Sarcopenia and Post-Operative Morbidity and Mortality in Patients with Gastric Cancer

Evolving concepts on perioperative nutrition of sarcopenic cancer patients

The recent recognition of the association of sarcopenia with an increased risk of complications after a surgical procedure calls for rethinking the proper approach of the perioperative care in cancer patients. Sarcopenia is broadly considered in literature according to three different definitions: loss of muscle mass, loss of muscle mass plus reduced muscle function and myosteatosis. The aim of this short review on this issue is to define the excess of risk by type of primary and of surgical procedure, depending on the definition of sarcopenia, to speculate on this association (casual versus causal) and to examine the current therapeutical approaches. The analysis of the data shows that sarcopenia, defined as loss of muscle mass plus reduced muscle function, has the higher predictive power for the occurrence of postoperative complications than the two other definitions, and any definition of sarcopenia works better than the usual indexes or scores of surgical risk. Our analysis supports the concept that: a) sarcopenia is frequently associated with inflammation, but inflammation cannot be considered the only or the absolute cause for sarcopenia, b) sarcopenia is not a simple marker of risk but can have a direct role in the increase of risk. Data on perioperative care of sarcopenic cancer patients are scanty but a correct approach cannot rely on nutritional support alone but on a combined approach of optimized nutrition and exercise, hopefully associated with an anti-inflammatory treatment. This strategy should be applied proactively in keeping with the recent recommendations of the American Society of Clinical Oncology for the medical treatment of advanced cancer patients even if a clear demonstration of effectiveness is still lacking.

The Emerging Role and Clinical Applications of Morphomics in Diagnostic Imaging

Analytic morphomics refers to the accurate measurement of specific biological markers of human body composition in diagnostic medical imaging. The increasing prevalence of disease processes that alter body composition including obesity, cachexia, and sarcopenia has generated interest in specific targeted measurement of these metrics to possibly prevent or reduce negative health outcomes. Typical morphomic measurements include the area and density of muscle, bone, vascular calcification, visceral fat, and subcutaneous fat on a specific validated axial level in the patient's cross-sectional diagnostic imaging. A distinct advantage of these measurements is that they can be made retrospectively and opportunistically with pre-existing datasets. We provide a narrative review of the current state of art in morphomics, but also consider some potential future directions for this exciting field. Imaging based quantitative assessment of body composition has enormous potential across the breadth and scope of modern clinical practice. From risk stratification to treatment planning, and outcome assessment, all can be enhanced with the use of analytic morphomics. Moreover, it is likely that many new opportunities for personalized medicine will emerge as the field evolves. As radiologists, embracing analytic morphomics will enable us to contribute added value in the care of every patient.

MalnutritiOn assessment with biOelectrical impedaNce analysis in gastRic cancer patIentS undergoing multimodaltrEatment (MOONRISE)-Study protocol for a single-arm multicenter cross-sectional longitudinal study

European data suggests that over 30% of gastric cancer (GC) patients are diagnosed with sarcopenia before surgery, while unintentional weight loss occurs in approximately 30% of patients following gastrectomy. Preoperative sarcopenia significantly increases the risk of major postoperative complications, and preoperative body weight loss remains a superior predictor of outcome and an independent prognostic factor for overall survival (OS) in patients with GC. A standardized approach of nutritional risk screening of GC patients is yet to be established. Therefore, the MOONRISE study aims to prospectively analyze the changes in nutritional status and body composition at each stage of multimodal treatment among GC patients from five Western expert centers. Specifically, we seek to assess the association between nutritional status and body composition on tumor response following neoadjuvant chemotherapy (NAC). Secondary outcomes of the study are treatment toxicity, postoperative complications, quality of life (QoL), and OS. Patients with locally advanced gastric adenocarcinoma scheduled for multimodal treatment will be included in the study. Four consecutive nutritional status assessments will be performed throughout the treatment. The following study was registered in ClinicalTrials.gov (Identifier: NCT05723718) and will be conducted in accordance with the STROBE statement. The anticipated duration of the study is 12-24 months, depending on the recruitment status. Results of this study will reveal whether nutritional status and body composition assessment based on BIA will become a validated and objective tool to support clinical decisions in GC patients undergoing multimodal treatment.

Applicability of the CT Radiomics of Skeletal Muscle and Machine Learning for the Detection of Sarcopenia and Prognostic Assessment of Disease Progression in Patients with Gastric and Esophageal Tumors

PURPOSE

Sarcopenia is considered a negative prognostic factor in patients with malignant tumors. Among other diagnostic options, computed tomography (CT), which is repeatedly performed on tumor patients, can be of further benefit. The present study aims to establish a framework for classifying the impact of sarcopenia on the prognosis of patients diagnosed with esophageal or gastric cancer. Additionally, it explores the significance of CT radiomics in both diagnostic and prognostic methodologies.

MATERIALS AND METHODS

CT scans of 83 patients with esophageal or gastric cancer taken at the time of diagnosis and during a follow-up period of one year were evaluated retrospectively. A total of 330 CT scans were analyzed. Seventy three of these patients received operative tumor resection after neoadjuvant chemotherapy, and 74% of the patients were male. The mean age was 64 years (31-83 years). Three time points (t) were defined as a basis for the statistical analysis in order to structure the course of the disease: t1 = initial diagnosis, t2 = following (neoadjuvant) chemotherapy and t3 = end of the first year after surgery in the "surgery" group or end of the first year after chemotherapy. Sarcopenia was determined using the psoas muscle index (PMI). The additional analysis included the analysis of selected radiomic features of the psoas major, quadratus lumborum, and erector spinae muscles at the L3 level. Disease progression was monitored according to the response evaluation criteria in solid tumors (RECIST 1.1). CT scans and radiomics were used to assess the likelihood of tumor progression and their correlation to sarcopenia. For machine learning, the established algorithms decision tree (DT), K-nearest neighbor (KNN), and random forest (RF) were applied. To evaluate the performance of each model, a 10-fold cross-validation as well as a calculation of Accuracy and Area Under the Curve (AUC) was used.

RESULTS

During the observation period of the study, there was a significant decrease in PMI. This was most evident in patients with surgical therapy in the comparison between diagnosis and after both neoadjuvant therapy and surgery (each p < 0.001). Tumor progression (PD) was not observed significantly more often in the patients with sarcopenia compared to those without sarcopenia at any time point (p = 0.277 to p = 0.465). On average, PD occurred after 271.69 ± 104.20 days. The time from initial diagnosis to PD in patients "with sarcopenia" was not significantly shorter than in patients "without sarcopenia" at any of the time points (p = 0.521 to p = 0.817). The CT radiomics of skeletal muscle could predict both sarcopenia and tumor progression, with the best results for the psoas major muscle using the RF algorithm. For the detection of sarcopenia, the Accuracy was 0.90 ± 0.03 and AUC was 0.96 ± 0.02. For the prediction of PD, the Accuracy was 0.88 ± 0.04 and the AUC was 0.93 ± 0.04.

CONCLUSIONS

In the present study, the CT radiomics of skeletal muscle together with machine learning correlated with the presence of sarcopenia, and this can additionally assist in predicting disease progression. These features can be classified as promising alternatives to conventional methods, with great potential for further research and future clinical application. However, when sarcopenia was diagnosed with PMI, no significant correlation between sarcopenia and PD could be observed.

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.

The association between skeletal muscle mass index (SMI) and survival after gastrectomy: A systematic review and meta-analysis of cohort studies

OBJECTIVE

Low skeletal muscle mass index (SMI) is frequently identified in gastric cancer patients but its association with patient survival rate is not clear. This systematic review and meta-analysis aimed to clarify the association between SMI and overall survival in gastric cancer patients after gastrectomy.

METHODS

PubMed, Scopus, and Web of Science were searched from database inception until July 2021. Studies were eligible if they included gastric cancer patients, measured the SMI level, reported SMI before gastrectomy, defined sarcopenia according to SMI, and had a cohort or case-control design. Primary outcome was cancer survival rate. The risk of bias of individual studies was assessed using the Newcastle - Ottawa Scale.

RESULTS

Overall, 22 cohort studies including 7,203 participants were included. The quality of the included studies was moderate to high. A higher overall survival rate was associated with a higher SMI (RR = 1.62, 95% CI: 1.42-1.85). Subgroup analysis suggested a stronger association in overweight or obese patients (RR = 2.39, 95% CI: 1.13-5.09; I2 = 77%; heterogeneity P < 0.01). But no significant differences in the association based on the surgery type (curative surgery vs radical surgery) or the type of gastrectomy (total gastrectomy vs sub-total gastrectomy) were observed.

CONCLUSIONS

It is suggested that SMI can be a prognostic indicator for overall survival in gastric cancer patients, especially in overweight and obese patients.

Gastric Cancer with Sarcopenia: an Area Worth Focusing On

OPINION STATEMENT

Gastric cancer (GC) is the fifth most common cancer and the third leading cause of cancer death worldwide, which seriously endangers human health. A number of studies have shown that sarcopenia occurs more frequently in patients with gastric cancer than in the general population and can significantly affect the disease status and survival of patients, which is of great significance in predicting the prognosis of gastric cancer. Patients with gastric cancer may suffer sarcopenia no matter before or after surgery, and the pathogenesis is complex. Abnormal nutrient metabolism and reduced exercise are the leading causes. In addition, surgical treatment and chemotherapy for gastric cancer might participate in the physiological and pathological mechanism of sarcopenia. Generally speaking, exercise and nutritional therapy are the main prevention and treatment methods for sarcopenia. But more prospective evidence is needed to establish reasonable interventions, and other drug treatments are in their infancy. For the diagnostic criteria of sarcopenia, the cut-off values of the skeletal muscle mass index obtained from CT images vary widely and need to be standardized and unified. We also need to explore simple predictors to facilitate sarcopenia risk assessment. More research is needed to formulate more appropriate treatments for gastric cancer patients with sarcopenia.

Post-operative weight loss affects 3-year survival in patients with gastric adenocarcinoma after gastrectomy and hyperthermic intraperitoneal chemotherapy

INTRODUCTION

Patients with advanced gastric adenocarcinoma are at high risk of malnutrition. Some patients benefit from total gastrectomy associated with hyperthermic intraperitoneal chemotherapy (HIPEC) with or without cytoreduction surgery (CR) as a curative strategy. The aim of this study was to describe pre- and post-operative nutritional assessments and their impact on survival in these patients.

MATERIALS AND METHODS

All patients with advanced gastric adenocarcinoma treated with gastrectomy and HIPEC with or without CR at Lyon University Hospital were retrospectively included from April 2012 to August 2017. Carcinologic data, history of weight, anthropometric measures, nutritional biological markers and CT-scan body composition were collected.

RESULTS

54 patients were included. Malnutrition affected 48.1% before and 64.8% after surgery, and severe malnutrition respectively 11.1% and 20.3%. Pre-operative sarcopenia diagnosed by CT scan was found in 40.7% of the patients while 81.1% of the sarcopenic patients had a normal or high body mass index. A loss of ⩾ 20% of usual weight on discharge was a pejorative factor of survival at 3 years of follow-up (p = 0.0470). Only 14.8% of the patients continued artificial nutrition following discharge but artificial nutrition was resumed in 30.4% of the patients within 4 months after discharge owing to weight loss.

CONCLUSIONS

Patients with advanced gastric adenocarcinoma undergoing gastrectomy and HIPEC with or without CR are at high risk of malnutrition. Post-operative weight loss has a pejorative impact on outcome. These patients should be systematically screened for malnutrition with early interventionist nutritional care and close nutritional follow-up.

Preoperative sarcopenia combined with prognostic nutritional index predicts long-term prognosis of radical gastrectomy with advanced gastric cancer: a comprehensive analysis of two-center study

PURPOSE

This study aims to investigate the predictive value of the combined index smni(skeletal muscle index (SMI)-prognostic nutrition index(PNI)) for the postoperative survival of patients with advanced gastric cancer(AGC).

METHODS

650 patients with AGC from two centers (290 cases from the First Affiliated Hospital of Dalian University and 360 points from the Fujian Medical University Union Hospital) were selected as the study subjects based on unified screening criteria. Clinical data, preoperative abdominal CT images, results of hematology-related examinations, tumor-related characteristics, and surgical and follow-up data of the patients were collected and organized. The L3 vertebral level muscle area was measured using computer-assisted measurement techniques, and the skeletal muscle index(SMI) was calculated based on this measurement. The prognostic nutrition index (PNI) was calculated based on serum albumin and lymphocyte count indicators. The Kaplan-Meier survival analysis of data from the First Affiliated Hospital was used to determine that SMI and PNI are significantly correlated with the postoperative survival rate of patients with advanced gastric cancer. Based on this, a novel combined index smni was fitted and stratified for risk. Cox proportional hazards regression analysis was used to determine that the index smni is an independent prognostic risk factor for patients with AGC after surgery. The ROC curve was used to describe the predictive ability of the new combined index and its importance and predictive power in predicting postoperative survival of patients with AGC, which was verified in the data of Fujian Medical University Union Hospital.

RESULT

The Kaplan-Meier curve analysis of the combined indicator smni Is clearly associated with long-term survival(3-year OS (P < 0.001) and DSS (P < 0.001)), univariate analysis and multivariate analysis showed that smni was an independent prognostic risk factor, The ROC curve for the first center 3-year OS(AUC = 0.678), DSS(AUC = 0.662) show good predictive ability and were validated in the second center.

CONCLUSION

The combined index smni has a good predictive ability for the postoperative survival rate of patients with AGC and is expected to provide a new reference basis and more accurate and scientific guidance for the postoperative management and treatment of patients with AGC.

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.

Preoperative computed tomography-determined sarcopenia is a reliable prognostic factor in patients with gastric cancer after radical gastrectomy: A sex-specific analysis

Background

The predictive role of sarcopenia in cancer prognosis is an area of increasing concern. However, the influence of sex difference on the predictive role of sarcopenia in cancer prognosis has not been clearly defined. This retrospective cohort study investigated the effect of preoperative sarcopenia on the long-term outcomes of patients with gastric cancer (GC) based on sexual dimorphism.

Methods

Preoperative abdominal computed tomography (CT) scans from 379 GC patients who underwent radical gastrectomy were carefully analyzed. The patients were categorized into sarcopenia and non-sarcopenia groups according to the L3 skeletal muscle index (L3 SMI) measured on CT scans. Moreover, other indexes which can be used to evaluate the muscle area or the muscle quality, including skeletal muscle area (SMA), visceral fat area (VFA), subcutaneous fat area (SFA), skeletal muscle radiation attenuation (SM-RA), visceral fat index (VFI), subcutaneous fat index (SFI), and subcutaneous and visceral ratio (SV), were obtained from CT scans.

Results

There were 254 men and 125 women included in our study. After calculation, we defined sex-specific SMI-related mortality cutoff as 39.73 and 32.97 cm²/m² for men and women. Univariable analysis showed that pathological tumor-node-metastasis (pTNM), depth of invasion, lymph node metastasis, differentiation degree, preoperative sarcopenia (for men), SMA (for men), L3 SMI, SFA (for women), SFI (for women), SV (for women), and SM-RA (especially for men) were significant independent predictors of overall survival (OS). Multivariable analysis showed that pTNM, depth of invasion, poor differentiation, and SM-RA were significantly associated with 5-year OS in GC patients. However, CT-determined sarcopenia was associated with significantly worse OS only in men, and SFA was significantly associated with 5-year OS only in women.

Conclusion

SM-RA is a reliable prognostic factor in patients with GC after radical gastrectomy. The impact of indexes mentioned above on survival outcomes is dependent on sex. CT-determined preoperative sarcopenia, a muscle-related indicator, was associated with outcomes in men. Adipose-related indicator (SFA), instead, was associated with outcomes in women.

Use of computed tomography for the diagnosis of surgical sarcopenia: Review of recent research advances

Sarcopenia, also known as muscle decay, is associated with high morbidity among surgical patients. It is highly correlated with adverse clinical outcomes, such as increased postoperative complications, prolonged hospital stay, and increased mortality. Computed tomography (CT) is one of the main methods for diagnosing sarcopenia, which has the advantages of intuitiveness, rapidity, and accuracy. Clinical studies have shown that CT-defined sarcopenia can help predict the clinical outcomes and prognosis of surgical patients and provide an important reference for the formulation of antitumor treatment protocols. In recent years, some scholars have tried to construct an intelligent CT-based diagnostic model, which is expected to improve the diagnostic efficiency and establish standardized diagnostic criteria for CT-defined sarcopenia. In this review, we summarize the recent progress in the understanding of the diagnosis of sarcopenia and its potential prognostic value in surgery.

Sarcopenia is Associated with Reduced Survival following Surgery for Adrenocortical Carcinoma

AIM

Adrenocortical cancer (ACC) is an aggressive malignancy and robust prognostic factors remain unclear. The presence of sarcopenia has been shown to negatively impact survival for other malignancies, but has not been extensively analyzed in ACC.

METHODS

Patients who underwent resection of their ACC between 2010 and 2020 were identified; therapeutic, operative, and outcome data were analyzed. Sarcopenia was assessed by calculation of the skeletal muscle index (SMI) and was defined as an SMI <52.4cm²/m² for males and <38.5cm²/m² for females.

RESULTS

Data on 35 patients (18 F: 17 M; median age 54 [range: 18-86]) who had primary surgical treatment were analyzed. Median tumor size was 10 cm [range:3-15]. In eleven patients (31%), the tumor was hormonally active (cortisol = 8;23%). Seventeen patients (49%) were classified as having sarcopenia on their pre-operative CT scan. The Intraclass Correlation Coefficient (ICC) for intra- and inter-observer variability showed very good agreement (0.99 and 0.98). There was no difference in incidence of sarcopenia stratifying for sex, BMI, or tumor-size, but incidence was higher with increasing age (p < .05). Overall median survival was 36 months, with 1- and 3-year survival rates of 77% and 52%. The presence of sarcopenia was strongly associated with a shorter overall survival (HR = 3.21; [95%CI: 1.06-9.69];p = .03) on unadjusted analyses. Moreover, age, higher T-stage, and presence of capsular invasion were also associated with poorer survival on univariable analyses.

CONCLUSION

The presence of sarcopenia in patients undergoing surgery for ACC could be a predictor of reduced overall survival, although replications of these analyses should be performed in similar, larger cohorts. Specifically, the influence of a patient's hormonal status on the manifestation of sarcopenia should be further defined.

Body Composition Is a Predictor for Postoperative Complications After Gastrectomy for Gastric Cancer: a Prospective Side Study of the LOGICA Trial

PURPOSE

There is a lack of prospective studies evaluating the effects of body composition on postoperative complications after gastrectomy in a Western population with predominantly advanced gastric cancer.

METHODS

This is a prospective side study of the LOGICA trial, a multicenter randomized trial on laparoscopic versus open gastrectomy for gastric cancer. Trial patients who received preoperative chemotherapy followed by gastrectomy with an available preoperative restaging abdominal computed tomography (CT) scan were included. The CT scan was used to calculate the mass (M) and radiation attenuation (RA) of skeletal muscle (SM), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). These variables were expressed as Z-scores, depicting how many standard deviations each patient's CT value differs from the sex-specific study sample mean. Primary outcome was the association of each Z-score with the occurrence of a major postoperative complication (Clavien-Dindo grade ≥ 3b).

RESULTS

From 2015 to 2018, a total of 112 patients were included. A major postoperative complication occurred in 9 patients (8%). A high SM-M Z-score was associated with a lower risk of major postoperative complications (RR 0.47, 95% CI 0.28-0.78, p = 0.004). Furthermore, high VAT-RA Z-scores and SAT-RA Z-scores were associated with a higher risk of major postoperative complications (RR 2.82, 95% CI 1.52-5.23, p = 0.001 and RR 1.95, 95% CI 1.14-3.34, p = 0.015, respectively). VAT-M, SAT-M, and SM-RA Z-scores showed no significant associations.

CONCLUSION

Preoperative low skeletal muscle mass and high visceral and subcutaneous adipose tissue radiation attenuation (indicating fat depleted of triglycerides) were associated with a higher risk of developing a major postoperative complication in patients treated with preoperative chemotherapy followed by gastrectomy.

Strong impact of sarcopenia as a risk factor of survival in resected gastric cancer patients: first Italian report of a Bicentric study

Gastric cancer (GC) accounts for 4% of all cancers in Europe. Sarcopenia is a complex syndrome characterized by a loss of muscle mass and function associated with age, often present in neoplastic patients. Recently, several studies have shown a significant association between sarcopenia and poor prognosis in various pathological conditions. The current observational retrospective study investigates the association between sarcopenia and overall survival (OS) and recurrence-free survival (RFS) in patients with GC undergoing up-front surgery with curative intent. Resected GC patients' clinical records and CT images were retrospectively assessed. The preoperative CT calculation of the skeletal muscle index (SMI) at L3 level allowed us to categorize patients as sarcopenic or not. Kaplan-Meyer and univariate and multivariate Cox regression analyses were performed to determine the difference in survival and presence of independent prognostic factors. Fifty-five patients, 28 male and 27 female, out of 298 studied for gastric cancer were enrolled in the current study from two cancer referral centers in Italy. The preoperative CT calculation of the SMI at L3 level allowed us to identify 39 patients with and 16 without sarcopenia. A statistically significant difference between the sarcopenic and non-sarcopenic groups was observed in both OS and RFS (p < 0.023; p < 0.006). Moreover, sarcopenia was strongly correlated to a higher risk of recurrence in univariate and multivariate analysis (p < 0.02). Sarcopenia can be considered a critical risk factor for survival in patients with resectable GC treated with up-front surgery. Identifying sarcopenic patients at the time of diagnosis would direct selection of patients who could benefit from early nutritional and/or physical treatments able to increase their muscle mass and possibly improve the prognosis. More extensive multicenter studies are needed to address this issue.

Impact of preoperative sarcopenia on postoperative complications and prognosis of gastric cancer resection: A meta-analysis of cohort studies

Background The effect of preoperative sarcopenia on postoperative complications and prognosis in patients undergoing gastrectomy for gastric cancer has been controversial. The purpose of this study was to explore the effect of preoperative sarcopenia on postoperative complications and prognosis of patients with gastric cancer through meta-analysis method, providing new ideas for the prognosis study of patients undergoing gastrectomy for gastric cancer. Methods From databases establishment to April 2021, we systematically searched PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, WanFang Data, and Chinese Biomedical Literature Database (CBM) to collect cohort studies on the effect of sarcopenia on postoperative complications or prognosis of gastric cancer. Based on the inclusion and exclusion criteria, two researchers independently screened the literature and extracted the data. The Newcastle-Ottawa Scale was used to evaluate the quality of the included studies and Revman 5.3 software was used for the meta-analysis. Result A total of 20 studies (11 prospective cohort studies and 9 retrospective cohort studies) involving 7615 patients were finally included. Meta-analysis showed that: 1) preoperative sarcopenia significantly increased the risk of overall complications (risk ratio[RR] =2.89, 95% confidence interval[CI]: 1.86, 4.49; P < 0.000 01), serious complications (Clavien-Dindo grade ≥ III, RR = 3.01, 95% CI: 1.73, 5.23; P < 0.000 01), pneumonia (RR =2.64, 95% CI: 1.71, 4.09; P < 0.0001), and obstruction (RR = 3.96, 95% CI: 2.27, 6.90; P < 0.000 01), but did not increase the risk of postoperative delayed gastric emptying (RR = 1.44, 95% CI: 0.63, 3.25; P = 0.38), intra-abdominal infection (RR =2.09, 95% CI: 0.88, 5.00; P = 0.10), and anastomotic leakage (RR = 1.26, 95% CI: 0.69, 2.32; P = 0.45); 2) preoperative sarcopenia reduced the overall survival rate (HR = 1.71, 95% CI: 1.53, 1.91; P < 0.00001). Conclusion Preoperative sarcopenia increased the risk of postoperative complications and reduced the overall survival rate of patients undergoing gastrectomy for gastric cancer. Therefore, for patients with gastric cancer, preoperative risk assessment and active intervention for sarcopenia are necessary to reduce the risk of postoperative complications and improve poor prognosis. Future studies should focus on the effect of preoperative sarcopenia on the quality of life after gastrectomy for gastric cancer.

Body Composition, Inflammation, and 5-Year Outcomes in Colon Cancer

IMPORTANCE

Obesity, particularly visceral obesity and sarcopenia, are poor prognostic indicators in colon cancer.

OBJECTIVES

To explore the association between body composition profiles and 5-year colon cancer outcomes and delineate the associated underlying inflammatory processes.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter translational cohort study included patients with nonmetastatic colon cancer who did not have underlying chronic inflammatory disorders and were not receiving anti-inflammatory drugs referred to tertiary cancer centers from 2009 to 2015. Preoperative acute phase proteins (white cell count, C-reactive protein, and albumin), cytokines (interleukin [IL]-1b, IL-2, IL-6, IL-10, interferon γ, and tumor necrosis factor α), vascular endothelial growth factor (VEGF), and cell surface receptor expression levels (CD11b and CD14) were measured. All patients underwent follow-up for at least 5 years. Data were analyzed in December 2020.

EXPOSURE

Nonmetastatic colon cancer.

MAIN OUTCOMES AND MEASURES

The associations of body composition profiles with 5-year cancer recurrence and disease-specific mortality were analyzed using Mantel Cox log-rank test and Kaplan-Meier curves.

RESULTS

A total of 28 patients were included (median [interquartile range] age, 67 [58-72] years; 22 [78.6%] men). Low skeletal muscle area (SMA) and high visceral to total fat ratio were associated with poor clinical and oncological outcomes, including increased 5-year recurrence (low SMA: hazard ratio [HR], 2.30 [95% CI, 1.41-2.89]; P = .04; high visceral to total fat ratio: HR, 5.78 [95% CI, 3.66-7.95]; P = .02). High visceral to total fat ratio was associated with increased 5-year disease-specific mortality (HR, 5.92 [95% CI, 4.04-8.00]; P = .02). Patients with low SMA who developed a cancer recurrence, compared with those who did not, had higher C-reactive protein (mean [SD], 31.24 [6.95] mg/dL vs 8.11 [0.58] mg/dL; P = .003), IL-6 (mean [SD], 1.93 [1.16] ng/mL vs 0.88 [0.14] ng/mL; P = .004), VEGF (mean [SD], 310.03 [122.66] ng/mL vs 176.12 [22.94] ng/mL; P = .007), and CD14 (mean [SD], 521.23 [302.02] ng/mL vs 322.07 [98.35] ng/mL; P = .03) expression and lower albumin (mean [SD], 3.8 [0.6] g/dL vs 43.50 [3.69] g/dL; P = .01), IL-2 (mean [SD], 0.45 [0.25] ng/mL vs 0.94 [0.43] ng/mL; P < .001), IL-10 (mean [SD], 8.15 [1.09] ng/mL vs 16.32 [4.43] ng/mL; P = .004), and interferon γ (mean [SD], 2.61 [1.36] ng/mL vs 14.87 [3.43] ng/mL; P = .02) levels. Patients with high visceral to total fat ratio who developed recurrence had higher levels of IL-6 (mean [SD], 5.26 [7.05] ng/mL vs 2.76 [3.11] ng/mL; P = .03) and tumor necrosis factor α (mean [SD], 5.74 [4.53] ng/mL vs 4.50 [1.99] ng/mL; P = .03).

CONCLUSIONS AND RELEVANCE

These findings suggest that low SMA and high visceral to total fat ratio were associated with worse colon cancer outcomes and with increased expression of proinflammatory cytokines and VEGF and inhibition of anti-inflammatory cytokines.

Prognostic Impact of Sarcopenia and Radiotherapy in Patients With Advanced Gastric Cancer Treated With Anti-PD-1 Antibody

Background

We explored the combined effects of sarcopenia (SAR) and radiotherapy (RT) on outcomes in patients with advanced gastric cancer (AGC) treated with immune-checkpoint blockade (ICB).

Methods

Among 185 patients with AGC treated with ICB, we defined SAR as skeletal muscle index <49 cm2/m2 for men and <31 cm2/m2 for women; 93 patients met criteria. We defined high neutrophil-to-lymphocyte ratio (hNLR) as NLR≥3. Palliative RT was performed in 37 patients (20%) before ICB.

Results

We frequently observed hNLR in patients with SAR (53% vs. 35%, p = 0.02). The median overall survival (OS) for the entire cohort was 5 months. Stratification by risk factors of SAR or hNLR revealed a significant difference in median OS (0 [N = 60] vs. 1 [N = 76] vs. 2 [N = 49]: 7.6 vs. 6.4 vs. 2.2 months, p < 0.001). Patients with microsatellite instability-high (MSI-H, N = 19) or Epstein-Barr virus (EBV)-positive tumors (N = 13) showed favorable outcomes compared to those with microsatellite stable (MSS, N = 142) tumors (median OS, not reached vs. 16.8 vs. 3.8 months, respectively). The benefit of RT was evident in patients with both SAR and hNLR (median OS, 3.1 vs. 1.3 months, p = 0.02) and MSS/EBV-negative tumor (median OS, 6.5 vs. 3.5 months, p = 0.03), but outcomes after RT in MSI-H tumor were not significantly different. In multivariable analysis, SAR/hNLR, molecular subtypes, and a history of RT were associated with OS (all p < 0.05).

Conclusions

We demonstrated the negative predictive value of SAR/hNLR on outcomes after ICB for AGC, and the history of RT could overcome the negative impact of SAR/hNLR and the MSS/EBV-negative subtype.

AWGS2019 vs EWGSOP2 for diagnosing sarcopenia to predict long-term prognosis in Chinese patients with gastric cancer after radical gastrectomy

BACKGROUND

Sarcopenia is a nutrition-related disease and has a profound effect on the long-term overall survival (OS) of patients with gastric cancer. Its diagnostic criterion is critical to clinical diagnosis and treatment. However, previous research reported widely differing sarcopenia prevalence due to different criteria. AWGS2019 and EWGSOP2 are the two latest and widely adopted criteria.

AIM

To compare the effects of AWGS2019 and EWGSOP2 on the long-term OS of Chinese gastric cancer patient after radical gastrectomy.

METHODS

An observational study was conducted from July 2014 to January 2017, which included 648 consecutive gastric cancer patients who underwent radical gastrectomy. The sarcopenia elements (skeletal muscle index, handgrip strength, and gait speed) were measured within 1 mo or 7 d before surgery. The patients were followed at fixed intervals to gain the outcomes. Multivariate Cox regression analysis was performed to determine the association between sarcopenia and the long-term OS of these patients according to the two criteria separately. The predictive performance of the models with AWGS2019 and EWGSOP2 were evaluated by the concordance index (C-index) and area under the time-dependent receiver operating characteristic curve (AUC). The Akaike information criterion (AIC) was applied to compare model fits.

RESULTS

The prevalence of sarcopenia was 20.5% and 11.3% according to AWGS2019 and EWGSOP2, respectively. Sarcopenia was an independent risk factor for the long-term OS no matter based on AWGS2019 or EWGSOP2, but AWGS2019-sarcopenia in multivariate model had a higher hazard ratio (HR) [2.150 (1.547-2.988)] than EWGSOP2-sarcopenia [HR 1.599 (1.092-2.339)]. Meanwhile, the model with AWGS2019-sarcopenia [C-index 0.773 (0.742-0.804); AIC 2193.7; time-dependent AUC 0.812 (0.756-0.867) for 1-year OS, 0.815 (0.778-0.852) for 3-year OS, and 0.809 (0.759-0.859) for 5-year OS] had better predictive power and model fits than the model with EWGSOP2-sarcopenia [C-index 0.762 (0.729-0.795); AIC 2215.2; time-dependent AUC 0.797 (0.741-0.854) for 1-year OS, 0.804 (0.767-0.842) for 3-year OS, and 0.799 (0.748-0.850) for 5-year OS].

CONCLUSION

Sarcopenia is an independent risk factor for the long-term OS in Chinese gastric cancer patients undergoing radical gastrectomy. The prediction model with AWGS2019-sarcopenia has better predictive power and model fits than the prediction model with EWGSOP2-sarcopenia. AWGS2019 may be more appropriate for diagnosing sarcopenia in these Chinese patients than EWGSOP2.

A Novel Technique for Radiographic Diagnosis of Sarcopenia that Accurately Predicts Postoperative Complications in Lower Extremity Free Flap Patients

INTRODUCTION

 Sarcopenia is linked to poor outcomes throughout the surgical literature and can be assessed on preoperative imaging to potentially aid in risk stratification. This study examined the effects of sarcopenia on surgical morbidity following lower extremity (LE) reconstruction, and also compared two methods of assessment, one of which is novel ("ellipse method").

METHODS

 A retrospective cohort study of 50 patients receiving free flap-based reconstruction of the LE was performed. Bilateral psoas density and area were quantified at L4 through tracing ("traditional method") and encircling ("ellipse method") to calculate Hounsfield unit average calculation (HUAC). Logistic regression and receiving operator curve analysis for the primary outcome of any postoperative complication was used to determine HUAC cutoffs (≤ 20.7 vs. ≤ 20.6) for sarcopenia. Risk of complications associated with sarcopenia was evaluated using Fisher's exact tests.

RESULTS

 Twelve patients (24%) met criteria for sarcopenia via the traditional method and 16 (32%) via the ellipse method. By both methods, sarcopenic patients were older and more often female and diabetic. These patients also had higher American Society of Anesthesiologists scores and lower serum prealbumin levels. The ellipse method was found to be more accurate, sensitive, and specific than the traditional method in predicting postoperative morbidity (p = 0.009). Via the ellipse method, sarcopenic patients were at higher risk for any complication (p = 0.002) and were at a higher risk for a deep vein thrombus or pulmonary embolism via the traditional method (p = 0.047).

CONCLUSION

 Sarcopenia is associated with greater pre- and postoperative morbidity in LE reconstruction. The novel ellipse method is a simplified and accurate method of assessing sarcopenia that can be easily performed in the clinical setting.

Body Composition Changes in Gastric Cancer Patients during Preoperative FLOT Therapy: Preliminary Results of an Italian Cohort Study

Background: The impact of the new chemotherapy, fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) on body composition in gastric cancer (GC) patients remains unknown. We assessed body composition changes of GC patients receiving the FLOT regimen and their impact on treatment outcomes. Methods: Preoperative pre- and post-FLOT computed tomography (CT) scans of advanced GC patients were studied. Lumbar skeletal muscle index (SMI) and adipose indices were calculated before and after FLOT. Results: A total of 26 patients were identified between April 2019 and January 2020. Nineteen patients were sarcopenic at diagnosis. The mean BMI decreased (from 24.4 ± 3.7 to 22.6 ± 3.1; p < 0.0001) as well as the SMI (from 48.74 ± 9.76 to 46.52 ± 9.98; p = 0.009) and visceral adipose index (VAI) (from 49.04 ± 31.06 to 41.99 ± 23.91; p = 0.004) during preoperative FLOT therapy. BMI, SMI, and VAI variations were not associated with toxicity, Response Evaluation Criteria in Solid Tumors (RECIST), response, delay and completion of perioperative FLOT chemotherapy, and the execution of gastrectomy; a decrease of SMI ≥ 5% was associated with a higher Mandard tumor regression grade (p = 0.01). Conclusions: Almost three-quarters (73.1%) of GC patients were sarcopenic at diagnosis. Preoperative FLOT was associated with a further reduction in SMI, BMI, and VAI. These changes were not associated with short-term outcomes.

Pre-operative low muscle mass is associated with major complications and lower recurrence-free survival after gastric cancer surgery

BACKGROUND

Low muscle mass (LMM) has been associated with post-operative morbidity. This study aimed to examine the relationship between pre-operative LMM and major post-operative complications and survival in patients undergoing curative resection for gastric cancer.

METHODS

A single-centre retrospective cohort study was conducted on consecutive patients who underwent surgical resection for gastric adenocarcinoma between 2008 and 2018. Patient demographics, radiological parameters, pathological data and complications were recorded. Skeletal muscle index was calculated using OsiriX software by manually measuring the cross-sectional skeletal muscle area at the third lumbar vertebra and correcting to the patient's height. Univariate and multivariate analyses were used to identify the risk factors associated with the outcomes.

RESULTS

A total of 62 patients (36 males, mean age 68.3 ± 1.5 years) met the inclusion criteria. Twenty-six (41.9%) patients had LMM pre-operatively. Demographic data in the non-LMM and LMM groups were equally matched except for body mass index (27.6 ± 0.8 kg/m² versus 24.3 ± 1.1 kg/m² ; P = 0.012) and serum albumin (36.7 ± 0.7 g/L versus 33.8 ± 1.0 g/L; P = 0.017), which were higher in the non-LMM. LMM was associated with higher incidence of total (35.5% versus 64.5%; P = 0.006), minor (40% versus 60%; P = 0.030), major (9.1% versus 90.9%; P = 0.004) post-operative complications and decreased recurrence-free survival (hazard ratio 2.29; 95% confidence interval 1.10-4.77; P = 0.027).

CONCLUSION

LMM is a significant independent risk factor for major post-operative complications and recurrence-free survival after gastrectomy. Pre-operative identification of LMM could be a useful tool for prognostication and may identify a group suitable for prehabilitation.

Prevalence and associated factors of sarcopenia among patients underwent abdominal CT scan in Tertiary Care Hospital of South India

Objective:

To estimate the proportion of radiologically significant (LSMI) sarcopenia and the factors associated with it among patients undergoing Computerized Tomography scan.

Methods:

A Cross sectional study was conducted among 152 patients underwent CT scan in the radiology department of Government medical college Thiruvananthapuram. Sarcopenia was estimated based on lumbar skeletal muscle index obtained using cross sectional areas of various abdominal muscles by CT scan. The proportion of sarcopenia was estimated and associated factors studied. Binary logistic regression model was used to adjust the confounders.

Results:

Out of 152 individuals, sarcopenia was present in a total of 82 (53.95%) individuals. Male gender (Adjusted OR= 8.42, 3.64 - 19.52 (95% CI)) was a risk factor for and a body mass index more than 25Kg/m² (Adjusted OR= 0.36, 0.15- 0.67 (95% CI)) was a protective factor against sarcopenia.

Conclusion:

The burden of sarcopenia is found to be high and considering the double burden of sarcopenia and obesity in the Kerala community, newer strategies for health promotion and early detection need to be developed.

Nutritional assessment by subjective methods versus computed tomography to predict survival in oncology patients

OBJECTIVES

The aim of this study was to analyze the association between survival and two validated methods of nutritional assessment: body composition through computed tomography (CT) scans and Patient-Generated Subjective Global Assessment (PG-SGA).

METHODS

Cancer-bearing patients (n = 103) hospitalized in the Oncology Ward of Clínica Alemana in Santiago, Chile, for palliative or curative treatment were assessed by both methods. Images from abdominal CT scans at the L3 level were analyzed by SliceOmatic (version 5.0), to measure muscle and fat areas and densities. Skeletal muscle mass index (MMI) was calculated using total abdominal mass area (psoas + rest of muscles)/ height². These were compared with those obtained for assessment of trauma of 130 healthy young adults (18-40 y of age), as reference control values. Sarcopenia was established as MMI<1 SD compared with control participants.

RESULTS

Patients with cancer had less muscle and higher abdominal fat areas compared with controls (P < 0.05). According to the PG-SGA, ~50% were classified as malnourished. Patients were followed for 38 mo, when 53% had died. Survival time was significantly and negatively correlated with PG-SGA score, cancer stage, and sarcopenia, independent of age and sex. Multivariate analysis included both cancer stage and nutritional assessment variables.

CONCLUSIONS

Together with cancer stage, both CT measurements and subjective assessment of nutritional status through PG-SGA can adequately identify cancer patients with a higher mortality risk, independent of age and sex. However, the latter is less costly and simple to use; it should be included as a valuable tool during management of patients with cancer.

Role of HOXB7 in promoting gastric cancer progression and oxaliplatin (L-OHP) resistance

BACKGROUND AND AIM

Our study aimed to investigate the ways by which HOXB7 affects gastric cancer progression and oxaliplatin (L-OHP) resistance.

METHODS

First, the expression of HOXB7 in paired cancer and paracancerous tissues of L-OHP-sensitive and L-OHP-resistant gastric cancer patients was qualitatively and quantitatively analyzed by immunohistochemistry. Then, the expression of HOXB7 in these tissues was further quantitatively analyzed at protein and transcriptional levels. The expression of HOXB7 in the SGC-7901 L-OHP-resistant gastric cancer cell line was further verified by immunofluorescence, western blot, and RT-qPCR. In addition, by transfecting the SGC-7901 cell line, control (sh-con) and HOXB-7-silenced (sh-HOXB7) gastric cancer cell lines were created. Subsequently, the migratory and invasive abilities of these cells were determined by the transwell assay. The proliferation rate of both control and HOXB-7-silenced cells induced by varying concentrations of L-OHP was detected by the CCK-8 assay, while the degree of apoptosis in the same cells induced by 60 µM L-OHP was detected by flow cytometry.

RESULTS AND CONCLUSION

Results suggested that HOXB7 was overexpressed in both the tissues of L-OHP-resistant gastric cancer patients and the SGC-7901 gastric cancer cell line. Moreover, HOXB7 promoted the migratory and invasive abilities of gastric cancer cells. By silencing HOXB7 protein expression, the proliferation rate of L-OHP-resistant gastric cancer cells decreased considerably, while their degree of apoptosis increased significantly. These results showed that HOXB7 promoted gastric cancer progression and L-OHP resistance.

Thigh sarcopenia and hypoalbuminemia predict impaired overall survival after infrainguinal revascularization in patients with critical limb ischemia

Objective

This study was performed to determine whether thigh sarcopenia can serve as a clinically relevant predictor of postoperative complications and overall survival after revascularization in patients with critical limb ischemia.

Methods

Patients who underwent preoperative computed tomography followed by infrainguinal revascularization from 2006 to 2015 were retrospectively analyzed. An axial computed tomography image was obtained at the midpoint of a line extending from the superior border of the patella to the greater trochanter of the femur. The thigh muscle area and bone area were measured. Thigh sarcopenia was defined as thigh muscle area/thigh bone area of <9.

Results

We included 117 patients with critical limb ischemia who underwent infrainguinal revascularization. The overall survival rates at two years were 86.5% and 55.1% in the thigh sarcopenia (−) and (+) groups, respectively ( p < 0.01). The multivariate analysis showed that thigh sarcopenia (hazard ratio, 2.64; 95% confidence interval, 1.11–6.70; p = 0.03), cerebrovascular disease (hazard ratio, 3.18; 95% confidence interval, 1.31–7.36; p = 0.01), and serum albumin level (1 g/dL per increments) (hazard ratio, 0.41; 95% confidence interval, 0.21–0.81; p = 0.01) were the risk factors for overall survival two years after revascularization.

Conclusion

Thigh sarcopenia is a risk factor for two-year overall survival in patients with critical limb ischemia after infrainguinal revascularization.

The Predictive Value of Low Muscle Mass as Measured on CT Scans for Postoperative Complications and Mortality in Gastric Cancer Patients: A Systematic Review and Meta-Analysis

Risk assessment is relevant to predict outcomes in patients with gastric cancer. This systematic review aimed to investigate the predictive value of low muscle mass for postoperative complications in gastric cancer patients. A systematic literature search was performed to identify all articles reporting on muscle mass as measured on computed tomography (CT) scans in patients with gastric cancer. After full text screening, 15 articles reporting on 4887 patients were included. Meta-analysis demonstrated that patients with low muscle mass had significantly higher odds of postoperative complications (odds ratio (OR): 2.09, 95% confidence interval (CI): 1.55–2.83) and severe postoperative complications (Clavien–Dindo grade ≥III, OR: 1.73, 95% CI: 1.14–2.63). Moreover, patients with low muscle mass had a significantly higher overall mortality (hazard ratio (HR): 1.81, 95% CI: 1.52–2.14) and disease-specific mortality (HR: 1.58, 95% CI: 1.36–1.84). In conclusion, assessment of muscle mass on CT scans is a potential relevant clinical tool for risk prediction in gastric cancer patients. Considering the heterogeneity in definitions applied for low muscle mass on CT scans in the included studies, a universal cutoff value of CT-based low muscle mass is required for more reliable conclusions.

Association between preoperative potential sarcopenia and survival of cancer patients undergoing major surgical procedures

ABSTRACT Objective: to evaluate the impact of probable sarcopenia (PS) on the survival of oncological patients submitted to major surgeries. Method: prospective cohort bicentrical study enrolling adult oncological patients submitted to major surgeries at Cancer Hospital and Santa Casa de Misericordia in Cuiabá-MT. The main endpoint was the verification of postoperative death. Demographic and clinical data was collected. PS was defined as the presence of 1) sarcopenia risk assessed by SARC-F questionnaire and 2) low muscle strength measured by dynamometry. The cumulative mortality rate was calculated for patients with either PS or non PS using Kaplan Meier curve. The univariate and multivariate Cox regression model was used to evaluate the association of mortality with various investigated confounding variables. Results: a total of 220 patients with a mean (SD) age of 58.7±14.0 years old, 60.5% males participated of the study. Patients with PS had higher risk to postoperative death (RR=5.35 95%CI 1.95-14.66; p=0,001) and for infectious complications (RR=2.45 95%CI 1.12-5.33; p=0.036). The 60 days mean survival was shorter for patients with PS: 44 (IQR=32-37) vs 58 (IQR=56-59) days (log rank <0,001). The Cox multivariate regression showed that PS was an independent risk factor (HR=5.8 95%CI 1.49-22.58; p=0.011) for mortality. Conclusion: patients bearing PS submitted to major oncological surgery have less probability of short term survival and preoperative PS is an independent risk for postoperative mortality.

CT-assessed sarcopenia is a predictive factor for both long-term and short-term outcomes in gastrointestinal oncology patients: a systematic review and meta-analysis

Background

The impact of sarcopenia on the outcome of gastrointestinal (GI) oncological patients is still controversial. We aim to discuss the prevalence of sarcopenia and its relation to the oncological outcome.

Methods

Embase, Medline, PubMed, and the Cochrane library were systematically searched for related keywords. Studies using CT to assess sarcopenia and evaluate its relationship with the outcome of GI oncological patients were included. Long-term outcomes, including overall survival and disease-free survival, were compared by hazard ratios (HRs) with 95% confidence intervals (CIs). Short-term outcomes, including total complications and major complications (Clavien-Dindo ≥IIIa) after curable surgery, were compared by the risk ratio (RR) and 95% CI.

Results

A total of 70 studies including 21,875 patients were included in our study. The median incidence of sarcopenia was 34.7% (range from 2.1 to 83.3%). A total of 88.4% of studies used skeletal muscle index (SMI) in the third lumbar level on CT to define sarcopenia, and a total of 19 cut-offs were used to define sarcopenia. An increasing trend was found in the prevalence of sarcopenia when the cut-off of SMI increased (β = 0.22, 95% CI = 0.12–0.33, p < 0.001). The preoperative incidence of sarcopenia was associated both with an increased risk of overall mortality (HR = 1.602, 95% CI = 1.369–1.873, P < 0.001) and with disease-free mortality (HR = 1.461, 95% CI = 1.297–1.646, P < 0.001). Moreover, preoperative sarcopenia was a risk factor for both total complications (RR = 1.188, 95% CI = 1.083–1.303, P < 0.001) and major complications (RR = 1.228, 95% CI = 1.042–1.448, P = 0.014).

Conclusion

The prevalence of sarcopenia depends mostly on the diagnostic cut-off points of different criteria. Preoperative sarcopenia is a risk factor for both long-term and short-term outcomes.

EWGSOP2 versus EWGSOP1 for sarcopenia to predict prognosis in patients with gastric cancer after radical gastrectomy: Analysis from a large-scale prospective study

BACKGROUND

In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) reached a consensus on sarcopenia (EWGSOP1). In 2018, the EWGSOP met again (EWGSOP2) to update original definition of sarcopenia. This study aimed to investigate the association of sarcopenia and survival and compare the prognostic effects of sarcopenia as defined by EWGSOP1 and EWGSOP2 after gastrectomy.

METHODS

We conducted a prospective study including patients who underwent curative gastrectomy for gastric cancer from August 2014 to February 2018. The sarcopenia elements, including skeletal muscle index, muscle attenuation, handgrip strength, and gait speed were measured before surgery. Patients were followed up after gastrectomy to gain the actual clinical outcomes.

RESULTS

The prevalence of sarcopenia was 17.0% and 18.9% according to the EWGSOP1 and EWGSOP2 respectively. Sarcopenia was independent risk factor for postoperative complications. Compared with EWGSOP1-sarcopenia, EWGSOP2-sarcopenia and had a higher odds ratio (OR) (2.453 vs. 1.550) in multivariate model. Area under the ROC curve of model including EWGSOP2-sarcopenia was larger than that of the model including EWGSOP1-sarcopenia (AUC 0.653 vs. 0.634, P = 0.021). For both of EWGSOP1 and EWGSOP2, sarcopenia was an independent risk factor for overall survival (OS) and disease-free survival (DFS), but EWGSOP2-sarcopenia seemed to have a higher hazard ratio (OS, 1.667 vs. 1.449; DFS, 1.603 vs. 1.563). In addition, severe sarcopenia, as defined by either EWGSOP2 or EWGSOP1, had a strong predictive power (OR 4.909 vs. 3.827) for postoperative complications. Both versions of severe sarcopenia were significantly predictive of OS and DFS in Cox analysis.

CONCLUSION

Sarcopenia at uniform diagnosis standard was an independent risk factor for survival in patients undergoing radical gastrectomy for gastric cancer. Sarcopenia defined by EWGSOP2 criteria better predicts clinical outcomes than that defined by EWGSOP1 criteria in patients with gastric cancer after gastrectomy.

Muscle mass, assessed at diagnosis by L3-CT scan as a prognostic marker of clinical outcomes in patients with gastric cancer: A systematic review and meta-analysis

BACKGROUND & AIMS

Computed tomographic (CT) imaging at third lumbar vertebra (L3), routinely used by oncologists, represents a reliable tool to quantify muscle mass. A systematic review and meta-analysis was performed to assess the efficacy of CT scan to define muscle mass as a prognostic marker in gastric cancer (GC) patients undergoing gastrectomy and/or chemotherapy. The primary outcomes were overall survival (OS) and recurrence-free survival (RFS) and the secondary outcomes included postoperative length of hospital stay (P-LOS), total and severe complications in GC patients undergoing gastrectomy.

METHODS

Three electronic bibliographic databases - MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials - were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria, until April 2019. The adjusted and unadjusted hazard ratio (HR), odds ratio (OR) and mean difference (MD) with 95% confidence interval (CI) were used to analyse the dichotomous variables (OS, RFS, total and severe complications) and continuous variables (P-LOS). Random- and fixed effects models were used according to the heterogeneity.

RESULTS

A total of 5610 GC patients from 20 studies were identified. Low muscle mass at diagnosis was found in 32.7% of GC patients and was significantly associated with poorer OS (HR 2.02, 95% CI 1.71-2.38, p < 0.00001, I² = 47%) and worse RFS (HR 1.97, 95% CI 1.71-2.26, p < 0.00001, I² = 0%). Meta-analysis of adjusted HR from multivariable analyses confirmed the association between OS and low muscle mass (HR 1.89, 95% CI 1.68-2.12, p < 0.00001, I² = 36%). Furthermore, low muscle mass and poorer OS were significantly associated in metastatic GC patients exclusively undergoing chemotherapy (HR 1.61, 95% CI 1.23-2.11, p < 0.0006, I² = 18%). Moreover, preoperative low muscle mass was significantly associated with longer P-LOS (MD 1.19, 95% CI 0.68-1.71, p < 0.00001, I² = 0%), higher risk of postoperative complications (OR 1.76, 95% CI 1.17-2.66, p = 0.007, I² = 77%) and severe complications (OR 1.54, 95% CI 1.03-2.29, p = 0.04, I² = 49%) in GC patients undergoing gastrectomy.

CONCLUSIONS

Low muscle mass, assessed by L3 CT-scan, affects almost 1/3 of GC patients at diagnosis and acts as a negative prognostic marker on many clinical outcomes. Therefore, identifying GC patients with low muscle mass at diagnosis or at follow-up visit should be recommendable. Clinical nutritionists should be part of tumor boards meetings to screen low muscle mass in order to prompt personalized nutritional support.

Effects of weight loss and sarcopenia on response to chemotherapy, quality of life, and survival

It has frequently been shown that patients with cancer are one of the largest hospital patient groups with a prevalence for malnutrition. Weight loss is a frequent manifestation of malnutrition in patients with cancer. Several large-scale studies over the past 35 y have reported that involuntary weight loss affects 50% to 80% of these patients with the degree of weight loss dependent on tumor site and type and stage of disease. The aim of this review was to determine the consequences of malnutrition, weight loss, and muscle wasting in relation to chemotherapy tolerance, postoperative complications, quality of life, and survival in patients with cancer. The prognostic impact of weight loss on overall survival has long been recognised with recent data suggesting losses as little as 2.4% predicts survival independent of disease, site, stage or performance score. Recently the use of gold-standard methods of body composition assessment, including computed tomography, have led to an increased understanding of the importance of muscle abnormalities, such as low muscle mass (sarcopenia), and more recently low muscle attenuation, as important prognostic indicators of unfavourable outcomes in patients with cancer. Muscle abnormalities are highly prevalent (ranging from 10-90%, depending on cancer site and the diagnostic criteria used). Both low muscle mass and low muscle attenuation have been associated with poorer tolerance to chemotherapy; increased risk of postoperative complications; significant deterioration in a patients' performance status, and poorer psychological well-being, overall quality of life, and survival.

Diagnosis of Sarcopenia in Head and Neck Computed Tomography: Cervical Muscle Mass as a Strong Indicator of Sarcopenia

OBJECTIVES

Patients with head and neck cancer (HNC) have a high risk of sarcopenia, which is associated with poor prognosis. Skeletal-muscle area and index at the third lumbar (L3) vertebra level (L3MA and L3MI) are recommended for the detection of sarcopenia. However, L3 level is not included in many imaging protocols and there are no data for optimal levels and cutoffs for the diagnosis of sarcopenia in head and neck computed tomography (HNCT) scans. Our aim was to assess the relationship between cervical paravertebral muscle values and L3MI and to investigate optimal level to diagnose sarcopenia on HNCTs.

METHODS

Patients with HNC (n=159) who underwent positron emission tomography-CT for tumor staging were retrospectively analyzed. On CT images, paravertebral and sternocleidomastoid muscle areas at second (C2), third (C3), and fourth (C4) cervical vertebrae levels (C2MA, C3MA, C4MA, SCMA) and L3MA were measured. Cross-sectional areas were normalized for stature (muscle area/height square) and muscle index (C2MI, C3MI, C4MI, SCMI, L3MI) values were obtained. Spearman correlation and linear regression analyses were used for assessing correlations. To calculate the diagnostic performance of SCMI, C2MI, C3MI, and C4MI for the diagnosis of sarcopenia with respect to the cutoffs of L3MI, receiver operating characteristic (ROC) analysis was used.

RESULTS

Males had significantly higher muscle areas than females. Although C2MI, C3MI, C4MI, and SCMI values all showed very strong and significant correlation with L3MI (P<0.001). According to the ROC analysis, the best discriminative for sarcopenia was C3MI in males (area under curve [AUC], 0.967) and SCMI in females (AUC, 0.898).

CONCLUSION

C2MI, C3MI, C4MI, and SCMI values can be used as alternatives for the diagnosis of sarcopenia in routine HNCT examinations.