Splenic irradiation for splenomegaly: A systematic review

Multicenter phase II study of moderate low-dose radiotherapy in indolent non-Hodgkin lymphoma: CLCG-iNHL-01 protocol

Background: Radiotherapy is an effective treatment for indolent non-Hodgkin lymphoma (iNHL); however, the optimal radiotherapy dose remains to be determined. We hypothesize that a suitable dose may exist between 4 and 24 Gy. Methods: This prospective multicenter phase II trial intends to recruit 73 sites of iNHL patients, who will receive involved-site radiotherapy of 12 Gy in four fractions. The primary objective is the 6-month clinical complete response rate. Tumor tissue, blood and conjunctival specimens will be collected to identify potential predictive biomarkers. Discussion: The CLCG-iNHL-01 trial will evaluate the efficacy and toxicity of 12 Gy in patients with iNHL and provide information on a novel hypofractionation regimen of low-dose radiotherapy. Clinical Trial Registration: NCT05543070 (ClinicalTrials.gov).

Extreme environments and human health: From the immune microenvironments to immune cells

Exposure to extreme environments causes specific acute and chronic physiological responses in humans. The adaptation and the physiological processes under extreme environments predominantly affect multiple functional systems of the organism, in particular, the immune system. Dysfunction of the immune system affected by several extreme environments (including hyperbaric environment, hypoxia, blast shock, microgravity, hypergravity, radiation exposure, and magnetic environment) has been observed from clinical macroscopic symptoms to intracorporal immune microenvironments. Therefore, simulated extreme conditions are engineered for verifying the main influenced characteristics and factors in the immune microenvironments. This review summarizes the responses of immune microenvironments to these extreme environments during in vivo or in vitro exposure, and the approaches of engineering simulated extreme environments in recent decades. The related microenvironment engineering, signaling pathways, molecular mechanisms, clinical therapy, and prevention strategies are also discussed.

Advances in management of primary myelofibrosis and polycythaemia vera: Implications in clinical practice

Primary myelofibrosis (PMF) and polycythaemia vera (PV) are rare BCR-ABL1-negative myeloproliferative neoplasms, associated with an increased risk of thrombosis, haemorrhagic complications and progression to fibrosis or leukaemia or fibrosis for PV. Both diseases are characterised by biological and clinical heterogeneity, leading to great variability in their management in routine clinical practice. In this review, we present an updated overview of the diagnosis, prognosis and treatment of PMF and PV, and we discuss how our multidisciplinary expert group based across France translates this evidence-based knowledge into routine clinical practice.

Splenomegaly in patients with primary or secondary myelofibrosis who are candidates for allogeneic hematopoietic cell transplantation: a Position Paper on behalf of the Chronic Malignancies Working Party of the EBMT

Splenomegaly is a hallmark of myelofibrosis, a debilitating haematological malignancy for which the only curative option is allogeneic haematopoietic cell transplantation (HCT). Considerable splenic enlargement might be associated with a higher risk of delayed engraftment and graft failure, increased non-relapse mortality, and worse overall survival after HCT as compared with patients without significantly enlarged splenomegaly. Currently, there are no standardised guidelines to assist transplantation physicians in deciding optimal management of splenomegaly before HCT. Therefore, the aim of this Position Paper is to offer a shared position statement on this issue. An international group of haematologists, transplantation physicians, gastroenterologists, surgeons, radiotherapists, and radiologists with experience in the treatment of myelofibrosis contributed to this Position Paper. The key issues addressed by this group included the assessment, prevalence, and clinical significance of splenomegaly, and the need for a therapeutic intervention before HCT for the control of splenomegaly. Specific scenarios, including splanchnic vein thrombosis and COVID-19, are also discussed. All patients with myelofibrosis must have their spleen size assessed before allogeneic HCT. Myelofibrosis patients with splenomegaly measuring 5 cm and larger, particularly when exceeding 15 cm below the left costal margin, or with splenomegaly-related symptoms, could benefit from treatment with the aim of reducing the spleen size before HCT. In the absence of, or loss of, response, patients with increasing spleen size should be evaluated for second-line options, depending on availability, patient fitness, and centre experience. Splanchnic vein thrombosis is not an absolute contraindication for HCT, but a multidisciplinary approach is warranted. Finally, prevention and treatment of COVID-19 should adhere to standard recommendations for immunocompromised patients.

Prophylactic Splenectomy and Hyposplenism in Spaceflight

BACKGROUND: There is debate whether astronauts traveling to space should undergo a prophylactic splenectomy prior to long duration spaceflight. Risks to the spleen during flight include radiation and trauma. However, splenectomy also carries significant risks.METHODS: Systematic review of data published over the past 5 decades regarding risks associated with splenectomies and risks associated with irradiation to the spleen from long duration spaceflight were analyzed. A total of 41 articles were reviewed.RESULTS: Acute risks of splenectomy include intraoperative mortality rate (from hemorrhage) of 3-5%, mortality rate from postoperative complications of 6%, thromboembolic event rate of 10%, and portal vein thrombosis rate of 5-37%. Delayed risks of splenectomy include overwhelming postsplenectomy infection (OPSI) at 0.5% at 5 yr post splenectomy, mortality rate as high as 60% for pneumococcal infections, and development of malignancy with relative risk of 1.53. The risk of hematologic malignancy increases significantly when individuals reach 40 Gy of exposure, much higher than the 0.6 Gy of radiation experienced from a 12-mo round trip to Mars. Lower doses of radiation increase the risk of hyposplenism more so than hematologic malignancy.CONCLUSION:For protection against hematologic malignancy, the benefits of prophylactic splenectomy do not outweigh the risks. However, there is a possible risk of hyposplenism from long duration spaceflight. It would be beneficial to prophylactically provide vaccines against encapsulated organisms for long duration spaceflight to mitigate the risk of hyposplenism.Siu M, Levin D, Christiansen R, Kelly E, Alouidor R, Kamine TH. Prophylactic splenectomy and hyposplenism in spaceflight. Aerosp Med Hum Perform. 2022; 93(12):877-881.

Spleen as an organ at risk in adjuvant chemoradiotherapy for gastric cancer: a retrospective dosimetric study

Introduction:

This study aimed to determine the radiation dose to the spleen in adjuvant chemoradiotherapy for gastric cancer, resulting in haematological toxicities.

Methods:

This retrospective analysis of a prospectively maintained database was conducted at a tertiary referral cancer centre. All patients with biopsy-proven non-metastatic gastric adenocarcinoma planned for adjuvant chemoradiotherapy from January 2017 to December 2021 were included. The mean dose to the spleen (Dmean) was estimated and correlated with the development of haematological toxicities.

Results:

The mean spleen volume was 186·65 cc. The Dmean to the spleen was 35·35 Gy (20–42 Gy). Grade 3 leukopenia was observed in 67%, grade 4 in 15%, and grade 3 thrombocytopenia was noted in 41% of patients. Radiotherapy (RT) dose > 35·5 Gy to the spleen resulted in ≥ grade 3 leukopenia. RT dose ≥ 36·5 Gy resulted in grade 3 thrombocytopenia. The occurrence of leukopenia and thrombocytopenia was also affected by the location of the primary gastric cancer (higher incidence in distal than in proximal tumours).

Conclusion:

The spleen should be considered as an important organs at risk during adjuvant RT for gastric cancer. Dmean to the spleen should be < 35·5 Gy to prevent major haematological toxicities.

Pre-transplant Splenic Irradiation in Patients with Myeloproliferative Neoplasms

Purpose

Allogeneic hematopoietic cell transplantation (HCT) serves as the only curative treatment option for patients with myelofibrosis and other myeloproliferative neoplasms. Splenomegaly commonly manifests in patients with myeloproliferative neoplasms and can lead to delayed or poor engraftment, increased transfusion burden, and worse survival. Methods to decrease the effect of splenomegaly include splenectomy and splenic irradiation. We sought to report on clinical outcomes for patients treated with splenic irradiation as part of their transplant conditioning.

Methods and Materials

Patients with splenomegaly measuring greater than 22 cm were referred for splenic irradiation. They received radiation to the entire spleen to 10 Gy in 5 fractions using 3-dimensional conformal radiation with anteroposterior/posteroanterior or opposed tangent fields. Blood counts were monitored closely on treatment. Changes in splenic size were measured using first and last treatment image guided radiation therapy and pre- and posttransplant diagnostic imaging.

Results

Seventeen patients completed pretransplant splenic irradiation between 2012 and 2021. Median platelet, white blood cell, and hemoglobin levels decreased on treatment. One patient required platelet transfusion and 3 required packed red blood cell transfusions. Mean decrease in spleen size during radiation was -8.5% in the craniocaudal dimension. Prolonged decreases, measured 2 to 12 months after transplant, averaged 14.64%. All patients engrafted. Fourteen (82.4%) were alive at time of analysis with median follow-up of 4.2 years from hematopoietic cell transplantation.

Conclusions

Splenic irradiation offers a safe method of managing significant splenomegaly as part of transplant conditioning. Transplant outcomes in this series were excellent. Prospective data may be beneficial to determine the absolute benefit of this addition to pretransplant conditioning in this patient population.

Giant spleen as a surgical challenge: Case report and literature review

Introduction. According to the guidelines of the European Association of Endoscopic Surgery (EAES), any case where the maximum craniocaudal splenic diameter exceeds 20 cm is considered as massive splenomegaly. In addition to metabolic, hematological, and hemodynamic problems enlarged spleen may cause mechanical difficulties due to the pressure to surrounding organs and vascular structures. The aim of this paper is to present the surgical challenges and technique applied in massive splenomegaly, in a patient who had neglected the importance of regular medical checkups. Case outline. We present a 62-year-old male patient who was admitted to hospital for treatment of previously clinically and radiologically verified splenomegaly but who neglected the importance of regular checkups and medical treatment. Splenectomy was performed with splenic specimen 38 cm in its maximal diameter. Conclusion. Taking into consideration all the possible benefits and possible complications of surgical treatment, including the quality of life of splenectomized patients, comprehensive preoperative assessment should be made, and surgical treatment selectively applied.

Extramedullary hematopoiesis in myeloproliferative neoplasms: Pathophysiology and treatment strategies

Extramedullary hematopoiesis (EMH) is often a physiologic response to ineffective marrow production of hematologic cells. While this can be found incidentally in various physiologic and pathophysiologic states, the myeloproliferative neoplasms (MPNs) are some of the most common underlying conditions found in patients with EMH. Although this process can assist with hematologic production in defective states, the burden of EMH can lead to symptomatic discomfort and mechanical obstructive complications, most commonly in the spleen and liver. Here we describe the pathophysiology of EMH, treatment options, including medical, surgical and radiation-based approaches.

Radiation therapy-associated toxicity: Etiology, management, and prevention

Radiation therapy (RT) is a curative treatment for many malignancies and provides effective palliation in patients with tumor-related symptoms. However, the biophysical effects of RT are not specific to tumor cells and may produce toxicity due to exposure of surrounding organs and tissues. In this article, the authors review the clinical context, pathophysiology, risk factors, presentation, and management of RT side effects in each human organ system. Ionizing radiation works by producing DNA damage leading to tumor death, but effects on normal tissue may result in acute and/or late toxicity. The manifestation of toxicity depends on both cellular characteristics and affected organs' anatomy and physiology. There is usually a direct relationship between the radiation dose and volume to normal tissues and the risk of toxicity, which has led to guidelines and recommended dose limits for most tissues. Side effects are multifactorial, with contributions from baseline patient characteristics and other oncologic treatments. Technological advances in recent decades have decreased RT toxicity by dramatically improving the ability to deliver RT that maximizes tumor dose and minimizes organ dose. Thus the study of RT-associated toxicity is a complex, core component of radiation oncology training that continues to evolve alongside advances in cancer management. Because RT is used in up to one-half of all patients with cancer, an understanding of its acute and late effects in different organ systems is clinically pertinent to both oncologists and nononcologists.

Protective effect of acute splenic irradiation in rats with traumatic brain injury

OBJECTIVE

To explore the protective effect of acute splenic irradiation against traumatic brain injury (TBI) in rats.

METHODS

A rat model of TBI was established according to Feeney's method. Splenic irradiation was performed by the reverse intensity-modulated radiation therapy (IMRT) source-axis distance (SAD) irradiation technique. Rat brain tissue samples were collected, the water content of the rat brain tissue was determined and the abundance of microglia was detected by immunofluorescence. Spleens were collected to measure the spleen index. Lung, liver, small intestine and kidney tissues were taken for hematoxylin and eosin staining to observe whether there was radiation-induced pathological damage. Peripheral blood was collected to detect tuftsin and the inflammatory factors IL-6 and IL-10.

RESULTS

Compared with the nonirradiated TBI rat group, the 4-h spleen irradiation TBI rat group showed (1) increased behavioral scores at 3 days after TBI (P  < 0.05), (2) reduced water content of the ipsilateral hemisphere at 3 days after TBI, (3) reduced spleen index at 3 and 7 days after TBI, (4) reduced number of microglia cells infiltrating around the lesion at 7 days after TBI, (5) reduced IL-6 levels at 3 days after TBI, (6) increased IL-10 levels at 3 and 5days after TBI and (7) Compared with the nonirradiated TBI rat group, the 8-h spleen irradiation TBI rat group showed reduced tuftsin levels at 3 and 7days after TBI.

CONCLUSIONS

Acute splenic irradiation had a protective effect in rats with TBI.

Dosimetric accuracy of dual isocenter irradiation in low magnetic field resonance guided radiotherapy system for extended abdominal tumours

PURPOSE

Due to limited field size of Magnetic Resonance Linear Accelerators (MR-Linac), some treatments could require a dual-isocenter planning approach to achieve a complete target coverage and thus exploit the benefits of the online adaptation. This study evaluates the dosimetric accuracy of the dual-isocenter intensity modulated radiation therapy (IMRT) delivery technique for MR-Linac.

MATERIAL AND METHODS

Dual-isocenter multi leaf collimator (MLC) and couch accuracy tests have been performed to evaluate the delivery accuracy of the system. A mono-isocenter plan delivered in clinical practice has then been retrospectively re-planned with dual-isocenter technique. The dual-isocenter plan has been re-calculated and delivered on a 3-dimensional (3D) ArcCHECK phantom and 2-dimensional (2D) films to assess its dosimetric accuracy in terms of gamma analysis. Clinical and planning target volume (CTV and PTV respectively) coverage robustness was then investigated after the introduction of ± 2 mm and ± 5 mm positioning errors by shifting the couch.

RESULTS

MLC and couch accuracy tests confirmed the system accuracy in delivering a dual-isocenter irradiation. 2D/3D gamma analysis results occurred always to be above 95% if considered a gamma criteria 1%/2 mm and 1%/1 mm respectively for the 2D and 3D analysis. The mean variations for CTV D98% and PTV V95% were 0.2% and 1.1% respectively when positioning error was introduced separately in each direction, while the maximum observed variations were 0.9% (CTV) and 3.7% (PTV).

CONCLUSION

The dosimetric accuracy of dual-isocenter irradiation has been verified for MR-Linac, achieving accurate and robust treatment strategy and improving dose conformality also in presence of targets whose extension exceeds the nominal maximum field size.

Radiotherapy for symptom palliation of splenomegaly in patients with haematological malignancies

Splenomegaly severely compromises the quality of life of those affected. The aim of the present study was to describe the clinical characteristics of patients with haematological disorders who receive radiotherapy for splenomegaly, particularly focusing on the changes in spleen volume. The present study conducted a retrospective analysis of consecutive patients with haematological disorders who underwent splenic radiotherapy with palliative intent at the Department of Radiology of the University of Tokyo Hospital between June 2008 and June 2019. Pre- and post-radiotherapy spleen volumes were measured from computed tomography images. A total of 8 patients (5 men and 3 women) with a median age of 59 years (range, 46-76 years) were included. The median total prescription and fractional doses were 4.5 Gy (range, 1.5-10 Gy) and 0.78 Gy (range, 0.5-2.0 Gy), respectively. A total of 5 patients (62.5%) experienced a reduction in spleen volume. The mean ± SD spleen sizes pre- and post-radiotherapy were 1,887±1,011 and 1,368±577 ml, respectively. The mean variation rate in spleen volume was -19.1±24.7%, and the case with the most notable improvement in the present study exhibited a -52.4% change. Of the 5 patients who experienced pain prior to radiotherapy, 3 achieved pain relief, 1 did not experience any change and 1 patient was not assessed post-radiotherapy. Therefore, the findings of the present study revealed that palliative radiotherapy for splenomegaly may achieve symptom palliation and radiological volumetric effects in patients with haematological disorders.

Current and Emerging Therapeutic Options for Hairy Cell Leukemia Variant

Hairy cell leukemia variant (HCL-v) is a rare B-cell lymphoproliferative disorder with distinct immunophenotypic and molecular characteristics when compared to classical hairy cell leukemia (HCL-c). In contrast to the enormous progress in therapeutic options for HCL-c, HCL-v remains a therapeutic challenge due to inferior outcomes with standard chemoimmunotherapy and BCR signaling pathway inhibitors, and due to the fact that HCL-v has limited molecular therapeutic targets. In addition, because of the rarity of the disease, there is a paucity of later phase studies or multicenter trials to guide treatment decisions. In this article, we briefly review the diagnostic criteria and clinical characteristics of HCL-v and present a comprehensive overview of current therapeutic options in HCL-v.

Survival after palliative radiation therapy for cancer: The METSSS model

BACKGROUND

We propose a predictive model that identifies patients at greatest risk of death after palliative radiotherapy, and subsequently, can help medical professionals choose treatments that better align with patient choice and prognosis.

METHODS

The National Cancer Database was queried for recipients of palliative radiotherapy during first course of treatment. Cox regression models and adjusted hazard ratios with 95% confidence intervals were used to evaluate survival predictors. The mortality risk index was calculated using predictors from the estimated Cox regression model, with higher values indicating higher mortality risk. Based on tertile cutpoints, patients were divided into low, medium, and high risk groups.

RESULTS

A total of 68,505 patients were included from 2010-2014, median age 65.7 years. Several risk factors were found to predict survival: (1) location of metastases (liver, bone, lung, and brain); (2) age; (3) tumor primary (prostate, breast, lung, other); (4) gender; (5) Charlson-Deyo comorbidity score; and (6) radiotherapy site. The median survival times were 11.66 months, 5.09 months, and 3.28 months in the low (n=22,621), medium (n=22,638), and high risk groups (n=22,611), respectively. A nomogram was created and validated to predict survival, available online, https://tinyurl.com/METSSSmodel. Harrel's C-index was 0.71 and receiver operator characteristic area under the curve was 0.76 at 4 years.

CONCLUSION

We created a predictive nomogram for survival of patients receiving palliative radiotherapy during their first course of treatment (named METSSS), based on Metastases location, Elderly (age), Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy.

How we treat mature B-cell neoplasms (indolent B-cell lymphomas)

Mature B cell neoplasms, previously indolent non-Hodgkin lymphomas (iNHLs), are a heterogeneous group of malignancies sharing similar disease courses and treatment paradigms. Most patients with iNHL have an excellent prognosis, and in many, treatment can be deferred for years. However, some patients will have an accelerated course and may experience transformation into aggressive lymphomas. In this review, we focus on management concepts shared across iNHLs, as well as histology-specific strategies. We address open questions in the field, including the influence of genomics and molecular pathway alterations on treatment decisions. In addition, we review the management of uncommon clinical entities including nodular lymphocyte-predominant Hodgkin lymphoma, hairy cell leukemia, splenic lymphoma and primary lymphoma of extranodal sites. Finally, we include a perspective on novel targeted therapies, antibodies, antibody-drug conjugates, bispecific T cell engagers and chimeric antigen receptor T cell therapy.

Modern management of splenomegaly in patients with myelofibrosis

Myelofibrosis (MF) is a chronic myeloproliferative neoplasm which can lead to massive splenomegaly secondary to extramedullary hematopoiesis. Patients frequently exhibit debilitating symptoms including pain and early satiety, in addition to cellular sequestration causing severe cytopenias. JAK 1/2 inhibitors, such as ruxolitinib and fedratinib, are the mainstay of therapy and produce significant and durable reductions in spleen volume. However, many patients are not eligible for JAK 2 inhibitor therapy or become refractory to treatment over time. Novel therapies are in development that can reduce the degree of splenomegaly for some of these patients. However, splenectomy, splenic irradiation, and partial splenic artery embolization remain valuable therapeutic options in select patients. In this review, we will discuss currently available pharmacologic therapies and describe promising drugs currently in development. We will also delve into the efficacy and safety concerns of splenectomy, splenic irradiation, and partial splenic artery embolization. Finally, we will propose a treatment algorithm to help guide clinicians in the management of symptomatic splenomegaly in patients with MF.

Identification of a Splenic Marginal Zone Lymphoma Signature: Preliminary Findings With Diagnostic Potential

Splenic marginal zone lymphoma (SMZL) is a rare, indolent non-Hodgkin's lymphoma that affects 0. 13 per 100,000 persons annually. Overall survival of SMZL is estimated to reach 8-11 years in most cases, but up to 30% of SMZL cases develop aggressive presentations resulting in greatly diminished time of survival. SMZL presents with a very heterogeneous molecular profile, making diagnosis problematic, and accurate prognosis even less likely. The study herein has identified a potential diagnostic gene expression signature with highly specific predictive utility, coined the SMZL-specific Gene Expression Signature (SSGES). Additionally, five of the most impactful markers identified within the SSGES were selected for a five-protein panel, for further evaluation among control and SMZL patient samples. These markers included EME2, ERCC5, SETBP1, USP24, and ZBTB32. When compared with control spleen and other B-cell lymphoma subtypes, significantly higher expression was noticed in SMZL samples when stained for EME2 and USP24. Additionally, ERCC5, SETBP1, USP24, and ZBTB32 staining displayed indications of prognostic value for SMZL patients. Delineation of the SSGES offers a unique SMZL signature that could provide diagnostic utility for a malignancy that has historically been difficult to identify, and the five-marker protein panel provides additional support for such findings. These results should be further investigated and validated in subsequent molecular investigations of SMZL so it may be potentially incorporated into standard oncology practice for improving the understanding and outlook for SMZL patients.

Micellar Formulation of Talazoparib and Buparlisib for Enhanced DNA Damage in Breast Cancer Chemoradiotherapy

Chemoradiation is an effective combined modality therapeutic approach that utilizes principles of spatial cooperation to combat the adaptability associated with cancer and to potentially expand the therapeutic window. Optimal therapeutic efficacy requires intelligent selection and refinement of radiosynergistic pharmaceutical agents, enhanced delivery methods, and temporal consideration. Here, a monodisperse sub-20 nm mixed poloxamer micelle (MPM) system was developed to deliver hydrophobic drugs intravenously, in tandem with ionizing radiation. This report demonstrates in vitro synergy and enhanced radiosensitivity when two molecularly targeted DNA repair inhibitors, talazoparib and buparlisib, are encapsulated and combined with radiation in a 4T1 murine breast cancer model. Evaluation of in vivo biodistribution and toxicity exhibited no reduction in particle accumulation upon radiation and a lack of both acute and chronic toxicities. In vivo efficacy studies suggested the promise of combining talazoparib, buparlisib, and radiation to enhance survival and control tumor growth. Tissue analysis suggests enhanced DNA damage leading to apoptosis, thus increasing efficacy. These findings highlight the challenges associated with utilizing clinically relevant inclusion criteria and treatment protocols because complete tumor regression and extended survival were masked by an aggressively metastasizing model. As with clinical treatment regimens, the findings here establish a need for further optimization of this multimodal platform.

Splenic oligometastasis: Report of a patient successfully treated with stereotactic body radiation therapy

The use of SRS/SBRT has been extensively reported on for tumors of the lung, liver, pancreas, adrenal gland, brain, and spine. Tumor control and associated toxicities of treatment are well understood and the use of SBRT in these sites is well-accepted. Here we uniquely report a detailed case of SBRT to the spleen and demonstrate pre- and post-treatment imaging along with treatment planning implications. We demonstrate excellent local control at 4 year follow-up with no development of late toxicity.

Palliative splenic irradiation for symptomatic splenomegaly in non-Hodgkin lymphoma

INTRODUCTION AND AIMS

Splenic marginal zone lymphoma, an uncommon subtype of non-Hodgkin lymphoma (NHL), is usually present with symptomatic splenomegaly. Although splenectomy has long been considered the first-line therapy in symptomatic or cytopenic patients, it can lead to significant morbidity and mortality. Splenic irradiation is an option for patients who have a poor response to systemic therapy and/or are not surgical candidates. In this paper, we present a case report of a patient who received splenic radiotherapy for symptomatic splenomegaly.

METHODS

An 85-year-old Caucasian man with a 4 year history of low-grade NHL presented with progressive pancytopenia, significant weight loss and symptomatic splenomegaly (abdominal discomfort, sense of fullness and limitation of mobility due to spleen size). The patient refused splenectomy and, in December 2017, was referred to palliative splenic radiotherapy. He was initially treated with five fractions of one Grey (Gy) in order to evaluate clinical and haematology response. After that, 1.5 Gy daily, 5 days a week for 3 weeks. 3D conformal radiotherapy, multiple fields and mixed energy (6 and 15 Mv) were used.

RESULTS

Radiotherapy allowed significant splenic reduction to almost half the size, resolving abdominal discomfort and improving quality of life. There was no decline of haemoglobin, leukocytes and platelet counts; in fact, there was a marginal increase.

CONCLUSION

Palliative splenic irradiation was well tolerated confirming that it is a safe treatment option for palliation of symptomatic splenomegaly. Thereby, splenic irradiation should be strongly considered in the management of symptomatic splenomegaly, for selected patients who are refractory to or unsuitable for other options or when the patient refuses other treatments.

The role of bone marrow and spleen irradiation in the development of acute hematologic toxicity during chemoradiation for esophageal cancer

Purpose

The purpose of this study was to determine the impact of splenic and thoracic bone marrow irradiation on hematologic toxicity in the setting of chemoradiation therapy for esophageal cancer.

Methods and materials

We analyzed 60 patients with carcinoma of the distal esophagus or gastroesophageal junction who received concurrent chemoradiation in the preoperative or definitive setting. Dosimetric and volumetric parameters were calculated for the spleen, thoracic spine, and posterior ribs. The primary endpoint was grade ≥3 hematologic toxicity (HT3+). Associations were assessed using logistic and linear regression models.

Results

Twenty-one patients (35%) experienced HT3+, including 18 patients with leukopenia and 5 with thrombocytopenia. Higher spleen V5-V20 was correlated with a lower risk of HT3+ on multivariable analysis (odds ratio: 0.83 per 10 cm³ increase in V10; P = .013). A dose-dependent decrease in spleen volume was observed after radiation therapy, and a greater decrease was independently associated with a lower risk of HT3+ (odds ratio: 0.93 per 1% volume decrease; P = .014). Dosimetric parameters of the thoracic spine were not significantly associated with HT3+.

Conclusions

A greater decrease in spleen size after radiation therapy and a higher spleen V5-V20 were independently associated with a lower risk of severe hematologic toxicity. Splenic irradiation may mitigate leukopenia associated with chemoradiation therapy.

Splenomegaly: Pathophysiological bases and therapeutic options

The spleen is the largest immune organ in the human body and is also essential for red blood cell homeostasis and iron recycling. An average human spleen is approximately 10 centimetres in length and weighs 150g. Pathological conditions can result in the spleen weighing in excess of 2000g and extending over 30 centrimetres in length. This remarkable property of the spleen to expand is termed splenomegaly. Splenomegaly can occur as a physiological response to stress or as a chronic process that is often detrimental to the wellbeing of the individual. Here, we will discuss the normal function and physiology of the spleen, the pathophysiological bases of splenomegaly and the commonly available therapeutic options. Additionally we will address experimental systems to determine the regulatory mechanisms underlying splenomegaly.