Extracellular water to total body water ratio may mediate the association between phase angle and mortality in patients with cancer cachexia: A single-center, retrospective study

Phase angle as a prognostic factor in patients with cancer: a systematic review of the existing evidence via a meta-analysis

BACKGROUND

the phase angle (PA) is expressed via bioelectrical impedance and an indicator of cell membrane health, integrity, hydration, and nutritional status. The associations between PA and cancer survival are inconsistent and unclear. This study aimed to assess PA's role as a prognostic marker of cancer survival.

METHODS

we searched PubMed and EMBASE to identify all relevant studies up to December 2023. A meta-analysis was performed to clarify PA's prognostic role for cancer patients.

RESULTS

a total of 30 studies covering 6587 participants were included in this study. There was a significant prognostic role for PA in the context of cancer patients' survival (HR = 0.73; 95 % CI, 0.66-0.81, p < 0.0001, I2 = 0.0 %). Patients with low PA values were 27 % less likely to survive than patients with high values. Our subgroup analyses showed that geographical population (American: HR = 0.66, 95 % CI: 0.55-0.79, I2 = 0.0 %; European: HR = 0.63, 95 % CI: 0.47-0.84, I2 = 23.2 %; Asian: HR = 0.48, 95 % CI: 0.31-0.74), the type of cancer (head and neck, colorectal, lung, or pancreatic cancer), and type of therapy (palliative vs. non-palliative treatment) did not change the prognostic value.

CONCLUSIONS

the findings highlight the potential of PA to be a non-invasive, cost-effective prognostic tool in oncological care.

Phase Angle (PhA) Is an Easy and Complementary Tool for Assessing Nutritional Status in Ulcerative Colitis (UC) Patients: A Cross-Sectional Study

BACKGROUND

Accumulating evidence has proposed phase angle (PhA) as a marker for assessing cellular integrity and nutritional status in ulcerative colitis (UC) patients; the aim of the study was to evaluate the efficacy of PhA in assessing nutritional status in patients with UC, investigating its potential as a biomarker of disease activity.

METHODS

We conducted a cross-sectional study in patients with UC and healthy controls. We determined PhA by electrical bioimpedance and categorized participants through bioelectrical impedance analysis. They were classified as normal PhA > 6.1° and low PhA < 6.1° in men and normal PhA > 5.6° and low PhA < 5.6° in women.

RESULTS

PhA was significantly lower in UC patients than in controls (5.8 ± 0.8 vs. 6.6 ± 0.7°; p < 0.001). Among UC patients, participants with low PhA showed a decrease in lean, dry mass (LDM) (p < 0.001), total body water (p = 0.008), and intracellular water (p = 0.005), accompanied by an increase in extracellular water (p = 0.001) compared to UC patients with normal PhA.

CONCLUSIONS

PhA significantly decreases in UC patients compared to healthy controls and is even more reduced when UC is active. A cut-off point of <6.1 for men and <5.6 for women could be suitable for nutritional diagnosis in patients with UC, but it still needs to be validated.

Positive association of the thigh muscle thickness to intracellular-water ratio with handgrip strength, but not with the risk of mortality in hospitalized cancer patients: a longitudinal study

This study explored the relationship between handgrip strength, muscle thickness, and the intracellular water ratio (MT/ICW) in cancer patients. It aimed to identify a cut-off point for the MT/ICW ratio that might influence survival. Conducted as an exploratory, longitudinal study in a public hospital, it included patients from 2018 to 2022, with follow-up until August 31, 2023. The cut-off for the MT/ICW ratio was determined based on its sensitivity for mortality. Results indicated that patients with an MT/ICW ratio >0.97 had significantly lower extracellular water percentages and greater muscle thickness. A positive association was found between the MT/ICW ratio and handgrip strength, even after adjusting for age, sex, extracellular water, and body mass index. However, patients with an MT/ICW ratio ≤0.97 showed no significant mortality risk. In conclusion, MT/ICW ratio >0.97 mm/L in hospitalized cancer patients was positively associated with handgrip strength, but not risk of mortality.

Association between ICW/TBW ratio and cancer prognosis: Subanalysis of a population-based retrospective multicenter study

BACKGROUND & AIMS

Disease burden is known to alter cellular integrity and water balance. Therefore, the intracellular water/total body water (ICW/TBW) ratio is used as an adjunctive indicator to predict disease severity and prognosis. The ICW/TBW ratio of patients with cancer, who typically present with low muscle mass, poor nutritional status, and high inflammatory response, reportedly differs from that of the healthy population. Herein, we aimed to evaluate the effect of the ICW/TBW ratio on the prognosis of different subgroups of patients with cancer.

METHODS

This multicenter cohort study included 2787 patients with malignancies between June 2014 and December 2018. The association between covariates and overall survival (OS) was assessed using restricted cubic spline models. The multivariate Cox regression model included variables demonstrating a statistical significance in the univariate Cox regression analysis (P < 0.05) without multicollinearity. The generated nomogram used the C-index and calibration curves to validate the predictive accuracy of the scoring system.

RESULTS

The optimal cut-off value for the ICW/TBW ratio was 0.61. The ICW/TBW ratio was an independent prognostic factor (hazard ratio [HR]: 0.621; 95 % confidence interval [CI]: 0.537-0.719, P < 0.001). Moreover, the ICW/TBW ratio had a greater impact on the prognosis of patients receiving chemoradiotherapy than on those receiving chemotherapy alone (chemoradiotherapy: HR = 0.495, P = 0.005 vs. chemotherapy: HR = 0.646, P < 0.001). Multivariate Cox regression analysis showed that sex, age, tumor stage, body mass index, neutrophil-to-lymphocyte ratio (NLR), and ICW/TBW ratio were associated with OS. Subsequently, a nomogram was developed incorporating these variables and yielded a C-index of 0.743.

CONCLUSIONS

The ICW/TBW ratio was associated with muscle mass, nutritional status, and inflammation. A low ICW/TBW ratio is an independent risk factor for poor prognosis in patients with cancer, especially when they are female, have advanced cancer stage, have sarcopenia, and are receiving radiotherapy.

Extracellular water to total body water ratio, a novel predictor of recurrence in patients with colorectal cancer

Background

Total body water (TBW) fraction, which accounts for 60% of body weight, is an important indicator of body composition, and the extracellular water to TBW ratio (ECW/TBW) is reportedly useful in predicting clinical outcomes of patients with organ disorders. We aimed to clarify the clinical impact of preoperative ECW/TBW status on survival outcomes in cancer patients.

Methods

We used a database of 320 colorectal cancer (CRC) patients who underwent potentially curative resections. Preoperative ECW/TBW was measured using a bioelectrical impedance analysis (BIA), and its correlation with patient survival outcomes, clinicopathological factors, laboratory data, and comorbidities were analyzed.

Results

A high preoperative ECW/TBW was significantly associated with poorer relapse-free survival (RFS; p = 0.001) and overall survival (OS; p = 0.003). A high ECW/TBW ratio was significantly associated with older age (p < 0.001), low BMI (p = 0.009), and right-sided tumors (p = 0.03). In a multivariate analysis, a high ECW/TBW significantly predicted a higher RFS mortality (HR: 2.07, 95% CI: 1.10-3.88, p = 0.024) and OS mortality (HR: 3.23, 95% CI: 1.25-8.36, p = 0.016). Furthermore, a high ECW/TBW was significantly associated with lower hemoglobin (p < 0.001) and albumin levels (p < 0.001), but not comorbidities.

Conclusions

A high preoperative ECW/TBW was a predictive factor for recurrence and poorer overall survival independent of the tumor, node, and metastasis (TNM) stage. Our data suggest that preoperative evaluation of ECW/TBW using BIA might serve as a novel tool for developing CRC treatment strategies.

Preventing lower limb lymphedema after pelvic lymphadenectomy with progressive resistance exercise training: A randomized controlled trial

Objective

This study aimed to assess the efficacy of a self-designed progressive resistance exercise training program for preventing the development of lower limb lymphedema.

Methods

An open-label randomized controlled trial was conducted in patients who underwent radical surgery for cervical cancer treatment in our department between October 7, 2019, and October 7, 2021. The participants were randomly assigned to one of three groups: progressive resistance exercise training, graduated compression stocking, and control group.

Results

A total of 267 patients were enrolled (89 in each group). The incidence of lower limb lymphedema was 9.0% (n = 8) in the progressive resistance exercise training group, 28.1% (n = 25) in the graduated compression stocking group, and 42.7% (n = 38) in the control group. Over the 2-year follow-up period, the risk of lower limb lymphedema was significantly lower in the progressive resistance exercise training group than in the control group, with a hazard ratio (HR) (95% confidence interval [CI]) of 0.156 (0.073-0.335). The study was underpowered to demonstrate a statistically significant reduction in risk in the graduated compression stocking group, with an HR (95% CI) of 0.624 (0.376-1.033).

Conclusions

Progressive resistance exercise training is an effective strategy for preventing lower limb lymphedema after pelvic lymphadenectomy for cervical cancer. It imposes no additional economic burden and can be performed conveniently without the need for dedicated exercise facilities. This makes it particularly accessible to patients in developing countries, allowing them to exercise at their convenience.

Trial registration

ChiCTR1800014905.

Assessment of Nutritional Status by Bioelectrical Impedance in Adult Patients with Celiac Disease: A Prospective Single-Center Study

The gluten-free diet [GFD] has been linked to an increased risk of weight gain and the development of metabolic disorders. Most of the studies have focused on the effect of GFD on the Body Mass Index [BMI]. We aimed to evaluate the nutritional status using specific nutritional parameters in patients with celiac disease [CeD] at diagnosis and on a GFD compared to healthy controls. We recruited subjects at our outpatient clinic at the University of Padua. We collected demographic and clinical data and values obtained with bioelectrical impedance analysis. A total of 24 CeD patients and 28 healthy controls were enrolled. CeD patients at diagnosis had a lower body cell mass index [BCMI, p = 0.006], fat-free mass index [FFMI, p = 0.02], appendicular skeletal muscle index [ASMI, p = 0.02], and phase angle [PA] [p < 0.001] compared to controls. Their percentage of extracellular water [ECW] was also higher [p < 0.001]. Considering CeD patients after GFD, nutritional status significantly improved after 6 months of GFD. We did not observe differences in BMI among groups [p = ns]. CeD patients at diagnosis were found to have a poorer nutritional status than healthy controls, with a positive effect of the GFD on their nutritional status, underlining the inefficacy of evaluating this aspect through only BMI evaluation.

Rectus Femoris Muscle and Phase Angle as Prognostic Factor for 12-Month Mortality in a Longitudinal Cohort of Patients with Cancer (AnyVida Trial)

BACKGROUND

Cancer-related malnutrition is still unrecognized and undertreated in clinical practice. The morphofunctional assessment of disease-related malnutrition (DRM) is a new approach that focuses on evaluating changes in body composition and function. The aim of this study is to evaluate the prognostic value of classic and emerging assessment of malnutrition at 12-months survival in cancer patients.

METHODS

We conducted a prospective study on cancer outpatients. Bioelectrical impedance with phase angle (PhA), nutritional ultrasound by rectus femoris cross-sectional area (RFCSA), hand grip strength, and "Timed Up and Go Test" (TUG) were evaluated as predictors of mortality.

RESULTS

Fifty-seven patients were included. The non-survivors had lower PhA values than the survivors (4.7° vs. 5.4°; p < 0.001), and we had the same results with RFCSA 2.98 cm2/m2 vs. 4.27 cm2/m2 (p = 0.03). Cut-off points were identified using the ROC (receiver operating characteristic) curves for PhA (≤5.6° cancer patients, ≤5.9° men, ≤5.3° women), RFCSA (≤4.47 cm2/m2 cancer patients, ≤4.47° men, ≤2.73° women) and rectus femoris-Y-axis (RF-Y-axis; ≤1.3 cm cancer patients, ≤1.06 men, ≤1 women). In multivariate logistic regression analysis, we found that high PhA was significantly associated with a lower mortality hazard ratio (HR: 0.42 95% CI: 0.21-0.84, p = 0.014). Likewise, high RFCSA was associated with a decrease in mortality risk in the crude model (HR: 0.61 95% CI: 0.39-0.96, p = 0.031). This trend was also maintained in the adjusted models by the confounding variables.

CONCLUSIONS

Low PhA and RFCSA values are significant independent predictors of mortality in cancer patients. These cut-off points are clinical data that can be used for nutritional assessment and the prediction of clinical outcomes.

Phase angle and cellular health: inflammation and oxidative damage

Phase angle is a composite measure that combines two raw bioelectrical impedance analysis measures: resistance and reactance. Phase angle has been considered an indicator of cellular health, integrity, and hydration. As inflammation and oxidative stress can damage cellular structures, phase angle has potential utility in early detecting inflammatory and oxidative status. Herein, we aimed to critically review the current understanding on the determinants of phase angle and its relationship with markers of inflammation and oxidative stress. We also discussed the potential role of phase angle in detecting chronic inflammation and related adverse outcomes. Several factors have been identified as predictors of phase angle, including age, sex, extracellular to intracellular water ratio, and fat-free mass. In addition to these factors, body mass index (BMI) also seems to influence phase angle. Available data also show that lower phase angle values are correlated (negligible to high correlation coefficients) with higher c-reactive protein, tumour necrosis factor-α, interleukin-6, and interleukin-10 in studies involving the general and aging populations, as well as patients with chronic conditions. Although fewer studies have evaluated the relationship between phase angle and markers of oxidative stress, available data also suggest that phase angle has potential to be used as an indicator (for screening) of oxidative damage. Future studies including diverse populations and bioelectrical impedance devices are required to confirm the validity and accuracy of phase angle as a marker of inflammation and oxidative stress for clinical use.