Splenectomy as Part of Cytoreductive Surgery in Recurrent Epithelial Ovarian Cancer

Results

Splenectomy as part of secondary cytoreduction. In the subgroup of patients submitted to splenectomy at secondary cytoreduction, the mean age at initial diagnosis was 54.7 years (range 34 to 75 years), while International Federation of Gynecology and Obstetrics (FIGO) stage at diagnosis was stage III or higher in 14 cases. Postoperatively, all patients were submitted to taxane- and platinum salt-based adjuvant chemotherapy. The mean disease-free survival between ending the adjuvant oncological treatment and re-appearance of symptoms was 31 months (range 13 to 37 months).

At secondary cytoreduction, the most frequent associated visceral resection was colic or rectosigmoidial resection, which was performed in 16 cases (76.1%). Upper abdominal tumor burden involved the diaphragmatic peritoneum in 12 cases (57.1%), the gall bladder in six (28.5%), the distal part of the pancreas in four (19%), the diaphragm in three (14.2%), the liver by peritoneal seeding in two (9.5%), hematogenous route in one case (4.76%) and the stomach in one case (4.76%). Complete resection, defined as no macroscopic residual disease was achieved in all cases.

The main pre- and intraoperative characteristics of the cohort are shown in Table I.

The histopathological studies revealed the presence of the serous type in 95.2% of cases while the mucinous type was present in a single case (4.8% of cases). The same study revealed the presence of peritoneal seeding in 52.3% of cases, while the hematogenous route was incriminated in 42.8%; hilum-limited tumoral burden was found in 4.7% of patients.

The median length of hospitalization was 14 days (range 2 to 89 days). Early postoperative complications (occurring within the first 30 postoperative days) were reported in six cases. In three cases re-operation was needed: the first patient necessitated early re-operation due to a high-flow enteral fistula, the second case had a pancreatic fistula unresponsive to conservative treatment, while in the third case, re-operation was required due to early postoperative hemoperitoneum. The overall mortality rate was 9.5%; death occurred in two cases, due to uncontrolled abdominal sepsis in one case and hemorrhagic shock associated with disseminated intravascular coagulopathy developing on the third postoperative day in the second case.

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Figure 1.

The influence on overall survival of patients with peritoneal versus those with parenchymatous splenic involvement.

The main postoperative complications classified according to Dindo-Clavien scale (14) are shown in Table II.

The median overall survival after secondary cytoreduction was 24 months. The median overall survival in patients with splenic involvement via peritoneal route was 35 months, while in cases with hematogenous splenic lesion, it was 12 months (p=0.2) (Figure 1).

Splenectomy as part of tertiary cytoreduction. At tertiary cytoreduction, splenectomy was performed in six cases. The mean age at initial diagnosis was 42.8 years (range 39 to 46 years), while the FIGO stage was IIC in four cases, IIIA in one case and IIIC in one case.

Tertiary cytoreduction was performed at a median interval of 50 months after primary cytoreduction. All patients were submitted to adjuvant chemotherapy with platinum-based salts and taxane after primary and secondary cytoreduction. Other upper abdominal resections included: diaphragmatic peritonectomy in two cases, cholecystectomy in three cases, distal pancreatectomy in one case and atypical hepatectomy for a parenchymatous lesion in one case.

The main preoperative and intraoperative characteristics are shown in Table III.

Although an R0 resection was attempted in all cases, it was achieved in four out of the six patients; in the other two cases, R1 and R2 resection were performed. The histopathological studies revealed the presence of a serous sub-type in five cases, while the sixth case was diagnosed with a mucinous epithelial ovarian tumor. When it comes to the type of splenic involvement, the peritoneal route was incriminated in four cases, while the other two cases had hematogenous lesions, entirely surrounded by normal splenic parenchyma. Postoperatively, two patients developed complications: an abdominal abscess and a biliary fistula, respectively, both being managed by conservative methods. The median hospitalization was 11 days (range 6 to 21 days).

The median overall survival was 6.7 months. The median overall survival in patients with splenic involvement via peritoneal route was 21 months, while in cases with hematogenous splenic lesion, it was 4 months (p=0.08).

Splenectomy for relapsed epithelial ovarian cancer beyond tertiary cytoreduction. Splenectomy was performed at quaternary cytoreduction in a single patient. At initial diagnosis of stage IIC ovarian cancer, the patient was 48 years old. The quaternary cytoreduction was performed 102 months after the initial diagnosis and consisted of splenectomy, atypical hepatectomy, partial gastrectomy and partial cystectomy for a pelvic recurrence invading the urinary bladder, an upper abdominal recurrence invading the great curvature of the stomach and the spleen, and a unique liver lesion which proved to have hematogenous origin. The histopathological studies revealed the presence of a moderately differentiated serous epithelial ovarian tumor; the specimen of splenectomy presented disseminated peritoneal lesions. The postoperative course was uneventful, the patient being discharged on the 11th postoperative day. The patient died of disease 20 months after tertiary cytoreduction.