Oncological long-term outcome of 4772 patients with prostate cancer undergoing radical prostatectomy: does the anaesthetic technique matter?

Effect of regional anesthesia and analgesia on long-term survival following abdominal cancer Surgery-A systematic review with meta-analysis

Background

The impact of regional anesthesia and analgesia (RAA) on long-term survival following cancer surgery is a topic of debate. The aim of this study was to investigate the effects of perioperative RAA on long-term oncological outcomes in patients undergoing major abdominal cancer surgery.

Methods

The authors searched computerized databases and reference lists from inception to December 20, 2022. All studies that investigated the effects of perioperative RAA on long-term oncological outcomes following major abdominal cancer surgery were included. Using the inverse variance method with a random-effects model, hazard ratios (HR) and 95% confidence intervals (CI) were calculated.

Results

The systematic review included 51 retrospective studies, one prospective study, and three randomized controlled trials (RCTs), with a total of 95,046 patients. The results showed that perioperative RAA may improve long-term overall survival (HR: 0.85, 95% CI: 0.80 to 0.91, P = 0.00, I2 = 60.2%). However, there was no significant association between perioperative RAA and reduced cancer recurrence (HR: 0.98, 95% CI: 0.90 to 1.03, P = 0.31, I2 = 52.3%). When performing a pooled analysis of the data from the three RCTs, no statistically significant effect of RAA was found in either case.

Conclusion

The systematic review suggests perioperative RAA may improve long-term overall survival but does not appear to reduce cancer recurrence in patients undergoing major abdominal cancer surgery. The limited number of RCTs included in this study did not confirm this finding, highlighting the need for further RCTs to corroborate these results.

The Role of Anesthetic Drugs and Statins in Prostate Cancer Recurrence: Starting at the Actual Knowledge and Walking through a New Paradigm

Prostate cancer has become a major health problem in men. Its incidence is increasing as the average age of the affected population tends to be higher. Of all the possible treatments, surgery is the gold standard in its treatment. Surgery produces a deregulation in the immune system that can favour the development of distant metastases. Different anesthetic techniques have raised the hypothesis that different anesthetic drugs influence tumor recurrence and prognosis. Some mechanisms are beginning to be understood by which halogenated agents in cancer patients and the use of opioids may negatively affect patients. In this document, we group together all the available evidence on how the different anesthetic drugs affect tumor recurrence in prostate cancer.

Anesthesia Techniques and Long-Term Oncological Outcomes

Despite advances in cancer treatments, surgery remains one of the most important therapies for solid tumors. Unfortunately, surgery promotes angiogenesis, shedding of cancer cells into the circulation and suppresses anti-tumor immunity. Together this increases the risk of tumor metastasis, accelerated growth of pre-existing micro-metastasis and cancer recurrence. It was theorized that regional anesthesia could influence long-term outcomes after cancer surgery, however new clinical evidence demonstrates that the anesthesia technique has little influence in oncologic outcomes. Several randomized controlled trials are in progress and may provide a better understanding on how volatile and intravenous hypnotics impact cancer progression. The purpose of this review is to summarize the effect of the anesthesia techniques on the immune system and tumor microenvironment (TME) as well as to summarize the clinical evidence of anesthesia techniques on cancer outcomes.

Anesthetic care influences long-term outcomes: What is the evidence?

Despite advances in cancer therapy surgery remains one of the most important treatments for solid tumors; however, even with the development of better and less invasive surgical techniques, surgery is characterized by the increased risk of tumor metastasis, accelerated growth of pre-existing micrometastasis and cancer recurrence. Total intravenous anesthesia (TIVA) and regional anesthesia have been proposed to improve long-term outcomes after cancer surgery by different mechanisms, including attenuation of the neuroendocrine response, immunosuppression, decreased opioid requirements (opioids promote angiogenesis and tumor growth) and avoidance of volatile inhalational agents. Much of the data that support these ideas originate from laboratory studies, while there is no clear consensus from the retrospective cohort studies to date. Several randomized controlled trials (RCTs) are in progress and may provide a better understanding regarding the role of the anesthesiologist in cancer surgery. The purpose of this review is to summarize the experimental and human data regarding the effect of anesthesia agents and anesthesia techniques on cancer outcomes.

Voltage-Gated Sodium Channels as Potential Biomarkers and Therapeutic Targets for Epithelial Ovarian Cancer

Simple Summary

Voltage-gated sodium channels are membrane proteins that change conformation in response to depolarization of the membrane potential, allowing sodium ions to flow into cells. While voltage-gated sodium channels are normally studied in terms of neuron impulses and skeletal or cardiac muscle contraction, abnormal ion channel expression is a feature of many cancer cells. The aim of our study was to assess the expression of voltage-gated sodium channels in ovarian cancer cells. We found that ovarian cancer cells generally express lower levels of voltage-gated sodium channels than normal cells and that two voltage-gated sodium channels, SCN8A and SCN1B, were prognostic biomarkers for ovarian cancer overall survival. In vitro studies suggested that drugs that block voltage-gated sodium channels, such as certain anti-epileptic drugs and local anesthetics, might sensitize ovarian cancer cells to chemotherapy. These findings suggest that voltage-gated sodium channels may be interesting targets for ovarian cancer therapy.

Abstract

Abnormal ion channel expression distinguishes several types of carcinoma. Here, we explore the relationship between voltage-gated sodium channels (VGSC) and epithelial ovarian cancer (EOC). We find that EOC cell lines express most VGSC, but at lower levels than fallopian tube secretory epithelial cells (the cells of origin for most EOC) or control fibroblasts. Among patient tumor samples, lower SCN8A expression was associated with improved overall survival (OS) (median 111 vs. 52 months; HR 2.04 95% CI: 1.21–3.44; p = 0.007), while lower SCN1B expression was associated with poorer OS (median 45 vs. 56 months; HR 0.69 95% CI 0.54–0.87; p = 0.002). VGSC blockade using either anti-epileptic drugs or local anesthetics (LA) decreased the proliferation of cancer cells. LA increased cell line sensitivity to platinum and taxane chemotherapies. While lidocaine had similar additive effects with chemotherapy among EOC cells and fibroblasts, bupivacaine showed a more pronounced impact on EOC than fibroblasts when combined with either carboplatin (ΔAUC −37% vs. −16%, p = 0.003) or paclitaxel (ΔAUC −37% vs. −22%, p = 0.02). Together, these data suggest VGSC are prognostic biomarkers in EOC and may inform new targets for therapy.

The role of regional anaesthesia in the emerging subspecialty of onco-anaesthesia: a state-of-the-art review

Cancer accounts for millions of deaths globally each year, predominantly due to recurrence and metastatic disease. The majority of patients with primary solid organ cancers require surgery, however, some degree of tumour dissemination related to surgery is inevitable. The surgical stress response and associated immunosuppression, pain, inflammation, tissue hypoxia and angiogenesis have all been implicated in promoting tumour survival, proliferation and recurrence. Regional anaesthesia was hypothesised to reduce the surgical stress response and immunosuppression, minimise the need for volatile anaesthesia and reduce pain and opioid requirements, thus mitigating pro-tumour pathways associated with the peri-operative period and improving long-term oncological outcomes. While some retrospective studies suggested an association between regional anaesthesia and reduced cancer recurrence, the first large randomised controlled trial on the effect of anaesthetic technique on cancer outcome found no significant difference between paravertebral regional anaesthesia and volatile anaesthesia with opioid analgesia in patients undergoing breast cancer surgery. Randomised controlled trials on the long-term oncological outcomes of regional anaesthesia in other tumour types are ongoing. The focus on how peri-operative interventions, especially regional anaesthesia, during cancer resection surgery, may enhance short-term recovery and perhaps influence long-term outcome has spawned the global emergence of the subspecialty of onco-anaesthesia. This review aims to discuss the most recent evidence on the use of regional anaesthesia in cancer surgery and the significance of its role in onco-anaesthesia.

The role of regional anesthesia in the propagation of cancer: A comprehensive review. Best Pract Res Clin Anaesthesiol. 2019;33:507-522. [PMID: 31791567 DOI: 10.1016/j.bpa.2019.07.004]

New cancer incidences worldwide will eclipse 18 million in 2019, with nearly 10 million cancer-related deaths. It is estimated that in the United States, almost 40% of individuals will be diagnosed with cancer in their lifetime. Surgical resection of primary tumors remains a cornerstone of cancer treatment; however, the surgical process can trigger an immune-suppressing sympathetic response, which promotes tumor growth of any residual cancerous cells post surgery. Regional and local anesthesia have become staples of anesthesia and analgesia during and after surgery. Recently, much evidence in the form of retrospective and prospective studies has come to light regarding the protective, antitumor properties of anesthetic and analgesic agents across a wide variety of cancers and patient demographics. It is believed that by blocking afferent pain signals, the body does not mount the sympathetic response that contributes to the perpetuation of disease after surgical treatment. This review, therefore, investigates these studies as they pertain to the treatment and outcomes of cancers treated surgically to elucidate the role of regional anesthesia in the propagation of cancer.

Influence of perioperative anaesthetic and analgesic interventions on oncological outcomes: a narrative review. Br J Anaesth. 2019;123:135-150. [PMID: 31255291 DOI: 10.1016/j.bja.2019.04.062]

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

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.

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.

The Prognostic Factors of Biochemical Recurrence-Free Survival Following Radical Prostatectomy

Objective: To evaluate outcomes, biochemical recurrence-free survival (BCRFS) and to identify parameters influencing BCRFS of radical prostatectomy (RP) and bilateral pelvic lymph node dissection in a single-institution. Methods: A retrospective review of prostate cancer (PC) patients received RP was identified from the medical records. Data was collected from 2007 to 2016. 178 patients received RP were enrolled in a study. These patients were evaluated on efficacy of RP by using prostate-specific antigen (PSA) to analyze BCRFS and compared with Gleason score, pathologic staging, margin status and lymph node status with BCRFS. Results: The median follow up was 32.5 months (n = 178). Sixty-nine patients had extracapsular extension on pathologic results whereas 93 patients were classified as a high risk group. The median time for biochemical recurrence (BCR) was 22.3 months. The 3-year BCRFS in patients with a Gleason score 6, 3+4, 4+3, 8 and 9-10 were 85.8%, 84.6%, 78.7%, 53.3% and 35.8% . Multivariate analysis showed that extracapsular extension was independently associated with BCRFS. Conclusions: New group grading system indicates impact on BCRFS on univariate analysis but show negative impact on a multivariate Cox regression, only pathologic staging was independently associated with the cancer control outcome.

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.

Multimodal analgesia and regional anaesthesia

Multimodal analgesia provides quality analgesia, with fewer side effects due to the use of combined analgesics or analgesic techniques. Regional anaesthesia plays a fundamental role in achieving this goal. The different techniques of regional anaesthesia that include both peripheral and central blocks in either a single dose or in continuous infusion help to modulate the nociceptive stimuli that access the central level. The emergence of the ultrasound as an effective system to perform regional anaesthesia techniques has allowed the development of new regional anaesthesia techniques that formerly could not be carried out since only neurostimulation or skin references were used. It is essential to take into account that even with effective blocking it is advisable to associate other drugs by other routes, in this way we will be able to reduce the required doses individually and attempt to achieve a synergistic, not purely additive, effect.

The Relationship Between Regional Anesthesia and Cancer: A Metaanalysis

BACKGROUND

Some studies have suggested using epidural analgesia after cancer surgery to reduce metastasis. This article examines the relationship between regional anesthesia (RA) and cancer metastasis in an array of cancers.

METHODS

We conducted a review of the literature using PubMed and included 67,577 patients across 28 studies in a metaanalysis, evaluating the hazard ratios (HRs) of overall survival, recurrence-free survival, and biochemical recurrence-free survival.

RESULTS

We found no benefit to RA as it relates to cancer. The HR was 0.92 for overall survival, 1.06 for recurrence-free survival, and 1.05 for biochemical recurrence-free survival. Despite the overall analysis showing no benefit, we found some benefit when we evaluated only the randomized trials. However, we found no significant benefit of RA when we evaluated the cancers (gastrointestinal, prostate, breast, and ovarian) individually.

CONCLUSION

This metaanalysis shows that RA has no overall survival, recurrence-free survival, or biochemical recurrence-free survival benefit. However, some individual studies have shown significant benefit in terms of cancer recurrence. Further, RA reduces the use of opioids, which has led to some secondary benefits. Further studies are needed to establish the benefits of RA as it relates to cancer.

A comparison of regional and general anesthesia effects on 5 year survival and cancer recurrence after transurethral resection of the bladder tumor: a retrospective analysis

BACKGROUND

Recent studies have reported that cancer surgeries involving regional anesthesia have better outcomes than those under general anesthesia. However, the effects of anesthetic technique have not been investigated in patients with bladder cancer. Therefore, this retrospective study was conducted to investigate which anesthetic technique results in a better bladder cancer prognosis.

METHODS

Sixty-one of 531 patients underwent transurethral resection of a bladder tumor under general anesthesia from 2001 to 2008 in our hospital. Patients who attended five years of follow-up and who had pathological findings of urothelial carcinoma grades I-II were enrolled. Finally, 24 patients (G group) who underwent general anesthesia and 137 (R group) who underwent regional (spinal or epidural) anesthesia were compared. Five-year survival and recurrence-free time were compared using the chi-square and t-tests, respectively. A logistic regression and partial correlation analysis were performed to evaluate other factors affecting survival.

RESULTS

Five-year survival was 87.5% for general anesthesia and 96.3% for regional (P = 0.099). The regression analysis showed that older age contributed to reduced survival (odds ratio = 0.85, P = 0.001). Regional anesthesia showed higher 5-year survival (coefficient = -0.167, P = 0.044) more than general anesthesia through the partial correlation analysis.

CONCLUSIONS

Though partial correlation analysis show that five-year survival is higher in patients whose surgery is under regional than general anesthesia, the association was not significant in the chi-square test and logistic regression analysis. Large prospective studies are needed to determine whether the association between regional anesthesia and survival is causative.

Regional anesthesia/analgesia and the risk of cancer recurrence and mortality after prostatectomy: a meta-analysis

AIMS

To determine whether the use neuraxial anesthesia/analgesia is associated with longer biochemical recurrence-free survival (BRFS) and overall survival (OS) after radical prostatectomy.

METHODS

Ten studies were included in the meta-analysis. A random-effects model was used to estimate the hazard ratios (HRs).

RESULTS

The HR for BRFS was 1.02 (95% CI: 0.91-1.15) for all studies and 1.08 (95% CI: 0.91-1.15) for those that included propensity score matching. For OS, the HR across all studies was 0.91 (95% CI: 0.7-1.15) and 0.81 (95% CI: 0.68-0.96; p = 0.016) for those reporting propensity score matching.

CONCLUSION

The anesthetic technique used during oncologic prostatectomy surgery is not associated with longer BRFS. By contrast, the use of regional analgesia appears to improve OS.

Prostate cancer and neuroendocrine differentiation: more neuronal, less endocrine?

Neuroendocrine differentiation (NED) marks a structural and functional feature of certain cancers, including prostate cancer (PCa), whereby the malignant tissue contains a significant proportion of cells displaying neuronal, endocrine, or mixed features. NED cells produce, and can secrete, a cocktail of mediators commonly encountered in the nervous system, which may stimulate and coordinate cancer growth. In PCa, NED appears during advanced stages, subsequent to treatment, and accompanies treatment resistance and poor prognosis. However, the term “neuroendocrine” in this context is intrinsically vague. This article seeks to provide a framework on which a unified view of NED might emerge. First, we review the mutually beneficial interplay between PCa and neural structures, mainly supported by cell biology experiments and neurological conditions. Next, we address the correlations between PCa and neural functions, as described in the literature. Based upon the integration of clinical and basic observations, we suggest that it is legitimate to seek for true neural differentiation, or neuromimicry, in cancer progression, most notably in PCa cells exhibiting what is commonly described as NED.

Contemporary 90-day mortality rates after radical cystectomy in the elderly

INTRODUCTION

Existing radical cystectomy (RC) perioperative mortality estimates may underestimate the contemporary rates due to more advanced age, more baseline comorbidities and potentially broader inclusion criteria for RC, relative to past criteria.

METHODS

Within the most recent Surveillance, Epidemiology, and End Results (SEER)-Medicare database we identified clinically non-metastatic, muscle-invasive (T2-T4a) urothelial carcinoma of the urinary bladder (UCUB) patients, who underwent RC between 1991 and 2009. Mortality at 30- and 90-day after RC was quantified. Multivariable logistic regression analyses tested predictors of 90-day mortality.

RESULTS

Within 5207 assessable RC patients 30- and 90-day mortality rates were 5.2 and 10.6%, respectively. According to age 65-69, 70-79 and ≥ 80 years, 90-day mortality rates were 6.4, 10.1 and 14.8% (p < 0.001). Additionally, 90-day mortality rates increased with increasing Charlson Comorbidity Index (CCI, 0, 1, 2 and ≥ 3): 6.3, 10.3, 12.6 and 15.9% (p < 0.001). 90-day mortality rate in unmarried patients was 13.0 vs. 9.3% in married individuals (p < 0.001). In multivariable logistic regression analyses, advanced age, higher CCI, low socioeconomic status, unmarried status and non organ-confined stage were independent predictors of 90-day mortality (all p < 0.05).

CONCLUSIONS

The contemporary SEER-Medicare derived 90-day mortality rates are substantially higher than previously reported estimates from centers of excellence, and even exceed previous SEER reports. More advanced age, higher CCI score, and other patient characteristics that distinguish the current population from others account for these differences.