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Robotic port-site and pelvic recurrences after robot-assisted laparoscopic radical hysterectomy for a stage IB1 adenocarcinoma of the cervix with negative lymph nodes
Abstract
Port-site metastasis (PSM) following minimally invasive surgery for gynaecological cancer has been recognized as a potential problem over the last two decades.
A 60 year-old woman with stage Ib1 adenocarcinoma of the cervix was treated with radical hysterectomy, bilateral salpingo-oophorectomy and bilateral pelvic lymph node dissection, using robot-assisted laparoscopy.
Eighteen months after primary surgery, the patient developed a pelvic recurrence invading both the bladder mucosa and the parametrium. During the routine recurrence work-up, we found an 8 mm robotic port-site metastasis (PSM) on the abdominal computed tomography (CT) scan.
This is the first case report emphasizing the risk of PSM and early pelvic recurrences in robot-assisted laparoscopic radical hysterectomy and bilateral pelvic lymph node dissection for an early-stage cervical adenocarcinoma patient with negative lymph nodes, histologically examined by immunohistochemical ultrastaging.
... [1][2][3][4] Previous case reports of PSM in patients with cervical cancer have demonstrated advanced stage disease at the time of surgery as a risk factor. 5,6 Here, we present a case report of an isolated PSM occurring after robotic-assisted laparoscopic surgery in a patient with early stage, node-negative cervical adenocarcinoma and provide review of recent literature on management as well as oncologic outcomes of PSM. 7 ...
Background:
Minimally invasive oncologic surgery has become the standard of care in many gynecologic cancers. While laparoscopic surgery provides many benefits to patients, such as faster recovery, there are unique challenges associated with minimally invasive techniques. Port-site metastasis is a rare complication after laparoscopic oncologic surgery in management of gynecologic malignancies.
Methods:
We present the case of a 44-year-old female with isolated port-site recurrence following laparoscopic radical hysterectomy with node-negative, clinical stage IB1 cervical adenocarcinoma. In addition, we provide an updated review of the literature on management and oncologic outcomes of port-site metastasis.
Conclusion:
Port-site metastasis prevention necessitates a better understanding of underlying risk factors and pathophysiology in order to optimize outcomes. Future studies are needed on risk-reducing strategies and standardization of management for port-site metastasis.
... Our case is distinct in that our patient underwent a robotic surgery and involved bilateral ovarian preservation and suspension. Finally, Sert et al. [8] published a case of PSM following robotic-assisted laparoscopic surgery for node-negative stage IB1 cervical adenocarcinoma. This patient, however, had evidence of widespread metastases at the time of her re-presentation, including involvement of the bladder mucosa and parametrium. ...
Introduction
Port site metastasis after laparoscopic surgery for cervical cancer is a rare phenomenon.
Methods
We present a case report of isolated port site recurrence 4 years following laparoscopic surgery in a patient with node-negative, clinical stage IB1 cervical adenocarcinoma.
Results
A 44 year-old woman presented with a necrotic cervical lesion. A biopsy of the mass revealed invasive endocervical adenocarcinoma. She underwent a robotic-assisted radical hysterectomy, bilateral salpingectomy, and pelvic lymph node dissection with bilateral oophoropexy. All lymph nodes were placed in an Endocatch bag prior to removal via the 12 mm assistant port. There was no clinical evidence of metastatic disease and final pathology revealed negative surgical margins and lymph nodes. Four years later, she re-presented with a soft tissue mass in her abdominal wall underlying the site of the prior laparoscopic assistant port. This was confirmed by transcutaneous biopsy to be metastatic adenocarcinoma of endocervical origin. Further work-up revealed no other evidence of metastatic disease. The recurrence was excised and all margins were negative.
Conclusion
This is the first case report describing an isolated port site recurrence in a patient who underwent robotic-assisted laparoscopic surgery for early-stage cervical adenocarcinoma with negative margins and negative lymph nodes. The mechanism underlying this isolated recurrence remains unknown.
... One case of port-site metastasis following a robotic-assisted laparoscopic radical hysterectomy with bilateral pelvic lymph node dissection for a cervical adenocarcinoma has been described [27]. ...
Initially used for diagnostic, laparoscopy has become a method of treatment in the field of gynecological surgery, but also in many other fields. The results of laparoscopic surgery are now comparable with those obtained by laparotomy in benign and malignant pathologies. Laparoscopy provides improved results in the short term and at least equivalent results in terms of long-term recurrence when compared with open surgery. Robotic-assisted laparoscopy was performed to prevent the disadvantages of conventional laparoscopy. It emerged as a revolutionary technology and has spread in less than a decade in many surgical fields, including urology, cardiothoracic surgery, pediatric surgery and general surgery. Minimally invasive techniques provide a lower rate of complications during surgery as compared to open surgery, which is appropriate tissue due to handling and better anatomical views. Laparoscopic treatment of cervical cancer provides benefits on increasing comfort with decreased convalescence time, but these cases should be reserved for surgeons with extensive experience in laparoscopic procedures. One of the most important advantages of minimally invasive surgical techniques is the short duration of hospitalization.
There are always risks and benefits to consider when performing a surgical procedure. With the continuing advancement of technology and the growing role of robotics in surgery, there are more variables to consider that have the potential for surgical complications. It is the responsibility of surgeons to become educated of not only the surgical procedures but the technical equipment as well. Thorough preparation includes considering the individual patient, the surgical route, the method and procedural steps, the operative timing, and the variety of equipment and how they are to be used. With careful planning and due caution, adverse events can be mitigated or prevented entirely. However, to err is to be human. Despite the due diligence of surgeons in their surgical preparation, complications can arise from time to time. These can range from a thermal injury to bowel or urologic damage, or even a major vascular complication. It is paramount that surgeons are taught to prepare for the unexpected. They should be knowledgeable in recognizing an adverse event and also skilled in managing it. The appropriate prevention, recognition, and resolution of a complication can mean the difference between a positive and negative patient outcome.
Robotic laparoendoscopic single-site (R-LESS) seems to be the next route in advancing minimal invasive surgery, with the potential for better cosmetic results and reduced patient morbidity compared with multi-port surgery. This review describes the history and development of (R-LESS) gynecologic surgery and outlines the latest advancements in the realm of gynecology. The review was conducted according to the PRISMA guidelines. Pubmed and ClinicalTrials.gov (www.clinicaltrials.gov) were the main search engines utilized for retrieval of study data (1990 – present). The following subject headings and keywords were searched: “robotic laparoscopic single incision”, “robotic laparoendoscopic single site”, “single incision robotic surgery” and “single-port robotic surgery”. All original research articles including randomized, non-randomized controlled trials, cohort studies, patient series, and case reports were included. The search produced a total of 1127 results. After duplicate removal, 452 remained, and each title and abstract was reviewed by 2 reviewers. Subsequently, 56 full texts were selected for full review and an additional 20 excluded, leaving 36 studies that were included in the final review. Based on the data gathered we reached the conclusion that R-LESS surgery is feasible, safe and has equivalent surgical outcomes as conventional LESS surgery; in addition to shorter recovery times, less postoperative pain and better cosmetic outcomes than robotic multi-port surgery. To conclude, R-LESS is a feasible approach with low complication rates, minimal blood loss and postsurgical pain, fast recovery, and virtually scar-free results. However, the lack of large comparative prospective randomized controlled studies prevents drawing absolute conclusions.
Introduction
Port-site metastasis (PSM) is cancer growth at the site of a port insertion after laparoscopic surgery for cancer. The pathophysiology of isolated PSM is unknown. Metastatic workup need to be done in all cases to confirm its isolated recurrence or widespread metastasis.
Material and methods
We present a case report on isolated PSM with review of the literature.
Conclusion
Isolated PSM should be treated with surgery. For disseminated metastasis, palliative chemotherapy or best supportive care are options.
Radical hysterectomy belongs to classical procedures in gynecological oncology with a history longer than a hundred years. The surgical technique and the role of radical hysterectomy in the management of cervical cancer have been developing dramatically and are still in progress. A commonly accepted indication is the treatment of cervical cancer stage IB1, in which radical hysterectomy achieves excellent oncological outcomes. Ongoing randomized trials are validating the possibility of abandoning parametria resection and replacing radical with simple hysterectomy in selected subgroups of patients with small tumors of IB1 stage. Surgical treatment can achieve satisfactory outcomes also in the management of locally advanced tumors of stages IB2, IIA and selected IIB on the condition that adequate radicality of hysterectomy and lymphadenectomy is performed.
Acceptance of harmonized terminology and a unified classification system is a challenging task for the specialty to enable comprehensive collaboration and further research. The ABCD classification system represents a modern and simple solution which recognizes four types of radical hysterectomy (B, C1, C2, D), including nerve sparing modification. A critical parameter for the classification is the resection extent of all three parts of parametria.
The extent of parametrectomy, particularly in vertical dimension, is the crucial factor for early and late morbidity. The most significant symptom in the early postoperative period is a failure of spontaneous voiding, while bladder dysfunctions, including urinary incontinence and impairment of bladder sensation, belong to common late postoperative complications. Quality of life can be also compromised due to less frequent symptoms such as anorectal dysfunctions, mainly constipation and flatulence incontinence as well as sexual dysfunctions.
Laparoscopic pelvic and para-aortic lymphadenectomy was performed in a 33-year-old patient who presented with stage 1B poorly differentiated adenocarcinoma of the cervix. Two 10-mm and two 5-mm ports were used for the lymph node dissection. Histological examination of frozen sections of the pelvic and para-aortic lymph nodes submitted confirmed the presence of metastatic disease. As a consequence of this, the planned Schauta-type radical vaginal hysterectomy was abandoned. The patient was given post-operative pelvic irradiation. Unfortunately, she presented 9 months later with histologically proven metastatic disease at the 10-mm port site.
Background:
The aim was to describe the rate of laparoscopic trocar-related subcutaneous tumor implants in women with underlying malignant disease.
Methods:
An analysis of a prospective database of all patients undergoing transperitoneal laparoscopic procedures for malignant conditions performed by the gynecologic oncology service.
Results:
Between 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.
Conclusion:
The 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.
Laparoscopic pelvic lymph node staging is widely used in patients with cervical cancer prior to the initiation of primary chemoradiation therapy. Data on the morbidity of this procedure are sparse.
Between 1995 and 2007, 71 patients with locally advanced cervical cancer (FIGO stage IB2-IIIB) underwent laparoscopic pelvic lymph node staging prior to primary chemoradiation therapy. Surgical outcome and perioperative morbidity were evaluated.
The median operation time, number of resected lymph nodes and time between surgery and the initiation of chemoradiation therapy was 100 minutes, 15 lymph nodes and 18 days, respectively. Intraoperatively, one laceration of the obturatoric artery and one bladder injury occurred. One procedure was converted to a laparotomy. Three short-term postoperative complications including one hematoma in the port side area, one umbilical suture insufficiency requiring a hernia reposition, and one postoperative bleeding that required rehospitalization were noted. Two patients with intraabdominal abscesses required repeat laparoscopy. Of note, three patients developed port site metastases during followup.
Although patients experienced perioperative morbidity, the present study provides further evidence that, overall, laparoscopic pelvic lymph node staging is a relatively safe procedure for patients with cervical cancer.
We report a case of port-site metastasis near the optic trocar site after extraperitoneal laparoscopic lymphadenectomy for cervical carcinoma. A 42-year-old woman with International Federation of Gynecology and Obstetrics clinical stage IIb squamous cell carcinoma of the cervix was evaluated with laparoscopic extraperitoneal paraaortic lymphadenectomy for staging. The aortic nodes were positive. The patient was treated with chemotherapy and radiotherapy. Then brachytherapy was performed. The patient was treated with 6 cycles of weekly topotecan. At month 12, a 4-cm left retroperitoneal mass was detected and excised. Pathologic examination showed an invasive squamous cell carcinoma with tumor-positive margins. Laparoscopic surgery for cancer may result in iatrogenic metastases at the port sites. But all of the port-site recurrence can not be explained by current factors leading to tumor metastases.
The authors describe a case of developing local tumor metastases after laparoscopy. In the second week after laparoscopy metastases developed at the place of the penetration of the pneu-needle and the trocar by the mediation of ascites containing malignant cell groups. This form of metastatisation seems to be extremely rare.
A patient with FIGO Stage IIB cervical carcinoma underwent an extraperitoneal lymphadenectomy with exploratory laparotomy and washings for surgical staging. Intraperitoneal tumor was found. Seven months later, the tumor recurred as a subcutaneous nodule in the surgical incision. The implications of this recurrence are discussed.
Cutaneous metastases from gynecologic malignancies other than ovarian cancer are extremely uncommon. Metastases to the skin, even in advanced cases of cervical cancer, have rarely been reported with only eight previous cases since 1940. Three patients with cutaneous metastases to the abdominal wall as a preterminal event are reported.
The spread of cervical carcinoma associated with parturition through a tumorous cervix is rarely demonstrated. This report details two patients with adenocarcinoma of the cervix who delivered term fetuses vaginally and subsequently presented with tumor nodules in the episiotomy scars. Although both patients appear to have had their recurrences treated successfully, follow-up on one patient has been only 10 months since the completion of therapy. Tumor implantation of the episiotomy wound is a potential risk associated with vaginal delivery in a pregnant patient with cervical carcinoma. However, this iatrogenic mechanism of tumor spread may permit an opportunity for successful treatment of the local recurrence.
Laparoscopic surgery is excellent for treating benign disease of the colon and rectum, and for palliative operations for malignancy. Its application for cure of colorectal malignancy, however, must be approached with caution. Port site recurrence of tumour is a particular, and increasingly recognized, drawback. This review discusses the evidence to date to support prospective randomized trials of laparoscopic colectomy for cure of carcinoma.
A squamous cell carcinoma of the cervix metastatic to the skin at the site of a previous retroperitoneal drain is detailed. A review of the literature concerning skin metastases in cervical cancer is also presented. This is the only case the authors can find in the literature of squamous carcinoma of cervix metastasizing to a drain site.