An audit of the indications for and techniques of palliative splenic radiotherapy in the UK

Palliative splenic irradiation for symptomatic splenomegaly in non-Hodgkin lymphoma

INTRODUCTION AND AIMS

Splenic marginal zone lymphoma, an uncommon subtype of non-Hodgkin lymphoma (NHL), is usually present with symptomatic splenomegaly. Although splenectomy has long been considered the first-line therapy in symptomatic or cytopenic patients, it can lead to significant morbidity and mortality. Splenic irradiation is an option for patients who have a poor response to systemic therapy and/or are not surgical candidates. In this paper, we present a case report of a patient who received splenic radiotherapy for symptomatic splenomegaly.

METHODS

An 85-year-old Caucasian man with a 4 year history of low-grade NHL presented with progressive pancytopenia, significant weight loss and symptomatic splenomegaly (abdominal discomfort, sense of fullness and limitation of mobility due to spleen size). The patient refused splenectomy and, in December 2017, was referred to palliative splenic radiotherapy. He was initially treated with five fractions of one Grey (Gy) in order to evaluate clinical and haematology response. After that, 1.5 Gy daily, 5 days a week for 3 weeks. 3D conformal radiotherapy, multiple fields and mixed energy (6 and 15 Mv) were used.

RESULTS

Radiotherapy allowed significant splenic reduction to almost half the size, resolving abdominal discomfort and improving quality of life. There was no decline of haemoglobin, leukocytes and platelet counts; in fact, there was a marginal increase.

CONCLUSION

Palliative splenic irradiation was well tolerated confirming that it is a safe treatment option for palliation of symptomatic splenomegaly. Thereby, splenic irradiation should be strongly considered in the management of symptomatic splenomegaly, for selected patients who are refractory to or unsuitable for other options or when the patient refuses other treatments.

Treatment of symptomatic splenomegaly with low doses of radiotherapy: Retrospective analysis and review of the literature

OBJECTIVES

To evaluate the effectiveness of low doses of radiation therapy for symptomatic splenomegaly in malignant and benign diseases.

PATIENTS AND METHODS

5 patients with symptomatic splenomegaly were treated with low doses of radiation in our centre (January 2008-December 2016). 4/5 patients had malignant neoplasia (acute myeloid leukemia, non Hogdkin lymphoma and prolymphocytic B cell leukemia) and splenomegaly was caused by extramedullary hematopoiesis. 1/5 patient had benign disease (HBV liver cirrhosis) and splenomegaly was caused by vascular ectasia. Median age was 73 years (range 61-86 years). There were 4 females and 1 male. These patients had exclusively splenic pain or abdominal discomfort in 20%, exclusively cytopenias 40% and both 40%. Patients needed radiation therapy for symptomatic control. Dose per fraction was 0.5 Gy every two days; total dose initially prescribed 10 Gy. IGRT were performed in all patients to ensure an appropriate position and to adapt the treatment volume to the changes in the spleen volume along the treatment. Median craneocaudal length size of the spleen was more than 26 cm (range 15.2-34.9 cm).

RESULTS

Median radiation doses were 4.85 Gy (range 2.5-10). Median craneocaudal spleen size reduction was 4.6 cm (0-8 cm). Splenic pain and abdominal disturbances improved in all patients. Median increase of haemoglobin and platelets levels was 1.6 mg/dl and 27.950 cells respectively in the first week after the end of radiotherapy.One patient had to interrupt her treatment due to grade II neutropenia. No other toxicities were described. With a median follow-up of 39 months (16-89 months), only one recurrence was described at 24 months and consisted of thrombocytopenia. The patient received a second course of radiotherapy with excellent response.

CONCLUSION

Low doses of radiation therapy for treatment of symptomatic splenomegaly were effective, with a low rate of side effects. Splenic pain and abdominal discomfort completely improved and cytopenias rised to secure levels.

Splenic irradiation for splenomegaly: A systematic review

Splenic irradiation (SI) is a palliative treatment option for symptomatic splenomegaly (i.e. for pain, early satiety, pancytopenia from sequestration) secondary to hematologic malignancies and disorders. The purpose of the current article is to review the literature on SI for hematologic malignancies and disorders, including: (1) patient selection and optimal technique; (2) efficacy of SI; and (3) toxicities of SI. PICOS/PRISMA methods are used to select 27 articles including 766 courses of SI for 486 patients from 1960 to 2016. The most common cancers treated included chronic lymphocytic leukemia and myeloproliferative disorders; the most common regimen was 10Gy in 1Gy fractions over two weeks, and 27% of patients received retreatment. A partial or complete response (for symptoms, lab abnormalities) was obtained in 85-90% of treated patients, and 30% were retreated within 6-12months. There was no correlation between biologically equivalent dose of radiation therapy and response duration, pain relief, spleen reduction, or cytopenia improvement (r2 all <0.4); therefore, lower doses (e.g. 5Gy in 5 fractions) may be as effective as higher doses. Grade 3-4 toxicity (typically leukopenia, infection) was noted in 22% of courses, with grade 5 toxicity in 0.7% of courses. All grade 5 toxicities were due to either thrombocytopenia with hemorrhage or leukopenia with sepsis (or a combination of both); they were sequelae of cancer and not directly caused by SI. In summary, SI is generally a safe and efficacious method for treating patients with symptomatic splenomegaly.

Impact of splenectomy on thrombocytopenia, chemotherapy, and survival in patients with unresectable pancreatic cancer

BACKGROUND

Patients with unresectable pancreatic cancer (PDAC) or endocrine tumors (PET) often develop splenic vein thrombosis, hypersplenism, and thrombocytopenia which limits the administration of chemotherapy.

METHODS

From 2001 to 2009, 15 patients with recurrent or unresectable PDAC or PET underwent splenectomy for hypersplenism and thrombocytopenia. The clinical variables of this group of patients were analyzed. The overall survival of patients with PDAC was compared to historical controls.

RESULTS

Of the 15 total patients, 13 (87%) had PDAC and 2 (13%) had PET. All tumors were either locally advanced (n = 6, 40%) or metastatic (n = 9, 60%). The platelet counts significantly increased after splenectomy (p < 0.01). All patients were able to resume chemotherapy within a median of 11.5 days (range 6-27). The patients with PDAC had a median survival of 20 months (range 4-67) from the time of diagnosis and 10.6 months (range 0.6-39.8) from the time of splenectomy.

CONCLUSIONS

Splenectomy for patients with unresectable PDAC or PET who developed hypersplenism and thrombocytopenia that limited the administration of chemotherapy, significantly increased platelet counts, and led to resumption of treatment in all patients. Patients with PDAC had better disease-specific survival as compared to historical controls.

A national survey investigating UK prescribers' opinions on chemotherapy dosing and 'dose-banding'

AIMS

The primary purpose of dose-banding for cancer chemotherapy is to reduce patient waiting times, but dose-banding also has additional benefits, such as reduced drug wastage, reduced stress for staff, and prospective quality control of infusions. However, the uptake of dose-banding seems fairly low. Possible reasons for this are a reluctance to use dose-banding for clinical reasons or a lack of awareness. Despite the seemingly minor change from established practice of dose preparation, dose-banding has the potential to alter patient chemotherapy exposure. The aim of this study was to investigate prescribers' awareness of dose-banding and their opinions on the scope and limitations of dose-banding in the context of UK chemotherapy services.

MATERIALS AND METHODS

This survey was performed throughout the UK by use of a postal questionnaire, which was validated before national distribution to 1104 oncologists and haematologists. The questionnaire contained both quantitative and qualitative elements. A database was created for data entry and analysis.

RESULTS

The response from prescribers was encouraging for a postal questionnaire, with a 35% response rate (387 responses). Many were aware of the concept of dose-banding (>80%) and were also supportive of the system. The weakness around body surface area-based dosing was a commonly discussed topic. However, opinions on which is the maximum acceptable deviation from the prescribed dose with dose-banding were controversial, and there was a concern about the lack of evidence to support the use of dose-banding. The views on whether carboplatin and targeted therapies should be dose-banded were also divided.

CONCLUSIONS

There was general support for dose-banding, but concerns about the lack of an evidence base could be a barrier to the wider introduction of the system. Consequently, more clinical studies are required to justify the safety and efficacy of dose-banding, and also to evaluate whether dose-banding is acceptable within clinical trials.

Low-dose palliative splenic irradiation in haematolymphoid malignancy

Patients are treated with palliative splenic irradiation (SI) to relieve pain, volume effects and the clinical consequences of hypersplenism. The case records of 19 patients treated with palliative SI at our centre, from April 2003 to November 2004, were reviewed. Twenty-two courses of SI were identified. The radiation doses delivered ranged from 150 to 800 cGy (median 450 cGy). The fraction sizes ranged from 25 to 100 cGy. Parallel-opposed anteroposterior-posteroanterior portals were the most common field arrangement. The target volume was reduced in 18 out of 22 courses. The percentage of field reduction ranged from 0 to 59.57% (mean 24.82%). Twelve of 14 courses were successful in achieving symptom palliation. Of the six patients who received SI for a combination of splenic symptoms and abnormal blood tests, five had symptomatic palliation but only one patient responded haematologically. Of two patients who were started on palliative SI for abnormal haematology alone, only one responded. In summary, 17 of 20 (85%) courses of SI initiated for symptom control resulted in effective palliation. Only two of eight (25%) courses of SI started for abnormal blood counts produced a desired response. To conclude, SI offers an effective and well-tolerated palliative treatment option.

Coagulation abnormalities in patients who have liver disease

The liver plays a central role in the maintenance of normal hemostatic function. Because liver disease alters pathways of coagulation and anticoagulation, patients who have advanced disease can experience severe bleeding or thrombotic complications. Complications of advanced liver disease may also contribute to bleeding or thrombosis. This article reviews and discusses the management of the most common coagulation problems encountered in patients who have end-stage liver disease, which are thrombocytopenia and impaired humoral coagulation as measured by prolongation of the prothrombin time and international normalized ratio.