Splenectomy as Part of Cytoreductive Surgery in Recurrent Epithelial Ovarian Cancer

Abstract

Aim: To determine the impact of survival of peritoneal versus splenic metastasis in cases submitted to splenectomy as part of cytoreductive surgery in recurrent epithelial ovarian cancer.

Patients and methods: Between January 2002 and May 2014, 28 patients were submitted to splenectomy as part of secondary, tertiary and beyond tertiary cytoreduction at the Dan Setlacec Center of Gastrointestinal Disease and Liver Transplantation, Fundeni Clinical Institute, Bucharest.

Results: Splenectomy was performed as follows: at secondary cytoreduction in 21 cases, at tertiary cytoreduction in six cases, and beyond tertiary cytoreduction in one case. An R0 resection was attempted in all cases; however, in two cases submitted to splenectomy as part of tertiary cytoreduction, R1 and R2 resection, were performed, respectively. Histopathological studies revealed the presence of peritoneal seeding in 11 cases at secondary cytoreduction and in four cases submitted to splenectomy as part of tertiary cytoreduction. Parenchymatous lesions were described in nine cases submitted to splenectomy as part of secondary cytoreduction and in two cases at tertiary cytoreduction. In a single case in which splenectomy was performed in the context of secondary cytoreduction, hilar involvement was found. Peritoneal seeding was described in the patient for whom splenectomy was performed at quaternary cytoreduction. Early postoperative mortality for the entire cohort (within 30 days) was 7.1% (death occurred in two cases submitted to splenectomy during the secondary cytoreduction). The median overall survival in patients with splenic involvement via peritoneal route was 35 months, while in cases with hematogenous splenic lesions, it was 12 months (p=0.2) at secondary cytoreduction. In the sub-group of patients submitted to splenectomy as part of tertiary cytoreduction, the median overall survival in patients with splenic involvement via peritoneal route was 21 months, while in cases with hematogenous splenic lesions it was 4 months (p=0.08). The patient submitted to quaternary cytoreduction died of disease 20 months later.

Conclusion: splenectomy as part of secondary, tertiary and quaternary cytoreduction can be performed safely, with acceptable rates of morbidity and mortality. The maximal survival benefit seems to be obtained for patients with splenic involvement via peritoneal route, while those with hematogenous spread live a shorter period; further study is required in order to assess if resection in such cases is preferable to palliative chemotherapy. Maximal survival benefit occurs in the setting of secondary cytoreduction, although in selected cases, even quaternary cytoreduction can be followed by long-term survival.

Keywords: Relapsed ovarian cancer; peritoneal lesions; secondary cytoreduction; splenectomy.