Does cancer surgery trigger metastasis?

This is an automatically translated article.

Posted by Specialist Doctor I Le Thi Nha Hien - Internal Oncologist - Department of Medical Examination & Internal Medicine - Vinmec Nha Trang International General Hospital.

There is some sporadic clinical and experimental support for the role of surgery and inflammation as potential factors in disease recurrence. Surgery increases the spread of cancer cells into the circulatory system, suppresses anti-tumor immunity allowing circulating cells to survive, enhances adhesion molecules in target organs , which captures immune cells that have the ability to entrain tumor cells and induce changes in the target tissue as well as the cancer cells themselves to enhance migration. Surgical trauma that induces local and systemic inflammatory responses may also contribute to the rapid growth of metastatic cancer. Furthermore, there is a role of factors such as anesthesia, blood transfusion, hypothermia, and postoperative complications that may contribute to early recurrence.
The rate of cancer in the world is increasing, surgery is still one of the main treatment methods for this disease. Surgery can remove the primary tumor, or even the metastatic tumor, to prolong the patient's life, but there are some suggestions that surgical intervention can accelerate the recurrence of the tumor. u. This was warned in the early 20th century by Paget and Halsted, who discovered that patients who had surgery to remove their tumors did not survive as long as expected. Such reports were generally dismissed until more recent evidence demonstrated that surgical operation can create an easy environment for tumor growth.

1. Can cancer surgery create new metastases?

For cancer cells to metastasize to a distant organ, a complex series of events must occur. Cancer cells must reach the circulation, survive through host defense mechanisms, become trapped at a regional or distant site, and eventually invade and thrive in the metastatic site. new. All tissue injuries, including aseptic dissection performed by surgeons, induce a variety of local and systemic cell and humoral inflammatory diseases, with potential for cell arrest. cancer cells, supporting its survival and metastasis.
The inevitable damage to the patient's tissues during resection and manipulation of the tumor and its vascular system has been shown to result in the ejection of tumor cells into the bloodstream and lymphatic circulation. Tumor treatment can result in at least a 10-fold increase in circulating tumor cells. Furthermore, the circulating level of cancer cells before and during surgery has been shown to be a strong predictor of recurrence. In addition to dispersing circulating cells, certain post-operative changes help cancer cells survive in the circulation and increase the likelihood of distant engraftment. Macrophages and natural killer (NK) cells play an important role in eliminating circulating cancer cells and preventing the formation of metastases. In experimental models, the postoperative increase in tumor growth was associated with decreased NK cell toxicity, impaired macrophage function, and was proportional to the extent and extent of surgery.
In addition, several studies support the hypothesis that the acute inflammatory response to cancer surgery facilitates the capture of tumor cells at foreign sites. The influx of neutrophils following surgical trauma seems to further promote tumor capture and growth.
The liver is very susceptible to metastases from primary solid tumors of the gastrointestinal tract. Among the many potential reasons is that surgical trauma can impair the integrity of liver endothelial cells with reduced expression of tight junction proteins that facilitate cancer cell migration. into the liver parenchyma. In addition, catecholamines, prostaglandins released, and networks formed in response to surgical trauma may promote the metastatic potential of adhesive circulating cancer cells by increasing cell migration and invasion. tumor cells into distant organs. Thus, surgical injury synchronizes the increased number of circulating cancer cells, suppressed anti-tumor immunity, and the anti-metastatic environment of targeted organs in the sugar watershed. liver digestion.

2. Cancer surgery promotes the development of micro-metastatic lesions, making it easier to relapse?

Metastatic cancer cells may leave the primary tumor early in its development and form clinically undetectable microparticles at distant sites. Local and systemic inflammatory events associated with surgical trauma can unpredictably unleash their developmental potential.
Surgery can also promote immune escape by activating postoperative adaptive immune response downregulation. Furthermore, cancer surgery attenuated the function of T helper 1 (Th1) in humans. Impairment of the Th1 response, which is often an essential step in specific cellular immunity and proliferation of cytotoxic T cells, may also interfere with antitumour cytotoxicity. Surgery-induced immunosuppression persisted for weeks and longer after laparotomy compared with laparoscopy.

3. What other factors associated with surgery increase the risk of recurrence?

Anesthesia, blood transfusion, hypothermia and postoperative complications are factors that increase the risk of recurrence.
Anesthetics can directly affect the microenvironment and tumor growth.
Similarly, the use of opioids for pain management has been shown in animals and humans to trigger stress responses, suppress cell-mediated immunity, increase angiogenesis, and promote progression development of cancer metastasis. Evidence from observational clinical studies shows that both anesthetics and opioid analgesics increase relapse rates.
Blood transfusions are often performed during cancer surgery. It has been repeatedly shown that blood transfusion is independently associated with a significant increase in mortality in some types of cancer. Transfusion of blood products may induce immunosuppression, increase prostaglandin production, and inhibit NK cell activity. These negative effects are exacerbated with transfusion of more units, the use of whole blood instead of packed RBCs, and with the infusion of longer preserved units.
Despite efforts to maintain body temperature during prolonged surgeries, generalized hypothermia is common and even a few degrees of perioperative hypothermia can have devastating consequences. immune system. Hypothermia can also cause abnormalities in platelet function and in the coagulation cascade and thus may increase the need for blood transfusions.
Postoperative infection in cancer patients is associated with adverse cancer outcomes, and severe postoperative infectious complications are significantly associated with increased metastatic disease mortality.

4. Remedial options?

Adjuvant chemotherapy after surgery. Several immunomodulatory approaches performed in animals and/or humans have shown promise for ameliorating surgical immunosuppression and restoring antitumor cytotoxicity in the postoperative period. art. For the adjustment of perioperative clinical factors, based on the available clinical and experimental evidence detailed above, may it be more beneficial to use regional anesthetics and analgesics? opioids during cancer surgery. Likewise, reducing blood transfusions, avoiding whole blood transfusions, using units with a shorter shelf life, and maintaining anemia during surgery and the immediate postoperative period have may prevent immunosuppression associated with adverse cancer outcomes. In summary, metastasis is a common cause of morbidity and mortality in cancer patients. Surgery is a treatment to remove and reduce tumor volume, which can paradoxically also increase the development of metastases. If one can address these factors in the surgical stage, the risk of recurrence or distant metastasis can be reduced.

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