Journal of the College of Physicians and Surgeons Pakistan
ISSN: 1022-386X (PRINT)
ISSN: 1681-7168 (ONLINE)
Affiliations
doi: 10.29271/jcpsp.2021.11.1314ABSTRACT
Objective: To investigate the effect of sarcopenia on surgical outcomes in patients with primary high-grade serous ovarian cancer undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC).
Study Design: Descriptive study.
Place and Duration of Study: Department of Surgical Oncology, Faculty of Medicine, Ankara University Ankara, Turkey, from January 2013 to January 2020.
Methodology: Forty patients, who underwent CRS and HIPEC with the diagnosis of primary high-grade serous ovarian cancer and peritoneal carcinomatosis were included in the study. Preoperative staging CT images were used to determine total psoas ındex values by measuring psoas muscle area at the level of L3 vertebra. Patients with total psoas ındex values below the cut-off levels were considered sarcopenic. Demographic, clinicopathological and perioperative results were compared between sarcopenic and non-sarcopenic patients.
Results: Serious postoperative complications (36.4% vs. 6.9%, p=0.039) and infective (54.5% vs. 17.2%, p=0.042) and pulmonary (72.7% vs. 34.5%, p=0.040 complications were significantly higher in sarcopenic patients. Hospital stay [20(12-25) vs. 12(9-16.5) days, p=0.017] and ICU stay [4(2-6) vs. 2(1-2.5) days, p=0.013)] were found to be longer in sarcopenic patients. In univariate analysis, advanced age (OR: 1.40 95% CI: 1.07-1.84; p=0.021) and sarcopenia (OR: 7.71% 95 CI: 1.17-51.06; p=0.039) were significantly associated with serious postoperative complications. The presence of sarcopenia (OR: 0.050 95% CI: 0.004-0.675; p=0.024) was found to be independent predictor of serious postoperative complications.
Conclusion: Sarcopenia can easily be diagnosed without additional cost or radiation exposure with routine preoperative staging CT images. Identification of sarcopenic ovarian cancer patients in preoperative period may affect patient selection, predictability of possible serious complications, elective operation preparation process with a combination of nutrition and exercise therapy, thus postoperative complication rates may be reduced and short-term results may be improved.
Key Words: Cytoreductive surgery, Ovarian cancer, Sarcopenia.
INTRODUCTION
Ovarian cancer (OC) is the leading cause of cancer-related deaths among all gynecological cancers, and its incidence reaches 2% in women over the age of 50 years.1
Despite the development and experience gained in the diagnosis, staging and treatment of ovarian cancer in recent years, high recurrence rates, long-term oncologic results and overall survival rates have not reached satisfactory levels.2 The low probability of distant metastasis and the progression of the disease mostly in the form of local invasion and peritoneal spread suggested that successful results obtained in other gastrointestinal cancers with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) can also be achieved in ovarian cancer. In addition to the positive effect of CRS and HIPEC treatment on oncological results, high cellular stress caused by complex surgical procedures; and cytotoxicity and immunosuppression after chemotherapy can cause serious postoperative complications and even mortality.3
The low performance status of the patients, cancer cachexia and malnutrition also negatively affect postoperative results. Therefore, the preoperative physical condition of the patients is one of the issues that should be considered in the preoperative period. Sarcopenia, which is observed especially in elderly patients and expressed as progressive loss of muscle mass, has also been studied many times in recent years and has been shown to be perhaps the most important objective indicator of physical condition.4
Many studies have shown that sarcopenia is an independent prognostic factor on postoperative outcomes in gastrointestinal cancers such as pancreatic, hepatic and biliary malignancies, and urological cancers.5-8 In the present study, patients with TPI values below the cut-off levels that were determined by Kim et al., according to age and gender, were considered sarcopenic. 9
The aim of the study was to determine effect of sarcopenia on surgical outcomes in patients who underwent CRS and HIPEC with the diagnosis of primary high grade serous ovarian cancer and peritoneal carcinomatosis.
METHODOLOGY
This is a descriptive study conducted at the Department of Surgical Oncology, Faculty of Medicine, Ankara University, Ankara, Turkey from January 2013 to January 2020. Forty patients who underwent CRS and HIPEC, with the diagnosis of primary high-grade serous ovarian carcinoma and peritoneal carcinomatosis and whose psoas muscle mass measurements could be obtained, were included in the study. Patients’ demographic data, laboratory results, pathology results and all data related to postoperative results were retrospectively reviewed by surgical oncologists through the hospital database. Patients whose data could not be accessed, who had recurrent disease, low grade tumors, and who could not undergo CRS and HIPEC considering that CC-0/1 cytoreduction could not be performed by intraoperative exploration, were excluded from the study. Clinical and demographic data and perioperative outcomes were compared between sarcopenic and non-sarcopenic groups. Postoperative complications were determined on the basis of the modified clavien dindo classification (CD), and grade three or higher complications were accepted as serious complications.10
Interval cytoreduction was planned for patients who were diagnosed with FIGO stage IIIC primary high-grade serous ovarian cancer and achieved stable disease or remission after three cycles of neoadjuvant chemotherapy.The anatomical extension of the OC in the peritoneal cavity was evaluated by the PC index (PCI),11 CRS desicion was made at the time of surgery and it was applied in cases where CC-0 (no visible tumor) or CC-1(tumor nodules persisting after cytoredction are less than 2.5 mm in diameter) cytoreduction was predicted to be performed.12 HIPEC was simultaneously performed in each patient with CC-0 and 1 cytoreduction.
In preoperative staging abdominal computerised tomography (CT) scans, the right and left psoas muscle areas at the level of the L3 vertebra were measured three consecutive times in each patient by two independent radiologists. The average of the values obtained was determined as the psoas muscle area. The measurement of the psoas muscle at the third lumbar vertebra level and the calculation of the total psoas ındex (TPI) with patients’ height have been described in previous studies.13 TPI is calculated by dividing the total area of the right and left psoas muscles by the square of the individual's height in meters [(right psoas muscle area + left psoas muscle area) / height (m)2]. Patients with TPI values below the cut-off levels determined according to age groups and gender by Kim et al. were considered sarcopenic (4 cm2/m2 for 20-39 years age; 2.88 cm2/m2for 40-49 years age; 2.43 cm2/m2 for 50-59 years age; 2.20 cm2/m2for 60-69 years age and 1.48 cm2/m2 for 70-89 years age). The patients were divided into two groups as sarcopenic and non-sarcopenic.
Numerical data were expressed as mean ± standard deviation, median (IQR: 25th percentile-75th percentile) or percentages. The normal distribution of the data was determined by histogram graphics and the Shapiro-WilkTest. In comparison of clinical and demographic data and perioperative results between sarcopenic and non-sarcopenic patients, Chi-square test or Fisher Exact test were used for categorical variables. Student t-test or Man-Whitney U-test was carried out for numerical variables. Binary logistic regression analysis was used to determine the factors affecting serious postoperative complications. All p-values less than 0.05 were considered statistically significant. These analyses were performed using IBM® SPSS statistic version 23.0.
RESULTS
According to the cut-off levels determined, while there were no sarcopenic patients in the 20-39 years age group, a total of 11 (27.5%) patients were diagnosed as sarcopenic in other age groups (1, 2, 4 and 4 patients in age groups of 40-49, 50-59, 60-69 and 70-89 years, respectively). The mean TPI value was 2.06 ± 0.48 in the sarcopenic group, and 3.73 ± 0.82 in the non-sarcopenic group (p<0.001).
The relationship between demographic and clinical variables with sarcopenia is summarised in Table I. The median age of the patients included in the study was 64.0 (54.25-69.0) years. Although it was found that patients in the sarcopenic group had lower mean body mass index (BMI) values compared to the other group and there were more patients in the ASA III group, the difference was not statistically significant.
The relationship between perioperative results and sarcopenia is summarised in Table II. While there was no difference between the groups in terms of PCI, CC score, operation time, intraoperative blood loss and in-hospital mortality, it was observed that serious complications of modified CD grade 3 and above were significantly more common in the sarcopenic group (36.4% vs. 6.9%; p = 0.039).
Table I: The relationship between demographic and clinical variables with sarcopenia.|
Variables |
Total (n=40) |
Sarcopenic (n=11) |
Non-sarcopenic (n=29) |
pvalue |
|
Age |
64.0 (54.25-69.0) |
67.0 (54.0-73.0) |
62.0 (54.0-69.0) |
0.339 |
|
BMI (kg/m2) |
28.95 (24.15-32.38) |
30.08 (22.04-32.37) |
28.19 (24.17-32.39) |
0.868 |
|
ASA score n (%) I II III |
14 (35) 14 (35) 12 (30) |
2 (18.2) 4 (36.4) 5 (45.4) |
12 (41.4) 10 (34.5) 7 (24.1) |
0.372
|
|
Comorbid diseases n(%) HT DM Cardiac Pulmonary |
22 (55) 11 (27.5) 9 (22.5) 8 (20) |
7 (63.6) 5 (45.4) 4 (36.4) 3 (27.3) |
15 (51.7) 6 (20.7) 5 (17.2) 5 (17.2) |
0.723 0.137 0.227 0.660 |
|
CA-125 (IU/ml) |
254.5 (169-340.75) |
280 (183-345) |
238 (168-339.5) |
0.515 |
|
Albumin (g/dl) |
4.11 (3.78-4.37) |
3.93 (3.61-4.32) |
4.11 (3.84-4.42) |
0.596 |
|
Ascites (%) None Minimal/medium Massive |
13(32.5) 20 (50) 7 (17.5) |
3 (27.3) 6 (54.5) 2 (18.2) |
10 (34.5) 14 (48.3) 5 (17.2) |
0.906 |
|
TPI (cm2/m2) |
3.27 ± 1.05 |
2.06 ± 0.48 |
3.73 ± 0.82 |
<0.001 |
|
Numerical data are given as mean ± standard deviation, median (IQR) or percentages. BMI: Body mass ındex, ASA: American society of anesthesiologist, HT: Hypertension, DM: Diabetes mellitus, CA: Carcinoembryonic antigen, IU: International unit, TPI: Total psoas ındex. |
||||
|
Variables |
Total (n=40) |
Sarcopenic (n=11) |
Non-sarcopenic (n=29) |
p-value |
|
PCI* n(%) PCI≤5 5 |