www.nature.

com/scientificreports

OPEN Thigh muscle by CT images

as a predictor of mortality
in patients with newly diagnosed
colorectal cancer
Gláucia Mardrini Cassiano Ferreira 1, Jarson Pedro da Costa Pereira 2,
Ana Lúcia Miranda 1,3, Galtieri Otavio Cunha de Medeiros 1, Nithaela Alves Bennemann 4,
Viviane Andrade Alves 4, Eduardo Caldas Costa 5, Sara Maria Moreira Lima Verde 6,
Gabriela Villaça Chaves 7, Leonardo Borges Murad 7, M. Cristina Gonzalez 8, Carla M. Prado 9 &
Ana Paula Trussardi Fayh 1,4*

This study aimed to evaluate the prognostic value of thigh muscle assessed by CT images to predict
overall mortality in patients with colorectal cancer (CRC). This was a multicenter cohort study
including adults (≥ 18 years old) newly diagnosed with CRC, who performed a diagnostic computed
tomography (CT) exam including thigh regions. CT images were analyzed to evaluate skeletal
muscle (SM in ­cm2), skeletal muscle index (SMI in ­cm2/m2), and skeletal muscle density (SMD in HU).
Muscle abnormalities (low SM, SMI, and SMD) were defined as the values below the median by sex.
Kaplan–Meyer curves and hazard ratios (HRs) for low SM, SMI and SMD were evaluated for overall
mortality, stratified by sex. A total of 257 patients were included in the final analysis. Patients’ mean
age was 62.6 ± 12.1 years, and 50.2% (n = 129) were females. In males, low thigh SMI was associated
with shorter survival (log-rank P = .02). Furthermore, this low thigh SMI ­(cm2/m2) was independently
associated with higher mortality rates (HR adjusted 2.08, 95% CI 1.03–4.18). Our additional findings
demonstrated that low SMD was independently associated with overall mortality among early-stage
patients (I–III) (HR adjusted 2.78, 95% CI 1.26–6.15).

Keywords Cancer, Muscle mass, Skeletal muscle radiodensity, Skeletal muscle index, Mortality, Body
composition

Skeletal muscle mass (SMM) evaluation is essential to assessing overall h ­ ealth1,2. It is pivotal in understanding
and diagnosing conditions related to abnormal muscle, including sarcopenia and m ­ alnutrition1,2. In patients with
cancer, low SMM correlates to surgical c­ omplications , chemotherapy t­ oxicity , impaired quality of l­ ife9,10 and
3–5 6–8

poor ­survival11–15. In oncology care, computed tomography (CT) is as a valuable reference method for accurately
quantifying ­SMM16,17. It is widely utilized as an imaging technique to opportunistically assess body composition,
including muscle ­parameters16–18. The landmark at the third lumbar vertebra (L3) in the abdominal region is
widely utilized in studies due to its robust correlation with whole-body S­ MM19.
Low SMM is prevalent in patients with colorectal cancer (CRC)20–22. CRC is one of the most commonly
diagnosed cancers w ­ orldwide23,24, ranking as the third most common cancer in men and the second in w ­ omen23.
Low SMM and sarcopenia are additional factors contributing to the impaired prognosis in these ­patients25–29,

1
Postgraduate Program in Health Science, Health Sciences Center, Universidade Federal do Rio Grande do
Norte, Avenida Senador Salgado Filho, nº 3000, Natal, RN 59078‑970, Brazil. 2Postgraduate Program in
Nutrition and Public Health, Department of Nutrition, Federal University of Pernambuco, Recife, PE, Brazil. 3Liga
Norteriograndense Contra o Câncer, Natal, RN, Brazil. 4PesqClin Lab, Onofre Lopes University Hospital, Brazilian
Company of Hospital Services (EBSERH), Federal University of Rio Grande do Norte, Natal, Brazil. 5ExCE Research
Group, Department of Physical Education, Federal University of Rio Grande do Norte, Natal, Brazil. 6Postgraduate
Program in Nutrition and Health, Ceara State University, Fortaleza, Ceara, Brazil. 7Brazilian National Cancer
Institute, Rio de Janeiro, RJ, Brazil. 8Postgraduate Program in Nutrition and Food, Federal University of Pelotas,
Pelotas, Rio Grande do Sul, Brazil. 9Department of Agricultural, Food and Nutritional Science, University of Alberta,
Edmonton, Canada. *email: [email protected]

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 1

Vol.:(0123456789)
 www.nature.com/scientificreports/

emphasizing the critical role of assessing body composition. However, this assessment in patients with CRC
presents unique challenges, particularly for those who have undergone colostomy. This surgical procedure can
affect the evaluation of SMM using CT images at the L3 landmark. The colostomy position in the abdominal
wall alters the region’s muscle anatomy, potentially compromising the accuracy and practicality of SMM
measurements (refer to Supplementary Fig. 1). Thus, it is necessary to explore alternatives landmarks, such as
the thigh region. Since this region can be assessed using low radiation dose p ­ rotocol30, it can be an alternative
when CT exam does not be done.
Our previous work has demonstrated an excellent agreement between muscle characteristics at the L3 and
thigh landmarks in a healthy p ­ opulation30, reinforcing the potential of this level. Although low SMM in the lower
limbs (including thigh muscle) has been associated with higher mortality and other adverse outcomes in both
­healthy31,32 and clinical p
­ opulations33,34, few studies have evaluated the thigh muscle using CT as an indicator of
low SMM in patients with cancer. Supporting this assertion, a meta-analysis examining the impact of CT-based
sarcopenia (based on SMI) on adverse outcomes in CRC patients includes studies that specifically evaluate
muscle mass at the L3 l­ evel35,36. Therefore, this study aimed to evaluate the prognostic value of thigh muscle, as
measured by CT-images, in predicting overall mortality among patients with CRC.

Results
Of the 568 patients in the original cohort, 272 had CT images that included the thigh muscle. Fifteen patients were
excluded due to the presence of artifacts or anatomical variations in the CT images (e.g. distortions hindering
image sharpness; tumor obstructions). A total of 257 subjects (with available thigh CT scans) were included in the
final analysis. A detailed flowchart of participants is presented in Fig. 1. The mean age was 62.6 ± 12.1 years; 58.4%
were non-Caucasian, and 50.2% were females. Table 1 presents socio-demographic and clinical characteristics
of patients according to sex. SM, SMI and SMD from thigh and L3 levels were positively and strongly correlated:
ρ 0.83, P < .001; ρ 0.73, P < .001; ρ 0.79, P < .001, respectively (data not shown in tables).
Data was available from a median follow-up of 36 months (IQ range: 24.1–59.2), with the maximum obser-
vation period extending over 14.5 years. Overall mortality occurred in 26.5% of the sample. Table 2 presents
univariate sex-stratified survival associations with clinical and nutritional characteristics. Tumor stage was asso-
ciated with a higher relative risk for mortality among both males and females (P = .001; P < .001, respectively).
Low thigh SMI was associated with a high relative risk of mortality, specifically among males (P = .020). No other
variable was associated with mortality.
KM curves revealed notable differences in survival rates. Among males, low thigh SMI ­(cm2/m2) was
associated with a shorter survival (log-rank P .020), while among females, no skeletal muscle parameter was
associated with survival (Fig. 2). Cox regression analysis showed no associations between low thigh SM or SMD
with mortality, for both males and females, in its crude and adjusted models. However, low thigh SMI ­(cm2/
m2) was independently associated with higher mortality rates among males (Table 3), even after adjusting for
age, tumor site, and type of treatment. An additional Cox model, which accounted for the disease stage, was

Figure 1.  Study flow diagram. CT: computed tomography.

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 2

Vol:.(1234567890)
www.nature.com/scientificreports/

Males Females
Characteristics Total n = 128 (49.8%) n = 129 (50.2%) P
Age (years) 62.6 ± 12.1 61.6 ± 12.5 63.5 ± 11.7 .23 a
Ethnicity1 .08 b
Non-Caucasian 150 (59.1) 66 (52.4) 84 (65.6)
Caucasian 104 (40.9) 60 (47.6) 44 (34.4)
Comorbidities .19b
No comorbidities 135 (52.7) 62 (48.4) 73 (56.6)
With comorbidities 122 (47.5) 66 (51.6) 56 (43.4)
Tumor site 0.85b
Colon 121 (47.1) 61 (47.7) 60 (46.5)
Rectum 136 (52.9) 67 (52.3) 69 (53.5)
TNM stage .47b
I 04 (1.6) 01 (08) 03 (02.3)
II 78 (30.4) 44 (34.4) 34 (26.4)
III 77 (30.0) 38 (29.7) 39 (30.2)
IV 48 (18.7) 24 (18.8) 24 (18.6)
Unknown 50 (19.5) 21 (16.4) 29 (22.5)
BMI (kg/m2) 25.2 ± 4.4 25.02 ± 4.3 25.33 ± 4.7 .59a
CT thigh level
SM ­(cm2) 217.1 (178.6;264.2) 258.3 (229.3;291.0) 179.8 (163.1;196.3) < .001c
SMI ­(cm2/m2) 84.6 (73.9;97.9) 93.8 (84.3;105.4) 78.0 (69.2;85.4) < .001c
SMD (HU) 34.5 (31.1;39.4) 38.2 (33.2;42.0) 32.6 (29.4;37.2) < .001c
CT L3 level 2
SM ­(cm2) 115.5 (95.1;144.3) 144.3 (128.3;162.1) 96.5 (86.1;107.5) < .001c
SMI ­(cm2/m2) 46.1 (39.7;53.6) 53.1 (46.3;58.9) 42.2 (36.4;46.2) < .001c
SMD (HU) 33 (27.2;38.2) 37.2 (32.2;40.5) 29 (24.5;33.2) < .001c
Mortality .55b
No 189 (73.5) 92 (71.9) 97 (75.2)
Yes 68 (26.5) 36 (28.1) 32 (24.8)

Table 1.  Demographic and clinical characteristics of patients with colorectal cancer by sex (N = 257).
a
Independent Student’s “t” test (mean ± standard deviation). b Pearson’s χ2 or Fisher’s Exact test (frequencies,
N %). c Mann–Whitney U test (median and interquartile ranges). 1 Three data missing (two males and one
female); 2N = 222. BMI, body mass index; SM, skeletal muscle cross-sectional area; SMI, skeletal muscle index;
SMD, skeletal muscle density; HU, Hounsfield Unit. Significant values are in bold.

constructed. However this variable was subsequently excluded from the Cox analysis due to multicollinearity
issues resulting in parameters approaching infinity and a lower goodness-of-fit. After investigating the outcome
concerning the clinical TNM stages, we found that a low SMD was independently associated with mortality in
stages I–III (HR adjusted 2.78, 95% CI 1.26 to 6.15).

Discussion
The importance of assessing body composition in patients with cancer, particularly using CT images, is well
established. While previous literature has extensively explored SMM measurement at the L3 level, its evaluation
at the thigh level is a relatively novel approach. To our knowledge, this is the first study to assess muscle thigh
using CT and its association with mortality in patients with CRC. Our main findings demonstrated that a low
thigh SMI was independently associated with shorter overall survival in men with CRC. Furthermore, a low
SMD was independently associated with shorter overall survival in early-stage tumors (I–III).
Although approximately 50% of the SMM tissue is located in the lower limbs, with a substantial portion
in the thigh ­region37, most studies focused on measuring SMM at the L3 region. A recent systematic review,
encompassing 32 studies in patients with cancer, evaluated the most commonly used landmarks for SMM assess-
ment when the L3 was not ­available38. This analysis reviewed 32 studies with retrospective and cross-sectional
designs. Interestingly, none evaluated muscle mass in the thigh region. When analyzing other populations, more
evidence emerges. For instance, in a diverse adult population (n = 39,804), low SMM at the thigh level, assessed
by magnetic resonance images, was a strong, and independent predictor of all-cause mortality during a follow-
up period of 2.9 ± 1.4 years after i­ maging39.
The anatomical location chosen for measuring SMM can markedly affect the prediction of adverse events. For
example, Arribas et al.40, in a prospective cohort study assessing body composition, monitored four anatomical
levels: upper arm, thigh, chest and abdomen using CT images from 38 middle-aged male patients with squamous

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 3

Vol.:(0123456789)
 www.nature.com/scientificreports/

Mortality
Males n = 36 Females n = 32
Variables Yes, n (%) No, n (%) Pa,b RR (95% CI) Yes, n (%) No, n (%) Pa,b RR (95% CI)
Age
> 65 y 15 (31.2) 33 (68.8) .57 1.18 (0.67;2.05) 19 (31.1) 42 (68.9) .11 1.63 (0.88;3.01)
< 65 y 21 (26.6) 58 (73.4) (Reference) 13 (19.1) 55 (80.9) (Reference)
Tumor site
Colon 20 (32.8) 41 (67.2) .26 1.37 (0.78;2.40) 16 (26.7) 44 (73.3) .65 1.20 (0.54;2.68)
Rectum 16 (23.9) 51 (76.1) (Reference) 16 (23.2) 53 (76.8) (Reference)
Ethnicity
Caucasian 18 (30.0) 42 (70.0) .66 1.19 (0.55;2.57) 15 (34.1) 29 (65.9) .08 2.06 (0.91;4.69)
Non-Caucasian 18 (26.5) 50 (73.5) (Reference) 17 (20.0) 68 (80.0) (Reference)
TNM stage
I–III 18 (21.7) 65 (41.7) (Reference) 15 (19.7) 61 (80.3) (Reference)
IV 14 (58.3) 10 (41.7) .001 2.69 (1.58;4.57) 15 (62.5) 9 (37.5) < .001 3.17 (1.83;5.48)
Comorbidities
No 21 (33.9) 41 (66.1) (Reference) 22 (30.1) 51 (69.9) (Reference)
Yes 15 (22.7) 51 (77.3) .16 0.67 (0.38;1.18) 10 (17.9) 46 (82.1) .11 0.59 (0.31;1.15)
Overweight (BMI ≥ 25 kg/m2)
No 18 (26.5) 50 (73.5) (Reference) 15 (23.1) 50 (76.9) (Reference)
Yes 18 (30.0) 42 (70.0) 0.66 1.13 (0.65;1.91) 16 (25.4) 47 (74.6) .76 1.10 (0.60;2.03)
Obesity (BMI ≥ 30 kg/m2)
No 29 (26.6) 80 (73.4) (Reference) 29 (26.4) 81 (73.6) (Reference)
Yes 07 (36.8) 12 (63.2) 0.36 1.39 (0.71;2.70) 02 (11.1) 16 (88.9) .24b 0.42 (0.11;1.62)
Low SM
No 14 (21.9) 50 (78.1) 0.12 (Reference) 14 (25.0) 42 (75.0) (Reference)
Yes 22 (34.4) 42 (65.6) 0.64 (0.36;1.13) 18 (24.7) 55 (75.3) .96 1.01 (0.55;1.86)
Low SMI
No 12 (18.8) 52 (81.2) (Reference) 15 (23.1) 5 (76.9) (Reference)
Yes 24 (37.5) 40 (62.5) .018 2.00 (1.10;3.65) 17 (26.6) 47 (73.4) .65b 0.87 (0.48;1.59)
Low SMD
No 16 (24.6) 49 (75.4) (Reference) 15 (22.1) 53 (77.9) (Reference)
Yes 20 (31.7) 43 (68.3) .37 1.57 (0.89;2.78) 17 (27.9) 44 (72.1) .37 0.79 (0.43;1.45)

Table 2.  Associations of clinical and nutritional characteristics with colorectal cancer mortality according to
sex (N = 257). a Pearson’s χ2 test (frequencies, N %). b Fisher’s exact test (Frequencies, N %). Age (n = 256). BMI,
body mass index; SM, skeletal muscle cross-sectional area; SMI, skeletal muscle index; SMD, skeletal muscle
radiodensity; HU, Hounsfield Unit; RR, relative risk. Significant values are in bold.

cell carcinoma of the head and neck at two time points. The median interval between scans was 224 days. Their
findings indicated that low SMM in the tight was significantly higher than in the other regions, underscoring
the importance of thigh muscle assessment whenever possible.
Advancements in medical imaging have enabled the noninvasive assessment of human body composition,
thereby enriching our understanding of the variations between sexes. Our research group has previously shown
that the relationship between SMM, strength, and adverse outcomes is more pronounced in males than in
­females11,41,42. Additionally, sex hormones could be contributing factors to these sex-related differences. In men,
testosterone plays a pivotal role in developing and maintaining SMM and ­strength43, which becomes particularly
relevant for patients with cancer undergoing treatments like chemotherapy, with its myriad side e­ ffects13,14. This
may partly explain our observation that thigh muscle mass is a predictor of mortality predominantly in males.
Another possible explanation is the aging process, as a substantial proportion of our cohort (42.8%) was over
65 years old. Although aging has been associated with loss of SMM, independent of sex, and with greater loss of
SMM in the lower b ­ ody44, men have a greater magnitude of SMM loss compared to w ­ omen45. As they age, men
become increasingly vulnerable to muscle loss due to decreased anabolic hormones such as growth hormone,
insulin-like growth factor, and testosterone. This hormonal decline could exacerbate clinical outcomes, thereby
explaining the sex differences noted in our s­ tudy46. Collectively, these findings suggest that low lower-limb SMM
in males with cancer may be more clinically meaningful when compared to females, indicating the need for more
intense interventional approaches to counteract lower-limb SMM loss in men.
In our study, given the absence of established cut-off values for thigh muscle measurements, we chose to use
the median value of our sample’s data distribution. We acknowledge this decision as a potential limitation in our
analysis. This median point was selected noting that nearly half of our cohort was diagnosed at an advanced stage

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 4

Vol:.(1234567890)
www.nature.com/scientificreports/

Figure 2.  Kaplan–Meier survival curves for patients with colorectal cancer based on thigh muscle
abnormalities from CT scans. SMA: skeletal muscle cross-sectional area; SMD: skeletal muscle radiodensity;
SMI: skeletal muscle index.

Mortality
Males Females TNM I–III TNM IV
HR (95% CI) P HR (95% CI) P HR (95% CI) P HR (95% CI) P
Low SM
Crude 1.66 (0.85; 3.25) .14 0.90 (0.44; 1.83) .77 0.92 (0.40; 2.11) .84 1.28 (0.59; 2.75) .53
­Adjusteda 1.71 (0.86;3.41) .13 0.92 (0.45; 1.89) .83 1.03 (0.39; 2.73) .95b 1.19 (0.46; 3.08) .73c
Low SMI
Crude 2.22 (1.11; 4.44) .024 0.90 (0.31; 2.58) .84 1.69 (0.76; 3.77) .20 1.62 (0.67; 3.99) .30
­Adjusteda 2.08 (1.03;4.18) .041 1.12 (0.55; 2.28) .77 2.10 (0.86; 5.13) .10b 1.72 (0.67; 4.41) .26c
Low SMD
Crude 1.28 (0.66; 2.47) .46 1.12 (0.56; 2.25) .75 2.26 (1.14; 4.68) .020 0.92 (0.44; 1.91) .83
Adjusted a 1.25 (0.61; 2.56) .55 1.35 (0.64; 2.85) .43 2.78 (1.26; 6.15) .012b 0.76 (0.32; 1.83) .54c

Table 3.  Independent associations between thigh muscle abnormalities using CT and mortality in patients
with colorectal cancer, according to sex and TNM stages (N = 257). a Models were adjusted for age, tumor site,
and type of treatment. b Models were adjusted for sex, age, tumor site, and type of treatment. c Models were
adjusted for sex, age and tumor site. Type of treatment was removed due to multicollinearity. HR, hazard ratio;
SM, skeletal muscle cross-sectional area in ­cm2; SMI, skeletal muscle index in ­cm2/m2; SMD, skeletal muscle
radiodensity in Hounsfield Unit (HU). Significant values are in bold.

(III and IV TNM), which likely impacted their SM (leading to a greater prevalence of low SM). Alternatively,
SM variables could be treated as continuous data. Bardoscia et al.47 assessed SM in 225 patients with head and
neck cancer undergoing radical chemo-radiation therapy using retrospective CT scans. SMI and SMD were
both measured at the L3 and thigh levels. In the absence of a specific thigh-level cutoffs, the authors test these
as continuous variables. In contrast, for the L3 region, they applied cutoffs based on the sample distribution and
existing ­literature47,48. Their results showed that only L3-SMD (not L3-SMI) exhibited a significant association
with survival. However, when assessing the indices at the thigh level as continuous variables, an increase in both
SMI and SMD were significant protective factors for all survival outcomes.
Our additional findings underscored the prognostic significance of a low SMD in patients with early-stage
tumors (I–III). We observed that poor muscle composition, as indicated by SMD, rather than low muscle mass
alone, independently correlated with overall mortality. This contributes significantly to the expanding evidence
emphasizing the importance of evaluating this morphological marker of muscle quality. Our results are sup-
ported by a growing body of evidence indicating that alterations in muscle composition may manifest earlier
than changes in muscle mass, potentially impacting strength and leading to increased m ­ ortality49,50.

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 5

Vol.:(0123456789)
 www.nature.com/scientificreports/

Our study has limitations that warrant acknowledgment. The convenience sample and retrospective data
collection preclude the establishment of causal relationships. Furthermore, unmeasured confounding variables
were not considered in our regression models, potentially skewing our results. The reliance on medical records
may introduce bias in the overall mortality frequency, providing different follow-up periods, limiting the col-
lection of detailed clinical data (e.g., specific type of treatment, and specific acquisition contrast phase). Future
studies with larger sample size and prospective design are needed to overcome these limitations. These studies
could explore additional landmarks (e.g. gluteus). On a positive note, our study contributes valuable insights to
the growing body of evidence by investigating the relationship between baseline thigh SMM and mortality in
patients with CRC.
In conclusion, our data demonstrate an association between thigh SMI and SMD and overall mortality in
newly diagnosed patients with CRC. From a clinical perspective, our findings underscore the prognostic signifi-
cance of assessing CT-derived lower-limb SMM in CRC.

Materials and methods

Study design and subjects
This multicenter retrospective cohort study included patients (≥ 18 years old) newly diagnosed with CRC and
referred to a specialized cancer treatment center. Inclusion criteria were individuals who had CT images of the
thigh area within ± 90 days of diagnosis, as well as body weight (kg) and height (m) within the same period. The
availability of abdominal CT scans was conveniently also included For secondary analysis purposes. Data from
three oncology centers across two different regions of Brazil were analyzed, encompassing three states: Southeast
(104 patients from Rio de Janeiro, RJ) and Northeast (111 patients from Fortaleza, CE, and 42 patients from Natal,
RN). Individuals with concomitant consumptive diseases (AIDS, non-cancerous liver diseases, tuberculosis), or
with anasarca/leg edema which made it impossible to analyze their CT images were excluded. This study was in
accordance of with the Declaration of Helsinki, and was approved by the Research Ethics Committee (protocol
number 4.431.753, CAAE 40,019,020.0.1001.5292). Due to the retrospective nature of data collection, informed
consent was waived by the Research Ethics Committee of the coordinating center, Onofre Lopes University
Hospital, Natal, RN, Brazil.

Procedures and outcome

A web-based application (Research Electronic Data Capture—REDCap) was used to collect data from centers
and create a database. Patient characteristics such as age at diagnosis, comorbidities, ethnicity, site, and tumor
stage, were extracted from electronic medical records. Body mass index (BMI) was calculated using height
­(m2) and weight (kg) data closest (up to three months) to the CT scan evaluation, and then classified according
to the criteria of the World Health Organization: underweight (< 18.5 kg/m2), normal weight (18.5 a 24.9 kg/
m2), overweight (25 a 29.9 kg/m2) and obese (≥ 30 kg/m2)51. Data regarding treatment administered during this
period, including surgical procedures, chemotherapy, and/or radiotherapy, were also recorded. Overall survival
was measured from the date of the CT scan to either the date of death or the end of follow-up. Mortality was
verified in the medical records or asked by phone contact, when the information was unavailable. Patients were
followed for a maximum follow-up duration of almost 15 years.

Skeletal muscle mass analysis

All analyzed CT images were under contrast through manual segmentation with Slice-O-Matic software (v.5,
Tomovision®). Hounsfield Unit (HU) boundaries from − 29 to + 150 were used to quantify S­ MM52. Muscle thigh
was analyzed according to a previous study of our g­ roup30. Briefly, was selected the area at the level of the lower
margin of the lesser trochanter of the femur and included the following muscles: quadriceps (rectus femoris,
vastus medialis, vastus intermedius, vastus lateralis), pectineus, tensor fasciae latae, iliopsoas, sartorius, adductor
longus, adductor brevis, adductor minimus, adductor magnus, gracilis, semitendinosus and gluteus maximus.
Both legs were assessed, and the sum of muscle areas was considered to quantify thigh skeletal muscle area
(SM, in c­ m2). The SMI (­ cm2/m2) was calculated as a ratio between SM and height squared (­ m2). The skeletal
muscle radiodensity (SMD) was determined by the mean Hounsfield Units (HU) value of both legs. Figure 3
demonstrates an example of CT image at thigh level in our cohort.
Muscle abnormalities were categorized based on sample distribution (median), as follows: (i) low SM < 258.3
for males, < 179.8 for females; (ii) low SMI < 93.8 for males, < 78 for females; (iii) low SMD < 38.2 for males, < 32.6
for females. For additional analysis, CT images were processed to measure tissue cross-sectional area ­(cm2) at the
third lumbar vertebra (L3). Total area at L3 was quantified for SM in c­ m2 encompassing psoas, erector spinae,
quadratus lumborum, transversus abdominus, external and internal obliques, and rectus abdominus muscles, as
well as SMD in HU. CT-derived HU thresholds for SMD were also defined within a range of − 29 HU to + 150.

Statistical analysis
Data were analyzed using MedCalc version 22.0.0.9 software (MedCalc, Mariakerke, Belgium) and Statistical
Package for the Social Sciences (SPSS), version 20.0 (SPSS Inc., Chicago, IL, USA). Data normality was assessed
using the Shapiro–Wilk test. Normally distributed data were described using mean ± standard deviation (SD).
Means were compared using independent Student "t" test. Non-normally distributed data were described using
medians and interquartile (IQ) ranges. Medians were compared using the Mann–Whitney U test. Categorical
variables were presented as absolute frequencies (N) and relative percentages (%). Comparisons of categorical
data were conducted using Pearson’s χ2 or Fisher’s Exact tests, when appropriate. Spearman’s correlation test was
employed to analyze the relationship between muscle parameters from L3 and thigh level. The magnitude of these
analyses was categorized as follows: very strong (ρ = 0.90–1.00), strong (ρ = 0.70–0.90), moderate (ρ = 0.50–0.70),

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 6

Vol:.(1234567890)
www.nature.com/scientificreports/

Figure 3.  CT images at the thigh level showing two patients of our cohort. Image (A) refers to a 56-year-old
male patient with skeletal muscle cross-sectional area (SMA) of 265 c­ m2 and skeletal muscle radiodensity
(SMD) of 60.1 Hounsfield Units (HU). Image (B) refers to a 56-year-old female patient with SMA of 193.5 ­cm2
and SMD of 42.7 (HU).

weak (ρ = 0.30–0.50), or negligible (ρ = 0.00–0.30). Missing data was not imputed. Kaplan–Meier (KM) curves
were constructed to evaluate the association between CT-based muscle abnormalities and overall survival. P
values (< .05) for the Log-rank, Breslow, and Tarone-Ware tests were examined to assess the significance of the
KM analysis over the entire follow-up period. A Cox proportional hazards analysis was conducted in both its
crude and adjusted models to assess the independent associations. Adjustments were made based on prognostic
factors. Statistical significance was set at P < .05 for all analyses.

Data availability
The datasets generated during and/or analysed during the current study are not publicly available due to ethical
and privacy restrictions but are available from the corresponding author on reasonable request.

Received: 28 March 2024; Accepted: 18 July 2024

References
1. Cruz-Jentoft, A. J. et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age Ageing 48, 1–16 (2018).
2. Fayh, A. P. T., de Sousa, I. M. & Gonzalez, M. C. New insights on how and where to measure muscle mass. Curr. Opin. Support
Palliat Care 14(4), 316–323 (2020).
3. De Carvalho, A. L. M. et al. Low skeletal muscle radiodensity is the best predictor for short-term major surgical complications in
gastrointestinal surgical cancer: A cohort study. PLoS One 16(2), e0247322 (2021).
4. Chen, W. Z. et al. Impact of visceral obesity and sarcopenia on short-term outcomes after colorectal cancer surgery. Dig. Dis. Sci.
63, 1620 (2018).
5. Martin, L. et al. Assessment of computed tomography (CT)-defined muscle and adipose tissue features in relation to short-term
outcomes after elective surgery for colorectal cancer: A multicenter approach. Ann. Surg. Oncol. 25(9), 2669–2680 (2018).
6. da Rocha, I. M. G. et al. Is cachexia associated with chemotherapy toxicities in gastrointestinal cancer patients? A prospective
study. J. Cachexia Sarcopenia Muscle. 10(2), 445–54 (2019).
7. Mazzuca, F. et al. Lean body mass wasting and toxicity in early breast cancer patients receiving anthracyclines. Oncotarget 9(39),
25714–25722 (2018).
8. Prado, C. M. M. et al. Body composition as an independent determinant of 5-fluorouracil—Based chemotherapy toxicity. Clin.
Cancer Res. 13(11), 3264–3268 (2007).
9. Derksen, J. W. G. et al. The association between changes in muscle mass and quality of life in patients with metastatic colorectal
cancer. J. Cachexia Sarcopenia Muscle 31(11), 919–928 (2020).
10. Bye, A. et al. Muscle mass and association to quality of life in non- small cell lung cancer patients. J. Cachexia Sarcopenia Muscle
8, 759–767 (2017).
11. Sousa, I. M. et al. Low calf circumference is an independent predictor of mortality in cancer patients: A prospective cohort study.
Nutrition 79–80, 110816 (2020).
12. de Sousa, I. M. & Fayh, A. P. T. Is the ECOG-PS similar to the sarcopenia status for predicting mortality in older adults with cancer?
A prospective cohort study. Support Care Cancer 31(6), 370 (2023).
13. Jung, H. W. et al. Effect of muscle mass on toxicity and survival in patients with colon cancer undergoing adjuvant chemotherapy.
Support Care Cancer 23(3), 687–94. https://​doi.​org/​10.​1007/​s00520-​014-​2418-6 (2015).
14. Prado, C. M. et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and
gastrointestinal tracts: A population-based study. Lancet Oncol. 9(7), 629–635 (2008).
15. Xiao, J. et al. Association of low muscle mass and low muscle radiodensity with morbidity and mortality for colon cancer surgery.
JAMA Surg. 155, 942 (2020).

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 7

Vol.:(0123456789)
 www.nature.com/scientificreports/

16. Ryan, A. M. et al. Cancer-associated malnutrition, cachexia and sarcopenia: The skeleton in the hospital closet 40 years later. Proc.
Nutr. Soc. 75(2), 199–211 (2016).
17. Prado, C. M. M. & Heymsfield, S. B. Lean tissue imaging: A new era for nutritional assessment and intervention. J. Parenter. Enter.
Nutr. 38(8), 940–53. https://​doi.​org/​10.​1177/​01486​07114​550189 (2014).
18. de Liguori, A. A. L. & Fayh, A. P. T. Computed tomography: An efficient, opportunistic method for assessing body composition
and predicting adverse outcomes in cancer patients. Radiol. Bras. 56(6), VIII–IX (2023).
19. Shen, W. et al. Total body skeletal muscle and adipose tissue volumes: Estimation from a single abdominal cross-sectional image.
J. Appl. Physiol. 97(6), 2333–8 (2004).
20. Caan, B. J. et al. Explaining the obesity paradox: The association between body composition and colorectal cancer survival
(C-SCANS study). Cancer Epidemiol. Biomark. Prev. 26(7), 1008–1015 (2017).
21. Daly, L. E., Prado, C. M. & Ryan, A. M. A window beneath the skin : how computed tomography assessment of body composition
can assist in the identification of hidden wasting conditions in oncology that profoundly impact outcomes. Proc. Nutr. Soc. 77,
135–151 (2018).
22. da Silva Nascimento, M. L. et al. Examining variations in body composition among patients with colorectal cancer according to
site and disease stage. Sci. Rep. 14(1), 1–9. https://​doi.​org/​10.​1038/​s41598-​024-​61790-0 (2024).
23. Sung, H. et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185
countries. CA Cancer J. Clin. 71(3), 209–249 (2021).
24. International Agency for Research on Cancer. Latest global cancer data: Cancer burden rises to 18.1 million new cases and 9.6
million cancer deaths in 2018. Ganeva (2018).
25. Boer, B. C. et al. Skeletal muscle mass and quality as risk factors for postoperative outcome after open colon resection for cancer.
Int. J. Colorectal Dis. 31(6), 1117–1124 (2016).
26. Souza, N. C. et al. Comparative Analysis between computed tomography and surrogate methods to detect low muscle mass among
colorectal cancer patients. J. Parenter. Enter. Nutr. 44, 1328 (2019).
27. Kroenke, C. H. et al. Muscle radiodensity and mortality in patients with colorectal cancer. Cancer 124(14), 3008–3015 (2018).
28. Brown, J. C. et al. The deterioration of muscle mass and radiodensity is prognostic of poor survival in stage I–III colorectal cancer:
A population-based cohort study (C-SCANS). J Cachexia Sarcopenia Muscle 9(4), 664–672 (2018).
29. De Sousa, I. M., Silva, F. M., das Virgens, I. P. A., Costa, E. C. & Fayh, A. P. T. Independent and joint association of sarcopenia and
frailty with mortality in older patients with gastrointestinal cancer: A cohort study with prospective data collection. Support Care
Cancer 32(1), 1–8 (2024).
30. de Medeiros, G. O. C. et al. Comparative assessment of abdominal and thigh muscle characteristics using CT-derived images vio
Cunha de Medeiros a, Iasmin Matias de Sousa a, Gabriela Villa c. Nutrition 99–100, 111654 (2022).
31. Farsijani, S. et al. Body composition by computed tomography vs dual- energy X-ray absorptiometry: Long-term prediction of
all-cause mortality in the health ABC cohort. J. Gerontol. Ser. A Biol. Sci. Med. Sci. 76(12), 2256–2264 (2021).
32. Gao, J. et al. Influencing factors for the decline of limb muscle strength and the association with all-cause mortality: evidence from
a nationwide population-based cohort study. Aging Clin. Exp. Res. 34(2), 399–407. https://​doi.​org/​10.​1007/​s40520-​021-​01940-w
(2022).
33. Quinlan, J. I. et al. Impaired lower limb muscle mass, quality and function in end stage liver disease: A cross-sectional study. Exp.
Physiol. 108(8), 1066–1079 (2023).
34. Fukasawa, H. et al. Lower thigh muscle mass is associated with all-cause and cardiovascular mortality in elderly hemodialysis
patients. Eur. J. Clin. Nutr. 71(1), 64–69 (2017).
35. He, J., Luo, W., Huang, Y. & Song, L. Sarcopenia as a prognostic indicator in colorectal cancer: An updated meta-analysis. Front.
Oncol. 13, 1247341 (2023).
36. Zhu, Y., Guo, X., Zhang, Q. & Id, Y. Y. Prognostic value of sarcopenia in patients with rectal cancer: A meta-analysis. PLoS One
17(6), e0270332. https://​doi.​org/​10.​1371/​journ​al.​pone.​02703​32 (2022).
37. Janssen, I. A. N., Heymsfield, S. B., Wang, Z. I. M. & Ross, R. Skeletal muscle mass and distribution in 468 men and women aged
18–88 yr. J. Appl. Physiol. 89, 81–88 (2000).
38. Vangelov, B., Bauer, J., Kotevski, D. & Smee, R. I. The use of alternate vertebral levels to L3 in computed tomography scans for
skeletal muscle mass evaluation and sarcopenia assessment in patients with cancer: A systematic review. Br. J. Nutr. 127, 722–735
(2022).
39. Linge, J., Petersson, M., Forsgren, M. F., Sanyal, A. J. & Leinhard, O. D. Adverse muscle composition predicts all-cause mortality
in the UK Biobank imaging study. J. Cachexia Sarcopenia Muscle 12, 1513–1526 (2021).
40. Arribas, L. et al. Assessing dynamic change in muscle during treatment of patients with cancer: Precision testing standards. Clin.
Nutr. 41(5), 1059–1065 (2022).
41. Barbalho, E. R. et al. Is skeletal muscle radiodensity able to indicate physical function impairment in older adults with
gastrointestinal cancer ?. Exp. Gerontol. 125(May), 110688. https://​doi.​org/​10.​1016/j.​exger.​2019.​110688 (2019).
42. de Alves, C. P. L. et al. Agreement between upper and lower limb measures to identify older adults with low skeletal muscle strength,
muscle mass and muscle quality. PLoS One 17(1), e0262732 (2022).
43. Wells, J. C. K. Sexual dimorphism of body composition. Best Pract. Res. Clin. Endocrinol. Metab. 21(3), 415–430 (2007).
44. Bredella, M. A. Sex differences in body composition. In Sex and Gender Factors Affecting Metabolic Homeostasis, Diabetes and
Obesity (ed. Mauvais-Jarvis, F.) 9–27 (Springer International Publishing, 2017).
45. Goodpaster, B. et al. Attenuation of skeletal muscle and strength in the elderly: The Health ABC Study. J. Appl. Physiol. 90,
2157–2165 (2001).
46. Roubenoff, R. & Hughes, V. A. Sarcopenia: Current concepts. J. Gerontol. Med. Sci. 55(12), 716–724 (2000).
47. Bardoscia, L. et al. Impact of low skeletal muscle mass and quality on clinical outcomes in patients with head and neck cancer
undergoing (chemo) radiation. Front. Nutr. 9, 994499 (2022).
48. Martin, L. et al. Cancer cachexia in the age of obesity: Skeletal muscle depletion is a powerful prognostic factor, independent of
body mass index. J. Clin. Oncol. 31(12), 1539–1547 (2013).
49. Perkisas, S., De Cock, A., Verhoeven, V. & Vandewoude, M. Physiological and architectural changes in the ageing muscle and their
relation to strength and function in sarcopenia. Eur. Geriatr. Med. 7(3), 201–206 (2016).
50. da Costa Pereira, J. P. et al. Strength-to-muscle radiodensity: A potential new index for muscle quality. Clin. Nutr. 43(7), 1667–74
(2024).
51. World Health Organization. Obesity and overweight [Internet]. 2014. Available from: http://w ​ ww.w
​ ho.i​ nt/m
​ ediac​ entre/f​ actsh
​ eets/​
fs311/​en/
52. Mitsiopoulos, N. et al. Cadaver validation of skeletal muscle measurement by magnetic resonance imaging and computerized
tomography. J. Appl. Physiol. 85(1), 115–122 (1998).

Author contributions
G.M.C.F., M.C.G., C.M.P. and A.P.T.F. contributed to the conception and design of the research; G.M.C.F., A.L.M.,
S.M.M.V.V., G.V.C., L.B.M. and N.A.B. conducted the acquisition of the data; G.O.C.M., N.A.B. and V.A.A.
analyzed the computed tomography images, G.M.C.F., J.P.C.P., E.C.C., M.C.G., C.M.P. and A.P.T.F. contributed

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 8

Vol:.(1234567890)
www.nature.com/scientificreports/

to the analysis and wrote the manuscript. All authors critically reviewed, interpreted, and approved of the final
manuscript.

Funding
Partial financial support was received from the Federal University of Rio Grande do Norte (Grant 001/2020
PROPESQ), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code
001 and Brazilian National Council for Scientific and Technological Development (CNPq). APTF, ECC and MCG
received a productivity scholarship from the CNPq. The supporting sources had no involvement or restrictions
regarding this publication.

Competing interests
The authors declare no competing interests.

Additional information
Supplementary Information The online version contains supplementary material available at https://​doi.​org/​
10.​1038/​s41598-​024-​68008-3.
Correspondence and requests for materials should be addressed to A.P.T.F.
Reprints and permissions information is available at www.nature.com/reprints.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and
institutional affiliations.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-
NoDerivatives 4.0 International License, which permits any non-commercial use, sharing,
distribution and reproduction in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the
licensed material. You do not have permission under this licence to share adapted material derived from this
article or parts of it. The images or other third party material in this article are included in the article’s Creative
Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the
article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the
permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

© The Author(s) 2024

Scientific Reports | (2024) 14:17267 | https://doi.org/10.1038/s41598-024-68008-3 9

Vol.:(0123456789)