Evaluation Of The Influence Of Anesthetic Interventions On The Evolution Of Hepatic Neoplastic Processes

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality worldwide, with rising incidence in the context of chronic liver disease, viral hepatitis, non-alcoholic fatty liver disease, and cirrhosis. Surgical resection, whether curative or cytoreductive, is a cornerstone of management in selected patients with HCC or secondary hepatic malignancies. However, accumulating evidence highlights that perioperative factors, especially those related to anesthetic management may influence not only immediate postoperative recovery but also long-term oncologic outcomes. Debates persist regarding the optimal anesthesia for oncologic patients. While some studies favored total intravenous anesthesia (TIVA), recent retrospective studies show no significant difference between inhalational and intravenous techniques. However, adjunct therapies, such as perioperative lidocaine, may influence recurrence and outcomes.

Recent investigations into cancer biology have emphasized the role of systemic inflammation, immune dysregulation, and neutrophil behavior in promoting tumor progression, immune escape, and metastatic dissemination. A novel contributor to this inflammatory pro-tumorigenic environment is NETosis, the formation of neutrophil extracellular traps (NETs). NETs are composed of chromatin fibers (e.g., MPO, elastase, citrullinated histones), which, beyond their physiological role in infection containment, are increasingly implicated in cancer-related processes such as angiogenesis, tumor invasion, thrombosis, and immune suppression.

Research goal The aim of the study is to evaluate the involvement of NETosis in the progression of hepatocellular carcinoma.

Main objective:

To assess the influence of the type of anesthesia used in hepatobiliary oncologic surgery on postoperative evolution and immune response.

Secondary objective:

• To evaluate the impact of anesthesia type-TIVA versus inhalational-on NET formation.
• To assess the role of NETs in the progression of neoplastic disease and correlate their levels with clinical outcomes.
• To evaluate the effect of perioperative lidocaine administration on the generation of NETs.

Study type: prospective, interventional, longitudinal, randomized Methodology - presentation of work protocols

1. Logistical organization stage - ethics committee agreement; includes identification of laboratories and methods of collecting biological products (blood) for plasma concentration measurements, study-specific forms (informed consent form, data culture form)
2. Patient Enrollment Phase and Completion of Study Groups: 2.1 Formation of four study groups, each around of 50 patients diagnosed with hepatocellular carcinoma or hepatic metastases, according to the type of anesthesia administered during surgery: Group 1 - TIVA (propofol) + lidocaine Group 2 - TIVA (propofol) + placebo Group 3 - Sevoflurane + lidocaine Group 4 - Sevoflurane + placebo 2.2 Inclusion Criteria: Patients eligible for the study are those aged between 18 and 80 years, diagnosed with hepatocellular carcinoma or hepatic metastases, and scheduled for elective surgery (hepatectomy or metastasectomy). 2.3 Exclusion Criteria: The following patients will be excluded from the study: those undergoing emergency surgery; Barcelona-Clinic Liver Cancer stage C; Child-Pugh Class C; patients on chronic immunosuppressive therapy; individuals with contraindications to any of the study medications; patients with psychiatric disorders (depression, bipolar disorder, schizophrenia); individuals with autoimmune diseases or corticosteroid-dependent bronchial asthma; patients with congenital or acquired coagulation disorders; chronic users of anticoagulants and/or antiplatelet agents; HIV-positive patients; pregnant women; and those receiving antiarrhythmic therapy (verapamil, propafenone, amiodarone) that may interfere with lidocaine's antiarrhythmic action.
3. Biological Sample Analysis for NETosis Quantification To quantify NETosis (which cannot be measured directly), surrogate biomarkers will be used that correlate reliably with NET formation. Promising markers include MPO-DNA complexes, cell-free DNA (cfDNA), and citrullinated histone H3 (H3Cit), all of which reflect the extent of NET generation.
4. Patient Follow-Up Patients will be followed for one year to assess overall survival and progression-free survival. Follow-up methods will include direct contact, telephone, and email. Data will be collected regarding general health status, disease progression, timing and presence of tumor recurrence, and any hospitalizations occurring after the surgical intervention along with the reasons for medical visits. Results of follow-up investigations (CT, ultrasound, and laboratory tests) requested by the attending surgeon or oncologist will be collected.
5. Data Processing and Study Completion

5.1 Analysis of H3Cit, MPO-DNA, and cfDNA concentrations in correlation with the type of anesthesia and surgical technique used.

5.2 Evaluation of associations between conventional inflammatory markers and progression of hepatocellular carcinoma or hepatic metastases.

5.3 Determination of the type of correlation between inflammatory markers and NETosis.

5.4 Comparison of plasma concentrations of local anesthetics with values reported in the literature (where antineoplastic effects were observed).

5.5 Statistical analysis and establishment of correlations between the local anesthetic used and cancer recurrence.

Brief Description of Study Procedures This is a prospective, randomized, interventional, single-center clinical trial including patients with hepatocellular carcinoma or hepatic metastases undergoing elective surgery. Tumor staging will be performed according to AJCC (American Joint Committee on Cancer) and BCLC (Barcelona Clinic Liver Cancer) criteria. Patients with ASA physical status I, II, or III will be included. Ethics approvals will be obtained from the UMF Cluj and IRGH Ethics Committees. All participants will sign written informed consent.

Inclusion criteria:

Patients aged 18-80 years with hepatocellular carcinoma or hepatic metastases undergoing elective liver resection (hepatectomy or metastasectomy).

Exclusion criteria:

Patients undergoing emergency surgery; Barcelona-Clinic Liver Cancer stage C; Child-Pugh Class C; chronic immunosuppressive therapy users; individuals with contraindications to any of the study medications; patients with psychiatric disorders (depression, bipolar disorder, schizophrenia); individuals with autoimmune diseases or corticosteroid-dependent bronchial asthma; patients with congenital or acquired coagulation disorders; chronic users of anticoagulants and/or antiplatelet agents; HIV-positive individuals; pregnant women; and patients on antiarrhythmic drugs (verapamil, propafenone, amiodarone) that could interfere with lidocaine's antiarrhythmic action.

Anesthetic protocol:

Low molecular weight heparin will be administered 12 hours prior to surgery, along with preoperative fasting as per recommendations. Premedication will include midazolam 1 mg IV. Induction will consist of fentanyl 2-3 mcg/kg, propofol 1-1.5 mg/kg, and rocuronium 0.5-0.6 mg/kg for muscle relaxation. Lidocaine 1% at 1.5 mg/kg IV bolus will also be administered at induction.

Maintenance of anesthesia:

Inhalational group: Sevoflurane administered at an EtSevo of 1-1.5 MAC, adjusted in steps of 0.25-0.5 MAC depending on BIS levels (target range 40-59).

TIVA group: Propofol administered using the Schneider pharmacokinetic model, starting with an effect-site concentration of 4 µg/ml, adjusted according to BIS (target 40-59).

All patients will receive mechanical ventilation with volume- or pressure-controlled modes, FiO₂ of 40-60% to maintain SpO₂ ≥94%, in a semi-closed circuit, with a fresh gas flow of 2-2.5 L/min, tidal volume of 6-7 mL/kg ideal body weight, and PEEP adjusted based on patient and surgical specifics.

Intraoperative analgesia:

Administer fentanyl 0.5-1 µg/kg as needed (e.g., if blood pressure or heart rate increases >20% from baseline, or signs of sympathetic activation such as mydriasis, lacrimation, sweating).

Thirty minutes before the end of surgery, nefopam 40 mg IV will be administered, depending on comorbidities.

Lidocaine infusion:

A continuous infusion of 1% lidocaine at 1 mg/kg/hour will be administered intraoperatively, up to a maximum of 200 mg/hour, from intubation until awakening.

Postoperative analgesia:

Morphine at 0.1-0.2 mg/kg IV will be administered 30 minutes prior to awakening from anesthesia.

Intraoperative monitoring:

Standard ASA monitoring (blood pressure, heart rate, temperature, peripheral oxygen saturation, end-tidal CO₂), BIS (target 40-55), and total fentanyl and lidocaine consumption will be recorded.

Blood sampling:

10 mL of peripheral venous blood will be collected preoperatively and 6 hours postoperatively to determine the levels of MPO-DNA and cfDNA, both strongly correlated with NETosis. Samples will be centrifuged at 3000 rpm, and serum stored at -80°C. Additional inflammatory markers will be measured, including C-reactive protein (CRP), total leukocyte count, blood glucose, procalcitonin, and interleukins IL-6, IL-8, IL-10, and IL-17 for selected cases.

Patients will be followed for one year to monitor the incidence of metastases and postoperative complications.

Ethical Considerations All patients will be enrolled based on written informed consent and will be monitored according to the Research Ethics Guidelines of the "Iuliu Hațieganu" University of Medicine and Pharmacy, as well as the recommendations and requirements of the Research Ethics Committee, in compliance with international regulations and human rights protections.

The study will be approved by the Ethics Committees of UMF Cluj and IRGH.