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Jacobs LM, Helder LS, Albers KI, Kranendonk J, Keijzer C, Joosten LA, Strobbe LJ, Warlé MC. The role of surgical tissue injury and intraoperative sympathetic activation in postoperative immunosuppression after breast-conserving surgery versus mastectomy: a prospective observational study. Breast Cancer Res 2024; 26:42. [PMID: 38468349 PMCID: PMC10926636 DOI: 10.1186/s13058-024-01801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/28/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Breast cancer is the second most common cause of death from cancer in women worldwide. Counterintuitively, large population-based retrospective trials report better survival after breast-conserving surgery (BCS) compared to mastectomy, corrected for tumour- and patient variables. More extensive surgical tissue injury and activation of the sympathetic nervous system by nociceptive stimuli are associated with immune suppression. We hypothesized that mastectomy causes a higher expression of plasma damage associated molecular patterns (DAMPs) and more intraoperative sympathetic activation which induce postoperative immune dysregulation. Immune suppression can lead to postoperative complications and affect tumour-free survival. METHODS In this prospective observational study, plasma DAMPs (HMGB1, HSP70, S100A8/A9 and S100A12), intraoperative sympathetic activation (Nociception Level (NOL) index from 0 to 100), and postoperative immune function (plasma cytokine concentrations and ex vivo cytokine production capacity) were compared in patients undergoing elective BCS (n = 20) versus mastectomy (n = 20). RESULTS Ex vivo cytokine production capacity of TNF, IL-6 and IL-1β was nearly absent in both groups one hour after surgery. Levels appeared recovered on postoperative day 3 (POD3), with significantly higher ex vivo production capacity of IL-1β after BCS (p = .041) compared to mastectomy. Plasma concentration of IL-6 was higher one hour after mastectomy (p = .045). Concentrations of plasma alarmins S100A8/A9 and S100A12 were significantly higher on POD3 after mastectomy (p = .003 and p = .041, respectively). Regression analysis showed a significantly lower percentage of NOL measurements ≤ 8 (absence of nociception) during mastectomy when corrected for norepinephrine equivalents (36% versus 45% respectively, p = .038). Percentage of NOL measurements ≤ 8 of all patients correlated with ex vivo cytokine production capacity of IL-1β and TNF on POD3 (r = .408; p = .011 and r = .500; p = .001, respectively). CONCLUSIONS This pilot study revealed substantial early postoperative immune suppression after BCS and mastectomy that appears to recover in the following days. Differences between BCS and mastectomy in release of DAMPs and intraoperative sympathetic activation could affect postoperative immune homeostasis and thereby contribute to the better survival reported after BCS in previous large population-based retrospective trials. These results endorse further exploration of (1) S100 alarmins as potential therapeutic targets in breast cancer surgery and (2) suppression of intraoperative sympathetic activation to substantiate the observed association with postoperative immune dysregulation.
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Affiliation(s)
- Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Leonie S Helder
- Department of Anaesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Kim I Albers
- Department of Anaesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Josephine Kranendonk
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands
| | | | - Leo Ab Joosten
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
- Department of Medical Genetics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj- Napoca, Romania
| | - Luc Ja Strobbe
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein zuid 10, Nijmegen, 6525 GA, The Netherlands.
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Bijkerk V, Visser J, Jacobs LMC, Keijzer C, Warlé MC. Deep versus moderate neuromuscular blockade during total hip arthroplasty to improve postoperative quality of recovery and immune function: protocol for a randomised controlled study. BMJ Open 2023; 13:e073537. [PMID: 37640469 PMCID: PMC10462972 DOI: 10.1136/bmjopen-2023-073537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION There is accumulating evidence that deep neuromuscular blockade (NMB) improves intraoperative surgical conditions during laparoscopic surgery. Studies investigating the effects of deep NMB in open surgery are scarce. In theory, by limiting surgical damage through deeper muscle relaxation, postoperative inflammation and concomitant immune suppression can be reduced. Therefore, this study will investigate the effects of deep NMB during total hip arthroplasty, which demands a relatively large exposure of the hip joint through and in between muscles. METHODS AND ANALYSIS This study is a monocentre blinded randomised controlled trial in 100 patients undergoing total hip arthroplasty under general anaesthesia. Patients will be randomised in a 1:1 fashion to an intervention group of intraoperative deep NMB (a post-tetanic count of 1-2) or a control group receiving moderate NMB (a train-of-four count of 1-2). NMB will be achieved by continuous or bolus administration of rocuronium, respectively. The primary endpoint is the quality of recovery at postoperative day 1 measured by the Quality of Recovery-40 Questionnaire, analysed by Analysis of Variance. The secondary endpoint is postoperative innate immune function, measured by ex vivo production capacity of tumour necrosis factor and interleukin-1β on endotoxin stimulation of whole blood. ETHICS AND DISSEMINATION Ethical approval for this study was granted by the Medical Ethics Committee 'METC Oost-Nederland' (reference number 2022-15754). Informed consent will be obtained prior to study participation. Study results will be published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBERS ClinicalTrials.gov Registry (NCT05562999) and EudraCT Registry (2022-002451-19).
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Affiliation(s)
- Veerle Bijkerk
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
- Department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Jetze Visser
- Department of Orthopedics, Radboudumc, Nijmegen, The Netherlands
| | | | | | - Michiel C Warlé
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
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Chen Y, Ouyang Y, Li Z, Wang X, Ma J. S100A8 and S100A9 in Cancer. Biochim Biophys Acta Rev Cancer 2023; 1878:188891. [PMID: 37001615 DOI: 10.1016/j.bbcan.2023.188891] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
S100A8 and S100A9 are Ca2+ binding proteins that belong to the S100 family. Primarily expressed in neutrophils and monocytes, S100A8 and S100A9 play critical roles in modulating various inflammatory responses and inflammation-associated diseases. Forming a common heterodimer structure S100A8/A9, S100A8 and S100A9 are widely reported to participate in multiple signaling pathways in tumor cells. Meanwhile, S100A8/A9, S100A8, and S100A9, mainly as promoters, contribute to tumor development, growth and metastasis by interfering with tumor metabolism and the microenvironment. In recent years, the potential of S100A8/A9, S100A9, and S100A8 as tumor diagnostic or prognostic biomarkers has also been demonstrated. In addition, an increasing number of potential therapies targeting S100A8/A9 and related signaling pathways have emerged. In this review, we will first expound on the characteristics of S100A8/A9, S100A9, and S100A8 in-depth, focus on their interactions with tumor cells and microenvironments, and then discuss their clinical applications as biomarkers and therapeutic targets. We also highlight current limitations and look into the future of S100A8/A9 targeted anti-cancer therapy.
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Albers KI, Polat F, Loonen T, Graat LJ, Mulier JP, Snoeck MMJ, Panhuizen IF, Vermulst AA, Scheffer GJ, Warlé MC. Visualising improved peritoneal perfusion at lower intra-abdominal pressure by fluorescent imaging during laparoscopic surgery: A randomised controlled study. Int J Surg 2020; 77:8-13. [DOI: 10.1016/j.ijsu.2020.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 02/08/2023]
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Calprotectin and Calgranulin C as Biomarkers of Pancreatic Tumors: Baseline Levels and Level Changes after Surgery. Mediators Inflamm 2019; 2019:6985703. [PMID: 31582902 PMCID: PMC6754944 DOI: 10.1155/2019/6985703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/16/2019] [Accepted: 08/01/2019] [Indexed: 12/27/2022] Open
Abstract
Pancreatic tumors and their surgical resection are associated with significant morbidity and mortality, and the biomarkers currently used for these conditions have limited sensitivity and specificity. Because calprotectin and calgranulin C serum levels have been demonstrated to be potential biomarkers of certain cancers and complications of major surgery, the levels of both proteins were tested in the current study in patients with benign and malignant pancreatic tumors that were surgically removed. The baseline serum levels and kinetics of calprotectin and calgranulin C during the 7-day postoperative period were evaluated with immunoassays in 98 adult patients who underwent pancreatic surgery. The baseline serum levels of calprotectin and calgranulin C in patients with malignant (n = 84) and benign tumors (n = 14) were significantly higher (p < 0.01) when compared to those in the healthy controls (n = 26). The serum levels of both proteins were also significantly (p < 0.05) higher in patients with benign tumors than in those with malignant tumors. After surgery, the serum levels of calprotectin and calgranulin C were significantly (p < 0.01) higher than their baseline values, and this elevation persisted throughout the seven days of the follow-up period. Interestingly, starting on day 1 of the postoperative period, the serum levels of both proteins were significantly (p < 0.05) higher in the 37 patients who developed postoperative pancreatic fistulas (POPFs) than in the patients who had uneventful recoveries (n = 61). Moreover, the serum levels of calprotectin and calgranulin C demonstrated a significant predictive value for the development of POPF; the predictive values of these two proteins were better than those of the serum level of C-reactive protein and the white blood cell count. Taken together, the results of this study suggest that calprotectin and calgranulin C serum levels are potential biomarkers for pancreatic tumors, surgical injury to the pancreatic tissue and the development of POPFs.
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Bartáková E, Štefan M, Stráníková A, Pospíšilová L, Arientová S, Beran O, Blahutová M, Máca J, Holub M. Calprotectin and calgranulin C serum levels in bacterial sepsis. Diagn Microbiol Infect Dis 2018; 93:219-226. [PMID: 30420210 DOI: 10.1016/j.diagmicrobio.2018.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/02/2018] [Accepted: 10/10/2018] [Indexed: 01/18/2023]
Abstract
The aim of this study was to evaluate the serum levels of calprotectin and calgranulin C and routine biomarkers in patients with bacterial sepsis (BS). The initial serum concentrations of calprotectin and calgranulin C were significantly higher in patients with BS (n = 66) than in those with viral infections (n = 24) and the healthy controls (n = 26); the level of calprotectin was found to be the best predictor of BS, followed by the neutrophil-lymphocyte count ratio (NLCR) and the level of procalcitonin (PCT). The white blood cell (WBC) count and the NLCR rapidly returned to normal levels, whereas PCT levels normalized later and the increased levels of calprotectin, calgranulin C, and C-reactive protein persisted until the end of follow-up. Our results suggest that the serum levels of calprotectin are a reliable biomarker of BS and that the WBC count and the NLCR are rapid predictors of the efficacy of antimicrobial therapy.
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Affiliation(s)
- Eva Bartáková
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic.
| | - Marek Štefan
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic.
| | - Alžběta Stráníková
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic.
| | - Lenka Pospíšilová
- Department of Clinical Biochemistry, Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic.
| | - Simona Arientová
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic.
| | - Ondřej Beran
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic.
| | - Marie Blahutová
- Department of Clinical Biochemistry, Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic.
| | - Jan Máca
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic; Department of Anesthesiology and Intensive Care Medicine, University Hospital of Ostrava, 17. listopadu 1790/5, 708 52 Ostrava-Poruba, Czech Republic.
| | - Michal Holub
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské nemocnice 1200, 169 02 Praha 6, Czech Republic.
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Xie N, Matigian N, Vithanage T, Gregory K, Nassar ZD, Cabot PJ, Shaw PN, Kirkpatrick CMJ, Cao KAL, Sturgess D, Parat MO. Effect of Perioperative Opioids on Cancer-Relevant Circulating Parameters: Mu Opioid Receptor and Toll-Like Receptor 4 Activation Potential, and Proteolytic Profile. Clin Cancer Res 2018; 24:2319-2327. [PMID: 29511031 DOI: 10.1158/1078-0432.ccr-18-0172] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/16/2018] [Accepted: 02/28/2018] [Indexed: 11/16/2022]
Abstract
Purpose: The purpose of this study is to investigate the potential interplay between opioid analgesia and tumor metastasis through modulation of μ-opioid receptor (MOR), Toll-like receptor 4 (TLR4) activation, and matrix degradation potential.Experimental Design: Plasma samples were collected from 60 patients undergoing elective lower limb joint replacement preoperatively and at 3, 6, and 24 hours after surgery; pain scores were documented at the same time points. Opioid administration was recorded and converted into morphine IV equivalents. Plasma samples were also collected from 10 healthy volunteers. Alphascreen cyclic AMP assay and MOR-overexpressing cells were employed to quantify MOR activation. HEK-Blue hTLR4 were utilized to measure TLR4 activation. Circulating matrix metalloprotease and tissue inhibitor of matrix protease activities were assessed by gelatin zymography and reverse zymography, respectively.Results: Postoperative plasma samples displayed the ability to activate MOR and to inhibit lipopolysaccharide (LPS)-induced TLR4 activation. Linear mixed model analysis revealed that MOR activation had a significant effect on inhibition of LPS-induced TLR4 activation. Furthermore, TLR4 had a significant effect to explain pain scores. Postoperative samples also displayed altered circulating matrix-degrading enzymes activity potential, but this was correlated neither to opioid administration nor to MOR activation potential.Conclusions: Our results show for the first time that (i) opioids administered to surgery patients result in modulation of ligand-induced TLR4 activation and (ii) postoperative pain is associated with increased circulating TLR4 activation potential. Our study further promotes the use of MOR activation potential rather than opioid intake in clinical studies measuring opioid exposure at a given time point. Clin Cancer Res; 24(10); 2319-27. ©2018 AACR.
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Affiliation(s)
- Nan Xie
- School of Pharmacy, the University of Queensland, Woolloongabba, Queensland, Australia
| | - Nicholas Matigian
- The University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, Queensland, Australia
| | - Tharindu Vithanage
- Mater Research Institute (MRI-UQ), the University of Queensland, Brisbane, Queensland, Australia
| | - Kye Gregory
- Mater Research Institute (MRI-UQ), the University of Queensland, Brisbane, Queensland, Australia
| | - Zeyad D Nassar
- School of Pharmacy, the University of Queensland, Woolloongabba, Queensland, Australia
| | - Peter J Cabot
- School of Pharmacy, the University of Queensland, Woolloongabba, Queensland, Australia
| | - Paul N Shaw
- School of Pharmacy, the University of Queensland, Woolloongabba, Queensland, Australia
| | - Carl M J Kirkpatrick
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Kim-Anh Lê Cao
- The University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, Queensland, Australia
| | - David Sturgess
- Mater Research Institute (MRI-UQ), the University of Queensland, Brisbane, Queensland, Australia
| | - Marie-Odile Parat
- School of Pharmacy, the University of Queensland, Woolloongabba, Queensland, Australia. .,Outcome Research Consortium, Cleveland, Ohio
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Reimer P, Máca J, Szturz P, Jor O, Kula R, Ševčík P, Burda M, Adamus M. Role of heart-rate variability in preoperative assessment of physiological reserves in patients undergoing major abdominal surgery. Ther Clin Risk Manag 2017; 13:1223-1231. [PMID: 29033572 PMCID: PMC5614745 DOI: 10.2147/tcrm.s143809] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Major abdominal surgery (MAS) is associated with increased morbidity and mortality. The main objective of our study was to evaluate the predictive value of heart-rate variability (HRV) concerning development of postoperative complications in patients undergoing MAS. The secondary objectives were to identify the relationship of HRV and use of vasoactive drugs during anesthesia, intensive care unit length of stay (ICU-LOS), and hospital length of stay (H-LOS). Patients and methods Sixty-five patients scheduled for elective MAS were enrolled in a prospective, single-center, observational study. HRV was measured by spectral analysis (SA) preoperatively during orthostatic load. Patients were divided according to cardiac autonomic reactivity (CAR; n=23) and non-cardiac autonomic reactivity (NCAR; n=30). Results The final analysis included 53 patients. No significant difference was observed between the two groups regarding type of surgery, use of minimally invasive techniques or epidural catheter, duration of surgery and anesthesia, or the amount of fluid administered intraoperatively. The NCAR group had significantly greater intraoperative blood loss than the CAR group (541.7±541.9 mL vs 269.6±174.3 mL, p<0.05). In the NCAR group, vasoactive drugs were used during anesthesia more frequently (n=21 vs n=4; p<0.001), and more patients had at least one postoperative complication compared to the CAR group (n=19 vs n=4; p<0.01). Furthermore, the NCAR group had more serious complications (Clavien–Dindo ≥ Grade III n=6 vs n=0; p<0.05) and a greater number of complications than the CAR group (n=57 vs n=5; p<0.001). Significant differences were found for two specific subgroups of complications: hypotension requiring vasoactive drugs (NCAR: n=10 vs CAR: n=0; p<0.01) and ileus (NCAR: n=11 vs CAR: n=2; p<0.05). Moreover, significant differences were found in the ICU-LOS (NCAR: 5.7±3.5 days vs CAR: 2.6±0.7 days; p<0.0001) and H-LOS (NCAR: 12.2±5.6 days vs CAR: 7.2±1.7 days; p<0.0001). Conclusion Preoperative HRV assessment during orthostatic load is objective and useful for identifying patients with low autonomic physiological reserves and high risk of poor post-operative course.
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Affiliation(s)
- Petr Reimer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Jan Máca
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Pavel Szturz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Ondřej Jor
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Roman Kula
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Pavel Ševčík
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava
| | - Michal Burda
- Institute for Research and Applications of Fuzzy Modeling, Centre of Excellence IT4Innovations, University of Ostrava, Ostrava
| | - Milan Adamus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Olomouc, Olomouc, Czech Republic
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