Association of increased postoperative opioid administration with non-small-cell lung cancer recurrence: a retrospective analysis

Recurrence-free survival after curative resection of non-small cell lung cancer between inhalational gas anesthesia and propofol-based total intravenous anesthesia: a multicenter, randomized, clinical trial (GAS TIVA trial): protocol description

BACKGROUND

Surgery is the primary treatment for non-small cell lung cancer (NSCLC), but microscopic residual disease may be unavoidable. Preclinical studies have shown that volatile anesthetics might suppress host immunity and promote a pro-malignant environment that supports cancer cell proliferation, migration, and angiogenesis, whereas propofol may preserve cell-mediated immunity and inhibit tumor angiogenesis. However, clinical evidence that propofol-based total intravenous anesthesia (TIVA) can reduce tumor recurrence after curative resection remains inconsistent due to the retrospective observational nature of previous studies. Therefore, we will test the hypothesis that the recurrence-free survival (RFS) after curative resection of NSCLC is higher in patients who received TIVA than volatile anesthetics (GAS) in this multicenter randomized trial.

METHODS

This double-blind, randomized trial will enroll patients at 22 international sites, subject to study registration, institutional review board approval, and patient written informed consent. Eligible patients are adult patients undergoing lung resection surgery with curative intent for NSCLC. Exclusion criteria will be contraindications to study drugs, American Society of Anesthesiologists physical status IV or higher, or preexisting distant metastasis or malignant tumor in other organs. At each study site, enrolled subjects will be randomly allocated into the TIVA and GAS groups with a 1:1 ratio. This pragmatic trial does not standardize any aspect of patient care. However, potential confounders will be balanced between the study arms. The primary outcome will be RFS. Secondary outcomes will be overall survival and complications within postoperative 7 days. Enrollment of 5384 patients will provide 80% power to detect a 3% treatment effect (hazard ratio of 0.83) at alpha 0.05 for RFS at 3 years.

DISCUSSION

Confirmation of the study hypothesis would demonstrate that a relatively minor and low-cost alteration in anesthetic management has the potential to reduce cancer recurrence risk in NSCLC, an ultimately fatal complication. Rejection of the hypothesis would end the ongoing debate about the relationship between cancer recurrence and anesthetic management.

TRIAL REGISTRATION

The study protocol was prospectively registered at the Clinical trials ( https://clinicaltrials.gov , NCT06330038, principal investigator: Hyun Joo Ahn; date of first public release: March 25, 2024) before the recruitment of the first participant.

Diaphragm-sparing efficacy of subparaneural upper trunk block for arthroscopic shoulder surgery: A randomised controlled trial

BACKGROUND

Inter-scalene block (ISB) is associated with an inevitable risk of hemi-diaphragmatic paresis (HDP). To reduce the risk of HDP, an upper trunk block (UTB) has been proposed at the brachial plexus division level.

OBJECTIVE

We hypothesised that UTB would be associated with a lower incidence of HDP than ISB while providing sufficient analgesia following arthroscopic shoulder surgery.

DESIGN

Randomised controlled trial.

SETTING

A tertiary teaching hospital.

PATIENTS

Seventy patients aged 20 to 80 years undergoing arthroscopic rotator cuff repair.

INTERVENTION

Ultrasound-guided ISB or UTB was performed with 5 ml 0.75% ropivacaine.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of complete HDP, assessed by diaphragm excursion using ultrasound, defined as a decrease to 25% or less of baseline or occurrence of paradoxical movement. Postoperative pulmonary function change, pain scores, opioid consumption and pain-related outcomes were the secondary outcomes.

RESULTS

The UTB group had a significantly lower incidence of complete HDP than the ISB group [5.9% (2/34) vs. 41.7% (15/36); absolute difference, 35.8%; 95% confidence interval (CI), 17.8 to 53.7%; P < 0.001]. The postblockade decline in pulmonary function was more pronounced in the ISB group than that in the UTB group. The pain score at 1 h postoperatively was not significantly different between the groups (ISB vs. UTB group: median 0 vs. 1; median difference, -1; 95% CI, -2 to 0.5). No significant difference was observed in any other secondary outcomes.

CONCLUSION

UTB was associated with a lower incidence of HDP compared with ISB while providing excellent analgesia in arthroscopic shoulder surgery.

TRIAL REGISTRATION

Clinical Trial Registry of Korea (https://cris.nih.go.kr) identifier: KCT0007002.

IRB NUMBER

Chungnam National University Hospital Institutional Review Board No. 2021-12-069.

A novel investigation into the negative impact of opioid use on the efficacy of immune checkpoint inhibitors in advanced non-small cell lung cancer patients

OBJECTIVE

Immune checkpoint inhibitors (ICIs) have effectively improved the clinical outcome of advanced non-small cell lung cancer (NSCLC). Opioids are commonly used for pain relief in cancer patients. This study aims to clarify the prognostic impact of opioid use in advanced NSCLC patients receiving ICI therapy.

METHODS

A systematic literature review was carried out using online databases before July 2023. The meta-analysis was used to clarify the correlation of opioid use with the overall survival (OS) or progression-free survival (PFS) of ICI-treated NSCLC patients, both of which were determined using hazard ratios (HRs) coupled with 95 % confidence intervals (CIs). Then, an independent cohort enrolling 181 NSCLC patients was utilized for validation. Finally, a comprehensive bioinformatics analysis based on TCGA cohort was performed to investigate the prognostic significance of opioid target genes (OTGs) and their correlation with immune infiltration in NSCLC patients.

RESULTS

A total of 8 studies enrolling 1174 patients were included in the meta-analysis. Opioid use was negatively associated with worse PFS (HR = 2.16, 95 %CI: 1.26-3.71) and OS (HR = 2.02, 95 %CI: 1.54-2.63) in ICI-treated NSCLC patients. The retrospective validation confirmed the above result and identified opioid use as an independent unfavorable predictor for PFS and OS in both the entire cohort and ICI subgroup. The bioinformatic analysis identified 14 prognostic OTGs (CYP17A1, PDYN, PYCARD, FGA, NTSR1, FABP1, HPCA, PENK, PDGFB, LIN7A, FKBP5, TYMS, CACNA1H and LDHA), most of which were correlated with immune infiltration in NSCLC. A risk model was constructed based on 14 OTGs and found to effectively stratify the clinical outcome in both the training and validation set, independent of age, gender and TNM staging system. The model was also significantly correlated with infiltration of activated dendritic cells, neutrophils and tumor infiltrating lymphocytes. Finally, a nomogram was constructed based on the model, age, gender and TNM stage, which could predict well the 1-, 3- and 5-year survival of NSCLC patients.

CONCLUSION

Opioid use is correlated with the poor clinical outcome in ICI-treated NSCLC patients. Precise pain management is highly advocated and opioids are recommended to be cautiously used in these patients. OTGs have the potential to be prognostic biomarkers for NSCLC patients and their role in tumor immunity needs to be further investigated.

Pain management after thoracic surgery or chest trauma

Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management is to promote effective coughing and early mobilization to reduce atelectasis and ventilation disorders induced by pulmonary contusion. The incidence of chronic pain can affect more than 35% of patients after both thoracotomy and thoracoscopy as well as after chest trauma. As the severity of acute pain is associated with the incidence of chronic pain, early and effective pain management is very important. In this narrative review, we propose to detail systemic and regional analgesia techniques to minimize postoperative pain, while reducing transitional pain, surgical stress response and opioid side effects. We provide the reader with practical recommendations based on both literature and clinical practice experience in a referral level III thoracic trauma center.

Perioperative opioids and survival outcomes in resectable head and neck cancer: A systematic review

BACKGROUND

Opioids are a mainstay in pain control for oncologic surgery. The objective of this systematic review is to evaluate the associations of perioperative opioid use with overall survival (OS) and disease-free survival (DFS) in patients with resectable head and neck cancer (HNC).

METHODS

A systematic review of PubMed, SCOPUS, and CINAHL between 2000 and 2022 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies investigating perioperative opioid use for patients with HNC undergoing surgical resection and its association with OS and DFS were included.

RESULTS

Three thousand three hundred seventy-eight studies met initial inclusion criteria, and three studies representing 562 patients (intraoperative opioids, n = 463; postoperative opioids, n = 99) met final exclusion criteria. One study identified that high intraoperative opioid requirement in oral cancer surgery was associated with decreased OS (HR = 1.77, 95% CI 0.995-3.149) but was not an independent predictor of decreased DFS. Another study found that increased intraoperative opioid requirements in treating laryngeal cancer was demonstrated to have a weak but statistically significant inverse relationship with DFS (HR = 1.001, p = 0.02) and OS (HR = 1.001, p = 0.02). The last study identified that patients with chronic opioid after resection of oral cavity cancer had decreased DFS (HR = 2.7, 95% CI 1.1-6.6) compared to those who were not chronically using opioids postoperatively.

CONCLUSION

An association may exist between perioperative opioid use and OS and DFS in patients with resectable HNC. Additional investigation is required to further delineate this relationship and promote appropriate stewardship of opioid use with adjunctive nonopioid analgesic regimens.

Perioperative pain management in thoracic surgery: A survey of practices in Australia and New Zealand

There are few data on current trends in pain management for thoracic surgery in Australia and New Zealand. Several new regional analgesia techniques have been introduced for these operations in the past few years. Our survey aimed to assess current practice and perceptions towards various modalities of pain management for thoracic surgery among anaesthetists in Australia and New Zealand. A 22-question electronic survey was developed and distributed in 2020 with the assistance of the Australian and New Zealand College of Anaesthetists Cardiac Thoracic Vascular and Perfusion Special Interest Group. The survey focused on four key domains-demographics, general pain management, operative technique, and postoperative approach. Of the 696 invitations, 165 complete responses were obtained, for a response rate of 24%. Most respondents reported a trend away from the historical standard of thoracic epidural analgesia, with a preference towards non-neuraxial regional analgesia techniques. If representative of anaesthetists in Australia and New Zealand more widely, this trend may result in less exposure of junior anaesthetists to the insertion and management of thoracic epidurals, potentially resulting in reduced familiarity and confidence in the technique. Furthermore, it demonstrates a notable reliance on surgically or intraoperatively placed paravertebral catheters as the primary analgesic modality, and suggests the need for future studies assessing the optimal method of catheter insertion and perioperative management. It also gives some insight into the current opinion and practice of the respondents with regard to formalised enhanced recovery after surgery pathways, acute pain services, opioid-free anaesthesia, and current medication selection.

Impact of Opioids on Cellular Metabolism: Implications for Metabolic Pathways Involved in Cancer

Opioid utilization for pain management is prevalent among cancer patients. There is significant evidence describing the many effects of opioids on cancer development. Despite the pivotal role of metabolic reprogramming in facilitating cancer growth and metastasis, the specific impact of opioids on crucial oncogenic metabolic pathways remains inadequately investigated. This review provides an understanding of the current research on opioid-mediated changes to cellular metabolic pathways crucial for oncogenesis, including glycolysis, the tricarboxylic acid cycle, glutaminolysis, and oxidative phosphorylation (OXPHOS). The existing literature suggests that opioids affect energy production pathways via increasing intracellular glucose levels, increasing the production of lactic acid, and reducing ATP levels through impediment of OXPHOS. Opioids modulate pathways involved in redox balance which may allow cancer cells to overcome ROS-mediated apoptotic signaling. The majority of studies have been conducted in healthy tissue with a predominant focus on neuronal cells. To comprehensively understand the impact of opioids on metabolic pathways critical to cancer progression, research must extend beyond healthy tissue and encompass patient-derived cancer tissue, allowing for a better understanding in the context of the metabolic reprogramming already undergone by cancer cells. The current literature is limited by a lack of direct experimentation exploring opioid-induced changes to cancer metabolism as they relate to tumor growth and patient outcome.

No association of postoperative opioid usage with long-term surgery outcomes in patients with liver cancer: a population-based retrospective cohort study

ABSTRACT

Hepatocellular carcinoma (HCC) is a fatal cancer worldwide, and surgical resection remains the standard treatment. Postoperative opioid prescription has been believed to affect cancer recurrence through complex biological pathways. We conducted a retrospective cohort study using the Longitudinal Health Insurance Database of Taiwan to evaluate the relationship between postoperative opioid use and long-term surgical outcomes of patients with HCC. This study had a retrospective cohort design. In total, 812 patients older than 20 years who underwent hepatectomy because of HCC were included. The exposure group comprised patients who used opioids during hospitalization postoperatively. The comparison group included those who never used opioids during hospitalization postoperatively. A Cox proportional hazards model was used to evaluate the overall survival or recurrence-free survival rate between the opioid group and the nonopioid group. A total of 530 patients received opioids postoperatively and 282 patients did not. The hazard ratios of overall survival and recurrence-free survival were 1.10 (95% confidence interval [CI], 0.85-1.41) and 1.15 (95% CI, 0.91-1.46), respectively. Total postoperative opioids were converted into oral morphine milligram equivalents and then divided into 3 equal subgroups: low dose, <40 mg; medium dose, 40 to 144 mg; and high dose, ≥145 mg. The hazard ratios of overall survival were 0.88 (95% CI, 0.63-1.24) for the low-dose group, 1.27 (95% CI, 0.92-1.74) for the medium-dose group, and 1.14 (95% CI, 0.83-1.58) for the high-dose group. Postoperative opioids do not affect overall and recurrence-free survival in patients undergoing hepatectomy or liver transplantation because of HCC. Cancer recurrence should not be a clinical concern regarding postoperative opioid prescription.

Mu opioid receptor mRNA overexpression predicts poor prognosis among 18 common solid cancers: A pan-cancer analysis

Background

Opioids are widely used for patients with solid tumors during surgery and for cancer pain relief. We conducted a pan-cancer genomic analysis to investigate the prognostic features of Mu opioid receptor (MOR) mRNA expression across 18 primary solid cancers.

Methods

All the data of cancer with MOR mRNA were retrieved from cBioPortal for Cancer Genomics. Logistic regression was used to determine the associations between MOR mRNA expression and clinicopathological features. Log-rank test and Cox regression was used for survival analysis. Subgroup analysis and propensity score matching were also carried out.

Results

7,274 patients, including 1,112 patients with positive MOR mRNA expression, were included for data analyses. Positive MOR mRNA expression was associated with more advanced stage of T (adjusted Odds ratio [OR], 1.176; 95% confidence interval [CI], 1.022-1.354; P=0.024), M (adjusted OR, 1.548; 95% CI, 1.095-2.189; P=0.013) except N (adjusted OR, 1.145; 95% CI, 0.975-1.346; P=0.101), and worse prognosis for overall survival (Hazard ratio [HR] 1.347, 95% CI 1.200-1.512, P&lt;0.001), progression-free survival (HR 1.359, 95% CI 1.220-1.513, P&lt;0.001), disease-free survival (HR 1.269, 95% CI 1.016-1.585, P&lt;0.001) and disease-specific survival (HR 1.474, 95% CI 1.284-1.693, P&lt;0.001). Patients with positive MOR mRNA expression tended to be classified as tumor microenvironment immune types II, representing low PD-L1 and low CD8A expression.

Conclusion

MOR mRNA overexpression is associated with poor prognosis and poor response to PD-L1 therapy.

Effects of Erector Spinae Plane Block on Postoperative Pain and Quality of Recovery Questionnaire Scores in Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Study

OBJECTIVES

Opioid-free anesthesia with erector spinae plane block (ESPB) has the potential to decrease perioperative opioid need, thereby potentially reducing related complications. This study aimed to compare opioid-free anesthesia with ESPB and standard opioid-based balanced anesthesia in patients undergoing video-assisted thoracic surgery (VATS) in terms of postoperative opioid need (through patient control analgesia) as well as postoperative pain management, recovery quality, and opioid-related side effects.

METHODS

Seventy-four patients, ranging in age from 18 to 75 years, who underwent lobectomy with VATS were included in this randomized-controlled study. The opioid-free group had ESPB, and no opioid was used during anesthesia maintenance. The opioid group received standard anesthesia with opioid use. Postoperative morphine requirement, postoperative pain as measured by the visual analog scale (VAS), intraoperative vital parameters, recovery quality using the Quality of Recovery-40 (QoR-40) questionnaire, and opioid-related complications were compared between groups.

RESULTS

The opioid-free group received a significantly lower total dose of morphine during the first 24 postoperative hours through patient-controlled analgesia (PCA) when compared to the opioid group (7.3±3.4 vs. 21.7±7.9 mg, p<0.001). In addition, the opioid-free group had significantly better postoperative pain scores and QoR-40 scores (184.3±7.5 versus 171.2±6.4, p<0.001), shorter times to mobilization (5.5±0.8 versus 8.1±1.1 hours, p<0.001), and oral intake (5.8±0.6 versus 6.4±0.6 hours, p<0.001), as well as less frequent opioid-related side effects.

CONCLUSION

The findings of this study suggest that opioid-free anesthesia with ESPB represents a promising option for patients undergoing lobectomy with VATS. It has the potential to decrease postoperative opioid need, improve postoperative pain management, and reduce opioid-related unwanted consequences.

The Effect of Intraoperative Fentanyl Consumption on Prognosis of Colorectal Liver Metastasis treated by Simultaneous Resection: A Propensity Score Matching Analysis

Background: No previous studies have reported the effect of intraoperative opioid consumption in colorectal liver metastasis (CRLM).

Methods: Medical records of patients who received simultaneous resection of CRLM were retrospectively reviewed. Patients with epidural anesthesia, intraoperative morphine, or intraoperative oxycodone were excluded. Patients were separated into high- and low-dose groups by median intraoperative equianalgesic fentanyl dose. Short-term outcomes, progression-free surcical (PFS) and overall survival (OS) were compared between groups before and after 1:1 propensity score matching (PSM). Univariable and multivariable Cox regression analysis were performed to identify independent predictors of survival.

Results: The final study population included 343 patients. Patients were separated into the low dose group (n=172) and the high dose group (n=171) by median intraoperative equianalgesic fentanyl dose (8.33 μg/kg). After PSM, 55 patients in the low dose group were matched to 55 patients in the high dose group and the baseline characteristics of the two groups were balanced. The two groups had no statistically significance difference in severity and categories of postoperative complications before and after PSM. Before PSM, the two groups had similar PFS (median 10.2 vs. 12.4 months, P=0.54) and OS (median 59.0 vs. 58.3 months, P=0.76). Univariate and multivariate Cox regression analyses revealed no statistically significant association between intraoperative equianalgesic fentanyl and PFS (multivariate HR=0.852, 95% CI 0.655-1.11, P=0.235) and OS (multivariate HR=1, 95% CI 0.68-1.49, P = 0.981). After PSM, the two groups also had similar PFS (median 9.2 vs. 10.7 months, P=0.98) and OS (median 51.0 vs. 46.0 months, P=0.39). Univariate and multivariate Cox regression analyses revealed no statistically significant association between intraoperative equianalgesic fentanyl and PFS (multivariate HR=1.05, 95% CI 0.632-1.73, P=0.861) and OS (multivariate HR=1.74, 95% CI 0.892-3.38, P = 0.105).

Conclusion: Intraoperative opioids consumption was not correlated with outcomes of CRLM patients treated with simultaneous resection.

Examining the interrelationships between mindfulness-based interventions, depression, inflammation, and cancer survival

Depression is highly prevalent in those diagnosed with cancer and is also associated with poorer prognostic outcomes. Mindfulness-based interventions are effective in reducing depressive symptoms and improving quality of life in patients with cancer. The objective of this review was to investigate whether mindfulness practices can improve survival and, if so, what mechanisms of action may contribute to these outcomes. Although no long-term studies have investigated this hypothesis, the current literature supports an inflammatory basis for depression, implicating proinflammatory cytokines and hypothalamic-pituitary-adrenal axis dysfunction as contributing factors. Markers of inflammation, such as interleukin-6, tumor necrosis factor-α, and cortisol, are all found at elevated concentrations in many depressed individuals. These exact mechanisms are associated with higher mortality in patients with cancer. Mindfulness has been studied for its effects on cytokine and cortisol levels, and there are promising data to support that the intervention can measurably decrease inflammation. Therefore, it is conceivable that mindfulness programs can affect survival in this population. There are limited data on the long-term effects of mindfulness on depression and inflammatory markers in patients with cancer, and there are potential barriers to the implementation of mindfulness-based interventions as part of a comprehensive treatment plan. Therefore, it is necessary to further explore these questions through longitudinal studies to establish a survival correlation. CA Cancer J Clin. 2022;72:490-502.

Perioperative Inflammatory Response and Cancer Recurrence in Lung Cancer Surgery: A Narrative Review

While surgical resection is the gold standard treatment for solid tumors, cancer recurrence after surgery is common. Immunosurveillance of remnant tumor cells is an important protective mechanism. Therefore, maintenance of anti-tumor cell activity and proper levels of inflammatory mediators is crucial. An increasing body of evidence suggests that surgery itself and perioperative interventions could affect these pathophysiological responses. Various factors, such as the extent of tissue injury, perioperative medications such as anesthetics and analgesics, and perioperative management including transfusions and methods of mechanical ventilation, modulate the inflammatory response in lung cancer surgery. This narrative review summarizes the pathophysiological mechanisms involved in cancer recurrence after surgery and perioperative management related to cancer recurrence after lung cancer surgery.

Intraoperative opioids are associated with decreased recurrence rates in colon adenocarcinoma: a retrospective observational cohort study

BACKGROUND

Opioid-induced immunomodulation may be important in colon adenocarcinoma, where tumour DNA mismatch repair (MMR) can determine the level of immune activation with consequences for therapeutic response and prognosis. We evaluated the relationship between intraoperative opioid exposure, MMR subtype, and oncological outcomes after surgery for colon adenocarcinoma.

METHODS

Intraoperative opioid use (standardised by calculating morphine milligram equivalents) during stage I-III colon adenocarcinoma resection was reviewed retrospectively. Tumours were classified as DNA mismatch repair deficient (dMMR) or proficient (pMMR) by immunohistochemistry. The primary outcome was local tumour recurrence, distant tumour recurrence, or both (multivariable analysis). The exposures of interest were intraoperative analgesia and tumour subtype. Opioid-related gene expression was analysed using The Cancer Genome Atlas Colon Adenocarcinoma transcriptomic data.

RESULTS

Clinical and pathological data were analysed from 1157 subjects (median age, 60 [51-70] yr; 49% female) who underwent curative resection for stage I-III colon adenocarcinoma. Higher intraoperative opioid doses were associated with reduced risk of tumour recurrence (hazard ratio=0.92 per 10 morphine milligram equivalents; 95% confidence interval [95% CI], 0.87-0.98; P=0.007), but not with overall survival. In tumours deficient in DNA MMR, tumour recurrence was less likely (HR=0.38; 95% CI, 0.21-0.68; P=0.001), with higher opioid dose associated with eightfold lower recurrence rates. Gene expression related to opioid signalling was different between dMMR and pMMR tumours.

CONCLUSIONS

Higher intraoperative opioid dose was associated with a lower risk of tumour recurrence after surgery for stage I-III colon adenocarcinoma, but particularly so in tumours in which DNA MMR was deficient.

Can Infusion of Lidocaine During Breast Cancer Surgery Promote Higher In-vitro Apoptosis in Comparison with Fentanyl?

Background: Although several numbers of the common anesthetic drugs are frequently used in breast cancer (BC) surgery, their possible effects on the behavior of cancer cells are still unknown. Objectives: The main objective of the present study was to examine the effect of administered lidocaine versus fentanyl during BC surgery on the apoptosis index of BC cells in-vitro. Methods: Patients with BC with the same grade of cancer and American Society of Anesthesiologists (ASA) score I–III, who underwent surgery were randomly divided into 2 groups of lidocaine and fentanyl infusion based on the analgesic drugs they received. Blood samples were drawn before and after the surgery and then cells from the BC cell line (MCF-7) were exposed to them at 24, 48, and 72 hours post-culture. Flow cytometry was performed to measure the mean percentage of apoptosis index; To investigate the cells’ viability, 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was also applied. Results: Sixty patients were enrolled. Quantitative cell death analysis revealed that the proportion of apoptotic cells in both lidocaine and fentanyl groups significantly increased when the cells were treated with post-operation sera compared to pre-operation sera exposure at various time intervals. In both groups, intra-group cell death analysis showed that there was not any statistically significant difference among the cultured cells exposed to pre-operation sera at various interval times (P < 0.001) with respect to apoptosis and cell viability. Conclusions: The study findings proposed that lidocaine infusion can reach the apoptosis index of BC cells in-vitro, as much as that fentanyl did; and both drugs had significant effects.

Agonists Specific for κ-Opioid Receptor Induces Apoptosis of HCC Cells Through Enhanced Endoplasmic Reticulum Stress

Cancer pain is an important factor affecting life quality of patients especially in the advanced stage and relieving pain is one of fundamental strategies for cancer treatment. Opioids such as morphine are the most widely used in clinics. However, they have been reported to be associated with the occurrence and development of several types of cancer. Thus, search for an opioid that has analgesic effect and can retard cancer progress simultaneously is critical for cancer management. In this study, we first examined the expression of μ and κ (MOR and KOR) in cell lines and tumor tissues of hepatocellular carcinoma (HCC), a malignant tumor with high mortality, and then compared the effects of opioid receptors-specific agonists on malignant phenotypes of HCC cells in vitro and tumor growth in an HCC xenograft mouse model. KOR and MOR were found to be highly expressed in HCC cell lines and HCC tissues. The KOR-specific agonist U50488h, oxycodone (agonist for both KOR and MOR) and the MOR-specific agonist morphine inhibited HCC cell proliferation, while only U50488h and oxycodone suppressed colony formation and migration of HCC cells. U50488h and oxycodone, but not morphine, induced HCC apoptosis. Further detection of PERK, GRP78 and CHOP revealed that PERK signaling was upregulated by treatment with U50488h, while treatment with the PERK inhibitor GSK2656157 partially reversed the promotion of apoptosis and inhibition of cell proliferation by U50488h, indicating that endoplasmic reticulum stress is associated with its suppressing effect on HCC malignant phenotypes. Similar to the in vitro results, HCC growth was significantly reduced by administration of U50488h and oxycodone, but not by morphine, in the HCC xenograft mouse model. PERK and caspase-3 in the HCC tissues were up-regulated by U50488h treatment as detected by immunohistochemistry and western blotting. Taken together, our results revealed that activation of KOR by U50488h inhibited malignant phenotypes of HCC both in vitro and in vivo, while activation of MOR by morphine did not have such effect. Because of their dual roles in the relief of pain and in the suppression of malignant phenotypes, opioids such as U50488h that act on KOR should be considered as the first choice for HCC management.

Effects of Anesthesia and Anesthetic Techniques on Metastasis of Lung Cancers: A Narrative Review

Purpose

Tumor recurrence and metastasis are essential for the mortality and morbidity of cancer. Surgical resection of solid tumors is the conventional treatment approach for malignant tumors. However, even after undergoing radical surgery, certain patients develop local or distant metastasis, which may contribute to treatment failure. Anesthesia and anesthetic techniques are widely used in the perioperative period. Emerging evidence indicates that anesthetics influence tumor recurrence and metastasis. Therefore, the current review summarizes the effects of anesthesia and anesthetic techniques on tumor recurrence and lung metastasis.

Methods

Relevant literature was retrieved from the following databases: Medline/PubMed, CNKI and Wanfang. A total of 109 articles were selected and analyzed in this research.

Results

(1) A variety of intravenous anesthetics may affect metastasis or tumor growth, though the evidence is contradictory and inconsistent, and the clinical data are still inconclusive. (2) Volatile anesthetics have proinflammatory effects and may have direct and indirect effects on the survival of cancer cells. (3) Although the relevant clinical data are limited, there is strong evidence in vitro that local anesthetics have a protective effect on cancer recurrence. (4) No mode of anesthesia has been determined to be beneficial to patients with cancer, but clinical studies are currently recommended for anesthesia modality and composite use.

Conclusion

Available data suggest that anesthesia and anesthetic techniques might play an important role in tumor progression and lung metastasis, the understanding of which will help in designing more effective management of the tumor and attaining fewer side effects.

Morphine promotes the malignant biological behavior of non-small cell lung cancer cells through the MOR/Src/mTOR pathway

BACKGROUND

Morphine, a µ-opioid receptor (MOR) agonist, has been shown to be related to the activity of cancer cells, and a higher morphine dosage reduces the survival time of patients with lung cancer. However, the effect of morphine on the malignant behavior of lung cancer cells remains unclear. The aim of this study was to investigate the specific molecular mechanism by which morphine regulates the malignant biological behavior of non-small cell lung cancer.

METHODS

Immunofluorescence staining and Western blot analyses were performed to detect MOR expression. H460 non-small cell lung cancer cells were used in this study, and cell proliferation, the cell cycle and apoptosis were evaluated using Cell Counting Kit-8 (CCK-8) and flow cytometry assays, respectively. Cell migration and invasion were detected using wound healing and Transwell assays. The effect of morphine on lung cancer development in vivo was examined by performing a xenograft tumor assay following morphine treatment.

RESULTS

Morphine promoted the growth of H460 cells both in vivo and in vitro. Morphine enhanced cell migration and invasion, modified cell cycle progression through the S/G₂ transition and exerted an antiapoptotic effect on H460 cells. Additionally, morphine increased Rous sarcoma oncogene cellular homolog (Src) phosphorylation and activated the phosphoinositide 3 kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway. Treatment with the MOR antagonist methylnaltrexone (MNTX) and the Src inhibitor protein phosphatase 1 (PP1) reduced the phosphorylation induced by morphine. Furthermore, MNTX, PP1, and the PI3K/AKT inhibitor deguelin reversed the antiapoptotic effect of morphine on lung cancer cells.

CONCLUSION

Morphine promotes the malignant biological behavior of H460 cells by activating the MOR and Src/mTOR signaling pathways.

Opioid-free anesthesia compared to opioid anesthesia for lung cancer patients undergoing video-assisted thoracoscopic surgery: A randomized controlled study

BACKGROUND

Reducing intra-operative opioid consumption benefits patients by decreasing postoperative opioid-related adverse events. We assessed whether opioid-free anesthesia would provide effective analgesia-antinociception monitored by analgesia index in video-assisted thoracoscopic surgery.

METHODS

Patients (ASA Ⅰ-Ⅱ, 18-65 years old, BMI <30 kg m-2) scheduled to undergo video-assisted thoracoscopic surgery under general anesthesia were randomly allocated into two groups to receive opioid-free anesthesia (group OFA) with dexmedetomidine, sevoflurane plus thoracic paravertebral blockade or opioid-based anesthesia (group OA) with remifentanil, sevoflurane, and thoracic paravertebral blockade. The primary outcome variable was pain intensity during the operation, assessed by the depth of analgesia using the pain threshold index with the multifunction combination monitor HXD‑I. Secondary outcomes included depth of sedation monitoring by wavelet index and blood glucose concentration achieved from blood gas.

RESULTS

One hundred patients were randomized; 3 patients were excluded due to discontinued intervention and 97 included in the final analysis. Intraoperative pain threshold index readings were not significantly different between group OFA and group OA from arriving operation room to extubation (P = 0.86), while the brain wavelet index readings in group OFA were notably lower than those in group OA from before general anesthesia induction to recovery of double lungs ventilation (P <0.001). After beginning of operation, the blood glucose levels in group OFA increased compared with baseline blood glucose values (P < 0.001). The recovery time and extubation time in group OFA were significantly longer than those in group OA (P <0.007).

CONCLUSIONS

This study suggested that our OFA regimen achieved equally effective intraoperative pain threshold index compared to OA in video-assisted thoracoscopic surgery. Depth of sedation was significantly deeper and blood glucose levels were higher with OFA. Study's limitations and strict inclusion criteria may limit the external validity of the study, suggesting the need of further randomized trials on the topic. Trial registration: ChiCTR1800019479, Title: "Opioid-free anesthesia in video-assisted thoracoscopic surgery lobectomy".

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Opioid-Sparing Multimodal Analgesia Protocol for Lumpectomy Patients Results in Superior Postoperative Pain Control

Background

We sought to determine if lumpectomy patients who received perioperative opioid-sparing multimodal analgesia reported less pain when compared with those who received traditional opioid-based care.

Study Design

A prospective cohort of patients undergoing lumpectomy who received an opioid-sparing multimodal analgesia protocol [no opioids group (NOP)] was compared with a large cohort of patients who received traditional care [opioids group (OG)]. In-hospital and discharge opioids were compared using oral morphine equivalents (OMEs). Postoperative day one and week one pain scores were compared using the Kruskal–Wallis test.

Results

Overall, 1153 patients underwent lumpectomy: 634 patients received the protocol (NOP), and 519 patients did not (OG). Median pain scores were significantly lower in the NOP cohort when compared with the OG cohort the day after surgery (2 vs. 0, p < 0.001) and the week after surgery (1 vs. 0, p < 0.001). NOP patients were significantly less likely to report severe pain (7–10 on a 10-point scale) the day after surgery compared with OG patients (15.7% vs. 6.9%, p = 0.004). Patients in the NOP cohort were discharged with a median of zero OMEs (range 0–150), while patients in the OG were discharged with a median of 90 OMEs (range 0–360; p < 0.001).

Conclusion

Implementation of an opioid-sparing multimodal analgesia protocol for lumpectomy patients resulted in superior pain control without a routine opioid prescription. Surgeons can improve their own patients’ outcomes while addressing the larger societal issue of the opioid crisis by adopting similar protocols that decrease the quantity of opioids available for diversion.

Current Understanding on Perioperative Management in Lung Cancer: Implications for Anesthetic Considerations

Narcotic drugs are often used to treat perioperative pain for patients with lung cancer. However, anesthetic management and narcotic substance use may have significant impacts on patients with lung cancer, including anti-cancer or promoting cancer effects. In this study, we summarize the effects of anesthetic management and its related substances on lung cancer. An evidence-based review of the influence of anesthetic techniques and narcotic substances used on lung cancer was performed. The effects of perioperative pain management and the method of choosing anesthesia for patients with lung cancer were explored. Different management techniques of anesthesia have been indicated to suppress both cell-mediated immunity and humoral immunity and have effects on the recurrence and metastasis of lung cancer. Evidence suggests that the effects of narcotic substances used on lung cancer were still inconsistent. However, the mechanisms by which anesthetics and analgesics inhibit the tumor are complicated. Perioperative management leads to decreased immunity in patients with lung cancer, which to some extent contributes to recurrence and metastasis. Various narcotic substances used may modulate signal pathways, including the mitochondrial pathway, and appear to exert different effects on the recurrence and metastasis of lung cancer. The anesthesiologists should consider these effects on perioperative management with lung cancer.

Morphine-3-glucuronide upregulates PD-L1 expression via TLR4 and promotes the immune escape of non-small cell lung cancer

Objective

Patients with cancer pain are highly dependent on morphine analgesia, but studies have shown a negative correlation between morphine demand and patient outcomes. The long-term use of morphine may result in abnormally elevated serum morphine-3-glucuronide (M3G) levels. Hence, the effects of M3G on tumor progression are worth studying.

Methods

The effects of M3G on PD-L1 expressions in human non-small cell lung cancer (NSCLC) cell lines were first evaluated. Activation of TLR4 downstream pathways after M3G treatment was then determined by Western blot. The effects of M3G on human cytotoxic T lymphocytes (CTL) cytotoxicity and INF-γ release was also detected. Finally, the LLC murine lung adenocarcinoma cell line were used to establish a murine lung cancer model, and the effects of M3G on tumor growth and metastasis were determined.

Results

M3G promoted the expressions of PD-L1 in the A549 and H1299 cell lines in a TLR4-dependent manner (P < 0.05). M3G activated the PI3K and the NFκB signaling pathways, and this effect was antagonized by a TLR4 pathway inhibitor. A PI3K pathway inhibitor reversed the M3G-mediated PD-L1 upregulation. M3G inhibited the cytotoxicity of CTL on A549 cells and decreased the level of INF-γ. Repeated M3G intraperitoneal injections promoted LLC tumor growth and lung metastasis through the upregulation of tumor expressed PD-L1 and the reduction of CTL in the tumor microenvironment.

Conclusions

M3G specifically activated TLR4 in NSCLC cells and upregulated PD-L1 expression through the PI3K signaling pathway, thereby inhibiting CTL cytotoxicity and finally promoting tumor immune escape.

The association of prescription opioid use with incident cancer: A Surveillance, Epidemiology, and End Results-Medicare population-based case-control study

BACKGROUND

Cancer is the second leading cause of death globally, and researchers seek to identify modifiable risk factors Over the past several decades, there has been ongoing debate whether opioids are associated with cancer development, metastasis, or recurrence. Basic science, clinical, and observational studies have produced conflicting results. The authors examined the association between prescription opioids and incident cancers using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. A complex relation was observed between prescription opioids and incident cancer, and cancer site may be an important determinant.

METHODS

By using linked SEER cancer registry and Medicare claims from 2008 through 2013, a case-control study was conducted examining the relation between cancer onset and prior opioid exposure. Logistic regression was used to account for differences between cases and controls for 10 cancer sites.

RESULTS

Of the population studied (n = 348,319), 34% were prescribed opioids, 79.5% were white, 36.9% were dually eligible (for both Medicare and Medicaid), 13% lived in a rural area, 52.7% had ≥1 comorbidity, and 16% had a smoking-related diagnosis. Patients exposed to opioids had a lower odds ratio (OR) associated with breast cancer (adjusted OR, 0.96; 95% CI, 0.92-0.99) and colon cancer (adjusted OR, 0.90; 95% CI, 0.86-0.93) compared with controls. Higher ORs for kidney cancer, leukemia, liver cancer, lung cancer, and lymphoma, ranging from lung cancer (OR, 1.04; 95% CI, 1.01-1.07) to liver cancer (OR, 1.19; 95% CI, 1.08-1.31), were present in the exposed population.

CONCLUSIONS

The current results suggest that an association exists between prescription opioids and incident cancer and that cancer site may play an important role. These findings can direct future research on specific patient populations that may benefit or be harmed by prescription opioid exposure.

Age Is Associated With Pain Experience and Opioid Use After Head and Neck Free Flap Reconstruction

OBJECTIVES

To describe pain experience and opioid use after major head and neck reconstructive surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients undergoing major head and neck surgery with microvascular free tissue transfer (free flaps) at a tertiary academic center were included. Pain scores (0-10) and demographic and clinical data were ascertained from medical records. Discharge opioid prescriptions and refills obtained within 30 days were recorded. Patient characteristics were compared with pain scores using nonparametric rank-sum tests and with likelihood of refill using logistic regression models to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

The study population comprised 445 patients. Median age was 60 years (interquartile range 50-68). Most patients had cancer (N = 350, 78%). The majority of free flaps were fibula (N = 153, 34%) or radial forearm (N = 159, 36%). Older patients reported significantly lower pain scores, whereas patients with opioid tolerance, anxiety, current smokers, and those undergoing larger volume resections or boney free flaps reported significantly higher pain scores. One-quarter (N = 115, 26%) of patients obtained opioid refills. Patients aged ≥ 60 years had one-half the odds of obtaining a refill compared with patients aged < 60 years (adjusted odds ratio [aOR] = 0.52, 95% confidence interval [CI] = 0.33-0.84), whereas surgical defect volume ≥ 100 cm³ (aOR = 1.92, 95% CI = 1.21-3.07) and higher pain score (aOR = 1.19, 95% CI = 1.07-1.32 per 1 point increase) increased the odds of refill.

CONCLUSION

Continued opioid use after discharge is common among patients undergoing major head and neck reconstruction, particularly for younger patients and after more extensive surgery. Older patients reported lower pain intensity and were less likely to obtain opioid refills, highlighting the wisdom of judicious opioid use for this vulnerable population.

LEVEL OF EVIDENCE

IV Laryngoscope, 130: E469-E478, 2020.

Outcomes of Patients With Advanced Gastrointestinal Cancer in Relationship to Opioid Use: Findings From Eight Clinical Trials

BACKGROUND

This study assessed the patterns of opioid use among patients with advanced gastrointestinal cancers who were included in 8 clinical trials and evaluated the impact of opioid use on survival outcomes of included patients.

METHODS

Deidentified datasets from 8 clinical trials evaluating first-line systemic treatment of advanced gastrointestinal cancers were accessed from the Project Data Sphere platform (ClinicalTrial.gov identifiers: NCT01124786, NCT00844649, NCT00290966, NCT00678535, NCT00699374, NCT00272051, NCT00305188, and NCT00384176). These trials evaluated patients with pancreatic carcinoma, gastric carcinoma, hepatocellular carcinoma (HCC), and colorectal carcinoma. Multivariable logistic regression analysis was used to evaluate factors predicting the use of opioids. Kaplan-Meier survival estimates were used to compare survival outcomes in each disease entity among patients who did or did not receive opioid treatment. Multivariable Cox regression analysis was then used to further assess the impact of opioid use on survival outcomes in each disease entity.

RESULTS

A total of 3,441 participants were included in the current analysis. The following factors predicted a higher probability of opioid use within logistic regression analysis: younger age at diagnosis (odds ratio [OR], 0.990; 95% CI, 0.984-0.997; P=.004), nonwhite race (OR for white vs nonwhite, 0.749; 95% CI, 0.600-0.933; P=.010), higher ECOG score (OR for 1 vs 0, 1.751; 95% CI, 1.490-2.058; P<.001), and pancreatic primary site (OR for colorectal vs pancreatic, 0.241; 95% CI, 0.198-0.295; P<.001). Use of opioids was consistently associated with worse overall survival (OS) in Kaplan-Meier survival estimates of each disease entity (P=.008 for pancreatic cancer; P<.001 for gastric cancer, HCC, and colorectal cancer). In multivariable Cox regression analysis, opioid use was associated with worse OS among patients with pancreatic cancer (hazard ratio [HR], 1.245; 95% CI, 1.063-1.459; P=.007), gastric cancer (HR, 1.725; 95% CI, 1.403-2.122; P<.001), HCC (HR, 1.841; 95% CI, 1.480-2.290; P<.001), and colorectal cancer (HR, 1.651; 95% CI, 1.380-1.975; P<.001).

CONCLUSIONS

Study findings suggest that opioid use is consistently associated with worse OS among patients with different gastrointestinal cancers. Further studies are needed to understand the underlying mechanisms of this observation and its potential implications.

Postoperative administration of ketorolac averts morphine-induced angiogenesis and metastasis in triple-negative breast cancer

AIMS

Opioids (i.e. morphine) were found to induce triple negative breast cancer (TNBC) metastasis while nonsteroidal anti-inflammatory drugs (i.e. ketolorac) were associated with decreased metastasis in TNBC. These contradictory findings demand clarification on the effect of postoperative morphine and ketorolac on TNBC metastasis.

MATERIALS AND METHODS

TNBC xenograft mice were established using MDA-MB-231 cells. When tumors reached ~100 mm³, the primary tumor was resected. Mice were then randomly assigned to four groups (n = 14): (i) saline, (ii) morphine (10 mg kg^-1) (iii) morphine + ketorolac (10 mg kg^-1 of morphine and 20 mg kg^-1 of ketorolac) (iv) ketorolac (20 mg kg^-1); administrated for three consecutive days after resection. Three weeks after resection, the number of lung metastases was measured. Microvessel density, thrombospondin-1 (TSP-1) and c-Myc expression in recurrent tumors were determined. To elucidate the above phenomenon in vitro, MDA-MB-231 cells were treated according to the regiment above; with or without supplementation of an AKT inhibitor to determine the activation of PI3K/AKT/c-Myc pathway.

KEY FINDINGS

In mice, morphine promoted TNBC metastasis and angiogenesis, decreased TSP-1 expression and increased c-Myc expression, while co-administration of ketorolac significantly reversed the phenotypes above (p < .05). Mechanistically, morphine inhibited TSP-1 secretion by activating PI3K/AKT/c-Myc pathway (p < .05), while ketorolac promoted TSP-1 secretion (p < .05) by suppressing PI3K/AKT/c-Myc pathway.

SIGNIFICANCE

Our study indicated that morphine enhanced TNBC metastasis and angiogenesis while ketorolac suppressed this effect. Mechanistically, this may be related to the enhancement of TSP-1 synthesis after ketorolac administration which further de-activated PI3K/AKT/c-Myc pathway.

A randomised evaluation of intercostal block as an adjunct to epidural analgesia for post-thoracotomy pain

Background and Aims:

Post-thoracotomy pain can be severe and disabling. The aim of this study was to examine the efficacy of intercostal nerve block when used as adjunct to thoracic epidural analgesia in patients undergoing posterolateral thoracotomy.

Methods:

This was a parallel-group randomised patient and assessor-blinded study carried out at a tertiary-referral cancer center. We included 60 adult patients undergoing elective lung resection under general anaesthesia with thoracic epidural analgesia. In addition, the intervention arm received single-shot intercostal blocks with 10 ml of 0.25% bupivacaine at the level of and two levels above and below the thoracotomy. We assessed post-operative pain scores at 2 to 4 hours and 18 to 24 hours after surgery, peri-operative fentanyl requirement, percentage of patients who needed fentanyl PCA and maximum volume achieved on bedside spirometry 18 to 24 hours after surgery. Groups were compared using the unpaired t-test for continuous data and the chi square test for categorical data at a 5% level of significance.

Results:

2 to 4 hours post-operatively, mean pain scores at rest were 3.0 in both groups (difference 0.04, 95% CI -1.1 to + 1.1) and on coughing were 4.6 (ICB group) and 4.9 (C group) (difference 0.32, 95% CI -1.0 to + 1.6). There were no differences between the groups for any of the other outcomes.

Conclusion:

Addition of intercostal block to epidural analgesia does not confer any benefit in terms of post-operative pain, fentanyl requirements or volume achieved on spirometry.

Opioids and Cancer Mortality

OPINION STATEMENT

Opioids are the gold standard for the treatment of cancer-related pain. Preclinical studies have associated opioids with cancer progression and overall survival. In mice models, opioids have been shown to possess pro-tumor activity secondary to immunosuppression, migration of tumor cells, increased activity of vascular endothelial growth factor receptors, and angiogenesis leading to tumor progression. In contrast, opioids have also been associated with having antitumor activity by activation of apoptosis and phagocytosis. However, high-quality randomized controlled trials in humans that are focused on the association between opioids and survival in cancer patients are lacking, which underscores the importance of being cautious when interpreting the results of the preclinical studies. Cancer-related pain is complex and multifactorial and may worsen as the disease progresses leading to higher opioid utilization. Moreover, cancer pain by itself has been associated with poor survival. The survival in these advanced cancer patients taking opioids may be more likely to be associated with cancer progression and not the opioid use. Adequate treatment of cancer pain has the potential to improve quality of life and performance status, highlighting the importance of continuing to use opioids to manage pain efficiently. More research is clearly needed.

Suppression of Human Natural Killer Cells by Different Classes of Opioids

BACKGROUND

The use of regional and other opioid-sparing forms of anesthesia has been associated with a decrease in the recurrence of certain malignancies. Direct suppression of human natural killer cells by opioids has been postulated to explain this observation. However, the effect of different classes of opioids on suppression of natural killer cell cytotoxicity has not been systematically characterized.

METHODS

After confirming that freshly isolated natural killer cells from peripheral human blood express opioid receptors, cells were incubated with increasing concentrations of clinically used or receptor-specific opioid agonists. We also evaluated the effect of pretreatment with receptor-specific antagonists or naloxone. Treated natural killer cells were then coincubated with a carboxyfluorescein succinimidyl ester-labeled target tumor cell line, K562. Annexin V staining was used to compare the percent of tumor cell apoptosis in the presence of opioid-pretreated and untreated natural killer cells. Treated samples were compared to untreated samples using Kruskal-Wallis tests with a post hoc Dunn correction.

RESULTS

Morphine, methadone, buprenorphine, loperamide, [D-Ala2, N-MePhe4, Gly-ol]-enkephalin, and U-50488 significantly decreased natural killer cell cytotoxicity. When natural killer cells were pretreated with naloxone, cyprodime, and nor-binaltorphimine before exposure to morphine, there was no difference in natural killer cytotoxicity, compared to the amount observed by untreated natural killer cells. Fentanyl, O-desmethyltramadol, and [D-Pen2,D-Pen5] enkephalin did not change natural killer cell cytotoxicity compare to untreated natural killer cells.

CONCLUSIONS

Incubation of isolated natural killer cells with certain opioids causes a decrease in activity that is not observed after naloxone pretreatment. Suppression of natural killer cell cytotoxicity was observed with μ- and κ-receptor agonists but not δ-receptor agonists. These data suggest that the effect is mediated by μ- and κ-receptor agonism and that suppression is similar with many clinically used opioids.

Perioperative Management May Improve Long-term Survival in Patients After Lung Cancer Surgery: A Retrospective Cohort Study

BACKGROUND:

Surgical resection is the main treatment for patients with non–small-cell lung cancer (NSCLC), but patients’ long-term outcome is still challenging. The purpose of this study was to identify predictors of long-term survival in patients after lung cancer surgery.

METHODS:

Patients who underwent surgery for NSCLC from January 1, 2006, to December 31, 2009, were enrolled into this retrospective cohort study. The primary outcome was the survival length after surgery. Predictors of long-term survival were screened with the multivariable Cox proportional hazard model.

RESULTS:

Postoperative follow-up was completed in 588 patients with a median follow-up duration of 5.2 years (interquartile range, 2.0–6.8). Two hundred ninety-one patients (49.5%) survived at the end of follow-up with median survival duration of 64.3 months (interquartile range, 28.5–81.6). The overall survival rates were 90.8%, 70.0%, and 57.1% at the end of the first, third, and fifth year after surgery, respectively. Limited resection (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.08–1.98; P = .013) and large tumor size (HR, 1.29; 95% CI, 1.17–1.42; P < .001) were associated with short survival; whereas high body mass index grade (HR, 0.82; 95% CI, 0.69–0.97; P = .021), highly differentiated tumor (HR, 0.59; 95% CI, 0.37–0.93; P = .024), dissection of mediastinal lymph node during surgery (HR, 0.45; 95% CI, 0.30–0.67; P < .001), and perioperative use of dexamethasone (HR, 0.70; 95% CI, 0.54–0.90; P = .006) were associated with long survival. No association was found between perioperative use of flurbiprofen axetil and long survival (HR, 0.80; 95% CI, 0.62–1.03; P = .086). However, combined administration of dexamethasone and flurbiprofen axetil was associated with longer survival (compared to no use of both: adjusted HR, 0.57; 95% CI, 0.38–0.84; P = .005).

CONCLUSIONS:

Certain factors in particular perioperative dexamethasone and flurbiprofen axetil therapy may improve patients’ long-term survival after surgery for NSCLC. Given the small sample size, these findings should be interpreted with caution, and randomized clinical trials are needed for further clarification.

Influence of perioperative anaesthetic and analgesic interventions on oncological outcomes: a narrative review

Surgery is an important treatment modality for the majority of solid organ cancers. Unfortunately, cancer recurrence following surgery of curative intent is common, and typically results in refractory disease and patient death. Surgery and other perioperative interventions induce a biological state conducive to the survival and growth of residual cancer cells released from the primary tumour intraoperatively, which may influence the risk of a subsequent metastatic disease. Evidence is accumulating that anaesthetic and analgesic interventions could affect many of these pathophysiological processes, influencing risk of cancer recurrence in either a beneficial or detrimental way. Much of this evidence is from experimental in vitro and in vivo models, with clinical evidence largely limited to retrospective observational studies or post hoc analysis of RCTs originally designed to evaluate non-cancer outcomes. This narrative review summarises the current state of evidence regarding the potential effect of perioperative anaesthetic and analgesic interventions on cancer biology and clinical outcomes. Proving a causal link will require data from prospective RCTs with oncological outcomes as primary endpoints, a number of which will report in the coming years. Until then, there is insufficient evidence to recommend any particular anaesthetic or analgesic technique for patients undergoing tumour resection surgery on the basis that it might alter the risk of recurrence or metastasis.

Effects of epidural analgesia on cancer recurrence and long-term mortality in patients after non-small-cell lung cancer resection: a propensity score-matched study

OBJECTIVES

Previous studies showed reductions in recurrence and mortality rate of several cancer types in patients receiving perioperative epidural analgesia. This study aimed to investigate the effects of thoracic epidural analgesia on oncological outcomes after resection for lung cancer.

DESIGN

Retrospective study using propensity score matching methodology.

SETTING

Single medical centre in Taiwan.

PARTICIPANTS

Patients with stages I-III non-small-cell lung cancer undergoing primary tumour resection between January 2005 and December 2015 and had either epidural analgesia, placed preoperatively and used intra- and postoperatively, or intravenous analgesia were evaluated through May 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary endpoint was postoperative recurrence-free survival and secondary endpoint was overall survival.

RESULTS

The 3-year recurrence-free and overall survival rates were 69.8% (95% CI 67.4% to 72.2%) and 92.4% (95% CI 91% to 93.8%) in the epidural group and 67.4% (95% CI 62.3% to 72.5%) and 89.6% (95% CI 86.3% to 92.9%) in the non-epidural group, respectively. Multivariable Cox regression analysis before matching demonstrated no significant difference in recurrence or mortality between groups (adjusted HR: 0.93, 95% CI 0.76 to 1.14 for recurrence; 0.81, 95% CI 0.58 to 1.13 for mortality), similar to the results after matching (HR: 0.97, 95% CI 0.71 to 1.31; 0.94, 95% CI 0.57 to 1.54). Independent risk factors for both recurrence and mortality were male, higher pretreatment carcinoembryonic antigen level, advanced cancer stage, poor differentiation, lymphovascular invasion, microscopic necrosis and postoperative radiotherapy.

CONCLUSIONS

Thoracic epidural analgesia was not associated with better recurrence-free or overall survival in patients receiving surgical resection for stages I-III non-small-cell lung cancer.

A comparison of the incidence of supraventricular arrhythmias between thoracic paravertebral and intercostal nerve blocks in patients undergoing thoracoscopic surgery: A randomised trial

BACKGROUND

Postoperative supraventricular arrhythmias are common in patients after thoracoscopic lobectomy. Inadequate pain control has long been recognised as a significant risk factor for arrhythmias. The performance of ultrasound-guided (USG) thoracic paravertebral block (PVB) is increasing as an ideal technique for postoperative analgesia.

OBJECTIVE

We conducted this study to evaluate whether a single-shot USG thoracic PVB would result in fewer postoperative supraventricular tachycardias (SVT) than intercostal nerve blocks (ICNBs) after thoracoscopic pulmonary resection.

DESIGN

A randomised controlled study.

SETTING

A single university hospital.

PATIENTS

Sixty-eight patients undergoing thoracoscopic lobectomy were randomised into two equal groups of 34.

INTERVENTIONS

For postoperative pain control, all patients received a total of 0.3 ml kg of a mixture containing 0.5% ropivacaine and 1/200 000 epinephrine after placement of needles for either a single thoracic PVB or two individual ICNBs, both guided by ultrasound. Data were obtained during the first 48 postoperative hours.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of SVT after thoracoscopic pulmonary resection.

RESULTS

During the first 48 postoperative hours, the incidences of SVT and atrial fibrillation were lower in the USG thoracic PVB group (14.7 vs. 46.9%, P = 0.004 and 3.0 vs. 18.8%, P = 0.037, respectively). The requirement for β-receptor blockade was more frequent in the ICNBs group than in the PVB group (5.9 vs. 25%, P = 0.033).

CONCLUSION

After placement of the needle using ultrasound guidance, a single-shot thoracic PVB is a well tolerated and effective technique to reduce the incidences of postoperative SVT and atrial fibrillation in patients undergoing thoracoscopic pulmonary resection.

TRIAL REGISTRATION

http://www.chictr.org/cn/, registration number: ChiCTR-IOR-17010952.

Does postoperative morphine consumption for acute surgical pain impact oncologic outcomes after colorectal cancer resection?: A retrospective cohort study

Whether morphine used in human cancer surgery would exert tumor-promoting effects is unclear. This study aimed to investigate the effects of morphine dose on cancer prognosis after colorectal cancer (CRC) resection.In a retrospective study, 1248 patients with stage I through IV CRC undergoing primary tumor resections and using intravenous patient-controlled analgesia for acute surgical pain at a tertiary center between October 2005 and December 2014 were evaluated through August 2016. Progression-free survival (PFS) and overall survival (OS) were analyzed using proportional hazards regression models.Multivariable analysis demonstrated no dose-dependent association between the amount of morphine dose and PFS (adjusted hazard ratio, HR = 1.31, 95% confidence interval, CI = 0.85-2.03) or OS (adjusted HR = 0.86, 95% CI = 0.47-1.55). Patients were further classified into the high-dose and low-dose groups by the median of morphine consumption (49.7 mg), and the morphine doses were mean 75.5 ± standard deviation 28.8 mg and 30.1 ± 12.4 mg in high-dose and low-dose groups, respectively. Multivariable models showed no significant difference in PFS or OS between groups, either (adjusted HR = 1.24, 95% CI = 0.97-1.58 for PFS; adjusted HR = 1.01, 95% CI = 0.71-1.43 for OS).Our results did not support a definite association between postoperative morphine consumption and cancer progression or all-cause mortality in patients following CRC resection.

Nociceptin Receptor Is Overexpressed in Non-small Cell Lung Cancer and Predicts Poor Prognosis

Classic opioid receptors, mu (μ), delta (δ), and kappa (κ), have been reported to be expressed in non-small cell lung cancer (NSCLC) cell lines and tumor tissues and to play a role in tumor prognosis. However, the expression and role of the non-classic opioid receptor, nociceptin receptor (NOP) in cancer are unclear. Our hypothesis was that NOP was also highly expressed in NSCLC tumor tissues and this could be correlated with patients' prognostic characters. Expression of NOP was examined in archived cancer tissues from 129 enrolled NSCLC patients by immunohistochemistry and was further analyzed with the patients' outcomes. NOP expression in NSCLC cell lines was also detected. The dataset from Kaplan-Meier Plotter was used to explore the correlation between the levels of NOP mRNA in cancerous tissue and the prognosis of NSCLC patients. Cell functional assays were performed to detect the effect of NOP activation on tumor aggressive furthers. Results showed NOP expression was highly expressed in cancer tissues and human cancer cell lines. NOP expression was not associated with patients' opioid requirement but closely with some clinicopathological indicators which reflected the malignancy. Moreover, NOP staining level was the independent poor prognostic factor for NSCLC patients receiving lobectomy, which was further verified by determining the mRNA expression levels through the online dataset. In vitro experiments revealed that NOP activation promotes the proliferation and invasion of A549 cells via PI3K/Akt signaling pathway. We conclude that NOP is overexpressed in NSCLC and is inversely correlated with patient's postoperative survival.

Network Pharmacology-Based identification of pharmacological mechanism of SQFZ injection in combination with Docetaxel on lung cancer

Docetaxel is the widely-used first-line therapy to treat lung cancer around the world. However, tumor progression and severe side effect occurred in some patients with docetaxel treatment. Most of the side effects were caused by immunocompromise, which limits the long-term use of docetaxel. Shenqi Fuzheng (SQFZ) injection has been used as adjuvant therapy to treat lung cancer which may enhance immunity as well. Owing to the complexity of drug combination, the mechanism of SQFZ injection in combination with docetaxel on lung cancer remains unclear. Therefore, a network pharmacology-based strategy was proposed in this study to help solve this problem. Network pharmacology approach comprising multiple components, candidate targets of component and therapeutic targets, has been used in this study. Also, in vivo and in vitro experiment was applied to verify the predicted targets from network pharmacology We established mouse lung cancer model and inject with docetaxel and SQFZ injection. Tumour weight, spleen index, thymus index, immunohistochemical staining and ELISA were conducted to evaluate the effect and underlying mechanisms of docetaxel and SQFZ injection. Besides A549 cells were also administrated by docetaxel and SQFZ.The indexes BCL2, CASP3 and CASP9 were determined after administration. The results indicated that combination of SQFZ and docetaxel could reduce tumour weight, enhance the spleen index, thymus index. Meanwhile, it could improve the activity of caspase-3 and IL-2 in mice and caspase-3, caspase-9 in A549 cell and inhibit the activity of BCL-2 in A549 cell, which verified the potential protective targets predicted by network pharmacology. In conclusion, combination of SQFZ and docetaxel could increase the curative effect by inducing tumour to apoptosis and play a key role on immunoprotection to reduce side effects.

Regional anesthesia and analgesia in cancer care: is it time to break the bad news?

PURPOSE OF REVIEW

There is ongoing controversy regarding the tumor-protective effects of regional anesthesia in patients undergoing cancer surgery. Evidence of up-to-date systematic reviews will be presented alongside recent updates on the effects of opioids and local anesthetics.

RECENT FINDINGS

In recent years, the literature regarding the effects of regional anesthesia techniques on cancer recurrence has raised many unanswered questions. Ongoing randomized controlled trials may not be able to shed light on the controversial discussion regarding the tumor protective effects of regional anesthesia because the expected effect size and event rate in those studies may be overstated.Recent more refined animal data, provides no evidence to suggest that opioids promote cancer recurrence or facilitate the development of metastatic disease.In addition, local anesthetics have promising preclinical anticarcinogenic effects that extend beyond their voltage-gated sodium channel blocking properties and could be of therapeutic value.

SUMMARY

Cancer recurrence in patients undergoing surgery remains a global burden. Current evidence suggests that regional techniques, opioid analgesia and local anesthetics in onco-anesthesia may require a tailored individual approach due to the phenotypic and genotypic heterogeneity within and between different tumors. The authors surmise that future or ongoing randomized controlled trials regarding regional anesthesia techniques and cancer outcome may not be able to reproduce clear results, as it will be challenging to prove the efficacy of one single intervention (e.g. regional anesthesia) in an otherwise complex multifactorial perioperative oncological setting.

Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery

Background

Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting.

Methods

Providers from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians.

Results

A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p < 0.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with > 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002).

Conclusions

While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

Effect of preoperative gabapentin and acetaminophen on opioid consumption in video-assisted thoracoscopic surgery: a retrospective study

Background

Patients undergoing video-assisted thoracoscopic surgery (VATS) are particularly vulnerable to opioid-induced sedation and hypoventilation. Accordingly, reducing opioid consumption in these patients is a primary goal of multimodal analgesic regimens. Although administration of preoperative gabapentin and acetaminophen has been shown to decrease postoperative opioid consumption in other surgeries, this approach has not been studied in VATS lobectomy. Our objective was to examine the impact of the addition of preoperative gabapentin and acetaminophen to a VATS lobectomy multimodal analgesic plan on postoperative opioid consumption, nausea/vomiting, and sedation.

Methods

With IRB approval, we performed a retrospective chart review of patients who underwent VATS lobectomy at a single center between 2015 and 2016 to identify those that received preoperative gabapentin and acetaminophen and those that received neither. Opioid consumption in the first 24 hours postoperatively was converted to oral morphine equivalents (OMEQs). Postoperative sedation was evaluated using Aldrete scores and the percentage of patients requiring antiemetics in the first 24 hours was also examined.

Results

There were 133 patients who were opioid naive: 31 received preoperative gabapentin and acetaminophen and 102 received neither. Median 24 hour postoperative opioid consumption was lower but not statistically significant in the gabapentin and acetaminophen group vs. neither (36 mg vs. 45 mg, p = 0.08). Notably, there was a change in the distribution of opioid consumption, with no patients in the gabapentin and acetaminophen group requiring more than 200 mg OMEQ in the first 24 hours postoperatively. No significant difference in postoperative nausea/vomiting or sedation was observed.

Conclusions

The addition of preoperative gabapentin and acetaminophen to a VATS lobectomy multimodal analgesic regimen reduces the incidence of high dose postoperative opioid consumption without observed negative side effects.