LB097 - GLIM PHENOTYPIC MALNUTRITION AND REFEEDING SYNDROME IN OUTPATIENT ESOPHAGEAL CANCER: INSIGHTS FROM SERIAL CT SCANS

LB097

GLIM PHENOTYPIC MALNUTRITION AND REFEEDING SYNDROME IN OUTPATIENT ESOPHAGEAL CANCER: INSIGHTS FROM SERIAL CT SCANS

A. Bode^1,*, M. Garcia Luis¹, C. Bury¹

¹Digestive Disease Institute, Cleveland Clinic, Cleveland, United States

Rationale: Malnutrition and refeeding syndrome (RFS) are frequently underrecognized in oncology patients with obesity, particularly in outpatient settings. Conventional screening tools relying on weight loss and intake alone may fail to identify sarcopenia masked by excess adiposity. This case illustrates how CT-based body composition analysis revealed significant muscle depletion and biochemical RFS despite a high BMI, underscoring the need for more specific and objective assessments.

Methods: A 69-year-old male with stage IVB lower third esophageal cancer (T3N1M1) and a BMI of 31.98 kg/m² underwent routine CT imaging as part of outpatient oncology care. Baseline and follow-up axial images were retrospectively analyzed using Voronoi DAFS v3 to quantify skeletal muscle, subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT). Muscle quality was assessed by mean Hounsfield Units (HU), and intramuscular adipose tissue (IMAT) was calculated. GLIM criteria were applied to confirm malnutrition, with specific attention to phenotypic features utilizing  a technical tool (CT) for muscle mass.

Results: The patient met both phenotypic and etiologic GLIM criteria for malnutrition: >10% unintentional weight loss over six months, reduced energy intake (<25% of needs in the prior week), and reduced muscle mass. CT analysis showed a 15% loss in skeletal muscle area, 6% reduction in SAT, and a 28% decrease in muscle density (HU), consistent with low muscle quality. IMAT increased by 37%. Despite preserved adipose stores, the CT data confirmed a phenotype of sarcopenic obesity. Following the initiation of enteral nutrition, the patient developed biochemical RFS with severe hypophosphatemia (nadir 1.1 mg/dL), which was not anticipated by existing outpatient screening protocols.

Conclusion: This case underscores the value of incorporating CT-based body composition into nutritional assessment, especially in high-BMI patients. While the patient met GLIM criteria for malnutrition based on both phenotypic (muscle loss and quality) and etiologic factors, the addition of CT imaging provided objective, quantifiable data that clarified the extent of risk. Traditional screening tools alone may underestimate RFS vulnerability in obese cancer patients. Emerging imaging biomarkers such as HU and IMAT may help enhance RFS risk stratification. Integrating CT analysis into routine nutrition care has the potential to improve early detection, personalize interventions, and optimize outcomes in outpatient oncology.

References: Barazzoni, R. et al (2022). Guidance for assessment of the muscle mass phenotypic criterion for the Global Leadership Initiative on Malnutrition (GLIM) diagnosis of malnutrition. Clinical Nutrition, 41(6), 1425–1433. https://doi.org/10.1016/j.clnu.2022.02.001

da Silva et al Parenteral Nutrition Safety and Clinical Practice Committees, American Society for Parenteral and Enteral Nutrition (2020). ASPEN Consensus Recommendations for Refeeding Syndrome. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 35(2), 178–195. https://doi.org/10.1002/ncp.10474

Marquardt, J. et al Subcutaneous and Visceral Adipose Tissue Reference Values From the Framingham Heart Study Thoracic and Abdominal CT. Investigative Radiology 60(2):p 95-104, February 2025. | DOI: 10.1097/RLI.0000000000001104

Disclosure of Interest: A. Bode Grant / Research Support from: Morrison Cleveland Clinic Research Collaborative , M. Garcia Luis: None declared, C. Bury: None declared