The role of intraoperative cell salvage for musculoskeletal sarcoma surgery

Raja Bhaskara Rajasekaran; Antony J R Palmer; Duncan Whitwell; Thomas D A Cosker; David Pigott; Orosz Zsolt; Robert Booth; M R J P Gibbons; Andrew Carr; Collaborators

doi:10.1016/j.jbo.2021.100390

The role of intraoperative cell salvage for musculoskeletal sarcoma surgery

J Bone Oncol. 2021 Sep 16:30:100390. doi: 10.1016/j.jbo.2021.100390. eCollection 2021 Oct.

Authors

Raja Bhaskara Rajasekaran¹, Antony J R Palmer¹, Duncan Whitwell¹, Thomas D A Cosker¹, David Pigott², Orosz Zsolt³, Robert Booth⁴, M R J P Gibbons¹, Andrew Carr⁵; Collaborators

Affiliations

¹ Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK.
² Consultant Anaesthetist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
³ Consultant Pathologist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁴ Transfusion Practitioner, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁵ Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK.

Abstract

Background: The efficacy and safety of cell salvage for musculoskeletal sarcoma surgery have not been reported, and concerns over re-infusion of tumour cells remain. This study aims to i) describe the intra-operative blood loss and cell salvage reinfusion volumes for lower limb sarcoma and pelvic sarcoma procedures ii) and explore whether there is evidence of tumour cells in reinfused blood.

Methods: Retrospective analysis of 109 consecutive surgical procedures for biopsy-proven sarcoma or bone metastasis performed between 1 July 2015 and 30 October 2019. Salvaged blood was processed and reinfused when intraoperative blood loss exceeded 500 ml. Primary bone tumour (n = 86(79%)) and metastasis (n = 23(21%) constituted the study group and surgeries were classified under hemipelvectomy (n = 43(39%)), lower limb endoprosthesis replacement (LLE) (n = 50(46%)) and wide excision surgery (WE) (n = 16(15%)). Microscopic examination of imprint cytology of leuco-depletion(LD) filters, and peripheral smear examination was performed for reinfused blood.

Results: Median (IQR) intra-operative blood loss was 1750 (600-3000) ml for hemipelvectomy, 850 (600-1200) ml for LLE, and 1000 (550-2000) ml for WE. Salvaged blood was re-infused in 102 of 109 (94%) patients. The mean (SD) volume of re-infusion was 445(4 2 5) ml for hemipelvectomy, 206(1 3 1) ml for LLE, and 184(1 0 6) ml for WE. In total, 64 of 109 (59%) patients received an allogeneic red blood transfusion within 72 h of surgery. Cytology analysis of imprints taken from the filtered blood available in 95(87%) patients and peripheral smear examination of reinfused blood available in 32(29%) patients did not reveal evidence of tumour cells on microscopic examination of any samples.

Conclusion: Our study demonstrates that musculoskeletal sarcoma surgery is associated with significant blood loss, and cell salvage permits reinfusion of autologous blood in most patients. The cytological analysis did not reveal evidence of tumour cells in reinfused blood, consistent with other studies where cell salvage is used for cancer surgery.

Keywords: Cell salvage; ICS, Intra-operative cell salvage; LDF, Leucocyte depletion filter; LLE, Lower Limb endoprosthesis; Musculoskeletal oncology; Reinfusion; Sarcoma; Transfusion; WE, Wide Excision.