Body composition change during neoadjuvant chemotherapy for breast cancer

Targeting osteosarcopenia and multimorbidity for frailty prevention through identification and deep phenotyping methods in healthy ageing and high-burden disease cohorts (OPTIMA-C): a longitudinal observational cohort study protocol for neuromusculoskeletal muscle health

INTRODUCTION

Sarcopenia and frailty have been identified as negative predictors of health outcomes. Patients with stroke, traumatic brain injury (TBI), knee osteoarthritis (OA) and breast cancer commonly experience low physical activity levels in the chronic phase of recovery. This prospective study aims to explore the feasibility of multimodal screening and longitudinal tracking of various biomarkers from the acute to chronic phase of disease to determine the relationship with frailty outcomes.

METHODS AND ANALYSIS

A prospective longitudinal observational cohort study involving Asian populations is planned over 3 years. Enrolled participants with index conditions of acute stroke, TBI, knee OA and breast cancer will be recruited from rehabilitation hospitals and clinics and followed longitudinally. Reference thresholds from the Asian Working Group on Sarcopenia will be used. Variables include self-reported questionnaires, disease and comorbidity characteristics, anthropometric measurements, appetite questionnaires, muscle ultrasound (MUS), muscle/bone mass, blood biomarkers and markerless gait motion systems. In particular, physical performance (short physical performance battery and hand grip strength), sarcopenia (SARC-F questionnaire) and frailty assessment (FRAIL score, clinical frailty scale), four-region MUS, body composition analysis, dual X-ray absorptiometry, bone mineral densitometry, physical activity levels (International Physical Activity Questionnaire for the elderly [IPAQ-E], fitness trackers) and health-related quality of life assessment (EuroQoL-5D questionnaire five level [EQ5D-5L]) will be used. Blood biomarkers measuring metabolic health (eg, glycated haemoglobin, cholesterol, fasting glucose and 25-OH vitamin D) and inflammation (eg, Tumor Necrosis Factor-alpha [TNF-α] and Monocyte Chemoattractant Protein-1 [MCP-1]) will be measured at baseline. Data collection will take place at postrecruitment baseline (hospital admission), 1, 6 months, 12 months and 2 years postrecruitment (inpatient) and at postrecruitment baseline, 6 months, 12 months and 2 years postrecruitment (outpatient).

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the National Healthcare Group Domain Specific Review Board (2023/00105). Findings will be disseminated through conference presentations and publication in scientific journals.

TRIAL REGISTERATION NUMBER

NCT06073106.

Effect of subcutaneous fat on long-term survival after surgery for stage I-III breast cancer as determined by computed tomography

Introduction

Monitoring body composition through Computed Tomography (CT) scans, including muscle and adipose tissue, plays a key role in the prognosis of various cancers. However, abdominal CT is impractical for patients with breast cancer (BC), making chest CT an essential tool for postoperative surveillance. This study aims to evaluate the effect of subcutaneous fat tissue at the 11th thoracic vertebral plane on the postoperative prognosis of BC patients by analyzing chest CT images, providing evidence for postoperative nutritional and rehabilitation guidance.

Methods

We conducted a retrospective analysis of the medical records of 188 BC patients treated and discharged from the Second Affiliated Hospital of Wenzhou Medical University between January 1, 2013, and December 31, 2013. The subcutaneous fat area (SFA) at the 11th thoracic vertebra (T11) was measured using chest CT images, and the subcutaneous fat index (SFI, area/height2) was calculated. Using multivariate Cox proportional hazards models and propensity score matching (PSM), the relationships between the SFI and overall survival (OS), as well as recurrence-free survival (RFS), were assessed. Additionally, Kaplan-Meier survival curves were applied to compare prognostic differences between the groups.

Results

The median follow-up duration was 128 months (range: 27-188 months). Of the 188 patients included in the study, the optimal cutoff value for the SFI was determined to be 49.31 cm²/m². Multivariate analysis indicated that SFI was an independent prognostic factor for both OS (HR 2.50, 95% CI 1.07-5.83, P = 0.034) and RFS (HR 2.04, 95% CI 1.10-3.78, P = 0.024). After PSM, Kaplan-Meier survival curve analysis revealed significant differences in both RFS and OS between the two groups (P = 0.025 and P = 0.018, respectively). All the results showed that the prognosis of BC with more subcutaneous fat was poor.

Discussion

The findings demonstrated that the SFI at T11 was negatively correlated with patient survival. This offers a new perspective on personalized management for BC patients, suggesting that future research should validate these results and investigate combining imaging assessments with lifestyle interventions, such as exercise, nutrition, and diet, to optimize patient outcomes.

Automatic assessment of body composition in children with lymphoma: results of a [18F]FDG-PET/MR study

OBJECTIVES

To use Dixon-MR images extracted from [18F]FDG-PET/MR scans to perform an automatic, volumetric segmentation and quantification of body composition in pediatric patients with lymphoma.

MATERIALS AND METHODS

Pediatric patients with lymphoma examined by [18F]FDG-PET/MR at diagnosis and restaging were included. At each time point, axial fat and water Dixon T1w images of the thighs were automatically segmented and muscle volume, subcutaneous, intramuscular, and intermuscular fat volume were quantified. The metabolic activity of the largest nodal lesion and of muscles and subcutaneous fat was recorded. The paired samples t-test and Spearman's correlation coefficient were applied to evaluate potential differences between the two time points and the relationship between metabolic and body composition metrics, respectively. By logistic regression analysis, the prognostic role of the investigated variables was assessed. The applied significance level was p < 0.05 for all analyses.

RESULTS

Thirty-seven patients (mean age ± SD 14 ± 3-years-old; 20 females) matched the inclusion criteria. After chemotherapy (interval between the two PET/MR scans, 56-80 days; median 65 days), muscle volume significantly decreased (629 ± 259 cm3 vs 567 ± 243 cm3, p < 0.001) while subcutaneous, intramuscular and intermuscular fat increased (476 ± 255 cm3 vs 607 ± 254 cm3, p < 0.001; 63 ± 20 cm3 vs 76 ± 26 cm3, p < 0.001; 58 ± 19 cm3 vs 71 ± 23 cm3, p < 0.001); the metabolic activity of the main nodal lesion, muscles, and subcutaneous fat significantly decreased (p < 0.05, each). None of the examined variables acted as predictors of the response to treatment (p = 0.283). A strong correlation between BMI and subcutaneous fat volume at diagnosis (r = 0.675, p < 0.001) and restaging (r = 0.600, p < 0.001) emerged.

CONCLUSIONS

The proposed method demonstrated that pediatric patients with lymphoma undergo muscle loss and an increase of subcutaneous fat during treatment.

CLINICAL RELEVANCE STATEMENT

The proposed automatic and volumetric MR-based assessment of body composition in children with lymphoma can be used to monitor the effect of chemotherapy and may guide tailored exercise programs during chemotherapy.

KEY POINTS

T1w Dixon images can be used for the automatic segmentation and quantification of body composition. Muscle and subcutaneous fat volume do not act as predictors of the response to treatment in children with lymphoma. Chemotherapy induces changes in body composition in children with lymphoma.

The application of QCT in the prognostic assessment of mCRC undergoing first-line treatment based on bevacizumab

BACKGROUND

Bevacizumab induces muscle atrophy by changing the gene expression level of muscle tissue. Quantitative computed tomography (QCT) enables precise measurement of various body compositions, including muscle area.

MATERIALS & METHODS

A total of 102 patients with metastatic colorectal cancer (mCRC) undergoing first-line chemotherapy based on bevacizumab were enrolled at thirst Affiliated Hospital of the University of Science and Technology of China. Their body compositions were measured respectively 1 month before and 1 month after the treatment.

RESULTS

Treatment-related decline in skeletal muscle index and visceral fat infiltration significantly affect patient prognosis.

CONCLUSION

A predictive model constructed by integrating changes in body composition with patient clinical characteristics effectively predicts the 9-month progression-free survival (PFS) of patients with mCRC.

Age-related and cancer-related sarcopenia: is there a difference?

PURPOSE OF REVIEW

The aim of this review is the attempt to differentiating the pathophysiologic and clinical features of the aging-related sarcopenia from cancer-related sarcopenia. In fact, there is some controversy among the experts mainly regarding two points: is always sarcopenia, even that aging-related one, the expression of a generalized disease or may exist independently and without major alteration of the muscle function? Are always aging-related and cancer-related sarcopenia completely separated entities?

RECENT FINDINGS

Literature shows that sarcopenia, defined as simple skeletal muscle mass loss, may range from a mainly focal problem which is common in many healthy elderly people, to a component of a complex multiorgan syndrome as cancer cachexia. Disuse, malnutrition and (neuro)degenerative processes can account for most of the aging-related sarcopenias while systemic inflammation and secretion of cancer-and immune-related molecules play an additional major role in cachexia.

SUMMARY

A multimodal approach including physical exercise and optimized nutritional support are the key measures to offset sarcopenia with some contribution by the anti-inflammatory drugs in cancer patients. Results are more promising in elderly patients and are still pending for cancer patients where a more specific approach will only rely on the identification and contrast of the key mediators of the cachectic process.

Sarcopenia among treated cancer patients before and after neoadjuvant chemotherapy: a systematic review and meta-analysis of high-quality studies

BACKGROUND

Neoadjuvant chemotherapy, used to shrink tumors before surgery, is increasingly applied in clinical practice. However, retrospective studies indicate that it may increase sarcopenia rates and consequently result in an elevated occurrence rate of postoperative severe complications such as severe surgical incision infection, severe respiratory failure, and severe postoperative hemorrhage, especially in the elderly population. Currently, no systematic analysis examines the association between neoadjuvant chemotherapy and sarcopenia. This study aims to fill this gap with a comprehensive meta-analysis focused on this critical aspect of the field.

METHODS

A systematic literature search was conducted in the PubMed and Web of Science databases from their inception to January 2024. The included studies encompassed patients who received neoadjuvant chemotherapy and underwent computed tomography (CT) scans both before and after treatment to calculate skeletal muscle index (SMI) or categorize them for the presence of sarcopenia. The determination of sarcopenia status was based on well-established and validated threshold criteria. Data extraction was performed independently by two reviewers. A meta-analysis was employed to estimate the pooled odds ratio (OR) and its corresponding 95% confidence interval (95% CI) to assess the risk of neoadjuvant chemotherapy-induced muscle reduction.

RESULTS

In the 14 studies with complete categorical variable data, comprising 1853 patients, 773 patients were identified as having sarcopenia before neoadjuvant treatment and 941 patients had sarcopenia after neoadjuvant therapy. The OR and its 95% CI was calculated as 1.51 [1.31, 1.73]. Among these, 719 patients had digestive system cancer, with 357 patients having sarcopenia before neoadjuvant treatment and 447 patients after, resulting in an OR of 1.74 [1.40, 2.17]. In the remaining 1134 patients with non-digestive system cancers, 416 were identified as having sarcopenia before neoadjuvant treatment, and 494 patients had sarcopenia after, with an OR of 1.37 [1.15, 1.63]. Additionally, in seven studies with complete continuous variable data, including 1228 patients, the mean difference in the change of SMI before and after neoadjuvant treatment was  - 1.13 [- 1.65,  - 0.62]. After excluding low-quality small-sample studies with fewer than 50 patients, the same trend was observed in the analysis.

CONCLUSION

The risk of muscle reduction significantly increases in cancer patients after neoadjuvant chemotherapy and digestive system cancers tend to have a higher risk of developing sarcopenia post-treatment compared to non-digestive system cancers.

Early Implementation of Exercise to Facilitate Recovery After Breast Cancer Surgery: A Randomized Clinical Trial

Importance

Recovery of shoulder function following breast cancer surgery is crucial for physical functioning and quality of life. While early implementation of shoulder rehabilitation exercises may enhance recovery, the optimal timing and exercise program remain unclear.

Objective

To investigate whether an early exercise intervention, initiated 1 day postsurgery and continued for 1 month through subsequent visits, could improve shoulder range of motion (ROM) and strength in patients with breast cancer.

Design, Setting, and Participants

A parallel-group, 2-arm randomized clinical trial was conducted between June 2020 and October 2021 at the Breast Cancer Center in Seoul, South Korea. Fifty-six patients (of 119 screened) with early-stage breast cancer who were scheduled for partial or total mastectomy were randomized into a tailored resistance exercise group (n = 28) or a usual care group (n = 28). Data were analyzed from November 2021 to June 2022.

Interventions

The exercise intervention commenced 1 day postsurgery and consisted of 4 supervised exercise education sessions corresponding with surgeon visits and daily home-based exercises for the first postoperative month. Tailored programs, including stretching and strength exercises, were adjusted based on individual shoulder function recovery status.

Main Outcomes and Measures

Primary end points were shoulder ROM and strength at 1 and 6 months postsurgery. Physical activity, body composition, and quality of life were assessed at 6 months.

Results

Of 56 patients randomized (mean [SD] age, 50.3 [6.6] years), 54 completed the trial (96%), with 100% and 97% compliance to supervised and home-based exercise sessions, respectively. At 1 month postsurgery, 19 (67.9%) in the exercise group had fully recovered shoulder strength compared to 1 (3.6%) in the usual care group (P < .001). At 6 months, 22 (78.6%) in the exercise group had fully recovered shoulder ROM and 24 (85.7%) had fully recovered strength compared to 6 (21.4%) and 5 (17.9%), respectively, in the usual care group (P < .001). The exercise group exhibited less loss in muscle mass and improved physical activity and quality of life compared to the usual care group.

Conclusion and Relevance

In this trial, 1-month tailored exercise program, initiated immediately after breast cancer surgery and supplemented with supervised sessions coinciding with surgeon visits, significantly improved shoulder function in patients with breast cancer.

Trial Registration

WHO International Clinical Trials Registry identifier: KCT0006997.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence and clinical implications of sarcopenia in breast cancer: a systematic review and meta-analysis

PURPOSE

The impact of sarcopenia in oncology is increasingly recognized, yet little is known about its clinical implications in breast cancer. This systematic review and meta-analysis estimates the overall prevalence of sarcopenia in breast cancer, quantifies skeletal muscle index (SMI), and comprehensively evaluates sarcopenia's impact on clinical outcomes.

METHODS

We systematically searched primary original research published before June 2023 in four databases: the Cochrane Library via Wiley, CINAHL Plus with Full Text, Embase via Elsevier Excerpta Medica, and Medline via Ovid. Standardized mean SMI and 95% confidence interval (CI) were calculated by applying the random-effects model. The methodological quality of the included studies was assessed using the National Institutes of Health quality assessment checklist.

RESULTS

The systematic review included 17 studies with a total of 9863 patients; the meta-analysis included 12 of these studies. The mean prevalence of sarcopenia in breast cancer (stages I-III) was 32.5%. The mean SMI assessed by CT was 43.94 cm2/m2 (95% CI 42.87, 45.01; p < .01). Overall, low muscle mass was associated with chemotherapy toxicities, dose reductions, dose delays, or treatment discontinuation. Low muscle mass was generally associated with poor survival, but in some studies, this association was not significant or reversed direction.

CONCLUSION

Sarcopenia is not just a state of muscle mass loss, but an influencing factor on therapeutic effects and survival rates in oncology. It is thus necessary to recognize the risk of sarcopenia throughout the trajectory of cancer treatment, identify low muscle mass early, and manage it from a prehabilitation perspective.

A real-world clinicopathological model for predicting pathological complete response to neoadjuvant chemotherapy in breast cancer

Purpose

This study aimed to develop and validate a clinicopathological model to predict pathological complete response (pCR) to neoadjuvant chemotherapy (NAC) in breast cancer patients and identify key prognostic factors.

Methods

This retrospective study analyzed data from 279 breast cancer patients who received NAC at Zhejiang Provincial People's Hospital from 2011 to 2021. Additionally, an external validation dataset, comprising 50 patients from Lanxi People's Hospital and Second Affiliated Hospital, Zhejiang University School of Medicine from 2022 to 2023 was utilized for model verification. A multivariate logistic regression model was established incorporating clinical, ultrasound features, circulating tumor cells (CTCs), and pathology variables at baseline and post-NAC. Model performance for predicting pCR was evaluated. Prognostic factors were identified using survival analysis.

Results

In the 279 patients enrolled, a pathologic complete response (pCR) rate of 27.96% (78 out of 279) was achieved. The predictive model incorporated independent predictors such as stromal tumor-infiltrating lymphocyte (sTIL) levels, Ki-67 expression, molecular subtype, and ultrasound echo features. The model demonstrated strong predictive accuracy for pCR (C-statistics/AUC 0.874), especially in human epidermal growth factor receptor 2 (HER2)-enriched (C-statistics/AUC 0.878) and triple-negative (C-statistics/AUC 0.870) subtypes, and the model performed well in external validation data set (C-statistics/AUC 0.836). Incorporating circulating tumor cell (CTC) changes post-NAC and tumor size changes further improved predictive performance (C-statistics/AUC 0.945) in the CTC detection subgroup. Key prognostic factors included tumor size >5cm, lymph node metastasis, sTIL levels, estrogen receptor (ER) status and pCR. Despite varied pCR rates, overall prognosis after standard systemic therapy was consistent across molecular subtypes.

Conclusion

The developed predictive model showcases robust performance in forecasting pCR in NAC-treated breast cancer patients, marking a step toward more personalized therapeutic strategies in breast cancer.

Current Therapeutic Targets in Cancer Cachexia: A Pathophysiologic Approach

Significant progress in our understanding of cancer cachexia has occurred in recent years. Despite these advances, no pharmacologic agent has achieved US Food and Drug Administration approval for this common and highly morbid syndrome. Fortunately, improved understanding of the molecular basis of cancer cachexia has led to novel targeted approaches that are in varying stages of drug development. This article reviews two major thematic areas that are driving these pharmacologic strategies, including those targeting signal mediators at the level of the CNS and skeletal muscle. Additionally, pharmacologic strategies are being tested in combination with targeted nutrients, nutrition therapy, and exercise to treat cancer cachexia. To this end, we highlight recently published and ongoing trials evaluating cancer cachexia therapies in these specific areas.

Development and validation of a radiopathomic model for predicting pathologic complete response to neoadjuvant chemotherapy in breast cancer patients

BACKGROUND

Neoadjuvant chemotherapy (NAC) has become the standard therapeutic option for early high-risk and locally advanced breast cancer. However, response rates to NAC vary between patients, causing delays in treatment and affecting the prognosis for patients who do not sensitive to NAC.

MATERIALS AND METHODS

In total, 211 breast cancer patients who completed NAC (training set: 155, validation set: 56) were retrospectively enrolled. we developed a deep learning radiopathomics model(DLRPM) by Support Vector Machine (SVM) method based on clinicopathological features, radiomics features, and pathomics features. Furthermore, we comprehensively validated the DLRPM and compared it with three single-scale signatures.

RESULTS

DLRPM had favourable performance for the prediction of pathological complete response (pCR) in the training set (AUC 0.933[95% CI 0.895-0.971]), and in the validation set (AUC 0.927 [95% CI 0.858-0.996]). In the validation set, DLRPM also significantly outperformed the radiomics signature (AUC 0.821[0.700-0.942]), pathomics signature (AUC 0.766[0.629-0.903]), and deep learning pathomics signature (AUC 0.804[0.683-0.925]) (all p < 0.05). The calibration curves and decision curve analysis also indicated the clinical effectiveness of the DLRPM.

CONCLUSIONS

DLRPM can help clinicians accurately predict the efficacy of NAC before treatment, highlighting the potential of artificial intelligence to improve the personalized treatment of breast cancer patients.

Adverse effects of systemic cancer therapy on skeletal muscle: myotoxicity comes out of the closet

PURPOSE OF REVIEW

Systemic cancer therapy-associated skeletal muscle wasting is emerging as a powerful impetus to the overall loss of skeletal muscle experienced by patients with cancer. This review explores the clinical magnitude and biological mechanisms of muscle wasting during systemic cancer therapy to illuminate this adverse effect. Emerging strategies for mitigation are also discussed.

RECENT FINDINGS

Clinical findings include precise, specific measures of muscle loss over the course of chemotherapy, targeted therapy and immunotherapy. All these therapeutic classes associate with quantitatively important muscle loss, independent of tumor response. Parallel experimental studies provide understanding of the specific molecular basis of wasting, which can include inhibition of protein synthesis, proliferation and differentiation, and activation of inflammation, reactive oxygen species, autophagy, mitophagy, apoptosis, protein catabolism, fibrosis and steatosis in muscle. Strategies to mitigate these muscle-specific adverse effects of cancer therapy remain in the earliest stages of development.

SUMMARY

The adverse side effect of cancer therapy on skeletal muscle has been largely ignored in the development of cancer therapeutics. Given the extent to which loss of muscle mass and function can bear on patients' function and quality of life, protection/mitigation of these side effects is a research priority.