Anesthetic technique and cancer outcomes: a meta-analysis of total intravenous versus volatile anesthesia

Effects of perioperative anesthetics on the postoperative prognosis of patients undergoing surgery for cervical cancer

Cervical cancer is a common malignancy among women, and tumor excision is the most common surgical intervention. Anesthetics used during surgery include general intravenous, volatile, local anesthetics, sedative and analgesic. Studies have shown that the selection of perioperative surgical methods and anesthetics may influence postoperative metastasis and cancer recurrence through their effects on the immune response and tumor cells. Therefore, the selection of perioperative anesthetic has a significant impact on patients undergoing surgery for cervical cancer. This study summarizes the effects and related mechanisms of common anesthetics on the prognosis of patients undergoing surgery for cervical cancer to provide a basis for developing more optimal anesthesia protocols.

Etomidate Inhibits Hepatic Ischemia-Reperfusion Injury Depending on the Activation of Nrf2-HO-1 Signaling Pathway

Hepatic ischemia-reperfusion (I/R) injury (HIRI) is recognized as a local aseptic inflammatory response driven by innate immunity and is considered a leading cause of early organ dysfunction and failure following liver transplantation. Etomidate (Eto), an anesthetic drug known for its ability to inhibit inflammatory response and apoptosis, was the focus of our investigation. In this study, we conducted hepatic I/R surgery in vivo on C57 mice, analyzing liver damage through histopathology. Additionally, primary hepatocytes isolated from mice were cultured and subjected to hypoxia/reoxygenation (H/R) insult in vitro, with cell activity assessed using the CCK8 assay and immunofluorescence staining employed to analyze liver inflammatory cell infiltration and apoptosis. Results showed that Eto effectively inhibited liver injury, inflammatory response, and apoptosis induced by HIRI surgery, with the greatest effect observed at an Eto concentration of 10 mg/kg. Furthermore, Eto also showed the ability to inhibit H/R-induced cell damage, inflammatory activation, and apoptosis in primary hepatocytes. Further mechanistic studies revealed that Eto could promote the activation of the Nrf2-HO-1 signaling pathway, and the protective effect of Eto on HIRI was nullified when the Nrf2 inhibitor ML385 was utilized. This study highlights the potential of Eto to protect against HIRI by promoting the Nrf2-HO-1 signaling axis.

Anesthetic Approaches and Their Impact on Cancer Recurrence and Metastasis: A Comprehensive Review

Cancer recurrence and metastasis remain critical challenges following surgical resection, influenced by complex perioperative mechanisms. This review explores how surgical stress triggers systemic changes, such as neuroendocrine responses, immune suppression, and inflammation, which promote the dissemination of residual cancer cells and circulating tumor cells. Key mechanisms, such as epithelial-mesenchymal transition and angiogenesis, further enhance metastasis, while hypoxia-inducible factors and inflammatory responses create a microenvironment conducive to tumor progression. Anesthetic agents and techniques modulate these mechanisms in distinct ways. Inhaled anesthetics, such as sevoflurane, may suppress immune function by increasing catecholamines and cytokines, thereby promoting cancer progression. In contrast, propofol-based total intravenous anesthesia mitigates stress responses and preserves natural killer cell activity, supporting immune function. Opioids suppress immune surveillance and promote angiogenesis through the activation of the mu-opioid receptor. Opioid-sparing strategies using NSAIDs show potential in preserving immune function and reducing recurrence risk. Regional anesthesia offers benefits by reducing systemic stress and immune suppression, though the clinical outcomes remain inconsistent. Additionally, dexmedetomidine and ketamine exhibit dual effects, both enhancing and inhibiting tumor progression depending on the dosage and context. This review emphasizes the importance of individualized anesthetic strategies to optimize long-term cancer outcomes. While retrospective studies suggest potential benefits of propofol-based total intravenous anesthesia and regional anesthesia, further large-scale trials are essential to establish the definitive role of anesthetic management in cancer recurrence and survival.

Recommendation for the practice of total intravenous anesthesia

This Recommendation was developed by the Japanese Society of Intravenous Anesthesia Recommendation Making Working Group (JSIVA-WG) to promote the safe and effective practice of total intravenous anesthesia (TIVA), tailored to the current situation in Japan. It presents a policy validated by the members of JSIVA-WG and a review committee for practical anesthesia management. Anesthesiologists should acquire and maintain the necessary knowledge and skills to be able to administer TIVA properly. A secure venous access is critically important for TIVA. To visualize and understand the pharmacokinetics of intravenous anesthetics, use of real-time pharmacokinetic simulations is strongly recommended. Syringe pumps are essential for the infusion of intravenous anesthetics, which should be prepared according to the rules of each individual anesthesia department, particularly with regard to dilution. Syringes should be clearly labeled with content and drug concentration. When managing TIVA, particularly with the use of muscle relaxants, monitoring processed electroencephalogram (EEG) is advisable. However, the depth of sedation/anesthesia must be assessed comprehensively using various parameters, rather than simply relying on a single EEG index. TIVA should be swiftly changed to an alternative method that includes inhalation anesthesia if necessary. Use of antagonists at emergence may be associated with re-sedation risk. Casual administration of antagonists and sending patients back to surgical wards without careful observation are not acceptable.

Roles of epidural block in combination with general anesthesia in stress response and immune function of patients after surgery for cervical cancer

We aimed to explore the roles of epidural block in combination with general anesthesia in the stress response and immune function of patients after surgery for cervical cancer. A total of 108 patients undergoing radical surgery of cervical cancer were randomly assigned into a general anesthesia combined with epidural block (observation) group and a general anesthesia (control) group. Peripheral blood was collected before anesthesia (t0), during anesthesia maintenance, as well as 10 min, 1 d, 2 d and 7 d after surgery. The levels of cytokines interferon-γ (IFN-γ), interleukin-4 (IL-4) and transforming growth factor-β1 (TGF-β1) were detected by ELISA, and IFN-γ/IL-4 ratio was calculated. Compared with the control group, the observation group had significantly lower levels of GH, PRL and Cor, proportions of Th2 and Treg cells, and levels of IL-4 and TGF-β1 during anesthesia maintenance and at each time point after surgery (P < 0.05), but higher proportion of Th1 cells, Th1/Th2 cell ratio, IFN-γ level and IFN-γ/IL-4 ratio (P < 0.05). General anesthesia in combination with epidural block can work better in mitigating the stress response and protecting the immune function of patients after cervical cancer surgery.

The Role of Anesthetic Management in Lung Cancer Recurrence and Metastasis: A Comprehensive Review

Lung cancer remains a leading cause of cancer-related mortality worldwide. Although surgical treatment is a primary approach, residual cancer cells and surgery-induced pathophysiological changes may promote cancer recurrence and metastasis. Anesthetic agents and techniques have recently been shown to potentially impact these processes by modulating surgical stress responses, immune function, inflammatory pathways, and the tumor microenvironment. Anesthetics can influence immune-modulating cytokines, induce pro-inflammatory factors such as HIF-1α, and alter natural-killer cell activity, affecting cancer cell survival and spread. Preclinical studies suggest volatile anesthetics may promote tumor progression by triggering pro-inflammatory signaling, while propofol shows potential antitumor properties through immune-preserving effects and reductions in IL-6 and other inflammatory markers. Additionally, opioids are known to suppress immune responses and stimulate pathways that may support cancer cell proliferation, whereas regional anesthesia may reduce these risks by decreasing the need for systemic opioids and volatile agents. Despite these findings, clinical data remain inconclusive, with studies showing mixed outcomes across patient populations. Current clinical trials, including comparisons of volatile agents with propofol-based total intravenous anesthesia, aim to provide clarity but highlight the need for further investigation. Large-scale, well-designed studies are essential to validate the true impact of anesthetic choice on cancer recurrence and to optimize perioperative strategies that support long-term oncologic outcomes for lung cancer patients.

Repurposing propofol for breast cancer therapy through promoting apoptosis and arresting cell cycle

Breast cancer is the most prevalent cancer among women worldwide, characterized by a high mortality rate and propensity for metastasis. Although surgery is the standard treatment for breast cancer, there is still no effective method to inhibit tumor metastasis and improve the prognosis of patients with breast cancer after surgery. Propofol, one of the most widely used intravenous anesthetics in surgery, has exhibited a positive association with improved survival outcomes in patients with breast cancer post‑surgery. However, the underlying molecular mechanism remains to be elucidated. The present study revealed that triple negative breast cancer cells, MDA‑MB‑231 and 4T1, exposed to propofol exhibited a significant decrease in cell viability. Notably, propofol exhibited minimal cytotoxic effects on HUVECs under the same conditions. Furthermore, propofol significantly inhibited the migration and invasion ability of MDA‑MB‑231 and 4T1 cells. Propofol promoted apoptosis in 4T1 cells through upregulation of Bax and cleaved caspase 3, while downregulating B‑cell lymphoma‑extra large. Concomitantly, propofol induced cell cycle arrest of 4T1 cells by downregulating cyclin E2 and phosphorylated cell division cycle 6. Furthermore, propofol exhibited excellent anticancer efficacy in a 4T1 breast cancer allograft mouse model. The present study sheds light on the potential of propofol as an old medicine with a novel use for breast cancer treatment.

The Impact of Different Anesthetics on the Distribution and Cytotoxic Function of NK Cell Subpopulations: An In Vitro Study

Only some subpopulations of natural killer (NK) cells have cytotoxic functionality, and the effects of anesthetics on these subpopulations are unknown. This study aimed to evaluate the in vitro effects of various anesthetics, both alone and in combination, on the distribution and cytotoxic function of NK cells and their subpopulations. Peripheral blood mononuclear cells (PBMCs) from eight healthy volunteers were treated for 4 h in vitro with dexmedetomidine, remifentanil, lidocaine, propofol, sevoflurane, and combinations in clinically relevant concentrations or left untreated. Flow cytometry was used to quantify the percentage of sampled NK cells and evaluate their distribution (CD56brightCD16neg, CD56brightCD16dim, CD56dimCD16neg, CD56dimCD16bright, and CD56negCD16bright) and cytotoxicity (Granzyme B (GrzB) and perforin) of NK cell subpopulations. Although the percentage of total NK cells did not change following exposure to anesthesia, the most important cytotoxic subpopulation (CD56dimCD16bright NK cells) decreased after exposure to both propofol (-3.58%, p = 0.045) and sevoflurane (-16.10%, p = 0.008) alone, and most combinations, especially in combination with lidocaine (propofol with lidocaine (-9.66%, p = 0.002) and sevoflurane with lidocaine (-21.90%, p < 0.001)). Dexmedetomidine and remifentanil had no effect on CD56dimCD16bright NK cells. Furthermore, no anesthetic regimen or combination altered the expression of GrzB and perforin in NK cells or NK cell subpopulations. In short, propofol and sevoflurane suppressed the highly cytotoxic phenotype (CD56dimCD16bright) of NK cells, with those exposed to sevoflurane combinations showing greater reductions. Immunosuppression was intensified with the inclusion of lidocaine in the anesthetic regimen.

Establishment and Clinical Significance of the Patient-Derived Xenograft Model of Colorectal Cancer

OBJECTIVES

Patient-derived xenograft (PDX) models are widely acknowledged for their ability to reflect the heterogeneity of human cancers and can be used to improve preclinical models. In this study, we evaluated the factors affecting the tumor formation rate of the PDX colorectal cancer (CRC) model and conducted preliminary drug sensitivity tests.

METHODS

CRC patients who underwent elective surgery at Shaoxing People's Hospital from November 2019 to October 2020 were included. The tumor tissue obtained from surgery was transplanted to the back of NSG mice, and the PDX model was established and subcultured to the F3 generation. Factors that affected tumorigenicity were analyzed and compared histologically. Drug interventions included 5-fluorouracil, oxaliplatin, and propofol.

RESULTS

Sixty CRC patients were included in this study, and tumorigenesis was observed in CRC tissue derived from 37 cases (62%). The primary tumor malignancy degree (tumor stage and degree of cell differentiation), preoperative carcinoembryonic antigen level, and tumor location in CRC patients could affect the tumorigenicity of the PDX model. Histopathological analysis of CRC-PDX transplanted tumor tissue was highly consistent with the patient's tumor tissue. All four chemotherapy regimens could inhibit tumor growth and cause tumor tissue damage. Propofol could inhibit diarrhea in mice and protect intestinal mucosa.

CONCLUSIONS

The CRC-PDX model established in this study can maintain the biological characteristics of primary tumors and can be used as a reference model for the individualized treatment of CRC patients. The degree of malignancy of the primary tumor is the primary factor affecting the tumorigenesis rate of the PDX model.

The role of perioperative factors in the prognosis of cancer patients: A coin has two sides

Cancer, the second leading cause of mortality globally, poses a significant health challenge. The conventional treatment for solid tumors involves surgical intervention, followed by chemo- and radio-therapies as well as target therapies, but the recurrence and metastasis of cancers remain a major issue. Anesthesia is essential for ensuring patient comfort and safety during surgical procedures. Despite its crucial role during the surgery, the precise effect of anesthesia on cancer patient outcomes is not clearly understood. This comprehensive review aims to elucidate the various anesthesia strategies used in the perioperative care of cancer patients and their potential effects on patients' prognosis, but understanding the complex relationship between anesthesia and cancer outcomes is crucial, given the complexity in cancer treaments. Examining potential implications of anesthesia strategies on cancer patient prognosis may help better understand treatment efficacy and risk factors of cancer recurrence and metastasis. Through a detailed analysis of anesthesia practices in cancer surgery, this review aims to provide insights that may lead to improving the existing anesthesia protocols and ultimately reduce risk factors for patient outcomes in the field of oncology.

NKG2D (Natural Killer Group 2, Member D) ligand expression and ameloblastoma recurrence: a retrospective immunohistological pilot study

BACKGROUND/PURPOSE

This retrospective immunohistological pilot study aimed to investigate the influence of natural killer group 2, member D (NKG2D) ligand expression on ameloblastoma recurrence after surgical resection. It also aimed to elucidate additional clinical factors that could serve as predictors of ameloblastoma recurrence.

MATERIALS AND METHODS

This study included 96 patients who were histologically diagnosed with ameloblastoma after surgical resection. The expression of NKG2D ligands, including UL16-binding proteins (ULBPs) 1-3 and major histocompatibility complex class I chain-related molecule (MIC) A/B, was evaluated in formalin-fixed paraffin-embedded tumor tissues via immunohistochemistry assays. Furthermore, the patients' electronic medical records were reviewed. Multivariate Cox regression analysis was conducted, and data were expressed as adjusted hazard ratios [HRs] with 95% confidence intervals [95% CIs].

RESULTS

Multivariate analysis revealed that recurrent tumors (ref.: primary; adjusted HR [95% CI]: 2.780 [1.136, 6.803], p = 0.025) and positive MICA/B expression (ref.: negative; adjusted HR [95% CI]: 0.223 [0.050, 0.989], p = 0.048) independently affected recurrence-free survival in ameloblastoma.

CONCLUSION

This study identified recurrent cases and loss of MICA/B expression as independent predictors of early ameloblastoma recurrence following surgical resection. The findings suggest that decreased MICA/B expression might undermine NKG2D-mediated tumor immunosurveillance, thereby influencing early recurrence.

The synergistic mechanisms of propofol with cisplatin or doxorubicin in human ovarian cancer cells

BACKGROUND

Most ovarian cancer cases are diagnosed at an advanced stage, leading to poor outcomes and a relatively low 5-year survival rate. While tumor resection in the early stages can be highly effective, recurrence following primary treatment remains a significant cause of mortality. Propofol is a commonly used intravenous anesthetic agent in cancer resection surgery. Previous research has shown that propofol anesthesia was associated with improved survival in patients undergoing elective surgery for epithelial ovarian cancer. However, the underlying antitumor mechanisms are not yet fully understood.

METHODS

This study aimed to uncover the antitumor properties of propofol alone and combined with cisplatin or doxorubicin, in human SKOV3 and OVCAR3 ovarian cancer cells. We applied flowcytometry analysis for mitochondrial membrane potential, apoptosis, and autophagy, colony formation, migration, and western blotting analysis.

RESULTS

Given that chemotherapy is a primary clinical approach for managing advanced and recurrent ovarian cancer, it is essential to address the limitations of current chemotherapy, particularly in the use of cisplatin and doxorubicin, which are often constrained by their side effects and the development of resistance. First of all, propofol acted synergistically with cisplatin and doxorubicin in SKOV3 cells. Moreover, our data further showed that propofol suppressed colony formation, disrupted mitochondrial membrane potential, and induced apoptosis and autophagy in SKOV3 and OVCAR3 cells. Finally, the effects of combined propofol with cisplatin or doxorubicin on mitochondrial membrane potential, apoptosis, autophagy, and epithelial-mesenchymal transition were different in SKOV3 and OVCAR3 cells, depending on the p53 status.

CONCLUSION

In summary, repurposing propofol could provide novel insights into the existing chemotherapy strategies for ovarian cancer. It holds promise for overcoming resistance to cisplatin or doxorubicin and may potentially reduce the required chemotherapy dosages and associated side effects, thus improving treatment outcomes.

Ropivacaine Administration Suppressed A549 Lung Adenocarcinoma Cell Proliferation and Migration via ACE2 Upregulation and Inhibition of the Wnt1 Pathway

BACKGROUND

Previous studies have suggested that perioperative anesthesia could have direct impacts on cancer cell biology. The present study investigated the effects of ropivacaine administration on lung adenocarcinoma cells.

METHODS

Ropivacaine was administered to A549 cells at concentrations of 0.1, 1, and 6 mM for 2 h. Angiotensin-converting enzyme 2 (ACE2) small interfering RNA (siRNA) transfection was performed 6 h prior to ropivacaine administration. Cell proliferation and migration were assessed with cell counting kit 8 (CCK-8) and a wound healing assay at 0 and 24 h after anesthesia exposure. PCR arrays were performed, followed by PCR validation.

RESULTS

Ropivacaine administration inhibited A549 cell proliferation and migration in a concentration-dependent manner, with ACE2 upregulation and HIF1α (hypoxia-inducible factor 1α) downregulation. The anticancer effect of ropivacaine was canceled out via ACE2 siRNA transfection. PCR arrays showed specific gene change patterns in the ropivacaine and respective ACE2-knockdown groups. EGFR (epidermal growth factor receptor), BAX (Bcl-2-associated X protein) and BCL2 (B-cell/CLL lymphoma 2) were suppressed with ropivacaine administration; these effects were reversed via ACE2 siRNA induction.

CONCLUSION

Ropivacaine administration inhibited A549 cell biology in conjunction with ACE2 upregulation via the inhibition of the Wnt1 (wingless/Integrated 1) pathway.

Influence of Anesthetic Techniques on Colorectal Cancer Recurrence: A Comprehensive Review

Colorectal cancer is a leading cause of cancer-related morbidity and mortality worldwide, with a significant risk of recurrence following surgical treatment. Emerging evidence suggests that perioperative factors, particularly anesthetic techniques, may influence cancer recurrence rates. This comprehensive review aims to critically analyze the impact of various anesthetic techniques on colorectal cancer recurrence. We explore the distinct immunomodulatory and inflammatory effects of general, regional, and combined anesthetic approaches and their potential influence on tumor biology. The review synthesizes findings from clinical studies, experimental research, and theoretical models, highlighting the differential impact of anesthetic choices on long-term oncological outcomes. By examining recurrence rates, immune responses, and inflammatory markers associated with different anesthetic techniques, this review provides a holistic understanding of the role of anesthetic management in colorectal cancer surgery. Our findings suggest that anesthetic techniques can modulate the immune and inflammatory responses in ways that may affect tumor recurrence, underscoring the need for further research to optimize anesthetic protocols. The review offers clinical recommendations based on current evidence and identifies gaps in knowledge, proposing directions for future investigations. This comprehensive analysis aims to inform clinical practice and guide future research, ultimately improving long-term outcomes for colorectal cancer patients.

Survival benefits of propofol-based versus inhalational anesthesia in non-metastatic breast cancer patients: a comprehensive meta-analysis

Whether the anesthesia technique, inhalational general anesthesia (IGA) or propofol-based anesthesia (PBA), influences the long-term survival of non-metastatic breast cancer (eBC) remain unclear and controversial. We carried out a literature search on 16thJuly, 2022 for studies comparing IGA and PBA in eBC undergoing standard surgery, according to PRISMA 2020. The major endpoint in our study was overall survival (OS). Seventeen studies including four randomized clinical trials and thirteen retrospective cohort studies were included in the meta-analysis. Ten studies provided data for crude OS in unweighted eBC patients (imbalance in baseline characteristics). The summarized estimate HRs of the PBA group versus the IGA group (ten studies, N = 127,774, IGA group: 92,592, PBA group: 35,182.) was 0.83 (95%CI: 0.78-0.89). Compared with IGA, PBA was associated with both better 1-year OS (two studies, N = 104,083, IGA group: 84,074, PBA group: 20,009. Pooled HR = 0.80, 0.73-0.89) and 5-year OS (six studies, N = 121,580, IGA group: 89,472, PBA group: 32,108. HR = 0.80, 0.74-0.87). Ten studies applied PSM method to balance the baseline characteristics. In these weighted patients, PBA still showed a better OS (ten studies, N = 105,459, IGA group: 79,095, PBA group: 26,364. HR = 0.93, 0.87-1.00), a better 1-year OS (two studies, N = 83,007, IGA group: 67,609, PBA group: 15,398. HR = 0.88, 0.78-0.98) and a trend towards a better 5-year OS (nine studies, N = 121,580, IGA group: 76,797, PBA group: 24,066. HR = 0.95, 0.88-1.03). Loco-regional recurrence-free survival (LRRFS) was also better in PBA group (HR = 0.73, 0.61-0.86). The present study is the first comprehensive meta-analysis to demonstrate that propofol-based anesthesia could significantly improve OS and LRRFS in non-metastatic breast cancer patients, compared with inhalational anesthesia.

Comparisons of different general anesthetic techniques on immune function in patients undergoing flap reconstruction for oral cancer

BACKGROUND

Anesthetic-induced immunosuppression is of particular interest in tumor surgery. This study aimed to investigate the influence of the 4 most common general anesthetic techniques on immune function in patients undergoing flap reconstruction for oral cancer.

METHODS

116 patients were randomly divided into 4 groups. Patients in group S were given sevoflurane-based anesthesia. Group P was administered propofol-based anesthesia. The SD group received sevoflurane combined with dexmedetomidine anesthesia. The propofol combined with dexmedetomidine anesthesia (PD) group received PD. Blood samples were obtained at 5 time points: baseline (T0), 1 hour after the start of the operation (T1), end of the operation (T2), 24 hours (T3), and 48 hours (T4) after the operation. Lymphocyte subsets (including CD3+, CD4+, CD8+, and B lymphocytes) and dendritic cells were analyzed by flow cytometry. Blood glucose, norepinephrine, and cortisol levels were measured using ELISA and a blood gas analyzer respectively.

RESULTS

In total, 107 patients were included in the final analysis. Immunological indicators, except CD8+ counts, were all decreased in groups S, P, and SD at T1-4 compared with the baseline value, and the counts of CD3+, CD4+, and dendritic cells, as well as CD4+/CD8+ ratios, were significantly higher in the PD group than in the S, P, and SD at T1-3 (P < .05). There were no significant differences between groups P and SD at any observation time point. Intraoperative stress indices, including norepinephrine and cortisol levels, were significantly lower in the PD group than in the other 3 groups at T1-2 (P < .05).

CONCLUSION

These findings suggest that PD as a probably optimal choice can alleviate immunosuppression in patients undergoing flap reconstruction for oral cancer.

Volatile vs Total intravenous Anaesthesia for major non-cardiac surgery: a pragmatic randomised triaL (VITAL)

BACKGROUND

Improving outcomes after surgery is a major public health research priority for patients, clinicians and the NHS. The greatest burden of perioperative complications, mortality and healthcare costs lies amongst the population of patients aged over 50 years who undergo major non-cardiac surgery. The Volatile vs Total Intravenous Anaesthesia for major non-cardiac surgery (VITAL) trial specifically examines the effect of anaesthetic technique on key patient outcomes: quality of recovery after surgery (quality of recovery after anaesthesia, patient satisfaction and major post-operative complications), survival and patient safety.

METHODS

A multi-centre pragmatic efficient randomised trial with health economic evaluation comparing total intravenous anaesthesia with volatile-based anaesthesia in adults (aged 50 and over) undergoing elective major non-cardiac surgery under general anaesthesia.

DISCUSSION

Given the very large number of patients exposed to general anaesthesia every year, even small differences in outcome between the two techniques could result in substantial excess harm. Results from the VITAL trial will ensure patients can benefit from the very safest anaesthesia care, promoting an early return home, reducing healthcare costs and maximising the health benefits of surgical treatments.

TRIAL REGISTRATION

ISRCTN62903453. September 09, 2021.

Perioperative Immunosuppressive Factors during Cancer Surgery: An Updated Review

Surgical excision of the primary tumor represents the most frequent and curative procedure for solid malignancies. Compelling evidence suggests that, despite its beneficial effects, surgery may impair immunosurveillance by triggering an immunosuppressive inflammatory stress response and favor recurrence by stimulating minimal residual disease. In addition, many factors interfere with the immune effectors before and after cancer procedures, such as malnutrition, anemia, or subsequent transfusion. Thus, the perioperative period plays a key role in determining oncological outcomes and represents a short phase to circumvent anesthetic and surgical deleterious factors by supporting the immune system through the use of synergistic pharmacological and non-pharmacological approaches. In line with this, accumulating studies indicate that anesthetic agents could drive both protumor or antitumor signaling pathways during or after cancer surgery. While preclinical investigations focusing on anesthetics' impact on the behavior of cancer cells are quite convincing, limited clinical trials studying the consequences on survival and recurrences remain inconclusive. Herein, we highlight the main factors occurring during the perioperative period of cancer surgery and their potential impact on immunomodulation and cancer progression. We also discuss patient management prior to and during surgery, taking into consideration the latest advances in the literature.

Uncovering essential anesthetics-induced exosomal miRNAs related to hepatocellular carcinoma progression: a bioinformatic investigation

BACKGROUND

Anesthetic drugs may alter exosomal microRNA (miRNA) contents and mediate cancer progression and tumor microenvironment remodeling. Our study aims to explore how the anesthetics (sevoflurane and propofol) impact the miRNA makeup within exosomes in hepatocellular carcinoma (HCC), alongside the interconnected signaling pathways linked to the tumor immune microenvironment.

METHODS

In this prospective study, we collected plasma exosomes from two groups of HCC patients (n = 5 each) treated with either propofol or sevoflurane, both before anesthesia and after hepatectomy. Exosomal miRNA profiles were assessed using next-generation sequencing (NGS). Furthermore, the expression data from The Cancer Genome Atlas-Liver Hepatocellular Carcinoma (TCGA-LIHC) was used to pinpoint the differentially expressed exosomal miRNAs (DEmiRNAs) attributed to the influence of propofol or sevoflurane in the context of HCC. Gene set enrichment analysis (GSEA) and gene set variation analysis (GSVA) were used to dissect the signaling pathways and biological activities associated with the identified DEmiRNAs and their corresponding target genes.

RESULTS

A total of 35 distinct DEmiRNAs were exclusively regulated by either propofol (n = 9) or sevoflurane (n = 26). Through TCGA-LIHC database analysis, 8 DEmiRNAs were associated with HCC. These included propofol-triggered miR-452-5p and let-7c-5p, as well as sevoflurane-induced miR-24-1-5p, miR-122-5p, miR-200a-3p, miR-4686, miR-214-3p, and miR-511-5p. Analyses revealed that among these 8 DEmiRNAs, the upregulation of miR-24-1-5p consistently demonstrated a significant association with lower histological grades (p < 0.0001), early-stage tumors (p < 0.05) and higher survival (p = 0.029). Further analyses using GSEA and GSVA indicated that miR-24-1-5p, along with its target genes, were involved in governing the tumor immune microenvironment and potentially inhibiting tumor progression in HCC.

CONCLUSIONS

This study provided bioinformatics evidence suggesting that sevoflurane-induced plasma exosomal miRNAs may have a potential impact on the immune microenvironment of HCC. These findings established a foundation for future research into mechanistic outcomes in cancer patients.

Long-term Survival after Volatile or Propofol General Anesthesia for Bladder Cancer Surgery: A Retrospective National Registry Cohort Study

BACKGROUND

Prospective interventional trials and retrospective observational analyses provide conflicting evidence regarding the relationship between propofol versus inhaled volatile general anesthesia and long-term survival after cancer surgery. Specifically, bladder cancer surgery lacks prospective clinical trial evidence.

METHODS

Data on bladder cancer surgery performed under general anesthesia between 2014 and 2021 from the National Quality Registry for Urinary Tract and Bladder Cancer and the Swedish Perioperative Registry were record-linked. Overall survival was compared between patients receiving propofol or inhaled volatile for anesthesia maintenance. The minimum clinically important difference was defined as a 5-percentage point difference in 5-yr survival.

RESULTS

Of 7,571 subjects, 4,519 (59.7%) received an inhaled volatile anesthetic, and 3,052 (40.3%) received propofol for general anesthesia maintenance. The two groups were quite similar in most respects but differed in American Society of Anesthesiologists Physical Status and tumor stage. Propensity score matching was used to address treatment bias. Survival did not differ during follow-up (median, 45 months [interquartile range, 33 to 62 months]) in the full unmatched cohort nor after 1:1 propensity score matching (3,052 matched pairs). The Kaplan-Meier adjusted 5-yr survival rates in the matched cohort were 898 of 3,052, 67.5% (65.6 to 69.3%) for propofol and 852 of 3,052, 68.5% (66.7 to 70.4%) for inhaled volatile general anesthesia, respectively (hazard ratio, 1.05 [95% CI, 0.96 to 1.15]; P = 0.332). A sensitivity analysis restricted to 1,766 propensity score-matched pairs of patients who received only one general anesthetic during the study period did not demonstrate a difference in survival; Kaplan-Meier adjusted 5-yr survival rates were 521 of 1,766, 67.1% (64.7 to 69.7%) and 482 of 1,766, 68.9% (66.5 to 71.4%) for propofol and inhaled volatile general anesthesia, respectively (hazard ratio, 1.09 [95% CI, 0.97 to 1.23]; P = 0.139).

CONCLUSIONS

Among patients undergoing bladder cancer surgery under general anesthesia, there was no statistically significant difference in long-term overall survival associated with the choice of propofol or an inhaled volatile maintenance.

EDITOR’S PERSPECTIVE

Enhanced recovery after surgery for oncological breast surgery reduces length of stay in a resource limited setting

BACKGROUND

Early recovery after surgery (ERAS) protocols in breast surgery optimizes resources and reduces healthcare costs by facilitating early discharges. These protocols are well established in tertiary centres, but not commonly adopted in regional centres. ERAS implementation potentially impacts smaller hospitals significantly, where resources are limited and persistent bed shortages with mounting waitlist pressures exist. Our study evaluates the feasibility of early discharge with the application of our ERAS protocol to mastectomies in a resource-constrained and rural setting.

METHODS

Breast cancer patients who underwent mastectomies with or without reconstruction between January 2017 and July 2023 were retrospectively reviewed. From January 2022, we implemented a standardized ERAS protocol for patients undergoing mastectomy. This incorporated a combination of pre-, intra- and post-operative elements to enhance patient readiness for discharge. Our study compared these patients (post-ERAS group) with the outcomes of mastectomies performed prior to January 2022 (pre-ERAS group).

RESULTS

104 patients were identified. In the post-ERAS group, 74.4% were discharged within 24 h compared to 23.1% in the pre-ERAS group. Length of stay was reduced from 2.26 to 1.42 days. There were no differences in unplanned clinician reviews or early representation to the emergency department between the two groups.

CONCLUSION

Reducing the length of stay without increased complications can be achieved in a resource-limited environment with our protocolized ERAS principals. Our protocol has been instrumental in allowing safe discharges within 24 h. Other regional centres may benefit in adopting strategies implemented by us for their own ERAS protocols in breast cancer surgery.

A Comparison of the Health Benefits of Customized Multivitamins and Standard Supplementation Post-bariatric Surgery: A Systematic Review

Rates of obesity increase worldwide year after year. This review explored if customized multivitamins (CMV) resulted in less micronutrient deficiency and higher serum levels of vitamins and minerals when compared to standard multivitamins (SMV) post-bariatric surgery in adults. Vitamins investigated were vitamins B1, B6, B12, D, parathyroid hormone (PTH), calcium, iron, hemoglobin, ferritin, folic acid, zinc, and magnesium. In Roux-en-Y gastric bypass (RYGB) patients weight loss surgeries (WLS) Forte or chewable CMV were studied, while in sleeve gastrectomy (SG) patients, WLS Optimum 1.0 (Opt. 1.0) or WLS Optimum 2.0 (Opt. 2.0) multivitamins were studied. An electronic search was performed on three databases (PubMed (n=28), Embase (n=120), and Cochrane (n=106)) to identify clinical trials and cohort studies. The inclusion criteria focused on studies since 2011 for adults ≥18 years old post-GB and SG. The keywords included bypass, sleeve, WLS, and multivitamins. Four clinical trials and three cohort studies were included. Jadad Scale was used to assess the quality and the bias risk in the clinical trials and the Newcastle-Ottawa scale (NOS) was used for the cohort studies. The PICO model and PRISMA rules were followed, where the outcomes targeted certain vitamin serum levels and the levels of deficiencies. The results of WLS Forte were better than SMV. The chewable CMV and Opt. 1.0 results were comparable to SMV. Opt. 2.0 was slightly better than Opt. 1.0. Further modifications would enhance the CMV presented in this systemic review. SMV would still be recommended until CMV are modified and tested. Multi-center trials that monitor the effect of the modified CMV on the serum levels of vitamins and minerals in the longer term in different wider populations are needed.

The effects of anaesthesia and analgesia on short- and long-term outcomes following colorectal cancer surgery: Protocol for an international, pragmatic, cohort study (ENCORE∗)

BACKGROUND

Colorectal cancer (CRC) is the second most frequent cause of global cancer mortality. Most patients with CRC require surgical tumour resection, with certain stages of CRC (Stage II/III) also requiring postoperative chemotherapy. The timing of postoperative chemotherapy is largely determined by postoperative recovery. Delayed return to intended oncologic therapy (RIOT) by >8 weeks results in worse oncologic outcomes. RIOT is thus an important surrogate marker of outcome for patients with stage II/III CRC. We will test the hypothesis that anaesthetic technique during CRC resection surgery may affect RIOT.

OBJECTIVE

To test the association between anaesthetic and analgesic technique during CRC surgery and RIOT. To document Short-term Secondary outcomes including individual postoperative complications and a composite of all postoperative complications, the Comprehensive Complications Index (CCI) and to measure the time to recurrence (TTR) of cancer at 3 years.

DESIGN

This is a prospective, international, multicentre, observational cohort study.

SETTING

Global healthcare setting, with >140 centres in >30 nations.

PATIENTS

Inclusion criteria: All patients age >18 years, ASA I-III, with CRC stage I-III scheduled for elective CRC surgery (open or minimally invasive).Exclusion criteria: Uncontrolled renal or liver disease, restrictive (limiting mobility) heart failure or ischemic heart disease (ASA IV-V). Speech, language, or cognitive difficulties precluding signing informed consent to participate and Stage IV CRC.

PRIMARY OUTCOME MEASURES

Short -term: The duration from day of surgery to RIOT among patients expected to receive postoperative chemotherapy. Long-term: incidence of recurrence and time to recurrence (TTR) at 3 years after primary curative surgery.

SECONDARY OUTCOMES

Postoperative complications within 30 days of surgery, length of hospital stay, Days at Home at 30 and 90 days (DAH-30, DAH-90) after surgery, and adverse events related to oncological treatment. We will also assess the burden of preoperative modifiable comorbid disease in patients. Exploratory endpoints will assess practice variation (including incidence of RIOT by demographic e.g. gender of patient, type of institution, country).

RESULTS

N/A.

CONCLUSIONS

N/A.

TRIAL REGISTRATION

The Effects of aNesthesia in COloREctal cancer outcome study: ENCORE, ClinicalTrials.gov Identifier: NCT04493905.

The Surgical Stress Response and Anesthesia: A Narrative Review

The human physiological response "to stress" includes all metabolic and hormonal changes produced by a traumatic event at the micro or macro cellular levels. The main goal of the body's first response to trauma is to keep physiological homeostasis. The perioperative non-specific adaptation response can sometimes be detrimental and can produce systemic inflammatory response syndrome (SIRS), characterized by hypermetabolism and hyper catabolism. We performed a narrative review consisting of a description of the surgical stress response's categories of changes (neurohormonal and immunological response) followed by reviewing methods found in published studies to modulate the surgical stress response perioperatively. We described various preoperative measures cited in the literature as lowering the burden of surgical trauma. This article revises the anesthetic drugs and techniques that have an impact on the surgical stress response and proven immune-modulatory effects. We also tried to name present knowledge gaps requiring future research. Our review concludes that proper preoperative measures, adequate general anesthetics, multimodal analgesia, early postoperative mobilization, and early enteral nutrition can decrease the stress response to surgery and ease patient recovery. Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system and inflammatory system, with a consecutive impact on cancer recurrence and long-term outcomes.

Effect of different anaesthetic techniques on the prognosis of patients with colorectal cancer after resection: a systematic review and meta-analysis

Background

The effect of total intravenous anaesthesia (TIVA) and inhalation anaesthesia (IA) on the prognosis of patients with colorectal cancer after resection is controversial. This study aimed to explore the effects of different anaesthesia methods on the postoperative prognosis of colorectal cancer.

Methods

PubMed, Embase and Cochrane Library databases were searched for relevant literature from each database's inception until 18 November 2023. The literature topic was to compare the effects of TIVA and IA on the prognosis of patients undergoing colorectal cancer resection.

Results

Six studies were selected for meta-analysis. The studies involved 111043 patients, with a trial size of 1001-88184 people. A statistically significant difference was observed in the overall survival (OS) between colorectal cancer patients administered TIVA and IA (hazard ratio [HR], 0.83; 95% confidence interval [CI], 0.70-0.99), but none in recurrence-free survival (RFS) (HR, 0.99; 95% CI, 0.90-1.08). In the subgroup analysis of OS, no statistically significant difference was observed between colorectal cancer patients administered TIVA and IA in Asia (HR, 0.77; 95% CI, 0.57-1.05), and not in Europe (HR, 0.99; 95% CI, 0.93-1.06). Regarding tumour location, no significant association was found between TIVA and IA in the colon, rectum and colorectum ((HR, 0.70; 95% CI, 0.38-1.28), (HR, 0.95; 95% CI, 0.83-1.08) and (HR, 0.99; 95% CI, 0.93-1.06), respectively).

Conclusion

OS differed significantly between patients administered TIVA and IA when undergoing colorectal cancer resection, but no difference was observed in RFS. The prognostic effects of TIVA and IA differed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023453185, identifier CRD42023453185.

Propofol-induced LINC01133 inhibits the progression of colorectal cancer via miR-186-5p/NR3C2 axis

Colorectal cancer (CRC) is a formidable threat to human well-being, characterized by a largely enigmatic occurrence and progression mechanism. A growing body of literature has underscored the potential influence of propofol, a frequently administered anesthetic, on clinical outcomes in malignant tumor patients. However, the precise molecular mechanisms underlying the impact of propofol on the progression of CRC have yet to be fully elucidated. This study reveals a notable upregulation of LINC01133 expression in CRC cells subsequent to propofol treatment, which is mediated by FOXO1. Subsequently, a series of experiments were conducted to elucidate the role and mechanisms underlying propofol-induced LINC01133 in CRC development. Our study uncovers that the upregulation of LINC01133 exerts a substantial inhibitory effect on the proliferation, migration, and invasion of CRC cells. Further investigation revealed that LINC01133 can attenuate the proliferation, invasion, and migration of CRC cell lines through the miR-186-5p/NR3C2 axis. Results from in vivo experiments unequivocally demonstrated a significant reduction in the growth rate of subcutaneous implant tumors upon LINC01133 overexpression in CRC cells. These findings posit that propofol induces LINC01133 expression, leading to the inhibition of CRC progression. This revelation offers a novel perspective on propofol's antitumor properties and underscores the potential of LINC01133 as a promising therapeutic target for CRC.

PRESS (Propofol, Remifentanil, Electricity/EEG, Setup and Setting) to Start: Introducing a Total Intravenous Anaesthesia Checklist at a Large Teaching Hospital

Total intravenous anaesthesia (TIVA) is becoming more widely used, and as of yet there are few safety checks for the use of TIVA when compared to inhaled anaesthesia. This study aims to assess the feasibility and utility of introducing a TIVA checklist at a large teaching hospital. Methods A survey was sent out to all consultant and trainee anaesthetists at our hospital regarding their use of TIVA and errors in practice related to its use. A checklist was created based on common errors reported in the survey, errors described in NAP5 and our hospital's standard operating procedure. The checklist was introduced, and another survey was distributed a month later to assess compliance and utility and to gain feedback. Results In the first survey, there were 39 responses. A total of 64% had seen an error with the use of TIVA. For those using TIVA 70% of the time or more, 31% had seen an error in the last three months. Twelve per cent of those who had seen errors found that the errors led to patient harm. Only 33% used a method to double-check for errors prior to commencing TIVA. In the follow-up survey, 80% of those who used the checklist had found it useful, and 30% had corrected an error while using the checklist. Eighty-seven per cent felt the checklist would prevent errors from being made. Eighty per cent of respondents said they would use the checklist in their future practice. The checklist was found to be more useful for trainees, and for those who use TIVA less often. Discussion The 'PRESS to start TIVA" checklist has been shown to be a useful tool to prevent errors and a majority of anaesthetists at our hospital plan to use it going forward. Our data suggests that anaesthetists who are less experienced with TIVA benefit more from having a checklist. There was a marked increase in the number of anaesthetists who would use a checklist in the future, compared to those who used one in the initial survey. This shows that introducing a checklist is feasible and is likely to reduce errors going forward.

Reducing the carbon footprint of general anaesthesia: a comparison of total intravenous anaesthesia vs. a mixed anaesthetic strategy in 47,157 adult patients

Global warming is a major public health concern. Volatile anaesthetics are greenhouse gases that increase the carbon footprint of healthcare. Modelling studies indicate that total intravenous anaesthesia is less carbon intensive than volatile anaesthesia, with equivalent quality of care. In this observational study, we aimed to apply the findings of previous modelling studies to compare the carbon footprint per general anaesthetic of an exclusive TIVA strategy vs. a mixed TIVA-volatile strategy. This comparative retrospective study was conducted over 2 years in two French hospitals, one using total intravenous anaesthesia only and one using a mixed strategy including both intravenous and inhalation anaesthetic techniques. Based on pharmacy procurement records, the quantity of anaesthetic sedative drugs was converted to carbon dioxide equivalents. The primary outcome was the difference in carbon footprint of hypnotic drugs per intervention between the two strategies. From 1 January 2021 to 31 December 2022, 25,137 patients received general anaesthesia in the hospital using the total intravenous anaesthesia strategy and 22,020 in the hospital using the mixed strategy. The carbon dioxide equivalent footprint of hypnotic drugs per intervention in the hospital using the total intravenous anaesthesia strategy was 20 times lower than in the hospital using the mixed strategy (emissions of 2.42 kg vs. 48.85 kg carbon dioxide equivalent per intervention, respectively). The total intravenous anaesthesia strategy significantly reduces the carbon footprint of hypnotic drugs in general anaesthesia in adult patients compared with a mixed strategy. Further research is warranted to assess the risk-benefit ratio of the widespread adoption of total intravenous anaesthesia.

Inhaled anesthesia associated with reduced mortality in patients with stage III breast cancer: A population-based study

BACKGROUND

Patients diagnosed with stage III breast cancer often undergo surgery, radiation therapy, and chemotherapy as part of their treatment. The choice of anesthesia technique during surgery has been a subject of interest due to its potential association with immune changes and prognosis. In this study, we aimed to compare the mortality rates between stage III breast cancer patients undergoing surgery with propofol-based intravenous general anesthesia and those receiving inhaled anesthetics.

METHODS

Using data from Taiwan's National Health Insurance Research Database and Taiwan Cancer Registry, we identified a cohort of 10,896 stage III breast cancer patients. Among them, 1,506 received propofol-based intravenous anesthetic maintenance, while 9,390 received inhaled anesthetic maintenance. To ensure comparability between the two groups, we performed propensity-score matching.

RESULTS

Our findings revealed a significantly lower mortality rate in patients who received inhaled anesthetics compared to those who received propofol-based intravenous anesthesia. Sensitivity analysis further confirmed the robustness of our results.

CONCLUSIONS

This study suggests that inhaled anesthesia technique is associated with a lower mortality rate in clinical stage III breast cancer. Further research is needed to validate and expand upon these results.

The influence of anaesthesia on cancer growth

BACKGROUND

Oncological patients make up a large proportion of all surgical patients. Through its influence on the patient's inflammatory and immune system, the choice of anaesthetic technique has an indirect impact on the health of the individual patient and on public health. Both the specific and the non-specific immune system have a major influence on the recurrence of carcinomas. The pathophysiological basis for growth and metastasis after surgery is the physiological response to stress. Inflammation is the organism's universal response to stress. Anaesthetics and adjuvants influence perioperative inflammation in different ways and have an indirect effect on tumour growth and metastasis. In vitro studies have shown how individual anaesthetics influence the growth and spread of cancer, but clinical studies have not confirmed these results. Nevertheless, it is advisable to use an anaesthetic that has shown lesser effect on the growth of cancer cells in vitro.

CONCLUSIONS

In this review, we focus on the area of the effects of anaesthesia on tumour growth. The field is still relatively unexplored, there are only few clinical prospective studies and their results are controversial. Based on the review of new research findings we report on recommendations about anaesthetics and anaesthetic techniques that might be preferable for oncological surgical procedures.

Effects of anesthesia on long-term survival in cancer surgery: A systematic review and meta-analysis

Backgrounds

The association between anesthesia and long-term oncological outcome after cancer surgery remains controversial. This study aimed to investigate the effect of propofol-based anesthesia and inhalation anesthesia on long-term survival in cancer surgery.

Methods

A comprehensive literature search was performed in PubMed, Medline, Embase, and the Cochrane Library until November 15, 2023. The outcomes included overall survival (OS) and recurrence-free survival (RFS). The hazard ratio (HR) and 95 % confidence interval (CI) were calculated with a random-effects model.

Results

We included forty-two retrospective cohort studies and two randomized controlled trials (RCTs) with 686,923 patients. Propofol-based anesthesia was associated with improved OS (HR = 0.82, 95 % CI:0.76-0.88, P < 0.00001) and RFS (HR = 0.80, 95 % CI:0.73-0.88, P < 0.00001) than inhalation anesthesia after cancer surgery. However, these positive results were only observed in single-center studies (OS: HR = 0.76, 95 % CI:0.68-0.84, P < 0.00001; RFS: HR = 0.76, 95 % CI:0.66-0.87, P < 0.0001), but not in multicenter studies (OS: HR = 0.98, 95 % CI:0.94-1.03, P = 0.51; RFS: HR = 0.95, 95 % CI:0.87-1.04, P = 0.26). The subgroup analysis revealed that propofol-based anesthesia provided OS and RFS advantages in hepatobiliary cancer (OS: HR = 0.58, 95 % CI:0.40-0.86, P = 0.005; RFS: HR = 0.62, 95 % CI:0.44-0.86, P = 0.005), gynecological cancer (OS: HR = 0.52, 95 % CI:0.33-0.81, P = 0.004; RFS: HR = 0.51, 95 % CI:0.36-0.72, P = 0.0001), and osteosarcoma (OS: HR = 0.30, 95 % CI:0.11-0.81, P = 0.02; RFS: HR = 0.32, 95 % CI:0.14-0.75, P = 0.008) surgeries.

Conclusion

Propofol-based anesthesia may be associated with improved OS and RFS than inhalation anesthesia in some cancer surgeries. Considering the inherent weaknesses of retrospective designs and the strong publication bias, our findings should be interpreted with caution. Well-designed multicenter RCTs are still urgent to further confirm these findings.

General anaesthetics reduce acute lymphoblastic leukaemia malignancies in vitro and in vivovia CXCR4 and osteopontin mediated mechanisms

Background

Acute lymphoblastic leukaemia (ALL) is a common type of cancer in children. General anaesthetics are often used on patients undergoing painful procedures during ALL treatments but their effects on ALL malignancy remain unknown. Herein, we aim to study the effect of propofol and sevoflurane on the migration, homing and chemoresistance of ALL cells.

Methods

NALM-6 and Reh cells were treated with propofol (5 and 10 μg/ml) or sevoflurane (3.6%) in vitro for six hours. Then, cells were harvested for adhesion assay and migration assay in vitro. In in vivo experiments, GFP-NALM-6 cells were pre-treated with propofol (10 μg/ml) or sevoflurane (3.6%) for six hours. Then, cells were injected intravenously to C57BL/6 female mice followed by intravital microscopy. For chemoresistance study, cells were treated with rising concentrations of Ara-c (0.05-50 nM) plus 10μg/ml of propofol or Ara-C plus 3.6% of sevoflurane for 4 hours, followed by the assessment of cell viability via CCK-8 assay and detection of autophagy via flow cytometry.

Results

Both anaesthetics reduced in vivo migration and in vivo homing as exemplified by 1) the reduction in the number of cells entering the bone marrow and 2) the disturbance in homing location in relation to endosteal surface. Our results indicated that general anaesthetics reduced the surface CXCR4 expression and the adhesion of leukaemia cells to thrombin cleaved osteopontin (OPN) was reduced. Those changes might result in the alterations in migration and homing. In addition, both anaesthetics sensitised ALL cells to Ara-c possibly through CXCR4 mediated mechanisms. Propofol but not sevoflurane enhanced chemo-related cell death via inducing cytotoxic autophagy.

Conclusion

Together, our data suggest that both propofol and sevoflurane could reduce ALL migration, and homing in vivo and in vitro via CXCR4 and OPN mediated mechanisms. Both anaesthetics could sensitise ALL cells to chemotherapy possibly via CXCR4 mediated mechanisms.

Impact of prognostic nutritional index change on prognosis after colorectal cancer surgery under propofol or sevoflurane anesthesia

BACKGROUND

The alteration of the prognostic nutritional index (PNI) or the utilization of distinct anesthesia strategies has been linked to the prognosis of various cancer types, but the existing evidence is limited and inconclusive, particularly for colorectal cancer (CRC). Our objective was to evaluate the association between PNI change and progression free survival (PFS) and overall survival (OS) in patients treated with CRC surgery after propofol-based or sevoflurane-based anesthesia.

METHODS

We conducted a retrospective analysis of 414 patients with CRC who underwent surgical resection. Among them, 165 patients received propofol-based total intravenous anesthesia (TIVA-P), while 249 patients received sevoflurane-based inhalation anesthesia (IA-S). The PNI change (ΔPNI) was calculated by subtracting the pre-surgery PNI from the post-surgery PNI, and patients were categorized into high (≥ -2.25) and low (< -2.25) ΔPNI groups. Univariate and multivariate analyses were employed to evaluate the effects of the two anesthesia methods, ΔPNI, and their potential interaction on PFS and OS.

RESULTS

The median duration of follow-up was 35.9 months (interquartile range: 18-60 months). The five-year OS rates were 63.0% in the TIVA-P group and 59.8% in the IA-S group (hazard ratio [HR]: 0.96; 95% confidence interval [CI]: 0.70-1.35; p = 0.864), while the five-year PFS rates were 55.8% and 51.0% (HR: 0.92; 95% CI: 0.68-1.26; p = 0.614), respectively. In comparison to patients in the low ΔPNI group, those in the high ΔPNI group exhibited a favorable association with both OS (HR: 0.57; 95% CI: 0.40-0.76; p < 0.001) and PFS (HR: 0.58; 95% CI: 0.43-0.79; p < 0.001). Stratified analysis based on ΔPNI revealed significant protective effects in the propofol-treated participants within the high ΔPNI group, whereas such effects were not observed in the low ΔPNI group, for both OS (p for interaction = 0.004) and PFS (p for interaction = 0.024).

CONCLUSIONS

Our data revealed that among patients who underwent CRC surgery, those treated with TIVA-P exhibited superior survival outcomes compared to those who received IA-S, particularly among individuals with a high degree of PNI change.

Propofol inhibits the proliferation, invasion, migration, and angiogenesis of oral squamous cell carcinoma through circ_0008898-mediated pathway

Propofol has been shown to inhibit oral squamous cell carcinoma (OSCC) progression. However, it is not clear whether propofol mediates OSCC progression through regulating circular RNA (circRNA) network. Quantitative real-time PCR was used to detect circ_0008898, miR-545-3p, and CT10 regulator of kinase-like protein (CRKL) expression. Cell functions were determined using CCK8 assay, Edu staining, MTT assay, transwell assay, wound healing assay, tube formation assay, and flow cytometry. Protein levels were examined by western blot analysis. RNA interaction was confirmed by dual-luciferase reporter assay and RIP assay. Our data showed that propofol repressed OSCC cell proliferation, invasion, migration, angiogenesis, and promoted apoptosis. circ_0008898 was highly expressed in OSCC, and its expression could be decreased by propofol. circ_0008898 silencing aggravated the suppressive effect of propofol on OSCC progression. In the mechanism, circ_0008898 could target miR-545-3p to positively regulate CRKL. MiR-545-3p inhibitor abolished the regulation of circ_0008898 silencing on propofol-mediated OSCC cell progression. MiR-545-3p inhibited the progression of propofol-treated OSCC cells, and this effect was reversed by CRKL overexpression. Also, circ_0008898 knockdown reduced OSCC tumor growth by regulating miR-545-3p/CRKL. In conclusion, propofol suppressed OSCC progression, which was achieved through regulating the circ_0008898/miR-545-3p/CRKL axis.

Effects of sevoflurane on metalloproteinase and natural killer group 2, member D (NKG2D) ligand expression and natural killer cell-mediated cytotoxicity in breast cancer: an in vitro study

BACKGROUND

We investigated the effects of sevoflurane exposure on the expression of matrix metalloproteinase (MMP), expression and ablation of natural killer group 2, member D (NKG2D) ligands (UL16-binding proteins 1-3 and major histocompatibility complex class I chain-related molecules A/B), and natural killer (NK) cell-mediated cytotoxicity in breast cancer cells.

METHODS

Three human breast cancer cell lines (MCF-7, MDA-MB-453, and HCC-70) were incubated with 0 (control), 600 (S6), or 1200 μM (S12) sevoflurane for 4 h. The gene expression of NKG2D ligands and their protein expression on cancer cell surfaces were measured using multiplex polymerase chain reaction (PCR) and flow cytometry, respectively. Protein expression of MMP-1 and -2 and the concentration of soluble NKG2D ligands were analyzed using western blotting and enzyme-linked immunosorbent assays, respectively.

RESULTS

Sevoflurane downregulated the mRNA and protein expression of the NKG2D ligand in a dose-dependent manner in MCF-7, MDA-MB-453, and HCC-70 cells but did not affect the expression of MMP-1 or -2 or the concentration of soluble NKG2D ligands in the MCF-7, MDA-MB-453, and HCC-70 cells. Sevoflurane attenuated NK cell-mediated cancer cell lysis in a dose-dependent manner in MCF-7, MDA-MB-453, and HCC-70 cells (P = 0.040, P = 0.040, and P = 0.040, respectively).

CONCLUSIONS

Our results demonstrate that sevoflurane exposure attenuates NK cell-mediated cytotoxicity in breast cancer cells in a dose-dependent manner. This could be attributed to a sevoflurane-induced decrease in the transcription of NKG2D ligands rather than sevoflurane-induced changes in MMP expression and their proteolytic activity.

Compounds targeting ferroptosis in breast cancer: progress and their therapeutic potential

In recent years, there has been a significant increase in the incidence of Breast cancer (BC), making it the most common cancer among women and a major threat to women's health. Consequently, there is an urgent need to discover new and effective strategies for treating BC. Ferroptosis, a novel form of cell death characterized by the accumulation of iron-dependent lipid reactive oxygen species, has emerged as a distinct regulatory pathway separate from necrosis, apoptosis, and autophagy. It is widely recognized as a crucial factor in the development and progression of cancer, offering a promising avenue for BC treatment. While significant progress has been made in understanding the mechanisms of ferroptosis in BC, drug development is still in its early stages. Numerous compounds, including phytochemicals derived from dietary sources and medicinal plants, as well as synthetic drugs (both clinically approved medications and laboratory reagents), have shown the ability to induce ferroptosis in BC cells, effectively inhibiting tumor growth. This comprehensive review aims to examine in detail the compounds that target ferroptosis in BC and elucidate their potential mechanisms of action. Additionally, the challenges associated with the clinical application of ferroptosis-inducing drugs are discussed, offering valuable insights for the development of novel treatment strategies for BC.

Prevalence and risk factors of tuberculosis among people living with HIV/AIDS in China: a systematic review and meta-analysis

OBJECTIVE

To estimate the prevalence and risk factors associated with tuberculosis (TB) among people living with human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) in China.

METHODS

A systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. After the literature was screened based on the inclusion and exclusion criteria, STATA® version 17.0 software was used for the meta-analysis. The heterogeneity among study data was assessed using I2 statistics. Subgroup analysis and meta-regressions were performed to further explore the source of heterogeneity.

RESULTS

A total of 5241 studies were retrieved. Of these, 44 studies were found to be eligible. The pooled prevalence of HIV/TB co-infection was 6.0%. The risk factors for HIV/TB co-infection included a low CD4+ T cell count, smoking, intravenous drug use and several other sociodemographic and clinical factors. Bacillus Calmette-Guérin (BCG) vaccination history was a protective factor.

CONCLUSION

A high prevalence of TB was observed among people living with HIV/AIDS in China. Low CD4+ T cell count, smoking, and intravenous drug use were the primary risk factors for HIV/TB co-infection, whereas BCG vaccination history was a protective factor. Checking for TB should be prioritized in HIV screening and healthcare access.

SYSTEMATIC REVIEW REGISTRATION

Registered on PROSPERO, Identifier: CRD42022297754.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Propofol and survival: an updated meta-analysis of randomized clinical trials

BACKGROUND

Propofol is one of the most widely used hypnotic agents in the world. Nonetheless, propofol might have detrimental effects on clinically relevant outcomes, possibly due to inhibition of other interventions' organ protective properties. We performed a systematic review and meta-analysis of randomized controlled trials to evaluate if propofol reduced survival compared to any other hypnotic agent in any clinical setting.

METHODS

We searched eligible studies in PubMed, Google Scholar, and the Cochrane Register of Clinical Trials. The following inclusion criteria were used: random treatment allocation and comparison between propofol and any comparator in any clinical setting. The primary outcome was mortality at the longest follow-up available. We conducted a fixed-effects meta-analysis for the risk ratio (RR). Using this RR and 95% confidence interval, we estimated the probability of any harm (RR > 1) through Bayesian statistics. We registered this systematic review and meta-analysis in PROSPERO International Prospective Register of Systematic Reviews (CRD42022323143).

RESULTS

We identified 252 randomized trials comprising 30,757 patients. Mortality was higher in the propofol group than in the comparator group (760/14,754 [5.2%] vs. 682/16,003 [4.3%]; RR = 1.10; 95% confidence interval, 1.01-1.20; p = 0.03; I2 = 0%; number needed to harm = 235), corresponding to a 98.4% probability of any increase in mortality. A statistically significant mortality increase in the propofol group was confirmed in subgroups of cardiac surgery, adult patients, volatile agent as comparator, large studies, and studies with low mortality in the comparator arm.

CONCLUSIONS

Propofol may reduce survival in perioperative and critically ill patients. This needs careful assessment of the risk versus benefit of propofol compared to other agents while planning for large, pragmatic multicentric randomized controlled trials to provide a definitive answer.

Outcomes of intravenous and inhalation anesthesia on patients undergoing esophageal cancer surgery: a retrospective observational study

BACKGROUND

Different anesthetics may have opposite effects on the immune system, thus affecting the prognosis of tumor patients. Cell-mediated immunity forms the primary defense against the invasion of tumor cells, so manipulation of the immune system to produce an enhanced anti-tumor response could be utilized as an adjuvant oncological therapy. Sevoflurane has proinflammatory effects, while propofol, has anti-inflammatory and antioxidant effects. Therefore, we compared the overall survival (OS) and disease-free survival (DFS) of patients with esophageal cancer under total intravenous anesthesia and inhalation anesthesia.

METHODS

This study collected the electronic medical records of patients undergoing esophagectomy from January 1, 2014 to December 31, 2016. According to the intraoperative anesthetics, the patients were divided into total intravenous anesthesia (TIVA) group or inhalational anesthesia (INHA) group. Stabilized inverse probability of treatment weighting (SIPTW) was used to minimize differences. Kaplan-Meier survival curve was established to evaluate the correlation between different anesthesia methods in overall survival and disease-free survival of patients undergoing esophageal cancer surgery.

RESULTS

A total of 420 patients with elective esophageal cancer were collected, including 363 patients eligible for study (TIVA, n = 147, INHA, n = 216). After SIPTW there were no significant differences between two groups in overall survival and disease-free survival. However, the adjuvant therapy was statistically significant in improving OS, and the degree of differentiation was correlated with OS and DFS.

CONCLUSIONS

In conclusion, there were no significant difference in overall survival and disease-free survival between total intravenous anesthesia and inhalational anesthesia in patients undergoing esophageal cancer surgery.

GABAergic signaling as a potential therapeutic target in cancers

GABA is the most common inhibitory neurotransmitter in the vertebrate central nervous system. Synthesized by glutamic acid decarboxylase, GABA could specifically bind with two GABA receptors to transmit inhibition signal stimuli into cells: GABAA receptor and GABAB receptor. In recent years, emerging studies revealed that GABAergic signaling not only participated in traditional neurotransmission but was involved in tumorigenesis as well as regulating tumor immunity. In this review, we summarize the existing knowledge of the GABAergic signaling pathway in tumor proliferation, metastasis, progression, stemness, and tumor microenvironment as well as the underlying molecular mechanism. We also discussed the therapeutical advances in targeting GABA receptors to provide the theoretical basis for pharmacological intervention of GABAergic signaling in cancer treatment especially immunotherapy.

Propofol-mediated circ_0000735 downregulation restrains tumor growth by decreasing integrin-β1 expression in non-small cell lung cancer

Propofol, an intravenous anesthetic agent, exerts an anti-tumor peculiarity in multifarious tumors. Circular RNA hsa_circ_0000735 (circ_0000735) is involved in non-small cell lung cancer (NSCLC) progression. The purpose of this study is to investigate whether propofol can curb NSCLC progression via regulating circ_0000735 expression. Cell viability, proliferation, apoptosis, and invasion were detected using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide, 5-ethynyl-2'-deoxyuridine, flow cytometry, and transwell assays. Evaluation of protein levels was performed using western blotting or immunohistochemistry. Detection of circ_0000735 in tissue samples and cells was carried out using a real-time quantitative polymerase chain reaction. The molecular mechanisms associated with circ_0000735 were predicted by bioinformatics analysis and verified by dual-luciferase reporter assays. The relationship between propofol and circ_0000735 in vivo was verified by xenograft models. The results showed that circ_0000735 was overexpressed in NSCLC samples and cells. Propofol treatment overtly decreased circ_0000735 expression in NSCLC cells and repressed NSCLC cell viability, proliferation, invasion, and facilitated NSCLC cell apoptosis, but these effects mediated by propofol were counteracted by circ_0000735 overexpression. Circ_0000735 functioned as a miR-153-3p sponge and regulated integrin-β1 (ITGB1) expression via adsorbing miR-153-3p. ITGB1 overexpression reversed circ_0000735 silencing-mediated effects on NSCLC cell viability, proliferation, invasion, and apoptosis. In conclusion, propofol restrained NSCLC growth by downregulating circ_0000735, which functioned as a miR-153-3p sponge and regulated ITGB1 expression via adsorbing miR-153-3p. This study provides evidence to support that propofol curbs NSCLC progression by regulating circRNA expression.

General Anesthetics in CAncer REsection Surgery (GA-CARES) randomized multicenter trial of propofol vs volatile inhalational anesthesia: protocol description

BACKGROUND

Studies indicate that patients can be "seeded" with their own cancer cells during oncologic surgery and that the immune response to these circulating cancer cells might influence the risk of cancer recurrence. Preliminary data from animal studies and some retrospective analyses suggest that anesthetic technique might affect the immune response during surgery and hence the risk of cancer recurrence. In 2015, experts called for prospective scientific inquiry into whether anesthetic technique used in cancer resection surgeries affects cancer-related outcomes such as recurrence and mortality. Therefore, we designed a pragmatic phase 3 multicenter randomized controlled trial (RCT) called General Anesthetics in Cancer Resection (GA-CARES).

METHODS

After clinical trial registration and institutional review board approval, patients providing written informed consent were enrolled at five sites in New York (NY) State. Eligible patients were adults with known or suspected cancer undergoing one of eight oncologic surgeries having a high risk of cancer recurrence. Exclusion criteria included known or suspected history of malignant hyperthermia or hypersensitivity to either propofol or volatile anesthetic agents. Patients were randomized (1:1) stratified by center and surgery type using REDCap to receive either propofol or volatile agent for maintenance of general anesthesia (GA). This pragmatic trial, which seeks to assess the potential impact of anesthetic type in "real world practice", did not standardize any aspect of patient care. However, potential confounders, e.g., use of neuroaxial anesthesia, were recorded to confirm the balance between study arms. Assuming a 5% absolute difference in 2-year overall survival rates (85% vs 90%) between study arms (primary endpoint, minimum 2-year follow-up), power using a two-sided log-rank test with type I error of 0.05 (no planned interim analyses) was calculated to be 97.4% based on a target enrollment of 1800 subjects. Data sources include the National Death Index (gold standard for vital status in the USA), NY Cancer Registry, and electronic harvesting of data from electronic medical records (EMR), with minimal manual data abstraction/data entry.

DISCUSSION

Enrollment has been completed (n = 1804) and the study is in the follow-up phase. This unfunded, pragmatic trial, uses a novel approach for data collection focusing on electronic sources.

TRIAL REGISTRATION

Registered (NCT03034096) on January 27, 2017, prior to consent of the first patient on January 31, 2017.

Association of regional anesthesia with oncological outcomes in patients receiving surgery for bladder cancer: A meta-analysis of observational studies

Background

This meta-analysis was conducted to compare cancer recurrence and survival rates in patients with bladder cancer receiving surgery under general anesthesia alone (i.e., GA group) or regional anesthesia (RA) with or without GA (i.e., RA ± GA group).

Methods

Literature search on Cochrane library, EMBASE, Google scholar, and Medline databases was performed to identify all relevant studies from inception to April 30, 2022. The primary outcome was cancer recurrence rate, while the secondary outcomes included overall survival rate and cancer-specific survival rate. Subgroup analyses were performed based on study design [(Propensity-score matching (PSM) vs. no-PSM)] and type of surgery [transurethral resection of bladder tumor (TURBT) vs. radical cystectomy].

Results

Ten retrospective studies with a total of 13,218 patients (RA ± GA group n=4,884, GA group n=8,334) were included. There was no difference between RA ± GA group and GA group in age, the proportion of males, severe comorbidities, the proportion of patients receiving chemotherapy, and the pathological findings (all p >0.05). Patients in the RA ± GA group had significantly lower rate of bladder cancer recurrence [odds ratio (OR): 0.74, 95%CI: 0.61 to 0.9, p=0.003, I^{2 =} 24%, six studies] compared to those in the GA group. Subgroup analyses based on study design revealed a consistent finding, while the beneficial effect of RA ± GA on reducing cancer recurrence was only significant in patients receiving TURBT (p=0.02), but not in those undergoing radical cystectomy (p=0.16). There were no significant differences in overall survival rate and cancer-specific survival rate between RA ± GA and GA groups.

Conclusions

For patients receiving surgery for bladder cancer, the application of regional anesthesia with or without general anesthesia is associated with significant decrease in cancer recurrence, especially in patients undergoing TURBT for non-muscle invasive bladder cancer. Because of the limited number of studies included and potential confounding factors, our results should be interpreted carefully.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022328134.

Influence of Perioperative Anesthesia on Cancer Recurrence: from Basic Science to Clinical Practice

PURPOSEOF REVIEW

In this review, we will summarize the effects of these perioperative anesthetics and anesthetic interventions on the immune system and tumorigenesis as well as address the related clinical evidence on cancer-related mortality and recurrence.

RECENT FINDINGS

Cancer remains a leading cause of morbidity and mortality worldwide. For many solid tumors, surgery is one of the major therapies. Unfortunately, surgery promotes angiogenesis, shedding of circulating cancer cells, and suppresses immunity. Hence, the perioperative period has a close relationship with cancer metastases or recurrence. In the perioperative period, patients require multiple anesthetic management including anesthetics, anesthetic techniques, and body temperature control. Preclinical and retrospective studies have found that these anesthetic agents and interventions have complex effects on cancer outcomes. Therefore, well-planned, prospective, randomized controlled trials are required to explore the effects of different anesthetics and techniques on long-term outcomes after cancer surgery. Due to the conflicting effects of anesthetic management on cancer recurrence, further preclinical and clinical trials are required and beneficial to the development of systemic cancer therapies.

Total versus inhaled intravenous anesthesia methods for prognosis of patients with lung, breast, or esophageal cancer: A cohort study

Objective

To explore the influences of total intravenous anesthesia (TIVA) and inhaled-intravenous anesthesia on the prognosis of patients with lung, breast, or esophageal cancer.

Methods

In this retrospective cohort study, patients with lung, breast, or esophageal cancer who underwent surgical treatments at Beijing Shijitan Hospital between January 2010 and December 2019 were included. The patients were categorized into the TIVA group and inhaled-intravenous anesthesia group, according to the anesthesia methods used for the patients for surgery of the primary cancer. The primary outcome of this study included overall survival (OS) and recurrence/metastasis.

Results

Totally, 336 patients were included in this study, 119 in the TIVA group and 217 in the inhaled-intravenous anesthesia group. The OS of patients in the TIVA group was higher than in the inhaled-intravenous anesthesia group (P = 0.042). There were no significant differences in the recurrence/metastasis-free survival between the two groups (P = 0.296). Inhaled-intravenous anesthesia (HR = 1.88, 95%CI: 1.15-3.07, P = 0.012), stage III cancer (HR = 5.88, 95%CI: 2.57-13.43, P < 0.001), and stage IV cancer (HR = 22.60, 95%CI: 8.97-56.95, P < 0.001) were independently associated with recurrence/ metastasis. Comorbidities (HR = 1.75, 95%CI: 1.05-2.92, P = 0.033), the use of ephedrine, noradrenaline or phenylephrine during surgery (HR = 2.12, 95%CI: 1.11-4.06, P = 0.024), stage II cancer (HR = 3.24, 95%CI: 1.08-9.68, P = 0.035), stage III cancer (HR = 7.60, 95%CI: 2.64-21.86, P < 0.001), and stage IV cancer (HR = 26.61, 95%CI: 8.57-82.64, P < 0.001) were independently associated with OS.

Conclusion

In patients with breast, lung, or esophageal cancer, TIVA is preferable than inhaled-intravenous anesthesia group for longer OS,, but TIVA was not associated with the recurrence/metastasis-free survival of patients.

Etomidate elicits anti-tumor capacity by disrupting the JAK2/STAT3 signaling pathway in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a leading malignancy of the digestive system, especially in China. Although radiotherapy, chemotherapy, and transarterial chemoembolization have achieved tremendous success, surgical resection remains the primary treatment for HCC patients. Recent studies have shown that intravenous anesthetic drugs may affect the malignant behaviors of tumor cells, ultimately leading to differences in the postoperative prognosis of patients. Etomidate is one of the most widely used intravenous anesthetic drugs for the induction and maintenance of anesthesia in tumor patients undergoing surgery. However, the effects and underlying mechanisms of etomidate on HCC cells have not yet been characterized. Our study indicated that etomidate significantly impedes the malignant progression of HCC cells. Mechanistically, etomidate inhibits phosphorylation and, ultimately, the activity of Janus kinase 2 (JAK2) by competing with ATP for binding to the ATP-binding pocket of JAK2. Thus, it suppresses the JAK2/STAT3 signaling pathway in HCC cells to exert its anti-tumor efficacy. Herein, we provide preclinical evidence that etomidate is the optimal choice for surgical treatment of HCC patients.

Comparison of volatile/inhalational and IV anesthesia in long-term survival of patients with breast cancer: a retrospective study

OBJECTIVE

Breast cancer is a worldwide health concern, and surgical removal has remained the preferred therapeutic option in most patients. Furthermore, the current study was designed to investigate the disease-free survival and overall survival in breast cancer patients, who receive either propofol or isoflurane during operation.

METHOD

This retrospective study was conducted on 994 patients (IV group, n = 530; volatile/inhalational group, n = 464) who underwent breast cancer operation from January 2006 to December 2016 at Faghihi Hospital, Shiraz, Iran. All studied patients were followed up till 2020. Patients are classified into two groups, IV and volatile/inhalational, according to the received anesthesia. For statistical analysis, The Cox regression test was conducted to investigate the association between factors affecting the recurrence of the disease and the Log Rank test was utilized to assess the patients' survival. Finally, to reduce the effect of confounding factors, all patients were matched according to age, tumor size and tumor grade.

RESULTS

Based on results from the log-rank test, the volatile/inhalational group had a better recurrence-free survival (P = 0.039) compared to the total IV group. However, the overall survival was not considerably different (P = 0.520).

CONCLUSION

The current study showed that although 2-year disease-free survival is higher in the volatile/inhalational group, there is no meaningful association between the 5-year overall survival and anesthesia technique.

Effect of anesthesia on the outcome of high-grade glioma patients undergoing supratentorial resection: study protocol for a pragmatic randomized controlled trial

BACKGROUND

High-grade glioma (HGG) is the most malignant brain tumor with poor outcomes. Whether anesthetic methods have an impact on the outcome of these patients is still unknown. Retrospective study has found no difference between intravenous and inhalation anesthesia on the overall survival (OS) of the HGG patients, however, intravenous anesthesia with propofol might be beneficial in a subgroup of patients with a Karnofsky Performance Status (KPS) Scale less than 80. Further prospective studies are needed to evaluate the results.

METHODS

This is a single-centered, randomized controlled, parallel-group trial. Three hundred forty-four patients with primary HGG for tumor resection will be randomly assigned to receive either intravenous anesthesia with propofol or inhalation anesthesia with sevoflurane. The primary outcome is the OS of the patients within 18 months. Secondary outcomes include progression-free survival (PFS), the numerical rating scale (NRS) of pain intensity and sleep quality, the postoperative encephaloedema volume, complications, and the length of hospital stay of the patients.

DISCUSSION

This is a randomized controlled trial to compare the effect of intravenous and inhalation anesthesia maintenance on the outcome of supratentorial HGG patients. The results will contribute to optimizing the anesthesia methods in these patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02756312. Registered on 29 April 2016 and last updated on 9 Sep 2020.