Jose N. Galeas
Louise M. W. Man
Ryan D. Gentzler
Patricia J. Hollen
Richard J. Gralla
Received: 26 April 2017 /Accepted: 15 January 2018 /Published online: 7 February 2018
Springer-Verlag GmbH Germany, part of Springer Nature 2018
Purpose Ongoing cancer cachexia trials evaluate sarcopenia by skeletal muscle index (SMI) at the L3 vertebrae level, commonly
used as a standard. Routine chest CT institutional protocols widely differ in including L3. We investigated whether SMI at L1
assessment, rather than L3, would be reliable and more practicable for non-small cell lung cancer (NSCLC).
Methods NSCLC patients with routine CT chest had SMI measurements performed at L1 using Slice-O-Matic software.
Accuracy of including L1 level, imaging quality, and ability to detect sarcopenia was collected and correlation of L1 SMI with
body mass index (BMI) was performed.
Results Thirty-seven patients with NSCLC (73 CT assessments) were enlisted at three institutions. Characteristics: 47% female;
medians: age 59, KPS 80%; BMI 25.49, weight 72.97 kg, SMI 59.24. Sarcopenia was detected in 14.7% of patients; 20% had
sarcopenic obesity. Of the 73 CTs, 94.5% included L1 (95% CI 86.6–98.5%). Three images (4%) were difficult to evaluate.
Inclusion of L1 was similar among the three participating institutions (90.4 to 96.7% inclusion). BMI correlation with SMI was
weak (r =0.329).
Conclusions SMI assessment at L1 is achievable in patients with NSCLC receiving routine chest CT, with 96% having acceptable
quality evaluations. Similar to results previously reported at L3, BMI showed poor correlation and low sensitivity to detect
muscle mass loss. The use of CT at L1 is reliable and presents the opportunity for easier patient evaluation of sarcopenia in
patients with lung cancer without the need for additional testing or radiation exposure.
Keywords Lung cancer
Skeletal muscle mass
Cancer anorexia-cachexia syndrome, including skeletal mus-
cle wasting, is a key aspect affecting survival and quality of
life of cancer patients . Definitions for these terms vary and
at times can be controversial . Nonetheless, it has been
widely accepted that sarcopenia, defined as loss of skeletal
muscle mass, is a major component of cancer cachexia .
Sarcopenia is an independent predictor of poor quality of life,
increased chemotherapy toxicity, lower response to treatment,
shorter time to tumor progression, prolonged length of stay
and post-operative complications, and decreased quality of
life and survival in numerous different malignancies with am-
ple supportive evidence [4–8]. As is the case with other can-
cers, sarcopenia in lung cancer has been shown to be associ-
ated with similarly poor outcomes [9–13]. This study was
initiated to document a practical approach to assess early
sarcopenia in non-small cell lung cancer (NSCLC) for daily
management of patients and/or for use in research settings.
Over the past decade, several methods to measure skeletal
muscle mass in cancer have been investigated, as listed in
Table 1 [14–17]. All of these methods are more accurate than
routine anthropometric measurements such as weight or body
* Richard J. Gralla
Jacobi Medical Center, Albert Einstein College of Medicine,
Bronx, NY 10461, USA
University of Virginia, Charlottesville, VA, USA
Supportive Care in Cancer (2018) 26:2353–2359
Enhancing evaluation of sarcopenia in patients with non-small cell lung
cancer (NSCLC) by assessing skeletal muscle index (SMI) at the first
lumbar (L1) level on routine chest computed tomography (CT)