Tumor excision is a necessary life-saving procedure in most solid cancers. However, surgery and the days before and following it, known as the immediate perioperative period (IPP), entail numerous prometastatic processes, including the suppression of antimetastatic immunity and direct stimulation of minimal residual disease (MRD). Thus, the IPP is pivotal in determining long-term cancer outcomes, presenting a short window of opportunity to circumvent perioperative risk factors by employing several therapeutic approaches, including immunotherapy. Nevertheless, immunotherapy is rarely examined or implemented during this short timeframe, due to both established and hypothetical contraindications to surgery. Herein, we analyze how various aspects of the IPP promote immunosuppression and progression of MRD, and how potential IPP application of immunotherapy may interact with these deleterious processes. We discuss the feasibility and safety of different immunotherapies during the IPP with a focus on the latest approaches of immune checkpoint inhibition. Last, we address the few past and ongoing clinical trials that exploit the IPP timeframe for anticancer immunotherapy. Accordingly, we suggest that several specific immunotherapies can be safely and successfully applied during the IPP, alone or with supporting interventions, which may improve patients’ resistance to MRD and overall survival.

Background: The perioperative period often involves stress responses and surgery-induced hypothermia, which were suggested to hinder antimetastatic immunity and promote cancer metastasis. During this critical period, immunotherapies are rarely used, given contraindications to surgery. However, recent preclinical studies support the feasibility of perioperative TLR-9 activation using CpG-C. Materials and methods: Herein, we employed hypothermic-stress and normothermic-stress paradigms to assess their impact on perioperative CpG-C immune stimulation and resistance to experimental hepatic metastasis of CT26 colorectal cancer in BALB/c mice. Results: Perioperative hypothermic wet-cage stress markedly abrogated CpG-C-induced increase in plasma IL-12 levels, a persistent deleterious effect across different CpG-C doses and administration routes. These effects were not attenuated by blocking glucocorticoids, adrenergic, or opioid signaling, nor by adrenalectomy, suggesting a direct immunosuppressive impact of hypothermia on immunocytes. Indeed, normothermic wet-cage stress, which induced a similar corticosterone response, caused significantly less deleterious effects on IL-12 levels, hepatic NK cell maturation and cytotoxicity, and CT26 metastasis. Additionally, in-vitro exposure of PBMCs to 33°C markedly decreased CpG-C-induced IL-12 production. Last, two normothermic stress paradigms, tilt&light and restraint, did not jeopardize CpG-C-induced IL-12 response nor resistance to CT26 metastases. Interestingly, attenuating glucocorticoid signaling under tilt&light conditions improved CpG-C efficacy. Conclusions: Overall, these findings suggest that perioperative hypothermic stress can jeopardize antimetastatic immunity and resistance to metastasis, and prevent perioperative response to immune stimulation and its beneficial antimetastatic impacts, effects that are not mediated through classical neuroendocrine stress responses, but potentially through direct hypothermic impact on leukocytes. These findings may have clinical implications in operated cancer patients, many of whom suffer hypothermic stress.

Numerous case studies have reported spontaneous regression of recognized metastases following primary tumor (PT) excision, but underlying mechanisms are elusive. Here we present a model of metastases regression and latency following PT excision, and identify potential underlying mechanisms. Using MDA-MB-231 ^HM human breast cancer cells that express highly sensitive luciferase, we were able to monitor early stages of spontaneous metastases development in BALB/c nu/nu mice. Removal of the PT caused marked regression of the smallest micro-metastases, but not of larger metastases, and in vivo supplementation of tumor secretome diminished this regression, suggesting that PT-secreted factors promote early metastatic growth. Correspondingly, cancer cell conditioned medium reduced apoptosis and enhanced MDA-MB-231 ^HM adhesion in vitro . To identify specific mediating factors, cytokine array and proteomic analysis of MDA-MB-231 ^HM secretome were conducted. Results identified significant enrichment of angiogenesis, growth factors binding and activity, focal adhesion, metalloprotease regulation, and apoptosis regulation processes. Simultaneous in vivo blockade of four secreted key potential mediators of these processes, IL-8, PDGFaa, Serpin E1 (PAI-1), and MIF, arrested development of micro-metastases in the presence of the PT. Interestingly, using the public TCGA provisional dataset, high protein levels of these four factors were correlated with poor survival in a cohort of lung adenocarcinoma patients. These results demonstrate regression and latency of micro-metastases following PT excision, and a crucial role for PT-secretome in promoting early metastatic stages in MDA-MB-231 ^HM xenografts. If generalized, such findings can suggest novel approaches to control minimal residual disease during and following PT excision.