Low-dose palliative splenic irradiation in haematolymphoid malignancy

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.

Radiation exposure of the spleen during (177)Lu-DOTATATE treatment and its correlation with haematological toxicity and spleen volume

Background

Somatostatin analogue-based radionuclide therapy with ¹⁷⁷Lu-DOTATATE is an important treatment option for patients with advanced neuroendocrine tumours overexpressing somatostatin receptors. In addition to the kidneys, the bone marrow is a major dose-limiting organ. The correlation between developed haematological toxicity and absorbed dose to the bone marrow is poor, which indicates that other factors affect haematological response. The spleen has an important role in the haematopoetic system, including being a reservoir for blood cells. It is also the organ that receives the highest mean absorbed dose during ¹⁷⁷Lu-DOTATATE treatment. The aim of this study was to analyse mean absorbed dose to the spleen and its correlation with haematological toxicity, and to explore changes in splenic volume.

The study included 41 patients treated with 7.2 GBq (3.5–8.3 GBq) of ¹⁷⁷Lu-DOTATATE on two to five occasions. Following each fraction, planar whole-body scans were acquired at 2, 24, 48, and 168 h, and a SPECT/CT at 24 h post-injection. Mean absorbed spleen dose was calculated utilising planar images for time-activity data and SPECT to adjust activity amounts. Splenic volume information was collected from diagnostic CT scans at baseline and follow-up.

Results

Median and total absorbed spleen doses were estimated to 4.5 and 15 Gy, respectively. Total absorbed spleen dose correlated with decrease in Hb (p = 0.02), but not WBC (p = 0.31) or PLT (p = 0.65) counts. For patients without bone metastases, mean absorbed spleen dose correlated with decrease in PLT (p = 0.04) but not Hb (p = 0.16) or WBC (p = 0.42) counts. The spleen volume was reduced to 75 % (p < 0.001) of original values (200 vs. 260 ml) at a mean follow-up of 36 months.

Conclusions

Haematological toxicity according to Hb counts was moderately but significantly correlated with total absorbed spleen dose. This supports the possibility that radiation exposure of the spleen affects overall haematological response during ¹⁷⁷Lu-DOTATATE treatment.

Radiotherapy versus interventional therapy for hepatogenic hypersplenism: An analysis of 75 cases

AIM: To compare the clinical effects, adverse reactions and hospitalization expenses of external irradiation therapy, three dimensional conformal radiation therapy and interventional therapy for the treatment of hepatogenic hypersplenism.

METHODS: Sixty patients with hypersplenism secondary to liver cirrhosis and 15 patients with hypersplenism secondary to liver cancer were selected. Patients with hypersplenism secondary to liver cirrhosis were divided into two groups: one was treated with external irradiation and the other with interventional therapy. Patients with hypersplenism secondary to liver cancer were treated with three dimensional conformal radiation therapy. Spleen size, blood routine index, adverse reactions and hospitalization expenses were compared among the three groups.

RESULTS: Spleen size was reduced and white blood cell count, hemoglobin and platelet count increased significantly in all the three groups of patients after treatment (all P < 0.05). But no significant differences were observed in spleen size and routine blood parameters between the three groups after treatment (P > 0.05). Fever index and pain index were significantly reduced in the external irradiation and three dimensional conformal radiation therapy groups compared to the interventional therapy group (0.57 ± 0.55, 0.64 ± 0.51 vs 1.80 ± 1.21; 0.36 ± 0.63, 1.67 ± 1.12 vs 4.59 ± 3.22, all P < 0.05). The hospitalization expenses were reduced in the external irradiation group compared to the other two groups.

CONCLUSION: External irradiation and three dimensional conformal radiation therapy can achieve the same effects as the interventional therapy and are associated with reduced side effects and hospitalization expenses in the treatment of hepatogenic hypersplenism.

Radiotherapy of splenomegaly : a palliative treatment option for a benign phenomenon in malignant diseases

PURPOSE

Since the 20(th) century, radiotherapy (RT) has been used for treatment of symptomatic splenomegaly (SM). SM occurs in association with hematologic disorders. The purpose of this analysis was to determine the indication, treatment concepts, and efficiency of RT.

MATERIAL AND METHODS

Clinical features, treatment concepts, and outcome data during the past 20 years were analyzed. Endpoints were pain relief, symptomatic and hematological response, and treatment-related side effects.

RESULTS

From 1989-2009, a total of 122 patients received 246 RT courses because of symptomatic SM. Overall 31 patients had chronic myelogenous leukemia (CML), 37 had chronic lymphocytic leukemia (CLL), 23 had osteomyelofibrosis (OMF), 17 had polycythemia vera (PV), 5 had acute myelogenous leukemia, 4 had idiopathic thrombocytopenic purpura (ITP), 3 had non-Hodgkin lymphoma (NHL), and 2 had multiple myeloma (MM). Patients were treated with (60)Co gamma rays or 5-15MV photons. The fraction size ranged from 10-200 cGy and the total dose per treatment course from 30-1600 cGy. Significant pain relief was achieved for 74.8% of the RT courses given for splenic pain. At least 50% regression was attained for 77% of the RT courses given for SM. 36 patients died within 2 months due to the terminal nature of their disease. Of the RT courses applied for cytopenia, 73.6% achieved a significant improvement of hematological parameters and reduction of transfusion need. Notable hematologic toxicities were reported < EORTC/RTOG II°.

CONCLUSION

The present analysis documents the efficacy of RT. In addition, RT as a palliative treatment option for symptomatic SM should not be forgotten.