Influence of nutritional status and body composition on postoperative events and outcome in patients treated for primary localized retroperitoneal sarcoma

Influence of nutritional status and body composition on postoperative events and outcome in patients treated for primary localized retroperitoneal sarcoma

Radiology and Oncology

Volume 58 (2024): Issue 1 (March 2024)

By:

Manuel Ramanovic, Marko Novak, Andraz Perhavec, Taja Jordan, Karteek Popuri and Nada Rotovnik Kozjek

Open Access

|Feb 2024

Figures & Tables

Patients' flow diagram. Out of 123 patients, 58 (47.1%) with primary localized retrperitoneal sarcomas (RPS) were included in the study and 65 were excluded. 34 (27.6%) were excluded as they presented as primary metastatic cases (6), locally recurrent cases (14) or cases with residual disease after operation elsewhere (14), and 31 patients (25.2%) were excluded as they had CT performed > 30 days from initial assessment or CT image was not technically adequate for analysis

Kaplan-Meier curves for OS (A–D) and forest plots of multivariate Cox regression analysis of factors associated with OS (E) and LRFS (F). Kaplan-Meier curves for OS according to presence of: (A) myopenia based on EWGSOP2 criteria (red = myopenic, blue = non-myopenic), (B) cancer cachexia (red = cachectic, blue = non-cachectic), (C) high SATI (red = SATI above estimated cohort cut-off, blue = SATI below estimated cohort cut-off) and (D) high VSR (red = VSR > 0.26, blue = VSR < 0.26);EWGSOP2 = The European Working Group on Sarcopenia in Older People revised criteria from 2018; SATI = Subcutaneous Adipose Tissue Index, cm2/m2; SMI = Skeletal Muscle Index; VSR = Visceral-to-subcutaneous adipose tissue area ratio; OS = Overall survival; LRFS = Local recurrence-free survival; HR = Hazard ratio; AIC = Akaike Information Criterion

Association between overall morbidity following surgery for primary RPS and body composition (A–F) and linear correlation analysis between VSR and VATI (G) and VSR and fat mass (H). VSR (F) and intraoperative blood loss (E) independently predicted worse postoperative outcome. In multivariate analysis skeletal muscle index (SMA), lean body mass (LBM), subcutaneous adipose tissue area (SAT) and visceral adipose tissue area (VAT) were not associated with statistically higher overall postoperative morbidity (A–D).VATI = Visceral Adipose Tissue Index; VSR = Visceral-to-subcutaneous adipose tissue area ratio. ȓPearson = Pearson Correlation Coefficient; tStudent = result of t-test for correlation

Results of optimal stratification analysis for body composition parameters

BMI, kg/m²	Skeletal Muscle Index^a, cm²/m²		Visceral Adipose Tissue Index^b, cm²/m²		Subcutaneous Adipose Tissue Index^b, cm²/m²		Visceral to subcutaneous ratio^c		Muscle Radiation Attenuation^d, HU

	Male	Female	Male	Female	Male	Female	Male	Female	Male	Male
< 25	49.21	49.21	61.38	25.55	49.23	86.89	0.26		47.41
≥ 25	49.90	50.64	61.38	25.55	49.23	86.89	0.26		35.88

Summary of univariate and multivariate analysis of association between body composition and outcome following surgery for primary RPS

Clinicopathological factor	Length of hospital stay (> 10 days)				Clavien-Dindo > IIIa				Any complication (overall morbidity)

	Uni-variable		Multi-variable		Uni-variable		Multi-variable		Uni-variable		Multi-variable

	OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p
Myopenia, yes vs. no^a	1.34 (0.38–5.54)	0.664	-	-	0.32 (0.07–1.18)	0.112	-	-	3.11 (0.85–15.08)	0.112	-	-
Visceral obesity, yes vs. no	2.54 (0.68–12.40)	0.196	-	-	0.65 (0.18–2.13)	0.49	-	-	3.61 (1.09–14.44)	0.047	-	-
Myopenic obesity, yes vs. no	0.01 (0.00–0.001)	0.993	-	-	20090605.83 (0.00–NA)	0.993	-	-	279.10 (0.00–NA)	0.993	-	-
Myosteatosis, yes vs. no	1.39 (0.39–5.76)	0.626	-	-	2.17 (0.58–10.58)	0.282	-	-	5.05 (1.39–24.41)	0.023	4.63 (1.03–28.42)	0.063
Cancer cachexia, yes vs. no	0.68 (0.18–2.94)	0.585	-	-	2.83 (0.76–10.59)	0.117	-	-	0.95 (0.27–3.60)	0.935	-	-
Body mass index, kg/m²	1.00 (0.89–1.14)	0.992	-	-	0.94 (0.81–1.06)	0.351	-	-	0.95 (0.27–3.60)	0.935	-	-
Skeletal Muscle Area, HU	1.00 (0.99–1.02)	0.869	-	-	1.00 (0.98–1.01)	0.679	-	-	1.00 (0.99–1.02)	0.681	-	-
Skeletal Muscle Index, cm²/m²	1.00 (0.95–1.07)	0.88	-	-	1.00 (0.95–1.06)	0.909	-	-	1.04 (0.98–1.10)	0.230	-	-
Muscle Radiation Attenuation, HU	0.98 (0.92–1.04)	0.526	-	-	0.99 (0.93–1.05)	0.775	-	-	0.94 (0.88–1.00)	0.076	-	-
SAT, cm²	1.00 (0.99–1.00)	0.336	-	-	1.00 (0.99–1.00)	0.48	-	-	1.00 (0.99–1.01)	0.866	-	-
VAT, cm²	1.00 (1.00–1.01)	0.769	-	-	1.00 (0.99–1.00)	0.622	-	-	1.00 (1.00–1.01)	0.205	-	-
VSR	1.55 (0.53–5.51)	0.456	-	-	1.09 (0.39–2.861)	0.861	-	-	1.72 (0.66–5.19)	0.292	-	-
High VSR^b, yes vs. no	2.50 (0.63–9.52)	0.179	-	-	2.75 (0.63–19.26)	0.224	-	-	6.19 (1.69–26.52)	0.008	5.05 (1.08–29.74)	0.05
Body fat, %	0.96 (0.87–1.05)	0.380	-	-	1.00 (0.92–1.09)	0.962	-	-	1.00 (0.93–1.09)	0.912	-	-
Lean Body Mass, kg	1.01 (0.96–1.07)	0.765	-	-	1.02 (0.97–1.08)	0.381	-	-	1.02 (0.97–1.08)	0.381	-	-
SATI, cm²/m²	0.99 (0.97–1.01)	0.279	-	-	0.99 (0.97–1.01)	0.344	-	-	1.00 (0.99–1.02)	0.794	-	-
VATI, cm²/m²	1.00 (0.99–1.02)	0.625	-	-	1.00 (0.98–1.01)	0.706	-	-	1.01 (1.00–1.04)	0.122	-	-
High SATI^c, yes vs. no	1.80 (0.52–6.25)	0.346	-	-	0.90 (0.26–2.93)	0.863	-	-	1.50 (0.49–4.81)	0.481	-	-
High VATI^d, yes vs. no	0.49 (0.10–1.87)	0.327	-	-	0.38 (0.08–1.44)	0.184	-	-	2.83 (0.84–11.45)	0.111	-	-

Clinical characteristics of study population

Clinical characteristic (N = 58)	Median (IQR); n (%)
Age, years	61.0 (46.0 – 67.0)
Gender
Male	34 (58.6%)
Female	24 (41.4%)
ASA grade
1	9 (16%)
2	30 (52%)
3	16 (28%)
4	3 (5.2%)
Baseline albumin, g/L	41.0 (34.2 – 45.0)
Baseline C-reactive protein, mg/L	13.5 (2.0 – 66.5)
Neutrophil-lymphocyte ratio	3.3 (2.1 – 4.7)
Body Mass Index, kg/m²	26.0 (24.7 – 29.7)
Nutrition and body composition characteristics
Nutritional team support before operation	28(48.3%)
Skeletal Muscle Area, cm²	45.5 (115.9 – 170.1)
Visceral Fat Area, cm²	104.5 (53.6 – 168.7)
Subcutaneous Adipose Tissue Area, cm²	167.9 (127.9 – 231.6)
Total Fat Area, cm²	23.6 (19.8 – 29.1)
Total Body Fat, %	30.6 (26.8 – 32.4)
Lean Body Mass, kg	52.7 (50.0 – 57.2)
Skeletal Muscle Index, cm²/m²	50.2 (44.0 – 55.6)
Appendicular Skeletal Muscle Index, cm²/m²	6.70 (6.00 – 7.3)
Myopenia based on estimated cut-off value for SMI^a	18 (31.0%)
Myopenia based on EWGSOP2 criteria for SMI	19 (32.8%)
Cancer cachexia	13 (22.4%)
Visceral obesity	21 (36.2%)
Myopenic obesity	4 (6.9%)
Myosteatosis^a	37 (63.7%)
Pathologic characteristics and postoperative outcome data
Postoperative (90 day) complication rate	37 (64%)
Abdominal complication	24 (41%)
Systemic complication	17 (29%)
Abdominal and systemic complications	5 (9.0%)
Clavien-Dindo > IIIa
Yes	17 (29%)
No	41 (71%)
Comprehensive Complication Index	20.92 (0.0–32.55)
Histologic type
Liposarcoma	35 (60%)
Leiomyosarcoma	9 (16%)
Pleomorphic sarcoma	1 (1.7%)
Other	13 (22%)
Tumour size, cm	20 (11–30)
FNCLCC grade
1	15 (26%)
2	11 (19%)
3	23 (40%)
Unknown	9 (16%)
Stage AJCC (8^th edition)
1A	1 (1.7%)
1B	23 (40%)
3A	6 (10%)
3B	28 (48%)
Completeness of surgical resection
R0	47 (81%)
R1/R2	11 (19%)

Comparison of clinical and body composition parameters between myopenic and non-myopenic patients (EGSWOP2 criteria)

Clinicopathological factor	Level^a	Myopenic^b	Non Myopenic^b	p
Age, years	Median (IQR)	66.0 (50.5–71.5)	61.0 (46.0–64.8)	0.236
Gender	Male	11(57.9)	23 (60.5)	1
Gender	Female	8(42.1)	15 (39.5)	1
ASA Grade, 2–3 vs. 1	1	3 (15.8)	6 (15.8)	1
ASA Grade, 2–3 vs. 1	2–3	16 (84.2)	32 84.2)	1
FNCLCC Grade	1	5 (29.4)	10 (32.3)	0.547
	2	5 (29.4)	5 (16.1)
	3	7 (41.2)	16 (51.6)
	(Missing)	7 (18.4)	2 (10.5)
Tumour size, cm	Median (IQR)	26.0 (20.5–34.0)	17.5 (10.0–24.8)	0.005
Clavien-Dindo > IIIa	Yes	3 (15.8)	14 (36.8)	0.183
Clavien-Dindo > IIIa	No	16 (84.2)	24 (63.2)
Neutrophil-lymphocyte ratio	Median (IQR)	3.9 (2.4–4.7)	3.0 (2.1–4.7)	0.504
Baseline albumin, g/L	Median (IQR)	40.0 (32.0–42.5)	43.0 (35.0–45.8)	0.232
Baseline C-reactive protein, mg/L	Median (IQR)	44.0 (7.5–99.5)	6.0 (2.0–45.0)	0.088
Haemoglobin level, g/L	Median (IQR)	128.0 (101.5–136.5)	132.5 (115.2–145.8)	0.141
Preoperative radiotherapy	No	19 (100.0)	37 (97.4)	1
Preoperative radiotherapy	Yes	0 (0.0)	1 (2.6)
Resection status	R0	17 (89.5)	29 (76.3)	0.406
Resection status	R1	2 (10.5)	9 (23.7)
Intraoperative blood loss, ml	Median (IQR)	1300.0 (425.0–4100.0)	1350.0 (500.0–2075.0)	0.78
Stage AJCC, 8th edition	1A–1B	7 (36.8)	17 (44.7)	0.776
Stage AJCC, 8th edition	3A–3B	12 (63.2)	21 (55.3)
Histology subtype	Pleomorphic	1 (5.3)	0 (0.0)	0.184
	Liposarcoma	14 (73.7)	21 (55.3)
	Leiomyosarcoma	2 (10.5)	6 (15.8)
	Other	2 (10.5)	11 (28.9)
Nutrition team before surgery	Yes	12 (63.2)	16 (42.1)	0.223
Nutrition team before surgery	No	7 (36.8)	22 (57.9)
Length of hospital stay, days	Median (IQR)	20.0 (11.0–28.8)	15.0 (11.5–27.0)	0.593
Visceral obesity	Yes	4 (21.1)	16 (42.1)	0.202
Visceral obesity	No	15 (78.9)	22 (57.9)
Myosteatosis	Yes	16 (84.2)	21 (56.8)	0.079
Myosteatosis	No	3 (15.8)	16 (43.2)
Cancer cachexia	No	12 (63.2)	31 (83.8)	0.163
Cancer cachexia	Yes	7 (36.8)	6 (16.2)
Body Mass Index, kg/m²	Median (IQR)	25.7 (23.3–27.2)	26.9 (24.8–30.9)	0.071
Skeletal Muscle Area, HU	Median (IQR)	115.8 (106.5–153.3)	149.9 (130.6–177.1)	0.019
Skeletal Muscle Index, cm²/m²	Median (IQR)	41.0 (38.3–46.8)	53.5 (46.2–58.8)	< 0.001
Muscle Radiation Attenuation, HU	Median (IQR)	35.6 (31.8–43.2)	38.1 (29.9–42.2)	0.959
Subcutaneous Adipose Tissue Area, cm²	Median (IQR)	156.4 (103.2–194.4)	185.4 (131.4–254.1)	0.078
Visceral Adipose Tissue Area, cm²	Median (IQR)	64.6 (38.1–131.6)	125.5 (66.1–201.7)	0.07
Visceral-to-subcutaneous adipose tissue area ratio	Median (IQR)	0.5 (0.2–0.9)	0.8 (0.3–1.1)	0.393
Body fat, %	Median (IQR)	28.3 (21.3–31.6)	31.1 (28.1–33.3)	0.024
Lean Body Mass, kg	Median (IQR)	52.5 (50.4–57.7)	52.8 (49.8–56.4)	0.684
Subcutaneous Adipose Tissue Index, cm²/m²	Median (IQR)	46.8 (30.6–67.2)	64.6(43.9–95.0)	0.048
Visceral Adipose Tissue Index, cm²/m²	Median (IQR)	20.6 (13.2–43.8)	42.3 (24.2–63.6)	0.025

DOI: https://doi.org/10.2478/raon-2024-0013 | Journal eISSN: 1581-3207 | Journal ISSN: 1318-2099

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Language: English

Page range: 110 - 123

Submitted on: Jul 26, 2023

Accepted on: Nov 3, 2023

Published on: Feb 21, 2024

Published by: Association of Radiology and Oncology

In partnership with: Paradigm Publishing Services

Publication frequency: 4 times per year

Keywords:

obesity,

retroperitoneal sarcoma

Related subjects:

Medicine,

Clinical medicine,

Internal medicine,

Haematology, oncology,

Radiology

© 2024 Manuel Ramanovic, Marko Novak, Andraz Perhavec, Taja Jordan, Karteek Popuri, Nada Rotovnik Kozjek, published by Association of Radiology and Oncology
This work is licensed under the Creative Commons Attribution 4.0 License.

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Influence of nutritional status and body composition on postoperative events and outcome in patients treated for primary localized retroperitoneal sarcoma

Figures & Tables

FIGURE 1.

FIGURE 2.

FIGURE 3.

Results of optimal stratification analysis for body composition parameters

Summary of univariate and multivariate analysis of association between body composition and outcome following surgery for primary RPS

Clinical characteristics of study population

Comparison of clinical and body composition parameters between myopenic and non-myopenic patients (EGSWOP2 criteria)

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