Should leucodepleted (white blood cell reduced) and irradiated blood products be used for patients with malignancy (cancer)?

Blood Product Requirements for Cancer Patients

For patients with malignancy, both leukodepleted and irradiated blood products should be used, with specific requirements depending on the type of cancer and treatment regimen. 1, 2

Indications for Leukodepleted Blood Products

Leukodepletion (removal of white blood cells) is recommended for all cancer patients because it:

• Reduces febrile non-hemolytic transfusion reactions 1
• Decreases immunosuppressive effects of blood transfusion 1
• Helps prevent platelet alloimmunization 1
• Reduces risk of cytomegalovirus (CMV) transmission 1

According to the NCCN guidelines, leukocyte-depleted products should be used for all transfusions in patients with acute myeloid leukemia (AML) and, by extension, other malignancies 1.

Indications for Irradiated Blood Products

Irradiation (minimum 25 Gy) is specifically indicated for:

• Patients with hematologic malignancies (e.g., Hodgkin lymphoma) 2
• Patients receiving immunosuppressive therapy (e.g., fludarabine, other purine analogues) 1, 2, 3
• Recipients of autologous or allogeneic stem cell transplants 1, 2
• Patients treated with alemtuzumab 2
• Patients with severe immunosuppression from cancer or treatment 2
• Patients receiving intensive chemotherapy for neoplastic disease 4

Important Clinical Considerations

Transfusion-Associated Graft-Versus-Host Disease (TA-GVHD)

• TA-GVHD is a rare but often fatal complication (90% mortality) 5
• Symptoms include fever, skin rash, nausea, vomiting, diarrhea, hepatitis, and pancytopenia 4
• Only irradiation can prevent TA-GVHD; leukoreduction alone is insufficient 2
• Gamma irradiation with 25 Gy is the standard method, though X-irradiation is an emerging alternative 2, 6

Which Blood Components Need Treatment

• Cellular components require irradiation: whole blood, red cells, platelets, and granulocytes 4
• All cellular products for at-risk patients must be both leukoreduced and irradiated 1

Timing Considerations

For stem cell transplant recipients:

• Begin irradiated products from the start of conditioning until 6 months post-transplant for allogeneic HSCT (longer if chronic GVHD develops) 1
• For autologous HSCT, begin 7 days before stem cell harvest until 3 months post-transplant 1
• Some centers start as soon as a patient is identified as a potential HSCT candidate 1

Common Pitfalls to Avoid

1. Relying solely on leukoreduction: Leukoreduction alone does not prevent TA-GVHD; irradiation is required for at-risk patients 2

2. Overlooking patients on purine analogues: Patients receiving fludarabine or other purine analogues require irradiated products regardless of transplant status due to profound immunosuppression 2, 3

3. Failing to communicate requirements: Ensure clear communication between oncology teams and blood banks regarding which patients need specialized blood products 2

4. Delaying irradiation: For emergency situations, have protocols in place to quickly obtain irradiated products, as delays could impact patient care

5. Assuming all cancer patients need irradiated products: Stable patients with solid tumors without additional risk factors may not require irradiation 2

By following these guidelines, the risk of transfusion complications in cancer patients can be significantly reduced while ensuring optimal supportive care during treatment.