Red blood cell transfusions and the survival in patients with cancer undergoing curative surgery: a systematic review and meta-analysis

Perioperative blood transfusion does not impair survival after partial pancreaticoduodenectomy for periampullary cancer

BACKGROUND

The aim of this study was to analyze whether perioperative blood transfusions are an independent risk factor for a reduced survival in patients after partial pancreaticoduodenectomy (PD) for periampullary malignancies.

METHODS

This single-centre retrospective study analysed overall survival (OS) and disease-free survival (DFS) after PD for periampullary malignancies. Patients receiving perioperative blood transfusion were compared to patients receiving no blood transfusion using univariable and multivariable Cox regression analysis and propensity score matched analysis.

RESULTS

Between 2010 and 2022, 214 patients were included, 32 of whom received perioperative blood transfusion. Perioperative blood transfusions were associated with lower preoperative hemoglobin levels (p = 0.004), higher intraoperative blood loss (p = 0.004), longer duration of surgery (p = 0.014), and postpancreatectomy hemorrhage (p < 0.001). In multivariable analysis, blood transfusions were not an independent risk factor for a reduced OS (OR = 1.11, CI: 0.59-2.08, p = 0.724) or DFS (OR = 0.94, CI: 0.51-1.73, p = 0.843). These results were confirmed by propensity matched analysis (OS: OR = 0.79, CI: 0.28-2.20, p = 0.647; DFS: OR = 0.97, CI: 0.46-2.08, p = 0.957).

CONCLUSION

Perioperative blood transfusions in patients undergoing PD for periampullary malignancies are not an independent risk factor for reduced OS and DFS. As high intraoperative blood loss and post-pancreatectomy hemorrhage impair survival intraoperative blood loss should be minimized and postpancreatectomy hemorrhage should be prevented.

Prognostic significance of the hemoglobin, albumin, lymphocyte, platelet (HALP) score after hepatectomy for colorectal liver metastases

PURPOSE

Inflammatory, nutritional, and immune biomarkers are associated with the prognosis of patients with various tumors. Recently, a comprehensive predictive biomarker, the hemoglobin, albumin, lymphocyte, and platelet (HALP) score, was introduced to predict clinical outcomes. We investigated the prognostic impact of preoperative HALP scores in patients who underwent hepatectomy for colorectal liver metastasis (CRLM).

METHOD

The subjects of this study were 209 patients who underwent hepatectomy for CRLM between February, 2005 and September, 2023. The HALP score was defined as (albumin [mg/dL] × hemoglobin [g/L] × lymphocyte [count/L]) / platelet [count/L]. The cutoff value was calculated according to the receiver operating characteristic curve based on 3-year survival.

RESULTS

The cutoff value of the HALP score was 35, and a low HALP score was confirmed in 107 patients (51%). Multivariate analysis of disease-free survival identified lymph node metastasis (HR 1.53, p = 0.03), extrahepatic lesions (HR 2.48, p < 0.01), and a low HALP score (HR 2.0, p < 0.01) as independently poor prognostic factors. Multivariate analysis of overall survival identified extrahepatic lesions (HR 2.98, p < 0.01), a high CEA (HR 1.78, p = 0.02), and a low HALP score (HR 1.92, p = 0.02) as independently poor prognostic factors.

CONCLUSIONS

The HALP score is a useful prognostic factor for patients undergoing hepatectomy for CRLM.

Minimally Invasive Versus Open Distal Gastrectomy for Locally Advanced Gastric Cancer: Trial Sequential Analysis of Randomized Trials

BACKGROUND

Minimally invasive distal gastrectomy (MIDG) has been shown to be associated with improved short-term outcomes compared to open distal gastrectomy (ODG) in patients with locally advanced gastric cancer (LAGC). The impact of MIDG on long-term patient survival remains debated. Aim was to compare the MIDG vs. ODG effect on long-term survival.

METHODS

Systematic review and trial sequential analysis (TSA) of randomized controlled trials (RCTs). Web of Science, Scopus, MEDLINE, the Cochrane Central Library, and ClinicalTrials.gov were queried. Hazard ratio (HR) and 95% confidence intervals (CI) were used as pooled effect size measures. Five-year overall (OS) and disease-free survival (DFS) were primary outcomes.

RESULTS

Five RCTs were included (2835 patients). Overall, 1421 (50.1%) patients underwent MIDG and 1414 (49.9%) ODG. The ages ranged from 48 to 70 years and 63.4% were males. The pooled 5-year OS (HR = 0.86; 95% CI 0.70-1.04; I2 = 0.0%) and 5-year DFS (HR = 1.03; 95% CI 0.87-1.23; I2 = 0.0%) were similar for MIDG vs. ODG. The TSA shows a cumulative z-curve without crossing the monitoring boundaries line (Z = 1.96), thus suggesting not conclusive 5-year OS and DFS results because the total information size was not sufficient.

CONCLUSIONS

MIDG and ODG seem to have equivalent 5-year OS and DFS in patients with LAGC. However, the cumulative evidence derived from the TSA showed that the actual information size is not sufficient to provide conclusive data.

The Association Between Perioperative Red Blood Cell Transfusions and 1-Year Mortality After Major Cancer Surgery: An International Multicenter Observational Study

BACKGROUND

Packed red blood cell (pRBC) transfusions in patients undergoing surgery for cancer are given to treat anemia or acute hemorrhage. Evidence indicates that pRBC transfusions are associated with poor perioperative and oncological outcomes. The ARCA-1 (Perioperative Care in the Cancer Patient-1) study was designed to test the association between perioperative pRBC transfusions and postoperative morbidity and mortality in patients undergoing cancer surgery. The primary hypothesis of our study was that perioperative pRBC transfusions have a negative impact on postoperative morbidity and 1-year mortality.

METHODS

ARCA-1 was an international multicenter prospective observational cohort study. Participating centers enrolled a minimum of 30 consecutive adult patients with cancer who underwent surgery with curative intent. The primary end point was all-cause mortality 1 year after major cancer surgery. Secondary end points were rates of perioperative blood product use, 1-year cancer-specific mortality, overall survival, and 30-day morbidity and mortality. We performed a propensity score matching analysis to adjust for selection bias. A multivariable logistic regression model was fitted to estimate the effects of significant covariates on 1-year mortality, cancer-related mortality, and overall survival.

RESULTS

A total of 1079 patients were included in the study. The rate of perioperative pRBC transfusions was 21.1%. Preoperative comorbidities, including anemia, American Society of Anesthesiologists (ASA) score of III to IV, a history of coronavirus disease 2019 (COVID-19), myocardial infarction, stroke, need for dialysis, history of blood transfusions, and metastatic disease were statistically significantly more frequent in transfused patients compared to nontransfused patients. The 1-year mortality rate was higher in transfused patients before (19.7% vs 6.5%; P < .0001) and after (17.4% vs 13.2%; P = .29) propensity score matching. 1-year mortality was 1.97 times higher in transfused than in no-transfused patients (odd ratio [OR], 1.97; 95% confidence interval [CI], 1.13-3.41). The odds of 1-year cancer mortality for patients who had perioperative pRBCs was 1.82 times higher (OR, 1.82; 95% CI, 0.97-3.43) compared to those who did not receive perioperative pRBC transfusion. The effect of perioperative pRBC transfusion on overall survival was also significant (hazard ratio [HR], 1.85; 95% CI, 1.15-2.99). Transfused patients also had a higher rate of 30-day postoperative mortality before (3.5% vs 0.7%; P = .0009) and after propensity score matching (4.2% vs 1.8%; P = .34).

CONCLUSIONS

This international, multicenter observational study showed that perioperative pRBC transfusion was associated with an increased mortality risk.

Are outcomes of locally advanced cervical cancer associated with prebrachytherapy hemoglobin values and transfusion practice? An observational study comparing two large academic centres with divergent clinical guidelines

BACKGROUND AND PURPOSE

Anemia is common in locally advanced cervical cancer. Clinical practice varies greatly for management of anemia during brachytherapy, with some centres providing red cell transfusion to increase hemoglobin levels above 100 g/L.

MATERIALS AND METHODS

This is a retrospective observational cohort study of adult patients with cervical cancer treated with brachytherapy at two academic hospitals. One hospital (H1) uses a liberal transfusion strategy with hemoglobin threshold of 100 g/L during brachytherapy and the other uses a restrictive target of 70 g/L (H2).

RESULTS

Overall, 336 patients met inclusion criteria (H1: 150 patients, H2: 186 patients). 11 patients were excluded (2 at H1, 9 at H2). Demographics at both sites were comparable, except for cancer stage and smoking history. External beam radiation and chemotherapy provided was similar. Hemoglobin values were compared at baseline (within 4 weeks of oncology consult), and prior to the first and second brachytherapy treatments. In total, 101red blood cell (RBC) units were transfused to patients at H1 and 19 units to patients at H2. Patients were followed for a median of 37.0 months (0.6-80.5) at H1, and 33.3 months (1.6-82.0) at H2. There was no significant difference in progression-free or overall survival. Multivariable logistic regression analysis showed that FIGO stage was a predictor for both overall survival and cancer progression. Age, tumor size, chemotherapy, and hemoglobin levels were not predictors of disease progression or mortality.

CONCLUSIONS

The practice of liberal transfusion should be re-evaluated in the absence of robust data to support its use.

The association of perioperative blood transfusion with survival outcomes after major cancer surgery: a population-based cohort study in South Korea

PURPOSE

The correlation between perioperative blood transfusions and the prognosis after major cancer surgery remains controversial. We investigated the association between perioperative blood transfusion and survival outcomes following major cancer surgeries and analyzed trends in perioperative blood transfusions.

METHODS

Data for this population-based cohort study were obtained from the National Health Insurance Service of South Korea. Adult patients who underwent major cancer surgery between January 1, 2016, and December 31, 2020, were included. The primary endpoint was 90-day mortality.

RESULTS

The final analysis included 253,016 patients, of which 55,094 (21.8%) received perioperative blood transfusions. In the multivariable logistic regression model, select factors, including neoadjuvant/adjuvant chemotherapy, an increased preoperative Charlson Comorbidity Index, moderate or severe liver disease, liver cancer surgery, and small bowel cancer surgery, were associated with an increased likelihood of blood transfusion. In the multivariable Cox regression model, patients who received blood transfusion had a significantly higher risk of 90-day mortality (hazard ratio: 5.68; 95% confidence interval: 5.37, 6.00; P < 0.001) than those who did not.

CONCLUSION

We identified potential risk factors for perioperative blood transfusions. Blood transfusion is associated with an increased 90-day mortality risk after major cancer surgery.

Perioperative Immunosuppressive Factors during Cancer Surgery: An Updated Review

Surgical excision of the primary tumor represents the most frequent and curative procedure for solid malignancies. Compelling evidence suggests that, despite its beneficial effects, surgery may impair immunosurveillance by triggering an immunosuppressive inflammatory stress response and favor recurrence by stimulating minimal residual disease. In addition, many factors interfere with the immune effectors before and after cancer procedures, such as malnutrition, anemia, or subsequent transfusion. Thus, the perioperative period plays a key role in determining oncological outcomes and represents a short phase to circumvent anesthetic and surgical deleterious factors by supporting the immune system through the use of synergistic pharmacological and non-pharmacological approaches. In line with this, accumulating studies indicate that anesthetic agents could drive both protumor or antitumor signaling pathways during or after cancer surgery. While preclinical investigations focusing on anesthetics' impact on the behavior of cancer cells are quite convincing, limited clinical trials studying the consequences on survival and recurrences remain inconclusive. Herein, we highlight the main factors occurring during the perioperative period of cancer surgery and their potential impact on immunomodulation and cancer progression. We also discuss patient management prior to and during surgery, taking into consideration the latest advances in the literature.

Anaemia in Hospitalized Cancer Patients: A Retrospective Study of Two Cohorts before and after the Guideline Update

INTRODUCTION

The incidence of anaemia and its consequences are often underestimated during cancer management. We propose to evaluate the situation before and after the recommendations were updated in order to assess their impact on the day-to-day practice.

METHODS

In this single-centre retrospective study, eligible patients were treated for cancer and warranted overnight hospitalization over two periods (n = 206 in 2011, n = 143 in 2018). The diagnosis of anaemia was defined by a haemoglobin level below 12 and 13 g/dL for women and men, respectively.

RESULTS

The prevalence of anaemia was 26% in 2011 and 16% in 2018 (p < 0.001). Biological assessment had changed between the two periods, with more tests of iron metabolism and measurements of inflammatory parameters. Patients hospitalized in 2018 had more advanced cancer and more severe anaemia (8.2 g/dL [±1.07] in 2011 vs. 7.9 g/dL [±1.18] in 2018). Rate of transfusion therapy did not change, but patients with mild and moderate anaemia were transfused less in 2018 (57% in 2011 vs. 44% in 2018). Intravenous iron and erythropoiesis-stimulating agent were used more frequently in 2018 (1 and 5 and 13 and 23% in 2011 and 2018, respectively), mainly for mild anaemia and life-threatening anaemia, respectively. Overall survival was poor in both cohorts at 24 months (15.4% in 2011 and 6.5% in 2018, p = 0.048).

CONCLUSION

Practices have changed in the diagnosis of anaemia and prescriptions for erythropoiesis-stimulating agents and intravenous iron have increased. Efforts must continue to explore the causes of anaemia, optimize patients' quality of life, and reduce transfusions.

Predictors of Blood Transfusion in Patients Undergoing Cytoreductive Surgeries for Ovarian Malignancy

OBJECTIVES

The aims of this study were to describe the baseline estimated blood loss (EBL) in surgery and transfusion rate in patients undergoing cytoreductive surgeries for ovarian malignancy, and identify perioperative variables associated with blood loss and transfusion.

METHODS

A retrospective cohort study at a single institution was performed that included patients with known or suspected ovarian malignancy undergoing cytoreductive surgery between 2016 and 2021. t tests, χ2 tests, and multiple logistic regression analyses were used.

RESULTS

Among 44 patients meeting inclusion criteria, 61% received perioperative blood transfusion. There were significant differences in EBL and preoperative hemoglobin levels between patients who did and did not receive transfusion (EBL 442.6 vs 236.8 mL, P = 0.0008; preoperative hemoglobin 10.2 vs 11.2 g/dL, P = 0.049). After adjusting for preoperative hemoglobin, the risk of transfusion increased for each additional 200 mL of EBL (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.5-9.5). Stratified by race, the association between EBL and transfusion risk remained statistically significant only for non-Latinx White patients (OR 6.1, 95% CI 1.7-21.9), who made up 77% of the study population, but not for patients of other races and ethnicities (OR 1.0, 95% CI 0.16-6.42).

CONCLUSIONS

Perioperative blood transfusion is common in patients undergoing cytoreductive surgery. In this study, EBL and preoperative hemoglobin levels were significantly associated with transfusion receipt. Clinicians should optimize hemoglobin levels and intraoperative blood conservation strategies to reduce the need for transfusion. The results also highlight the importance of considering racial and ethnic differences when developing strategies to reduce transfusion risk.

Long-Term Impact of Severe Postoperative Complications after Esophagectomy for Cancer: Individual Patient Data Meta-Analysis

BACKGROUND

Severe postoperative complications (SPCs) may occur after curative esophagectomy for cancer and are associated with prolonged hospital stay, augmented costs, and increased in-hospital mortality. However, the effect of SPCs on survival after esophagectomy is uncertain.

AIM

To assess the impact of severe postoperative complications (SPCs) on long-term survival following curative esophagectomy for cancer, we conducted a systematic search of PubMed, MEDLINE, Scopus, and Web of Science databases up to December 2023. The included studies examined the relationship between SPCs and survival outcomes, defining SPCs as Clavien-Dindo grade > 3. The primary outcome measure was long-term overall survival (OS). We used restricted mean survival time difference (RMSTD) and 95% confidence intervals (CIs) to calculate pooled effect sizes. Additionally, we applied the GRADE methodology to evaluate the certainty of the evidence.

RESULTS

Ten studies (2181 patients) were included. SPCs were reported in 651 (29.8%) patients. The RMSTD overall survival analysis shows that at 60-month follow-up, patients experiencing SPCs lived for 8.6 months (95% Cis -12.5, -4.7; p < 0.001) less, on average, compared with no-SPC patients. No differences were found for 60-month follow-up disease-free survival (-4.6 months, 95% CIs -11.9, 1.9; p = 0.17) and cancer-specific survival (-6.8 months, 95% CIs -11.9, 1.7; p = 0.21). The GRADE certainty of this evidence ranged from low to very low.

CONCLUSIONS

This study suggests a statistically significant detrimental effect of SPCs on OS in patients undergoing curative esophagectomy for cancer. Also, a clinical trend toward reduced CSS and DFS was perceived.

Lack of RBC transfusion independence by Day 30 following allogeneic hematopoietic stem cell transplant strongly predicts inferior survival and high non-relapse mortality in acute myeloid leukemia patients

BACKGROUND

Studies have suggested that acute myeloid leukemia (AML) patients with incomplete hematologic recovery undergoing allogeneic stem cell transplantation (allo-HSCT) had inferior overall survival (OS).

STUDY DESIGN AND METHODS

This single-center, retrospective study of AML patients evaluated the relationship between red blood cell (RBC) and platelet (PLT) transfusion requirements during the first 30 days and long-term outcomes after allo-HSCT through multivariate analyses.

RESULTS

A total of 692 AML patients received peripheral blood stem cells (89.2%), marrow (5.6%), or umbilical cord (5.2%) from matched related (37.4%), unrelated (49.1%), or haploidentical (8.2%) donors in 2011-2017. Transfusion requirements during the first 30 days for RBC (89.5% transfused, median 3, range 1-18 units) or PLT (98.2% transfused, median 6, range 1-144 units) were variable. By Day 30, 56.7% (95% confidence interval [CI]: 52.8-60.3%) and 86.1% (95% CI: 83.2-88.5%) had achieved RBC and PLT transfusion independence, respectively. Median follow-up among survivors (n = 307) was 7.1 years (range: 2.7-11.8). Lack of RBC transfusion independence by Day 30 was strongly and independently associated with worse 5-year OS (39.2% vs. 59.6%, adjusted hazard ratio [HR] 1.83, 95% CI: 1.49-2.25), leukemia-free survival (35.8% vs. 55.5%, HR = 1.75, 95% CI: 1.43-2.14), and NRM (29.7% vs. 13.7%, HR = 2.05, 95% CI: 1.45-2.89) (p < .001). There was no difference in relapse rates among patients who achieved or did not achieve RBC (p = .34) or PLT (p = .64) transfusion independence.

CONCLUSION

Prolonged RBC dependence predicted worse survival and NRM rates, but not increased relapse. Posttransplant surveillance of such patients should be adjusted with more attention to non-relapse complications.

Preoperative hemoglobin levels, extended resections and the body mass index influence survival after pancreaticoduodenectomy

PURPOSE

The negative influence of perioperative transfusion of packed red blood cells on the prognosis of various malignancies is the focus of recent research interest. The development of a propensity score for the prediction of perioperative transfusion of packed red blood cells (pRBCs) and the identification of independent risk factors for survival, that can either be known prior to or during surgery in patients undergoing pancreaticoduodenectomy for pancreatic head cancer are the two objectives of this study.

METHODS

Logistic regression analyses and Cox regression modeling were used to identify independent risk factors for perioperative transfusion of pRBCs and to determine individual risk factors for patient survival. A total of 101 adult patients who underwent surgery between 01/01/2016 and 12/31/2020 were investigated in a single-center retrospective analysis.

RESULTS

Preoperative hemoglobin levels (OR: 0.472, 95%-CI: 0.312-0.663, p < 0.001) and extended resections (OR: 4.720, 95%-CI: 1.819-13.296, p = 0.001) were identified as independent risk factors for perioperative transfusion of pRBCs, enabling the prediction of pRBC transfusion with high sensitivity and specificity (AUROC: 0.790). The logit of the derived propensity model for the transfusion of pRBCs (HR: 9.231, 95%CI: 3.083-28.118, p < 0.001) and preoperative Body Mass Index (BMI) (HR, 0.925; 95%-CI: 0.870-0.981, p = 0.008) were independent risk factors for survival.

CONCLUSIONS

Low preoperative hemoglobin levels, low BMI values, and extended resections are significant risk factors for survival that can be known and thus potentially be influenced prior to or during surgery. Patient blood management programs and prehabilitation programs should strive to increase preoperative hemoglobin levels and improve preoperative malnutrition.

Hematological toxicities of immune checkpoint inhibitors and the impact of blood transfusion and its microbiome on therapeutic efficacy and recipient's safety and survival outcome:A systematic narrative appraisal of where we are now!

Classically, patients with solid and hematologic malignancies have been treated with a combination of chemotherapy with or without a holistic targeted strategy using approved conventional therapy. While the evidence-based use of Immunomodulatory drugs and Immune checkpoint inhibitors (ICIs), including those targeting the PD-1, PD-L1 and CTLA-4, have reshaped the treatment paradigm for many malignant tumors and significantly stretched the life expectancy of patients, as for any interventional therapy, the rise in ICI applications, was associated with the observation of more immune-related hematological adverse events. Many of these patients require transfusion support during their treatment in line with precision transfusion. It has been presumed that transfusion-related immunomodulation (TRIM) and the microbiome can pose immunosuppressive effects on the recipients. Looking to the past and beyond and translating available data into practice in the evolving role of pharmaceutical therapy to ICI-receiving patients, we performed a narrative review of the literature on the immune-related hematological adverse events of ICIs, immunosuppressive mechanisms linked to blood product transfusions, as well as the detrimental impact of transfusions and its related microbiome on the sustained efficacy of ICIs and the patients' survival outcomes. Recent reports are pointing to the negative impact of transfusion on ICI response. Studies have concluded that packed RBC [PRBC] transfusions lead to an inferior progression-free and overall survival in patients with advanced cancer receiving ICIs, even after adjustments for other prognostic variables. The attenuation of the effectiveness of immunotherapy likely results from the immunosuppressive effects of PRBC transfusions. It is, therefore, wise to look retrospectively and prospectively at the impact of transfusion on ICI effects and adopt, in the interim, a restrictive transfusion strategy, if applicable, for those patients.

Effect of blood product transfusion on the prognosis of patients undergoing hepatectomy for hepatocellular carcinoma: a propensity score matching analysis

BACKGROUND

Hepatectomy, the most common treatment for hepatocellular carcinoma, is associated with greater intraoperative blood loss than is resection of other malignancies. The effect of blood product transfusion (red blood cell [RBC], platelet, fresh frozen plasma [FFP], 5 and 25% albumin) on prognosis remains unclear. This study examined effects of blood product transfusion on prognoses of patients who underwent hepatectomy for hepatocellular carcinoma.

METHODS

We included 2015 patients with pathologically confirmed hepatocellular carcinoma who underwent hepatectomy at our institution during 1990-2019. Patients (n = 534) who underwent repeat hepatectomy, non-curative hepatectomy, those with synchronous cancer in other organs, those who died within 1 month of surgery, and those with missing data were excluded. Finally, 1481 patients (1142 males, 339 females; median age: 68 years) with curability A or B were included.

RESULTS

Intraoperative blood loss (> 500 mL) was an independent predictor of RBC transfusion (odds ratio, 8.482; P < 0.001). All transfusion groups had poorer recurrence-free survival (RFS) and overall survival (OS) than non-transfusion groups. After propensity score matching, the 5 year RFS rate was 13.4 and 16.3% in the RBC and no-RBC groups, respectively (P = 0.020). The RBC group had a significantly lower 5 year OS rate than the no-RBC group (42.1 vs. 48.8%, respectively; P = 0.035) and the FFP group (57.0%) than the no-FFP group (63.9%) (p = 0.047). No significant between-subgroup differences were found for other blood transfusion types.

CONCLUSIONS

RBC transfusion promotes hepatocellular carcinoma recurrence and RBC/FFP transfusions reduced long-term survival and RFS and OS in patients who underwent radical liver resection of HCC.

Effect of Perioperative Blood Transfusions and Infectious Complications on Inflammatory Activation and Long-Term Survival Following Gastric Cancer Resection

Background: The aim of this study was to evaluate the impact of perioperative blood transfusion and infectious complications on postoperative changes of inflammatory markers, as well as on disease-free survival (DFS) in patients undergoing curative gastric cancer resection. Methods: Multicenter cohort study in all patients undergoing gastric cancer resection with curative intent. Patients were classified into four groups based on their perioperative course: one, no blood transfusion and no infectious complication; two, blood transfusion; three, infectious complication; four, both transfusion and infectious complication. Neutrophil-to-lymphocyte ratio (NLR) was determined at diagnosis, immediately before surgery, and 10 days after surgery. A multivariate Cox regression model was used to analyze the relationship of perioperative group and dynamic changes of NLR with disease-free survival. Results: 282 patients were included, 181 in group one, 23 in group two, 55 in group three, and 23 in group four. Postoperative NLR changes showed progressive increase in the four groups. Univariate analysis showed that NLR change > 2.6 had a significant association with DFS (HR 1.55; 95% CI 1.06−2.26; p = 0.025), which was maintained in multivariate analysis (HR 1.67; 95% CI 1.14−2.46; p = 0.009). Perioperative classification was an independent predictor of DFS, with a progressive difference from group one: group two, HR 0.80 (95% CI: 0.40−1.61; p = 0.540); group three, HR 1.42 (95% CI: 0.88−2.30; p = 0.148), group four, HR 2.85 (95% CI: 1.64−4.95; p = 0.046). Conclusions: Combination of perioperative blood transfusion and infectious complications following gastric cancer surgery was related to greater NLR increase and poorer DFS. These findings suggest that perioperative blood transfusion and infectious complications may have a synergic effect creating a pro-inflammatory activation that favors tumor recurrence.

Red blood cell transfusions impact response rates to immunotherapy in patients with solid malignant tumors

Red blood cell (RBC) transfusions have been shown to exert immunosuppressive effects in different diseases. In consequence, RBC transfusions might also negatively influence the response to immunotherapeutic treatment approaches. To address how RBC transfusions impact response rates of antitumor immunotherapy (IT), we conducted a retrolective clinical study of patients with different solid tumors treated with IT (atezolizumab, pembrolizumab, nivolumab and/or ipilimumab). We assessed the number of RBC concentrates received within 30 days before and 60 days after the start of IT. Primary objective was the initial therapy response at first staging, secondary objectives the number of immune related adverse events and infections. 15 of 55 included patients (27.3%) received RBC concentrates. The response rates were 77.5% in the non-transfused (n=40) versus 46.7% in the transfused patient group (n=15) and reached statistical significance (p=0.047). The correlation between therapy response and transfusion was statistically significant (p=0.026) after adjustment for the only identified confounder “line of therapy”. In contrast, transfusion in the interval 30 days before IT showed no significant difference for treatment response (p=0.705). Moreover, no correlation was detected between RBC transfusion and irAE rate (p=0.149) or infection rate (p=0.135). In conclusion, we show for the first time that the administration of RBC transfusions during, but not before initiation of IT treatment, negatively influences the response rates to IT. Our findings suggest a restrictive transfusion management in patients undergoing IT to receive optimal response rates.

Outcome Prediction in Critically-Ill Patients with Venous Thromboembolism and/or Cancer Using Machine Learning Algorithms: External Validation and Comparison with Scoring Systems

Intensive care unit (ICU) patients with venous thromboembolism (VTE) and/or cancer suffer from high mortality rates. Mortality prediction in the ICU has been a major medical challenge for which several scoring systems exist but lack in specificity. This study focuses on two target groups, namely patients with thrombosis or cancer. The main goal is to develop and validate interpretable machine learning (ML) models to predict early and late mortality, while exploiting all available data stored in the medical record. To this end, retrospective data from two freely accessible databases, MIMIC-III and eICU, were used. Well-established ML algorithms were implemented utilizing automated and purposely built ML frameworks for addressing class imbalance. Prediction of early mortality showed excellent performance in both disease categories, in terms of the area under the receiver operating characteristic curve (AUC–ROC): VTE-MIMIC-III 0.93, eICU 0.87, cancer-MIMIC-III 0.94. On the other hand, late mortality prediction showed lower performance, i.e., AUC–ROC: VTE 0.82, cancer 0.74–0.88. The predictive model of early mortality developed from 1651 VTE patients (MIMIC-III) ended up with a signature of 35 features and was externally validated in 2659 patients from the eICU dataset. Our model outperformed traditional scoring systems in predicting early as well as late mortality. Novel biomarkers, such as red cell distribution width, were identified.

ABO Mismatch in Allogeneic Hematopoietic Stem Cell Transplant: Effect on Short- and Long-term Outcomes

Supplemental Digital Content is available in the text.

Background.

The impact of ABO incompatibility (ABO-I) on hematopoietic stem cell transplant outcomes is still debated.

Methods.

We retrospectively investigated 432 consecutive transplants performed at our center (2012–2020). All patients but 6 were affected by hematologic malignancies. The effect of different ABO match combinations on engraftment rate, transfusion support, acute and chronic graft-versus-host disease incidences, nonrelapse mortality (NRM), disease-free survival, and overall survival was assessed in univariate and multivariate analysis. Significance was set at P < 0.05.

Results.

ABO match distribution among transplants was as follows: 223 ABO-compatible, 94 major ABO-I, 82 minor ABO-I, and 33 bidirectional ABO-I. At univariate analysis, major ABO-I delayed the engraftment of neutrophils, platelets, and erythroid cells. At multivariate analysis, major ABO-I transplants displayed delayed erythroid engraftment (odds ratio [OR], 0.51; 95% confidence intervals [CIs], 0.38-0.70; P < 0.0001) and hindered transfusion independence for both red blood cells (OR, 0.52; 95% CI, 0.37-0.72; P = 0.0001) and platelets (0.60; 95% CI, 0.45-0.86; P = 0.0048). Moreover, major ABO-I transplants received greater amounts of blood products (P < 0.0001 for red blood cells and P = 0.0447 for platelets). In comparison with other ABO matches, major ABO-I was associated with an increased NRM (OR, 1.67; 95% CI, 1.01-2.75; P = 0.0427). No effects of ABO-mismatch were found on graft-versus-host disease, disease-free survival, and overall survival.

Conclusions.

Major ABO mismatch delays multilineage engraftment hinders transfusion independence and increases NRM. The prognostic impact of transfusion burden in hematopoietic stem cell transplantation deserves to be explored.