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The rare indication for splenectomy as part of cytoreductive surgery in ovarian cancer
GYNECOLOGIC
ONCOLOGY
16, 282-287
(1983)
The Rare Indication for Splenectomy as Part of Cytoreductive Surgery in Ovarian Cancer GUNTER
DEPPE, M.D.,
EDWARD A. ZBELLA, M.D., ION DUMITRU, M.D.
KENT
SKOGERSON, M.D.,
AND
Division of Gynecologic Oncology and Department of Obstetrics and Gynecology, Mount Sinai Hospital Medical Center, California Avenue at 15th Street, and Rush Medical College, Chicago, Illinois 60608 Received March 21. 1983 Advanced ovarian carcinoma is being treated with aggressive debulking surgery including complete removal of the tumor whenever possible followed by adjuvant therapy. Secondary debulking including splenectomy in a patient with recurrent ovarian carcinoma is reported. It is suggested that splenectomy may have a place in the management of a few patients with ovarian cancer. The technique and complications of splenectomy are described.
INTRODUCTION
Ovarian carcinoma is the most lethal gynecological malignancy. An estimated 11,400 deaths occurred in 1982 from this disease [l]. The currently available screening techniques are inadequate for early detection and the majority of patients have advanced cancer at the time of presentation. Retrospective analysis revealed that prolonged survival in patients with advanced ovarian cancer could be achieved when the size of the largest residual tumor mass was smaller than 1.6 cm in diameter [2]. Newer chemotherapeutic combinations may change the discouraging results of treatment of advanced ovarian cancer [3,4]. Complete remission after a maximal debulking operation can be obtained with combination chemotherapy, therefore, optimal bulk resection of the tumor appears to be justified as part of primary treatment for ovarian cancer [3,5,6]. Ovarian carcinoma may disseminate throughout the peritoneal cavity and occasionally involve the spleen. Splenectomy, as part of a surgical debulking operation, is occasionally necessary. The topic of splenectomy has not been widely discussed in the gynecologic literature. The gynecologic oncologist should be familiar with this procedure since he will be primarily responsible for adequate debulking which may necessitate splenectomy. This report focuses on the management of a patient with recurrent ovarian carcinoma by surgical debulking including splenectomy. The technique of splenectomy and potential complications is presented. 282 0090-8258/83 Copyright All rights
$1.50
0 1983 by Academic Press, Inc. of reproduction in any form reserved
SPLENECTOMY
IN
OVARIAN
283
CANCER
CASE REPORT A 66-year-old, para 0, black female presented with pelvic and abdominal masses suggesting ovarian carcinoma. Five years ago the patient had been treated for a Stage III serous cystadenocarcinoma of the ovary with an abdominal hysterectomy and bilateral salpingo-oophorectomy followed by abdominal radiation. A partial cystectomy, ileocecal resection, rectosigmoid resection, omentectomy, and splenectomy were performed. The splenectomy included resection of part of the diaphragm to which the spleen was attached by tumor. The postoperative course was uncomplicated. Three weeks following surgery cisplatin at a dosage of 75 mg/m’ of body surface and cyclophosphamide at a dosage of 750 mg/m* of body surface were given intravenously. This treatment was administered every 4 weeks. Shortly after the ninth course, the patient refused further therapy. At no time did the patient experience peripheral neuropathy, nephrotoxicity, or symptoms suggesting a gross hearing defect. Nausea and vomiting occurred with each course of treatment. During the 4 months after discontinuation of chemotherapy the patient has remained without clinical evidence of cancer. OPERATIVE
TECHNIQUE
OF SPLENECTOMY
In accomplishing a splenectomy, the procedure is performed differently depending on the indications [7,8]. Our approach in elective splenectomy for debulking is to open the lesser sac (Fig. 1). Next the gastrosplenic ligament is incised in an avascular area while traction is applied to the stomach medially (Fig. 2). It is
PERITONEAL
SPLEEN
FIGURE
1
284
DEPPE
ET
Al..
) SPLEEN
GASTRO-SPLENIC LIGAMENT
STOM
’ FIGURE
LEFT GASTROEPIPLOIC ARTERY
2
imperative to obtain control primarily of the splenic vessels. First the splenic artery can be seen and palpated on the superior border of the pancreas. Double ligatures are passed around the splenic artery midway between the spleen and the celiac axis (Fig. 3). Second, the splenic vein is identified and clamped (Fig. 4.). Care should be taken, if the vein divides into several branches, that those are ligated individually. Then the gastrosplenic vessels are clamped and tied appropriately, SPLENIC
Sl ‘OMACH
FIGURE
3
ARTERY
SPLENECTOMY
SPLENIC
IN
OVARIAN
285
CANCER
AR1
;PLENIC FIGURE
VEIN
4
The spleen can now be mobilized and delivered into the wound. The splenorenal ligament is incised taking care to avoid injuring pancreatic tissue. The ligament between spleen and colon is cut (Fig. 5). The vessels are divided and the spleen is removed. The splenic bed is inspected for hemostasis. Reperitonialization, if feasible, should be carried out.
SPLEEN LIENORENAL i
FIGURE
5
286
DEPPE ET AL.
DISCUSSION
The precise
role of secondary cytoreductive surgery in the management of ovarian carcinoma remains to be defined. In view of effective primary and improved second-line chemotherapy this approach may be justifiable [3,4,9-l 11. In our experience, a limited number of patients will require a splenectomy as part of optimal primary or secondary debulking surgery. Usually it is possible to avoid splenectomy in ovarian cancer surgery since most ovarian cancers grow around and not into the spleen. Our patient with recurrent ovarian cancer underwent maximal surgical debulking including intestinal resection and splenectomy. In spite of prior radiation therapy she tolerated the procedure extremely well allowing her, to date, 12 months of excellent quality survival. Secondary debulking including splenectomy must be individualized. Anticipated complications of splenectomy are hemorrhage, infection, thrombosis, left lower lobe atelectasis, and gastric and pancreatic fistulas. If severe intraoperative hemorrhage from the spleen occurs the tail of the pancreas should be grasped to compress the splenic artery and splenic vein in this area. Further control can then be accomplished by clamping the splenic pedicle. Postoperative hemorrhage related to splenectomy may require laparotomy to religate splenic artery and vein. Hemorrhage usually occurs because adequate hemostasis was not established at the initial surgery. Overwhelming infections may occur in splenectomized patients [121. hophy]actic antibiotics and vaccination with pneumococcal vaccine have been recommended [139141. Platelet counts may be increased after splenectomy and may lead to thrombosis. Anticoagulant therapy should be reserved for the clinically symptomatic patients. Gastric fistula due to injury of the stomach wall at time of splenectomy onlv requires reoperation if peritonitis develops. Pancreatic fistulas resulting. fexLfl T1e most surgical trauma to the tail of the pancreas usually close spontaneously. Common complication after splenectomy is atelectasis and pneumo tia of the left lower lobe. Deep breathing exercises and meticulous trachea’ toilet may be helpful as a preventive measure [ 151. To perform a safe splenectomy as part of primary or secondary optimal debulking for patients with advanced ovarian carcinoma the gynecologic oncologist must be adequately trained. As with any surgical procedure competence, extensive experience and surgical judgement are essential for successful outcome. patients
with
recurrent
REFERENCES 1. American Cancer Society, Cancer, fucrs, undfigures (1982). 2. Griffiths, C. T.. Grogan, R. H., and Hall, with surgery, radiotherapy, chemotherapy,
T. C. Advanced ovarian cancer, Cancer 29, l-7 (1972).
primary
treatment
3. Young, R. C., Chabner, B. A., Hubbard, S. P., Fisher, R. I., Bender, R. A., Anderson, T., Simon, R. M., Canellos, G. P., and Devita, V. T. Advanced ovarian adenocarcinoma. A prospective clinical trial of melphalan (L-PAM) vs combination chemotherapy, N. Engl. J. Med. 299, 1261-1266 (1978). 4. Bruckner, H. W., Cohen, C. J., Goldberg, J. D., Kabakow, B., Wallack, R. C., Deppe, G., Greenspan, E. M., Gusberg, S. B., and Holland, J. F. Improved chemotherapy for ovarian cancer with cis-diamminedichloroplatinum and adriamycin. Cancer 47, 2288-2294 (1981).
SPLENECTOMY
IN
OVARIAN
CANCER
287
5. Griffiths, C. T. Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma, Natl. Cancer Inst. Monogr. 42, 101-104 (1975). 6. Griffiths, C. T., Parker, I., Fuller, A. Role of cytoreductive surgical treatment in the management of advanced ovarian cancer, Cancer Treat. Rep. 63, 235-240 (1979). 7. Zollinger, R. M., and Zollinger, R. M., Jr. Surgican operations, Macmillan Co., New York, pp. 218-222 (1975). 8. Block, G. E., and Exelby, P. E. Operative surgev, principles and techniques, Lea & Febiger, Philadelphia, pp. 670-677 (1980). 9. Berek, J. S., Hacker, N. F., Lagasse, L. D., Nieberg, R. K., and Elashoff, R. M. Survival of patients following secondary cytoreductive surgery in ovarian cancer, Obstet. Gynecol. 61, 189-193 (1983). 10. Vogel, S. E., Grunwald, E., Kaplan, B. H., Moukhtar, M., and Wollner, D. Ovarian cancereffective treatment after alkylating-agent failure, J. Amer. Med. Assoc. 241, 1908-1911 (1979). 11. Bruckner, W. H., Ratner, L. H., Cohen, C. J., Deppe, G., Wallach, R. C., Kabakow, B., Greenspan, E. M., and Holland, J. F. Combination chemotherapy for ovarian carcinoma with cyclophosphamide, adriamycin, and cis-dichlorodiammineplatinum (II) after failure of initial chemotherapy, Cancer Treat. Rep. 62, 1021-1023 (1978). 12. Edwards, L. D., and Digiola, R. Infections in splenectomized patients: A study of 131 patients, Stand. J. Infect. Dis. 8, 255-261 (1976). 13. Prevention of serious infections after splenectomy, Med. Lett. Drugs Ther. 19, 2-4 (1977). 14. Ammann, A. J., and Diamond, M. D. Indications for pneumococcal vaccine in patients with impaired splenic function, N. Engl. J. Med. 299, 778 (1978). 15. Schwartz, S. I. The spleen, in Manual of preoperative and postoperative care (J. M. Kinney et al., Eds.), Saunders, Philadelphia, pp. 508-516 (1983).
ONCOLOGY
16, 282-287
(1983)
The Rare Indication for Splenectomy as Part of Cytoreductive Surgery in Ovarian Cancer GUNTER
DEPPE, M.D.,
EDWARD A. ZBELLA, M.D., ION DUMITRU, M.D.
KENT
SKOGERSON, M.D.,
AND
Division of Gynecologic Oncology and Department of Obstetrics and Gynecology, Mount Sinai Hospital Medical Center, California Avenue at 15th Street, and Rush Medical College, Chicago, Illinois 60608 Received March 21. 1983 Advanced ovarian carcinoma is being treated with aggressive debulking surgery including complete removal of the tumor whenever possible followed by adjuvant therapy. Secondary debulking including splenectomy in a patient with recurrent ovarian carcinoma is reported. It is suggested that splenectomy may have a place in the management of a few patients with ovarian cancer. The technique and complications of splenectomy are described.
INTRODUCTION
Ovarian carcinoma is the most lethal gynecological malignancy. An estimated 11,400 deaths occurred in 1982 from this disease [l]. The currently available screening techniques are inadequate for early detection and the majority of patients have advanced cancer at the time of presentation. Retrospective analysis revealed that prolonged survival in patients with advanced ovarian cancer could be achieved when the size of the largest residual tumor mass was smaller than 1.6 cm in diameter [2]. Newer chemotherapeutic combinations may change the discouraging results of treatment of advanced ovarian cancer [3,4]. Complete remission after a maximal debulking operation can be obtained with combination chemotherapy, therefore, optimal bulk resection of the tumor appears to be justified as part of primary treatment for ovarian cancer [3,5,6]. Ovarian carcinoma may disseminate throughout the peritoneal cavity and occasionally involve the spleen. Splenectomy, as part of a surgical debulking operation, is occasionally necessary. The topic of splenectomy has not been widely discussed in the gynecologic literature. The gynecologic oncologist should be familiar with this procedure since he will be primarily responsible for adequate debulking which may necessitate splenectomy. This report focuses on the management of a patient with recurrent ovarian carcinoma by surgical debulking including splenectomy. The technique of splenectomy and potential complications is presented. 282 0090-8258/83 Copyright All rights
$1.50
0 1983 by Academic Press, Inc. of reproduction in any form reserved
SPLENECTOMY
IN
OVARIAN
283
CANCER
CASE REPORT A 66-year-old, para 0, black female presented with pelvic and abdominal masses suggesting ovarian carcinoma. Five years ago the patient had been treated for a Stage III serous cystadenocarcinoma of the ovary with an abdominal hysterectomy and bilateral salpingo-oophorectomy followed by abdominal radiation. A partial cystectomy, ileocecal resection, rectosigmoid resection, omentectomy, and splenectomy were performed. The splenectomy included resection of part of the diaphragm to which the spleen was attached by tumor. The postoperative course was uncomplicated. Three weeks following surgery cisplatin at a dosage of 75 mg/m’ of body surface and cyclophosphamide at a dosage of 750 mg/m* of body surface were given intravenously. This treatment was administered every 4 weeks. Shortly after the ninth course, the patient refused further therapy. At no time did the patient experience peripheral neuropathy, nephrotoxicity, or symptoms suggesting a gross hearing defect. Nausea and vomiting occurred with each course of treatment. During the 4 months after discontinuation of chemotherapy the patient has remained without clinical evidence of cancer. OPERATIVE
TECHNIQUE
OF SPLENECTOMY
In accomplishing a splenectomy, the procedure is performed differently depending on the indications [7,8]. Our approach in elective splenectomy for debulking is to open the lesser sac (Fig. 1). Next the gastrosplenic ligament is incised in an avascular area while traction is applied to the stomach medially (Fig. 2). It is
PERITONEAL
SPLEEN
FIGURE
1
284
DEPPE
ET
Al..
) SPLEEN
GASTRO-SPLENIC LIGAMENT
STOM
’ FIGURE
LEFT GASTROEPIPLOIC ARTERY
2
imperative to obtain control primarily of the splenic vessels. First the splenic artery can be seen and palpated on the superior border of the pancreas. Double ligatures are passed around the splenic artery midway between the spleen and the celiac axis (Fig. 3). Second, the splenic vein is identified and clamped (Fig. 4.). Care should be taken, if the vein divides into several branches, that those are ligated individually. Then the gastrosplenic vessels are clamped and tied appropriately, SPLENIC
Sl ‘OMACH
FIGURE
3
ARTERY
SPLENECTOMY
SPLENIC
IN
OVARIAN
285
CANCER
AR1
;PLENIC FIGURE
VEIN
4
The spleen can now be mobilized and delivered into the wound. The splenorenal ligament is incised taking care to avoid injuring pancreatic tissue. The ligament between spleen and colon is cut (Fig. 5). The vessels are divided and the spleen is removed. The splenic bed is inspected for hemostasis. Reperitonialization, if feasible, should be carried out.
SPLEEN LIENORENAL i
FIGURE
5
286
DEPPE ET AL.
DISCUSSION
The precise
role of secondary cytoreductive surgery in the management of ovarian carcinoma remains to be defined. In view of effective primary and improved second-line chemotherapy this approach may be justifiable [3,4,9-l 11. In our experience, a limited number of patients will require a splenectomy as part of optimal primary or secondary debulking surgery. Usually it is possible to avoid splenectomy in ovarian cancer surgery since most ovarian cancers grow around and not into the spleen. Our patient with recurrent ovarian cancer underwent maximal surgical debulking including intestinal resection and splenectomy. In spite of prior radiation therapy she tolerated the procedure extremely well allowing her, to date, 12 months of excellent quality survival. Secondary debulking including splenectomy must be individualized. Anticipated complications of splenectomy are hemorrhage, infection, thrombosis, left lower lobe atelectasis, and gastric and pancreatic fistulas. If severe intraoperative hemorrhage from the spleen occurs the tail of the pancreas should be grasped to compress the splenic artery and splenic vein in this area. Further control can then be accomplished by clamping the splenic pedicle. Postoperative hemorrhage related to splenectomy may require laparotomy to religate splenic artery and vein. Hemorrhage usually occurs because adequate hemostasis was not established at the initial surgery. Overwhelming infections may occur in splenectomized patients [121. hophy]actic antibiotics and vaccination with pneumococcal vaccine have been recommended [139141. Platelet counts may be increased after splenectomy and may lead to thrombosis. Anticoagulant therapy should be reserved for the clinically symptomatic patients. Gastric fistula due to injury of the stomach wall at time of splenectomy onlv requires reoperation if peritonitis develops. Pancreatic fistulas resulting. fexLfl T1e most surgical trauma to the tail of the pancreas usually close spontaneously. Common complication after splenectomy is atelectasis and pneumo tia of the left lower lobe. Deep breathing exercises and meticulous trachea’ toilet may be helpful as a preventive measure [ 151. To perform a safe splenectomy as part of primary or secondary optimal debulking for patients with advanced ovarian carcinoma the gynecologic oncologist must be adequately trained. As with any surgical procedure competence, extensive experience and surgical judgement are essential for successful outcome. patients
with
recurrent
REFERENCES 1. American Cancer Society, Cancer, fucrs, undfigures (1982). 2. Griffiths, C. T.. Grogan, R. H., and Hall, with surgery, radiotherapy, chemotherapy,
T. C. Advanced ovarian cancer, Cancer 29, l-7 (1972).
primary
treatment
3. Young, R. C., Chabner, B. A., Hubbard, S. P., Fisher, R. I., Bender, R. A., Anderson, T., Simon, R. M., Canellos, G. P., and Devita, V. T. Advanced ovarian adenocarcinoma. A prospective clinical trial of melphalan (L-PAM) vs combination chemotherapy, N. Engl. J. Med. 299, 1261-1266 (1978). 4. Bruckner, H. W., Cohen, C. J., Goldberg, J. D., Kabakow, B., Wallack, R. C., Deppe, G., Greenspan, E. M., Gusberg, S. B., and Holland, J. F. Improved chemotherapy for ovarian cancer with cis-diamminedichloroplatinum and adriamycin. Cancer 47, 2288-2294 (1981).
SPLENECTOMY
IN
OVARIAN
CANCER
287
5. Griffiths, C. T. Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma, Natl. Cancer Inst. Monogr. 42, 101-104 (1975). 6. Griffiths, C. T., Parker, I., Fuller, A. Role of cytoreductive surgical treatment in the management of advanced ovarian cancer, Cancer Treat. Rep. 63, 235-240 (1979). 7. Zollinger, R. M., and Zollinger, R. M., Jr. Surgican operations, Macmillan Co., New York, pp. 218-222 (1975). 8. Block, G. E., and Exelby, P. E. Operative surgev, principles and techniques, Lea & Febiger, Philadelphia, pp. 670-677 (1980). 9. Berek, J. S., Hacker, N. F., Lagasse, L. D., Nieberg, R. K., and Elashoff, R. M. Survival of patients following secondary cytoreductive surgery in ovarian cancer, Obstet. Gynecol. 61, 189-193 (1983). 10. Vogel, S. E., Grunwald, E., Kaplan, B. H., Moukhtar, M., and Wollner, D. Ovarian cancereffective treatment after alkylating-agent failure, J. Amer. Med. Assoc. 241, 1908-1911 (1979). 11. Bruckner, W. H., Ratner, L. H., Cohen, C. J., Deppe, G., Wallach, R. C., Kabakow, B., Greenspan, E. M., and Holland, J. F. Combination chemotherapy for ovarian carcinoma with cyclophosphamide, adriamycin, and cis-dichlorodiammineplatinum (II) after failure of initial chemotherapy, Cancer Treat. Rep. 62, 1021-1023 (1978). 12. Edwards, L. D., and Digiola, R. Infections in splenectomized patients: A study of 131 patients, Stand. J. Infect. Dis. 8, 255-261 (1976). 13. Prevention of serious infections after splenectomy, Med. Lett. Drugs Ther. 19, 2-4 (1977). 14. Ammann, A. J., and Diamond, M. D. Indications for pneumococcal vaccine in patients with impaired splenic function, N. Engl. J. Med. 299, 778 (1978). 15. Schwartz, S. I. The spleen, in Manual of preoperative and postoperative care (J. M. Kinney et al., Eds.), Saunders, Philadelphia, pp. 508-516 (1983).