Yes ! Bertrand Godeau Centre de rfrence des cytopnies auto-immunes - PowerPoint PPT Presentation

CHU Henri MONDOR ASSISTANCE PUBLIQUE HÔPITAUX DE PARIS 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 bertrand.godeau@hmn.aphp.fr

• 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 ? Pro Con • Experience • Patients and physicians • Not reluctant … • Long term response ? expensive • Cure • Long term safety ? • Is it possible to predict the response (isotopic study ?)

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

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 Purpura Gregory Cheng 1* , Terry Gernsheimer, MD 2 , Harold J. Olney, MD, CM 3 , James B. Bussel, MD 4 , Palvi Shah 5* , Andres Brainsky 6* , Kelly M. Grotzinger 6* and Manuel Aivado 6 50% of relapse during the first yr

Complications of splenectomy • Infection • Malignancy ? • Vascular complications – Arteriothrombosis – Venous thrombosis – Cardiovascular events – Pulmonary hypertension

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

Risk for hospital contact with infection in patients with splenectomy. A population-based cohort study Thomsen et al , Ann Intern Med 2009; 151: 546-55 Splenectomized ITP Non splenectomized ITP Adjusted RR patients patients (95% CI) n = 269 n = 1345 Median days since 196 196 splenectomy indicated 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 11 (5.7) 59 (6.5) 1 (0.5-2) 100pt yr) > 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 study Thomsen 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 111 In-Labeled Platelet Sequestration Studies in Patients with Primary Immune Thrombocytopenia (ITP): A Report From the United Kingdom Registry Ameet Sarpatwari, M.Phil 1* , Drew Provan, MD 2* , Ravin Sobnack, PhD 3* , Sebhat Erqou, MD, M.Phil 4* , F. W. David Tai, BSc. 5* , Simon Sanderson, MD 4* and Adrian Newland, MD, FRCP 6

Don’t forget splenectomy !

Don’t forget splenectomy ? TPO-r agonists - Elderly - Contra-indication to splenectomy - severe comorbidities - Liver sequestration on isotopic study - Reluctant ? Splenectomy - Young patients - Splenic or hepato/splenic sequestration on isotopic study