Sarcopenia and body mass index predict sunitinib-induced early dose-limiting toxicities in renal cancer patients

Sonographic Measurements of Rectus Femoris Muscle Thickness Strongly Predict Neutropenia in Cancer Patients Receiving Chemotherapy

The objective of this study was to explore the possible association between low skeletal muscle mass (SMM)-assessed by computed tomography (CT) and ultrasound (US)-and hematologic toxicity in cancer patients. A prospective cohort study was conducted in cancer patients who received anthracycline-based chemotherapy between 2018 and 2020 and who had baseline abdominal CT including L3 level for measuring SMM. Regional muscle measurements were carried out using US. A total of 65 patients (14 males, 51 females) were included. ROC (receiver operating characteristic) analysis identified threshold values of 18.0 mm [AUC (area under the curve) = 0.765] for females and 20.0 mm (AUC = 0.813) for males, predicting severe neutropenia. Using these cut-offs, females with low rectus femoris (RF) thickness (<18.0 mm) had a significantly higher incidence of grade ≥3 neutropenia (50.0% vs. 10.8%, p = 0.005), and males with low RF values (<20.0 mm) had a higher incidence (80.0% vs. 22.2%, p = 0.063). A regression analysis, irrespective of age, gender, and body mass index, revealed that only low RF muscle thickness increased the risk of grade 3-4 neutropenia by 9.210 times (95% CI = 2.401-35.326, p = 0.001). Utilizing US to measure RF muscle thickness aids in identifying cancer patients at an elevated risk of developing neutropenia. Needless to say, US can serve as a convenient and easily accessible tool for assessing low SMM, providing repeat point-of-care evaluations in clinical practice.

Prognostic value of pan-immune-inflammation value and body mass index in geriatric patients with metastatic renal cell carcinoma treated with tyrosine kinase inhibitors as first line treatment. A single-center retrospective study

Introduction

Geriatric patients with metastatic renal cell carcinoma (mRCC) are underrepresented in clinical trials. Evaluation of the efficacy of the treatment and assignation of individuals to proper prognostic groups is an absolute necessity to guarantee them the best possible care.

Material and methods

A total of 138 geriatric patients with mRCC treated with first-line tyrosine kinase inhibitors (TKIs) at the Maria Skłodowska-Curie National Research Institute of Oncology were retrospectively analyzed to determine whether the body mass index (BMI) and pan-immune-inflammation value (PIV) are prognostic values for overall survival (OS) and progression-free survival (PFS) in this type of cancer. For this purpose, Cox's proportional hazard model was used.

Results

The median duration of follow-up for surviving patients was 46.6 (95% CI: 17.4-75.8) months. The median OS and PFS were respectively 33.8 months (95% CI: 23.8-47.8) and 19.1 months (95% CI: 15.0-23.3). BMI (p = 0.034) and PIV (p < 0.001) were statistically significantly associated with OS, and PIV (p = 0.001) was statistically significantly associated with PFS. The risk of death for patients from the high-PIV group (cut-off point: 548) was 3.4 times higher than for those with lower PIV values. The corresponding risk of progression for patients from the high-PIV group was 2.2 times higher. The G8 geriatric screening tool was not identified as a prognostic factor.

Conclusions

Lower PIV and obesity are associated with longer OS in geriatric mRCC patients treated with TKIs in the first line. These factors may be considered while making treatment decisions if further studies show the same results.

[Sarcopenia in patients with pancreatic cancer, an independant prognostic factor]

BACKGROUND

Pancreatic cancer is despite modern diagnostic tools and treatment regimen associated with poor outcome. Many patients show cachexia and sarcopenia.

METHODS

In a retrospective analysis the SMI (cm²/m²) was measured by determining the skelettal muscle area in a computed tomography image at lumbar vertebrae 3. Further clinical parameters were measured to determine the outcome.

RESULTS

The mean survival after diagnosis in the population with sarcopenia was significantly lower (14,4 vs 17,7 months, p=0,046). Significantly shorter survival was also seen for higher age (p=0,006), no tumor resection (p=0,004), metastases (p=0,002) and high CA19-9 level (p=0,002) CONCLUSION: Sarcopenia is an indipendant prognostic factor in patients with pancreatic cancer. SMI should be measured clinical practice and further studies are necessary to asses a potential therapeutic strategy.

Sarcopenia assessments as predictors of overall survival in patients with metastatic renal cell carcinoma

BACKGROUND

Sarcopenia represents an important prognostic marker in tumor patients. However, measurement methods and threshold values are not uniformly defined. The aim of this study is therefore to determine the prognostic value of current definitions of sarcopenia in patients with metastatic renal cell carcinoma treated with tyrosine-kinase-inhibitors (TKIs).

METHODS

In 93 patients with metastatic renal cell carcinoma, sarcopenia was assessed based on manually assisted software measurements of sarcopenia indices based on different muscle areas. Whole muscle area and psoas muscle area at L3 were estimated and adjusted to patient's height in routine CT imaging before the start of first-line TKI therapy. The correlation of different sarcopenia definitions to overall survival was investigated in a univariate analysis as well as in a multivariate analysis.

RESULTS

The mean patients' age at inclusion was 65.8 years (21-86 years). Median survival was 12.3 months (IQR: 5.7-29.8 months), and mean survival was 18.8 months (SD: 17.2 months). As the definitions of sarcopenia differ considerably, 7.6% to 96.7% of the patients were classified as sarcopenic. In univariate analysis, sarcopenia was significantly associated with overall survival. Multivariate analysis, taking into account the Memorial Sloan Kettering Cancer Center risk score, revealed that some sarcopenia-indices are additional and independent prognostic markers. The risk of death was approximately doubled in sarcopenic patients.

CONCLUSIONS

Sarcopenia is an important prognostic factor in patients with metastatic renal cell carcinoma treated with TKIs. Multivariate analysis demonstrates a doubling of the risk of death in sarcopenic patients. The assessment of sarcopenia can be performed by the analysis of routine staging imaging using indices of the total muscle area or the psoas muscle area.

Comprehensive assessment of pretreatment sarcopenia impacts on patients with EGFR-mutated NSCLC treated with afatinib

BACKGROUND

This study aimed to comprehensively evaluate the efficacy and toxicity of afatinib in patients with sarcopenia, an important prognostic factor for treatment efficacy and toxicity in patients with cancer.

METHODS

The clinical features of patients with advanced NSCLC treated with frontline afatinib between 2014 and 2018 at a medical center in Taiwan were retrospectively reviewed. Sarcopenia was evaluated based on the total cross-sectional area of skeletal muscles assessed by computed tomography (CT) imaging at the L3 level. Baseline characteristics, response rates, survival rates, and adverse events (AEs) were compared between sarcopenic and nonsarcopenic patients.

RESULTS

A total of 176 patients evaluated for sarcopenia by CT and treated with afatinib were enrolled in the current study. Sarcopenia was significantly associated with good performance status, low body mass index (BMI), low body surface area (BSA), and low total mass area (TMA). Sarcopenia did not influence the response rate (69.2% vs. 72.0%, p = 0.299), progression-free survival (median 15.9 vs. 14.9 months, p = 0.791), or overall survival (median 26.5 vs. 27.2 months, p = 0.441). However, BSA ≤ 1.7 and the 40 mg afatinib dose were associated with dose reduction. TMA was the only independent factor for afatinib discontinuation due to AEs.

CONCLUSION

Sarcopenia was not associated with treatment efficacy or toxicity among patients with NSCLC harboring common mutations treated with afatinib, indicating sarcopenic patients should not be excluded from afatinib treatment. Other factors, such as BSA and TMA, were associated with dose reduction and afatinib discontinuation, respectively, which may require additional evaluations in future studies.

Obesity, cancer, and response to immune checkpoint inhibitors: Could the gut microbiota be the mechanistic link?

Immune checkpoint inhibitors (ICI) have deeply changed the therapeutic management of a broad spectrum of solid tumors. Recent observations showed that obese patients receiving ICIs might have better outcomes than those with normal weight, while obesity was historically associated with a worse prognosis in cancer patients. Of note, obesity is associated with alterations in the gut microbiome profile, which interacts with immune and inflammatory pathways, both at the systemic and intratumoral levels. As the influence of the gut microbiota on the response to ICI has been repeatedly reported, a specific gut microbiome profile in obese cancer patients may be involved in their better response to ICI. This review summarizes recent data on the interactions between obesity, gut microbiota, and ICIs. In addition, we highlight possible pathophysiological mechanisms supporting the hypothesis that gut microbiota could be one of the links between obesity and poor response to ICIs.

Impact of sarcopenia indexes on survival and severe immune acute toxicity in metastatic non-small cell lung cancer patients treated with PD-1 immune checkpoint inhibitors

BACKGROUND & AIMS

Sarcopenia has long been associated with higher toxicity induced by anti-cancer treatments and shorter survival in patients with solid tumors. The creatinine-to-cystatin ratio (CC ratio, serum creatinine/cystatin C × 100) and the sarcopenia index (SI, serum creatinine × cystatin C (CysC)-based glomerular filtration rate (eGFR_CysC)) are have been reported to be correlated with skeletal muscle mass. The aim of this study is to assess primarily whether the CC ratio and the SI could predict mortality in metastatic non-small cell lung cancer (NSCLC) patients treated with PD-1 inhibitors, and secondarily their impact on severe immune-related adverse effects (irAEs).

METHODS

From the prospective CERTIM cohort, we analyzed retrospectively stage IV NSCLC patients, who received PD-1 inhibitors between June 2015 and November 2020 in Cochin Hospital (Paris, France). We assessed sarcopenia measuring skeletal muscle area (SMA) by computed tomography and handgrip strength (HGS) by a hand dynamometer.

RESULTS

In total, 200 patients were analyzed. The CC ratio and the IS were significantly correlated with SMA and HGS: r_CC/SMA = 0.360, r_SI/SMA = 0.407, r_CC/HGS = 0.331, r_SI/HGS = 0.370. In multivariate analysis of overall survival, a lower CC ratio (HR 1.73, P = 0.033) and a lower SI (HR 1.89, P = 0.019) were independent predictors of poor prognosis. In univariate analysis of severe irAEs, CC ratio (OR 1.01, P = 0.628) and SI (OR 0.99, P = 0.595) were not associated with a higher risk of severe irAEs.

CONCLUSIONS

In metastatic NSCLC patients treated with PD-1 inhibitors, a lower CC ratio and a lower SI are independent predictors of mortality. However, they are not associated with severe irAEs.

Imaging Techniques to Determine Degree of Sarcopenia and Systemic Inflammation in Advanced Renal Cell Carcinoma

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date understanding regarding the literature on sarcopenia and inflammation as prognostic factors in the context of renal cell carcinoma (RCC).

RECENT FINDINGS

Sarcopenia is increasingly recognized as a prognostic factor in RCC. Emerging literature suggests monitoring quantity of muscle on successive imaging and examining muscle density may be additionally informative. Inflammation has prognostic ability in RCC and is also considered a key contributor to development and progression of both RCC and sarcopenia. Recent studies suggest these two prognostic factors together may provide additional prognostic ability when used in combination. Ongoing developments include quality control regarding sarcopenia research and imaging, improving understanding of muscle loss mechanisms, and enhancing clinical incorporation of sarcopenia via improving imaging analysis practicality (i.e., artificial intelligence) and feasible biomarkers. Sarcopenia and systemic inflammation are complementary prognostic factors for adverse outcomes in patients with RCC. Further study on high-quality sarcopenia assessment standardization and expedited sarcopenia assessment is desired for eventual routine clinical incorporation of these prognostic factors.

Overcoming barriers to timely recognition and treatment of cancer cachexia: Sharing Progress in Cancer Care Task Force Position Paper and Call to Action

Cachexia is a life-threatening disorder affecting an estimated 50-80% of cancer patients. The loss of skeletal muscle mass in patients with cachexia is associated with an increased risk of anticancer treatment toxicity, surgical complications and reduced response. Despite international guidelines, the identification and management of cancer cachexia remains a significant unmet need owing in part to the lack of routine screening for malnutrition and suboptimal integration of nutrition and metabolic care into clinical oncology practice. In June 2020, Sharing Progress in Cancer Care (SPCC) convened a multidisciplinary task force of medical experts and patient advocates to examine the barriers preventing the timely recognition of cancer cachexia, and provide practical recommendations to improve clinical care. This position paper summarises the key points and highlights available resources to support the integration of structured nutrition care pathways.

Nutrition care is an integral part of patient-centred medical care: a European consensus

While healthcare is becoming more patient-centred, evidence-based nutrition interventions are still not accessible to all patients with cancer. As nutrition interventions directly improve clinical and socioeconomic outcomes, patient-centred care is not complete without nutrition care. While awareness of the negative impact of malnutrition on clinical outcomes, quality of life, and functional and emotional wellbeing in cancer is growing, there is relatively poor awareness amongst patients, clinicians, policymakers, and payers that nutrition interventions -particularly those begun in the early stages of the disease course- are an effective method for improving such outcomes. The European Beating Cancer Plan recognises the need for a holistic approach to cancer but lacks actionable recommendations to implement integrated nutrition cancer care at member state level. When considering nutrition care as a human right, the impact on quality of life and functional status must be prioritized, as these may be equally as important to patients, especially in advanced cancer where improvements in clinical outcomes such as survival or tumour burden may not be attainable. We formulate actions needed at the regional and the European level to ensure integrated nutrition care for all patients with cancer. The 4 main Take Home Messages are as follows: 1. The goals of Europe's Beating Cancer Plan cannot be achieved without integrating nutrition across the cancer care continuum. 2. Malnutrition negatively impacts clinical outcomes and has socioeconomic consequences for patients and healthcare systems. 3. Championing integrating nutrition care into cancer care is therefore the duty and ethical responsibility of clinicians (Hippocratic Oath-primum non nocere) and 4. Nutrition care is a cost effective, evidence-based therapy.

The prognostic value of the combination of body composition and systemic inflammation in patients with cancer cachexia

BACKGROUND

Changes in body composition and systemic inflammation are important characteristics of cancer cachexia. This multi-centre retrospective study aimed to explore the prognostic value of the combination of body composition and systemic inflammation in patients with cancer cachexia.

METHODS

The modified advanced lung cancer inflammation index (mALI), which combines body composition and systemic inflammation, was defined as appendicular skeletal muscle index (ASMI) × serum albumin/neutrophil-lymphocyte ratio. The ASMI was estimated according to a previously validated anthropometric equation. Restricted cubic splines were used to evaluate the relationship between mALI and all-cause mortality in patients with cancer cachexia. Kaplan-Meier analysis and Cox proportional hazard regression analysis were used to evaluate the prognostic value of mALI in cancer cachexia. A receiver operator characteristic curve was used to compare the effectiveness of mALI and nutritional inflammatory indicators in predicting all-cause mortality in patients with cancer cachexia.

RESULTS

A total of 2438 patients with cancer cachexia were enrolled, including 1431 males and 1007 females. The sex-specific optimal cut-off values of mALI for males and females were 7.12 and 6.52, respectively. There was a non-linear relationship between mALI and all-cause mortality in patients with cancer cachexia. Low mALI was significantly associated with poor nutritional status, high tumour burden, and high inflammation. Patients with low mALI had significantly lower overall survival (OS) than those with high mALI (39.5% vs. 65.5%, P < 0.001). In the male population, OS was significantly lower in the low mALI group than in the high group (34.3% vs. 59.2%, P < 0.001). Similar results were also observed in the female population (46.3% vs. 75.0%, P < 0.001). mALI was an independent prognostic factor for patients with cancer cachexia (hazard ratio [HR] = 0.974, 95% confidence interval [CI] = 0.959-0.990, P = 0.001). For every standard deviation [SD] increase in mALI, the risk of poor prognosis for patients with cancer cachexia was reduced by 2.9% (HR = 0.971, 95%CI = 0.943-0.964, P < 0.001) in males and 8.9% (HR = 0.911, 95%CI = 0.893-0.930, P < 0.001) in females. mALI is an effective complement to the traditional Tumour, Lymph Nodes, Metastasis (TNM) staging system for prognosis evaluation and a promising nutritional inflammatory indicator with a better prognostic effect than the most commonly used clinical nutritional inflammatory indicators.

CONCLUSIONS

Low mALI is associated with poor survival in both male and female patients with cancer cachexia and is a practical and valuable prognostic assessment tool.

Impact of low and high body mass index on predicting therapeutic efficacy and prognosis in patients with metastatic renal cell carcinoma treated with first-line tyrosine kinase inhibitors

OBJECTIVE

To evaluate the significance of both low and high body mass index (BMI) as a biomarker in first-line tyrosine kinase inhibitors (TKIs) for metastatic renal cell carcinoma (mRCC).

METHODS

The oncological outcome of 235 patients with mRCC treated with TKI from 2007 to 2018 was reviewed retrospectively. All patients received first-line TKI as therapy. We analyzed the relationship between BMI (low and high) and disease control rate. The primary outcome was progression free survival and overall survival, and the association between BMI and survival prognosis was evaluated.

RESULTS

The median BMI was 22.5 kg/m² , and 25 patients (10.7%) had a low BMI (<18.5 kg/m² ), 158 patients (67.2%) had a normal BMI (18.5-25 kg/m² ), and 52 patients (22.1%) had a high BMI (≥ 25 kg/m² ). Patients in the low BMI group had a significantly lower disease control rate, whereas patients in the high BMI group had a significantly higher disease control rate (p = 0.002 and p = 0.030, respectively). A log-rank test showed prognosis to be significantly poorer in the low BMI group and to be significantly better in the high BMI group than that in the normal BMI group. Multivariable Cox regression analysis showed that low BMI was an independent indicator of poor prognosis, whereas high BMI was an independent indicator of favorable prognosis.

CONCLUSION

We showed the impact of both low and high BMI on predicting therapeutic efficacy and prognosis in mRCC patients treated with TKI.

The Effectiveness of Sarcopenia Interventions for Cancer Patients Receiving Chemotherapy: A Systematic Review and Meta-analysis

BACKGROUND

Among people with cancer undergoing chemotherapy, generalized loss of muscle mass, termed secondary sarcopenia , is associated with treatment toxicities and physical disability.

OBJECTIVE

This systematic review and meta-analysis aimed to provide an overview of current interventions for sarcopenia in cancer patients receiving chemotherapy and to assess potentially effective interventions.

METHODS

We searched PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus, and EMBASE for primary original research of exercise and nutrition interventions for sarcopenia published in English. The review used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Standardized mean difference and 95% confidence interval (CI) were calculated as effect measures by applying the random-effects model.

RESULTS

The 6 included studies showed a trend toward significantly increasing skeletal muscle mass after intervention (mean difference, 0.168; 95% CI, -0.015 to 0.352; P = .072), with no significant changes in lean body mass loss after intervention (mean difference, -0.014; 95% CI, -1.291 to 1.264; P = .983). Resistance exercise and combined exercise and nutrition intervention were more effective at preserving or increasing muscle mass.

CONCLUSIONS

Early implementation of a resistance exercise intervention or a combined exercise and nutrition intervention is a promising strategy for avoiding muscle mass loss during chemotherapy. Additional evidence-based assessments of interventions for secondary sarcopenia are needed to identify the most effective approach.

IMPLICATIONS FOR PRACTICE

In clinical practice, oncology nurses should frequently assess cancer patients' muscle mass and when warranted should implement the most feasible early sarcopenia intervention to minimize the adverse outcomes of this condition.

Pre-Therapeutic Sarcopenia among Cancer Patients: An Up-to-Date Meta-Analysis of Prevalence and Predictive Value during Cancer Treatment

This study will address the prevalence of pre-therapeutic sarcopenia (PS) and its clinical impact during cancer treatment among adult cancer patients ≥ 18 years of age. A meta-analysis (MA) with random-effect models was performed via a MEDLINE systematic review, according to the PRISMA statement, focusing on articles published before February 2022 that reported observational studies and clinical trials on the prevalence of PS and the following outcomes: overall survival (OS), progression-free survival (PFS), post-operative complications (POC), toxicities (TOX), and nosocomial infections (NI). A total of 65,936 patients (mean age: 45.7-85 y) with various cancer sites and extensions and various treatment modes were included. Mainly defined by CT scan-based loss of muscle mass only, the pooled prevalence of PS was 38.0%. The pooled relative risks were 1.97, 1.76, 2.70, 1.47, and 1.76 for OS, PFS, POC, TOX, and NI, respectively (moderate-to-high heterogeneity, I²: 58-85%). Consensus-based algorithm definitions of sarcopenia, integrating low muscle mass and low levels of muscular strength and/or physical performance, lowered the prevalence (22%) and heterogeneity (I² < 50%). They also increased the predictive values with RRs ranging from 2.31 (OS) to 3.52 (POC). PS among cancer patients is prevalent and strongly associated with poor outcomes during cancer treatment, especially when considering a consensus-based algorithm approach.

Oncology-Led Early Identification of Nutritional Risk: A Pragmatic, Evidence-Based Protocol (PRONTO)

Nutritional issues, including malnutrition, low muscle mass, sarcopenia (i.e., low muscle mass and strength), and cachexia (i.e., weight loss characterized by a continuous decline in skeletal muscle mass, with or without fat loss), are commonly experienced by patients with cancer at all stages of disease. Cancer cachexia may be associated with poor nutritional status and can compromise a patient's ability to tolerate antineoplastic therapy, increase the likelihood of post-surgical complications, and impact long-term outcomes including survival, quality of life, and function. One of the primary nutritional problems these patients experience is malnutrition, of which muscle depletion represents a clinically relevant feature. There have been recent calls for nutritional screening, assessment, treatment, and monitoring as a consistent component of care for all patients diagnosed with cancer. To achieve this, there is a need for a standardized approach to enable oncologists to identify patients commencing and undergoing antineoplastic therapy who are or who may be at risk of malnutrition and/or muscle depletion. This approach should not replace existing tools used in the dietitian's role, but rather give the oncologist a simple nutritional protocol for optimization of the patient care pathway where this is needed. Given the considerable time constraints in day-to-day oncology practice, any such approach must be simple and quick to implement so that oncologists can flag individual patients for further evaluation and follow-up with appropriate members of the multidisciplinary care team. To enable the rapid and routine identification of patients with or at risk of malnutrition and/or muscle depletion, an expert panel of nutrition specialists and practicing oncologists developed the PROtocol for NuTritional risk in Oncology (PRONTO). The protocol enables the rapid identification of patients with or at risk of malnutrition and/or muscle depletion and provides guidance on next steps. The protocol is adaptable to multiple settings and countries, which makes implementation feasible by oncologists and may optimize patient outcomes. We advise the use of this protocol in countries/clinical scenarios where a specialized approach to nutrition assessment and care is not available.

Contribution of skeletal muscle to cancer immunotherapy: A focus on muscle function, inflammation, and microbiota

Sarcopenia, characterized by degenerative and systemic loss of skeletal muscle mass and function, is a multifactorial syndrome commonly observed in individuals with cancer. Additionally, it represents a poor nutritional status and indicates possible presence of cancer cachexia. Recently, with the extensive application of cancer immunotherapy, the effects of sarcopenia/cachexia on cancer immunotherapy, have gained attention. The aim of this review was to summarize the influence of low muscle mass (sarcopenia/cachexia) on the response and immune-related adverse events to immunotherapy from the latest literature. It was revealed that low muscle mass (sarcopenia/cachexia) has detrimental effects on cancer immunotherapy in most cases, although there were results that were not consistent with this finding. This review also discussed potential causes of the paradox, such as different measure methods, research types, muscle indicators, time point, and cancer type. Mechanically, chronic inflammation, immune cells, and microbiota may be critically involved in regulating the efficacy of immunotherapy under the condition of low muscle mass (sarcopenia/cachexia). Thus, nutritional interventions will likely be promising ways for individuals with cancer to increase the efficacy of immunotherapy in the future, for low muscle mass (sarcopenia/cachexia) is an important prognostic factor for cancer immunotherapy.

The role of sarcopenia in treatment-related outcomes in patients with renal cell carcinoma: A systematic review and meta-analysis

BACKGROUND

in recent years, more attention has been paid to the fuzzy relationship between skeletal muscle components and renal cell carcinoma (RCC). This study attempts to conduct a meta-analysis using all relevant research evidence to explore the impact of sarcopenia on the final survival and recurrence outcome of RCC patients and the change process of this impact after treatment.

METHODS

This systematic review and Meta-analysis study took "sarcopenia", "kidney" and "tumor" and their synonyms as the main search terms, and comprehensively searched all relevant literatures published in PubMed, web of science, SpringerLink, EMBASE, Cochrane Library, Ovid (Lww oup), Wiley, ScienceDirect and Scopus databases since February 2, 2022. Multivariate hazard ratio (HR) and 95% confidence interval (CI) of overall survival (OS), cancer specific survival (CSS), and progression free survival (PFS), as well as rough data of Kaplan-Meier survival curve, were combined as the main analysis results. Subgroup analyses based on cohort characteristics (treatment, ethnicity, and BMI factors) for each study were used as secondary outcomes. The combined effect was estimated by random effect model or fixed effect model, and the heterogeneity was evaluated by I2 value. Because this study belongs to secondary literature, the medical ethics committee of the First Affiliated Hospital of Xinjiang Medical University considers that ethical review is unnecessary.

RESULTS

Eighteen retrospective studies involving 3591 patients with RCC were analyzed, of which 71.5% were men and the median age of the cohort was 61.6. The prevalence of sarcopenia was 43% (38-48%). Sarcopenia is an independent predictor of OS (HR: 1.83, 95% CI = [1.41, 2.37]), and this prognostic value can also be reflected in Asian populations (HR: 2.59, 95% CI = [1.90, 3.54]) and drug treated patients (HR: 2.07, 95% CI = [1.07, 4.04]). Sarcopenia can also be used as an independent predictor of CSS (HR: 1.78, 95% CI = [1.34, 2.36]) and PFS (HR: 1.98, 95% CI = [1.34, 2.92]). The effect of low skeletal muscle mass on OS and CSS increased slowly from 1 to 5 years.

CONCLUSION

Sarcopenia can be used as a comprehensive prognostic factor in RCC population, but the detailed effects from ethnic characteristics and treatment mechanism need to be further studied.

Weight and skeletal muscle loss with cabozantinib in metastatic renal cell carcinoma

BACKGROUND

Cabozantinib, a standard of care metastatic renal cell carcinoma (mRCC), may be associated with weight and muscle loss. These effects of new generation VEGFR tyrosine kinase inhibitor on muscle mass loss are poorly described.

METHODS

All cabozantinib-treated mRCC patients from January 2014 to February 2019 in our institution were included. Clinical data including weight were collected during therapy. Computed tomography images were centrally reviewed for response assessment, and axial sections at the third lumbar vertebrae were used to measure the total muscle area. Toxicities and cabozantinib outcomes were evaluated. Co-primary endpoints included skeletal muscle loss and weight loss (WL), longitudinally evaluated during treatment. WL has been classified according to CTCAEv5.0: Grade 1 (loss of 5 to <10% of baseline body weight), Grade 2 (loss of 10% to <20% of baseline body weight), and Grades 3-4 (loss >20% of baseline body weight).

RESULTS

Patients were mostly men (70.3%), median age was 59.2 (range: 22.0-78.0) years, and median baseline body mass index was 25.0 (range: 16.4-49.3) kg/cm² . Prognosis according to International Metastatic RCC Database Consortium score was good, intermediate, and poor for 13 (13.0%), 63 (63.0%), and 24 (24.0%) patients, respectively. Out of a total of 120 patients, 101 patients with a median follow-up of 22.3 months (range: 4.5-62.2) were eligible for analysis; 85 experienced muscle loss and muscle loss >10% increased during cabozantinib exposition, especially after 6 months of treatment. At cabozantinib baseline, 71 patients (70.3%) had sarcopenia, and 16/30 (53.3%) non-sarcopenic patients developed sarcopenia during treatment. Baseline sarcopenia was associated with lower response rates (P = 0.031) and higher grades 3-4 toxicities (P = 0.001). Out of 92 patients included in the WL analysis, 44 (47.8%) and 12 (13.0%) experienced grades 2 and 3 WL, respectively.

CONCLUSIONS

We report a high incidence of grades 3-4 WL, fourth times higher than reported in prior pivotal trials, and half of the patients developed sarcopenia while on cabozantinib treatment. Weight and muscle mass loss with cabozantinib are underreported and may require further investigations and early management.

A Profile of Avelumab Plus Axitinib in the Treatment of Renal Cell Carcinoma

Until recently, the approved first-line treatment for metastatic RCC (mRCC) consisted of tyrosine kinase inhibitors (TKI) targeting the vascular endothelial growth factor receptors (VEGFR) monotherapy. The landscape of first-line treatment has been transformed in the last few years with the advent of immune checkpoint inhibitors (ICI) or VEGFR TKI plus ICI combinations. This article focuses on the profile of one of these ICI plus VEGFR TKI combination, avelumab plus axitinib. We detail the characteristics of each drug separately, and then we explore the rationale for their association, its efficacy and the resulting toxicity. Finally, we examine the factors associated with avelumab plus axitinib outcomes, and their impact on therapeutic strategy.

Clinical Features and Body Composition in Men with Hormone-Sensitive Metastatic Prostate Cancer: A Pilot Study Examining Differences by Race

Black men treated with frontline therapies for metastatic prostate cancer (MPC) show better clinical outcomes than non-Black men receiving similar treatments. Variations in body composition may contribute to these findings. However, preliminary data are required to support this concept. We conducted a retrospective cohort study for all men with MPC evaluated at our center over a 4-year period, collecting demographic and clinical data (N = 74). Of these, 55 men had diagnostic computed tomography images to quantify adipose tissue and skeletal muscle, specifically sarcopenia and myosteatosis. Nineteen men had repeat imaging to explore changes over time. Frequencies, medians, interquartile ranges, and time to event analyses (hazard ratios (HR); confidence interval (CI)) are presented, stratified by race. Overall, 49% (n = 27) of men had sarcopenia, 49% (n = 27) had myosteatosis, and 29% (n = 16) had sarcopenia and myosteatosis simultaneously. No significant relationship between body mass index (Log-rank $p=0.86$ ; HR: 1.05, 95% CI: 0.45–2.49) or sarcopenia (Log-rank $p=0.92$ ; HR: 1.01, 95% CI: 0.46–2.19) and overall survival was observed. However, the presence of myosteatosis at diagnosis was associated with decreased overall survival (Log-rank $p=0.09$ ; HR: 2.34, 95% CI: 1.05–5.23), with more pronounced (statistically nonsignificant) negative associations for Black (HR: 4.39, 95% CI: 0.92–21.1, $p=0.06$ ) versus non-Black men (HR: 1.89, 95% CI: 0.79–4.54, $p=0.16$ ). Over the median 12.5 months between imaging, the median decline in skeletal muscle was 4% for all men. Black men displayed a greater propensity to gain more adipose tissue than non-Black men, specifically subcutaneous ( $p=0.01$ ). Because of the potential for Type II errors in this pilot, future studies should seek to further evaluate the implications of body composition on outcomes. This will require larger, adequately powered investigations with diverse patient representation.

CT-Derived Body Composition Assessment as a Prognostic Tool in Oncologic Patients: From Opportunistic Research to Artificial Intelligence-Based Clinical Implementation

CT-based body composition measures are well established in research settings as prognostic markers in oncologic patients. Numerous retrospective studies have shown the role of objective measurements extracted from abdominal CT images of skeletal muscle, abdominal fat, and bone mineral density in providing more accurate assessments of frailty and cancer cachexia in comparison with traditional clinical methods. Quantitative CT-based measurements of liver fat and aortic atherosclerotic calcification have received relatively less attention in cancer care but also provide prognostic information. Patients with cancer routinely undergo serial CT scans for staging, treatment response, and surveillance, providing the opportunity for performing quantitative body composition assessment as part of routine clinical care. The emergence of fully automated artificial intelligence-based segmentation and quantification tools to replace earlier time-consuming manual and semi-automated methods for body composition analysis will allow these opportunistic measures to transition from the research realm to clinical practice. With continued investigation, the measurements may ultimately be applied to achieve more precise risk stratification as a component of personalized oncologic care.

Impact of Baseline Muscle Mass and Myosteatosis on the Development of Early Toxicity During First-Line Chemotherapy in Patients With Initially Metastatic Pancreatic Cancer

Objectives

Although chemotherapy is the only treatment option for metastatic pancreatic cancer (PDAC), patients frequently encounter adverse events during chemotherapy leading deterioration of patients’ quality of life and treatment interruption. We evaluated the role of baseline CT-assessed body composition in predicting early toxicity during first cycle of the first-line chemotherapy in patients with metastatic PDAC.

Methods

This retrospective study included 636 patients with initially metastatic PDAC who underwent first-line chemotherapy from January 2009 to December 2019. Chemotherapy regimen, baseline laboratory data, and body composition parameters acquired from baseline CT were obtained. The skeletal muscle index (SMI) was used to identify patients with a low muscle mass (SMI &lt; 41 cm2/m2 for women, and &lt; 43 cm2/m2 [body mass index &lt; 25 cm/kg2] or &lt; 53 cm2/m2 [body mass index ≥ 25 cm/kg2] for men), and myosteatosis was defined as low-attenuated muscle area divided by skeletal muscle area (LAMA/SMA index) ≥ 20%. Univariate and multivariable binary logistic regression analyses were performed using bootstrapping with 500 interactions to identify predictors of grade 3–4 toxicity and any treatment-modifying toxicity which led to a dose reduction, delayed administration, drug skip or discontinuation.

Results

During the first cycle of the first-line chemotherapy, grade 3–4 toxicity and treatment-modifying toxicity occurred in 160 patients (25.2%) and in 247 patients (38.8%), respectively. The presence of both low muscle mass and myosteatosis was significantly associated with the occurrence of both grade 3-4 toxicity (odd ratio [OR], 1.73; 95% confidence interval [CI], 1.14–2.63) and treatment-modifying toxicity (OR, 1.83; 95% CI, 1.26–2.66) whereas low muscle mass alone did not.

Conclusions

The presence of both low muscle mass and myosteatosis assessed on baseline CT may be used to predict early chemotherapy-related toxicity in patients with metastatic PDAC.

Prognostic Role of "Radiological" Sarcopenia in Lymphoma: A Systematic Review

Sarcopenia is considered to be a poor prognostic factor for several oncological diseases; however, some promising results for lymphoma are now available. The definition of sarcopenia is mainly based upon muscle strength, quantity or quality and physical performance, but some imaging tools (such as CT) have been introduced to estimate quantitatively the muscle areas as an indirect expression of sarcopenia. Our aim was to perform a systematic review on the prognostic role of "radiological" sarcopenia in lymphoma. A comprehensive online search of PubMed/MEDLINE, Embase and Cochrane library databases was conducted up to June 2021 to find relevant articles on the prognostic role of sarcopenia in lymphoma measured by CT. In total, 25 articles with a total of 4454 patients were included. Diffuse large B-cell lymphoma was the most common lymphoma variant studied, followed by Hodgkin lymphoma. Skeletal muscle area (SMA) was defined as the parameter to distinguish between sarcopenic and nonsarcopenic lymphoma on CT scans and was usually measured at the level of the third lumbar vertebra. In the literature, different thresholds are used to define sarcopenia, related to the features of patients included in the studies. Despite this heterogeneity, in most cases, sarcopenia was demonstrated to be significantly correlated with OS and PFS. Sarcopenia measurement with CT (high dose or low dose) is a safe, accurate and precise method.

Preoperative Muscle-Adipose Index: A New Prognostic Factor for Gastric Cancer

BACKGROUND

Studies have shown that traditional nutrition indicators and body composition indicators are closely related to prognosis after radical gastric cancer (GC) surgery. However, the effect of the combined muscle and adipose composite on the prognosis of GC has not been reported.

METHODS

The clinicopathological data of 514 patients with GC were retrospectively analyzed. The skeletal muscle adipose tissue were measured by preoperative CT images to obtain the muscle index and adipose index. X-tile software was used to determine the diagnostic threshold of muscle-adipose imbalance.

RESULTS

The 5-year OS and RFS of the muscle-adipose imbalanced group were significantly worse than those of the balanced group. Multivariate analysis showed that muscle-adipose imbalance and the CONUT score were independent prognostic factors of OS and RFS (p < 0.05). The nuclear density curve showed that the recurrence risk of the muscle-adipose imbalanced group was higher than that of the balanced group, whereas the nuclear density curve of the CONUT score was confounded. Incorporating the muscle-adipose index into cTNM has the same prognostic performance as the pTNM staging system. Chemotherapy-benefit analysis showed that stage II/III patients in the muscle-adipose balanced group could benefit from adjuvant chemotherapy.

CONCLUSIONS

The preoperative muscle-adipose index discovered for the first time is a new independent prognostic factor that affects the prognosis with GC. In addition, the preoperative muscle-adipose index is better than traditional nutrition and body composition indicators in terms of the prognostic evaluation of GC patients and the predictive value of recurrence risk.

Impact of adjuvant imatinib on bone and muscle density in patients with resected gastrointestinal stromal tumors

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By its action on macrophage-colony stimulating factor, imatinib can act on bone microenvironment.

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Imatinib can influence bone mineral density in patients with chronic myeloid leukemia.

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The role of imatinib on bone health in GIST patients has not been investigated so far.

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Imatinib can increase bone mineral density in patients with resected GIST.

Adjuvant treatment with Imatinib is the standard of care for high-risk resected GISTs. Imatinib is known to have an impact on bone mineral density in patients affected by chronic myeloid leukemia, however this effect has never been investigated in GISTs.

We retrospectively evaluated, on CT scans, the effect of adjuvant Imatinib (400 mg/die) on bone mineral density and muscle composition in 14 patients with surgically resected GISTs and in a control group of 8 patients who did not received any treatment. The effect of bone and muscle composition on Imatinib-tolerance was assessed as well.

Overall patients receiving Imatinib experienced an increase in bone mineral density during treatment (p = 0.021); with higher increase in patients with basal values < 120 mg/cm³ (p = 0.002). No changes were observed in the control group (p = 0.918).

Skeletal muscle index and lean body mass did not change over time during Imatinib therapy; however, patients with lower lean body mass and lower body mass index experienced more grade 3 treatment related toxicities (p = 0.024 and p = 0.014 respectively). We also found a non-significant trend between basal BMD and grade 3 toxicities (p = 0.060)

Use of computed tomography for the diagnosis of surgical sarcopenia: Review of recent research advances

Sarcopenia, also known as muscle decay, is associated with high morbidity among surgical patients. It is highly correlated with adverse clinical outcomes, such as increased postoperative complications, prolonged hospital stay, and increased mortality. Computed tomography (CT) is one of the main methods for diagnosing sarcopenia, which has the advantages of intuitiveness, rapidity, and accuracy. Clinical studies have shown that CT-defined sarcopenia can help predict the clinical outcomes and prognosis of surgical patients and provide an important reference for the formulation of antitumor treatment protocols. In recent years, some scholars have tried to construct an intelligent CT-based diagnostic model, which is expected to improve the diagnostic efficiency and establish standardized diagnostic criteria for CT-defined sarcopenia. In this review, we summarize the recent progress in the understanding of the diagnosis of sarcopenia and its potential prognostic value in surgery.

Older cancer patients receiving radiotherapy: a systematic review for the role of sarcopenia in treatment outcomes

BACKGROUND

Previous studies have evaluated the prognostic effects of sarcopenia in cancer patients receiving various treatments, including chemotherapy and surgery, but few studies have focused on radiotherapy (RT).

AIMS

We aimed to investigate the prevalence of sarcopenia and the relationship between sarcopenia and outcomes in older cancer patients who underwent RT without chemotherapy.

METHODS

A systematic review of the literature was conducted in Pubmed/Medline and Cochrane databases in September 2021. We used the search terms and medical subject heading terms "sarcopenia," "low muscle mass (LMM)," "low muscle strength," "LMM and low muscle strength," "LMM and low muscle strength and low physical performance," and "RT." Outcomes were overall survival (OS), progression-free survival, non-cancer death, cancer death, disease-specific survival, local failure-free survival, distant failure-free survival, and RT-related toxicities.

RESULTS

Among 460 studies, 8 studies were eligible for inclusion. The prevalence of sarcopenia was between 42.8% and 72%. Sarcopenia was not associated with OS or OS at 3 years in seven studies in which it was defined as the presence of LMM, while it was related in one study, in which it was defined as the concomitant presence of LMM and muscle strength/function.

DISCUSSION

There was heterogeneity between the studies because there was diversity in their inclusion criteria, definition and assessment methods used for detection of sarcopenia, considered cutoffs for low muscle mass and strength, cross-sectional locations on imaging to assess muscle mass and included covariates. The discrepancy in the results of the studies may also result from the variations in diagnoses, sample sizes, and treatment modalities. The low number of included studies and a small number of patients in each study limited generalizability.

CONCLUSIONS

Sarcopenia may be a prognostic factor, especially in OS when low muscle strength/function is integrated into its definition. We suggest that clinicians focus on muscle strength/function while considering sarcopenia and its association with cancer and RT-related outcomes.

Expected and paradoxical effects of obesity on cancer treatment response

Obesity, whose prevalence is pandemic and continuing to increase, is a major preventable and modifiable risk factor for diabetes and cardiovascular diseases, as well as for cancer. Furthermore, epidemiological studies have shown that obesity is a negative independent prognostic factor for several oncological outcomes, including overall and cancer-specific survival, for several site-specific cancers as well as for all cancers combined. Yet, a recently growing body of evidence suggests that sometimes overweight and obesity may associate with better outcomes, and that immunotherapy may show improved response among obese patients compared with patients with a normal weight. The so-called 'obesity paradox' has been reported in several advanced cancer as well as in other diseases, albeit the mechanisms behind this unexpected relationship are still not clear. Aim of this review is to explore the expected as well as the paradoxical relationship between obesity and cancer prognosis, with a particular emphasis on the effects of cancer therapies in obese people.

The impact of sarcopenia on the efficacy and safety of immune checkpoint inhibitors in patients with solid tumours

BACKGROUND

Evidence suggests that sarcopenia is a significant predictive factor of worst outcomes and treatment-associated toxicities in patients with metastatic solid tumours. The aim of this study was to explore the relationship between low muscle mass and clinical outcomes and immune-related severe toxicities (IrST) in patients treated with immune checkpoint inhibitors (ICIs).

METHODS

A retrospective cohort of 261 consecutive metastatic solid tumour patients treated with ICIs were included in our study. Low muscle mass was defined as skeletal muscle index <41 cm²/m² for females and <43 cm²/m² for males if body mass index (BMI) <25 kg/m² or <53 cm²/m² if BMI ≥ 25 kg/m². Severe toxicities (ST), including grade III-IV toxicities and side effects leading to treatment interruption, were recorded.

RESULTS

The majority of patients (n = 179; 69%) included in this study had metastatic lung cancer. The prevalence of low muscle mass was 47%. The median progression-free survival (PFS) was 32.2 weeks for low muscle mass patients and 24.3 weeks for non-low muscle mass patients (adjusted HR, 0.80; 95% CI, 0.60-1.055; p = 0.11). For low muscle mass and non-low muscle mass lung cancer patients, median PFS was 24.0 weeks and 18.8 weeks (adjusted HR, 0.70; 95% CI, 0.50-0.98; p = 0.04) and median overall survival was 50.7 weeks and 41.1 weeks (adjusted HR, 0.77; 95% CI, 0.54-1.10, p = 0.15) respectively. Immune-related severe toxicities occurred in 3.3% and 9.4% of low muscle mass and non-low muscle mass patients respectively (adjusted OR, 0.69; 95% CI: 0.31-1.49; p = 0.35).

CONCLUSION

No difference in outcomes and safety was observed for low muscle mass and non-low muscle mass patients treated with ICIs.

Association of body composition with toxicity to first-line chemotherapy and three-year survival in women with ovarian adenocarcinoma

BACKGROUND

This study aimed to evaluate the association of body composition with toxicity to first-line chemotherapy and three-year survival in women with ovarian adenocarcinoma.

METHODS

We enrolled, in a retrospective cohort, 239 women treated with carboplatin and paclitaxel between 2008 and 2017. Pretreatment computed tomography scans were used to quantify skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), and subcutaneous adipose tissue index (SATI). Chemotherapy doses, related toxicities, potential drug-drug interactions (DDI), and clinical variables were collected from medical records. Outcomes were the number of adverse events ≥ grade 3 toxicity, toxicity-induced modification of treatment (TIMT), and three-year survival.

RESULTS

Average age was 56.3 years and 35.1% had myopenia. Almost 33% had TIMT and 51.3% presented any grade 3 toxicity. Potential severe DDI occurred in 48.1% of the patients and 65.1% died three years after the first treatment. The SMD and SATI below the median were independent predictors for the number of adverse events ≥ grade 3 and TIMT. Also, SMD was the only body composition parameter able to predict reduced three-year survival. The SMI was not associated with any of the outcomes.

CONCLUSION

Fewer amounts of SATI and low SMD were associated with the occurrence of toxicity to chemotherapy, and the low SMD increased the risk of death in the three years after oncologic treatment.

Risk factors for immune-related adverse events: what have we learned and what lies ahead?

Immune checkpoint inhibitors (ICIs) have heralded the advent of a new era in oncology by holding the promise of prolonged survival in severe and otherwise treatment-refractory advanced cancers. However, the remarkable antitumor efficacy of these agents is overshadowed by their potential for inducing autoimmune toxic effects, collectively termed immune-related adverse events (irAEs). These autoimmune adverse effects are often difficult to predict, possibly permanent, and occasionally fatal. Hence, the identification of risk factors for irAEs is urgently needed to allow for prompt therapeutic intervention. This review discusses the potential mechanisms through which irAEs arise and summarizes the existing evidence regarding risk factors associated with the occurrence of irAEs. In particular, we examined available data regarding the effect of a series of clinicopathological and demographic factors on the risk of irAEs.

Low skeletal muscle mass is a predictor of treatment related toxicity in oncologic patients. A meta-analysis

BACKGROUND & AIMS

The purpose of this meta-analysis was to summarize the published data regarding associations between occurrence of severe treatment related toxicity and low skeletal muscle mass (LSMM) in oncologic patients and to perform a meta-analysis based on a large sample.

METHODS

MEDLINE, Cochrane, and SCOPUS databases were screened for associations between LSMM and treatment related toxicity in oncologic patients up to June 2021. Overall, 48 studies met the inclusion criteria. The following data were extracted: authors, year of publication, study design, number of patients, influence of LSMM on treatment toxicity (odds ratios and confidence intervals). The methodological quality of the involved studies was checked according to the QUADAS instrument. The meta-analysis was undertaken by using RevMan 5.4 software. DerSimonian and Laird random-effects models with inverse-variance weights were used to account for the heterogeneity between the studies.

RESULTS

The included 48 studies comprised 4803 patients with different malignant diseases. LSMM occurred in 1966 patients (40.9%). LSMM was associated with therapy toxicity (simple logistic regression) with an odds ratio OR = 2.19, CI95%= (1.78-2.68). LSMM was associated with DLT in patients underwent curative treatment (16 studies, 2381 patients) with OR = 2.48, CI95%= (1.77-3.48). LSMM predicted DLT in patients underwent palliative chemotherapy (30 studies, 2337 patients)with OR = 2.06, CI95%= (1.56-2.74). In the subgroups received different palliative therapies, relationships between LSMM and DLT were as follows: conventional chemotherapies (7 studies, 600 patients) OR = 2.14, CI95%= (1.38-3.31); different kinases inhibitors (13 studies, 906 patients) OR = 3.08, CI95%= (1.87-5.09); checkpoint inhibitors (7 studies, 557 patients) OR = 1.30, CI95%= (0.79-2.11).

CONCLUSIONS

LSMM is an essential factor of treatment toxicity in oncologic patients. Association between LSMM and DLT is strongest in patients received therapy with kinases inhibitors. The influence of LSMM on DLT is lowest in patients underwent treatment with checkpoint inhibitors. The presence of LSMM should be included into radiological reports and provided to oncologists to optimize chemotherapy. LSMM should be included into dose calculation for chemotherapy.

Prognostic value of skeletal muscle mass during tyrosine kinase inhibitor (TKI) therapy in cancer patients: a systematic review and meta-analysis

Low muscle mass has been associated with worse clinical outcomes in various cancers. This work investigated whether, during tyrosine kinases inhibitors (TKIs) therapy, low muscle mass was associated with treatment toxicity and survival outcomes. A systematic literature search was performed in Pubmed, Web of Science, and Scopus databases from inception to June 2020, based on fixed inclusion and exclusion criteria. Effect sizes were estimated with hazard ratios (HR) and odds ratios (OR) with 95% confidence interval (CI) and heterogeneity was assessed by measuring inconsistency (I²) based on the Chi squared test. A total of 24 retrospective studies were identified, enrolling patients treated with sorafenib (n = 12), sunitinib (n = 6), lenvatinib (n = 3), regorafenib (n = 2), gefitinib (n = 1), imatinib (n = 1), and pazopanib (n = 1). Thirteen studies were deemed eligible for pooled analyses. Meta-analyses found a significant effect of low muscle mass on dose-limiting toxicity (DLT) (OR 2.40, 95% CI 1.26-4.58, p = 0.008, I² = 51%) in patients treated with TKI therapy. A subgroup analysis by treatment showed an association between DLT and low muscle during sorafenib or sunitinib, although not significant. A significant association between low skeletal muscle index and poorer overall survival was observed in HCC patients treated with sorafenib (HR 1.45, 95% CI 1.07-1.96, p = 0.02). For other TKIs, although some results showed an association between low muscle mass and worse outcomes, the number of studies for each TKI therapy was too small to reach conclusions. Skeletal muscle mass could influence the prognosis of some TKI-treated patients. This effect is demonstrated in sorafenib-treated HCC patients but remains almost unexplored in other cancer patients undergoing TKI therapy. Further prospective studies with large sample size and sufficient follow-up are needed to clarify the role of muscle mass in the metabolism of TKI-based cancer treatment, and its association with toxicity and survival.

Loss of skeletal muscle area and fat-free mass during dabrafenib/trametinib and vemurafenib/cobimetinib treatments in patients with BRAF-mutant metastatic malignant melanoma

This study aimed to assess whether dabrafenib/trametinib and vemurafenib/cobimetinib treatments are associated with a change in skeletal muscle area (SMA) and total fat-free mass (FFM) assessed by computed tomography (CT), and to compare the efficacy and safety profile of these treatments in patients with metastatic melanoma. Thirty-one patients treated with B-Raf proto-oncogene, serine/threonine kinase/MAPK extracellular receptor kinase inhibitors were included between 2016 and 2019. Eighteen patients received dabrafenib/trametinib and remaining patients received vemurafenib/cobimetinib. CT scans were performed at baseline and at 4-6 months of follow-up to measure cross-sectional areas of SMA. FFM and skeletal muscle index (SMI) values were calculated. Of the patients, including 18 treated with dabrafenib/trametinib (58.1%) and 13 with vemurafenib/cobimetinib (41.9%); 58.1% were male, 41.9% were female and median age was 52 years. A significant decrease in SMA was observed after dabrafenib/trametinib and vemurafenib/cobimetinib treatments (P = 0.003 and P = 0.002, respectively). A significant decrease in FFM values was observed after dabrafenib/trametinib and vemurafenib/cobimetinib treatments (P = 0.003 and P = 0.002, respectively). Dose-limiting toxicity (DLT) was observed in 35.9% of the patients with sarcopenia. No significant difference was seen between the dabrafenib/trametinib and vemurafenib/cobimetinib groups in median progression-free survival (PFS) (11.9 vs. 7.3 months, respectively, P = 0.28) and in median overall survival (OS) (25.46 vs. 13.7 months, respectively, P = 0.41). Baseline sarcopenia was not significantly associated with PFS or OS (P = 0.172 and P = 0.326, respectively). We found a significant decrease in SMI values determined at 4-6 months compared to the values before treatment both in dabrafenib/trametinib and vemurafenib/cobimetinib groups. DLT was similar with both treatments. Baseline sarcopenia was not significantly associated with PFS or OS.

The effectiveness of systemic therapies after surgery for metastatic renal cell carcinoma to the spine: a propensity analysis controlling for sarcopenia, frailty, and nutrition

OBJECTIVE

The effectiveness of starting systemic therapies after surgery for spinal metastases from renal cell carcinoma (RCC) has not been evaluated in randomized controlled trials. Agents that target tyrosine kinases, mammalian target of rapamycin signaling, and immune checkpoints are now commonly used. Variables like sarcopenia, nutritional status, and frailty may impact recovery from spine surgery and are considered when evaluating a patient's candidacy for such treatments. A better understanding of the significance of these variables may help improve patient selection for available treatment options after surgery. The authors used comparative effectiveness methods to study the treatment effect of postoperative systemic therapies (PSTs) on survival.

METHODS

Univariable and multivariable Cox regression analyses were performed to determine factors associated with overall survival (OS) in a retrospective cohort of adult patients who underwent spine surgery for metastatic RCC between 2010 and 2019. Propensity score-matched (PSM) analysis and inverse probability weighting (IPW) were performed to determine the treatment effect of PST on OS. To address confounding and minimize bias in estimations, PSM and IPW were adjusted for covariates, including age, sex, frailty, sarcopenia, nutrition, visceral metastases, International Metastatic RCC Database Consortium (IMDC) risk score, and performance status.

RESULTS

In total, 88 patients (73.9% male; median age 62 years, range 29-84 years) were identified; 49 patients (55.7%) had an intermediate IMDC risk, and 29 (33.0%) had a poor IMDC risk. The median follow-up was 17 months (range 1-104 months) during which 57 patients (64.7%) died. Poor IMDC risk (HR 3.2 [95% CI 1.08-9.3]), baseline performance status (Eastern Cooperative Oncology Group score 3 or 4; HR 2.7 [95% CI 1.5-4.7]), and nutrition (prognostic nutritional index [PNI] first tertile, PNI < 40.74; HR 2.69 [95% CI 1.42-5.1]) were associated with worse OS. Sarcopenia and frailty were not significantly associated with poor survival. PST was associated with prolonged OS, demonstrated by similar effects from multivariable Cox analysis (HR 0.55 [95% CI 0.30-1.00]), PSM (HR 0.53 [95% CI 0.29-0.93]), IPW (HR 0.47 [95% CI 0.24-0.94]), and comparable confidence intervals. The median survival for those receiving PST was 28 (95% CI 19-43) months versus 12 (95% CI 4-37) months for those who only had surgery (log-rank p = 0.027).

CONCLUSIONS

This comparative analysis demonstrated that PST is associated with improved survival in specific cohorts with metastatic spinal RCC after adjusting for frailty, sarcopenia, and malnutrition. The marked differences in survival should be taken into consideration when planning for surgery.

Muscle hypertrophy in cancer patients and survivors via strength training. A meta-analysis and meta-regression

BACKGROUND

Muscle wasting has a negative effect on treatment toxicity and cancer prognosis. Resistance training appears to be a promising approach to counteract the loss of muscle mass.

METHODS

Pubmed, Cochrane Library, SportDiscus and CINAHL. Randomized controlled resistance training trials with cancer survivros where eligible if lean body mass (LBM) or muscle mass were assessed.

RESULTS

A total of 34 trials were included into the primary analysis. Compared to the control individuals, the intervention groups show a superiority in LBM of 0.85 kg (95 % CI = 0.26-1.43, p = .004). Isolated, the participants in the intervention groups show an increase in LBM of 0.51 kg (95 % CI = -0.05-1.06, p = .072); the control groups displayed a decrease of -0.59 kg (95 % CI= -1.04 to 0.06, p = .078). Supervision displayed an mediating role.

CONCLUSIONS

Resistance training can counteract the loss of muscle mass in cancer patients. Especially in a supervised setting.

Prognostic role of sarcopenia in metastatic colorectal cancer patients during first-line chemotherapy: A retrospective study

BACKGROUND

Sarcopenia is a condition characterized by decreased skeletal muscle mass due to physiological ageing or to a concomitant disease such as neoplasia. In cancer patients, a low lean body mass is suggested to be a negative prognostic factor for survival and for the development of dose-limiting chemotherapy toxicities irrespective of disease stage.

AIM

To evaluate the prognostic role of sarcopenia in patients with metastatic colorectal cancer (mCRC) undergoing first-line chemotherapy.

METHODS

Our retrospective analysis included 56 mCRC patients who received first-line chemotherapy from 2014 to 2017 at the Medical Oncology Unit of our hospital. Computerized scans were performed before starting chemotherapy and at the first disease reassessment. Sarcopenia was assessed using the skeletal mass index = muscle area in cm²/(height in m²) calculated at the L3 vertebra. Overall survival and objective response rate were evaluated. Toxicities were analyzed during the first four cycles of therapy and graded according to Common Terminology Criteria for Adverse Events version 4.0. A loss of skeletal muscle mass ≥ 5% was considered indicative of deterioration in muscle condition.

RESULTS

Median age was 67 years and 35.7% of patients were ≥ 70 years old. Fourteen patients (25%) were sarcopenic at baseline computed tomography (CT) scan (7/33 men; 7/23 women); 5/14 sarcopenic patients were ≥ 70 years old. Median follow-up was 26.8 mo (3.8-66.8 mo) and median overall survival was 27.2 mo (95%CI: 23.3-37.3). Sarcopenia was not correlated to overall survival (P = 0.362), to higher toxicities reported during the first 4 cycles of chemotherapy (P = 1.0) or to response to treatment (P = 0.221). At the first disease reassessment, a skeletal muscle loss (SML) ≥ 5% was found in 17 patients (30.3%) 3 of whom were already sarcopenic at baseline CT scan, while 7 patients became sarcopenic. SML was not correlated to overall survival (P = 0.961). No statistically significant correlation was found between baseline sarcopenia and age (P = 1.0), body mass index (P = 0.728), stage at diagnosis (P = 0.355) or neutrophil/lymphocyte ratio (P = 0.751).

CONCLUSION

Neither baseline sarcopenia nor SML affected survival. In addition, baseline sarcopenia was not related to worse treatment toxicity. However, these results must be interpreted with caution due to the limited sample size.

Sarcopenia and serum biomarkers of oxidative stress after a 6-month physical activity intervention in women with metastatic breast cancer: results from the ABLE feasibility trial

Purpose

Sarcopenia has been identified as an important prognostic factor for patients with cancer. This study aimed at exploring the potential associations between a 6-month physical activity intervention and muscle characteristics, sarcopenia, oxidative stress and toxicities in patients with metastatic breast cancer.

Methods

Women newly diagnosed with metastatic breast cancer (N = 49) participated in an unsupervised, personalized, 6-month physical activity intervention with activity tracker. Computerized tomography images at the third lumbar vertebra were analysed at baseline, three months and six months to assess sarcopenia (muscle mass index < 40 cm²/m²) and muscle quality (poor if muscle attenuation < 37.8 Hounsfield Units). Oxidative markers included plasma antioxidant enzymes (catalase, glutathione peroxidase and superoxide dismutase activities), prooxidant enzymes (NADPH oxidase and myeloperoxidase activities) and oxidative stress damage markers (advanced oxidation protein products, malondialdehyde (MDA) and DNA oxidation.

Results

At baseline 53% (mean age 55 years (SD 10.41)) were sarcopenic and 75% had poor muscle quality. Muscle cross sectional area, skeletal muscle radiodensity, lean body mass remained constant over the six months (p = 0.75, p = 0.07 and p = 0.75 respectively), but differed significantly between sarcopenic and non-sarcopenic patients at baseline and 6-months. Sarcopenic patients at baseline were more likely to have an increase of MDA (p = 0.02) at 6 months. Being sarcopenic during at least one moment during the 6-month study was associated with a higher risk of developing severe toxicities (grade > 2) (p = 0.02).

Conclusions

This study suggests potential benefits of physical activity for maintenance of muscle mass. Sarcopenia can alter many parameters and disturb the pro and antioxidant balance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06238-z.

Impact of body mass index on survival and serious adverse events in advanced non-small cell lung cancer treated with bevacizumab: a meta-analysis of randomized clinical trials

PURPOSE

Lung cancer accounts for 28% of all cancer deaths, more deaths than any other cancer in the United States. The influence of body composition has been evaluated in several studies, specifically, the influence of obesity on lung cancer survival. Outcomes have been mixed, with some studies demonstrating a paradoxical beneficial effect in early lung cancer where survival is improved in obese patients. The study aim was to evaluate the impact of obesity on overall survival (OS), progression free survival (PFS), and occurrence of serious adverse events (SAE) in clinical trials evaluating bevacizumab for advanced non-small cell lung cancer (NSCLC).

METHODS

We performed a post hoc analysis combining available individual level data from bevacizumab randomized clinical trials available through the Clinical Study Data Request database. The primary outcome measured in our analysis was the influence of bevacizumab on OS stratified by body mass index (BMI). In addition to OS, both PFS and the occurrence of SAE requiring therapy interruption were evaluated. All endpoints were evaluated in patients who were obese (BMI ≥30.0 kg/m²) compared with non-obese (BMI <30.0 kg/m²). As a sensitivity analysis, endpoints were also evaluated in patients who were overweight (BMI ≥25.0 kg/m²) compared with non-overweight (BMI <25.0 kg/m²). In addition to analysis of each individual study, a meta-analysis was performed in order to calculate pooled hazard ratios (HR). Hazard ratios for both OS and PFS were calculated using multivariable Cox proportional hazards models. Odds ratios for SAE were calculated using multivariable logistic regression. The validity of the regression models was tested using a log-log plot and overall fit using the goodness of fit test.

RESULTS

After adjusting for covariates using a Cox proportional hazards model and combining the resulting adjusted hazard ratios using meta-analysis, there was no significant difference between obese and non-obese groups for OS or PFS. In addition, when treatment discontinuation due to an adverse event was assessed, none of the trials showed a significant difference between the obese and non-obese groups.

CONCLUSION

In this analysis of clinical trial data, obesity was not associated with worse survival versus non-obese individuals in advanced NSCLC. In addition, serious adverse events were similar between patients with and without obesity.

Sarcopenia and modified Glasgow Prognostic Score predict postsurgical outcomes in localized renal cell carcinoma

BACKGROUND

Body composition and inflammation are gaining importance for prognostication in cancer. This study investigated the individual and combined utility of the preoperative skeletal muscle index (SMI) and the modified Glasgow Prognostic Score (mGPS) for estimating postoperative outcomes in patients with localized renal cell carcinoma (RCC) undergoing nephrectomy.

METHODS

The authors performed a retrospective review of 352 patients with localized RCC. SMI was measured via computed tomography or magnetic resonance imaging. Patients met the criteria for sarcopenia by body mass index- and sex-stratified thresholds. Multivariable and Kaplan-Meier analyses of associations of sarcopenia and mGPS with overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS) were performed. Variables were analyzed independently and combined into risk groups: low risk (nonsarcopenic, low mGPS), medium risk (sarcopenia only), medium risk (inflammation only), and high risk (sarcopenic, high mGPS). Receiver operating characteristic (ROC) curves were used to analyze risk groups in comparison with the Stage, Size, Grade, and Necrosis (SSIGN) score and the modified International Metastatic RCC Database Consortium (IMDC) score.

RESULTS

The majority of the patients were at stage pT3 (63%), 39.5% of the patients were sarcopenic, and 19.3% had an elevated mGPS at the baseline. The median follow-up time was 30.4 months. Sarcopenia and mGPS were independently associated with worse OS (hazard ratio for sarcopenia, 1.64; P = .006; hazard ratio for mGPS, 1.72; P = .012), CSS, and RFS. Risk groups had an increasing association with worse RFS (P = .015) and CSS (P = .004) but not OS (P = .087). ROC analyses demonstrated a higher area under the curve for risk groups in comparison with the SSIGN and IMDC scores at 5 years.

CONCLUSIONS

Sarcopenia and an elevated mGPS were associated with worse clinical outcomes in this study of patients with localized RCC. This has implications for preoperative prognostication and treatment decision-making.

LAY SUMMARY

Kidney cancer is a disease with a wide variety of outcomes. Among patients undergoing surgical removal of the kidney for cancer that has not spread beyond the kidney, many are cured, but some experience recurrence. Physicians are seeking ways to better predict who is at risk for recurrence or death from kidney cancer. This study has evaluated body composition and markers of inflammation before surgery to predict the risk of recurrence or death after surgery. Specifically, low muscle mass and an elevated inflammation score (the modified Glasgow Prognostic Score) have been associated with an increased likelihood of recurrence of kidney cancer and death.

Prognostic significance of sarcopenia and decreased relative dose intensity during the initial two cycles of first-line sunitinib for metastatic renal cell carcinoma

Targeted therapy for metastatic renal cell carcinoma (mRCC) treatment requires the identification of clinically important factors that can predict the therapeutic effect. We retrospectively investigated the prognostic roles of pre-treatment sarcopenia and relative dose intensity during the initial two cycles (2c-RDI) of sunitinib treatment in patients with mRCC. In total, 41 (52.6%) patients were classified as having sarcopenia and 16 (20.5%) patients were classified with low 2c-RDI at <75%. The mean dose reduction during sunitinib treatment was higher for sarcopenic than for non-sarcopenic patients. The median progression-free survival (PFS) and overall survival (OS) were significantly shorter in sarcopenic patients with low 2c-RDI (n = 14, 17.9%) than in non-sarcopenic patients with high 2c-RDI (n = 35, 44.9%). Multivariate analysis identified sarcopenia and low 2c-RDI as poor prognostic factors for PFS and OS. Our findings provide new insights into the prognostic role of sarcopenia and 2c-RDI for targeted therapy in mRCC.

Pathophysiological mechanisms explaining poor clinical outcome of older cancer patients with low skeletal muscle mass

Low skeletal muscle mass is highly prevalent in older cancer patients and affects 5% to 89% depending on the type and stage of cancer. Low skeletal muscle mass is associated with poor clinical outcomes such as post-operative complications, chemotherapy toxicity and mortality in older cancer patients. Little is known about the mediating pathophysiological mechanisms. In this review, we summarize proposed pathophysiological mechanisms underlying the association between low skeletal muscle mass and poor clinical outcomes in older cancer patients including a) systemic inflammation; b) insulin-dependent glucose handling; c) mitochondrial function; d) protein status and; e) pharmacokinetics of anticancer drugs. The mechanisms of altered myokine balance negatively affecting the innate and adaptive immune system, and altered pharmacokinetics of anticancer drugs leading to a relative overdosage of anticancer drugs are best-substantiated. The effects of glucose intolerance and circulating mitochondrial DNA as a consequence of low skeletal muscle mass are topics of interest for future research. Restoring myokine balance through physical exercise, exercise mimetics, neuro-muscular activation and adapting anticancer drug dosing on skeletal muscle mass could be targeted approaches to improve clinical outcomes in older cancer patients with low skeletal muscle mass.

Visceral Adiposity as a Significant Predictor of Sunitinib-Induced Dose-Limiting Toxicities and Survival in Patients with Metastatic Clear Cell Renal Cell Carcinoma

Sunitinib is a first-line treatment for metastatic renal cell carcinoma (mRCC). Little is known about the predictive factors of sunitinib-induced dose-limiting toxicity (DLT) in Asian populations. We investigated whether body composition predicts sunitinib-induced DLT. We retrospectively reviewed sunitinib-treated Korean patients with clear cell mRCC from eight institutions. Body composition was measured using computed tomography. DLT was defined as any adverse event leading to dose reduction or treatment discontinuation. Univariate analysis was used to compare body composition indices, and logistic regression analyses were performed for factors predicting early DLT. Overall, 111/311 (32.5%) of patients experienced DLT. Significant differences were observed in the subcutaneous adipose tissue index (SATI; p = 0.001) and visceral adipose tissue index (VATI; p < 0.001) between patients with and without DLT. Multivariate analyses revealed that VATI (odds ratio: 1.013; p = 0.029) was significantly associated with early DLT. Additionally, 20% of patients who had a body mass index (BMI) greater than 23 kg/m² and a low VATI experienced DLT, whereas 34.3% of the remaining groups had DLT (p = 0.034). Significant differences were observed for median progression-free survival (13.0 vs. 26.0 months, respectively; p = 0.006) between patients with low and high VATI. Visceral adiposity was a significant predictor of sunitinib-associated DLT and survival. Patients with a low VATI and a BMI greater than 23 kg/m² experienced lower DLTs.

The Predictive Value of Low Skeletal Muscle Mass Assessed on Cross-Sectional Imaging for Anti-Cancer Drug Toxicity: A Systematic Review and Meta-Analysis

Low skeletal muscle mass (LSMM) is increasingly recognized for its predictive value for adverse events in cancer patients. In specific, the predictive value of LSMM has been demonstrated for anti-cancer drug toxicity in a variety of cancer types and anti-cancer drugs. However, due to the limited sample size and study populations focused on a single cancer type, an overall predictive value of LSMM for anti-cancer drug toxicity remains unknown. Therefore, this review aims to provide a comprehensive overview of the predictive value of LSMM and perform a meta-analysis to analyse the overall effect. A systematic search was conducted of MEDLINE, Scopus, EMBASE, and Cochrane. Inclusion criteria were skeletal muscle mass (SMM) evaluated with computed tomography (CT) or magnetic resonance imaging (MRI), articles published in English, SMM studied in humans, SMM measurement normalized for height, and patients did not receive an intervention to treat or prevent LSMM. A meta-analysis was performed using a random-effects model and expressed in odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was assessed using χ² and I² statistics. The search yielded 907 studies. 31 studies were included in the systematic review. Sample sizes ranged from 21 to 414 patients. The occurrence of LSMM ranged from 12.2% to 89.0%. The most frequently studied cancer types were oesophageal, renal, colorectal, breast, and head and neck cancer. Patients with LSMM had a higher risk of severe toxicity (OR 4.08; 95% CI 2.48-6.70; p < 0.001) and dose-limiting toxicity (OR 2.24; 95% CI 1.28-3.92; p < 0.001) compared to patients without LSMM. To conclude, the predictive value of LSMM for anti-cancer drug toxicity can be observed across cancer types. This information increases the need for further research into interventions that could treat LSMM as well as the possibility to adapt treatment regimens based on the presence of LSMM.

Impact of musculoskeletal degradation on cancer outcomes and strategies for management in clinical practice

The prevalence of malnutrition in patients with cancer is one of the highest of all patient groups. Weight loss (WL) is a frequent manifestation of malnutrition in cancer and several large-scale studies have reported that involuntary WL affects 50-80% of patients with cancer, with the degree of WL dependent on tumour site, type and stage of disease. The study of body composition in oncology using computed tomography has unearthed the importance of both low muscle mass (sarcopenia) and low muscle attenuation as important prognostic indications of unfavourable outcomes including poorer tolerance to chemotherapy; significant deterioration in performance status and quality of life (QoL), poorer post-operative outcomes and shortened survival. While often hidden by excess fat and high BMI, muscle abnormalities are highly prevalent in patients with cancer (ranging from 10 to 90%). Early screening to identify individuals with sarcopenia and decreased muscle quality would allow for earlier multimodal interventions to attenuate adverse body compositional changes. Multimodal therapies (combining nutritional counselling, exercise and anti-inflammatory drugs) are currently the focus of randomised trials to examine if this approach can provide a sufficient stimulus to prevent or slow the cascade of tissue wasting and if this then impacts on outcomes in a positive manner. This review will focus on the aetiology of musculoskeletal degradation in cancer; the impact of sarcopenia on chemotherapy tolerance, post-operative complications, QoL and survival; and outline current strategies for attenuation of muscle loss in clinical practice.

Mitochondrial Function and Protein Turnover in the Diaphragm are Altered in LLC Tumor Model of Cancer Cachexia

It is established that cancer cachexia causes limb muscle atrophy and is strongly associated with morbidity and mortality; less is known about how the development of cachexia impacts the diaphragm. The purpose of this study was to investigate cellular signaling mechanisms related to mitochondrial function, reactive oxygen species (ROS) production, and protein synthesis during the development of cancer cachexia. C57BL/J6 mice developed Lewis Lung Carcinoma for either 0 weeks (Control), 1 week, 2 weeks, 3 weeks, or 4 weeks. At designated time points, diaphragms were harvested and analyzed. Mitochondrial respiratory control ratio was ~50% lower in experimental groups, which was significant by 2 weeks of cancer development, with no difference in mitochondrial content markers COXIV or VDAC. Compared to the controls, ROS was 4-fold elevated in 2-week animals but then was not different at later time points. Only one antioxidant protein, GPX3, was altered by cancer development (~70% lower in experimental groups). Protein synthesis, measured by a fractional synthesis rate, appeared to become progressively lower with the cancer duration, but the mean difference was not significant. The development and progression of cancer cachexia induces marked alterations to mitochondrial function and ROS production in the diaphragm and may contribute to increased cachexia-associated morbidity and mortality.

Skeletal Muscle Loss during Multikinase Inhibitors Therapy: Molecular Pathways, Clinical Implications, and Nutritional Challenges

In cancer patients, loss of muscle mass is significantly associated with low tolerability of chemotherapy and poor survival. Despite the great strides in the treatment of cancer, targeted therapies such as tyrosine kinase inhibitors (TKIs) could exacerbate muscle wasting. Over recent years, the impact of skeletal muscle loss during TKI therapy on clinical outcomes has been in the spotlight. In this review, we focus on the different molecular pathways of TKIs potentially involved in muscle wasting. Then, we report the results of the studies assessing the effects of different TKI therapies—such as sorafenib, regorafenib, sunitinib, and lenvatinib—on muscle mass, and highlight their potential clinical implications. Finally, we discuss an integrative nutritional approach to be adopted during TKI treatment. The assessment of muscle mass from computerized tomography imaging could be helpful in predicting toxicity and prognosis in patients treated with TKI such as sorafenib. Early recognition of low muscle mass and effective personalized nutritional support could prevent or attenuate muscle mass wasting. However, the role of nutrition is still overlooked, and future clinical trials are needed to find the optimal nutritional support to countermeasure muscle mass depletion during TKI therapy.

Prognostic Significance of Sarcopenia in Advanced Biliary Tract Cancer Patients

Background: Sarcopenia, systemic inflammation, and low muscularity significantly impact the survival of cancer patients. However, few studies have investigated how sarcopenia and systemic inflammation affect the prognosis of biliary tract cancer with distant metastasis. In this study, we investigated the association between sarcopenia with systemic inflammation and prognosis of metastatic biliary tract cancer. Materials and Methods: Data collected from 353 metastatic biliary tract cancer patients from 2007 to 2016 were analyzed. To evaluate the skeletal muscle mass, computed tomography images at the upper level of the third lumbar vertebra (L3) were used. Sarcopenia was defined using the Japan Society of Hepatology guideline; L3 muscle index <42 cm²/m² for male and <38 cm²/m² for female patients. Systemic inflammation was evaluated using the neutrophil lymphocyte ratio (NLR). Patients with NLR > 3 were categorized into the inflammatory category. The overall survival (OS) and progression free survival (PFS) were analyzed. Subgroup analysis was performed on those who received gemcitabine/cisplatin (GP) chemotherapy and depending on the presence of sarcopenia and inflammation. Results: Patients with sarcopenia showed lesser 1-year OS than those without (25.5 vs. 38.2%, p = 0.019). The patients with high NLR (NLR > 3) were associated with a shorter OS than were those with a low NLR (NLR ≤ 3) (21.0 vs. 52.8%, p < 0.001). Based on these results, we categorized the patients into three groups; sarcopenia accompanied by high NLR, no sarcopenia and low NLR, and either sarcopenia or high NLR. The OS of patients was well-stratified according to this grouping (1-year OS; 18.3 vs. 30.3 vs. 55.8%, p < 0.001). Concordant with OS results, the PFS was well-stratified based on the presence of either sarcopenia or high NLR (Sarcopenia; 9.5 vs. 19.4%, p < 0.001, NLR; 10.0 vs. 23.4%, p < 0.001). The PFS was significantly associated with high NLR and sarcopenia (1-year PFS; 7.8 vs. 13.0 vs. 27.9%, p < 0.001). Conclusion: Sarcopenia with inflammation was associated with inferior OS and PFS. In addition, sarcopenia accompanied by inflammation was associated with poor prognosis. Conservative treatments such as nutritional support, exercise, and pharmacologic intervention could help metastatic biliary tract cancer patients to overcome sarcopenia and the inflammatory status.

Sarcopenia in aging, obesity, and cancer

Sarcopenia, defined as loss of muscle mass, strength and physical performance, is a hallmark of aging and is invariably associated with perturbation of amino acid metabolism, increased muscle protein catabolism relative to anabolism, and loss of muscle fibers. Sarcopenia may be associated with general loss of body mass, or it may also occur along with obesity [sarcopenic obesity (SO)]. Although sarcopenia is associated with multiple comorbidities in older adults, its effects may even be more severe in patients with malignant disease where it has been shown to contribute to poor surgical outcomes, increased chemotherapy toxicity associated with both cytotoxic and targeted agents, as well as adversely impacting survival. While development of sarcopenia is a common age-related phenomenon, the associated catabolic processes appear to be promoted by physical inactivity, inadequate nutrition, and systemic low-grade inflammation, as well as intrinsic muscle and molecular changes, including mitochondrial dysfunction and impaired muscle stem cell regenerative capacity. Increased physical activity and adequate protein intake can reduce incidence and severity of sarcopenia in cancer patients, but many older cancer patients do not meet physical activity and nutrition recommendations, and cancer treatment can make it more difficult to make favorable lifestyle changes. Sarcopenia is discussed in terms of its adverse clinical consequences in older subjects and particularly, in older patients with cancer. Contributions of lifestyle, molecular, and cellular factors are likewise reviewed with suggestions for interventions to improve sarcopenia and its comorbid sequalae.