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

Regional anesthesia might reduce recurrence and metastasis rates in adult patients with cancers after surgery: a meta-analysis

BACKGROUND

The influence of anesthesia techniques on cancer recurrence and metastasis following oncological surgery is a topic of growing interest. This meta-analysis investigates the potential effects of regional anesthesia (RA), either independently or combined with general anesthesia (GA), on these outcomes.

METHODS

We performed an extensive search across PubMed, Embase, and the Cochrane Library databases. The primary outcome was cancer recurrence, while the secondary outcomes were local recurrence and distant metastasis. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by utilizing random-effects models. The Newcastle-Ottawa Scale (NOS) was used for quality assessment of observational studies, the Cochrane Risk of Bias Tool for Randomized Trials (Rob 2.0) was used for randomized controlled trials, and all the outcomes were assessed by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

This study included 32 studies comprising 24,724 cancer patients. RA, either alone or in combination with GA, was significantly associated with reduced cancer recurrence compared to GA alone (OR = 0.82; 95% CI = 0.72 to 0.94; p < 0.01). This association remained significant for prostate cancer patients in subgroup analyses (OR = 0.71; 95% CI = 0.51 to 0.98; p = 0.04) and in the context of epidural anesthesia combined with GA. However, there were no significant associations noted for local recurrence or distant metastasis.

CONCLUSIONS

This meta-analysis provides evidence that RA, used alone or adjunctively with GA, is associated with a lower risk of cancer recurrence, particularly in patients with prostate cancer. However, no significant effects were observed on local recurrence or distant metastasis. Further prospective studies should be conducted to clarify this important issue.

Effects of epidural anesthesia on the prognosis of ovarian cancer-a systematic review and meta-analysis

INTRODUCTION

The global low survival rate among ovarian cancer patients has resulted in significant social and economic burdens. Nevertheless, previous studies have produced mixed results when exploring the link between anesthetic techniques and the prognosis of ovarian cancer. The study aims to compare the effect of epidural anesthesia with general anesthesia on survival time after cytoreductive surgery in patients with ovarian cancer.

METHODS

The PubMed (National Library of Medicine), Cochrane library, Web of science, Embase, CNKI (China National Knowledge Internet), Wanfang Med Online (China database), were systematically searched from inception to May, 2023, using the Medical Subject Headings [MeSH] of "Ovarian Neoplasm" and "Anesthesia, Epidural" and free words to identify systematic reviews or meta-analyses. The research methodology involved analyzing randomized controlled trials (RCTs), as well as prospective or retrospective cohort studies, which compared the long-term prognosis of patients with ovarian cancer under general anesthesia combined with epidural anesthesia (GEA) versus general anesthesia alone (GA). The Newcastle Ottawa Scale (NOS) was used to assess methodological quality and bias. Data extraction and assessment of study quality were conducted by two independent reviewers. A meta-analysis was then performed to calculate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). Overall survival (OS) was defined as the primary outcome, time to tumor recurrence (TTR) was the secondary outcome. Epidural anesthesia could be used intraoperatively and immediately postoperatively (EIP), or postoperatively only (EP). GEA includes EIP and EP.

RESULTS

In total, 8 retrospective cohort studies with 2036 participants met the inclusion criteria. The pooled results demonstrated that GEA could extend OS (HR 0.75, 95% CI 0.67-0.84, I2 = 0%, P < 0.05, fixed-effect model) when compared with GA in ovarian cancer patients undergoing cytoreductive surgery, but not TTR (sensitivity analysis revealed substantial heterogeneity among the included studies). The result of analyzing a total of 1490 patients in 4 studies was that EIP had a better prognosis on OS than GA (HR 0.68, 95%CI 0.55-0.85, I2 = 61%, P < 0.05, random-effect model). However, EP had no advantage in TTR (sensitivity analysis revealed it was unstable outcome). Ovarian cancer FIGO(International Federation of Gynecology and Obstetrics) stage III, stage IV compared to stage I on OS was statistically significant, HRs respectively are 3.67 (95%CI 2.25-5.98), I2 = 0%, fixed-effect model, P < 0.05, and 7.43 (95%CI 3.67-15.03), I2 = 31%, fixed-effect model, P < 0.05, but there was no statistically significant difference between stage II and stage I, HR 2.00, 95%CI0.98-4.09, I2 = 0%, fixed-effect model, P > 0.05. 1-10 mm tumor residuals shorten TTR compared with 0 residuals, HR 1.75, 95% CI1.50-2.04, I2 = 0%, fixed-effect model, P < 0.05.

CONCLUSIONS

It is hard to conclude that postoperative epidural analgesia offers greater benefits than GA. However, general anesthesia combined with epidural anesthesia (EIP) can improve overall survival in ovarian cancer patients, allowing the anesthesiologist to use anesthesia techniques to provide a favorable prognosis for the ovarian cancer patient. Tumor staging and the extent of cell reduction are also critical factors that significantly influence the long-prognosis of ovarian cancer patients.

Effect of regional versus general anesthesia on recurrence of non-muscle invasive bladder cancer: a systematic review and meta-analysis of eight retrospective cohort studies

BACKGROUND

Regional anesthesia appears to reduce cancer recurrence, but the optimal anesthesia modality for non-muscle invasive bladder cancer (NMIBC) were still under debate. Therefore, we sought to assess the effect of regional and GA only upon the recurrence and long-term prognosis of NMIBC through this meta-analysis.

METHODS

We performed an extensive literature search of PubMed, Embase, Web of Science, the Cochrane Library and China National Knowledge Infrastructure (up to October 30, 2022) to identify eligible articles on the possible impact of different anesthetic modalities for the recurrence rate of NMIBC.

RESULTS

Eight studies comprising 3764 participants, including 2117 subjects with RA and 1647 with GA, were finally enrolled. Cancer recurrence rate was significantly lower in subjects with RA than those with GA (RR 0.84, 95%CI 0.72-0.98, P = 0.03). We didn't detect the differences between GA and RA in the time of recurrence (SMD 2.07, 95% CI -0.49-4.63, P = 0.11) and cancer progression (RR 1.14, 95%CI 0.71-1.84, P = 0.59). Results from subgroup analysis demonstrated that spinal anesthesia could significantly decrease the incidence of cancer recurrence in comparison with general anesthesia (RR 0.80, 95%CI 0.72-0.88, P < 0.001) and high-risk NMIBC patients who received RA tended to have less recurrence (HR 0.55, 95%CI 0.39-0.79, P = 0.001) than those receiving GA.

CONCLUSIONS

RA, especially spinal anesthesia, may be effective in reducing the recurrence rate after transurethral resection of NMIBC. More prospective experimental and clinical studies are needed to validate our findings.

TRIAL REGISTRATION

INPLASY registration INPLASY2022110097.

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.

Role of spinal anesthesia in robot-assisted radical prostatectomy: Gamble or opportunity?

To the Editor, Although postoperative pain associated with robot-assisted radical prostatectomy (RARP) is less than pain following the open technique, it remains a fundamental issue as it can be a significant source of discomfort for the patient and lengthen recovery times after surgery. The optimal management of pain after RARP is far from being fully elucidated and many factors have to be evaluated to choose the best analgesic approach. [...].

Effectiveness and safety of spinal anesthesia in patients undergoing open radical retropubic prostatectomy

OBJECTIVE

Prostate cancer is one of the most widespread neoplasms affecting the male gender. The most commonly used procedures in various urological centers are laparoscopic and robotic surgery because they are considered minimally invasive techniques. We present our experience in traditional open radical prostatectomy performed under spinal anesthesia.

MATERIALS AND METHODS

We reviewed the clinical courses of 88 consecutive patients who underwent open radical prostatectomy performed under spinal anesthesia at our Institution.

RESULTS

Median age: 67.7 years. Median follow up duration: 48 months. Median pre-operative PSA: 15,9 ng/ml, median Prostate weight: 44.5 gr, median surgical time: 96.5 minutes (range 55-138). Perioperative complications were recorded. The most frequent complication was anemia, 9 cases need blood transfusion after surgery. Complications directly related to spinal anesthesia were not observed. Most patients were discharged within 5 days from the procedure. After two weeks we observed a quick recovery of total continence in 90% of patients. After 6 months all patients were perfectly continent. Erectile dysfunction after 6 months was reported by 48 patients.

CONCLUSIONS

The reasons why the gold standard of radical prostatectomy surgery has been considered general anesthesia are essentially two: the long duration of the surgical procedure and the associated significant blood loss. Multiple evidences show that radical retropubic prostatectomy can be safely performed under spinal anaesthesia with various advantages. It is therefore no longer justified to consider general anesthesia as the gold standard for radical prostatectomy with an open technique.

The Role οf Ion Channels in the Development and Progression of Prostate Cancer

Ion channels have major regulatory functions in living cells. Apart from their role in ion transport, they are responsible for cellular electrogenesis and excitability, and may also regulate tissue homeostasis. Although cancer is not officially classified as a channelopathy, it has been increasingly recognized that ion channel aberrations play an important role in virtually all cancer types. Ion channels can exert pro-tumorigenic activities due to genetic or epigenetic alterations, or as a response to molecular signals, such as growth factors, hormones, etc. Increasing evidence suggests that ion channels and pumps play a critical role in the regulation of prostate cancer cell proliferation, apoptosis evasion, migration, epithelial-to-mesenchymal transition, and angiogenesis. There is also evidence suggesting that ion channels might play a role in treatment failure in patients with prostate cancer. Hence, they represent promising targets for diagnosis, staging, and treatment, and their effects may be of particular significance for specific patient populations, including those undergoing anesthesia and surgery. In this article, the role of major types of ion channels involved in the development and progression of prostate cancer are reviewed. Identifying the underlying molecular mechanisms of the pro-tumorigenic effects of ion channels may potentially inform the development of novel therapeutic strategies to counter this malignancy.

Regional anesthesia did not improve postoperative long-term survival of tumor patients: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Experimental research and clinical trials have reported a positive effect of regional anesthesia (RA) on prognosis of cancers. We systematically reviewed the efficacy of RA on recurrence-free survival (RFS) and overall survival (OS) after oncology surgeries.

METHODS

PubMed, Cochrane library, and Embase were searched from inception to June 20, 2022 for RCTs in which any form of RA was initiated perioperatively. Time-to-event data (hazard ratio (HR)) were extracted independently and in duplicate. The primary outcome was the association of RA with RFS and OS, while the secondary outcomes included time to tumor progression, 5-year RFS, and 5-year OS.

RESULTS

Fifteen RCTs with 5981 participants were included. Compared to GA, RA has no positive effect on RFS (HR, - 0.02; 95% CI, - 0.11 to 0.07), OS (HR, - 0.03; 95% CI, - 0.28 to 0.23), time to tumor progression (0.11; 95% CI, - 0.33 to 0.55), 5-year RFS (risk ratio (RR), 1.24; 95% CI, 0.88 to 1.76)), and 5-year OS (RR, 1.11; 95% CI, 0.85 to 1.44). Subgroup analysis based on study design, patient characteristics and tumor types also showed no effect of RA on RFS or OS.

CONCLUSIONS

Our results demonstrated that there is no significant evidence supporting the role of RA in improving long-term survival after oncology surgeries.

Association of regional anesthesia with oncological outcomes in patients receiving surgery for bladder cancer: A meta-analysis of observational studies

Background

This meta-analysis was conducted to compare cancer recurrence and survival rates in patients with bladder cancer receiving surgery under general anesthesia alone (i.e., GA group) or regional anesthesia (RA) with or without GA (i.e., RA ± GA group).

Methods

Literature search on Cochrane library, EMBASE, Google scholar, and Medline databases was performed to identify all relevant studies from inception to April 30, 2022. The primary outcome was cancer recurrence rate, while the secondary outcomes included overall survival rate and cancer-specific survival rate. Subgroup analyses were performed based on study design [(Propensity-score matching (PSM) vs. no-PSM)] and type of surgery [transurethral resection of bladder tumor (TURBT) vs. radical cystectomy].

Results

Ten retrospective studies with a total of 13,218 patients (RA ± GA group n=4,884, GA group n=8,334) were included. There was no difference between RA ± GA group and GA group in age, the proportion of males, severe comorbidities, the proportion of patients receiving chemotherapy, and the pathological findings (all p >0.05). Patients in the RA ± GA group had significantly lower rate of bladder cancer recurrence [odds ratio (OR): 0.74, 95%CI: 0.61 to 0.9, p=0.003, I^{2 =} 24%, six studies] compared to those in the GA group. Subgroup analyses based on study design revealed a consistent finding, while the beneficial effect of RA ± GA on reducing cancer recurrence was only significant in patients receiving TURBT (p=0.02), but not in those undergoing radical cystectomy (p=0.16). There were no significant differences in overall survival rate and cancer-specific survival rate between RA ± GA and GA groups.

Conclusions

For patients receiving surgery for bladder cancer, the application of regional anesthesia with or without general anesthesia is associated with significant decrease in cancer recurrence, especially in patients undergoing TURBT for non-muscle invasive bladder cancer. Because of the limited number of studies included and potential confounding factors, our results should be interpreted carefully.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022328134.

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.

Anesthesia and cancer recurrence: an overview

Several perioperative factors are responsible for the dysregulation or suppression of the immune system with a possible impact on cancer cell growth and the development of new metastasis. These factors have the potential to directly suppress the immune system and activate hypothalamic-pituitary-adrenal axis and the sympathetic nervous system with a consequent further immunosuppressive effect.Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system, inflammatory system, and angiogenesis, with a possible impact on cancer recurrence and long-term outcome. Even if the current data are controversial and contrasting, it is crucial to increase awareness about this topic among healthcare professionals for a future better and conscious choice of anesthetic techniques.In this article, we aimed to provide an overview regarding the relationship between anesthesia and cancer recurrence. We reviewed the effects of surgery, perioperative factors, and anesthetic agents on tumor cell survival and tumor recurrence.

Anesthesia With Propofol Sedation Reduces Locoregional Recurrence in Patients With Breast Cancer Receiving Total Mastectomy Compared With Non-Propofol Anesthesia

Purpose

We examined locoregional recurrence (LRR) in patients with breast invasive ductal carcinoma (IDC) receiving total mastectomy (TM) under propofol-based paravertebral block-regional anesthesia (PB-RA) versus sevoflurane-based inhalational general anesthesia (INHA-GA) without propofol. All-cause death and distant metastasis were secondary endpoints.

Patients and Methods

Patients with breast IDC receiving TM were recruited through propensity score matching and categorized into INHA-GA with sevoflurane and PB-RA with propofol groups. Cox regression analysis was performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

In the multivariate Cox regression analysis, the adjusted HR (aHR; 95% CI) of LRR for the PB-RA with propofol group was 0.52 (0.28–0.96) compared with the INHA-GA with sevoflurane group. The aHRs of LRR for differentiation grade II, grade III, the American Joint Committee on Cancer clinical stage II, stage III, pathological tumor (pT) stage 2, pT stage 3–4, pathological nodal (pN) stage 1, and pN stage 2–3 were 1.16 (1.04–2.08), 1.28 (1.07–2.12), 3.71 (1.82–7.59), 4.67 (1.65–13.18), 1.09 (1.02–1.21), 1.17 (1.03–2.16), 1.10 (1.03–1.33), and 1.22 (1.06–2.41), respectively, compared with differentiation grade I, clinical stage I, pT1, and pN0. The aHR of LRR for adjuvant RT was 0.88 (0.64–0.94) compared with that for no adjuvant RT.

Conclusion

PB-RA with propofol might be beneficial for reducing LRR in women with breast IDC receiving TM compared with INHA-GA without propofol.

Can Acute Postoperative Pain Management After Tumour Resection Surgery Modulate Risk of Later Recurrence or Metastasis?

Background

Cancer is a leading cause of mortality worldwide, but death is rarely from the primary tumour: Rather it is multi-organ dysfunction from metastatic disease that is responsible for up to 90% of cancer-related deaths. Surgical resection of the primary tumour is indicated in 70% of cases. The perioperative stress response, tissue hypoxia at the site of surgery, and acute pain contribute to immunosuppression and neo-angiogenesis, potentially promoting tumour survival, proliferation, and metastasis. Poorly controlled acute postoperative pain decreases Natural Killer (NK) immune cell activity, which could potentially facilitate circulating tumour cells from evading immune detection. This consequently promotes tumour growth and distal metastasis.

Methods

We conducted a comprehensive literature search for links between acute pain and cancer outcomes using multiple online databases. Relevant articles from January 1st, 2010 to September 1st, 2021 were analysed and appraised on whether postoperative pain control can modulate the risk of recurrence, metastasis, and overall cancer survival.

Results

Although experimental and retrospective clinical data suggest a plausible role for regional anaesthesia in cancer outcome modulation, this has not been supported by the single, largest prospective trial to date concerning breast cancer. While there are mixed results on anaesthesiology drug-related interventions, the most plausible data relates to total intravenous anaesthesia with propofol, and to systemic administration of lidocaine.

Conclusion

The hypothesis that anaesthetic and analgesic technique during cancer surgery could influence risk of subsequent recurrence or metastasis has been prevalent for >15 years. The first, large-scale definitive trial among women with breast cancer found robust equivalent findings between volatile anaesthesia with opioid analgesia and regional anaesthesia. Therefore, while regional anaesthesia during tumour resection does not seem to have any effect on cancer outcomes, it remains plausible that other anaesthetic techniques (e.g. total intravenous anaesthesia and systemic lidocaine infusion) might influence oncologic outcome in other major tumour resection surgery (e.g. colorectal and lung). Therefore, another large trial is needed to definitively answer these specific research questions. Until such evidence is available, perioperative analgesia for cancer surgery of curative intent should be based on patient co-morbidity and non-cancer endpoints, such as optimising analgesia and minimising postoperative complications.

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.

Regional anesthesia and cancer recurrence in patients with late-stage cancer: a systematic review and meta-analysis

BACKGROUND

Whether regional anesthesia may help to prevent disease recurrence in cancer patients is still controversial. The stage of cancer at the time of diagnosis is a key factor that defines prognosis and is one of the most important sources of heterogeneity for the treatment effect. We sought to update existing systematic reviews and clarify the effect of regional anesthesia on cancer recurrence in late-stage cancer patients.

METHODS

Medline, Embase, and Cochrane Library were searched from inception to September 2020 to identify randomized controlled trials (RCTs) and cohort studies that assessed the effect of regional anesthesia on cancer recurrence and overall survival (OS) compared with general anesthesia. Late-stage cancer patients were primarily assessed according to the American Joint Committee on Cancer Cancer Staging Manual (eighth edition), and the combined hazard ratio (HR) from random-effects models was used to evaluate the effect of regional anesthesia.

RESULTS

A total of three RCTs and 34 cohort studies (including 64,691 patients) were identified through the literature search for inclusion in the analysis. The risk of bias was low in the RCTs and was moderate in the observational studies. The pooled HR for recurrence-free survival (RFS) or OS did not favor regional anesthesia when data from RCTs in patients with late-stage cancer were combined (RFS, HR = 1.12, 95% confidence interval [CI]: 0.58-2.18, P = 0.729, I2 = 76%; OS, HR = 0.86, 95% CI: 0.63-1.18, P = 0.345, I2 = 48%). Findings from observational studies showed that regional anesthesia may help to prevent disease recurrence (HR = 0.87, 95% CI: 0.78-0.96, P = 0.008, I2 = 71%) and improve OS (HR = 0.88, 95% CI: 0.79-0.98, P = 0.022, I2 = 79%).

CONCLUSIONS

RCTs reveal that OS and RFS were similar between regional and general anesthesia in late-stage cancers. The selection of anesthetic methods should still be based on clinical evaluation, and changes to current practice need more support from large, well-powered, and well-designed studies.

Paravertebral block in regional anesthesia with propofol sedation reduces locoregional recurrence in patients with breast cancer receiving breast conservative surgery compared with volatile inhalational without propofol in general anesthesia

PURPOSE

We examined locoregional recurrence (LRR) in patients with breast invasive ductal carcinoma (IDC) receiving breast conservative surgery (BCS) under propofol-based paravertebral block-regional anesthesia (PB-RA) versus sevoflurane-based inhalational general anesthesia (INHA-GA) without propofol. All-cause death and distant metastasis were secondary endpoints.

PATIENTS AND METHODS

Patients with breast IDC receiving BCS were recruited through propensity score matching and categorized into INHA-GA with sevoflurane and PB-RA with propofol groups. Cox regression analysis was performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

In the multivariate Cox regression analysis, the adjusted HR (aHR; 95% CI) of LRR for the PB-RA with propofol group was 0.67 (0.46-0.99) compared with the INHA-GA with sevoflurane group. The aHRs of LRR for differentiation grade II, grade III, the American Joint Committee on Cancer clinical stage II, stage III, pathological tumor (pT) stage 2, pT stage 3-4, pathological nodal (pN) stage 2-3, and Her-2 positivity were 1.87 (1.03-3.42), 2.31 (1.20-4.44), 1.67 (1.09-2.56), 2.43 (1.18-4.97), 1.17 (1.03-1.19), 1.28 (1.13-2.24), 1.20 (1.05-2.22), and 1.59 (1.01-2.51), respectively, compared with those for differentiation grade I, clinical stage I, pT1, pN0, and HER-2 negativity. The aHR of LRR for adjuvant radiotherapy was 0.60 (0.38-0.97) compared with that for no adjuvant radiotherapy.

CONCLUSION

PB-RA with propofol might be beneficial for reducing LRR in women with breast IDC receiving BCS compared with INHA-GA without propofol.

Peridural Anesthesia and Cancer-Related Survival after Surgery for Pancreatic Cancer-A Retrospective Cohort Study

Background: In patients with prostatic and breast cancer the application of peridural anesthesia (PDA) showed a beneficial effect on prognosis. This was explained by reduced requirements for general anesthetics and perioperative opioids as well as a lower perioperative stress level. The impact of PDA in patients with more aggressive types of cancer has not been completely elucidated. Here, we analyzed the prognostic influence of PDA on overall survival after surgery as primary in patients that underwent radical resection of pancreatic adenocarcinoma. Methods: Records of 98 consecutive patients were reviewed. In 70 of these cases PDA was applied. Patient characteristics such as demographics, TNM stage, and operative data were retrospectively collected from medical records and analyzed. Survival data were analyzed by Cox’s proportional hazard regression model. Results: Overall, no significant prognostic influence of PDA on recurrence or overall survival (p = 0.762, Hazard Ratio [HR] 0.884, 95% confidence interval [CI] 0.398–1.961) was found. However, there was a trend towards a longer overall survival (p = 0.069, HR 0.394, 95% CI 0.144–1.078) associated with PDA in a subgroup of patients with better differentiation of pancreatic adenocarcinoma. Conclusion: The observation of longer survival associated with PDA in our subgroup of patients with better-differentiated pancreatic carcinomas is in line with previous reports on various other less aggressive tumor entities. Our results indicate that PDA might improve the oncological outcome of patients with pancreatic adenocarcinoma.

The Intersection of Regional Anesthesia and Cancer Progression: A Theoretical Framework

The surgical stress and inflammatory response and volatile anesthetic agents have been shown to promote tumor metastasis in animal and in-vitro studies. Regional neuraxial anesthesia protects against these effects by decreasing the surgical stress and inflammatory response and associated changes in immune function in animals. However, evidence of a similar effect in humans remains equivocal due to the high variability and retrospective nature of clinical studies and difficulty in directly comparing regional versus general anesthesia in humans. We propose a theoretical framework to address the question of regional anesthesia as protective against metastasis.

This theoretical construct views the immune system, circulating tumor cells, micrometastases, and inflammatory mediators as distinct populations in a highly connected system. In ecological theory, highly connected populations demonstrate more resilience to local perturbations but are prone to system-wide shifts compared with their poorly connected counterparts. Neuraxial anesthesia transforms the otherwise system-wide perturbations of the surgical stress and inflammatory response and volatile anesthesia into a comparatively local perturbation to which the system is more resilient. We propose this framework for experimental and mathematical models to help determine the impact of anesthetic choice on recurrence and metastasis and create therapeutic strategies to improve cancer outcomes after surgery.

Phantom Limb Pain and Sensations in Chinese Malignant Tumor Amputees: A Retrospective Epidemiological Study

OBJECTIVE

Phantom limb pain (PLP) was a common problem in malignant tumor amputees that can cause considerable suffering. The purposes of this study were to determine the incidence and factors associated with the occurrence of post-operation PLP, stump limb pain (SLP), and phantom limb sensations (PLS) in tumor amputees within the first month after surgery. Additionally, differences in phantom phenomena between upper and lower extremities were investigated.

METHODS

In total, 162 amputees participated in this retrospective study who underwent malignant limb amputation between 2012 and 2019. Clinical characteristics were collected from medical records and reconfirmed by telephone interviews. A numerical rating scale (NRS) was used to quantitate phantom phenomena. We used analysis of variance and non-parametric statistics for categorical variables and ordinal variables separately.

RESULTS

In the first month after malignant amputation, the incidence of PLP was 54.3%, that of PLS was 65.4%, and that of SLP was 32.7%. The duration of preoperative pain and amputation level was significantly different for the incidence of acute PLP. Further subgroup analysis of amputation level showed that patients whose amputation level was below the wrist and ankle joints had a significantly reduced incidence of PLP (p<0.0083 in Bonferroni test). Binary logistics regression analysis determined that amputation level was the primary risk factor for the incidence of PLP. Factors related to the severity of postoperative PLP also included amputation level, preoperative pain, and amputation times. By comparing the differences between upper and lower limbs after amputation, we found that the incidence of PLS was higher after lower limb amputation, but there was no significant difference in the incidence of PLP and SLP. Preoperative experience of chemotherapy was not a risk factor for PLP.

CONCLUSION

Proximal amputation and long-term preoperative pain seemed to count more for PLP incidence. Further research may be required to individually determine factors associated with the occurrence and chronicity of phantom phenomena.

Anesthesia Options and the Recurrence of Cancer: What We Know so Far?

Surgery is a critical period in the survival of patients with cancer. While resective surgery of primary tumors has shown to prolong the life of these patients, it can also promote mechanisms associated with metastatic progression. During surgery, patients require general and sometimes local anesthetics that also modulate mechanisms that can favor or reduce metastasis. In this narrative review, we summarized the evidence about the impact of local, regional and general anesthesia on metastatic mechanisms and the survival of patients. The available evidence suggests that cancer recurrence is not significantly impacted by neither regional anesthesia nor volatile or total intravenous anesthesia.

Immunomodulatory Effects of Surgery, Pain, and Opioids in Cancer Patients

Surgery is the mainstay of therapy for canine and human solid cancers. Alarmingly, evidence suggests that the process of surgery may exacerbate metastasis and accelerate the kinetics of cancer progression. Understanding the mechanisms by which cancer progression is accelerated as a result of surgery may provide pharmacologic interventions. This review discusses surgery-induced cancer progression. It focuses on immunomodulatory properties of anesthesia and opioids and evidence that studies evaluating the role of opioids in tumor progression are indicated. It concludes by discussing why companion animals with spontaneously arising cancer are an ideal model for clinical trials to investigate this phenomenon.

Peridural analgesia does not impact survival in patients after colon cancer resection: a retrospective propensity score-adjusted analysis

PURPOSE

To assess the putative impact of peridural analgesia on oncological outcome in patients undergoing resection of stages I-IV colon cancer.

METHODS

In a single-center study, 876 patients undergoing resection for primary colon cancer (AJCC stages I-IV) between 2001 and 2014 were analyzed. Mean follow-up of the entire cohort was 4.2 ± 3.5 years. Patients who did and did not receive peridural analgesia were compared using Cox regression and propensity score analyses.

RESULTS

Overall, 208 patients (23.7%) received peridural analgesia. Patients' characteristics were biased with regard to the use of peridural analgesia (propensity score 0.296 ± 0.129 vs. 0.219 ± 0.108, p < 0.001). After propensity score matching, the use of peridural analgesia had no impact on overall (HR 0.81, 95% CI 0.59-1.11, p = 0.175), cancer-specific (HR 0.72, 95% CI 0.48-1.09, p = 0.111), and disease-free survival (HR 0.89, 95% CI 0.66-1.19, p = 0.430). The 5-year overall survival after propensity score matching was 60.9% (95% CI 54.8-67.7%) for patients treated with peridural analgesia compared with 54.1% (95% CI 49.5-59.1%) for patients not treated with peridural analgesia. Cancer-specific and disease-free survival showed similar non-significant results.

CONCLUSIONS

Peridural analgesia in patients after colon cancer resection was not associated with a better oncological outcome after risk adjusting in multivariable Cox regression and propensity score analyses. Hence, oncological outcome should not serve as a reason for the use of peridural analgesia in patients with colon cancer.

Influence of perioperative anaesthetic and analgesic interventions on oncological outcomes: a narrative review

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.

Perioperative epidural use and survival outcomes in patients undergoing primary debulking surgery for advanced ovarian cancer

OBJECTIVE

Epidurals are associated with improved outcomes in some solid tumors, presumably due to their effect on surgical stress response. There are limited data on the prognostic significance of epidural anesthesia in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. We sought to assess the impact of epidural anesthesia on the survival outcomes of patients undergoing PDS for advanced ovarian cancer.

METHODS

In this retrospective study, consecutive patients with stage IIIB-IV epithelial ovarian, fallopian tube, or peritoneal carcinoma who underwent PDS at our institution from 01/2005-12/2013 were identified. Progression-free survival (PFS) and overall survival (OS) with regard to epidural use were analyzed.

RESULTS

Of 648 patients, 435 received an epidural and 213 did not. Patients in the former group were more likely to have higher stage disease (stage IV disease, 26% vs. 16%, respectively; P = .005), carcinomatosis (87% vs. 80%, respectively; P = .027), and bulky upper abdominal disease (66% vs. 58%, respectively; P = .046). Complete gross resection was achieved in 48% and 32%, respectively (P < .001). For the epidural vs. non-epidural groups, median PFS was 20.8 months and 13.9 months, respectively (P = .021); median OS was 62.4 months and 41.9 months, respectively (P < .001). After controlling for confounding factors, including residual disease, epidural use was independently associated with a decreased risk of progression (HR = 1.327; 95% CI, 1.066-1.653) and death (HR = 1.588; 95% CI, 1.224-2.06).

CONCLUSIONS

Perioperative epidural use was independently associated with improved PFS and OS in these patients. Epidural anesthesia at the time of PDS may be warranted in this 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.