Sarcopenia and gynecological cancer patients

Muscle mass progressively augments with growth reaching a variable peak during young adulthood (at approximately 25 years) and then it progressively declines. The age at which muscle loss begins is generally 40 years but may starts earlier or later according to different circumstances. Birth weight, nutrition, lifestyle and diseases influence muscle mass development and preservation. The phenomenon of age related muscle loss was firstly given the name of sarcopenia by Rosenberg. The term derives from the Ancient Greek σάρξ (sárx, “flesh”) +‎ πενῐ́ᾱ (peníā, “poverty”). The original definition referred only to the reduction in muscle mass over time. Initially it was thought that the loss of muscle mass was the cause of the reduction of muscle strength which untimely lead to functional impairment and adverse outcomes. This link was beard by cross-sectional studies, which demonstrated that about one third of the variability in muscle strength in young adults was predicted by muscle mass. However, more recent longitudinal studies have shown that there was a disassociation between age-related changes in muscle mass and strength. Indeed, in prospective studies less than 5% of variations of muscle strength over time were attributable to the corresponding reduction in muscle mass. Moreover, strength (1.5-5% year) declines more rapidly than muscle mass (1-2% year) and is strongly associated with physical performance, development of disability and other adverse outcomes. These associations are instead weak or not found when considering muscle mass alone. Although the term “sarcopenia” has become widespread, the criteria for an operational definition vary among studies and experts. Initial work on defining sarcopenia was based on measures of muscle mass alone Baumgartner and colleagues defined sarcopenia a reduction in relative muscle mass measured Appendicular skeletal muscle mass through DXA and adjusting it for body size by dividing for height squared. A cut-off of ASM/height2 < 2 SDs the young normal mean value was arbitrarily chosen to define sarcopenia. The positive correlation of this index of relative muscle mass (ASM/height2) with BMI, cause an underestimation of sarcopenia in overweight and obese subjects. Newman et al. proposed alternative definitions of sarcopenia. They used a linear regression to model the relationship of ALM, measured by DXA on fat mass (kg) and height (m). Residuals from linear regression were calculated. The 20th percentile of the distribution of residuals was used as the cut-point for sarcopenia. This definition was compared to the one of Baumgartener by using a different cut-point the sex-specific lowest 20% of the distribution of the index (with results superimposable to the ones found by Baumgartner). There was a good correlation between the two definition of sarcopenia (r=0.88 in men and r=0.71 in women), but each method classified a different subset of people as sarcopenic. The method of Baumgartner tended to identify the presence of sarcopenia mainly in thin people, but few overweight and no obese persons were classified as sarcopenic. Instead, by taking into account both fat and height more overweight and obese people were considered sarcopenic. In 2009 the European Working Group on Sarcopenia in Older People proposed a definition of sarcopenia which represented a major change from the past since it added muscle function to former definitions based only on the evaluation of muscle mass. The presence of both low muscle mass and low muscle function (strength or performance) was necessary for the diagnosis of sarcopenia. The 2009 EWGSOP consensus was based on expert opinions and lacked access to large data sets to validate recommendations. Therefore the Foundation for the National Institutes of Health (FNIH) Sarcopenia Project was created to operationalize a data-driven set of criteria for clinically relevant weakness and low lean mass using pooled data from multiple studies. Nine studies were included in the project. Mobility impairment was used as the clinically relevant functional state to determine meaningful weakness. Mobility impairment was defined by a usual gait speed ≤ 0.8 m/s. Grip strength was considered the primary measure of weakness. Lean mass was assessed with DXA and in particular ALM (the sum of lean mass from both arms and legs) was considered. Grip strength less than 26 kg in men and less than 16 kg in women were considered the cut-off for weakness (Figure 5a and b) since they were associated with more than 7 (OR 7.62, 95% C.I. 6.13-9.49) and 4 (OR 4.42, 95%C.I. 3.94-4.97) times respectively the odds of slow walking (≤ 0.8 m/sec). regression tree (CART) analysis was applied to derive cut-points for ALM which best discriminated for the presence of weakness. Primary analyses, identified the following cut-points: ALM <19.75 kg in men and <15.02 kg in women. Sensitivity analyses standardizing ALM for various body size measures identified a secondary definition of lean mass which correlated with weakness: ALM divided by BMI (ALMBMI). The following cut-points were described: <0.789 in men and <0.512 in women. In 2018, the Working Group met again (EWGSOP2) to update to the definition of sarcopenia on the basis of the new scientific evidences. The new definition low muscle strength overtook the role of low muscle mass as a principal determinant of the condition because strength demonstrated to be a better predictor than mass for adverse outcomes. Moreover, this change was expected to facilitate prompt identification of sarcopenia in practice. The new criteria considered sarcopenia probable when low muscle strength was detected. The diagnosis was confirmed by the presence of low muscle quantity or quality. The assessment of physical performance was then use to grade the severity of the condition. The main objective of this study was calculating the concordance among the various definitions of sarcopenia in older patients suffering from a gynecological neoplasm. We used data from a study conducted at the Oncological Gynaecology Unit of the “Agostino Gemelli” University Hospital in 2007. The original aim of the study was to evaluate the impact of a multidisciplinary approach on the management of old patients with gynaecologic cancer. In particular we used data from the phase II prospective observational phase. We included all cancer patients aged 65 years and older who among the comprehensive geriatric assessment (CGA) underwent a complete body composition assessment through DXA. Five definitions of sarcopenia were considered.