Implantation metastasis in a 13-year-old girl: a case report

Left cheek sclerosing rhabdomyosarcoma and development of isolated free flap donor site metastasis

Rhabdomyosarcoma is a rare mesenchymal malignancy with four different morphological subtypes: alveolar, embryonal, pleomorphic and spindle cell/sclerosing. It is the most common soft tissue sarcoma of children and adolescents but occurs less commonly in adults. We describe a male patient in his 20s with sclerosing rhabdomyosarcoma of the left cheek who developed an isolated free flap donor site metastasis in the first instance but subsequently progressed with bilateral pulmonary metastases. Multidisciplinary team involvement in a sarcoma specialist centre is essential and collaboration between the pathologist, radiologist, head and neck surgeon, orthopaedic surgeon, radiation oncologist and medical oncologist were integral in providing optimal management in this patient. Furthermore, this case report highlights this phenomenon of implantation metastasis in a patient with rhabdomyosarcoma, and emphasises the importance of surgical barriers between the resection and reconstruction teams in an oncological case.

The Risk of Tumor Contamination Associated With Thoracic Instrumentation in Patients With Osteosarcoma: 2 Case Reports and a Literature Review

Orthopedic surgeons are well aware of tumor contamination at the site of initial biopsy in osteosarcoma. However, tumor contamination in patients with osteosarcoma associated with thoracic instrumentation is not well described. The authors summarize 2 reported cases in addition to the 2 cases at their institution of this phenomenon. Knowledge of tumor contamination and preventative measures against tumor contamination is sparse in the literature, especially pertaining to patients with osteosarcoma undergoing thoracic instrumentation. In this report, the authors hope to increase awareness of these cases and suggest preventative measures to mitigate against tumor contamination in patients with osteosarcoma. The authors report that the median time between thoracic instrumentation and the visible detection of tumor migration to local sites was 5 months. They conclude that tumor contamination associated with thoracic instrumentation is characterized by patients with multiple sites of relapse and aggressive, fatal disease.

Implantation of Squamous Cell Carcinoma in a Free Flap Donor Site

INTRODUCTION

It is well known that malignant cells can be implanted at distant donor sites due to iatrogenic surgical contamination. Only a small number of reports, however, have been published describing this.

CASE PRESENTATION

We present a case of oral cavity Squamous Cell Carcinoma (SCC) reconstructed with a radial forearm free flap in which SCC developed in the subcutaneous tissues beneath the donor incision site 6 months after surgery.

MANAGEMENT

The implanted tumor was excised and the field was subsequently treated with radiation. The patient remains disease-free on follow-up.

DISCUSSION

We present the second report of tumor implanted in a free flap donor site. Additionally, we discuss the risks of tumor implantation, review the literature, and make recommendations to avoid this complication.

Iatrogenic Implantation of Cancer Cells During Surgery

In the late 1800s, the concept of iatrogenic implantation of cancer cells during surgery was put forth. The most dramatic example is a recurrence in a donor graft site, which is often distant to the primary site of excision. This eliminates the possibility of incomplete removal as the etiology of recurrence. However, in addition to direct transplantation to the graft site via gloves or instruments, several other possibilities exist, including de novo lesions of squamous cell carcinoma in the graft, as well as systemic metastases. This article reviews 15 published case reports of cancer recurrence in graft donor sites in which the authors considered seeding via gloves or instruments. Viewing these cases in the context of a 2018 study demonstrates the varying opinions of surgeons on the possibility of cancer seeding. This article strongly advises the changing of gloves and instruments following resection of any suspicious or established cancerous tumors.

Distant metastasis of intraosseous dentinogenic ghost cell tumour to the donor site of a bone graft

A dentinogenic ghost cell tumour (DGCT) is an extremely rare odontogenic tumour which is considered as a solid, neoplastic variant of calcifying odontogenic cyst. Intraosseous DGCTs are more aggressive than extraosseous DGCTs and have a high propensity for local recurrence. This report describes a case of a diagnosis of recurrent DGCT at the primary site and a distant donor site. A 25-year-old female patient visited a dental hospital for a complaint of facial swelling for the previous month. Incisional biopsy was performed and the specimen was diagnosed as DGCT. Partial mandibulectomy for tumour resection and iliac bone graft was performed. 2 years later, the tumour recurred on the mandible and iliac bone. The recurrent lesion on the donor site was diagnosed as metastasized DGCT. This report highlights the possibility of distant metastasis occurring at a graft donor site.

The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma

OBJECTIVE

Uterine leiomyosarcoma (LMS) is usually diagnosed after surgery for leiomyoma; thus tumor morcellation frequently occurs. We evaluated the impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine LMS.

METHODS

Outcomes were retrospectively compared between patients who underwent total abdominal hysterectomy without tumor morcellation and those who underwent surgery that included abdominal, vaginal or laparoscopic tumor morcellation.

RESULTS

We assessed 56 consecutive patients with stage I and II uterine LMS between 1989 and 2010, 25 with and 31 without tumor morcellation. There were no significant between group differences in age, parity, menopausal status, body mass index, stage, mitotic count, tumor grade, lymph node dissection, adjuvant therapy, and follow-up duration. However, tumor size was significantly smaller (9.8 cm vs. 7.3 cm, P=0.022) and ovarian tissue was more frequently preserved (38.7% vs. 72%, P=0.013) in patients with tumor morcellation. In univariate analysis, only tumor morcellation was significantly associated with poorer disease-free survival (DFS) (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.03-6.50; P=0.043), and higher stage (I vs. II; (OR, 19.12; 95% CI, 1.19-307.11; P=0.037)) and tumor morcellation (OR, 3.07; 95% CI, 1.05-8.93; P=0.040) were significantly associated with poorer overall survival (OS). In multivariate analysis, higher stage (OR, 20.34; 95% CI, 1.27-325.58; P=0.033) and tumor morcellation (OR, 3.11; 95% CI, 1.07-9.06; P=0.038) were significantly associated with poorer OS. The percentage of patients with abdomino-pelvic dissemination, as shown by peritoneal sarcomatosis or vaginal apex recurrence, was significantly greater in patients with than without tumor morcellation (44% vs. 12.9%, P=0.032).

CONCLUSION

Tumor morcellation during surgery increased the rate of abdomino-pelvic dissemination and adversely affected DFS and OS in patients with apparently early uterine LMS.

The impact of tumor morcellation during surgery on the outcomes of patients with apparently early low-grade endometrial stromal sarcoma of the uterus

BACKGROUND

The purpose of this study was to evaluate the impact of tumor morcellation on the outcomes of patients with apparently early low-grade endometrial stromal sarcoma (LGESS).

METHODS

Outcomes were retrospectively compared between patients with apparently early LGESS who did not (group A, n=27) or did (group B, n=23) undergo tumor morcellation.

RESULTS

There were no between-group differences in age, menopausal status, parity, body mass index, and preoperative presumptive diagnosis, nor were there between-group differences in tumor stage, tumor size, myometrial invasion, lymphovascular space invasion, frequency of ovarian preservation, adjuvant therapy, or follow-up time. More patients in group A underwent lymph node dissection (51.9 vs. 21.7%; P=0.029). Only 1 patient in each group had distant recurrence. There were 2 patients (7.4%) in group A and 7 (31.4%) in group B who had abdominopelvic recurrence. The risk of abdominopelvic recurrence was significantly higher in group B than in group A (odds ratio [OR], 5.47; 95% confidence interval [95% CI], 1.04-29.70; P=0.035). The 5-year disease-free survival (DFS) rates were 84% for group A and 55% for group B (P=0.028) and the 5-year abdominopelvic DFS rates were 89 and 58% (P=0.023), respectively. Multivariate analysis showed that tumor morcellation were significantly associated with poorer DFS (OR, 4.03; 95% CI, 1.06-15.30; P=0.040) and abdominopelvic DFS (OR, 5.06; 95% CI, 1.02-25.04; P=0.047).

CONCLUSIONS

Inadvertent tumor morcellation during surgery has an adverse impact on the outcomes of patients with early LGESS.

Iatrogenic seeding of a giant cell tumor of the patella to the proximal tibia

Iatrogenic transplantation of tumor is a rare but avoidable complication, often resulting in additional morbidity or even mortality. We present a case of a 22-year-old woman with a giant cell tumor of the patella initially treated by curettage and bone grafting from the ipsilateral proximal tibia. Local recurrence and tumor growth in the proximal tibia required extensive surgeries. We will discuss the risk of iatrogenic metastasis by direct implantation, often attributable to inadequate surgical planning or poor surgical techniques. The cause and prevention of implantation metastasis are discussed and the basic principles of musculoskeletal tumor management emphasized.