The relationship between subcutaneous adipose tissue thickness and visceral adipose tissue area measurements in preoperative computerized tomography and postoperative morbidity and survival in endometrial cancer

Objective: The aim of this study was to evaluate the relationship between subcutaneous adipose tissue thickness, abdominal total adipose tissue area, subcutaneous adipose tissue area, visceral adipose tissue area, subcutaneous total muscle area and subcutaneous total muscular adipose tissue area values of patients with endometrial cancer and postoperative morbidity and survival in patients with endometrial cancer and to investigate whether these values can be used in endometrial cancer. Materials and Methods: Our thesis study was double centered and included patients diagnosed with endometrial cancer. Patients who underwent surgery in these two centers and whose medical treatment continued afterwards were included in the study. In our clinics, 200 patients who underwent surgery for endometrial cancer in our two centers between 01.05.2017-01.05.2023 were included in the study, 48 patients were excluded from the study because they did not meet the inclusion criteria, and 152 patients who met the inclusion criteria were included in the study. Patients underwent total hysterectomy + bilateral salpingoopherectomy + pelvic lymphadenectomy ± paraaortic lymphadenectomy ± omentectomy for endometrial cancer. Patients' age, gravida and parity status, menopausal status, history of cancer, family history of cancer, history of systemic disease, drug use, smoking status, alcohol use status, body mass index, preoperative abdominal surgery, reason for admission to the hospital, preoperative endometrial sampling results, surgeries performed on the patients, pathology diagnosis of the patients, surgical stages of endometrial cancer and pathology results of the patients were analyzed and evaluated. Duration of operation, postoperative hospitalization, postoperative complications, postoperative complications, postoperative morbidity and survival of the patients were evaluated. In the pathological results of the patients, tumor grade, uterine diameter, tumor diameter, myometrial invasion status of the tumor, lymphovascular invasion of the tumor, presence of tumor surgical margin involvement, presence of tumoral cells in the abdominal washing fluid, pelvic-paraaortic lymph node involvement, main material surgical stage were examined. Since our study was conducted in two centers, the images were taken by Toshiba Activion 16 and Simens Somatom go Top computed tomography devices in both centers. Body mass index (BMI) of the patients was calculated by dividing their body weight in kilograms by their height in meters per square meter (kg/m2). Subcutaneous adipose tissue thickness (SAT) was calculated by visualizing the incision in the axial plane from the upper border of the sacral 1 vertebra (S1) and the middle of the rectus abdominis muscle on computed tomography and measuring the SAT value in mm. Computed tomography (CT) data were obtained from the axis showing the navel around lumbar vertebra 3-4 (L3-L4) with the software program http://datasharing.aim-aicro.com/morphometry and the area measurements of total adipose tissue area (TFA), subcutaneous adipose tissue area (SFA), visceral adipose tissue area (VFA), total subcutaneous muscle area (Total-MA) and total subcutaneous muscle fat area (Total-MFA) parameters were calculated and the area measurements of TFA, SFA, VFA, Total-MA and Total-MFA parameters were calculated in cm². In the preoperative period, computed tomography was performed and the measurements of the parameters planned to be evaluated from the patients were calculated with a special software program. The software program with the address http://datasharing.aim-aicro.com/morphometry was used in the evaluation of the parameters. Calculations were made using a single software program for the data in the double-center study. Results: The mean age of our patients was 62.37 ± 10.84 years (min-max 40-90). The number of gravida was 3 ± 1.6. The number of parities was 2.6 ± 1.9. In our study, the mean age of our patients was found to be compatible with the literature. Patients were diagnosed as a result of endometrial biopsy performed after abnormal uterine bleeding or postmenopausal bleeding. Patients underwent total hysterectomy (laparoscopic or laparoscopic) + bilateral salpingoopherectomy + pelvic lymphadenectomy ± paraaortic lymphadenectomy +omentectomy + abdominal lavage fluid removal. The mean follow-up period was 9.5 (3-23) years and the mean postoperative survival rate was 84%. In our study, patient survival was found to be compatible with the studies in the literature. Increasing BMI of the patients was found to increase the risk of developing endometrial cancer. In our study, BMI value was found to be effective on grade and stage and when grade and stage groups were compared, a statistically significant difference was found in both groups (p=0.003 and p<0.05). In our study, we evaluated BMI, SAT, TFA, TFA, SFA, VFA, Total-MA and Total-MFA parameters separately according to grade and stage in patients diagnosed with endometrial cancer. In our evaluation according to grade, we divided the patients into two groups as grade1 and grade2-3. We evaluated the prognosis of these parameters according to the grade and stage of the patients. We evaluated the effects of these values on survival and examined their compatibility with the literature. When we compared the SFA value according to grade and stage, we found a statistically significant difference (p=0.026 and p<0.05). SFA value is higher in the group with higher grade and stage. BMI and SAT, TFA, SFA, VFA, Total-MA and Total-MFA parameters on preoperative CT were calculated. We identified these 7 risk factors and analyzed them with logistic regression. In our study, no relationship was found between parameters indicating adipose tissue distribution and BMI and prediction of surgical complications. In our study, the correlation between the parameters of adipose tissue distribution and BMI and operation time was evaluated. According to these findings, statistically significant correlations were found between operation time and SAT, TFA, SFA, VFA and Total-MA variables. Especially negative correlations were found between TFA, SFA, VFA and Total-MA variables and operation time. There was no significant correlation between BMI and operation time. We showed that there was a positive correlation between SAT and operation time and this correlation was statistically significant. In the light of these findings, we think that subcutaneous adipose tissue thickness is an effective parameter that increases the operation time. Among BMI, SAT, TFA, TFA, SFA, VFA, Total-MA and Total MFA parameters we evaluated, the data we examined regarding Total-MA and Total-MFA are limited in number and we think that these data may have an effect on morbidity and survival if there are more data on these two data in future studies. In the Cox regression model analysis we performed on the risk factors affecting survival, the effect of VFA on survival was found to be statistically high (p=0.032) among the factors we evaluated. VFA was the value with the most significant result among the parameters we evaluated in the regression analysis, but HR: 1 (95% CI: 1.00-1.00), so it was found to have no effect in this sample size. However, it was considered as a parameter that may become significant when the sample size is increased in further studies. Conclusion: Many studies have been conducted in the literature on patients with endometrial cancer. Many literature studies on the diagnosis, treatment, prognosis, morbidity and survival of endometrial cancer were reviewed and evaluated. Subcutaneous adipose tissue thickness, abdominal total adipose tissue area, subcutaneous adipose tissue area, visceral area adipose tissue area, subcutaneous total muscle area and subcutaneous total muscle fat area were calculated on preoperative computed tomography. BMI values of the patients were calculated. Among BMI, SAT, TFA, TFA, SFA, VFA, Total-MA and Total MFA parameters we evaluated, the data we examined regarding Total-MA and Total-MFA are limited in number and we think that these parameters may have an effect on morbidity and survival if there is more data on these two parameters in future studies. When we compared the SFA value according to grade and stage in our study, we found a statistically significant difference (p=0.026 and p<0.05). SFA value is higher in the group with higher grade and stage. In the logistic regression analysis we performed to evaluate the predictability of complications with BMI and CT parameters showing adipose tissue distribution, we found that these parameters did not have a statistically significant effect in predicting complications. It shows that there is a positive correlation between SAT and operation time and this correlation is statistically significant. In the light of these findings, we think that subcutaneous adipose tissue thickness is an effective parameter that increases the operation time. In addition, in the Cox regression analysis we performed on the risk factors affecting morbidity and survival, the effect of VFA on survival among the factors we evaluated was found to be statistically high (p=0.032). VFA was the value with the most significant result among the parameters we evaluated in the regression analysis, but HR: 1 (95% CI: 1.00-1.00), so it was found to have no effect in this sample size. However, it was considered as a parameter that may become significant when the sample size is increased in further studies. All these findings reveal the complexity of the factors that should be taken into account during the planning of surgical intervention and follow-up of patients. Further prospective studies with larger groups and longer follow-up periods are needed to measure body adipose tissue composition and its metabolomic impact on treatment and prognosis. It is important to better understand and perhaps find a way to more selectively identify women with and at risk of endometrial cancer. Keywords: endometrial cancer, computed tomography, subcutaneous adipose tissue thickness, abdominal total adipose tissue area, subcutaneous adipose tissue area, visceral adipose tissue area, subcutaneous total muscle area, subcutaneous total muscle fat area