Impact of Sarcopenia on Adverse Outcomes After Allogeneic Hematopoietic Cell Transplantation

Nutrition issues in adult hematopoietic cell transplantation: A narrative review of latest advances

Patients undergoing hematopoietic cell transplantation (HCT) are a highly heterogenous population with respect to their unique nutrient requirements and need for nutrition support. Dose-intensive conditioning regimens in addition to the debilitating effects of graft-vs-host disease impact and adversely affect the transplant recipient's nutrition status. Decreased oral intake, increased nutrient requirements, and impaired nutrient absorption and utilization often necessitate specialized nutrition support. The use of parenteral nutrition and enteral nutrition support, as well as dietary intervention strategies for immunocompromised patients, have varied over the past five decades and are highly dependent on the type of transplant used. This review highlights adult nutrition assessment components, nutrition support practices, and management of complex nutrition consequences associated with HCT.

Sarcopenia and clinical outcomes in lymphoma and multiple myeloma patients receiving hematopoietic cell transplantation: a systematic review and meta-analysis

BACKGROUND

Sarcopenia, characterized by skeletal muscle loss, is increasingly recognized as a predictor of poor outcomes in hematologic malignancies. This study evaluated the impact of sarcopenia on survival and post-transplant outcomes in lymphoma and multiple myeloma patients undergoing hematopoietic cell transplantation (HCT).

METHODS

A systematic review of eleven retrospective studies (2015-2024) including 1866 patients was conducted. Sarcopenia was assessed by CT, with some variation in diagnostic criteria. Pooled analyses were conducted to examine associations with mortality, progression-free survival (PFS), and non-relapse mortality (NRM).

RESULTS

The overall prevalence of sarcopenia was 45.7% (lymphoma: 44.2%, multiple myeloma: 49%). Sarcopenia significantly increased mortality risk in lymphoma (HR 1.92, 95% CI 1.61-2.29, p < 0.00001) and multiple myeloma patients (HR 1.12, 95% CI 1.03-1.22, p = 0.01). PFS was worse in lymphoma patients (HR 2.40, 95% CI 1.44-4.36, p = 0.0009), but NRM did not differ significantly.

CONCLUSION

Sarcopenia is a significant risk factor for poor outcomes in HCT recipients. Routine assessment and targeted interventions, including nutritional and exercise strategies, may improve patient outcomes. Further prospective studies are needed to establish standardized diagnostic criteria and explore therapeutic interventions.

Muscle measures from computed tomography, bioelectrical impedance, and ultrasound in hematopoietic cell transplantation patients

BACKGROUND

Low muscle mass is associated with adverse outcomes following hematopoietic cell transplantation (HCT). Computed tomography (CT) is a gold standard approach to measuring skeletal muscle but is associated with radiation exposure and no longer routinely performed in all patients before HCT. Alternative methods are needed for early identification, intervention, and serial evaluation of low muscle mass after HCT. Optimal methods should be portable and readily accessible. We thus evaluated the correlation between quadriceps muscle ultrasound (US), whole-body bioelectrical impedance analysis (BIA), and muscle CT in patients planned to undergo HCT.

METHODS

This study included 71 consecutive patients ≥18 years who underwent first HCT between 2020 and 2024. Pearson correlation examined the relationship between skeletal muscle measurements of cross-sectional area (CSA) from CT images at the third lumbar vertebra (L3), whole-body skeletal muscle mass (SMM) from BIA, and CSA from quadriceps muscle US.

RESULTS

Median age at evaluation was 52.6 years (range: 18.6-76.6). CT-derived L3 skeletal muscle CSA positively correlated with quadriceps muscle US CSA (r = 0.73; P < 0.0001) and BIA SMM (r = 0.92; P < 0.0001). Quadriceps muscle US and BIA SMM were also positively correlated (r = 0.74; P < 0.0001). Positive correlations were consistent across body mass index (BMI) and age categories.

CONCLUSIONS

Quadriceps muscle US and whole-body BIA offer reliable alternatives to estimate skeletal muscle without radiation exposure. US is more readily available, allowing for detailed phenotypic evaluation of individual muscles and identification of muscle compromise that may occur following HCT. This can enable development and monitoring of tailored and targeted interventions to improve muscle health and HCT outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of Obesity on GVHD in Patients Undergoing Allogeneic Hematopoietic Cell Transplant for Hematologic Malignancies

BACKGROUND

The relationship between obesity and graft-versus-host disease (GVHD) has been studied in both preclinical and clinical studies with varying results.

OBJECTIVES

We aimed to investigate the impact of obesity, as measured by body mass index (BMI), on the incidence, severity, and response to therapy of GVHD in a contemporary cohort.

STUDY DESIGN

We conducted a retrospective study of patients undergoing allogeneic hematopoietic cell transplant (HCT) for acute myelogenous leukemia and myelodysplastic syndrome between January 2010 and December 2021 at the Cleveland Clinic. Incidence, grade, organ involvement, and response to therapy of acute and chronic GVHD were compared between patients with obesity (BMI ≥30) and without obesity. Secondary outcomes included relapse, nonrelapse mortality (NRM), and overall survival (OS).

RESULTS

531 patients were identified, with a median follow-up of 19 months (range, 7-49). Mean (SD) BMI at time of HCT was 29.1 (6.3) kg/m2. There was no significant difference in demographic and HCT characteristics between patients with obesity (N = 199) and without obesity (N = 332). Development of any acute (42% versus 43%) or chronic (29% versus 30%) GVHD was similar in patients with and without obesity. Patients with obesity were less likely to have gastrointestinal involvement from chronic GVHD (28% versus 48%, P = .01). Skin (64% versus 56%), mouth (45% versus 35%) and eye (35% versus 27%) involvements were higher in patients with obesity, although statistically not significant. There were no significant differences in OS, NRM, or relapse.

CONCLUSION

There were no significant differences in incidence of GVHD among patients with and without obesity. Additional studies are needed to further understand potential differences in organ involvement.

Factors affecting pretransplant muscle strength in allogeneic stem cell transplant candidates prior transplantation

PURPOSE

Physical performance is crucial for prognosis after allogeneic hematopoietic stem cell transplantation (allo-HCT). Cardiorespiratory fitness has already been shown to have prognostic value, and there is increasing evidence that muscle strength and associated parameters (e.g., sarcopenia) are also of clinical relevance. Therefore, there is a need for the quantification of muscle strength and defining risk factors for reduced performance values.

METHODS

Maximal voluntary isokinetic (MVIC) and isometric (MIPT) muscle strength was assessed 2.4 ± 7.1 days prior admission for allo-HCT with a stationary isokinetic testing machine (IsoMed2000). We calculated percentiles for knee extension and hip flexion using healthy reference values. Regression models were used to identify predictors for reduced muscle strength including gender, age, body mass index (BMI), number of previous cardiotoxic therapies, number of previous transplantations, comorbidity index (HCT-CI), hemoglobin level, and physical activity.

RESULTS

Data of 212 patients (male n = 143, female n = 69), with a mean age of 54.49 ± 11.4, revealed considerably deviations from healthy reference values. Patients were located in the following percentiles: MVICKnee 37.5 ± 30.3, MVICHip 39.5 ± 31.3 and MIPTKnee 22.9 ± 26.5; MIPTHip 22.6 ± 27.4. Sub-group analyses showed that patients with younger age and male gender possess the highest deviations. Muscle strength values were significantly (p < 0.05) influenced by age, female gender, lower BMI, and higher HCT-CI.

CONCLUSION

Muscle strength is considerably reduced immediately prior to allo-HCT. Identified patient characteristics for reduced muscle strength point to the population that should be primarily targeted with exercise respectively resistance training interventions prior to allo-HCT to contribute to a well prepared transplant candidate.

TRIAL REGISTRATION

NCT01374399.

Impact of immunological aging on T cell-mediated therapies in older adults with multiple myeloma and lymphoma

The treatment landscape for lymphoma and multiple myeloma, which disproportionally affect older adults, has been transformed by the advent of T cell-mediated immunotherapies, including immune checkpoint inhibition, T cell-engaging bispecific antibodies, and chimeric antigen receptor (CAR) T cell therapy, during the last decade. These treatment modalities re-enable the patient's own immune system to combat malignant cells and offer the potential for sustained remissions and cure for various diseases.Age profoundly affects the physiological function of the immune system. The process of biological aging is largely driven by inflammatory signaling, which is reciprocally fueled by aging-related alterations of physiology and metabolism. In the T cell compartment, aging contributes to T cell senescence and exhaustion, increased abundance of terminally differentiated cells, a corresponding attrition in naïve T cell numbers, and a decrease in the breadth of the receptor repertoire. Furthermore, inflammatory signaling drives aging-related pathologies and contributes to frailty in older individuals. Thus, there is growing evidence of biological aging modulating the efficacy and toxicity of T cell-mediated immunotherapies.Here, we review the available evidence from biological and clinical studies focusing on the relationship between T cell-mediated treatment of hematologic malignancies and age. We discuss biological features potentially impacting clinical outcomes in various scenarios, and potential strategies to improve the safety and efficacy of immune checkpoint inhibitors, T cell-engaging bispecific antibodies, and CAR-T cell therapy in older patients.

An integrative review of cancer-related cachexia and sarcopenia: A different focus in malignant hematology

Introduction/background

An improved understanding of cancer-related cachexia and sarcopenia among patients with hematologic malignancies can improve their health outcomes. Patients with hematologic malignancies are affected by cancer-related cachexia and sarcopenia, but this aspect of their care is rarely studied. This review aims to increase awareness and knowledge of cancer-related cachexia and sarcopenia for patients with hematologic malignancies through a comprehensive synthesis of current research.

Methods

An integrative literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Ovid MEDLINE, CINAHL Complete, Embase, and Web of Science databases were searched for studies published between 2012 and 2022 using search terms of hematologic malignancies and cancer-related cachexia or sarcopenia.

Results

Twenty-nine studies were examined with data on 5,687 patients, primarily diffuse large B-cell lymphoma.

Conclusion

The results are grouped by themes identified in the studies of cancer-related cachexia and sarcopenia in hematologic cancers. The major themes identified were health outcomes, patient identification, transplant effects, and sex differences. Cancer-related cachexia and sarcopenia are associated with decreased overall survival and progression-free survival, similar to solid tumors. Cancer-related cachexia and sarcopenia reduce tolerance to chemotherapy and increase hematologic toxicities. With this effect, biomarkers and cachexia prognostic scores are available to improve patient identification, prognostication, and support. These affected individuals will benefit from increased awareness by the healthcare team to tailor care and mitigate the deleterious effects of the condition.

Quality of skeletal muscles during allogeneic stem-cell transplantation: a pilot study

OBJECTIVES

This study investigated the muscle fat fraction (FF) and muscle-related parameters before and after allogeneic hematopoietic stem cell transplantation (HSCT).

METHODS

Fat and water signals were derived from the in-phase and out-of-phase MR signal intensities of the pelvis and thigh using the two-point Dixon technique. They were analysed using Synapse Vincent, and muscle quality was evaluated using the FF. The muscle mass was assessed by measuring the thigh and gluteal muscle areas using a manual trace on the MR image. The association between the muscle FF and clinical data was retrospectively determined.

RESULTS

This study included 11 patients (6 males). Their mean age was 42.7 years, and eight had leukaemia. Eight were assessed at a mean of 65.4 days post-HSCT. The hip and thigh skeletal muscle FFs were not significantly different during HSCT. The grip and lower limb muscle strengths decreased significantly after HSCT. Patients with low FFs before transplantation tended to lose muscle strength, and the increase in FF and decrease of muscle strength were correlated.

CONCLUSIONS

Muscle strength and quantity decrease during the early phase after HSCT, especially in patients with low FF muscles. Therefore, interventions based on muscle quality and quantity are essential.

Impact of Malnutrition on the Length of Stay for Hospitalized Chimeric Antigen Receptor T-cell (CAR-T) Therapy Patients in the United States (2020)

Background Chimeric antigen receptor T-cell (CAR-T) therapy offers a promising treatment for certain malignancies but can be associated with complications. Malnutrition and cachexia are common in cancer patients and may worsen outcomes. This study investigated the impact of malnutrition on the length of hospital stay (LOS) in patients with hematologic malignancies undergoing CAR-T therapy. The analysis focused on different subpopulations, including those with acute lymphoblastic leukemia (ALL), multiple myeloma (MM), diffuse large B-cell lymphoma (DLBCL), and non-Hodgkin lymphoma (NHL) excluding DLBCL. Methods Utilizing the 2020 National Inpatient Sample (NIS) data, we performed survey-based mean estimation analyses for LOS across various subpopulations of CAR-T therapy patients. These subpopulations were defined by specific diagnoses: ALL, myeloma, DLBCL, and NHL excluding DLBCL. We compared the LOS between patients with and without malnutrition using STATA accounting for the complex survey design. Cachexia was included as disease-induced malnutrition. Results The total CAR-T population used for analyses included 439 patients, and malnutrition was present in 50 (11.39%). The overall CAR-T population demonstrated a significantly longer LOS for patients with malnutrition (30.92 days, 95% CI: 24.30 to 37.54) compared to those without malnutrition (17.97 days, 95% CI: 15.48 to 20.46, p = 0.0002). This trend held true across subgroups. Specifically, the ALL population had a significantly longer LOS with malnutrition (45.25 days, 95% CI: 35.46 to 55.04) compared to non-malnourished patients (27.58 days, 95% CI: 16.74 to 38.42, p = 0.0279). For the DLBCL population, the mean LOS was 24.47 days (95% CI: 19.22 to 29.71) with malnutrition and 17.17 days (95% CI: 13.29 to 21.04, p = 0.0161) without malnutrition. The NHL population excluding DLBCL exhibited a mean LOS of 33.86 days (95% CI: 22.66 to 45.07) for malnourished patients and 17.44 days (95% CI: 14.76 to 20.11, p = 0.0055) for non-malnourished patients. The myeloma population showed a similar trend although not statistically significant, with a mean LOS of 39.00 days (95% CI: -3.54 to 81.54) for malnourished patients and 18.03 days (95% CI: 15.02 to 21.03, p = 0.3337) for non-malnourished patients. These findings highlight significant variations in LOS across different CAR-T-treated cancer subtypes, emphasizing the impact of malnutrition on healthcare resource utilization in oncology. Conclusion Malnutrition is associated with a significantly longer hospital stay among patients undergoing CAR-T therapy. This trend is consistent across various subpopulations, including those with ALL, DLBCL, and NHL (excluding DLBCL). While the impact of malnutrition on LOS was not statistically significant in the myeloma population, this could potentially be attributed to the smaller sample size in this group. Overall, these findings underscore the critical role of nutritional status in managing patients undergoing CAR-T therapy. Future studies should investigate the most effective methods for identifying and treating malnutrition in this patient population to reduce hospital stays and optimize overall patient care.

Body composition and late-occurring chronic health conditions after autologous stem cell transplantation for lymphoma

BACKGROUND

Autologous peripheral blood stem cell transplantation (aPBSCT) is the standard of care for adults with relapsed lymphoma, yet recipients remain at risk of developing chronic health conditions (CHCs). It was hypothesized that body composition measurements of skeletal muscle and fat are associated with late-onset CHCs and nonrelapse mortality after aPBSCT.

METHODS

Leveraging the Blood or Marrow Transplant Survivor Study, we examined association between pre-aPBSCT body composition and new-onset grade 3-5 CHCs among 187 adults with lymphoma treated with aPBSCT (2011-2014) surviving ≥2 years after aPBSCT. Using computed tomography scans at the L3 level, skeletal muscle mass (skeletal muscle area and skeletal muscle density [SMD]) and body fat (subcutaneous adipose tissue and visceral adipose tissue) were measured and quantified as sex-specific z-scores. Competing risk models were built to study the impact of body composition on incident grade 3 through 5 CHCs and nonrelapse mortality (NRM) adjusting for confounders.

RESULTS

The study cohort had a median age at aPBSCT of 57 years with 63% males, 77% non-Hispanic Whites and 81% with non-Hodgkin lymphoma. The 5-year cumulative incidence of grade 3 through 5 CHCs was 47% (95% Confidence Interval, CI, 38%-56%). Each SD increase in SMD was associated with 30% reduced risk of grade 3 through 5 CHCs (95% CI, 0.50-0.96). The 10-year cumulative incidence of NRM was 16% (95% CI, 10-22). No body composition measure was associated with NRM.

CONCLUSIONS

The association between SMD and grade 3 through 5 CHCs following aPBSCT could inform development of prognostic models to identify adults with lymphoma at greatest risk of morbidity following aPBSCT.

Malnutrition and cachexia are associated with poor CAR T-cell therapy outcomes including survival

BACKGROUND & AIMS

Chimeric Antigen Receptor (CAR) T-cell therapy has emerged as a revolutionary treatment for patients with refractory or relapsed B-cell malignancies. However, a significant proportion of patients experience negative outcomes, including severe inflammatory toxicities and relapse. Cachexia and malnutrition are known secondary syndromes in many cancer patients, attributed to the effects of active malignancy, systemic inflammation, and cumulative treatment burden; however, further research is required to accurately characterise these issues in CAR T-cell patients. The aims of this service evaluation were to explore the changes in nutritional status (malnutrition and cachexia) in CAR T-cell therapy patients and the potential impact on patient outcomes including survival. Additionally, we describe the utilisation of dietetic resources in this specific patient population in a London tertiary referral centre.

METHODS

Adult haematology patients receiving licensed CD19-targeting CAR T-cell therapy at University College London Hospital between 01/04/19 and 01/09/21 were included. Data were collected from the time of treatment consent, and throughout admission to day of discharge: body weight (BW), C-reactive protein, albumin, lactate dehydrogenase, nutrition-risk screening scores (hospital-specific) and dietetic input. Clinical outcomes such as 12-month all-cause mortality, intensive care unit (ICU) admission, high-grade toxicities, and length of hospital stay (LoS) were also recorded. Cachexia and malnutrition were defined using the modified Glasgow Prognostic Score (mGPS) and Global Leadership Initiative on Malnutrition (GLIM) consensus, respectively.

RESULTS

114 patients (55.6 ± 15.1 years; 57% males) with B-cell non-Hodgkin's lymphoma (n = 109) and B-cell acute lymphoblastic leukaemia (n = 5), receiving axicabtagene ciloleucel (n = 89) and tisagenlecleucel (n = 25) were included. Median LoS for treatment was 34 (27-38) days. Prior to treatment, 31.5% of patients developed malnutrition, with pre-cachexia/refractory cachexia (mGPS) identified in 43.6% of patients. This altered nutritional status pre-treatment was significantly associated with adverse patient outcomes post-infusion; mGPS was independently associated with inferior overall survival (HR = 3.158, CI = 1.36-7.323, p = 0.007), with malnutrition and mGPS associated with increased LoS (p = 0.037), sepsis (p = 0.022) and ICU admission (p = 0.039). During admission, patients experienced significant BW loss (-5.6% (-8.8 to -2.4); p=<0.001), with 68.4% developing malnutrition. Malnutrition screening during admission identified 57% patients at-risk, with 66.6% of patients referred to dietetics; however, there was a lack of malnutrition screening and dietetic referrals prior to treatment.

CONCLUSION

Pre-treatment malnutrition and cachexia was significantly associated with adverse CAR T patient outcomes, including mGPS cachexia status independently associated with inferior overall survival. Further research in this novel space is essential to confirm the extent and impact of nutritional issues, to assist with implementing dietetic pathways, and to identify potential interventions with a view to optimising outcomes.

Cardiovascular Disease After Hematopoietic Stem Cell Transplantation in Adults: JACC: CardioOncology State-of-the-Art Review

The use of hematopoietic cell transplantation (HCT) has expanded in the last 4 decades to include an older and more comorbid population. These patients face an increased risk of cardiovascular disease after HCT. The risk varies depending on several factors, including the type of transplant (autologous or allogeneic). Many therapies used in HCT have the potential to be cardiotoxic. Cardiovascular complications after HCT include atrial arrhythmias, heart failure, myocardial infarction, and pericardial effusions. Before HCT, patients should undergo a comprehensive cardiovascular assessment, with ongoing surveillance tailored to their individual level of cardiovascular risk. In this review, we provide an overview of cardiotoxicity after HCT and outline our approach to risk assessment and ongoing care.

Health professional attitudes and perceptions of prehabilitation and nutrition before haematopoietic cell transplantation

BACKGROUND

Nutritional prehabilitation may improve haematopoietic cell transplantation (HCT) outcomes, although little evidence exists. The present study aimed to understand healthcare professional (HCP) perceptions of prehabilitation and nutritional care pre-HCT in UK centres.

METHODS

An anonymous online survey (developed and refined via content experts and piloting) was administered via email to multidisciplinary HCPs in 39 UK adult centres, between July 2021 and June 2022. Data are presented as proportions of responses. Routine provision denotes that care was provided >70% of time.

RESULTS

Seventy-seven percent (n = 66) of HCPs, representing 61.5% (n = 24) of UK adult HCT centres, responded. All HCPs supported prehabilitation, proposing feasible implementation between induction chemotherapy (60.4%; n = 40) and first HCT clinic (83.3%; n = 55). Only 12.5% (n = 3) of centres had a dedicated prehabilitation service. Nutrition (87.9%; n = 58), emotional wellbeing (92.4%; n = 61) and exercise (81.8%; n = 54) were considered very important constituents. HCPs within half of the HCT centres (n = 12 centres) reported routine use of nutrition screening pre-HCT with a validated tool; 66.7% of HCPs (n = 36) reported using the malnutrition universal screening tool (MUST). Sixty-two percent (n = 41) of HCPs reported those at risk, received nutritional assessments, predominantly by dietitians (91.6%; n = 22) using the dietetic care process (58.3%; n = 14). Body mass index (BMI) was the most frequently reported body composition measure used by HCPs (70.2%, n = 33). Of 59 respondents, non-dietitians most routinely provided dietary advice pre-HCT (82.4%; n = 28 vs. 68%; n = 17, p = 0.2); including high-energy/protein/fat and neutropenic diet advice. Prophylactic enteral feeding pre-HCT was rare, indicated by low BMI and significant unintentional weight loss. Just under half (n = 25 of 59, 42.4%) HCPs reported exercise advice was given routinely pre-HCT.

CONCLUSIONS

Nutrition and prehabilitation pre-HCT are considered important and deliverable by HCPs, but current provision in UK centres is limited and inconsistent.

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

INTRODUCTION

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

METHODS

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

RESULT

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

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

Long-Term Rehabilitation Therapy Is Effective for Physical Function in a Patient With Amyloid Light Chain Amyloidosis Complicated by Nephrotic Syndrome: A Case Report and Literature Review

We report on the rehabilitation of a patient with amyloid light chain (AL) amyloidosis complicated by nephrotic syndrome. Various symptoms produced by AL amyloidosis, including nephrotic syndrome, complicate rehabilitation therapy. In this case report, long-term physical therapy was initiated prior to autologous peripheral blood stem cell transplantation owing to the risk of further decline in physical function due to decreased mobility and physical activity. Patients were instructed on how to perform home exercise therapy. Furthermore, compliance was monitored using a checklist and regular face-to-face feedback. There was no increase in skeletal muscle mass, but improvements in grip strength, lower extremity muscle strength, and phase angle were observed after 24 weeks of physical therapy. Despite the absence of partial remission (urinary protein level of 3.5 g/gCre or higher), nephrotic syndrome demonstrated a trend toward improvement. Since the effectiveness of physical therapy in such patients has not yet been fully established, this report suggests that long-term rehabilitation therapy for physical function in patients with nephrotic syndrome complicated by persistent proteinuria may be effective.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Low subcutaneous adipose tissue and myosteatosis are prognostic factors after allogeneic hematopoietic stem cell transplantation

OBJECTIVE

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) represents the only curative treatment option for several hematological neoplasms. This study aimed to assess the parameters of body composition as predictors of post-transplant overall survival (OS) and adverse events in patients with leukemia, myelodysplastic syndromes (MDS), and myeloproliferative neoplasms (MPN).

METHODS

This was a retrospective study of 122 adult patients who underwent their first allo-HSCT. The CT-based semi-automated measurement of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), visceral-to-subcutaneous fat ratio (VSR), sarcopenia in terms of skeletal muscle index (SMI), and myosteatosis based on the skeletal muscle radiation attenuation (SM-RA) was performed. Cox regression analysis was used to assess the association of body composition parameters with OS.

RESULTS

In the univariate analysis, low SAT and myosteatosis were associated with lower OS (hazard ratio [HR] 2.02, 95% confidence interval [CI] 1.16-3.51, p = 0.01) and (HR 2.50, 95% CI 1.48-4.25, p =< 0.001), respectively. This association remained significant after adjusting for relevant covariates, with HR 2.32, 95% CI 1.23-4.38, p = 0.01 and HR 2.86, 95% CI 1.51-5.43, p =< 0.001, respectively. On the contrary, VAT, VSR, sarcopenia, and sarcopenic obesity were not statistically significant in OS. Severe post-transplant adverse events were more common in the low SAT group (odds ratio [OR] 3.12, 95% CI 1.32-7.40, p = 0.01) and OR 3.17, 95% CI 1.31-7.70, p =< 0.01 in the age- and sex-adjusted analysis.

CONCLUSION

Low SAT and myosteatosis may contribute to an increased risk of post-transplant mortality, while low SAT appears to increase the risk of severe post-transplant adverse events.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Parameters of body composition do not predict survival in patients with multiple myeloma undergoing autologous stem cell transplantation

Studies regarding the influence of body composition parameters as predictors on overall survival (OS) in patients with multiple myeloma (MM) are scarce. OS and progression-free survival (PFS) were retrospectively assessed in 129 patients with MM undergoing autologous stem cell transplantation (ASCT) after a follow-up of 2 years. A computed tomography (CT) based semi-automated assessment of body composition was performed. No statistically significant differences were noted in 2-year OS, PFS, or post-transplant adverse events in the body composition groups of subcutaneous adipose tissue (SAT) (low vs. high-SAT), visceral adipose tissue (VAT) (low vs. high-VAT), visceral-to-subcutaneous fat ratio (VSR) (low vs. high VSR), and sarcopenia in terms of skeletal muscle index (SMI) (non-sarcopenic vs. sarcopenic). In conclusion, adipose and muscle tissue do not limit OS or affect the PFS in patients with MM undergoing ASCT.

Neuromuscular electrical stimulation for physical function maintenance during hematopoietic stem cell transplantation: Study protocol

Hematopoietic stem cell transplantation is a common life-saving treatment for hematologic malignancies, though can lead to long-term functional impairment, fatigue, muscle atrophy, with decreased quality of life. Although traditional exercise has helped reduce these effects, it is inconsistently recommended and infrequently maintained, and most patients remain sedentary during and after treatment. There is need for alternative rehabilitation strategies, like neuromuscular electrical stimulation, that may be more amenable to the capabilities of hematopoietic stem cell transplant recipients. Patients receiving autologous HCT are being enroled in a randomized controlled trial with 1:1 (neuromuscular electrical stimulation:sham) design stratified by diagnosis and sex. Physical function, body composition, quality of life, and fatigue are assessed prior to hematopoietic stem cell transplant (prior to initiating preparatory treatment) and 24±5 days post hematopoietic stem cell transplant (Follow-up 1); physical function and quality of life are also assessed 6-months post hematopoietic stem cell transplant (Follow-up 2). The primary outcome is between-group difference in the 6-minute walk test change scores (Follow-up 1-Pre-transplant; final enrolment goal N = 23/group). We hypothesize that 1) neuromuscular electrical stimulation will attenuate hematopoietic stem cell transplant-induced adverse effects on physical function, muscle mass, quality of life, and fatigue compared to sham at Follow-up 1, and 2) Pre-transplant physical function will significantly predict fatigue and quality of life at Follow-up 2. We will also describe feasibility and acceptability of neuromuscular electrical stimulation during hematopoietic stem cell transplant. This proposal will improve rehabilitative patient care and quality of life by determining efficacy and feasibility of a currently underutilized therapeutic strategy aimed at maintaining daily function and reducing the impact of a potent and widely used cancer treatment. This trial is registered with clinicaltrials.gov (NCT04364256).

Tripartite prehabilitation of patients with acute myeloid leukaemia and high-risk myelodysplastic syndromes during intensive chemotherapy before allogeneic haematopoietic stem cell transplantation (COHABILIT): protocol for an innovating prospective multicentre study

OBJECTIVES

Acute myeloid leukaemia (AML) and high-risk myelodysplastic syndromes (MDS) are often treated with intensive chemotherapy followed by allogeneic haematopoietic stem cell transplantation (allo-HSCT). The pretransplant treatment results in a general deterioration of the patient's health and quality of life. Furthermore, allo-HSCT can be responsible for significant toxicity with risks of graft-versus-host disease (GvHD). Developing strategies to prevent physical deconditioning, undernutrition and psychological distress could help maintain a satisfactory general state of health before transplantation and thus limit these deleterious effects. This protocol evaluates the feasibility and adherence to a personalised prehabilitation programme, which can be modulated and assisted by connected objects, provided from the diagnosis to the allo-HSCT.

METHODS AND ANALYSIS

This multicentre interventional study will include 50 patients treated for AML or high-risk MDS with intensive chemotherapy and eligible for allo-HSCT. The intervention consists of a coached, supervised or self-directed physical activity programme, organised during the hospitalisation phases and periods at home. At the same time, patients will receive a weekly dietary follow-up. The whole intervention is controlled and modulated through the use of a dedicated application and connected objects allowing adaptation and individualisation. The rate of participation in the prescribed physical activity sessions will assess the feasibility of this study. In addition, the evolution of physical capacities (Short Physical Performance Battery, grip and quadriceps strengths), psychosocial parameters (Functional Assessment of Cancer Therapy - Leukaemia, Functional Assessment of Cancer Therapy - Fatigue, subjective well-being, Hospital Anxiety and Depression Scale, self-efficacy, Coach-Athlete Relationship Questionnaire, interviews) and clinical status (weight, lean body mass, survival rate, number of infections, days of hospitalisation, GvHD) will be evaluated.

ETHICS AND DISSEMINATION

The study procedures have been approved by the National Ethics Committee (21.00223.000003). Consent is given in person by each participant. The information collected on the participants contains only a non-identifiable study identifier. The results of this protocol will be published in a scientific paper and communicated to the medical staff of the medical centre.

TRIAL REGISTRATION NUMBER

NCT03595787.

Burden of Morbidity and Mortality in Adolescent and Young Adult Cancer Survivors

There are an estimated 650,00 survivors of adolescent and young adult (AYA) cancers in the United States, a number that is expected to markedly increase in the coming decades. The recognition of the potential for some cancer treatments to affect the health of patients for many years after the initial diagnosis has prompted investigators to examine the evolving burden of late morbidity and mortality in AYAs with cancer after treatment completion. Studies in large international cohorts of AYA cancer survivors have now shown that the burden of late effects in survivors treated during the past four decades is substantial, affecting the health and well-being of the survivor, health systems' preparedness to meet their health care needs in the future, and societal economic costs that are largely affected by loss of productivity. We highlight the unique considerations for AYA cancer survivors, identify gaps in knowledge for future research, and provide an overview of emerging efforts to mitigate late effects in these survivors. Ongoing multidisciplinary bench-to-bedside collaborations are critical to understanding the biology of late effects in AYA cancer survivors and to developing personalized interventions to mitigate them. The growing population of AYA cancer survivors makes it imperative that these efforts extend across the cancer care continuum, which will allow survivors to ultimately live to their fullest potential.

The Role of Exercise in Cancer-Related Sarcopenia and Sarcopenic Obesity

One of the most common adverse effects of cancer and its therapeutic strategies is sarcopenia, a condition which is characterised by excess muscle wasting and muscle strength loss due to the disrupted muscle homeostasis. Moreover, cancer-related sarcopenia may be combined with the increased deposition of fat mass, a syndrome called cancer-associated sarcopenic obesity. Both clinical conditions have significant clinical importance and can predict disease progression and survival. A growing body of evidence supports the claim that physical exercise is a safe and effective complementary therapy for oncology patients which can limit the cancer- and its treatment-related muscle catabolism and promote the maintenance of muscle mass. Moreover, even after the onset of sarcopenia, exercise interventions can counterbalance the muscle mass loss and improve the clinical appearance and quality of life of cancer patients. The aim of this narrative review was to describe the various pathophysiological mechanisms, such as protein synthesis, mitochondrial function, inflammatory response, and the hypothalamic-pituitary-adrenal axis, which are regulated by exercise and contribute to the management of sarcopenia and sarcopenic obesity. Moreover, myokines, factors produced by and released from exercising muscles, are being discussed as they appear to play an important role in mediating the beneficial effects of exercise against sarcopenia.

Muscle and fat composition in patients with newly diagnosed multiple myeloma

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

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

Background & aims

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

Methods

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

Results

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

Conclusion

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

Systematic review registration

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

Sarcopenia and gut microbiota alterations in patients with hematological diseases before and after hematopoietic stem cell transplantation

Objective

The aim of this study was to investigate the prevalence of sarcopenia (SP) and its relationship with gut microbiota alterations in patients with hematological diseases before and after hematopoietic stem cell transplantation (HSCT).

Methods

A total of 108 patients with various hematological disorders were selected from Peking University People's Hospital. SP was screened and diagnosed based on the 2019 Asian Sarcopenia Diagnosis Strategy. Physical measurements and fecal samples were collected, and 16S rRNA gene sequencing was conducted. Alpha and beta diversity analyses were performed to evaluate gut microbiota composition and diversity.

Results

After HSCT, significant decreases in calf circumference and body mass index (BMI) were observed, accompanied by a decline in physical function. Gut microbiota analyses revealed significant differences in the relative abundance of Enterococcus, Bacteroides, Blautia and Dorea species before and after HSCT (P<0.05). Before HSCT, sarcopenic patients had lower Dorea levels and higher Phascolarctobacterium levels than non-sarcopenia patients (P<0.01). After HSCT, no significant differences in species abundance were observed. Alpha diversity analysis showed significant differences in species diversity among the groups, with the highest diversity in the post-HSCT 90-day group and the lowest in the post-HSCT 30-day group. Beta diversity analysis revealed significant differences in species composition between pre- and post-HSCT time points but not between SP groups. Linear discriminant analysis effect size (LEfSe) identified Alistipes, Rikenellaceae, Alistipes putredinis, Prevotellaceae defectiva and Blautia coccoides as biomarkers for the pre-HSCT sarcopenia group. Functional predictions showed significant differences in anaerobic, biofilm-forming and oxidative stress-tolerant functions among the groups (P<0.05).

Conclusions

This study demonstrated a significant decline in physical function after HSCT and identified potential gut microbiota biomarkers and functional alterations associated with SP in patients with hematological disorders. Further research is needed to explore the underlying mechanisms and potential therapeutic targets.

Lower Body Mass Index and Prognostic Nutritional Index Are Associated with Poor Posttransplant Outcomes in Lymphoma Patients Undergoing Autologous Stem Cell Transplantation

INTRODUCTION

Pretransplant inflammatory and nutritional status has not been widely explored in terms of its impact on autologous hematopoietic stem cell transplantation (auto-HSCT) outcomes in lymphoma patients. We aimed to evaluate the impact of body mass index (BMI), prognostic nutritional index (PNI), and C-reactive protein to albumin ratio (CAR) on auto-HSCT outcomes.

METHODS

We retrospectively analyzed 87 consecutive lymphoma patients who underwent their first auto-HSCT at the Adult Hematopoietic Stem Cell Transplantation Unit at Akdeniz University Hospital.

RESULTS

The CAR had no impact on posttransplant outcomes. PNI ≤50 was an independent prognostic factor for both shorter progression-free survival (PFS) (hazard ratio [HR] = 2.43, p = 0.025) and worse overall survival (OS) (HR = 2.93, p = 0.021), respectively. The 5-year PFS rate was significantly lower in patients with PNI ≤50 than in patients with PNI >50 (37.3% vs. 59.9%, p = 0.003). The 5-year OS rate in patients with PNI ≤50 was significantly low when compared with patients who had PNI >50 as well (45.5% vs. 67.2%, p = 0.011). Patients with BMI <25 had higher 100-day transplant-related mortality compared with patients with BMI ≥25 (14.7% vs. 1.9%, p = 0.020). BMI <25 was an independent prognostic factor associated with shorter PFS and OS (HR = 2.98 [p = 0.003], HR = 5.06 [p < 0.001], respectively). The 5-year PFS rate was significantly lower in patients with BMI <25 than patients with BMI ≥25 (40.2% vs. 53.7%, p = 0.037). Similarly, the 5-year OS rate in patients with BMI <25 was significantly inferior compared to patients with BMI ≥25 (42.7% vs. 64.7%, p = 0.002).

CONCLUSION

Our study confirms that lower BMI and CAR have negative impacts on auto-HSCT outcomes in lymphoma patients. Furthermore, higher BMI should not be considered an obstacle for lymphoma patients who need auto-HSCT; conversely, it could be an advantage for posttransplant outcomes.

Monitoring of strength, inflammation and muscle function in allogenic stem-cell transplantation patients - a pilot study for novel biomarker and risk stratification determination

Background

Low aerobic capacity is associated with an increased mortality risk in allogenic stem-cell transplantation (alloSCT) patients, but currently used risk scores in the pre-transplantation workup are still underestimating physical activity as a prognostic factor.

Aim

To examine the physical condition, muscle function, blood inflammation and training adherence of alloSCT patients during inpatient time to identify potential biomarkers associated with development of myopathy and sarcopenia.

Methods

Patients undergoing alloSCT were examined at four time points (T0: before alloSCT; T_ha: hospital admission; T1: engraftment; T2: inpatient discharge). T0 included cardiopulmonary performance, body composition, grip and knee strength, motor skill tests (One-leg stand/Tinetti/Chair-rising), blood sampling (blood cell profiling and inflammation targets (Kynurenin/high sensitivity C-reactive Protein (hsCRP)/Tumor necrosis factor alpha (TNF-alpha)/Musclin/Galectin-3) and quality of life, state of health, fatigue, muscle weakness and physical activity by questionnaires (IPAQ/BSA/SARC-F/Fatigue). At T1 and T2, blood samples, grip strength and motor skill tests were repeated. Glucocorticoid dose and daily physical activity were documented during inpatient stay.

Results

26 of 35 included patients (4 females; age 55.58 ± 12.32 years; BMI 24.70 ± 3.27 kg/m²; VO_2peak 16.55 ± 4.06 ml/min/kg) could proceed to alloSCT. Grip strength and Tinetti decreased from T0 until T2, no difference in Chair-rising test, One-leg and Tandem stand. All patients engrafted after 24.9 days ± 3.9 days. HsCRP and Kynurenine increased from T0 to T1, decreased at T2. TNF-alpha (T0vsT2/T1vsT2) and Musclin (T0vsT1) decreased. At T2, Galectin-3 was higher compared to T0/T1. Correlation analysis of grip strength and inflammatory markers revealed a positive correlation with TNF-alpha at T2. 50% of patients documented physical activity and questionnaire and reported a 50%-reduction of daily endurance and strength training between T1 to T2.

Conclusion

Allogeneic stem-cell transplantation is associated with immune system vulnerability due to conditioning, increased inflammation and fatigue, and loss of muscle strength and function. In addition to hsCRP, Kynurenine seems to be a reliable biomarker to monitor acute and regenerative inflammation status of alloSCT patients, while Musclin and Galectin-3 may be added to physiological assessment regarding myopathy and sarcopenia. Grip strength and daily activity level should be documented by professionals to identify risk patients early and support them with optimal (exercise) therapy.

Toxicity risk score and clinical decline after adjuvant chemotherapy in older breast cancer survivors

BACKGROUND

Chemotoxicity risk scores were developed to predict grade 3-5 chemotherapy toxicity in older women with early breast cancer. However, whether these toxicity risk scores are associated with clinically meaningful decline in patient health remains unknown.

METHODS

In a prospective study of women aged 65 years and older with stage I-III breast cancer treated with chemotherapy, we assessed chemotoxicity risk using the Cancer and Aging Research Group-Breast Cancer (CARG-BC) score (categorized as low, intermediate, and high). We measured patient health status before (T1) and after (T2) chemotherapy using a clinical frailty index (Deficit Accumulation Index, categorized as robust, prefrail, and frail). The population of interest was robust women at T1. The primary outcome was decline in health status after chemotherapy, defined as a decline in Deficit Accumulation Index from robust at T1 to prefrail or frail at T2. Multivariable logistic regression was used to examine the association between T1 CARG-BC score and decline in health status, adjusted for sociodemographic and clinical characteristics.

RESULTS

Of the 348 robust women at T1, 83 (24%) experienced declining health status after chemotherapy, of whom 63% had intermediate or high CARG-BC scores. After adjusting for sociodemographic and clinical characteristics, women with intermediate (odds ratio = 3.14, 95% confidence interval = 1.60 to 6.14, P < .001) or high (odds ratio = 3.80, 95% confidence interval = 1.35 to 10.67, P = .01) CARG-BC scores had greater odds of decline in health status compared with women with low scores.

CONCLUSIONS

In this cohort of older women with early breast cancer, higher CARG-BC scores before chemotherapy were associated with decline in health status after chemotherapy independent of sociodemographic and clinical risk factors.

Imaging modalities for measuring body composition in patients with cancer: opportunities and challenges

Body composition assessment (ie, the measurement of muscle and adiposity) impacts several cancer-related outcomes including treatment-related toxicities, treatment responses, complications, and prognosis. Traditional modalities for body composition measurement include body mass index, body circumference, skinfold thickness, and bioelectrical impedance analysis; advanced imaging modalities include dual energy x-ray absorptiometry, computerized tomography, magnetic resonance imaging, and positron emission tomography. Each modality has its advantages and disadvantages, thus requiring an individualized approach in identifying the most appropriate measure for specific clinical or research situations. Advancements in imaging approaches have led to an abundance of available data, however, the lack of standardized thresholds for classification of abnormal muscle mass or adiposity has been a barrier to adopting these measurements widely in research and clinical care. In this review, we discuss the different modalities in detail and provide guidance on their unique opportunities and challenges.

Impact of the quantity and quality of the skeletal muscle on survival among patients undergoing allogeneic hematopoietic stem cell transplantation

INTRODUCTION

Poor skeletal muscle function is relatively high in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), leading to various negative health outcomes. This study aimed to investigate the relationship between the quantity and quality of skeletal muscle before transplantation and the short-to long-term survival after transplantation in patients undergoing allo-HSCT.

METHODS

This retrospective cohort study included 156 patients undergoing allo-HSCT (men, 67.3 %; median age, 53 years; interquartile range, 42-61 years). The quantity and quality of the skeletal muscle were measured at the psoas major at the level of the third lumbar vertebrae using a computed tomography (CT) and were defined as psoas muscle index (PMI) and CT values (CTV), respectively. The outcome measure of this study was overall survival (OS) after allo-HSCT, and we examined the relationship between survival at three time points (6, 12, and 24 months) after transplantation, PMI, and CTV.

RESULTS

PMI was significantly associated with survival at all time points in the crude model (P < 0.001), and a significant association was observed in the fully adjusted model (P < 0.01). CTV was significantly associated with survival at all time points in the crude model (P < 0.05), but not in the fully adjusted model (P > 0.05).

CONCLUSIONS

We found that the quantity and quality of the skeletal muscle before transplantation were significantly associated with OS at 6, 12, and 24 months after transplantation, showing a particularly robust association with quantity.

Enhanced Recovery Stem-Cell Transplantation: Multidisciplinary Efforts to Improve Outcomes in Older Adults Undergoing Hematopoietic Stem-Cell Transplant

PURPOSE

Older adults have unique risk factors for poor outcomes after hematopoietic stem-cell transplant (HSCT). We sought to determine the impact of our multidisciplinary supportive care program, Enhanced Recovery after stem-cell transplant (ER-SCT), on survival outcomes in patients age 65 years and older who underwent HSCT.

PATIENTS AND METHODS

In this retrospective study, clinicodemographic data, nonrelapse mortality (NRM), overall survival (OS), and relapse were compared between 64 patients age 65 years and older who underwent allogeneic stem-cell transplant during ER-SCT program's first year, October 2017 through September 2018, and 140 historical controls age 65 years and older who underwent allogeneic HSCT, January 2015 through September 2017.

RESULTS

In the ER-SCT cohort, 41% (26 of 64) of patients were women, and the median (range) age was 68 (65-74) years; in the control cohort, 38% (53 of 140) of patients were women, and the median (range) age was 67 (65-79) years. Hematopoietic cell transplant comorbidity index and donor type/cell source were similar between cohorts. The ER-SCT cohort had a lower 1-year NRM rate (13% v 26%, P = .03) and higher 1-year OS rate (74% v 53%, P = .007). Relapse rate did not differ significantly between cohorts. In multivariate analyses, ER-SCT was associated with improved 1-year NRM (hazard ratio, 0.4; 95% CI, 0.2 to 0.9; P = .02) and improved 1-year OS (hazard ratio, 0.5; 95% CI, 0.3 to 0.9; P = .03).

CONCLUSION

A multidisciplinary supportive care program may improve NRM and OS in older patients undergoing allogeneic HSCT. Randomized studies are warranted to confirm this benefit and explore which program components most contribute to the improved outcomes.

IMPROVE-BMT: a protocol for a pilot randomised controlled trial of prehabilitation exercise for adult haematopoietic stem cell transplant recipients

INTRODUCTION

Haematopoietic stem cell transplant (HSCT) in adults is an intensive medical procedure for a variety of haematological malignancies. Although there is a large body of evidence demonstrating the negative effects of HSCT on physical function and psychosocial parameters, there is limited evidence on the impact of HSCT on body composition and bone health. Further, aerobic and resistance-training exercise interventions aimed at improving physical function and patient-reported outcomes largely take place during the peritransplant and post-transplant period. Prehabilitative exercise, or exercise prior to medical treatment, has been successfully deployed in presurgical candidates and other tumour sites, yet there is a paucity of evidence on the effect of prehabilitation in HSCT patients. The aim of this study is to investigate the feasibility, acceptability and safety of a resistance training exercise programme in patients with haematological malignancies prior to HSCT.

METHODS AND ANALYSIS

IMpact of PRehabilitation in Oncology Via Exercise-Bone Marrow Transplant is a single-site, pilot randomised controlled trial of an exercise intervention compared with usual care. The primary aim is to assess the feasibility, acceptability and safety of the resistance-training exercise intervention prior to HSCT. Secondary aims include evaluating the differences in physical function, body composition, bone mineral density and patient-reported outcomes between the exercise group and usual care control group. Outcome measurements will be assessed: prior to HSCT, on/around day of HSCT admission, +30 days post-HSCT and +100 days post-HSCT. The exercise intervention is a home-based resistance training exercise programme that incorporates resistance band and body weight exercises. The primary outcomes will be reported as percentages and/or mean values. The secondary outcomes will be analysed using appropriate statistical methods to portray within-group and between-group differences.

ETHICS AND DISSEMINATION

The study has Penn State College of Medicine approval. Results will be disseminated through scientific publication and presentation at exercise-related and oncology-related scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03886909.

Impact of muscle loss in children with hematologic malignancies undergoing allogeneic hematopoietic cell transplantation

The widespread recognition of the concept of sarcopenia, or muscle loss, has impacted the prognosis of patients undergoing high-intensity treatments. We focused on the effect of muscle loss on the prognosis of pediatric patients with hematologic diseases. A total of 65 patients with hematologic malignancies who underwent allogeneic HCT once were investigated. The change in cross-sectional psoas muscle area (PMA) measured on computed tomography (CT) images was expressed as the muscle loss index (MLI), which was calculated by dividing the pre-HCT PMA by the baseline PMA. In this study, patients with MLI values less than 0.85 were classified into the muscle loss group. Muscle loss was observed in 27 patients (41.5%). Patients who experienced muscle loss were older than those who did not. Muscle loss was an independent predictor of higher non-relapse mortality (NRM) (p = 0.012) and inferior overall survival (OS) (p = 0.045) at 5 years. Multivariate analysis showed that muscle loss was an independent risk factor for higher NRM (p = 0.046), and inferior EFS (p = 0.048). Muscle loss observed pre-HCT may be a predictor of increased NRM, poor OS and EFS in pediatric patients with hematologic malignancies undergoing allogeneic HCT.

Nutritional modulation of the gut microbiome in allogeneic hematopoietic stem cell transplantation recipients

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) represents a potentially curative strategy for many oncological and non-oncological diseases, but it is associated with marked morbidity and mortality. The disruption of gut microbiota (GM) eubiosis has been linked to major allo-HSCT complications, including infections and acute graft vs. host disease (aGvHD), and correlates with mortality. This increasing knowledge on the role of the GM in the allo-HSCT procedure has led to fascinating ideas for modulating the intestinal ecosystem in order to improve clinical outcomes. Nutritional strategies, either by changing the route of nutritional supplementation or by administering specific molecules, are increasingly being considered as cost- and risk-effective methods of modulating the GM. Nutritional support has also emerged in the past several years as a key feature in supportive care for allo-HSCT recipients, and deterioration of nutritional status is associated with decreased overall survival and higher complication rates during treatment. Herein we provide a complete overview focused on nutritional modulation of the GM in allo-HSCT recipients. We address how pre transplant diet could affect GM composition and its ability to withstand the upsetting events occurring during transplantation. We also provide a complete overview on the influence of the route of nutritional administration on the intestinal ecosystem, with a particular focus on the comparison between enteral and parenteral nutrition (PN). Moreover, as mounting evidence are showing how specific components of post-transplant diet, such as lactose, could drastically shape the GM, we will also summarize the role of prebiotic supplementation in the modulation of the intestinal flora and in allo-HSCT outcomes.

Exercise training and NR supplementation to improve muscle mass and fitness in adolescent and young adult hematopoietic cell transplant survivors: a randomized controlled trial {1}

BACKGROUND

Advances in hematopoietic cell transplantation (HCT) have led to marked improvements in survival. However, adolescents and young adults (AYAs) who undergo HCT are at high risk of developing sarcopenia (loss of skeletal muscle mass) due to the impact of HCT-related exposures on the developing musculoskeletal system. HCT survivors who have sarcopenia also have excess lifetime risk of non-relapse mortality. Therefore, interventions that increase skeletal muscle mass, metabolism, strength, and function are needed to improve health in AYA HCT survivors. Skeletal muscle is highly reliant on mitochondrial energy production, as reflected by oxidative phosphorylation (OXPHOS) capacity. Exercise is one approach to target skeletal muscle mitochondrial OXPHOS, and in turn improve muscle function and strength. Another approach is to use "exercise enhancers", such as nicotinamide riboside (NR), a safe and well-tolerated precursor of nicotinamide adenine dinucleotide (NAD+), a cofactor that in turn impacts muscle energy production. Interventions combining exercise with exercise enhancers like NR hold promise, but have not yet been rigorously tested in AYA HCT survivors.

METHODS/DESIGN

We will perform a randomized controlled trial testing 16 weeks of in-home aerobic and resistance exercise and NR in AYA HCT survivors, with a primary outcome of muscle strength via dynamometry and a key secondary outcome of cardiovascular fitness via cardiopulmonary exercise testing. We will also test the effects of these interventions on i) muscle mass via dual energy x-ray absorptiometry; ii) muscle mitochondrial OXPHOS via an innovative non-invasive MRI-based technique, and iii) circulating correlates of NAD+ metabolism via metabolomics. Eighty AYAs (ages 15-30y) will be recruited 6-24 months post-HCT and randomized to 1 of 4 arms: exercise + NR, exercise alone, NR alone, or control. Outcomes will be collected at baseline and after the 16-week intervention.

DISCUSSION

We expect that exercise with NR will produce larger changes than exercise alone in key outcomes, and that changes will be mediated by increases in muscle OXPHOS. We will apply the insights gained from this trial to develop individualized, evidence-supported precision initiatives that will reduce chronic disease burden in high-risk cancer survivors.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05194397. Registered January 18, 2022, https://clinicaltrials.gov/ct2/show/NCT05194397 {2a}.

Persistent Musculoskeletal Deficits in Pediatric, Adolescent and Young Adult Survivors of Allogeneic Hematopoietic Stem-Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is a common therapy for pediatric hematologic malignancies. With improved supportive care, addressing treatment-related late effects is at the forefront of survivor long-term health and quality of life. We previously demonstrated that alloHSCT survivors had increased adiposity, decreased lean mass, and lower bone density and strength, 7 years (median) from alloHSCT compared to their healthy peers. Yet it is unknown whether these deficits persist. Our longitudinal study characterized changes in muscle and bone over a period of 3.4 (range, 2.0 to 4.9) years in 47 childhood alloHSCT survivors, age 5-26 years at baseline (34% female). Tibia cortical bone geometry and volumetric density and lower leg muscle cross-sectional area (MCSA) were assessed via peripheral quantitative computed tomography (pQCT). Anthropometric and pQCT measurements were converted to age, sex, and ancestry-specific standard deviation scores, adjusted for leg length. Muscle-specific force was assessed as strength relative to MCSA adjusted for leg length (strength Z-score). Measurements were compared to a healthy reference cohort (n = 921), age 5-30 years (52% female). At baseline and follow-up, alloHSCT survivors demonstrated lower height Z-scores, weight Z-scores, and leg length Z-scores compared to the healthy reference cohort. Deficits in MCSA, trabecular volumetric bone density, and cortical bone size and estimated strength (section modulus) were evident in survivors (all p < 0.05). Between the two study time points, anthropometric, muscle, and bone Z-scores did not change significantly in alloHSCT survivors. Approximately 15% and 17% of alloHSCT survivors had MCSA and section modulus Z-score < -2.0, at baseline and follow-up, respectively. Furthermore, those with a history of total body irradiation compared to those without demonstrated lower MCSA at follow-up. The persistent muscle and bone deficits in pediatric alloHSCT survivors support the need for strategies to improve bone and muscle health in this at-risk population. © 2022 American Society for Bone and Mineral Research (ASBMR).

Prevalence of low skeletal muscle quantity and quality and their associated factors in patients before allogeneic hematopoietic stem cell transplantation

Both quality and quantity of skeletal muscle are considered important for prognostic factors and clinical outcomes in solid cancers. However, few studies have examined both quality and quantity of skeletal muscle in patients with hematological malignancies. The aim of the present study was to clarify the prevalence of low skeletal muscle quantity and quality and their associated factors in patients before allogeneic hematopoietic stem cell transplantation (allo-HSCT). Pretransplant plain CT imaging at the third lumber vertebra level was used to measure the psoas muscle mass index (PMI) and the intramuscular adipose tissue content (IMAC) in 113 adult patients (age 47.1 ± 14.6 years) before HSCT. We analyzed the factors associated with PMI and IMAC, respectively. Although 62.8% of all patients had low skeletal muscle mass, only 8% had poor skeletal muscle quality. Multivariable logistic analysis showed that older age [odds ratio (OR) = 2.45, confidence interval (CI) = 1.04-5.76, P = 0.04], male (OR = 4.35, CI = 0.05-0.97, P = 0.04), and low BMI (OR = 0.83, CI = 0.71-0.97, P = 0.02) were independent risk factors for low PMI before HSCT. Only age (≤ 50 years) was significantly associated with muscle quality (modified OR = 0.07, CI = 0.00-0.43, P < 0.01) in univariate analysis. Most patients already showed low skeletal muscle mass before allo-HSCT although skeletal muscle quality was relatively preserved. These results may be indicative of pre-cachexia and may be useful for its long-term management in allo-HSCT patients.

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

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

Influence of body composition assessed by computed tomography on mortality in older adults undergoing hematopoietic stem cell transplantation

BACKGROUND

The incidence of most hematologic malignancies increases with age. Hematopoietic stem cell transplantation (HSCT) provides a potentially life-prolonging or curative option for many patients in this scenario. Limited data assessed from computed tomography (CT) images are available on muscle mass and density outcomes after HSCT. We evaluate the influence of body composition on morbidity and mortality in older adults undergoing HSCT.

METHODS

Retrospective longitudinal study conducted with 50 patients ≥ 60 years old undergoing HSCT. Body composition was assessed by chest CT (CCT), and treatment-related mortality, graft-vs-host disease (GVHD), neutrophil grafting, and overall survival were analyzed.

RESULTS

148 HSCT patients were evaluated; 50 patients were eligible: 60% with autologous and 40% with allogeneic transplantation. Body mass index in patients was (female: 26.9 ± 4.7 kg/m² ; male: 30.1 ± 4.9 kg/m² ) - autologous and, (female: 24.3 ± 5.1 kg/m² ; male: 26.4 ± 2.0 kg/m² ) - allogeneic. In the autologous group, we found a positive association between age and death risk, with 63.5% increased risk of death (P = 0.006), and also Karnofsky Performance Score, with a 11.9% decrease in death risk (P < 0.001). A negative association between muscle radiodensity and death risk was observed in patients who received an allogeneic transplantation, with a risk decrease of 20.1% (P = 0.032). We found a positive association between the fourth thoracic vertebra muscle area and radiodensity and risk of acute GVHD (P = 0.028).

CONCLUSION

Body composition assessed by CCT showed the importance of radiodensity for better prognosis.

Body Composition Impacts Hematopoietic Stem Cell Transplant Outcomes in Both Autologous and Allogeneic Transplants: A Systematic Review

According to World Health Organization, over 50,000 hematopoietic stem cell transplants (HSCTs) are performed annually worldwide. Though HSCT can extend life-expectancy and improve disease-related health burdens, it is not without risks. Post-transplant overall survival is improving; therefore, it is imperative that factors contributing to or impeding further improvements are well understood. The purpose of this systematic review is to explore current data on body composition (specifically weight loss, BMI, obesity and sarcopenia) and the relation to HSCT outcomes. A literature search was conducted via PubMed and Web of Science databases. Key words included "body composition," "sarcopenia," "hematopoietic stem cell transplant," "malnutrition," "body mass index," and "obesity." Results indicated that 16 out of 18 analyzed studies found a statistically significant relationship between body composition, in particular higher BMI and weight loss, and at least one survival-related outcome variable (eg., non-relapse mortality, overall survival and/or relapse). Based on the findings of this review, body composition, whether evaluated before or during HSCT, can impact a wide variety of post-transplant outcomes. This speaks to the importance of evaluating patients pre-transplant, identifying potential risk factors for worsened outcomes, and providing immediate interventions in order to optimize transplant outcomes.

Allogeneic haematopoietic stem cell transplantation-clinical outcomes: impact of leg muscle strength

OBJECTIVES

Muscle strength decline is reported to predict mortality in many cancers. However, there is little knowledge of the relation between muscle strength decline and clinical outcomes of allogeneic haematopoietic stem cell transplantation (allo-HSCT). This study aimed to determine the impact of pre-transplant lower extremity muscle strength (LEMS) on post-transplant overall survival (OS) and non-relapse mortality (NRM).

METHODS

In this retrospective cohort study, 97 adult patients underwent allo-HSCT during 2012-2020. LEMS was defined as knee extension force divided by patient's body weight. The patients were divided into low and high LEMS groups based on pre-transplant LEMS. OS was measured using the Kaplan-Meier method and the Cox proportional hazards model. The cumulative incidence of NRM was evaluated using the Fine and Gray method, with relapse considered as a competing risk event.

RESULTS

Probability of OS was significantly lower in the low LEMS groups (HR 2.48, 95% CI 1.20 to 5.12, p=0.014) than in the high LEMS group on multivariate analysis. Five-year OS was 25.8% and 66.4% in the low and high LEMS groups, respectively. Risk of NRM was significantly higher in the low LEMS group (HR 4.49, 95% CI 1.28 to 15.68, p=0.019) than in the high LEMS group. The cumulative incidence of NRM was 41.4% and 11.1% in the low and high LEMS groups, respectively.

CONCLUSIONS

Pre-transplant LEMS was a significant factor in predicting OS and NRM.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

Late-occurring infections in a contemporary cohort of hematopoietic cell transplantation survivors

Background

There is a paucity of studies describing the incidence and risk factors for late‐occurring (≥1 year) infectious complications in contemporary survivors of hematopoietic cell transplantation (HCT).

Methods

This was a retrospective cohort study of 641 1‐year survivors of HCT, transplanted between 2010 and 2013 as adults, and in remission from their primary disease. Standardized definitions were used to characterize viral, fungal, and bacterial infections. Cumulative incidence of infections was calculated, with relapse/progression considered as a competing risk event. Fine‐Gray subdistribution hazard ratio estimates and 95% confidence intervals (CI) were obtained, adjusted for relevant covariates.

Results

Median age at HCT was 55.2 years (range 18.1–78.1 years); 54.0% were survivors of allogeneic HCT. The 5‐year cumulative incidence of a late‐occurring infection for the entire cohort was 31.6%; the incidence of polymicrobial (≥2) infections was 10.1%. In survivors who developed at least one infection, the 5‐year incidence of a subsequent infection was 45.3%. Among allogeneic HCT survivors, patients with acute lymphoblastic (HR = 1.82 95% CI [1.12–2.96]) or myeloid (HR = 1.50 95% CI [1.02–2.20]) leukemia, and those with an elevated HCT‐Comorbidity index score (HR = 1.09 95% CI [1.01–1.17]) were more likely to develop late‐occurring infections; there was an incremental risk associated with severity of graft versus host disease (GVHD) at 1‐year post‐HCT (mild: HR = 2.17, 95% CI [1.09–4.33]; moderate/severe: HR = 3.78, 95% CI [1.90–7.53]; reference: no GVHD).

Conclusions

The burden of late‐occurring infections in HCT survivors is substantial, and there are important patient‐ and HCT‐related modifiers of risk over time. These findings may help guide personalized screening and prevention strategies to improve outcomes after HCT.

Risks of Muscle Atrophy in Patients with Malignant Lymphoma after Autologous Stem Cell Transplantation

OBJECTIVE

Muscle atrophy is associated with autologous stem cell transplantation (ASCT)-related outcomes in patients with malignant lymphoma (ML). However, the impact of ASCT on muscle mass remains unclear in patients with ML. The aims of this study were to investigate changes in muscle mass and risk profiles for muscle atrophy after ASCT.

METHOD

We enrolled 40 patients with refractory ML (age 58 [20-74] years, female/male 16/24, body mass index (BMI) 21.1 kg/m² [17.1-29.6]). Psoas muscle mass was assessed using the psoas muscle index (PMI) before and after ASCT.

STATISTICAL ANALYSIS USED

Independent factors associated with a severe decrease rate of change in PMI were evaluated by decision-tree analysis, respectively.

RESULTS

PMI was significantly decreased after ASCT (4.61 vs. 4.55 cm²/m²; P=0.0425). According to the decision-tree analysis, the regimen was selected as the initial split. The rates of change in PMI were -5.57% and -3.97% for patients administered MCEC and LEED, respectively. In patients who were administered LEED, the second branching factor was BMI. In patients with BMI < 20.3 kg/m², the rate of change in PMI was -7.16%. On the other hand, the rate of change in PMI was 4.05% for patients with BMI ≥ 20.3 kg/m².

CONCLUSION

We demonstrated that muscle mass decreased after ASCT in patients with ML. Patients who received MCEC and patients with low BMI were at risk for a decrease in muscle mass.