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

Exploring the role of human papillomavirus (HPV) status in body composition and nutritional features in patients with oropharyngeal cancer

BACKGROUND AND AIMS

Patients with oropharyngeal squamous cell carcinoma (OPSCC) are highly prone to malnutrition and sarcopenia due to the tumor's location and treatment-related toxicity. Human papillomavirus (HPV)-related and HPV-unrelated OPSCC represent two distinct biological entities. This study aimed to assess nutritional characteristics and body composition differences at diagnosis, as well as 3- and 6-months post- (chemo) radiation treatment, stratified by HPV status in OPSCC patients.

METHODS

Retrospective data analysis of a prospective cohort of OPSCC patients diagnosed and treated with curative intent from 2016 to 2022 at our center. Sociodemographic, clinical, and nutritional data were retrieved from medical records from diagnosis to 6 months post-treatment. Body composition parameters were assessed by analyzing the cross-sectional area of the third lumbar vertebra (L3) using available positron emission tomography (PET) and computed tomography (CT) scans at baseline, 3- and 6-months post-treatment.

RESULTS

Seventy patients were included, 33 (47.1 %) of whom had HPV-related OPSCC. HPV-related patients had higher body mass index (27.3 vs 21.9 kg/m2; p < 0.001) and better baseline nutritional status (p = 0.023), but no differences in skeletal muscle index (SMI, p = 0.103) compared to HPV-unrelated patients. At 3- and 6-months post-treatment the two groups showed similar SMI and total adipose tissue index loss (p > 0.05 for both). HPV status was not independently associated with body composition changes over time (p = 0.624).

CONCLUSIONS

Although HPV-related patients were better nourished than HPV-unrelated patients at diagnosis, by the end of treatment, both groups exhibited similar nutritional deterioration.

Nutritional characterization of patients with oropharyngeal cancers: impact of human papillomavirus status

BACKGROUND

Oropharyngeal squamous cell carcinoma (OPSCC) of human papillomavirus (HPV)-positive status is increasing relative to HPV-negative disease. Nutritional features of OPSCC patients according to HPV status is unclear.

SUBJECTS/METHODS

Canadian and Spanish patients with OPSCC were assessed for body mass index (BMI), weight loss grade (WLG), and computed tomography-defined skeletal muscle index (SMI). Chi-square, t-test, Mann-Whitney-U, Kruskal-Wallis tests were conducted to compare HPV positive and negative groups. Overall survival (OS) was assessed by univariable Kaplan-Meier and Cox proportional hazard methods.

RESULTS

No differences in BMI, WLG, SMI, and adipose tissue index between the 308 (Canada) and 134 (Spain) patients according to HPV status; hence cohorts were pooled (n = 442). HPV-positive patients (n = 317) were overweight/obese (72.8%), had WLG of 0/1 (59.6%) and high SMI (83.4%) while HPV-negative patients were normal/underweight (61.5%), had high WLG 3/4 (50.8%), and moderate/severe SMI depletion (46.9%) (p < 0.003). These overall differences notwithstanding, there was crossover i.e. 35% of HPV-positive patients had high WLG and/or moderate/severe muscle depletion and 29% of HPV-negative patients had minimal weight loss and high SMI. HPV-negative patients had a higher risk of mortality (HR 3.78, 95% CI 2.70-5.29, P < 0.001) and this difference was retained after multivariable adjustment for WLG, SMI, age, disease stage, and planned treatment (HR 3.30, 95% CI 2.17-5.02, P < 0.001).

CONCLUSION

Nutrition features of patients with OPSCC did not differ between Canada and Spain. Distinctive nutrition features exist in patients according to HPV status. The high heterogeneity of individual nutritional profiles invites an individualized approach to nutrition care.

Quantifying the severity of sarcopenia in patients with cancer of the head and neck

BACKGROUND & AIMS

Existing skeletal muscle index (SMI) thresholds for sarcopenia are inconsistent, and do not reflect severity of depletion. In this study we aimed to define criterion values for moderate and severe skeletal muscle depletion based on the risk of mortality in a population of patients with head and neck cancer (HNC). Additionally, we aimed to identify clinical and demographic predictors of skeletal muscle depletion, evaluate the survival impact of skeletal muscle depletion in patients with minimal nutritional risk or good performance status, and finally, benchmarking SMI values of patients with HNC against healthy young adults.

METHODS

Population cohort of 1231 consecutive patients and external validation cohorts with HNC had lumbar SMI measured by cross-sectional imaging. Optimal stratification determined sex-specific thresholds for 2-levels of SMI depletion (Class I and II) based on overall survival (OS). Adjusted multivariable regression analyses (tumor site, stage, performance status, age, sex, dietary intake, weight loss) determined relationships between 2-levels of SMI depletion and OS.

RESULTS

Mean SMI (cm2/m2) was 51.7 ± 9.9 (males) and 39.8 ± 7.1 (females). The overall and sex-specific population demonstrated an increased risk of mortality associated with decreasing SMI. Sex-specific SMI (cm2/m2) depletion thresholds for 2-levels of muscle depletion determined by optimal stratification for males and females, respectively (male: 45.2-37.5, and <37.5; female: 40.9-34.2, and <34.2). In the overall population, Normal SMI, Class I and II SMI depletion occurred in 65.0%, 24.0%, and 11.0%, respectively. Median OS was: Normal SMI (114 months, 95% CI, 97.1-130.8); Class I SMI Depletion (42 months, 95% CI, 28.5-55.4), and Class II SMI Depletion (15 months, 95% CI, 9.8-20.1). Adjusted multivariable analysis compared with Normal SMI (reference), Class I SMI Depletion (HR, 1.49; 95% CI, 1.18-1.88; P < .001), Class II SMI Depletion (HR, 1.91; 95% CI, 1.42-2.58; P < .001).

CONCLUSIONS

Moderate and severe SMI depletion demonstrate discrimination in OS in patients with HNC. Moderate and severe SMI depletion is prevalent in patients with minimal nutrition risk and good performance status. Benchmarking SMI values against healthy young adults exemplifies the magnitude of SMI depletion in patients with HNC and may be a useful method in standardizing SMI assessment.

Muscle quality and not quantity as a predictor of survival in head and neck squamous cell carcinoma

BACKGROUND

Sarcopenia is frequent in head and neck squamous cell carcinoma (HNSCC), as a consequence of malnutrition related to risk factors or tumoral mass. Treatment is associated with toxicities that lead to reduced calories intake and muscle mass wasting. Sarcopenia has been negatively associated with tumor control and survival outcomes.

PURPOSE

Our aim is to evaluate the prognostic impact of sarcopenia on overall survival (OS) and progression free survival (PFS) in HNSCC patients undergoing chemoradiation therapy within a prospective clinical trial of chemoradiation vs induction chemotherapy followed by radiation and cetuximab (INTERCEPTOR).

MATERIALS AND METHODS

On baseline CT or MRI, we investigated the association between OS and PFS with radiological markers of sarcopenia, measured at the third cervical vertebra level. We studied paravertebral skeletal muscles area (cm2), muscle density (HU), muscle index (cm2/m2), and intermuscular adipose tissue (IMAT) area (cm2).

RESULTS

Imaging of 128 patients was evaluable. We found out that higher body mass index (BMI) was associated with better OS (p = 0.02), and PFS (p = 0.04). Skeletal muscle area (p = 0.02), and IMAT (p = 0.02) were negatively associated with PFS. IMAT was positively correlated with muscle area (Correlation coefficient 0.6, CI95% 0.47-0.7), and negatively associated with muscle density (Correlation coefficient -0.37, CI95% -0.53 - -0.18).

CONCLUSIONS

IMAT can be used as predictor of PFS in HNC patients undergoing chemoradiation therapy. The amount of intermuscular fat deposits induces alterations of muscle quality, without alterations of muscle quantity, influencing patients' prognosis.