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• W3143445087 abstract "HomeRadiologyVol. 299, No. 3 PreviousNext Reviews and CommentaryFree AccessEditorialBody Composition at CT in Chronic Obstructive Pulmonary Disease: Regional Analysis Is WorthwhileNicola Sverzellati , Filippo CademartiriNicola Sverzellati , Filippo CademartiriAuthor AffiliationsFrom the Scienze Radiologiche, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126, Parma, Italy (N.S.); and Department of Radiology, SDN IRCCS, Naples, Italy (F.C.).Address correspondence to N.S. (e-mail: [email protected]).Nicola Sverzellati Filippo CademartiriPublished Online:Apr 6 2021https://doi.org/10.1148/radiol.2021204737MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Pishgar et al in this issue.Dr Sverzellati is a professor in diagnostic imaging and chairman of the radiology unit Scienze Radiologiche in the Department of Medicine and Surgery of the University of Parma. He is the radiology lead for imaging of chest disorders at the University Hospital of Parma. His research activity is focused on imaging interstitial lung disease, chronic obstructive pulmonary disease, and lung cancer.Download as PowerPointOpen in Image Viewer Dr Cademartiri is the chairman of radiology department for the NHS Hospital of Urbino (Area Vasta 1/ASUR Marche) and senior research consultant for the Scientific Institute SDN IRCCS in Naples (Italy). He underwent medical training and radiology residency at the University of Parma (Italy). He was staff radiologist at the Erasmus Medical Center University in Rotterdam (the Netherlands). He worked in several centers mainly focusing on cardiovascular and cardiothoracic imaging.Download as PowerPointOpen in Image Viewer The article by Pishgar et al in this issue of Radiology (1)evaluates the reliability and prognostic value of chest CT–derived markers of body composition in chronic obstructive pulmonary disease (COPD). The authors investigated both the amount of fat mass according to subcutaneous adipose tissue (SAT) and the amount and quality of lean mass according to intermuscular adipose tissue (IMAT) and pectoralis muscles (PMs) indexes. Both obesity and sarcopenia are known in association with chronic inflammatory status, a well-known condition in COPD syndrome. The study findings showed that body composition is altered in patients with COPD in whom CT metrics are associated with survival and add to other radiologic risk factors to survival. The authors expanded the predictive value of chest CT beyond the primary clinical indication for pulmonary assessment in COPD and likely project the CT yield in multidimensional characterization of such a complex disorder.Although intrapulmonary abnormalities (ie, emphysema and airway disease) represent its main manifestation, COPD is regarded as a heterogeneous, complex, and multisystemic disease, with several extrapulmonary manifestations. Extrapulmonary comorbidities are increasingly recognized as important contributors to functional decline in patients with COPD (2). The chronic inflammatory status of COPD lung disease encompasses a systemic sustained oxidative stress, which represents a source of multiorgan burden and dysfunction, ultimately leading to increased morbidity and mortality (3). COPD-related comorbid conditions include cardiovascular disease, metabolic syndrome, and musculoskeletal dysfunction with osteoporosis, among other conditions (2).Changes in soft-tissue composition have been explored since the early description of the two well-known COPD phenotypes, namely “pink puffer” and “blue bloater” (4). These two phenotypes of COPD implied that the disease processes extended beyond the lung. The “pink puffers” were characterized as having emphysematous lungs and a thin body habitus, whereas the “blue bloaters” were considered as being obese and having central cyanosis with little or no emphysema, often considered as the chronic bronchitis subtype of COPD (4). Indeed, clinical studies mainly evaluated either obesity or severe muscle wasting, termed sarcopenia, in COPD.The prevalence of obesity in COPD ranges between 18% and 54% and seems higher in early COPD stages (5). Whereas obesity usually is associated with higher mortality rates, an obesity survival paradox has been found in patients with COPD. Several explanations (eg, obese patients with more muscle mass have likely better outcomes) have been postulated for this paradox (5). COPD-related sarcopenia varied between 12.4% and 28.1% in clinical settings and 7.9% and 8.4% in population-based settings (6). Sarcopenia leads to decreased skeletal muscle function and exercise capacity, enhanced energy expenditure, and compromised overall health status. Furthermore, reduced muscle load on bones can reduce bone formation and increase bone resorption.However, COPD-related changes in body composition can be difficult to detect because they can occur independent of age and are not adequately captured by body mass index. Clinical diagnostic criteria rely on both the assessment of muscle strength and the evaluation of anthropometric indexes (eg, skeletal muscle mass index, fat mass index, and fat-free mass index). However, there is a lack of uniformity in measurement standards, and especially in cutoffs across these criteria (6).Both biolelectrical impedance analysis and dual-energy x-ray absorptiometry are widely used for the assessment of sarcopenia in COPD. However, both bioelectrical impedance analysis and dual-energy x-ray absorptiometry are also affected by some limitations. Despite its higher precision, CT is not recommended for this purpose, likely because of the higher levels of radiation exposure. Chest CT is not considered standard of care in the diagnosis and management of mild to moderate COPD (7). Nevertheless, expanding use of CT for other purposes demands that clinicians understand how to deal with radiologic “background” information that becomes available. This is true in both routine care and large epidemiologic study settings. In particular, compared with dual-energy x-ray absorptiometry, the broader use of chest CT might offer the opportunity to routinely assess the soft-tissue composition in patients with COPD and, potentially, in other chronic diseases.These CT benefits are captured by Pishgar et al (1), who evaluated a number of CT-derived markers of body composition in 2994 older participants in the MESArthritis ancillary study. Among these participants, 265 (9%) had COPD. Compared with prior COPD studies, the authors expanded on the CT-derived markers of body composition by comparing the predictive value of adipose depots with heterogeneous distribution as an expression of either fat accumulation or sarcopenia. The authors set a validated acquisition and reconstruction protocol for the utmost consistent investigation of such subtle densitometric indexes. They showed that two CT indexes had divergent effects on the mortality rate, as follows: higher SAT was associated with lower risk of all-cause mortality (hazard ratio, 0.2; P < .001, at each doubling), whereas higher IMAT was associated with higher mortality rate (hazard ratio, 1.4; P = .04, at each doubling). The protective value of SAT index is somewhat coherent with the obesity paradox in COPD. The authors suggested that IMAT may be a better prognostic marker than SAT, which was supported by three key observations. In particular, we agree in underscoring that the IMAT index might be less perturbated by confounding factors (eg, weight loss or weight gain, as reflected by its low correlation with the fat mass index), and that IMAT index might have some proinflammatory capacity as supported by its association with diabetes and hypertension. However, the use of IMAT in multivariable model did not increase the stratification of survival, whereas SAT increased the yield of the risk model.The higher risk of mortality associated with increasing IMAT is in keeping with previous study findings in both healthier participants (eg, survivors from the Reykjavik study) and other COPD cohorts (8,9). However, the PM index was not associated with the study outcome, likely because of underrepresentation of advanced-stage COPD. In fact, sarcopenia is generally diagnosed when muscle strength is altered, thus more frequently in moderate-to-severe COPD or during acute COPD exacerbations. The study findings suggest that CT signs of muscle wasting might be appreciated later than CT changes in adipose depots, thus strengthening the predictive value of the IMAT index.It is worth emphasizing that the study results are of particular relevance because the CT-derived markers were predictive in mild-to-moderate COPD, namely in the group of participants with COPD who are increasingly evaluated by using CT in both clinical and research settings, including lung cancer screening. Furthermore, the assessment of soft-tissue composition of the chest seems fast, straightforward, and reliable. In fact, soft-tissue markers were quantified on a single CT section by using an in-house written macro that was run onto an open-source software, with a good interoperator variability.However, a number of questions remain. First, the improvement in the predictive performance obtained with the CT-derived indexes was observed in models adjusted for basic variables (eg, age, sex, race and/or ethnicity, body mass index, baseline pulse oximetry, smoking status, pack-years of cigarette smoking, and employment status). The authors have not shown whether and to what extent the CT indexes of body composition improve the predictive performance when major determinants of patients’ COPD prognosis, either functional indexes of airflow obstruction (eg, forced expiratory volume in 1 second) or CT metrics of pulmonary emphysema and airway disease, are included in the models. Second, it would be important to explore the association between indexes of body composition and both emphysema and airways metrics to further characterize COPD at CT. If a relevant cross talk between adipose tissue and lung exists and if the adipose tissue directly influences the lung, it is still poorly understood. Nevertheless, another recent study (10) showed that patients with the lowest PM area and PM density exhibited a higher extent of emphysema, with no difference in bronchial wall area percentage.The study by Pishgar et al (1) has the merit to reiterate that chest CT can also offer a comprehensive assessment of extrapulmonary disease without additional radiation exposure. Chest CT can also be used to quantify various sources of fat, muscles, and bones. Indeed, the analysis of body composition fits the complexity of COPD, in which relationship seems to exist between the lungs, endothelium, bone marrow, and adipose tissue. Chest CT has the potential to become a powerful tool in the quest for personalized medicine in COPD. Whether it is incorporated into routine assessment for patients with COPD will ultimately depend on our ability to demonstrate that this information changes treatment and improves outcomes.The study by Pishgar et al (1) encourages the assessment of body composition for other chronic complex disorders in which alterations in either muscular or adipose tissue may be associated with pulmonary disease (eg, connective tissue diseases, chronic heart failure, or lung cancer).Disclosures of Conflicts of Interest: N.S. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed consultancy from ERT, Galapagos, Boehringer Ingelheim, Roche, Chiesi; payment for expert testimony from Roche, Boehringer Ingelheim; payment for lectures from Roche, Boehringer Ingelheim; and travel/accommodations/meeting expenses from GE, Bracco. Other relationships: disclosed no relevant relationships. F.C. disclosed no relevant relationships.References1. Pishgar F, Shabani M, Silva TQAC, . Quantitative Analysis of Adipose Depots by Using Chest CT and Associations with All-Cause Mortality in Chronic Obstructive Pulmonary Disease: Longitudinal Analysis from MESArthritis Ancillary Study. Radiology 2021. https://doi.org/10.1148/radiol.2021203959. Published online April 6, 2021. Google Scholar2. Agustí A, Barberà JA, Wouters EF, Peinado VI, Jeffery PK. Lungs, bone marrow, and adipose tissue. A network approach to the pathobiology of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2013;188(12):1396–1406. Crossref, Medline, Google Scholar3. Wouters EF, Creutzberg EC, Schols AM. Systemic effects in COPD. Chest 2002;121 (5 Suppl):127S–130S. Crossref, Medline, Google Scholar4. Filley GF, Beckwitt HJ, Reeves JT, Mitchell RS. Chronic obstructive bronchopulmonary disease. II. Oxygen transport in two clinical types. Am J Med 1968;44(1):26–38. Crossref, Medline, Google Scholar5. Brock JM, Billeter A, Müller-Stich BP, Herth F. Obesity and the Lung: What We Know Today. Respiration 2020;99(10):856–866. Crossref, Medline, Google Scholar6. Benz E, Trajanoska K, Lahousse L, . Sarcopenia in COPD: a systematic review and meta-analysis. Eur Respir Rev 2019;28(154):190049. Crossref, Medline, Google Scholar7. Labaki WW, Rosenberg SR. Chronic Obstructive Pulmonary Disease. Ann Intern Med 2020;173(3):ITC17–ITC32. Crossref, Medline, Google Scholar8. Reinders I, Murphy RA, Brouwer IA, . Muscle Quality and Myosteatosis: Novel Associations With Mortality Risk: The Age, Gene/Environment Susceptibility (AGES)-Reykjavik Study. Am J Epidemiol 2016;183(1):53–60. Crossref, Medline, Google Scholar9. McDonald MN, Diaz AA, Rutten E, . Chest computed tomography-derived low fat-free mass index and mortality in COPD. Eur Respir J 2017;50(6):1701134. Crossref, Medline, Google Scholar10. Chung JH, Hwang HJ, Han CH, Son BS, Kim DH, Park MS. Association between sarcopenia and metabolic syndrome in chronic obstructive pulmonary disease: the Korea National Health and Nutrition Examination Survey (KNHANES) from 2008 to 2011. COPD 2015;12(1):82–89. Crossref, Medline, Google ScholarArticle HistoryReceived: Jan 07 2021Revision requested: Jan 13 2021Revision received: Jan 14 2021Accepted: Jan 19 2021Published online: Apr 06 2021Published in print: June 2021 FiguresReferencesRelatedDetailsAccompanying This ArticleQuantitative Analysis of Adipose Depots by Using Chest CT and Associations with All-Cause Mortality in Chronic Obstructive Pulmonary Disease: Longitudinal Analysis from MESArthritis Ancillary StudyApr 6 2021RadiologyRecommended Articles Quantitative Analysis of Adipose Depots by Using Chest CT and Associations with All-Cause Mortality in Chronic Obstructive Pulmonary Disease: Longitudinal Analysis from MESArthritis Ancillary StudyRadiology2021Volume: 299Issue: 3pp. 703-711Small Airway Disease and Emphysema Are Associated with Future Exacerbations in Smokers with CT-derived Bronchiectasis and COPD: Results from the COPDGene CohortRadiology2021Volume: 300Issue: 3pp. 706-714Relationship between Emphysema Progression at CT and Mortality in Ever-Smokers: Results from the COPDGene and ECLIPSE CohortsRadiology2021Volume: 299Issue: 1pp. 222-231CT-based Visual Classification of Emphysema: Association with Mortality in the COPDGene StudyRadiology2018Volume: 288Issue: 3pp. 859-866Visual Emphysema at Chest CT in GOLD Stage 0 Cigarette Smokers Predicts Disease Progression: Results from the COPDGene StudyRadiology2020Volume: 296Issue: 3pp. 641-649See More RSNA Education Exhibits Opportunistic CT Screening for Assessment of Vertebral Fracture RiskDigital Posters2020Light as Air: Imaging Course of Lung Transplantation from Patient Selection to Postoperative ComplicationsDigital Posters2019Role Of Radiology In Addressing The Challenge Of Lung Cancer After Lung Transplantation.Digital Posters2021 RSNA Case Collection Spontaneous Intercostal Lung HerniaRSNA Case Collection2021Pulmonary HamartomaRSNA Case Collection2021Small cell lung carcinomaRSNA Case Collection2020 Vol. 299, No. 3 Metrics Altmetric Score PDF download" @default.
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