Splenectomy in Cytoreductive Surgery for Ovarian Cancer: Do Patients Benefit?

Letter to the Editor

Eugenia Halkia, MD, and John Spiliotis, MD.

Dr. Eugenia Halkia, Department of Gynaecology, "METAXA" Cancer Memorial Hospital, Piraeus, Greece. Dr. John Spiliotis, Head of Department of Surgery, "METAXA" Cancer Memorial Hospital, Piraeus, Greece.

To the Editors:

The benefits of additional splenectomy for patients with a primary gastrointestinal or ovarian cancer aiming at achieving better locoregional tumor control still remains controversial over the last three decades. Although splenectomy can increase local curability it may be associated with a rise in postoperative morbidity and reduced survival through immune system depression.

Ovarian cancer is the most deadly gynecologic cancer. Mortality is roughly 70% for patients with advanced tumor who account for 75% of ovarian cancer diagnoses. Standard of care for these women with late diagnosis is cytoreductive surgery with systemic and intraperitoneal chemotherapy. Promising but not yet established treatments options are hyperthermic intraperitoneal chemotherapy (HIPEC) or neoadjuvant treatments which are under active investigation [1]. However, the role of splenectomy as part of cytoreductive surgery has been debated.

In a recent issue of Annals of Surgical Oncology McCann and colleagues [2] report the results of a retrospective study. Aiming to assess the impact of splenectomy as a part of cytoreductive surgery on early and long-term outcomes of patients with ovarian cancer, the authors analyzed the data of 44 ovarian cancer patients who underwent cytoreductive surgery including splenectomy at their institution. In 37 of these (84%) patients, cytoreductive surgery could be completed as an optimally procedure with splenectomy to have substantially contributed to this surgically optimization. Median time to first chemotherapy was 13.5 (5-54) days. As compared to a median overall survival of 45 months for 171 patients who did not undergo splenectomy (no-splenectomy group) the survival of 30 months in the optimally cytoreduced in the splenectomy cohort was significantly shorter (P < 0.045). The authors conclude that although the addition of splenectomy to up-front cytoreductive surgery was safe, it was associated with worse survival and suggest splenectomy for optimal cytoreduction in more biologically aggressive disease.

The study by McCann et al [2] increases the uncertainty for the preservation or resection of the spleen during cytoreductive surgery rather than to solve the problem. It is difficult to classify the patients into more and less biologically aggressive disease for deciding on splenectomy and more data are need for such a decision. Taken examples for other solid tumors, as for example gastric cancer, every effort should be made to prevent the spleen and splenectomy is indicated only when radicality without reception of the spleen cannot be achieved.

The question of additional splenectomy will probably continue to remain controversial in the near future. Research endeavour is currently focused on discovering a set of proteins and their interactions that causatively related to ovarian cancer development. These proteomics-based developments of diagnostic tools alone or in combination microRNAs and their importance in predicting ovarian cancer networks may lead to the discovery of biomarkers to accurately predict ovarian cancer in asymptomatic women. Apart of early detection of the disease through robust biomarkers-based screening of the general population, new therapies are required. Rational strategies for the development of novel effective therapies and predictors of response to these therapies include ovarian cancer whole genome and exome sequencing and translational research towards understanding how somatic and inherited mutations, epigenetic modifications and microRNAs dysregulate gene expression [1, 3].

Acknowledgment: There is no research support for this article.
Conflict of interest: The authors declare no conflict of interest.

References

1. Spiliotis J, Halkia E, Roukos Ovarian cancer screening and peritoneal carcinomatosis: standards, omics, and miRNAs for personalized management. Exp Rev Mol Diagn 2011 Jun;11(5):465-7

2. McCann CK, Growdon WB, Munro EG, Del Carmen MG, Boruta DM, Schorge JO, Goodman A. Prognostic Significance of Splenectomy as Part of Initial Cytoreductive Surgery in Ovarian Cancer. Ann Surg Oncol. 2011 Mar 22. DOI: 10.1245/s10434-011-1661-z

3. Garzon R, Marcucci G, Croce CM. Targeting microRNAs in cancer: rationale, strategies and challenges. Nat Rev Drug Discov. 2010; 9(10): 775-89.


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