Choosing what type of anesthesia to use and where to administer it for a cancer biopsy can be challenging. For one, anesthesia providers must take into account the risk factors associated with each patient. Anesthesia can also interact negatively with patients’ monocytes and macrophages, particularly with those cells’ chemotactic and phagocytic functions [1]. Furthermore, anesthesia can also compromise patients’ antigen recognition mechanisms [1]. Accordingly, the choices made by anesthesia providers when performing cancer biopsies should not be taken lightly. This article will address some anesthesia recommendations for three forms of cancer biopsies: lung/abdominal, breast, and prostate.
Image-guided percutaneous needle biopsies (PNBs) are the predominant method of searching for cancer in the lungs and abdomen [2]. Local anesthetic is recommended for most patients undergoing a PNB [2]. Physicians tend to administer lidocaine (from 10 to 20 mL) 1 to 2% along the needle’s predicted route [2]. This method is highly successful. When performed with local anesthesia, PNBs used for non-small cell lung cancer detection have a 95% diagnostic accuracy [3]. Complications are rare, with the most common issue being pneumothorax in 5-10% of cases [3]. Despite local anesthesia’s high success rates, general anesthesia may be more appropriate for children, along with any other patients who might have difficulty following instructions during the procedure [2].
For breast cancer biopsies, researchers have experimented with various forms of anesthesia in recent years [4]. In 2018, Levins et al. investigated the interaction between different forms of anesthesia and the body’s distribution of μ-opioid receptors (MOR), natural killer cells, and other immune cells–all of which are related to cancer prognoses [4]. They did not find a significant difference between a balanced general anesthetic with opioid analgesia and a propofol-paravertebral anesthetic with continuing analgesia in terms of how each affected immune cell marker expression [4]. However, the former method increased resected tumor MOR expression [4]. Because of the correlation between MOR expression and a tumor’s level of aggression, these results may dissuade anesthesia providers from administering general anesthesia [4]. Given the well-documented success of local anesthetics during breast cancer biopsies, a transition away from general anesthesia appears feasible [5].
Prostate biopsies are usually conducted using transrectal ultrasounds (TRUS) [6]. The two most common forms of anesthesia for TRUS are periprostatic nerve block (PNB) and intrarectal topical anesthesia (ITA) [6]. While PNB was considered, for a long time, to be more reliable and successful than ITA in reducing pain during TRUS biopsies, recent evidence has revealed that ITA can also significantly reduce TRUS-related pain, albeit not as well as PTB [6]. Regardless, given their comparably low rates of adverse events, this knowledge could support administering joint ITA and PNB regimens during transrectal ultrasounds [6]. Alternatives to TRUS have also been researched recently, with a study by Stefanova et al. suggesting that transperineal prostate biopsies under local anesthesia could be feasibly adopted [7]. In that study, transperineal prostate biopsies seemed a safer alternative than TRUS, with patients experiencing no more than mild levels of discomfort [7]. Depending on the method chosen, anesthesia providers have multiple options when treating prostate cancer biopsy patients.
While these are just some of the recent discoveries related to anesthesia in cancer biopsies, they reflect the general idea that techniques are evolving and skewing away from general anesthesia when possible.
References
[1] M. Alieva, J. van Rheenen, and M. L. D. Broekman, “Potential impact of invasive surgical procedures on primary tumor growth and metastasis,” Clinical & Experimental Metastasis, vol. 35, no. 4, p. 319-331, May 2018. [Online]. Available: https://doi.org/10.1007/s10585-018-9896-8. [2] L. Dalag, J. K. Fergus, and S. M. Zangan, “Lung and Abdominal Biopsies in the Age of Precision Medicine,” Seminars in Interventional Radiology, vol. 36, no. 3, p. 255-263, August 2019. [Online]. Available: https://doi.org/10.1055/s-0039-1693121. [3] P. Lavaud et al., “Focus on Recommendations for the Management of Non-small Cell Lung Cancer,” Cardiovascular Interventional Radiology, vol. 42, no. 9, p. 1230-1239, May 2019. [Online]. Available: https://doi.org/10.1007/s00270-019-02222-9. [4] K. J. Levins et al., “The effect of anesthetic technique on µ-opioid receptor expression and immune cell infiltration in breast cancer,” Journal of Anesthesia, vol. 32, no. 6, p. 792-796, September 2018. [Online]. Available: https://doi.org/10.1007/s00540-018-2554-0. [5] B. M. Saputra et al., “ESRA19-0646 Ultrasound guided erector spinae plane block as regional anesthesia techniques for breast cancer biopsy, a case series,” Regional Anesthesia & Pain Medicine, vol. 44, supp. 1, p. A264-A265, February 2019. [Online]. Available: https://doi.org/10.1136/rapm-2019-ESRAABS2019.485. [6] Y. Yang et al., “The Efficiency and Safety of Intrarectal Topical Anesthesia for Transrectal Ultrasound-Guided Prostate Biopsy: A Systematic Review and Meta-Analysis,” Urologic Internationalis, vol. 99, no. 4, p. 373-383, December 2017. [Online]. Available: https://doi.org/10.1159/000481830. [7] V. Stefanova et al., “Transperineal Prostate Biopsies Using Local Anesthesia: Experience with 1,287 Patients. Prostate Cancer Detection Rate, Complications and Patient Tolerability,” Journal of Urology, vol. 201, no. 6, p. 1121-1126, June 2019. [Online]. Available: https://doi.org/10.1097/JU.0000000000000156.