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Anic K, Schmidt MW, Schmidt M, Krajnak S, Löwe A, Linz VC, Schwab R, Weikel W, Brenner W, Westphalen C, Rissel R, Hartmann EK, Conradi R, Hasenburg A, Battista MJ. Impact of perioperative red blood cell transfusion, anemia of cancer and global health status on the prognosis of elderly patients with endometrial and ovarian cancer. Front Oncol 2022; 12:967421. [PMID: 36185177 PMCID: PMC9524224 DOI: 10.3389/fonc.2022.967421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Perioperative red blood cell (RBC) transfusions have been associated with increased morbidity and worse oncological outcome in some solid neoplasms. In order to elucidate whether RBC transfusions themselves, the preoperative anemia of cancer (AOC), or the impaired global health status might explain this impact on patients with endometrial cancer (EC) or ovarian cancer (OC), we performed a retrospective, single-institution cohort study. Materials and methods Women older than 60 years with EC or OC were included. The influence of RBC transfusions, AOC, and frailty status determined by the G8 geriatric screening tool (G8 score), as well as the clinical-pathological cancer characteristics on progression-free survival (PFS) and overall survival (OS), was determined by using the Kaplan-Meier method and the Cox regression analyses. Results In total, 263 patients with EC (n = 152) and OC (n = 111) were included in the study. Patients with EC receiving RBC transfusions were faced with a significantly shorter 5-year PFS (79.8% vs. 26.0%; p < 0.001) and 5-year OS (82.6% vs. 25.7%; p < 0.001). In multivariable analyses, besides established clinical-pathological cancer characteristics, the RBC transfusions remained the only significant prognostic parameter for PFS (HR: 1.76; 95%-CI [1.01–3.07]) and OS (HR: 2.38; 95%-CI [1.50–3.78]). In OC, the G8 score stratified the cohort in terms of PFS rates (G8-non-frail 53.4% vs. G8-frail 16.7%; p = 0.010) and AOC stratified the cohort for 5-year OS estimates (non-anemic: 36.7% vs. anemic: 10.6%; p = 0.008). Multivariable Cox regression analyses determined the G8 score and FIGO stage as independent prognostic factors in terms of PFS (HR: 2.23; 95%-CI [1.16–4.32] and HR: 6.52; 95%-CI [1.51–28.07], respectively). For OS, only the TNM tumor stage retained independent significance (HR: 3.75; 95%-CI [1.87–7.53]). Discussion The results of this trial demonstrate the negative impact of RBC transfusions on the prognosis of patients with EC. Contrastingly, the prognosis of OC is altered by the preoperative global health status rather than AOC or RBC transfusions. In summary, we suggested a cumulatively restrictive transfusion management in G8-non-frail EC patients and postulated a more moderate transfusion management based on the treatment of symptomatic anemia without survival deficits in OC patients.
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Affiliation(s)
- Katharina Anic
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- *Correspondence: Katharina Anic,
| | - Mona Wanda Schmidt
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marcus Schmidt
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Slavomir Krajnak
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Amelie Löwe
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Valerie Catherine Linz
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Roxana Schwab
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Wolfgang Weikel
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Walburgis Brenner
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christiane Westphalen
- Department of Geriatric Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - René Rissel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Erik Kristoffer Hartmann
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Roland Conradi
- Blood Transfusion Center, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Annette Hasenburg
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marco Johannes Battista
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Frietsch T, Steinbicker AU, Horn A, Metz M, Dietrich G, Weigand MA, Waters JH, Fischer D. Safety of Intraoperative Cell Salvage in Cancer Surgery: An Updated Meta-Analysis of the Current Literature. Transfus Med Hemother 2022; 49:143-157. [PMID: 35813601 PMCID: PMC9210012 DOI: 10.1159/000524538] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/06/2022] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Allogeneic blood transfusions in oncologic surgery are associated with increased recurrence and mortality. Adverse effects on outcome could be reduced or avoided by using intraoperative autologous blood cell salvage (IOCS). However, there are concerns regarding the safety of the autologous IOCS blood. Previous meta-analyses from 2012 and 2020 did not identify increased risk of cancer recurrence after using autologous IOCS blood. The objective of this review was to reassess a greater number of IOCS-treated patients to present an updated and more robust analysis of the current literature. METHODS This systematic review includes full-text articles listed in PubMed, Cochrane, Cochrane Reviews, and Web of Science. We analyzed publications that discussed cell salvage or autotransfusion combined with the following outcomes: cancer recurrence, mortality, survival, allogeneic transfusion rate and requirements, length of hospital stay (LOS). To rate the strength of evidence, a Grading of Recommendations Assessment, Development and Evaluation (GRADE) of the underlying evidence was applied. RESULTS In the updated meta-analysis, 7 further observational studies were added to the original 27 observational studies included in the former 2020 analysis. Studies compared either unfiltered (n = 2,311) or filtered (n = 850) IOCS (total n = 3,161) versus non-IOCS use (n = 5,342). Control patients were either treated with autologous predonated blood (n = 484), with allogeneic transfusion (n = 4,113), or did not receive a blood transfusion (n = 745). However, the current literature still contains only observational studies on these topics, and the strength of evidence remains low. The risk of cancer recurrence was reduced in recipients of autologous salvaged blood with or without LDF (odds ratio [OR] 0.76, 95% confidence interval [CI]: 0.64-0.90) compared to nontransfused patients or patients with allogeneic transfusion. There was no difference in mortality (OR 0.95, 95% CI: 0.71-1.27) and LOS (mean difference -0.07 days, 95% CI: -0.63 to 0.48) between patients treated with IOCS blood or those in whom IOCS was not used. Due to high heterogeneity, transfusion rates or volumes could not be analyzed. CONCLUSION Randomized controlled trials comparing mortality and cancer recurrence rate of IOCS with or without LDF filtration versus allogeneic blood transfusion were not found. Outcome was similar or better in patients receiving IOCS during cancer surgery compared to patients with allogeneic blood transfusion or nontransfused patients.
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Affiliation(s)
- Thomas Frietsch
- IAKH − German Interdisciplinary Task Force for Clinical Hemotherapy, Marburg, Germany
| | - Andrea U. Steinbicker
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Audrey Horn
- Department of Anesthesiology Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Matthes Metz
- Department of Biostatistics, GCP-Service International Ltd. & Co. KG, Bremen, Germany
| | - Gerald Dietrich
- Department of Anesthesia, Intensive Care Medicine, Pain Therapy and Transfusion Medicine, Rottal-Inn-Kliniken, Eggenfelden, Germany
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jonathan H. Waters
- Anesthesiology & Bioengineering, Patient Blood Management, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dania Fischer
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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Abstract
BACKGROUND Allogeneic blood transfusion is avoidable in many oncological interventions by the use of cell salvage or mechanical autotransfusion (MAT). As irradiation is elaborate and expensive, the safety of leucocyte depletion filters (LDF) for autologous blood from the surgical field might be a more acceptable alternative for the prevention of cancer recurrences. A previous meta-analysis could not identify an increased risk of cancer recurrence. The aim of this review article is to provide an update of a previous meta-analysis from 2012 as well as a safety analysis of cell salvage with LDF due to the improved data situation. MATERIAL AND METHODS This systematic review included all studies in PubMed, Cochrane, Cochrane Reviews and Web of Science on cell salvage or autotransfusion combined with outcomes, e.g. cancer recurrence, mortality, survival, blood transfusion, length of hospital stay (LOS) after the use of MAT without irradiation and with or without LDF. The grades of recommendations (GRADE) assessment of underlying evidence was applied. RESULTS A total of seven new observational studies and seven meta-analyses were found that compared unfiltered or filtered cell salvage with autologous predeposition, allogeneic transfusion or without any transfusion. No randomized controlled trials have been completed. A total of 27 observational and cohort studies were included in a meta-analysis. The evidence level was low. The risk of cancer recurrence in recipients of autologous salvaged blood with or without LDF was reduced (odds ratio, OR 0.71, 95% confidence interval, CI 0.58-0.86) as compared to non-transfused subjects, allogeneic or predeposited autologous transfusion. The transfusion rate could not be assessed due to the substantial selection bias and large heterogeneity. Cell salvage does not change mortality and LOS. Leucocyte depletion studies reported a removal rate of cancer cells in the range of 99.6-99.9%. CONCLUSION Randomized controlled trials on a comparison of MAT and allogeneic blood transfusion as well as LDF and irradiation would be desirable but are not available. From observational trials and more than 6300 subjects and various tumors, cell salvage in cancer surgery with or without LDF appears to be sufficiently safe. The efficacy of leucocyte depletion of autologous salvaged blood is equivalent to irradiation. Unavailability of radiation is not a contraindication for cell salvage use in cancer surgery. By usage of leucocyte depleted salvaged autologous blood, the risks of allogeneic transfusion can be avoided.
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Links between Inflammation and Postoperative Cancer Recurrence. J Clin Med 2021; 10:jcm10020228. [PMID: 33435255 PMCID: PMC7827039 DOI: 10.3390/jcm10020228] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/24/2022] Open
Abstract
Despite complete resection, cancer recurrence frequently occurs in clinical practice. This indicates that cancer cells had already metastasized from their organ of origin at the time of resection or had circulated throughout the body via the lymphatic and vascular systems. To obtain this potential for metastasis, cancer cells must undergo essential and intrinsic processes that are supported by the tumor microenvironment. Cancer-associated inflammation may be engaged in cancer development, progression, and metastasis. Despite numerous reports detailing the interplays between cancer and its microenvironment via the inflammatory network, the status of cancer-associated inflammation remains difficult to recognize in clinical settings. In the current paper, we reviewed clinical reports on the relevance between inflammation and cancer recurrence after surgical resection, focusing on inflammatory indicators and cancer recurrence predictors according to cancer type and clinical indicators.
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Kumar N, Tan JH, Ravikumar N, Tan JYH, Milavec H, Agrawal R, Kannan R, Kumar A. Evaluation of the Feasibility of Transfusing Leucocyte Depletion Filter (LDF) Processed Intra-Operative Cell Salvage (IOCS) Blood in Metastatic Spine Tumour Surgery (MSTS): Protocol for a Non Randomised study (Preprint). JMIR Res Protoc 2019. [DOI: 10.2196/16986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Galaal K, Lopes A, Pritchard C, Barton A, Wingham J, Marques EMR, Faulds J, Palmer J, Vickery PJ, Ralph C, Ferreira N, Ewings P. Trial of intraoperative cell salvage versus transfusion in ovarian cancer (TIC TOC): protocol for a randomised controlled feasibility study. BMJ Open 2018; 8:e024108. [PMID: 30389760 PMCID: PMC6224724 DOI: 10.1136/bmjopen-2018-024108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/21/2018] [Accepted: 09/26/2018] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Ovarian cancer is the leading cause of death from gynaecological cancer, with more than 7000 new cases registered in the UK in 2014. In patients suitable for surgery, the National Institute of Health and Care Excellence guidance for treatment recommends surgical resection of all macroscopic tumour, followed by chemotherapy. The surgical procedure can be extensive and associated with substantial blood loss which is conventionally replaced with a donor blood transfusion. While often necessary and lifesaving, the use of donor blood is associated with increased risks of complications and adverse surgical outcomes. Intraoperative cell salvage (ICS) is a blood conservation strategy in which red cells collected from blood lost during surgery are returned to the patient thus minimising the use of donor blood. This is the protocol for a feasibility randomised controlled trial with an embedded qualitative study and feasibility economic evaluation. If feasible, a later definitive trial will test the effectiveness and cost-effectiveness of ICS reinfusion versus donor blood transfusion in ovarian cancer surgery. METHODS AND ANALYSIS Sixty adult women scheduled for primary or interval ovarian cancer surgery at participating UK National Health Service Trusts will be recruited and individually randomised in a 1:1 ratio to receive ICS reinfusion or donor blood (as required) during surgery. Participants will be followed up by telephone at 30 days postoperatively for adverse events monitoring and by postal questionnaire at 6 weeks and 3 monthly thereafter, to capture quality of life and resource use data. Qualitative interviews will capture participants' and clinicians' experiences of the study. ETHICS AND DISSEMINATION This study has been granted ethical approval by the South West-Exeter Research Ethics Committee (ref: 16/SW/0256). Results will be disseminated via peer-reviewed publications and will inform the design of a larger trial. TRIAL REGISTRATION NUMBER ISRCTN19517317.
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Affiliation(s)
- Khadra Galaal
- Gynaeoncology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - Colin Pritchard
- Research, Development and Innovation, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Andrew Barton
- NIHR research and Design Services (South West), NIHR South West Research Design Service, Plymouth, UK
| | | | | | - John Faulds
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Joanne Palmer
- Research, Development and Innovation, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - Catherine Ralph
- Department of Anaesthesia, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - Paul Ewings
- NIHR research and Design Services (South West), NIHR South West Research Design Service, Plymouth, UK
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Kumar N, Ravikumar N, Tan JYH, Akbary K, Patel RS, Kannan R. Current Status of the Use of Salvaged Blood in Metastatic Spine Tumour Surgery. Neurospine 2018; 15:206-215. [PMID: 30071572 PMCID: PMC6226127 DOI: 10.14245/ns.1836140.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/13/2018] [Indexed: 12/15/2022] Open
Abstract
To review the current status of salvaged blood transfusion (SBT) in metastatic spine tumour surgery (MSTS), with regard to its safety and efficacy, contraindications, and adverse effects. We also aimed to establish that the safety and adverse event profile of SBT is comparable and at least equal to that of allogeneic blood transfusion. MEDLINE and Scopus were used to search for relevant articles, based on keywords such as "cancer surgery," "salvaged blood," and "circulating tumor cells." We found 159 articles, of which 55 were relevant; 20 of those were excluded because they used other blood conservation techniques in addition to cell salvage. Five articles were manually selected from reference lists. In total, 40 articles were reviewed. There is sufficient evidence of the clinical safety of using salvaged blood in oncological surgery. SBT decreases the risk of postoperative infections and tumour recurrence. However, there are some limitations regarding its clinical applications, as it cannot be employed in cases of sepsis. In this review, we established that earlier studies supported the use of salvaged blood from a cell saver in conjunction with a leukocyte depletion filter (LDF). Furthermore, we highlight the recent emergence of sufficient evidence supporting the use of intraoperative cell salvage without an LDF in MSTS.
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Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Nivetha Ravikumar
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Joel Yong Hao Tan
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Kutbuddin Akbary
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Ravish Shammi Patel
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Rajesh Kannan
- Department of Anaesthesiology, National University Hospital, Singapore
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Moulton LJ, Rose PG, Mahdi H. Adverse post-operative outcomes in Jehovah's witnesses with gynecologic cancer within 30 days of surgery: A single institution review of 36 cases. Gynecol Oncol Rep 2017; 22:32-36. [PMID: 29018838 PMCID: PMC5626912 DOI: 10.1016/j.gore.2017.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 07/31/2017] [Accepted: 09/19/2017] [Indexed: 11/24/2022] Open
Abstract
Rates of blood transfusion are reported as high as 32% in women undergoing major gynecologic cancer surgery. Therefore, care of the gynecologic oncology patient who refuses blood products, such as Jehovah's witnesses, can pose a unique challenge. The objective of this study was to determine rate of adverse post-operative outcomes within 30 days of surgery in Jehovah's witnesses with gynecologic cancer. This was a retrospective cohort study of Jehovah's witnesses undergoing laparotomy or minimally invasive surgery (MIS) for gynecologic cancer at a single institution. Data for post-adverse complications within 30 days of surgery were recorded. In total, 36 patients were included with a median age of 58.5 years (32–85 years). The majority had endometrial adenocarcinoma (n = 23; 63.9%) or epithelial ovarian, fallopian tube or peritoneal cancer (EOC) (n = 8; 22.2%). 61.1% (n = 22) of patients underwent laparotomy and 38.9% (n = 14) had MIS procedures. 31.8% of laparotomies (n = 7) were terminated prematurely due to surgeon concern for ongoing blood loss. In patients with advanced stage EOC, the rate of suboptimal cytoreduction (> 1 cm) was 50%. In the laparotomy cohort, there were four (18.2%) ICU admissions and two (9.1%) mortalities. The time to adjuvant chemotherapy or radiation was 45.5 days (31–64) for laparotomy compared to 35.0 days (12–64) for MIS. While the majority of patients (97.2%) were unwilling to accept packed red blood cells, over one third (38.9%) were agreeable to autologous blood transfusion. Additionally, five (13.9%) patients were accepting of fresh frozen plasma, six (16.7%) patients were agreeable to cryoprecipitate and seven (19.4%) patients were willing to accept platelet transfusions. There is a high rate of postoperative adverse outcomes among Jehovah's witnesses undergoing laparotomy for gynecologic malignancy compared. Acceptance of blood products is low among Jehovah's witnesses, even in the setting of major oncologic surgery. Rate of adverse perioperative outcomes is high in Jehovah's witnesses. Laparotomy is associated with higher mortality and ICU admission. Acceptance of blood products is low in Jehovah's witnesses with gynecologic cancer. Patients should be counseled on risks of blood product refusal prior to surgery.
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Affiliation(s)
- Laura J. Moulton
- Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
- Corresponding author.
| | - Peter G. Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Haider Mahdi
- Division of Gynecologic Oncology, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
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Kumar N, Zaw AS, Kantharajanna SB, Khoo BL, Lim CT, Thiery JP. Metastatic efficiency of tumour cells can be impaired by intraoperative cell salvage process: truth or conjecture? Transfus Med 2017; 27 Suppl 5:327-334. [PMID: 28833768 DOI: 10.1111/tme.12453] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/17/2017] [Accepted: 07/21/2017] [Indexed: 01/16/2023]
Abstract
The use of salvaged blood in oncological surgery has been a matter of controversy over the years. This is due to the concern of systemic dissemination of reinfused tumour cells. Recent literature, across disciplines, has shed considerable light on its safety in terms of tumour recurrence, progression and overall survival rates. This clinical safety demonstrates the apparent metastatic inefficiency of reinfused tumour cells. The proof of this concept comes from various studies that have shown that salvaged blood has no tumour cells, or has a significantly lower count as compared to the patient's original circulatory tumour load. Recently, we took a step further and found that the tumour cells in the salvaged blood lose the capacity to replicate. In this review, we revisited the safety of salvaged blood from the point of view of metastatic potential. We have presented basic and applied science evidence regarding the innocuous nature of tumour cells that have been subjected to the cell salvage process. The understanding of the metastatic efficiency or the lack of it in tumour cells subjected to salvage process is key to allay the concerns conventionally associated with the use of salvaged blood in tumour surgery. Based on the available literature, we surmise that the prevalent apprehensions on the usage of salvaged blood are ill-founded and further substantiate why tumour cells in the salvaged blood could be regarded as cells with non-metastatic potential.
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Affiliation(s)
- N Kumar
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - A S Zaw
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - S B Kantharajanna
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - B L Khoo
- BioSystems and Micromechanics (BioSyM) Inter-Disciplinary Research Group, Singapore MIT Alliance for Research and Technology (SMART), National University of Singapore, Singapore, Singapore
| | - C T Lim
- Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore
| | - J P Thiery
- BioSystems and Micromechanics (BioSyM) Inter-Disciplinary Research Group, Singapore MIT Alliance for Research and Technology (SMART), National University of Singapore, Singapore, Singapore
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Cybulska P, Goss C, Tew WP, Parameswaran R, Sonoda Y. Indications for and complications of transfusion and the management of gynecologic malignancies. Gynecol Oncol 2017; 146:416-426. [PMID: 28528916 PMCID: PMC5527999 DOI: 10.1016/j.ygyno.2017.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 05/01/2017] [Accepted: 05/08/2017] [Indexed: 02/06/2023]
Abstract
Anemia, which is highly prevalent in oncology patients, is one of the most established negative prognostic factors for several gynecologic malignancies. Multiple factors can cause or contribute to the development of anemia in patients with gynecologic cancers; these factors include blood loss (during surgery or directly from the tumor), renal impairment (caused by platinum-based chemotherapy), and marrow dysfunction (from metastases, chemotherapy, and/or radiation therapy). Several peri- and intra-operative strategies can be used to optimize patient management and minimize blood loss related to surgery. Blood transfusions are routinely employed as corrective measures against anemia; however, blood transfusions are one of the most overused healthcare interventions. There are safe and effective evidence-based blood transfusion strategies used in other patient populations that warrant further investigation in the surgical oncology setting. Blood is a valuable healthcare resource, and clinicians can learn to use it more judiciously through knowledge of the potential risks and complications of blood interventions, as well as the ability to properly identify the patients most likely to benefit from such interventions.
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Affiliation(s)
- Paulina Cybulska
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cheryl Goss
- Hematology and Coagulation Laboratory Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William P Tew
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Rekha Parameswaran
- Transfusion Medicine Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Hematology Service, Department of Medicine, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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Zaw AS, Bangalore Kantharajanna S, Kumar N. Is Autologous Salvaged Blood a Viable Option for Patient Blood Management in Oncologic Surgery? Transfus Med Rev 2017; 31:56-61. [DOI: 10.1016/j.tmrv.2016.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 06/03/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
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Are we ready for the use of intraoperative salvaged blood in metastatic spine tumour surgery? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:3997-4007. [PMID: 26188770 DOI: 10.1007/s00586-015-4112-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 07/04/2015] [Accepted: 07/05/2015] [Indexed: 01/27/2023]
Abstract
PURPOSE To evaluate the feasibility of using intraoperative cell salvage (IOCS) in combination with leucocyte depletion filter (LDF) in eliminating tumour cells from blood salvaged during metastatic spine tumour surgery (MSTS). This is with the view to pave the path for use of IOCS-LDF in MSTS and musculoskeletal oncological surgery. METHODS Sixty consecutive patients with known primary epithelial tumour, who were offered surgery for metastatic spine disease at our university hospital, were recruited. Blood samples were collected at three different stages during surgery: from operative field prior to IOCS processing, after IOCS processing and after IOCS-LDF processing. Three separate samples (5 ml each) were taken at each stage. Samples were examined by cell block technique using immunohistochemical monoclonal antibodies to identify tumour cells of epithelial origin in the samples. RESULTS Of 60 patients, ten were excluded for not fulfilling the inclusion criteria leaving 50 patients. Malignant tumour cells were detected in the samples from operative field prior to IOCS processing in 24 patients and in the samples from the transfusion bag post-IOCS processing in 4 patients. No viable malignant cells were detectable in any of the blood samples after passage through both IOCS and LDF. CONCLUSIONS The findings support the notion that IOCS-LDF combination works effectively in eliminating tumour cells from salvaged blood so this technique can possibly be applied in MSTS and even musculoskeletal oncological surgery. This concept can then be extended to other oncological surgeries in general with further appropriate clinical studies.
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Transfusions of blood products and cancer outcomes. ACTA ACUST UNITED AC 2015; 62:461-7. [PMID: 25896733 DOI: 10.1016/j.redar.2015.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 01/17/2023]
Abstract
Approximately half of cancer patients scheduled for major surgery are anemic. Also, a significant number of patients will present to the operating room with low platelet counts and coagulopathic disorders. Unfortunately, administration of red blood cells, platelets concentrates and fresh-frozen plasma is associated with unwanted adverse effects including fever, hemolytic reactions and transfusion-related immunomodulation (TRIM). TRIM is a multifactorial immunologic phenomenon in the recipient mediated by donor leukocytes, microparticles such as ectosomes, and growth factors. As some of these molecules are secreted in a time-dependent manner, blood storage time may play an important in TRIM, although the evidence is limited. Perioperative administration of red blood cells and associated TRIM has also been associated with increased recurrence of certain solid tumors, such as colorectal, lung, and hepatobiliary tumors. In this continuing education article, we review the available evidence on how perioperative blood product transfusions can affect oncological outcomes, such as cancer recurrence.
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Kumar N, Lam R, Zaw AS, Malhotra R, Tan J, Tan G, Setiobudi T. Flow cytometric evaluation of the safety of intraoperative salvaged blood filtered with leucocyte depletion filter in spine tumour surgery. Ann Surg Oncol 2014; 21:4330-5. [PMID: 25069862 DOI: 10.1245/s10434-014-3950-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Intraoperative cell salvage (IOCS) has not been widely adopted in oncological surgery due to the hypothetical concern of reinfusion of malignant cells. We evaluated the feasibility of IOCS in combination with leucocyte depletion filter (LDF) in metastatic spine tumour surgery (MSTS). METHODS Patients with known primary epithelial tumour, operated for metastatic spinal disease, were recruited. Blood samples were collected at five different stages during surgery: 2 stages from patient vein during induction and at the time of maximum tumour manipulation, 3 stages from the operative blood prior to IOCS processing, after IOCS processing, and after IOCS-LDF processing. Of the samples taken at each stage, 5 ml were analyzed for tumour cells using flow cytometry. RESULTS Of 12 patients recruited, only 11 could be finally analyzed. Flow cytometry analysis of their samples showed that 8 of 11 patients had tumour cells in the unfiltered salvaged blood. In filtered salvaged blood, the tumour cell count was zero in the majority of samples (8/11 patients), whereas three patients' samples had a few tumour cells. The mean difference between the tumour cell quantity in the samples from the patient vein and filtered salvaged blood was significant. CONCLUSIONS IOCS-LDF was shown to be effective in removing tumour cells from the blood salvaged during MSTS. If there were any tumour cells found, the quantity was significantly less than that in the patient's circulation. The results of this study reiterates the conclusions of our previous published work where we showed that IOCS-LDF treated blood in MSTS is safe for transfusion.
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Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, NUHS Tower Block, Level 11, National University Health System, Singapore, 119228, Singapore,
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Hoogendam JP, Verheijen RHM, Wegner I, Zweemer RP. Oncological outcome and long-term complications in robot-assisted radical surgery for early stage cervical cancer: an observational cohort study. BJOG 2014; 121:1538-45. [DOI: 10.1111/1471-0528.12822] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- JP Hoogendam
- Department of Gynaecological Oncology; Woman and Baby Division; University Medical Centre Utrecht; Utrecht the Netherlands
| | - RHM Verheijen
- Department of Gynaecological Oncology; Woman and Baby Division; University Medical Centre Utrecht; Utrecht the Netherlands
| | - I Wegner
- Department of Gynaecological Oncology; Woman and Baby Division; University Medical Centre Utrecht; Utrecht the Netherlands
| | - RP Zweemer
- Department of Gynaecological Oncology; Woman and Baby Division; University Medical Centre Utrecht; Utrecht the Netherlands
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Kumar N, Ahmed Q, Lee VKM, Chen Y, Zaw AS, Goy R, Agrawal RV, Dhewar AN, Wong HK. Can There be a Place for Intraoperative Salvaged Blood in Spine Tumor Surgery? Ann Surg Oncol 2014; 21:2436-43. [DOI: 10.1245/s10434-014-3569-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Indexed: 01/16/2023]
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Use of intraoperative cell-salvage for autologous blood transfusions in metastatic spine tumour surgery: a systematic review. Lancet Oncol 2014; 15:e33-41. [DOI: 10.1016/s1470-2045(13)70245-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Cata JP, Wang H, Gottumukkala V, Reuben J, Sessler DI. Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions. Br J Anaesth 2013; 110:690-701. [PMID: 23599512 DOI: 10.1093/bja/aet068] [Citation(s) in RCA: 306] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Debate on appropriate triggers for transfusion of allogeneic blood products and their effects on short- and long-term survival in surgical and critically ill patients continue with no definitive evidence or decisive resolution. Although transfusion-related immune modulation (TRIM) is well established, its influence on immune competence in the recipient and its effects on cancer recurrence after a curative resection remains controversial. An association between perioperative transfusion of allogeneic blood products and risk for recurrence has been shown in colorectal cancer in randomized trials; whether the same is true for other types of cancer remains to be determined. This article focuses on the laboratory, animal, and clinical evidence to date on the mechanistic understanding of inflammatory and immune-modulatory effects of blood products and their significance for recurrence in the cancer surgical patient.
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Affiliation(s)
- J P Cata
- Department of Anaesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Centre, 1515 Holcombe Blvd, Unit 409, Houston, TX 77030, USA.
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Chen Y, Tai BC, Nayak D, Kumar N, Chua KH, Lim JW, Goy RWL, Wong HK. Blood loss in spinal tumour surgery and surgery for metastatic spinal disease: a meta-analysis. Bone Joint J 2013; 95-B:683-8. [PMID: 23632682 DOI: 10.1302/0301-620x.95b5.31270] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is currently no consensus about the mean volume of blood lost during spinal tumour surgery and surgery for metastatic spinal disease. We conducted a systematic review of papers published in the English language between 31 January 1992 and 31 January 2012. Only papers that clearly presented blood loss data in spinal surgery for metastatic disease were included. The random effects model was used to obtain the pooled estimate of mean blood loss. We selected 18 papers, including six case series, ten retrospective reviews and two prospective studies. Altogether, there were 760 patients who had undergone spinal tumour surgery and surgery for metastatic spinal disease. The pooled estimate of peri-operative blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic blood loss as high as 5000 ml, which is rare. Aside from two studies that reported large amounts of mean blood loss (> 5500 ml), the resulting funnel plot suggested an absence of publication bias. This was confirmed by Egger's test, which did not show any small-study effects (p = 0.119). However, there was strong evidence of heterogeneity between studies (I(2) = 90%; p < 0.001). Spinal surgery for metastatic disease is associated with significant blood loss and the possibility of catastrophic blood loss. There is a need to establish standardised methods of calculating and reporting this blood loss. Analysis should include assessment by area of the spine, primary pathology and nature of surgery so that the amount of blood loss can be predicted. Consideration should be given to autotransfusion in these patients.
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Affiliation(s)
- Y Chen
- National University Health System, Department of Orthopaedic Surgery, NUHS Tower Block, Level 11, 1E Kent Ridge Road, 119228, Singapore
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Should intraoperative cell-salvaged blood be used in patients with suspected or known malignancy? Can J Anaesth 2012; 59:1058-70. [PMID: 22996966 DOI: 10.1007/s12630-012-9781-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 08/23/2012] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Intraoperative cell salvage (ICS) is used as an alternative to allogeneic blood transfusion in an attempt to avoid or minimize the risks associated with allogeneic blood. Intraoperative cell salvage is generally avoided in surgeries where malignancy is confirmed or suspected due to concern for potential metastasis or cancer recurrence. The application of post-processing methods for ICS is hypothesized to eliminate this potential risk. The purpose of this narrative review is to examine the in vitro experimental evidence as it pertains to the removal of tumour cells from ICS blood and to review the clinical studies where ICS blood has been used in patients with malignancy. SOURCE A search of the English literature for relevant articles published from 1973 to 2012 was undertaken using MEDLINE and Cochrane databases. Bibliographies were cross-referenced to locate further studies. PRINCIPAL FINDINGS Leukoreduction filters are an effective method for removal of malignant cells from ICS blood. Small non-randomized clinical studies to date do not show evidence of an increased rate of metastasis or cancer recurrence. Although a theoretical risk of disease recurrence persists, the decision to use autologous ICS blood must be weighed against the known risks of allogeneic blood transfusion. CONCLUSION Transfusion of autologous blood harvested via ICS should be considered a viable option for reduction or avoidance of allogeneic product during many oncologic surgeries and may be a lifesaving option for those patients who refuse allogeneic blood products.
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Intraoperative autologous blood transfusion use during radical hysterectomy for cervical cancer: long-term follow-up of a prospective trial. Arch Gynecol Obstet 2012; 286:717-21. [PMID: 22569711 DOI: 10.1007/s00404-012-2351-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 04/19/2012] [Indexed: 01/07/2023]
Abstract
PURPOSE A primary operative complication of radical hysterectomy for cervical cancer is hemorrhage. Intraoperative autologous blood transfusion (ABT) may be beneficial in reducing the need for homologous blood transfusion. METHODS Our institution published a prospective cohort study examining the use of ABT in cervical cancer patients undergoing radical hysterectomy in 1995. Patients who were initially consented to participate in this prospective trial using intraoperative ABT (cell saver) were evaluated with a median follow-up of 3 years. We sought to update this original report with 16-year follow-up data collected from the clinical charts, Tumor Registry, and the Social Security Death Index. RESULTS Two groups of patients undergoing radical hysterectomy were compared: patients who received ABT, and those who did not. Of the 71 original patients, all were included in this updated review, with an average follow-up of 12.4 years for both groups. Originally, thirty-one patients received an ABT. In this group, 1 patient was lost to follow-up, and 4 (12.9 %) are deceased including 1 (3 %) with disease. In the non-autologous group, there were 7 (17.5 %) patient deaths, including 3 (7.5 %) with disease. Eighty-three percent were alive after 12 years in both groups. The ABT group had 1 patient (3 %) who developed a secondary malignancy, a colon adenocarcinoma. The non-autologous group had 2 patients (5 %) who developed a secondary malignancy; one patient developed multiple myeloma and one patient developed a verrucous cancer of the tongue. CONCLUSIONS Autologous blood transfusion during radical hysterectomy for cervical cancer appears safe and effective.
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Waters JH, Yazer M, Chen YF, Kloke J. Blood salvage and cancer surgery: a meta-analysis of available studies. Transfusion 2012; 52:2167-73. [PMID: 22321196 DOI: 10.1111/j.1537-2995.2011.03555.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Intraoperative blood salvage (IBS) is a technique that is frequently used in major blood loss surgery. Classically, it is avoided during cancer surgery where a fear exists of entraining cancer cells into the shed blood. In this study, all reports of this practice were collected to determine if this fear is warranted. STUDY DESIGN AND METHODS A literature search was performed including the search phrases "blood salvage,""intraoperative blood salvage,""cell salvage,""cell saver,""cell saving,""autotransfusion," and "autologous transfusion." Data extracted from suitable papers included the authors' names, publication year, cancer type, exclusion criteria, sample size, length of follow-up, and the mean patient age. The primary endpoint of this meta-analysis was a comparison of the odds ratio (OR) for cancer recurrence or the development of metastases. RESULTS Eleven studies were included in the analysis. The pooled summary of the OR was 0.65 (95% confidence interval, 0.43-0.98; p = 0.0391) using a random-effects model. Measures of heterogeneity, Q-statistics (p= 0.1615) and I(2) (30.90%), did not indicate a high degree of between-study variability. CONCLUSIONS While significant variability existed between studies, this meta-analysis suggests that outcomes after the use of IBS are not inferior to traditional intraoperative allogeneic transfusion. An adequately powered prospective, randomized trial of IBS use is required to determine its true risk during cancer surgery.
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Affiliation(s)
- Jonathan H Waters
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Simou M, Thomakos N, Zagouri F, Vlysmas A, Akrivos N, Zacharakis D, Papadimitriou CA, Dimopoulos MA, Rodolakis A, Antsaklis A. Non-blood medical care in gynecologic oncology: a review and update of blood conservation management schemes. World J Surg Oncol 2011; 9:142. [PMID: 22051161 PMCID: PMC3225312 DOI: 10.1186/1477-7819-9-142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 11/03/2011] [Indexed: 11/29/2022] Open
Abstract
This review attempts to outline the alternative measures and interventions used in bloodless surgery in the field of gynecologic oncology and demonstrate their effectiveness. Nowadays, as increasingly more patients are expressing their fears concerning the potential risks accompanying allogenic transfusion of blood products, putting the theory of bloodless surgery into practice seems to gaining greater acceptance. An increasing number of institutions appear to be successfully adopting approaches that minimize blood usage for all patients treated for gynecologic malignancies. Preoperative, intraoperative and postoperative measures are required, such as optimization of red blood cell mass, adequate preoperative plan and invasive hemostatic procedures, assisting anesthetic techniques, individualization of anemia tolerance, autologous blood donation, normovolemic hemodilution, intraoperative cell salvage and pharmacologic agents for controlling blood loss. An individualised management plan of experienced personnel adopting a multidisciplinary team approach should be available to establish non-blood management strategies, and not only on demand of the patient, in the field of gynecologic oncology with the use of drugs, devices and surgical-medical techniques.
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Affiliation(s)
- Maria Simou
- Department of Obstetrics and Gynecology, Alexandra Hospital, School of Medicine, University of Athens, Greece
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Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944-82. [PMID: 21353044 DOI: 10.1016/j.athoracsur.2010.11.078] [Citation(s) in RCA: 859] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 11/20/2010] [Accepted: 11/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. METHODS The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. RESULTS In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. CONCLUSIONS Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.
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Feuer G, Benigno B, Krige L, Alvarez P. Comparison of a novel surgical approach for radical hysterectomy: robotic assistance versus open surgery. J Robot Surg 2009; 3:179. [DOI: 10.1007/s11701-009-0159-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 09/18/2009] [Indexed: 11/24/2022]
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Boggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, Fowler WC. A case-control study of robot-assisted type III radical hysterectomy with pelvic lymph node dissection compared with open radical hysterectomy. Am J Obstet Gynecol 2008; 199:357.e1-7. [PMID: 18928973 DOI: 10.1016/j.ajog.2008.06.058] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 03/18/2008] [Accepted: 06/19/2008] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purpose of this study was to compare robotically assisted hysterectomy (RAH) with open (ORH) type III radical hysterectomy in the treatment of early-stage cervical cancer. STUDY DESIGN The outcomes of 51 consecutive patients who underwent RAH were compared with the outcomes of 49 patients who underwent ORH. RESULTS There were no differences with regard to patient demographics. There were significant differences between the groups with regard to operative blood loss (P < .0001), operative time (P = .0002), and lymph node retrieval (P = .0003), all of which were in favor of the RAH cohort. All patients with RAH were discharged on postoperative day 1, compared with a 3.2-day average hospitalization for the cohort with ORH. The incidence of postoperative complications was 7.8% and 16.3% for the RAH and ORH cohorts, respectively (P = .35). CONCLUSION Robotic type III radical hysterectomy with pelvic node dissection is feasible and may be preferable over open radical hysterectomy in patients with early-stage cervical cancer. Further study will determine procedure generalizability and long-term oncologic outcomes.
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Nagarsheth NP, Shander A, Malovany R, Tzeng J, Ibrahim I. Bloodless surgery in a Jehovah's Witness patient with a 12.7-kg uterine leiomyosarcoma. JOURNAL OF SURGICAL EDUCATION 2007; 64:212-9. [PMID: 17706574 DOI: 10.1016/j.jsurg.2007.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Revised: 03/20/2007] [Accepted: 03/21/2007] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Bloodless surgery aims to optimize outcomes in patients undergoing surgical procedures who wish to avoid allogeneic transfusion. Using a series of interventions and management strategies related to this goal, patients who were previously considered extremely high risk or inoperable without a blood transfusion can now undergo complex surgical procedures with acceptable outcomes. The techniques of bloodless surgery have been incorporated in order to care for a patient with a large uterine sarcoma with involvement and invasion into adjacent organs. CASE A 52-year-old female Jehovah's Witness patient refusing allogeneic blood transfusion presented to the gynecologic oncology division with a 40-cm pelvic mass and anemia. She was enrolled into the bloodless surgery program at the authors' institution and subsequently underwent surgical resection of a 12.7-kg uterine leiomyosarcoma. Although her intraoperative course was significant for severe anemia with a hemoglobin of 2.5 g/dl and her postoperative course required long-term hospitalization, the patient regained full function to her preoperative performance status. CONCLUSIONS Bloodless surgery in patients with a potential for large-volume intraoperative blood loss requires a well-organized systematic, multidisciplinary approach to achieve the best possible outcome.
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Affiliation(s)
- Nimesh P Nagarsheth
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Englewood Hospital and Medical Center, Englewood, New Jersey, USA.
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Abstract
PURPOSE OF REVIEW As a result of advances in pathogen testing and transfusion standards over the last decade, the risk of disease transmission through allogeneic blood transfusions has decreased markedly. The effects of allogeneic blood transfusions on the immune system, however, have received more attention, as they appear to influence outcome. The following review summarizes the effects of allogeneic blood transfusions on selected outcome parameters and the influence of white blood cell reduction on these parameters. RECENT FINDINGS Adverse effects of allogeneic blood transfusions on outcome variables such as postoperative infection, cancer recurrence, pulmonary function, length of stay, and mortality have been shown in multiple trials, but most were not randomized or blinded. One proposed approach to reduce unwanted side-effects is to reduce the donor's white blood cell count before transfusion. This can be done either by individual bedside filtration or by pre-storage (or post-storage) universal white blood cell reduction. Studies investigating this approach have yielded conflicting results. SUMMARY Although the results of a number of studies suggest a negative impact of allogeneic blood transfusions on immune function and consequently outcome parameters, this has not been proven in rigorously controlled randomized trial, or in meta-analyses. Reduction of white blood cells might be beneficial in selected patient populations, but at this time does not appear warranted in the general surgical population. As universal white blood cell reduction is a very costly process, it probably should not be implemented until such a benefit is proven.
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Affiliation(s)
- Danja Strumper-Groves
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia 22908-0710, USA.
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Goodnough LT. Rationale for Blood Conservation. Surg Infect (Larchmt) 2005. [DOI: 10.1089/sur.2005.6.s-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Stoffel JT, Topjian L, Libertino JA. Analysis of peripheral blood for prostate cells after autologous transfusion given during radical prostatectomy. BJU Int 2005; 96:313-5. [PMID: 16042720 DOI: 10.1111/j.1464-410x.2005.05621.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- John T Stoffel
- Department of Urology, Lahey Clinic, Burlington, MA, USA.
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Goodnough LT. Rationale for blood conservation. Surg Infect (Larchmt) 2005; 6 Suppl 1:S3-8. [PMID: 19284355 DOI: 10.1089/sur.2005.6.s1-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Exposure of patients to allogeneic blood transfusion can be minimized or avoided by the systematic use of multiple blood conservation techniques. Current use of these technologies is variable. METHODS Review of pertinent English language literature. RESULTS Enthusiasm for preoperative autologous blood donation (PAD) has declined considerably, perhaps due to increased cost and inconvenience to patients. Acute normovolemic hemodilution (ANH) has several practical advantages over PAD, but has not become generally accepted as a blood conservation strategy. Erythropoietin, iron, and artificial oxygen carriers are pharmacologic alternatives. CONCLUSIONS Pharmacologic stimulation of erythropoiesis offers substantial potential to progress toward a goal of bloodless medicine. The potential of artificial blood substitutes is still being defined.
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Affiliation(s)
- Lawrence T Goodnough
- Department of Pathology and Medicine, Transfusion Service, Stanford University Medical Center, Stanford, California 94305-5626, USA.
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Hertel H, Köhler C, Michels W, Possover M, Tozzi R, Schneider A. Laparoscopic-assisted radical vaginal hysterectomy (LARVH): prospective evaluation of 200 patients with cervical cancer. Gynecol Oncol 2003; 90:505-11. [PMID: 13678717 DOI: 10.1016/s0090-8258(03)00378-0] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the survival of cervical cancer patients treated with laparoscopically assisted radical vaginal hysterectomy (LARVH). We quantify morbidity and correlate survival with known risk factors. METHODS Between August 1994 and June 2002, 200 patients with cervical cancer (TNM stage 1a1, L1 n = 6, 1a2 n = 21, 1b1 n = 89, 1b2 n = 26, 2a n = 11, 2b n = 45, 3a n = 1, 4 n = 1; squamous cell carcinoma 76.5%, adenocarcinoma 23.5%) were treated with LARVH (type II n = 102, type III n = 98). RESULTS Paraaortic lymphadenectomy was performed in 170 (85%) patients and pelvic lymphadenectomy was performed in all 200 patients. In 26 (13%) patients positive lymph nodes were found. Major intraoperative injuries occurred in 6% of patients. Postoperative complications occurred in 8% of patients. Incidence of complications decreased significantly when comparing the first half with the second half of patients. After a median follow-up time of 40 months, overall 5-year survival could be projected to 83%; 18.5% of patients experienced recurrence with 35% exclusively extrapelvic and 11% of patients died of recurrence. Independent prognostic factors for recurrence-free survival were tumor stage, lymph node status, and combined involvement of lymphovascular and angiovascular space. In the absence of these risk factors projected 5-year survival was 98%. CONCLUSION Patients with tumor <4 cm, negative lymph nodes, and the absence of the combination of angio- and lymphovascular space involvement can be identified by laparoscopic staging and are ideal candidates for LARVH.
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Affiliation(s)
- Hermann Hertel
- Department of Gynecology, Friedrich Schiller University of Jena, Bachstrasse 18, D-07740 Jena, Germany
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Goodnough LT, Shander A, Spence R. Bloodless medicine: clinical care without allogeneic blood transfusion. Transfusion 2003; 43:668-76. [PMID: 12702192 DOI: 10.1046/j.1537-2995.2003.00367.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Anaemia is a common complication of cancer. The incidence is variable and depends on several factors. A linear correlation between haemoglobin levels and quality of life (QOL) parameters has been found. Erythropoiesis is a finely regulated responsive process and erythropoietin (EPO) is the most important factor influencing progenitor cell proliferation. Impaired EPO production is mediated by inflammatory cytokines liberated in cancer patients. For this reason, EPO has been proposed as an alternative to blood transfusions, which involve many hazards. EPO treatment has been found to be effective in preventing anaemia and reducing the need for blood transfusions, although it would be useful to identify high-risk patient subgroups who would benefit most from this expensive treatment.
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Affiliation(s)
- S Mercadante
- Pain Relief and Palliative Care Unit, La Maddalena Clinic for Cancer, Palermo, Italy.
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Abstract
Radical abdominal hysterectomy and pelvic lymphadenectomy remain the gold standard procedures for the treatment of early cervical cancer. Over the years, the establishment of formal gynecologic oncology training programs, general medical advancements, and new surgical techniques have resulted in a satisfactory tumor resection, with improved overall therapeutic index and reliable cure rates. The role of neoadjuvant and adjuvant therapy continues to be defined as the results from randomized trials emerge.
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Affiliation(s)
- N R Abu-Rustum
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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