Blood Salvage and Autotransfusion With Single Leukoreduction Does Not Increase the Risk of Tumor Recurrence After Liver Transplantation for Advanced Hepatocellular Carcinoma

Abstract

The aim of this study was to determine whether autotransfusion of salvaged blood with single leukoreduction is associated with post-transplant tumor recurrence in patients with advanced hepatocellular carcinoma (HCC). Background: Previous studies have consistently demonstrated the safety of autotransfusion of salvaged and leukoreduced blood during liver transplantation for HCC. However, the effects of this technique remained unknown for advanced HCC. Methods: Of 349 patients who underwent living donor liver transplantation for advanced HCC: 74 of 129 without autotransfusion were matched with 74 of 220 with autotransfusion using propensity score based on tumor biology, allogeneic transfusion, and others. Survival analysis was performed with death as a competing risk event. The primary outcome was HCC recurrence. Results: Recipients in autotransfusion group received 811 (497-1247) mL of salvaged blood with single leukoreduction. In the matched cohort, cumulative overall recurrence probability at 1/2/5 years after transplantation was 24.6%/ 38.3%/39.7% for nonautotransfusion group and 16.2%/23.1%/32.5% for autotransfusion group. There were no significant differences between the 2 groups in overall recurrence [hazard ratio (HR) = 0.72 (0.43-1.21)], intrahepatic recurrence [HR = 0.70 (0.35-1.40)], and extrahepatic recurrence [HR = 0.82 (0.46-1.47)]. Also, there were no significant differences in overall death [HR = 0.57 (0.29-1.12)], HCCrelated death [HR = 0.59 (0.29-1.20)], and HCC-unrelated death [HR = 0.48 (0.09-2.65)].Conclusions: When allogeneic transfusion was matched, autotransfusion was not significantly related to HCC recurrence, with more favorable probabilities for autotransfusion, in patients with advanced HCC. Thus, blood salvage and autotransfusion could be safely used with single leukoreduction, without double-filtered leukoreduction, during liver transplantation for HCC with potential benefits from avoiding allogeneic red blood cell transfusion.

Safety of Intraoperative Cell Salvage in Cancer Surgery: An Updated Meta-Analysis of the Current Literature

“…We included two study pairs from the same institution (Kwon et al [20] and Han et al [21], Fujimoto et al [18] and Hirano et al [56]) despite a potentially overlapping patient population (overlap by 74 vs. 222, 46 vs. 50 IOCS-treated and analyzed subjects). Since enrollment periods and numbers of enrolled subjects varied, we assumed two different populations.…”

Perioperative management of adult living donor liver transplantation: Part 1 – recipients

“…Some investigators advocated the safety of this technique during LT in patients with hepatocellular carcinoma 6 based on findings showing an extremely low tumor recurrence rate. 93,94 Point-of-care coagulation monitoring devices have been widely used to avoid excessive allogeneic blood transfusion in LT. These viscoelastic tests (VETs) provide objective measures of global coagulation status at the bedside and allow clinicians to perform goal-directed coagulation management.…”

French editorial from the ACHBPT: blood salvage and autotransfusion during liver transplantation for advanced hepatocellular carcinoma

“…Moreover, the risk of HCC recurrence (both in intrahepatic and extrahepatic recurrence) or death showed a trend in favor of autotransfusion, although statistical significance was not reached. Because the amount of transfused allogeneic RBCs was controlled by matching, these results were not thought to be due to sparing of allogeneic RBCs and reduced immunomodulation with autotransfusion but due to the direct effects of autotransfusion (1).…”

“…This issue remains a concern because the American Medical Council, in its report on autologous blood transfusion in 1986 promulgated a contraindication to the use of cell saver in cancer surgery based on a single case report in 1975, where a 52-year-old patient undergoing pneumonectomy was found to have malignant cells in salvaged blood (3,6). This dogma has become obsolete because since then, many authors have shown that the use of autologous blood in cancer patients can be safely used and does not impact the risk of neoplastic recurrence (1,3,7), event in HCC patients after LT (5,8). Moreover, in advanced HCC patients, who have greater metastatic potential, the uncertainty remains on the need of a single or a double-filtered leukoreduction during the treatment of the collected blood (9)(10)(11).…”

“…Moreover, in advanced HCC patients, who have greater metastatic potential, the uncertainty remains on the need of a single or a double-filtered leukoreduction during the treatment of the collected blood (9)(10)(11). This concern has never been assessed while the requirement of double-filtered leukoreduction delays the preparation of autologous blood and possibly increases the use of allogeneic RBCs (1).…”