br Table years of age with newly diagnosed
Table 1 years of age) with newly diagnosed pancreatic cancer at our insti-tute. CT was performed to evaluate local extension (T stage), regional Fulvestrant node status (N stage) and possible metastasis (M stage) according to the American Joint Committee on Cancer (AJCC) guidelines, 7th edition . Clinical data, including age, gender, presence of diabetes or smoking, body weight (BW), BH, body mass index (BMI), albumin (Alb) level, and received curative resection or not were obtained from electric medical records. Age was catego-rized as equal to or below 70 years old (y/o) or above 70 y/o. For patients equal to or below 70 y/o, BMI was categorized as under-weight (<18.5 kg/m2) versus non-underweight (S18.5 kg/m2) and for patients above 70 y/o, BMI was categorized as underweight (<22 kg/m2) versus non-underweight (S22 kg/m2) according to the European Society of Clinical Nutrition and Metabolism consensus statement . The Alb level was categorized as equal to or below 40 g/L or above 40 g/L. The digital imaging and commu-nications in medicine (DICOM) files for the CT scans were collected from our picture archiving and communication system (PACS). The time interval for acquiring clinical, laboratory and CT data was within one week. A total of 162 patients were consecutively enrolled in this study from October 2013 to October 2016. We included patients with an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0e1, and PS 2e4 patients were excluded because comorbidities could exist. Finally, a total of 146 patients were included. All patients underwent standard treat-ments after staging and clinical evaluation. Demographic charac-teristics are presented in Table 1.
2.2. Imaging processing
The DICOM files of abdominal CT at the L3 level were collected from our PACS. The CT scanner differentiates body tissues by HU from non-enhanced images based on tissue-specific attenuation values, including TSM ( 29, þ150), visceral adipose tissue (VAT, 150, 50) and subcutaneous adipose tissue (SAT, 190, 30). The images were processed on a compatible computer using the open source software ImageJ available from the National Institutes of Health, and a radiologist (C.H.W) with 10 years of experience in abdominal imaging performed the processing according to previous literature . Finally, the areas and mean signal intensities of the TSM, VAT and SAT were derived from the CT (Fig. 1) images. An in-dependent research team at the Federal Medical and Rehabilitation Center, Russian Academy of Continuous Medical Education, Mos-cow, who was blinded to our results also performed the TSM, VAT and SAT measurements. Under the Western criteria, sarcopenia is
Demographic data show that the presence of sarcopenia diagnosed by the Western criteria and the Eastern criteria.
Clinical, laboratory and Total Sarcopenia by Non-sarcopenia p value Sarcopenia by Non-sarcopenia p value imaging parameters (N ¼ 146) Western by Western
Eastern criteria by Eastern
F: female, M: male, BW: body weight, BH: body height, BMI: body mass index, Alb: albumin, TSM: total skeletal muscle, VAT: visceral adipose tissue, SAT: subcutaneous adipose tissue, *: p < 0.05.
Fig. 1. A 73-year-old male had stage 3 pancreatic cancer. The non-enhanced CT image (A) at the L3 level was analyzed to determine the TSM (B), VAT (C), and SAT (D) using ImageJ. The TSM, VAT and SAT areas were 122.79, 118.41 and 91.52 cm2 by our measurements and 125.50, 121.00, and 82.88 cm2 as measured by the Russian institute, respectively. These values are consistent with each other. However, the TSM index measured by our team was 40.56 cm2/m2, which is regarded as non-sarcopenic by our criteria, and the TSM index measured by the Russian institute was 41.45 cm2/m2, which is regarded as sarcopenic by the Western criteria. Disagreement can be found between the two criteria. TSM: total skeletal muscle, VAT: visceral adipose tissue, SAT: subcutaneous adipose tissue.
defined as less than 52.4 cm2/m2 for males and less than 38.5 cm2/m2 for females, according to the protocol in Prado's article . How-ever, for the Eastern diagnostic criteria for sarcopenia, we used less than 36.2 cm2/m2 for males and less than 29.6 cm2/m2 for females, according to the criteria used in Fujiwara's study , because the body shape of our patients is more similar to that of the Japanese population than to that of Western populations. Two different sets of diagnostic criteria for sarcopenia, one developed for Western pop-ulations and one developed for Eastern populations, were used to assess the effect on overall survival (OS) in patients with pancreatic cancer. Additionally, visceral obesity, which refers to the excessive accumulation of visceral fat in the abdominal cavity, was calculated as the ratio of the VAT area to the SAT area, where a ratio greater than 0.4 was considered visceral obesity (VO), which affects the outcomes of cardiovascular disease , colorectal cancer  and pancreatic cancer .