Platinum Priority – Bladder CancerEditorial by George N. Thalmann on pp. 846–847 of this issueThe Impact of Perioperative Blood Transfusion on Cancer Recurrence and Survival Following Radical Cystectomy
Introduction
The potential immunosuppressive effect of red blood cell transfusion was first described by Opelz and Terasaki in 1974, in a report of enhanced renal allograft survival among patients receiving a transfusion [1]. Similarly, a later series noted lower recurrence rates in patients with Crohn's disease who received a perioperative blood transfusion (PBT) [2]. PBT has been associated with subsequent disease recurrence in a number of malignancies, including colon, esophageal, and hepatic carcinomas [3], [4], [5]. While multiple hypotheses regarding the biologic activity of PBT—including immunomodulation and growth factor delivery from red blood cells—have been offered, no definitive mechanistic link has been established [6], [7], [8].
Conflicting data have been reported regarding the association of PBT with recurrence rates for prostate cancer (PCa) patients undergoing radical prostatectomy [9], [10], [11], [12], as well for renal cell carcinoma patients following nephrectomy [13], [14]. With regard to bladder cancer (BCa), there has been a paucity of data regarding the association of PBT with postoperative outcomes after radical cystectomy (RC) [15], [16]. As RC remains associated with a relatively high rate of transfusion [16], [17], [18], [19], determining the association of PBT with postoperative cancer control and mortality remains important for optimizing patient management.
Using a large cohort of patients with long-term follow-up, we evaluated the association of PBT with disease recurrence and survival following RC, controlling for clinicopathologic variables.
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Patients and methods
Following institutional review board approval, we reviewed the Mayo Clinic Cystectomy Registry and identified 2060 patients treated with RC for BCa at our institution between 1980 and 2005. RC with lymphadenectomy was performed using standard techniques by various surgeons over the time frame of the study. Given the time span of patients included, the extent of lymph node dissection varied but currently extends from the mid–common iliac artery proximally to the Cooper ligament distally,
Results
Of 2060 patients undergoing RC, 1279 patients (62%) received a PBT, with 2 U as the median number of units transfused (interquartile range [IQR]: 2–4 units). Clinicopathologic demographics for these patients, as well as for the cohort who did not receive a PBT, are provided in Table 1. As can be seen, patients receiving PBT were significantly older (p < 0.0001) and more likely to be female (p < 0.0001), with a worse ECOG performance status (p < 0.0001), a lower body mass index (p < 0.0001), and a lower
Discussion
We found in this study with a large cohort of patients undergoing RC with long-term postoperative follow-up that receipt of a PBT was associated with significantly increased risks of cancer recurrence, death from BCa, and all-cause mortality. Additionally, among patients who received a PBT, an increasing number of units transfused was associated with significantly increased risks of cancer-specific and all-cause mortality. These findings remained significant after controlling for
Conclusions
We found an association of PBT with significantly increased risks of tumor recurrence and mortality following RC. This association remained when accounting for potential confounding clinical and pathologic features. While these data require external validation, continued efforts to limit the use of blood products in these patients are warranted; these efforts include implementing restrictive transfusion criteria or alternative strategies for blood replacement and surgical techniques to minimize
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