Epithelial ovarian cancer (EOC) is one of the most lethal gynecologic cancers, despite advances in treatment modalities. The standard treatment for EOC is primary debulking surgery (PDS), followed by adjuvant or neoadjuvant chemotherapy, followed by interval debulking surgery. The extent of residual disease after surgery is one of the most crucial factors affecting survival rates, along with International Federation of Gynecology and Obstetrics (FIGO) stage, tumor grade, and performance status (PS). Patients with a worse PS and restricted functional capacity often struggle to tolerate aggressive cancer treatments. Consequently, these patients typically experience less favorable outcomes compared to more physically fit patients.

Sarcopenia, characterized by a decrease in muscle mass, function, and quality, was found to be related to low Eastern Cooperative Oncology Group PS in cancer patients [1]. Sarcopenia appears to be related to disability, poor quality of life, higher rates of postoperative complications, and decreased survival rates in various cancers [2, 3, 4]. Previous studies conducted in gynecologic cancer patients also showed that sarcopenia is associated with poor oncologic outcomes [5, 6]. Additionally, patients with sarcopenia are at a higher risk of chemotoxicity, possibly resulting in treatment delays, interruptions, or discontinuation [7, 8].

However, studies reported conflicting results about the prognostic significance of sarcopenia in patients with EOC. A retrospective study of 323 patients demonstrated that low muscle attenuation (MA); in housefield units (HU) is predictive of poor survival after PDS [9]. Nevertheless, another study of EOC patients found that sarcopenia is not related to overall survival (OS) [10]. Accordingly, we aimed to evaluate the influence of preoperative skeletal muscle quantification using computed tomography (CT) scan on prognosis in patients with EOC treated with PDS.

We analyzed 222 patients, and based on our predefined criteria, the healthy muscle group comprised of 84 patients and the remaining 138 patients were included in the unhealthy muscle group. Baseline characteristics of the two groups were compared (Table 1). The mean age of patients with healthy muscle was lower than that of patients with unhealthy muscle (p 0.001). Compared to healthy muscle patients, a higher proportion of unhealthy muscle patients was diagnosed with advanced stage of EOC (p 0.001) and had serous histology (p = 0.032). Moreover, there was significantly more patients with residual disease $\ge$1 cm postoperatively in the unhealthy muscle group (p 0.001). CA125 level before PDS was significantly higher in the unhealthy muscle group (p = 0.049).

During the median follow-up of 55.34 months, OS was significantly improved in healthy muscle patients compared to unhealthy muscle patients (p = 0.005) (Fig. 1A). Similarly, a significant difference in PFS was found between the healthy muscle and unhealthy muscle groups (not reached vs. 27.80 months, respectively; p 0.001) (Fig. 1B).

Fig. 1.

Kaplan-Meier curves in study populations. (A) Overall survival (OS) in patients with healthy and unhealthy muscles. (B) Progression-free survival (PFS) in patients with healthy and unhealthy muscle.

From univariate analysis, we found that the advanced stage, high-grade histology, suboptimal surgery, and unhealthy muscle predicted poor OS. From multivariate analysis, advanced stage (HR = 3.02, 95% CI: 1.28–7.14, p = 0.012), high-grade histology (HR = 4.60, 95% CI: 1.11–19.14, p = 0.036), suboptimal surgery (HR = 3.74, 95% CI: 2.19–6.38, p 0.001), and unhealthy muscle (HR = 2.58, 95% CI: 1.33–5.02, p = 0.005) remained independent risk factors for decreased OS (Table 2).

Univariate analysis showed that advanced stage, high-grade histology, and suboptimal surgery were poor prognostic factors for PFS. Significant predictors in multivariable analysis were advanced stage (HR = 3.24, 95% CI: 1.79–5.84, p 0.001), high-grade histology (HR = 3.28, 95% CI: 1.31–8.23, p = 0.011), suboptimal surgery (HR = 2.35, 95% CI: 1.53–3.61, p 0.001), and unhealthy muscle (HR = 1.60, 95% CI: 1.01–2.53, p = 0.045) (Table 3). Unhealthy muscle was predictive of both PFS and OS in our analysis.

In this study, we analyzed prognostic significance of sarcopenia in patients with EOC who underwent PDS for primary treatment. We found that sarcopenia was strongly associated with poor PFS and OS. As is widely recognized, survival rates were also associated with advanced stage, high-grade histology, and residual disease after PDS. Although multivariate analysis adjusted for key confounders including stage, grade, and residual disease, poor muscle quality may also represent a marker of more advanced disease or systemic inflammatory state rather than a completely independent prognostic determinant. Increased muscle protein catabolism, mainly through the adenosine triphosphate (ATP)–ubiquitin proteolytic pathway, and cytokine-mediated suppression of myogenic factors contribute to cancer-associated muscle wasting [12].

Sarcopenia has been shown to result in poor clinical outcomes in several studies. Recent research indicates that pre-therapeutic sarcopenia, defined as low skeletal muscle index (SMI; adjustment of skeletal muscle area for height) using CT scan-based assessment, was strongly associated with poor PFS and OS in patients with various cancers, including gastric, colorectal, or breast cancer [13]. Besides, gynecologic cancer patients with skeletal muscle loss were at higher risk of treatment complications and decreased survival rates [5, 14, 15]. Tumor-derived inflammatory cytokines such as tumor necrosis factor-alpha (TNF-$\alpha$), interleukin-6 (IL-6), and interleukin-1 (IL-1) can activate proteolytic pathways including the ATP–ubiquitin–proteasome system, leading to muscle protein degradation and metabolic dysregulation. These inflammatory processes contribute to the decline of skeletal muscle quality, which may reduce treatment tolerance, delay recovery after therapy, and ultimately worsen survival outcomes in cancer patients [16].

The present study identified sarcopenia, consistent with findings in other cancers, as an important prognostic factor in EOC. Unfortunately, there is controversy over the adverse effects of sarcopenia on patient survival. In a retrospective study, EOC patients were assessed for SMI and MA preoperatively; while several SMI cut-off levels were not associated with OS, low MA (32 HU) predicted poor survival, particularly in patients with residual tumor after PDS [9]. However, another retrospective study reported contrary results. In the study, sarcopenia, defined as SMI $\le$38.73 cm²/m², was found to predict OS in univariate analysis, but this association did not persist in multivariate analysis [10]. In contrast to studies that applied an absolute HU threshold to define sarcopenia, we adopted a proportional measure of low-attenuation muscle relative to the total skeletal muscle area. The cut-off value of 23.5% was determined using the maximal chi-square method, which objectively identifies the threshold that best discriminates survival outcomes between groups. This data-driven approach minimizes arbitrary selection bias and provides a reproducible standard that can be applied to independent datasets. Because absolute HU thresholds can be affected by scanner calibration and patient population, our proportional, radiodensity-based cut-off reflects both muscle quality and quantity. Therefore, it may offer a more stable and generalizable index for assessing skeletal muscle status across diverse clinical settings.

Skeletal muscle mass is measured using bioelectrical impedance, dual-energy X-ray absorptiometry, and CT scan. Among these methods, CT is most commonly used to analyze muscle composition at the cross-sectional area of the third lumbar vertebra (L3) [17, 18, 19]. We employed CT scans to diagnose sarcopenia, as CT scan is routinely performed for diagnostic purposes in cancer patients. Nevertheless, CT-based assessment is limited in use because acceptable cut-off values for sarcopenia have not been established. Sarcopenia, characterized by reduced muscle quantity and quality, is assessed through skeletal mass and density, respectively. Low radiodensity indicates excessive lipid accumulation within skeletal muscle tissue. As fat content within muscle increases, the radiological density of muscle decreases. Previous studies reported that skeletal muscle density (SMD) rather than muscle mass better reflected frailty and physical function [20, 21]. SMI was not found to be an indicator of frailty. Instead, decreased SMD and skeletal muscle gauge, as determined by multiplying SMI $\times$ SMD, were more associated with an increased prevalence of frailty even after controlling for age and gender. We found that the percentage of low-attenuation muscle within the overall skeletal muscle area was an independent poor prognostic factor and established a threshold of 23.5% that best distinguishes patients with sarcopenia from those without. More validation studies in the future are warranted to confirm our cut-off value.

There is growing evidence supporting the importance of overcoming sarcopenia for patients with cancer. Management strategies such as physical activity, nutritional support, and pharmacological interventions have been proposed as key components in sarcopenia [22]. Exercise is the most important factor. Aerobic exercise aids in regulating metabolism, diminishing oxidative stress, and increasing athletic capabilities. Meanwhile, resistance training helps to enhance both muscle strength and mass [23]. Additionally, ensuring adequate energy intake and supplementation of specific nutrients are essential measures in the prevention and treatment of sarcopenia [24]. Still, several pharmacological agents have been investigated, but evidence is insufficient to establish them as a main treatment [25].

Future prospective studies are warranted to validate our findings in larger, multicenter cohorts. Moreover, interventional trials focusing on nutritional and exercise strategies to improve muscle quality may further clarify whether reversing sarcopenia can translate into better oncologic outcomes.

In the present study, we examined the impact of sarcopenia measured by skeletal muscle quantification using CT on prognosis and found that sarcopenia negatively affects PFS and OS in patients who underwent PDS for EOC. Hence, there is a need for active screening and management for sarcopenia in conjunction with cancer treatment for ovarian cancer patients.

The data supporting this study’s findings are available from the corresponding author upon reasonable request.

SO contributed to data analysis and manuscript writing, EYK contributed to data acquisition and analysis, KGK contributed to study design and critical revision, SL contributed to study conception and critical revision. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was conducted in accordance with the Declaration of Helsinki. The research protocol was approved by the Ethics Committee of the Gil Medical Center (GDIRB2021-276). The need for informed consent was waived due to the retrospective nature of this study.

Not applicable.

This work was supported by the Gachon University research fund of 2024 (GCU-202410680001).

The authors declare no conflict of interest.