PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 137 | POJ_0129)

Original Clinical Investigation

Prevalence of Computed Tomography Defined Sarcopenia in newly diagnosed non-metastatic Cancer Patients

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | Back to Total Name and Codes page2

Submitted: | Posted:

Authors:

Vince Leenard M. Yabut, MD (1)*, Reynaldo P. Sinamban MD, FPCS, DPBCN (1,2), Divina Cristy Redondo-Samin, MD, DPBCN(3) Natheniel Paragas, MD (4) Irene S. Bandong, MD (5), Angelica Cordova Gallespen, MD, FPCP (6)

Institution where research was conducted:

  1. Clinical Nutrition Services, St. Luke’s Medical Center, Quezon City, Metro Manila, Philippines
  2. Institute of Surgery, St. Luke’s Medical Center, Global Taguig City,Philippines
  3. Makati Medical Center Makati City, Philippines
  4. Premiere Medical Center, Nueva Ecija, Philippines
  5. Institute of Radiology, St. Luke’s Medical Center, Quezon City, Philippines
  6. Cancer Institute, St. Luke’s Medical Center, Quezon City, Philippines

 

ABSTRACT: Back

Background:

Cancer-associated malnutrition is prevalent in patients with cancer. It is may be present at the time of diagnosis or begin and aggravated with the disease progression and treatment modalities.

Objective:

Loss of skeletal muscle mass, and is a clinical manifestation of cancer-associated malnutrition which can lead to development of sarcopenia. Sarcopenia is associated with mortality and cancer-specific outcomes, hence early diagnosis of low muscle mass may be crucial for prognostic decision making and offer guided nutrition intervention.

Methodology:

We investigated the prevalence of computed tomography- defined sarcopenia (class I sarcopenia and class II sarcopenia) and its related factors in newly diagnosed cancer patients. This is cross sectional study in St. Luke’s Medical Center.

Results:

  1. Retrospectively, newly diagnosed cancer patients were evaluated for skeletal muscle index using computed tomography scan.
  2. Patients (n=225) were 56.8 ± 12.2 years, 83% female, and 51% had stage III disease.
  3. Class I and Class II sarcopenia were present in 108(43%) and 26(10%) patients.
  4. Higher BMI (p value <0.001) was significantly related to sarcopenia.
  5. However, advancing age, gender and stage of cancer were not statistically significant associated with sarcopenia. (p = 0.92, 0.09, and 0.63 respectively).

Conclusion:

In conclusion, this first prevalence study conducted using computed tomography in Filipino cancer patients and CT-defined sarcopenia were notably prevalent among newly diagnosed cancer patients. Since sarcopenia is an objective finding of malnutrition with poor clinical outcomes (treatment failure, increased complications, impaired functionality and survival), it is important to detect sarcopenia give focused nutritional measures to prevent further sarcopenia and cachexia.

 

KEYWORDS: Sarcopenia, Malnutrition, Cancer, Computed Tomography, Early Sarcopenia, Cancer Sarcopenia, Computed tomography Defined Sarcopenia, Early Sarcopenia screening

INTRODUCTION | Back

Cancers are among the leading causes of morbidity and mortality worldwide, with increasing number of new cases over the next decades. Consecutively, cancer treatment, such as surgery, radiation therapy, and chemotherapy are also improving with higher precision and power, impacting survival and morbidity. Cancer patients are at risk of malnutrition, not only due to physical and metabolic effects of the cancer, but also due to the effects of these anticancer therapies, and malnutrition is associated with poorer prognosis and quality of life. In addition, metabolic derangements like obesity and insulin resistance are also associated with increased risks of cancer recurrence. [1]

Primary Sarcopenia is defined as decreasing muscle mass related to aging, while secondary sarcopenia refers to muscle loss related to disuse, inflammation, or malnutrition. Subsequently, cancer is a major cause of secondary sarcopenia and was recently highlighted in numerous studies of cancer patients. [2] Sarcopenia defined commonly as a combination of low muscle strength, reduced muscle mass, and/or reduced physical performance, reported in wide range of prevalence in cancer patients. In a systematic review of 38 studies published from 2008 to 2015, the prevalence of pre-therapeutic sarcopenia (defined by only low SMI) in cancer patients ranged from 15% to 74%. [3]

Sarcopenia also can overlap with Cancer cachexia, a debilitating syndrome characterized by weight loss with concomitant loss of muscle and/or fat mass. This leads to further functional impairment, reduced physical performance and poorer survival. [4]

Computed tomographic (CT) images are frequently obtained as part of cancer staging and metastatic disease assessment, can be used to assess skeletal muscle mass using a single slice at the 3 level of the third vertebra (L3). Cross-sectional skeletal muscle area (SMA, cm2) at this level is highly correlated with total body skeletal muscle mass. Advantage is that abdominal CT scans are conducted as part of routine care in several patient populations. This method can be used for muscle analysis without additional burden to the patient. Thus, this modality can offer an opportunity for screening and timely provision of therapeutic intervention to prevent further sarcopenia and improve patient management when utilized as a prognostic measure [5]. Regarding CT-defined skeletal muscle mass, there are differences in ethnicity, genetic background, and body size hence the EWGSOP and IWGS criteria might not apply to Asians [6]. Recently, a large cohort of Korean healthy subjects was made to establish and determine diagnostic cutoff points for sarcopenia based on reference values for abdominal muscle area measured at the L3 lumbar vertebra level by CT scan. Although quantification of skeletal muscle is not yet a standard component of the assessment of newly diagnosed adults with cancer, computed tomographic (CT) images, frequently obtained as part of cancer staging and metastatic disease assessment, can be used to assess skeletal muscle mass and provide prognostic information in cancer populations [7].

Problem: As per ESPEN recommendation, there is need for screening to increase awareness and allow early recognition and treatment, which include screening for sarcopenia to prevent cachexia. Identifying occult sarcopenia using computed tomography may offer the opportunity to screen and diagnose so to provide timely therapeutic intervention. Previously, no study has specifically evaluated the body composition measurement using CT scan in newly diagnosed Asian cancer patients. In this context, we aimed to assess the skeletal muscle index and evaluate the prevalence of sarcopenia in Filipino patients newly diagnosed with solid tumor. We also aimed to determine the association of CT-defined sarcopenia across age trends, body mass index, site of cancer and stage of cancer presented.

Scope and Limitations: The study is a preliminary study that determined the prevalence rate of Sarcopenia in newly diagnosed cancer patients at St. Luke’s Medical Center, Quezon City.

METHODOLOGY | Back

This is a cross-sectional study of adults who were newly diagnosed breast, colon, liver, lung cancer with no metastasis noted on routine, biochemical, and at least radiological, endoscopic or histological parameters. The study examined all patients aged 18 years old and above who were admitted or worked up as outpatient at St. Luke’s Medical Center from January 2015 – December 2019. Breast, colorectal, lung and liver cancers were selected since these represent Top 4 of morbidity and mortality with total percentage of 50% of cancer cases (Lung 18%, Liver 13%, Breast 11%, Colorectal 8%) according to the latest 2015 Philippine Cancer Facts and Estimates [19].

Newly diagnosed stage I-III cancer adult patients (admitted and outpatient) with CT scans done within four months of diagnosis of cancer and before any chemotherapy or radiation were included. Exclusion criteria includes: age less than 18 years old, received any enteral or parenteral nutrition, with previous stroke, dementia, gastrointestinal malabsorption, congenital abnormalities, previous cancer diagnosis, trauma, neuromuscular diseases.

The following information were acquired from the database of the Medical oncology of St. Luke’s Medical Center, with proper permission and confidentiality: demographic data, anthropometrics and therapeutic modalities given. Weight and height measurements of all patients were measured with Detecto scales. no part of weigh platform or load receptor were touching a fixed object, and with patient’s clothes worn in minimum. Patients’ Body mass index were computed using this formula: BMI = weight (kg) / height (m)2. The BMI categories typically applied to mature individuals were used to classify the patients as follows: < 20.0 kg/m2, underweight; 20.0 to 24.9 kg/m2, normal weight; 25.0 to 29.9 kg/m2, overweight; and 30 kg/m2 to 34.9 kg/m2, obese class I; 35 kg/m2 to 39.9 kg/m2, obese class II then > 40 kg/m2, obese class III.

Contrast-enhanced pelvic or whole abdominal CT scan protocol of St. Luke’s Medical Center QC was employed. Scans are made in three phases: First, a plain study or non-contrast scan is made. Then a contrast-enhanced study follows by administering first 90 ml of an iodinated contrast agent intravenously which is diluted in saline with a concentration of 300 mg iodine/ml and 30 ml of saline diluent. There was a 90-120 seconds interval between time of contrast administration to acquisition of contrast-enhanced images. Lastly, after 15 minutes, a delayed focus scan of the pelvis to include the urinary bladder is performed. Subjects have to breath-hold for a few seconds during all the scan phases. Axial image reconstruction is done using 3 x 1.5 mm thickness with coronal and sagittal reformatted planes.

Skeletal muscle analysis was measured at the level of L3 vertebral body where both vertebral transverse processes were clearly delineated. The plain and contrast images obtained in the same subject were selected and examined at the same time using a split screen monitor lay-out. The muscles analyzed include the paraspinal, psoas, transverses abdominis, inferior/exterior obliques and rectus abdominis muscles. SMA was measured in cm2 using Image J software [37]. These muscles were identified as muscle when CT attenuation falls within the range of -29 to +150 HU corresponding to the density of skeletal muscle tissue. [20] Measurement of SMA using computed tomography (CT) is similar to CT volumetric/measurement analysis of liver tumors and intraparenchymal brain hemorrhage.

A board-certified radiologist performed the SMA measurement using CT volumetric/measurement analysis. The radiologist performed the CT measurement of SMA is a graduate of the Institute of Radiology in St. Luke’s Medical Center-Quezon City in 2001 and have completed her CT-MRI subspecialty training in the same institution in 2004. One 10 radiologist did all CT analysis assisted by a fourth-year resident of the Institute of Radiology. No inter-rater reliability was expected. Intra-rater reliability was minimized through the use of a CT imaging viewer application software on which assisted the radiologist in the measurement of SMA and increases reproducibility of measurements. The SMA was adjusted by the square of the height (SMA/height2), weight (SMA/ weight), and body mass index (SMA/BMI), which were collectively referred to as the skeletal muscle indices (SMIs).

Sarcopenia was diagnosed according to EWSGOP and AWGS consensuses, recommends using cutoff points at -2 SD from the mean reference value. The gender-specific SMI threshold values used were from the calculation of T-score and criteria for sarcopenia derived from the study of Eun Hee Kim et al. T-score for SMA or SMIs (height-, weight-, and BMI- adjusted) by calculating the difference between an individual’s measured SMA or SMIs and the mean SMA or SMIs of healthy young adults, and dividing that difference by the SD of sex-specific young adults. The formula for T-score calculation is as follows:

Measurement value – Young adult mean T-score = Young adult SD

BMI-adjusted index (SMA/BMI) was the best CT index for reflecting the age-related muscle changes and for maximizing the diagnostic yield for sarcopenia, especially in Asian populations. SMA/BMI reference cutoffs were 4.97 and 3.46 in men and women, respectively. Subjects were classified as “normal” when the T-score was higher than −1.0. Class I and II sarcopenia were defined as −2.0 ≤ T-scores < −1.0 and T-scores less than −2.0, respectively. [21,22]

Sample size was calculated based on previous reports of prevalence of sarcopenia in newly diagnosed cancer patients. Previous reports of prevalence of sarcopenia in corresponding type of cancer (breast, colon, liver and lung) were considered. Overall prevalence of pre-therapeutic sarcopenia was 38.6% with a maximum allowable error of 5% and reliability of 80%, sample size calculated is 255 using results from study of Pamoukdjian et al as the reference [17].

Data were described using mean and standard deviation for continuous variables and frequency and proportion for categorical variables. Prevalence was calculated with the corresponding 95 confidence intervals. The independent t-test was performed to compare skeletal muscle mass parameters between males and females. Pearson chi-squared test was used to compare subjects with or without sarcopenia. Fisher’s exact was used to determine nonrandom associations between related factors and sarcopenia. All tests were two–tailed and considered significant when p-values falls less than 0.05

Ethical consideration: The clinical protocol and all relevant documents was reviewed and approved by the SLMC Institutional Ethics Review Committee. Patient confidentiality was respected by ensuring anonymity of patient records. All study data were recorded.

RESULTS | Back

Baseline Characteristics of study participants

The study design is shown in (Fig. S1). A total of 255 cancer patients (211 females, 44 males) were included in the study. All patients who meet the inclusion criteria are included in this study. Analyzable CT images were available for 64% of patients initially screened of 400.

The mean values and ranges are presented for gender, age at diagnosis, BMI, site of cancer, TNM staging at baseline table 1. Patients were 83% female, with an average age of 56.8 (+ 12.2) years, mostly within age range of 40-70s. BMI included were mostly normal (47%) and 13% were classified as obese. Patients predominantly diagnosed with stage III cancer (51%). Among the patients included in our study; 67% were breast cancer, 22% were colon cancer, and rest were lung (8%) and liver cancer (2%).

Table 1. Baseline Characteristics of Cancer patients

Parameters

Total Sample = 255

Age, years mean (SD)

56.84 (12.2)

Sex, n (%)

Female

Male

Sex

211 (82.75)

44 (17.25)

Age range groups, n (%)

20-29

30-39

40-49

50-59

60-69

70-79

>80

Groups

2 (0.78)

20 (7.84)

55 (21.57)

67 (26.27)

72 (28.24)

33 (12.94)

6 (2.35)

Weight, kg (mean SD)

63 (12.74)

Height, m (mean SD)

1.58 (0.08)

Skeletal muscle area (cm2)

113.83 (24.91)

SMA/BMI

4.59 (1.03)

BMI (kg/m2), n (%)

Underweight (<15)

Normal status (18.5-24.9)

Overweight (25.0-29.9)

Obese I (30-34.9)

Obese II (>35)

25.29 (4.99)

11 (4.31)

121 (47.45)

89 (34.9)

25 (9.8)

9 (3.53)

Site of cancer, n (%)

Breast

Colon

Liver

Lung

Number

172 (67.45)

56 (21.96)

6 (2.35)

21 (8.24)

Site of cancer, n (%)

Breast

Colon

Liver

Lung

Number

172 (67.45)

56 (21.96)

6 (2.35)

21 (8.24)

Age trends of Skeletal Muscle of Cancer patients

Data on the skeletal muscle mass, SMA/ht2, SMA/wt and SMA/BMI in age groups per gender are shown in (Fig.3). The skeletal muscle mass and SMA/height in female increased until 35 years of age then showed a steady linear curve until 70s. After this, it finally started to decrease. While SMA/BMI and SMA/weight in female, showed slight increased until 40 years of age then remained constant throughout. In men, parameters of SMA, SMA/wt, SMA/BMI and SMA/ht showed similar patterns. There was a rapid decrease until 50 years of age, then slowed down until 70s. After this, it started again to decrease rapidly.

The overall proportion of sarcopenic patients in our study were 43% and 10%, class I and class II respectively using the Gender-specific cutoffs (Table 2).

Table 2. Prevalence of sarcopenia in newly diagnosed non-metastatic cancer patients – using Gender specific cut-offs

N = 255 Value (%)
No Sarcopenia 121 (47)
Class 1 Sarcopenia 108 (43)
Class II Sarcopenia 26 (10)

Based on (Fig.4), a significant number of sarcopenic patients fall within 50-70s years of age. Sarcopenia among cancer patients started around 30s with a steady increase until 60 years of age followed by a decreased.

Table 3 present the clinical variables of age trends, gender, body mass index, site and stage of cancer. This showed the association of cancer sarcopenia with Age Ranges which was not statistically significant. (p=0.918). Most of the participants are female, and showed higher prevalence on both Class I and Class II sarcopenia in comparison with male participants (Gender specific cut-off p=0.09). Compared with subject without sarcopenia, those diagnosed with cancer sarcopenia were more likely to be older and had higher body mass index, which was statistically significant (p <0.0001) (Fig 5). Sarcopenia were more prevalent in patients with breast and liver cancer (p=0.764) (Fig 6). With regard with TNM stage, patients with stage I cancer also had predominance of 26% and175%, class I and class II sarcopenia respectively (p=0.63) (Fig 7).

Table 3. Prevalence and association of cancer sarcopenia across demographics and disease characteristics using Gender specific cut-offs

  Non-Sarcopenic Sarcopenic Class 1 Sarcopenic Class 11 p-value

Age groups

20-29

30-39

40-49

50-59

60-69

70-79

> 80

Age groups

2 (1.36)

14 (9.52)

33 (22.45)

34(23.13)

41 (27.89)

19 (12.93)

4 (2.72)

Age groups

0 (0)

5 (6.1)

18 (21.95)

25 (30.49)

22 (26.83)

10 (12.2)

2 (2.44)

Age groups

0 (0)

1 (3.85)

4 (15.38)

8 (30.77)

9 (34.62)

4 (15.38)

0 (0)

0.918

Sex

Female

Male

Sex

117 (80)

30 (20)

Sex

74 (90)

8 (10)

Sex

20 (77)

6 (23)

0.09

BMI (kg/m2)

Underweight (<15)

Normal status (18.5-24.9)

Overweight (25.0- 29.9)

Obese Class I (30-34.9)

Obese Class II (35-39.9)

BMI

10 (6.8)

90 (61.2)

41 (27.9)

6 (4)

0 (0)

BMI

1 (1.2)

28 (34)

37 (45.1)

13 (15.9)

3 (3.7)

Sites

0 (0)

3 (11.5)

11 (42.3)

6 (23)

6 (23)

<0.01

Site of cancer

Breast

Colon

Liver

Lung

Sites

94 (64)

36 (24.5)

3 (2)

14 (9.5)

Sites

58 (70.7)

16 (19.5)

2 (2.4)

6 (7.3)

Sites

20 (77)

4 (15.4)

1 (3.9)

1 (3.9)

0.764

Cancer Stage

I

II

III

Stage

17 (11.6)

51 (34.7)

79 (53.7)

Stage

8 (9.8)

33 (40.2)

41 (50)

Stage

5 (19.2)

10 (38.5)

11 (42.3)

0.63

(From the Results - Some figures and images on parenthesis can not be reprodced in this paper)

 

DISCUSSION: | Back

CT-identified sarcopenia utilizing the L3 region refers to skeletal muscle index below a specific threshold. The use of CT scan was due to the feasibility for using this imagery in cancer patients for diagnosis and prior treatment management workup. However, studies in the literature present a wide range of threshold, which are varied by demographics, race, body built and geographical location. Reiterating the importance of ethnicity and gender specific reference standards for an accurate diagnosis of sarcopenia due to the fundamental difference in the body habitus, diet and physical activity of Asian, Indians and Westerners. Hence, this study used the recently published article by Eun Hee Kim, [7] as reference data for the T-scores of Lumbar Skeletal muscle Indices. T-score < −2.0 was used as the cutoff for defining sarcopenia (ie, class II sarcopenia), the sex-specific cutoff points of SMA/BMI were 4.97 and 3.46 in men and women, respectively. It is based on the high diagnostic yield that SMA/BMI may be an ideal index for diagnosing sarcopenia, especially in Asian populations. [23].

In the present study, we analyzed the CT-defined skeletal muscle mass, first article in Filipino cancer patients. The overall prevalence of class I and class II sarcopenia in newly diagnosed cancer patients were 43% and 10%, respectively (14% men and 10% women, p = 0.09). Pearson’s logistic analysis showed higher BMI was significantly related to sarcopenia. Advanced age and gender were associated with sarcopenia however, not statistically significant. The present related literatures present varying prevalence of sarcopenia among cancer patients. In a study conducted with DXA-determined body composition in a total of 493 Korean patients with cancer, sarcopenia prevalence was found to be 11.2% with 30% in men and 0.6% in women (p < 0.001); the same study also reports the prevalence of sarcopenia among advanced-age men to be 38% [24]. Recent studies suggest that prevalence of CT-defined sarcopenia is high among chronically ill patients, ranging from 15%–50% in patients with cancer, 30%–45% with liver failure, and 60%–70% for critically ill patients in the intensive care unit [2].

Our study reported higher prevalence of sarcopenia among male (14%) than female patients (10%), however beginning sarcopenia was noted more among female patients (35% vs 18%). The review of 26 studies by Pamoukdjian et al. (n, 5936) reported the prevalence of sarcopenia by gender as 25% in men and 13.1%in women. These findings are consistent with other related literatures, maybe since men have higher skeletal lean mass to begin with. In consideration with the figures, male cancer patients tend to have more steep decline of muscle mass with advancing years of age [17].

With regard to the skeletal muscle indices vs age trends, cancer sarcopenia began in 30-39 age group (4%) with increasing prevalence then peak in 60-69 age group (35%). Higher sarcopenia prevalence found among older male patients were similar to the findings of a previous study [24]. Age-related muscle loss is a well-known phenomenon, with muscle mass peaking in the 20s and continuously decreasing with age. As prevalence increases with age, sarcopenia prevalence rate increases and especially among cancer patients. In addition, with decrease mobility and inadequate nutritional intake, patient’s age-related sarcopenia may be aggravated further due to chronic inflammatory state of malignancy [2]. Genetic predisposition, problems associated with cancer treatment, or lifestyle factors might account for the higher sarcopenia prevalence among cancer survivors. [25]. Moreover, increased inflammation and impaired nutrient intake, bed rest or sedentary lifestyle, chronic diseases, and certain drug treatments associated with cancer may exacerbate muscle loss among older individuals. [26,27] These alterations in metabolism induce approximately 1% loss of muscle mass annually, beginning at 30 years of age and accelerating after 65 year. In addition, with decrease mobility and inadequate nutritional intake, patient’s age-related sarcopenia may be aggravated further due to chronic inflammatory state of malignancy [28. 29].

In this study, prevalence of class II sarcopenia across types of cancer are as follows: Breast cancer 12%, Colon cancer 8%, Liver cancer 7%, and Lung cancer 5%. In correlation, studies by Prado et al and Martin et al reported that CT-defined sarcopenia prevalence ranges from 15%-50% among respiratory/GI cancer patients. In these two separate studies of characterizing body composition of early stage (II vs III) breast cancer by Weinberg et al and Villaseñor et al, the overall sarcopenia prevalence was 16-34%. The HEAL study reported the sarcopenia prevalence of 16%, was associated with an increased risk of overall mortality in breast cancer survivors [10]. Su et al systematic review and meta-analysis for colon cancer showed 34.7% as median incidence of sarcopenia [30]. Meza-Junco et al examined the prevalence of T-defined sarcopenia in patients with cirrhosis and hepatocellular carcinoma which showed 45% prevalence. This article reported that patients with sarcopenia had a lower BMI and higher MELD score and were more likely to be categorized as Child-Pugh C. In addition, a meta-analysis that included 32 studies, overall pretherapeutic sarcopenia (defined by low SMI before both chemotherapy and surgery) prevalence among a total of 6505 patients was 39%, while pre-chemotherapy sarcopenia prevalence was reported to be 29% [31]. Lastly, another meta-analysis that included 38 studies (11 studies on hepatocellular, 6 on pancreaticobiliary, and 4 on gastroesophageal cancer) with a total of 7843 patients with cancer, the sarcopenia prevalence was between 11% and 74% [13]

On the other hand, class I sarcopenia as more prevalent in this study which showed 34%, 29%, 33%, 29% for breast, colon, liver and lung cancers, respectively. These results signify that there is beginning sarcopenia upon diagnosis of cancer prior treatment modalities. Pre-sarcopenia was declared prognostic factor of overall survival. In one study by Takada et al, 57% (n=123) was found pre-sarcopenic which resulted with worse overall survival than those without sarcopenia in patients with hepatocellular carcinoma. In another study that determine the prognostic factor of pre- sarcopenia in early-stage hepatoma undergoing radiofrequency ablation, 16.2% patients were diagnosed with pre-sarcopenia [32]. Reduced OS rates were observed in the pre-sarcopenia group, of which the 1-, 3-, and 5- year cumulative OS rates were 81.8%, 54.5%, 44.1% compared to those without pre-sarcopenia. Pre-sarcopenia imply more severe liver disease and higher mortality even in patients with very early or early HCC. [33] One meta-analysis report indicated that patients with sarcopenia or pre-sarcopenia had poor outcomes after treatment [34]

In this article, prevalence rate of class I sarcopenia is increasing with increasing TNM stage however reciprocally seen with class II sarcopenia. Patients with stage III cancer had prevalence of 24 16% and 5%, class I and class II sarcopenia respectively, which was statistically insignificant. Most of patients in this study were Breast cancer (67%) and with stage III. Most of the related article showed corresponding increase in prevalence of sarcopenia with advanced TNM staging. In a meta- analysis regarding predictive factor of CT-assessed sarcopenia on clinical outcome, the prevalence ranges of tumor stages I, II, and III were 2.78–46.39%, 10.63–56.49%, and 16.12–89.36%. [30] Most of the related literatures illustrate that prevalence of sarcopenia did not differ by or correlate to tumor stages, but was related to increasing age, worse overall health, and a significant reduced likelihood of receiving adjuvant chemotherapy [35]. In the article of Prade et al 2008, sarcopenic obesity was independent of TNM stage and history of previous weight loss. However, cancer sarcopenia in advanced stage along with functional status, correlate well to patient’s overall survival. Median survival was shorter for patients with stage IV cancer (10·0 months) than for those with stage II cancer (30·9 months), stage III cancer (34·1 month), and stage I cancer (mean survival 24·2 months) [14].

Sarcopenic obesity was prevalent our cancer patients in this study. In comparison with subjects without sarcopenia, those diagnosed with cancer sarcopenia were more likely to be older and had higher body mass index, which was statistically significant. 30% of our cancer patients were elderly, 13% and 38% of those were class II and class I sarcopenic, respectively. In this study, sarcopenic obesity was more prevalent in female patients compared with male patients. Sarcopenic obesity was also identified throughout the age trends and TNM staging of our patients. This finding was contrary to the previous studies, since male has a higher muscle mass, body built and are at greater risk.

Sarcopenic obesity in cancer patients have a higher risk for malnutrition and poor clinical outcome than with sarcopenia with normal BMI (Figure 8). In a prospective, observation study by 25 Martin et al 2019, patients with body mass index &25.0 kg/m2 with newly diagnosed head and neck cancer (any stage) or lung and gastrointestinal tract cancer (locally recurrent or metastatic) were screened and examined during presentation to oncology clinics. 64% of overweight and obese patients were at nutrition risk (PG-SGA SF score > 4), and 36% were in critical need of nutrition intervention with improved symptom management (PG-SGA SF > 9). In a similar prospective study of ambulatory oncology outpatient, the Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and the Nutritional Risk Index (NRI) were used for screening and assessing malnutrition. CT analysis revealed cancer cachexia in 42%, sarcopenia in 41%, and myosteatosis in 46%. NRI was most sensitive, with scores <97.5 detecting 85.8%, 88.6%, and 92.9% of sarcopenia, myosteatosis, and CC cases, respectively [36].

The prevalence of sarcopenia in our study was lower than the mean of other studies. There is a high number of breast cancer patients in our present study than the other types of cancer, and there is a lower incidence of sarcopenia in patients with breast cancer, which might explain why the incidence was found to be low in our study. This study presents a higher prevalence of sarcopenia in patients over 65 than those under 65 years (21.9 vs 11.8, respectively), and mostly found in older patients which was similar to the results reported by a previous study [10].

To the best of our knowledge, the current study is the first to determine the prevalence of low muscle mass at the time of diagnosis, which give us an objective finding of ongoing malnutrition in cancer patients. This study clearly illustrates that can higher patients can have sarcopenia regardless of age, site of cancer and stage of cancer, however advanced age and higher BMI will have a higher propensity to develop sarcopenia. At present time, the identification and management of malnutrition and muscle assessment in cancer patients is not clearly considered well. Our results highlight the importance of nutrition risk screening even upon first clinic and the importance of CT- defined skeletal muscle indices determination. Interventions for older adults with cancer cachexia should focus on improving nutrition and increasing physical activity, while pharmacologic treatments remain in development.

Although the present study was the first in Filipino population, it was conducted retrospectively and had certain limitations. First, it was a single-center study; second, patient homogeneity was not achieved to the full extent since most of the populations were female; third, unequal distribution of types of cancer since some cancer were found at a higher frequency in our center. Also, the need of prospective validation findings. Lastly, a limitation of CT image analysis is availability of CT images within the patient medical record. CT images were not available for 64% of our sample, which potentially introduces as selection bias.

Although the present study was the first in Filipino population, it was conducted retrospectively and had certain limitations. First, it was a single-center study; second, patient homogeneity was not achieved to the full extent since most of the populations were female; third, unequal distribution of types of cancer since some cancer were found at a higher frequency in our center. Also, the need of prospective validation findings. Lastly, a limitation of CT image analysis is availability of CT images within the patient medical record. CT images were not available for 64% of our sample, which potentially introduces as selection bias.

CONCLUSION: | Back

In conclusion, this is the first investigation of cancer sarcopenia using computed tomography in Asian patients with newly diagnosed cancer. The present study demonstrates that prevalence of class I and class II sarcopenia is approximately 43% and 10%, respectively, and also shows higher BMI, female gender, and advanced age significantly predict presence of sarcopenia among this population. Therefore, since sarcopenia is associated with poor clinical outcomes such as increased toxicity from chemotherapy and poor prognosis, it is important to detect and give focused nutritional measures to prevent sarcopenia and cachexia. Further investigations are needed on physical and functional aspect of cancer sarcopenia, also the identification of myosteatosis/muscle quality was described closely associated with functional impairment and clinical outcomes.

REFERENCES: | Back

  1. Jann Arends, Patrick Bachmann, Vickie Baracos; ESPEN guidelines on nutrition in cancer patients 2016, Department of Medicine I, Medical Center e University of Freiburg, Faculty of Medicine, University of Freiburg, Germany http://dx.doi.org/10.1016/j.clnu.2016.07.015

  2. Sarah Peterson, Carol A. Braunschweig; Prevalence of Sarcopenia and Associated Outcomes in the Clinical Setting Department of Food and Nutrition, Rush University Medical Center, Chicago, Illinois; and the Department of Kinesiology and Nutrition, University of Illinois at Chicago, Illinois. 2015 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533615622537

  3. Shachar S, Williams G, Muss H., Prognostic value of sarcopenia in adults with solid tumours: A meta-analysis and systematic review, UNC Lineberger Comprehensive Cancer Center, 450 West Drive, Chapel Hill, NC 27514, USA, 29 December 2015, European Journal of Cancer 57 (2016) http://dx.doi.org/10.1016/j.ejca.2015.12.030

  4. Richard F. Dunne, Kah Poh Loh, Grant R. Williams; Cachexia and Sarcopenia in Older Adults with Cancer: A Comprehensive Review 2020, Division of Hematology/Oncology, University of Alabama at Birmingham School of Medicine, Birmingham, AL 35233, USA, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, N14642, USA

  5. Carla M.M. Prado, Laura A. Birdsell and Vickie E. Baracos , The emerging role of computerized tomography in assessing cancer cachexia, Department of Oncology, Division of Palliative Care Medicine, University of Alberta, Edmonton, Alberta, Canada , Curr Opin Support Palliative Care 2009 3:269–275

  6. Liang-Kung Chen, Wei-Ju Lee., Recent Advances in Sarcopenia Research in Asia: 2016 Update from the Asian Working Group for Sarcopenia Aging and Health Research Center, 29 National Yang Ming University, Taipei, Taiwan, The Society for Post-Acute and Long-Term Care Medicine. JAMDA 2016 DOI:http://dx.doi.org/10.1016/j.jamda.2016.05.016

  1. Eun Hee Kim, MD et al, Reference Data and T-Scores of Lumber Skeletal Muscle Area and its Skeletal Muscle Indices Measured by CT Scan in a Healthy Korean Population, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Republic of Korea, 2020

  2. Abellan van Kan G. Epidemiology and consequences of sarcopenia. J Nutr Health Aging. 2009;13(8):708-712.

  3. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39(4):412-423.

  4. Villaseñor A, Ballard-Barbash R, Baumgartner K, Baumgartner R, Bernstein L, McTiernan A, Neuhouser ML (2012) Prevalence and prognostic effect of sarcopenia in breast cancer survivors: the HEAL Study. J Cancer Surviv 6(4):398–406

11. Kondrup J, Allison P, Eila M., ESPEN guidelines for Nutrition Screening 2002, Rigshospitalet University Hospital Copenhagen, Denmark, Clinical Nutrition (2003) 22(4): 415–421, doi:10.1016/S0261-5614(03)00098-0

  1. Jensen G, Cederholm T, Llido L., GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report from the Global Clinical Nutrition Community, GLIM Core Leadership Committee, Journal of Parenteral and Enteral Nutrition Volume 0 Number 0 2018 1–9, DOI: 10.1002/jpen.1440

  2. Shachar S, Williams G, Muss H., Prognostic value of sarcopenia in adults with solid tumours: A meta-analysis and systematic review, UNC Lineberger Comprehensive Cancer Center, 450 West Drive, Chapel Hill, NC 27514, USA, 29 December 2015, European Journal of Cancer 57 (2016) http://dx.doi.org/10.1016/j.ejca.2015.12.030

  1. Prado CM, Lieffers JR, McCargar LJ, et al. Prevalence and clinical impli- cations of sarcopenic obesity in patients with solid tumours of the respira- tory and gastrointestinal tracts: a population-based study. Lancet Oncol. 2008;9(7):629-635.

  2. Martin L, Birdsell L, Macdonald N, et al. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013;31(12):1539-1547

  3. Elizabeth Cespedes Feliciano; Wendy Y. Chen, Clinical implications of low skeletal muscle mass in early-stage breast and colorectal cancer, Division of Research, Kaiser Permanente, Oakland, CA, USA. 2018 doi:10.1017/S0029665118000423

  4. Frederic Pamoukdjian, Thierry Bouillet, Vincent Levy; Prevalence and predictive value of pre-therapeutic sarcopenia in cancer patients: A systematic review, APHP, Avicenne Hospital, Geriatric Department, Coordination Unit in Geriatric Oncology, F-93000, Bobigny, France, Clinical Nutrition Journal March 2017 1-13

  5. Ueno A, Yamaguchi K, Sudo M, Imai S., Sarcopenia as a risk factor of severe laboratory adverse events in breast cancer patients receiving perioperative epirubicin plus cyclophosphamide therapy. Department of Surgery, Kurashiki Central Hospital, Miwa, Kurashiki, Okayama, Japan 2020 doi: 10.1007/s00520-019-05279-x

  6. Laudico A, Mirasol-Lumague M, Medina V., 2015 Philippine Cancer Facts and Estimates, Philippine Cancer Society, Manila Cancer Registry, DOH, 2015

  1. Anne van der Werf, et al, Skeletal muscle analyses: agreement between noncontrast and contrast CT scan measurements of skeletal muscle area and mean muscle attenuation, Clin Physiol Funct Imaging 2018; 38(3): 366-72

  2. Janssen I, Heymsfield SB, Ross R. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. J Am Geriatr Soc. 2002; 50:889–896. doi:

  3. Kim KM, Lim S, Choi SH, et al. Cardiometabolic implication of sarcopenia: The Korea National Health and Nutrition Examination Study (KNHANES) 2008–2010. IJC Metabolic & Endocrine. 2014; 4:63–69. doi: 10.1016/j.ijcme.2014.06.001

  4. Anne B. Newman, Varant Kupelian, Marjolein Visser, Sarcopenia: Alternative Definitions and Associations with Lower Extremity Function, Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; American Geriatrics Society 2003

  5. Kim EY, Kim K, Kim YS, Ahn HK, Jeong YM, Kim JH, Choi W- J (2017) Prevalence of and factors associated with sarcopenia in Korean cancer survivors: based on data obtained by the Korea National Health and Nutrition Examination Survey (KNHANES) 2008–2011. Nutr Cancer 69(3):394–401

  6. Baracos VE, Reiman T, Mourtzakis M, Gioulbasanis I, Antoun S. Body composition in patients with non-small cell lung cancer: a contemporary view of cancer cachexia with the use of computed tomography image analysis. Am J Clin Nutr. 2010;91(4):1133s-1137s

  7. Thompson DD (2007) Aging and sarcopenia. J Musculoskelet Neuronal Interact 7:344–345

  8. Paddon-Jones D, Short KR, Campbell WW et al (2008) Role of dietary protein in the sarcopenia of aging. Am J ClinNutr 87: 1562S–1566S

  9. Abellan van Kan G. Epidemiology and consequences of sarcopenia. JNutr Health Aging. 2009;13(8):708-712.

  1. Hughes VA, Frontera WR, Roubenoff R, Evans WJ, Singh MA. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am J Clin Nutr. 2002;76(2):473-481

  2. Huaiying Su, Junxian Ruan , Tianfeng Chen; 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, Department of Ultrasonic, Quanzhou Women’s and Children’s Hospital, 700 Fengze Road, Quanzhou 362000, Fujian Province, People’s Republic of China, Cancer Imaging (2019) 19:82

  3. Prado CM, Lieffers JR, Bowthorpe L, Baracos VE, Mourtzakis M, McCargar LJ (2013) Sarcopenia and physical function in over- weight patients with advanced cancer. Can J Diet Pract Res 74: 69–74

  4. Takada H, Kurosaki M, Nakanishi H, Takahashi Y, Itakura J, Tsuchiya K, et al. (2018) Impact of pre-sarcopenia in sorafenib treatment for advanced hepatocellular carcinoma. PLoS ONE 13 (6): e0198812. https://doi.org/10.1371/journal. pone.0198812

  5. Yeh WS, Chiang PL, Kee KM, Chang CD, Lu SN, Chen CH, Wang JH. Pre-sarcopenia is the prognostic factor of overall survival in early- stage hepatoma patients undergoing radiofrequency ablation. Medicine 2020; 99:23(e20455).

  6. Chang KV, Chen JD, Wu WT, et al. Association between loss of skeletal muscle mass and mortality and tumor recurrence in hepatocellular carcinoma: a systematic review and meta- analysis. Liver Cancer 2018; 7:90–103.

  7. Hopkins J, Reif R, Baracos V, (2019) The Impact of Muscle and Adipose Tissue on Long- term Survival in Patients with Stage I to III Colorectal Cancer. Department of General Surgery, University of Alberta, Edmonton, Alberta, Canada Dis Colon Rectum 2019; 62: 549–560 DOI: 10.1097/DCR.0000000000001352 ASCRS 2019

36. Martin L, Gioulbasanis I, Senesse P, Baracos V (2019) Cancer-Associated Malnutrition and CT-Defined Sarcopenia and Myosteatosis Are Endemic in Overweight and Obese Patients, Journal of Parenteral and Enteral Nutrition American Society for Parenteral and Enteral Nutrition DOI: 10.1002/jpen.1597

37. Richards CH, Roxburgh CSD, MacMillan MT, Isswiasi S, Robertson EG, et al. (2012) The Relationships between Body Composition and the Systemic Inflammatory Response in Patients with Primary Operable Colorectal Cancer. PLoS ONE 7(8): e41883. doi:10.1371/journal.pone.00418

 

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Name and Codes page2