melanoma are unclear. Further research should be conducted to elucidate impacts of body composition in melanoma.

Body Composition, Inflammation, and 5-Year Outcomes in Colon Cancer

IMPORTANCE

Obesity, particularly visceral obesity and sarcopenia, are poor prognostic indicators in colon cancer.

OBJECTIVES

To explore the association between body composition profiles and 5-year colon cancer outcomes and delineate the associated underlying inflammatory processes.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter translational cohort study included patients with nonmetastatic colon cancer who did not have underlying chronic inflammatory disorders and were not receiving anti-inflammatory drugs referred to tertiary cancer centers from 2009 to 2015. Preoperative acute phase proteins (white cell count, C-reactive protein, and albumin), cytokines (interleukin [IL]-1b, IL-2, IL-6, IL-10, interferon γ, and tumor necrosis factor α), vascular endothelial growth factor (VEGF), and cell surface receptor expression levels (CD11b and CD14) were measured. All patients underwent follow-up for at least 5 years. Data were analyzed in December 2020.

EXPOSURE

Nonmetastatic colon cancer.

MAIN OUTCOMES AND MEASURES

The associations of body composition profiles with 5-year cancer recurrence and disease-specific mortality were analyzed using Mantel Cox log-rank test and Kaplan-Meier curves.

RESULTS

A total of 28 patients were included (median [interquartile range] age, 67 [58-72] years; 22 [78.6%] men). Low skeletal muscle area (SMA) and high visceral to total fat ratio were associated with poor clinical and oncological outcomes, including increased 5-year recurrence (low SMA: hazard ratio [HR], 2.30 [95% CI, 1.41-2.89]; P = .04; high visceral to total fat ratio: HR, 5.78 [95% CI, 3.66-7.95]; P = .02). High visceral to total fat ratio was associated with increased 5-year disease-specific mortality (HR, 5.92 [95% CI, 4.04-8.00]; P = .02). Patients with low SMA who developed a cancer recurrence, compared with those who did not, had higher C-reactive protein (mean [SD], 31.24 [6.95] mg/dL vs 8.11 [0.58] mg/dL; P = .003), IL-6 (mean [SD], 1.93 [1.16] ng/mL vs 0.88 [0.14] ng/mL; P = .004), VEGF (mean [SD], 310.03 [122.66] ng/mL vs 176.12 [22.94] ng/mL; P = .007), and CD14 (mean [SD], 521.23 [302.02] ng/mL vs 322.07 [98.35] ng/mL; P = .03) expression and lower albumin (mean [SD], 3.8 [0.6] g/dL vs 43.50 [3.69] g/dL; P = .01), IL-2 (mean [SD], 0.45 [0.25] ng/mL vs 0.94 [0.43] ng/mL; P < .001), IL-10 (mean [SD], 8.15 [1.09] ng/mL vs 16.32 [4.43] ng/mL; P = .004), and interferon γ (mean [SD], 2.61 [1.36] ng/mL vs 14.87 [3.43] ng/mL; P = .02) levels. Patients with high visceral to total fat ratio who developed recurrence had higher levels of IL-6 (mean [SD], 5.26 [7.05] ng/mL vs 2.76 [3.11] ng/mL; P = .03) and tumor necrosis factor α (mean [SD], 5.74 [4.53] ng/mL vs 4.50 [1.99] ng/mL; P = .03).

CONCLUSIONS AND RELEVANCE

These findings suggest that low SMA and high visceral to total fat ratio were associated with worse colon cancer outcomes and with increased expression of proinflammatory cytokines and VEGF and inhibition of anti-inflammatory cytokines.

Ectopic fat in liver and skeletal muscle is associated with shorter overall survival in patients with colorectal liver metastases

BACKGROUND

Myosteatosis has been associated with shorter overall survival in cancer patients. The increase in ectopic fat might not be limited to skeletal muscle only and might also extend to other sites such as the liver, resulting in non-alcoholic fatty liver disease (NAFLD). In this study, we assessed the relationship between myosteatosis and NAFLD and their association with overall survival in patients with colorectal liver metastases undergoing partial hepatectomy.

METHODS

Patients were selected from a prospective cohort of 289 consecutive patients with colorectal liver metastases. All patients with a preoperative computed tomography (CT)-scan and liver biopsy obtained during surgery were included. If available a second pre-operative CT scan was used to calculate changes in body composition over time. Muscle radiation attenuation was defined as the average Hounsfield units on CT of all muscle tissue at the L3 level. Liver biopsies were graded by a liver pathologist using the steatosis, activity, and fibrosis scoring system for NAFLD.

RESULTS

Two-hundred and eighteen patients had an available liver biopsy of which 131 patients had two available pre-operative CT scans with an average time interval of 3.2 months. One-hundred and thirty-five (62%) biopsies were classified as NAFLD. In multivariable Cox-regression analysis, NAFLD [hazard ratio (HR): 1.8, 95%-confidence interval (CI) 1.0-3.0, P = 0.037], increase in myosteatosis (HR 1.8, 95%-CI 1.1-2.9, P = 0.018), and skeletal muscle loss (HR 1.7, 95%-CI 1.0-2.9, P = 0.035) were independently associated with shorter overall survival while high visceral adipose tissue fat content was associated with longer overall survival (HR: 0.7, 95%-CI 0.5-0.9, P = 0.014).

CONCLUSIONS

Ectopic fat content of liver as well as skeletal muscle tissue is independently associated with shorter overall survival in patients with colorectal liver metastases, while increased visceral adipose tissue fat content is associated with longer overall survival.

Quantification of adipose tissues by Dual-Energy X-Ray Absorptiometry and Computed Tomography in colorectal cancer patients

BACKGROUND & AIMS

Excess adipose tissue may affect colorectal cancer (CRC) patients' disease progression and treatment. In contrast to the commonly used anthropometric measurements, Dual-Energy X-Ray Absorptiometry (DXA) and Computed Tomography (CT) can differentiate adipose tissues. However, these modalities are rarely used in the clinic despite providing high-quality estimates. This study aimed to compare DXA's measurement of abdominal visceral adipose tissue (VAT) and fat mass (FM) against a corresponding volume by CT in a CRC population. Secondly, we aimed to identify the best single lumbar CT slice for abdominal VAT. Lastly, we investigated the associations between anthropometric measurements and VAT estimated by DXA and CT.

METHODS

Non-metastatic CRC patients between 50-80 years from the ongoing randomized controlled trial CRC-NORDIET were included in this cross-sectional study. Corresponding abdominal volumes were acquired by Lunar iDXA and from clinically acquired CT examinations. Also, single CT slices at L2-, L3-and L4-level were obtained. Agreement between the methods was investigated using univariate linear regression and Bland-Altman plots.

RESULTS

Sixty-six CRC patients were included. Abdominal volumetric VAT and FM measured by DXA explained up to 91% and 96% of the variance in VAT and FM by CT, respectively. Bland-Altman plots demonstrated an overestimation of VAT by DXA compared to CT (mean difference of 76 cm³) concurrent with an underestimation of FM (mean difference of -319 cm³). A higher overestimation of VAT (p = 0.015) and underestimation of FM (p = 0.036) were observed in obese relative to normal weight subjects. VAT in a single slice at L3-level showed the highest explained variance against CT volume (R² = 0.97), but a combination of three slices (L2, L3, L4) explained a significantly higher variance than L3 alone (R² = 0.98, p < 0.006). The anthropometric measurements explained between 31-65% of the variance of volumetric VAT measured by DXA and CT.

CONCLUSIONS

DXA and the combined use of three CT slices (L2-L4) are valid to predict abdominal volumetric VAT and FM in CRC patients when using volumetric CT as a reference method. Due to the poor performance of anthropometric measurements we recommend exploring the added value of advanced body composition by DXA and CT integrated into CRC care.

The effect of smoking, obesity and diabetes on recurrence-free and overall survival in patients with stage III colon cancer receiving adjuvant chemotherapy

Background

The association between smoking, diabetes and obesity and oncological outcomes in patients with stage III colon cancer treated with surgery and adjuvant chemotherapy is unclear.

Aim

To evaluate whether smoking, obesity and diabetes are associated with the disease‐free survival and overall survival rates of patients with stage III colon cancer who have received adjuvant chemotherapy.

Methods

Patients were selected from the prospectively maintained Australian Cancer Outcomes and Research Database (ACCORD). All stage III colon cancer patients who received adjuvant chemotherapy between January 2003 to December 2015 were retrospectively analyzed. The three primary exposures of interest were smoking status, body mass index (BMI) and diabetic (DM) status. The primary outcomes of interest were disease‐free survival (DFS) and overall survival (OS).

Results

A total of 785 patients between 2003 and 2015 were included for analysis. Using Kaplan‐Meier survivorship curves, there was no association between OS and smoking (P = .71), BMI (P = .3) or DM (P = .72). Similarly, DFS did not reveal an association with smoking (P = .34), BMI (P = .2) and DM (P = .34). Controlling for other covariates the results did not reach statistical significance in adjusted multiple regression models.

Conclusion

Smoking, obesity and DM were not shown to influence DFS or OS for patients with stage III colon cancer who have received adjuvant chemotherapy.

High-fat diet-fed ovariectomized mice are susceptible to accelerated subcutaneous tumor growth potentially through adipose tissue inflammation, local insulin-like growth factor release, and tumor associated macrophages

Background: The association between obesity and colorectal cancer (CRC) risk has been well established. This relationship appears to be more significant in men than in women, which may be attributable to sex hormones. However, controlled animal studies to substantiate these claims and the mechanisms involved are lacking.

Materials and Methods: MC38 murine colon adenocarcinoma cells were injected subcutaneously into high-fat diet (HFD) fed male, female and ovariectomized (OVX) female C57BL/6 mice.

Results: HFD increased tumor growth (main effect) that was consistent with metabolic perturbations (P < 0.01). HFD OVX mice exhibited the most significant tumor growth compared to HFD male and female mice (p < 0.05) and this was associated with increased subcutaneous adipose tissue (p < 0.05). Further, the subcutaneous adipose tissue depots within HFD OVX mice exhibited more severe macrophage associated inflammation compared to female (P < 0.01), but not male mice. Conditioned media from subcutaneous adipose tissue of HFD OVX contained higher IGF-1 levels compared to male (P < 0.01), but not female mice. Finally, HFD OVX mice had increased M2-like gene expression in their tumor-associated macrophages (TAMs) compared to female mice (P < 0.01).

Conclusions: This work provides evidences suggesting adiposity, adipose specific IGF-1, macrophage associated adipose inflammation, and TAMs as potential mechanisms driving obesity-enhanced CRC in females lacking ovarian hormones.

A paradox between preoperative overweight/obesity and change in weight during postoperative chemotherapy and its relationship to survival in stage Ⅱ and Ⅲ colorectal cancer patients

BACKGROUND & AIMS

The roles of obesity and weight management in colorectal cancer (CRC) recurrence and survival have gained a considerable amount of attention. However, whether a change in weight affects the risk of recurrence and death remains unclear.

METHODS

A retrospective study was conducted using Kaplan-Meier curves, multivariable Cox proportional hazards models, and restricted cubic splines in 902 patients with stage Ⅱ and Ⅲ CRC to investigate the impact of the preoperative BMI and change in weight during postoperative chemotherapy on disease-free survival (DFS) and overall survival (OS).

RESULTS

The lowest risk of cancer events (recurrence/metastasis and new CRC cases) and death occurred in patients who had a normal weight (BMI range from 18.5 to 23.9 kg/m²) or had weight gain of < 5%; the patients who were underweight (BMI ≤ 18.5 kg/m²) or overweight/obese (BMI ≥ 24.0 kg/m²) and had weight loss or weight gain of ≥ 5% had a higher risk of cancer events and death. The association between preoperative BMI and the risk of cancer events and death exhibited U-shaped curves; the inflection points were at BMI = 24 kg/m² and BMI = 25 kg/m² for the risk of cancer events and death, respectively. The association between the change in weight and risk of death also exhibited a U-shaped curve, while the association between the change in weight and risk of cancer events was nearly linear. Multivariable Cox proportional hazards models showed that the preoperative BMI and change in weight played bidirectional roles in both the OS and DFS.

CONCLUSIONS

An obesity paradox exists in patients with CRC, with both weight loss and excessive weight gain being detrimental. Patients with CRC may require a reasonable weight management program, and gaining < 5% of the preoperative weight might be an appropriate goal at 6 months after surgery.

The Association of Abdominal Adiposity With Mortality in Patients With Stage I-III Colorectal Cancer

BACKGROUND

The quantity and distribution of adipose tissue may be prognostic measures of mortality in colorectal cancer patients, and such associations may vary by patient sex.

METHODS

This cohort included 3262 stage I-III colorectal cancer patients. Visceral and subcutaneous adipose tissues were quantified using computed tomography. The primary endpoint was all-cause mortality. Restricted cubic splines estimated statistical associations with two-sided P values.

RESULTS

Visceral adipose tissue was prognostic of mortality in a reverse L-shaped pattern (nonlinear P = .02); risk was flat to a threshold (∼260 cm2) then increased linearly. Subcutaneous adipose tissue was prognostic of mortality in a J-shaped pattern (nonlinear P < .001); risk was higher at extreme (<50 cm2) but lower at intermediate values (>50 to ≤560 cm2). Patient sex modified the prognostic associations between visceral adipose tissue (Pinteraction = .049) and subcutaneous adipose tissue (Pinteraction = .04) with mortality. Among men, visceral adiposity was associated with mortality in a J-shaped pattern (nonlinear P = .003), whereas among women, visceral adiposity was associated with mortality in a linear pattern (linear P = .008). Among men, subcutaneous adiposity was associated with mortality in an L-shaped pattern (nonlinear P = .01), whereas among women, subcutaneous adiposity was associated with mortality in a J-shaped pattern (nonlinear P < .001).

CONCLUSIONS

Visceral and subcutaneous adipose tissue were prognostic of mortality in patients with colorectal cancer; the shape of these associations were often nonlinear and varied by patient sex. These results offer insight into the potential biological mechanisms that link obesity with clinical outcomes in patients with cancer, suggesting that the dysregulated deposition of excess adiposity is prognostic of mortality.

Association of adipose tissue and skeletal muscle metrics with overall survival and postoperative complications in soft tissue sarcoma patients: an opportunistic study using computed tomography

Background

To determine the relationship between adipose tissue and skeletal muscle measurements on computed tomography (CT) and overall survival and major postoperative complications in patients with soft-tissue sarcoma (STS).

Methods

The retrospective study included 137 STS patients (75 men, 62 women; mean age, 53 years, SD 17.7; mean BMI, 28.5, SD 6.6) who had abdominal CT exams. On a single CT image, at the L4 pedicle level, measurements of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and skeletal muscle area and attenuation were obtained using clinical PACS and specialized segmentation software. Clinical information was recorded, including STS characteristics (size, depth, grade, stage, and site), overall survival, and postoperative complications. The relationships between CT metrics and survival were analyzed using Cox proportional hazard models and those between CT metrics and postoperative complications using logistic regression models.

Results

There were 33 deaths and 41 major postoperative complications. Measured on clinical PACS, the psoas area (P=0.003), psoas index (P=0.006), psoas attenuation (P=0.011), and total muscle attenuation (P=0.023) were associated with overall survival. Using specialized software, psoas attenuation was also associated with overall survival (P=0.018). Adipose tissue metrics were not associated with survival or postoperative complications.

Conclusions

In STS patients, CT-derived muscle size and attenuation are associated with overall survival. These prognostic biomarkers can be obtained using specialized segmentation software or routine clinical PACS.

Metabolomics profiling of visceral and abdominal subcutaneous adipose tissue in colorectal cancer patients: results from the ColoCare study

PURPOSE

Underlying mechanisms of the relationship between body fatness and colorectal cancer remain unclear. This study investigated associations of circulating metabolites with visceral (VFA), abdominal subcutaneous (SFA), and total fat area (TFA) in colorectal cancer patients.

METHODS

Pre-surgery plasma samples from 212 patients (stage I-IV) from the ColoCare Study were used to perform targeted metabolomics. VFA, SFA, and TFA were quantified by computed tomography scans. Partial correlation and linear regression analyses of VFA, SFA, and TFA with metabolites were computed and corrected for multiple testing. Cox proportional hazards were used to assess 2-year survival.

RESULTS

In patients with metastatic tumors, SFA and TFA were statistically significantly inversely associated with 16 glycerophospholipids (SFA: pFDR range 0.017-0.049; TFA: pFDR range 0.029-0.048), while VFA was not. Doubling of ten of the aforementioned glycerophospholipids was associated with increased risk of death in patients with metastatic tumors, but not in patients with non-metastatic tumors (phet range: 0.00044-0.049). Doubling of PC ae C34:0 was associated with ninefold increased risk of death in metastatic tumors (Hazard Ratio [HR], 9.05; 95% confidence interval [CI] 2.17-37.80); an inverse association was observed in non-metastatic tumors (HR 0.17; 95% CI 0.04-0.87; phet = 0.00044).

CONCLUSION

These data provide initial evidence that glycerophospholipids in metastatic colorectal cancer are uniquely associated with subcutaneous adiposity, and may impact overall survival.

Lipid-Based Drug Delivery Nanoplatforms for Colorectal Cancer Therapy

Colorectal cancer (CRC) is a prevalent disease worldwide, and patients at late stages of CRC often suffer from a high mortality rate after surgery. Adjuvant chemotherapeutics (ACs) have been extensively developed to improve the survival rate of such patients, but conventionally formulated ACs inevitably distribute toxic chemotherapeutic drugs to healthy organs and thus often trigger severe side effects. CRC cells may also develop drug resistance following repeat dosing of conventional ACs, limiting their effectiveness. Given these limitations, researchers have sought to use targeted drug delivery systems (DDSs), specifically the nanotechnology-based DDSs, to deliver the ACs. As lipid-based nanoplatforms have shown the potential to improve the efficacy and safety of various cytotoxic drugs (such as paclitaxel and vincristine) in the clinical treatment of gastric cancer and leukemia, the preclinical progress of lipid-based nanoplatforms has attracted increasing interest. The lipid-based nanoplatforms might be the most promising DDSs to succeed in entering a clinical trial for CRC treatment. This review will briefly examine the history of preclinical research on lipid-based nanoplatforms, summarize the current progress, and discuss the challenges and prospects of using such approaches in the treatment of CRC.

Associations of Abdominal Skeletal Muscle Mass, Fat Mass, and Mortality among Men and Women with Stage I-III Colorectal Cancer

BACKGROUND

The associations of abdominal skeletal muscle mass index (SMI), visceral and subcutaneous adipose tissue (VAT and SAT, respectively), and mortality among patients with stage I-III colorectal cancer may differ for men and women, but only few studies stratified their data into men and women. We investigated associations of abdominal SMI, VAT, and SAT with overall mortality among men and among women with stage I-III colorectal cancer.

METHODS

SMI, VAT, and SAT were assessed from abdominal CT images for 1,998 patients with stage I-III colorectal cancer diagnosed between 2006 and 2015. Restricted cubic splines (RCS) were used to investigate associations of SMI, VAT, and SAT with overall mortality.

RESULTS

Average age of the participants was 67.9 ± 10.6 years and 58% were men. During a median follow-up of 4.3 years, 546 (27%) patients died. Among men, the association of SMI and mortality was statistically significant in a nonlinear way in the RCS analyses, with lower SMI levels associated with higher mortality. SMI was not associated with mortality among women. SAT was associated with mortality in a nonlinear way for men and for women, with lower SAT levels being associated with higher mortality. VAT was not significantly associated with mortality in men or women.

CONCLUSION

Associations of abdominal skeletal muscle mass with mortality among patients with colorectal cancer were not the same for men and for women.

IMPACT

This study stresses the importance for more attention on sex-related differences in body composition and cancer outcomes.

Left ventricular myocardial deformation: a study on diastolic function in the Chinese male population and its relationship with fat distribution

Background

Obesity has become an epidemic in China with its increased prevalence, especially in the male population. Disparities in fat distribution rather than increasing body mass index (BMI) confer the risk of different diseases, including cardiac abnormalities. Therefore, early detection of cardiac abnormalities is important for treatment to reverse the progression to heart failure. Nowadays, strain analysis based on cardiac magnetic resonance (CMR) imaging has been established to assess myocardial function in diverse cardiac diseases. We aimed to assess the relationship between fat distribution and subclinical diastolic dysfunction in obese Chinese men assessed by deformation registration algorithm (DRA)-based myocardial strain rate (SR) analysis.

Methods

A total of 115 male participants with different BMI underwent CMR scanning using a 1.5T MAGNETOM Aera (Siemens Healthcare, Erlangen, Germany) and computed tomography (CT) scan. All the participants were enrolled from September 2017 to April 2018. They were classified into 3 groups according to their BMIs with 23 and 27.5 kg/m² being the cutoff values. A Trufi-Strain prototype software (version 2.0, Siemens Healthcare, Erlangen, Germany) was used to quantify SR in both early and late diastole from CMR cine images. Ratios of early and late SRs were calculated. Areas of epicardial and pericardial adipose tissue (EAT and PAT) were measured on a single 4-chamber-view slice of cine images. Volumes of visceral and subcutaneous adipose tissue (VAT and SAT) were acquired semi-automatically from CT images using the dedicated software Cardiac Risk2.0 (Siemens Healthcare). Waist and hip circumferences were manually measured (WC and HC). Analysis of variance or nonparametric tests, along with correlation and stepwise multivariate regression analysis models, was applied for statistical analysis.

Results

Peak late diastolic SRs were higher in obese men compared with their lean counterparts [-36.25±10.46 vs. -29.46±8.17, 66.97±18.58 vs. 45.62 (42.44, 55.96), and 56.81±15.07 vs. 41.40±6.41 for radial, circumferential, and longitudinal SRs, respectively; P<0.05]. All SR ratios in the obese subgroups were lower than those of lean men (3.12±1.14 vs. 4.63±1.24, 2.12±0.58 vs. 2.96±0.62 and 1.63±0.50 vs. 2.20±0.63 for radial, circumferential, and longitudinal directions, respectively; P<0.05). EAT was a significant predictor of diastolic function assessed by radial and circumferential SR ratios (β=-0.439 and -0.337 respectively; all P<0.001), while VAT was a significant predictor of circumferential and longitudinal SR ratios (β=-0.216 and -0.355, respectively, P<0.05).

Conclusions

Decreased LV diastolic function assessed by DRA-based SR analysis in obesity is associated with fat distribution. Furthermore, EAT and VAT might be better predictors of a decrease of diastolic function in obese Chinese men than BMI.

Is visceral obesity associated with colorectal cancer? The first volumetric study using all CT slices

PURPOSE

We aimed to examine the possible relationship between abdominal adiposity parameters and the presence of colorectal cancer (CRC) and between these adiposity parameters and various histopathologic findings of the tumor.

METHODS

A total of 60 control subjects and 111 CRC patients, 63 with early-stage and 48 with advanced-stage disease, were enrolled. Medical data and abdominopelvic computed tomography (CT) examinations of each study group were retrospectively reviewed. Abdominal adiposity parameters, including visceral adipose tissue (VAT) volume, subcutaneous adipose tissue (SAT) volume, and total adipose tissue (TAT) volume, were calculated on all slices of the CT examinations with specialized software, and results for each study group were compared. Adiposity parameters were also compared with tumor histopathologic findings.

RESULTS

We found lower VAT and higher SAT volumes in advanced-stage CRC patients, compared with the early-stage group. However, this relationship was not statistically significant (P = 0.721 for VAT and P = 0.432 for SAT volumes). We detected significantly lower VAT and SAT volumes in the early-stage CRC group compared with the control group (P = 0.014 for both). There was no significant relationship between TAT volumes and the study groups (P = 0.06). No statistically significant relationship was detected between adipose tissue parameters and histopathologic features of the CRC group (P > 0.05).

CONCLUSION

We found statistically significant lower VAT and SAT volumes in patients with early-stage CRC compared with the control group. Volumetric adipose tissue measurements may be more accurate than area measurements and can easily be performed on abdominopelvic CT examination, which is the routine imaging modality for CRC patients.

The Importance of Body Composition in Explaining the Overweight Paradox in Cancer-Counterpoint

Despite a greater risk of cancer associated with higher BMI, overweight (BMI 25-<30 kg/m²) and class I obese (BMI 30-<35 kg/m²) patients often have a paradoxically lower risk of overall mortality after a cancer diagnosis, a phenomenon called the "obesity paradox." Only when patients exceed a BMI ≥35 kg/m² are elevations in mortality risk consistently noted. This paradox has been dismissed as the result of methodologic bias, which we will describe and debate here. However, even if such bias influences associations, there is growing evidence that body composition may in part explain the paradox. This phenomenon may more accurately be described as a BMI paradox. That is, BMI is a poor proxy for adiposity and does not distinguish muscle from adipose tissue, nor describe adipose tissue distribution. Low muscle mass is associated with higher risk of recurrence, overall and cancer-specific mortality, surgical complications, and treatment-related toxicities. Patients with who are overweight or obese have on average higher levels of muscle than their normal-weight counterparts. Also, there is some evidence that patients with moderate levels of subcutaneous adipose tissue may have lower mortality. More research utilizing body composition is needed to clarify the effects of adiposity on cancer mortality. Cancer Res; 78(8); 1906-12. ©2018 AACR.

The Plausibility of Obesity Paradox in Cancer-Point

In contrast to the convincing evidence that obesity (measured by body mass index, BMI) increases the risk of many different types of cancer, there is an ambiguity in the role of obesity in survival among cancer patients. Some studies suggested that higher BMI decreased mortality risk in cancer patients, a phenomenon called the obesity paradox. The spurious positive association between BMI and cancer survival is likely to be explained by several methodologic limitations including confounding, reverse causation, and collider stratification bias. Also, the inadequacy of BMI as a measure of body fatness in cancer patients commonly experiencing changes in body weight and body composition may have resulted in the paradox. Other factors contributing to the divergent results in literature are significant heterogeneity in study design and method (e.g., study population, follow-up length); time of BMI assessment (pre-, peri-, or post-diagnosis); and lack of consideration for variability in the strength and directions of associations by age, sex, race/ethnicity, and cancer subtype. Robust but practical methods to accurately assess body fatness and body compositions and weight trajectories in cancer survivors are needed to advance this emerging field and to develop weight guidelines to improve both the length and the quality of cancer survival. Cancer Res; 78(8); 1898-903. ©2018 AACR.

Impact of genetic mutations and nutritional status on the survival of patients with colorectal cancer

Background

The prognosis of colorectal cancer (CRC) patients can be influenced by genetic mutations and nutritional status. The relationship between these variables is unclear. The objective of the study was to verify the variables involved in the nutritional status and genetic mutations, which correlate with survival of CRC patients.

Methods

Patients with surgical intervention for tumor resection were evaluated using body mass index, nutritional screening, patient self-produced global subjective assessment, phase angle, and computed tomography to calculate the areas of visceral adipose tissue (VAT) and subcutaneous adipose tissue, and muscle mass for the determination of sarcopenia. Ten gene mutations involved in CRC carcinogenesis were studied (PIK3CA, KRAS, BRAF, EGFR, NRAS, TP53, APC, PTEN, SMAD4, and FBXW7). DNA was extracted from fresh tumor or paraffin tissues.

Results

Of the 46 patients, 29 (64.4%) were at nutritional risk and 21 (45.7%) were moderately malnourished. However, there was a high percentage of VAT in 24 (61.5%) and sarcopenia in 19 (48.7%) patients. These variables were associated with a higher risk of mortality. Nutritional risk, moderate or severe malnutrition, phase angle < 5°, VAT < 163.8 cm² in men and <  80.1 cm² in women, and sarcopenia were associated with the relative risk of death, with respective hazard ratios/odds ratios and 95% confidence intervals of 8.77 (1.14–67.1), 3.95 (1.11–14.0), 3.79 (1.10–13.1), 3.43 (1.03–11.4), and 3.95 (1.06–14.6). Increased VAT was associated with a lower risk of death, even in patients older than 60 years or those harboring mutated KRAS.

Conclusions

Patients with positive indicators for malnutrition or risk of malnutrition had an increased risk of death. No relationship was identified between the presence of mutations and survival.

The Impact of Muscle and Adipose Tissue on Long-term Survival in Patients With Stage I to III Colorectal Cancer

BACKGROUND

Computed tomography-derived body composition parameters are emerging prognostic factors in colorectal cancer.

OBJECTIVE

This study aimed to determine the roles of sarcopenia, myosteatosis, and obesity as independent and overlapping parameters in stage I to III colorectal cancer.

DESIGN

This is a retrospective cohort study from a prospectively collected database. Multivariate Cox proportional hazards models were performed to assess the associations between body composition parameters and survival.

SETTINGS

All patients were seen in a tertiary care cancer center.

PATIENTS

Adult patients with stage I to III colorectal cancer, undergoing curative resection from 2007 to 2009, were included.

INTERVENTION

Computed tomography-derived quantification of skeletal muscle and adipose tissues was used to determine population-specific cutoffs for sarcopenia, myosteatosis, and total adiposity.

MAIN OUTCOME MEASURES

Primary outcome measures were overall, recurrence-free, and cancer-specific survival.

RESULTS

In the 968 patients included, there were a total of 254 disease recurrences and 350 deaths. Body mass index and CT-derived measures of adiposity did not result in worse survival outcomes. Sarcopenia was independently predictive of worse overall (HR, 1.45; 95% CI, 1.16-1.84), recurrence-free (HR, 1.32; 95% CI, 1.00-1.75), and cancer-specific survival (HR, 1.46; 95% CI, 1.09-1.94) in a multivariate model. Myosteatosis was also independently predictive of overall survival (HR, 1.53; 95% CI, 1.19-1.97). In a model considering joint effects of sarcopenia and myosteatosis, the presence of both predicted the worst overall (HR, 2.23; 95% CI, 1.62-3.06), recurrence-free (HR, 1.53; 95% CI, 1.06-2.21), and cancer-specific survival (HR, 2.40; 95% CI, 1.69-3.42) in a multivariate model.

LIMITATIONS

The limitations of this study are inherent in retrospective observational studies.

CONCLUSIONS

Sarcopenia and myosteatosis are independent predictors of worse survival in stage I to III colorectal cancer, and their joint effect is highly predictive of reduced overall, recurrence-free, and cancer-specific survival. See Video Abstract at http://links.lww.com/DCR/A923.

Preoperative Visceral Adiposity and Muscularity Predict Poor Outcomes after Hepatectomy for Hepatocellular Carcinoma

OBJECTIVE

Visceral adiposity, defined as a high visceral-to-subcutaneous adipose tissue area ratio (VSR), has been shown to be associated with poor outcomes in several cancers. However, in the surgical field, the significance of visceral adiposity remains controversial. The present study investigated the impact of visceral adiposity as well as sarcopenic factors (low muscularity) on outcomes in patients undergoing hepatectomy for hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

This retrospective study analyzed data from 606 patients undergoing hepatectomy for HCC at our institution between April 2005 and March 2016. Using preoperative plain computed tomography imaging at the level of the third lumbar vertebra, visceral adiposity, skeletal muscle mass, and muscle quality were evaluated by the VSR, skeletal muscle mass index (SMI), and intramuscular adipose tissue content (IMAC), respectively. The impact of these parameters on outcomes after hepatectomy for HCC was analyzed.

RESULTS

The overall survival rate was significantly lower among patients with a high VSR (p < 0.001) than among patients with a normal VSR. Similarly, the recurrence-free survival rate was significantly lower among patients with a high VSR (p = 0.016). A high VSR, low SMI, and high IMAC contributed to an increased risk of death (p < 0.001) and HCC recurrence (p < 0.001) in an additive manner. Multivariate analysis showed that not only preoperative low muscularity but also visceral adiposity was a significant risk factor for mortality (hazard ratio [HR] = 1.566, p < 0.001) and HCC recurrence (HR = 1.329, p = 0.020) after hepatectomy for HCC.

CONCLUSIONS

Preoperative visceral adiposity, as well as low muscularity, was closely related to poor outcomes after hepatectomy for HCC. It is crucial to establish a new strategy including perioperative nutritional interventions with rehabilitation for better outcomes after hepatectomy for HCC.

Usefulness of metabolic activity of adipose tissue in FDG PET/CT of colorectal cancer

PURPOSE

To determine the relationship between metabolic activity of adipose tissue on FDG PET/CT and prognosis in colorectal cancer.

METHODS

A total of 176 colorectal cancer patients with curative surgical resection were retrospectively enrolled. Volume and metabolic activity of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) on FDG PET/CT images were measured. The maximum standardized uptake value (SUV) of primary tumor (SUVtumor) was also obtained. Univariate analysis with log-rank test and multivariate Cox regression analyses were used to evaluate prognostic values of volume and metabolic activity of SAT and VAT as well as SUVtumor and clinicopathologic factors.

RESULTS

Of 176 patients, 26 experienced recurrence during follow-up. SUVtumor showed significant correlation with serum C-reactive protein level (r = 0.242, p = 0.001), SUV of VAT (r = 0.167, p = 0.026), and size of primary tumor (r = 0.341, p < 0.001). In univariate analysis with log-rank test, SUV of VAT (p = 0.009) and SAT (p = 0.006), volume of VAT (p = 0.015), N stage (p < 0.001), M stage (p < 0.001), tumor involvement of resection margin (p = 0.001), and lymphatic invasion (p = 0.024) were significantly associated with recurrence-free survival (RFS). However, SUVtumor showed no significant association with RFS. In multivariate Cox regression analysis, SUV of VAT (p = 0.016), presence of lymph node metastasis (p < 0.001), and tumor involvement of resection margin (p = 0.011) were independent prognostic factors for RFS.

CONCLUSIONS

The SUV of VAT in patients with colorectal cancer is significantly associated with FDG uptake of primary tumor. It is an independent predictor for RFS.

Influence of Visceral Fat in the Outcomes of Colorectal Cancer

AIM

To determine the relationship of visceral fat (VF) with the surgical outcome of the patients with colorectal cancer (CRC) submitted to curative surgery.

METHODS

Retrospective analysis of all patients submitted to CRC surgery during 3 years with a minimum of 5 years of follow-up. We assessed the length of hospital stay, complications, pathologic reports, surgical re-interventions and hospital re-admissions, relapses, survival time and disease-free time. VF was calculated based on patients' pre-operative CT-scan. The patients were divided into quartiles according to the VF area. Linear regression models and logistic regression models were used to establish a relationship between VF and all data collected.

RESULTS

The study included 199 patients (129 with colon cancer [CC] and 70 with rectal cancer). The average area of VF was 115.7 cm2. Patients with CRC revealed a direct relationship between VF and postoperative complications (p = 0.043), anastomotic leakage (p = 0.009) and re-operation (p = 0.005). The subgroup of patients with CC had an inverse association between VF and lymph nodes harvested (p = 0.027). Survival analyses did not reveal significant differences.

CONCLUSION

VF has an influence on postoperative complications, anastomotic leakage and re-operation. A negative influence of VF on lymph nodes harvested was observed on CC patients.

Synergy of Sex Differences in Visceral Fat Measured with CT and Tumor Metabolism Helps Predict Overall Survival in Patients with Renal Cell Carcinoma

Purpose To determine if sex differences in abdominal visceral fat composition, measured by using computed tomography (CT), and tumor glucose metabolism, measured by gene expression, can help predict outcomes in patients with clear cell renal cell carcinoma (RCC). Materials and Methods This retrospective cohort study included 222 patients with clear cell RCC from The Cancer Imaging Atlas. By using CT, body fat was segmented into subcutaneous fat and visceral fat areas (VFAs) and normalized to total fat to obtain the relative VFA (rVFA) and relative subcutaneous fat area. Multivariate Cox proportional hazard regression models were performed to identify effects of rVFA on sex-specific survival. Expression profiles for 39 glycolytic genes in tumors from these patients were obtained from The Cancer Genome Atlas to determine sex differences in metabolism and compared with rVFA. Key mutations in clear cell RCC were analyzed for association with rVFA and tumor glycolytic profiles. Results Women with rVFA greater than 30.9% had an increased risk of death (hazard ratio, 3.66 [95% confidence interval: 1.64, 8.19]) for women vs 1.13 ([95% confidence interval: 0.58, 2.18] for men, P = .028). Glycolytic gene expression stratified both men and women, and the combination of low rVFA and low glycolysis identified 19 women with excellent overall survival (P < .001). SETD2 and BAP1 mutations were uniquely enriched in female tumors with high glycolysis (P = .036 and .001, respectively). No significant differences were identified in tumor mutations between patients with high and low rVFA. Conclusion Sex differences in visceral fat and tumor glucose metabolism may provide a new risk-stratification system for patients with clear cell RCC. ^© RSNA, 2018 Online supplemental material is available for this article.

Barriers to the Interpretation of Body Composition in Colorectal Cancer: A Review of the Methodological Inconsistency and Complexity of the CT-Defined Body Habitus

BACKGROUND

Measurement of body composition by computed tomography (CT) is an advancing field. Sarcopenia, myosteatosis, and visceral obesity (VO) have been identified as predictive of survival in colorectal cancer (CRC). We performed a systematic review of contemporary studies to characterize this association and highlight methodological inconsistencies.

METHODS

MEDLINE and PubMed were queried for articles published from January 2000 on, with populations of resectable CRC and with CT-measured body composition and survival data. The study quality was assessed by two independent reviewers using the Newcastle-Ottawa Scale.

RESULTS

Twenty studies met inclusion criteria, with a total of 8895 patients. Only two of the studies scored as high quality and nine as moderate quality. The remaining nine studies scored as low quality. Ten studies considered sarcopenia and 12 considered visceral obesity (VO). Cutoff points to define sarcopenia, myosteatosis, and VO were identified by optimal stratification, quartiles, or median values. The prevalence of sarcopenia varied from 15 to 60%, which based on study population and cutoff value used. Sarcopenia was associated with worse overall and disease-free survival in eight of the included studies. Myosteatosis was considered in three studies with a prevalence of 19-78%. It was significantly predictive of worse overall and disease-free survival in all three studies. VO had a prevalence of 14-70% and was inconsistently predictive of survival outcomes.

CONCLUSIONS

There is a lack of methodological consistency within the currently published literature. Despite this, sarcopenia and myosteatosis, but not VO, are consistently associated with worse survival outcomes, when population and cancer-specific cutoffs are utilized.

Cardiorespiratory Fitness and Body Composition Responses to Different Intensities and Frequencies of Exercise Training in Colorectal Cancer Survivors

INTRODUCTION

Deteriorations in cardiorespiratory fitness (V˙o_2peak) and body composition are associated with poor prognosis after colorectal cancer treatment. However, the optimal intensity and frequency of aerobic exercise training to improve these outcomes in colorectal cancer survivors is unknown.

PATIENTS AND METHODS

This trial compared 8 weeks of moderate-intensity continuous exercise (MICE; 50 minutes; 70% peak heart rate [HR_peak]; 24 sessions), with high-intensity interval exercise (HIIE; 4 × 4 minutes; 85%-95% HR_peak) at an equivalent (HIIE; 24 sessions) and tapered frequency (HIIE-T; 16 sessions) on V˙o_2peak and on lean and fat mass, measured at baseline, 4, 8, and 12 weeks.

RESULTS

Increases in V˙o_2peak were significantly greater after both 4 (+3.0 mL·kg^-1·min^-1, P = .008) and 8 (+2.3 mL·kg^-1·min^-1, P = .049) weeks of HIIE compared to MICE. After 8 weeks, there was a significantly greater reduction in fat mass after HIIE compared to MICE (-0.7 kg, P = .038). Four weeks after training, the HIIE group maintained elevated V˙o_2peak (+3.3 mL·kg^-1·min^-1, P = .006) and reduced fat mass (-0.7 kg, P = .045) compared to the MICE group, with V˙o_2peak in the HIIE-T also being superior to the MICE group (+2.8 mL·kg^-1·min^-1, P = .013).

CONCLUSION

Compared to MICE, HIIE promotes superior improvements and short-term maintenance of V˙o_2peak and fat mass improvements. HIIE training at a reduced frequency also promotes maintainable cardiorespiratory fitness improvements. In addition to promoting accelerated and superior benefits to the current aerobic exercise guidelines, HIIE promotes clinically relevant improvements even with a substantial reduction in exercise training and for a period after withdrawal.

Clinical Predictors of Early Mortality in Colorectal Cancer Patients Undergoing Chemotherapy: Results From a Global Prospective Cohort Study

Background

Early mortality is a major problem in colorectal cancer (CRC). We have shown that Khorana Score is predictive of early mortality in other cancers. Here, we evaluated the value of this score and other prognostic variables in predicting early mortality in CRC.

Methods

CANTARISK was a prospective, noninterventional, global cohort study in patients with CRC initiating a new chemotherapy regimen. Data were collected at zero, two, four, and six months. Early mortality was defined as death within six months of enrollment. All data were compiled centrally and analyzed after the study closed. Statistically significant univariate associations were tested in multivariable models; adjusted odds ratios (ORs) are presented. Statistical tests were two-sided.

Results

From 2011 to 2012, 1789 CRC patients were enrolled. The median age was 62 years; 71% were Caucasian. One-third (35%) had a rectal primary, and 65% had metastatic disease. There were 184 (10.3%) patients who died during their first six months in the study. For low, intermediate, and high Khorana Score, there were 8.1%, 11.2% and 32.5% deaths, respectively. In multivariable analyses, Khorana Score was an independent predictor of early death (OR for high/intermediate vs low score = 1.70, P = .0027), in addition to age (OR for each incremental year = 1.03, P = .0014), presence of metastatic disease (OR = 3.28, P < .0001), and Easter Cooperative Oncology Group Performance Status Score of 2 or higher (OR = 3.85, P < .0001).

Conclusions

This study demonstrates that Khorana Score is predictive of early mortality in CRC patients. Intermediate- or high-risk patients, as defined by this score, may benefit from additional interventions aimed at reducing early mortality.

Lifestyle after Colorectal Cancer Diagnosis in Relation to Survival and Recurrence: A Review of the Literature

PURPOSE OF REVIEW

This review summarizes the evidence regarding diet, physical activity, smoking, and body composition after colorectal cancer (CRC) diagnosis in relation to all-cause and CRC-specific mortality and disease recurrence and gives suggestions for future research directions.

RECENT FINDINGS

Overall, this review suggests that some, albeit not all, of the well-known modifiable risk factors for cancer incidence might also be associated with CRC survival. CRC prognosis appears to be worse with increased physical inactivity, smoking, or being underweight after CRC diagnosis. Emerging evidence suggests that diets associated with a positive energy balance, e.g., high consumption of sugar-sweetened beverages, may negatively impact survival in CRC survivors. In contrast, there is currently little evidence to support the recommendation to limit red and processed meat or alcohol intake after CRC diagnosis. Whether being overweight and obese after CRC diagnosis improves or worsens CRC prognosis remains controversial and may depend on the measure used to assess body fatness.

SUMMARY

Further research on post-diagnosis lifestyle patterns is needed to understand the multifactorial influence on CRC prognosis. Disease recurrence and the development of comorbidities should be included as key outcomes in future studies and lifestyle should preferably be repeatedly measured.

Explaining the Obesity Paradox: The Association between Body Composition and Colorectal Cancer Survival (C-SCANS Study)

Background: Body composition may partially explain the U-shaped association between body mass index (BMI) and colorectal cancer survival.Methods: Muscle and adiposity at colorectal cancer diagnosis and survival were examined in a retrospective cohort using Kaplan-Meier curves, multivariable Cox regression, and restricted cubic splines in 3,262 early-stage (I-III) male (50%) and female (50%) patients. Sarcopenia was defined using optimal stratification and sex- and BMI-specific cut points. High adiposity was defined as the highest tertile of sex-specific total adipose tissue (TAT). Primary outcomes were overall mortality and colorectal cancer-specific mortality (CRCsM).Results: Slightly over 42% patients were sarcopenic. During 5.8 years of follow-up, 788 deaths occurred, including 433 from colorectal cancer. Sarcopenic patients had a 27% [HR, 1.27; 95% confidence interval (CI), 1.09-1.48] higher risk of overall mortality than those who were not sarcopenic. Females with both low muscle and high adiposity had a 64% higher risk of overall mortality (HR, 1.64; 95% CI, 1.05-2.57) than females with adequate muscle and lower adiposity. The lowest risk of overall mortality was seen in patients with a BMI between 25 and <30 kg/m², a range associated with the greatest number of patients (58.6%) who were not at increased risk of overall mortality due to either low muscle or high adiposity.Conclusions: Sarcopenia is prevalent among patients with non-metastatic colorectal cancer, and should, along with adiposity be a standard oncological marker.Impact: Our findings suggest a biologic explanation for the obesity paradox in colorectal cancer and refute the notion that the association between overweight and lower mortality is due solely to methodologic biases. Cancer Epidemiol Biomarkers Prev; 26(7); 1008-15. ©2017 AACR.

Prognostic Value of Computed Tomography: Measured Parameters of Body Composition in Primary Operable Gastrointestinal Cancers

Background

Previous reports suggest that body composition parameters can be used to predict outcomes for patients with gastrointestinal (GI) cancers. However, evidence for an association with long-term survival is conflicting, with much of the data derived from patients with advanced disease. This study examined the effect of body composition on survival in primary operable GI cancer.

Methods

Patients with resectable adenocarcinoma of the GI tract (esophagus, stomach, colon, rectum) between 2006 and 2014 were identified from a prospective database. Computed tomography (CT) scans were analyzed using a transverse section at L3 to calculate sex-specific body composition indices for skeletal muscle, visceral fat, and subcutaneous fat. Kaplan–Meier and log-rank analysis were used to compare unadjusted survival. Multivariate survival analyses were performed using a proportional hazards model.

Results

The study enrolled 447 patients (191 woman and 256 men) with esophagogastric (OG) (n = 108) and colorectal (CR) (n = 339) cancer. Body composition did not predict survival for the OG cancer patients. Among the CR cancer patients, survival was shorter for those with sarcopenia (p = 0.017) or low levels of subcutaneous fat (p = 0.005). Older age (p = 0.046) and neutrophilia (p = 0.013) were associated with sarcopenia in patients with CR. Tumor stage (p = 0.033), neutrophil count (p = 0.011), and hypoalbuminemia (p = 0.023) were associated with sarcopenia in OG cancer patients. In the multivariate analysis, no single measure of body composition was an independent predictor of reduced survival.

Conclusion

Sarcopenia and reduced subcutaneous adiposity are associated with reduced survival for patients with primary operable CR cancer. However, in this study, no parameter of body composition was an independent prognostic marker when considered with age, tumor stage, and systemic inflammation.

Obesity and Energy Balance in GI Cancer

The prevalence of overweight (body mass index [BMI], 25 to 29.9 kg/m2) and obesity (BMI ≥ 30 kg/m2) have increased dramatically in the United States. Because increasing BMI is associated with the development of multiple different cancer types, including most GI cancers, providers will frequently encounter patients with GI cancer who are overweight or obese. Mounting evidence associates overweight and/or obesity with worsened prognosis in multiple GI cancers, including esophageal, gastric, hepatocellular, pancreatic, and colorectal. However, these data are observational and may be subject to bias and/or confounding. Furthermore, in some cancer types, the associations between BMI and outcomes is not linear, where overweight and class I obese patients may have an improvement in outcome. This report provides a brief highlight of existing studies that have linked overweight and/or obesity to prognosis in GI cancer; provides recommendations on best management practices; and discusses limitations, controversies, and future directions in this rapidly evolving area. There are multiple areas of promise that warrant continued investigation: What are the comparative contributions of energy balance, including weight, dietary patterns, and physical activity on cancer prognosis? What are the specific physiologic pathways that mediate the relationship between energy balance and prognosis? What is the relationship between low muscle mass (sarcopenia) or sarcopenic obesity and cancer prognosis? Are there subsets of patients for whom purposefully altering energy balance would be deleterious to prognosis? This area is rich with opportunities to understand how states of energy (im)balance can be favorably altered to promote healthy survivorship.

Visceral adiposity and cancer survival: a review of imaging studies

Although obesity is a well-known risk factor for cancer, the association between obesity and cancer survival remains controversial. This is partially due to the inability of conventional obesity measures to directly assess adiposity or adipose tissue distribution. As a metabolic organ, visceral adipose tissue (VAT) secrets a variety of cytokines and cytokine-like factors, potentially affecting cancer survival. The objective of this review was to investigate the influence of imaging-assessed VAT on cancer survival. A total of 22 studies assessing the impact of visceral adiposity on survival were included. Negative associations between VAT and survival were more frequently observed among patients with colorectal (four of six studies) and pancreatic (three of five studies) cancers, compared to higher VAT predicting longer survival in most studies of renal cell carcinoma patients (four of five studies). Methodological limitations, including unstandardised VAT measurement methods, lack of other body composition measurement (i.e. muscle mass), small sample size and heterogeneous cohort characteristics, may explain controversial findings related to the impact of VAT on cancer survival.

Obesity and colorectal cancer: molecular features of adipose tissue

The huge part of population in developed countries is overweight or obese. Obesity is often determined by body mass index (BMI) but new accurate methods and ratios have recently appeared to measure body fat or fat located in the intestines. Early diagnosis of obesity is crucial since it is considered an increasing colorectal cancer risk factor. On the one hand, colorectal cancer has been strongly associated with lifestyle factors. A diet rich in red and processed meats may increase colorectal cancer risk; however, high-fiber diets (grains, cereals and fruits) have been associated with a decreased risk of colorectal cancer. Other life-style factors associated with obesity that also increase colorectal cancer risk are physical inactivity, smoking and high alcohol intake. Cutting-edge studies reported that high-risk transformation ability of adipose tissue is due to production of different pro-inflammatory cytokines like IL-8, IL-6 or IL-2 and other enzymes like lactate dehydrogenase (LDH) and tumour necrosis factor alpha (TNFα). Furthermore, oxidative stress produces fatty-acid peroxidation whose metabolites possess very high toxicities and mutagenic properties. 4-hydroxy-2-nonenal (4-HNE) is an active compounds that upregulates prostaglandin E2 which is directly associated with high proliferative colorectal cancer. Moreover, 4-HNE deregulates cell proliferation, cell survival, differentiation, autophagy, senescence, apoptosis and necrosis via mitogen-activated protein kinase (MAPK), phosphoinositide 3-kinase (PIK3CA)—AKT and protein kinase C pathways. Other product of lipid peroxidation is malondialdehyde (MDA) being able to regulate insulin through WNT-pathway as well as having demonstrated its mutagenic capability. Accumulation of point mutation enables genomic evolution of colorectal cancer described in the model of Fearon and Vogelstein. In this review, we will summarize different determination methods and techniques to assess a truthfully diagnosis and we will explain some of the capabilities that performs adipocytes as the largest endocrine organ.