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(P088) Splenic Irradiation for Splenomegaly: A Meta-Analysis

Article in International journal of radiation oncology, biology, physics June 2017

DOI: 10.1016/j.ijrobp.2017.02.184

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 Splenic irradiation for splenomegaly: a meta-analysis
Nicholas G Zaorsky, MD;*1
Graeme R Williams, BSE, Stefan K Barta, Nestor F Esnaola, BA;* 1 MD; 2 MD; 3
2 1
Patricia L Kropf, MD ; Shelly B Hayes, MD; Joshua E Meyer, MD 1
* Contributed equally
(1) Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
(2) Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA
(3) Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA

Background Results
Figure 1. Partial response rates of SI in different Patients:
Splenic irradiation (SI) is a palliative cancers Median patient age: 60.5 years
treatment option for symptomatic The rate of partial or complete response from each Common indications:
splenomegaly. study is plotted vs. indicated disease (e.g. CLL/CML; CLL/CML (23.7%)
A number of studies have been PLL, HCL, MPD; or studies that include multiple MPD (16.9%)
published on this therapy, but few cancers). Some studies cited various
guidelines exist to guide clinical The size of the circle corresponds to the number of indications for SI (57.8%) such
decision-making. patients included (inset). as polycythemia vera, multiple
There is no apparent outlier hematologic malignancy myeloma, idiopathic
that markedly different response rates to SI vs. other thrombocytopenic purpura, and
Purpose malignancies.
The response is determined by directly reporting from
non-Hodgkins lymphoma.
97% of patients were treated for
paper abstracts or calculating a response rate based painful splenomegaly, 61% for
To determine: cytopenias.
on data provided in the paper.
1. patient selection criteria and optimal 58% received therapy prior to
For studies that reported separate outcomes for
SI technique SI (prednisone or
splenomegaly, pain, and CBC responses, a weighted
2. efficacy of SI chemotherapy).
average is calculated based on the number of courses.
3. toxicities of SI Treatments:
Figure 2. Efficacy and toxicity vs. BED
Dose/fraction range: 0.1-2.5 Gy.
for all cancers
Total dose range: 0.15-30.5 Gy.
Methods (A) Response rate (with PR or CR) for
Most common fractionation: 1
any symptom alleviation vs. BED10 is
Gy/fraction to total dose 10 Gy.
plotted. There is no improvement in
27% of patients could be
A PICOS/PRISMA approach is used to symptoms with increasing dose. The
analyzed for total courses
determine search criteria most common fractionation regimen is
received; median number of
A PubMed search for the terms 1 Gy per fraction, to a total of 10 Gy,
courses is 1 (range 1-9).
splenomegaly, radiotherapy, and which corresponds to a BED10 of 11 Gy
77% delivered by photon linear
splenic irradiation is conducted (vertical line co-plotted).
accelerators, 16% by Cobalt-60
27 articles including 766 courses of SI (B) Response rate (with PR or CR) for
teletherapy units, 7% by
for 486 patients from 1960 to 2016 individual symptom alleviation vs. BED is
electrons.
were included in the analysis plotted. With respect to outcomes, 65
93% of courses delivered by
Studies are excluded if the full 100% of patients experienced pain relief,
AP/PA fields.
manuscript cannot be obtained, if not 60100% had a reduction in spleen size,
Outcomes:
authored in English, if it has insufficient while the number with CBC improvement
72% of courses reduced spleen
data regarding SI, or if SI is used is variable. The median response
size.
exclusively for non-malignant duration is 11 months (range 2216).
59% of courses relieved pain.
conditions (e.g. sickle cell disease, There is no improvement in symptoms
78% of courses improved
cirrhosis, etc.) with increasing dose (r = 0.01 0.05).
2
cytopenias.
Data abstracted from studies include The size of the circle corresponds to the
Median PR rate for any
patient age, indication for SI, prior number of patients included (inset)
symptom: 88%.
treatments (i.e. chemotherapy), percent (C) Toxicity rate (grade 35) vs. BED is
Duration of symptom relief is 6-
of patients presenting with splenic pain plotted. The rate of any toxicity is
12 months.
or CBC irregularities, radiation setup between 5 and 60% among most
There is no relationship
techniques, median dose per fraction studies. There is no association in
between BED and efficacy or
and course, total courses received per symptoms with increasing dose
toxicity.
patient, and toxicities according to (r = 0.02 0.34). The size of the circle
2
Grade 4+ toxicities likely due to
RTOG criteria corresponds to the number of patients
cancer and underlying disease,
Radiation dose is calculated by: included (inset).
rather than to SI.
BED = (nd[1 + d/(/)])
n is the number of radiation
fractions
Abbreviations:
d is the fraction size BED10: biologically equivalent dose, with / =
Table 1. RTOG toxicities after SI
/ is 10 10
Symptoms n Grade 1 or 2 Grade 3 or 4 Grade 5 Low grade% (1 or 2)/high grade% (35) CBC: complete blood count
Nausea/vomiting/abdominal cramps 9 8 1 0 89%/11% CM: chronic myelogenous leukemia
Leukopenia/neutropenia and/or CLL: chronic lymphocytic leukemia
CR: complete response
thrombocytopenia 114 5 104 5 4%/96% HCL: hairy cell leukemia
Anemia 48 12 36 0 25%/75% MPD: myeloproliferative disorder
PML: prolymphocytic leukemia
Cardiovascular (myocardial infarction) 1 0 1 0 0%/100%
PR: partial response
Totals 172 25 142 5 15%/85% RTOG: Radiation Therapy Oncology Group
Toxicity-free courses N = 594 (77%) SI: splenic irradiation

Correspondence
Nicholas G Zaorsky, MD
nicholaszaorsky@gmail.com
Joshua E Meyer, MD
Joshua.meyer@fccc.edu
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Conclusion
SI is a safe and efficacious method for treating symptomatic splenomegaly from hematologic malignancies
@Nicholas Zaorsky
The most common dose regimen in 10 Gy in 1 Gy fractions over two weeks; however, lower doses may be equally effective
Given the limited hematologic reserve of these patients, physicians should follow them closely during SI and have a low threshold for holding therapy