Moorthy Aneurin, Eochagáin Aisling Ní, Buggy Donal J
Anaesthesiology & Perioperative Medicine Research Fellow, Division of Anaesthesiology and Peri-operative Medicine, Mater Misericordiae University Hospital, Dublin, Ireland.
Anaesthesiology Research Fellow, St. James's University Hospital, Dublin, Ireland.
Front Oncol. 2021 Dec 16;11:802592. doi: 10.3389/fonc.2021.802592. eCollection 2021.
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.
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.
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.
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.
癌症是全球主要的死亡原因之一，但死亡很少源于原发性肿瘤，而是转移性疾病导致的多器官功能障碍，其占癌症相关死亡的比例高达90%。70%的病例需要对原发性肿瘤进行手术切除。围手术期应激反应、手术部位的组织缺氧和急性疼痛会导致免疫抑制和新血管生成，有可能促进肿瘤存活、增殖和转移。术后急性疼痛控制不佳会降低自然杀伤（NK）免疫细胞活性，这可能会促使循环肿瘤细胞逃避免疫检测，从而促进肿瘤生长和远处转移。
我们使用多个在线数据库对急性疼痛与癌症结局之间的联系进行了全面的文献检索。对2010年1月1日至2021年9月1日期间的相关文章进行了分析和评估，以确定术后疼痛控制是否能调节复发风险、转移风险和总体癌症生存率。
尽管实验和回顾性临床数据表明区域麻醉在调节癌症结局方面可能发挥合理作用，但迄今为止关于乳腺癌的最大规模的单一前瞻性试验并未支持这一点。虽然麻醉学药物相关干预的结果不一，但最合理的数据与丙泊酚全静脉麻醉和利多卡因全身给药有关。
癌症手术期间的麻醉和镇痛技术可能会影响后续复发或转移风险这一假设已经流行了15年以上。在乳腺癌女性患者中进行的第一项大规模确定性试验发现，挥发性麻醉联合阿片类镇痛与区域麻醉之间的结果相当可靠。因此，虽然肿瘤切除期间的区域麻醉似乎对癌症结局没有任何影响，但其他麻醉技术（如全静脉麻醉和全身输注利多卡因）可能会影响其他主要肿瘤切除手术（如结直肠癌和肺癌手术）的肿瘤学结局，这仍然是有可能的。因此，需要另一项大型试验来明确回答这些具体的研究问题。在获得此类证据之前，根治性癌症手术的围手术期镇痛应基于患者的合并症和非癌症终点，如优化镇痛和减少术后并发症。
