Depletion of skeletal muscle mass adversely affects long-term outcomes for men undergoing gastrectomy for gastric cancer

Preoperative sarcopenia and postoperative accelerated muscle loss negatively impact survival after resection of locally advanced gastric cancer

BACKGROUND

Gastric cancer remains a major health concern worldwide, with locally advanced gastric cancer (LAGC) posing significant challenges due to frequent lymph node metastasis and poor prognosis. While curative gastrectomy with D2 lymph node dissection is the standard treatment, sarcopenia and perioperative skeletal muscle loss (SML) have emerged as critical prognostic factors.

METHODS

We retrospectively analyzed 198 LAGC patients who underwent curative gastrectomy. Preoperative and postoperative sarcopenia were assessed via computed tomography (CT)-derived skeletal muscle index (SMI) at the L3 level. SML was defined based on sex-specific thresholds of SMI changes (%/30 days). Prognostic significance for overall survival (OS) and disease-free survival (DFS) was evaluated using Kaplan-Meier and Cox regression analyses.

RESULTS

The prevalence of sarcopenia increased from 23.7% preoperatively to 33.3% postoperatively. Patients with significant muscle loss (SML) showed worse OS and DFS compared to non-SML patients (P < 0.05). SML was also associated with a higher incidence of Clavien-Dindo grade ≥ 3a complications (P < 0.05). Multivariate analysis identified preoperative sarcopenia (HR = 2.332, P = 0.001), postoperative sarcopenia (HR = 3.189, P = 0.011), and SML (HR = 11.231, P = 0.002) as independent risk factors for OS. Adjuvant chemotherapy significantly improved both OS (HR = 0.532, P = 0.015) and DFS (HR = 0.587, P = 0.041).

CONCLUSIONS

Both preoperative sarcopenia and perioperative SML may negatively impact postoperative prognosis in LAGC patients, suggesting that perioperative evaluation of skeletal muscle mass may help identify high-risk surgical candidates for targeted interventions.

Impact of malnutrition and nutritional support after gastrectomy in patients with gastric cancer

Malnutrition, characterized by altered body composition and impaired function, is particularly prevalent among gastric cancer patients, affecting up to 60% of them. Malnutrition in these patients can manifest both before and after surgery, due to factors such as gastric outlet obstruction, cancer cachexia, and anatomical changes. Notably, total gastrectomy (TG) presents the most significant nutritional challenges. However, function-preserving gastrectomy, such as pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG), have shown promise in improving nutritional outcomes. Effective nutritional risk screening and assessment are vital for identifying patients at risk. Nutritional support not only improves nutritional parameters but also reduces complications, enhances quality of life (QoL) and survival rates. Those unable to maintain more than 50% of the recommended intake for over 7 days are recommended for nutritional support. Common methods of nutritional support include oral nutrition supplements (ONS), enteral nutrition (EN), or parenteral nutrition (PN) depending on the patient's status. Effect of perioperative nutritional support remains controversial. Preoperative interventions including ONS and PN have shown mixed results, with selective benefits in patients with sarcopenia or hypoalbuminaemia, while impact of EN in gastric outlet obstruction patients have been positive. In contrast postoperative support appears to be consistent. Tube feeding after TG has shown improvements, and ONS have been effective in reducing weight loss and improving nutritional biomarkers. PN was also associated with benefits such as weight maintenance and QoL. This review explores the mechanisms, assessment, and clinical impact of malnutrition, emphasizing the importance of nutritional support in gastric cancer patients undergoing gastrectomy.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

BACKGROUND

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

METHODS

The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

RESULTS

A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

CONCLUSION

Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Preoperative Frailty Assessed Comprehensively by a Questionnaire Predicts a Poor Survival Following Curative Resection of Gastric Cancer

Background/Aim

The concept of frailty has been attracting attention as a comprehensive indicator of the various effects of aging, but no conclusion has been reached on how to evaluate it. The present study investigated the adverse effect of preoperative frailty on short- and long-term outcomes in patients with gastric cancer using a questionnaire about frailty.

Patients and Methods

One hundred and twenty-five patients with pathological stage (p Stage) I/II/III who underwent radical gastrectomy for gastric cancer at the Department of Gastroenterological Surgery, Osaka, Japan from April 2015 to December 2016 were enrolled in this study. The frailty index (FI) was calculated by dividing the total score of 50 questions consisting of 1 point per question by 50. The study used multiple logistic regression analysis with 5-year overall survival (OS) as the endpoint to create a receiver operating characteristic (ROC) curve to determine the cut-off point for the FI. The short- and long-term outcomes of the frail and non-frail groups were then compared, and prognostic factors for OS were examined.

Results

Regarding the short-term outcomes, the postoperative complication rates did not differ significantly between the two groups. Regarding the 5-year OS rates of the patients with p Stages II/III, the outcomes in the frail group were significantly poorer than those in the non-frail group. In the multivariate analysis of OS, frailty was independently associated with unfavorable outcomes in patients with p Stages II/III gastric cancer.

Conclusion

Frailty evaluation in this study may be useful in predicting long-term prognosis in patients undergoing surgical treatment for advanced gastric cancer.

The Cancer Cachexia Index Can Be Used to Prognostically Predict Patients with Gastric Cancer Undergoing Gastrectomy

INTRODUCTION

Cancer cachexia occurs in cancer patients more frequently as the cancer progresses, with a negative impact on treatment outcomes. In this study, we sought to clarify the clinical impact of a cancer cachexia index (CXI) in patients with gastric cancer (GC) undergoing gastrectomy.

METHODS

Between January 2013 and December 2018, we reviewed data from 556 patients treated for GC at our hospital. CXI was calculated using skeletal muscle index (SMI), serum albumin, and neutrophil-lymphocyte ratios (NLR). Patients were divided into high (n = 414) or low CXI (n = 142) groups. We investigated the clinical impact of CXI in patients with GC undergoing gastrectomy.

RESULTS

Multivariate analyses of 5-year overall survival (OS) and cancer-specific survival (CSS) rates indicated that a low CXI was independently associated with unfavorable outcomes for patients with GC. In multivariate analyses, SMI was independent predictor of OS but not CSS. NLR was not an independent predictor of either OS or CSS. Complication incidences (≥ Clavien Dindo 3) were non-significantly higher in the low (vs. high) CXI group.

CONCLUSION

CXI was a more valuable prognostic biomarker when compared with SMI or NLR in GC patients undergoing gastrectomy. We suggest that patients with low CXI values should be given more comprehensive treatment, including exercise and nutritional therapy to improve clinical outcomes.

A prospective clinical study evaluating short-term changes in body composition and quality of life after gastrectomy in elderly patients receiving postoperative exercise and nutritional therapies

BACKGROUND

Muscle mass loss after gastrectomy is associated with a negative impact on quality of life (QOL) and long-term prognosis following gastric cancer treatment, especially in elderly patients. We conducted a prospective study to examine short-term changes in body composition and QOL after gastrectomy in elderly patients with gastric cancer who received exercise and nutritional therapies.

METHODS

Patients over aged 65 years of age who underwent gastrectomies for gastric cancer were enrolled in our study. Patients received exercise and nutritional therapies with branched-chain amino acid (BCAA)-rich supplements during 1 month after surgery. Body composition was evaluated using InBody S10 before surgery, and at 1 week and 1 month postoperatively. Other variables including QOL status (EQ-5D-5 L), serum albumin level, hand grip strength, and gait speed were evaluated at the same time.

RESULTS

Eighteen patients were analyzed. The mean loss of skeletal muscle mass index (SMI) was 4.6% (1 week) and 2.1% (1 month) compared to the preoperative period. QOL scores showed almost the same degree of recovery at 1 month after gastrectomy as preoperative scores. Serum albumin levels, hand grip strength, and gait speed decreased at 1 week and then increased at 1 month after surgery, similar to the changes seen in SMI.

CONCLUSIONS

Multidisciplinary approaches play key role in the surgical treatment of elderly patients. Postoperative exercise and nutritional therapies with BCAA-rich supplements may benefit elderly patients after gastrectomy by reducing loss of SMI and decreases in QOL.

TRIAL REGISTRATION

UMIN Clinical Trials Registry; UMIN000034374 (registration date: 10/10/2018).

Sarcopenia provides extra value outside the PULP score for predicting mortality in older patients with perforated peptic ulcers

BACKGROUND

Perforated peptic ulcer (PPU) remains challenging surgically due to its high mortality, especially in older individuals. Computed tomography (CT)-measured skeletal muscle mass is a effective predictor of the surgical outcomes in older patients with abdominal emergencies. The purpose of this study is to assess whether a low CT-measured skeletal muscle mass can provide extra value in predicting PPU mortality.

METHODS

This retrospective study enrolled older (aged ≥ 65 years) patients who underwent PPU surgery. Cross-sectional skeletal muscle areas and densities were measured by CT at L3 and patient-height adjusted to obtain the L3 skeletal muscle gauge (SMG). Thirty-day mortality was determined with univariate, multivariate and Kaplan-Meier analysis.

RESULTS

From 2011 to 2016, 141 older patients were included; 54.8% had sarcopenia. They were further categorized into the PULP score ≤ 7 (n=64) or PULP score > 7 group (n=82). In the former, there was no significant difference in 30-day mortality between sarcopenic (2.9%) and nonsarcopenic patients (0%; p=1.000). However, in the PULP score > 7 group, sarcopenic patients had a significantly higher 30-day mortality (25.5% vs. 3.2%, p=0.009) and serious complication rate (37.3% vs. 12.9%, p=0.017) than nonsarcopenic patients. Multivariate analysis showed that sarcopenia was an independent risk factor for 30-day mortality in patients in the PULP score > 7 group (OR: 11.05, CI: 1.03-118.7).

CONCLUSION

CT scans can diagnose PPU and provide physiological measurements. Sarcopenia, defined as a low CT-measured SMG, provides extra value in predicting mortality in older PPU patients.

Impact of Body Mass Index on Survival Depending on Sex in 14,688 Patients with Gastric Cancer in a Tertiary Hospital in South Korea

Background/Aims

The incidence and prognosis of gastric cancer (GC) shows sex difference. This study aimed to evaluate the effect of body mass index (BMI) on GC survival depending on sex.

Methods

The sex, age, location, histology, TNM stages, BMI, and survival were analyzed in GC patients from May 2003 to February 2020 at the Seoul National University Bundang Hospital.

Results

Among 14,688 patients, there were twice as many males (66.6%) as females (33.4%). However, under age 40 years, females (8.6%) were more prevalent than males (3.1%). Cardia GC in males showed a U-shaped distribution for underweight (9.6%), normal (6.4%), overweight (6.1%), obesity (5.6%), and severe obesity (9.3%) but not in females (p=0.003). Females showed decreased proportion of diffuse-type GC regarding BMI (underweight [59.9%], normal [56.8%], overweight [49.5%], obesity [44.8%], and severe obesity [41.7%]), but males did not (p<0.001). Both sexes had the worst prognosis in the underweight group (p<0.001), and the higher BMI, the better prognosis in males, but not females. Sex differences in prognosis according to BMI tended to be more prominent in males than in females in subgroup analysis of TNM stages I, II, and III and the operative treatment group.

Conclusions

GC-specific survival was affected by BMI in a sex-dependent manner. These differences may be related to genetic, and environmental, hormonal factors; body composition; and muscle mass (Trial registration number: NCT04973631).

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

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

Prognostic role of pretreatment skeletal muscle index in gastric cancer patients: A meta-analysis

Background: The association between pretreatment skeletal muscle index (SMI) and long-term survival of gastric cancer patients remains unclear up to now. The aim of this meta-analysis was to identify the prognostic value of pretreatment SMI in gastric cancer. Methods: The PubMed, EMBASE and Web of Science electronic databases were searched up to 5 June 2022 for relevant studies. The primary outcome was overall survival (OS) and the second outcomes were disease-free survival (DFS) and cancer-specific survival (CSS). The hazard ratios (HRs) and 95% confidence intervals (CIs) were combined to assess the relationship between pretreatment SMI and survival of gastric cancer patients. All statistical analyses were conducted by STATA 15.0 software. Results: A total of 31 retrospective studies involving 12,434 patients were enrolled in this meta-analysis. The pooled results demonstrated that lower pretreatment was significantly associated with poorer OS (HR = 1.53, p < 0.001). Besides, lower pretreatment SMI was also related with worse DFS (HR = 1.39, p < 0.001) and CSS (HR = 1.96, p < 0.001). Conclusion: Pretreatment SMI was significantly associated with prognosis of gastric cancer patients and lower SMI predicted worse survival. However, more prospective high-quality studies are still needed to verify our findings.

Sarcopenia: imaging assessment and clinical application

Sarcopenia is a progressive, generalized skeletal muscle disorder characterized by reduction of muscle mass and strength. It is associated with increased adverse outcomes including falls, fractures, physical disability, and mortality, particularly, in elderly patients. Nowadays, sarcopenia has become a specific imaging biomarker able to predict clinical outcomes of patients. Muscle fibre reduction has shown to be an unfavourable pre-operative predictive factor in patients with cancer, and is associated with worse clinical outcomes in terms of postoperative complications, morbidity, mortality, and lower tolerance of chemoradiation therapy. Several imaging modalities, including dual-energy X-ray absorptiometry, CT, MRI, and US can be used to estimate muscle mass and quality to reach the diagnosis of sarcopenia. This article reviews the clinical implications of sarcopenia, how this condition can be assessed through different imaging modalities, and future perspectives of imaging of sarcopenia.