<p>Anesthetic Strategies in Oncological Surgery: Not Only a Simple Sleep, but Also Impact on Immunosuppression and Cancer Recurrence</p>

Abstract

Tumor recurrences or metastases remain a major hurdle in improving overall cancer survival. In the perioperative period, the balance between the ability of the cancer to seed and grow at the metastatic site and the ability of the patient to fight against the tumor (i.e. the host antitumor immunity) may determine the development of clinically evident metastases and influence the patient outcome. Up to 80% of oncological patients receive anesthesia and/or analgesia for diagnostic, therapeutic or palliative interventions. Therefore, anesthesiologists are asked to administer drugs such as opiates and volatile or intravenous anesthetics, which may determine different effects on immunomodulation and cancer recurrence. For instance, some studies suggest that intravenous drugs, such as propofol, may inhibit the host immunity to a lower extent as compared to volatile anesthetics. Similarly, some studies suggest that analgesia assured by local anesthetics may provide a reduction of cancer recurrence rate; whilst on the opposite side, opioids may exert negative consequences in patients undergoing cancer surgery, by interacting with the immune system response via the modulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, or directly through the opioid receptors on the surface of immune cells. In this review, we summarize the main findings on the effects induced by different drugs on immunomodulation and cancer recurrence.

Informed consent and a risk‐based approach to oncologic surgery in a cancer center during the COVID‐19 pandemic

“…The IC also addresses the fact that, despite all the cautions in the algorithm, it is not possible to avoid all the risks of perioperative COVID‐19 infection or its complications. The IC informs the patient of the possibility of immunological changes secondary to surgical trauma or anesthesiology 35,36 . It also clarifies that respiratory complications can occur after major surgeries and are not necessarily synonymous with COVID‐19.…”

“…Due to the great challenge the pandemic has brought us and to assure the window of opportunity for radical surgery, it is fundamental to keep in mind that many surgical candidates with solid tumors present some frailty or some competing risk factors (elderly, high body mass index, cardiovascular or pulmonary diseases, tobacco exposure, or immunosuppressive therapies as systemic chemotherapy or radiotherapy) for the SARS‐CoV‐2 infection and its severe complications 13 . Additionally, surgical and anesthetic interventions can result in further immunosuppression in oncologic patients 35,36 …”

“…The IC informs the patient of the possibility of immunological changes secondary to surgical trauma or anesthesiology. 35,36 It also clarifies that respiratory complications can occur after major surgeries and are not necessarily synonymous with COVID-19.…”

“…13 Additionally, surgical and anesthetic interventions can result in further immunosuppression in oncologic patients. 35,36 For each patient, according their clinical situation, demographics, tumor characteristics, and preferences, a personalized therapeutic decision must be developed to minimize the risks of the usual approach (upfront surgery) versus its postponement or alternative treatments during the pandemic. When skilled professionals discuss each case in tumor boards, taking into account these multiple variables, the probability of more favorable outcomes increases.…”

<p>Effects of Anesthesia on Postoperative Recurrence and Metastasis of Malignant Tumors</p>

“…[7][8][9] In surgery-naïve healthy individuals, epidural anesthesia and general anesthesia were found to induce mild transient immune suppression; however, surgical stress significantly increased the risk of peri-/postoperative cancer recurrence and metastasis. 1,10 Contrastingly, epidural anesthesia reduces the risk of cancer recurrence through surgical stress reduction. Although there is no report of paravertebral block reducing cancer recurrence, it is associated with a higher overall survival rate after lung cancer surgery.…”