The choice between splenectomy and medical treatment in patients with advanced agnogenic myeloid metaplasia

Abstract

The objective of the study was to explore the risks and benefits of splenectomy in advanced agnogenic myeloid metaplasia (AMM). We searched the literature (Medline, 1970-1987) for studies of postoperative survival, operative mortality and effects of splenectomy on painful splenomegaly, and portal hypertension or transfusion requirements in patients with AMM. We employed formal decision analysis to determine the relative value of medical and surgical treatment of advanced AMM. Results of data synthesis showed that splenectomy in AMM is associated with an operative mortality of 13.4% (95% confidence intervals (CI): 9.5-17.2%), an early morbidity of 45.3% (CI: 39.6-51.1%), and a late morbidity of 16.3% (CI: 9.9-22.5%). Almost all patients with portal hypertension and painful splenomegaly, but only about half of those with thrombopenia and anemia were reported to have experienced relief in their symptoms or signs after splenectomy. We found no evidence that splenectomy affects survival in AMM. We concluded that splenectomy in advanced AMM is a palliative procedure that carries a substantial risk. It may be considered for symptomatic patients after they have been informed about the operative mortality, morbidity, and chances of palliation. Decisions about treatment of advanced AMM should be guided predominantly by the patient's preferences.

Liver Dysfunction following Splenectomy in Idiopathic Myelofibrosis: A Study of 10 Patients

“…As in 2 patients of the present series, it has been re ported previously that in some IM patients the in crease in hepatic myeloid metaplasia following sple nectomy can be so massive as to provoke prominent clinical and biological signs of liver dysfunction, even leading to death [10,14,15,18,19]. The reason why some patients develop this overwhelming complica tion is not known, and no preoperative clinical or lab oratory data have been found that predict this course [ …”

“…Some authors also include portal hypertension secondary to splenomegaly among the indications for splenectomy in IM [5,7,12], It must be pointed out, however, that the influ ence of splenectomy on both the disease evolution and the patients' survival is not clear. Thus, although some authors have reported a survival advantage for splenectomized IM patients [5], in a recent review, Ben-bassat et al [19] considered that splenectomy would prolong the survival of patients with thrombo cytopenia exclusively.…”

“…However, it has been pointed out that this proportion increases markedly following splenectomy [5][6][7], a procedure that can be useful in those IM patients with painful splenomegaly or pancytopenia secondary to hypersplenism [2,[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Whereas infection and bleed ing are the most frequent and well-known complica tions of splenectomy in IM, information on the he patic abnormalities that subsequently develop in such patients is scarce [19]. The aim of the present study was to analyze the hepatic alterations that appeared following splenectomy in a series of 10 IM patients.…”

Allogeneic bone marrow transplantation for agnogenic myeloid metaplasia

“…Splenectomy can be proposed for symptomatic splenomegaly, but its high post-operative mortality and morbidity rates have undermined this procedure (Silverstein & ReMine, 1979;Malmaeus et al, 1986;Benbassat et al, 1990;Barosi et al, 1993). Currently, since none of these treatments has demonstrated any impact on the overall survival of these patients, they can only be considered as palliative.…”

Modern management of myelofibrosis

“…The reason for such an increase is not clear, but it has been speculated that a possible effect of splenectomy is to accelerate a pre-existing myeloid proliferation, since the procedure is not associated with a higher risk of acute leukaemia in healthy individuals. There are several reasons to consider splenectomy in IM, including symptomatic splenomegaly refractory to treatment, severe constitutional symptoms, uncontrollable haemolysis, transfusion-dependent anaemia unresponsive to therapy, portal hypertension secondary to increased portal flow, and marked thrombocytopenia (Benbassat et al, 1990;Barosi et al, 1993b;Lafaye et al, 1994;Tefferi et al, 2000). The benefits derived from splenectomy vary depending on the indication.…”