Abdominal wall port site metastasis after robotically staged endometrial carcinoma: A case report

Abstract

INTRODUCTION

The incidence of port-site metastasis following robotic-assisted laparoscopic hysterectomy is unknown.

PRESENTATION OF CASE

We present a case of a 78-year-old female diagnosed with an incidental grade 3 endometrial adenocarcinoma on a final hysterectomy specimen. She subsequently underwent a robotic staging surgery with a gynecologic oncologist where nodal pathology was found to be negative; her final stage was 1B. One year following diagnosis, she developed a recurrence on her abdominal wall at the former port-sites with concomitant vaginal cuff recurrence.

DISCUSSION

We hypothesize possible modes of metastasis and present limited published data to date on port site metastasis following robotic hysterectomy for endometrial cancer.

CONCLUSION

This is the second reported case of port-site metastasis following robotic surgery for endometrial cancer.

1. Introduction

Port-site metastasis (PSM) after laparoscopic and robotic surgeries for gynecologic cancers is rare, and the incidence after laparoscopic staging remains low.^1,2 One study reported a port-site metastasis rate of 0.4% for all laparoscopic procedures and 0.33% for uterine cancers alone.¹ Another large series reported a PSM risk of 1.18% for all laparoscopic cancer surgeries with a risk of 0.059% for endometrial cancer.² Robotic-assisted laparoscopic hysterectomy for surgical staging is now widely used by gynecologic oncologists for the management of endometrial cancer. The current published literature on PSM in gynecologic oncology largely pertains to laparoscopic procedures with only one reported case of PSM from endometrial cancer after robotic hysterectomy.³ To the best of our knowledge this is the second reported case of abdominal wall PSM following robotic staging surgery for endometrial cancer.

2. Presentation of case

A 78-year-old multiparous woman presented to her gynecologist with postmenopausal vaginal bleeding. Both an endometrial biopsy and a dilation and curettage specimen were negative for endometrial malignancy. She subsequently underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy by her gynecologist. The final hysterectomy specimen revealed a FIGO grade 3 endometrioid endometrial adenocarcinoma measuring 3.2 cm in maximum tumor diameter and a 1.4 cm out of 1.7 cm depth of myometrial invasion. No lymphovascular space invasion was noted. The patient was then referred to a gynecologic oncologist and subsequently underwent a robotic-assisted pelvic and paraaortic lymphadenectomy, omentectomy, vaginal cuff biopsies, and cystoscopy two months following her initial operation. Intraoperatively, care was taken to place the lymph nodes into the endo-catch bags without excessive manipulation or replacement of the robotic trocars. A total of 27 lymph nodes (20 pelvic and 7 paraaortic) were sampled and were negative for malignancy. All pelvic washings, vaginal cuff biopsies, and omental specimens were also negative. The diagnosis was a stage IB, grade 3 endometrioid endometrial cancer, and the patient elected to undergo adjuvant vaginal brachytherapy.

She remained without evidence of disease until her 12-month follow-up when she was incidentally found to have two 1.5 cm nodules on her anterior abdominal wall in the right and left lower quadrants, confirmed by CT imaging (Fig. 1). Both nodules were three cm inferior to the previous robotic trocar sites. Two nodules were also noted at the vaginal cuff. She underwent surgical exploration of the abdominal wall, resection of the two abdominal wall masses, vaginal cuff biopsies and cystoscopy. Intraoperative findings were significant for the abdominal wall masses imbedded within the fascia on the right and both the fascia and the peritoneum on the left.

Fig. 1.

Abdominal CT (axial). Abdominal wall port site metastasis, right sided nodule (left image) and left-sided nodule (right image).

The pathology of these masses revealed metastatic, poorly differentiated adenocarcinoma, FIGO grade 3, consistent with the endometrial primary. The largest mass diameter measured 2.9 cm. All vaginal cuff biopsies were also consistent with adenocarcinoma.

Postoperatively, the patient received six cycles of chemotherapy with IV carboplatin and paclitaxel and had a robust response with no evidence of clinically measurable disease. She is currently disease free one year after treatment.

3. Discussion

Port-site metastasis (PSM) following robotic surgery for early-stage endometrial cancer is exceedingly rare. To the best of our knowledge, this is the second case of port-site metastasis after robotically staged endometrial cancer to be reported in the literature. Interestingly, the recurrent abdominal wall nodules in this patient were located 3 cm below the previous trochar sites bilaterally but away from the patient's prior Pfannenstiel scar. We hypothesize that this was likely do to the angulation of the robotic trocars toward the pelvis during surgery.

Despite negative nodal pathology, the patient's cancer recurred at the previous trocar sites. As mentioned, care was taken to minimize manipulation of trocars, which were also removed prior to complete deflation of the abdomen. Given the patient's negative lymph nodes, pelvic washings, and omentectomy, it is unusual that the patient's recurrence would present as tumor nodules at the robotic port-sites. Although we cannot explain these findings, we hypothesize a few considerations. Positive pelvic and/or paraaortic lymph nodes not sampled by the surgeon may have disseminated hematogenously to the site of recent trauma, i.e. the port sites. Penetration of tissue planes during staging surgery upon entry of the peritoneum with trocars as well as entry into the retroperitoneum with robotic instrumentation may have allowed direct spread of latent tumor cells to implant at these sites. Although this would not explain metastatic tumor nodules at the vaginal cuff, colpotomy at the time of the patient's primary surgery may have resulted in direct spread of tumor cells that manifested grossly with time, coincidentally with the abdominal tumor recurrences.

The incidence of port site metastasis in endometrial cancer is likely to grow with increasing use of robotic staging surgery. Only one other case, by Ndofor et al., has been reported on abdominal PSM following robotic hysterectomy in endometrial cancer.³ One patient, out of 116 who underwent RA-TLH for uterine cancer, had a port site recurrence at the umbilical trocar site with concommitant retroperitoneal lymphadenopathy and peritoneal carcinomatosis.³ The risk of developing PSM in this series was 1.1% for all gynecologic cancers and 0.055% for uterine cancer.³ These rates are similar to those for laparoscopic surgeries performed for gynecologic malignancies (0.4–1.18%).^1,2 Although four cases of isolated PSM can be found in the laparoscopic literature, isolated PSM, without metastasis to other sites, in robotically staged endometrial cancer patients have not been published.⁴

In another series on PSM following laparoscopic-assisted vaginal hysterectomy (LAVH), one out of 547 patients with uterine cancer had PSM.² This same series found that all gynecologic cancer patients who developed PSM within seven months of surgery had a median survival of 12 months, while those who developed PSM at an interval greater than seven months had 37 month median survival (P = .004).² It has been reported that an aggressive histologic grade is more commonly associated with non-isolated or concomitant PSM as affirmed in this case.⁴ It appears that laparoscopy-related port-site metastases are uncommon and seem to predominantly occur in the setting of advanced disease.⁴

4. Conclusion

Due to the limited number of cases of PSM following robotic surgery for endometrial cancer we believe that the rates of simultaneous carcinomatosis as well as survival data for LAVH PSM can be extrapolated to robotic cases for gynecologic malignancies when counseling patients on prognosis.

As more robotic procedures are performed worldwide, for both endometrial and other gynecologic cancers, similar cases will need to be published before uniform prevention strategies can be proposed.

Conflict of interest

The authors have no conflict of interest to declare for this paper.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Authors’ contributions

M. Nguyen contributed to conception and design, data collection, manuscript preparation and finalization; J. Friedman contributed to data collection and manuscript preparation; T. Pradhan contributed to conception and revision for intellectual content; T. Pua contributed to conception and manuscript preparation; S. Tedjarati contributed as primary surgeon for robotic case and manuscript finalization.