Elsevier

Gynecologic Oncology

Volume 142, Issue 2, August 2016, Pages 311-316
Gynecologic Oncology

Muscle composition measured by CT scan is a measurable predictor of overall survival in advanced ovarian cancer

https://doi.org/10.1016/j.ygyno.2016.05.027Get rights and content

Highlights

  • Sarcopenia and low mean skeletal attenuation are commonly found in advanced epithelial ovarian cancer patients.

  • Low mean skeletal attenuation is associated with shorter overall survival in patients with advanced ovarian cancer.

Abstract

Objectives

To assess the impact of muscle composition and sarcopenia on overall survival in advanced epithelial ovarian cancer (EOC) after primary debulking surgery (PDS).

Methods

Women with stage IIIC/IV EOC who underwent PDS with curative intent between 1/1/2006 and 12/31/2012 were included. Patient variables and vital status were abstracted. Body composition was evaluated in a semi-automated process using Slice-O-Matic software v4.3 (TomoVision). Skeletal muscle area and mean skeletal muscle attenuation were recorded. Associations with overall survival were evaluated using Cox proportional hazards models and recursive partitioning.

Results

We identified 296 patients and 132 (44.6%) were classified as sarcopenic. The average mean skeletal muscle attenuation of the entire cohort was 33.4 Hounsfield units (HU). A multivariate model of overall risk of death included histology, residual disease, and mean skeletal attenuation. Among patients without residual disease, overall survival, but not progression free survival was significantly different between patients with low versus high mean skeletal attenuation (median survival, 2.8 vs. 3.3 years). Among patients with residual disease, overall survival was significantly different between patients with low versus high mean skeletal attenuation ≥ 36.40 vs. < 36.40 HU (median survival, 2.0 vs. 3.3 years).

Conclusions

Sarcopenia and low mean skeletal muscle attenuation are common in women undergoing PDS for advanced EOC. These factors are associated with poorer outcomes, and can be used in preoperative risk stratification and patient counseling. Further research into body composition and whether this risk factor can be altered via nutrition or fitness in this population is warranted.

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

References (25)

  • American Cancer Society

    Cancer Facts & Figs

    (2016)
  • M.J. Englesbe et al.

    Analytic morphomics, core muscle size, and surgical outcomes

    Ann. Surg.

    (2012)
  • Cited by (0)

    View full text