Propofol-based total intravenous anesthesia is associated with better survival than desflurane anesthesia in limb-salvage surgery for osteosarcoma: A retrospective analysis

Effects of anesthesia on long-term survival in cancer surgery: A systematic review and meta-analysis

Backgrounds

The association between anesthesia and long-term oncological outcome after cancer surgery remains controversial. This study aimed to investigate the effect of propofol-based anesthesia and inhalation anesthesia on long-term survival in cancer surgery.

Methods

A comprehensive literature search was performed in PubMed, Medline, Embase, and the Cochrane Library until November 15, 2023. The outcomes included overall survival (OS) and recurrence-free survival (RFS). The hazard ratio (HR) and 95 % confidence interval (CI) were calculated with a random-effects model.

Results

We included forty-two retrospective cohort studies and two randomized controlled trials (RCTs) with 686,923 patients. Propofol-based anesthesia was associated with improved OS (HR = 0.82, 95 % CI:0.76-0.88, P < 0.00001) and RFS (HR = 0.80, 95 % CI:0.73-0.88, P < 0.00001) than inhalation anesthesia after cancer surgery. However, these positive results were only observed in single-center studies (OS: HR = 0.76, 95 % CI:0.68-0.84, P < 0.00001; RFS: HR = 0.76, 95 % CI:0.66-0.87, P < 0.0001), but not in multicenter studies (OS: HR = 0.98, 95 % CI:0.94-1.03, P = 0.51; RFS: HR = 0.95, 95 % CI:0.87-1.04, P = 0.26). The subgroup analysis revealed that propofol-based anesthesia provided OS and RFS advantages in hepatobiliary cancer (OS: HR = 0.58, 95 % CI:0.40-0.86, P = 0.005; RFS: HR = 0.62, 95 % CI:0.44-0.86, P = 0.005), gynecological cancer (OS: HR = 0.52, 95 % CI:0.33-0.81, P = 0.004; RFS: HR = 0.51, 95 % CI:0.36-0.72, P = 0.0001), and osteosarcoma (OS: HR = 0.30, 95 % CI:0.11-0.81, P = 0.02; RFS: HR = 0.32, 95 % CI:0.14-0.75, P = 0.008) surgeries.

Conclusion

Propofol-based anesthesia may be associated with improved OS and RFS than inhalation anesthesia in some cancer surgeries. Considering the inherent weaknesses of retrospective designs and the strong publication bias, our findings should be interpreted with caution. Well-designed multicenter RCTs are still urgent to further confirm these findings.

Propofol-based total intravenous anesthesia is associated with less postoperative recurrence than desflurane anesthesia in thyroid cancer surgery

BACKGROUND

The effects of anesthesia in patients undergoing thyroid cancer surgery are still not known. We investigated the relationship between the type of anesthesia and patient outcomes following elective thyroid cancer surgery.

METHODS

This was a retrospective cohort study of patients who underwent elective surgical resection for papillary thyroid carcinoma between January 2009 and December 2019. Patients were grouped according to the type of anesthesia they received, desflurane or propofol. A Kaplan-Meier analysis was conducted, and survival/recurrence curves were presented from the date of surgery to death/recurrence. Univariable and multivariable Cox regression models were used to compare hazard ratios for recurrence after propensity matching.

RESULTS

A total of 621 patients (22 deaths, 3.5%) under desflurane anesthesia and 588 patients (32 deaths, 5.4%) under propofol anesthesia were included. Five hundred and eighty-eight patients remained in each group after propensity matching. Propofol anesthesia was not associated with better survival compared to desflurane anesthesia in the matched analysis (P = 0.086). However, propofol anesthesia was associated with less recurrence (hazard ratio, 0.38; 95% confidence interval, 0.25-0.56; P < 0.001) in the matched analysis.

CONCLUSIONS

Propofol anesthesia was associated with less recurrence, but not mortality, following surgery for papillary thyroid carcinoma than desflurane anesthesia. Further prospective investigation is needed to examine the influence of propofol anesthesia on patient outcomes following thyroid cancer surgery.

Anesthesia-related postoperative oncological surgical outcomes: a comparison of total intravenous anesthesia and volatile anesthesia. A meta-analysis

Introduction

In patients undergoing cancer surgery, it is ambiguous whether propofol-based total intravenous anesthesia (TIVA) elicits a significantly higher overall survival rate than volatile anesthetics (VA). Consequently, evaluating the impact of TIVA and VA on long-term oncological outcomes is crucial.

Aim

This study compared TIVA versus VA for cancer surgery patients and investigated the potential correlation between anesthetics and their long-term surgical outcomes.

Material and methods

A comprehensive search of Medline, EMBASE, Scopus, and Cochrane Library identified English-language peer-reviewed journal papers. The statistical measurements of hazard ratio (HR) and 95% CI were calculated. We assessed heterogeneity using Cochrane Q and I2 statistics and the appropriate p-value. The analysis used RevMan 5.3.

Results

The meta-analysis included 10 studies with 14036 cancer patients, 6264 of whom received TIVA and 7777 VA. In this study, we examined the long-term oncological outcomes of cancer surgery patients with TIVA and VA. Our data show that the TIVA group had a considerably higher overall survival rate (HR = 0.49, 95% CI: 0.30-0.80) and recurrence-free survival rate (HR = 0.56, 95% CI: 0.32-0.97). Each outcome was statistically significant (p < 0.05).

Conclusions

The present study concludes that TIVA is a more effective anesthetic agent than VA in obtaining better long-term oncological outcomes in cancer patients after surgery as it provides a higher overall survival rate, a higher recurrence-free survival rate and fewer post-operative pathological findings in patients who have undergone surgery for cancer as compared to VA.

The Potential Effect of General Anesthetics in Cancer Surgery: Meta-Analysis of Postoperative Metastasis and Inflammatory Cytokines

Metastasis or recurrence following curative surgery is the main indicator of tumor progress and is the main cause of patient death. For more than three decades, the potential for general anesthesia to affect cancer outcomes has been a subject of concern with considerable research interest. Here, we conducted this systematic review and meta-analysis to summarize the effect of inhalational anesthesia (IHNA) vs. propofol-based total intravenous anesthesia (TIVA) on metastasis and recurrence after cancer surgery from clinical and pre-clinical studies. The relative risk for metastasis/recurrence in TIVA is 0.61 (95% confidence interval (95% CI) 0.46 to 0.82, p = 0.0009) compared to IHNA. Inflammatory cytokines have been implicated in cancer metastasis following cancer surgery, thus we analyzed inflammatory cytokines levels after surgery under IHNA or TIVA. Based on pooled analysis, a lower IL-6 level was noticed in TIVA in comparison to IHNA (standardized mean difference (SMD) = 0.77, 95% CI = 0.097 to 1.44, I² = 92%, p = 0.02) but not TNF-α or IL-10. Preclinical animal model studies show that inhalational anesthetics increase the risk of breast cancer metastasis compared to propofol. In conclusion, the current evidence suggests intravenous anesthetic propofol is associated with less metastasis/recurrence and lower postoperative IL-6 level over inhaled anesthetics in the oncological surgery. We urge more well-designed clinical and preclinical studies in this field.

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.