Perioperative blood transfusion and recurrence and death after resection for cancer of the colon and rectum

Haemoglobin drift in patients following Whipple's procedure

BACKGROUNDS

This study aims to identify the objective findings of haemoglobin (Hb) drift in patients that had a Whipple's procedure in the last 10 years, their transfusion status intraoperatively and post-operatively, the potential factors affecting Hb drift, and the outcomes following Hb drift.

METHODS

A retrospective study was conducted at Northern Health, Melbourne. All adult patients who were admitted for a Whipple's procedure from 2010 to 2020 were included and information collected retrospectively for demographics, pre-operative, operative and post-operative details.

RESULTS

A total of 103 patients were identified. The median Hb drift calculated from a Hb level at the end of operation was 27.0 g/L (IQR 18.0-34.0), and 21.4% of patients received a packed red blood cell (PRBC) transfusion during the post-operative period. Patients received a large amount of intraoperative fluid with a median of 4500 mL (IQR 3400-5600). Hb drift was statistically associated with intraoperative and post-operative fluid infusion leading to concurrent issues with electrolyte imbalance and diuresis.

CONCLUSION

Hb drift is a phenomenon that does happen in major operations such as a Whipple's procedure, likely secondary to fluid over-resuscitation. Considering the risk of fluid overload and blood transfusion, Hb drift in the setting of fluid over-resuscitation needs to be kept in mind prior to blood transfusion to avoid unnecessary complications and wasting of other precious resources.

Links between Inflammation and Postoperative Cancer Recurrence

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.

Do packed red blood cell transfusions really worsen oncologic outcomes in colon cancer?

BACKGROUND

Data from small retrospective studies have argued that perioperative packed red blood cell transfusions may increase the risk of developing metastatic recurrence in cancer patients. This study tests this assumption in a large cohort spanning a decade of operatively treated colon cancer patients.

METHODS

All patients undergoing primary resection of a colon cancer at a tertiary care center between 2004-2014 (n = 1,423) were included in a retrospective review of a prospectively maintained data repository. Survival and disease-free survival were compared and also adjusted in multivariable Cox regression standardized for follow-up, American Society of Anesthesiologists score, age, sex, postoperative chemotherapy, baseline staging, and tumor grade.

RESULTS

Of the 1,423 patients, 305 (21.4%) received a perioperative packed red blood cell transfusion during their index admission. During follow-up, overall mortality was greater in patients who received perioperative packed red blood cell (53.1% vs 30.9%; P < .001); however, there were no appreciable differences in rates of long-term distant recurrence (in patients without baseline metastasis 11.1% vs 13.9%; P = .25), or disease-specific mortality (21.3% vs 17.3%; P = .104; without baseline metastasis: 8.6% vs 8.9%; P = .89). Similarly, multivariable Cox regression showed no statistical difference in recurrence (hazard ratio: 0.83, 95% confidence interval, 0.83-1.26; P = .38) or disease-specific mortality (hazard ratio: 1.12, 95% confidence interval, 0.83-1.51; P = .47).

CONCLUSION

Mortality rates were significantly greater in patients with perioperative packed red blood cell transfusions, a finding that is backed by a body of evidence that associates perioperative packed red blood cell transfusion with comorbidity and serious illness, but contrary to earlier evidence, findings in our cohort do not support a hypothesis that perioperative perioperative packed red blood cell transfusions have a detrimental effect on recurrence rates of operatively treated colon cancer patients.

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

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

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

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

Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions

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.

Is there a role for intravenous iron therapy in patients undergoing colorectal cancer resection?

Worldwide, colorectal cancer (CRC) is one of the most common forms of malignancy and is increasing in incidence in many regions. At diagnosis, approximately 40% of patients with CRC are anemic, a figure that increases over the course of a patient's treatment due to many factors, including ongoing hemorrhage. Preoperative anemia is therefore associated with increased allogenic red blood cell transfusion (ARBT) rates. In the context of CRC, perioperative ARBT has been linked with adverse postoperative outcomes, including higher morbidity, mortality and cancer recurrence rates. Therefore, strategies to potentially reduce the need for ARBT have been the focus of several recent studies. We critically evaluate a recent paper that explores intravenous iron III sucrose as a treatment option for the management of postoperative anemia in CRC patients. This study is a retrospective, observational case-controlled study that was designed to evaluate whether the use of postoperative intravenous iron reduces the incidence of ARBT following CRC resection.

Blood Transfusion and Risk of Metastatic Disease or Recurrence in Patients Undergoing Immediate TRAM Flap Breast Reconstruction: A Clinical Study and Meta-Analysis

BACKGROUND

The transfusion of blood products has a known immunomodulatory effect that may affect cancer recurrence. The present study examined whether blood transfusion is an independent risk factor for recurrence or development of metastatic disease among patients undergoing immediate breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap.

METHODS

Records of 103 patients who underwent mastectomy and immediate reconstruction with a TRAM flap between 1991 and 2001 were reviewed. A logistic regression analysis was used to identify independent risk factors for metastasis or recurrence. For the meta-analysis, all English-language studies regarding blood transfusion and breast cancer recurrence were reviewed, and 2 x 2 contingency tables were constructed from which a summary relative risk was calculated.

RESULTS

There were 57 free and 35 pedicle TRAM flaps. Forty-nine patients (48 percent) received perioperative transfusion of nonautologous blood. Twenty patients (19 percent) experienced metastatic disease or local recurrence. Follow-up ranged from 4 to 14 years (mean, 6.7 years). There was a higher observed rate of adverse outcome in patients who received transfusion, but this was not statistically significant (p = 0.90). Of the 11 articles identified by the meta-analysis, eight used a regression analysis controlling for the effect of stage and nodal status. The summary relative risk in these studies was 1.03 (95% CI, 0.90 to 1.26).

CONCLUSIONS

Perioperative blood transfusion does not seem to be an independent risk factor for metastasis or cancer recurrence in patients undergoing TRAM flap reconstruction. The observed correlation in this and prior studies may be due to the effect of other, more significant factors, such as tumor stage and nodal status.

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.

Perioperative blood transfusions for the recurrence of colorectal cancer

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

[Perioperative transfusion in colorectal surgery]

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

Colorectal cancer--a multivariate analysis of prognostic factors

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

Transfusion does not influence patient survival after resection of colorectal cancer

Two recent reviews reached opposing conclusions regarding the apparent detrimental effect of peri-operative blood transfusion on patient survival after resection of colorectal cancer. However, both sides agree that the influence of confounding variables has not been controlled adequately in most studies. The present study is based on 433 patients who had a curative resection for colorectal cancer between 1984 and 1989 and whose details and follow-up information were recorded in the Concord Hospital Colorectal Cancer Registry, Sydney. The association between peri-operative transfusion and patient survival after resection of colorectal cancer was examined taking into account 20 other prognostic variables. A proportional hazards regression model showed that transfusion did not have a statistically significant independent effect on survival after controlling for the patient's poor general condition, the complexity of the surgery and the occurrence of postoperative complications.

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

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

[Transfusion and cancer]

Relationship between blood transfusion and cancer is considered from five points of view: 1) The cancer patient as a blood donor. Cancer must remain a cause of exclusion from blood donation. 2) Autologous blood transfusion for cancer patients. Predeposited autologous blood transfusion is only possible for a small number of patients. Intraoperative blood salvage carries with it the risk of disseminating tumor cells. 3) History of blood transfusion and the risk of having a cancer: a) the persistence of immune alterations following blood transfusion for years might expose the patient to an increased risk of having a cancer; b) blood transfusion might carry immunosuppressive viruses, and hepatitis viruses are related to the risk of liver cancer. 4) Cancer recurrence and blood transfusion. Conclusion of most of the published studies is that blood transfusion is associated with an increased risk of recurrence of colorectal cancer. The only realistic randomized study would compare different transfusion strategies (allogenic, leukocyte poor allogenic and autologous blood transfusion) to determine which is the best for cancer patients. 5) Post-transfusion GVH in cancer patients. Some cases have recently been published. They all can be explained by a particular HLA compatibility between the recipient and one of the blood donors.

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

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

The association between perioperative blood transfusion and survival of patients with colorectal cancer

BACKGROUND

The authors undertook this study to test the hypothesis that perioperative blood transfusion has an adverse effect on survival of patients with colorectal cancer.

METHODS

A retrospective analysis was performed on 725 patients who underwent curative resection for Dukes Stage B and C colorectal cancers in our institution between 1981-1985 and who were followed for 5-11 years.

RESULTS

Rectal cancers occurred more frequently in the transfused than in the nontransfused patients (64% versus 47%; P = 0.0001). In the patients with colon cancer, no significant effect of transfusion on recurrence-free survival was seen (P = 0.8, log-rank; P = 0.49, Cox regression analysis). The cumulative 5-year survival rate was 77% (95% confidence interval, 69-85%) for the nontransfused and 78% (72-83%) for the transfused patients. In patients with rectal cancer, the 5-year survival rate was 79% (67-87%) for the nontransfused and 67% (59-71%) for the transfused patients. A significant association was noted in patients with Stage B cancer (P = 0.002, log-rank; P = 0.02, Cox regression analysis), but not in those with Stage C cancer (P = 0.05, log-rank; P = 0.15, Cox regression analysis). In patients with Stage B rectal cancer, more frequent abdominoperineal resections (APR) were performed among the transfused patients (65% versus 32%; P = 0.0001). This subgroup was further stratified by operative procedure and reanalyzed using the same Cox regression model. Transfusion had no effect on survival of patients treated by APR (P = 0.31) or of those having a sphincter-saving procedure (P = 0.53).

CONCLUSION

The seemingly adverse effect of perioperative blood transfusion on the survival of patients with colorectal cancer may be explained by other covariates.

Perioperative blood transfusion and outcome after resection for colorectal carcinoma

The degree of immunomodulation by perioperative blood transfusion and its effect on oncological surgery remain controversial. A major problem with previous clinical studies has been the inadequate patient population in each and the presence of confounding variables. To resolve some of the controversy, all studies published between 1982 and 1990 were reviewed using the statistical method of Mantel-Haentszel-Peto to determine a cumulative estimate of the direction and magnitude of this association. Some 20 papers were included in the analysis, representing 5236 patients. The cumulative odds ratios (95 per cent confidence interval) of disease recurrence, death from cancer and death from any cause were 1.80 (1.30-2.51), 1.76 (1.15-2.66) and 1.63 (1.12-2.38) respectively. These results support the hypothesis that perioperative blood transfusion is associated with an increased risk of recurrence of colorectal carcinoma and death from this malignancy.