Splenectomy for immune thrombocytopenic purpura: Surgery for the 21st century

Dolan, James P.; Sheppard, Brett C.; DeLoughery, Thomas G.

doi:10.1002/ajh.21029

Cited by 33 publications

(29 citation statements)

References 30 publications

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“…43 We recommend pneumococcal, meningococcal, and Haemophilus influenzae vaccination before splenectomy and periodically every 5 years or according to titers. 1,44 Splenectomy reduces cost. Before TPO-RA, the annual cost of treating severe chronic ITP was estimated to be $40 000, 45 although comprehensive cost-effectiveness studies are lacking in adults.…”

Section: Prosmentioning

confidence: 99%

How I treat immune thrombocytopenia: the choice between splenectomy or a medical therapy as a second-line treatment

Ghanima

Godeau

Cines

et al. 2012

Blood

208

162

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The paradigm for managing primary immune thrombocytopenia (ITP) in adults has changed with the advent of rituximab and thrombopoietin receptor agonists (TPO-RAs) as options for second-line therapy. Splenectomy continues to provide the highest cure rate (60%-70% at 5؉ years). Nonetheless, splenectomy is invasive, irreversible, associated with postoperative complications, and its outcome is currently unpredictable, leading some physicians and patients toward postponement and use of alternative approaches. An important predicament is the lack of studies comparing secondline options to splenectomy and to each other. Furthermore, some adults will improve spontaneously within 1-2 years. Rituximab has been given to more than 1 million patients worldwide, is generally well tolerated, and its short-term toxicity is acceptable. In adults with ITP, 40% of patients are complete responders at one year and 20% remain responders at 3-5 years. Newer approaches to using rituximab are under study. TPO-RAs induce platelet counts > 50 000/L in 60%-90% of adults with ITP, are well-tolerated, and show relatively little short-term toxicity. The fraction of TPO-RA-treated patients who will be treatment-free after 12-24 months of therapy is unknown but likely to be low. As each approach has advantages and disadvantages, treatment needs to be individualized, and patient participation in decision-making is paramount. (Blood. 2012;120(5):960-969)

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Section: Prosmentioning

confidence: 99%

How I treat immune thrombocytopenia: the choice between splenectomy or a medical therapy as a second-line treatment

Ghanima

Godeau

Cines

et al. 2012

Blood

208

162

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“…However, increasing numbers of patients are reluctant to undergo splenectomy and physicians are hesitant to recommend it. 9,10 In addition, the risk of overwhelming postsplenectomy infections, although rare, is not predictable and represents a major concern. [11][12][13] Moreover, some authors reported that, despite initial good responses to splenectomy, the risk of late relapse persists during long-term follow-up 14,15 and severe morbidity resulting from surgery is associated with 11% to 30% postoperative complications requiring prolonged hospitalization or readmission.…”

Section: Introductionmentioning

confidence: 99%

Rituximab efficacy and safety in adult splenectomy candidates with chronic immune thrombocytopenic purpura: results of a prospective multicenter phase 2 study

Godeau

Porcher

Fain

et al. 2008

Blood

236

196

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IntroductionImmune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by low platelet counts and may be responsible for mucocutaneous bleeding of variable severity. 1 ITP is usually chronic (Ͼ 6 months) in adults and, after this time, the probability of spontaneous remission is low. Standard management is to initiate steroids, anti-Rh 0 (D) immune globulins, and/or intravenous immunoglobulins (IVIgs) for the more severe forms. [2][3][4][5] The response rate is high but most often transient. That the spleen plays a major role in the removal of damaged platelets has long been known and, to date, splenectomy is still considered the "gold standard" treatment in many countries for the management of chronic ITP with platelet counts less than 30 ϫ 10 9 /L, especially when hemorrhagic complications are present. Approximately two thirds of chronic ITP patients who undergo splenectomy achieve lasting responses. 6 As suggested in the guidelines of the American Society of Hematology (ASH) 7 and the British Committee for Standards in Hematology (BCSH), 8 splenectomy should be considered the main second-line therapy for patients who fail to respond durably to first-line therapy, with persistent platelet counts less than 30 ϫ 10 9 /L. However, increasing numbers of patients are reluctant to undergo splenectomy and physicians are hesitant to recommend it. 9,10 In addition, the risk of overwhelming postsplenectomy infections, although rare, is not predictable and represents a major concern. 11-13 Moreover, some authors reported that, despite initial good responses to splenectomy, the risk of late relapse persists during long-term follow-up 14,15 and severe morbidity resulting from surgery is associated with 11% to 30% postoperative complications requiring prolonged hospitalization or readmission. 11,16 For these reasons, an effective and safe alternative to splenectomy would improve management of chronic ITP.Rituximab is a chimeric, humanized monoclonal antibody directed against the CD20 determinant on B cells. It was initially developed for the treatment of malignant lymphoma but has also been used in autoantibody-mediated disorders, such as rheumatoid arthritis, 17 systemic lupus erythematosus, 18 autoimmune hemolytic anemia, 19 or thrombotic thrombocytopenic purpura. 20 Case reports and several uncontrolled studies described its promising results in ITP patients. Arnold et al 21 conducted a systematic review of published reports on rituximab use in adults with chronic ITP. A complete response, usually observed 3 to 8 weeks after the first infusion, was obtained in 46% of patients. The median response duration was 10.5 months (interquartile range [IQR]: 6.3-17.8 months), but long-term For personal use only. on May 10, 2018. by guest www.bloodjournal.org From responses were not mentioned in all published studies. Arnold et al 21 pointed out the heterogeneity of patients' prior rituximab use and particularly their splenectomy status. Moreover, the short follow-up in some reports and the possible bias due to th...

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“…Some ITP patients who are unresponsive to medical treatment, however, never undergo a splenectomy, perhaps because patients and physicians are reluctant to have a healthy organ removed, and they fear surgical complications like severe bleeding in the setting of low platelet count [3,4]. It is likely that the age or frailty of a patient plays an important role in whether a splenectomy is recommended; thus, patients who ultimately undergo a splenectomy probably represent a selected group.…”

Section: Introductionmentioning

confidence: 99%

Predictors for splenectomy among patients with primary chronic immune thrombocytopenia: a population-based cohort study from Denmark

et al. 2010

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Splenectomy for immune thrombocytopenic purpura: Surgery for the 21st century

Cited by 33 publications

References 30 publications

How I treat immune thrombocytopenia: the choice between splenectomy or a medical therapy as a second-line treatment

How I treat immune thrombocytopenia: the choice between splenectomy or a medical therapy as a second-line treatment

Rituximab efficacy and safety in adult splenectomy candidates with chronic immune thrombocytopenic purpura: results of a prospective multicenter phase 2 study

Predictors for splenectomy among patients with primary chronic immune thrombocytopenia: a population-based cohort study from Denmark

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