Splenic irradiation for myelofibrosis prior to hematopoietic cell transplantation: A global collaborative analysis

Splenomegaly is the clinical hallmark of myelofibrosis. Splenomegaly at the time of allogeneic hematopoietic cell transplantation (HCT) is associated with graft failure and poor graft function. Strategies to reduce spleen size before HCT especially after failure to Janus kinase (JAK) inhibition represent unmet clinical needs in the field. Here, we leveraged a global collaboration to investigate the safety and efficacy of splenic irradiation as part of the HCT platform for patients with myelofibrosis. We included 59 patients, receiving irradiation within a median of 2 weeks (range, 0.9-12 weeks) before HCT. Overall, the median spleen size prior to irradiation was 23 cm (range, 14-35). Splenic irradiation resulted in a significant and rapid spleen size reduction in 97% of patients (57/59), with a median decrease of 5.0 cm (95% confidence interval, 4.1-6.3 cm). The most frequent adverse event was thrombocytopenia, with no correlation between irradiation dose and hematological toxicities. The 3-year overall survival was 62% (95% CI, 48%-76%) and 1-year non-relapse mortality was 26% (95% CI, 14%-38%). Independent predictors for survival were severe thrombocytopenia and anemia before irradiation, transplant-specific risk score, higher-intensity conditioning, and present portal vein thrombosis. When using a propensity score matching adjusted for common confounders, splenic irradiation was associated with significantly reduced relapse (p = .01), showing a 3-year incidence of 12% for splenic irradiation versus 29% for patients with immediate HCT and 38% for patients receiving splenectomy. In conclusion, splenic irradiation immediately before HCT is a reasonable approach in patients experiencing JAK inhibition failure and is associated with a low incidence of relapse.

Treatment by Splenic Irradiation in 22 Chronic Lymphocytic Leukemia Patients

Twenty-two patients with chronic lymphocytic leukemia, score 2 according to Rai et al. (10), who received only a course of splenic irradiation are reviewed. Splenic doses ranged from 420 to 1080 rad. Response to splenic irradiation was rated by evaluating peripheral lymphocytosis, hepatosplenomegaly, adenomegaly and disease-related symptoms. Following splenic irradiation, 8 patients showed a significant reduction in splenomegaly; 7 patients showed a significant reduction in peripheral lymphocytosis (< 10,000/mm3), which has lasted from 15–42 months without any other treatment. In 14 patients, response to splenic irradiation was partial, and it has successively been necessary to treat 12 patients with chemotherapy. Methods of splenic irradiation, survival, clinical and hematologic behavior are discussed in detail.

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.

Splenic irradiation as palliative treatment for symptomatic splenomegaly due to secondary myelofibrosis: a multi-institutional experience

PURPOSE

To evaluate the impact of splenic irradiation as a palliative treatment for symptomatic splenomegaly due to secondary myelofibrosis.

METHODS

Seventeen patients with chronic myelogenous leukemia and 3 with idiopathic polycythaemia presented with splenomegaly, splenic pain and anemia. Due to symptomatic splenomegaly, despite first-line treatment, the patients underwent splenic irradiation. Two patients received two different schedules of external radiotherapy (580 cGy in 5 fractions and 600 cGy in 6 fractions). Eight patients received 980 cGy in 14 fractions. Ten patients received two courses of 360 cGy in 6 fractions, 3 months apart. Median follow-up was 12 months post irradiation.

RESULTS

The patients showed excellent response to treatment one month post-radiotherapy, while treatment was well tolerated without severe toxicity. The dimensions of the spleen decreased significantly. Pain-related Visual Analogue Score (VAS) regressed after completion of irradiation. During 12-month follow-up all patients maintained the benefit of radiotherapy.

CONCLUSION

This study indicates that splenic irradiation could be a safe and effective palliative treatment for symptomatic splenomegaly due to secondary myelofibrosis.

Splenic irradiation in hematologic malignancies and other hematologic disorders--single institution experience

Splenic irradiation has long been known as a palliative treatment modality in patients with various malignant hematologic diseases aiming to ameliorate clinical symptoms of splenomegaly as well as clinical sequels of hypersplenism. It provides considerable effect with low toxicity although exact radiotherapy dose and fractionation schedule are not known. During the 1996-2010 period, eleven patients were treated at our institution with splenic irradiation. They received 16 courses of fractionated radiotherapy. There were six patients with non-Hodgkin's lymphoma, four with chronic lymphocytic leukemia, and one patient with myelofibrosis. The median of the dose received was 7 Gy, while the median of dose received per fraction was 1 Gy. Both parallel opposed anterior-posterior fields and tangential fields were used. Due to the clinical target volume shrinkage, the treatment field was reduced in 44% of courses. Of the courses initiated for symptom control, 71% resulted in effective palliation, whereas of the courses started to treat hematologic sequels of hypersplenism 50% produced desirable effects. The most common side effects included thrombocytopenia and anemia. Splenic irradiation provides effective and low-toxic palliation of symptoms but it is much less successful in treating hematologic disorders caused by hypersplenism.

Effective management of accelerated phase myelofibrosis with low-dose splenic radiotherapy

The main cause of hepatosplenomegaly in primary (PMF), post polycythemia vera (post-PV MF), and post essential thrombocythemia (post-ET MF) myelofibrosis (MF) is extramedullary hematopoiesis (EMH). Drug-refractory symptomatic splenomegaly in MF is usually managed by splenectomy or involved-field radiotherapy. The latter is most effective in the treatment of MF-associated bone pain and pulmonary hypertension.Our previous experience with hepatosplenic radiotherapy in MF showed efficacy in the majority of treated patients but its utility was limited by the transient nature of its benefit and the occurrence of treatment-related pancytopenia. In an effort to address these issues,we have adopted an induction-maintenance treatment strategy that utilizes lower radiation doses-induction with 100 cGy total in four daily doses of 25 cGy and maintenance with either the same or lower intensity regimen. Herein, we report our most recent experience using this treatment plan in two cases, who in addition to their expected response from the standpoint of splenomegaly, also unexpectedly showed a marked response of their underlying accelerated phase disease,including clearance of circulating blasts and basophilia.

Radiation therapy for palliation of Eisenmenger's syndrome-associated painful splenomegaly

Painful splenomegaly has a clinical presentation that is often associated with myeloproliferative disorders, such as acute or chronic lymphoblastic or myelogenous leukemia. In these situations low-dose radiotherapy is effective in reducing the splenomegaly and relieving pain. The potential benefit of radiotherapy for cardiogenic splenomegaly is less well established. The present report discusses a case in which radiotherapy was employed to benefit a patient with Eisenmenger's-associated painful splenomegaly. Because of the patient's high anesthesia risk, palliative surgical splenectomy was not feasible. The patient underwent three-dimensional conformal treatment planning, and a total of 42.5 Gy at 2.5 Gy per fraction was prescribed to the spleen. At 4 months following radiotherapy completion, the patient reported durable pain relief and no untoward small bowel effects; moreover, there was a 43% reduction in splenic volume on follow-up CT. Although there have been previous reports of hematological and myeloproliferative-associated splenomegaly that have been treated with a lower dose per fraction and lower total dose radiotherapy, we advocate the use of 2.0-2.5 Gy per fraction to a total dose approaching 40 Gy for adequate duration of response when treating cardiogenic-associated painful splenomegaly in patients for whom surgical splenectomy cannot be performed.

[Splenic irradiation: apropos of 8 cases. Clinical indications and literature review]

Clinical indications of splenic irradiation in haematological disorders include the irradiation in lymphoproliferative disorders with spleen infiltration, palliative treatment of splenomegaly in malignant diseases like chronic lymphocytic leukaemia or myeloproliferative disorders, with the purpose of relief from abdominal pain associated with capsular enlargement size and decrease cytopenias secundaries to hypersplenism.This paper reports our experience with spleen irradiation in the Hospital General Universitario Gregorio Marañón in the last five years, and analyzes indications, results and toxicity, and an actual review of the literature.

[Anemia in chronic lymphatic leukemia: is erythropoietin the solution?]

Anemia is a common complication in the clinical course of chronic lymphocytic leukemia. Low hemoglobin levels both correlate with an adverse prognosis and adversely affect the quality of life of chronic lymphocytic leukemia patients. Different physiopathological phenomena may lead to anemia: marrow infiltration, hypersplenism, immune hemolysis or toxicity of chemotherapy. Treatment with human recombinant erythropoietic agents has been shown to be effective for anemia associated with different lymphoproliferative syndromes. This paper analyses the available evidence on erythropoietic agent treatment for chronic lymphocytic leukemia associated anemia. The comparative effect of different dosage schemes, the role of possible response-prediction factors such as the endogenous erythropoietin level and the results achieved using darbopoietin alpha are reviewed.

Hydroxyurea and splenic irradiation-induced tumour lysis syndrome: a case report and review of the literature

Therapeutic agents for chronic myeloid leukaemia (CML) in the chronic phase include hydroxyurea, interferon alpha, allogeneic stem cell transplantation and the tyrosine kinase inhibitor imatinib (STI 571, Gleevec). For elderly patients, oral hydroxyurea is suitable for the relief of symptoms caused by hyperleukocytosis, and splenic irradiation would be considered if abdominal discomfort or fullness induced by splenomegaly were present. Tumour lysis syndrome (TLS) is seldom seen in the treatment for CML, and TLS caused by hydroxyurea or splenic irradiation is rarely observed. Herein, we report an elderly CML patient who received treatment with hydroxyurea, allopurinol, hydration and splenic irradiation. After 3 days, acute TLS developed. Aggressive supportive treatment, including haemodialysis, stabilized the condition.

Radiotherapy for splenomegaly

Radiotherapy for massive, symptomatic splenomegaly has been used in a palliative setting since the early 1990's. Massive splenomegaly may be seen in CML, CLL, hairy cell leukemia and splenic marginal zone lymphomas, prolymphocytic leukemia, myeloproliferative disorders such as polycythaemia rubra, polycythaemia vera or essential thrombocytosis or myelofibrosis. Splenic radiation therapy has been shown to be effective in palliation of the signs and symptoms due to massive splenomegaly. We present here one such case of myelofibrosis where the patient was treated with radiotherapy to the spleen for symptomatic relief. The patient achieved excellent response to the treatment.

Experimental study on the feasibility and safety of radiofrequency ablation for secondary splenomagely and hypersplenism

AIM: To assess the feasibility and safety of radiofrequency ablation (RFA) in treatment of secondary splenomagely and hypersplenism.

METHODS: Sixteen healthy mongrel dogs were randomly divided into two groups, group I (n = 4) and group II (n = 12). Congestive splenomegaly was induced by ligation of splenic vein and its collateral branches in both groups. At the end of 3rd week postoperation, RFA in spleen was performed in group II via laparotomy, complications of RFA were observed, CT scan was performed and the spleens were obtained. The radiofrequency (RF) thermal lesions and histopathology of spleen were examined regularly.

RESULTS: No complication or death was observed in both groups; CT revealed that the splenomegaly lasted over 2 months after ligation of splenic vein; the segmental RF lesions included hyperintense zone of coagulative necrosis and more extensive peripheral hypointense infarcted zone, the latter was called “bystander effect”. The infarcted zone would be absorbed and subsequently disappeared in 4-6 weeks after RFA accompanied with shrinkage of the remnant spleen. The fundamental histopathological changes of splenic lesions caused by RF thermal energy included local coagulative necrosis, peripheral thrombotic infarction zone, subsequent tissue absorption and fibrosis in the zone of thrombotic infarction, the occlusion of vessels in remnant viable spleen, deposition of extensive fibrous protein, and disappearance of congestive splenic sinusoid - “splenic carnification”. Those pathologic changes were underline of shrinkage of spleen.

CONCLUSION: It is feasible and safe to perform RFA in spleen to treat experimental splenomegaly and hypersplenism. The RFA could be safely performed clinically via laparotomy or laparoscopic procedure while spleen was strictly separated from surrounding organs.

Palliative irradiation of the spleen

We analyzed the efficacy of splenic irradiation in a population of patients with hematologic diseases. The records of the Radiation Oncology Division, Naval Medical Center San Diego were retrospectively reviewed for all patients treated with splenic irradiation (SI) between January 1, 1990 and March 1, 2001. The charts of 17 patients were identified: 5 patients had chronic myelogenous leukemia, 4 had chronic lymphocytic leukemia, 4 had idiopathic myelofibrosis, 2 had polycythemia vera, and 1 patient each had idiopathic thrombocytopenic purpura and acute myelogenous leukemia. Patient ages ranged from 37 to 88 years. Sixteen of 17 suffered from symptomatic splenomegaly. Twenty-six courses of splenic irradiation were delivered to these 17 patients. Treatment courses generally consisted of two fractions of 50 cGy in the first week, two fractions of 75 cGy the second week, and two fractions of 100 cGy the third week. Blood counts were checked prior to each treatment. Seven of the 17 patients died 1 month or less after SI due to the terminal nature of their disease. Twenty-two of 25 treatment courses for splenomegaly resulted in decreased pain and symptoms. Five patients required two treatment courses for splenomegaly, and one patient required five treatment courses. Three of four patients treated for thrombocytopenia demonstrated improvement, but only one was evaluable for more than 2 weeks due to disease-related mortality. Three of five patients treated for leukocytosis had significant improvement. In general, patients suffered few significant complications from this palliative intervention. Splenic irradiation can effectively palliate symptomatic splenomegaly in patients for whom splenectomy is not an option. Retreatment is possible. Splenic irradiation is less effective in the treatment of thrombocytopenia or leukocytosis.

Short-time splenic irradiation for splenomegaly

BACKGROUND

Splenic irradiation is routinely used in the supportive treatment of lymphoepithelial and hemopoietic diseases associated with splenomegaly. A new short-time irradiation schedule with conventional dosage (Group A: 2 Gy/fract.) was compared retrospectively with low-dose prolonged treatment schedules (Group B: < or = 1 Gy/fract.) to establish its tolerance and its efficacy in terms of relieving splenomegaly-associated symptoms.

PATIENTS AND METHOD

Between 12/1996 and 3/2002 49 patients (6 with CLL, 14 with CML, 6 with NHL, 16 with MPD, 6 with OMF and 1 with AML) underwent 85 treatment courses (13 courses low-dose prolonged treatment and 72 courses short-time treatment).The spleens had been exposed to pretreatment doses of 3-70 Gy (mean 20.75 Gy). Splenic size was 12-35 cm (mean 22.76 cm). One treatment was done with 60Co. 9-20 MeV electron beams were used in 23 treatments and 6 MV photons in 61 treatments. Blood counts were monitored daily. Clinical improvement (pain relief, improvement of splenomegaly-associated symptoms), spleen volume reduction and effects on blood counts were evaluated and documented at the end of the treatment.

RESULTS

Of the 85 treated patients, 55 (Group A: 47/72, Group B: 8/13) showed a > 10% reduction of spleen volume and 62 (Group A: 57/72, Group B: 5/13) clinical improvement. 15 of 49 patients underwent multiple irradiation (2-8 courses) without clinical or hematologic complications. The intervals between the courses were 2-19 months. Rapid response in terms of reduction in splenic size in 23 patients permitted field reduction during treatment. Significant hematologic abnormalities were absent throughout.

CONCLUSION

The short-time treatment schedule ensured a rapid response with relief of pain and improvement of gastrointestinal and pulmonary symptoms at an overall treatment time shorter than that of low-dose prolonged treatment schedules. No differences in terms of hematologic abnormalities were found between single doses of 2 Gy and < or = 1 Gy.

Advanced waldenström's macroglobulinemia: a case of possible cure after systemic chemotherapy, splenic radiation and splenectomy

A 41-year-old man with advanced Waldenström's macroglobulinemia (WM) associated with the hyperviscosity syndrome, massive splenomegaly and with IgM concentration of 10 g/dl, was treated in January 1984 with plasmapheresis, systemic chemotherapy (M2 protocol) and splenic radiotherapy. He rapidly improved and was discharged 1 month later. Fourteen months later he underwent splenectomy since a mild splenomegaly persisted though the normalization of bone marrow, peripheral blood and electrophoresis with an IgM concentration of 140 mg/dl. However, at this time immunofixation and immunoelectrophoresis showed a small IgM-kappa monoclonal component. The histological and immunohistochemical analysis showed minimal splenic involvement by WM. Two months after splenectomy, immunofixation and immunoelectrophoresis showed no monoclonal component. The spleen was the probable site of minimal residual disease. The patient was treated with monthly chlorambucil and prednisone for 2 years. Subsequently clinical and laboratory tests persisted within normal limits. The last control performed in January 2002 showed that the patient was in good health; bone marrow examination (aspiration, biopsy with immunohistochemical analysis) and immunofixation persisted normally. This interesting case report, with advanced WM, alive, in good health and without signs of disease 18 years from diagnosis, is presented here and the role of splenectomy is debated.

Successful treatment with low-dose splenic irradiation for massive splenomegaly in an elderly patient with hairy-cell leukemia

The therapeutic approach to hairy-cell leukemia (HCL) is in some instances still debated. Although management with alpha-interferon and purine analogues is well established, there is an alternative role for therapeutic splenectomy in patients with massive splenomegaly who have failed to respond to systemic therapy. Most patients with HCL will not be suitable for treatment with splenectomy as their ages at diagnosis are high. Here, we report an elderly Japanese HCL patient whose refractory massive splenomegaly responded well to low-dose splenic irradiation.

Improvement of quality of life after splenectomy in an HTLV-I carrier with T-cell prolymphocytic leukemia

A 34-year-old woman of HTLV-I carrier with T-PLL, whose quality of life improved and survival was prolonged after splenectomy, is described. The patient had marked splenomegaly, generalized lymphadenopathy and marked proliferation of abnormal lymphocytes in the peripheral blood with an irregular nucleus, deeply basophilic cytoplasm and a single prominent nucleolus, which were positive for CD2, CD3, CD5, CD7, CD4 and CD8. Although the patient had serum antibody against HTLV-I, HTLV-I proviral DNA integration was not detected. She was diagnosed as an HTLV-I carrier with T-PLL and received combination chemotherapy and 15.1 Gy splenic irradiation. However, the generalized lymphadenopathy and splenomegaly did not improve. The patient underwent splenectomy to palliate abdominal distension and hypersplenism. After the operation, her symptoms improved dramatically and within a week her hemoglobin concentration and platelet count normalized. She was discharged from hospital two weeks after the splenectomy, however 11 months later, she relapsed and despite treatment with chemotherapy and alpha-interferon, she died two months after the second admission. Autopsy findings revealed that PLL cells had invaded the bone marrow, lymph nodes, liver, lungs, kidneys, uterus, ovaries and adrenal glands.

Splenic irradiation in myelofibrosis with myeloid metaplasia: a review

Morbidity from myeloid metaplasia and myelofibrosis arises from progressive anemia and abdominal discomfort related to massive splenomegaly, which may be associated with hypercatabolic symptoms. To date, no therapy, other than allogeneic bone marrow transplantation, has been shown to cure or to prolong the survival of these patients. Thus, current management strategies are palliative and include red cell transfusional support and androgen therapy for anemia; chemotherapeutic agents for control of thrombocytosis, leukocytosis, and hypermetabolic symptoms; and splenectomy or splenic irradiation for symptomatic splenomegaly. The major indication for splenic irradiation is left upper quadrant discomfort related to massive splenomegaly, usually in patients for whom splenectomy is contraindicated or has been declined. In most patients, it provides relief from abdominal pain and a moderate reduction in splenic size. Although responses are transient, some patients may experience prolonged relief. Splenic irradiation can result in prolonged myelosuppression in certain patients. This calls for cautious dosing, because individual sensitivity is variable and cannot be predicted. The use of splenic irradiation does not preclude subsequent splenectomy; however, the increased risk of postoperative hemorrhage should discourage consideration of splenic irradiation as an alternative or a temporizing measure before splenectomy when indicated.

[Radiotherapy in leukemia excluding total body irradiation]

Radiation techniques and indications in leukemias have been described in detail, yet prophylactic cranial irradiation in acute leukemia still has few indications. Cerebrospinal and testicular irradiation are reserved for relapsing disease. Radiation usually results in rapid functional improvement when used in neurologic emergencies and symptomatic neurologic or gross tumors relapses. Nevertheless, the improvements recently obtained by systemic chemotherapy have resulted in the reduction in the use of irradiation, especially in children, where it was considered deleterious with neuropsychological sequellae. Splenic irradiation remains useful for symptomatic myeloproliferative syndrome.

Splenic irradiation for symptomatic splenomegaly associated with myelofibrosis with myeloid metaplasia

Twenty-three patients who had myelofibrosis with myeloid metaplasia (MMM) were treated at our institution with 50 courses of splenic irradiation (SI) for symptomatic splenomegaly. The median dose of radiation per course was 277.5 cGy, administered in a median of 7.5 fractions. 8/23 patients received multiple courses of SI. Of 49 evaluable courses of SI, 46 (93.9%) resulted in an objective decrease in spleen size. The median duration of response was 6 months (range 1-41). Reduction in spleen size was associated with symptomatic relief in all patients. Overall median survival after SI was 22 months. Significant cytopenia occurred in 10 (43.5%) patients, or 16 (32%) of the 50 courses of SI. Prolonged, life-threatening pancytopenia after a single course of SI occurred in six patients (26%), resulting in fatal sepsis or haemorrhage in three (13%). Nine patients underwent subsequent splenectomy: the perioperative mortality rate was 11%. One third of patients experienced postoperative intra-abdominal haemorrhage necessitating surgical re-exploration. SI can provide symptomatic relief and a reduction in spleen size in most MMM patients. The increased risk of postoperative bleeding in patients requiring subsequent splenectomy dictates against considering SI as an alternative to splenectomy for patients who are otherwise good surgical candidates.

Splenic irradiation for prolymphocytic leukemia: is it preferable as an initial treatment or not?

We describe a case of B-cell prolymphocytic leukemia (PLL) successfully treated with splenic irradiation (SI). A 69-year-old woman was admitted to our hospital because of massive splenomegaly and leukocytosis. Peripheral blood showed hemoglobin (Hb) 7.4 g/dl, platelets 48 x 10(9)/l and white blood cells (WBC) 50.3 x 10(9)/l with 90% prolymphocytes. Bone marrow was hypercellular with 60% prolymphocytes. Surface marker analysis revealed that prolymphocytes were positive for CD20, CD22, FMC7, HLA-DR and surface immunoglobulin (mu, delta and lambda), but negative for CD5 and mouse erythrocyte rosette. A diagnosis of B-cell PLL was made. SI (1.5 Gy x 4/week, total dose 19.5 Gy) was chosen for the treatment and a remarkable response was achieved immediately after the first irradiation. Finally, a single course of SI induced complete remission without any significant side effect. One year after the SI, she showed no splenomegaly and almost normal peripheral blood cell count (Hb 11.2 g/dl, platelets 100 x 10(9)/l, WBC 3.6 x 10(9)/l with 71% neutrophils and no prolymphocyte). She has been well for more than 24 months. This case showed that SI may remain valuable for an initial course of PLL treatment.

Splenic irradiation for hairy cell leukaemia

Splenic irradiation in the management of hairy cell leukaemia is previously unreported. A case is presented here to illustrate that splenic irradiation may be a useful addition to systemic therapies.

[Splenic irradiation in myeloid hemopathies: evaluation and toxicity]

PURPOSE

Splenomegaly occurs frequently in patients with myelofibrosis (MF) or chronic myelogenous leukemia (CML), indicating significant splenic metaplasia. Symptomatic radiation therapy can be delivered, but the best irradiation scheme is still unknown. Results of splenic irradiation in patients with myelofibrosis or chronic leukemia were retrospectively analyzed.

PATIENTS AND METHODS

There were 24 patients: 15 presented with MF and 9 with CML. Median irradiation doses were 9.8 and 7.7 Gy, respectively. The hematologic toxicity was moderate (except for platelets in the acute phase of the disease).

RESULTS

No toxicity was observed. Various factors predictive of the response to radiation therapy are described. While high (around 14 Gy) radiation therapy dose appears necessary for MF and should be started before the increase in transfusion need, huge splenomegalies should be excluded in regard to CML. As for other cases, the optimal dose is still unclear, but should probably be high enough, ie, around 10 Gy.

CONCLUSION

To further study and better understand biological mechanisms underlying response to radiotherapy in patients with MF, prospective radio-chemotherapy phase II trials should be conducted in both CML and MF patients.

Splenic irradiation in the palliation of patients with lymphoproliferative and myeloproliferative disorders

INTRODUCTION

Splenic irradiation is an accepted mode of treatment for palliation of hypersplenism and splenic pain for patients with lymphoproliferative or myeloproliferative disorders. However, results are conflicting regarding the duration of palliation and the toxicity associated with this treatment.

METHODS

Twenty-five patients with lymphoproliferative or myeloproliferative disorders were treated with splenic irradiation for palliation of splenomegaly and pain. The spleen was measured and pain and toxicity were assessed during radiation therapy.

RESULTS

Splenomegaly and splenic pain decreased in 60 percent and 91 percent of patients, respectively. Radiation doses higher than 500 cGy appeared to be more effective than lower doses in reducing the spleen size in patients with chronic lymphocytic leukemia. Regression of splenomegaly and pain relief were maintained for less than one year and more than six months, respectively. Acute radiation toxicity resulted in the cessation of radiotherapy in two patients.

CONCLUSION

Splenic irradiation is effective in the short-term palliation of splenomegaly and pain and may be most useful in the subset of patients with a life expectancy of less than one year. Terminally ill patients with splenomegaly secondary to lymphoproliferative or myeloproliferative disorders may benefit from splenic irradiation to minimize pain and pressure symptoms in addition to possible reduction of narcotic use.

The efficacy of chemotherapy and splenic irradiation in the management of chronic myelogenous leukaemia at Ibadan, Nigeria

Chronic myelogenous leukaemia (CML) in Nigerians shows a male predominance over females as has been observed in other centres. Out of 25 patients treated between 1987 and 1990, 18 were male. The mean survival of CML patients on chemotherapy was 48.7 months with a median of 38 months, while the mean survival of patients who had chemotherapy plus splenic irradiation was 53.3 months with a median survival of 53 months. The difference between the two mean survival rates was non-significant. Splenic irradiation resulted in significant reduction in splenic size with total disappearance of gastrointestinal symptoms. The need for red cell and blood products transfusion diminished. Patients had a feeling of well being though short-lived. In a developing country, the added cost of irradiation must be weighted against the relatively brief improvement in well-being when deciding mode of management of the disease. Cause of death in all cases was septicaemia, complications of thrombocytopaenia and marrow failure.

Prolymphocytic leukemia: a very satisfactory response to treatment with recombinant interferon alpha

We report the case of a patient with prolymphocytic leukemia in whom a lengthy survival of 5 years was observed after treatment with splenic irradiation and chemotherapy. The patient obtained a surprising improvement with a significant reduction in the absolute count of the prolymphocytes and considerable reduction in splenomegaly after 3 months' therapy with interferon alpha.

Splenic irradiation in chronic lymphocytic leukemia

52 patients with CLL, presenting primarily with splenomegaly, stage II-IV according to the Rai stage system, were treated with a regime of low-dose splenic irradiation (SI) between January, 1979 and December 1987. The treatment modality consisted of 1 Gy, from 1 to 10 doses, given at weekly intervals. The median given dose was 700 cGy (100-1000). CHR occurred in 23/52 (44%), PR in 20/52 (38%) and no response (NR) in 9/52 (17%) of the patients. The median duration of remission was 9 months (range 3-24), 15 and 7 months for patients achieving CHR and PR, respectively. At relapse, 14 patients received a second course of SI by the same modalities: 2 of them obtained a second CHR, 9 a PR and 3 NR. The median duration of remission was 4 months. In conclusion, SI represents a suitable therapy for CLL patients presenting primarily with splenomegaly. The low rate of response and the short remission duration after the second treatment suggest that SI should be combined either with splenectomy or with other therapeutic approaches.

Hairy cell leukemia. A therapeutical update

This is a review of current treatment for hairy cell leukemia (HCL). Data for this analysis were obtained from the Italian HCL Registry, as well as from other published series. We have given space to the impact of interferon and pentostatin on the management of this disease. Other issues are also discussed, such as the relevance of achieving a complete remission with respect to overall and relapse-free survival. We include a final section on recommendations which may prove useful in designing an appropriate therapeutic strategy.

A study of splenic irradiation in chronic lymphocytic leukemia

A retrospective study was performed to assess the effect of splenic irradiation (SI) on splenomegaly, splenic pain, anemia, and thrombocytopenia in patients with chronic lymphocytic leukemia. Twenty-two patients received 32 courses of SI. Of 31 courses of SI given for splenomegaly there were 19 responders (61%). Ten courses of SI were given for splenic pain resulting in partial relief of pain in 4 courses and complete relief in 4 courses. Only 4 of 16 courses given for anemia resulted in elevations of hemaglobin of 2 g/dL or more. Of the 14 courses of SI given for thrombocytopenia there were only 2 responses with platelet counts decreasing further in another 9 courses. The median duration of response was 14 months (range: 3-116 months). There was no dose-response relationship detected for SI in CLL. Treatment related toxicity was hematologic and secondary to leucopenia and thrombocytopenia. We recommend the use of small fraction sizes of 25 cGy to 50 cGy and close monitoring of hematological parameters. Splenic irradiation effectively palliates splenomegaly and reduces spleen size in CLL. It was of limited value in correcting anemia and thrombocytopenia in this patient population.

[Splenic irradiation in the treatment of idiopathic myelofibrosis. Retrospective study of 14 cases]

A retrospective study was conducted on 14 patients with idiopathic myelofibrosis after splenic irradiation in order to cure the symptoms due to secondary splenomegaly. Radiation dose ranged from 700 to 2400 cGy, depending on both clinical response and hematological toxicity. Relief of symptoms was observed in all patients (100%); reduction of splenic size ranged from 30 to 70%, with more than 50% reduction in 13/16 cases. Side effects were mild neutropenia and thrombocytopenia, which did not require interruption of treatment; four patients registered a severe anemia. All the hematological side effects stopped with the suspension of treatment. This study shows the beneficial effect of radiation therapy on the symptoms connected to splenomegaly; however, the short duration of response suggests the advantage of splenic low-dose irradiation, to be periodically repeated.

Splenic irradiation in the treatment of patients with chronic myelogenous leukemia or myelofibrosis with myeloid metaplasia. Results of daily and intermittent fractionation with and without concomitant hydroxyurea

Seventeen patients with either chronic myelogenous leukemia (CML) or myelofibrosis with myeloid metaplasia (MMM) received 24 courses of splenic irradiation at this institution from 1973 to 1982. Eleven of the 17 patients had received prior chemotherapy. Patients were treated with 60Co gamma rays or 6 MV photons. The fraction size ranged from 15 to 100 rad and the total dose per treatment course from 15 to 650 rad, with the exception of one patient who received 1650 rad. Fourteen of 19 courses (71%) given for splenic pain yielded significant subjective relief while 17 of 26 courses given for splenomegaly obtained at least 50% regression of splenic size. Blood counts were carefully monitored before each treatment to limit hematologic toxicity. From this experience, the authors conclude that splenic irradiation effectively palliates splenic pain and reverses splenomegaly in the majority of patients with CML and MMM. Intermittent fractionation (twice or thrice weekly) is more convenient for the patient, appears to be as effective as daily treatment, and may be associated with less hematologic toxicity. Preliminary results of concurrent treatment with splenic irradiation and oral hydroxyurea show promise and warrant further study.

[Symptomatic irradiation therapy of the spleen in advanced osteomyelosclerosis]

A retrospective analysis of spleen irradiation in 25 patients with progressive idiopathic myelosclerosis (agnogenic myeloid metaplasia), treated between 1948 and 1983, shows that there is a place for the mechanical effect of irradiation being an indication for its use as a palliative measure. A decrease in spleen size of varying extent was achieved in 84% of patients, while the symptoms of abdominal compression improved in 88%. Remission period averaged 10 months. On the other hand, in all seven patients in whom a decrease in the size of the spleen might have been expected to signal an improved blood picture, the frequency of transfusion remained unchanged.

Spleen irradiation in chronic lymphocytic leukemia (CLL): palliation in patients unfit for splenectomy

In 22 patients with CLL given 30 courses of spleen irradiation, 23 responses were observed (77%, 95% confidence limits, 58-90%). Response was defined as reduction in palpable spleen size accompanied by relief of symptoms (pain, abdominal discomfort, and sweating) or improvement in hypersequestration or hemolytic anemia. Reduction in leukocyte count alone was not regarded as response. All responses were partial. The median response duration was 1 year. Subsequently, three patients underwent splenectomy. The median survival from the beginning of spleen irradiation was 2.5 years (range: 1 month-greater than 5 years). Only six patients had minor side effects from the gastrointestinal tract. The hematologic effect was most pronounced on the white blood cell count, but also the platelet count was affected. It is concluded that spleen irradiation is a gentle and effective alternative in CLL patients suffering from splenomegaly (pain and hypersplenism), refractory to chemotherapy and glucocorticosteroids and unfit for splenectomy. Splenic irradiation may also be used with benefit preoperatively before splenectomy in patients with excessive splenomegaly and hypersplenism.

Nonvisualization of an enlarged spleen on Ga-67 scintigraphy but demonstrated by CT after splenic irradiation

Presence of enlarged spleen using CT with absence of splenic visualization in Ga-67 citrate images in a patient with chronic myelogenous leukemia and splenomegaly after splenic irradiation was observed. Since Howell-Jolly bodies had not been identified in the peripheral circulation, the finding of splenic nonvisualization was explained by disassociated splenic functions, which are not tightly coupled, and some activities that can be suppressed by irradiation without impairing others. The Ga-67 splenic localization mechanism is probably more sensitive and liable to disruption by irradiation, and was independent of spleen size. Ga-67 scintigraphy and Tc-99m sulfur colloid liver-spleen scintigraphy are two organ function-dependent imaging procedures, while CT provides anatomic information.

Splenic irradiation in B-prolymphocytic leukaemia

Twelve patients with B-cell prolymphocytic leukaemia (PLL) were treated with splenic irradiation at a weekly dose of 100 cGy to a maximum total dose of 1000 cGy. There was no morbidity associated with this treatment. SEven patients responded. Three achieved a good response and four a partial response. Two of the patients who had a partial response have subsequently died of unrelated causes. Four of the five patients who failed to respond have died as a result of their disease. When more than 25% of the prolymphocytes formed rosettes with mouse red blood cells (MRBC) the patients appeared to respond better to splenic irradiation. There was no correlation between response and the initial white cell count or the size of the spleen.

The role of splenic irradiation in chronic lymphocytic leukemia

Fourteen patients with chronic lymphocytic leukemia (CCL) who received a total of 23 courses of splenic irradiation (SI)for various combinations of painful splenomegaly, progressive leukocytosis, lymphocytosis, thrombocytopenia, and anemia are reviewed. Splenic midplane doses ranged from 200-1750 rads (3-14 days), while the most typicalregimen was 300-450 rads in two to three fractions of 150 rads given over 3-8 days. Response to SI was rated according to a scoring system which evaluated the splenic and hematologic response, as well as the response of disease-related symptons. According to this scoring system, most patients demonstrated a significant relief of painful splenomegaly, along with improvement of hemogram and bone marrow parameters. While those patients judged as failures to prior chemotherapy or total body irradiation showed improvement following SI, those who had received minimal therapy prior to SI showed a superior response. SI, in those showing a satisfactory response, was repeated successfully in several patients (up to six times in one instance). The onset and duration of response to SI, dose-reponse data, survival, clinical and hemotologic responses, and the possible mechanism of action of SI are discussed with reference to the available literature.

32P-therapy in polycythemia vera

A group of 52 consecutive patients with polycythemia vera was submitted to long-term therapy with radioactive phosphorus (32P). Initial phase of therapy induced complete remissions (normalization of hematogram; spleen not palpable) in 45% of the patients, and partial remissions in the remaining 55%. During maintenance therapy of the complete remission group, mean remission time was about 3.5 years. Individual remission times ranged between 1 and 6 years. In the group of patients with incomplete remission, mean remission time increased with the progression of the disease due to gradual development of "spent" -polycythemia. In patients with splenomegaly, remission time was negatively correlated to spleen size. In both groups the increment of annual accumulated dose averaged 2.4 mCi 32P. When considering polycythemia related causes of death only, mean survival time attained 12 years after initial treatment with 32P. Acute leukemia occurred in 2 patients (4%).