Use of Splenectomy in Adult Immune Thrombocytopenic Purpura

Transcript: Ivy Altomare, MD: I do want to circle back to splenectomy. We talked about it, and we talked about its place in the current ASH [American Society of Hematology] guidelines. But again for completion’s sake, let’s talk about what the outcomes are after a splenectomy since it’s still a possible treatment. And also, what are the rates of failure, and is that associated with the regrowth of an accessory spleen? Ralph, anything more to say about splenectomy?

Ralph V. Boccia, MD: Well again, just to remind that it’s been pushed back more than a year. Number 2, used in perhaps an earlier line of therapy, because that’s where most of the data come from, about 80% of patients will have a response. But unfortunately, 3 to 5 years later that’s down to 40% to 50%. So it’s, perhaps we can say, a coin toss whether the patient’s going to get a long-term benefit from that. And then balancing it, when in the patient’s clinical course it occurs, how old is the patient, what other intercurrent medical problems do they have, where that risk might aggravate the potential for thrombosis and bleeding?

Ivy Altomare, MD: Yeah, absolutely.

Ralph V. Boccia, MD: Cardiovascular events.

Ivy Altomare, MD: Yes.

Terry B. Gernsheimer, MD: I have had patients who did have a splenule, and we’ve always been taught that there’s no point in taking it out. I have seen responses after taking it out. I’ve also seen responses of irradiating that splenule. So if you’ve had a patient who has had a long-term response, it’s not a bad idea to do a liver spleen scan if suddenly they relapse, just to see if perhaps there’s something there.

Ivy Altomare, MD: Yes.

Amit Mehta, MD: Anecdotally, I had a case of a splenule that got radioembolized and resulted in a response several years ago. As Terry mentioned, you never know if you might target that accessory splenule, it could be potentially beneficial for the patient and achieve long-term responses potentially as well.

The other challenge I found, and I think I’ve heard it from some of my colleagues elsewhere in the country as well, is that because splenectomies are done so much less nowadays than they used to be, there are also fewer surgeons who are easy to go to, to comfortably do a splenectomy in an immune thrombocytopenic patient.

Ivy Altomare, MD: I’ve heard that as well, yes.

Amit Mehta, MD: I know at Duke University Medical Center, for example, there were only a couple of people who I would send the patient to surgically, who I felt they were comfortable telling me directly that: “Yes, we can on the case; we’ll be happy to operate.”

Ivy Altomare, MD: Who’s going to train them?

Amit Mehta, MD: Some of the younger surgeons, they have fewer cases that they’re seeing nowadays compared to the way it used to be, especially back in the days of Hodgkin lymphoma staging and such, where things have changed completely.

Terry B. Gernsheimer, MD: I think it’s important to point out to the surgeon when they’re doing it. First of all, they’re going to do it laparoscopically, hopefully. But also that you can use a platelet transfusion in this situation, but make sure that they clamp that splenic artery, that they clamp the vessels before they pour in those platelets.

Ivy Altomare, MD: Yes. I could talk to you all afternoon, but I do think that our time is up. This has been extremely informative for me and hopefully for the audience. Before we close I’d like to get final thoughts from each of our panelists. Dr Boccia.

Ralph V. Boccia, MD: I think we’re in a new era. We’re in a new era because we have so many more therapeutic options for our patients. We’re in a new era because now with those therapeutic options, we’re no longer required to even suggest early on that the patient have a splenectomy, which I think is a real benefit to people. We now have drugs that can change their lifestyle, their fatigue will improve. Their ability to have more social interaction, more sports, more activity is a real benefit to society I think.

Ivy Altomare, MD: Yes. Dr Gernsheimer.

Terry B. Gernsheimer, MD: I think we’re actually in a very good time. But I think one of the most important things is that we have to remember this is frequently a life-long journey for the patient. And it’s very important to discuss with them their lifestyle, what their particular goals are, and to keep them optimistic that we will get somewhere but to make sure we know what it is they want and need.

Ivy Altomare, MD: Well said. Dr McDonough.

Richard F. McDonough, MD: Along those lines we talked about before, we didn’t get too much into the fact that the majority of our patients are going to have this for a long period. So at that initial diagnosis you’re doing that education early on to understand that’s something that’s going to be potentially lifelong that they’re dealing with. But to echo both of your comments, certainly it’s exciting that we have more options that are more targeted. We’re not going to have quite as many off-target immune effects that they’re going to raise other concerns for infection and also things like thrombosis and that. So exciting, and other things are coming up in the future.

Ivy Altomare, MD: And Dr Mehta.

Amit Mehta, MD: Yes, I’m most clinically happy that because of all these options we can now differentiate more adverse effects that may not be a good fit for a given patient. Whether it’s a liver problem or food issues or thrombosis history, or infection risk in general. I think those are all very pertinent and clinically useful data to say, now we can use these subtle features that are clinically very meaningful when we have a lot of options. We’re targeting the pathophysiology, we’re targeting different mechanisms, which is great, and we can actually pick and choose a little bit. I think that’s very helpful for us in practice.

Ivy Altomare, MD: Yes, absolutely. And my final thought is that along those lines I really hope to have more clinical and maybe even molecular predictors in the future to help link a therapy with a patient.

Thank you all so much. On behalf of our panel, we hope that you found this Peer Exchange to be useful and informative. Thank you.

Transcript Edited for Clarity