Successful elimination of falciparum malaria following the introduction of community-based health workers in Eastern Myanmar: A retrospective analysis.

BACKGROUND: Myanmar has a large majority of all malaria in the Greater Mekong Subregion. In the past decade, substantial progress was made in malaria control. The residual burden of malaria is in remote areas where currently recommended malaria elimination approaches are generally not feasible. In such hard-to-reach communities in Mon state, East Myanmar, Medical Action Myanmar introduced community health workers (CHWs) to deliver early diagnosis and treatment for malaria. We conducted a retrospective analysis to assess the impact of this intervention. METHODS AND FINDINGS: This retrospective analysis involved data collected routinely from a CHW programme in Mon state conducted between 2011 and 2018. A network of 172 CHWs serving a population of 236,340 was deployed. These CHWs carried out 260,201 malaria rapid diagnostic tests (RDTs) to investigate patients with acute febrile illness. The median blood examination rate was 1.33%; interquartile range (IQR) (0.38 to 3.48%); 95% CI [1.28%, 1.36%] per month. The changes in malaria incidence and prevalence in patients presenting with fever were assessed using negative binomial regression mixed effects models fitted to the observed data. The incidence of Plasmodium falciparum malaria (including mixed infections) declined by 70%; 95% CI [65%, 75%]; p < 0.001 for each year of CHW operation. The incidence of P. vivax malaria declined by 56%; 95% CI [50%, 62%]; p < 0.001 per year. Malaria RDT positivity rates for P. falciparum and P. vivax declined by 69%; 95% CI [62%, 75%]; p < 0.001 and 53%; 95% CI [47%, 59%]; p < 0.001 per year, respectively. Between 2017 and 2018, only 1 imported P. falciparum case was detected in 54,961 RDTs. The main limitations of the study are use of retrospective data with possible unidentified confounders and uncharacterised population movement. CONCLUSIONS: The introduction of CHWs providing community-based malaria diagnosis and treatment and basic health care services in remote communities in Mon state was associated with a substantial reduction in malaria. Within 6 years, P. falciparum was eliminated and the incidence of P. vivax fell markedly.

Annulo-Nucleoplasty Using Disc-Fx in the Management of Degenerative Lumbar Disc Pathology: How Long Can the Effect Last?

STUDY DESIGN: Prospective analysis. OBJECTIVES: To evaluate 2-year clinical outcomes in patients undergoing Disc-FX for the management of low back pain (LBP) due to degenerate disc (DD) or contained lumbar disc herniation (CLDH). To study salient factors that can potentially influence the clinical outcomes. METHODS: We analyzed the prospectively collected data of 51 patients who underwent Disc-FX procedure for DD or CLDH, nonresponsive to 6 months of nonoperative treatment. Clinical outcome measures collected were visual analogue scale (VAS), Oswestry Disability Index (ODI), and MacNab scores. These preoperative values were compared with respective values at immediate, 6 months, 1 year, and 2 years postoperation. Minimum clinically important difference values for these outcomes in accordance with previously published data was used to evaluate the effectiveness of Disc-FX intervention. RESULTS: Of 51 patients, 84% had DD and 16% had CLDH. Significant improvement (P < .01) in VAS and ODI scores was observed at all assessment periods compared to the respective preoperative values. Based on the MacNab scores, there was significant increase (P < .01) in the proportion of patients with excellent/good MacNab outcomes at each time point after the procedure; 78% achieving excellent/good outcomes at 2-year follow-up. Ease of access to the disc space was significantly influencing VAS, ODI, and MacNab scores at 1-year and 2-year follow-ups. VAS and MacNab scores were negatively influenced by high body mass index and smoking status at 6 and 12 months postoperation. CONCLUSIONS: Our data suggests that Disc-FX may be helpful in selected patients with symptomatic degenerative disc disease providing favorable outcomes lasting up to 2 years or more. The results were more favorable in patients with easier access to disc space.

Evaluation of Prognostic Factors and Proposed Changes to the Modified Tokuhashi Score in Patients With Spinal Metastases From Breast Cancer.

STUDY DESIGN: A retrospective study of all patients with histologically confirmed breast cancer spinal metastases presenting to a single institution between May 2001 and April 2012. OBJECTIVES: The aim of this study was to investigate whether the 2014mT is more accurate than the 2005mT. SUMMARY OF BACKGROUND DATA: The commonly used 2005 modified Tokuhashi score (2005mT) has become more inaccurate as oncologists move toward treating tumors according to their molecular and genomic profile, rather than their tissue-of-origin. In attempts to improve the accuracy of the 2005mT, a revised score (2014mT) was published, suggesting that hormone receptor negative and triple-negative breast cancer patients be given a modified Tokuhashi histological score of 3 rather than 5. METHODS: Demographic characteristics, tumor receptor status, clinical findings in relation to the primary tumor and its metastases, and actual survival time were collated. The 2005mT was compared with the 2014mT. Univariate and multivariate Cox regression analyses were used to evaluate the influence of each parameter on survival, and receiver operating characteristic curves were used to determine predictive values of each score version. RESULTS: Of the 185 patients included, 32 underwent operative treatment, while 153 were managed nonoperatively for their spinal metastases. The overall cohort had a median survival time of 24 months following the diagnosis of spinal metastases, with a 6-month survival rate of 90%. Hormone, HER2 and triple-negative receptor statuses were significant predictors of poorer survival upon multivariate analysis (P = 0.004, P = 0.007, P < 0.001, and P < 0.001, respectively). Age, the original Tokuhashi score components, previous breast surgery for cancer, previous radiotherapy to the breast, previous radiotherapy to the spine, previous chemotherapy, and previous immunotherapy were not significant. At 6 months, the 2005mT AUROC was 0.62, while that of the 2014mT was 0.64 (P = 0.5394). CONCLUSION: Tumor histological subtype is crucial when prognosticating the survival of patients with breast cancer spinal metastases. Although the 2014mT was marginally more accurate than the 2005mT, its predictive ability remains poor. LEVEL OF EVIDENCE: 3.

Metastatic spine tumor surgery: does perioperative blood transfusion influence postoperative complications?

BACKGROUND: The question of independent association between allogeneic blood transfusion (ABT) and postoperative complications in cancer surgeries has been controversial and remains so. In metastatic spine tumor surgery (MSTS), previous studies investigated the influence of ABT on survival, but not on postoperative complications. We aimed to evaluate the influence of perioperative ABT on postoperative complications and infections in patients undergoing MSTS. STUDY DESIGN AND METHODS: This retrospective study included 247 patients who underwent MSTS at a single tertiary institution between 2005 and 2014. The outcome measures were postoperative complications and infections within 30 days after MSTS. Multivariate logistic regression analyses were performed to assess influence of blood transfusion on the outcomes after adjusting for potential confounders. RESULTS: Of 247 patients, 133 (54%) received ABT with overall median (range) of 2 (0-10) units. The adjusted odds of developing any postoperative complication was 2.27 times higher in patients with transfusion (95% confidence interval [CI], 1.17-4.38; p = 0.01) and 1.24 times higher odds per every unit increase in blood transfusion (95% CI, 1.05-1.46; p < 0.01). Exposure to blood transfusion also increased the odds of having overall postoperative infections (odds ratio, 3.58; 95% CI, 1.15-11.11; p = 0.02) and there were 1.24 times higher odds per every unit increase in transfusion (95% CI, 1.01-1.54; p = 0.04). CONCLUSIONS: This study adds evidence to the literature implicating ABT to be influential on postoperative complications and infections in patients undergoing MSTS. Appropriate blood management measures should, therefore, be given a crucial place in the care of these patients so as to reduce any putative effect of blood transfusion.

Preoperative embolization in spinal tumour surgery: Enhancing its effectiveness.

We conducted a retrospective review of 221 patients, who underwent spinal oncologic surgery at a tertiary university hospital between 2005 and 2014; in order to identify and validate factors that influence the impact of preoperative embolization of spinal tumours on outcome measures of blood loss and transfusion requirements in spinal oncologic surgery. We also focused on primary tumour type and type of spinal surgery performed. Patients' electronic and physical records were reviewed to provide demographic data, tumour characteristics, embolization techniques and surgical procedure details. These data were analysed against recorded outcome measures of blood loss (absolute volume and haemoglobin reduction) and transfusion requirements. Forty eight patients who received preoperative embolization were compared against 173 patients who did not. There was a tendency towards reduced blood loss and transfusion requirements in embolized spinal metastases from HCC and thyroid; as well as primary spine tumours, though the differences were not significant. Total embolization of arterial supply to spinal tumours resulted in significantly less blood loss as compared to partial or subtotal embolization. In addition, median blood loss was lower in patients receiving a more proximal embolization and in patients who underwent surgery between 13 and 24h post-embolization despite the insignificant difference. To conclude, preoperative spinal tumour embolization is likely to be effective in reducing blood loss if a total embolization is performed 13-24h prior to the surgery. Similarly, the impact of embolization is likely to be more profound in metastases from HCC, thyroid and primary spine tumours.

Unusual presentation of osteoblastoma as vertebra plana-a case report and review of literature.

BACKGROUND: Osteoblastoma is rare and accounts for 3% of all benign tumors and 1% of all bone tumors. The spine is the most common site of occurrence, constituting 32% to 45% of all osteoblastomas. It has a strong predilection for the posterior elements, most often occurring in the lumbar spine. METHOD: In this case report, we describe an unusual presentation of spinal osteoblastoma presenting as thoracic T9 vertebra plana in a 20-year-old female. She presented with discomfort over the midback with unsteadiness of gait. The patient underwent detailed investigations including computed tomography (CT), magnetic resonance imaging, and CT-guided biopsy. To our knowledge, this is the first case report of vertebra plana due to spinal osteoblastoma in the English literature. RESULT: The patient successfully underwent posterior decompression of T9 with laminectomy followed by minimally invasive surgery posterior instrumentation from T7 to T11. Histopathology of the intraoperative specimen was consistent with osteoblastoma. The patient had an uneventful postoperative recovery and no evidence of tumor recurrence could be demonstrated on positron emission tomography scan at 15 months' follow-up. CONCLUSION: In conclusion, the differential diagnosis for vertebra plana is extensive and we add spinal osteoblastoma as another etiology to the existing list. Diagnosis and treatment of vertebra plana involve multimodality radiological imaging, and careful histological and surgical evaluation to identify the underlying etiology.

Perioperative blood transfusion: does it influence survival and cancer progression in metastatic spine tumor surgery?

BACKGROUND: Despite advances in surgical techniques for spinal metastases, there is often substantial blood loss, resulting in patients requiring blood transfusion during the perioperative period. Allogeneic blood transfusion (ABT) has been the main replenishment method for lost blood. However, the impact of ABT on cancer-related outcomes has been controversial in various studies. We aimed to evaluate the influence of perioperative ABT on disease progression and survival in patients undergoing metastatic spinal tumor surgery (MSTS). STUDY DESIGN AND METHODS: We conducted a retrospective study that included 247 patients who underwent MSTS at a single tertiary institution between 2005 and 2014. The impact of using perioperative ABT (either exposure to or quantities of transfusion) on disease progression and survival was assessed using Cox regression analyses while adjusting for potential confounding variables. RESULTS: Of 247 patients, 133 (54%) received ABT. The overall median number of blood units transfused was 2 (range, 0-10 units). Neither blood transfusion exposure nor quantities of transfusion were associated with overall survival (hazard ratio [HR], 1.15 [p = 0.35] and 1.10 [p = 0.11], respectively) and progression-free survival (HR, 0.87 [p = 0.18] and 0.98 [p = 0.11], respectively). The factors that influenced overall survival were primary tumor type and preoperative Eastern Cooperative Oncology Group performance status, whereas primary tumor type was the only factor that had an impact on progression-free survival. CONCLUSIONS: This is the first study providing evidence that disease progression and survival in patients who undergo MSTS are less likely to be influenced by perioperative ABT. The worst oncologic outcomes are more likely to be caused by the clinical circumstances necessitating blood transfusion, but not transfusion itself. However, because ABT can have a propensity toward developing postoperative infections, including surgical site infection, the use of patient blood management interventions would be worthwhile rather than relying solely on ABTs for these patients, if and whenever possible.

Is Autologous Salvaged Blood a Viable Option for Patient Blood Management in Oncologic Surgery?

Oncologic surgery is sometimes associated with substantial blood loss, and principles of patient blood management can be applied in the perioperative care of these patients. Although autologous salvaged blood is an option for perioperative blood conservation, it is often not used in oncologic surgery over concern of reinfusing tumor cells and thereby causing tumor dissemination. We reviewed the literature regarding safety and effectiveness of salvaged blood in oncologic surgery. Salvaged blood seems to be comparable to allogeneic blood in terms of safety. Because patients with primary or metastatic cancer are known to have circulating tumor cells in the absence of surgery, the concern of reinfusing malignant cells from the salvaged blood may be overstated. Reinfusion of salvaged blood has not been found to promote tumor dissemination or distant metastases. When used in patients with substantial blood loss, salvaged blood can be cost-effective. Intraoperative salvaged blood may be a useful adjunct to allogeneic blood resources.

Survival Prognostication in Patients with Skeletal Metastases from Nasopharyngeal Carcinoma: An Evaluation of the Scandinavian Sarcoma Group, Katagiri and Bauer Scoring Systems.

INTRODUCTION: Nasopharnygeal carcinoma (NPC) is characterised by early metastases with the skeleton being the most common site of metastases. The ability to prognosticate survival is crucial in the decision whether or not to offer surgery to these patients and the choice of surgery offered. We aimed to evaluate the scoring systems namely: Bauer, Katagiri and Scandinavian Sarcoma Group (SSG) in NPC patients with skeletal metastases. MATERIALS AND METHODS: A total of 92 patients with skeletal metastases from NPC were studied. We retrospectively analysed the actual survival of these patients and compared with predicted survival according to the 3 scoring systems. The predicted survival according to each system was calculated and labelled as A scores. These were then re-scored by assigning NPC as a better prognostic tumour and labelled as B scores. The predicted survival of scores A and B were compared to actual survival. Univariate and multivariate Cox regression analyses were performed. The predictive values of each scoring were calculated. RESULTS: The median overall survival for the whole cohort was 13 months (range: 1 to 120 months). In multivariate analysis, general condition and visceral metastases showed significant effect on survival. There were statistically significant differences (P <0.001) between the subgroups of the SSG B as well as Katagiri B scoring systems where NPC was classified as a better prognostic tumour. SSG B provided the highest predictive value (0.67) as compared to the other 2 scoring systems. CONCLUSION: The SSG and Katagiri score could be used to prognosticate NPC with a statistically significant association with actual survival.

Evaluation of Scoring Systems and Prognostic Factors in Patients With Spinal Metastases From Lung Cancer.

STUDY DESIGN: A retrospective study of 180 patients with lung cancer spinal metastases, wherein prognostic score-predicted survival was compared with actual survival. OBJECTIVE: To evaluate and compare the accuracy of prognostic scoring systems in lung cancer spinal metastases. SUMMARY OF BACKGROUND DATA: The modified Tokuhashi, Tomita, modified Bauer, and Oswestry scores are currently used to guide decisions regarding operative treatment of patients with spinal metastases. The best system for predicting survival in patients with lung cancer spinal metastases remains undetermined. The high incidence of spinal metastases from lung cancer and improved survival of patients treated with systemic therapy warrants evaluation of these scoring systems in this particular context. METHODS: Patients with lung cancer spinal metastases treated at our institution between May 2001 and August 2012 were studied. Fifty-one patients were treated surgically. The primary outcome measure was survival from the time of diagnosis. Scoring-predicted survival was compared with actual survival. Potential prognostic factors were investigated using Cox regression analyses. Predictive values of each scoring system for 3- and 6-month survival were measured via receiver operating characteristic (ROC) curves. RESULTS: Histological subtype (P = 0.015), sex (P = 0.001), Karnofsky performance scale (P = 0.001), extent of neurological palsy (P = 0.002), and visceral metastases (P = 0.037) are significant predictors of survival. Besides the Oswestry spinal risk index, no significant differences were found between different prognostic subgroups within the individual scoring systems. Although the modified Bauer score was most accurate, all four scoring systems had areas under the ROC curve 0.5 or less. CONCLUSION: Although better prognostic scores correlated with longer survival, all four scoring systems are inaccurate in prognosticating patients with lung cancer spinal metastases. Specific lung cancer histology appears prognostic and should be considered, especially given the increased survival of patients receiving new targeted therapies appropriate to their disease. LEVEL OF EVIDENCE: 3.

The role of preoperative vascular embolization in surgery for metastatic spinal tumours.

PURPOSE: To determine the effect of preoperative embolization on intraoperative blood loss in surgery for metastatic spinal tumours stratified by tumour type, type of surgical approach and extent of surgery. METHODS: We retrospectively analysed 218 patients undergoing open surgery for metastatic spine tumours in our institution between 2005 and 2014. The cohort was divided to those who underwent preoperative embolization and those who did not. The patients were further stratified into different subgroups by tumour types, types of surgical procedure, levels of instrumentation and levels of decompression. Estimated blood loss, duration of surgery and length of hospital stay were compared between embolized and non-embolized cases in each subgroup. The impact of embolization extent, the time gap between embolization and index surgery on blood loss were also studied. RESULTS: Preoperative embolization was performed in 45 out of 218 patients. Non-embolized cases had insignificantly lesser blood loss and shorter duration of surgery compared to embolized cases in all subgroups. Embolization, however, conferred reduction in length of hospital stay in some of the subgroups, yet the differences were not significant. The patients who achieved total embolization bled less than those who achieved subtotal or partial embolization. The effectiveness of the embolization procedure in reducing intraoperative blood loss was found to be profound when the gap between embolization and surgery was within 24 h. CONCLUSIONS: Our study demonstrated that success of embolization in reducing blood loss depends on the extent of embolization and time interval between embolization and index surgery.

Intraoperative cell salvage in metastatic spine tumour surgery reduces potential for reinfusion of viable cancer cells.

PURPOSE: This study aimed at evaluating our hypothesis that tumour cells, which pass through the intraoperative cell salvage (IOCS) machine, lose viability due to possible injury to the cell membrane during centrifugation and filtration, enabling safe reinfusion even without filtration. METHODS: Thirteen patients who underwent metastatic spine tumour surgery (MSTS) at our institution were recruited. Blood samples (5 ml each) were collected at five different stages during surgery, namely, stage A and B: from patients' vein during induction and at the time of maximum tumour manipulation; stage C, D and E: from the operative blood prior to IOCS processing, after IOCS processing and after IOCS-LDF (leucocyte depletion filter) processing, respectively. The samples were then analysed for viability of tumour cells using microwell-based culture. RESULTS: The median age of the patients was 65 years (range 37-77 years). The most common primary tumour was lung, followed by breast, hepatocellular and renal cell carcinoma. The median blood loss was 680 ml (range 300-1500 ml). Analysis of cultured blood samples showed that CTC-containing clusters were developed from some samples before IOCS-LDF processing (stage A: three patients, stage B: three patients and stage C: one patient). None of the samples from stages D and E generated clusters after culture, suggesting the absence of viable cancer cells after IOCS processing. CONCLUSIONS: The salvaged blood may contain some tumour cells after processing with IOCS machine, but these cells are damaged and hence unable to replicate and unlikely to metastasise. The results of this study support the hypothesis that salvaged blood in MSTS is safe for transfusion.

Blood Loss and Transfusion Requirements in Metastatic Spinal Tumor Surgery: Evaluation of Influencing Factors.

BACKGROUND: Metastatic spine tumor surgery (MSTS) can be associated with significant blood loss. Previous studies did not provide comprehensive data on blood loss in MSTS. Thorough study elaborating the blood loss, transfusion requirement, and their influencing factors is required. This study aimed to investigate the estimated blood loss and transfusion requirements associated with various surgical approaches and surgically managed vertebral levels for spinal metastases from different primary tumors. METHODS: The study retrospectively evaluated 243 patients who underwent surgery for metastatic spine tumors at the authors' institution between 2005 and 2014. Estimated intraoperative blood loss and transfusion requirement were assessed for different primary tumors including lung, breast, prostate, gastrointestinal, renal, liver, thyroid, myeloma/lymphoma, and others; types of surgical procedure (cervical corpectomy ± stabilization, thoracolumbar posterior decompression ± instrumentation, thoracolumbar corpectomy, minimally invasive surgery); and levels of instrumentation and decompression. Multivariate linear regression was attempted to investigate the factors influencing blood loss and transfusion requirements. RESULTS: The mean blood loss was 870 ± 720 ml, and the average blood transfusion was 1.5 ± 1.9 U. The mean blood loss was 1103 ml for patients who received blood transfusion and 597 ml for those who did not. Multivariate analysis showed that the significant factors influencing blood loss were primary tumor, type of surgery, and prolonged operative time. The influencing factors for blood transfusion were primary tumor, type of surgery, preoperative hemoglobin, and prolonged operative time. CONCLUSIONS: Significant variations in blood loss and transfusion requirement were based on primary tumor of spinal metastases, surgical approaches, and operative time. These findings will help clinicians in preoperative planning to address the problem of blood loss during MSTS.

Are we ready for the use of intraoperative salvaged blood in metastatic spine tumour surgery?

PURPOSE: To evaluate the feasibility of using intraoperative cell salvage (IOCS) in combination with leucocyte depletion filter (LDF) in eliminating tumour cells from blood salvaged during metastatic spine tumour surgery (MSTS). This is with the view to pave the path for use of IOCS-LDF in MSTS and musculoskeletal oncological surgery. METHODS: Sixty consecutive patients with known primary epithelial tumour, who were offered surgery for metastatic spine disease at our university hospital, were recruited. Blood samples were collected at three different stages during surgery: from operative field prior to IOCS processing, after IOCS processing and after IOCS-LDF processing. Three separate samples (5 ml each) were taken at each stage. Samples were examined by cell block technique using immunohistochemical monoclonal antibodies to identify tumour cells of epithelial origin in the samples. RESULTS: Of 60 patients, ten were excluded for not fulfilling the inclusion criteria leaving 50 patients. Malignant tumour cells were detected in the samples from operative field prior to IOCS processing in 24 patients and in the samples from the transfusion bag post-IOCS processing in 4 patients. No viable malignant cells were detectable in any of the blood samples after passage through both IOCS and LDF. CONCLUSIONS: The findings support the notion that IOCS-LDF combination works effectively in eliminating tumour cells from salvaged blood so this technique can possibly be applied in MSTS and even musculoskeletal oncological surgery. This concept can then be extended to other oncological surgeries in general with further appropriate clinical studies.

Versatility of percutaneous pedicular screw fixation in metastatic spine tumor surgery: a prospective analysis.

BACKGROUND: Posterior percutaneous spinal fixation (PPSF) has evolved to address the problems associated with metastatic spinal disease (MSD). This study was designed to evaluate the feasibility and spectrum of application of PPSF in the management of MSD, highlighting its clinical advantages. METHODS: Twenty-seven consecutive patients with MSD treated with PPSF in our institution from January 2011 to June 2014 were studied. After a multidisciplinary assessment, all patients were considered for surgical intervention due to clinical presentation of either neural deficit, skeletal instability, or both. Some of these patients belonged to the poor prognostic category based on survival prognostic scoring systems. The patients were categorized into seven groups depending on the modality of PPSF used. Demographic data, operative details, and clinical outcomes were investigated for each category and compared pre- and postoperatively. RESULTS: The median age was 60 years (range 49-78 years). Generally, all patients either maintained or improved their neurological status and achieved pain alleviation. Ambulatory status and Eastern Cooperative Oncology Group (ECOG) scores were improved using any modality of PPSF. The pure-stabilization group had the lowest amount of mean blood loss, shortest operative time, and intensive care unit (ICU) and hospital stays, while the long-construct group was observed to have the greatest amount of blood loss, and longest operative time and ICU stay. CONCLUSIONS: For patients with MSD, even with predicted poor prognosis on survival prognostic scoring systems, it is possible to improve functional outcomes and quality of life with PPSF, keeping surgical morbidity to a minimum. PPSF allows patients with pure spinal instability to be addressed successfully with least morbidity.

Flow cytometric evaluation of the safety of intraoperative salvaged blood filtered with leucocyte depletion filter in spine tumour surgery.

BACKGROUND: Intraoperative cell salvage (IOCS) has not been widely adopted in oncological surgery due to the hypothetical concern of reinfusion of malignant cells. We evaluated the feasibility of IOCS in combination with leucocyte depletion filter (LDF) in metastatic spine tumour surgery (MSTS). METHODS: Patients with known primary epithelial tumour, operated for metastatic spinal disease, were recruited. Blood samples were collected at five different stages during surgery: 2 stages from patient vein during induction and at the time of maximum tumour manipulation, 3 stages from the operative blood prior to IOCS processing, after IOCS processing, and after IOCS-LDF processing. Of the samples taken at each stage, 5 ml were analyzed for tumour cells using flow cytometry. RESULTS: Of 12 patients recruited, only 11 could be finally analyzed. Flow cytometry analysis of their samples showed that 8 of 11 patients had tumour cells in the unfiltered salvaged blood. In filtered salvaged blood, the tumour cell count was zero in the majority of samples (8/11 patients), whereas three patients' samples had a few tumour cells. The mean difference between the tumour cell quantity in the samples from the patient vein and filtered salvaged blood was significant. CONCLUSIONS: IOCS-LDF was shown to be effective in removing tumour cells from the blood salvaged during MSTS. If there were any tumour cells found, the quantity was significantly less than that in the patient's circulation. The results of this study reiterates the conclusions of our previous published work where we showed that IOCS-LDF treated blood in MSTS is safe for transfusion.

Can there be a place for intraoperative salvaged blood in spine tumor surgery?

BACKGROUND: Intraoperative cell salvage (IOCS) has been used in musculoskeletal surgery extensively. However, it has never found its place in musculoskeletal oncologic surgery. We have conducted the first-ever study to evaluate the feasibility of IOCS in combination with a leucocyte-depletion filter (LDF) in metastatic spine tumor surgery. This was to pave the path for use of IOCS-LDF in musculoskeletal oncologic surgery. METHODS: Patients with a known primary epithelial tumor, who were offered surgery for metastatic spinal disease, were recruited. Blood samples were collected at three different stages during the surgery: from the operative field before IOCS processing, after IOCS processing, and after IOCS-LDF processing. Three separate samples (5 mL each) were taken at each stage. Samples were examined using immunohistochemical monoclonal antibodies to identify tumor cells of epithelial origin. RESULTS: Of 30 patients in the study, 6 were excluded for not fulfilling the inclusion criteria, leaving 24 patients. Malignant tumor cells were detected in the samples from the operative field before IOCS processing in eight patients and in the samples from the transfusion bag after IOCS processing in three patients. No viable malignant cell was detectable in any of the blood samples after passage through both IOCS and LDF. CONCLUSIONS: The findings support the notion that the IOCS-LDF combination works effectively in eliminating tumor cells from salvaged blood, so this technique can be applied successfully in spine tumor surgery. This concept can then further be extended to whole musculoskeletal tumor surgery and other oncologic surgeries with further appropriate clinical studies.