Can sarcopenia predict survival in locally advanced rectal cancer patients?

Impact of Preoperative CT-Measured Sarcopenia on Clinical, Pathological, and Oncological Outcomes After Elective Rectal Cancer Surgery

Background: Patients with rectal cancer may be exposed to a loss of muscle strength and quality. This study aimed to assess the role of preoperative CT-based sarcopenia on postoperative clinical, pathological, and oncological outcomes after rectal cancer surgery. Methods: This retrospective monocentric study included patients who underwent elective oncologic resection for rectal adenocarcinoma between 01/2014 and 03/2022. The skeletal muscle index (SMI) was measured using CT at the third lumbar vertebral level, and sarcopenia was defined based on pre-established sex-specific cut-offs. Patients with sarcopenia were compared to those without sarcopenia in terms of outcomes. A Cox proportional hazard regression analysis was used to determine the independent prognostic factors of disease-free survival (DFS) and overall survival (OS). Results: A total of 208 patients were included, and 123 (59%) had preoperative sarcopenia. Patients with sarcopenia were significantly older (66 vs. 61 years, p = 0.003), had lower BMI (24 vs. 28 kg/m2, p < 0.001), and were mainly men (76 vs. 48%, p < 0.001). There was no difference in overall and major complication rates between the sarcopenia and non-sarcopenia group (43 vs. 37%, p = 0.389, and 17 vs. 17%, p = 1.000, respectively). Preoperative and postoperative features related to rectal surgery were comparable. The only predictive factor impacting OS was R1/R2 resection (HR 4.915, 95% CI, 1.141-11.282, p < 0.001), while sarcopenia (HR 2.013, 95% CI 0.972-4.173, p = 0.050) and T3/T4 status (HR 2.108, 95% CI 1.058-4.203, p = 0.034) were independently associated with DFS. Conclusions: A majority of patients undergoing rectal cancer surgery had preoperative CT-based sarcopenia. In this cohort, sarcopenia had no impact on postoperative morbidity and OS but was independently associated with DFS.

A Scoping Review of the Implications and Applications of Body Composition Assessment in Locally Advanced and Locally Recurrent Rectal Cancer

Background: A strong body of evidence exists demonstrating deleterious relationships between abnormal body composition (BC) and outcomes in non-complex colorectal cancer. Complex rectal cancer (RC) includes locally advanced and locally recurrent tumours. This scoping review aims to summarise the current evidence examining BC in complex RC. Methods: A literature search was performed on Ovid MEDLINE, EMBASE, and Cochrane databases. Original studies examining BC in adult patients with complex RC were included. Two authors undertook screening and full-text reviews. Results: Thirty-five studies were included. Muscle quantity was the most commonly studied BC metric, with sarcopenia appearing to predict mortality, recurrence, neoadjuvant therapy outcomes, and postoperative complications. In particular, 10 studies examined relationships between BC and neoadjuvant therapy response, with six showing a significant association with sarcopenia. Only one study examined interventions for improving BC in patients with complex RC, and only one study specifically examined patients undergoing pelvic exenteration. Marked variation was also observed in terms of how BC was quantified, both in terms of anatomical location and how cut-off values were defined. Conclusions: Sarcopenia appears to predict mortality and recurrence in complex RC. An opportunity exists for a meta-analysis examining poorer BC and neoadjuvant therapy outcomes. There is a paucity of studies examining interventions for poor BC. Further research examining BC specifically in patients undergoing pelvic exenteration surgery is also lacking. Pitfalls identified include variances in how BC is measured on computed tomography and whether external cut-off values for muscle and adipose tissue are appropriate for a particular study population.

Prognostic significance of preoperative CT-based sarcopenia in locally advanced rectal cancer: a multicenter retrospective study

OBJECTIVES

The association between preoperative CT-based sarcopenia and prognosis in locally advanced rectal cancer (LARC) remains unclear. The aim of this study was to investigate the relationship between CT-based sarcopenia and clinical outcomes in patients with LARC.

MATERIALS AND METHODS

This multicenter retrospective study analyzed 503 LARC patients who underwent radical resection in three tertiary hospitals in China from January 2018 to June 2021 and were pathologically confirmed. All patients were followed for a period of at least three years. Clinical, pathological, and imaging data were carefully collected. According to the sex-specific skeletal muscle index (SMI), patients were evaluated for the presence of CT-based sarcopenia. The SMI was obtained by measuring the cross-sectional muscle area and standardizing it by the height of different patients. The primary endpoint was post-operative overall survival (OS), and the secondary endpoint included disease-free survival (DFS), postoperative complications, prolonged length of stay (LOS), readmission, and cancer-specific survival (CSS).

RESULTS

This study included 503 patients [mean age: 61.5 ± 10.8 years; 353 male (70.2%)], who were divided into the non-sarcopenic group (375 patients, 74.5%) and the sarcopenic group (128 patients, 25.5%). Over a mean follow-up period of 47 months (range 4-73), a total of 108 (21.4%) deaths and 162 (32.2%) combined endpoints, including recurrence or metastasis, were observed. Multivariate Cox regression analysis revealed that CT-based sarcopenia (hazard ratio [HR], 2.41; 95% confidence interval [CI], 1.49 ~ 3.87; P < 0.001) was independently associated with worse OS in LARC patients over a three-year period, but was not associated with shorter DFS (HR, 1.34; 95% CI, 0.89 ~ 2.03; P = 0.163). CT-based sarcopenia was not significantly associated with postoperative complications of grade II or greater (odds ratio [OR]: 1.29, 95% CI: 0.62 ~ 2.68, P = 0.496) or prolonged LOS (OR: 1.05, 95% CI: 0.6 ~ 1.86, P = 0.853). However, sarcopenic patients showed a higher risk of readmission (OR: 5.53, 95% CI: 1.57 ~ 19.5, P = 0.008) and a significant correlation with poorer CSS (HR: 2.78, 95% CI: 1.64 ~ 4.72, P < 0.001). Kaplan-Meier analysis showed that sarcopenic LARC patients had a significantly higher cumulative hazard of OS compared to non-sarcopenic patients (P < 0.001, log-rank test). Similar patterns of association were observed in subgroup analyses (all P values for interaction > 0.05).

CONCLUSIONS

Preoperative CT-based sarcopenia is independently associated with decreased OS, CSS, and an elevated risk of readmission in patients with LARC. These findings emphasize the importance of identifying sarcopenic patients at higher risk for adverse outcomes and suggest that interventions aimed at improving physical strength and endurance may play a critical role in informing treatment strategies and guiding clinical decisions.

Impact of Sarcopenia on Treatment Outcomes and Toxicity in Locally Advanced Rectal Cancer

Background and Objectives: Sarcopenia, a condition characterized by muscle mass loss, is prevalent in up to 68% of rectal cancer patients and has been described as a negative prognostic factor, impacting overall survival and tumor response. While there are extensive data on rectal cancer globally, only a handful of studies have evaluated the role of sarcopenia in locally advanced rectal cancer (LARC). Our study aimed to investigate the relationship between sarcopenia, overall response rate, and toxicity in patients who underwent total neoadjuvant treatment (TNT) for LARC. Materials and Methods: We performed a retrospective study of patients with rectal cancer treated with TNT and surgery with curative intent between 2021 and 2023 at Prof. Dr. Ion Chiricuta Institute of Oncology, Cluj-Napoca. Sarcopenia was assessed on MRI images by measuring the psoas muscle area (PMA) at the level of the L4 vertebra before and after neoadjuvant therapy. The primary endpoints were the overall complete response rate (oCR) and acute toxicity. Results: This study included 50 patients with LARC. The oCR rate was 18% and was significantly associated with post-treatment sarcopenia (OR 0.08, p = 0.043). Patients who did not achieve a clinical or pathologic complete response had, on average, an 8% muscle loss during neoadjuvant therapy (p = 0.022). Cystitis and thrombocytopenia were significantly associated with post-treatment sarcopenia (p = 0.05 and p = 0.049). Conclusions: Sarcopenia and loss of psoas muscle during neoadjuvant therapy were negatively associated with tumor response in locally advanced rectal cancer. Thrombocytopenia and cystitis are more frequent in sarcopenic than non-sarcopenic patients undergoing neoadjuvant chemoradiation for rectal cancer.

Artificial intelligence measured 3D body composition to predict pathological response in rectal cancer patients

BACKGROUND

The treatment of locally advanced rectal cancer (LARC) is moving towards total neoadjuvant therapy and potential organ preservation. Of particular interest are predictors of pathological complete response (pCR) that can guide personalized treatment. There are currently no clinical biomarkers which can accurately predict neoadjuvant therapy (NAT) response but body composition (BC) measures present as an emerging contender. The primary aim of the study was to determine if artificial intelligence (AI) derived body composition variables can predict pCR in patients with LARC.

METHODS

LARC patients who underwent NAT followed by surgery from 2012 to 2023 were identified from the Australian Comprehensive Cancer Outcomes and Research Database registry (ACCORD). A validated in-house pre-trained 3D AI model was used to measure body composition via computed tomography images of the entire Lumbar-3 vertebral level to produce a volumetric measurement of visceral fat (VF), subcutaneous fat (SCF) and skeletal muscle (SM). Multivariate analysis between patient body composition and histological outcomes was performed.

RESULTS

Of 214 LARC patients treated with NAT, 22.4% of patients achieved pCR. SM volume (P = 0.015) and age (P = 0.03) were positively associated with pCR in both male and female patients. SCF volume was associated with decreased likelihood of pCR (P = 0.059).

CONCLUSION

This is the first study in the literature utilizing AI-measured 3D Body composition in LARC patients to assess their impact on pathological response. SM volume and age were positive predictors of pCR disease in both male and female patients following NAT for LARC. Future studies investigating the impact of body composition on clinical outcomes and patients on other neoadjuvant regimens such as TNT are potential avenues for further research.

Predictive role of preoperative sarcopenia for long-term survival in rectal cancer patients: A meta-analysis

PURPOSE

To identify the predictive role of sarcopenia in long-term survival among rectal cancer patients who underwent surgery based on available evidence.

METHODS

The Medline, EMBASE and Web of Science databases were searched up to October 20, 2023, for relevant studies. Overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS) were the endpoints. Hazard ratios (HRs) and 95% confidence intervals (CIs) were combined to evaluate the association between sarcopenia and survival.

RESULTS

Fifteen studies with 4283 patients were included. The pooled results demonstrated that preoperative sarcopenia significantly predicted poorer OS (HR = 2.07, 95% CI = 1.67-2.57, P<0.001), DFS (HR = 1.85, 95% CI = 1.39-2.48, P<0.001) and CSS (HR = 1.83, 95% CI = 1.31-2.56, P<0.001). Furthermore, subgroup analysis based on neoadjuvant therapy indicated that sarcopenia was a risk factor for worse OS and DFS in patients who received (OS: HR = 2.44, P<0.001; DFS: HR = 2.16, P<0.001) but not in those who did not receive (OS: HR = 2.44, P<0.001; DDFS: HR = 1.86, P = 0.002) neoadjuvant chemoradiotherapy. In addition, subgroup analysis based on sample size and ethnicity showed similar results.

CONCLUSION

Preoperative sarcopenia is significantly related to poor survival in surgical rectal cancer patients and could serve as a novel and valuable predictor of long-term prognosis in these patients.

Sarcopenia as a prognostic indicator in colorectal cancer: an updated meta-analysis

Background

Sarcopenia, often observed in the elderly, is associated with declining skeletal muscle mass and impaired muscle function. This condition has been consistently linked to a less favorable prognosis in various malignancies. Computed tomography (CT) is a frequently employed modality for evaluating skeletal muscle mass, enabling the measurement of the skeletal muscle index (SMI) at the third lumbar vertebra (L3) level. This measurement serves as a defining criterion for sarcopenia. The meta-analysis dealt with evaluating the promise sarcopenia held as a prognostic indicator in individuals with colorectal cancer.

Methods

Research relevant to the subject was determined by systematically searching PubMed, Embase, Web of Science, WANFANG, and CNKI (up to June 11, 2023, published studies). In this meta-analysis, the incidence of sarcopenia in individuals with colorectal cancer was combined to analyze the disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) of these individuals with and without sarcopenia. The included research was evaluated for quality per the Newcastle-Ottawa Scale (NOS) score. In the multivariate analysis of each study, the direct extraction of hazard ratio (HR) with a 95% confidence interval (CI) was executed. STATA 11.0 was applied to integrate and statistically analyze the data.

Results

Overall 20 articles participated in this meta-analysis. A 34% incidence of sarcopenia was noted in colorectal cancer. The presence of sarcopenia denoted a decrease in OS (HR=1.72,95% CI=1.45-2.03), DFS (HR=1.42,95% CI=1.26-1.60) and CSS (HR=1.48,95% CI=1.26-1.75) in individuals with colorectal cancer. In addition, the subgroup analysis depicted a pattern consistent with the overall analysis results.

Conclusion

CT-defined sarcopenia exhibits promise as an indicator of survival prognosis in individuals with colorectal cancer. Future studies need a more rigorous definition of sarcopenia to further verify these findings.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023431435.