Transfusion of red blood cells does not impact progression-free and overall survival after surgery for ovarian cancer

Outcomes following perioperative red blood cell transfusion in patients undergoing elective major abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Perioperative red blood cell transfusion is a double-edged sword for surgical patients. While transfusion of red cells can increase oxygen delivery by increasing haemoglobin levels, its impact on short- and long-term postoperative outcomes, particularly in patients undergoing elective major abdominal surgery, is unclear.

METHODS

We conducted a systematic review and meta-analysis on the effect of perioperative blood transfusions on postoperative outcomes in elective major abdominal surgery. PubMed, Cochrane, and Scopus databases were searched for studies with data collected between January 1, 2000 and June 6, 2020. The primary outcome was short-term mortality, including all-cause 30-day or in-hospital mortality. Secondary outcomes included long-term all-cause mortality, any morbidity, infectious complications, overall survival, and recurrence-free survival. No randomised controlled trials were found. Thirty-nine observational studies were identified, of which 37 were included in the meta-analysis.

RESULTS

Perioperative blood transfusion was associated with short-term all-cause mortality (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.89-3.91, P<0.001), long-term all-cause mortality (hazard ratio 1.35, 95% CI 1.09-1.67, P=0.007), any morbidity (OR 2.18, 95% CI 1.81-2.64, P<0.001), and infectious complications (OR 1.90, 95% CI 1.60-2.26, P<0.001). Perioperative blood transfusion remained associated with short-term mortality in the sensitivity analysis after excluding studies that did not control for preoperative anaemia (OR 2.27, 95% CI 1.59-3.24, P<0.001).

CONCLUSIONS

Perioperative blood transfusion in patients undergoing elective major abdominal surgery is associated with poorer short- and long-term postoperative outcomes. This highlights the need to implement patient blood management strategies to manage and preserve the patient's own blood and reduce the need for red blood cell transfusion.

TRIAL REGISTRATION

PROSPERO (CRD42021254360).

Transfusion use and effect on progression-free, overall survival, and quality of life in upfront treatment of advanced epithelial ovarian cancer: evaluation of the European Organization for Research and Treatment EORTC-55971 Cohort

BACKGROUND

The impact of blood transfusion on ovarian cancer survival is uncertain.

OBJECTIVE

To investigate whether peri-operative blood transfusion negatively impacted progression-free survival, overall survival, and quality of life in patients with advanced ovarian cancer.

METHODS

We performed an ancillary analysis of the European Organization for Research and Treatment (EORTC) 55971 phase III trial, in which patients were randomized to primary debulking surgery versus neoadjuvant chemotherapy. Patients included in the per-protocol analysis were categorized by receipt of a transfusion.

RESULTS

612 of 632 (97%) of patients had adequate data for analysis. Of those, 323 (53%) received a transfusion. The transfusion cohort was more likely to have had better Word Health Organization (WHO) performance status, serous histology, undergone primary debulking surgery, and received more aggressive surgery, with higher rates of no gross residual disease. Median overall survival was 34.0 vs 35.2 months in the no transfusion and transfusion cohorts (p=0.97). The adjusted HR for death was 1.18 (95% CI 0.94 to 1.48) in favor of the transfusion cohort. Median progression-free survival was 13.6 vs 12.6 months in the no transfusion and transfusion cohorts (p=0.96). The adjusted HR for progression was 1.14 (95% CI 0.91 to 1.43). There were no significant differences in global quality of life, fatigue, dyspnea, or physical functioning between the two cohorts at baseline or at any of the four assessment times. Grade 3 and 4 surgical site infections were more common in the transfusion cohort.

CONCLUSION

Transfusion did not negatively impact progression-free survival or overall survival; however, it was associated with increased peri-operative morbidity without improvements in quality of life.

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.

Responses of human colon and breast adenocarcinoma cell lines (LoVo, MCF7) and non-tumorigenic mammary epithelial cells (MCF-10A) to the acellular fraction of packed red blood cells in the presence and absence of cisplatin

Perioperative blood transfusion in colorectal and some other cancer patients has been linked to the increased risk for recurrence, but a causal mechanism remains unclear. During the preparation and storage of packed red blood cells (PRBCs) bio-active substances accumulate in the acellular fraction (supernatant). Viability, proliferation, reactive oxygen species (ROS) levels, and DNA damage of colon (LoVo) and breast (MCF7) adenocarcinoma cells and non-tumorigenic MCF-10A cell line were determined in response to the supernatants of fresh and long-stored (day 42) PRBCs, leukoreduced (LR) or non-leukoreduced (NLR). The effect of supernatants on the cytotoxicity of cisplatin (cisPt) towards the cells was also examined. Supernatants, especially from a day 1 PRBCs, both LR and NLR, reduced the viability and inhibited proliferation of tumor cells (LoVo, MCF7), accompanying by the excessive ROS production, but these were not the case in MCF-10A. Moreover, supernatants had no effect on the cytotoxicity of cisPt against LoVo and MCF7 cells, while caused increased drug resistance in MCF-10A cells. The findings suggest the acellular fraction of PRBCs does not exhibit any pro-proliferative activity in the cancer cell lines studied. However, these are pioneering issues and require further research.

Transfusion‑related immunomodulation in patients with cancer: Focus on the impact of extracellular vesicles from stored red blood cells (Review)

Red blood cell (RBC) transfusions may have a negative impact on the prognosis of patients with cancer, where transfusion‑related immunomodulation (TRIM) may be a significant contributing factor. A number of components have been indicated to be associated with TRIM. Among these, the impact of extracellular vesicles (EVs) has been garnering increasing attention from researchers. EVs are defined as nano‑scale, cell‑derived vesicles that carry a variety of bioactive molecules, including proteins, nucleic acids and lipids, to mediate cell‑to‑cell communication and exert immunoregulatory functions. RBCs in storage constitutively secrete EVs, which serve an important role in TRIM in patients with cancer receiving a blood transfusion. Therefore, the present review aimed to first summarize the available information on the biogenesis and characterization of EVs. Subsequently, the possible mechanisms of TRIM in patients with cancer and the impact of EVs on TRIM were discussed, aiming to provide an outlook for future studies, specifically for formulating recommendations for managing patients with cancer receiving RBC transfusions.

Survival impact of bowel resection at the time of interval cytoreductive surgery for advanced ovarian cancer

Objectives

To evaluate the impact of bowel resection at the time of interval cytoreductive surgery on survival.

Methods

We identified patients with advanced ovarian cancer who underwent neoadjuvant chemotherapy and interval cytoreductive surgery between 2008 and 2018 from a single-institution tumor registry. Kaplan-Meier survival analysis and Cox proportional hazards models were performed comparing patients who underwent bowel resection to those who did not.

Results

Of 158 patients, 43 (27%) underwent bowel resection. Rates of optimal (95%) and sub-optimal (5%) resection did not differ with bowel resection. Patients that required bowel resection had worse three-year survival (43% vs. 63%), even after adjusting for confounding variables of age, stage, number of neoadjuvant cycles, R0 resection, and ASA score (HR 2.27, p < 0.01). Adjusted progression-free survival did not differ between groups (HR 0.92, p = 0.72). Patients who underwent bowel resection were more likely to require blood transfusion (p < 0.01), and have a longer hospital stay (5 days vs 7.5 days, p < 0.01).

Conclusions

Bowel resection at the time of interval cytoreduction confers a greater than 2-fold increased risk of mortality and does not impact progression-free survival. Long-term sequelae of the peri-operative morbidity of bowel resection may contribute to increased mortality, and bowel resection may be a surrogate for disease biology with poor prognosis.

Perioperative blood transfusion and ovarian cancer survival rates: A meta-analysis based on univariate, multivariate and propensity score matched data

The negative impact of perioperative blood transfusion on survival outcomes has been reported in several cancer types. The purpose of the present study is to summarize existing evidence in ovarian cancer patients. We searched the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases for observational and randomized trials that assessed the impact of perioperative blood transfusion on the disease-free survival (DFS) and overall survival (OS) of ovarian cancer patients that undergone debulking surgery were selected for inclusion. The methodological quality of the included studies was assessed by using the Newcastle-Ottawa Scale. Statistical meta-analysis was performed with the RevMan 5.3 software using the Der-Simonian Laird random effects model. Seven studies were identified which included 2341 ovarian cancer patients. Meta-analyses that were based on univariate and multivariate reporting revealed that perioperative blood transfusion had a significant negative impact on the patient`s OS rates (OR 1.78, 95 %CI 1.16, 2.74 and OR 1.31, 95 %CI 1.00, 1.71 respectively). Disease free survival rates were also influenced according to the results of the univariate analysis (OR 1.58, 95 %CI 1.14, 2.19), however, the effect was not significant in the multivariate analysis. The analysis that was based on propensity score matched populations did not reveal differences among transfused and non-transfused. Concluding, the findings of our meta-analysis suggest that transfusion of blood products during the perioperative period is not an independent factor that may affect survival outcomes of ovarian cancer patients. Nevertheless, it should be noted that patients that receive transfusion have several potential confounders that may affect their survival outcomes.

Impact of perioperative red blood cell transfusion on postoperative recovery and long-term outcome in patients undergoing surgery for ovarian cancer: A propensity score-matched analysis

BACKGROUND

The impact of perioperative red blood cell transfusion (PRBCT) on cancer survival has remained controversial.

METHODS

We conducted a retrospective study in patients undergoing primary debulking surgery (PDS) for ovarian cancer between January 2013 and December 2017. The patients were divided into two groups based on whether they received PRBCT. Clinical characteristics were compared between groups. After propensity score matching, perioperative systemic inflammation-based scores, quality of recovery, postoperative outcomes, disease-free survival (DFS), and overall survival (OS) were compared between groups. Univariate and multivariable Cox proportional hazard models were used to evaluate the association between covariates and survival outcomes.

RESULTS

A total of 1037 patients were enrolled in this study, and 31.7% of patients received PRBCT. After propensity matching, there was no significant difference in the clinical characteristics between groups. Patients receiving PRBCT had more postoperative fluctuations in systemic inflammatory response-related indicators (P < 0.001), a higher incidence of postoperative grade II complications (28.4% vs. 14.8%), a longer length of stay (10.6 d vs. 6.2 d) and higher 30-day and total readmission rates (7.1% vs. 4.4% and 11.2% vs. 8.1%, P < 0.001, respectively) than patients who did not receive PRBCT. The OS and DFS rates 3 years after surgery were significantly lower in the patients receiving PRBCT than in patients not receiving PRBCT (58.9% vs. 74.5%, 39.6% vs. 52.3%).

CONCLUSIONS

PRBCT was significantly associated with more fluctuations in systemic inflammatory indicators, a prolonged length of stay, higher postoperative complication rates and increased cancer recurrence and overall mortality in ovarian cancer patients undergoing PDS.