| Summary: | Sarcopenia is a muscle loss syndrome known as a risk factor of various carcinomas. The impact of sarcopenia and sarcopenia-related inflammatory/nutritional markers in metastatic urothelial carcinoma (mUC) treated with pembrolizumab was unknown, so this retrospective study of 27 patients was performed. Psoas muscle mass index (PMI) was calculated by bilateral psoas major muscle area at the L3 with computed tomography. The cut-off PMI value for sarcopenia was defined as ≤6.36 cm<sup>2</sup>/m<sup>2</sup> for men and ≤3.92 cm<sup>2</sup>/m<sup>2</sup> for women. Neutrophil-to-lymphocyte ratio (NLR) ≥ 4.0 and sarcopenia correlated with significantly shorter progression-free survival (PFS) (hazard ratio (HR) 3.81, <i>p</i> = 0.020; and HR 2.99, <i>p</i> = 0.027, respectively). Multivariate analyses identified NLR ≥ 4.0 and sarcopenia as independent predictors for PFS (HR 2.89, <i>p</i> = 0.025; and HR 2.79, <i>p</i> = 0.030, respectively). Prognostic nutrition index < 45, NLR ≥ 4.0 and sarcopenia were correlated with significantly worse for overall survival (OS) (HR 3.44, <i>p</i> = 0.046; HR 4.26, <i>p</i> = 0.024; and HR 3.92, <i>p</i> = 0.012, respectively). Multivariate analyses identified sarcopenia as an independent predictor for OS (HR 4.00, <i>p</i> = 0.026). Furthermore, a decrease in PMI ≥ 5% in a month was an independent predictor of PFS and OS (HR 12.8, <i>p</i> = 0.008; and HR 6.21, <i>p</i> = 0.036, respectively). Evaluation of sarcopenia and inflammatory/nutritional markers may help in the management of mUC with pembrolizumab.
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