Rapid development of malignant metastases in the abdominal wall after laparoscopy

Isolated abdominal wall metastasis 42 years after curative surgery for ovarian cancer: A case report

Despite the rarity of abdominal or chest wall metastases in ovarian cancer patients, reports have described instances of isolated late recurrence at surgical incision sites. We report the case of an 85-year-old woman who present with a massive metastatic tumor on the right anterior abdominal wall 42 years after undergoing a total abdominal hysterectomy and bilateral salpingo-oophorectomy for primary ovarian cancer. The abdominal wall tumor was resected en bloc, and abdominal wall reconstruction was performed using a mesh. Histology revealed a low-grade serous carcinoma. This report highlights the possibility of abdominal wall metastases after prolonged survival following the treatment of ovarian cancer. Surgical excision combined with mesh reconstruction represents an adequate treatment approach for such cases. Caution should be exercised during laparotomy to ensure complete removal of malignant tissue and to prevent parietal dissemination. Long-term follow-up is crucial for ovarian cancer patients, as late recurrences, although rare, can occur even decades after initial treatment.

The minimally invasive resection of port-site metastasis of ovarian cancer after laparoscopy with cutaneous integrity: a case report and literature review

BACKGROUND

Postoperative wound recovery following laparotomy for port-site metastasis (PSM) resection is a concern. Reports indicate that wound healing disorders occur in patients with PSM. The challenges associated with PSM resection include the complete removal of the lesion, ensuring rapid wound healing, and maintaining the integrity of the abdominal wall. To date, there have been no reports on a minimally invasive approach for PSM resection following ovarian cancer through the inner side of the abdominal wall.

CASE PRESENTATION

A 66-year-old G2P1 patient with a history of high-grade serous ovarian adenocarcinoma IIA presented with two abdominal wall masses, suspected to be PSM. She underwent laparoscopic resection of the lesions under general anesthesia. The excised masses measured approximately 10 cm and 5 cm, and margins were negative. The surgery lasted 1 hour and 33 minutes, with minimal intraoperative bleeding and no complications. The postoperative recovery was smooth. No recurrence was observed during the 12-month follow-up.

CONCLUSIONS

In our view, laparoscopy may be used as a minimally invasive technique that allows for PSM in the abdominal wall.

Port Site Metastasis in Women with Low- or Intermediate-Risk Endometrial Carcinoma: A Systematic Review of Literature

Background: Port site metastasis (PSM) has been reported as a rare metastasis in women with endometrial carcinoma (EC). However, even more rarely, it has also been described in patients with low- or intermediate-risk EC. Unfortunately, knowledge appears limited on the topic. Objectives: Our objective was to systematically review the literature on PSM in low- or intermediate-risk EC. Search Strategy: A systematic review of the literature was performed by searching six electronic databases from their inception to January 2023. Selection Criteria: We included in our research all peer-reviewed studies which reported PSM in low- or intermediate-risk EC women. Data Collection and Analysis: Data on PSM were collected from the included studies and compared. Results: Seven studies with 13 patients (including our case) were included in the systematic review. PSM was reported in patients with low- or intermediate-risk EC independently from tumor histologic characteristics, endoscopic approach, lymph node staging type, number and site of the port, route of specimen removal, prevention strategies for PSM, and concomitant metastases. Among several proposed treatments, local resection and radiotherapy with or without chemotherapy might be the most appropriate ones. Nevertheless, the prognosis appears poor. Conclusions: In patients with low- or intermediate-risk EC, PSM can occur as a rare metastasis, regardless of tumor characteristics or surgical strategy. Unfortunately, no consensus has been reached regarding treatment, and the prognosis appears poor. Additional cases are needed in order to confirm and further explore this rare EC metastasis.

Incidence, Timing, and Pattern of Atypical Recurrence after Minimally Invasive Surgery for Urothelial Carcinoma

The management of urothelial carcinoma has evolved with the introduction of minimally invasive techniques such as laparoscopic or robotic procedures, challenging the traditional approach of open surgery, and giving rise to atypical recurrences (ARs). ARs include port-site metastasis and peritoneal carcinomatosis, yet discrepancies persist among authors regarding their precise classification. Incidence rates of ARs vary widely across studies, ranging from less than 1% to over 10% in both muscle-invasive bladder cancer (MIBC) and upper tract urothelial tumor (UTUC). Peritoneal metastases predominate as the most common ARs in patients with MIBC, while retroperitoneal metastases are prevalent in those with UTUC due to differing surgical approaches. The timing of AR presentation and survival outcomes closely mirror those of conventional recurrences, with which they are frequently associated. Pneumoperitoneum has progressively been regarded less as the cause of ARs, while surgical-related risk factors have gained prominence. Current major surgical-related causes include tumor spillage and urinary tract violation during surgery, avoidance of endo bag use for specimen extraction, and low surgical experience. Factors such as tumor stage, histological variants, and lympho-vascular invasion correlate with the risk of ARs, suggesting a close association with tumor biology. Further studies are required to better understand the incidence, risk factors, characteristics, and outcomes of ARs.

Recurrent Renal Cell Carcinoma Presenting as Port-Site Metastases, Detected on 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography

The incidence of port-site metastases (PSMs) varies with the tumor type with adenocarcinoma having a high incidence. However, it is rarely seen in urological malignancies and more so in renal cell carcinoma (RCC). We hereby describe one such case of PSM after laparoscopic radical nephrectomy for RCC, which was detected on 18F-fluorodeoxyglucose positron emission tomography-computed tomography.

Unusual Case of Gallbladder Adenocarcinoma Metastasis to the Abdominal Wall 11 Years Later: Synchronous Presentation with Two Malignant Colon Tumors, Coincidence or Not?

INTRODUCTION

Abdominal wall masses are a common finding in clinical practice. A high percentage of these masses are malignant. We present the case of a patient operated for a gallbladder adenocarcinoma, who consulted eleven years later for a malignant mass of the abdominal wall in synchrony with two adenocarcinomas of the left colon and sigmoid. Case Report. A 75-year-old male underwent a laparoscopic cholecystectomy with an incidental diagnosis of adenocarcinoma in situ (TisN0M0 according to AJCC 8th edition). The operative report mentioned that the removal of the gallbladder was difficult due to the inflammatory process, and the gallbladder was accidentally opened during the operation. It was not clear from the operative report whether an extraction bag was utilized to remove the specimen, but the histopathological study confirmed an open gallbladder. He presented 11 years later with an asymptomatic heterogeneous complex cystic mass involving the anterior rectus abdominis muscle. Colonoscopy showed synchronous tumors in the descending and sigmoid colon with pathology confirming adenocarcinoma. The patient underwent an elective laparotomy with resection of the anterior abdominal wall mass, left hemicolectomy, and sigmoidectomy. The histopathological results of the abdominal mass (CK7, CK20, EMA, CEA positive) were described as metastasis of adenocarcinoma of biliary origin. Discussion. Port site recurrences are rare complications following laparoscopic surgery when malignancy is unsuspected. Possible factors related to local implantation include direct seeding of spilled bile or tumor cells into the wound or shedding of tumor cells due to pneumoperitoneum-induced loss of the peritoneal barrier at the trocar site. In the absence of distant metastasis, treatment should include wide port site excision with malignancy-free surgical margins.

CONCLUSION

Abdominal wall metastasis from gallbladder carcinoma is rare, and its synchronous presentation with a malignant neoplasm of the colon is exceptional. This is the first report of a patient with abdominal wall metastasis from a gallbladder adenocarcinoma operated eleven years ago that debuted synchronously with two adenocarcinomas of the left colon and sigma.

The Pathogenesis and Prevention of Port-Site Metastasis in Gynecologic Oncology

Port-site metastasis (PSM) is a specific and challenging complication of laparoscopic gynecologic oncologic procedures. Research has demonstrated that PSM is associated with significant morbidity and poor outcome. The exact pathogenesis of PSM in gynecologic patients is not clear. Several preventive measures of PSM have been addressed in the relevant literature, and novel approaches to prevent this uncommon complication keep emerging. In this review, we summarized the potential mechanisms of PSM and discuss the controversies and merits of proposed preventive measures of PSM in gynecologic oncology. We undertook a literature search using the Medline database to identify studies on the pathogenesis and prevention of laparoscopic PSM. Hypotheses of PSM pathogeneses center on the immune response, pneumoperitoneum, wound contamination, and surgical method. Cogent evidence of effective prevention of PSM after laparoscopic surgery is lacking. Traditional preventive actions such as irrigation and tumor manipulation should be taken individually. Insufflation of hyperthermic CO₂ and humidified CO₂ leads to a better outcome in patients with a malignant tumor who undergo a laparoscopic procedure compared with normal CO₂ pneumoperitoneum. Port-site resection shows no advantage in survival and results in more wound events. PSM prevention plays a crucial part in the overall care of patients with gynecologic malignancies who undergo laparoscopic procedures.

Peritoneal and port site seeding of an undiagnosed urothelial carcinoma of the bladder after robot-assisted laparoscopic prostatectomy

Laparoscopic prostatectomy and robot-assisted laparoscopic prostatectomy are common procedure performed for the treatment of localized prostate cancer. Port site and peritoneal seeding is an exceedingly rare but known complications associated with this procedure. We present a case of a 71-year old male with low-intermediate risk prostate adenocarcinoma who underwent a robot-assisted laparoscopic prostatectomy. Pathology at that time was negative for extraprostatic extension, seminal vesicle invasion, or margins. Seven months later, the patient presented with gross hematuria and was found to have multiple superficial tumors of the bladder urothelium consistent with high-grade papillary urothelial carcinoma. He then began to experience increasing lower abdominal pain and a palpable, right anterior abdominal mass. Computed tomography-guided biopsy revealed high-grade papillary urothelial carcinoma which strongly suggests peritoneal seeding from his recent robot-assisted laparoscopic prostatectomy. Despite its rarity, the morbidity associated with this phenomenon could help justify a recommendation of careful pathologic examination of each prostate specimen for a second urothelial primary with subsequent cystoscopy if one is found.

Port site recurrence of esophageal adenocarcinoma after minimally invasive esophagectomy: a case report

BACKGROUND

Port site recurrence has been observed after a variety of oncologic resection procedures. However, few have reported port site recurrence of esophageal cancer.

CASE PRESENTATION

A 51-year-old man underwent minimally invasive esophagectomy for pT3(AD)N3M0 adenocarcinoma of the esophagus. One year after surgery, he presented with a rapidly growing tumor on the right thoracic wall. Contrast computed tomography demonstrated an enhancing tumor with uptake on positron emission tomography. We performed resection of the thoracic wall, including the skin and subcutis. The pathologic diagnosis was poorly differentiated adenocarcinoma, consistent with metastasis of esophageal origin.

CONCLUSION

This was the first report on thoracic port site recurrence of esophageal adenocarcinoma. We recommend elimination of leakage around the thoracoscopic ports to prevent such recurrence. We should provide prudent postoperative clinical surveillance.

Incidence of Port Site Metastasis in Laparoscopic Radical Nephroureterectomy: Single-institution Experience

OBJECTIVE

To address the incidence and potential risk factors of port site metastasis (PSM) in patients who underwent laparoscopic radical nephroureterectomy (RNU) for upper tract urothelial carcinoma.

MATERIALS AND METHODS

Between January 2013 and December 2018 laparoscopic RNU were performed in 240 patients at our institution, including 145 with renal pelvic tumor and 135 with ureteral tumor (40 patients have both tumor). Laparoscopies were performed through the transperitoneal approach in 28 patients, and retroperitoneal in 212 patients. Clinical data are retrospectively collected.

RESULTS

Perioperative and pathologic data are available in all 240 cases. After a mean follow-up of 12.6 months (range 3-45 months), 4 patients (1.7%) developed PSM following retroperitoneal RNU at an average of 4.3 months. Tumor stage is T2N0M0 in one, T3N0M0 in two, and T3N1M0 in one, respectively. Tumor grade are high-grade urothelial carcinoma in all. The incidence of PSM is 2.8% (4/145) and 0.7% (1/135) in renal pelvic and ureteral tumor, respectively.

CONCLUSION

We report a 1.7% incidence of PSM in upper tract urothelial carcinoma after laparoscopic RNU. We suggest that air leakage during retroperitoneal approach, high tumor stage (pT3) and grade, and advanced renal pelvic tumor with micrometastases could increase the potential risks of PSM.

Effects of CO2 pneumoperitoneum on proliferation, apoptosis, and migration of gastrointestinal stromal tumor cells

BACKGROUND

The purpose of the study was to investigate the proliferation and migration capability of human gastrointestinal stromal tumor line GIST-T1 after exposure to different pressures and times of CO₂ pneumoperitoneum.

METHODS

We established simulated CO₂ pneumoperitoneum environment in vitro and divided the human GIST cell GIST-T1 into open control group, 8 mmHg CO₂ pneumoperitoneum treatment group and 15 mmHg CO₂ pneumoperitoneum treatment group. Each group was divided into two subgroups respectively cultured for 1 h and 3 h. pH value of cell culture, cell growth curve, and cell cycle distribution of each group was measured. By application of scratch healing tests and Transwell chamber experiments, mobility ratio and number of cells through 8 µm membranes were measured to assess the migration ability of cells in each group after intervention.

RESULTS

Cell culture pH value of each subgroup in CO₂ group decreased significantly after exposed in CO₂ pneumoperitoneum (P < 0.01). The proliferation of GIST-T1 cells in 15 mmHg CO₂ group was significantly inhibited early (1-2 days) (P < 0.05) and the proliferation of GIST-T1 cells in 8 mmHg CO₂ 1 h subgroup and 15 mmHg CO₂ 1 h subgroup was increased significantly late (4-6 days) (P < 0.05) after the interventions of CO₂ pneumoperitoneum. The percentage of cells in G0-G1 phase increased, the percentage of S phase cells decreased (P < 0.01) in 1-h subgroup and 3-h subgroup of 15 mmHg CO₂ group 24 h after exposure to CO₂. The percentage of cells in S phase increased in 1-h subgroup of 8 mmHg CO₂ group and decreased in 3-h subgroup of 15 mmHg CO₂ group 72 h after exposure to CO₂. In the Transwell chamber experiment, the cell number through 8-µm membrane increased significantly (P < 0.01) in 3-h subgroup of CO₂ group compared to that in 3-h subgroup of control group.

CONCLUSIONS

The routine pressure and duration of CO₂ pneumoperitoneum used in clinic did not promote the proliferation of gastrointestinal stromal tumors, but had a potential risk of increasing postoperative recurrence and distant metastasis.

Port-Site Metastasis of Undiagnosed Pancreatic Adenocarcinoma After Laparoscopic Radical Prostatectomy: Case Report and Literature Review

Background: Laparoscopic port-site metastases remain rare for urologic tumors, despite the increasing use of laparoscopic techniques on the approach of urologic malignancy. Herein, we report a case of port-site mass after laparoscopic radical prostatectomy whose immunohistochemistry demonstrated metastasis from a pancreatic lesion.

Case Presentation: A 62-year-old man presented to our ambulatory clinic with an elevated prostate-specific antigen (PSA) of 7.7 ng/mL. Transrectal biopsies revealed prostate cancer Gleason 6 (3 + 3) on the right side. He was subjected to a transperitoneal laparoscopic radical prostatectomy at our institution. The PSA on postoperative week 6 was 0.04 ng/mL. Three months after the surgery, he comes back to the emergency department complaining of an abdominal pain especially on the right flank. Our examination of the abdomen revealed a small palpable mass at the right upper port-site scar. Computed tomography of the abdomen and pelvis, with contrast, revealed a hypodense nodular lesion located on the abdominal wall near the upper port site and adjacent to the pancreatic tail. An excisional biopsy of the lesion confirmed the presence of metastatic adenocarcinoma. Immunohistochemistry demonstrated metastasis from a pancreatic lesion.

Conclusion: Port-site mass after laparoscopic radical prostatectomy is uncommon especially in quite different tumors like this one with Gleason score 6 (3 + 3). Generally, port-site recurrences after a urologic laparoscopic surgery are uncommon and are not associated with diffused peritoneal carcinomatosis. Therefore, in this situation, another tumor site should be investigated as the primary source.

Port-site metastasis as a primary complication following diagnostic laparoscopy of fallopian tube carcinoma: A case report

RATIONALE

Fallopian tube carcinoma is a rare female genital cancer with no specific clinical and surgical features. It is hardly diagnosed on imaging due to non-specific presentation. Laparoscopy has been recommended as the diagnostic procedure for the assessment of suspicious ovarian and adnexal masses. However, it has brought new complications like tumor recurrences at the trocar insertion sites, called port-site metastasis (PSM).

PATIENT CONCERNS

A 65-year-old, postmenopausal woman presented to hospital with loss of appetite, Ultrasound showed ill-defined pelvic mass. The patient was diagnosed with fallopian tube carcinoma by a diagnostic laparoscopy.

DIAGNOSES

The PSM as a primary complication following diagnostic laparoscopy of fallopian tube carcinoma, which is presumed by positron emission tomography/computed tomography and confirmed by Nodule resection and further pathological assessment.

INTERVENTIONS

As port-site metastasis was suspected, the patient was advised to undergo umbilical mass resection.

OUTCOMES

the patient has no signs of recurrence was detected 20 months after the last surgery during follow-up.

LESSIONS

Laparoscopy plays a significant role in the diagnose and treatment of fallopian tubal and ovarian malignancies but has a risk of PSM occurrence. When isolated PSM occurs the management should be local resection.

Viability of Airborne Tumor Cells during Excision by Ultrasonic Device

Background. Laparoscopic surgery has become more widely used, but peritoneal dissemination and port-site metastasis have been reported to occur in these surgeries. One reason for these problems is the ultrasonically activated scalpel (UAS) used for laparoscopic surgery. This study aimed to investigate the viability of airborne cells released during cancer dissection using a UAS. Methods. Flank tumors measuring about 2 cm were induced in male NOD-Cg-Rag1^tm1MomIL2rg^tm1wjl/SzJ mice by subcutaneous injection of 1 × 10⁶ HepG2 cells. Dissection was performed with UAS (in high or low power modes) and PowerStar bipolar scissors. The mist of released tissue was collected in cell culture medium. The viability of the cellular material was assessed with trypan blue exclusion cell counting, counting after immunofluorescence staining, and flow cytometric analysis. Results. Large quantities of cellular debris were trapped in the tissue dispersed by both devices. In all experiments, there were significantly more viable cells produced by the UAS in high power mode. By using suction at the excision site, the number of viable cancer cells was reduced. Conclusions. This study demonstrates that viable cancer cells can be released into the nearby environment during tumor ablation with a UAS.

A case report of wound site seeding following cholecystectomy for dysplastic gallbladder

Wound site metastasis following cholecystectomy is an uncommon but well recognised complication following laparoscopic surgery for unsuspected gallbladder carcinoma. We describe a case of implantation of dysplastic cells with subsequent malignant transformation at the incision site 3 years post-cholecystectomy for an inflamed gallbladder. Histopathological examination of this tumour confirmed adenocarcinoma of pancreatobiliary origin, possibly secondary to gallbladder cells implantation and subsequent carcinomatous change. Unlike previously reported cases, the present case has two unique features: Firstly, the histology of the resected gallbladder at the initial operation was that of a low-grade dysplasia and not carcinoma; and secondly, there was a long interval between initial surgery and subsequent development of the wound site tumour. This case highlights that careful handling of the specimen tissue intraoperatively is paramount as cells implanted in the wound site can survive and undergo malignant transformation. All new masses occurring along the surgical wound site should be followed up and investigated to exclude implanted tumours.

Current and emerging robotic assisted intervention for Notes

INTRODUCTION

Natural orifices transluminal endoscopic surgery (notes) procedures are limited by a number of factors including closure of the internal entry point, loss of triangulation, and unstable operative platform. Areas covered: In this paper, new technical developments in different aspects of robotic assisted NOTES interventions are reviewed. We further address new research opportunities for more widespread clinical acceptance of robotic assisted NOTES procedures. Expert commentary: The application of robotics in NOTES intervention is still in its infancy. The development of more compact, smart and intuitive robotic NOTES systems holds much promise for the future of NOTES application.

Prognostic Impact of Port-Site Metastasis After Diagnostic Laparoscopy for Epithelial Ovarian Cancer

BACKGROUND

This study was designed to evaluate the prevalence, morbidity, and prognostic impact of port-site metastasis (PSM) in patients with epithelial ovarian cancer (EOC) undergoing laparoscopy before subsequent primary debulking surgery (PDS).

METHODS

All consecutive patients treated between 2000 and 2014, who had a laparoscopy followed by PDS, were extracted from our prospectively maintained database. All patients with histological examination of port-sites were included in this unicentric exploratory analysis.

RESULTS

A total of 250 (25.5 %) of 982 patients with EOC underwent laparoscopy before PDS. Port-site resection was performed in those 214 (85.6 %) patients in whom a complete or almost complete resection with residuals ≤1 cm was achieved. Median interval between laparoscopy and PDS was 25 days. PSM was detected in 100 of 214 patients (46.7 %). Risk factors for PSM were higher tumor stage (odds ratio [OR] 13.5, 95 % confidence interval [CI] 2.9-62.0, p = 0.04), positive lymph node status (OR 3.0, 95 % CI 1.3-6.7, p = 0.009), and ascites >500 mL (OR 3.9, 95 % CI 1.5-10.0, p = 0.005). Wound healing disorders and postoperative morbidity were significantly higher in patients with PSM (Clavien-Dindo Classification grade 3-5: 41.0 vs. 14.9 %, p < 0.001). However, multivariate Cox-regression models did not identify PSM as independent prognostic factor.

CONCLUSIONS

The prevalence of PSM after laparoscopy in EOC patients is considerably high. PSM had no impact on survival; however, PSM were associated with more postoperative complications and a higher surgical treatment burden. This should be balanced with the expected benefit when laparoscopy is considered for the management of EOC.

Cervical cancer with a rare umbilical metastases in prior surgical site

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We describe the case of an unusual port-site cervical cancer metastasis.

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We perform a review of the current published literature of port-site metastases.

•

We demonstrate that our patient’s case is unlike others previously described.

Introduction

Port-site metastasis of cervical cancer is a relatively rare occurrence, and has been reported in the published literature as a pre-terminal event.

Presentation of case

We present the case of a 52-year-old female who was diagnosed with cervical cancer after presenting to our institution’s hospital with urinary symptoms not relieved by multiple treatments with antibiotics. To fully evaluate the extent of disease, positron emission tomography-computed tomography imaging was obtained, showing an area of mildly increased fluorodeoxyglucose uptake in her umbilicus. While undergoing external-beam radiotherapy treatment for her cervical cancer, she began to experience pain in the umbilicus associated with a mass. A biopsy was taken, revealing metastatic cervical cancer at the site of a previous port-site incision for a cholecystectomy that the patient underwent 18 months before the finding.

Discussion

Port-site metastasis have been reported following kidney, bladder, and colon cancer resections, with reports of cervical cancer cases being exceedingly rare. Several hypotheses have emerged as potential explanations for port-site metastasis.

Conclusion

To our knowledge, this represents the first reported case of a port-site metastasis to an incision site created for an unrelated laparoscopic surgery, performed well in advance of the diagnosis of cervical cancer.

Long-Term Survival Following Port-Site Metastasectomy in a Patient with Laparoscopic Gastrectomy for Gastric Cancer: A Case Report

A 78-year-old man underwent laparoscopy-assisted total gastrectomy for gastric cancer (pT3N0M0). Multiple port sites were used, including a 10 mm port for a videoscope at the umbilical point and three other working ports. During the six-month follow-up evaluation, a 2 cm enhancing mass confined to the muscle layer was found 12 mm from the right lower quadrant port site, suggesting a metastatic or desmoid tumor. Follow-up computed tomography imaging two months later showed that the mass had increased in size to 3.5 cm. We confirmed that there was no intra-abdominal metastasis by diagnostic laparoscopy and then performed a wide resection of the recurrent mass. The histologic findings revealed poorly differentiated adenocarcinoma, suggesting a metastatic mass from the stomach cancer. The postoperative course was uneventful, and the patient completed adjuvant chemotherapy with TS-1 (tegafur, gimeracil, and oteracil potassium). There was no evidence of tumor recurrence during the 50-month follow-up period.

Medical Device Safety and Surgical Dissemination of Unrecognized Uterine Malignancy: Morcellation in Minimally Invasive Gynecologic Surgery

There is a risk of dissemination of uterine malignancies during minimally invasive hysterectomies when morcellation is used. Although the technique of uterine power morcellation allows timely removal of large benign tumors through small laparoscopic incisions, there are concerns about iatrogenic spread of cancers and reduced survival for women with preoperatively unrecognized malignancies. This review examines the literature on intraperitoneal spread and implantation of mechanically disrupted malignant tissue, discusses the current diagnostic tools for preoperative assessment of uterine tumors, and summarizes the current recommendations of the Society of Gynecologic Oncologists, the American College of Obstetricians and Gynecologists, and the American Association of Gynecologic Laparoscopists. Recommendations include informed consent of the risk of disseminating an otherwise contained malignancy, appropriate preoperative evaluation for malignancy, and development of alternatives to intracorporeal morcellation.

IMPLICATIONS FOR PRACTICE

Preoperative assessment of uterine masses or abnormal uterine bleeding must include understanding of the limitations of an endometrial biopsy and imaging studies to evaluate the possibility of a uterine malignancy. Minimally invasive surgery using morcellation of benign uterine growths is well established and safe; however, alternative surgical techniques to morcellation must be considered when the malignant potential of a uterine mass is uncertain. Morcellation carries the risk of widespread peritoneal seeding of an unrecognized uterine malignancy. Gynecologic surgeons must weigh the unlikely occurrence of disseminating an undiagnosed uterine sarcoma with the much more common surgical risks of abdominal surgery.

Isolated port-site metastases after minimally invasive hysterectomy for endometrial cancer: outcomes of patients treated with radiotherapy

OBJECTIVE

The management and prognosis of isolated port-site metastases after laparoscopic surgery for endometrial cancer is poorly understood and rarely described in the literature. We report a series of cases treated with radiotherapy to better characterize outcomes in these patients.

METHODS

We retrospectively reviewed medical records of patients with endometrial cancer who developed isolated port-site metastases and were treated with radiation therapy at MD Anderson Cancer Center from 1996 to 2013. Seven patients met these criteria for whom treatment and outcome data were collected.

RESULTS

The median interval from initial surgery to port-site recurrence was 15 months. Recurrent tumor size varied from 0.5 to 9 cm as measured on axial imaging. Six of the 7 patients underwent surgical resection of the recurrence. All received radiotherapy to a dose of 45 to 66 Gy. At a median follow-up of 2 years from the time of the port-site recurrence, the rate of disease-free survival at 1 and 2 years after the recurrence was 100% and 44%, respectively. The rate of local control and overall survival at 2 years was 100%.

CONCLUSIONS

Isolated port-site metastases in the setting of endometrial cancer are associated with high rates of local control when treated with multimodality therapy including radiotherapy. Long-term disease-free outcomes in some patients suggest the potential for cure and justify aggressive local therapy. The optimal integration of surgery, chemotherapy, and radiation is unknown.

Port-site metastases after robotic surgery for gynecologic malignancy

The rate of port site metastasis in patients undergoing robot-assisted laparoscopic surgery for gynecologic malignancy is similar to the rate of port site metastasis for traditional laparoscopic surgery.

Background and Objectives:

Robotic-assisted laparoscopic surgery is increasingly used for the management of patients with gynecologic malignancies. The rate of port-site metastases in patients undergoing these procedures is unknown.

Methods:

We conducted a retrospective cohort analysis of a prospective database. A total of 220 women underwent robotic-assisted surgery from 2007 through 2011. Malignancy was detected in 145 cases, and 142 met the inclusion criteria with histologically proven cancer and robotically completed surgery. All women who underwent surgical treatment for their malignancies were followed up at the study site for oncology treatments.

Results:

There were 710 potential port sites for metastasis. We found that 2 of 142 patients each had a single port-site metastasis, for an overall rate of 1.41%, or 0.28% per trocar site. Recurrent disease was not isolated in the two patients found to have port-site metastases because both had concurrent sites of pelvic recurrence.

Conclusion:

The rate of port-site metastases in patients undergoing robotic-assisted laparoscopic surgery for gynecologic malignancies is similar to the published rate in the literature for traditional laparoscopic oncology.

Does carbon dioxide pneumoperitoneum enhance wound metastases following laparoscopic abdominal tumor surgery? A meta-analysis of 20 randomized control studies

The mechanisms involved in the development of wound metastasis following laparoscopic abdominal tumor surgery remain unclear. The aim of this study was to accurately assess whether the duration of carbon dioxide pneumoperitoneum (CDP) during laparoscopic abdominal tumor surgery enhances wound metastases. We conducted a systematic review of PubMed, Cochrane Library, and Embase through December 2013 to identify animal experiments comparing wound recurrence between laparoscopic and gasless laparoscopic procedures or open procedures. The outcome of interest was the number of animals with a wound tumor. Meta-regression was used to assess whether heterogeneity was explained by study level covariates (animal model, study size, CDP pressure, duration, and evaluated time). Twenty randomized control studies involving 1,229 animals were included. Wound recurrence was not significant in the laparoscopic surgery (LP) vs. gasless laparoscopic surgery (GLP) subgroups [odds ratio (OR), 2.23; 95 % confidence interval (CI), 0.90-5.55; P = 0.08) or the LP vs. laparotomy (LA) subgroups (OR, 0.97; 95 % CI, 0.31-3.00; P = 0.08). Overall postoperative wound recurrence results were not significantly different between the study groups and controls (OR, 1.47; 95 % CI, 0.74-2.92; P = 0.28). A meta-regression analysis showed that the outcome was not correlated with the covariates (animal model: P = 0.82; evaluated time: P = 0.30; pressure of CDP: P = 0.12; duration time: P = 0.80). Current evidence suggests that CDP does not enhance wound metastases following laparoscopic abdominal tumor surgery. Additional large sample, well-designed, randomized, controlled trials are needed to further confirm whether CDP duration in laparoscopic abdominal tumor surgery significantly enhances wound recurrence.

Port site and peritoneal metastases after robot-assisted radical prostatectomy

INTRODUCTION

Port site metastasis after minimally invasive urologic surgery is a rare event despite the widespread utility of laparoscopic techniques in the management of urologic malignancies. Herein, we report a case of port site metastasis after robot-assisted radical prostatectomy.

PRESENTATION OF CASE

A currently 77-year-old male patient, who was diagnosed with cT2c, Gleason 7 (4+3) prostate adenocarcinoma in our clinic back in 2009, had undergone robot-assisted radical prostatectomy elsewhere. Histopathological examination revealed pT3a, Gleason 9 (4+5) disease. Lymph nodes were negative, however surgical margins were positive on the right side. PSA recurred after 9 months and maximal androgen blockade was initiated. Despite antiandrogenic manipulations, PSA reached 0.83ng/ml, 33 months postoperatively. Concurrently, we noticed a palpable anterior abdominal mass which demonstrated metabolic hyperactivity on PET scanning. Percutaneous biopsy of the lesion confirmed the presence of metastatic adenocarcinoma. PSA did not normalize after the complete excision of the metastatic focus. Repeated PET scan revealed multiple implants on the peritoneal surfaces of various organs.

DISCUSSION

Port site and peritoneal metastasis of prostate cancer after robot-assisted radical prostatectomy has not been reported so far. This peculiar dissemination pattern is most probably the result of tumor biology and perioperative factors.

CONCLUSION

Although encountered extremely rarely, surgeons should be aware of the possibility of port site and/or peritoneal metastases after minimally invasive radical prostatectomy.

Camera-port site metastasis of a renal-cell carcinoma after robot-assisted partial nephrectomy

BACKGROUND AND PURPOSE

Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN.

PATIENT AND METHODS

A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed.

RESULTS

Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction.

CONCLUSION

PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

Laparoscopic versus open surgery for rectal cancer: a clinical comparative study

OBJECTIVE

To compare short-term surgical outcomes and long-term survival following laparoscopic or open resection for rectal cancer.

METHODS

A total of 381 patients undergoing laparoscopic surgery and 276 undergoing open surgery for curative resection of rectal cancer were included. Long-term survival and peri- and postoperative data were retrospectively reviewed from a prospectively-collected database.

RESULTS

Surgical groups were comparable regarding age, gender, tumour stage and preoperative comorbidities. Laparascopic surgery was associated with significantly longer duration of surgery, less intraoperative blood loss and fewer postoperative infections than open surgery. Patients who underwent laparoscopic resection had significantly earlier recovery of gastrointestinal function than those who underwent open surgery. There were no significant between-group differences in number of lymph nodes excised, specimen length or distal margin. The 3- and 5-year survival rates and overall survival were similar in the two groups, and survival was not influenced by tumour location.

CONCLUSION

Laparoscopic surgery can achieve the same oncological results as open resection in patients with rectal cancer, supporting its continued use in the management of this disease.

Port-site metastasis after laparoscopic surgical staging of endometrial cancer: a systematic review of the published and unpublished data

Port-site metastases, also called trocar-site metastasis, have been described after laparoscopic surgery for non-gynecological and gynecological cancers. The aim of this review was to obtain evidence for port-site metastases after laparoscopic surgical staging of endometrial cancer. A systematic search of published and unpublished cases of port-site metastases after laparoscopic staging of endometrial cancer was conducted. All the authors responsible for correspondence were contacted to obtain any missing data. The patients' characteristics and oncologic, surgical, and safety data were recorded and analyzed. Twelve cases of port-site metastases were identified and examined. In 4 cases they were "isolated," that is, recurrence without association with peritoneal carcinomatosis, whereas in 8 cases they were "nonisolated." The port-site metastases did not occur as a result of trocar site localization or dimension. No univocal strategy to prevent port-site metastases was adopted. Among patients with nonisolated port-site metastases, an aggressive histologic condition and a high grade were found in 3 of 6 patients and in 3 of 5 patients, respectively. Among patients with isolated port-site metastases, an early-stage endometrioid adenocarcinoma G2 endometrial cancer and a stage IIB G2 endometrioid adenocarcinoma were described in 3 of 4 patients and in only 1 case, respectively. All the patients with nonisolated port-site metastases died of disease. Similarly, among patients with isolated port-site metastases, only 1 was alive and free of disease after 10 months from recurrence diagnosis. Port-site metastases of endometrial cancer are an entity rarely reported but probably the expression of an aggressive disease. The available data do not allow us to draw conclusions or suggestions for their prevention and the treatment.

Incidence of port-site metastasis after undergoing robotic surgery for biliary malignancies

AIM: To investigate the incidence of clinically detected port-site metastasis (PSM) in patients who underwent robotic surgery for biliary malignancies.

METHODS: Using a prospective database, the patients undergoing fully robotic surgery for biliary malignancies between January 2009 and January 2011 were included. Records of patients with confirmed malignancy were reviewed for clinicopathological data and information about PSM.

RESULTS: Sixty-four patients with biliary tract cancers underwent robotic surgery, and sixty patients met the inclusion criteria. The median age was 67 year (range: 40-85 year). During a median 15-mo follow-up period, two female patients were detected solitary PSM after robotic surgery. The incidence of PSM was 3.3%. Patient 1 underwent robotic anatomatic left hemihepatectomy and extraction of biliary tumor thrombi for an Klatskin tumor. She had a subcutaneous mass located at the right lateral abdominal wall near a trocar scar. Patient 2 underwent robotic pancreaticoduodenectomy for distal biliary cancer. She had two metachronous subcutaneous mass situated at the right lateral abdominal wall under a same trocar scar at 7 and 26 mo. The pathology of the excised PSM masses confirmed metastatic biliary adenocarcinoma.

CONCLUSION: The incidence of PSMs after robotic surgery for biliary malignancies is relatively low, and biliary cancer can be an indication of robotic surgery.

Is port site metastasis a result of systemic involvement?

Aims:

Port site metastasis (PSM) is an unwelcome consequence of laparoscopy for oncological procedures with uncertain etiology. We present the clinical evidence to prove that PSM is likely to be due to the hematogenous spread of tumor cells.

Materials and Methods:

Six cases of port site metastasis, four following laparoscopic radical nephrectomy for localized renal cell carcinoma (RCC), one after laparoscopic radical prostatectomy done in two patients and one after laparoscopic partial cystectomy for tumor at bladder dome done in two were studied. One case of metastatic RCC with bilateral gluteal masses and two cases of open radical nephrectomy, with recurrence at the drain and incision site were also studied.

Results:

During the median follow up of 59 months (range 24–120), 4/136 patients with RCC (1.47%) developed port site metastasis between 7–36 months after surgery. All six cases of PSM had advanced disease and recurrences at other sites, that is, peritoneum, omentum, bones, and lungs. None of the patients had isolated PSM. One patient of metastatic RCC, who did not have any intervention but repeated intramuscular injections of analgesics-developed bilateral gluteal masses, confirmed to be RCC on fine needle aspiration cytology. Two patients had metastasis at the incision site (one at the drain site) with distance, including cutaneous metastases.

Conclusions:

Port site metastasis did not develop in isolation. There could be a likely existence of circulating tumor cells at the time of surgical trauma of penetrating nature, that is, port site or injection site, which manifest in some patients depending upon their immune response.

Port-site recurrence in a patient undergoing robot-assisted gynecologic cancer surgery for endometrial cancer - A case report

► First case of port-site metastasis after robotic staging surgery for uterine cancer. ► Changes to robotic surgical technique to reduce risk of port-site recurrence. ► Further areas of investigation worth examining in this aspect of robotic surgery.

Port-site metastasis after laparoscopic surgery for urological malignancy: forgotten or missed

Purpose. Port-site metastasis has been a concern with the common use of laparoscopy in urologic oncology. We conducted this study to provide a review of port-site metastases reported after the laparoscopy in managing urologic malignancies, possible contributing factors and preventative measures. Materials and Methods. An electronic search of MEDLINE using the combined MESH key words “port-site metastasis” and “Urology”. Results. 51 articles addressing port-site metastasis after laparoscopic surgery for urolo¬gical malignancy were identified. Conclusion. Port-site metastasis after laparoscopic surgery for urolo¬gical malignancy is rare. The incidence is comparable to the rate for surgical wound metastases.

Early port-site metastasis during neoadjuvant chemotherapy in advanced stage ovarian cancer: report of two cases

Port-site metastases in gynecological malignancies subsequent to laparoscopy have been reported with an incidence of 1.1-16%. These metastases tend to be disappearing after primary debulking surgery and subsequent primary chemotherapy. Local resection, chemotherapy and/or radiotherapy have been defined in the management of these metastases with enhanced clinical success. However, in extremely rare cases these metastases were also defined very early during neoadjuvant chemotherapy. Herein, we present two ovarian cancer cases which are clinically diagnosed with port site metastasis during neoadjuvant chemotherapy following diagnostic laparoscopy. Although neoadjuvant chemotherapy is sometimes needed in cases of fully advanced ovarian cancers, port-site metastasis may be encountered during neoadjuvant chemotherapy. The possible poor prognosis of these patients, especially those who have ascites, should make us careful in performing diagnostic laparoscopy with preventive measures for port-site metastasis and to start the chemotherapy immediately.

Rate of port-site metastasis is uncommon in patients undergoing robotic surgery for gynecological malignancies

OBJECTIVE

To describe the rate of port-site metastasis in patients who underwent robotic surgery for suspected gynecological malignancy.

METHODS

Using a prospective database, we identified all patients who underwent robotic surgery performed by the Gynecologic Oncology service at 1 institution between December 2006 and March 2010. Records of patients with confirmed malignancy were reviewed for clinicopathological data and information about port-site metastasis.

RESULTS

One hundred eighty-one patients met the inclusion criteria. The median age was 55.4 years (range, 19-82 years), and the median body mass index was 29.6 kg/m² (range, 17.9-70.7 kg/m²). Port-site metastases were detected in 2 patients (1.1%) at 3 weeks (patient 1) and 11 months (patient 2) after surgery. Patient 1 underwent surgery for an adnexal mass, and pathological examination revealed gallbladder adenocarcinoma metastatic to the ovary. She had a recurrence in the right lateral abdominal wall robotic trocar site with concurrent metastases in the gallbladder fossa and liver. Patient 2 was diagnosed with adenocarcinoma of unclear (cervical vs endometrial) origin. Imaging showed metastases in pelvic and para-aortic lymph nodes. She underwent laparoscopy and was found intraoperatively to have gross disease on the right ovary. The patient underwent right salpingo-oophorectomy and chemoradiation. She had residual disease in the cervix and subsequently underwent robotic hysterectomy and left salpingo-oophorectomy. Pathological examination revealed endometrial cancer. She had a recurrence at the transumbilical trocar site concurrent with retroperitoneal lymphadenopathy and carcinomatosis. There were no cases of isolated port-site metastasis.

CONCLUSIONS

The rate of port-site metastasis after robotic surgery in women with gynecological cancer is low and similar to the rate for laparoscopic procedures.

Low incidence of port-site metastases after laparoscopic staging of uterine cancer

OBJECTIVE

To estimate the incidence of clinically detected port-site metastases (PSM) in patients with endometrial and cervical cancer treated at two gynecologic oncology services with extensive experience.

METHODS

All eligible uterine cancer patients laparoscopically staged at Centre Oscar Lambret in Lille and Institut Claudius Regaud in Toulouse, France, were reviewed. MEDLINE database was searched to identify articles on PSM after laparoscopic procedures for cervical and endometrial cancer.

RESULTS

During the study period, 1216 laparoscopic procedures for uterine cancer were performed. 921 patients underwent laparoscopic staging for cervical cancer and 295 for endometrial cancer. The overall incidence of PSM in our institutions was 0.4% per procedure (5 patients), and the incidence of PSM after laparoscopy for cervical and endometrial cancer was 0.43% and 0.33%, respectively. Excluding patients with peritoneal carcinomatosis, the rate of port-site recurrence in our series lowered to 0.16%, and the rate of isolated PSM to 0%. The median time to the development of PSM was 8 months (range 6-48), the median overall survival from diagnosis for all patients was 26 months (range 7-30), and median survival from recurrence was 5 months (range 1-20).

CONCLUSION

Although PSM is recognized as a complication of laparoscopy for ovarian cancer. PSM is a rare complication of laparoscopic staging for endometrial and cervical cancer. The majority of patients with PSM presented with associated synchronous disease. The incidence of isolated PSM can be maintained virtually to 0% by an adequate operative technique. We believe that PSM in patients with uterine cancer cannot be used as an argument against laparoscopic staging in uterine cancer.