Colorectal cancer is one of the common malignant tumors in the gastrointestinal tract. With the improvement of living standard in recent years, the incidence rate has been increasing year by year, and now ranks third after lung cancer and stomach cancer. Currently, it is believed that autoimmunity plays a role in the development of colorectal cancer. Because perioperative blood transfusion can affect the human autoimmune system, its relationship with colorectal cancer has become one of the hot spots of research in recent years.
Articles on this subject are reported from time to time, and the present paper reviews this issue as follows.
Since Burrows and Tartler first reported that blood transfusion is associated with high recurrence rate and short survival in colorectal cancer in 1982, the issue has been attracting more and more attention and is considered as a “red danger”, and many scholars have made in-depth studies in recent years.
M(1) studied 120 cases of colorectal cancer patients with allogeneic or autologous blood transfusion and found that the risk of tumor recurrence was significantly higher in the allogeneic transfusion group (RR=5.16, P=0.034), and concluded that the mode of blood transfusion had a significant effect on tumor recurrence after colorectal cancer surgery, and allogeneic blood transfusion was an independent risk factor for tumor recurrence, and further speculated that the change of transfusion mode had a significant effect on tumor recurrence after colorectal cancer surgery. tumor recurrence after surgery for colorectal cancer may outweigh the selection of any of the new adjuvant treatment strategies.
In China, Xie Liaojin et al. studied 71 patients with rectal cancer and concluded that the higher the amount of perioperative blood transfusion, especially intraoperative transfusion, the higher the chance of postoperative recurrence. Meanwhile, he also studied the effect of hypotension on the prognosis of rectal cancer, and concluded that hypotension has a greater impact. The longer the duration of hypotension, the shorter the postoperative cancer recurrence time was significantly. Because there are many factors affecting intraoperative hypotension, many of which were not included in the article, and no analysis of covariance was performed, the relationship between hypotension and prognosis of rectal cancer is not obvious, and the existence of confounding factors cannot be excluded.
Corman reported 281 patients with colon cancer surgery, and the results showed that there was a significant difference between postoperative survival with and without blood transfusion, and the more blood transfusion, the worse the prognosis. Francis and Judon (3) reported that among 53 cases of perioperative blood transfusion in patients with colorectal cancer, the recurrence rate was 52% (15/29) in 29 cases of intraoperative transfusion; 24 cases of preoperative and postoperative transfusion, and the recurrence rate was 17% (4/24), showing a greater prognostic impact of intraoperative blood transfusion on patients with cancer, but given the small number of cases further studies are needed.
VAMVAKAS made a meta-analysis of patients undergoing surgery for several tumors and concluded that the negative outcome of perioperative blood transfusion in patients undergoing surgery for colorectal cancer had a hazard ratio of 1.49 (95% CI. 1.23-1.79) and was also worse in patients with malignant tumors of the breast, bone, head and neck, and stomach. tom.H et al. studied 336 colorectal cancer patients with a median follow-up of 5.8 years, and their OX2 regression showed that patients with perioperative blood transfusion had higher rates of local recurrence and distant metastases with a relative hazard ratio of 2.7 ( 95% CI 1.4-5.2),and the length of stored blood was not associated with prognosis.
Other scholars have discussed the mechanism in depth, and Sun Jiatan et al. studied the changes of perioperative blood transfusion on T lymphocyte subsets, NK cells and serum SIL-IR levels.
The study speculated that the decrease in T cells due to perioperative transfusion may be.
1, related to the clonal incompetence of T cells after transfusion, the abnormality of MHC in antigen presentation after transfusion, so that T cells can not effectively play a functional effect, only the transformation of T lymphocytes is blocked and T cells decline;
2. Increased Fe2+ load, 20% of red blood cells are phagocytosed by mononuclear endothelial system within 24 hours after transfusion, increased Fe3+ load, which causes prostaglandin E release through certain mechanisms, prostaglandin E can inhibit the transformation of T cells into mother cells and inhibit mitosis, causing T cells to decline, and reduced NK cells can make the microscopic cancer emboli free during surgery to become viable, causing postoperative recurrence and metastasis, resulting in poor prognosis for patients. It causes poor prognosis of patients. The experimental SIL-IR and monocyte activity suggest impaired immune function.
Perttila et al. suggested that blood cell components such as tissue antigens (human blood cell antigens) could cause immune abnormalities and subsequent immunosuppression.
Lawtance RT. et al. suggested that tumor cells are often accompanied by platelet thrombi, which disintegrate to form platelet plugs of tumor cells into the circulation, and that platelets release degranulation-derived growth factors (derived from serum, which can affect the survival of tumor cells disseminated intraoperatively into the vasculature and peritoneal cavity) upon stimulation, promoting tumor growth; tumor cells can also activate platelets, accelerating platelet aggregation and platelet formation, and platelet-derived growth factors in stock blood The activity of platelet-derived growth factors in stock blood continues to increase with the extension of stock time, so the longer the stock blood is stored, the more unfavorable the prognosis for patients.
Kim werther. studied preoperative SVEGF perioperative blood transfusion and survival in primary colorectal cancer, soluble VEGF and tumorigenic angiogenic stimulating factor. There was clearly an increase in soluble VEGF after blood transfusion, which facilitated the formation of blood vessels within the tumor and made the tumor cells favorable for release into the blood for metastasis to other organs. Interestingly, it was only found that perioperative blood transfusion was associated with prognosis in rectal cancer and not in colon cancer. They explained that 1) blood transfusion is more frequent in rectal cancer patients than in colon cancer patients and the side effects of transfusion are more pronounced than in colon cancer; 2) blood transfusion is more frequent in rectal cancer patients during and after surgery, while in colon cancer patients it is more frequent before surgery.
Naoto et al. investigated the relationship between perioperative blood transfusion and postoperative interleukin-6 levels in patients undergoing colorectal cancer surgery. The study showed that postoperative levels of interleukin-6 were significantly higher in the transfused group than in the non-transfused group. It is well known that interleukin-6 is a suppressor of the body’s autoimmune system, i.e., a negative regulator, and its elevation will undoubtedly reduce the tumor patients’ own immunity and cause the metastasis or recurrence of tumor cells.
But there are many opposite conclusions. Ganlu et al. studied 339 patients with colorectal cancer and used Hazard risk proportion analysis for overall survival and recurrence-free survival, and despite the absence of parameters such as tumor fixation and location (which directly affect the survival rate of the transfusion group), the differences in the statistical analysis were still not significant. Therefore, they concluded that perioperative blood transfusion has no effect, if any, on the prognosis of patients operated for colorectal cancer.
The Dutch scholar Busch OR successfully randomized patients with surgical colorectal cancer according to whether they received autologous transfusion or allogeneic transfusion, and nearly half of them received autologous transfusion, and this study showed no significant difference in tumor-free survival and overall survival between the two groups.Sibbering (12) also held the same view.Vamvakas made a meta-analysis of perioperative blood transfusion and showed that the difference between perioperative transfusion and allogeneic transfusion was not significant. analysis, showing that allogeneic transfusion was not significantly associated with proximal and distant mortality but in a subgroup analysis, transfusion in cardiac surgery was found to be associated with mortality.
There are still conflicting opinions regarding the prognosis of patients undergoing perioperative blood transfusion and colorectal cancer surgery, but in general there is support for a prognostic impact of blood transfusion in colorectal cancer patients. Nowadays, most people believe that intraoperative transfusion and transfusion of blood with long storage time are not good for prognosis of colorectal cancer patients, and that autologous transfusion is better than allogeneic transfusion.
However, the author also has the following questions.
1. Tumor cells are generated under the uncontrolled autoimmunity of tumor patients, and they keep growing. Even if blood transfusion reduces autoimmunity, it will not cause uncontrolled growth of tumor. Without surgery and radiotherapy, tumor cells are still difficult to die out. Besides, surgery and radiotherapy are not suppressing autoimmunity, so the fear of “red danger” of blood transfusion during surgery should not arise.
2.The Stephane Benoist study showed that perioperative blood transfusion is mainly for patients aged >65 years, body mass index >27kg2/m2, preoperative hemoglobin ≤12.5g/dl, ASA >2, all of whom are in poor general condition, so there may be bias in it.
3, whether there is article publication view bias.
4, the mechanism of blood transfusion and immunosuppression is not very clear and needs further study. From the current study results are uncertain, the author believes that it should be handled according to the surgical routine, should be transfused when the blood transfusion is still beneficial.