Splenic RT

[Haybrant]

Im being referred a patient with transfusion dependent MDS/MPD (hgb hangs out bt 6-8), hes been on hydroxyurea for 8-10 months then presented with enlarging spleen with significant abd pain. Was switched to dacitabine with some improvement in counts but no change in splenic size. His oncologist is requesting consideration of splenic RT. Current Hgb is 8.6 but his platelets are 35.

Is pre RT platelet count of 35 a contraindication? Ive seen a few RT schedules used, just want to see if anyone has experience here. Do you check blood counts prior to each treatment? Thank you

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[Palex80]

Yes, we regularly check, depending on the schedule you are going to use I would certainly do it before the first couple of sessions.
35 is not a contraindication, we have treated patients with lower counts.

Abdominal pain is a good indication, you can try RT. We have had a few patients who underwent a second course of treatment 9-12 months later, remission after RT sometimes is not durable.

 

[Haybrant]

thanks palex, that schedule did you use? I saw 0.5 Gy twice a week as one option or an escalating dose over 3 weeks, twice a week. Also, if you get labs are you just looking for anemia and transfusing for hgb below a certain number? Anything else to consent for beyond fatigue/cytopenias? Thanks

 

[Palex80]

0.5 Gy twice a week up to 3 Gy is an viable option. I have seen colleagues doing 0.3 Gy per fraction as well.

Im only looking for anemia and thrombocytopenia. We have a big hematology department over here and they take care of them.

These patients generally have chronic anemia anyhow and the cutoff value to transfuse them depends on patient risk factors. Hb lower than 70 g/l generally means transfusion. With a history of strokes / ischemic cardiac disease or in patients over the age of 75 the cutoff is higher at 80 g/l.
Thrombocytopenia is the main concern here. My hematologist colleagues generally do not transfuse any of these patients, unless the are bleeding because of low counts and they would give platelets if the patients presents with fever with a cutoff of 20.

I have read that a low dose rate is advised to minimize nausea. We treat at 200 MU/min.

 

[Mandelin Rain]

I'm about to embark on a course of splenic XRT for autoimmune hemolytic anemia. Not for palliation of splenomegaly, but rather to replace splenectomy.

Any suggests on dose/fractionation for such a patient? I was going to take her higher than 3Gy.

 

[Palex80]

I'm about to embark on a course of splenic XRT for autoimmune hemolytic anemia. Not for palliation of splenomegaly, but rather to replace splenectomy.
Any suggests on dose/fractionation for such a patient? I was going to take her higher than 3Gy.

Oh my... That's rather adventurous. Is there any data supporting this approach?

Provided that the autoimmune hemolytic anemia is caused by a clone of plasma cells which are producing the wrong antibodies and they are all in the spleen?
2 x 2 Gy may be effective?

 

[Krukenberg]

I'm about to embark on a course of splenic XRT for autoimmune hemolytic anemia. Not for palliation of splenomegaly, but rather to replace splenectomy.

Any suggests on dose/fractionation for such a patient? I was going to take her higher than 3Gy.

Do you mean hereditary spherocytosis? Standard of care is splenectomy


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[Palex80]

Do you mean hereditary spherocytosis? Standard of care is splenectomy


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I believe he is referring to ITP (immune thrombocytopenic purpura).

Immune thrombocytopenic purpura - Wikipedia

And indeed there is some limited data available on radiaton therapy for this...

Splenic radiation for corticosteroid-resistant immune thrombocytopenia. - PubMed - NCBI

The dose range is "interesting"...

 

[Haybrant]

This study worries me from Mayo - the rates of life-threatening cytopenia after a single course was 26% (6 of 23 pts) and fatal sepsis hemorrhage in 3 patients (13%). Their mean dose per fraction was around 30 cGy up to 2.1 Gy.

Splenic irradiation for symptomatic splenomegaly associated with myelofibrosis with myeloid metaplasia - Elliott - 2002 - British Journal of Haematology - Wiley Online Library

Any thoughts on this, seems really high rate of complication from just a single dose?

Also what's the threshold to transfuse? Do you try to keep them above 8?

 

[Palex80]

There is no threshold to give platelets to a non-bleeding, non-feverous patient.

 

[medgator]

There is no threshold to give platelets to a non-bleeding, non-feverous patient.

I think most people would give platelets to someone with a count of 10K here

 

[Mandelin Rain]

I believe he is referring to ITP (immune thrombocytopenic purpura).

Immune thrombocytopenic purpura - Wikipedia

And indeed there is some limited data available on radiaton therapy for this...

Splenic radiation for corticosteroid-resistant immune thrombocytopenia. - PubMed - NCBI

The dose range is "interesting"...

She is an elderly lady with refractory autoimmune hemolytic anemia, currently requiring large doses of steroid and transfusion to keep her Hgb above 6. Most of these people go for splenectomy, but she is high-risk for surgery. There isn't much on radiation for this disease. The spleen is the chief site of extravascular hemolysis and is an important site of antibody production. I guess that is the mechanism by which it works. I'm assuming it's similar for ITP, though I'm not going to pretend to be expert in either disease.

Splenic irradiation in treating warm autoimmune haemolytic anaemia. - PubMed - NCBI
Remission of autoimmune hemolytic anemia associated with chronic lymphocytic leukemia following splenic irradiation. - PubMed - NCBI

 

[Haybrant]

I think most people would give platelets to someone with a count of 10K here

For Hgb though?

 

[medgator]

For Hgb though?

Prob not unless symptomatic, or maybe if cardiac risk factors?