To investigate the safety and efficacy of splenic radiofrequency ablation for the treatment of intractable immune thrombocytopenia (ITP). Methods The efficacy of the first international case of splenic radiofrequency ablation for ITP conducted at the Second Artillery General Hospital was retrospectively analyzed. Results A 43-year-old female esophageal cancer patient with combined primary severe ITP confirmed by repeated peripheral blood counts, blood smears and bone marrow aspiration had a platelet count <5-10×109/L and was treated ineffectively with standard anti-H. pylori therapy, intravenous human immunoglobulin, methylprednisolone, vincristine and platelet transfusions. The patient underwent laparoscopic radiofrequency ablation of the spleen on August 15, 2010, and the platelet count returned to normal on postoperative day 22 with no perioperative complications; the patient has shown a complete response at more than 8 months of follow-up to date. Conclusion Splenic radiofrequency ablation is safe and effective in the treatment of recalcitrant ITP, and it is worthwhile to expand the clinical trial to further validate its efficacy. Immune thrombocytopenia (ITP) is an acquired immune disorder characterized by increased platelet destruction and decreased platelet production, and clinically manifested by spontaneous bleeding or a pronounced bleeding tendency [1-3]. Approximately 1/4 of patients will develop chronic ITP, and splenectomy is most often required when chronic patients fail to respond to traditional first- and second-line medications such as hormones, intravenous immunoglobulin (IVIg) and immunosuppressive drugs [1-4]. Case report Patient, female, 44 years old. She was admitted to the hospital with progressive dysphagia with thrombocytopenia for 4 months. The patient was initially diagnosed with dysphagia by gastroscopy on 2010-4-15, which revealed an ulcer-like neoplasm with raised margins and bleeding 21-27 cm from the incisors, and biopsy pathology diagnosed esophageal cancer (squamous cell carcinoma). The biopsy pathology diagnosed esophageal carcinoma (squamous cell carcinoma). The original surgery was planned, and the preoperative routine blood test showed Hb 80g/L, platelets 0×109/L, bone marrow aspiration showed active bone marrow proliferation, no significant abnormalities in granulocyte and red lineage, 300 megakaryocytes, mainly granular megakaryocytes, including 1% primitive megakaryocytes, 5% naïve megakaryocytes, 58% granular megakaryocytes, 31% plate-producing megakaryocytes, 5% nucleated megakaryocytes The platelet scattering was rare. The diagnosis of "immune thrombocytopenia" was confirmed. He was treated with methylprednisolone, vincristine and platelet transfusion, and his platelet count reached a maximum of 78×109/L. He was then given 16 times of regional radiotherapy for esophageal tumors, and his dysphagia was relieved. Thereafter, dynamic monitoring of platelet count indicated a progressive decrease in platelets (<5×109/L); a repeat bone marrow image still indicated a maturation disorder of the megakaryocytic system and few platelets. She complained of significantly increased menstrual flow and prolonged menstrual period after the onset of her illness. On 2010-7-13, she came to our hematology department for further treatment. After admission, bone marrow aspiration showed that the bone marrow proliferation was obviously active, granulocyte and red lineage proliferation was active, 66 megakaryocytes were found in the whole film, no platelet production was seen, and platelets were rare; gastroscopy did not show clear tumor cell infiltration in the esophagus; routine blood tests showed a platelet count of 4×109/L. On the day of admission, human immunoglobulin (Hualan Bio, 400mg/kg/d) was given intravenously for 5 days, but was ineffective. On July 23, he was given methylprednisolone (120mg, 2mg/kg, decreasing), platelet transfusion (10 units) on July 24, and vincristine (2g) on July 24 and August 9, respectively. The platelet count continued to drop even after the above combined treatment (see Figure 1 for details), suggesting that this case of immune thrombocytopenia was ineffective with systemic medical treatment, so it was transferred to surgery for further treatment on August 13. The patient refused splenectomy and agreed to perform radiofrequency ablation of the spleen. After signing the informed consent form, laparoscopic splenic radiofrequency ablation was performed on August 15. After general anesthesia, the patient was placed in the horizontal position, and a 5mm Trocar was punctured under the umbilicus and subxiphoid process, 5 cm to the left of the umbilicus, and the laparoscopic lens and instruments were placed, respectively. Exploration revealed normal spleen size, morphology and color. The head was laterally rivered and the left side of the torso was elevated 20° to properly separate the splenic colonic ligament to prevent injury to the colon during ablation of the lower pole of the spleen (Figure 2A). A RITA radiofrequency electrode needle (Boston Scitific Corp., USA) with a maximum working diameter of 5 cm was inserted by puncture at the left posterior axillary line at the 10-11 rib space, and the diaphragmatic surface of the middle and lower pole of the spleen was sequentially selected as the ablation puncture site (Figure 2B), with a total of 6 overlapping sites ablated for a total of 65 min, and the needle tract was cauterized at each withdrawal. The operation was terminated after the splenic puncture needle tract was clearly free of active bleeding under direct laparoscopic view. Prophylactic antibiotics and other treatments were given for 1 week postoperatively. A liquid diet was started on postoperative day 1; he was discharged at 2 weeks. The platelet count was maintained above 120-200×109/L at regular follow-up for 8 months; there were no episodes of fever, abdominal pain, or influenza during the perioperative period and follow-up. The preoperative serum protein electrophoresis and complement C3 and C4 measurements were only slightly low in IgG (6.02 g/L, normal 7-16), and the postoperative follow-up immune function was normal. The postoperative review 1 week after surgery showed that the ablated spleen parenchyma accounted for about 50% of the total spleen volume (Figure 4A), and there were no complications such as pleural effusion, abdominal bleeding and splenic rupture. At 7 months postoperatively, the repeat CT showed that the ablated spleen foci were completely absorbed and the volume of the remaining spleen parenchyma was significantly reduced (Figure 4B). The patient is currently undergoing regional radiation therapy for esophageal cancer due to recurrence of esophageal cancer at 7 months postoperatively. Discussion Immune throbocytopenia (ITP), also known as immune or idiopathic thrombocytopenic purpura, is the most common clinical bleeding disorder.ITP is an immune-mediated syndrome characterized by thrombocytopenia, and the pathogenesis includes decreased platelet production and increased destruction [1-3]. First- and second-line treatments for ITP include glucocorticoids, IVIg, immunosuppressive agents, Rituximab, thrombopoietin agonists (eltrombopag, romiplostim), and splenectomy [1-4]. Patients with chronic or persistent ITP have indications for splenectomy when they do not respond to or are intolerant to conventional drug therapy such as glucocorticoids and IVIg. Splenectomy is effective in 80% of chronic ITP, and about 2/3 of them can achieve a durable response for more than 5-10 years without additional treatment. However, splenectomy is associated with more complications, such as fever, bleeding, infection, pleural effusion, thrombosis, etc. Especially, the risk of overwhelming postsplenectomy infection (OPSI) increases after removal of the spleen, the largest lymphatic organ in the body. a systematic analysis by Kojouri et al [4] found that the complication rate of splenectomy was 12.9% for open and 9.6% for laparoscopic. The mortality rate was 1.0% open and 0.2% laparoscopic. Partial splenic embolization (PSE) has been attempted in the literature for ITP [5,6], but its near- and long-term outcomes are weaker than splenectomy. post-embolization syndrome such as fever and abdominal pain are more common after PSE, and there is a risk of serious complications such as splenic abscess and portal vein system thrombosis. Therefore, there is a clinical need to explore new minimally invasive treatments for ITP that effectively replace splenectomy and preserve part of the spleen function. In this case, the patient was not responding to traditional first- and second-line ITP medications, so splenectomy was indicated. Due to the refusal of splenectomy, the patient opted for minimally invasive radiofrequency ablation of the spleen [7-11]. Radiofrequency ablation (RFA) is the use of radiofrequency current (450-500 KHz) to cause ion oscillation and frictional heat generation (>50-110°C) in the tissue around the electrode to cause local tissue coagulative necrosis to destroy the lesion.RFA has been widely used to treat solid tumors such as liver cancer and kidney cancer. We started to apply RFA for the treatment of cirrhotic hypersplenism in 2003 and achieved remarkable efficacy [7-11]. The effect of RF heat on the vascular-rich spleen includes 3 cascading areas of amplification [7,8]: (i) a central zone of coagulative necrosis; (ii) a more extensive surrounding zone of thrombotic infarction (bystander effect); and (iii) thermal energy deposition resulting in microscopically visible-only thermal damage to the splenic sinusoids and diffuse microthrombi that can involve the entire remnant spleen, while imaging such as CT shows a “normal” remnant spleen “. The ablated area is gradually aspirated, and the “normal” remnant spleen tissue undergoes less vascularized “consolidation of remnant spleen” (consolidation of remnant spleen) changes. Therefore, the ablation of splenic parenchyma and extensive disruption of the reticuloendothelial system caused by radiofrequency heat are the main mechanisms of action of RFA in the correction of ITP. The efficacy of RFA for ITP is closely related to the volume of ablation, so we chose an umbrella-shaped multi-electrode RF needle with a maximum spread of 5 cm to improve efficiency. most patients with ITP do not have splenomegaly, and there is a great risk of RF needle damage to the peri-splenic gastrointestinal tract due to heat conduction during the operation. Therefore, we chose the laparoscopic route in this case [7] and operated under direct vision to avoid the important tissues and vessels of the gastrointestinal tract and peripancreatic area, thus improving the safety of the RFA operation. The follow-up 8 months after surgery confirmed that the patient was in a continuous complete response (CR) state after surgery and achieved the expected treatment outcome. The minimally invasive treatment was safe, without complications, and effective in maintaining partial splenic immune function, as observed during the perioperative period and the 8-month postoperative follow-up. This case is the first attempt of splenic RFA for recalcitrant ITP carried out internationally with remarkable efficacy. We are currently conducting more clinical trials of ITP cases to further validate the safety and efficacy of the minimally invasive RFA technique for the treatment of ITP and to lay the foundation for the subsequent promotion of this technique.