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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 36  |  Issue : 1  |  Page : 25-27

Port-site metastasis after laparoscopic subtotal gastrectomy in gastric cancer: An uncommon case report


1 Department of Surgery, Division of General Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan, China
2 Department of Surgery, Division of General Surgery, Tri-Service General Hospital, Songshan, Taipei, Taiwan, China

Date of Submission11-Sep-2015
Date of Decision10-Nov-2015
Date of Acceptance15-Dec-2015
Date of Web Publication23-Feb-2016

Correspondence Address:
Chien-Yi Yang
Division of General Surgery, Tri-Service General Hospital, No. 325, Cheng-Kung Road, Sec 2, Neihu 114, Taipei, Taiwan
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1011-4564.177174

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  Abstract 

We present a case of port-site metastasis in a 60-year-old Taiwanese woman who underwent laparoscopic gastrectomy. Seventeen months after surgery, the patient presented with a firm mass (4 cm × 4 cm in size) over the site of the umbilical surgical wound. Wide excision of the umbilicus was performed. Histological examination of the excised mass showed umbilical adenocarcinoma with no evidence of peritoneal nodules, and the patient was discharged to receive further chemotherapy treatment. After 15 months of follow-up, there was no indication of tumor metastasis.

Keywords: Adenocarcinoma, gastric cancer, laparoscopy, port-site metastasis


How to cite this article:
Yang CY, Chan DC, Yu JC, Lu HE. Port-site metastasis after laparoscopic subtotal gastrectomy in gastric cancer: An uncommon case report. J Med Sci 2016;36:25-7

How to cite this URL:
Yang CY, Chan DC, Yu JC, Lu HE. Port-site metastasis after laparoscopic subtotal gastrectomy in gastric cancer: An uncommon case report. J Med Sci [serial online] 2016 [cited 2019 Oct 13];36:25-7. Available from: http://www.jmedscindmc.com/text.asp?2016/36/1/25/177174


  Introduction Top


Port-site metastasis has been documented for malignancies with an estimated incidence of about 1-2% for patients undergoing laparoscopic surgery.[1] In 1978, Döbrönte et al. described a "port-site" tumor implant in a patient with malignant ascites 2 weeks following laparoscopy.[2] In another report, eight local recurrences in 1098 laparoscopic procedures for urologic malignancies were described.[3] [Table 1] summarizes published reports of port-site metastases following laparoscopic surgeries.
Table 1: Representative reports of port-site metastasis following laparoscopic surgery: Incidences of port-site metastasis showed wide variation in terms of time to recurrence, the primary malignancies, and laparoscopic procedures used

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Etiologic factors of port-site metastasis include direct wound contamination, immune status, laparoscopy-related factors (use and type of gas, insufflation, desufflation, and pneumoperitoneum), and experience of the surgical team.[9] We reported the case of a 60-year-old Taiwanese woman with port-site metastasis after laparoscopic gastrectomy.


  Case Report Top


A 60-year-old woman from Taiwan presented to the clinic with an umbilical surgical wound. The woman had ovarian tumor surgery and radiotherapy treatment 30 years ago. This time, she presented with adenocarcinoma of stomach, T3N0M0, Stage IIA, and underwent laparoscopic subtotal gastrectomy, D2 lymph nodes dissection, and further cholecystectomy 1 month later.

Seventeen months after surgery, the patient presented with a hard lump over the umbilical surgical scar. She was admitted to the ward for further evaluation, and a wide excision procedure was performed.

A firm mass with mild erythematous change, nontender, about 4 cm × 4 cm in size that had invaded into the parietal peritoneum was revealed on examination [Figure 1]a. After wide excision, no peritoneal nodules were found [Figure 1]b. The wound was closed layer by layer with retention sutures and nylon sutures. Histopathology revealed a metastatic adenocarcinoma and was suspected to stem from the gastrointestinal tract [Figure 1]c. The final diagnosis was metastatic adenocarcinoma of the umbilicus. The patient was discharged from hospital 1 week later for further chemoradiotherapy treatment. She was followed-up after 15 months. However, no evidence of tumor metastasis was noted at any site.
Figure 1: (a) A firm mass with mild erythematous change, nontenderness, is about 4 cm × 4 cm in size, over para-umbilical region. (b) The tumor mass lesion with invasion of parietal peritoneum after wide excision. (c) Microscopically, histopathology characterized by pleomorphic tumor cells with prominent nucleoli and frequent mitoses arranged in fused glandular pattern infiltration

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  Discussion Top


Recurrence of adenocarcinoma within port-sites following laparoscopic resection has been documented at frequencies of about 1-5% for gastrointestinal malignancies and 1-14% for ovarian malignancies.[10] The incidence of port-site metastasis is higher when the tumor is manipulated. However, the true incidence and the actual number of such recurrences are unknown.

There have been several reports of carcinoma recurrence at port-site after laparoscopic surgery involving cancers of different organs [Table 1]; thus, several authors have questioned the effectiveness of laparoscopic surgery in the management of malignancies.[8],[11] Furukawa et al. described a case of port-site metastasis after laparoscopic surgery for borderline mucinous ovarian tumors.[8] However, laparoscopic surgery has several advantages such as better tumor staging, lesser pain, quicker recovery, and shorter hospitalization.[12]

We report a very rare case of port-site metastasis after laparoscopic surgery for gastric cancer. The published literature suggests that umbilical neoplasms represent only one-fourth or one-sixth of the metastatic tumors at the same location.[13] Furthermore, there have been reports of adenocarcinomas of the umbilicus that produce subcutaneous nodules or intestinal-like epithelial structures, [13] as in the present case, these are very rare. The patient showed no recurrence at the 15-month follow-up visit.

The removal of tumors during surgery, particularly laparoscopy, without spilling of cyst contents is critical to prevent metastasis.[14] If there is tumor exposure during laparoscopic procedure or manipulation of the stomach during the operation, we should use wound protector or tissue endobag for preventing tumor exposure or contamination over the umbilical wound while removal of the specimen from abdominal cavity. In our case, the specimen of the gastric tumor was large; therefore, we used the wound protector on the trocar site of the umbilical wound on the abdomen, instead of using the tissue bag. The risks of port-site metastasis following laparoscopic surgery are also influenced by factors such as the use of carbon dioxide for insufflation, leakage of gas around the trocars leading to aerosolization of tumor cells at the port-sites, local immune system effects, surgical technique, potential for direct contamination of the trocar site with viable tumor cells, and presence of ascites.[1],[15],[16]

Several measures have been suggested to prevent port-site metastasis including sufficient technical preparation, avoidance of laparoscopy if ascites are present, trocar fixation with avoidance of gas leakage, use of a bag for intact specimen removal, povidone-iodine irrigation of laparoscopic instruments, trocar and port-site wounds, intraperitoneal irrigation with chemotherapy solution, and closure of the peritoneal defect.[9] A study showed a 50% decrease in the incidence of port-site metastases when preventive measures were taken, and the risk of developing port-site recurrence was reduced by 7.7-fold.[17]


  Conclusion Top


We suggest that laparoscopic surgery should be avoided in patients with advanced malignancies such as intra-abdominal carcinomatosis. Surgeons should carefully extract tumors during surgery, particularly laparoscopic procedures without spilling tumor cells or cyst contents. Patients undergoing laparoscopic surgery for treatment of their malignancies should be followed-up for longer periods so that any occurrence of port-site metastasis might be detected at an early stage.

Acknowledgment

We thank the grants from the Pathology Department of Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, China.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ramirez PT, Wolf JK, Levenback C. Laparoscopic port-site metastases: Etiology and prevention. Gynecol Oncol 2003;91:179-89.  Back to cited text no. 1
    
2.
Döbrönte Z, Wittmann T, Karácsony G. Rapid development of malignant metastases in the abdominal wall after laparoscopy. Endoscopy 1978;10:127-30.  Back to cited text no. 2
    
3.
Rassweiler J, Tsivian A, Kumar AV, Lymberakis C, Schulze M, Seeman O, et al. Oncological safety of laparoscopic surgery for urological malignancy: Experience with more than 1,000 operations. J Urol 2003;169:2072-5.  Back to cited text no. 3
    
4.
Sakurai K, Tanaka H, Lee T, Muguruma K, Kubo N, Yashiro M, et al. Port site metastasis after laparoscopic-assisted distal gastrectomy (LADG). Int Surg 2013;98:363-6.  Back to cited text no. 4
    
5.
Kim SH, Kim DJ, Kim W. Long-term survival following port-site metastasectomy in a patient with laparoscopic gastrectomy for gastric cancer: A case report. J Gastric Cancer 2015;15:209-13.  Back to cited text no. 5
    
6.
Lee YJ, Ha WS, Park ST, Choi SK, Hong SC. Port-site recurrence after laparoscopy-assisted gastrectomy: Report of the first case. J Laparoendosc Adv Surg Tech A 2007;17:455-7.  Back to cited text no. 6
    
7.
Chaturvedi S, Bansal V, Kapoor R, Mandhani A. Is port site metastasis a result of systemic involvement? Indian J Urol 2012;28:169-73.  Back to cited text no. 7
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8.
Furukawa N, Nishioka K, Noguchi T, Kajihara H, Horie K. Port-site metastasis of mucinous borderline ovarian tumor after laparoscopy. Case Rep Oncol 2014;7:804-9.  Back to cited text no. 8
    
9.
Kadi N, Isherwood M, Al-Akraa M, Williams S. Port-site metastasis after laparoscopic surgery for urological malignancy: Forgotten or missed. Adv Urol 2012;2012:609531.  Back to cited text no. 9
    
10.
Påhlman L. The problem of port-site metastases after laparoscopic cancer surgery. Ann Med 1997;29:477-81.  Back to cited text no. 10
    
11.
Poncelet C, Bouret JM, Boulay I, Tsatsaris V, Ferrand J, Mintz JP, et al. Umbilical metastasis of an endometrial adenocarcinoma: "Sister (Mary) Joseph's nodule". Review of the literature. J Gynecol Obstet Biol Reprod (Paris) 1996;25:799-803.  Back to cited text no. 11
    
12.
Rao S, Rathod A, Kamble A, Gupta D. Delayed presentation of port-site metastasis from an unknown gastrointestinal malignancy following laparoscopic cholecystectomy. Singapore Med J 2014;55:e73-6.  Back to cited text no. 12
[PUBMED]    
13.
Glazer G. Primary adenocarcinoma arising in a vitello-intestinal duct remnant at the umbilicus. Br J Surg 1973;60:247-9.  Back to cited text no. 13
[PUBMED]    
14.
Balli JE, Franklin ME, Almeida JA, Glass JL, Diaz JA, Reymond M. How to prevent port-site metastases in laparoscopic colorectal surgery. Surg Endosc 2000;14:1034-6.  Back to cited text no. 14
    
15.
Huang KG, Wang CJ, Chang TC, Liou JD, Hsueh S, Lai CH, et al. Management of port-site metastasis after laparoscopic surgery for ovarian cancer. Am J Obstet Gynecol 2003;189:16-21.  Back to cited text no. 15
    
16.
Ozmen B, Sükür YE, Atabekoglu CS, Heper AO, Sönmezer M, Güngör M. Early port-site metastasis during neoadjuvant chemotherapy in advanced stage ovarian cancer: Report of two cases. J Gynecol Oncol 2011;22:57-60.  Back to cited text no. 16
    
17.
Schneider C, Jung A, Reymond MA, Tannapfel A, Balli J, Franklin ME, et al. Efficacy of surgical measures in preventing port-site recurrences in a porcine model. Surg Endosc 2001;15:121-5.  Back to cited text no. 17
    


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