Can we lower the platelet threshold of ≥ 50 × 109/L for performing a lumbar puncture safely in patients with hematological malignancies?

• Published in: Annals of hematology Vol. 102; no. 3; pp. 663 - 668
• Main Authors: Jordan, Aryanna, Jain, Akriti G., Koipallil, Gautam Krishna, Reddy, Meghana, Chakkoli, Sanjay, Midha, Shonali, Phuoc, Vania, Eatrides, Jennifer, Erhardt, Crystal, Patel, Ankita K., Rico, Juan, Visweshar, Nathan, Mhaskar, Rahul, Parikh, Nainesh, Laber, Damian, Jaglal, Michael
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.03.2023; Springer Nature B.V
• Subjects: Blood cancer; Chemotherapy; Hematology; Medicine; Medicine & Public Health; Oncology; Original Article; Thrombocytopenia; Intrathecal chemotherapy; Platelet transfusion; Lumbar puncture
• ISSN: 0939-5555; 1432-0584; 1432-0584
• DOI: 10.1007/s00277-022-05073-6

Lumbar punctures (LP) are routinely used to administer intrathecal chemotherapy for children and adults with hematologic malignancies. The current guidelines suggest a platelet threshold of ≥ 50 × 10 9 /L prior to LP for intrathecal chemotherapy (ITC). This can be challenging in patients with hematological malignancies who are thrombocytopenic. We conducted a retrospective chart review of 900 LPs for ITC and compared adverse events in patients with a platelet count of ≥ 50 × 10 9 /L and < 50 × 10 9 /L. Cohort 1 included 682 LPs (75.8%) with a pre-procedure platelet count ≥ 50 × 10 9 /L, and cohort 2 included 218 LPs (24.2%) with a pre-procedure platelet count < 50 × 10 9 /L. Cohort 2 was further subdivided into pre-procedure platelet counts of 41 × 10 9 /L–49 × 10 9 /L ( n  = 43), 31 × 10 9 /L–40 × 10 9 /L ( n  = 77), 21 × 10 9 /L–30 × 10 9 /L ( n  = 84), and 11 × 10 9 /L–20 × 10 9 /L ( n  = 14). Among 900 LP procedures, a pre-procedure platelet count < 50 × 10 9 /L did not demonstrate a higher rate of post-procedure adverse events (6.5% vs 6.8%, p  = 0.8237). When cohort 2 was further stratified, the cohort with a pre-procedure platelet count of 21 × 10 9 /L–30 × 10 9 /L had the highest percentage of complications from LP (9.5%) and the highest rates of traumatic taps with observed LP RBC count > 200 (35.7%, p  = 0.0015). The rate of red blood cells (RBC) in the CSF was significantly higher in the group with platelets < 50 × 10 9 /L with observed LP RBC count ≥ 200 (31.2% vs 20.5%, p  = 0.0016), ≥ 500 (27.1% vs 14.6%, p  < 0.0001), and ≥ 1000 (23% vs 11.6%, p  < 0.0001). No instances of epidural hematomas were seen. We found no significant difference in bleeding complications between patients undergoing LPs for ITC with a platelet count above or below 50 × 10 9 /L.