The clinical significance of sarcopenia in patients with hepatocellular carcinoma treated with lenvatinib and PD-1 inhibitors

Background and aim

Sarcopenia has gained considerable attention in the context of hepatocellular carcinoma, as it has been correlated with a poorer prognosis among patients undergoing sorafenib or lenvatinib treatment for hepatocellular carcinoma (HCC). The clinical significance of sarcopenia in first-line advanced HCC patients treated with lenvatinib and programmed death-1 (PD-1) inhibitors needs to be clarified.

Methods

Sarcopenia was diagnosed using CT (Computed tomography) or MRI (Magnetic Resonance Imaging), with the psoas muscle index (PMI) as the surrogate marker. Patients were grouped based on sarcopenia presences, and a comparative analysis examined characteristics, adverse events, and prognosis. The Cox regression analysis was applied to identify independent prognostic factors for survival, while nomograms were constructed to predict 1-year survival.

Results

Among 180 patients, 46 had sarcopenia. Patients with baseline sarcopenia demonstrated significantly inferior median progression-free survival (mPFS) (3.0 vs. 8.3 months) and median overall survival (mOS) (7.3 vs. 21.6 months). The same results for mPFS (3.3 vs. 9.2 months) and mOS (9.4 vs. 24.2 months) were observed in patients who developed sarcopenia after treatment. Furthermore, significantly higher grade 3 or higher adverse events (AEs) (73.91% vs 41.79%, p<0.001) were recorded in the sarcopenia group compared to the non-sarcopenia group. In the multivariate analysis, distant metastasis, elevated PLR and CRP levels, and low PMI remained independent predictive factors for poor OS. Additionally, skeletal muscle loss remained a significant independent risk factor for PFS. We developed a nomogram incorporating these four indicators, which predicted 12-month survival with a C-index of 0.853 (95% CI, 0.791 - 0.915), aligning well with actual observations.

Conclusion

The prognosis of patients with HCC and sarcopenia is significantly worse when treated with lenvatinib and PD-1 inhibitors. The combination regimen of lenvatinib plus PD-1 inhibitors should be cautiously recommended due to the inferior prognosis and higher AEs.

The predictive value of sarcopenia and myosteatosis in trans-arterial (chemo)-embolization treated HCC patients

BACKGROUND

We conducted a meta-analysis to provide evidence-based results for the predictive values of sarcopenia, skeletal muscle index, psoas muscle index and the myosteatosis regarding the impact of survival outcomes and tumor response in patients treated by trans-arterial (chemo)-embolization (TAE/TACE), thereby optimizing therapeutic strategies and maximizing clinical benefits for hepatocellular carcinoma patients.

METHODS

Qualified studies were retrieved from PubMed, the Cochrane Library, EMBASE, and Google Scholar before June 19, 2023. We investigated the relationships between sarcopenia, SMI, PMI, myosteatosis, and the overall survival of TAE/TACE-treated hepatocellular carcinoma patients with pooling data.

RESULTS

A total of 167 studies were collected and 12 studies were finally included for analysis. The meta-analysis assisted that the sarcopenia (HR: 1.46, 95% CI: 1.30-1.64, p < 0.001), skeletal muscle index (HR: 1.48, 95% CI: 1.29-1.69, p < 0.001), and psoas muscle index (HR: 1.45, 95% CI: 1.19-1.77, p < 0.001) were significantly related to a shorter OS of hepatocellular carcinoma patients who treated by TAE/TACE. Sarcopenia significantly contributed to a lower objective response rate of TAE/TACE treated hepatocellular carcinoma patients (OR: 0.80, 95% CI: 0.65-0.98, p = 0.032). But there was no significant association between the myosteatosis and the overall survival (HR: 1.29, 95% CI: 0.74-2.25, p = 0.366). Sensitivity analysis supported the stability and dependability of above analyses conclusions.

CONCLUSION

Sarcopenia, skeletal muscle index and psoas muscle index, are significant prognostic predictors for TAE/TACE treated hepatocellular carcinoma patients. While myosteasis does not demonstrate a prognostic impact on the overall survival of TAE/TACE treated hepatocellular carcinoma patients.

Cachexia and Sarcopenia in Oligometastatic Non-Small Cell Lung Cancer: Making a Potential Curable Disease Incurable?

Among patients with advanced NSCLC, there is a group of patients with synchronous oligometastatic disease (sOMD), defined as a limited number of metastases detected at the time of diagnosis. As cachexia and sarcopenia are linked to poor survival, incorporating this information could assist clinicians in determining whether a radical treatment should be administered. In a retrospective multicenter study, including all patients with adequately staged (FDG-PET, brain imaging) sOMD according to the EORTC definition, we aimed to assess the relationship between cachexia and/or sarcopenia and survival. Of the 439 patients that were identified between 2015 and 2021, 234 met the criteria for inclusion and were included. The median age of the cohort was 67, 52.6% were male, and the median number of metastasis was 1. Forty-six (19.7%) patients had cachexia, thirty-four (14.5%) had sarcopenia and twenty-one (9.0%) had both. With a median follow-up of 49.7 months, median PFS and OS were 8.6 and 17.3 months, respectively. Moreover, a trend toward longer PFS was found in patients without cachexia and sarcopenia compared to those with cachexia and/or sarcopenia. In multivariate analysis, cachexia and sarcopenia were not associated with an inferior survival, irrespective of receiving radical treatment. High CRP was associated with inferior survival and could be a prognostic factor, helping the decision of clinicians in selecting patients who may benefit from the addition of LRT. However, despite the homogeneous definition of oligometastatic disease and the adequate staging, our subgroups were small. Therefore, further studies are needed to better understand our hypothesis and generating findings.

Associations among Preoperative Malnutrition, Muscle Loss, and Postoperative Walking Ability in Intertrochanteric Fractures: A Retrospective Study

Sarcopenia and malnutrition are increasing in older adults and are reported risk factors for functional impairment after hip fracture surgery. This study aimed to investigate the associations between skeletal muscle mass loss, malnutrition, and postoperative walking ability in patients with hip fracture. We retrospectively reviewed patients who underwent intertrochanteric fracture surgery at our institute. The psoas muscle index, controlling nutritional status score, and functional ambulation category (FAC) were used to evaluate skeletal muscle mass, nutritional status, and walking ability, respectively. Six months after surgery, walking ability was assessed as either "gait disturbance" or "independent gait". Multivariate binomial logistic regression analysis, with skeletal muscle mass, nutritional status, and other factors, was used to predict the risk of being assigned to the gait disturbance group. This study included 95 patients (mean age, 85.2 years; 70 women). Sixty-six patients had low skeletal muscle mass, 35 suffered from malnutrition, and 28 had both. Malnutrition and low skeletal muscle mass were significantly associated with postoperative gait disturbance (FAC < 3). Preoperative low skeletal muscle mass and malnutrition were risk factors for postoperative poor walking ability. Further preventive interventions focusing on skeletal muscle mass and nutritional status are required.

Psoas Muscle Index as a Predictor of Perioperative Outcomes in Geriatric Patients Undergoing Spine Surgery

STUDY DESIGN

Single-center retrospective study.

OBJECTIVE

The objective of this study was to evaluate the association of psoas muscle mass defined sarcopenia with perioperative outcomes in geriatric patients undergoing elective spine surgery.

METHODS

We included geriatric patients undergoing thoracolumbar spinal surgery. Total psoas surface area (TPA) was measured on preoperative axial computerized tomography or magnetic resonance imaging at the L3 vertebra and normalized to the L3 vertebral body area. Patients were divided into quartiles by normalized TPA, and the fourth quartile (Q4) was compared to quartiles 1-3 (Q1-3). Outcomes included perioperative transfusions, length of stay (LOS), delirium, pseudoarthrosis, readmission, discharge disposition, revision surgery, and mortality.

RESULTS

Of the patients who met inclusion criteria (n = 196), the average age was 73.4 y, with 48 patients in Q4 and 148 patients in Q1-3. Q4 normalized TPA cut-off was <1.05. Differences in Q4 preoperative characteristics included significantly lower body mass index, baseline creatinine, and a greater proportion of females (Table 1). Q4 patients received significantly more postoperative red blood cell and platelet transfusions and had longer ICU LOS (P < .05; Table 2). There was no difference in intraoperative transfusion volumes, delirium, initiation of walking, discharge disposition, readmission, pseudoarthrosis, or revision surgery (Tables 2 and 3). Mortality during follow-up was higher in Q4 but was not statistically significant (P = .075).

CONCLUSION

Preoperative TPA in geriatric patients undergoing elective spine surgery is associated with increased need for intensive care and postoperative blood transfusion. Preoperative normalized TPA is a convenient measurement and could be included in geriatric preoperative risk assessment algorithms.

Psoas Muscle Index: A Simple and Reliable Method of Sarcopenia Assessment on Computed Tomography Scan in Chronic Liver Disease and its Impact on Mortality

Objectives

Psoas muscle parameters have been proposed as a simple and quick method for sarcopenia assessment. The aim of this study was to assess sarcopenia in cirrhotics by psoas muscle on computed tomography and its impact on mortality.

Methods

One hundred and fifty patients (75 cirrhotics, 75 subjects) were assessed for psoas muscle on CT scan. Psoas muscle index (PMI) was calculated as 'total psoas muscle area/(height of subject)2'. Cut off values for sarcopenia diagnosis were derived from local subjects (n = 75) who did not have cirrhosis/other causes of sarcopenia.

Results

Sarcopenia assessed by PMI was seen in 36% (n = 27) of the cirrhotics. Sarcopenia was significantly higher in patients having Child-Pugh C. Ascites, hepatic encephalopathy (HE) and gastro-intestinal bleed were seen in 48%, 18.7% and 24%, respectively. Sarcopenia was significantly associated with ascites and HE (P < 0.05). Out of the 75 cases, 53 cases completed the follow-up period of 1 year. Among the 20 cases who had sarcopenia, 35% (n = 7) succumbed to liver-related illness during 1 year follow-up, and out of the 33 cases without sarcopenia, only 6% (n = 2) died. The association of sarcopenia and 1 year mortality was statistically significant (P = 0.01).

Conclusions

The PMI, a simple method for sarcopenia assessment detected sarcopenia in 36% of cirrhotics. Patients with sarcopenia had a significantly higher 1 year mortality rate and appropriate prognostication of such patients is needed.

Combination of Muscle Quantity and Quality Is Useful to Assess the Necessity of Surveillance after a 5-Year Cancer-Free Period in Patients Who Undergo Radical Cystectomy: A Multi-Institutional Retrospective Study

BACKGROUND

Although continuous surveillance after a 5-year cancer-free period in patients with bladder cancer (BC) who undergo radical cystectomy (RC) is recommended, optimal candidates for continuous surveillance remain unclear. Sarcopenia is associated with unfavorable prognosis in various malignancies. We aimed to investigate the impact of low muscle quantity and quality (defined as severe sarcopenia) on prognosis after a 5-year cancer-free period in patients who underwent RC.

METHODS

We conducted a multi-institutional retrospective study assessing 166 patients who underwent RC and had five years or more of follow-up periods after a 5-year cancer-free period. Muscle quantity and quality were evaluated using the psoas muscle index (PMI) and intramuscular adipose tissue content (IMAC) using computed tomography images five years after RC. Patients with lower PMI and higher IMAC values than the cut-off values were diagnosed with severe sarcopenia. Univariable analyses were performed to assess the impact of severe sarcopenia on recurrence, adjusting for the competing risk of death using the Fine-Gray competing risk regression model. Moreover, the impact of severe sarcopenia on non-cancer-specific survival was evaluated using univariable and multivariable analyses.

RESULTS

The median age and follow-up period after the 5-year cancer-free period were 73 years and 94 months, respectively. Of 166 patients, 32 were diagnosed with severe sarcopenia. The 10-year RFS rate was 94.4%. In the Fine-Gray competing risk regression model, severe sarcopenia did not show a significant higher probability of recurrence, with an adjusted subdistribution hazard ratio of 0.525 (p = 0.540), whereas severe sarcopenia was significantly associated with non-cancer-specific survival (hazard ratio 1.909, p = 0.047). These results indicate that patients with severe sarcopenia might not need continuous surveillance after a 5-year cancer-free period, considering the high non-cancer-specific mortality.

Sarcopenia measurements and clinical outcomes in Crohn's disease surgical patients

BACKGROUND

Patients with Crohn's disease (CD) have a high likelihood of being sarcopenic. Several studies have shown a positive correlation between sarcopenia measured as skeletal muscle index (SMI) and poor surgical outcomes in patients with CD. Our primary aim was to correlate SMI with the psoas muscle index (PMI), an easier measurement of sarcopenia. Secondary aim was to correlate SMI and PMI with clinical outcomes in a cohort of CD patients requiring surgery.

METHODS

A retrospective cohort study of CD patients who underwent surgery at a public health service from January 2010 to December 2019. Using computed tomography and magnetic resonance enterography studies, skeletal muscle area was measured at the third lumbar vertebra level. SMI and PMI were calculated and correlated. Correlation between SMI and PMI with surgical outcomes was performed.

RESULTS

Seventy-six patients were included. Median length of stay (LOS) was 6 days (IQR, 5 to 9). Eleven patients (14.5%) required ICU admission, nine patients (11.8%) required TPN and thirteen patients (17.1%) had complications. The prevalence of sarcopenia was 63.2% based on the SMI threshold of 52.4 and 38.5 cm² /m² for men and women, respectively. A positive correlation between SMI and PMI was found (r = 0.72, P < 0.0001). Sarcopenia status based on reported thresholds for SMI and for PMI showed no significant correlation with outcomes (LOS, ICU admission and complications).

CONCLUSIONS

SMI and PMI show good correlation but there is insufficient evidence to suggest that sarcopenia status using either measurement has a significant impact on predicting clinical outcomes.

Psoas muscle index predicts time to rehospitalization in liver cirrhosis: An observational study

Sarcopenia is frequent in liver cirrhosis (LC) where it is associated with morbidity and mortality. However, prognostic scores such as model for end-stage liver disease (MELD), MELD-sodium (MELD-Na), or Child-Turcotte-Pugh (CTP) do not contain sarcopenia as a variable. For this study, we utilized psoas muscle index (PMI) to objectively determine sarcopenia in hospitalized LC patients, and evaluated it as a predictor of time between discharge and readmission in LC. Abdominal computed tomography and magnetic resonance imaging scans of 65 consecutive LC patients were retrospectively examined to determine PMI. MELD, MELD-Na, and CTP were calculated from clinical data. PMI was then combined with CTP to form an experimental score: CTP sarcopenia (CTPS). For PMI alone and for each score, correlation with time between discharge and readmission for liver-related complications was calculated. PMI was also tested for correlation with sex, body mass index (BMI), MELD, MELD-Na, and CTP. CTPS was most closely correlated with time to readmission (R = 0.730; P < .001), followed by CTP (R = 0.696; P < .001), MELD-Na (R = 0.405; P = .009), and PMI alone (R = 0.388; P = .01). Correlation with MELD (R = 0.354; P = .05) was lowest. Additionally, there were significant differences in PMI between male and female individuals (5.16 vs 4.54 cm2/m2; P = .04) and in BMI between sarcopenic and nonsarcopenic individuals (29.63 vs 25.88 kg/m2; P = .009). Sarcopenia is an independent short-term prognostic factor in LC. By combining data on sarcopenia with CTP, we created an experimental score that predicts time to readmission better than MELD, MELD-Na, or CTP.

Association of the Psoas Muscle Index and Sagittal Spinal Alignment With Patient-Reported Outcomes After Total Hip Arthroplasty: A Minimum 5-Year Follow-Up

BACKGROUND

The aim of this study is to assess the association between a spinopelvic malalignment and patient-reported perception of the hip as being "artificial" after total hip arthroplasty (THA). This is a critical issue as an age-related spinopelvic mismatch has been postulated to be associated with the risk of poor outcomes after THA.

METHODS

This is a retrospective case-control study of 274 THAs (244 of whom were women), with a mean follow-up of 6.2 (range 5.0-8.2) years. Hip perception was assessed by asking subjects whether their joint felt "natural" or "artificial." The association between an artificial perception and the following factors was evaluated: age, gender, psoas muscle index (PMI, cross-sectional area of bilateral psoas at L3 divided by height squared), and spinopelvic measures using logistic regression analysis.

RESULTS

An artificial hip perception (130 hips, 47.4%) was associated with a lower PMI (P = .016), Hip Disability and Osteoarthritis Outcome Score Joint Replacement score (P = .035), EuroQol 5-Dimension score (P = .041), and a higher incidence of a pelvic incidence-minus-lumbar lordosis (PI-LL) mismatch >10° (P < .001). A flatback deformity (odds ratio 2.24, 95% confidence interval 1.22-6.31, P = .001) and PMI (odds ratio 0.61, 95% confidence interval 0.34-0.82, P = .012) were predictive of an artificial perception. With the threshold of PI-LL set to 10°, PMI (P = .034), Hip Disability and Osteoarthritis Outcome Score Joint Replacement score (P < .001), joint perception (P = .020), EuroQol 5-Dimension score (P = .028), pain (P = .031), and satisfaction (P < .001) differed between the 2 groups.

CONCLUSION

A flatback deformity is associated with the risk of an artificial perception post-THA, especially in patients with sarcopenia. PMI and PI-LL measurements may help predict THA outcomes.

Sarcopenia and Systemic Inflammation Response Index Predict Response to Systemic Therapy for Hepatocellular Carcinoma and Are Associated With Immune Cells

Background

Systemic therapies, including immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs), have challenged the use of conventional therapies for hepatocellular carcinoma (HCC). It is crucial to determine which patients could benefit most from combination therapy. This study aims to examine the associations of sarcopenia and systemic inflammation response index (SIRI) with the treatment responses and efficacies in patients with HCC treated with ICIs and tyrosine kinase inhibitors TKIs, as well as investigate the correlation between sarcopenia and inflammatory or immune states.

Methods

We reviewed 160 patients with HCC treated with TKIs and ICIs. The patients' psoas muscle size was measured on axial computed tomography scans and normalized for the patients' height squared. This value was referred to as the psoas muscle index (PMI). Sarcopenia was determined from PMI and their relationships with patients' clinicopathological characteristics, inflammation indexes, peripheral blood T-cell subsets and survival were evaluated.

Results

Sarcopenia and systemic inflammation response index (SIRI) were independent predictors for overall survival and progression-free survival. Patients with high PMI and low SIRI demonstrated significantly better median overall survival and progression-free survival (36.0 months and 9.6 months, respectively) than those with either low PMI or high SIRI (20.8 months and 6.0 months, respectively) and those with both high SIRI and low PMI (18.6 months and 3.0 months, respectively). Portal vein tumor thrombus (P=0.003), eastern cooperative oncology group performance status score of 1 (P=0.048), high alkaline phosphatase (P=0.037), high neutrophil-to-lymphocyte ratio (NLR) (P=0.012), low lymphocyte-to-monocyte ratio (LMR) (P=0.031), high platelet-to-lymphocyte ratio (PLR) (P=0.022) and high SIRI (P=0.012) were closely associated with an increased incidence of sarcopenia. PMI was negatively correlated with SIRI (r = -0.175, P=0.003), NLR (r = -0.169, P=0.036), and PLR (r = -0.328, P=0.000) and was significantly positively correlated with LMR (r = 0.232, P=0.004). The CD3+ and CD4+ T-cell counts of the high PMI group were significantly higher than those of the low PMI group.

Conclusion

Sarcopenia and high SIRI were associated with reduced survival in patients with HCC treated with ICIs and TKIs. Sarcopenia could affect inflammatory states and the immune microenvironment.

Integration of low muscle mass into the IPS system and its prognostic significance in patients with Hodgkin's lymphoma

Aim: The aim of this study is to determine whether a novel prognostic score can be obtained by including low muscle mass in the international prognostic score (IPS) system. Materials & Methods: Psoas muscle areas were determined in the PET/CT scans of the patients taken for staging at the time of diagnosis and after two cycles of ABVD. After evaluating the effect of low muscle mass on overall survival, receiver operating characteristic (ROC) analyzes were performed by including it in IPS systems. Results: Overall survival was significantly lower in patients with low muscle mass. Adding low muscle mass to IPS scores increased AUC, sensitivity and specificity. Conclusion: The integration of low muscle mass into the IPS scoring systems increased the success of these systems in predicting a prognosis.

Prognostic Role of Preoperative Sarcopenia Evaluation of Cervical Muscles with Long-Term Outcomes of Patients with Oral Squamous Cell Carcinoma

Accumulating evidence has shown that sarcopenia in patients with oral squamous cell carcinoma (OSCC) is at a risk of poor prognosis. There is no universal consensus on how to assess sarcopenia in patients with OSCC in daily practice. It is important to validate the usefulness of sarcopenia assessment from cervical muscles, which are frequently used in routine clinical practice in patients with OSCC. In this study, we investigated whether preoperative lumbar (L3) skeletal muscle mass and adiposity in OSCC patients were associated with cervical (C3) skeletal muscle mass and adiposity from CT measurements. We also investigated whether skeletal muscle mass and adiposity in the C3 muscles were associated with survival rates in patients with OSCC. We demonstrated that both the quality and quantity of muscle between the C3 and L3 levels were positively correlated with each other. We also demonstrated that the survival rates in patients with low sternocleidomastoid muscle mass index, high processus spinosus muscle-intramuscular adipose tissue content, and the combination of both were significantly lower than those in the controls. These results suggest that the assessment of sarcopenia from multiple neck muscles by preoperative CT measurements may be useful in predicting the prognosis of patients with OSCC.

Correlation between Psoas Muscle Index and Degeneration of Spinal Back Muscle in Patients with Back Pain

Sarcopenia is characterized by a decline in systemic muscle mass and physical performance. Disc degeneration also causes back muscle atrophy. Therefore, we aimed to evaluate the influence of systemic muscle mass decline on back muscle atrophy and fatty infiltration compared to disc degeneration. We included 127 patients (65.54 ± 14.93 years) with back pain who underwent lumbar spine magnetic resonance imaging (MRI). Axial T2-weighted MRI data of the L4-5 and L5-S1 levels were used to measure the cross-sectional area (CSA) of the psoas and spinal muscles. The psoas index (cm²/m²) was used as a surrogate for systemic muscle mass. The Pfirrmann grading system was used to evaluate intervertebral disc degeneration. The functional area of the back muscles was calculated by subtracting the fat infiltration area from the CSA; the functional CSA ratio was calculated by dividing the functional CSA by the CSA. Image-processing software (ImageJ; National Institutes of Health, Bethesda, MD, USA) was used for analysis. Psoas index and aging significantly affected CSA and the ratio of functional CSA of the back muscles and multifidi. Disc degeneration did not significantly affect the back muscles beyond aging in patients with back pain. Males showed substantially higher CSA of the back muscles and multifidi than females; however, sex did not affect the functional CSA ratio of these muscles. Systemic muscle mass decline showed a more powerful influence on back muscle atrophy and fatty infiltration than disc degeneration. Therefore, proper evaluation of sarcopenia is needed for patients with chronic back pain and back muscle degeneration.

Low psoas muscle index as an unfavorable factor in children with end-stage liver disease undergoing liver transplantation

Sarcopenia is common in cirrhotic adults and associated with waitlist mortality and worse outcome after liver transplantation. Psoas muscle mass has been used to define sarcopenia. Therefore, we aimed to determine the association between psoas muscle mass and waitlist mortality as well as post-transplant outcome in children with end-stage liver disease. Medical records and abdominal imaging of pediatric liver transplant candidates during 2010-2019 were reviewed. A subset of images was measured by two radiologists to determine inter-rater reliability. Psoas muscle surface area was determined at intervertebral lumbar disk 3-4 (L3-4) and 4-5 (L4-5) levels. PMI was calculated by psoas muscle surface area divided by height squared. We included 105 children, most with biliary atresia (84%). Patients with waitlist mortality had lower PMI compared to the ones who survived to transplantation (PMI at L3-4 levels 352.8 ± 162.5 vs. 416.8 ± 136.2 mm² /m² and at L4-5 levels 497.3 ± 167.8 vs. 571.4 ± 163.4 mm² /m² , both p = .04), but not in the multivariate analyses. For transplanted patients (n = 75), a higher rate of re-operation (39% vs. 15%, p = .03) and longer hospital stay (53 vs. 45 days, p = .02) were found in patients with lower PMI. Lower PMI is associated with higher re-operation rate and longer hospital stay following transplantation, but not waitlist mortality. PMI may be taken into consideration with other biomarkers to predict post-transplant complications.

Psoas Muscle Index Defined by Computer Tomography Predicts the Presence of Postoperative Complications in Colorectal Cancer Surgery

Background and Objectives: Sarcopenia is a recognized prognostic factor for both complications and survival in cancer patients. This study aims to analyze the relationship between sarcopenia measured by psoas muscle index on computer tomography scans and the presence of postoperative complications in colorectal cancer surgery. Materials and Methods: In a prospective study we recorded data from 51 patients who underwent colorectal cancer surgery in the Mures County Clinical Hospital, Romania. Total psoas muscle area and psoas density were measured at the level of the third lumbal vertebra (L3) for further index calculation. We also evaluated the general characteristics and laboratory analyses to obtain more information about status of the patients. Short-term postoperative complications were scored according to the Clavien-Dindo classification. Results: The majority of the 51 patients were male (61%) and the median age was 65 years. More than half of the cancer was located in the rectum (56.9%), a quarter in the right colon (25.5%), the rest in the sigmoid (11.8%), and the left colon (5.9%). Twenty-one patients (41.2%) developed a complication, five (9.8%) of these were Clavien-Dindo grade 3, 4 or 5 (high grade) and sixteen (31.3%) grade 1 or 2 (low grade). The low- and high-grade groups showed a significantly lower right psoas muscle area, left psoas muscle area, total psoas muscle area, and psoas muscle index (p < 0.001 in all cases). Among laboratory analyses, a significantly lower perioperative hematocrit, hemoglobin, and albumin level were found in patients who developed complications. Furthermore we observed that an elevated serum C-reactive protein level was associated with a higher grade of complication (p < 0.043). Conclusions: The psoas muscle index (PMI) influence on the postoperative outcome is an important factor in our single center prospective study and it appears to be a good overall predictor in colorectal surgery. A lower PMI is directly associated with a low or high grade complication by Clavien-Dindo classification. Perioperative inflammatory and nutritional status evidenced by serum C-reactive protein (CRP) and albumin level influences the presence of postoperative complications.

Evaluation of Muscle Cramp Associated with Liver Cirrhosis with a Focus on the Liver Function and Nutritional Status

Objective We investigated the muscle cramp status of patients with liver cirrhosis by focusing on the degree of liver damage, skeletal muscle mass, and nutritional status. Methods All enrolled patients completed a questionnaire about muscle cramps. The degree of liver damage was examined using the Child-Pugh classification and the albumin-bilirubin (ALBI) grade. The nutritional status and skeletal muscle mass were examined using the Controlling Nutritional Status (CONUT) method and the psoas muscle index (PMI). Results Among the respondents, 55.7% of the patients reported experiencing muscle cramps. An analysis of the two patient groups-those who experienced muscle cramps and those who did not-revealed significant differences in Child-Pugh classification (muscle cramp-positive vs. muscle cramp-negative: A/B/C, 54.1%/32.4%/13.5% vs. 90.0%/10.0%/0.0%; p=0.004), ALBI grade (1/2/3, 20.5%/71.8%/7.7% vs. 54.8%/38.7%/6.5%; p=0.011), modified ALBI grade (1/2a/2b/3, 20.5%/20.5%/51.3%/7.7% vs. 54.8%/22.6%/16.1%/6.5%; p=0.008), CONUT score (normal/mild/moderate/severe, 25.6%/28.2%/41.0%/5.1% vs. 22.6%/61.3%/12.9%/3.2%; p=0.024), and PMI (3.85±1.13 cm²/m² vs. 4.94±1.86 cm²/m²; p=0.012). Conclusion Our findings suggest that muscle cramps occur more frequently in patients with liver cirrhosis due to their decreased liver function and poorer nutritional status.

Psoas muscle depletion during preoperative chemotherapy for advanced gastric cancer has a negative impact on long-term outcomes after gastrectomy

Aim

The significance of sarcopenia in cancers has been widely recognized. However, few studies have focused on chronological changes in sarcopenia in cancer patients. This study aimed to clarify the clinical significance of changes in the psoas muscle area before and after preoperative chemotherapy.

Methods

This study included 39 patients who underwent gastrectomy followed by preoperative chemotherapy for advanced gastric cancer between January 2010 and December 2016 in our hospital. The psoas muscle area was measured at the umbilical level before and after chemotherapy, and the relationship between its chronological changes and the long‐term prognosis was examined.

Results

Patients were classified into two groups according to changes in the psoas muscle area before and after preoperative chemotherapy: remarkable muscle depletion and normal groups. No significant differences were observed in clinicopathological factors. Notably, the remarkable muscle depletion group included significantly more male patients (P = .018) and showed a high weight loss rate (P < .001). Although no significant difference was observed in the recurrence‐free survival between the two groups (P = .484), overall survival was significantly worse in the remarkable muscle depletion group (P < .001). Multivariate analysis for prognosis revealed that pathological stage III or higher (P = .022) and decreased psoas muscle area (P = .038) were independent prognostic factors.

Conclusions

The present findings suggest that psoas muscle depletion during preoperative chemotherapy is a prognostic factor for poor long‐term outcomes in patients who underwent gastrectomy followed by preoperative chemotherapy for advanced gastric cancer.

Low psoas muscle index associates with long-term mortality in cirrhosis: construction of a nomogram

Background

To develop a nomogram incorporating indicator of muscle waste to prognosticate long-term mortality in liver cirrhosis (LC), and identify the prognostic impact of psoas muscle index (PMI).

Methods

A total of 251 LC patients who underwent computed tomography were included in this study. Multiple Cox regression was performed, and sex-specific nomogram models incorporating PMI were developed. The utility of the proposed models were evaluated by Harrell’s concordance index (C-index), calibration curve and decision curve analysis. X-tile was used to determine optimal cutpoint for stratifying subjects with distinct outcomes. Subgroup analysis was implemented in terms of age and MELD score. The correlation between PMI and gait speed was also evaluated.

Results

On multiple analysis, independent predictors for 3-year all-cause mortality were age, BMI, PMI and MELD for males, and age, PMI and MELD for females. Both nomogram models gave rise to moderately strong discrimination, with a C-index of 0.792 (95% CI: 0.723–0.861) in males and 0.715 (95% CI: 0.637–0.793) in females, respectively. The calibration curve implied predicted survival corresponding optimally with the actual outcomes. The proposed models were feasible in clinical settings based on decision curve analysis. On subgroup analysis, PMI might confer valid predictive value on LC patients with MELD <15. Moreover, a definitely positive correlation between PMI and gait speed was revealed.

Conclusions

Our proposed nomogram embedding PMI rendered an individualized predictive tool for long-term mortality in LC. The diminishing value of PMI is likely indicative of muscle dysfunction.

Predictive value of immuno-inflammatory and nutritional measures modulated by neoadjuvant chemotherapy on the response of neoadjuvant chemotherapy and long-term outcomes in patients with esophageal cancer

It has been reported that immuno-inflammatory and nutritional parameters are associated with long-term survival in various malignancies. However, little is known regarding the associations between alterations of these parameters during neoadjuvant chemotherapy (NAC) and the response to NAC in patients with esophageal cancer. The present study examined the clinical significance of alterations in these parameters during NAC in terms of the response to NAC and the long-term outcomes in patients with esophageal cancer. Various systemic immuno-inflammatory and nutritional measures including the systemic neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP)-to-albumin ratio (CAR) and psoas muscle index (PMI) were examined before and after NAC. Statistical analyses were performed to determine the significance of immuno-inflammatory and nutritional parameters prior to NAC and alterations during NAC regarding the response to NAC and long-term outcomes. The NLR, PMI, neutrophil count and platelet count declined significantly following NAC, whereas no alterations in PLR, CAR, lymphocyte counts, CRP levels and albumin concentration were observed. The decreases in NLR and neutrophil counts following NAC were strongly associated with a favorable overall survival (P=0.006). In conclusion, decreases in NLR and neutrophil counts following NAC were clinically significant predictors of the response to NAC and of survival in esophageal cancer, respectively.

Effect of pretreatment psoas muscle mass on survival for patients with unresectable pancreatic cancer undergoing systemic chemotherapy

To the best of our knowledge, there are few previous studies that have investigated the effect of decreased skeletal muscle mass (DSMM) on survival in patients with unresectable advanced pancreatic cancer (APC) who are undergoing systemic chemotherapy. Thus, the present study aimed to investigate the impact of DSMM, as determined by the psoas muscle index (PMI) following computed tomography and prior to systemic chemotherapy, on the outcomes of patients with unresectable APC (n=61). The primary endpoint used was the overall survival (OS) rate. The OS rates in the PMI-High group (exceeds the median PMI value in each gender) were retrospectively compared with those in the PMI-Low group (below the median PMI value in each gender), and factors associated with OS were investigated using univariate and multivariate analyses. The study cohort included 31 male and 30 female patients with a median age of 72 years, 13 of whom were stage IVA, and 48 were stage IVB. The median PMI in males was 4.3 cm²/m² (range, 1.6-8.2 cm²/m²), while that in females was 2.3 cm²/m² (range, 0.7-6.1 cm²/m²). The proportion of patients with performance status 0 in the PMI-High group was significantly high, compared with that in the PMI-Low group [83.3% (25/30) vs. 58.1% (18/31); P=0.0486]. Body mass index in the PMI-High group was significantly higher compared with that in the PMI-Low group (P=0.0154). The 1-year cumulative survival rate was 43.3% in the PMI-High group and 12.9% in the PMI-Low group (P=0.0027). Following multivariate analysis, PMI (P=0.0036), prothrombin time (P=0.0044) and carbohydrate antigen 19-9 (P=0.0451) were identified to be significant predictors of OS. In conclusion, DSMM, as determined by the PMI, could be a significant predictor of prognosis in patients with unresectable APC who are receiving systemic chemotherapy.