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Tumor Necrosis Factor Alpha: Implications of Anesthesia on Cancers. Cancers (Basel) 2023; 15:cancers15030739. [PMID: 36765695 PMCID: PMC9913216 DOI: 10.3390/cancers15030739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
Cancer remains a major public health issue and a leading cause of death worldwide. Despite advancements in chemotherapy, radiation therapy, and immunotherapy, surgery is the mainstay of cancer treatment for solid tumors. However, tumor cells are known to disseminate into the vascular and lymphatic systems during surgical manipulation. Additionally, surgery-induced stress responses can produce an immunosuppressive environment that is favorable for cancer relapse. Up to 90% of cancer-related deaths are the result of metastatic disease after surgical resection. Emerging evidence shows that the interactions between tumor cells and the tumor microenvironment (TME) not only play decisive roles in tumor initiation, progression, and metastasis but also have profound effects on therapeutic efficacy. Tumor necrosis factor alpha (TNF-α), a pleiotropic cytokine contributing to both physiological and pathological processes, is one of the main mediators of inflammation-associated carcinogenesis in the TME. Because TNF-α signaling may modulate the course of cancer, it can be therapeutically targeted to ameliorate clinical outcomes. As the incidence of cancer continues to grow, approximately 80% of cancer patients require anesthesia during cancer care for diagnostic, therapeutic, or palliative procedures, and over 60% of cancer patients receive anesthesia for primary surgical resection. Numerous studies have demonstrated that perioperative management, including surgical manipulation, anesthetics/analgesics, and other supportive care, may alter the TME and cancer progression by affecting inflammatory or immune responses during cancer surgery, but the literature about the impact of anesthesia on the TNF-α production and cancer progression is limited. Therefore, this review summarizes the current knowledge of the implications of anesthesia on cancers from the insights of TNF-α release and provides future anesthetic strategies for improving oncological survival.
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Buddeberg BS, Seeberger MD. Anesthesia and Oncology: Friend or Foe? Front Oncol 2022; 12:802210. [PMID: 35359377 PMCID: PMC8963958 DOI: 10.3389/fonc.2022.802210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/17/2022] [Indexed: 12/24/2022] Open
Abstract
Cancer is a leading cause of death, and surgery is an important treatment modality. Laboratory research and retrospective studies have raised the suspicion that the choice of anesthetics for cancer surgery might affect the course of cancerous disease. The aim of this review is to provide a critical overview of the current state of knowledge. Inhalational anesthesia with volatiles or total intravenous anesthesia (TIVA) with propofol are the two most commonly used anesthetic techniques. Most data comparing volatile anesthetics with TIVA is from either in vitro or retrospective studies. Although conflicting, data shows a trend towards favoring propofol. Opioids are commonly used in anesthesia. Data on potential effects of opioids on growth and recurrence of cancer are scarce and conflicting. Preclinical studies have shown that opioids stimulate cancer growth through the µ-opioid receptor. Opioids also act as immunosuppressants and, therefore, have the potential to facilitate metastatic spread. However, the finding of an adverse effect of opioids on tumor growth and cancer recurrence by some retrospective studies has not been confirmed by prospective studies. Regional anesthesia has not been found to have a beneficial effect on the outcome of surgically treated cancer patients, but prospective studies are scarce. Local anesthetics might have a beneficial effect, as observed in animal and in vitro studies. However, prospective clinical studies strongly question such an effect. Blood products, which may be needed during extensive cancer surgery suppress the immune system, and data strongly suggest a negative impact on cancer recurrence. The potential effects of other commonly used anesthetic agents on the outcome of cancer patients have not been sufficiently studied for drawing valid conclusions. In conclusion, laboratory data and most retrospective studies suggest a potential advantage of TIVA over inhalational anesthesia on the outcome of surgical cancer patients, but prospective, randomized studies are missing. Given the state of weak scientific evidence, TIVA may be used as the preferred type of anesthesia unless there is an individual contraindication against it. Studies on the effects of other drugs frequently used in anesthesia are limited in number and quality, and have found conflicting results.
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Affiliation(s)
- Bigna S. Buddeberg
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
- Medical School, University of Basel, Basel, Switzerland
| | - Manfred D. Seeberger
- Medical School, University of Basel, Basel, Switzerland
- *Correspondence: Manfred D. Seeberger,
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Market M, Tennakoon G, Auer RC. Postoperative Natural Killer Cell Dysfunction: The Prime Suspect in the Case of Metastasis Following Curative Cancer Surgery. Int J Mol Sci 2021; 22:ijms222111378. [PMID: 34768810 PMCID: PMC8583911 DOI: 10.3390/ijms222111378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
Surgical resection is the foundation for the curative treatment of solid tumors. However, metastatic recurrence due to the difficulty in eradicating micrometastases remain a feared outcome. Paradoxically, despite the beneficial effects of surgical removal of the primary tumor, the physiological stress resulting from surgical trauma serves to promote cancer recurrence and metastasis. The postoperative environment suppresses critical anti-tumor immune effector cells, including Natural Killer (NK) cells. The literature suggests that NK cells are critical mediators in the formation of metastases immediately following surgery. The following review will highlight the mechanisms that promote the formation of micrometastases by directly or indirectly inducing NK cell suppression following surgery. These include tissue hypoxia, neuroendocrine activation, hypercoagulation, the pro-inflammatory phase, and the anti-inflammatory phase. Perioperative therapeutic strategies designed to prevent or reverse NK cell dysfunction will also be examined for their potential to improve cancer outcomes by preventing surgery-induced metastases.
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Affiliation(s)
- Marisa Market
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1G 8M5, Canada; (M.M.); (G.T.)
- The Ottawa Hospital Research Institute, Ottawa, ON K1G 4E3, Canada
| | - Gayashan Tennakoon
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1G 8M5, Canada; (M.M.); (G.T.)
| | - Rebecca C. Auer
- The Ottawa Hospital Research Institute, Ottawa, ON K1G 4E3, Canada
- Department of General Surgery, The Ottawa Hospital, Ottawa, ON K1Y 4E9, Canada
- Correspondence: ; Tel.: +1-613-722-7000
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Immunophenotype Rearrangement in Response to Tumor Excision May Be Related to the Risk of Biochemical Recurrence in Prostate Cancer Patients. J Clin Med 2021; 10:jcm10163709. [PMID: 34442004 PMCID: PMC8396861 DOI: 10.3390/jcm10163709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/10/2021] [Accepted: 08/16/2021] [Indexed: 02/07/2023] Open
Abstract
Background: Prostate cancer (PCa) is known to exhibit a wide spectrum of aggressiveness and relatively high immunogenicity. The aim of this study was to examine the effect of tumor excision on immunophenotype rearrangements in peripheral blood and to elucidate if it is associated with biochemical recurrence (BCR) in high risk (HR) and low risk (LR) patients. Methods: Radical prostatectomy (RP) was performed on 108 PCa stage pT2–pT3 patients. Preoperative vs. postoperative (one and three months) immunophenotype profile (T- and B-cell subsets, MDSC, NK, and T reg populations) was compared in peripheral blood of LR and HR groups. Results: The BCR-free survival difference was significant between the HR and LR groups. Postoperative PSA decay rate, defined as ePSA, was significantly slower in the HR group and predicted BCR at cut-off level ePSA = −2.0% d−1 (AUC = 0.85 (95% CI, 0.78–0.90). Three months following tumor excision, the LR group exhibited a recovery of natural killer CD3 − CD16+ CD56+ cells, from 232 cells/µL to 317 cells/µL (p < 0.05), which was not detectable in the HR group. Prostatectomy also resulted in an increased CD8+ population in the LR group, mostly due to CD8+ CD69+ compartment (from 186 cells/µL before surgery to 196 cells/µL three months after, p < 001). The CD8+ CD69+ subset increase without total T cell increase was present in the HR group (p < 0.001). Tumor excision resulted in a myeloid-derived suppressor cell (MDSC) number increase from 12.4 cells/µL to 16.2 cells/µL in the HR group, and no change was detectable in LR patients (p = 0.12). An immune signature of postoperative recovery was more likely to occur in patients undergoing laparoscopic radical prostatectomy (LRP). Open RP (ORP) was associated with increased MDSC numbers (p = 0.002), whereas LRP was characterized by an immunity sparing profile, with no change in MDSC subset (p = 0.16). Conclusion: Tumor excision in prostate cancer patients results in two distinct patterns of immunophenotype rearrangement. The low-risk group is highly responsive, revealing postoperative restoration of T cells, NK cells, and CD8+ CD69+ numbers and the absence of suppressor MDSC increase. The high-risk group presented a limited response, accompanied by a suppressor MDSC increase and CD8+ CD69+ increase. The laparoscopic approach, unlike ORP, did not result in an MDSC increase in the postoperative period.
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Zhang X, Guo X, Zong Y, Xu C, Wang J, Zhang B, Liu C, Gong Y, Xue L, Ma L, Zhang S, Li Y, Zeng H. CTCs detection from intraoperative salvaged blood in RCC-IVC thrombus patients by negative enrichment and iFISH identification: a preliminary study. BMC Urol 2021; 21:89. [PMID: 34112129 PMCID: PMC8191124 DOI: 10.1186/s12894-021-00803-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intra-operative cell salvage (IOCS) and leukocyte-depleted filter (LDF) are widely used and effective in saving blood. However, the safety issue concerning reinfusion of IOCS-LDF processed blood to renal cell carcinoma (RCC) patients with inferior vena cava (IVC) thrombus were inconclusive for fear of increased risk of cancer metastases. This study intends to analyze the circulating tumor cell (CTC) eliminating effect of IOCS-LDF in 5 RCC-IVC thrombus patients. METHODS A novel strategy integrating negative enrichment by immunomagnetic beads and immunostaining-fluorescence in situ hybridization with probes identifying aneuploid of 8 and/or 7 were used to detect CTCs from salvages blood. Blood samples were collected from 4 stages in each patient. RESULTS Of the 5 RCC patients, the number of CTCs decreased (from 3, 4, 10, 7, 3, respectively, to all zero) after IOCS-LDF treatment. The triploid of chromosome 7 and/or chromosome 8 were most common karyotype for RCC patients with IVC thrombus. Tetraploid of chromosome 8 occurred in only one sample and no polypoid (number of chromosome > 4) were found. CONCLUSION IOCS-LDF might be a promising way of reducing of allogeneic product transfusion based on current preliminary outcome. More convincing conclusions are to be drawn with enlarged sample size and long-term follow-up for patients prognosis.
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Affiliation(s)
- Xiaoqing Zhang
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China
| | - Xiangyang Guo
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China
| | - Yanan Zong
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China
| | - Chuanya Xu
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China
| | - Jilian Wang
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China
| | - Bin Zhang
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China
| | - Chang Liu
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China
| | - Yueqing Gong
- Biological Sample Bank, Peking University Third Hospital, Beijing, China
| | - Lixiang Xue
- Biological Sample Bank, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yi Li
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China.
| | - Hong Zeng
- Department of Anesthesia, Peking University Third Hospital, Huayuan 49# Rd, Haidian Dist., Beijing, China.
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Xu J, Kinnear N, Johns Putra L. Safety, efficacy and cost of intra-operative cell salvage during open radical prostatectomy. Transl Androl Urol 2021; 10:1241-1249. [PMID: 33850759 PMCID: PMC8039577 DOI: 10.21037/tau-20-1265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background We aim to examine the safety and efficacy of intra-operative cell salvage (ICS) in radical prostatectomy. Methods A retrospective cohort study was performed, enrolling consecutive patients undergoing open radical prostatectomy at two institutions during 01/01/18–31/12/19. Patients were grouped by ICS use. Primary outcomes were allogeneic transfusion rates, and biochemical recurrence (prostate specific antigen >0.2 mg/mL). Secondary outcomes were use of adjuvant therapies, Clavien-Dindo complications and transfusion-related cost (allogeneic transfusion + ICS setup + ICS reinfusion). Results In total, 168 men were enrolled. Patients were grouped based on whether they received no blood conservation technique (126 men) or ICS (42 men). Groups were similar in median age, pre- and post-operative haemoglobin and length of stay. They also had similar post-operative tumour Gleason score, TNM-stage and positive surgical margin rates. Compared with controls, the ICS group had shorter follow up (336 vs. 225 days; P=0.003). The groups had similar rates of biochemical recurrence (17% vs. 14%; P=0.90), adjuvant therapy use (30% vs. 29%; P=0.85) and complications (14% vs. 19% patients; P=0.46). There was no metastatic progression or cancer-specific mortality in either group. Although a similar proportion of patients received allogenic transfusion (2.4% vs. 4.8%; P=0.33) and units of packed red blood cells (PRBC) (9 vs. 5 units), transfusion-related costs were higher amongst the ICS group (AUD $11,422 vs. $43,227). Conclusions ICS use in radical prostatectomy was not associated with altered rates of allogeneic transfusion, complications, biochemical recurrence or adjuvant or salvage therapies. Transfusion related costs were higher in the ICS group.
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Affiliation(s)
- Jennifer Xu
- Department of Urology, Ballarat Base Hospital, Ballarat, Australia
| | - Ned Kinnear
- Department of Urology, Ballarat Base Hospital, Ballarat, Australia.,St John of God Hospital, Ballarat, Australia
| | - Lydia Johns Putra
- Department of Urology, Ballarat Base Hospital, Ballarat, Australia.,St John of God Hospital, Ballarat, Australia
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Plücker J, Wirsik NM, Ritter AS, Schmidt T, Weigand MA. Anaesthesia as an influence in tumour progression. Langenbecks Arch Surg 2021; 406:1283-1294. [PMID: 33523307 PMCID: PMC8370957 DOI: 10.1007/s00423-021-02078-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/01/2021] [Indexed: 12/19/2022]
Abstract
Purpose Tumour growth and the formation of metastases are essential elements in the progression of cancer. The centre of treatment is the surgical resection of primary solid tumours. But even if the tumour can be removed without microscopic residual cells, local recurrences and distant metastases occur and determine the patient’s fate. During the operation, tumour cells are shed from the primary tumour and released into the circulation. These circulating tumour cells might play an important role in the formation of new tumour sites. Therefore, a functional innate and adaptive immune system is essential, especially in this perioperative period. Anaesthesia influences consciousness and pain perception and interacts directly with the immune system and tumour cells. Methods Review of the current literature concerning intra- and postoperative anaesthetic decisions and tumour progression. Results There are beneficial aspects for patient survival associated with total intravenous anaesthesia, the use of regional anaesthetics and the avoidance of allogeneic red blood cell transfusions. Alternatives such as irradiated intraoperative blood salvage and preoperative iron supplementation may be advantageous in cases where transfusions are limited or not wanted. The immunosuppressive properties of opioids are theoretical, but strong evidence to avoid them does not exist. The application of nonsteroidal anti-inflammatory drugs and postoperative nausea and vomiting prophylaxis do not impair the patient’s survival and may even have a positive effect on tumour regression. Conclusion Anaesthesia does play an important part in the perioperative period in order to improve the cancer-related outcome. Further research is necessary to make more concrete recommendations.
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Affiliation(s)
- Jadie Plücker
- Department of Anaesthesiology, University of Heidelberg, Heidelberg, Germany.
| | - Naita M Wirsik
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alina S Ritter
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anaesthesiology, University of Heidelberg, Heidelberg, Germany
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8
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Jiang Y, Karri J, Mathias K, Abd-Elsayed A. The Effects of Perioperative Transfusion of Allogenic Blood Products of Cancer Recurrence. ESSENTIALS OF BLOOD PRODUCT MANAGEMENT IN ANESTHESIA PRACTICE 2021:397-403. [DOI: 10.1007/978-3-030-59295-0_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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An In Vitro Pilot Study Comparing the Novel HemoClear Gravity-Driven Microfiltration Cell Salvage System with the Conventional Centrifugal XTRA™ Autotransfusion Device. Anesthesiol Res Pract 2020; 2020:9584186. [PMID: 32963523 PMCID: PMC7495155 DOI: 10.1155/2020/9584186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/22/2020] [Accepted: 08/05/2020] [Indexed: 11/18/2022] Open
Abstract
Background In 2013, the World Health Organization reported a shortage of 17 million red blood cell units, a number that remains growing. Acts to relieve this shortage have primarily focused on allogeneic blood collection. Nevertheless, autologous transfusion can partially alleviate the current pressure and dependence on blood banking systems. To achieve this, current gold standard autotransfusion devices should be complemented with widely available, cost-efficient, and time-efficient devices. The novel HemoClear cell salvage device (HemoClear BV, Zwolle, Netherlands), a gravity-driven microfilter, potentially is widely employable. We evaluated its performance in the cardiac postoperative setting compared to the centrifugal XTRA™ autotransfusion device. Methods In a split-unit study (n = 18), shed blood collected 18 hours after cardiothoracic surgery was divided into two equal volumes. One-half was processed by the XTRA™ device and the other with the HemoClear blood separation system. In this paired set-up, equal washing volumes were used for both methods. Washing effectivity and cellular recovery were determined by measuring of complete blood count, free hemoglobin, complement C3, complement C4, and D-dimer in both concentrate as filtrate. Also, processing times and volumes were evaluated. Results The HemoClear and XTRA™ devices showed equal effectiveness in concentrating erythrocytes and leucocytes. Both methods reduced complement C3, complement C4, and D-dimer by ≥90%. The centrifugal device reduced solutes more significantly by up to 99%. Free hemoglobin load was reduced to 12.9% and 15.5% by the XTRA™ and HemoClear, respectively. Conclusion The HemoClear device effectively produced washed concentrated red blood cells comparably to the conventional centrifugal XTRA™ autotransfusion device. Although the centrifugal XTRA™ device achieved a significantly higher reduction in contaminants, the HemoClear device achieved acceptable blood quality and seems promising in settings where gold standard cell savers are unaffordable or unpractical.
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Mühlbauer J, de Gilde J, Mueller-Steinhardt M, Porubsky S, Walach M, Nuhn P, Klüter H, Wagener N, Kriegmair MC. Perioperative Blood Transfusion Is a Predictor of Acute and Chronic Renal Function Deterioration after Partial and Radical Nephrectomy for Renal Cell Carcinoma. Urol Int 2020; 104:775-780. [PMID: 32721964 DOI: 10.1159/000509206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/07/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim was to evaluate the impact of perioperative blood transfusions (PBTs) on renal function after surgery for renal cell carcinoma (RCC). METHODS Consecutive patients with RCC who underwent partial nephrectomy or radical nephrectomy between 2005 and 2015 at a tertiary care center were included. Minimum follow-up period was 6 months. A PBT was defined as the transfusion of packed erythrocyte concentrate (EC) within 7 days before until 30 days after surgery. The multivariable analyses were carried out by Cox regression. RESULTS The overall cohort included 851 patients, of whom 93 (10.9%) received a PBT. The median follow-up was 46 months (range 28-72). In case of a PBT, a median of 2 EC was transfused. PBT patients were older and had a poorer performance status and more comorbidities as well as locally more advanced or metastatic tumors. In the multivariable analyses, PBT was an independent prognostic factor for acute as well as chronic renal impairment (hazard ratio (HR) 2.72, 95% confidence interval (95% CI) 1.45-5.10, p = 0.002 and HR 2.23, 95% CI 1.26-3.70, p = 0.007). CONCLUSION PBT is associated with acute and chronic deterioration of kidney function after surgery for RCC. Thus, it may be used to identify patients requiring close nephrological monitoring.
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Affiliation(s)
- Julia Mühlbauer
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany,
| | - Johannes de Gilde
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Mueller-Steinhardt
- German Red Cross Blood Service of Baden-Württemberg - Hessen gGmbH, Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan Porubsky
- Department of Pathology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Margarete Walach
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Philipp Nuhn
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Klüter
- German Red Cross Blood Service of Baden-Württemberg - Hessen gGmbH, Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nina Wagener
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Maximilian C Kriegmair
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Kang HW, Seo SP, Kim WT, Yun SJ, Lee SC, Kim WJ, Hwang EC, Kang SH, Hong SH, Chung J, Kwon TG, Kim HH, Kwak C, Byun SS, Kim YJ. Intraoperative allogeneic blood transfusion is associated with adverse oncological outcomes in patients with surgically treated non-metastatic clear cell renal cell carcinoma. Int J Clin Oncol 2020; 25:1551-1561. [PMID: 32504136 DOI: 10.1007/s10147-020-01694-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/29/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The objective of this study was to provide more definitive information about the prognostic impact of perioperative blood transfusion (PBT) on patients with surgically treated renal cell carcinoma (RCC). METHODS A database of 4019 patients with clear cell RCC, all of whom underwent radical or partial nephrectomy as primary therapy as part of a multi-institutional Korean collaboration between 1988 and 2015, was analyzed retrospectively. PBT was defined as transfusion of allogeneic red blood cells during surgery or postsurgical period. Receipt of a PBT, as well as the amount and time of blood transfusion (BT), was compared. RESULTS Overall, 335 (8.3%) patients received a PBT: 84 received postoperative BT, 202 received intraoperative BT, and 49 received both intraoperative and postoperative BT. Patients receiving a PBT had a poor preoperative immuno-nutritional status, and aggressive tumor characteristics. Multivariate analyses identified PBT as an independent predictor of recurrence-free survival and cancer-specific survival. Prognostic impact of PBT was restricted to those with locally advanced stage (pT3-4), and who underwent radical nephrectomy. Among patients who received a PBT, intraoperative (but not postoperative) BT was a prognostic factor for survival. Among patients who received intraoperative BT, those receiving three or more transfusion units had a significantly worse survival. CONCLUSION Receipt of a PBT was an independent predictor of RFS and CSS in patients with surgically treated RCC, specifically locally advanced disease. Regarding the prognostic impact of timing or dose of PBT on survival, intraoperative BT and ≥ 3 pRBC units were associated with adverse oncological outcomes.
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Affiliation(s)
- Ho Won Kang
- Department of Urology, Chungbuk National University College of Medicine, 1st Chungdae-ro, Seowon-gu, Cheongju, Chungbuk, 28644, South Korea.,Department of Urology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Sung Pil Seo
- Department of Urology, Chungbuk National University College of Medicine, 1st Chungdae-ro, Seowon-gu, Cheongju, Chungbuk, 28644, South Korea.,Department of Urology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Won Tae Kim
- Department of Urology, Chungbuk National University College of Medicine, 1st Chungdae-ro, Seowon-gu, Cheongju, Chungbuk, 28644, South Korea.,Department of Urology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Seok Joong Yun
- Department of Urology, Chungbuk National University College of Medicine, 1st Chungdae-ro, Seowon-gu, Cheongju, Chungbuk, 28644, South Korea.,Department of Urology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Sang-Cheol Lee
- Department of Urology, Chungbuk National University College of Medicine, 1st Chungdae-ro, Seowon-gu, Cheongju, Chungbuk, 28644, South Korea.,Department of Urology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Wun-Jae Kim
- Department of Urology, Chungbuk National University College of Medicine, 1st Chungdae-ro, Seowon-gu, Cheongju, Chungbuk, 28644, South Korea.,Department of Urology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Hwasun Hospital, Hwasun-gun, South Korea
| | - Seok Ho Kang
- Department of Urology, Korea University School of Medicine, Seoul, South Korea
| | - Sung-Hoo Hong
- Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jinsoo Chung
- Department of Urology, National Cancer Center, Goyang, South Korea
| | - Tae Gyun Kwon
- Department of Urology, Kyungpook National University College of Medicine, Daegu, South Korea
| | - Hyeon Hoe Kim
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Cheol Kwak
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam, Kyunggi-do, 463-707, South Korea.
| | - Yong-June Kim
- Department of Urology, Chungbuk National University College of Medicine, 1st Chungdae-ro, Seowon-gu, Cheongju, Chungbuk, 28644, South Korea. .,Department of Urology, Chungbuk National University Hospital, Cheongju, South Korea.
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Prognostic value of perioperative red blood cell transfusion and anemia on survival and recurrence in oral squamous cell carcinoma. Oral Oncol 2020; 107:104773. [PMID: 32388408 DOI: 10.1016/j.oraloncology.2020.104773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the prognostic effect of allogenic red blood cell transfusion (RBT) and preoperative anemia in patients with oral squamous cell carcinoma (OSCC) undergoing primary tumor resection. METHODS We retrospectively analyzed a cohort of 621 patients, diagnosed with OSCC receiving tumor resection in curative intention. Preoperative anemia and perioperative RBT were evaluated according to WHO definition. Overall survival (OAS) as well as recurrence-free survival (RFS) was evaluated in transfused and non-transfused as well as in anemic and non-anemic patients. In addition, outcome parameters were calculated for distinct amounts of perioperatively administered RBTs. Data analysis was performed by uni- and multivariate statistics. Mean follow-up time was 7.3 years. RESULTS Preoperative anemia was diagnosed in 29% of OSCC patients. Anemic patients displayed a significantly decreased five-year OAS (44%) in comparison to non-anemic equivalents (69%). 70% of non-transfused OSCC patients were alive after five years, whereas in case of RBT five-year OAS was 41%. These findings were substantiated by subgroup analysis in patients without preoperative anemia. For anemic patients however, no deleterious effect on survival in case of perioperative RBT was seen. Increasing numbers of received RBTs were shown to worsen outcome of OSCC patients in a dose-dependent manner. CONCLUSION Preoperative anemia and RBT are significantly associated with impaired long-term outcome of patients suffering from OSCC. Future studies are needed to evaluate differentiated effects of RBTs in anemic and non-anemic OSCC patients and accordingly providing individual transfusion strategies to ameliorate outcome of patients suffering from OSCC.
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Zhu NN, Lu MJ, Chen YQ, Jin XJ, Zhou X, Wei HW, Liu XQ, Duan LS, Yin L, Guo JR. Autologous blood transfusion stimulates wound healing in diabetic mice through activation of the HIF-1α pathway by improving the blood preservation solution. FASEB J 2020; 34:6038-6054. [PMID: 32202355 DOI: 10.1096/fj.201900324rrr] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 12/05/2019] [Accepted: 12/31/2019] [Indexed: 11/11/2022]
Abstract
Transfusion of autologous blood is a timesaving, convenient, safe, and effective therapy from a clinical perspective, and often employed for the treatment of diabetic patients. Stabilization of HIF-1α has been widely reported to be a critical factor in the improvement of wound healing in diabetes. Therefore, our study reveals the roles of improved autologous blood in wound healing in diabetes, through autologous blood transfusion in a mouse model. Initially, BALB/c mice were subjected to streptozotocin for diabetic mouse model establishment. Diabetic mice were transfused with improved or standard autologous blood in perfusion culture system. Roles of improved autologous blood in mediating HIF-1α pathway were determined by measuring expression of VEGF, EGF, HIF-1α, and HSP-90. In order to assess the detailed regulatory mechanism of improved autologous blood in perspective of wound healing, cell proliferation, migration and cell cycle, fibroblasts isolated from diabetic mice were transfected with HIF-1α siRNA. Mice transfused with improved autologous blood exhibited increased levels of CD31 and α-SMA in skin tissues, and reduced TNF-α, IL-1β, and IL-6 levels, indicating that improved autologous blood promoted wound healing ability and reduced the release of inflammatory factors. Diabetic mice transfused with improved autologous blood presented activated HIF-1α pathway. The survival rate, proliferation, and migration of fibroblasts were elevated via activation of the HIF-1α pathway. Taken together, improved blood preservation solution could enhance the oxygen carrying capacity of red blood cells and wound healing in mice with diabetes, which is achieved through regulation of HIF-1α pathway.
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Affiliation(s)
- Na-Na Zhu
- Department of Anesthesiology, Gongli Hospital, the Second Military Medical University, Shanghai, P. R. China
| | - Ming-Jun Lu
- Department of Anesthesiology, Gongli Hospital, the Second Military Medical University, Shanghai, P. R. China
| | - Yong-Quan Chen
- Department of Anesthesiology, Yijishan Hospital, the Wannan Medical College, Wuhu, P. R. China
| | - Xiao-Ju Jin
- Department of Anesthesiology, Yijishan Hospital, the Wannan Medical College, Wuhu, P. R. China
| | - Xun Zhou
- Department of Anesthesiology, Gongli Hospital, the Second Military Medical University, Shanghai, P. R. China.,Ningxia Medical University, Gongli Hospital of Shanghai Pudong New Area Training Base, Shanghai, P. R. China
| | - Han-Wei Wei
- Department of Anesthesiology, Yijishan Hospital, the Wannan Medical College, Wuhu, P. R. China
| | - Xiao-Qian Liu
- Department of Anesthesiology, Gongli Hospital, the Second Military Medical University, Shanghai, P. R. China
| | - Li-Shuang Duan
- Department of Anesthesiology, Gongli Hospital, the Second Military Medical University, Shanghai, P. R. China
| | - Lei Yin
- Department of Anesthesiology, Gongli Hospital, the Second Military Medical University, Shanghai, P. R. China
| | - Jian-Rong Guo
- Department of Anesthesiology, Gongli Hospital, the Second Military Medical University, Shanghai, P. R. China.,Ningxia Medical University, Gongli Hospital of Shanghai Pudong New Area Training Base, Shanghai, P. R. China
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Pratschke K. Approach to haemoabdomen in small animal patients. IN PRACTICE 2020. [DOI: 10.1136/inp.l6819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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15
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Fisher OM, Alzahrani NA, Kozman MA, Valle SJ, Liauw W, Morris DL. Intraoperative packed red blood cell transfusion (iPRBT) and PCI-normalised iPRBT rates (iPRBT/PCI ratio) negatively affect short- and long-term outcomes of patients undergoing cytoreductive surgery and intraperitoneal chemotherapy – An analysis of 880 patients. Eur J Surg Oncol 2019; 45:2412-2423. [DOI: 10.1016/j.ejso.2019.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/21/2019] [Accepted: 07/29/2019] [Indexed: 01/09/2023] Open
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Hunsicker O, Gericke S, Graw JA, Krannich A, Boemke W, Meyer O, Braicu I, Spies C, Sehouli J, Pruß A, Feldheiser A. Transfusion of red blood cells does not impact progression-free and overall survival after surgery for ovarian cancer. Transfusion 2019; 59:3589-3600. [PMID: 31633819 DOI: 10.1111/trf.15552] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/11/2019] [Accepted: 09/15/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Allogeneic red blood cells (RBCs) have the potential to impact the immunosurveillance of the recipient and may therefore increase the risk of recurrence after cancer surgery. In this article the relationship between perioperative RBC transfusion and the risk of recurrence after ovarian cancer surgery is examined. STUDY DESIGN AND METHODS This is a retrospective cohort analysis of a prospective database of patients who underwent surgery due to primary ovarian cancer between 2006 and 2014 and who had no residual disease after surgery. Patients who did and did not receive perioperative RBC transfusion were compared. The primary endpoint was progression-free survival (PFS). Propensity score matching (PSM) and Cox proportional hazards regression (CPH) was used to control for between-group differences of prognostic determinants. RESULTS A total of 529 patients with a median follow-up of 51.4 months (95% CI, 46.1-56.5) were eligible for analysis. Of those, 408 patients (77.1%) received allogeneic, leukoreduced RBCs with a median of 4 units (IQR, 2-6) per patient. There was a strong selection bias of prognostic determinants between patients with and without transfusion. In unadjusted analysis, transfusion of RBCs was associated with an increased risk of cancer recurrence (hazard ratio [HR] of PFS 2.71 [95% CI, 1.94-3.77], p < 0.001). After bias reduction, transfusion of RBCs was no longer associated with an increased risk of cancer recurrence, neither in PSM-adjusted (HR 1.03 [95% CI, 0.59-1.80], p = 0.91), nor in multivariable CPH-adjusted analysis (HR 1.26 [95% CI, 0.85-1.86], p = 0.23). CONCLUSION Perioperative transfusion of RBCs did not increase the risk of recurrence after ovarian cancer surgery.
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Affiliation(s)
- Oliver Hunsicker
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sara Gericke
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jan Adriaan Graw
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alexander Krannich
- Clinical Trial Office, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Willehad Boemke
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Oliver Meyer
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ioana Braicu
- Department of Gynecology, European Competence Center for Ovarian Cancer, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jalid Sehouli
- Department of Gynecology, European Competence Center for Ovarian Cancer, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Axel Pruß
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Aarne Feldheiser
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Influence of perioperative anaesthetic and analgesic interventions on oncological outcomes: a narrative review. Br J Anaesth 2019; 123:135-150. [PMID: 31255291 DOI: 10.1016/j.bja.2019.04.062] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/18/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Surgery is an important treatment modality for the majority of solid organ cancers. Unfortunately, cancer recurrence following surgery of curative intent is common, and typically results in refractory disease and patient death. Surgery and other perioperative interventions induce a biological state conducive to the survival and growth of residual cancer cells released from the primary tumour intraoperatively, which may influence the risk of a subsequent metastatic disease. Evidence is accumulating that anaesthetic and analgesic interventions could affect many of these pathophysiological processes, influencing risk of cancer recurrence in either a beneficial or detrimental way. Much of this evidence is from experimental in vitro and in vivo models, with clinical evidence largely limited to retrospective observational studies or post hoc analysis of RCTs originally designed to evaluate non-cancer outcomes. This narrative review summarises the current state of evidence regarding the potential effect of perioperative anaesthetic and analgesic interventions on cancer biology and clinical outcomes. Proving a causal link will require data from prospective RCTs with oncological outcomes as primary endpoints, a number of which will report in the coming years. Until then, there is insufficient evidence to recommend any particular anaesthetic or analgesic technique for patients undergoing tumour resection surgery on the basis that it might alter the risk of recurrence or metastasis.
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Impact of Perioperative Blood Transfusions on the Outcomes of Patients Undergoing Kidney Cancer Surgery: A Systematic Review and Pooled Analysis. Clin Genitourin Cancer 2019; 17:e72-e79. [DOI: 10.1016/j.clgc.2018.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/31/2018] [Accepted: 09/16/2018] [Indexed: 12/27/2022]
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Abstract
Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.
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Munting KE, Klein AA. Optimisation of pre-operative anaemia in patients before elective major surgery - why, who, when and how? Anaesthesia 2019; 74 Suppl 1:49-57. [DOI: 10.1111/anae.14466] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2018] [Indexed: 12/12/2022]
Affiliation(s)
- K. E. Munting
- Department of Anaesthesia; University Medical Centre Utrecht; The Netherlands
| | - A. A. Klein
- Department of Anaesthesia and Intensive Care; Royal Papworth Hospital; Cambridge UK
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Abu-Ghanem Y, Ramon J. Impact of perioperative blood transfusions on clinical outcomes in patients undergoing surgery for major urologic malignancies. Ther Adv Urol 2019; 11:1756287219868054. [PMID: 31447936 PMCID: PMC6691668 DOI: 10.1177/1756287219868054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 07/15/2019] [Indexed: 01/17/2023] Open
Abstract
The association between allogeneic perioperative blood transfusion (PBT) and decreased survival among patients undergoing various oncological surgeries has been established in various malignant diseases, including colorectal, thoracic and hepatocellular cancer. However, when focusing on urologic tumors, the significance of PBT and its adverse effect remains debatable, mainly due to inconsistency between studies. Nevertheless, the rate of PBT remains high and may reach up to 62% in patients undergoing major urologic surgeries. Hence, the relatively high rate of PBT among related operations, along with the increasing prevalence of several urologic tumors, give this topic great significance in clinical practice. Indeed, recent retrospective studies, followed by systematic reviews in both prostate and bladder cancer surgery have supported the association that has been demonstrated in several malignancies, while other major urologic malignancies, including renal cell carcinoma and upper tract urothelial carcinoma, have also been addressed retrospectively. It is only a matter of time before the data will be sufficient for qualitative systematic review/qualitative evidence synthesis. In the current study, we performed a literature review to define the association between PBT and the oncological outcomes in patients who undergo surgery for major urologic malignancies. We believe that the current review of the literature will increase awareness of the importance and relevance of this issue, as well as highlight the need for evidence-based standards for blood transfusion as well as more controlled transfusion thresholds.
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Affiliation(s)
- Yasmin Abu-Ghanem
- Department of Urology, Chaim Sheba Medical Centre, Tel-Hashomer, Ramat-Gan, 52621, Israel
| | - Jacob Ramon
- Department of Urology, Sheba Medical Centre, Ramat-Gan, Israel
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23
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Recommendations on RBC Transfusion Support in Children With Hematologic and Oncologic Diagnoses From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S149-S156. [PMID: 30161070 PMCID: PMC6126910 DOI: 10.1097/pcc.0000000000001610] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and supporting evidence for RBC transfusions in critically ill children with hematologic and oncologic disease from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The hematologic/oncologic subgroup included seven experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS The hematologic/oncologic subgroup developed 14 recommendations (seven clinical, seven research); all achieved greater than 80% agreement. In patients with sickle cell disease, Transfusion and Anemia Expertise Initiative recommends: 1) RBC transfusion to achieve a target hemoglobin concentration of 10 g/dL rather than hemoglobin of less than 30% prior to surgical procedures requiring general anesthesia and 2) exchange transfusion over simple (nonexchange) transfusion if the child's condition is deteriorating (based on clinical judgment), otherwise a simple, nonexchange RBC transfusion is recommended. There is insufficient evidence to make recommendations on transfusion thresholds for patients with sickle cell disease prior to minor procedures, with acute stroke or with pulmonary hypertension. For patients with oncologic disease or undergoing hematopoietic stem cell transplant, a hemoglobin concentration of 7-8 g/dL is recommended. Due to lack of evidence, research is needed to clarify the appropriate transfusion thresholds in these patients. CONCLUSIONS Transfusion and Anemia Expertise Initiative developed specific pediatric recommendations regarding RBC transfusion management in critically ill children with sickle cell disease, oncologic disease, and hematopoietic stem cell transplant and recommendations to help guide future research priorities.
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Nizri E, Kusamura S, Fallabrino G, Guaglio M, Baratti D, Deraco M. Dose-Dependent Effect of Red Blood Cells Transfusion on Perioperative and Long-Term Outcomes in Peritoneal Surface Malignancies Treated with Cytoreduction and HIPEC. Ann Surg Oncol 2018; 25:3264-3270. [PMID: 30051371 DOI: 10.1245/s10434-018-6630-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are associated with increased red blood cell transfusion (RBT) demand. Although the deleterious effects of RBT are documented in various settings, its effect in this setting is obscure. In this study, we evaluated the effects of different-grade RBT on the short- and long-term outcomes of CRS and HIPEC. METHODS We analyzed 231 patients with diffuse malignant peritoneal mesothelioma (DMPM) and 273 patients with pseudomyxoma peritonei (PMP) operated in our unit. RBT was categorized according to the amount of packed red blood cell units (PRBCs) administered (0, 1-2, 3-5, > 6). The effects of RBT on long-term oncological outcomes [progression-free survival (PFS) and overall survival (OS)] were assessed by using multivariate analysis. RESULTS Overall, 74% of the patients were transfused with a median of 2 PRBCs (range 0-37). Transfusion level correlated with operative time, surgical extent (as measured by the peritoneal carcinomatosis index), and age. Postoperatively, patients with major transfusion (> 6 PRBCs) had increased mortality rate (11.1%, p = 0.01) and length of hospital stay (31.2 ± 16.8 days, p = 0.01) compared with other levels of RBT. RBT was dose-dependently associated with oncological outcomes in both DMPM and PMP for both PFS [hazard ratio (HR) = 1.40, 95% confidence interval (CI) 1.12-1.74, p = 0.003; HR = 1.44, 95% CI 1.15-1.81, p = 0.001, respectively] and OS (HR = 1.57, 95% CI 1.21-2.03, p = 0.001; HR = 1.43, 95% CI 1.15-1.90, p = 0.01, respectively). CONCLUSIONS Our data show a dose-dependent relationship between RBT and oncological outcomes. Further research to develop transfusion sparing protocols is needed in this extensive surgical procedure.
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Affiliation(s)
- Eran Nizri
- Division of Surgery, Department of Surgery A, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giuditta Fallabrino
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Guaglio
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Dario Baratti
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies Unit, Colon and Rectal Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Kinnear N, O'Callaghan M, Hennessey D, Liddell H, Newell B, Bolt J, Lawrentschuk N. Intra-operative cell salvage in urological surgery: a systematic review and meta-analysis of comparative studies. BJU Int 2018; 123:210-219. [PMID: 29726092 DOI: 10.1111/bju.14373] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate systematically the safety and efficacy of intra-operative cell salvage (ICS) in urology. METHODS A search of Medline, Embase and Cochrane Library to August 2017 was performed using methods pre-published on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible titles were comparative studies published in English that used ICS in urology. Primary outcomes were allogeneic transfusion rates (ATRs) and tumour recurrence. Secondary outcomes were complications and cost. RESULTS Fourteen observational studies were identified, with a total of 4 536 patients. ICS was compared with no the blood conservation technique (seven studies), preoperative autologous donation (PAD; five studies) or both (two studies). Cohorts underwent open prostatectomy (11 studies), open cystectomy (two studies) or open partial nephrectomy (one study). Meta-analysis was possible only for ATRs within prostatectomy studies. In this setting, ICS reduced ATR compared with no the blood conservation technique (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.76) but not PAD (OR 0.76, 95% CI 0.39-1.31). In the non-prostatectomy setting, ATRs amongst patients who underwent ICS were significantly higher or similar in one and two studies, respectively. Tumour recurrence was found to be significantly less common (two studies), similar (eight studies) or not measured (four studies). All six studies reporting complications found no difference in their ICS cohorts. Regarding cost, one study from 1995 found ICS more expensive than PAD, while two more recent studies found ICS to be cheaper than no blood conservation technique. As a result of inter-study heterogeneity, meta-analyses were not possible for recurrence, complications or cost. CONCLUSION Low-level evidence exists that, compared with other blood conservation techniques, ICS reduces ATR and cost while not affecting complications. It does not appear to increase tumour recurrence post-prostatectomy, although follow-up durations were short. Small study sizes and short follow-ups mean conclusions cannot be drawn with regard to recurrence after nephrectomy or cystectomy. Randomized trials with long-term follow-up evaluating ICS in urology are required.
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Affiliation(s)
- Ned Kinnear
- Department of Urology, Austin Health, Melbourne, Vic., Australia.,Department of Urology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Michael O'Callaghan
- South Australian Prostate Cancer Clinical Outcomes Collaborative, Flinders Medical Centre, Adelaide, SA, Australia.,School of Medicine, University of Adelaide, Adelaide, SA, Australia.,Flinders Centre for Innovation in Cancer, Adelaide, SA, Australia
| | - Derek Hennessey
- Department of Urology, Austin Health, Melbourne, Vic., Australia.,Department of Urology, Craigavon Area Hospital, Portadown, UK
| | - Heath Liddell
- Department of Urology, Austin Health, Melbourne, Vic., Australia.,Department of Urology, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Melbourne, Vic., Australia
| | - Bradley Newell
- Department of Urology, Austin Health, Melbourne, Vic., Australia
| | - John Bolt
- Department of Urology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Nathan Lawrentschuk
- Department of Urology, Austin Health, Melbourne, Vic., Australia.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Vic., Australia.,Olivia Newton-John Cancer Research Institute, Melbourne, Vic., Australia
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Kinnear N, Heijkoop B, Hua L, Hennessey DB, Spernat D. The impact of intra-operative cell salvage during open radical prostatectomy. Transl Androl Urol 2018; 7:S179-S187. [PMID: 29928615 PMCID: PMC5989116 DOI: 10.21037/tau.2018.04.19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background To examine the effect of intra-operative cell salvage (ICS) in open radical prostatectomy. Methods In this retrospective cohort study, all patients undergoing open radical prostatectomy for malignancy at our institution between 10/04/2013 and 10/04/2017 were enrolled. Patients were grouped and compared based on whether they received ICS. Primary outcomes were allogeneic transfusion rates, and disease recurrence. Secondary outcomes were complications and transfusion-related cost. Results Fifty-nine men were enrolled; 30 used no blood conservation technique, while 29 employed ICS. There were no significant differences between groups in age, pre- or post-operative haemoglobin, Charlson comorbidity index, operation duration or length of stay. Tumour characteristics were also similar between groups, including pre-operative prostate specific antigen, post-operative Gleason score, T-stage, nodal status and rates of margin positivity. Compared with controls, the ICS group had longer follow up (945 vs. 989 days; P=0.0016). The control and ICS groups were not significantly different in rates of tumour recurrence (6 vs. 3 patients; P=0.30) or complications (10 vs. 5 patients; P=0.16). While the proportion of patients receiving allogenic transfusion was similar (9 vs. 6 patients; P=0.41), fewer red blood products transfused (40 vs. 12 units) meant transfusion related costs were lower in ICS patients (AUD $47,666 vs. $37,429). Conclusions ICS reduced transfusion related costs, without affecting allogeneic transfusion rates, tumour recurrence or complication rates. These findings extend the literature supporting ICS in oncological surgery. Prospective randomised studies are needed to confirm the existing level III evidence.
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Affiliation(s)
- Ned Kinnear
- Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Bridget Heijkoop
- Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Lina Hua
- Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
| | | | - Daniel Spernat
- Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
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Perelman I, Winter R, Sikora L, Martel G, Saidenberg E, Fergusson D. The Efficacy of Postoperative Iron Therapy in Improving Clinical and Patient-Centered Outcomes Following Surgery: A Systematic Review and Meta-Analysis. Transfus Med Rev 2018; 32:89-101. [DOI: 10.1016/j.tmrv.2017.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/19/2017] [Accepted: 10/16/2017] [Indexed: 02/07/2023]
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Reflections on multiple strategies to reduce transfusion in cancer patients: A joint narrative. Transfus Apher Sci 2017; 56:322-329. [DOI: 10.1016/j.transci.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Tzounakas VL, Seghatchian J, Grouzi E, Kokoris S, Antonelou MH. Red blood cell transfusion in surgical cancer patients: Targets, risks, mechanistic understanding and further therapeutic opportunities. Transfus Apher Sci 2017. [PMID: 28625825 DOI: 10.1016/j.transci.2017.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Vassilis L Tzounakas
- Department of Biology, School of Science, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Jerard Seghatchian
- International Consultancy in Blood Component Quality/Safety Improvement, Audit/Inspection and DDR Strategy, London, UK.
| | - Elissavet Grouzi
- Department of Transfusion Service and Clinical Hemostasis, "Saint Savvas" Oncology Hospital, Athens, Greece
| | - Styliani Kokoris
- Department of Blood Transfusion, Medical School, "Attikon" General Hospital, NKUA, Athens, Greece
| | - Marianna H Antonelou
- Department of Biology, School of Science, National and Kapodistrian University of Athens (NKUA), Athens, Greece.
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