Laparoscopic Treatment of Isolated Spleen Metastases in Recurrent Ovarian Cancer

Introduction

Recurrence of ovarian cancer occurs via the peritoneum, which presents with multiple seedings and is commonly associated with peritoneal carcinomatosis. Unlike most other cancers, ovarian cancer rarely disseminates through the vasculature even though it may involve pelvic and/or paraaortic lymph nodes [1]. As a consequence of its pathophysiologic mechanism, isolated parenchymal metastasis of any organ in ovarian cancer is rare and this is particularly the case with isolated spleen metastasis. However, single organ metastasis, such as spleen, is often reported in other types of malignancies. The majority of splenic metastases arise from hematological malignancies, such as malignant lymphoma or leukemia. Secondary debulking may be considered as a treatment option since it may improve the prognosis when there is no sign of residual disease, but it will not be effective when there are multiple seedings or multiple organ metastases. However, it can be considered an effective treatment option only if there is a solitary lesion of recurrence. To our knowledge only 36 cases of isolated spleen parenchymal metastases have been reported. We report three cases of isolated splenic metastasis as the first site of recurrence of ovarian cancer and suggest laparoscopic splenectomy as an effective therapeutic modality for this type of metastasis in ovarian cancer.

Discussion

The biological behavior of ovarian carcinoma is markedly different from the classic and well-known pattern of hematogenous metastasis found in most other cancers. Once the cancer cells have detached as single Copyright© Cho CH

cells or clusters from the primary ovarian tumor, it is thought that they metastasize through a passive mechanism, carried by the physiological movement of peritoneal fluid to the peritoneum and omentum. Clinical observation and retrospective clinical studies suggest that serous ovarian carcinomas grow very efficiently within the peritoneal cavity in a pattern of multiple seeding but rarely metastasize to a single organ [2]. This type of carcinoma usually spreads transperitoneally to neighboring organs, such as the rectum, sigmoid colon, and urinary bladder. In addition to direct and peritoneal invasion, lymphatic and hematogenous dissemination are also common. The most common sites of lymph node involvement are intra-abdominal and para-aortic lymph nodes. Only 36 cases of isolated parenchymal metastasis of ovarian cancer have been reported in the literature. Solitary parenchymal metastases of the spleen are most probably generated through the hematogenic route, which is rare because of several mechanisms, including rhythmic contractions of the splenic capsule, the sharp angle of the splenic artery branching from the celiac artery, lack of afferent lymphatic vessels to the spleen, and mostly the inhibitory effect of the splenic microenvironment on the growth of metastatic cells [3]. The current treatment of advanced ovarian carcinoma relies on aggressive surgical cytoreduction followed by platinum-based chemotherapy. Although the role of secondary cytoreductive surgery in the treatment of disseminated disease remains unclear, patients with solitary metastases seem to have better survival after optimal secondary debulking. Solitary metastases can often be treated successfully with an expectation of prolonged survival. Secondary debulking has been advocated as a means of augmenting the durability of response to subsequent adjuvant chemotherapy [4]. A recent retrospective study by Magrina et al. [5] compared laparotomic, laparoscopic, and robotic surgeries among 52 selected recurrent ovarian cancer patients undergoing secondary cytoreduction. Their study showed that patients localize disease benefit from a laparoscopic or robotic secondary cytoreduction and experience comparable survival, whereas laparotomy is the preferred treatment for patients with widespread peritoneal implants, multiple sites of recurrence, or extensive adhesions. For an isolated splenic metastasis, most reported cases are of open laparotomy [6, 7]; however, laparoscopic splenectomy can provide several advantages over laparotomy, such as a shorter operation time, better Cho CH. Laparoscopic Treatment of Isolated Spleen Metastases in Recurrent Ovarian Cancer. J Gynecol 2016, 1(5): 000127.

visualization, less blood loss, shorter hospital stay, and the possibility of an earlier initiation of postoperative chemotherapy. Three cases were included in this case reports with institutional ethics board approval (No. 2015-07-025). In our third case, a newly developed, solitary, metastatic spleen lesion was observed in preoperative imaging, but biopsy results showed no tumor. This is a good example of the laparoscopic approach compared to open laparotomy as the patient will not receive any unnecessary adjuvant chemotherapy. Consequently, laparoscopic approach can offer better postoperative quality of life from a faster recovery without compromising patient survival. When an isolated splenic lesion is detected during follow-up imaging, the laparoscopic approach can be an effective surgical method of diagnosis and treatment at the same time without increasing morbidity. In a short period of time, it can provide more guidance to the next therapeutic approach. We suggest that laparoscopic splenectomy can be a proper and feasible therapeutic modality for isolated splenic metastasis.

Acknowledgment

This work was supported by the Scholar Research Grant of Keimyung University in 2015.