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

Impact of perioperative blood transfusions on clinical outcomes in patients undergoing surgery for major urologic malignancies

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.

Perioperative Blood Transfusion as a Significant Predictor of Biochemical Recurrence and Survival after Radical Prostatectomy in Patients with Prostate Cancer

Purpose

There have been conflicting reports regarding the association of perioperative blood transfusion (PBT) with oncologic outcomes including recurrence rates and survival outcomes in prostate cancer. We aimed to evaluate whether perioperative blood transfusion (PBT) affects biochemical recurrence-free survival (BRFS), cancer-specific survival (CSS), and overall survival (OS) following radical prostatectomy (RP) for patients with prostate cancer.

Materials and Methods

A total of 2,713 patients who underwent RP for clinically localized prostate cancer between 1993 and 2014 were retrospectively analyzed. We performed a comparative analysis based on receipt of transfusion (PBT group vs. no-PBT group) and transfusion type (autologous PBT vs. allogeneic PBT). Univariate and multivariate Cox-proportional hazard regression analysis were performed to evaluate variables associated with BRFS, CSS, and OS. The Kaplan-Meier method was used to calculate survival estimates for BRFS, CSS, and OS, and log-rank test was used to conduct comparisons between the groups.

Results

The number of patients who received PBT was 440 (16.5%). Among these patients, 350 (79.5%) received allogeneic transfusion and the other 90 (20.5%) received autologous transfusion. In a multivariate analysis, allogeneic PBT was found to be statistically significant predictors of BRFS, CSS, and OS; conversely, autologous PBT was not. The Kaplan-Meier survival analysis showed significantly decreased 5-year BRFS (79.2% vs. 70.1%, log-rank, p = 0.001), CSS (98.5% vs. 96.7%, log-rank, p = 0.012), and OS (95.5% vs. 90.6%, log-rank, p < 0.001) in the allogeneic PBT group compared to the no-allogeneic PBT group. In the autologous PBT group, however, none of these were statistically significant compared to the no-autologous PBT group.

Conclusions

We found that allogeneic PBT was significantly associated with decreased BRFS, CSS, and OS. This provides further support for the immunomodulation hypothesis for allogeneic PBT.

Effect of perioperative blood transfusion on mortality for major urologic malignancies

INTRODUCTION

Patients who undergo surgical treatment for malignancy often receive perioperative blood transfusion (PBT). We examined the association between PBT and mortality in patients who received surgical treatment of prostate, bladder, and kidney cancer.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare data set from 1992-2009, we identified 28,854 men with prostate cancer, 5462 patients with bladder cancer, and 14,379 patients with renal cell carcinoma who underwent radical prostatectomy (RP), radical cystectomy (RC), or radical (RN) or partial nephrectomy (PN) as primary therapy. Univariate and multivariate models were used to evaluate the association of PBT with cancer-specific mortality (CSM) and all-cause mortality (ACM).

RESULTS

The rate of PBT in bladder and kidney cancer have been increasing over time, and PBT in prostate cancer steadily increased and peaked in 2002 and declined afterward. The median follow-up for the RP, RC, and RN/PN cohorts were 70 months, 21 months, and 39 months, respectively. In the RP cohort, PBT was associated with greater CSM (hazard ratio [HR], 1.609; 95% confidence interval [CI], 1.235-2.097; P = .0004) and ACM (HR, 1.121; 95% CI, 1.006-1.251; P = .0394). In the RC cohort, PBT was not associated with greater CSM (HR, 1.047; 95% CI, 0.917-1.195; P = .4962) or ACM (HR, 1.095; 95% CI, 0.998-1.200; P = .0547). In the nephrectomy cohort, PBT was associated with greater CSM (HR, 1.365; 95% CI, 1.167-1.597; P = .0001) and ACM (HR, 1.402; 1.273-1.544; P < .0001).

CONCLUSION

PBT was associated with increased CSM and ACM for prostate and kidney cancer in a multivariate model. Although these data do not identify a causative relationship between PBT and mortality, efforts made to limit PBT in patients who undergo urologic cancer surgery can yield long-term survival benefits.

Perioperative allogeneic nonleukoreduced blood transfusion and prostate cancer outcomes after radical prostatectomy

BACKGROUND

Allogeneic blood transfusion induces immunosuppression, and concern has been raised that it may increase propensity for cancer recurrence; however, these effects have not been confirmed. We examined the association of perioperative transfusion of allogeneic blood long-term oncologic outcomes in patients with prostate cancer who underwent prostatectomy.

STUDY DESIGN AND METHODS

We reviewed medical records of patients who underwent radical prostatectomy between 1991 and 2005 and received allogeneic nonleukoreduced blood. Each transfused patient was matched to two controls who did not receive blood: matching included age, surgical year, prostate-specific antigen level, pathologic tumor stages, pathologic Gleason scores, and anesthetic type. Primary outcome was systemic tumor progression, with secondary outcomes of prostate cancer death and all-cause mortality. Stratified proportional hazards regression analysis was used to assess differences in outcomes between the transfused and nontransfused group.

RESULTS

A total of 379 prostatectomy patients who were transfused and 758 nontransfused controls were followed for 9.4 and 10.2 years (median), respectively. In a multivariable analysis that took into account the matched study design and adjusted for positive surgical margins and adjuvant therapies, the use of allogeneic blood was not associated with systemic tumor progression (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.39-1.99; p = 0.76), prostate cancer-specific death (HR, 1.69; 95% CI, 0.44 to 6.48; p = 0.44), or all-cause death (HR, 1.20; 95% CI, 0.87 to 1.67; p = 0.27).

CONCLUSIONS

When adjusted for clinicopathologic and procedural variables transfusion of allogeneic blood was not associated with systemic tumor progression and survival outcomes.

Influence of blood transfusions during radical retropubic prostatectomy on disease outcome

OBJECTIVES

Blood transfusion in patients with malignant neoplasms may alter the disease outcome because of a theoretical immunomodulatory effect. This effect may reduce prostate-specific antigen (PSA)-free and disease-specific survival in patients with prostate cancer after radical prostatectomy. However, the results in published studies have been contradictory, and this effect has not yet been determined.

METHODS

We evaluated 1412 patients after radical prostatectomy from 1984 to 2003 in a retrospective analysis, with a special focus on the rate and type of blood transfusions, specifically heterologous versus autologous blood. Univariate analysis and Cox regression analysis were performed to evaluate the impact of blood transfusions on disease outcome.

RESULTS

The overall transfusion rate was 56.7%. The rate dropped from 88.9% in 1988 to 9.1% in 2002. PSA recurrence (greater than 0.5 ng/mL) was noted in 11.0% in patients without and in 26.0% with blood transfusions, which was not statistically significant on Kaplan-Meier analysis. Again, no difference was noted when patients were stratified according to the type (autologous versus heterologous) or the amount (2 U or less versus more than 2 U) of blood transfusion. Evaluating overall survival, again no differences were found. The established Cox regression model also proved that blood transfusions had no impact on disease outcome.

CONCLUSIONS

Our retrospective analysis did not detect any effect of blood transfusions in patients with prostate cancer after radical prostatectomy. If a negative adverse effect occurs, this effect must be minimal. However, the infectious risk and the costs of blood transfusions should be reason enough to reduce blood loss and the transfusion rate further in patients with prostate cancer.

Analysis of peripheral blood for prostate cells after autologous transfusion given during radical prostatectomy

OBJECTIVES

To determine if cells expressing prostate-specific antigen (PSA) can be detected in blood collected by a cell-saver during radical prostatectomy (RP) or in the peripheral blood after intraoperative autotransfusion (IAT).

PATIENTS AND METHODS

In all, 112 men with clinical T1c-T2 prostate cancer undergoing RP were prospectively assessed. A cell-saver system was used in each to collect blood from the surgical field after prostate manipulation. IAT was given based on clinical indications. Standardized peripheral blood samples were collected from patients before RP, in the recovery room afterward, and at 3-5 weeks after surgery. A reverse-transcriptase-polymerase chain reaction assay for PSA mRNA was used to detect prostate cells in cell-saver and peripheral blood samples. Patients were followed after surgery with PSA measurements to assess biochemical failure.

RESULTS

PSA-expressing cells were detected in 88% of cell-saver reservoir and 13% of preoperative blood samples. No PSA-expressing prostate cells were detected in any peripheral blood samples collected 3-5 weeks after surgery. Analysis of data with 40 months of follow-up showed IAT was not an independent predictor of biochemical failure in multivariate analysis.

CONCLUSIONS

Although IAT blood contains PSA-expressing cells, none could be detected 3-5 weeks after surgery. IAT during RP was not associated with a greater risk of biochemical failure.

Intraoperative cell salvage in radical retropubic prostatectomy

OBJECTIVES

To investigate the efficacy and safety of intraoperative cell salvage with autotransfusion using leukocyte reduction filters in patients undergoing radical retropubic prostatectomy (RRP).

METHODS

Between September 1996 and March 1999, 62 patients (age range 48 to 70 years) with clinically localized prostate cancer underwent RRP with intraoperative cell salvage as the sole blood management technique. Salvaged blood was passed through a leukocyte reduction filter before autotransfusion. The 62 cell salvage patients were compared with a cohort who predonated 1 to 3 U autologous blood (n = 101). The estimated blood loss, preoperative and postoperative hematocrit, need for homologous transfusion, and biochemical recurrence rates were compared between the two groups. The progression-free survival rates were compared using the Kaplan-Meier method.

RESULTS

No difference was found in preoperative prostate-specific antigen level, pathologic stage, or estimated blood loss between the cell salvage and autologous predonation groups. The preoperative and postoperative hematocrit levels were higher in the cell salvage group (42.7% versus 39.6% and 31.3% versus 27.9%, respectively; P <0.001 for each). The homologous transfusion rates were lower in the cell salvage group (3% versus 14%, P = 0.04). The incidence of progression-free survival (prostate-specific antigen level 0.4 ng/mL or greater) was no different between the groups (P = 0.41).

CONCLUSIONS

Intraoperative cell salvage with autotransfusion using leukocyte reduction filters in RRP results in higher perioperative hematocrit levels and low homologous transfusion rates and eliminates the need for autologous predonation. Cell salvage does not appear to be associated with an increased risk of early biochemical progression after RRP.

The influence of perioperative blood transfusion on intrahepatic recurrence after curative resection of hepatocellular carcinoma

OBJECTIVE

This study retrospectively evaluated the association between perioperative blood transfusion and intrahepatic recurrence in patients with hepatocellular carcinoma (HCC) who had undergone curative hepatic resections.

METHODS

Hepatic resection was performed with curative intent in 195 patients with primary HCC between 1985 and 1996. Patients who had received perioperative blood transfusion (transfused group: n = 117) and those who had no perioperative blood transfusion (nontransfused group: n = 78) were compared in terms of conventional prognostic variables and cancer-free survival by the univariate and multivariate analyses.

RESULTS

The 1-, 3-, and 5-yr cancer-free survival rates in the nontransfused and transfused groups were 83.4% and 67.9%, 43.0% and 36.7%, and 23.1% and 24.6%, respectively (p = 0.175). Multivariate analysis of prognostic factors in all patients revealed that vascular invasion, tumor size (> or =5 cm), and Child's class were independent factors for intrahepatic recurrence. Further analyses in various stratified groups showed that perioperative blood transfusion was an independent predictor of prognosis in HCC patients with portal vein invasion (RR: 2.8, p = 0.0038). The 1-, 3-, and 5-yr survival rates in the nontransfused and transfused groups with portal vein invasion were 71.9% and 41.6%, 54.5% and 10.9%, and 26% and 0%, respectively (p = 0.0003).

CONCLUSIONS

We conclude that perioperative blood transfusions enhance the risk of intrahepatic recurrence of HCC in patients with portal vein invasion. As well, the more difficult surgery and the increased manipulation of the liver that occur in these cases create a greater possibility of tumor dissemination.

Perioperative blood transfusions reduce long-term survival following surgery for colorectal cancer

PURPOSE

The aim of the study contained herein was to investigate the association between blood transfusion and long-term outcome for patients treated for colorectal cancer, controlling for the effect of other prognostic factors. We also wanted to study whether blood storage time influenced the prognosis.

METHODS

Cox's proportional hazards regression analysis was used to analyze data from 336 patients who survived resection with curative intent. Median follow-up was 5.8 (2-16.8) years or until death.

RESULTS

Local recurrences and distant metastases were significantly more frequent when more than two units of blood had been transfused. In the multivariate Cox's analysis, with backward elimination of nonsignificant factors at the 10 percent level, the following risk factors were significantly related to death by colorectal cancer: tumor stage (T stage and N stage), perforation of tumor, age, and the need for a blood transfusion. Transfusions of more than two units of blood were independently and significantly associated with death from colorectal cancer (relative hazard, 2.7; 95 percent confidence intervals, 1.4-5.2). Time of blood storage had no effect on the prognoses. In patients dying from diseases unrelated to colorectal cancer, age and American Society of Anesthesiologists group were significantly related to death, whereas blood transfusion was not.

CONCLUSION

We found an independent and significant association between perioperative blood transfusion and poor prognosis in colorectal cancer patients. Blood storage time was not a prognostic factor.

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.

Intraoperative blood loss and prognosis in prostate cancer patients undergoing radical retropubic prostatectomy

PURPOSE

To assess more thoroughly the prognostic significance of perioperative transfusions, we examined a previously ignored factor, namely intraoperative blood loss.

MATERIALS AND METHODS

Univariate and multivariate stepwise regression analysis was performed on results of a 10-year series of 251 consecutive men who underwent radical retropubic prostatectomy for clinically localized carcinoma.

RESULTS

Gleason score, operative blood loss and pathological stage were significantly (p < 0.0001) associated with progression-free survival. A risk ratio of 1.08 (95% confidence interval 1.05 to 1.10) was demonstrated for every 100 ml. of operative blood loss.

CONCLUSIONS

The operative blood loss but not the type (autologous or allogeneic) of blood transfused was significantly related to decreased recurrence-free survival after radical retropubic prostatectomy. This finding implies that the operative events necessitating transfusion are potentially more significant than the immunological effects of the transfusion.