The minimally invasive resection of port-site metastasis of ovarian cancer after laparoscopy with cutaneous integrity: a case report and literature review

Abstract

Background

Postoperative wound recovery following laparotomy for port-site metastasis (PSM) resection is a concern. Reports indicate that wound healing disorders occur in patients with PSM. The challenges associated with PSM resection include the complete removal of the lesion, ensuring rapid wound healing, and maintaining the integrity of the abdominal wall. To date, there have been no reports on a minimally invasive approach for PSM resection following ovarian cancer through the inner side of the abdominal wall.

Case presentation

A 66-year-old G2P1 patient with a history of high-grade serous ovarian adenocarcinoma IIA presented with two abdominal wall masses, suspected to be PSM. She underwent laparoscopic resection of the lesions under general anesthesia. The excised masses measured approximately 10 cm and 5 cm, and margins were negative. The surgery lasted 1 hour and 33 minutes, with minimal intraoperative bleeding and no complications. The postoperative recovery was smooth. No recurrence was observed during the 12-month follow-up.

Conclusions

In our view, laparoscopy may be used as a minimally invasive technique that allows for PSM in the abdominal wall.

Background

Ovarian cancer ranks as the eighth most commonly diagnosed cancer among women globally, accounting for approximately 3.7% of all cancer cases and 4.7% of cancer-related deaths in 2020 [1]. As a minimally invasive approach, laparoscopy can be effectively used for the surgical management of early-stage ovarian cancer. Patients with early ovarian cancer who undergo laparoscopic surgery achieve survival outcomes comparable to those who have traditional laparotomy, with the added benefits of potentially reduced recovery times and improved cosmetic results [2, 3].

However, there are certain disadvantages associated with laparoscopic surgery for ovarian cancer, one of which is port-site metastasis (PSM)—the dissemination of cancer cells to the site where laparoscopic instruments are introduced. PSM was first documented following laparoscopy for ovarian cancer by Döbrönte in 1978 and has also been reported in other gynecological malignancies [4,5,6]. The estimated prevalence of PSM following minimally invasive surgery for gynecologic cancers ranges from 0.4% to 2.3%, a rate that is comparable to wound implantation observed in open surgical techniques. Current literature indicates that the incidence of PSM after laparoscopic surgery for ovarian cancer is higher than that found in cervical and endometrial cancers, which had reported prevalence rates of 0.43% and 0.33%, respectively [7, 8]. In contrast, the prevalence of PSM following diagnostic laparoscopy for ovarian cancer has been reported to range from 16% to 47% [7,8,9,10]. However, there remains a lack of data regarding the incidence of port-site metastasis in laparoscopic surgeries for various stages of ovarian cancer, particularly after primary debulking and interval debulking surgeries.

Postoperative wound recovery after laparotomy for port-site resection is also a concern, with reports of wound healing disorders in patients with port-site metastasis [10]. The challenges associated with PSM resection include complete lesion removal, promoting rapid wound healing, and preserving abdominal wall integrity. We have reported a case of a patient with ovarian cancer who developed two port-site metastases after laparoscopy. We successfully utilized laparoscopy to resect these metastases through the inner abdominal wall while maintaining cutaneous integrity. To date, there have been no reports detailing a minimally invasive approach for the resection of PSM following ovarian cancer via the inner side of the abdominal wall.

Case presentation

A 66-year-old G2P1 patient was admitted to our hospital with two abdominal wall masses. Two years earlier, she had been diagnosed with high-grade serous ovarian adenocarcinoma Stage IIA (FIGO). The patient had no other significant medical history. A laparoscopic procedure was performed, which included hysterectomy, oophorectomy, omentectomy, and pelvic lymphadenectomy, achieving optimal debulking. Following the surgery, she received six cycles of chemotherapy. Recently, the patient noticed two masses in her abdominal wall that gradually enlarged over a period of four months, although she did not seek medical attention prior to this.

Physical examination revealed two masses on both sides of the lower abdominal wall, corresponding to the sites of the ports used in the previous laparoscopy. Color ultrasound identified a mass measuring 5.2 × 2.8 × 5.7 cm in the left lower abdominal wall and another measuring 2.8 × 2.4 × 2.9 cm in the right lower abdominal wall, both considered metastatic carcinoma (Fig 1a, b). Enhanced CT scans confirmed the presence of these two masses, primarily situated in the lower abdominal wall (Fig 1c, d), with no evidence of metastasis elsewhere. The CA-125 level was elevated at 82.5 U/ml, leading to a diagnosis of port-site metastatic carcinoma.

Fig. 1

a-d Ultrasound examination revealed a 5.2×2.8×5.7cm mass in the left lower abdominal wall (blue arrow in a) and a 2.8×2.4×2.9cm mass in the right lower abdominal wall (blue arrow in b). Enhanced CT displayed two masses in left side (blue arrow in c) and right side (blue arrow in d) of the lower abdominal wall

The patient underwent laparoscopic resection of the port-site metastasis lesions via the inner side of the abdominal wall under general anesthesia. The camera port was positioned 3 cm above the navel, and two additional operational ports were placed on the right side of the abdominal wall. During the procedure, bowel adhesions were encountered on the peritoneum adjacent to the metastatic carcinoma. These adhesions were safely separated using a combination of monopolar electrotome and ultrasound knife until the smooth peritoneum was exposed (Fig. 2a-b). The peritoneum was incised with a monopolar electrotome, and the carcinomas were excised along with a 2 cm margin using an ultrasound knife through the inner aspect of the abdominal wall (Fig. 2c-d).The successful excision of the two lesions was confirmed (Fig. 3a-b). The left lesion had an approximate diameter of 10 cm, while the right lesion measured about 5 cm (Fig. 3c-d). The excised carcinomas were placed in a laparoscopic pouch and removed through the operational port. The procedure lasted 1 hour and 33 minutes, with an intraoperative blood loss of 30 ml. There were no intraoperative or postoperative complications. The postoperative visual analog scale (VAS) score at 24 hours was 1, and intestinal function recovered within 24 hours post-operation. Antibiotic treatment was not used. The patient was discharged after a three-day hospital stay.

Fig. 2

Monopolar electrotome combined with ultrasound knife was used to separate the adhesion till the smooth peritoneum exposed (a, b). Incision of peritoneum with monopolar electrotome (c). Resection of the lesion with ultrasound knife (d)

Fig. 3

The image of the left (blue arrow in a) and right side (blue arrow in b) abdominal wall after the lesions removed successfully. The diameter of left lesion was about 10cm (c) and the right lesion was about 5cm (d)

Pathological examination confirmed metastatic carcinoma of ovarian cancer (Fig. 4a), with all margins clear. The skin remained intact (Fig. 4b). At the one-month follow-up, the CA-125 level had decreased to 33.5 U/ml and returned to normal by the two-month follow-up. Following this operation, the patient received six cycles of chemotherapy (TP). A CT examination performed three months later revealed no recurrence in the abdominal wall (Fig. 4c). No recurrence has been noted during the subsequent 12 months of follow-up.

Fig. 4

Pathological examination confirmed adenocarcinoma (a, x100).The skin reserved integrally after the operation (b). The enhanced CT showed no recurrence in the abdominal wall followed up 3 months (c)

Discussion and conclusion

PSM typically occurs deep within the abdominal wall, and patients often exhibit no obvious symptoms during the early stages. Our patient did not adhere to the recommended follow-up schedule, which led to a delayed detection of the lesion. Based on our previous experience, strictly following the routine follow-up recommendations and examinations outlined in the NCCN guidelines is sufficient for the timely identification of port-site metastasis [11]. In the follow-up process for ovarian cancer, it is essential to regularly monitor the patient's condition through physical examinations, imaging studies, and tumor marker assessments. Ultrasound should be used as an additional imaging modality alongside other methods for the early diagnosis of port-site metastasis in ovarian cancer patients. Ultrasound allows for dynamic assessment of blood flow and tissue characteristics, which aids in differentiating between benign and malignant lesions. By integrating ultrasound into follow-up protocols, healthcare providers can significantly enhance the early detection of PSM. In our case, ultrasound was employed as the first-line imaging method, in conjunction with clinical check-ups, for the early diagnosis of PSM. Furthermore, patient education regarding symptoms to watch for and the importance of adhering to follow-up schedules is crucial for effective health management. This approach fosters early detection of any recurrence or complications, facilitating timely intervention and improving patient outcomes.

The influence of port-site metastasis (PSM) on prognosis remains uncertain. Nunez et al. reported that PSM is an independent prognostic factor [12]. In contrast, Heitz et al. and Vergote et al. found that the survival outcomes were not associated with the occurrence of PSM [13, 14]. Furthermore, the prognosis for patients who experience PSM following diagnostic laparoscopy prior to debulking surgery remains unclear. Ataseven et al. reported a high incidence of PSM after diagnostic laparoscopy, noting no impact on prognosis. However, they also highlighted that perioperative morbidity was significantly higher in patients with PSM [10].

The hypotheses regarding the pathogenesis of port-site metastasis (PSM) involve several factors, including the immune response, pneumoperitoneum, wound contamination, and surgical techniques [7, 15]. Increased intra-abdominal pressure, intraoperative rupture of the ovarian tumor, and improper tumor retrieval can contribute to the dissemination of free tumor cells, leading to implantation at the port site [16]. The causes of PSM are multifaceted and cannot be solely attributed to the surgical approach. Hyperthermic CO2 insufflation and humidified CO2 insufflation have shown promise as adjuvant treatments to prevent the development of PSM [7, 15]. Gasless laparoscopy should also be considered to minimize the risk of intraperitoneal tumor cell dissemination. Based on literature reports and our own experience, effective prevention strategies to avoid recurrence of port-site metastasis during surgery include proper and minimally traumatic tumor manipulation and morcellation, securing the ports to prevent tumor cell invasion into the wound, cautiously retrieving the tumor using a specially designed laparoscopic pouch, frequent irrigation of the abdominal cavity and wounds, and ensuring proper closure of the abdominal wall layers after laparoscopy [7, 15, 16].

Conventionally, the best treatment for localized metastasis is surgical resection, supported by chemotherapy [17]. The studies about PSM in recent 10 years was included in Table 1 [10, 18,19,20]. Postoperative wound recovery after laparotomy is also a concern. Laparotomy often leads to poor wound healing and scarring, which can hamper patient outcomes. In our view, laparoscopy may be considered as a minimally invasive technique that allows for port-site metastases to be removed without compromising the cutaneous integrity. Currently, there is insufficient published data comparing the prognosis of port-site metastasis resection between open and laparoscopic surgeries. However, case reports indicate that recurrences can also occur after open resections of port-site metastases [18]. The decision to perform laparoscopic resection of port-site metastasis (PSM) cannot be based solely on the size of the lesions. It should be made considering the patient's overall situation, including patient’s age, concomitant disease (diabetes, coagulopathy), and cosmetic desire of the patient. Furthermore, there is still ongoing debate regarding whether to remove PSM after diagnostic laparocopy. A study by Lago et al. compared 41 cases of non-resected PSM with 82 cases of resected metastasis and found no significant differences in survival outcomes [19]. They suggested that in patients undergoing laparoscopy prior to debulking surgery, port-site resection may not be advisable in the absence of macroscopic port-site metastasis [19]. We believe that resecting isolated large port-site tumors may primarily benefit chemotherapy by reducing the tumor burden.

Table 1 The included studies on PSM following ovarian cancer surgery using laparoscopy over the past 10 years