Perioperative blood transfusion adversely affects prognosis of patients with stage I non-small-cell lung cancer

Blood transfusions may adversely affect survival outcomes of patients with lung cancer: a systematic review and meta-analysis

Background

Despite common use in clinical practice, the impact of blood transfusions on prognosis among patients with lung cancer remains unclear. The purpose of the current study is to perform an updated systematic review and meta-analysis to evaluate the influence of blood transfusions on survival outcomes of lung cancer patients.

Methods

We searched PubMed, Embase, Cochrane Library, and Ovid MEDLINE for publications illustrating the association between blood transfusions and prognosis among people with lung cancer from inception to November 2019. Overall survival (OS) and disease-free survival (DFS) were the outcomes of interest. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using the random-effects model. Study heterogeneity was evaluated with the I² test. Publication bias was explored via funnel plot and trim-and-fill analyses.

Results

We included 23 cohort studies with 12,175 patients (3,027 cases and 9,148 controls) for meta-analysis. Among these records, 22 studies investigated the effect of perioperative transfusions, while one examined that of transfusions during chemotherapy. Two studies suggested the possible dose-dependent effect in accordance with the number of transfused units. In pooled analyses, blood transfusions deleteriously influenced both OS (HR=1.35, 95% CI: 1.14–1.61, P<0.001, I²=0%) and DFS (HR=1.46, 95% CI: 1.15–1.86, P=0.001, I²=0%) of people with lung cancer. No evidence of significant publication bias was detected in funnel plot and trim-and-fill analyses (OS: HR=1.26, 95% CI: 1.07–1.49, P=0.006; DFS: HR=1.35, 95% CI: 1.08–1.69, P=0.008).

Conclusions

Blood transfusions were associated with decreased survival of patients with lung cancer.

Prognostic impact of blood transfusion in patients with metastatic non-small cell lung cancer receiving chemotherapy

PURPOSE

To investigate the prognostic effects of Allogeneic Blood Transfusion (ABT) in patients with metastatic Non-Small Cell Lung Cancer (NSCLC) receiving Chemotherapy (CT) in the first-line treatment, comparing untransfused patients to those receiving blood transfusion during treatment period or before treatment period.

METHODS

This was a retrospective study of 433 patients with metastatic NSCLC receiving CT in the first-line treatment. Patients were categorized into 3 groups according to the transfusion strategy as follows; group-U(Untransfused patients, n = 303), group-B(patients receiving transfusion Before treatment period, n = 43), and group-D(patients receiving transfusion During treatment period, n = 87).

RESULTS

There were 433 patients in the analysis, consisting of 388 (89.6%) males, with a median age of 60 years(range, 21-92). The median Overall Survival(mOS) according to the ABT was 14 months for group-U, 9 months for group-B, and 7 months for group-D (p < 0.001). In subgroup analysis, patients with squamous cell carcinoma subtype, mOS was 11 months for group-U, 12 months for group-B, and 9 month for group-D (p = 0.074) The corresponding mOS durations for adenocarcinoma subtype were 21 months, 7 months, and 6 months (p < 0.001). Performing ABT during treatment period was found to be a negative independent factor related to OS (HR 1.50 for progression-free survival, 95% CI 1.15-1.97, HR 1.36 for OS, 95% CI 1.04-1.80).

CONCLUSION

Our results demonstrated that ABT was significantly associated with earlier progression and shorter survival in patients with metastatic NSCLC, especially in adenocarcinoma histology, hence suggesting that transfusion strategy in this group should remain limited, and its benefit should outweigh the risk of progression.

Perioperative blood transfusion has a dose-dependent relationship with disease recurrence and survival in patients with non-small cell lung cancer

OBJECTIVE

Perioperative blood transfusions have been implicated in decreased overall survival (OS) and disease-free survival (DFS) after resection for non-small cell lung cancer (NSCLC). We investigated the effects of single- and multiple-unit blood transfusions on OS, DFS, and recurrence after anatomic pulmonary resection.

METHODS

From January 1, 2000, to June 30, 2016, 5709 consecutive patients underwent pulmonary resection for NSCLC at our institution. Exclusion criteria were stage IIIB-IV disease, incomplete resections, ill-defined histologic subtypes, and nonanatomic wedge resections. For the 0 versus single-unit analysis, propensity scores were calculated from a logistic regression model that predicted the probability of patients receiving a single-unit transfusion. The resulting matching weights were incorporated into Cox models for OS, DFS, and cumulative incidence of recurrence, to compare no versus single-unit blood transfusion. We determined whether increasing numbers of blood transfusions influenced survival or recurrence using multivariable Cox models.

RESULTS

Approximately 10% of patients received perioperative blood transfusion (median follow-up, 7.46 years [25th-75th percentile, 3.98-11.8]). There was no difference in OS, DFS, or cumulative incidence of recurrence between patients receiving no transfusion and those receiving single-unit transfusion (P > .05). However, a dose-response relationship was observed, demonstrating worse OS (overall P < .001), DFS (overall P < .001), and recurrence (overall P = .010) with increasing units of blood transfused.

CONCLUSIONS

Although a single-unit blood transfusion did not affect survival in patients undergoing resection for NSCLC, greater unit perioperative blood transfusions were associated with significantly decreased long-term outcomes in a dose-dependent manner, suggesting avoidance or minimization of transfusions could improve long-term survival after lung resection.

Impact of intraoperative blood transfusion on long-term outcomes of liver transplantation for hepatocellular carcinoma

OBJECTIVE

To investigate the impact of intraoperative blood transfusion on the long-term outcomes of liver transplantation for hepatocellular carcinoma.

METHOD

Adult patients who had non-salvage liver transplantation at our centre between January 2005 and December 2012 for hepatocellular carcinomas that were within the University of California, San Francisco criteria and could not be resected or ablated were divided into groups with and without intraoperative blood transfusion. Comparisons were made between groups.

RESULTS

Ninety-nine patients were included in the study. Sixty-two (62.6%) patients received intraoperative blood transfusion. Patients without transfusion were younger (54 versus 56 years; P = 0.04) and had a lower Model for End-stage Liver Disease score (11 versus 14; P < 0.001). Most of them had stage-I tumours (64.9 versus 37.1%; P = 0.007) and fewer of them had postoperative complications of grade IIIA or above in the Clavien-Dindo classification (21.6 versus 48.4%; P = 0.008). The groups were comparable in hospital mortality (3.2 versus 2.7%; P = 1.00), 5-year overall survival (90.8 versus 89.2%; P = 0.611) and 5-year disease-free survival (90.5 versus 89.2%; P = 0.835). On multivariate analysis, postoperative complications of grade IIIA or above were associated with worse survival (hazard ratio, 7.108; 95% confidence interval, 1.455-34.712; P = 0.015).

CONCLUSION

Intraoperative blood transfusion was shown to have no significant impact on the long-term outcomes of liver transplantation for hepatocellular carcinoma, whereas postoperative complications of grade IIIA or above were associated with worse recipient survival.

Perioperative red blood cell transfusion in orofacial surgery

In the field of orofacial surgery, a red blood cell transfusion (RBCT) is occasionally required during double jaw and oral cancer surgery. However, the question remains whether the effect of RBCT during the perioperative period is beneficial or harmful. The answer to this question remains challenging. In the field of orofacial surgery, transfusion is performed for the purpose of oxygen transfer to hypoxic tissues and plasma volume expansion when there is bleeding. However, there are various risks, such as infectious complications (viral and bacterial), transfusion-related acute lung injury, ABO and non-ABO associated hemolytic transfusion reactions, febrile non-hemolytic transfusion reactions, transfusion associated graft-versus-host disease, transfusion associated circulatory overload, and hypersensitivity transfusion reaction including anaphylaxis and transfusion-related immune-modulation. Many studies and guidelines have suggested RBCT is considered when hemoglobin levels recorded are 7 g/dL for general patients and 8-9 g/dL for patients with cardiovascular disease or hemodynamically unstable patients. However, RBCT is occasionally an essential treatment during surgeries and it is often required in emergency cases. We need to comprehensively consider postoperative bleeding, different clinical situations, the level of intra- and postoperative patient monitoring, and various problems that may arise from a transfusion, in the perspective of patient safety. Since orofacial surgery has an especially high risk of bleeding due to the complex structures involved and the extensive vascular distribution, measures to prevent bleeding should be taken and the conditions for a transfusion should be optimized and appropriate in order to promote patient safety.

Blood Transfusions and Tumor Biopsy May Increase HCC Recurrence Rates after Liver Transplantation

Introduction. Beneath tumor grading and vascular invasion, nontumor related risk factors for HCC recurrence after liver transplantation (LT) have been postulated. Potential factors were analyzed in a large single center experience. Material and Methods. This retrospective analysis included 336 consecutive patients transplanted for HCC. The following factors were analyzed stratified for vascular invasion: immunosuppression, rejection therapy, underlying liver disease, age, gender, blood transfusions, tumor biopsy, caval replacement, waiting time, Child Pugh status, and postoperative complications. Variables with a potential prognostic impact were included in a multivariate analysis. Results. The 5- and 10-year patient survival rates were 70 and 54%. The overall 5-year recurrence rate was 48% with vascular invasion compared to 10% without (p < 0.001). Univariate analysis stratified for vascular invasion revealed age over 60, pretransplant tumor biopsy, and the application of blood transfusions as significant risk factors for tumor recurrence. Blood transfusions remained the only significant risk factor in the multivariate analysis. Recurrence occurred earlier and more frequently in correlation with the number of applied transfusions. Conclusion. Tumor related risk factors are most important and can be influenced by patient selection. However, it might be helpful to consider nontumor related risk factors, identified in the present study for further optimization of the perioperative management.

Adverse oncologic effects of intraoperative transfusion during pancreatectomy for left-sided pancreatic cancer: the need for strict transfusion policy

BACKGROUND

The aim of the present study was to investigate the prognostic impact of transfusion following distal pancreatectomy (DP) for left-sided pancreatic ductal adenocarcinoma (PDAC).

METHODS

Retrospective analysis was performed to identify prognostic factors in patients who underwent DP from July 1992 to October 2012.

RESULTS

Forty-eight patients were male, and 35 were female with a mean age of 62 ± 9 years. Twenty-three (27.7%) of the patients received intraoperative blood transfusion. In univariate analysis, combined organ resection (P = 0.046), intraoperative transfusion (P < 0.001), pathologic tumor size (≥3 cm, P = 0.051), clinical tumor size (≥3 cm, P = 0.008), lymph node metastasis (P = 0.021), lymph node ratio (LNR ≥ 0.017, P < 0.001), and tumor differentiation (P = 0.013) were analyzed to predict tumor recurrence. Multivariate analysis showed that lymph node metastasis (Exp(β) = 2.136, P = 0.016), LNR (Exp(β) = 2.003, P = 0.049), and intraoperative transfusion (Exp(β) = 2.793, P = 0.001) were independent prognostic factor predicting tumor recurrence. The amount of estimated blood loss was closely associated with intraoperative transfusion (P < 0.001).

CONCLUSION

Intraoperative transfusion should be avoided by gentle operative handling to minimize intraoperative bleeding, and the appropriate transfusion policy should be followed to increase the survival outcome.

Association between Perioperative Blood Transfusion and Oncologic Outcomes after Curative Surgery for Renal Cell Carcinoma

Purpose: We aimed to elucidate the association between perioperative blood transfusion (PBT) and the prognosis of patients undergoing curative surgery for renal cell carcinoma (RCC).

Methods: In all, 3,832 patients with RCC who had undergone curative surgery were included in this study from a multicenter database. PBT was defined as the transfusion of packed red blood cells within seven days before surgery, during surgery, or within the postoperative hospitalization period. The association of PBT with oncologic outcomes was evaluated using univariate and multivariate Cox regression analyses, and regression adjustment with propensity score matching.

Results: Overall, 11.7% (447/3,832) of patients received PBT. Patients receiving PBT were significantly older at diagnosis, and had lower BMI, higher comorbidities, worse ECOG performance status, and more initial symptoms. Moreover, higher pathologic TNM stage, larger mass size, higher nuclear grade, more sarcomatoid differentiation, and more tumor necrosis were all observed more frequently in patients who received PBT. In univariate analysis, relapse-free survival, cancer-specific survival, and overall survival rates were worse in patients who received PBT; however, these factors became insignificant in the matched pairs after propensity score matching. On multivariate Cox regression analysis and regression adjustment with propensity score matching, significant prognostic effects of PBT on disease relapse, cancer-specific mortality, and all-cause mortality were not observed.

Conclusions: This multicenter database analysis demonstrates no significant prognostic association between PBT and oncologic outcomes in patients with RCC.

Anaesthetic and pharmacological techniques to decrease blood loss in liver surgery: a systematic review

BACKGROUND

There is increasing evidence that perioperative blood loss and blood transfusions are associated with poorer short- and long-term outcomes in patients undergoing hepatectomy. The aim of this study was to systematically review the literature for non-surgical measures to decrease intraoperative blood loss during liver surgery.

METHODS

The literature search was performed using PubMed, Embase, Cochrane Library, CINAHL and Google Scholar databases. The primary outcome measures were perioperative blood loss and transfusion requirements. A secondary outcome measure was development of ischaemia-reperfusion injury.

RESULTS

Seventeen studies met the inclusion criteria and included 1573 patients. All were randomized controlled studies. In eight studies (n = 894), pharmacological methods, and in another nine studies (n = 679), anaesthetic methods to decrease blood loss were investigated. Anti-fibrinolytic drugs, acute normovolaemic haemodilution, autologous blood donation and use of inhalational anaesthetic agent may affect blood loss and post-operative hepatic function.

CONCLUSIONS

There is potential for use of non-surgical techniques to decrease perioperative bleeding. However, on the basis of this review alone, due to heterogeneity of randomized trials conducted, no particular strategy can be recommended. Future studies should be conducted looking at pathways to decrease bleeding in liver surgery.

Allogeneic blood transfusion and the prognosis of gastric cancer patients: systematic review and meta-analysis

BACKGROUND

Perioperative allogeneic blood transfusion (ABT) may be a deleterious predictor on the prognosis of gastric cancer (GC) for subjects who had undergone curative surgeries. In this article we proposed to figure out the effect of ABT with a systematic review and meta-analysis.

METHODS

Relevant articles were identified by searching Pubmed and Embase to March 2014. A random-effects model or fixed-effects model was used to calculate pooled odds ratios (ORs). Sensitivity analysis, meta-regression, stratified analysis, dose-response meta-analysis were conducted, and publication bias tested.

RESULTS

Eighteen studies (9120 GC patients) were included, of which 36.3% received transfusions. ABT was associated with increased all-cause mortality (OR, 2.17; 95% confidence interval [CI], 1.72-2.74; p<0.001; I2=75%). Sensitivity analysis showed significant changes in ORs while meta-regression had little influence on ORs. Galbraith plot revealed the OR reduced to 2.10 (95% CI, 1.86-2.37; p<0.001) with tau2 reduced to 0.00 and I2 reduced to 0%. RESULTS of stratified analysis were robust and consistent. Dose-response meta-analysis revealed that all-cause mortality was significantly lower in patients transfused with ≤800 mL of blood than those transfused with >800 mL (OR, 0.58; 95% CI, 0.37-0.92; p=0.02; I2=54%). ABT was also associated with increased cancer-related mortality (OR, 2.57, p=0.011) and recurrence (OR, 1.52, p=0.017).

CONCLUSIONS

In GC patients undergoing curative surgeries, ABTs are associated with a worse prognosis, including all-cause mortality, cancer-related mortality and recurrence. Patient blood management should be investigated further to minimize use of ABT.

Peri-operative blood transfusion in gastric cancer surgery: prognostic or confounding factor?

BACKGROUND AND PURPOSE

The relationship between peri-operative blood transfusions (PBTs) and poor prognosis in gastric cancer (GC) patients is still debated. The aim of this study is to examine the real prognostic impact of PBTs in comparison to well-known prognostic factors.

METHODS

We retrospectively analyzed a series of 224 patients who underwent surgery with curative intent for GC from January 1995 to December 2011. Among 224 patients, 46 (20%) required PBTs.

RESULTS

The overall 5-year survival was 77% in non-transfused patients and 65% in patients who received PBTs (p = 0.03). PBTs did not further stratify any recognized prognostic category (such as pT or pN according to the 7th edition of the TNM staging system). Multivariate analysis including all known prognostic variables (both cancer- and non-cancer-related) did not select PBTs as an independent prognostic factor. Only preoperative hemoglobin and albumin level, pT and operative time were significantly associated with the requirement for PBTs.

CONCLUSIONS

The study showed a worse prognosis for transfused patients, but PBTs seem a confounding factor more than a prognostic indicator, as they are obviously affected by other variables.

Perioperative blood transfusion adversely affects prognosis after resection of lung cancer: a systematic review and a meta-analysis

Background

It is speculated that blood transfusion may induce adverse consequences after cancer surgery due to immunosuppression. This study was intended to assess the impact of perioperative blood transfusion on the prognosis of patients who underwent lung cancer resection.

Methods

Eligible studies were identified through a computerized literature search. The pooled relative risk ratio (RR) with 95% confidence interval (CI) was calculated using Review Manager 5.1 Software.

Results

Eighteen studies with a total of 5915 participants were included for this meta-analysis. Pooled analysis showed that perioperative blood transfusion was associated with worse overall survival (RR: 1.25, 95% CI: 1.13-1.38; P <0.001) and recurrence-free survival (RR: 1.42, 95% CI: 1.20-1.67; P <0.001) in patients with resected lung cancer.

Conclusions

Perioperative blood transfusion appears be associated with a worse prognosis in patients undergoing lung cancer resection. These data highlight the importance of minimizing blood transfusion during surgery.

Impact of intraoperative blood loss on long-term survival after lung cancer resection

PURPOSE

The purpose of this study was to clarify relationships between intraoperative blood loss (IBL) and long-term postsurgical survival in lung cancer patients.

METHODS

We retrospectively analyzed 1336 patients undergoing surgery: lobectomy in 1016, sublobar resection in 174, pneumonectomy in 106, and combined resection with adjacent organs in 40. The lobectomy group was stratified further by pathologic stages; overall survival difference was examined according to amount of IBL.

RESULTS

Volume of IBL differed significantly according to surgical procedure when all patients were included. Within the lobectomy group, IBL differed significantly between gender, pathologic stage, histologic type (adenocarcinoma vs. non-adenocarcinoma), and year of operation (1983 to 2002 vs. 2003 to 2012). After stratification by pathologic stage, survival differed with IBL for stages IB to IIIB. Multivariate analysis identified gender, patients age (<69 vs. ≥69), pathologic stage (IA to IIB vs. IIIA to IV), year of operation, histologic type, and IBL as significant predictors of survival.

CONCLUSION

Since degree of IBL is an independent predictor of overall survival after lung cancer resection, IBL should be minimized carefully during surgery.

Perioperative blood transfusions and survival in patients with non-small cell lung cancer: a retrospective study

Background

Perioperative blood transfusions have been associated with poor clinical outcomes in the context of oncological surgery. Current literature is inconclusive whether blood transfusions are linked to shorter recurrence free and overall survival after lung cancer surgery. We hypothesize that blood transfusions in patients undergoing surgery for non-small cell lung cancer are associated with poor oncological survival.

Methods

After IRB approval, perioperative data from 636 patients who underwent lung cancer surgery was collected. Patients were evaluated for time to tumor recurrence and overall survival.

Results

60 patients were transfused and 576 subjects were not. Patients who received transfusion were more likely to have more advanced disease (p = 0.018), and preoperative low hemoglobin concentrations (p < 0.0001) compared to non-transfused patients. In the multivariable Cox regression analysis, blood transfusion was associated with a significant reduction in recurrence free survival (p = 0.025), HR: 1.55 (95% CI: 1.06-2.27) and overall survival (p = 0.0002) HR: 2.04 (95% CI: 1.41-2.97). However, analysis after propensity score matching between the two groups revealed that the effect of blood transfusion was significant for reduction in overall survival (p = 0.0356), HR: 1.838 (95% CI: 1.04-3.22) but not for recurrence free survival (p = 0.1460), HR: 1.493 (95% CI: 0.87-2.56).

Conclusions

Perioperative administration of red blood cells appears be associated with a decreased overall survival but not recurrence free survival after lung cancer surgery. Our study has the limitations of a retrospective review. Hence, our results should be confirmed by a prospective randomized control trial.

Prognostic effect of blood transfusion in children with acute lymphoblastic leukemia

Background

Most children with acute lymphoblastic leukemia (ALL) receive blood transfusions. Transfusions may affect ALL outcomes through transfusion-related immunomodulation (TRIM).

Methods

We analyzed overall survival (OS) and event-free survival (EFS) in relation to leukocyte reduced and irradiated (LR/IRR) blood products transfused during the induction phase in 136 children with ALL. Hazard ratios (HRs) for death and relapse were estimated through Cox regression analysis.

Results

One hundred and twenty patients (89%) were transfused with packed red blood cells (PRBCs) and 79 (58%) with single donor platelets (SDPs). The median number of transfusions was 2 (interquartile range [IQR]=1-3 events) and 1 (IQR=0-3 events) for PRBCs and SDPs, respectively. Patients who had white blood cell (WBC) count >50,000×10⁹/L, were classified as high risk according to the high National Cancer Institute criteria, displayed a T cell phenotype, or were minimal residual disease-positive at end of induction were more likely to receive >3 transfusions during induction (P=0.001, 0.002, 0.03, and 0.01, respectively). In univariate analysis, PRBC, SDP, and fresh frozen plasma transfusions did not have any significant association with relapse or death. For PRBC transfusions, the HRs for EFS and OS were 1.02 (95% CI, 0.85-1.24; P=0. 76) and 1.03 (95% CI, 0.83-1.27; P=0.76), respectively. For SDP transfusions, HRs were 1.03 (95% CI, 0.90-1.18; P=0.64) and 0.98 (95% CI, 0.80-1.20; P=0.87) for EFS and OS, respectively.

Conclusion

LR/IRR blood products may not confer a TRIM effect in childhood ALL and are unlikely to affect outcome.

Leukocyte-depleted blood transfusion is associated with decreased survival in resected early-stage lung cancer

OBJECTIVES

Blood transfusion has been shown to have deleterious effect on lung cancer survival, but little data are available that assess whether leukocyte-depleted (LD) blood has a similar adverse effect. Our institution has been using LD red cells since 2001. We sought to determine whether LD blood has an effect on survival after resection of early-stage lung cancer.

METHODS

From a prospective database, we evaluated all patients with pathologic stage I non-small cell lung cancer. Patients receiving LD blood were compared with those receiving no transfusion. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis by Cox regression was used to identify independent risk factors affecting survival.

RESULTS

From 2001 to 2009, 361 patients were evaluated; 63 received LD red cell cell transfusion and 298 received no transfusion. Median follow-up was 48 months. Disease-free survival (P < .001) and overall survival (P < .001) were worse in patients receiving LD blood. Stratifying for stage, disease-free survival continued to be worse with transfusion for stage IA (P = .002) and IB (P = .002). Similarly, overall survival continued to be worse with transfusion for stage IA (P < .001) and IB (P < .001). For disease-free and overall survival, univariate analysis revealed increased age, male gender, anemia, transfusion, and higher stage to be adverse factors, with transfusion and higher stage continuing to be significant adverse factors after multivariate analysis.

CONCLUSIONS

Our data suggest that transfusion of LD blood is associated with a worse disease-free and overall survival in patients with resected stage I non-small cell lung cancer.

Does blood transfusion increase the chance of recurrence in patients undergoing surgery for lung cancer?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether blood transfusion increases the chance of recurrence in patients undergoing surgery for lung cancer. Altogether 468 papers were found using the reported search, of which 21 represented the best evidence to answer the clinical question. The authors, journal date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Nineteen cohort studies (two of which examined the same or similar data sets as two other studies already included), one comment article and one meta-analysis were identified. In total, the outcomes of 5378 patients undergoing surgical resection for lung cancer were analysed. The transfusion rate varied between 15 and 67%. The primary endpoints in all 21 papers were recurrence, survival or disease-free survival. We conclude that the research undertaken to examine the relationship between blood transfusion and lung cancer recurrence, survival and disease-free survival comes to no definite conclusion. Half of the papers relating to recurrence state that there is no significantly increased risk of recurrence with transfusion, whereas the other half state that there is. However, four of the five papers examining disease-free survival demonstrate a significant adverse relationship between this primary outcome and blood transfusion. With regard to survival, five of the papers reviewed showed no effect of blood transfusion, whereas five showed some form of adverse effect. Although there is no overwhelming agreement among the presented evidence, there is a slightly larger body of evidence supporting the theory that blood transfusions are associated with poorer outcomes in patients undergoing resection for lung cancer. However, whether this is a direct effect, or a surrogate marker for other factors such as anaemia, is unclear.

Advantage of autologous blood transfusion in surgery for hepatocellular carcinoma

AIM: To evaluate the significance of autologous blood transfusion (AT) in reducing homologous blood transfusion (HT) in surgery for hepatocellular carcinoma (HCC).

METHODS: The proportion of patients who received HT was compared between two groups determined by the time of AT introduction; period A (1991-1994, n = 93) and period B (1995-2000, n = 201). Multivariate logistic regression analysis was performed in order to identify independent significant predictors of the need for HT. We also investigated the impact of AT and HT on long-term postoperative outcome after curative surgery for HCC.

RESULTS: The proportion of patients with HT was significantly lower in period B than period A (18.9% vs 60.2%, P < 0.0001). Multivariate logistic regression analysis identified AT administration as a significant independent predictor of the need for HT (P < 0.0001). Disease-free survival in patients with AT was comparable to that without any transfusion. Multivariate analysis identified HT administration as an independent significant factor for poorer disease-free survival (P = 0.0380).

CONCLUSION: AT administration significantly decreased the need for HT. Considering the postoperative survival disadvantage of HT, AT administration could improve the long-term outcome of HCC patients.

Fresh frozen plasma transfusion does not affect outcomes following hepatic resection for hepatocellular carcinoma

AIM: To investigate whether fresh frozen plasma (FFP) transfusion affects outcomes following hepatic resection for hepatocellular carcinoma (HCC) in terms of liver function, postoperative complications and cancer prognosis.

METHODS: We retrospectively compared the incidence of postoperative complications between 204 patients who underwent hepatectomy for HCC with routine FFP transfusion in an early period (1983-1993, Group A) and 293 with necessity for FFP transfusion during a later period (1998-2006, Group B), and also between two subgroups of Group B [22 patients with FFP transfusion (Group B1) and 275 patients without FFP transfusion (Group B2)]. Additionally, only in limited patients in Group B1 and Group B2 with intraoperative blood loss ≥ 2000 mL (Group B1_{≥ 2000 mL} and Group B2_{≥ 2000 mL}), postoperative complications, liver function tests, and cancer prognosis were compared.

RESULTS: No mortality was registered in Group B, compared to 8 patients (3.9%) of Group A. The incidence of morbidity in Group B2 [23.2% (64/275)] was not significantly different from Group B1 [40.9% (9/22)] and Group A [27.0% (55/204)]. The incidence of complications and postoperative liver function tests were comparable between Group B1_{≥ 2000 mL}vs Group B2_{≥ 2000 mL}. Postoperative prognosis did not correlate with administration of FFP, but with tumor-related factors.

CONCLUSION: The outcome of hepatectomy for HCC is not influenced by FFP transfusion. We suggest FFP transfusion be abandoned in patients who undergo hepatectomy for HCC.

Combination of low vascular endothelial growth factor A (VEGF-A)/VEGF receptor 2 expression and high lymphocyte infiltration is a strong and independent favorable prognostic factor in patients with nonsmall cell lung cancer

BACKGROUND

There seems to be a close interplay between angiogenesis and the immune system. The authors of this report investigated the prognostic role of angiogenic markers in coexpression with immune system markers in patients with nonsmall cell lung cancer (NSCLC).

METHODS

Tumor resection samples from 335 patients with stage I to IIIA NSCLC were obtained, and tissue microarrays were constructed. Immunohistochemistry was used to evaluate the expression of vascular endothelial growth factor (VEGF) A (VEGF-A), VEGF receptor 2 (VEGFR-2), and lymphocytes that were positive for the cluster of differentiation 4 (CD4) and CD8 coreceptors.

RESULTS

In univariate analysis, 5-year survival rates were 87% for the combination of low tumor cell expression of VEGF-A and VEGFR-2 (↓VEGF-A/↓VEGFR-2) and high tumor cell expression of CD4 and CD8 (↑CD4/↑CD8) (n = 19), 58% for mixed combinations (n = 290), and 27% for the ↑VEGF-A/↑VEGFR-2 and ↓CD4/↓CD8 combination (n = 26). In multivariate analysis, the coexpression of ↑VEGF-A/↑VEGFR-2 and ↓CD4/↓CD8 was an independent negative prognostic factor (hazard ratio, 9.16; 95% confidence interval, 2.11-39.8; P = .003).

CONCLUSIONS

Low tumor cell VEGF-A and VEGFR-2 expression in combination with high adaptive immune cell expression in the tumor-related stroma had a strong and independent favorable prognostic impact in patients with NSCLC.

Negative impact of blood transfusion on recurrence and prognosis of hepatocellular carcinoma after hepatic resection

BACKGROUND

In perioperative management of hepatic resection for hepatocellular carcinoma, excessive blood loss and blood transfusion greatly influence postoperative complications and prognosis of the patients. We evaluated the influence of blood products use on postoperative recurrence and prognosis of patients with hepatocellular carcinoma.

METHODS

The subjects were 66 patients who underwent elective hepatic resection for hepatocellular carcinoma without concomitant microwave or radiofrequency ablation therapy nor other malignancies between January 2001 and June 2006. We retrospectively investigated the influence of the use of blood products including red cell concentration and fresh frozen plasma on recurrence of hepatocellular carcinoma and overall survival.

RESULTS

In multivariate analysis, the dose of blood products transfusion was a significant predictor of disease-free and overall survival. Both disease-free and overall survival rates of those who were given blood products were significantly worse than those who did not receive. On the other hand, in univariate analysis of disease-free and overall survival after hepatic resection and clinical variables, the amount of blood loss was not a significant predictor of recurrence or death.

CONCLUSION

Transfusion of blood products is associated with increased recurrence rate and worse survival after elective hepatic resection for patients with hepatocellular carcinoma.

Effect of perioperative blood transfusion on clinical outcomes in hepatic surgery for cancer

Allogeneic blood transfusion during liver resection for malignancies has been associated with an increased incidence of different types of complications: infectious complications, tumor recurrence, decreased survival. Even if there is clear evidence of transfusion-induced immunosuppression, it is difficult to demonstrate that transfusion is the only determinant factor that decisively affects the outcome. In any case there are several motivations to reduce the practice of blood transfusion. The advantages and drawbacks of different transfusion alternatives are reviewed here, emphasizing that surgeons and anesthetists who practice in centers with a high volume of liver resections, should be familiar with all the possible alternatives.

Blood loss in surgical oncology: neglected quality indicator?

Quality indicators can be defined as "specific and measurable elements of practice that can be used to assess the quality of care". Surgical blood loss is one of the most significant perioperative predictors of patient outcome. Blood loss is a modifiable quality indicator for oncologic cancer surgery. Surgical oncologists need to alter their surgical technique to promote bloodless surgery and decrease the variability in reported blood loss and rates of blood transfusion.

Influence of blood transfusions and preoperative anemia on long-term survival in patients operated for non-small cell lung cancer

It has been postulated that transfusions have immunosuppressive effects that promote tumor growth and metastasis. Moreover perioperative anemia is considered an independent prognostic factor on outcome in patients operated for malignancy. We evaluated the influence of red blood cell (RBC) transfusions and perioperative anemia on survival in non-small cell lung carcinoma (NSCLC) patients. From 1999 through 2005, 331 consecutive patients, male/female=295/36 (mean age 64+/-9 years), who underwent radical surgery for NSCLC were prospectively enrolled in this cohort and followed up for a mean of 27.2 months. The overall survival of patients was analyzed in relation to RBC transfusions and perioperative anemia. These parameters were analyzed in the whole cohort of patients and separately for stage I patients. Patients were divided according to perioperative transfusion, into Group A (transfused) and Group B (non-transfused) and according to the preoperative haemoglobin (Hb) level into Group 1(Hb<12g/dl) and Group 2(Hb> or =12g/dl), respectively. The overall transfusion rate was 25.7%. Univariate analysis showed that in the whole cohort of patients overall survival was significantly shorter in Group A (mean 33.6 months, 5-year survival 25.1%) compared to Group B (mean 48.0 months, 5-year survival 37.3%) (p=0.001). It also showed that patients with preoperative Hb level <12g/dl (Group 1), (mean of 33.0 months, 5-year survival 21.3%) had shorter survival compared to Group 2 patients (mean 49.3 months and 5-year survival 40.0%), respectively (p=0.002). Multivariate analysis in the whole cohort of patients showed that preoperative anemia was an independent risk factor for survival while RBC transfusion was not. In particular for stage I patients, it was shown that RBC transfusion was an independent prognostic factor for long-term survival as detected by multivariate analysis (p=0.043), while anemia was not. RBC transfusions affect adversely the survival of stage I NSCLC patients, while do not exert any effect on survival of patients with surgically resectable more advanced disease, where preoperative anemia is an independent negative prognostic factor. These findings indicate that RBC transfusion might exert an immunomodulatory effect on patients with early disease while in more advanced stages this effect is not apparent.

The impact of perioperative blood transfusion on clinical outcomes in colorectal surgery

Colorectal cancer is the second-leading cause of cancer-related death in the US. The prognosis of advanced colorectal cancer remains poor in spite of the advances obtained in recent years with new therapeutic agents, new approaches in surgical procedures and new diagnostic methods. Currently, colorectal cancer is the second most common cancer in Europe both in terms of incidence and mortality. Approximately 90% of all cancer deaths arise from the metastatic dissemination of primary tumors. It is a matter of vital importance whether perioperative blood transfusion promotes tumor recurrence and morbidity. This paper reviews the relevant medical literature published in English language on the theoretical background, methodological problems, results, as well as the possible clinical impact of blood transfusions in colorectal surgery with well-controlled trials. Searches were last update August 2007.

The sequence of vessel interruption during lobectomy — does it affect the amount of blood retained in the lobe?

OBJECTIVE

In a previous study, we have shown that the sequence of vessel interruption (SVI) during lobectomy has no impact on tumor recurrence. The aim of the present study was to determine whether SVI has an impact on the amount of blood retained in the resected lobe.

PATIENTS AND METHODS

A non-randomized prospective study including 30 patients undergoing lobectomy for neoplasms. Group A-1'st had all lobar arteries ligated before interruption of the lobar vein and group V-1'st had a reverse sequence. Generous exclusion criteria were used, so as to include only patients with straightforward lobectomy, attempting to isolate SVI as the only factor that could affect blood loss. Lobar weight was recorded immediately after lobectomy. All ligatures and staplers were removed; blood drained from the lobe, collected and measured, and thereafter the lobe was weighed again.

RESULTS

Sixteen patients entered group A-1'st and 14 group V-1'st. The groups were similar in age, sex, body surface, histology, prior therapy, stage, FEV1%, length of operation, and number of segments resected. The amount of blood drained from the lobe was 31.4+/-13 and 34.2+/-14.8ml in group A-1'st and V-1'st, respectively. The lobar weights before and after blood drainage were 177.6+/-56.9, 141.7+/-49.1g and 201.5+/-74.2, 161.6+/-69.7g, respectively. The amount of blood divided to the lobar weight was 0.178+/-0.052 in group A-1'st and 0.177+/-0.099 in group V-1'st. All of these figures did not differ statistically. No patient required blood transfusion during or after surgery.

CONCLUSIONS

In straightforward lobectomy the amount of blood retained in the resected lobe is small. This amount is not affected by the sequence of hilar vessel interruption.

Long-term safety of autotransfusion during hepatectomy for hepatocellular carcinoma

PURPOSE

To evaluate the long-term safety of autotransfusion (AT) in hepatectomy for hepatocellular carcinoma (HCC).

METHODS

Between 1988 and 1989, 46 patients with HCC underwent hepatectomy with AT (group 1). For a comparison, we matched 50 patients with HCC who underwent hepatectomy, and received homologous but not autologous blood (group 2). The 10-year cumulative survival curves and cancer-free curves of the two groups were examined, and the pattern of recurrence was compared.

RESULTS

Group 1 had a significantly higher cumulative 10-year survival rate than group 2, at 20% vs 8%, respectively (P < 0.05). Among the patients who underwent curative resection, those in group 1 had significantly better cumulative survival and cancer-free survival rates than those in group 2, at 27% vs 11% (P < 0.05) and 13% vs 0% (P < 0.05), respectively. Among the patients with stage I-II HCC, those in group 1 had significantly better cumulative survival and cancer-free survival rates than those in group 2, at 30% vs 5% (P < 0.01) and 20% vs 5% (P < 0.05), respectively. However, the rates were similar among patients with stage III-IV disease in both groups. The pattern of recurrence in the two groups was similar.

CONCLUSION

Autotransfusion promoted survival in patients undergoing hepatectomy for stage I or II HCC.

The Effects of Perioperative Blood Transfusion on Morbidity and Mortality After Esophagectomy

The effect of blood transfusion on outcomes in esophageal surgery remains controversial. The contrasting conclusions drawn from a number of retrospective analyses with different methodologies create a landscape that is difficult to interpret. Because of the scope of esophageal resection, the need for blood transfusion cannot be eliminated. What recommendations then, if any, can be made for the practicing surgeon? First, surgeons and anesthesiologists need to reevaluate their transfusion thresholds. The age-old practice of keeping the hemoglobin above 10 g/dL has very little evidence-based support. A multicenter, randomized, controlled clinical trial in Canada demonstrated that a restrictive strategy of blood transfusion, in which patients were transfused only for a hemoglobin level of less than 7 g/dL, was at least as effective as and possibly was superior to a liberal transfusion strategy in critically ill patients. It has also been estimated that more than 25% of patients undergoing colorectal resections may receive at least one unit of unnecessary blood. Further, the immediate reduction in the hemoglobin concentration caused by the normovolemic hemodilution associated with surgery and crystalloid fluid replacement is not associated with any increased morbidity or mortality. If these data are examined in the context of the results of Langley and Tachibana indicating that a threshold amount of blood needs to be transfused to impact outcomes, it becomes even more important to limit transfusion to only the amount that is essential. Thus, surgeons and anesthesiologists should adopt a more stringent set of requirements for blood transfusion. Second, with the proven feasibility and reduction in infectious complications associated with autologous blood-donation programs, any patient who meets the criteria discussed here should be encouraged to participate in such a program. Although the effect of autologous blood on cancer outcomes remains unclear, the other advantages certainly make such a program worthy of consideration. This discussion leads to a final point, namely that patients should be encouraged, whenever possible, to participate in clinical trial research. The only way that the community of surgeons treating patients who have esophageal cancer can hope to address properly the question of how blood transfusion affects outcomes is with well-designed clinical trials. A large, multicenter, randomized trial (level I) would be ideal. Short of such a trial, inclusion criteria and study methodology should be discussed among various institutions to avoid the differences in studies that make direct comparisons of results among different investigators difficult and potentially meaningless. This measure would at least allow different level II to IV data to be compared directly with some validity.

Patterns of Surgical Care of Lung Cancer Patients

BACKGROUND

This survey was performed to determine the patterns of surgical care provided patients with non-small cell lung carcinoma (NSCLC).

METHODS

In 2001, the American College of Surgeons carried out a patient care survey of 729 hospitals to retrieve information of NSCLC patients' history, evaluation, pathology, and surgical treatment.

RESULTS

Inclusion criteria were met by 40,090 patients: of whom 11,668 (29.1%) were treated surgically; 74.2% alone and 25.8% as part of multimodality therapy. Of these patients, 59.5% were in stage I, 17.5% in stage II, 17.0% in stage III, and 6.0% in stage IV. Surgery patient demographics were the following: 55% male and 45% female; 46.8% 70 years or older; and 76.3% had significant comorbidities. Tumor characteristics: squamous 28%, adenocarcinoma 37.6%, other 34.4%. Staging: in addition to radiologic examinations, preoperative mediastinoscopy was performed in 27.1% of operated patients with node biopsy in only 46.6% of these procedures.

OPERATIONS

wedge resection 15.6%, lobectomy 70.8%, pneumonectomy 13.6%. Surgical margins were positive in 7.8%, but only 65.2% had frozen section analysis. Perioperative mortality was 5.2%, but was 4.0% in nontransfused patients and 12.7% in transfused patients and was 3.2% in high-volume (more than 90 operations per year) versus 4.8% in low-volume hospitals (p < 0.001).

CONCLUSIONS

(1) Patients being operated for NSCLC are elderly with significant comorbid conditions. (2) More patients than previously are female and have adenocarcinoma. (3) Mediastinoscopy is infrequently performed and lymph nodes are biopsied in less than 50% of them. (4) Lobectomy is the most common operation, and positive surgical margins are too frequent. (5) Operative mortality is reasonable but transfusion is a marker for increased risk and outcomes are superior in high-volume hospitals. (6) Hospitals with higher volume had fewer perioperative deaths.

[Use of blood products in patients treated surgically for stage I non-small cell lung cancer]

OBJECTIVE

Retrospective study on the relation between the use of blood products and survival rates in patients treated surgically for stage I non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

The study included 856 patients who underwent surgical resection from 1969 to 2000 for stage I NSCLC, classified histologically according to the current guidelines of the Spanish Society of Pulmonary and Thoracic Surgery (SEPAR). Patients who died in the postoperative period were excluded from the study. A series of clinicopathological variables were recorded, including the perioperative use or not of blood products. Descriptive, univariate, and multivariate statistical analyses were performed. Follow up concluded in December of 2003.

RESULTS

One hundred twenty-five patients (14.6%) underwent a perioperative transfusion. A significant association was found between the use of blood products and tumor size (P<.001), pneumectomy (P<.001), and cell type (P<.05). The respective 2, 5, and 10-year survival rates were 78%, 63%, and 54% for the nontransfusion group, and 73%, 59%, and 46% for the transfusion group. Both survival curves were compared and no significant differences were found (P=.23). Multivariate regression analysis included tumor size, patient age, and histologic cell type (squamous cell carcinoma or not); no relation between transfusion and survival was found.

CONCLUSIONS

In our series, we found no difference in survival rates for patients with stage I NSCLC after perioperative blood transfusion.

Pulmonary adenocarcinoma is associated with poor long-term survival after surgical resection. Effect of allogeneic blood transfusion

BACKGROUND

The significance of allogeneic blood transfusion in the prognosis of patients with nonsmall lung carcinoma (NSCLC) remains controversial. Reports have suggested that patients with adenocarcinoma have a worse prognosis from cancer than patients with squamous cell carcinoma (SCC), but this evidence is lacking in NSCLC. The objective of the current study was to elucidate the correlation between perioperative allogeneic blood transfusion and the prognosis in patients with adenocarcinoma and SCC.

METHODS

The study group comprised 329 consecutive patients (172 men and 157 women) with a mean age of 67 years who underwent lung resection between 1996 and 2003 in 1 unit. The clinicopathologic and survival data were compared between 62 patients (42.7%) with adenocarcinoma and 58 patients (48.3%) with SCC who received a perioperative blood transfusion and 83 patients (57.3 %) with adenocarcinoma and 126 patients (61.3%) with SCC who did not.

RESULTS

The overall surgical mortality rate was 3.9% (13 deaths). The median surgical blood loss was 380 mL (range, 125-4500 mL). The mean blood transfusion received was 1.9 U (range, 0-8 U). The overall actuarial 1, 3, and 5-year survival rates in the adenocarcinoma and SCC groups were 82.3%, 49.6%, and 19.4% and 87.9%, 71.7%, and 32.7%, respectively (P = 0.021). Multivariate analysis demonstrated that the factors that appeared to be independent prognostic factors in both groups were T-classification (P < 0.001), lymph node metastasis (P < 0.001), and postoperative complications (P = 0.029). Perioperative blood transfusion was not an independent prognostic indicator in either group.

CONCLUSIONS

The current study demonstrated that long-term survival in patients with adenocarcinoma of the lung was significantly worse compared with patients with SCC, but was independent of allogeneic perioperative blood transfusion. The results reaffirmed the importance of tumor invasion and lymph node involvement in the overall poor prognosis of these patients.

The influence of blood transfusion on survival in operated non-small cell lung cancer patients

BACKGROUND

It has been postulated that allogeneic transfusions have immunosuppressive effects that can promote tumor growth and metastasis formation. Despite the variety of publications on this controversial topic, the influence of blood transfusion on survival is not yet clearly identified. The impact of autologous blood transfusion on survival has only occasionally been analyzed in cancer patients.

OBJECTIVE

To determine the effect of perioperative allogeneic and autologous blood transfusions on survival in non-small cell lung cancer patients treated with curative pulmonary resection.

METHODS

Of 493 consecutive patients, 185 (37.5%) received allogeneic blood products and 145 (29.4%) received autologous blood products, whereas 163 patients (33.1%) received no blood products. Survival analysis included univariate log-rank test and multivariate Cox regression model.

RESULTS

Three-year survival probabilities in allogeneic, autologous, and nontransfused groups were 40%, 48%, and 61%, respectively, and the estimated 5-year survival probabilities were 34%, 38%, and 48%, respectively. In the univariate analysis there was a reduced survival in allogeneic versus nontransfused group (P <.01). In the multivariate analysis stage (P <.01), initial hemoglobin level (P =.01) and sedimentation rate (P =.03) remained significant factors, whereas the type of blood transfusion (allogeneic versus autologous) was no longer significant. There was no significant impact of transfusion in the multivariate analysis when patients in stage III or patients who underwent pneumonectomy were excluded.

CONCLUSION

Neither allogeneic nor autologous blood transfusion has independent, adverse survival impact in non-small cell lung cancer patients treated with radical pulmonary resection.

Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases

OBJECTIVE

To determine if transfusion affected perioperative and long-term outcome in patients undergoing liver resection for metastatic colorectal cancer.

SUMMARY BACKGROUND DATA

Blood transfusion produces host immunosuppression and has been postulated to result in adverse outcome for patients undergoing surgical resection of malignancies.

METHODS

Blood transfusion records and clinical outcomes for 1,351 patients undergoing liver resection at a tertiary cancer referral center were analyzed.

RESULTS

Blood transfusion was associated with adverse outcome after liver resection. The greatest effect was in the perioperative course, where transfusion was an independent predictor of operative mortality, complications, major complications, and length of hospital stay. This effect was dose-related. Patients receiving one or two units or more than two units had an operative mortality of 2.5% and 11.1%, respectively, compared to 1.2% for patients not requiring transfusions. Transfusion was also associated with adverse long-term survival by univariate analysis, but this factor was not significant on multivariate analysis. Even patients receiving only one or two units had a more adverse outcome.

CONCLUSIONS

Perioperative blood transfusion is a risk factor for poor outcome after liver resection. Blood conservation methods should be used to avoid transfusion, especially in patents currently requiring limited amounts of transfused blood products.

Correlation between perioperative blood transfusion and prognosis of patients subjected to surgery for stage I lung cancer

BACKGROUND

It has been reported, but not proven, that perioperative blood transfusions have a detrimental effect on the survival of patients undergoing surgery for lung cancer.

STUDY DESIGN

and methods: A prospective study was carried out on the patients undergoing lobectomy for stage I lung cancer at our department from 1995 to 2000. The criteria for exclusion included previous cases of malignancy, autoimmune diseases, and any other relevant comorbidity.

RESULTS

Two hundred eighty-one patients were observed, 24.6% of whom received transfusions. The only significant difference between the transfused and nontransfused patients was their preoperative hemoglobin (Hb) concentration (12.5 +/- 1.20 g/dL vs 13.3 +/- 1.22 g/dL, p < 0.001). The disease-free interval of the transfused patients was significantly lower than that of the nontransfused patients (53% vs 78% at 73 months, p < 0.005), as was also the case for actuarial survival (52% vs 71% at 73 months, p < 0.02). Blood transfusion was significantly predictive of tumor relapse according to the Cox model adjusted for the T state, preoperative Hb concentration, sex, age, histologic type, and grading (hazard ratio, 2.3; p = 0.017).

CONCLUSIONS

Our data show that perioperative blood transfusion is significantly correlated to worse prognosis in patients undergoing surgery for stage I lung cancer.

The sequence of vessel interruption during lobectomy for non-small cell lung cancer: is it indeed important?

OBJECTIVE

During pulmonary resections for non-small cell lung cancer, the pulmonary vein is traditionally interrupted first to prevent seeding of malignant cells and consequently decrease metastatic implantation. This hypothesis was never confirmed scientifically. The aim of the present study was to determine whether the sequence of vessel interruption during lobectomy (lobar vein or lobar artery first) affects disease recurrence.

METHODS

A historical prospective study was performed of 279 consecutive patients with complete follow-up, who survived lobectomy for non-small cell lung cancer during 1992 to 1998, in a single center. Pre-, intra-, and postoperative variables were collected from the medical records; recurrence and vital status were obtained from follow-up files, central population registry, and personal confirmation, updated to December 2000. Comparison of recurrence rates by sequence of ligation and other independent variables was assessed by univariate and multivariate logistic regression analyses.

RESULTS

A total of 133 patients (48%) had vein interruption before the artery (V-first) and 146 (52%) had artery interruption first (A-first). The distribution of demographic, clinical, and other characteristics was similar between the 2 groups, except for the operated side and performing surgeons. The morbidity, blood requirement, and length of stay were equal for both groups. The total recurrence rate (A-first, 53%; V-first, 51%) was similar. Multivariate analysis (controlling for the effect of the performing surgeon) revealed elevated risk for recurrence among patients with high disease stage (odds ratio = 2.54), male gender (odds ratio = 1.59), intraoperative lung manipulation (odds ratio = 2.72), and blood transfusion (odds ratio = 1.49). Sequence of vessel interruption was not found as a risk factor for recurrence (odds ratio = 1.29; 95% 0.73 to 2.29, P =.4).

CONCLUSIONS

Our results did not show that sequence of vessel interruption during lobectomy plays a role in tumor recurrence. A prospective study with randomization in selection of method as well as surgeons for each patient is needed to confirm these results.

Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases

OBJECTIVE

To determine if transfusion affected perioperative and long-term outcome in patients undergoing liver resection for metastatic colorectal cancer.

SUMMARY BACKGROUND DATA

Blood transfusion produces host immunosuppression and has been postulated to result in adverse outcome for patients undergoing surgical resection of malignancies.

METHODS

Blood transfusion records and clinical outcomes for 1,351 patients undergoing liver resection at a tertiary cancer referral center were analyzed.

RESULTS

Blood transfusion was associated with adverse outcome after liver resection. The greatest effect was in the perioperative course, where transfusion was an independent predictor of operative mortality, complications, major complications, and length of hospital stay. This effect was dose-related. Patients receiving one or two units or more than two units had an operative mortality of 2.5% and 11.1%, respectively, compared to 1.2% for patients not requiring transfusions. Transfusion was also associated with adverse long-term survival by univariate analysis, but this factor was not significant on multivariate analysis. Even patients receiving only one or two units had a more adverse outcome.

CONCLUSIONS

Perioperative blood transfusion is a risk factor for poor outcome after liver resection. Blood conservation methods should be used to avoid transfusion, especially in patents currently requiring limited amounts of transfused blood products.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Erythropoietin for patients undergoing radiotherapy: a pilot study

BACKGROUND AND PURPOSE

To evaluate the feasibility and efficacy of using recombinant human erythropoietin (rhEPO) to correct decreased hemoglobin levels in patients undergoing radiotherapy and to get an estimate of its influence on the efficacy of radiotherapy.

MATERIALS AND METHODS

Fifty patients with cancer of the head and neck and the pelvis were randomized before radiotherapy to different rhEPO treatments (none, 3 x 150 U/kg per week i.v., 3 x 300 U/kg per week i.v. and 3 x 150 U/kg per week s.c.). Hematological parameters were evaluated weekly and the locoregional tumor control rates were determined in 38 patients with head and neck cancer.

RESULTS

rhEPO-treated patients showed a significant increase in their hemoglobin values (0.7 g/100 ml per week). The rhEPO response was comparable for patients with cancer of the head and neck and the pelvis. A delayed recovery was seen when iron deficiency or impaired iron mobilization was present. No serious toxicity was observed. Locoregional tumor control was improved, although not statistically significantly, in those head and neck cancer patients who experienced a rapid rise of hemoglobin.

CONCLUSIONS

Low hemoglobin levels can be safely and quickly corrected with rhEPO. This may improve the effectiveness of radiotherapy.

Effect of subcutaneous recombinant human erythropoietin in cancer patients receiving radiotherapy: final report of a randomized, open-labelled, phase II trial

The purpose of this study was to determine the safety, efficacy and impact on quality of life of recombinant human erythropoietin (r-HuEPO) for cancer patients undergoing radiotherapy (RT). An open-labelled randomized design was used, with patients randomized to either treatment or control arms. Patients in the treatment arm received r-HuEPO given by subcutaneous injection at a dose of 200 units kg(-1) day(-1) plus oral iron supplements (ferrous sulphate 325 mg p.o. t.i.d.). Entry was restricted to patients with carcinoma of the lung, uterine cervix, prostate or breast who presented for RT with anaemia parameters reflective of 'the anaemia of chronic disease'. Radiotherapy policies (portals, doses, fraction size, etc.) were determined by the site and stage of disease. Complete blood counts (CBCs) were obtained weekly. The target level of haemoglobin was 15 g dl(-1) for men and 14 g dl(-1) for women. Quality of life (QOL) was assessed weekly by using an analogue scale to judge energy, activities of daily living and overall quality of life. Forty-eight patients were entered in the study, 24 in the treatment arm and 24 in the control arm. The prerandomization demographic characteristics and mean laboratory values were comparable in both arms. The mean haemoglobin at completion was 13.6 g dl(-1) for r-HuEPO-treated patients compared with 11.0 g dl(-1) for control subjects (P = 0.0012). Patients who received r-HuEPO demonstrated a mean weekly haemoglobin increase of 0.41 g dl(-1) compared with a decrease in mean haemoglobin level in controls for 6 of the 7 weeks of the study (mean weekly decrease of 0.073 g dl(-1)). Target levels of haemoglobin were achieved by 41.6% of r-HuEPO-treated patients compared with none of the control subjects. The mean platelet count declined in both arms of the study with RT but the decline from pretreatment was less rapid in r-HuEPO-treated patients (11.2% decrease) compared with controls (26.3% decrease) and was statistically significant during weeks 4-6. Toxicity was minor with only mild irritation at the injection site. Mean quality of life end points were superior in the treatment arm but not statistically significant. r-HuEPO had a beneficial effect on weekly haemoglobin levels in patients undergoing RT with response rates similar to other studies. There was also a less rapid decline in weekly platelet counts in r-HuEPO-treated patients compared with control subjects. Further studies are needed to address the optimum dose and scheduling as well as the impact of r-HuEPO on clinical outcomes.

Effects of perioperative blood transfusion on prognosis in early-stage cervical cancer

BACKGROUND

This study was designed to evaluate the prognostic effects of transfusion on patients undergoing radical hysterectomy for early cervical cancer.

METHODS

This retrospective chart review analyzed 412 patients with stage IA-IIA disease, of whom 374 were evaluable.

RESULTS

Three hundred (80%) patients received transfusions and 74 (20%) did not. The clinical characteristics of the two groups were similar, with the exception that the transfused group was older. Pathologic comparisons found that microscopic parametrial disease and larger cervical lesions were more common in the transfused group. Follow-up analysis revealed no difference between the two groups in recurrence or survival. Multivariate analysis found only grade, depth of invasion, and nodal status as independent predictors of recurrence and survival. Kaplan-Meier survival analysis showed no difference in overall survival or disease-free interval between the transfused and nontransfused groups.

CONCLUSIONS

After correction for other prognostic factors, blood transfusion had no prognostic significance in patients with early cervical cancer undergoing radical hysterectomy.