Comment on "Effect of total intravenous versus inhalation anesthesia on long-term oncological outcomes in patients undergoing curative resection for early-stage non-small cell lung cancer: a retrospective cohort study"

Article information

Korean J Anesthesiol. 2023;76(4):390-391

Publication date (electronic) : 2023 February 9

doi : https://doi.org/10.4097/kja.23017

Rohan Magoon¹, Devishree Das^,2, Jes Jose³

¹Department of Cardiac Anesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India

²Department of Cardiac Anesthesia and Critical Care, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India

³Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Corresponding author: Devishree Das, M.D., D.M. Department of Cardiac Anesthesia and Critical Care, Cardiothoracic Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India Tel: +91-8895299296 Email: devishreedas111@gmail.com

Received 2023 January 7; Accepted 2023 February 3.

Dear Editor,

An interesting article published recently in the Korean Journal of Anesthesiology by Seo et al. [1] features pertinent research investigating the role of anesthetic immunomodulation on oncological outcomes. This study outlines improved recurrence-free survival (RFS) and overall survival (OS) in the total intravenous anesthesia group compared to the inhalational anesthesia group by analyzing the retrospective data of 1,508 patients with non-small cell lung cancer (NSCLC) undergoing curative resections [1]. While we commend the authors on their research endeavors, the findings must be carefully interpreted in consideration of the following observations.

First, the index analysis did not account for the nutritional status of the participants in the respective study groups. Considering that existing literature associates low serum albumin (SA) levels with poor survival in NSCLC, this is an important omission [2]. A study by Jin et al. [3] highlighted significantly longer RFS following surgical resection in patients with stage I NSCLC with preoperative SA levels ≥ 3.5 g/dl than in patients with documented hypoalbuminemia (SA < 3.5 g/dl, P = 0.008), and notably, the study by Seo et al. [1] also included the early-stage malignancies.

Second, outcome prediction literature has also delineated the merits of composite immuno-nutritional profiling in oncology. In this context, a meta-analysis conducted by Peng et al. [4] that included a pooled analysis of 11 studies (3,029 patients) evaluating the effect that controlling patients’ nutritional status pre-treatment (Controlling Nutritional Status [CONUT] score computed using SA, total cholesterol, and lymphocyte count) had on NSCLC prognosis has attracted attention. A major finding of this meta-analysis was the correlation between a high CONUT score and poor OS and shortened disease-free survival (DFS) or RFS (hazard ratio [HR], 95% CI: 1.63, 1.40, 1.88 and 1.65, 1.35, 2.01; P < 0.001) [4]. Moreover, the CONUT score continued to predict poor OS in the subgroup analysis, regardless of the treatment modality (surgical or non-surgical). The fact that 9 out of 11 of the studies employed surgical resection as the central treatment modality is worth mentioning, as the study conducted by Seo et al. was limited to patients undergoing curative resections [1,4].

Lastly, it is equally difficult to overlook the prognostic implications that patient frailty has on surgical outcomes, particularly in early-stage cancers, as Shaw et al. [5] have emphasized. We hope that this discussion will motivate well-designed future research aimed at further clarifying the links between anesthetic immunomodulation and oncological outcomes.