Transfusions of blood products and cancer outcomes

Impact of perioperative red blood cell transfusion, anemia of cancer and global health status on the prognosis of elderly patients with endometrial and ovarian cancer

Introduction

Perioperative red blood cell (RBC) transfusions have been associated with increased morbidity and worse oncological outcome in some solid neoplasms. In order to elucidate whether RBC transfusions themselves, the preoperative anemia of cancer (AOC), or the impaired global health status might explain this impact on patients with endometrial cancer (EC) or ovarian cancer (OC), we performed a retrospective, single-institution cohort study.

Materials and methods

Women older than 60 years with EC or OC were included. The influence of RBC transfusions, AOC, and frailty status determined by the G8 geriatric screening tool (G8 score), as well as the clinical-pathological cancer characteristics on progression-free survival (PFS) and overall survival (OS), was determined by using the Kaplan-Meier method and the Cox regression analyses.

Results

In total, 263 patients with EC (n = 152) and OC (n = 111) were included in the study. Patients with EC receiving RBC transfusions were faced with a significantly shorter 5-year PFS (79.8% vs. 26.0%; p < 0.001) and 5-year OS (82.6% vs. 25.7%; p < 0.001). In multivariable analyses, besides established clinical-pathological cancer characteristics, the RBC transfusions remained the only significant prognostic parameter for PFS (HR: 1.76; 95%-CI [1.01–3.07]) and OS (HR: 2.38; 95%-CI [1.50–3.78]). In OC, the G8 score stratified the cohort in terms of PFS rates (G8-non-frail 53.4% vs. G8-frail 16.7%; p = 0.010) and AOC stratified the cohort for 5-year OS estimates (non-anemic: 36.7% vs. anemic: 10.6%; p = 0.008). Multivariable Cox regression analyses determined the G8 score and FIGO stage as independent prognostic factors in terms of PFS (HR: 2.23; 95%-CI [1.16–4.32] and HR: 6.52; 95%-CI [1.51–28.07], respectively). For OS, only the TNM tumor stage retained independent significance (HR: 3.75; 95%-CI [1.87–7.53]).

Discussion

The results of this trial demonstrate the negative impact of RBC transfusions on the prognosis of patients with EC. Contrastingly, the prognosis of OC is altered by the preoperative global health status rather than AOC or RBC transfusions. In summary, we suggested a cumulatively restrictive transfusion management in G8-non-frail EC patients and postulated a more moderate transfusion management based on the treatment of symptomatic anemia without survival deficits in OC patients.

Increased Oxidative Stress in Acute Myeloid Leukemia Patients after Red Blood Cell Transfusion, but Not Platelet Transfusion, Results Mainly from the Oxidative/Nitrative Protein Damage: An Exploratory Study

Chronic oxidative stress (OS) can be an important factor of acute myeloid leukemia (AML) progression; however, there are no data on the extent/consequence of OS after transfusion of packed red blood cells (pRBCs) and platelet concentrates (PCs), which are commonly used in the treatment of leukemia-associated anemia and thrombocytopenia. We aimed to investigate the effects of pRBC/PC transfusion on the OS markers, i.e., thiol and carbonyl (CO) groups, 3-nitrotyrosine (3-NT), thiobarbituric acid reactive substances (TBARS), advanced glycation end products (AGE), total antioxidant capacity (TAC), SOD, GST, and LDH, in the blood plasma of AML patients, before and 24 h post-transfusion. In this exploratory study, 52 patients were examined, of which 27 were transfused with pRBCs and 25 with PCs. Age-matched healthy subjects were also enrolled as controls. Our results showed the oxidation of thiols, increased 3-NT, AGE levels, and decreased TAC in AML groups versus controls. After pRBC transfusion, CO groups, AGE, and 3-NT significantly increased (by approximately 30, 23, and 35%; p < 0.05, p < 0.05, and p < 0.01, respectively) while thiols reduced (by 18%; p < 0.05). The PC transfusion resulted in the raise of TBARS and AGE (by 45%; p < 0.01 and 31%; p < 0.001), respectively). Other variables showed no significant post-transfusion changes. In conclusion, transfusion of both pRBCs and PCs was associated with an increased OS; however, transfusing the former may have more severe consequences, since it is associated with the irreversible oxidative/nitrative modifications of plasma proteins.

Perioperative Transfusions for Gastroesophageal Cancers: Risk Factors and Short- and Long-Term Outcomes

BACKGROUND

Perioperative blood transfusions have been associated with increased morbidity and poorer oncologic outcomes for numerous surgical procedures. However, this issue is understudied among patients with gastroesophageal malignancies. The objective was to clarify the risk factors and impact of perioperative transfusions on quality of life and surgical and oncologic outcomes among patients undergoing gastric and esophageal cancer surgery.

METHODS

Patients undergoing curative-intent resections for gastroesophageal cancers between 2010 and 2018 were included. Perioperative blood transfusion was defined as any transfusion within 24 h pre-operatively, during surgery, or the primary post-operative hospitalization period. Patient and tumor characteristics, surgical and oncological outcomes, and quality of life were compared.

RESULTS

A total of 435 patients were included. Perioperative transfusions occurred in 184 (42%). Anemia, blood loss, female sex, open surgical approach, and operative time emerged as independent risk factors for transfusions. Factors found to be independently associated with overall survival were neoadjuvant therapy, tumor size and stage, major complications, and mortality. Transfusions did not independently impact overall survival, disease-free survival, or quality of life.

CONCLUSIONS

Perioperative transfusions did not impact oncologic outcomes or quality of life among patients undergoing curative-intent surgery for gastroesophageal cancers.

The role of extracellular vesicles from stored RBC units in B lymphocyte survival and plasma cell differentiation

Extracellular vesicles (EVs) are small, double-membrane vesicles derived from erythrocytes, leukocytes, platelets, and cells of multiple tissues under physiologic or pathologic conditions. The role of EVs in stored RBC units is of great interest with respect to transfusion-related immunomodulation. The current study focuses on the quantity of EVs isolated from stored RBC units and their action on B cell-mediated immune responses. The in vitro experiment demonstrated that EVs exhibited a negative role in B cell survival, plasmacytic differentiation, and class switch recombination under LPS stimulation. Furthermore, LPS-induced antibody production was significantly decreased after EVs injection in vivo. Biochemical analysis revealed that EVs hampered the expression of Blimp-1 and IRF4 and the activation of NF-κB pathway in LPS-primed B cells. Overall, these data imply a vital role for EVs isolated from RBC units in B cell-mediated immune responses.

Influence of a cell salvage washing system and leukocyte reduction filtration on bacterial contamination of canine whole blood ex vivo

OBJECTIVE

To determine the ability of cell salvage washing and leukoreduction filtration to remove bacterial contamination from canine whole blood.

STUDY DESIGN

Ex vivo nested cohort study.

SAMPLE POPULATION

Commercially purchased fresh canine whole blood (n = 33 units).

METHODS

Commercially obtained canine whole blood was inoculated with known concentrations of one of three species of bacteria, Escherichia coli (ATCC 25922), Staphylococcus pseudintermedius (quality control strain; Texas A&M University), or Pseudomonas aeruginosa (ATCC 27853). Negative controls were inoculated with sterile saline. The inoculated blood was processed through a cell salvage system and filtered through a series of two leukocyte reduction filters. Samples were aseptically collected at five points during processing (inoculum, prewash, postwash, post-first filtration, and post-second filtration) for bacterial enumeration.

RESULTS

Bacterial concentrations were reduced by 85.2%, 91.5%, and 93.9% for E coli, S pseudintermedius, and P aeruginosa, respectively, after washing (P < .0001), and bacterial concentrations were reduced by 99.9%, 100%, and 100%, respectively, after the first filtration (P < .0001). After the second filtration, none of the three species of bacteria could be isolated (100% reduction). No bacterial growth was obtained from negative controls throughout the study. The type of bacteria (P = .29) did not allow prediction of bacterial reduction.

CONCLUSION

Cell salvage washing combined with leukoreduction filtration eliminated bacterial contamination of whole dog blood (P < .0001).

CLINICAL SIGNIFICANCE

Cell salvage washing and leukoreduction filtration could be applied to intraoperative autotransfusion in clinical animals, especially those treated for trauma or hemorrhage with concurrent bacterial contamination.

Effect of postoperative haemoglobin variation on major cardiopulmonary complications in high cardiac risk patients undergoing anatomical lung resections

OBJECTIVES

Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections.

METHODS

We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017-February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions.

RESULTS

Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P < 0.001], along with higher ThRCRI classes (classes A-B versus C-D: OR 0.09; P < 0.001). Interaction terms with transfusion were not statistically significant, indicating that the harmful effect of ΔHb was independent. According to receiver operating characteristic curve analysis, a ΔHb of 29 g/l was found to be the best cut-off value for predicting complications.

CONCLUSIONS

In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status.

Impact of perioperative transfusion in patients undergoing resection of colorectal cancer liver metastases: A population-based study

BACKGROUND

Perioperative allogeneic blood transfusion is associated with poorer outcomes.

AIM

To identify the factors that were associated with perioperative transfusion and to examine the impact of perioperative transfusion in patients undergoing resection of colorectal cancer (CRC) liver metastases.

METHODS

The United States National Inpatient Sample (NIS) database was searched for patients with CRC who received surgery for liver metastasis. Linear and logistic regression analyses were performed.

RESULTS

A total of 2018 patients were included, and 480 had a perioperative transfusion. Emergency admission (adjusted odds ratio [aOR] = 1.42; 95%CI: 1.07-1.87), hepatic lobectomy (aOR = 1.76; 95%CI: 1.42-2.19), and chronic anemia (aOR = 2.62; 95%CI: 2.04-3.35) were associated with increased chances of receiving a transfusion, but receiving surgery at a teaching hospital (aOR = 0.75; 95%CI: 0.58-0.98) was associated with a decreased chance of receiving a transfusion. Receiving a perioperative transfusion was significantly associated with increased in-hospital mortality (aOR = 3.38; 95%CI: 1.57-7.25), and increased overall postoperative complications (aOR = 1.67; 95%CI: 1.31-2.13), as well as longer length of hospital stay

CONCLUSION

Patients with an emergency admission, hepatic lobectomy, chronic anemia, and who have surgery at a non-teaching hospital are more likely to receive a perioperative transfusion. Patients with CRC undergoing surgery for hepatic metastases who receive a perioperative transfusion are at a higher risk of in-hospital mortality, postoperative complications, and longer length of hospital stay.

Artificial Oxygen Carriers-Past, Present, and Future-a Review of the Most Innovative and Clinically Relevant Concepts

Blood transfusions are a daily practice in hospitals. Since these products are limited in availability and have various, harmful side effects, researchers have pursued the goal to develop artificial blood components for about 40 years. Development of oxygen therapeutics and stem cells are more recent goals. Medline (https://www.ncbi.nlm.nih.gov/pubmed/?holding=ideudelib), ClinicalTrials.gov (https://clinicaltrials.gov), EU Clinical Trials Register (https://www.clinicaltrialsregister.eu), and Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au) were searched up to July 2018 using search terms related to artificial blood products in order to identify new and ongoing research over the last 5 years. However, for products that are already well known and important to or relevant in gaining a better understanding of this field of research, the reader is punctually referred to some important articles published over 5 years ago. This review includes not only clinically relevant substances such as heme-oxygenating carriers, perfluorocarbon-based oxygen carriers, stem cells, and organ conservation, but also includes interesting preclinically advanced compounds depicting the pipeline of potential new products. In- depth insights into specific benefits and limitations of each substance, including the biochemical and physiologic background are included. "Fancy" ideas such as iron-based substances, O₂ microbubbles, cyclodextranes, or lugworms are also elucidated. To conclude, this systematic up-to-date review includes all actual achievements and ongoing clinical trials in the field of artificial blood products to pursue the dream of artificial oxygen carrier supply. Research is on the right track, but the task is demanding and challenging.

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.

Adaptation of the Nursing Activities Score for oncologic care

OBJECTIVE

To adapt the contents of the Nursing Activities Score (NAS) tool to assist patients with cancer.

METHOD

Methodological research that according to the Delphi Technique is a method aiming at the validation of content through agreement of experts.

RESULTS

It took two rounds of opinion of experts, which added content contributions without modifying the structure and score of the original tool. The level of agreement ranged from 71 to 86%, and biological factors and assistance were more suggested: Monitoring and controls; Laboratory investigations; Support and care for family members and patients; Intravenous replacement; Renal support; Management activities.

CONCLUSION

A high level of complexity of patients with cancer, and the demand for care and biopsychosocial-spiritual care was diagnosed. This tool will enable the measurement of the workload of the Oncology Nursing team, which can contribute to the staffing dimensioning.

Effect of storage period of red blood cell suspensions on helper T-cell subpopulations

BACKGROUND

The aim of this study was to investigate the immunological alterations that occur during the storage of erythrocyte suspensions which may lead to transfusion-related immunomodulation following allogeneic blood transfusion.

MATERIALS AND METHODS

One part of the erythrocyte suspensions obtained from donors was leucoreduced while the other part was not. The leucoreduced (LR) and non-leucoreduced (NL) erythrocyte suspensions were then further divided into three equal amounts which were stored for 0, 21 or 42 days prior to measurements, by enzyme-linked immunosorbent assays, of cytokine levels in their supernatants. T-helper (Th) lymphocyte subgroups and gene expression were analysed in the NL erythrocyte suspensions by flow cytometry and real-time polymerase chain reaction, respectively. Results were compared to those of storage day 0.

RESULTS

By day 21, the number of Th2 cells had increased significantly and the numbers of Th1, Th22 and Treg cells had decreased significantly in the NL erythrocyte suspensions. On day 42 the numbers of Th2 and Treg cells in the NL suspensions were significantly increased while the number of Th1 cells was significantly decreased. The levels of transcription factors (TBX21, GATA3, and SPI.1) were significantly decreased on days 21 and 42, and AHR, FOXP3 and RORC2 levels were significantly increased on day 42 in NL erythrocyte suspensions. The decrease in interleukin-22 and increase in transforming growth factor-β levels found in NL erythrocyte suspensions on day 21 were statistically significant. Elevated levels of interleukin-17A were found in both LR and NL erythrocyte suspensions on day 42.

DISCUSSION

Our results suggest that allogeneic leucocytes and cytokines may play significant roles in the development of transfusion-related immunomodulation.

Perioperative blood transfusion has no effect on overall survival after esophageal resection for esophageal squamous cell carcinoma: A retrospective cohort study

BACKGROUND

The impact of perioperative blood transfusion (PBT) on the prognosis of esophageal cancer patients remains inconclusive. The purpose of this study was to assess the association between PBT and survival in esophageal squamous cell carcinoma (ESCC) patients.

MATERIALS AND METHODS

In this retrospective study, patients with ESCC who underwent esophageal resection from January 2008 to December 2011 were analyzed. The overall survival and postoperative outcomes between PBT and non-PBT patients were compared using Cox regression and propensity score matching (PSM) analysis.

RESULTS

A total of 935 patients were enrolled in this study. Before PSM, the 5-year overall survival rates in PBT and non-PBT patients were 48.4% and 56.3% (P = 0.001), respectively. The postoperative infection rate in PBT patients was 32.32%, which exceeded the rate of 24.22% in non-PBT patients (P = 0.008). PSM created 306 pairs of patients. After PSM, the 5-year overall survival rates in PBT and non-PBT patients were 49.4% and 51.0% (P = 0.334), respectively. The postoperative infection rate in PBT patients was 31.04%, which was higher than the rate of 26.47% in non-PBT patients (P = 0.105). Multivariable Cox regression analyses showed that PBT was not an independent risk factor for overall survival (HR: 0.792, 95% CI: 0.615-1.021, P = 0.072).

CONCLUSION

Perioperative blood transfusion has no effect on the overall survival of ESCC patients.

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.