Morphine stimulates cancer progression and mast cell activation and impairs survival in transgenic mice with breast cancer

Morphine Contributes to Epithelial-Mesenchymal Transition in Triple-Negative Breast Cancer Cells by Blocking COX-2 Methylation via Regulating the miR-23a-3p/DNMT3A Feedback

To investigate the effects and mechanisms of morphine on epithelial-mesenchymal transformation (EMT) in triple-negative breast cancer (TNBC). The levels of miR-23a-3p, DNMT3A, and COX-2 in tumor tissues from metastatic TNBC patients treated with morphine were assessed using qRT-PCR. Functional assays assessed morphine's impact on TNBC cell malignancy. Dual luciferase reporter and RNA pull-down assays investigated the interaction between miR-23a-3p and DNMT3A. miR-23a-3p inhibitor and DNMT3A siRNA were transfected into TNBC cells. Protein expression was analyzed by Western blot. Methylation status of miR-23a-3p and COX-2 was assessed via methylation-specific PCR. Rescue experiments were performed to research whether morphine modulates EMT in TNBC through COX-2 methylation regulation via the miR-23a-3p/DNMT3A feedback loop. The effects of morphine on TNBC in nude mice xenotransplantation were studied. In metastatic TNBC patients treated with morphine, miR-23a-3p and COX-2 expression were elevated, and DNMT3A levels were reduced. In TNBC cells, morphine enhanced migration, invasion, and EMT, and suppressed apoptosis. It upregulated miR-23a-3p and COX-2; downregulated DNMT3A; and inhibited methylation of miR-23a-3p and COX-2. miR-23a-3p directly inhibited DNMT3A expression. In morphine-treated TNBC cells, silencing DNMT3A reduced methylation of miR-23a-3p and COX-2. miR-23a-3p inhibitor suppressed migration, invasion, and EMT, and promoted apoptosis; however, these effects were reversed by DNMT3A silencing. In vivo, morphine promoted tumor EMT and metastasis in TNBC; reduced miR-23a-3p and COX-2 methylation; and decreased DNMT3A expression. Morphine accelerated EMT in TNBC by inhibiting COX-2 methylation through the miR-23a-3p/DNMT3A loop.

Potential influence of different peri-operative analgesic regimens on tumour biology and outcome after oncologic surgery: A narrative review

The management of peri-operative pain is one of the pillars of anaesthesia and is of particular importance in patients undergoing surgery for solid malignant tumours. Amongst several options, the most commonly employed analgesic regimens involve opioids, NSAIDs and regional anaesthesia techniques with different local anaesthetics. In recent years, several research reports have tried to establish a connection between peri-operative anaesthesia care and outcome after cancer surgery. Experimental studies have indicated that certain pain management substances may influence cancer progression, mainly by modifying the tumour's response to surgical stress and peri-operative inflammation. However, these promising in-vitro and in-vivo data have yet to be confirmed by randomised clinical trials. The reason for this might lie with the nature of tumour biology itself, and in the diversity of patient and tumour phenotypes. In a translational approach, future research should therefore concentrate on patient and tumour-related factors or biomarkers, which might either influence the tumour and its microenvironment or predict potential responses to interventions, including the choice of the analgesic. This might not only be relevant for the daily practice of clinical anaesthesia, but would also be of great importance for patients undergoing cancer surgery, who might be able to receive an individualised anaesthetic regimen based on their phenotypic profile.

The Comparative Effect of Morphine on Proliferation of Cancer Cell Lines Originating from Different Organs: An In Vitro Study

Background/Objectives: Opium consumption was recently classified by the International Agency for Research on Cancer (IARC) monograph as carcinogenic to humans based on strong evidence for cancers of the larynx, lung, and urinary bladder, and limited evidence for cancers of the oesophagus, stomach, pancreas, and pharynx. This poses the question of a potential pro-cancer effect of pharmaceutical opioid analgesics. In vitro studies employing a variety of experimental conditions suggest that opioid alkaloids have proliferative or antiproliferative effects. We set out to reconcile this discrepancy and explore the hypothesis that opioids promote cancer cell proliferation in an organ-dependent fashion. Methods: Using strictly controlled conditions, we tested the effect of morphine on the proliferation of a series of human cancer cell lines isolated from organs where cancer risk was linked causally to opium consumption in human studies (i.e., lung, bladder, and larynx), or control organs where no link between cancer risk and opium consumption has been reported in human studies (i.e., breast, colon, prostate). Results: Our results showed a minimal effect on proliferation on any cell line and no trend supporting an organ-specific effect of morphine. Conclusions: This argues against a direct effect of opioids on tumour cell proliferation to support their organ-specific effect.

Bidirectional effects of morphine on pancreatic cancer progression via the p38/JNK pathway

Cancer patients commonly use morphine to alleviate advanced pain. Studies have shown that morphine may influence and intervene in the malignancy of various cancers, but its role and effects on pancreatic cancer are less studied. This study aims to examine how morphine affects pancreatic cancer and its possible mechanisms. In vitro experiments were conducted using the CCK-8 experiment, colony formation experiment, EdU test, wound healing experiment, and transwell migration and invasion experiment. Tumor xenograft tests were employed to investigate the in vivo impact of morphine on pancreatic cancer. The Western blot (WB) assay was used to detect possible changes in key proteins of the related signaling pathway. Our experimental results showed that low concentrations of morphine (25 µM) promoted the progression of pancreatic cancer, while high concentrations of morphine (100 µM) inhibited its progression. Further, we demonstrated that morphine may interfere with the progression of pancreatic cancer by acting on the p38/JNK signaling pathway. Morphine may affect pancreatic cancer progression through the p38/JNK pathway in a bidirectional manner at different concentrations.

Can combined paravertebral and erector spinae block provide perioperative analgesia for mastectomy with LD flap reconstruction surgery? An observational study

Background

Mastectomy and breast reconstruction with latissimus dorsi myocutaneous flap (LDF) is a major surgery that covers eight or more dermatomes causing severe pain in the postoperative period.

Objectives

We evaluated the analgesic effect of a hybrid technique of ultrasound-guided combined thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) in a single needle pass in ten consecutive patients scheduled for mastectomy with LDF reconstruction as a part of a multimodal analgesia regimen.

Design

Prospective observational study.

Setting

A tertiary-level cancer hospital in Eastern India. The study was conducted between 01/09/2023 and 20/12/2023.

Patients

10 consecutive consenting female patients of age between 18 and 75 years suffering from breast cancer, scheduled for a mastectomy with LDF reconstruction were recruited in this study, excluding patients with body mass index more than 40, coagulopathy or thrombocytopenia, skin conditions such as dermatitis, infection and so on, and known allergy to local anaesthetics (LAs).

Interventions

The recruited patients received an ultrasound-guided combined thoracic paravertebral and erector spinae (COMPARES) block at the third thoracic (T3) level in a single needle pass, with 10 mL in the TPVB and 30 mL in the ESPB compartment, respectively, in a cephalad to caudad approach before induction of general anaesthesia.

Main outcome measures

The primary endpoint was pain score at 9:00 am on postoperative day one. Other outcome measures were pain scores at postoperative hours 0 (immediately after awakening from general anaesthesia), 4, 8 and 12, postoperative nausea vomiting, requirement of rescue analgesics and pain score on shoulder movements on postoperative day one.

Results

Median (range) resting pain scores at 0, 4, 8 and 24 hours were 1.5 (0-5), 2.5 (0-4), 2.5 (2-5) and 3 (2-4), and dynamic pain score on shoulder mobilization on postoperative day one morning was 3 (2-6). Only one patient required rescue analgesia.

Conclusions

We found the technique inexpensive and potentially useful, but difficult in obese and short-statured patients due to increased depth and narrowing of the intertransverse space. This technique should be further evaluated in a randomised controlled trial.

Trial registration

This trial was registered with the Clinical Trials Registry of India with the registration number CTRI/2023/08/057119.

The role of perioperative factors in the prognosis of cancer patients: A coin has two sides

Cancer, the second leading cause of mortality globally, poses a significant health challenge. The conventional treatment for solid tumors involves surgical intervention, followed by chemo- and radio-therapies as well as target therapies, but the recurrence and metastasis of cancers remain a major issue. Anesthesia is essential for ensuring patient comfort and safety during surgical procedures. Despite its crucial role during the surgery, the precise effect of anesthesia on cancer patient outcomes is not clearly understood. This comprehensive review aims to elucidate the various anesthesia strategies used in the perioperative care of cancer patients and their potential effects on patients' prognosis, but understanding the complex relationship between anesthesia and cancer outcomes is crucial, given the complexity in cancer treaments. Examining potential implications of anesthesia strategies on cancer patient prognosis may help better understand treatment efficacy and risk factors of cancer recurrence and metastasis. Through a detailed analysis of anesthesia practices in cancer surgery, this review aims to provide insights that may lead to improving the existing anesthesia protocols and ultimately reduce risk factors for patient outcomes in the field of oncology.

Impact of opioids and mu-opioid receptors on oncologic metastasis

Opioids are the most effective and widely used treatments for acute and chronic pain in patients with cancer. This review focuses on the impact of opioids and mu-opioid receptors (MORs) on the stages of oncologic metastasis. Studies have shown that opioids can facilitate tumor progression and are related to a poor prognosis in patients with cancer. As the primary receptor for opioids, MORs play a significant role in regulating malignant tumor transformation and are involved in processes, such as proliferation, angiogenesis, epithelial-mesenchymal transition (EMT), circulating tumor cells (CTCs) and the tumor microenvironment (TME). While clinical trials have investigated the relationship between opioids and patient prognosis, further research is needed to clarify the relationship between opioids, MORs and metastasis.

Morphine promotes non-small cell lung cancer progression by downregulating E-cadherin via the PI3K/AKT/mTOR pathway

Morphine has been suggested to affect cancer cell dynamics and decrease survival rates in lung cancer patients at specific doses, but the precise mechanisms poorly understood. In this study, we aimed to investigate the molecular mechanisms by which morphine modulates the malignant characteristics of non-small cell lung cancer. Cell proliferation was assessed via the Cell Counting Kit-8 assay, and cell migration and invasion were examined via wound healing and Transwell assays. We employed immunofluorescence staining to evaluate E-cadherin expression in A549 and Lewis lung cancer (LLC) cell lines and immunohistochemistry to evaluate E-cadherin expression in nude mice tumours. Additionally, the in vivo effects of morphine on lung cancer progression were explored in a xenograft tumour experiments, in which naloxone was used as a morphine antagonist. Western blot analysis was performed to detect E-cadherin, phosphorylated mTOR (p-mTOR), mTOR, phosphorylated AKT (p-AKT), AKT, phosphorylated PI3K (p-PI3K), and PI3K protein levels in A549 and LLC cells as well as in tumour samples. Morphine (10 µM) significantly increased the proliferation of A549 and LLC cells in vitro (p < 0.05). It also enhanced the migratory and invasive capacities of these cell lines (p < 0.01). Mechanistically, morphine treatment (10 µM) led to a reduction in the expression of E-cadherin, and an increase in the phosphorylation of PI3K, AKT, and mTOR in A549 and LLC cells (p < 0.01). Morphine treatment (1.5 mg/kg) also reduced E-cadherin expression in xenograft tumours and promoted tumour growth in vivo (p < 0.05). This effect was reversed by naloxone (0.1 mg/kg). The results demonstrated that morphine stimulates the malignant proliferation of A549 and LLC cell lines and promotes xenograft tumour growth. Perhaps by specifically targeting MOR, morphine triggers a signalling cascade that activates the PI3K/AKT/mTOR pathway while inhibiting the EMT marker E-cadherin, which may consequently promote the progression of lung cancer.

Anesthesia and cancer recurrence: a narrative review

Cancer is a leading cause of death worldwide. With the increasingly aging population, the number of emerging cancer cases is expected to increase markedly in the foreseeable future. Surgical resection with adjuvant therapy is the best available option for the potential cure of many solid tumors; thus, approximately 80% of patients with cancer undergo at least one surgical procedure during their disease. Agents used in general anesthesia can modulate cytokine release, transcription factors, and/or oncogenes. This can affect host immunity and the capability of cancer cells to survive and migrate, not only during surgery but for up to several weeks after surgery. However, it remains unknown whether exposure to anesthetic agents affects cancer recurrence or metastasis. This review explores the current literature to explain whether and how the choice of anesthetic and perioperative medication affect cancer surgery outcomes.

Interpectoral and Pectoserratus Plane Block vs. Local Anesthetic Infiltration for Partial Mastectomy: A Prospective Randomized Trial

Background

Patients undergoing breast surgery are at risk of severe postoperative pain. Several opioid-sparing strategies exist to alleviate this condition. Regional anesthesia has long been a part of perioperative pain management for these patients.

Aim

This randomized study examined the benefits of interpectoral and pectoserratus plane block (IPP/PSP), also known as pectoralis nerve plain block, compared with advanced local anesthetic infiltration.

Methods

We analyzed 57 patients undergoing partial mastectomy with sentinel node dissection. They received either an ultrasound-guided IPP/PSP block performed preoperatively by an anesthetist or local anesthetic infiltration performed by the surgeon before and during the surgery.

Results

Pain measured with the numerical rating scale (NRS) indicated no statistically significant difference between the groups (IPP/PSP 1.67 vs. infiltration 1.97; p value 0.578). Intraoperative use of fentanyl was significantly lower in the IPP/PSP group (0.18 mg vs 0.21 mg; p value 0.041). There was no statistically significant difference in the length of stay in the PACU (166 min vs 175 min; p value 0.51). There were no differences in reported postoperative nausea and vomiting (PONV) between the groups. The difference in postoperative use of oxycodone in the PACU (p value 0.7) and the use of oxycodone within 24 hours postoperatively (p value 0.87) was not statistically significant.

Conclusions

Our study showed decreased intraoperative opioid use in the IPP/PSP group and no difference in postoperative pain scores up to 24 hours. Both groups reported low postoperative pain scores. This trial is registered with NCT04824599.

TEDOFA Trial Study Protocol: A Prospective Double-Blind, Randomized, Controlled Clinical Trial Comparing Opioid-Free versus Opioid Anesthesia on the Quality of Postoperative Recovery and Chronic Pain in Patients Receiving Thoracoscopic Surgery

Introduction

Seeking effective multimodal analgesia and anesthetic regimen is the basis for the success of ERAS. Opioid-free anesthesia (OFA) is a multimodal anesthesia associating hypnotics, N-methyl-D-aspartate (NMDA) antagonists, local anesthetics, anti-inflammatory drugs and α-2 agonists. Although previous studies have confirmed that OFA is safe and feasible for VATS surgery, there is great heterogeneity in how to select and combine anti-harm drugs to replace opioids. We hypothesized that the reduced opioid use during and after surgery allowed by OFA compared with standard of care will be associated with a reduction of postoperative opioid-related adverse events and an improvement in the quality of rehabilitation of patients after partial VATS lung resection.

Methods/Analysis

The TEDOFA Study is a prospective double-blind, randomized, controlled clinical trial with a concealed allocation of patients scheduled to undergo elective partial VATS pneumonectomy 1:1 to receive either a standard anesthesia protocol or an OFA. A total of 146 patients were recruited in the study. Primary endpoint was the 15-item recovery quality scale (QoR-15) at 24 hours after surgery.

Ethics and Dissemination

This trial has been approved by the Institutional Review Board of Beijing Friendship Hospital of China Capital University. The TEDOFA trial study protocol was approved on 27 February 2023. The trial started recruiting patients after registered on the Chinese Clinical Trial Registry.

Trial Registration Number

ChiCTR2300069210; Pre-results.

Influence of exogenous opioids on the acute inflammatory response in the perioperative period of oncological surgery: a clinical study

BACKGROUND

Recently, opioids have been related to trigger changes in cytokine release and tumor angiogenesis processes, influencing tumor growth, metastasis, and recurrence.

METHODS

This is a prospective randomized clinical study to test whether if exogenous opioids used in the anesthesia during cancer surgery can affect the systemic inflammatory and immunological patterns. Patients were randomly allocated to the OP (opioid...inclusive) or OF (opioid-free) anesthesia group. A total of 45 patients were selected, being carriers of prostate, stomach, pancreas, bile ducts, breast, colon, lung, uterus, kidneys, or retroperitoneum tumors. Plasma levels of IL-4, IL-12, IL-17A, and TNF-.., and their oxidative stress profile before and after surgery were evaluated in both groups. In vitro tests were performed by using healthy donor blood incubated with each isolated drug used in patients... anesthesia for 1...hour, the same cytokines were measured in plasma.

RESULTS

There was a significant reduction in lipid peroxidation in both groups. Patients from OF group had a significant consumption of IL-12 in the perioperative period. The other cytokines evaluated did not vary. It was also observed a significant correlation between IL-12 and TNF-.. levels in the OF-post group. Except for atracurium, all tested drugs led to a reduction in IL-12 levels.

CONCLUSIONS

This study demonstrated that there is a reduction of IL-12 in the OF-post patients, suggesting acute consumption and that this seems to be a general mechanism of anesthetic drugs, as demonstrated in vitro. Also, these findings bring us to reflect if IL-12 changes may influence the disease progression and recurrence.

Role of Endorphins in Breast Cancer Pathogenesis and Recovery

Understanding the relationship between stress and breast cancer development is essential to preventing and alleviating the cancer. Recent research has shed light on the cognitive, physiological, cellular, and molecular underpinnings of how the endorphin pathway and stress pathway affect breast cancer. This chapter consists of two parts. Part 1 will discuss the role of endorphins in breast cancer development. This includes a discussion of three topics: (1) the neurophysiological effect of endorphins on breast tumor growth in vivo, along with further experiments that will deepen our knowledge of how β-endorphin affects breast cancer; (2) how both the opioid receptor and somatostatin receptor classes alter intracellular signaling in breast cancer cells; and (3) genetic alleles in the opioid signaling pathway that are correlated with increased breast cancer risk. Part 2 will discuss the role of endorphins in recovery from breast cancer. This includes a discussion of three topics: (1) the relationship between breast cancer diagnosis and depression; (2) the effectiveness of cognitive behavioral therapy in reducing stress in breast cancer patients; and (3) the effect of psychotherapy and exercise on preserving telomere length in breast cancer patients.

Anti-Algics in the Therapeutic Response of Breast and Urological Cancers

The effect of anti-algics on tumor progression and the overall survival of patients is controversial and remains unclear. Herein, we disclose the in vitro effects of the local anesthetics lidocaine, ropivacaine, and levobupivacaine on breast (MCF7), prostate (PC3, LNCaP), and bladder (TCCSUP, HT1376) cancer cell lines, both as monotherapy and in combination with standard-of-care therapeutics. Assays for cell proliferation, viability, death profile, and migration were performed. Additionally, we explored the clinical outcomes of opioid use through a cross-sectional study involving 200 metastatic prostate cancer patients. The main clinical data collected included the type of opioid therapy administered, dosage, treatment duration, disease progression, and overall survival. Results obtained demonstrate that treatment with local anesthetics has a promising selective anti-tumor effect on these types of cancer, with higher effects when associated with docetaxel. This points out the use of local anesthetics as an added value in the treatment of prostate carcinoma patients. Alternatively, chronic opioid use was correlated with reduced overall survival (p < 0.05) and progression-free survival (p < 0.05) at each treatment line in the observational study. While these results provide valuable insights, larger prospective studies are imperative to comprehensively evaluate the clinical impact of opioid analgesics in prostate cancer patients.

Activation of kappa opioid receptor (KOR) inhibits estrogen receptor (ER)-positive breast cancer through the KOR-ER-XBP1 pathway

Opioids are commonly used in patients with breast cancer (BC), both for perioperative analgesia and for the relief of chronic cancer pain. Studies have suggested a potential association of opioid receptors (ORs) with the prognosis of BC patients. However, the exact roles of different ORs remain poorly understood. In this study, we found that κ opioid receptor (KOR) was the only OR (among the four types of ORs) that was significantly decreased in BC tumor tissues compared with peritumoral normal tissues. In addition, decreased expression of KOR correlated with poor clinical outcomes in patients with estrogen receptor (ER)-positive BC. In vitro studies confirmed the anti-tumor effects of KOR agonists in ER-positive MCF-7 and T47D cells by showing that activation of KOR significantly inhibited cellular proliferation and promoted apoptosis. Using Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and protein-protein interaction network (PPI) analysis, we found that KOR-ER-XBP1 was the potential downstream signaling pathway mediating the anti-tumor effects of KOR agonist. Finally, the role of XBP1 was confirmed as KOR activation-induced increase in the proliferative and monoclonal formation abilities of ER-positive BC cells were both significantly abolished after silencing of XBP1. These findings provide us a better understanding of the roles of different ORs in BC, identifying KOR agonists as better opioids than traditional μ opioid receptor (MOR) agonists for providing analgesia in ER-positive BC patients owing to their association with better prognosis.

Crosstalk of Mast Cells and Natural Killer Cells with Neurons in Chemotherapy-Induced Peripheral Neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is a major comorbidity of cancer. Multiple clinical interventions have been studied to effectively treat CIPN, but the results have been disappointing, with no or little efficacy. Hence, understanding the pathophysiology of CIPN is critical to improving the quality of life and clinical outcomes of cancer patients. Although various mechanisms of CIPN have been described in neuropathic anti-cancer agents, the neuroinflammatory process involving cytotoxic/proinflammatory immune cells remains underexamined. While mast cells (MCs) and natural killer (NK) cells are the key innate immune compartments implicated in the pathogenesis of peripheral neuropathy, their role in CIPN has remained under-appreciated. Moreover, the biology of proinflammatory cytokines associated with MCs and NK cells in CIPN is particularly under-evaluated. In this review, we will focus on the interactions between MCs, NK cells, and neuronal structure and their communications via proinflammatory cytokines, including TNFα, IL-1β, and IL-6, in peripheral neuropathy in association with tumor immunology. This review will help lay the foundation to investigate MCs, NK cells, and cytokines to advance future therapeutic strategies for CIPN.

Opioid-Free Versus Opioid-Based Anesthesia on Postoperative Pain After Thoracoscopic Surgery: The Use of Intravenous and Epidural Esketamine

BACKGROUND

The effectiveness and safety of opioid-free anesthesia (OFA) regimens in distinct types of surgeries remain controversial. In this study, we investigated whether OFA could reduce the occurrence of chronic postoperative pain in patients receiving video-assisted thoracoscopic surgery (VATS).

METHODS

We conducted a 2-center, randomized, controlled trial from September 2021 to January 2022. A total of 162 lung tumor patients scheduled to undergo VATS were randomly divided into an opioid-based anesthesia (OA) group and an OFA group. The OA group received general anesthesia combined with thoracic epidural block using morphine, while the OFA group received general anesthesia combined with thoracic epidural block using esketamine. Patient-controlled epidural analgesia (PCEA) was used after surgery (ropivacaine and morphine for the OA group versus ropivacaine and esketamine for the OFA group). The primary end point was chronic pain rates at 3 months after VATS, which were analyzed using a logistic regression model. The secondary end points were chronic pain rates at 6 months, acute pain rates at 24 hours and 48 hours postoperatively, postoperative side effects, and perioperative variables.

RESULTS

The final analysis included 159 patients. Acute postoperative pain at 24 hours occurred in 0 of the 79 (0%) patients in the OA group and 10 of the 80 (17.5%) patients in the OFA group (odds ratio, 52.14; 95% confidence interval [CI], 6.47-420.10; P < .001). Acute postoperative pain at 48 hours occurred in 3 of the 79 (3.8%) patients in the OA group and 2 of the 80 (2.5%) patients in the OFA group (odds ratio, 2.07; 95% CI, 0.99-4.32; P = .053). In this study, none of the patients had moderate or severe pain in either group at 3 and 6 months postsurgically. Mild chronic postoperative pain at 3 months occurred in 27 of the 79 (34.2%) patients in the OA group and 14 of the 80 (17.5%) patients in the OFA group (odds ratio, 3.52; 95% CI, 1.49-8.31; P = .004). At 6 months, mild chronic pain still occurred in 23 of the 79 (29.1%) patients in the OA group and 9 of the 80 (11.3%) patients in the OFA group (odds ratio, 5.55; 95% CI, 2.01-15.33; P = .001). In addition, the OFA group included fewer patients with side effects, including nausea, vomiting, and pruritus, within 48 hours after surgery.

CONCLUSIONS

Replacement of opioids by esketamine, intraoperatively as intravenous injection and epidural infusion and postoperatively as epidural infusion, reduces the incidence of mild chronic postoperative pain and side effects in patients after VATS.

Esketamine opioid-free intravenous anesthesia versus opioid intravenous anesthesia in spontaneous ventilation video-assisted thoracic surgery: a randomized controlled trial

Background

Opioid-free anesthesia (OFA) provides adequate analgesia and can reduce postoperative opioid consumption, but its efficacy in spontaneous ventilation video-assisted thoracic surgery (SV-VATS) has not been demonstrated. We aimed to investigate the hypothesis that OFA could provide the same perioperative pain control as opioid anesthesia (OA), maintain safe and stable respiration and hemodynamics during surgery, and improve postoperative recovery.

Methods

Sixty eligible patients (OFA group: n=30; OA group: n=30) treated between September 15, 2022, and December 15, 2022, at The First Hospital of Guangzhou Medical University were included. They were randomized to receive standard balanced OFA with esketamine or OA with remifentanil combined with sufentanil. The primary outcome was the pain numeric rating score (NRS) at postoperative 24 h, and the secondary outcomes were intraoperative respiratory and hemodynamic data, opioid consumption, vasoactive drug dosage, and recovery in the post-anesthesia care unit and ward.

Results

There was no significant difference in the postoperative pain scores and recovery quality between the two groups. The OFA group had a significantly lower dose of phenylephrine (P=0.001) and a lower incidence of hypotension (P=0.004) during surgery. The OFA group resumed spontaneous respiration faster (P<0.001) and had a higher quality of lung collapse (P=0.02). However, the total doses of propofol and dexmetomidine were higher (P=0.03 and P=0.02), and the time to consciousness was longer (P=0.039) in the OFA group.

Conclusions

OFA provides the same level of postoperative pain control as OA, but it is more advantageous in maintaining circulatory and respiratory stability and improving the quality of pulmonary collapse in SV-VATS.

Mapping the Evidence for Opioid-Mediated Changes in Malignancy and Chemotherapeutic Efficacy: Protocol for a Scoping Review

BACKGROUND

Numerous reports contend opioids can augment or inhibit malignancy. At present, there is no consensus on the risk or benefit posed by opioids on malignancy or chemotherapeutic activity. Distinguishing the consequences of opioid use from pain and its management is challenging. Additionally, opioid concentration data is often lacking in clinical studies. A scoping review approach inclusive of preclinical and clinical data will improve our understanding of the risk-benefit relationship concerning commonly prescribed opioids and cancer and cancer treatment.

OBJECTIVE

The aim of the study is to map diverse studies spanning from preclinical to clinical regarding opioids with malignancy and its treatment.

METHODS

This scoping review will use the Arksey six stages framework to (1) identify the research question; (2) identify relevant studies; (3) select studies meeting criteria; (4) extract and chart data; (5) collate, summarize, and report results; and (6) conduct expert consultation. An initial pilot study was undertaken to (1) parameterize the extent and scale of existing data for an evidence review, (2) identify key factors to be extracted in systematic charting efforts, and (3) assess opioid concentration as a variable for its relevance to the central hypothesis. Six databases will be searched with no filters: MEDLINE, Embase, CINAHL Complete, Cochrane Library, Biological Sciences Collection, and International Pharmaceutical Abstracts. Trial registries will include ClinicalTrials.gov, Cochrane CENTRAL, International Standard Randomised Controlled Trial Number Registry, European Union Clinical Trials Register, and World Health Organization International Clinical Trials Registry. Eligibility criteria will include preclinical and clinical study data on opioids effects on tumor growth or survival, or alteration on the antineoplastic activity of chemotherapeutics. We will chart data on (1) opioid concentration from human subjects with cancer, yielding a "physiologic range" to better interpret available preclinical data; (2) patterns of opioid exposure with disease and treatment-related patient outcomes; and (3) the influence of opioids on cancer cell survival, as well as opioid-related changes to cancer cell susceptibility for chemotherapeutics.

RESULTS

This scoping review will present results in narrative forms as well as with the use of tables and diagrams. Initiated in February 2021 at the University of Utah, this protocol is anticipated to generate a scoping review by August 2023. The results of the scoping review will be disseminated through scientific conference proceedings and presentations, stakeholder meetings, and by publication in a peer-reviewed journal.

CONCLUSIONS

The findings of this scoping review will provide a comprehensive description of the consequences of prescription opioids on malignancy and its treatment. By incorporating preclinical and clinical data, this scoping review will invite novel comparisons across study types that could inform new basic, translational, and clinical studies regarding risks and benefits of opioid use among patients with cancer.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/38167.

Association of preoperative opioid use and postoperative complications following breast reconstruction

BACKGROUND

Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL).

METHODS

We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use.

RESULTS

Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant.

CONCLUSION

We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.

The association between perioperative opioids and breast cancer recurrence: a narrative review of the literature

Background and Objective

Opioid use disorder is an evolving crisis, and 17.2% of postsurgical patients continue to fill an opioid prescription one year after surgery. Preclinical studies suggest perioperative opioid use, defined here as opioids used in the setting of operative pain, may be linked to inferior oncologic outcomes. If this were true, opioid minimization strategies for surgical patients may reduce opioid-related deaths in more than one way. This review aims to describe the association between perioperative opioid use and breast cancer recurrence.

Methods

On November 1, 2021, we searched the Ovid and EMBASE databases for the terms "breast neoplasm", "opioid analgesics", "neoplasm recurrence", and "neoplasm metastasis". Of the 350 articles retrieved, 11 met our inclusion criteria. The review was undertaken using the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) checklist for quality.

Key Content and Findings

Clinical studies report no clear association between perioperative opioid use and local or distant breast cancer recurrence. Mixed results were found when assessing perioperative opioid use and overall survival. Multiple studies paradoxically found opioid use to be associated with lower recurrence rates, despite higher mortality rates. Most studies showed no difference in recurrence or survival in breast cancer surgery patients who did or did not receive opioid-containing analgesia, although most findings were limited by study design and low event rates in patients with breast cancer.

Conclusions

The lack of a clear connection between perioperative opioid use and breast cancer recurrence contradicts some preclinical data, which describes mechanisms through which opioids upregulate tumor proliferation which might worsen oncologic outcomes. Existing clinical literature is limited to mostly retrospective studies in patients with predominantly early-stage breast cancers, with low event rates. Given the worsening opioid epidemic and preclinical study findings, opioid minimization strategies should still be explored. Future work should be prospective and examine cancer recurrence in high-risk patients with more advanced tumor pathologies.

The role of KLF transcription factor in the regulation of cancer progression

Kruppel-like factors (KLFs) are a family of zinc finger transcription factors that have been found to play an essential role in the development of various human tissues, including epithelial, teeth, and nerves. In addition to regulating normal physiological processes, KLFs have been implicated in promoting the onset of several cancers, such as gastric cancer, lung cancer, breast cancer, liver cancer, and colon cancer. To inhibit cancer progression, various existing medicines have been used to modulate the expression of KLFs, and anti-microRNA treatments have also emerged as a potential strategy for many cancers. Investigating the possibility of targeting KLFs in cancer therapy is urgently needed, as the roles of KLFs in cancer have not received enough attention in recent years. This review summarizes the factors that regulate KLF expression and function at both the transcriptional and posttranscriptional levels, which could aid in understanding the mechanisms of KLFs in cancer progression. We hope that this review will contribute to the development of more effective anti-cancer medicines targeting KLFs in the future.

The Interactions of Magnesium Sulfate and Cromoglycate in a Rat Model of Orofacial Pain; The Role of Magnesium on Mast Cell Degranulation in Neuroinflammation

Mast cell degranulation impacts the development of pain and inflammation during tissue injury. We investigated the antinociceptive effect of a combination of cromoglycate and magnesium in the orofacial model of pain and the histological profile of the effect of magnesium in orofacial pain. In male Wistar rats, formalin (1.5%, 100 µL) was injected subcutaneously into the right upper lip of rats after cromoglycate and/or magnesium. Pain was measured as the total time spent on pain-related behavior. Toluidine blue staining was used to visualize mast cells under the light microscope. In the formalin test, in phase 1, magnesium antagonized the antinociceptive effect of cromoglycate, while in phase 2, it potentiated or inhibited its effect. Magnesium significantly reduced mast cell degranulation in the acute phase by about 23% and in the second phase by about 40%. Pearson’s coefficient did not show a significant correlation between mast cell degranulation and pain under treatment with magnesium. The cromoglycate–magnesium sulfate combination may prevent the development of inflammatory orofacial pain. The effect of a combination of cromoglycate–magnesium sulfate depends on the nature of the pain and the individual effects of the drugs. Magnesium reduced orofacial inflammation in the periphery, and this effect did not significantly contribute to its analgesic effect.

Kinin B1 and B2 receptors mediate cancer pain associated with both the tumor and oncology therapy using aromatase inhibitors

Pain caused by the tumor or aromatase inhibitors (AIs) is a disabling symptom in breast cancer survivors. Their mechanisms are unclear, but pro-algesic and inflammatory mediators seem to be involved. Kinins are endogenous algogenic mediators associated with various painful conditions via B1 and B2 receptor activation, including chemotherapy-induced pain and breast cancer proliferation. We investigate the involvement of the kinin B1 and B2 receptors in metastatic breast tumor (4T1 breast cancer cells)-caused pain and in aromatase inhibitors (anastrozole or letrozole) therapy-associated pain. A protocol associating the tumor and antineoplastic therapy was also performed. Kinin receptors' role was investigated via pharmacological antagonism, receptors protein expression, and kinin levels. Mechanical and cold allodynia and muscle strength were evaluated. AIs and breast tumor increased kinin receptors expression, and tumor also increased kinin levels. AIs caused mechanical allodynia and reduced the muscle strength of mice. Kinin B1 (DALBk) and B2 (Icatibant) receptor antagonists attenuated these effects and reduced breast tumor-induced mechanical and cold allodynia. AIs or paclitaxel enhanced breast tumor-induced mechanical hypersensitivity, while DALBk and Icatibant prevented this increase. Antagonists did not interfere with paclitaxel's cytotoxic action in vitro. Thus, kinin B1 or B2 receptors can be a potential target for treating the pain caused by metastatic breast tumor and their antineoplastic therapy.

Immunosuppression by opioids: Mechanisms of action on innate and adaptive immunity

Opioids are excellent analgesics for the clinical treatment of various types of acute and chronic pain, particularly cancer-related pain. Nevertheless, it is well known that opioids have some nasty side effects, including immunosuppression, which is commonly overlooked. As a result, the incidence of opportunistic bacterial and viral infections increases in patients with long-term opioid use. Nowadays, there are no effective medications to alleviate opioid-induced immunosuppression. Understanding the underlying molecular mechanism of opioids in immunosuppression can enable researchers to devise effective therapeutic interventions. This review comprehensively summarized the exogenous opioids-induced immunosuppressive effects and their underlying mechanisms, the regulatory roles of endogenous opioids on the immune system, the potential link between opioid immunosuppressive effect and the function of the central nervous system (CNS), and the future perspectives in this field.

Ultramicronized N-Palmitoylethanolamine Regulates Mast Cell-Astrocyte Crosstalk: A New Potential Mechanism Underlying the Inhibition of Morphine Tolerance

Persistent pain can be managed with opioids, but their use is limited by the onset of tolerance. Ultramicronized N-palmitoylethanolamine (PEA) in vivo delays morphine tolerance with mechanisms that are still unclear. Since glial cells are involved in opioid tolerance and mast cells (MCs) are pivotal targets of PEA, we hypothesized that a potential mechanism by which PEA delays opioid tolerance might depend on the control of the crosstalk between these cells. Morphine treatment (30 μM, 30 min) significantly increased MC degranulation of RBL-2H3 cells, which was prevented by pre-treatment with PEA (100 μM, 18 h), as evaluated by β-hexosaminidase assay and histamine quantification. The impact of RBL-2H3 secretome on glial cells was studied. Six-hour incubation of astrocytes with control RBL-2H3-conditioned medium, and even more so co-incubation with morphine, enhanced CCL2, IL-1β, IL-6, Serpina3n, EAAT2 and GFAP mRNA levels. The response was significantly prevented by the secretome from PEA pre-treated RBL-2H3, except for GFAP, which was further upregulated, suggesting a selective modulation of glial signaling. In conclusion, ultramicronized PEA down-modulated both morphine-induced MC degranulation and the expression of inflammatory and pain-related genes from astrocytes challenged with RBL-2H3 medium, suggesting that PEA may delay morphine tolerance, regulating MC-astrocyte crosstalk.

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.

Total versus inhaled intravenous anesthesia methods for prognosis of patients with lung, breast, or esophageal cancer: A cohort study

Objective

To explore the influences of total intravenous anesthesia (TIVA) and inhaled-intravenous anesthesia on the prognosis of patients with lung, breast, or esophageal cancer.

Methods

In this retrospective cohort study, patients with lung, breast, or esophageal cancer who underwent surgical treatments at Beijing Shijitan Hospital between January 2010 and December 2019 were included. The patients were categorized into the TIVA group and inhaled-intravenous anesthesia group, according to the anesthesia methods used for the patients for surgery of the primary cancer. The primary outcome of this study included overall survival (OS) and recurrence/metastasis.

Results

Totally, 336 patients were included in this study, 119 in the TIVA group and 217 in the inhaled-intravenous anesthesia group. The OS of patients in the TIVA group was higher than in the inhaled-intravenous anesthesia group (P = 0.042). There were no significant differences in the recurrence/metastasis-free survival between the two groups (P = 0.296). Inhaled-intravenous anesthesia (HR = 1.88, 95%CI: 1.15-3.07, P = 0.012), stage III cancer (HR = 5.88, 95%CI: 2.57-13.43, P < 0.001), and stage IV cancer (HR = 22.60, 95%CI: 8.97-56.95, P < 0.001) were independently associated with recurrence/ metastasis. Comorbidities (HR = 1.75, 95%CI: 1.05-2.92, P = 0.033), the use of ephedrine, noradrenaline or phenylephrine during surgery (HR = 2.12, 95%CI: 1.11-4.06, P = 0.024), stage II cancer (HR = 3.24, 95%CI: 1.08-9.68, P = 0.035), stage III cancer (HR = 7.60, 95%CI: 2.64-21.86, P < 0.001), and stage IV cancer (HR = 26.61, 95%CI: 8.57-82.64, P < 0.001) were independently associated with OS.

Conclusion

In patients with breast, lung, or esophageal cancer, TIVA is preferable than inhaled-intravenous anesthesia group for longer OS,, but TIVA was not associated with the recurrence/metastasis-free survival of patients.

Does the Choice of Anaesthesia Affect Cancer? A Molecular Crosstalk between Theory and Practice

In recent years, there has been an increasing scientific interest in the interaction between anaesthesia and cancer development. Retrospective studies show that the choice of anaesthetics may influence cancer outcome and cancer recurrence; however, these studies show contradictory results. Recently, some large randomized clinical trials have been completed, yet they show no significant effect of anaesthetics on cancer outcomes. In this scoping review, we compiled a body of in vivo and in vitro studies with the goal of evaluating the biological effects of anaesthetics on cancer cells in comparison to clinical effects as described in recent studies. It was found that sevoflurane, propofol, opioids and lidocaine are likely to display direct biological effects on cancer cells; however, significant effects are only found in studies with exposure to high concentrations of anaesthetics and/or during longer exposure times. When compared to clinical data, these differences in exposure and dose-effect relation, as well as tissue selectivity, population selection and unclear anaesthetic dosing protocols might explain the lack of outcome.

Investigating the Influence of Anaesthesiology for Cancer Resection Surgery on Oncologic Outcomes: The Role of Experimental In Vivo Models

The incidence and societal burden of cancer is increasing globally. Surgery is indicated in the majority of solid tumours, and recent research in the emerging field of onco-anaesthesiology suggests that anaesthetic-analgesic interventions in the perioperative period could potentially influence long-term oncologic outcomes. While prospective, randomised controlled clinical trials are the only research method that can conclusively prove a causal relationship between anaesthetic technique and cancer recurrence, live animal (in vivo) experimental models may more realistically test the biological plausibility of these hypotheses and the mechanisms underpinning them, than limited in vitro modelling. This review outlines the advantages and limitations of available animal models of cancer and how they might be used in perioperative cancer metastasis modelling, including spontaneous or induced tumours, allograft, xenograft, and transgenic tumour models.

New, long-term opioid use after lung cancer surgery is associated with reduced 2-year survival: a retrospective population-based cohort study in South Korea

INTRODUCTION

We aimed to investigate the proportion and associated factors for new long-term opioid use and its long-term effects after lung cancer surgery.

METHODS

The South Korean National Health Insurance Database was used as a nationwide registration data source. All patients undergoing lung cancer surgery between 2011 and 2018 were included, and patients who were preoperative opioid users were excluded from the analysis. New long-term opioid use was defined as an active opioid prescription at 6 months postoperatively.

RESULTS

In total, 54 509 patients were included in the final analysis. At 6 months postoperatively, 3325 (6.1%) patients who were newly prescribed opioids comprised the new long-term opioid user group. Older age, male sex, wider surgical extent, open thoracotomy, increased Charlson Comorbidity Index score, neoadjuvant or adjuvant chemotherapy, preoperative anxiety disorder and insomnia disorder were associated with a higher rate of new long-term opioid use. The new long-term opioid user group showed a 40% (HR, 1.40; 95% CI 1.29 to 1.53; p<0.001) higher risk of 2-year all-cause mortality. Moreover, the new long-term potent opioid user and less potent opioid user groups showed a 92% (HR, 1.92; 95% CI 1.67 to 2.21; p<0.001) and 22% (HR, 1.22; 95% CI 1.10 to 1.36; p<0.001) higher risk of 2-year all-cause mortality, respectively.

CONCLUSIONS

Among preoperative opioid-naive patients in South Korea, 6.1% became new long-term opioid users after lung cancer surgery. Certain factors are potential risk factors for new long-term opioid use, which could be associated with poorer long-term survival outcomes.

Intraoperative low-dose dopamine is associated with worse survival in patients with hepatocellular carcinoma: A propensity score matching analysis

Background

Dopamine is widely used in patients during surgery. We evaluated the association between intraoperative low-dose dopamine administration and recurrence-free survival (RFS) and overall survival (OS) in patients with hepatocellular carcinoma (HCC).

Methods

Consecutive patients with nonmetastatic HCC who underwent radical hepatectomy were enrolled between 2008 and 2010. Univariate and multivariate logistic regression analyses were used to evaluate the prognostic factors for RFS and OS. Survival outcomes were evaluated using Kaplan–Meier analyses with the log-rank test. A one-to-one propensity score matching (PSM) analysis was performed to reduce confounding bias.

Results

A total of 805 HCC patients, including 699 patients who did not receive dopamine consumption and 106 patients who received low-dose dopamine during the operation, were retrospectively analyzed. The patients who were assigned low-dose dopamine had worse RFS (p = 0.009) and OS (p = 0.041) than those who did not receive dopamine. Multivariate regression analysis showed that the intraoperative administration of low-dose dopamine was an independent unfavorable predictor for RFS (p = 0.004) but not for OS (p = 0.059). After PSM, the low-dose dopamine-treated group still had significantly poorer RFS (p = 0.003) and OS (p = 0.002). When stratified by time of recurrence, patients with low-dose dopamine use had a significantly greater chance of recurrence within 2 years (p = 0.007) but not after 2 years (p = 0.186).

Conclusions

Intraoperative low-dose dopamine use has a negative impact on RFS and OS in HCC patients who have undergone radical hepatectomy. Further prospective studies are required to assess the effects of low-dose dopamine on surgical outcomes in HCC patients.

MOR promotes epithelial-mesenchymal transition and proliferation via PI3K/AKT signaling pathway in human colorectal cancer

The mu-opioid receptor (MOR), a membrane-bound G protein-coupled receptor, is implicated in progression and long-term outcome of several types of tumors. However, the expression and clinical significance of MOR in colorectal cancer (CRC) remain unclear. In this study, a total of 180 paraffin-embedded samples of paired tumors and normal tissues from CRC patients are used to explore expression levels of MOR by immunohistochemistry (IHC). Results show that MOR is highly expressed in tumors compared with that in paired normal tissues (P<0.0001). MOR expression levels are associated with the degree of differentiation (P<0.001) and the regional lymph node metastasis (P<0.001). In addition, a significant difference is also found in the overall survival (OS) between MOR low- and high-expression groups (P=0.002), especially in patients with TNM stage III or IV CRC (P=0.007). Both univariate (P=0.002) and multivariate (P=0.013) analyses indicated that MOR is an independent risk factor associated with CRC prognosis. We further investigate the mechanism in MOR-positive CRC cell line HCT116. The results show that silencing of MOR significantly suppresses epithelial-mesenchymal transition (EMT), in addition to suppressing cell proliferation, migration, and invasion. In addition, the expression of downstream p-AKT is also significantly downregulated, and the above suppression effect could be rescued by PI3K/AKT signaling agonist. We conclude that MOR mediates EMT via PI3K/AKT signaling, facilitating lymph node metastasis and resulting in poor survival of CRC patients. Our findings suggest that MOR is a novel prognostic indicator and the application of opioid receptor antagonists may be a novel therapeutic strategy for CRC patients with high MOR expression.

Morphine counteracts the effects of paclitaxel in triple-negative breast cancer cells

Background & objectives

Several studies have provided evidence that opioids may play a role in cancer recurrence and metastasis. Multiple research data indicate that morphine can act as a proliferative or suppressive agent on tumour cells depending on the applied concentration. Therefore, this study was aimed to investigate whether the presence of clinically relevant concentrations of morphine has any effect on the efficacy of paclitaxel, a widely used chemotherapeutic drug, on the viability and apoptosis of human triple-negative breast cancer cell line.

Methods

MDA.MB.231 cells were treated with paclitaxel in the presence or absence of morphine and examined for cell proliferation by the MTT assay. In addition, the effect of morphine on paclitaxel-induced apoptosis was investigated by flow cytometric assay and by the ratio of Bax/Bcl-2 mRNA expression levels with quantitative real-time (qRT)-PCR.

Results

Morphine significantly increased the proliferation of breast cancer cells at low concentrations (0.1-2.5 μM) but higher concentrations showed cytotoxic effect. Pre-treatment with 0.1 or 1 μM of morphine decreased the paclitaxel-induced cytotoxicity, the proportion of apoptotic cell, and the ratio of Bax/Bcl-2 mRNA expressions.

Interpretation & conclusions

Our data suggest that morphine promotes breast cancer cell viability at clinically relevant plasma concentrations and reduces the apoptotic effect of paclitaxel. This interaction may be very important in clinical settings; however, more studies are needed to explore the plausible mechanisms of interaction and to correlate such findings through in vivo animal studies as well as clinically.

Opioids and cancer survival: are we looking in the wrong place?

There is a controversial narrative in the anaesthetic literature suggesting that anaesthetic technique (including opioids) may be detrimental to survival after tumour resection. The initial observations were retrospective. Several prospective studies are ongoing; one in breast cancer has reported no adverse outcome. The evidence for an effect of opioids stems from three pieces of information: (1) opioids depress the immune system, (2) opioids potentially promote angiogenesis, and (3) opioids potentially support tumour growth. Although the evidence for (2)/(3) is unclear, combinations of these effects are beneficial to tumours and potentially promote metastatic reseeding. Accepted wisdom suggests that opioid effects are driven by opioid receptor activation but the presence of opioid receptors on immune cells for example is unlikely. Immune cells, vascular endothelium and a range of tumour cells express Toll-like receptor 4 (TLR4) receptors (for Gram-negative bacterial wall components), and there is growing evidence for opioids interacting with this alternative receptor; and for some there is paradoxical naloxone sensitivity. Is the focus on opioid receptors and cancer the wrong target? TLR4 receptor activation produces immune activation, stimulates angiogenesis, and supports tumour survival. We know that some opioids are more immune suppressive than others (there is no such comparative information for angiogenesis and tumour survival); this may correlate with TLR4 activation. If there are clusters of opioids that have more opioid than TLR4 profiles and vice versa, this may influence outcome. If this is the case, then evidence-based advice could be given for perioperative use in the oncology-anaesthesia setting.

The other side of the coin: Positive view on the role of opioids in cancer

Opioids have been used for medicinal purposes as an analgesic and recreational purposes as a euphorigenic throughout human history. Cancer patients are often treated with different doses of opioids concurrently with anti-cancer drugs for pain relief without exhibiting excessive adverse effects. The intersection of the biology of pain, opioid therapy, and disease progression represents the crux of the matters and is of potentially great importance in cancer care. For more than 20 years, multiple investigations have focused on the stimulatory effects of opioids on cancer cell growth, while in-depth studies on the inhibitory effects on cancer cell growth development have usually been neglected. This paper reviews the evidence regarding opioid therapies and their anti-cancer effects on various malignancies. Likewise, we have a glimpse into the molecular mechanisms necessary for pinpointing their positive or negative impacts on malignancies to raise awareness and stimulate more excellent dialogue regarding their carcinogenic/anticarcinogenic roles.

Beta 2 adrenergic receptor and mu opioid receptor interact to potentiate the aggressiveness of human breast cancer cell by activating the glycogen synthase kinase 3 signaling

BACKGROUND

Opioid and beta-adrenergic receptors are recently shown to cross talk via formation of receptor heterodimers to control the growth and proliferation of breast cancer cells. However, the underlying cell signaling mechanism remained unclear.

METHODS

To determine the effect of the interaction of the two systems in breast cancer, we employed triple-negative breast cancer cell lines MDA-MB-231 and MDA-MB-468, CRISPR or chemical inhibition or activation of beta-adrenergic receptors (B2AR) and mu-opioid receptors (MOR) gene, and PCR array technology and studied aggressive tumor phenotype and signaling cascades.

RESULTS

We show here that in triple-negative breast cancer cells, the reduction in expression B2AR and MOR by genetic and pharmacological tools leads to a less aggressive phenotype of triple-negative breast cancer cells in vitro and in animal xenografts. Genomic analysis indicates the glycogen synthase kinase 3 (GSK3) pathway as a possible candidate messenger system involved in B2AR and MOR cross talk. GSK3 inactivation in MDA-MB-231 and MDA-MB-468 cells induced similar phenotypic changes as the inhibition of B2AR and/or MOR, while a GSK3 activation by wortmannin reversed the effects of B2AR and/or MOR knockdown on these cells. GSK3 inactivation also prevents B2AR agonist norepinephrine or MOR agonist DAMGO from affecting MDA-MB-231 and MDA-MB-468 cell proliferation.

CONCLUSIONS

These data confirm a role of B2AR and MOR interaction in the control of breast cancer cell growth and identify a possible role of the GSK3 signaling system in mediation of these two receptors' cross talk. Screening for ligands targeting B2AR and MOR interaction and/or the GSK3 system may help to identify novel drugs for the prevention of triple-negative breast cancer cell growth and metastasis.

Chronic Cancer Pain: Opioids within Tumor Microenvironment Affect Neuroinflammation, Tumor and Pain Evolution

Pain can be a devastating experience for cancer patients, resulting in decreased quality of life. In the last two decades, immunological and pain research have demonstrated that pain persistence is primarily caused by neuroinflammation leading to central sensitization with brain neuroplastic alterations and changes in pain responsiveness (hyperalgesia, and pain behavior). Cancer pain is markedly affected by the tumor microenvironment (TME), a complex ecosystem consisting of different cell types (cancer cells, endothelial and stromal cells, leukocytes, fibroblasts and neurons) that release soluble mediators triggering neuroinflammation. The TME cellular components express opioid receptors (i.e., MOR) that upon engagement by endogenous or exogenous opioids such as morphine, initiate signaling events leading to neuroinflammation. MOR engagement does not only affect pain features and quality, but also influences directly and/or indirectly tumor growth and metastasis. The opioid effects on chronic cancer pain are also clinically characterized by altered opioid responsiveness (tolerance and hyperalgesia), a hallmark of the problematic long-term treatment of non-cancer pain. The significant progress made in understanding the immune-mediated development of chronic pain suggests its exploitation for novel alternative immunotherapeutic approaches.

Τhe Effect of Opioid Administration on Cytologic and Histopathologic Diagnosis of Canine Cutaneous Mast Cell Tumors Treated by Surgical Excision

Mast cell tumor (MCT) is a frequent cutaneous tumor in dogs, with a variable biological behavior. Studies correlate cytologic and histopathologic features of MCTs with their biological behavior, prognosis, and response to treatment. The use of preoperative opioids is common in canine patients undergoing surgical removal of these tumors. Certain opioids can induce or downregulate mast cell degranulation and influence cancer progression. The aim of the present study was to investigate whether the administration of morphine or butorphanol during surgical excision of canine cutaneous MCTs affects their cytologic and histopathologic appearance, thus influencing cytologic and histopathologic grading. This was a prospective, blinded, randomized, cohort clinical study. Forty-five dogs with cutaneous MCTs were randomly allocated into three groups according to preanaesthetic medication: dexmedetomidine combined with morphine (group M) or butorphanol (group B) or normal saline (group C). Cytologic specimens and histopathologic samples were obtained both prior to and after surgery. Samples were graded according to Kiupel’s and Patnaik’s systems, examined immunohistochemically for Ki-67 protein (Ki-67) and c-kit proto-oncogene product (KIT) expression, and histochemically for argyrophilic nucleolar organizing regions (AgNORs). Based on both Kiupel’s and Patnaik’s systems, no statistically significant differences were noted concerning the number of cases with grading discrepancies in grades allocated prior to versus after surgery among the groups. The same applied for cytological grading and immunohistochemical and histochemical evaluation. It seems that administration of morphine or butorphanol as part of the preanesthetic medication for surgical removal of canine cutaneous mast cell tumors does not influence histopathologic and cytologic grading of MCTs.

Agonists Specific for κ-Opioid Receptor Induces Apoptosis of HCC Cells Through Enhanced Endoplasmic Reticulum Stress

Cancer pain is an important factor affecting life quality of patients especially in the advanced stage and relieving pain is one of fundamental strategies for cancer treatment. Opioids such as morphine are the most widely used in clinics. However, they have been reported to be associated with the occurrence and development of several types of cancer. Thus, search for an opioid that has analgesic effect and can retard cancer progress simultaneously is critical for cancer management. In this study, we first examined the expression of μ and κ (MOR and KOR) in cell lines and tumor tissues of hepatocellular carcinoma (HCC), a malignant tumor with high mortality, and then compared the effects of opioid receptors-specific agonists on malignant phenotypes of HCC cells in vitro and tumor growth in an HCC xenograft mouse model. KOR and MOR were found to be highly expressed in HCC cell lines and HCC tissues. The KOR-specific agonist U50488h, oxycodone (agonist for both KOR and MOR) and the MOR-specific agonist morphine inhibited HCC cell proliferation, while only U50488h and oxycodone suppressed colony formation and migration of HCC cells. U50488h and oxycodone, but not morphine, induced HCC apoptosis. Further detection of PERK, GRP78 and CHOP revealed that PERK signaling was upregulated by treatment with U50488h, while treatment with the PERK inhibitor GSK2656157 partially reversed the promotion of apoptosis and inhibition of cell proliferation by U50488h, indicating that endoplasmic reticulum stress is associated with its suppressing effect on HCC malignant phenotypes. Similar to the in vitro results, HCC growth was significantly reduced by administration of U50488h and oxycodone, but not by morphine, in the HCC xenograft mouse model. PERK and caspase-3 in the HCC tissues were up-regulated by U50488h treatment as detected by immunohistochemistry and western blotting. Taken together, our results revealed that activation of KOR by U50488h inhibited malignant phenotypes of HCC both in vitro and in vivo, while activation of MOR by morphine did not have such effect. Because of their dual roles in the relief of pain and in the suppression of malignant phenotypes, opioids such as U50488h that act on KOR should be considered as the first choice for HCC management.

Less Well-Known Consequences of the Long-Term Use of Opioid Analgesics: A Comprehensive Literature Review

BACKGROUND

The adverse effects of short-term opioid analgesics are well known and acknowledged; however, the spectrum of the sequelae of long-term use seems less clear. Some effects may remain undetected but still have the potential to cause harm and reduce patients' quality of life.

OBJECTIVE

To review the literature on the adverse effects of long-term opioid therapy.

METHODS

We performed a quasi-systematic search, analyzing articles published in the MEDLINE database between January 2000 and March 2021 that identified adverse effects of opioids used for chronic pain treatment.

RESULTS

Growing evidence indicates that there are multiple serious adverse effects of opioid treatment. Long-term opioid use may have significant effects on the endocrine, immune, cardiovascular, respiratory, gastrointestinal, and neural systems. Studies show that long-term opioid treatment increases the risk of fractures, infections, cardiovascular complications, sleep-disordered breathing, bowel dysfunction, overdose, and mortality. Opioids may potentially affect cancer development. Most consequences of the long-term use of opioids have been identified in studies of patients with non-malignant pain.

CONCLUSION

Studies indicate that long-term use of opioids increases the risk of drug-related events in a significant number of patients. Clinicians should be aware of these complications associated with prescribing opioids, discuss them with patients, prevent complications, if possible, and diagnose them early and manage adequately. More human studies are needed to assess the risk, including trials with individual opioids, because they have different adverse effect profiles.

The Effect of Single-Shot Erector Spinae Plane Block (ESPB) on Opioid Consumption for Various Surgeries: A Meta-Analysis of Randomized Controlled Trials

Study Objective

Design

Setting

Patients

Intervention

Measurements

Results

Conclusion

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.

The Potential Effect of Lidocaine, Ropivacaine, Levobupivacaine and Morphine on Breast Cancer Pre-Clinical Models: A Systematic Review

Breast cancer (BC) is one of the most common types of cancer and the second leading cause of death in women. Local anaesthetics (LAs) and opioids have been shown to influence cancer progression and metastasis formation in several pre-clinical studies. However, their effects do not seem to promote consensus. A systematic review was conducted using the databases Medline (via PubMed), Scopus, and Web of Science (2010 to December 2021). Search terms included "lidocaine", "ropivacaine", "levobupivacaine", "morphine", "methadone", "breast cancer", "breast carcinoma" and "breast neoplasms" in diverse combinations. The search yielded a total of 784 abstracts for initial review, 23 of which met the inclusion criteria. Here we summarise recent studies on the effect of analgesics and LAs on BC cell lines and animal models and in combination with other treatment regimens. The results suggest that local anaesthetics have anti-tumorigenic properties, hence their clinical application holds therapeutic potential. Regarding morphine, the findings are conflicting, but this opioid appears to be a tumour-promoting agent. Methadone-related results are scarce. Additional research is clearly required to further study the mechanisms underlying the controversial effects of each analgesic or LA to establish the implications upon the outcome and prognosis of BC patients' treatment.

Dubious effects of methadone as an "anticancer" drug on ovarian cancer cell-lines and patient-derived tumor-spheroids

BACKGROUND

The opioid agonist D,L-methadone exerts analgesic effects via the mu opioid receptor, encoded by OPRM1 and therefore plays a role in chronic pain management. In preclinical tumor-models D,L-methadone shows apoptotic and chemo-sensitizing effects and was therefore hyped as an off-label "anticancer" drug without substantiation from clinical trials. Its effects in ovarian cancer (OC) are completely unexplored.

METHODS

We analyzed OPRM1-mRNA expression in six cisplatin-sensitive, two cisplatin-resistant OC cell-lines, 170 OC tissue samples and 12 non-neoplastic control tissues. Pro-angiogenetic, cytotoxic and apoptotic effects of D,L-methadone were evaluated in OC cell-lines and four patient-derived tumor-spheroid models.

RESULTS

OPRM1 was transcriptionally expressed in 69% of OC-tissues and in three of eight OC cell-lines. D,L-methadone exposure significantly reduced cell-viability in five OC cell-lines irrespective of OPRM1 expression. D,L-methadone, applied alone or combined with cisplatin, showed no significant effects on apoptosis or VEGF secretion in cell-lines. Notably, in two of the four spheroid models, treatment with D,L-methadone significantly enhanced cell growth (by up to 121%), especially after long-term exposure. This is consistent with the observed attenuation of the inhibitory effects of cisplatin in three spheroid models when adding D,L-methadone. The effect of methadone treatment on VEGF secretion in tumor-spheroids was inconclusive.

CONCLUSIONS

Our study demonstrates that certain OC samples express OPRM1, which, however, is not a prerequisite for D,L-methadone function. As such, D,L-methadone may exert also detrimental effects by stimulating the growth of certain OC-cells and abrogating cisplatin's therapeutic effect.

Anesthesia and Cancer, Friend or Foe? A Narrative Review

Cancer remains the leading cause of death worldwide with close to 10 million deaths reported annually. Due to growth of the advanced age cohort in our population, it is predicted that the number of new cancer cases diagnosed between now until 2035 is to reach potentially 24 million individuals, a staggering increase in a relatively short time period. For many solid tumors, surgical resection along with chemotherapy is the best available approach to a potential cure which leads to almost 80% of cancer patients undergoing at least one surgical procedure during the course of their disease. During surgical intervention, the exposure to general anesthesia can be lengthy, complex and often involves various modalities resulting in an important question as to the role, if any, anesthesia may play in primary recurrence or metastatic conversion. Many components of the stress and inflammatory responses exhibited in the perioperative period can contribute to cancer growth and invasion. The agents used to induce and maintain general anesthesia have variable interactions with the immune and neuroendocrine systems and can influence the stress response during surgery. Thus, debating the best type of anesthesia that would help to attenuate sympathetic and/or pro-inflammatory responses while modulating cytokine release and transcription factors/oncogenes remains at the forefront. This may affect inducible cancer cell survival and migratory abilities not only intra-operatively, but also during the immediate post-operative phase of recovery. The ultimate question becomes how and whether the choice of anesthesia may influence the outcomes of cancer surgery with two major approaches being considered, i.e., regional and general anesthesia as well as the various hypnotics, analgesics and sympatholytics commonly used. In this review, we will address the latest information as to the role that anesthesia may play during cancer surgery with specific focus on primary recurrence and metastasis.

Mast cell density in the primary tumor predicts lymph node metastases in patients with breast cancer

Breast cancer (BrCa) is the most frequent neoplastic disease in female, with high morbidity and mortality. Most of the researches were focused on tumor cells concerning their natural evolution, molecular profile, and potential response to therapy. Few and uncertain data are available about the tumor microenvironment and its impact on the progression of the disease. Mast cells (MCs) associated to BrCa have been reported many years ago, but their real and specific role in the biology of this disease remained elusive. In the current study, we have investigated the predictive role of MCs from the primary tumor on lymph node metastasis on patients stratified based on the molecular classification. We investigated 156 patients with BrCa, stratified as luminal A, luminal B, human epidermal growth factor receptor 2 (HER2) type, basal-like, and unclassified. MCs were identified with anti-MC tryptase antibody in a double immunohistochemical reaction combined with anti-cluster of differentiation 34 (CD34) antibody. Mast cell density (MCD) was calculated based on the hot-spot method, on three fields with maximum density of MCs in each case. The final result was the arithmetic media that was compared with the molecular profile and lymph node metastases. We found no significant correlation between MCD and the molecular profile of the primary tumor, but we noticed a strong correlation between intratumor MCD and lymph node metastases, regardless of the molecular type.