Impact Of Sarcopenia on Survival in Patients with Advanced Hepatocellular Carcinoma

Purpose/Objective(s)Sarcopenia is defined as skeletal muscle depletion, and is associated with poor outcomes in patients suffering from either malignancy. This study aims to evaluate the significance of pre stereotactic body radiation therapy (SBRT) sarcopenia on survival in patients of advanced hepatocellular carcinoma (HCC) with underlying cirrhosis.Materials/MethodsIt is a retrospective observational study done between May 2020 and Nov 2021. The data was collected from 35 patients with Barcelona Clinic Liver Cancer C group (BCLC-C) HCC, who were unsuitable for other liver-directed therapies. Patients with Child-Pugh score A5-B7 along with normal liver reserve ≥ 700cc were included. Sarcopenia was assessed from radiation planning computed tomography (CT) scans using skeletal muscles at the level of the L3 (Lumbar) vertebra. The muscles were identified at a predefined CT density of29 to +150 Hounsfield Unit (HU). The sum of the area of six abdominal muscles (erector spinae, quadrates lumborum, psoas, transversus abdominis, interior/exterior oblique, and rectus abdominis) was defined as skeletal muscle area (SMA, in cm2). SMA was normalized for height in m2 and expressed as skeletal muscle index (SMI) in cm2/m2. Sarcopenia was defined as skeletal muscle index <36 cm2/m2 for men and <29 cm2/m2 for women as per institutional specific cutoffs. The overall survival rates were calculated according to Sarcopenia by using the Kaplan-Meier method and were compared using the log-rank testResultsIn the cohort, the median age was 61 years (range 39-83 yrs). Portal vein and IVC tumor thrombosis were present in 94.3% and 22.85% patients respectively. Lung and nodal metastasis were found in 31.4% and 60% of patients respectively. The median Tumor diameter was 11 cm (range 3-21) and the median GTV volume was 563cc (80-1925cc). The median SBRT dose prescription was 40Gy (25-45Gy) in 5 to 10 fractions. Median SMI was 40.55cm2/m2 (range: 22.71 to 57.09) After normalization (sarcopenia: <36 cm2/m2, female; <29cm2/m2, male), 10 patients (28.6%) had sarcopenia. Pre-SBRT sarcopenia was associated with higher PIVKA-II values (5310.5 vs 13545). At a median follow up of 8 months, median overall survival (mOS) in sarcopenic patients was lower as compared to non-sarcopenic pts (6 vs 11 months, p <0.05). SMI had no association with PFS (p = 0.63). Increasing BMI was associated with improved OS (HR 1.06, 95% CI 0.45-2.5).ConclusionSarcopenia in HCC patients receiving SBRT is an independent prognostic factor for poor survival outcomes. Increasing BMI is associated with improved OS. Future, prospective work is needed to define the impact of sarcopenia on cancer specific outcomes for HCC patients.