Aim This 5-year prospective follow-up of women randomized to general anesthesia (GA) with or without a thoracic paravertebral block (TPVB) examined the risk of local recurrence, metastasis and mortality after breast cancer surgery. Patients and methods A total of 180 patients undergoing modified radical mastectomy were randomized to one of three study groups: standardized GA only; GA with a single-injection TPVB (s-TPVB) and placebo paravertebral infusion after surgery for 72-h; and GA plus with continuous TPVB (c-TPVB) for 72-h postoperatively. Cox proportional models were used to assess the effect of TPVB on long-term outcomes. Equivalence testing was used to help interpret the results. Results The incidence [95% confidence interval (CI)] of cancer recurrence, metastatic spread and all-cause mortality was 2.3% (0.7-5.4%), 7.9% (4.6-12.6%) and 6.8% (3.6-11.2%), respectively. Four women had cancer recurrence and had metastatic spread. Compared to the GA-only group, the risk of metastatic spread was not different from that of GA with s-TPVB [hazard ratio (HR)=1.11, 95% CI=0.32-3.83) nor from that with GA plus c-TPVB (HR=0.79, 95% CI=0.21-2.96) (p=0.88). Compared to the GA-only group, the risk of mortality was similarly not different from that of the two other groups (HR=2.57, 95% CI=0.66-9.92; and HR=0.66, 95% CI=0.11-3.97, respectively, p=0.15). Conclusion Although the original study was underpowered to properly address long-term outcomes, the results of this analysis suggest that TPVB, administered whether as a single-injection or continuous infusion during the perioperative period, had little to no appreciable effect on local recurrence, metastasis or mortality after breast cancer surgery.

/pdf/survival-analysis-of-patients-with-breast-cancer-undergoing-1883ubyen2.pdf

Survival Analysis of Patients with Breast Cancer Undergoing a Modified Radical Mastectomy With or Without a Thoracic Paravertebral Block: a 5-Year Follow-up of a Randomized Controlled Trial.

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review

Background
Sepsis, systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) remain the most frequent causes of complications and death in severely injured patients. A main reason for the development of these syndromes is a post-traumatic dysregulation of the immune system. Several studies in intensive care unit (ICU) patients could detect a pivotal role of HLA-DR expression on monocytes. So far, its importance for development of SIRS, sepsis or MODS in the severely injured patient is not clear.

/pdf/hla-dr-expression-on-monocytes-is-decreased-in-c9a6dhz4cl.pdf

HLA-DR expression on monocytes is decreased in polytraumatized patients

The novel coronavirus respiratory illness (COVID-19) is a public health emergency of global concern. Patients with cancer are at high risk of infections, due to an overall immunocompromised status. However, this connection is not straightforward for coronavirus (CoV) infection, in which the host immune response is the main driver of tissue damage. We performed a thorough review of data on CoV pathogenesis and morbidity rate in cancer patients, through the analysis of the previous CoV pandemics. Considering the interaction between CoV and the host immune system, cancer patients receiving immunotherapy might be more at risk for an aberrant immune response in case of infection, and might therefore deserve additional precautions. The limited available data do not allow us to provide practical indications for the management of cancer patients in this critical situation. Efforts should be made to prospectively collect data, to identify effective interventions to guide treatment decision.

/pdf/coronavirus-infection-and-immune-system-an-insight-of-covid-2jh2jmd1ue.pdf

Coronavirus infection and immune system: An insight of COVID-19 in cancer patients.

Over the past decade, targeted therapy for oncogene-driven NSCLC and immune checkpoint inhibitors for non-oncogene-driven NSCLC, respectively, have greatly improved the survival and quality of life for patients with unresectable NSCLC. Increasingly, these biomarker-guided systemic therapies given before or after surgery have been used in patients with early-stage NSCLC. In March 2022, the US FDA granted the approval of neoadjuvant nivolumab and chemotherapy for patients with stage IB-IIIA NSCLC. Several phase II/III trials are evaluating the clinical efficacy of various neoadjuvant immune checkpoint inhibitor combinations for non-oncogene-driven NSCLC and neoadjuvant molecular targeted therapies for oncogene-driven NSCLC, respectively. However, clinical application of precision neoadjuvant treatment requires a paradigm shift in the biomarker testing and multidisciplinary collaboration at the diagnosis of early-stage NSCLC. In this comprehensive review, we summarize the current diagnosis and treatment landscape, recent advances, new challenges in biomarker testing and endpoint selections, practical considerations for a timely multidisciplinary collaboration at diagnosis, and perspectives in emerging neoadjuvant precision systemic therapy for patients with resectable, early-stage NSCLC. These biomarker-guided neoadjuvant therapies hold the promise to improve surgical and pathological outcomes, reduce systemic recurrences, guide postoperative therapy, and improve cure rates in patients with resectable NSCLC. 

/pdf/emerging-precision-neoadjuvant-systemic-therapy-for-patients-3j3bx3k0.pdf

Emerging precision neoadjuvant systemic therapy for patients with resectable non-small cell lung cancer: current status and perspectives

Hintergrund: Jeder chirurgische Eingriff fuhrt aufgrund des operativen Traumas zu einer Veranderung der Immunkompetenz Kommt es in dieser Phase zu septischen Komplikationen, kann das Immunsystem nicht adaquat reagieren Das Ausmas der postoperativen Immunsuppression kann anhand der HLA-DR-Expression auf zirkulierenden Monozyten bestimmt werden Patienten/Material und Methoden: In der vorliegenden Arbeit wurde eine themenbezogene Literaturrecherche durchgefuhrt sowie Patienten mit viszeralchirurgischen und thorakalen Eingriffen untersucht Hierbei wurde zwischen kleiner und groser Chirurgie unterschieden 17 Patienten bildeten die Gruppe „minor surgery“ mit Cholezystektomien, Thyreoidektomien oder Hernienrepair 101 Patienten waren in der Gruppe „major surgery“ zusammengefasst (grose resezierende Eingriffe der Thorax- und Viszeralchirurgie) Die Expression von HLA-DR auf zirkulierenden Monozyten wurde nach FACS-Analyse bestimmt, die Genexpression der T-Zellen mittels Gene-Array Ergebnisse: Bei Patienten mit kompliziertem postoperativen Verlauf und insbesondere bei Patienten, die im Verlauf eine schwere Sepsis entwickeln, ist die Expression von HLA-DR auf zirkulierenden Monozyten signifikant reduziert Die postoperative Immunsuppression wird dabei durch die Art des Eingriffs beeinflusst: Nach kolonchirurgischen Eingriffen ist die Immunsuppression langer nachweisbar im Vergleich zu thoraxchirurgischen und rektumresezierenden Eingriffen Zusatzlich ist die Immunsuppression im postoperativen Verlauf abhangig von den vorhandenen Risikofaktoren: Bei Adipositas zusammen mit weiteren Risikofaktoren ist die Expression von HLA-DR signifikant vermindert Im Rahmen der Genexpressionsanalyse lasst sich eine ausgedehnte Herabregulation der transkriptionalen Aktivitat der T-Zellen nach einer chirurgischen Intervention nachweisen Dieser Effekt ist deutlich starker ausgepragt bei Patienten mit schweren septischen Komplikationen Schlussfolgerung: Die Expression von HLA-DR auf Monozyten stellt einen zuverlassigen Parameter zur Beschreibung der postoperativen Immunsuppression dar Die Regulation der transkriptionalen Aktivitat von T-Zellen kann daruber hinaus zusatzliche Informationen uber den postoperativen Immunstatus geben

Characterisation of Postoperative Immune Suppression by Validated Parameters in Visceral Surgery

I. Alwayn, Halifax D.K. Bartsch, Marburg C. Bassi, Verona W.O. Bechstein, Frankfurt am Main J.A. Bradley, Cambridge M. Cikirikcioglu, Geneva P.-A. Clavien, Zurich C. Eipel, Rostock R.W.F. de Bruin, Rotterdam H. Friess, Munich S. Fichtner-Feigl, Regensburg G. Galata, London D.J. Gouma, Amsterdam J.K. Habermann, Lübeck M. Heberer, Basel W.R. Jarnagin, New York, NY J.C. Kalff , Bonn M.W. Laschke, Homburg/Saar H.-A. Lehr, Lausanne C.M. Malata, Cambridge T. Minor, Bonn M. Morino, Torino J. Pirenne, Leuven R. Schramm, Munich L. Steinstraesser, Bochum T.M. van Gulik, Amsterdam M.A. Venermo, Helsinki D.C. Winter, Dublin Y. Yamamoto, Akita Clinical and Experimental Surgery

Contents Vol. 48, 2012

Background: In postoperative sepsis, mortality is increased due to the surgically induced immune dysfunction. Further causes of this traumatic effect on the immune system include burn injuries and polytrauma, as well as endogenous traumata like stroke. Several animal models have been defined to analyse the characteristics of trauma-induced immune suppression. This article will correlate our results from animal studies and clinical observations with the recent literature on postoperative immune suppression. Methods: The previously described model of surgically induced immune dysfunction (SID) was performed in mice by laparotomy and manipulation of the small intestine in the antegrade direction. Blood samples were collected 6 and 72 h following SID to analyse the white blood cell count and corticosterone levels. To assess the postoperative immune status in humans, we analysed expression of HLA-DR on monocytes of 118 patients by flow cytometry prior to and 24, 48 and 72 h after surgery. Results: The postoperative immune suppression in our SID model is characterised by lymphocytopenia and significantly increased corticosterone levels in mice dependent on the degree of surgical trauma. This is comparable to the postoperative situation in humans: major and especially long-lasting surgery results in a significantly reduced expression of HLA-DR on circulating monocytes. Previous studies describe a similar situation following burn injury and endogenous trauma, i.e. stroke. Conclusions: We suggest the completion of our previously published sepsis classification due to the immune status at the onset of sepsis: type A as the spontaneously acquired sepsis and type B as sepsis in trauma-induced pre-existing immune suppression.

/pdf/surgical-trauma-and-postoperative-immune-dysfunction-52ltovfjd6.pdf

Surgical trauma and postoperative immune dysfunction.

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Characterisation of Postoperative Immune Suppression by Validated Parameters in Visceral Surgery

Contents Vol. 48, 2012

Surgical trauma and postoperative immune dysfunction.