Cancer morbidity in blood recipients--results of a cohort study

Cancer risk among 21st century blood transfusion recipients

Background

Some carcinogenic viruses are known to be transmissible by blood transfusion. Intensive viral screening of transfused blood now exists in most countries. In the UK, high-sensitivity nucleic acid amplification tests for hepatitis C virus were introduced in 1999 and it was thought that this would reduce, and possibly eliminate, transfusion-related liver cancer. We aimed to investigate cancer risk in recipients of blood transfusion in 2000 or after.

Methods

A total of 1.3 million UK women recruited in 1998 on average were followed for hospital records of blood transfusion and for cancer registrations. After excluding women with cancer or precancerous conditions before or at the time of transfusion, Cox regression yielded adjusted relative risks of 11 site-specific cancers for women with compared to without prior blood transfusion.

Results

During follow up, 11 274 (0.9%) women had a first recorded transfusion in 2000 or after, and 1648 (14.6%) of them were subsequently diagnosed with cancer, a mean 6.8 years after the transfusion. In the first 5 years after transfusion there were significant excesses for most site-specific cancers examined, presumably because some had preclinical cancer. However, 5 or more years (mean 8 years) after blood transfusion, there were significant excess risks only for liver cancer (adjusted relative risk = 2.63, 95%CI 1.45-4.78) and for non-Hodgkin lymphoma (adjusted relative risk = 1.74, 1.21-2.51). When analyses were restricted to those undergoing hip or knee replacement surgery, the commonest procedure associated with transfusion, these relative risks were not materially altered.

Conclusions

In a large cohort of UK women, transfusions in the 21st century were associated with long-term increased risks of liver cancer and non-Hodgkin lymphoma. Some of these malignancies may have been caused by carcinogenic agents that are not currently screened for in transfused blood.

Marseillevirus in lymphoma: a giant in the lymph node

The family Marseilleviridae is a new clade of giant viruses whose original member, marseillevirus, was described in 2009. These viruses were isolated using Acanthamoeba spp primarily from the environment. Subsequently, a close relative of marseillevirus was isolated from the faeces of a healthy young man, and others were detected in blood samples of blood donors and recipients and in a child with lymph node adenitis. In this Grand Round we describe the detection of marseillevirus by PCR, fluorescence in-situ hybridisation, direct immunofluorescence, and immunohistochemistry in the lymph node of a 30-year-old woman diagnosed with Hodgkin's lymphoma, together with IgG antibodies to marseillevirus. A link with viruses and bacteria has been reported for many lymphomas. We review the literature describing these associations, the criteria used to consider a causal association, and the underlying mechanisms of lymphomagenesis. Our observations suggest that consideration should be given to marseillevirus infections as an additional viral cause or consequence of Hodgkin's lymphoma, and that this hypothesis should be tested further.

No evidence of transmission of chronic lymphocytic leukemia through blood transfusion

Transfusion recipients’ risk of CLL is not affected by postdonation CLL in donor. Recipient CLL does not cluster to individual donors, arguing against MBL transmission.

Medical history, lifestyle, family history, and occupational risk factors for follicular lymphoma: the InterLymph Non-Hodgkin Lymphoma Subtypes Project

BACKGROUND

Follicular lymphoma (FL) has been linked with cigarette smoking and, inconsistently, with other risk factors.

METHODS

We assessed associations of medical, hormonal, family history, lifestyle, and occupational factors with FL risk in 3530 cases and 22639 controls from 19 case-control studies in the InterLymph consortium. Age-, race/ethnicity-, sex- and study-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression.

RESULTS

Most risk factors that were evaluated showed no association, except for a few modest or sex-specific relationships. FL risk was increased in persons: with a first-degree relative with non-Hodgkin lymphoma (OR = 1.99; 95% CI = 1.55 to 2.54); with greater body mass index as a young adult (OR = 1.15; 95% CI = 1.04 to 1.27 per 5 kg/m(2) increase); who worked as spray painters (OR = 2.66; 95% CI = 1.36 to 5.24); and among women with Sjögren syndrome (OR = 3.37; 95% CI = 1.23 to 9.19). Lower FL risks were observed in persons: with asthma, hay fever, and food allergy (ORs = 0.79-0.85); blood transfusions (OR = 0.78; 95% CI = 0.68 to 0.89); high recreational sun exposure (OR = 0.74; 95% CI = 0.65 to 0.86, fourth vs first quartile); who worked as bakers or millers (OR = 0.51; 95% CI = 0.28 to 0.93) or university/higher education teachers (OR = 0.58; 95% CI = 0.41 to 0.83). Elevated risks specific to women included current and longer duration of cigarette use, whereas reduced risks included current alcohol use, hay fever, and food allergies. Other factors, including other autoimmune diseases, eczema, hepatitis C virus seropositivity, hormonal drugs, hair dye use, sun exposure, and farming, were not associated with FL risk.

CONCLUSIONS

The few relationships observed provide clues suggesting a multifactorial etiology of FL but are limited in the extent to which they explain FL occurrence.

Association between red blood cell transfusions and development of non-Hodgkin lymphoma: a meta-analysis of observational studies

The incidence of non-Hodgkin lymphoma (NHL) has increased steadily for the past few decades. Previous studies have suggested an association between blood transfusions and NHL. The main objective of this study was to evaluate this relationship with a meta-analysis of observational studies. A literature search was undertaken, looking for case-control and cohort studies evaluating the risk of developing NHL in persons who received allogeneic blood transfusions; 14 studies were included. Outcome was calculated and reported as relative risk (RR). Heterogeneity was assessed with Cochrane Q and I2 statistics. Dissemination bias was evaluated by funnel plot visualization and trim-and-fill analysis. Quality assessment was performed with the Newcastle-Ottawa scale. Our analysis showed a RR of developing NHL of 1.05 (95% CI, 0.89-1.25; P = .42) and 1.34 (95% CI, 1.15-1.55; P < .01) in case-control and cohort studies, respectively. When pooling all studies, RR was 1.2 (95% CI, 1.07-1.35; P < .01). In subset analysis, RR of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) was 1.66 (95% CI, 1.08-2.56; P = .02). The RR of NHL was elevated in both men and women and in persons receiving transfusions either before or after 1992. Blood transfusions appear to increase the risk of developing NHL; however, the risk of CLL/SLL appears higher than for other NHL subtypes.

Blood transfusions and the subsequent risk of hematologic malignancies

BACKGROUND

Blood transfusions are associated with viral transmission and immunomodulation, perhaps increasing subsequent risk of hematologic malignancies (HMs). Prior studies of transfusion recipients have lacked details on specific HM subtypes.

STUDY DESIGN AND METHODS

Risk of HM after blood transfusion was evaluated in a US population-based case-control study (77,488 elderly HM cases identified through cancer registries, 154,509 controls). Transfusions were identified using linked Medicare hospitalization claims. Polytomous logistic regression was used to calculate odds ratios (ORs) associating transfusion and HM subtypes by features suggestive of a causal relationship.

RESULTS

A history of transfusion was present in 7.9% of HM cases versus 5.9% of controls. Associations for most HM subtypes suggested reverse causality: ORs were elevated only during the shortest latency periods; ORs for unspecified anemia and gastrointestinal bleeding, which may be related to undiagnosed HM, were stronger than for surgeries, which are unlikely to be related to HM; and/or there was no dose response. In contrast, risk for lymphoplasmacytic lymphoma (1397 cases) was elevated at long latency (OR, 1.56 at 10+ years after transfusion), after transfusions related to surgeries (OR, 1.22-1.47), and in a dose-response relationship with number of transfusion-related hospitalizations (OR, 1.53 with one hospitalization; OR, 1.80 with two or more hospitalizations, p trend < 0.0001). Risk for marginal zone lymphoma (1915 cases) was also elevated at 10+ years after transfusion (OR, 1.80).

CONCLUSION

Consistent with prior studies, blood transfusions did not increase risk of most HM subtypes. Patterns of elevated risk for lymphoplasmacytic and marginal zone lymphomas suggest an etiologic role for transfusion.

Blood transfusion, anesthesia, surgery and risk of non-Hodgkin lymphoma in a population-based case-control study

The incidence of NHL has increased dramatically since at least the 1950s, and during this timeframe there has been a major increase in the use of blood transfusions, invasive surgical procedures and anesthesia, all of which can impact immune function. We evaluated these factors with NHL risk in a population-based study of 759 cases and 589 frequency-matched controls. Risk factor data were collected during in-person interviews. Unconditional logistic regression was used to estimate ORs and 95% CIs, adjusted for the matching factors. History of transfusion was associated with a 26% higher risk of NHL (95% CI 0.91-1.73), and the elevated risk was specific to transfusions first given 5-29 years before the reference date (OR = 1.69; 95% CI 1.08-2.62) and transfusions given for a medical condition (OR = 2.09; 95% CI 1.03-4.26). The total number of surgeries and dental procedures (OR = 1.53 for 26+ surgeries compared to 0-6; 95% CI 1.02-2.29) and to a lesser extent the total number of exposures to general or local/regional anesthesia (OR = 1.35 for 24+ times compared to 0-6; 95% CI 0.91-2.02) were positively associated with risk of NHL. Inclusion of transfusion and surgery or transfusion and anesthesia in the same model did not attenuate these associations. All results were broadly consistent for both DLBCL and follicular subtypes. Blood transfusions were associated with NHL risk, but appear to be a marker for underlying medical conditions. Multiple surgical procedures and/or repeated administration of anesthesia have not been previously reported to be associated with risk of NHL and these exposures warrant further evaluation.

Cancer incidence in blood transfusion recipients

BACKGROUND

Blood transfusions may influence the recipients' cancer risks both through transmission of biologic agents and by modulation of the immune system. However, cancer occurrence in transfusion recipients remains poorly characterized.

METHODS

We used computerized files from Scandinavian blood banks to identify a cohort of 888,843 cancer-free recipients transfused after 1968. The recipients were followed from first registered transfusion until the date of death, emigration, cancer diagnosis, or December 31, 2002, whichever came first. Relative risks were expressed as ratios of the observed to the expected numbers of cancers, that is, standardized incidence ratios (SIRs), using incidence rates for the general Danish and Swedish populations as a reference. All statistical tests were two-sided.

RESULTS

During 5,652,918 person-years of follow-up, 80,990 cancers occurred in the transfusion recipients, corresponding to a SIR of 1.45 (95% confidence interval [CI] = 1.44 to 1.46). The SIR for cancer overall decreased from 5.36 (95% CI = 5.29 to 5.43) during the first 6 months after transfusion to 1.10 or less for follow-up periods more than 2 years after the transfusion. However, the standardized incidence ratios for cancers of the tongue, mouth, pharynx, esophagus, liver, and respiratory and urinary tracts and for squamous cell skin carcinoma remained elevated beyond 10 years after the transfusion.

CONCLUSIONS

The marked increase in cancer risk shortly after a blood transfusion may reflect the presence of undiagnosed occult cancers with symptoms that necessitated the blood transfusion. The continued increased risk of tobacco- and alcohol-related cancers suggests that lifestyle and other risk factors related to conditions prompting transfusion rather than transfusion-related exposures per se are important to the observed cancer occurrence in the recipients.

The non-Hodgkin lymphomas: a review of the epidemiologic literature

The non-Hodgkin lymphomas (NHL) are a heterogeneous group of B-cell and T-cell neoplasms that arise primarily in the lymph nodes. NHL incidence rates in the US doubled between about 1970 and 1990, and stabilized during the 1990s. NHL accounts for approximately 3.4% of cancer deaths in the US. Although some of the observed patterns in NHL have been related to HIV/AIDS, these conditions cannot fully explain the magnitude of the changes; neither do changes in classification systems nor improved diagnostic capabilities. Studies of occupational and environmental exposures (e.g., pesticides, solvents) have produced no consistent pattern of significant positive associations. Inverse associations with ultraviolet radiation exposure and alcohol and fish intake, and positive associations with meat and saturated fat intake have been reported in several studies; additional studies are needed to confirm or refute these associations. Family history of NHL or other hematolympho-proliferative cancers and personal history of several autoimmune disorders are associated with increased risk of NHL, but are not likely to account for a large proportion of cases. HIV and other infectious agents, such as human herpesvirus 8 and Epstein-Barr, appear to be associated with differing types of NHL, such as some B-cell lymphomas. Future epidemiologic studies should evaluate associations by NHL type, enhance exposure information collected, and elucidate factors that may identify susceptible (or resistant) subpopulations because of genetic, immunologic or other characteristics. The extent to which the etiology of NHL types may differ is important to resolve in ongoing and future studies.

Risk of cancer after blood transfusion from donors with subclinical cancer: a retrospective cohort study

BACKGROUND

Although mechanisms for detection of short-term complications after blood transfusions are well developed, complications with delayed onset, notably transmission of chronic diseases such as cancer, have been difficult to assess. Our aim was to investigate the possible risk of cancer transmission from blood donors to recipients through blood transfusion.

METHODS

We did a register-based retrospective cohort study of cancer incidence among patients who received blood from donors deemed to have a subclinical cancer at the time of donation. These precancerous donors were diagnosed with a cancer within 5 years of the donation. Data from all computerised blood bank registers in Sweden and Denmark gathered between 1968 and 2002 were merged into a common database. Demographic and medical data, including mortality and cancer incidence, were ascertained through linkages with nationwide, and essentially complete, population and health-care registers. The risk of cancer in exposed recipients relative to that in recipients who received blood from non-cancerous donors was estimated with multivariate Poisson regression, adjusting for potential confounding factors.

FINDINGS

Of the 354 094 transfusion recipients eligible for this analysis, 12,012 (3%) were exposed to blood products from precancerous donors. There was no excess risk of cancer overall (adjusted relative risk 1.00, 95% CI 0.94-1.07) or in crude anatomical subsites among recipients of blood from precancerous donors compared with recipients of blood from non-cancerous donors.

INTERPRETATION

Our data provide no evidence that blood transfusions from precancerous blood donors are associated with increased risk of cancer among recipients compared with transfusions from non-cancerous donors.

History of blood transfusion before 1990 is a risk factor for stroke and cardiovascular diseases: the Japan collaborative cohort study (JACC study)

BACKGROUND

We have previously shown novel evidence that history of blood transfusion is a risk factor for mortality from subarachnoid hemorrhage. This study was conducted to assess history of transfusion as a risk factor for other hemorrhagic stroke or ischemic stroke and cardiovascular diseases.

STUDY DESIGN AND METHODS

A total of 88,312 Japanese participants (36,823 men and 51,489 women), aged 40-79 years, without history of stroke, heart disease or cancer, completed a questionnaire including history of transfusion under the JACC Study from 1988 to 1990. Participants were followed up annually until deceased, or when they moved away from the surveyed community, or at the end of 1999. The underlying causes of death were determined according to the International Classification of Diseases, 10th revision (ICD-10).

RESULTS

Total follow-up person-years were 871,437 (males 359,437, females 512,000). During this 10-year period, 309 died from intracerebral hemorrhage, 587 from ischemic stroke and 472 from coronary heart disease. The multivariate relative risks of a transfusion history were 2.16 (95% CI 1.42-3.27, p < 0.001) for intracerebral hemorrhage, 1.63 (95% CI 1.18-2.27, p = 0.004) for ischemic stroke and 1.66 (95% CI 1.17-2.36, p = 0.005) for coronary heart disease, after adjustment for conventional cardiovascular risk factors.

CONCLUSION

A transfusion history was associated with increased mortality from stroke and coronary heart disease.

The epidemiology of non-Hodgkin's lymphoma

The incidence of non-Hodgkin's lymphoma (NHL) has doubled over the past two decades in the US and most other westernized countries. While improved cancer reporting, changes in lymphoma classification, and increases in AIDS-associated lymphomas have contributed to the startling escalation of disease incidence, these factors are estimated to account for only about 50% of the increase in observed incidence. The elucidation of etiologic factors and their mechanistic role in the pathogenesis of this malignancy are critical to advancements in disease prevention and treatment. Current evidence suggests that factors/conditions that precipitate either chronic antigenic stimulation or immunosuppression may provide a preferential milieu for development of NHL. High rates of lymphoma have been observed among individuals with autoimmune disease, organ transplants, and primary or acquired immunodeficiencies. Ultraviolet radiation, previously demonstrated to have an immunosuppressive effect, has also been suggested as a possible risk factor for NHL. Several pathogens have been linked to the risk of lymphoma, including Epstein-Barr virus, human immunodeficiency virus, human T-cell lymphotropic virus-1, Helicobacter pylori, hepatitis C, and simian virus 40. Whether these microbes are responsible for specific genetic mutations that initiate tumor growth, antigenic stimulation leading to B-cell proliferation, and increased potential of random cell replication errors, or immunosuppression, which thereby promotes tumor growth, has not been clearly delineated. Other exogenous factors which have been implicated in lymphomagenesis are chemicals and agricultural exposures, hair dyes, and blood transfusions. We must build on our current knowledge regarding the etiology of NHL in order that prevention, treatment, and ultimately, cure of this malignancy becomes a reality.

An update of the epidemiology of non-Hodgkin's lymphoma

The incidence of non-Hodgkin's lymphoma (NHL) has increased approximately 80% since the 1970s, and is now the fifth most common cancer in the United States. The incidence of NHL is approximately 50% higher among men than women and 35% higher among white people than black people. The incidence rates of all subtypes of NHL have increased, especially diffuse large-cell and immunoblastic subtypes. Extranodal NHL has increased more rapidly than nodal NHL. The overall NHL incidence rates stabilized in the early 1990s and then began to decrease between 1996 and 2000, resulting in part from a decrease in the incidence of AIDS. The incidence of NHL types not associated with AIDS and NHL in groups at low risk of AIDS has continued to increase throughout the 1990s. The increasing incidence of NHL is poorly understood. Improved diagnostic techniques, the effects of the human immunodeficiency virus epidemic, and immunosuppressive therapies accounted for only one third of the increase. Increase in NHL may be attributed to immunodeficiency, various infections, familial aggregation, blood transfusion, genetic susceptibility to NHL, diet, and chemical exposures to pesticides and solvents. Some studies also suggest that associations between risk factors and specific NHL subtypes may be stronger than associations between the same risk factors and NHL in aggregate. Future epidemiologic studies should incorporate the new World Health Organization classification of NHL and new techniques such as cytogenetic molecular analyses to identify subtype-specific etiologic factors. Evaluation of polymorphisms in genes involved in immune function, inflammation, and the activation or detoxification of environmental and occupational chemicals is also warranted.

Prospective study of hepatitis C viral infection as a risk factor for subsequent B-cell neoplasia

Several case-control studies have found increased prevalence of hepatitis C virus (HCV) in patients with non-Hodgkin lymphoma (NHL) and other B-cell lymphoproliferative disorders. We examined whether HCV infection preceded the development of these neoplasms in a prospective cohort study of 48 420 individuals in northern California. Stored sera from 95 subjects with NHL (n = 57), multiple myeloma (n = 24), or Hodgkin disease (n = 14) diagnosed a mean of 21 years after phlebotomy were screened for antibodies to HCV as well as viral RNA, based on previous reports of antibody-negative viremia. Sera from 4 cases and one of 95 age-, sex-, and race-matched controls were repeatedly reactive by enzyme immunoassay, but none were confirmed by recombinant immunoblot assay; none of the case sera had HCV RNA by reverse transcription- polymerase chain reaction. Although acquisition in later life cannot be ruled out, these prospective data do not support a substantial role of chronic HCV infection in the etiology of B-cell neoplasia.

Current controversies in shock and resuscitation

Many controversies and uncertainties surround resuscitation of hemorrhagic shock caused by vascular trauma. Whereas the basic pathophysiology is better understood, much remains to be learned about the many immunologic cascades that lead to problems beyond those of initial fluid resuscitation or operative hemostasis. Fluid therapy is on the verge of significant advances with substitute oxygen carriers, yet surgeons are still beset with questions of how much and what type of initial fluid to provide. Finally, the parameters chosen to guide therapy and the methods used to monitor patients present other interesting issues.

An unusual presentation of non-Hodgkin's lymphoma in the head and neck

The lymphomas are a group of lymphoproliferative disorders that can be divided histologically in the two main groups of Hodgkin's and non-Hodgkin's lymphoma. They sometimes present in the head and neck, and the diagnosis and management require a multidisciplinary approach. An unusual case is described presenting at an advanced stage because of patient delay in seeking medical help.

Immunological aspects of blood transfusions

Donor selection based on blood group phenotypes, and blood processing such as leukocyte-depletion, gamma-irradiation or washing to remove plasma, are approaches for therapeutic or preventive use to manage the immunological complications of transfusion. Indications for specific components are prescribed in guidelines provided by (inter)national Transfusion Societies. Although the use of guidelines and protocols is in line with modern medicine, these can create a state of tension with the political sense of values to improve the viral safety of blood products and with the commercial exploitation of pooled plasma-products.A century of blood transfusion therapy has facilitated cancer treatment and advanced surgical interventions. The transfusion product has improved progressively, although mostly in response to disasters such as wars and AIDS. Every blood transfusion interacts with the immune system of the recipient. There are, however, very few quantitative figures to estimate the consequences. This review is based on the available literature on the clinical consequences of transfusion induced immunization and modulation. To a large degree the clinical consequences of transfusion induced immune effects are still a mystery.A blood transfusion is a medical intervention, which in many cases remains experimental with respect to the benefit/risk ratio. Ideally, this uncertainty should be communicated to patients and every transfusion included in a study. Such studies preferentially should be randomized because the perceived need for transfusion is associated with clinical conditions with a worse prognosis than those that do not receive transfusion. This difference may mask the interpretation of the transfusion effect. Since the blood supply services in almost all Western countries have been reorganized and nationalized, or at least operate to national quality standards, the measurement of risk: benefit of transfusion, whether political or evidence-based, needs to be reconsidered. Differences in emphasis and responsibilities between transfusion providers and transfusion prescribers will drive the providers to political and liability criteria - ever safer products - that will increase hospital costs with undetermined clinical benefits.

Human retrovirus 5 sequences in peripheral blood cells of patients with B-cell non-Hodgkin's lymphoma

A recently described sequence from a probable 5th human exogenous retrovirus, HRV-5, is related to type A, B and D retroviruses. It was initially detected in a salivary gland biopsy from a patient with Sjögren's syndrome, but it is not consistently associated with this disease. We searched for the HRV-5 sequence in DNA extracted from whole blood of 300 blood donors, 81 patients with hematological malignancy and 21 patients with neurological disease using PCR. While samples from none of the blood donors and the neurological patients became positive, 3 of the 81 patients with hematological malignancy were HRV-5 DNA positive. All 3 had B-cell non-Hodgkin's lymphoma of low grade. The difference in frequency between NHL and controls is statistically significant. HRV-5 DNA was found in DNA from whole blood and in plastic-adherent cells but not in tumor cell DNA. Thus, monocytes/macrophages may be preferred targets for HRV-5. Our result, together with a previous finding of HRV-5 DNA in 2 NHL cases, is compatible with an association between HRV-5 and NHL, whether causal or not.

Soluble vascular endothelial growth factor in various blood transfusion components

BACKGROUND

Blood transfusion may reduce survival after curative surgery for solid tumors. This may be related to extracellular content of cancer growth factors present in transfusion components. Vascular endothelial growth factor (VEGF) is a potent stimulator of angiogenesis in solid tumors. The potential content of VEGF in various blood components for transfusion was evaluated.

STUDY DESIGN AND METHODS

Soluble VEGF (sVEGF, isotype 165) was determined by an enzyme-linked immunosorbent assay (EIA) in serum and plasma samples and in lysed cells from healthy volunteers. Subsequently, total content of sVEGF was determined in nonfiltered and prestorage white cell-reduced whole blood (WB), buffy coat-depleted saline-adenine-glucose-mannitol (SAGM) blood, platelet-rich plasma (PRP), and buffy coat-derived platelet (BCP) pools obtained from volunteer, healthy blood donors. As a control, total content of platelet-derived soluble plasminogen activator inhibitor type 1 (sPAI-1) was determined by an EIA in the same samples. Finally, the extracellular accumulation of sVEGF was determined in nonfiltered WB and SAGM blood during storage for 35 days and in BCP pools during storage for 7 days.

RESULTS

In the healthy volunteers, median total sVEGF content was 97 (range, 20-303) pg per mL in serum and 19 (13-37) pg per mL in plasma (n = 12, p < 0.002) and 445 (280-990) pg per mL in lysed cells. Median total sPAI-1 content was 94 (64-127) ng per mL in serum, 8 (6-11) ng per mL in citrated plasma, and 95 (78-123) ng per mL in lysed cells. In SAGM blood, the median total sVEGF content was 25.3 (3.3-48.4) ng per unit in nonfiltered units and undetectable in white cell-reduced units. Median total sVEGF content was 29.2 (24.8-124.9) ng per unit in nonfiltered PRP and 28.7 (24.5-118.6) ng per unit in white cell-reduced PRP. The sVEGF accumulated significantly in WB, SAGM blood, and BCP pools, depending on the storage time.

CONCLUSION

The sVEGF (isotype 165) appears to be present in various blood transfusion components, depending on storage time.

The rise in incidence of lymphomas in Europe 1985-1992

A collaborative study was carried out of the descriptive epidemiology of the lymphomas from seven countries across Europe in the period 1985-1992. Careful attention was paid to sources of information and the data quality in close collaboration with expert histopathologists. The data were classified as non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD). An attempt was made to put the data into a modified version of the Revised European American Lymphoma (REAL) classification. We observed an overall rise in total NHL throughout the time period in all European countries but no such trend in HD. The increase in NHL overall being 4.2% per annum, representing an increase of 4.8% in males and 3.4% in females per annum, was only marked in middle and old age. Such increases were observed in all participating areas except in Burgundy. Different countries, however, have different base rates, the rates being highest in Scandinavia and the Netherlands. The analysis by subcategory classification suggested that the increase in NHL was confined to the follicle centre cell type, extranodal B-cell, nodal T-cell and nodal lymphomas not otherwise specified, categories. These new observations present a picture of real increase in case incidence with no obvious explanation. The increases in NHL do not appear to be due solely to better diagnoses. Pending other explanations or refutation, these present a compelling picture of an inexorable rise in incidence of this disease.

Effect of blood transfusion on survival after esophagogastrectomy for carcinoma

BACKGROUND

There is growing evidence that blood transfusion is associated with clinical factors that can lead to transfusion-induced immunosuppression. This effect can be beneficial or deleterious.

METHODS

The effect of perioperative allogeneic blood transfusion on survival was studied retrospectively in 524 patients who were discharged from the hospital after esophagogastrectomy for carcinoma performed in a single unit over a 10-year period.

RESULTS

The median operative blood loss for the series was 500 mL (range, 50 to 3,750 mL). Three hundred thirty-five patients (64%) received a perioperative allogeneic blood transfusion related to esophagogastrectomy, and 189 (36%) did not. The median perioperative blood transfusion administered was 900 mL (range, 300 to 12,950 mL). Perioperative allogeneic blood transfusion was associated with reduced survival for patients in stage III (p < 0.05) at 1 year, but no significant difference was found in this stage at 3 or 5 years after resection. Stage III disease accounted for 250 (48%) of the 524 patients discharged.

CONCLUSIONS

Although perioperative allogeneic blood transfusion does not affect long-term survival after esophagogastrectomy for carcinoma, it does have a significant association with short-term survival in a group whose overall survival is often limited after resection. Attention should be directed toward minimizing operative blood loss and transfusing only for factors known to be clinically important, such as oxygen delivery and hemodynamics, not arbitrary hemoglobin levels.

Blood transfusion: influence of transfusion therapy on outcome

Few studies have addressed the influence of different transfusion therapies on outcome in a convincing way. Proven adverse impact of allogeneic blood on outcome is minimal. Acute mortality has declined to about 1 : 500,000 and the rate of transfusion-transmitted infections is decreasing, too. Data on postoperative infections and non-Hodgkin's lymphoma as possible adverse effects are controversial. Evidence for an increased risk of tumour recurrences is lacking. Alternatives to allogeneic blood may have appreciable risks: perioperative blood recovery had a fatality rate of more than 1 : 40,000. Reduction of allogeneic blood exposure may not be equated with improved outcome.

Allogeneic versus autologous blood during abdominal aortic aneurysm surgery

OBJECTIVES

To determine if cell-salvaged autologous blood can serve as an alternative to homologous blood, and to examine the incidence of infected complications and length of postoperative stay.

DESIGN

A prospective randomised study comprising autologous and homologous blood transfusions in patients undergoing elective infrarenal abdominal aortic surgery.

METHODS

Fifty patients undergoing AAA surgery were prospectively randomised to homologous blood (n = 27), or autologous blood transfusion (n = 23), using a cell salvage autotransfusion device.

RESULTS

The haemoglobin at the time of hospital discharge was similar for both groups (11.0 vs. 10.8 g/dl) with no difference in perioperative mortality. The length of stay was reduced in those patients who received autologous blood (9 days vs. 12 days, p < 0.05 Mann-Whitney U test). There were four infected cases in the autologous group and 12 in the homologous group (p = n.s., Fisher's exact probability test). However, patients who received 3-4 units of homologous blood had an increased risk of infection compared to those who received a similar amount of autologous blood (50% vs. 0%).

CONCLUSIONS

Cell salvage autologous blood can safely replace, or at least decrease, exposure to homologous blood transfusion, with a reduction in the mean hospital stay.

The risk of malignant tumours in first-degree relatives of men with early onset prostate cancer: a population-based cohort study

Previous studies have indicated that hereditary prostate cancer is common among men with early onset prostate cancer. The aim of this study was to investigate the incidence of malignant tumours in first-degree relatives of men with early onset prostate cancer. All prostate cancer cases diagnosed before the age of 51 years from 1958 to 1994 were identified in the population-based Swedish Cancer Register. The first-degree relatives of clinical cases were identified through parish data. Their vital status and cancer incidence were studied in the Swedish Cancer Register, the Cause of Death Register and the Census Register. The expected incidence of malignant tumours for the first-degree relatives were calculated using regional cancer register data. Cause-specific standardised incidence ratios (SIR) and 95% confidence intervals (CI) were calculated. The study included 423 first-degree relatives of 89 men with clinical prostate cancer. The first-degree relatives' SIR for malignant tumours was 0.99 (95% CI 0.78-1.23). The SIR for prostate cancer diagnosed at any age was 1.43 (95% CI 0.82-2.33), and 3.37 for first-degree relatives diagnosed before the age of 70 years (95% CI 1.36-6.94). There was no significantly increased risk of any non-prostatic malignant tumour. Only in five of the families did the pedigree show a pattern of hereditary prostate cancer. The first-degree relatives of men with early onset prostate cancer had more than a 3-fold increase in the risk of developing prostate cancer before the age of 70 years, but their total cancer risk was not increased. This study does not support the assumption that dominantly inherited susceptibility is a major cause of early onset prostate cancer.

Second primary cancers following non-Hodgkin's lymphoma in Japan: increased risk of hepatocellular carcinoma

We evaluated the risk of development of second primary cancers, with particular reference to subsequent hepatocellular carcinoma (HCC), in 592 patients diagnosed as non-Hodgkin's lymphoma (NHL), at Osaka Medical Center for Cancer and Cardiovascular Diseases. During 1978-1994, 2,163 person-years of observation were accrued, and 27 of the patients developed a second primary cancer, yielding an observed-to-expected ratio (O/E) of 1.53 [95% confidence interval (CI) = 1.01-2.23]. Significant excess risk was noted for primary liver cancer (PLC; O/E = 4.36, 95% CI = 1.99-8.28; O = 9) and non-lymphocytic leukemia (O/E = 26.17, 95% CI = 5.26-76.46; O = 3). The excess risk of PLC was relatively constant within the first 10 years after the NHL diagnosis. Patients who received chemotherapy as the NHL treatment had a significantly increased risk of PLC (O/E = 5.91, 95% CI = 2.70-11.23; O = 9). Their clinical reports indicated that all nine patients with PLC were diagnosed as HCC, and eight of them had clinical and/or histologic evidence of cirrhosis at the time of HCC diagnosis. None of the nine patients had a history of blood transfusion between the first NHL treatment and the diagnosis of HCC. These findings suggested that Japanese NHL patients might have an increased risk of developing HCC, and they indicated the importance of medical surveillance for liver malignancies, as well as subsequent leukemias. Possible explanations for the excess risk of subsequent HCC are discussed.

Medical history risk factors for non-Hodgkin's lymphoma in older women

BACKGROUND

It has been suggested that certain medical conditions and drug exposures might suppress the immune system and increase the risk of developing non-Hodgkin's lymphoma (NHL).

PURPOSE

We investigated whether specific medical conditions and drug exposures were associated with the risk of NHL in a cohort of older women who were enrolled in the Iowa Women's Health Study.

METHODS

A cohort of 41837 women, 55-69 years of age at baseline, was followed prospectively for the development of cancer from 1986 through 1992. These women had completed a baseline questionnaire in January 1986 that inquired about the occurrence and age at onset of specific medical conditions, about family history of cancer, and about the use of selected medications. Follow-up questionnaires were mailed to the women in 1987, 1989, and 1992. Incident cancers and deaths were ascertained through linkages to state and national databases. For most analyses, women with a self-reported history of cancer at baseline (n = 3903) were excluded. Relative risks (RRs) and 95% confidence intervals (CIs), adjusted for age or for age and other variables, were used as a measure of the association between NHL and medical history factors. Reported P values are two-sided.

RESULTS

One hundred fourteen incident cases of NHL were identified in the cohort during follow-up. A history of adult-onset diabetes mellitus (i.e., first diagnosed after the age of 30 years) was associated with an increased risk of developing NHL (age-adjusted RR = 2.18; 95% CI = 1.22-3.90). In addition, there was an association between the duration of adult-onset diabetes and increasing risk of NHL (P for trend = .004), with an age-adjusted RR of 2.90 (95% CI = 1.07-7.90) for women with a diagnosis of diabetes for 15 or more years compared with women with no diagnosis of diabetes. Women with a history of blood transfusion were also at increased risk for the development of NHL (age-adjusted RR = 1.95; 95% CI = 1.33-2.85). The risk estimates for diabetes and transfusion history were independent of each other and were not changed substantially after adjustment for other risk factors. History of a previous cancer (excluding hematopoietic and lymphatic cancers) was associated with an increased risk of NHL (age-adjusted RR = 1.92; 95% CI = 1.21-3.06); this risk estimate was attenuated somewhat after adjustment for a history of diabetes, transfusion history, and other major risk factors (RR = 1.66; 95% CI = 1.02-2.69). No statistically significant associations were found between NHL and a history of chronic colitis, nonestrogen steroid use, use of exogenous estrogens, or use of thyroid medications.

CONCLUSIONS AND IMPLICATIONS

A history of adult-onset diabetes mellitus, blood transfusion, and a history of cancer (or its treatment) appear to be independent risk factors for NHL in older women.

New epidemiologic leads in the etiology of non-Hodgkin lymphoma in the elderly: the role of blood transfusion and diet

The incidence of non-Hodgkin lymphoma (NHL) in persons over the age of 65 years has increased dramatically since the 1950s in western countries. The strongest known risk factors for NHL are primary or acquired immunosuppression, but these severe deficiencies are relatively rare and cannot explain the rapid increase observed in the elderly. Recent work suggests that common exposures which influence immunocompetence, albeit at a much weaker level, may also be risk factors for NHL. Two such risk factors recently associated with NHL are prior history of blood transfusion and certain aspects of diet. In four out of four studies, prior history of blood transfusion was associated with approximately a doubling in NHL risk, even for a transfusion first received a decade or more before diagnosis. Other studies suggest that diets high in animal proteins and fats may increase the risk of NHL while fruit and vegetable consumption may decrease risk. Allogeneic blood transfusion is known to suppress the immune system, and diets high in protein and fat may also lead to altered immunocompetence, although other mechanisms such as viral transmission or the effects of heterocyclic amines and N-nitroso compounds may also play a role. Follow-up of these observations my lead to a better understanding of the NHL epidemic and new approaches to the prevention of NHL.

Risk of cancer following splenectomy

Only 2 small population-based studies have previously evaluated cancer risk in splenectomized patients. Our objective was thus to investigate cancer incidence following splenectomy for external trauma or for surgical treatment of non-malignant conditions of adjacent organs. Using the unique personal identification number assigned to each Swedish resident, we linked centralized hospitalization records with nationwide total population and cancer incidence data. We excluded cancers diagnosed within the first 12 months after splenectomy and computed standardized incidence ratios for 1,295 patients (contributing 14,390 person-years) splenectormized for external trauma and for 985 patients (contributing 8,91 1 person-years) whose splenectomy accompanied surgical treatment of non-malignant conditions of adjacent organs (mostly peptic ulcers), using age-, sex- and period-specific rates for cancer incidence derived from the entire Swedish population. Patients undergoing splenectomy for external trauma had no significant excess of total or site-specific cancers. Individuals splenectormized in conjunction with surgery for non-malignant conditions of adjacent organs had a non-significant 40% elevated risk of total cancer, with significant increases of lung and ovarian cancers. The excesses of lung and ovarian cancers may be due to chance, but we could not exclude the conditions for which the surgery was performed, other treatments or common predisposing factors (such as cigarette smoking, which has been linked with both peptic ulcer and lung cancer).

Blood transfusion as a risk factor for non-Hodgkin lymphoma

In a case-control study of 280 out of 426 consecutive patients with a recent diagnosis of non-Hodgkin lymphoma (NHL) and 1827 control subjects, 53 (19%) and 230 (13%) respectively had received blood transfusions 1 year or more before the interview. Using an age- and sex-stratified analysis the odds ratio (OR) for transfusion was 1.74 (95% CI 1.24-2.44). ORs were also determined for transfusions received in the intervals 1-5, 6-15, 16-25 and > or = 26 years before diagnosis. In the interval 6-15 years, the OR for transfusion was 2.83 (95% CI 1.60-4.99) whereas ORs for transfusions received in other intervals were lower and not significantly elevated. Histological diagnoses (Kiel classification) and results of staging procedures were known for 185 patients. For low-grade NHL of nodal B-cell chronic lymphocytic leukaemia (B-CLL) or immunocytoma type, the OR for transfusions was 4.15 (95% CI 1.92-9.01). For low-grade nodal lymphomas of follicle centre cell type and high-grade nodal lymphomas, no relation to transfusions could be demonstrated. For high-grade extranodal lymphoma as sole manifestation, OR for transfusions was 3.27 (95% CI 1.30-8.24). It is concluded that blood transfusion may be a risk factor for NHLs especially those of B-CLL or immunocytoma type and for high-grade extranodal lymphoma.

Histamine-2 receptor antagonists as immunomodulators: new therapeutic views?

Considerable evidence has emerged to suggest that histamine participates in the regulation of the inflammatory response, immune reaction, coagulation cascade, and cardiovascular function. Furthermore, histamine may play a major role in the growth of normal and malignant tissue as a regulator of proliferation and angiogenesis. Specific histamine receptors have been identified on the surface of bone marrow cells, immune competent cells, endothelial cells, fibroblasts, and also on malignant cells. This has prompted research in regulation by specific histamine receptor agonists and antagonists. Results from such studies are currently accumulating and suggest that the histamine-2 receptor antagonists have potential beneficial effects in the treatment of certain malignant, autoimmune and skin diseases, either alone or in combination with other drugs. The beneficial effect of histamine-2 receptor antagonists as adjuvant single drugs to reduce trauma-, blood transfusion- and sepsis-induced immunosuppression has led to research in combined treatment regimens in major surgery, particularly, of patients operated on for malignant diseases.

Evidence of an association between non-Hodgkin's lymphoma and skin cancer

OBJECTIVE

To investigate a possible link between exposure to ultraviolet light and the almost epidemic increase in non-Hodgkin's lymphoma worldwide. Because ultraviolet light is known to cause skin cancers, the association between non-Hodgkin's lymphoma and skin cancer was studied.

DESIGN

Secondary occurrence of either malignant melanoma or squamous cell skin cancer in cohorts of patients with a first diagnosis of either non-Hodgkin's lymphoma or chronic lymphocytic leukaemia, and vice versa, were studied. Expected numbers of subsequent cancers were calculated by sex, age, and period specific national incidence rates multiplied by the person years under observation in the cohorts.

SETTING

Denmark (1943-89) and Sweden (1958-89).

SUBJECTS

Four population based cohorts identified in the nationwide cancer registries (34,641 people with non-Hodgkin's lymphoma, 17,400 with chronic lymphocytic leukaemia, 34,989 with malignant melanoma, 25,980 with squamous cell skin cancer). A total of 562,085 person years were accrued for the analysis.

MAIN OUTCOME MEASURES

The ratios of observed to expected cancers (the standardised incidence ratio) served as a measure of the relative risk.

RESULTS

The relative risk for developing squamous cell skin cancer was 5.5 (95% confidence interval 4.6 to 6.6) among patients with non-Hodgkin's lymphoma and 8.6 (7.2 to 10.3) among patients with chronic lymphocytic leukaemia. The relative risks remained high over more than 15 years of follow up. Relative risks for malignant melanoma were 2.4 (1.8 to 3.2) for patients with non-Hodgkin's lymphoma and 3.1 (2.1 to 4.4) for patients with chronic lymphocytic leukaemia. After squamous cell skin cancer had been diagnosed there was a twofold excess risk for non-Hodgkin's lymphoma and chronic lymphocytic leukaemia. By contrast, in each of the cohorts the general cancer risks excluding skin and lymphoproliferative malignancies were close to the expected.

CONCLUSIONS

The occurrence of non-Hodgkin's lymphoma and skin cancer are strongly associated; this supports the hypothesis that the secular increase in exposure to ultraviolet light may have contributed to the increasing incidence of non-Hodgkin's lymphoma in recent decades.

Detrimental effects of perioperative blood transfusion

Evidence suggests that perioperative allogeneic blood transfusion increases the risk of infectious complications after major surgery and of cancer recurrence after curative operation. This has been attributed to immunosuppression. Several authors have suggested that filtered whole blood and/or red cell concentrate, or leucocyte- and buffy coat-reduced red cells in artificial medium or their own plasma, may reduce postoperative immunosuppression. It was also anticipated that the use of autologous blood might minimize the risk of perioperative transfusion, but studies have unexpectedly shown similar postoperative infectious complications and cancer recurrence and/or survival rates in patients receiving autologous blood donated before operation and those receiving allogeneic blood. Future studies should identify common risk factors associated with blood storage.