Impact of body composition on clinical outcomes in patients with hepatocellular carcinoma: A systematic review and meta-analysis.

BACKGROUND

Abnormalities in body composition are common in patients with hepatocellular carcinoma (HCC); however, their impact across different treatment modalities remains poorly understood. We systematically reviewed the prognostic value of body composition in patients with HCC, stratified by curative, locoregional, and systemic therapies.

METHODS

Following PRISMA 2020 guidelines, we searched PubMed, Embase, the Cochrane Library, and Web of Science (January 2015-March 2025) for studies reporting associations between CT/MRI or bioelectrical impedance analysis (BIA)-assessed body composition and outcomes in HCC.

RESULTS

Ninety-two studies were included (35 curative, 10 locoregional, 39 systemic, 8 mixed). Sarcopenia prevalence ranged from 6.4% to 62.8% (median study-level prevalence 38%-50% depending on treatment stratum). Sarcopenia independently predicted worse overall survival across all strata: curative (HR 1.52-3.76), locoregional (HR 1.72-2.51), and systemic therapies (HR 1.34-2.20). Sarcopenic obesity conferred the highest risk in the curative setting (HR up to 3.15). In systemic therapy, myosteatosis independently predicted mortality (HR 1.45-2.01), whereas visceral adiposity was protective (HR 0.56-0.66). In a random-effects meta-analysis of 44 studies, sarcopenia was associated with a pooled HR of 1.85 (95% CI 1.75-1.94; I2=0%), with consistent effects across curative (HR 1.86), locoregional (HR 2.10), and systemic strata (HR 1.71). Sarcopenia also predicted recurrence after curative treatment (pooled HR 1.71, 95% CI 1.61-1.82; k=14).

CONCLUSIONS

Sarcopenia predicts mortality in HCC, independently of treatment modality. Visceral adiposity appears detrimental after curative treatment but may be paradoxically protective during systemic therapy. Body composition should be integrated into clinical decision-making in HCC, though a clear consensus on measurement standardization is needed.