Partial splenic embolization to permit continuation of systemic chemotherapy

Abstract

Systemic chemotherapy treatments, commonly those that comprise oxaliplatin, have been linked to the appearance of distinctive liver lesions that evolves to portal hypertension, spleen enlargement, platelets sequestration, and thrombocytopenia. This outcome can interrupt treatment or force dosage reduction, decreasing efficiency of cancer therapy. We conducted a prospective phase II study for the evaluation of partial splenic embolization in patients with thrombocytopenia that impeded systemic chemotherapy continuation. From August 2014 through July 2015, 33 patients underwent partial splenic embolization to increase platelets count and allow their return to treatment. Primary endpoint was the accomplishment of a thrombocyte level superior to 130 × 10⁹ /L and the secondary endpoints were the return to chemotherapy and toxicity. Partial splenic embolization was done 36 times in 33 patients. All patients presented gastrointestinal cancer and colorectal malignancy was the commonest primary site. An average of 6.4 cycles of chemotherapy was done before splenic embolization and the most common regimen was Folfox. Mean platelet count prior to embolization was 69 × 10⁹ /L. A total of 94% of patients achieved primary endpoint. All patients in need reinitiated treatment and median time to chemotherapy return was 14 days. No grade 3 or above adverse events were identified. Aiming for a 50% to 70% infarction area may be sufficient to achieve success without the complications associated with more extensive infarction. Combined with the better safety profile, partial splenic embolization is an excellent option in the management of thrombocytopenia, enabling the resumption of systemic chemotherapy with minimal procedure-related morbidity.

Keywords: Cancer; interventional Radiology; oxaliplatin; partial splenic embolization; spleen; systemic chemotherapy; thrombocytopenia.

Figure 1

(A) Computed tomography showing enlarged spleen in a patient with colorectal cancer after 7 cycles of Folfox. (B) Pre‐embolization arteriogram showing usual splenic arterial anatomy. (C) Immediate post partial splenic embolization (PSE) arteriogram showing embolization of approximately 50% of the splenic parenchyma (D) Computed tomography 2 weeks after PSE showing partial spleen necrosis, which accurately correlated with the post PSE arteriogram.

Figure 2

Platelets by week: Mean platelet count prior to partial splenic embolization (PSE) was 69 × 109/L. Mean platelet count at weeks 1, 2, 3, and 4 post‐PSE were, respectively, 141 × 109/L, 188 × 109/L, 154 × 109/L, 122 × 109/L. Platelets count new decrease at week 3 followed the return of patients to Systemic chemotherapy (SC) treatment.

Figure 3

Estimated fraction of spleen necrosis by angiography significantly correlated with the estimated fraction of spleen necrosis by computed tomography.