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

Significance Statement


There remain great controversies among orthopaedic and spine surgeons worldwide on the use of IOCS in ‘metastatic spine tumor surgery’ (MSTS). We conceived the idea that salvaged blood is safe for transfusion in patients undergoing operative procedures. There has been no evidence in the literature supporting the use of IOCS in metastatic spine tumour surgery. In October 2011, we started our observational study on the feasibility of IOCS-LDF in removing tumour cells from blood salvaged during metastatic spine tumor surgery. We previously reported our preliminary results of 24 patients in Annals of Surgical Oncology, showing that filtered salvaged blood was devoid of tumour cells and safe to be reinfused. The most significant finding in our study was – using cell block technique, no malignant cells could be detected in any of the samples of salvaged blood after passing through both IOCS and LDF (100% of the final samples were negative for tumour cells), providing the proof-of-concept that the combination of IOCS-LDF is effective in complete removal of tumour cells from blood salvaged during MSTS. Three out of 24 patients had tumour cells after IOCS processing and before LDF filtration, indicating that IOCS alone was successful in removing tumour cells in nearly 90% of the samples. The study is still ongoing until we have appropriate resources to conduct a clinical trial. Till date, we have recruited 50 patients of which, 40 of them cleared the eligibility criteria.

Our results still show that none of the samples taken from filtered salvaged blood were positive for tumour cells, strongly supporting our hypothesis. In our study, we could examine whether tumour cells were present or not and their density in the form of the number of tumour cells per high power field (semi-quantitative data). Our results were consistent with previous studies which revealed a total removal of tumour cells from salvaged blood after IOCS-LDF processing. In order to validate our findings, we also completed a quantitative study on IOCS-LDF in removing tumour cells using flow cytometry in 10 consecutive patients. We reported the findings in Annals of Surgical Oncology. This study showed similar results – the tumour cells count in IOCS-LDF processed blood was significantly lower than that in blood from patients’ circulation at any time.

The results of our studies challenge the prevailing myth of avoiding cell salvage in spine tumour surgery or even musculoskeletal surgery because of the unsubstantiated concern of tumour dissemination, supporting the safety of filtered salvaged blood for reinfusion.

Figure legend: Epithelial tumour cells in the cell block (hematoxylin-eosin, original magnification x200)

Can there be a place for intraoperative salvaged blood in spine tumor surgery?- - Global Medical Discovery











Journal Reference

Kumar N, Ahmed Q, Lee VK, Chen Y, Zaw AS, Goy R, Agrawal RV, Dhewar AN, Wong HK.

Ann Surg Oncol. 2014 ;21(7):2436-43.

Department of Orthopaedic Surgery, National University Health System, Singapore, Singapore, [email protected]



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.


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 immuno-histochemical monoclonal antibodies to identify tumor cells of epithelial origin.


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.


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.

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