Successful management of thrombocytopenia by partial splenic embolization in patients with advanced gastric cancer and invasion of the splenic vein: Case reports.

RATIONALE: Hypersplenism causes thrombocytopenia, which may lead to the reduction or discontinuation of chemotherapy. Partial splenic embolization (PSE) is an effective treatment for thrombocytopenia associated with hypersplenism. However, there have been no reports of patients with gastric cancer who have resumed and continued chemotherapy after PSE for splenic hypersplenism associated with tumor infiltration.Here, we report two cases in which we performed PSE for hypersplenism associated with gastric cancer that had invaded the splenic vein. Chemotherapy was continued in both cases. PATIENT CONCERNS: Both patients developed thrombocytopenia with splenomegaly due to advanced gastric cancer that required discontinuation of chemotherapy. DIAGNOSIS: Upper gastrointestinal endoscopy and computed tomography showed advanced gastric cancer with invasion of the splenic vein and splenomegaly. Both patients developed thrombocytopenia. INTERVENTIONS: Patients were treated with PSE. OUTCOMES: PSE produced an increase in thrombocyte count, and chemotherapy could be resumed. LESSONS: PSE seems to be a useful treatment for thrombocytopenia with splenomegaly associated with advanced gastric cancer and may allow continuation of chemotherapy.

Partial Splenic Embolization for Hypersplenism Associated with Steatohepatitis in a Hemodialysis Patient.

Hypersplenism (HS) is a disorder characterized by a triad of splenomegaly, peripheral cytopenia due to premature destruction of blood cells and normocellular bone marrow. Its etiology is diverse and includes (a) primary autoimmune cytopenias, (b) secondary to congestion due to portal hypertension in cirrhosis and, other causes such asperiportal fibrosis, infections, autoimmune diseases, lymphoproliferative disorders, infiltrative diseases and hemolytic anemias. The latter diseases are common in patients with end-stage kidney disease. In severe cases, co-existence of multiple co-morbid conditions, coagulopathy of uremia and dialysis-anticoagulation, and their immunosuppressive state render surgical splenectomy at highrisk. Mid-segment partial splenic infarction and with an aim at 50%-70% splenic volume loss was shown to be a less invasive therapy for HS. In our case report, we describe its first successful trial in a hemodialysis patient with severe HS due to cirrhosis.

Effect of partial splenic embolization on transarterial chemoembolization for hepatocellular carcinoma with hypersplenism.

ABSTRACT: This study retrospectively studied transarterial chemoembolization (TACE) combined with partial splenic embolization (PSE) in the treatment of hepatocellular carcinoma (HCC) with severe hypersplenism.Seventy patients with HCC in Barcelona Clinic Liver Cancer (BCLC) stage B or C with hypersplenism were divided into non-partial splenic embolization group (N-PSE, n = 51) and partial splenic embolization group (PSE, n = 19). The N-PSE group was further divided into N-PSE with mild to moderate hypersplenism (N-PSE-M, 47 cases) and N-PSE with severe hypersplenism (N-PSE-S, 4 cases).In the PSE group, leukocytes, neutrophils, lymphocytes, and platelets were significantly increased (P < .05) and were significantly different from that in the N-PSE group (P < .05). In the N-PSE group, except for a slight increase in neutrophils, other blood cells were decreased, including lymphocytes that were significantly decreased (P < .05). There was no significant difference in the changes of liver function between the 2 groups before and after surgery (P > .05). The analysis showed a significant increase in ascites after 6 months of TACE in the N-PSE group (P < .05). According to the follow-up results, the median overall survival (OS) in the PSE group was 24.47 ±â€Š3.68 (months) and progression-free survival (PFS) was 12.63 ±â€Š4.98 (months). Regardless of OS or PFS, the PSE group was superior to the N-PSE group and its subgroups, with a statistically significant difference in PFS between the N-PSE group and PSE group (P < .05). Moreover, the time of extrahepatic progression was significantly earlier in the N-PSE group than in the PSE group (P < .05). N-PSE-S group had the worst prognosis, and PFS and OS were worse than the other 2 groups, suggesting that PSE in severe hypersplenism may improve PFS and OS.In patients with HCC and severe hypersplenism, TACE should be actively combined with PSE treatment.

Bevacizumab Does Not Influence the Efficacy of Partial Splenic Embolization in the Management of Chemotherapy-Induced Hypersplenism.

BACKGROUND: Antiangiogenics attenuate chemotherapy-related hepatotoxicity and portal hypertension. The potential impact of bevacizumab on the efficacy and safety of partial splenic embolization (PSE) in the management of chemotherapy-induced hypersplenism (CIH) has never been investigated. PATIENTS AND METHODS: We conducted a retrospective study with gastrointestinal cancer patients who have undergone PSE for the treatment of thrombocytopenia resulting from hypersplenism. Pre- and post-PSE platelet count (PC), the percentage of patients who resumed systemic therapy, and complication rates were compared between patients exposed and not exposed to bevacizumab. RESULTS: A total of 110 patients were eligible. Colorectal cancer was the predominant neoplasm (60%), and 5-fluorouracil, oxaliplatin, and bevacizumab were the most commonly provided drugs (70%, 65%, and 65% of patients, respectively). After PSE, 80% of patients recovered PC ≥ 100 × 109/L (100K). Systemic therapy was resumed in 81% of patients. Seventy-one patients exposed to bevacizumab had a median PC before PSE of 77.5K and after PSE of 167.0K, with a mean difference of 108K (P < .0001). Thirty-nine patients not exposed to bevacizumab had a median PC of pre-PSE of 73.0K and post-PSE of 187.0K, with a mean difference of 117.7K (P < .0001). Both groups had similar values of percentages of patients with PC post-PSE ≥ 100K (83% vs. 74%; P = .463), resumption of systemic therapy (85% vs. 74%; P = .213), and complication rates. A linear association between splenic infarction rate and increment in PC was found (P < .0001). CONCLUSION: PSE is a safe and effective procedure in the management of CIH, regardless of the provision of bevacizumab. Splenic infarction rate should be optimized to enhance patient outcomes.

Durability of partial splenic artery embolization on platelet counts for cancer patients with hypersplenism-related thrombocytopenia.

PURPOSE: Partial splenic artery embolization (PSAE) has shown promise in increasing platelet counts in cancer patients with hypersplenism-related thrombocytopenia. The purpose of this study was to identify response predictors and to longitudinally evaluate PSAE efficacy and durability in a large cohort of cancer patients with hypersplenism-related thrombocytopenia. METHODS: A single-institution, IRB-approved, HIPAA-compliant retrospective review of all PSAEs for thrombocytopenia between 2012 and 2015 was performed. Patients were classified as complete responders (CR, no platelet value < 100 × 109/L following PSAE), partial responders (PR, initial increase in platelets but subsequent decrease in platelets < 100 × 109/L), and non-responders (NR, platelets never > 100 × 109/L following PSAE). RESULTS: Of the 98 patients included in the study, 58 had CR (59%), 28 had PR (29%), and 12 patients had NR (12%). The percent splenic tissue embolized was significantly greater in the CR group compared to the PR group (P = 0.001). The percent volume of splenic tissue embolized was linearly correlated with the magnitude of platelet increase without a minimum threshold. At least one line of chemotherapy was successfully restarted in 97% of patients, and 41% of patients did not experience recurrence of thrombocytopenia for the duration of their survival. The major complication rate was 8%, with readmission following initial hospitalization for persistent "post-embolization syndrome" symptoms the most common. CONCLUSIONS: In cancer patients with hypersplenism-related thrombocytopenia, PSAE is a safe intervention that effects a durable elevation in platelet counts across a range of malignancies and following the re-initiation of chemotherapy.

Refractoriness to red blood cell transfusion therapy due to hypersplenism.

BACKGROUND: A 55-year-old male presented with myelodysplastic/myeloproliferative neoplasm and severe splenomegaly. The patient is blood group O, D+ with a negative indirect antiglobulin test. Transfusion of 5 units of red blood cells (RBCs) increased the hemoglobin (Hb) level from 6.7 to 7.2 g/dL. No active bleeding or hemolysis was evident. The patient was readmitted 1 week later with a Hb level of 3.3 g/dL. An additional 6 units of RBCs showed only an increase from 3.3 to 3.5 g/dL. Partial splenic embolization was performed, which resulted in a stabilization of the Hb level at approximately 7 g/dL. Because of this, total splenectomy was performed, which resulted in a gradual increase in Hb level to approximately 13 g/dL. The patient remains transfusion independent 160 days postsplenectomy. RESULTS: RBC transfusion increases Hb concentration by 1 g/dL per unit in a typical adult. This increase is attenuated in the presence of ongoing hemolysis or active blood loss. Occasionally, a low-RBC-volume unit transfused to a recipient with a large intravascular blood volume may show an unexpectedly small increase. In rare situations, however, the etiology of a greatly attenuated response is more perplexing. The pattern of Hb concentration posttransfusion was suggestive of splenic sequestration in our patient. CONCLUSION: Severe refractoriness to RBC transfusion attributable to severe hypersplenism is a rare event. Our case suggests that splenic artery embolization may be a useful initial approach in individual cases and a potential predictor of the utility of a subsequent surgical splenectomy.

Partial splenic embolization in the treatment of prolonged thrombocytopenia due to hypersplenism in metastatic cancer patients.

BACKGROUND: Hypersplenism-related thrombocytopenia (HST) may delay or preclude chemotherapy. Partial splenic embolization (PSE) has been used at our center to overcome prolonged HST. PATIENTS AND METHODS: Between November 2012 and April 2015, 11 PSE procedures were performed in 10 patients; 9 had metastatic colorectal cancer and 1 had widespread pancreatic cancer. PSE was performed by selective catheterization of the splenic artery followed by injection of embolic particles, ranging from 300-700 um, until a 50% reduction in the splenic parenchyma blush was achieved. RESULTS: Splenomegaly was evaluated by splenic index, mean value 970 cm3 (range, 358-2277 cm3), normal mean 120-480 cm3. Mean platelet count immediately prior to PSE was 64.5 K/UL (range, 17-104 K/UL); within 10-14 days following the procedure, it increased to 224 K/UL (range, 83-669 K/UL). Only one patient's count remained less than 100 K/UL 2 weeks after embolization. After the procedure, all patients complained of mild abdominal pain that lasted for a few days; one patient developed post-embolization syndrome. No other significant complications were observed. Mean hospital stay was 2.5 days (range, 2-5 days). Chemotherapy was resumed 7-53 days (mean, 18 days) after the procedure in nine patients. One patient did not receive chemotherapy; he underwent local treatment of liver metastasis. Prolonged thrombocytopenia recurred in four patients, one of whom was successfully retreated by PSE. CONCLUSIONS: PSE can be considered as a treatment option for HST.

Successful Treatment of Hypersplenism in Wilson's Disease by Partial Splenic Embolization.

AIM: Hypersplenism can occur in patients with Wilson's disease (WD). Surgical splenectomy is a conventional treatment for this condition; however, emotional and neurological deterioration may follow splenectomy. In recent years, partial splenic embolization (PSE) has been increasingly performed as a nonsurgical alternative treatment for hypersplenism. The aim of this study was to evaluate the effectiveness and safety of PSE compared with splenectomy in the treatment of hypersplenism in WD patients. METHODS: Fifty WD patients with hypersplenism were randomly divided into two groups (group A and group B), each including 25 patients. Patients in groups A and B were treated with PSE and splenectomy, respectively. Data were collected on the clinical efficacy of each procedure, adverse reactions, hematologic and blood chemistry test results, and abdominal computed tomography (CT) scan findings (group A only). RESULTS: Marked improvements in the platelet and leukocyte counts after PSE and splenectomy were observed in all patients. PSE was associated with improved liver function without severe complications, and no significant changes in emotional and neurological symptoms were observed. In contrast, seven WD patients suffered neurological deterioration after splenectomy. CONCLUSIONS: Hypersplenism in WD patients was successfully treated by PSE, which appears to be a safe and effective alternative treatment for WD-induced hypersplenism.

[Utility of Partial Splenic Embolization Prior to Lung Resection in Patients Demonstrating Platelet Transfusion Refractoriness Due to Hypersplenism].

It is often difficult to control perioperative bleeding in patients with liver cirrhosis and concurrent thrombocytopenia and coagulation factor deficiency. Partial splenic embolization (PSE), an auxiliary treatment strategy in management of liver cirrhosis and hepatocellular carcinoma, can not only increase platelets but also improve liver function. With advances in interventional radiology, PSE is a safer and more reliable procedure compared to a splenectomy. We present the case of a 69-year-old man diagnosed with left lung cancer, with thrombocytopenia, and hepatitis C virus-related cirrhosis. Although he was administered prophylactic platelet transfusion prior to operation, he was noted to be refractory to platelet transfusion. PSE was performed to improve his thrombocytopenia, following which we could safely perform left upper lobectomy of the lung and ND2a-1 lymph node dissection without any major bleeding. PSE is useful induction therapy to provide a wider choice of treatment options for patients with thrombocytopenia.

Klippel-Trenaunay-Weber syndrome with atypical presentation of hypersplenism and nephrotic syndrome: a case report.

BACKGROUND: Klippel-Trenaunay-Weber syndrome is a rare syndrome; unfortunately, very few studies of the connection between hypersplenism, nephrotic syndrome, and Klippel-Trenaunay-Weber syndrome have been published. CASE PRESENTATION: We report the case of a 40-year-old white man with a typical clinical presentation of Klippel-Trenaunay-Weber syndrome, including "port-wine stains," varicose veins, hypertrophy of lower extremities, and arteriovenous fistula, as well as an unfortunate development of hypersplenism and nephrotic syndrome. CONCLUSIONS: This case report described considerable atypical relevance of Klippel-Trenaunay-Weber syndrome and hypersplenism together with nephrotic syndrome. A multidisciplinary approach was made. Unfortunately, hypersplenism is characterized by pancytopenia that suggests splenectomy, whereas nephrotic syndrome is an indication for renal biopsy; the splenectomy and renal biopsy were delayed due to our patient's severe condition. Deeper analysis including study of other patients with Klippel-Trenaunay-Weber syndrome would help us to understand the connection between elevated spleen and liver sizes, nephrotic syndrome, and Klippel-Trenaunay-Weber syndrome.

Treatment of Hypersplenism by Partial Splenic Embolization Through Gastric Collaterals.

We report a case of Chronic lymphocytic leukemia (CLL) with associated hypersplenism, that was referred to us for partial splenic embolization (PSE) as the patient was not a surgical candidate for splenectomy. Initially, we were not successful in catheterizing the splenic artery from the celiac trunk due to significant atherosclerotic disease. Therefore, we successfully managed to access the distal splenic artery through patent gastro-epiploic collateral circulation along the greater curvature of the stomach. Partial splenic embolization was successfully performed and resulted in improvement of the patient's peripheral blood cell count as well as 60-70% reduction in the size of the spleen on follow up. Our case highlights an alternative pathway for splenic artery embolization when catheterization of the splenic artery is not feasible. To our knowledge, the use of gastro-epiploic collaterals to embolize the spleen has not been previously reported in literature.

A Comparative Study of Surgical Splenectomy, Partial Splenic Embolization, and High-Intensity Focused Ultrasound for Hypersplenism.

OBJECTIVES: This study compared splenectomy, partial splenic embolization, and high-intensity focused ultrasound (HIFU) therapy, which represent the traditional, mature, and newest methods for improving thrombocytopenia in hypersplenism, respectively. METHODS: A total of 69 patients with hypersplenism were treated with surgical splenectomy (n = 31), HIFU (n = 26), or partial splenic embolization (n = 12). They were followed closely for at least 6 months, and the effectiveness of the treatments was compared. RESULTS: Among the 3 groups, splenectomy was the most effective treatment for increasing peripheral blood cells. Embolization reduced the operating time and hospital stay, but HIFU was relatively safer and less invasive than the other treatments. CONCLUSIONS: High-intensity focused ultrasound has wide clinical indications for hypersplenism and may be safer than other treatment methods. Therefore, it is a good alternative procedure for patients with a high surgical risk.

An innovative modification of sandwich embolization technique for simultaneous management of ruptured pseudoaneurysm of branch of splenic artery and hypersplenism syndrome.

Pancreatitis induced ruptured pseudoaneurysm (PSA) of the peri-pancreatic and splenic arteries may become a source of life-threatening hemorrhage. Its management is challenging and requires an individualized and multidisciplinary approach. The index case is a 32-year-old chronic alcoholic male presented with multiple episodes of hematemesis and melena. Pathological and imaging findings were consistent with anemia and acute pancreatitis with ruptured PSA of branch of splenic artery, portal cavernoma formation, and splenomegaly. Thrombosis of PSA sac, embolization of offending branch of splenic artery, and splenic infarction were successfully contemplated in a single session by direct percutaneous embolization with gelfoam and glue as embolic agents under guidance of duplex ultrasound imaging. We describe a modified sandwich embolization technique, its long-term success and complications of simultaneous management of ruptured PSA of branch of splenic artery and hypersplenism syndrome in limited resource scenario.

Big spleens and hypersplenism: fix it or forget it?

Hypersplenism is a common manifestation of portal hypertension in the cirrhotic. More than half of cirrhotics will have low platelet counts, but neutropenia is much less common. Despite being common in the cirrhotic population, the presence of hypersplenism is of little clinical consequence. The presence of hypersplenism suggests more advanced liver disease and an increase in risk of complications, but there is no data showing that correcting the hypersplenism improves patient survival. In most series, the most common indications for treating the hypersplenism is to increase platelet and white blood cell counts to allow for use of drugs that suppress the bone marrow such as interferon alpha and chemotherapeutic agents. There are several approaches used to treat hypersplenism. Portosystemic shunts are of questionable benefit. Splenectomy, either open or laparoscopically, is the most effective but is associated with a significant risk of portal vein thrombosis. Partial splenic artery embolization and radiofrequency ablation are effective methods for treating hypersplenism, but counts tend to fall back to baseline long-term. Pharmacological agents are also effective in increasing platelet counts. Development of direct acting antivirals against hepatitis C will eliminate the most common indication for treatment. We lack controlled trials designed to determine if treating the hypersplenism has benefits other than raising the platelet and white blood cell counts. In the absence of such studies, hypersplenism in most patients should be considered a laboratory abnormality and not treated, in other words forget it.

Selective splenic artery embolization for the treatment of thrombocytopenia and hypersplenism in paroxysmal nocturnal hemoglobinuria.

BACKGROUND: PNH is associated with abdominal vein thrombosis, which can cause splenomegaly and hypersplenism. The combination of thrombosis, splenomegaly, and thrombocytopenia (TST) is challenging because anticoagulants are indicated but thrombocytopenia may increase the bleeding risk. Splenectomy could alleviate thrombocytopenia and reduce portal pressure, but it can cause post-operative thromboses and opportunistic infections. We therefore sought to determine whether selective splenic artery embolization (SSAE) is a safe and effective alternative to splenectomy for TST in patients with PNH. METHODS: Four patients with PNH and TST received successive rounds of SSAE. By targeting distal vessels for occlusion, we aimed to infarct approximately 1/3 of the spleen with each procedure. RESULTS: Three of 4 patients had an improvement in their platelet count, and 3 of 3 had major improvement in abdominal pain/discomfort. The one patient whose platelet count did not respond had developed marrow failure, and she did well with an allo-SCT. Post-procedure pain and fever were common and manageable; only one patient developed a loculated pleural effusion requiring drainage. One patient, who had had only a partial response to eculizumab, responded to SSAE not only with an improved platelet count, but also with an increase in hemoglobin level and decreased transfusion requirement. CONCLUSIONS: These data indicate that SSAE can decrease spleen size and reverse hypersplenism, without exposing the patient to the complications of splenectomy. In addition, SSAE probably reduces the uptake of opsonised red cells in patients who have had a limited response to eculizumab, resulting in an improved quality of life for selected patients.

[Splenic embolization combined with double-mirror method in treatment of cirrhosis with hypersplenism of advanced schistosomiasis patients: a report of 38 cases].

A total of 38 patients with schistosomiasis cirrhosis complicated with hypersplenism were cured by endoscopic variceal ligation (EVL), partial splenic embolization (PSE) and laparoscopic splenectomy (LS). After the surgery, the hemogram and liver function of all the patients recovered within two weeks. The average hospitalization time was shorter, the average hospitalization expense was less, and the complications were also less compared with those of the patients who received the routine therapy. In conclusion, the combination therapy of EVL and PSE combined with LS is effective and safe in the treatment of schistosomiasis cirrhosis complicated with hypersplenism.

Experimental studies and clinical experiences on treatment of secondary hypersplenism with extracorporeal high-intensity focused ultrasound.

The aim of this study is to investigate the efficacy and safety of extracorporeal high-intensity focused ultrasound (HIFU) in treatment of hypersplenism. Fifteen adult dogs, weighing 13-18 kg were divided into three groups: sham group, SVL group undergoing splenic vein ligation (SVL) after laparotomy, and SVL + HIFU group receiving SVL followed by extracorporeal HIFU. Pathologic and hematologic analyses were performed. We also reviewed the clinical data of 19 patients with secondary hypersplenism caused by liver cirrhosis or hepatocellular carcinoma who underwent extracorporeal HIFU. Extracorporeal HIFU significantly diminished the volume of the spleen of animals, coupled with occurrence of coagulation necrosis and fibrosis in the target area. Both platelet and red blood cell counts were significantly restored by HIFU intervention. Similarly, HIFU treatment improved the hematologic parameters in patients with hypersplenism, and no major complications were encountered. Extracorporeal HIFU intervention is effective and safe in managing secondary hypersplenism.

Splenic artery embolization as a treatment option for chronic pancytopenia secondary to hypersplenism: a case report and review of literature.

It is well known that splenectomy is the standard of care in the management of clinically significant hypersplenism; however, some patients are found to be unacceptably high risk to tolerate open or even laparoscopic surgery. We present a 62-year-old female with significant comorbidities who was declared a very high risk for any open surgical intervention. She underwent splenic artery embolization with remarkable improvement of her platelet count. Her postoperative course was uneventful and the patient was discharged from the hospital on the fifth hospital day.

Role of splenic artery partial embolization in a patient with portal hypertension and pancytopenia undergoing hysterectomy under anesthesia.

Management of a patient with portal hypertension and hypersplenism who is scheduled for elective surgery is a challenge for anesthesia providers. We report a case that was scheduled for elective surgery in which preoperative splenic artery embolization improved the hematologic parameters. A 32-year-old woman was scheduled for total abdominal hysterectomy for multiple fibroids and menorrhagia with pancytopenia. She also had diagnoses of chronic liver disease with cirrhotic changes, portal hypertension, and grade IV Manageesophageal varices with hepatosplenomegaly. In view of pancytopenia, splenic artery partial embolization was done preoperatively. Her hematologic parameters improved, and she underwent surgery under general anesthesia with intrathecal morphine analgesia, uneventfully. The condition of patients with portal hypertension with associated hypersplenism and pancytopenia who are scheduled for elective surgery can be optimized with preoperative partial splenic artery embolization.