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

Effect of Co-Administration of Midazolam and Dexmedetomidine on Haemodynamics and Stress Response in Elderly Patients with Non-Small Cell Lung Cancer

OBJECTIVE

This study aimed to evaluate the effect of co-administration of midazolam and dexmedetomidine on hemodynamics and stress response in elderly patients with non-small cell lung cancer (NSCLC).

METHODS

In this prospective, randomized controlled trial, 154 elderly NSCLC patients scheduled for lobectomy in our oncology department from January 2019 to December 2021 were recruited. Patients were randomized 1:1 to receive either dexmedetomidine (control group) or dexmedetomidine plus midazolam (study group) for anesthesia during lobectomy via the random number table method, with 77 patients in each group. Perioperative indicators, hemodynamics, and stress reactions of the patients were recorded and compared between the two groups to investigate the efficacy of the two different anesthetic protocols.

RESULTS

No significant differences were observed between the two groups in terms of operative time, anesthesia time, and intraoperative bleeding volume (p > 0.05). Preoperative pain, pain at anesthesia recovery, and pain levels 7 days postoperatively were also comparable between the two groups. In the study group, the awakening time was 15 ± 2 min significantly shorter compared to the control group (25 ± 3 min). Cooperation within the first hour was significantly faster by 8.5 ± 0.5 min compared to 6.0 ± 1.0 min in the control group (p < 0.05). The cost of materials used was significantly higher in the study group, with an average of 300 ± 25 USD, compared to 200 ± 20 USD in the control group (p < 0.05). Additionally, the two groups showed no significant difference in the need for experience and surveillance (p > 0.05). Significantly lower visual analog scale (VAS) scores were found one day after the surgery in patients given dexmedetomidine plus midazolam than those anesthetized administered with dexmedetomidine only, suggesting an enhanced pain mitigation effect after incorporating midazolam for anesthetic induction. Patients treated with dexmedetomidine plus midazolam presented with a more stable hemodynamic status than those treated with dexmedetomidine only, as evidenced by the significantly lower variability of mean arterial pressure (MAP), oxygen saturation (SpO2), and heart rate (HR). Co-administration of dexmedetomidine plus midazolam for lobectomy anesthesia resulted in significantly lower serum cortisol (Cor) and norepinephrine (NE) concentrations in patients at anesthesia recovery than dexmedetomidine alone. However, this difference was not observed one day postoperatively. There was no statistically significant difference in the incidence of adverse reactions between the two groups.

CONCLUSION

The combination of midazolam with dexmedetomidine anesthesia in lobectomy improves the intraoperative hemodynamic status of elderly patients with NSCLC and mitigates their stress response. However, further research is required to explore the underlying mechanisms.

Hyaluronic acid-modified biomimetic liposomes co-loaded with doxorubicin and melatonin for targeted inhibition of breast cancer proliferation and metastasis

The tumor microenvironment (TME) plays an important role in tumor development. In TME, cancer-associated fibroblasts (CAFs) and neutrophil extracellular traps (NETs) facilitate tumor proliferation, drug resistance, and metastasis. Anti-tumor strategies targeting CAFs and NETs might be effective therapeutic modalities to inhibit tumor growth, drug resistance, and metastasis. In this study, a platelet membrane-encapsulated hyaluronic acid (HA)-acid-modified biomimetic nano-delivery system co-loaded with doxorubicin (DOX) and melatonin (MT) was prepared. MCF-7 + MRC-5 co-culture cell model and 4 T1 + NIH-3 T3 co-implanted in situ breast cancer model were used to simulate the real breast cancer microenvironment. As expected, the HA-PLIP-based nano-delivery system enhanced drug internalization and inhibited drug efflux. The growth and proliferation of breast cancer cells were significantly inhibited. Histological analysis showed that DM/HA-PLIP significantly inhibited tumor growth, suppressed extracellular matrix (ECM) deposition reduced tumor neovascularization and α-SMA protein expression, and significantly reduced the number of metastatic nodules and NETs. In summary, DM/HA-PLIP is expected to substantially improve the therapeutic efficacy of breast cancer by inhibiting the crosstalk of CAFs and NETs with tumor cells, which has a broad clinical application prospect.

Anesthetic Techniques and Cancer Outcomes: What Is the Current Evidence?

It is almost 2 decades since it was first hypothesized that anesthesia technique might modulate cancer biology and thus potentially influence patients' long-term outcomes after cancer surgery. Since then, research efforts have been directed towards elucidating the potential pharmacological and physiological basis for the effects of anesthetic and perioperative interventions on cancer cell biology. In this review, we summarize current laboratory and clinical data. Taken together, preclinical studies suggest some biologic plausibility that cancer cell function could be influenced. However, available clinical evidence suggests a neutral effect. Observational studies examining cancer outcomes after surgery of curative intent for many cancer types under a variety of anesthetic techniques have reported conflicting results, but warranting prospective randomized clinical trials (RCTs). Given the large patient numbers and long follow-up times required for adequate power, relatively few such RCTs have been completed to date. With the sole exception of peritumoral lidocaine infiltration in breast cancer surgery, these RCTs have indicated a neutral effect of anesthetic technique on long-term oncologic outcomes. Therefore, unless there are significant new findings from a few ongoing trials, future investigation of how perioperative agents interact with tumor genes that influence metastatic potential may be justified. In addition, building multidisciplinary collaboration to optimize perioperative care of cancer patients will be important.

Comparing postoperative pain relief: ketorolac and Nasocalcin spray versus lidocaine and Nasocalcin spray in abdominal surgery patients

Objectives

Postoperative pain management is critical for patient recovery after abdominal surgery. This study compared intravenous lidocaine and ketorolac for reducing postoperative pain and opioid use, along with Nasocalcin nasal spray.

Methods

In this randomized controlled trial, 58 abdominal surgery patients were allocated to receive either intravenous lidocaine plus Nasocalcin spray (n=29) or intravenous ketorolac plus Nasocalcin spray (n=29) before surgery. Pain intensity (visual analog scale) and postoperative opioid consumption were assessed at 1, 6, 12, and 24 h after surgery.

Results

Patients receiving ketorolac plus Nasocalcin spray reported significantly lower pain scores at all time points compared to lidocaine plus Nasocalcin (P<0.001). Average 24-h pain scores were 4.5 with ketorolac versus 5.1 with lidocaine. Mean opioid consumption was also lower in the ketorolac group (31.9 mg) versus the lidocaine group (43.9 mg, P<0.001).

Conclusion

Preoperative ketorolac plus Nasocalcin nasal spray resulted in superior pain relief and less opioid use compared to lidocaine plus Nasocalcin after abdominal surgery. Ketorolac may be a more effective analgesic option, while Nasocalcin spray is a safe adjunct. These findings can inform clinical practice for optimizing postoperative analgesia.

Inflammation-Driven Nanohitchhiker Enhances Postoperative Immunotherapy by Alleviating Prostaglandin E2-Mediated Immunosuppression

Inflammation contributes to the immunosuppressive microenvironment and leads to the recurrence of surgically resected tumors. The COX-2/PGE2 axis is considered a key player in shaping the immunosuppression microenvironment. However, targeted modulation of the postoperative tumor microenvironment is challenging. To specifically curb the inflammation and alleviate immunosuppression, here, we developed a PGE2 inhibitor celecoxib (CXB)-loaded bionic nanoparticle (CP@CM) coated with activated murine vascular endothelial cell (C166 cells) membrane to target postoperative melanoma and inhibit its recurrence. CP@CM adhered to inflammatory white blood cells (WBCs) through the adhesion molecules, including ICAM-1, VCAM-1, E-selectin, and P-selection, expressed on the surface of C166 cells. Leveraging the natural tropism of the WBC to the inflammatory postoperative tumor site, CP@CM efficiently targeted postoperative tumors. In melanoma postoperative recurrence models, CXB significantly reduced PGE2 secretion and the recruitment of immunosuppressive cells such as myeloid-derived suppressor cells (MDSCs) and regulatory T cells (Treg) by inhibiting the activity of COX-2. This was followed by an increase in the infiltration of CD8+ T cells and CD4+ T cells in tumor tissues. Additionally, the immune responses were further enhanced by combining a PD-L1 monoclonal antibody. Ultimately, this immunotherapeutic strategy reversed the tumor immunosuppressive microenvironment and inhibited tumor recurrence, demonstrating a promising potential for postoperative immunotherapy for melanoma.

Anaesthetic Techniques and Strategies: Do They Influence Oncological Outcomes?

BACKGROUND

With the global disease burden of cancer increasing, and with at least 60% of cancer patients requiring surgery and, hence, anaesthesia over their disease course, the question of whether anaesthetic and analgesia techniques during primary cancer resection surgery might influence long term oncological outcomes assumes high priority.

METHODS

We searched the available literature linking anaesthetic-analgesic techniques and strategies during tumour resection surgery to oncological outcomes and synthesised this narrative review, predominantly using studies published since 2019. Current evidence is presented around opioids, regional anaesthesia, propofol total intravenous anaesthesia (TIVA) and volatile anaesthesia, dexamethasone, dexmedetomidine, non-steroidal anti-inflammatory medications and beta-blockers.

CONCLUSIONS

The research base in onco-anaesthesia is expanding. There continue to be few sufficiently powered RCTs, which are necessary to confirm a causal link between any perioperative intervention and long-term oncologic outcome. In the absence of any convincing Level 1 recommending a change in practice, long-term oncologic benefit should not be part of the decision on choice of anaesthetic technique for tumour resection surgery.

A Meta-Analysis Showing the Quantitative Evidence Base of Preemptive Pregabalin for Postoperative Pain from Cancer-Related Surgery

Background and Objectives: As an adjunct to postoperative multimodal analgesic regimens, pregabalin has been reported in reducing postoperative acute pain and opioid consumption. However, there is only a small amount of evidence for preemptive pregabalin in patients undergoing cancer-related surgery. This systematic review was conducted to integrate high-quality evidence to evaluate the preemptive analgesic effects of pregabalin in cancer-related surgery. Materials and Methods: Seven electronic databases were searched in a combination of subject terms and free words. Efficacy and safety of preemptive pregabalin on postoperative pain for cancer-related surgery were evaluated by assessing resting and dynamic pain scores postoperatively, cumulative morphine equivalent consumption, time to first analgesic request, hemodynamic parameters, and the safety indicators. Results: Thirteen trials were incorporated for quantitative synthesis. The pooled results showed administration of pregabalin preoperatively is clinically significant for improving resting (weighted mean difference (WMD), -1.53 cm; 95% CI, -2.30 to -0.77) and dynamic (WMD, -1.16 cm; 95% CI, -2.22 to -0.11) pain severity scores at 2 h postoperatively and prolonging time to first analgesic request (WMD, 2.28 h; 95% CI, 0.79 to 3.77) in cancer-related surgery. Preemptive pregabalin was also statistically effective in some other pain indicators but would increase the risk of pregabalin-related side effects after surgery. Conclusions: Our findings do not support the administration of pregabalin in doses larger than 300 mg when put in cancer-related surgery. Taken together, more high-quality research particularly focused on the optimal dosages and timing of pregabalin in cancer-related surgery is needed in the future to establish stronger evidence for therapeutic effects.

Postoperative Long-Term Outcomes and Independent Risk Factors of Non-Small-Cell Lung Cancer Patients With Propofol versus Sevoflurane Anesthesia: A Retrospective Cohort Study

Background: Existing studies have shown that the relationship between anesthetic agents and non-small-cell lung cancer (NSCLC) prognosis remains controversial. Therefore, this retrospective cohort study was designed to investigate the effects of propofol or sevoflurane anesthesia on the long-term oncologic outcomes of NSCLC patients.

Methods: We identified 1,778 eligible patients (propofol-based total intravenous anesthesia (TIVA) group, n = 686; sevoflurane-based inhalation anesthesia (INHA) group, n = 1,092) out of 2,388 patients undergoing elective NSCLC surgery from June 2013 to June 2016 in the Harbin Medical University Cancer Hospital. The primary endpoints were five-year overall survival and recurrence-free survival. The secondary endpoints were independent risk factors of cancer recurrence or all-cause mortality. The data were analyzed with propensity score matching, Kaplan–Meier survival, and Cox multivariate analyses as appropriate.

Results: After propensity score matching, there were 672 patients in each group. The median follow-up period was 69 months (interquartile range: 68–70 months) for all patients. Five-year overall survival was 75.7% (95% confidence interval (CI) 72.4–79.1) in the TIVA group and 71.8% (68.4–75.4) in the INHA group (p = 0.160) (hazard ratio (HR), 0.86; 95% CI, 0.70–1.06; p = 0.158), and five-year recurrence-free survival was 68.5% (65.0–72.2) and 62.7% (59.1–66.5 (p = 0.108) (HR, 0.90; 95% CI, 0.75–1.08; p = 0.253), respectively. Subgroup analyses showed there were no significant difference in the overall survival or recurrence-free survival between the two groups in each TNM stage of NSCLC. The independent risk factors included age ≥60 years, male, blood transfusion, segmental/wedge resection and pneumonectomy, thoracotomy, postoperative complications, lung adenocarcinoma, TNM stages, high CEA and CYFRA211 levels, and postoperative radiotherapy.

Conclusions: Our data indicated no difference between the propofol-based TIVA and sevoflurane-based INHA in terms of five-year overall survival and recurrence-free survival after NSCLC surgery.

Combinatorial Therapy of Cancer: Possible Advantages of Involving Modulators of Ionic Mechanisms

Cancer is a global health problem that 1 in 2-3 people can expect to experience during their lifetime. Several different modalities exist for cancer management, but all of these suffer from significant shortcomings in both diagnosis and therapy. Apart from developing completely new therapies, a viable way forward is to improve the efficacy of the existing modalities. One way is to combine these with each other or with other complementary approaches. An emerging latter approach is derived from ionic mechanisms, mainly ion channels and exchangers. We evaluate the evidence for this systematically for the main treatment methods: surgery, chemotherapy, radiotherapy and targeted therapies (including monoclonal antibodies, steroid hormones, tyrosine kinase inhibitors and immunotherapy). In surgery, the possible systemic use of local anesthetics to suppress subsequent relapse is still being discussed. For all the other methods, there is significant positive evidence for several cancers and a range of modulators of ionic mechanisms. This applies also to some of the undesirable side effects of the treatments. In chemotherapy, for example, there is evidence for co-treatment with modulators of the potassium channel (Kv11.1), pH regulation (sodium-hydrogen exchanger) and Na+-K+-ATPase (digoxin). Voltage-gated sodium channels, shown previously to promote metastasis, appear to be particularly useful for co-targeting with inhibitors of tyrosine kinases, especially epidermal growth factor. It is concluded that combining current orthodox treatment modalities with modulators of ionic mechanisms can produce beneficial effects including (i) making the treatment more effective, e.g., by lowering doses; (ii) avoiding the onset of resistance to therapy; (iii) reducing undesirable side effects. However, in many cases, prospective clinical trials are needed to put the findings firmly into clinical context.

Impact of Ultrasound-Guided Deep Serratus Anterior Plane Block Combined With Dexmedetomidine as an Adjuvant to Ropivacaine Inpatient Quality of Recovery Scores Undergoing Modified Radical Mastectomy: A Randomized Controlled Trial

Background

Breast cancer has overtaken lung cancer as the most commonly diagnosed malignancy and is the leading cause of cancer-related death in women. Surgery is the only possible cure for breast cancer, and the incidence of acute postoperative pain (APP) is high in breast surgery. Previous reports suggested that ultrasound-guided deep serratus anterior plane block (dSAPB) provided effective blockade to relieve pain after modified radical mastectomy for breast cancer. In fact, despite the long-acting local anesthetic agents used, the patient’s pain cannot completely be eliminated due to the short duration of anesthesia. Dexmedetomidine as an adjunct to local anesthetics can prolong peripheral nerve block duration. However, no study has investigated the role of dSAPB with dexmedetomidine in the quality of recovery scores undergoing modified radical mastectomy. Thus, this study was conducted aiming at this aspect.

Material and Methods

This single-center, double-blind, randomized clinical trial was conducted at Bethune International Peace Hospital. A total of 88 participants of elective modified radical mastectomy were enrolled from May and November 2021. Ultrasound-guided dSAPB combined with 30 ml of 0.375% ropivacaine or 30 ml of 0.375% ropivacaine with dexmedetomidine (1 μg/kg) was administrated before anesthesia at the fourth to fifth ribs of the axillary midline. The primary outcome was quality of recovery, measured 24 h postoperatively using the QoR-15. Secondary outcomes were the Visual Analogue Scale (VAS) scores at rest and movement at 1, 6, 12, 24, and 48 h after surgery, 48 h sufentanil consumption postoperatively, the incidence of postoperative nausea and vomiting (PONV), length of post-anesthesia care unit (PACU) stay, dizziness, delirium, SAPB-related adverse events, and patient’s satisfaction with pain management.

Results

Among the 88 participants, 8 did not meet the inclusion criteria; the other 80 were randomized to receive dSAPB combined with ropivacaine (Group R, N=40) and dSAPB combined with ropivacaine plus DEX (Group RD, N=40), of which a total of 7 (4 in Group R and 3 in Group RD) were excluded due to protocol deviation. Eventually,73 participants (36 in Group R and 37 in Group RD) were included for final analysis, with age (SD, years, 54.08[6.28] vs. 54.62[7.44], p=0.740), body mass index (BMI) (SD, 27.96[1.67] vs. 27.57[2.38], p=0.428), and median preoperative global QoR-15 score (interquartile range (IQR), 127[123.25–131] vs. 126[121–130], p=0.662). The median postoperative global QoR-15 score (IQR, 107[103–112] vs. 109.5[107–114], p=0.016), VAS score at rest at 12th hour (IQR, 1[1–2] vs. 1[1–2], p=0.033), VAS score in movement at 12th hour (IQR, 2[1–3] vs. 2[1–3], p=0.014) and at 24th hour (IQR, 3[2–3] vs. 3[2–3], p=0.040), and median sufentanil rescues consumption (IQR, 14[12–17 vs. 14[12–15], p=0.022] of Group RD were significantly lower than those of the Group R. Patient satisfaction score (SD, 8.28[0.70] vs. 8.62[0.59], p=0.024) of Group RD were significantly higher than those of the Group R.

Conclusion

The ultrasound-guided dSAPB combined with dexmedetomidine plus ropivacaine may improve the QoR-15 in patients undergoing modified radical mastectomy and indicates that it may be a useful intervention to aid recovery following breast cancer surgery. Furthermore, participants in the ropivacaine with DEX group met the superior pain relief in the early postoperative period, reduced postoperative cumulative opioid consumption, increased patient satisfaction, and no increase in the incidence of complications.