Different Anesthesia Methods In Preserving Antitumor T-helper Polarization And Relationship With Hepatic Cancer Metastasis

Although the diagnosis and treatment methods of hepatocellualr carcinoma have been consistently improved, surgery is still the first choice to of cure which can improve the HCC patients’ prognosis, prolong survival time. But surgery also affects patients’ inner environment and immune function unavoidable which would impact post-operative tumor metastasis and survival time.T helper cell is a kind of immune cells which were paid more and more attention in recent years, also be called CD4+cells. There are four major subgroups, Th1, Th2, Th17and Treg, they all played connection role in immune reaction. Because Th cells’ special function, they played important function in body immune scout to tumor cells, which had direct relationship with tumor metastasis and recurrence.In human normal physiological circumstances, Th1and Th2were at a balance state, called Th1/Th2balance. Once the balance was broken, Th balance shifted towards Th1or Th2, then all kinds of pathological situation appeared. In hosts with tumor, if Th1/Th2balance shifted towards Thl hinted body has active immune ability to anti-tumor, at the opposite, if Th1/Th2balance shifted towards Th2revealed protective tumor escape.The reaction of these4T helper cell subgroups to tumor was different. Th1cell attacks tumor cell by producing IFN-γ to kill the tumor. On the contrary, Th2, Th17and Treg cells assisted tumor growth.Th cell number in4subgroups is very important for tumor patients, but the balance of Th cell subgroup is more critical which determined the immune trend toward tumor and patient’s prognosis. Suitable anesthesia methods choice through eliminate the disturbance and suppress of surgery on immune function could help tumor patients recovered from the broken Th subgroup balance as well as maintain the balance towards anti-tumor direction. So the purpose of anesthesia method choice is to decrease the post-operative tumor metastasis and recurrence, increase the tumor patients’ survival rate.The purpose of this research is to reveal the influence of liver cancer resection itself and different anesthesia methods on peri-operative T helper cell’s number and subgroup balance through experiments on Orthotopic hepatocellular carcinoma rat model and clinical HCC patients. We are also interested in the relationship between anesthesia method choice and HCC metastasis recurrence through further post-operative follow-up. Part oneInfluence of different anesthesia methods on peri-operative T helper cells and tumor metastasis in orthotopic hepatocellular carcinoma rat modelObjective:To explore the influence of different anesthesia methods on T helper cells and tumor metastasis after hepatectomy in rat liver cancer model.Method:Set up ACI rat liver cancer models, randomized30rats into3groups, there are surgery+epidural+general anesthesia (G+E) group, surgery+general anesthesia (G) group and control (C) group,10rats in each group, treated with different method. On14th day after liver tumor planted, rats in G+E group and G group were treated with hepatectomy and pain control with different anesthesia method. Then observe level of pain once a day for seven days after operation. Collect venous blood from tail vein at2nd,7th and30th day after surgery to test the serum level of IFN-y, IL-4, IL-17, IL-10and TGF-β1. Execute all30rats at30th day after surgery to observe abdominal cava lymph node metastasis, malignant ascites, implantation metastasis to abdominal wall and visible lung metastasis nodules.Results:Rats in control group had more visible lung metastasis, higher abdominal cava lymph node metastasis rate, malignant ascites rate and implantation metastasis rate to abdominal wall. Rats in G+E group had fewer visible lung metastasis and lower abdominal cava lymph node metastasis rate than rats in G group. The concentration of serum IFN-y, IL-4, IL-17, IL-10, TGF-β1in both G+E and G group were higher at d2than those at dO, then partly recovered at d7, finally returned back to baseline before surgery at d30. INF-γ/IL-4ratio in both groups were lower at d2than which at dO, then recovered at d7and d30in G+E group, but the ratio in G group went further lower at d7and d30. The concentration of serum IFN-γ, IL-4, IL-17, IL-10, TGF-β1at dO showed no difference in all three groups, at d2those in G+E and G group were higher at different extent, then covered at d7, went back to the baseline at d30which is similar with C group. But these cytokines serum concentration in G+E and G group at d2, d7and d30showed a few statistical differences. G+E group was characterized by higher INF-γ level, while IL-4, IL-17, IL-10, TGF-β1level in G group were much higher. INF-γ/IL-4ratio showed no difference at dO and d2in all three groups, but at d7and d30, the ratios in G+E group were statistically higher than which in G group.Conclusion:Rat liver cancer models went through hepatectomy those under epidural combined with general anesthesia had less tumor metastasis than those under general anesthesia. Epidural combined with general anesthesia is superior to general anesthesia alone in shifting the Thl/Th2balances towards Thl, as well as decreased cytokines secreted by Th2, Th17and Treg cells might be the critical reason.Part twoInfluence of different anesthesia methods on peri-operaive T helper cell in HCC patients undergoing hepatectomyObjective:To investigate impact of different anesthesia methods on the balances of T helper cells subsets (T helper1cells [Thl], T help2cells [Th2], T helper17cells [Th17] and regulatory T cells [Treg] in hepatocellular carcinoma (HCC) patients undergoing hepatectomy.Method:Sixty-one patients with HCC undergoing hepatectomy was randomly assigned into epidural combined general anesthesia (G+E) group (n=31) and general anesthesia (G) group (n=30). Blood sample was obtained at3points:the morning before operation (dO), the second (d2) and seventh (d7) days after operation. Thl, Th2, Th17and Treg content on different levels were evaluated using flow cytometry (Th cell frequencies), real-time RT-PCR (IFN-y, interleukin [IL]-4, IL-17and FoxP3) and ELISA (IFN-y, IL-4, IL-17, IL-10and TGF-β1).Results:On dO, the Th cell frequencies, mRNA expression of Th cell markers and plasma cytokine levels showed no difference between G+E and G groups. Of all the61patients, compared to dO, Thl, Th2frequencies and IFN-γ mRNA expression markedly increased on d2, then partly recovered on d7, while Thl/Th2ratio showed no change on d2, but obviously increased on d7. In contrast, Th17and Treg frequencies, IL-17and FoxP3mRNA expression on d2showed no change, but markedly decreased on d7. The plasma IFN-y, IL-4, IL-17and TGF-β1concentrations on d2were higher than those on dO, and then IFN-y and IL-17levels recovered on d7, while IL-4, IL-10and TGF-(31levels remained relatively high on d7. As compared with G group, Thl frequencies and Thl/Th2ratio were higher, while Th2, Th17and Treg frequencies were lower in G+E group on d7. On d7, IFN-y mRNA level and IFN-y/IL-4ratio of G+E group was higher, while IL-17mRNA level of G+E group were lower than that of G group. On d7, in G+E group IFN-y concentration and IFN-y/IL-4ratio were higher, while IL-17and TGF-β1concentrations were lower than those of G group.Conclusion:Removal of HCC tumor shifted Thl/Th2balance towards Thl, with concomitant Thl7and Treg decrease. In particular, epidural combined with general anesthesia is superior to general anesthesia alone in shifting the Thl/Th2balances towards Thl, and decreasing Th17and Treg amount, which might benefit HCC patients by promoting antitumor T-helper polarization. Part threeInfluence of different anesthesia method on tumor recurrence, metastasis and prognosis of HCC patients undergoing hepatectomyObjective:Compare the influence of two different anesthesia methods:epidural block combined with general anesthesia and general anesthesia alone, on tumor recurrence, metastasis and prognosis of HCC patients undergoing hepatectomy. Also analyze whether the results were consistent with their influence on peri-operative T helper cells subgroup balance.Method:On the basis of research part two, collect follow up data of61patients who undergone hepactoectomy, recorded status and discovered time of tumor recurrence or metastasis as well as further treatment method. Univariate analyses and multivatiate analyses of factors associated with survival and recurrence. Kaplan-Meier analysis of disease-free survival and overall survival for G+E and G groups.Results:On univariate analysis, age, sex, hepatitis history, cirrhosis, AFP level, Child-Pugh score, and tumor differentiation showed no prognostic significance for OS and DFS. For DFS, tumor number, encapsulation, TNM stage and vascular invasion were predictors. In addition to4variates above, tumor size was also associated with OS. Anesthesia was a predictor for DFS but not for OS. Clinicopathologic features showing significance by univariate analysis were adopted as covariates when multivariate Cox proportional hazards analyses were performed. Vascular invasion, an established prognostic predictor for HCC, remained associated with both DFS and OS. However TNM stage, tumor number, tumor size and encapsulation were not independent prognostic factors. Anesthesia method was also not a independent prognostic factors.Conclusion:Patients in G+E group had lower post-operative HCC recurrence rate, low DFS compared to who in G group. But OS between two groups showed no significant difference. Epidural block combined with general anesthesia compared to general anesthesia alone is a better choice for hepatectomy.