Splenectomy in the context of primary cytoreductive operations for advanced epithelial ovarian cancer

Abstract

Objective.

To determine if the need to perform splenectomy due to metastatic disease in the context of complete primary cytoreduction for ovarian cancer diminishes the prognosis for survival.

Methods.

Between 1990 and 2004, 356 stage IIIC epithelial ovarian cancer patients underwent resection of all visible disease before systemic platinum-based combination chemotherapy. Forty-nine (13.8%) required a splenectomy due to metastatic disease. Survival was analyzed (log rank) on the basis of whether splenectomy was necessary. The frequency of performing other procedures, operative time, blood loss, transfusion rate, and hospitalization, was compared (Chi-square test; discrete and binomial data, t test; continuous data) on the basis of whether a splenectomy was required.

Results.

Survival was not influenced (log rank) by the requirement of splenectomy (required; median 56.4 months, estimated 5-year survival of 48% vs. not required; median 76.8 months, estimated 5-year survival of 58% P = 0.4). The splenectomy subgroup more commonly required en-bloc resection of reproductive organs with rectosigmoid (89.8% vs. 55.7%, P < 0.001), diaphragm stripping (63.3% vs. 33.6%, < 0.001)), full-thickness diaphragm resection (28.6% vs. 9.4%, P < 0.001), and resection of grossly positive retroperitoneal nodes (67.3% vs. 46.3%, P = 0.006). The splenectomy group had a longer operative time (238 min vs. 192 min, P = 0.004), estimated blood loss (1663 ml vs. 1167 ml, P = 0.001), transfusion rate (5.3 units prbc vs. 3.2 units prbc, P = 0.002), and hospitalization (16.1 vs. 12.2 days P = 0.001).

Conclusions.

The need for splenectomy to achieve complete cytoreduction is a reflection of advanced disease but is not a manifestation of tumor biology precluding long-term survival.

Introduction

Numerous reports have demonstrated the completeness of primary cytoreductive operations for advanced epithelial ovarian cancer to correlate with the prognosis for survival [1], [2], [3], [4], [5], [6], [7]. However, it has been suggested that a widespread upper abdominal tumor burden reflects “biologically aggressive” disease and that requirement of extensive as opposed to minimal upper abdominal operations to attain a visibly disease-free cytoreductive outcome may diminish or preclude the possibility of long-term survival [8], [9], [10], [11], [12]. Hence, the extent to which the natural history of advanced stage epithelial ovarian cancer can be altered if multiple upper abdominal procedures are necessary to accomplish “optimal” or complete cytoreduction remains somewhat controversial. The need to perform splenectomy in particular has been suggested to reflect a disease that is “biologically aggressive”, and the appropriateness of splenectomy in the context of primary cytoreductive operations has been questioned [11], [12]. In this series, we analyze whether the necessity to perform a splenectomy to achieve complete cytoreduction for stage IIIC epithelial ovarian cancer, due to splenic involvement with metastatic disease, increases morbidity and diminishes the probability of survival.