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375 The elderly head and neck cancer patient: sarcopenia and survival radiologically assessed SMM only rather than a combination of low SMM and low MF. 24–27 Our study highlights the importance of defining sarcopenia as a combination of SMM and MF. Inmultivariate analysis including the covariates age, Hb level, MUST-score, BMI and comorbid - ity; sarcopenia remained a statistically significant prognostic factor for overall survival. When including TNM-stage in the multivariate analysis, sarcopenia did not remain a statistically significant prognostic factor for overall survival. Subgroup analyses according to TNM-stage and, treatment intention shows that sarcopenia is a statistically significant prognostic factor for overall survival in patients with TNM-stage I-III and in all patients with curative treatment intention. In patients with TNM-stage IV, sarcopenia is not a statistically significant prognostic factor for overall survival. In this study, 39 patients (45.9%) had an TNM-stage IV, it is possible that sarcopenia did not remain a significant prognostic factor in model 2 of the multivariate analysis because of the high number of patients with TNM-stage IV. This finding is in accor - dance with a previous study performed in patients with gastric cancer which showed that sarcopenia is a significant prognostic factor for overall survival in patients with TNM-stage II-III. 28 It is also in accordance with a recent systematic review, which showed that sarcopenia is a significant prognostic factor for overall survival in different types of cancers independent of TNM-stage. 29 The existing literature on sarcopenia in patients with head and neck cancer is scarce and focuses mainly on low SMM in patients who receive (chemo)radiotherapy 7 or patients who undergo a total laryngectomy 10,11 To our knowledge, our study is the first to investigate the impact of sarcopenia, defined as a combination of SMM and MF, in elderly (≥ 70-year-old) head and neck cancer patients. This study has some limitations. It was designed as a retrospective single-center study, which increases the risk for systemic errors. It had limited number of included patients which may have led to type II errors. Only patients with available data on SMM and MF were included in the study. As it is more likely that MF parameters were examined for frail patients than for fit patients, this may have resulted in a biased study population in which it is probably more difficult to show the prognostic value of sarcopenia. Therefore, sarcopenia as combination of SMM and MF should be further evaluated as a prognostic factor for overall survival in elderly patients with head and neck cancer. Concerning the imaging techniques used to assess SMM, we decided to include both CT scans and MRI scans of the head and neck area to assess SMM, in order to maximize the number of patients that could be included. Whenever available, we used CT imaging instead of MRI be - cause most research on SMM in cancer patients is performed using CT imaging. However, the CT measurement method for SMM was formulated on MRI-based research. 30–32 Theoretically there is no difference in SMM between CT imaging and MRI, as bothmethods are very accurate for SMM assessment. Therefore, we believe it is acceptable to use MRI for SMMmeasurement when CT imaging is not available. Research should be conducted to investigate this further. 18