Body Composition and Dose-limiting Toxicity in Colorectal Cancer Chemotherapy Treatment; a Systematic Review of the Literature. Could Muscle Mass be the New Body Surface Area in Chemotherapy Dosing?

Chemotherapy dosing is traditionally based on body surface area calculations; however, these calculations ignore separate tissue compartments, such as the lean body mass (LBM), which is considered a big pool of drug distribution. In our era, colorectal cancer patients undergo a plethora of computed tomography scans as part of their diagnosis, staging and monitoring, which could easily be used for body composition analysis and LBM calculation, allowing for personalised chemotherapy dosing. This systematic review aims to evaluate the effect of muscle mass on dose-limiting toxicity (DLT), among different chemotherapy regimens used in colorectal cancer patients. This review was carried out according to the PRISMA guidelines. MEDLINE and EMBASE databases were searched from 1946 to August 2019. The primary search terms were 'sarcopenia', 'myopenia', 'chemotherapy toxicity', 'chemotherapy dosing', 'dose limiting toxicity', 'colorectal cancer', 'primary colorectal cancer' and 'metastatic colorectal cancer'. Outcomes of interest were - DLT and chemotoxicity related to body composition, and chemotherapy dosing on LBM. In total, 363 studies were identified, with 10 studies fulfilling the selection criteria. Seven studies were retrospective and three were prospective. Most studies used the same body composition analysis software but the chemotherapy regimens used varied. Due to marked study heterogeneity, quantitative data synthesis was not possible. Two studies described a toxicity cut-off value for 5-fluorouracil and one for oxaliplatin based on LBM. The rest of the studies showed an association between different body composition metrics and DLTs. Prospective studies are required with a larger colorectal cancer cohort, longitudinal monitoring of body composition changes during treatment, similar body composition analysis techniques, agreed cut-off values and standardised chemotherapy regimens. Incorporation of body composition analysis in the clinical setting will allow early identification of sarcopenic patients, personalised dosing based on their LBM and early optimisation of these patients undergoing chemotherapy.

Assessment of Computed Tomography (CT)-Defined Muscle and Adipose Tissue Features in Relation to Short-Term Outcomes After Elective Surgery for Colorectal Cancer: A Multicenter Approach

BACKGROUND

Sarcopenia, visceral obesity (VO), and reduced muscle radiodensity (myosteatosis) are suggested risk factors for postoperative morbidity in colorectal cancer (CRC), but usually are not concurrently assessed. Published thresholds used to define these features are not CRC-specific and are defined in relation to mortality, not postoperative outcomes. This study aimed to evaluate body composition in relation to length of hospital stay (LOS) and postoperative outcomes.

METHODS

Pre-surgical computed tomography (CT) images were assessed for total area and radiodensity of skeletal muscle and visceral adipose tissue in a pooled Canadian and UK cohort (n = 2100). Sex- and age-specific values for these features were calculated. For 1139 of 2100 patients, LOS data were available, and sex- and age-specific thresholds for sarcopenia, myosteatosis, and VO were defined on the basis of LOS. Association of CT-defined features with LOS and readmissions was explored using negative binomial and logistic regression models, respectively.

RESULTS

In the multivariable analysis, the predictors of LOS (P < 0.001) were age, surgical approach, major complications (incidence rate ratio [IRR] 2.42; 95% confidence interval [CI] 2.18-2.68), study cohort, and three body composition profiles characterized by myosteatosis combined with either sarcopenia (IRR, 1.27; 95% CI 1.12-1.43) or VO (IRR, 1.25; 95% CI 1.10-1.42), and myosteatosis combined with both sarcopenia and VO (IRR, 1.58; 95% CI 1.29-1.93). In the multivariable analysis, risk of readmission was associated with VO alone (odds ratio [OR] 2.66; 95% CI 1.18-6.00); P = 0.018), VO combined with myosteatosis (OR, 2.72; 95% CI 1.36-5.46; P = 0.005), or VO combined with myosteatosis and sarcopenia (OR, 2.98; 95% CI 1.06-5.46; P = 0.038). Importantly, the effect of body composition profiles on LOS and readmission was independent of major complications.

CONCLUSION

The findings showed that CT-defined multidimensional body habitus is independently associated with LOS and hospital readmission.

The body composition profile is associated with response to anti-TNF therapy in Crohn's disease and may offer an alternative dosing paradigm

BACKGROUND

Anti-tumour necrosis factor (TNF)s form a major part of therapy in Crohn's disease and have a primary nonresponse rate of 10%-30% and a secondary loss of response rate of 5% per year. Myopenia is prevalent in Crohn's disease and is measured using body composition analysis tools.

AIM

To test the hypothesis that body composition can predict outcomes of anti-TNF primary nonresponse and secondary loss of response.

METHODS

Between January 2007 and June 2012, 106 anti-TNF naïve patients underwent anti-TNF therapy for Crohn's disease with body composition parameters analysed using CT scans to estimate body fat-free mass. The outcome measures were primary nonresponse and secondary loss of response. COX-regression analysis was used with 3 year follow-up data.

RESULTS

A total of 106 patients were included for analysis with 26 (24.5%) primary nonresponders and 29 (27.4%) with secondary loss of response to anti-TNF therapy. Sex-specific cut-offs for muscle and fat were ascertained by stratification analysis. On univariate analysis, primary nonresponse was associated with low albumin (OR 0.94; 0.88-0.99, P = .04) and presence of myopenia (OR 4.69; 1.83-12.01, P = .001) when taking into account patient's medical therapy, severity of disease and body composition. On multivariate analysis, presence of myopenia was associated with primary nonresponse (OR 2.93; 1.28-6.71, P = .01). Immunomodulator therapy was associated with decreased secondary loss of response (OR 0.48; 0.23-0.98, P = .04). BMI was poorly correlated with lean body mass (r² = 0.15, P = .54).

CONCLUSIONS

In this cohort study, body composition profiles did not correlate well with BMI. Myopenia was associated with primary nonresponse with potential implications for dosing and serves as an explanation for pharmacokinetic failure.

Component analysis of enhanced recovery pathways for esophagectomy

The objective of this systematic review is to identify key components of enhanced recovery protocols (ERP) that lead to improved length of hospital stay (LOS) following esophagectomy. Relevant electronic databases were searched for studies comparing clinical outcome from esophagectomy followed by a conventional pathway versus ERP. Relevant outcome measures were compared and metaregression was performed to identify the key ERP components associated with reduced in LOS. Thirteen publications were included, ERP was associated with no changes in in-hospital mortality, total complications, anastomotic leak, or pulmonary complications compared with a conventional pathway, however LOS was reduced in the ERP group. Metaregression identified that immediate extubation was associated with reduced LOS (OR = -0.51, 95%CI -0.77 to -0.25; P < 0.01). Several postoperative factors were associated with a significant reduction in length of hospital stay, and in order of most important were (i) gastrograffin swallow ≤5 days (OR = -4.27, 95%CI -4.50 to -4.03); (ii) mobilization on postoperative day ≤1 (OR = -2.49, 95%CI -2.63 to -2.34); (iii) removal of urinary catheter ≤2 days (OR = -0.99, 95%CI -1.15 to -0.84); (iv) oral intake with at least sips of fluid ≤1 day (OR = -0.96, 95%CI -1.24 to -0.68); (v) enteral diet with feeding jejunostomy or gastrostomy ≤ 1 day (OR = -0.57, 95%CI -0.80 to -0.35) and (vi) epidural removal ≤ 4 days (OR = -0.17, 95%CI -0.27 to -0.07). Several core ERP components and principles appear to be associated with LOS reduction. These elements should form a part of the core ERP for the specialty, while surgical teams incorporate other elements through an iterative process.

Meta-analysis of adjuvant therapy following curative surgery for periampullary adenocarcinoma

BACKGROUND

Periampullary cancers are uncommon malignancies, often amenable to surgery. Several studies have suggested a role for adjuvant chemotherapy and chemoradiotherapy in improving survival of patients with periampullary cancers, with variable results. The aim of this meta-analysis was to determine the survival benefit of adjuvant therapy for periampullary cancers.

METHODS

A systematic review was undertaken of literature published between 1 January 2000 and 31 December 2015 to elicit and analyse the pooled overall survival associated with the use of either adjuvant chemotherapy or chemoradiotherapy versus observation in the treatment of surgically resected periampullary cancer. Included articles were also screened for information regarding stage, prognostic factors and toxicity-related events.

RESULTS

A total of 704 titles were screened, of which 93 full-text articles were retrieved. Fourteen full-text articles were included in the study, six of which were RCTs. A total of 1671 patients (904 in the control group and 767 who received adjuvant therapy) were included. The median 5-year overall survival rate was 37·5 per cent in the control group, compared with 40·0 per cent in the adjuvant group (hazard ratio 1·08, 95 per cent c.i. 0·91 to 1·28; P = 0·067). In 32·2 per cent of patients who had adjuvant therapy, one or more WHO grade 3 or 4 toxicity-related events were noted. Advanced T category was associated worse survival (regression coefficient -0·14, P = 0·040), whereas nodal status and grade of differentiation were not.

CONCLUSION

This systematic review found no associated survival benefit for adjuvant chemotherapy or chemoradiotherapy in the treatment of periampullary cancer.

Meta-analysis of determinants of survival following treatment of recurrent hepatocellular carcinoma

Background

Intrahepatic recurrence of hepatocellular carcinoma (HCC) following resection is common. However, no current consensus guidelines exist to inform management decisions in these patients. Systematic review and meta-analysis of survival following different treatment modalities may allow improved treatment selection. This review aimed to identify the optimum treatment strategies for HCC recurrence.

Methods

A systematic review, up to September 2016, was conducted in accordance with MOOSE guidelines. The primary outcome was the hazard ratio for overall survival of different treatment modalities. Meta-analysis of different treatment modalities was carried out using a random-effects model, with further assessment of additional prognostic factors for survival.

Results

Nineteen cohort studies (2764 patients) were included in final data analysis. The median 5-year survival rates after repeat hepatectomy (525 patients), ablation (658) and transarterial chemoembolization (TACE) (855) were 35·2, 48·3 and 15·5 per cent respectively. Pooled analysis of ten studies demonstrated no significant difference between overall survival after ablation versus repeat hepatectomy (hazard ratio 1·03, 95 per cent c.i. 0·68 to 1·55; P = 0·897). Pooled analysis of seven studies comparing TACE with repeat hepatectomy showed no statistically significant difference in survival (hazard ratio 1·61, 0·99 to 2·63; P = 0·056).

Conclusion

Based on these limited data, there does not appear to be a significant difference in survival between patients undergoing repeat hepatectomy or ablation for recurrent HCC. The results also identify important negative prognostic factors (short disease-free interval, multiple hepatic metastases and large hepatic metastases), which may influence choice of treatment.

Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality.

METHODS

MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data.

RESULTS

Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy.

CONCLUSION

Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).

Influence of body composition profile on outcomes following colorectal cancer surgery

BACKGROUND

Muscle depletion is characterized by reduced muscle mass (myopenia), and increased infiltration by intermuscular and intramuscular fat (myosteatosis). This study examined the role of particular body composition profiles as prognostic markers for patients with colorectal cancer undergoing curative resection.

METHODS

Patients with colorectal cancer undergoing elective surgical resection between 2006 and 2011 were included. Lumbar skeletal muscle index (LSMI), visceral adipose tissue (VAT) surface area and mean muscle attenuation (MA) were calculated by analysis of CT images. Reduced LSMI (myopenia), increased VAT (visceral obesity) and low MA (myosteatosis) were identified using predefined sex-specific skeletal muscle index values. Univariable and multivariable Cox regression models were used to determine the role of different body composition profiles on outcomes.

RESULTS

Some 805 patients were identified, with a median follow-up of 47 (i.q.r. 24·9-65·6) months. Multivariable analysis identified myopenia as an independent prognostic factor for disease-free survival (hazard ratio (HR) 1·53, 95 per cent c.i. 1·06 to 2·39; P = 0·041) and overall survival (HR 1·70, 1·25 to 2·31; P < 0·001). The presence of myosteatosis was associated with prolonged primary hospital stay (P = 0·034), and myopenic obesity was related to higher 30-day morbidity (P = 0·019) and mortality (P < 0·001) rates.

CONCLUSION

Myopenia may have an independent prognostic effect on cancer survival for patients with colorectal cancer. Muscle depletion may represent a modifiable risk factor in patients with colorectal cancer and needs to be targeted as a relevant endpoint of health recommendations.

A systematic review of enhanced recovery care after colorectal surgery in elderly patients

AIM

Enhanced recovery after surgery (ERAS) can decrease complications and reduces hospital stay. Less certain is whether elderly patients can fully adhere to and benefit from ERAS. We aimed to determine the safety, feasibility and efficacy of enhanced recovery after colorectal surgery in patients aged ≥ 65 years old.

METHOD

A systematic search of Medline, EMBASE and Cochrane was performed to identify (i) studies comparing elderly patients managed with ERAS vs traditional care, (ii) cohort studies of ERAS with results of elderly vs younger patients and (iii) any case series of ERAS in elderly patients. End-points of interest were length of hospital stay, complications, mortality, readmission and re-operation, and ERAS protocol adherence.

RESULTS

Sixteen studies were included. Two randomized controlled trials demonstrated shorter hospital stay in elderly patients with ERAS compared with elderly patients with non-ERAS (9 vs 13.2 days, P < 0.001; 5.5 vs 7 days, P < 0.0001). Fewer complications occurred with ERAS in both randomized controlled trials (27.4% vs 58.6%, P < 0.0001; 5% vs 21.1%, P = 0.045). The majority of observational studies did not show differences in outcome between elderly and younger patients in terms of hospital stay, morbidity or mortality. Inconsistent findings between cohort studies may reflect the disparities in ERAS protocol definitions or differences in study populations.

CONCLUSION

ERAS can be safely applied to elderly patients to reduce complications and shorten length of hospital stay. Further studies are required to assess whether elderly patients are able to adhere to, and benefit from, ERAS protocols to the same extent as younger patients.

Impact of chronic kidney disease on postoperative outcome following colorectal cancer surgery

AIM

Chronic kidney disease (CKD) is increasing in prevalence and is associated with cardiovascular events and mortality in asymptomatic and vascular surgery populations. This study aimed to determine the role of CKD in stratifying peri- and postoperative risk for colorectal cancer (CRC) patients with nonmetastatic disease undergoing elective curative resection.

METHOD

Patients diagnosed with nonmetastatic colorectal adenocarcinoma and undergoing surgical resection between 2006 and 2011 were identified from a prospectively collated database. Further information on survival and cause of death was gathered from a regional cancer registry. Estimated glomerular filtration rates were calculated using the Modification of Diet in Renal Disease (MDRD) equation. Kaplan-Meier survival curves were constructed for disease-free and overall survival. Multivariate Cox regression models were used to determine the role of CKD after stratification by several clinicopathological factors.

RESULTS

Seven-hundred and eight colorectal resections were studied [median follow up: 45 (interquartile range, 21-65) months). Overall postoperative complications were similar, but patients with CKD were more likely to develop cardiovascular morbidity (P < 0.001) and 30-day mortality [4.8% (six of 124) in the CKD group vs 2.1% (12/580) in the non-CKD group]. Kaplan-Meier analysis revealed poorer overall survival for localized (Stage I-II; P = 0.019) and Stage III (P = 0.001) CRC in the CKD population. Multivariate Cox regression analysis identified CKD as an independent prognostic factor for noncancer death [hazard ratio (HR) = 1.82 (95% CI: 1.07-3.10); P = 0.027] but not for overall survival [HR = 1.21 (95% CI: 0.90-1.47); P = 0.116].

CONCLUSION

Patients with CKD may be more likely to develop cardiovascular complications following CRC resection and have an increased risk of a noncancer death. Future research should explore the interaction of CKD in competing mortality risks following CRC surgery.

High-intensity focused ultrasound: advances in technology and experimental trials support enhanced utility of focused ultrasound surgery in oncology

High-intensity focused ultrasound (HIFU) is a rapidly maturing technology with diverse clinical applications. In the field of oncology, the use of HIFU to non-invasively cause tissue necrosis in a defined target, a technique known as focused ultrasound surgery (FUS), has considerable potential for tumour ablation. In this article, we outline the development and underlying principles of HIFU, overview the limitations and commercially available equipment for FUS, then summarise some of the recent technological advances and experimental clinical trials that we predict will have a positive impact on extending the role of FUS in cancer therapy.

Diffusion-weighted imaging in the assessment of tumour grade in endometrial cancer

OBJECTIVE

Endometrial cancer is the most common gynaecological malignancy in developed countries. Histological grade and subtype are important prognostic factors obtained by pipelle biopsy. However, pipelle biopsy "samples" tissue and a high-grade component that requires more aggressive treatment may be missed. The purpose of the study was to assess the use of diffusion-weighted MRI (DW-MRI) in the assessment of tumour grade in endometrial lesions.

METHOD

42 endometrial lesions including 23 endometrial cancers and 19 benign lesions were evaluated with DW-MRI (1.5T with multiple b-values between 0 and 750 s mm(-2)). Visual evaluation and the calculation of mean and minimum apparent diffusion coefficient (ADC) value were performed and correlated with histology.

RESULTS

The mean and minimum ADC values for each histological grade were 1.02 ± 0.29×10(-3) mm(2) s(-1) and 0.74 ± 0.24×10(-3) mm(2) s(-1) (grade 1), 0.88 ± 0.39×10(-3) mm(2) s(-1) and 0.64 ± 0.36×10(-3) mm(2) s(-1) (grade 2), and 0.94 ± 0.32×10(-3) mm(2) s(-1) and 0.72 ± 0.36×10(-3) mm(2) s(-1) (grade 3), respectively. There was no statistically significant difference between tumour grades. However, the mean ADC value for endometrial carcinoma was 0.97 ± 0.31, which was significantly lower (p<0.0001) than that of benign endometrial pathology (1.50 ± 0.14). Applying a cut-off mean ADC value of less than 1.28 × 10(-3) mm(2) s(-1)we obtained a sensitivity, specificity, positive predictive value and negative predictive value for malignancy of 87%, 100%, 100% and 85.7%, respectively.

CONCLUSION

Tumour mean and minimum ADC values are not useful in differentiating histological tumour grade in endometrial carcinoma. However, mean ADC measurement can provide useful information in differentiating benign from malignant endometrial lesions. This information could be clinically relevant in those patients where pre-operative endometrial sampling is not possible.

Real-life experience study of the safety and efficacy of travoprost 0.004% / timoptol 0.50% fixed combination ophthalmic solution in intraocular pressure control

PURPOSE

To evaluate the safety and efficacy of timolol 0.5%/travoprost 0.004% combination (duotrav) as observed in primary open-angle glaucoma (POAG), ocular hypertension (OHT) and normal tension glaucoma (NTG) in real-life conditions.

MATERIALS AND METHODS

Patients with uncontrolled intraocular pressure (IOP) on other medication and no contraindication to β-blockers were switched to duotrav in 56 eyes of 28 patients. The drop in IOP was the primary outcome measured.

RESULTS

Switch to duotrav provided an additional IOP reduction after 3-month follow-up that was statistically significant for those on latanoprost (P=0.02857), bimatoprost (P =0.04978) and travoprost (P =0.0078). Patients on latanotrost had an additional 25.9% drop 3 months after switching to duotrav while those on bimatoprost and travatan had 18.04% and 17.59% drop, respectively, after the switch. It was effective in lowering the IOP to clinically significant levels of ≤ 18.5 mmHg in POAG, NTG and OHT (12.5-17.9% drop), but not in chronic angle closure glaucoma.

CONCLUSION

Duotrav was well-tolerated and produced significant additional IOP reduction when switched from other anti-glaucoma drugs in patients with uncontrolled glaucoma. It also achieved IOP of ≤ 18.5 mmHg in glaucoma patients.

When a groin lump is more than a simple groin lump

Groin lump secondary to avulsion fracture of the adductor muscles of the middle thigh in the absence of any hernia is rare. The authors discuss a case of a young footballer who presented with a painful groin swelling. Surgical exploration revealed that the cause of the lump was an avulsion fracture of the adductor muscles.