A Novel Use for Pelvic MRI Scans to Estimate Lean Body Mass and Screen for Sarcopenia in Patients With Rectal Cancer.

BACKGROUND: Sarcopenia, the combination of low lean body mass and decreased muscle strength, is associated with significant morbidity and mortality among patients with colorectal cancer. Standard methods for assessing lean body mass and muscle strength, such as bioelectric impedance analysis and handgrip dynamometry, are rarely obtained clinically. Per National Cancer Center Network recommendations, pelvic MRI is routinely collected for staging and surveillance among patients with rectal cancer. However, there are no data assessing the relationship of pelvic MRI lean body mass measurements at the fifth lumbar vertebrae with bioelectric impedance analysis, handgrip strength, or abdominal CT in patients with rectal cancer. Therefore, we aimed to assess whether pelvic MRI lean body mass correlates with a standard for lean body mass measurement (bioelectric impedance analysis), muscle function (handgrip strength), and an imaging modality frequently used in the literature to identify sarcopenia (abdominal CT at the third lumbar vertebrae). IMPACT OF INNOVATION: Lean body mass measurements from routinely collected pelvic MRI at the fifth lumbar vertebrae accurately and reproducibly estimate lean body mass and modestly correlate with handgrip strength. Rectal cancer pelvic MRI may be repurposed for identifying sarcopenia without increasing inconvenience, ionizing radiation exposure, or expenditure to patients with rectal cancer. TECHNOLOGY, MATERIALS, AND METHODS: Patients with locally advanced rectal cancer with pretreatment bioelectric impedance analysis and handgrip strength measurements within 3 months of their staging pelvic MRI were eligible. Axial skeletal muscle areas were segmented using T1-weighted series pelvic MRI at the fifth lumbar vertebrae and abdominal CT at the third lumbar vertebrae using Slice-O-Matic (Tomovision, Montreal, Canada). Lean body mass (kilograms) was derived from skeletal muscle area with standard equations. Handgrip strength (kilograms) was the maximum of 3 dominant hand attempts in the standing anatomical position. The primary outcome was the agreement between lean body mass measured by pelvic MRI (at the fifth lumbar vertebrae) and bioelectric impedance analysis. Secondary outcomes included the concordance of pelvic MRI lean body mass (at the fifth lumbar vertebrae) with abdominal CT (at the third lumbar vertebrae) and handgrip strength. Additionally, the intra- and interobserver validity, internal consistency, and the mean difference (bias) between lean body mass measurements by pelvic MRI and bioelectric impedance analysis were evaluated. PRELIMINARY RESULTS: Sixteen patients were eligible. The average lean body mass was similar and consistent across 2 observers between bioelectric impedance analysis and pelvic MRI. There was a strong correlation between lean body mass measured on pelvic MRI, bioelectric impedance analysis, and abdominal CT. The reliability of 2 pelvic MRI lean body mass measurements (2 weeks apart by blinded observers) and the correlation of lean body mass between pelvic MRI and bioelectric impedance analysis was strong. Inter- and intraobserver correlation, reliability, and internal consistency were strong for the entire cohort. There was a moderate correlation between pelvic MRI lean body mass and handgrip strength. CONCLUSIONS: Lean body mass measured at the fifth lumbar vertebrae on pelvic MRI is reproducible and correlates strongly with measurements from bioelectric impedance analysis (standard) and abdominal CT at the third lumbar vertebrae and modestly with handgrip strength. These data suggest that MRI lean body mass measurements may be a method to screen patients with rectal cancer for sarcopenia. FUTURE DIRECTIONS: Future studies may evaluate changes in lean body mass on serial pelvic MRI studies among patients with rectal cancer.

Predictors of opioid-free discharge after laparoscopic cholecystectomy.

BACKGROUND: Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. STUDY DESIGN: Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. RESULTS: Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge. CONCLUSION: Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.

Evaluating Age as a Predictor of Postoperative Opioid Use and Prescribing Habits in Older Adults With Cancer.

OBJECTIVE: To assess the narcotic use of older patients after oncologic resection. DESIGN: Retrospective review. SETTING AND PARTICIPANTS: Adults with neoplasms undergoing resection at a tertiary academic medical center. METHODS: Open and minimally invasive resections of the pancreas, bowel, rectum, lung, breast, and skin were included. Emergent procedures, chronic opioid users, and benign pathology were excluded. Narcotic use was measured using morphine equivalents (MEQs, milligrams of morphine) at multiple time points and compared between younger and older (aged ≥65 years) patients. Refill requests were within 30 days of index procedure. RESULTS: A total of 445 patients were eligible, and 245 were ≥65 years old. Despite longer length of stay (3 vs 2 days, P = .01), older patients used less narcotic medication [39.8 (150) mg vs 84 (229) mg, P = .004], and reported lower pain scores [1.3 (3.3) vs 2.8 (4.5), P = .0001] over the course of their hospitalization. Additionally, older patients had lower normalized narcotic use [15.3 (150) mg vs 77.4 (240) mg, P = .0001] in the last 48 hours of their admission. Following discharge, older patients had a lower median discharge MEQ (DC MEQ) compared with younger patients, 75 (150) mg vs 112.5 (102.5) mg, P = .002. Further stratifying older patients into age cohorts (65-74 years, 75-84 years, ≥85 years) revealed progressively less narcotic use as measured by total inpatient MEQ and final 48 hours. Additionally, progressively older patients were discharged with progressively lower DC MEQ compared with younger patients, 90 (112.5) mg, 50 (131.3) mg, and 0 (60) mg vs 112.5 (102.5) mg, P < .0001, respectively. Finally, older patients requested refills less often than younger counterparts, 6.5% vs 14.5%, P = .006. CONCLUSIONS AND IMPLICATIONS: Older patients with cancer reported lower pain scores, consumed less narcotics, were discharged with significantly less narcotics, and called for refills less often compared with younger patients after surgery. These data suggest this population may require less opioids for satisfactory pain control, and development of a guideline targeting postoperative multimodal analgesia in older adults is warranted.

Immune Dysfunction, Cytokine Disruption, and Stromal Changes in Myelodysplastic Syndrome: A Review.

Myelodysplastic syndromes (MDS) are myeloid neoplasms characterized by bone marrow dysfunction and increased risk of transformation to leukemia. MDS represent complex and diverse diseases that evolve from malignant hematopoietic stem cells and involve not only the proliferation of malignant cells but also the dysfunction of normal bone marrow. Specifically, the marrow microenvironment-both hematopoietic and stromal components-is disrupted in MDS. While microenvironmental disruption has been described in human MDS and murine models of the disease, only a few current treatments target the microenvironment, including the immune system. In this review, we will examine current evidence supporting three key interdependent pillars of microenvironmental alteration in MDS-immune dysfunction, cytokine skewing, and stromal changes. Understanding the molecular changes seen in these diseases has been, and will continue to be, foundational to developing effective novel treatments that prevent disease progression and transformation to leukemia.