Effects of in-hospital exercise on sarcopenia in hepatoma patients who underwent transcatheter arterial chemoembolization

The Asian Pacific association for the study of the liver clinical practice guidelines for the diagnosis and management of metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD) affects over one-fourth of the global adult population and is the leading cause of liver disease worldwide. To address this, the Asian Pacific Association for the Study of the Liver (APASL) has created clinical practice guidelines focused on MAFLD. The guidelines cover various aspects of the disease, such as its epidemiology, diagnosis, screening, assessment, and treatment. The guidelines aim to advance clinical practice, knowledge, and research on MAFLD, particularly in special groups. The guidelines are designed to advance clinical practice, to provide evidence-based recommendations to assist healthcare stakeholders in decision-making and to improve patient care and disease awareness. The guidelines take into account the burden of clinical management for the healthcare sector.

A short-term predictive model for disease progression in acute-on-chronic liver failure: integrating spectral CT extracellular liver volume and clinical characteristics

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a life-threatening hepatic syndrome. Therefore, this study aimed to develop a comprehensive model combining extracellular liver volume derived from spectral CT (ECVIC-liver) and sarcopenia, for the early prediction of short-term (90-day) disease progression in ACLF.

MATERIALS AND METHODS

A retrospective cohort of 126 ACLF patients who underwent hepatic spectral CT scans was included. According to the Asia-Pacific Association for the Study of the Liver (APASL) criteria, patients were divided into the progression group (n = 70) and the stable group (n = 56). ECVIC-liver was measured on the equilibrium period (EP) images of spectral CT, and L3-SMI was measured on unenhanced CT images, with sarcopenia assessed. A comprehensive model was developed by combining independent predictors. Model performance was evaluated using receiver operating characteristic (ROC) curve analysis, calibration curves, and decision curve analysis (DCA).

RESULTS

In the univariate analysis, BMI, WBC, PLT, PTA, L3-SMI, IC-EP, Z-EP, K140-EP, NIC-EP, ECVIC-liver, and Sarcopenia demonstrated associations with disease progression status at 90 days in ACLF patients. In multivariate logistic regression, white blood cell count (WBC) (OR = 1.19, 95% CI: 1.02-1.40; P = 0.026), ECVIC-liver (OR = 1.27, 95% CI: 1.15-1.40; P < 0.001), sarcopenia (OR = 4.15, 95% CI: 1.43-12.01; P = 0.009), MELD-Na score (OR = 1.06, 95%CI: 1.01-1.13;P = 0.042), and CLIF-SOFA score (OR = 1.37, 95%CI:1.15-1.64; P<0.001) emerged as independent risk factors for ACLF progression. The combined model exhibited superior predictive performance (AUCs = 0.910, sensitivity = 80.4%, specificity = 90.0%, PPV = 0.865, NPV = 0.851) compared to CLIF-SOFA, MELD-Na, MELD and CTP scores(both P < 0.001). Calibration curves and DCA confirmed the high clinical utility of the combined model.

CONCLUSIONS

Patients without sarcopenia and/or with a lower ECVIC-liver have a better prognosis, and the integration of WBC, ECVIC-liver, Sarcopenia, CLIF-SOFA and MELD-Na scores in a composite model offers a concise and effective tool for predicting disease progression in ACLF patients.

TRIAL REGISTRATION

Not Applicable.

Increment of Skeletal Muscle Mass Predicts Survival Benefit for Hepatocellular Carcinoma Treated with Transarterial Chemoembolization Combining Molecular Targeted Agents and Immune Checkpoint Inhibitors

Purpose

To assess the relationship between clinical prognosis and changes of skeletal muscle mass for unresectable hepatocellular carcinoma (uHCC) patients who received transarterial chemoembolization (TACE) with molecular-targeted agents and immune checkpoint inhibitors (TACE-MTAs-ICIs).

Methods

From June 2019 to June 2023, a total of 92 uHCC patients who received TACE-MTAs-ICIs therapy were included. Skeletal muscle mass was assessed before and 6 months after treatment. Skeletal muscle index (SMI) is calculated as skeletal muscle area at the L3 vertebra divided by the square of height, then the change rate of SMI (ΔSMI) is calculated. Patients were stratified based on ΔSMI as muscle gain and non-muscle gain groups. Overall survival (OS) was compared between groups and prognostic factors for OS were analyzed. Progression-free survival (PFS) was also recorded.

Results

The median OS in the muscle gain group was significantly longer than that in the non-muscle gain group (Not reach vs 25.2 months, P < 0.001). The median PFS did not reach significant between two groups (16.2 vs 9.1 months, P = 0.101). Multivariate analyses revealed that skeletal muscle gain (HR = 0.20; 95% CI, 0.06-0.68; P = 0.010) and Barcelona Clinic Liver Cancer stage (HR = 1.94; 95% CI, 1.02-3.69; P = 0.044) were independent prognostic factors for OS.

Conclusion

SMI increment appeared as a favorable predictor for these uHCC patients who received TACE-MTAs-ICIs therapy.

Impact of nutrition risk index, prognostic nutritional index and skeletal muscle index on early myelosuppression of first-line chemotherapy in stage IV gastric cancer patients

BACKGROUND

In gastric cancer (GC) patients, malnutrition is common and has a negative impact on treatment tolerance, survival, and prognosis. The purpose of this study was to explore the relationship between prechemotherapy nutritional state and early myelosuppression in stage IV GC patients treated with first-line chemotherapy.

METHODS

This retrospective study included patients with stage IV GC who received first-line chemotherapy between July 2012 and December 2021. Clinical and laboratory data were collected within 1 week before chemotherapy to calculate nutrition risk index, prognostic nutritional index. Pretreatment abdominal computed tomography scans were used to quantify skeletal muscle index (SMI). The main measurable outcome was the incidence of grade ≥ 2 early myelosuppression after chemotherapy.

RESULTS

Among 102 patients eligible for analysis, 50% were malnourished, 50% were poor prognoses and 49% were sarcopenic at baseline.The side effects were generally well managed, with a 26.5% occurrence of grade 3/4 side effects. Pre-chemotherapy patients with low Nutrition Risk Index (NRI) (p = 0.002), low prognostic nutritional index (PNI) (p = 0.001), and low SMI (p = 0.001) had significantly higher incidences of grade ≥ 2 myelosuppression occurred after the first cycle of chemotherapy. Moreover, the high level of PNI was associated with higher completion rate of chemotherapy (p = 0.01). Multivariate logistic regression analysis revealed that SMI at baseline (p = 0.006) and hemoglobin level (p = < 0.001) were prognostic factors for grade ≥ 2 early myelosuppression.

CONCLUSION

Stage IV GC patients with low NRI, low PNI and low SMI experienced significantly more grade ≥ 2 early myelosuppression during the first line of chemotherapy.

Association of Omega-3 Polyunsaturated Fatty Acids with Sarcopenia in Liver Cirrhosis Patients with Hepatocellular Carcinoma

Background and Aims

Sarcopenia is associated with the prognosis of patients with liver cirrhosis and hepatocellular carcinoma (HCC). Given their diverse physiological activities, we hypothesized that plasma fatty acids might influence the progression of sarcopenia. This study aimed to clarify the association between fatty acids and sarcopenia in cirrhotic patients with HCC.

Methods

In this single-center retrospective study, we registered 516 cases and analyzed 414 cases of liver cirrhosis and HCC. The skeletal muscle mass index was measured using a transverse computed tomography scan image at the third lumbar vertebra. The cutoff value for sarcopenia followed the criteria set by the Japan Society of Hepatology. Fatty acid concentrations were measured by gas chromatography.

Results

Fatty acid levels, particularly omega-3 (n-3) polyunsaturated fatty acid (PUFA), were lower in patients with poor liver function (Child-Pugh grade B/C) and were negatively correlated with the albumin-bilirubin score (p<0.0001). The prognosis of HCC patients with low PUFA levels was significantly worse. Among the different fatty acid fractions, only n-3 PUFAs significantly correlated with skeletal muscle mass index (p=0.0026). In the multivariate analysis, the n-3 PUFA level was an independent variable associated with sarcopenia (p=0.0006).

Conclusions

A low level of n-3 PUFAs was associated with sarcopenia in patients with liver cirrhosis and HCC.

Effects of Exercise Training on Muscle Mass and Physical Function in Patients with Hepatocellular Carcinoma After Diagnosis: A Systematic Review

BACKGROUND AND AIMS

Decreased muscle mass and physical function are common complications in hepatocellular carcinoma (HCC) patients who are associated with increased morbidity and mortality. Thus, there have been targeted efforts to prevent and/or improve both by enrolling these patients in exercise training programs. We performed a systematic review to evaluate the effects of exercise training on muscle mass and physical function in people with HCC after diagnosis.

METHODS

A systematic literature search was conducted using the Medline, Base, PubMed, Cochrane and Scopus, and trial registries, through April 2023 for studies that assessed the effects of an exercise training program in adults with HCC. The primary outcomes were muscle mass and physical function. To assess the risk of bias, we used the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project.

RESULTS

Eight studies met inclusion criteria, comprising a total of 809 participants. Interventions included aerobic exercise training, resistance exercise training, balance and flexibility training, or home-based exercise training. Four studies showed statistically significant improvements in at least one muscular outcome. Three studies showed a maintenance of muscular outcomes, and one study showed a decrease in muscle mass. Four articles showed statistically improvements in at least one physical fitness variable, and two showed a maintenance of physical function variable.

CONCLUSION

Together, the results suggest that patients may benefit from physical exercise training after treatment to improve muscle mass and physical function.

The Negative Impact of Sarcopenia on Hepatocellular Carcinoma Treatment Outcomes

INTRODUCTION

Hepatocellular carcinoma (HCC) represents a major global health concern, characterized by evolving etiological patterns and a range of treatment options. Among various prognostic factors, sarcopenia, characterized by loss of skeletal muscle mass, strength, and function, has emerged as a pivotal contributor to HCC outcomes. Focusing on liver transplantation, surgical resection, locoregional treatments, and systemic therapies, this review aims to analyze the impact of sarcopenia on HCC treatment outcomes, shedding light on an underexplored subject in the pursuit of more personalized management.

METHODS

A comprehensive literature review was conducted by searching peer-reviewed articles on sarcopenia and treatment outcomes in patients with HCC from inception up to October 2023.

RESULTS

Sarcopenia was found to be prevalent among HCC patients, exhibiting different occurrence, possibly attributable to diverse diagnostic criteria. Notably, despite variations in studies utilizing skeletal muscle indices, sarcopenia independently correlated with lower overall survival (OS), recurrence-free survival (RFS), and progression-free survival (PFS) across surgical (both transplantation and resection), locoregional, and systemic therapies, including tyrosine-kinase inhibitors (TKIs) and immune-checkpoint inhibitors (ICIs). Moreover, a link between sarcopenia and increased rate and severity of adverse events, particularly in surgery and TKIs recipients, and larger tumor size at diagnosis was observed. While baseline sarcopenia negatively influenced treatment outcomes, alterations in muscle mass post-treatment emerged as primary determinants of reduced OS.

CONCLUSIONS

Sarcopenia, either present before or after HCC treatment, negatively correlates with response to it, across all etiologies and therapeutic strategies. Although only a few studies have evaluated the impact of supervised physical activity training on muscle mass and OS after HCC treatment, it is crucial to evaluate the presence of sarcopenia before treatment initiation, to better stratify patients' prognosis, thus performing a more tailored approach, and identify therapies able to restore muscle mass in HCC patients. Conversely, the impact of sarcopenia on HCC recurrence and extrahepatic spread remains inadequately explored.

Network meta-analysis of the intervention effects of different exercise measures on Sarcopenia in cancer patients

PURPOSE

This study aims to investigate the impact of four exercise modes (aerobic exercise, resistance exercise, aerobic combined with resistance multimodal exercise, and stretching) on the physical performance of cancer patients.

METHODS

Randomized controlled trials (RCTs) were exclusively collected from PubMed, EMBASE, Web of Science, and The Cochrane Library, with a search deadline of April 30, 2023. Different exercise interventions on the physical performance of cancer patients were studied, and the Cochrane risk of bias assessment tool was employed to evaluate the quality of the included literature. Data analysis was conducted using STATA 15.1 software.

RESULTS

This study included ten randomized controlled trials with a combined sample size of 503 participants. Network meta-analysis results revealed that aerobic combined with resistance multimodal exercise could reduce fat mass in cancer patients (SUCRA: 92.3%). Resistance exercise could improve lean mass in cancer patients (SUCRA: 95.7%). Furthermore, resistance exercise could enhance leg extension functionality in cancer patients with sarcopenia (SUCRA: 83.0%).

CONCLUSION

This study suggests that resistance exercise may be more beneficial for cancer-related sarcopenia.In clinical practice, exercise interventions should be tailored to the individual patients' circumstances.

REGISTRATION NUMBER

This review was registered on INPLASY2023110025; DOI number is https://doi.org/10.37766/inplasy2023.11.0025 .

Physical activity and exercise in liver cancer

Sarcopenia and physical deconditioning are common complications in patients with liver cancer, which are frequently caused by insufficient physical activity and poor nutritional status, resulting in physical frailty and a significant impact on the patient's physical fitness. Notably, sarcopenia, frailty, and poor cardiopulmonary endurance have all been linked to higher mortality rates among patients with liver cancer. Exercise intervention significantly improves various health parameters in liver cancer patients, including metabolic syndrome, muscle wasting, cardiorespiratory endurance, health-related quality of life, and reduction in hepatic venous pressure gradient. However, the link between physical exercise and liver cancer is commonly overlooked. In this article, we will examine the impact of exercise on liver cancer and present the most recent evidence on the best types of exercise for various stages of liver cancer. This article also summarizes and discusses the molecular mechanisms that control metabolism and systemic immune function in tumors. In brief, physical exercise should be considered an important intervention in the prevention and treatment of liver cancer and its complications.

A survey questionnaire evaluating physical activity patterns and determinants in patients with chronic liver disease

BACKGROUND

Physical activity can reduce the risk of morbidity and mortality in patients with chronic liver disease (CLD), whereas physical inactivity adversely affects clinical outcomes. Since data on physical activity in CLD are scarce, we conducted a questionnaire survey to assess the physical activity patterns and determinants in patients with CLD.

METHODS

We surveyed 437 patients from outpatient clinics at Gifu University Hospital about their physical activity patterns and determinants in 2022 using a validated questionnaire. The primary objective was to examine the proportion of patients who exercised and the clinical characteristics of patients who achieved high levels of physical activity. The secondary objectives were to explore the types, motivations, barriers, and preferences for physical activity.

RESULTS

Among the 397 eligible patients (median age 68 years; 51% men; and median Model for End-Stage Liver Disease score 6), 55.4% reported performing physical activity less than once a week. Physical activity frequency was not associated with sex, body mass index, comorbidities, or hepatic reserve. Among the respondents, 60.4% expressed concern regarding physical strength, and 80.6% expressed concern regarding physical inactivity. The main barriers to physical activity were work, household chores, and health problems. However, many respondents expressed their willingness to increase their physical activity frequency with some promotional policies. Walking was the most common physical activity practiced in the past year and the activity most respondents wanted to try in the future.

CONCLUSIONS

Patients with CLD are insufficiently active and need physical activity interventions, especially regarding walking.

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.

Impact of sarcopenia and sarcopenic obesity on survival in patients with primary liver cancer: a systematic review and meta-analysis

Background

Sarcopenia and sarcopenic obesity are associated with an increased possibility of adverse clinical outcomes; however, the effects of sarcopenia and sarcopenic obesity on patients with primary liver cancer remain controversial. Therefore, the present study aimed to determine the impact of sarcopenia and sarcopenic obesity on survival in patients with primary liver cancer.

Methods

We searched studies published in English in PubMed, Embase, Web of Science, and Cochrane Library databases up to 13 November 2022. Cohort studies that reported the association among sarcopenia, sarcopenic obesity, and patient survival were included.

Results

A total of 64 cohort studies with data on 11,970 patients with primary liver cancer were included in the meta-analysis. Sarcopenia was associated with poor overall survival in patients with primary liver cancer [adjusted hazard ratio (HR) 2.11, 95% confidence interval (CI): 1.89-2.36, P < 0.0001], with similar findings for sarcopenic obesity (adjusted HR: 2.87, 95% CI: 2.23-3.70, P < 0.0001). Sarcopenia was also associated with poor overall survival across the subgroups analyzed by ethnicity, type of liver cancer, treatment modalities, method used to define sarcopenia, and etiology of liver cancer. We also found a negative correlation among sarcopenia, sarcopenic obesity, and recurrence-free/disease-free survival (adjusted HR: 1.73, 95% CI: 1.50-1.99, P < 0.001; adjusted HR: 2.28, 95% CI: 1.54-3.35, P < 0.001, respectively).

Conclusion

Sarcopenia and sarcopenic obesity were significantly associated with poor overall survival and recurrence-free/disease-free survival in patients with primary liver cancer.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=378433, PROSPERO [42022378433].

The Systemic Immune Inflammation Index (SII) Combined with the Creatinine-to-Cystatin C Ratio (Cre/CysC) Predicts Sarcopenia in Patients with Liver Cirrhosis Complicated with Primary Hepatocellular Carcinoma

BACKGROUND

Sarcopenia is a risk factor for poor cancer prognosis. Early identification and timely intervention of sarcopenia can improve patient prognosis.

METHODS

A total of 91 patients with liver cirrhosis complicated with primary hepatocellular carcinoma were retrospectively analyzed. Based on the results of multivariable logistic regression analysis, a nomogram was developed. Moreover, 50 patients were enrolled for external validation. The predictive efficacy of the nomogram was evaluated using the receiver operating characteristic curve (ROC).

RESULTS

According to the logistic regression analysis results, age, body mass index (BMI), creatinine-to-cystatin C ratio (Cre/CysC), and systemic immune inflammation index (SII) were independent risk factors of sarcopenia in patients with cirrhosis complicated with primary hepatocellular carcinoma (HCC) (all p < 0.05). The ABCS nomogram model was established, and the area under the ROC curve (AUC) was 0.896 (84.7% sensitivity, 81.2% specificity). The calibration curve of the nomogram was close to the ideal diagonal line. The predictive efficacy of the nomogram was verified through the external validation.

CONCLUSION

The ABCS model based on SII and Cre/CysC can be used to identify high-risk sarcopenia in patients with cirrhosis complicated with HCC in the early stage.

Subcutaneous Fat Thickness of the Lower Limb is Associated with Trunk Muscle Mass in Patients with Hepatocellular Carcinoma: A Simple Assessment for Sarcopenia Using Conventional Ultrasonography

OBJECTIVE

Trunk muscle mass can be evaluated by skeletal muscle index (SMI), which is a prognostic factor in patients with hepatocellular carcinoma (HCC); however, this requires the use of computed tomography, and a simpler assessment for trunk muscle mass is urgently needed. We aimed to examine whether an association between SMI and lower extremity compartments including muscle and subcutaneous fat thickness of lower limbs (SFT-LL) could be identified by means of ultrasonography in patients with HCC.

METHODS

We retrospectively enrolled male patients with HCC (n=30). Trunk muscle mass was evaluated by SMI using computed tomography. Ultrasonography was used for assessment of muscle and SFT-LL. Factors associated with SMI were evaluated by decision-tree analysis.

RESULTS

There was no significant correlation between SMI and muscle thickness of lower limbs. However, a significant correlation was seen between SMI and left SFT-LL (r=0.406, P=0.026). In decision-tree analysis for SMI, left SFT-LL was selected as the initial split variable with an optimal cut-off value of 5 mm. In patients with left SFT-LL ≥ 5 mm, SMI was 39.4±3.4 cm²/m², whereas SMI was 31.6±6.3 cm²/m² in patients with left SFT-LL <5 mm.

CONCLUSION

Left SFT-LL evaluated by ultrasonography was associated with SMI. Thus, ultrasonography may be a useful tool to evaluate trunk muscle mass. Moreover, left SFT-LL may be a useful indicator of sarcopenia in patients with HCC.

A comprehensive discharge planning program on fatigue and functional status of patients with hepatocellular carcinoma undergoing transarterial chemoembolization: A randomized clinical controlled trial

Background

Post transarterial chemoembolization (post-TACE) causes side effects that impact patients, which leads to fatigue symptoms and reduced functional status. However, unrelieved fatigue and reduced functional status may cause patients to withdraw from treatment and negatively affect their lives. Unfortunately, the patients post-TACE only receive routine medical care at the hospital but no follow-up and continuity of care back home. Therefore, comprehensive discharge planning for these problems is necessary.

Objective

This study examined the effectiveness of the comprehensive discharge planning program on fatigue and functional status of patients with hepatocellular carcinoma undergoing transarterial chemoembolization.

Methods

A randomized clinical controlled trial was used. Fifty-two patients who met the study criteria were randomly assigned to an experimental group (n = 26) receiving the comprehensive discharge planning plus routine care and a control group (n = 26) receiving routine care only. The discharge planning program was developed based on the Transitional Care Model. A demographic and health data questionnaire, Fatigue Severity Scale (FSS), and Enforced Social Dependency Scale (ESDS) were used for data collection. Chi-square, Fisher's exact, Wilcoxon signed-rank, and Mann-Whitney U tests were used for data analysis.

Results

The mean scores for fatigue at 30 days after treatment between the experimental and control groups were significantly different (p = 0.003). The mean scores for the fatigue symptoms in the experimental and control groups were 1.27 ± 0.58 and 1.77 ± 0.85, respectively. The functional status from Day 7 to Day 14 after transarterial chemoembolization was different (p = 0.020). In addition, the mean scores for functional status between the experimental and control groups were significantly different (p = 0.020). On Day 14, after transarterial chemoembolization, the experimental group had an increased score in functional status from Day 7 over the scores for those in the control group.

Conclusion

The comprehensive discharge planning program effectively reduces fatigue symptoms and enhances the functional status in patients with hepatocellular carcinoma undergoing transarterial chemoembolization. Therefore, the comprehensive discharge planning program can be used by nurses and multidisciplinary teams in order to achieve the effectiveness of nursing care for patients.

A prognostic model of acute-on-chronic liver failure based on sarcopenia

BACKGROUND

Acute-on-chronic liver failure (ACLF) is characterized by the development of a syndrome associated with a high risk of short-term death in patients with acute decompensated cirrhosis, and better indicators are needed to predict such outcomes. Sarcopenia, a common complication of cirrhosis, is closely associated with poor prognosis and increased mortality. In this study, the skeletal muscle index of ACLF patients was measured to determine whether sarcopenia combined with clinical parameters can aid in identifying those at high risk of progression.

METHODS

A total of 433 hospitalized patients with ACLF according to the APASL criteria were included and allocated into two groups: transplantation-free survival (n = 293) or progression (n = 140, 107 died; 33 underwent liver transplantation) within 90 days. Muscle mass was assessed based on the skeletal muscle index. The optimal cut-off value of the AMPAS1 model (age, MELD score, platelet count, alpha-fetoprotein level, sarcopenia, and more than one complication combination) for progression prediction was identified using receiver-operating characteristic (ROC) analysis.

RESULTS

Sarcopenia was an independent risk factor for progression in the ACLF population (HR 3.771 95% CI 2.114-6.727, p < 0.001). AMPAS1 was a good predictor, with an area under the ROC curve of 0.865, and the cut-off value for poor outcome prediction was 0.31 (sensitivity 79.4%, specificity 76.4%).

CONCLUSION

We demonstrate that sarcopenia is a simple and objective indicator for predicting short-term prognosis in patients with ACLF. Moreover, compared to conventional prognostic scores, AMPAS1 is a better model for predicting 90 day adverse outcomes in ACLF patients.

Sarcopenia Predicts Major Complications after Resection for Primary Hepatocellular Carcinoma in Compensated Cirrhosis

Simple Summary

Sarcopenia, which is defined as a loss of skeletal muscle mass, function and strength, is the result of major metabolic changes often observed in advanced liver disease. Its evaluation mirrors the nutritional and functional status of the patients, and thus has been recently implicated as an outcome predictor of patients with liver diseases and hepatocellular carcinoma. This study provides evidence that sarcopenia, as assessed by the skeletal muscle index, is associated with age and body mass index in liver surgery candidates. More importantly, it is associated with higher rates of major complications (Clavien-Dindo grade III or IV) in patients with compensated advanced chronic liver disease and/or portal hypertension undergoing liver resection for primary hepatocellular carcinoma.

Abstract

The burden of post-operative complications of patients undergoing liver resection for hepatocellular carcinoma (HCC) is a cause of morbidity and mortality. Recently, sarcopenia has been reported to influence the outcome of patients with cirrhosis. We aimed to assess factors associated with sarcopenia and its prognostic role in liver surgery candidates. We included all patients with compensated advanced chronic liver disease (cACLD) undergoing liver resection for primary HCC consecutively referred to the University of Bologna from 2014 to 2019 with an available preoperative abdominal CT-scan performed within the previous three months. A total of 159 patients were included. The median age was 68 years, and 80.5% of the patients were male. Sarcopenia was present in 82 patients (51.6%). Age and body mass index (BMI) were associated with the presence of sarcopenia at multivariate analysis. Thirteen (8.2%) patients developed major complications and 14 (8.9%) presented PHLF grade B-C. The model for end-stage liver disease score was associated with the development of major complications, whereas cACLD presence, thrombocytopenia, portal hypertension (PH), Child-Pugh score and Albumin-Bilirubin score were found to be predictors of clinically significative PHLF. The rate of major complications was 11.8% in sarcopenic patients with cACLD compared with no complications (0%) in patients without sarcopenia and cACLD (p = 0.032). The rate of major complications was significantly higher in patients with (16.3%) vs. patients without (0%) sarcopenia (p = 0.012) in patients with PH. In conclusion, sarcopenia, which is associated with age and BMI, may improve the risk stratification of post-hepatectomy major complications in patients with cACLD and PH.

Effect of Exercise on Sarcopenia among Cancer Survivors: A Systematic Review

Simple Summary

Sarcopenia is a condition characterized by loss of skeletal muscle mass and low muscle strength or physical performance. Cancer survivors are likely to be impacted by sarcopenia and suffer from a worse prognosis. Exercise has been suggested to be a promising tool to attenuate sarcopenia, but its effect among cancer survivors has not been systematically tested yet. We conducted a systematic review of seven interventional studies examining the effects of exercise on sarcopenia among cancer survivors. Results suggested that exercise improved muscle quantity and potentially reversed sarcopenia among breast, gastric, prostate and liver cancer survivors. If the relationship is further supported by larger trials, we could potentially identify cancer survivors at higher risk of adverse health outcomes by screening for sarcopenia and improve their prognosis and quality of life through exercise interventions.

Abstract

Sarcopenia is related to adverse health outcomes in cancer survivors. Previous reviews reported exercise improved muscle mass or function in cancer survivors, but thus far a systematic review examining the effect of exercise on sarcopenia in this population has not been conducted. Therefore, we systematically searched PubMed, CENTRAL (Cochrane Central Register of Controlled Trials) and ClinicalTrials.gov for publications and ongoing trials (through November 2021) that reported exercise interventions and diagnosed sarcopenia among cancer survivors. Seven exercise trials were eligible for this review. Six of seven studies showed exercise increased skeletal muscle post intervention (1.6% to 5.4% increase within intervention groups compared to baseline, p ≤ 0.07; 2.1% to 12.8% greater increase for intervention than control groups, p ≤ 0.02) and in the three studies that reported sarcopenia reversal, an improvement (18.2% to 42.9% decrease in sarcopenia in exercise groups, 5.2% increase to 16.7% decrease in sarcopenia in control groups, p = 0.04) was observed. Existing research indicates the potential for exercise to improve health outcomes for cancer survivors through building muscle and attenuating sarcopenia. More high-quality, long-term, large randomized controlled trials examining effects of different exercise types and doses to improve sarcopenia should be conducted to further explore this important topic.

Sarcopenia in hepatocellular carcinoma: Current knowledge and future directions

Liver cancer is the second most occurring cancer worldwide and is one of the leading causes of cancer-related deaths. Hepatocellular carcinoma (HCC) is the most common (80%-90%) type among malignant liver cancers. Sarcopenia occurs very early in HCC and can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional, systemic, and transplant management. Multiple prognostic stating systems have been developed in HCC, such as Barcelona Clinic Liver Cancer, Child-Pugh score and Albumin-Bilirubin grade. However, the evaluation of patients' performance status is a major limitation of these scoring systems. In this review, we aim to summarize the current knowledge and recent advances about the role of sarcopenia in cirrhosis in general, while focusing specifically on HCC. Additionally, the role of sarcopenia in predicting clinical outcomes and prognostication in HCC patients undergoing loco-regional therapies, liver resection, liver transplantation and systematic therapy has been discussed. A literature review was performed using databases PubMed/MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL on April 1, 2021, to identify published reports on sarcopenia in HCC. Sarcopenia can independently predict HCC-related mortality especially in patients undergoing treatments such as loco-regional, surgical liver transplantation and systemic therapies. Basic research is focused on evaluating a balance of anabolic and catabolic pathways responsible for muscle health. Early clinical studies have shown promising results in methods to improve sarcopenia in HCC which can potentially increase prognosis in these patients. As sarcopenia occurs very early in HCC, it can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional, systemic, and transplant management. Further, sarcopenia measurement can obviate the confounding caused by the abdominal ascites in these patients. The use of sarcopenia can add to the existing scoring systems to better prognosticate the HCC.

Effectiveness of early exercise on reducing skeletal muscle loss during preoperative neoadjuvant chemotherapy for esophageal cancer

PURPOSE

To investigate if early exercise can help prevent skeletal muscle loss and improve the clinical outcomes of esophageal cancer patients receiving preoperative neoadjuvant chemotherapy (NAC).

METHODS

This was a single-center, retrospective observational cohort study of 110 patients with advanced esophageal cancer. We analyzed the effect of early exercise on the risk of skeletal muscle loss (defined as > 2.98%) during NAC and the subsequent clinical outcomes. Patients in the early exercise group (n = 71) started exercise therapy 8 days earlier than those the late exercise group (n = 39).

RESULTS

The median age of the patients was 65.4 years, the mean BMI was 21.1 kg/m², and 92 (84%) of the 110 patients were men. Skeletal muscle loss occurred in 34% and 67% of the early and late exercise groups, respectively (p < 0.001). There was a lower risk of surgical site infection in the early exercise group (1% vs 16%, p = 0.021). Multivariate analysis revealed that early exercise reduced the risk of skeletal muscle loss (OR = 0.25, 95% CI 0.09-0.65, p = 0.006).

CONCLUSIONS

Our results suggest that early exercise reduces the risk of both skeletal muscle loss during NAC and subsequent surgical site infection in patients with esophageal cancer.

Lifestyle and Hepatocellular Carcinoma What Is the Evidence and Prevention Recommendations

Simple Summary

The increasing public health burden of Hepatocellular carcinoma (HCC) emphasizes the importance of defining important modifiable risk factors. In the following review, we will discuss the evidence for the relation of major lifestyle risk factors, mostly from large population-based studies. Generally, it is has been shown that healthy lifestyle habits, including minimizing obesity, eating a healthy diet, avoidance of smoking and alcohol, and increasing physical activity, have the potential to prevent HCC. Dietary composition is important beyond obesity. Consumption of n-3 polyunsaturated fatty acids, as well as fish and poultry, vegetables and fiber, are inversely associated with HCC, while red meat, saturated fat, cholesterol and sugar are related to increased risk. Data from multiple studies clearly show a beneficial effect for physical activity in reducing the risk of HCC. Smoking and alcohol can lead to liver fibrosis and liver cancer and jointly lead to an even greater risk.

Abstract

The increasing burden of hepatocellular carcinoma (HCC) emphasizes the unmet need for primary prevention. Lifestyle measures appear to be important modifiable risk factors for HCC regardless of its etiology. Lifestyle patterns, as a whole and each component separately, are related to HCC risk. Dietary composition is important beyond obesity. Consumption of n-3 polyunsaturated fatty acids, as well as fish and poultry, are inversely associated with HCC, while red meat, saturated fat, and cholesterol are related to increased risk. Sugar consumption is associated with HCC risk, while fiber and vegetable intake is protective. Data from multiple studies clearly show a beneficial effect for physical activity in reducing the risk of HCC. However, the duration, mode and intensity of physical activity needed are yet to be determined. There is evidence that smoking can lead to liver fibrosis and liver cancer and has a synergistic effect with alcohol drinking. On the other hand, an excessive amount of alcohol by itself has been associated with increased risk of HCC directly (carcinogenic effect) or indirectly (liver fibrosis and cirrhosis progression. Large-scale intervention studies testing the effect of comprehensive lifestyle interventions on HCC prevention among diverse cohorts of liver disease patients are greatly warranted.

Myostatin as a fibroblast-activating factor impacts on postoperative outcome in patients with hepatocellular carcinoma

AIM

In patients with liver cirrhosis, high levels of serum myostatin are associated with poor prognosis. We aimed to clarify the influence of myostatin on the prognosis of patients with non-alcoholic fatty liver disease-hepatocellular carcinoma (NAFLD-HCC) without cirrhosis and on the progression of liver fibrosis.

METHODS

Serum myostatin levels were evaluated in 234 patients who underwent primary surgical resection for single HCC. To clarify the impact of myostatin on liver fibrosis, we established human primary liver fibroblasts from resected livers, and cultured them in the presence of myostatin.

RESULTS

The median age was 67.4 years, the median L3 skeletal muscle mass index was 44.4 cm² /m² , and the median body mass index was 23.4 kg/m² . Eighty-two (35.0%) patients had sarcopenia (L3 skeletal muscle mass index: men <42, women <38 cm² /m² ). The etiologies of liver disease were hepatitis B virus (n = 61), hepatitis C virus (n = 86), and non-B non-C hepatitis (n = 87) including NAFLD (n = 74). High preoperative serum myostatin and vascular invasion were independent predictors of poor overall survival (OS). High serum myostatin was associated with poor OS in patients with no sarcopenia (n = 152). In patients without advanced liver fibrosis (Fibrosis stage, 0-2; n = 58), high levels of serum myostatin were also associated with poor OS, regardless of sarcopenia. Serum myostatin levels were increased with the progression of liver fibrosis. Liver fibroblasts were activated and produced collagen following stimulation with myostatin.

CONCLUSIONS

In patients with NAFLD-HCC without advanced liver fibrosis, high levels of serum myostatin were associated with poor OS. Myostatin activated primary fibroblasts and stimulated collagen production.

Lymphocyte-C-reactive protein ratio as a prognostic marker associated with the tumor immune microenvironment in intrahepatic cholangiocarcinoma

BACKGROUND

Changes in immune cell and inflammation-associated protein levels, either independently or in combination, are commonly used as prognostic factors for various cancers. The ratio of lymphocyte count to C-reactive protein concentration (lymphocyte-CRP ratio; LCR) is a recently identified prognostic marker for several cancers. Here, we examined the prognostic value of LCR and its relationship to various aspects of the tumor immune microenvironment in patients with intrahepatic cholangiocarcinoma (ICC).

METHODS

This was a single-center, retrospective study of patients who underwent surgical resection for ICC between 1998 and 2018. Patients were dichotomized into high- and low-LCR status groups, and the relationships between LCR status, prognosis, and other clinicopathological characteristics were analyzed. Tumor-infiltrating CD8+ and FOXP3s+ lymphocytes and tumor expression of CD34 and programmed death-ligand 1 were evaluated by immunohistochemical staining of resected tumors.

RESULTS

A total of 78 ICC patients were enrolled and assigned to the high (n = 44)- and low (n = 34)-LCR groups. Compared with the high-LCR group, patients in the low-LCR group had a significantly higher serum CA19-9 level (median 20.6 vs. 77.3 U/mL, P = 0.0017) and larger tumor size (median 3.5 vs. 5.5 cm, P = 0.0018). LCR correlated significantly with tumor microvessel density (r = 0.369, P = 0.0009) and CD8+ T lymphocyte infiltration (r = 0.377, P = 0.0007) but not with FOXP3+ T lymphocyte infiltration or tumor PD-L1 expression. Low-LCR status was significantly associated with worse overall survival by multivariate analysis (P = 0.0348).

CONCLUSIONS

Low-LCR status may reflect a poor anti-tumor immune response and predict worse outcomes in ICC patients.

Prevalence and profiles of ramucirumab-associated severe ascites in patients with hepatocellular carcinoma

Severe ascites is an adverse event of ramucirumab (RAM), a second-line treatment for hepatocellular carcinoma (HCC). Ascites can be associated with various factors, including nutritional status and muscle quality. The aim of the present study was to investigate the prevalence and profiles of RAM-associated severe ascites in patients with HCC. This retrospective study enrolled 14 consecutive patients with HCC treated with RAM (median age, 72 years; Barcelona Clinic Liver Cancer stage B/C, 6/8). Nutritional status and muscle quality were evaluated using the controlling nutritional status (CONUT) score and intramuscular adipose tissue (IMAT) content, respectively. Factors associated with severe ascites were evaluated using decision-tree analysis. The median progression-free survival (PFS) time was 2.1 months, and the overall objective response and disease control rates were 14 and 50%, respectively. Severe ascites developed in 57.1% of the patients, and the median onset was 37.5 days (range, 14-61 days) after initiation of RAM treatment. In the decision-tree analysis, the CONUT score and IMAT content were the first and second splitting variables for the development of severe ascites. In patients with a CONUT score ≥5 and IMAT <-0.54, the prevalence of severe ascites was 80 and 100%, respectively. A high incidence of severe ascites was observed in patients treated with RAM. A CONUT score ≥5 and an IMAT <-0.54 were associated with severe ascites. Thus, caution must be taken for severe ascites in patients with HCC treated with RAM, in particular patients with malnutrition and fat infiltration in muscle.

Effects of In-Hospital Exercise on Frailty in Patients with Hepatocellular Carcinoma

Frailty including physical inactivity is associated with the survival of patients with hepatocellular carcinoma (HCC). We aimed to investigate the effects of in-hospital exercise on frailty in patients with HCC. This was a multi-center observational study. Patients with HCC were classified into exercise (n = 114) and non-exercise (n = 67) groups. The exercise group was treated with a mixture of aerobic and resistance exercises (20-40 min/day, median four days). Frailty was assessed using the liver frailty index (LFI). Factors for changes in LFI were examined by multivariate and decision-tree analyses. The factors were also examined after propensity score matching. During hospitalization, LFI was significantly improved in the exercise group compared to the non-exercise group (ΔLFI -0.17 vs. -0.02, p = 0.0119). In multivariate analysis, exercise (odds ratio (OR) 2.38, 95% confidence interval (CI) 1.240-4.570, p = 0.0091) and females (OR 2.09; 95%CI, 1.062-4.109; p = 0.0328) were identified as independent factors for the improvement of LFI. In the decision-tree analysis, exercise was identified as an initial classifier associated with the improvement of LFI. Similar findings were also seen in the propensity score matching analyses. We demonstrated that in-hospital exercise improved frailty in patients with HCC. Thus, in-hospital exercise may be beneficial for improving physical function in patients with HCC.

Effects of In-Hospital Physical Therapy on Activities of Daily Living in Patients with Hepatocellular Carcinoma

Activities of daily living (ADL) are frequently impaired in patients with hepatocellular carcinoma (HCC). In this retrospective study, we aimed to investigate the effects of physical therapy on ADLs in patients with HCC during hospitalization for cancer treatment. Nineteen patients with HCC were enrolled. During hospitalization, patients performed a combination of resistance training, stretching, and aerobic exercise (20–60 min/day). ADLs were assessed using the functional independence measure (FIM). Changes in FIM were evaluated by before–after analysis. No significant difference was seen in Child–Pugh class before and after physical therapy. The bilateral knee extension strength and chair stand test were significantly increased after physical therapy compared with before physical therapy (p = 0.001 and p = 0.008, respectively). The total FIM score was significantly increased after physical therapy compared with that before physical therapy (p = 0.0156). Among the 18 indexes of FIM, the stairs index was significantly improved after physical therapy compared with that before physical therapy (5.9 vs. 6.4 points, p = 0.0241). We demonstrated that physical therapy improved muscle strength without worsening liver function. Furthermore, physical therapy improved FIM, especially in the stairs index, in patients with HCC. Thus, physical therapy may be beneficial in patients with HCC during cancer treatment.

Clinical impact of sarcopenia assessment in patients with hepatocellular carcinoma undergoing treatments

Changes in body composition are associated with poor outcomes in cancer patients including hepatocellular carcinoma (HCC). Sarcopenia, defined as the loss of skeletal muscle mass, quality and function, has been associated with a higher rate of complications and recurrences in patients with cirrhosis and HCC. The assessment of patient general status before HCC treatment, including the presence of sarcopenia, is a key-point for achieving therapy tolerability and to avoid short- and long-term complications leading to poor patients' survival. Thus, we aimed to review the current literature evaluating the role of sarcopenia assessment related to HCC treatments and to critically provide the clinicians with the most recent and valuable evidence. As a result, sarcopenia can be predictive of poor outcomes in patients undergoing liver resection, transplantation and systemic therapies, offering the chance to clinicians to improve the muscular status of these patients, especially those with high-grade sarcopenia at high risk of mortality. Further studies are needed to clarify the predictive value of sarcopenia in other HCC treatment settings and to evaluate its role as an additional staging tool for identifying the most appropriate treatment. Besides, interventional studies aiming at increasing the skeletal muscle mass for reducing complications and increasing the survival in patients with HCC are needed.

Profiles Combining Muscle Atrophy and Neutrophil-to-Lymphocyte Ratio Are Associated with Prognosis of Patients with Stage IV Gastric Cancer

We aimed to investigate the impact of muscle atrophy and the neutrophil-to-lymphocyte ratio (NLR), a sub-clinical biomarker of inflammation and nutrition, on the prognosis of patients with unresectable advanced gastric cancer. We retrospectively enrolled 109 patients with stage IV gastric cancer (median age 69 years; female/male 22%/78%; median observational period 261 days). Independent factors and profiles for overall survival (OS) were determined by Cox regression analysis and decision-tree analysis, respectively. OS was calculated using the Kaplan–Meier method. The prevalence of muscle atrophy was 82.6% and the median NLR was 3.15. In Cox regression analysis, none of factors were identified as an independent factor for survival. The decision-tree analysis revealed that the most favorable prognostic profile was non-muscle atrophy (OS rate 36.8%). The most unfavorable prognostic profile was the combination of muscle atrophy and high NLR (OS rate 19.6%). The OS rate was significantly lower in patients with muscle atrophy and high NLR than in patients with non-muscle atrophy (1-year survival rate 28.5% vs. 54.7%; log-rank test p = 0.0014). In conclusion, “muscle atrophy and high NLR” was a prognostic profile for patients with stage IV gastric cancer. Thus, the assessment of muscle mass, subclinical inflammation, and malnutrition may be important for the management of patients with stage IV gastric cancer.

Sarcopenia as a predictor of survival in patients undergoing bland transarterial embolization for unresectable hepatocellular carcinoma

Sarcopenia has been associated with lower overall survival in patients with cirrhosis and hepatocellular carcinoma (HCC) undergoing surgical resection, TACE, TARE, or transplantation. This monocentric study evaluated the prognostic significance of sarcopenia in patients affected by HCC who received bland transarterial embolization (TAE) therapy, by analyzing its impact on survival and treatment-related complications. All consecutive patients who underwent the 1st TAE between March 1st 2011 and July 1st 2019 in our Institution were retrospectively studied. To evaluate sarcopenia, the skeletal muscle index (SMI) was calculated by normalizing the cross-sectional muscle area at the level of L3 on an abdominal CT scan prior to embolization (cm2) by patient height (m2). SMI cut-off values for sarcopenia were considered ≤ 39 cm2/m2 for women and ≤55 cm2/m2 for men. Data about age, gender, body mass index (BMI), underlying liver disease, liver function, MELD score, Child-Pugh score, multifocal disease, performance status, previous interventions, length of stay (LOS), complications after the procedure, readmission rate within 30 days, survival time from TAE and total number and type of TAE received following the first procedure were collected. From 2011 to 2019, 142 consecutive patients underwent 305 TAEs. Observation time ranged from 1.4 to 100.5 months (median 20.1 SD = 22). Sarcopenia at baseline was present in 121 (85%) patients. Overall 87 (61.2%) patients died during follow-up with survival rates at 1-, 2-, 3-, 4-, and 5-year of 71%, 41%, 22%, 16% and 11% respectively. After multivariate analysis sarcopenia (HR = 2.22, p = 0.046), previous ablation/resection (HR = 0.51, p = 0.005) and multifocal disease (HR = 1.84, p = 0.02) were associated with reduced survival. Sarcopenia did not influence the safety of TAE in terms of LOS (2 days vs 1.5 days, p = 0.2), early complications rate (8% vs 5%, p = 0.5) and readmission rate within 30 days (7% vs 5%, p = 0.74). Sarcopenia, estimated by the L3SMI method, is an emerging prognostic factor in patients with HCC undergoing bland TAE therapy as it is associated with increased mortality, without impairing the safety of the locoregional treatment. Measures to ameliorate the SMI, such as nutritional support and physical exercise, should be evaluated in clinical trials for HCC patients receiving liver embolization to determine their impact on overall survival.

Clinical utility of the Liver Frailty Index for predicting muscle atrophy in chronic liver disease patients with hepatocellular carcinoma

AIM

Muscle atrophy is a prognostic factor for patients with chronic liver disease (CLD) and hepatocellular carcinoma (HCC). The Liver Frailty Index (LFI) is a simple physical function test; however, an association between LFI and muscle mass remains unclear. We aimed to investigate the utility of LFI for predicting muscle atrophy in CLD patients with HCC.

METHODS

We enrolled 138 CLD patients with HCC (aged 77 years, female/male 34.8%/65.2%). Muscle mass was assessed by skeletal muscle index, and patients were classified into the muscle atrophy group (n = 109) or the non-muscle atrophy group (n = 29). Physical frailty was assessed by LFI. The optimal cut-off value of LFI for predicting muscle atrophy was identified by receiver operating characteristic analysis.

RESULTS

In the muscle atrophy group, the prevalence of pre-frail/frail was significantly higher than the non-muscle atrophy group (87.2% vs. 58.6%, P = 0.0005). In the logistic regression analysis, being female and pre-frail/frail were identified as independent factors associated with muscle atrophy (pre-frail/frail; OR 3.601, 95% CI 1.381-9.400, P = 0.0088). In patients with normal grip strength, 71.1% of patients were pre-frail/frail, in which 82.8% of patients showed muscle atrophy. Receiver operating characteristic statistics provided an area under the curve of 0.74, and an LFI cut-off value of 2.94 for predicting muscle atrophy (sensitivity 88.06%, specificity 52.17%, accuracy 77.91%).

CONCLUSIONS

We showed that pre-frail/frail was an independent factor for muscle atrophy in CLD patients with HCC. Furthermore, LFI predicted muscle atrophy with high sensitivity, even in patients with normal grip strength. Thus, LFI might be a useful screening tool for muscle atrophy in CLD patients with HCC.

Impact of cancer rehabilitation on the prognosis of patients with hepatocellular carcinoma

Sarcopenia is a prognostic factor for patients with hepatocellular carcinoma (HCC). Cancer rehabilitation (CR) improves patients' physical function and muscle mass. We investigated the effects of CR on the prognosis of patients with HCC. The present study was a prospective observational study, which analyzed 152 patients with HCC who underwent transcatheter arterial chemoembolization (TACE) between 2013 and 2016. Patients were classified into the CR (n=85) and control (n=67) groups. The effects of CR on muscle mass were evaluated by changes in the skeletal muscle index (SMI) before and after TACE. Independent factors associated with survival were evaluated by Cox regression analysis. Kaplan-Meier analysis was used to compare the survival rate between the CR and control groups. The difference in survival rate between the two groups was also examined after propensity score matching. SMI was significantly increased in the CR group compared with the control group. In Cox regression analysis, independent factors associated with survival were CR and Child-Pugh class A (estimate 1.760, 95% CI 0.914–3.226, P=0.001; estimate 1.602, 95% CI 0.426–2.998, P=0.0129). The survival rate was significantly higher in the CR group than in the control group (median 552 vs. 424 days; P=0.0359). The survival rate was also significantly higher in the CR group than that in the control group after propensity score matching (median 529 vs. 369 days; P=0.0332). CR was associated with prolonged survival in patients with HCC who underwent TACE. Patients with cancer are recommended to maintain physical activity even during cancer treatment.

Effectiveness of a Short-Term Mixed Exercise Program for Treating Sarcopenia in Hospitalized Patients Aged 80 Years and Older: A Prospective Clinical Trial

OBJECTIVES

To assess the effectiveness of short-term exercise for treating sarcopenia in hospitalized older patients aged 80 years and over.

DESIGN

Prospective clinical trial.

SETTING

A post-acute care unit.

PARTICIPANTS

Sarcopenic patients aged 80 years or over.

INTERVENTIONS

The participants were allocated to the intervention group (to receive a mixed exercise program with 10 sessions over two weeks) or the control group (usual care) based on the sequence of admission.

OUTCOMES

The primary outcome was the improvement in activities of daily living (ADL) estimated by the change in Barthel Index (BI) score from the baseline to the end of the 2-week intervention. The secondary outcomes were the changes in gait speed, handgrip strength, the time "UP and GO" test (TUG) score, and the Short Physical Performance Battery (SPPB) score.

RESULTS

We included 121 participants (intervention group: n = 62; control group: n = 59). All participants in the intervention group finished all 10 exercise sessions. After the 2-week intervention, patients in the mixed exercise group achieved a significant improvement in ADL compared with their counterparts in the control group (the adjusted mean difference of the change in BI score was 7.8 points, 95% confidence interval (CI) 4.0 to 11.8 points). The mixed exercise program significantly but slightly improved gait speed (adjusted group difference in mean change: 0.06 m/s, 95% CI 0.02 to 0.11 m/s). However, the mixed exercise program did not significantly improve the handgrip strength, SPPB score, or TUG score compared with usual care.

CONCLUSION

Very old inpatients with sarcopenia can benefit from a mixed exercise program (even as short as two weeks) by improving their ADL and gait speed. However, the long-term effects of exercise on important clinical outcomes need to be further evaluated.

Slow walking speed overlapped with low handgrip strength in chronic liver disease patients with hepatocellular carcinoma

AIM

Walking speed and grip strength are parameters of muscle function; however, evaluating walking speed is not always available in clinical practice. We aimed to investigate the impact of walking speed on the evaluation of muscle dysfunction in chronic liver disease (CLD) patients with hepatocellular carcinoma (HCC).

METHODS

We enrolled 107 consecutive CLD patients with HCC in this study (age 76 years [range 60-92 years]; female/male 39/68; body mass index 22.9 [range 20.0-25.3]; chronic hepatitis/liver cirrhosis 25/82). Muscle dysfunction was evaluated using the Asian Working Group for Sarcopenia criteria (grip strength or walking speed) and the Japan Society of Hepatology criteria (grip strength). A correlation between walking speed and skeletal muscle index was evaluated. Independent factors for slow walking speed were evaluated using a logistic regression analysis.

RESULTS

There was no significant correlation between walking speed and skeletal muscle index (r = 0.14, P = 0.16). For both the Asian Working Group for Sarcopenia and Japan Society of Hepatology criteria, 33.6% of all patients were classified as having muscle dysfunction. All patients with slow walking speed (4.7% of all patients) also showed low handgrip strength. The logistic regression analysis identified grip strength as an independent factor for slow walking speed (OR 0.65; 95% CI 0.432-0.838; P = 0.008).

CONCLUSIONS

No difference was seen in the prevalence of muscle dysfunction between the Asian Working Group for Sarcopenia and Japan Society of Hepatology criteria in CLD patients with HCC. Furthermore, all patients with slow walking speed also showed low handgrip strength. Thus, for the evaluation of muscle dysfunction, grip strength might be a suitable proxy for walking speed in CLD patients with HCC.