Perioperative anemia and blood transfusions as prognostic factors in patients undergoing resection for non-small cell lung cancers
Introduction
Complete surgical resection of the primary tumor and metastatic lymph nodes remains the only potentially curative treatment for patients with NSCLC [1]. Although a role for prognostic factors such as histology, leukocyte count and carcinoembryonic antigen (CEA) level has been suggested, only tumor size and nodal involvement are commonly accepted and used as prognostic indicators in the daily clinical practice [2].
Emerging evidence over the past decade has suggested that anemia may be related to poor clinical outcomes, including survival. The importance of Hb level as a prognostic and predictive factor for outcome has been examinated in a variety of solid tumors. A low Hb level was found to be prognostic for overall survival especially in patients with head and neck cancer and with cervical cancer [3].
Furthermore, several studies examined the prognostic influence of anemia on advanced NSCLC [4], [5].
More recently, Pradier et al. showed that the Hb levels prior to radio-chemotherapy have an influence on prognosis of NSCLC, where lower levels were associated with worse outcome [6].
In patients with lung cancer, the prevalence of anemia is high (50–60% with Hb levels <11 g/dl) [7], [8], and approximately 43% of this patient population receive blood transfusions, compared with only 19% of patients with breast carcinoma cases [9].
After the initial publication by Burrows an Tartter [10] showing a detrimental effect of perioperative blood transfusions given to patients that had undergone apparently curative resection for colon cancer, multiple studies have attempted to elucidate this correlation, its dependency upon the type of cancer and its clinical significance [11], [12], [13], [14], [15], [16], [17], [18], [19], [20].
It is suspected that an immune mechanism could be involved in this phenomenon. In fact, an immune disorder caused by blood transfusion is well described in the medical literature and goes by the name of “allogeneic blood transfusion-associated immunomodulation” (TRIM) [21]. This mechanism is the same one considered responsible for improved survival of kidney allografts in transplanted patients receiving preoperative blood transfusions [22]. It has been postulated that a state of non-specific immunosuppression induced by the transfused blood allows the kidney recipient to better tolerate the transplanted organ, with subsequent decreases in rejection episodes and improved survival [23].
In a similarly way, immunosuppression may be produced in cancer patients who have received blood transfusions perioperatively, thus resulting in the possible proliferation of residual tumor cells that had not been resected after the “curative” surgery [24].
However, the hypothetically negative effect of blood transfusions in solid tumors may be simply the consequence of the anemic status of the patients, and its role may be overestimated. Nevertheless it is also possible that blood transfusion request could only represent an epiphenomenon for a deeper alteration in tumor angiogenic pathways caused by anemia.
In order to explore the clinical implications of anemia as indicator of prognosis, we therefore assessed the correlation of preoperative anemia with survival in patients with resected NSCLC, and finally to assess the role of anemia and blood transfusion, respectively, in the determination of the prognosis of the patients.
Section snippets
Patients selection
The study includes all the consecutive patients who underwent radical surgery for NSCLC at the Department of Thoracic Surgery of Universita Politecnica delle Marche from January 1996 to December 2001.
Data for patients entered onto the analysis included age, sex, type of surgery, histological type, pathological stage of disease, risk factor (smoking), preoperative Hb levels, whether preoperative transfusions were administered and the number of transfusions were also reported.
Transfusions were
Results
From January 1996 through December 2001, 439 patients underwent radical surgery for NSCLC at the Department of Thoracic Surgery of Università Politecnica delle Marche. Median age at surgery was 68 years (range 37–84); male/female ratio was 374/65.
Two hundreds and thirteen patients (48.5%) were diagnosed with adenocarcinoma, 172 patients (39.2%) with squamous cell carcinoma and 25 patients (5.7%) had undifferentiated carcinoma.
Pathologic stage of disease was as follows: IA in 77 patients
Discussion
Anemia has been demonstrated to be a prognostic indicator for lower survival probability in patients with advanced lung cancer receiving a chemotherapy and/or radiotherapy. Results from a number of studies suggest that better outcomes are associated with Hb levels ≥11–12 g/dl [26], [27], [28], [29].
The results of the present study seem to indicate that anemia is a prognostic factor even for radically resected lung cancer patients. In fact our analysis revealed a significant difference in
Acknowledgement
Supported by CNR-MIUR—Lex 449/97.
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Preoperative Anemia is Associated With Worse Long-Term Survival After Lung Cancer Resection: A Multicenter Cohort Study of 5,029 Patients
2022, Journal of Cardiothoracic and Vascular AnesthesiaPrognostic impact of blood transfusion in patients with metastatic non-small cell lung cancer receiving chemotherapy
2019, Lung CancerCitation Excerpt :But, it is not known how ABT affects the treatment outcomes in patients treated with immunotherapy, thus further studies are needed on this issue. So far, studies on this area have remained limited and included only early-stage operated patients [6,17,18,21–28]. Unlike other studies, our study included metastatic NSCLC patients at diagnosis, but even so our study had some limitations as follows; 1- It had retrospective nature, 2- We could not reach the data regarding the number of transfusions performed before treatment period or during treatment period, thus we do not know how this condition affects survival, 3- We don't exactly know after which cycle we performed transfusion.
Optimizing Preoperative Anemia to Improve Patient Outcomes
2018, Anesthesiology ClinicsCitation Excerpt :Likewise, in their retrospective analysis of 125 patients with non–small cell lung cancer, Yovino and colleagues30 found that preoperative hemoglobin level less than 12 g/dL predicted worse relapse-free and overall survival. Berardi and colleagues31 found that perioperative anemia predicted postoperative mortality and this relationship remained after correction of anemia with red blood cell transfusion. In contrast, Melis and colleagues32 showed that preoperative anemia was not associated with poor outcomes in patients undergoing esophagectomy, but preoperative anemia was independently associated with increased rate of perioperative blood transfusions, and such transfusions were associated with higher risk of overall complications and surgical site infections.
Transfusions of blood products and cancer outcomes
2015, Revista Espanola de Anestesiologia y ReanimacionCitation Excerpt :This study indicates that in patients with cancer who undergo major cancer surgery the compensatory mechanisms to improve oxygen into different organs might fail below a threshold of 9 g/dL. Preoperative anemia is an independent risk factor for cancer recurrence; thus, it has been hypothesized that the association between blood transfusions and poor oncological outcomes may only represent the effect the intervention (blood transfusion) to correct low hemoglobin concentrations.7–9 In the context of surgery, low hemoglobin concentrations may be associated with poor oncological outcomes due to several reasons including: (1) tumoral hypoxia which can trigger adaptive mechanisms that may alter the phenotype of the cancer cells turning them more aggressive and (2) the release of pro-inflammatory cytokines that can stimulate tumor growth.10
Perioperative blood transfusion is associated with worse clinical outcomes in resected lung cancer
2014, Annals of Thoracic SurgeryLeukocyte-depleted blood transfusion is associated with decreased survival in resected early-stage lung cancer
2012, Journal of Thoracic and Cardiovascular Surgery