Impact of sarcopenia and myosteatosis on survival outcomes for patients with head and neck cancer undergoing curative-intent treatment

Geriatric nutritional risk index and body composition dictate the prognosis of elderly patients with intrahepatic cholangiocarcinoma

Background and aims

Malnutrition is a well-recognized predictor of poor prognosis in malignancies. Recent studies suggest that the geriatric nutritional risk index (GNRI) is a more accurate determinant of prognosis in elderly patients than conventional body mass index (BMI). This study aimed to evaluate the GNRI and body composition parameters in elderly patients with intrahepatic cholangiocarcinoma (ICC) and assess their prognostic impact on long-term outcomes.

Methods

A total of 157 elderly ICC patients (aged ≥65 years) who underwent radical resection between 2009 and 2018 were retrospectively analyzed. Skeletal muscle index (SMI), muscle attenuation (MA), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral-to-subcutaneous fat ratio (VSR) were quantified using computed tomography. Prognostic analyses were conducted using the Kaplan-Meier method, with adjustments using inverse probability weighting. A nomogram based on multivariate Cox regression was constructed and internally validated, comparing its prognostic accuracy with the TNM staging system.

Results

Among the body composition parameters, low SMI (sarcopenia, 56.1%), high VSR (visceral adiposity, 54.8%), and low MA (intramuscular fat deposition, 50.3%) were significantly associated with overall survival (OS) and recurrence-free survival (RFS) (all p < 0.05). Low GNRI was also a strong predictor of poor prognosis (p < 0.001). Multivariate analysis identified low GNRI (p = 0.009), sarcopenia (p = 0.020), visceral adiposity (p = 0.033), and intramuscular fat deposition (p = 0.036) as independent prognostic factors for OS and RFS. The nomogram, incorporating GNRI, SMI, VSR, MA, microvascular invasion (MVI), CA19-9 levels, and lymph node invasion, demonstrated superior prognostic performance compared to the TNM stage, with a C-index of 0.734 (OS) and 0.704 (RFS) and an AUC of 0.809 (OS) and 0.815 (RFS).

Conclusion

GNRI, sarcopenia, IMF deposition, and visceral adiposity independently predict mortality and tumor recurrence in elderly ICC patients. Body composition is a major determinant of prognosis in patients with ICC. Our nomogram based on body composition reveals superior prognostic efficacy over TNM stages.

Tumor metabolism as a factor affecting diversity in cancer cachexia

Cancer cachexia is a multifaceted metabolic syndrome characterized by muscle wasting, fat redistribution, and metabolic dysregulation, commonly associated with advanced cancer but sometimes also evident in early-stage disease. More subtle body composition changes have also been reported in association with cancer, including sarcopenia, myosteatosis, and increased fat radiodensity. Emerging evidence reveals that body composition changes including sarcopenia, myosteatosis, and increased fat radiodensity, arise from distinct biological mechanisms and significantly impact survival outcomes. Importantly, these features often occur independently, with their combined presence exacerbating poor prognoses. Tumor plays a pivotal role in driving these host changes, either by acting as a metabolic parasite or by releasing mediators that disrupt normal tissue function. This review explores the diversity of tumor metabolism. It highlights the potential for tumor-specific metabolic phenotypes to influence systemic effects, including fat redistribution and sarcopenia. Addressing this tumor-host metabolic interplay requires personalized approaches that disrupt tumor metabolism while preserving host health. Promising strategies include targeted pharmacological interventions and anticachexia agents like growth differentiation factor 15 (GDF-15) inhibitors. Nutritional modifications such as ketogenic diets and omega-3 fatty acid supplementation also merit further investigation. In addition to preserving muscle, these therapies will need to be evaluated for their capability to improve survival and quality of life. This review underscores the need for further research into tumor-driven metabolic effects on the host and the development of integrative treatment strategies to address the interconnected challenges of cancer progression and cachexia.

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

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

Malnutrition and radiation therapy in head and neck cancers, a systematic review on reported definitions and associated factors

Radiation therapy is a major treatment in head and neck cancers that can induce mucositis, pain, and dysgeusia that could impair oral intake and lead to weight loss and malnutrition. Intensity modulation has diminished toxicity of radiation therapy. We performed a review to assess the rate of malnutrition and how malnutrition was defined across cohorts of patients undergoing modern curative radiation therapy. We performed a systematic review of prospective cohorts to assess how was defined malnutrition and severe malnutrition as binary outcomes and to report their rates depending on their definition. We screened 250 papers and included 27 papers in the review. Only two studies reported malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) criteria, and the most reported criteria were PG SGA (patient-graded subjective global assessment) B or C and weight loss above 10%. The most frequently reported factors associated with malnutrition were concomitant chemotherapy, tumoral stage, and tumor site. Our review highlighted the major heterogeneity of the reporting of patient's nutritional state across cohorts of head and neck cancers treated by modern curative radiotherapy. Using consensual definition of malnutrition would help to provide stronger evidence on preventive enteral nutrition as well as the causes and consequences of malnutrition in head and neck cancers.

Sarcopenia Is a Prognostic Factor of Adverse Effects and Mortality in Patients With Tumour: A Systematic Review and Meta-Analysis

BACKGROUND

The relationship between sarcopenia and the prognosis of patients with tumours who received radio- and/or chemotherapy still needs to be determined. In this study, we aim to investigate the relationship between sarcopenia and adverse effects and mortality in patients with tumours that received radio- and/or chemotherapy, stratified by study design, tumour category, the method sarcopenia assessed, treatment options, study location and among other factors.

METHODS

PubMed, Web of Science and Embase were searched from inception to 15 August 2024, without language restrictions and with a manual search of references for additional articles retrieval. Cohort studies of ≥ 100 patients with tumours that evaluated the association between sarcopenia or muscle mass and the adverse effects or overall survival induced by radio- and/or chemotherapy were included.

RESULTS

Thirty-nine studies were included, involving 8966 patients with tumours, including 3383 patients with sarcopenia. The pooled prevalence of sarcopenia in patients with tumours was 0.42 (95% CI 0.36-0.48, p < 0.001) overall. The prevalence of sarcopenia is higher in Oceania patients 0.60 (95% CI 0.28-0.89, p < 0.001), those with reproductive tumour 0.57 (95% CI 0.30-0.83, p < 0.001), and sarcopenia assessed by the lumbar-skeletal muscle index 0.46 (95% CI 0.39-0.53, p < 0.001) than in other subgroups, but not show significant differences in sex. Sarcopenia was associated with an increased risk of adverse effects in patients who received radio- and/or chemotherapy, with a relative risk (RR) of 1.44 (95% CI 1.21-1.71, p < 0.001). Retrospective studies (RR = 1.49; 95% CI 1.24-1.79; p < 0.001), sarcopenia assessed by other methods (RR = 2.98; 95% CI 1.52-5.87; p < 0.001), and patients in Europe (RR = 1.92; 95% CI 1.15-3.22; p = 0.013), received chemoradiotherapy (RR = 1.47; 95% CI 1.23-1.76; p < 0.001), and with head and neck tumours (RR = 1.54; 95% CI 1.17-2.01; p = 0.010) had higher relative risk than other subgroups. Sarcopenia was also associated with reduced overall survival in patients with tumours, with a pooled hazard ratio (HR) of 1.66 (95% CI 1.40-1.96, p < 0.001). Prospective studies (HR = 1.72; 95% CI 0.97-3.07; p = 0.065), sarcopenia assessed by the cervical-skeletal muscle index (HR = 2.66; 95% CI 1.73-4.09; p < 0.001), and patients in Asia (HR = 1.91; 95% CI 1.50-2.42; p < 0.001), received chemoradiotherapy (HR = 1.85; 95% CI 1.46-2.45; p < 0.001) and with head and neck tumours (HR = 2.35; 95% CI 1.88-2.95; p < 0.001) had higher HR than other subgroups.

CONCLUSIONS

Sarcopenia was associated with a higher risk of adverse effects and mortality in patients with tumours received radio- and/or chemotherapy.

Prognostic value of sarcopenia and myosteatosis alterations on survival outcomes for esophageal squamous cell carcinoma before and after radiotherapy

OBJECTIVE

We assessed the impact and prognostic significance of alterations in muscle quality and quantity (myosteatosis and sarcopenia, respectively) in patients with esophageal cancer treated with radiotherapy (RT).

METHODS

We retrospectively pooled 258 patients with esophageal squamous cell cancer who underwent RT. Myosteatosis and sarcopenia were determined based on the skeletal muscle index derived from the muscle area and attenuation at the L3 level from computed tomography images. Subgroups were formed as 2 subgroups of non-sarcopenia/myosteatosis and sarcopenia/myosteatosis (with or without other muscle status) at either timepoint of RT, 3 subgroups of only-sarcopenia, only myosteatosis (without other muscle status), and the co-presence of sarcopenia and myosteatosis at either timepoint of RT, as well as 4 subgroups of continuous sarcopenia/myosteatosis, developed sarcopenia/myosteatosis, reduced sarcopenia/myosteatosis and non-sarcopenia/myosteatosis according to alterations of muscle status at both timepoints of RT. Overall survival (OS) was compared. Univariate and multivariate analyses based on Cox regression identified independent risk factors for prognosis.

RESULTS

Either pre- or post-RT, patients with sarcopenia and myosteatosis (with or without other muscle status) had poor OS. Patients with only myosteatosis (without other muscle status) showed the best OS (1352 days pre-RT vs. 1648 days post-RT), while patients with concurrent myosteatosis and sarcopenia had the worst OS (907 days pre-RT vs. 706 days post-RT). The ascending order of OS for sarcopenia alterations was as follows: continuous sarcopenia (1093 days), non-sarcopenia (1740 days), developed sarcopenia (2187 days), and reduced sarcopenia (2208 days) (P = 0.002). The ascending order of OS for myosteatosis alterations was ranked as follows: continuous myosteatosis (1165 days), reduced myosteatosis (1275 days), developed myosteatosis (1783 days), and non-myosteatosis (1942 days) (P = 0.061). Univariate and multivariate Cox regression analyses revealed that increased age, longer tumor length, developed myosteatosis, and continuous myosteatosis were independent prognostic factors for OS.

CONCLUSIONS

Muscle mass status at presentation and alterations in patients with esophageal cancer before and after RT should be considered prognostic indicators.

Comprehensive Geriatric Assessment and Quality of Life Aspects in Patients with Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma (HNSCC)

To define frailty in older cancer patients, the aim of this study was to assess the geriatric status and quality of life (QoL) aspects in patients suffering from recurrent/metastatic head and neck squamous cell carcinoma (r/m HNSCC) under palliative treatment. A comprehensive geriatric assessment (CGA) was performed on 21 r/m HNSCC patients at two defined assessments, and the QoL aspects and the impact of descriptive data were evaluated. The Kolmogorov-Smirnov test, Spearman's rho correlation, and two-way mixed ANOVA were used for statistical analysis. All patients were found to be "frail". Pain, fatigue, and the burden of illness were the highest-rated symptoms. Oral function and orofacial appearance were highly impaired. A significant impact of descriptive data on the CGA and QoL results was found (all p ≤ 0.05). Thus, the CGA results revealed high frailty, severe comorbidities, and high impairments in QoL aspects. The CGA and QoL results were negatively affected by the primary HNSCC treatment approach, the need for prosthetic treatment, and worse oral functional capacity. Therefore, frailty in r/m HNSCC patients seems to be multidimensional. The evaluation of the CGA and QoL aspects in r/m HNSCC patients can be recommended to detect special needs, organize aftercare, and improve the support for frail and vulnerable cancer patients to create a multidisciplinary treatment approach.

Preoperative CT-Based Skeletal Muscle Mass Depletion and Outcomes after Total Laryngectomy

PURPOSE

To assess the role of preoperative CT-based skeletal muscle mass depletion on postoperative clinical outcomes and survival in patients who underwent total laryngectomy for cancer.

METHODS

Patients operated on between January 2011 and March 2020 were retrospectively included. Skeletal muscle area and intra- and inter-muscular fat accumulation were measured at the third lumbar vertebral level on preoperative CT scans. Skeletal muscle mass depletion was defined based on pre-established cut-off values. Their association with postoperative morbidity, length of stay (LOS), costs, and survival was assessed.

RESULTS

A total of 84 patients were included, of which 37 (44%) had preoperative skeletal muscle mass depletion. The rate of postoperative fistula (23% vs. 35%, p = 0.348), cutaneous cervical dehiscence (17% vs. 11%, p = 0.629), superficial incisional surgical site infections (SSI) (12% vs. 10%, p = 1.000), and unplanned reoperation (38% vs. 37%, p = 1.000) were comparable between the two patient groups. No difference in median LOS was observed (41 vs. 33 days, p = 0.295), nor in treatment costs (119,976 vs. 109,402 CHF, p = 0.585). The median overall survival was comparable between the two groups (3.43 vs. 4.95 years, p = 0.09).

CONCLUSIONS

Skeletal muscle mass depletion alone had no significant impact on postoperative clinical outcomes or survival.

Performance assessment and external validation of specific thresholds of total psoas muscle cross-sectional area as predictors of mortality in oncologic spine surgery for spinal metastases

PURPOSE

The purpose of this study was to assess the utility of low muscle mass (LMM) in predicting 90-day and 12-month mortality after spinal tumor surgery.

METHODS

We identified 115 patients operated on for spinal metastases between April 2012 and August 2022 who had available perioperative abdominal or lumbar spine CT scans and minimum 90-day follow-up. LMM was defined as a total psoas muscle cross-sectional area (TPA) at the L4 pedicle level less than 10.5 cm² for men and less than 7.2 cm² for women based on previously reported thresholds. A secondary analysis was performed by analyzing TPA as a continuous variable. The primary endpoint was 90-day mortality, and the secondary endpoint was 12-month mortality. Multivariate logistic regression analyses were performed.

RESULTS

The 90-day mortality was 19% for patients without and 42% for patients with LMM (p = 0.010). After multivariate analysis, LMM was not independently associated with increased odds of 90-day mortality (odds ratio 2.16 [95% confidence interval 0.62 to 7.50]; p = 0.223). The 12-month mortality was 45% for patients without and 71% for patients with LMM (p = 0.024). After multivariate analysis, LMM was not independently associated with increased odds of 12-month mortality (OR 1.64 [95% CI 0.46 to 5.86]; p = 0.442). The secondary analysis showed no independent association between TPA and 90-day or 12-month mortality.

CONCLUSION

Patients with LMM had higher rates of 90-day and 12-month mortality in our study, but this was not independent of other parameters such as performance status, hypoalbuminemia, or primary cancer type.

Prevalence and Impact of Computed Tomography-Defined Sarcopenia on Survival in Patients with Human Papillomavirus-Positive Oropharyngeal Cancer: A Systematic Review

Sarcopenia is a known independent prognostic factor for decreased survival in patients with head and neck cancer; yet, its importance for the growing number of younger patients diagnosed with human papillomavirus (HPV)-positive oropharyngeal carcinoma (OPC+) has not been established. This systematic literature review aimed to determine the prevalence and impact of computed tomography (CT)-defined sarcopenia on survival outcomes for adult OPC+ patients (>18 y) undergoing any treatment modality. Prospective studies were searched using PubMed, Embase, CENTRAL, CINAHL, and Web of Science up until and including February 2022. Bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. In total, 9 studies (total pooled OPC+ patients, n  = 744) were identified and included in this review; 2 at low, 6 at moderate, and 1 at high risk of bias. All studies varied in sarcopenia assessment methods and skeletal muscle index threshold cutoff values. These studies demonstrated the cumulative prevalence of sarcopenia for OPC+ patients to be 42.9% (95% CI: 37.8%, 47.9%). While overall survival (3 studies, n = 253) and progression-free survival (1 study, n = 117) was lower in sarcopenic OPC+ patients, this was not statistically significant. GRADE certainty of evidence for impact of pretreatment sarcopenia on overall survival was low and progression-free survival was very low. Although these studies showed there to be a high prevalence of pretreatment sarcopenia in patients with OPC+, which may decrease survival, the impact on progression-free survival is very uncertain. Further, high-quality research utilizing consistent sarcopenia definitions and assessment methods that are conducted specifically in OPC+ is required to strengthen evidence certainty and determine if sarcopenia is an independent prognostic factor for this population.

Impact of low skeletal muscle mass and quality on clinical outcomes in patients with head and neck cancer undergoing (chemo)radiation

The study aimed to explore the impact of low skeletal muscle mass and quality on survival outcomes and treatment tolerance in patients undergoing radical chemo-radiation therapy for head and neck cancer (HNC). This is significant given the growing interest in sarcopenia as a possible negative predictive/prognostic factor of disease progression and survival. From 2010 to 2017, 225 patients were included in the study. Pre-treatment computed tomography (CT) scans of HNC patients undergoing (chemo)radiation therapy were retrospectively reviewed. The skeletal muscle area, normalized for height to obtain the skeletal muscle index (SMI), the skeletal muscle density (SMD) and the intramuscular adipose tissue area (IMAT) were measured at the level of the L3 vertebra. Low SMD and low SMI were defined according to previously reported thresholds, while high IMAT was defined using population-specific cut-point analysis. SMI, SMD, and IMAT were also measured at the proximal thigh (PT) level and tested as continuous variables. Clinical morpho-functional parameters, baseline nutritional markers with a known or suspected impact on HNC treatment, clinical outcomes and sarcopenia were also collected. In multivariate analyses, adjusted by age, sex, stage, diabetes, body mass index (BMI), and weight loss, L3-SMI was not significantly associated with survival, while poor muscle quality was negatively associated with overall survival (OS) (HR = 1.88, 95% CI = 1.09-3.23, p = 0.022 and HR = 2.04, 95% CI = 1.27-3.27, p = 0.003, for low L3-SMD and high L3-IMAT, respectively), progression-free survival (PFS) (HR = 2.26, 95% CI = 1.39-3.66, p = 0.001 and HR = 1.97, 95% CI = 1.30-2.97, p = 0.001, for low L3-SMD and high L3-IMAT, respectively) and cancer-specific survival (CSS) (HR = 2.40, 95% CI = 1.28-4.51, p = 0.006 and HR = 1.81, 95% CI = 1.04-3.13, p = 0.034, for low L3-SMD and high L3-IMAT, respectively). Indices at the PT level, tested as continuous variables, showed that increasing PT-SMI and PT-SMD were significant protective factors for all survival outcomes (for OS: HR for one cm²/m² increase in PT-SMI 0.96; 95% CI = 0.94-0.98; p = 0.001 and HR for one HU increase in PT-SMD 0.90; 95% CI = 0.85-0.94; p < 0.001, respectively). PT-IMAT was a significant risk factor only in the case of CSS (HR for one cm² increase 1.02; 95% CI = 1.00-1.03; p = 0.046). In conclusion, pre-treatment low muscle quality is a strong prognostic indicator of death risk in patients affected by HNC and undergoing (chemo)radiotherapy with curative intent.

Sarcopenia as a Prognostic Marker in Elderly Head and Neck Squamous Cell Carcinoma Patients Undergoing (Chemo-)Radiation

Sarcopenia is associated with reduced survival and increased toxicity in malignant diseases. The prevalence of sarcopenia increases with age and is an important cause of functional decline. We analyzed sarcopenia and sarcopenia dynamics in elderly head-and-neck squamous cell carcinoma (HNSCC) patients undergoing (chemo)radiation. Skeletal muscle mass of 280 elderly HNSCC-patients (>65 yrs) receiving curative (chemo)radiation was manually outlined and quantified on CT scans at the level of the C3 (C3MA). Cross-sectional muscle area at L3 (L3MA) was calculated and normalized to height (L3MI). Frequency distributions of clinical parameters as well as overall survival (OS), progression-free survival (PFS) and locoregional control (LRC) were calculated regarding sarcopenia. Calculated L3MA correlated with pretherapeutic hemoglobin-levels (ρ = 0.280) bodyweight (ρ = 0.702) and inversely with patient-age (ρ = −0.290). Sarcopenic patients featured larger tumors (T3/4 69.0% vs. 52.8%, p < 0.001), a higher burden of comorbidity (age-adjusted Charlson Comorbidity Index 4.8 vs. 4.2, p = 0.015) and more severe chronic toxicities (CTCAE grade 3/4 24.0% vs. 11.8%, p = 0.022). OS was significantly deteriorated in sarcopenic patients with a median of 23 vs. 91 months (logrank p = 0.002) (HR 1.79, CI 1.22−2.60, p = 0.003) and sarcopenia remained an independent prognostic factor for reduced OS in the multivariate analysis (HR 1.64, CI 1.07−2.52, p = 0.023). After therapy, 33% of previously non-sarcopenic patients developed sarcopenia, while 97% of pre-treatment sarcopenic remained sarcopenic. Median bodyweight decreased by 6.8%, whereas median calculated L3MA decreased by 2.4%. In contrast to pretherapeutic, post-therapeutic sarcopenia is no prognosticator for reduced OS. Pretherapeutic sarcopenia is a significant prognostic factor in elderly HNSCC patients undergoing (chemo-)radiation and should be considered in pretherapeutic decision-making. Its role as a predictive marker for tailored supportive interventions merits further prospective evaluation.

Everything You Always Wanted to Know about Sarcopenia but Were Afraid to Ask: A Quick Guide for Radiation Oncologists (Impact of Sarcopenia in Radiotherapy: The AFRAID Project)

Sarcopenia (SP) is a syndrome characterized by age-associated loss of skeletal muscle mass and function. SP worsens both acute and late radiation-induced toxicity, prognosis, and quality of life. Myosteatosis is a pathological infiltration of muscle tissue by adipose tissue which often precedes SP and has a proven correlation with prognosis in cancer patients. Sarcopenic obesity is considered a "hidden form" of SP (due to large fat mass) and is independently related to higher mortality and worse complications after surgery and systemic treatments with worse prognostic impact compared to SP alone. The evaluation of SP is commonly based on CT images at the level of the middle of the third lumbar vertebra. On this scan, all muscle structures are contoured and then the outlined surface area is calculated. Several studies reported a negative impact of SP on overall survival in patients undergoing RT for tumors of the head and neck, esophagus, rectum, pancreas, cervix, and lung. Furthermore, several appetite-reducing side effects of RT, along with more complex radiation-induced mechanisms, can lead to SP through, but not limited to, reduced nutrition. In particular, in pediatric patients, total body irradiation was associated with the onset of SP and other changes in body composition leading to an increased risk of cardiometabolic morbidity in surviving adults. Finally, some preliminary studies showed the possibility of effectively treating SP and preventing the worsening of SP during RT. Future studies should be able to provide information on how to prevent and manage SP before, during, or after RT, in both adult and pediatric patients.