title: Still a role for surgery as first-line therapy of splenic marginal zone lymphoma? Results of a prospective observational study.
abstract: OBJECTIVE
  Assessment of hematologic improvement, survival and peri-operative morbidity after first-line splenectomy for splenic marginal zone lymphoma (SMZL).
  
  
  METHODS
  Forty-three patients undergoing open splenectomy were prospectively analyzed. Perioperative clinical course, overall and progression-free survival (OS-PFS) were evaluated. Risk factors analyzed were gender, age, ASA-grade, ECOG performance status, presence of B-symptoms, body mass index, steroidal treatment, serum albumin concentration, IIL-score, operative time, spleen size and weight.
  
  
  RESULTS
  The median follow-up was 31 months (IQR 15-76; range 24-154). Anemia and thrombocytopenia resolved in 80% of patients at 6 months; in 60% at 2 years. The 5-year and 10-year PFS were 35% and 13% respectively, with a median of 35 months (shorter in patients with ECOG performance status ≥2 and B-symptoms). Nineteen cases (44.2%) had a progression of disease within 2 years. Of these, 14 (32.6%) received adjuvant chemotherapy (mainly R-FC or R-CVP). Progression was attributed to high-grade B lymphoma in 7 (16.3%) patients. The median time between diagnosis and progression to aggressive lymphoma was 25.5 months (range 18.8-81.8). The median time to next treatment was 83.5 months (95% CI 49-118). The 5-year and 10-year OS were 75% and 53% respectively. Mortality was due to disease progression and histological transformation in high-grade B lymphoma in 50% of cases, myelodisplastic syndrome in 15%, recurrence of hemolytic anemia in 15%, Hodgkin lymphoma in 7% and to infections (mainly pulmonary) in the remaining 13% of cases. Post-operative morbidity was 2.3% (1 patient with grade-3 complication). Overall grade ≥2 complication rate was 32.5% (mainly hemorrhagic and pulmonary complications). Spleen weight was the only independent risk factor for morbidity. Mortality was nil.
  
  
  CONCLUSIONS
  Splenectomy is safe and effective as regards cytopenia resolution and OS, although disease progression is frequently observed at follow-up. Such results are strictly linked to accurate pre- and post-operative clinical management and optimal anesthesiologic approach.
authors.affiliation: Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy. Electronic address: giacomopata@alice.it.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Pata
authors.affiliation: Department of Medical & Surgical Sciences, 2nd Division of General Surgery, University of Brescia School of Medicine, Brescia, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Bartoli
authors.affiliation: Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Damiani
authors.affiliation: Department of Medical & Surgical Sciences, 2nd Division of General Surgery, University of Brescia School of Medicine, Brescia, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Solari
authors.affiliation: Division of Hematology, Brescia Civic Hospital, Brescia, Italy.
authors.forename: Antonella
authors.initials: A
authors.lastname: Anastasia
authors.affiliation: Division of Hematology, Brescia Civic Hospital, Brescia, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Pagani
authors.affiliation: Division of Hematology, Brescia Civic Hospital, Brescia, Italy.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Tucci
mesh_terms: D000328:Adult; D000368:Aged; D000740:Anemia / Q000209:etiology; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant / Q000379:methods; D018450:Disease Progression; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D018442:Lymphoma, B-Cell, Marginal Zone / Q000188:drug therapy / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D011184:Postoperative Period; D011446:Prospective Studies; D013156:Splenectomy / Q000009:adverse effects*; D013160:Splenic Neoplasms / Q000188:drug therapy / Q000601:surgery*; D013921:Thrombocytopenia / Q000209:etiology; D016896:Treatment Outcome
keywords: Complications; Outcomes; SMZL; Splenectomy; Surgery; Survival