Port-site recurrence following laparoscopic surgery in cervical cancer

Abstract. Tjalma WAA, Winter-Roach BA, Rowlands P, de Barros Lopes A. Port-site recurrence following laparoscopic surgery in cervical cancer.
Port-site metastasis (PSM) after laparoscopic lymphadenectomy in cervical cancer is a new phenomenon. This situation creates potential therapeutic difficulties, especially in node-negative and early stages of disease. We report a case of port-site metastases following laparoscopic removal of para-aortic lymph nodes in a 74-year-old women with stage IIIb squamous cancer of the cervix, together with an update of all the previous published cases in the literature. None of the removed lymph nodes showed evidence of metastatic carcinoma. The patient received radiation therapy and a complete response was accomplished. Fifteen months after the operation, the patient presented with a suspicious lesion around the umbilical port-site. The lesion was excised and histology confirmed metastatic disease. The patient was further treated with cisplatin. However, she died of her disease after 24 months. The development of a port-site recurrence after laparoscopic surgery in cervical cancer could jeopardize use of this approach. Therefore, all patients undergoing laparoscopic surgery for malignancies should have careful follow-up with special attention to the port sites.     

Laparoscopic port-site metastases in patients with gynecological malignancies

OBJECTIVE: The purpose of this study is to review all reported cases of laparoscopic port-site metastases in patients with gynecological malignancies. Potential etiologies as well as options for prevention are discussed. METHODS: We searched the Medline database for English-language articles presenting raw data on laparoscopic port-site metastases in patients with gynecological malignancies. RESULTS: We found 31 articles describing port-site metastases in 58 patients. Forty patients had low malignant potential (seven patients) or invasive ovarian carcinoma (33 patients). The median age of these patients was 50 years (range: 22-79), and 83% had advanced (stage III or IV) disease. Seventy-one percent of the patients (24 of 34) had ascites, and 97% (29 of 30) had carcinomatosis. Seventy-five percent of the laparoscopic procedures in this group were performed for diagnosis. Median time to diagnosis of port-site metastases was 17 days (range: 4-730). Seventy-one percent of port-site recurrences (15 of 21) were isolated to a tissue-manipulating port. Twelve patients had port-site metastases after laparoscopy for cervical cancer. The median age was 44 years (range: 31-74). Eighty percent of cases were squamous cell carcinoma. In 75% of the patients, laparoscopy was performed for therapeutic purposes. The median time to diagnosis of port-site metastases was 5 months (range: 1.5-19). Four patients had port-site metastases after laparoscopy for uterine cancer. The median age was 63 years (range: 56-72). The median time to diagnosis of metastases was 13.5 months (range: 6-21). Half of the recurrences were in the tissue-manipulating port. Port-site metastases after laparoscopy were reported for one patient each with a diagnosis of fallopian tube carcinoma and vaginal carcinoma. CONCLUSIONS: Laparoscopic port-site metastases are a potential complication of laparoscopy in patients with gynecological malignancies, even in patients with early-stage disease.     

Laparoscopic port-site recurrence following surgery for a stage IB squamous cell carcinoma of the cervix with negative lymph nodes

BACKGROUND: Port-site metastases are commonly reported after laparoscopic surgery for ovarian cancer, but have also been reported in patients with cervical or endometrial cancer with positive lymph nodes. Recently, a case of port-site recurrence after laparoscopic surgery for a patient with node-negative early-stage adenocarcinoma of the cervix was reported. We report the first case of port-site metastasis in a patient with stage IB squamous cell carcinoma of the cervix with negative lymph nodes. CASE: A 31-year-old woman had a laparoscopy for pelvic pain. Under anesthesia, she was noted to have a grossly abnormal-looking cervix and a biopsy revealed squamous cell carcinoma. She was referred to a gynecological oncologist and underwent radical hysterectomy and pelvic lymph node dissection through a transverse lower abdominal incision 6 weeks later. Nineteen months postoperatively, she presented with a soft tissue mass in a suprapubic laparoscopic trocar site. CONCLUSION: It is postulated that cells dislodged at the time of cervical manipulation and biopsy may have passed through the fallopian tubes and implanted in the laparoscopic port site due to the "chimney effect" caused by the pneumoperitoneum.     

Port-site recurrence after laparoscopic surgery for endometrial carcinoma

Background: Women with endometrial carcinoma are being treated with laparoscopic surgery, but the risk of port-site recurrences remains undefined.Case: A 58-year-old woman underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic lymphadenectomy for endometrial cancer. Final surgical stage was IA, with grade 2 histology. Twenty-one months later, she developed a 5-cm recurrent tumor mass at a lateral laparoscopic port site. The mass was resected, and a restaging laparotomy performed, without evidence of other metastases. Radiation therapy was administered to the involved anterior abdominal wall. Two and one half years later, there is no evidence of recurrence.Conclusion: An isolated laparoscopic port-site recurrence might be attributable to the initial laparoscopic management of an otherwise good-prognosis endometrial carcinoma.     

Feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy

OBJECTIVE: The aim of this study is to evaluate the feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy for cervical and endometrial carcinoma. METHODS: Seventy-six patients underwent extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy between February 1999 and September 2005. The lymph nodes dissected with the laparoscopic procedure included the inframesenteric para-aortic lymph nodes, the sacral lymph nodes, and the bilateral common iliac lymph nodes. The extraperitoneal laparoscopic operation was performed with pelvic open surgery using Lap Disc to ensure the safety of patients. RESULTS: The number of patients with cervical and endometrial carcinoma was 36 and 40, respectively. The median age of patients was 51 years (range 24-75 years). Conversion to open surgery was necessary in 8 patients. These include 3 patients who encountered blood loss of 400, 136 and 128 ml; 2 extremely obese women; and 3 patients who had peritoneal tears causing CO2 gas leakage. Among the remaining 68 patients, the median operating time for extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy was 75 min (range 45-145 min), and the median estimated blood loss was 5 ml (range 5-138 ml). The median total number of resected nodes was 14 (range 2-31), and 4 patients had lymph node metastasis. No patient encountered postoperative complications attributable to extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy. CONCLUSIONS: Extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy with pelvic open surgery using Lap Disc is a feasible procedure, particularly in the surgeons learning phase.     

Port site metastases after laparoscopic lymph node staging of cervical carcinoma.

The literature revealed only six cases of cervical carcinoma metastatic to a port site after laparoscopic lymphadenectomy. A woman with a poorly differentiated squamous cell carcinoma of the cervix had port site metastases after laparoscopic lymph node staging. The frequency of this event might be higher than expected. Therefore, surgeons should reduce mechanical irritation of port sites and spillage of tumor cells.     

Microinvasive squamous carcinoma of the cervix: treatment modalities

Patients with FIGO stage IA1 squamous cell carcinoma of the cervix can be treated conservatively with simple hysterectomy or, if young and desiring to preserve their fertility, with conization only, provided surgical margins are free of dysplasia or invasive disease. When the surgical margins are involved a repeat conization should be performed. Patients with FIGO stage IA2 or stage IA1 carcinoma with extensive lymph vascular space invasion benefit from a modified radical hysterectomy with pelvic lymph node dissection. If preservation of fertility is an issue, then conization with extraperitoneal or laparoscopic pelvic lymphadenectomy can be performed. Alternatively, radical trachelectomy with pelvic lymphadenectomy may be a safer procedure. Individualization of therapy based on an exhaustive pathological evaluation of an adequate cone biopsy specimen is of paramount importance for treatment planning and disease control.     

Port-site metastasis after laparoscopic surgery for gynecologic cancer. A report of six cases

BACKGROUND: Port-site metastasis after laparoscopic surgery for gynecologic cancer is a recognized entity. CASES: Five patients underwent laparoscopic peritoneal biopsies for a stage III (n = 4) or IV (n = 1) ovarian cancer with moderate or poor differentiation. The sixth patient underwent a laparoscopic lymphadenectomy for vaginal carcinoma with bulky metastatic pelvic lymph nodes. CONCLUSION: In order to avoid port-site metastasis, patients with an obviously malignant ovarian tumor and ascites should not be treated with laparoscopy using pneumoperitoneum. If a malignant ovarian tumor is discovered during laparoscopy, the interval between initial surgery and complete cytoreductive surgery (with resection of laparoscopic ports) followed by chemotherapy should be as short as possible. For patients with uterine cancer and bulky nodes, laparoscopic lymphadenectomy should be avoided to avoid trocar implantation metastasis.     

Métastase orificielle sur site de trocart après lymphadénectomie rétropéritonéale pour un adénocarcinome endométrial

Port-site metastasis is a rare but serious complication of laparoscopic surgery. The etiologies are poorly identified and multiple. We report the case of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma. In the literature, three cases of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy are reported: two cases concerning cervical cancer and one case concerning a kidney cancer. To our knowledge, this is the only case about port site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma.     

Bilateral primary squamous cell carcinoma of the ovary: a case report of isolated metastasis to the lateral pelvic wall

Primary squamous cell carcinoma of the ovary is rare. The majority of cases arise most commonly from the lining of a dermoid cyst, and less often in endometriosis or a Brenner tumor. A 40-year-old woman underwent exploratory laparotomy and was found to have a right ovarian tumor adherent to the lateral pelvic wall with no ascites. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy, infracolic omentectomy, appendectomy, and right nephrectomy for bilateral primary squamous cell carcinoma of the ovary. She was started on multiagent chemotherapy. On follow-up after two years the patient had died of cerebral metastases. To our knowledge in this report we present the first case in the English literature of bilateral pure squamous cell carcinoma of the ovary.     

Technical development and results of left extraperitoneal laparoscopic paraaortic lymphadenectomy for cervical cancer

OBJECTIVE: The aim of this study was to describe the development of our technique for laparoscopic paraaortic lymphadenectomy for cervical cancer and to evaluate the accuracy of the left extraperitoneal route to perform complete paraaortic lymphadenectomy. METHODS: A retrospective study of a consecutive series of 44 patients with cervical cancer undergoing laparoscopic paraaortic lymphadenectomy between July 1992 and November 1998 was performed, as well as a comparison of the three routes successively used to perform paraaortic lymphadenectomy: transperitoneal, bilateral extraperitoneal, and left extraperitoneal. RESULTS: The initial choice of surgical access was transperitoneal (n = 9) in 20%, bilateral extraperitoneal (n = 14) in 32%, and left extraperitoneal (n = 21) in 48% of cases. Success rates of laparoscopic paraaortic lymphadenectomy were 78% for the transperitoneal approach, 93% for the bilateral extraperitoneal approach, and 95% for the left extraperitoneal approach. Conversion from extraperitoneal to transperitoneal laparoscopic paraaortic lymphadenectomy, because of a peritoneal tear, was necessary in 3 cases (21.4%) for the bilateral extraperitoneal route and in 3 cases (14.3%) for the left extraperitoneal route (P = 0.43). The extent of dissection varied with experience. Systematic paraaortic lymphadenectomy (up to the left renal vein) was performed via the transperitoneal route in 1 case with 19 aortic nodes removed (common iliac nodes excluded) in 160 min, via the bilateral extraperitoneal route in 6 cases with a mean of 16 +/- 2 (range: 14-19) aortic nodes removed in 153 +/- 22 min (range: 130-180), and via the left extraperitoneal route in 12 cases with a mean of 15 +/- 3 (range: 10-19) aortic nodes removed in 119 +/- 14 min (range: 100-150). There were no statistically significant differences in the total number of nodes removed between the two extraperitoneal routes, although the bilateral extraperitoneal route yielded more right-sided aortic nodes (P < 0. 01). The operating time was significantly shortened using the left extraperitoneal route (P < 0.05). CONCLUSION: Systematic paraaortic lymphadenectomy by a left extraperitoneal route is feasible. Information on right-sided aortic nodes can be obtained although the sampling is reduced compared to that of bilateral extraperitoneal route. It provides the advantages related to the use of the extraperitoneal route while reducing manipulations and thus the risk of peritoneal tearing compared to those of the bilateral extraperitoneal route.     

The rate of port-site metastases after 2251 laparoscopic procedures in women with underlying malignant disease

BackgroundThe aim was to describe the rate of laparoscopic trocar-related subcutaneous tumor implants in women with underlying malignant disease.MethodsAn analysis of a prospective database of all patients undergoing transperitoneal laparoscopic procedures for malignant conditions performed by the gynecologic oncology service.ResultsBetween July 1991 and April 2007, laparoscopic procedures were performed in 1694 patients with a malignant intraabdominal condition and in 505 breast cancer patients undergoing risk-reducing, diagnostic or therapeutic laparoscopic procedures without intraabdominal disease. Port-site metastases were documented in 20 of 1694 patients (1.18%) who underwent laparoscopic procedures for a malignant intraabdominal condition. Of these, 15 patients had a diagnosis of epithelial ovarian or fallopian tube carcinoma, 2 had breast cancer, 2 had cervical cancer, and 1 had uterine cancer. Nineteen of 20 patients (95%) had simultaneous carcinomatosis or metastases to other sites at the time of port-site metastasis. Patients who developed port-site metastases within 7 months from the laparoscopic procedure had a median survival of 12 months whereas patients who developed port-site metastasis > 7 months had a median survival of 37 months (P = 0.004). No port-site recurrence was documented in patients undergoing risk-reducing, diagnostic or therapeutic laparoscopic procedures for breast cancer without intraabdominal disease.ConclusionThe rate of port-site tumor implantation after laparoscopic procedures in women with malignant disease is low and almost always occurs in the setting of synchronous, advanced intraabdominal or distant metastatic disease. The presence of port-site implantation is a surrogate for advanced disease and should not be used as an argument against laparoscopic surgery in gynecologic malignancies.     

Para-aortic and Right Obturator Lymphadenectomy for Surgical Staging of Advanced Cervical Cancer through the TU-LESS Extraperitoneal Approach

ObjectiveTo present an innovative transumbilical laparoendoscopic single-site (TU-LESS) extraperitoneal approach for lymphadenectomy in a patient with advanced cervical carcinoma.DesignDemonstration of the novel technique through video.SettingIn advanced cervical cancer, determining the status of the para-aortic lymph nodes is essential because extended-field radiologic therapy is recommended for a patient with positive para-aortic lymph nodes [1]. Nonetheless, the sensitivity and specificity of currently available imaging workup for positive lymph nodes are limited. Surgical staging enables precise evaluation. However, laparotomy has potential wound complications and leads to treatment delay. Multiport laparoscopic transperitoneal and extraperitoneal approaches limit surgeons’ ability to reach the para-aortic area or obturator fossa in the same operation [2]. Thus, we take full use of these approaches’ advantages and avoid their disadvantages to design a promising minimally invasive surgery approach [3].InterventionsPara-aortic and obturator lymphadenectomy through the TU-LESS extraperitoneal approach was successfully performed without complications. The patient recovered quickly and received subsequent concurrent chemoradiation on schedule.ConclusionTU-LESS extraperitoneal para-aortic lymphadenectomy provides satisfactory exposure and easy access to both the para-aortic area and obturator fossa. In addition, the bowels are uplifted by an extraperitoneal air cushion to achieve excellent exposure and reduce the risk of bowel injury. With quick recovery, the patient could start accurate radiation treatment promptly.     

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.     

The side of groin node metastases in unilateral vulvar carcinoma

The purpose of this study was to analyze the occurrence of ipsilateral, bilateral and contralateral inguinofemoral node metastases in unilateral vulvar carcinoma. One hundred and eighty-five women with a T1 or T2 squamous cell carcinoma who underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy were surveyed. Inguinofemoral lymph node metastases were found in 23 (22.1%) out of the 104 patients with a unilateral primary tumor. These lymph node metastases were found solely on the ipsilateral side in 21 (91.3%) out of the 23 patients. One patient presented with bilateral extranodal growth in the groins. Another patient with a history of endometrial carcinoma had a right-sided vulvar tumor with contralateral groin node metastases. Half a year later, she was diagnosed with recurrent endometrial cancer on the right pelvic side-wall. Our study endorses clinical evidence that the preferential lymph flow is to the ipsilateral groin. Established lymph node metastases may disturb the normal lymph flow with contralateral metastases as a possible consequence.     

Laparoscopic port-site metastases: etiology and prevention

OBJECTIVE: The purpose of this article is to summarize current hypotheses for the possible sources of laparoscopic port-site metastasis, to review the results of experimental models that support such hypotheses, and to discuss the potential options for preventing these metastases. METHODS: We performed a Medline search to identify in vitro and in vivo studies and clinical trials that analyzed port-site metastases associated with laparoscopic surgery. We report the incidence of port-site metastases and causative factors associated with this condition. RESULTS: The estimated incidence of port-site metastases in all patients undergoing laparoscopic surgery for malignant disease is approximately 1-2%. Multiple factors are associated with this complication. Among the most common proposed etiologies are the wound implantations caused by the surgical technique and instrumentation; the leakage of insufflation gas through the ports, known as the "chimney effect"; and the impact of pneumoperitoneum on local immune reactions. Several preventive measures, have been suggested, including careful patient selection, lavage of the peritoneal cavity as well as of the port wounds with cytotoxic agents, and modifications of surgical technique. CONCLUSIONS: Only through the results of well-conducted large multi-institutional prospective randomized trials will we learn not only the true incidence of port-site metastases, but also the potential factors that lead to the occurrence of this complication.     

Relevance of microinvasion in carcinoma of the vulva.

Retrospective analysis of 22 cases of Stage I invasive carcinoma of the vulva showed 11 cases in which the depth of tumor invasion was 5 mm or less. All of these patients were treated with radical vulvectomy and lymphadenectomy. In 3 cases positive groin node metastases were discovered. A fourth patient with minimal stromal invasion (less than 5 mm) was prospectively managed with vulvectomy alone and subsequently developed groin node metastasis leading to death from disseminated tumor. Depth of the invasion alone, therefore, is not a reliable indicator of the likelihood of groin node involvement, and lymphadenectomy should continue to be considered for all patients with invasive squamous cell carcinoma of the vulva.     

Extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of fallopian tube carcinoma

The endoscopic retroperitoneal approach is a minimally invasive method for surgical staging of cervical cancer. A 57-year-old woman had an intraoperative diagnosis of carcinoma of the left fallopian tube and undergone a retroperitoneal pelvic and para-aortic lymphadenectomy with no peritonization during surgical staging. Small suspicious nodes in the serous membrane of the sigmoid colon and peritoneal washings were positive for malignancy. A total of 12 nodes were obtained, all of which were negative. She received six cycles of paclitaxel and platinum-based chemotherapy and showed a complete clinical response. Thirty-two months after surgery, the abdominal computed tomography scan showed a left para-aortic lymph node, 19 mm in diameter, which was successfully removed through an extraperitoneal laparoscopic approach. The extraperitoneal laparoscopic approach of the para-aortic region is a feasible procedure after previous transperitoneal lymphadenectomy and chemotherapy.     

CT findings in two cases of port-site metastasis after laparoscopy for ovarian cancer

CASES: Two patients with histologically proven port-site metastasis following laparoscopic procedures for ovarian cancer underwent a CT scan. These two patients were initially treated for a stage IA and III ovarian cancer. Port-site recurrence occurred six and 19 weeks following the laparoscopic procedure. In one patient, the abdominal wall recurrence was associated with peritoneal carcinosis. In both patients, CT scan revealed the presence of an heterogeneous nodular lesion inside the left oblique muscle. Histologic analysis confirmed the diagnosis of port-site recurrence. CONCLUSIONS: Port-site metastases could be observed in the treated patients with a laparoscopic approach for ovarian cancer. When this diagnosis is clinically suspected, a CT scan should be performed in order to precise the diagnosis of port-site metastasis and to evaluate potential intra-abdominal recurrent disease. However, only histologic examination can confirm a diagnosis of port-site recurrence.