[Splenectomy for chronic myeloid leukaemia in the early and late phases (author's transl)]

Splenectomy was perfomed in three patients with typical chronic myeloid leukaemia after a compensated stage had been reached with busulphan. Marked pancytopenia as a result of hypersplenism occurred in one patient 14 months after the end of the primary induction, and was successfully treated by splenectomy after radiotherapy of the spleen had failed. Splenectomy was performed without complication, and the histological appearance of the spleen showed myeloid infiltrates while there was none in the liver biopsy. After another 18 months the patient remained compensated, without busulphan administration. In the two other patients splenectomy was performed in the recompensated stage, one month and five years, respectively, after the primary induction had been concluded. In these two patients, too, there was myeloid infiltration of the spleen. In both, mild leucocytosis with shift to the left as far as promyelocytes occurred six and two weeks, respectively, after splenectomy and busulphan was started again. Twelve and ten months, respectively, after splenectomy they are both in the compensated stage. The importance of splenectomy in the early phase lies in the possibility of delaying blast crisis and avoiding myelofibrosis, as well as in the prevention of complications in the later stages.

Chronic myelogenous leukemia: management of splenectomy in a high-risk population

Splenectomies have been performed on 58 patients with chronic myelogenous leukemia (CML) during the last 16 years. For the 27 patients operated upon during the first 12 years, the operative mortality was 26%. Four patients also had to be re-explored for bleeding and three required drainage of subphrenic abscesses. There has been no operative mortality in the 31 patients operated using a standardized procedure during the last four years but two had to be re-explored for bleeding and one required drainage of a subphrenic abscess. The operative risks for leukemic patients are infection, perhaps related to granulocyte abnormalities and hemorrhage in patients with thrombocytopenia or qualitative platelet abnormalities. When the splenectomy in patients with CML is timed with the patient's chemotherapy cycle, the use of local antibiotics and platelet concentrates should permit a safe operation. Survival rates were not comprised even when the patients had their splenectomy during CML-blast crisis.

Intracerebellar chloroma (granulocytic sarcoma): a neurosurgical complication of acute myelocytic leukemia

A discrete intracerebellar mass of myeloblasts was found in a 26-year-old woman with acute myelocytic leukemia in remission. This chloroma (granulocytic sarcoma) was treated successfully by surgical extirpation. An aggressive neurosurgical role seems appropriate in handling central nervous system leukemic nodules in view of the improved patient survival created by current chemotherapy regimens.

Splenectomy in chronic myelogenous leukemia

There were no deaths or major complications in three chronic myelogenous leukemia patients in group 1 who were selected under well controlled conditions and had the spleen removed. Intensive chemotherapy in the treatment of chronic myelogenous leukemia patients who undergo splenectomy remains to be resolved. Well controlled prospective clinical trials are now being conducted to evaluate the value of splenectomy in chronic myelogenous leukemia.

Defective neutrophil chemotaxis in bone marrow transplant patients

Infection is a frequent cause of death in patients receiving bone marrow transplants. Although lymphocyte dysfunction has been observed in a few such patients, no systematic study of neutrophil function has yet been reported. Neutrophil chemotaxis was evaluated by a 51Cr-radioassay after bone marrow transplantation in 34 patients with acute leukemia or aplastic anemia. The response to a chemotactic stimulus (C5a) was severely depressed (less than 35% of normal) in 18 patients, moderately depressed (35-65% of normal) in an additional 6, and normal in 10 subjects. The mean response in the absence of graft vs. host disease and antithymocyte globulin administration was 73.3+/-9.2% (SE) in contrast to 29.7+/-9.6% (P is less than 0.01) in patients with graft vs. host disease treated with antithymocyte golbulin. Both graft vs. host disease and antithymocyte globulin were implicated since the presence of either factor alone was associated with depressed chemotaxis (31.1+/-4.9% for graft vs. host disease, P is less than 0.01; 17.0+/-7.8% for antithymocyte globulin, P is less than 0.02). When normal neutrophils were incubated with antithymocyte globulin in vitro, their chemotactic response was markedly suppressed in the absence of a cytotoxic effect. Transplant patients with defective chemotaxis experienced significantly more infections than those with normal chemotaxis, and analysis of specific etiologic agents showed that this was predominantly related to bacterial pathogens. Chemotactic inhibitors were detected in the sera of seven patients and elevated IgE levels were found in nine subjects, eight of whom had graft vs. host disease. Generation of chemotactic activity by endotoxin activation of serum was reduced in five patients. The results demonstrate a severe defect in neutrophil chemotaxis in some bone marrow transplant patients and suggest that neutrophil dysfunction may predispose to infection in such patients.

The problem of splenectomy in a leukemic patient population

An attempt has been made in an experimental group of 20 patients, with leukemia or one of the myeloproliferative disorders, to devise a safe method of splenectomy by timing the operation to coincide with optimal response to chemotherapy, preoperative bowel preparation with antibiotics to minimize infections, and availability of platelet concentrates, matched for HL-A antigens when possible, to control massive hemorrhage. The results in this experimental group were compared with a historical control group of 26 patients. Two-thirds of all the patients had chronic myelocytic leukemia, and the mean weight of the spleens removed was just over 1,800 grams. Operative mortality was 35% in the historical group and zero in the more recent group, six of whom were operated on while in blastic crisis. Splenectomy can be done safely in leukemic patients, and is not contraindicated. Future planned studies will determine its possible therapeutic role in reducing tumor burden.

Evaluation of splenectomy in chronic myelogenous leukemia

Splenectomy was performed in 45 patients with chronic myelogenous leukemia; 23 were in the chronic phase and 22 in the acute phase. Indications for operation included inability to control the disease by chemotherapy or radiation therapy, severe thrombocytopenia, frequent need for blood transfusion and extensive splenomegaly causing discomfort. Median survival time for these patients was better than survival time of other reported groups of patients who did not have a splenectomy. According to our criteria, splenectomy was beneficial to 15 patients in the chronic phase as well as to eight in the acute phase of chronic myelogenous leukemia. Median survival time after splenectomy was higher in patients who had splenectomy within two years of the diagnosis as compared with those who had the operation after two years. Splenectomy did not prevent the future onset of fatal blastic crisis. Although significant abnormalities in coagulation studies were seen in 37 of the patients, intraoperative hemorrhage was not a major problem. Considering the poor general condition, inadequate healing and susceptibility to infection, the postoperative mortality and complication rates were comparable with those reported in series in which splenectomy was performed for other diseases. It seems that splenectomy benefits a selected group of patients with chronic myelogenous leukemia; however, a randomized series would furnish better data upon which to make decisions.

Splenectomy in the chronic phase of chronic granulocytic leukemia. Effects in 32 patients

Splenectomy in the chronic phase of chronic granulocytic leukemia was done in 32 patients, in 24 as part of a trial of elective splenectomy in early disease and in 8 because of thrombocytopenia preventing adequate therapy of the chronic phase. Patients with splenectomy had a median survival after diagnosis of 60 months. However, survival of patients operated on within 1 year of diagnosis was no different (median, 44 months) from that recorded in 120 consecutive Philadelphia chromosome-positive patients treated during the same time period (median, 42 months). After blastic transformation of disease, splenectomy patients survived slightly longer, responded more frequently to platelet transfusions, and avoided the morbidity of massive splenomegaly seen in 30% of patients treated with spleens retained. Response to blastic phase chemotherapy, however, was not improved. Prophylactic splenectomy in the chronic phase of disease did not influence survival but may ameliorate some complications of the terminal stages of illness.

Myeloproliferative disorders

Forty-three operative procedures were performed on a population of 250 patients with myeloproliferative disorders, including polycythemia vera, myeloid metaplasia (MM) and chronic myelogenous leukemia (CML). The overall operative mortality was approximately 7% and the incidence of excessive bleeding which could be related to coagulopathy was 5%. Twenty-one patients with MM or CML underwent splenectomy for palliation of symptoms related to the enlarged spleen or hematologic problems. Eighty-four percent of the latter group were improved. Adverse hematologic effects which could be attributed to splenectomy in these patients were confined to two patients who developed marked thrombocytosis. Among the 23 patients with MM, 9 had portal hypertension. Three underwent portacaval shunt and one a splenorenal shunt for bleeding varices. One of the patients died of hepatic necrosis. Estimated hepatic blood flow determinations (EHBF) in 4 patients with portal hypertension demonstrated a marked absolute increase and an increase in the ratio of EHBF/Cardiac Index. Absence of any evidence of intrahepatic or extrahepatic obstruction in these patients and the demonstration that splenectomy relieved portal hypertension defined at surgery in 4 patients, suggests that augmented adhepatic flow contributes to portal hypertension in some cases. The review leads to the conclusions that: 1) Operative procedures in prepared patients with myeloproliferative disorders are not associated with prohibitive mortality and morbidity rates. 2) Splenectomy is indicated for patients with increasing transfusion requirements and symptomatic splenomegaly or hypersplenism and should be performed early in the course of disease. 3) When associated portal hypertension and bleeding varices are present, hemodynamic studies should be carried out to define if splenectomy alone, or a portal systemic decompressive procedure is indicated.

Chronic granulocytic leukaemia: effect of elective splenectomy on the course of disease

Conventional treatment by drugs or irradiation produces little prolongation of life in patients with chronic granulocytic leukaemia (C.G.L.) because the onset of metamorphosis of the disease from a chronic to an acute or subacute leukaemic process is not substantially postponed. Isolated clinical observations as well as both cytogenetic and cytokinetic evidence suggest that the spleen may play a special though not exclusive role in the development of undifferentiated cell clones which lead to metamorphosis of C.G.L. The results of a study of elective splenectomy during the chronic phase of the disease are reported. Twenty-six patients with C.G.L. underwent splenectomy during clinical remission of their disease, and there were no deaths after the operation. Twenty-one patients were alive at the time of writing, two of them eight years after splenectomy. Five cases of metamorphosis of C.G.L. to a refractory phase occurred whereas 10 would have been expected, a significant difference. After the onset of metamorphosis the quality of life was better in splenectomized than in non-splenectomized patients. These results show that splenectomy is a reasonable and safe procedure in C.G.L., and its apparently beneficial effects on prognosis justify a larger controlled clinical trial.

[A misleading diagnosis of ovarian tumours in a case of paramyeloblastosis (author's transl)]

A case is reported of bilateral ovarian tumours in a 44 year-old patient, who was submitted to total hysterectomy with removal of both appendages. Preoperative laboratory investigations had not yielded any useful information. Histologically, both ovaries showed replacement of the normal tissue by sheets of undifferentiated tumour cells. A sudden rise in temperature with rigors occurred on the 8th postoperative day, in conjunction with a considerable degree of anaemia, the appearance of ascites and a massive increase in size of the liver. Shortly afterwards, 50% of the peripheral leucocytes were found to be paramyeloblasts, the total leucocyte count being 4300. Sternal puncture confirmed the diagnosis of paramyeloblastosis, which proved rapidly fatal in spite of intensive therapy with corticosteroids, antibiotics and blood transfusions. The typical picture of paramyeloblastosis with tumour formation was observed on post-mortem examination, with leukaemic invasion of the liver, spleen, lymph glands and bone marrow.