Prognosis and postoperative lymphocyte count in patients with hepatocellular carcinoma who received intraoperative allogenic blood transfusion: A retrospective study

https://doi.org/10.1016/j.ejso.2007.02.010Get rights and content

Abstract

Aims

The effect of perioperative blood transfusion on the survival of hepatocellular carcinoma (HCC) has not been fully investigated. To clarify the prognostic value of intraoperative allogenic blood transfusion, we conducted a comparative retrospective analysis of 224 patients with HCC who underwent hepatic resection.

Methods

We compared clinicopathologic background and survival after hepatic resection between patients who received intraoperative blood transfusion (n = 101) and those who did not (n = 123).

Results

Patients with blood transfusion had a larger tumor and more frequent vascular invasion than those without blood transfusion. The 5-year cancer-related survival rate after hepatic resection, but not the disease-free survival rate, was significantly lower in patients who underwent blood transfusion than in those who did not (38.3% vs. 66.7%, P < 0.01). Multivariate analysis showed intraoperative blood transfusion (P = 0.02), microscopic portal invasion (P < 0.01), and preoperative serum alpha-fetoprotein elevation (P = 0.03) to be independent risk factors for poor outcome after hepatic resection. The negative effect of blood transfusion on postoperative survival was observed only in patients with a tumor larger than 50 mm in diameter. The absolute peripheral blood lymphocyte count on postoperative day 1 was significantly lower in patients who underwent blood transfusion (880/mm3) than in those who did not (1081/mm3) (P < 0.01).

Conclusions

Our data suggest that intraoperative blood transfusion results in immunosuppression in the early postoperative period, allowing for progression of residual HCC after resection. Therefore, intraoperative allogenic blood transfusion should be avoided in patients with resectable HCC, particularly in those with a large tumor.

Introduction

Hepatocellular carcinoma (HCC) is common worldwide. HCC is frequently accompanied by chronic hepatitis or liver cirrhosis related to hepatitis B virus or hepatitis C virus (HCV) infection, and most patients have poor liver function reserve. Particularly in patients with HCC accompanied by liver cirrhosis, the platelet count and peripheral blood prothrombin time are decreased, and the risk of hemorrhage is increased. Surgical treatment has been considered the most effective therapy for large HCC tumors.1 However, even such surgical techniques as hepatic pedicle clamping2 and predissected liver ablation3 often involve perioperative blood transfusion.

Despite recent progression in surgical techniques and postoperative management, the recurrence rate after surgical resection of HCC is high.4 Intrahepatic recurrence of HCC is due to either intrahepatic metastasis or multicentric cancer development.5 HCC cells frequently invade the portal vein and form intrahepatic metastases. Vascular invasion of HCC cells increases with tumor size.6, 7 Therefore, it has been suggested that anatomic resection may improve the survival of patients with large HCC.8 Postoperative adjuvant chemotherapy, such as intrahepatic arterial infusion, may also improve survival after hepatic resection.9 However, tumor cells often remain in the liver after hepatic resection.

Several recent studies have shown that perioperative blood transfusion has an adverse effect on postoperative outcome after resection for some types of malignant tumor.10 Although the mechanism remains unclear, several investigators have suggested that allogenic blood transfusion may induce immunosuppression.11, 12 Several reports have shown that natural killer cell11, 12 and/or helper T-cell activities are decreased and that suppressor T-cell activity is increased after allogenic blood transfusion.13 With respect to HCC, some investigators have reported that perioperative allogenic blood transfusion decreases the long-term survival rate after resection.14, 15 Asahara et al. reported that perioperative allogenic blood transfusion decreased survival after resection only in patients with stage I or II HCC.16 However, Kwon et al. reported no effect of perioperative blood transfusion on survival after hepatic resection.17 Therefore, the effect of perioperative allogenic transfusion in patients with HCC remains unclear. To clarify the effect of intraoperative allogenic blood transfusion on long-term survival of patients with HCC, we retrospectively investigated the relation between intraoperative allogenic blood transfusion and survival of patients with HCC, with a focus on tumor size.

Section snippets

Patients

During the period February 1983 through January 2005, 259 patients with HCC underwent curative hepatic resection at the Department of Surgery I, Oita University Faculty of Medicine, Oita, Japan. Of these patients, 20 who died of complications within 30 days after surgery, 9 for whom postoperative outcome was uncertain, and 6 for whom the tumor was shown to be completely necrotic were excluded from the present study. Therefore, 224 patients were included. We defined curative resection according

Patient characteristics

The patient group comprised 172 men and 52 women. Mean age at the time of hepatic resection was 63.2 years (range, 36–84 years). Serum HCVAb test results were positive in 114 of the 177 patients tested. Mean greatest tumor dimension was 48.8 mm (median, 40 mm; range, 5–186 mm). Mean and median preoperative serum AST levels were 66.9 IU/l and 54 IU/l, respectively; AFP levels were 2860 ng/ml and 39 ng/ml, respectively. One hundred nineteen patients underwent hepatic resection of less than

Perioperative blood transfusison and prognosis

Adverse effects on survival have been reported for perioperative blood transfusion after resection for several types malignant tumors such as cancer of the stomach,19 esophagus,20 colorectum,21 lung,22 pancreas,23 periampullary region,24 and bile duct.25 Watering et al. reported that perioperative allogenic blood transfusion was associated with decreased survival but not with recurrence of colorectal cancer.26 With respect to HCC, several investigators have reported that perioperative blood

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