Anesthesia in patients with cancer disorders

Perioperative Ketamine and Cancer Recurrence: A Comprehensive Review

Cancer is a significant global health threat and a leading cause of death worldwide. Effective early-stage interventions, particularly surgery, can potentially cure many solid tumors. However, the risk of postoperative cancer recurrence remains high. Recent research highlights the influence of perioperative anesthetic and analgesic choices on the fate of residual cancer cells, potentially affecting recurrence risks. Among these agents, ketamine-a well-known anesthetic and analgesic-has garnered interest due to its antitumor properties, mainly through inhibiting the N-methyl-D-aspartate (NMDA) receptor found in various cancer tissues. Additionally, ketamine's potential immunomodulatory effects, given the expression of NMDA receptors on immune cells, suggest that it plays a significant role during the perioperative period. This review synthesizes current evidence on ketamine's impact on cancer cell biology, inflammation, immune modulation, and the role of the gut microbiota, proposing ketamine as a promising agent for enhancing oncological outcomes.

Effects of propofol intravenous general anesthesia and inhalational anesthesia on T-lymphocyte activity after breast cancer surgery: A meta-analysis

Background

Breast cancer is one of the most common cancers in women. General anesthesia is a commonly used anesthesia method for breast cancer surgery, and studies have confirmed that general anesthesia can induce immunosuppression in breast cancer patients and increase the metastasis rate of tumors. However, the difference between the effects of intravenous general anesthesia and inhalation anesthesia on the function of T-lymphocytes is still controversial, and it is necessary to explore reasonable anesthesia methods to reduce immunosuppression caused by surgery and anesthesia.

Materials and Methods

Databases (Embase, PubMed, Cochrane Library, CBM, CNKI, and Wanfang) were searched (up to October 2022) for randomized controlled trials (RCTs) comparing intraoperative inhalation anesthesia and propofol intravenous anesthesia in breast cancer patients, with the outcome of T-lymphocyte subsets. The meta-analysis was performed by STATA 14.0.

Results

Six RCTs with 352 patients were included in the study. Compared with inhalation anesthesia, there was no difference in T-lymphocyte subsets between the two groups immediately after surgery, but the activities of CD4+ T cells in patients with propofol anesthesia were higher (standard mean difference [SMD] = 0.234, 95% confidence interval [CI]: 0.003-0.466, P = 0.047, I2 = 44.1%) than those under inhalation anesthesia 1 day after surgery, and CD4+/CD8+ activities in patients with propofol anesthesia were higher (SMD = 304, 95% CI: 0.072-0.537, P = 0.010, I2 = 48.0%) than those under inhalation anesthesia 1 day after surgery.

Conclusion

There were no differences in the effects of propofol and inhalation anesthetics on T-lymphocytes immediately after surgery, but the inhibitory effects of inhalation anesthetics on CD4+ and CD4+/CD8+ cells were stronger 1 day after surgery.

Anaesthesia in Veterinary Oncology: The Effects of Surgery, Volatile and Intravenous Anaesthetics on the Immune System and Tumour Spread

Throughout the course of oncological disease, the majority of patients require surgical, anaesthetic and analgesic intervention. However, during the perioperative period, anaesthetic agents and techniques, surgical tissue trauma, adjuvant drugs for local pain and inflammation and other non-pharmacological factors, such as blood transfusions, hydration, temperature and nutrition, may influence the prognosis of the disease. These factors significantly impact the oncologic patient's immune response, which is the primary barrier to tumour progress, promoting a window of vulnerability for its dissemination and recurrence. More research is required to ascertain which anaesthetics and techniques have immunoprotective and anti-tumour effects, which will contribute to developing novel anaesthetic strategies in veterinary medicine.

Tumor Necrosis Factor Alpha: Implications of Anesthesia on Cancers

Cancer remains a major public health issue and a leading cause of death worldwide. Despite advancements in chemotherapy, radiation therapy, and immunotherapy, surgery is the mainstay of cancer treatment for solid tumors. However, tumor cells are known to disseminate into the vascular and lymphatic systems during surgical manipulation. Additionally, surgery-induced stress responses can produce an immunosuppressive environment that is favorable for cancer relapse. Up to 90% of cancer-related deaths are the result of metastatic disease after surgical resection. Emerging evidence shows that the interactions between tumor cells and the tumor microenvironment (TME) not only play decisive roles in tumor initiation, progression, and metastasis but also have profound effects on therapeutic efficacy. Tumor necrosis factor alpha (TNF-α), a pleiotropic cytokine contributing to both physiological and pathological processes, is one of the main mediators of inflammation-associated carcinogenesis in the TME. Because TNF-α signaling may modulate the course of cancer, it can be therapeutically targeted to ameliorate clinical outcomes. As the incidence of cancer continues to grow, approximately 80% of cancer patients require anesthesia during cancer care for diagnostic, therapeutic, or palliative procedures, and over 60% of cancer patients receive anesthesia for primary surgical resection. Numerous studies have demonstrated that perioperative management, including surgical manipulation, anesthetics/analgesics, and other supportive care, may alter the TME and cancer progression by affecting inflammatory or immune responses during cancer surgery, but the literature about the impact of anesthesia on the TNF-α production and cancer progression is limited. Therefore, this review summarizes the current knowledge of the implications of anesthesia on cancers from the insights of TNF-α release and provides future anesthetic strategies for improving oncological survival.

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

PURPOSEOF REVIEW

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

RECENT FINDINGS

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

Bile duct anastomosis does not promote bacterial contamination of autologous blood salvaged during living donor liver transplantation

Bile duct surgeries are conventionally considered to promote bacterial contamination of the surgical field. However, liver transplantation recipients' bile produced by the newly implanted liver graft from healthy living donors may be sterile. We tested bacterial contamination of autologous blood salvaged before and after bile duct anastomosis (BDA) during living donor liver transplantation (LDLT). In 29 patients undergoing LDLT, bacterial culture was performed for four blood samples and one bile sample: two from autologous blood salvaged before BDA (one was nonleukoreduced and another was leukoreduced), two from autologous blood salvaged after BDA (one was nonleukoreduced and another was leukoreduced), and one from bile produced in the newly implanted liver graft. The primary outcome was bacterial contamination. The risk of bacterial contamination was not significantly different between nonleukoreduced autologous blood salvaged before BDA and nonleukoreduced autologous blood salvaged after BDA (44.8% and 31.0%; odds ratio 0.33, 95% confidence interval 0.03-1.86; p = 0.228). No bacteria were found after leukoreduction in all 58 autologous blood samples. All bile samples were negative for bacteria. None of the 29 patients, including 13 patients who received salvaged autologous blood positive for bacteria, developed postoperative bacteremia. We found that bile from the newly implanted liver graft is sterile in LDLT and BDA does not increase the risk of bacterial contamination of salvaged blood, supporting the use of blood salvage during LDLT even after BDA. Leukoreduction converted all autologous blood samples positive for bacteria to negative. The clinical benefit of leukoreduction for salvaged autologous blood on post-LDLT bacteremia needs further research.

Propofol inhibits the malignant development of osteosarcoma U2OS cells via AMPK/FΟΧO1‑mediated autophagy

It has previously been reported that propofol regulates the development of human osteosarcoma (OS). However, the specific molecular mechanisms underlying the effect of propofol on OS remain poorly understood. Therefore, the aim of the present study was to explore the effects of propofol on OS U2OS cells and the potential underlying mechanism. The Cell Counting Kit-8 and colony formation assays were performed to assess cell viability and proliferation. Furthermore, cell apoptosis was assessed using the TUNEL assay and western blotting. Wound healing and Transwell assays were performed to evaluate OS cell migration and invasion abilities, respectively. The protein expression levels of epithelial-mesenchymal transition (EMT)-, autophagy- and adenosine monophosphate-activated protein kinase (AMPK)/FOXO1 signaling pathway-related proteins were also determined using western blotting. The results demonstrated that propofol significantly reduced the viability of OS cells and promoted autophagy in a dose-dependent manner. Moreover, cell treatment with propofol significantly enhanced the protein expression levels of phosphorylated (p)-AMPK and FOXO1, while decreasing the protein levels of p-FOXO1. Furthermore, treatment with propofol significantly suppressed cell viability, migration and invasion abilities and the EMT of OS cells, and potentially promoted cell apoptosis via inducing autophagy via the AMPK/FOXO1 signaling pathway. In summary, the present study indicated that propofol potentially had an inhibitory effect on the development of OS cells via AMPK/FOXO1-mediated autophagy. These results have therefore provided an experimental basis for further studies into the therapeutic effect of propofol on OS.

Propofol Inhibits Proliferation and Augments the Anti-Tumor Effect of Doxorubicin and Paclitaxel Partly Through Promoting Ferroptosis in Triple-Negative Breast Cancer Cells

Background

Triple-negative breast cancer (TNBC) is relatively common in women and is associated with a poor prognosis after surgery and adjuvant chemotherapy. Currently, the mechanism underlying the relationship between propofol and breast cancer is controversial and limited to cell apoptosis. Moreover, there are only a few studies on the effect of propofol on the chemotherapeutic sensitivity of TNBC cells. Therefore, this study explored whether propofol and its commonly used clinical formulations affect the proliferation and chemotherapeutic effects on TNBC cells by regulating cell ferroptosis.

Methods

We selected MDA-MB-231 cells, and the effects of propofol, propofol injectable emulsion (PIE), or fospropofol disodium, alone or combined with doxorubicin or paclitaxel on cell viability, apoptosis, intracellular reactive oxygen species (ROS) accumulation, ferroptosis-related morphological changes, intracellular Fe²⁺ levels, and the expression and localization of ferroptosis-related proteins were investigated.

Results

We found that propofol significantly inhibited MDA-MB-231 cell proliferation, and all three propofol formulations augmented the anti-tumor effects of doxorubicin and paclitaxel. The results from the ROS assay, transmission electron microscopy, intracellular Fe²⁺ assay, western blotting, and multiplex immunohistochemistry revealed that propofol not only induced apoptosis but also triggered ferroptosis-related changes, including morphological changes of mitochondria, increased intracellular ROS levels, and intracellular iron accumulation in MDA-MB-231 cells. The ferroptosis-related p53-SLC7A11-GPX4 pathway was also altered under different treatment propofol, doxorubicin, or paclitaxel regimens.

Conclusion

Propofol showed anti-proliferation effects on TNBC cells and could be a potential adjuvant to enhance the chemotherapeutic sensitivity of TNBC cells partly by promoting cell ferroptosis.

Application of Anesthetics in Cancer Patients: Reviewing Current Existing Link With Tumor Recurrence

Surgery remains the most effective cancer treatment, but residual disease in the form of scattered micro-metastases and tumor cells is usually unavoidable. Whether minimal residual disease results in clinical metastases is a function of host defense and tumor survival and growth. The much interesting intersection of anesthesiology and immunology has drawn increasing clinical interest, particularly, the existing concern of the possibility that the perioperative and intraoperative anesthetic care of the surgical oncology patient could meaningfully influence tumor recurrence. This paper examines current data, including recent large clinical trials to determine whether the current level of evidence warrants a change in practice. Available pieces of evidence from clinical studies are particularly limited, largely retrospective, smaller sample size, and often contradictory, causing several questions and providing few answers. Recent randomized controlled clinical trials, including the largest study (NCT00418457), report no difference in cancer recurrence between regional and general anesthesia after potentially curative surgery. Until further evidence strongly implicates anesthesia in future clinical trials, clinicians may continue to choose the optimum anesthetic-analgesic agents and techniques in consultation with their cancer patients, based on their expertise and current best practice.

Evaluation of the antimicrobial and cytotoxic potential of endophytic fungi extracts from mangrove plants Rhizophora stylosa and R. mucronata

Mangrove endophytic fungi are tolerant to numerous stresses and are inevitably capable of exhibiting excellent biological activity by producing impressive numbers of metabolites with special biological functions, based on previous work on the biological potential of mangrove-derived endophytic fungi. To obtain marked antimicrobial and cytotoxic fermentation products of culturable endophytic fungi from mangrove forests, our research evaluated the antimicrobial and cytotoxic activities of crude extracts of endophytic fungi from Rhizophora stylosa and Rhizophora mucronata. Forty-six fungal isolates were cultured on four different media, namely, dextrose agar (PDA), Czapek’s agar (CZA), rice medium (RM) and grain medium (GM) and harvested by ethyl acetate solvent at 40 days. The extracts were tested for antimicrobial activity by the microdilution method against the gram-negative bacteria Pseudomonas adaceae (PA), gram-positive bacteria Enterococcus faecalis (EF), methicillin-resistant Staphylococcus aureus (MRSA) and pathogenic fungus Monilia albicans (MA). The cytotoxic activity of the extracts was evaluated by MTT assay using A549 human lung cancer cells, HeLa human cervical carcinoma cells, and HepG2 human hepatocellular cells. The results showed that rice medium could promote the secretion of antimicrobial and antitumour secondary metabolites of endophytic fungi in comparison with other cultivation media. Seventeen strains (68%) from R. stylosa exhibited inhibitory effects on indicators, especially N. protearum HHL46, which could inhibit the growth of four microbes with MIC values reaching 0.0625 mg/mL. Fifteen strains (71.4%) from R. mucronata displayed activities against human pathogenic microbes; in particular, Pestalotiopsis sp. HQD6 and N. protearum HQD5 could resist the growth of four microbes with MIC values ranging from 0.015 to 1 mg/mL. In the cytotoxicity assay, the extracts of 10 strains (40%), 9 strains (40%) and 13 strains (52%) of R. stylosa and 13 strains (61.9%), 10 strains (47.6%) and 10 strains (47.6%) of R. mucronata displayed cytotoxicity against A549, HeLa and HepG2 cancer cells with cell viability values ≤ 50%. Neopestalotiopsis protearum HHL46, Phomopsis longicolla HHL50, Botryosphaeria fusispora HQD83, Fusarium verticillioides HQD48 and Pestalotiopsis sp. HQD6 displayed significant antitumour activity with IC₅₀ values below 20 μg/mL. These results highlighted the antimicrobial and antitumour potential of endophytic fungi from R. stylosa and R. mucronata and the possibility of exploiting their antimicrobial and cytotoxic agents.

Effects of Propofol Versus Sevoflurane on Postoperative Breast Cancer Prognosis: A Narrative Review

Perioperative interventions produce substantial biologic perturbations which are associated with the risk of recurrence after cancer surgery. The changes of tumor microenvironment caused by anesthetic drugs received increasing attention. Till now, it’s still unclear whether or not anesthetic drugs may exert positive or negative impact on cancer outcomes after surgery. Breast cancer is the most common tumor and the leading cause of cancer deaths in women. Propofol and sevoflurane are respectively the most commonly used intravenous and inhaled anesthetics. Debates regarding which of the two most commonly used anesthetics may relatively contribute to the recurrence and metastasis vulnerability of breast cancer postoperatively remain. This review aimed to provide a comprehensive view about the effect of propofol versus sevoflurane on the prognosis of breast cancer obtained from pre-clinical studies and clinical studies. Laboratory and animal studies have demonstrated that sevoflurane may enhance the recurrence and metastasis of breast cancer, while propofol is more likely to reduce the activity of breast cancer cells by attenuating the suppression of the immune system, promoting tumor cells apoptosis, and through other direct anti-tumor effects. However, retrospective clinical studies have shown contradictory results about the effects of propofol and sevoflurane on long-term survival in breast cancer patients. Furthermore, recent prospective studies did not identify significant differences between propofol and sevoflurane in breast cancer metastasis and recurrence. Therefore, more preclinical studies and randomized controlled studies are needed to guide the choice of anesthetics for breast cancer patients.

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.

Opioids and Breast Cancer Recurrence: A Systematic Review

Breast cancer has the greatest epidemiological impact in women. Opioids represent the most prescribed analgesics, both in surgical time and in immediate postoperative period, as well as in chronic pain management as palliative care. We made a systematic review analyzing the literature's evidence about the safety of opioids in breast cancer treatment, focusing our attention on the link between opioid administration and increased relapses. The research has been conducted using the PubMed database. Preclinical studies, retrospective and prospective clinical studies, review articles and original articles were analyzed. In the literature, there are several preclinical in vitro and in vivo studies, suggesting a possible linkage between opioids administration and progression of cancer disease. Nevertheless, these results are not confirmed by clinical studies. The most recent evidence reassures the safety of opioids during surgical time as analgesic associated with anesthetics drugs, during postoperative period for optimal cancer-related pain management and in chronic use. Currently, there is controversial evidence suggesting a possible impact of opioids on breast cancer progression, but to date, it remains an unresolved issue. Although there is no conclusive evidence, we hope to arouse interest in the scientific community to always ensure the best standards of care for these patients.

The immunomodulatory effect of ketamine in colorectal cancer surgery: a randomized-controlled trial

PURPOSE

Ketamine's inhibitory action on the N-methyl-D-aspartate receptor and anti-inflammatory effects may provide beneficial immunomodulation in cancer surgery. We investigated the effect of subanesthetic-dose ketamine as an adjunct to desflurane anesthesia on natural killer (NK) cell activity and inflammation in patients undergoing colorectal cancer surgery.

METHODS

A total of 100 patients were randomly assigned to a control or ketamine group. The ketamine group received a bolus of 0.25 mg·kg^-1 ketamine five minutes before the start of surgery, followed by an infusion 0.05 mg·kg^-1·hr^-1 until the end of surgery; the control group received a similar amount of normal saline. We measured NK cell activity and proinflammatory cytokines (interleukin-6 [IL-6] and tumour necrosis factor-α [TNF-α]) before surgery and one, 24, and 48 hr after surgery. C-reactive protein (CRP) was measured before surgery and one, three, and five days after surgery. Carcinoembryonic antigen and cancer recurrence/metastasis were assessed two years after surgery.

RESULTS

The NK cell activity was significantly decreased after surgery in both groups, but the change was not different between groups in the linear mixed model analysis (P = 0.47). Changes in IL-6, TNF-α, CRP, and carcinoembryonic antigen levels were not different between groups (P = 0.27, 0.69, 0.99, and 0.97, respectively). Cancer recurrence within 2 years after surgery was similar between groups (10% vs 8%, P = 0.62).

CONCLUSIONS

Intraoperative low-dose ketamine administration did not convey any favourable impacts on overall postoperative NK cell activity, inflammatory responses, and prognosis in colorectal cancer surgery patients.

TRIAL REGISTRATION

www.clinicaltrial.gov (NCT03273231); registered 6 September 2017.

Effects of transcutaneous electrical acupoint stimulation on perioperative immune function and postoperative analgesia in patients undergoing radical mastectomy: A randomized controlled trial

Radical mastectomy may lead to suppression of cellular immune function in patients with malignant tumors. Transcutaneous electrical acupoint stimulation (TEAS) is widely used in clinical practice. However, there have been relatively few studies on the effects of TEAS on postoperative analgesia and immune function. The present study aimed to evaluate the effects of TAES on postoperative pain and immune function in patients undergoing radical mastectomy. A total of 65 patients were enrolled and allocated to either receive TEAS or sham TEAS. TEAS was implemented on bilateral Hegu (LI4), Neiguan (PC6) and Zusanli (ST36) acupoints simultaneously for 30 min before induction of anesthesia at 4 and 12 h post-operation. The primary outcomes included visual analogue scale (VAS) scores at 4 h (T₁), 12 h T₂), 24 h (T₃) and 48 h (T₄) post-operation, and serum levels of IL-2, IL-4, IFN-γ and the IL-2/IL-4 ratio at 30 min before TEAS (T₀), T₁, T₂, T₃ and T₄. Secondary outcomes included the cumulative time of rescue analgesia within 48 h post-surgery, as well as the incidence of postoperative nausea and vomiting (PONV) and pruritus. Compared with the sham TEAS group, postoperative VAS scores at T₂ and T₃, the total consumption of opioids in the patient-controlled analgesia (PCA) pump, pressing times of the PCA pump and the incidences of PONV and headache were significantly lower in the TEAS group. The serum levels of IFN-γ at T₃ and T₄, and the serum levels of IL-2 and the IL-2/IL-4 ratio at T₂, T₃ and T₄ were higher in the TEAS group compared with the sham TEAS group. By contrast, the serum levels of IL-4 were lower at T₂, T₃ and T₄ in the TEAS group compared with the sham TEAS group. The results indicated that TEAS could improve postoperative analgesia, reduce postoperative consumption of opioids and alleviate postoperative side effects. Simultaneously, TEAS was able to reverse decreased serum levels of IL-2 and IFN-γ, reduce the level of IL-4 and restore the balance of Th1/Th2, thereby partially attenuating perioperative immune function depression in patients with breast cancer. The current trial was registered prior to participant enrollment at www.chictr.org.cn (Clinical Trial no. ChiCTR1800017768).

Ropivacaine inhibits the proliferation and migration of colorectal cancer cells through ITGB1

To study whether ropivacaine inhibits the proliferation and migration of colon cancer cells through ITGB1 (Integrin beta-1). First, the effect of ropivacaine on cell proliferation and migration was detected by MTT and Transwell. DAPI staining, annexin V staining and Western blot were used to detect the expression of apoptosis-related proteins to investigate the effect of ropivacaine on cell apoptosis. Using bioinformatics software to predict the potential drug targets of ropivacaine. RT-PCR, Western blot and immunofluorescence verify the distribution and expression of the drug target ITGB1, and detect its downstream-related proteins to further prove that ropivacaine affects colon cancer cells by acting on ITGB1 protein. 1. Ropivacaine significantly inhibited the proliferation of colon cancer cells and promoted their apoptosis 2. Ropivacaine could interact with ITGB1 protein, and inhibited the expression of ITGB1 protein in colon cancer cells, thereby affecting its downstream signaling pathway. Ropivacaine regulates the function of colon cancer cells by targeting the expression of ITGB1 protein and affecting the activation of its downstream signaling pathways.

Abbreviation: Integrin beta-1 (ITGB1); 3-(45)-dimethylthiahiazo (-z-y1)-35-di- phenytetrazoliumromide (MTT); 4. 6-diamimo-2-phenyl indole (DAPI); Reverse transcrption PCR (RT-PCR); Colorectal cancer (CRC); Local anesthetics (LA); voltage-gated sodium channel (VGSC); dulbecco s modifed eade medium (DMEM); propidium iodide (PI); dodecyl sulf ate, sodium salt-Polyacrylamide gel electrophoresis (SDS-PAGE); Polyvinylidene Fluoride (PVDF); BCL2 associated X (Bax); Focal Adhesion Kinase (FAK); extracellular signal-regulated kmase (ERK); alpha serme threcnime-proteim kinase (AKT); Glyceraldehyde-3-phosphate dehydrogenase (GAPDH); Tris-buffered salme with 0.1% Tween 20 (TBST); Similarty ensemble approach (SEA)

Effects of propofol on the development of cancer in humans

Cancer is one of most the significant threats to human health worldwide, and the primary method of treating solid tumours is surgery. Propofol, one of the most widely used intravenous anaesthetics in surgery, was found to be involved in many cancer‐related pathophysiology processes, mainly including anti‐tumour and minor cancer‐promoting effects in various types of cancer. An increasing number of studies have identified that propofol plays a role in cancer by regulating the expression of multiple signalling pathways, downstream molecules, microRNAs and long non‐coding RNAs. Emerging evidence has indicated that propofol can enhance the anti‐tumour effect of chemotherapeutic drugs or some small molecular compounds. Additionally, in vivo animal models have shown that propofol inhibits tumour growth and metastasis. Furthermore, most clinical trials indicate that propofol is associated with better survival outcomes in cancer patients after surgery. Propofol use is encouraged in cancers that appear to have a better prognosis after its use during surgery. We hope that future large and prospective multicenter studies will provide more precise answers to guide the choice of anaesthetics during cancer surgery.

The Role of Inhaled Anesthetics in Tumorigenesis and Tumor Immunity

Inhaled anesthetics are widely used for induction and maintenance of anesthesia during surgery, including isoflurane, sevoflurane, desflurane, haloflurane, nitrous oxide (N₂O), enflurane and xenon. Nowadays, it is controversial whether inhaled anesthetics may influence the tumor progression, which urges us to describe the roles of different inhaled anesthetics in human cancers. In the review, the relationships among the diverse inhaled anesthetics and patient outcomes, immune response and cancer cell biology were discussed. Moreover, the mechanisms of various inhaled anesthetics in the promotion or inhibition of carcinogenesis were also reviewed. In summary, we concluded that several inhaled anesthetics have different immune functions, clinical outcomes and cancer cell biology, which could contribute to opening new avenues for selecting suitable inhaled anesthetics in cancer surgery.

The influence of dexmedetomidine and propofol on circulating cytokine levels in healthy subjects

Background

Surgery and diseases modify inflammatory responses and the immune system. Anesthetic agents also have effects on the human immune system but the responses they induce may be altered or masked by the surgical procedures or underlying illnesses. The aim of this study was to assess how single-drug dexmedetomidine and propofol anesthesia without any surgical intervention alter acute immunological biomarkers in healthy subjects.

Methods

Thirty-five healthy, young male subjects were anesthetized using increasing concentrations of dexmedetomidine (n = 18) or propofol (n = 17) until loss of responsiveness (LOR) was detected. The treatment allocation was randomized. Multi-parametric immunoassays for the detection of 48 cytokines, chemokines and growth factors were used. Concentrations were determined at baseline and at the highest drug concentration for each subject.

Results

The changes in the concentration of eotaxin (decrease after dexmedetomidine) and platelet-derived growth factor (PDGF, increase after propofol) were statistically significantly different between the groups. Significant changes were detected within both groups; the concentrations of monocyte chemotactic protein 1, chemokine ligand 27 and macrophage migration inhibitory factor were lower in both groups after the drug administration. Dexmedetomidine decreased the concentration of eotaxin, interleukin-18, interleukin-2Rα, stem cell factor, stem cell growth factor and vascular endothelial growth factor, and propofol decreased significantly the levels of hepatocyte growth factor, IFN-γ-induced protein 10 and monokine induced by IFN-γ, and increased the levels of interleukin-17, interleukin-5, interleukin-7 and PDGF.

Conclusions

Dexmedetomidine seemed to have an immunosuppressive effect on the immune system whereas propofol seemed to induce mixed pro- and anti-inflammatory effects on the immune system. The choice of anesthetic agent could be relevant when treating patients with compromised immunological defense mechanisms.

Trial registration

Before subject enrollment, the study was registered in the European Clinical Trials database (EudraCT number 2013–001496-21, The Neural Mechanisms of Anesthesia and Human Consciousness) and in ClinicalTrials.gov (Principal Investigator: Harry Scheinin, number NCT01889004, The Neural Mechanisms of Anesthesia and Human Consciousness, Part 2, on the 23rd of June 2013).

Effect of lidocaine and ropivacaine on primary (SW480) and metastatic (SW620) colon cancer cell lines

Regional anesthesia may prolong survival following surgery for different types of cancers. The mechanisms behind this are unclear but direct effects on cancer cells by local anesthetics (LA) have been suggested. The aim of this study was to investigate if lidocaine or ropivacaine have a dose-dependent effect on the cell viability and proliferation of a primary and a secondary colon carcinoma cell line in vitro. The colon cancer cell lines SW480 derived from primary tumor and SW620 from a metastatic site in the same patient were exposed to increasing concentrations of lidocaine and ropivacaine (5-1,000 µM). Cell viability was measured using CellTiter-Blue^® and cell proliferation by PKH67 after exposure for up to 72 h. Cell viability was significantly reduced by ropivacaine at the highest concentration (1,000 µM) after 48 and 72 h in the cell line SW480 and at 72 h in SW620. Exposure to lidocaine did not show any significant reduction in cell viability. Notably, low concentrations of both lidocaine and ropivacaine significantly increased cell viability after 48 and 72 h in SW620. Cell proliferation was significantly reduced by 1,000 µM lidocaine in SW480 and by 1,000 µM ropivacaine in SW620. In summary, both lidocaine and ropivacaine showed an anti-proliferative effect in the colon cancer cell lines at high concentrations and after prolonged exposure to LA in vitro. Our findings also indicate that lower concentrations promote cell viability in the metastatic cell line.

Propofol promotes apoptosis of colorectal cancer cells via alleviating the suppression of lncRNA HOXA11-AS on miRNA let-7i

To date, surgical resection is the mainstay for the treatment of colorectal cancer (CRC). Propofol (2,6-diisopropylphenol), one of the most commonly used intravenous anaesthetic agents, has been reported to be involved in modulating the malignancy of a variety of human cancers. However, the underlying mechanisms remain poorly understood. In this study, using a cell counting kit (CCK-8), flow cytometry, and caspase-3 cleavage assays, we found that propofol promoted cell apoptosis and inhibited cell proliferation in both Colo205 and SW620 cells, through the down-regulation of HOXA11-AS and up-regulation of let-7i. Moreover, gain-of-function studies of HOXA11-AS or loss-of-function studies of let-7i also revealed a negative correlation between HOXA11-AS and let-7i in propofol-mediated biological functions of CRC cells. Furthermore, our mechanistic experiments revealed that HOXA11-AS acts as a molecular sponge for let-7i, thereby regulating the expression of ABCC10. We investigate the theory that propofol suppresses colorectal cancer tumorigenesis by modulating the HOXA11-AS-let-7i-ABCC10 regulatory network, indicating the potential for propofol to control CRC development.

An analysis of the survival impact of dexmedetomidine in children undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

OBJECTIVE

Recent evidence suggests the α2-adrenoreceptor agonist dexmedetomidine may promote metastasis of cancer cells. In this study we sought to evaluate the impact of dexmedetomidine administration on the survival of children and adolescents with cancer.

DESIGN

Retrospective chart review.

SETTING

Comprehensive cancer center.

PATIENTS

Children and adolescents who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis.

INTERVENTION

Intraoperative and/or early postoperative (within 24 hours of surgery) administration of dexmedetomidine.

MEASUREMENTS

Multivariable cox proportional hazard models were used to assess the association between dexmedetomidine administration and progression free survival (PFS) or overall survival (OS).

MAIN RESULTS

Ninety-three patients were identified. The median age was 12 years, 42% were female, and 35% received dexmedetomidine. There were no significant differences between the baseline and perioperative characteristics of patients who received dexmedetomidine and those who did not. In the multivariable analysis, the administration of dexmedetomidine was not associated with PFS (HR = 1.20, 95% CI [0.60-2.41], p = .606) or OS (HR = 0.81, 95% CI [0.35-1.85], p = .611).

CONCLUSION

In this retrospective study of children and adolescents who had undergone a major oncologic surgery, the intraoperative and/or early postoperative administration of dexmedetomidine was not associated with survival.

Prediction of perioperative complications after robotic-assisted radical hysterectomy for cervical cancer using the modified surgical Apgar score

BACKGROUND

Although there has been marked development in surgical techniques, there is no easy and fast method of predicting complications in minimally invasive surgeries. We evaluated whether the modified surgical Apgar score (MSAS) could predict perioperative complications in patients undergoing robotic-assisted radical hysterectomy.

METHODS

All patients with cervical cancer undergoing robotic-assisted radical hysterectomy at our institution between January 2011 and May 2017 were included. Their clinical characteristics were retrieved from their medical records. The surgical Apgar score (SAS) was calculated from the estimated blood loss, lowest mean arterial pressure, and lowest heart rate during surgery. We modified the SAS considering the lesser blood loss typical of robotic surgeries. Perioperative complications were defined using a previous study and the Clavien-Dindo classification and subdivided into intraoperative and postoperative complications. We analyzed the association of perioperative complications with low MSAS.

RESULTS

A total of 138 patients were divided into 2 groups: with (n = 53) and without (n = 85) complications. According to the Clavien-Dindo classification, 49 perioperative complications were classified under Grade I (73.1%); 13, under Grade II (19.4%); and 5, under Grade III (7.5%); 0, under both Grade IV and Grade V. Perioperative complications were significantly associated with surgical time (p = 0.026). The MSAS had a correlation with perioperative complications (p = 0.047). The low MSAS (MSAS, ≤6; n = 52) group had significantly more complications [40 (76.9%), p = 0.01]. Intraoperative complications were more correlated with a low MSAS than were postoperative complications [1 (1.2%) vs. 21 (40.4%); p < 0.001, 13 (15.1%) vs. 25 (48.1%); p = 0.29, respectively]. We also analyzed the risk-stratified MSAS in 3 subgroups: low (MSAS, 7-10), moderate (MSAS 5-6), and high risks (MSAS, 0-4). The prevalence of intraoperative complications significantly increased as the MSAS decreased p = 0.01).

CONCLUSIONS

This study was consistent the concept that the intuitive and simple MSAS might be more useful in predicting intraoperative complications than in predicting postoperative complications in minimally invasive surgeries, such as robotic-assisted radical hysterectomy for cervical cancer.

Isoflurane decreases interleukin-2 production by increasing c-Cbl and Cbl-b expression in rat peripheral blood mononuclear cells

Objective

To evaluate how isoflurane affects T-cell function by assaying interleukin (IL)-2 production and the expression of two Casitas B-lineage lymphoma (Cbl) family proto-oncogenes (c-Cbl and Cbl-b) in rat peripheral blood mononuclear cells (PBMCs).

Methods

Adult male Sprague–Dawley rats were randomly allocated to those that underwent blood collection after brief isoflurane anesthesia (control group), immediately after 4 hours of isoflurane general anesthesia (4I group), and 1 day after 4 hours of isoflurane general anesthesia (1D 4I group). IL-1, IL-2, and IL-6 mRNA levels and c-Cbl and Cbl-b levels in PBMCs were determined by polymerase chain reaction. Ubiquitination of protein kinase Cθ (PKCθ) and phospholipase C-γ1 (PLC-γ1) in PBMCs was assessed by immunoprecipitation.

Results

The IL-2 mRNA level in rat PBMCs was significantly lower in the 4I and 1D 4I groups than in the control group. c-Cbl, Cbl-b, and ubiquitin expression was significantly increased and zeta-chain-associated protein kinase 70, PLC-γ1, and PKCθ protein levels were significantly decreased in the 4I group. Ubiquitination of PLC-γ1 and PKCθ was significantly increased in the 4I group.

Conclusion

Isoflurane influences ubiquitin, c-Cbl, and Cbl-b expression in rat PBMCs, indicating suppression of receptor tyrosine kinase signaling pathways. These results suggest that isoflurane suppresses T-cell function.

Effects of anesthetic interventions on breast cancer behavior, cancer-related patient outcomes, and postoperative recovery

This narrative review will summarize our current understanding of the effects of perioperative interventions on patients undergoing surgical removal of breast malignancies. It will focus on how different anesthetic agents and perioperative interventions might affect both breast cancer behavior and/or tumor recurrence as well as postoperative recovery. The main objective of this study will be to describe the evidence and critically analyze preclinical and clinical studies on the use of intravenous versus inhaled anesthetic agents, opioids, regional anesthetics, and anesthetic adjuncts in patients undergoing breast cancer resection. We will look both at the evidence regarding cancer-related outcomes and postoperative recovery. A search of PubMed, from inception to May 2017 was performed using Mesh terms Breast Neoplasms [Mesh] OR cancer AND breast AND Anesthesia [Mesh]; "Anesthetics"[Mesh] AND "Breast Neoplasms/surgery"[Mesh]. Although no optimal anesthetic combination has been identified for patients undergoing breast cancer resection, it should be noted that based on the available evidence, an ideal anesthetic in this patient population would involve a combination of TIVA (propofol), regional anesthesia (paravertebral block)), non opioid sedatives (clonidine or dexmedetomidine), and COX-2 inhibition (ketorolac). Based on the current evidence, this combination of anesthetic and analgesic agents has the best chance of improving cancer-related outcomes and postoperative recovery.

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.

The Price We Pay for Radical Curative Pelvic Exenterations: Prevalence and Management of Pain

BACKGROUND

Pelvic exenterations are extensive surgical procedures for locally advanced or recurrent malignancies of the pelvis. However, this is often at the cost of significant morbidity due to perioperative pain, which has been poorly studied.

OBJECTIVE

This study aims to review perioperative pain management in patients undergoing pelvic exenteration.

DESIGN

This is a retrospective review of patients undergoing pelvic exenteration between January 2013 and December 2014. Data were gathered from medical records and a prospectively maintained database.

SETTING

This study was conducted at a single quaternary referral center for pelvic exenteration.

PATIENTS

Consecutive patients underwent pelvic exenteration at a single center.

INTERVENTIONS

Pelvic exenteration was performed in consecutive patients.

MAIN OUTCOMES MEASURES

Primary outcomes were the prevalence of preoperative pain, preoperative opiate use (type, dosage), and postoperative pain (verbal numerical rating scale). Secondary outcomes included the number of pain consultations and correlations between preoperative opiate use, length of stay, and extent of resection (en bloc sacrectomy and nerve excision).

RESULTS

Ninety-nine patients underwent pelvic exenteration. Sixty-one patients (61.6%) underwent major nerve resection and/or sacrectomy. Thirty patients (30%) required opiates preoperatively, with a mean daily morphine equivalent of 72.9 mg (SD 65.0 mg). Patients on preoperative opiates were more likely to have worse pain postoperatively and to require higher opiate doses and more pain consultations (9.3 vs 4.8; p < 0.001). Major nerve excision and sacrectomy were not associated with worse postoperative pain. By discharge, 60% still required opiate analgesia.

LIMITATIONS

Retrospective study design, the subjective nature of pain assessment because of a lack of valid methods to objectively quantify pain, and the lack of long-term follow-up were limitations of this study.

CONCLUSIONS

Perioperative pain is a significant issue among patients undergoing pelvic exenteration. One in three patients require high-dose opiates preoperatively that is associated with worse pain outcomes. Potential areas to improve pain outcomes in these complex patients could include increased use of regional anesthesia, antineuropathic agents, and opiate-sparing techniques. See Video Abstract at http://links.lww.com/DCR/A572.

Surgical Apgar Score predicts 30-day morbidity in elderly patients who undergo non-laparoscopic gynecologic surgery: A retrospective analysis

INTRODUCTION

The aim of this study was to determine whether a preoperative health status index and intraoperative data could predict perioperative morbidity and mortality in women over the age of 65 years undergoing surgery for gynecologic disorders.

METHODS

The medical records of 68 female patients who were ≥65 years of age and who underwent surgery under general anesthesia in our institute from January 2014 to December 2015 were retrospectively reviewed. Preoperative data were extracted from a database and included comorbidities, American Society of Anesthesiologists physiological status classification, the Charlson Comorbidity Index, the Subjective Global Assessment 2011 revision, the subjects' risk of falling, body mass index, and age. The intraoperative factors investigated included the type of surgery and the Surgical Apgar Score (SAS). Major postoperative complications were defined as > Grade 3 based on the Clavien-Dindo classification version 2.0.

RESULTS

Of the 68 elderly gynecological patients, 6 (8.8%) developed serious Grade 3 or worse complications within 30 days of surgery. The only factor that significantly affected postoperative complications was the SAS, an index of the patient's intraoperative condition. The optimum cut-off SAS for the occurrence of complications was determined by the receiver operating characteristic curve to be ≤ 6 points; a score ≤6 points predicted the development of postoperative complications with 66.7% sensitivity and 79.0% specificity.

CONCLUSION

In this study, the SAS predicted the development of serious complications in elderly gynecological patients within 30 days of surgery more accurately than did other comorbidities, preoperative assessments, and type of surgery.

Anesthetic technique and cancer recurrence in oncologic surgery: unraveling the puzzle

Surgery/anesthetic technique-stimulated immunosuppression in the perioperative period might cause an increase in cancer-related mortality. Whether anesthetic technique can affect the outcomes of cancer patients remains inconclusive. This review discusses data from the available literature on anesthetic techniques applied in oncologic surgery, the long-term outcomes of anesthetic technique, and their relation to survival and cancer recurrence. Searches of the PubMed database up to June 30, 2016, were conducted to identify publications with the terms "anesthetic technique and cancer recurrence," "regional anesthesia and cancer recurrence," "local anesthesia and cancer recurrence," "anesthetic technique and immunosuppression," and "anesthetic technique and oncologic surgery." Surgery/anesthesia-stimulated activation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS) provides immunosuppression through several soluble factors. Volatile anesthetics and opioids suppress cell-mediated immunity (CMI) and promote the proliferation of cancer cells and angiogenesis, whereas propofol does not suppress CMI and inhibits tumor angiogenesis. Regional anesthesia (RA) protects CMI and diminishes the surgical neuroendocrine stress response by blocking afferent neural transmission that stimulates the HPA axis and SNS, decreasing the requirement for opioids and volatile anesthetics and thereby decreasing cancer recurrence. Preclinical and retrospective studies highlight a potential benefit of anesthetic technique in reducing cancer-related mortality and recurrence by attenuating immunosuppression following surgical treatment in patients with specific types of cancer. Several well-planned, prospective, randomized controlled trials (RCTs) are underway that may provide more conclusive and definitive results regarding the benefits of anesthetic technique on survival in oncologic surgery.

Comparing the Effects of Combined General/Epidural Anaesthesia and General Anaesthesia on Serum Cytokine Levels in Radical Cystectomy

OBJECTIVE

Surgical stress combined with general anaesthesia (GA) suppresses the immune system and leads to cancer cell growth and premature metastasis in major oncological interventions. Epidural analgesia decreases the need for inhalation agents and opioids during surgery by suppressing sympathetic and neuroendocrine responses in the postoperative period. This study aimed to compare the effects of combined general/epidural anaesthesia (GEA)+patient-controlled epidural analgesia (PCEA) and GA+IV patient-controlled analgesia (PCA) on serum tumour necrosis factor-alpha TNF-α), interleukin-1 beta (IL-1β) and interferon-gamma (IFN-γ) levels in patients undergoing radical cystectomy.

METHODS

Sixty-five patients were enrolled in this prospective study. Patients were randomly enrolled to the GEA group, i.e., combined GEA+ PCEA (0.1% bupivacaine+1 μg mL^-1 fentanyl), and the GA group, namely combined GA+IV PCA (0.03 mg mL^-1 morphine). To evaluate the cytokine response, blood samples were collected at preoperative, postoperative 1^st and 24^th hours.

RESULTS

There was no statistically significant difference in serum TNF-α, IL-1β and IFN-γ levels between groups GA and GEA at preoperative and postoperative 1^st hour and 24^th hour. Total remifentanil consumption was significantly lower and length of hospital stay was significantly shorter in the GEA group than in the GA group (p<0.05).

CONCLUSION

There is no difference between two anaesthesia methods in terms of serum cytokine levels; however, combined GEA+PCEA technique appeared to be superior to GA+IV PCA because of lower intraoperative narcotic analgesic consumption and shorter hospital stay.

Effects of combined general-epidural anesthesia and total intravenous anesthesia on cellular immunity and prognosis in patients with non‑small cell lung cancer: A comparative study

The aim of the present study was to investigate the effects of combined general-epidural anesthesia (CGEA) and total intravenous anesthesia (TIVA) on cellular immunity and prognosis in patients with non-small cell lung cancer (NSCLC) in a Chinese population. One-hundred and twenty NSCLC patients were randomly divided into a TIVA group (n=60) and a CGEA group (n=60) using a random number table. All patients underwent video-assisted thoracoscopic surgery for radical resection. Blood pressure (BP) and peripheral oxygen saturation (SpO₂) were measured. Post-operative analgesic effects were evaluated with a visual analog scale pain score. Flow cytometry was applied to measure T lymphocyte subsets [cluster of differentiation (CD)3⁺, CD4⁺, CD8⁺ and CD4⁺/CD8⁺] and natural killer cell CD56⁺. A 3-year follow-up was conducted to observe the prognosis. The analgesic effects of CGEA were identified to be better than those of TIVA. Compared with the TIVA group, the CGEA group demonstrated a shorter time of spontaneous breathing recovery, eyes opening, and extubation, lower heart rate, blood pressure and mean arterial pressure, and higher SpO₂. At 24 and 48 h after surgery, CD3⁺, CD4⁺, CD4⁺/CD8⁺ and CD56⁺ in the CGEA group were higher than those in the TIVA group. At 72 h after surgery, CD3⁺, CD4⁺, CD4⁺/CD8⁺ in the CGEA group were higher than those in the TIVA group. These results indicate that CGEA and TIVA effected cellular immunity, and CGEA had a reduced effect on cellular immunity and improved postoperative analgesic effects.

Perioperative Anesthesia Care and Tumor Progression

This narrative review discusses the most recent up-to-date findings focused on the currently available "best clinical practice" regarding perioperative anesthesia care bundle factors and their effect on tumor progression. The main objective is to critically appraise the current literature on local anesthetics, regional outcome studies, opioids, and nonsteroidal anti-inflammatory drugs (NSAIDs) and their ability to decrease recurrence in patients undergoing cancer surgery. A brief discussion of additional topical perioperative factors relevant to the anesthesiologist including volatile and intravenous anesthetics, perioperative stress and anxiety, nutrition, and immune stimulation is included. The results of several recently published systematic reviews looking at the association between cancer recurrences and regional anesthesia have yielded inconclusive data and provide insufficient evidence regarding a definitive benefit of regional anesthesia. Basic science data suggests an anti tumor effect induced by local anesthetics. New refined animal models show that opioids can safely be used for perioperative pain management. Preliminary evidence suggests that NSAIDs should be an essential part of multimodal analgesia. Volatile anesthetics have been shown to increase tumor formation, whereas preclinical and emerging clinical data from propofol indicate tumor protective qualities. The perioperative period in the cancer patient represents a unique environment where surgically mediated stress response leads to immune suppression. Regional anesthesia techniques when indicated in combination with multimodal analgesia that include NSAIDs, opioids, and local anesthetics to prevent the pathophysiologic effects of pain and neuroendocrine stress response should be viewed as an essential part of balanced anesthesia.

The Effects of Perioperative Anesthesia and Analgesia on Immune Function in Patients Undergoing Breast Cancer Resection: A Prospective Randomized Study

Introduction: Perioperative anesthesia and analgesia exacerbate immunosuppression in immunocompromised cancer patients. The natural killer (NK) cell is a critical part of anti-tumor immunity. We compared the effects of two different anesthesia and analgesia methods on the NK cell cytotoxicity (NKCC) in patients undergoing breast cancer surgery. Methods: Fifty patients undergoing breast cancer resection were randomly assigned to receive propofol-remifentanil anesthesia with postoperative ketorolac analgesia (Propofol-ketorolac groups) or sevoflurane-remifentanil anesthesia with postoperative fentanyl analgesia (Sevoflurane-fentanyl group). The primary outcome was NKCC, which was measured before and 24 h after surgery. Post-surgical pain scores and inflammatory responses measured by white blood cell, neutrophil, and lymphocyte counts were assessed. Cancer recurrence or metastasis was evaluated with ultrasound and whole body bone scan every 6 months for 2 years after surgery. Results: The baseline NKCC (%) was comparable between the two groups (P = 0.082). Compared with the baseline value, NKCC (%) increased in the Propofol-ketorolac group [15.2 (3.2) to 20.1 (3.5), P = 0.048], whereas it decreased in the Sevoflurane-fentanyl group [19.5 (2.8) to 16.4 (1.9), P = 0.032]. The change of NKCC over time was significantly different between the groups (P = 0.048). Pain scores during 48 h after surgery and post-surgical inflammatory responses were comparable between the groups. One patient in the Sevoflurane-fentanyl group had recurrence in the contralateral breast and no metastasis was found in either group. Conclusions: Propofol anesthesia with postoperative ketorolac analgesia demonstrated a favorable impact on immune function by preserving NKCC compared with sevoflurane anesthesia and postoperative fentanyl analgesia in patients undergoing breast cancer surgery.

Effects of anesthetic and analgesic techniques on cancer metastasis

The rate of mortality and morbidity among cancer patients is at an alarming rate and its ratio of incidence is increasing as a result of its effects of metastasis and recurrence in its patients. Several factors including anesthetic agents and analgesia techniques have been identified as causative agents for cancer metastasis. In this mini-review, we will summarize some of the available effects of anesthetic and analgesic techniques on cancer metastasis as derived from experimental cell culture and live animal data and also form clinical studies.

Survival rate and perioperative data of patients who have undergone hemipelvectomy: a retrospective case series

Background

Hemipelvectomy is a major orthopedic surgical procedure indicated in specific situations. Although many studies discuss surgical techniques for hemipelvectomy, few studies have presented survival data, especially in underdeveloped countries. Additionally, there is limited information on anesthesia for orthopedic oncologic surgeries. The primary aim of this study was to determine the survival rate after hemipelvectomy, and the secondary aims were to evaluate anesthesia and perioperative care associated with hemipelvectomy and determine the influence of the surgical technique (external hemipelvectomy [amputation] or internal hemipelvectomy [limb sparing surgery]) on anesthesia and perioperative care in Brazil.

Methods

This retrospective case series collected data from 35 adult patients who underwent hemipelvectomy between 2000 and 2013. Survival rates after surgery were determined, and group comparisons were performed using the Kaplan–Meier method and the log-rank test. Mantel–Cox test and multiple linear regression analysis with stepwise forward selection were performed for univariate and multivariate analyses, respectively.

Results

Mean survival time was 32.8 ± 4.6 months and 5-year survival rate was 27 %. Of the 35 patients, 23 patients (65.7 %) underwent external hemipelvectomy and 12 patients (34.3 %) underwent internal hemipelvectomy. The survival rate was significantly higher in patients with bone tumors than in those with soft tissue sarcomas (P = 0.024). The 5-year cumulative probability of survival was significantly lower in patients who underwent external hemipelvectomy than in those who underwent internal hemipelvectomy (P = 0.043). In the univariate and multivariate analyses, only advanced disease stage (3 and 4) was identified as a significant independent predictor of reduced survival (P = 0.0003). Balanced general anesthesia combined with epidural block was the most frequent anesthesia technique. Median intraoperative crystalloid volume and red blood cell transfusions were 3500 mL and 2 units, respectively.

Conclusions

Overall mean survival time after hemipelvectomy was 32.8 months. Advanced disease stage might be independently associated with reduced survival. Smaller amounts of fluids and transfusions were administered and time to discharge was shorter. Acute and chronic pain as well as wound complications are still important challenges in hemipelvectomy.

Merkel cell carcinoma: An algorithm for multidisciplinary management and decision-making

Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine tumor of the skin. Therapeutic approach is often unclear, and considerable controversy exists regarding MCC pathogenesis and optimal management. Due to its rising incidence and poor prognosis, it is imperative to establish the optimal therapy for both the tumor and the lymph node basin, and for treatment to include sentinel node biopsy. Sentinel node biopsy is currently the most consistent predictor of survival for MCC patients, although there are conflicting views and a lack of awareness regarding node management. Tumor and node management involve different specialists, and their respective decisions and interventions are interrelated. No effective systemic treatment has been made available to date, and therefore patients continue to experience distant failure, often without local failure. This review aims to improve multidisciplinary decision-making by presenting scientific evidence of the contributions of each team member implicated in MCC management. Following this review of previously published research, the authors conclude that multidisciplinary team management is beneficial for care, and propose a multidisciplinary decision algorithm for managing this tumor.

Rationale and Design of the Balanced Anesthesia Study: A Prospective Randomized Clinical Trial of Two Levels of Anesthetic Depth on Patient Outcome After Major Surgery

BACKGROUND

An association between relatively deep anesthesia, as guided by the bispectral index (BIS), and increased postoperative mortality has been demonstrated in 6 of 8 published observational studies, but association does not necessarily mean causality. Small clinical trials of anesthetic depth have demonstrated increased delirium and postoperative cognitive dysfunction in patients who were relatively deeply anesthetized, but have been inadequately powered to study mortality. A large-scale randomized study is required to determine whether causality exists.

METHODS

The primary hypothesis of our study is that "light" anesthesia, defined as a BIS target of 50, will reduce all-cause mortality within 1 year of surgery in comparison with "deep" anesthesia, defined as a BIS target of 35, in patients aged ≥60 years presenting for major surgery under general anesthesia. The trial is an international multicenter, randomized, parallel-group, double-blind (patients and investigators) prospective, intention-to-treat, safety and efficacy study. The relative reduction in mortality in the light anesthesia group is expected to be 20%, giving an absolute risk reduction from 10% to 8%. Power analysis using a = 0.049 and b = 0.2 indicates that 3250 patients are required in each group.

RESULTS

The study is underway, and 1325 patients have been recruited in 40 centers in 5 countries. It is anticipated that the study will be completed in 3 years.

CONCLUSIONS

This randomized controlled trial should definitively answer the question of whether titrating anesthetic depth makes a difference to patient outcome in a vulnerable patient group.

Modulation of Dendritic Cell Activation and Subsequent Th1 Cell Polarization by Lidocaine

Dendritic cells play an essential role in bridging innate and adaptive immunity by recognizing cellular stress including pathogen- and damage-associated molecular patterns and by shaping the types of antigen-specific T cell immunity. Although lidocaine is widely used in clinical settings that trigger cellular stress, it remains unclear whether such treatment impacts the activation of innate immune cells and subsequent differentiation of T cells. Here we showed that lidocaine inhibited the production of IL–6, TNFα and IL–12 from dendritic cells in response to toll-like receptor ligands including lipopolysaccharide, poly(I:C) and R837 in a dose-dependent manner. Notably, the differentiation of Th1 cells was significantly suppressed by the addition of lidocaine while the same treatment had little effect on the differentiation of Th17, Th2 and regulatory T cells in vitro. Moreover, lidocaine suppressed the ovalbumin-specific Th1 cell responses in vivo induced by the adoptive transfer of ovalbumin-pulsed dendritic cells. These results demonstrate that lidocaine inhibits the activation of dendritic cells in response to toll-like receptor signals and subsequently suppresses the differentiation of Th1 cell responses.

Enhanced recovery after surgery protocols for open hepatectomy--physiology, immunomodulation, and implementation

There has been recent interest in enhanced-recovery after surgery (ERAS®) or "fast-track" perioperative protocols in the surgical community. The subspecialty field of colorectal surgery has been the leading adopter of ERAS protocols, with less data available regarding its adoption in hepato-pancreato-biliary surgery. This review focuses on available data pertaining to the application of ERAS to open hepatectomy. We focus on four fundamental variables that impact normal physiology and exacerbate perioperative inflammation: (1) the stress of laparotomy, (2) the use of opioids, (3) blood loss and blood product transfusions, and (4) perioperative fasting. The attenuation of these inflammatory stressors is largely responsible for the improvements in perioperative outcomes due to the implementation of ERAS-based pathways. Collectively, the data suggest that the implementation of ERAS principles should be strongly considered in all patients undergoing hepatectomy.

[Interaction of anesthetics and analgesics with tumor cells]

The results of preclinical and clinical studies indicate that the perioperative period is a vulnerable period for cancer progression and metastasis. The risk of cancer cell dissemination is enhanced by the combination of surgical manipulation and perioperative immunosuppression. Whether the oncological outcome of cancer patients can be influenced by the choice of anesthetic techniques is still a matter of debate. This review summarizes the molecular characteristics of cancer and interaction of anesthetic and analgesic drugs with cancer cells.