The cardiopulmonary bypass and cancer dissemination puzzle

Early cancer diagnosis, new therapies that increased survival of patients, besides the increasingly elderly population are some factors would be associated with possible cancer dissemination in patients under cardiopulmonary bypass (CPB) cardiac surgery. Also, the benefits, and risks, regarding long-term survival, have not yet been established. Therefore, cardiac surgery morbimortality may be superior in patients with cancer disease. Also, immunologic and inflammatory changes secondary to CPB can also increase tumor recurrence. After a brief introduction and CPB immunologic the two main topic subjects included: 1) Combined heart surgery and lung resection and; 2) Possible influence of neoplasia type. After observing the relative literature scarcity, we keep the opinion that “CPB has a modest association with cancer progression” and that “CPB and cancer dissemination should be a logical but unlikely association.”

Key words:
Cardiopulmonary Bypass; Thoracic Surgery

Authorship

Paulo Roberto Barbosa Évora

PhD, Full Professor, Division of Thoracic and Cardiovascular Surgery, Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo (FMRP-USP), Ribeirao Preto-SP, Brazil. Conception and design of the study, manuscript writing, critical revision.Universidade de São PauloBrazilRibeirao Preto, SP, BrazilPhD, Full Professor, Division of Thoracic and Cardiovascular Surgery, Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo (FMRP-USP), Ribeirao Preto-SP, Brazil. Conception and design of the study, manuscript writing, critical revision.

Agnes Afrodite Sumarelli Albuquerque

Fellow Master degree, Experimental Medicine Program, Division of Thoracic and Cardiovascular Surgery, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Acquisition of data.USPBrazilRibeirao Preto, SP, BrazilFellow Master degree, Experimental Medicine Program, Division of Thoracic and Cardiovascular Surgery, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Acquisition of data.

Tales Rubens de Nadai

Fellow PhD degree, Experimental Medicine Program, Division of Thoracic and Cardiovascular Surgery, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Acquisition of data.USPBrazilRibeirao Preto, SP, BrazilFellow PhD degree, Experimental Medicine Program, Division of Thoracic and Cardiovascular Surgery, Department of Surgery and Anatomy, FMRP-USP, Ribeirao Preto-SP, Brazil. Acquisition of data.

Enio David Mente

PhD, Assistant Professor, Department of Surgery and Anatomy, Division of Digestive Surgery, FMRP-USP, Ribeirao Preto-SP, Brazil. Acquisition of data.USPBrazilRibeirao Preto, SP, BrazilPhD, Assistant Professor, Department of Surgery and Anatomy, Division of Digestive Surgery, FMRP-USP, Ribeirao Preto-SP, Brazil. Acquisition of data.

Ajith Kumar Sankarankuty

Orlando Castro-e-Silva

Full Professor, Surgery and Anatomy Department, FMRP-USP, Ribeirao Preto-SP, and Department of Gastroenterology, Medical School, USP, Sao Paulo-SP, Brazil. Critical revision.USPBrazilRibeirao Preto, SP, BrazilFull Professor, Surgery and Anatomy Department, FMRP-USP, Ribeirao Preto-SP, and Department of Gastroenterology, Medical School, USP, Sao Paulo-SP, Brazil. Critical revision.

Correspondence:
Prof. Dr. Paulo Roberto Barbosa Évora Hospital das Clínicas de Ribeirão Preto, Departamento de Cirurgia e Anatomia Avenida Bandeirantes 3900, Campus Universitário 14049-900 Ribeirão Preto - SP Brasil Tel.: (55 16)3602-2593 prbevora@fmrp.usp.br

Conflict of interest:

none

SCIMAGO INSTITUTIONS RANKINGS

Figures | Tables

Figures (1)
Tables (2)

Thumbnail

Figure 1
Rationale graphical presentation.

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Table 1
Learning remarks.

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Table 2
- The seven references that were freely chosen for the elaboration of ideas about the influence of CPB in patients with cancer.

Figure 1 Rationale graphical presentation.

Table 1 Learning remarks.

1. Increasingly elderly population, early cancer diagnosis and new therapies that increased survival of patients with malignancies. Since both cardiac disease and malignancy are widely prevalent, it is not infrequent to see patients facing both active cardiac disease and malignancy at the same time.

2. Inflammatory phenomena and immunologic changes secondary to CPB can increase tumor recurrence. There are two possible mechanisms through which CPB might contribute to the hematogenous dissemination of tumor cells. First, tumor cells contaminated in the reservoir blood might spread through the arterial cannula. Second, modiﬁcation of homeostasis by CPB may liberate tumor cells to which has been suppressed by the host defense system.

3. Cancer progression has a modest association with CPB.

4. Usually, patients who need cardiac intervention 10 years or more after cancer treatment have survival equivalent to age-matched non-cancer patients.

5. In some reports, hematological malignancies should not be considered a contraindication for cardiac CPB surgery.

6. Cardiac surgery using CPB did not have a negative impact on the natural course of chronic lymphatic leukemia (CLL).

7. Cardiac disease management in active cancer patients is sophisticated and requires a multi-disciplinary approach, with input from cardiology, cardiothoracic surgery, and oncology.

Table 2 - The seven references that were freely chosen for the elaboration of ideas about the influence of CPB in patients with cancer.

Suzuki et al. (2010) studied seventy-four cancer patients who underwent cardiac surgery before cancer therapy were followed up for 42 ± 37 months; 45 had cardiac surgery with CPB. Asian Cardiovasc Thorac Am. 2010;18(6):536-40.

Pinto (2013). An increased risk for overall cancer incidence (17%) and cancer-specific mortality (16% overall, 12% case fatality) was observed; without statistical significance. Cancer. 2013;13:519.

Plumereau et al. (2014) found four case series and four case-control series concluding that hematological malignancies should not be considered a contraindication for cardiac CPB surgery. Interact Cardiovasc Thorac Surg. 2014 Sep;19(3):474-8.

Miller et al. (1994) from 1965 through 1992, evaluated 30 patients (23 men and 7 women) underwent pulmonary resection for primary lung cancer and a concomitant open-heart operation, concluding that resection for lung cancer in patients undergoing concomitant open heart operation can be performed safely with low morbidity and mortality, long-term survival may be compromised. Ann Thorac Surg. 1994 Oct;58(4):989-93.

Danton et al. (1998). Simultaneous pulmonary resection and cardiac surgery in thirteen patients was associated with acceptable operative morbidity and mortality. Eur J Cardiothorac Surg. 1998 Jun;13(6):667-72.

Cathenis et al. (2009). Performed a retrospective review of 27 patients who underwent pulmonary and cardiac surgery, from 2000 to 2008, concluding that simultaneous procedures for cardiac disease and pulmonary lesions can be performed without life-threatening morbidity and no in hospital mortality. Acta Chir Belg. 2009 May-Jun;109(3):306-11.

Santavy et al. (2015) based on ten patients, combined treatment of cardiac disease and lung cancer is a feasible and safe method with excellent results. Cor Vasa. 2015 April;57(2):e82-e85.

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