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Quality is more important than quantity: pre-operative sarcopenia is associated with poor survival in advanced ovarian cancer
  1. Clarissa Polen-De1,
  2. Priyal Fadadu1,
  3. Amy L Weaver2,
  4. Michael Moynagh3,
  5. Naoki Takahashi3,
  6. Aminah Jatoi4,
  7. Nathan K LeBrasseur5,
  8. Michaela McGree2,
  9. William Cliby1 and
  10. Amanika Kumar1,4
  1. 1 Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
  3. 3 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  4. 4 Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
  5. 5 Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Amanika Kumar, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA; kumar.amanika{at}


Background Sarcopenia is prevalent among older patients with cancer and is associated with poor outcomes.

Objective To explore the relationship between muscle mass, quality, and patient age with overall survival after surgery for advanced ovarian cancer.

Methods Patients with advanced stage (IIIC/IV) ovarian cancer who underwent primary cytoreductive surgery between January 2006 and July 2016 were included. Body composition measures were calculated from pre-operative CT imaging: skeletal muscle index (skeletal muscle index=skeletal muscle area normalized for height), skeletal muscle density, and skeletal muscle gauge (product of skeletal muscle index and skeletal muscle density). Each measure was transformed to a z-score and evaluated for association with risk of death using Cox proportional hazards models. Recursive partitioning was used to classify patients into homogeneous subgroups considering age and skeletal muscle gauge as predictors of overall survival.

Results The study included 429 patients (mean age 64.2 years). Increased age moderately correlated with decreased skeletal muscle gauge (r=−0.45). Decreasing skeletal muscle density and skeletal muscle gauge were significantly associated with increased risk of death; HR (95% CI) per 1-unit decrease in z-score of 1.24 (1.10 to 1.39) for skeletal muscle density and 1.27 (1.12 to 1.44) for skeletal muscle gauge. Associations were diluted after adjusting for age (1.13 (1.00 to 1.29) skeletal muscle density and 1.14 (0.99 to 1.30) skeletal muscle gauge). Recursive partitioning identified three subgroups: <60 years old, ≥60 years old with skeletal muscle gauge ≥937.3, and ≥60 years old with skeletal muscle gauge <937.3; median overall survival was 5.8, 3.3, and 2.3 years, respectively (p<0.001).

Conclusions Skeletal muscle gauge, a novel sarcopenia measure incorporating quantity and quality, was associated with poorer survival in patients with advanced ovarian cancer, particularly among patients older than 60. Expanding our knowledge of how sarcopenia relates to solid tumor outcomes among high-risk patients can modify our treatment approach.

  • Ovarian Cancer
  • Gynecologic Surgical Procedures
  • Surgical Oncology
  • Postoperative Care
  • Cytoreduction surgical procedures

Data availability statement

Data are available upon reasonable request.

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  • Presented at Sarcopenia in ovarian cancer: Sarcopenic patients have decreased survival Polen-De, C., Weaver, A., McGree, M., Jatoi, A., Cliby, W., Kumar, A. Western Association for Gynecologic Oncology June 2020 (virtual).

  • Contributors CP-D: conceptualization, data curation, investigation, writing – original draft; PF: data curation, investigation, writing – review and editing; ALW, MMc: formal analysis, methodology, writing – review and editing; MMo: methodology, resources, software, writing – review and editing; NT: resources, software, writing – review and editing; AJ, WC: conceptualization, methodology, supervision, writing – review and editing; NKL: conceptualization, writing – review and editing; AK: guarantor, conceptualization, investigation, sata curation, methodology, visualization, supervision, writing – review and editing.

  • Funding Funding provided to Dr Cliby by the Virgil S. Counsellor MD Professorship in Surgery, Mayo Clinic.

  • Competing interests MM has a restricted research grant Phillips Medical, unrelated to this project. Funding provided to WC by the Virgil S Counseller MD Professorship in Surgery, Mayo Clinic.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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