Pathology Review After Splenectomy Often Unnecessary

Although routine pathology review of tissue specimens after splenectomy is clinically beneficial for patients with splenomegaly, abnormal imaging results, a previous diagnosis of cancer, or a grossly abnormal spleen, it has no effect on the medial management of patients who have undergone trauma-related splenectomy, new research shows.

“Our study confirms previous studies indicating that routine pathologic assessment of spleens assessed following trauma do not yield for the vast majority of patients any new pathologic diagnoses with medical implications,” said senior researcher Jonathan Canaani, MD, from the Hematology Division at Chaim Sheba Medical Center, in Tel Aviv, Israel.

“I believe that guidelines should be amended specifically for splenectomy for trauma reasons, as the diagnostic yield and, most important, the clinical benefit for patients is negligible,” he told Medscape Medical News.

The spleen is the organ most commonly injured by blunt trauma and, consistent with guidelines for most organs removed in surgery, splenectomy tissue specimens are typically sent for pathology review, the researchers explain.

However, previous studies have shown that findings are clinically significant in only a tiny fraction — less than about 1% — of patients who undergo splenectomy for trauma-related reasons. This has led some to question whether the routine review is necessary.

Some studies have described the features specifically associated with undiagnosed conditions, such as spleen size and patient age, but a broader assessment has been lacking.

“To our knowledge, no comprehensive assessment of all clinical factors associated with a diagnostic spleen pathology review has yet been performed,” the researchers note.

For their study, published this week in JAMA Open Network, Canaani and his colleagues examined 90 patients who underwent splenectomy at the Chaim Sheba Medical Center in Israel from January 2013 to December 2018.

Median age in the study cohort was 59 years, 59% of the patients were male, and 45% of the splenectomies were for therapeutic purposes, 27% were for trauma, 17% were for diagnostic purposes, and 10% were for a combination of therapeutic and diagnostic purposes.

Overall, pathology reviews of spleen tissue revealed a new malignant neoplasm in 15% of patients, a new non-neoplastic medical condition in 9%, and a new diagnosis leading to a change in medical management in 18%.

For patients with no previous diagnosis of cancer, the majority of pathology reviews were normal (73%), but 13% (seven biopsies) revealed a diagnosis of a hematologic malignant neoplasm (P < .001).

Patients with clinical splenomegaly were significantly more likely to receive a diagnosis of cancer on the pathology review than those without splenomegaly (58% vs 7%; P < .001).

Postop pathology review was normal in 91% of the patients with normal presurgery imaging; however, postop pathology review identified new hematologic malignant neoplasms in 82% of patients with a diagnosis of splenomegaly on presurgery imaging (P < .001).

Postop pathology review was more likely to change treatment management in older patients (mean age, 59 vs 50 years; P = .03), but did not change treatment decisions in 95% of patients with no history of malignant neoplasm.

However, for those with a previous diagnosis of malignancy, 40% had treatment changes after the pathology review.

None of the splenectomy patients who’d experienced trauma were diagnosed with a new medical condition after pathology review, and none of their treatment management changed.

In addition to providing little benefit in the case of trauma, the routine pathology review of spleen specimens for very-low-risk patients is an unnecessary use of medical resources, Canaani noted.

“It is important for clinicians to have a sense of the diagnostic yield and expected clinical benefit of any medical test performed,” he added.

“Spleen pathology results provide a clinically beneficial result in a significant minority of patients,” he said, noting that about 25% of patients with splenomegaly, abnormal presurgery imaging studies, a previous diagnosis of cancer, or grossly abnormal spleens do benefit.

“This sets the expectations for clinicians and patients awaiting the results of the pathology study,” he added.

“Our data further solidify the notion that routine pathology review of spleens obtained in the setting of trauma is unnecessary,” Canaani added.

“Wrongheaded” to Change Guidelines

These findings do not point to a need for a change in guidelines, said Dennis P. O’Malley, MD, first author on the most recent recommendations from the International Spleen Consortium on examination of surgical specimens of the spleen..

“There is a suggestion that at least 80% of the spleen samples are abnormal, whether neoplastic or non-neoplastic,” O’Malley told Medscape Medical News.

However, “throwing away samples based on the thought of only missing 20% of the pathologic samples is wrong-headed,” he added.

“The guidelines should not be changed,” he said.

The authors have disclosed no relevant financial relationships.

JAMA Netw Open. 2021;4(8):e2120946. Full text

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