Hematologic changes after splenectomy for cytoreduction: implications for predicting infection and effects on chemotherapy

Pancytopenia after administration of hyperthermic intraperitoneal chemotherapy with mitomycin-C: local therapy and systemic toxicity

Cytoreductive surgery (CRS) coupled with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard of treatment for many cancers with peritoneal metastasis. Mitomycin-C (MMC), the most common chemotherapy utilized with HIPEC, is associated with neutropenia but the degree of hematologic toxicity is unclear when splenectomy is included as part of CRS with MMC. We present an interesting case of pancytopenia following treatment with HIPEC using MMC and comment on the possible role of splenectomy in exacerbating its cytotoxic effects. Our unique case highlights potential hematologic toxicity following MMC-HIPEC and splenectomy. It suggests that spleen removal may enhance toxicity profiles of chemotherapy such as MMC. Because MMC is the preferred agent of choice used in CRS-HIPEC, future studies should investigate optimal MMC dosing and patient selection when splenectomy is performed to balance survival benefit with hematologic toxicities.

Splenectomy and distal pancreatectomy in advanced ovarian cancer

Splenectomy or distal pancreatectomy (DP) is sometimes performed for optimal cytoreduction in advanced ovarian cancer (AOC). In particular, it is considered to remove tumors involving the splenic hilum or the capsule of the spleen to secure tumor-free margins sufficiently. For splenectomy, the gastro-splenic ligament is opened, and the short gastric vessels are dissected. After the splenocolic ligament and splenic flexure of the colon are transected, the peritoneal attachments, including the splenorenal and splenophrenic ligaments, are divided to mobilize the spleen, and then the splenic artery and vein are identified and ligated separately. If DP is needed for en bloc resection of tumors, a linear cutting stapler is used to remove the tail of the pancreas, and suture reinforcement with 2-0 or 3-0 prolene on the cut section of the pancreas is performed to prevent postoperative pancreatic fistula (POPF). Immunization with a polyvalent pneumococcal vaccine is required after splenectomy to avoid overwhelming post-splenectomy infection (OPSI) caused by Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. If POPF occurs after splenectomy or DP, continued drainage with close monitoring is needed with the administration of board spectrum antibiotics in grade A or B POPF according to the criteria of the International Study Group of Pancreatic Fistula (ISGPF). In contrast, grade C POPF requires aggressive management using nothing by mouth, total parenteral nutrition, and somatostatin analogs, and sometimes reoperation if deteriorating signs such as sepsis and organ dysfunction. Thus, the effort for preserving pancreatic tail is needed to reduce hospitalization and the risk of POPF despite the minimal impact of DP on the success rate of optimal cytoreduction.

Hematologic changes after splenectomy for ovarian cancer debulking surgery, and association with infection and venous thromboembolism

INTRODUCTION

The spleen plays a role in the immune and coagulative responses, yet a splenectomy may be required during ovarian cancer surgery to achieve complete cytoreduction. The aim of the study was to correlate hematologic changes with the development of infection and venous thromboembolism in patients undergoing splenectomy.

METHODS

This single-institution retrospective review includes all patients undergoing splenectomy during cytoreductive surgery for advanced ovarian cancer, March 2001 to December 2016. We compared postoperative hematologic changes (evaluated daily before discharge) in patients developing infection within 30 days' post-surgery (Infection group) with those who did not (No-Infection group). We also compared patients developing venous thromboembolism with those without.

RESULTS

A total of 265 patients underwent splenectomy. Median age was 64 years (range 22-88): 146 (55%) patients had stage IIIC and 114 (43%) patients had stage IV. The majority, 201 (76%) patients underwent splenectomy during primary debulking. A total of 132 (50%) patients comprised the Infection group (most common: urinary tract infection, 54%). Median time from surgery to infection was 8 days (range, 0-29). After initial rise in white blood cell count in both groups, the Infection group had a second peak on postoperative day 10 (median 16.6K/mcL, IQR 12.5-21.2) not seen in the No-Infection group (median 12K/mcL, IQR 9.3-16.3). A total of 40 (15%) patients developed venous thromboembolism, median time of 6.5 days (range, 1-43). All patients demonstrated a continuous rise in platelets during postoperative days 0-15. Thrombocytosis was present in 38/40 (95%) patients with venous thromboembolism vs 183/225 (81%) patients without (P=0.036). Median days with thrombocytosis was higher in venous thromboembolism (8 days, range 1-15) vs non groups (6 days, range 1-16, P=0.049).

CONCLUSION

We identified initial leukocytosis after splenectomy in all patients. The Infection group had a second peak in white blood cell count on postoperative day 10, not present in the No-Infection group. Among patients with venous thromboembolism, thrombocytosis was more frequent and of longer duration.

Post-operative pancreatic fistula following splenectomy with or without distal pancreatectomy at cytoreductive surgery in advanced ovarian cancer

OBJECTIVE

Splenectomy with or without distal pancreatectomy may be necessary at time of cytoreductive surgery to achieve complete cytoreduction in advanced ovarian cancer. However, these procedures have been associated with peri-operative morbidity. The aims of this study were to determine the incidence of distal pancreatectomy among patients undergoing splenectomy during cytoreductive surgery for advanced ovarian cancer and to determine the incidence, management, treatment, and prognosis of patients with post-operative pancreatic fistula.

METHODS

Retrospective cohort study of all consecutive patients with FIGO stage IIIC-IVB ovarian, fallopian tube, or primary peritoneal cancer who underwent splenectomy with or without distal pancreatectomy, during primary, interval, or secondary cytoreductive surgery between January 2007 and December 2017. All histologic subtypes were included; patients with borderline ovarian tumor and those undergoing emergency surgery were excluded from analysis. Univariate analyses for survival were generated by Kaplan-Meier survival curves and log-rank (Mantel-Cox) tests for statistical significance. Patients who underwent surgery for recurrence were excluded from survival analysis. Inter-group statistics were performed using Student's t-test for continuous variables, and chi-square test and Fisher's exact test for categorical variables.

RESULTS

A total of 156/804 (19.4%) women underwent splenectomy, and of these 22 (14.1%) patients had distal pancreatectomy. Of patients who underwent splenectomy only, 2/134 (1.5%) developed grade B post-operative pancreatic fistula and 6/22 (27.3%) patients who underwent distal pancreatectomy developed grade B and C post-operative pancreatic fistula. Five (83.3%) of six of these patients were symptomatic. Distal pancreatectomy patients had a higher risk of developing post-operative pancreatic fistula when compared with patients who underwent splenectomy only (63.7% vs 9.7%, p=0.0001). Median length of hospital stay was longer in patients with post-operative pancreatic fistula: 16.5 (range 7-38) days compared with 10 (range 7-15) days (p=0.019). There was no progression-free survival (p=0.42) and disease-specific survival (p=0.33) difference between patients undergoing splenectomy with or without distal pancreatectomy.

CONCLUSION

Clinically relevant post-operative pancreatic fistula is a relatively frequent complication (27.3%) following distal pancreatectomy and it is a possible complication after splenectomy only (1.5%).

Doppler ultrasonographic evaluation of brachial and femoral veins, and coagulation and lipid profiles in dogs following open splenectomy

In dogs, splenectomy is mandatory as an emergency following splenic rupture with resultant hemoperitoneum and hypotensive shock. The present work aimed to evaluate the Doppler ultrasonographic parameters of brachial and femoral veins in splenectomized dogs and to investigate the effect of splenectomy on the coagulation and lipid profiles. A total number of 9 dogs underwent clinical, abdominal ultrasonographic and laboratory examinations prior to the surgical operation and kept for 60-day observation period post-splenectomy. Follow-up ultrasonography revealed no serious complications post-splenectomy. Both brachial and femoral veins were imaged medial to their corresponding arteries. Doppler ultrasonographic parameters of both veins showed no significant changes throughout the study period (P > 0.05). Haematological analysis revealed development of anemia, leukocytosis, and thrombocytosis in dogs post-splenectomy. Coagulation profile exhibited no significant variations in prothrombin and activated partial thromboplastin times (P > 0.05). In comparison with their baseline values, the mean concentrations of total cholesterol, low-density lipoprotein, and triglycerides were significantly increased 30-day post-splenectomy. In conclusion, it may seem that open splenectomy has no influence on the Doppler ultrasonographic indices of brachial and femoral veins with no evidence of deep vein thrombosis in dogs. However, persistent leukocytosis and thrombocytosis, as well as altered lipid profile may increase the risk of vascular complications with the long run. Therefore, a further long-term study may be required.

Diagnostic value of post-operative platelet-to-white blood cell ratio after splenectomy in patients with advanced ovarian cancer

INTRODUCTION

Splenectomy-induced thrombocytosis and leukocytosis may obscure the early diagnosis of post-operative infection or sepsis. In trauma patients after splenectomy, a platelet-to-white blood cell ratio of <20 has been shown to reliably differentiate post-operative sepsis from transient physiological responses.

OBJECTIVE

To determine whether the platelet-to-white blood cell ratio can be applied to differentiate between reactive post-operative changes and latent infection.

METHODS

All consecutive patients with ovarian cancer who underwent splenectomy between January 2013 and October 2018 in two large European gynecological cancer centers were retrospectively evaluated. Main outcome measures were white blood cell count, platelet count, and platelet-to-white blood cell ratio on post-operative days 1, 5, and 7. These were correlated with surgical outcome and morbidity according to the Clavien-Dindo classification. A binomial logistic regression was applied to assess the predictive value of day 5 platelet-to-white blood cell ratio, white blood cell count, and platelet count for predicting grade III post-operative sepsis.

RESULTS

Ninety-five patients with ovarian cancer (mean age 54 years, range 18-75) were identified. Seventeen patients (17.9%) developed a grade III post-operative sepsis. In all post-operative patients, mean white blood cell count on day 5 decreased (from 15.4×10³/μL to 11.4×10³/μL), while the mean platelet count rose (from 260.7×10³/μL to 385.3×10³/μL). A high platelet count (>313×10³/μL) failed to show any predictive value (OR=0.94; 95% CI 0.30 to 3.0; p=0.921). A low platelet-to-white blood cell ratio (<26) (OR=3.49; 95% CI 1.18 to 10.32; p=0.0241) and high white blood cell count (>14.5×10³/μL) on day 5 (OR=11.0; 95% CI 3.3 to 36.2; p<0.001) were significant for predicting sepsis. Despite a significant OR, the sensitivity and specificity were low; day 5 platelet-to-white blood cell ratio at a cut-off point of 26 achieved a sensitivity of 72% and specificity of 53% (area under the curve 0.637, 95% CI 0.480 to 0.796) in predicting grade III post-operative sepsis.

CONCLUSIONS

Platelet-to-white blood cell ratio after cytoreductive surgery for ovarian cancer with splenectomy does not appear to have a strong predictive value in differentiating between sepsis and reactive splenectomy-induced changes. Leukocytosis, in combination with clinical assessment, may remain the most useful tool for prediction of sepsis after cytoreductive surgery with splenectomy.

Incidence of leukopenia after intraperitoneal vs combined intravenous/intraperitoneal chemotherapy in pseudomyxoma peritonei

AIM: To investigate the clinical impact of post-hyperthermic intraperitoneal chemotherapy (HIPEC) leukopenia, intraperitoneal and combined intravenous/intraperitoneal drug administrations were compared.

METHODS: Two patient cohorts were retrospectively analyzed regarding the incidence of postoperative leukopenia. The first cohort (n = 32) received Mitomycin C (MMC)-based HIPEC intraperitoneally (35 mg/m² for 90 min) and the second cohort (n = 10) received a bi-directional therapy consisting of oxaliplatin (OX) (300 mg/m² for 30 min) intraperitoneally and 5-fluorouracil (5-FU) 400 mg/m² plus folinic acid 20 mg/m² intravenously. The following data were collected retrospectively: Age, sex, length of operation, length of hospital stay, amount of resection including extent of peritonectomy, peritoneal cancer index, CC (completeness of cytoreduction)-status and leukocyte-count before cytoreductive surgery (CRS) and HIPEC, on days 3, 7 and 14 after CRS and HIPEC. HIPEC leukopenia was defined as < 4000 cells/m³.

RESULTS: Leukopenia occurred statistically more often in the MMC than in the OX/5-FU-group (10/32 vs 0/10; P = 0.042). Leukopenia set-on was on day 7 after CRS and MMC-HIPEC and lasted for two to three days. Three patients (33%) required medical treatment. Patients affected by leukopenia were predominantly female (7/10 patients) and older than 50 years (8/10 patients). The length of hospital stay tended to be higher in the MMC-group without reaching statistical significance (22.5 ± 11 vs 16.5 ± 3.5 d). Length of operation (08:54 ± 01:44 vs 09:48 ± 02:28 h) were comparable between patients with and without postoperative leukopenia. Prior history of systemic chemotherapy did not trigger post-HIPEC leukopenia. Occurrence of leucopenia did not trigger surgical site infections, intraabdominal abscess formations, hospital-acquired pneumonia or anastomotic insufficiencies.

CONCLUSION: Surgeons must be aware that there is a higher incidence of postoperative leukopenia in MMC-based HIPEC protocols primarily affecting females and older patients.

Platelet Dynamics in Peritoneal Carcinomatosis Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Oxaliplatin

The aim of the study was to characterize the platelet count (PLT) dynamics in peritoneal carcinomatosis patients treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal oxaliplatin (HIO). Data from patients treated with CRS alone (N = 18) or CRS and HIO (N = 62) were used to estimate the baseline platelet count (PLT0), rate constants for platelet maturation (k tr ) and platelet random destruction (k s ), feedback on progenitor cell proliferation (γ), and the drug-specific model parameters (α, β). Plasma oxaliplatin concentrations, C p , reduced the proliferation rate of progenitor cells (k prol) according to a power function α × C p (β) . The surgery effect on k prol and k s was explored. The typical values (between subject variability) of the PLT0, k tr , k s , γ, α, and β were estimated to be 237 × 10(9) cells/L (32.9%), 7.09 × 10(-3) h(-1) (47.1%), 8.86 × 10(-3) h(-1) (80.0%), 0.621, 0.88 L/mg (56.9%), and 2.63. Surgery induced a maximal 2.09-fold increase in k prol that was attenuated with a half-life of 8.42 days. Splenectomy decreased k s by 47.5%. Age, sex, body surface area, sex, total proteins, and HIO carrier solution did not impact the model parameters. The model developed suggests that, following CRS and HIO, thrombocytopenia and thrombocytosis were reversible and short-lasting; the severity of the thrombocytopenia and thrombocytosis was inversely correlated, with splenectomized patients having thrombocytopenia of lower severity and thrombocytosis of higher severity; and the HIO dose and treatment duration determine the severity and duration of the thrombocytopenia. Higher HIO dose or longer treatment duration could be used without substantially increasing the risk of major hematological toxicity.

Splenectomy increases the number of circulating hematopoietic stem/progenitor cells in patients with hepatitis C virus-associated liver cirrhosis

AIM

The spleen is not believed to contribute to hematopoiesis in healthy adults. However, several reports have demonstrated that the spleen in adults contains a large number of hematopoietic stem/progenitor cells (HSC). Although splenectomy increases platelet and leukocyte counts, the effects of splenectomy on circulating HSC have not been elucidated. In this study, we evaluated the association between the number of circulating HSC and splenectomy in patients with hepatitis C virus (HCV)-associated liver cirrhosis (LC).

METHODS

In 48 patients with various stages of HCV-associated chronic liver disease and seven patients with LC who underwent splenectomy, and 10 healthy volunteers, we determined the numbers of circulating CD34⁺ cells and colony-forming unit culture by flow cytometry and methylcellulose culture, respectively. Plasma stromal cell-derived factor-1α (SDF-1α) concentrations were measured using an enzyme-linked immunosorbent assay.

RESULTS

The numbers of circulating CD34⁺ cells and colony-forming unit culture decreased but the plasma SDF-1α concentration increased with the progression of liver disease. There was an inverse correlation between the number of circulating HSC and the plasma SDF-1α concentration. The numbers of circulating HSC and platelets were determined before and after splenectomy in seven patients with LC. In these patients, the numbers of circulating HSC and platelets increased significantly after splenectomy and the enhancing effect persisted for a long time.

CONCLUSION

Our data suggest that the spleen plays an important role in modulating HSC dynamics in patients with HCV-associated chronic liver disease. Our results also imply that splenectomy may improve liver function in patients with LC.

Splenectomy ameliorates hematologic toxicity of hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a promising modality for peritoneal carcinomatosis. Splenectomy is frequently required, however effect upon hematotoxicity is unknown.

METHODS

195 patients undergoing the procedure were evaluated and granulocyte colony stimulating factor administered for white blood cell counts <4.0.

RESULTS

52% of 195 underwent splenectomy; average white blood cell and platelet nadirs were 6.1,172. Non-splenectomy patients averaged white blood cell nadir 4.6, platelet nadir 164.1. Granulocyte colony stimulating factor administered in 29% of splenectomy, 43% of non-splenectomy (P=0.043).

CONCLUSION

Splenectomy ameliorates hematotoxicity of hyperthermic intraperitoneal chemotherapy and significantly reduces post-operative granulocyte colony stimulating factor requirements.

A comparison of hematologic toxicity profiles after heated intraperitoneal chemotherapy with oxaliplatin and mitomycin C

BACKGROUND

Although peritoneal carcinomatosis (PC) from colorectal and appendiceal tumors is consistent with metastatic disease, complete cytoreduction with hyperthermic intraperitoneal chemotherapy (HIPEC) using mitomycin C (MMC) can improve survival. A recent phase I study by our group using hyperthermic intraperitoneal oxaliplatin has demonstrated its safety and appropriate dose. Our goal in this study is to present a single institution's experience with the hematologic toxicities of the two agents.

METHODS

We performed a retrospective review of 187 patients with PC of colorectal or appendiceal origin who underwent HIPEC with MMC or oxaliplatin between October 2006 and September 2009. Hematologic toxicities were graded according to the NCI Common Terminology Criteria for Adverse Events Version 4.0.

RESULTS

Of the 187 patients, 55 had oxaliplatin-based HIPEC while 132 patients received MMC. Splenectomy was performed in 95 patients (50.8%) due to disease involvement. When comparing hematologic toxicity for MMC and oxaliplatin among the cohort of patients who underwent splenectomy, a statistically significant difference was noted in the incidence of platelet (P = .02) and neutrophil (P = .05) toxicity, with oxaliplatin having a higher incidence of grade 3 and grade 4 platelet and neutrophil toxicity respectively. However, no statistically significant difference in hematologic toxicity was noted between the two agents in patients who did not undergo splenectomy during cytoreductive surgery.

CONCLUSIONS

Oxaliplatin-based HIPEC for PC of colorectal and appendiceal origin is associated with similar white blood cell toxicity and higher platelet and neutrophil toxicity compared to MMC-based HIPEC.

Incidence, risk factors, and impact of severe neutropenia after hyperthermic intraperitoneal mitomycin C

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the standard of care for patients with peritoneal dissemination of appendiceal cancer and are increasingly being evaluated for use in patients with carcinomatosis from colon cancer. Mitomycin C (MMC) is one of the most frequently used HIPEC agents in the management of peritoneal-based gastrointestinal malignancies. This study analyzes the incidence and risk factors for developing neutropenia following MMC-HIPEC combined with CRS.

METHODS

All patients undergoing CRS and MMC-HIPEC for appendiceal cancer between January 1993 and October 2006 were retrospectively reviewed. Logistic regression was used to identify risk factors for the development of neutropenia, defined as an absolute neutrophil count (ANC) <1,000/mm(3).

RESULTS

One hundred and twenty MMC-HIPEC were performed in 117 patients with appendiceal cancer. The incidence of neutropenia was 39%. Neutropenia occurred in 57.6% of female and 21.3% of male patients (p < 0.0001). Female gender and MMC dose per body surface area (BSA) were independent risk factors for neutropenia on multivariable logistic regression [odds ratio (OR) of neutropenia in females = 3.58 (95% confidence interval, CI: 1.52, 8.43); OR for 5 unit (mg/m(2)) increase in MMC dose per BSA = 3.37 (95% CI: 1.72, 6.63)]. Neutropenia did not increase the risk of mortality, postoperative infection or length of hospital stay.

CONCLUSION

Neutropenia is a frequent complication associated with MMC-HIPEC. Female sex and MMC dose per BSA are independent risk factors for neutropenia. These differences must be considered in the management of patients undergoing MMC-HIPEC to minimize the toxicity of the procedure.

Incidence and management of pancreatic leaks after splenectomy with distal pancreatectomy performed during primary cytoreductive surgery for advanced ovarian, peritoneal and fallopian tube cancer

OBJECTIVE

To determine the incidence, management, and outcome of patients diagnosed with a pancreatic leak after a distal pancreatectomy during primary surgical cytoreduction for ovarian, peritoneal, or tubal cancer.

METHODS

We performed a retrospective chart review of all patients who had a distal pancreatectomy at the time of primary surgery. Charts were reviewed to identify those patients who developed a persistent left upper quadrant abdominal fluid collection with elevated amylase levels.

RESULTS

A total of 17 patients had a distal pancreatectomy; of these, 4 patients (24%) developed a postoperative pancreatic leak. In these patients, persistent leukocytosis prompted evaluation with a computed tomography scan, which subsequently revealed a fluid collection. The median time from surgery to drainage of this collection was 9 days (range, 8-66). The drain remained in situ for a median of 29 days (range, 22-82). The median amylase level of the fluid was 22,945 U/L (range, 763-47,250). The median length of hospital stay for those patients with a leak was 33 days (range, 25-44), which was longer than those without a leak. However, the median time from surgery to treatment with systemic chemotherapy was 31 days (range, 16-43), which was equivalent to those without a pancreatic leak.

CONCLUSION

Twenty-four percent of patients who had undergone a distal pancreatectomy developed a pancreatic leak. This complication, which usually presents early in the postoperative period, can be managed conservatively with percutaneous drainage. Oral intake may be resumed, and total parenteral nutrition is not needed in the majority of cases. Systemic chemotherapy can be administered without significant delay.