The Use of Splenectomy in HCL Treatment

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Farhad Ravandi-Kashani, MD: In terms of choice of therapy for second-line, we have been using the same combination of cladribine followed by rituximab. And it’s interesting that in our hands, the few patients, about 10 patients who have done this, their second remission—at least in the patients who’ve been followed long enough—has been longer than their original remission with cladribine alone or pentostatin alone. This is important also as a confirmation of the usefulness of that strategy because historically there are publications from various groups that have shown that if you retreat a hairy cell leukemia [HCL] patient with the same nucleoside analog on subsequent relapse, subsequent remission durations will be progressively shorter. In my opinion, the standard of care for a relapsed patient these days who has received prior nucleoside analog should be to use nucleoside analog plus rituximab. I don’t know if you have any other alternative strategies in mind.

Robert J. Kreitman, MD: No, I totally agree. I think that in our hands that approach, and I think in your hands too, that approach gives you a complete remission rate of 100%. Whereas if you treat with purine analog alone, you’re going to get a complete remission rate of around 65%. There are other options for second-line treatment of hairy cell that don’t involve chemotherapy. But those do not offer this same 100% complete remission rate. So, I agree with that. We actually are randomizing patients at the NIH [National Institutes of Health] with immediate or delayed rituximab for patients with 1 prior cladribine. I definitely agree with that. When would you use splenectomy? I imagine you wouldn’t use it after the first treatment of cladribine with a relapsed patient.

Farhad Ravandi-Kashani, MD: I can say that in the past 20 years, I’ve not used a splenectomy for any patient with hairy cell leukemia, and I think this is probably going to become even more of an obsolete strategy with the availability of newer agents such as BRAF inhibitors, as well as combinations of BRAF inhibitors with anti-CD20 antibodies, as well as even a B-cell receptor inhibitor. Ibrutinib is useful in some patients. I think splenectomy is probably now for the archives of medicine.

Robert J. Kreitman, MD: Right, and I completely agree with that. I know that there are a lot of traditionalists out there who do recommend splenectomy for earlier lines of treatment. For myself, I did recommend this for a patient with hairy cell leukemia-variant, who had a very aggressive form of hairy cell. In hairy cell leukemia-variant, this is a subject that we haven’t talked yet today about, but it’s really classified as a separate disease from hairy cell leukemia since they have different characteristics. For these patients, the cells are slightly different. They may still have these hairy projections, but they have different characteristics, CD25-negative.

They generally don’t have the BRAF mutations, so these patients are not eligible for the BRAF inhibitors. These patients are not eligible for as many things. There are some patients who have very aggressive hairy cell leukemia-variant. There was a patient who had terribly severe splenomegaly and wouldn’t respond or relapsed after other treatments. We used splenectomy to buy him a few more months, and that’s exactly what it did. I think that it was helpful in that respect. But there are many other treatments now that we’ll touch on.

Transcript Edited for Clarity

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