The site of destruction of autologous ¹¹¹In‐labelled platelets and the efficiency of splenectomy in children and adults with idiopathic thrombocytopenic purpura: a study of 578 patients with 268 splenectomies

Abstract

Summary.The indication for splenectomy in chronic idiopathic thrombocytopenic purpura (ITP) remains a controversial subject. The mortality rate of persistent thrombocytopenia is very low, except in severe cases. Conversely, the risks of splenectomy are significant (in the present series, morbidity: 4 . 1% mortality: 1 . 4%), with a success rate of only 60-75%. It is therefore useful to define a parameter able to predict the efficacy or failure of splenectomy.An analysis of 578 cases of chronic ITP, where the site of platelet destruction has been determined, is presented. 268 of these cases had been splenectomized. When platelet destruction was splenic, 96% of subjects aged 5-30 years and 91% of cases over the age of 30 years obtained a remission. Conversely, when platelet destruction was hepatic or diffuse, failure or incomplete results were observed in 92% of cases. The site of platelet destruction therefore constitutes a parameter which can help the clinician to make the decision to perform splenectomy.Keywords: thrombocytopenic purpura, platelet kinetics, site of platelet sequestration, splenectomy.We have previously reported a correlation between the site of platelet destruction and the efficacy of splenectomy in 222 cases of idiopathic thrombocytopenic purpura (ITP), 103 of whom underwent splenectomy (Najean et al, 1991). Our conclusions concerning children were criticized at that time, more because of the surgical indications (which were considered to be excessive) than for the actual isotope study (Reid, 1992). Only one similar study has since been published, confirming the predictive value of the method in 51 cases (Lamy et al, 1993). In a recent retrospective study (George et al, 1996), which proposed a practice guideline for diagnosis and treatment of ITP, isotopic assessment was only briefly considered as a measurement of platelet life-span for diagnostic purposes, but not for determination of the site of destruction as an aid to therapeutic decisions.At the time of writing, 578 cases of chronic ITP have undergone a kinetic study of autologous platelets labelled with 111 Indium-oxinate, 268 of whom have been splenectomized. PATIENTS AND METHODSAll of the cases studied (103 children aged 5-15 years, 146 adolescents or young adults aged 15-30 years, and 329 cases over the age of 30 years) had clinically documented thrombocytopenic purpura which could be considered to be idiopathic (systemic lupus erythematosus, viral infection, especially by HIV, lymphoma, and, in the elderly, myelodysplasia, were eliminated). Cases of genetic chronic thrombocytopenia due to a production defect were excluded. These cases of ITP were chronic, and had symptoms present for at least 6 months. We did not investigate pregnant women or very young children. The sex ratio in each age-group showed the same female predominance (M=F ¼ 0 : 6).Almost all patients had been previously treated (corticosteroids, immunoglobulins, danazol, and, in rare cases, azathioprine or vincristine). At the time of the isotope study, one half of the c...

Romiplostim safety and efficacy for immune thrombocytopenia in clinical practice: 2-year results of 72 adults in a romiplostim compassionate-use program

“…However, conflicting results have been reported regarding the value of this complementary investigation to predict splenectomy outcome. 18,19 Future studies focusing on the predictive value of platelet-longevity scintigraphy may help determine better whether a patient could benefit from romiplostim before undergoing splenectomy.…”

Does treatment with intermittent infusions of intravenous anti-D allow a proportion of adults with recently diagnosed immune thrombocytopenic purpura to avoid splenectomy?

“…However, although both the site of platelet destruction and the response to intravenous immunoglobulin (IVIG) have been suggested to predict response to splenectomy, there is no universally acknowledged way to predict which patients will respond. [12][13][14][15][16] Patients are often reluctant to be exposed to the inherent risks of surgery and the small but significant risk of overwhelming sepsis after splenectomy without a guarantee of success. 17,18 Because the standard of practice has been to perform early splenectomy in steroid nonresponders, little is known of the natural history of those patients who do not go into early remission.…”

Management of Idiopathic Thrombocytopenic Purpura in Adult: A Review Article

“…Various indicators of the likely response to splenectomy have been reviewed including response to oral steroids, which has a low predictive value, response to high dose IVIg which, in two small series, correlated well with response to splenectomy l5 , and indium-labelled autologous platelet scanning which appears to be the most sensitive predictor of response to splenectomy, to date 16 . Accessory splenic tissue.…”