Manuscript ID ZUMJ-2011-2020 (R4) DOI 10.21608/zumj.2021.50403.2020 ORIGINAL ARTICLE CAN PARTIAL SPLENIC EMBOLIZATION BE A PROMISING TREATMENT FOR HYPERSPLENISM–RELATED THROMBOCYTOPENIA IN ONCOLOGICAL PATIENTS REQUIRING SYSTEMIC CHEMOTHERAPY: A RETROSPECTIVE ANALYSIS 1-Dena Abd El Aziz El Sammak Radiodiagnosis department, Zagazig university hospital, Egypt 2- Rabab M. Abdelhay Radiodiagnosis department, Zagazig university hospital, Egypt 3-Hala M. Allam Internal medicine department, Zagazig university hospital, Egypt Corresponding author ABSTRACT Dena Abd El Aziz El Background: Partial splenic embolization has been safely used to improve hypersplenism–related thrombocytopenia by reducing the splenic volume using Sammak conventional transarterial superselective embolization technique. Partial splenic Radiodiagnosis embolization provides an increase in hematologic indices to facilitate initiation and department, Zagazig continuation of systemic chemotherapy in oncological patients who are not surgical university hospital, Egypt candidates and for whom splenectomy is contraindicated. [email protected] Objective: The aim of this study was to evaluate primary, secondary end points, technical parameters, outcomes and complications of partial splenic embolization in oncological patients with hypersplenism-related thrombocytopenia requiring Submit Date 2020-11-19 systemic chemotherapy. Revise Date 2021-02-10 Methods: This retrospective study comprised 24 oncological patients (18 males and Accept Date 2021-02-20 6 females; their ages ranged 35–70 years old), they underwent partial splenic embolization for correcting thrombocytopenia in order to initiate (n=6) or continue (n=18) their optimally dosed systemic chemotherapy. The primary endpoint was the achievement of a platelet count >130×109/L and the secondary endpoint was the initiation or continuation of systemic chemotherapy. Results: Mean platelet count prior to partial splenic embolization was 69.08 ± 3.54× 109/L (range 62–75× 109/L).The percentage of splenic necrosis was estimated by angiography, mean post-embolization splenic infarction percentage was 58.33 ± 8.16 %. Mean platelet counts at days 10, 20 and 30 post-embolization were 273.58±77.30× 109/L, 218.54±60.06× 109/L and 157.16±44.90× 109/L, respectively (P<0.05). Primary and secondary endpoints were reached in 24 (100%) of 24 patients. 16 (66.7%) patients had moderate post-embolization syndrome. No puncture site hematomas, or major complications or severe post-embolization syndrome occurred. No one-month mortality rate among the 24 patients. Conclusion: Partial splenic embolization is secure and efficient in handling hypersplenism-related thrombocytopenia in oncological patients, facilitating the initiation or continuation of systemic chemotherapy with minimal procedure-related morbidity. Keywords: partial splenic embolization, hypersplenism, thrombocytopenia, systemic chemotherapy INTRODUCTION The reduction in the platelet count in hrombocytopenia is defined as low blood hypersplenism is triggered through T platelets level, a normal platelet count augmented splenic sequestration, ranges from 150× 109/L to 450× 109/L (1). thrombocytes damage, or thrombopoietin Hypersplenism-induced thrombocytopenia degradation (3). has different causes, the most common is Oncological patients treated with systemic portal hypertension on top of cirrhosis (2). chemotherapy (SC) are liable to hypersplenism and subsequently thrombocytopenia that precludes 10.21608/zumj.2021.50403.2020 962 | P a g e Dena A., et al Volume 27, Issue 5, September 2021 administration of SC or necessitates dose They underwent PSE for correcting attenuation, thus decreasing efficiency of thrombocytopenia in order to initiate (n=6) or cancer therapy (4). continue (n=18) their optimally dosed SC. Oncological patients develop The inclusion criteria were oncological thrombocytopenia by different mechanisms; patients with hypersplenism, SC treatments may cause hepatic damage thrombocytopenia (platelet count ≤ 75×109/L) that leads to portal hypertension and and splenomegaly. Exclusion criteria were: hypersplenism, moreover hepatic affection (1) allergy to contrast medium, (2) renal reduces thrombopoietin production. insufficiency, (3) life-expectancy <3 months. Pancreatic tumors may cause splenic vein All patients underwent history taking, clinical thrombosis, portal hypertension then examination, laboratory investigations (CBC, hypersplenism. Also, patients with hepatic function test and renal function test), hematologic malignancies develop abdominal ultrasound (US) and contrast thrombocytopenia secondary to the disease enhanced multislice computed tomography process or as a complication of SC (5). (MSCT). Platelets transfusion is a temporary and Platelets counts were recorded immediately impractical solution for patients with before PSE and 10, 20 and 30 days post PSE. hypersplenism–related thrombocytopenia due Splenic infarction percentage was evaluated to platelets sequestration and destruction (6). by post PSE angiography. If drug treatment is unsuccessful, The 1ry (primary) endpoint was the splenectomy will be the last resort for achievement of a platelet count >130×ퟏퟎퟗ/L treatment of thrombocytopenia, however and the 2ry (secondary) endpoint was the splenectomy has perioperative and initiation or continuation of SC. postoperative complications especially in Post procedure abdominal US was performed patients with poor general condition, so in all patients four weeks post PSE for partial splenic embolization (PSE) will be an assessment of splenic length, width and efficient substitutional to splenectomy (7). splenic volume ( calculated using the standard PSE has safely improved prolate ellipsoid formula; length × width × hypersplenism–related thrombocytopenia by depth × 0.523) (9). reducing the splenic volume using Technical parameters (duration of scope, conventional transarterial superselective hospital discharge and Dose area embolization technique. PSE increases the product DAP) were additionally recorded. No hematologic indices, facilitating the initiation vaccinations were taken prior to the and continuation of SC in oncological patients procedure, as the immune protection of the for whom splenectomy is contraindicated (8). spleen will not be completely eliminated. The aim of this study was to evaluate 1ry The 24 patients were classified into two end points, 2ry end points, technical groups, patients with hematological parameters, outcomes and complications of malignancies (11 patients) and non- PSE in oncological patients with hematological malignancies (13 patients). hypersplenism-related thrombocytopenia Written informed consent was obtained requiring SC. from all participants, the study was PATIENTS AND METHODS approved by the research ethical Patients committee of Faculty of Medicine, Zagazig This retrospective study comprised 24 University. The study was done according oncological patients (18 males and 6 females; to The Code of Ethics of the World their ages ranged 35–70 years old), they were Medical Association (Declaration of referred from Clinical Oncology Department Helsinki) for studies involving humans. to the Interventional unit in Radiodiagnosis Vascular anatomy of the spleen department during the period from December The splenic artery arises from the celiac axis 2019 to June 2020. (Figure 1), in 8% of patients, it arises directly from the abdominal aorta. 10.21608/zumj.2021.50403.2020 963 | P a g e Dena A., et al Volume 27, Issue 5, September 2021 The main splenic artery bifurcates into upper artery). Embolization under fluoroscopy and lower polar divisions, which then divide control was done using gelatin sponge into 4 to 6 intrasplenic segmental branches. (Gelfoam cube, Upjohn, Kalamazoo, USA) The dorsal pancreatic and pancreatica magna (1–2 mm) suspended in an antibiotic solution arteries arise off the proximal and mid-splenic (1 gram cefazolin containing solution) and artery and supply the body and tail of the contrast medium. Middle and inferior splenic pancreas. Visceral arteries arising from the branches were preferred than upper branch to splenic artery include the left gastroepiploic, decrease the incidence of pleural effusion and short gastric and accessory left colic arteries subdiaphragmatic abscess. Immediate post- (Figure 2). embolization arteriogram was done after each Recognition of the aforementioned collaterals injection. A final arteriogram was performed is important to decrease the risk of non-target to achieve a splenic infarction percentage of embolization during splenic artery 50-70% to avoid sever post embolization intervention (10). syndrome. PSE technique Manual vascular compression was applied for In this study, thrombocytopenia precluded at least thirty minutes. the continuation of SC in 18 patients, the Evaluation of the splenic infarction median time between the cessation of SC percentage during the procedure is and undergoing PSE procedure was 14 subjective and depends on the experience days (mean 17.7 days) . of the operator. The procedure was done using high resolution Post-PSE supportive care digital subtraction angiography (DSA) C-arm All patients were hospitalized (mean hospital machine (Siemens Artis-zee) at the discharge was 4.16±1.68 days after PSE, interventional unit in the Radiodiagnosis range 2–7 days) for appropriate post- department. procedure care including hydro-electrolytic All patients received preprocedure infusion, systemic antibiotics (amoxicillin intravenous sedative (2.5 mg of