The impact of sarcopenia on sarcoma patients: a systematic review and meta-analysis

Abstract

Purpose: Sarcopenia has been linked to poor outcomes in various cancers, but its specific effect on sarcoma patients remains unclear. This systematic review and meta-analysis investigates the impact of sarcopenia, estimated using CT, on sarcoma patients, focusing on prognostic implications and associated outcomes.

Materials and methods: The PubMed, Embase, and SCOPUS databases were searched up to March 2025. Then, a meta-analysis of the data was performed. Overall survival (OS) and relapse-free survival (RFS) were the endpoints. Hazard ratios and 95% confidence intervals were assessed to evaluate the association between sarcopenia and survival of sarcoma patients.

Results: Eighteen studies with a total of 1699 patients met the inclusion criteria. Liposarcoma was the most reported histotype in 67% of the studies, with extremities being the most common tumor location (50%), and chemotherapy was the primary intervention in 89% of cases, followed by radiation therapy (78%) and surgery (67%). Analyzing seven articles, a pooled HR of 1.91 (95% CI 1.09-3.34) for OS was reached, indicating that sarcopenic patients have a 91% higher risk of mortality compared to non-sarcopenic patients (p < 0.01). There is no evidence of selective publication (p = 0.137). The meta-analysis for the two studies that reported HR of RFS resulted 1.16 (95% CI 0.85-1.59), not significant (p = 0.28). The quality of the included studies demonstrated high methodological rigor.

Conclusions: Worse outcomes have been observed in sarcopenic patients with sarcomas, but the impact of sarcopenia on OS and RFS still remains uncertain, highlighting the need for further research and standardized approaches. Trial Registration The protocol for this review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (registration unique identifying number: CRD42024578969).

Keywords: Meta-analysis; Mortality; Sarcoma; Sarcopenia; Survival; Systematic review.

Fig. 1

Flowchart of study selection

Fig. 2

Forest plot representing the individual hazard ratios for overall survival for each study and the pooled estimate. The plot also includes the confidence intervals for each study and the overall pooled HR

Fig. 3

Forest plot representing the individual hazard ratios for relapse-free survival for each study and the pooled estimate. The plot also includes the confidence intervals for each study and the overall pooled HR

Fig. 4

Funnel plot assessing publication bias in the meta-analysis of sarcopenia’s impact on sarcoma outcomes. The funnel plot does not indicate a potential publication bias. The Egger’s test does not support the presence of funnel plot asymmetry (p = 0.137) for the OS analysis. The vertical red line represents no effect, and the spread of points indicates variability in the standard errors of the reported hazard ratios

Fig. 5

Axial CT images obtained at L3 level in 49-year-old woman which was used to determine skeletal muscle area (SMA). SMA measured 109.5 cm². Blue indicates automated segmentation of visceral adipose tissue (VAT), and yellow denotes automated segmentation of subcutaneous adipose tissue (SAT)

Fig. 6

Computerized tomography (CT) abdomen image of a 49-year-old patient showing standardized measurements of the psoas area (mm2) and density (HU)