The promotion of tumor metastasis by surgery and stress: immunological basis and implications for psychoneuroimmunology

STING Membrane Prevents Post-Surgery Tissue Adhesion and Tumor Recurrence of Colorectal Cancer

Surgery is the standard treatment regimen for resectable colorectal cancer (CRC). However, it is very hard to completely remove all cancer cells in clinical practice, leading to the high recurrence rates of the disease. Moreover, the post-surgery tissue adhesion greatly prevents the possibility of reoperation, significantly limiting the long-term surviving of CRC patients. To overcome CRC recurrence and avoid the post-surgery tissue adhesion, this work develops a novel stimulator of interferon genes "STING" membrane based on the coaxial electrospinning technology and hyaluronic acid modification. A reactive oxygen species responsive prodrug of gambogic acid (GB) and a potent STING agonist (CDN) are coloaded in the core-shell structure of the membrane, which endows the loaded drug with sustained and sequential release patterns. The localized delivery of GB and CDN can selectively induce efficient immunogenic cell death of cancer cells and then evoke the systemic anticancer immunity by activating the Cyclic GMP-AMP (cGAMP) synthase/STING pathway. As-designed "STING" membrane not only safely prevents tumor recurrence through the synergistic chemoimmunotherapy but also efficiently avoids the post-surgery tissue adhesion, facilitating the clinical intervention of CRC.

Peri-operative individually tailored psychological intervention in breast cancer patients improves psychological indices and molecular biomarkers of metastasis in excised tumors

Perioperative stress and inflammatory signaling can invigorate pro-metastatic molecular processes in patients' tumors, potentially worsening long-term survival. Yet, it is unknown whether pre-operative psychotherapeutic interventions can attenuate such effects. Herein, three weeks before surgery, forty women diagnosed with stage I-III invasive ductal/lobular breast carcinoma were randomized to a 6-week one-on-one psychological intervention (6 meetings with a medical psychologist and bi-weekly phone calls) versus standard nursing-staff-attention. The intervention protocol was individually tailored based on evaluation of patients' emotional, cognitive, physiological, and behavioral stress response-patterns, and also included psychoeducation regarding medical treatments and recruitment of social support. Resected primary tumors were subjected to whole-genome RNA sequencing and bioinformatic analyses, assessing a priori hypothesized cancer-relevant molecular signatures. Self-report questionnaires (BSI-18, Hope-18, MSPSS, and a stress-scale) were collected three (T1) and one (T2) week before surgery, a day before (T3) and after (T4) surgery, and three weeks (T5) and 3-months (T6) following surgery. The intervention reduced distress (GSI), depression, and somatization scores (BSI-18: p < 0.01, p < 0.05, p < 0.05; T5 vs. T1). Additionally, tumors from treated patients (vs. controls) showed: (i) decreased activity of transcription control pathways involved in adrenergic and glucocorticoid signaling (CREB, GR) (p < 0.001), pro-inflammatory signaling (NFkB) (p < 0.01), and pro-malignant signaling (ETS1, STAT and GATA families) (p < 0.001, p < 0.01, p < 0.005); (ii) increased M1 macrophage polarization (p < 0.05), and CD4+ T cell activity (p < 0.01); and an unexpected increase in epithelial-to-mesenchymal-transition (EMT) signature (p < 0.005). This is the first randomized controlled trial to show beneficial effects of a psychological perioperative intervention on tumor pro-metastatic molecular biomarkers.

Thoracic Epidural Analgesia Is Not Associated With Improved Survival After Pancreatic Surgery: Long-Term Follow-Up of the Randomized Controlled PAKMAN Trial

BACKGROUND

Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are common forms of analgesia after pancreatic surgery. Current guidelines recommend EDA over PCIA, and evidence suggests that EDA may improve long-term survival after surgery, especially in cancer patients. The aim of this study was to determine whether perioperative EDA is associated with an improved patient prognosis compared to PCIA in pancreatic surgery.

METHODS

The PAKMAN trial was an adaptive, pragmatic, international, multicenter, randomized controlled superiority trial conducted from June 2015 to October 2017. Three to five years after index surgery a long-term follow-up was performed from October 2020 to April 2021.

RESULTS

For long-term follow-up of survival, 109 patients with EDA were compared to 111 patients with PCIA after partial pancreatoduodenectomy (PD). Long-term follow-up of quality of life (QoL) and pain assessment was available for 40 patients with EDA and 45 patients with PCIA (questionnaire response rate: 94%). Survival analysis revealed that EDA, when compared to PCIA, was not associated with improved overall survival (OS, HR, 1.176, 95% HR-CI, 0.809-1.710, P = .397, n = 220). Likewise, recurrence-free survival did not differ between groups (HR, 1.116, 95% HR-CI, 0.817-1.664, P = .397, n = 220). OS subgroup analysis including only patients with malignancies showed no significant difference between EDA and PCIA (HR, 1.369, 95% HR-CI, 0.932-2.011, P = .109, n = 179). Similar long-term effects on QoL and pain severity were observed in both groups (EDA: n = 40, PCIA: n = 45).

CONCLUSIONS

Results from this long-term follow-up of the PAKMAN randomized controlled trial do not support favoring EDA over PCIA in pancreatic surgery. Until further evidence is available, EDA and PCIA should be considered similar regarding long-term survival.

Parameters of Metabolic Response to Surgical Trauma Induced via Unilateral Total Mastectomy Associated or Not to Ovariohysterectomy in Dogs

Surgical excision of solid tumors is required for local control of neoplasms. However, surgical trauma can stimulate the release of proangiogenic growth factors, suppressing cell-mediated immunity and favoring the development of micrometastases and progression of residual disease. The present study aimed to evaluate the intensity of the metabolic response to trauma induced via unilateral mastectomy in bitches with mammary neoplasia, the consequences of its joint performance with ovariohysterectomy, and their respective effects on the organic response. Two groups of animals were evaluated in seven perioperative moments, namely, unilateral mastectomy (G1) and unilateral mastectomy associated with ovariohysterectomy (G2). Thirty-two female dogs were selected, ten clinically healthy, and twenty-two diagnosed with mammary neoplasia. Surgical trauma reduced serum concentrations of albumin and interleukin-2 but increased blood levels of glucose and interleukin-6 in the postoperative of G1 and G2 patients. Moreover, serum cortisol levels increased after unilateral mastectomy associated with ovariohysterectomy. Our findings allowed us to conclude that unilateral mastectomy induces significant metabolic alterations in female dogs with mammary neoplasms and its joint performance with ovariohysterectomy increases the organic response to trauma.

Regional anesthesia did not improve postoperative long-term survival of tumor patients: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Experimental research and clinical trials have reported a positive effect of regional anesthesia (RA) on prognosis of cancers. We systematically reviewed the efficacy of RA on recurrence-free survival (RFS) and overall survival (OS) after oncology surgeries.

METHODS

PubMed, Cochrane library, and Embase were searched from inception to June 20, 2022 for RCTs in which any form of RA was initiated perioperatively. Time-to-event data (hazard ratio (HR)) were extracted independently and in duplicate. The primary outcome was the association of RA with RFS and OS, while the secondary outcomes included time to tumor progression, 5-year RFS, and 5-year OS.

RESULTS

Fifteen RCTs with 5981 participants were included. Compared to GA, RA has no positive effect on RFS (HR, - 0.02; 95% CI, - 0.11 to 0.07), OS (HR, - 0.03; 95% CI, - 0.28 to 0.23), time to tumor progression (0.11; 95% CI, - 0.33 to 0.55), 5-year RFS (risk ratio (RR), 1.24; 95% CI, 0.88 to 1.76)), and 5-year OS (RR, 1.11; 95% CI, 0.85 to 1.44). Subgroup analysis based on study design, patient characteristics and tumor types also showed no effect of RA on RFS or OS.

CONCLUSIONS

Our results demonstrated that there is no significant evidence supporting the role of RA in improving long-term survival after oncology surgeries.

Survival outcomes of autologous breast reconstruction after mastectomy: A matched case-control study

Background

Due to the lack of strong evidence-based medical evidence, the relationship between autologous breast reconstruction (ABR) after mastectomy and long-term prognosis is unclear. This study aims to explore if ABR after mastectomy is associated with the prognosis of breast cancer (BC) patients based on the data from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

We collected data for all cases diagnosed with BC who underwent or did not undergo ABR after mastectomy from 2010-2015 in the SEER database. The primary outcome of our study was overall survival (OS) and cancer specific survival (CSS). The Propensity Score-Matched (PSM) analysis was used to eliminate the effects of non-random statistics, setting the caliper as 0.0001 to balance the baseline variables within the groups. Chi-square test, Kaplan-Meier method, univariate and multivariate cox regression analysis were used to analyze the data and subgroup analysis was performed to find the subgroups of people who might benefit from ABR.

Result

Of 27893 eligible patients, 11038 patients were matched. The cohort consisted of 5519 (50%) ABR patients and 5519 (50%) non-ABR patients after PSM. After PSM, on multivariate cox regression analysis, ABR still exerted a significant influence on the OS (hazard ratio (HR), 0.83, P< 0.05). However, no statistical difference was shown on CSS (HR, 0.93, P = 0.31). Kaplan-Meier survival analysis showed ABR group had better OS (P = 0.001), but similar CSS (P = 0.174) between ARB and mastectomy groups. Subgroup analysis showed that after matching, those with 50-59 years old, earlier stages of disease, without a marital partner and living in urban areas had better OS after ABR.

Conclusions

ABR after mastectomy was associated with better OS, but not affect CSS.

Local anesthetic lidocaine induces growth suppression of HeLa cells by decreasing and changing the cellular localization of the proliferation marker Ki-67

Although surgery is a basic therapy for cancer, it causes inflammation and immunosuppression, often resulting in recurrence and metastasis. Previous studies have suggested that anesthetic management influences the prognosis of cancer surgery patients. Administration of local anesthetics, such as lidocaine, for pain control reportedly improves their clinical outcomes; however, the precise underlying mechanism has not been fully elucidated. The growth of human embryonic kidney (HEK) 293T and cervical cancer HeLa cells was inhibited by lidocaine treatment and these cell lines showed different sensitivities for lidocaine. Ki-67 is a significant prognostic marker of cancer because it is expressed in the nucleus of actively proliferating cells. In lidocaine-treated HeLa cells, Ki-67 was detected not only in the nucleus but also in the cytoplasm. In addition, lidocaine-induced cytoplasmic Ki-67 partly colocalized with the increased ER chaperone, glucose-regulated protein 78, which is crucial for protein folding and maintenance of cellular homeostasis. Furthermore, lidocaine decreased Ki-67 levels and increased the population of HeLa cells in the G0/G1 phase. These results indicate that lidocaine plays a significant role in growth suppression by regulating the expression and distribution of Ki-67. This article is protected by copyright. All rights reserved.

The Effect of Pre-operative Psychological Interventions on Psychological, Physiological, and Immunological Indices in Oncology Patients: A Scoping Review

Introduction

The stressful pre-operative period exerts a profound impact on psychological, physiological and immunological outcomes. Oncological surgeries, in particular, elicit significantly higher stress responses than most other surgeries. Managing these responses through psychological interventions may improve long-term outcomes. The purpose of the current research was to review studies that have explored pre-operative psychological interventions in cancer patients in order to map the types of current interventions and provide an initial assessment of whether these interventions improved psychological, physiological, and/or immunological indices as well as long-term cancer outcomes.

Methods

A systematic literature search for studies that included pre-operative psychological interventions in oncology patients was conducted, using the databases PubMed and Web of Science. Inclusion criteria included studies pertaining to oncological surgery in adults, study designs that included a clearly defined pre-operative psychological intervention and control group.

Results

We found 44 studies, each using one of the following interventions: psychoeducation, cognitive interventions, relaxation techniques, integrated approaches. All the studies reported improved immediate post-operative psychological, physiological, and/or immunological outcomes. Only a few studies addressed long-term cancer outcomes, and only one reported improved survival.

Conclusions

Research on pre-operative interventions with cancer patients is missing systematic methods. Studies provide varying results, which makes it difficult to compare them and reach reliable conclusions. There is considerable heterogeneity in the literature regarding the specific intervention used, the timing of intervention, the characteristics of the patients studied and the outcome measures. In order to improve research in this field, including the measurement of long-term outcomes, we suggest some steps that should be taken in further research.

m6A methyltransferase KIAA1429 acts as an oncogenic factor in colorectal cancer by regulating SIRT1 in an m6A-dependent manner

N6-methyladenosine (m6A) modifications of RNAs are involved in various aspects of colorectal carcinogenesis via regulation of mRNA stability, splicing, and translation. KIAA1429, an m6A methyltransferase, was found deregulated in multiple cancer types. However, its role in colorectal cancer remains elusive. By analyzing TCGA and GEPIA database, we found that KIAA1429 in colorectal cancer was highly expressed. In addition, we used immunohistochemistry, western blotting, and QRT-PCR to detect the expression of KIAA1429 in colorectal cancer samples and cell lines, and we found that KIAA1429 was overexpressed in colorectal cancer sample and cell line. Functionally, silencing of KIAA1429 by shRNA in colorectal cancer cell lines resulted in decreased cell proliferation, colony formation, and migration. On the contrary, overexpression of KIAA1429 increased cell proliferation, colony formation, and migration. Further mechanism analysis demonstrated that KIAA1429 increased the expression of SIRT1 via regulating its mRNA stability in an m6A-dependent manner. More importantly, in vivo experiment showed that depletion of KIAA1429 significantly inhibited colorectal tumor growth. In conclusion, our results suggested that the m6A methyltransferase KIAA1429 promotes the growth and motility of colorectal cancer and could be a potent therapeutic target.

Stress hormone signaling inhibits Th1 polarization in a CD4 T-cell-intrinsic manner via mTORC1 and the circadian gene PER1

Stress hormones are believed to skew the CD4 T‐cell differentiation towards a Th2 response via a T‐cell‐extrinsic mechanism. Using isolated primary human naïve and memory CD4 T cells, here we show that both adrenergic‐ and glucocorticoid‐mediated stress signalling pathways play a CD4 naïve T‐cell‐intrinsic role in regulating the Th1/Th2 differentiation balance. Both stress hormones reduced the Th1 programme and cytokine production by inhibiting mTORC1 signalling via two parallel mechanisms. Stress hormone signalling inhibited mTORC1 in naïve CD4 T cells (1) by affecting the PI3K/AKT pathway and (2) by regulating the expression of the circadian rhythm gene, period circadian regulator 1 (PER1). Both stress hormones induced the expression of PER1, which inhibited mTORC1 signalling, thus reducing Th1 differentiation. This previously unrecognized cell‐autonomous mechanism connects stress hormone signalling with CD4 T‐cell differentiation via mTORC1 and a specific circadian clock gene, namely PER1.

Effects of Perioperative Epidural Analgesia on Cancer Recurrence and Survival

Surgical resection is the main curative avenue for various cancers. Unfortunately, cancer recurrence following surgery is commonly seen, and typically results in refractory disease and death. Currently, there is no consensus whether perioperative epidural analgesia (EA), including intraoperative and postoperative epidural analgesia, is beneficial or harmful on cancer recurrence and survival. Although controversial, mounting evidence from both clinical and animal studies have reported perioperative EA can improve cancer recurrence and survival via many aspects, including modulating the immune/inflammation response and reducing the use of anesthetic agents like inhalation anesthetics and opioids, which are independent risk factors for cancer recurrence. However, these results depend on the cancer types, cancer staging, patients age, opioids use, and the duration of follow-up. This review will summarize the effects of perioperative EA on the oncological outcomes of patients after cancer surgery.

The disbalance of LRP1 and SIRPα by psychological stress dampens the clearance of tumor cells by macrophages

The relationship between chronic psychological stress and tumorigenesis has been well defined in epidemiological studies; however, the underlying mechanism remains underexplored. In this study, we discovered that impaired macrophage phagocytosis contributed to the psychological stress-evoked tumor susceptibility, and the stress hormone glucocorticoid (GC) was identified as a principal detrimental factor. Mechanistically, GC disturbed the balance of the “eat me” signal receptor (low-density lipoprotein receptor-related protein-1, LRP1) and the “don't eat me” signal receptor (signal regulatory protein alpha, SIRPα). Further analysis revealed that GC led to a direct, glucocorticoid receptor (GR)-dependent trans-repression of LRP1 expression, and the repressed LRP1, in turn, resulted in the elevated gene level of SIRPα by down-regulating miRNA-4695-3p. These data collectively demonstrate that stress induces the imbalance of the LRP1/SIRPα axis and entails the disturbance of tumor cell clearance by macrophages. Our findings provide the mechanistic insight into psychological stress-evoked tumor susceptibility and indicate that the balance of LRP1/SIRPα axis may serve as a potential therapeutic strategy for tumor treatment.

Systemic Inflammation after Uniport, Multiport, or Hybrid VATS Lobectomy for Lung Cancer

BACKGROUND

 Different video-assisted thoracic surgery (VATS) approaches can be adopted to perform lobectomy for non-small cell lung cancer. Given the hypothetical link existing between postoperative inflammation and long-term outcomes, we compared the dynamics of systemic inflammation markers after VATS lobectomy performed with uniportal access (UNIVATS), multiportal access (MVATS), or hybrid approach (minimally invasive hybrid open surgery, MIHOS).

METHODS

 Peripheral blood-derived inflammation markers (neutrophil-to-lymphocyte [NTL] ratio, platelet-to-lymphocyte [PTL] ratio, and systemic immune-inflammation index [SII]) were measured preoperatively and until postoperative day 5 in 109 patients undergoing UNIVATS, MVATS, or MIHOS lobectomy. Differences were compared through repeated-measure analysis of variance, before and after 1:1:1 propensity score matching. Time-to-event analysis was also done by measuring time to NTL normalization, based on the reliability change index for each patient.

RESULTS

 After UNIVATS, there was a faster decrease in NTL ratio (p = 0.015) and SII (p = 0.019) compared with other approaches. MVATS exhibited more pronounced PTL rebound (p = 0.011). However, all these differences disappeared in matched analysis. After MIHOS, NTL ratio normalization took longer (mean difference: 0.7 ± 0.2 days, p = 0.047), yet MIHOS was not independently associated with slower normalization at Cox's regression analysis (p = 0.255, odds ratio: 1.6, confidence interval: 0.7-4.0). Furthermore, surgical access was not associated with cumulative postoperative morbidity, nor was it with incidence of postoperative pneumonia.

CONCLUSION

 In this study, different VATS approaches resulted into unsubstantial differences in postoperative systemic inflammatory response, after adjusting for confounders. The majority of patients returned back to preoperative values by postoperative day 5 independently on the adopted surgical access. Further studies are needed to elaborate whether these small differences may still be relevant to patient management.

Association of postoperative infection and oncological outcome after breast cancer surgery

Background

Surgical-site infection (SSI) is a well known complication after breast cancer surgery and has been reported to be associated with cancer recurrence. The aim of this study was to investigate the association between SSI and breast cancer recurrence, adjusting for several known confounders. The secondary aim was to assess a possible association between any postoperative infection and breast cancer recurrence.

Method

This retrospective cohort study included all patients who underwent breast cancer surgery from January 2009 to December 2010 in the Uppsala region of Sweden. Data collected included patient, treatment and tumour characteristics, infection rates and outcome. Association between postoperative infection and oncological outcome was examined using Kaplan–Meier curves and Cox regression analysis.

Results

Some 492 patients (439 with invasive breast cancer) with a median follow-up of 8.4 years were included. Mean(s.d.) age was 62(13) years. Sixty-two (14.1 per cent) of those with invasive breast cancer had an SSI and 43 (9.8 per cent) had another postoperative infection. Some 26 patients had local recurrence; 55 had systemic recurrence. Systemic recurrence was significantly increased after SSI with simple analysis (log rank test, P = 0.035) but this was not observed on adjusted analysis. However, tumour size and lymph node status remained significant predictors for breast cancer recurrence on multiple regression. Other postoperative infections were not associated with recurrence.

Conclusion

Neither SSI nor other postoperative infections were associated with worse oncological outcome in this study. Rather, other factors that relate to both SSI and recurrence may be responsible for the association seen in previous studies.

The difference in local, regional and distant breast cancer recurrence between the immediate and delayed DIEP flap procedure; a retrospective cohort study

Purpose

It has been hypothesized that autologous breast reconstruction can cause reactivation of dormant micro metastases by its extensive tissue trauma, influencing the risk of breast cancer recurrence. However, about the specific effect of timing on breast cancer recurrence in the deep inferior epigastric perforator (DIEP) flap reconstruction is not much known. In this study the rate of local, regional and distant recurrence between patients undergoing an immediate and delayed autologous DIEP flap breast reconstruction were evaluated.

Methods

In this retrospective cohort study, breast cancer patients undergoing a DIEP flap breast reconstruction between 2010 and 2018 in three hospitals in the Netherlands were evaluated. Cox proportional hazards regression analyses were performed to assess the impact of different factors on breast cancer recurrence. The primary endpoint was local breast cancer recurrence. Secondary endpoints were regional and distant recurrence.

Results

A total of 919 DIEP-flap reconstructions were done in 862 women of which 347 were immediate- and 572 were delayed DIEP flap reconstructions. After a median follow-up of 46 months and 86 months respectively (p < 0.001), local breast cancer recurrence occurred in 1.5% and in 1.7% of the patients resulting in an adjusted hazard ratio of 2.890 (p = 0.001, 95% CI 1.536, 5437).

Conclusion

This study suggests an increased risk for breast cancer recurrence in women receiving a delayed DIEP flap reconstruction as compared to women receiving an immediate DIEP flap reconstruction. However, these data should be interpreted carefully as a result of selection bias.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06199-3.

The immunomodulatory mechanism of dexmedetomidine

Dexmedetomidine has been increasingly introduced into the perioperative care of surgical patients. Because a subset of anesthetics/sedatives are immunomodulatory, it is critical to understand the role of dexmedetomidine in our host immune functions. Here we reviewed the role of dexmedetomidine in different immune cells. We also reviewed published clinical articles that described the role of dexmedetomidine in organ injury, cancer surgery, and infection. In animal studies, dexmedetomidine attenuated organ injury. In clinical studies, dexmedetomidine was associated with an improvement in outcomes in cardiac surgery and transplant surgery. However, there is a paucity in research examining how dexmedetomidine is associated with these outcomes. Further studies are needed to understand its clinical application from immunological standpoints.

β-endorphin neuron transplantation: A possible novel therapy for cancer prevention

We summarize here our new discovery that the endogenous opioid peptide β-endorphin (BEP), by virtue of reducing body stress and maintaining active immune system, as well as, balancing the levels of pro-inflammatory and anti-inflammatory cytokines, destroys tumor cells and stops them from being transformed into metastatic cancer cells.

Trousseau's syndrome associated with rapidly emerging pancreatic adenocarcinoma soon after esophagectomy: A case report

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The first reported case of Trousseau’s syndrome associated with rapidly emerging pancreatic cancer potentially triggered esophagectomy.

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The aggressively emerging pancreatic cancer with mucin production may be a potential mechanism for cancer-related thrombosis.

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When a patient with cancer encountered small, multiple cerebral infarctions postoperatively, the body should be checked for occult malignancy.

Introduction

Trousseau’s syndrome is characterized as an unexpected, cancer-associated thrombotic event. We describe the first reported case of Trousseau’s syndrome associated with rapidly emerging pancreatic cancer potentially triggered by esophagectomy.

Presentation of case

A 79-year-old asymptomatic male with clinical stage I esophageal squamous cell carcinoma underwent thoracoscopic subtotal esophagectomy. On postoperative day 46, the patient presented with weakness of his left upper extremity due to multiple cerebral and cerebellar infarctions, with no evidence of atherosclerotic or cardiogenic thrombi. An abdominal computed tomography (CT) showed a pancreatic tumor with multiple liver metastases. Extremely high D-dimer and the CT findings suggested Trousseau’s syndrome associated with a rapidly emerging neoplasm as the etiology of the brain infarction. Although further thrombotic events did not occur, his condition deteriorated rapidly and died on the 31st days of onset. The autopsy revealed multiple small infarctions, with multiple thrombi in the cerebral hemispheres, brain stem, and cerebellum. Histological evaluation revealed pancreatic adenocarcinoma with nodal and liver metastases.

Discussion

A hypercoagulable state associated with the aggressively emerging pancreatic adenocarcinoma, accompanied by cancer cell production of mucin, may be a potential mechanism for cancer-related thrombosis.

Conclusion

In patients who received intensive surgical treatment and encountered unexplained brain infarctions in the multi-arterial territory, Trousseau’s syndrome should be considered, and investigation for occult malignancy is required.

Stress and cancer. Part II: Therapeutic implications for oncology

Accumulated evidence has confirmed the ability of stress to promote the induction and progression of cancer (for review see Stress and cancer. Part I: Mechanisms mediating the effect of stressors on cancer). In support of this, data from clinical trials utilizing approaches that reduce stress-related signaling have shown prolonged survival of cancer patients. Therefore, the question has arisen as to how we can utilize this knowledge in the daily treatment of cancer patients. The main aim of this review is to critically analyze data from studies utilizing psychotherapy or treatment by β-blockers on the survival of cancer patients. Because these approaches, especially treatment by β-blockers, have been routinely used in clinical practice for decades in the treatment of non-cancer patients, their wider introduction into oncology might be realized in the near future.

Can stress promote the pathophysiology of brain metastases? A critical review of biobehavioral mechanisms

Chronic stress can promote tumor growth and progression through immunosuppressive effects and bi-directional interactions between tumor cells and their microenvironment. β-Adrenergic receptor signaling plays a critical role in mediating stress-related effects on tumor progression. Stress-related mechanisms that modulate the dissemination of tumor cells to the brain have received scant attention. Brain metastases are highly resistant to chemotherapy and contribute considerably to morbidity and mortality in various cancers, occurring in up to 20% of patients in some cancer types. Understanding the mechanisms promoting brain metastasis could help to identify interventions that improve disease outcomes. In this review, we discuss biobehavioral, sympathetic, neuroendocrine, and immunological mechanisms by which chronic stress can impact tumor progression and metastatic dissemination to the brain. The critical role of the inflammatory tumor microenvironment in tumor progression and metastatic dissemination to the brain, and its association with stress pathways are delineated. We also discuss translational implications for biobehavioral and pharmacological interventions.

The Autonomic Regulation of Tumor Growth and the Missing Links

Accumulating evidence now indicates that peripheral nerves and solid tumors mutually support the growth of each other. Tumor-derived molecular cues guide nerve infiltration to the tumor milieu, while the tumor-infiltrating nerves provide molecular support to promote tumor growth and dissemination. In this mini-review, we discuss the unique roles of sympathetic and parasympathetic nerves in promoting tumor growth and metastasis. The contribution of adrenergic and cholinergic signals, the specific receptors involved, and the downstream molecular links in both cancer cells and stromal cells are discussed for their intrinsic capacity to modulate tumor growth. We identified unappreciated niche areas in the field, an investigation of which are critical to filling the knowledge gap in understanding the biology of neuromodulation of cancers.

Prevention of liver metastases through perioperative acute CpG-C immune stimulation

Following excision of colorectal tumors, metastatic disease is prevalent, primarily occurs in the liver, and is highly predictive of poor prognosis. The perioperative period is now recognized as critical in determining the incidence of postoperative metastases and long-term cancer outcomes. Thus, various perioperative prophylactic interventions are currently studied during this time frame. However, immune stimulation during the perioperative period has rarely been attempted due to specific contraindications to surgery and various adverse effects. Here, to prevent liver metastases, we perioperatively employed a TLR-9 agonist, CpG-C, which exhibits minimal pyrogenic and other adverse effects in patients. We found that marginating-hepatic (MH) cells in BALB/c mice contained high percentage of NK cells, but exhibited negligible NK cytotoxicity, as previously reported in humans. However, a single CpG-C administration (25-100 µg/mouse) doubled MH-NK cell numbers, increased NK cell activation and maturation markers (NKp46, CD11b), decreased the inhibitory NKG2A ligand, and dramatically increased MH-NK-cell cytotoxicity against the syngeneic CT26 colon cancer line. Moreover, in operated mice, this innocuous intervention also markedly improved resistance to CT26 and MC38 hepatic metastases in BALB/c and C57BL/6 mice, respectively. Beneficial effects of CpG-C were mediated through activation of MH-NK cells, as indicated by an in vivo NK depletion study. Last, CpG-C protected against surgery-induced suppression of MH-NK cytotoxicity and improved their activation indices. Thus, we suggest that systemic perioperative CpG-C treatment should be considered and studied as a novel therapeutic approach to improve long-term cancer outcomes in colorectal cancer patients.

Multiple liver metastases with synchronous gastric and transverse colon cancer diagnosed by gastric perforation successfully treated by SOX plus bevacizumab and completely resected by surgery: a case report

Background

Synchronous double cancer of the colon and stomach accompanied by liver metastasis is rare. It is often difficult to determine an appropriate treatment strategy for multiple liver metastases of synchronous gastric cancer and colorectal cancer. Multidisciplinary treatment is required based on the progression and location of each tumor and chemotherapy for complete resection.

Case presentation

A 57-year-old male who complained of acute abdominal pain and fever visited his local hospital. He underwent emergent surgery for peritonitis caused by a gastric perforation. The cytodiagnosis of ascites did not show any tumor cells. There was a liver metastasis in the lateral segment of the liver. We performed a primary closure of the defect and then applied an omentum flap. After surgery, the patient was diagnosed as having synchronous cStage IV transverse colon cancer with multiple liver metastases and cStage IIB gastric cancer. The [18F]-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) showed 18F-FDG uptake by the colon tumor and multiple liver metastases, but there was no uptake in the gastric tumor or lymph nodes. We retrospectively reevaluated the CT findings from a local hospital and detected a liver nodule in segment 2/3 (from 35 to 60 mm) and segment 6 (from 26 to 57 mm), and the tumors had dramatically grown in size in only 2 months. Because complete tumor resection would be difficult, S-1 and oxaliplatin (SOX) plus bevacizumab therapy was started to control tumor progression. After 20 courses of chemotherapy, the clinical diagnosis was ycStage IV transverse colon cancer and ycStage IIa gastric cancer. We planned a two-step procedure to completely resect the primary tumors and multiple liver metastases. We first performed a laparoscopic right-colon resection+D3 lymphadenectomy and open distal gastrectomy+D2 lymphadenectomy. The patient was discharged home on postoperative day 18. After 1 month, we performed open liver resection. The pathological findings showed that the transverse colon was ypT2 (MP) with grade 2 therapeutic effects and that there were no atypical cells in the gastric tumor and multiple liver nodules (pathological complete response).

Conclusion

The SOX plus bevacizumab regimen could be an option for controlling tumor progression in synchronous double cancer of the colon and stomach with liver metastasis and led to the complete resection of such tumors.

Dezocine promotes T lymphocyte activation and inhibits tumor metastasis after surgery in a mouse model

Dezocine is an opioid analgesic with both μ-receptor agonist and antagonist activities. Administration of opioids influences the immune system through immune cells. Dendritic cells (DC) play crucial functions in inducing T cell response and mediating immune functions. DC surface displays several different opioid receptors whose expression is induced during DC maturation. We aimed to explore the effects of dezocine on DCs and T cells, as well as on tumor treatment. Mice were intraperitoneally administrated with increasing doses of dezocine (0.75, 1.25 and 2.0 mg/kg). Mouse bone marrow-derived dendritic cells (BMDCs) were then isolated from the bone marrow. The BMDC surface markers were evaluated by flow cytometry. T cell proliferation was assessed by the carboxyfluorescein succinimidyl ester assay. The number of mature DCs were increased by dezocine treatment in both human umbilical cord blood and mouse peripheral blood, suggesting that dezocine enhanced BMDC maturation. Dezocine-treated BMDCs promoted CD8+ T cell proliferation and cytotoxicity, while dezocine treatment inhibited tumor metastasis in mice. We therefore conclude that the administration of dezocine promotes BMDC maturation and inhibits tumor metastasis through elevating CD8+ T cell proliferation and cytotoxicity.

Myeloid-Derived Suppressor Cells Promote Metastasis in Breast Cancer After the Stress of Operative Removal of the Primary Cancer

Objective: To investigate the role of myeloid-derived suppressor cells (MDSC) in cancer progression after the stress of operative removal and the potential treatment value of MDSC depletion. Summary Background Data: Surgery is the most important treatment strategy in breast cancer. Recent research has provided evidence that operations may promote cancer metastases under some circumstances. Methods: A mouse model of breast cancer (administration of the murine breast cancer 4T1 cells subcutaneously) and the stress of operation were used to compare immune responses and survival outcomes. Flow cytometry was performed to detect the expression of CD11b and Gr1 MDSCs in tumor tissues and lung metastases. Cytokine levels were detected with three-color flow cytometry and enzyme-linked immunosorbent assay (ELISA). MDSCs were isolated and co-cultured with 4T1 cells to identify any morphological change with immunofluorescence. The anti Gr-1 antibody was used to detect the function of the anti-Gr1 treatment in breast cancer. Results: The operative stress impaired the overall survival, leading to an increased number of MDSCs that preferentially infiltrated the tumor microenvironment and promoted tumor metastasis. In both in vitro and in vivo assays, MDSCs induced the epithelial-mesenchymal transition (EMT) of tumor cells through the up-regulation of TGF-beta1, VEGF, and IL-10. Furthermore, a treatment strategy of MDSC depletion was found to reduce pulmonary metastases after operations. Conclusions: The stress of operation could impair the overall survival in mice. The infiltrated MDSCs appear to induce EMT of tumor cells and increase metastases through the up-regulation of TGF-beta1, VEGF, and IL-10 levels. MDSC depletion could be a promising treatment strategy to prevent immune evasion after operations.

Postoperative Serum C-Reactive Protein Level Predicts Long-term Outcomes in Stage I Gastric Cancer

BACKGROUND

The aim of this study was to investigate the prognostic impact of postoperative systemic inflammation in patients with stage I gastric cancer.

METHODS

This study reviewed the medical records of 470 patients with stage I gastric cancer who underwent gastrectomy. The postoperative serum C-reactive protein (CRP) level on postoperative days (PODs) 1 and 3 and its peak value were evaluated as prognostic factors. A receiver operating characteristics curve analysis was performed to determine their cut-off values.

RESULTS

The CRP level on POD 3 (P = 0.001) and the peak CRP level (P = 0.007) were significantly associated with the overall survival rate. In the multivariate analysis, the CRP level on POD 3 (P = 0.002) and the peak CRP level (P = 0.008) were identified as independent predictors of the overall survival. The high CRP on POD3 group had significantly higher mortality rate from relapse of gastric cancer (P = 0.001) and infectious disease (P = 0.003) than the low CRP on POD 3 group. The CRP level on POD 3 was significantly associated with the patient sex, surgical procedure, duration of the operation, amount of blood loss, postoperative infectious complication, and peak CRP level.

CONCLUSIONS

The serum CRP level during the early postoperative period predicts the long-term outcomes in stage I gastric cancer. The present study suggests a significant influence of postoperative systemic inflammation on the survival of patients with stage I gastric cancer.

Serum Inflammatory Cytokines Comparison in Gastric Cancer Therapy

To compare serum inflammatory cytokines between laparoscopic-assisted and open radical gastrectomy in the perioperative period, 80 cases of advanced gastric cancer were chosen for the study. They were divided into laparoscopy group (40 cases) and abdominal open surgery group (40 cases), performed laparoscopic-assisted radical gastrostomy and conventional open radical gastrectomy, respectively. Serum Heme oxygenase-1 (HO-1), TNF-α, IL-6 and CRP were measured by ELISA on preoperative day 1, post-operative day 1 and post-operative day3. Serum HO-1, TNF-α, IL-6 and CRP had no significant difference between the laparoscopy group and the open group on pre-operative day 1. Serum HO-1, IL-6 and CRP of the laparoscopy group were significantly lower than that of the open group on post-operative day 1 and day 3 except for Serum TNF-α which had no significant difference. Laparoscopic-assisted radical gastrectomy was minimally invasive compared with conventional open radical gastrectomy in advanced gastric cancer patients.

Butyrate inhibits the proliferation and induces the apoptosis of colorectal cancer HCT116 cells via the deactivation of mTOR/S6K1 signaling mediated partly by SIRT1 downregulation

Butyrate, a histone deacetylase inhibitor, is a typical short chain fatty acid produced by gut microbiota, the dysmetabolism of which has been consistently associated with colorectal diseases. However, its role in tumorigenesis and progression of colorectal cancer cells remains under‑investigated. The present study examined the antitumor function of butyrate in the colorectal cancer cell line HCT116 and investigated the underlying molecular mechanism. MTT assay was used to measure cell proliferation and ELISA assay was used to determine cell apoptosis by measuring histone release and caspase‑3 activation. The results demonstrated that butyrate treatment significantly inhibited proliferation and induced apoptosis in HCT116 cells with an increased B‑cell lymphoma-2 (Bcl‑2)‑associated X protein/Bcl‑2 ratio. Western blotting demonstrated that the phosphorylation of mammalian target of rapamycin (mTOR) at Ser2448, ribosomal protein S6 kinase β‑1 (S6K1) at Thr389, S6 at Ser235/236 and expression of silent mating type information regulation 2 homolog (SIRT)1 were decreased following butyrate treatment, while the acetylation of S6K1 was indicated to be increased. Silencing of SIRT1 by small interfering RNA technology demonstrated a similar inhibition on growth, induction of apoptosis, elevation of S6K1 acetylation and deactivation of mTOR/S6K1 signaling. Butyrate treatment also enhanced the inhibition of SIRT1 silencing on cell proliferation and activity of mTOR/S6K1. The activation of mTOR/S6K1 signaling and upregulation of cell proliferation mediated by overexpression of SIRT1 were blocked by butyrate. These data suggested that butyrate inhibited proliferation and induced apoptosis in HCT116 cells by deactivating mTOR/S6K1 signaling, possibly through its inhibition of SIRT1.

Perioperative transfusion and the prognosis of colorectal cancer surgery: a systematic review and meta-analysis

Background

Perioperative transfusion can reduce the survival rate in colorectal cancer patients. The effects of transfusion on the short- and long-term prognoses are becoming intriguing.

Objective

This systematic review and meta-analysis aimed to define the effects of perioperative transfusion on the short- and long-term prognoses of colorectal cancer surgery.

Results

Thirty-six clinical observational studies, with a total of 174,036 patients, were included. Perioperative transfusion decreased overall survival (OS) (hazard ratio (HR), 0.33; 95% confidence interval (CI), 0.24 to 0.41; P < 0.0001) and cancer-specific survival (CSS) (HR, 0.34; 95% CI, 0.21 to 0.47; P < 0.0001), but had no effect on disease-free survival (DFS) (HR, 0.17; 95% CI, − 0.12 to 0.47; P = 0.248). Transfusion could increase postoperative infectious complications (RR, 1.89, 95% CI, 1.56 to 2.28; P < 0.0001), pulmonary complications (RR, 2.01; 95% CI, 1.54 to 2.63; P < 0.0001), cardiac complications (RR, 2.20; 95% CI, 1.75 to 2.76; P < 0.0001), anastomotic complications (RR, 1.51; 95% CI, 1.29 to 1.79; P < 0.0001), reoperation(RR, 2.88; 95% CI, 2.05 to 4.05; P < 0.0001), and general complications (RR, 1.86; 95% CI, 1.66 to 2.07; P < 0.0001).

Conclusion

Perioperative transfusion causes a dramatically negative effect on long-term prognosis and increases short-term complications after colorectal cancer surgery.

Oncological safety of autologous breast reconstruction after mastectomy for invasive breast cancer

Background

The number of patients requesting autologous breast reconstruction (ABR) after mastectomy for breast cancer has increased over the past decades. However, concern has been expressed about the oncological safety of ABR. The aim of our study was to assess the effect of ABR on distant relapse.

Methods

In this retrospective cohort study, data was analysed from patients who underwent mastectomy for invasive breast cancer in University Hospitals Leuven between 2000 and 2011. In total, 2326 consecutive patients were included, 485 who underwent mastectomy with ABR and 1841 who underwent mastectomy alone. The risk of relapse in both groups was calculated using a Cox proportional hazards analysis, adjusted for established prognostic factors. ABR was considered as a time-dependent variable. Additionally, the evolution of the risk over follow-up time was calculated.

Results

With a median follow-up of 68 months, 8% of patients in the reconstruction group developed distant metastases compared to 15% in the mastectomy alone group (univariate HR 0.70, 95% CI 0.50–0.97, p = 0.0323). However, after adjustment for potential confounding factors in a Cox multivariable analysis, the risk of distant relapse was no longer significantly different between groups (multivariate HR 0.82, 95% CI 0.55–1.22, p = 0.3301). Moreover, the risk of metastasis after reconstruction was not time-dependent.

Conclusions

These findings suggest that there is no effect of ABR on distant relapse rate and thus that ABR is an oncological safe procedure. The rate of local recurrence was too low to make any significant conclusions.

Perioperative epidural use and survival outcomes in patients undergoing primary debulking surgery for advanced ovarian cancer

OBJECTIVE

Epidurals are associated with improved outcomes in some solid tumors, presumably due to their effect on surgical stress response. There are limited data on the prognostic significance of epidural anesthesia in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. We sought to assess the impact of epidural anesthesia on the survival outcomes of patients undergoing PDS for advanced ovarian cancer.

METHODS

In this retrospective study, consecutive patients with stage IIIB-IV epithelial ovarian, fallopian tube, or peritoneal carcinoma who underwent PDS at our institution from 01/2005-12/2013 were identified. Progression-free survival (PFS) and overall survival (OS) with regard to epidural use were analyzed.

RESULTS

Of 648 patients, 435 received an epidural and 213 did not. Patients in the former group were more likely to have higher stage disease (stage IV disease, 26% vs. 16%, respectively; P = .005), carcinomatosis (87% vs. 80%, respectively; P = .027), and bulky upper abdominal disease (66% vs. 58%, respectively; P = .046). Complete gross resection was achieved in 48% and 32%, respectively (P < .001). For the epidural vs. non-epidural groups, median PFS was 20.8 months and 13.9 months, respectively (P = .021); median OS was 62.4 months and 41.9 months, respectively (P < .001). After controlling for confounding factors, including residual disease, epidural use was independently associated with a decreased risk of progression (HR = 1.327; 95% CI, 1.066-1.653) and death (HR = 1.588; 95% CI, 1.224-2.06).

CONCLUSIONS

Perioperative epidural use was independently associated with improved PFS and OS in these patients. Epidural anesthesia at the time of PDS may be warranted in this setting.

The impact of unplanned reoperations in head and neck cancer surgery on survival

OBJECTIVES

Unplanned reoperation causes physical and psychological stress in patients and it costs more in terms of medical, economic and social resource. The purpose of the study was to evaluate the incidence, risk factors and clinical significance of unplanned reoperation (any unscheduled surgery within 30 days from the initial surgery) in patients who had undergone head and neck cancer (HNC) surgery.

MATERIALS AND METHODS

A total of 574 consecutive patients who had received surgery for HNC with or without flap reconstruction from 2010 to 2015 were analyzed. Clinical and biochemical characteristics, cause of unplanned reoperation, cancer subsites, and previous treatment history were compared between unplanned reoperation group (n = 60) and control group (n = 514). Multivariable analyses were performed to identify risk factors for unplanned reoperation. Clinical significance was evaluated by multivariable survival analyses using Cox proportional hazard model.

RESULTS

Overall rate of unplanned reoperation was 10.5%. Flap complication (40.0%) was the most common cause, followed by infection (16.7%), necrosis (11.7%), and bleeding (8.3%). Higher N (N2) classification, long operation time and previous treatment before surgery were identified as risk factors for unplanned reoperation. Based on multivariable survival analyses, recurrence-free survival was significantly decreased in unplanned reoperation group (Hazard ratio = 1.85, 95% confidence interval [1.23-2.80]), but not overall survival.

CONCLUSION

Unplanned reoperation significantly decreased recurrence-free survival in patients with HNC surgery. Thus, careful surgical/ perioperative management is needed to reduce unplanned reoperation in HNC patients with advanced nodal disease, long operation time or previous treatment history.

The impact of surgical resection of the primary tumor on the development of synchronous colorectal liver metastasis: a systematic review

BACKGROUND

In recent years different therapeutic strategies for synchronously liver metastasized colorectal cancer were described. Apart from the classical staged surgical approach, simultaneous and liver-first strategies are now commonly used. One theoretical drawback of the classical approach is, however, the stimulatory effect on liver metastases growth that may result from resection of the primary tumour. This systematic review, therefore, aims to investigate the current insights on the stimulatory effects of colorectal surgery on the growth of synchronous colorectal liver metastases in humans.

METHODS

The systematic review was conducted according to the PRISMA statement. A literature search was performed using PubMed and Embase. Articles investigating the effects of colorectal surgery on synchronous colorectal liver metastases were included. Primary endpoints were metastatic tumor volume, metabolic and proliferative activity and tumour vascularization.

RESULTS

Four articles meeting the selection criteria were found involving 200 patients. These studies investigate the effects of resection of the primary tumour on synchronous liver metastases using histological and radiological techniques. These papers support a possible stimulatory effect of resection of the primary tumor.

CONCLUSIONS

Some limited evidence supports the hypothesis that colorectal surgery might stimulate the growth and development of synchronous colorectal liver metastases.

Postoperative complications are associated with worse survival after laparoscopic surgery for non-metastatic colorectal cancer - interim analysis of 3-year overall survival

Introduction

Postoperative morbidity after colorectal resections for cancer remains a significant problem. Data on the influence of complications on survival after laparoscopic colorectal resection are still limited.

Aim

To analyze the impact of postoperative complications on long-term survival after radical laparoscopic resection for colorectal cancer.

Material and methods

Two hundred and sixty-five consecutive non-metastatic colorectal cancer patients undergoing laparoscopic colorectal resection for cancer were included in the analysis. The entire study group was divided into two subgroups based on the occurrence of postoperative complications. Group 1 included patients without postoperative morbidity and group 2 included patients with complications. The primary outcome was overall survival.

Results

Median follow-up was 45 (IQR: 34–55) months. Group 1 consisted of 187 (70.5%) patients and group 2 comprised 78 (29.5%) patients. Studied groups were comparable in terms of sex, age, body mass index, ASA class, cancer staging, localization of the tumor and operative time. Patients in group 1 had significantly better overall 3-year survival compared to those with complications (84.9% vs. 69.8%, p = 0.022). Kaplan-Meier curves showed significantly improved survival rates in patients without complications compared with complicated cases. The Cox proportional multivariate model showed that postoperative complications (HR = 2.83; 95% CI: 1.35–5.92; p = 0.0058) and AJCC III (HR = 3.17; 95% CI: 1.52–6.6; p = 0.0021) were independent predictors of worse survival after laparoscopic colorectal cancer surgery.

Conclusions

Our analysis of interim results after 3 years confirms that complications after laparoscopic colorectal cancer surgery have an impact on survival. For this reason, these patients should be carefully monitored after surgery aiming at early detection of recurrence.

Stimulatory effect of desipramine on lung metastases of adenocarcinoma MADB 106 in stress highly-sensitive and stress non-reactive rats

The effect of antidepressant drugs on tumor progress is very poorly recognized. The aim of the present study was to examine the effect of individual reactivity to stress and 24-day desipramine (DES) administration on the metastatic colonization of adenocarcinoma MADB 106 cells in the lungs of Wistar rats. Wistar rats were subjected to stress procedure according to the chronic mild stress (CMS) model of depression for two weeks and stress highly-sensitive (SHS) and stress non-reactive (SNR) rats were selected. SHS rats were more prone to cancer metastasis than SNR ones and chronic DES treatment further increased the number of lung metastases by 59% and 50% in comparison to vehicle-treated appropriate control rats. The increase in lung metastases was connected with DES-induced skew macrophage activity towards M2 functional phenotype in SHS and SNR rats. Moreover, during 24h after DES injection in healthy rats, the decreased number of TCD8⁺ and B cells in SHS and SNR rats as well as NK cell cytotoxic activity in SNR rats could be attributed to the lowered capacity to defend against cancer metastasis observed in chronic DES treated and tumor injected rats.

Effects of dermal wounding on distal primary tumor immunobiology in mice

BACKGROUND

Before primary oral tumors are treated, various prophylactic procedures that require tissue repair are often necessary (e.g. biopsies, tooth extractions, radiation, and tracheotomies). Wound healing and tumor growth harness similar immune/inflammatory mechanisms. Our previous work indicates that tumors impair wound healing, although the extent to which tissue repair conversely influences tumor growth is poorly understood. Here, we test the hypothesis that dermal wound healing exacerbates primary tumor growth and influences tumor immunobiology.

MATERIALS AND METHODS

Female, immunocompetent mice were inoculated subcutaneously with murine oral cancer cells (AT-84) to induce flank tumors. Half of the mice received dermal excisional wounds (4 × 3.5 mm diameter) on their dorsum 16 days later, whereas the skin of controls remained intact. Tumor and blood tissues were harvested 1 and 5 days post wounding, and tumor myeloid cell populations and inflammatory gene expression were measured. Circulating myeloid cells, cytokines, and corticosterone were also quantified.

RESULTS

Wounding increased tumor mass, early tumor infiltration of macrophages, and tumor inflammatory gene expression. While wounding attenuated tumor growth-induced increases in circulating myeloid cells, no effects of wounding on circulating cytokine/endocrine measures were observed.

CONCLUSIONS

These results indicate that modest skin immune/inflammatory processes can enhance distal tumor growth and alter innate tumor immunity. The implication for this work is that, in the presence of a tumor, the benefits of tissue-damaging procedures that occur clinically must be weighed against the potential consequences for tumor biology.

The effect of neuraxial anesthesia on cancer recurrence and survival after cancer surgery: an updated meta-analysis

Several animal and observational studies have evaluated the effects of neuraxial anesthesia on the recurrence and survival of cancer surgery; studies reported benefit, whereas others did not. To provide further evidence that neuraxial anesthesia(combined with or without general anesthesia (GA))may be associated with reduced cancer recurrence and long-term survival after cancer surgery, we conducted this meta-analysis. A total of 21 studies were identified and analyzed, based on searches conducted using PubMed, Web of Science, EMBASE database and the Cochrane Database of Systematic Reviews. After data abstraction, adjusted hazard ratios (HR) with 95% confidence intervals (CIs) were used to assess the impact of neuraxial anesthesia (combined with or without GA) and GA on oncological outcomes after cancer surgery. For overall survival (OS), a potential association between neuraxial anesthesia and improved OS (HR 0.853, CI 0.741-0.981, P = 0.026, the random-effects model) was observed compared with GA. Specifically, we found a positive association between neuraxial anesthesia and improved OS in colorectal cancer (HR 0.653, CI 0.430-0.991, P = 0.045, the random-effects model). For recurrence-free survival (RFS), a significant association between neuraxial anesthesia and improved RFS (HR 0.846, CI 0.718-0.998, P = 0.047, the random-effects model) was detected compared with GA. Our meta-analysis suggests that neuraxial anesthesia may be associated with improved OS in patients with cancer surgery, especially for those patients with colorectal cancer. It also supports a potential association between neuraxial anesthesia and a reduced risk of cancer recurrence. More prospective studies are needed to elucidate whether the association between neuraxial use and survival is causative.

Dexmedetomidine promotes metastasis in rodent models of breast, lung, and colon cancers

BACKGROUND

Perioperative strategies can significantly influence long-term cancer outcomes. Dexmedetomidine, an α₂-adrenoceptor agonist, is increasingly used perioperatively for its sedative, analgesic, anxiolytic, and sympatholytic effects. Such actions might attenuate the perioperative promotion of metastases, but other findings suggest opposite effects on primary tumour progression. We tested the effects of dexmedetomidine in clinically relevant models of dexmedetomidine use on cancer metastatic progression.

METHODS

Dexmedetomidine was given to induce sub-hypnotic to sedative effects for 6-12 h, and its effects on metastasis formation, using various cancer types, were studied in naïve animals and in the context of stress and surgery.

RESULTS

Dexmedetomidine increased tumour-cell retention and growth of metastases of a mammary adenocarcinoma (MADB 106) in F344 rats, Lewis lung carcinoma (3LL) in C57BL/6 mice, and colon adenocarcinoma (CT26) in BALB/c mice. The metastatic burden increased in both sexes and in all organs tested, including lung, liver, and kidney, as well as in brain employing a novel external carotid-artery inoculation approach. These effects were mediated through α₂-adrenergic, but not α₁-adrenergic, receptors. Low sub-hypnotic doses of dexmedetomidine were moderately beneficial in attenuating the deleterious effects of one stress paradigm, but not of the surgery or other stressors.

CONCLUSIONS

The findings call for mechanistic translational studies to understand these deleterious effects of dexmedetomidine, and warrant prospective clinical trials to assess the impact of perioperative dexmedetomidine use on outcomes in cancer patients.

Neuroendocrine factors: The missing link in non‑melanoma skin cancer (Review)

Non‑melanoma skin cancer (NMSC) is the most common form of cancer worldwide, comprising 95% of all cutaneous malignancies and approximately 40% of all cancers. In spite of intensive efforts aimed towards awareness campaigns and sun‑protective measures, epidemiological data indicate an increase in the incidence of NMSC. This category of skin cancers has many common environmental triggers. Arising primarily on sun‑exposed skin, it has been shown that ultraviolet radiation is, in the majority of cases, the main trigger involved in the pathogenesis of NMSC. Aside from the well‑known etiopathogenic factors, studies have indicated that several neuroactive factors are involved in the carcinogenesis of two of the most common types of NMSC, namely basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), with the exception of penile SCC, for which a paucity of specific data on their pathogenic role exists. The complex interaction between the peripheral nervous system and target cells in the skin appears to be mediated by locally released neuroendocrine factors, such as catecholamines, substance P, calcitonin gene‑related peptide and somatostatin, as well as neurohormones, such as proopiomelanocortin and its derived peptides, α‑melanocyte‑stimulating hormone and adrenocorticotropin. All these factors have been, at least at some point, a subject of debate regarding their precise role in the pathogenesis of NMSC. There is also a significant body of evidence indicating that psychological stress is a crucial impact factor influencing the course of skin cancers, including SCC and BCC. Numerous studies have suggested that neuroendocrine factor dysregulation, as observed in stress reactions, may be involved in tumorigenesis, accelerating the development and progression, and suppressing the regression of NMSC. Further studies are required in order to elucidate the exact mechanisms through which neuroactive molecules promote or inhibit cutaneous carcinogenesis, as this could lead to the development of more sophisticated and tailored treatment protocols, as well as open new perspectives in skin cancer research.

Association Among Blood Transfusion, Sepsis, and Decreased Long-term Survival After Colon Cancer Resection

OBJECTIVE

To investigate the potential additive effects of blood transfusion and sepsis on colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival after colon cancer surgery.

BACKGROUND

Perioperative blood transfusions are associated with infectious complications and increased risk of cancer recurrence through systemic inflammatory effects. Furthermore, recent studies have suggested an association among sepsis, subsequent systemic inflammation, and adverse cardiovascular outcomes. However, no study has investigated the association among transfusion, sepsis, and disease-specific survival in postoperative patients.

METHODS

The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I to III colon cancer resections from 2004 to 2011. Propensity-adjusted survival analyses assessed the association of perioperative allogeneic blood transfusion, sepsis, and 5-year colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival.

RESULTS

Among 24,230 patients, 29% received a transfusion and 4% developed sepsis. After risk adjustment, transfusion and sepsis were associated with worse colon cancer disease-specific survival [(+)transfusion: hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.09-1.30; (+)sepsis: HR 1.84, 95% CI 1.44-2.35; (+)transfusion/(+)sepsis: HR 2.27, 95% CI 1.87-2.76], cardiovascular disease-specific survival [(+)transfusion: HR 1.18, 95% CI 1.04-1.33; (+)sepsis: HR 1.63, 95% CI 1.14-2.31; (+)transfusion/(+)sepsis: HR 2.04, 95% CI 1.58-2.63], and overall survival [(+)transfusion: HR 1.21, 95% CI 1.14-1.29; (+)sepsis: HR 1.76, 95% CI 1.48-2.09; (+)transfusion/(+)sepsis: HR 2.36, 95% CI 2.07-2.68] relative to (-)transfusion/(-)sepsis. Additional analyses suggested an additive effect with those who both received a blood transfusion and developed sepsis having even worse survival.

CONCLUSIONS

Perioperative blood transfusions are associated with shorter survival, independent of sepsis, after colon cancer resection. However, receiving a transfusion and developing sepsis has an additive effect and is associated with even worse survival. Restrictive perioperative transfusion practices are a possible strategy to reduce sepsis rates and improve survival after colon cancer surgery.

Feasibility of Cervical Epidural Anesthesia for Breast Cancer Surgery

Background

Effects of perioperative cervical level neuraxial blocks on the dissemination of cancer metastases have become a matter of substantial interest. However, experience with these catheters has been limited and data on feasibility and efficacy is sparse.

Methods

Data from 39 patients scheduled to undergo breast cancer surgery while awake with a cervical epidural alone was retrospectively analyzed.

Results

In 26 patients (66,7%, 95% CI 51,7–81,7) the cervical epidural catheter was sufficient for surgery. In one patient (2.6%, 95% CI 0–7.6) identification of the epidural space was not possible. Four patients (10.3%, 95% CI 0,7–19,9) had an insufficient sensory block. Seven patients (17.9%, 95% CI 5,7–30,1) had a partially insufficient sensory block. Rates of failed epidural blocks were not significantly different between different insertion levels. 21 patients (80.8%, 95% CI 65,4–96,1) developed hypotension and required an intravenous vasopressor. One patient developed nausea. In one patient the dura was accidentally punctured. No neurological damage was observed. No other major complications were observed.

Discussion

Epidural punctures in the cervical region are feasible but do bear potential for major complications. Anesthesiologists should familiarize themselves with high epidural block techniques.

Tumor reductive therapies and antitumor immunity

Tumor reductive therapy is to reduce tumor burden through direct killing of tumor cells. So far, there is no report on the connection between antitumor immunity and tumor reductive therapies. In the last few years, a new category of cancer treatment, immunotherapy, emerged and they are categorized separately from classic cytotoxic treatments (chemo and radiation therapy). The most prominent examples include cellular therapies (LAK and CAR-T) and immune checkpoint inhibitors (anti-PD-1 and CTLA-4). Recent advances in clinical immunotherapy and our understanding of the mechanism behind them revealed that these therapies have a closer relationship with classic cancer treatments than we thought. In many cases, the effectiveness of classic therapies is heavily influenced by the status of the underlying antitumor-immunity. On the other hand, immunotherapies have shown better outcome when combined with tumor reductive therapies, not only due to the combined effects of tumor killing by each therapy but also because of a synergy between the two. Many clinical observations can be explained once we start to look at these classic therapies from an immunity standpoint. We have seen their direct effect on tumor antigen in vivo that they impact antitumor immunity more than we have realized. In turn, antitumor immunity contributes to tumor control and destruction as well. This review will take the immunological view of the classic therapies and summarize historical as well as recent findings in animal and clinical studies to make the argument that most of the cancer treatments exert their ultimate efficacy through antitumor immunity.

Maintaining unperturbed cerebral blood flow is key in the study of brain metastasis and its interactions with stress and inflammatory responses

Blood-borne brain metastases are associated with poor prognosis, but little is known about the interplay between cerebral blood flow, surgical stress responses, and the metastatic process. The intra-carotid inoculation approach, traditionally used in animal studies, involves permanent occlusion of the common carotid artery (CCA). Herein we introduced a novel intra-carotid inoculation approach that avoids CCA ligation, namely - assisted external carotid artery inoculation (aECAi) - and compared it to the traditional approach in C57/BL6 mice, assessing cerebral blood flow; particle distribution; blood-brain barrier (BBB) integrity; stress, inflammatory and immune responses; and brain tumor retention and growth. Doppler flowmetry and two-photon imaging confirmed that only in the traditional approach regional and capillary cerebral blood flux were significantly reduced. Corticosterone and plasma IL-6 levels were higher in the traditional approach, splenic numbers of NK, CD3+, granulocytes, and dendritic cells were lower, and many of these indices were more profoundly affected by surgical stress in the traditional approach. BBB integrity was unaffected. Administration of spherical beads indicated that CCA ligation significantly limited brain distribution of injected particles, and inoculation of D122-LLC syngeneic tumor cells resulted in 10-fold lower brain tumor-cell retention in the traditional approach. Last, while most of the injected tumor cells were arrested in extra-cranial head areas, our method improved targeting of brain-tissue by 7-fold. This head versus brain distribution difference, commonly overlooked, cannot be detected using in vivo bioluminescent imaging. Overall, it is crucial to maintain unperturbed cerebral blood flow while studying brain metastasis and interactions with stress and inflammatory responses.

Reducing liver metastases of colon cancer in the context of extensive and minor surgeries through β-adrenoceptors blockade and COX2 inhibition

Liver metastases are a major cause of colorectal cancer death, and the perioperative period is believed to critically affect the metastatic process. Here we tested whether blocking excess release of catecholamines and prostaglandins during surgical procedures of different extent can reduce experimental liver metastasis of the syngeneic CT26 colon cancer in female and male BALB/c mice. Animals were either treated with the beta-blocker, propranolol, the COX-2 inhibitor, etodolac, both drugs, or vehicle. The role of NK cells in controlling CT26 hepatic metastasis and in mediating the effect of the drugs was assessed by in vivo depletion or stimulation of NK cells, using anti-asialo GM1 or CpG-C, respectively. Surgical extent was manipulated by adding laparotomy to small incision, extending surgical duration, and enabling hypothermia. The results indicated that combined administration of propranolol and etodolac, but neither drug alone, significantly improved host resistance to metastasis. These beneficial effects occurred in both minor and extensive surgeries, in both sexes, and in two tumor inoculation approaches. NK cell-mediated anti-CT26 activity is involved in mediating the beneficial effects of the drugs. Specifically, CpG-C treatment, known to profoundly activate mice marginating-hepatic NK cytotoxicity, reduced CT26 hepatic metastases; and NK-depletion increased metastases and prevented the beneficial effects of the drugs. Overall, given prevalent perioperative psychological and physiological stress responses in patients, and ample prostaglandin release by colorectal tumors and injured tissue, propranolol and etodolac could be tested clinically in laparoscopic and open colorectal surgeries, attempting to reduce patients' metastatic disease.

Stress and Cancer in Dogs: Comparison Between a Population of Dogs Diagnosed with Cancer and a Control Population - A Pilot Study

It is widely accepted that psychological stress and mental illness can compromise the function of the immune system. Clinical and epidemiological studies on humans recognized that specific psychosocial factors, such as stress, chronic depression and lack of social support are risk factors for the development and progression of cancer. Unfortunately, most of the animals studies on this subject are based on laboratory tests performed on mice. This retrospective cohort study aims to analyze the relation between stress and tumor in pet dogs, by evaluating and comparing the stress level in two groups of 69 dogs each, balanced for sex and age: the oncologic group consists of dogs diagnosed with cancer and the control group consists of healthy dogs. Our results show that, before the cancer diagnosis, more dogs in the oncologic group faced changes in their household and routine as opposed to the control group (p<0.05). More dogs of the oncologic group than the control group also showed signs of stress and anxiety, before the cancer diagnosis (p<0.05). As reported by their owners, these included attention seeking, hiding without a specific reason, following the owner around the house, hyper-vigilance, fear of fireworks and gunshots, biting, aggression towards other dogs, licking and chewing excessively parts of their body. Our results are aligned with the evidence from human research, indicating that dogs with cancer are significantly more likely to have shown signs of stress compared to the control dogs during their life.

Surgery accelerates the development of endometriosis in mice

BACKGROUND

Surgery is currently the mainstay treatment for solid tumors and many benign diseases, including endometriosis, and women tend to receive substantially more surgeries than men mainly because of gynecological and cosmetic surgeries. Despite its cosmetic, therapeutic, or even life-saving benefits, surgery is reported to increase the cancer risk and promotes cancer metastasis. Surgery activates adrenergic signaling, which in turn suppresses cell-mediated immunity and promotes angiogenesis and metastasis. Because immunity, angiogenesis, and invasiveness are all involved in the pathophysiology of endometriosis, it is unclear whether surgery may accelerate the development of endometriosis.

OBJECTIVE

The objective of the study was to test the hypothesis that surgery activates adrenergic signaling, increases angiogenesis, and accelerates the growth of endometriotic lesions.

STUDY DESIGN

This was a prospective, randomized experimentation. The first experiment used 42 female adult Balb/C mice, and the second used 90 female adult Balb/C mice. In experiment 1, 3 days after the induction of endometriosis, mice were randomly divided into 3 groups of approximately equal sizes, control, laparotomy, and mastectomy. In experiment 2, propranolol infusion via Alzet pumps was used to forestall the effect of sympathetic nervous system activation by surgery. In both experiments, mice were evaluated 2 weeks after surgery. Lesion size, hotplate latency, and immunohistochemistry analysis of vascular endothelial growth factor, CD31-positive microvessels, proliferating cell nuclear antigen, phosphorylated cyclic adenosine monophosphate-responsive element-binding protein, β2-adrenergic receptor (ADRB)-2, ADRB1, ADRB3, ADRA1, and ADRA2 in ectopic implants.

RESULTS

Both mastectomy and laparotomy increased lesion weight and exacerbated hyperalgesia, increased microvessel density and elevated the immunoreactivity against ADRB2, phosphorylated cyclic adenosine monophosphate-responsive element-binding protein, vascular endothelial growth factor, and proliferating cell nuclear antigen but not ADRB1, ADRB3, ADRA1, and ADRA2, suggesting activated adrenergic signaling, increased angiogenesis, and accelerated growth of endometriotic lesions. β-Blockade completely abrogated the facilitory effect of surgery, further underscoring the critical role of β-adrenergic signaling in mediating the effect of surgery.

CONCLUSION

Surgery activates adrenergic signaling, increases angiogenesis, and accelerates the growth of endometriotic lesions in the mouse, but such a facilitory effect of surgery can be completely abrogated by β-blockade. Whether surgery can promote the development of endometriosis in humans warrants further investigation.

Does the mobilization of circulating tumour cells during cancer therapy cause metastasis?

Despite progressive improvements in the management of patients with locoregionally confined, advanced-stage solid tumours, distant metastasis remains a very common - and usually fatal - mode of failure after attempted curative treatment. Surgery and radiotherapy are the primary curative modalities for these patients, often combined with each other and/or with chemotherapy. Distant metastasis occurring after treatment can arise from previously undetected micrometastases or, alternatively, from persistent locoregional disease. Another possibility is that treatment itself might sometimes cause or promote metastasis. Surgical interventions in patients with cancer, including biopsies, are commonly associated with increased concentrations of circulating tumour cells (CTCs). High CTC numbers are associated with an unfavourable prognosis in many cancers. Radiotherapy and systemic antitumour therapies might also mobilize CTCs. We review the preclinical and clinical data concerning cancer treatments, CTC mobilization and other factors that might promote metastasis. Contemporary treatment regimens represent the best available curative options for patients who might otherwise die from locally confined, advanced-stage cancers; however, if such treatments can promote metastasis, this process must be understood and addressed therapeutically to improve patient survival.

Surgical cytoreduction of the primary tumor reduces metastatic progression in a mouse model of prostate cancer

Metastatic prostate cancer (mPCa) is one of the most prevalent cancers in men worldwide. The main cause of death in these patients is androgen-resistant metastatic disease. Surgery of the primary tumor has been avoided in these patients as there is no strong evidence that supports a beneficial effect. From the biological point of view, it appears rational to hypothesize that the primary tumor may contribute to the establishment and growth of metastases. Considering this, we propose that cytoreductive surgery (CS) in advanced metastatic stage slows the progression of metastatic disease. To test this, we used a mouse model of resectable orthotopic prostate cancer (PCa) and performed CS. After surgery, metastases were smaller and less numerous in the treated mice; an effect that was observable until the end of the experiment. These results suggest that CS alone delays the progression of metastatic disease and that although this effect may be temporary, it may translate to prolonged survival, especially when used with adjuvant therapy.