Leukocyte-depleted blood transfusion is associated with decreased survival in resected early-stage lung cancer

Association between perioperative red blood cell transfusions and postoperative venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Whether perioperative red blood cell transfusions increases the risk of postoperative venous thromboembolism is controversial and uncertain.We aims to explore the relationship between perioperative red blood cell transfusions and the risk of postoperative venous thromboembolism by conducting a meta-analysis.

OBJECTIVE

To conduct a meta-analysis to systematically evaluate the relationship between perioperative red blood cell transfusions and the risk of postoperative venous thromboembolism.

METHODS

PubMed, Embase, Cochrane, and Web of Science databases were searched to identify studies examining the relationship between perioperative red blood cell transfusions and the risk of postoperative venous thromboembolism. The databases were searched from establishment to August 2023.Two researchers independently screened literature and extracted data according to inclusion and exclusion criteria. Newcastle-ottawa Scale was used for quality assessment. Meta-analysis of data was performed using RevMan 5.4 software.

RESULTS

A total of 15 studies involving 1,880,990 patients were included in this study.Meta-analysis showed that perioperative red blood cell transfusions increased the risk of postoperative venous thromboembolism [OR = 1.61, 95%CI (1.37, 1.89), P < 0.001]. Subgroup analyses showed that the transfusion dose,transfusion timing,study population and follow-up time were closely related to the risk of postoperative venous thromboembolism.

CONCLUSIONS

In summary, this meta-analysis demonstrated a significant positive association between perioperative red blood cell transfusions and postoperative venous thromboembolism.Healthcare professionals should pay attention to the influence of blood transfusions on postoperative venous thromboembolism, strengthen management and prevention.

Haemoglobin drift in patients following Whipple's procedure

BACKGROUNDS

This study aims to identify the objective findings of haemoglobin (Hb) drift in patients that had a Whipple's procedure in the last 10 years, their transfusion status intraoperatively and post-operatively, the potential factors affecting Hb drift, and the outcomes following Hb drift.

METHODS

A retrospective study was conducted at Northern Health, Melbourne. All adult patients who were admitted for a Whipple's procedure from 2010 to 2020 were included and information collected retrospectively for demographics, pre-operative, operative and post-operative details.

RESULTS

A total of 103 patients were identified. The median Hb drift calculated from a Hb level at the end of operation was 27.0 g/L (IQR 18.0-34.0), and 21.4% of patients received a packed red blood cell (PRBC) transfusion during the post-operative period. Patients received a large amount of intraoperative fluid with a median of 4500 mL (IQR 3400-5600). Hb drift was statistically associated with intraoperative and post-operative fluid infusion leading to concurrent issues with electrolyte imbalance and diuresis.

CONCLUSION

Hb drift is a phenomenon that does happen in major operations such as a Whipple's procedure, likely secondary to fluid over-resuscitation. Considering the risk of fluid overload and blood transfusion, Hb drift in the setting of fluid over-resuscitation needs to be kept in mind prior to blood transfusion to avoid unnecessary complications and wasting of other precious resources.

Blood transfusion has an adverse impact on the prognosis of patients receiving chemotherapy for advanced colorectal cancer: experience from a single institution with a patient blood management program

PURPOSE

Perioperative blood transfusion in early stage cancer patients had a negative effect on the prognosis of patients, but the prognostic impact of transfusion in advanced cancer patients remains unclear. To minimize and guide rational transfusion, an institutional patient blood management (PBM) program was launched, and we evaluated the new program that has changed the practice and impacted on the prognosis of advanced cancer patients.

METHODS

We investigated the medical records of colorectal cancer patients who received chemotherapy from 2015 to 2020. The amount and frequency of transfusion, iron replacement and laboratory findings, and overall survival were compared before and after implementation of PBM.

RESULTS

The rate of transfusion in colorectal cancer patients was significantly decreased from 23.5/100 person-quarter in 2015 to 1.2/100 person-quarter in 2020, but iron supplementation therapy was frequently used, and the proportion of patients who received transfusion under hemoglobin 7 g/dL significantly increased from 15.9% in 2015 to 55.3% in 2020. Multivariate analysis revealed that transfusion was a significant risk factor affecting the overall survival of patients (HR 2.70, 95% CI: 1.93-3.78, p<0.001). Kaplan-Meier analysis revealed that overall survival was significantly longer in non-transfused patients than in transfused patients (11.0 versus 22.4 months; HR 0.69, 95% CI: 0.56-0.86, p<0.001).

CONCLUSIONS

This study shows that minimized transfusion through an institutional PBM can positively affect the prognosis of patients who are receiving chemotherapy for advanced colorectal cancer.

Preoperative Anemia is Associated With Worse Long-Term Survival After Lung Cancer Resection: A Multicenter Cohort Study of 5,029 Patients

OBJECTIVES

Although some evidence to suggest an association between preoperative anemia and reduced overall survival exists, contemporary studies investigating the impact of preoperative anemia on outcomes after resection for primary lung cancer are lacking.

DESIGN

A multicenter retrospective review.

SETTING

Two tertiary cardiothoracic surgery centers in the Northwest of England.

PARTICIPANTS

A total of 5,029 patients between 2012 and 2018.

INTERVENTIONS

All patients underwent lung resection for primary lung cancer. Patients were classified as anemic based on the World Health Organization definition. Men with hemoglobin <130 g/L and women with hemoglobin <120 g/L were considered to be anemic.

MEASUREMENTS AND MAIN RESULTS

Outcomes assessed included perioperative mortality, 90-day mortality, and overall survival. Multivariate logistic and Cox regression analyses were used to assess the impact of preoperative anemia on 90-day mortality and overall survival, respectively. Overall, preoperatively, 24.0% (n = 1207) of patients were anemic. The 90-day mortality for anemic and nonanemic patients was 5.6% and 3.1%, respectively (p < 0.001). After multivariate adjustment, preoperative anemia was not associated with increased 90-day mortality. However, a log-rank analysis demonstrated reduced overall survival for anemic patients (p < 0.001). After multivariate adjustment, preoperative anemia was found to be independently associated with reduced overall survival (hazard ratio 1.287, 95% confidence interval 1.141-1.451, p < 0.001).

CONCLUSIONS

Although anemia was not an independent predictor of short-term outcomes, it was independently associated with significantly reduced survival for patients undergoing resection for lung cancer. Further work is required to understand why anemia reduces long-term survival and whether pathways for anemic patients can be adapted to improve long-term outcomes.

Blood transfusions may adversely affect survival outcomes of patients with lung cancer: a systematic review and meta-analysis

Background

Despite common use in clinical practice, the impact of blood transfusions on prognosis among patients with lung cancer remains unclear. The purpose of the current study is to perform an updated systematic review and meta-analysis to evaluate the influence of blood transfusions on survival outcomes of lung cancer patients.

Methods

We searched PubMed, Embase, Cochrane Library, and Ovid MEDLINE for publications illustrating the association between blood transfusions and prognosis among people with lung cancer from inception to November 2019. Overall survival (OS) and disease-free survival (DFS) were the outcomes of interest. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using the random-effects model. Study heterogeneity was evaluated with the I² test. Publication bias was explored via funnel plot and trim-and-fill analyses.

Results

We included 23 cohort studies with 12,175 patients (3,027 cases and 9,148 controls) for meta-analysis. Among these records, 22 studies investigated the effect of perioperative transfusions, while one examined that of transfusions during chemotherapy. Two studies suggested the possible dose-dependent effect in accordance with the number of transfused units. In pooled analyses, blood transfusions deleteriously influenced both OS (HR=1.35, 95% CI: 1.14–1.61, P<0.001, I²=0%) and DFS (HR=1.46, 95% CI: 1.15–1.86, P=0.001, I²=0%) of people with lung cancer. No evidence of significant publication bias was detected in funnel plot and trim-and-fill analyses (OS: HR=1.26, 95% CI: 1.07–1.49, P=0.006; DFS: HR=1.35, 95% CI: 1.08–1.69, P=0.008).

Conclusions

Blood transfusions were associated with decreased survival of patients with lung cancer.

The blood cells in NSCLC and the changes after RFA

Lung cancer has attracted a lot of attention because of its high morbidity and mortality. The emergence of RFA provides a new treatment for unresectable NSCLC patients. In addition to killing in situ lung tumors, RFA also provides new immuno-activated antigens, for the treatment of lung cancer. It changes the tumor microenvironment and activates the entire immune system of patients. The peripheral blood cell count is easy to achieve and the blood cells are important in tumor immunity, which changes after RFA. On the one hand, the changes in blood cells identify the immune changes of NSCLC; on the other hand, it provides support and suspicion for the treatment of RFA.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

Preoperative anemia as a prognostic factor in patients with lung cancer: a systematic review and meta-analysis of epidemiological studies

The evidence of current epidemiological studies investigating the relationship between preoperative anemia and progression of lung cancer (LC) patients remains controversial. The PubMed, EMBASE, and Web of Science databases were comprehensively searched by two independent authors to identify related epidemiological studies from inception through January 31, 2019. Similarly, two researchers separately extracted data and any differences were resolved by discussion. Summarized hazard ratios (HRs) and 95% confidence intervals (CIs) were summarized with inverse variance weighted random effects meta-analysis. Heterogeneity among studies was assessed with the I² statistic. Twenty-two studies were included in this meta-analysis. As compared with LC patients without anemia, those with pre-operative anemia were at a 1.6-fold greater risk of death (summarized HR = 1.58; 95% CI = 1.44-1.75), with moderate heterogeneity (I² = 53.1%). Funnel plot and statistical analyses showed no evidence of publication bias. Associations between pre-operative anemia and OS were broadly consistent across numerous subgroups analyses stratified by the study design, geographic location, number of cases, tumor, node, and metastasis (TNM) stage, histology, quality, and adjustment for potential confounders (age, sex, body mass index, TNM stage, histology, performance status, surgery, blood transfusion, and systemic inflammatory response markers). Similar patterns were observed in the sensitivity analyses. The results of meta-regression analysis suggested no evidence of significant heterogeneity between subgroups. In conclusion, pre-operative anemia was associated with poorer overall survival among LC patients.

Prognostic impact of blood transfusion in patients with metastatic non-small cell lung cancer receiving chemotherapy

PURPOSE

To investigate the prognostic effects of Allogeneic Blood Transfusion (ABT) in patients with metastatic Non-Small Cell Lung Cancer (NSCLC) receiving Chemotherapy (CT) in the first-line treatment, comparing untransfused patients to those receiving blood transfusion during treatment period or before treatment period.

METHODS

This was a retrospective study of 433 patients with metastatic NSCLC receiving CT in the first-line treatment. Patients were categorized into 3 groups according to the transfusion strategy as follows; group-U(Untransfused patients, n = 303), group-B(patients receiving transfusion Before treatment period, n = 43), and group-D(patients receiving transfusion During treatment period, n = 87).

RESULTS

There were 433 patients in the analysis, consisting of 388 (89.6%) males, with a median age of 60 years(range, 21-92). The median Overall Survival(mOS) according to the ABT was 14 months for group-U, 9 months for group-B, and 7 months for group-D (p < 0.001). In subgroup analysis, patients with squamous cell carcinoma subtype, mOS was 11 months for group-U, 12 months for group-B, and 9 month for group-D (p = 0.074) The corresponding mOS durations for adenocarcinoma subtype were 21 months, 7 months, and 6 months (p < 0.001). Performing ABT during treatment period was found to be a negative independent factor related to OS (HR 1.50 for progression-free survival, 95% CI 1.15-1.97, HR 1.36 for OS, 95% CI 1.04-1.80).

CONCLUSION

Our results demonstrated that ABT was significantly associated with earlier progression and shorter survival in patients with metastatic NSCLC, especially in adenocarcinoma histology, hence suggesting that transfusion strategy in this group should remain limited, and its benefit should outweigh the risk of progression.

Perioperative blood transfusion has a dose-dependent relationship with disease recurrence and survival in patients with non-small cell lung cancer

OBJECTIVE

Perioperative blood transfusions have been implicated in decreased overall survival (OS) and disease-free survival (DFS) after resection for non-small cell lung cancer (NSCLC). We investigated the effects of single- and multiple-unit blood transfusions on OS, DFS, and recurrence after anatomic pulmonary resection.

METHODS

From January 1, 2000, to June 30, 2016, 5709 consecutive patients underwent pulmonary resection for NSCLC at our institution. Exclusion criteria were stage IIIB-IV disease, incomplete resections, ill-defined histologic subtypes, and nonanatomic wedge resections. For the 0 versus single-unit analysis, propensity scores were calculated from a logistic regression model that predicted the probability of patients receiving a single-unit transfusion. The resulting matching weights were incorporated into Cox models for OS, DFS, and cumulative incidence of recurrence, to compare no versus single-unit blood transfusion. We determined whether increasing numbers of blood transfusions influenced survival or recurrence using multivariable Cox models.

RESULTS

Approximately 10% of patients received perioperative blood transfusion (median follow-up, 7.46 years [25th-75th percentile, 3.98-11.8]). There was no difference in OS, DFS, or cumulative incidence of recurrence between patients receiving no transfusion and those receiving single-unit transfusion (P > .05). However, a dose-response relationship was observed, demonstrating worse OS (overall P < .001), DFS (overall P < .001), and recurrence (overall P = .010) with increasing units of blood transfused.

CONCLUSIONS

Although a single-unit blood transfusion did not affect survival in patients undergoing resection for NSCLC, greater unit perioperative blood transfusions were associated with significantly decreased long-term outcomes in a dose-dependent manner, suggesting avoidance or minimization of transfusions could improve long-term survival after lung resection.

The prognostic impact of decreased pretreatment haemoglobin level on the survival of patients with lung cancer: a systematic review and meta-analysis

BACKGROUND

Many studies have reported the prognostic value of haemoglobin level for cancers. Whereas the prognostic impact of decreased pretreatment haemoglobin level on the survival of patients with lung cancer remains controversial, herein, a systematic review and meta-analysis were conducted to investigate whether a decreased haemoglobin level before treatment is a significant predictor of survival in patients with lung cancer.

METHODS

We performed a systematic review and meta-analysis of observational studies to evaluate the prognostic impact of a decreased haemoglobin level on the survival of patients with lung cancer. Relevant studies were retrieved from databases including PubMed, Embase, Web of Science and the Cochrane Library. Reference lists were hand-searched for potentially eligible studies. The Newcastle-Ottawa scale was used to assess the quality of included studies. Observational studies were included if they provided sufficient information for the extraction of the pooled hazard ratios (HR) and 95% confidence intervals (95% CI) for overall survival, disease-free survival, relapse-free survival, progression-free survival, event-free survival and time to progression. Subgroup analysis, meta-regression and sensitivity analyses were applied to explain the heterogeneity.

RESULTS

Fifty-five articles involving a total of 22,719 patients were obtained to evaluate the correlation between haemoglobin level and survival. The results indicated that decreased haemoglobin level was significantly associated with poor overall survival of patients with lung cancer (HR 1.51, 95% CI 1.42-1.61), both in non-small cell lung cancer (HR 1.57, 95% CI 1.44-1.72) and in small cell lung cancer (HR 1.56, 95% CI 1.21-2.02). We also found that the lower the haemoglobin level, the shorter was the overall survival of patients with lung cancer (HR 1.11, 95% CI 1.06-1.16). However, the relationship between decreased haemoglobin and relapse-free survival was not significant (HR 1.37, 95% CI 0.91-2.05).

CONCLUSION

A decreased pretreatment haemoglobin level among patients with lung cancer is a prognostic factor of poor survival that can serve as an important indicator in survival prediction, risk stratification and treatment selection. In clinical practice, more attention should be paid to monitoring pretreatment haemoglobin levels among patients with lung cancer.

Association between red blood cell transfusion and long-term mortality in patients with cancer of the esophagus after esophagectomy

The impact of red blood cell transfusion on long-term mortality has not been well characterized in patients with cancer of the esophagus after esophagectomy. Our retrospective observational study investigated 611 patients with cancer of the esophagus after esophagectomy from January 2005 to December 2012. Perioperative red blood cell transfusion was defined as red blood cell transfusion during intraoperative and postoperative period. One hundred ninety-six (32.1%) patients received red blood cell transfusion. During follow-up period, 153 (36.9%) patients without red blood cell transfusion and 120 (61.2%) patients with red blood cell transfusion died. Multivariable analysis identified that there was an incremental association between the amount of red blood cell transfusion and long-term mortality (hazard ratio 1.06, 95% confidence interval 1.04-1.08, P < 0.001). The association between red blood cell transfusion and worse long-term mortality was also demonstrated in propensity-matched patients (hazard ratio 1.62, 95% confidence interval 1.15-2.28, P = 0.006). Therefore, there might be an independent association between perioperative red blood cell transfusion and worse long-term mortality in patients with cancer of the esophagus after esophagectomy. Furthermore, there was an incremental increase in long-term mortality in patients who was transfused with red blood cell during perioperative period.

Restrictive Transfusion Strategy Does Not Affect Clinical Prognosis in Patients with Ectopic Pregnancy

To assess the effects of restrictive transfusion strategy on hemoglobin (Hb) levels and prognosis in patients with ectopic pregnancy and severe hemorrhage undergoing emergency surgery, patient data were collected from 2012 to 2016. Following transfusion guidelines, restrictive transfusion was performed; at Hb levels of 60-70 to 100 g/L, transfusion was continued or not based on disease status. The patients were divided into four groups: blood loss < 400 ml (N1), 400-799 ml (N2), 800-1199 ml (N3), and ≥1200 ml (N4). Several prognosis parameters were assessed. Group N4 was further divided based on blood loss amounts (1200-1999, 2000-2999, 3000-3999, and 4000-5000 ml) for subgroup analyses. Blood loss, hemoglobin levels at discharge, and American Society of Anesthesiologists (ASA) scores were not associated with patient prognostic parameters, including intensive care unit (ICU) occupancy, cure, and healing rates, and surgical complications and hospital stay. No statistically significant difference was obtained in hospital stay among N1, N2, and N3 groups. Compared with N1 patients, cases with blood loss ≥ 1200 ml had significantly longer hospital stay. Interestingly, hospital stay was correlated with surgical approach, location of pregnancy, and operation time. Restrictive transfusion strategy could be safely used for emergency surgery in ectopic pregnancy with acute blood loss.

Allogenic Blood Transfusion Is an Independent Predictor of Poorer Peri-operative Outcomes and Reduced Long-Term Survival after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: a Review of 936 Cases

INTRODUCTION

There is a paucity of data on the impact of allogenic blood transfusion (ABT) on morbidity and survival outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

METHODS

Nine hundred and thirty-five consecutive CRS/HIPEC procedures were performed between 1996 and 2016 at a high-volume institution in Sydney, Australia. Of these, 337(36%) patients required massive ABT (MABT) (≥5 units). Peri-operative complications were graded according to the Clavien-Dindo classification. The association of concomitant MABT with 21 peri-operative outcomes and overall survival (OS) was assessed using univariate and multivariate analyses.

RESULTS

In-hospital mortality was 1.8%. Patients requiring MABT had more extensive disease as reflected by a higher peritoneal cancer index (≥17) (70 vs. 29%, p < 0.001) and longer operative times (≥9 h) (82 vs. 35%, p < 0.001). After accounting for confounding factors, MABT was associated with in-hospital mortality (relative risk (RR), 7.72; 95% confidence interval (CI), 1.35-10.11; p = 0.021) and grade III/IV morbidity (RR, 2.05; 95% CI, 1.42-2.95; p < 0.001). MABT was associated with an increased incidence of prolonged hospital stay (≥28 days) (RR, 1.86; 95% CI, 1.26-2.74; p = 0.002) and intensive care unit stay (≥4 days) (RR, 1.83; 95% CI, 1.24-2.70, p = 0.002). It was also associated with a significant OS in patients with colorectal cancer peritoneal carcinomatosis (RR 4.49; p < 0.001) and pseudomyxoma peritonei (RR, 4.37; p = 0.026), but not appendiceal cancer (p = 0.160).

CONCLUSION

MABT is an independent predictor for poorer peri-operative outcomes including in-hospital mortality and grade III/IV morbidity. It may also compromise long-term survival, particularly in patients with colorectal cancer peritoneal carcinomatosis.

Red blood cell transfusion in surgical cancer patients: Targets, risks, mechanistic understanding and further therapeutic opportunities

Anemia is present in more than half of cancer patients and appears to be an independent prognostic factor of short- and long-term adverse outcomes. It increases in the advanced period of cancer and perioperatively, in patients with solid tumors who undergo surgery. As a result, allogeneic red blood cell (RBC) transfusion is an indispensable treatment in cancer. However, its safety remains controversial, based on several laboratory and clinical data reporting a linkage with increased risk for cancer recurrence, infection and cancer-related mortality. Immunological, inflammatory and thrombotic reactions mediated by the residual leukocytes and platelets, the stored RBCs per se, the biological response modifiers and the plasticizer of the unit may underlie infection and tumor-promoting effects. Although the causality between transfusion and infection has been established, the effects of transfusion on cancer recurrence remain confusing; this is mainly due to the extreme biological heterogeneity that characterizes RBC donations and cancer context. In fact, the functional interplay between donation-associated factors and recipient characteristics, including tumor biology per se, inflammation, infection, coagulation and immune activation state and competence may synergistically and individually define the clinical impact of each transfusion in any given cancer patient. Our understanding of how the potential risk is mediated is important to make RBC transfusion safer and to pave the way for novel, promising and highly personalized strategies for the treatment of anemia in surgical cancer patients.

Preoperative anemia, blood transfusion, and neutrophil-to-lymphocyte ratio in patients with stage i non-small cell lung cancer

Perioperative and postoperative blood transfusions (BT), anemia and inflammation are associated with poor survivals in patients with non-small cell lung cancer (NSCLC). This study investigated the impact of perioperative BT on the survival of patients with NSCLC taking into account their preoperative inflammatory status and the presence of anemia. Demographic, perioperative, and survival data for 861 patients with stage I NSCLC was collected retrospectively. The primary endpoints of interest were recurrence-free (RFS) and overall survival (OS). Before and after propensity score matching, univariate and multivariable Cox proportional hazards models were used to evaluate the association between covariates and survival. A neutrophil-to-lymphocyte ratio (NLR) < 5 (hazard ratio [HR]: 0.58, 95% CI: 0.38-0.87; p = 0.009) and normal Hb concentration (HR: 0.72, 95% CI: 0.72; p = 0.022) were independently associated with longer RFS. The administration of blood perioperatively was associated with a trend towards worse RFS (HR: 0.69, 95% CI: 0.47-1.02; p = 0.066). The multivariate analysis also revealed that an NLR < 5 (HR: 0.48, 95% CI: 0.3-0.76; p = 0.001) and the absence of BT (HR: 0.63, 95% CI: 0.4-0.98; p = 0.04) were significantly associated with lower mortality risk. The propensity score matching analysis did not confirm the association between BT and poor RFS (HR: 0.63, 95% CI: 0.35-1.1; p = 0.108) and OS (HR: 0.52, 95% CI: 0.26-1.04; p = 0.06). Inflammation and anemia are common finding in patients with stage 1 NSCLC. After adjusting for these two important confounders, this study confirms that previous reports demonstrating an association between BT and poor survival after NSCLC surgery.

Transfusion of Blood and Blood Products

In transfusion medicine, several blood products can be prepared and used as replacement therapy; however, four of these products are more commonly used in general practice: RBCs, fresh frozen plasma (FFP), platelets and cryoprecipitate. RBC transfusions are mainly administered to improve tissue oxygenation in cases of anaemia or acute blood loss due to trauma or surgery. FFP, platelets and cryoprecipitate are used for the prevention and treatment of bleeding.

Perioperative blood transfusion adversely affects prognosis after resection of lung cancer: a systematic review and a meta-analysis

Background

It is speculated that blood transfusion may induce adverse consequences after cancer surgery due to immunosuppression. This study was intended to assess the impact of perioperative blood transfusion on the prognosis of patients who underwent lung cancer resection.

Methods

Eligible studies were identified through a computerized literature search. The pooled relative risk ratio (RR) with 95% confidence interval (CI) was calculated using Review Manager 5.1 Software.

Results

Eighteen studies with a total of 5915 participants were included for this meta-analysis. Pooled analysis showed that perioperative blood transfusion was associated with worse overall survival (RR: 1.25, 95% CI: 1.13-1.38; P <0.001) and recurrence-free survival (RR: 1.42, 95% CI: 1.20-1.67; P <0.001) in patients with resected lung cancer.

Conclusions

Perioperative blood transfusion appears be associated with a worse prognosis in patients undergoing lung cancer resection. These data highlight the importance of minimizing blood transfusion during surgery.

Impact of intraoperative blood loss on long-term survival after lung cancer resection

PURPOSE

The purpose of this study was to clarify relationships between intraoperative blood loss (IBL) and long-term postsurgical survival in lung cancer patients.

METHODS

We retrospectively analyzed 1336 patients undergoing surgery: lobectomy in 1016, sublobar resection in 174, pneumonectomy in 106, and combined resection with adjacent organs in 40. The lobectomy group was stratified further by pathologic stages; overall survival difference was examined according to amount of IBL.

RESULTS

Volume of IBL differed significantly according to surgical procedure when all patients were included. Within the lobectomy group, IBL differed significantly between gender, pathologic stage, histologic type (adenocarcinoma vs. non-adenocarcinoma), and year of operation (1983 to 2002 vs. 2003 to 2012). After stratification by pathologic stage, survival differed with IBL for stages IB to IIIB. Multivariate analysis identified gender, patients age (<69 vs. ≥69), pathologic stage (IA to IIB vs. IIIA to IV), year of operation, histologic type, and IBL as significant predictors of survival.

CONCLUSION

Since degree of IBL is an independent predictor of overall survival after lung cancer resection, IBL should be minimized carefully during surgery.

Perioperative blood transfusions and survival in patients with non-small cell lung cancer: a retrospective study

Background

Perioperative blood transfusions have been associated with poor clinical outcomes in the context of oncological surgery. Current literature is inconclusive whether blood transfusions are linked to shorter recurrence free and overall survival after lung cancer surgery. We hypothesize that blood transfusions in patients undergoing surgery for non-small cell lung cancer are associated with poor oncological survival.

Methods

After IRB approval, perioperative data from 636 patients who underwent lung cancer surgery was collected. Patients were evaluated for time to tumor recurrence and overall survival.

Results

60 patients were transfused and 576 subjects were not. Patients who received transfusion were more likely to have more advanced disease (p = 0.018), and preoperative low hemoglobin concentrations (p < 0.0001) compared to non-transfused patients. In the multivariable Cox regression analysis, blood transfusion was associated with a significant reduction in recurrence free survival (p = 0.025), HR: 1.55 (95% CI: 1.06-2.27) and overall survival (p = 0.0002) HR: 2.04 (95% CI: 1.41-2.97). However, analysis after propensity score matching between the two groups revealed that the effect of blood transfusion was significant for reduction in overall survival (p = 0.0356), HR: 1.838 (95% CI: 1.04-3.22) but not for recurrence free survival (p = 0.1460), HR: 1.493 (95% CI: 0.87-2.56).

Conclusions

Perioperative administration of red blood cells appears be associated with a decreased overall survival but not recurrence free survival after lung cancer surgery. Our study has the limitations of a retrospective review. Hence, our results should be confirmed by a prospective randomized control trial.

Does regional anaesthesia and analgesia or opioid analgesia influence recurrence after primary cancer surgery? An update of available evidence

Cancer continues to be a key cause of morbidity and mortality worldwide and its overall incidence continues to increase. Anaesthetists are increasingly faced with the challenge of managing cancer patients, for surgical resection to debulk or excise the primary tumour, or for surgical emergencies in patients on chemotherapy or for the analgesic management of disease- or treatment-related chronic pain. Metastatic recurrence is a concern. Surgery and a number of perioperative factors are suspected to accelerate tumour growth and potentially increase the risk of metastatic recurrence. Retrospective analyses have suggested an association between anaesthetic technique and cancer outcomes, and anaesthetists have sought to ameliorate the consequences of surgical trauma and minimise the impact of anaesthetic interventions. Just how anaesthesia and analgesia impact cancer recurrence and consequent survival is very topical, as understanding the potential mechanisms and interactions has an impact on the anaesthetist's ability to contribute to the successful outcome of oncological interventions. The outcome of ongoing, prospective, randomized trials are awaited with interest.

Effect of intraoperative HES 6% 130/0.4 on the need for blood transfusion after major oncologic surgery: a propensity-matched analysis

OBJECTIVES

To evaluate the effect of the intraoperative use of hydroxyethyl starch on the need for blood products in the perioperative period of oncologic surgery. The secondary end-points included the need for other blood products, the clotting profile, the intensive care unit mortality and length of stay.

METHODS

Retrospective observational analysis in a tertiary oncologic ICU in Brazil including 894 patients submitted to oncologic surgery for a two-year period from September 2007. Patients were grouped according to whether hydroxyethyl starch was used during surgery (hydroxyethyl starch and No-hydroxyethyl starch groups) and compared using a propensity score analysis. A total of 385 propensity-matched patients remained in the analysis (97 in the No-hydroxyethyl starch group and 288 in the hydroxyethyl starch group).

RESULTS

A higher percentage of patients in the hydroxyethyl starch group required red blood cell transfusion during surgery (26% vs. 14%; p = 0.016) and in the first 24 hours after surgery (5% vs. 0%; p = 0.015) but not in the 24- to 48-hour period after the procedure. There was no difference regarding the transfusion of other blood products, intensive care unit mortality or length of stay.

CONCLUSION

Hydroxyethyl starch use in the intraoperative period of major oncologic surgery is associated with an increase in red blood cell transfusions. There are no differences in the need for other blood products, intensive care unit length of stay or mortality.

Can anaesthetic and analgesic techniques affect cancer recurrence or metastasis?

Cancer is a leading cause of morbidity and mortality worldwide and the ratio of incidence is increasing. Mortality usually results from recurrence or metastases. Surgical removal of the primary tumour is the mainstay of treatment, but this is associated with inadvertent dispersal of neoplastic cells into the blood and lymphatic systems. The fate of the dispersed cells depends on the balance of perioperative factors promoting tumour survival and growth (including surgery per se, many anaesthetics per se, acute postoperative pain, and opioid analgesics) together with the perioperative immune status of the patient. Available evidence from experimental cell culture and live animal data on these factors are summarized, together with clinical evidence from retrospective studies. Taken together, current data are sufficient only to generate a hypothesis that an anaesthetic technique during primary cancer surgery could affect recurrence or metastases, but a causal link can only be proved by prospective, randomized, clinical trials. Many are ongoing, but definitive results might not emerge for a further 5 yr or longer. Meanwhile, there is no hard evidence to support altering anaesthetic technique in cancer patients, pending the outcome of the ongoing clinical trials.

Transfusion immunomodulation--the case for leukoreduced and (perhaps) washed transfusions

During the last three decades, a growing body of clinical, basic science and animal model data has demonstrated that blood transfusions have important effects on the immune system. These effects include: dysregulation of inflammation and innate immunity leading to susceptibility to microbial infection, down-regulation of cellular (T and NK cell) host defenses against tumors, and enhanced B cell function that leads to alloimmunization to blood group, histocompatibility and other transfused antigens. Furthermore, transfusions alter the balance between hemostasis and thrombosis through inflammation, nitric oxide scavenging, altered rheologic properties of the blood, immune complex formation and, no doubt, several mechanisms not yet elucidated. The net effects are rarely beneficial to patients, unless they are in imminent danger of death due to exsanguination or life threatening anemia. These findings have led to appeals for more conservative transfusion practice, buttressed by randomized trials showing that patients do not benefit from aggressive transfusion practices. At the risk of hyperbole, one might suggest that if the 18th and 19th centuries were characterized by physicians unwittingly harming patients through venesection and bleeding, the 20th century was characterized by physicians unwittingly harming patients through current transfusion practices. In addition to the movement to more parsimonious use of blood transfusions, an effort has been made to reduce the toxic effects of blood transfusions through modifications such as leukoreduction and saline washing. More recently, there is early evidence that reducing the storage period of red cells transfused might be a strategy for minimizing adverse outcomes such as infection, thrombosis, organ failure and mortality in critically ill patients particularly at risk for these hypothesized effects. The present review will focus on two approaches, leukoreduction and saline washing, as means to reduce adverse transfusion outcomes.