S. Levolger

Body composition and outcome in patients undergoing resection of colorectal liver metastases.

Recent evidence suggests that depletion of skeletal muscle mass (sarcopenia) and an increased amount of intra‐abdominal fat (central obesity) influence cancer statistics. This study investigated the impact of sarcopenia and central obesity on survival in patients undergoing liver resection for colorectal liver metastases (CLM).

Systematic review of sarcopenia in patients operated on for gastrointestinal and hepatopancreatobiliary malignancies

Preoperative risk assessment in cancer surgery is of importance to improve treatment and outcome. The aim of this study was to assess the impact of CT‐assessed sarcopenia on short‐ and long‐term outcomes in patients undergoing surgical resection of gastrointestinal and hepatopancreatobiliary malignancies.

Systematic Review and Meta‐Analysis of the Impact of Computed Tomography–Assessed Skeletal Muscle Mass on Outcome in Patients Awaiting or Undergoing Liver Transplantation

Liver transplant outcome has improved considerably as a direct result of optimized surgical and anesthesiological techniques and organ allocation programs. Because there remains a shortage of human organs, strict selection of transplant candidates remains of paramount importance. Recently, computed tomography (CT)‐assessed low skeletal muscle mass (i.e. sarcopenia) was identified as a novel prognostic parameter to predict outcome in liver transplant candidates. A systematic review and meta‐analysis on the impact of CT‐assessed skeletal muscle mass on outcome in liver transplant candidates were performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines. Nineteen studies, including 3803 patients in partly overlapping cohorts, fulfilled the inclusion criteria. The prevalence of sarcopenia ranged from 22.2% to 70%. An independent association between low muscle mass and posttransplantation and waiting list mortality was described in 4 of the 6 and 6 of the 11 studies, respectively. The pooled hazard ratios of sarcopenia were 1.84 (95% confidence interval 1.11–3.05, p = 0.02) and 1.72 (95% confidence interval 0.99–3.00, p = 0.05) for posttransplantation and waiting list mortality, respectively, independent of Model for End‐stage Liver Disease score. Less‐consistent evidence suggested a higher complication rate, particularly infections, in sarcopenic patients. In conclusion, sarcopenia is an independent predictor for outcome in liver transplantation patients and could be used for risk assessment.

Sarcopenia impairs survival in patients with potentially curable hepatocellular carcinoma.

A reduction in skeletal muscle mass (sarcopenia) independently predicts poor survival in patients with hepatocellular carcinoma (HCC) undergoing treatment with curative intent. Whether this is due to an increased risk of recurrence and disease specific death, or due to an increased risk of postoperative morbidity and mortality is currently unclear. In this study, we investigate the association between sarcopenia and death in a cohort of HCC patients undergoing treatment with curative intent.

A comparative study of software programmes for cross-sectional skeletal muscle and adipose tissue measurements on abdominal computed tomography scans of rectal cancer patients

The association between body composition (e.g. sarcopenia or visceral obesity) and treatment outcomes, such as survival, using single‐slice computed tomography (CT)‐based measurements has recently been studied in various patient groups. These studies have been conducted with different software programmes, each with their specific characteristics, of which the inter‐observer, intra‐observer, and inter‐software correlation are unknown. Therefore, a comparative study was performed.

Low skeletal muscle mass is associated with increased hospital expenditure in patients undergoing cancer surgery of the alimentary tract

Background Low skeletal muscle mass is associated with poor postoperative outcomes in cancer patients. Furthermore, it is associated with increased healthcare costs in the United States. We investigated its effect on hospital expenditure in a Western-European healthcare system, with universal access. Methods Skeletal muscle mass (assessed on CT) and costs were obtained for patients who underwent curative-intent abdominal cancer surgery. Low skeletal muscle mass was defined based on pre-established cut-offs. The relationship between low skeletal muscle mass and hospital costs was assessed using linear regression analysis and Mann-Whitney U-tests. Results 452 patients were included (median age 65, 61.5% males). Patients underwent surgery for colorectal cancer (38.9%), colorectal liver metastases (27.4%), primary liver tumours (23.2%), and pancreatic/periampullary cancer (10.4%). In total, 45.6% had sarcopenia. Median costs were €2,183 higher in patients with low compared with patients with high skeletal muscle mass (€17,144 versus €14,961; P<0.001). Hospital costs incrementally increased with lower sex-specific skeletal muscle mass quartiles (P = 0.029). After adjustment for confounders, low skeletal muscle mass was associated with a cost increase of €4,061 (P = 0.015). Conclusion Low skeletal muscle mass was independently associated with increased hospital costs of about €4,000 per patient. Strategies to reduce skeletal muscle wasting could reduce hospital costs in an era of incremental healthcare costs and an increasingly ageing population.

SUN-P201: Contrast-Enhancement Influences Skeletal Muscle Density, but Not Skeletal Muscle Mass, Measurements on Computed Tomography

BACKGROUND & AIMSnLow skeletal muscle mass and density have recently been discovered as prognostic and predictive parameters to guide interventions in various populations, including cancer patients. The gold standard for body composition analysis in cancer patients is computed tomography (CT). To date, the effect of contrast-enhancement on muscle composition measurements has not been established. The aim of this study was to determine the effect of contrast-enhancement on skeletal muscle mass and density measurements on four-phase CT studies.nnnDESIGNnIn this observational study, two observers measured cross-sectional skeletal muscle area corrected for patients height (skeletal muscle index [SMI]) and density (SMD) at the level of the third lumbar vertebra on 50 randomly selected CT examinations with unenhanced, arterial, and portal-venous phases. The levels of agreement between enhancement phases for SMI and SMD were calculated using intra-class correlation coefficients (ICCs).nnnRESULTSnMean SMI was 42.5 (±9.9)xa0cm2/m2 on the unenhanced phase, compared with 42.8 (±9.9) and 43.6 (±9.9)xa0cm2/m2 for the arterial and portal-venous phase, respectively (both pxa0<xa00.01). Mean SMD was lower for the unenhanced phase (30.9xa0±xa08.0xa0Hounsfield units [HU]) compared with the arterial (38.0xa0±xa09.9xa0HU) and portal-venous (38.7xa0±xa09.2xa0HU) phase (both pxa0<xa00.001). No significant difference was found between SMD in the portal-venous and arterial phase (pxa0=xa00.161). The ICCs were excellent (≥0.992) for all SMIs and for SMD between the contrast-enhanced phases (0.949). The ICCs for the unenhanced phase compared with the arterial (0.676) and portal-venous (0.665) phase were considered fair to good.nnnCONCLUSIONSnStatistically significant differences in SMI were observed between different enhancement phases. However, further work is needed to assess the clinical relevance of these small differences. Contrast-enhancement strongly influenced SMD values. Studies using this measure should therefore use the portal-venous phase of contrast-enhanced CT examinations.

The impact of sarcopenia on survival and complications in surgical oncology: A review of the current literature: Comment on Joglekar et al

Dear Editor, We read with great interest the paper by Joglekar and colleagues that systematically reviewed the current literature regarding the impact of sarcopenia on survival and complications in patients undergoing cancer surgery [1]. To date, sarcopenia is a burning topic of clinical relevance, since preoperative body composition deviation has been identified as a strong prognostic marker in surgical oncological populations. In the last 5 years, many studies have investigated the effect of sarcopenia on outcomes in surgical oncology. As readers may go astray as a result of the plethora of publications on this topic, a systematic review enables a clear overview of all available evidence. Therefore, we congratulate the authors with their initiative. However, we would like to address some issues regarding the methodology of their study. First of all, the definition of the investigated patient population (i.e., “surgical oncology”) remains ambiguous for the uncommitted reader. On the one hand, studies describing the impact of sarcopenia in patients undergoing bladder cancer resection and lymph node resection for melanoma were included [1], whereas studies in patients undergoing surgery for endometrial [2] or penile [3] cancer were not. Besides the fact that only one database (PubMed) has been searched, the strings for the systematic search consisted of a limited number of search terms. For example, only sarcopenia was used, instead of the combination with terms like body composition, myopenia, or skeletal muscle wasting, -depletion, -atrophy, or -loss [4]. Consequently, this has led to the exclusion of multiple relevant studies that have reported the impact of sarcopenia in patients undergoing cancer surgery and were published (on-line) before the last search date (May 4th 2015). For instance, two studies among patients with perihilar cholangiocarcinoma [5,6], one with pancreatic cancer patients [7], one with colorectal cancer patients [8], and one with primary liver tumor patients [9] undergoing resection, which are populations known for their high postoperative morbidity and mortality rates and poor prognosis, were missed. Moreover, a study that has frequently been cited in the studies that were included in the review—and thus should have been identified by crossreferencing as described in themethods section—was not included [10]. Notably, the results of two studies that described an association between skeletal muscle mass and impaired postoperative outcome after colorectal cancer surgery that were referred to in the introduction of the article [11,12], have not been included. Finally, a study among patients undergoing resection for colorectal liver metastases is briefly mentioned in the text, but not depicted in table II [13]. These concerns would probably have been prevented if the authors would have complied with the PRISMA guidelines for systematic reviews and its corresponding flow-chart, depicting study selection [14]. Since all included studies have an observational, retrospective design, no causative relationship between sarcopenia and outcome measures has been established. Therefore, findings should be placed in perspective and confirmed in prospective studies. Furthermore, the majority of studies measured skeletal muscle mass using abdominal computed tomography (CT) scans. As explained by the authors, a great diversity in methods to measure or define sarcopenia (i.e., different cutoff values used, various muscles measured) was observed in these studies. These measures and definitions may not be applicable to all populations. We feel that it is important to emphasize that one should strive for a uniform definition of CT-assessed sarcopenia with outcomerelated cut-off values adjusted for age, gender, ethnicity, and tumor type to improve future comparability of studies.

Muscle wasting and survival following pre-operative chemoradiotherapy for locally advanced rectal carcinoma

BACKGROUND & AIMSnNeoadjuvant chemoradiotherapy (NACRT) has increased local control in locally advanced rectal cancer. Reduced skeletal muscle mass (sarcopenia), or ongoing muscle wasting, is associated with decreased survival in cancer. This study aims to assess the change in body composition during NACRT and its impact on outcome using computed tomography (CT) imaging in locally advanced rectal cancer (LARC) patients.nnnMETHODSnLARC patients treated with NACRT were selected from a prospectively maintained database and retrospectively analyzed. One-hundred twenty-two patients who received treatment between 2004 and 2012 with available diagnostic CT imaging obtained before and after NACRT were identified. Cross-sectional areas for skeletal muscle was determined, and subsequently normalized for patient height. Differences between skeletal muscle areas before and after NACRT were computed, and their influence on overall and disease-free survival was assessed.nnnRESULTSnA wide distribution in change of body composition was observed. Loss of skeletal muscle mass during chemoradiotherapy was independently associated with disease-free survival (HR0.971; 95% CI: 0.946-0.996; pxa0=xa00.025) and distant metastasis-free survival (HR0.942; 95% CI: 0.898-0.988; pxa0=xa00.013). No relation was observed with overall survival in the current cohort.nnnCONCLUSIONSnLoss of skeletal muscle mass during NACRT in rectal cancer patients is an independent prognostic factor for disease-free survival and distant metastasis-free survival following curative intent resection.

Low Skeletal Muscle Density Is Associated with Early Death in Patients with Perihilar Cholangiocarcinoma Regardless of Subsequent Treatment

Background: Low skeletal muscle mass is associated with increased postoperative morbidity and worse survival following resection for perihilar cholangiocarcinoma (PHC). We investigated the predictive value of skeletal muscle mass and density for overall survival (OS) of all patients with suspected PHC, regardless of treatment. Methods: Baseline characteristics and parameters regarding disease and treatment were collected from all patients with PHC from 2002 to 2014. Skeletal muscle mass and density were measured at the level of the third lumbar vertebra on CT. The association between skeletal muscle mass and density with OS was investigated using the Kaplan-Meier method and Cox survival. Results: Median OS in 233 included patients did not differ between those with and without low skeletal muscle mass (p = 0.203), whereas a significantly different median OS (months) was observed between patients with low (HR 7.0, 95% CI 4.7–9.3) and high (HR 12.1, 95% CI 8.1–16.1) skeletal muscle density (p = 0.004). Low skeletal muscle density was independently associated with decreased OS (HR 1.78, 95% CI 1.03–3.07, p = 0.040) within the first 6 months but not after 6 months (HR 0.68, 95% CI 0.44–1.07, p = 0.093), after adjusting for age, tumour size and suspected peritoneal or other distant metastases on imaging. Conclusion: A time-dependent effect of skeletal muscle density on OS was found in patients with PHC, regardless of subsequent treatment. Low skeletal muscle density may identify patients at risk for early death.