The effect of perioperative blood transfusion on survival in head and neck cancer

The effect of transfusion on survival in head and neck cancer after free tissue reconstruction

Objective

To examine if perioperative blood transfusion affects overall survival (OS) and recurrence-free survival (RFS) in head and neck cancer patients who undergo free tissue reconstruction.

Design

Retrospective cohort study.

Methods

The medical records of free tissue flaps between 2007 and 2010 were reviewed. Differences in demographics and clinical factors based on the level of transfused packed red blood cells (PRBC) were examined using chi-squared tests, Kruskal-Wallis tests, and/or ANOVA tests. Survival time was compared using a Cox proportional hazard model.

Results

Data were available for 183 patients. Patients who had PRBC transfusion significantly differed from the non-transfused group by flap type, flap with bone, Charlson Comorbidity Index (CCI), and hemoglobin and hematocrit. When stratified into three groups based on units of PRBC; flap type, flap with bone, CCI, preoperative hemoglobin, and hematocrit were found to differ significantly. The 2-year Kaplan-Meier plot demonstrated improved OS for those who did not receive any PRBC transfusion. The use of more than 3 units of blood decreased 2-year OS significantly when compared to the non-transfused group. Finally, after adjusting for CCI using a Cox proportional hazard model, survival was significantly affected by CCI.

Conclusion

After controlling for patient age, oncologic stage, cancer subsite, histology, type of free flap, vascularized bone-containing flap, recurrence type, CCI, and preoperative hemoglobin and hematocrit, patients who received 3 or more units of PRBC in the perioperative period had significantly decreased OS. RFS did not differ between the transfused versus non-transfused groups.

Level of Evidence

Level 4.

Prognostic value of perioperative red blood cell transfusion and anemia on survival and recurrence in oral squamous cell carcinoma

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.

Predictive factors for perioperative blood transfusion in neck dissection

OBJECTIVES/HYPOTHESIS

There is growing interest in reducing the exposure of patients to allogeneic blood transfusions by lowering preoperative cross-matched blood ordering and adopting alternative practices, such as autologous blood donations. Our aim was to investigate the predictors for perioperative blood transfusion (PBT) in head and neck cancer patients undergoing neck dissection (ND).

STUDY DESIGN

Retrospective cohort study.

METHODS

Retrospective observational study. All patients who underwent ND between January 2011 and August 2014. The primary outcome measure was PBT. Predictors tested included: gender, age, American Society of Anesthesiologists comorbidity score, Charlson comorbidity index, preoperative hemoglobin level, head and neck primary tumor location, tumor and nodal staging, side and laterality of ND, central versus lateral ND, elective ND, preoperative chemotherapy/radiotherapy/I(131) therapy, history of previous ND, other surgical procedures in addition to the ND, bone resection, use and type of reconstruction, and the use of bony free flap reconstruction.

RESULTS

Twenty-one preoperative and operative variables were tested for an association with PBT using univariate and multivariate analyses. Multivariate analysis found only the following three predictors to be significantly associated with PBT in patients undergoing ND: low preoperative hemoglobin level, advanced N stage, and concurrent reconstructive surgery.

CONCLUSION

Evaluation of specific risk factors for predicting the need for PBT prior to neck dissection may be helpful in identifying the head and neck cancer patients in whom preoperative ordering of cross-matched blood is required or who could benefit from alternative means, such as preoperative autologous blood donation.

LEVEL OF EVIDENCE

4.

Transfusion Requirements in Microsurgical Reconstruction in Maxillofacial Surgery: Ethical and Legal Problems of Patients Who Are Jehovah's Witnesses

Objective To study transfusion requirements in patients with cancer undergoing head and neck reconstructive surgery and to discuss surgical and anesthetic strategies to reduce blood loss when the patient is a Jehovah's Witness. Material and Methods A descriptive study to expose the percentage of blood transfusions performed in patients with cancer undergoing microsurgical reconstructions in the department of oral and maxillofacial surgery of the referred hospital in the past 9 years. Results Two hundred thirty-seven microsurgical reconstructions were performed in head and neck tumors between January 2001 and December 2009. Statistical analysis shows a significant decrease (p = 0.035) in the number of patients needing transfusions patients in recent years. Conclusions The treatment of patients who are Jehovah's Witnesses is an ethical and moral dilemma for the clinician and in particular for surgeons.

An evaluation of the preoperative hemoglobin level as a prognostic factor for oral squamous cell carcinoma

Background

Hypoxia seems to be an influencing factor for oral squamous cell carcinomas (SCC), and several immunohistochemical markers have been discussed in this regard. The aim of the present study was to evaluate preoperative hemoglobin levels as a prognostic factor for oral SCC.

Materials and methods

The files of 287 patients who had been treated for oral SCC between 1999 and 2008 were studied retrospectively. Hemoglobin levels between 1 and 5 days prior to surgical treatment were compared to Tumor (T)- and Nodal (N)- status, local recurrence, and lymph node metastases rate. The minimum follow-up period was 12 months.

Results

From a total of 287 patients with oral SCC, 205 (71.4%) were in the normal hemoglobin (Hb) group (female Hb≥12.0 g/dl; male Hb≥13.0 g/dl), 53 (18.5%) in the mild anemia (female Hb = 11.0-11.9 g/dl; male Hb = 11.0-12.9 g/dl), and 29 (10.1%) in the severe anemia group (female & male Hb<11.0 g/dl). Anemia was significant for the development of lymph node metastasis (p = 0.005) as well as for local recurrence (p = 0.001). No significant correlation was found to the initial T status (p = 0.183).

Conclusion

Our data suggests that an Hb of below 11 g/dl contributes to and is an indicator for a poor prognosis. Consequently, pre-treatment Hb corrections may significantly improve outcome, but further investigations, including blood transfusion/application of erythropoietin due to tumor anemia, independent of intraoperative blood-loss are necessary to ascertain their role in an improved survival.

Microvascular free-tissue transfer for head and neck reconstruction in Jehovah's Witness patients

BACKGROUND

Jehovah's Witnesses' religious convictions disallow blood transfusion. Major surgery in these patients is therefore problematic. The objective of this study is to describe our experience with microvascular reconstruction of complex head and neck defects in Jehovah's Witness patients.

METHODS

This was a retrospective review of all Jehovah's Witnesses' patients undergoing head and neck free-flap reconstruction at a tertiary academic referral center from 1997 to 2006.

RESULTS

Five Jehovah's Witnesses patients underwent a total of 7 free-flap reconstructions (6 radial, 1 rectus). Four flaps were immediate: 1 osteocutaneous radial forearm, 2 fasciocutaneous radial forearm, and 1 rectus abdominus myocutaneous. One fasciocutaneous radial forearm flap was staged. Two patients were planned secondary reconstructions, both facsciocutaneous radial forearm. Iron supplements and/or erythropoietin were administered perioperatively in 6 of the 7 microvascular reconstructions. Selective external carotid embolization was performed preoperatively in 1 patient. Hematocrit levels were 36% to 46% preoperatively and 30% to 41% postoperatively. Immediate postoperative hematocrit decline was 5.2% (3.0% to 6.0%). No transfusions or blood products were administered.

CONCLUSIONS

Our case series supports the feasibility of head and neck free-flap reconstruction in these challenging patients.

The influence of allogenic blood transfusion in patients having free-flap primary surgery for oral and oropharyngeal squamous cell carcinoma

The influence of perioperative blood transfusion in oral and oropharyngeal squamous cell carcinoma remains uncertain. It is believed that blood transfusion downregulates the immune system and may have an influence on cancer recurrence and survival. In all, 559 consecutive patients undergoing primary surgery for oral and oropharyngeal squamous cell carcinoma between 1992 and 2002 were included in this study. Known prognostic variables along with transfusion details were obtained from head and neck cancer and blood transfusion service databases, respectively. Adjusting for relevant prognostic factors in Cox regression, the hazard ratio for patients having 3 or more transfused units relative to those not transfused was 1.52 (95% confidence interval (CI) 0.93–2.47) for disease-specific and 1.52 (95% CI 1.05–2.22) for overall mortality. Blood transfusion of 3 or more units might confer a worse prognosis in patients undergoing primary surgery for oral and oropharyngeal squamous cell carcinoma. Therefore, every effort should be made to limit the amount of blood transfused to the minimum requirement.

The effect of replacement fluids and normovolaemic haemodilution on the survival of dorsal skin flaps in rats

The objective of this study is to investigate the effect of normovolaemic haemodilution (anaemia), haemoglobin level and replacement fluids on the survival of local flaps in rats. Fifty male Wistar rats were divided into four study groups and one control group (10 rats for each). In the study groups, 20% or 30% of blood was withdrawn and replaced by either Gelofusine or saline (0.9%). Single 1.5 cm x 3 cm cranially based dorsal random skin flaps consisting of skin and panniculus carnosus were elevated in all rats. No difference was determined between the control and 20% exsanguinated groups regarding flap survival area. There was a statistically significant difference between the flap survival areas of 20% exsanguinated groups and 30% exsanguinated groups. If the blood loss exceeds 30% of total volume and/or haemoglobin (Hb) level is lower than 10.72 g/dL, the risk of flap necrosis increases significantly.

Prognostic significance of perioperative blood transfusion in oral cavity squamous cell carcinoma

BACKGROUND

The influence of perioperative blood transfusion on survival in squamous cell carcinoma of the head and neck is still not convincingly determined. To investigate the effect of perioperative allogeneic transfusion on survival in stage II-IV squamous cell carcinoma of the oral cavity, we studied a consecutive series of 105 patients undergoing primary tumor resection and neck dissection.

METHODS

Retrospective analyses were performed using Cox proportional hazards models with 16 variables.

RESULTS

Perioperative red blood cell transfusion was required in 64 (61%) patients. Multivariate analysis demonstrated that the number of positive nodes and > or =3 units of red blood cell transfusion were an independent prognostic indicators. The calculated odds ratio for death after > or =3 units transfused was 5.79 (95% confidence interval, 1.56-21.53, p <.01).

CONCLUSIONS

More than 3 units of allogeneic red blood cells transfused might shorten the survival of patients with oral cavity cancer.

Effect of Anemia on the Fasciocutaneous Flap Survival in a Rat Model

OBJECTIVE/HYPOTHESIS

Ablative surgery for head and neck cancer that creates large composite defects often results in a significant decrease in the hematocrit level. These defects are best reconstructed with a microvascular free tissue transfer. Effect of the decreased hematocrit on microvascular flap survival is controversial. The purpose of this study was to assess the effect of isovolemic anemia on flap survival in a rat model.

STUDY DESIGN

Prospective analysis.

METHODS

Ninety rats were used (30 control and 60 experimental animals). Experimental animals were rendered anemic by blood draw and volume resuscitated with either a colloid (30 animals) or crystalloid (30 animals) solution. In all animals a ventral fasciocutaneous flap was raised. A vascular clamp was applied to the arteriovenous pedicle, and different ischemic times were allowed to elapse before clamp removal. Flap survival was assessed at 5 days. Probit analysis was performed for the three animal groups.

RESULTS

A significantly increased probability of the flap survival was found in the anemic animals compared with the control group (P < or = .05). No difference was found between the colloid and crystalloid resuscitation groups.

CONCLUSIONS

A decreased hematocrit level increases fasciocutaneous flap tolerance to ischemia and significantly increases the primary ischemic time in the ventral flap clamp model in rats. Fluid replacement with either crystalloid or colloid produces identical results.

Severe anemia is associated with poor tumor oxygenation in head and neck squamous cell carcinomas

PURPOSE

To investigate the relationship between tumor oxygenation and the blood hemoglobin (Hb) concentration in patients with squamous cell carcinoma of the head and neck (SCCHN).

METHODS AND MATERIALS

A total of 133 patients with SCCHN underwent pretreatment polarographic pO2 measurements of their tumors. In 66 patients measurements were also made in sternocleidomastoid muscles. The patients were divided into three groups according to their Hb concentration-severe anemia (Hb < 11.0 g/dl), mild anemia (female: Hb 11.0-11.9 g/dl; male: Hb 11.0-12.9 g/dl), and normal Hb concentration (female: Hb > or =12.0 g/dl; male: > or =13.0 g/dl).

RESULTS

No significant difference in tumor oxygenation could be detected between mildly anemic patients and patients with a normal Hb level. However, the tumor oxygenation in the severely anemic group was significantly below that of each of the other two groups (p < 0.0001). There was no significant difference between the Hb groups in oxygenation of sternocleidomastoid muscles. In a multivariate analysis including Hb group, tumor volume, smoking habits, gender, T-stage, N-stage, and histologic grade a Hb level < 11 g/dl was found to be the strongest predictor for a poor tumor oxygenation. Smoking also had a marginal influence on median pO2.

CONCLUSION

Our data suggest that a low Hb concentration and cigarette smoking contribute to inadequate oxygenation of SCCHN and thus for increased radioresistance. Consequently, Hb correction and abstinence from smoking may significantly improve tumor oxygenation.

Blood transfusion requirements in otolaryngology--head and neck surgery

BACKGROUND

Blood requirements for Head and Neck surgical procedures have not been studied carefully. In order to set up an autotransfusion program, the blood loss and transfusion requirements should be known precisely.

METHODS

The blood bank database was used to determine which Head and Neck procedures required blood transfusion during the previous 5 years. A list of 10 transfusion-associated operations was established, the records of all patients who underwent these procedures during a 5-year period were reviewed, and average the blood loss and number of units transfused determined.

RESULTS

All procedures were for cancer resection. The operations were classified in 3 groups according to their transfusion probability: high (> 80%), low (< 5%) and moderate. For the moderate transfusion group, age, preoperative hemoglobin, and past medical history of cardiac and pulmonary disease were associated with higher incidence of transfusion. An average delay of 3 weeks was found between the diagnosis and the actual surgery.

CONCLUSION

The transfusion requirements of Head and Neck surgical procedures could be safely met by an autotransfusion protocol, given the average delay of 3 weeks between diagnosis and surgery.

Blood transfusions in laryngeal cancer: effect on prognosis

METHODS

To evaluate the influence of homologous perioperative transfusion on oncologic control and survival in patients with larynx and hypopharynx carcinomas, we conducted a retrospective study of 269 patients with larynx and hypopharynx carcinoma treated by major surgical procedures. A total of 20 variables were analyzed for each patient.

RESULTS

Perioperative transfusion was required in 86 (32%) patients, with packed red blood cells being used in all cases. Recurrence at a local, regional, or distant level was 31% for nontransfused and 35% for transfused patients. The 5-year adjusted survival was 68% for patients without transfusion and 63% for patients with transfusion. Neither the univariate nor the multivariate analysis showed that perioperative transfusion or the number of units of packed red blood cells used had any prognostic capacity.

CONCLUSIONS

Homologous perioperative transfusion did not imply a significant risk regarding global control or survival in our larynx or hypopharynx cancer patients.