Is there still a role for splenectomy in ITP? Yes presenta… · • Retrospective study using Delphi panel design • 610 patients (F, Ge, It, Sp, UK) • 6% of splenectomy • Strong

Is there still a role for splenectomy in ITP?

Yes !Bertrand Godeau

Centre de référence des cytopénies auto-immunes de l’adulte

Service de médecine interne

CHU Henri Mondor, 94000 Créteil, France

[email protected]

ASSISTANCE PUBLIQUE HÔPITAUX DE PARIS

CHU Henri MONDOR

• Retrospective review of 135 case series• 2623 patients

• Complete response: 66 % (follow-up 1 to 153 months)

• Relapse: 15 %• Mortality with laparoscopy: 0.2 %

The long-term prognosis of splenectomized patients is favorable, even in the subgroup of patients who intially failed to respond to splenectomy ?

With the development of new therapeutic strategies, Is there still a role

for Splenectomy in ITP ?

• Rituximab- Effective- Not expensive- Simple to administer- Can cure- Safety ?- No license

- Long-term response: only 20% ?

Is there still a role for Splenectomy in ITP ?

Con• Patients and physicians

reluctant …• Long term response ?• Long term safety ?• Is it possible to predict the

response (isotopic study ?)

Pro• Experience• Not

expensive• Cure

• Retrospective study using Delphi panel design

• 610 patients (F, Ge, It, Sp, UK)

• 6% of splenectomy

• Strong consensus that first line treatment should be corticosteroids (91%) and second line treatment splenectomy (71%)

• Many physicians would modify their choice of treatment if patients expressed concern about splenectomy (74%) or in presence of comorbidities

Treatment practices in adults with chronic immune thrombocytopenia – a European perspectiveRodeghiero et al, European Journal of Haematology 2009; 84: 160-8

Short-term and long-term failure of laparoscopic splenectomy in adult immune thrombocytopenic purpura patients: a systematic review.Mikhael et al Am J Hematol. 2009; 84:743-8.

- 1,223 laparoscopic splenectomies - The pooled short-term surgical non-response rate:

8.2% (95% CI 5.4-11.0) - The pooled long-term relapse rate:

4,4 per 100 patient years (95% CI 2.8.-6.7)

Failure rate of 28% at 5 years

Splenectomy may have higher initial relapse rates, particularly, in the first 2 years after surgery, and the rate may decline over time

Splenectomy Response to long term (late relapse) ?

Time to Splenectomy Failure in Patients with Recurrent or Refractory Chronic Immune Thrombocytopenic PurpuraGregory Cheng1*, Terry Gernsheimer, MD2, Harold J. Olney, MD, CM3, James B. Bussel, MD4, Palvi Shah5*, Andres Brainsky6*, Kelly M. Grotzinger6* and Manuel Aivado6

50% of relapse

during the first yr

• Infection• Malignancy ?• Vascular complications

– Arteriothrombosis– Venous thrombosis– Cardiovascular events– Pulmonary hypertension

Complications of splenectomy

Risk for hospital contact with infection in patients with splenectomy.A population-based cohort studyThomsen et al, Ann Intern Med 2009; 151: 546-55

Risk for hospital contact with infection in patients with splenectomy.A population-based cohort studyThomsen et al, Ann Intern Med 2009; 151: 546-55

Splenectomized ITP patientsn = 269

Non splenectomized ITP patientsn = 1345

Adjusted RR (95% CI)

Median days since splenectomy indicated

196 196

Infection involving hospital contact

0 to 90 d, n (%) 15 (5.6) 36 (2.7) 2.6 (1.3-5.1)

91 to 365 d, n (n p 100pt yr)

11 (5.7) 59 (6.5) 1 (0.5-2)

> 365 d 56 (4.6) 173 (3.3) 1.4 (1-2)

Risk for hospital contact with infection in patients with splenectomy.A population-based cohort studyThomsen et al, Ann Intern Med 2009; 151: 546-55

ITP: hyperexpression of Cell-derived microparticles

Fontana et al, Thrombosis Research 2008; 122: 599-603

Splenectomy as a cause of Chronic Thromboembolism Pulmonary Hypertension (CTEPH) ?

Jaïs et al, Thorax 2005; 60: 1031-4

Can the results of isotopic study help the clinicans to make the decision to perform splenectomy ?

Autologous 111In-Labeled Platelet Sequestration Studies in Patients with Primary Immune Thrombocytopenia (ITP): A Report From the United Kingdom RegistryAmeet Sarpatwari, M.Phil1*, Drew Provan, MD2*, Ravin Sobnack, PhD3*, Sebhat Erqou, MD, M.Phil4*, F. W. David Tai, BSc.5*, Simon Sanderson, MD4* and Adrian Newland, MD, FRCP6

Don’t forget splenectomy !

Don’t forget splenectomy ?

- Elderly

- Contra-indication to splenectomy

- severe comorbidities

- Liver sequestration on isotopic study

- Reluctant ?

TPO-r agonists

- Young patients

- Splenic or hepato/splenic sequestration

on isotopic study

Splenectomy