Immunologic and Stress Responses Following Video-Assisted Thoracic Surgery and Open Pulmonary Lobectomy in Early Stage Lung Cancer

https://doi.org/10.1016/j.thorsurg.2007.04.001Get rights and content

Conventional open major surgery evokes an injury response involving endocrine, neural, and immunologic mechanisms. The immunologic responses are characterized by release of cytokines, inflammatory mediators, and acute-phase proteins and by adverse disturbances in immune cell function. The use of a minimal access approach strategy is associated with a significant reduction in the cytokine response, as exemplified by reduced interleukin-6 levels and a corresponding reduction in acute-phase protein generation with reduced C-reactive protein levels. Circulating immune cell function and numbers also are better preserved. These changes have been demonstrated in comparing open with video-assisted thoracoscopic surgery (VATS) lobectomy and, together with further investigation into local immune function, may offer some insight into the excellent survival data reported for VATS resection of stage I non–small cell lung cancer.

Section snippets

The stress response

Multiple inputs contribute to and modify the surgical response to injury (Fig. 1). This process may be considered as having endocrine, neural, and immunologic components [1], all of which are subject to varying degrees of mutual interaction (Box 1).

The evolution of our understanding of the stress response to surgery has been reviewed in detail elsewhere [2], and the general metabolic response to surgery is summarized in Table 1. The importance of neural afferent stimuli in the generation of the

Relationship between immune mechanisms and cancer

Patients who have lung cancer undergo major stress against a background of preexisting compromise. For example, CD4, CD8, and natural killer (NK) cell numbers are already suppressed in this group [7]. Therefore, it is relevant to briefly consider the current thinking with regard to immune mechanisms and cancer. This is well reviewed elsewhere [8], [9], [10], [11].

Adaptive immunity (ie, that related to antibody production) has limited relevance because tumors generally (and lung cancer, in

Endocrine and neuroendocrine responses

Endocrine and sympathetic nervous system responses to surgery have been studied in some detail in relation to a wide range of laparoscopic procedures, including cholecystectomy, herniorrhaphy, colonic resection, hysterectomy, and various other procedures and reviewed in detail by Kehlet [13]. Typically, corticotropin, cortisol, prolactin, and catecholamines were studied. In general, there is little evidence for a significant difference in endocrine responses between open and laparoscopic

Discussion

The studies available for comparison between open and minimal access surgery have important limitations. As in many areas, we may be “measuring the measurable rather than the meaningful.” Tissue active cytokines and other immunomodulatory factors may exhibit localized plasma and tissue levels. Sampling times are, of necessity, fixed, and therefore, may miss effects. Also, much of the area of greatest interest (ie, local immune mechanisms) involves interactions within microsystems (eg, the

Acknowledgments

We are grateful to Dr. Dino Rotondo (Strathclyde University, Glasgow, UK) and Dr. Maria Teresa Rizzo (Signal Transduction Laboratory, Indianapolis, Indiana) for critical analysis of the manuscript.

References (35)

  • A. Rodgers et al.

    Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials

    Br Med J

    (2000)
  • W.B. Ross et al.

    Immune effects of blood transfusion: macrophage prostaglandin E2 and oxidative responses to endotoxin

    Prostaglandins Leucot Essent Fatty Acids

    (1993)
  • T. Payner et al.

    Microsomal prostaglandin E synthase-1 regulates human glioma cell growth via prostaglandin E2-dependent activation of type II protein kinase A

    Mol Cancer Ther

    (2006)
  • Y. Sato et al.

    Lymphocyte subsets in pulmonary venous and arterial blood of lung cancer patients

    Jpn J Clin Oncol

    (1989)
  • H.J. Zeh et al.

    Addicted to death: invasive cancer and the immune response to unscheduled cell death

    J Immunother

    (2005)
  • W. Zou

    Immunosuppressive networks in the tumour environment and their therapeutic relevance

    Nat Rev Cancer

    (2005)
  • A.E. Germenis et al.

    Immunoepigenetics: the unseen side of cancer immunoediting

    Immunol Cell Biol

    (2007)
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