Use of the Cell Saver in Oncologic Surgery

Abstract

SUMMARY Use of the cell saver in oncologic surgery is controversial because of the risk of reinfusion of cancer cells remaining in the packed erythrocytes. Experimental and clinical studies have indeed confirmed the presence of residual cancer cells in packed red cells. However, six clinical studies with a limited number of patients showed no metastatic spread after processing of the blood with a cell saver. The adjunctive use of a leukocyte depletion filter (LDF) greatly reduces the number of cancerous cells in the pack whereas irradiation of the pack with 50 Gy destroys all the cancer cells. Strictly speaking, the stringent application of this safety principle would require use of a cell saver only in conjunction with an irradiator. Studies indicate that cancer cell seeding from infiltrative tumors seems to be greater than that observed when a cell saver is used. In the final analysis, we feel that it is reasonable to use the cell saver in oncologic surgery, if possible with a leukocyte filter, not only in cases of unexpected bleeding risk but also during scheduled procedures with a high risk of massive blood loss.

Should intraoperative cell-salvaged blood be used in patients with suspected or known malignancy?

“…84 Given the difficulty of these studies, the suggestion of establishing local, national, or international registries to monitor tumour recurrence and patient survival deserves attention and has been suggested previously in the literature. 85 Avoidance of allogeneic blood products is not possible for all patients undergoing resection of malignancy. Nevertheless, transfusion of autologous blood harvested via ICS should be considered a viable option for reduction or avoidance of allogeneic product and may be a lifesaving option for those patients who refuse allogeneic blood products.…”

Cell Salvage in the Presence of Malignancy

“…The contraindication of cell salvage in cancer surgery has been questioned because of clinical studies showing "no major cancer risk associated with the use of the cell saver," because of the "metastatic inefficiency" of transfused tumor cells, because of the existence of spontaneously released "circulating tumor cells," because of a "substantially reduced risk after leukocyte filtration." 45 Usually, we consider transfusion risks according to impact, rather than to incidence. What then is a "major" risk, if not metastasis?…”

“…Objections have been raised against blood irradiation 45 : "Access to an irradiator, a radiophysics setting and authorization", is necessary. This is standard for any blood irradiation, which is common in the treatment of oncologic patients.…”

Advantages of Intraoperative Blood Salvage with Blood Irradiation in Cancer Surgery

“…The use of leukocyte depletion filters also did not allow to eliminate the risk of tumor cell dissemination by retransfusion, as it only permits a 3-4 log reduction of tumor cells [10]. On other hand, viable tumor cells in high incidence and number were found in wound blood salvaged during cancer surgery, confirming the contraindication [15] The analysis and characterization of these cells may be more suitable than clinical studies to evaluate the risk of retransfusing these cells. Moreover, strategies for their elimination may be developed and tested, and specific clinical questions may be answered, e.g.…”

“…In contrast, the proof of circulating tumor cells ad no prognostic significance. Therefore, it is not warranted to play down the impact of tumor cells in wound blood and the implied risks by referring to the insignificance of tumor cells in the circulation or to the low metastatic efficiency of cells derived from solid tumors [13,15]. Even in cases with established metastasis or cancer cells in the circulation, a retransfusion of wound blood must to be strictly avoided since otherwise tumor cells of much higher malignant potential might get access to all organ systems via hematogenic dissemination.…”