Effects of anesthetic technique and surgery on myeloid-derived suppressor cells and prognosis in women who underwent breast cancer surgery: a prospective study

Recurrence-free survival after hepatectomy using propofol-based total intravenous anaesthesia and sevoflurane-based inhalational anaesthesia: a randomised controlled study

BACKGROUND

While evidence from preclinical and observational cohort studies have suggested potential disparities in tumour behaviour associated with the choice of intra-operative anaesthetics, clinical evidence of tumour recurrence and metastasis remains inconclusive. We aimed to compare the impact of intra-operative anaesthesia on oncologic outcomes following hepatectomy for hepatocellular carcinoma.

METHODS

Adult patients scheduled for elective hepatectomy for hepatocellular carcinoma were assigned randomly (1:1) to either propofol-based total intravenous anaesthesia or sevoflurane-based inhalational anaesthesia. For recurrence-free survival, overall survival, intrahepatic recurrence-free survival and extrahepatic recurrence-free survival, the survival curves of the two groups were estimated using the Kaplan-Meier method and compared with the log-rank test. The primary outcome was one-year recurrence-free survival.

RESULTS

Among the 536 patients enrolled, primary analysis comprised 228 and 226 patients in the total intravenous anaesthesia and sevoflurane-based inhalational anaesthesia groups, respectively. The probability of recurrence-free survival at one year was 79.1% (47 events) and 77.7% (50 events) in the total intravenous anaesthesia and sevoflurane-based inhalational anaesthesia groups, respectively (adjusted hazard ratio 1.04, 95%CI 0.72-1.52). The probability of intrahepatic and extrahepatic recurrence-free survival, as well as overall survival at one year, was not significantly different between total intravenous anaesthesia and sevoflurane-based inhalational anaesthesia: 81.3% (42 events) vs. 81.7% (41 events); 91.5% (19 events) vs. 88.8% (25 events); 99.1% (2 events) vs. 100.0% (no event), respectively. Subgroup analyses revealed that in patients undergoing open hepatectomy, total intravenous anaesthesia was associated with a significantly lower hazard of tumour recurrence or death (hazard ratio 0.49, 95%CI 0.25-0.95, p = 0.034), while in patients undergoing laparoscopic surgery, no significant difference was observed (hazard ratio 1.14, 95%CI 0.73-1.80, p = 0.558).

DISCUSSION

Intra-operative anaesthesia technique did not affect postoperative recurrence and overall survival in patients with hepatocellular carcinoma undergoing hepatectomy.

Survival benefits of propofol-based versus inhalational anesthesia in non-metastatic breast cancer patients: a comprehensive meta-analysis

Whether the anesthesia technique, inhalational general anesthesia (IGA) or propofol-based anesthesia (PBA), influences the long-term survival of non-metastatic breast cancer (eBC) remain unclear and controversial. We carried out a literature search on 16thJuly, 2022 for studies comparing IGA and PBA in eBC undergoing standard surgery, according to PRISMA 2020. The major endpoint in our study was overall survival (OS). Seventeen studies including four randomized clinical trials and thirteen retrospective cohort studies were included in the meta-analysis. Ten studies provided data for crude OS in unweighted eBC patients (imbalance in baseline characteristics). The summarized estimate HRs of the PBA group versus the IGA group (ten studies, N = 127,774, IGA group: 92,592, PBA group: 35,182.) was 0.83 (95%CI: 0.78-0.89). Compared with IGA, PBA was associated with both better 1-year OS (two studies, N = 104,083, IGA group: 84,074, PBA group: 20,009. Pooled HR = 0.80, 0.73-0.89) and 5-year OS (six studies, N = 121,580, IGA group: 89,472, PBA group: 32,108. HR = 0.80, 0.74-0.87). Ten studies applied PSM method to balance the baseline characteristics. In these weighted patients, PBA still showed a better OS (ten studies, N = 105,459, IGA group: 79,095, PBA group: 26,364. HR = 0.93, 0.87-1.00), a better 1-year OS (two studies, N = 83,007, IGA group: 67,609, PBA group: 15,398. HR = 0.88, 0.78-0.98) and a trend towards a better 5-year OS (nine studies, N = 121,580, IGA group: 76,797, PBA group: 24,066. HR = 0.95, 0.88-1.03). Loco-regional recurrence-free survival (LRRFS) was also better in PBA group (HR = 0.73, 0.61-0.86). The present study is the first comprehensive meta-analysis to demonstrate that propofol-based anesthesia could significantly improve OS and LRRFS in non-metastatic breast cancer patients, compared with inhalational anesthesia.

A potential immunotherapy target for breast cancer: parenchymal and immune-stromal expression of the NLRP3 inflammasome pathway

BACKGROUND

The NOD-, LRR- and pyrin domain‑containing 3 (NLRP3) inflammasome is a critical component of the innate immune system. It has been known to play an important role in the carcinogenesis and prognosis of breast cancer patients. While the clinical evidence of the relationship between NLRP3 inflammasome activation and long-term survival is still limited, the possible roles of parenchymal or immune-stromal cells of breast cancer tissues in contributing to such carcinogenesis and progression still need to be clarified. This study is an analysis of patients receiving breast cancer surgery in a previous clinical trial.

METHODS

Immunohistochemistry (IHC) was used to detect the expression levels of NLRP3 inflammasome pathway-related proteins, including NLRP3, caspase-1, apoptosis-associated speck-like protein (ASC), IL-1β, and IL-18, in parenchymal and immune-stromal cells of breast cancer tissues compared to those of adjacent normal tissues, respectively. The relationship between NLRP3 inflammasome expression and clinicopathological characteristics, as well as 5-year survivals were analyzed using the Chi-square test, Kaplan-Meier survival curves, and Cox regression analysis.

RESULTS

In the parenchymal cells, ASC and IL-18 protein levels were significantly up-regulated in breast cancer tissues compared with adjacent normal tissues (P<0.05). In the immune-stromal cells, all the five NLRP3 inflammasome pathway-related proteins were significantly elevated in breast cancer tissues compared with adjacent normal tissues (P < 0.05). Carcinoma cell embolus was found to significantly correlate with high NLRP3 expression in parenchymal cells of the tumor (x2=4.592, P=0.032), while the expression of caspase-1 was negatively correlated with tumor progression. Histological grades were found to have a positive correlation with IL-18 expression in immune-stromal cells of the tumor (x2=14.808, P=0.001). Kaplan-Meier survival analysis revealed that high IL-18 expression in the immune-stromal cells and the positive carcinoma cell embolus were both associated with poor survival (P < 0.05). The multivariable Cox proportional hazards regression model implied that the high IL-18 expression and positive carcinoma cell embolus were both independent risk factors for unfavorable prognosis.

CONCLUSIONS

The activation of NLRP3 inflammasome pathways in immune-stromal and tumor parenchymal cells in the innate immune system was not isotropic and the main functions are somewhat different in breast cancer patients. Caspase-1 in parenchymal cells of the tumor was negatively correlated with tumor progression, and upregulation of IL-18 in immune-stromal cells of breast cancer tissues is a promising prognostic biomarker and a potential immunotherapy target.

TRIAL REGISTRATION

This clinical trial has been registered at the Chictr.org.cn registry system on 21/08/2018 (ChiCTR1800017910).

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.

The Effect of Propofol versus Inhalation Anesthetics on Survival after Oncological Surgery

Every year, 19.3 million patients worldwide are diagnosed with cancer. Surgical resection represents a major therapeutical option and the vast majority of these patients receive anesthesia. However, despite surgical resection, almost one third of these patients develop local recurrence or distant metastases. Perioperative factors, such as surgical stress and anesthesia technique, have been suggested to play a role to a greater or lesser extent in the development of recurrences, but oncology encompasses a complicated tumor biology of which much is still unknown. The effect of total intravenous anesthesia (TIVA) or volatile anesthesia (VA) on survival after oncological surgery has become a popular topic in recent years. Multiple studies conclude in favor of propofol. Despite the a priori probability that relevant differences in postoperative outcomes are due to the anesthesia technique employed, TIVA or VA, is extremely small. The existing literature includes mainly hypothesis-forming retrospective studies and small randomized trials with many methodological limitations. To date, it is unlikely that use of TIVA or VA affect cancer-free survival days to a clinically relevant extent. This review addresses all relevant studies in the field and provides a substantiated different view on this deeply controversial research topic.

Effect of Different General Anesthesia Methods on the Prognosis of Patients with Breast Cancer after Resection: A Systematic Review and Meta-analysis

Background

The effect of total intravenous anesthesia (TIVA) and inhalation anesthesia (IA) on the prognosis of breast cancer patients has been controversial. The study is aimed at exploring the effects of different anesthesia methods on the postoperative prognosis of breast cancer patients.

Methods

Literature retrieval was conducted in PubMed, EMBASE, MEDLINE, Embase, CENTRAL, and CNKI databases. The literature topic was to compare the effects of TIVA and IA on the prognosis of patients undergoing breast cancer resection. Two researchers extracted data from the literature independently. This study included randomized controlled trials that evaluated for risk of bias according to the “Risk assessment Tool for Bias in Randomized Trials” in the Cochrane Manual. The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in observational studies. The chi-square test was used for the heterogeneity test. Publication bias was assessed using funnel plots and Egger's test. If heterogeneity existed between literature, subgroup analysis and sensitivity analysis were used to explore the source of heterogeneity. Sensitivity analysis was performed by excluding low-quality and different-effect models. Data were statistically analyzed using the Cochrane software RevMan 5.3. Hazard ratio (HR) and 95% confidence interval (CI) were used for statistical description.

Results

Seven literatures were selected for meta-analysis. There were 9781 patients, 3736 (38.20%) receiving TIVA and 6045 (61.80%) receiving inhalation anesthesia. There was no significant difference in overall survival (OS) between TIVA and IA breast cancer patients (HR = 1.05, 95% CI (0.91, 1.22), Z = 0.70, P = 0.49). There was no difference in the literature (χ² = 6.82, P = 0.34, I² = 12%), and there was no obvious publication bias. There was no significant difference in recurrence-free survival (RFS) between TIVA and IA patients (HR = 0.95, 95% CI (0.79, 1.13), Z = 0.61, P = 0.54). There was no heterogeneity in the literature (χ² = 5.23, P = 0.52, I² = 0%), and there was no significant publication bias.

Conclusion

There is no significant difference in OS and RFS between TIVA and IA patients during breast cancer resection. The prognostic effects of TIVA and IA were similar.

Current Status and Prospects of Anesthesia and Breast Cancer: Does Anesthetic Technique Affect Recurrence and Survival Rates in Breast Cancer Surgery?

The relationship between the anesthetic technique and cancer recurrence has not yet been clarified in cancer surgery. Surgical stress and inhalation anesthesia suppress cell-mediated immunity (CMI), whereas intravenous (IV) anesthesia with propofol and regional anesthesia (RA) are known to be protective for CMI. Surgical stress, general anesthesia (GA) with inhalation anesthesia and opioids contribute to perioperative immunosuppression and may increase cancer recurrence and decrease survival. Surgical stress and GA activate the hypothalamic-pituitary-adrenal axis and release neuroendocrine mediators such as cortisol, catecholamines, and prostaglandin E₂, which may reduce host defense immunity and promote distant metastasis. On the other hand, IV anesthesia with propofol and RA with paravertebral block or epidural anesthesia can weaken surgical stress and GA-induced immunosuppression and protect the host defense immunity. IV anesthesia with propofol and RA or in combination with GA may reduce cancer recurrence and improve patient survival compared to GA alone. We review the current status of the relationship between anesthesia and breast cancer recurrence using retrospective and prospective studies conducted with animal models and clinical samples, and discuss the future prospects for reducing breast cancer recurrence and improving survival rates in breast cancer surgery.

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.

Targeting Myeloid-Derived Suppressor Cells Derived From Surgical Stress: The Key to Prevent Post-surgical Metastasis

Myeloid-derived suppressor cells (MDSCs) are known to play an essential part in tumor progression under chronic stress settings through their manipulation of adaptive and innate immune systems. Previous researches mainly focus on MDSC's role in the chronic tumor immune environment. In addition, surgery can also serve as a form of acute stress within the patient's internal environment. Nevertheless, the part that MDSCs play in post-surgical tumor development has not gained enough attention yet. Although surgery is known to be an effective definite treatment for most localized solid tumors, there are still plenty of cancer patients who experience recurrence or metastasis after radical resection of the primary tumor. It is believed that surgery has the paradoxical capability to enhance tumor growth. Many possible mechanisms exist for explaining post-surgical metastasis. We hypothesize that surgical resection of the primary tumor can also facilitate the expansion of MDSCs and their pro-tumor role since these surgery-induced MDSCs can prepare the pre-metastatic niche (the "soil") and at the same time interact with circulating tumor cells (the "seeds"). This vicious, reciprocal mechanism is a crucial point in the emergence of post-surgical metastasis. According to our hypothesis, MDSCs can be the precise target to prevent cancer patients from post-surgical recurrence and metastasis during the perioperative phase to break the wretched cycle and provide better long-term survival for these patients. Future studies are needed to validate this hypothesis.

Comparison of Outcomes After Breast Cancer Surgery Between Inhalational and Propofol-Based Intravenous Anaesthesia: A Systematic Review and Meta-Analysis

Background

General anaesthesia is the commonly provided for breast cancer surgery, but the effects of inhalational anaesthesia and propofol-based intravenous anaesthesia on short- and long-term outcomes after breast cancer surgery are not clear. In this study, we conduct a meta-analysis of randomized controlled trials (RCTs) to explore the superior anaesthetic for breast cancer surgery patients.

Methods

We searched the Embase, Medline, Cochrane Library, Web of Science, CNKI, and Wanfang databases (up to January, 2021) for RCTs in which inhalational anaesthesia and propofol-based intravenous anaesthesia were compared and short- and long-term outcomes were assessed in breast cancer surgical patients. The meta-analysis was performed by Stata 12.0.

Results

Twenty RCTs with a total of 2201 patients were included. Compared with inhalational anaesthesia, propofol-based intravenous anaesthesia was associated with more postoperative rescue analgesia (I²=0%, RR: 1.18, 95% CI: 1.07–1.30, P=0.001) but a lower incidence of postoperative nausea and vomiting (PONV) (I²=25.5%, RR: 0.71, 95% CI: 0.62–0.81, P<0.001) and postoperative rescue antiemetics (I²=0%, RR: 0.69, 95% CI: 0.58–0.82, P<0.001). Propofol-based intravenous anaesthesia preserved nature killer cell cytotoxicity (I²=86.2%, SMD: 0.76, 95% CI: 0.13–1.39, P=0.018), decreased IL-6 level (I²=98.0%, SMD: −3.09, 95% CI: −5.70– −0.48, P=0.021) and neutrophil-to-lymphocyte ratio (I²=0%, SMD: −0.28, 95% CI: −0.53– −0.03, P=0.030), and increased 2-year recurrence-free survival rate (I²=0%, RR: 1.10, 95% CI: 1.00–1.20, P=0.043) but did not affect recurrence or the overall survival rate (P>0.05).

Conclusion

Propofol-based intravenous anaesthesia increases postoperative rescue analgesia but reduces PONV compared with inhalational anaesthesia in breast cancer surgery. The benefit of propofol over inhalational anaesthetics in the preservation of anti-cancer immunity is obvious, but it is difficult to conclude that propofol can exert long-term benefits due to the small sample size.

Modeling of the immune response in the pathogenesis of solid tumors and its prognostic significance

BACKGROUND

Tumor initiation and subsequent progression are usually long-term processes, spread over time and conditioned by diverse aspects. Many cancers develop on the basis of chronic inflammation; however, despite dozens of years of research, little is known about the factors triggering neoplastic transformation under these conditions. Molecular characterization of both pathogenetic states, i.e., similarities and differences between chronic inflammation and cancer, is also poorly defined. The secretory activity of tumor cells may change the immunophenotype of immune cells and modify the extracellular microenvironment, which allows the bypass of host defense mechanisms and seems to have diagnostic and prognostic value. The phenomenon of immunosuppression is also present during chronic inflammation, and the development of cancer, due to its duration, predisposes patients to the promotion of chronic inflammation. The aim of our work was to discuss the above issues based on the latest scientific insights. A theoretical mechanism of cancer immunosuppression is also proposed.

CONCLUSIONS

Development of solid tumors may occur both during acute and chronic phases of inflammation. Differences in the regulation of immune responses between precancerous states and the cancers resulting from them emphasize the importance of immunosuppressive factors in oncogenesis. Cancer cells may, through their secretory activity and extracellular transport mechanisms, enhance deterioration of the immune system which, in turn, may have prognostic implications.