Splenectomy for thrombocytopenia in chronic granulocytic leukemia

Platelet kinetics and decreased transfusion requirements after splenectomy for hematologic malignancy

OBJECTIVE

Thrombocytopenia is a significant and morbid problem in patients with hematologic malignancy, resulting in frequent platelet transfusions and significant resource consumption. We undertook this study to determine the impact of splenectomy on transfusion requirements in patients with chronic leukemia, acute leukemia, myelodysplastic syndrome, and lymphoma.

METHODS

Records of 134 patients with hematologic malignancies who underwent splenectomy were reviewed. Results are reported as mean +/- standard error of the mean.

RESULTS

Mean preoperative (preop) platelet count was 97 +/- 8 K/microL. A significant rise in platelets, compared with preop, was observed starting on postsplenectomy day 1 (141 +/- 8 K/microL, P < 0.001 versus preop) and persisted through day 7. Counts remained significantly elevated at 3 and 6 months and years 1-5. In profoundly thrombocytopenic patients (preop levels < 20 K/microL), preop count was 11 +/- 1 K/microL. A significant postsplenectomy platelet rise persisted for at least 1 year (137 +/- 52 K/microL, P < 0.05 versus preop). An increased platelet level was observed in all hematologic subgroups; in the chronic leukemias (n = 58, P < 0.01) and in lymphoma (n = 59, P < 0.001), this reached significance. Mean platelet transfusions were significantly decreased from preop (3 months preop: 8.6 +/- 2 units) compared with postsplenectomy (3 months postsplenectomy: 5.0 +/- 1 unit, P = 0.03). This decrease was even more pronounced in profoundly thrombocytopenic patients (31.6 +/- 10.6 units preop versus 8.9 +/- 4.8 units postoperative, P = 0.01).

CONCLUSIONS

In the hematologic malignancies, splenectomy produces a significant and longlasting restoration of platelet levels and a resultant decrease in platelet transfusion requirements. These beneficial effects of splenectomy hold true even for the most profoundly thrombocytopenic patients.

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.

Splenectomy for palliation of chronic myelocytic leukemia

Sixty patients with chronic myelocytic leukemia (CML) (most, in the "terminal phase" of the disease) were subjected to splenectomy because of symptomatic splenomegaly, thrombocytopenia or anemia for which they required frequent transfusions. Surgical morbidity and mortality were high when the procedure was performed on a "casual" basis, but both were reduced sharply after care of these patients was restricted to a single medical-surgical-nursing team and improved technics of surgery and perioperative management were developed. Significant hematologic and clinical benefit was achieved in half of the patients and temporary arrest of the disease was often observed, but in most patients, the basic evolution of CML was not greatly altered. In eight patients, however, long-lasting improvement (one to nine years) was recorded. Measurement of the doubling time of circulating leukemic cells and other observations were consistent with the hypothesis that, in some patients, the spleen contains a more rapidly proliferating and "more malignant" population of leukemic cells than the marrow. We conclude that splenectomy is often a useful palliative procedure in advanced stages of CML, and that it may be strikingly beneficial in 10 to 15 per cent of such cases.

Splenectomy or radiation and splenectomy for hypersplenism in lymphosarcoma

This is a retrospective study of 14 patients with lymphosarcoma with hypersplenism. Eight patients received radiation to the spleen followed by splenectomy for recurrence of hypersplenism. Six patients underwent primary splenectomy for hypersplenism. Radiation decreases the size of the spleen but recurrence of hypersplenism is seen in an average of 8 mo. Splenectomy in these cases improves the hematological picture. Average postsplenectomy survival is 27.6 mo. Splenectomy alone in hypersplenism also improves the hematological picture. Postsplenectomy survival in this group is 13 mo. One case of primary lymphosarcoma of the spleen is reported.

Splenectomy for complications of chronic granulocytic leukaemia

13 patients with chronic granulocytic leukaemia (C.G.L.) which was unsatisfactorily controlled underwent splenectomy. 3 out of 4 patients with hypersplenism did well, as did 5 out of 8 patients in whom the C.G.L. had undergone metamorphosis to a refractory phase. In a case of C.G.L. complicated by severe myelofibrosis the need for transfusion was reduced but survival was short. Splenectomy should be considered when C.G.L. in its chronic phase is complicated by hypersplenism, and may be considered as a part of the treatment after C.G.L. has undergone metamorphosis to a refractory phase. However, a favourable outcome is unlikely for patients over 65 years, and in the presence of coexistent illnesses, rapidly progressive metamorphosis to an acute phase, or severe bone-marrow failure from any cause. In C.G.L., elective splenectomy early in the chronic phase must be clearly distinguished from splenectomy performed at a later stage when the disease is not well controlled.

Surgery in management of patients with leukaemia

Though leukaemia is not a "surgical" disease, the need for surgery in patients with leukaemia is increasing. Acute surgical problems in such patients present diagnostic difficulties, and accepted surgical principles do not necessarily apply in patients with very abnormal haematological and immunological features. The improved prognosis in some types of leukaemia means that elective surgical procedures, which formerly would not have been considered, may now be applicable just as they would be in patients with non-malignant conditions.Recent advances in the management of the leukaemias include several surgical procedures-for example, to facilitate intravenous or intrathecal therapy. Splenectomy is of value in chronic lymphocytic leukaemia when the correct indications are present, while early elective splenectomy, when no classical indications are present, may have a useful role in the management of patients with chronic granulocytic leukaemia.