Muscle composition measured by CT scan is a measurable predictor of overall survival in advanced ovarian cancer
Introduction
Epithelial ovarian cancer (EOC) is estimated to affect 22,280 US women in 2016 and resulted in 14,240 deaths [1]. Patients presenting with advanced stage EOC often have a large tumor and ascites burden that has resulted in decreased oral intake and compromised bowel function; therefore they are often malnourished at the time of presentation.
Sarcopenia is the loss of skeletal muscle mass with a decrease in functional strength, and according to an international group gathered to define sarcopenia in cancer patients, it is a fundamental part of cancer cachexia and an important part of the cancer patient evaluation [2]. Previous studies in non-ovarian cancer have shown deleterious effects of sarcopenia on both surgical outcomes and oncologic outcomes including longer hospital stay, increased rates of infections, and decreased progression-free and overall survival [3], [4], [5], [6], [7], [8], [9]. Further, sarcopenic obesity has emerged as an important factor in morbidity and overall survival in cancer patients [6], [7], [8]. Muscle attenuation is a radiologic measurement of muscle density, and has been shown to represent the degree of lipid deposition in skeletal muscle; it may be a surrogate for muscle quality. However, findings in ovarian cancer are limited, and few papers have addressed sarcopenia in ovarian cancer patients and none have addressed muscle quality. Further, no papers have addressed sarcopenic overweight/obesity, that is, the finding of low muscle mass in patients with a body mass index (BMI) ≥ 25.0 kg/m2. Sarcopenia and sarcopenic overweight/obesity are important parts of the overall frailty of a patient, which can have significant impact on surgical recovery, ability to tolerate physiologic stress, and ability to tolerate chemotherapy [10]. The ability to identify these patients may have an impact on choice of treatment approach (primary surgery versus neoadjuvant chemotherapy), and have an impact on overall management and counseling for patients and their families.
Evaluating sarcopenia can be challenging as it requires sophisticated measurement and characterization of muscle mass. Multiple methods have been used to do this, including dual energy x-ray absorptiometry (DEXA), ultrasound, and bioelectric impendence. Computerized tomography (CT) scan has emerged as a readily accessible method of assessing muscle mass. We have previously demonstrated in a pilot study that body composition is associated with overall survival and hospital length of stay in patients undergoing primary EOC debulking surgery [11]. Here we seek to expand on this research. Specifically we aimed to better characterize body composition in advanced stage EOC patients and evaluate the role of sarcopenia and sarcopenic overweight/obesity on overall risk of death.
Section snippets
Patient eligibility
We conducted a single institution cohort study that was approved by the Mayo Clinic Institutional Review Board. Data was obtained from a prospectively maintained ovarian cancer surgical database and through medical record review. All patients consented to the use of medical records for research. Inclusion criteria included patients who underwent primary cytoreductive surgery for stage IIIC or IV EOC (including primary peritoneal carcinoma and fallopian tube cancer) between 1/1/2006 and
Patient demographics
Of the 451 patients with primary debulking surgery for stage IIIC or IV ovarian cancer during the study period, 296 patients met criteria for study inclusion. The most common reason for exclusion was unavailability of preoperative digital CT images (139 cases) and poor quality images making analysis unfeasible (16 cases). While most patients had a CT scan performed pre-operatively, those scans from outside institutions were not always digitally available in our system. Table 1 summarizes
Discussion
Our study is the first to explore body composition and sarcopenia in advanced epithelial ovarian cancer using readily available tools. We observed that 1) low mean skeletal attenuation and sarcopenia are common in patients presenting with advanced ovarian cancer, 2) lower mean skeletal attenuation was associated with worse overall survival but not progression free survival and 3) after accounting for other variables that effect overall survival, histology and residual disease, lower mean
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