This has been demonstrated see more in some tumors, particularly in bladder carcinoma, which is promoted by chronic inflammation and is uniquely sensitive to acute inflammation [2, 3].

In addition, the surgical stress associated with general anesthesia causes immune suppression that accelerates the growth of neoplastic cells and premature enhanced metastasis [4–6]. Tumor-associated macrophages and T cells modify the microenvironment and are relevant to cancer progression. Tumor cell proliferation and invasion are also correlated with the release of specific cytokines [1, 7]. Proinflammatory cytokines such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and interleukin -1beta (IL-1β), which are released from tumor-infiltrating leukocytes, can activate signal transducers and activators of transcription protein 3 (STAT3), which induces

immunosuppression that favors tumor cell proliferation [8, 9]. T cells can exert both tumor suppression and cancer-promoting effects. Two subpopulations of lymphocytes have been described: LGK 974 those with Th1 or Th2 activity [10]. Th1 cells secrete pro-inflammatory cytokines, namely interferon-gamma (IFN-γ), and favor activation of macrophages and the inflammatory response. Th2 cells, with their pattern of cytokines interleukin-4 (IL-4) and interleukin-10 (IL-10), mediate the production of antibodies and have anti-inflammatory effects. In many tumors, such as colorectal cancer, melanoma, and pancreatic cancer, the Th1 response

correlates with better prognosis [1, 11, 12]. Th1 cells probably exert a tumor suppressive effect also in bladder cancer [13]. Furthermore, induction of the T-helper type 1 immune response is Adenosine required for effective bacillus Calmette-Guérin immunotherapy for bladder cancer [14]. Recent studies suggest that regulatory T cells (Tregs), a subpopulation of CD4+ T cells, play a fundamental role in maintaining immune tolerance [15–17]. Increasing evidence suggests that infiltrating and circulating Tregs inhibit antitumor immunity and promote tumor growth and disease progression, as observed in some clinical studies [18, 19]. Nevertheless, only a few studies have evaluated the immunosuppressive effect of different anesthetic techniques in cancer patients undergoing major surgery. No guidelines for anesthesia procedures for cancer patients are available even though guidelines for operative procedures have been formulated for different types of cancer [20]. Previous studies on the role of inhaled and intravenous anesthetics in immune suppression showed contradictory results and appeared to be correlated with the type of cancer and surgery [20–23]. To our ATM inhibitor knowledge, no study has evaluated the effect of different anesthetic techniques in patients undergoing surgery for bladder cancer. Only Wang et al.