Long-term influence of splenectomy on immune functions in patients with Hodgkin's disease

Persistent changes in circulating white blood cell populations after splenectomy

The effect of splenectomy on the incidence of infections and thromboembolisms has been investigated thoroughly. Nevertheless, the long-term effects of splenectomy on immunological profile and circulating blood counts have not been described before. To study such long-term effects, we analysed several parameters in splenectomised trauma patients and compared the results of this group ("otherwise healthy patients") to patients with a specific underlying disease. We measured platelet count, leukocytes and differential, lymphocyte subsets, serum levels of immunoglobulins, and complement pathways in 113 patients. Indications to perform a splenectomy were trauma (n = 42), Hodgkin lymphoma (n = 24), hereditary spherocytosis (n = 21), and immune thrombocytopenia (n = 26). In trauma patients lymphocytes and lymphocytes subsets were particularly elevated compared to normal population values. Splenectomised patients with Hodgkin lymphoma had significant lower numbers of T lymphocytes than trauma patients. Significant increases in platelets, leukocytes, and monocytes were observed in patients with hereditary spherocytosis. Occurrence of MBL genotype was different in ITP patients than in other splenectomised groups and the normal population. In splenectomised patients (> 4 years), platelet counts and lymphocyte subsets are increased which persist over time. As a result, these blood counts in splenectomised patients differ from reference values in the normal population.

Prognostic influence of early diagnostic splenectomy in Hodgkin's disease. A long-term follow-up

The influence of early laparotomy with splenectomy on prognosis in patients with Hodgkin's disease who were regarded as having uncertain prognostic indices (all patients except those with lymphocytic predominance and nodular sclerosis stages IA and IIA with right-sided presentation, stage IV disease, splenomegaly or age greater than 65 years) was evaluated in a randomized trial initiated in Jan. 1973. The patients were treated with total nodal irradiation (excluding the splenic and hepatic areas) and 33 of 69 patients were randomized to laparotomy with splenectomy. No significant difference in relapse-free or overall survival was found between the two groups after a median observation time of 85 months. Progressive or recurrent disease was as common in splenectomized as in non-splenectomized patients. Splenectomized patients with splenic tumour involvement fared worse than those without. It is concluded that diagnostic laparotomy with splenectomy is of no benefit in this clinical setting.

Adverse effect of splenectomy on recurrence in total gastrectomy cancer patients with perioperative transfusion

BACKGROUND

To investigate the interactions between splenectomy and perioperative transfusion in gastric cancer patients.

METHODS

Medical records of 449 gastric cancer patients who had undergone total gastrectomies for curative intent between 1991 and 1995 were reviewed. The influence of splenectomy on tumor recurrence and survival both in the transfused and nontransfused patients were evaluated by univariate and multivariate analysis.

RESULTS

The recurrence rate in the splenectomy group was 48.1% as compared with 22.6% in the spleen-preserved group among transfused patients (P=.001); it was 40.7% compared with 26.5% among nontransfused patients (P=.086). There was no significant difference in the mean survival between the splenectomy group and the spleen-preserved group in a subgroup analysis by stage. Multivariate analysis identified splenectomy as an independent risk factor for recurrence but not as a predictor for survival among transfused patients.

CONCLUSIONS

Splenectomy does not appear to abrogate the adverse effect of perioperative transfusion on prognosis in gastric cancer patients. Moreover, it may increase postoperative recurrence in transfused patients.

A prospective study on antibody response to repeated vaccinations with pneumococcal capsular polysaccharide in splenectomized individuals with special reference to Hodgkin's lymphoma

BACKGROUND

Splenectomy is accompanied by a life-long risk of overwhelming postsplenectomy infection (OPSI), mainly caused by polysaccharide (PS) encapsulated bacteria such as Streptococcus pneumoniae. Despite extensive prophylactic efforts the mortality and morbidity rates remain high. The present study was based on a strategy with a predefined vaccination algorithm including repeated 23-valent pneumococcal vaccinations and monitoring of pneumococcal antibody levels. The antibody levels of splenectomized Hodgkin's lymphoma (HL) patients were compared with those patients splenectomized due to immune-mediated cytopenias [autoimmune haemolytic anaemia (AIHA) and immune thrombocytopenic purpura (ITP)] and also individuals who were splenectomized because of trauma (TRAUMA).

METHODS

A total of 311 splenectomized individuals were included in this prospective study (208 HL; 15 AIHA; 60 ITP; 28 TRAUMA). Depending on their individual anti-PS antibody levels measured by enzyme-linked immunosorbent assay technique the patients were revaccinated with 23-valent pneumococcal PS vaccine up to four times in accordance with the predefined algorithm. For each vaccination occasion, serum was collected at vaccination, after 1 month +/- 2 weeks (peak), and after 1 year +/- 6 months (follow-up). Patient files, a national population-based database, and microbiological databases were checked for 124 HL patients to identify OPSI.

RESULTS

A significant response was recorded on primary vaccination as well as on two revaccination occasions for HL, AIHA/ITP, as well as TRAUMA patients. None of the variables age, gender, or time elapsed between splenectomy and first pneumococcal vaccination was found to be associated with mean PS antibody levels at prevaccination, peak or follow-up. No severe adverse events were reported. Amongst 124 clinically monitored HL patients, 10 OPSI were recorded in seven patients during the study period. One of these patients, a middle-aged female, died as a result of fulminant pneumococcal bacteraemia, which was her third OPSI during a 7-year period.

CONCLUSIONS

A significant response to pneumococcal PS vaccination was found in all three groups (HL, AIHA/ITP and TRAUMA) of splenectomized patients. Importantly, both primary and repeated vaccinations were safe. Until further knowledge is gained regarding the protective concentration of serotype-specific antibody concentrations we believe that the value of vaccination and frequent revaccination (every 1-5 years) in combination with education of patients and health care professionals and clinical monitoring is beneficial for these patients at risk for OPSI.

Long-term complications of laparotomy in Hodgkin's disease

OBJECTIVE

The authors determined the incidence of complications in 133 patients who had undergone staging laparotomy with splenectomy before treatment for Hodgkin's disease (stages I-IV).

METHODS AND MATERIALS

Medical records were reviewed, and the patients or their relatives were interviewed. Median follow-up after laparotomy was 15.7 years (range = 2.5-28 years).

RESULTS

Ten episodes of overwhelming postsplenectomy infection (OPSI) were documented in nine patients (6.8%). None of 25 patients who received pneumococcal vaccine before splenectomy developed OPSI. Patients with advanced (stages III-IV) or recurrent Hodgkin's disease were at higher risk of OPSI than those with early disease, and those who received combined modality oncologic therapy were at greater risk than those receiving less intensive treatment. Surgical complications included small bowel obstruction in 13 patients (9.8%), necessitating repeat laparotomy in 9 patients (6.8%), atelectasis in 17 patients, abscess in 3 patients, and 1 wound dehiscence. No deaths occurred as a result of surgical complications. Causes of death in the 29 patients who died included Hodgkin's disease (12 patients), acute treatment-related morbidity (1 patient), leukemia (5 patients), bone marrow failure (3 patients), solid malignancy (2 patients), intercurrent disease (4 patients), unknown causes (1 patient), and OPSI (1 patient).

CONCLUSION

With presplenectomy pneumococcal vaccination and modern surgical techniques, the long-term risks of laparotomy with splenectomy are acceptable if knowledge of the pathologic extent of abdominal Hodgkin's disease would alter treatment regimens.

A longitudinal study of class and subclass antibody response to pneumococcal vaccination in splenectomized individuals with special reference to patients with Hodgkin's disease

Antibody class and subclass response to pneumococcal vaccination was monitored in 173 splenectomized individuals. The distribution according to indication for splenectomy was Hodgkin's disease (HD; n = 41), non-Hodgkin lymphoma (NHL; n = 25), autoimmune hemolytic anemia or idiopathic thrombocytopenic purpura (n = 17), accidental splenectomy during abdominal surgery for malignant (AMA; n = 15) and benign (ABE; n = 42) disease and splenectomy due to splenic rupture caused by trauma (TRAUMA; n = 33). Pre-vaccination total IgG pneumococcal antibody values (i.e. against the whole antigen = the vaccine) in the NHL patients were lower than in the ABE and TRAUMA groups (p less than 0.05). The response to vaccination in HD and NHL patients did not differ from that in the other patient groups. Furthermore, pre-vaccination values did not differ between HD patients vaccinated before splenectomy and treatment and those vaccinated after, although the former group showed a better response to vaccination (p less than 0.05). HD and TRAUMA patients were followed by serial serum sampling. The antibody values declined to pre-treatment levels after 3 years but no differences either between HD and TRAUMA patients or between HD patients vaccinated before or after splenectomy and treatment were observed with regard to antibody decrease. It is concluded that pneumococcal antibody levels increased in all splenectomized patient groups following vaccination. The pattern of the antibody decline motivates revaccination studies in patients 2 yr post-immunization.

Infection after splenectomy for Hodgkin's disease

The incidence of non-fatal infections after staging laparotomy in 95 adult patients with Hodgkin's disease was compared with that of 94 non-splenectomized patients. In addition, mortality of infections in 248 splenectomized patients was compared with mortality in 275 non-splenectomized patients. The observation time was 10 years from start of therapy. No difference was found between splenectomized and non-splenectomized adult Hodgkin's patients as to frequency and death from infection. However, the incidence of more serious infections was significantly higher in advanced disease (stage III and IV) as compared with localized disease (stage I and II). Deaths from rapid fatal infection occurred only in patients with advanced disease, unrespective of splenectomy.

A prospective study of the changes in immune status following radiotherapy for Hodgkin's disease

In a prospective study, immune status was measured in 23 previously untreated patients with Hodgkin's disease Stage I-IIIA. Assessments of immunologic capacity were performed at diagnosis and repeated after staging laparotomy and after radiotherapy. The immune status was measured using delayed-type hypersensitivity tests to common recall antigens, the number of T- and B-lymphocytes in the peripheral blood, in vitro lymphocyte responsiveness to mitogens, antigens, and allogeneic lymphocytes, and serum levels of immunoglobulins. Skin reactivity was not significantly affected by either the staging laparotomy with splenectomy or the radiotherapy. Absolute T-lymphocyte count increased after splenectomy (P less than 0.025) and decreased after radiotherapy (P less than 0.005 compared to postsplenectomy values). In vitro lymphocyte responsiveness after splenectomy was comparable to the initial presenting level and diminished after radiotherapy (P less than 0.005). Serum levels of IgM were lowered after radiotherapy (P less than 0.05) while the fall was not significant after splenectomy. Three months after radiotherapy, lowest mean T-cells percentages were noted, but the responses to mitogens were significantly higher than those obtained immediately after treatment (P less than 0.01). While the reduction in the proportion of the T-lymphocytes persisted for 18 months, the mean lymphocyte responsiveness to mitogens, antigens, and allogeneic lymphocytes increased on follow-up. Apart from a severe impairment of the immune status following radiotherapy, this study also shows the existence of significant repair mechanisms during the follow-up period.

A prospective study of the changes in the immune status before, during, and after multiple-agent chemotherapy for Hodgkin's disease

In a prospective study, immune status was measured in 20 previously untreated patients with Stage III and IV Hodgkin's disease. Assessments of immunologic capacity were performed at diagnosis and repeated after eventual staging laparotomy and after multiple-agent chemotherapy. The immune status was measured using delayed-type hypersensitivity tests to common recall-antigens and in vitro lymphocyte responsiveness to mitogens, antigens, and allogeneic lymphocytes. Immunoglobulin levels were determined on each point of assessment. In untreated patients, the disturbances in the cell-mediated immunity had no predictive value with respect to the chance to achieve a complete remission. During chemotherapy the mean value of the unstimulated culture in responders increased, whereas it decreased in nonresponders (P less than 0.05 between both groups). After treatment, the proliferative capacity of lymphocytes in vitro was severely affected, while the reactivity to skin tests improved. Chemotherapy also reduced the IgM level, irrespective of the performance of splenectomy. Thirteen patients achieved a complete remission after chemotherapy. In this group, measurements of immunologic capacity were continued. The patients showing a relapse did so despite gradual improvement of delayed-type hypersensitivity and the lymphocyte responsiveness to phytohemagglutinin in vitro.

Late infections following splenectomy in Hodgkin's disease

Here 145 reported post-splenectomy infections in 115 patients with Hodgkin's disease are reviewed. Such infections can occur at any age (median age 19.8 years) and the interval from splenectomy to the infection is quite variable (median 21.9 months). Most infections are present clinically as pneumonia, septicemia, meningitis, or a combination thereof, with the most common offending organism being pneumococcus. The infection can be fulminant and even fatal. It is recommended that the spleen should only be removed when essential. A staging laparotomy and splenectomy seem justifiable only in cases of Hodgkin's disease where a change of staging would lead to a change of planned therapy. Prophylactic penicillin should be administered at least for 3 years and possibly indefinitely since post-splenectomy infections can occur many years later. Pneumococcal vaccine should also be given before any chemotherapy or radiotherapy is initiated. Prompt and aggressive treatment should be given when post-splenectomy infection is diagnosed.

Longitudinal studies of blood lymphocyte capacity in Hodgkin's disease

Blood lymphocyte functional capacity and serum immunoglobulins were studied in 40 patients with Hodgkin's disease (HD) admitted to Radiumhemmet, Stockholm, before treatment and in complete remission 2-56 months following termination of radiotherapy (total nodal irradiation [TNI]; n = 29) or chemotherapy (MOPP; n = 11). Lymphocyte studies included determination of total lymphocyte and T-cell counts and evaluation of spontaneous DNA synthesis during the first day of culture and mitogen-(concanavalin A, pokeweed mitogen) and antigen (purified protein derivative, PPD)-induced activation on the third day. Blood lymphocyte and T-cell counts decreased dramatically following TNI. A slow restitution was seen, but pretreatment levels were not reached even four years following therapy. The responses to ConA and PPD but not PWM were significantly reduced shortly after TNI. The mitogen response did not increase with time as did the PPD response. Lymphocyte counts and lymphocyte stimulation, which were severely depressed before treatment of patients in the chemotherapy group, remained unchanged 2-36 months after termination of therapy. A significant reduction of IgM levels was observed regardless of the mode of treatment. Splenectomy prevented the profound reduction of blood lymphocyte and T-cell counts following therapy but did not influence the other immunologic variables under study.

Blood lymphocyte functions in relation to splenic weight and tumor involvement in untreated Hodgkin's disease

Spontaneous and mitogen induced blood lymphocyte DNA synthesis was studied in relation to weight and tumor involvement of the spleen in 33 untreated patients with Hodgkin's Disease. Splenic tumor involvement was found in 14 patients. In this group there was a strong inverse correlation between spleen weight and lymphocyte DNA synthesis induced by PWM, ConA and PPD. In patients with uninvolved spleens the spontaneous blood lymphocyte DNA synthesis increased with spleen weight. No correlation with the mitogen response was observed in this group.