Role of Splenectomy in Immune Thrombocytopenia Treatment

James Bussel, MD: For this patient, who might be a young woman, Caroline outlined specifically why dexamethasone and rituximab may be good. We’ve been talking about the risks of vaccination, and I thought you’d bring up flu vaccines. The other thing we talked about was TPO [thrombopoietin] agents. Caroline, how do you feel about splenectomy? Does your center do it anymore?

Caroline Piatek, MD: I’m a millennial, so I don’t do splenectomies. Our institution [Keck School of Medicine] also doesn’t commonly do splenectomies. We have more options, and high response rates with the TPO agents, so you don’t have to go to splenectomy very often. It remains an effective treatment, however, because of the well-known risks and infection in thrombosis with splenectomy. It’s not used as often as it was some years ago.

Craig Kessler, MD: I use it very sparingly. In the last 5 years, I may have only had 2 patients who went to splenectomy. Typically, it’s patient resistance more than anything else, because there’s a role for splenectomy in individuals. You have to be very selective. The last time I did a splenectomy on an older individual, he had marginal zone lymphoma in the spleen, which was the actual cause of his ITP [immune thrombocytopenia]. So you have to be very careful. Looking at this patient in retrospect, they had a very small monoclonal spike that was intermittently present in the past—not when I saw him, but years before. Maybe that was a hint that there was another cause. You can use splenectomy sparingly and youthfully, but the resistance from the patient is what prevents us from using it more.

James Bussel, MD: One thing that’s embarrassing for us as a field is the way things used to be. If you had 100 patients with ITP and also presentation, how many would get better on their own within a year or more? I would have thought the answer was 5, 10, maybe nobody. It turns out to be at least 30%. One study we have from Austria for 3 years suggested 60%. Then there’s the conundrum of those patients not treated, which must have been milder or different from the ones we treat. You want to do the ones who need treatment. That’s a confounder. Back to the risk benefit, on any given day it always seems better to pick a TPO agent over a splenectomy. I’m not saying that’s right, but from the patient point of view, that’s a very strong force. The article from Shruti Chaturvedi, Donald Arnold, and Keith McCrae in Blood from 2018 explains how splenectomies are down but not out. It has a very nice discussion of why it should not be completely eliminated from the armamentarium.

Transcript Edited for Clarity