Impact of visceral adipose tissue on compliance of adjuvant chemotherapy and relapse-free survival after gastrectomy for gastric cancer: A propensity score matching analysis

Prognostic impact of adipose tissue loss at 1 month after surgery in patients with gastric cancer

BACKGROUND

The postoperative impact of short-term changes in skeletal muscle loss (SML) and adipose tissue loss (ATL) on treatment outcomes is unclear in patients with gastric cancer (GC). We investigate the role of SML and ATL at 1 month after surgery in determining postoperative survival and recurrence rates in patients with GC.

METHODS

We analyzed 540 patients with GC and assessed their skeletal muscle mass, visceral fat mass, and subcutaneous fat mass using computed tomography scans preoperatively and 1 month postoperatively. Patients were categorized into high and low groups based on their levels of SML, visceral ATL (v-ATL), and subcutaneous ATL (s-ATL). Additionally, they were classified into three groups (high ATL, intermediate ATL, and low ATL) based on their v-ATL and s-ATL measurements.

RESULTS

Patients with higher v-ATL and s-ATL had lower overall survival (OS) and recurrence-free survival (RFS) rates. High ATL was an independent prognostic factor for decreased OS (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.16-4.42; and P = 0.02) and RFS (HR 2.51; 95% CI 1.34-4.71; and P = 0.004) rates.

CONCLUSION

A reduction in adipose tissue volume shortly after surgery (1 month) could potentially indicate an increased risk of recurrence and mortality in patients with GC.

Association of CVAI, LAP and SMI with risk of haematological toxicity after immunochemotherapy in patients with DLBCL: a retrospective study

Background

The occurrence of adverse events after immunochemotherapy in patients with diffuse large B-cell lymphoma (DLBCL) frequently affects the course of chemotherapy, leading to a further decline in quality of life and survival.

Objectives

The primary objective of this study was to investigate the association between Chinese visceral adiposity index (CVAI), lipid accumulation product (LAP) index and skeletal muscle mass index (SMI) at initial diagnosis and the risk of haematological toxicity following immunochemotherapy in patients with DLBCL.

Design

Retrospective, single-centre study.

Methods

CVAI, LAP and SMI were calculated by combining clinical data of the patients. This study included 213 patients, of whom 117 (55%) patients experienced grades 3-4 haematological toxicity after immunochemotherapy. Participants were divided into four groups (Q1, Q2, Q3, Q4) based on the quartiles of CVAI, LAP and SMI.

Results

In the fully adjusted model, the risk of grades 3-4 haematological toxicity in group with the highest CVAI and LAP was reduced by 75.1% (OR: 0.249, 95% CI: 0.102-0.606, p = 0.002) and by 77.3% (OR: 0.227, 95% CI: 0.095-0.542, p = 0.001) compared to the group with the lowest CVAI and LAP. For SMI, the risk of grades 3-4 haematological toxicities in the group with the highest SMI was reduced by 62.9% compared with the lowest SMI group in the unadjusted model. The multivariable-adjusted restricted cubic spline curves and subgroup interaction analyses further confirmed the robustness of these findings.

Conclusion

The results indicate that DLBCL patients with relatively high CVAI, LAP and SMI at initial diagnosis have a lower risk of severe haematological toxicity following chemotherapy. Therefore, CVAI, LAP and SMI at initial diagnosis are reliable and effective biomarkers for predicting severe haematological toxicity after immunochemotherapy in DLBCL patients.

Trial registration

This is a retrospective study, and no registration on ClinicalTrials.gov.

Adherence to Oral Anticancer Agents Among Adults With Gastrointestinal Tract Cancer: A Scoping Review

BACKGROUND

Patients with gastrointestinal tract cancer reported suboptimal adherence to oral anticancer agents (OAAs), reducing their therapeutic benefit and increasing mortality risk. A scoping review can comprehensively map available evidence on adherence to OAAs and inform appropriate support to improve treatment outcomes.

OBJECTIVE

The aim of this study was to comprehensively map studies on adherence to OAAs among adults with gastrointestinal tract cancer, including the adherence rate, nonadherence reasons, influential factors, management strategies, and theories that guide these studies.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews Checklist and the 5-stage methodological framework of scoping review were followed. According to the 5 research questions, 7 databases were systematically searched for peer-reviewed original studies, and a narrative synthesis was performed.

RESULTS

Fifty-two studies were included. Adherence ranged from 16.7% to 100%, giving a median rate of 68% by self-report. Seven categories of nonadherence reasons were identified, with adverse effects, cancer progression, patient refusal, and forgetfulness being most frequently reported. Furthermore, more than 40 influential factors were identified. They are related to patient, disease condition, therapy, socioeconomic, and healthcare-system dimensions. Education and follow-up care were the main components of management strategies, but the effectiveness was inconsistent. Currently, only 3 of 52 studies adopted theoretical frameworks.

CONCLUSION

Adherence to OAAs among adults with gastrointestinal tract cancer is suboptimal. Future studies with rigorous designs and theoretical frameworks are needed to develop adherence-enhancing strategies and explain theoretical mechanisms.

IMPLICATIONS FOR PRACTICE

Routine assessments and preventive actions are suggested to delay modifiable nonadherence.

A novel model based on clinical and computed tomography (CT) indices to predict the risk factors of postoperative major complications in patients undergoing pancreaticoduodenectomy

Background

Postoperative complications are prone to occur in patients after radical pancreaticoduodenectomy (PD). This study aimed to construct and validate a model for predicting postoperative major complications in patients after PD.

Methods

The clinical data of 360 patients who underwent PD were retrospectively collected from two centers between January 2019 and December 2023. Visceral adipose volume (VAV) and subcutaneous adipose volume (SAV) were measured using three-dimensional (3D) computed tomography (CT) reconstruction. According to the Clavien-Dindo classification system, the postoperative complications were graded. Subsequently, a predictive model was constructed based on the results of least absolute shrinkage and selection operator (LASSO) multivariate logistic regression analysis and stepwise (stepAIC) selection. The nomogram was internally validated by the training and test cohort. The discriminatory ability and clinical utility of the nomogram were evaluated by area under the receiver operating characteristic (ROC) curve (AUC), calibration curve, and decision curve analysis (DCA).

Results

The major complications occurred in 13.3% (n = 48) of patients after PD. The nomogram revealed that high VAV/SAV, high system inflammation response index (SIRI), high triglyceride glucose-body mass index (TyG-BMI), low prognostic nutritional index (PNI) and CA199 ≥ 37 were independent risk factors for major complications. The C-index of this model was 0.854 (95%CI [0.800-0.907]), showing excellent discrimination. The calibration curve demonstrated satisfactory concordance between nomogram predictions and actual observations. The DCA curve indicated the substantial clinical utility of the nomogram.

Conclusion

The model based on clinical and CT indices demonstrates good predictive performance and clinical benefit for major complications in patients undergoing PD.

Body Composition Decrease and Impact on Clinical Outcome in Gastric Cancer Patients Undergoing Radical Gastrectomy After Neoadjuvant Treatment

This study investigates the impact of neoadjuvant therapy (NT) on body composition and its correlation with long-term survival and other clinical outcomes in patients with advanced gastric cancer. We utilized Computed Tomography (CT) scans to measure body composition before and after NT, including Subcutaneous Adipose Tissue Index (SATI), Visceral Adipose Tissue Index (VATI), Skeletal Muscle Index (SMI), and Muscle Density (MA). We then analyzed the decrease in body composition in relation to tumor regression, inflammatory markers, nutritional scores, and long-term survival. Our findings reveal a negative correlation between the decrease in SATI and VATI after NT, and both tumor regression and nutritional score. Notably, patients who experienced a significant loss in SATI or VATI post-NT had shorter Recurrence-Free Survival (RFS) and Overall Survival (OS). Additionally, significant loss in SATI and VATI emerged as an independent risk factor for both RFS and OS. In conclusion, our study convincingly demonstrates that in patients with advanced gastric cancer, SATI and VATI decreases after NT and is negatively associated with tumor regression and nutritional score. A significant loss in SATI and VATI is a risk factor for shorter RFS and OS, thereby underscoring the importance of maintaining body composition during NT.

Creatinine-to-cystatin C ratio and body composition predict response to PD-1 inhibitors-based combination treatment in metastatic gastric cancer

Background

Creatinine-to-cystatin C ratio (CCR) and body composition (BC) parameters have emerged as significant prognostic factors in cancer patients. However, the potential effects of CCR in gastric cancer (GC) remains to be elucidated. This multi-center retrospective study explored the predictive and prognostic value of CCR and BC-parameters in patients with metastatic GC receiving PD-1 inhibitors-based combination therapy.

Methods

One hundred and thirteen GC patients undergoing PD-1 inhibitors-based combination therapy were enrolled at three academic medical centers from January 2021 to July 2023. A deep-learning platform based on U-Net was developed to automatically segment skeletal muscle index (SMI), subcutaneous adipose tissue index (SATI) and visceral adipose tissue index (VATI). Patients were divided into two groups based on the median of CCR or the upper tertile of BC-parameters. Logistic and Cox regression analysis were used to determine the effect of CCR and BC-parameters in predicting response rates and survival rates.

Results

The CCR was positively correlated with SMI (r=0.43; P<0.001), but not with SATI or VATI (P>0.05). Multivariable logistic analysis identified that both low CCR (OR=0.423, P=0.066 for ORR; OR=0.026, P=0.005 for DCR) and low SATI (OR=0.270, P=0.020 for ORR; OR=0.149, P=0.056 for DCR) were independently associated with worse objective response rate (ORR) and disease control rate (DCR). Patients with low CCR or low SATI had significantly lower 8-month progression-free survival (PFS) rate and 16-month overall survival (OS) rate than those with high CCR (PFS rate, 37.6% vs. 55.1%, P=0.011; OS rate, 19.4% vs. 44.9%, P=0.002) or those with high SATI (PFS rate, 37.2% vs. 53.8%, P=0.035; OS rate, 8.0% vs. 36.0%, P<0.001). Multivariate Cox analysis showed that low CCR (HR=2.395, 95% CI: 1.234-4.648, P=0.010 for PFS rate; HR=2.528, 95% CI: 1.317-4.854, P=0.005 for OS rate) and low SATI (HR=2.188, 95% CI: 1.050-4.560, P=0.037 for PFS rate; HR=2.818, 95% CI: 1.381-5.752, P=0.004 for OS rate) were both independent prognostic factors of poor 8-month PFS rate and 16-month OS rate. A nomogram based on CCR and BC-parameters showed a good performance in predicting the 12- and 16-month OS, with a concordance index of 0.756 (95% CI, 0.722-0.789).

Conclusions

Low pre-treatment CCR and SATI were independently associated with lower response rates and worse survival in patients with metastatic GC receiving PD-1 inhibitors-based combination therapy.

Impact of Preoperative Nutritional Assessment on Other-Cause Survival after Gastrectomy in Patients with Gastric Cancer

This study aimed to clarify the factors associated with death due to other diseases after a gastrectomy for gastric cancer. This retrospective cohort study included consecutive patients who had undergone gastrectomy between April 2008 and June 2018 for primary stage II-III gastric cancer. The primary outcome was other-cause survival. To identify prognostic factors for other-cause survival for univariate analysis, we used a Cox proportional hazard regression model. A total of 512 patients met the inclusion criteria. The average age was 67.93 years, and the average body mass index was 22.75 kg/m², with 84 (16.4%) being moderately malnourished and 88 (17.2%) being severely malnourished, as defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria. The other-cause survival for the malnourished group was significantly worse than that for the normal group (p < 0.001). The prognosis was worse when the severity of malnutrition was worse (p < 0.001). Multivariate analysis showed that severe malnutrition was significantly independent of prognostic factors for other-cause survival (hazard ratio: 3.310; 95% confidence interval: 1.426-7.682; p = 0.005). Undernutrition, as defined by the GLIM criteria, is useful for the preoperative prediction of death due to other diseases after gastrectomy in patients with advanced gastric cancer.

Prognostic values of myosteatosis for overall survival in patients with gastric cancers: A meta-analysis with trial sequential analysis

OBJECTIVES

Gastric cancer is among the most common and lethal cancers worldwide. Recently, studies have reported that myosteatosis is a prognosticator for adverse survival outcomes in patients with gastric cancer, but with inconsistent conclusions. Therefore, this meta-analysis aimed to systematically quantify the predictive power of myosteatosis for overall survival in the gastric cancer setting.

METHODS

A systematic literature earch was conducted based on three databases (PubMed/Medline, EMBASE, and Web of Science) from inception until November 30, 2021. This meta-analysis pooled the hazard ratios and their 95% confidence intervals of mortality risk in patients with gastric cancer with myosteatosis versus nonmyosteatosis using a fixed-effects model.

RESULTS

Twelve studies of 5904 patients were included. Myosteatosis was associated with higher mortality risk (hazard ratio: 1.46; 95% confidence interval, 1.32-1.61; P < 0.001; I² = 23.8%) in the gastric cancer setting. The results of the subgroup analysis revealed that patients with myosteatosis undergoing surgery had significantly shortened overall survival. Overall, the results of this meta-analysis are robust to sensitivity and trial sequential analyses.

CONCLUSIONS

Myosteatosis was identified as a strong predictor of reduced overall survival in the gastric cancer population.

Effect of malnutrition as defined by the Global Leadership Initiative on Malnutrition criteria on compliance of adjuvant chemotherapy and relapse-free survival for advanced gastric cancer

OBJECTIVES

The aim of the present study was to clarify the effect of malnutrition as defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria on compliance with postoperative adjuvant chemotherapy and relapse-free survival (RFS) in patients with gastric cancer.

METHODS

This single-center, retrospective cohort study included 281 consecutive patients with gastric cancer who underwent radical gastrectomy for pathologic stages II and III and received postoperative S-1 adjuvant chemotherapy between April 2008 and June 2018. Treatment failure was defined as discontinuation of adjuvant chemotherapy ≤1 y. Nutritional assessment was preoperatively performed according to the GLIM criteria for all patients. We analyzed risk factors for treatment failure and poor prognostic factors for RFS using multivariate analyses.

RESULTS

Treatment failure and recurrence were observed in 50 (17.8%) and 97 (34.5%) of the 281 patients, respectively. The median follow-up period was 52 mo. The treatment failure rate was higher (P = 0.032) and RFS was worse (P = 0.017) in the malnutrition group. In multivariate analyses, GLIM criteria-defined malnutrition was an independent risk factor for treatment failure (odds ratio = 3.110; 95% confidence interval [CI], 1.020-9.470; P = 0.046). Furthermore, severe malnutrition was an independent poor prognostic factor for RFS (hazard ratio = 1.767; 95% CI, 1.132-2.759; P = 0.012).

CONCLUSIONS

Preoperative malnutrition as defined by the GLIM criteria was an independent risk factor for poor compliance with adjuvant S-1 chemotherapy and a poor prognostic factor for RFS after radical gastrectomy in patients with advanced gastric cancer. <END ABSTRACT>.

Association of visceral adipose tissue with postoperative outcome in upper gastrointestinal cancer: a systematic review and meta-analysis

BACKGROUND

There is no consensus on the relation between visceral fat mass and long-term postoperative prognosis in patients with upper gastrointestinal (GI) cancer.

OBJECTIVES

The purpose of this study was to investigate the association of preoperative visceral fat mass with postoperative complications and overall survival (OS) in patients with upper GI cancer.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE (Dialog), the WHO International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception through 20 July 2022. We conducted a systematic review and random-effects meta-analysis of studies including patients who were surgically treated for upper GI cancer and whose visceral fat mass was assessed on the basis of body composition. We independently assessed the risk of bias and quality of evidence using the Quality In Prognosis Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. The primary outcome was OS. HRs and 95% CIs for OS were pooled.

RESULTS

Ninety-one studies (n = 20,583) were included. All studies used computed tomography (CT) to assess the body composition of patients. Twenty-four studies reported the relation between high visceral fat and postoperative outcomes, and their results were synthesized. Compared with low visceral adipose tissue, high visceral adipose tissue assessed by CT may improve OS (HR: 0.69; 95% CI: 0.55, 0.87; I2 = 65%; n = 3407). The risk of bias for OS in each study was moderate or high. The certainty of evidence for OS was very low because of inconsistency in the forest plot, the moderate or high risk of bias, and publication bias.

CONCLUSIONS

High visceral fat may be associated with improved OS after radical resection in patients with upper GI cancer. Further studies are needed to confirm these findings and mitigate the risk.

Visceral Adipose Tissue Assessment Enhances the Prognostic Value of GLIM Criteria in Patients with Gastric Cancer Undergoing Radical Gastrectomy after Neoadjuvant Treatment

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria has been recently published for diagnosing malnutrition in adults. However, the validity of the GLIM criteria has not been well-established in patients with gastric cancer (GC) treated with neoadjuvant treatment (NT) followed by radical gastrectomy. The present study aimed to explore the prognostic value of GLIM-defined malnutrition before NT and after NT in GC patients and to investigate whether additional visceral adipose tissue (VAT) assessment could improve the predictive power of the GLIM criteria for NT-related adverse events (AEs) and long-term survival.

METHODS

GC patients who underwent radical surgery after NT from June 2016 to June 2020 were enrolled in this study. The cross-sectional areas of total skeletal muscle (TSM) and VAT were measured using computed tomography (CT) before NT and after NT. GLIM-defined malnutrition was diagnosed using the two-step approach, including nutritional risk screening and diagnostic assessment. Low VAT was also added to the diagnosis of malnutrition in this study. The predictive value of these malnutrition diagnoses for NT-related AEs, and long-term survival was evaluated in GC patients.

RESULTS

A total of 182 GC patients were included in this study, of which 66 (36.3%) patients before NT and 55 (30.2%) patients after NT were diagnosed with GLIM-defined malnutrition, respectively. In addition to GLIM-defined malnutrition, 54 (29.7%) patients had additional low VAT before NT, and 39 (21.4%) patients had additional low VAT after NT. GLIM-defined malnutrition alone before NT was not associated with NT-related AEs in GC patients. The addition of low VAT to GLIM-defined malnutrition led to a significant predictive value for NT-related AEs. Furthermore, GLIM-defined malnutrition before NT and after NT were both identified as independent risk factors for overall survival (OS) and disease-free survival (DFS). The combination of low VAT and GLIM-defined malnutrition showed a higher hazard ratio for the prediction of OS and DFS both before NT and after NT.

CONCLUSIONS

The addition of VAT assessment using CT improved the predictive value of GLIM-defined malnutrition for NT-related AEs and long-term survival in GC patients treated with NT followed by radical gastrectomy, which further supports the prognostic importance of assessing adipose tissue simultaneously during the routine nutritional assessment in patients with cancer.

Impact of malnutrition as defined by the global leadership initiative on malnutrition criteria on the long-term prognosis in older patients with gastric cancer after gastrectomy

PURPOSE

This study investigated whether or not the impact of malnutrition, as defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria, on the long-term prognosis after gastrectomy differed between older and young patients with advanced gastric cancer.

METHODS

This study included patients with primary stage I-III gastric cancer who underwent gastrectomy between April 2008 and June 2018. Patients were divided into normal, moderate, and severe malnutrition groups according to the GLIM criteria for the body mass index (BMI) and body weight loss (BWL). The primary endpoint was the overall survival (OS).

RESULTS

Of the 512 patients, 274 (53.5%) were included in the younger group (< 70 years old) and 238 (46.5%) in the older group (≥ 70 years old). The prevalence of moderate and severe malnutrition was significantly higher in the older group than in the younger group (P < 0.001 and P = 0.001, respectively). A multivariate analysis showed that moderate malnutrition [hazard ratio (HR) 1.793, P = 0.028] and severe malnutrition (HR 2.374, P = 0.002) were independent prognostic factors in the older group but not in the younger group.

CONCLUSION

GLIM criteria-defined malnutrition did not correlate with the prognosis in the younger group, whereas moderate and severe malnutrition were independent poor prognostic factors for the OS in the older group.

The evolving view of thermogenic fat and its implications in cancer and metabolic diseases

The incidence of metabolism-related diseases like obesity and type 2 diabetes mellitus has reached pandemic levels worldwide and increased gradually. Most of them are listed on the table of high-risk factors for malignancy, and metabolic disorders systematically or locally contribute to cancer progression and poor prognosis of patients. Importantly, adipose tissue is fundamental to the occurrence and development of these metabolic disorders. White adipose tissue stores excessive energy, while thermogenic fat including brown and beige adipose tissue dissipates energy to generate heat. In addition to thermogenesis, beige and brown adipocytes also function as dynamic secretory cells and a metabolic sink of nutrients, like glucose, fatty acids, and amino acids. Accordingly, strategies that activate and expand thermogenic adipose tissue offer therapeutic promise to combat overweight, diabetes, and other metabolic disorders through increasing energy expenditure and enhancing glucose tolerance. With a better understanding of its origins and biological functions and the advances in imaging techniques detecting thermogenesis, the roles of thermogenic adipose tissue in tumors have been revealed gradually. On the one hand, enhanced browning of subcutaneous fatty tissue results in weight loss and cancer-associated cachexia. On the other hand, locally activated thermogenic adipocytes in the tumor microenvironment accelerate cancer progression by offering fuel sources and is likely to develop resistance to chemotherapy. Here, we enumerate current knowledge about the significant advances made in the origin and physiological functions of thermogenic fat. In addition, we discuss the multiple roles of thermogenic adipocytes in different tumors. Ultimately, we summarize imaging technologies for identifying thermogenic adipose tissue and pharmacologic agents via modulating thermogenesis in preclinical experiments and clinical trials.

Associations of radiological features of adipose tissues with postoperative complications and overall survival of gastric cancer patients

OBJECTIVES

To evaluate the associations of the radiological features of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) with the postoperative complications and overall survival (OS) of patients undergoing laparoscopic radical gastrectomy for gastric cancer.

METHODS

One hundred forty-two patients underwent laparoscopic radical gastrectomy for gastric cancer from February 2013 to May 2016. The radiological features of SAT and VAT were studied by preoperative computed tomography, and the relationships between the parameters of adipose tissues and the intraoperative and postoperative conditions and OS rate of patients were evaluated.

RESULTS

A positive linear correlation was found between VAT area and operation duration, and a negative linear correlation was found between VAT density and intraoperative blood loss (p < 0.05 in both). VAT area was an independent risk factor for postoperative complications. VAT area and VAT density were independent risk factors for OS in gastric cancer.

CONCLUSIONS

A high VAT area was an independent risk factor for postoperative complications of gastric cancer, whereas a low VAT area and high VAT density were independent risk factors for poor prognosis in terms of OS in gastric cancer.

KEY POINTS

• A large visceral adipose tissue (VAT) area is an unfavourable factor affecting the outcomes of radical gastrectomy for gastric cancer. • Low VAT density may be more likely to cause intraoperative bleeding. • VAT area and VAT density were independent risk factors for the OS of patients with gastric cancer.