Anaesthesia after neoadjuvant chemotherapy, immunotherapy or radiotherapy

Cardiotoxicity and peri-operative considerations in immune checkpoint inhibitor and chimeric antigen receptor T-cell therapy: a narrative review

INTRODUCTION

Immunotherapy has transformed cancer treatment, particularly with immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy. Despite their efficacy, these therapies can induce cardiotoxicity, presenting significant clinical challenges. Immune checkpoint inhibitors can cause myocarditis; pericarditis; arrhythmias; and myocardial infarction through immune-mediated inflammation. Chimeric antigen receptor T-cell therapy may result in cardiovascular complications due to cytokine release syndrome, including myocardial dysfunction, endothelial damage and arrhythmias.

METHODS

We used PubMed, Embase and Google Scholar to search for peer-reviewed articles in September 2024 without setting any date limits. Our selection criteria encompassed studies focusing on cardiotoxicity related to immune checkpoint inhibitors or chimeric antigen receptor T-cell therapy, comprising original research, meta-analyses, clinical trials and review articles. The findings were reported narratively.

RESULTS

Early diagnosis of cardiotoxicity is critical but challenging due to non-specific symptoms. Diagnostic tools include ECG; cardiac biomarkers; echocardiography; cardiac magnetic resonance imaging; and endomyocardial biopsy. However, no single tool is definitive. High-dose corticosteroids are the first-line treatment for immune checkpoint inhibitor-induced myocarditis, with additional immunosuppressive therapies for refractory cases. Standard heart failure management protocols should be followed in cases of heart failure. Tocilizumab and corticosteroids are utilised for chimeric antigen receptor T-cell therapy-induced cytokine release syndrome, alongside supportive care, including fluid resuscitation and vasopressors for severe cases.

DISCUSSION

As the use of immunotherapy expands, understanding the mechanisms, risk factors and management strategies for cardiotoxicity is increasingly important. Collaborative efforts among oncologists, cardiologists and anaesthetists are essential to mitigate these risks, especially in peri-operative settings. Ongoing research is vital to improve the safe and effective use of immunotherapeutic drugs while minimising cardiovascular adverse effects.

Anaesthetic management of oncological disease in pregnancy: a narrative review

INTRODUCTION

Cancer complicates approximately 1 in 2000 pregnancies, with increasing incidence due to factors such as increased maternal age, obesity and advancements in antenatal testing. Anaesthetists play a crucial role in managing pregnant patients with cancer, both during delivery and in providing anaesthesia for oncological treatments. This review explores the challenges in anaesthetic management and specific considerations for common cancers encountered in pregnant patients.

METHODS

An electronic literature search was carried out using PubMed and Google Scholar to identify peer-reviewed articles published in English from 1 January 1990 to 30 July 2024.

RESULTS

Two main areas were identified: anaesthetic management related to pregnancy and the peripartum period in patients with cancer; and oncological management during pregnancy. Current data suggest that pregnancy does not worsen cancer prognosis, but diagnosis and treatment are complicated by the overlap of cancer symptoms with physiological changes of pregnancy and concerns about the safety of diagnostic procedures and treatments. Ultrasound and magnetic resonance imaging are preferred imaging modalities, while careful use of ionising radiation is advised. Treatment during pregnancy, including surgery, chemotherapy and radiotherapy is possible, with specific timing and modality considerations to ensure maternal and fetal safety. Anaemia, poor nutrition and preterm birth are significant concerns in managing pregnant patients with cancer. For operative births, neuraxial techniques are preferred, though general anaesthesia may be required in complex cases. Comprehensive multidisciplinary support, including psychosocial care, is essential for optimal outcomes. Oncological surgery during pregnancy should preferably be scheduled for the second trimester, with consideration for fetal monitoring and steroids. Regional anaesthesia should be utilised if possible and uteroplacental perfusion maintained. Increased risks of thromboembolism should be addressed postoperatively, along with psychological support.

DISCUSSION

Effective and safe anaesthetic management of cancer in pregnancy requires a multidisciplinary approach to balance maternal and fetal safety, with a focus on careful planning and individualised care.

Effect of different intraoperative blood pressure regulation levels on postoperative myocardial injury in patients undergoing radical mastectomy for breast cancer after receiving neoadjuvant chemotherapy: a study protocol for a randomised controlled trial

INTRODUCTION

For patients with breast cancer receiving preoperative neoadjuvant chemotherapy with anthracyclines, there is an increased risk of postoperative myocardial injury due to the cardiotoxicity of the chemotherapeutic agents. The optimal intraoperative blood pressure regulation regimen for these patients is unclear. This study is being conducted to determine whether targeting mean arterial pressure (MAP) to 100%-120% of the patient's baseline blood pressure reduces the incidence of myocardial injury after non-cardiac surgery (MINS) compared with targeting MAP to 80%-100%. MINS is defined as elevated cardiac troponin levels within 30 days after non-cardiac surgery with or without clinical and electrocardiographic signs of cardiac ischaemia.

METHODS AND ANALYSIS

The study is a single-centre, single-blind, prospective randomised controlled trial. It is expected to enrol 166 subjects receiving neoadjuvant chemotherapy with anthracyclines, between the ages of 40 and 75 years, scheduled for radical mastectomy. Participants will be randomised 1:1 to a lower-level group:intraoperative MAP control at 80%-100% of baseline values or a higher-level group:intraoperative MAP control at 100%-120% of baseline values. The primary outcome is defined by the incidence of MINS at 6-8 hours, 24 hours and 48 hours postoperatively. The secondary outcomes are heart-type free fatty acid-binding protein values at 1-2 hours, 6-8 hours and 24 hours postoperatively; the incidence of acute kidney injury within 48 hours postoperatively; the Quality of Recovery-15 score at 24 hours, 48 hours postoperatively; post-anaesthesia care unit length of stay; other postoperative cardiovascular complications; the number of times rescue analgesia and antiemetics are required; the time to first ambulation and length of postoperative hospitalisation.

ETHICS AND DISSEMINATION

This study involves the participation of human subjects and has received approval from the Clinical Trial Ethics Committee at The Affiliated Lianyungang Hospital of Xuzhou Medical University (approval number: KY-20230915001). Study results will be presented at scientific meetings and in scientific publications.

TRIAL REGISTRATION NUMBER

ChiCTR2300077675.

Radiotherapy Effects on Airway Management in Patients with Nasopharyngeal Cancer

Background: At present, there is a paucity of data in the literature pertaining to the impact of radiotherapy (RT) on the success of tracheal intubation in patients with nasopharyngeal cancer (NPC). The aim of this study is to investigate the frequency of difficult tracheal intubation in patients with NPC following RT. Methods: Patients with NPC who underwent RT followed by surgery between 2012 and April 2024 at the University Hospital Heidelberg were retrospectively analyzed. Results: Twenty-three patients, predominantly males (73.9%) with a mean age of 52.9 years, were enrolled. Overall, 65.2% of the patients had an American Society of Anesthesiologists (ASA) class of III. The mean total laryngeal dose was 53.5 Gy for the main and boost plan, and the maximum total laryngeal dose was 66.61 Gy. Direct laryngoscopy was performed in 69.6% of cases, followed by 26.1% videolaryngoscopy, and 4.2% required fiberoptic intubation. In total, 47.8% of the patients had a Cormack/Lehane grade of I, followed by 43.5% with grade II and 8.7% with grade III. Overall, 87% of patients were successfully intubated on the first attempt. Conclusions: It has been demonstrated by previous studies that RT has the potential to enhance complications and difficulties encountered during airway management. While the results must be interpreted with caution, our study provides no evidence of severe impairment in advanced airway management in patients with nasopharyngeal cancer who have undergone radiotherapy.

Impact of Radiotherapy on Endotracheal Intubation Quality Metrics in Patients with Esophageal Cancer: A Challenge for Advanced Airway Management?

(1) Background: Currently, no data are available in the literature investigating the influence of radiotherapy (RT) on endotracheal intubation success in patients with esophageal cancer. This study aims to evaluate the impact of RT on endotracheal intubation quality metrics in patients with esophageal cancer. (2) Methods: Patients with esophageal cancer who underwent RT followed by surgery between 2012 and 2023 at the University Hospital Heidelberg, Germany, were retrospectively analyzed. (3) Results: Fifty-five patients, predominantly males 65.5% with a mean age of 64 years, were enrolled. Overall, 81.8% of the patients had an ASA class of III, followed by 27.2% ASA II. The mean prescribed cumulative total dose to the primary tumor and lymph node metastasis was 48.2 Gy with a mean single dose of 1.8 Gy. The mean laryngeal total dose was 40.0 Gy. Direct laryngoscopy was performed in 80.0% of cases, followed by 12.1% videolaryngoscopy, and 7.2% required fiberoptic intubation. Overall, 96.4% of patients were successfully intubated on the first attempt. (4) Conclusions: It has been demonstrated that post-RT effects can increase the risk of airway management difficulties and complications. The results of our study did not indicate any evidence of impaired advanced airway management in patients with esophageal cancer who had undergone RT.

The Use of Muscle Relaxants After Chemotherapy and Radiotherapy

Introduction

Patients after chemotherapy and radiotherapy while being operated can suffer from different systemic problems, which may complicate the anesthetic management. Some interactions between muscle relaxants and chemotherapeutics can occur.

Aim

This article aims to present the use of muscle relaxants in cancer patients who have undergone chemotherapy and radiotherapy.

Material and Methods

Our work is based on the available literature and the authors' experience.

Conclusion

Based on our observations and a thorough examination of the medical literature, it is advisable to exercise significant caution when employing muscle relaxants in individuals undergoing chemotherapy and radiotherapy. All muscle relaxants can behave differently after chemotherapy and radiotherapy, and for this reason, practitioners should familiarize themselves with the pharmacodynamics and pharmacokinetics of their chosen muscle relaxant.

Cytotoxic Activity of Amaryllidaceae Plants against Cancer Cells: Biotechnological, In Vitro, and In Silico Approaches

Cancer is a major cause of death and an impediment to increasing life expectancy worldwide. With the aim of finding new molecules for chemotherapeutic treatment of epidemiological relevance, ten alkaloid fractions from Amaryllidaceae species were tested against six cancer cell lines (AGS, BT-549, HEC-1B, MCF-7, MDA-MB 231, and PC3) with HaCat as a control cell line. Some species determined as critically endangered with minimal availability were propagated using in vitro plant tissue culture techniques. Molecular docking studies were carried out to illustrate binding orientations of the 30 Amaryllidaceae alkaloids identified in the active site of some molecular targets involved with anti-cancer activity for potential anti-cancer drugs. In gastric cancer cell line AGS, the best results (lower cell viability percentages) were obtained for Crinum jagus (48.06 ± 3.35%) and Eucharis bonplandii (45.79 ± 3.05%) at 30 µg/mL. The research focused on evaluating the identified alkaloids on the Bcl-2 protein family (Mcl-1 and Bcl-xL) and HK2, where the in vitro, in silico and statistical results suggest that powelline and buphanidrine alkaloids could present cytotoxic activity. Finally, combining experimental and theoretical assays allowed us to identify and characterize potentially useful alkaloids for cancer treatment.

Opioid-Free Anesthesia and Postoperative Outcomes in Cancer Surgery: A Systematic Review

BACKGROUND

Surgery is an essential component of the treatment of solid tumors, but the perioperative course can be complicated by different factors (including anesthesia). Opioid-free anesthesia (OFA) may mitigate adverse outcomes of opioid-based anesthesia (OBA), but major questions remain on the actual impact in terms of analgesia and the improvement of surgical outcomes. To address this issue, we present a systematic review to evaluate the efficacy of OFA compared to OBA in the specific subset of cancer patients undergoing surgery.

METHODS

following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), we searched MEDLINE, Embase and the Cochrane CENTRAL Library to include randomized controlled trials (RCTs) on adults undergoing oncological surgery, comparing OFA and OBA up to March 2022. Additional papers were added from the reference lists of identified sources. Papers were manually reviewed by two independent authors to ascertain eligibility and subsequent inclusion in qualitative analysis.

RESULTS

only two studies were eligible according to inclusion criteria. It was not possible to perform any meta-analysis. The two studies included patients undergoing prostate and gynecologic surgery on 177 patients, with significant heterogeneity in the outcomes.

CONCLUSIONS

randomized controlled trial specifically addressed to cancer patients are lacking. A knowledge gap exists, neither confirming nor rejecting the capacity of OFA to improve early postoperative outcomes in cancer surgery. Long-term consequences on specific oncological outcomes are far from being elucidated. We expect a growing body of literature in the coming years. Further studies are required with homogeneous methodology and endpoints.