Evaluation of the Feasibility of Transfusing Leukocyte Depletion Filter–Processed Intraoperative Cell Salvage Blood in Metastatic Spine Tumor Surgery: Protocol for a Non–Randomized Study
Authors: Kumar Naresh , Hui Si Jian , Lee Renick , Athia Sahil , Tan Joel Yong Hao , Tan Jonathan Jiong Hao 
Published: July 2024

Background
Metastatic spine tumor surgery (MSTS) is often complex and extensive leading to significant blood loss. Allogeneic blood transfusion (ABT) is the mainstay of blood replenishment but with immune-mediated postoperative complications. Alternative blood management techniques (salvaged blood transfusion [SBT]) allow us to overcome such complications. Despite widespread use of intraoperative cell salvage (IOCS) in oncological and nononcological surgical procedures, surgeons remain reluctant to use IOCS in MSTS.

Objective
This study aims to analyze safety of IOCS-leukocyte depletion filter (LDF)–processed blood transfusion for patients undergoing MSTS by assessing clinical outcomes—disease progression: tumor progression and overall survival. This study evaluates whether reinfusion of IOCS-LDF–processed blood reduces ABT rates in patients undergoing MSTS by sorting patients undergoing MSTS who require ABT into patients who consent to receive or not receive SBT.

Methods
We aim to recruit a minimum of 90 patients—30 patients for SBT, 30 patients for ABT, and 30 patients with no blood transfusion. SBT and ABT form the 2 experimental arms, whereas no blood transfusion forms the control cohort. Available patient data will be reviewed to determine tumor burden secondary to metastasis and postoperative survival and disease progression, improvement in pain, and neurological and ambulatory status. Data collected will be studied postoperatively at 3, 6, 12, 24, 36, and 48 months or until demise, whichever occurs first. Outcomes of the experimental groups will be compared with those of the control group. Outcomes will be analyzed using 1-way ANOVA and Fisher exact test. The Kaplan-Meier curve and a log-rank test will be used to study overall survival. A multivariate and competing risk analysis will be used to study the association between blood transfusion type and tumor progression. All statistical analyses will be done using Stata Special Edition 14.0 (StataCorp LP).

Results
This is the largest clinical study on use of IOCS in MSTS from various primary malignancies to date. It will provide significant clinical evidence regarding the safety and applicability of IOCS in MSTS. It will help reduce use of ABT, improving overall blood management of patients undergoing MSTS. A limitation of this study is that not all patients undergoing MSTS will survive for the follow-up period (4 years), theoretically leading to underreporting of disease progression. Study commenced in 2016 and patient recruitment continued till 2019. As of September 2019, we have collected operative data on 140 patients. However, the 2-year outcomes of about 40.0% (56/140) of patients are in the process of collection. The study is aimed to be published in the years 2023-2024.

Conclusions
Results will be disseminated via peer-reviewed publications, paving the way for future studies.

International Registered Report Identifier (IRRID)
DERR1-10.2196/54609