Modulation of tumor growth by allogeneic blood transfusion

A small mammal model of tumour implantation, dissemination and growth factor expression after partial hepatectomy

BACKGROUND

Surgical resection remains the most effective therapy for metastatic colorectal cancer confined to the liver, although the extrahepatic recurrence rate is high.

AIM OF THE STUDY

To develop a mammal model in order to investigate by which mechanisms liver surgery affects distant tumour recurrence.

METHODS

In this animal study the effect of partial hepatectomy (phX) on the development of tumour noduli in the lungs was evaluated. CC531 rat colon carcinoma cells were inoculated i.v. 24h before, during or 24h after surgery. Rat serum was obtained at different time-points after phX and added to in vitro CC531 cell cultures. Finally, phX was compared with an ileum resection (ilX).

RESULTS

phX leads to increased tumour noduli in the lungs, compared to Sham operation (p=0.002), but only when performed directly before the injection of tumour cells and not when performed 24h before or after the inoculation. Comparable results were obtained for ilX. No growth stimulation of tumour cells after incubation with rat serum, obtained at different time-points after phX, could be detected in vitro.

CONCLUSION

Not only phX, but also surgery, in general promotes distant tumour recurrence exerting the effect during the early phase of tumour cell adhesion and not during tumour outgrowth.

Red blood cells inhibit tumour cell adhesion to the peritoneum

BACKGROUND

Perioperative blood transfusion has been associated with increased tumour recurrence and poor prognosis in colorectal cancer. Blood loss in the peritoneal cavity might be a tumour-promoting factor for local recurrence. The aim of this study was to investigate whether blood in the peritoneal cavity affects local tumour recurrence.

METHODS

In an established in vivo rat model the effect of 1.5 ml syngeneic whole blood on tumour cell adhesion and tumour growth was investigated. In the same model the effect of 1.5 ml pure red blood cell (RBC) concentrate and 1.5 ml RBC-derived substances on tumour cell adhesion was studied. In an established in vitro model the effect of increasing numbers of RBCs (0-250 bx 10(6)) on tumour cell adhesion and tumour growth was assessed.

RESULTS

Both the presence of blood and RBC concentrate in the peritoneal cavity prevented tumour cell adhesion in vivo (overall P </= 0.001 and P </= 0.05 respectively), rather than promoting adherence. RBC concentrate and RBC-derived substances had a comparable inhibitory effect on tumour cell adhesion. In in vitro studies RBCs inhibited tumour cell adhesion but not tumour growth.

CONCLUSION

RBC-derived factors prevent tumour cell adhesion to the peritoneum, and consequently tumour recurrence.

Effect of perioperative blood transfusions on recurrence of colorectal cancer: meta-analysis stratified on risk factors

PURPOSE

This study was undertaken to evaluate the influence of perioperative blood transfusions on colorectal cancer recurrence.

METHODS

All articles published up to December 1996 in English (or with an English abstract) were retrieved, both using MEDLINE and scanning their references, to be considered for this meta-analysis.

RESULTS

One hundred thirty-one articles were identified, and 99 of them were excluded because they analyzed survival or mortality, were repetitive publications, or were reviews or letters. Thirty-two original studies (9 were prospective) on 11,071 patients were included for further analysis; 20 showed a detrimental effect of perioperative blood transfusions. Nineteen articles used also multivariable techniques, and 11 found perioperative blood transfusions to be an independent prognostic factor. Pooled estimates of the effect of perioperative blood transfusions on colorectal cancer recurrence yielded an overall odds ratio of 1.68 (95 percent confidence interval, 1.54-1.83) and a rate difference of 0.13 (95 percent confidence interval, 0.09-0.17) against patients who received transfusions. Stratified meta-analyses also confirmed these findings when stratifying patients by site and stage of disease. The effect of perioperative blood transfusion was observed in a dose-related fashion, regardless of timing and type, although some heterogeneity was detected. Data on surgical techniques were not available for further analysis.

CONCLUSIONS

A consistently detrimental association was discovered between the use of perioperative blood transfusion and colorectal cancer recurrence. Further studies are needed to confirm that blood transfusion has a causal association.

The effect of blood transfusion on tumor growth in sarcoma-bearing rats

BACKGROUND

The effect of blood transfusion on tumor growth is controversial. Under experimental conditions, even similar animal models can give varied results. This study was undertaken to characterize the nature of the effect of blood transfusion on tumor growth.

METHODS

Sixty-five Fischer 344 rats subcutaneously implanted with a methylcholanthrene-induced sarcoma were studied with additive blood transfusion at 1% tumor burden in two separate experiments. In experiment 1, the effects of syngeneic fresh whole blood transfusion (5, 10, and 15 ml/kg) and allogeneic (5 ml/kg) were tested. To determine if stored blood influenced the results, experiment 2 was performed with syngeneic blood transfusion (15 ml/kg) and allogeneic blood transfusion at 5 ml/kg. Tumor dimensions were determined daily by external measurement, and tumor weight and growth rate were calculated.

RESULTS

No significant differences in final tumor weights or tumor growth rates were found in transfused rats compared with controls. This held true for syngeneic blood transfusion regardless of dose, allogeneic blood transfusion, and regardless of whether the blood was fresh or stored.

CONCLUSIONS

Additive blood transfusion does not affect tumor growth in this animal model. This finding, together with the general inconclusiveness in the reported literature on this topic, speaks against a dominant role for the effect of blood transfusion on tumor behavior.

Homologous blood transfusion in patients with prostate cancer: no effect on tumor progression or survival

OBJECTIVE

To determine the effect of perioperative blood transfusions in patients with prostate cancer who underwent radical prostatectomy, we analyzed 1,785 patients with a follow-up of five years or more who were treated during a twenty-one-year period (1966 to 1987).

METHODS

Patients were divided into three groups according to the number of units transfused during the perioperative period: group 1, 0 units (n = 440), group 2, 1 to 2 units (n = 746), and group 3, 3 or more units (n = 599).

RESULTS

With univariate analysis, no statistically significant differences were found among the three groups in overall survival rate (71%, 75%, and 71% at ten years; p = 0.48), cause-specific survival rate (89%, 88%, and 86% at ten years; p = 0.36), or progression-free survival rate (61%, 68%, and 68% at ten years; p = 0.83). Adjusting for tumor grade, pathologic stage, and hormonal therapy using the Cox statistical model, we found no significant association between the blood-use group and overall survival rate (p = 0.45), cause-specific survival rate (p = 0.17), or progression-free survival rate (p = 0.34). The estimated relative risk and 95 percent confidence interval associated with blood transfusion (three or more units versus none) were as follows: 1.03 and 0.76 to 1.38 for total mortality, 1.56 and 0.95 to 2.56 for cause-specific death, and 1.20 and 0.91 to 1.57 for disease progression, respectively.

CONCLUSIONS

According to these findings, withholding homologous blood transfusion, except for infectious precautions, should not be based on the suspicion that it can accelerate death from cancer in patients who undergo radical prostatectomy for prostate cancer.

Colorectal cancer recurrence and perioperative blood transfusions: a critical reappraisal

The last 2 decades the immunomodulatory effect of blood transfusions has been investigated intensively. The effect of blood transfusions on the prognosis of colorectal cancer patients is reviewed in this paper. We made an evaluation of the material from animal and from clinical studies present in the literature. The results from clinical randomized trials dealing with this subject, which have been published recently, are discussed as well.

Characterization of effector cells against B16 melanoma in mice inoculated with allogeneic spleen cells

Inbred C57BL/6 (B6) mice which had received an inoculation of allogeneic spleen cells showed remarkable antitumor activity against syngeneic tumor challenge with B16 melanoma cells 3 days after the allogeneic cell inoculation. This antitumor activity was not specific to the inoculated alloantigen, since the challenging B16 cells are syngeneic to B6 mice and since it was induced by BALB/c spleen cells as well as C3H/He spleen cells. The antitumor activity was sensitive to an in vivo treatment with anti-asialo GM1 (AGM1) antiserum or anti-Thy.1 monoclonal antibody (mAb) just before the tumor challenge and was resistant to an in vivo treatment with anti-CD8 (Ly.2) mAb. These results suggest that AGM1+Thy.1+CD8- activated natural killer (NK) cells were generated by alloantigen inoculation and took an important part in the antitumor effect of the alloantigen inoculation.

[Transfusion and cancer]

Relationship between blood transfusion and cancer is considered from five points of view: 1) The cancer patient as a blood donor. Cancer must remain a cause of exclusion from blood donation. 2) Autologous blood transfusion for cancer patients. Predeposited autologous blood transfusion is only possible for a small number of patients. Intraoperative blood salvage carries with it the risk of disseminating tumor cells. 3) History of blood transfusion and the risk of having a cancer: a) the persistence of immune alterations following blood transfusion for years might expose the patient to an increased risk of having a cancer; b) blood transfusion might carry immunosuppressive viruses, and hepatitis viruses are related to the risk of liver cancer. 4) Cancer recurrence and blood transfusion. Conclusion of most of the published studies is that blood transfusion is associated with an increased risk of recurrence of colorectal cancer. The only realistic randomized study would compare different transfusion strategies (allogenic, leukocyte poor allogenic and autologous blood transfusion) to determine which is the best for cancer patients. 5) Post-transfusion GVH in cancer patients. Some cases have recently been published. They all can be explained by a particular HLA compatibility between the recipient and one of the blood donors.

Allogeneic blood transfusion reduces murine pulmonary natural killer (NK) activity and enhances lung metastasis of a syngeneic tumour

A model was established whereby C57BL/6 (B6) blood injected i.v. into C3H mice 7 days prior to i.v. injection of syngeneic UV-2237 tumour cells significantly increased the number of pulmonary metastases counted 21 days later as compared with levels observed in mice treated with saline, C3H or NZW blood or SRBC. This regimen of B6 allogeneic blood transfusion of C3H mice also significantly depressed splenic and pulmonary NK activity as assayed by lysis of 51Cr YAC-I in vitro and by clearance of 111In YAC-I in vivo respectively. Anti-asialo GMI treatment, which depletes NK activity in vivo, and Poly I:C treatment, which enhances NK activity in vivo, were associated with significantly increased and decreased pulmonary metastasis of UV-2237, respectively, in C3H mice. Depletion of CD4+ and CD8+ T cells had no effect. Cyclophosphamide pretreatment which, among other effects, depletes NK cells, significantly increased pulmonary metastasis of UV-2237 in C3H mice. This was corrected by adoptive transfer of normal C3H spleen cells but not spleen cells from anti-asialo GMI-treated C3H mice or B6-blood-transfused C3H mice. Furthermore, a 1:1 mixture of normal C3H spleen cells with spleen cells from B6-blood-transfused C3H mice also failed to reconstitute the cyclophosphamide-pre-treated C3H mice. We conclude that allogeneic blood transfusion augments pulmonary metastasis of the UV-2237 sarcoma in C3H mice and that the mechanism involves suppression of NK activity.

Effect of perioperative blood transfusions on survival of patients after radical surgery for colorectal cancer

The effect of perioperative blood transfusion on the survival of patients with colorectal cancer was evaluated in 128 patients undergoing curative surgery between 1980 and 1988. The following clinical and histopathological variables were also studied: age, sex, duration of symptoms, presence of intestinal obstruction, tumour site, extent of spread through the bowel wall, lymph node involvement, Dukes' stage, grade of differentiation, venous invasion and type of surgical procedure performed. The need for perioperative blood transfusion was unrelated to the stage of disease. In the transfused patients (n = 73) the 5-year recurrence-free survival, calculated by the Kaplan-Meyer technique, was 37% and in the non-transfused (n = 55) was 60% (P = 0.0027, Mantel-Cox). Similar differences were found in the comparison of the groups with (n = 68) and without (n = 60) transfusions on the day of operation. The deleterious effect of transfusion was evident in patients who received only one unit of blood (n = 19)--these had a 5-year survival rate of 45% compared those who had more than one unit of blood (n = 54) (5-year survival rate 35%) (P = 0.0062). With a multivariate analysis, using a Cox proportional hazard model, taking into account all the variables studied, a significant and independent effect on survival was found for lymph node involvement (beta coefficient = 3.97), blood transfusion (beta coefficient = 2.16) and extent of bowel wall spread (beta coefficient = 1.75).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of allogeneic blood transfusion on solid tumor growth and pulmonary metastases in mice

The effect of allogeneic blood transfusions on solid tumor growth and pulmonary metastases was examined in two different strains of mice. Recipient mice (C57B1 or DBA/2) were given transfusions from allogeneic donors (Balb/c or B6AF1, respectively). The effect of allogeneic blood transfusion on solid tumor growth (B16 in C57B1 mice and P815 in B6AF1 mice) as well as the number of pulmonary metastases (B16 in C57B1 mice) was examined utilizing inoculations of varying numbers of tumor cells. In both solid tumor models, allogeneic transfusion resulted in significant enhancement of tumor growth when smaller (1.25 x 10(5), 2.5 x 10(5)) numbers of tumor cells were inoculated into the host animal. In contrast, no effect of allogeneic transfusion on tumor growth was observed when higher (4.5 x 10(5)) numbers of tumor cells were inoculated. Similarly, increased numbers of pulmonary metastases following allogeneic blood transfusion were observed when lower numbers (1 x 10(5)) of B16 tumor cells were administered; whereas no effect was observed with higher (4.5 x 10(5)) tumor cell numbers. The data in the present study suggest that the number of tumor cells inoculated into the recipient animal has a strong bearing in the allogeneic blood-transfusion-induced tumor growth effect.

Relationship between blood transfusion and tumour behaviour

Blood transfusion results in significant alterations in some parameters of immune function. Because some human cancers appear to stimulate immune responses and may be influenced by host immunity, the possibility arises that transfusion could alter the behaviour of tumours. Experimental studies indicate that allogeneic transfusion can directly alter tumour growth in some circumstances, but at present studies of human cancers do not provide evidence of a causal association between transfusion and tumour growth.

Immunomodulation by recombinant rat interferon-gamma in vivo

Most studies on the immunomodulating effects of interferon-gamma (IFN-gamma) have been performed in vitro, using recombinant mouse and human IFN-gamma preparations. Recently, recombinant rat IFN-gamma (rRIFN-gamma) became available, enabling extensive studies with this new preparation in vivo. In the present study a LEW rat model was used to determine the efficacy of rRIFN-gamma on immune functions in vivo. LEW rats were treated with rRIFN-gamma by continuous intravenous infusion at a dosage of 1.5 x 10(5) U/kg.h for 2 consecutive days. Twelve hours after cessation of rRIFN-gamma administration immune functions, including NK-cell activity, phagocytosis, and mitogen-induced blastogenesis, were assessed. All experimental animals displayed a marked reduction in the number of peripheral blood and bone marrow cells when compared with controls (p less than 0.005). Assessment of immune functions revealed a significant enhancement of NK-cell activity (p less than 0.001), phagocytosis (p less than 0.05), and mitogen-induced blastogenesis (p less than 0.05). These findings indicate that rRIFN-gamma, when given in high dosages, has a stimulatory effect on various immune functions, which substantiates its important immunological role in vivo.

Immunosuppressive effects of blood transfusion in anaesthesia and surgery

The immunosuppressive effects of blood transfusion at surgical operations become manifest as enhanced graft survival, increased cancer recurrence and decreased patient survival, and increased susceptibility to postoperative infections. Blood transfusion in transplant recipients no longer offers this advantage when cyclosporine A is used. The deleterious effects of blood transfusion on the prognosis of some cancers found in the statistical analyses of retrospective studies are considered to be of increasing clinical importance. Therefore, unnecessary blood transfusions should be avoided and special attention directed to the use of autologous blood. Leucocyte-free red blood concentrates are the least immunosuppressive homologous blood preparations. Conventional red blood cell concentrates may also be used in cancer patients until ongoing prospective randomized studies confirm that there is a true association between the use of homologous blood and increased recurrence of cancer.

Effect of perioperative blood loss and perioperative blood transfusions on colorectal cancer survival

Results of various studies suggest that the perioperative administration of blood transfusions in cancer patients operated upon for cure is associated with a diminished patient survival. Furthermore, recent results from our laboratory indicate that blood loss may also be capable of promoting tumor growth. In order to elucidate these findings a retrospective study was initiated towards the survival of 164 patients with colorectal carcinoma, operated upon for cure, at the University Hospital, Rotterdam. In 117 patients who perioperatively received blood transfusions the 5-year survival was 68%, as compared to 80% in the non-transfusion group (P = 0.039; Wilcoxon). The 5-year survival in the group of patients with a perioperative blood loss exceeding 500 ml (n = 88) was 70%, as compared to 73% in the group with a blood loss of 500 ml or less (not significant). Multivariate analysis, adjusting for 11 relevant parameters, showed that only tumor stage and the administration of blood transfusions were significantly associated with a decrease in survival. It is concluded that perioperative blood transfusions adversely affect colorectal carcinoma survival in this group of patients. Perioperative blood loss was not a significant prognostic factor.

Consequences of blood loss on growth of artificial metastases

Previous studies have shown that lung metastases from a nonimmunogenic sarcoma (LS175) in BN (homozygous for RTln) rats were stimulated by blood transfusions. Enhanced growth was also observed after abdominal surgery combined with allogeneic blood transfusions while syngeneic blood transfusions had no effect. These experimental findings have been confirmed in retrospective clinical studies. The allogeneic blood transfusion effect may be avoided in cancer patients by autologous blood transfusions although this implies blood donation before surgery. The aim of the present study was to investigate the effect of blood loss before surgery on formation ('take') of lung colonies, and on the outgrowth of established metastases in the BN rat model. These aspects of tumour behaviour were also investigated in rats undergoing surgery, or receiving blood transfusion, or both, after blood loss. The results indicate that blood loss has a profound stimulating effect on the growth of established metastases, but not on the 'take' of tumour cells. This stimulating effect was also present when blood loss was combined with surgery, while previously surgery alone was found to have no effect. Allogeneic and syngeneic transfusions in combination with blood loss both had a strong stimulating effect on growth of established lung metastases. The results indicate that blood loss may be an important factor in determining the outcome of metastatic growth.

Perioperative blood transfusion and solid tumour recurrence

Evidence regarding the association of blood transfusions with recurrence of solid tumours is largely conflicting. This is perhaps unsurprising given the retrospective nature of the studies performed to date, the complexity of the disease and its treatment, and variations in local transfusion practices. Nonetheless, new data demonstrating that transfusions of whole blood, as opposed to red cell concentrates, are associated with earlier cancer recurrence are most readily explained by a cause and effect relationship. There is a growing literature documenting previously unforeseen immunologic consequences of homologous blood transfusion. These possible clinical consequences include earlier cancer recurrence and increased susceptibility to infection with bacteria and viruses. The questions raised in this review can be answered conclusively only by controlled prospective studies. For the present the prudent clinician will select red blood cells rather than whole blood for transfusion, employ autologous transfusions whenever feasible, and recognize that blood transfusion is a therapy with considerable benefits, but also considerable risks.

Enhanced growth of artificial tumor metastases following blood transfusion: the effect of erythrocytes, leukocytes and plasma transfusion

Clinical and experimental investigations have shown that allogeneic blood transfusions may modulate the growth of tumors. Dependent on the tumor model used in animal studies, the effects observed ranged from inhibition to stimulation of tumor growth. We have demonstrated previously that allogeneic blood transfusions gave rise to enhanced growth of a transplantable sarcoma (LS 175) in BN rats. In the experiments reported here the effect of transfusion of different allogeneic blood constituents on the growth of artificial LS 175 lung metastases was investigated. Erythrocytes and leukocytes were found to promote tumor growth to a similar degree as whole blood transfusions, plasma transfusions had no effect.

Perioperative blood transfusion and solid tumor recurrence--a review

Evidence regarding the association of blood transfusions with recurrence of solid tumors is largely conflicting. This is perhaps not surprising given the retrospective nature of the studies, the complexity of the disease and its treatment, and variations in local transfusion practices. Nonetheless, data demonstrating that transfusions of whole blood are associated with earlier cancer recurrence are most readily explained by a cause and effect relationship. There is a growing literature documenting previously unforeseen immunologic consequences of homologous blood transfusion. These possible clinical consequences may include earlier cancer recurrence, and increased susceptibility to infection with bacteria and viruses. The questions raised in this review will likely be answered by further studies. For the present, the prudent clinician will select red blood cells rather than whole blood for transfusion, and recognize that blood transfusion is a therapy with considerable benefits, but also considerable risks.