Prediction of clinical outcomes through assessment of sarcopenia and adipopenia using computed tomography in adult patients with acute myeloid leukemia

Associations of various medical nutrition therapy strategies with body composition, and physical and clinical outcomes in acute myeloid leukemia patients undergoing intensive remission-induction treatment: A multicenter prospective correlational study

BACKGROUND & AIMS

Medical nutrition therapy (MNT) is commonly used in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing intensive remission-induction treatment to prevent malnutrition, particularly the loss of fat-free mass (FFM)/muscle mass, as well as associated adverse outcomes. However, studies examining the associations of proactive versus wait-and-see approaches toward MNT with nutritional, physical, and clinical outcomes in these patients are lacking. Therefore, this study aimed to explore the associations of these different MNT approaches with body composition changes, as well as physical and clinical outcomes in AML/MDS patients undergoing intensive remission-induction treatment. Additionally, the study aimed to explore the relationships between body composition changes and physical and clinical outcomes, and whether these associations varied between the proactive and wait-and-see strategies.

METHODS

In this multicenter prospective correlational study, newly diagnosed AML/MDS patients undergoing intensive remission-induction treatment were included. Patients were treated in one of five hospitals using a proactive approach toward MNT, initiating MNT when nutritional intake became inadequate, or in the single hospital in the Netherlands that followed a wait-and-see strategy, limiting the use of MNT to exceptional and severe cases only. Body composition was assessed at the start of treatment, weekly during admission and at discharge, and handgrip strength, and patient-reported physical functioning and fatigue at treatment initiation and discharge. Information on number of complications, and duration of fever and hospital length of stay (LOS) was collected from medical records. Within-group changes in body composition and between-group differences were tested using paired or independent t, Wilcoxon signed-rank or two-sample tests, respectively, or chi-square/Fisher's exact tests for proportions. The longitudinal patterns between proactive MNT approach/wait-and-see strategy hospitals were compared by means of linear mixed effects models. Associations between body composition changes and physical and clinical outcomes were explored using multiple linear regression models, and compared between proactive MNT approach/wait-and-see strategy hospitals.

RESULTS

In this study, 204 AML/MDS patients (54 % male, mean age: 56.3 ± 13.0 years) were included, of whom 140 underwent treatment in a hospital using a proactive approach toward MNT and 64 in the hospital following a wait-and-see strategy. In the proactive MNT approach hospitals, 57 % of patients received MNT during the first chemotherapy cycle versus 8 % of patients in the wait-and-see hospital (p < 0.0001). Both approaches toward MNT were associated with significant decreases in body weight, FFM/muscle mass, and muscle strength. However, losses in FFM/muscle mass and muscle strength did not differ significantly between the strategies, while body weight loss was lower with the proactive approach (estimated between-group difference during the first cycle: 0.44 kg/week (95 % CI 0.18-0.70 kg/week, p = 0.0008), primarily due to better preservation of fat mass (FM) (p < 0.05). Additionally, the proactive MNT strategy was associated with fewer nutrition impact symptoms (p < 0.0001), fewer complications (p = 0.01), and shorter LOS (33 days (IQR: 27-41) vs 29 days (IQR: 26-34), p = 0.009). Similar results were observed during the second chemotherapy cycle. Furthermore, better maintenance of body weight and indicators of FFM/muscle mass and FM were significantly associated with shorter LOS and fever duration, fewer complications, improved physical functioning and/or reduced fatigue. Several associations differed significantly between the two MNT strategies, given that decreased body composition parameters were associated with worse physical and clinical outcomes in the wait-and-see hospital, while in the proactive MNT approach hospitals these associations were opposite or attenuated and non-significant.

CONCLUSION

In AML/MDS patients undergoing intensive remission-induction treatment, a proactive approach toward MNT should be used, as it was associated with fewer nutrition impact symptoms, fewer complications, shorter LOS, and better body weight maintenance, mainly through better preservation of FM, compared to a wait-and-see strategy. Maintenance of body weight, FFM/muscle mass and/or FM was associated with improved physical and clinical outcomes. Given that proactive use of MNT could not prevent loss of FFM/muscle mass and muscle strength, future research should focus on combined nutritional and physical exercise interventions aimed at reducing these losses.

The prognostic impact of body composition assessed by computed tomography in adult patients with newly diagnosed acute lymphoblastic leukemia

BACKGROUND

Body composition has emerged as a significant determinant of cancer patient outcomes, with computed tomography (CT) assessment at the L3 level offering a reliable evaluation method. While muscle mass and adiposity have been linked to poorer outcomes in hematological malignancies, their impact remains unstudied in adults with acute lymphoblastic leukemia (ALL).

METHODS

This retrospective single-center study enrolled adults newly diagnosed with ALL. Skeletal muscle, visceral, and subcutaneous fat areas were quantified. Low muscle mass was defined as a skeletal muscle index (SMI) less than 55 cm2/m2 in men, and less than 39 cm2/m2 in women, and receiver operating characteristic curves determined cutoff points for SMI, subcutaneous adipose tissue index (SATI) and visceral adipose tissue index (VATI) correlated with mortality.

RESULTS

Ninety patients were included. Low muscle mass was associated with mortality in patients treated with a pediatric inspired regimen (PIR) (HR 4.92, 95 % CI [1.38-17.57], p = 0.014) and lower median SMI was observed in patients who died during induction (p = 0.016). High visceral adiposity (HR 1.89, 95 % CI [1-3.57], p = 0.049) and high subcutaneous adiposity (HR 1.99, 95 % CI [1-3.96], p = 0.05) were also associated with mortality in the whole population. Furthermore, a higher VATI was observed in patients who developed an infectious episode during induction (p = 0.03), and a higher VATI was observed in patients who were treated with a PIR who had measurable residual disease positivity after induction chemotherapy (p = 0.044).

CONCLUSION

CT-assessed muscle mass, and adiposity bear prognostic significance in newly diagnosed ALL patients.

Association of Muscle Radiodensity and Muscle Mass With Thoracic Aortic Calcification Progression in Dialysis Patients

BACKGROUND

Recent findings have spotlighted sarcopenia as a critical factor exacerbating cardiovascular risk in dialysis patients. However, no studies have investigated the relationship of muscle characteristics with thoracic aortic calcification (TAC). We explored whether skeletal muscle radiodensity (SMD) and skeletal muscle index (SMI) are associated with TAC in dialysis patients.

METHODS

In this study, 2517 dialysis patients (between January 2020 and June 2023) from four centres with chest computed tomography (CT) scans were analysed cross-sectionally. A cohort of 544 initial-dialysis patients (between January 2014 and December 2020) was followed for TAC progression. Chest CT images were used to assess SMD and SMI at the L1 level, as well as to measure the scores of TAC, including ascending TAC (ATAC), aortic arch calcification (AoAC) and descending TAC (DTAC). Multivariable linear regression models were employed to assess the effects of SMD and SMI on TAC and its progression. Restricted cubic spline was used to assess the potential non-linear relationships of SMD and SMI with TAC progression.

RESULTS

The mean (SD) age for the cross-sectional study was 54.8 (14.0) years, with males accounting for 58.2%. Over a mean (SD) follow-up duration of 3.45 (1.82) years, 85.7% showed TAC progression. Comparing the highest quartile of SMD to the lowest quartile, a significant inverse association was observed with TAC (β, -1.08 [-1.42 to -0.75]; p < 0.001); similar trends were noted for SMI (β, -0.42 [-0.74 to -0.10]; p = 0.011). SMD and SMI as continuous variables were also both significantly negatively correlated with TAC. In the longitudinal study, multivariable linear regression models revealed that an increase of 1 SD in SMD resulted in a decrease of 0.10 SD (95% CI, -0.17 to -0.02; p = 0.011) in TAC progression, and an increase of 1 SD in SMI resulted in a decrease of 0.12 SD (95% CI, -0.20 to -0.04; p = 0.003) in TAC progression. Restricted cubic spline models excluded non-linear trends for the relationships of SMD and SMI with TAC progression. The associations of SMD and SMI with DTAC were consistent with those observed for TAC, but neither showed a significant association with ATAC.

CONCLUSIONS

Higher SMD and higher SMI were significantly associated with lower TAC and its progression in dialysis patients. Improving SMD and SMI could be a new approach for reducing TAC.

Changes in nutritional status and associations with physical and clinical outcomes in acute myeloid leukemia patients during intensive chemotherapy

BACKGROUND/OBJECTIVES

Patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) often receive medical nutrition therapy (MNT) during intensive remission-induction treatment. Since little is known about changes in nutritional status, specifically body composition, in this patient population, these changes and their associations with physical and clinical outcomes were assessed.

SUBJECTS/METHODS

In this multicenter prospective observational study, newly diagnosed AML/MDS patients who received intensive remission-induction chemotherapy, routine dietary counseling by a dietician and MNT immediately upon inadequate nutritional intake, were included. At treatment initiation and discharge, nutritional status, including Patient-Generated Subjective Global Assessment (PG-SGA)-scores and body composition, physical outcomes and fatigue were assessed. Associations of nutritional status/body composition with physical outcomes, fatigue, fever duration, number of complications, time to neutrophil engraftment and hospital length of stay (LOS) (collected from medical records) were examined using multiple regression analysis.

RESULTS

In >91% of the 126 AML/MDS patients included, nutritional intake was adequate, with 61% receiving MNT. Nevertheless, body weight decreased significantly (p < 0.001) and mainly consisted of a loss of muscle/fat-free mass (FFM) (p < 0.001), while fat mass (FM) remained unchanged (p-value range = 0.71-0.77). Body weight and waist circumference showed significant negative associations with fever duration and/or number of complications. Significant positive associations were found between mid-upper arm muscle circumference (MUAMC) and physical functioning and between PG-SGA-scores and fatigue. Body weight and MUAMC were also negatively associated with LOS.

CONCLUSION

Despite MNT in AML/MDS patients undergoing intensive chemotherapy, muscle/FFM decreased while FM remained unchanged. Maintenance of nutritional status was associated with improved physical and clinical outcomes.

The association between an inflammation-based nutritional tool (Glasgow Prognostic Score) and length of hospital stay in patients with haematological cancer

BACKGROUND

This is a retrospective study to identify if Glasgow Prognostic Score (GPS) is associated with length of hospital stay (LOS) in haematological cancer.

METHODS

The participants were adult inpatients at a single centre in between 2018 and 2022. Serum levels of CRP and albumin were measured at admission. GPS was calculated as follows: point "0" as CRP < 10 mg/L and albumin ≥ 35 g/L; point "2" as CRP ≥ 10 mg/L and albumin < 35 g/L; point "1" as either CRP ≥ 10 mg/L or albumin < 35 g/L. Patients with point "0" were classified as low risk whilst point "2" as high risk. LOS was defined as the interval between the admission and discharge date.

RESULTS

As a result, the average age was 59.6 ± 12.6 years and the average LOS was 6.0 days (IQR = 2 days, 11 days). Of 1621 patients, 8.8% of them were high risk. GPS was associated with LOS (β = 2.7 days; 95% CI = 0.8 days, 4.6 days; p trend < 0.001) after full adjustment. Each point of GPS was associated with 1.9 days (95% CI = 1.4 days, 2.4 days) longer in LOS with full adjustment. The association was more prominent in younger patients (< 65 years), patients with leukaemia and myelodysplastic syndrome, and those with normal body weight status (18.5-24 kg/m2), compared with their counterparts.

CONCLUSION

GPS was associated with LOS in Chinese patients with haematological cancer, indicating GPS could be a useful tool to predict outcome.

Changes in skeletal muscle function during chemotherapy and related factors in patients with acute leukemia

INTRODUCTION

Skeletal muscle function is an important prognostically relevant indicator in patients with acute leukemia (AL), but skeletal dysfunction during chemotherapy is not well understood. This study aimed to investigate the factors that influence changes in skeletal muscle function from before the start of chemotherapy to before allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

This was a retrospective cohort study that included 90 patients with AL who underwent chemotherapy before transplantation to perform allo-HSCT (men, 67.3%; median age, 53 years). The outcome measure was defined as changes in skeletal muscle function from before chemotherapy to before allo-HSCT, and was assessed by measuring the psoas muscle index (PMI) as skeletal muscle quantity and computed tomography values (CTV) as skeletal muscle quality using a computed tomography scanner. We examined the differences in PMI and CTV before chemotherapy and allo-HSCT, and the factors associated with changes in PMI.

RESULT

The mean PMI for before chemotherapy and allo-HSCT were 4.6 ± 1.4 cm2/m2 and 4.0 ± 1.3 cm2/m2 and significant differences were observed (p < 0.001). However, the mean CTV before chemotherapy and allo-HSCT were 47.3 ± 4.5 HU and 47.4 ± 5.0 HU, respectively, and no significant differences were found (p = 0.798). In stepwise multiple regression analysis, age and sex were identified as factors related to changes in PMI (age, p = 0.019; sex, p = 0.001).

CONCLUSION

We found that skeletal muscle quantity decreased during chemotherapy in patients with AL and was influenced by male sex and older age.

TRIAL REGISTRATION NUMBER

  TRIAL REGISTRATION NUMBER: 34-096(11,243). Date of registration: September 11, 2023.

Low skeletal muscle mass and treatment outcomes among adults with haematologic malignancies: A systematic review and meta-analysis

BACKGROUND

Low skeletal muscle mass (LSMM) and/or, function associated with an increased risk of treatment-related toxicities and inferior overall survival (OS) among adults with solid malignancies. However, the association between LSMM and treatment-related toxicities among adults with haematologic malignancies remains unclear.

METHODS

Using a pre-published protocol (CRD42020197814), we searched seven bibliographic databases from inception to 08/2021 for studies reporting the impact of LSMM among adults ≥18 years with a known haematologic malignancy. The primary outcome of interest was OS, and secondary outcomes included progression free survival (PFS) and non-relapse mortality (NRM). These effect sizes were quantified in terms of hazards ratio (HR) along with 95% confidence interval (CI) and pooled across studies using a DerSimonian-Laird random-effects model. Heterogeneity was assessed using the Cochran's Q and the I2 statistic. All hypothesis testing was two-sided with an alpha of 0.05.

RESULTS

Of 3791 studies screened, we identified 20 studies involving 3468 patients with a mean age of 60 years; 44% were female and the most common malignancy was diffuse large B-cell lymphoma (42%). Most studies measured muscle mass using single slice computed tomography imaging at the L3 level. The presence of LSMM was associated with worse OS (pooled HR = 1.81, 95% CI = 1.48-2.22, P < 0.001) with moderate heterogeneity (Cochran's Q, I2 = 60.4%), PFS (pooled HR = 1.61, 95% CI = 1.28-2.02, P < 0.001) with moderate heterogeneity (Cochran's Q, I2 = 66.0%). Similarly, LSMM was associated with worse NRM (HR = 1.72, 95% CI = 1.34-2.22, P < 0.001) with little evidence of heterogeneity (Cochran's Q, I2 = 0.0%).

CONCLUSIONS

LSMM is associated with worse survival outcomes among adults with haematologic malignancies. Further research into understanding the underlying mechanism of this association and mitigating the negative effects of LSMM among adults with haematologic malignancies is needed.

The evolution and impact of sarcopenia in severe aplastic anaemia survivors following allogeneic haematopoietic cell transplantation

BACKGROUND

Sarcopenia is a potential risk factor for adverse outcomes in haematopoietic cell transplantation (HSCT) recipients. We aimed to explore longitudinal body changes in muscle and adipose mass and their prognostic value in allogeneic HSCT-treated severe aplastic anaemia (SAA) patients.

METHODS

We retrospectively analysed consecutive SAA patients who underwent allogeneic HSCT between January 2017 and March 2022. Measurements of pectoral muscle and corresponding subcutaneous fat mass were obtained via chest computed tomography at baseline and at 1 month, 3 months, 6 months, and 12 months following HSCT. Sarcopenia was defined as pectoral muscle index (PMI) lower than the sex-specific median at baseline. Changes in body composition over time were evaluated by generalized estimating equations. Cox regression models were used to investigate prognostic factors affecting overall survival (OS) and failure-free survival (FFS). A nomogram was constructed from the Cox regression model for OS.

RESULTS

We included 298 adult SAA patients (including 129 females and 169 males) with a median age of 31 years [interquartile range (IQR), 24-39 years] at baseline. Sarcopenia was present in 148 (148/298, 50%) patients at baseline, 218 (218/285, 76%) patients post-1 month, 209 (209/262, 80%) patients post-3 month, 169 (169/218, 78%) patients post-6 month, and 129 (129/181, 71%) patients post-12 month. A significant decrease in pectoral muscle mass was observed in SAA patients from the time of transplant to 1 year after HSCT, and the greatest reduction occurred in post 1-3 months (P < 0.001). The sarcopenia group exhibited significantly lower 5-year OS (90.6% vs. 100%, log-rank P = 0.039) and 5-year FFS (89.2% vs. 100%, log-rank P = 0.021) than the nonsarcopenia group at baseline. Sarcopenia at baseline (hazard ratio, HR, 6.344; 95% confidence interval, CI: 1.570-25.538; P = 0.01; and HR, 3.275; 95% CI: 1.159-9.252; P = 0.025, respectively) and the delta value of the PMI at 6 months post-transplantation (ΔPMI6) (HR, 0.531; 95% CI: 0.374-0.756; P < 0.001; and HR, 0.666; 95% CI: 0.505-0.879; P = 0.004, respectively) were demonstrated to be independent prognostic factors for OS and FFS in SAA patients undergoing HSCT, and were used to construct the nomogram. The C-index of the nomogram was 0.75, and the calibration plot showed good agreement between the predictions made by the nomogram and actual observations.

CONCLUSIONS

Sarcopenia persists in SAA patients from the time of transplant to the 1-year follow-up after HSCT. Both sarcopenia at baseline and at 6 months following HSCT are associated with poor clinical outcomes, especially in patients with persistent muscle mass loss up to 6 months after transplantation.

A chest CT-based nomogram for predicting survival in acute myeloid leukemia

BACKGROUND

The identification of survival predictors is crucial for early intervention to improve outcome in acute myeloid leukemia (AML). This study aim to identify chest computed tomography (CT)-derived features to predict prognosis for acute myeloid leukemia (AML).

METHODS

952 patients with pathologically-confirmed AML were retrospectively enrolled between 2010 and 2020. CT-derived features (including body composition and subcutaneous fat features), were obtained from the initial chest CT images and were used to build models to predict the prognosis. A CT-derived MSF nomogram was constructed using multivariate Cox regression incorporating CT-based features. The performance of the prediction models was assessed with discrimination, calibration, decision curves and improvements.

RESULTS

Three CT-derived features, including myosarcopenia, spleen_CTV, and SF_CTV (MSF) were identified as the independent predictors for prognosis in AML (P < 0.01). A CT-MSF nomogram showed a performance with AUCs of 0.717, 0.794, 0.796 and 0.792 for predicting the 1-, 2-, 3-, and 5-year overall survival (OS) probabilities in the validation cohort, which were significantly higher than the ELN risk model. Moreover, a new MSN stratification system (MSF nomogram plus ELN risk model) could stratify patients into new high, intermediate and low risk group. Patients with high MSN risk may benefit from intensive treatment (P = 0.0011).

CONCLUSIONS

In summary, the chest CT-MSF nomogram, integrating myosarcopenia, spleen_CTV, and SF_CTV features, could be used to predict prognosis of AML.

Effect of low skeletal muscle mass on NK cells in patients with acute myeloid leukemia and its correlation with prognosis

The objective of this study was to analyze the correlation between skeletal muscle mass and the distribution of peripheral blood lymphocytes and natural killer (NK) cells, as well as their impact on prognosis in patients with acute myeloid leukemia (AML). A retrospective analysis was conducted on 211 newly diagnosed AML patients, evaluating skeletal muscle index (SMI), NK cell proportion, and absolute value, along with relevant clinical data. Linear regression and Spearman's correlation coefficient were used to assess the relationship between various indicators and SMI, followed by multiple linear regression for further modeling. Univariate and multivariate Cox proportional hazards regression models were used to identify independent predictors for overall survival (OS). Among the 211 AML patients, 38 cases (18.0%) were diagnosed with sarcopenia. Multiple linear regression analysis included weight, fat mass, ECOG score, body mass index, and peripheral blood NK cell proportion, constructing a correlation model for SMI (R2 = 0.745). Univariate analysis identified higher NK cell count (> 9.53 × 106/L) as a poor predictor for OS. Multivariate Cox proportional hazards regression model indicated that age ≥ 60 years, PLT < 100 × 109/L, ELN high risk, sarcopenia, and B cell count > 94.6 × 106/L were independent adverse prognostic factors for AML patients. Low skeletal muscle mass may negatively impact the count and function of NK cells, thereby affecting the prognosis of AML. However, further basic and clinical research is needed to explore the specific mechanisms underlying the relationship between NK cells and SMI in AML.

Prevalence and prognostic value of baseline sarcopenia in hematologic malignancies: a systematic review

Background

The correlation between sarcopenia and hematological malignancy prognosis is still controversial. Design: A systematic review and meta-analysis. Objectives: To explore sarcopenia's prevalence and prognostic value in hematologic malignancies.

Data sources and methods

We searched Embase, MEDLINE, and Cochrane Library through Ovid SP using an appropriate search strategy on August 28, 2022, and updated the search results on January 9, 2023. Study quality was assessed using the Newcastle-Ottawa scale. The pooled prevalence of sarcopenia was calculated with a 95% confidence interval (CI). Relationships between sarcopenia and prognostic value were expressed as hazard ratio (HR) and 95% CI. HR means the probability of something undesirable, i.e., death or disease progression.

Results

The search identified more than 3992 studies, and 21 (3354 patients, median or mean age ranging from 36 to 78 years) were finally included. The risk of bias in the studies was low to medium. All included studies were diagnosed based on low muscle mass (LMM). Muscle mass was assessed mainly through imaging technologies, and different cut-offs were applied to determine LMM. The prevalence of sarcopenia was 44.5%, which could fluctuate by age. Subgroup analysis showed that older people had a higher sarcopenic rate than the non-elderly group. Sarcopenia resulted in an inferior prognosis [overall survival: HR 1.821, 95% CI 1.415-2.343; progression-free survival: HR 1.703, 95% CI 1.128-2.571).

Conclusion

Sarcopenia has a prevalence of over 30% in malignant hematologic patients and is associated with a poorer prognosis. Future studies with a standardized sarcopenia diagnostic criterion were needed to investigate sarcopenia's prevalence and prognostic effects in hematologic malignancies.

Muscle and fat composition in patients with newly diagnosed multiple myeloma

Measures of muscle and adipose tissue mass have been associated with outcomes in several malignancies, but studies in multiple myeloma (MM) are inconsistent. The aim of this study was to evaluate the association between muscle and fat areas and radiodensity, and overall survival (OS) in patients with newly diagnosed MM. We included 341 patients diagnosed with MM from 2010-2019 who had an 18F-fluorodeoxyglucose positron emission tomography/computed tomography at diagnosis. A cross-sectional image at the third lumbar vertebrae was segmented into muscle and fat components. Median follow up was 5.7 years. There was no association between sarcopenia and baseline disease characteristics or OS. Low muscle radiodensity was associated with higher disease stage, anemia, and renal failure. OS was 5.6 vs. 9.0 years in patients with muscle radiodensity in the lower vs. middle/upper tertiles, respectively (P = 0.02). High subcutaneous adipose tissue (SAT) radiodensity was associated with higher stage, anemia, thrombocytopenia, hypercalcemia, renal failure, and high LDH. OS was 5.4 years vs. not reached in patients with SAT radiodensity in the upper vs. middle/lower tertiles, respectively (P = 0.001). In conclusion, sarcopenia was not associated with OS in MM patients. High SAT radiodensity and low muscle radiodensity were associated with advanced disease stage and adverse laboratory characteristics.

The association of body composition and outcomes following autologous hematopoietic stem cell transplantation in patients with non-Hodgkin lymphoma

Recently there has been a growing interest in evaluating body composition as a marker for prognosis in cancer patients. The association of body composition parameters and outcomes has not been deeply investigated in patients with autologous hematopoietic stem cell transplantation (HSCT) recipients with non-Hodgkin lymphoma (NHL). We conducted a retrospective cohort study of 264 NHL patients who received autologous HSCT. PreHSCT abdominal CT scans at the levels of L3 were assessed for body composition measures. We evaluated sarcopenia, myosteatosis, high visceral adipose tissue (VAT) and high visceral adipose tissue density (VATD). Using multivariable Cox proportional regression, we analyzed the association of clinical and transplant-related characteristics with overall survival (OS), relapse-free survival (RFS), and non-relapse mortality (NRM). In a multivariate regression model, patients with higher VATD had worse OS (HR 1.78; 95% confidence intervals CI 1.08-2.95, p = 0.02) and worse NRM (HR 2.31 95% CI 1.08-4.95, p = 0.02) than with lower VATD. Patients with lower levels of VAT also had worse RFS (HR 1.49 95% CI 1.03-2.15, p = 0.03). Sarcopenia and myosteatosis were not associated with outcomes. High pre-transplant VATD was associated with lower OS and higher NRM, and low pre-transplant VAT was associated with worse RFS in patients with NHL undergoing autologous HSCT.

Computed tomography-determined skeletal muscle density predicts 3-year mortality in initial-dialysis patients in China

BACKGROUND

Skeletal muscle mass and quality assessed by computed tomography (CT) images of the third lumbar vertebra (L3) level have been established as risk factors for poor clinical outcomes in several illnesses, but the relevance for dialysis patients is unclear. A few studies have suggested a correlation between CT-determined skeletal muscle mass and quality at the first lumbar vertebra (L1) level and adverse outcomes. Generally, chest CT does not reach beyond L1. We aimed to determine whether opportunistic CT scan (chest CT)-determined skeletal muscle mass and quality at L1 are associated with mortality in initial-dialysis patients.

METHODS

This 3-year multicentric retrospective study included initial-dialysis patients from four centres between 2014 and 2017 in China. Unenhanced CT images of the L1 and L3 levels were obtained to assess skeletal muscle mass [by skeletal muscle index, (SMI), cm2 /m2 ] and quality [by skeletal muscle density (SMD), HU]. Skeletal muscle measures at L1 were compared with those at L3. The sex-specific optimal cutoff values of L1 SMI and L1 SMD were determined in relation to all-cause mortality. The outcomes were all-cause death and cardiac death. Cox regression models were applied to investigate the risk factors for death.

RESULTS

A total of 485 patients were enrolled, of whom 257 had both L1 and L3 images. Pearson's correlation coefficient between L1 and L3 SMI was 0.84 (P < 0.001), and that between L1 and L3 SMD was 0.90 (P < 0.001). No significant association between L1 SMI and mortality was observed (P > 0.05). Low L1 SMD (n = 280, 57.73%) was diagnosed based on the optimal cutoff value (<39.56 HU for males and <33.06 HU for females). Multivariate regression analysis revealed that the low L1 SMD group had higher risks of all-cause death (hazard ratio 1.80; 95% confidence interval 1.05-3.11, P = 0.034) and cardiac death (hazard ratio 3.74; 95% confidence interval 1.43-9.79, P = 0.007).

CONCLUSIONS

In initial-dialysis patients, there is high agreement between the L1 and L3 measures for SMI and SMD. Low SMD measured at L1, but not low SMI, is an independent predictor of both all-cause death and cardiac death.

Gut microbiota alterations induced by intensive chemotherapy in acute myeloid leukaemia patients are associated with gut barrier dysfunction and body weight loss

BACKGROUND & AIMS

Acute myeloid leukaemia (AML) chemotherapy has been reported to impact gut microbiota composition. In this study, we investigated using a multi -omics strategy the changes in the gut microbiome induced by AML intense therapy and their association with gut barrier function and cachectic hallmarks.

METHODS

10 AML patients, allocated to standard induction chemotherapy (SIC), were recruited. Samples and data were collected before any therapeutic intervention (T0), at the end of the SIC (T1) and at discharge (T4). Gut microbiota composition and function, markers of inflammation, metabolism, gut barrier function and cachexia, as well as faecal, blood and urine metabolomes were assessed.

RESULTS

AML patients demonstrated decreased appetite, weight loss and muscle wasting during hospitalization, with an incidence of cachexia of 50%. AML intensive treatment transiently impaired the gut barrier function and led to a long-lasting change of gut microbiota composition characterized by an important loss of diversity. Lactobacillaceae and Campylobacter concisus were increased at T1 while Enterococcus faecium and Staphylococcus were increased at T4. Metabolomics analyses revealed a reduction in urinary hippurate and faecal bacterial amino acid metabolites (bAAm) (2-methylbutyrate, isovalerate, phenylacetate). Integration using DIABLO revealed a deep interconnection between all the datasets. Importantly, we identified bacteria which disappearance was associated with impaired gut barrier function (Odoribacter splanchnicus) and body weight loss (Gemmiger formicilis), suggesting these bacteria as actionable targets.

CONCLUSION

AML intensive therapy transiently impairs the gut barrier function while inducing enduring alterations in the composition and metabolic activity of the gut microbiota that associate with body weight loss.

TRIAL REGISTRATION

NCT03881826, https://clinicaltrials.gov/ct2/show/NCT03881826.

Prevalence and effect on survival of pre-treatment sarcopenia in patients with hematological malignancies: a meta-analysis

Background & aims

Evidence regarding the prevalence of pre-treatment sarcopenia and its impact on survival in patients with hematological malignancies (HM) varies across studies. We conducted a systematic review and meta-analysis to summarize this discrepancy.

Methods

PubMed, Embase and Cochrane library were systematically searched for relevant studies. Outcomes assessed were: prevalence of pre-treatment sarcopenia, overall survival (OS), progression-free survival (PFS) and complete response (CR). Weighted mean proportion, odds ratios (ORs) and hazard ratios (HRs) were estimated using a fixed-effects and a random-effects model.

Results

A total of 27 retrospective cohort studies involving 4,991 patients were included in this study. The prevalence of pre-treatment sarcopenia was 37.0% (95% CI: 32.0%-42.0%) in HM patients <60 years and 51.0% (95% CI: 45.0%-57.0%) in≥60 years. Patients with leukemia had the lowest prevalence, compared with those with other HM (38.0%; 95% CI: 33.0%-43.0%; P = 0.010). The presence of sarcopenia was independently associated with poor OS (HR = 1.57, 95% CI = 1.41-1.75) and PFS (HR = 1.50, 95% CI = 1.22-1.83) throughout treatment period, which may be partially attributed to decreased CR (OR = 0.54, 95% CI = 0.41-0.72), particularly for BMI ≥ 25 (P = 0.020) and males (P = 0.020).

Conclusion

Sarcopenia is highly prevalent in patients with HM and an adverse prognostic factor for both survival and treatment efficacy. HM and sarcopenia can aggravate each other. We suggest that in future clinical work, incorporating sarcopenia into risk scores will contribute to guide patient stratification and therapeutic strategy, particularly for the elderly.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier (CRD42023392550).

Prognostic Impact of Quantifying Sarcopenia and Adipopenia by Chest CT in Severe Aplastic Anemia Patients Treated With Allogeneic Hematopoietic Stem Cell Transplantation

RATIONALE AND OBJECTIVES

To investigate the prognostic role of chest CT-defined sarcopenia and adipopenia in severe aplastic anemia (SAA) patients treated with hematopoietic stem cell transplantation (HSCT).

MATERIALS AND METHODS

This was a retrospective study of 123 consecutive SAA patients treated with HSCT. CT imaging was performed to quantify the pectoralis muscle (including major and minor) index (PMI) and the corresponding subcutaneous adipose tissue index (SAI). Sarcopenia and adipopenia were defined as PMI and SAI lower than the respective sex-specific medians. Correlations of the PMI and SAI with anthropometric indexes were calculated. Transplant-related outcomes were compared between the sarcopenia and adipopenia groups. Prognostic factors for overall survival (OS) and fail-free survival (FFS) were identified by Cox regression and were used to create a nomogram. The accuracy of the nomogram was evaluated by ROC curves.

RESULTS

PMI showed good correlation with BMI and fat-free mass index (p < 0.001). SAI correlated with BMI and fat mass index (p < 0.001). The sarcopenia group (47.2%) had a significantly worse 3-year OS (90.8% vs. 77.6%, p = 0.045) and 3-year FFS (89.2% vs. 74.1%, p = 0.035) than the nonsarcopenia group. Sarcopenia status and diagnostic category were used to construct the nomogram of OS, as these were independent prognostic factors in the multivariate analysis for OS and FFS (p < 0.05). The area under the curve of the nomogram at one year and three years was 0.801 and 0.721, respectively.

CONCLUSION

Sarcopenia indicates a poor prognosis in SAA patients undergoing HSCT. Intensive supportive care is suggested for SAA patients with sarcopenia before transplantation.

Standardization of Body Composition Status in Patients with Advanced Urothelial Tumors: The Role of a CT-Based AI-Powered Software for the Assessment of Sarcopenia and Patient Outcome Correlation

BACKGROUND

Sarcopenia is a well know prognostic factor in oncology, influencing patients' quality of life and survival. We aimed to investigate the role of sarcopenia, assessed by a Computed Tomography (CT)-based artificial intelligence (AI)-powered-software, as a predictor of objective clinical benefit in advanced urothelial tumors and its correlations with oncological outcomes.

METHODS

We retrospectively searched patients with advanced urothelial tumors, treated with systemic platinum-based chemotherapy and an available total body CT, performed before and after therapy. An AI-powered software was applied to CT to obtain the Skeletal Muscle Index (SMI-L3), derived from the area of the psoas, long spine, and abdominal muscles, at the level of L3 on CT axial images. Logistic and Cox-regression modeling was implemented to explore the association of sarcopenic status and anthropometric features to the clinical benefit rate and survival endpoints.

RESULTS

97 patients were included, 66 with bladder cancer and 31 with upper-tract urothelial carcinoma. Clinical benefit outcomes showed a linear positive association with all the observed body composition variables variations. The chances of not experiencing disease progression were positively associated with ∆_SMI-L3, ∆_psoas, and ∆_long spine muscle when they ranged from ~10-20% up to ~45-55%. Greater survival chances were matched by patients achieving a wider ∆_SMI-L3, ∆_abdominal and ∆_long spine muscle.

CONCLUSIONS

A CT-based AI-powered software body composition and sarcopenia analysis provide prognostic assessments for objective clinical benefits and oncological outcomes.

Influence of reduced muscle mass and quality on ventilator weaning and complications during intensive care unit stay in COVID-19 patients

BACKGROUND & AIMS

Sarcopenia, a loss of muscle mass, quality and function, which is particularly evident in respiratory muscles, has been associated with many clinical adverse outcomes. In this study, we aimed at evaluating the role of reduced muscle mass and quality in predicting ventilation weaning, complications, length of intensive care unit (ICU) and of hospital stay and mortality in patients admitted to ICU for SARS-CoV-2-related pneumonia.

METHODS

This was an observational study based on a review of medical records of all adult patients admitted to the ICU of a tertiary hospital in Milan and intubated for SARS-CoV-2-related pneumonia during the first wave of the COVID-19 pandemic. Muscle mass and quality measurement were retrieved from routine thoracic CT scans, when sections passing through the first, second or third lumbar vertebra were available.

RESULTS

A total of 81 patients were enrolled. Muscle mass was associated with successful extubation (OR 1.02, 95% C.I. 1.00-1.03, p = 0.017), shorter ICU stay (OR 0.97, 95% C.I. 0.95-0.99, p = 0.03) and decreased hospital mortality (HR 0.98, 95% C.I. 0.96-0.99, p = 0.02). Muscle density was associated with successful extubation (OR 1.07, 95% C.I. 1.01-1.14; p = 0.02) and had an inverse association with the number of complications in ICU (Β -0.07, 95% C.I. -0.13 - -0.002, p = 0.03), length of hospitalization (Β -1.36, 95% C.I. -2.21 - -0.51, p = 0.002) and in-hospital mortality (HR 0.88, 95% C.I. 0.78-0.99, p = 0.046).

CONCLUSIONS

Leveraging routine CT imaging to measure muscle mass and quality might constitute a simple, inexpensive and powerful tool to predict survival and disease course in patients with COVID-19. Preserving muscle mass during hospitalisation might have an adjuvant role in facilitating remission from COVID-19.

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 Prognostic Value of Sarcopenia in Acute Myeloid Leukemia Patients and the Development and Validation of a Novel Nomogram for Predicting Survival

BACKGROUND

Acute myeloid leukemia (AML) occurs frequently in the elderly, of whom the prognosis is dismal. Sarcopenia is a progressive and generalized skeletal muscle disorder associated with an increased possibility of adverse outcomes. This study aims to explore the prognostic value of sarcopenia in AML patients and develop a novel prognostic model.

METHODS

A total of 227 AML patients were enrolled. Body composition was assessed by bioelectrical impedance analysis before treatment. Sarcopenia was diagnosed by low muscle quantity. Cox proportional hazard regression model were applied to verify prognostic variables for overall survival (OS) and disease-free survival (DFS). A novel prognostic model of nomogram was developed and validated by 'R'.

RESULTS

Forty-one (18.1%) patients were defined as sarcopenia. The median age of the sarcopenic group was significantly greater than the non-sarcopenic group (median 70 vs. 64 years, P = 0.001). Sarcopenic patients showed significantly less height (P = 0.002), weight (P <0.001), Body Mass Index (P <0.001), Fat Mass (P = 0.017), Fat-free Mass (P <0.001), Appendicular Skeletal Muscle Mass (P <0.001), Skeletal Muscle Index (P <0.001), Fat-free Mass Index (P <0.001), and hemoglobin level (P = 0.025) than the non-sarcopenic ones. Patients in the sarcopenic group also showed a statistically shorter OS and DFS (median OS: 13.7 vs. 55.6 months, P = 0.003; median DFS: 12.5 months vs. not reached, P = 0.026). ELN high risk [Hazard Ratio (HR): 1.904, 95% Confidence Interval (CI): 1.018-3.562, P = 0.044), sarcopenia (HR: 1.887, 95% CI: 1.071-3.324, P = 0.028), and reduced-intensity regimens (HR: 3.765, 95% CI: 1.092-12.980, P = 0.036) were independent predictors for OS in multivariate analysis. A nomogram for predicting OS was constructed using the above three factors. The c index, calibration plots and decision curve analyses (DCA) showed better discrimination, calibration, and net benefits of the nomogram than the ELN model.

CONCLUSION

Sarcopenia was common and had an inferior prognosis in AML and needs more attention in clinical practice.

Evaluating Sarcopenia by Using the Bioelectrical Impedance Analysis in Patients with Acute Myeloid Leukemia After Chemotherapy

Background

We aimed to explore the potential association of body composition parameters measured by bioelectrical impedance analysis (BIA) with the incidence of sarcopenia in patients with acute myeloid leukemia (AML) (non-M3) after chemotherapy.

Patients and Methods

This was a single-center observational study. Sixty-nine patients with newly diagnosed AML underwent BIA at the time of initial diagnosis and after completion of three chemotherapy sessions. Pre- and post-chemotherapy BIA parameters were compared. Sarcopenia was defined as low skeletal muscle mass plus low muscle strength according to the Asian Working Group for Sarcopenia (AWGS). Association of sarcopenia with mid-arm muscle circumference (MAMC) and intracellular water (ICW) was assessed by multivariate logistic regression.

Results

There was a significant increase in the prevalence of sarcopenia after chemotherapy (39.1% vs 14.5%, P<0.001). Skeletal muscle mass (SMM), fat-free mass (FFM), and soft lean mass (SLM) showed a significant decrease after chemotherapy (P<0.05). MAMC, ICW, and total body water (TBW) significantly decreased after chemotherapy (P<0.05). BIA indices including appendicular skeletal muscle mass (ASM) (r=0.889, P<0.001), ICW (r=0.869, P<0.001), MAMC (r=0.849, P<0.001) showed a positive correlation with SMI. Moreover, ASM (r=−0.453 P=0.001), ICW (r=−0.322, P<0.05), and MAMC (r=−0.352, P<0.05) showed a negative correlation with sarcopenia. On multivariate logistic regression analysis, increased ICW was associated with decreased risk of sarcopenia [odds ratio (OR): 0.50; 95% confidence interval (CI) 0.30–0.82]. Each additional unit of MAMC after chemotherapy was associated with 71% lower risk of sarcopenia (OR: 0.29; 95% CI 0.13–0.66).

Conclusion

The incidence of sarcopenia was associated with chemotherapy of patients with AML (non-M3) as reflected by body composition changes.

Cachectic muscle wasting in acute myeloid leukaemia: a sleeping giant with dire clinical consequences

Acute myeloid leukaemia (AML) is a haematological malignancy with poor survival odds, particularly in the older (>65 years) population, in whom it is most prevalent. Treatment consists of induction and consolidation chemotherapy to remit the cancer followed by potentially curative haematopoietic cell transplantation. These intense treatments are debilitating and increase the risk of mortality. Patient stratification is used to mitigate this risk and considers a variety of factors, including body mass, to determine whether a patient is suitable for any or all treatment options. Skeletal muscle mass, the primary constituent of the body lean mass, may be a better predictor of patient suitability for, and outcomes of, AML treatment. Yet skeletal muscle is compromised by a variety of factors associated with AML and its clinical treatment consistent with cachexia, a life-threatening body wasting syndrome. Cachectic muscle wasting is associated with both cancer and anticancer chemotherapy. Although not traditionally associated with haematological cancers, cachexia is observed in AML and can have dire consequences. In this review, we discuss the importance of addressing skeletal muscle mass and cachexia within the AML clinical landscape in view of improving survivability of this disease.