Blood transfusion and prognosis in Dukes' B and C colorectal cancer

The Effect of whole-Blood Transfusion on Survival of Patients with Breast Cancer: Why the Controversies?

Disputes still arise about the adverse effect of perioperative transfusion on survival of patients with malignant solid tumors. In order to find some answers to these controversies the author has studied 880 new patients with operable breast cancer, among whom 486 (55.2%) had received perioperative transfusion. In 86% of the patients the tumor size, when known, measured 3.0 cm (T2) or less. In general the ten-year actuarial survival of the 486 transfused patients has been 59.9% versus 66.7% for 394 nontransfused ones, X2 = 4.47; d.o.f. = 1, P <0.05.

In multivariate analysis it was noted that only positive nodes had affected the survival significantly (P = 10-9) and blood group had produced a trend (P = 0.08). However, when the period cohort was eliminated, the adverse effect of transfusion became evident in patients with blood group A in the 1968-69 and 1970-71 cohorts but not in those with blood group O.

It is concluded that the combined effect of transfusion and blood group, as a risk factor, is not as strong as positive nodes and large size of tumor. This study confirms that transfusion effect, at surgery, is a blood-group-related phenomenon.

Genetic variations affecting serum carcinoembryonic antigen levels and status of regional lymph nodes in patients with sporadic colorectal cancer from Southern China

BACKGROUND

Serum carcinoembryonic antigen (sCEA) level might be an indicator of disease. Indeed, an elevated sCEA level is a prognostic factor in colorectal cancer (CRC) patients. However, the genetic determinants of sCEA level in healthy and CRC population remains unclear. Thus we investigated the genetic markers associated with elevated serum sCEA level in these two populations and its clinical implications.

METHODS AND FINDINGS

Genome-wide association study (GWAS) was conducted in a cohort study with 4,346 healthy male adults using the Illumina Omni 1 M chip. Candidate SNPs associated with elevated sCEA levels were validated in 194 CRC patients on ABI Taqman platform. Eight candidate SNPs were validated in CRC patients. The rs1047781 (chr19- FUT2) (A/T) was associated with elevated sCEA levels, and rs8176746 (chr9- ABO) was associated with the regional lymph metastasis in the CRC patients. The preoperative sCEA level was a risk factor for tumor recurrence in 5 years after operation (OR = 1.427, 95% CI: 1.005∼1.843, P = 0.006). It was also one of the risk factors for regional lymph node metastasis (OR = 2.266, 95% CI: 1.196∼4.293, P = 0.012). The sCEA level in rs1047781-T carriers was higher than that in the A carriers in CRC patients without lymph node metastasis (P = 0.006). The regional lymph node metastasis in patients with homozygote AA of rs8176746 was more common than that in the heterozygote AG carriers (P = 0.022). In addition, rs1047781-AT and TT CRC patients exhibited a worse disease-free survival than AA genotype carriers (P = 0.023).

CONCLUSIONS

We found candidate SNPs associated with elevated sCEA levels in both healthy males and CRC population. Rs1047781 (chr19- FUT2) may be the susceptible locus for recurrence of CRC in a population from Southern China.

Perioperative blood transfusions do not impact overall and disease-free survival after curative rectal cancer resection: a propensity score analysis

OBJECTIVE

To assess the putative impact of perioperative blood transfusions on overall and disease-free survival in patients undergoing curative resection of stage I-III rectal cancer by applying propensity-scoring methods.

BACKGROUND

Whether perioperative blood transfusions negatively impact survival remains a matter of great debate.

METHODS

In a single-center study, 401 patients undergoing open curative resection of stage I-III rectal cancer between 1996 and 2008 were assessed. The median follow-up was 34.2 months. Patients who did and did not receive perioperative blood transfusions were compared using Cox regression and propensity score analyses.

RESULTS

Overall, 217 patients (54.1%) received blood transfusions. Patients' characteristics were highly biased concerning transfusions (propensity score 0.77±0.23 vs. 0.28±0.25; P<0.001). In unadjusted analysis, blood transfusions were associated with a 119% increased risk of mortality [hazard ratio (HR): 2.19, 95% confidence interval (CI): 1.34-3.57, P=0.001]. In propensity score-adjusted Cox regression (HR: 1.02, 95% CI: 0.65-1.58, P=0.970), blood transfusions did not increase the risk of overall survival. Similarly, in propensity score-adjusted Cox regression (HR: 0.86, 95% CI: 0.60-1.23, P=0.672), blood transfusions were not associated with an increased risk of recurrence.

CONCLUSIONS

This is the first propensity score-based analysis providing compelling evidence that worse oncological outcomes after curative rectal cancer resection in patients receiving perioperative blood transfusions are caused by the clinical circumstances requiring transfusions, not due to the blood transfusions themselves. Therefore, concerns about overall and disease-free survival should be no issue in the decision-making regarding perioperative blood transfusions in patients undergoing curative rectal cancer resection.

Importance of hemoglobin concentration and its modification for the outcome of head and neck cancer patients treated with radiotherapy

INTRODUCTION

Hypoxia induced radioresistance has been acknowledged for decades. One of the indirect evidences of the influence of hypoxia on radiation response comes from the observations of a correlation between tumor control and hemoglobin level. This review examines the clinical data on the prognostic and predictive role of hemoglobin level and hemoglobin manipulation in radiotherapy of squamous cell carcinomas of the head and neck, a tumor type where hypoxic radioresistance have been previously documented.

THE INFLUENCE OF HEMOGLOBIN CONCENTRATION ON TUMOR OXYGENATION AND OUTCOME

The aim is to evaluate the existing literature for information of the influence of hemoglobin concentration and hemoglobin modifications on tumor oxygenation and outcome in head and neck squamous cell cancer patients. The data from several randomized trials show that while most studies have confirmed the prognostic value of hemoglobin, increasing the hemoglobin level through transfusion or erythropoietin stimulation did not result in improved outcome for patients with low initial hemoglobin levels. Clinical studies showed that smoking reduced the oxygen carrying capacity of the blood through formation of carboxyhemoglobin, and lead to poorer response to radiotherapy in smokers compared to non-smokers. Smoking also increased the risk of the development of secondary cancers.

CONCLUSION AND FUTURE PERSPECTIVES

In conclusion, low hemoglobin is a significant negative prognostic factor for radiotherapy of head and neck cancer. Correction of pre-treatment low hemoglobin by blood transfusion and/or erythropoietin stimulating agents does, however, not improve the outcome. Smoking leads to a decrease in effective hemoglobin and poorer treatment outcome. Smoking should be avoided in order to improve the therapeutic efficacy of radiotherapy and development of other smoking-related diseases and/or secondary cancers.

Does transfusion improve the outcome for HNSCC patients treated with radiotherapy? - results from the randomized DAHANCA 5 and 7 trials

BACKGROUND

Patients with head and neck squamous cell carcinoma (HNSCC) and a low level of hemoglobin often have a poor response to radiation that may be related to hypoxia-induced radioresistance. We have previously published the importance of hemoglobin level and the effect of transfusion by the results from the randomized DAHANCA 5 trial, including 414 patients in the analysis. Aim of the current analysis was to gain additional power by adding patients from the continued subrandomization in the DAHANCA 7 trial, now including a total of almost 1200 patients.

MATERIAL AND METHODS

Patients were randomized to treatment in the DAHANCA 5 and 7 study (nimorazole vs. placebo and five fx/week vs. six fx/week), and in addition, patients with "low" pre-irradiation hemoglobin values (females <13 g/dl; males <14.5 g/dl) were subrandomized to plus or minus transfusion. Transfusion was given with packed red blood cells with the aim to achieve a hemoglobin level in the "high" value range.

RESULTS

A total of 1166 patients were included, 701 patients had high hemoglobin levels and 465 had low hemoglobin levels. Among the low hemoglobin patients, 235 were randomized to receive transfusion. Patient characteristics and treatment arms were well balanced. In the majority of patients, transfusion resulted in increased hemoglobin levels although this decreased slightly throughout treatment as in the non-transfused patients. Overall, the patients with low hemoglobin level had a significant reduced probability of locoregional control, disease-specific and overall survival. In the low hemoglobin group, transfusion did not improve the outcome in locoregional control, disease-specific or overall survival. In multivariate analyses, HPV/p16 status, T and N classification were significant factors for all outcome measures, whereas there was no significant influence of transfusion or hemoglobin level on endpoints.

CONCLUSION

Transfusion prior to and during radiation treatment did not improve the outcome in patients with HNSCC and low hemoglobin values, but may have a negative impact on survival.

Leucocyte depletion of perioperative blood transfusion does not affect long-term survival and recurrence in patients with gastrointestinal cancer

BACKGROUND

Perioperative red blood cell (RBC) transfusion may be associated with a poor prognosis in cancer surgery. Allogeneic leucocytes are assumed to play a causal role. This study evaluated the long-term effect of transfusion with leucocyte-depleted (LD) blood in patients with gastrointestinal cancer.

METHODS

The Transfusion Associated Complications = Transfusion Induced Complications? (TACTIC) study is a multicentre randomized controlled trial evaluating the short-term benefits of LD versus non-LD RBC transfusions. The present study evaluated 5-year survival and cancer recurrence among 512 patients with gastrointestinal cancer included in the TACTIC study.

RESULTS

Some 89.2 per cent of patients had a primary tumour and 79.7 per cent underwent surgery with curative intent; 243 patients received perioperative RBC transfusion (median 3 units). The 5-year overall survival rate of patients with any type of gastrointestinal cancer was 50.8 per cent in the LD group and 45.8 per cent in the non-LD group (P = 0.191). Corresponding 5-year disease-free survival rates were 60.0 and 56.6 per cent (P = 0.482), and recurrence rates 32.9 and 34.3 per cent (P = 0.864).

CONCLUSION

Leucocyte depletion is not associated with better long-term survival and lower recurrence rates in patients with gastrointestinal cancer.

Is harmonic scalpel an effective tool for oesophagectomy?

INTRODUCTION

Use of electrocautery in oesophagectomy is standard; however, the introduction of the harmonic scalpel (HS) and its use has changed the methodology of oesophagectomy in recent years. We have assessed the efficiency of HS in oesophageal cancer surgery. The parameters studied were blood loss, transfusion rates, and postoperative complications.

METHODS

Our cohort included 142 patients who underwent elective oesophagectomy from January 1999 to December 2004. The control group was the patients undergoing electrocautery oesophagectomy (n=98) between 1999 and 2002. Furthermore, 44 patients who were operated with the HS were included in the study group.

RESULTS

The numbers of units transfused were significantly less in HS group (median 0) in comparison with controls (median 2), p=0.003. Median blood loss in HS and the controls was 500 and 700 ml respectively (p=0.123). Mortality in HS group was 2.27%compared to 3.06% in controls (p=0.14). The complication (principally respiratory) rate was only 13.6% of patients in HS group compared to 17.3% in the controls.

CONCLUSION

Our study shows that HS reduces transfusion rates and postoperative complications, highlighting it as a safe and effective alternative to traditional electrocautery.

Effects of blood transfusion with leucocyte depletion on length of hospital stay, respiratory assistance and survival after curative surgery for colorectal cancer

PURPOSE

To investigate effects of blood transfusion, with/without leucocyte depletion, on duration of hospital stay, need for respiratory support, mortality and long-term survival after curative surgery for colorectal cancer.

METHODS

The trial was a prospective, randomised, multicenter study. Six hundred and forty two patients with colorectal cancer were included. Blood transfusion was given when needed during and/or after operation, randomised to packed red blood cells (RBC) or leucocyte-depleted red blood cells (LDB) using leucocyte filtration. Assisted ventilation in ICU, hospital stay, malignant and nonmalignant specific mortality and overall survival were outcome measures.

RESULTS

The RBC group had higher need for assisted ventilation post-operatively (8.1% vs. 3.6%) and significantly higher proportion of patients with prolonged (> 20 days) hospital stay. After median follow-up time of 99.5 months there was no significant difference in mortality or long-term survival between the groups. The median cumulative survival time of 55 months in LDB vs. 36 months in RBC group did not reach significance level. Non-transfused patients had a significantly lower proportion of prolonged hospital stay, and significantly increased survival, compared to transfused patients.

CONCLUSION

Leucocyte depleted transfusions improved the postoperative course following surgery for colorectal cancer, compared with packed red blood cell transfusions.

Perioperative blood transfusions for the recurrence of colorectal cancer

BACKGROUND

The improvement of renal allograft survival by pre-transplantation transfusions alerted the medical community to the potential detrimental effect of transfusions in patients being treated for cancer.

OBJECTIVES

The present meta-analysis aims to evaluate the role of perioperative blood transfusions (PBT) on colorectal cancer recurrence. This is accomplished by validating the results of a previously published meta-analysis (Amato 1998); and by updating it to December 2004.

SEARCH STRATEGY

Published papers were retrieved using Medline, EMBASE, the Cochrane Library, controlled trials web-based registries, or the CCG Trial Database. The search strategy used was: {colon OR rectal OR colorectal} WITH {cancer OR tumor OR neoplasm} AND transfusion. The tendency not to publish negative trials was balanced by inspecting the proceedings of international congresses.

SELECTION CRITERIA

Patients undergoing curative resection of colorectal cancer (classified either as Dukes stages A-C, Astler-Coller stages A-C2, or TNM stages T1-3a/N0-1/M0) were included if they had received any amount of blood products within one month of surgery. Excluded were patients with distant metastases at surgery, and studies with short follow-up or with no data.

DATA COLLECTION AND ANALYSIS

A specific form was developed for data collection. Data extraction was cross-checked, using the most recent publication in case of repetitive ones. Papers' quality was ranked using the method by Evans and Pollock. Odds ratios (OR, with 95% confidence intervals) were computed for each study, and pooled estimates were generated by RevMan (version 4.2). When available, data were stratified for risk factors of cancer recurrence.

MAIN RESULTS

The findings of the 1998 meta-analysis were confirmed, with small variations in some estimates. Updating it through December 2004 led to the identification of 237 references. Two-hundred and one of them were excluded because they analyzed survival (n=22), were repetitive (n=26), letters/reviews (n=66) or had no data (n=87). Thirty-six studies on 12,127 patients were included: 23 showed a detrimental effect of PBT; 22 used also multivariable analyses, and 14 found PBT to be an independent prognostic factor. Pooled estimates of PBT effect on colorectal cancer recurrence yielded overall OR of 1.42 (95% CI, 1.20 to 1.67) against transfused patients in randomized controlled studies. Stratified meta-analyses confirmed these findings, also when stratifying patients by site and stage of disease. The PBT effect was observed regardless of timing, type, and in a dose-related fashion, although heterogeneity was detected. Data on surgical techniques was not available for further analysis.

AUTHORS' CONCLUSIONS

This updated meta-analysis confirms the previous findings. All analyses support the hypothesis that PBT have a detrimental effect on the recurrence of curable colorectal cancers. However, since heterogeneity was detected and conclusions on the effect of surgical technique could not be drawn, a causal relationship cannot still be claimed. Carefully restricted indications for PBT seems necessary.

[Perioperative transfusion in colorectal surgery]

Several studies have evaluated the role and effect of blood transfusion in colorectal surgery. To date, no recommendation concerning its use in colorectal surgery has been yet published. However, blood transfusion is often required in colorectal surgery, especially in anaemic patients who suffer from malignant disease. The aim of this review is to define the effect of blood transfusion on oncologic and operative results, and to evaluate the clinical potential of alternative to allogeneic blood transfusion in order to promote the development of transfusion policy in colorectal surgery.

Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer. Danish RANX05 Colorectal Cancer Study Group

BACKGROUND

The frequency of postoperative infectious complications is significantly increased in patients with colorectal cancer receiving perioperative blood transfusion. It is still debated, however, whether perioperative blood transfusion alters the incidence of disease recurrence or otherwise affects the prognosis.

METHODS

Patient risk variables, variables related to operation technique, blood transfusion and the development of infectious complications were recorded prospectively in 740 patients undergoing elective resection for primary colorectal cancer. Endpoints were overall survival (n = 740) and time to diagnosis of recurrent disease in the subgroup of patients operated on with curative intention (n = 532). The patients were analysed in four groups divided with respect to administration or not of perioperative blood transfusion and development or non-development of postoperative infectious complications.

RESULTS

Overall, 19 per cent of 288 non-transfused and 31 per cent of 452 transfused patients developed postoperative infectious complications (P< 0.001). The median observation period was 6.8 (range 5.4-7.9) years. In a multivariate analysis, risk of death was significantly increased among patients developing infection after transfusion (n = 142) compared with patients receiving neither blood transfusion nor developing infection (n = 234): hazard ratio 1.38 (95 per cent confidence interval (c.i.) 1.05-1.81). Overall survival of patients receiving blood transfusion without subsequent infection (n = 310) and patients developing infection without preceding transfusion (n = 54) was not significantly decreased. In an analysis of disease recurrence the combination of blood transfusion and subsequent development of infection (hazard ratio 1.79 (95 per cent c.i. 1.13-2.82)), localization of cancer in the rectum and Dukes classification were independent risk factors.

CONCLUSION

Blood transfusion per se may not be a risk factor for poor prognosis after colorectal cancer surgery. However, the combination of perioperative blood transfusion and subsequent development of postoperative infectious complications may be associated with a poor prognosis.

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.

Randomized multicentre trial of the influence of recombinant human erythropoietin on intraoperative and postoperative transfusion need in anaemic patients undergoing right hemicolectomy for carcinoma

BACKGROUND

The possible immunosuppressive effect of blood transfusion and its influence on survival after surgery for cancer makes it worthwhile to seek methods to avoid transfusion wherever possible. Patients with right-sided colonic cancer are frequently anaemic. Such patients were entered into a study that employed erythropoietin to avoid homologous transfusion.

METHODS

In a prospectively randomized double-blind placebo-controlled multicentre trial, patients with moderate anaemia (haemoglobin concentration greater than 8.5 g/dl and less than or equal to 13.5 g/dl) presenting with right-sided colonic cancer and scheduled for hemicolectomy were treated with recombinant human erythropoietin (epoetin beta) 20,000 units/day subcutaneously or placebo for at least 10 days over the operative period.

RESULTS

Perioperative treatment with epoetin beta was well tolerated and there were no significant differences in morbidity and mortality. Following hemicolectomy, median cumulative blood loss in the two groups was similar (epoetin beta 440 ml versus placebo 345 ml). Sixteen (33 per cent) of 48 patients treated with epoetin beta and 15 (28 per cent) of 54 in the placebo group received perioperative blood transfusions (P not significant). The increase in reticulocyte count between baseline and the last preoperative value was more pronounced in the epoetin beta group than in those receiving placebo (P = 0.036).

CONCLUSION

Despite the perioperative administration of 20,000 units erythropoietin per day for at least 10 days, it was not possible to reduce the intraoperative and postoperative transfusion need. None the less, a positive change in the haematological variables of treated patients was clearly discernible. The negative result may be due to the short treatment interval and to iron deficiency, which was present in the majority of patients. The general change of attitude towards allogeneic blood transfusion is demonstrated by the overall low frequency of blood transfusion in this study.

Invasive therapy of metastatic colorectal cancer to the liver

Resection, when possible, is still the best hope for cure of colorectal metastasis to the liver. Poor prognostic indicators for survival include heavy tumor burden, the presence of extrahepatic disease, synchronous metastasis, and the inability to perform resection with a 1-cm margin. Questionable poor prognostic indicators include multiple metastases (more than three), bilobar disease, and the need to transfuse patients during resection. Preoperatively, a patient must be evaluated for the extent of liver disease and the presence of extrahepatic disease with a CT of the abdomen and routine studies of the chest. Intraoperatively, a surgeon should be able to perform or obtain ultrasonography of the liver to detect occult metastases and delineate anatomy. The surgeon should be experienced in wedge, segmental, and lobar resection. Equipment for cryotherapy and arterial infusion devices should be available, and staff experienced in these modalities should be present. If all of these factors are present, the options for the invasive treatment of colorectal metastasis to the liver can be carried out in a manner that should provide the most benefit at a low morbidity to this population of patients.

Colorectal cancer--a multivariate analysis of prognostic factors

The data from 1050 patients who had undergone colorectal carcinoma resection at the University of Cologne between 1976 and 1990 were studied. The aim of the study was to determine the concomitant effects on survival of several patient characteristics (sex, age, tumour localization, blood transfusion) and histopathological variables (Dukes' staging). We first calculated survival rates, both including and excluding post-operative mortality. We set up a hierarchical log-linear model for the detection of relationships between selected crossclassified categorial variables. We then used Cox's proportional hazard regression method to study the relationship between survival and different prognostic patterns. Dukes' staging was shown to be a highly discriminating factor in survival (P<0.001). Survival rates were better in women (P<0.001), and better for younger patients (<70 years; P<0.001). Tumour site (colon; P = 0.0362) and blood transfusion (P = 0.0857) also correlated with survival.

Histopathologic, stereologic, epidemiologic, and clinical parameters in the prognostic evaluation of squamous cell carcinoma of the oral cavity

BACKGROUND

Prognostic indicators that could assist in a more precise selection of patients with oral cancer for differentiated therapy would be clinically valuable.

METHODS

A consecutive series of 161 cases of intraoral squamous cell carcinoma (SCC) occurring during a 5-year period in a population of 1.4 million inhabitants, was evaluated by histopathologic (the modified classification of Jakobsson et al.), stereologic, clinical, and epidemiologic parameters and the serum markers hemoglobin and rhesus blood group.

RESULTS

Univariate analysis established a significant prognostic value in terms of cause-specific survival for T stage (P < .0001), stage (P < .0001), maximum tumor diameter (P < .0001), N stage (N+/NO) (P < .0001), alcohol consumption (P = .03), stereologic estimates of nuclear volume (P = .04), and the histomorphologic parameters mode of invasion (P = .001), pattern (P = .01), vascular invasion (P = .02), depth (P = .006), and mean histologic score. Tobacco consumption was borderline significant (P = .055). A multivariate analysis using the Cox proportional hazard analysis showed that both clinical (stage, P < .0001; size, P = .0027), epidemiologic (tobacco consumption, P = .0054), morphohistopathologic (mode of invasion P < .0001), and stereologic (nuclear volume, P = .0010) parameters had an independent significant effect on survival. Inversely, the mean histologic score had no prognostic value. From the final regression model prognostic forecasts were calculated. Twelve patients (25%) with stage I disease had unfavorable histologic and stereologic parameters. The observed survival (+/- 1 standard error of the estimate) for these patients was 33% +/- 18%. The observed survival for stage I patients with more favorable histologic and stereologic characteristics (n = 36) was 76% +/- 8%.

CONCLUSION

The use of a combination of clinical, histologic, epidemiologic, and stereologic parameters will assist the design of treatment strategies for intraoral SCC.

Plasma tetranectin and colorectal cancer

The prognostic significance of plasma tetranectin (PL-TN) in colorectal cancer was retrospectively examined in 504 patients (80 Dukes' A, 174 Dukes' B, 98 Dukes' C and 152 Dukes' D). Follow-up time was 7-12 years. No significant prognostic variable was found for Dukes' A patients by Cox multivariate analysis. In stage B, PL-TN was the second strongest prognostic variable [relative hazard (RH) = 3.3 for patients with PL-TN < or = 7.5 mg/l]. The other prognostic variables were perineural invasion (RH = 3.7), tumour distance < or = 10 cm from the anal verge (RH = 3.0), postoperative radiotherapy (RH = 2.9) and a high carcinoembryonic antigen (CEA) score (RH = 1.8). In Dukes' C, only CEA score and gender were of prognostic significance. For Dukes' D, PL-TN was the only prognostic variable (RH = 1.7). Testing all patients in one multivariate analysis, Dukes' staging was the strongest and PL-TN the second strongest prognostic variable. The shortened survival for patients with low PL-TN levels is illustrated with lifetables.

Extent of blood transfusion and cancer-related mortality after cystectomy and urinary diversion for bladder cancer

OBJECTIVE

To assess the possible adverse effect of peri-operative blood transfusion on cancer-related survival after radical cystectomy for bladder cancer.

PATIENTS AND METHODS

The hospital records of 130 patients treated with cystectomy and urinary diversion for bladder cancer between 1967 and 1986 were retrospectively reviewed.

RESULTS

Standard proportional hazards estimation revealed tumour stage and radiation response after pre-operative irradiation to be significantly associated with cancer-related mortality, whereas age, tumour grade or the extent of peri-operative blood transfusion were not. In models which allowed time varying effects a significantly changed effect of blood transfusion (> or = 7 versus < or = 6 units) was observed, from an initially insignificantly increased relative hazard (RH) (RH = 1.44 at 6 months) to an insignificantly decreased effect after longer follow-up (RH = 0.53 after 2 years).

CONCLUSION

Although no overall association between blood transfusion and cancer-related mortality was found, a tendency towards an increased risk early in the follow-up period was observed if more than 6 units were transfused. However, these results need confirmation in further studies before a restrictive attitude towards peri-operative blood transfusion is recommended.

The effect of previous blood transfusion on lymphocyte subsets and natural killer cell function in patients with colorectal cancer

To elucidate the possible influence of previous blood transfusion on immune functions, the transfusion history of 153 patients admitted to hospital for elective colorectal surgery was correlated with lymphocyte subsets and natural killer (NK) cell function. The subsets determined were CD2, CD3, CD4, CD8, CD16, CD20, CD56, CD57 and HLA-DR-positive. The NK cell function was determined by measuring the killing capacity against cFDA-labelled K562 target cells monitored via a flow-cytometer. We found that 42 patients (27%) had been transfused before surgery, of these 13 had been transfused less than 30 days before surgery and 29 (19%) transfused more than 30 days before (median 10 years, range 0.1-37 years). In transfused patients, we found a significantly reduced number of B lymphocytes (CD20; p = 0.01), a reduction in HLA-DR-positive cells (p = 0.02) and a just significant reduction of NK cell function in transfused compared to nontransfused patients. The reduction in NK cell function is marginal and the NK cell function is within normal range, and probably without clinical significance. Reduction in NK cell function has been described before, whereas the reduction in B cells has not been reported earlier. The results may suggest an impaired humoral immunity and a minor reduction in cellular immunity in patients following blood transfusion.

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.

Blood transfusion has no effect on colorectal cancer survival. A population-based study

This study was conducted to evaluate the impact on survival of perioperative blood transfusion in a series of 698 colorectal cancer patients undergoing radical surgery. Patients were identified, and follow-up was carried out by the local population-based cancer registry. Data on blood transfusion was obtained by record linkage with the files of the blood banks operating in the area covered by the registry. Prognostic factors were age, Dukes stage and topography of the primary tumour. Relative risk (RR) for Dukes B patients was 1.53 [95% confidence interval (CI) 0.94-2.50] and for Dukes C, 3.57 (95% CI 2.22-5.75) when compared with Dukes A patients. For the left colon, RR was 0.96 (0.61-1.52) and for the rectum 1.87 (1.22-2.86) when compared with the right colon. When adjusting for these factors and excluding operative mortality, RR for transfused patients was 1.16 (95% CI 0.87-1.55). It is concluded that blood transfusion does not adversely affect survival in colorectal cancer patients.

Local recurrence of colorectal cancer: the problem, mechanisms, management and adjuvant therapy

Local recurrence of colorectal cancer after 'curative' surgery is a major clinical problem. Typically, 50-70 per cent of patients presenting to a surgical clinic will undergo apparently curative surgery for disease and of these about 10-25 per cent will develop local recurrence, in either the tumour bed or bowel wall. The wide differences in local recurrence rate both between and within institutions is probably caused by variation in surgical technique. The main causes of local recurrence are inadequate excision of the primary tumour or the draining lymph nodes, and intraoperative tumour cell implantation. The most significant single factor prognostic of local recurrence is Dukes' tumour stage. Other important factors include tumour grade and fixity, level of the tumour in the rectum, blood and lymphatic vessel invasion, inadvertent perforation of the tumour during resection, and the surgeon's experience. The prognosis of patients with local recurrence is poor. Prevention of recurrence by adequate surgery and adjuvant therapy as well as its early detection offer the best prospect of improving results.

Blood transfusions and prognosis in colorectal cancer

BACKGROUND

Blood transfusions may adversely affect the prognosis of patients treated surgically for cancer, although definite proof of this adverse effect has not been reported.

METHODS

We carried out a randomized trial to investigate whether the prognosis in patients with colorectal cancer would be improved by a program of autologous blood transfusion as compared with the current practice of allogeneic transfusion. Patients in the autologous-transfusion group were required to donate two units of blood before surgery.

RESULTS

A total of 475 patients were evaluated. We found no significant difference in prognosis between the allogeneic-transfusion group (236 patients) and the autologous-transfusion group (239 patients); colorectal cancer-specific survival rates at four years were 67 percent and 62 percent, respectively (P = 0.39). Among the 423 patients who underwent curative surgery, 66 percent of those in the allogeneic-transfusion group and 63 percent of those in the autologous-transfusion group had no recurrence of colorectal cancer at four years (P = 0.93). We also found that the risk of recurrence was significantly increased in patients who received blood transfusions, either allogeneic or autologous, as compared with patients who did not require transfusions; the relative rates of recurrence were 2.1 (P = 0.01) and 1.8 (P = 0.04), respectively; these rates did not differ significantly from each other.

CONCLUSIONS

The use of autologous blood as compared with allogeneic blood for transfusion does not improve the prognosis in patients with colorectal cancer. Regardless of their type, transfusions are associated with poor prognosis, probably because of the circumstances that necessitate them.

The association of perioperative blood transfusion with colorectal cancer recurrence

The relationship between blood transfusion, disease-free survival, and other potential prognostic factors was prospectively studied in 339 consecutive patients with colorectal cancer. Admission and discharge hematocrit, Dukes' stage, and blood loss were significantly related to both blood transfusion and disease-free survival. Using Cox proportional hazards model, however, the association of transfusion with disease-free survival was significant (p = 0.0196) after controlling for age, sex, blood loss, procedure, tumor differentiation, stage, admission hematocrit, duration of surgery, length of the specimen, and tumor size. Dukes' stage (p < 0.0001) and blood transfusion (p < 0.0001) were the only variables independently related to disease-free survival. Forty per cent (44) of the 110 patients who received transfusions developed cancer recurrence, compared with 22% (50) of the 229 patients who did not receive blood (p < 0.0001). Five-year disease-free survival of the transfused patients was 57%, compared with 77% for nontransfused patients. Patients who developed recurrence received an average of twice as much blood as patients without recurrence (1.26 versus 0.61 units, p = 0.0128). Perioperative blood transfusion is a significant independent prognostic factor for colorectal cancer.

Time to loco-regional recurrence after resection of Dukes' B and C colorectal cancer with or without adjuvant postoperative radiotherapy. A multivariate regression analysis

Factors influencing time to loco-regional recurrence were identified in a multivariate regression analysis of data from a series of 468 radically operated patients (260 Dukes' B and 208 Dukes' C) with carcinoma of the rectum and the rectosigmoid. A number of clinical and pathological characteristics were prospectively collected and recorded. In addition, carcinoembryonic antigen (CEA) was measured within 1 week before surgery. The endpoint used was recurrence below the level of the umbilicus. All patients were followed for at least 5 years or until time of death. The two Dukes' stages B and C were analysed in two separate analyses using the Cox proportional hazards model. In patients with Dukes' B tumours, an increased risk of loco-regional recurrence was associated with perineural invasion, tumour located less than 10 cm from the anal verge, patient aged above 70 years, and small tumour size. In patients with Dukes' C tumours, the necessity to resect neighbour organs, perineural and venous invasion, tumour located less than 10 cm from the anal verge, and large tumour size were all associated with a poor loco-regional outcome. Postoperative radiotherapy was not a significant prognosticator for loco-regional control. An update of the 5-year results of the randomised study of post-operative radiotherapy (50 Gy with 2 Gy per fraction in an overall treatment time of 7 weeks) showed no survival benefit from adjuvant radiotherapy in either Dukes' category and no statistically significant improvement in the 5-year loco-regional control rate. However, when the comparison was restricted to a group of high-risk patients there was a statistically significant benefit from radiotherapy with respect to loco-regional control (P = 0.03) but not with respect to survival (P = 0.23). The potential advantage, in terms of the required number of patients, of restricting clinical trials of intensified loco-regional therapies to the high-risk patients, is illustrated.

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.