Patients with solid malignancies who were not candidates for tumor resections in the past are now presenting for extensive oncological resections. Cancer patients are at risk for thromboembolic complications due to an underlying hypercoagulable state; however, some patients may have an increased risk for bleeding due to the effects of chemotherapy, the administration of anticoagulant drugs, tumor-related fibrinolysis, tumor location, tumor vascularity, and extent of disease. A common potential complication of all complex oncological surgeries is massive intra- and postoperative hemorrhage and the subsequent risk for massive blood transfusion. This can be anticipated or unexpected. Several surgical and anesthesia interventions including preoperative tumor embolization, major vessel occlusion, hemodynamic manipulation, and perioperative antifibrinolytic therapy have been used to prevent or control blood loss with varying success. The exact incidence of massive blood transfusion in oncological surgery is largely unknown and/or underreported. The current literature mostly consists of purely descriptive observational studies. Thus, recommendation regarding specific perioperative intervention cannot be made at this point, and more research is warranted. 1. Introduction Surgical oncology, perioperative medicine, and anesthesia for oncological care have been evolving over the last four decades. Aggressive chemoradiation regimens, newer and bolder surgical techniques, effective anesthesia modalities, and impressive intensive care medicine strategies have facilitated tumor resections, which were considered difficult or unadvisable in the past [1–4]. Thus, patients with large hypervascularized tumors or cancers encasing major blood vessels are now considered acceptable surgical candidates [4]. One of the consequences of performing surgery in such patients is the risk of significant intra- and postoperative blood loss. When bleeding occurs unexpectedly and uncontrollably in the perioperative period, there is a sharp increase in mortality [5, 6]. It has been suggested that patients with cancer are more likely to be transfused with blood products than noncancer patients [7]. Moreover, an unknown percentage of these patients are at risk for massive blood transfusion, which is commonly defined as the transfusion of more that 10 units of packed red blood cells in a 24-hour period [8]. Massive blood transfusions during oncological surgery can be anticipated or unexpected. In the former situation, since anesthesiologists, surgeons, and the blood bank services are aware of
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