Perioperative blood transfusions and cancer recurrence

Recombinant human erythropoietin for patients with AIDS treated with zidovudine

Bone marrow suppression and anemia are frequent side effects of treatment of the acquired immunodeficiency syndrome (AIDS) with zidovudine (formerly azidothymidine [AZT]). We conducted a randomized, double-blind, placebo-controlled clinical trial of recombinant human erythropoietin (100 U per kilogram of body weight thrice weekly by intravenous bolus) in 63 patients with AIDS treated with zidovudine (29 in the erythropoietin group and 34 in the placebo group). Reductions in the number of units of red cells transfused and the number of patients given transfusions per month became apparent in the second and third months of the trial. The reductions were observed in patients with endogenous erythropoietin levels less than or equal to 500 IU per liter at base line, but not in patients whose levels were greater than 500 IU per liter at the beginning of the study. Although the hematocrit and hemoglobin level were not used as the primary criteria of efficacy because the patients received transfusions when their physicians decided that they needed them, a significantly higher rate of increase in the hematocrit was observed in the patients treated with recombinant human erythropoietin whose levels of endogenous erythropoietin were less than or equal to 500 IU per liter (0.00353 points per week) than in the patients given placebo (0.00116 points per week). This effect was not seen in patients with higher levels of endogenous erythropoietin. Serious side effects did not occur more often in the group treated with erythropoietin than in the placebo group. We conclude that recombinant human erythropoietin may be useful in patients with AIDS treated with zidovudine, although the indicators for its use remain to be clarified.

Variable infection risk following allogeneic blood transfusions

These studies address infection risk of allogeneic transfusion in an untraumatized, nonseptic rodent model. A' Segaloff Cancer Institute rats served as blood donors and Lewis rats as recipients. Lewis rats' delayed-type hypersensitivity (DTH) response and their ability to clear subdermal Staphylococcus aureus abscesses and Candida albicans pyelonephritis were measured as tests of the effect of transfusions. The effect of pharmacological immunosuppression with either cortisone acetate or cyclosporine provided a "yardstick" to measure the magnitude of transfusion effects. Repeated transfusions at 1-week intervals diminished DTH response to recall antigens (keyhole limpet hemocyanin), but otherwise they showed no evidence of immunosuppression in these experiments. In contrast, we found that transfusions by themselves produced mild immunostimulation. Subcutaneous Staphylococcus abscesses were smaller in animals receiving transfusions. The magnitude of immunostimulation from one transfusion was sufficient to reverse the immunosuppressive effect of cyclosporine by about 50% in a Candida pyelonephritis infection. These studies suggest that blood transfusions have complex interactions with different components of the immune response. T-cell function is impaired by repeated transfusions (diminished DTH response), but other inflammatory responses are accentuated. This suggests that blood transfusions may harm immune response in traumatized animals by causing excessive complement activation or cytokine release.

New diagnostic, staging, and therapeutic aspects of early breast cancer

Many advances have occurred in breast cancer through research and clinical trials. More confidence in new biological consumptions about invasive breast cancer indicate that: (1) details of the primary breast cancer do not control survival; (2) breast-only failures after local excision do not bias against survival; and (3) cancer cell dissemination occurs at the same time via both lymphatic and hematogenous routes. Early detection with mammographic screening has indicated a greater number of smaller breast cancers, including sharp increases in ductal carcinoma in situ (DCIS). With proper analysis and control, DCIS of limited extent can be treated by local excision with or without radiation. Invasive breast cancer of limited extent can frequently be managed by lumpectomy and radiation therapy with survival rates equivalent to the more traditional mastectomy. Patient desires regarding breast preservation and quality of life are paramount. Risk: benefit analyses for individual patients need to be emphasized in issues of breast preservation and in selecting adjuvant therapy, both regional (radiotherapy) and systemic (chemotherapy) and hormonal therapy). We are entering an era of highly selective therapy based on more sophisticated analysis of the primary cancer. In the future, not only statistical predictions of outcome as achieved by flow cytometry, for example, will be more widely used, but individual prognostic factors may be developed such as with oncogene expression. Such individual prognostic factors will enable more selective therapy.

Autotransfusion and blood conservation in urologic oncology

Autotransfusion is the reinfusion of the patient's own blood. Currently utilized forms include preoperative donation, perioperative hemodilution, and intraoperative salvage. The principal benefit of autotransfusion is a reduction in the complications associated with receipt of homologous blood products. Principal among these are febrile reactions, allergic and hemolytic reactions, alloimmunization, and the transmission of hepatitis and acquired immune deficiency syndrome. An additional benefit in the management of cancer patients is the avoidance of transfusion induced immunosuppression. Predeposit autologous transfusion is a simple and safe method to reduce patient's requirements for exogenous blood. Although well suited for cancer patients, predeposit programs remain underutilized with only 5% participation. Perioperative hemodilution can be a valuable adjunct in selected patients. Although the presence of malignancy has been regarded as a contraindication to the use of intraoperative autotransfusion, preliminary reports suggest that intraoperative autotransfusion can be safely used in patients undergoing surgery for urologic malignancies.