How regional analgesia might reduce postoperative cancer recurrence

Impact of anesthesia choice in cutaneous melanoma surgery

Invasive cutaneous melanoma is the most lethal skin cancer, but fortunately, the vast majority can be surgically treated with wide local excision, and sometimes additionally with sentinel or index lymph node biopsy for prognostication. Melanomas are particularly immunogenic malignancies, and preclinical studies have demonstrated that use of volatile anesthetics and opioids, unlike local agents, can suppress the immune system during the perioperative period. Immunosuppression has implications for creating a potentially favorable microenvironment for the survival and propagation of residual melanoma cells or micro-metastases, which could lead to disease relapse, both in the local tumor bed and distally. Results from observational clinical studies are mixed, but the literature would suggest that patients are at risk of decreased melanoma-specific survival after undergoing general anesthesia compared to regional anesthesia and spinal blocks. With the safety of close observation now established rather than automatic completion or total lymph node dissection for patients with either a positive sentinel lymph node biopsy or significant clinical response to neoadjuvant immunotherapy after index node sampling, the indications for definitive surgery with local or regional anesthesia have increased tremendously in recent years. Therefore, cutaneous melanoma patients might benefit from avoidance of general anesthesia and other perioperative drugs that suppress cell-mediated immunity if the option to circumvent systemic anesthesia agents is feasible.

Regional anesthesia might reduce recurrence and metastasis rates in adult patients with cancers after surgery: a meta-analysis

BACKGROUND

The influence of anesthesia techniques on cancer recurrence and metastasis following oncological surgery is a topic of growing interest. This meta-analysis investigates the potential effects of regional anesthesia (RA), either independently or combined with general anesthesia (GA), on these outcomes.

METHODS

We performed an extensive search across PubMed, Embase, and the Cochrane Library databases. The primary outcome was cancer recurrence, while the secondary outcomes were local recurrence and distant metastasis. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by utilizing random-effects models. The Newcastle-Ottawa Scale (NOS) was used for quality assessment of observational studies, the Cochrane Risk of Bias Tool for Randomized Trials (Rob 2.0) was used for randomized controlled trials, and all the outcomes were assessed by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

This study included 32 studies comprising 24,724 cancer patients. RA, either alone or in combination with GA, was significantly associated with reduced cancer recurrence compared to GA alone (OR = 0.82; 95% CI = 0.72 to 0.94; p < 0.01). This association remained significant for prostate cancer patients in subgroup analyses (OR = 0.71; 95% CI = 0.51 to 0.98; p = 0.04) and in the context of epidural anesthesia combined with GA. However, there were no significant associations noted for local recurrence or distant metastasis.

CONCLUSIONS

This meta-analysis provides evidence that RA, used alone or adjunctively with GA, is associated with a lower risk of cancer recurrence, particularly in patients with prostate cancer. However, no significant effects were observed on local recurrence or distant metastasis. Further prospective studies should be conducted to clarify this important issue.

Intraoperative opioid exposure, tumour genomic alterations, and survival differences in people with lung adenocarcinoma

BACKGROUND

Opioids have been linked to worse oncologic outcomes in surgical patients. Studies in certain cancer types have identified associations between survival and intra-tumoural opioid receptor gene alterations, but no study has investigated whether the tumour genome interacts with opioid exposure to affect survival. We sought to determine whether intraoperative opioid exposure is associated with recurrence-specific survival and overall survival in early-stage lung adenocarcinoma, and whether selected tumour genomics are associated with this relationship. Associations between ketamine and dexmedetomidine and outcomes were also studied.

METHODS

Surgical patients (N=740) with pathological stage I-III lung adenocarcinoma and next-generation sequencing data were retrospectively reviewed from a prospectively maintained database.

RESULTS

On multivariable analysis, ketamine administration was protective for recurrence-specific survival (hazard ratio = 0.44, 95% confidence interval 0.24-0.80; P=0.007), compared with no adjunct. Higher intraoperative oral morphine milligram equivalents were significantly associated with worse overall survival (hazard ratio=1.09/10 morphine milligram equivalents, 95% confidence interval 1.02-1.17; P=0.010). Significant interaction effects were found between morphine milligram equivalents and fraction genome altered and morphine milligram equivalents and CDKN2A, such that higher fraction genome altered or CDKN2A alterations were associated with worse overall survival at higher morphine milligram equivalents (P=0.044 and P=0.052, respectively). In contrast, alterations in the Wnt (P=0.029) and Hippo (P=0.040) oncogenic pathways were associated with improved recurrence-specific survival at higher morphine milligram equivalents, compared with unaltered pathways.

CONCLUSIONS

Intraoperative opioid exposure is associated with worse overall survival, whereas ketamine exposure is associated with improved recurrence-specific survival in patients with early-stage lung adenocarcinoma. This is the first study to investigate tumour-specific genomic interactions with intraoperative opioid administration to modify survival associations.

Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery

BACKGROUND

Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia.

OBJECTIVES

To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality.

SEARCH METHODS

On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome.

MAIN RESULTS

Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.

Impact of anesthesia and analgesia techniques on glioblastoma progression. A narrative review

Glioblastoma (GBM) is an aggressive malignant CNS tumor with a median survival of 15 months after diagnosis. Standard therapy for GBM includes surgical resection, radiation, and temozolomide. Recently, anesthetics and analgesics have received attention for their potential involvement in mediating tumor growth. This narrative review investigated whether various members of the 2 aforementioned classes of drugs have a definitive impact on GBM progression by summarizing pertinent in vitro, in vivo, and clinical studies. Recent publications regarding general anesthetics have been inconsistent, showing that they can be pro-tumoral or antitumoral depending on the experimental context. The local anesthetic lidocaine has shown consistent antitumoral effects in vitro. Clinical studies looking at anesthetics have not concluded that their use improves patient outcomes. In vitro and in vivo studies looking at opioid involvement in GBM have demonstrated inconsistent findings regarding whether these drugs are pro-tumoral or antitumoral. Nonsteroidal anti-inflammatory drugs, and specifically COX-2 inhibitors, have shown inconsistent findings across multiple studies looking at whether they are beneficial in halting GBM progression. Until multiple repeatable studies show that anesthetics and analgesics can suppress GBM growth, there is no strong evidence to recommend changes in the anesthetic care of these patients.

A systematic scoping review on natural killer cell function in colorectal cancer

PURPOSE

Natural Killer (NK) cells are a vital part of immune surveillance and have been implicated in colorectal cancer development and prognosis. This systematic review aims to distil the literature on NK cells as it relates to colorectal cancer.

METHODS

All published studies over 10 years relating to NK cells and colorectal cancer were reviewed. All studies publishing in English, searchable via pubmed or through reference review and reporting directly on the nature or function of NK cells in colorectal cancer patients were included. Outcomes were determined as alterations or new information regarding NK cells in colorectal cancer patients.

RESULTS

Natural killer cells may be implicated in the development of colorectal cancer and may play a role in prognostication of the disease. NK cells are altered by the treatment (both surgical and medical) of colorectal cancer and it seems likely that they will also be a target for manipulation to improve colorectal cancer survival.

CONCLUSIONS

NK cell morphology and function are significantly affected by the development of colorectal cancer. Observation of NK cell changes may lead to earlier detection and better prognostication in colorectal cancer. Further study is needed into immunological manipulation of NK cells which may lead to improved colorectal cancer survival.

Anesthesia Options and the Recurrence of Cancer: What We Know so Far?

Surgery is a critical period in the survival of patients with cancer. While resective surgery of primary tumors has shown to prolong the life of these patients, it can also promote mechanisms associated with metastatic progression. During surgery, patients require general and sometimes local anesthetics that also modulate mechanisms that can favor or reduce metastasis. In this narrative review, we summarized the evidence about the impact of local, regional and general anesthesia on metastatic mechanisms and the survival of patients. The available evidence suggests that cancer recurrence is not significantly impacted by neither regional anesthesia nor volatile or total intravenous anesthesia.

Emerging effect of anesthesia on post-operative tumor recurrence and metastasis

Post-operative recurrence and metastasis of malignant tumors are difficult to control, which probably results from multiple factors that affect the prognosis and the undefined mechanism. Anesthesia may be an influential factor. Researchers have performed many meaningful studies on the relationship between anesthetic drugs/methods and tumor growth/immune function, which provide important references for the anesthetic selection and peri-operative management of tumor patients. Anesthetics, analgesics, and sedatives should be used with caution because their effects in post-operative patients remain controversial. This review summarizes the emerging progress on the effect of anesthesia on post-operative tumor recurrence and metastasis, particularly focusing on the effects of anesthetic drugs, anesthetic methods, and post-operative analgesia on tumor growth and metastasis. Future studies should provide strict criteria for the proper use of anesthetics in patients with malignant tumors and provide experimental evidence for the improvement and development of novel anesthetics and anesthetic methods that have the important clinical significance.

Long-Term Oncologic Outcomes, Opioid Use, and Complications after Esophageal Cancer Surgery

Effective and adequate opioid use and prevention of postoperative complications are important for enhanced recovery after surgery. We examined the effects of postoperative opioid use and postoperative complications on overall survival and recurrence-free survival after esophageal cancer surgery. This retrospective cohort study analyzed the records of patients diagnosed with esophageal cancer who underwent the Ivor Lewis operation between January 2005 and December 2011. We collected data on total opioid use for 8 days postoperatively, as well as information on postoperative complications (Clavien-Dindo classification). One hundred and twenty-one patients were included in the final analysis. Total opioid use was not significantly associated with overall survival (p = 0.520) and recurrence-free survival (p = 0.818). In contrast, the hazard ratio of postoperative overall survival was significantly higher with respect to Clavien-Dindo classification 1-2 (hazard ratio: 2.009, p = 0.046), 3a-3b (hazard ratio: 5.759, p < 0.001), and 4a-5 (hazard ratio: 3.982, p = 0.020) complications compared to no complications. Additionally, the hazard ratio of the recurrence-free survival was significantly higher in class 1-2 complications (hazard ratio: 2.336, p = 0.028) compared to none. Our study demonstrates that postoperative opioid use is not associated with survival and recurrence-free survival after esophageal cancer surgery, while postoperative complications may increase the hazard ratio for survival and recurrence-free survival.

Association of high-dose postoperative opioids with recurrence risk in esophageal squamous cell carcinoma: reinterpreting ERAS protocols for long-term oncologic surgery outcomes

Esophageal squamous cell carcinoma (ESCC) is associated with a poor prognosis and high postoperative recurrence rate. Although postoperative opioid use has been associated with cancer recurrence, its relevance in ESCC has not been determined. Therefore, this study investigated whether high-dose postoperative opioid use was associated with recurrence risk in patients with ESCC. For this retrospective analysis, the medical records of patients who were diagnosed with ESCC and who underwent surgery between January 2006 and December 2010 in the National Cancer Center, Korea were evaluated. Total opioid administration over a 10-day period, from during surgery to postoperative day 9, was calculated. A cutoff value was determined using receiver operating characteristic curve analysis, and patients were classified into the high-use and low-use groups. The primary and secondary outcomes of the study were freedom from recurrence and overall survival, respectively. After propensity score matching, the effect of opioid use on freedom from recurrence and overall survival was evaluated using the Kaplan-Meier method. The final analysis set included 258 patients. The cumulative opioid dose cutoff point was 1783.5 mg of oral morphine. High-dose postoperative opioid use was a significant factor affecting recurrence (Hazard ratio [HR], 2.162; 95% confidence interval [CI], 1.583-2.954; P < 0.0001). In contrast, postoperative opioid use was not associated with death (HR, 1.274; 95% CI, 0.922-1.761; P = 0.1422). In patients with ESCC, compared with low-dose opioid use, high-dose intraoperative and postoperative opioid use was significantly associated with an increased risk of recurrence. However, opioid dosage did not affect overall survival.

Investigation of opioid use and long-term oncologic outcomes for non-small cell lung cancer patients treated with surgery

Opioids are commonly used for postoperative pain control in cancer patients. In addition to pain control, an association between opioid use and long-term oncologic outcomes, such as recurrence or overall survival, has been postulated. The aim of this study was to determine whether postoperative opioid use in patients with non-small cell lung cancer is associated with long-term oncologic outcomes, including recurrence and death. Data obtained from 1009 medical records of patients who underwent curative resection at the National Cancer Center, Korea between January 2006 and December 2010 were retrospectively analyzed. Seven-day opioid use was divided into four quartiles to analyze probability of recurrence and death. Multivariate regression analyses of recurrence and death was conducted, including the calculation of odds ratios. A total of 871 patients were analyzed. When opioid dosage was examined by quartiles, the probability of death and recurrence increased gradually with increasing opioid use. However, in the multivariate regression analysis, the amount of opioid usage did not affect the risk of recurrence or death of lung cancer (P = 0.520 for recurrence; P = 0.659 for death). Opioid use was correlated with outcome when stratified by lung cancer stage (P = 0.004 for recurrence; P = 0.049 for death); however, the odds ratios only slightly increased (1.001 for stage IA–IIIA) for both outcomes. In non-small cell lung cancer patients, the amount of opioid usage does not affect the risk of recurrence and death of lung cancer. There was an association with stage (IA–IIIA), but the effect was negligible. A well-designed prospective study is needed.

Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach

ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of "multimodal" and "multidisciplinary" approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of "outcome" may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards "protective" techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery.

Potential Use of Natural Killer Cell Transfer Therapy in the Perioperative Period to Improve Oncologic Outcomes

Immune suppression after oncologic surgery is a common phenomenon. Several studies have demonstrated that it is associated with poor survival owing to cancer progression. Immunotherapy, especially NK cell transfer therapy, is an attractive alternative because current methodologies to isolate, generate, and expand NK cells have shown good safety profiles in current active investigations. We believe that the use of NK cell transfer therapy in the context of postoperative minimal residual disease deserves significant investigation.

Can acute pain treatment reduce postsurgical comorbidity after breast cancer surgery? A literature review

Regional analgesia, opioids, and several oral analgesics are commonly used for the treatment of acute pain after breast cancer surgery. While all of these treatments can suppress the acute postsurgical pain, there is growing evidence that suggests that the postsurgical comorbidity will differ in accordance with the type of analgesic used during the surgery. Our current study reviewed the effect of analgesics used for acute pain treatments on the major comorbidities that occur after breast cancer surgery. A considerable number of clinical studies have been performed to investigate the relationship between the acute analgesic regimen and common comorbidities, including inadequate quality of recovery after the surgery, persistent postsurgical pain, and cancer recurrence. Previous studies have shown that the choice of the analgesic modality does affect the postsurgical comorbidity. In general, the use of regional analgesics has a beneficial effect on the occurrence of comorbidity. In order to determine the best analgesic choice after breast cancer surgery, prospective studies that are based on a clear definition of the comorbidity state will need to be undertaken in the future.

Intraoperative opioids use for laryngeal squamous cell carcinoma surgery and recurrence: a retrospective study

STUDY OBJECTIVE

To assess whether the use of intraoperative opioids is associated with poor recurrence-free survival (RFS) and overall survival (OS) after lung cancer surgery.

DESIGN

Retrospective study.

SETTING

Academic hospital.

SUBJECTS

Patients with laryngeal primary or recurrent laryngeal squamous cell carcinoma who had surgery.

INTERVENTIONS

Intravenous opioids (remifentanil, fentanyl, sufentanil, and hydromorphone).

MEASUREMENTS

Univariate and multicovariate Cox proportional hazards models were applied to assess the effects of covariates of interest on OS and RFS.

MAIN RESULTS

A total of 195 patients were included. All received opioids intraoperatively. The multivariate analysis demonstrated that age (hazard ratio [HR], 1.03; P = .005), negative margin status (HR, 0.163; P = .001], postoperative chemotherapy (HR, 7.38; P < .001), and concurrent chemotherapy and radiation (HR, 3.11; P < .001) treatment and fentanyl equivalent use (HR, 1.001; P = .02) were all predictor factors for 3- and 5-year RFS. The same variables were predictor factors for OS (age: HR, 1.03 [P = .003]; negative margin status: HR, 0.14 [P = .001]; postoperative chemotherapy: HR, 4 [P < .0001]; and fentanyl equivalent use: HR, 1.001 [P = .02]).

CONCLUSIONS

Our study demonstrates a very weak association between the use of intraoperative opioids and cancer recurrence after laryngeal squamous cell carcinoma surgery.

Continuous wound infusion of local anesthetic and steroid after major abdominal surgery: study protocol for a randomized controlled trial

Background

Inflammatory response is one of the key components of pain perception. Continuous infusion (CWI) of local anesthetics has been shown to be effective in controlling pain and reducing postoperative morphine consumption, but the effect of adding a potent anti-inflammatory drug (such as a steroid) has never been addressed. In our study, we want to investigate the effect of CWI with local anesthetic + methylprednisolone on acute and persistent pain, correlating clinical data with biomarkers of inflammation and genetic background.

Methods/Design

After approval by their institutional review board, three hospitals will enroll 120 patients undergoing major abdominal surgery in a randomized, double-blind, phase III study. After a 24-h CWI of ropivacaine 0.2 % + methylprednisolone 1 mg/kg, patients will be randomly assigned to receive either ropivacaine + steroid or placebo for the next 24 h. Then, patient-controlled CWI with only ropivacaine 0.2 % or placebo (according to the group of randomization) is planned after 48 h up to 7 days (bolus 10 ml, lock-out 1 h, maximum dose of 40 ml in 4 h). Morphine equivalent consumption up to 7 days will be analyzed, together with any catheter- or drug-related side effect. Persistent post-surgical pain (PPSP) incidence will also be investigated. Our primary endpoint is analgesic consumption in the first 7 days after surgery; we will evaluate, as secondary endpoints, any catheter- or drug-related side effect, genotype/phenotype correlations between some polymorphisms and postoperative outcome in terms of morphine consumption, development of the inflammatory response, and incidence of PPSP. Finally, we will collect, in a subgroup of patients, wound exudate samples by micro-dialysis, blood samples, and urine samples up to 72 h to investigate local and systemic inflammation and oxidative stress.

Discussion

This is a phase III trial to evaluate the safety and efficacy of wound infusion with steroid and local anesthetic. The study is aimed also to evaluate how long this infusion has to be maintained in order to maximize effectiveness. Our data are intended to quantify the amount of ropivacaine and methylprednisolone needed by patients undergoing major abdominal surgery, to be stored in a new nanotechnology device for sustained pain treatment after surgery. We also aim to clarify the roles of inflammatory response, oxidative stress, and genetic background on postoperative and persistent pain after major abdominal surgery.

Trial registration

The trial was registered on ClinicalTrials.gov (NCT02002663) on 24 Oct. 2013.

Regional anesthesia/analgesia and the risk of cancer recurrence and mortality after prostatectomy: a meta-analysis

AIMS

To determine whether the use neuraxial anesthesia/analgesia is associated with longer biochemical recurrence-free survival (BRFS) and overall survival (OS) after radical prostatectomy.

METHODS

Ten studies were included in the meta-analysis. A random-effects model was used to estimate the hazard ratios (HRs).

RESULTS

The HR for BRFS was 1.02 (95% CI: 0.91-1.15) for all studies and 1.08 (95% CI: 0.91-1.15) for those that included propensity score matching. For OS, the HR across all studies was 0.91 (95% CI: 0.7-1.15) and 0.81 (95% CI: 0.68-0.96; p = 0.016) for those reporting propensity score matching.

CONCLUSION

The anesthetic technique used during oncologic prostatectomy surgery is not associated with longer BRFS. By contrast, the use of regional analgesia appears to improve OS.

Exploiting the critical perioperative period to improve long-term cancer outcomes

Evidence suggests that the perioperative period and the excision of the primary tumour can promote the development of metastases—the main cause of cancer-related mortality. This Review first presents the assertion that the perioperative timeframe is pivotal in determining long-term cancer outcomes, disproportionally to its short duration (days to weeks). We then analyse the various aspects of surgery, and their consequent paracrine and neuroendocrine responses, which could facilitate the metastatic process by directly affecting malignant tissues, and/or through indirect pathways, such as immunological perturbations. We address the influences of surgery-related anxiety and stress, nutritional status, anaesthetics and analgesics, hypothermia, blood transfusion, tissue damage, and levels of sex hormones, and point at some as probable deleterious factors. Through understanding these processes and reviewing empirical evidence, we provide suggestions for potential new perioperative approaches and interventions aimed at attenuating deleterious processes and ultimately improving treatment outcomes. Specifically, we highlight excess perioperative release of catecholamines and prostaglandins as key deleterious mediators of surgery, and we recommend blockade of these responses during the perioperative period, as well as other low-risk, low-cost interventions. The measures described in this Review could transform the perioperative timeframe from a prominent facilitator of metastatic progression, to a window of opportunity for arresting and/or eliminating residual disease, potentially improving long-term survival rates in patients with cancer.

Opioids and cancer recurrence

PURPOSE OF REVIEW

With the majority of deaths from cancer because of their metastases, strategies to reduce this from occurring are at the forefront of treatment. It has been hypothesized that morphine may result in an increase in cancer metastases, following many in-vitro and animal studies, but the evidence from human retrospective data is inconclusive. This article will explore the possible mechanisms by which opioids can impact on the natural history of the cancer cell and whether they are likely to be harmful in individuals with cancer.

RECENT FINDINGS

Although there have been trials demonstrating benefits with regional anaesthesia techniques (opioid sparing) in the surgical population, it is not clear whether the source of the benefit arises directly from the avoidance of opioids or an added benefit afforded by regional anaesthesia. Research has shown that in particular cancer cell types, morphine may actually be beneficial and that the μ-opioid receptor (MOR) plays a role in cancer disease. With the crystal structure of the MOR having recently been elucidated, this may offer new opportunities for treatments aimed at reducing cancer metastasis.

SUMMARY

The role opioids play in the development of cancer metastasis and recurrence is far from clear and appears to differ depending on the cancer cell type in question. Prospective randomized controlled trials are currently underway in humans to help clarify the situation further and there results are awaited with anticipation. The negative impact of pain on the immune system is well documented and it appears that appropriate analgesia is paramount in minimizing this. Opioids still constitute a central role in the management of moderate-to-severe cancer pain.

Innate immune function after breast, lung, and colorectal cancer surgery

BACKGROUND

The cytotoxic activity and count of natural killer (NK) cells appear to be reduced after surgery; however, it is unknown whether the magnitude of this immune suppression is similar among different types of oncological surgery. In this study, we compared the innate immune function of patients undergoing three different oncological surgeries.

METHODS

We compared the number and function of NK cells obtained from patients who had undergone mastectomies (n = 17), thoracotomies (n = 21), or liver resections for cancer (n = 22). Cytotoxicity assays were performed to measure the function of NK cells. We also determined the plasma concentrations of interleukins (IL) 2 and 4, interferon-γ, granzyme B, perforin, soluble major histocompatibility complex class I-related chain A, and epinephrine, both before and 24 h after surgery. Differences in immunologic parameters were compared preoperatively and postoperatively and by type of surgery. P values <0.05 were considered statistically significant.

RESULTS

The preoperative NK cell count differed statistically (P < 0.006) among all three types of surgeries; however, within surgery postoperative counts and changes compared with baseline did not. The postoperative function of NK cells was similar among types of surgeries, but was significantly reduced compared with preoperative levels (mastectomy P < 0.0001, thoracotomy P = 0.001, and liver resections P = 0.002). We observed a significant increase in the postoperative plasma concentrations of epinephrine, whereas the concentrations of major histocompatibility class I polypeptide-related sequence A and the IL-2 and/or IL-4 ratio remained unchanged before and after surgery.

CONCLUSIONS

The magnitude of innate immune suppression is similar among different oncological procedures. More studies are needed to better understand this complex phenomenon.

Inflammation-based scores: a new method for patient-targeted strategies and improved perioperative outcome in cancer patients

Systemic inflammatory response (SIR) has actually been shown as an important prognostic factor associated with lower postoperative survival in several types of cancer. Thus, the challenge for physicians is to find specific, low-cost, and highly reliable inflammatory markers, clearly correlated with prognosis and able to preoperatively stratify patient's risk. Inflammation is a promising target to improve perioperative outcome, and data show that anti-inflammation techniques have a great potential in the perioperative period of cancer surgery. Inflammation scores could be useful to stratify patients with a potential better response to anti-inflammation strategies. Furthermore, inflammation scores could prevent failure of clinical trials by a better definition of patients to be included in such trials; inflammation scoring could clarify the real role of different drugs and techniques on outcome after cancer surgery, defining if different therapies are required for different patients. The role of this review is to focus on the currently available scores, in order to clarify their rationale and to analyze the actual evidence and limits, providing physicians with an updated overview of the possible inflammation-based prognostic scores for cancer patients undergoing surgery.

A retrospective analysis of the effect of intraoperative opioid dose on cancer recurrence after non-small cell lung cancer resection

Preclinical studies have demonstrated that opioid receptor agonists increase the rate of non-small cell lung cancer (NSCLC) growth and metastasis. Following institutional review board approval, we retrieved data on 901 patients who underwent surgery for NSCLC at MD Anderson Cancer Center. Comprehensive demographics, intraoperative data, and recurrence-free survival (RFS) and overall survival (OS) at 3 and 5 years were obtained. Cox proportional analyses were conducted to assess the association between intraoperative opioid exposure and RFS and OS. The median intraoperative fentanyl equivalents dosage was 10.15 μg/kg. The multivariate analysis by stage indicated that a trend toward significance for opioid consumption as a risk factor in stage I patients (P = 0.053). No effect was found on RFS for stage II or III patients. Alternatively, opioid consumption was a risk factor for OS for stage I patients (P = 0.036), whereas no effect was noted for stage II or III patients. Intraoperative opioid use is associated with decreased OS in stage I but not stage II–III NSCLC patients. Until randomized controlled studies explore this association further, opioids should continue to be a key component of balanced anesthesia.

Ultrasound-guided Multilevel Paravertebral Blocks and Total Intravenous Anesthesia Improve the Quality of Recovery after Ambulatory Breast Tumor Resection

Background:

Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection.

Methods:

Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time.

Results:

Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P &lt; 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced.

Conclusion:

Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

Effects of postoperative epidural analgesia on recurrence-free and overall survival in patients with nonsmall cell lung cancer

STUDY OBJECTIVE

To determine whether postoperative epidural analgesia is associated with better recurrence-free survival and overall survival after lung cancer surgery.

DESIGN

Retrospective study.

SETTING

Academic hospital.

MEASUREMENTS

Data of patients with stage 1, stage 2, and stage 3 nonsmall cell lung cancer, who underwent tumor resection surgery, were studied. Patient data were grouped into three different postoperative pain management interventions: intravenous patient-controlled analgesia, patient-controlled epidural analgesia, and their combination. Univariate and multicovariate Cox proportional hazards models were applied to assess the effects of covariates of interest on overall survival and recurrence-free survival.

MAIN RESULTS

The type of postoperative analgesia used for patients who underwent surgery for nonsmall cell lung cancer did not affect recurrence-free survival or overall survival. However, certain variables, including age ≥ 65 years, male gender, body mass index ≥ 25 kg/m(2), ASA physical status 4, and the need for preoperative blood transfusions, pneumonectomy, and postoperative radiation, were associated with decreased recurrence-free survival and overall survival.

CONCLUSIONS

The type of postoperative analgesia used after surgery for nonsmall cell lung cancer is not associated with better 2-year or 5-year recurrence-free survival or overall survival rates.

Challenges in research related to perioperative cancer care and cancer outcomes

Surgery is one of the most commonly used treatments to attempt cure of early-stage and some late-stage solid tumours. Paradoxically, surgery itself and some of the medical interventions involved in the perioperative care of cancer patients may be associated with an increased chance of metastasis. Researchers and perioperative clinicians have studied the phenomenon of surgery-induced immunosuppression and postoperative cancer recurrence for several decades. Unfortunately, the translation of basic science research into human studies is not clear. Moreover, a recent proliferation of retrospective studies with conflicting results and significant limitations has not shed light on the understanding of whether regional anaesthesia, anti-inflammatory interventions or blockade of the sympathetic response improve survival after cancer surgery. Ultimately, randomised controlled trials are required to answer some of the questions raised by preclinical and retrospective studies; however, investigators face many challenges in conducting these trials. Unless sufficient funding is obtained and cooperative research is developed in the near future, clinicians will not know whether anticancer perioperative interventions are useful to improve cancer-related survivals.

Anaesthetic agents for thoracic surgery: what's best?

PURPOSE OF REVIEW

Pneumonectomy is still associated with a 5% 30-day mortality in a large series involving a variety of anaesthetic agents and techniques.

RECENT FINDINGS

As well as the immediate 'anaesthetic' complications of pain, nausea and vomiting and respiratory dysfunction, differences between anaesthetic agents have emerged in systemic inflammation, postoperative cognitive dysfunction, immune suppression and cell signalling after surgery.

SUMMARY

No one anaesthetic agent has emerged as best. There is a trade-off between initial success and long-term problems or vice versa.

Effects of surgery, general anesthesia, and perioperative epidural analgesia on the immune function of patients with non-small cell lung cancer

STUDY OBJECTIVE

To assess preoperative and postoperative immune function in patients undergoing surgical resection of non-small cell lung cancer during general anesthesia and postoperative epidural analgesia.

DESIGN

Observational single-center study.

SETTING

University-affiliated academic center.

PATIENTS

24 adult, ASA physical status 3 and 4 patients with stage 1, 2, or 3 non-small cell lung cancer. No study patient received preoperative chemotherapy or radiation.

INTERVENTIONS

Patients underwent thoracotomy with general anesthesia and postoperative epidural analgesia.

MEASUREMENTS

Bispectral index monitoring, sevoflurane requirements, and intraoperative transfusions were recorded. Total fentanyl consumption and pain (verbal numeric rating scale) were recorded 24 hours after surgery. Preoperative and 24-hour postoperative natural killer cell percentage and function and percentages of natural killer T cells, T helper cells (CD4+), and cytotoxic T lymphocytes (CD8+) were measured. Plasma concentrations of the TH1 cytokine interleukin-2 and interferon-gamma and the TH2 cytokines interleukin-4 were measured at the same time points.

RESULTS

The percentage (preoperative, 13.07 ± 9.81% vs postoperative, 9.6 ± 6.57%, P < 0.001) and function (preoperative, 31.61 ± 21.96%; postoperative, 13.61 ± 9.36%; P < 0.001) of natural killer cells was significantly decreased after surgery, but the percentage of natural killer T cells, T helper cells (CD4+), and cytotoxic T lymphocytes (CD8+) remained unchanged postoperatively; thus, the CD4/CD8 ratio remained unchanged. Postoperative plasma concentrations of the three cytokines were similar to preoperative levels; therefore, the TH1/TH2 ratio also remained unchanged.

CONCLUSIONS

Innate immunity is depressed in patients with non-small cell lung cancer after surgical resection, and immunity is not preserved by the use of postoperative epidural analgesia.