43
Figura 1
È illustrato il rapporto fra forza muscolare (misurata con grip test) e l’avanzare dell’età. Per evitare di raggiungere stati di sarcopenia e/o di disabilità con scarse performance fisiche risulta essenziale elevare il picco nella giovane età, mantenere la forza nell’età adulta e ridurre la perdita nella vecchiaia.
44
Figura 2
La figura illustra i sottogruppi della sarcopenia e categorizzati come forma primaria (aging) e secondarie (disease, inactivity, malnutrition). Numerosi fattori hanno un ruolo importante in ciascuna categoria, per cui l’interazione di questi, anche con piccoli aggiustamenti, può determinare una variazione importante della quantità e qualità di muscolo.
45
Figura 3
Il questionario SARC-F attualmente utilizzato come principale strumento di approccio alla sarcopenia.
46
Figura 4
L’algoritmo diagnostico EWGSOP2 per identificare i casi di sarcopenia. L’acronimo FACS (find, assess, confirm, severity) descrive gli step progressivi per la definizione della patologia, in un continuum diagnostico che parte dal questionario SARC-F (o dalla clinica), passando per la valutazione della forza muscolare, quindi valutazione di qualità/quantità muscolare e delle performance fisiche per valutare il grado di disabilità.
47
Figura 5
Incidenza di recidiva post-chirurgica di metastasi epatiche di carcinoma colorettale in funzione della sarcopenia97.
48
Figura 6
Sopravvivenza attuariale post-resezione chirurgica in funzione della sarcopenia in pazienti affetti da metastasi epatiche di carcinoma colorettale97.
49
Figura 7
La figura illustra come sono ottenuti i valori di densità media e di L3 index. Arrivati a livello di L3, nel momento in cui sia possibile vedere entrambi i processi trasversi, viene manualmente posto un confine (in giallo) e si evidenzia in rosso la zona muscolare interessata. Il software restituisce quindi valori di area (cm3) e densità media della selezione (HU).
50
Figura 8
51
Figura 9
52
Figura 10
53
Figura 11
È illustrata la dispersione della variabile altezza misurata in MT all’interno della popolazione.
54
Figura 12
È illustrata la dispersione dell’indice di massa corporea (BMI) (peso/altezza2)
55
Figura 13
È illustrata la distribuzione del valore di L3 totale e L3 index all’interno della popolazione.
56
Figura 14
È possibile osservare la distribuzione del valore di HU medio della scansione all’interno della popolazione.
57
Figura 15
Sopravvivenza attuariale globale (OS), libera da recidiva neoplastica (RFS) e libera da malattia (DFS) della popolazione oggetto di studio.
%
a
n
n
i
%58 Tabella 1 CRITERI Anno, Paese Estensione campione
Contenuto dei criteri Sopravvivenza
a 5 anni
UCSF 2001,
America
70 DDLT Un nodulo ≤ 6,5cm;
≤ 3 noduli con diametro maggiore ≤4,5cm e somma dei diametri ≤8cm
OS: 75,2% RFS: -
UP-TO-7 2009, Italia 1404 DDLT 121 LDLT
La somma fra il numero delle nodularità il diametro maggiore deve essere ≤7
OS: 71,2%
Tokyo 2007,
Giappone
78 LDLT Un massimo di 5 nodularità con diametro massimo di 5cm
OS: 75% RFS (3y): 94%
Hangzhou 2008, Cina 195 DDLT Diametro massimo ≤8cm, se ≥8cm GI/GII e AFP ≤ 400ng/mL OS: 78,3%. RFS: 62,4%. Kyushu 2007, Giappone Diametro massimo ≤5cm e DCP ≤ 300 mAU/mL OS: 82,7%. Kyoto 2007, Giappone
125 DDLT ≤ 10 noduli, diametro massimo ≤ 5cm, DCP ≤ 400 mAU/mL
OS: 86,7%.
Shanghai 2009, Cina 1074 DDLT 4 LDLT
Una nodularità ≤ 9cm, ≤ 3
nodularità con diametro maggiore ≤ 5cm, assenza di invasione macrovascolare e linfonodale OS: 78,1%. RFS: 52,6%. Toso et Al. 2009, Svizzera
6478 LT TTV ≤ 115cm3, AFP ≤ 400ng/mL Outside criteria OS
≤ 50%.
Toronto 2016,
Canada
294 LT Tumore indifferenziato fuori dai MC purchè in assenza di: MTS extraepatiche Trombosi VP
Perdita di peso >4,5kg in 3 mesi Severo decadimento del performance status
OS: 94% 1y, 76% 3y, 69% 5y.
59
Tabella 2
Test Valore di cutoff per uomini Valore di cutoff per donne
Grip strength <27kg <16kg
Chair stand >15 secondi per 5 alzate >15 secondi per 5 alzate
ASM <20kg <15kg
ASM/altezza2 <7kg/m2 <5,5kg/m2
Gait Speed ≤0,8 m/s ≤0,8m/s
SPPB <8 point score <8 Point Score
TUG >20secondi >20secondi
400 m walk test
Non completato o ≥ 6 minuti Non completato o ≥ 6 minuti
Cutoff elaborati dal gruppo EWGSOP2 per i test di valutazione della performance fisica. Valori inferiori sono suggestivi di sarcopenia.
60
Tabella 3
GRADO Definizione Terapia necessaria
Grado I Ogni deviazione dal
normale decorso post- operatorio.
Non si rende necessario intervento
farmacologico, chirurgico, endoscopico o radiologico. Vengono considerati farmaci antiemetici, antipiretici, analgesici, diuretici, somministrazione di elettroliti e fisioterapia. Infezioni delle ferite o piccoli ascessi vi rientrano
Grado II Alterazioni del normale
corso.
Necessario intervento farmacologico non incluso nel grado I. Comprese anche le trasfusioni e la nutrizione parenterale
Grado III Alterazioni che
necessitano interventi.
Nel grado IIIA sono necessari interventi fatti sotto anestesia locale, nel grado IIIB invece sotto anestesia epidurale o generale
Grado IV Alterazioni che mettono a
rischio la vita del paziente e necessitano di supporto UTI
Grado IVA include singole alterazioni d’organo mentre il IVB include condizioni di insufficienza multiorgano
Grado V Morte del paziente
Classificazione delle complicanze post-operatorie chirurgiche secondo Clavien- Dindo.
61
Tabella 4
Variabile Popolazione = 98 pazienti
Maschi, n (%) 84 (85,7)
Età, media (DS) (anni) 57,1 (6,6)
Peso, media (DS) (kg) 71 (10,6) Altezza, media (DS) (m) 1,7 (0,07) BMI, media (DS) (k/m2) Normopeso (18,5; <25), n (%) Sovrappeso (25; <30), n (%) Obeso lieve (30; <35), n (%) 25,6 (2,6) 41 (41,8) 51 (52,0) 6 (6,1) Sarcopenia*, n (%) 40 (40,8) Fumatori, n (%) 71 (72,4) Co-morbilità cardiovascolari, n (%) 14 (14,3) Co-morbilità polmonari, n (%) 16 (16,3) Diabete mellito, n (%) 23 (23,5) Cause dell’epatopatia, n (%) Infezione HCV, n (%) Infezione HBV, n (%) Alcol, n (%) NASH/NAFLD, n (%)
Colangite biliare primitiva, n (%) Altro, n (%) 38 (38,8) 17 (17,3) 19 (19,4) 11 (11,2) 4 (4,1) 9 (9,2) Complicanze dell’epatopatia Varici esofagee, n (%) Ascite, n (%) Encefalopatia epatica 52 (53,1) 24 (24,5) 5 (5,1) Stadio Child-Pugh A, n (%) B, n (%) C, n (%) 51 (52,0) 35 (35,7) 12 (12,2) MELD, media (DS) 15,2 (1,3)
62 Caratteristiche della neoplasia**
Noduli per paziente, media (DS) Diametro massimo, media (DS) (mm) AFP, media (ng/mL) 2,9 (2,1) 40 (16,0) 60,5 (152,3) Donatore deceduto, n (%) 98 (100) Graft intero, n (%) 98 (100)
NOTE: BMI: body mass index (kg/m2); MELD: model for end-stage liver disease; *sulla base del L3
index; **valutazione radiologica pre-trapianto.
63
Tabella 5
Variabile Popolazione = 98 pazienti
Score L3 totale, media (DS) 154,6 (26,8)
L3 index, media (DS) 51,7 (7,9)
HU, media (DS) 41,1 (6,9)
Sarcopenia (in base a L3 index), n (%)
L3 index pazienti sarcopenici, media (DS)
L3 index pazienti non sarcopenici, media (DS)
40 (40,1) 45,2 (5,9)
56,1 (5,9) p = 0,0385
64
Tabella 6
Variabile Popolazione = 98 pazienti
Noduli per paziente, media (DS) 2,9 (2,1)
Diametro massimo, media (DS) (mm) 39,2 (15,8)
Grading Ben differenziato, n (%) Moderatamente indifferenziato, n (%) Scarsamente indifferenziato, n (%) Indifferenziato, n (%) Non disponibile, n (%) 7 (7,1) 48 (48,9) 22 (22,4) 11 (11,2) 10 (10,2) Invasione microvascolare, n (%) 45 (45,9) Milano in, n (%) 17 (17,3)
65
Tabella 7
Variabile Popolazione = 98 pazienti
Decessi, n (%) Recidiva HCC, n (%) Recidiva HCV, n (%) ITBL, n (%) Sepsi, n (%) 16 (16,3) 11 (11,2) 3 (3,1) 1 (1,0 1 (1.0) Recidiva HCC, n (%) 12 (12,2) Recidiva HCV, n (%) 12 (12,2) ITBL, n (%) 4 (4,1)
NOTE: HCC, carcinoma epatocellulare; HCV, virus epatite C; ITBL, colangiopatia ischemica post- trapianto.
66
Tabella 8
Variabile indipendente Variabile dipendente
Rischio di mortalità
Età del donatore P=0.042
AFP pre-trapianto P<0.0001
HCV+ P=0.037
Milan out istologico P=0.041
Rischio di recidiva HCC
AFP pre-trapianto P<0.0001
Milan out istologico P=0.039
Rischio composito di mortalità, recidiva HCC e patologia del graft
Età del donatore P=0.024
AFP pre-trapianto P<0.0001
HCV+ P=0.031
Milan out istologico P=0.041
MELD al trapianto P=0.038
Analisi univariata del rischio di mortalità, di recidiva di HCC e del rischio composito di mortalità, recidiva di HCC e patologia del graft.
67
Tabella 9
Variabile indipendente Variabile dipendente
Rischio di mortalità
AFP pre-trapianto P<0.0001
Rischio di recidiva HCC
AFP pre-trapianto P<0.0001
Rischio composito di mortalità, recidiva HCC e patologia del graft
AFP pre-trapianto P<0.0001
Età del donatore P=0.032
HCV+ P=0.025
Analisi multivariata del rischio di mortalità, di recidiva di HCC e del rischio composito di mortalità, recidiva di HCC e patologia del graft.
68
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