Port site metastases following laparoscopic liver resection for hepatocellular carcinoma

Outcomes for Atypical Tumor Recurrences Following Minimally Invasive Kidney Cancer Operations

Background

We managed a cohort of patients treated with minimally invasive surgery (MIS) for a kidney tumor presenting with atypical tumor recurrence (ATR) involving port sites, intraperitoneal carcinomatosis, and nephrectomy bed/perinephric tumor implants.

Objective

To determine the clinical characteristics, management, and oncologic outcomes for patients with localized renal cell carcinoma (RCC) who develop ATR following curative-intent MIS for partial or radical nephrectomy.

Design, setting, and participants

The study cohort comprised patients from 1999 to 2021 with localized RCC managed at Memorial Sloan Kettering Cancer Center (New York, NY, USA) after MIS for partial or radical nephrectomy who developed ATR. Outcome measurements and statistical analysis: We collected data on clinicopathologic characteristics, treatments, time to ATR, and overall survival.

Results and limitations

The median age of the 58 RCC patients was 61 yr. Forty-one patients (71%) were male, 26 (45%) had robot-assisted operations, and 39 (67%) had clear cell RCC. Twenty-nine patients had stage pT1 disease (50%) and ten (17%) had positive surgical margins. The most common ATR site was perinephric/nephrectomy bed implants (n = 28, 48%). Management included: surgical resection alone (n = 11, 19%), systemic therapy alone (n = 12, 21%), surgical resection and systemic therapy (n = 17, 29%), and palliative care (n = 8, 14%). At median follow-up of 59 mo (interquartile range [IQR] 28–92), the median time to ATR was 12 mo (IQR 5–28). Overall survival at 5 yr was 69.0% (95% confidence interval 57.4–83.1%) with only nine patients alive with no evidence of disease. Limitations include the potential for referral, detection, and selection biases, as well as uncertainty regarding the true incidence of ATR.

Conclusions

ATR following MIS for partial or radical nephrectomy is an understudied, poor prognostic event which leads to a heavy treatment burden. Further investigation into its etiology and means of prevention is warranted.

Patient summary

Patients experiencing recurrence of kidney cancer in an atypical site require a heavy treatment burden and have a guarded overall prognosis. Continued research is needed to determine the precise incidence of these recurrences and identify methods for mitigating them.

Cytoreduction surgery and hyperthermic intraperitoneal chemotherapy for treating advanced peritoneal metastases of hepatocellular carcinoma

BACKGROUND

An effective treatment strategy for peritoneal metastasis (PM) of hepatocellular carcinoma (HCC-PM) has yet to be established. Although cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have shown favorable outcomes in certain malignancies, their role in peritoneal metastatic HCC is unclear. Herein, we present a series of patients with HCC-PM treated with CRS/HIPEC and evaluate their outcomes.

METHODS

Records of patients with HCC-PM who had undergone CRS/HIPEC at the Hyperthermia Center of Yuan's General Hospital, Kaohsiung, Taiwan, between September 2015 and December 2016 were reviewed retrospectively. Patients were followed up until September 2019. We assessed the clinical courses and outcomes of these patients to clarify the benefits of CRS/HIPEC.

RESULTS

Six patients were included in our study. HCC-PM occurred synchronously in one patient and occurred metachronously in five patients after therapeutic minimally invasive procedures, including radiofrequency ablation, laparoscopic hepatectomy, robotic hepatectomy or spontaneously. The median peritoneal cancer index was 18.5. All patients experienced complete peritoneal cytoreduction without perioperative mortality. One patient had two CTCAE grade 3 complications. The median follow-up was 16 months. The median overall survival was 15.7 months. Four patients died of lung metastasis or liver failure owing to intrahepatic recurrence. The survival rates observed at 1, 2, and 4 years were 66.7%, 33.3%, and 33.3%, respectively.

CONCLUSIONS

CRS followed by HIPEC is feasible in patients with HCC-PM and might provide selected patients a chance for local disease control and longer survival. CRS/HIPEC might be considered as a treatment option in highly selected patients, as part of multimodal therapy approaches.

An unusual case of sarcomatoid renal cell carcinoma presenting in the skin by direct extension at a laparoscopic port site

Although renal cell carcinoma (RCC) is known for its propensity to metastasize widely throughout the body, cutaneous metastases are uncommon and seen in less than 3% of RCCs. A 56-year-old man presented with a painful red lesion with satellite nodules on his abdomen at a laparoscopic port site from a partial nephrectomy for a pT1a clear-cell RCC that was performed 28 months prior. The lesion was excised; however, after excision the lesion recurred with continued pain and drainage from the surgical site. This was treated with multiple courses of antibiotics. Because of the persistent nature of the lesion, it was re-biopsied, and an atypical, keratin-positive, spindle-cell proliferation was identified within the dermis. The patient's previous skin excision was reexamined, and the same atypical cells were identified within large areas of necrosis, granulation tissue, and fibrosis. Further workup was performed on the initial excision, and the atypical cells showed expression of CD10, CAIX, PAX8, EMA, and vimentin, consistent with cutaneous involvement by RCC. Because of the rarity of skin metastases in RCC and the location at a previous laparoscopic port site, this lesion is presumed to have resulted from direct extension of tumor at the time of surgery.

Robotic hepatic surgery in malignancy: review of the current literature

The use of minimally invasive liver surgery, such as laparoscopic and robotic surgery, is increasing worldwide. Robot-assisted laparoscopy is a new surgical technique that improves surgical handling. The advantage of this technique is improved dexterity, which leads to increased surgical precision and no tremor or fatigue. Comparable oncological results were documented for laparoscopic and open surgery. Currently, "conventional" laparoscopic liver surgery has limitations with respect to the treatment of lesions in the posterior-superior segments, and there are limited technical features for the reconstruction steps. These limitations might be overcome with the use of robotic surgery. The use of robotic surgery for hepatic procedures originated because of the technical potential to overcome several of the major technical limitations known from conventional laparoscopy and the possibility of performing more extended liver resections. Additionally, there is increasing evidence indicating that robotic hepatic surgery is feasible and safe in resections of the posterior segments. Studies showed that using the robotic technique is associated with a decreased or at least equal amount of intraoperative blood loss compared to that of the conventional laparoscopic or open technique. There is increasing evidence that robotic liver surgery might be as safe as conventional laparoscopic procedures in cancer cases in terms of resection margins, disease-free and overall survival. Furthermore, robotic surgery might be more favorable with respect to postoperative patient recovery. Despite promising results, still large, multicenter, randomized and prospective studies are needed to analyze the exact value of robotic liver surgery in patients with malignant liver tumors.

Isolated port-site metastasis of hepatocellular carcinoma after laparoscopic liver resection

Port-site metastasis of hepatocellular carcinoma (HCC) is extremely rare, and only one case has been reported in the English-language literature. Contamination with malignant cells along the needle tract during percutaneous biopsy or radiofrequency ablation is a well-recognized cause of HCC recurrence. Here, we describe a case of port-site metastasis after laparoscopic liver resection of HCC. The patient, who had undergone laparoscopic partial resection of the left lateral segment of the liver 18 months earlier, was diagnosed with HCC. CT showed a nodule in the abdominal wall where the laparoscopic port had been inserted during resection. Local excision was performed, and histological examination revealed HCC consistent with recurrence after laparoscopic resection. The experience described in this report highlights the risk of port-site metastasis of HCC. Imaging for oncologic surveillance after laparoscopic resection must include all port sites.