title: Laparoscopic Partial Splenectomy for Unknown Primary Cancer: A Stepwise Approach.
abstract: BACKGROUND
  Laparoscopic partial splenectomy (LPS) for focal splenic lesions is technically demanding and carries risk of hemorrhage. Nevertheless, it can be a valuable option, particularly for children and adults in whom attempt at preservation of splenic immunologic function outweighs risk associated with organ preservation.
  
  
  METHODS
  A 58-year-old man was diagnosed with a focal splenic lesion at the upper splenic pole on surveillance imaging following axillary lymph node metastasis for cancer of unknown primary origin (CUP). After an interval of 8 months, repeat FDG-PET showed increase in size and PET-avidity without any evidence of new lesions. Due to isolated site and history of CUP, the patient was considered for a LPS.
  
  
  METHODS
  With the patient in reversed modified French position, the upper pole splenic vessels were controlled and a well-defined area of ischemia encompassing the lesion identified. Under intermittent inflow occlusion and ultrasonography guidance, the parenchymal transection was performed. Total operative time was 180 min, estimated blood loss was 175 cc, the patient was discharged on postoperative day 2, and final pathology confirmed an Epstein-Barr virus associated inflammatory pseudotumor.1,2 CONCLUSION: Safe LPS requires systematic pre-operative assessment of hilar vascular anatomy and a stepwise approach to controlling the vessels intra-operatively. Anatomic parenchymal transection and intermitted vascular isolation for lesions close to the demarcation zone minimizes blood loss. Risk/benefit stratification of LPS may be beneficial in select patients only. Whether in patients with CUP LPS may aid in preserving innate and adaptive immunity with potential clinical, including oncologic, benefits will require further investigations.3-5.
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Eduardo A
authors.initials: EA
authors.lastname: Vega
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Suguru
authors.initials: S
authors.lastname: Yamashita
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Chun Yun
authors.initials: CY
authors.lastname: Shin
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Kim
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Jason B
authors.initials: JB
authors.lastname: Fleming
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Mathew H
authors.initials: MH
authors.lastname: Katz
authors.affiliation: Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Kanwal P S
authors.initials: KP
authors.lastname: Raghav
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Lee
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. cconrad1@mdanderson.org.
authors.forename: Claudius
authors.initials: C
authors.lastname: Conrad
mesh_terms: D006801:Humans; D010535:Laparoscopy; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009382:Neoplasms, Unknown Primary / Q000473:pathology*; D059351:Organ Sparing Treatments / Q000379:methods*; D013156:Splenectomy / Q000379:methods*; D013160:Splenic Neoplasms / Q000556:secondary / Q000601:surgery*