Gastric
& Breast Cancer
DOI: 10.2122/gbc.2002.0006
ORIGINAL
Preservation
vs Resection of the Spleen for Gastric Cancer
Matthias
Lorenz, MD, Dimitrios H. Roukos, MD, Christof Hottenrott, MD and
Albrecht Encke, MD
From
the Departments of Surgery (DHR) and Pathology (NJA), Ioannina
University School of Medicine, 45110 Ioannina, Greece,
droukos@cc.uoi.gr
Background
Resection of the spleen en-block with the stomach for gastric
cancer is still widely performed for a curative resection (R0),
but the presence of the spleen may influence outcome. Balancing
risks and benefits of spleen preservation is challenging. We tested
the hypothesis that in the critical early postsurgical period,
the spleen interferes with the surgical stress-induced immunosuppression
promoted by splenectomy, resulting in a suppression of recurrencedevelopment
from micrometastasis.
Methods Patients were included if they underwent
gastrectomy, with or without splenectomy, for a gastric adenocarcinoma.
Standardized, strongly-defined criteria were used for stratification
of patients who had an extended (D2) lymph node dissection into
the R0 group [limited (D1) resection is insufficient for R-stratification).
Prospectively defined primary endpoints were early (within two
years) and overall recurrence and death from any cause, and secondary
endpoints were postsurgical risks (morbidity, mortality) and metastases
to the splenic hilum nodes.
Results Overall survival for total population
studied (n=202; intent-to-treat) was better for preservation-versusresection
of the spleen among R0 patients (p=0.0001), but not for those
with non-curative resection (p=0.42). On R0 D2 group of patients,
preservation (n=59) over resection (n=67) of the spleen, given
similar postsurgical mortality (3.4% vs 0%), produced at a median
follow-up of1 12 months a significant reduction in risks of early
recurrence (HR, 0.33; 95% CI, 0.16 to 0.69; p=0.003), overall
recurrence (p=0.002) and death from any cause (p=0.009) after
adjustment analysis.
This treatment effect was consistent with subgroup analyses according
to the prognostic factors (nodal/serosal status) needed because
of significant imbalance of these variables at baseline. In multivariate
analysis, preservation of the spleen was an independent predictor
of outcome. An overestimation of the risk for residual disease
in the splenic hilum nodes in the case of spleen preservation
was obtained in 94% of splenectomized patients.
Conclusions Our findings indicate that preservation
of the spleen is associated with a clearly reduced risk of early
and overall recurrence translated into a better survival in patients
receiving curative surgery for gastric cancer.
Key Words: gastric cancer, gastrectomy with spleen
preservation / splenectomy, recurrence, survival
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