Total Psoas Area and Total Muscular Parietal Area Affect Long-Term Survival of Patients Undergoing Pneumonectomy for Non-Small Cell Lung Cancer

Simple Summary Lung cancer continues to be one of the leading cause of cancer-related deaths. In multimodality management of non-small cell lung cancer, surgery remains the mainstay, and in particular, pneumonectomy remains the only possible surgical procedure in patients with centrally located lesions. However, despite improvements in technique and perioperative management, it continues to be associated with significant postoperative mortality. Thus, identifying patients at high postoperative risk is of paramount importance to select surgical candidates, but identifying patients more likely to achieve definitive cure after surgery is at least as important. Among all the evaluated parameters, we found that being sarcopenic at both psoas and parietal muscles is an independent negative prognostic factor of overall survival. The whole muscular area had the best predictive value among all of the tested factors evaluating sarcopenia. There is no standardization in methods to assess sarcopenia; in particular the prognostic significance of muscular fatty infiltration in lung cancer patients undergoing surgery has not been evaluated so far. We thus performed several computed tomography (CT)-based morphometric measurements of sarcopenia in 238 consecutive non-small cell lung-cancer patients undergoing pneumonectomy from 1 January 2007 to 31 December 2015. Sarcopenia was assessed by the following CT-based parameters: cross-sectional total psoas area (TPA), cross-sectional total muscle area (TMA), and total parietal muscle area (TPMA), defined as TMA without TPA. Measures were performed at the level of the third lumbar vertebra and were obtained for the entire muscle surface, as well as by excluding fatty infiltration based on CT attenuation. Findings were stratified for gender, and a threshold of the 33rd percentile was set to define sarcopenia. Furthermore, we assessed the possibility of being sarcopenic at both the TPA and TPMA level, or not, by taking into account of not fatty infiltration. Five-year survival was 39.1% for the whole population. Lower TPA, TMA, and TPA were associated with lower survival at univariate analysis; taking into account muscular fatty infiltration did not result in more powerful discrimination. Being sarcopenic at both psoas and parietal muscle level had the optimum discriminating power. At the multivariable analysis, being sarcopenic at both psoas and parietal muscles (considering the whole muscle areas, including muscular fat), male sex, increasing age, and tumor stage, as well as Charlson Comorbidity Index (CCI), were independently associated with worse long-term outcomes. We conclude that sarcopenia is a powerful negative prognostic factor in patients with lung cancer treated by pneumonectomy.

Automated summary

Lung cancer surgery is still the main treatment for non-small cell lung cancer, but it is associated with high postoperative mortality. Computed tomography scans can be used to assess sarcopenia by evaluating the psoas and parietal muscles, which are important prognostic factors for survival in lung cancer patients.